The proper use of periodontal instrumentation is the ability to adequately remove calculus and arrest or recover a patient’s periodontal disease and is an essential function of a dental hygienist. There is an increasing variety of instrument types available for dental hygienists to perform this task. These instruments range from traditional manual hand scaling, ultrasonic scalers, air polishers, and more. The studies found show that different calculus removal instruments available to dental hygienists today are effective in the removal of calculus. The question that is being left asking is after removing the calculus, what is the condition of the surface of the root? When the surface of a tooth’s root is smooth, there is less surface area in order for bacteria to adhere to. Rougher root surface can increase the rate of periodontal disease and calculus build-up. Looking at these studies does one instrument produce less damaging outcomes to the tooth surface?
Review of Literature
Scaling and root planing, also known as traditional periodontal therapy, constitutes the removal of dental plaque and calculus and then the smoothing, or planing, of the surfaces of the roots, in turn removing cementum or dentin. In the treatment of periodontal disease, A variety of instruments are available to Dental Hygienists today to aid in the removal of these agents that contribute to the disease process. These instruments include manual hand scalers and curettes, ultrasonic scalers, air polishers, planing burs, and laser therapy as well.
Competently performed scaling and root planing can achieve superior outcomes utilizing the least damaging choice of instrumentation.
Existing studies assessing the fluctuations in the extent of root surface changes created by manual, and ultrasonic instruments is lacking (Walmsley et al., 2008; Oda et al., 2004; Kocher et al., 2002). While some studies report manual scalers as removing more root substance (Jacobson et al., 1994), other conflicting studies report statistically significant differences with the ultrasonic scaler being more damaging overall (Oda et al., 2004). Another study set out to evaluate the root surface roughness after SRP with erbium, yttrium aluminum garnet (er.YAG) laser, in comparison to ultrasonic and hand instruments (Attaei, E.; Birang, E.; Birang, R.; Nachsh, N.; Yaghini, J., 2015).
During scaling and root planing procedures with ultrasonic instruments, the wrong application of the tip to the tooth surface or unintentional over-instrumentation of calculus-free subgingival root areas may cause surface alterations including scratches, gouges, and nicks on the tooth.
There is a considerable amount of published literature on the comparative effectiveness of proper instrumentation during periodontal scaling and root planing and the potentially deleterious effects the different instruments can have on the tooth surface. A small cross-section of the available studies within the last 5-7 years set out to critically examine the impact of various currently available and commonly utilized Hygiene instruments in the removal of plaque and calculus while removing the least amount of tooth surface or providing the smoothest tooth surface post-treatment.
Four studies published between 2012 and 2018, will be examined all of which have a congruent goal to examine the role of instrumentation within periodontal therapy for effective treatment while preventing further harm to the patient. The specific objective of the study by Bozbay E, Dominici F, Gokbuget AY, Cintan S, Guida L, Aydin MS, Mariotti A, Pilloni A., 2018, was to evaluate three distinct periodontal treatment instrumentation methods to hand instrumentation on residual cementum of periodontally diseased teeth. Devaraj C G, Marda P, Prakash S, Vastardis S., 2012 set out to determine the correlation between the remaining calculus, the loss of tooth substance, and the roughness of root surface after root planing. The instruments utilized in the study included the Gracey curette, ultrasonic instrument (Slimline® insert FSI-SLI-10S), and DesmoClean® rotary bur. Antush M., Ashish S. N., Ranganath V, Vuppalapati R., 2014 Designed their study in order to compare the weather different ultrasonic scalers and a periodontal curette were more or less useful for calculus removal on the tooth surface as well as the differences on root surface roughness. Attaei, E.; Birang, E.; Birang, R.; Nachsh, N.; Yaghini, J., 2015 set out to discover if the root surface after an SRP with a erbium: yttrium aluminum garnet (Er.YAG) laser compared to ultrasonic and hand instrumentation in the root surface post treatment.
Data for the study Preservation of root cementum: a comparative evaluation of power-driven versus hand instruments (Bozbay E. et al., 2018) was collected using forty-eight otherwise healthy, single-rooted teeth. The patients involved in the study were diagnosed with severe chronic periodontitis and had existing treatment plans for tooth extractions. These teeth slated for extraction were treated using four different instrumentation methods. The teeth were treated subgingivally at one approximal site utilizing one of the four distinct instrumentation methods: hand curettes, piezoelectric ultrasonic scalers, piezoelectric ultrasonic scalers following air polishing or air polishing alone. The instrumented and non-instrumented teeth were analyzed post extraction with a dissecting microscope and SEM for measurement of the amount of change in the surface characteristics of the residual cementum. The research methods in the investigation of A comparison of root surface instrumentation using manual, ultrasonic and rotary instruments: An in vitro study using scanning electron microscopy (Devaraj C G, Marda P, Prakash S, Vastardis S., 2012) were both qualitative and quantitative. This data allowed the researchers to provide an analysis of how effective calculus removal was between the three test instruments: the amount of lost tooth substance, and the root surface roughness resulting from the instruments used within the study. The three test instrument types were a hand curette, an ultrasonic instrument, and a rotary bur. SEM examined Thirty-six extracted mandibular incisors. The basis of the measurements is the remaining calculus index (RCI), The loss of tooth substance index (LTSI), and the roughness loss of tooth substance index (RLTSI). Each instrument treated twelve of the thirty-six samples. The time required for the completion of each instrumentation treatment was also noted — the use of the Kruskal-Wallis ANOVA method for multiple group comparisons and the Mann-Whitney test for group-wise comparisons aided in the statistical analysis of the data. The analysis was carried out with SPSS® software (version 13).
