Hand instruments
Discussion Topics
A. What is the effect on bacteria and endotoxins of root instrumentation with:
a) hand curettes
b) ultrasonic/sonic scalers
c) air/powder abrasives
d) rotary scalers
B. Discuss bacterial reinfection after root planing.
C. Describe the possible healing sequences after root planing and give approximate times for various milestones.
D. What is the role of tartar control toothpastes in maintaining periodontal health?
F. Which tartar control formulas are currently available? Are they effective?
G. What is the physical effect of root surface instrumentation with:
a) hand curettes
b) ultrasonic/sonic scalers
c) air/powder abrasives
d) rotary scalers
H. How important to periodontal success is the goal of a smooth root ?
I. What are the technical and clinical limits of closed root planing?
Molar vs non – molar teeth?
J. Compare the effectiveness of closed vs. open root planning
Endoscopy in root planning
Topic Overview
Greestein G: Periodontal Response to Mechanical and Non-Surgical Therapy: A Review. J Periodontol 63:118-130, 1992
AAP Position Paper: Sonic and ultrasonic scalers in Periodontics. J Periodontol 71: 1792 – 1801, 2000
Greenstein G: Nonsurgical periodontal therapy in 2000: A literature review. J Am Dent Assoc 2000:131:1580-92
Evidence Based Review
Hallmon, W, Rees, T: Local anti-infective therapy: Mechanical and physical approaches. A systematic review. Ann Periodonto, 2003: Dec; 8 (1): 99 – 1144
Suvan, J. Effectiveness of mechanical non-surgical pocket therapy. Periodonto 2000; 2005; 37: 48 – 71
Hand Root Planing – Ultrasonics: Surface Effects
Riffle AB: The cementum during curettage. J. Periodontol. 23:170-180, 1952.
Coldiron NB, et al. A quantitative study of cementum removal with hand curettes. J. Periodontol. 61:293-299, 1990.
Leknes, K et al: Influence of tooth instrumentation roughness on subgingival microbial colonization. J Periodonto 65: 303 – 308, 1994
Kocher T, Plagmann H-C. The diamond-coated sonic scaler tip. Part II. Loss of substance and alteration of root surface texture after different scaling modalities. Int J Perio Rest Dent 17:485-493, 1997.
Yukna RA, Scott JB, Aichelmann-Reidy ME, LeBlanc DM, Mayer ET. Clinical evaluation of the speed and effectivenesss of subgingival calculus removal on single-rooted teeth with diamond -coated ultrasonic tips. J. Periodontol. 1997; 68: 436-444.
Nicoll B, Peters R. Heat generation during ultrasonic instrumentation of dentin as affected by different irrigation methods. J Periodontol 69:884-888, 1998.
Barnes JB, Harrel SK, Rivera-Hidalgo F. Blood contamination of the aerosols produced by in vivo use of ultrasonic scalers. J Periodontol 69:434-438, 1998.
Are Manual and ultrasonic/sonic instrumentation equally capable of improving clinical parameters?
Hand VS Ultrasonics
Nishimine D, O'Leary TJ: Hand instrumentation versus ultrasonics in the removal of endotoxins from root surfaces. J. Periodontol. 50:345-349, 1979.
Drisko C: Root instrumentation. Power-driven versus manual scalers, which one? Dent Clin North Am 1998;42:229-244
Cobb C. Non-surgical pocket therapy: Mechanical. Ann Periodontol 1996;1:443-490
Leon L.,Vogel R. A comparison of the effectiveness of hand scaling and ultrasonic debridement in furcations as evaluated by differential dark – field microscopy. J Periodontol 1987;58:86-94
Croft L., Nunn M., et al. Patient preference for ultrasonic or hand instruments in periodontal maintenance. Int J Periodontics Restorative Dent 2003;23:567-573
Dahiya P et al> Comparative evaluation of hand and power-driven instruments on root surface characteristics: A scanning electron microscopy study. Contemp Clin Dent 2011;2:79-83
Cobb C. Clinical significance of non-surgical periodontal therapy: An evidence based perpective of scaling and root planning. J Clin Periodontol 2002;29suppl 2) :6-16
Effectiveness
Stambaugh R, Dragoo M, et al: The limits of subgingival scaling. Int J Perio Restor Dent 1:30-41, 1981
Rabbani G, Ash MM, Caffesse R: The effectiveness of subgingival scaling and root planing in calculus removal. J. Periodontol. 52:119-123, 1981.
Closed vs. Open Root Planing
A. Non – Molars
Brayer WK, et al. Scaling and root planing effectiveness: The effect of root surface access and operator experience. J. Periodontol. 60:67-72, 1989.
B. Molars
Caffesse RG, Sweeney PL, Smith BA: Scaling and root planing with and without periodontal flap surgery. J. Clin. Periodontol. 13:205-210, 1986.
Fleischer, H, Mellonic J et al: Scaling and root planning efficacy in multirooted teeth. J Periodontol 60: 402-409, 1989
C. In Furcations
Bower R. Furcation morphology relative to periodontal treatment. Furcation entrance architecture. J Periodontol 1979;50:23-27
Parashis, A., et al: Calculus removal from multirooted teeth with and without surgical access. (I) Efficacy on external and furcation surfaces in relation to probing depth. J Clin Periodontol 20:63-68, 1993
Parashis, A et al: Calculus removal from multirooted teethwith and without surgical access (II). Comparisson between external and furcation surfaces and effect of furcation entrance width. J Clin Periodontol 20:294-298, 1993
D. Endoscopy
Michaud, R et al: The efficacy of subgingival calculus removal with endoscopy – aided and root planning : A study on multi rooted teeth. J Perio 2007 (12); 2238 - 2245
Soft Tissue Effects
Waerhaug, J Healing of the dento-epithelial junction following subgingival plaque control II. As observed on extracted teeth. J Periodontol 49: 119 – 134, 1978
Lindhe J, et al: Scaling and root planing in shallow pockets. J Clin Periodontol 9:415-18, 1982
Claffey N, et al: The relative effects of therapy and periodontal disease on loss of probing attachment after root debridement. J Clin Periodontol 15:163- , 1988.
Sherman PR, Hutchens LH, Jewson LG. The effectiveness of subgingival scaling and root planing. II. Clinical responses related to residual calculus. J Periodontol 61:9-15, 1990.
Bacteremia
Lafaurie, G et al: Periodontopathic microorganisms in peripheric blood after scaling and root planning. J Clin Periodontol, 2007;34: 873-879
Clinical and Microbiological Parameters
Renvert, S et al: The clinical and microbiological effects of non-surgical periodontal therapy in smokers and non-smokers. J Clin Peridontol 25: 153 – 157, 1998
Cugini, M., Hafajee, A et al: The effect of scaling and root planning on the clinical and microbiological parameters of periodontal disease. J Clin Periodonto 27: 30 – 36, 2000
Full Mouth Disinfection
Eberhard, J et al. Full – mouth treatment concepts for chronic periodontitis: A systematic review. J Clin Periodontol 2008; 35: 591 – 604
Calculus Control Agents
LeGeros RZ, Rohanizadeh R, Lin S, Mijares D, LeGeros JP, Charles CH, Pan PC. Dental calculus composition following use of essential-oil/ZnCl2 mouthrinse. Am J Dent. 2003 Jun;16(3):155-60
Schiff T.. Anticalculus effect of a cetylpyridinium chloride/zinc gluconate mucoadhesive gel: results of a randomized, double-blind, controlled clinical trial. J Clin Dent. 2007;18(3):79-81
Schiff T, Delgado E, DeVizio W, Proskin HM. A clinical investigation of the efficacy of two dentifrices for the reduction of supragingival calculus formation. J Clin Dent. 2008;19(3):102-5.
Topic Overview
Greenstein 1992 ARTICLE
Keywords: mechanical, non-surgical therapy, oral hygiene, saturn, uranus, neptune,bacterial alteration, molar furcation, endotoxin, histology, maintenance, effectiveness
P: Review “Periodontal response to mechanical non-surgical therapy”
D:
- Effects of oral hygiene – Well proven that elimination of supra AND subgingival bacterial deposits can resolve inflammation and arrest disease progression. Literature shows that removal of supragingival plaque can help resolve inflammation, however hygiene alone has limited effects on periodontal disease (i.e. if you have pockets > 5 mm).
- Effectiveness of nonsurgical SRP – General assumption that closed SRP if pockets exceeding 5 mm is ineffective. Caffesse – showed that 83% of root surfaces were clean in pockets 1-3 mm, 43% in 4-6 mm pockets, and 32% in sites > 6 mm.
- Bacterial alterations – SRP decreases gram negative organisms and spirochetes, and increases gram positive rods and cocci. There is conflicting literature on A.a.
- Molar Furcation – This article stated that molars and nonmolars respond similar to SRP with the exception of the furcation. The anatomy of the furcation provides limited accessability.
- Endotoxin – Endotoxins are routinely found on the root surface –author supports the fact that you don’t need to remove all of the cementum, but understand that endotoxins may reattach.
