118raspadores ultrasonicos2.pdf

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CLINICAL AND RESEARCH REPORTS

Periodontal Debridement with Sonic and Ultrasonic Scalers

Gregor J. Petersilka, Thomas F. Flemmig

Biofilm and calculus removal are very important components of periodontal therapy, and a vari-ety of instruments may be used for debridement purposes. In recent years, the application rangeof sonic and ultra sonic scalers in such debridement procedures has been extended to the sub-gingival area as slim instrument tips allowing good access to the root surfaces have been devel-oped. Treatment using oscillating scalers offers greater patient and operator comfort, and theirtreatment outcomes may be as successful as with hand instruments. However, a thorough knowl-edge of instrument function and profound clinical skills are necessary to allow safe, efficientapplication of these instruments.

Key words: periodontal therapy, root surface debridement, sonic scaler, ultrasonic scaler, handinstrumentation, clinical results, operating systematics

INTRODUCTION

The development of narrow, delicate instrument tipshas significantly extended the application range ofsonic and ultrasonic scalers (Fig. 1).The relativelylarge, bulky instrument tips of ultrasonic scalers pre-viously limited the application range of these instru-ments to the supragingival area. Today, however,plaque and calculus can be removed efficientlyeven from deep and narrow pockets with power-driven instruments (Petersilka et al, 2002). Apartfrom enhancing patient comfort, ultrasonic andsonic scalers can now be used as an alternative tothe more complicated and tiring handling of handinstruments in most cases. A critical comparison ofclinical studies reveals that the therapeutic resultsobtained with oscillating scalers are equivalent tothose of hand instrumentation (Tunkel et al, 2002).Nevertheless, power-driven instruments have to beapplied with special care to avoid unnecessarydamage to the hard tissue of the treated roots.

Oscillating scalers are used at various stages ofperiodontal therapy and as with hand instru-ments the objectives of debridement may varyfrom case to case. During initial therapy, a moreefficient instrument should enable fast removal ofthe sometimes larger amounts of calculus that arefirmly attached to the tooth surface. During thesubsequent periodontal maintenance therapy,however, the main aim is to remove the supra-and subgingival biofilm, taking great care to min-imize any damage to the hard and soft tissue.This takes into account that a patient presentingregularly for maintenance therapy will have onlysmall amounts of supragingival calculus and nonew subgingival calculus formation. In bothmodes of periodontal therapy, however, a thor-ough knowledge of the functioning of oscillatingscalers, the correct application technique, andcompliance with consistent working systematicsare prerequisites for their safe, efficient clinicalapplication.

Sonic und ultrasonic scalers

In sonic scalers (e.g., Sirona Siroair, KaVoSonicflex, W&H Synea Handpiece), the air pres-sure from the turbine flange of the dental unit is usedto generate high frequency vibrations between 6and 8 kHz (Fig. 2). For this purpose, a pivoted hol-low cylinder within the handpiece of the sonicscaler is made to rotate by the air flow, and theresulting vibrations are conveyed to the instrumenttip. The scaler tip vibrates almost circularly with anamplitude of ca. 60 to 1000 m, depending on

the brand (Figs 3 and 4) (Menne et al, 1994). Inrecently developed sonic scalers, the amplitude ofthe vibrations of the tip can be modified and repro-duced accordingly by adjusting the power on thehandpiece. In addition, the vibration mode can beinfluenced by adjusting the turbine air pressure.Regardless of the position of the instrument tip inrelation to the tooth, i.e., mesial, distal, buccal, orlingual, calculus is removed by localized hammer-ing motions of the working end, which may be con-sidered a potential advantage of sonic scalers overultrasonic scalers (Fig. 5).

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Petersilka and Flemmig Periodontal Debridement with Sonic and Ultrasonic Scalers

Fig. 1 Narrow, delicate scalertips enable efficient periodontaldebridement (from left to right: peri-odontal probe, 3A probe, ultrason-ic scaler tip).

