Powered Instrumentation PDF

Powered Instrumentation Clinic II Lab Megan Ciacci Petrella, MSDH, RDH, CDA Powered instrumentation devices use a rapidly vibrating irrigated working- end to dislodge calculus from the tooth surface, disrupt plaque biofilm, and flush out bacteria from the periodontal pocket Usually consist of an u...

Powered Instrumentation Clinic II Lab Megan Ciacci Petrella, MSDH, RDH, CDA Powered instrumentation devices use a rapidly vibrating irrigated working- end to dislodge calculus from the tooth surface, disrupt plaque biofilm, and flush out bacteria from the periodontal pocket Usually consist of an ultrasonic generator, a handpiece, and interchangeable tips or inserts 2 Timeline for Evolution of Powered Instrumentation Late 1950s Late 1980s development of first electronically powered slim working-ends developed instruments modern powered working-ends have been shown to be as effective as hand instruments powered instruments used to remove heavy for removing subgingival deposits, biofilms, calculus deposits, mostly supragingival and bacterial products 1960–70s Today  Powered Device Classification  Types of Powered Instrumentation Devices Sonic powered devices—operate at lower frequency of 3,000 to 8,000 cycles per second - Air-driven turbine -Tip moves in a circular orbital motion Sonic powered devices Sonic instrument tips attach directly to the handpiece. Some devices have special wrenches to lock the instrument tip in place. These instruments have been replaced with ultrasonic handpieces. Their technology is obsolete. Types of Powered Instrumentation Devices Ultrasonic powered devices—operate at 18,000 to 45,000 cycles per second Piezoelectric devices (“piezo”) Magnetostrictive devices (“magneto”) https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.kavo.com%2Fdental-instruments%2Fpiezoled-scaler-special- instruments&psig=AOvVaw1L2jlEwcP9da5eU3yBKW3E&ust=1674334512058000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCKDHsqOE1_ wCFQAAAAAdAAAAABAF  Powered Device Classification Piezo devices—use electrical energy to activate crystals within the handpiece to vibrate the instrument tip https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.researchgate.net%2Ffigure%2FDental-ultrasonic-scaler-upper- view_fig10_229029169&psig=AOvVaw0cQoj3fZPR4dMJKWaKzl8Y&ust=1674334656170000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCLi mkuiE1_wCFQAAAAAdAAAAABAW  Magneto devices— transfer electrical energy to metal stacks made of nickel–iron alloy or to a ferrous rod to vibrate the insert https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.ultimatedental.com%2Fuploads%2FDentsply- GettingtheMostoutofUltrasonicScaling.pdf&psig=AOvVaw12tYb8kk9ws0R6Fw4CacJK&ust=1674335094908000&source=images&cd=vfe&ved= 0CA8QjRxqFwoTCIi4ubmG1_wCFQAAAAAdAAAAABAR  Magnetostrictive devices have removable Instrument instrument inserts that fit into the handpiece. Inserts Devices are available in two different kilohertz options (25 & 30K) , with insert options to match. Our units- 30K *Important to know your unit!  ‐ Effectively removes supra- and subgingival calculus deposits Strengths of ‐ Effectively removes subgingival plaque Powered biofilms Instrumentation ‐ Slim tips reach deeper into periodontal pockets than hand instruments ‐ Slim tips provide access to furcation areas ‐ Water irrigation flushes bacterial products from pockets ‐ Instrumentation time reduced Pocket Penetration and Irrigation Found on page 663. Limitations of Powered Instrumentation ‐ As with hand instrumentation, skill level of clinician affects outcome ‐ Either piezo or magneto instrumentation is technique sensitive ‐ Less tactile sensitivity than with hand instruments ‐ Cannot be used on all patients Modes and Mechanisms of Action  Mechanical removal Very rapid vibrations of powered working-end create microfractures in calculus deposits Water irrigation Constant stream of water exits near point of the Modes of working-end and is called fluid lavage Water dissipates heat caused