Patent Application
20210093200
This invention generally relates to dentistry and dental materials. In alternative embodiments, provided are methods and products of manufacture for photoacoustic imaging of the periodontium of individuals in need thereof for noninvasive periodontal probing depth measurements and periodontal pocket imaging and gingival thickness. In alternative embodiments, products of manufacture as provided herein can observe or measure soft tissue contrast, e.g., gums, or the periodontium or the oral mucosa can be imaged and/or measured, including hypoxia and inflammation/infection.
Periodontitis affects nearly 50% of Americans and exerts both local and systemic effects on the body. These range from mild discomfort to debilitating pain, tooth loss, and excessive activation of the immune system. Studies have identified the chronic inflammation from periodontitis as a risk factor for conditions such as cardiovascular disease, cancer, and dementia. Thus, it is critical to diagnose periodontal disease early while the symptoms are mild and reversible.
Current metrics for monitoring periodontal health include attachment level, probing depth, bone loss, mobility, recession, and degree of inflammation. For example, a periodontal examination evaluates the periodontium for signs of inflammation or damage and is the basis for subsequent intervention. One key feature of this assessment is the measurement of probing depths, which is a numeric metric that reflects the extent of apical epithelial attachment relative to the gingival margin and is critical for disease staging. Probing depth measurements can identify periodontal disease and monitor response to intervention. The probe depths offer insight into clinical attachment loss, furcation involvement, and bone loss when used in conjunction with radiography and the oral examination.
Probing depths are commonly measured with a periodontal probe, which has remained popular despite the advent of many next-generation tools. Unfortunately, the periodontal probe is a relatively unsophisticated tool. Probing depth measurements using the periodontal probe are error prone and suffer from poor reproducibility, largely due to variation in probing force. Indeed, a recent meta-analysis showed that a range of probing forces were used, which varied across multiple orders of magnitude. Other error sources include variation in the insertion point, probe angulation, the patient's overall gingival health (weakly inflamed tissue), and the presence of calculus. Thus, the examination is subject to large errors with interoperator variation as high as 40% and r values<0.80. Furthermore, the probe can only measure depth at the point of insertion, with no information on the full width or contour of the pocket.
These error sources can result in poor patient treatment and, hence, poor patient outcomes. The variation also compromises epidemiologic studies and makes it difficult to compare outcomes among dentists or among populations. Furthermore, the probe often penetrates the inflamed epithelium, resulting in patient discomfort, bleeding on probing, and producing probe depths that are up to 1 mm deeper than the actual anatomic value.
While some studies have shown that a constant force probe or digital probe might overcome most limitations, such tools underestimate probing with little improvement in reproducibility. Clearly, new tools, including improved imaging tools, are urgently needed to improve this vital procedure.
Ultrasound is an affordable, high-resolution, sensitive, nonionizing, and real-time tool for imaging, but it is rarely used in dentistry. Previous studies have used ultrasound with frequencies 20 MHz to image facial crestal bone or the cementoenamel junction, but these approaches lacked the spatial resolution and contrast needed to measure probing depth.
More recently, photoacoustic imaging has been used in addition to ultrasound to combine the temporal and spatial resolution of acoustics with the spectral behavior and increased contrast of optics. In addition, the use of high frequency offers<100-μm resolution to image the probing depths.
In alternative embodiments, provided are products of manufacture or dental devices for imaging a periodontal tissue or a periodontium, wherein optionally the periodontal tissue comprises an oral mucosa or gingiva, the method comprising:
a mouthpiece or mold capable of fitting over one or several teeth, or all teeth, in an arch (optionally a maxillary or mandibular arch, or both), and optionally also fitting over or covering (e.g., at least part of) the periodontal tissue or periodontium,
wherein optionally the mouthpiece or mold is manufactured to: image and collect signal(s) from a contrasting or imaging agent, and/or, to hold, carry and deliver to the contrasting agent or imaging agent to the periodontal tissue or periodontium, when the mouthpiece or mold is placed or fitted over the one or several or all teeth in the arch, optionally also covering periodontal tissue or periodontium or gingiva, and
one or more photoacoustic imaging sensors and corresponding transducers, wherein the one or more photoacoustic imaging sensors comprise ultrasound and/or optical imaging sensors capable of generating imaging data, and the ultrasound and optical imaging sensors are operatively linked to the corresponding ultrasound and optical transducers, and the ultrasound and/or optical transducer is capable of transmitting the imaging data to a remote receiver,
wherein the one or more photoacoustic imaging sensors can image the periodontium or periodontal tissue, or a periodontal pocket, and generate imaging data,
and optionally the imaging data from the one or more photoacoustic imaging sensors is capable of being converted to: an image of the periodontium or periodontal tissue, or an image of the periodontal pocket, or a periodontal probing depth image or measurement.
In alternative embodiments, of the products of manufacture or dental devices as provided herein:
In alternative embodiments products of manufacture or dental devices as provided herein do not comprise a photoacoustic imaging agent, but rather a photoacoustic signal is generated via hemoglobin and deoxyhemoglobin in the gingiva or periodontal pocket. This vascular imaging can indicate the degree of inflammation or infection.