Fig. 2 Customary sonic and ultra-sonic scalers (from top to bottom:sonic scaler, insert for magne-tostrictive ultrasonic scaler withstack of metal strips, insert for mag-netostrictive ultrasonic scaler withferrite rod, piezoelectric ultrasonicscaler).

Fig. 3 Circular vibration pattern ofan oscillating sonic scaler tip underundamped conditions (magnifica-tion 40X). With kind permission ofClovis M. Faggion.

Fig. 4 Vibration pattern of anoscillating sonic scaler tip underdamped conditions (1 N dampingat dentin). The circular vibrationpattern found under undampedconditions became polygonal.With kind permission of Clovis M.Faggion.

Fig. 5 Schematic presentation ofthe vibration behavior of oscillatingscaler tips: circular vibration pat-tern of the sonic scaler (left), linearvibration pattern of the piezoelec-tric scaler (middle), ellipsoidalvibration pattern of the magne-tostrictive scaler (right).

The difference between the ultrasonic scalers incurrent use is based on their magnetostrictive orpiezoelectric systems for generating tip oscillation.In magnetostrictive ultrasonic scalers (e.g.,Dentsply Cavitron, Odontoson M, Perio-Select),the vibrations are generated either by stackedmetal strips firmly attached to the instrument tip orby a ferrite rod (Fig. 2). This ferromagnetic materi-al is pushed into the shaft of the handpiece and isthus exposed to a changing magnetic field, caus-ing it to vibrate at high frequency. Depending onthe type of instrument, vibrations ranging from 20to more than 45 kHz are generated, making theinstrument tip vibrate in circular or ellipsoidal pat-tern with an amplitude of up to ca. 100 m(Menne et al, 1994; Trenter et al, 2003; Lea et al,2003). Due to the mostly ellipsoidal, spatial vibra-tions, the instrument tip is unlikely to remove calcu-lus uniformly and actively in all directions.Depending on how the tip is aligned, it either hitsthe tooth surface or passes by; this is an importantcriterion when applying these instruments (s. Fig. 5).In piezoelectric ultrasonic scalers, a quartz crystalis inserted into the interior of the handpiece to gen-erate vibrations (e.g., EMS Piezon Master, SatelecP-Max, and most of the stationary ultrasonic hand-pieces in use at the dental unit (Fig. 2)). The quartzcrystal is provided with high frequency alternatingcurrent and the bipolar structure of the quartz mol-ecules causes it to expand or to contract and thusto vibrate. Depending on the type of instrument,the vibration frequency can reach 20 to 35 kHz.The vibration mode is mostly linear, i.e., on thesame level, at an amplitude of 12 to 72 m(Menne et al, 1994; Lea et al, 2003). It is thusunlikely that all parts of the instrument tip removecalculus to the same extent and, depending on howthe working end is aligned to the tooth surface, thepattern of calculus removal will be a merely ham-mering or scratching one (s. Fig. 5).The Vector (Drr Dental, Bietigheim-Bissingen,Germany) occupies an exceptional position amongthe piezoelectric sonic scalers. According to themanufacturer, it differs from conventional ultrasonicscalers in that the instrument tip vibrates along itslongitudinal axis with an amplitude of ca. 30 mand a frequency of approx. 25 kHz. As the longi-tudinal direction of vibration probably reduces theamplitude and mechanical effect of the workingend of the Vector unit compared with previous ultra-sonic scalers, an abrasive medium (e.g., aqueous

suspension of hydroxyapatite crystals) should beadded to the irrigation fluid for compensation. Thus,calculus removal could be achieved by mechanicalinteraction of the crystals in the abrasive mediumcaused to flow laminarly by the vibration of theinstrument tip - a technical procedure resembling so-called lapping (Braun et al, 2003). All ultrasonic scaler systems allow power adjust-ment directly at the unit, thus entailing a change inamplitude but not in frequency. In sonic scalers,both the frequency and the amplitude of the instru-ment tip vibration are influenced by the air pressure.