by rapid vibrations Action Water flushes toxic products and bacteria from pocket Cavitation Formation of tiny bubbles when the water stream contacts the vibrating working end When the bubbles collapse, they produce shock waves that may alter or destroy bacteria by tearing the cell wall  Acoustic microstreaming is another energy released around ultrasonic devices. This phenomenon is characterized by the movement of small currents in the water. Transports the cavitation bubbles in the mouth Microstreaming commonly occurs around oscillating objects, such as cavitation bubbles or the scaler tip. https://www.google.com/url?sa=i&url=https%3A%2F%2Fhelseultrasonic.com%2Fprocedure%2Factivating-irrigation- solution%2F&psig=AOvVaw3BeJUkuEBC9c4KnZGiPRsS&ust=1674328380622000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCNDyq8jt1vwC FQAAAAAdAAAAABAY Mechanism ‐ Frequency—measure of how many times a of Action powered working-end vibrates per second ‐ Amplitude—measure of how far the powered working-end moves back and forth ‐ Controlled with power setting on unit. Frequency (Vibration) Compare the working-end frequency to car windshield wipers: low frequency—wipers only go back and forth a few times in a minute high frequency—wipers go back and forth many times in a minute  ‐ Lower amplitude—delivers a shorter, less Amplitude powerful stroke (Stroke ‐ Higher amplitude—delivers a stronger, more powerful stroke Length) ‐ Research finds no difference between efficiency of high-powered or medium- powered instrumentation; to maximize patient comfort and minimize potential damage to tooth surface, the power setting should rarely be placed above the medium power setting  Understanding Amplitude—Pushing a Swing Lower Amplitude High Amplitude  ‐ Cleaning efficiency—determined by Cleaning combination of frequency and amplitude Efficiency of ‐ Lower frequency, lower amplitude: Powered fewer vibrations and shorter strokes; Instrumentation ideal for removal of plaque biofilm ‐ Higher frequency, higher amplitude: Many (more) vibrations and longer strokes; ideal for removal of tenacious calculus deposits * Again- no evidence to support high-power Pattern of Working-End Movement Magneto working-end- primarily moves in an elliptical motion However, depending on the unit and the type and shape of the working-end, the movement ranges from nearly linear to elliptical or circular Piezo working-end- activated by dimensional changes in crystals housed within the handpiece as electricity passes over the surface of the crystals This makes for a primarily linear movement https://www.google.com/url?sa=i&url=https%3A%2F%2Fpocketdentistry.com%2F3-what-is-ultrasonic- instrumentation%2F&psig=AOvVaw1VB5k- Z7ZZOPlp07oC8v76&ust=1674329977588000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCLD1grLz1vwC FQAAAAAdAAAAABAH https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.rdhmag.com%2Fpatient-care%2Farticle%2F16409218%2Fmagnetostrictive-vs- piezoelectric-survey-compares-merits-of-ultrasonic- scalers&psig=AOvVaw0cQoj3fZPR4dMJKWaKzl8Y&ust=1674334656170000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCLimkuiE1_wCFQAA AAAdAAAAABAv Powered Instrumentation Features Water Flow to Powered Working-End ‐ Heat factor ‐ Piezo devices—only working-end needs to be cooled by water to prevent over- heating ‐ Magneto devices—handpiece and working-end should be irrigated with water to prevent over-heating ‐ Common mistake is using too little water; a warm working-end indicates inadequate water ‐ Note: Sonic tips do not overheat, and thus require no water cooling. Water Flow to Powered Working-End Provides Cavitation and irrigation of acoustic areas microstreaming Fluid Reservoirs for Powered Instrumentation ‐ Independent fluid reservoir—a bottle used to deliver distilled/treated water or other fluid solutions to the working-end ‐ Can be found on stand alone unit or as part of the dental unit ‐ Use of chemotherapeutic agents with ultrasonic instruments has not been shown to enhance pocket depth reduction