In alternative embodiments, provided are methods for:
(a) providing a product of manufacture or a dental device of any of the preceding claims;
(b) providing a photoacoustic imaging agent, and/or an acoustic coupling medium or a gel, or equivalent,
wherein optionally photoacoustic imaging agent comprises a food based imaging agent, or optionally comprises a food-grade squid ink or an equivalent optionally also comprising a cornstarch or an equivalent,
wherein optionally photoacoustic imaging agent comprises an optical absorber, optionally a strong optical absorber, or optionally an optical absorber comprising a melanin,
(c) placing the photoacoustic imaging agent and/or acoustic coupling medium or a gel, or equivalent on the periodontium, gingiva, or the oral mucosa of an individual, optionally a dental patient, or placing the photoacoustic imaging agent and/or acoustic coupling medium or a gel, or equivalent in the product of manufacture or the dental device such that the photoacoustic imaging agent comes into contact with the periodontium or oral mucosa,
(d) taking a photoacoustic and/or acoustic coupling medium or a gel, or equivalent imaging of the periodontium or oral mucosa with the one or more photoacoustic imaging sensors to generate ultrasound and/or optical imaging data, and
optionally, (e) saving the ultrasound and/or optical imaging data in the product of manufacture or the dental device, wherein the product of manufacture or a dental device comprises a data memory storage, or transmitting the ultrasound and optical imaging data to a computer, a memory and/or a database.
In alternative embodiments of methods as provided herein:
In alternative embodiments provided are Uses of a product of manufacture or dental device of any of the preceding claims for:
In alternative embodiments provided are products of manufacture or dental devices (as provided herein) for use in:
In alternative embodiments provided are kits comprising a product of manufacture or dental device of any of the preceding claims, and optionally further comprising a photoacoustic imaging agent and/or acoustic coupling medium or a gel, or equivalent, wherein optionally photoacoustic imaging agent comprises a food based imaging agent, or optionally comprises a food-grade squid ink or an equivalent optionally also comprising a cornstarch or an equivalent, wherein optionally photoacoustic imaging agent comprises an optical absorber, optionally a strong optical absorber, or optionally an optical absorber comprising a melanin, and optionally further comprising instructions for practicing a method of any of the preceding claims.
In alternative embodiments, kits as provided herein further comprise:
In alternative embodiments of kits as provided herein:
a processor;
a wired or wireless interface for operably communicating, directly or indirectly, with the photoacoustic imaging sensors;
computer-executable instructions stored on a non-transitory memory for causing the processor to receive the image data and generate the at least one image of the periodontal tissue or periodontium;
generate an additional ultrasound image of the periodontal tissue or periodontium, or portion thereof, and
overlay one of the generate the at least one image of the periodontal tissue or periodontium or the generated additional ultrasound image, or vice versa, to produce a composite image.
In alternative embodiments, kits as provided herein further comprise: an additional processing device for receiving the imaging data directly from the photoacoustic imaging sensors, storing at least a portion of the receiving imaging data, and transmitting the stored imaging data, wired and/or wirelessly, to the processing device.
The details of one or more exemplary embodiments of the invention are set forth in the accompanying drawings and the description below. Other features, objects, and advantages of the invention will be apparent from the description and drawings, and from the claims.
All publications, patents, patent applications cited herein are hereby expressly incorporated by reference for all purposes.
The drawings set forth herein are illustrative of exemplary embodiments provided herein and are not meant to limit the scope of the invention as encompassed by the claims.
Figures are described in detail herein.
Like reference symbols in the various drawings indicate like elements.
In alternative embodiments, provided are methods, products of manufacture, and kits effective for measuring and high-spatial resolution imaging of periodontal tissues, including periodontal pockets, including high-spatial resolution imaging to image and measure probing depths of periodontal pockets. In alternative embodiments, provided are methods and products of manufacture using photoacoustic imaging for probing depth measurements with applications to the dental field, including but not limited to use as tools for automated dental (e.g., periodontal) examinations or noninvasive examinations.
In alternative embodiments, example methods and products of manufacture and kits comprise use a combination of ultrasound and optical imaging referred to as photoacoustic (PA) imaging, in tandem with an oral rinse, e.g., a food based imaging agent, e.g., an imaging agent based on food-grade squid ink and cornstarch, or equivalents, that the individual in need thereof, e.g., a dental patient, can use briefly before imaging. In alternative embodiments, the rinse comprising the imaging agent (e.g., comprising food-grade squid ink, or melanin) increases the amount of photoacoustic signal in the pocket depth because it contains strong optical absorbers such as melanin, e.g., it contains strong optical absorbers from the squid ink (melanin).
An example method uses down to 10 microliters of imaging (contrast) agent per pocket, though this amount can be greater or smaller. In a particular example described below (Example 1), the imaging agent includes melanin nanoparticles. Alternative or additional imaging agents include, but are not limited to an FDA approved dye such as methylene blue or indocyanine green, activated charcoal, so long as the material absorb light and be safe for the animal or human being tested. The taste of the imaging agent can also be configured to be more acceptable by the subject for use, as will be appreciated by those of ordinary skill in the art.
