Advances in Power Driven Pocket Root Instrumentation (2008) - PDF

J Clin Periodontol 2008; 35 (Suppl. 8): 22–28 doi: 10.1111/j.1600-051X.2008.01258.x Advances in power driven pocket/ A. Damien Walmsley1, Simon C. Lea1,...

J Clin Periodontol 2008; 35 (Suppl. 8): 22–28 doi: 10.1111/j.1600-051X.2008.01258.x Advances in power driven pocket/ A. Damien Walmsley1, Simon C. Lea1, Gabriel Landini1 and Anthony J. Moses2 root instrumentation 1 School of Dentistry, The University of Birmingham, St. Chad’s Queensway, Birmingham, UK; 2Wolfson Centre for Magnetics, Cardiff University, Cardiff, UK Walmsley AD, Lea SC, Landini G, Moses AJ. Advances in power driven pocket/root instrumentation. J Clin Periodontol 2008; 35 (Suppl. 8): 22–28. doi: 10.1111/j.1600- 051X.2008.01258.x. Abstract Objectives: The primary aim was: ‘‘Does power-driven pocket/root instrumentation offer a clinical advantage over hand instrumentation’’? Secondary aim was to update knowledge base of power-driven instrumentation post Tunkel et al. (2002). Material and Methods: A literature search of power-driven instruments (in vitro, in vivo and controlled clinical trials) was performed from April 2001 using similar criteria to Tunkel et al. (2002). Primary outcome was whether power-driven instruments offered an advantage over hand instrumentation; secondary outcomes were effect on root surface, effectiveness of new instrument designs, and role of biophysical effects such as cavitation. Results: From a total of 41 studies, 14 studies involved comparison of power-driven devices with hand instrumentation for non-surgical therapy. These were subdivided into new designs of power instrumentation, full-mouth debridement and irrigation and patient acceptance. Use of power-driven instrumentation provides similar clinical outcomes compared with hand instrumentation. Difficulty of pooling studies continues to hinder the drawing of definitive conclusions. Key words: periodontal therapy/non surgical; Conclusion: Newer designs of powered instruments have not shown any benefit when power driven instrumentation; scaling and root compared with other ultrasonic devices in non-surgical periodontal therapy. New in planing; systematic review vitro research shows there is variation in the performance of different tip designs and generators, but its clinical relevance remains unknown. Accepted for publication 20 May 2008 Deposits on tooth root surfaces may reduce the pathogens that are present the vibrations may also generate cavita- range from simple biofilms to hard (Slots 1979, Slots & Ting 1999) to allow tion within the water which could assist tenacious calculus. Mechanical removal periodontal health to return. in the cleaning process. Compared with of these deposits from the root surface is Hand instruments are available in hand scalers, power-driven instruments required for establishing and maintain- various designs, described as curettes, have the advantage of being easier to ing periodontal health. This removal hoes or scalers. They all have a sharp use and may take significantly less time may be achieved via hand or powered working tip, which is used to mechani- than hand instruments (Tunkel et al. instrumentation (Tunkel et al. 2002). cally break the bond between deposit 2002). The disadvantage is that the The aim of such treatment is to disrupt and tooth. The process is time consum- clinician may lose tactile control the subgingival biofilm and in doing so ing and physically demanding, but is although it is reported that this may seen as the treatment of choice as it is only be of a transient nature, with the Conflict of interest and source of believed that the clinician has direct operator regaining sensation with time funding statement tactile control over the hand instrumen- (Ryan et al. 2005). The powered instru- The authors have declared no conflicts of tation process compared with the use of ment has the potential to damage the interest. powered devices (Meyer & Lie 1977). root surface producing indentations and The authors wish to acknowledge the sup- Power-driven instruments differ from unwanted scratches on the hard tissue port of the Engineering and Physical their hand counterparts in that they are surface although no definite conclusion Sciences Research Council, UK; Grant relatively blunt and rely on the accel- has been reached on this subject (Drisko Nos: GR/T22551 and GR/T22568. The eration of the vibrating tip to disrupt the et al. 2000). The selection and use of the 6th European Workshop on Periodontology plaque and calculus. During use, cooling two methods (hand or power) is a per- was supported by unrestricted educational water is passed over the tip to