Power Instrumentation for the Dental Professional [1 ed.] 9781284235999, 9781284289350

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Power Instrumentation Academic Chair Dental Hygiene, Dental Assisting, and Surgical Technology at Dallas College

World Headquarters Jones & Bartlett Learning 25 Mall Road Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC, and such reference shall not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. Power Instrumentation for the Dental Professional, First Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious but are used for instructional purposes only. 24877-7 Production Credits Vice President, Product Management: Marisa R. Urbano Vice President, Content Strategy and Implementation: Christine Emerton Director, Product Management: Matthew Kane Product Manager: Bill Lawrensen Director, Content Management: Donna Gridley Manager, Content Strategy: Carolyn Pershouse Content Strategist: Ashley Malone Director, Project Management and Content Services: Karen Scott Manager, Project Management: Jackie Reynen Project Manager: Brooke Haley EBook Project Manager: Collen Lamy Digital Project Manager: Erin Bosco

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Library of Congress Cataloging-in-Publication Data Names: Mayo, Lisa (Dental hygienist), author. Title: Power instrumentation for the dental professional / Lisa Mayo. Description: First edition. | Burlington, MA : Jones & Bartlett Learning,   [2023] | Includes bibliographical references and index. Identifiers: LCCN 2022026690 | ISBN 9781284235999 (hardcover) Subjects: MESH: Dental Care--instrumentation | Dental Care--methods |   Dental Instruments Classification: LCC RK681 | NLM WU 26 | DDC 617.600284--dc23/eng/20220906 LC record available at https://lccn.loc.gov/2022026690 6048 Printed in the United States of America 27 26 25 24 23   10 9 8 7 6 5 4 3 2 1

Dedication I would like to dedicate this book to three groups of people. The first group is my family who supported me along this journey and instilled in me the character traits of humility, faith, courage, dedication, and drive. Thank you to my husband, Eric, and two beautiful children, Brayden and Brinley, for your sacrifices and love to make this dream a reality. The second group is every past, present, and future dental professional and student who has graced my life. You all inspire me and have shaped the oral health-care provider and educator I am today. The third group consists of my publisher and the manufacturers featured in this textbook; without you, this project would not be possible.

Brief Contents Preface xiii The Integrated Learning and Teaching Package xiv Acknowledgments xv Reviewers xvi

iv

CHAPTER 1

Dental Aerosols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

CHAPTER 2

Infection Prevention for Aerosol-Generating Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

CHAPTER 3

Ultrasonic Physics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

CHAPTER 4

Ultrasonic Device and Attachments. . . . . . . . . . . . . . . . 47

CHAPTER 5

Ultrasonic Insert and Tip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

CHAPTER 6

Ultrasonic Mechanism of Action. . . . . . . . . . . . . . . . . . . . . 91

CHAPTER 7

Ultrasonic Historical and Contemporary Clinical Applications and Contraindications. . . . . . 107

CHAPTER 8

Clinical Perspectives of Tooth Anatomy. . . . . . . . . . . . 131

CHAPTER 9

Grasp, Stabilization, and Positioning. . . . . . . . . . . . . . 149

CHAPTER 10

Adaptation, Angulation, and Orientation . . . . . . . . . . 171

CHAPTER 11

Activation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

CHAPTER 12

Ultrasonic Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

CHAPTER 13

Dentsply Sirona. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

CHAPTER 14

HuFriedyGroup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

CHAPTER 15

Curved Inserts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

CHAPTER 16

Curved Insert Technique Practice. . . . . . . . . . . . . . . . . . 293

Brief Contents

CHAPTER 17

EMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

CHAPTER 18

Acteon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

CHAPTER 19

EMS Curved Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345

CHAPTER 20 Acteon Curved Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 CHAPTER 21

Air Polishing Introduction. . . . . . . . . . . . . . . . . . . . . . . . . 391

CHAPTER 22 Air Polishing Powders and Clinical Applications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 CHAPTER 23 Coronal to CEJ Air Polishing. . . . . . . . . . . . . . . . . . . . . . . 425 CHAPTER 24 Coronal and Apical to CEJ Air Polishing. . . . . . . . . . . 447 CHAPTER 25 Air Polishing Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . 483 CHAPTER 26 Implant Case Definitions and Assessment. . . . . . . . 525 CHAPTER 27 Mechanical Implant Maintenance. . . . . . . . . . . . . . . . . 553 CHAPTER 28 Nonmechanical Implant Maintenance . . . . . . . . . . . . . 571

Glossary 589 Index 599

v

Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii The Integrated Learning and Teaching Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Reviewers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi

CHAPTER 1  Dental Aerosols. . . . . . . . . . 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Oral Flora. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Aerosols and Spatter Droplets. . . . . . . . . . . . . . . 3 Aerosol Particle Size . . . . . . . . . . . . . . . . . . . . . . . . . 3

Dental Aerosols. . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Sequence of Events of Dental Aerosol Production and Movement in the Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Pathogenic Dental Aerosols. . . . . . . . . . . . . . . . . 4 Acute Respiratory Infection. . . . . . . . . . . . . . . . . . 6 Dental Aerosols and the DHCP. . . . . . . . . . . . . . . 7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

CHAPTER 2  Infection Prevention for Aerosol-Generating Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Dental Aerosol Management . . . . . . . . . . . . . . . 13 Maintenance of Dental Unit Lines. . . . . . . . . . . . . . Personal Protective Equipment (PPE) . . . . . . . . . . . Pre-Procedural Antimicrobial Rinses. . . . . . . . . . . . Evacuation Devices. . . . . . . . . . . . . . . . . . . . . . . . . Ventilation Systems. . . . . . . . . . . . . . . . . . . . . . . . . Air Decontamination. . . . . . . . . . . . . . . . . . . . . . . .

13 17 23 23 25 25

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 vi

CHAPTER 3  Ultrasonic Physics. . . . . . 31 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Sound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Sound and Wave Theory. . . . . . . . . . . . . . . . . . . . . 32

Ultrasound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Dental Ultrasonic Device. . . . . . . . . . . . . . . . . . . 35 Active Medium . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transducer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mechanical Energy . . . . . . . . . . . . . . . . . . . . . . . . . Ultrasonic Sound Waves. . . . . . . . . . . . . . . . . . . . . Piezoelectric Ultrasonic. . . . . . . . . . . . . . . . . . . . . . Magnetostrictive Ultrasonic. . . . . . . . . . . . . . . . . . . Ultrasonic Wave Antinodes and Nodes. . . . . . . . . . Auditory Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . .

35 35 36 36 36 38 40 41

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

CHAPTER 4  Ultrasonic Device and Attachments . . . . . . . . . . . . . . . . . . . . 47 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Direction for Use (DFU). . . . . . . . . . . . . . . . . . . . 48 Dental Ultrasonic Device. . . . . . . . . . . . . . . . . . . 48 Integrated Ultrasonic Device. . . . . . . . . . . . . . . . . . 48 Stand-Alone Ultrasonic Device . . . . . . . . . . . . . . . . 48

Foot Pedal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Integrated Ultrasonic Device. . . . . . . . . . . . . . . . . . 49 Stand-Alone Ultrasonic Device . . . . . . . . . . . . . . . . 50 Foot Pedal Design and Functionality. . . . . . . . . . . . 50

Water and Air Lines. . . . . . . . . . . . . . . . . . . . . . . 51 Water Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Air Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Ergonomics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Contents

CHAPTER 5  Ultrasonic Insert and Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Ultrasonic Insert and Tip Parts and Terminology. . . . . . . . . . . . . . . . . . . . . . . . 62 Magnetostrictive . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Piezoelectric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Water Port . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Insert and Tip Shank. . . . . . . . . . . . . . . . . . . . . . 69 Shank Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shank Anatomy and Activity. . . . . . . . . . . . . . . . . . Shank Coating. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shank Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shank Clinical Selection Criteria. . . . . . . . . . . . . . . Shank Movement . . . . . . . . . . . . . . . . . . . . . . . . . . Power Control and Shank Displacement Amplitude. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shank Wear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

69 69 70 71 72 77 79 81

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

CHAPTER 6  Ultrasonic Mechanism of Action . . . . . . . . . . . . . . . . 91 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Mechanism of Action. . . . . . . . . . . . . . . . . . . . . . 92 Mechanical Mechanism of Action . . . . . . . . . . . . . . 92 Fluid Mechanism of Action. . . . . . . . . . . . . . . . . . . 92 Acoustic Cavitation. . . . . . . . . . . . . . . . . . . . . . . . . 92 Acoustic Microstreaming. . . . . . . . . . . . . . . . . . . . . 98 Liquid Jets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Coolant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Lavage and Irrigation. . . . . . . . . . . . . . . . . . . . . . . 101

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

CHAPTER 7  Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications. . . . . . . . . . . . . . . . . . . 107

vii

Theoretical Approaches to Ultrasonic Instrumentation . . . . . . . . . . . . . . . . . . . . . . . 115 Traditionalist Approach to Ultrasonic Instrumentation. . . . . . . . . . . . . . . . . . . . . . . . . 116 Contemporary Approach to Ultrasonic Instrumentation. . . . . . . . . . . . . . . . . . . . . . . . . 116

Periodontal Debridement. . . . . . . . . . . . . . . . . 117 Periodontal Disease Pathogenesis. . . . . . . . . . . . . . 117 Periodontal Disease Statistics. . . . . . . . . . . . . . . . . 117 Preventive Clinical Treatment . . . . . . . . . . . . . . . . 118

Considerations and Contraindications. . . . . . . 120 Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . 121 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

CHAPTER 8  Clinical Perspectives of Tooth Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Instrumentation Considerations. . . . . . . . . . . . 132 Hard Tissue Histology. . . . . . . . . . . . . . . . . . . . . . 132 Instrument Selection. . . . . . . . . . . . . . . . . . . . . . . 132 Instrumentation of Cementum . . . . . . . . . . . . . . . 133

Complex Root Anatomy. . . . . . . . . . . . . . . . . . . 134 Root Nomenclature. . . . . . . . . . . . . . . . . . . . . . . . 134 Root Concavity and Convexity . . . . . . . . . . . . . . . 135 Furcation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

CHAPTER 9  Grasp, Stabilization, and Positioning . . . . . . . . . . . . . . . . . . . . . 149 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Grasp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Magnetostrictive Grasp. . . . . . . . . . . . . . . . . . . . . Piezoelectric Grasp . . . . . . . . . . . . . . . . . . . . . . . . Advanced Grasp . . . . . . . . . . . . . . . . . . . . . . . . . . Light Grasp. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Grasp Skill Building . . . . . . . . . . . . . . . . . . . . . . .

150 151 152 152 153

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Medical Clinical Applications of Ultrasonics . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Dental Clinical Applications of Ultrasonics . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Stabilization. . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Historical Clinical Applications. . . . . . . . . . . . . . . 109 Contemporary Clinical Applications. . . . . . . . . . . 111

Operator and Patient Positioning Selection. . . . . . 158 Aerosol Control. . . . . . . . . . . . . . . . . . . . . . . . . . . 160

Intraoral Finger Rest. . . . . . . . . . . . . . . . . . . . . . . 155 Extraoral Finger Rest. . . . . . . . . . . . . . . . . . . . . . . 155

Operator and Patient Chair Positioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

viii

Contents

Operator Chair Position by Area of the Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Posterior Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Anterior Teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

CHAPTER 13  Dentsply Sirona. . . . . . 239

Comparison of Ultrasonic and Hand-Activated Instrumentation. . . . . . . . . . 165 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 Magnetostrictive Ultrasonic Devices . . . . . . . . 240

CHAPTER 10  Adaptation, Angulation, and Orientation . . . . . . . 171 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Shank Surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

Angulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 90-Degree Angulation. . . . . . . . . . . . . . . . . . . . . . 174 0- to 15-Degree Angulation. . . . . . . . . . . . . . . . . . 176

Orientation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Vertical Orientation. . . . . . . . . . . . . . . . . . . . . . . . 176 Transverse Orientation. . . . . . . . . . . . . . . . . . . . . 177

Skill Building Adaptation, Angulation, and Orientation. . . . . . . . . . . . . . . . . . . . . . . . 179 Comparison of Ultrasonic and Hand-Activated Instrumentation. . . . . . . . . . 193 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196

CHAPTER 11  Activation. . . . . . . . . . . . . 197 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Activation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Finger Motion. . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Ultrasonic Activation Stroke . . . . . . . . . . . . . . . . . 198 Tap Stroke. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

Comparison of Ultrasonic and Hand-Activated Instrumentation. . . . . . . . . . 220 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

CHAPTER 12  Ultrasonic Technique. . . . . . . . . . . . . . . . . . . . . . . . . . 223 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Maxillary Left Central Incisor . . . . . . . . . . . . . . . . 224 Mandibular Molar. . . . . . . . . . . . . . . . . . . . . . . . . 224

Mandibular First Molar Lingual. . . . . . . . . . . . . . . 224

Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emerging Technology . . . . . . . . . . . . . . . . . . . . . . Digital Cavitron Ultrasonic Scaling Systems. . . . . . Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

240 240 240 242 247

Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 Insert Portfolio. . . . . . . . . . . . . . . . . . . . . . . . . . 249 Thick Diameter Cavitron Powerline Ultrasonic Inserts. . . . . . . . . . . . . . . . . . . . . . . . Thin Diameter Cavitron Slimline Ultrasonic Inserts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ultra-Thin Diameter Cavitron Thinsert. . . . . . . . . Implant Insert. . . . . . . . . . . . . . . . . . . . . . . . . . . . Diamond-Coated Insert. . . . . . . . . . . . . . . . . . . . .

249 251 253 254 255

Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Cavitron Ultrasonic Scaler. . . . . . . . . . . . . . . . . . . 257 Insert. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

CHAPTER 14  HuFriedyGroup . . . . . . 263 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 HuFriedyGroup Magnetostrictive Ultrasonic Device. . . . . . . . . . . . . . . . . . . . . . 264 Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SWERV3 30K . . . . . . . . . . . . . . . . . . . . . . . . . . . . Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

264 264 264 265

Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266 Insert Portfolio. . . . . . . . . . . . . . . . . . . . . . . . . . 267 Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 273 SWERV3 Device. . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Insert. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276

CHAPTER 15  Curved Inserts . . . . . . . 279 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Magnetostrictive Curved Insert Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . 279

Contents

Magnetostrictive Curved Insert Adaptation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 Vertical Orientation. . . . . . . . . . . . . . . . . . . . . . . . 281 Transverse Orientation. . . . . . . . . . . . . . . . . . . . . 285

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

CHAPTER 16  Curved Insert Technique Practice . . . . . . . . . . . . . . . . 293 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Skill Building: Vertical and Transverse Orientation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Setup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Buccal Furcation Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Mesial-Buccal Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Distal-Buccal Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Lingual Debridement of the Mandibular First Molar Supragingival Interproximal Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lingual Furcation Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Distal-Lingual Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Mesial-Lingual Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Buccal Debridement of the Mandibular First Molar Supragingival Interproximal Area. . . . . . .

CHAPTER 18  Acteon . . . . . . . . . . . . . . . 327 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 Acteon Piezoelectric Ultrasonic Devices. . . . . 328 Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emerging Technology . . . . . . . . . . . . . . . . . . . . . . Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

328 328 329 330 331

Acteon Tip Portfolio. . . . . . . . . . . . . . . . . . . . . . 332 Prophylaxis Tips. . . . . . . . . . . . . . . . . . . . . . . . . . 333 Periodontic Tips . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Implant Tips. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336

Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 337

293

Ultrasonic Device . . . . . . . . . . . . . . . . . . . . . . . . . 337

294 295

Soprocare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343

298

CHAPTER 19  EMS Curved Tips. . . . . 345

299 300 302 303 305

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

CHAPTER 17  EMS . . . . . . . . . . . . . . . . . . 309 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309 EMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310 Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emerging Technology . . . . . . . . . . . . . . . . . . . . . . Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ix

310 310 311 313

EMS Tip Portfolio. . . . . . . . . . . . . . . . . . . . . . . . 319 Thick Diameter Tips. . . . . . . . . . . . . . . . . . . . . . . 319 Thin Diameter Tips. . . . . . . . . . . . . . . . . . . . . . . . 320 Implant Tip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320

Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Ultrasonic Device . . . . . . . . . . . . . . . . . . . . . . . . . 321 Tip, Wrench (EMS CombiTorque Wrench), and Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . 321

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 EMS Piezoelectric Curved Tip Introduction. . . 345 EMS Piezoelectric Curved Tip Adaptation. . . . 347 Identifying Correct Adaptation . . . . . . . . . . . . . . . 348

Skill Building: Debridement Curved Tips. . . . . 350 Setup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Buccal Furcation Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Mesial-Buccal Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Distal-Buccal Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Lingual Furcation Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Distal-Lingual Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Mesial-Lingual Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . .

350 352 353 355 356 357 359

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363

CHAPTER 20  Acteon Curved Tips. . . 365 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 Acteon Piezoelectric Curved Tips Introduction. . . . . . . . . . . . . . . . . . . . . . . 365 Acteon Piezoelectric Curved Tip Adaptation. . . . 368 Identifying Correct Adaptation . . . . . . . . . . . . . . . 368

Skill Building: Debridement Curved Tips. . . . . 374 Setup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374

x

Contents

Buccal Furcation Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Mesial-Buccal Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Distal-Buccal Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Lingual Furcation Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Distal-Lingual Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . . Mesial-Lingual Root Debridement of the Mandibular First Molar . . . . . . . . . . . . . . . . . . .

375 377 379 380 382 384

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389

CHAPTER 21  Air Polishing Introduction . . . . . . . . . . . . . . . . . . . . . . . . 391 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392 Tooth Polishing. . . . . . . . . . . . . . . . . . . . . . . . . . 392 Rotary Handpiece Polishing . . . . . . . . . . . . . . . 393 Provider Technique. . . . . . . . . . . . . . . . . . . . . . . . 396

Air Polishing. . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Air Polishing Devices. . . . . . . . . . . . . . . . . . . . . . . 397 Nozzle Design. . . . . . . . . . . . . . . . . . . . . . . . . . . . 399 Air Polishing Mechanism of Action. . . . . . . . . . . . 401

Rotary and APD Polishing Comparison. . . . . . . . . . . . . . . . . . . . . . . . . . . 403 Polishing Contraindications and Considerations . . . . . . . . . . . . . . . . . . . . . . . . 404 Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . 405 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 405

Calcium Sodium Phosphosilicate Powder. . . . . . . Calcium Carbonate Powder. . . . . . . . . . . . . . . . . . Glycine Powder. . . . . . . . . . . . . . . . . . . . . . . . . . . Erythritol Powder. . . . . . . . . . . . . . . . . . . . . . . . . Powder Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Air Polishing Literature. . . . . . . . . . . . . . . . . . . . .

415 415 415 415 416 416

APD Considerations. . . . . . . . . . . . . . . . . . . . . . 416 Gingival Status . . . . . . . . . . . . . . . . . . . . . . . . . . . 416 Sodium Bicarbonate Powder. . . . . . . . . . . . . . . . . 416

APD and Dental Materials. . . . . . . . . . . . . . . . . 417 Dental Materials: Safe Use of an APD. . . . . . . . . . . 418 Dental Materials: APD Use With Caution. . . . . . . . 418 Dental Materials: APD Use Contraindicated. . . . . . 419

Adverse Effects . . . . . . . . . . . . . . . . . . . . . . . . . 420 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423

CHAPTER 23  Coronal to CEJ Air Polishing . . . . . . . . . . . . . . . . . . . . . . . 425 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426 Dentsply Sirona Air Polishing Devices. . . . . . . 426 Dentsply Sirona Polishing Powders. . . . . . . . . 427 Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System. . . . . . . . . 427 Powder Bowl. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Powder Velocity Control. . . . . . . . . . . . . . . . . . . . Prophy Mode Cycles. . . . . . . . . . . . . . . . . . . . . . . Foot Pedal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nozzle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

427 429 430 433 434 435 437

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408

Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 440

CHAPTER 22  Air Polishing Powders and Clinical Applications . . . . . . . . . . . . . . . . . . . . . . . . 411

Clinical Technique. . . . . . . . . . . . . . . . . . . . . . . 440 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 APD Clinical Applications. . . . . . . . . . . . . . . . . 412 APD Powder Particle Size and Mohs Hardness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413 Particle Size. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413 Mohs Hardness. . . . . . . . . . . . . . . . . . . . . . . . . . . 413

APD Powder Chemical Composition and Clinical Applications. . . . . . . . . . . . . . . . 414 Sodium Bicarbonate Powder. . . . . . . . . . . . . . . . . 414 Aluminum Trihydroxide Powder. . . . . . . . . . . . . . 415

Air Polishing Device . . . . . . . . . . . . . . . . . . . . . . . 440 Handpiece and Nozzle Insert. . . . . . . . . . . . . . . . . 440

CHAPTER 24  Coronal and Apical to CEJ Air Polishing . . . . . . . . 447 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448 Subgingival Air Polishing in Periodontal Debridement. . . . . . . . . . . . . . . . . . . . . . . . . . 448 Overall Clinical Outcomes. . . . . . . . . . . . . . . . . . . Delivery of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . Hard and Soft Tissue Effects . . . . . . . . . . . . . . . . . Microbiological. . . . . . . . . . . . . . . . . . . . . . . . . . .

448 449 449 449

Contents

EMS Air Polishing Devices . . . . . . . . . . . . . . . . 449 EMS Air Polishing Powders. . . . . . . . . . . . . . . . 449 EMS AIRFLOW One and AIRFLOW Prophylaxis Master. . . . . . . . . . . . . . . . . . . . . 451 Powder Chambers. . . . . . . . . . . . . . . . . . . . . . . . . Powder Velocity Control. . . . . . . . . . . . . . . . . . . . Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Air. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

451 452 454 458

EMS AIRFLOW Handy 3.0 . . . . . . . . . . . . . . . . . 458 Body. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458 Powder Chamber. . . . . . . . . . . . . . . . . . . . . . . . . . 460 Foot Pedal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464

EMS Handpiece and Nozzles . . . . . . . . . . . . . . 465 AIRFLOW Handpieces . . . . . . . . . . . . . . . . . . . . . 465 PERIOFLOW Handpiece. . . . . . . . . . . . . . . . . . . . 468

Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 471 Air Polishing Devices. . . . . . . . . . . . . . . . . . . . . . . 471 Handpieces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472

EMS Guided Biofilm Therapy (GBT) . . . . . . . . . 472 GBT Step 1: Assessment and infection control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GBT Step 2: Disclose, and GBT Step 3: Motivate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GBT Step 4: AIRFLOW Max. . . . . . . . . . . . . . . . . Step 5: PERIOFLOW. . . . . . . . . . . . . . . . . . . . . . . GBT Step 6: Piezon PS. . . . . . . . . . . . . . . . . . . . . . GBT Step 7: Check . . . . . . . . . . . . . . . . . . . . . . . . GBT Step 8: Recall. . . . . . . . . . . . . . . . . . . . . . . . .

472 472 474 474 474 474 474

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481

CHAPTER 25  Air Polishing Technique. . . . . . . . . . . . . . . . . . . . . . . . . . 483 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483 Clinical Technique. . . . . . . . . . . . . . . . . . . . . . . 483 Grasp and Stabilization. . . . . . . . . . . . . . . . . . . . . Aerosol Control. . . . . . . . . . . . . . . . . . . . . . . . . . . Operator Chair Positioning. . . . . . . . . . . . . . . . . . Patient Positioning. . . . . . . . . . . . . . . . . . . . . . . . . Patient Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

483 484 484 484 484

Skill Building: Air Polishing on Inanimate Objects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485 Penny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486 Quail Egg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487

xi

Air Polishing Posterior Smooth Surfaces . . . . . . . . 497 Dentsply Sirona APD Breakdown:. . . . . . . . . . . . . 499

Skill Building: Air Polishing with EMS Guided Biofilm Therapy . . . . . . . . . . . . . . . . . 501 EMS AIRFLOW Prophylaxis Master Setup. . . . . . . GBT Step 1: Assessment and infection control. . . . GBT Step 2: Disclose, and GBT Step 3: Motivate. . . GBT Step 4: AIRFLOW MAX. . . . . . . . . . . . . . . . . GBT Step 5: PERIOFLOW. . . . . . . . . . . . . . . . . . . GBT Step 6: Piezon PS, GBT Step 7: Check, and GBT Step 8: Recall. . . . . . . . . . . . . . . . . . .

502 504 504 504 513 516

Skill Building: Air Polishing with EMS AIRFLOW Handy 3.0 . . . . . . . . . . . . . . . . . . . . 516 AIRFLOW Handy 3.0 Perio. . . . . . . . . . . . . . . . . . 516 AIRFLOW Handy 3.0 Classic . . . . . . . . . . . . . . . . 520 AIRFLOW Handy 3.0 Perio and AIRFLOW Handy 3.0 Classic Breakdown. . . . . . . . . . . . . . 521

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523

CHAPTER 26  Implant Case Definitions and Assessment. . . . . . . 525 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525 Dental Implant Anatomy and Physiology. . . . . 526 Keratinized Outer Masticatory Mucosa . . . . . . . . . Non-keratinized Inner Masticatory Mucosa. . . . . . Mucosa Remodeling Factors . . . . . . . . . . . . . . . . . Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implant Baseline. . . . . . . . . . . . . . . . . . . . . . . . . .

528 528 528 530 533

Peri-Implant Diseases and Conditions . . . . . . 533 Peri-Implant Health. . . . . . . . . . . . . . . . . . . . . . . . Peri-Implant Mucositis . . . . . . . . . . . . . . . . . . . . . Peri-Implantitis. . . . . . . . . . . . . . . . . . . . . . . . . . . Peri-Implant Soft and Hard Tissue Deficiencies. . . .

533 534 534 534

Clinical Assessments . . . . . . . . . . . . . . . . . . . . 537 Visual and Palpatory Tissue Assessment . . . . . . . . 539 Periodontal Charting Assessment. . . . . . . . . . . . . . 539

Recall Recommendations. . . . . . . . . . . . . . . . . 543 Oral Hygiene Instructions. . . . . . . . . . . . . . . . . 544 Brushing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544 Interdental Aids. . . . . . . . . . . . . . . . . . . . . . . . . . . 544

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550

Skill Building: Air Polishing with Dentsply Sirona Device. . . . . . . . . . . . . . . . . . 489

CHAPTER 27  Mechanical Implant Maintenance. . . . . . . . . . . . . . 553

Dentsply Sirona APD Setup. . . . . . . . . . . . . . . . . . 489 Air Polishing Posterior Occlusal Surfaces. . . . . . . . 493 Air Polishing Anterior Smooth Surfaces. . . . . . . . . 495

Implant Debridement Goals . . . . . . . . . . . . . . . . . 554

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553 Implant Debridement Overview . . . . . . . . . . . . 553

xii

Contents

Surface Topography. . . . . . . . . . . . . . . . . . . . . . 555 Implant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 Abutment and Prosthesis. . . . . . . . . . . . . . . . . . . . 555

Mechanical Debridement . . . . . . . . . . . . . . . . . 556 Hand-Activated Instrumentation. . . . . . . . . . . . . . 556 Ultrasonic Instrumentation. . . . . . . . . . . . . . . . . . 557 Air Polishing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558

Peri-Implant Mucositis Debridement. . . . . . . . 559 Peri-Implant Mucositis Literature . . . . . . . . . . . . . 559

Peri-Implantitis Debridement. . . . . . . . . . . . . . 559

Nonmechanical Debridement. . . . . . . . . . . . . . 572 Dental Lasers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chlorhexidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . Ozone and Hydrogen Peroxide. . . . . . . . . . . . . . . Locally Administered Antibiotics. . . . . . . . . . . . . .

573 575 577 580

Nonmechanical Debridement and Peri-Implantitis. . . . . . . . . . . . . . . . . . . . . . . . 581 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585

Implant Debridement . . . . . . . . . . . . . . . . . . . . . . 559

Mechanical Debridement Technique . . . . . . . . 561 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567

CHAPTER 28  Nonmechanical Implant Maintenance. . . . . . . . . . . . . . . 571 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572 Implant Debridement Goals. . . . . . . . . . . . . . . 572

Glossary 589

Index 599

Preface The field of dental ultrasonics and air polishing has become mainstream as the technology has evolved. Power Instrumentation for the Dental Professional aims to bridge the gap of knowledge between education and clinical practice by allowing the learner to acquire the skills needed to implement power technology effectively in patient care with a contemporary approach to preventive, maintenance, and nonsurgical periodontal procedures. The first two chapters begin power instrumentation education with the infection prevention required for the safe delivery of care. The middle of the book, Chapters 3–20, focus on dental ultrasonic technology and technique. Chapters 3–8 present ultrasonic science, physics, mechanism of action, functionality, and universal terminology. By Chapter 9, the learner will be able to incorporate a contemporary approach to ultrasonic instrumentation and identify ultrasonic limitations, contraindications, and clinical indications for use. Ultrasonic instrumentation technique is taught over Chapters 9–12. Skills are broken down into building blocks starting with grasp and stabilization, operator and patient positioning, and aerosol control in Chapter 9. Chapters 10 and 11 add the building blocks of adaptation, angulation, orientation, and activation. Chapter 12 brings all the building blocks together with step-by-step hands-on practice exercises. Chapters 13–16 present magnetostrictive ultrasonic technology from Dentsply Sirona and ­HuFriedyGroup, Chapters 17–20 present piezoelectric ultrasonic

technology from EMS and Acteon. Manufacturers’ specific terminology is introduced, and step-by-step hands-on practice exercises are provided to further develop technique. Chapters 21–25 are dedicated to air polishing education. Chapters 21 and 22 present the science, physics, mechanism of action, functionality, uses, limitations, contraindications, and universal terminology for air polishing. Chapters 23 and 24 teach the equipment, clinical technique, and manufacturers’ specific terminology for air polishing coronal and apical to the CE. Chapter 25 combines all the information learned into multiple step-by-step hands-on practice exercises for Dentsply Sirona and EMS technology. Chapters 26–28 wrap up the text by discussing dental implant maintenance with a focus on power technology and instrumentation in three chapters. Chapter 26 defines the case definitions of peri-­ implant health and disease based on a series of clinical assessments. Chapters 27 and 28 teach the mechanical and nonmechanical debridement techniques for dental implants, abutments, and prosthesis using evidence-based research and science. As with any form of clinical practice, power instrumentation is best learned through continued repetition. The exercises in this book allow the learner to move at their own pace to gain proficiency. The videos that accompany the text will provide visual and auditory instruction that can be watched multiple times while developing and honing clinical instrumentation skills.

xiii

The Integrated Learning and Teaching Package Integrating the text with constructive instructor resources is crucial to deriving their full benefit. Based on feedback from instructors and students, Jones & Bartlett Learning has made the following resources available to qualified instructors:

• Test Bank with questions for every chapter. • Slides in PowerPoint format.

xiv

• Instructor’s • •

Manual, containing answers to the in-text end-of-chapter and case study questions, worksheets, teaching tips, and clinical rubrics. Image Bank, supplying key figures from the text. Skills-based videos that demonstrate various techniques from the text.

Acknowledgments Manufacturers Thank you to the manufacturers, whose generosity and support in providing imaging, reviews, and equipment enhanced the content quality of this book immensely:

• Dentsply Sirona: Gail Malone, RDH, BS; Rachel • • •

Dorn, RDH, MS; and Michele Lash, RDH, BA. Acteon: Chip Vagnoni HuFriedyGroup: Janelle Armstead and Drew Eschweiler EMS: Melissa Obrotka, RDH, BA.

Professors Thank you to all the professors who seek to prepare the next generation of oral health-care providers for contemporary clinical practice. I hope you find this

book provides you with the tools necessary to enrich your institutions’ power instrumentation clinical curriculum. Thank you for your dedication to the dental field and student teaching. I welcome any comments or suggestions you have for changes to future editions.

Students Students, you are the junior ambassadors to the dental field. I give you my sincere appreciation and gratitude for joining the profession I hold so dear. You represent the next generation of oral health-care professionals who will strike a path forward in improving patient care and experiences through power instrumentation. I thank you for your commitment to patient excellence and welcome any comments or suggestions you have for future editions.

xv

Reviewers Cheri L. Barton, RDH, BSDH, MSDH

Jeffery V. McMinn, RDH, MA

Lecturer/Senior Clinic Lead/Clinic Coordinator Eastern Washington University and University of Washington Adjunct Faculty in the Periodontal Department University of Washington School of Dentistry

Assistant Professor Hudson Valley Community College

Lisa Bilich, RDH, MSEd

Professor/Department Chair Eastern Washington University Donna L. Catapano, MD, DHSc, RDH, CDA

Clinical Assistant Professor Department of Dental Hygiene and Dental Assisting, NYU College of Dentistry Christine A. Dominick, CDA, RDH, MEd

Associate Dean and Professor Forsyth School of Dental Hygiene, Massachusetts College of Pharmacy and Health Sciences Deborah A. Graeff, MS, RDH

Professor/Retired Erie Community College Holly Houck, RDH, MSDH

Instructional Faculty; Dental Studies Department Head Pima Community College Jena N. Iversen, RDH, MA

Faculty Hudson Valley Community College Brenda Kibbel, RDH, BSDH, MEd

Assistant Professor Tennessee State University Lisa M. Lavery, RDH, MPH

Instructor Hudson Valley Community College Petal Leuwaisee, RDH, CHES, BSDH, MA

Associate Professor Hostos Community College

xvi

Martha Lynne Morgan. RDH, MS, MA

Adjunct Professor for Dental and Dental Hygiene Continuing Education Director for Dental Hygiene Divisions of Integrated Clinical Foundations and Simulations Dental Hygiene and Dental Hygiene Continuing Education University of Detroit Mercy School of Dentistry Kristeen Perry, RDH, MSDH

Associate Professor Forsyth School of Dental Hygiene, Massachusetts College of Pharmacy and Health Sciences Maryse Rodger, RDH, BSDH, MBA

Assistant Professor Regis College Windy Rothmund, RDH, MSDH

Assistant Professor Department of Dental Hygiene, Eastern Washington University Irina Smilyanski, RDH, MSDH, DHS

Associate Professor of Dental Hygiene Forsyth School of Dental Hygiene, Massachusetts College of Pharmacy and Health Sciences Laura Tubbs, RDH, MA

Assistant Professor Department of Dental Hygiene, Hudson Valley Community College Tiffany Wilson DDS, MPH

Assistant Professor Meharry Medical College School of Dentistry

CHAPTER 1

Dental Aerosols LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Differentiate between oral symbiosis and dysbiosis. 2. Define an aerosol and spatter droplet and correlate particle size to potential health hazards. 3. Understand the sequence of events of dental aerosol production, release, and movement in an environment. 4. Understand disease transmission risk when performing a dental aerosol-generating procedure. 5. Identify equipment capable of producing and releasing large volumes of aerosols.

KEY TERMS

small particle size (50 µm) product created and released into the environment during a dental aerosol-generating procedure. Symbiosis: balance of microbiota in the human microbiome that leads to health, wellness, and the promotion of homeostasis. Zoonotic disease: an infectious disease that is spread between animals and humans.

• • • • •

•

• •

•

•

• •

•

1

2

Chapter 1 Dental Aerosols

Introduction Infection prevention is of upmost importance in any health-care setting as it saves lives. Central to the education of power instrumentation is infection prevention and the understanding of aerosol and spatter droplet production. The technology taught in this textbook introduces high volumes of aerosols that have an unpredictable behavior once they enter the environment. They can become part of the centralized ventilation, travel great distances from the source of creation, and stay suspended in the air for long periods of time. They have the potential to cause disease in humans who unintentionally inhale them. According to the World Health Organization (WHO, 2014), “Acute respiratory infections (ARIs) are the leading cause of morbidity and mortality from infectious diseases in the world.” The COVID-19 pandemic caused by the SARS-CoV-2 virus and variants is an example of an ARI capable of causing a public health emergency. Adverse health events increase in a dental health-care setting when aerosols are not properly controlled. This chapter will introduce key terms used throughout the textbook and define aerosol and spatter droplet production, release, and behavior in the environment.

A

Oral Flora The mouth has an extensive and diverse microbiome composed of bacteria, fungi, protozoa, viruses, ­genetic material, and environmental influences ­ (nicotine, ­pollutants) that make up the oral flora.

B

• When these natural residents all live in harmony

Figure 1-1  Oral dysbiosis A. Dental caries on a maxillary

•

with one another, a symbiotic environment exists, and the patient’s oral microbiome is balanced, healthy, and homeostasis is maintained. When the residents do not live in harmony with one another, a dysbiotic microbiome occurs in which disease can manifest. The most common oral diseases from a dysbiotic state are dental caries (tooth decay, cavity) and periodontal disease ((inflammatory disease with resultant infection and loss of the supportive apparatus of teeth) see Figure 1-1). When disease is present, pathogenic organisms (organisms capable of causing disease) are found in higher concentrations.

The term dental health-care personnel (DHCP), as defined by the Centers for Disease Control and Prevention (CDC, 2003), refers to “all paid and unpaid personnel in the dental health-care setting who might be occupationally exposed to infectious materials, including body substances and contaminated,

anterior tooth; B. Periodontal disease. Note the inflammation of the gingiva and oral deposits on the anterior teeth

equipment, environmental surfaces, water, or air.” Examples of DHCP per the CDC are listed in Box 1-1. For the purposes of this book, the term oral health-care provider is used to reference a trained and licensed DHCP who is actively involved in direct patient care, treatment, and management of oral conditions within their scope of practice. Examples include, but are not limited to, a dentist, specialist, dental hygienist, or dental assistant. The oral health-care provider has the highest risk of exposure to a patient’s oral flora residents as they work intimately in the mouth with equipment that generates large volumes of aerosols, and studies have shown the highest exposure risk zone to an oral health-care provider is 1–3 feet from the patient’s mouth (Innes et al., 2021; Manish et al., 2020; Muzzin et al., 1999; Zemouri, 2020).

Aerosols and Spatter Droplets

Box 1-1 Dental Health-Care Personnel ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Dentist Dental hygienists Dental assistants Dental laboratory technicians Student Contractual personnel Administrative staff Housekeeping Maintenance Volunteer

Center for Disease Control. (2003, December 19). Guidelines for infection control in dental health-care settings – 2003. MMWR, 52, RR-17, 1–76. Reference to specific commercial products, manufacturers, companies, or trademarks does not constitute its endorsement or recommendation by the U.S. Government, Department of Health and Human Services, or Centers for Disease Control and Prevention.

Aerosols and Spatter Droplets An oral health-care provider uses air-driven equipment during patient procedures. This equipment generates and expels aerosols and spatter droplets into the dental environment.

• Aerosol:

•

An aerosol is a small particle size (50 µm) product created and released from equipment that emits water and air. Matys & Grzech-Lesniak, 2020; Singh et al., 2020). Due to its larger size, the spatter droplet will bounce from surface to surface and land from the force of gravity faster than an aerosol (CDC, 2003, 2020). Spatter droplet can be seen with the naked eye, but once dried on a surface, may be difficult to detect (CDC, 2020).

An oral health-care provider has extreme close contact with their patient and is exposed to large ­volumes of spatter droplets and aerosols throughout

3

Table 1-1  Particle Size and Time of Suspension in Air

Particle Size Average Time of Suspension in the Air* 100 µm

3–5.8 seconds

10 µm

4–8.2 minutes

1–3 µm

1–12 hours

*Time of air suspension will vary based on the amount of turbulence in the air from natural ventilation (windows or doors opening and closing) and mechanical ventilation (heating, air-conditioning, fans). Data from Kulkarni, P., Baron, P.A., & Willeke, K. (2011). Aerosol measurement: Principles, techniques, and applications. (3rd Ed.). Hoboken, NJ:Wiley.

