1. PERIODONTOLOGY SONIC AND ULTRASONIC INSTRUMENTATION
D. Logien Al Ghazal
(B.D.S , MFD-RCSI, D.D.S, FFD-RCSI)

2. Objectives Types of Power Instruments Mechanism of Action
The Efficacy and Clinical Outcomes
Efficiency
Contraindications to use
Principles of Instrumentation
Summary

3. PERI ODONTO LOGY

4. Why do we use instruments for periodontal therapy?
Supra- and subgingival debridement results in the mechanical disruption of the plaque biofilm and remains the “gold standard” modality for periodontal treatment.

6. Types of sonic and ultrasonic instrumentation
Sonic scalers.
magnetostrictive .
piezoelectric ultrasonic.
ablative laser therapy.

7. Type
Brands
Frequency
Motion
Angulation to root surface
Removes deposits by
Sonic scalers
Titan S
6000 Hz to 9000 Hz
circular
Any angulation
tapping
Magnetostrictive ultrasonic scalers
Dentsply Cavitron
20,000 Hz to 45,000 Hz
elliptical
Depends on angulation
hammering or scraping motion
Piezoelectric scalers
EMS Piezon Master
20,000 to 45,000 Hz
linear
tapping or a scraping
nature,

9. Mechanism of action:
Magnetostrictive ultrasonic scalers either driven by a metal stack consisting of nickel-iron alloy strips or a Ferrite Insert inserted into a hand-piece. Inside the hand-piece a live coil generates an alternating electromagnetic field that leads to expansion or contraction of the ferromagnetic material.
Piezoelectric scalers: The vibration is generated by changes in the dimension of a quartz crystal caused by the application of an alternating current.

10. Ablative laser therapy
Targets both the soft and hard tissues of the periodontium. It has bacteriocidal and detoxification effects and can remove the epithelium lining and granulation tissue within the periodontal pocket which may potentially improve healing.
However, studies have shown that curettage of granulation tissues had no added benefit over scaling and root planning.

11. What do you use instruments for ?
Scaling: a procedure to remove plaque and calculus from the tooth surface. Depending on the location where you perform the scaling it is classified as subgingival and supragingival.
Root planning is a procedure where the softened cementum is removed leaving the root surface and hard and smooth.
Changing name of root planning to root debridement due to the fact of the presence Microbes giving rise to and colonizing the surface of dental calculus have been shown to produce lipopolysaccharides (LPS) were thought to be present within calculus and underlying cementum.

13. Safety and Efficacy of Oscillating Sealers
Depends on :
Instrumentation time.
lateral force.
scaler tip angulation.
instrument power setting.
The scaler tip is angulated parallel to the root surface and the forces applied do not exceed 2N

14. Effect of instrumentation on probing depth, loss of clinical attachment

15. Initial probing depth
Plaque
Bleeding 3
50-10%
55-15%
4-6
80-15%
80-25% 7
90-25%
90-30%
Pocket depth
PD reduction
Probing attachment level
Recession 3
-0.5
4-6
1-2
0-1 7
2-3

16. It has been shown to provide better access to deep pockets and furcation areas.
Subgingival debridement has been observed to result in a decrease in the total number of microbes.
A decrease in the total bacterial count for sites of 3 mm or greater depth, from 91 ±11 × 10 5 to 23 ± 6× 105, has been observed immediately following subgingival debridement.
Subgingival debridement has been observed to result in a decrease in the mean counts and number of sites colonized by P. gingivalis, A. actinomycetemcomitans, Pr. Intermedia.
In the absence of appropriate home care, the reestablishment of the pretreatment microflora as well as the rebound of clinical improvements due to treatment will occur in a matter of weeks.

17. Contraindications to use Sonic and ultrasonic scalers:
1.Transmissible diseases, since aerosol and splatter caused by sonic and ultrasonic scalers are a potential health hazard to the operating dental staff.
2. Magnetostrictive may interfere with some cardiac pacemakers, their use is also not recommended in affected patients due to health concerns.

18. Principles of Sonic and Ultrasonic Instrumentation
Slim sonic or ultrasonic scaler tips allow access tooth furcation and have been shown to be superior to hand instruments in cleaning furcation areas in vitro.
That the average width of molar furcational entrances is smaller than the working end of conventional curettes. It is difficult to implement proper working strokes.
High volume evacuators aid in minimizing the aerosol dispersion and therefore are of high importance for infection control.

20. Patient and Operator Positioning
Patient and operator positioning for sonic and ultrasonic instrumentation follow the same principles as for hand instrumentation.
For instrumentation of the upper arch, the patient is seated in a supine position with the chin slightly lifted up. approximately 45-degree angulation to the floor.
If treatment is carried out in the mandible a slight lowering of the patient's chin allows good visibility to the lingual aspects of the lower front teeth.

21. The Role of Coolant in Subgingival Sonic and Ultrasonic Scaling
High frequency oscillation of sonic and ultrasonic scaler tips generates heat which necessitates the application of a cooling irrigation.
A flow rate of at least 14 ml/min to 23 ml/min cooling agent appears to be sufficient to prevent thermal damages in periodontal pocket.
Bacterial biofilm removal in vivo is most likely caused by mechanical disruption due to the oscillating tip.
Fluids used for irrigation:
Distalled water.
Saline.
Povidone-iodine solutions.
0.2 % chlorhexidine digluconate.

22. Instrument Power Setting
Medium setting are favorable for all power driven instruments.
Instrument Grasp and Finger Rest
Modified pen grasp.
Finger rest usually extraoral.
Systematic Approach

23. Type of strokes:
Because the contact surface between a rounded power-driven scaler tip and the spherical root surface is rather small, thorough mechanical debridement can only be attained by a series of overlapping horizontal serpentine-like strokes in a coronal-apical direction.

24. Roots should be instrumented with the scaler tip in constant motion until the surface feels smooth and clean.
It is of utmost importance that they be inserted into the pocket in a manner in which the convex working surface of the tip is in contact to the root.
An explorer helps detect residual calculus and prevents root over instrumentation.

25. Summary:
Ultrasonic and sonic instrumentation perform the same function as hand instruments.
They reduce time and effort.
Should be used with care by applying all safety measures.
Infection control.
Always re-check the surface of the tooth after instrumentation to prevent over instrumentation.

26. References:
1. Carranza's Clinical Periodontology 9 th edit. by Michael G.
Newman,Henry Takei, Fermin A. Carranza Dr. ODONT Fermin Carranza
Henry Takei.
2. Clinical Periodontology and Implant Dentistry, 2 Volumes 2010 by Jan Lindhe , Niklaus P. Lang, Thorkild Karring.