Efficacy+of+Manual+Root+Planing+and+Power+Scaling



In the late 1950s, the first power scalers were being utilized for heavy supracalculus removal with favorable results. During the 1960s, these instruments were declared acceptable, effective devices for supracalculus and stain removal.Throughout the 1960s and into the 1970s, clinicians and patients were warming up to the idea of power scaling as the procedure was less fatiguing for operators and patients spent less time in the chair.
 * 1. Power scaling removes bacteria as accurate as, if not better than, manual scaling. RK 7**

Power scaling is accomplished with a light touch and light pressure, keeping the tip parallel to the tooth surface and constantly in motion. In order to fracture and remove the calculus, the working end of the power scaler must come in contact with the calculus. As when using manual hand instruments, the tip of the power scaler must be correctly adapted in order to be effective. Unlike the small, short, overlapping strokes that are taken with manual hand instruments to insure complete coverage of the tooth; a power scaler stroke consists of light stokes with a blunt vibrating working end, heavy lateral pressure is unnecessary because the vibrational energy of the instrument dislodges the calculus. Upon completion of scaling with an ultrasonic scaler, thorough exploring should take place to detect the residual calculus. Any remaining irregularities of the tooth surface can be removed with a sharpened hand instrument.

While both methods of instrumentation are able to effectively remove plaque and calculus, studies have been conduct to compare the reduction of bacteria with each technique. One study containing participants with severe periodontitis, evaluated the effectiveness of manual instruments verses power instruments and their ability to reduce bacteria. The study collected the following assessments before and after treatment: supra-gingival plaque, gingival index, bleeding on probing, probing depths, and clinical attachment level. In addition sub-gingival plaque was collected and analyzed by a Multiplex Polymerase Chain Reaction to evaluate the presence of A.A., C. rectus, E. corrodens, F. nucleatum, P. intermedia, P. gingivalis, T. forsythensis, and T. denticola. When comparing the baseline readings, the study found that scaling with both techniques showed a reduction in gingival index, probing depths, clinical attachment level, and bleeding on probing. The results for bacterial reduction showed a decrease in C. rectus and R. gingivalis when using the manual instruments and a reduction in T. forsythensis, E. corrodens, and T. denticola when using the power instruments. In closing, they believed that both were effective in treating severe periodontitis in terms of clinical and microbiological effects.

Although the final result of ultrasonic scalers can be produced by using hand scalers, ultrasonic scalers are considerably faster and often less irritating to the client. Ultrasonic scalers do create aerosols, which can spread pathogens when a client carries an infectious disease. In addition, maximizing patient comfort while delivering periodontal debridement is of primary importance to the dental hygienist, so proper use of the ultrasonic instrument with regard to tip adaptation and selection, power setting, and irrigant flow will greatly minimize patient discomfort. Additionally, the operator should avoid areas of hypersensitivity and demineralization while instrumenting with an ultrasonic device to prevent discomfort and permanent damage to tooth structures. Although the use of an ultrasonic scaler can remove the majority of calculus, any remaining irregularities of the tooth surface can best be removed with a sharpened hand instrument. In conclusion relying solely on ultrasonic scalers for all scaling is inadequate and it is best to follow ultrasonic scaling with hand scaling.

References

D'Ercole, S, Piccolomini, R, Capaldo, G, & Catamo, G. (2006, April 29). Effectiveness of ultrasonic instruments in the therapy of severe periodontitis: a comparative clinical-microbiological assessment with curettes.. Retrieved from [].

2. ** Scaling and root planing shows a higher decrease in amounts of T. forsythia and T. denticola six months after treatment LM # 11. **
Patients were separated into two group one group had scaling and root planing completed and the second group had ultrasonic scalers used during treatment. The study was used in order to determine the effectiveness of SRP compared to ultrasonic scaling by using subgingival samples of bacteria. At 3 and 6 month interval subgingival samples were taken in order to determine the amounts of different bacteria in the periodontal pockets. Results of the study show that the levels of the bacteria were equal. However, at six months the results showed that T. forsythis and T. denticola had lower amounts in the SRP group. ===3. **Improvements to ultrasonic instrument tips have demonstrated it's efficacy in producing an equal smooth surface or smoother surface than hand scaling, with minimal tooth loss of tooth substance. MC#3**=== Ultrasonic instruments have gained more popularity, because of it's advantages. New designs in their inserts have made them more effective in plaque and calculus removal. Manufactors claim that they are able to remove more bacteria from the periodontal pocket than hand instrumentation, and leave a smoother surface with minimal loss of tooth substance when compared to hand scaling. One study evaluated the smoothness after the intervention and concluded that hand scaling left a smoother surfaces when compared to ultrasonic scalers. However, there is conflicting eveidence because a different study found that ultrasonic scalers left a smoother surfaces that hand instrumentation. It is important to mention that smooth surface has not been determined to help with wound healing.

4. Power scalers are recommended to better access furcations over conventional hand instruments. KT4
With class I furcations hand scaling and power scalers were found to be equal in reducing bacteria. Ultra sonic scalers have been shown to be more effective for class II and III furcations. Tips specifically designed for furcations were deamed effective on class II furcations. Some believe the use of antimicrobial with ultrasonic devices have benefits for furcation areas.