BREAKOUT POINT An aerosol is a small particle-size product that stays suspended in the air for long periods of time and will travel great distances from its source of creation, increasing the potential for disease transmission.

a workday. Aerosols and spatter droplets have the potential to enter the human body through respiratory inhalation (inhaling while breathing) or through absorption via the skin or eye. Humans are capable of easily inhaling particle sizes under 100 µm (Thomas, 2013). If inhaled, these particles gain access to the respiratory system and can cause an adverse health effect when they contain pathogenic organisms generated from the oral microbiome. BREAKOUT POINT Aerosol and spatter droplet particles can be inhaled or absorbed through the skin or eye, increasing the risk for human-to-human disease transmission.

Aerosol Particle Size

Aerosol particle size plays a large role in the potential health hazard risk to humans. The process that generated the particle dictates the size. A human expels particle sizes under 1 µm during normal breathing, talking, singing, and shouting (Kumar & ­Subramanian, 2020; Asadi et al., 2019; Fabian et al., 2011). Thousands of aerosols and spatter droplets are expelled with a human sneeze, pant, or cough and can contain pathogenic organisms such as viruses and bacteria. See Figure 1-2. Millions of aerosols are

4

Chapter 1 Dental Aerosols

Sequence of Events of Dental Aerosol Production and Movement in the Environment There are six steps in the production, release, and movement of an aerosol in the environment.

Figure 1-2  Human Sneeze © Hatcha/Shutterstock.

created and released during a dental aerosol-generating procedure (defined later). As seen in Table 1-1, the smaller the particle size generated, the longer it will remain suspended in the air because the aerosol particle moves by passive diffusion in an environment. Diffusion is the movement of a substance from an area of high concentration to low concentration throughout an environment. A small-sized aerosol will remain suspended in the air for minutes to hours depending on the amount of air turbulence (air-conditioning, heating, open window, fan) in the environment. Pathogenic aerosols can pose a threat to a health-care facility’s ventilation system if they gain access and circulate throughout the building (Fennelly, 2020).

Dental Aerosols A dental aerosol is a man-made aerosol generated by air-driven dental equipment that emits an aqueous solution (most commonly used is water). Dental equipment refers to any machine or accessory used in the practice of dentistry. A dental aerosol-­ generating procedure is any procedure that produces and releases spatter droplets or aerosols into the environment. Examples of air-driven equipment that generate dental aerosols are:

1. Air-driven dental equipment emits water that is released into the mouth during active use and mixes with the oral flora of the oral cavity (see Figure 1-4a). 2. A dental aerosol is formed and combines with the water and oral flora mixture inside the mouth. The aerosol becomes slightly ionized (charged) when it combines with the water and oral flora mixture (Asadi et al., 2019). 3. Slightly ionized aerosol particle leaves the mouth and is forcefully expelled into the environment. 4. Water evaporates from the aerosol when it interacts with ions in the ambient air (oxygen, ­carbon dioxide, hydrogen, nitrogen) and causes the aerosol particle to become highly ionized (see Figure 1-4b; Asadi et al., 2019). 5. The highly ionized aerosols react violently in the environment with one another due to their charged state. They repel off one another and aggressively bounce around in the environment (see Figure 1-4c; Asadi et al., 2019). 6. As the aerosol particles move about the environment, they begin to interact with ions in the air and slowly start to deionize. When they lose their charge, they become less reactive and will eventually fall to the ground. After 30 minutes, dental aerosol particle movement is greatly reduced (Asadi et al., 2019).

Pathogenic Dental Aerosols

• Dental drill. Commonly used for the removal of

A pathogenic dental aerosol is a dangerous airborne aerosol created and released during a dental aerosolgenerating procedure that contains a pathogenic organism (bacteria, viruses, fungi, protozoa) capable of causing disease once the organism enters a host. When inhaled, the pathogenic aerosol will penetrate the respiratory system and can cause an adverse health event.

•

• Mycobacterium

•

tooth decay. See Figure 1-3a. Dental ultrasonic or air polisher used for the removal of stain, biofilm, or dental calculus (see Figure 1-3b and c). Air/water syringe used for drying and rinsing the mouth (see Figure 1-3d).

tuberculosis, pseudomonas aeruginosa, influenza, coronaviruses, rhinovirus, and measles have been found in aerosols as small as 3–5 µm particle size and can penetrate both the lower and upper respiratory tract of a human (see Figure 1-4c;

Pathogenic Dental Aerosols

A

B

C

D

Figure 1-3  Air-driven dental equipment: A. Dental drill; B. Dental ultrasonic (Dentsply Sirona Cavitron Slimline 1000

30K Ultrasonic Insert); C. Dental air polisher (EMS AIR-FLOW Max handpiece); D. Air/water syringe A: © Milos Batinic/Shutterstock; B: Reproduced with permission from Dentsply Sirona.

H2O Flora Dental aerosol

A

B

C

Figure 1-4  Sequence of Events of Dental Aerosol Production and Behavior. A. Air-Driven

Equipment B. Aerosol Made of Water and Oral Flora. Water Evaporates and Aerosol Becomes Ionized C. Aerosol Repel From One Another A: © Milos Batinic/Shutterstock.

5

6

Chapter 1 Dental Aerosols

Table 1-2  Pathogen Size and Respiratory System Penetration

Pathogenic Aerosol Size

Respiratory System Penetration

1–4 µm

Lower and upper airway

5–12 µm

Upper airway

Data from Fennelly, K. (2020, July 24). Particle sizes of infectious aerosols: Implications for infection control. The Lancet, 8, 914–924; Kumar, P.S., & Subramanian, K. (2020). Demystifying the mist: Sources of microbial bioload in dental aerosols. Journal of Periodontology, 91, 1113–1122; and Thomas, R.J. (2013, November 13). Particle size and pathogenicity in the respiratory tract. Virulence, 4(8), 847–858.

Upper respiratory tract

Nasal cavity Pharynx (throat)

External nose

Larynx Trachea Lower respiratory tract

Bronchi

Lungs

see Table 1-2; Fennelly, 2020; Kumar & Subramanian, 2020; Thomas, 2013).

Bronchiole

Alveoli

The respiratory system is divided into two r­ egions: the upper and lower respiratory tract as depicted in Figure 1-5.

• Upper •

respiratory tract: consists of the nose, ­nasal cavity, paranasal sinuses, and pharynx. See Figure 1-5a. Lower respiratory tract: consists of the larynx, trachea, bronchial tree and the lungs (see Figure 1-5a). The bronchial tree, is made of primary, secondary, and tertiary bronchi. The tertiary bronchi branch into small bronchioles, which house air-filled sacs called alveoli. See Figure 1-5b. When an organism gains access to the lower respiratory tract, infections are challenging to treat and can become life-threatening, especially in a vulnerable, medically compromised individual (Vos et al., 2021). Examples include, but are not limited to, pneumonia, bronchitis, and tuberculosis (Vos et al., 2021).

Figure 1-5  Respiratory System

ARIs with the potential to cause a public health emergency at either a pandemic or epidemic level are:

• Severe

BREAKOUT POINT A small particle-size pathogenic dental aerosol can invade the lower and upper respiratory tract of a human and cause infection.

Acute Respiratory Infection An acute respiratory infection (ARI) is an infection capable of interfering with respiratory system function, including breathing. According to the WHO (2014), “ARIs are the leading cause of morbidity and mortality from infectious diseases in the world” with 98% of death occurring due to viral and bacterial diseases that invade the lower respiratory tract.

•

acute respiratory syndrome coronavirus (SARS-CoV): The virus is linked to a bat reservoir as zoonotic infection, which emerged in 2002 and disappeared by 2004 (WHO, 2014; National Institute of Allergy and Infectious Disease, 2020). A zoonotic disease is an infectious disease that is spread between animals and humans. The duration of infectivity for SARS-CoV is not well defined, and an oral health-care provider should use extreme caution when performing an aerosol-generating procedure on a patient with a known SARS-CoV infection within the last 81 days (WHO, 2014). Severe acute respiratory syndrome ­coronavirus two (SARS-CoV-2): The virus that causes COVID-19 is linked to a bat reservoir as zoonotic infection (WHO, 2018; National Institute of Allergy and Infectious Disease, 2020). The duration of infectivity of SARS-CoV-2 and its variants is not known at the time of this book’s publication. It would be prudent for the oral health-care provider to treat a recovered SARS-CoV-2 patient in a similar manner as a SARS-CoV patient because both illnesses are caused by a coronavirus (WHO, 2014). For now, there are no set guidelines from the WHO

Dental Aerosols and the DHCP

•

•

on how long to avoid an aerosol-generating procedure for any patient with a known current or previous SARS-CoV-2 infection (WHO, 2014). Middle East respiratory syndrome coronavirus (MERS-CoV): The virus is linked to a camel reservoir as zoonotic infection identified in 2012 (WHO, 2014; National Institute of Allergy and Infectious Disease, 2020). Human influenza caused by a new subtype, including human episodes of avian influenza (H5N1, H7N9, H7N2, H9N2), are zoonotic infections from birds. H7N9 first emerged in a human in 2013 (WHO, 2014). According to the WHO (2014), influenza A (H1N1) appeared in April 2009 and resulted in a pandemic until August 2010.

Dental Aerosols and the DHCP Studies have shown a dental aerosol can travel as much as six to nine feet away from the source (patient mouth) and move in both a horizontal and vertical direction (Innes et al., 2021; Kumar & Subramanian, 2020; Dhand & Li, 2020; Milejczak & Bowden, 2005). This means the aerosol travels up to the ceiling and down to the floor while also moving left to right of the patient (see Figure 1-6). Because aerosol concentration is highest the first 10–30 minutes after a dental aerosol-generating procedure and can stay suspended for hours in the air, a DHCP should wear a mask to protect their airway.

7

BREAKOUT POINT Dental aerosols are at their highest concentration 10–30 minutes immediately following the conclusion of a dental aerosol-generating procedure.

BREAKOUT POINT A small particle-size dental aerosol will travel a minimum of 6–9 feet away from the patient’s mouth in both horizontal and vertical directions.

During a dental aerosol-generating procedure, the highest exposure risk zone is 1–3 feet from the patient’s mouth (Innes et al., 2021; Manish et al., 2020; Muzzin et al., 1999; Zemouri et al., 2020).

• The heaviest contamination to the oral health-care

•

provider is their mask, face shield, face, and arms (Innes et al., 2021; Zemouri et al., 2020). Without the use of aerosol appropriate PPE (presented in Chapter 2), the provider is at higher risk for disease transmission from a pathogenic dental aerosol (see the practice exercise shown in Figure 1-7). The heaviest contamination to the patient is on their face and chest (Innes et al., 2021; Zemouri et al., 2020.

BREAKOUT POINT Heaviest contamination during an aerosol-generating procedure is on the provider’s mask, face shield, face, and arms.

When a dental aerosol-generating procedure is performed, there are specific infection prevention protocols that must be followed. The next chapter will present a six-tier multilayer approach to protecting all humans in the dental environment. In addition, DHCPs should also:

Figure 1-6  Dental Aerosol Movement in Dental

Environment

1. Manually disinfect all surfaces and equipment within a 10-foot radius of the dental aerosol-generating equipment with an Environmental Protection Agency (EPA)-­registered intermediate-level disinfectant. Refer to the products direction/instruction for use (DFU/IFU) to ensure correct application and contact time is followed. EPA-registered intermediate-level disinfectants vary in their: • Contact times. • Number of wipes and contact time when using towelettes. Some are one-step while ­others are two-step wipe systems. • Claims against specific bacterial microorganisms and viruses.

8

Chapter 1 Dental Aerosols

Figure 1-7  Dental aerosol-generating procedure and

inappropriate PPE

What is wrong with this picture? Both male and female oral health-care providers’ hair, scalp, and skin of the face and neck are exposed with no face shield or hair covering. The female’s arms and torso are exposed with no gown. The male’s torso is exposed with the gown open. The patient is missing protective glasses.

Figure 1-8  Towelette Lid Left Open (Medicom

Pro-Surface)

Reproduced with permission from Medicom.

© CandyBox Images/Shutterstock.

• When using towelettes, follow these recommendations: 1. Use the correct number of wipes per the manufacturer. Using fewer wipes than recommended will compromise disinfection results. 2. Leave the solution untouched for the required contact time. 3. When wiping a large area, using largersized towelettes may improve efficiency. Many manufacturers sell different size towelettes with varied scents. 4. Always close the lid tightly on a towelette container to prevent towelettes from drying (see Figure 1-8). 2. Consider rescheduling any patient who presents to an appointment with a fever or active infection.

According to the WHO (2014), “There is a significant research gap regarding the epidemiology of ARI transmission from patients to health-care workers during aerosol-generating procedures.” Due to this knowledge gap, the dental office should have strong protocols and regular training for staff on the risk for disease transmission during a dental aerosol-generating procedure. 3. Remove carpet that is within 10 feet of aerosolgenerating equipment. Carpet allows aerosols to recirculate in an environment, prolonging their suspension time in the air (Organization for Safety, Asepsis, and Protection, 2018). When a person walks on carpet, they crush the fibers against one another. If an aerosol is trapped in the carpet ­fibers, it will become airborne again as the carpet fibers are crushed against one another (Organization for Safety, Asepsis, and Protection, 2018).

CASE STUDY

You are a practicing dental hygienist in a country where you work under the supervision of a licensed dentist. Your first patient of the day presents for a procedure that will generate large volumes of dental aerosols. The patient reports they tested positive for SARS-CoV-2 yesterday and today their temperature is 101.0 degrees Fahrenheit. You relay this information to your supervisor who is not a licensed dentist. She tells you to proceed because the patient already prepaid for their procedure and she does not want to deal with rescheduling or refunding the patient. 1. What are the potential consequences if you follow your supervisor’s order and proceed with treatment? 2. How should this situation be handled? 3. If you proceed with the procedure, could you be found guilty of a negligent tort?

Questions

Summary

This chapter presented the dental equipment that creates and releases large volumes of dental aerosols into the environment. Dental aerosol and spatter droplet production, release, circulation, behavior, movement, particle size, and pathogenicity were discussed. Oral health-care providers are at an increased risk for disease transmission because they provide direct

Questions

1. Which of the following is a natural resident of the oral flora? a. Bacteria b. Fungi c. Protozoa d. Genetic material e. All of the above

Match the following terms to their correct definitions for questions 2–5. There is only one correct answer for each term. 2. Dysbiosis

A. Balance of microbiota in the human microbiome that leads to health and wellness, and promotes homeostasis. 3. Aerosol B. Large particle size (>50 µm) product created and released into the environment during a dental aerosol-generating procedure that stays airborne for less time and an aerosol. 4. Spatter C. Small particle (1 MHz) ultrasound imaging is •

• •

•

•

used to view internal structures and monitor fetal development. Low-frequency (20–60 kHz) ultrasonics are used in surgical procedures for tissue cutting and ablation in multiple disciplines such as orthopedic, ophthalmic, surgical, gastrointestinal, oral maxillofacial, urological, neurosurgery, and cardiovascular (O’Daly et al., 2008; Zilonova et al., 2019). Drug and gene delivery can be enhanced through ultrasonic acoustic cavitation and microstreaming (Zilonova et al., 2019; Ng & Liu, 2002; Pitt et al., 2004). Physical therapy uses ultrasonics to decrease muscle and joint pain through ultrasound diathermy (delivery of heat), which utilizes an ultrasound wave frequency range of 800 kHz–1 MHz (Forfang et al., 2013). Ultrasound is also used for rehabilitation therapy of musculoskeletal injuries (Spratt et al., 2014). Orthopedic professionals use ultrasonics during surgical procedures to determine when they are cutting through bone cement and cortical bone (Forfang et al., 2013; Novak et al., 2008). Ultrasonics are also used to enhance bone fracture healing with extracorporeal shock wave therapy (Forfang et al., 2013; Novak et al., 2008). Ultrasonic shock wave therapy is used to dissolve calcified tendonitis, break apart gallstones and kidney stones, and remove fatty tissue during lipoplasty (liposuction; Schoenfield et al., 1990; Yang et al., 2019; Zocchi et al., 2020).

Dental Clinical Applications of Ultrasonics This section will discuss the historical and contemporary clinical applications of dental ultrasonics. You will gain an in-depth perspective of ultrasonic instrumentation as you learn theories of the past and present.

Dental Clinical Applications of Ultrasonics

Historical Clinical Applications

In the 1950s, clinical trials began showing an ultrasonic device with a frequency range of 20–60 kHz in the presence of a water medium was capable of removing oral deposits and hard and soft tissues in the mouth (O’Daly et al., 2008; Arabaci et al., 2007). The magnetostrictive ultrasonic device came to the dental market first in the 1950s, followed by piezoelectric in the 1970s.

Magnetostrictive Ultrasonic Devise Dentsply Sirona was the first manufacturer to produce a dental magnetostrictive ultrasonic device in 1957 called the Cavitron Model 30 Scaler (see Figure 7-1). The device was first marketed as an instrument to remove decay in operative dentistry but could not compete with the efficiency and effectiveness of highand low-speed turbine drills (Bains et al., 2008; Chen et al., 2013). The device was then explored for a potential role in periodontics, and by the 1960s, was rebranded for oral deposit removal. The device was manufactured without a set ultrasonic sound wave frequency. The oral health-care provider had to manually “tune” the transducer and active medium to produce the desired ultrasonic sound wave frequency (see Figure 7-2). Tuning the device to a specific wave frequency was challenging and produced great variability in ultrasonic treatment outcomes and patient comfort.

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The original insert design was a short, straight, thick-diameter shank with an external water port because it was originally designed for decay removal (see Figure 7-3). Once the magnetostrictive ultrasonic device was rebranded for the field of periodontics and oral deposit removal, the single design of the insert limited the use and functionality in the mouth. Access subgingivally and adaptation to complex root anatomy was a challenge and not always possible.

Piezoelectric Ultrasonic Device The first dental piezoelectric ultrasonic device was marketed for oral deposit removal in 1970 and then later developed for surgical procedures (Chen et  al.,  2013). Satalec, now blanketed under Aceton, was the first manufacturer to sell a dental piezoelectric ultrasonic device (see Figure 7-4). Tip design options were similar to the original insert design, which limited subgingival access and adaptation to complex root anatomy.

Tuning knob

Figure 7-2  Dentsply Sirona Cavitron Model 30 Scaler

tuning knob top right.

Reproduced with permission from Dentsply Sirona

Figure 7-1  Early magnetostrictive ultrasonic device—

Figure 7-3  Early magnetostrictive insert (Dentsply

Dentsply Sirona Cavitron Model 30 Scaler.

Sirona Cavitron P Series 10 Metal Grip 25K Ultrasonic Insert.

Reproduced with permission from Dentsply Sirona

Reproduced with permission from Dentsply Sirona

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Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications

Figure 7-4  Early piezoelectric ultrasonic device by

Satalec.

Reproduced with permission from ACTEON

Sonic Scaler The sonic scaler is not an ultrasonic device and is not covered in this textbook because its technology for periodontal debridement is obsolete. The sonic scaler was released to the dental market in the 1970s as a less expensive alternative to ultrasonic technology for scaling and root planing procedures (Lea & Walmsley, 2000). The sonic scaler does not have a transducer or active medium but is an air-driven turbine unit with a low-frequency range 2–6 kHz (Arabaci et al., 2007). Tip movement produced by the low frequency range is a circular orbital motion (Lea & Walmsley, 2000). Ultrasonic devices have replaced the sonic scaler for periodontal debridement because the sonic scaler:

• Does • • • •

not produce acoustic cavitation, acoustic microstreaming, or liquid jets (Arabaci et al., 2007; Lea & Walmsley, 2000). Causes increased cemental damage and roughness compared to an ultrasonic device (Arabaci et al., 2007; Lea & Walmsley, 2000). Does not remove oral deposits as efficiently or effectively as an ultrasonic device. Causes more patient discomfort than an u ­ ltrasonic device due to its low-frequency range. Includes tip designs that are limited and bulkier than an ultrasonic insert or tip, limiting its use subgingivally.

Periodontal Therapy From 1957 until the mid-1990s, ultrasonic instrumentation was used an adjunct to traditional hand-­ activated instrumentation because there was a lack of ultrasonic insert and tip designs on the market. The provider was taught to use aggressive and forceful scaling strokes with hand-activated instruments to remove oral deposits, cementum, and diseased epithelial tissue. Cementum was root planed to a “glassy-smooth finish” and the focus of dental hygiene

procedures was on the removal of dental calculus. This methodology of dental hygiene treatment stopped by the mid-1990s when a paradigm shift in the identification, treatment, and management of periodontal disease occurred. In the early 1990s, dental biofilm and free-­floating planktonic bacteria were discovered to be the etiological agents of periodontal disease in a susceptible host and not dental calculus. The term periodontal debridement was introduced by Irene Woodall, RDH, PhD, in 1993 as a procedure of instrumentation that promotes tooth conservation while removing oral deposits to decontaminate periodontal pockets and the mouth (Hinchman et al., 2016). Periodontal debridement taught the provider to conserve cementum during instrumentation and not root plane it to a “glassy-smooth finish.” Debridement focused on biofilm reduction and not dental calculus removal.

BREAKOUT POINT Periodontal debridement is a procedure of instrumentation that promotes tooth conservation while removing oral deposits to decontaminate periodontal pockets.

This paradigm shift inspired dental ultrasonic manufacturers to create a new portfolio of inserts and tips in the 1990s. Thinner diameter, longer length, and curved shank shapes were designed to access the subgingival environment and conform to complex root anatomy (see Figure 7-5a and b). Research was demonstrating better root conservation and less cemental injury, removal, alteration, and abrasion with these new ultrasonic insert and tip designs compared to hand-activated instruments. By 1999, the American Academy of Periodontology (AAP) had released a new classification system of periodontal health and disease, which was used for the next 19 years until 2018 when the AAP and the European Federation of Periodontology launched a new classification system called the “2018 classification of periodontal and peri-implant diseases and conditions” (Armitage, 2000). In 2000, the AAP released a position paper supporting the use of a thin-diameter curved shank shape for debriding furcation defects due to their smaller diameter, longer reach, and cemental conservation compared to hand-activated instruments (Drisko et al., 2000). The AAP also stated that ultrasonic instrumentation was equally effective

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A

Figure 7-6  Periapical lesion on the maxillary right

lateral incisor.

Endodontics The clinical applications of a dental ultrasonic device in the field of endodontics includes:

• Debridement

• • B Figure 7-5  Thin diameter straight and curved shape

shanks: A. Dentsply Sirona Slimline 10L (curved), 10S (straight), 10R (curved) Fitgrip 30K Ultrasonic Inserts, B. Acteon P2R, P2L curved tips. Reproduced with permission from Dentsply Sirona

in the removal of biofilm, calculus, and endotoxins ­compared to hand-activated instrumentation (Drisko et al., 2000).

Contemporary Clinical Applications

Today, magnetostrictive and piezoelectric ultrasonics have a magnitude of clinical applications in the field of dentistry.

and smear layer removal during root canal procedures through the effects of acoustic cavitation, acoustic microstreaming, and liquid jet production (Van der Sluis et al., 2007). Delivery of chemical medicaments to the root canal space (Van der Sluis et al., 2007). Removal of existing materials such as gutta percha, silver points, and posts during retreatment of a failed root canal (Chen et al., 2013; see Figure 7-6).

Operative Dentistry The clinical applications of a dental ultrasonic device in the field of operative dentistry includes (Nitovas et al., 2017):

• Removal

of demineralized hard tissue (see

Figure 7-7).

• Preservation of intact marginal ridges when prepping for restoration placement. of inaccessible cervical margins (see Figure 7-8). Finite finishing of crown or veneer margins to avoid gingival injury with a rotary bur.

• Beveling •

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Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications

Figure 7-7  Demineralization and staining in the pits and

fissures of two mandibular molar teeth.

Figure 7-9  Implant and maxillary sinus augmentation.

Note the maxillary sinus wall apical to the maxillary left molar and premolar teeth.

Figure 7-10  Alveolar nerve repositioning. Note the

alveolar nerve outlined on the mandibular right. Figure 7-8  Cervical facial decay of the maxillary

right canine.

• Soft-tissue lesions such as cysts (pathologic sac or

Oral and Maxillofacial Surgery (OMS) The clinical applications of a dental ultrasonic device in the field of OMS includes:

• Cutting of bone (osteotomy) to section hard tis•

• •

sues (Chen et al., 2013). Implant surgeries to aid in alveolar bone crest augmentation, removal of a dental implant, bone harvesting, crestal bone splitting, and maxillary sinus floor elevation (Chen et al., 2013; see Figure 7-9). Repositioning of the inferior alveolar nerve (Mohan et al., 2015; see Figure 7-10). Disintegrating calcium deposits in salivary ducts with extracorporeal shock wave therapy (Ntovas et al., 2017).

OMS uses ultrasonography to image structures inside the body with a frequency above 1 MHz. Imaging is used for the viewing of:

• • • • •

cavity lined with epithelium and enclosed in a connective tissue capsule; Ibsen & Phelan, 2018), granulomas (mass of inflammatory tissue consisting of macrophages, giant cells, and lymphocytes; Ibsen & Phelan, 2018), and tumors (neoplastic swelling or enlargement growth either benign or malignant; Johns Hopkins Medicine, 2020; see Figure 7-11a to c). Infections in the superficial facial spaces such as an abscess (Mohan et al., 2015). Periapical lesions caused by a bacterial infection of the root, pulp, or periodontal tissue (see Figure 7-12; Chen et al., 2013). Assess bone healing post-surgery (Mohan et al., 2015). Detect and aid in removal techniques of foreign bodies such as a broken dental instrument (Mohan et al., 2015). Structures associated with the temporomandibular joint (TMJ) such as the joint, discs, and adjacent soft tissues to aid in the management and treatment of temporomandibular disorder (TMD) and

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A

Figure 7-12  Periapical lesion on the maxillary right

lateral incisor.

Figure 7-13  Temporomandibular joints visible on a

panoramic radiograph. B

• • •

orthognathic surgery (Mohan et al., 2015); see Figure 7-13). Bone fractures of the face (Mohan et al., 2015). Salivary gland pathology such as sialolith (salivary gland stone) and sialadenitis ­(swelling of the salivary gland; Mohan et al., 2015; see Figure 7-14). Head and neck lymph nodes to evaluate for lymphadenopathy (disease of a lymph node that causes a palpable enlarged node), and cancer metastasis and staging (Yusa et al., 1999).

Orthodontics C Figure 7-11  Soft tissue lesions: A. Lesion on the buccal

mucosa, B. Lesion on the left retromolar pad, C. Left lateral border of the tongue lesion.

The clinical applications of a dental ultrasonic device in the field of orthodontics includes:

• Orthodontic bracket debonding and residual cement removal (Chen et al., 2013).

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Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications

Periodontics and Dental Hygiene The clinical applications of a dental ultrasonic device in the field of periodontics and dental hygiene include:

• Removal of oral deposits. • Biofilm reduction. • Aid in periodontal surgeries. • Removal of a small amalgam or composite res•

toration overhang. Figure 7-15 shows large overhangs where a rotatory bur would be the better option for removal than an ultrasonic. Removal of small to medium-size retained cement around a fixed prosthesis (crown, inlay, onlay) as

Figure 7-14  Salivary gland swelling left floor of the

mouth.

• Decreasing root resorption by decreasing osteo•

clast number and activity (Mehta et al., 2016). Decreasing orthodontic treatment time by accelerating alveolar bone remodeling (Mehta et al., 2016).

A

Similar to OMS, the specialty of orthodontics uses ultrasonography to image structures inside the body. Imaging is used for:

• Tongue posture and swallowing patterns (Mehta •

• •

et al., 2016). Thickness of the masseter muscle, which influences craniofacial growth patterns and malocclusion risk (Chen et al., 2013; Patini et al., 2019). Orthodontic appliances have the potential to change muscle thickness and subsequently change the forces transmitted to skeletal and dental tissues (Patini et al., 2019). Facial structures to aid in appliance selection (Mehta et al., 2016). Gingival soft tissue thickness to aid in temporary anchorage device (TAD) positioning (Mehta et al., 2016). TADs such as a miniscrew, miniplate, or implant provide anchorage to aid in tooth movement with appropriate forces to decrease undesired effects. TADs are used for many purposes such as to close spaces, intrude or extrude teeth, reposition teeth upright, and aid in erupting an impacted tooth, or for palatal expansion (Uzuner & Aslan, 2015).

B Figure 7-15  Restoration overhangs: A. Overhang

restoration on the distal of the mandibular right first molar, B. Overhang restoration on the distal of the mandibular left first premolar.

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A

Figure 7-17  Stained fissures and pits on the occlusal

surface of a premolar tooth.

Theoretical Approaches to Ultrasonic Instrumentation

B Figure 7-16  Fixed prosthesis retained cement:

A. Cement on the mesial and distal of the maxillary left first molar, B. Cement on the mesial of the mandibular right second molar.

• • • •

seen in Figure 7-16. If the cement is large, a rotary bur is a better option for removal than an ultrasonic. Removal of small to medium retained orthodontic cement. If the cement is large, a rotary bur is needed for removal. Direct and indirect removal of organisms to promote oral symbiosis through acoustic cavitation, acoustic microstreaming, and liquid jet production. Removal of hard or soft tissue as the scope of practice allows. Debridement of grooves, pits, and fissures prior to sealant placement (see Figure 7-17).

In 2015–2017, the AAP, European Federation of Periodontology, and more than 100 experts from Asia and Australia came together to build a new classification system for gingival health and diseases to replace the 1999 system. In 2017, the World Workshop took place in Chicago, Illinois, and four case types were defined and released as the “2018 Classification of Periodontal and Peri-Implant Diseases and Conditions” (Caton et al., 2018). The new classification system provided another paradigm shift in the field of dentistry. For the first time, the term periodontal medicine was introduced to the dental community. Periodontal medicine:

• Is the act of considering individual patient needs in • •

the diagnosing, strategizing, and treatment of gingival and periodontal conditions (Caton et al., 2018). Identifies periodontal disease as a multidimensional disorder with varying severity and complexity factors contributing to disease management (Caton et al., 2018). Accepts the procedure of periodontal debridement with root detoxification and conservation because it can promote oral symbiosis and long-term patient health and stability in managing disease processes.

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Table 7-1  Approaches to ultrasonic instrumentation Traditionalist Approach

Contemporary Approach

Insert and tip design

Single thick or thin diameter Straight shank Short shank

Thick, thin, and ultra-thin diameters Straight and curved shanks Short and long shanks

Number of inserts and tips used

One

Many

Supragingival/Subgingival access ­Complex Root Anatomy

Supragingival (subgingival ­access limited with thick ­diameter shanks) Cannot adapt to complex root anatomy

Supragingival and subgingival Can adapt to complex root anatomy

Primary patient criteria

Dental calculus Stain

Biofilm Inflammation Bacterial by-products

Secondary patient criteria

None

Dental calculus Stain

Hand instrumentation required for full mouth debridement

Yes

No

Based on Asadoorian, J., Bobtyl, D., & Goulding, M.J. (2015). Dental hygienists’ perception of preparation and use for ultrasonic instrumentation. International Journal of Dental Hygiene, 13, 30-41.

It is important to recognize the historical and contemporary approaches to periodontal management because they have influenced the development of ultrasonic technology and the theoretical approaches to instrumentation. There are two theoretical approaches to ultrasonic instrumentation that have developed over the past 70 years: the traditionalist approach and the contemporary approach. Both approaches are summarized in Table 7-1.

Traditionalist Approach to Ultrasonic Instrumentation

The traditionalist approach to ultrasonic instrumentation was used from the 1950s until the time periodontal debridement was widely accepted in the mid-1990s. This approach was based on the methodology that dental calculus was the etiological agent of periodontal disease and not plaque biofilm in a susceptible host. The traditionalist approach used only one primary patient criterion for the use of ultrasonic instrumentation:

• Primary

criterion: presence of dental calculus and/or stain.

A traditionalist provider used ultrasonic instrumentation as an adjunct to traditional hand-activated

instrumentation. Only one ultrasonic insert or tip was used on all tooth surfaces and then significant hand-activated instrumentation was followed. The insert or tip design was a short, straight, thick or thin diameter shank, which was unable to adapt into complex root anatomy. BREAKOUT POINT The traditionalist approach uses dental calculus and stain presence as the primary selection criteria for ultrasonic instrumentation.

Contemporary Approach to Ultrasonic Instrumentation

The contemporary approach to ultrasonic instrumentation promotes the AAPs practice of periodontal medicine and is widely used today. In the contemporary approach, ultrasonic instrumentation is used to:

• Reduce oral biofilm and bacterial by-products. • Conserve cementum. • Detoxify tooth structures. • Preserve gingival integrity. • Decrease inflammatory mediators.

Periodontal Debridement

The contemporary approach uses primary and secondary patient criteria for the use of ultrasonic instrumentation:

• Primary •

criteria: presence of biofilm, bacterial by-products, and inflammation. Secondary criterion: presence of dental calculus and/or stain.

Table 7-2  Periodontal disease risk factors Host risk factors

A host risk factor is an attribute that increases the risk of periodontal disease and influences one’s ability to control inflammatory mediators such as: ■ Immunological and metabolic genetic disorders (Albandar et al., 2018). ■ Systemic diseases such as diabetes mellitus, cardiovascular diseases, autoimmune diseases, rheumatoid arthritis, osteoarthritis, obesity, osteoporosis, AIDS, and inflammatory diseases (Albandar et al., 2018). ■ Oral risks: presence of periodontal pockets, restorations, root anatomy, tooth position (crowding or spacing), traumatic occlusal forces, ability of the patient to properly cleanse their mouth, or the presence of mucogingival defects (gingival recession, lack of keratinized gingiva; Albandar et al., 2018; Lang & Bartold, 2017).

Microbiological composition

There are over 700 organisms that inhabit the oral cavity and up to 200 can be present in just one individual patient (Aas et al., 2005). The host composition of oral flora and the presence of supragingival and subgingival biofilm contribute to disease susceptibility (Lang & Bartold, 2017).

Environmental influences

Nicotine, medications, emotional stress, mental illness (depression, bipolar), diet, and nutrition contribute to disease susceptibility (Lang & Bartold, 2017).

In the contemporary approach, ultrasonic instrumentation is not used as an adjunct to hand-activated instrumentation as is done in the traditionalist approach. A full mouth debridement is completed with a variety of insert and tip designs using staged instrumentation. The conjunctive use of hand-activated instruments is only utilized when the provider encounters a barrier for ultrasonic instrumentation. Ultrasonic instrumentation is performed on every patient to reduce biofilm and inflammatory mediators through the delivery of acoustic cavitation, acoustic microstreaming, and liquid jets in the mouth to promote oral symbiosis. BREAKOUT POINT The contemporary approach to ultrasonic instrumentation allows for full mouth debridement without the adjunctive use of hand-activated instruments to remove biofilm, bacterial by-products, dental calculus, and stain, and to reduce the overall inflammatory burden of the mouth.

Periodontal Debridement The clinical objective of periodontal debridement is to remove the etiological agents of infection while conserving healthy enamel, dentin, and cementum by using the least aggressive instrumentation to achieve this goal. Oral health-care providers perform supragingival and subgingival instrumentation with hand-activated instruments, ultrasonic instruments, and air polishing systems to reduce biofilm levels to promote a symbiotic oral microbiome.

Periodontal Disease Pathogenesis

Pathogenesis is a term that describes the man-

ner of disease development. While there are multiple perspectives for the specific role of bacteria in periodontal disease, it is widely recognized that when specific pathogenic microbial species combine in an oral biofilm complex, uncontrolled immune reactions occur in a susceptible host that lead to ­attachment loss.

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Periodontitis represents a dysbiotic oral state characterized by progressive destruction of tooth supporting apparatus structures mediated by hostimmune responses to microbial insults. Gingival, periodontal, and peri-­implant diseases are multifactorial and multidimensional, involving host risk factors, and microbiological and environmental influences (see Table 7-2).

Periodontal Disease Statistics

According to the WHO (2021), 10% of the global population has severe periodontal disease, which may result in tooth loss. Inequities are noted for those of

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Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications

a lower socioeconomic status. In the United States, the Centers for Disease Control and Prevention (CDC) (2013) reports the following statistics for periodontal disease prevalence:

• 47.2% of adults 30 years and older have periodontal disease.

• 70.1% of adults over the age of 65 have periodon•

tal disease. Those living below the federal poverty level and those with less than a high school education have prevalence rates above 65%.

It is clear from these statistics that a greater number of adults are living in a state of oral dysbiosis rather than symbiosis. In times of inflammation, dysbiosis, periodontal pocketing, and active infection, supragingival and subgingival periodontal instrumentation is needed to arrest disease progression and restore symbiosis. Ultrasonic instrumentation causes profound microbiological change in the mouth through acoustic cavitation, acoustic microstreaming, and liquid jet release and aids in the treatment of dysbiosis.

Preventive Clinical Treatment

Ultrasonic and hand-activated instrumentation differ from each another in their delivery of care, but not in overall clinical outcomes. There is a large body of evidence dating back to the 1980s that has shown comparable periodontal debridement clinical o­utcomes between hand-activated and ultrasonic instrumentation as measured by the reduction of bleeding and probe depths, as well as gains in clinical attachment (Drisko et al., 2000; Barendgret et al., 2008; D’Ercole et al., 2006; Khosravi et al., 2004; Muniz et al., 2020; Oosterwaal et al., 1987; Timkel et al., 2002; Walmsley et al., 2008). It is in the delivery of care where dramatic differences are seen between the two. The subgingival access, microbial reduction, furcation access, cemental alterations, efficiency, and clinician ergonomics are not the same for ultrasonic and hand-activated instrumentation.

Subgingival Access Thin and ultra-thin ultrasonic shanks are narrower in diameter than a standard hand-activated instrument blade, which allows them to access subgingivally with minimal to no tissue distension. The advantages of ultrasonic thin and ultra-thin shanks over hand-activated instruments are:

• Improved access subgingivally when tissues are • •

firm, hard, and tightly adherent to the tooth root, as seen in Figure 7-18 (Zhang et al., 2020). Less tissue injury while instrumenting tooth roots (Zhang et al., 2020). Ease of access to deeper periodontal pockets with thinner diameter, curved shape, and longer shanks (Barendgret et al., 2008; Oosterwaal et al., 1987; Zhang et al., 2020; Beuchat et al., 2001).

BREAKOUT POINT Thin and ultra-thin ultrasonic diameter shanks are slimmer than a standard hand-activated instrument blade and access subgingivally with minimal to no tissue distension.

Microbial Reduction Dental ultrasonic acoustic cavitation, acoustic microstreaming, and liquid jet production change the oral flora of the mouth by detaching adherent biofilm; reducing the number of spirochetes, filaments, gram-negative bacteria, and motile rods; and increasing the number of coccoid bacteria (Baehni et al., 1992; Gartenmann et al., 2017; Gomez-Suzrez et al., 2001; Mueller et al., 2011; National Institutes of Health, 2000; Pecheva et al., 2016; Stricker et al., 2013; Thilo & Baehni, 1987). These changes favor a symbiotic oral microbiome. A hand-activated instrument will only remove organisms through direct blade contact and does not produce microbiological effects through acoustic cavitation, acoustic microstreaming, or liquid jets.

Figure 7-18  Tissue consistency that is firm, hard, and tightly adherent on the maxillary anterior lingual surfaces.

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BREAKOUT POINT Ultrasonic instrumentation removes biofilm and bacterial pathogens through direct and indirect contact with tooth surfaces.

Furcation Access An ultrasonic insert or tip is superior to a handactivated instrument for accessing and debriding a furcation area, especially in more involved furcation defects where the probe penetrates deeper into the furca space (Drisko et al., 2000; Tunkel et al., 2002; Dragoo 1992; Leon & Vogel, 1987; Oda & Ishikawa, 1989). Furcation widths vary dramatically, as seen in Figure 7-19a and b. The average furcation entrance width, is often less than 1 mm. Thin and ultra-thin diameter shanks are less than 0.5 mm in width, allowing for easy access into narrow furcation entrances (Drisko et al., 2000). An area-specific hand-activated instrument blade is thicker than these ultrasonic shanks and many times too bulky to be used in narrow furcation entrances (see Figure 7-20a and b). More detail on this topic will be presented in later chapters.