reduce sonal decision but there seems to be a grant from Straumann AG. frictional heating (Lea et al. 2004a) but trend among clinicians to select power- 22 r 2008 The Authors Journal compilation r 2008 Blackwell Munksgaard  Power-driven pocket/root instrumentation 23 driven scalers over hand instruments within the handle of the handpiece which ellipsoidal shapes thus producing the (Drisko et al. 2000, Tunkel et al. 2002) will oscillate in the presence of an elec- oscillation (Sculean et al. 2004). The partially due to improved ergonomics. tromagnetic field. Both magnetostrictive instrument oscillation is powered by a However, the use of these instruments and piezoelectric devices will have a piezoelectric generator. The Vector sys- might have potential health hazards scaler tip design that resembles a hand tem is used in conjunction with a pol- (Trenter & Walmsley 2003). scaler which is either fixed or detachable. ishing fluid containing hydroxyapatite There have been a number of key There have been reports in the literature granules o10 mm (Braun et al. reviews in the area of powered instru- of sharpening sonic scaling tips to improve 2007a, b, Kahl et al. 2007a, b). mentation. In 2000 the Research, efficiency (Checchi et al. 1991). This idea Science and Therapy Committee of the led onto diamond coating the scaler tips American Academy of Periodontology (Yukna et al. 2007), which were shown to Scaler Tip Movement undertook a qualitative review of the produce faster removal of calculus Until recently there has been limited literature (Drisko et al. 2000). It sum- although it did lead to more root surface understanding of the movement of the marized that ultrasonic and sonic scalers removal using an in vitro model to simu- tips of ultrasonic scalers as the move- produce similar results to hand instru- late the clinical situation (Kocher et al. ment was at a high frequency with small ments following periodontal therapy. It 2001; Vastardis et al. 2005). Alterations to displacement amplitudes (Walmsley did recommend that more randomized the probe can also lead to a decrease in et al. 1986). With the introduction of clinical-controlled trials should be efficiency. Scaler tips wear with use and advanced technology of scanning laser undertaken to determine whether there this may be a problem if clinicians do not vibrometry, it is now possible to study is a significant advantage in using ultra- regularly update their equipment. The the vibrations of the tips at ultrasonic sonic scalers. A detailed systematic movement of the tips becomes variable frequencies (Lea et al. 2002, 2004b). review of the clinical use of powered and generally decreases as the length of One of the main findings made possible instruments compared with hand instru- the probe is reduced with wear (Lea through laser vibrometry is the signifi- ments (Tunkel et al. 2002) based on the et al. 2006). This could lead to poor cant variability observed in the oscilla- informed selection of randomized-con- clinical outcomes of treatment but further tion characteristics of dental ultrasonic trolled trials, found that there were research is needed to establish whether scalers. This might be expected between similar clinical outcomes compared this is the case. Another approach has been scalers whose tips are of different with hand instrumentation in the effi- to design scaler tips with a paddle-like designs but has also been observed cacy in the subgingival debridement of working end covered with spheroid con- between instruments that are nominally single rooted teeth. The powered instru- vexities (Petersilka et al. 2003). This is the same (Lea et al. 2003a, b). This ment was found to complete subgingival designed to ‘‘pound’’ the calculus and effect was particularly significant for debridement quicker compared with dislodge it from the tooth surface. It has slimmer designs of tips such as the hand scalers. A structured review has been claimed that the tip provides shear Slimline (Dentsply International, York, also been undertaken on the hazards as- stresses that remove the calculus leaving PA, USA) and the P-tip (Electro Medical sociated with ultrasonic scalers (Trenter the underlying root surface undamaged. Systems SA, Nyon, Switzerland), both & Walmsley 2003) including aerosol All powered scalers that are available unloaded (oscillating freely in air) and production, effect on cardiac pace- to clinicians, have various designs of when placed under loads similar to those makers and auditory hazards to both tips that may range from a traditional which may be encountered clinically clinician and patient. Unlike the review broad shape to a Slimline design. This (Lea et