Effectiveness and Efficiency in Ultrasonic Scaling

The standard non-surgical treatment for periodontal disease is supraand subgingival scaling to disrupt and thoroughly remove biofilm, calculus deposits, periodontal pathogens, and debris. Instrumentation options include hand scalers and ultrasonic scalers. Considerations in the choice of method include efficacy, efficiency, safety, patient comfort, and ergonomics. Ultrasonic devices have enabled clinicians to effectively and efficiently remove supragingival and subgingival hard deposits and biofilm. When selected and used appropriately, they are clinician and patient friendly. Scaling inserts have evolved to include slim, complementary tips which are curved right and left, straight, beavertail, and angulated insert tips; as well as specialty instruments, inserts and tips designed for safe and effective implant care without altering the integrity of implants. Instrumentation strategies used in debriding implants must ensure that the instruments are compatible with the implant surface. Plastic scaling instruments and plastic-tipped ultrasonic scalers have been found to be safe and effective to use around implants. The latest generation of ultrasonic scalers offers the ability to thoroughly instrument deep pockets and furcation areas, and offers benefits over conventional hand scalers which include improved operator ergonomics and comfort, improved patient comfort, less tooth substance removal and more efficient and effective treatment. Introduction Periodontal disease relies upon the presence of a mature biofilm rich in periodontopathogens, and is evident to varying degrees in the majority of U.S. adults.1 The progression of periodontal disease is highly variable and dependent largely upon the host response, with bacterial variances between individuals accounting for only 20% of cases progressing.2 Nonetheless, the removal of bacteria and their byproducts is essential to prevent and halt periodontal disease. Home care oral hygiene measures can be effective in removing supragingival biofilm when properly performed. However, once a mature subgingival biofilm has developed, or dental calculus is present, home care is ineffective and clinical care is required. In the absence of clinical intervention, periodontal disease progression in individual patients leads to soft tissue attachment loss and bone loss. The relationship of biofilm, calculus, and periodontal disease Within 48 hours of dental biofilm formation, sufficient numbers of periodontopathic anaerobes are established for the onset of gingivitis. If the biofilm is not disrupted, its maturation will result in a complex subgingival biofilm three to twelve weeks after the biofilm starts to form. The subgingival biofilm is highly structured, and contains mainly gram-negative anaerobes.3 Research has found that a small proportion of these anaerobic species form complexes associated with periodontal disease.4 Mature biofilm both harbors and protects bacteria by enveloping them in a well-structured and resistant biofilm. The deepest regions of the biofilm harbor the most periodontopathogens, and are where the highest levels of bacterial vitality are seen.5 The reversible gingivitis which develops 48 hours after the formation of biofilm will transform to an active process whereby the host responds by releasing antibodies, neutrophils, lymphocytes, and macrophages into the adjacent tissue. Interleukin 1 and tumor necrosis factor are cytokines produced by the leukocytes. These inflammatory markers then stimulate the production of matrix metalloproteinases (MMPs). The production of cytokines, prostaglandins, and chemokines leads to inflammation and bone loss.6 Dental calculus is present in the majority of adults supraand subgingivally, and is 70%-80% inorganic.7 Calculus formation results from calcification of dental biofilm and exfoliated oral epithelial cells. The mineral ions responsible for this originate in the saliva and additionally from the crevicular fluid.8 In addition, dental calculus contains bacterial debris interspersed within a mineral deposit of mainly calcium phosphate (Figure 1). Research has found that supragingival calculus also has nonmineralized areas within it containing bacteria.9 Endotoxins are slowly released from dental calculus10 into the adjacent soft tissue, where they may become destructive to the soft and hard tissues of the periodontium. The disruption and removal of subgingival biofilm and calculus requires clinical intervention, and is typically carried out by non-surgical periodontal treatment.