- Repeated instrumentation – Conflicting results – Caton reports that a single episode of SRP is the same as multiple episodes. Magnusson reduced average probing depths by 1.2 at one visit, then rescaled 16 weeks later, and reduce an additional 1.1 mm.
- When to reevaluate
: Proye – reported a gain in CAL at 3 weeks and saw no additional gain for 3 months
: Morrison – healing takes 4 weeks
: Badersten – gradual decrease in probing over 4-5 months
: Cercek – clinical improvements continue for 8 months
: Conclusion – greatest changes in probing depth and attachment level occur within 4-6 weeks,
but understand that repair and maturation of periodontium may occur up to 1 year
- Histologic healing after SRP – LJE
- Hand instruments vs Ultrasonics – HI results in smoother surface, but time consuming, US - less fatigue, faster, better in furcations, more potential to alter microflora
- Surgical vs nonsurgical –
: In shallow sites – SRP is better and will cause less loss of attachment. Don’t do surgery in
shallow sites.
: In deeper sites – Mixed results – Most studies show that surgery has greater gain of
attachment, but there are some studies that say SRP is just as effective in long term. There
is a high risk of reoccurrence of pockets in surgery patients – so maintenance very important.
- Factors that limit effectiveness
: Length of therapy – should be spending at least 10 minutes per tooth
: Skill level
: Patient compliance
: Maintenance
AAP Position Paper 2000 NO ARTICLE
Keywords: Ultrasonic, sonic scalers, irrigation, cementum
Ultrasonic and sonic scalers appear to attain similar results (reductions in BOP and PD) as hand instruments for removing plaque, calculus, and disrupting subgingival microbiota. And although plaque removal appears to be the same for mechanical vs hand instruments, the lavage needed to keep the power-driven scalers cool has an added flushing effect, as well as the potential cavitation effect on cell walls seen with ultrasonic. Ultrasonic scalers used at medium power seem to produce less root surface damage than hand or sonic scalers. Due to instrument width, furcations and the base of very deep pockets may be more accessible using ultrasonic or sonic scalers than manual scalers. It is not clear whether root surface roughness is more or less pronounced following power-driven scalers or manual scalers. It is also unclear if root surface roughness affects long-term wound healing. Periodontal scaling and root planing includes thorough calculus removal, but complete cementum removal should no longer be a goal of periodontal therapy. Studies have established that endotoxin is weakly adsorbed to the root surface, and can be easily removed with light, overlapping strokes with an ultrasonic scaler. One disadvantage of power-driven instruments is the potential to damage surfaces of restorations, especially porcelain or composite. A significant disadvantage of power-driven scalers is the production of contaminated aerosols. Because ultrasonics and sonics produce aerosols, additional care is required to achieve and maintain good infection control when incorporating these instrumentation techniques into dental practice. (Comment about Hep B and HIV). Preliminary evidence suggests that the addition of certain antimicrobials to the lavage during ultrasonic instrumentation may be of minimal clinical benefit. However, more randomized controlled clinical trials need to be conducted over longer periods of time to better understand the long-term benefits of ultrasonic and sonic debridement.
BL: power driven scalers are at least as good as hand instruments in removing plaque, calculus, and endotoxin, but may have some additional benefits with the irrigation system, thinness of the instrument, and acces to difficult-to-reach areas. Substantial caution needs to be taken around restorations, with the production of aerosols, and in patients that have a pacemaker.
Greenstein 2000 ARTICLE
Keywords: Non-surgical therapy
P: To review periodontal disease, the new classification, pathogenesis, and the efficiency of non-surgical periodontal therapy
D:
- Hand Instrumentation: Cobb (1996) in a thorough review calculated pocket depth reductions of 1.29 mm and 2.16 mm, in 4-6 mm PD and >7 mm respectively, and mean gains of clinical attachment of 0.55 mm and 1.29 mm. (As a rule of thumb, clinicians can expect the gain of clinical attachment to be about half the probing depth reduction). After six weeks, most of the healing has occurred, but repair can continue for an additional nine months. Procedures performed in clinical practice settings may be less thorough than those performed in clinical trials. Furthermore, clinical trials— which often have been cited to show that nonsurgical and surgical therapy achieved equivalent results—usually did not provide a fair comparison with respect to the efficacy of treatment techniques at probing sites that were greater than 6 mm in depth. Caffesse et. al demonstrated that when pockets exceeded 5 mm, clinicians often failed to adequately debride root surfaces and removed deposits completely only 32 percent of the time. Nonsurgical therapy also is not effective in suppressing A.a. In general, mechanical instrumentation has been successful in stabilizing clinical attachment levels for most patients with mild to moderate periodontitis.
- Ultrasonic debridement: Comparable results to hand instrumentation, for example, at sites initially manifesting probing depths greater than 4 mm, the mean probing depth reduction ranged from 1.20 to 2.3 mm after root planing, and from 1.70 to 1.9 mm after ultrasonic debridement. overinstrumentation of the roots, which can cause dentinal hypersensitivity. Furthermore, ultrasonic debridement may result in less chair time and operator fatigue than does manual instrumentation. On the other hand, root planing attains a smoother root surface at the microscopic level than does ultrasonic debridement, but the difference does not appear to have any clinical significance. Chlorhexidine use as an irrigant has not proven useful, where as povidine iodine has shown significant reduction of P.g. One problem associated with ultrasonic instrumentation is the development of aerosols that contain blood and bacteria, Aerosols develop within several feet of the operator and remain in the air for approximately 30 minutes, clinicians should wear a mask, use high-speed suction, and ask patients to use a preprocedural rinse.
- Supragingival irrigation: became most popular in the early 1980’s, it appears to have benefits in decreasing gingival inflammation (6.5-54%) in patients performing less than ideal oral hygiene practices. Standard supragingival tips were shown to deliver water or medicaments up to 3 mm subgingivally, however, a device called Pik Pocket had a subgingival tip, that is placed 1 mm subgingivally, this allowed penetration of 90% of the depth of 6 mm pockets. Some studies have shown that the use of medicaments is better than water, including using 0.02% chlorhexidine to decrease staining. Clinicians should be aware that irrigation is not the best in removing biofilms, do not substitute mechanical cleaning.
- Subgingival irrigation: Eight studies indicated that irrigation did not enhance the therapeutic effect attained with root planing alone. Six other studies noted minimal additional benefit, one studies showed significantly enhanced effect on SRP using 10% TCN as irrigant, but the results were short term and no benefit was found at 6 months.
- Local Drug Delivery: Studies addressing the efficacy of 10% doxycycline hyclate (Atridox, Block Drug Corp.), 25% metronidazole gel (Elyzol, Dumex Ltd. [available in Europe]) and tetracycline impregnated fibers (Actisite, ALZA Corp.) have shown that treatment with these drugs achieved similar results to those achieved with root planing with regard to probing depth reduction (about 1 mm) and gain of clinical attachment. Only PerioChip and Atridox have two device characteristics that are highly desirable: resorbability and controlled release of the drug. Insufficient data exist to suggest that local drug delivery results in less disease progression, and there are no data to indicate that if used, these systems facilitate a longer interval between maintenance visits. Local drug delivery is not effective against tissue-invasive organisms (for example, A.a.). Use of local drug delivery devices as a monotherapy remains controversial, since root planing alone usually achieves a similar result. Furthermore, since equivalent results can be attained without using medications, administration of these drugs as adjuncts to conventional therapy usually is unnecessary. In general, use of local drug delivery devices should be reserved for sites in patients who fail to respond to mechanical instrumentation.
- Systemic Antibiotic Therapy: More than 500 species of bacteria have been identified within periodontal pockets, but only a limited number have been associated with periodontal diseases.
|
Antibiotic |
Dosage |
| Augmentin | 500 mg tid for 8 days |
| Ciprofloxacin | 500 mg bid for 8 days |
| Clindamycin | 150 mg tid for 8 days |
| Doxycycline | 200 mg initially; 100 mg for 7 days |
| Metronidazole | 500 mg tid for 8 days |
| Metronidazole and Amoxicillin with Clavulanic acid | 250 mg tid for 8 days (each drug) |
| Metronidazole and Ciprofloxacin | 500 mg tid for 8 days (each drug) |
| Tetracycline | 500 mg tid for 21 days |
- Host Modulation: 20 mg of Doxycycline hyclate as a collagenase inhibitor (Periostat CollaGenex Pharmaceuticals Inc.) Caton et al. found that adjunctive use of periostat with SRP (nine month duration) has resulted in a small, but statistically significant, clinical improvement over root planing alone, the mean clinical attachment gain at sites with an initial probing depth of 4 to 6 mm had an additional gain of 0.17 mm (0.26 mm in PD). For sites with an initial probing depth of 7 mm or greater, the mean clinical attachment level gain benefit was and additional 0.38 mm. (0.48 mm in PD). Subantimicrobial dosing with doxycycline probably will prove most advantageous in the treatment of patients with refractory or recurrent disease; however, this concept needs to be verified in controlled clinical trials.