A

BREAKOUT POINT Thin and ultra-thin ultrasonic shanks can access narrow (,1 mm) furcation entrances.

Cementum Alterations An ultrasonic insert and tip shank causes less cementum injury, removal, alteration, and abrasion than a hand-­activated instrument blade during oral deposit removal (Drisko et al., 2000; Kawashina et al., 2006; Kumar et al., 2015; Maritato et al., 2018; Mittal et al., 2014; Ritz et al., 1991; Santos, et al., 2008; Singh et  al., 2012). More detail on this topic will be presented in a later chapter. BREAKOUT POINT Ultrasonic instrumentation causes less alterations to cementum than hand-activated instrumentation during oral deposit removal.

Efficiency The removal of oral deposits with a hand-activated instrument is achieved through mechanically breaking

B Figure 7-19  Furcation entrance: A. Narrow furcation

entrances on the maxillary first premolar and mandibular molar, B. Wide furcation entrance on a mandibular molar.

the bond between the deposit and the tooth, which is physically demanding and time-consuming, and requires expert-level technique to avoid injury to cementum and tissue. An ultrasonic tip or insert mechanically chips the deposit away from tooth structures for the provider. Studies have demonstrated a 20.0– 36.6% reduction in oral deposit removal time with the

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Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications

Contemporary health-care models for dentistry and medicine have shortened the time a provider spends with their patient but still demand highquality outcomes. The provider is expected to produce the same quality outcomes as in years past with less time allotted for patient care. With these time constraints on a patient appointment, the oral health-care provider needs to use all available technology that maximizes efficiency and minimizes treatment time.Ultrasonic instrumentation is an example of this because it will decrease procedure time while producing comparable clinical outcomes as handactivated instrumentation.

Ergonomics

A

Dental professionals are at an increased risk for workrelated musculoskeletal disorders (WMSDs). WMSDs are injuries of muscles, nerves, tendons, joints, cartilage, and spinal discs that occur and are made worse by the work environment (CDC, 2020). The increased risk for WMSDs is attributed to (CDC, 2020):

• Sustained repetitive motions and tasks. • Static posture and positioning for long periods of time.

• Awkward positioning. • Force put on small muscle

groups and nerves

during procedures.

B Figure 7-20  Instrument furcation access: A. Ultrasonic

active area antinode of the shank adapting and easily accessing a narrow furcation entrance on the mandibular second molar, B. Area-specific handactivated instrument blade unable to access a narrow furcation entrance on the mandibular second molar.

use of a dental ultrasonic compared to hand-activated instrumentation with similar treatment outcomes (Muniz et al., 2020; Tunkel et al., 2002; Benchat et al., 2001; Copulos et al., 1993). BREAKOUT POINT Ultrasonic instrumentation decreases total treatment time by 20.0–36.6% when compared to hand-activated instrumentation.

National Institute for Occupational Safety and Health (NIOSH) has a Musculoskeletal Health CrossSector Program aimed at reducing “the burden of WMSD through a focused program of research and prevention that protects workers” (CDC, 2019). The program helps improve efficiency of workplace interventions for health-care workers (CDC, 2019). Ultrasonic instrumentation offers protection for oral health-care providers by:

• Decreasing active patient treatment time. • Allowing for more flexible operator • •

chair positioning. Mechanically chipping away oral deposits for the provider, which decreases labor intensity.. Allowing for a light and relaxed grasp when instrumenting, which reduces wrist, arm, and hand fatigue.

Considerations and Contraindications A consideration is a factor or variable that should be taken into account and the potential consequences weighed against the benefits prior to implementing

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121

a technology or procedure into a patient care plan. A  contraindication is a situation when a patient should not receive treatment because it may be harmful. There are considerations and contraindications for ultrasonic instrumentation. The field of ultrasonic technology has changed dramatically from its inception. The considerations and contraindications have also changed dramatically as the technology has evolved. Caution should be exercised when referencing dated literature for considerations and contraindications because this information applied to technology of that time and may not represent the technology of today. In the United States, a dental ultrasonic device is classified as a “medical device” by the FDA (2020), which requires scientific research and reporting for considerations and contraindications. Considerations and contraindications vary by model and manufacturer and can be referenced in the direction for use/ instruction for use (DFU/IFU). This section will discuss general considerations and contraindications for ultrasonic use, but it is not a comprehensive list for each manufacturer as there are too many devices on the market to cite each one.

• Sealant • Dental ceramics (porcelain, alumina, zirconia) • All-metal castings (gold, palladium, platinum) • Porcelain bonded alloys (porcelain fused to

Contraindications

• • •

Dental ultrasonics are contraindicated for a patient with an active communicable disease and are contraindicated for use on fixed and removable dental materials.

Communicable Disease Patients with active ARIs such as tuberculosis, coronavirus, or influenza should not be seen in the dental office and certainly not be subjected to an aerosol-generating procedure until they are recovered from their active infection. This places the entire dental environment at risk for disease transmission from pathogenic aerosols. The patient is also put at risk for further disease complications due to their compromised immune state.

Fixed Dental Materials An ultrasonic shank has the potential to scratch, chip, or roughen fixed dental materials. This contributes to poor esthetics, discoloration, and oral deposit accumulation, which can increase the risk for secondary caries and gingival inflammation. A stainless-steel shank should not directly contact the following fixed dental materials:

• Composite resin • Glass ionomer cement

• •

a metal crown) Stainless steel alloys (crowns commonly placed on pediatric patients) Amalgam

BREAKOUT POINT Avoid direct contact of a stainless-steel shank on a fixed dental material.

Removable Dental Materials A dental ultrasonic device may scratch, roughen, puncture, or chip removable dental materials. A ­stainless-steel shank should not directly contact the following removable dental materials:

• Acrylic resins such as those used on dentures and partials Denture teeth (acrylic, composite, porcelain) Denture liners Bruxism guard (hard, soft, Thermoguard)

Considerations

The following require special consideration or technique adjustments to ultrasonic instrumentation. The risks versus benefits should be weighed prior to ultrasonic exposure.

Demineralized and Decayed Hard Tissues All forms of instrumentation (hand-activated and ultrasonic) should be used with caution on demineralized or carious hard tissue. This hard tissue has an increased risk for further loss and destruction, which may contraindicate all forms of instrumentation depending on the level of demineralization (see Figure 7-21a to c for examples).

Dental Implant There are ultrasonic inserts and tips specifically designed for safe dental implant debridement, as seen in Chapter 5 (see Figure 7-22). A stainless-steel shank is not designed for direct contact on a dental implant, abutment, prosthesis, or superstructure.

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Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications

A

B

C Figure 7-21  Demineralized hard tissue: A. Cervical facial demineralization and caries of the maxillary right canine;

instrumentation should be used with caution to avoid further breakdown of the hard tissue, B. Interproximal demineralization and carious lesions on the maxillary left central and lateral incisors; instrumentation should be used with caution to avoid further breakdown the of the hard tissues; C. Advanced carious lesion occlusal of a maxillary molar; instrumentation is contraindicated.

Figure 7-22  Dental implant on the mandibular right first molar.

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123

Dentin Hypersensitivity

• Ultrasonic modifications: Use low power output

If a patient has active dentinal hypersensitivity from exposed root structures, as seen in Figure 7-23a and b, all forms of instrumentation will be challenged. Instrumentation technique will need to be modified when working on a patient with dentinal hypersensitivity to avoid eliciting a painful stimulus. These modifications include, but are not limited to:

• •

• Application of a desensitization product prior to instrumentation.

settings with correct water flow rate. Adapt less active surfaces of the shank (back, lateral) to the tooth surface (described in Chapter 9). Provide breaks during instrumentation. Administer injectable local anesthesia.

If the patient is experiencing active dentinal hypersensitivity on a tooth that cannot be controlled through these technique modifications, then all forms of instrumentation may be completely contraindicated.

HIV The oral health-care provider may want to obtain the patient’s CD4+ T-lymphocyte count or viral load count prior to performing an aerosol-generating procedure. If the risk for a bacteremia is low and the risk for environmental contamination of pathogenic aerosols is low, ultrasonic instrumentation may be safely performed.

Individual Patient Factors Dental ultrasonics should be used with caution for patients who present with:

A

• Increased risk of aspiration • Difficulty swallowing • Respiratory challenges • Challenged airway (see Figure 7-24) • Persistent or violent coughing • Exaggerated gag reflex

B Figure 7-23  Recession and dentin exposure:

A. Recession on the maxillary left first molar buccal surface, B. Recession on mandibular anterior facial surfaces.

Figure 7-24  Challenged airway. Notice the patient’s

tongue covers their airway when they open.

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Ultrasonic instrumentation may be possible for these patients if the provider can manage the complication with positioning and evacuation techniques. Using semi-supine or upright patient positioning, stand-up operator positioning, low to medium power output with lower water flow rates, or four-handed dentistry, may provide a manageable work-around for these patients with limiting factors.

Pediatric Patients The American Academy of Pediatric Dentistry (2020) published a policy on the role of dental prophylaxis in Pediatric Dentistry and listed the dental ultrasonic as a recommended device to remove biofilm, stain, and dental calculus on pediatric patients. In the past, the ultrasonic device was thought to be contraindicated because of the larger pulp chamber size in younger children and the concern for potential discomfort. The provider can safely use a dental ultrasonic device on a pediatric patient with modifications such as avoiding high power output settings, using correct water flow rates, and adapting less active surfaces of the shank (back, l­ateral)

to the tooth surface (described in Chapter 9). Today’s ultrasonic devices have improved dissipation of heat, which improves patient comfort and decreases the risk for a pupal response.

Orthodontic Appliances Ultrasonic instrumentation is indicated for debriding tooth and root surfaces around orthodontic appliances with modifications such as avoiding high power ­output settings and avoiding placing the shank directly on the bonded material around brackets to prevent chipping (see Figure 7-25a and b).

Pacemaker The presence of a pacemaker is not an absolute contraindication for ultrasonic instrumentation. The oral health-care provider should reference the manufacturer’s DFU/IFU for specific recommendations and warnings on ultrasonic use and cardiac pacemakers prior to instrumentation. The patient may also consult with their medical specialist for questions regarding dental procedures.

A

B Figure 7-25  Bonded orthodontic brackets: A. Bonded brackets on the maxillary anterior teeth facial surfaces

B. Bonded brackets on the mandibular anterior teeth facial surfaces.

Considerations and Contraindications

BREAKOUT POINT The presence of a pacemaker is not an absolute contraindication for ultrasonic instrumentation.

Patients with arrhythmias or heart failure may have an implanted cardiac pacemaker. A pacemaker is a pulse generator with electronics and leads that travel to the heart and deliver depolarizing pulses. The battery has a specified life-span but does not typically last a lifetime. Older models were unable to sense intrinsic cardiac activity and were pacing only, but contemporary models sense and pace with a patient’s intrinsic cardiac activity for improved performance (National Institutes of Health, 2021). There are different types of pacemakers such as wired transvenous, epicardial, and wireless (Mulpuru et al., 2017). There are also numerous manufacturers of pacemakers. One of the largest manufacturers is Medtronic, which released the first pacemaker in 1957 (National Institutes of Health, 2021). Each manufacturer provides a detailed list of household items and medical and dental equipment and procedures that have the potential to interfere with the function of their pacemaker. Best practice would be to obtain of a copy of the patient’s pacemaker card and place in their permanent record. This will assist with completeness of information for future appointments. In the past, electromagnetic interferences from the environment were a concern to the functionality of a pacemaker. With the improvements of pacemaker designs in shielding, electrode optimization

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that minimizes current flow and preserves battery life, noise protection algorithms, bipolar pacing, and nonphysiological signal rejection interference, electromagnetic interference from cell phones, medical and dental equipment is less of a concern (National Institutes of Health, 2021; Conde-Mir et al., 2018). The following is an example list from three pacemaker manufacturers of the potential for electromagnetic interference from dental equipment: • Medtronic (2018) states, “Dental apex locator, dental drills, dental ultrasonic scaler or cleaners, dental x-rays, and dental pulp tester have no known risk to pacemaker function.” • Boston Scientific (2021) states, “Dental drills, dental ultrasonic cleaning equipment, diagnostic x-rays, and diagnostic ultrasound are procedures that will not affect pacemaker function.” • Biotronik (2017) states, “Ultrasonic dental cleaning should be kept at a minimum distance of 15cm (0.49 feet) from the pacemaker.” Numerous studies have been conducted in the dental field on an ultrasonics’ potential to interfere with a cardiac pacemaker. A recent in vivo study by Conde-Mir et al. (2018) found no potential electromagnetic interferences when using a dental ultrasonic scaler, dental electric pulp tester, or dental electronic apex locator for patients with a pacemaker.

Surgical Procedures Reference the manufacturer’s DFU/IFU for the surgical applications (if any) of the ultrasonic device. Some ultrasonics can be used for surgical procedures while others cannot.

CASE STUDY

A dental hygienist is seeing a new patient at ten o’clock in the morning. The 58-year-old patient arrives late and takes a long time to complete the medical and dental history form. By the time the patient is ready to go back into the treatment room, the hygienist is already 30 minutes into an 80-minute appointment. The hygienist neglects to review the medical history and proceeds directly into radiographs and periodontal probing, trying to make up time. A prophylaxis is indicated, and the hygienist asks the patient if they have any medical issues while they are setting up the ultrasonic for the prophylaxis. The patient states he had a heart attack seven months ago and a pacemaker was placed. The hygienist is in a hurry due to starting late and decides since the pacemaker is so new there is probably nothing to worry about when using an ultrasonic scaler. The rest of the appointment proceeds without any issues. Were the actions of the hygienist right or wrong? Was the patient at risk for an adverse health event because of the hygienist's actions? What should have been done differently during this appointment?

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Summary

This chapter explored the use of ultrasonic technology in both the medical and dental field. Historical and contemporary theoretical approaches to dental ultrasonic instrumentation were introduced and related to periodontal disease treatment, management, and pathogenesis. Historical and contemporary ultrasonic considerations and contraindications for instrumentation were reviewed.

Understanding the general differences between hand-­ activated and ultrasonic instrumentation assists the provider in making the best treatment decision for their patient’s needs. Complete periodontal debridement with ultrasonic instrumentation supports the practice of periodontal medicine and improves clinical efficiency which may offer some protection from WMSDs.

Questions 1. A magnetostrictive ultrasonic device was first marketed for which type of dental procedure? a. Removal of oral deposits b. Removal of decay c. Endodontic procedures d. Orthodontic procedures 2. Which of the following procedures can a dental hygienist perform with a dental ultrasonic device if it is within their scope of practice? a. Removal of a small restoration overhang b. Removal of retained orthodontic cement c. Removal of oral deposits d. All of the above 3. Which of the following is TRUE of the dental magnetostrictive ultrasonic devices manufactured in the 1950s? a. The operator had to manually tune the ultrasonic to set the wave frequency. b. Both external and internal water port designs were an option on an insert. c. Insert diameter options were thick and thin. d. Insert design allowed for easy access subgingivally. 4. Which of the following is TRUE of contemporary periodontal debridement procedures? a. Cementum should be root planed to a glassy-smooth finish. b. Root structures should be conserved during oral deposit removal. c. Debridement is focused on reducing biofilm and decontaminating periodontal pockets. d. Both B and C Match the following descriptions to the correct theoretical approach to ultrasonic instrumentation for questions 5–9. Answer A for the traditionalist approach and B for the contemporary approach. There is only one correct answer for each question.

5. Complete debridement is possible without the adjunctive use of hand-activated instrumentation. 6. Ultrasonic instrumentation can be performed using a variety of insert and tip diameters (thick, thin, ultra-thin) and shapes (straight, curved). 7. Dental calculus and stain presence if the primary criteria for ultrasonic instrumentation. 8. Biofilm and inflammation presence is the primary criteria for ultrasonic instrumentation. 9. One ultrasonic shank shape and diameter can be used for a whole mouth procedure. 10. True or False. Hand-activated and ultrasonic instrumentation produce comparable periodontal debridement clinical outcomes as measured by bleeding and probe depth reduction and gains in clinical attachment. a. True b. False 11. Ultrasonic instrumentation is preferred over hand-activated instrumentation in which of the following patient case scenarios? a. Shallow pocket depth with tightly adherent gingival tissues b. Furcation entrance with a narrow width c. Procedure with limited time d. All of the above 12. Which of the following puts an oral health-care provider at an increased risk for work-related musculoskeletal disorders? a. Sustained repetitive motion and tasks b. Static postures for a long period of time c. Force put on small muscle groups and nerves during procedures d. All of the above

References

13. Which of the following is a contraindication for ultrasonic use? a. Porcelain crown b. Sealant c. Patient with active influenza d. All of the above 14. Which of the following can be safely debrided with a stainless-steel ultrasonic shank? a. Denture tooth b. Dental implant abutment c. Dentin with active hypersensitivity d. A stainless-steel shank cannot be used in any of these situations

References

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15. Which of the following is a consideration that could influence the use of a dental ultrasonic? a. Patient with a gag reflex b. Patient with persistent and violent cough c. Patient with HIV d. Patient with a pacemaker e. All of the above

12. Boston Scientific. (2021). Medical and dental procedures. https://www.bostonscientific.com/en-US/patients/about -your-device/pacemakers/living-with-a-pacemaker/medical -and-dental-procedures.html 13. Caton, J. G., Armitage, G., Berglundh, T., Chapple, I. C., Jepsen, S., Kornman, K., Mealey, B. L., Papapanou, P. N., Sanz, M., & Tonetti, M. S. (2018). A new classification scheme for periodontal and peri-implant diseases and conditions—introduction and key changes from the 1999 classification. Journal of Periodontology, 89(1), S1–S8. https:// doi.org/10.1002/JPER.18-0157 14. Centers for Disease Control and Prevention. (2013). Oral health. https://www.cdc.gov/oralhealth/conditions /periodontal-disease.html 15. Centers for Disease Control and Prevention. (2019). Musculoskeletal health program. https://www.cdc.gov/niosh /programs/msd/default.html 16. Centers for Disease Control and Prevention. (2020). Work-related musculoskeletal disorders & ergonomics. https:// www.cdc.gov/workplacehealthpromotion/health-strategies /musculoskeletal-disorders/index.html 17. Chen, Y. L., Chang, H. H., Chiang, Y. C., & Lin, C. P. (2013). Application and development of ultrasonics in dentistry. Journal of the Formosan Medical Association, 112, 659–665. https://doi.org/10.1016/j.jfma.2013.05.007 18. Conde-Mir, I., Miranda-Ruis, J., Trucco, E., Lahor-Soler, E., Brunet-Llobet, L., Domingo, R., Tolsana, J. M., & Mont, L. (2018). European Journal of Oral Sciences, 126, 307–315. 19. Copulos, T. A., Low, S. B., Walker, C. B., Trebilock, Y. Y., & Hefti, A. F. (1993). Comparative analysis between a modified ultrasonic tip and hand instruments on clinical parameters of periodontal disease. Journal of Periodontology, 64(8), 694–700. 20. D’Ercole, S., Piccolomini, R., Capaldo, G., Catamo, G., Perinetti, G., & Guida, L. (2006). Effectiveness of ultrasonic instruments in the therapy of severe periodontitis: A comparative clinical-microbiological assessment with curettes. New Microbiology, 29(2), 101–110. 21. Dragoo, M. R. (1992). A clinical evaluation of hand and ultrasonic instruments in subgingival debridement, Part 1. With unmodified and modified ultrasonic inserts. International Journal of Periodontics & Restorative Dentistry, 12(4), 311–323.

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22. Drisko, C. L., Cochran, D. L., Blieden, T., Bouwsma, O. J., Cohen, R. E., Damoulis, P., Fine, J. B., Greenstein, G., Hinrichs, J., Somermman, M. J., Iacono, V., & Genco, R. J. (2000). Position paper: Sonic and ultrasonic scalers in periodontics. Journal of Periodontology, 71(11), 1792–1801. https://doi.org/10.1902/jop.2000.71.11.1792 23. Food and Drug Administration. (2020). CFR—Code of Federal Regulations. https://www.accessdata.fda.gov/scripts /cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=872.4850 24. Forfang, W., You, B. H., & Song, I. H. (2013). Ultrasonic dental therapy: Trends and prospects. European International Journal of Science and Technology, 2(1), 1–6. 25. Gartenmann, S. J., Thurnheer, T., Attin, T., & Schmidlin, P. R. (2017). Influence of ultrasonic tip distance and orientation on biofilm removal. Clinical Oral Investigations, 21(4), 1029–1036. https://doi.org/10.1007/s00784-016-1854-8 26. Gomez-Suzrez, C., Busscher, H., Henry, C., & Mei, V. D. (2001). Analysis of bacterial detachment from substratum surfaces by the passage of air-liquid interfaces. Applied and Environmental Microbiology, 67(6), 2531–2537. https://doi .org/10.1128/AEM.67.6.2531-2537.2001 27. Hinchman, S. S., Funk, A., DeBiase, C., & Frere, C. (2016). Ultrasonic instrumentation instruction in dental hygiene programs in the United States. Journal of Dental Hygiene, 90(2), 135–142. 28. Ibsen, O., & Phelan, J. (2018). Oral pathology for the dental hygienist with general pathology introductions (7th ed.). Elsevier. 29. Johns Hopkins Medicine. (2020). What is cancer? http:// pathology.jhu.edu/pc/BasicTypes1.php 30. Kawashima, H., Sata, S., Kishida, M., & Ito, K. (2006). A comparison of root surface instrumentation using two piezoelectric ultrasonic scalers and a hand scaler in vivo. Journal of Periodontal Research, 42, 90–95. 31. Khosravi, M., Bahrami, Z. S., Atabaki, M. S. J., Shokrgozar, M. A., & Shokri, F. (2004). Comparative effectiveness of hand and ultrasonic instruments in root surface planing in vitro. Journal of Clinical Periodontology, 31, 160–165. 32. Kumar, P., Das, S. J., Sonowal, S. T., & Chawla, J. (2015). Comparison of root surface roughness produced by hand instruments and ultrasonic scalers: An in vitro study. Journal of Clinical and Diagnostic Research, 9(11), ZC56–ZC60. https:// doi.org/10.7860/ JCDR/2015/13744.6828 33. Lang, N., & Bartold, P. (2017). Periodontal health. Journal of Periodontology, 89(1), S9–16. https://doi.org/10.1002 /JPER.16-0517 34. Lea, S. C., & Walmsley, A. D. (2000). Mechano-physical and biophysical properties of power-driven scalers: Driving the future of powered instrument design and evaluation. Periodontology, 51(2009), 63–78. 35. Leon, L. E., & Vogel, R. I. (1987). A comparison of the effectiveness of hand scaling and ultrasonic debridement in furcations as evaluated by differential dark-field microscopy. Journal of Periodontology, 58(2), 86–94. 36. Maritato, M., Orazi, L., Laurito, D., Formisano, G., Serra, E. Lollobrigida, M., Molinari, A., & De Biase, A. (2018). Root surface alterations following manual and mechanical scaling: A comparative study. International Journal of Dental Hygiene, 16, 553–558. https://doi.org/10.1111/idh.12349 37. Medtronic. (2018). Medical and dental procedures electromagnetic compatibility guide for implantable cardiac devises. https://www.medtronic.com/us-en/patients/electromagnetic -guide/medical-dental.html

38. Mehta, P., Sagarkar, R. M., Silju, M., Prashantha, G. S., & Srijan, S. (2016). Review ultrasonics: Applications of ultrasound in orthodontics. Journal of Dental & Oro-facial Research, 12(1), 30–32. 39. Mittal, A., Nichani, A. S., Venugopal, R., & Rajani, V. (2014). The effect of various ultrasonic and hand instruments on the root surfaces of human single rooted teeth: A planimetric and profilometric study. Journal of Indian Society of Periodontology, 18(6), 710–717. 40. Mohan, K. R., Rao, N. K., Krishna, G. L., Kumar, V.  S., Ranaganath, N., & Lakshmi, U. V. (2015). Role of ultrasonography in oral and maxillofacial surgery: A review of literature. Journal Maxillofacial Oral Surgery, 14(2), 162–170. https://doi.org/10.1007/s12663-014-0616-x 41. Mueller, P., Guggenheim, B., Attin, T., Marlinghaus, E., & Schmidlin, P. R. (2011). Potential of shock waves to remove calculus and biofilm. Clinical Oral Investigations, 15(6), 959–965. https://doi.org/10.1007/s00784-010-0462-2 42. Mulpuru, S. K., Madhavan, M., McLeod, C. J., Cha, Y. M., & Friedman, P. A. (2017). Journal of the American College of Cardiology, 69(2), 189–210. 43. Muniz, F. W. M. G., Langa, G. P. J., Pimentel, R. P., Martins, J. R., Pereira, D. H., & Rosing, C. K. (2020). Comparison between hand and sonic/ultrasonic instruments for periodontal treatment: Systematic review with meta-analysis. Journal of International Academy of Periodontology, 22(4), 187–204. 44. National Institutes of Health. (2000). Section 2—Definitions and description of nonthermal mechanisms. Journal of Ultrasound in Medicine, 19(2), 77–168. 45. National Institutes of Health. (2021). Pacemakers. https:// www.nhlbi.nih.gov/health-topics/pacemakers 46. Ng, K., & Liu, Y. (2002). Therapeutic ultrasound: Its application in drug delivery. Medicinal Research Reviews, 22(2), 204–223. 47. Novak, K. F., Govindaswami, M., Ebersole, J. L., Schadan, W., House, N., & Novak, M. J. (2008). Effects of low-energy shock waves on oral bacteria. Journal of Dental Research, 87(10), 928–931. 48. Ntovas, P., Doukoudakis, S., Tzoutzas, J., & Lagouvardos, P. (2017). Evidence provided for the use of oscillating instruments in restorative dentistry: A systematic review. European Journal of Dentistry, 11(2), 268–273. https://doi .org/10.4103/ejd.ejd_232_16 49. Oda, S., & Ishikawa, I. (1989). In vitro effectiveness of a newly-designed ultrasonic scaler tip for furcation areas. Journal of Periodontology, 60(11), 634–639. 50. O’Daly, B., Gavin, G., O’Bryne, J., & McGuinness, G. (2008). High-power low-frequency ultrasound: A review of tissue dissection and ablation in medicine and surgery. Journal of Materials Technology, 200(1–3), 38–58. 51. Oosterwaal , P. J. M., Matee, M. I., Mikx, F. H. M, Van’t Hof, M. A., & Renggli, H. H. (1987). The effect of subgingival debridement with hand and ultrasonic instruments on the subgingival microflora. Journal of Clinical Periodontology, 14, 528–533. 52. Patini, R., Gallenzi, P., Lione, R., Cozza, P., & Cordaro, M. (2019). Ultrasonographic evaluation of the effects of orthodontic or functional orthopaedic treatment on masseter muscles: A systematic review and meta-analysis. Medicina, 55(256), 3–15. https://doi.org/10.3390/medicina55060256 53. Pecheva, E., Sammons, R. L., & Walmsley, A. D. (2016). The performance characteristics of a piezoelectric ultrasonic dental scaler. Medical Engineering and Physics, 38, 199–203.

References 54. Pitt, W. G., Husseini, G., & Staples, B. J. (2004). Ultrasonic drug delivery—a general review. Expert Opinion on Drug Delivery, 1(1), 37–56. 55. Ritz, L., Hefti, A. F., & Rateitschak, K. H. (1991). An in vitro investigation on the loss of root substance in scaling with various instruments. Journal of Clinical Periodontology, 18(9), 643–647. https://doi.org/10.1111/j.1600-051x.1991. tb00104.x 56. Santos, F. A., Pohapski, M. T., Leal, P. C., Gimenes-Sakima, P. P., & Marcantonio, E. (2008). Comparative study on the effect of ultrasonic instruments on the root surface in vivo. Clinical Oral Investigation, 12, 143–150. https://doi.org/10.1007 /s00784-007-0167-3 57. Schoenfield, L. J., Berci, G., Carnovale, R. L., Casarella, W., Caslowitz, P., Chumley, D., Davis, R. C., Gillenwater,  J.  Y., Johnson, C., Jones, S., Jordan, L. G., Kafonek, D. R., Laufer, I., Lillemoe, K. D., Lu, S., Maglinte, D., Maher, J. W., Malet, P. F., Malt, R. A., . . . Torres, W. E. (1990). The effect of ursodiol on the efficacy and safety of extracorporeal shock-wave lithotripsy of gallstones. New England Journal of Medicine, 323(18), 1239–1245. 58. Singh, S., Uppoor, A., & Nayak, D. (2012). A comparative evaluation of the efficacy of manual, magnetostrictive and piezoelectric ultrasonic instruments—an in vitro profilometric and SEM study. Journal of Applied Oral Science, 20(1), 21–26. 59. Spratt, H., Levine, D., & Tillamn, L. (2014). Physical therapy clinic therapeutic ultrasound equipment as a source for bacterial contamination. Physiotherapy Theory and Practice, 30(7), 507– 511. https://doi.org/10.3109/09593985.2014.900836 60. Stricker, L., Dollet, B., Rivas, D. F., & Lohse, D. (2013). Interacting bubble clouds and their sonochemical production. Journal of the Acoustical Society of America, 1854–1862. https:// doi.org/10.1121/1.4816412 61. Thilo, B. E., & Baehni, P. C. (1987). Effect of ultrasonic instrumentation on dental plaque microflora in vitro. Journal of Periodontal Research, 22, 518–521. 62. Tunkel, J., Heinecke, A., & Flemming, T. F. (2002). A  systematic review of efficacy of machine-driven and

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CHAPTER 8

Clinical Perspectives of Tooth Anatomy LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Explain the histological differences in dental hard tissues and relate this to conservative and safe instrumentation. 2. Identify the ultrasonic insert or tip that should be selected for use on complex and noncomplex root anatomy. 3. Identify the presence of root concavities, convexities, and furcations on anterior and posterior teeth. 4. Identify the average position of a furcation on the root trunk of bifurcated and trifurcated teeth. 5. Utilize periodontal probing, exploration, and radiographs for the assessment of a furcation defect as well as its anatomy, topography, position on the root trunk, and entrance width. 6. Recognize two-dimensional radiographic limitations in the identification of a furcation defect. 7. Describe the advantages of a curved thin diameter ultrasonic shank in the debridement of a furcation defect as compared to a hand-activated instrument.

KEY TERMS

tooth root with two roots. • Bifurcation: junction (CEJ): junction between • Cementoenamel the cementum and dentin that is not visible in health and is visible in the presence of bone loss, recession, or previous crown lengthening. Confounding variable: an extraneous variable not accounted or controlled for in a study design that affects results.

•

variable: a factor in a research design • Extraneous that influences a change in study results. anatomical division between tooth • Furcation: roots present on multi-rooted teeth. defect: pathological condition where the • Furcation furcation is no longer filled in with alveolar bone. Also referred to as furcation involvement.

involvement: see furcation defect. • Furcation Index: furcation index with four grades • Glickman that report on furcation defect severity and extent. the study of the parts of an organism • Morphology: and the relationships between structures. concavity: linear concave indentation in • Root cementum. Also referred to as a root depression or groove.

convexity: a curved bulge in cementum. • Root depression: see root concavity. • Root Root see root concavity. • Root groove: trunk: area on a tooth root from the CEJ to • entrance of the furcation. root: the area on a tooth root that is covered • Tooth by cementum from the CEJ to the root apex. • Trifurcation: tooth root with three roots.

Introduction The goal of periodontal instrumentation is to remove oral deposits and diseased structures while conserving healthy tooth structures. Hard tissues of teeth differ in their mineralized content. Cementum is the least mineralized and enamel is the most mineralized hard tissue. Over-instrumentation of cementum will cause injury and removal, which adversely affects the periodontium's health. This chapter will discuss hard 131

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tissue composition and provide research-based evidence that ultrasonic instrumentation causes less alterations and removal of cementum than hand-activated instrumentation. Root anatomy and topography is complex with concavities, convexities, and furcations. A strong working knowledge of root anatomy is needed to prevent cemental injury during instrumentation. Debriding complex root anatomy subgingivally poses a significant challenge for the oral health-care provider because they cannot visually see these structures. They must rely on their root anatomy knowledge and assessments such as periodontal charting, explorer evaluation, and radiographs to assist them in safe instrumentation. This chapter will strengthen your knowledge of complex root anatomy so you can perform safe ultrasonic instrumentation.

Instrumentation Considerations

Enamel has the greatest percentage of calcified content, and cementum has the least. This means cementum is more prone to injury during periodontal instrumentation than enamel due its lower mineralized content. The goal of instrumentation with hand-activated or ultrasonic instruments is to remove disease contributors without scratching, gouging, altering, removing, or injuring healthy structures. BREAKOUT POINT Cementum is more prone to injury during periodontal instrumentation than enamel.

Instrument Selection

The oral health-care provider selects which instrument to use for oral deposit removal based on the following criteria:

• Tooth tissue histology: Dentin and cementum are

A tooth is made of multiple hard tissues that vary in their histology, anatomy, and topography. These differences influence periodontal instrumentation technique and instrument selection by the oral health-care provider. The goal of periodontal debridement is to remove oral deposits and diseased structures while preserving healthy structures.

•

Hard Tissue Histology

During periodontal instrumentation, the oral healthcare provider is routinely debriding oral deposits from enamel, dentin, and cementum both supragingivally and subgingivally. Histologically enamel, dentin, and cementum vary in their mineral, protein, and water content. See Table 8-1. It is important for the provider to recognize these histological differences so the best instrument can be selected for safe oral deposit removal.

Table 8-1  Hard Tissue Content Enamel

Dentin

Cementum

Percentage calcified (mineralized) tissue

96%*

70%*

45–50%*

Percentage proteins and water

4%*

30%*

50%*

*These percentage values represent an average and are not an absolute. Nedoklan et al. (2021), Sheldahl & Yapp (2020)

•

•

less mineralized than enamel. The instruments and technique used on enamel are not the same for dentin and cementum as they are more prone to injury. Tooth anatomy and topography: Teeth vary in their anatomy and topography. Instruments are specially designed to adapt to these differences. For example, multi-rooted teeth have furcations and deeper concavities, and the hand-activated instruments designed for this anatomy have longer, more complex shanks. The ultrasonic shank designed for this root anatomy is a thin diameter curved shape. Oral deposit characteristics: Oral deposits can be lightly adherent or tenaciously attached to the crowns and roots of teeth. Deposits vary in thickness (light, moderate, heavy). Hand-activated and ultrasonic instruments with thicker diameters are designed for heavier deposits while thinner diameters are designed for lighter deposits. Tissue consistency: Tissue consistency varies from patient to patient. Tissues can be firm, hard, avascularized, and tightly adherent to tooth roots or soft, spongy, swollen, and movable. Wide diameter instruments are unable to access subgingival areas with tightly adherent tissues.

BREAKOUT POINT Tooth tissue histology, anatomy, topography, oral deposit type and level, and tissue consistency all influence which instrument the provider chooses to use for oral deposit removal.

Instrumentation Considerations

Instrumentation of Cementum

Careful consideration for instrument selection must be exercised when debriding cementum. Unintentional cementum removal through incorrect instrument selection or technique can cause permanent root topography change and contributes to disease processes (Tunkel et al., 2002). Cementum has a regulatory and reattachment role in periodontal disease management. Chronic over-instrumentation leads to damage that compromises tooth survival (Tunkel et al., 2002). Diseased cementum loses its biocompatibility with gingival fibers through hypermineralization and degeneration of collagen matrix (Khosravi et al., 2004). These pathogenic changes occur in the outer superficial layers of the cementum, so the removal of multiple outer or any inner layer of cementum is not necessary during debridement to promote periodontal health (Tunkel et al., 2002). While a toxin-free cemental surface will allow for proper fibroblast adhesion and epithelial binding to the tooth root, over-instrumentation has a negative and adverse effect (Khosravi et al., 2004). There is an extensive body of literature, spanning multiple decades, evaluating root alterations during hand-activated and ultrasonic instrumentation. Drawing definitive conclusions and making meaningful comparisons from studies is a challenge due to many factors, such as:

• Study

•

design end points: Studies vary in their designs and end points. Some end points are the total elimination of dental calculus deposits while others are the root alterations based on a specific number, pressure, and length of strokes applied to cementum by the researcher. Controlling for variables: Controlling for extraneous variables (factors that influence change in study results) and confounding variables (extraneous variables not accounted or controlled for in a study design that affect results) is difficult in clinical instrumentation studies. Some common examples of these variables in root alteration studies include: • Clinical technique: Variations exist between examiners in their adaptation, angulation, and orientation of instruments. Applied stroke forces and lateral pressure are impossible to calibrate between examiners. • Amount and extent of oral deposits in the study. • Model of ultrasonic device or hand instrument used is not always reported.

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• Ultrasonic power settings and water flow rates are not the same between manufacturers and are not always reported. • Insert and tip displacement amplitude, diameter, and shank design vary between manufacturers and are not always reported. • Instrument contact time is not always reported or accounted for. Regardless of varied study designs and confounding and extraneous variables, decades of studies have reported two constant outcomes when comparing hand-activated to ultrasonic instrumentation of cemental root surfaces: 1. Ultrasonic instrumentation of the cemental surface produces on average 50% less removal, alteration, and injury than hand-activated instrumentation during oral deposit removal (Drisko et al., 2000; Kawashima et al., 2006; Kumar et al., 2015; Maritato et al., 2018; Mittal et al., 2014; Ritz et al., 1991; Santos et al., 2008; Singh et al., 2012). 2. Hand and ultrasonic instrumentation will both remove oral deposits and diseased cementum, but hand-activated instruments produce a more glassy-smooth cemental finish (Drisko et al., 2000; Kawashima et al., 2006; Kumar et al., 2015; Maritato et al., 2018; Mittal et al., 2014; Ritz et  al., 1991; Santos et al., 2008; Singh et al., 2012). If you recall from Chapter 7, glassysmooth cemental surfaces are not a desirable outcome of instrumentation.

BREAKOUT POINT Ultrasonic instrumentation produces, on average, 50% less alteration to cemental surfaces than hand-activated instrumentation.

Ultrasonic instrumentation matches the goal of periodontal debridement in removing oral deposits, decontaminating periodontal pockets, and removing diseased cementum while conserving healthy cementum with the use of:

• Thin and ultra-thin shank diameters that can ac•

cess subgingival spaces with minimal to no tissue distension. Thin, curved ultrasonic shanks adapt to complex root anatomy and debride root concavities and furcations with less alteration to the cementum (Drisko et al., 2000; Dragoo, 1992).

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Chapter 8 Clinical Perspectives of Tooth Anatomy

Complex Root Anatomy

to instrument in and around extremely complex and variable root anatomy.

A strong working knowledge of tooth root anatomy is needed to safely debride and detoxify structures without damaging cementum. When alveolar bone loss occurs due to disease processes, the provider is forced

Root Nomenclature

Common root nomenclature is listed in Table 8-2.

Table 8-2  Root Nomenclature Cementoenamel junction (CEJ)

Junction between cementum and enamel. In health the CEJ is not visible. In the presence of bone loss, recession, or previous crown lengthening, the CEJ is visible.

Tooth root

Area on a tooth root that is covered by cementum from the CEJ to the root apex.

Root trunk

Area on a tooth root from the CEJ to the entrance of the furcation.

Root concavity

A linear, concave indentation in cementum. Also referred to as a root depression or groove.

Complex Root Anatomy

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Root convexity

A curved bulge in cementum.

