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| Year : 2012 | Volume
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| Issue : 2 | Page : 164-170 |
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| A comparison of root surface instrumentation using manual, ultrasonic and rotary instruments: An in vitro study using scanning electron microscopy |
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Preeti Marda1, Shobha Prakash1, CG Devaraj1, S Vastardis2
1 Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India
2 Louisiana State University School of Dentistry, New Orleans, USA
Click here for correspondence address and email
| Date of Submission | 08-Aug-2010 |
| Date of Decision | 21-May-2011 |
| Date of Acceptance | 08-Nov-2011 |
| Date of Web Publication | 3-Sep-2012 |
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 Abstract | | |
Background: The commonly accepted idea concerning root planing is that excessive removal of cementum is not necessary for removal of endotoxins. The ideal instrument should enable the removal of all extraneous substances from the root surfaces, without causing any iatrogenic effects.
Aim: To compare the remaining calculus, loss of tooth substance, and roughness of root surface after root planing with Gracey curette, ultrasonic instrument (Slimline® insert FSI-SLI-10S), and DesmoClean® rotary bur.
Materials and Methods: The efficiency of calculus removal, the amount of lost tooth substance, and root surface roughness resulting from the use of hand curette, ultrasonic instrument, and rotary bur on 36 extracted mandibular incisors were examined by SEM. We used three indices to measure the changes: Remaining calculus index (RCI), Loss of tooth substance index (LTSI), and Roughness loss of tooth substance index (RLTSI). Twelve samples were treated with each instrument. The time required for instrumentation was also noted.
Statistical Analysis: Kruskal-Wallis ANOVA was used for multiple group comparisons and the Mann-Whitney test for group-wise comparisons. Analysis was carried out with SPSS® software (version 13).
Results and Conclusion: The RCI and LTSI showed nonsignificant differences between the three groups. RLTSI showed a significant difference between Slimline™ and hand curette as well as Slimline™ and Desmo-Clean™. Slimline™ showed the least mean scores for RCI, LTSI, and RLTSI. Thus, even though the difference was not statistically significant, Slimline™ insert was shown to be better than the other methods as assessed by the indices scores and the instrumentation time. Keywords: Gracey curette, root planing, rotary bur, scanning electron microscopy, ultrasonic instrument
How to cite this article:
Marda P, Prakash S, Devaraj C G, Vastardis S. A comparison of root surface instrumentation using manual, ultrasonic and rotary instruments: An in vitro study using scanning electron microscopy. Indian J Dent Res 2012;23:164-70 |
How to cite this URL:
Marda P, Prakash S, Devaraj C G, Vastardis S. A comparison of root surface instrumentation using manual, ultrasonic and rotary instruments: An in vitro study using scanning electron microscopy. Indian J Dent Res [serial online] 2012 [cited 2023 Mar 25];23:164-70. Available from: https://www.ijdr.in/text.asp?2012/23/2/164/100420 |
Instruments used to prepare root surfaces mechanically should not excessively damage, gouge, trough, or remove injudicious amounts of root structure. The smoothest root possible should be one goal of root planing. [1] Although, in vivo, residual root roughness has only a minimal effect on the healing of the periodontal apparatus, [2] it may facilitate further bacterial accumulation and subsequent calculus deposition. Therefore, the ideal instrument should enable the removal of all extraneous substances from the root surfaces without causing any iatrogenic effects. One study [3] has shown that in periodontal disease endotoxins are located on the root surface rather than within it. Hence, the commonly accepted idea that excessive removal of cementum in order to remove endotoxins is unnecessary during scaling and root planing procedures.
Adequate root preparation in the treatment of periodontal disease typically involves mechanical instrumentation to remove plaque, calculus, and perhaps contaminated cementum and dentin. [4],[5],[6] Meticulous mechanical preparation of the root surface appears to be an important aspect of the surgical techniques associated with gingival attachment and advanced regenerative periodontal procedures. [7],[8]
Other important considerations in periodontal therapy include the amount of root surface removed as a result of instrumentation and the roughness of the root surface after treatment. [9],[10] Periodontal root planing procedures aimed at removing dental plaque and calculus from the root surface also, by design, remove a portion of the root surface. [9],[11]
Root surface instrumentation with hand instruments is often difficult and time consuming, besides requiring a substantial amount of physical effort. Various powered instruments are available to the clinician for mechanical root preparation, including sonic, ultrasonic, and rotary instruments. [9] Several studies have evaluated the amount of tooth structure removed mechanically by hand instruments, [9],[11],[12] ultrasonic scalers, [13],[14] and air abrasives. [15] Each of these instruments had it own disadvantages, which include decreased tactile sensitivity, [16] uncontrolled damage to the root surfaces, [1],[17] and inadequate edge retention. [12],[15] While each of these instruments have shown clinical effectiveness, none has been proven to be more effective than the others.
