Dental Hygiene Powered Instrumentation Quiz

Powered Instrumentation

• Powered instrumentation devices use a rapidly vibrating working-end to remove calculus, disrupt plaque biofilm, and flush out bacteria from the periodontal pocket.
• Typical components include an ultrasonic generator, a handpiece, and interchangeable tips or inserts.

Timeline for Evolution of Powered Instrumentation

• Late 1950s: Development of the first electronically powered instruments.
• 1960-70s: Powered instruments were initially used to remove heavy calculus deposits, mostly supragingivally.
• Late 1980s: Slim working-ends were developed.
• Today: Modern powered working-ends are as effective as manual instruments for removing subgingival deposits, biofilms, and bacterial products.

Powered Device Classification

• Powered instrumentation is categorized as either ultrasonic, piezo, or sonic.
• Ultrasonic devices operate at 18,000 to 45,000 cycles per second.
• Piezoelectric devices are triggered via electricity, activating crystals within the handpiece.
• Magnetostrictive devices use electrical energy to activate nickel-iron alloys or ferrous rods to vibrate the insert.
• Sonic instruments operate at a frequency of 3,000- 8,000 cycles per second. Air-driven turbine tips move in an orbital motion. Sonic tips attach directly to the handpiece.

Instrument Inserts

• Magnetostrictive devices utilize removable instrument inserts.
• The inserts fit into the handpiece and come in two kilohertz options (25 & 30K), with corresponding insert options available.

Strengths of Powered Instrumentation

• Effective supra- and subgingival calculus removal.
• Effective removal of subgingival plaque and biofilms.
• Slim tips penetrate deeper into periodontal pockets than conventional hand instruments.
• Slim tips allow access to difficult furcation areas.
• Water irrigation flushes bacteria from pockets.
• Reduces instrumentation time.

Pocket Penetration and Irrigation

• Visuals demonstrate the process of pocket penetration and irrigation.

Comparison of Powered and Hand Instrumentation

• Several action mechanisms (mechanical, water irrigation, and cavitation) are used in ultrasonic instrumentation (versus one mechanism in manual instrumentation).
• Ultrasonic instruments are smaller in size than hand instruments.
• Powered instruments can be easily inserted with minimal pocket wall distension.
• Powered instruments remove calculus above, beginning at the gingival margin and working apically towards the junctional epithelium.
• Hand instruments typically remove calculus, beginning at the junctional epithelium and moving coronally towards the gingival margin.
• Powered instruments are less likely to cause tissue damage.
• Hand instruments require more frequent sharpening.
• Treatment outcomes depend on the clinician's skill level with either instrument.
• Aerosol production is greater with powered instruments and can be a factor in contamination concerns.

Limitations of Powered Instrumentation

• Skill level of clinician impacts patient outcome, (similar to hand instrumentation).
• Piezo and Magneto instrumentation is more technique sensitive than hand instrumentation.
• Powered instrumentation often has reduced tactile sensitivity compared to hand instruments.
• Not all patients are suitable for powered instrumentation.

Modes and Mechanisms of Action

• Mechanical Removal: Rapid vibrations of the powered working-end create microfractures in calculus deposits.
• Water Irrigation: Constant stream of water near the working-end; flushes out toxic products and bacteria; dissipates heat caused by rapid vibrations.
• Cavitation: Formation of tiny bubbles from water stream contact with the vibrating working-end; collapses and produces shock waves that can destroy bacteria.
• Acoustic Microstreaming: Another phenomenon in ultrasonic devices characterized by small currents moving in the water, transporting cavitation bubbles within the mouth; common around oscillating objects including the cavitation tip or scaler tip.

Mechanism of Action

• Frequency: Number of vibrations a powered working-end completes per second.
• Amplitude: Distance the powered working-end moves back and forth.
• Controlled by power setting on the unit.