Data for the study The effect of various ultrasonic and hand instruments on the root surfaces of human single-rooted teeth: A Planimetric and Profilometric study (Antush M., Ashish S. N., Ranganath V, Vuppalapati R., 2014) utilized 40 single-rooted teeth with subgingival calculus destined for extraction. Assignment of each tooth went to one of three experimental groups and one control group. Each group had a sample size of 10 teeth, and the control group was left untreated. Group one treated the teeth with the Piezoelectric ultrasonic. Group two treated their sample teeth with the Magnetostrictive ultrasonic. Also, group three had treatment with hand instrumentation (Curette). After instrumentation, and extraction of the treated teeth the presence of residual deposits and root surface roughness were analyzed using the Planimetric analyzing tool and Surface Profilometer. Root surface was evaluated qualitatively using SEM.
Data for the study Root Surface Roughness After Scaling and Root Planing with Er:YAG Laster Compared to Hand and Ultrasonic Instruments by Profilometry (Attaei, E.; Birang, E.; Birang, R.; Naghsh, N.; Yaghini, J., 2015) utilized 56 extracted sound single rooted teeth with moderate level of calculus which were selected and randomly divided into four groups: SRP was performed with Er.YAG later) in group 1, Manual in group 2, and ultrasonic in group 3. Group 4 was considered the control group. After SRP all samples were cut by a Servocut cutting machine into pieces. The samples were mounted in acrylic resin. The surface roughness of the samples were evaluated with profile entry, and the data was analyzed using one-way ANOVA and Tukey’s test in SPSS software.
Bozbay et al. (2018) found that the percentage of coronal cementum remaining following subgingival instrumentation was 84% for U, 80% for U + AP, 94% for AP and 65% for HC. Although subgingival instrumentation of apical portions of the cementum demonstrated 6% less retained cementum in comparison with coronal portions, the amount of retained cementum with AP was still significantly higher than with HC. SEM results found the smoothest root surfaces created by the HC followed by the AP, while root surfaces instrumented by U or U + AP presented grooves and scratches. This study demonstrated that AP was superior to U devices in preserving cementum, whereas HC were the most effective instruments in removing cementum. While Devaraj C G, Marda P, Prakash S, Vastardis S. (2012) determined that the RCI and LTSI show statistically nonsignificant differences between all the three experiment cohorts, the RLTSI showed a statistically significant difference between the Slimline™ ultrasonic insert and a hand curette as well as between the Slimline™ and the Desmo-Clean™ ultrasonic. The Slimline™ showed the least mean scores for RCI, LTSI, and RLTSI. Though the difference was not correctable, the Slimline™ insert was shown to be more effective than the other methods as scored by the indices and the instrumentation time.
Moreover, Antush M., Ashish S. N., Ranganath V, Vuppalapati R. (2014) showed that residual deposits were similar in all experimental groups. Concerning roughness parameters, Root mean square roughness and Total roughness, the study observed a significant difference between hand instrumentation and ultrasonic devices. The SEM analysis revealed a similar root surface pattern for the ultrasonic devices, but the curette showed many instrument scratches, gouges, and removal of large amounts of cementum. The curette produced the rougher root surfaces than two ultrasonic devices used in the study and caused more root surface removal. Piezoelectric devices produced minimum root surface roughness but caused more root substance removal and more cracks than Magnetostrictive ultrasonic devices. And Attaei, E., Birang, E., Birang, R., Naghsh, N., Yaghini, J. (2015) showed the surface after SRP with the Er:(YAG) laser was not statistically different from hand scaling but did produce a higher root surface roughness than the utilization of the ultrasonic methods.
Methods and Procedures
The decision to research the effectiveness and comparative effect various instrumentation options have on the remaining tooth structures post scaling and root planing and the potential consequences these effects can have on patient’s overall periodontal health in order to understand the effect that dental hygienists have on future patient periodontal treatments, and the instrumentation choices made in order to provide the most effective treatment.