A new type ultrasonic insert called Slimline® has been designed to facilitate greater pocket penetration and better debridement in deep pockets. Design features include a narrower diameter of tine and tip, and an angulation of the tip approximating to that of hand curettes.
Desmo-Clean® is a rotating instrument for gentle root planing and curettage. It is used in a slowly rotating (7000-10000 rpm) contra-angle handpiece, employing slight pressure and water spray. These burs with their non-cutting elliptical, hexagonal heads in four different shaft designs are as gentle as hand-held instruments and as fast as diamond burs. Moreover, Desmo-Clean® burs produce a smoother surface, without leaving the traces typical of diamond instruments.
The present study was undertaken to evaluate the efficacy of root planing and to compare the remaining calculus, loss of tooth substance, and roughness of root surface after root planing with Gracey curette, ultrasonic instrument (Slimline® insert FSI-SLI-10S straight), and Desmo-Clean® burs using scanning electron microscopy (SEM).
| Materials and Methods | |  |
This in vitro study was conducted on 36 extracted mandibular incisor teeth. Approval for this study was obtained from the ethical committee of the institute. The selection criteria included the following: teeth extracted due to severe periodontal disease, no previous history of professional periodontal treatment, and teeth with intact root surfaces. Immediately after extraction, the teeth were rinsed in running tap water and the soft tissue attached to the teeth was removed with a scaler. Following this the teeth were fixed in 10% formaldehyde solution for 24-48 hours. [18],[19]
The 36 teeth were separated into three groups of 12 teeth each, ensuring that there was a similar amount of proximal calculus, as assessed by naked eye, in each group.
One proximal surface (mesial) of each tooth was randomly chosen to receive treatment, as follows:
- Group I - Hand instrumentation using a rigid Gracey curette No. 1/2 (Hu-Friedy Co., Chicago, IL, US)
- Group II - Ultrasonic instrumentation using medium power setting, copious water flow, and a Slimline® insert FSI-SLI-10S (straight) (Cavitron Dentsply, New York, US).
- Group III - Rotary instrumentation using DesmoClean® bur no. 3 (Hager and Werken, Duisburg, Germany).
A test area was marked on the mesial surface of the incisors. Two grooves in a faciolingual direction, 5 mm apart, delineated the test surface. The tooth was held in the left hand while the experimental area was instrumented by the operator in accordance with a standardized procedure.
Ultrasonic instrumentation was performed with very light horizontal pressure, moving the instrument back and forth over the surface in a sweeping motion with only the lateral side of the insert in contact with the surface so that the pattern of vibration was parallel to root surface. Instrumentation was performed with medium power setting and with the use of water cooling (as instructed by the manufacturer). Desmo-Clean® bur was used in the customary finishing strokes (as instructed by the manufacturer), with slight pressure and with a water spray. With the hand instrument, on completion of one root surface, the curette was resharpened with a medium India stone (as recommended by the manufacturer).
The same operator, already trained in scaling and root planing, performed all instrumentations. The criterion for adequate treatment was a smooth, hard, root surface, with no trace of calculus. The cleanliness and smoothness of the root surface were checked using a fine dental probe. The length of time required for scaling and root planing with each instrument was recorded in seconds.
The specimens were then examined using a scanning electron microscope (JEOL JSM 840A, operating at 15 kV). Standardized photomicrographs of the selected sites were obtained at magnifications of ×50 and ×200 for each specimen.
The amount of remaining calculus, roughness, and loss of tooth substances was recorded using the following indices:
Remaining calculus index (RCI) [20]
0: No calculus remaining on the root surface
1: Small patches of extraneous material, probably consisting of calculus
2: Definite patches of calculus confined to relatively small areas
3: Considerable amount of remaining calculus, appearing as one or a few voluminous patches or as several smaller patches scattered on the treated surface
Loss of tooth substance index (LTSI) [20]
0: No detectable loss of tooth substance
1: Slight loss of tooth substance restricted to localized areas; most of the cementum intact
2: Definite loss of tooth substance on most of the treated surface, but without deep instrumental marks in the dentin; cementum may be absent in some areas
3: Considerable loss of tooth substance with deep instrumental marks in the dentin; most of the cementum is removed.
