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A Blended Approach

Roberta Shaklee, DDS, discusses using both ultrasonic and hand instrumentation for efficacious scaling and root planing.

Q. In your experience, what percentage of clinicians do you think use power-driven instrumentation, such as sonic and ultrasonic scalers?

A. When I lecture on the topic of ultrasonic scalers, I usually ask the audience how many operators are using the ultrasonic scaler. It is interesting to note that when I began to lecture in the early 1990s, the usage was about 50% in an audience, now it is nearly 100%. Since the mid-1980s, integration of ultrasonic instrumentation into dental hygiene services has become part of the dental hygiene curriculum. I would estimate that the average percentage of clinicians using power driven instruments is 75%. In the future, it will be 100%. The late adopters are dentists and dental hygienists who were trained at a time when using the ultrasonic was considered a short cut that was not as effective as using hand instruments. The late adopters are practitioners who may not be aware of the newer research and innovations in ultrasonic inserts that allow for subgingival debridement without root surface damage.

Q. Do most clinicians use a combination of hand-activated and power-driven scalers?

A. Speaking with educators in dental programs, dental hygiene programs, and periodontal programs, using a blended instrument selection is the most popular approach.

The trend is moving toward incorporating more power driven scalers. In fact, several authors recommend completing all debridement procedures with ultrasonic instrumentation alone such as Holbrook,1 Kwan,2 and Mooney.3 A review article by Drisko discusses the dilemma of hand versus power driven scalers.4 The use of hand instruments can result in greater operator fatigue and greater removal of cementum, which can lead to root surface sensitivity, and damage to the root surface.

Q. Is there research to show the effect of power-driven scalers compared to manual instrumentation alone?

A. The Annals of Periodontology 2003 Workshop cited three studies comparing manual instrumentation alone with mechanically driven instrumentation.5 No significant difference was reported based on bleeding on probing, gain in clinical attachment level, or reduction in probing depth. One of the studies compared the sonic instrument with manual instrumentation and found that manual instrumentation was slightly more effective in sites with a probing depth of 6 mm or greater. The conclusion of the section in the evidence-based workshop was that both manual and mechanical instrumentation are: “effective in improving the clinical parameters associated with periodontal health.”

Q. What is the effect of subgingival irrigation of medicaments in combination with powered scaling devices?

A. Unfortunately, the evidence-based workshop did not cite any studies that compared subgingival irrigation in combination with powered scaling. The Annals of Periodontology 2003 Workshop5 did review the use of subgingival irrigation as an adjunct to manual instrumentation. This combination demonstrated no advantage for improving periodontal health.

Q. Has one type of power-driven scaler , eg, sonic, magnetostrictive, piezoelectric, been shown to be more effective than another?

A. There have been no studies demonstrating that one power driven scaler is superior to another. Recently, a study by Busslinger et al in the Journal of Clinical Periodontology compared the magnetostrictive ultrasonic scaler, the piezoelectric ultrasonic scaler, and the curette.6 The conclusion was that all three instruments tested can produce a calculus free root surface.

Q. Based on current research, what recommendations would you make for clinicians when deciding on hand or powered instrumentation.

A. Based on the research I am familiar with, I strongly recommend the use of an ultrasonic scaler in conjunction with hand instrumentation. The sequence of instrumentation for scaling and root planing includes starting with a standard size ultrasonic insert for gross debridement. This removes the supragingival and gross subgingival deposits and provides water lavage. The water lavage provides improved vision and less bleeding. After a thorough debridement with the standard size tips, area specific curettes should be used to explore the root surface and gain access to deep, tortuous pocket anatomy. Hand instrumentation produces a smear layer. The debris is moved over the subgingival root surface so after the curette is used, the ultrasonic should be used on a low setting with a thinner insert. This will provide a final smoothing stroke and remove the smear layer. A study by Dragoo demonstrated the advantages of the modified ultrasonic insert, including removing the most calculus, leaving the smoothest root surface, and reaching deepest into the pocket. The study compared ultrasonic standard tip size, ultrasonic modified tip size, and hand instruments.7


  1. Croft LK, Nunn ME, Crawford LC, Holbrook TE, McGuire MK, Kerger MM, Zacek GA. Patient preference for ultrasonic or hand instruments in periodontal maintenance. Int J Periodontics Restorative Dent. 2003;23:567-573.
  2. Kwan JY. Enhanced periodontal debridement with the use of micro ultrasonic, periodontal endoscopy. J Calif Dent Assoc. 2005;33:241-248.
  3. Mooney MK. Ultrasonics come of age. RDH. 1992;12(4):25-8, 30.
  4. Drisko CL. Scaling and root planing without overinstrumentation: hand versus power-driven scalers. Curr Opin Periodontol. 1993:78-88.
  5. Hallmon WW, Rees TD. Local anti-infective therapy: mechanical and physical approaches. A systematic review. Ann Periodontol. 2003;8:99-114.
  6. Busslinger A, Lampe K, Beuchat M, Lehmann B. A comparative in vitro study of a magnetostrictive and a piezoelectric ultrasonic scaling instrument. J Clin Periodontol. 2001;28:642-649.
  7. Dragoo MR. A clinical evaluation of hand and ultrasonic instruments on subgingival debridement. 1. With unmodified and modified ultrasonic inserts. Int J Periodontics Restorative Dent. 1992;12:310-323.

From Dimensions of Dental Hygiene. April 2006;4(4): 26-27.

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