Frequency (Vibration)

• Comparing the working-end frequency to car windshield wipers: - Low frequency: wipers move back and forth a few times per minute - High frequency: wipers move back and forth several times per minute.

Amplitude (Stroke Length)

• Lower Amplitude: Produces a shorter, less powerful stroke.
• Higher Amplitude: Creates a stronger, more powerful stroke.
• Research suggests no significant difference in efficiency between high and medium-powered instrumentation to maximize patient comfort and minimize tooth surface damage. Setting power above medium is therefore not recommended.

Understanding Amplitude-Pushing a Swing

• Visual shows the relationship between Amplitude (and its corresponding power) and the working stroke of a swing.

Cleaning Efficiency of Powered Instrumentation

• Cleaning efficiency is determined by a combination of frequency and amplitude.
• Low frequency and amplitude work best to remove plaque biofilm using fewer vibrations and shorter strokes;
• Higher frequency and amplitude are best for tenacious calculus using more vibrations and longer strokes.

Pattern of Working-End Movement

• Magneto: Primarily elliptical. Movement can range from nearly linear to elliptical/circular, depending on the type/shape of tip and machine.
• Piezo: Primarily linear; dimensional changes in crystals caused by electrical energy.

Comparison of Ultrasonic Scalers

• Magnetostrictive: Frequency range 20-40 kHz, elliptical stroke pattern; uses a metal rod or stack of metal sheets; active on all surfaces.
• Piezoelectric: Frequency range 29-50 kHz, linear stroke pattern; uses crystals activated by a ceramic handpiece; active on lateral surfaces only.

Water Flow to Powered Working-End

• Piezo devices require cooling with water to manage heat over time.
• Magneto devices are also maintained with water irrigation.
• Using too little water can result in overheating. Sonic tips do not overheat and therefore do not require continuous water.

Fluid Reservoirs for Powered Instrumentation

• Independent fluid reservoirs deliver distilled/treated water or other fluid solutions to the working-end (connected to the dental unit).
• Some devices use a fluid reservoir instead of direct water hoses, which is better in some cases for preventing contamination.

Part of Dental Unit

• Parts of the dental unit and their layout are shown, particularly important places to consider in the clinic layout (infection control, water access).

Water Adjustment on Working-End

• Visuals of the adjustment mechanisms for water flow and pressure.

Water Delivery Designs

• Different types of water delivery, with descriptions of each.

Power Setting Controls

• Images showcasing the many controls on dental units for adjusting power and output.

Activating Rheostat

• Illustrations showing how the rheostat is adjusted or activated.

Powered Working-End Design

• Diagram comparisons for hand instruments versus powered instrument tips. Note the different active tip areas.

Powered Tip Design

• Two types of powered tips are available. - Standard: Larger, shorter shank tips; best for supragingival, supra gingival/subgingival calculus removal. - Slim perio: Smaller, longer shank; good for deep periodontal pockets, root concavities, and furcation areas.

Powered Tip Selection

• Selection is based on tip shape, size, length, curvature, and attachment method.
• Consider the mode and extent of calculus attachment, calculus size/hardness, calculus location/depth, and if it is supra- or subgingival.

The Proper Tip for the Task at Hand

• Appropriate tips for different debridement tasks: - Standard: Moderate-to-heavy supragingival calculus and shallow pockets - Slim Perio: Light-to-moderate calculus and root surfaces - Round: Biofilm and light calculus deposits. - Flat Lateral Surfaces: Medium-to-large deposits

Standard Tip

• Characteristics: Standard size, shorter shank length. -Use: Removing heavy supragingival and easily accessed subgingival calculus; Minimal tissue distention due to shorter shank length.

Slim Perio Tip

• Characteristics: Up to 40% smaller size, longer shank lengths. -Use: Light-to-moderate calculus and deep periodontal pockets; root concavities and furcation areas.

Left and Right Curved Tips

• Illustrations show left and right curved tips, for various areas of the mouth.