Efficiency of and damage by hand instrumentsand oscillating scalers

The amount of calculus to be removed and thus thehandling of any instrument used in periodontaltherapy must be adjusted to the individual treat-ment need, with substance loss being avoided asfar as possible. Especially during repeatedly per-formed periodontal maintenance therapy, evenminor damage to the root surfaces can accumu-late over time to form deep defects. The mode ofcalculus removal with hand instruments has beenextensively investigated. Defects resulting from theuse of hand instruments - a sharp-edged instrumentand its correct angulation are essential - dependon the number of tractions and the applied force,and can thus be easily regulated by the operator(fig. 6) (Kaya et al, 1995; Zappa et al, 1991).The working parameters time, force, angle, andinstrument adjustment are the crucial factors for thecorrect application of sonic and ultrasonic scalersin the various forms of therapy, i.e., initial therapyand supportive periodontal therapy, so that thesafety and efficiency of calculus removal may varyconsiderably. In vitro investigations have providedmore detailed information on the impact of com-binations of various working parameters in partic-ular. For this purpose, extracted teeth were treatedwith sonic and ultrasonic scalers under standard-ized conditions with a combination of variousparameters being applied, and the amount of cal-culus removed was quantified. Subsequently, therelative influence of various parameters on theamount of calculus removed was determined bymultiple regression analysis (Flemmig et al, 1997;Flemmig et al, 1998a; Flemmig et al, 1998b).The investigation of the sonic scaler (Sonicflex withperio tip no. 8; KaVo, Biberach, Germany) showed

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that surface pressure and angulation of the scalertip had the same influence. This means that theinstrument can be applied gently when the scalertip is aligned almost parallel to the root surface,i.e., at an angle of 0. For all powers between 0.5and 2 N, investigations have shown that theamount of calculus removed from a tooth surfacewithin 40 sec. and within one year of supportiveperiodontal therapy (Badersten et al, 1981;Badersten et al, 1984) remains below the criticalvalue of 50 m (Flemmig et al, 1997) regardingsubstance loss. However, combinations of steeperangulations and greater force result in significantsubstance loss within a short time (Fig. 7, center). Ithas not yet been conclusively determined whetherthe safety and efficiency of the newly developedairscaler handpieces can be regulated and repro-duced by adjusting the instrument power on thehandpiece. The different movement of the investi-gated magnetostrictive ultrasonic scaler (Cavitronwith slim-line tip; Dentsply, Konstanz, Germany)results in a variable amount of substance removal.The influence of angulation and surface pressure isabout the same; at all settings, steeper angulationcombined with increased lateral force in vitro soonleads to deep defects, even to perforations into theroot canal (Fig. 7, left). In contrast, a higher powersetting on the instrument does not cause such a pro-nounced increase in defect depths. Nevertheless,to avoid exceeding the critical value of 50 m, thepower setting on the instrument must be low tomedium, and absolutely parallel angulation of the

instrument tip as well as low force (

gains and pocket probing depth reductions can beobtained after subgingival scaling with sonic andultrasonic as well as with hand instruments (Tunkel etal, 2002) (Tables 1 and 2). Regarding the effi-ciency of calculus removal in furcations of multi-root-ed teeth, sonic and ultrasonic scalers allow formore efficient cleaning than hand instruments(Kocher et al, 1998; Loos et al, 1987). As com-bining both instrumentation modes is unlikely tolead to better clinical results, one single instrumen-tation mode must be generally considered suffi-

cient. In an interesting and critical review, the use ofoscillating scalers proved to save more than 30% oftreatment time compared with hand instrumentation(Tunkel et al, 2002). Nevertheless, up to 8 minutesor more are considered necessary for the debride-ment of a severely periodontally diseased tooth,e.g., during initial therapy (Table 3).The irrigation medium needed to cool the heatedscaler shank reaches the edge of the instrument tipin the pocket, preventing thermal damage to thetooth (subject to a correct evacuation technique).

