DH102: Clinic II Ultrasonic Scaling Lisa Mayo, RDH, BSDH Concorde Career College

Reference Nield: CH 25&26 Wilkins CH39: Nonsurgical Periodontal Instrumentation You will need to read both Nield chapters, test questions will come from power point as well as the reading!

Topics for today History of Power instruments Mode of action Mechanism of action Limitations Contraindications Occupational risks Types Controls Calculus removal Clinical steps

Powered Instruments Rapidly vibrating tip to dislodge calculus from the tooth surface, disrupt plaque and biofilm and flush out bacteria Technology been around since 1950s Started as sonic scalers Now have ultrasonic and piezo technology Parts Handpiece that attaches to dental unit Interchangeable tips Power supply

Handpiece and Tip

Interchangeable Tip

Tip In action

Objective #1 History of power instruments

Objective #2 Mode of action

2. Mode of action Mechanical vibration Power-driven scaling devices convert electrical energy (ultrasonic) or air pressure (sonic) into high-frequency sound waves Sound waves produce rapid vibrations in the specially designed scaling tips Calculus is incrementally shattered from the tooth surface when the vibrations are applied to the deposit

Water Irrigation/Lavage 2. Mode of action Water Irrigation/Lavage Water is required to dissipate the heat produced at the vibrating tip Occurs when the water meets the vibrating tip Minute bubbles are created that collapse and release energy Little influence on hard deposit removal Capable of destroying surface bacteria Remove endotoxins from the root surface Better vision in bleeding sulcus

Acoustic Microstreaming of the Water 2. Mode of action Water Irrigation: Acoustic Microstreaming of the Water Swirling effect produced within the confined space of a periodontal pocket by the continuous stream of fluid flowing over the vibrating tip May play a role in the disruption of sub-g plaque biofilms assoc w/ perio disease Limited to an area immediately surrounding the instrument tip In order to most effectively remove plaque biofilm – tip must touch every part of the root surface

Water Irrigation: Cavitation of the Water 2. Mode of action Water Irrigation: Cavitation of the Water Formation of tiny bubbles in water stream Energy release that occurs when tiny bubbles in the fluid spray collapse When bubbles collapse, they produce shock waves that alter or destroy bacteria by tearing the bacterial cell walls

Pocket penetration of tip & water

Review The water spray in ultrasonic and sonic scaling devices penetrates to the base of the pocket to provide a continuous flushing of debris, bacteria, and endotoxin. Oscillation of the ultrasonic tip causes hydrodynamic waves to surround the tip; this acoustic turbulence is believed to have a disruptive effect on surface bacteria. A) The first statement is true and the second statement is true B) The first statement is false and the second statement is false C) The first statement is true and the second statement is false D) The first statement is false and the second statement is true

Answer A) The first statement is true and the second statement is true is the correct answer. In ultrasonic scalers, water spray acts as a lavage to flush debris from the base of the pocket; tip oscillation causes acoustic turbulence resulting in disruption of bacteria.

Objective #3 Mechanism of Action

How effectively instrument runs determined by: 3. Mechanism of action How effectively instrument runs determined by: Tips vibration frequency Stroke length Stroke motion Surface of the instrument tip in contact with the tooth .

3. Mechanism of action Frequency Measure of how many times the electronically powered instrument tip vibrates per second Can be compared to windshield wipers on a car Low Frequency: wiper setting on low, go back and forth few times in a min = tip vibrates fewer times per sec High Frequency: wipers back and forth multiple times per min = tip vibrates more times per sec

3.Mechanism of action amplitude Amplitude or stroke measures how far the instrument tip moves back and forth during one stroke cycle Ultrasonic devises have a power knob that is used to change the length of the stroke (strength) Higher amplitude delivers a longer, more powerful stroke Lower amplitude delivers short, less powerful stroke

Frequency/Amplitude http://www.youtube.com/watch?v=iNcKT4uJZBY Frequency: 0-1min Amplitude: 2-3min