al. 2003a, b, Trenter et al. 2003). by the American Academy of Perio- movement to a thinner design of tip is Loading will damp the vibrations of dontology it did not discuss which related to accessibility of the furcation all types of scaler tips, whether driven instrument causes most disruption of area of posterior teeth (Dragoo 1992). by magnetostriction or piezoelectricity the tooth surface (Drisko et al. 2000). There are ultrasonic devices which (Lea et al. 2003b). Slimmer designs of resemble endodontic files such as those scaler tips are more susceptible to load- used in Endosonics. The first of these ing than the traditional tips which have Review of Available Instrumentation was the Periosonics (Micro-Mega, Pro- larger dimensions. Increases in genera- Powered instruments may be categorized donta SA, Geneva, Switzerland) which tor power setting, under a variety of as either sonic or ultrasonic. Ultrasonic was driven by compressed air (Rees loads, showed that slimmer tips had a devices work in the frequency range of et al. 1999, Beuchat et al. 2001) in a highly variable change in tip vibration, 25–42 kHz while the sonic devices typi- similar manner to a sonic scaler. This whereas the wider tips were more likely cally work at frequencies between 6 and instrument was a direct copy from endo- to produce a linear increase in displace- 8 kHz. The manner of oscillation produc- dontic instrumentation and the idea was ment amplitude with increasing power tion for the two classes is different. Sonic to reproduce the flushing and cleansing (Lea et al. 2003a, Trenter et al. 2003). devices rely on the passage of com- action of endosonic instrumentation in Such variations of tip movement should pressed air over an eccentric rod that is the root canal but within the periodontal be factored into clinical trials to allow driven to vibrate. Ultrasonic devices may pocket. A variation of the traditional for more meaningful comparisons. be categorized by the method of ultra- ultrasonic oscillation the Vector system sound generation that may be either (Dürr Dental GmbH & Co. KG, magnetostrictive or piezoelectric. The Bietigheim-Bissingen, Germany) was Cavitation and Microstreaming magnetostrictive devices have a nickel introduced where the vibration is pro- The ultrasonic scalers are operated with stack that is driven to vibrate by an duced by attaching a thin metallic probe a water flow which serves several pur- electromagnetic current. In contrast, (similar to an periodontal probe) to a poses including (with magnetostric- piezoelectric devices incorporate a crystal metal ring, which is induced to flex into tive scalers) cooling of the generator r 2008 The Authors Journal compilation r 2008 Blackwell Munksgaard 24 Walmsley et al. magnetic core material which drives the Material and Methods  Wennström et al. (2005) – ultra- scaler probe oscillations. The water also Acknowledging the presence of the sonic debridement provides cooling at the treatment site, three substantial reviews (Drisko et al.  Tomasi et al. (2006) – ultrasonic where too little water can potentially 2000; Tunkel et al. 2002; Trenter & debridement lead to rapid heating due to friction Walmsley 2003), a literature search of between the probe and the tooth (Lea all studies that included the use of  Patient acceptance et al. 2004a). Water also clears the power-driven (ultrasonic instruments) treatment site of material which is was performed from April 2001 up to  Braun et al. (2003) removed during the treatment, aiding December 2007 using similar search  Kocher et al. (2005) the operator’s visibility, potentially criteria as in the review by Tunkel  Bonner et al. (2005) speeding up the procedure. et al. (2002). Studies retrieved included Another documented benefit of the in vitro, in vivo and controlled clinical Those clinical studies which investi- flowing water is the inception of biophy- trials which compared power-driven gated the new designs of power instru- sical forces – namely cavitation and instruments with hand instruments for mentation (Vector and Periosonic) in streaming. The potential effects of these the treatment of chronic periodontitis. comparison with conventional hand have been shown in vitro (Walmsley et The search was limited to English instrumentation did not find statistically al. 1988, 1990, Khambay & Walmsley language publications. Further hand significant differences in the clinical 1999). Their contribution to the clinical searching of the main periodontal publica- outcomes. In the full-mouth debride- result remains unclear although many tions; Journal of Clinical Periodontology, ment and irrigation studies the authors clinicians consider the