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Study Treatment Phase Statistical Mean Clinical attachment Gain Analysis based on and Standard Deviation in Milimeters

HI MDDBadersten et al 1981 Initial Therapy Site 0.3 0.5Badersten et al 1984 Initial Therapy Site 0.5 0.2Kocher et al 2001 Initial Therapy Subject 0.531.16 0.711.07Copulos et al 1993 PMT Subject 0.101.71 0.201.34

Table 1 Medium attachment gains after machine-driven debridement (MDD) and hand instrumentation (HI). PMT:Periodontal Maintenance Therapy (References 2, 3, 8, 22, 43).

Study Treatment Phase Statistical Mean Reduction in Pocket Probing DepthAnalysis based on and Standard Deviation in Milimeters

HI MDDBadersten et al 1981 Initial Therapy Site 1 0.5Badersten et al 1984 Initial Therapy Site 1.4 0.2Kocher et al 2001 Initial Therapy Subject 0.770.80 1.100.70Copulos et al 1993 PMT Subject 0.721.09 0.751.20

Table 2 Medium reduction in probing pocket depth after machine-driven debridement (MDD) and hand instrumentation(HI). PMT: Periodontal Maintenance Therapy (References 2, 3, 8, 22, 43).

Study Treatment Phase Instrumentation Time in Minutesand Standard Deviation

HI MDDBadersten et al 1981 Initial Therapy 5.35 6.15Badersten et al 1984 Initial Therapy 6.85 6.85

Dragoo 1992 Initial Therapy 7.55 9.6Laurell & Petterson 1988 Initial Therapy 8.003.00 12.005.00

Moscow & Bressmann 1964 Initial Therapy 3.3 3.8Torfason et al 1979 Initial Therapy 3 3.8Yukna et al 1997 Initial Therapy 2.801.3 4.803.2

Badersten et al 1981 PMT 0.35 0.4Badersten et al 1984 PMT 1.35 1.3Copulos et al 1993 PMT 3.901.20 5.902.10Torfason et al 1979 PMT 2.1 2.4

Table 3 Average time needed for periodontal debridement of a tooth during initial therapy or supportive periodontaltherapy (maintenance). PDD: Power-driven debridement, HI: Hand instrumentation, PMT: Periodontal MaintenanceTherapy (References 2, 3, 8, 9, 24, 30, 41, 43, 46).

Calculus and biofilm components are loosened bythe mechanical action of the tip and are thenflushed away from the periodontal pocket by thecoolant (Nosal et al, 1991). However, a relevantadditional cleaning effect of the irrigation mediumin the pocket by so-called microstreaming effects oreven an antimicrobial effect on periodontalpathogens by cavitation, i.e., the implosion ofminute gas bubbles at the tip of oscillating scalers,has yet to be proven in vivo (Schenk et al, 2000).The use of special antimicrobial irrigants (e.g.,chlorhexidine or iodine solutions) as an adjunctiveirrigation medium for sonic and ultrasonic scalersdoes not lead to a clinically better treatment out-come (Chapple et al, 1992; Taggart et al, 1990).Therefore, water can be recommended as acoolant. Regarding the safety of oscillating scalers,it must be kept in mind that sonic or ultrasonicscalers produce a potentially infective aerosol con-sisting of disrupted biofilm, blood, saliva, andcoolant. Antiseptic mouthrinsing prior to therapy(e.g., with chlorhexidine digluconate solution orListerine) as well as the correct use of high volumeevacuators can substantially reduce the bacterialcounts in the aerosol. However, a possible infectionrisk for the operator cannot be completely ruled out(Barnes, 1998). For this reason, a face mask andgloves in addition to well-fitting safety glassesshould be worn when using high frequency oscil-lating instruments. In the treatment of patients withinfectious diseases, preference should be given tothe use of hand instruments (Barnes, 1998).The results of numerous studies investigating the sur-face structure of the root after different instrumenta-tion modes were partially discrepant. Depending onthe type of study, smoother surfaces were found afterhand instrumentation (Allen, 1963; Jones et al,1972; Kerry, 1967; Rosenberg and Ash, 1974;Van Vulkinburg, 1976) or after the use of ultrasonicinstruments (Ewen et al, 1976; Moskow andBressman, 1964; Pameijer et al, 1972). In onecase, the surface morphology was found to be thesame for both instrumentation modes (Lie andMeyer, 1977), and smoother (Kocher et al,2001a), equally rough, (Loos et al, 1987) orrougher surfaces were each found once for sonicscalers compared with ultrasonic instrumentation(Van Volkinburg, 1976; Jotikasthira et al, 1992). Asthe roughness of the root surface appears to be oflittle significance for periodontal healing(Oberholzer et al, 1996; Waerhaugh, 1956), the