3. Mechanism of action Cleaning efficiency Combo of frequency and amplitude Frequency = determines # vibrations Amplitude = determines length of each stroke Rule of thumb = use lowest setting (frequency) to achieve goal For a Dentsply cavitron – will live in BLUE setting Gray setting a power BOOST setting and should ONLY be used for gross/heavy calculus If vibrates too fast = will skim over calculus on roots without removing

3. Mechanism of action Strength of power instruments Effective calculus removal and plaque biofilm Effective at deplaquing Disrupt or remove sub-g plaque biofilm from root surfaces and pocket space Pocket penetration Can penetrate deeper than many instruments Access to Furcations Class II & III better access with slim line tips Irrigation (Lavage) Wash toxic products & free-floating bacteria from pocket Improve vision Shorter instrumentation time than hand instruments (shorter, not better!)

Objective #4 Limitations of power instruments

4. Limitations of power instruments Clinician skill level Skill level more important than power vs hand Very technique sensitive like hand instruments Have to have complete understanding of root anatomy Reduced tactile sensitivity Occupational risks Infection control: some components CANNOT be sterilized Aerosol production: high levels Muscoskeletal & Auditory Damage

Objective #5 contraindications

Objective #6 Occupational risks

6. Occupational risks contaminated aerosols Dental aerosols airborne particles that are compromised of debris, microorganisms, blood which are smaller than 50μm Aerosols stay airborne and float on office air currents moving some distance from the point of origin Very small particles can remain suspended at the end of the procedure for many hours Can inhale through nose and intubate in respiratory tree The mouth contains large numbers of Stretococci Staphylococci Gram (-) bacteria Viruses

6. Occupational risks contaminated aerosols Power ultrasonic instrum. are the greatest produces of small-particle aerosol contamination in dentistry!!! Can suspend blood particles!! Preventive measures Barrier protection High volume suction: can reduce up to 90-98% aerosols Saliva ejector does not substitute as HVE Isolite: can be difficult to use, patients not always like Pre-procedural rinse: CHX or Listerine for 1min

isolite

6. Occupational risks musculoskeletal damage Nerve damage from dental instruments that cause vibration Blunt the sense of touch Muscle weakness Reduction strength and tactile sensitivity due to vibration

6. Occupational risks Hearing loss Research ongoing! Tinnitus: early stage of hearing loss Hearing protection devises has been an emerging science Custom earplugs like musicians use Can still hear patient but drowns out high-pitch frequencies

Objective #7 Types of power instruments

7. Types of power instruments

7. Types of power instruments Sonic Low frequency 3,000-8,000 cycles per sec (Hz) Driven by compressed air from dental unit No heat is generated so little water used as a lavage Not good use for heavy deposits

7. Types of power instruments Ultrasonic: 18,000-50,000 cycles per sec Piezoelectric Use electric energy to activate crystals within the handpiece to vibrate the tip Magnetostrictive Transfer electrical energy to metal stacks made of nickel-iron alloy or to a ferrous rod

7. Types of power instruments

7. Types of power instruments sonic Handpiece that attached to dental unit high-speed handpiece and interchangeable tips

7. Types of power instruments Sonic Scaling Devices Tip activation Tip motion: Driven by compressed air from the dental unit rather than electrical energy. Moves in an elliptical pattern. All surfaces of the tip are active. Amplitude. Less powerful than ultrasonic scalers Frequency. Producing vibrations at the tip; range between 2,500 and 7,000 cps. Because of fewer vibrations produced, calculus removal is more difficult. Water source. Water is required to cool the friction between the instrument tip and the tooth surface. Heat is not generated by the scaling tip.