beyond that of instrumentation with water  Example of Fluid Reservoir Bottle _______________________________________ https://www.google.com/search?q=ultrasonic+within+dental+unit&rlz=1C1GCEA_enUS968US968&source=lnms&tbm=isch&sa=X&ved=2ahUK EwiC7PS69db8AhW3MlkFHZYNBjIQ_AUoAnoECAEQBA&biw=1280&bih=577&dpr=1.5  Part of Dental Unit https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.a-dec.com%2Fdelivery-systems%2Fa-dec- 300&psig=AOvVaw1fw2hSxjFH4H75w- gvH50F&ust=1674330543869000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCNCVnb_11vwCFQAAAAAdAAAAABAb Water Adjustment on Working-End Water Delivery Designs https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.hufriedygroup.com%2Fblog%2Fselecting-ultrasonic- inserts&psig=AOvVaw0C5u7bheIFDv1UKNAoCHjb&ust=1674334127214000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCJiWk- yC1_wCFQAAAAAdAAAAABAK https://www.google.com/search?q=dental+unit+controls&tbm=isch&ved=2ahUKEwjx492t-db8AhXftXIEHVrUCZgQ2- cCegQIABAA&oq=dental+unit+controls&gs_lcp=CgNpbWcQAzoECAAQQzoFCAAQgAQ6BAgAEB46BggAEAgQHlDHBljoEGCCEmgAcAB4AIABOYgBhwSSAQIxMJgBAKABAaoBC2d3cy13aXotaW1nwAEB&sclient=img&ei=RPTKY_GxE9_rytMP2qinwAk&bih=577&biw =1280&rlz=1C1GCEA_enUS968US968#imgrc=HfPHzvAqO-kQ_M Power Setting Controls Activating Rheostat Powered Working-End Design Hand Instrument Versus Powered Tip Powered Tip Design ‐ A wide variety of instrumentation tip designs available for powered devices ‐ Two basic types of powered tips: standard tips—larger in size with shorter shank lengths slim perio tips—up to 40% smaller in size with longer, more complex shanks https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.hufriedygroup.com%2Fcontent%2Fultrasonic-insights-sevententh- edition&psig=AOvVaw0YcGon_SdJl-4LAzv- dgIB&ust=1674332096570000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCKCExqP71vwCFQAAAAAdAAAAABAR Powered Tip Selection ‐ Powered tips vary in shape, size, length, and curvature ‐ Tip selection based on : extent and mode of calculus attachment small, large deposits, tenacious deposits location of calculus deposits supra– or subgingival deposits https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.scottsdental.com%2Fpiezo-scaling-tips-satalec-nsk-type-hu- friedy.html&psig=AOvVaw0YcGon_SdJl-4LAzv- dgIB&ust=1674332096570000&source=images&cd=vfe&ved=0CAsQjRxqFwoTCKCExqP71vwCFQAAAAAdAAAAABAZ The Proper Tip for the Task at Hand ‐ Standard tip: removes moderate to heavy deposits above gingival margin and shallow pockets ‐ Slim perio tip: removes light to moderate calculus deposits on anterior teeth and posterior root surfaces ‐ Round tip: removes biofilm and light calculus deposits ‐ Flat lateral surfaces: removes medium- to large-sized deposits Standard Tip Characteristics Standard size Shorter shank lengths Use Heavy deposit removal: supragingival use and for subgingival deposits easily accessed without undue tissue distension Slim Perio Tip Characteristics Up to 40% smaller in size Longer shank lengths Use Light to moderate deposits and deplaquing Instrumentation of root concavities and furcation areas Left and Right Curved Tips Powered Tips for Dental Implants ‐ Instruments used for assessment and debridement of implant teeth should be made of material softer than titanium ‐ Tips coated with nonmetallic plastic or carbon material are appropriate for instrumentation of dental implants ‐ Metal instruments may scratch the titanium implant surface Plastic- Coated Piezo Tip Instrument Tip Wear and Replacement ‐ Inspect powered instrumentation tips regularly ‐ With use, the tip is worn down and less effective ‐ A rule of thumb, 1 mm of wear results in approximately 25% less efficiency ‐ A tip with 2 mm of wear should be discarded Tip Wear Guide Instrumentation Technique Fundamental Skills for Powered Instrumentation ‐ Powered instrumentation relies on basic skills for a successful outcome ‐ Clinician position—similar as those for hand instrumentation ‐ Patient position—normal supine position, with patient’s head positioned