10.59987/ads/2012.3-4.90-94
Aim. The present study wants to evaluate the effectiveness in the improvement of several periodontal indices, such as probing pocket depth, bleeding on probing and plaque index, and the patient subjective preference to the treatment of root planning with tips for delicate -micro ultrasonic therapy comparing to traditional ones.
Methods. Thirty patients were selected for our randomized split mouth study; in each patient two quadrants (test) were treated with tips for delicate micro-ultrasonic root planing, and two quadrants (control) with tips for traditional ultrasonic root planing. Probing pocket depth, bleeding on probing and plaque index were collected at baseline, after six weeks and after six months. Patients were asked to assess the subjective preference of the type of treatment with Visual Analogue Scale (Vas) especially designed and immediately administered after the treatment.
Results. Probing pocket depth and plaque index had a parallel improvement in both groups, while the bleeding on probing improved significantly in test group. The majority of patients (23 to 30, 76,6%) has expressed preference with VAS for the treatment with new tips.
Conclusions. The new tips created for periodontal maintaining can be really advantageous in terms of reduction of plaque and bleeding indexes; the main point in favor of these tips is the reduction of the discomfort for the patient. Finally this approach tends to be less time consuming than a manual instrumentation method.
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Effectiveness of tips for delicate micro-ultrasonic root planing comparing to tips for traditional ultrasonic root planing
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S. Sabatini 
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Effectiveness of tips for delicate micro-ultrasonic root planing comparing to tips for traditional ultrasonic root planing
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                                                                                                           Original article


Effectiveness of tips for delicate micro-ultrasonic
root planing comparing to tips for traditional
ultrasonic root planing




                                                                                                 li
                                                                                              na
Gianna Maria Nardi, RDH, DHA                                     the connective tissue attachment and the alveolar bone.
Roberto Di Giorgio, MD, DDS                                      Plaque and bacteria are generally recognized as the pri-




                                                                                           io
Silvia Sabatini, RDH, DHA                                        mary cause of the periodontal disease. Nowadays, scal-
                                                                 ing and root planning (SRP) represents the most widely
                                                                 used procedure in the treatment of the periodontitis. Its
Department of Oral and Maxillofacial Sciences, Sapienza          main goal is the removal of the components of the sub-




                                                                                        az
University of Rome, Italy                                        gingival biofilm, which have the major role in the initiation
                                                                 and in the progression of the disease.
                                                                 A primary goal in the treatment of periodontitis is the re-
Corresponding author:                                            moval of bacterial deposits and the arrest of disease pro-




                                                                         n
Gianna Maria Nardi                                               gression. Mechanical removal of these deposits from the
Department of Oral and Maxillofacial Sciences,                   root surface is required for establishing and maintaining pe-




                                                                      er
Sapienza University of Rome, Italy                               riodontal health (1). Large number of studies has reported
Via Caserta, 6                                                   beneficial results from mechanical therapy in term of both
00161 Rome, Italy                                                clinical and microbiological aspects (1,2). Since long, the
Phone: +39 3289850146
E-mail: giannamaria.nardi@uniroma1.it
                                            nt                   hand instruments were the first choice of clinicians. It was
                                                                 believed that these instruments produced a smooth root
                                                                 surface; however, considerable manual dexterity is re-
                                                                 quired for their effective operation. Moreover, hand instru-
                                          iI
Summary                                                          ments are more time consuming and are unable to reach
Aim. The present study wants to evaluate the effective-          deeper root surface where pockets are more than 4 mm
ness in the improvement of several periodontal indices,          deep (3). Ultrasonic tips were originally designed for gross
                                        on

such as probing pocket depth, bleeding on probing and
                                                                 scaling and removal of supragingival calculus and stains.
plaque index, and the patient subjective preference to the
                                                                 More recently, these power driven instruments have been
treatment of root planning with tips for delicate -micro ul-
trasonic therapy comparing to traditional ones.                  modified to have smaller diameter tips and longer working
Methods. Thirty patients were selected for our randomized        lengths, thereby providing better access to deep probing
                                i


split mouth study; in each patient two quadrants (test)          sites and more efficient subgingival instrumentation.
                             iz


were treated with tips for delicate micro-ultrasonic root        It is known from literature (1-3) that ultrasonic scaling and
planing, and two quadrants (control) with tips for traditional   root planing have the same effectiveness of manual in-
ultrasonic root planing. Probing pocket depth, bleeding on       strumentation in biofilm removal and in creating a biolog-
              Ed