7. Types of power instruments Ultrasonic piezo Portable electronic generator Handpiece Instrument tips

7. Types of power instruments Piezoelectric Ultrasonic Scalers Composition Ceramic rod in handpiece Activation Dimensional changes in quartz or metal alloy crystal transducers housed in handpiece Tip motion Moves in a linear pattern, forward and backward Only the lateral surfaces of the tip are active Handpiece position will adjust at each line angle to maintain adaptation of the lateral surface of the tip to the tooth

7. Types of power instruments Piezoelectric Ultrasonic Scalers Technique Placement and movement of the tip is specific Position the lateral surface of the tip in contact with the tooth Use only the terminal 2-4 mm of the tip’s lateral surface Keep terminal lateral surface adapted at all times around curvatures and line angles using wrist pivot Tip shape Cross section of tip varies from trapezoidal with angular edges to round or bladed Frequency Varies according to manufacturer # of times per second a tip moves back and forth during one cycle Ranges from 25,000 to 50,000 cps

7. Types of power instruments Magnetostrictive Ultrasonic Portable unit Electronic generator Handpiece Interchangeable tips/inserts Available in 25-kHz or 30-kHz

7. Types of power instruments 25K: inserts longer and thicker

7. Types of power instruments Magnetostrictive Inserts Metal Stack: converts electrical power into mechanical O-Ring: seal that keeps water flowing through the insert rather than flowing out of the handpiece Handle grip: portion of the insert grasped by the clinician during instrumentation Water outlet: provides water to the instrument Working-End: used for calculus removal You will need to be able to list all 5 parts of insert for Quiz!

7. Types of power instruments Tips Variety of designs and functions Different tips from different manufacturers not always interchangeable 2 Basic Types Standard-Diameter Larger in size Shorter shank lengths Similar to sickle scalers or universal Columbia 13/14 Slim-Diameter 40% smaller diameter Longer, more complex shanks Similar to area-specific curets

7. Types of power instruments Standard Diameter

7. Types of power instruments Slim Diameter

7. Types of power instruments Tip wear & replacement Rule of thumb = 1mm of wear results in 25% loss of efficiency 2mm wear = 50% loss of efficiency Inspect for signs of wear frequently Prevent from bending or will not work correctly Bag correctly: always place insert “BUTT-FIRST” into a bag Tips fragile, esp slim and ultra-slim designs Can easy bend/break If insert into unit while tip still hot – will bend as well

7. Types of power instruments Tip Selection Select based on size, shape, diameter, length, curvature – just like hand instruments Calculus size and location

7. Types of power instruments Tip selection & sequence of use Standard Diameter Tips Supra deposits Mod to heavy sub-g Extrinsic stain Medium power Straight Slim Diameter Tips Lt to mod deposits anterior teeth and post deposits sub-g Deep pockets Root scaling Low to medium power Curved Slim Diameter Tips Lt to mod calculus deposits on post roots Deeper pockets Low power

7. Types of power instruments Curved insert

7. Types of power instruments Standard tip

7. Types of power instruments tips

7. Types of power instruments tips

7. Types of power instruments Tips Set of Slim-Diameter Tips Straight Rt-Curved Lf-Curved Straight: similar to perio probe Curved: similar to Naber’s probe

Objective #8 controls

8. Controls Controls to adjust water and power Some allow to control frequency: Manually Tunes Ultrasonic

8. Controls Power Determine length of stroke Distance instrument travels back and forth in one cycle Higher = longer, more forceful stroke More uncomfortable for patient More likely to damage tooth surface Lower = shorter, less powerful stroke Recommended SLOWER IS BETTER!!! Most slim and ultra slim CANNOT be used on higher power settings = risk of breakage

8. Controls Tips that can be used on high power settings

8. Controls Frequency Automatic: We have in clinic 2 control knobs: power and water Clinician can adjust length stroke and water flow LOW to MED for patient comfort Water dissipates heat by vibrating tip Auto = allows the tip to vibrate at a frequency that produces the most effective calculus removal for the selected power setting

8. controls Frequency Manual 3 knows: power, water, tuning Clinician adjusts length of stroke (strength), tip frequency of vibration (#) and water flow Can set vibration frequency of the tips at a level above or below the resonant frequency Disadv: incorrectly tuned = ineffective calculus removal OLD SCHOOL!