to the side so water flow pools in corner of the mouth for evacuation ‐ Grasp—use a light, relaxed grasp ‐ Sequence- varies by skill level ‐ Can do all buccal/facial in a sextant then proximals or alternate while instrumenting Fundamental Skills for Powered Instrumentation ‐ Finger rests/fulcrum—use advanced finger rests including extraoral, cross arch, opposite arch ‐ At a distance from treatment site ‐ Lateral pressure—feather-light pressure is all that is needed; firm pressure decreases effectiveness of working-end ‐ Activation- Digital activation ‐ Assessment/end point—use the explorer to evaluate deposit removal Approaches to Instrumentation Hand instrumentation— Powered instrumentation— position hand instrument work from the coronal-most apical to the calculus region of the deposit; start deposit; start at the base of near the CEJ and work the pocket and work toward apically toward the base of the CEJ the pocket  Approaches to Instrumentation Approaches to Instrumentation “Top down approach” Calculus removal takes place from the top of the deposit working in an apical direction. Strokes for Calculus Removal ‐ Powered working-ends break up calculus deposits with microfractures ‐ A common misconception is that a powered instrument is like a magic wand, using a quick swipe of the working-end to remove deposits. ‐ The correct technique requires slow, repetitive strokes to accomplish calculus removal Strokes for Calculus Removal ‐ Only gentle pressure is needed during powered instrumentation to remove calculus ‐ Firm pressure reduces the effectiveness of the instrument ‐ Slower, repetitive strokes are more effective in removing tenacious calculus ‐ Overlapping strokes are most effective for calculus removal Strokes for Biofilm Removal ‐ Mechanical removal of plaque biofilm is needed ‐ Periodontal health cannot be achieved without removal or disruption of the established biofilm ‐ Ultrasonic instrumentation under low pressure can accomplish plaque removal ‐ Use methodical, overlapping strokes that are close together to effectively remove biofilm https://www.google.com/url?sa=i&url=https%3A%2F%2Fdoridentalarts.com%2Fblog%2Fwhat-is-plaque- really%2F&psig=AOvVaw2gSjd2sTLZ6Kh_x6D0J2qP&ust=1674333649203000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCNCv9ImB1_wCF QAAAAAdAAAAABAQ Strokes for ‐ Use a series of gentle sweeping motions over the root surface to remove plaque biofilm Biofilm ‐ Short strokes should cover every Removal millimeter of the root surface using strokes in vertical, oblique, or horizontal directions ‐ Normal sulci in the absence of inflammation are likely colonized by beneficial bacteria, and do not need debrided  Stain Removal https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.angelsmile.co.uk%2Ftooth-stain-removal-prophy- https://www.google.com/url?sa=i&url=https%3A%2F%2Frosevillesmiles.co.uk%2Fservices%2F flex%2F&psig=AOvVaw3YIna0auY7YrEG9KM3GFZM&ust=1674648284518000&source=images&cd=vfe&ved=0CA4QjRxqFwoTCID3gJaV4PwCFQ cosmetic-treatments%2Fstain- AAAAAdAAAAABAG removal%2F&psig=AOvVaw3YIna0auY7YrEG9KM3GFZM&ust=1674648284518000&source=ima ges&cd=vfe&ved=0CA8QjRxqFwoTCID3gJaV4PwCFQAAAAAdAAAAABAL  The powered working-end should be kept IMPORTANT moving at all times for patient comfort and to be effective!! TO NOTE Tip Adaptation and Orientation to the Tooth Surface **REMINDER**  ‐ Active tip area—the portion of the instrument tip capable of doing the work ‐ the last 2 to 4 mm of the lateral surfaces on powered tips Powered Tip ‐ Historically, lateral surfaces of the powered Adaptation tip were considered the most effective for calculus removal (similar to hand instrumentation, the “cutting edges” are used to remove calculus) ‐ The ability to utilize any surface of the tip (lateral surfaces, face, back) facilitates a greater degree of contact between the active tip area and the tooth surface ‐ More effective debridement ‐ The surface of the active tip that best conforms to the anatomy of the tooth should be utilized  ‐ Adapt the