probing and plaque index were collected at baseline, after       ically compatible surface on the root treated. It has been
six weeks and after six months. Patients were asked to as-       already proposed that there is no difference in the results
sess the subjective preference of the type of treatment with
                                                                 of different ultrasonic therapies (4), but to define which
Visual Analogue Scale (Vas) especially designed and im-
mediately administered after the treatment.                      kind of available technology is better to use for an ideal
Results. Probing pocket depth and plaque index had a             minimally invasive treatment plan is necessary. All this
parallel improvement in both groups, while the bleeding          could improve the patient acceptance and cutting the
 IC




on probing improved significantly in test group. The ma-         work time.
jority of patients (23 to 30, 76,6%) has expressed prefer-       “Root planing” can’t be considered as an appropriate
ence with VAS for the treatment with new tips.                   definition to describe the procedures of the non-surgical
Conclusions. The new tips created for periodontal main-          periodontal therapy, since it emphasizes the “polishing” or
C




taining can be really advantageous in terms of reduction         “smoothing” of the roots only, while the main aim of such
of plaque and bleeding indexes; the main point in favor
                                                                 a treatment is to decontaminate and lower the bacterial
of these tips is the reduction of the discomfort for the pa-
                                                                 load of the periodontal pocket. In the past the attention of
tient. Finally this approach tends to be less time consum-
                                                                 dental hygienists and dentists was to smoothen the roots
©




ing than a manual instrumentation method.
                                                                 as much as possible, many times with too aggressive ap-
Key words: root surfaces, periodontal disease, ultra-            proaches of instrumentation, and this often jeopardized
sonic instrumentation, cementum.                                 the root. Nowadays clinical research makes us aware of
                                                                 the importance of a minimally invasive approach of instru-
                                                                 mentation, to respect the surfaces of roots, particularly the
Introduction                                                     cementum and cementogenesis.
                                                                 The objective of this study is to evaluate the effectiveness
Periodontitis is an immuno inflammatory disease charac-          in the improvement of several periodontal indices, such
terized by the loss of tooth supporting structures included      as probing pocket depth, bleeding on probing and plaque

90                                                                                  Annali di Stomatologia 2012; III (3/4): 90-94
Effectiveness of tips for delicate micro-ultrasonic root planing comparing to tips for traditional ultrasonic root planing


index, and the patient subjective preference to the treat-
ment of root planning with tips for micro-delicate ultrasonic
therapy comparing to traditional ones.




                                                                                                    li
Materials and methods




                                                                                                 na
Study population and design

This research is a randomized split mouth study. Thirty pa-
tients who were 18 years old or older and able to sign an




                                                                                              io
informed consent form were selected for the study. They
were under periodontal maintenance, in a good systemic
health condition and they have at least a residual pocket
                                                                   Figure 2. Fluorescein plaque detector with curing light.
depth of ≥5 mm and a positive bleeding on probing for




                                                                                           az
each quadrant. The criteria for exclusion were as fol-
lows: smoking, assuming medications that could affect the          Once this clinical index had been collected, each patient re-
periodontal therapy such as long-term non-steroidal anti-          ceived ultrasonic supragingival scaling using a standard tip
inflammatory drug therapy, use of bisphosphonates, un-             Mectron® S1, with semi-circular cross-section for work on




                                                                            n
willingness to return for the follow-up examination. In            large areas on all tooth surfaces (Fig. 3), and subgingival
each patient two quadrants (test) were treated with tips for       scaling and root planing using a traditional periodontal tip




                                                                         er
delicate micro- ultrasonic root planing, and two quad-             Mectron® P1 for the quadrants taken as control and a new
rants (control) with tips for traditional ultrasonic root plan-    tip Mectron® P10 for delicate micro-ultrasonic root planing
ing. Each quadrant was randomly allocated to a test                for the other ones (Fig. 4). The insert P1 is straight with a



                                               nt
group or control group using a specific software package
(Random Allocation Software version 1.0, downloadable
on http://mahmoodsaghaei.tripod.com/Softwares/randal-
loc.html).
                                                                   round tip for universal root planing, the insert P10 is more
                                                                   anatomic with a straight, thin and curved working tip
                                                                   (Fig. 5). No anesthetic has been used.
                                             iI
Treatment
                                           on

In each patient two quadrants (test) were treated with tips
for delicate micro- ultrasonic root planing, and two quad-
rants (control) with tips for traditional ultrasonic root plan-
                                 i


ing. Clinical indices were collected at baseline (T0), after
                              iz


six weeks (T1) and after six months (T2).
At baseline (T0) probing pocket depth (PPD) and bleed-
ing on probing (BOP) were collected using a periodontal
              Ed




probe (Fig.1). To collect plaque index (PI) was used a flu-
orescein plaque detector with Blue Phase curing light
(Ivoclar®) to motivate the patients to the importance of
correct brushing and to make us have more information
about their oral hygiene behavior (Fig. 2).
Each patient had at least a pocket depth of ≥ 5 mm, PI was
 IC




37% in the test group and 35% in the control one, and BOP
was 15% in the test group and 16% in the control one.
C
©




Figure 1. Collecting clinical indexes with a periodontal probe.    Figure 3. This picture shows the design of tip S1.