8. Controls frequency, amplitude & water flow Cools by fluid to prevent overheating of vibrating tip Water is the coolant Continuous flow Disperses in a fine spray at or near the tip Clinicians can adjust the volume of water supplied to tip Lower rates of water flow increase heating changes = warmer water at the tip Too little = heat damage to pulp More water flow recommended for calculus removal and less water slow for deplaquing

8. Controls Water flow A: fine mist B: slow drip

8. Controls frequency, amplitude & water flow One of most common mistakes by beginning clinicians = using too little water If handpiece warms up in your hand = water too low Tip have external or internal flow

8. Controls Internal water flow (Our clinic uses)

8. controls External water flow

8. Controls frequency, amplitude & water flow Fluid Reservoirs Some have Distilled water, sterile saline, stannous fluoride, antimicrobials (CHX) Not been shown to enhance pocket depth resolve than regular instrumentation Pathogenic biofilms are highly resistant to antimicrobial agents and systemic antibiotics Only way to disrupt biofilm = mechanical removal

8. Controls Energy dispersion by working-end Vibrations from ea surface of working end Have to adapt correct tip surface to control energy dispersion and patient sensitivity Dependent on 3 factors (next slides) Energy output Pattern of Tip Movement Adaptation of Powered Tips

8. Controls 1.) Energy output Face, back, lateral surfaces and point produce different amts of energy Point of Tip Produced greatest amt of energy vibrations NEVER adapt directly on a tooth surface due to potential discomfort for the patient and damage of root surface Face of Tip (concave surface) 2nd greatest amt of energy vibrations NOT adapted – would be difficult to do

8. Controls 1.) Energy output Back of Tip (convex surface) Produces less energy than the face or the point 3rd greatest amt Lateral surfaces of tip Least amt To be used against tooth surface

8. Controls 1.) Energy output

8. Controls 1.) Energy output

8. Controls 2.) Pattern of tip movement Tip motion varies from lateral motion to an elliptical motion Motion is really more dependent on power setting and shape of instrument tip Elliptical motions appears to be better at efficient calculus removal

8. controls 3.) Adaptation of powered tips Follow manufacturer directions for instrument tip-to-tooth surface adaptation The point of tip and face of the tip should never be directly adapted to a tooth surface Backs of most ultrasonic and sonic instrument tips can be adapted to the tooth surface, following the recommendations of the tip manufacturer

8. controls 3.) Adaptation of powered tipstips Angle of adaptation: an angle of between 0-15 degrees is recommended for direct adaptation to tooth surfaces Lateral surfaces of the working end is recommended with sonic, piezoelectric, magnetostrictive ultrasonic Piezo: tip does not do as much vibration as magnetostrictive, it’s the lateral surfaces that are more effective

8. controls 3.) Adaptation of powered tips Active tip area: portion of the instruments that is capable of doing work Power to remove calculus is concentrated in the last 2-4mm of the length of a tip Test Alert!

8. controls 3.) Adaptation of powered tips & implants Tip HAS to be made of a material that is softer than titanium because titanium is a soft metal that can easily be damaged by metal instruments If scratch titanium implant = increase potential for biofilm adhesion by creating a roughened surface Power tip with nonmetal plastic or carbon tips are appropriate Some studies show they are more effective than hand-activated plastic instruments

8. controls 3.) Adaptation of powered tips Adaptation of tip surfaces to the tooth surface Point and face of a power tip Back and Lateral surface of a power tip Orientation of the powered tip to the tooth surface Transverse tip orientation (Curet Position) Vertical tip orientation (Probe Position)

8. controls 3.) Adaptation of powered tips Adaptation of tip surfaces to the tooth surface Point and face of a power tip NEVER be directly adapted to a tooth surface Great caution must be taken with the point of power tip = highest motion and vibration, surface area small = concentrated energy