potential benefit Journal of Periodontology, Journal of concluded that there was no statistically of such forces may, if properly har- Periodontal Research and Periodontology significant differences in the clinical nessed, improve the efficiency of these 2000 was also made to check for addi- result achieved whether hand instrumen- instruments. The cavitation and the asso- tional literature. The results were then tation or ultrasonic instruments were ciated jet effect (generated during asym- hand-checked to eliminate non-relevant used. In the studies on patient accep- metrical bubble collapse) may be of use subject areas. The articles selected were tance it was initially claimed in a clin- in removing material from tooth surfaces considered to be relevant to the use of the ical trial that the Vector was more (Walmsley et al. 1988) and is powerful ultrasonic and sonic scalers. comfortable to use and had greater enough to cause damage to the surface of patient acceptance over conventional the ultrasonic scaler (Lea et al. 2005). ultrasonic instrumentation (Braun et al. Acoustic microstreaming forces are Results 2003). A randomized-controlled trial by characterized by low-velocity flows but The search revealed 41 studies that used Kocher et al. (2005) found that there generate high shear stresses close to the power-driven instrumentation. Of these, was no statistically significant differ- ultrasonic probe (Khambay & Walmsley 21 were clinical studies. Closer inspection ence between the two types of instru- 1999). These may be useful in disrupting of these clinical studies showed that 14 mentation. It has been shown that the biofilm on root surfaces and for involved comparison of power-driven patients experienced similar discomfort removal of loosely attached material. devices with hand instrumentation for from routine supra-gingival scaling at non-surgical therapy. These clinical stu- the dentist irrespective of the procedure dies were further subdivided into the whether it is by manual instruments or following classes: ultrasonic scalers (Bonner et al. 2005). Summary and Aim of Present Review Although hard to quantify, it is likely that  New designs of power instrumentation the majority of patients attending for a Discussion routine appointment with their dentist/  Beuchat et al. (2001) – Periosonic This review has found similar results to clinician will be exposed to some form  Sculean et al. (2004) – Vector those of Tunkel et al. (2002) in that of powered instrument. There have been  Christgau et al. (2007) – Vector recent clinical studies do not indicate a a number of different powered devices  Kahl et al. (2007a, b) – Vector difference between ultrasonic/sonic and introduced into periodontology, including manual debridement in the treatment of those powered by traditional drills which chronic periodontitis. In many of the involve either a reciprocating or rotating  Full-mouth debridement and irrigation studies it is not possible to compare action. This review focuses on powered the operating characteristics of the ultra- oscillatory instruments/scalers. This  Del Peloso Ribeiro et al. (2006) – sonic scalers as there are few details of review intends to update our knowledge ultrasonic debridement with povi- the instrument settings and the duration of the use of power-driven instrumenta- done–iodine of the treatment. tion following up on publications which  Leonhardt et al. (2006) – ultraso- appeared after the reviews of Drisko et al. nic debridement with povidone– New designs of power instrumentation (2000) and Tunkel et al. (2002). iodine The primary objective was to deter-  Leonhardt et al. (2007) – ultraso- Since the review of Tunkel et al. (2002) mine whether power-driven instruments nic debridement with povidone– there has been the introduction of newer offered an advantage over hand instru- iodine designs of power instrumentation which mentation; secondary objectives were the  Rosling et al. (2001) – ultrasonic have mainly focussed on the Vector effect on the root surface, effectiveness of debridement with povidone–iodine system. Although cited as a significant new instrument designs and the role of  Koshy et al. (2005) – ultrasonic progress in power-driven instruments, biophysical effects such as cavitation. debridement this device uses a similar vibration r 2008 The Authors Journal compilation r 2008 Blackwell Munksgaard  Power-driven pocket/root instrumentation 25 mode to traditional ultrasonic scalers. It The loads used were different to the that the ultrasonic non-surgical treat- oscillates at similar ultrasonic frequen- previous studies 0.39 N for the US and ment reduced the number of positive cies and