Annali di Stomatologia 2012; III (3/4): 90-94                                                                                 91
G. M. Nardi et al.




                                                                                                  li
                                                                                               na
                                                                                            io
Figure 4. Delicate micro ultrasonic root planing with tip P10.   Figure 6. Airpolishing treatment with glycin powder.




                                                                                         az
                                                                 We gave oral hygiene instruction for home maintenance,
                                                                 suggesting to brush twice per day for two minutes at
                                                                 least with oscillating rotating mechanical toothbrush (Fig.




                                                                          n
                                                                 7) using a pea size quantity of generic fluoride toothpaste
                                                                 and to rinse mouth after brushing with zero alcohol essen-




                                                                       er
                                                                 tial oils mouthwash for 30 seconds. Patients had to per-
                                                                 form this protocol for six weeks, until they received the
                                                                 control visit.


                                              nt
                                            iI
                                 i        on
                              iz
              Ed




                                                                 Figure 7. Home maintenance protocol instruction with oscillating
                                                                 mechanical toothbrush.


                                                                 Clinical indices were collected again after six weeks from
                                                                 the treatment (T1), to assess if PI, PPD and BOP have
                                                                 had any improvement. There was a general improve-
 IC




                                                                 ment of clinical indices, so we performed airpolishing
                                                                 with glycine powder to remove the new biofilm where nec-
                                                                 essary and let the patients continue with the same home
                                                                 maintenance protocol until the final evaluation of the
C




Figure 5. This image shows the anatomic design of tip P10.
                                                                 study after six months from the initial treatment (T2).
                                                                 At T2 PI, PPD and BOP were collected again and profes-
After scaling and root planing have been performed, all          sional oral hygiene was scheduled for each patient the
dental surfaces, both of crowns and roots, received an air-      week after.
©




polishing treatment with glycine powder (Fig. 6).
Patients were asked to assess the subjective preference
of the type of treatment with Visual Analogue Scale (VAS)        Results
especially designed and immediately administered after
the treatment. The scale consisted of ten possible values,       The PI at baseline was 37% in test group and 35% in the
corresponding to six different stages of pain: 0 was “no         control one, and after six weeks both groups showed a PI
pain”, from 1 to 2 “mild annoying pain”, from 3 to 4 “un-        of 15%. Each patient had at least a residual pocket depth
comfortable pain”, from 5 to 6 “distressing pain”, from 7        ≥ 5 mm at baseline, while after the treatment no probing
to 8 “intense pain” and from 9 to 10 “worst possible pain”.      depths ≥ 3 mm were collected in both groups. BOP at

92                                                                                   Annali di Stomatologia 2012; III (3/4): 90-94
Effectiveness of tips for delicate micro-ultrasonic root planing comparing to tips for traditional ultrasonic root planing


baseline was 15% in the test group and 16% in the con-             Statistical analysis indicated that differences between test
trol one. At T1 it was 8% in the test group and 15% in the         and control sites were significant (t= -2.37, sdev=0.431, de-
control group. The values were the same at T2: the test            grees of freedom = 22, the probability of this result, assum-
group showed PI = 15%, PPD ≤ 3 mm and BOP = 8%,                    ing the null hypothesis, is 0.027< 0.05).
while the control group showed PI = 15%, PPD ≤ 3 mm                The majority of patients (23 to 30, 76,6%), has expressed




                                                                                                    li
and BOP = 15% (Figs. 8, 9).                                        preference with VAS for the treatment with new tips. The




                                                                                                 na
                                                                                              io
                                                                            n              az
                                                                         er
                                               nt
                                             iI
                                           on

Figure 8. Graph showing the changing of BOP from baseline to T2.
                                 i
                              iz
              Ed
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©




Figure 9. Graph showing the changing of PI from baseline to T2.


Annali di Stomatologia 2012; III (3/4): 90-94                                                                                93
G. M. Nardi et al.



Tips                 Score
                     0                  1                 2               3               4              5              6
P10                  14                 12                4               -               -              -              -
P1                   3                  10                11              5               -              -              1




                                                                                                       li
Table 1. Table showing numbers of patients that expressed scores collected with VAS after the treatment with tip P1 and tip P10.




                                                                                                    na
7 who did not preferred the tip P10 found no differences             high speed (2,00,000 revolutions per minute) and ultra-
between the two inserts. The maximum score attributed                sonic instruments caused more damaged to root surface
to the treatment with P10 was “2” (mild annoying pain),              when compared with hand curettes (11).