Representative Summary of Results:
|
Procedure |
PD reduction (mm) |
Attachment gain (mm) |
Bone fill (mm) |
| OFD | 3.0 | 1.5 | 1.1 |
| DFDBA Graft | 2.5 | 2.1 | 2.2 |
| GTR | 5.2 | 4.2 | 3.2 |
| SRP 4-6 mm PD >7 mm PD |
1.29 2.16 |
0.55 1.29 |
NA |
| TCN Fibers and SRP 4-6 mm PD >7 mm PD |
1.0 2.1 |
1.1 1.2 |
NA |
| Periochip and SRP | 0.95 | 0.65 | NA |
| Atridox | 1.3 | 0.8 | NA |
| Periostat 4-6 mm PD >7 mm PD |
1.03 1.68 |
0.95 1.55 |
NA |
| EMD | 3.1 | 2.2 | 2.6 |
Evidence Based Review of Root Planing
Hallmon 2003 ARTICLE
Keywords: periodontal disease/ therapy, scaling, comparison studies, review literature, outcome assessment
Purpose: Systematic review. Question: “In patients with periodontitis, what is the effect of mechanically –driven (power driven) and/or sub-g irrigation with and without manual instrumentation (MI) compared to manual instrumentation alone?
Materials and methods: MEDLINE, Cochrane and hand searches for articles published to 2002. Only randomized clinical trials, cohort studies, or case-control studies at least 3 months long were included. Study subjects had to be diagnosed with chronic or aggressive periodontitis and be at least 10 years of age. Test therapies for periodontitis were assessed and included manual (hand) instrumentation (MI) which served as the control therapy. Manual instrumentation was compared to mechanically-driven instrumentation (MDI) + water alone, MDI+ manual SRP, MDI +medicaments/agents (CHX, saline, H202), sub-g irrigation (SGI) with medicaments/agents and SGI+MI. Clinical changes in PD, CAL, BOP and gingival recession were recorded. Pt-centered outcome measures included facilitation of maintenance (% of treated sites<4mm), mean time (minutes) to treat a tooth and post-op complications.
Results: 9 studies met the inclusion criteria. 5/9 compared MI to MDI. Remaining 4 studies compared the adjunctive use of sub-g irrigation + MI to MI alone. No significant difference between MI and MDI in BOP, CAL, PD. No additional benefit from SGI.
BL: Comparable results with MI and MDI. No additional benefit from SGI.
Suvan 2005 ARTICLE
Keywords: instrumentation, root maintenance, non-surgical therapy, efficacy
P: Review of systematic reviews on effectiveness of mechanical non-surgical therapy
BL: The reviews demonstrated that mechanical debridement had a positive effect or is efficacious in treatment of periodontal disease, with the exception of sites with >3mm where CAL loss can occur.
Initial therapy: Non-surgical therapy reduces inflammation, PD and increases CAL. Greater PD will have better results, no difference in hand vs machined instrumentation on single rooted teeth.
Maintenance: reduction of inflammation and disruption of biofilm, effect on PD reduction and CAL is unclear, PD decrease and CAL gain have been shown, with maintenance, to remain stable.
Hand Root Planing or Ultrasonics- Surface Effects
Riffle 1952 NO ARTICLE
Keywords: curettage, cementum, cemental necrosis
P: To evaluate the effect on cementum during curettage procedures.
M&M: 500 extracted teeth were root planed with a sharp scraping instrument until they had a hard, glassy smoothness. Each tooth was photographed on each of its 4 surfaces, careful observations of the gross appearance of the cementum in the pathologic crevice recorded and measurements were made buccolingually and mesiodistally before and after SRP. Recordings were made during the procedure as to the character of the surface (soft or hard), whether scrapings were-shavings, flakes, or powder and the difficulty of removal (hard or easy).
R: In general, on younger patients only a few strokes were required to produce a hard glassy surface. In older adults more strokes were required. Observations showed that cementum was removed in its entirety during curettage and that it is impossible to produce a hard, glassy finish without doing so.
Coldiron 1990 ARTICLE
Keywords: curettage, instrument sharpness, tooth root, cementum removal
Purpose: To measure in vitro the depth of root surface removal using a single type of periodontal hand curetted with standardized pressure, sharpness and stroke number.
Materials and methods: 92 teeth extracted for non-periodontal reasons. Teeth had no visible calculus and no known previous therapy.
A pilot study was conducted using 32 teeth to determine the minimum number of strokes necessary to create a measurable surface defect and the maximum number of strokes until sharpening of curette was necessary. Results showed that with 25 strokes of the curette and a mean force of 680 grams a measurable surface defect was created. Also the curettes had to be sharpened every 10 strokes to maintain a standardized sharpness.
Remaining 60 teeth were divided in 6 groups. Following instrumentation teeth were decalcified, sectioned horizontally and 2mm sections were histologically examined. Thickness of cementum adjacent to the defect, remaining cementum, total cementum removed, mean depth of the defect and correlation with the force and number of strokes applied were measured.
Results: Clinical observations: A reflected white line form the curate blade occurred after 12 strokes on the root surface, and sounded sharp and was cutting smoothly at 35 strokes. The experimental forces applied were comparable to theses applied by clinicians.
Histologic observations: 558 sections of 52 teeth were studied. Cementum was totally removed with a minimum of 20 strokes, although cementum fragments remained even after 70 strokes. Four different types of rot defects were identified: 1) curette-shaped 2) sliced 3) fragmented (cementum remaining in the defect) and 4) different cemental thickness on either side of the defect. These variations were due to reflection of the curette during root planning and secondary to root anatomy and density.
There was a positive correlation between the number of strokes applied to the root surface and the mean depth of root defect.
An inverse relationship existed between mean force per stroke and mean defect depth.
Conclusion: The study emphasizes the inconsistency of presently employed mechanical therapy and may increase the significance of chemical Tx or detoxification in achieving a predictable healing response. Average depth of most root defects approached the extant of bacterial penetration only when 50 or more strokes were used per site.
Total Tx time for a patient with generalized moderate periodontitis, presuming a constant non-stop pace and four-handed dentistry, would approximate 90 minutes based on findings of this study.
Leknes 1994 ARTICLE
Keywords: Periodontal pockets/microbiology; planing/instrumentation; scaling/instrumentation; tooth root/microbiology
Purpose: To study the influence of tooth instrumentation roughness on subgingival microbial colonization in beagle dogs.
Methods: 5 beagle dogs with healthy periodontium had 10 maxillary and 10 mandibular 6x5mm (from the CEJ) defects created on buccal aspect of caninesAn equal number of root surfaces were treated 2 different ways:
Group 1:Instrumented with flame-shaped diamond points, designed for root surface
· Group 2: Instrumented with a sharp curet
Vertical horizontal notches were then created to demarcate instrumentation area and FGM. Areas were covered with foil, soft diet was prescribed, and a borad spectrum antibiotic was prescribed for 10 days. Next, plaque was allowed to accumulate for 70 days. Specimens were then harvested and evaluated. Bacteria colonization was quantified. Each specimen was divided into 3 zones of the defect (cervical, middle, and apical) to compare different pocket levels.
Results: At all levels, the diamond-instrumented surfaces, which resulted in rougher root surfaces, had more plaque than surfaces treated by curette (53% vs. 76%). Subgingival plaque was most abundant in the cervical zone and decreased in the apical direction. Mean % of defect containing bacteria were as follows:
|
Zone |
Diamond Instrumented |
Curette Instrumented |
|
I-Cervical Root |
99% |
91% |
|
II-Middle Root |
80% |
49% |
|
III-Apical Root |
62% |
34% |
Conclusions: Root debridement with a diamond can cause roughness, which promotes subgingival bacterial colonization. Root surfaces (supra\subgingival) should be left as smooth as possible. A curette appears more appropriate than a diamond point.
Keywords: curette, diamond tipped sonic scaler, scaling, efficacy
Purpose: To measure the loss of substance and root surface alteration that occurs during in vitro root surface instrumentation using different sonic scaler tips.
Materials and methods:
Results:
The 2 diamond tips had deep troughs connected by plateaus.
BL: Diamond-coated tips removed greater amount of teeth structure than conventional ones; the depth of substance removal is comparable to HI, & increase linearly w/ force applied. It remains to be determined whether the differences in surface texture are of clinical importance.
Yukna 1997 ARTICLE
Keywords: subgingival, calculus, removal, diamond coated ultrasonic tips
P: To evaluate the speed and effectiveness of diamond-coated ultrasonic tips in calculus removal on single-rooted teeth under the conditions of non-surgical clinical root debridement as part of patient treatment
M&M: 15 pts with advanced periodontal disease having single-rooted teeth planned for extraction. PDs > 5mm, no SRP for 6 mos prior to study, clinical and/or radiographically evident subgingival calculus. At least 4 teeth in each patient used. FGM, PD recorded and notched on the lateral aspect. Random assignment of Hand Instruments (HI), plain ultra sonic (US), fine grit diamond-coated (FIN) ultrasonic, medium grit diamond coated ultrasonic tip (MED). Single instrument was used until a smooth root surface was obtained; time needed was recorded. Teeth were then extracted. Treated surface was photographed at 10x, then overlaid with 4 mm grid and evaluated with a magnifying lens to ascertain percent of tooth surface with remaining calculus & generalized root surface roughness.