Furcation

Anatomical division between tooth roots present on multi-rooted teeth.

Bifurcation

Tooth root with two roots.

Trifurcation

Tooth root with three roots.

Furcation defect

A pathological condition where the furcation is no longer filled in with alveolar bone. Also referred to as furcation involvement.

Root Concavity and Convexity

Root concavities and convexities are a part of normal root anatomy that are routinely debrided. In the presence of alveolar bone loss, additional concavities and convexities must be debrided, which can pose a challenge for safe instrument adaptation. A thin, curved ultrasonic shank will safely debride root concavities

and convexities. Its thin diameter shank allows subgingival access with minimal to no tissue distension, and the curved shape will adapt to complex root anatomy with ease. A straight shank is not designed to conform to concave and convex anatomy and will either damage the cementum or leave behind deposits (Tunkel et al., 2002; Oda & Ishikawa, 1989; see Figure 8-1).

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Chapter 8 Clinical Perspectives of Tooth Anatomy

A

B

C

D

Figure 8-1  Straight and curved shanks: A. Straight thin diameter shank. Notice the gap

in adaptation of the active area antinode on the mesial root. B. Curved thin diameter shank. Notice the complete adaptation of the active area antinode on the mesial root anatomy. C. Straight thin diameter shank. Notice the gap in adaptation of the active area antinode on the distal root. D. Curved thin diameter shank. Notice the complete adaptation of the active area antinode on the distal root anatomy.

BREAKOUT POINT A thin, curved ultrasonic shank is used to debride a root concavity and convexity because it will adapt correctly and safely to complex root anatomy.

The most common root concavities and convexities on anterior teeth are listed in Table 8-3. Premolar teeth are in Table 8-4, and molar teeth are in Table 8-5. These tables show areas where the use of a thin, curved shank is useful for debridement.

Complex Root Anatomy

Table 8-3  Root Concavities and Convexities—Anterior Teeth Facial

Lingual

Mesial

Distal

Maxillary central incisor

Convex

Convex

Shallow concavity but cannot be felt until bone loss is in the middle third of the root.

Convex

Maxillary lateral incisor

Convex

Not common, but can have accessory groove from lingual fossa onto the root surface.

Inconsistent root concavity presence.

Convex

Mandibular central and lateral incisors All canines

Convex

Convex

Concavity

Concavity deeper than mesial.

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Chapter 8 Clinical Perspectives of Tooth Anatomy

Table 8-4  Root Concavities and Convexities—Premolar Teeth Facial

Lingual

Mesial

Convex

Convex

Deep mesial root concavity Concavity that begins on the crown and extends past the CEJ onto the root. Deeper than distal.

Maxillary second Convex premolars

Convex

Concavity, but cannot be felt until bone loss is in the middle third of the root.

Concavity, but cannot be felt until bone loss is in the middle third of the root. Deeper than mesial.

Mandibular first and second premolar

Convex

First premolar: Shallow concavity but cannot be felt until bone loss is in the middle third of the root. Second premolar: no concavity.

Concavity, but cannot be felt until bone loss is in the middle third of the root. Deeper than mesial.

Maxillary first premolar *Bifurcated root

Convex

Distal

Table 8-5  Root Concavities and Convexities—Molar Teeth Maxillary first and second molar *Trifurcated root

Facial

Lingual

Mesial

Distal

Concavity between mesiobuccal and distobuccal root.

Maxillary first lingual root convex shaped like a banana and may have longitudinal depression on straight lingual.

Convex MB root.

Concavity from CEJ to entrance of furcation.

DB

MB

L

MB L L

MB root: concavity mesial and distal surfaces.

DB

Second molar lingual root straighter.

MB L

DB

Complex Root Anatomy

Facial

139

Lingual

Mesial

Distal

Concavity between mesial and distal roots.

Deep concavity mesial surface of mesial root and even deeper concavity on distal surface of mesial root.

Concavity mesial surface distal root and inconsistent concavity distal surface distal root.

DB root: mesial concavity and convex distal.

DB

Mandibular first and second molar. *Bifurcated root

MB

Concavity between mesial and distal roots.

D

M

Third molars are left out of the table due to a vast number of anatomic variations such as (Scheid & Weiss, 2017): ■ Maxillary third molars are usually trifurcated and mandibular molars may have one or more extra roots than first and second mandibular molars. ■ Roots of third molars are shorter and frequently fused together. ■ Root trunks are longer and furcation is located in the apical third of the root.

Furcation

A furcation is the anatomical division between tooth roots that is only present on multi-rooted teeth. In health, the alveolar bone fills in the furcation area. A furcation defect, also known as furcation involvement, is a pathological condition where furcation is no longer filled in with alveolar bone. The provider will debride a furcation defect at each preventive appointment. Instrument selection and knowledge of furcation anatomy is imperative to safely and fully debride a defect.

Furcation Anatomy There are great variations in root trunk length, furcation width, and position of the furcation entrance.

Knowledge of the furcation position on a root trunk will guide the provider in instrument selection and instrumentation technique. In general, mandibular teeth have less variation than maxillary teeth. Table 8-6 provides a summary of multi-rooted teeth and their average root trunk length. Keep in mind, the root trunk length provided is an average, and patients may present with longer or shorter root trunks.

BREAKOUT POINT Knowledge of the position of a furcation entrance on the root trunk will guide the provider in instrument selection and debridement technique.

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Chapter 8 Clinical Perspectives of Tooth Anatomy

Table 8-6  Multi-Rooted Teeth and Furcations Tooth Maxillary first premolar

Number of Roots

Furcation Entrance and Detection (15)

Root Trunk Length (Distance from CEJ–Entrance of Furcation)*

Bifurcated: Buccal root Lingual root

Mid-mesial Mid-distal

7.5 mm*

Photo demonstrates the variability in root trunk length. Maxillary molars

Trifurcated Lingual root Mesiobuccal Distobuccal

Mid-buccal Mesiolingual Distolingual

Buccal 5 4 mm* 1st molar mesial 5 4.5 mm* 2nd molar mesial 5 5.5 mm* 1st molar distal 5 4.5 mm* 2nd molar distal 5 4 mm*

Photo demonstrates the variability in root trunk length. Mandibular molars

Bifurcated Mesial root Distal root

Mid-buccal Mid-lingual

1st molar buccal 5 3.0–3.5 mm* 1st molar lingual 5 5.5 mm* 2nd molar buccal 5 4 mm* 2nd molar lingual 5 3.5–4.0 mm*

Photo demonstrates the variability in root trunk length. * Ranges vary 1–9 mm for each tooth, and this number represents an average. Dababneh et al. (2011); Kadovic et al. (2017); Kerns et al. (1999)

Furcation Assessment Before debriding a furcation with a thin, curved ultrasonic shank, the oral health-care provider will perform three assessments to determine the degree of furcation defect, length of root trunk, and root topography: periodontal charting, explorative evaluation, and radiographic evaluation. Periodontal Charting. During periodontal charting, a curved periodontal probe is used to identify a furcation defect depth and aids in classification

(see  Figure 8-2). Knowledge of the probing depth and classification provides valuable information that is useful for instrumentation. There are over a dozen classification systems for detecting and recording furcation involvement on a periodontal chart. The first, and most widely used, was released in 1953 by Glickman (termed Glickman Index) and divides furcation involvement into four grades (denoted I–IV) based on furcation defect severity and extent (Glickman, 1972; Pilloni & Rojas, 2018). Many other classification systems have been released since Glickman’s that add more anatomic detail

Complex Root Anatomy

• Morphology of existing bone. Morphology is a

BREAKOUT POINT A curved periodontal probe will identify the depth and classification of a furcation defect to assist the provider in instrument selection and debridement technique.

to provide guidance on treatment recommendations and long-term prognosis. For example, some systems identify:

• Bone loss between varying surfaces on a tooth •

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(facial, lingual, proximal). Number of remaining boney walls.

• •

term that describes the study of the parts of an organism and the relationships between structures. Root trunk length variations. Length is then related to bone loss patterns (horizontal versus vertical). Radiographic evidence of furcation lesions.

Exploration Evaluation. The dental explorer is used to assess the anatomy and topography of a furcation. The explorer will identify the furcation entrance position on the root trunk, width of the entrance, presence of a concavity and convexity, and presence or absence of oral deposits. There is wide variability in furcation anatomy, topography, entrance widths, and length of root trunk. Furcation entrance widths can be as narrow as under a millimeter or well over (see Figure 8-3). BREAKOUT POINT An explorer will identify the anatomy, topography, entrance width, and presence of oral deposits of a furcation defect to aid the provider in debridement technique.

Figure 8-2  Furcation Probe (P2N6 Naber’s Probe by

HuFriedyGroup)

Courtesy of HuFriedyGroup Mfg. Co., LLC

Radiographic Evaluation. A dental radiograph will reveal important anatomy that is useful during instrumentation (see Figure 8-4). Not all furcation defects will appear on a two-dimensional image because facial and lingual structures are superimposed on one another (see Figure 8-5a and b). Cone-beam computer tomography (CBCT) provides a three-dimensional view of a tooth with more tooth anatomy detail and alveolar bone positioning (see Figure 8-6).

Length root trunk

4 mm

7 mm

2 mm

6 mm

3 mm

Width furca entrance

Under 1 mm

Under 1 mm

Under 1 mm

1 mm

4 mm

Figure 8-3  Furcation width and root trunk.

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Chapter 8 Clinical Perspectives of Tooth Anatomy

A

Figure 8-4  Radiograph furcation appearance.

Mandibular left first molar shows a radiolucent lesion in the furcation entrance with loss of lamina dura.

Furcation Debridement Once all furcation assessments are complete, the next step is instrument selection and debridement. Debriding a furcation defect is challenging because of the variable anatomy, position, and topography. The goal of periodontal instrumentation is to ensure the furcation defect is debrided without altering cementum to prevent further alveolar bone and attachment loss. A furcation may be clinically visible in the presence of gingival recession (see Figure 8-7a) or hidden under the gums (see Figure 8-7b). In the 1940s, prior to the advent of dental ultrasonic technology, hand-activated area-specific curettes were developed. The single cutting edge with a toe blade on a more complex and longer shank allowed for better adaptation into deeper periodontal pockets on the tooth root while protecting the gingiva from injury. However, when it came to furcation debridement, the blade was too thick to access narrow furcation entrance widths (see Figure 8-8a). The solution to this instrument challenge came with the development of thin, curved ultrasonic shanks whose width is only 0.5 mm, allowing them to access even the narrowest of furcation entrances (see Figure 8-8b).

B Figure 8-5  Maxillary molar furcation case: A. Maxillary

right first molar has a through-and-through furcation defect from the buccal. The curved furcation probe was able to strike the palatal root when inserted from the buccal midline. The radiograph is underreporting the furcation severity due to the superimposition of the palatal root on the two-dimensional digital image. However, the image still shows anatomy that is helpful for the provider such as root trunk length and alveolar bone position. B. Maxillary right first molar shows a significant vertical bone defect on the mesial of the tooth and horizontal bone loss on the distal (see red lines). This two-dimensional digital image does not show the direct mesial or distal of the tooth, making accurate radiographic furcation assessment challenging. The blue arrows are pointing to the furcation entrances on the proximal surface.

BREAKOUT POINT A thin, curved ultrasonic insert or tip allows access to narrow furcation entrances during debridement.

Complex Root Anatomy

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Figure 8-6  CBCT.

A

A

B Figure 8-7  Furcation: A. Furcation entrance visible on

mandibular left first molar, B. Furcation entrance not visible on maxillary right first molar intraoral camera photo. Radiograph reveals vertical bone loss on mesial. This tooth has furcation involvement straight buccal and mesial.

B Figure 8-8  Furcation entrance: A. Hand-activated

area-specific posterior Gracey curette: note the width of the blade does not allow access to the narrow furcation entrance, B. Ultrasonic curved thin insert: the narrow shank allows access to the narrow furcation entrance.

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Chapter 8 Clinical Perspectives of Tooth Anatomy

A

B

Figure 8-9  Straight and curved shank: A. Straight shank: Improper furcation adaptation of the active area antinode

that will lead to cementum damage. (Dentsply Sirona Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert), B. Curved shank: Proper furcation adaptation of the active area antinode that will not cause cemental damage (Dentsply Sirona Cavitron Slimline 10L 30K Ultrasonic Insert).

A straight ultrasonic shank is not designed to debride furcation anatomy and has been found to cause cemental damage (Tunkel et al., 2002; Oda & Ishikawa, 1989). As you will learn in later chapters, certain surfaces of the active area antinode on the shank have higher displacement amplitudes than others. These surfaces are more likely to damage

cementum. A straight shank will adapt these more active surfaces on a furcation defect, and a curved shank will not (see Figure 8-9). In summary, a thin, curved ultrasonic insert or tip is the instrument of choice for debriding furcation defects because of the following:

• Narrow diameter that allows for access to narrow •

BREAKOUT POINT A straight ultrasonic shank should not be used to debride furcation defects; a thin, curved shank should be used.

CASE STUDY 1

• •

furcation entrances (Drisko et al., 2000). Longer shank that allows for access to deeper periodontal pockets where furcation defects are found (Dragoo, 1992; Leon & Vogel, 1987). Detoxification ability through acoustic cavitation, acoustic microstreaming, and liquid jet production. Improved time efficiency of debridement (Tunkel et al., 2002).

You are working for a dental office that schedules two nonsurgical periodontal debridement procedures per day. The office has many hand-activated instrument choices such as sickle scalers, universal curettes, and area-specific curettes for anterior and posterior teeth. They also provide a magnetostrictive ultrasonic device in each operatory with a thick and thin straight insert. You are given 90 minutes to perform a half-mouth nonsurgical periodontal debridement on each patient. You find yourself struggling to finish in the time allotted and notice you are spending a lot of time hand-instrumenting posterior teeth furcations and interproximal root concavities. What are some solutions and educational points you should present to your employer to solve this dilemma?

Questions

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CASE STUDY 2

You are performing a periodontal debridement on the distal of the mandibular right first molar pictured here. Vertical bone loss is present, revealing a large distal root concavity that must be debrided.

What instrument would you select to debride this area and why? Why is it not safe to debride the distal root concavity with a straight thin ultrasonic shank?

Summary

Dental ultrasonic technology has revolutionized the treatment and management of periodontal disease through improved access to and complete debridement of complex root anatomy such as furcation defects, root concavities, and root convexities. Thin, curved ultrasonic shanks will allow for correct active area antinode adaptation in and around furcation defects and root concavities while conserving cementum.

Questions

1. Which of the following hard tissues has the highest percentage of mineralized structure? a. Enamel b. Dentin c. Cementum

Through the production of acoustic cavitation, acoustic microstreaming, and liquid jets, dental ultrasonic technology removes adherent pathogenic biofilm, and its direct-contact chipping action removes tenacious deposits in the subgingival environment. These actions promote a symbiotic oral environment and ward off disease processes.

2. Which of the following hard tissues is most prone to injury from periodontal instrumentation? a. Enamel b. Dentin c. Cementum

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Chapter 8 Clinical Perspectives of Tooth Anatomy

Match the following terms to their correct definitions for questions 3–7. There is one correct answer for each term. 3. Furcation 4. Root concavity

A. Tooth root with two roots. B. Linear concave indentation in the root. 5. Furcation defect C. A pathological condition where the furcation is no longer filled in with alveolar bone. 6. Bifurcation D. Area on a tooth root measured from the CEJ to the entrance of the furcation. 7. Root trunk E. Anatomical division between tooth roots. 8. True or False. Both hand-activated and ultrasonic instrumentation will remove oral deposits from cemental surfaces, but hand-activated instruments produce less gouging and removal of cementum than ultrasonic instrumentation. a. True b. False 9. Which periodontal instrument is the best selection for the removal of oral deposits in a narrow furcation? a. Thin, straight ultrasonic shank b. Thin, curved ultrasonic shank c. Area-specific curette d. Posterior sickle scaler 10. For which of the following would the use of a thin, curved ultrasonic shank be useful? a. Mesial root of maxillary first premolar b. Distal root of the mandibular canine c. Distal furcation involvement maxillary first molar d. All of the above Determine if the following have a root concavity or root convexity for questions 11–15. Answer A for root concavity and B for root convexity. There is only one correct answer for each question. 11. Buccal mandibular second premolar. 12. Distal mandibular central incisor. 13. Mesial mandibular first premolar with bone loss into the middle third.

14. Lingual root of maxillary first molar. 15. Mesial of mandibular first molar. 16. True or False. In health, alveolar bone fills in the furcation area. a. True b. False 17. True or False. There is one universal classification system for furcation involvement. a. True b. False 18. On average, how much bone loss must occur before a furcation defect can be detected on the maxillary first premolar? a. 7.5 mm b. 4.5 mm c. 3 mm d. 2 mm 19. On average, how much bone loss must occur before a furcation defect can be detected on the mesial of the maxillary first molar? a. 1 mm b. 2 mm c. 3 mm d. 4.5 mm 20. On average, how much bone loss must occur before a furcation defect can be detected on the buccal of the mandibular first molar? a. 1 mm b. 2 mm c. 3.0–3.5 mm d. The mandibular first molar does not have a furcation. 21. True or False. With alveolar bone loss, a furcation defect can occur and will always appear radiographically on a two-dimensional image. a. True b. False 22. Which of the following is an advantage of thin, curved ultrasonic shanks in furcation debridement? a. Narrow width b. Longer shank for reaching deeper pockets c. Detoxification and biofilm removal through acoustic cavitation, acoustic microstreaming, and liquid jet release d. All of the above

References

References

1. Dababneh, R., Samara, R., Abul-Ghanam, M. A., Obeidat, L., & Shudifat, N. (2011, March). Root trunk: Types and dimension and their influence on the diagnosis and treatment of periodontally involved first molars. Journal of the Royal Medical Services, 18(1), 45–51. 2. Dragoo, M. R. (1992). A clinical evaluation of hand and ultrasonic instruments in subgingival debridement, Part  1. With unmodified and modified ultrasonic inserts. International Journal of Periodontics & Restorative Dentistry, 12(4), 311–323. 3. Drisko, C. L., Cochran, D. L., Blieden, T., Bouwsma, O. J., Cohen, R. E., Damoulis, P., Fine, J. B., Greenstein, G., Hinrichs, J., Somermman, M. J., Iacono, V., & Genco, R. J. (2000). Position paper: Sonic and ultrasonic scalers in periodontics. Research, Science and Therapy Committee of the American Academy of Periodontology. Journal of Periodontology, 71(11), 1792–1801. https://doi.org/10.1902 /jop.2000.71.11.1792 4. Glickman, I.  (1972). Clinical periodontology: Prevention, diagnosis, and treatment of periodontal disease in the practice of general dentistry (4th ed., pp. 242–245). Saunders. 5. Kadovic, J., Novakovic, N., Jovanovic, M., Dordevic,  V., Petrovic, V., Stojcev-Stajcic, L., & Cakic, S. (2017). Anatomical characteristics of the furcation area and root surfaces of multi-rooted teeth: Epidemiological study. Military-Medical and Pharmaceutical Review, 76(00), 1–34. https://doi.org/10.2298/VSP170308149K 6. Kawashima, H., Sata, S., Kishida, M., & Ito, K. (2006). A comparison of root surface instrumentation using two piezoelectric ultrasonic scalers and a hand scaler in vivo. Journal of Periodontal Research, 42, 90–95. 7. Kerns, D., Greenwell, H., Wittwer, J., Drisko, C., Williams, J. N., & Kerns, L. L. (1999). Root trunk dimensions of 5 different tooth types. The International Journal of Periodontics & Restorative Dentistry, 19(1), 83–91. 8. Khosravi, M., Bahrami, Z. S., Atabaki, M. S. J., Shokrgozar,  M.  A., & Shokri, F. (2004). Comparative effectiveness of hand and ultrasonic instruments in root surface planing in vitro. Journal of Clinical Periodontology, 31, 160–165. 9. Kumar, P., Das, S. J., Sonowal, S. T., & Chawla, J. (2015). Comparison of root surface roughness produced by hand instruments and ultrasonic scalers: An invitro study. Journal of Clinical and Diagnostic Research, 9(11), ZC56–ZC60. https:// doi.org/10.7860/JCDR/2015/13744.6828 10. Leon, L. E., & Vogel, R. I. (1987). A comparison of the effectiveness of hand scaling and ultrasonic debridement in furcations as evaluated by differential dark-field microscopy. Journal of Periodontology, 58(2), 86–94.

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11. Maritato, M., Orazi, L., Laurito, D., Formisano, G., Serra, E. Lollobrigida, M., Molinari, A., & De Biase, A. (2018). Root surface alterations following manual and mechanical scaling: A comparative study. International Journal of Dental Hygiene, 16, 553–558. https://doi.org/10.1111/idh.12349 12. Mittal, A., Nichani, A. S., Venugopal, R., & Rajani, V. (2014). The effect of various ultrasonic and hand instruments on the root surfaces of human single rooted teeth: A planimetric and profilometric study. Journal of Indian Society of Periodontology, 18(6), 710–717. 13. Nedoklan, S., Knezovic, Z., Knezovic, N., & Sutlovic,  D. (2021). Nutrition and mineral content in human teeth through the centuries. Archives of Oral Biology, 124 (105075), 1–9. 14. Oda, S., & Ishikawa, I. (1989). In vitro effectiveness of a newly-designed ultrasonic scaler tip for furcation areas. Journal of Periodontology, 60(11), 634–639. 15. Pilloni, A., & Rojas, M. A. (2018). Furcation involvement classification: A comprehensive review and a new system proposal. Dentistry Journal, 6(3), 1–22. https://doi.org/10 .3390/dj6030034 16. Ritz, L., Hefti, A. F., & Rateitschak, K. H. (1991). An in vitro investigation on the loss of root substance in scaling with various instruments. Journal of Clinical Periodontology, 18(9), 643–647. https://doi.org/10.1111/j.1600-051x.1991 .tb00104.x 17. Santos, F. A., Pohapski, M. T., Leal, P. C., Gimenes-Sakima, P. P., & Marcantonio, E. (2008). Comparative study on the effect of ultrasonic instruments on the root surface in vivo. Clinical Oral Investigations, 12, 143–150. https://doi.org/10.1007/s00784 -007-0167-3 18. Scheid, R. C., & Weiss, G. (2017). Woelfel’s dental anatomy (9th ed.). Wolters Kluwer. 19. Sheldahl, L. C., & Yapp, R. A. (2020). Histology and embryology for the dental hygienist. Open Oregon Publishing. https:// openoregon.pressbooks.pub/histologyandembryology /chapter/chapter-4-histology-of-the-teeth-and-periodontal -tissue/#4teeth 20. Singh, S., Uppoor, A., & Nayak, D. (2012). A comparative evaluation of the efficacy of manual, magnetostrictive and piezoelectric ultrasonic instruments—an in vitro profilometric and SEM study. Journal of Applied Oral Science, 20(1), 21–26. 21. Tunkel, J., Heinecke, A., & Flemming, T. F. (2002). A systematic review of efficacy of machine-driven and manual subgingival debridement in the treatment of chronic periodontitis. Journal of Clinical Periodontology, 29(Suppl 3), 72–81.

CHAPTER 9

Grasp, Stabilization, and Positioning LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Grasp a magnetostrictive and piezoelectric ultrasonic handpiece correctly. 2. Identify the function of each finger of the dominant hand in an ultrasonic grasp. 3. Demonstrate intraoral and extraoral finger rests used for ultrasonic instrumentation. 4. Demonstrate operator chair positioning for posterior and anterior teeth during ultrasonic instrumentation. 5. Understand the use and positioning of the High volume evacuation (HVE) during ultrasonic instrumentation.

KEY TERMS

finger rest: extraoral stabilization • Cheek technique where the operator’s finger rest is on

the cheek while the ultrasonic shank is positioned inside the mouth on a tooth surface. Chin finger rest: extraoral stabilization technique where the operator’s finger rest is on the chin while the ultrasonic shank is positioned inside the mouth on a tooth surface. Cross-arch finger rest: intraoral stabilization technique where the operator’s finger rest is on the adjacent arch as the position of the ultrasonic shank on a tooth surface. Extraoral finger rest: stabilization technique where a finger rest of the operator’s dominant hand is outside the mouth during ultrasonic instrumentation. Finger rest: stabilization with the ring and pinkie fingers during ultrasonic instrumentation.

• •

the act of holding a dental device in a specific • Grasp: manner that promotes high-quality ergonomics. finger rest: a stabilization technique • Intraoral where the operator’s dominant hand is inside the mouth during ultrasonic instrumentation.

finger rest: intraoral stabilization • Opposite-arch technique where the operator’s finger rest is on

the same side of the mouth but opposite arch as the position of the ultrasonic shank on a tooth surface. Purevac HVE: a high-volume evacuation system manufactured by Dentsply Sirona. Purevac HVE Connector: a part of the Dentsply Sirona Purevac HVE system that connects the mirror tip to the HVE hose and rotates 360 degrees. Purevac HVE Hose: five-foot long hose that attaches to the HVE line on a dental unit that is part of the Dentsply Sirona Purevac HVE system. Purevac HVE Mirror Tip: an 8 mm bore hole HVE with affixed mirror that is part of the Dentsply Sirona Purevac HVE system. Same quadrant intraoral finger rest: intraoral stabilization technique where the operator’s finger rest is three or more teeth away in the same quadrant as the position of the ultrasonic shank on a tooth surface.

• •

• • •

•

Introduction

•

This is the first chapter in Section 3 that will teach ultrasonic instrumentation technique. Correct ultrasonic technique is taught as a series of building blocks as depicted in Figure 9-1. Chapter 9 covers 149

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Chapter 9 Grasp, Stabilization, and Positioning Pinkie

Grasp and stabilization

Ring

Middle

Index

Thumb

Operator and patient positioning Aerosol control Adaptation Angulation Orientation Activation

Figure 9-1  Ultrasonic Instrumentation Building Blocks

the green topics, Chapter 10 covers the blue, and Chapter 11 covers the orange. Chapter 12 puts all the building blocks together with chairside technique practice. This chapter will introduce the building blocks of grasp, finger rests, and operator and patient chair positioning required for proper ultrasonic instrumentation. Ultrasonic instrumentation utilizes a relaxed and light grasp with an intraoral or extraoral finger rest for stabilization. This differs from hand-activated instrumentation, which requires a tight, pinch-grip grasp on the instrument with a secure fulcrum for stabilization. A wrist rock with lateral pressure applied to the fingers and forearm is required to physically break the oral deposit bond from the tooth surface during hand-­ activated instrumentation. A dental ultrasonic shank will mechanically chip the oral deposit from the tooth for the oral health-care provider, allowing for a relaxed grasp with no lateral pressure to muscle groups. Small finger movements are used to position the active area antinode of the shank on tooth surfaces. Operator chair and patient positioning are fluid and flexible during ultrasonic instrumentation. The provider uses direct vision whenever possible because both hands are used simultaneously. The nondominant hand grasps the HVE, and the dominant hand grasps the ultrasonic handpiece. The HVE is used during ultrasonic instrumentation to control aerosols, remove fluid from the patient’s mouth, and retract oral structures for visibility. Direct vision is made possible through the use of bilateral chair positioning utilizing both the right and left sides of the patient chair regardless of the operator’s dominant hand. Intraoral and extraoral finger rests are used to accommodate direct vision, bilateral chair positioning, and a relaxed grasp.

Figure 9-2  Fingers for the ultrasonic grasp

Grasp The operator grasp refers to the hand and finger positioning around an instrument that promotes high-quality ergonomics. The oral health-care provider will grasp the ultrasonic handpiece in their dominant hand with a light and relaxed grasp.

• The thumb, index finger, and middle finger are

•

used to stabilize the handpiece in the grasp (see Figure 9-2—red circles). Their exact position on the handpiece is different for a magnetostrictive than a piezoelectric. The ring and pinkie finger are used as a finger rest (see Figure 9-2—blue circles). Finger rests are the same for magnetostrictive and piezoelectric ultrasonic instrumentation.

Magnetostrictive Grasp

A magnetostrictive ultrasonic is grasped with the thumb and index finger equidistant from one another on either side of the handpiece. The middle finger is advanced forward onto the colored grip of the insert. The handpiece itself lays in the webbing bet­ween the thumb and index finger (see Figure 9-3). The positioning of the handpiece in the webbing is important and should not be compromised as the oral healthcare provider is working. This grasp will promote optimal ergonomics by balancing the weight of the handpiece in the hand.

Grasp

151

Figure 9-3  Correct Magnetostrictive Handpiece Grasp

(Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert)

A

Reproduced with permission from Dentsply Sirona

BREAKOUT POINT In a magnetostrictive grasp, the thumb and first finger are on the handpiece and the middle finger is advanced onto the colored grip of the insert.

Hand and Finger Size Small palm size and short fingers (see Figure 9-4a):

• Thumb and index finger will grasp lower on the •

handpiece closer to the grip, but both fingers remain on the handpiece. Middle finger will be higher on the grip, farther away from the shank.

B Figure 9-4  Hand and finger size in magnetostrictive

grasp (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert): A. Small Hand and Short Fingers, B. Large Hand and Long Fingers Reproduced with permission from Dentsply Sirona

Large palm size and long fingers (see Figure 9-4b):

• Thumb and index finger will grasp higher on the •

handpiece, farther away from the grip than a provider with small palms and short fingers. Middle finger will be lower on the grip closer to the shank than a provider with short fingers.

Regardless of hand size, the middle finger should never be advanced forward within the terminal ½ inch of the grip (see Figure 9-5). This is to prevent excessive lateral pressure from being applied to the grasp and reduces the risk for shank breakage. Note: If using an insert that rotates, the magnetostrictive grasp may need to be modified to control the insert. The index finger or thumb may need to be advanced closer to or on the insert grip. If the finger position is modified, the oral health-care provider will need to ensure:

• The •

handpiece position stays in the webbing ­ etween the thumb and index finger. b Excessive lateral pressure is not applied to the ­fingers in the grasp.

Figure 9-5  Terminal 1/2 Inch of Insert Grip (Dentsply

Sirona Powerline 10 30K Ultrasonic Insert)

Piezoelectric Grasp

A piezoelectric is grasped with the thumb and index finger equidistant from one another on either side of the handpiece. The middle finger is touching and tucked behind the index finger. The handpiece lays in the webbing between the thumb and index finger to promote optimal ergonomics by balancing the weight of the handpiece in the hand (see Figure 9-6).

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Chapter 9 Grasp, Stabilization, and Positioning

Figure 9-6  Piezoelectric Handpiece Grasp

(Acteon Newtron Slim Handpiece and Tip 1) Reproduced with permission from ACTEON

A

BREAKOUT POINT In a piezoelectric grasp, the thumb and first finger contact the handpiece, and the middle finger is tucked behind the index finger.

Advanced Grasp

In an advanced ultrasonic grasp, the provider will move the handpiece from the webbing between the thumb and index finger to the second joint of the index finger (see Figure 9-7a and b). This grasp is useful in the following situations:

• Areas of the mouth that are challenging to see and • •

access, such as terminal molars. When using curved shank shapes. When the operator position is moved to their nondominant side of the patient chair.

This grasp is not an alternative to the primary ultrasonic grasp described previously. The palm of the hand and carpel tunnel are put under strain in an advanced grasp, so it is to be used as a last resort and temporarily. The provider should reestablish an ultrasonic grasp as soon as possible.

Light Grasp

The oral health-care provider uses a light, relaxed grasp with no lateral pressure applied to the fingers when the shank is loaded onto tooth surfaces during ultrasonic instrumentation. This is unlike hand-­ activated instrumentation where a firm, pinch-grip, engaged grasp with lateral pressure transmitted to the fingers is required to produce a productive scaling stroke. The difference in grasp is attributed to the functionality of the equipment.

B Figure 9-7  Advanced Handpiece Grasp:

A. Magnetostrictive advanced grasp (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece ad Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert), B. Piezoelectric advanced grasp (Acteon Newtron Slim Handpiece and Tip 1) A: Reproduced with permission from Dentsply Sirona; B: Reproduced with permission from ACTEON

The provider applies 0–10 g of lateral pressure in an ultrasonic grasp (Nagraj et al., 2020). The goal is to use as light a grasp as possible. When more than 10 g is used, increased pressure from the grasp will transmit to a loaded ultrasonic shank, which can lead to multiple adverse effects:

• Loss

of tactile sensitivity: Inability of the oral health-care provider to feel the tooth anatomy during ultrasonic instrumentation.

Stabilization

153

• Displacement amplitude of the shank will decrease. • •

•

This decreases the effectiveness and efficiency of oral deposit removal. Removal of oral deposits will take longer, increasing labor intensity and fatigue of the oral health-care provider. Increased risk for incomplete removal of oral deposits. This can lead to the incidental burnishing of dental calculus onto crown and root surfaces. Burnished calculus occurs when the outer portion of a dental calculus mass is removed and the inner layer is left behind on the tooth crown or root. This is not a desired clinical outcome. Equipment damage • An insert and tip will wear faster, causing the shank to lose length. This decreases the equipment’s life expectancy and efficiency. • The risk for shank breakage increases. Ultrasonic shanks are not designed for more than 10 g of lateral pressure and will break at their weakest structure, which is typically at one of the bends in the shank. If the breakage occurs during active ultrasonic instrumentation, the risk for an adverse patient event increases. The patient may aspirate or swallow the broken shank, which will require a medical referral. If the shank breaks subgingivally, the broken piece may become lodged in the tissue, requiring a retrieval procedure.

BREAKOUT POINT In an ultrasonic grasp, 0–10 g of lateral pressure is applied to a loaded ultrasonic shank.

Grasp Skill Building

You will need the following supplies: small kitchen scale, ultrasonic insert or tip, ultrasonic handpiece. Rationale: This exercise will provide a kinetic learning experience to practice lateral pressure. You will be able to evaluate and feel 0–10 g of lateral pressure transmitted to the insert or tip shank. Steps: 1. Place an insert or tip in the handpiece. 2. Place the kitchen scale on a flat surface. 3. Grasp the ultrasonic handpiece correctly. 4. Place the point of the insert or tip on the scale. 5. Apply lateral pressure until 10 g is reached (see Figure 9-8). 6. Repeat the exercise until 0–10 g of pressure is applied with each placement.

Figure 9-8  Lateral Pressure Skill Building (Dentsply

Sirona Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert) Reproduced with permission from Dentsply Sirona

Stabilization During ultrasonic instrumentation, a provider uses a finger rest to stabilize their hand and provide support for the shank active area antinode on tooth structures. The ring and pinkie fingers are used in a finger rest. Both fingers are relaxed. In a stable ultrasonic finger rest:

• The • •

• •

ring or pinkie finger may be used independently (Figure 9-9a) or together (Figure 9-9b). The ring and pinkie fingers do not have to touch one another (see Figure 9-9a). The ring finger can touch or not touch the middle finger (see Figure 9-10). A gapping between the middle and ring finger is useful to maintain proper grasp in many situations during ultrasonic instrumentation. Gapping the fingers can assist with maintaining the handpiece in the webbing between the thumb and index finger. The pad or side of the finger may be used in a finger rest (see Figure 9-11a and b). The ring and pinkie finger may be inside or outside the oral cavity.

Unlike hand-activated instrumentation, a stable and secure fulcrum with all fingers touching is not needed with ultrasonic instrumentation because the provider is not using lateral pressure, stroke force, or a wrist rock to manually break oral deposits from tooth surfaces (see Figure 9-12a and b).

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Chapter 9 Grasp, Stabilization, and Positioning

Figure 9-10  Finger rest gap Between Middle and Index

Finger (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert) Reproduced with permission from Dentsply Sirona

A

A

B Figure 9-9  Finger rest ring and Pinkie Fingers (Dentsply

Sirona Cavitron Steri-Mate Sterilizable, Detachable Handpiece and Cavitron Powerline 10 30K Ultrasonic Insert): A. Ring and Pinkie Finger Separated and Used Independently, B. Ring and Pinkie Finger Touching and Used Together A: Reproduced with permission from Dentsply Sirona

BREAKOUT POINT In an ultrasonic finger rest, the middle, ring, and pinkie fingers may separate.

B Figure 9-11  Finger Rest (Dentsply Sirona Cavitron Steri-

Mate 360 Handpiece and Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert): A. Side of Finger, B. Pad of Finger Reproduced with permission from Dentsply Sirona

Stabilization

155

A Figure 9-13  Intraoral same quadrant finger rest. The

shank is adapted to the mandibular right first molar and the finger rest is on the mandibular right lateral incisor. Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Slimline 10L Fitgrip 30K Ultrasonic Insert and Purevac HVE) Reproduced with permission from Dentsply Sirona

B Figure 9-12  Fulcrum and finger rest comparison:

A. Hand-activated Instrument Fulcrum (HuFriedyGroup SH6/7 Anterior Sickle Scaler), B. Ultrasonic Finger Rest (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert)

Intraoral Finger Rest

An intraoral finger rest is when the dominant hand finger rest is placed inside the mouth for ultrasonic instrumentation stabilization. There are three intraoral finger rest options: 1. Same quadrant finger rest: The finger rest is inside the mouth on the same quadrant as the shank active area antinode (see Figure 9-13). Due to the grasp used in ultrasonic instrumentation, the finger rest will be more than three teeth away from the position of the shank. This is unlike hand-activated instrumentation where the

fulcrum finger is one to three teeth away from the placement of the blade. 2. Cross-arch finger rest: The finger rest is inside the mouth on the adjacent arch as the shank active area antinode (see Figure 9-14). 3. Opposite-arch finger rest: The finger rest is inside the mouth on the same side of the mouth but opposite arch as the shank active area antinode (see Figure 9-15).

Extraoral Finger Rest

An extraoral finger rest is when the dominant hand finger rest is placed outside the mouth for ultrasonic instrumentation stabilization. The pads or side of the ring or pinkie finger can be used. Fingers can be split apart or together. There are two extraoral finger rests. 1. Cheek finger rest: Finger rest is on the outside of the mouth on the cheek as the shank active area antinode is adapted to tooth structures inside the mouth (see Figure 9-16).

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Chapter 9 Grasp, Stabilization, and Positioning

A

B

Figure 9-14  Intraoral Cross-Arch Finger Rest (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron

Powerline 10 Fitgrip 30K Ultrasonic Insert): A. Shank active area antinode is adapted to the maxillary right canine and the finger rest is on the maxillary left canine, B. Shank active area antinode is adapted to the mandibular left first premolar and the finger rest is on the mandibular right canine. Reproduced with permission from Dentsply Sirona

A

B

Figure 9-15  Intraoral Opposite-Arch Finger Rest (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron

Powerline 10 Fitgrip 30K Ultrasonic Insert): A. Shank active area antinode is adapted to the maxillary right first premolar and the finger rest is on the mandibular right lateral incisor, B. Shank active area antinode is adapted to the maxillary left second premolar and the finger rest is on the mandibular left canine. Reproduced with permission from Dentsply Sirona

Figure 9-16  Extraoral Cheek Finger Rest (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Thinsert

Fitgrip Ultrasonic Insert and Purevac HVE) Reproduced with permission from Dentsply Sirona

Operator and Patient Chair Positioning

Figure 9-17  Extraoral Chin Finger Rest (Dentsply

Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert and Purevac HVE) Reproduced with permission from Dentsply Sirona

Figure 9-18  Simultaneous use of dominant and non-

dominant hands during ultrasonic instrumentation (Dentsply Sirona Steri-Mate 360 Handpiece, Cavitron Thinsert Fitgrip 30K Ultrasonic Insert, Purevac HVE, Cavitron 300 Ultrasonic Scaling System) Reproduced with permission from Dentsply Sirona

2. Chin finger rest: Finger rest is on the outside of the mouth on the chin as the shank active area antinode is adapted to tooth structures inside the mouth (see Figure 9-17). BREAKOUT POINT An intraoral or extraoral finger rest is used during ultrasonic instrumentation.

