TITLE: Dental Loupes for Dental Procedures: A Review of the Clinical and Cost- Effectiveness DATE: 08 October 2008 CONTEXT AND POLICY ISSUES: The use of magnification in dentistry is expanding rapidly. Magnification is aimed to enhance visualization of dental details thus improving diagnosis and treatment, as well as to improve the ergonomics of dental practitioners. 1 Advanced magnification technologies such as surgical microscopes and telescopes are currently available for a variety of applications. 2-8 Surgical telescopes (referred to as loupes) are becoming the standard of care for most routine dental procedures, with a new survey indicating over 60% of practicing dental hygienists are using loupes. 9 Dental loupes can provide magnification from two to six times that of the unaided eye. 5,8 Two basic styles of loupes are offered: front-lens mounted or flip flop (FLM) and through-the-lens (TTL). 8,10-12 FLM and TTL loupes are typically provided in one of two magnification systems, Galilean (magnification up to 3.25x) or Prismatic (magnification greater than 3x). 13 Updated evidence on their clinical and cost-effectiveness as well as guidelines for use of dental loupes are needed to determine whether dental loupes are appropriate for use for all procedures and for all dental personnel. RESEARCH QUESTIONS: 1. What is the evidence for the comparative clinical effectiveness of dental loupes for dental procedures? 2. What is the cost-effectiveness of dental loupes? 3. What are the guidelines for use of dental loupes for dental procedures? Disclaimer: The Health Technology Inquiry Service (HTIS) is an information service for those involved in planning and providing health care in Canada. HTIS responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources and a summary of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. HTIS responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report. Copyright: This report contains CADTH copyright material. It may be copied and used for non-commercial purposes, provided that attribution is given to CADTH. Links: This report may contain links to other information on available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners own terms and conditions.
METHODS: A limited literature search was conducted on key health technology assessment resources, including PubMed, The Cochrane Library (Issue 3, 2008), University of York Centre for Reviews and Dissemination (CRD) databases, ECRI, EuroScan, international health technology agencies, and a focused Internet search. Results include articles published between 1998 and September 2008 and are limited to English publications only. No filters were applied to limit the retrieval by study type. SUMMARY OF FINDINGS: Clinical effectiveness of dental loupes Our literature search identified six studies 14-19 and no health technology assessments, systematic reviews, or meta analysis on clinical effectiveness of dental loupes. Five studies are in vitro studies, 14-16,18,19 and one is a survey. 17 All the six studies compared dental loupes with unaided vision. Five out of six reported beneficial effect of magnification by dental loupes. No study indicated industry sponsorship. The main findings of the studies are summarized in Table 1. Table 1: Summary of findings from studies on the clinical effectiveness of dental loupes Studies Type of Outcome Results loop/magnification Forgie et al. 14 FLM, 3.25x, Galilean Caries detection Magnification increases sensitivity and specificity Forgie et al. 15 Slaton et al. 16 2.6x (type of loupe 3.3x (type of loupe Change in size of cavity following removal of restoration* Identification of dentinal cracks Buhrley et al. 17 Varied Location of the MB2 canal Haak et al. 18 Hayashi et al. 19 FLM, 4.5x, Prismatic 2x (type of loupe Detection of proximal caries Detection of marginal discrepancies FLM = front lens mounted; MB2 canal: second mesiobuccal canal * The smaller the size change, the better the accuracy of the removal technique (p<0.05) Magnification makes cavity size change smaller (p>0.05) Magnification increases sensitivity and specificity (p>0.05) Magnification increases the frequency of detection (p<0.05) Magnification increases detection (p<0.05) if users are experienced in loupe utilization No difference found between magnification and unaided vision In addition to the studies on clinical effectiveness of dental loupe use, there are two studies looking at the effect of dental loupe use on the operator s posture. 20,21 Both studies, using TTL, 2.6x 20 and FLM, 2.5x, 21 reported significant improvement in dental hygiene posture when dental hygiene students are using loupes as compared to without loupe use. Dental Loupes for Dental Procedures 2