R:
- NSD among groups with regard to initial PD or mean percent of calculus remaining on the teeth after treatment.
- NSD among ultrasonic instruments, but all took significantly less time than HI (HI=289 sec US=194 sec FIN=167 sec MED=147 sec).
- All 3 powered tips demonstrated a greater frequency of totally clean surface compared to HI but HI had the highest frequency of “smooth” surfaces.
- The powered tips of all types most frequently resulted in a “slight” surface roughness on 50% of treated teeth. Only the FIN left a “rough” surface on 15%
BL: Clinically adequate root debridement as defined by visible calculus removal was achieved with all 4 types of instruments on single rooted teeth. Root roughness was slightly greater with the powered types. All powered instruments took significantly less time than HI, which in an entire quadrant would add up to be significant time
Nicoll 1998 ARTICLE
Keywords: Ultrasonic, sonic scalers, irrigation, cementum
Purpose: To compare the temperature rise in dentin during US scaling using either US handpiece irrigation or intermittent bulb irrigation.
Intermittent bulb irrigation is one way to deliver sterile coolant when using ultrasonic scalers not equipped with a dedicated sterile water reservoir.
Materials and methods: 60 extracted teeth were used. 20 dentin/cementum root slabs were prepared for each thickness of 0.5, 1.5, and 2.5 mm. 20 samples of each thickness were ultrasonically scaled during which dentin temperature was recorded. All 60 slabs were first treated with US handpiece water irrigation, followed by no irrigation, and finally by bulb irrigation with sterile saline.
Results: Dentin temperature increased with both decreasing slab thickness and with increasing duration of instrumentation. No difference between US and bulb irrigation for 2.5mm specimens scaled for 5 to 15 seconds duration. However, only scaling without irrigation produced a rise in dentin temperature from baseline to a level reported as deleterious to pulpal and periodontal tissues.
BL: Bulb syringe irrigation delivered as a continuous drip and ultrasonic unit water spray minimized heat generation to physiologically tolerable levels. Intermittent bulb irrigation appears to be an alternative to the use of US scaler water spray for cooling during US scaling w/sx.
Barnes 1998 ARTICLE
Keywords: air pollution prevention and control, aerosols, disease transmission, blood-borne pathogens, infection control, ultrasonic instrumentation, ultrasonic methods
P: To determine if aerosols from scalers contain blood from the gingival sulcus.
M&M: 40 areas consisting of 2 adjacent periodontally involved teeth (PD ≥ 5 mm on one site) scaled subgingivally with an ultrasonic scaler for 30 seconds. A high volume evacuator (HVE) tip positioned 3-5 cm away from the operating site to capture the aerosols produced. The water remaining in and on the HVE tube was tested for visible and occult blood by the guiac resin method. GI, mean PD, presence of bleeding with scaling, and presence of visible blood in the HVE tip were recorded.
R: All 40 test sites showed a positive result for blood in the captured aerosols despite the wide variation in the measured parameters.
BL: Subgingival scaling on periodontally involved teeth with ultrasonic scalers would be expected to produce aerosols containing blood
Are Manual and ultrasonic/sonic instrumentation equally capable of improving clinical parameters?
Hand VS Ultrasonics
Nishimine 1979 ARTICLE
Keywords: hand instruments, ultrasonics
P: To determine the relative effectiveness of hand instruments (HI) and ultrasonic scalers (US) in removing endotoxin from root surfaces in vivo.
M+M: Teeth had to meet the following criteria: 1) be removed from patients who were at least 30 years of age , with no known systemic factors which might have contributed to their periodontal condition, and who had received no periodontal treatment 2) non-carious, non-restored, anterior teeth or premolars 3) having proximal attachment loss of 5mm or more.
Four groups were created:
The treated groups were scaled until the root surface felt hard and smooth when examined with an explorer. Immediately after extraction each tooth was scrubbed by a sterile toothbrush and saline solution to remove accumulated surface plaque or debris. Limulus Amebocyte lysate, Pyrostat test was performed for quantitative determination of endotoxin.
R: 21.7% of HI teeth had residual calculus vs 30.4% of US-treated teeth.
LPS levels:
HI = 2.09 ng/ml
US = 16.8 ng/ml
Periodontally diseased control teeth= 169.5 ng/ml
Unerupted 3rds (periodontally healthy) = 1.46 ng/ml
BL: On visual inspection the root planed teeth had less calculus remaining (21.7% of the teeth) than the ultrasonically scaled teeth (30.4% of the teeth). HI produced endotoxin values similar to those for unerupted periodontally healthy teeth. US resulted in endotoxin values approximately 8 times greater.
Drisko 1998 NO ARTICLE
Keywords: instrumentation, root maintenance, non-surgical therapy, efficacy
P: Review comparing evidence to compare the effects of power-driven scalers and manual scalers on the subgingival microfora and clinical outcomes after both instrumentation techniques.
D: Effect on subgingival microflora: Studies consistently report SS reductions in % of spirochetes, other motile bacteria, and gram – bacteria (Pg, Tf, and Aa)
Oosterwaal- compared US of PD 6-9mm with hand scalingtwo methods relatively equal at reducing total microbial counts and colony-forming units
Plaque and calculus removal: Hand and power driven scalers have been shown to be equally effective in subgingival plaque and calculus removal in moderate and deep pckets.
Microscopic studies of extracted roots show that hand instruments and ultrasonic scalers are generally equally effective in removal of subgingival calculus.
Access to difficult sites: Calculus removal enhanced by 25-50% when flap access is compared to closed debridement, several studies show calculus removal superior using hand instruments in open flap curettage compared to closed.
Hunter et al and Kepic et al- have shown ultrasonic instruments are NSSD from hand instruments in removing calculus with or without flap access.
Endotoxin removal: Nishimine and O’Leary compared efficacy of manual and ultrasonic scalers in removing endotoxin from contaminated root surfaces. Both types were effective compared to controls, but ultrasonic scaler was found to be less effective in endotoxin removal than manual scaling.
More recent studies have found that ultrasonic instrumentation is effective in removing endotoxins.
Ultrasonic bactericidal debridement: To enhance anti-infective approach to non-surgical ultrasonic debridement, addition of chlorhexidine or povidone-iodine has been investigated.
Grossi- reported 0.12% CHX or 0.05% povidone-iodine was more effective in treating type 2 diabetics with severe periodontitis
Forabosco- showed gain in CAL, PD reductions, and improved bleeding scores in pts with moderate perio who were treated with ultra sonic debridement with 0.05% povidone-iodine lavage for 1 year
BL: Based on current literature, the use of ultrasonic scalers for periodontal debridement will result in improvements in clinical and microbial parameters at a level equal to or superior to hand scalers.
Cobb 1996 ARTICLE
Keywords: mechanical surgical therapy, periodontal disease, attachment lossP: To review the literature in order to gain an overview of the current state of affairs regarding mechanical non-sx perio tx.
D: 311 articles were incorporated into the review.
Very few sites within indicidual pts or a small % of pts within a population appear unresponsive to routine tx. The critical determinant of perio tx is not the choice of tx modality, but the detailed thoroughness of the root surface debridement and the pt’s OH. Based on the existing data, after the age of 20, 0.1-0.2mm is a justifiable range reflective of the mean annual rate of progression for un-tx perio dz. There is a positive correlation between increasing age and increasing loss of perio support. Severe period z is restricted to a small percent of a given population or a small percent of sites within a given dentition. There is still no entirely reliable clinical predictor of risk for future ALoss. Depending on the study, the most significant risk factors found have been tooth type, initial ALoss or bone height at baseline, moderate and severe gingival inflammation, presence of sub-g calculus, age, and smoking. Haffajee reported that it was possible to correctly classify 80% of pts (using 11 predictor variables) as to risk for dz progression. Mean annual tooth loss for un-tx perio dz is 0.28, while tx perio dz is 0.08 (3.5x difference).
It appears that sub-g microflora has supra-g origins as the quantity, composition and rate of sub-g plaque recolonization is, to some degree, dependent upon supra-g plaque accumulation. Effective control of supra-g plaque combined with frequent professional sub-g tx is crucial for controlling perio dz. Re-attachment of the attachment epithelium happens between 1-2wks. Differences between duplicate recordings may vary betwee 1-2mm, with deeper pockets and interproximal surfaces showing more variability. Studies have not shown a difference in recording PDs between manual probing and electronic probes.
