* Introduction

* Mode of action

* Sonic scaling devices

* Ultrasonic scaling devices

* Instrument tip design

* Indications

* Contraindications

* Efficacy and efficiency of the instruments

* Precaution/ special consideration

Manual instrumentation was the only method available for the

safe removal of supra and subgingival calculus until the

ultrasonic devices were introduced into 1950.

Ultrasonic/sonic scalers are famous by names of Power driven

scalers or machine driven scalers.

These scalers convert high frequency electrical energy

(ultrasonic) or air pressure (sonic) into high frequency sound

waves.

Hand piece

Cable Hand

piece

Power Control /

Variable Speed

Control

Water Speed

Control

Power Switch

Ultrasoni

cInserts/

Tips

Mechanical vibration- main mode of action

Cavitation

Acoustic turbulence

Irrigation/Lavage

Device technology

Ultrasonic

Magnatosrictive

18,000-45,000 cps

Elliptical motion

All sides active

Piezoelectric

25,000-50,000 cps

Linear motion

Lateral sides active

sonic

2500-7000 cps

Elliptical motion

All sides active

1. Magnatostrictive

Tip moves in elliptical pattern

All surfaces of the tip are active

Magnatostrictive generator with insert tips

2. Piezoelectric device

Tip moves in a linear pattern,

forward and backward

Only lateral surfaces of the tip

are active

Piezoelectric with insert tips

Device is composed of :

◦ 1. hand piece

◦ 2. interchangeable scaling tips

Driven by compressed air

Less amplitude than ultrasonic

Produce vibrations at tip between 2500

to 7000 cps.

Removal of supragingival calculus and tenacious stains.

Subgingival debridement:

◦ Removal of calculus, attached biofilm and endotoxins from

the root surface

◦ Removal of unattached biofilm from the sulcular space

Initial debridement:

◦ For patients of ANUG and other conditions that can be

relieved by removal of deposits

Debridement prior to oral surgery

Removal of orthodontic cement; debonding

Removal of overhanging margins of restorations

Step by step:

1. Pre procedural Antimicrobial rinse (Chlorhexidine gluconate 0.12% oral rinse)

or Listerine

2. Proper positioning of working tip

◦ Use probing depths and radiographs as guides for ultrasonic activation

◦ Use “Painting” strokes/Tapping Strokes for large deposits

◦ Keep insert moving at all times

◦ Use light lateral pressure

◦ Work from coronal areas apically to root surfaces

◦ Control water - Use saliva ejector to control aerosols

3. Application of desensitizing paste or varnish

4. Selective polishing

5. Flossing

6. Oral Hygiene Instructions

7. Antimicrobial rinse

Efficacy and clinical performance have been evaluated under

following parameters:

Plaque and calculus removal

Bacterial reduction and endotoxin/cementum removal

Leaving smoothest root surface

Reduction in bleeding on probing, probing depth and a gain in a

clinical attachment

Ability to access furcation

Traditionally, power driven instruments were used to remove

heavy supragingival calculus only.

Garnick and Dent (1989) showed that both hand and ultrasonic

instrumentations removed plaque equally.

Clifford et al. (1996) found no significant difference among traditional and

ultrasonicmini inserts in disrupting apical border of plaque. But

ultrasonicmini inserts disrupts apical plaque border better in pockets

greater than 7 mm.

Busslinger et al. (2001) found that hand and ultrasonic instrumentation

with either a magnatostrictive or a piezoelectric inserts were equally

effective in calculus removal.

According to Ganot et al. (2004) ultrasonic mini inserts were more

effective in apical plaque zone than curettes.

Clinical outcomes for scaling using either a hand or a power scaler are

similar.

Power driven instruments remove plaque, biofilm, bacteria by

mechanical action and activities like cavitation and acoustic

streaming facilitates subgingival bacterial reduction.

O’Leary et al. (1997) found that up to 5 minutes of ultrasonic

activation resulted in significant reduction of

A.actinomycetemcomitans & P.gingivalis

Leon and Vogel (1987) who found that ultrasonic

instrumentation in class II and class III furcations was more

effective than hand scaling

Chlorhexidine as a coolant and lavage – it did not reduce

subgingival pathogens better than water

Most studies found that ultrasonic devices to be effective in

reducing root surface endotoxins.

