“ Digital Microscopy and Near eye screens (Augmented reality)  in regular Dental Procedures”

During Covid 19 – Lock down new concepts were thought about, for examining dental patients. But this concept proved very effective and it requires future development. Dental professionals and Dental equipment manufacturers can take up this product and use it for every future dental chair unit. …

Dental Surgeon, Samuel Jeyakaran, with entrepreneur friend and Masters in Physics, Mr Jayanth K Newport, and a team of fellow dentists, Dr. Danie Shammy Kitchley and Dr. George Benedict came together, and the result is this innovative product.

HISTORY : During the Post COVID, dental procedures were done fearfully. Regular procedures were postponed or cancelled, due to the proximity of the dentist to the oral cavity which was the reason for the spread.  So IO ( Intra Oral ) cameras were used to diagnose.   Then we used an old exoscope of 2 MP and 70 mm FL, and procedures were attempted using digital screens. In this way, Dentist need not directly view into the oral cavity but stare at a screen.

DEVELOPMENT : More adjustments with different angles,  screens, wearing the near eye glasses were attempted. Doing procedures with mild variation of 15 – 20 degrees to the regular eye position were also attempted and the best option was decided. Soon, with long focal length  5 MP  microscope, good maneuverability, accuracy, desired  speed and comfort as desired by dentist was accomplished.

Visibility is a prime factor in Dentistry whether in Diagnosing or treating. Through History Devices had been added on to Dental equipment list to aid the clinician. Devices listed here.

ABOUT THIS EQUIPMENT : Digital  microscopes of 5 Mp (Megapixels), were  used to magnify the Oral cavity and procedures were done, viewed through smartphone supported AR glasses (Augmented Reality viewer).  VR boxes can also be used (Virtual Reality viewer).  Here we have used smart phone supported Augment Reality Glasses. Simply because we could not afford one of these. ( Occulus or Vuzix or NuLoupes )

It is important to note that dental procedures  using digital microscope and AR glasses were so for not reported, to our knowledge. Technology keeps improving daily. So , Please update us….  Meanwhile, we were  careful in establishing the success of this new concept  and are delighted  to share it here, as it is cost friendly.  At the same time,  there arose  shortfalls which are  listed in  the table …  under limitations.  These limitations which have to be developed by the manufacturers  dedicated to manufacturing dental equipment.

• WHY it is needed ? : For Dentists, doing routine Dental procedures evoke Musculo skeletal disorders and  up to 80 % of dentists who are practicing for more than 20 years are affected. While doing dental procedures dentist is required to encompass most of the following.
  • Working in a small restricted area, Difficult access areas.
  • Good  and clear vision, Coordination of vision and manual dexterity.
  • Manual control while working with high precession and power cutting instruments, Operator’s postural stillness  for many hours
  • And all Dentists are expected to cope with these stresses  by rigorous training, developing sills,  increased concentration, devoting their energy to  withstand. But at the same time they oversee  the fatigue and strain caused to themselves. Postural ergonomics is affected.
• And Dentist ruins his back  and fails on posture  because  he strains to get  better  visibility of the  field or area. Dentists fail in their postures due to failed visibility.  If we Improve the visibility of the restricted work area  by magnification, zooming, good lighting,  and give that visibility on a head mounted display or  near eye display ( smart phone based )  –  his comfortable position is maintained and his posture is unaffected.
• Also,  apart from dentist,  procedures are performed  unerring with more accuracy benefiting the patient. So Digital Magnification is a with near eye vision is a useful tool in Dentistry.

• PRINCIPLE :
• Magnification of Oral Cavity using Digital microscope, Using the maneuverable arm,  the digital microscope is adjusted to be at the required position.  Dentist or the Assistant uses his/ her  hands instead of back and neck, to focus the difficult access area,  sitting  easy and relaxed on the dental stool in  his most comfortable, neutral position, 
• Viewing   the area of work using a AR  viewer  attached near dentist’s eyes,   Dentist’s posture is in the neutral zone.
• Dental Procedures are performed at ease, with clarity and in detail.

SIMPLICITY : It is Simple , Cost effective for mass production in future. We  did not go through the high end buying Occulus or Vuzix (1000 USD or more ), or the  compatible high end digital microscope or gas spring maneuverable  arm, etc to incorporate in this experiment, simply because it is not cost friendly. So we restricted in simplifying the device to smartphone and smart phone based VR viewer  and  started doing  simple dental procedures with   common digital microscopes. If it has to benefit all the dentists, in improving their visibility and hence better dental work, the cost has to be under 1000 USD. It is in this scope that this essay is done to open out the concept to all entrepreneurs, equipment manufacturers, and budding Dental surgeons. Also we know, that in corporate setting, they do not want the product to be cheap, But We urge them to be considerate to benefit all dentists.