In alternative embodiments, any one or several contrast agent(s) that can image below the gum line (e.g., into the periodontal pocket), e.g., that can image a bacterial infection or inflammation below the gum line, can be used. In alternative embodiments, inflammation in the gums or below the gum line (e.g., into the periodontal pocket) is imaged by photoacoustic spectroscopy, e.g., by measuring hemoglobin/deoxyhemoglobin levels or concentrations in the gum tissue to quantify the inflammation.
In alternative embodiments, products of manufacture as provided herein can make pocket depth measurements automatically, e.g., to allow dentists or periodontists to see more patients or employ fewer hygienists.
In alternative embodiments, products of manufacture as provided herein can observe or measure soft tissue contrast, e.g., gums, the periodontium, or the oral mucosa can be imaged and/or measured. In comparison, X-ray and computer tomography (CT) imaging can only image hard tissues, e.g., bone.
In alternative embodiments, products of manufacture as provided herein can image bacterial infection, e.g., including the resulting inflammation, which can be difficult to identify during a dental exam.
In alternative embodiments, products of manufacture as provided herein are used with an oral rinse that absorbs light and converts that to acoustic waves. This rinse penetrates periodontal pockets and enhances contrast to measure pocket depths. This device works by using both ultrasound and photoacoustic signal. The ultrasound is specific to bones and some gum contrast, while the photoacoustic signal offers specific information on plaque, pocket depths, and/or bacterial infection.
In alternative embodiments, the term “photoacoustic detectable signal” as used herein refers to a signal derived from the contrasting agent absorbing light energy and converting it to thermal energy that generates the photoacoustic signal. The photoacoustic detectable signal is detectable and distinguishable from other background photoacoustic signals that are generated from the subject or sample. In other words, there is a measurable and statistically significant difference (e.g., a statistically significant difference is enough of a difference to distinguish among the photoacoustic detectable signal and the background, such as about 0.1%, 1%, 3%, 5%, 10%, 15%, 20%, 25%, 30%, or 40% or more difference between the photoacoustic detectable signal and the background) between photoacoustic detectable signal and the background. Standards and/or calibration curves can be used to determine the relative intensity of the photoacoustic detectable signal and/or the background.
In alternative embodiments, the term “photoacoustic imaging” as used herein refers to signal generation caused by a light pulse, absorption, and expansion of a contrast agent, followed by acoustic detection, where the contrasting agent absorbs the light energy and converts it to thermal energy that generates the photoacoustic signal. In alternative embodiments “photoacoustic imaging” also can refer to converting the detectable signal into a data form that may then be transformed into an image of the signal within the cell/s, tissue/s, or living animal or human, said image being visible and interpretable by an operator.
In alternative embodiments, the acoustic signal(s) are detected and quantified in real time using an appropriate detection system, i.e., any detection system known in the art. For example, two instruments that can be used quantifying acoustic signal are the NEXUS128™ (Endra Life Sciences, Ann Arbor, Mich.), and the VEVO™ 2100 (Fujifilm VisualSonics, Inc., Toronto, Canada). Others can be used and purchased from manufacturers such as but not limited to iThera. The units of acoustic signal can vary and include echogenicity units (EU) or mean grey scale. Input units include dB and frequency (MHz). Maximum intensity persistence imaging can also be used and is described by Pysz et al. in Investigative Radiology (2011) 46: 187-195. In alternative embodiments, other detection strategies, including capacitive micromachined ultrasonic transducers (CMUT) arrays, are also used to detect the acoustic signal.
In alternative embodiments, provided are kits that comprise products of manufacture and dental devices comprising photoacoustic probes and directions (written instructions for their use). These components can be tailored to the particular disease, biological event, or the like, being studied, imaged, and/or treated (e.g., cancer, cancerous, or precancerous cells). The kit can further include appropriate buffers and reagents known in the art for administering various combinations of the components as provided herein.
In alternative embodiments, acoustic energy is detected and quantified in real time using an appropriate detection system. The acoustic signal can be produced by one or more photoacoustic probes as provided herein. In alternative embodiments, exemplary acoustic energy detection systems are as described in: J. Biomedical Optics (2006) 11, p024015; Optics Letts. 30: 507-509, each of which are included herein by reference. In an embodiment, the acoustic energy detection system includes a 5 MHz focused transducer (25.5 mm focal length, 4 MHz bandwidth, F number of 2.0, depth of focus of 6.5 mm, lateral resolution of 600 μm, and axial resolution of 380 μm. A309S-SU-F-24.5-MM-PTF™, Panametrics), which can be used to acquire both pulse-echo and photoacoustic images. In addition, high resolution ultrasound images can also be simultaneously acquired using a 25 MHz focused transducer (27 mm focal length, 12 MHz bandwidth, F number of 4.2, depth of focus of 7.5 mm, lateral resolution of 250 μm, and axial resolution of 124 μm. V324-SU-25.5-MM™, Panametrics). Other detection strategies including capacitive micromachined ultrasonic transducers (CMUT) arrays can also be used to detect the acoustic signal.