Operator and Patient Chair Positioning Operator chair and patient positioning are fluid and flexible during ultrasonic instrumentation. Both hands are used simultaneously during active patient treatment. The dominant hand is grasping the ultrasonic handpiece and the nondominant hand is grasping the HVE (see Figure 9-18). The provider uses bilateral operator chair positioning, regardless of being dominant right- or left-handed, to use direct vision for all areas of the mouth. The only area where indirect vision is required is the maxillary anterior lingual surfaces and the maxillary posterior occlusal surfaces (see Figure 9-19).

Figure 9-19  Maxillary anterior lingual indirect vision

(Dentsply Sirona Cavitron Steri-Mate 360 Handpiece, Cavitron Thinsert Fitgrip 30K Ultrasonic Insert, and Purevac HVE) Reproduced with permission from Dentsply Sirona

BREAKOUT POINT Bilateral operator chair positioning is used during ultrasonic instrumentation.

157

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Chapter 9 Grasp, Stabilization, and Positioning

A

B

C

Figure 9-20  Patient Chair Positioning (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Powerline

10 Fitgrip 30K Ultrasonic Insert and Purevac HVE). A. Maxillary ultrasonic instrumentation: Patient is supine with chin slightly tilted upward. B. Mandibular ultrasonic instrumentation: Patient is semi-supine with chin slightly tilted downward. C. Mandibular ultrasonic instrumentation: Patient is in between supine and semi-supine with chin slightly downward.

Flexible bilateral operator chair positioning is an advantage of ultrasonic instrumentation made possible by the functionality of the equipment. The provider uses a finger rest, small finger motions, a light and relaxed grasp, and less than 10 g of lateral finger pressure as the active area antinode of the shank chips oral deposits from tooth surfaces. Unlike hand instrumentation where stringent chair positioning is required for safe instrumentation, ultrasonic instrumentation allows for multifunctional operator chair positioning. Patient positioning is also flexible during ultrasonic instrumentation to allow for direct vision and optimal ergonomics. Supine, semi-supine, upright, or any positioning in between may be utilized (see Figure 9-20a and b). For seated instrumentation:

• Maxillary •

arch: Patient positioning is typically supine, or in between supine and semi-supine, with the patient’s chin slightly tilted upward (see Figure 9-21). Mandibular arch: Patient positioning is either supine, in between supine and semi-supine, or semi-supine, with the patient’s chin slightly tilted downward (see Figure 9-22).

When direct vision is challenged in the seated position, changing to a stand-up operator positioning may resolve the issue (see Figure 9-23).

Figure 9-21  Maxillary Ultrasonic Instrumentation

Patient Chair Positioning (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert and Purevac HVE)

Operator and Patient Positioning Selection

The operator and patient positioning must not compromise ergonomics. If ergonomics becomes compromised, the operator has selected an incorrect chair

Operator and Patient Chair Positioning

159

will be different for each provider as human beings are built differently. Individual operator factors that influence appropriate chair positioning are:

• Height • Girth • Arm length • Leg length • Palm size • Finger length

Figure 9-22  Mandibular Ultrasonic Instrumentation

Patient Chair Positioning (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert and Purevac HVE)

For example, a taller individual with longer arms will position their operator chair farther away from the patient than a shorter individual. An individual with smaller palm size and finger length grasps the handpiece slightly different than an individual with a larger palm size and finger length. The difference in grasp influences the position of the finger rest. One individual may prefer an intraoral finger rest while another prefers extraoral while instrumenting the same tooth. Dental equipment also influences operator and patient chair positioning.

• Loupes and lighting. If the provider has a light

•

• Figure 9-23  Ultrasonic Instrumentation with Operator

Stand-Up Positioning (Dentsply Sirona Cavitron SteriMate 360 Handpiece and Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert and Purevac HVE)

position for ultrasonic instrumentation. The shoulder, torso, back, legs, and arms should be in neutral positioning. The handpiece grasp, HVE position, and shank placement on the tooth must be correct. Unique patient factors may influence chair positioning such as a limited opening, restricted airway, gag reflex, or Temporomandibular Disorder (TMD). There is no one correct operator chair position for each area of the mouth. The operator chair position

affixed to their loupes, they have more freedom in operator chair positioning. Using the overhead light attached to the dental unit restricts positioning. The provider must sit in a location where the dominant and nondominant hand positioning does not block the overhead light. Dental chair characteristics such as headrest position, height of dental chair, and maneuverability of the dental chair (ability to move the chair right and left). For example, if the dental chair will not raise high enough to perform stand-up operator positioning, this restricts the provider. If the patient headrest does not move, this will influence patient chair positioning and chin tilts. Dental operatory design. If the operatory design does not allow the provider passage from the left to the right side of the chair, direct vision in all areas of the mouth during ultrasonic instrumentation is not possible. In this situation, the use of an HVE with an affixed mirror is needed for indirect vision capability. If an HVE with affixed mirror is not available, the provider will be forced to switch to hand instrumentation to debride areas of the mouth where indirect vision is required. This will increase overall patient treatment time. The HVE is always used during ultrasonic instrumentation to reduce the quantity of aerosols and spatter droplets released into the environment. The provider may not switch to an LVE to accommodate for operatory design limitations because this contaminates the environment and reduces air quality.

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Chapter 9 Grasp, Stabilization, and Positioning

Aerosol Control

• If the HVE is positioned greater than 12 inches

An HVE is used during ultrasonic instrumentation and serves three functions: 1. Reduce aerosol and splatter droplet contamination of the dental environment. 2. Remove oral fluids from the patient’s mouth. 3. Retract oral structures to improve visibility.

•

HVE Positioning The HVE should be positioned 0.5–6.0 inches from the water port on the shank (see Figure 9-24). This distance allows for optimal aerosol removal and fluid control while allowing the water to produce its mechanisms of action.

away from the water port, excessive aerosol and spatter droplet contamination will enter the environment, and fluid will accumulate in the patient’s mouth (Nagraj et al., 2020; see Figure 9-24). If the HVE is too close to the active area antinode (< 0.5  inches), the water will be evacuated into the HVE before it has an opportunity to perform its fluid dynamic mechanisms of actions in the mouth, as learned in Chapter 6.

BREAKOUT POINT The HVE should be positioned 0.5–6.0 inches from the water port on the shank for optimal aerosol and fluid control.

HVE Grasp

A

The HVE is grasped differently depending on the device and the area of the mouth the provider is working. This textbook only presents an HVE that has the ability to remove 100 cubic feet of air per minute as this has been shown to reduce aerosol contamination over 90% (Nagraj et al., 2020; Avasth, 2018; Harrel & Molinari, 2004; Holloman et al., 2015). These devices typically have a large (8 mm) bore hole opening. Any device without a verified claim as an HVE is not presented. Manufacturers offer a variety of design options for an HVE. They can be short, long, angled, or affixed with a mirror (see Figure 9-25). They all attach to the HVE line of a dental unit. The Purevac HVE manufactured by Dentsply Sirona is a high-volume evacuation system that consists of:

• Mirror tip: Sterilizable 8 mm bore hole opening

• B Figure 9-24  HVE Position (Dentsply Sirona Cavitron

Steri-Mate 360 Handpiece and Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert) A. HVE 0.5-6 inches away from the water port on the shank B. HVE greater than 12 inches away from the water port on the shank B. Reproduced with permission from Dentsply Sirona

•

HVE evacuation device. The mirror tip has an affixed mirror that allows the provider to use indirect vision during ultrasonic instrumentation. The mirror tip is slightly angled (see Figure 9-26a and b). Connector: Connects the mirror tip to the HVE hose. The connector has a 360-degree swivel capability for provider ergonomics (see Figure 9-26c). Hose: A 5-foot long hose that attaches to the HVE line on the dental unit (see Figure 9-26c). The hose is 69% lighter weight than a standard HVE hose, which decreases strain on the provider’s  nondominant hand and improves ­ ergonomics.

Operator and Patient Chair Positioning

A

161

B

Figure 9-25  High-Volume Evacuation: A. Crosstex B. HVEsolo by Palmero

A

B

C

Figure 9-26  Dentsply Sirona Purevac System: A. Mirror tip, B. Mirror tip from the side. Notice the angulation. C. Hose

and 360-degree swivel connector with attached mirror tip Reproduced with permission from Dentsply Sirona

The Purevac HVE system emits less noise than a standard dental unit HVE. The HVE is grasped in a similar manner as the ultrasonic handpiece in a pen grasp with the mirror tip laying in the webbing between the thumb and index finger. The angulation of the mirror tip assists with this grasp. The provider can grasp lower or higher on the mirror tip depending on the clinical need (see Figure 9-27a and b). Ensure the fingers do not cover the port hole openings on the front of the mirror tip during use or the functionality may be decreased.

You can grasp a standard HVE in three ways: 1. Pen grasp: A pen grasp similar to an ultrasonic handpiece grasp. The HVE lays between the webbing of the thumb and index finger (see Figure 9-28a). This is the dominant grasp used for ultrasonic instrumentation because it decreases provider strain for improved ergonomics. 2. Alternate pen grasp. A variation of the pen grasp may be needed for various areas of the mouth depending on the weight of the HVE cord, HVE

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Chapter 9 Grasp, Stabilization, and Positioning

suction design, visibility, and patient positioning. The HVE is moved to the second joint of the index finger (see Figure 9-28b). This grasp should be used only when necessary. The provider should return to a pen grasp as soon as possible for optimal ergonomics.

A A

B

B Figure 9-27  Dentsply Sirona Purevac Grasp: A. Fingers

More Forward on Mirror Tip in Grasp, B. Fingers Farther Back on Mirror Tip in Grasp Reproduced with permission from Dentsply Sirona

C Figure 9-28  HVE Grasp: A. Pen Grasp, B. Alterante Pen

Grasp, C. Palm Grasp

Operator Chair Position by Area of the Mouth

3. Palm grasp. The thumb is collapsed on top of the index finger and the HVE is resting in the palm (see Figure 9-28c). This grasp may be needed for various posterior areas of the mouth when visibility is challenged and the HVE is needed for retraction. This grasp should be used only when necessary. The provider should return to a pen grasp as soon as possible for optimal ergonomics. The sequence of steps for selecting correct operator and patient chair positioning are as follows Grasp ultrasonic handpiece with the dominant hand

163

• Mandibular right buccal • Mandibular left lingual The operator chair position and patient head ­position is listed in Table 9-1. Surfaces Away. The posterior surfaces away for the  dominant right-handed provider are (see Figure 9-30):

• Maxillary right lingual • Maxillary left buccal • Mandibular right lingual • Mandibular left buccal The operator chair position and patient head ­position is listed in Table 9-2.

Grasp the HVE with the nondominant hand

Place the shank active area antinode on the tooth surface to be instrumented

Position HVE 0.5–6.0 inch from the water port

Select operator positioning for direct vision

Select patient chair positioning

Select an intraoral or extraoral finger rest

Begin instrumentation

Operator Chair Position by Area of the Mouth Posterior Teeth

Dominant Right-Handed

Surfaces Toward. The posterior surfaces toward for the dominant right-handed provider are (see Figure 9-29):

• Maxillary right buccal • Maxillary left lingual

Figure 9-29  Posterior Teeth Surface Toward Dominant

Right-Handed

Table 9-1  Posterior Teeth Surface Toward Dominant Right-Handed

Direct Vision Operator chair clock position

8–11 o’clock

Patient head

Turned away from the provider

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Chapter 9 Grasp, Stabilization, and Positioning

Figure 9-30  Posterior Teeth Surface Away Dominant

Right-Handed

Table 9-2  Posterior Teeth Surface Away Dominant Right-Handed

Direct Vision

Left-Handed

Indirect Vision

Operator chair 1–4 o’clock clock position

8–11 o’clock

Patient head

Turned toward the provider

Turned away from the provider

Figure 9-31  Posterior Teeth Surface Toward Dominant

Dominant Left-Handed

Surfaces Toward. The posterior surfaces t­oward for the dominant left-handed provider are (see Figure 9-31):

Table 9-3  Posterior Teeth Surface Toward Dominant Left-Handed

Direct Vision Operator chair clock position

1–4 o’clock

Patient head

Turned away from the provider

• Maxillary right lingual • Maxillary left buccal • Mandibular right lingual • Mandibular left buccal

• Mandibular right buccal • Mandibular left lingual

The operator chair position and patient head ­position is listed in Table 9-3.

Anterior Teeth

Surfaces Away. The posterior surfaces away for  the  dominant left-handed provider are (see Figure 9-32):

• Maxillary right buccal • Maxillary left lingual

The operator chair position and patient head ­position is listed in Table 9-4.

Dominant Right- and Left-Handed The maxillary and mandibular canines may require operator chair positioning for posterior teeth depending on the patient’s curve of Spee (exaggerated or excessive, narrow, or anatomically normal), opening, and chair position (supine, semi-supine, upright).

Comparison of Ultrasonic and Hand-Activated Instrumentation

165

A

Figure 9-32  Posterior Teeth Surface Awya Dominant

Left-Handed

Table 9-4  Posterior Teeth Surface Away Dominant Left-Handed

Direct Vision

Indirect Vision

Operator chair clock position

8–11 o’clock

1–4 o’clock

Patient head

Turned away from Turned toward the provider the provider

B Figure 9-33  Mandibular Anterior Surfaces Dominant

Right- and Left-Handed: A. Facial, B. Lingual

Table 9-5  Mandibular Arch Direct Vision

Mandibular Anterior Teeth. Dominant rightand left-handed providers will use 11-1 o’clock operator chair positioning with the patient chin down for facial and linugal surfaces (see Figure 9-33 and Table 9-5). Maxillary Anterior Teeth. Dominant right- and left-handed providers will use 11-1 o’clock operator chair positioning with the patient chin down for facial and linugal surfaces (see Figure 9-34). The maxillary lingual surfaces require indirect vision for instrumentation (see Table 9-6).

Operator chair clock position

11–1 o’clock

Patient head position

Chin down

Comparison of Ultrasonic and Hand-Activated Instrumentation Table 9-7

summarizes the differences between ultrasonic and hand-activated grasp, stabilization, and operator positioning.

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Chapter 9 Grasp, Stabilization, and Positioning

B

A

Figure 9-34  Maxillary Anterior Surfaces Dominant Right- and Left-Handed: A. Facial, B. Lingual

Table 9-6  Maxillary Arch Direct Vision

Indirect Vision

Operator chair clock position

11–1 o’clock

11–1 o’clock

Teeth surface

Facial

Lingual

Patient head position

Chin up

Chin up

Table 9-7  Hand-Activated Versus Ultrasonic Instrumentation Hand-Activated Instrumentation

Ultrasonic Instrumentation

Grasp

Tight, firm, pinch-grip. All fingers touching.

Light, relaxed. Fingers do not have to touch.

Lateral pressure

Strong lateral pressure utilized to manually break the bond between the oral deposit and tooth surface with a scrapping motion of the blade.

No lateral pressure utilized as the shank active area antinode mechanically chips the oral deposit from the tooth surface.

Stabilization

Stable and secure fulcrum. Intraoral fulcrum predominates. Advanced intraoral and extraoral fulcrums require provider to use finger motion instead of the ergonomically desired wrist-rock.

Relaxed finger rest intraoral and extraoral.

Aerosol and spatter droplet production

None.

Large volumes produced.

Operator positioning

Stringent operator chair positioning required for proper adaptation, angulation, and activation of instruments. Mastery of indirect vision, fulcrums, wrist rock, and grasp required to avoid fatigue and musculoskeletal injury.

Flexible bilateral operator chair positioning with direct vision predominately used.

Questions

167

CASE STUDY 1

Your first patient of the day requires a semi-supine position due to poorly controlled congestive heart failure. The patient has a strong gag reflex and limited opening. To accommodate these limitations for patient chair positioning, the oral health-care provider adjusts their ultrasonic instrumentation technique. For each adjustment, indicate whether this is a correct adjustment or an incorrect adjustment. Justify your answer. 1. The oral health-care provider uses stand-up operator positioning. 2. The oral health-care provider uses supine patient positioning regardless of the patient need because this is what they prefer. 3. The oral health-care provider uses semi-supine patient positioning but decides not to use the HVE so they can hold the instrument mirror with their nondominant hand for indirect vision. They tell the patient to hold the LVE themselves and place in their own mouth during ultrasonic instrumentation. 4. The oral health-care provider is dominant right-handed but uses the clock positions on the left side of the patient chair.

CASE STUDY 2

A dental hygienist is temping in a dental office for the first time. The dentist owns a piezoelectric ultrasonic. The hygienist has never used a piezoelectric device and grasps the handpiece the same way as a magnetostrictive. This feels awkward to the hygienist who applies over 10 grams of lateral pressure when in use. What consequences can occur due to the hygienist’s technique error?

Summary

During ultrasonic instrumentation, the oral healthcare provider grasps the handpiece lightly with no lateral pressure transmitted to the fingers. Bilateral operator chair positioning and flexible patient chair positioning is used with intraoral and extraoral finger rests made possible by the ultrasonic device

Questions

1. In an ultrasonic instrumentation grasp, what finger(s) are used for a finger rest? a. Index finger b. Middle finger c. Ring finger d. Pinkie finger e. Both C and D 2. In a magnetostrictive ultrasonic grasp, which finger is placed on the insert grip? a. Thumb b. Index finger c. Middle finger d. Ring finger

mechanically chipping away oral deposits through the vibratory elliptical motion of the insert and tip shank. Oral health-care providers have the freedom to choose their own individual positioning based on their body type as long as ergonomics are not compromised.

3. True or False. An oral health-care provider with a small palm size and short fingers will grasp a magnetostrictive handpiece the same as someone with a large palm size and long fingers. a. True b. False 4. Fill in the blank. Regardless of hand size, in a magnetostrictive grasp, the middle finger should never advance forward on the grip within the terminal ____ inch of the grip. a. ½ b. 1 c. 1½ d. 2

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Chapter 9 Grasp, Stabilization, and Positioning

5. In an ultrasonic grasp of a magnetostrictive or piezoelectric, which finger is on the handpiece? a. Index finger b. Middle finger c. Ring finger d. Pinkie finger

12. What is the ideal distance of the HVE from the water port on the shank? a. 1–2 mm b. 3–6 mm c. 0.5–6.0 inches d. 1–2 feet

6. What is the maximum lateral pressure that can be applied to the fingers in an ultrasonic grasp? a. 10 g b. 20 g c. 25 g d. 50 g

13. What is the maximum distance an HVE can be from the water port on the shank in order to control the number of aerosols that enter the environment? a. 15 inches b. 12 inches c. 10 inches d. 6 inches

7. Which of the following can occur when a provider uses excessive lateral pressure in an ultrasonic grasp? a. Removal of oral deposits takes longer. b. Incomplete removal of oral deposits. c. Insert or tip shank breakage. d. All of the above 8. True or False. In an ultrasonic instrumentation finger rest, all the fingers must be touching one another. a. True b. False 9. Which of the following finger rests can be used during ultrasonic instrumentation? a. Intraoral finger rest 1–2 teeth away from the insert or tip shank placement on a tooth b. Extraoral cheek rest c. Intraoral cross-arch d. Both B and C e. All of the above 10. Which of the following is a function of the HVE used during ultrasonic instrumentation? a. Reduce aerosol contamination of the dental environment. b. Remove oral fluids from the patient’s mouth. c. Retract the cheek and lip. d. All of the above. 11. True or False. If the dental operatory design does not allow the oral health-care provider to use bilateral operator chair positioning during ultrasonic instrumentation, it is acceptable to use the LVE instead of the HVE so an instrument mirror can be used for indirect vision. a. True b. False

14. True or False. There is one exact operator chair position for each area of the mouth during ultrasonic instrumentation. a. True b. False 15. A dominant right- and left-handed oral healthcare provider uses what clock position to perform ultrasonic instrumentation of the mandibular anterior central incisors? a. 8–11 o’clock b. 11–1 o’clock c. 1–4 o’clock d. 12 o’clock only 16. For a right-handed provider to perform ultrasonic instrumentation on the posterior teeth surfaces toward them, what clock positions should be used? a. 8–11 o’clock b. 11–1 o’clock c. 1–4 o’clock d. 12 o’clock only 17. For a left-handed provider to perform ultrasonic instrumentation on the posterior teeth surfaces toward them, what clock positions should be used? a. 8–11 o’clock b. 11–1 o’clock c. 1–4 o’clock d. 12 o’clock only

References

169

18. For a left-handed provider to perform ultrasonic instrumentation on the posterior teeth surfaces away from them, what clock positions are an option? a. 8–11 o’clock b. 11–1 o’clock c. 1–4 o’clock d. 12 o’clock only e. Both A and C

Match the following to either hand instrumentation or ultrasonic instrumentation for questions 20–27. Answer A for hand instrumentation and B for ultrasonic instrumentation. There is only one correct answer for each question.

19. For a right-handed provider to perform ultrasonic instrumentation on the posterior teeth surfaces away from them, what clock positions are an option? a. 8–11 o’clock b. 11–1 o’clock c. 1–4 o’clock d. 12 o’clock only e. Both A and C

22. Large volumes of aerosols and spatter droplets are created.

References

1. Avasth, A. (2018). High volume evacuator (HVE) in reducing aerosol—an exploration worth by clinicians. Journal of Dental Health Oral Disorders & Therapy¸ 9(3), 165–166. 2. Harrel, S., & Molinari, J. (2004). Aerosols and splatter in dentistry. Journal American Dental Association, 135, 429–437. 3. Holloman, J. L., Mauriello, S. M., Pimenta, L., & Arnold, R. R. (2015). Comparison of suction device with saliva ejector

20. Firm pinch grip with a stable and secure fulcrum. 21. Relaxed finger rest.

23. Wrist-rock movement of the instrument. 24. No lateral pressure in grasp. 25. Small finger motion to move the instrument.

for aerosol and spatter reduction during ultrasonic scaling. Journal American Dental Association, 146(1), 27–33. 4. Nagraj, K. S., Eachempati, P., Paisi, M., Nasser, M., Sivaramakrishnan, G., & Verbeek, J. H. (2020). Interventions to reduce contaminated aerosols produced during dental procedures for preventing infectious diseases: Review. Cochrane Database of Systematic Review, 10, Art No: CD013686. https://doi.org/10.1002/14651858.CD013686.pub.2

CHAPTER 10

Adaptation, Angulation, and Orientation LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Identify the four surfaces of an ultrasonic shank. 2. Compare and contrast the four surfaces of an ultrasonic shank to one another, identifying which surfaces have the highest displacement amplitude and which have the least. 3. Understand how to safely instrument tooth structures with the varying ultrasonic shank surfaces. 4. Correctly adapt the ultrasonic active area antinode to the crown and root surfaces. 5. Safely angle the shank active area antinode to the tooth surface in a 90-degree and 0- to 15-degree angulation. 6. Understand the clinical applications of the 90-degree and 0- to 15-degree angulation. 7. Adapt and angle the ultrasonic shank active area antinode in a vertical orientation. 8. Adapt and angle the ultrasonic shank active area antinode in a transverse orientation.

KEY TERMS

to 15-degree angulation: angulation of the • 0-shank active area antinode to the tooth surface

that is between 0- and 15-degrees that adapts the face, back, and lateral surfaces. 90-degree angulation: angulation of the shank active area antinode to the tooth surface at a 90-degree angle that adapts the point or just offset from the point. Adaptation: placement of an instrument against the surface of a tooth.

• •

degree of tilt an instrument has when • Angulation: adapted to the surface of a tooth. surface: the convex surface of a shank with • Back the third highest displacement amplitude. surface: the concave surface of a shank with • Face the second highest displacement amplitude. surface: the sides of a shank with the • Lateral lowest displacement amplitude. the position an instrument has in • Orientation: association with a structure. surface: the end of a shank with the highest • Point displacement amplitude. orientation: the active area antinode • Transverse of the shank is placed at a right angle to the long axis of the tooth.

orientation: the active area antinode of the • Vertical shank is placed vertical to the long axis of the tooth.

Introduction After learning the building blocks of grasp, finger rest, operator and patient chair positioning, and aerosol control in Chapter 9, the next steps to learn are shank adaptation, angulation, and orientation in this chapter (see Figure 10-1). Chapter 11 will add the last building block of activation. There are four surfaces of an ultrasonic shank: the point, face, back, and congruent lateral surfaces. The point and face have the highest displacement amplitude, making them the most active surfaces on the shank. Their adaptation onto dentin and cementum should be used with extreme caution as they could damage less mineralized hard tissues. 171

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Chapter 10 Adaptation, Angulation, and Orientation

Grasp and stabilization Operator and patient positioning Aerosol control Adaptation Angulation Orientation Activation

A

Figure 10-1  Ultrasonic instrumentation building blocks.

Two angulations are utilized for ultrasonic instrumentation. A 90-degree angulation is used less frequently than a 0- to 15-degree angulation; a 90-degree angulation is used for the debridement of heavy dental calculus and occlusal pits and fissures. A 0- to 15-degree angulation is used for the debridement of supragingival and subgingival tooth surfaces. Two orientations are used for ultrasonic instrumentation. An ultrasonic shank may be positioned in a vertical or transverse orientation. A vertical orientation is used for supragingival and subgingival debridement. A transverse orientation is used for debriding the interproximal spaces between teeth supragingivally. Transverse orientation is not used subgingivally. This chapter will provide instruction on the adaptation, angulations, and orientations used during ultrasonic instrumentation. These instrumentation techniques will prepare you for the next building block of instrumentation, which is activation.

B

Adaptation Adaptation refers to the placement of an instrument

against the surface of a tooth. The active area antinode (terminal 1.0–3.5 mm of the shank) is placed on the tooth surface for instrumentation because this area is responsible for the removal of oral deposits (see Figure 10-2).

Shank Surfaces

There are four surfaces on the shank of an insert and tip: point, face, back, and two congruent lateral sides (see Table 10-1). The four surfaces have different

C Figure 10-2  Ultrasonic active area antinode adaptation:

A. Active area antinode, B. Active area antinode adapted subgingivally, C. Active area antinode adapted supragingivally.

Adaptation

173

Table 10-1  Four Surfaces of an Ultrasonic Shank Surface

Displacement Amplitude Capability

Photo

Point

Greatest

  Face

2nd greatest

  Back

3rd greatest

Congruent lateral surfaces

Least

Dentsply Sirona Cavitron Powerline 10 30K Ultrasonic Insert and Acteon Tip 1S Reproduced with permission from Dentsply Sirona

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Chapter 10 Adaptation, Angulation, and Orientation

displacement amplitude capabilities at comparable power settings.

• Point: At all power settings, the point has the

•

•

•

greatest displacement amplitude, making it the most powerful surface (Pecheva et al., 2016). It is located at the end of the shank (see Table 10-1a). The point is useful for breaking apart large dental calculus deposits or when debriding occlusal pits and fissures. Extreme caution should be exercised and the risk versus benefit weighed prior to using the point on less mineralized hard tissues such as cementum and dentin. Face: The face has the second greatest displacement amplitude, making it less powerful than the point but still quite powerful (Pecheva et al., 2016). The face is the concave surface of the shank (see Table 10-1b). The face is useful for the removal of supragingival interproximal dental calculus deposits on enamel. Caution should be exercised and the risk versus benefit weighed prior to using the face on less mineralized hard tissues such as cementum and dentin. Back: The back has the third greatest displacement amplitude and is adapted to all supragingival and subgingival areas on enamel, dentin, or cementum (Pecheva et al., 2016). The back is the convex surface of the shank (see Table 10-1c). Lateral: The two lateral congruent surfaces have the least displacement amplitude and are adapted to all supragingival and subgingival areas on enamel, dentin, or cementum (Pecheva et al., 2016). The lateral surfaces are on either side of the shank (see Table 10-1d).

adapting the congruent lateral surfaces of a tip to the tooth surfaces for a smoother ultrasonic instrumentation experience. Reference the manufacturer directions for use/instructions for use (DFU/IFU) for these details.

Angulation Angulation refers to the degree of tilt an instrument

has when adapted to the surface of a tooth. During ultrasonic instrumentation, the active area is angled to the tooth surface with either a 90-degree angulation or 0- to 15-degree angulation.

90-Degree Angulation

A 90-degree angulation is used selectively and infrequently during ultrasonic instrumentation. This angulation is only used supragingivally. The point, or just offset from the point, is adapted to the tooth surface at a 90-degree angle (see Figure 10-3).

A

BREAKOUT POINT The point and face have the highest displacement amplitude and caution should be exercised when adapting to dentin and cementum.

BREAKOUT POINT The back and congruent lateral surfaces have the lowest displacement amplitude and can be safely adapted on all hard tissues.

As discussed previously, all surfaces of a magnetostrictive insert shank and piezoelectric tip shank are active when powered on. All surfaces can be adapted for ultrasonic instrumentation. However, some piezoelectric manufacturers recommend predominately

B Figure 10-3  90-degree angulation (Dentsply Sirona

Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert): A. Point directly adapted to occlusal surface, B. Shank tilted slightly toward the buccal, making the point slightly offset on the occlusal surface.

Angulation

A

175

B

C Figure 10-4  A. Heavy dental calculus deposit on occlusal, interproximal, and lingual surfaces of the maxillary right

terminal molars, B. Stain on the occlusal surface of mandibular molars, C. Stain on the incisal surfaces of anterior teeth.

A 90-degree angulation is useful in the following patient scenarios:

• To

•

fracture heavy dental calculus deposits, as seen in Figure 10-4a. Care should be used to stop the ultrasonic instrumentation when the heavy dental calculus breaks apart to avoid over-instrumentation with the high displacement amplitude of the point. To remove stain and decontaminate the pits and fissures on the occlusal surface of teeth, as seen in Figure 10-4b and c. This is useful prior to sealant

placement. Enamel is much thicker on the occlusal surface of a tooth than on smooth surfaces. The use of the point on the occlusal is safe unless the enamel is damaged by significant erosion, attrition, or demineralization, as seen in Figure 10-5. BREAKOUT POINT A 90-degree angulation is useful for debriding heavy dental calculus and stain.

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Chapter 10 Adaptation, Angulation, and Orientation

0- to 15-Degree Angulation

A 0- to 15-degree angulation is used frequently during ultrasonic instrumentation for the debridement of supragingival and subgingival tooth surfaces. The active area antinode of the face, back, or lateral surfaces of the shank is adapted between 0 and 15 degrees on the tooth surface. It is not possible to adapt the point with this angulation.

• 0-degree: Active area antinode is flush with the •

anatomy of the tooth. There is no gap between the active area and the tooth structure (see Figure 10-6a). 15-degree: Active area antinode is slightly angled to the anatomy of the tooth. There is a slight gap between the active area and the tooth structure (see Figure 10-6b).

If the active area is over-angled (>15 degrees), damage to gingival tissues and incidental removal of healthy tooth structures will occur as the point begins to adapt to tooth surfaces (see Figure 10-6c and d).

BREAKOUT POINT A 0- to 15-degree angulation is used for the debridement of supragingival and subgingival tooth surfaces.

Orientation Orientation describes the position an instrument

has in association with a tooth structure. In ultrasonic instrumentation, there are two orientations of the active area antinode to a tooth or tooth root: vertical orientation and transverse orientation.

Vertical Orientation

In vertical orientation, the active area antinode of the shank is placed vertically to the long axis of the tooth. This orientation resembles that of a periodontal probe orientation (see Figure 10-7). Vertical orientation is used for debriding supragingival and subgingival tooth surfaces. Figure 10-5  Contraindication for use of point: Attrition,

fracture, demineralization, and erosion on premolar and anterior teeth.

• The back and congruent lateral surfaces of the shank can be adapted to tooth surfaces in vertical orientation.

Orientation

A

B

C

D

177

Figure 10-6  Active area antinode shank angulation: A. 0-degree angulation, B. 15-degree angulation, C. 45-degree

angulation, D. 70-degree angulation.

BREAKOUT POINT Vertical orientation is used for debriding supragingival and subgingival tooth surfaces.

• The back and lateral surfaces are used on cemen-

tum and dentin as they are less active than the face or point.

Transverse Orientation

In transverse orientation, the active area antinode of the shank is placed at a right angle to the long axis of the tooth. This orientation resembles the orientation of a sickle scaler (see Figure 10-8). Transverse orientation is only used for supragingival interproximal debridement (see Table 10-2).

• The

face, back, and congruent lateral surfaces of the shank can be adapted to tooth surfaces in transverse orientation when adapting to enamel.

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Chapter 10 Adaptation, Angulation, and Orientation

• If recession is present and dentin is exposed, the •

BREAKOUT POINT

provider may want to avoid adapting the face (see Figure 10-9). The point would only be used to break apart large dental calculus deposits interproximally, and once the deposit is fractured, resume adaptation with the face, back, or congruent lateral surfaces.

Transverse orientation is used for debriding supragingival interproximal tooth surfaces.

A

A

B

B

Figure 10-7  Vertical orientation: A. Periodontal probe,

Figure 10-8  Transverse orientation: A. Posterior sickle

B. Ultrasonic (Dentsply Sirona Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert).

scaler, B. Ultrasonic (Dentsply Sirona Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert).

Table 10-2  Vertical and Transverse Orientation Supragingival/Subgingival

Shank

Resembles

Debridement Uses

Vertical orientation

Supragingival Subgingival

Parallel to the long axis of tooth

Probe

Shallow and deep periodontal pockets

Transverse orientation

Supragingival

Right angle to the long axis of tooth

Posterior sickle scaler

Interproximal areas under contacts

Skill Building Adaptation, Angulation, and Orientation

A

179

B

Figure 10-9  Gingival Recession: A. Recession of the facial of mandibular anterior central incisors. B. Recession on the

facial and interproximal of mandibular anterior teeth.

Skill Building Adaptation, Angulation, and Orientation You will need the following supplies: typodont, ultrasonic handpiece, straight thin or ultra-thin insert or tip. Rationale: This exercise will provide a kinetic learning experience to practice the building blocks of ultrasonic instrumentation learned in this chapter. You

will experience instrument adaptation, angulation, and both vertical and transverse orientations of the shank active area antinode on tooth surfaces. Insert and handpiece pictured: Dentsply Sirona Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert, Dentsply Sirona Cavitron Steri-Mate 360 Handpiece. Exercise 1: Posterior Tooth Vertical Orientation

• Adaptation: Lateral and back surface • Angulation: 0- to 15-degree • Orientation: Vertical

1. Place the insert or tip into the ultrasonic handpiece.

2. Position the typodont on a flat surface.

3. Correctly grasp the handpiece with the dominant hand and maintain the grasp throughout the exercise.

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Chapter 10 Adaptation, Angulation, and Orientation

4. Dominant right-handed provider: Identify the mandibular right first molar buccal surface. Dominant left-handed provider: Identify the mandibular left first molar buccal surface.

5. Establish a finger rest: intraoral same quadrant or cross-arch depending on the length of your fingers.

6. Dominant right-handed provider: Place the active area antinode lateral surface on the straight buccal occlusal-third of the mandibular right first molar in a vertical orientation

RT

Dominant left-handed provider: Place the active area antinode lateral surface on the straight buccal occlusal-third of the mandibular left first molar in a vertical orientation. D DB B MB M

LF

Skill Building Adaptation, Angulation, and Orientation

7. Establish a 0-degree angulation and then open slightly to a 15-degree angulation. Return to a 0-degree angulation.

181

RT

LF

8. Maintain lateral surface adaptation with 0- to 15-degree angulation of the active area antinode and slowly advance to the gumline. As the lateral surface is advanced apically, rotate the active area antinode to maintain contact with the anatomy of the tooth while maintaining a 0- to 15-degree angulation. Do not allow the active area antinode to lose contact with the tooth surface.

Incorrect: Notice the active area antinnode is not in contact with the tooth surface.

Correct.

9. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance subgingivally to a depth of 3 mm.

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Chapter 10 Adaptation, Angulation, and Orientation

10. Reposition the lateral surface of the active area antinode supragingival on the distal-buccal line angle occlusal third in a vertical orientation. D DB B MB M

11. Establish a 0-degree angulation and then open slightly to a 15-degree angulation. Return to a 0-degree angulation.

12. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance to the gumline.

13. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance subgingivally to a depth of 3 mm.

14. Magnetostrictive insert: Reposition the lateral or back surface of the active area antinode supragingival on the straight distal occlusal-third in a vertical orientation as if you were going to probe the distal col. Piezoelectric tip: Reposition the lateral surface of the active area antinode supragingival on the straight distal occlusal-third in a vertical orientation as if you were going to probe the distal col. D DB B MB M

15. Establish a 0-degree angulation and then open slightly to a 15-degree angulation. Return to a 0-degree angulation.

Skill Building Adaptation, Angulation, and Orientation

16. Maintain lateral or back surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance to the gumline.

17. Maintain lateral or back surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance subgingivally to a depth of 3 mm.

18. Reposition the lateral surface of the active area antinode supragingival on the mesial-buccal line angle occlusal-third in a vertical orientation. D DB B MB M

19. Establish a 0-degree angulation and then open slightly to a 15-degree angulation. Return to a 0-degree angulation.

20. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance to the gumline.

21. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance subgingivally to a depth of 3 mm.

22. Magnetostrictive insert: Reposition the lateral or back surface of the active area antinode supragingival on the straight mesial occlusal-third in a vertical orientation as if you were going to probe the mesial col. Piezoelectric tip: Reposition the lateral surface of the active area antinode supragingival on the straight mesial occlusal-third in a vertical orientation as if you were going to probe the mesial col. D DB B MB M

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23. Establish a 0-degree angulation and then open slightly to a 15-degree angulation. Return to a 0-degree angulation.

24. Maintain back or lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance to the gumline.

25. Maintain back or lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance subgingivally to a depth of 3 mm.

Exercise 2: Posterior Tooth Transverse Orientation

• Adaptation: Lateral and face surfaces • Angulation: 0-degree • Orientation: Transverse 1. Place the insert or tip into the ultrasonic handpiece. 2. Position the typodont on a flat surface.

3. Correctly grasp the handpiece with the dominant hand and maintain the grasp throughout the exercise.

4. Dominant right-handed provider: Identify the mandibular right first molar buccal surface. Dominant left-handed provider: Identify the mandibular left first molar buccal surface.

Skill Building Adaptation, Angulation, and Orientation

5. Establish a finger rest: intraoral same quadrant or cross-arch depending on the length of your fingers.

185

RT

Middle, index, and pinkie finger do not have to touch.

LF

6. Dominant right-handed provider: Place the lateral surface active area ­antinode on the distal of the mandibular right first molar in a transverse ­orientation with 0-degree angulation. Dominant left-handed provider: Place the lateral surface active area antinode on the distal of the mandibular left first molar in a transverse orientation with 0-degree angulation.

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7. Advance the active area antinode forward into the distal interproximal area, maintaining lateral surface adaptation with a 0-degree angulation. Only advance forward halfway into the interproximal as the provider only debrides half the interproximal contact from the buccal and the other half from the lingual.

8. Magnetostrictive insert: Change adaptation to the face surface and adapt directly under the distal contact, maintaining transverse orientation and a 0-degree angulation of the active area antinode. Piezoelectric tip: skip this step.

Exercise 3: Anterior Tooth Vertical Orientation

• Adaptation: Lateral and back surfaces • Angulation: 0- to 15-degree • Orientation: Vertical 1. Place the insert or tip into the ultrasonic handpiece. 2. Position the typodont on a flat surface.

3. Correctly grasp the handpiece with the dominant hand and maintain the grasp throughout the exercise.

4. Position the typodont directly in front of you as if you are sitting at 12 o’clock.

5. Dominant right-handed provider: Identify the maxillary left central incisor facial surface. Dominant left-handed provider: Identify the maxillary right central incisor facial surface.