the tip is set at right angles to 4.9 N for the hand. It was quoted that, at individuals but the results varied for the longitudinal oscillation of the hand- medium power setting, profilometry of the different bacterial species. piece. Ultrasonic scaler tips approach the root revealed that the Vector pro- this motion as the tip curves towards a duced a smoother surface but was the Removal of the biofilm right angle to the main driver. Although slowest in removing calculus. one study using this device reported a The biofilm is a complex hierarchy of reduction of the pain experienced during Full-mouth debridement and irrigation bacteria (Costerton et al. 1995) that dental treatment (Braun et al. 2003) forms on the surface of the tooth (it when compared with traditional ultra- Full-mouth debridement and irrigation does form on the root surface but also on sonic scalers, details of how the clinical is a frequent treatment approach for the enamel and on tooth restorations!). treatment was standardized were not chronic periodontitis. Such a technique The bacteria within the biofilm forms a clear and therefore difficult to replicate. allows treatment to be undertaken in a complex living community that serves In contrast, the RCT by Kocher et al. shorter time period (Koshy et al. 2005, to protect itself and thrive in an aqueous (2005) found no differences in the dis- Wennström et al. 2005), although the environment. The purpose of any instru- comfort that patients experienced eventual clinical results are similar mentation is to disrupt this biofilm thus whether the Vector or traditional ultra- (Tomasi et al. 2006). allowing the host to repair (Haffajee et sonic instruments were used. In order to optimize the full-mouth al. 2006). After treatment, roots will still Clinical studies have shown compar- debridement, studies have used che- harbour plaque and calculus as well as able clinical results between the Vector motherapeutic agents as the coolant or endotoxins attached to the root cemen- device and hand instrumentation (Sculean irrigant. Povidone–iodine is water-solu- tum (O’Leary et al. 1997). Many et al. 2004, Kahl et al. 2007a, b). How- ble and is a combination of polyvinyl- researchers have targeted the removal ever, in deep pockets root planing pyrrolidone and iodine (PVP–I). The of the biofilm via the use of ultrasonic rendered a better resolution of in- interest in this antimicrobial agent arises scalers (Del Peloso Ribeiro et al. 2007, flammation, although there was more due to its properties of having a broad Leonhardt et al. 2007) but could not find hypersensitivity. spectrum bactericidal activity, thereby it to be better than treatment with hand A series of articles have compared the showing much potential in perio- instruments. Vector system with hand scaling of teeth dontology (Hoang et al. 2003). Povi- The ultrasonic scaler does possess the both in vitro and in vivo (Braun et al. done–iodine as the cooling liquid in ability to disrupt the biofilm not only 2003, 2005a, b, 2006). The clinical stu- ultrasonic scalers has been shown to from tip contact but also via the effects dies follow a similar pattern in that they improve the effectiveness of non-surgi- of cavitation and microstreaming. How- have used four variables (1) hand instru- cal therapy (Rosling et al. 2001). A ever, lack of understanding of how and mentation with Gracey curettes, (2) a randomized clinical trial compared the where these phenomena do occur along traditional ultrasonic system (US) (3) use of ultrasonic scalers with either the ultrasonic scaler tip at present pre- Vector with hydroxyl apatite (VHA) distilled water or 10% PVP–I as the vents its optimal use in the clinical polishing fluid and (4) Vector with a cooling liquid in the treatment of lower debridement process. silicon carbide (VSC) containing abra- or upper molars (Del Peloso Ribeiro et The removal of plaque biofilm and sive fluid. The settings of the Vector al. 2006). The article provides few calculus is an important goal of perio- were at 30 mm which corresponds to details of how the scalers were used dontal therapy. The goal of the ultra- setting 7 on the instrument dial. One such as duration of use, time involved sonic scaler is to be at least as efficient operator was used throughout the and approach to treating the defects. as hand instrumentation in this removal studies who was trained to deliver the However, their conclusion was that process. While the removal of calculus lateral forces to the root surfaces which there were no additional benefits over is deemed important, assessment of the ranged from 4.76 N with the hand instru- conventional ultrasonic scaling. The use