Referring now to the drawings,
In alternative embodiments, example methods and products of manufacture and kits use a mouthpiece or mold (“mouthpiece” herein) 22 that is capable of partially or fully receiving (e.g., fitting over or covering) one or several teeth, or all teeth in an arch, and optionally also fitting over or covering (e.g., at least part of) the periodontium or gingiva. The arch can be, for example, a maxillary arch, a mandibular arch, or both. The example mouthpiece 22 is sized and shaped for fitting over several teeth in an arch, optionally also fitting over or covering some gingiva or periodontium, although this is not necessary in all embodiments.
In alternative embodiments, the example mouthpiece 22 has an outer body 24 that is similar to that of a conventional mouthpiece such as a 6-9 cm wide and 2-4 cm high. The outer body 24 can be molded or otherwise formed from conventional mouthpiece or mold materials, such as but not limited to acrylic, vinyl, or poly(methyl methacrylate) (PMMA) or any appropriate polymer. In alternative embodiments, the mouthpiece, or any subsection, subpiece or all structural components of a product of manufacture or dental device as provided herein can be 3D printed.
In alternative embodiments, disposed within or on the outer body 24 are one or more light generators 26, such as but not limited to light-emitting diodes (LEDs). As shown in
In alternative embodiments, further disposed within or on the outer body 24 are one or more transducers 32, e.g., acoustic transducers, for receiving an acoustic (photoacoustic) signal from the contrast agent and generating a data signal. Example transducers 32 include, but are not limited to, ultrasonic transducers, such as piezoelectric transducers, patterned silicone elastomers and the like. In an example embodiment, the transducers 32 are disposed within openings in the outer body 32 and arranged therein to generally align with target areas to be imaged, such as gingiva at one or more teeth. In example embodiments, an acoustic coupling medium or gel, or equivalent, can be provided to transmit acoustic waves from an oral mucosa, gum, tooth, or periodontal pocket to the transducers 32. Receiving circuitry (not shown) coupled to the transducers 32 may be disposed within the outer body 24 or external to the outer body, such as via line 30.
The mouthpiece 20 may, but need not, also include one or more wireless transmitters 34 and/or receivers (not shown) for transmitting data signals generated by the transducers 32 and/or for receiving control signals to operate the light generators 26. In the example mouthpiece shown in
The processing device can include a processor (which can include one or several processors), a memory (or several memories), an (optional) database(s), wired and/or wireless interface(s), and suitable computer-readable instructions stored on a non-transitory medium or media for causing the processor to perform example methods for receiving and processing image data signals to generate an image as disclosed herein. Alternatively or additionally, the processing device 36 may be configured to receive data signals (e.g., locally), and store and/or forward (wired or wirelessly, via a network, the Internet, etc.) the received data signals to an operatively linked remote receiver, such as another processing device. Particular, non-limiting example processing devices 36 for processing generated photoacoustic data signals are disclosed herein. Alternatively, receiving of data signals and/or generation of control signals can be provided via a wired connection such as through line 30 or elsewhere. Example processing methods can be performed by multiple processing devices operating example method steps in series or in parallel, and such multiple processing devices can be considered a “processing device” as used herein.
The received data signals, providing ultrasound and/or optical imaging data, are preferably capable of being converted to: an image of the periodontium or periodontal tissue, or an image of a periodontal pocket, or a periodontal probing depth measurement. In example embodiments, the processing device 36 is configured to convert the received data signals to: an image of the periodontium or periodontal tissue, or an image of a periodontal pocket, or a periodontal probing depth measurement. Example methods for converting the received data signals to images are disclosed herein. Generated images can be displayed as an interactive or non-interactive image, printed (hard printing or into a different format), stored in a database or other non-transitory memory, transmitted to another device, etc.
A suitable power supply (not shown), such as but not limited to a battery as will be appreciated by those of ordinary skill in the art, may be provided within the outer body 24 for providing power to one or more of the light generators 26, transducers 32, transmitters 34, or receivers if power for any or all of these is not provided via wired connection. Alternatively, power (and signals) for one or more of these may be provided via line 30 or other line.
An applicator (not shown) may be provided for providing (e.g., applying) the imaging or contrasting agent to the patient's teeth and/or gingiva or periodontium. The applicator may be, for instance, a container (e.g., a bottle) holding the imaging agent, a syringe, a pipette, a tray (e.g., fitted or formed to fit the dental arch or the teeth to be measured), or any injection device. If the imaging or contrasting agent is provided, for instance, in a mouth rinse, the applicator may simply be a container holding the mouth rinse (and optionally a dispenser).
In an example operation as shown in
Particular embodiments of the invention will be further described with reference to the examples described herein; however, it is to be understood that the invention is not limited to such examples.
This example demonstrates that exemplary methods and products of manufacture as provided herein are effective for measuring and high-spatial resolution imaging of periodontal tissues, including periodontal pockets, including high-spatial resolution imaging to image and measure probing depths of periodontal pockets. Photoacoustic (PA) imaging is used in tandem with an imaging agent, e.g., a food-grade oral rinse, to estimate probing depths in a porcine model, and the results were compared with a gold standard periodontal probe. The results demonstrate that photoacoustic imaging can be a complementary tool for the dental community to image pockets and measure probe depth noninvasively.