                                                                                                 io
while the maximum one given to treatment with P1 was                 All in all this research stresses the idea that these new tips
“6” (distressing pain). Using the test tip, the patients gave        created for periodontal maintaining can be really advan-
the following scores to the treatment: fourteen patients             tageous in terms of reduction of plaque and bleeding in-




                                                                                              az
gave “0”, twelve patients gave “1” and four patients gave            dexes. Moreover it should be considered that the main
“2”; using the control tip the scores were: three patients           point in favor of these tips is the reduction of the discom-
gave “0”, ten patients gave “1”, eleven patients gave “2”,           fort for the patient. Finally this approach tends to be less
five patients gave “3” and one patient gave “6” (Tab. 1).            time consuming than a manual instrumentation method.
                                                                     However what the effective advantage in term of preser-




                                                                              n
                                                                     vation of cementum is remains elusive. Further re-
Discussion                                                           searches in this area might include a quantitative study of




                                                                           er
                                                                     tooth substance loss with various periodontal instruments
Analyzing the clinical indices, they show a parallel im-             and effects of root surface characteristics on fibroblast at-
provement in PPD and PI. No patient had residual pocket              tachment after mechanical debridement. Such studies


                                             nt
depth ≥ 3 mm at T1 or T2, and PI was 15% in both
groups after six weeks and also after six months. There
were no significant differences in the indices measured in
the treated sites with the new tips comparing to those
                                                                     will be very helpful in opening new vistas of research for
                                                                     understanding the treatment modalities for optimal regen-
                                                                     eration of supporting tissue onto the tooth surface affected
                                                                     by periodontitis.
                                           iI
treated with traditional ones, except in BOP, which
showed an improvement in the test sites (test group:
BOP = 8%, control group: BOP = 15%), both at T1 and                  References
                                         on

T2. These results mean that ultrasonic therapy is efficient
in clinical indices’ reduction, as the patients of both groups       1.  Wilkins EM. La pratica clinica dell’igienista dentale, PICCIN
show improvement, but that the tip for a micro- delicate                 2010.
root planing is more efficient in managing bleeding on               2. Singh S, Uppoor A, Nayak D. A comparative evaluation of the
                                i


                                                                         efficacy of manual, magnetostrictive and piezoelectric ultra-
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The partial results were satisfying, but more satisfying
                                                                         J Appl Oral Sci. 2012 Feb;20(1):21-6.
were the final results: no differences were showed among             3. Dahiya P, Kamal R, Gupta R, Pandit N. Comparative evalu-
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                                                                         ation of hand and power-driven instruments on root surface
meaning that the home maintenance protocol was effi-                     characteristics: A scanning electron microscopy study. Con-
cient and the clinical situation can be considered perma-                temp Clin Dent. 2011 Apr;2(2):79-83.
nent.                                                                4. Silva LB, Hodges KO, Calley KH, Seikel JA. A comparison of
23 on 30 patients preferred the treatment with the test tip              dental ultrasonic technologies on subgingival calculus re-
and the other 7 found no difference between the two tips                 moval: a pilot study. J Dent Hyg. 2012;86(2):150-8.
used; no patients received anesthetics, so the insert P10            5. Clark S, Group H, Mabler D. The effect of ultrasonic instru-
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                                                                         mentation on root surfaces. J Periodontol. 1968;39:125-32.
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                                                                     6. Garrett JS. Effects of non-surgical periodontal therapy on Pe-
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Ultrasonic instruments have been used as valuable ad-                    1983;10:515-21.[PubMed]
juncts to conventional hand instruments for many years.
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                                                                     7. Dragoo MR. A clinical evaluation of hand and ultrasonic in-
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©




“stippled” root surface and had a greater potential for                  tation: Hand versus poser – driven scalers. Curr Opin Peri-
                                                                         odontol. 1993;3:78-84. [PubMed]
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                                                                     9. Jacobson L, Blomlof J. Root surface texture after different
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                                                                         scaling modalities. Scan J Dent Res. 1994;102:156-60.
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trasonic tips used on medium power may do less damage                11. Wilkinson RF, Maybury JE. Scanning electron microscopy of
to the root surface than the hand or sonic scalers (10).                 root surface following instrumentation. J Periodontol.
Some studies suggested that the rotary instruments at                    1973;44:559-63. [PubMed]


94                                                                                       Annali di Stomatologia 2012; III (3/4): 90-94
Effectiveness of tips for delicate micro-ultrasonic root planing comparing to tips for traditional ultrasonic root planing




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Annali di Stomatologia 2012; III (3/4): 90-94                                                                                95