8. controls 3.) Adaptation of powered tips Adaptation of tip surfaces to the tooth surface Back and Lateral surface of a power tip Magnetostrictive =BACK SURFACE most effective in breaking calculus deposits and LATERAL SURFACES most effective in breaking tenacious calculus deposits Both can be used for calculus removal=sonic, piezo, magnetostrictive Last 2-4mm of back and lateral surface=active portion–must be in contact w/tooth at all times and be adapted so that the point is not directed toward the root or against the soft tissue

8. controls 3.) Adaptation of powered tips Orientation of the powered tip to the tooth surface Transverse tip orientation (Curet Position) Length of the tip is positioned with the back or lateral surface in a transverse orientation or at a right angle to the long axis of the tooth Tip is placed in a similar fashion to a universal curet Zero degree angulation maintained between back or lateral surface of the tip to tooth Can be used when removing calculus above or slightly below gingival margin

8. controls 3.) Adaptation of powered tips Orientation of the powered tip to the tooth surface Vertical tip orientation (Probe Position) Length of tip is positioned w/ back or lateral surface in a manner similar to probing Back or lateral surface of tip at zero degree angulation to root surface Used for calculus removal and deplaquing shallow to deep pockets

8. controls 3.) Adaptation of powered tips For a transverse orientation, the power tip is positioned in a similar manner to a curet with the length of the back surface, or lateral surface, at a right angle to the long axis of the tooth

8. controls 3.) Adaptation of powered tips For a vertical orientation, the powered tip is positioned so the length of the back surface, or lateral surface, is positioned in a manner similar to that of a periodontal probe

8. controls 3.) Adaptation of powered tips Incorrect adaptation: the point of a power instrument tip should NOT be adapted against a tooth surface. Using a power tip in the manner can gouge cementum and dentin!!

8. controls 3.) Adaptation of powered tips Correct Adaptation of Lateral Surface in a Transverse Orientation

8. controls 3.) Adaptation of powered tips Correct adaptation of a lateral surface in a vertical orientation

8. controls 3.) Adaptation of powered tips Correct adaptation of the back surface in a vertical tip orientation. Use the convex side Will prevent injury to the root surface with the tip

8. controls 3.) Adaptation of powered tips Tip-to-tooth angulation should be as close to 0°as possible and should never exceed 15° Root surface will be gouged

Objective #9 Calculus removal with power instruments

9. Calculus removal with power tips Calculus removal technique with Curet Gracey positioned apical to or below the calculus deposit then vertical stroke coronally or up and away from the tissue Calculus removal with power tip Work top of the deposit downward Start at CEJ and work downward No need to position the tip beneath the deposit Great advantage when working in very deep pockets

9. Calculus removal with power tips Different techniques w/ power instrument tip and a hand-activated instrument A= power B=scaler

9. Strokes for calculus removal Tips break up heavy deposits by putting little microfractures in the deposit Power tip needs to be moved over the surface of a deposit some time in order to allow the microfractures to develop Slower, repetitive controlled strokes are more effective in removing large tenacious calculus deposits Keep tip moving at all times for patient comfort Oblique, overlapping, vertical most effective Light pressure Avoid Horizontal = tendency to burnish calculus into tooth and create a smooth veneer than remove it completely. Why we always follow up cavitron w/hand instruments

9. Strokes for calculus removal

9. Strokes for plaque biofilm removal 2-4mm of tip actively remove biofilm Gentle, light sweeping strokes in the pocket over the root surface Short, overlapping strokes will cover every mm of the root Vertical, oblique or horizontal direction ok Move tip at all times for patient comfort Can be a little faster than hand instruments Must hand instrument after to smooth back the surface ultrasonic roughs up LOW power setting to avoid removing cementum

9. Sweeping Motion

9. Calculus removal

Curved tips Lateral surface adapted to facial

Curved tips Lateral surface adapted to facial

Curved tips lateral surface adapted to proximal

Straight Tips back surface, vertical

Straight Tips lateral surface, vertical

Straight Tips back surface, vertical

Straight Tips back surface, transverse

9. Removing tenacious calculus Common mistake with beginners is that the power tips will snap the calculus off with one quick swipe Power tips are not magic wands!! Take many overlapping strokes just like hand instruments