• DEFINITIONS
  • Digital Microscopes are microscopes without eyepieces. A digital camera acts as a detector. Images are displayed on a screen, turning the microscopy workstation into an ergonomic digital workplace.
  • VR ( Virtual Reality ) can be defined as a system which incorporates a basic concentrated digital view
    • Replacing dentist’s real-world environment( optical) with a digital (virtual) one
    • real-time interaction, ( with latency )
    • accurate  registration of Magnified  real objects,
    • Concentrated  digital view of only what the microscope sees
  • AR ( Augmented Reality ) can be defined as a system that incorporates
    • A combination of optical (real)  and digital (virtual) worlds,
    • real-time interaction, ( with latency )
    • accurate  registration of Magnified  real objects,
    • Digital view of what microscope sees with preview of surroundings , patient face, instrument trays etc.

MATERIALS : As  said before,  We restricted our build to cost effectiveness so that it may be cost friendly to all dentists  and can be easily added on to their existing Dental chair.

1. Smart phone, light weight, low SAR, Microscope app
2. Digital Microscope 5 MP, (Wi-Fi) FL < 80 mm, fps 30+,
3. Near eye headset viewer (AR glasses) with comfortable cushions
4. Quick Lock Stand ( Bracket to attach to the required Arm )
5. Swivel arm  with lock
6. Boom arm or Serpent arm with maneuverability with Clip to hold microscope

I found it convenient to attach the Microscope to the dental Light arm. But it can be also attached to the Head rest, or Operator tray arm.I used a dedicated smartphone ( nokia C3)   of appropriate size for the AR viewer with app  to support the  microscope and used Wi-Fi to connect to the Microscope. There was no sim card inside the phone, to reduce further emr (Electro Magnetic Radiation). The Summarized concept looks like this .

Some Devices

DEVICES : Visiblity is a prime factor in Dentistry whether in Diagnosing or treating. Through out History Devices had been added on to Dental equipment list to aid the clinician. We now have the following:

1. Naked Human Eye
2. Magnifiers
3. Loupes
4. Surgical Operating Microscopes (SOM)
5. Procedure scopes
   • Digital Microscope and AR near eye viewer
6. Intra Oral camera
7. Digital scanners
8.  

COMPARISON of various devices

	MODE	RADIATION/ STRESS	STRAIN	Mag X	Examination	Procedures	Posture	COST (INR)
1	Naked Human Eye	No	YES	0	Yes	Yes	<40 deg head	0
2	Magnifiers	Mild	Mild	3.5 X	Yes	Yes	< 40 deg head	< 5,000
3	Loupes	Mild	MIld	3.5 X	Yes	Yes	< 25deg head, fixed position	< 20,000
4	SOM Surgical Operating Microscope	Moderate		20 X	Yes	Yes	< 5 deg head, fixed position	< 15,00,000
6	Procedure Scopes			25 X	Yes	Yes	Fixed Head position on screen
7	Digital Microscope	Wifi /  Blutooth	Nil	50 X +	Yes	Yes	Head in  Neutral position	< 80,000
8	Intra Oral camera			25 X	Yes	–	Fied position on  mounted screen	< 25,000
9	Digital scanners			25 X	Yes	–	Fixed positon  on mounted screen	< 10,00,000

Of these Loupes and operating Microscopes are useful in doing dental  procedures but give some head and neck strain   and they are  not digital.  Digital scope ( Ezscope 4)  is digital but fixed, and  also cause some strain. On the other hand  with Digital microscopes and AR viewer,  procedures can be done in comfort of the dentist with affordable cost.