Roughness loss of tooth substance index (RLTSI) [21]
0: Smooth or even root surface, without marks from the instrumentation and with no loss of tooth substance
1: Slightly roughened or corrugated local areas confined to the cementum
2: Definitely corrugated local areas where the cementum may be completely removed, although most of the cementum is still present
3: Considerable loss of tooth substance, with instrumentation marks extending into the dentin. The cementum is completely removed in large areas or there are a considerable number of lesions due to the instrumentation
The SEM photographs were interpreted by three examiners, who were blinded to the treatment received. Kruskal-Wallis ANOVA was used for multiple group comparisons followed by Mann-Whitney test for group-wise comparisons. Agreement between examiners was assessed by calculating the Kappa measure of agreement and the Spearman correlation coefficient. Comparison of means (of time taken for the procedure) was done by one-way ANOVA. Analysis was carried out with SPSS® software (version 13).
| Results | | |
The roots treated with the hand curette had many linear injuries, which were thought to have been caused by the instrumentation [Figure 1] and [Figure 2]. The roots treated with Slimline® insert had a clean smooth surface and showed less roughness [Figure 3] and [Figure 4]. Most specimens showed only slight loss of tooth substance, and most of the cementum was intact. The roots treated with Desmo-Clean® bur showed relatively more roughness and loss of tooth substance [Figure 5] and [Figure 6]. Evaluation of remaining calculus using RCI [Table 1] and loss of tooth substance using LTSI [Table 2] showed no significant differences between the three groups. Evaluation of root surface texture using RLTSI [Table 3] showed significant difference between hand curette and Slimline® insert (P=.02) and also between Slimline® insert and Desmo-Clean® (P=.05). Slimline® insert had the lowest scores with the indices and required the least time for root planing among the three groups [Table 4]. [Table 5] shows the comparison of scoring pattern as assessed by three examiners. | Figure 1: Scanning electron photomicrograph of the Gracey curette- treated root surface (original magnification ×50). Areas of remaining calculus are seen. Loss of tooth substance is seen in the center. Instrumentation marks can be appreciated all over
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 | Figure 2: Scanning electron photomicrograph of the Gracey curette- treated root surface (original magnification ×200). Small foci of remaining calculus are seen. Instrumentation marks can be very well appreciated
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 | Figure 3: Scanning electron photomicrograph of the Slimline® insert- treated root surface (original magnification ×50). Remaining calculus can be seen in the lower left area of the photograph
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 | Figure 4: Scanning electron photomicrograph of the Slimline® insert- treated root surface (original magnification ×200). The roots show a smooth clean surface
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 | Figure 5: Scanning electron photomicrograph of the Desmo-Clean® bur-treated root surface (original magnification ×50). Remaining calculus can be seen in the center and loss of tooth substance can be appreciated in the left half of the photograph
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 | Figure 6: Scanning electron photomicrograph of the Desmo-Clean® bur-treated root surface (original magnification ×200). Loss of tooth substance as well as roughness created on the root surface is seen
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 | Table 3: Showing roughness loss of tooth substance (RLTSI) for the three groups
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| Discussion | | |
Scaling and root planing are routine measures used in the treatment of periodontal diseases. A smooth clean root surface is a prerequisite for new attachment or healing. Standardization of experimental conditions is important in studies concerned with the evaluation of instruments and their effects on root surfaces. This is difficult to achieve in vivo due to variations in accessibility. The results of such in vitro studies cannot, however, be directly related to the clinical situation. On the other hand, in pure clinical studies, objective criterion for evaluation of the results are difficult to establish. In the present study, an in vitro test model was used as this would facilitate the selection of comparable test surfaces and permit the standardization of experimental procedures.
Various factors like instrument or device type, applied forces and tuning, tip design, time of instrumentation, and the protocol used, as well as the physical properties of the dentin (i.e., microhardness within different layers) influence the results when evaluating manual and rotary scaling devices. In this study modified rotary instruments with relatively small working ends have been used. However, since 2005, studies have generally focused on the use of lasers instead of rotary instruments.