Powered Tips for Dental Implants

• Instruments for implants should be made of a material softer than titanium to avoid scratching.
• Plastic or carbon coated tips are preferred for use with titanium implants.

Plastic-Coated Piezo Tip

• Illustrations of the tip coated with plastic ( for use with titanium implants).

Instrument Tip Wear and Replacement

• Regularly inspect powered instrumentation tips.
• Wear reduces efficiency.
• A one millimeter wear results in approximately a 25% efficiency loss.
• A 2 mm of wear should be cause for discarding the tip.

Tip Wear Guide

• Visual guide to illustrate tip wear and efficiency loss guidelines.

Instrumentation Technique

• Clinician position should be similar to hand instrumentation
• Patient position and head positioning should allow effective water flow.
• A light, relaxed grasp of the instrument is preferred.
• Instrumentation technique, sequence, and approaches vary by clinician skill level.

Fundamental Skills for Powered Instrumentation

• Powered instrumentation relies on basic skills.
• The clinician should adopt a similar position as with hand instrumentation.
• Patient positioning must be adequate for water flow drainage.
• A light, relaxed grasp is needed.
• Instrumenting procedures and order can be varied by skill level. -Sextant by sextant -Buccal/Facial first and then proximal regions.

Fundamental Skills for Powered Instrumentation (additional information)

• Finger rests/fulcrum: use extraoral, cross-arch, or opposite-arch to use advanced finger rests in a manner separate from the treatment area.
• Lateral pressure: use feather-light rather than firm pressure (firm pressure lessens effectiveness of instrument).
• Activation: digital activation needed, for example of devices with digital control systems.
• Assessment/end point: use explorer to evaluate deposit removal.

Approaches to Instrumentation

• Hand: Placement apical to the calculus deposit, starting at the base of the pocket and working towards the CEJ.
• Powered: Working from the coronal-most region of the deposit, starting near the CEJ and working apically towards the base of the pocket.

Approaches to Instrumentation (Top-Down Approach)

• Calculus is removed from above the deposit surface in an apical direction to the bottom of the deposit.

Strokes for Calculus Removal

• Slow, repetitive strokes work best for calculus removal rather than a quick, single stroke.
• Only minimal/gentle pressure is needed during powered instrumentation.
• Overlapping strokes are more effective.

Strokes for Biofilm Removal

• Mechanical removal of plaque biofilm is necessary to improve periodontal health.
• Ultra-sonic instrumentation with low pressure, using methodical, overlapping strokes that are close together will help in the removal of plaque biofilm.

Stain Removal

• (No specific information provided on this topic)

IMPORTANT TO NOTE

• Must maintain continuous motion of the powered working-end.

Tip Adaptation and Orientation to the Tooth Surface

• Active tip area is the portion of the tip doing the work (last 2-4 mm of the lateral surfaces of the powered tips).
• Historically, only lateral surfaces of powered instruments were considered to be the most effective.
• Utilizing any surface of tip (lateral, face, or back) allows a greater degree of contact with the tooth.
• Use surface of the tip that best conforms to the tooth anatomy.

Comparison of Ultrasonic Scalers (reminder)

• Different frequencies, stroke patterns, and energy conversion methods are present based on whether piezoelectric or magnetostrictive powered instruments are used.

Powered Tip Adaptation

• Adapt the proper tip surface to the tooth surface, to control energy dispersion.
• Never adapt the tip point directly onto a tooth surface.
• For piezoelectric devices, adapt lateral surfaces for calculus and biofilm removal.
• For magnetostrictive devices, adapt lateral, face, and back surfaces for calculus/biofilm removal.

Different Amounts of Energy

• Point of the tip will disperse the largest amount of energy
• The face of the tip disperses a medium amount of energy.
• The back of the tip disperses the smallest amount of energy.
• The lateral surfaces of the tip have the least amount of energy dispersion, and are the proper area to contact the demineralized surface of a tooth.