Photoacoustic ultrasound is used for high-spatial resolution imaging of probing depths. Photoacoustic imaging is a hybrid imaging modality that combines visible and near infrared excitation with acoustic detection (Wang and Hu 2012). It extends the utility of ultrasound by enabling contrast based on optical absorption (Beard 2011). Traditional ultrasound operates under the principle of “sound in, sound out”, but photoacoustic imaging shifts this concept to “light in, sound out” (Zackrisson et al. 2014).
Here, a near infrared laser excites a light-absorbing target. The target then undergoes spatially confined heating followed by thermoelastic expansion. This generates wideband acoustic waves that can be detected with high frequency ultrasound transducers for image generation. Photoacoustic imaging has been largely investigated for monitoring disease states, therapies, and image-guided surgeries (Mallidi et al. 2011; Emelianov et al. 2009). Though photoacoustic-ultrasound (PA-US) signal can be limited by tissue penetration, it has two significant advantages over radiography, the most common dental imaging modality (Vandenberghe et al. 2010): (1) it can image soft and hard tissue alike; and (2) it does not use ionizing radiation.
Specific contrast from dental pockets was achieved with food-grade cuttlefish ink as a contrast medium. Here, 39 porcine teeth (12 teeth with artificially deeper pockets) were treated with the contrast agent, and the probing depths were measured with novel photoacoustic imaging and a Williams periodontal probe. There were statistically significant differences between the 2 measurement approaches for distal, lingual, and buccal sites but not mesial. Bland-Altman analysis revealed that all bias values were <±0.25 mm, and the coefficients of variation for 5 replicates were <11%. The photoacoustic imaging approach also offered 0.01-mm precision and could cover the entire pocket, as opposed to the probe-based approach, which is limited to only a few sites. This demonstrates the use of photoacoustic imaging for probing depth measurements with applications to the dental field, including use as tools for automated dental examinations or noninvasive examinations.
Cuttlefish ink A was obtained from Conservas de Cambados, and ink B was obtained from Nortindal. Both contained cuttlefish ink, water, salt, and sodium carboxymethyl cellulose as a thickener. Cornstarch was purchased from a local food store. Porcine heads were purchased from a local butcher. Agarose was purchased from Life Technologies. India ink solution 0.2% in phosphate-buffered saline (PBS) buffer was purchased from Thermo Fisher Scientific. Intralipid 20% and PBS tablets were purchased from Sigma-Aldrich. Polyethylene tubing (outside diameter: 1.27 mm, inside diameter: 0.85 mm) was purchased from Harvard Apparatus.
Transmission electron microscopy (TEM) images were performed with a JEOL JEM-1200-EX II™ operating at 80 kV. The absorbance spectra were measured with a SPECTRAMAX M5™ spectrophotometer. The hydrodynamic radius was measured with a Zetasizer from Malvern via dynamic light scattering. The photoacoustic images were performed with a Vevo LAZR™ imaging system (Visualsonics) equipped with a 21 or 40 MHz—centered transducer as described previously (Ho et al. 2015; Wang et al. 2016).
To measure absorbance and photoacoustic spectra, 50% ink A (weight per volume) and 10% ink B (weight per volume) were prepared with 0.1M PBS solution, sonicated for 1 h, and further diluted. Ink A was diluted 50-fold and ink B, 10-fold, with 0.1M PBS solution to make a 1% solution. These samples were used for absorbance measurements; 1% solutions were made for photoacoustic spectral analysis. Corn starch (0.04 g) and ink A (0.04, 0.2, and 0.4 mL) were mixed in 0.1M PBS and boiled to prepare 2 mL of cornstarch-enhanced contrast agent. The pH of freshly prepared contrast agent with 2% cornstarch and 5% cuttlefish ink was 7.4. This was adjusted to pH 6.2, 6.6, 7.0, and 7.8 with 6N HCL and/or NaOH. Samples were placed in tubing for photoacoustic imaging.
A stock solution of ink A was diluted into 1% in Millipore water, sonicated for 1 h, and centrifuged at 5,000 g for 15 min (Chen et al. 2009). The supernatant was removed, and the pellet was resuspended in Millipore water. This was repeated 6 times, and the resulting pellet was suspended in pure ethanol for TEM imaging or PBS for dynamic light scattering.
The tissue-mimicking phantom was prepared with 0.5% (weight per volume [w/v]) ultrapure agarose solution, approximately 50% (volume per volume) India ink as the absorber, and 0.5% (w/v) Intralipid 20% as the scatter (Hanli et al. 1995; Nagarajan and Zhang 2011). These were prepared in 1% (w/v) ultrapure agarose. A custom phantom was used to measure penetration depth (Arconada-Alvarez et al. 2017).