Cost-effectiveness of dental loupes No study on cost-effectiveness of dental loupes was found. The price range for dental loupes is US$550 to US$1500. 22 Over a 20-year career in dental practice, a $1000 investment for a dental loupe comes out to $50 a year. 22 Guidelines for use of dental loupes Our literature search did not identify any guidelines for dental loupe use. CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING: Overall, five of the six studies found that dental loupes could enhance dental care. Magnification has the potential to increase the quality of dental care and supports the musculoskeletal health of dental practitioners. No guidelines on the use of dental loupes, including the indications for use, specifications for the dental loupes, or which personnel should be using the loupes were identified. No cost-effectiveness studies on dental loupes were identified. Even though the benefits of magnification are recognized, the costs, cross-infection if the loupes are touched to the treated areas, and peculiarity to patients, particularly children, need to be considered. 23 PREPARED BY: Chuong Ho, MD MSc, Research Officer Charlene Argáez, MLIS, Information Specialist Health Technology Inquiry Service Email: htis@cadth.ca Tel: 1-866-898-8439 Dental Loupes for Dental Procedures 3
REFERENCES: 1. Sunell S, Rucker L. Surgical magnification in dental hygiene practice. Int J Dent Hyg 2004;2(1):26-35. 2. Millar BJ. Focus on loupes. Br Dent J 1998;185(10):504-8. 3. Goldstep F, Freedman G. Magnification: improving the quality of care. Dentistry Today 2006;25(8):114-21. 4. Sheets CG, Paquette JM. The magic of magnification. Dentistry Today 1998;17(12):60-7. 5. van As AG. Magnification and the alternatives for microdentistry. Compend Contin Educ Dent 2001;22(11A):1008-6. 6. Winter RR, Cornell DF, Vingoren GJ, Patrick RB. Use of magnification in dental technology. J Esthet Restor Dent 2003;15(7):409-15. 7. Garcia A. Dental magnification: a clear view of the present and a close-up view of the future. Compend Contin Educ Dent 2005;26(6A Suppl):459-63. 8. Mansueto MA, Overton JD. A clinician's guide to purchasing surgical loupes. Tex Dent J 2007;124(2):174-86. 9. Thomas J, Thomas FD. Dental hygienists' opinions about loupes in education. J Dent Hyg 2007;81(4):82. 10. Benjamin SD. Current developments in magnification trends for improved visualization. Pract Proced Aesthet Dent 2003;15(9):715-9. 11. Weathers AK. Access to success: taking a closer look at magnification. Dentistry Today 2005;24(2):106-11. 12. Friedman MJ. Magnification in a restorative dental practice: from loupes to microscopes. Compend Contin Educ Dent 2004;25(1):48-55. 13. Freedman G, Goldstep F. Magnification: getting bigger every year. Dentistry Today 2003;22(8):108-13. 14. Forgie AH, Pine CM, Pitts NB. The use of magnification in a preventive approach to caries detection. Quintessence Int 2002;33(1):13-6. 15. Forgie AH, Pine CM, Pitts NB. Restoration removal with and without the aid of magnification. J Oral Rehabil 2001;28(4):309-13. 16. Slaton CC, Loushine RJ, Weller RN, Parker MH, Kimbrough WF, Pashley DH. Identification of resected root-end dentinal cracks: a comparative study of visual magnification. J Endod 2003;29(8):519-22. Dental Loupes for Dental Procedures 4
17. Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS. Effect of magnification on locating the MB2 canal in maxillary molars. J Endod 2002;28(4):324-7. 18. Haak R, Wicht MJ, Hellmich M, Gossmann A, Noack MJ. The validity of proximal caries detection using magnifying visual aids. Caries Res 2002;36(4):249-55. 19. Hayashi M, Watts DC, Ebisu S, Wilson NH. Influence of vision on the evaluation of marginal discrepancies in restorations. Oper Dent 2005;30(5):598-601. 20. Branson BG, Bray KK, Gadbury-Amyot C, Holt LA, Keselyak NT, Mitchell TV, et al. Effect of magnification lenses on student operator posture. J Dent Educ 2004;68(3):384-9. 21. Maillet JP, Millar AM, Burke JM, Maillet MA, Maillet WA, Neish NR. Effect of magnification loupes on dental hygiene student posture. J Dent Educ 2008;72(1):33-44. 22. Strassler HE, Syme SE, Serio F, Kaim JM. Enhanced visualization during dental practice using magnification systems. Compend Contin Educ Dent 1998;19(6):595-611. 23. Juggins KJ. The bigger the better: can magnification aid orthodontic clinical practice? J Orthod 2006;33(1):62-6. Dental Loupes for Dental Procedures 5