9. Removing tenacious calculus Select proper tip for your task: standard, slim, curved, etc.. Use a tip that can withstand medium pressure Low power may not remove heavy tenacious deposits Select appropriate water level: water should create a halo effects or light mist with no excessive dripping Maintain proper control and adaptation Keep 2-4mm of tip in contact with tooth

9. Removing tenacious calculus Attack deposit from all directions w/ different strokes Use correct surface of the powered tip: magnetostrictive vs piezo Change to a different tip Begin with a periodontal file first then switch to power Increase the power if all the above have been utilized first, last resort and make sure select a tip that can withstand higher powers!!

9. Calculus removal Furcation access Slim tips can be more effective than hand instruments many times in treating Class II and III furcations Standard gracey’s too wide to enter the furcation areas of over 50% of all maxillary and mand molars Avg facial furcation entrance of maxillary and mand first molars is from 0.63 – 1.04mm in width Width of standard Gracey curets ranges from 0.76 – 1mm Diameter of a modified slim-diameter instrument tip is 0.55mm or less

9. Calculus removal Furcation access

9. Calculus removal Furcation access

Objective #10 Clinical steps

10. Clinical steps Fundamentals Position Clinician same as for hand instruments Neutral seated Patient supine Patient head to one side so water does not choke them Grasp Modified pen grasp of handpiece Light and relaxed grasp – if have increased lateral pressure, tip will not work as effectively

10. Clinical steps Fundamentals Finger Rests Intraoral or advanced finger rest is CRITICAL!! Lateral Pressure Light Moderate or firm – decrease effectiveness of tip or can even stop vibration of the tip With proper technique, patients will not feel the tip Motion Activation Digital activation is recommended because the tip removes the calculus and not the clinician

10. Clinical steps Just like hand scaling, use explorer to feel for residual calculus deposit If have an endoscope – helpful for detecting residual calculus

10. Clinical steps Preparation Dental hygiene care plan Review medical hx for contraindications Assess calculus deposits and location Infection control measures Personal protective equipment: PPE’s Face shield to protect from aerosols Surgical cap to prevent contamination of hair Change mask every 20min or if it gets moist from aerosols Flush water lines just like A/W syringe 2min at beginning of day 20-30 sec in between patients

10. Clinical steps Preparation Plug in power cord to wall Connect water hose Fill handpiece with water Then insert the tip twisting gently until it snaps into place Select correct power setting Select correct water setting Pre-procedural rinse: Listerine or CHX for 2min

10. Clinical steps Preparation Point-of-Use Filter Some ultrasonic devises have preinstalled Reduced # microorganisms in the water flowing over instrument tip

10. Clinical steps Water containment techniques Fluid control in anterior sections Lower and upper lips can be cupped to contain the water spray Allows the lip to act as a barrier to deflect the water back into the mouth and a “cup” to collect the water

10. Clinical steps Water containment techniques Fluid control in posterior sections Hold cheek between thumb and index finger and pull out and up, or down, to form a cup Creates a “cheek cup” to catch water spray

10. Clinical steps Handpiece cord management Decrease fatigue of hands Several techniques to reduce pull of cord

10. Clinical steps Handpiece cord management

10. Clinical steps Handpiece cord management

10. Clinical steps Smoothing amalgam overhangs Overhang removal is a recontouring procedure used to correct defective margins of restorations to provide a smooth surface that will deter bacterial accumulation Overhangs act as a biofilm trap Power tips can be used to remove such as Burnett or Dentsply blue insert

10. Clinical steps Smoothing amalgam overhangs Both inserts are designed to withstand higher power settings and more lateral pressure than a conventional slim-line Uses: heavy deposits, overhangs, removing ortho cement