Frozen porcine heads were sliced sagittally with a band saw. The lower jaw was removed with a handsaw; soft tissues surrounding the jaw were dissected with a scalpel. Artificial deeper pockets were created with scalpels (Dynarex) to simulate periodontal lesions. The scalpel was applied parallel to the tooth with intrasulcular incisions until the scalpel contacted the bone (Weidmann et al. 2014). The contrast agent was pipetted onto the gingival line, and excess was rinsed with a syringe and 5 mL of deionized water. The jaw was immobilized in water for ultrasound coupling and imaged with a Vevo LAZR.
To test the signal stability, 1 molar of the mandible was rinsed 5 times with water after labeling. The jaw was imaged after each rinse to observe the photoacoustic signal. The tooth was then brushed for about 1 min without toothpaste after the final rinse. This study was expanded to 13 molars. For each, the tooth was labeled, imaged, and brushed 5 times to calculate a coefficient of variation for the probing depth.
The probing depth was measured with a Williams probe following the direction of the tooth root (Mayfield et al. 1996) before photoacoustic imaging. The same examiner measured the periodontal probing depths with photoacoustic imaging and a Williams periodontal probe (Listgarten 1980). The Williams probe was marked at 1, 2, 3, 5, 7, 9, and 10 mm. In the maxilla, the probing depths were recorded at 4 sites per tooth: the mesial and distal sites of the tooth as well as 2 buccal locations below the anterior and posterior cusps of maxillary molar and fourth premolar. In the mandible, probing depths were recorded on the mesial and distal ends of the tooth as well as at 2 lingual locations below the anterior and posterior cusps of the mandibular molar, as described in more detail below.
The gingival thickness values were measured with ultrasound imaging and compared with values collected with a needle and dental gauge analogous to methods with the UNC-15 and No. 25 K-file instruments (Vandana and Savitha 2005; Slak et al. 2015). Here, for each tooth, the measurement points were 2 mm below the gingival margin. A 28-gauge needle was then inserted perpendicularly into gingiva until it made contact with the tooth. A line was then drawn on the needle where it made contact with the gingiva. After removal of the needle, the distance between the marked location and the tip of the needle was measured with dental gauge (0.1-mm precision).
Typical imaging conditions included 100% laser energy; typical gains were 20 dB for photoacoustic and 10 dB for ultra-sound. Photoacoustic spectra were collected from 680 to 970 nm. Porcine jaws were aligned parallel to the 40-MHz transducer and scanned from the crown to the root. The 3-dimensional scans were performed by oscillating between 680- and 800-nm excitation. All 3-dimensional images were processed as a maximum intensity projection.
Photoacoustic data were analyzed with ImageJ 1.48 (Abramoff et al. 2004). The intensity of each tube was measured in 8 regions of interest for statistical analysis. To discriminate the photoacoustic signal from stains and contrast agent, data at both was collected 680 and 800 nm. The image at 680 nm was subtracted from the one at 800 nm excitation. The resulting pixels were coded blue. These blue pixels were overlaid on the original image created with 680-nm excitation that had already been coded red. Only 680-nm excitation was used to image stain in the absence of contrast agent. The periodontal probing depths were measured on the sagittal view of 3-dimensional images with the Vevo LAB software.
The mean, standard deviation, Bland-Altman plots, and coefficient of variation (CV) were based on GraphPad Prism 5 (Bland and Altman 1986). All error bars represent the standard deviation. Here, P<0.05 was considered significant.
TEM (
Next, the probing depth was measured with imaging and a Williams probe (
Photoacoustic data was compared with Williams probe data via a paired t test. There was no significant difference for the mesial data, but the distal and lingual/buccal groups were significantly different (P<0.05). The distal and mesial pockets were underestimated by photoacoustics, but the lingual and buccal sites were overestimated with photoacoustics relative to periodontal probe. The combined lingual/buccal groups were also divided into lingual only and buccal only. These also showed a significant difference (P<0.05). Thus, these data were further quantified via Bland-Altman analysis.
Bland-Altman plots show that 95% of the samples fell within 1.96 standard deviations of the differences between the 2 methods (95% confidence interval [95% CI]) at mesial, lingual and buccal, and distal locations (
Additional experiments were conducted to more carefully evaluate consistency of probing (
The gingival thickness measured with ultrasound imaging and with a needle for 45 teeth is 1.40±0.25 mm and 1.33±0.28 mm, respectively. The Bland-Altman plot (
These experiments demonstrate the use of photoacoustic imaging with the melanin nanoparticles in cuttlefish ink as a contrast agent for noninvasive measurements of probing depths. Melanin has broad optical absorption for photoacoustic imaging (Viator et al. 2004). It is a common foodstuff with no safety concerns (Chaitanya 2014). The pH of saliva can range from 6.2 to 7.4 (Schipper et al. 2007), but this contrast agent has good signal stability regardless of pH (
Porcine teeth often have yellow-brown stains with background photoacoustic signal, but this could be spectrally discriminated from the squid ink contrast agent (
One other issue with porcine models is the small probing depths relative to human subjects (2 to 3 mm, healthy; 4 to 5 mm with gingivitis; Wang et al. 2007). Most pockets were <3 mm, and only 10% of teeth had pockets>3 mm; thus, we created 12 deeper pockets were created and repeated the imaging and depth measurements were repeated. These are shown as squares in
Despite these challenges, the example photoacoustic imaging methods offer much more precise and continuous data on probing depths. In the clinic, probing depths are recorded at only 6 sites per tooth.