appropriate tip surface to the tooth surface to control energy dispersion ‐ Never adapt the point of Powered Tip a powered instrument tip directly on a tooth Adaptation ‐ surface Adapt the lateral surfaces of a piezo tip for removal of calculus and plaque biofilm ‐ Adapt the lateral surfaces, face, and back of a magneto tip for removal of calculus and plaque biofilm  Different Amounts of Energy Different amounts of energy are produced by the face, back, lateral surfaces, and point of the magneto tip. Amount of Energy Dispersed Point of Tip Disperses the greatest amount of energy Should NOT be adapted against the tooth surface It could damage the tooth! But…. Point of Tip The point may be placed against a large calculus deposit. In this illustration, only the lateral surface touches the tooth surface. Face of Tip Disperses the second greatest amount of energy Should NOT be adapted on demineralized surfaces Back of Tip Disperses less energy than the face Many tips allow adaptation of the back Adaptation of the Back Lateral Surfaces of Tip Least amount of energy dispersion Can be adapted directly against the tooth surface  Correct Adaptation 72  Transverse tip orientation—tip is positioned Transverse with the active surface in a transverse (right angle) orientation to the long axis of the Tip tooth, in a similar manner to the use of a scaler Orientation Used for supragingival interproximal debridement Transverse Tip Orientation with Lateral Surface  Vertical tip orientation—the tip is positioned with the active surface against the tooth Vertical Tip surface, in a similar manner to the perio probe Orientation Used for supragingival and subgingival areas Vertical Tip Orientation with Lateral Surface Straight Slim Tip in Vertical Orientation—Anterior Straight Slim Tip in Vertical Orientation—Posterior  The tip-to-tooth surface angulation should be close to Tip Angulation zero degrees. Working Stroke Varied in direction Equally-distributed Constant Overlapping Light pressure  Stroke Direction Horizontal Oblique Vertical Sweeping Motion Work in sections Tapping Against Deposits Recap- Powered Instrumentation Only gentle pressure is needed during powered instrumentation to remove calculus Firm pressure reduces the effectiveness of the instrument Slower, repetitive strokes are more effective in removing tenacious calculus Overlapping strokes are most effective for calculus removal Digital activation NOTE: Important to follow with hand instrumentation Considerations and Contraindications  Powered Instrumentation Aerosol Production Powered instruments generate high levels of contaminated aerosols. Microorganisms in dental aerosols have been shown to survive for up to 24 hours! The use of an antimicrobial mouth rinse before treatment can reduce bacterial counts in aerosols by about 92 percent. During treatment, evacuator tips should be used to reduce airborne contamination- HVE 8 mm (HVE) removed up to 8 times more aerosols A saliva ejector is not an effective means of controlling aerosols Mr. Thirsty and Isolite- options you may see in private practice In our clinic, our policy is to use two (2) forms of suction to reduce and control aerosols. High Volume Evacuation (HVE) Saliva Ejector Powered Instrumentation Review patient medical and dental histories before using powered instrumentation Some contraindications include: —respiratory problems, communicable disease transmission —susceptibility to infection, cardiac implantable devices —sensitive, demineralized teeth —difficulty in swallowing —titanium implant surfaces  It is important to remember that powered instruments are NOT recommended for use with all patients. AGAIN, before any treatment, review the Caution patient’s medical and dental history thoroughly.  Patients with cardiac pacemakers should NOT be exposed to magnetostrictive ultrasonic devices. Nield- Gehrig 2008 Piezoelectric ultrasonic devices do NOT generate a magnetic field and therefore do not interfere with the functioning of cardiac pacemakers. Cardiac Pacemakers Vagus Nerve stimulators: No adverse effect with use of ultrasonic scalers. Roberts, 2002  St. Jude Medical “no known risk "to pacemakers from dental drills and ultrasonic scalers. 