Several studies have shown that the initial gains in AL and/or reductions in PDs following SRP of molar tth are predictably followed by a continuous deterioration over time (sx pocket elimination tx should be considered). Cuation should be used in the interpretation of the results of tx vased on changes in PD and AL since longitudinal and cross-sectional studies indicate that relatively few sites and/or pts are at risk for active dz at any given time, even in the absence of tx. Studies report between 19-57% of tth initially diagnosed with furcations were lost over 15 years, while only 5-10% of tth without furcations were lost during the same period. Ramjford noted that 16/17 tth extracted during a 5-yr maintenance period after active tx initially presented with furcation involvement. Since a true calculus free root surface is not achieved, clinical success may be more dependent on reduction of calculus volume below the critical mass, as opposed to complete elimination at the microscopic level. Moore demonstrated that 99% of endotoxin could be removed from the root surface by gentle washing and/or brushing for 1min. Complete removal of the cementum during root planing is not a realistic objective (O’Leary and Kafrawy found it difficult, if not impossible to remove all of the cementum) and is not necessary to achieve clinical success.
BL: Very good, comprehensive review article on non-sx therapy. Application of each tx modality to the greatest advantage of the individual pt and/or specific dz site is critical to treatment.
Leon 1987 ARTICLE
Keywords: hand scaling, ultrasonic, GCF, subgingival floravvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvv
Purpose: to compare the effectiveness of a single session of either hand scaling or ultrasonics in debriding furcations. GCF flow was used to monitor the changes in the inflammatory state, and dark-field microscopy was used to evaluate changes in the subgingival flora.
Materials and methods: Patients in good health with no history of systemic diseases were selected. Patients taken antibiotics in the previous six months, pregnant or had received any professional debridement within the last six months were excluded.
33 molars with furcation involvement were evaluated and classified: 12 as Furcation I (less than or equal to 2mm horizontal or vertical depth), 12 as Furcation II (greater than 2mm horizontal or vertical depth but not through – and – through) and 9 as Furcation III (through-and-through involvement).
Groups of three furcations with comparable dimensions, PI and GCF flow were created. One tooth of each group received no treatment (Treatment 1), hand scaling with Gracey curettes (Treatment 2) and ultrasonics (Treatment 3).
At baseline subgingival plaque sample from the midbuccal surface was obtained, and samples were examined for the following categories of bacteria: coccoid cells, motile rods, spirochetes, total motile (spirochetes and motile rods) and other cells not falling into one.
After data collection treatment was performed and data were collected at 2 and 4 weeks and statistical analysis was performed.
Results: At baseline mean PI was 1 for class I furc, 2 for class II furc and 1.67 for class III furc, which were SSD. GCF was significantly lower in Class I furcation but no SSD was found between class II and III.
Coccoid cells: Class I>Class II>Class III
Motile rods: Class I and II>Class III
Spirochetes and total motile: Class III>Class II>Class I
Results of therapy: GCF decreased after two weeks of Tx, increased at 4 weeks but was still lower comparing to the baseline levels.
In class II and III furcations ultrasonics were more effective than hand instruments based on GCF measurements.
In class I furcation both treatments showed equivalent changes in the flora when comparing to baseline or no treatments. Coccoids showed increase and motile bacteria decreased at 2 weeks but were at baseline levels at 4 weeks, spirochetes and total motiles were lower at 2 weeks, increased between 2 and 4 weeks but still remained lower than baseline.
Both treatments increased the number of coccoids in class II and III furcations at 2 weeks ,counts then decreased at 4 weeks but remained higher than baseline. In class II ultrasonics maintained higher counts at 4 weeks than hand instruments.
Ultrasonic debridement was more effective in motile rods reduction in Class III furcation at 2 weeks but there was no difference at 4 weeks. Ultrasonics was also more effective at spirochetes reduction at both 2 and 4 week intervals.
Hand scaling was more effective in reduction of spirochetes and total motiles in Class I furcations while ultrasonics showed the same efficacy in Class I, II and III.
Conclusion: Ultrasonics were found to be more effective especially in Class II and III furcations, probably because of better acces and because they are designed to work in several angles contrary to hand instruments that are designed to be used at specific angulations.
Croft 2003 NO ARTICLE
Keywords: Ultrasonic instrumentation; hand instrumentation; patient preference; survey
P: To determine if patients prefer ultrasonics or hand instruments for periodontal maintenance.
M&M: 469 patients age 24-86 yr old were given a questionnaire that was completed anonymously. Patients came from 3 different periodontal practices who each received hand scaling and ultrasonic scaling. 2 practices used manually adjustable ultrasonic unit with modified tips for the ultrasonic scaling 100% of the time. The 3rd practice used this method for 85% of each maintenance apt and 15% of the time used hand instruments. Mean age of patients in each practice was 62.7yrs for the first practice, 58.6yrs for the second practice, and 56.9yrs for the third practice. 60% of those surveyed were female.
R: Pts had a strong preference for the ultrasonic scaling (74%) compared to hand scaling. Preference was due to effective buildup removal, less irritating sound, clean feeling, less overall pain, more overall efficiency and less mess. In the offices that used manually adjustable ultrasonic units with modified tips for 100% of each maintenance appt, respondents indicated a stronger preference for the ultrasonic scaling. Patients of the 3rd office showed less of a preference for ultrasonic scaling overall.
BL: Patients strongly preferred ultrasonic scaling because they felt it created a less irritating sound, had cleaner feeling, was less painful, more efficient and less messy.
Dahiya 2011 ARTICLE
Purpose: to compare root surface characteristics following root planning with various hand and power driven instruments
Materials and methods:
Results
Discussion
Conclusions
Keywords: nonsurgical therapy, manual, ultrasonic, subgingival, calculus, bacterial plaque, Probing, clinical attachment level, gingival inflammation
P: Review article “ Clinical significance of non-surgical periodontal therapy”
D:
Manual vs Sonic/Ultrasonic instrumentation
- Manual instrumentation generally takes longer to achieve the same clinical end-points than do sonic and/or ultrasonic scaling instruments
Control of subgingival bacterial plaque
- In general, subgingival scaling effectively decreases the population of G- microbes while concomitantly allowing for an increase in the populations of G+ rods and cocci. This sift towards a more dominate population of G+ microbes is usually associated with gingival health
- Although spirochetes, motile microbes, and Bacteriodes sp. Are routinely reduced in numbers after SRP, other species appear more resistant, such as Aa and Pg
Removal of subgingival calculus
- Clinically acceptable level of gingival wound healing occurs, despite the presence of microscopic aggregates of residual root calculus
Changes in PD and CAL
- Reduction in PD following mechanical instrumentation results from a combination of gain in CAL and gingival recession
- The magnitude is related to the initial measurement, deeper PD, more PD reduction and CAL gain
BOP and gingival inflammation
- In spite of a weak correlation, clinicians continue to use BOP as a primary indicator of disease activity. This persistence on behalf of the clinician is likely based on several studies which indicated that frequent BOP was a predictor of future CAL loss
- Because of the weak correlation, Lang et al. have suggested that an absence of BOP be used as a criterion for stability rather than using the presence of BOP as a predictor of disease activity
Effectiveness
Stambaugh 1981 NO ARTICLE
Keywords: subgingival, scaling, effectiveness, pockets
Purpose: To evaluate the limits of subgingival scaling
M&M: 42 periodontal pockets on 7 teeth were studied. PD were taken at the time of baseline and extraction. PD ranged from 1-10mm, with the average being 6.9mm. The teeth received a prophylaxis with ultrasonic instruments and one week later came in for SRP (until free of detectable roughness) from 2 hygienists who were judged to have extraordinary skill. No time limit was given, but the SRP was limited to one appointment. A notch at the level of the gingival margin was made and the teeth were extracted. The teeth were examined, photographed and sectioned. Teeth were examined for plaque, calculus and cementum.
Results: The actual attachment level ranged form 3mm more to 2mm less than that observed by clinical probing after ultrasonic scaling. The average depth of pocket instrumented to a plaque and calculus free surface which has hard, smooth, and free of gouges and scratches was 3.73mm with a SD of 0.97mm, with a range of 1 to 6mm. The maximum mean pocket depth at which evidence could be seen of instrumentation on the root surface (scratches or marks in remaining plaque or calculus) was 6.21mm with a SD of 1.32, with a range of 2 to 10mm. Average instrumentation time was 39 minutes for a maxillary posterior tooth, and 25 minutes for a mandibular posterior tooth. Instrumentation was more effective on the distal and mesial of teeth than on the buccal and lingual surfaces. The actual attachment levels were similar after extraction in comparison to those before extraction.
BL: In one appointment it may be impossible to achieve a disease free surface in pockets < 3.73mm.
Rabbani 1981 ARTICLE
Keywords: calculus removal
P: to determine whether any correlation exists between remaining calculus and PD and whether type of teeth scaled (anterior or posterior) influences remaining calculus.