The spatial resolution of the 40-MHz transducer is 100 μm by ultrasound and approximately 300 μm in photoacoustic mode. Thus, this approach offers more precision among different depths as opposed to the Williams probe, which rounds to the nearest millimeter. This may have utility in monitoring/predicting therapy where small changes can have significant implications (Fiorellini 2016). The photoacoustic approach had a positive bias in lingual and buccal locations perhaps because they were more easily aligned beneath the transducer (
The experiments disclosed above demonstrate that probing depths could be measured with photoacoustic imaging. Values that were achieved with this novel technique agreed nicely with the gold standard periodontal probe approach but were more precise, offered higher resolution images, and covered all areas of the tooth. The gingival thickness could also be easily measured.
It is also contemplated to use models of periodontal disease as well as automated algorithms to collect and process the data. Further, it is contemplated to use LED-based systems for reducing cost and complexity.
In an example method according to another embodiment, photoacoustic-ultrasound was used to image both the full depths and geometries of pockets in healthy human adults for non-invasive monitoring of gingival health after local irrigation of the pocket with contrast media.
Cuttlefish ink was purchased from Conservas de Cambados and contained ink, water, salt, and sodium carboxymethyl cellulose. Phosphate-buffered saline tablets were purchased from Sigma-Aldrich. Ultrasound gel was obtained from Next Medical Products. PA-US images were taken with a laser-integrated high frequency ultrasound system from Visualsonics (Vevo LAZR). A medical head immobilizer was purchased from DealMed. Disposable dental cheek retractors were obtained from Url Dental.
Contrast agent solutions were prepared individually from stock solutions of cuttlefish ink for each imaging experiment. Stock cuttlefish ink solutions (50% w/v in 0.1 M PBS) were aliquoted and refrigerated. To prepare the contrast agent, an aliquot was diluted and mixed with corn starch to a final solution containing 5% ink w/v and 2% corn starch. It was briefly heated to boiling to achieve homogeneity. The spherical melanin nanoparticles within the contrast agent were previously characterized with transmission electron microscopy, which indicated a mean particle size of 125 nm from 500 nanoparticles; and dynamic light scattering, which showed a hydrodynamic radius of 266 nm with a polydispersity index of 0.116 (Lin et al. 2017).
An experiment enrolled one 22-year old adult female with good oral hygiene. All work with human subjects was approved by the UCSD Institutional Review Board (170912) and conducted according to IRB guidelines. The participant gave written informed consent and teeth 7-10, 22-27 were imaged.
Pockets were measured with the Williams and Marquis probes (D. et al. 1997) by a licensed periodontist. The measurements were performed at the distobuccal, mesiobuccal, and buccal sites according to clinical convention (Savage et al. 2009). For distal and mesial measurements, the probe was inserted at a 10□ angle at the interproximal space between adjacent teeth. The buccal measurements were collected at the deepest point observed after walking the probe across the width of the pocket. Per standard clinical practice, measurements were rounded up to the nearest integer. For the Williams probe, all measurements<2 mm were recorded as 2 mm. For the Marquis probe, readings within the 3 mm intervals were estimated to be either in the lower 1.5 mm or upper 1.5 mm range and then rounded up to the nearest integer.
The subgingival pockets were labelled with ˜8 μL of contrast agent per tooth. A micropipette with a sterile 2-20 μL tip was placed in contact with the gingival sulcus and used to irrigate the region with contrast agent. Following imaging, the contrast agent was removed from the pockets by rinsing the mouth with water or gentle tooth brushing (<10 s).
Photoacoustic imaging was performed by pulsing light through two optical fiber bundles integrated with both sides of a rectangular, linear array transducer. The laser excitation (Q-switched Nd:YAG) used 5 ns pulses at 20 Hz (6 Hz frame rate). The ultrasound resolution was controlled by changing between three transducers:
This invention was made with government support under grant nos. DP2 HL 137187 and S10 OD021821. The government has certain rights in the invention. LZ-201 (center frequency=16 MHz), LZ-250 (center frequency=21 MHz), and LZ-550 (center frequency=40 MHz). Typical gains were 15 dB for photoacoustic signal and 10 dB for ultrasound. The human subject was seated in front of the imaging system and instructed to rest their chin on a flat surface in front of the transducer. Dental cheek retractors and a medical head immobilizer minimized vibrations that could perturb the imaging results. A layer of ultrasound gel was applied to the transducer, which was adjusted to 1 cm from the tooth. The 680 nm laser was initialized, and the stepper motor was scanned 17 mm (0.076 mm step size) to obtain a 3D PA-US image via maximum intensity projection (Fishman et al. 2006).
Following raw data acquisition, sagittal cross-sections were examined in Vevo Lab software to determine the penetration of contrast agent and quantify pocket depths. From this view, the PA signal from the contrast agent could be traced from the gingival margin to its subgingival terminus. The pixel density of every image was standardized to the same physical dimensions, which allowed a line to be drawn parallel to the PA signal. This line represented the pocket depth and its magnitude was the pocket measurement.