Smart et al. (1990) & chiew et al. (1991) found that using light

pressure with an ultrasonic instrument effectively removed

endotoxin while conserving the root structure.

Nisimine & O’Leary (1979) found that hand instruments were

more effective than an ultrasonic scaler for this purpose.

Studies have reported mixed results

Ritz et al. (1991) measured tooth substance loss on mandibular

incisors after 12 working strokes over an apicocoronal

distance of 6 mm by an ultrasonic scaler, sonic scaler and hand

instrument.

Results showed ultrasonic scaler removed the least substance,

11.6 μm, versus 93.5 μm for sonic scaler and 108.9 μm for

hand instrument.

both types demonstrates similar outcomes for reduction in

BOP, probing depth and gain in CAL.

Badersten et al. (1998) found both instruments reduce BOP

and pocket depth similarly

Boretti et al. (1995) observed similar gains in CAL with both

the instruments

Researches done by Kocher et al.(2001), and Loos et al.

(1989) found similar results

In many cases opening of the furcation is narrower than the

access achievable by the conventional hand instruments

Therefore, power scalers have been recommended as a mean

to improve access when scaling furcation.

Leon et al. (1987) demonstrated that ultrasonic scalers were

equal to hand scalers in reducing the bacteria in class I

furcations but more effective in class II and class III

furcations.

Sugaya et al.(2002) found that ultrasonic tips specifically

designed for furcations were more effective in deriding class II

and III furcations.

Aerosol production contaminated with blood

Neurologic disturbance of the hand caused by vibration

Hearing loss

Interference with cardiac pacemakers

Barnes et al. (1998) Demonstrated aerosol contaminated with

blood produced by the in Vivo use of power scalers.

Universal infection control procedures can help minimize the

amount of aerosol produced.

Harrel and Molinari (2004) recommended three levels of

defence in the reduction of dental aerosols:

1. personal protective barriers such as mask, gloves and

safety glasses

2. routine use of preprocedural antiseptic Rinse

3. use of high speed evacuation device

Miller et al. (1998) found atrial and ventricular pacing was

inhibited by electromagnetic interference produced by a

magnatostrictive ultrasonic scale.

Newer models of cardiac pacemakers have bipolar titanium

insulation that shields the unit from the effects of power

scalers

In general health conditions

1. communicable disease: Patient with a communicable

disease that can be transmitted by aerosols, such as TB.

2. Susceptibility to infection:

◦ Immunosupression from disease or chemotherapy, uncontrolled

diabetes, debilitation, or kidney or other organ transplant

3. Respiratory risk: septic material and microorganisms

from biofilm and pockets can be aspirated into the

lungs

◦ H/O- COPD, asthma or cystic fibrosis

◦ CVD with secondary pulmonary disease or breathing problem

4. swallowing difficulty or patients prone to gagging

5. cardiac pace makers

In oral conditions like,

1. demineralized areas

2. exposed dentinal surface

3. primary and newly erupted permanent teeth have large pulp

chambers, vibrations and heat from the ultrasonic scaler may

damage the pulp tissue

1. damage to integrity of restorations

◦ Porcelain- fracturing, loss of marginal integrity

◦ Amalgam- surface defects

◦ Composite- surface alteration

2. titanium implant abutments

Ultrasonic/sonic and hand instrumentation are both utilized in

initial and supportive periodontal therapy

Clinical studies have shown results (periodontal tissue health)

to be the same following ultrasonic/sonic or hand

instrumentation

The goal of both hand instrumentation and

ultrasonic/sonic instrumentation is debridement to a state

of periodontal health.

So, the key concept is,

◦ A combination of hand Instrumentation and

mechanized instrumentation is probably most effective

clinically and in terms of time management.

1. Esther M. Wilkins, Textbook of clinical practice of the dental hygienist,

10th edition, Wolters-Kluwer health publishers.

2. Newman, Takei, Klokkevold, Carranza’s Textbook of clinical

periodontology, 10th Ed.,Elsevire publication.

3. Current concepts and advances in manual and power-driven

instrumentation, Shigeru Oda, Hiroshi Nitta, Takashi Setoguchi, Yuichi

Izumi & Isao Ishikawa, Periodontology 2000, Vol. 36, 2004, 45–58.

4. www.hu-fridey.com

5. www.dentsplycoinc.com