Amount of Energy Dispersed

• The point of the tip disperses the greatest amount of energy.
• The second greatest amount is found on the face of the tip.
• The smallest amount is found on the back of the tip.
• Lateral surfaces of tips disperse the least amount of energy.

Point of Tip

• Disperses the largest amount of energy; Should not be adapted to the tooth surface due to risk of damage.
• Illustration demonstrates that the tip point NOT the surface is where contact occurs directly to a large calculus deposit.

Face of Tip

• Disperses second greatest amount of energy.
• Should not be adapted directly onto demineralized surfaces.

Back of Tip

• Disperses less energy than the face.
• Many tips are adapted to the back of the tip.

Adaptation of the Back

• Illustrations demonstrate how the back of a tip may be adapted to the tooth, depending on the instrument.

Lateral Surfaces of Tip

• Disperses the smallest amount of energy.
• Can be placed directly on tooth surface.

Correct Adaptation

• Illustration and description demonstrate the correct technique for tip adaptation.

Transverse Tip Orientation

• Transverse orientation uses the tip active surface in the transverse direction (at right angle to the tooth); typically used for supragingival interproximal debridement.

Transverse Tip Orientation with Lateral Surface

• Illustration demonstrates correct placement for supragingival interproximal debridement using a lateral surface.

Vertical Tip Orientation

• Vertical orientation uses the tip active surface similar to a perio probe, and is used for either supra- or subgingival areas/regions.

Vertical Tip Orientation with Lateral Surface

• Illustration demonstrates vertical placement for use in either supra- or subgingival regions using a lateral surface.

Straight Slim Tip in Vertical Orientation-Anterior/Posterior

• Illustrations demonstrate vertical tip placement for use on anterior and posterior teeth using a straight, slim tip.

Tip Angulation

• Tip should be positioned close to zero degrees relative to the tooth surface used in procedures (illustration demonstrates zero, 0-15, and 45-90 degrees).

Working Stroke

• Varying direction of the instrument is required; distribution of strokes must be even.
• Constant strokes must be maintained,
• Overlapping and light pressure are both important for effectiveness during working strokes.

Stroke Direction

• Illustrations demonstrate horizontal, oblique, and vertical stroke directions.

Sweeping Motion

• Illustration demonstrates the sweeping motion used while instrumenting a tooth.

Work in Sections

• Illustration and description show instrumenting in sections.

Tapping Against Deposits

• Illustration shows the tapping technique used when contacting a deposit.

Recap- Powered Instrumentation

• Gentle pressure is crucial.
• Slower, repetitive strokes are more effective.
• Overlapping strokes maximize effectiveness when removing tenacious deposits.
• Use of digital activation.
• Follow with hand instrumentation as necessary.

Angulation

• Illustrations demonstrate correct instrument placement relative to the tooth to ensure effective instrument contact and avoid damage to the tooth.

Considerations and Contraindications

• (No details or specific guidelines are provided).

Powered Instrumentation (Aerosol Production)

• Powered instruments generate high levels of contaminated aerosols.
• Microorganisms in aerosols can survive up to 24 hours.
• Antimicrobial mouth rinse reduces bacteria in aerosols by approximately 92%.
• Evacuator tips and high-volume evacuation (HVE) systems are used to reduce airborne contamination.
• Saliva ejectors are not effective means for controlling aerosols.
• Thirsty and Isolite systems may help for controlling aerosols in private practice.

In our Clinic, Our Policy...

• Two forms of suction (HVE and saliva ejector) are used to reduce and control aerosols during treatment.

Powered Instrumentation (Review Patient Medical and Dental Histories)

• Review relevant histories beforehand for patients undergoing mechanical treatment to prevent contraindications.
• Examples of conditions for contraindication include respiratory and/or cardiac conditions, communicable diseases, difficulty in swallowing, susceptibility to infection, demineralized surfaces of teeth, titanium implant surfaces.