M&M: 119 teeth from 25 patients with advanced periodontal disease. 62 were scaled and 57 controls. Teeth scored using calculus index of the P.D.I. (Ramjford). PD measured and gingival margin levels marked with bur to locate supragingival and subgingival calculus after extraction. Teeth were scaled with hand instruments then extracted and stained with methylene blue. Specimens were viewed under SEM. The % of surface covered by calculus was assessed on scaled and unscaled teeth.
R: high correlation between % of residual calculus and PD on scaled teeth. Also a significant correlation was found in control teeth. PD < 3 mm were easiest for S/RP and PD > 5 mm were the most difficult due to the narrowing of the apical part of deeper pockets making removal of calculus unlikely. NSSD between anterior or posterior teeth then scaled or unscaled.
BL: There is a significant correlation between PD and % residual calculus following S/RP. Teeth type (anterior vs. posterior) did not appear to influence the results. The greater the PD the greater the chance of failure.
Closed vs. Open Root Planing
A. Non – Molars
Brayer 1989 ARTICLE
Keywords: operator experience
P: To observe if the variables operator experience or root surface access affect the outcome of SRP.
M&M: 29 patients (27M/2F) 44-74 years, with 114 hopeless single-rooted teeth were recruited. No periodontal therapy within the last 12 months and no medical contraindications to treatment. 4 operators performed SRP (2 Board certified periodontists & two 2nd year periodontal residents). Patients were randomly assigned to have sc/rp closed or open. Unscaled teeth served as controls. Calculus index and PDs were recorded. A groove was instrumented around the circumference of teeth at the free gingival margin prior to treatment. All operators were scaled and root planed until they achieved a hard, smooth, calculus free root surface. No time limits were set on the operators. All providers initially used ultrasonic, then finished with hand instruments. After the procedure, the treatment time was recorded. Teeth were extracted then examined using a microscope and scored for calculus. There were a total of 396 treated root surfaces and 60 untreated control root surfaces.
R: The mean time for SRP during an open procedure was 5.3 min/tooth (periodontist) and 6.7 min/tooth (resident). For the closed procedure, mean times were 8.1 min/tooth and 9.5 min/tooth respectively. For open flap treatment, 96.4% of teeth were free of residual calculus for periodontists and 91.2% of teeth treated by residents. In closed SRP teeth, 86.2% of teeth where free of calculus when cleaned by periodontist and 65.7% calculus free when SRP done by resident. In shallow periodontal pockets there was NSD between groups for the percentage of root surfaces free of calculus. In moderate to deep (4-5mm) probing depths pockets, SRP with open flap access produced a significantly greater number of root surfaces free of calculus than SRP alone (88% - 62% respectively). In shallow depths, there was no difference between the experience levels. In deeper pockets, experience level did make a difference. Most calculus was left near CEJ, in root concavities, and along line angles.
BL: For single rooted teeth with PDs>4mm: (1) SRP with flap access resulted in fewer root surfaces containing residual calculus than SRP alone. (2) More experienced operators produced fewer root surfaces containing residual calculus than the less experienced operators for deeper pockets.
B. Molars
Caffesse 1986 ARTICLE
Keywords: flap access, scaling, root planning, calculus
P: To evaluate the effectiveness of SRP on calculus removal with and without flap for access.
M+M: 21 pts (29-88 years old) without history of periodontal tx who were planned for extractions and immediate denture placement were included. On day of extractions, 2 teeth had SRP with no flap, 2 had SRP following flap, 2 teeth served as controls, in each subject. The FGM was marked with a bur around the tooth to differentiate b/w supra and subG. Included teeth from both anterior and posterior. Teeth then extracted and residual calculus was examined by a stereomicroscope.
R: Percentages of calculus free surfaces after treatment
| Pocket depth | Scaling/ RP alone | Flap + Scaling/RP |
| 1-3 mm | 86% | 86% |
| 4-6 mm | 43% | 76% |
| > 6 mm | 32% | 50% |
NSSD between anterior and posterior. SSD for % of remaining calculus and PD (probability of leaving calculus increases as PD increases). Areas where residual calculus was found were apical to restorations, furcations, and developmental grooves, as well as the CEJ area.
BL: Periodontal flaps provide a mean to achieve more teeth surfaces free of calculus in pockets >3 mm. The % of residual calculus is related to PD, despite treatment approach. Anterior and posterior teeth respond similarly. Despite open flap approach, residual calculus was still found to be significant.
Fleischer 1989 ARTICLE
Keywords: multirooted teeth, flap access, scaling, root planning, calculus
P: To evaluate if the effectiveness of SRP on multirooted teeth enhanced by surgical access and if the results of this treatment different between operators with two different levels of experience.
M&M: 36 pts, 61 molars with PD >6mm at at least one site, no periodontal therapy within 12 mo and designated for extraction were randomly distributed among four operators of two different experience levels (Periodontist with 10+ years experience and perio residents) for SRP (Cavitron and HI) with or without surgical access. Calculus index and furcation grade were obtained prior to treatment. A groove was placed circumferentially around FGM to determine subgingival root. Following treatment the teeth were extracted and scored in a blind manner for residual calculus. Teeth were sectioned to allow assessment of the furcal aspects and examined with a stereomicroscope at 10x magnification. Time spent performing the SRP was also recorded (no time limit given; instructed to plane until achieved a hard, smooth, calculus free-surface).
R: - Operators of both experience levels obtained calculus-free root surfaces significantly more often with flap access than with a non-surgical approach.
- Operators with more experience achieved calculus-free root surfaces significantly more often than operators of lesser experience with both open and closed procedures in pockets 4mm or greater.
- The deeper the PDs, the less often the surfaces were calculus-free in both experience levels and for both procedures. However, when furcation aspect alone was assessed, it was found that the more experienced operators obtained a calculus-free surface only 68% of the time with an open approach vs. 44% with a closed approach (NSSD). Inexperienced operators had a calculus-free surface 43% of the time in the open approach, and 8% when closed (SS).
- NSSD between groups in time taken to complete the SRP for either procedure
BL: Both surgical access and a more experienced operator significantly enhance calculus removal in molars with furcation invasion. Total calculus removal in furcations utilizing conventional instrumentation may be limited. Non-experienced operators benefit more from an open approach when cleaning furcations than do experienced operators.
C. In Furcations
Bower 1979 ARTICLE
Keywords: furcations, curette, entrance diameter
Purpose: To investigate whether furcation morphology influences instrumentation using curettes in maxillary and mandibular first molars.
Materials and methods: 114 maxillary and 103 mandibular molars were used. Teeth with fused roots, evidence of extraction damage near the furcation area, caries or restorations apical to the CEJ were excluded.
Mesiodistal dimension of each tooth was measured, and the furcation entrance diameter was also recorded using a dissecting microscope and machine metal test gauges of known dimensions. Three measurements for furcation entrance were recorded for maxillary molars and two for the mandibular.
The blade face width of 12 unused commonly used curette types made by two manufacturers was measured too.
Results: Mesio-Distal width of the teeth: Mean width in max molars 7.9mm (range 7.10-9.3mm) and 9.2mm in mand molars (8-10.3mm)
Furcation entrance diameter: 81% the entrance was 1mm or less and in 58% 0.75mm or less (63% max and 50% mand).
No correlation was found between mesiodistal width and furcation diameter.
In all cases the blade face width was within the range of 0.75-1.10mm, with Gracey curettes having a narrower blade face than Columbia or McCall curettes.
Conclusion: In 58% of the cases furcations had a smaller entrance than the curettes suggesting that they may not be suitable for root preparation in these areas.
The buccal furcation areas tended to be smaller than the rest areas in both maxillary and mandibular molars.
Large teeth do no necessarily have larger furcation entrance diameters.
Parashis 1993 ARTICLE
Keywords: Calculus removal; furcation area; furcation entrance width; surgery versus non-surgery
P: The aim of the study was to evaluate the efficacy of calculus removal on molar teeth using closed approach, open approach and rotatory diamond instrumentation for the furcation areas. The effect of pocket depth on efficacy of SRP was also evaluated.
M&M: 30 lower molars were scheduled for extraction with PD ≥5 , CII- CIII furca involvement divided in to 3 groups: 10tth with SRP,10 w/ SRP with OFD and 10 teeth with using rotatory diamond w/ OFD. Teeth were extracted assessed for residual calculus.
R: percentage of residual calculus was S higher in closed method than open. Diamond group had 45%, open group had 15% and closed group had 5% calculus free surfaces.
Percentage of residual calculus on external surface was S diff in relation to PD 4-6 mm and ≥7 mm. The difference b/w 3 groups in the % of residual calculus were S in furcation area: median % of residual calculus in the furcation was 17.5% for closed group, 7.5% for open group and 2.5% for diamond group. Closed root planning left more surfaces of residual calculus in the flute (70%) and the roof (60%) of the furcation area than open SRP (35% and 50%). Diamond group removed 95% calculus from flute.
Conclusion: The calculus removal of the furcation using closed method is not effective. Open method increased the S effectiveness in calculus removal but the rotatory diamond was the most effective method for calculus removal from the furcation area.