Initially the “Darby” textbook was searched in order to determine if instructional methods included in Dental Hygiene education could be analyzed and compared to the most up-to-date research to verify educational programs are in line with current standards of periodontal care.
A google scholar search was completed to determine if the utilization of periodontal instrumentation had an effect on the treatment progress for periodontally compromised patients, and the effects on the tooth surface itself.
A suitable amount of valid, peer reviewed research has been completed within the last 10 years.
Resource Search and Selection
A review of the literature was narrowed down to the effects various periodontal instruments have on the surface structures of the tooth and root, and the subsequent consequences of these effects. This limited to search to 128 full text, peer reviewed articles published after 2013. Abstracts were reviewed in detail, and 4 articles were selected for a review of the relevant research.
Libraries/search engines and databases used. Multiple databases were used in the research for this literature review. The databases utilized were (a) Proquest, (b) Google Scholar, and (c) eBook Subscription Collection (EBSCObost).
Search terms. In order to find appropriately relevant sources for this literature review search terms were limited to (a) proper periodontal instrumentation, (b) dental hygiene periodontal instrumentation, (c) effects of periodontal instrumentation on periodontal disease, (d) effects of instrumentation on tooth structure, (d) comparison between periodontal instrumentation, and (e) comparisons between instrumentation and tooth structure. These search terms resulted in over 68,000 relevant articles across the databases.
Filters were utilized in order to narrow the focus of the search. These filters included: scholarly journals, trade journals, reports, statistics/data report, evidence based healthcare, full text, free to access, peer reviewed, and published after 2013. Limitations were also placed on the return of articles such as ruling out literature reviews and individual case studies.
Boolean strings. No Boolean strings were used.
Age of the Sources. After search results were parsed down in order to allow review of current significant research and literature, sources from the last 5 years were accepted as candidates for the literature review. One historical article was selected to complete the introduction section of this review.
Due to practical constraints, this paper cannot provide a comprehensive review of the effects that various periodontal scaling instruments have on the damage or lack thereof to the surface of the dentin and the effects this has on patient periodontal disease progression. While a considerable amount of literature has been published on the efficacy and continued practice of scaling and root planing regardless of the instrumentation utilized. I found that there is very little research that can conclusively state any one periodontal instrument provides a statistically significant benefit over another when it comes to the effect that scaling has on the dentin surface and the resulting effect on periodontal disease progression. Previously published studies on the effect various periodontal instruments have on the surface quality are not consistent. The nature of the dentin surface quality has not been found to affect in one way or another the periodontal health of patients regardless of the surface roughness due to the large amounts of in-vivo studies, vs. in-vitro studies. While these and previous studies have measured the dentin surface quality post scaling with various periodontal instruments, surprisingly I was unable to find any studies that quantified the long term effect on patient’s periodontal health regarding the choice of instrumentation utilized. At this time a full discussion into the validity of my thesis on the proper utilization of the periodontal instruments available lies beyond the scope of the current research published.
Looking at these studies does one instrument produce less damaging outcomes to the tooth surface? The experimental data between these three outlined studies, as well as previous studies, is somewhat controversial, and there is no general agreement about which instrumentation method provides the most effective treatment outcomes while limiting the excess damage to or removal of the remaining tooth cementum. These accounts fail to resolve the contradictions between the removal of plaque, calculus, additional microorganisms, and tissue contributing to periodontal disease in patients, and the most effective instrument in the treatment, prevention, and arrest of periodontal disease in the patient.
Other studies both previously and concurrent within the experiment time periods are overall inconclusive showing replication/validity could be called into question. The researchers within each study group acknowledge that the application of various tools with different sharpness and tip size, tip contact with root surface, operator’s skills and force applied during SRP could be a contributing factor in the creation of the controversial results in these and other various studies.
This project provided an important opportunity to advance the understanding of the proper utilization of the various instrumentation available in the ability to effectively arrest or recover periodontal disease processes. Unfortunately, research on the subject has been mostly restricted to the limited in-vivo comparisons on dentin surface quality, and not on the effect this has on the disease process itself. Therefore causal factors leading to the hygienist’s instrumentation of choice in order to best treat patients’ periodontal health is inconclusive at best due to the paucity of evidence in longitudinal in-vitro observations. This indicates a need to reassess the various perceptions regarding the continued practice of scaling and root planing that exist among the dental community today. Additional research is indicated in order to provide statistically significant evidence regarding the instrumentation effects in-vitro have not only on the surface quality of dentin post scaling and root planing, but the holistic effect the choice of instrumentation has on the periodontal health over an extended period of time. Future research can fill the void of knowledge into the proper utilization of periodontal instrumentation on the health of patients and can continue to propel the sphere of the Dental Hygienists’ roll as overall health care provider.
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