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The Evolution of Ultrasonic Therapy

FOR GENERATIONS, clinicians have struggled with the definition of debridement and the dental instruments used in the debridement process. O’Leary created the following terminology:

Scaling: Instrumentation to remove supragingival uncalcified and calcified accretions and all gross subgingival accretions.

Root Planing: Instrumentation to remove the microbial flora on the root surface or lying free in the pocket, all flecks of calculus, and all contaminated cementum and dentin.

After debridement is finished, the anticipated end result is that the sulcus is completely devoid of all irritants including plaque, calculus, endotoxin, and necrotic cementum. However, the primary protocol is the periodic removal or dissolution of an established biofilm.The question is what category of instrumentation—manual or mechanical—is the most effective in achieving periodontal health?

MANUAL VS MECHANICAL INSTRUMENTATION
The advent of power-driven instrumentation, both sonic and ultrasonic therapy, ushered in a new era for mechanical debridement. However, the acceptance of ultrasonic therapy in periodontal therapy has been fraught with controversy. The initial debate was over the potential damage to root surfaces with ultrasonic devices. Evidence demonstrated that this power (a magnetostrictive device at 18 kHz to 42 kHz) could create root roughness when compared to manual instrumentation. The tips used in these early devices were large in diameter and primarily for gross calculus removal.
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However, even though studies demonstrated increased root roughness with these devices, the degree of inflammation was less when compared to manual instrumentation.A manual instrument decreases periodontal pathology through the mechanical removal of plaque and calculus and by detoxifying the root by decreasing the levels of endotoxin. An ultrasonic device possibly affects the microbial population through cavitation. Walmsley demonstrated that ultrasonic machines with water irrigation decreased the biomass by five to eight times versus no water irrigation. In addition, studies show that periodontal pathogens are negatively affected by ultrasonification.
In the early 1980s, Holbrook suggested modifying ultrasonic tips to a decreased diameter. Since fabricating tips was a technique sensitive task, this action led to breakage and discomfort, especially when used in autotunable equipment. When manufacturers began producing tips with quality control and when tips were coordinated to specific generators, the use of ultrasonic therapy became more widely accepted, including implementation in academic settings.

Likewise, studies began to show positive effects of power-driven instrumentation. Dragoo demonstrated in an in vivo study that modified ultrasonic tips of decreased diameter were more effective than large diameter ultrasonic tips and that manual curets with the modified tips achieved root smoothness.
In a study of recare patients, Copulus showed that ultrasonic therapy maintained attachment levels compared to handheld curets with a significantly reduced timeframe.With dental equipment of furcations, Leon and Vogel suggested that ultrasonic tips were more effective than manual instrumentation in accessing class II and class III furcations.8 This is primarily because many curets have blade face widths that are larger than the apex width of most furcations. However, curets designed with mini-blades9 or manual diamond coated instruments can effectively access furcation anatomy. Hallmon’s and Rees’ review comparing mechanically driven instrumentation with manual instrumentation suggested that both are comparable in affecting improved clinical outcomes. The parameters included probing depths, clinical attachment levels, bleeding on probing, and recession.However, experienced clinicians appreciate the synergy that occurs when power-driven instrumentation and manual curets are used in conjunction with one another.

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