1. TECH ADOPTION LEARNING : Till passing the learning curve,  much time was wasted.  But after passing the learning curve,  time for each procedure  was reduced. While  in passing curve, following were noted.
   • Since microscope aiming was difficult, time was spent on adjusting, But just after a few procedures, adjusting the scope was not a problem.
   • Focusing  was needed   when  shifting from anterior  to posterior or  vice versa, and either the Dentist  or Assistant   had to  look into that
   • Dental over head light was not required  when doing a particular area or tooth.
   • Dental assistant will do the maneuverability, focusing and recording of the procedure as and when needed.  (Additional fixed screen was added  for the sake of visibility for the assistant. )
   • Time taken for each procedure had reduced, but since it was subjective, author did not tabulate that.
2. CROSS CONTAMINATION : Since the head has LED, It  is not submersible, or autoclaved but  gentle wipe with disinfectant was done. Boom arm and near eye headsets  and all surfaces were also wiped up to  avoid any cross contaminations.  Autoclaved surgical covers were used at times of surgeries only.
3. AR / VR COMPARISON : When Virtual Reality Case with Smartphone was worn, more of  blocking the “outside world view  feel”,  was experienced.  But for doing  concentrated RCT procedures, this was the needed feel. Eye adjustment was needed after removal of vr case, a mild blurred vision  was noted more in comparison  with AR.  Also  Handling of instruments proved tricky and  assistant had  to be specially well trained to place  every instrument like clock work  as and when needed. Both these models  of VR and AR are good, But doing the procedure, interacting with patient, communicating  with assistant all seemed a step above and harder  when  Full covered case of VR was used.  Doing the same with AR case was relatively easy.
4. OBSERVATION : Both the  microscope and the  Viewers used for the  concept study were  not costly and so they had  little discomforts. Also  with the technology  advancing daily, one have to get the latest affordable tool.  Very  high expensive  near eye glasses of AR  are required for comfort of  future dentists. Near eye glasses  are far better than a screen fixed on the wall, for doing procedures in First Person View (fpv).  A study confirms  this (3)

Some images captured while doing Procedures

Some Questions

• Do you accept the concept of digitalizing the procedures and treatments using digital microscopes, apps and AR glasses?
• Do you conveniently posture yourselves in comfort, while you treat your patients ?
• Is it not good that we think about us – Dentists- to protect our backs and necks, to be more free rather than bend our heads to get a better view?
• Do we magnify the teeth and gums so that our finished work quality is best ?
• Is it not good to encourage our clients by giving them a pre and post op scaling image just to motivate them for better oral care?
• Do we accept Digital Dentistry, A  Combination  of  digital microscope, some Augmented Reality,  and convenient storage which also comes affordable  and cheap to every dentist?
• Can you see Future Dentistry without digital magnification?

	LIMITATIONS	CORRECTIONS ( To Develop )
1	Battery running down after 4,5  hours	Both the  Microscope  and  the Near eye screen  need external batteries,  and get power supply from the Dental Unit itself
2	Latency or snag	microscopes with fps of 60 or more is needed
3	Auto focus of the  digital microscope	Microscope  needs  to be developed for the purpose of “Digital Oral Health Imaging” and add a sensor for auto focus. Or foot controlled focusing.
4	adaptation curve for accepting the AR, Digital microscopy, fpv of procedures	Dentist and Assistant need to be patient and persuasive and introduction and training in Dental colleges is needed.

RESULTS : Using of Digital microscope  with near eye smart glasses or AR is not a replacement of  naked eye vision,  in diagnosis or procedures, as all dentists  are trained  and sharpened our skills with our naked human eye. But digital microscopy and AR glasses are an useful tool, aiding Dental surgeon in doing procedures better.  It also gives lesser strain to the dentist. So while doing regular dental procedures, using  digital microscopes, and the near eye headset ( AR case with smartphone )  it results a better outcome to both dentist and his client.   Looking ahead, maybe with introduction of  maneuverable robotic arm with voice commands and powerful auto focus digital microscope,   it may replace the naked eye vision to do dental procedures in future.

DISCUSSION : Technology is out there.  Even Drone flyers, Laparoscopic surgeon, ENT surgeon, have incorporated  digital view, magnified / zoom view,  and FPV  of their work area to aid in their profession.  In dentistry,  so far, for doing dental procedures, surgical operating microscope, dental loupe or naked eye, and which are traditional is recommended. It is high time, In this digital era,  Dental fraternity  should use Digital Microscopes and screens (AR) on every dental chair to do dental procedures in an easy, affordable and better way, to benefit all dentists and their clients.

We recommend that, in future,  Dental Chair manufacturers  should roll out  every dental unit  with  built in Digital microscope, software and Near Eye screen.

BIBLIOGRAPHY / REFERENCE

1. https://doi.org/10.13075/ijomeh.1896.00724

2. https://doi.org/10.1002/ase.1696

3. https://www.dentistrytoday.com/introducing-a-new-digital-imaging-system

4. https://www.getezscope.com/