Over the past few decades, magnification in dentistry has been steadily gaining acceptance. When I attended dental school in the 1980s, some faculty members were using telescopic loupes, but never students or younger dentists. Today, loupes are now widely adopted and even required armamentarium for dental students at many dental schools. Over time, many dental practitioners (including hygienists) have come to appreciate the importance of magnification in dentistry for diagnosis, treatment and ergonomics. 

Due to their affordability and portability, dental loupes are the most common form of magnification used in dentistry today, but they do not come without limitations. Most loupes are typically only available in a single level of magnification. Additionally, in order for it to be optimally useful and to effectively increase visualization, magnification requires additional lighting, especially at higher levels of magnification. 

Dental loupes with clip-on light sources or head lamps can be cumbersome and add weight to the head, putting additional strain on the neck and back muscles. While ergonomics are modestly improved with loupes without light sources, it is still difficult to work in a completely neutral postural position without some forward head tilt. 

However, a technology called the dental operating microscope (DOM) is enjoying expanded interest within the profession for its distinct visual, technologic and ergonomic advantages, which can benefit both dentists and patients.

INTRODUCTION TO THE TECHNOLOGY 

DOMs were first used in endodontics in the 1980s and became more widely adopted by endodontists by the 1990s. Over time, as loupes became more popular in other areas of dentistry, areas such as periodontics and restorative dentistry also began incorporating DOMs. The main three advantages of DOMs over loupes are enhanced visualization through multiple levels of magnification and coaxial illumination, digital documentation capabilities, and improved ergonomics. Let’s explore each of these attributes. 

ENHANCED VISUALIZATION: MAGNIFICATION + ILLUMINATION 

As with loupes, the most obvious benefit of a DOM is magnification. Unlike loupes, however, the DOM can provide multiple levels of magnification with the turn of a dial. This is a great feature, because sometimes it is good to see things at a higher magnification, like when trying to locate a constricted canal, and sometimes it’s necessary to step back a bit so that an entire quadrant or arch can be visualized.

Magnification alone, however, is worthless without good illumination. At higher levels of magnification, illumination becomes increasingly important because, as magnification increases, the amount of available light decreases. The DOM offers superb illumination of the operating field that is free of shadows due to the true coaxial path of light, which is parallel to the path of vision. With loupes and a head lamp, for example, the path of light is not the exact same as the path of vision. 

Enhanced visualization augments the clinician’s ability to diagnose disease at earlier stages. It also enables the clinician to operate with a higher level of precision while also resulting in increasingly refined motor movements over time. 

DIGITAL DOCUMENTATION CAPABILITIES 

Many DOMs have the ability to integrate with digital single-lens reflex (DSLR) cameras and video sources. In order to do this, a beam splitter is often needed. I have both a live video feed and a DSLR camera attached to the DOM in my office. This changes everything. Images can easily and quickly be captured — before, during and after any procedure. This feature alone has three main benefits: improved patient communication and education, simplified communication with third-party providers, and risk management. 

While it is true that digital images can also be acquired using only a DSLR or intraoral camera, it is simply not as efficient as when using a DOM. DOMs allow one to acquire images seamlessly while working, without having to stop to take a picture. When images are quick and easy to obtain, more images will be taken. 

IMPROVED ERGONOMICS 

Ergonomics is where DOMs shine. It is well known that dental professionals are at higher risk of suffering from chronic neck and back pain issues. This is likely a result of years of working in oftentimes contorted postural positions to better visualize the operating field. When used appropriately, a DOM forces the clinician to work in an upright postural position. Further, there is no extra weight added to the head of the operator, as would be the case with high-power loupes with a light source attached. 

In a neutral working position and with no added weight to the head, the operator is able to work for longer periods of time without breaks and with significantly less or no neck or back pain.

PROCEDURES THAT BENEFIT FROM THE USE OF DOMS 

While this is not an all-inclusive list, procedures that benefit from DOMs include: 

• Endodontics: Minimize size of access opening; enable location of constricted or accessory canals; improve detection of root fractures. 
• Periodontics: Minimize size of surgical site; aid in microsuturing; improve detection of root fractures. 
• Restorative dentistry: Minimize size of cavity preparation; aid in caries detection and removal; increase precision of crown margin preparation; aid in inspection of marginal fit of restorations; facilitate finishing and polishing of margins; help ensure that all excess cement has been removed. 
• Laser dentistry: Aid in visualization of laser-tissue interactions. 
• Oral surgery: Assist in visualizing fractured root tips; assist in minimizing size of osteotomy; assist in identifying optimal purchase point location. 