surface morphology is of minor importance only,provided no substantial substance loss is induced atthe root surface by overinstrumentation.In terms of maximum instrumentation depth, smallerultrasonic scaler shafts seem to produce slightly bet-ter results compared with hand instruments (Dragoo,1992; Kawanami et al, 1988). Sonic and ultra-sonic scalers are clearly superior to hand instrumentswith regard to furcation instrumentation (Leon andVogel, 1987). Anatomical studies have shown thatthe access to furcations is mostly much smaller thanthe average width of the working end of hand instru-ments, (Bower, 1979) but that thin sonic or ultrason-ic tips might succeed. Modern inserts for sonic andultrasonic instruments are of the same dimension asthose of periodontal probes, i.e., they are muchsmaller than conventional hand instruments. In addi-tion, sonic and ultrasonic scalers need much lessspace for efficient working than do the tractionsneeded with hand instruments. For this reason, itappears easier to debride relatively inaccessible fur-cations with these modern instruments (Oda andIshikawa, 1989). It is much more comfortable andless tiring for the operator to work with power-driveninstruments, and most patients consider treatmentwith high frequency oscillating instruments to bemore comfortable Hartley et al, 1959). However,the successful and safe application of sonic andultrasonic instrumentation is subject to adequatetraining and experience as well as to observance ofconsistent working systematics guaranteeing com-plete instrumentation of all root areas in need of ther-apy (Kocher et al, 1997; Kocher et al, 1998).

Sonic and ultrasonic scaling technique

The application technique of sonic and ultrasonicscalers is fundamentally different from hand instru-mentation. In most cases, efficient debridement canbe achieved with contra-angularly curved scalertips which are used for various areas of the oralcavity (Fig. 8). The respective tip is aligned to thetooth in such a way that the convex working end isin principle guaranteed to contact the root surface(Figs. 9, 10 and 11). Thus, damage caused byscratching and hitting the root surface with the edgeof the tip can be avoided. The angulation in thesecond level of the area permits access to the rootareas despite any crown prominences. The scalertip is aligned correctly when its curvature is direct-ed towards the tooth being treated (Fig. 12).

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In clinical practice, the morphology and dimensionof the gingival pocket should first be determined bycareful, probing-like movements of the working end.The root surface is then cleaned systematically bycontinuously moving the scaler tip and performingserpentine-like, overlapping tractions (Fig. 13 andFigs. 14-17). If calculus is to be removed during ini-tial therapy, the efficiency of the instrument can beregulated individually by selecting adequate param-eter combinations. For almost exclusive biofilmremoval during supportive periodontal therapy,unnecessary substance loss should be avoided as faras possible by applying a force of less than 1 N,aligning the instrument tip largely parallel to thetooth, and selecting a lower power setting (Flemmiget al, 1997; Flemmig et al, 1998a; Flemmig et al,1998b). Supragingivally, the irrigation effect of thecoolant often leads to an optically clean appearanceafter a short treatment time. Subgingivally, however,there will still be biofilm or calculus left in the event ofunsystematic handling. As only the front edge of thescaler tip (generally ca. 1-2 mm) actively removes thebiofilm or hard accretion, thorough and systematicsubgingival instrumentation is of great importance.Root surface debridement with any instrumentationtechnique is complete when a tactilely and visibly

clean root surface is obtained. This can be checkedwith a probe and with the air flow of the air-watersyringe of the dental unit.