2013 Boston Scientific 2013: Medical and dental devices that are considered safe to use with pacemakers include dental drills and cleaning equipment , diagnostic x rays, ECG, mammography and ultrasound. Other Opinions Medtronic 2013: “no known risk” to pacemakers when the device is used as intended and is in good working order)…dental ultrasonic. “Recommended that patients advise their doctor of implanted device to evaluate possible risk.”  Individuals with communicable diseases that Communicable can be disseminated by aerosols Disease Patients with tuberculosis, respiratory infections  Individuals with high susceptibility to opportunistic infection that can be transmitted by contaminated dental unit water or aerosols High Susceptibility Patients with COPD, Cystic Fibrosis, Emphysema, Asthma, persons with to Infection uncontrolled diabetes or organ transplants, debilitated individuals with chronic medical problems, and immunosuppressed individuals (chemotherapy or disease)  Patients with multiple sclerosis, amyotrophic Difficulty in lateral sclerosis, muscular dystrophy, Parkinson Swallowing disease, or paralysis (stroke patient) may experience difficulty in swallowing or be prone or Prone to Gagging to gagging.  Primary and newly erupted teeth of young children have large pulp chambers that are Age more susceptible to damage from the vibrations and heat produced by ultrasonic instrumentation.  Avoid contact of tip with: hypersensitive teeth porcelain crowns composite resin restorations, Class V Oral Conditions demineralized enamel surfaces exposed dentinal surfaces Implants Not for use on titanium implants, unless the working-end of the powered instrument is covered with a specially designed plastic sleeve. Controlling Aerosols Helpful tricks for ultrasonic use… Patient Cotton rolls Dry angles assistance Short HVE Chairside Pain tips assistants management Refer to SAKAI for more videos and tips for powered instrument use. Setup of Ultrasonic Device 1. Put in Convenient Location Place on a stable countertop or cart within easy access to the dental chair Apply infection control barriers to device Our units- we do not have a separate, portable unit 2. Connect to Water Source Connect water hose to the water outlet on the dental unit Some units use a fluid reservoir instead of a water connection. In our clinic, it is within the hose, no need to connect separately  3. Turn on the Unit In our clinic, turning on the unit will turn on the ultrasonic device’s cord/housing 4. Flush the Water Lines Hold the handpiece over a sink, step on foot pedal to start water flow Flush the water tubing for a minimum of 2 min at the start of each day. 30 seconds between patients 5. Fill Handpiece with Water Prior to placing an instrument insert into the handpiece, fill the handpiece with water. Repeat this process whenever you change tips. Why fill the handpiece with water? THIS STEP EXPELS AIR BUBBLES AIR BUBBLES CAN CAUSE THE FROM THE HANDPIECE. HANDPIECE TO OVERHEAT. 6. Lubricate the O-Ring Use your fingertips to lubricate the O-ring with water from the handpiece. 7. Seat Insert in Handpiece Grasp the insert grip and gently push the insert into the handpiece until it snaps into place. 8. Adjust the Water Spray Water is controlled by a knob on the unit or on the ultrasonic handpiece. Water Spray The water spray should form a cloud of water spray. It should be readjusted every time that you change the power level or change tips during instrumentation. If you begin to feel heat in the handle, you need to increase the water. Handpiece Cord Management  Handpiece Cord The handpiece cord tends to weigh down the end of the handpiece and may cause the handpiece to twist during instrumentation. Several techniques are helpful in avoiding these problems….. Any Questions? Again, refer to the videos on SAKAI.