removal process is usually by careful ment to 0.83 N for the US. As the mode of PVP–I has been compared against visual inspection or by tactile sensa- of oscillation and how it may be affected other treatments: (1) ultrasonic sca- tion with a periodontal probe. Both by loading has not been visualized it is ling1subgingival irrigation with 0.5% techniques have their difficulties. In an difficult to draw any firm conclusions. PVP–I for 5 min./tooth, (2) ultrasonic attempt to overcome these problems, The Vector system produced smooth scaling1subgingival irrigation with sal- research has been performed into devel- surfaces (which may be due to factors ine solution for 5 min./tooth, (3) subgin- oping a smart device (Meissner et al. such as damping). The removal of cal- gival irrigation with saline solution for 2006). This device features a piezocera- culus was similar both with the HA 5 min./tooth, and (4) subgingival irriga- mic crystal that picks up small differ- system and the US. It was also reported tion with 0.5% PVP–I. Each tooth in the ences in the oscillation of the tip as it that the Vector was slower in removing assigned quadrant received 5 min. treat- moves over the root surface. While this calculus than the hand and US. ment time (Leonhardt et al. 2006). No device shows promise in vitro, it is yet Other groups have looked at the Vec- difference was found between the four to be trialed in clinical studies. tor system against traditional piezoelec- treatments, although it was accepted in tric ultrasonic devices. Extracted teeth the trial that their concentration was Improvements in cleaning root surfaces instrumented with a Vector HA were lower than that used by others (0.5% compared with both traditional ultraso- versus 10%). Further work evaluated the Furcation involvements are difficult to nic scaling (piezoelectric generator) and reduction in putative periodontal bacter- treat and often, due to accessibility pro- Gracey curettes (Kishida et al. 2004). ia (Leonhardt et al. 2007). It was found blems, there can be incomplete removal r 2008 The Authors Journal compilation r 2008 Blackwell Munksgaard 26 Walmsley et al. of calculus from the root surface. In the point of the instrumentation is also fairly Clinical comparison of the effectiveness of past this has been tackled by designing subjective, depending on the operator to novel sonic instruments and curettes for scaler tips which are termed ‘‘Slimline’’, accurately note the exact point at which periodontal debridement after 2 months. i.e. they are much thinner than conven- the root is clean and not to over-instrument Journal of Periodontology 28, 1145–1150. tional scaler tips (Dragoo 1992). This the surface. Studies which apply the instru- Bonner, B. C., Young, L., Smith, P. A., McCombes, W. & Clarkson, J. E. (2005) A has led to the use of specific furcation mentation for a known length of time or a randomised controlled trial to explore atti- tips (Amdent, Stockholm, Sweden) and a definite number of strokes are generally tudes to routine scale and polish and compare clinical trial looked at the treatment of more controlled in terms of contact loads, manual versus ultrasonic scaling in the gen- Class II furcations. It was found that contact angles, time of instrumentation, eral dental service in Scotland buccal and lingual involved furcations generator power setting, etc. [ISRCTN99609795]. BMC Oral Health 23, 3. responded better than their interproximal A limitation of these investigations, Braun, A., Cichocka, A., Semaan, E., Krause, counterparts following the use of such however, is that in each study, only one F., Jepsen, S. & Frentzen, M. (2007a) Root instruments (Del Peloso Ribeiro et al. of each type of the available tips is surfaces after ultrasonic instrumentation with 2007). The furcation involvements were investigated. Recent research (Lea et al. a polishing fluid. Quintessence International instrumented until a smooth, hard sur- 2003a, b) has demonstrated that signifi- 38, e490–e496. Braun, A., Jepsen, S. & Krause, F. (2007b) face was obtained. A difference in cant variability occurs between instru- Subjective intensity of pain during ultrasonic response was reported with buccal and ments of the same type and that this is supragingival calculus removal. Journal of lingual Class II furcation involvements particularly pronounced when the tips are Clinical Periodontology 34, 668–672. responding better to such non-surgical placed under load. In light of this, it Braun, A., Krause, F., Frentzen, M. & Jepsen, S. therapy. While the use of such ‘‘slim- cannot be certain that the instruments (2005a) Efficiency of subgingival calculus mer’’ tips continues