Until recently power scaling was mainly used to remove supragingival calculus because of their bulky working tips. However the availability of slender instruments that resemble probelike tips allow efficient instrumentation of deep periodontal pockets with less operator fatigue. A disadvantage to power scalers is that there are some contraindications. Some are that these divices have been shown to interfere with the function of older cardiac pacemakers and patients with known communicable disease that can be transmitted through aerosols. Patients at risk for respiratory disease, immunosuppressed or patients that have chronic pulmonary disorders should not be treated with power scalers. Another contraindication that is not medically related is burnished calculus, the ultrasonic scaling should not be on burnished calculus. Some studies have shown that power scaling appears to have a slightly lower rate of residual calculus compared to hand instrumentation. While other studies have shown that both power scaling and hand scaling have similar results. in conclusion the patients treatment plan should be planned and performed based on the patient's needs and clinician's preference. Both power scaling and hand instrumentation have been proven to provide benefits to the patient, and when used together can benefit both the patient and clinician.
 * 5. With the new technologic advances and new designs power scaling can be used more than just removing supragingival calculus. GE #6**

6. Ultrasonic instrumentation is equally effective in calculus removal as hand instrumentation. AP12
Using either a magnetostrictive or piezoelectric insert was just as effective in removing calculus as hand instruments. Although both instruments are able to remove similar amounts of calculus, it has not been confirmed that powered instruments are more effective than hand instruments.

With the use of the power scaler the clinician will not have the tactile sensitivity that one has with manual instruments. While using manual instruments the clinician will be able to detect the calculus thus removing it more effectively. It is most effective to begin treatment on patients with a calculus code of medium and above with the use of the power scaler to remove and break-up the bulk of the calculus to reduce fatigue and treatment time.
 * 7. Both power scalers and manual instruments have benefits, it is recommeded that they be used in combination with one another. MT18**

"...in the treatment of chronic periodontitis [the literature] found no difference in the efficacy of subgingival debridement using ultrasonic/sonic scalers versus hand instruments in the treatment of single-rooted teeth" (Carranza, pg 830) However, the power scaler has greater access to furcation areas, and can minimize time. In addition, the microultrasonic in combination with an endocoscpe has shown to be more successful than hand instrumentation. The use of both, the power scaler and hand instrumentation, would be the most effective.
 * 8. The clinical outcomes with the use of a power scaler are similar to that of hand instruments**. TL8


 * 9. Efficacy of power scalers and hand instrumentation depend on operator technique. MW 19**

Throughout his chapter on scaling and root planing, Carranza describes that operator technique is a key component in the successful removal of calculus. He states that for ultrasonic scaling, it is important for the operator to maintain a light touch and light pressure with continuous movement to avoid gouging. The operator must know which tip should be used (bulkier tips for supragingival deposits and narrower tips such as the 100 for subgingival calculus in deeper pockets), and what power setting should be used (higher power for heavier and more tenacious calculus). In addition, depending on the ultrasonic scaler, the tip may need to be adapted a certain way, such as on the lateral edge for a piezoelectric device due to the direction of the movement. Without the proper tips, settings, and adaptation the calculus will not be effectively removed, and may even become burnished. Similarly, with hand instrumentation, the success of the removal of calculus depends on the instrument selected, and the angulation and adaptation of the instrument. Carranza states that a blade angulation of between 45 and 90 degrees is ideal for scaling, whereas angles less than 45 and more than 90 will not remove calculus. In addition, the instrument must be adapted and in the right position to remove the calculus. This means that the blade must be underneath the calculus deposit, as well as "rolled in" in order to be sure to adapt to the anatomy of the tooth interproximally. These techniques will determine the efficacy of calculus removal. This could explain why there is conflicting research as to whether hand scaling is superior to ultrasonic scaling or vice versa.

The use of a power scaler and hand scaler are to remove the deposits of calculus and bacterial plaque. The studies have determined mixed results as to which one is more efficient. There are different properties where one has a better result than the other. For example the efficacy in calculus removal shows that hand scaling has had better results than the use of a piezo. This does not mean that hand scaling is better than power scaling. Power scaling has been shown remove less cementum and less invasive than hand scaling. Because each modality has a better outcome the use of hand scaling and power instrument should be combined to provide the best treatment. SR14
 * 10 To achieve the best outcome for patient care the combine use of a power scaler and hand instrumentation should be implemented. SR 14**

Clinical studies have proven that ultrasonic scaling has proven to have similar results as hand instrumentation. The advantages of using an ultrasonic scaler are easier access into furaction areas, as well as increased efficiency in the time needed for scaling. A disadvantage of power scalers is the aerosols that are produced, however, universal precautions can reduce this risk.
 * 11. Power scalers have emerged from being adjuncts for removing heavy supragingival calculus to a tool that may be used for all aspects of scaling, such as deplaquing, supragingival scaling, and subgingival scaling. CE5**

12. Calculus and plaque removal could both be achieved equally with either power scaling or manual scaling. The selection as far as which technique is used during treatment depends on the preference of the clinician, the experience of the clinician, and the need of the patient. It is the combination of the clinician's thoroughness of the procedure and the time devoted by the clinician during the procedure that makes the treatment a success. LL#9.