Working systematics

According to the shape of the currently used instru-ment tips, a complete dentition is divided into fourareas (Fig. 18). If the tip is aligned with the correctangulation, the buccal and interdental surfaces ofthe first quadrant can be treated from the most distalmolar to tooth 13; the same tip is used for thepalatal surfaces from the canine to the last molar ofthe second quadrant (red line in Fig. 18). Beforechanging the instrument tips, the interproximalspaces can be treated efficiently from the palatalaspect with the tip initially used for the buccal sur-faces, and the interdental surfaces of the teeth ini-tially cleaned from the palatal side can be treatedfrom the buccal aspect (see arrows in Fig. 18). Aftera change of instrument tips, the contralateral sur-faces can first be treated from the palatal and buc-cal aspect and then from the interproximal space. Ifthese systematics are observed and actually per-formed, thorough cleaning of all root surfacesshould be ensured.

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Fig. 8 Contra-angu-larly curved instru-ment tip (EMS,Nyon, Switzerland)for efficient debride-ment of the totaldentition.

Fig. 9 The instrument tip is correct-ly aligned when the curvature isdirected towards the tooth to betreated (e.g., left-curved tip to beused in the first quadrant from thebuccal aspect).

Fig. 10 Possibilities forcorrect scaler tip align-ment: The convex side ofthe shank is aligned par-allel to the tooth surfaceand to the tooth axis,avoiding merely puncti-form contact of the tipwith the root.

Fig. 11 In addition, thesame instrument tip (seeFig. 10) can be insertedtransversely or horizontallyinto the interproximal areafrom the opposite side.However, the tip also hasto be directed parallel tothe treated root surface inorder to prevent damageto the surface.

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Fig. 12 Schematic presentation of possible correctalignment techniques for ultrasonic scaler tips parallel(right) and transverse (left) to the longitudinal root axis.

Fig. 13 Various working systematics in hand instrumenta-tion and in sonic and ultrasonic scaling. In hand instru-mentation (left) the tractions result in calculus removal fromthe whole surface. The relatively small contact pointbetween scaler tip and tooth surface requires systematiccleaning by many overlapping tractions.

Fig. 14 Clinically, a 7-mm-deep pocket is present atthe mesial surface of tooth 22.

Fig. 15 The instrument tip has been placed on the gin-giva to show the instrumentation depth for demonstrationpurposes.

Fig. 16 The instrument tip has been inserted into thepocket after local anesthesia and the root surface cannow be cleaned as described in the text.

Fig. 17 Four months after nonsurgical therapy, the clini-cal attachment gain and probing pocket depth reductionare as expected.

Remark of the authors:

The present article corresponds to an updated andtranslated version of the publication SubgingivalesDebridement mit Schall- und Ultraschallscalernpublished in Parodontologie (1999; 3; 233-244).

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Fig. 18 Working ranges of con-tra-angularly curved scaler tips. Theworking range of the left-curvedscaler tip is marked in red, andthat of the right-curved instrumenttip in green.

CONCLUSIONS

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Reprint request:PD Dr. Gregor J. Petersilka,Poliklinik fr ParodontologieZentrum fr ZMK des Uniklinikums Mnster,Waldeyerstr. 30, 48149 MnsterE-Mail: [email protected]

362 Perio 2004: Vol 1, Issue 4: 353362


Documents

118raspadores ultrasonicos2.pdf