Parashis 1993 (II): ARTICLE
Keywords: calculus removal, furcation area, furcation entrance width, surgery vs. nonsurgery
Purpose: To evaluate the effect of furcation entrance width on the efficacy of calculus removal from furcation areas and to compare this efficacy between external and furcation surfaces after closed root planning, open root planning and use of a rotary diamond for the furcation areas.
Materials and methods:
Results:
BL:Narrow furcation surfaces had more residual calculus. Open scaling and root planning + rotary diamond improved calculus removal from both wide and narrow furcations. Open approach improves calculus removal.
D. Endoscopy
Michaud 2007 ARTICLE
Keywords: subgingival calculus, removal, endoscopy, perioscopy, root planning
P: To determine whether endoscopy-aided SRP resulted in a greater reduction of residual calculus compared to SRP alone in multi-rooted teeth.
M&M: 24 subjects contributed 35 tooth pairs (70 teeth in total). Each tooth per pair was randomly assigned to receive endoscopy-aided SRP (test) or SRP alone (control). Both teeth were extracted immediately after treatment, washed with water, and stained with methylene blue. The percentage of residual calculus was determined via stereomicroscopy and digital image software by a single masked examiner.
R: 1.16% less residual calculus at test versus control sites. At interproximal surfaces, test roots had 2.63% less residual calculus than control roots, while test roots had more residual calculus than controls at buccal/lingual surfaces (0.36%). There were no statistically significant differences in residual calculus between groups at deeper probing depths or at sites with deep furcation involvement. Only at shallower interproximal sites with probing depths less than or equal to 6 mm was significantly less residual calculus seen in roots treated with endoscopy. Treatment time decreased significantly as operator experience increased, however, no significant improvement in residual calculus levels was noted with greater experience.
BL: The use of the endoscope as an adjunct to traditional SRP provided no significant improvement in calculus removal in multi-rooted molar teeth.
Soft Tissue Effects
Waerhaug 1978 ARTICLE
P: to determine what happens on the tooth surface in the hidden area of the gingival pocket following subgingival plaque control.
M&M: 84 teeth slated for extraction with PD >3mm. Teeth had subgingival plaque removed by the use of curettes, hoes, and or diamond points. In 11 cases scaling was carried out in combination with flap surgery. 31 teeth had scaling before extraction. 53 had scaling at varying observation periods before extraction (to evaluate how quickly dento-ephithelial junction is reestablished and subgingival plaque reformed). Before extraction GI, PD, and a notch placed at gingival margin. Teeth were stained with tolouidine blue and examined under the stereomicroscope.
R: Plaque was left on one or more surfaces (90% of the time), and in the furcations. The most common location was the bottom of the pocket. Deficiency in the technique (strokes of scalers did not overlap in all areas) 9% of the time.
There was an 83% success in plaque removal on pockets <3mm and 11% on >5mm
Distance from the plaque front to the closest periodontal fibers: <0.5mm =44% (55 surfaces) of the time. 0.6-1.0mm =24% (29 surfaces) , >1mm= 28% (34 surfaces).
BL: Subgingival plaque is left behind 90% of the time, mostly in pockets >5mm. Distance from plaque to the bottom of pocket is 0.5mm or less 44% of the time. If all subgingival plaque is removed, the junctional epithelium will be readapted to the plaque-free tooth surface from the borderline of the attach fibers to the gingival margin. Plaque left behind, allows for additional plaque formation.
Reformation of subgingival plaque is slow, may take months or a full year. During this interval plaque may not induce inflammatory reaction that can be noticed at the gingival margin. Incomplete subgingival plaque control is equal to no plaque control at all or even worse. Surgical elimination of pockets deeper than 3mm is the most predictable method for subgingival plaque control.
Lindhe 1982 ARTICLE
Keywords: scaling
P: To assess histological attachment level alterations following repeated scaling and root planning in periodontal sites with 1-3 mm of sulcus depth.
M&M: 2 monkeys were used. PDs and bone height within normal limits. During a period of 6 months, the buccal surfaces of maxillary 1st and 2nd premolars, mandibular 2nd premolars, 1st and 2nd molars on the right side of the jaws were scaled and planed every 2 weeks. Contralateral teeth served as the controls. 6 months later animals were sacrificed and histology was performed. Histometric assesements: 1) CEJ-most apical cells of the JE, 2) JE-alveolar bone crest (BC)
R: In control teeth, the apical cells of the junctional epithelium were located at the CEJ. In the test teeth, the average distance CEJ-JE was 0.39mm. The difference was SS. The length of the attached supra-alveolar connective tissue was similar in control and test teeth (0.49 vs 0.45mm). This indicates that in test teeth resorption of the alveolar bone had occurred to a degree which corresponded to the apical displacement of the JE. Repeated scaling and root planning resulted in an average loss of attachment by 0.39mm and a corresponding recession of alveolar bone.
BL: Repeated SRP of shallow pocket depths creates attachment loss.
Claffey 1988: ARTICLE
Keywords: probing, attachment level, root planning, root scaling, periodontal diseas
P: To investigate the potential loss of attachment immediately and 12 months after a single episode of root planing.
M+M: 1,248 sites in 9 healthy pts (36-62 years old) with generalized BOP and generalized subgingival calculus, having at least 14 teeth and 10 sites with PD > 7mm. No periodontal tx for at least 5 yrs. OHI and baseline measurements 1 week before tx. Single round of SRP instrumented with ultrasonic (3.8 min/non-molar tooth, 6.5 min/molar tooth). PD and PAL measured at baseline, immediately pre- and post- SRP, 3, 6,9, 12 months by 3 independent examiners. Stents used to standardize.
R: PD PAL
< 3.5mm = no change 0.6mm loss
4-6mm = 1.3 mm decreaes 0.4mm gain
>7mm = 2.2 mm decrease 0.8mm gain
Mean loss of PAL was 0.5 to 0.6 mm after instrumentation irrespective of initial PD.
5% of all sites lost 1 mm from pre-instrumentation to 12 months.
91% of sites >7mm at baseline were < 7 mm at 12 months.
Attachment Loss seems to be attributable to instrumentation or to a remodeling process rather than to progressive periodontitis.
BL: Mean PAL loss after instrumentation is 0.5-0.6 mm. 5% of the sites lost 1 mm attachment after 12 months. The higher the initial PD, the greater the gain of attachment
Sherman 1990 (II) ARTICLE
Keywords: dental calculus therapy, diagnosis, root planning, root scaling, periodontal disease
P: To evaluate the changes in clinical parameters following SRP over a 3-month period and to relate these changes to the actual presence or absence of residual calculus
found on the root surfaces
M&M: 7 patients with moderately advanced periodontitis, 101 teeth, 6 sites for non-molars, 8 sites for maxillary molars, and 10 sites on mandibular molars. PD, PAL (from a stent with electronic probe), PI, and BOP. SRP using hand and ultrasonic instruments. Periodontal parameters recorded at baseline and every month following instrumentation (review OHI and supra-g scaling and polishing done monthly as well). Extraction at 3 months, stereomicroscopy to evaluate for residual calculus. Average time spent was 9.4 mins per tooth
R:
- Overall plaque score was high at end of study, 40-65%. Initially, it was about 80%. Authors feel it was high because it was difficult to motivate pts when they knew that their teeth were going to be extracted.
- Significant reduction in BOP (reduction from about 80 to 50%).
- PD depth reduction was higher in deeper pockets (3 mm or less was 0.35 mm, 3.5-6.0 was 1.25 mm, and 6.5 mm and deeper was 2.7 mm) after one month and little reduction in the following two months
- Recession was 0.55 mm in shallow sites, 1.05 mm for moderate pockets, and 1.50 mm in deeper pockets
- Loss of attachment in shallow and moderated sites in the first month. Deep sites had attachment gain.
- 61.9% of bleeding sites had calculus. 59.1% of non-bleeding sites had calculus
- Residual calculus did not appear to be consistently related to initial PD, it was found in high percentage in all pockets (50-80%). No significant relation of residual calculus to any of the clinical parameters, except for BOP. However, BOP had low sensitivity (50%) in sites microscopically exhibiting residual calculus.
BL: Short-term clinical response appears not to be related to the residual calculus remaining after thorough subgingival instrumentation.
Bacteremia
Lafaurie 2007 ARTICLE
Keywords: actinomyces spp, bacteremia, cardiovascular disease, periodontal disease, prophymonas gingivitis, scaling and root planing
Purpose: To establish the frequency of passage of periodontopathic microorganisms in periopheric blood after SRP in patients with periodontitis.
Materials and methods: 42 patients,27 with severe generalized chronic periodontitis, and 15 with generalized aggressive periodontitis participated to the study. Laboratory exams were requested to exclude medically compromised patients. Exclusion criteria included: congenital valve defects or any other risk situation for infectious endocarditis, low levels of hematocrit and/or hemoglobin, high risk of cardiovascular disease, diabetes and patients who had taken antibiotics within 1 month prior to the study. Periodontal examination included recording of PD, CAL, BOP of all sites examined and GI (Loe & SIlness 1963) and PD of the treated sites with SRP. Patients should have at least 10 sites with PD 7mm or more requiring periodontal surgery after SRP.