to prove popular used by each of these investigators were removal with the Vector-system compared with clinicians, in vitro work suggests typical of their type. If, for example, in to ultrasonic scaling and hand instrumenta- that such thin designs may be liable to one of the experiments a magnetostrictive tion in vitro. Journal of Periodontal Research variation in their movement due to their tip underperformed then the outcomes 40, 48–52. lower mass and may not, in certain may be significantly different. Braun, A., Krause, F., Frentzen, M. & Jepsen, S. (2005b) Removal of root substance with the contact situations, be working efficiently Vector-system compared with conventional (Trenter et al. 2003). This may partly Conclusions debridement in vitro. Journal of Clinical explain such clinical differences. A clin- Periodontology 32, 153–157. ical study compared conventional ultra- This review has updated the knowledge Braun, A., Krause, F., Hartschen, V., Falk, W. sonic scalers with Slimline tips. The base of ultrasonic scalers post Tunkel & Jepsen, S. (2006) Efficiency of the Vector- primary outcome of the study was that et al. (2002) system compared with conventional subgingi- the use of Slimline tips was associated val debridement in vitro and in vivo. Journal with greater comfort although a second-  The use of power-driven instrumenta- of Clinical Periodontology 33, 568–574. ary outcome was that the scaling process Braun, A., Krause, F., Nolden, R. & Frentzen, tion provides similar clinical outcomes took longer using such instruments M. (2003) Subjective intensity of pain during compared with hand instrumentation. (Braun et al. 2007a, b). Such findings the treatment of periodontal lesions with the The difficulty of pooling studies con- Vector-system. Journal of Periodontal may be consistent with the susceptibility tinues to hinder the drawing of defini- Research 38, 135–140. of such instruments to loading and there- tive conclusions. Busslinger, A., Lampe, K., Beuchat, M. & fore preventing them from oscillating.  The addition of antiseptic agents to Lehmann, B. (2001) A comparative in vitro coolants or irrigants do not provide study of a magnetostrictive and a piezoelec- Effects on root surface any additional clinical benefits. tric ultrasonic scaling instrument. Journal of  Newer designs of powered instru- Clinical Periodontology 28, 642–649. One of the most common methods for ments have not shown any benefit Checchi, L., Pelliccioni, G. A. & D’Achille, C. the evaluation of powered instrumenta- when compared with other ultraso- (1991) Sharpening of ultrasonic scalers. Jour- tion is to study their effects on tooth root nal of Clinical Periodontology 18, 505–507. nic devices in non-surgical perio- surfaces in vitro. This analysis is Christgau, M., Männer, T., Beuer, S., Hiller, K. dontal therapy. A. & Schmalz, G. (2007) Periodontal healing broadly performed using one of two  New in vitro research shows that after non-surgical therapy with a new ultra- methodologies. The first is to apply there is variation in the performance sonic device: a randomized controlled clin- powered instrumentation to the tooth of different tip designs and genera- ical trial. Journal of Clinical Periodontology or root surface for a known or controlled tors, but its clinical relevance 34, 137–147. time or number of strokes (Flemmig remains unknown. Costerton, J. W., Lewandowski, Z., Caldwell, et al. 1997, 1998a, b, Schmidlin et al. D. E., Korber, D. R. & Lappin-Scott, H. M. 2001, Folwaczny et al. 2004, Jepsen (1995) Microbial biofilms. Annual Review of Acknowledgements Microbiology 49, 711–745. et al. 2004). The second is to apply the instrumentation until the surface of the This paper was presented at the European Cross-Poline, G. N., Stach, D. J. & Newman, S. tooth is deemed to be clean and smooth Academy of Periodontology Workshop M. (1995) Effects of curet and ultrasonics on on Contemporary Periodontics held at root surfaces. American Journal of Dentistry (Cross-Poline et al. 1995, Busslinger Ittingen, Switzerland, February 2008. 8, 131–133. et al. 2001, Kawashima et al. 2007). Del Peloso Ribeiro, E., Bittencourt, S., Ambro- A drawback of the second method is sano, G. M., Nociti, F. H. Jr., Sallum, E. A., that the operational characteristics of the Sallum, A. W. & Casati, M. Z. (2006) References ultrasonic scalers are generally poorly Povidone-iodine used as an adjunct to non- recorded with limited data relating to loads Beuchat, M., Busslinger, A., Schmidlin, P. R., surgical treatment of furcation involvements. and contact angles used. The finishing Michel, B., Lehmann, B. & Lutz, F. 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