Skill Building Adaptation, Angulation, and Orientation

6. Establish a finger rest: intraoral cross-arch.

RT

LF

7. Dominant right-handed provider: Place the active area antinode lateral surface on the straight facial incisal-third of the maxillary left central incisor in a vertical orientation. Dominant left-handed provider: Place the active area antinode lateral surface on the straight facial incisal-third of the maxillary right central incisor in a vertical orientation.

D DF F MF M

8. Establish a 0-degree angulation.

9. Establish a 15-degree angulation and then return to a 0-degree angulation.

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10. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance to the gumline. As the lateral surface is advanced apically, rotate the active area antinode to maintain contact with the anatomy of the tooth while maintaining a 0- to 15-degree angulation. Do not allow the active area antinode to lose contact with the tooth surface.

11. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance subgingivally to a depth of 3 mm.

12. Reposition the lateral surface of the active area antinode supragingivally on the distal-facial line angle incisal-third in a vertical orientation. Establish a 0-degree angulation and then open slightly to a 15-degree angulation. Return to a 0-degree angulation.

D DF F MF M

13. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance to the gumline.

Skill Building Adaptation, Angulation, and Orientation

14. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance subgingivally to a depth of 3 mm.

15. Magnetostrictive insert: Reposition the lateral or back surface of the active area antinode supragingivally on the straight distal incisal-third in a vertical orientation, as if you were going to probe the distal col. Piezoelectric tip: Reposition the lateral surface of the active area antinode supragingivally on the straight distal incisal-third in a vertical orientation, as if you were going to probe the distal col.

D DF F MF M

16. Establish a 0-degree angulation and then open slightly to a 15-degree angulation. Return to a 0-degree angulation. Maintain lateral or back surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance to the gumline.

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Chapter 10 Adaptation, Angulation, and Orientation

17. Maintain lateral or back surface adaptation with a 0- to -15-degree angulation of the active area antinode and slowly advance subgingivally to a depth of 3 mm.

18. Reposition the lateral surface of the active area antinode supragingivally on the mesial-facial line angle incisal-third in a vertical orientation. Establish a 0-degree angulation and then open slightly to a 15-degree angulation. Return to a 0-degree angulation.

D DF F MF M

19. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance to the gumline.

20. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance subgingivally to a depth of 3 mm.

Skill Building Adaptation, Angulation, and Orientation

21. Magnetostrictive insert: Reposition the lateral or back surface of the active area antinode supragingivally on the straight mesial incisal-third in a vertical orientation, as if you were going to probe the mesial col.

RT

Piezoelectric tip: Reposition the lateral surface of the active area antinode supragingivally on the straight mesial incisal-third in a vertical orientation, as if you were going to probe the mesial col.

LF

D DF F MF M

22. Establish a 0-degree angulation and then open slightly to a 15-degree angulation. Return to a 0-degree angulation. Maintain back or lateral surface adaptation with a 0- to 15-degree angulation of the active area antinode and slowly advance to the gumline.

RT

LF

23. Maintain back surface adaptation with 0-degree angulation of the active area antinode and slowly advance subgingivally to a depth of 3 mm.

RT

LF

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Exercise 4: Anterior Tooth Transverse Orientation

• Adaptation: Lateral, back, and face surfaces • Angulation: 0-degree • Orientation: Transverse 1. Place the insert or tip into the ultrasonic handpiece. 2. Position the typodont on a flat surface.

3. Correctly grasp the handpiece with the dominant hand and maintain the grasp throughout the exercise.

4. Position the typodont directly in front of you as if you were sitting at 12 o’clock. Dominant right-handed provider: Identify the maxillary left central incisor facial surface. Dominant left-handed provider: Identify the maxillary right central incisor facial surface.

5. Establish a finger rest: intraoral cross-arch.

RT

LF

6. Magnetostrictive insert: Dominant right-handed provider, place the active area antinode lateral or face surface on the distal of the left central incisor in a transverse orientation with 0-degree angulation. Dominant left-handed provider, place the active area antinode lateral or face surface on the distal of the left central incisor in a transverse orientation with 0-degree angulation. Piezoelectric tip: Dominant right-handed provider, place the active area antinode lateral surface on the distal of the left central incisor in a transverse orientation with 0-degree angulation. Dominant left-handed provider, place the active area antinode lateral surface on the distal of the right central incisor in a transverse orientation with 0-degree angulation.

Face surface adaptation pictured

Comparison of Ultrasonic and Hand-Activated Instrumentation

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7. Advance the active area antinode forward into the distal interproximal area, maintaining face or lateral surface adaptation of the active area with a 0-degree angulation. Only advance forward halfway into the interproximal as the provider only debrides half the interproximal contact from the facial and the other half from the lingual.

Face surface adaptation pictured 8. Magnetostrictive insert: Dominant right-handed provider, place the back, lateral, or face surface active area antinode on the mesial of the maxillary left central incisor in a transverse orientation with 0-degree angulation. Dominant left-handed provider, place the back, lateral, or face surface active area antinode on the mesial of the right central incisor in a transverse orientation with 0-degree angulation. Piezoelectric tip: Dominant right-handed provider, place the active area antinode lateral surface on the mesial of the left central incisor in a transverse orientation with 0-degree angulation. Left-handed provider, place the active area antinode lateral surface on the mesial of the right central incisor in a transverse orientation with 0-degree angulation.

Back surface adaptation pictured

9. Advance the active area forward into the mesial interproximal area, maintaining back, lateral, or face surface adaptation of the active area antinode with a 0-degree angulation. Only advance forward halfway into the interproximal as the provider only debrides half the interproximal contact from the facial and the other half from the lingual.

Back surface adaptation pictured

Comparison of Ultrasonic and Hand-Activated Instrumentation Table 10-3

summarizes the differences between hand-activated and ultrasonic instrumentation adaptation, angulation, and orientation.

Table 10-3  Hand-activated versus ultrasonic instrumentation

Hand-Activated Instruments

Ultrasonic Instruments

Adaptation

1–2 mm of the blade adapted to the tooth surface.

1.0–3.5 mm active area antinode adapted to the tooth surface.

Angulation

60- to 80-degree angulation of blade to the tooth surface. Angulation technique varies based on instrument design of the blade, number of cutting edges, and internal and external angles.

90- or 0- to 15-degree angulation of active area antinode to the tooth surface.

Orientation Vertical or transverse

Vertical or transverse

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CASE STUDY

A 23-year-old female presents for a new patient appointment with the chief complaint that her “gums are bleeding and hurt sometimes.” She is a second-year nursing student with a noncontributory medical history. She smokes two cigarettes a day and drinks alcohol on the weekends when she goes out with her friends. She is not taking any medications and has no drug allergies. Her vitals are within normal limits.

Mandibular anterior facial surface

Maxillary right buccal and facial surfaces

Maxillary right second molar occlusal

Maxillary left buccal and facial surfaces

Oral hygiene exam: ■ ■ ■ ■

Generalized moderate to heavy supragingival and subgingival dental calculus. Generalized heavy biofilm. Generalized heavy stain. The patient reports brushing every other day or every two days. She never flosses her teeth because it “hurts and takes too long.”

Periodontal exam: ■ ■ ■ ■

Probe depths 4–7 mm generally. Horizontal bone loss scattered throughout the mouth. No recession or mobility is present in the mouth. Bleeding upon probing is present on 100% of surfaces.

Tissue description: ■ Punched out papillae mandibular anterior with a pseudomembrane once wiped away reveals fiery-red gingiva. ■ Generalized rolled and bulbous tissues. ■ Generalized erythema and edema. Diagnosis: The patient is diagnosed with necrotizing periodontitis and will receive an initial nonsurgical periodontal debridement with injectable local anesthesia. The patient does not appear to have active decay; however, another examination will be performed once the heavy oral deposits are removed. 1. What diameter shank should the provider select to begin the procedure and why? 2. What power setting should the provider use with this diameter shank and why?

Questions

195

3. What angulation should the provider use to remove the dental calculus on the occlusal of the maxillary right second molar? Justify your answer. 4. What surface of the shank should the provider use to remove the dental calculus on the occlusal of the maxillary right second molar? Justify your answer. 5. What orientation should the provider use to remove the dental calculus on the straight facial of the mandibular anterior teeth and maxillary left posterior buccal surfaces supragingivally and subgingivally? Justify your answer. 6. What angulation should the provider use when removing the dental calculus deposits on the straight facial of the mandibular anterior teeth and maxillary left posterior buccal surfaces supragingivally and subgingivally? Justify your answer. 7. What surface(s) of the shank should the provider use to remove the dental calculus interproximally on the maxillary right and left posterior teeth subgingivally? Justify your answer. 8. What orientation should the provider use to remove the dental calculus in the interproximal space under the contacts of the maxillary right and left posterior teeth supragingivally? Justify your answer. 9. What surface(s) of the shank should the provider use to remove the dental calculus interproximally on the maxillary right posterior teeth supragingivally? Justify your answer.

Summary

During ultrasonic instrumentation, the point, face, back, and congruent lateral surfaces of the shank active area antinode are used to remove oral deposits. Care should be exercised when debriding dentin and cementum due to their less mineralized content. The active area antinode is angled 0 to 15 degrees during supragingival and subgingival debridement in a vertical orientation. A 90-degree angulation is used to

Questions

1. Fill in the blank. The active area antinode is located at the terminal of an ultrasonic shank and is used to remove oral deposits. a. 1–5 mm b. 1–6 mm c. 1.0–3.5 mm d. 2–6 mm

Match the following shank surfaces to their correct descriptors for questions 2–5. There is one correct answer for each question. 2. Point

A. Used on supragingival and subgingival tooth surfaces.

3. Face

B. Highest amplitude displacement.

4. Back

C. Lowest amplitude displacement.

5. Lateral

D. Used in a transverse orientation for the removal of supragingival interproximal dental calculus deposits on enamel but is used with caution on dentin or cementum.

selectively remove heavy dental calculus deposits or debride the occlusal pits and fissures of teeth with the point. Transverse orientation is only used interproximally on supragingival structures. Mastering adaptation, angulation, and orientation will prepare you for the last building block of ultrasonic instrumentation, which is activation and is presented in the next chapter.

6. Which of the following surfaces of the shank should be used with caution on dentin and cementum? a. Point b. Face c. Back d. Lateral e. There is more than one correct answer. 7. A 90-degree angulation is used in which of the following patient scenarios? a. Remove stain and dental calculus on the occlusal surface of teeth b. Remove heavy dental calculus deposits supragingivally c. Remove heavy dental calculus deposits subgingivally on cementum d. Both A and B e. All of the above

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8. What degree angulation can be safely used on all hard tissues? a. 0–15 degrees b. 20–45 degrees c. 60–80 degrees d. 90 degrees

10. Used for debriding interproximal supragingival surfaces at a right angle to the long axis of the tooth.

Match the following orientation to its correct description for questions 9–14. Select A for vertical orientation and B for transverse orientation. There is only one correct answer for each question.

13. Active area antinode is parallel to the long axis of the tooth.

9. Used supragingivally only.

References

1. Pecheva, E., Sammons, R. L., & Walmsley, A. D. (2016). The performance characteristics of a piezoelectric ultrasonic dental scaler. Medical Engineering and Physics, 38, 199–203.

11. Used supragingivally and subgingivally. 12. Useful for debriding deep periodontal pockets.

14. Orientation is similar to the orientation of a periodontal probe.

CH APTER 11

Activation LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Define ultrasonic activation. 2. Understand the clinical indications for an ultrasonic activation stroke. 3. Perform and describe the two movements, horizontal and top-down, that produce an ultrasonic activation stroke. 4. Perform an ultrasonic activation stroke with an insert or tip while maintaining proper adaptation, angulation, and orientation of the active area antinode of the shank. 5. Understand the clinical indications for a tap stroke. 6. Perform a tap stroke while maintaining proper adaptation, angulation, and orientation of the shank active area antinode.

KEY TERMS

the pattern of movement an • Activation: instrument has on a structure. motion: the use of the thumb and • Finger index and middle fingers to move the active

area antinode of the shank during ultrasonic instrumentation. Horizontal movement: a component of the ultrasonic activation stroke where the active area antinode of the shank is moved back and forth in 2-mm increments at a steady consistent pace, with each horizontal cycle lasting 0.5–1.0 second. Tap stroke: a tapping activation with the ultrasonic point, or just offset from the point, to remove a large dental calculus deposit. Top-down movement: a component of the ultrasonic activation stroke where the active area antinode of the shank is moved from the most incisal/occlusal position (top) on a tooth surface to the most apical (down).

• • •

activation stroke: a combination of • Ultrasonic horizontal and top-down movement patterns

of the active area antinode on the shank used simultaneously to produce the activation required for ultrasonic instrumentation.

Introduction This chapter will add the final building block of activation for ultrasonic instrumentation technique (see Figure 11-1). There are two ultrasonic activation techniques, an ultrasonic activation stroke and a tap stroke. An ultrasonic activation stroke is a combination of two movements called horizontal and top-down. This stroke is used for the removal of oral deposits supragingivally and subgingivally. The active area antinode is kept in a constant 2-mm back-and-forth motion called h­orizontal movement. The active area antinode is placed coronal to an oral deposit and advanced apically for removal. This is referred to as the since horizontal movement is italicized in this paragrap, please add italics to top-down movement. A tap stroke is used for the removal of heavy dental calculus deposits. In this chapter you will learn both activation patterns and have an opportunity to practice them with step-by-step kinetic exercises.

Activation Activation describes the pattern of movement an in-

strument has on a tooth structure. The activation used for hand instrumentation is quite different than ultrasonic instrumentation. Hand-activated instrumentation requires the provider to manually break the oral 197

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Grasp and stabilization Operator and patient positioning Aerosol control Adaptation Angulation Orientation Activation

Figure 11-1  Ultrasonic instrumentation building blocks.

deposit bond from the tooth surface with significant lateral pressure and a scraping motion of the blade. The active area antinode on an ultrasonic insert and tip will mechanically chip oral deposits off tooth surfaces for the provider so no lateral pressure or scrapping motions are required. Let’s use an analogy to demonstrate:

• Hand-activated

•

instrumentation is comparable to brushing teeth with a manual toothbrush. The operator must manually move the bristles in a specific pattern with an applied force to cleanse the tooth. To produce an activation stroke with a hand instrument, the provider applies lateral pressure to the fingers in the grasp and uses a tight pinch grip. A strong and secure fulcrum is required as the blade is locked apical (under) the oral deposit, and a wrist-rock motion is used to manually scrape the blade against the deposit for removal. The blade is moved in a coronal direction with short, sharp, biting strokes. Multiple overlapping and multidirectional strokes are required to physically break the bond between the oral deposit and the tooth surface. Ultrasonic instrumentation is comparable to brushing teeth with an electric toothbrush. The operator simply positions the bristles on the tooth with no added pressure, and the electronic motion of the bristles cleanses the tooth. To produce an activation stroke with an ultrasonic shank, the active area antinode is placed on the deposit and lightly moved with small finger motions and no lateral pressure. The active area antinode

mechanically chips the deposit from the tooth surface for the provider with less overlapping and multidirectional strokes compared to hand instrumentation.

Finger Motion

During ultrasonic instrumentation, the provider will use their dominant-hand thumb and index and middle fingers to move the active area antinode of the shank along tooth surfaces. This is termed finger motion. A wrist rock is not used in ultrasonic instrumentation as is needed during hand-activated instrumentation. Once the ultrasonic active area antinode is adapted, angled, and oriented to the tooth structure, the provider will activate by depressing the foot pedal. The shank will instantaneously move in a vibratory elliptical motion with a displacement amplitude selected by the provider through the power control. When activated, the active area antinode is moved with a continuous fluid movement with finger motion. There are two types of activation used for ultrasonic instrumentation: ultrasonic activation stroke and tap stroke.

Ultrasonic Activation Stroke

The ultrasonic activation stroke is a combination of two movement patterns used simultaneously to produce the activation required for ultrasonic instrumentation. The two movement patterns are: horizontal movement and top-down movement.

Horizontal Movement

In horizontal movement, the active area antinode is moved back and forth horizontally in 2-mm increments at a steady consistent pace, with each horizontal cycle lasting 0.5–1.0 second depending on the oral deposit type and level. ­Multiple overlapping horizontal cycles are used to cover every surface of the tooth during ultrasonic instrumentation.

BREAKOUT POINT The horizontal movement of an ultrasonic activation stroke is produced by moving the active area 2 mm back and forth at a pace of 0.5–1.0 second.

Activation

199

Skill Building: Horizontal Movement of the Ultrasonic Activation Stroke You will need the following supplies: graph paper, black pen, red and blue crayons.

Rationale: This exercise will provide a kinetic learning experience to practice the horizontal movement of the ultrasonic activation stroke. You can transfer what you learn from this simulation of horizontal movement into active patient treatment. Steps: 1. Draw a maxillary central incisor on a piece of graph paper with the black pen. Include 12 boxes for the crown of the tooth.

2. On the crown of the teeth by the incisal edge, use the black pen and label the first box to the left 1 and the box to its right a 2 (see A), and so forth, until all boxes have either a 1 or a 2. You should have a total of six 1s and six 2s (see image B).

A

B

12

121212121212

(continues)

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Chapter 11 Activation

Skill Building: Horizontal Movement of the Ultrasonic Activation Stroke

(continued)

3. Use the black pen to draw a vertical line from the incisal edge of the crown to the apex of the root after every 2. The vertical lines contain two boxes each to simulate the 2-mm back-and-forth distance produced in the horizontal movement of the ultrasonic activation stroke.

1 2 1 2 1 2 1 2 1 2 1 2

4. Use the red crayon. Place the red crayon in the first vertical line segment farthest to the left just above the 1 and 2. Lay the crayon on its side (do not use the tip of the crayon).

1 2 1 2 1 2 1 2 1 2 1 2

5. Draw a horizontal line to the right with the red crayon and stop when you reach the next black vertical line. Put the red crayon down.

1 2 1 2 1 2 1 2 1 2 1 2

6. Use the blue crayon. Place the blue crayon where you stopped with the red crayon. Lay the crayon on its side (do not use the tip of the crayon).

1 2 1 2 1 2 1 2 1 2 1 2

7. Trace over the red line moving to the left. Stop when you reach the black vertical line. You have now completed one horizontal movement cycle.

1 2 1 2 1 2 1 2 1 2 1 2

Activation

Top-Down Movement

Top-down movement is performed simultaneously

with horizontal movement to produce an ultrasonic activation stroke. The active area antinode of the shank is placed at the most incisal/occlusal position (top) on a tooth surface and then moved in an apical direction (down) while continuous horizontal cycles are performed (see Figure 11-2). The top-down movement is the opposite of hand-activated instrumentation where the blade is placed apical (down) to an

A

B

201

oral deposit and then moved in a coronal direction (top) with a short, sharp, biting stroke. An ultrasonic activation stroke starts coronal to the oral deposit and moves in an apical direction. BREAKOUT POINT The top-down movement of an ultrasonic activation stroke moves the active area antinode in an apical direction.

C

Figure 11-2  Ultrasonic top-down movement (Dentsply Sirona Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert): A.

Active area antinode positioned at the incisal-third of the maxillary right central incisor, B. Active area antinode moved apical and now positioned at the middle-third of the tooth, C. Active area antinode moved further apically and now positioned at the cervical-third of the tooth.

Skill Building: Top-Down and Horizontal Movement of the Ultrasonic Activation Stroke You will need the following supplies: graph paper with the maxillary central incisor used in the horizontal movement skill-building exercise, and a red crayon.

Rationale: This exercise will provide a kinetic learning experience and combine the top-down and horizontal movement techniques of the ultrasonic activation stroke. You will experience the speed and distance of the horizontal movement as well as top-down movement. These techniques can then be transferred into active patient treatment. (continues)

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Skill Building: Top-Down and Horizontal Movement of the Ultrasonic Activation Stroke

(continued)

Steps: 1. Use the same central incisor graph paper from the horizontal movement practice and place the side of the red crayon on the red and blue line farthest to the left. Grasp the crayon as you would an ultrasonic handpiece.

1 2 1 2 1 2 1 2 1 2 1 2

2. Starting at the red and blue line, use the side of the crayon to color the first vertical line segment from the incisal edge toward the apex of the root using an ultrasonic grasp with light pressure and moving 0.5–1.0 second for each horizontal movement cycle. Make your coloring continuous without pausing or stopping. This simulates the continuous movement used for ultrasonic instrumentation.

1 2 1 2 1 2 1 2 1 2 1 2

3. Color the entire first segment all the way to the apex of the root and then lift the crayon off the paper.

1 2 1 2 1 2 1 2 1 2 1 2

4. Move to the next vertical line and repeat all steps.

1 2 1 2 1 2 1 2 1 2 1 2

5. Continue until all vertical lines are colored.

1 2 1 2 1 2 1 2 1 2 1 2

Activation

203

Skill Building: Ultrasonic Instrumentation Candle Exercise You will need the following supplies: 2 birthday candles with white stripe (darker colors work best as pictured here), ultrasonic device, ultrasonic handpiece, three diameter straight inserts or tips (thick, thin, ultra-thin), handactivated sickle scaler (anterior sickle preferred), sink or trash can to collect water.

Rationale: This exercise will build on the previous two exercises and provide a kinetic learning experience of ultrasonic instrumentation incorporating the ultrasonic activation stroke with varied power setting, and active area antinode adaptation, angulation, and orientation. The speed and movement of the ultrasonic activation stroke will be reinforced. The white stripe is close to 2 mm in diameter, which allows you to practice the horizontal movement. Ultrasonic adaptation with the lateral surfaces, 0-degree angulation, and vertical orientation will be used with varying power settings. You will answer reflection questions so you can transfer the kinetic experience into clinical applications. These techniques can then be transferred to active patient treatment. The goal of this exercise is to remove the white stripe of the candle with an ultrasonic shank active area antinode and hand-activated instrument without penetrating, roughening, or damaging the color portion of the candle under the white stripe. Complete steps 1–15 and record your observations. 1. Divide one candle into equal thirds: top, middle, and bottom.

2. Set up the ultrasonic device attaching the power, water, and/or air connectors. Turn on the device. 3. Flush the waterline for a minimum of 20–30 seconds. Always follow your clinic’s protocols for waterline maintenance, which may be different than a 20- to 30-second waterline flush. 4. Attach a sterile handpiece to the ultrasonic handpiece connector. (continues)

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Skill Building: Ultrasonic Instrumentation Candle Exercise

(continued)

5. Select a thick diameter insert or tip. • Magnetostrictive Dentsply Sirona Cavitron Powerline 10, Cavitron Powerline 100, or Cavitron Powerline 1000 Ultrasonic Inserts • Magnetostrictive HuFriedyGroup: #10 Universal, #1000 Triple Bend, Power PLUS Standard Conical, or Power PLUS Standard Bevel • Piezoelectric Acteon: Prophylaxis thick tips #1 or #10X • Piezoelectric EMS: Instrument A (This is a discontinued item, but if the institution has this tip, then you can use it in this section of the exercise. If not, then skip steps 5–15.) 6. Connect the thick diameter insert or tip to the ultrasonic handpiece. • Magnetostrictive Dentsply Sirona and HuFriedyGroup: Refer to Figure 5-7 for proper O-ring(s) lubrication. Fill the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360 degrees over the water dome until fully lubricated. Place the insert into the handpiece in the upright position. • Piezoelectric Acteon: Lubricate the O-ring with silicone paste. Torque the tip into the handpiece with the wrench provided by the manufacturer. • Piezoelectric EMS: Torque the tip into the handpiece with the wrench provided by the manufacturer. 7. Set the power level to high. • Magnetostrictive Dentsply Sirona: Dial control set to 2 o’clock or digital touch screen 60–75 (see Dentsply Sirona chapter 13 for details if needed). • Magnetostrictive HuFriedyGroup: Select operation mode blue and use numbers 8–10 (see HuFriedyGroup chapter 14 for details if needed). • Piezoelectric Acteon: Numbers 11–16 (blue color zone) (see Acteon chapter 18 for details if needed). • Piezoelectric EMS: Piezon 150 and 250 numbers 7–9, Piezon 700 dial set 12–2 o’clock on standard mode, AIRFLOW Prophylaxis Master numbers 8–10 (See EMS chapter 17 for details if needed,) 8. Set the water flow rate. • Magnetostrictive Dentsply Sirona and HuFriedyGroup: strong mist with no rapid drip (see Dentsply Sirona chapter 13 and HuFriedyGroup chapter 14 for details if needed). • Piezoelectric Acteon: strong mist with no rapid drip (see Acteon chapter 18 for details if needed). • Piezoelectric EMS: 70–100% (see EMS chapter 17 for details if needed). 9. Grip the candle at its base over a sink or trash can with your nondominant hand.

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10. Grasp the ultrasonic handpiece with your dominant hand with no lateral pressure transmitted to the fingers, as learned in chapter 9.

Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Powerline 10 30K Ultrasonic Insert 11. Adapt the lateral surface of the active area antinode of the thick diameter shank to the white stripe at the top of the candle. Use a vertical orientation with 0-degree angulation.

Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Powerline 10 30K change to Ultrasonic Insert

Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Powerline 10 30K Ultrasonic Insert

12. Depress the foot pedal to activate. Do not activate Boost mode if this is available on your device. Perform an ultrasonic activation stroke with horizontal movement from one side of the white stripe to the other. Once the white stripe begins to remove, advance the active area antinode downward (top-down) with continuous fluid overlapping horizontal movements at a pace of 0.5–1.0 second per horizontal cycle. Maintain active area antinode adaptation with 0-degree angulation while performing an ultrasonic activation stroke. Do not adapt the nodal point because the white stripe will not remove. Be sure to move the shank and not the candle. (continues)

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Skill Building: Ultrasonic Instrumentation Candle Exercise

13. Continue removing the white stripes in the top third of the candle using the same technique.

14. Remove the top third white stripe while trying to avoid injuring the solid color under the white stripe.

(continued)

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15. Remove the thick diameter insert or tip from the handpiece and record your observations. Observations: Record your observations for the thick diameter shank on high power candle exercise. 1. Was it difficult to remove the white stripe? Why or why not? 2. Was it difficult to avoid damaging the color portion of the candle under the white stripe? Why or why not? 3. Did the white stripe come off fast or slow? Why? 4. Did the white stripe lift off easily without breaking, as pictured here, or was it pulverized by the thick diameter shank on high power? Why?

16.

17.

18.

19.

20.

5. Was it challenging to move at the correct pace of 0.5–1.0 second per horizontal movement? Why or why not? 6. Was it challenging to maintain adaptation of the active area antinode as you performed top-down movement? Why or why not? Complete steps 16–25 and record your observations. Select a thin diameter insert or tip. • Magnetostrictive Dentsply Sirona: Cavitron Slimline 10S or Cavitron Slimline 1000 Ultrasonic Inserts • Magnetostrictive HuFriedyGroup: #100 Thin, Power PLUS Thin Conical, or Power PLUS Thin Bevel • Piezoelectric Acteon: Slim Prophylaxis tips #1S, #10P, or #10Z • Piezoelectric EMS: Instrument PS Connect the insert or tip to the handpiece. • Magnetostrictive Dentsply Sirona and HuFriedyGroup: Refer to Figure 5-7 for proper O-ring(s) lubrication. Fill the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360 degrees over the water dome until fully lubricated. Place the insert into the handpiece in the upright position. • Piezoelectric Acteon: Lubricate the O-ring with silicone paste. Torque the tip into the handpiece with the wrench provided by the manufacturer. • Piezoelectric EMS: Torque the tip into the handpiece with the wrench provided by the manufacturer. Set the power level to medium. • Magnetostrictive Dentsply Sirona: Dial control 10–2 o’clock or digital touch screen 30–60 (see Dentsply Sirona chapter 13 for details if needed). • Magnetostrictive Refer to Figure 5-7 for proper O-ring(s) lubrication. Fill the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360 degrees over the water dome until fully lubricated. Place the insert into the handpiece in the upright position.: Select operation mode blue and use numbers 4–7 (see HuFriedyGroup chapter 14 for details if needed). • Piezoelectric Acteon: Numbers 6–11 (yellow color zone) (see Acteon chapter 18 for details if needed). • Piezoelectric EMS: Piezon 150 and 250 numbers 4–6, Piezon 700 dial set 9–12 o’clock on standard mode, AIRFLOW Prophylaxis Master numbers 4–7 (see EMS chapter 17 for details if needed). Set the water flow rate. • Magnetostrictive Dentsply Sirona and HuFriedyGroup: rapid drip with fine mist halo (see Dentsply Sirona chapter 13 and HuFriedyGroup chapter 14 for details if needed). • Piezoelectric Acteon: rapid drip with fine mist halo (see Acteon chapter 18 for details if needed). • Piezoelectric EMS: 70–100% (see EMS chapter 17 for details if needed). Grip the candle at its base over a sink or trash can with your nondominant hand. (continues)

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(continued)

21. Grasp the ultrasonic handpiece with your dominant hand, with no lateral pressure transmitted to the fingers, as learned in chapter 9. 22. Adapt the lateral surface of the active area antinode of the thin diameter shank to the white stripe where the thick diameter shank left off on the middle third of the candle. Use a vertical orientation with 0-degree angulation.

Dentsply Sirona Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert 23. Depress the foot pedal to activate. Do not activate Boost mode if this is available on your device. Perform an ultrasonic activation stroke with horizontal movement from one side of the white stripe to the other. Once the white stripe begins to remove, advance the active area antinode downward (top-down) with continuous fluid overlapping horizontal movement at a pace of 0.5–1.0 second per horizontal cycle. Maintain active area antinode adaptation with 0-degree angulation while performing an ultrasonic activation stroke. Do not adapt the nodal point because the white stripe will not remove. Be sure to move the shank and not the candle. 24. Remove the middle third white stripe while trying to avoid injuring the solid color under the white stripe.

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25. Remove the thin diameter insert or tip from the handpiece and record your observations. Observations: Record your observations for the thin diameter shank on medium power candle exercise. 1. What overall clinical changes did you observe with a change in power setting? Was it easier to control the removal of the white stripe? Why or why not? 2. What overall clinical changes did you observe with a change in shank diameter? Was it easier to remove the white stripe without damaging the color portion of the candle? Why or why not? 3. Did the white stripe remove faster or slower with the thin diameter shank compared to the thick diameter shank? Why? 4. Did the white stripe lift off easily without breaking or was it pulverized by the thin diameter shank on medium power? Did this differ from the thick diameter at high power? Why? Complete steps 26–34 and record your observations. 26. Select an ultra-thin diameter insert or tip. • Magnetostrictive Dentsply Sirona: Cavitron Thinsert Ultrasonic Insert • Magnetostrictive HuFriedyGroup: XT or XT Triple Bend • Piezoelectric Acteon: Periodontic tips H3, TK1-1S, or TK1-1L • Piezoelectric EMS: If no ultra-thin tips are available, skip steps 26–34. 27. Connect the insert or tip to the handpiece. • Magnetostrictive Dentsply Sirona and HuFriedyGroup: Refer to Figure 5-7 for proper O-ring(s) lubrication. Fill the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360 degrees over the water dome until fully lubricated. Place the insert into the handpiece in the upright position. • Piezoelectric Acteon: Lubricate the O-ring with silicone paste. Torque the tip into the handpiece with the wrench provided by the manufacturer. 28. Set the power level to low. • Magnetostrictive Dentsply Sirona: Dial control 8–10 o’clock or digital touch screen set to 10–30 (see Dentsply Sirona chapter 13 for details if needed). • Magnetostrictive HuFriedyGroup: Select operation mode green and use numbers 1–3 (see HuFriedyGroup chapter 14 for details if needed). • Piezoelectric Acteon: Numbers 1–6 (green color zone). (see Acteon chapter 18 for details if needed). 29. Set the water flow rate. • Magnetostrictive Dentsply Sirona and HuFriedyGroup: rapid drip with fine mist halo (see Dentsply Sirona chapter 13 and HuFriedyGroup chapter 14 for details if needed). • Piezoelectric Acteon: rapid drip with fine mist halo (see Acteon chapter 18 for details if needed). 30. Grip the candle at its base over a sink or trash can with your nondominant hand. 31. Grasp the ultrasonic handpiece with your dominant hand with no lateral pressure transmitted to the fingers, as learned in chapter 9. 32. Adapt the lateral surface of the active area antinode of the ultra-thin diameter shank to the white stripe where the thin diameter shank left off on the bottom third of the candle. Use a vertical orientation with 0-degree angulation.

Dentsply Sirona Cavitron Thinsert 30K Ultrasonic Insert (continues)

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Skill Building: Ultrasonic Instrumentation Candle Exercise

(continued)

33. Depress the foot pedal to activate. Do not activate Boost mode if this is available on your device. Perform an ultrasonic activation stroke with horizontal movement from one side of the white stripe to the other. Once the white stripe begins to remove, advance the active area antinode downward (top-down) with continuous fluid overlapping horizontal movement at a pace of 0.5–1.0 second per horizontal cycle. Maintain active area adaptation with 0-degree angulation while performing an ultrasonic activation stroke. Do not adapt the nodal point because the white stripe will not remove. Be sure to move the shank and not the candle. 34. Remove the bottom third white stripe trying to avoid injuring the solid color under the white stripe. Remove the ultra-thin diameter insert or tip from the handpiece and record your observations.

Observations: Record your observations for the ultra-thin diameter shank on low power candle exercise. 1. What overall clinical changes did you observe with a change in power setting? Was it easier to control the removal of the white stripe? Why or why not? 2. What overall clinical changes did you observe with a change in shank diameter? Was it easier to remove the white stripe without damaging the color portion of the candle? Why or why not? 3. Did the white stripe remove faster or slower when compared to the thick and thin diameter shanks? Why? 4. Did the white stripe lift off easily without breaking or was it pulverized by the ultra-thin shank on low power? Why? Complete steps 35–41 and record your observations. 35. Select a hand-activated sickle scaler (anterior sickle preferred) and use the second candle. 36. Hold the candle at the base in your nondominant hand so that is parallel in your hand as pictures here.

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37. Grasp the hand scaler with a modified pen grasp. Establish a fulcrum with the ring finger behind the candle and ensure all fingers are touching one another. Do not allow the fulcrum finger to separate from the middle finger.

38. Select a white stripe to scale in the top third of the candle. Adapt the 1–2 mm of the working end (blade) 1/2 inch from the top of the white stripe.

(continues)

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Skill Building: Ultrasonic Instrumentation Candle Exercise

(continued)

39. Establish a 60- to 80-degree angle of the blade to the candle white stripe and produce a scaling stroke moving from apical to coronal with sharp, short, biting movements with a wrist rock to remove the white stripe.

40. Continue scaling until the white stripes in the top third of the candle are removed.

41. Record your observations. Observations: Record your observations for the hand-activated sickle scaler candle exercise. 1. What differences did you notice between the ultrasonic inserts and tips and the hand-activated instrument for the removal of the white stripe? 2. Which instrumentation technique took less time: ultrasonic or hand-activated? Why? 3. Which instrumentation technique was more labor intensive? Why? 4. Which instrumentation technique caused more damage to the solid color under the white stripe? Why?

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Skill Building: Curved Shank Ultrasonic Instrumentation Spoon Exercise You will need the following supplies: 2 clear spoons, Wite-Out, ultrasonic device, ultrasonic handpiece, thin curved shank insert or tip, thin or ultra-thin straight shank insert or tip, sink or trash can to collect water.

Rationale: This exercise will provide a kinetic learning experience to practice ultrasonic instrumentation with a curved ultrasonic shank. You will experience curved shank adaptation, angulation, and orientation while performing an ultrasonic activation stroke. You will use a straight and curved shank to remove Wite-Out from the concave surface of a plastic spoon. The concave spoon is simulating a root concavity. This will allow you to feel the difference between the two shank shapes (straight, curved) for adaptation into complex root anatomy such as a concavity. Goal of This Exercise: The goal of this exercise is to remove all the Wite-Out on the spoon without puncturing the spoon. Prior to Use: Apply a thin layer of Wite-Out on the inside center portion of the clear spoon and allow it to dry.

Identify a curved insert and tip. ■ ■

To correctly identify a right and left insert or tip, hold one insert/tip in your dominant hand and the other in your nondominant hand directly in front of your face so that the color grips or tip threaders are parallel to you. Look at the curve of the shank coming out of the grip. If the shank curves to the right, it is the right-curved insert/tip and if it curves to the left, it is the left-curved insert/tip. (continues)

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Skill Building: Curved Shank Ultrasonic Instrumentation Spoon Exercise

Dentsply Sirona Cavitron Slimline 10R and 10L Fitgrip 30K Ultrasonic Insert

(continued)

Acteon tips H4L and H4R

Complete steps 1–14 with the curved shank and record your observations. 1. Set up the ultrasonic device, attaching the power, water, and/or air connectors. Turn on the device. 2. Flush the waterline for a minimum of 20–30 seconds. Always follow your clinic’s protocols for waterline maintenance, which may be different than a 20- to 30-second waterline flush. 3. Attach a sterile handpiece to the ultrasonic handpiece connector. 4. Select the thin curved insert or tip from the list below: • Dominant right-handed provider: Magnetostrictive • Dentsply Sirona Cavitron Slimline 10R Ultrasonic Insert • HuFriedyGroup After Five Right • Dominant right-handed provider: Piezoelectric • Aceton periodontic tips P2L, TK2-1L, H4L • EMS PSR • Dominant left-handed provider: Magnetostrictive • Dentsply Sirona Cavitron Slimline 10L Ultrasonic Insert • HuFriedyGroup After Five Left • Dominant left-handed provider: Piezoelectric • Acteon periodontic tips P2R, TK2-1R, H4R • EMS PSL 5. Connect the thin curved insert or tip to the ultrasonic handpiece. • Magnetostrictive Dentsply Sirona and HuFriedyGroup: Refer to Figure 5-7 for proper O-ring(s) lubrication. Fill the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360 degrees over the water dome until fully lubricated. Place the insert into the handpiece in the upright position. • Piezoelectric Acteon: Lubricate the O-ring with silicone paste. Torque the tip into the handpiece with the wrench provided by the manufacturer. • Piezoelectric EMS: Torque the tip into the handpiece with the wrench provided by the manufacturer. 6. Set the power level allowed for the curved insert or tip. • Magnetostrictive Dentsply Sirona: Low to medium power with the dial 8 o’clock to 2 o’clock or digital touch screen 10–60 (see Dentsply Sirona chapter 13 for details if needed). • Magnetostrictive HuFriedyGroup: Low to medium power. Operation blue mode numbers number 3–7 or operation green mode numbers 1–5. (see HuFriedyGroup chapter 14 for details if needed). • Piezoelectric Acteon: Low power numbers 1–6 (green color zone) (see Acteon chapter 18 for details if needed). • Piezoelectric EMS: 10–60% (see EMS chapter 17 for details if needed).

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7. Set the water flow rate. • Magnetostrictive Dentsply Sirona and HuFriedyGroup: rapid drip with fine mist halo (see Dentsply Sirona chapter 13 and HuFriedyGroup chapter 14 for details if needed). • Piezoelectric Acteon: rapid drip with fine mist halo (see Acteon chapter 18 for details if needed). • Piezoelectric EMS: 70–100% (see EMS chapter 17 for details if needed). 8. Dominant right-handed provider: Grip the stem of the spoon over a sink or trash can with your left hand, with the spoon’s Wite-Out facing you. Dominant left-handed provider: Grip the stem of the spoon over a sink or trash can with your right hand, with the spoon’s Wite-Out facing you.

9. Do not move the spoon during this activity. The active area antinode of the shank is moved and not the spoon. 10. Grasp the ultrasonic handpiece with your dominant hand, with no lateral pressure transmitted to the fingers, as learned in chapter 9.