Caution

• Powered instruments are not recommended for all patient types.
• Thorough review of the patient's medical and dental history before treatment is mandatory.

Cardiac Pacemakers

• Patients with cardiac pacemakers should not be exposed to magnetostrictive ultrasonic devices.
• Piezoelectric devices do not generate magnetic fields thus pacemakers are typically not impacted by piezoelectric ultrasonic devices.
• Vagus nerve stimulators are not adversely impacted by the use of ultrasonic devices.

Other Opinions

• St. Jude Medical and Boston Scientific state that there is no known risk of use of powered dental instruments with pacemakers (however, physician consult should always be consulted). -Other medical device manufacturers also recommend physician consult for any implanted medical device before use during dental procedures.

Communicable Disease

• Individuals with communicable diseases that can be transmitted by dental aerosols or contaminated dental unit water.
• Patients with tuberculosis and respiratory infections may be at increased risk.

High Susceptibility to Infection

• Individuals with high susceptibility to opportunistic infection may result from contaminated dental unit water and aerosols.
• Examples of patients include those with chronic conditions such as COPD, Cystic Fibrosis, Emphysema, Asthma, uncontrolled diabetes, organ transplants, debilitated individuals and immunosuppressed patients, patients undergoing chemotherapy or other disease treatments..

Difficulty in Swallowing or Prone to Gagging

• Patients with neurological conditions such as multiple sclerosis, amyotrophic lateral sclerosis, muscular dystrophy, Parkinson disease, or paralysis may experience swallowing difficulties and gagging.

Age

• Primary and newly erupted teeth of young children, with large pulp chambers, are susceptible to damage from vibrations and heat by ultrasonic instrumentation.

Oral Conditions

• Avoid contact of tip with hypersensitivity, porcelain crowns, composite resins, demineralized enamel surfaces, and exposed dentinal surfaces.

Implants

• Do not use powered instrumentation on titanium implants unless covered by plastic sleeve.

Controlling Aerosols

• Use high-speed/high-volume evacuation suction to control aerosol spread.

Helpful Tricks for Ultrasonic Use

• Patient assistance, cotton rolls, and dry angles can minimize aerosol spread.
• Use of short HVE tips, chairside assistants, and pain management techniques to minimize aerosol spread.

Setup of Ultrasonic Device

• Place device on a stable countertop or cart within an easily accessible location to the dental chair.
• Apply infection-control barriers.
• (In some dental clinic setups a separate, portable unit is not used).

Connect to Water Source

• Connect water hose to the water outlet on the dental unit.
• In some systems, fluid reservoirs are used for water solutions instead of a direct hose connection.

Turn on the Unit

• Turning on the unit will also turn on the ultrasonic device.

Flush the Water Lines

• Flush the water tubing for 2 minutes at the start of each day and 30 seconds between each patient.

Fill Handpiece with Water

• Fill handpiece with water prior to placing the insert into the handpiece.
• Repeat this process for each tip change.

Why fill the handpiece with water?

• Removes air bubbles from handpiece.
• Eliminates the possibility of overheating the handpiece.

Lubricate the O-Ring

• Lubricate the O-ring with water from the handpiece using fingertips to help eliminate friction during usage.

Seat Insert in Handpiece

• Grasp the insert grip and gently push the insert into the handpiece until it snaps into place.

Adjust the Water Spray

• Adjust the water spray on the handpiece.

Water Spray

• Should be a cloud of water.
• Readjust as needed if changing tips, and power levels.
• Increase water if the handpiece begins to feel hot.

Handpiece Cord Management

• Handpiece cords tend to weigh down the end of the handpiece and cause handpiece twisting.

Additional Notes

• Refer to Sakai for additional videos and tips for use with powered dental instruments.

Test your knowledge on powered instrumentation devices used in dental hygiene. This quiz covers the functionality, characteristics, and recommendations for using various powered tips effectively. Assess your understanding of sonic powered devices and tips for optimal dental care.