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POWER SETTING

Augmenting the power setting increases the distance the active tip travels across the tooth from top to bottom of the stroke (Figure 1)—though not necessarily in a linear fashion.4 This movement creates a three-dimensional “chipping” of the tip against the surface, often referred to as displacement amplitude. High-power settings and long strokes remove more calculus, but also increase the probability of patient discomfort and overinstrumentation.
Low-power settings may create a better relationship between deposit removal, minimal loss of dentin, and surface roughness. The UIT should be tuned and the power setting increased as needed, depending on the deposit's tenacity. The use of low power with thin tips, however, can easily burnish calculus to a smooth veneer, making it almost impossible to remove. Therefore, thin UITs should not be utilized to remove heavy or tenacious calculus unless they are intended for use at high-power levels and have the ability to break deposits cleanly from the root surface. When high-power settings are implemented, adequate pain control is essential to successful instrumentation.
Power (length of stroke) and frequency (speed) are distinct aspects of ultrasonic dental instruments that work together when the energy is activated on a tooth. Frequency is how fast the tip moves across the surface in cycles-per-second, and it can be adjusted only with a manual-tuned unit. This adjustment allows the practitioner to balance the power and frequency for maximum effectiveness and comfort.
TIP ANGULATION
Incorrect application of the tip during instrumentation may cause undesirable surface alterations. Tip angulation must be mentally visualized because of the inability to use direct vision with subgingival debridement without an endoscope, and due to tip size obstructing the view of angulation. The greater the angle between the active tip and the root surface, the greater the energy output and chance of overinstrumentation.1 The active tip to tooth angle should be maintained at 15° or less. To prevent severe root damage, piezoelectric units should be used at close to 0° angulation.
In addition to tip angulation, adapting the terminal 2 mm to 4 mm is essential because this is the active tip area . The precise recommendation for active tip adaptation depends on the type of technology and the unit (refer to the manufacturer's instructions for information on the active tip area).
Correct adaptation of the tip is also crucial. With magnetostrictive inserts, although all sides of the tip are active, the lateral surfaces or back should be adapted because they generate the least amount of energy, which helps prevent overinstrumentation. Adapting the point of an insert to a root surface devoid of calculus may cause striations in the root structure or overinstrumentation.
The lateral sides of piezoelectric tips are the most effective. Though each mechanism requires adaptation of the lateral sides, the manner of movement—both loaded and unloaded—results in an elliptical motion. Oscillation patterns are not dependent on whether the unit uses piezoelectricity or magnetostriction; instead, power setting and shape/design of the UIT influence the patterns.
LATERAL PRESSURE
Calculus removal is less effective when strong lateral pressure is used. Strong lateral pressure interferes with the free movement of the tip to fracture deposits, and it can diminish the activation. Only light lateral pressure is needed; just enough to balance the dental equipment and let it work independently. Grasp pressure may also be related to root roughness/defects.11 Heavy pressure causes the tip to create roughness and remove more structure than necessary. An extraoral grasp with thin inserts is recommended, which helps maintain a light hold on the instrument and balance on the fulcrum. The majority of patients who do not begin therapy with sensitivity should not develop it post-treatment when a light touch is used.

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