CHOOSING THE RIGHT DOM FOR YOUR PRACTICE 

What features should general dentists look for in a microscope? It is important to note that some of the features listed below can be optional accessories for some DOMs and standard/included equipment on others. This is not a complete list, but consists of the features I find important for most users. 

• Beam splitter: As mentioned previously, a beam splitter allows for the integration of digital cameras and live video feeds. A live video feed, for instance, can be connected to the operatory computer. Most practice management software allows for easy capturing and storing of images directly into the patient chart without having to export/import images from a DSLR. A DSLR, however, will provide better quality images for teaching purposes and for use in publications. 
• Binocular extender: This accessory helps to extend the eye pieces closer to the operator, which helps to further eliminate any forward head tilt and improve ergonomics. 
• Curing light/laser filter: Most DOMs today utilize bright LED lighting, which could prematurely start to cure composite before completing application. If you are a laser user, laser filters can be added as well. 

While there are other accessory options available, these are the three I consider to be most important in utilizing a DOM to its fullest potential. Some other accessories an operator may find useful include:

• Multifocal lens: A DOM’s objective lens can be ordered with different focal distances depending on the height of the operator. Taller operators may require an objective lens with a focal distance of 350 millimeters, whereas shorter operators would do better with a focal distance of 250 mm. A multifocal lens allows the operator to quickly adjust the focal distance of the objective lens, which is a great benefit for offices with multiple operators. 
• Binocular rotation ring: This accessory allows for the body of the microscope to be tilted when needed while keeping the eyepieces level. This option helps to further improve ergonomics. 
• Light source: DOMs initially utilized halogen light sources. Due to these lights’ yellowish hue, some manufacturers changed over to metal halide. While metal halide provided a more whitish/ natural light, its intensity was not as great. Xenon provides the best lighting, in my opinion, and it is what I use. However, xenon bulbs are very expensive. Today, LED lighting has solved most of the issues caused by previous forms of lighting and is cost effective. In fact, LED lighting has now become the standard for most DOM manufacturers.

If you are considering purchasing a DOM, the best thing to do is to try out a few different brands. Some DOM manufacturers will allow their sales representatives to drop off a demo unit for anywhere from a few days to a week. The longer you can test the machine, the better. I have found this to be the best way to identify which brand will best suit a prospective user’s needs. 

Company support is another important consideration, and the level of support can sometimes vary greatly depending on geographic location. A bit of due diligence is required to ensure you will have access to the right support after purchasing. 

IS IT WORTH THE INVESTMENT? 

As is the case with any expensive dental equipment, return on investment (ROI) is a valid parameter for consideration. The problem with applying this thinking to DOMs, however, is that the ROI cannot be easily quantified in dollars. The ROI can be quantified by other means. If we look at CEREC CAD/CAM technology as an example, the ROI is much easier to calculate by simply taking the costs associated with a lab-fabricated crown (including impression materials and cost of a second insert visit) and subtracting it from the cost of a porcelain block. 

The net balance is then applied to the cost of the technology, and an estimated timeline of how long it will take to cover the cost of the technology can be calculated. This is not the case with DOMs, however, because, to a non-microscope user, the perceived ROI is zero. To a microscope user, however, the hidden ROI becomes very apparent over time. 

The value proposition of a DOM is much more meaningful than money alone. For instance, it is difficult to put a dollar figure on the ROI of a technology that: 

• Enables an operator to work pain-free and potentially extends his or her years in practice. 
• Can help the operator diagnose disease sooner. 
• Can help increase visibility and precision and refine motor movements. 
• Can help save time in educating and communicating with patients and insurance companies. 
• Can help to increase case acceptance and establish a trusting relationship quicker. 
• Can potentially protect a practitioner from medicolegal issues. 

To me, these ROI attributes offer significant value to the practitioner and patient and have the potential to offer something much more valuable than money alone. Working pain-free and in a way that can prevent work-related musculoskeletal issues from progressing is something that is difficult to quantify. 

Donato “Dino” Napoletano, DMD, is a restorative dentist at Donato Dental in Middletown, New York. He is also owner and a technology integration consultant CE provider at Donato Dental Systems, LLC, which is dedicated to helping dentists evaluate, select and integrate various technologies in a systematic and time-efficient manner. To comment on this article, email impact@agd.org.