Dentsply Sirona Steri-Mate 360 Handpiece and Cavitron Powerline 10 30K Ultrasonic Insert (continues)

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Skill Building: Curved Shank Ultrasonic Instrumentation Spoon Exercise

(continued)

11. Magnetostrictive: Adapt the back surface of the active area antinode with 0-degree angulation in a vertical orientation at the top of the spoon on the Wite-Out farthest to the left.

HuFriedyGroup Curved Insert After Five Right Piezoelectric: Adapt the lateral surface of the active area antinode with 0-degree angulation in a vertical orientation at the top of the spoon on the Wite-Out farthest to the left.

Acteon tip P2L

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12. Depress the foot pedal to activate. Do not activate Boost mode if this is available on your device. Perform an ultrasonic activation stroke with 2-mm increment horizontal movements. Once the Wite-Out begins to remove, advance the active area antinode of the shank downward (top-down) with continuous fluid overlapping horizontal movements at a pace of 0.5–1.0 second per horizontal cycle. Maintain active area antinode adaptation with 0-degree angulation while performing an ultrasonic activation stroke. Do not adapt the nodal point because the Wite-Out will not remove. Be sure to move the shank and not the spoon.

13. When the first 2-mm segment of the Wite-Out is removed, repeat the steps on the next 2 mm of the Wite out.

   HuFriedyGroup Curved Insert After Five Right

   (continues)

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Skill Building: Curved Shank Ultrasonic Instrumentation Spoon Exercise

(continued)

14. When all the Wite-Out is removed, the curved shank practice is complete. Record your observations. Observations: Record your observations for the curved shank on low-medium power spoon exercise. 1. Did the curved shank maintain adaptation of the lateral or back surface as the active area antinode was advanced into the concave surface of the spoon? 2. Did the curved shank maintain 0-degree angulation when the active area antinode was adapted into the concave surface of the spoon as shown here?

HuFriedyGroup Curved Insert After Five Left 3. Was all the Wite-Out removed with the curved shank? Complete steps 15–24 with the straight insert or tip and record your observations. 15. Remove the curved insert or tip from the handpiece. 16. Connect the thin or ultra-thin insert or tip to the ultrasonic handpiece. • Magnetostrictive Dentsply Sirona and HuFriedyGroup: Refer to Figure 5-7 for proper O-ring(s) lubrication. Fill the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360 degrees over the water dome until fully lubricated. Place the insert into the handpiece in the upright position. • Piezoelectric Acteon: Lubricate the O-ring with silicone paste. Torque the tip into the handpiece with the wrench provided by the manufacturer. • Piezoelectric EMS: Torque the tip into the handpiece with the wrench provided by the manufacturer. 17. Do not change the power level or water flow rate. 18. Dominant right-handed provider: Grip the stem of the spoon over a sink or trash can with your left hand, with the spoon’s Wite-Out facing you. Dominant left-handed provider: Grip the stem of the spoon over a sink or trash can with your right hand, with the spoon’s Wite-Out facing you. 19. Do not move the spoon during this activity. The active area antinode of the shank is moved and not the spoon. 20. Grasp the ultrasonic handpiece with your dominant hand, with no lateral pressure transmitted to the fingers, as learned in chapter 9. 21. Magnetostrictive: Adapt the back or lateral surface of the active area antinode with 0-degree angulation in a vertical orientation at the top of the spoon on the Wite-Out farthest to the left.

HuFriedyGroup Staright Insert After Five

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Piezoelectric: Adapt the lateral surface of the active area antinode with 0-degree angulation in a vertical orientation at the top of the spoon on the Wite-Out farthest to the left. 22. Depress the foot pedal to activate. Do not activate Boost mode if this is available on your device. Perform an ultrasonic activation stroke with 2-mm increment horizontal movements. Once the Wite-Out begins to remove, advance the active area antinode of the shank downward (top-down) with continuous fluid overlapping horizontal movement at a pace of 0.5–1.0 second per horizontal cycle. Maintain active area antinode adaptation with 0-degree angulation while performing an ultrasonic activation stroke with either the back or lateral surfaces. Do not adapt the nodal point because the Wite-Out will not remove. Be sure to move the shank and not the spoon. Do not adapt the face or point. Do not increase the angulation of the active area antinode. 23. When you have removed all the Wite-Out you can in the first 2-mm segment, repeat the steps on the next 2 mm of the Wite-Out. 24. When all Wite-Out that can be removed is done, the straight shank practice is complete. Record your observations. Observations: Record your observations for the straight shank on the low-medium power spoon exercise. 1. Did the straight shank maintain adaptation of the lateral or back surface as the active area was advanced into the concave surface of the spoon? Why or why not? 2. Did the straight shank maintain 0-degree angulation of the lateral or back surfaces when the active area antinode was adapted into the concave surface of the spoon? Why or why not? See the image that follows.

3. Was all the Wite-Out removed with the straight shank? Why or why not? 4. What were the limitations of the straight shank compared to the curved shank?

Tap Stroke

The tap stroke is useful for breaking apart large dental calculus deposits (see Figure 11-3a to c). The provider uses the point, or just offset from the point, and gently touches the deposit for 1–2 seconds, then removes the point for 1–2 seconds (see Figure 11-4). This movement is repeated until the dental calculus deposit fractures. The active area antinode is angled 90-degrees to adapt the point on the dental calculus deposit.

Beginner Tap Stroke When using a tap stroke clinically for the first time, it is best to tap on the deposit three times and then

return to an ultrasonic activation stroke for three passes. This technique will prevent the provider from unintentionally injuring a crown or root surface with the point. The sequence for a beginner tap stroke is: 1. Tap-tap-tap on the point or just offset from the point. 2. Ultrasonic activation stroke-stroke-stroke on the lateral, back, or face surfaces. 3. Repeat steps 1 and 2 until the large dental calculus deposit fractures. A tap stroke can be used on any tooth surface with heavy dental calculus deposits. Once the dental

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A

B

C

Figure 11-3  Tap stroke is useful for the following patient scenarios: A. Mandibular right anterior lingual surfaces with

moderate to heavy dental calculus and stain, B. Maxillary right first and second molar occlusal surfaces with heavy dental calculus, C. Mandibular anterior lingual surfaces with heavy dental calculus and stain.

A

B Figure 11-4  Tap stroke (Dentsply Sirona Cavitron Powerline 10 30K Ultrasonic Insert): A. Point in

contact, B. Point not in contact.

calculus fractures, the tap stroke is stopped, and an ultrasonic activation stroke is resumed. Care must be exercised not to contact the point directly on the crown or root surface once the dental calculus fractures.

Comparison of Ultrasonic and Hand-Activated Instrumentation Table 11-1

summarizes the differences between ultrasonic and hand-activated instrumentation.

Comparison of Ultrasonic and Hand-Activated Instrumentation

221

Table 11-1  Hand-Activated Instruments versus Ultrasonic Instruments Hand-Activated Instrumentation

Ultrasonic Instrumentation

Stroke

Scaling stroke: Short, sharp, biting with significant lateral pressure. Many forceful overlapping and multidirectional strokes.

Ultrasonic activation stroke Tap stroke No lateral pressure, light grasp, and overlapping multidirectional strokes.

Movement of the working end

Wrist rock

Finger motion

Removal of oral deposit

Provider manually breaks the bond between the oral deposit and tooth with a scraping motion of the blade.

Ultrasonic mechanically chips the oral deposit from the tooth surface with a vibratory elliptical motion of the shank.

CASE STUDY

You are performing a nonsurgical periodontal debridement on your patient from the previous chapter shown here.

Mandibular anterior facial surface

Maxillary right buccal and facial surfaces

Maxillary left buccal and facial surfaces

Maxillary right second molar occlusal.

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1. What activation stroke would you use first on the mandibular anterior facial surfaces, the maxillary right second molar occlusal surface, and the maxillary left facial and buccal surfaces? 2. Explain the shank angulation and technique you need to use for the stroke in question 1. 3. Explain why this stroke is used first. 4. What activation stroke would you use second on the mandibular anterior facial surfaces, the maxillary right second molar occlusal surface, and the maxillary left facial and buccal surfaces? 5. Explain the shank angulation and technique you need to use for the stroke in question 4. You remove the heavy dental calculus with a thick diameter shank using a combination of tap and ultrasonic activation strokes on the mandibular anterior facial surfaces, the maxillary right second molar occlusal surface, and the maxillary left facial and buccal surfaces. Now, a light layer of dental calculus remains on all supragingival tooth surfaces. 6. What diameter shank would you use to remove the light supragingival dental calculus? 7. Which activation stroke would you use to remove the light supragingival dental calculus? 8. What power level would you use to remove the light supragingival dental calculus?

Summary

During ultrasonic instrumentation, an ultrasonic activation stroke or tap stroke can be used with either a 90-degree or 0- to 15-degree angulation for oral deposit removal. A tap stroke is used for the removal of

Questions

1. How far back and forth does the provider move the shank active area antinode in a horizontal movement of an ultrasonic activation stroke? a. 8 mm b. 5 mm c. 3 mm d. 2 mm 2. True or False. In the ultrasonic activation stroke, the active area antinode is placed apical to an oral deposit and moved in a coronal direction with continuous horizontal cycles. a. True b. False 3. True or False. The tap stroke is produced by moving the active area in a 2-mm back-andforth continuous horizontal pattern with a topdown approach. a. True b. False 4. In which patient scenario is a tap stroke indicated? a. To break apart heavy dental calculus deposits b. To remove light stain and dental calculus from the smooth surfaces of teeth c. For biofilm reduction on the root surface d. All of the above

heavy dental calculus deposits. An ultrasonic activation stroke is produced through a combination of a horizontal 2-mm back-and-forth continuous motion of the active area antinode in a top-down approach.

Match the following to either hand instrumentation or ultrasonic instrumentation for questions 5–12. ­Answer A for hand instrumentation and B for ultrasonic instrumentation. There is only one correct ­answer for each question. 5. Manually breaking the bond between the tooth surface and an oral deposit. 6. Chipping action removes oral deposits from tooth surfaces. 7. Forceful scaling stroke with significant lateral pressure. 8. Light grasp with use of ultrasonic activation stroke or tap stroke. 9. Wrist rock to move the working end. 10. Finger motion to move the active area antinode. 11. Activation direction is coronal to apical. 12. Stroke direction is apical to coronal.

CHAPTER 12

Ultrasonic Technique LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Perform an ultrasonic activation stroke on anterior and posterior teeth with correct grasp, finger rest, operator and patient positioning, instrument adaptation, angulation, orientation, and activation. 2. Maintain proper ergonomics while performing ultrasonic instrumentation. 3. Transition from vertical and transverse orientation during ultrasonic instrumentation.

Introduction This chapter will combine all the building blocks of ultrasonic instrumentation learned in ­ Chapters  9 through 11. You will combine grasp, finger rest, operator and patient chair positioning, adaptation, angulation, orientation, and activation in a simulated patient care experience. Ultrasonic instrumentation, like hand-activated instrumentation, is best learned through repetition and practice because there are many technique demands placed on the oral health-care provider. When mastered, ultrasonic instrumentation conserves root structures, reduces pathogens, and improves ergonomics through decreased labor intensity and time for procedures. This chapter will provide you with a kinetic learning experience that you can transfer into live patient care.

Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning You will need the following supplies: typodont, ­typodont pole, dental chair, ultrasonic device, nail polish or Wite-Out, high-volume evacuation, ultrasonic handpiece, and a thin or thick ultrasonic insert or tip. Rationale: This exercise will provide a kinetic learning experience that incorporates ultrasonic instrumentation techniques of adaptation, angulation, orientation, and activation with aerosol control and patient and operator positioning to simulate an active patient treatment scenario. The goal of this exercise is to remove the nail polish or Wite-Out from the painted teeth while controlling fluid and aerosols using proper patient and operator positioning. Setup: 1. Paint nail polish, Wite-Out on the entire facial/ buccal, lingual, and interproximal surfaces on the following teeth: • Maxillary left central incisor. • Mandibular right first molar for dominant right-handed provider and mandibular left first molar for dominant left-handed provider. Instructors may add teeth to this exercise as they see fit. 2. Mount pole onto dental chair.

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Chapter 12 Ultrasonic Technique

3. Mount typodont onto pole. 4. Set up ultrasonic device attaching the power, ­water, and/or air connectors. Ensure psi’s of the dental unit is compatible with the ultrasonic ­device. Turn on the device. 5. Attach an High-volume evacuation (HVE) to the suction system. 6. Flush the water line for a minimum of 20 to 30  seconds. Always follow your clinic’s protocols for water-line maintenance, which may be  ­ different  than  a 20- to 30-second waterline flush. 7. Attach a sterile handpiece to the ultrasonic handpiece connector cord. 8. Select a thin or thick diameter shank and connect to the ultrasonic handpiece. • Magnetostrictive Dentsply Sirona and ­HuFriedyGroup: Position the handpiece vertically over a sink or trash can and fill with water until a water dome appears over the brim. Lubricate the O-ring(s) by rotating the O-ring(s) over the water dome until all aspects of the O-ring(s) have been coated. Then place the insert into the handpiece ensuring the O-ring(s) is/are firmly seated. See Chapter 5 for details. • Piezoelectric Acteon: Lubricate the O-ring with silicone paste. Torque the tip into the handpiece with the wrench provided by the manufacturer. • Piezoelectric EMS: The O-ring on the handpiece does not require lubrication. Torque the tip into the handpiece with the wrench provided by the manufacturer. 9. Set the power level to low or medium. 10. Set the water flow period at end of sentence missing • Magnetostrictive Dentsply Sirona and HuFriedyGroup: rapid drip with fine mist halo (see Dentsply Sirona, Chapter 13, and HuFriedyGroup, Chapter 14, for details if needed). • Piezoelectric Acteon: rapid drip with fine mist halo (see Acteon, Chapter 18, for details if needed). • Piezoelectric EMS: 70–100% (see EMS, ­Chapter 17, for details if needed).

Maxillary Left Central Incisor

Dominant right- and left-handed providers will perform ultrasonic instrumentation on the maxillary left central incisor.

D DF F MF M

Figure 12-1  Maxillary Left Central Incisor Facial Divided

in 2 mm Segments

Maxillary Left Central Incisor Facial Divide the maxillary left central incisor in 2 mm segments on the facial: distal, distal-facial, facial midline, mesial-facial, mesial (see Figure 12-1).

Maxillary Left Central Incisor Lingual Divide the maxillary left central incisor in 2 mm segments: distal, distal-lingual, lingual midline, ­mesial-­lingual, mesial (see Figure 12-2).

Mandibular Molar

Dominant right-handed provider: perform ultrasonic instrumentation on the mandibular right first molar. Dominant left-handed provider: perform ultrasonic instrumentation on the mandibular left first molar.

Mandibular First Molar Facial Divide the mandibular molar in 2 mm segments on the buccal: distal, distal-buccal, distal-buccal midline, buccal, mesial-buccal midline, mesial-buccal, mesial (see Figure 12-3).

Mandibular First Molar Lingual

Divide posterior teeth in 2 mm segments: distal, distal-­ lingual, distal-lingual midline, lingual, mesial-­lingual midline, mesial-lingual, mesial (see Figure 12-4).

Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning

• •

225

Grasp the ultrasonic handpiece with your dominant hand.See Chapter 9 for details. Magnetostrictive: Thumb and index finger equidistant from one another on either side of the handpiece. The middle finger is advanced forward onto the colored grip of the insert. The handpiece lays in the webbing between the thumb and index finger. Piezoelectric: Thumb and index finger equidistant from one another on either side of the handpiece. The middle finger is tucked behind the index finger. The handpiece lays in the webbing between the thumb and index finger.

Grasp the HVE with your nondominant hand. See Chapter 9 for details.

• •

Place the active area antinode on the tooth surface at the facial. Position the lateral surface of the active area antinode in a vertical orientation at the incisal edge of the facial midline of the maxillary left central incisor. Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port of the insert or tip.

Select the operator positioning for direct vision: 11–1 o’clock for dominant right- and left-handed providers.

Select the patient chair positioning for the maxillary arch. Patient chair supine with chin slightly upward.

Establish a finger rest intraoral or extraoral ensuring correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps in Table12-1.

Table 12-​1  Ultrasonic Instrumentation of the Maxillary Left Central Incisor Facial Surfaces Depress the foot pedal to activate the insert or tip. ■

■ ■ ■

Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the facial midline. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Do not allow the active area to lose contact with the tooth surface. Do not allow the shank to roll onto the nodal point (3.5–5.0 mm) as no action occurs and the nail polish or Wite-Out will not be removed. Remove all the nail polish or Wite-Out from the facial midline surfaces incisal to the gum line. D DF F MF M

(continues)

226

Chapter 12 Ultrasonic Technique

Table 12-​1  Ultrasonic Instrumentation of the Maxillary Left Central Incisor Facial Surfaces ■ ■ ■

■

(continued)

Reposition the lateral surface of the active area antinode at the incisal edge of the mesial-facial line angle in a vertical orientation with 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the mesial-facial line angle. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to15-degree angulation. Remove all the nail polish or Wite-Out from the mesial-facial line angle surfaces incisal to the gum line. D DF F MF M

■

■

■

■ ■

■ ■

■ ■ ■ ■

Dominant right-handed magnetostrictive insert: Reposition the back surface of the active area antinode at the incisal edge of the straight mesial in a vertical orientation with 0- to 15-degree angulation as if you were going to probe the mesial col. Dominant right-handed piezoelectric tip: Reposition the lateral surface of the active area antinode at the incisal edge of the straight mesial in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the mesial col. Dominant left-handed magnetostrictive insert and piezoelectric tip: Reposition the lateral surface of the active area antinode at the incisal edge of the straight mesial in a vertical orientation with 0- to 15-degree angulation as if you were going to probe the mesial col. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the mesial. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the mesial surfaces incisal to the gum line.

D DF F MF M

Magnetostrictive insert: Transition to a transverse orientation with the back, lateral, or face surface with a 0- to 15-degree angulation to debride the mesial interproximal contact supragingivally. Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a 0- to 15-degree angulation to debride the mesial interproximal contact supragingivally. Debride one-half of the mesial interproximal space. The other half is debrided from the lingual. Reposition the HVE as needed. Remove all the nail polish or Wite-Out from one-half of the mesial interproximal space. D DF F MF M

■ ■ ■

■

Reposition the lateral surface of the active area antinode at the incisal edge of the distal-facial line angle in a vertical orientation with 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the distal-facial line angle. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the distal-facial line angle surfaces incisal to the gum line. D DF F MF M

Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning ■

■

■

■ ■

■ ■

■ ■ ■ ■

Dominant right-handed magnetostrictive insert and piezoelectric tip: Reposition the lateral surface of the active area antinode at the incisal edge of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the distal col. Dominant left-handed magnetostrictive insert: Reposition the back surface of the active area antinode at the incisal edge of the straight distal in a vertical orientation with 0- to 15-degree angulation as if you were going to probe the distal col. Dominant left-handed piezoelectric tip: Reposition the lateral surface of the active area antinode at the incisal edge of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the distal col. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the distal. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the distal surfaces incisal to the gum line.

227

D DF F MF M

Magnetostrictive insert: Transition to a transverse orientation with the back, lateral, or face surface with a 0- to 15-degree angulation to debride the distal interproximal contact supragingivally. Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a 0- to 15-degree angulation to debride the distal interproximal contact supragingivally. Debride one-half of the distal interproximal space. The other half is debrided from the lingual. Reposition the HVE as needed. Remove all the nail polish or Wite-Out from one-half of the distal interproximal space. D DF F MF M

D DL L ML M

Figure 12-2  Maxillary Left Central Incisor Lingual

Divided in 2 mm Segments

228

Chapter 12 Ultrasonic Technique Grasp the ultrasonic handpiece with your dominant hand.

Grasp the HVE with affixed mirror with your nondominant hand. If an HVE with an affixed mirror is not available, skip the lingual surfaces of the maxillary left central incisor.

• •

Place active area antinode on the tooth surface at the lingual midline. Position the lateral surface of the active area antinode in a vertical orientation at the incisal edge of the lingual midline of the maxillary left central incisor. Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port of the insert or tip.

Select the operator positioning for indirect vision: 11-1 o’clock for dominant right- and left-handed providers.

Select the patient chair positioning for the maxillary arch. Patient chair supine with chin slightly upward.

Establish a finger rest intraoral or extraoral ensuring correct handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps in Table12-2.

Table 12-2  Ultrasonic Instrumentation of the Maxillary Left Central Incisor Lingual Surfaces Depress the foot pedal to activate the insert or tip. ■

■ ■ ■

Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the lingual midline. Advance the active area antinode in an apical direction at a pace of 0.5–1.0 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation Do not allow the active area to lose contact with the tooth surface. Do not allow the shank to roll onto the nodal point (3.5–5.0 mm) as no action occurs and the nail polish or Wite-Out will not be removed. Remove all the nail polish or Wite-Out from the lingual midline surfaces incisal to the gum line. D DL L ML M

Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning ■ ■ ■

■

229

Reposition the lateral surface of the active area antinode at the incisal edge of the mesiallingual line angle in a vertical orientation with a 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the mesial-lingual line angle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the mesial-lingual line angle surfaces incisal to the gum line. D DL L ML M

■

■

■

■ ■

■ ■

■ ■ ■ ■

Dominant right-handed magnetostrictive insert: Reposition the back surface of the active area antinode at the incisal edge of the straight mesial in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the mesial col. Dominant right-handed piezoelectric tip: Reposition the lateral surface of the active area antinode at the incisal edge of the straight mesial in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the mesial col. Dominant left-handed magnetostrictive insert and piezoelectric tip: Reposition the lateral surface of the active area antinode at the incisal edge of the straight mesial in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the mesial col. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the mesial. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the mesial surfaces incisal to the gum line.

D DL L ML M

Magnetostrictive insert: Transition to a transverse orientation with the back, lateral, or face surface with a 0- to 15-degree angulation to debride the mesial interproximal contact supragingivally. Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a 0- to 15-degree angulation to debride the mesial interproximal contact supragingivally. Debride one-half of the mesial interproximal space. The other half was debrided from the facial. Reposition the HVE as needed. Remove all the nail polish or Wite-Out from one-half of the mesial interproximal space. D DL L ML M

■ ■ ■

■

Reposition the lateral surface of the active area antinode at the incisal edge of the distallingual line angle in a vertical orientation with a 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the distal-lingual line angle. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the distal-lingual line angle surfaces incisal to the gum line.

D DL L ML M

(continues)

230

Chapter 12 Ultrasonic Technique

Table 12-2  Ultrasonic Instrumentation of the Maxillary Left Central Incisor Lingual Surfaces

■

■ ■

■ ■

■ ■ ■ ■

Magnetostrictive insert: Transition to a transverse orientation with the back, lateral, or face surface with a 0- to 15-degree angulation to debride the distal interproximal contact supragingivally. Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a 0- to 15-degree angulation to debride the distal interproximal contact supragingivally. Debride one-half of the distal interproximal space. The other half was debrided from the facial. Reposition the HVE as needed. Remove all the Wite-Out from one-half of the distal interproximal space.

D DB

B

MB midline

■

Dominant right-handed magnetostrictive insert and piezoelectric tip: Reposition the lateral surface of the active area antinode at the incisal edge of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the distal col. Dominant left-handed magnetostrictive insert: Reposition the back surface of the active area antinode at the incisal edge of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the distal col. Dominant left-handed piezoelectric tip: Reposition the lateral surface of the active area at the incisal edge of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the distal col. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the distal. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the Wite-Out from the distal surfaces incisal to the gum line.

DB midline

■

MB M

Figure 12-3  Mandibular First Molar Buccal Divided in 2 mm Segments.

(continued)

D DL L ML M

D DL L ML M

Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning

• •

231

Grasp the ultrasonic handpiece with your dominant hand. See Chapter 9 for details. Magnetostrictive: Thumb and index finger equidistant from one another on either side of the handpiece. The middle finger is advanced forward onto the colored grip of the insert. The handpiece lays in the webbing between the thumb and index finger. Piezoelectric: Thumb and index finger equidistant from one another on either side of the handpiece. The middle finger is tucked behind the index finger. The handpiece lays in the webbing between the thumb and index finger.

Grasp the HVE with your nondominant hand. See Chapter 9 for details.

• •

Place the active area antinode on the tooth surface at the straight buccal. Position the lateral surface of the active area antinode in a vertical orientation at the occlusal-third on the straight buccal of the mandibular first molar. Establish a 0- to 15-degree angulation.

Establish a 0- to 15-degree angulation.

Select the operator positioning for direct vision. • •

Dominant right-handed provider: 8–11 o’clock. Dominant left-handed provider: 1–4 o’clock.

Select the patient chair positioning for the mandibular arch. • • •

Supine, semi-supine, or in between supine and semi-supine. Patient chin slightly downward. Head slightly away from the provider depending on operator positioning.

Establish a finger rest intraoral or extraoral ensuring correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps in Table12-3.

Table 12-3  Ultrasonic Instrumentation of the Mandibular First Molar Buccal Surfaces

■ ■ ■

Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the straight buccal. Advance the active area antinode in an apical direction at a pace of 0.5–1.0 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Do not allow the active area to lose contact with the tooth surface. Do not allow the shank to roll onto the nodal point (3.5–5.0 mm) as no action occurs and the nail polish or Wite-Out will not be removed. Remove all the nail polish or Wite-Out from the straight buccal surfaces occlusal to the gum line.

D DB

B

MB midline

■

DB midline

Depress the foot pedal to activate the insert or tip.

MB M

(continues)

■

■

■

■ ■

■ ■

■ ■ ■ ■

Magnetostrictive insert: Reposition the back or lateral surface active area antinode at the occlusal-third of the straight mesial in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the mesial col. Piezoelectric tip: Reposition the lateral surface of the active area antinode at the occlusalthird of the straight mesial in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the mesial col. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the mesial. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the mesial surfaces occlusal to the gum line. Magnetostrictive insert: Transition to a transverse orientation with the lateral or back surface with a 0- to 15-degree angulation to debride the mesial interproximal contact supragingivally. Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a 0- to 15-degree angulation to debride the mesial interproximal contact supragingivally. Debride one-half of the mesial interproximal space. The other half is debrided from the lingual. Reposition the HVE as needed. Remove all the nail polish or Wite-Out from one-half of the mesial interproximal space.

D DB

D DB

D DB

MB midline

■

B

MB midline

■

Reposition the lateral surface of the active area antinode at the occlusal-third of the mesial-buccal in a vertical orientation with a 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the mesial-buccal. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the mesial-buccal occlusal to the gum line.

MB M

MB M

B

MB midline

■

B

MB M

B

MB midline

■

D DB

DB midline

■

DB midline

■

Reposition the lateral surface of the active area antinode at the occlusal-third of the mesial-buccal midline in a vertical orientation with a 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the mesial-buccal midline. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the mesial-buccal midline surfaces occlusal to the gum line.

DB midline

■

Chapter 12 Ultrasonic Technique

DB midline

232

MB M

233

■

■

■

■

■ ■

■ ■

■ ■ ■ ■

Magnetostrictive insert: Reposition the back or lateral surface of the active area antinode at the occlusal-third of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the distal col. Piezoelectric tip: Reposition the lateral surface of the active area antinode at the occlusalthird of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the distal col. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the distal. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the distal surfaces occlusal to the gum line. Magnetostrictive insert: Transition to a transverse orientation with the lateral or back surface with a 0- to 15-degree angulation to debride the distal interproximal contact supragingivally. Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a 0- to 15-degree angulation to debride the distal interproximal contact supragingivally. Debride one-half of the distal interproximal space. The other half is debrided from the lingual. Reposition the HVE as needed. Remove all the nail polish or Wite-Out from one-half of the distal interproximal space.

D DB

D DB

MB midline

■

Reposition the lateral surface of the active area antinode at the occlusal-third of the distalbuccal in a vertical orientation with a 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the distal-buccal. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the distal-buccal surfaces occlusal to the gum line.

B

MB midline

■

MB M

MB M

B

MB midline

■

B

MB M

D DB

B

MB midline

■

D DB

DB midline

■

DB midline

■

Reposition the lateral surface of the active area antinode at the occlusal-third of the distalbuccal midline in a vertical orientation with a 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the distal-buccal midline. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the distal-buccal midline surfaces occlusal to the gum line.

DB midline

■

DB midline

Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning

MB M

D DL

L

ML midline

Chapter 12 Ultrasonic Technique

DL midline

234

ML M

Figure 12-4  Mandibular First Molar Lingual Divided in 2 mm Segments

Grasp the ultrasonic handpiece with your dominant hand. An advanced grasp (moving the handpiece to the second joint of the index finger) may be needed because the provider will be on their non-dominant side of the patient chair. See Chapter 9 for details.

Grasp the HVE with your nondominant hand.

• •

Place the active area antinode on the tooth surface at the straight lingual. Position the lateral surface of the active area antinode in a vertical orientation at the occlusal-third on the straight lingual of the mandibular first molar. Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port of the insert or tip.

Select operator positioning for direct vision. • •

Right-handed provider: 1–4 o’clock. Left-handed provider: 8–11 o’clock.

Select the patient chair positioning for the mandibular arch • • •

Supine, semi-supine, or in between supine and semi-supine. Patient chin slightly downward. Head slightly away from the provider depending on operator positioning.

Establish a finger rest intraoral or extraoral ensuring correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps in Table12-4.

Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning

235

Table 12-4  Ultrasonic Instrumentation of the Mandibular First Molar Lingual Surfaces

■

■ ■ ■

■

■

■

■ ■

■

Reposition the lateral surface of the active area antinode at the occlusal-third of the mesial-lingual in a vertical orientation with a 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the mesial-lingual. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the Wite-Out from the mesial-lingual surfaces occlusal to the gum line.

Magnetostrictive insert: Reposition the back or lateral surface of the active area antinode at the occlusal-third of the straight mesial in a vertical orientation with 0- to 15-degree angulation as if you were going to probe the mesial col. Piezoelectric tip: Reposition the lateral surface of the active area antinode at the occlusal-third of the straight mesial in a vertical orientation with 0- to 15-degree angulation as if you were going to probe the mesial col. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the mesial. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the Wite-Out from the mesial surfaces occlusal to the gum line.

D DL

D DL

D DL

ML midline

■

L

ML midline

■

Reposition the lateral surface of the active area antinode at the occlusal-third of the mesial-lingual midline in a vertical orientation with a 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the mesial-lingual midline. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the mesial-lingual midline surfaces occlusal to the gum line.

ML M

ML M

L

ML midline

■

L

ML M

L

ML midline

■

DL midline

■

D DL

DL midline

■

Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the straight lingual. Advance the active area antinode in an apical direction at a pace of 0.5–1.0 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Do not allow the active area to lose contact with the tooth surface. Do not allow the shank to roll onto the nodal point (3.5–5.0 mm) as no action occurs and the nail polish or Wite-Out will not be removed. Remove all the nail polish or Wite-Out from the straight lingual occlusal to the gum line.

DL midline

■

DL midline

Depress the foot pedal to activate the insert or tip.

ML M

(continues)

■

■ ■ ■

■

■

■

■ ■

■

Reposition the lateral surface of the active area antinode at the occlusal-third of the distal-lingual in a vertical orientation with a 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the distal-lingual. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the distal-lingual surfaces occlusal to the gum line.

Magnetostrictive insert: Reposition the back or lateral surface of the active area antinode at the occlusal-third of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the distal col. Piezoelectric tip: Reposition the lateral surface of the active area antinode at the occlusal-third of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if you were going to probe the distal col. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the distal. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the nail polish or Wite-Out from the distal surfaces occlusal to the gum line.

D DL

D DL

D DL

ML midline

■

Reposition the lateral surface of the active area antinode at the occlusal-third of the distal-lingual midline in a vertical orientation with a 0- to 15-degree angulation. Reposition the HVE as needed. Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the nail polish or Wite-Out on the distal-lingual midline. Advance the active area antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation. Remove all the Wite-Out from the distal-lingual midline surfaces occlusal to the gum line.

L

ML midline

■

ML M

ML M

L

ML midline

■

L

ML M

L

ML midline

■

DL midline

■

D DL

DL midline

■

Magnetostrictive insert: Transition to a transverse orientation with the lateral or back surface with a 0- to 15-degree angulation to debride the mesial interproximal contact supragingivally. Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a 0- to 15-degree angulation to debride the mesial interproximal contact supragingivally. Debride one-half of the mesial interproximal space. The other half was debrided from the buccal. Reposition the HVE as needed. Remove all the nail polish or Wite-Out from one-half of the mesial interproximal space.

DL midline

■

Chapter 12 Ultrasonic Technique

DL midline

236

ML M

Summary

Table 12-4  Ultrasonic Instrumentation of the Mandibular First Molar Lingual Surfaces

■ ■ ■

D DL

L

ML midline

■

Magnetostrictive insert: Transition to a transverse orientation with the lateral or face surface with a 0- to 15-degree angulation to debride the distal interproximal contact supragingivally. Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a 0- to 15-degree angulation to debride the distal interproximal contact supragingivally. Debride one-half of the distal interproximal space. The other half was debrided from the buccal. Reposition the HVE as needed. Remove all the nail polish or Wite-Out from one-half of the distal interproximal space.

(continued) DL midline

■

237

ML M

Summary

Ultrasonic instrumentation is a safe and effective method to remove oral deposits. Continuous practice is required to achieve proficiency with the technique demands of the technology. When mastered,

ultrasonic instrumentation conserves root structures, reduces pathogens, and improves ergonomics through decreased labor intensity and time for procedures.

CHAPTER 13

Dentsply Sirona LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Identify Dentsply Sirona magnetostrictive ultrasonic products, parts, and accessories. 2. Recognize the design differences of inserts and select the best insert for the patient presentation. 3. Understand the operations of the foot pedal. 4. Perform proper water-line maintenance. 5. Select the correct water flow and power setting for each insert. 6. Reprocess handpieces and inserts according to the manufacturer’s recommendations.

KEY TERMS

mode: a power mode option activated • Boost through the foot pedal that delivers additional

power output. Cavitron Diamondcoat 30K Ultrasonic Insert: the name for the diamond-coated shank manufactured by Dentsply Sirona. Cavitron Powerline Ultrasonic Insert: the name for thick diameter inserts manufactured by Dentsply Sirona. Cavitron Slimline Ultrasonic Insert: the name of thin diameter inserts manufactured by Dentsply Sirona. Cavitron Softip Disposable Prophy Tip Removal Wrench: autoclavable wrench used to apply and remove the disposable single-use Softip on the shank of the Cavitron Softip Implant 30K Ultrasonic Insert manufactured by Dentsply Sirona. Cavitron Softip Implant 30K Ultrasonic Insert: the name for the implant insert manufactured by Dentsply Sirona. Cavitron Steri-Mate 360 Handpiece: handpiece with a 360-degree rotating nose cone manufactured by Dentsply Sirona.

• • • • • •

Steri-Mate Sterilizable, Detachable • Cavitron Handpiece: non-rotating nose-cone, detachable

handpiece for single mode ultrasonic scaling devices manufactured by Dentsply Sirona. Cavitron Thinsert 30K Ultrasonic Insert: the name of the ultra-thin diameter insert manufactured by Dentsply Sirona. Cavitron Ultrasonic Scaling System: the name of a Dentsply Sirona magnetostrictive ultrasonic device. Fitgrip: the name of an insert grip with larger width and rippled texturing manufactured by Dentsply Sirona. Jet-Mate Sterilizable, Detachable Handpiece: handpiece for dual mode ultrasonic scaling devices that provide both magnetostrictive ultrasonic scaling and air polishing manufactured by Dentsply Sirona. Softip: blue disposable single-use Polysulfone Amoco P-1700 tip that is placed onto the Dentsply Sirona Cavitron Softip Implant 30K Ultrasonic Insert for dental implant debridement. Tap-On technology: a feature in a Dentsply Sirona magnetostrictive ultrasonic device that allows the system to deliver active cavitation to the insert without a constant depression of the foot pedal.

• • • • • •

Introduction This chapter will explore magnetostrictive ultrasonic technology manufactured by Dentsply Sirona. The company’s research and development teams have ­continued to evolve the field of magnetostrictive technology, releasing new and innovative devices and insert designs since 1957. Although there are other manufacturers of magnetostrictive ultrasonic technology, it would be too lengthy for this book to cover every single one. For this reason, the author has chosen to focus on two of the largest global magnetostrictive manufacturers. 239

240

Chapter 13 Dentsply Sirona

This chapter will present Dentsply Sirona ultrasonic devices, handpieces, and insert portfolio. Detailed information for each insert with its clinical use, power settings, diameter, shape, length, cross-section, and coatings will be discussed. This knowledge will assist the oral health-care provider in implementing a contemporary approach to ultrasonic instrumentation. As discussed in other chapters, it is best practice to use the inserts from the company that made your ultrasonic device because there are many differences in manufacturing designs. Mismatching manufacturer technology is not recommended and has the potential to adversely affect efficiency and equipment performance, and possibly void the product’s warranty. This book will not discuss 25 kHz ultrasonic technology because this technology has been replaced by the 30 kHz market. As discussed in Chapter 3 to change the frequency of a magnetostrictive ultrasonic from 25 kHz to 30 kHz, the ferromagnetic laminate nickel plates are shortened, so a 25 kHz insert cannot be used in a 30 kHz device. Dentsply Sirona offers a single 25 kHz ultrasonic device with a limited selection of inserts. Newer inserts are now specifically designed for 30 kHz devices and not available in the older 25 kHz models.

Magnetostrictive Ultrasonic Devices The trade name for the Dentsply Sirona magnetostrictive ultrasonic device is Cavitron Ultrasonic Scaling System. Dentsply Sirona has been manufacturing magnetostrictive ultrasonic devices for the dental market since 1957, with many models developed over the years that offer a wide range of functionality and features, for example:

• Single mode models that provide magnetostric• • •

tive ultrasonic scaling. Dual-mode models that provide both magnetostrictive ultrasonic scaling and air polishing. Independent self-contained water reservoirs. Digital touch screen magnetostrictive ultrasonic scalers.

Frequency

Original models from the 1950s required the provider to manually tune a Cavitron Ultrasonic Scaling device to a specific frequency (see Chapter 7). By the 1980s, Cavitron Ultrasonic Scaling models had been sold with a set frequency. Many 30 kHz Cavitron Ultrasonic Scaling models have been released since the 1980s, each with improvements to the technology. The

Figure 13-1  Dentsply Sirona Cavitron Slimline 10S 25K

Ultrasonic Insert Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert Reproduced with permission from Dentsply Sirona.

30 kHz models have replaced the antiquated 25 kHz models, and newer inserts have been developed specifically for 30 kHz Cavitron Ultrasonic Scaling models, making the selection of inserts for a 25 kHz device different than 30 kHz. Due to the difference in length, a 25 kHz insert cannot be used in a 30 kHz ultrasonic device, and vice versa (see Figure 13-1).

Emerging Technology

The newest Cavitron Ultrasonic Scaling systems released by Dentsply Sirona are the Cavitron 300 ­Series Ultrasonic Scaling System and Cavitron Touch Ultrasonic Scaling System. They are the first digital magnetostrictive ultrasonic devices with touch screen technology. All previous models are analog.

• Analog ultrasonic scaling system: An analog ultra-

•

sonic scaler harnesses the energy produced by the ultrasonic sound waves from equilibrium to the crest of the wave (positive energy; see Figure 13-2a). The energy produced from the wave’s equilibrium to the trough (negative energy) is not used to drive the handpiece action and dissipates as heat, as seen in Figure 13-2a (dotted lines). Digital ultrasonic scaling system: A digital ultrasonic scaler harnesses and delivers both the positive and negative energy of the ultrasonic sound waves (see Figure 13-2b). Less heat is produced in this system so the provider can opt to lower the water flow rate during active instrumentation for improved visibility and aerosol control. Through harnessing all positive and negative energy created by the ultrasonic sound waves, lower power settings can be used to remove oral deposits, improving efficiency and patient comfort.