All the procedures in this study were done by the main investigator to eliminate inter-operator variability and to minimize variations in factors such as stroke length, force, and pressure applied during instrumentation. Evaluation of the amounts of remaining calculus, loss of tooth substance, and roughness resulting from the use of various instruments was based on visual inspection of standardized micrographs and scored according to defined criteria. This method is liable to errors inherent to any subjective assessment. Hence, to overcome this, the analysis was done using the average scores of three examiners, all of whom were blinded. The scoring of the indices reveal satisfactory agreement between the examiners, though examiner 3 gave somewhat higher scores than the other examiners.
Remaining calculus was recognized on the root surface as patches of varying size located on the treated surface or more continuous areas covering a greater part of the surface. The cracks consistently present in the surface layers of the cementum represented the artifacts produced by dehydration during specimen processing. Their presence actually was of considerable value both with regard to the distinction between cementum and calculus as well as in the assessment of lost tooth substance since neither calculus nor dentin displayed such cracks.
With the Simline® ultrasonic insert, the root surface was clean and smooth and cementum was observed intact; in contrast, with the Desmo-Clean® bur there was more roughness of root surface and more loss of cementum. The roots treated with the Gracey curette had many linear injuries. The RCI showed a statistically nonsignificant difference between the three groups, which indicates that all the instruments used in this study showed similar efficacy in removal of calculus deposits. The finding of this study are similar to that of Jones et al.[22] who found no difference in efficacy of calculus removal and least damage to root surface with ultrasonic instruments. Drisko [23] and Pameijer et al.[24] also found similar results on comparing manual and power-driven instruments.
Areas with loss of tooth substance were evident where cementum had been removed and there was exposure of dentin. The LTSI was also not significantly different between the three groups, though Slimline® showed the lowest score for LTSI. There was more loss of tooth substance seen with the hand-operated and rotary instruments when compared to the ultrasonic instrument. Similarly, Schmidlin et al.[25] and Jepsen et al.[26] have also reported least tooth substance loss with Slimline® .
Several studies [1],[27],[28] have suggested that hand instruments produce a significantly smoother root surface than ultrasonic scalers, whereas other studies [29] suggested that an ultrasonic scaler produced a smoother root surface than hand instruments. The objective of scaling and root planing is the complete removal of plaque and calculus from root surfaces. Cementum removal has been deemed generally unnecessary. What is essential is the removal of plaque, calculus, and the endotoxin adherent to the root surface. This cleaning of root surfaces is best done with judicious use of powered instrumentation. [30] There was significantly more roughness seen with hand and rotary instruments when compared to ultrasonic. This is similar to other studies by Dragoo [31] (1992), Jotikasthira et al.[32] , Vastardis et al.[33]
Roughness due to loss of tooth substance was evident with corrugated local areas in the cementum or in the area where cementum may have been completely removed, with instrumentation marks in the dentin. On comparison between the groups, Slimline® showed significant changes compared to the other two groups.
The time required for instrumentation of each specimen was recorded in seconds, the Slimline® group needed less time (mean: 1.2±0.9 seconds) than the manual and the rotary bur groups (1.8±1.1 seconds and 2.3±0.6 seconds, respectively).
In our study, all the inter-group comparisons showed nonsignificant results, which could be due to the small sample size. However, the Slimline® insert group had the lowest mean scores for all the indices, and the time required for the procedure was also the least in this group. Hence, according to this study, although Slimline® insert proved to be better in all aspects, the differences between the results with the three instruments were not statistically significant.
| Conclusion | | |
From the results of this study, it can be summarized that:
- The clinically clean surfaces after root planing show a little amount of remaining calculus. Because calculus is intimately attached to tooth surface, during root planing there is damage to the integrity of the root surface by instrumentation.
- The remaining calculus and loss of tooth substance was similar for the three instrument groups. There was comparatively less roughness and less loss of tooth substance seen with the Slimline® insert when compared to hand curette and Desmo-Clean® bur.
- Time required for instrumentation using Slimline® insert was significantly lower than that required with Desmo-Clean® bur and with hand curette.
All these findings suggest the superiority of Slimline® inserts over Gracey curette and Desmo-Clean® bur in the treatment of root surfaces during root planing. Further in vivo studies are needed to determine the efficiency and effectiveness of these instruments.
| Acknowledgments | | |
We are grateful to Mr. Gurulinga for his valuable help in making the SEM photographs of this study. Our special thanks to Mr. D. K. Sangam, Statistician, J.J.M Medical College, Davangere, for the statistical analysis of this study.
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Correspondence Address:
Shobha Prakash
Department of Periodontics, College of Dental Sciences, Davangere, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.100420
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5] |
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