All procedures were performed by the same operator, and SRP was performed for 1 min/site total of 10min/patient.
Blood samples were taken at four times 1) immediately before SRP, T1 2) immediately after SRP, T2 3) 15 minutes after treatment, T3 and 4) 30 minute after treatment, T4. They were cultured under anaerobic conditions for identification of perio pathogens.
Results: 80.9% of the patients presented positive cultures, this occurred more frequently immediately after treatment (93.7% in the Aggressive periodontitis patients and 74.1% in the chronic periodontitis patients). 38% of the patients had bacteremia at T3 and 19% of the patients still had microorganisms in the bloodstream 30 min. after the procedure. The periodontopathic microorganisms more frequently identified were P.g. and M. micros. Whereas Campylobacter species, Eikenella corrodens, T.f., Fusobacterium species, and P.i. were isolated less often. Actinomyces species were also found frequently during bacteremia after SRP. Aggressive periodontitis patients had bacteremia prior to SRP (about 8%).
Conclusion: Bacteremia is highly associated with periodontopathic microorganisms after SRP in patients with severe periodontitis.
Clinical and Microbiological Parameters
Renvert 1998 ARTICLE
Keywords: Smoking; microorganisms; non-surgical therapy
P: To compare the clinical and microbiological effects of SRP in sites with a PD ≥6mm, 6 months after treatment in smokers and non-smokers.
M&M: 28 healthy subjects, 13 smokers (>/eq 15 cigs/day) vs. 15 non-smokers, with untreated advanced disease(3 sites with BOP and PD ≥6mm) were enrolled in the study. OHI was given and SRP was performed. At 3 months patients were recalled, OHI was re-enforced and prophy given. PI, BOP, PD were measured at baseline and at 6 months. Microbial samples were taken with sterile paper points at baseline and 6 months for Pg, Pi, Pn (Prev nigrescens), and Aa.
R: At baseline the both groups had high PI and BOP. Mean PD was 7.6mm for non-smokers vs. 7.1mm for smokers. At 6 months non-smokers showed a more pronounced bleeding tendency. PD was reduced by 1.9mm for smokers and 2.5mm for non-smokers. The change in CAL was around 1mm for both groups. At baseline the amounts of microorganisms were comparable between the two groups. The reductions following 6 months of SRP were comparable; however Pi/Pn and Aa were more often eradicated from non-smoker sites.
BL: The microbiological response in this study seems to be in conformity with the clinical response, with little influence of the smoking habits.
Cugini 2000 ARTICLE
Keywords: periodontal diseases, periodontitis, treatment, SRP, microbiology, maintenance
Purpose: To evaluate microbial and clinical effects of SRP over a 12-month period.
Materials and methods:
Results:
BL: SRP can control periodontal disease in a major proportion of adult periodontitis subjects, since 60% (32/57) were successfully treated and maintained.
Full Mouth Disinfection
Eberhard 2008 ARTICLE
Keywords: Full-mouth, treatment, scaling, root planning, chronic periodontitis
P: Systematic review to evaluate the clinical effects of FMD (full mouth disinfection) or FMS (full mouth scaling) compared with conventional quadrant SRP for treatment of chronic periodontitis.
M+M: A search was conducted for randomized, controlled clinical trials including full-mouth scaling with or without the use of antiseptics and quadrant scaling (control). Data sources included COHG, CENTRAL, MEDLINE and EMBASE. The primary outcome was tooth loss, secondary outcomes were the reductions of PPD and BOP and a gain of CAL. Of 216 identified abstracts, seven trials were included.
R:
BL: In adults with chronic periodontitis only minor differences in treatment effects were observed between FMD and conventional SRP.
Calculus Control Agents
LeGeros 2003 NO ARTICLE
Keywords: Mouthrinse, calculus, essential-oil, ZnCl2
Background: The significance of having the composition affected is that it can change the solubility and stability of the inorganic component of the calculus and thus also affect the ease of removal of the calculus (author’s theory). Dicalcium phosphate dehydrate (DCPD) is the most soluble of the calcium phosphates in calculus and usually is not found in calculus older than 3 months
Purpose: To determine if anti-calculus agents can affect the composition of the inorganic component of the human dental calculus (HDC) formed.
.M&M: Supra-g HDC specimens were obtained by Pfizer from a 16-week study. It was taken from six mandibular incisors with a sterile scaler and placed in subject specific glass vials. The specimens were divided into 3 groups: group A: standard dentifrices (SD, Crest Cavity Protection), group B: pyrophosphate anti-tartar dentifrice (Crest Tartar Protection), group C: SD and Tartar Control Listerine.
The samples were rinsed with double-distilled water and air-dried over night. They were then analyzed by X-ray diffraction (XRD), Fourier Transform Infrared Spectroscopy (FTIR) and SEM to identify the composition of the calculus. 25 samples and 8 pooled samples were analyzed by XDR and FTIR, while 15 samples from each group were studied under SEM.
Results: Bacteria were found in: group A 100%, group B 60%, and group C 25%. Carbonate hydroxyapatite (CHA) was found in group A, B, and C in 100% of the samples. Dicalcium phosphate dihydrayte (DCPD), the most soluble of the calcium phosphates, was discovered in: group A 55%, group B 45%, and group C 80%.
Discussion: Authors feel that the presence of the Zn ions and the low pH of the mouthwash may stabilize DCPD and may prevent its conversion to the less soluble CHA. Also, since group C had less plaque, they feel that this may also be due to Zn ions (quoted two studies).
BL: Utilizing Listerine anti-tartar control promotes the formation of DCPD.
Schiff T 2007 NO ARTICLE
Keywords: Cetylpyridinium chrloride, zinc gluconate mucoadhesive gel
P: This randomized, double-blind, controlled clinical trial investigated the anticalculus effect of a cetylpyridinium chloride/ zinc gluconate (CPC/ZG) mucoadhesive gel.
M&M:The 80 adults who fulfilled the enrollment criteria were stratified based on total Volpe-Manhold Index (VMI) scores (low, medium, or high), gender, and other demographic data. Within these strata, they were randomly assigned to the CPC/ZG gel group or the placebo gel group, and underwent a baseline oral soft tissue (OST) examination. Subjects were dispensed Oral-B Indicator 35 Compact Head soft toothbrushes and Colgate Cavity Protection MFP toothpaste, and instructed to brush twice daily using these products. Every night for three months, following the nighttime brushing, subjects applied their assigned treatment gel to the lingual surfaces of the six mandibular anterior teeth. They were instructed not to eat or drink until morning and to avoid using other methods of interdental cleaning between the treated teeth, except to remove impacted food. Total VMI scores and OST examination findings obtained at three months were compared with baseline findings.
R: Seventy-eight (78) of the 80 subjects complied with the protocol and completed the study. After three months of treatment, the CPC/ZG group showed a 30% decrease in mean VMI score compared with a 0% decrease in the placebo group. OST examination at three months revealed no serious adverse events in either group.
C: Results of this clinical trial indicate that regular use of the CPC/ZG gel, with or without the use of floss or other interdental cleaning products, yields a statistically significant reduction in calculus
Schiff T, 2008 chiff 2008 NO ARTICLE
Keywords: colgate total, crest, triclosan, calculus
Purpose: To compare the efficacy of a dentifrice containing 0.3% triclosan/2.0% polyvinylmethyl ether/maleic acid (PVM/MA) copolymer/0.243% sodium fluoride in a 17% dual silica base (Colgate Total Advanced Toothpaste) to that of a commercially available dentifrice containing 0.243% sodium fluoride in a silica base (Crest Cavity Protection Toothpaste) with respect to the reduction of supra-g calculus formation.
M&M: 77 subjects received an evaluation of oral soft and hard tissues and were given a complete oral prophylaxis. They were provided with a non-tartar control placebo dentifrice and a soft-bristled adult toothbrush, and were instructed to brush their teeth twice daily (morning and evening) for one minute. After eight weeks of using the placebo dentifrice, baseline supra-g calculus was scored. Qualifying subjects were randomized into two treatment groups (test with dual silica system and control with 0 .243% sodium fluoride) and instructed to brush for one minute twice daily (in the morning and evening). Prior to each study visit, subjects refrained from brushing their teeth and eating and drinking for four hours.
Results: At the twelve-week examination, the Test Dentifrice group presented a mean Volpe-Manhold Calculus Index score of 19.66 and the Control Dentifrice group presented a score of 18.11. After twelve weeks of product use, the Test Dentifrice group exhibited 34.8% less supragingival calculus formation than the Control Dentifrice.
Conclusion: The twelve weeks use of Colgate Total provides significantly greater control of supra-g calculus formation relative to that of a commercially available dentifrice Crest Cavity Protection.