To avoid bias during quantitative comparison to physical probing, sagittal planes were chosen the same way each time: for distobuccal and mesiobuccal sites, we chose the first 8 sagittal planes (0.6 mm-wide sections) with a measurable pocket depth on each lateral side of the tooth. These sections mimicked the diameters of the physical probes. For the buccal sites, 0.6 mm-wide sections were selected from the images at the deepest part of the pocket. This dimension mimicked the diameter of the physical probes and the typical procedure of recording the lowest number obtained by walking the probe across the pocket width. For replicate measurements, images were collected on nonconsecutive days across two weeks.
The buccal contours of the pocket geometry were mapped by averaging five separate imaging events. The width of the pocket consisted of dozens of sagittal planes. For each plane, two measurements were taken: the distance from the crown of the tooth to the gingival margin, and the distance from the gingival margin to the edge of photoacoustic signal (the pocket depth). Together, these measurements determined the top and bottom of the pocket for that plane. Once these measurements were taken for all planes, they were used to reconstruct a full map of the pocket to overlap on top of the ultrasound image.
High-Resolution Ultrasound Imaging of Teeth and Soft Tissues Photoacoustic and ultrasound images were collected by adapting a commercial PA-US system for human operation (
Increasing the ultrasound transducer frequency (
The contrast agent possessed broad photoacoustic absorption from 680 to 970 nm due to the presence of melanin nanoparticles (Fan et al. 2014; Lin et al. 2017). Following administration of contrast agent, PA-US images were collected, and the 680-nm signal was overlaid on ultrasound to measure the periodontal pocket depths. Frontal and sagittal views of the lower central incisors in
To demonstrate reproducibility, five independent replicates were conducted by performing the entire labelling and imaging procedure from start to finish on different days. In
The pocket depth could be determined for a single plane, a region of planes, or the full buccal width of the pocket. The distance between each plane was 0.076 mm, corresponding to roughly 50-120 measurements per tooth.
The persistence of contrast agent in the pockets was evaluated following oral rinses with water as well as brushing (
Finally, the pocket measurements were compared with the gold standard (Williams and Marquis) probes. The lowest possible measurement from the probes, as determined by a periodontist, was 2 mm (any lower values were rounded up); this value was recorded for the buccal pockets of teeth 24 and 25 with both probes. 1.34 mm and 1.15 mm (n=5) were measured for teeth numbers 24 and 25 with PA-US, respectively, which agreed with the gold standard measurements while providing more precision.
This experiment illustrates a new application of PA imaging for monitoring dental and periodontal health in humans by using a food-grade contrast agent. An example technique is ideal for imaging periodontal pockets, gingival thickness, and the interface between hard and soft tissues. It was determined that a 40 MHz ultrasound frequency provided sufficient resolution for discerning these features without sacrificing the requisite penetration depth. The US-only mode is particularly suited for applications that require knowledge of how a tooth is situated within the gingiva-one potential example would be diagnosis and monitoring of patients with delayed tooth eruption (Suri et al. 2004).
The flow of contrast agent into the gingival sulcus allowed the imaging and measurement of pocket depths. It was common for the agent to coat the majority of the tooth surface even when it was locally administered to the gingival margin (
The PA imaging technique is highly reproducible (
It was observed that contrast agent could be easily removed from the gingival sulcus after imaging (
There were some limitations in this study. Due to the size of the PA-US transducer, only anterior teeth could be imaged. In principle, all 32 teeth and the periodontium can be imaged with this technique but the geometry of our PA-US transducer physically limited access. Fortunately, several groups have reported custom transducer geometries; a similar approach could overcome this limitation (Bell et al. 2014; Yang et al. 2015). The subject of the study had good oral hygiene and did not have deep (>4 mm) pockets indicative of periodontal disease. However, Example 1, above, further demonstrates that deep pockets could be imaged in swine, a good model of the human gingiva (Wang et al. 2007). Finally, because the periodontal pocket is a dynamic structure, imaging and probing across different days may have contributed to small variations in measurements.
This example shows an illustrative method of using photoacoustic imaging as a tool for measuring blood oxygen saturation in the gingiva. To collect the imaging data, a 40 MHz ultrasound transducer equipped with a near-infrared laser was placed over the lower central incisors of rabbits. A breathing mask was placed over the nose of the rabbits and the percent oxygen of the air was controlled.
A number of embodiments of the invention have been described. Nevertheless, it can be understood that various modifications may be made without departing from the spirit and scope of the invention. Accordingly, other embodiments are within the scope of the following claims.
This Patent Convention Treaty (PCT) International Application claims the benefit of priority to U.S. Provisional Application Serial No. (USSN) 62/561,965, Sep. 22, 2017. The aforementioned application is expressly incorporated herein by reference in its entirety and for all purposes.
This invention was made with government support under grant nos. DP2 HL 137187 and S10 OD021821. The government has certain rights in the invention.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/US2018/052270 | 9/21/2018 | WO | 00 |
| Number | Date | Country | |
|---|---|---|---|
| 62561965 | Sep 2017 | US |