Digital Cavitron Ultrasonic Scaling Systems

Digital Cavitron Ultrasonic Scaling Systems have many user-friendly features (as seen in Figure 13-3).

Magnetostrictive Ultrasonic Devices

241

Positive energy

Negative energy

A

Positive energy

Negative energy

B Figure 13-2  Analog and Digital Ultrasonic Scaling

A

Systems: A. Analog Ultrasonic Scaling System, B. Digital Ultrasonic Scaling System

Figure 13-3  Cavitron 300 Series Ultrasonic Scaling System Reproduced with permission from Dentsply Sirona.

• Touch screen: Allows for a change in a setting •

• •

without the use of a dial, as is used in analog models. This allows for more precise control. Automatic purge: When activated, automatic purge provides a constant water flow for two minutes. This timer can be stopped early by touching the control on the screen (see Figure 13-4a and b). Rinse: Provides an aqueous lavage flow from the insert without cavitation. The rinse feature is located under the purge button (as seen in Figure 13-4a). Settings icon: Located at the bottom left of the screen (see Figure 13-5). Settings allow for an

B Figure 13-4  Dentsply Sirona Cavitron Touch Ultrasonic

Scaling System Icons: A. Left side of screen, top icon is purge and second from the top icon is rinse, B. Purge Countdown for 120 Seconds. To Interrupt Automatic Purge, Touch the Icon (Scale) Next to the Counter Reproduced with permission from Dentsply Sirona.

•

adjustment in foot pedal settings and screen brightness. Preset power mode options: There are three programable preset power options. This allows for a quick touch selection during treatment. Icons are located on the right side of the screen. See ­Figure 13-5.

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Chapter 13 Dentsply Sirona

A

Figure 13-5  Dentsply Sirona Cavitron Touch Ultrasonic

Scaling System Icons

Reproduced with permission from Dentsply Sirona.

• Lock/unlock screen: The user can lock and unlock •

•

• • •

the screen. The light will diminish when the screen is locked. Simply hold the button for three seconds to activate and deactivate (see ­Figure 13-5). Foot pedal: Round, cord-free foot pedal with Bluetooth and Tap-On technology accompanies the device. The screen displays the battery level on the menu screen, similar to a smartphone with four bars (see Figure 13-6a). • Four bars: 75–100% charged • Three bars: 50–75% charged • Two bars: 25–50% charged • One bar: 0–25% charged The battery is charged via a USB cord that connects the pedal to the front of the device (see Figure 13-6b). Handpiece: Detachable and sterilizable Cavitron Steri-Mate 360 Handpiece is used with digital ultrasonic scaling systems. The handpiece has a rotating nose cone for improved ergonomics by decreasing operator repositioning and finger rest adjustments during active patient treatment (see Figure 13-7). Handpiece cord: The handpiece cord rotates during use and is lighter than analog models. Water control: Control is on the handpiece connector cord. Water filter: An icon will appear on the device when the water filter needs to be replaced.

B Figure 13-6  Battery Display and USB Charger Dentsply

Sirona Cavitron Touch Ultrasonic Scaling System: A. Green battery display is on the top right, B. Foot pedal charging is on the left Reproduced with permission from Dentsply Sirona.

Figure 13-7  Rotating Nose Cone, Dentsply Sirona

Cavitron Steri-Mate 360 Handpiece Reproduced with permission from Dentsply Sirona.

Power

The power output is controlled by either a dial or touch screen depending on the model. The foot pedal activates

Magnetostrictive Ultrasonic Devices

and deactivates the device and delivers the power level selected by the provider. Boost mode is an option on select models controlled through the foot pedal.

Power Control

•

Power output options are low, medium, and high, controlled through a dial or touch screen.

• Dial: Analog scalers are sold with a movable dial

that has varied color markings, depending on the model. It is easier to distinguish power settings on an analog movable dial if we compare it to a standard clock that tells time with a first and second hand (see Figure 13-8).

A

B Figure 13-8  Dentsply Sirona Cavitron Analog Dial

(Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System): A. Dial, B. Clock

•

243

• Power off: 6 o’clock • Low power: approximately 6 to 10 o’clock • Medium power: approximately 10 to 12 o’clock • High power: approximately 12 to 2 o’clock Dual models with air polishing and ultrasonic scaling have one dial to control both functions. Moving the dial past 2 o’clock will activate air polishing. The section may read, “Prophy Mode,” with a gray or purple color. The colors and marking vary by model (see Figure 13-9). Touch screen: Digital models are a touch screen with numbers 0–100. The power output is displayed in the middle of the screen (see Table 13-1).

Table 13-2 provides a summary of power settings for both analog and digital technology. • Low power: Used for the removal of light biofilm, bacterial by-products, stain, and dental calculus. • Medium power: Used for the removal of moderate to heavy biofilm, bacterial by-products, stain, and light to moderate dental calculus. • High power: Used for the removal of heavy stain and dental calculus.

Power settings past 2 o’clock on an analog model or over 75 on a digital model are generally not used for ultrasonic instrumentation because the displacement amplitude of the insert becomes so great that the effectiveness of oral deposit removal becomes compromised (see Figure 13-10). Each insert is designed for specific power out levels and should never be used at a power output not approved by the manufacturer. This information can be found in the instruction for use (IFU).

Figure 13-9  Dentsply Sirona Cavitron Jet Plus Ultrasonic

Scaling and Air Polishing System with Purple “Prophy Mode” on the Dial Reproduced with permission from Dentsply Sirona.

244

Chapter 13 Dentsply Sirona

Table 13-1  Power Settings (Dentsply Sirona Cavitron Touch Ultrasonic Scaling System) Low power

Approximately 0–30

          Medium power

Approximately 30–60

               High power

Approximately 60+

Reproduced with permission from Dentsply Sirona.

Table 13-2  Dentsply Sirona Power Settings Digital Cavitron Analog Cavitron Ultrasonic Scaling* Ultrasonic Scaling*

Biofilm, Bacterial By-Products

Stain

Dental Calculus

Low

0–30

Off position to 10 o’clock

Light

Light

Light

Medium

30–60

10–12 o’clock

Moderate, heavy

Moderate, heavy

Light, moderate

High

60+

12–2 o’clock

X

Moderate, heavy

Moderate, heavy

*Power levels are approximations. Reproduced with permission from Dentsply Sirona.

Boost Mode

Many, but not all, models have a Boost mode option. Refer to the model IFU to determine if Boost mode is available. Boost mode is controlled by the foot pedal, which is depressed all the way to the floor to activate, also called second position. Boost allows for uninterrupted ultrasonic instrumentation. When Boost mode is activated, the power output will increase by ­approximately 25%. Boost is a useful feature during debridement when a larger oral deposit is encountered. The provider does not need to stop ultrasonic instrumentation to increase the power setting. They simply depress the

pedal to its second position (all the way down) to activate Boost and increase the power to remove the larger deposit. See Figure 13-13a. The pedal is then returned to its first position (half-way down) to deactivate Boost. See Figure 13-13b.

• Analog Ultrasonic Scaling Systems: when Boost •

mode is activated, the light on the front of the device will change from green (on) to orange ­ (Boost; see Figure 13-11a). Digital Ultrasonic Scaling Systems: touch screen will display the word BOOST in orange above the power output level selected by the user when ­activated (see Figure 13-11b).

Magnetostrictive Ultrasonic Devices

245

A B Figure 13-10  Maximum Power Settings: A. Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling

and Air Polishing System dial set to 2 o’clock, B. Dentsply Sirona Cavitron Touch Ultrasonic Scaling System set to 75. Reproduced with permission from Dentsply Sirona.

A

B

C

Figure 13-11  Dentsply Sirona Cavitron Ultrasonic Scaling System Boost Mode: A. Green light ‘on’ (Dentsply Sirona

Cavitron Select SPS Ultrasonic Scaling System), B. Orange light ‘Boost mode”, C. Orange BOOST display (Dentsply Sirona Cavitron Touch Ultrasonic Scaling system). Reproduced with permission from Dentsply Sirona.

Foot Pedal

• Round foot pedal: Allows the provider to depress

Original models had a square foot pedal and newer models have a round foot pedal (see Figure 13-12a and b). Wireless Bluetooth technology, Boost, and Tap-On technology are available in specific models. Refer to the IFU to determine which features your model has.

• •

the pedal anywhere for activation. Boost: Activated by depressing the foot pedal to its second position to deliver an approximately 25% increase in power output (see Figure 13-13a). Tap-On technology: Tap-On technology wireless foot pedal eliminates the need to hold the

246

Chapter 13 Dentsply Sirona

A

A

B B Figure 13-12  Dentsply Sirona Cavitron Foot Pedals:

A. Round (Tap-On Technology Wireless Foot Pedal), B. Square

Figure 13-13  Dentsply Sirona Tap-On technology

wireless foot pedal: A. Boost (pedal depressed to second position which is all the way down), B. Tap-on (pedal depressed to the first position which is half-way down)

Reproduced with permission from Dentsply Sirona.

•

foot pedal down during active treatment. This allows the provider to relax their foot on the floor during ultrasonic instrumentation, which decreases strain on the leg, hips, and back. To activate Tap-On technology, the foot pedal is pressed to its first position and then quickly released (see Figure  13-13b). A digital Ultrasonic Scaling System can also enable tap-on from the settings screen. The length of time the device stays active varies based on the model purchased and is listed in the IFU. Tap-On technology only activates when a handpiece and insert is attached. Wireless Bluetooth technology: Allows ease of maneuverability for the provider as the pedal is not tethered to the ultrasonic device.

The foot pedal must be synched to the ultrasonic device upon delivery. The steps for synchronization follow.

Digital Cavitron System

Ultrasonic

Scaling

1. Turn the power on. 2. Stand within 10 feet of the unit. 3. Press and hold the settings icon on the touch screen (see Figure 13-5). 4. Press the sync icon. The icon will begin to rotate. 5. On the bottom of the foot pedal, press and hold the red button for three seconds. 6. The sync icon will stop rotating on the touch screen when the pedal is synchronized. Analog Cavitron System

Ultrasonic

1. Turn the power on. 2. Stand within 10 feet of the unit.

Scaling

Magnetostrictive Ultrasonic Devices

3. Press the purge button (see Figure 13-14). 4. Graphics will blink for 5–6 seconds. During this time, on the bottom of the foot pedal, press and hold the red button for three seconds. 5. All graphics will blink at the same time upon successful synchronization.

Water

The water flow rate is controlled either with the handpiece connector or with a dial depending on the  model. The water flow rate is selected based on the power output setting. If present, the water filter must be periodically checked and replaced at a specified interval by the manufacturer, which can be found in the IFU.

Water Control An analog device has a water control either on the handpiece connector cable or as a dial, depending on the model purchased. A digital model has a water control on the handpiece connector cable. The handpiece connector water display has either numbers or symbols depending on the model.

• Numbers: the lower the number, the lower the water flow rate (see Figure 13-15).

• Symbols: One water droplet has a lower water flow rate than three water droplets.

Water Flow Rate The water flow rate is chosen based on the power output setting.

• Low to medium power: Water flow rate is set for a •

rapid drip with a fine mist halo (see Figure 13-16a). High power: The water flow rate is turned up, so the rapid drip disappears, and a strong mist is expelled (see Figure 13-16b).

Water Filter If using a model with a water filter, the filter should be inspected regularly to ensure it is not in need of replacement prior to its recommended replacement interval. Replacement intervals are based on the water supply source being run through the unit (see Table 13-3 for details). The filter should be replaced more frequently if the:

• Filter has particulate matter buildup. • Filter discolors from the original color. • Water flow in the line is reduced or inconsistent. Insert Water Port Inserts have an internal water port as described in Chapter 5. Internal water ports are equipped with a small cannula tube embedded inside the shank that emerges from a small opening. The port position on the shank varies for each insert.

Figure 13-14  Purge button in blue (Dentsply Sirona

Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System) Reproduced with permission from Dentsply Sirona.

247

Figure 13-15  Dentsply Sirona Cavitron Ultrasonic

Scaling System Water Control Number 1-6

248

Chapter 13 Dentsply Sirona

Fine mist High power

Mist with droplets Low-med power

A

B

Figure 13-16  Water Settings: A. Low to medium power (Cavitron Slimline 10S 30K Ultrasonic Insert), B. High power

(Cavitorn Powerline 1000 30K Ultrasonic Insert) Reproduced with permission from Dentsply Sirona.

Table 13-3  Dentsply Sirona Cavitron Ultrasonic Scaling Water Filter Replacement

(Reproduced with permission from Dentsply Sirona)

Water Source

Municipal

Well

Hard

Soft

Bottle Systems

Replacement timing

1 × month

2 × month

2 × month

1 × month

2 × month

Reproduced with permission from Dentsply Sirona.

Handpiece Handpieces have evolved over the years to maintain compliance with changing Centers for Disease Control and Prevention (CDC) recommendations for handpiece reprocessing. The IFU will list the specific handpiece that is compatible with the model purchased. The provider must purchase the handpiece that is compatible with their model. Current models use a sterilizable handpiece.

• Dual mode Ultrasonic Scaling Systems that pro-

vide both magnetostrictive ultrasonic scaling and air polishing have a handpiece that is equipped for both an ultrasonic insert and air polishing nozzle

•

called the Jet-Mate Sterilizable, Detachable Handpiece (see Figure 13-17a). Analog Ultrasonic Scaling Systems use a non-­ rotating nose-cone, detachable handpiece (see  Figure 13-17b) called the Cavitron SteriMate Sterilizable, Detachable Handpiece

• Digital Ultrasonic Scaling Systems use the Cavitron Steri-Mate 360 Handpiece that features a rotating nosecone as seen in Figure 13-17c.

Connect the handpiece to the handpiece connector cable by aligning the electrical connections. Be gentle when attaching and removing the handpiece from the connector to avoid damage to the connections (see Figure 13-18).

Insert Portfolio

249

Insert Portfolio A

B

C Figure 13-17  Dentsply Sirona Cavitron Ultrasonic

Handpieces: A. Dual Model Jet-Mate Sterilizable, Detachable Ultrasonic Handpiece, B. Cavitron SteriMate Sterilizable, Detachable Handpiece, C. Cavitron Steri-Mate 360 Handpiece Reproduced with permission from Dentsply Sirona.

Dentsply Sirona manufactures a variety of shank shapes, diameters, cross-sections, and coatings for its analog and digital 30K Cavitron Ultrasonic Scaling Systems, which supports a contemporary approach to ultrasonic instrumentation. All inserts have a color grip covering the connecting body; one O-ring; and 16 ferromagnetic laminate nickel plates with markings of the company name, lot number, and date of insert creation. The O-ring is a wear-and-tear item and should be replaced when worn. The color of the grip is a patented color specific for Dentsply Sirona ultrasonic inserts. There are five color grips: 1. Thick diameter shank: Cavitron Powerline Ultrasonic Insert with a blue grip. 2. Thin diameter shank: Cavitron Slimline ­Ultrasonic Insert with a green grip. 3. Ultra-thin shank: Cavitron Thinsert 30K Ultrasonic Insert with a purple grip. 4. Implant insert: Cavitron Softip Implant 30K Ultrasonic Insert with a yellow grip. 5. Diamond insert: Cavitron DiamondCoat 30K Ultrasonic Insert with an orange grip. In 2014, a new style grip was released named

Fitgrip. The Fitgrip has a larger width with rippled

texturing (see Figure 13-19). Thicker grips improve ergonomics by decreasing muscle strain and pinch force. The texturing improves the provider’s grasp and decreases slipping.

Figure 13-18  Dentsply Sirona handpiece connector cable

on left and Jet-Mate Sterilizable, Detachable Ultrasonic Handpiece on the right

The handpiece should be filled with water prior to seating an insert and the O-ring lubricated as described in Chapter 5 (see Figure 5-7).

• Hold the handpiece upright over a sink, then step • • •

on the pedal to fill the handpiece with water until a dome of water appears on the brim. Allow any trapped air to exit the handpiece prior to seating an insert. Lubricate the O-ring on the insert by rotating the O-ring 360 degrees over the water dome. Place the insert into the handpiece in an upright position. Apply gentle pressure and use a pushtwist motion to fully seat the O-ring of the insert into the handpiece.

Thick Diameter Cavitron Powerline Ultrasonic Inserts

Thick diameter inserts have the largest surface area of the shank and are termed Cavitron Powerline ­Ultrasonic Inserts (see Figure 13-20a to d). They have a blue grip color. There are four Cavitron Powerline Ultrasonic Inserts that all have a straight shank. There are no curved shank shapes in the thick diameter insert portfolio because their surface area is too large to access subgingivally in tightly adherent tissues to reach complex root anatomy. The Cavitron Powerline Ultrasonic Insert portfolio offers a variety of bends in the terminal 4 mm of the shank. All inserts are still considered a straight shape because the overall shank is still bent in one plane with small bends in the terminal 4 mm. The  small bends change the cross-section and length of the shank. Table 13-4 provides a summary of cross-section and number of bends.

250

Chapter 13 Dentsply Sirona

• Cross-section: A one- and two-bended shank has •

a round or circular cross-section, and a threebended shank has a diamond cross-section. Adaptation: The diamond cross-section allows for easier adaption of the active area antinode

•

to interproximal areas and line angles (see Figure 13-21). Length: Every time the terminal 4 mm of the shank is bent, the shank length changes slightly. This is only clinically relevant if accessing deeper periodontal pockets.

Table 13-4  Dentsply Sirona Cavitron Powerline Ultrasonic Inserts

Number of Bends in Terminal 4 mm Crossof Shank Section

Name

Figure 13-19  Dentsply Sirona Fitgrip and Standard Grip

(Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert on left and Cavitron Powerline 10 30K Ultrasonic Insert on right)

Cavitron Powerline 10 30K Ultrasonic Insert

1

Round

Cavitron Powerline 100 30K Ultrasonic Insert

2

Round

Cavitron Powerline 1000 30K Ultrasonic Insert

3

Diamond

Cavitron Powerline 3 30K Ultrasonic Insert

1

Broad, flat, blunt design

Memory trick: The number of zeros indicate the number of bends in the terminal 4 mm of the shank.

Reproduced with permission from Dentsply Sirona.

A

B

C

D

Figure 13-20  Dentsply Sirona Powerline Ultrasonic Inserts: A. Cavitron

Powerline 10 Fitgrip 30K Ultrasonic Insert, B. Cavitron Powerline 100 Fitgrip 30K Ultrasonic Insert, C. Cavitron Powerline 1000 Fitgrip 30K Ultrasonic Insert, D. Cavitron Powerline 3 Fitgrip 30K Ultrasonic Insert Reproduced with permission from Dentsply Sirona.

Insert Portfolio

251

Figure 13-21  Dentsply Sirona Cavitron Powerline

1000 30k Ultrasonic Insert Adapted to the Line Angle of the Mandibular First Molar Buccal Surface. Diamond Cross-Section Inserts Adapted to the Curved Line Angle Anatomy of the Mandibular First Molar Buccal Surface. Notice the Active Area Antinode is in Contact With the Curved Line Angle Anatomy of the Mandibular First Molar Buccal Surface

Clinical Indications for Use Cavitron Powerline 10, 100, 1000 30K Ultrasonic Inserts:

• Used for the removal of moderate to heavy dental • •

calculus deposits and supragingival staining. If tissues are soft, spongy, and movable, they may be able to access subgingivally. When tissues are firm, hard, or tightly adherent, access may be restricted.

Cavitron Powerline 3 30K Ultrasonic Insert:

• •

Used for the removal of large, heavy supragingival dental calculus deposits. The provider will adapt the point directly onto the deposits for removal. Never used subgingival due to its broad, flat, and blunt shank shape (see Figure 3-20d).

Power Settings Cavitron Powerline Ultrasonic Inserts can be used at all power settings without injury to the shank. Clinically, since they are used for the removal of moderate to heavy dental calculus and stain, a high power is typically used.

Thin Diameter Cavitron Slimline Ultrasonic Inserts

Cavitron Slimline Ultrasonic Inserts have a shank

diameter that is 30% thinner than the Cavitron

Figure 13-22  Cavitron Slimline 10S Fitgrip 30K Ultrasonic

Insert on the left and Dentsply Sirona Cavitron Powerline Fitgrip 30K 10 Ultrasonic Insert on the right Reproduced with permission from Dentsply Sirona.

Powerline 10, 100, 1000 30K Ultrasonic Inserts (see Figure 3-22). They have a green color grip. Dentsply Sirona manufactures four Cavitron Slimline Ultrasonic Inserts listed in Table 13-5 (see Figure 13-23a to c).

• Straight shank shape: Cavitron Slimline 10S and •

1000 30K Ultrasonic Inserts. Curved shank shape: Cavitron Slimline 10R and 10L 30K Ultrasonic Inserts.

Clinical Indications for Use Cavitron Slimline Ultrasonic Inserts are used for the removal of light to moderate dental calculus and stain as well as all levels of biofilm and bacterial by-­ products. The 30% thinner shank diameter allows for subgingival access with little to no tissue distension. The Cavitron Slimline 10R and 10L 30K Ultrasonic Inserts have a long and curved shank shape, which allows access and adaptation to complex root anatomy (concavity, convexity, furcation) and deep periodontal pockets.

Power Settings Cavitron Slimline Ultrasonic Inserts vary on the power settings that can be safely used without injury to the shank. This is because the connecting body under the grip varies in design. Table 13-6 summarizes the power settings for each insert.

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Table 13-5  Dentsply Sirona Cavitron Slimline Ultrasonic Inserts Number of Bends in Terminal 4 mm of Shank

Name

Cross-Section Shape

Shank Shape

Cavitron Slimline 10S 30K Ultrasonic Insert

1

Round

Straight

Cavitron Slimline 1000 30K Ultrasonic Insert

3

Diamond

Straight

Cavitron Slimline 10R 30K Ultrasonic Insert

1

Round

Curved

Cavitron Slimline 10L 30K Ultrasonic Insert

1

Round

Curved

A

B

C

Figure 13-23  Dentsply Sirona Cavitron Slimline Ultrasonic Inserts: A. Cavitron Slimline 10S

Fitgrip 30K Ultrasonic Insert, B. Cavitron Slimline 1000 Fitgrip 30K Ultrasonic Insert, C. Cavitron Slimline 10L/10R Fitgrip 30K Ultrasonic Inserts Reproduced with permission from Dentsply Sirona.

• All power settings: Cavitron Slimline 1000 30K •

Ultrasonic Insert can be used on low, medium, and high power. Low to medium power: Cavitron Slimline 10S, 10R, 10L 30K Ultrasonic Inserts are used on low and medium power because the connecting body does not support the use of high power.

When incorrect power settings are used, the risk for insert damage or shank breakage increases. Patient safety is at risk if the shank were to break in the mouth while in use. The patient could aspirate the broken shank. If it breaks subgingivally, a retrieval procedure may be required.

Table 13-6  Dentsply Sirona Cavitron Slimline Ultrasonic Inserts Power Settings Insert

Power Setting

Cavitron Slimline 10S 30K Ultrasonic Insert

Low, medium

Cavitron Slimline 1000 30K Ultrasonic Insert

Low, medium, high

Cavitron Slimline 10R 30K Ultrasonic Insert

Low, medium

Cavitron Slimline 10L 30K Ultrasonic Insert

Low, medium

Insert Portfolio

Ultra-Thin Diameter Cavitron Thinsert

The Cavitron Thinsert 30K Ultrasonic Insert has a diameter shank that is 47% thinner than ­Cavitron Slimline Ultrasonic Inserts (see Figure 13-24a). The grip is a purple color. This insert has a similar thickness to an ODU11/12 periodontal explorer with similar tactile sensitivity (Partido et al., 2018; see Figure 13-24b).

Clinical Indications for Use The Cavitron Thinsert 30K Ultrasonic Insert is used for the removal of light to moderate dental calculus

253

deposits, staining, biofilm, and bacterial by-­products. The Cavitron Thinsert 30K Ultrasonic Insert is useful for:

• Adapting to tooth roots under the gums in firm, • • •

avascularized, tight epithelial tissue. The insert causes little to no tissue distension (see Figure 13-25). Accessing tight interproximal spaces when teeth are crowded (see Figure 13-26a to c). Debriding around a fixed orthodontic appliance such as a retainer (see Figure 13-27). Exploration to detect residual oral deposits during active ultrasonic instrumentation. A study by Partido et al. (2018) found an inactive Cavitron Thinsert 30K Ultrasonic Insert and a hand-activated ODU 11/12 explorer produced similar results in calculus detection. The advantage of using a Cavitron Thinsert 30K Ultrasonic Insert for exploration is the provider does not have to put down their ultrasonic handpiece and pick up an explorer to detect for residual oral deposits. This increases efficiency by not changing instruments.

Power Settings

A

The Cavitron Thinsert 30K Ultrasonic Insert may be used at all power settings without injury to the shank. Clinically, because the insert is commonly used for the removal of light to moderate dental calculus deposits and biofilm, low and medium power are commonly used. Since an inactive Cavitron Thinsert 30K Ultrasonic Insert can also be used as an explorer, if a dental calculus deposit were encountered, the provider could turn up the power to medium-high and use the Cavitron Thinsert 30K Ultrasonic Insert for its removal without damage to the shank.

B Figure 13-24  Dentsply Sirona Cavitron Thinsert 30K

Ultrasonic Insert: A. Cavitron Thinsert 30K Ultrasonic Insert and Slimline 10S Fitgrip 30K Ultrasonic Insert, B. Cavitron Thinsert 30K Ultrasonic Insert and HuFriedyGroup 11/12 Old Dominion University (ODU) Explorer Reproduced with permission from Dentsply Sirona.

Figure 13-25  Firm, Avascularized, Tight Epithelial

Tissue of a Patient Who Smokes Cigarettes

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Chapter 13 Dentsply Sirona

A Figure 13-27  Fixed lingual retainer on the mandibular

anterior lingual surfaces

B

C Figure 13-26  Crowded Teeth: A. Mandibular

arch, B. Mandibular anterior and premolar teeth, C. Mandibular anterior and premolar teeth. Figure 13-28  Dentsply Sirona Cavitron Softip Disposable

Implant Insert

The Cavitron Softip Implant 30K Ultrasonic ­Insert has a yellow color grip with an inactive shank. The inactive shank is covered with a blue disposable single-use Softip made of Polysulfone Amoco P-1700, which is a high-strength polymer. The disposable Softip cannot be placed on any insert other than the Cavitron Softip Implant 30K Ultrasonic Insert because the Softip may break or fall off while in use.

Prophy Tip Removal Wrench, Softip (blue), and Cavitron Softip Implant 30K Ultrasonic Insert (yellow grip)

An autoclavable wrench called the Cavitron Softip Disposable Prophy Tip Removal Wrench

is used to apply and remove the disposable single-use Softip on the shank of the Cavitron Softip Implant 30K Ultrasonic Insert (see Figure 13-28). Use aseptic technique for attaching the blue Softip to the shank to avoid cross-contamination. Use gloves

Insert Portfolio

255

when handling equipment and ensure the insert and wrench have been sterilized prior to use. The following are steps for attaching the single use disposable blue Softip to the shank of the Cavitron Softip Implant 30K Ultrasonic Insert: 1. Place the blue-colored Softip into the round opening on the top of the Cavitron Softip Disposable Prophy Tip Removal Wrench (see Figure 13-29a and b). 2. Place the Cavitron Softip Implant 30K U ­ ltrasonic Insert shank into the Softip opening (see Figure 13-29c). 3. Turn the insert one-quarter turn and remove the Softip from the Cavitron Softip Disposable Prophy Tip Removal Wrench. 4. Verify the Softip is in place by gently tugging on the blue Softip with your fingers.

A

Use aseptic technique when detaching the blue Softip from the shank to avoid cross-contamination. The following are steps for detaching the blue Softip from the shank of the Cavitron Softip Implant 30K Ultrasonic Insert:

B

1. Place the Softip, which is still affixed to the Cavitron Softip Implant 30K Ultrasonic Insert shank, into the slot opening on the Cavitron Softip Disposable Prophy Tip Removal Wrench (see Figure 13-30a). 2. Place your thumb and index finger over the Softip (see Figure 13-30b). 3. Gently push the Cavitron Softip Implant 30K Ultrasonic Insert downward to disengage the ­ Softip. 4. Dispose of the used Softip in accordance with the standards of biohazard material. 5. Reprocess the Cavitron Softip Implant 30K Ultrasonic Insert and Cavitron Softip Disposable Prophy Tip Removal Wrench as directed in the IFU.

Clinical Indications for Use and Power Settings

C Figure 13-29  Attaching Softip to the Cavitron Softip

Implant 30K Ultrasonic Insert: A. Round opening of the Cavitron Softip Disposable Prophy Tip Removal Wrench, B. Place Softip into the wrench opening, C. Place Cavitron Softip Implant 30K Ultrasonic Shank into Softip opening Reproduced with permission from Dentsply Sirona.

Low power is used when debriding a dental implant. The Cavitron Softip Implant 30K Ultrasonic Insert can be safely used to debride implant structures (see Figure 13-31a to c). The insert provides the benefit of delivering acoustic cavitation, acoustic microstreaming, liquid jet production, tissue lavage, and irrigation around peri-implant tissues.

Diamond-Coated Insert

The Cavitron Diamondcoat 30K Ultrasonic I­nsert is an orange color with an impregnated diamond

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Chapter 13 Dentsply Sirona

A A

B

B Figure 13-30  Detaching Softip from the Cavitron Softip

Implant 30K Ultrasonic Insert: A. Softip placed into slot opening of the Cavitron Softip Disposable Prophy Tip Removal Wrench, B. Thumb and index finger over the Softip Reproduced with permission from Dentsply Sirona.

coating of the active area antinode of the shank (see Figure 13-32). The Cavitron Diamondcoat 30K Ultrasonic Insert is used for:

•

Removal of extremely tenacious deposits of calculus in both nonsurgical and surgical procedures.

C Figure 13-31  Dental implants: A. Dental implants

mandibular right molars, B. Dental implant-supported crowns mandibular right molars, C. Dental implant retention for an overdenture

• Removal of restoration overhangs and recontouring of dental restorations (amalgam, gold, composite, acrylic, and porcelain) in both nonsurgical and surgical procedures (see Figure 13-33).

Reprocessing

257

Reprocessing Always use aseptic techniques during reprocessing that include full Personal Protective Equipment (PPE) and utility gloves when handling contaminated equipment to avoid cross-­contamination and operator injury.

Cavitron Ultrasonic Scaler

The power cord, air and water lines, handpiece cable, foot pedal and cord, and the device itself is not sterilizable but should be disinfected with an approved solution per the manufacturer, which you can find in the product IFU. Do not spray disinfectant solutions directly on the Ultrasonic Scaling System surfaces. Use a manufacturer approved chemical wipe with correct contact time. Keep analog models away from direct sunlight to prevent discoloration. Figure 13-32  Dentsply Sirona Cavitron Diamondcoat

Ultrasonic Insert

Figure 13-33  Distal amalgam overhang on the

mandibular right first molar

The Cavitron DiamondCoat Ultrasonic Insert is not intended for: • Use by a dental hygienist during nonsurgical procedures because the insert is very abrasive. • General ultrasonic prophylaxis procedures because damage to soft and hard tissues may result. • The recontouring of metallic dental crowns because premature wear of the diamond coating will occur.

Insert

Carefully remove the insert from the handpiece, being sure not to strip the O-ring or damage the ferromagnetic laminate nickel plates. Clean any soil on the insert with a disposable cloth under running water and place in an ultrasonic bath for 15 minutes with an approved solution by the manufacturer. It is always best practice to use the manufacturer’s cleaner to ­ensure compatibility. The insert may be placed in an automated instrument washer with an approved solution per the ­manufacturer. Prior to bagging for sterilization, ensure the insert is completely dry. Do not use a chemical disinfectant on inserts. Steam under pressure sterilization is recommended because cold liquid disinfection, chemical vapor, and dry heat sterilization have not been tested or validated for efficacy.

Handpiece

Detach the handpiece from the unit with a gentle straight pull motion. Do not twist or turn the handpiece upon removal to avoid damage to the connectors. Automatic and manual cleaning directions are provided in the product’s IFU. Do not place the handpiece in an ultrasonic bath. Prior to bagging for sterilization, ensure the handpiece is completely dry. Sterilize with a steam under pressure sterilizer.

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Chapter 13 Dentsply Sirona

CASE STUDY

A 24-year-old Hispanic male presents to the hygienist for a new patient appointment. He has not seen a dentist since he was 15 years old. He smokes eight cigarettes a day and has daily moderate alcohol intake. He has a metal tongue ring. He does not take any prescription or over-the-counter medications, he has no known drug allergies, and his vitals are within normal limits. His chief complaint is “something feels weird on my lower front teeth, but nothing hurts” (see Figure 13-34). Periodontal findings: Generalized heavy biofilm and light to moderate dental calculus throughout. Probe depths are 3–4 mm generally with 85% bleeding upon probing. Gingival tissues are generally erythematous with localized edema mandibular anterior central and lateral incisors. No attachment loss is present except the mandibular central and lateral incisors, which also have heavy lingual, interproximal, and facial dental calculus. The patient has severe recession mandibular central incisors only on the lingual. Treatment plan: A periodontist performs the examination and recommends a nonsurgical periodontal debridement procedure followed by bone and gingival grafting for the mandibular anterior central incisors. The dental hygienist carries out phase one of the treatment and performs a nonsurgical periodontal debridement. Even with local anesthesia, the patient experienced pain upon instrumentation of the mandibular anterior central incisors, and the dental hygienist debrided to the best of their ability (see Figure 13-35).

Figure 13-34  Periapical radiograph and intraoral photograph of the mandibular anterior teeth

Figure 13-35  Immediate post-operative intraoral

photograph of the mandibular anterior teeth

Reprocessing

259

Figure 13-36  Four Week Postoperative Intraoral Photographs of the Mandibular Anterior Teeth

The patient was seen four-weeks post-nonsurgical periodontal debridement (see Figure 13-36). He reports severe pain for the first week after the procedure. The severe pain has subsided, but he still has occasional sensitivity to hot and cold on the mandibular anterior teeth.

Questions for Initial Nonsurgical Periodontal Debridement 1. Which of the following is not a likely cause of the localized severe attachment loss seen in Figure 13-34 and Figure 13-35? a. Attachment loss caused by natural aging processes b. Presence of a metal tongue ring c. Malocclusion with a traumatic bite d. The patient’s brushing habits 2. Which of the following inserts should be used to begin debridement of the mandibular anterior lingual central incisors pictured in Figure 13-34? a. Cavitron Powerline Ultrasonic Insert b. Cavitron Slimline Ultrasonic Insert c. Cavitron Thinsert 30K Ultrasonic Insert d. Both B and C 3. What power setting should be used to begin debridement of the mandibular anterior lingual central incisors with the insert selected in question 2? a. High b. Medium c. Low 4. True or False: A tap stroke followed by an ultrasonic activation stroke should be initially used to debride the mandibular anterior lingual central incisors with the insert selected in question 2. a. True b. False 5. The Cavitron Powerline Ultrasonic Insert reduces the size of the dental calculus from heavy to light. Which insert should the dental hygienist use next to remove the light deposits? a. Continue using the Cavitron Powerline Ultrasonic Insert b. Change from a Cavitron Powerline Ultrasonic Insert to the Cavitron Slimline1000 30K Ultrasonic Insert c. Change from a Cavitron Powerline Ultrasonic Insert to the Slimline10S 30K Ultrasonic Insert d. Change from a Cavitron Powerline Ultrasonic Insert to the Slimline10R 30K Ultrasonic Insert

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Chapter 13 Dentsply Sirona

6. What power setting should be used with the insert selected in question 5? a. High b. Medium c. Low d. Both B and C 7. After the dental hygienist used the Cavitron Powerline Ultrasonic Insert and Cavitron Slimline 10S Ultrasonic Insert, there was still residual light dental calculus on the distal-facial line angle of the mandibular left central incisor. What insert would be the best selection to remove this deposit? a. Cavitron Slimline 1000 30K Ultrasonic Insert b. Cavitron Thinsert 30K Ultrasonic Insert c. Cavitron Powerline 100 30K Ultrasonic Insert d. Cavitron Powerline 1000 30K Ultrasonic Insert 8. What power level can be used for the insert selected in question 7? a. Low b. Medium c. High d. All of the above

Questions for Four-Week Follow-Up Appointment 1. Ultrasonic technology is contraindicated for the debridement of the mandibular right central incisor dental calculus as seen in Figure 13-36. a. True b. False 2. Which of the following inserts should be used to begin debridement of the mandibular anterior lingual central incisors pictured in Figure 13-36? a. Cavitron Powerline Ultrasonic Insert b. Cavitron Slimline Ultrasonic Insert c. Cavitron Thinsert 30K Ultrasonic Insert d. Both B and C

Summary

Dentsply Sirona offers a variety of magnetostrictive technologies that allows for a contemporary approach to ultrasonic instrumentation. Always read your product’s direction for use/instruction for use (DFU/IFU)

Questions

1. In which of the following scenarios would an oral health-care provider choose to use low power? a. Heavy dental calculus mandibular anterior lingual. b. Light biofilm generally throughout the mouth. c. Heavy stain maxillary anterior lingual. d. Low power is never indicated for use. 2. On which power setting is the water flow rate set to a rapid drip with fine mist halo? a. Low b. Medium c. High

prior to using it for the first time. There is pertinent information for the safe handling and delivery of care that must be followed to avoid equipment damage and to keep your patient safe.

d. Both A and B e. All of the above 3. Which of the following cross-sections of an insert allows for better adaptation to line angles and interproximal surfaces? a. Round b. Diamond c. Broad, flat, blunt 4. True or False. Dentsply Sirona manufactures a curved magnetostrictive insert with a thick and thin diameter? a. True b. False

Questions

5. Which of the following is TRUE of the grip? a. A thinner grip will reduce pinch force. b. Texturing improves the grasp. c. No texturing will reduce the chance of slipping. d. None of the above. 6. True or False. A digital ultrasonic scaling system will produce more heat than an analog ultrasonic scaling. a. True b. False 7. When using a Cavitron Ultrasonic Scaling Analog System that has a dial to control the power, what clock position range is medium power? a. Approximately 6–10 o’clock b. Approximately 10–12 o’clock c. Approximately 12–2 o’clock 8. When using a Cavitron Ultrasonic Scaling Digital System that has a touch screen to control the power, what number range is medium power? a. Approximately 0–30 b. Approximately 30–60 c. Approximately 60+ 9. Which of the following is TRUE of the Boost mode in a Cavitron Ultrasonic Scaling System? a. The Cavitron 300 Series will display the word Boost in orange when activated on the screen. b. Increases the power output by approximately 25%. c. Activated by depressing the foot pedal to its second position d. Allows for uninterrupted ultrasonic instrumentation when a larger oral deposit is encountered. e. All of the above are true. 10. How often should a Dentsply Sirona water filter be replaced if the office is using a bottle water system with a Cavitron Ultrasonic Scaling System whose water supply is from the dental unit? a. Annually b. One time per month c. Two times per month d. The water filter never needs to be replaced

261

11. True or False. The Cavitron Steri-Mate 360 Handpiece can be used on any Cavitron Ultrasonic Scaling System. a. True b. False Match the following terms with their correct description. There is only one correct answer for each question. 12. Cavitron Powerline Ultrasonic Insert

A. Grip is a purple color and can be used at all power settings.

13. Cavitron Slimline Ultrasonic Insert

B. Grip is a blue color and used for the removal of heavy dental calculus.

14. Cavitron Thinsert 30K Ultrasonic Insert

C. Grip is a yellow color and used to debride dental implants.

15. Cavitron Softip Implant 30K Ultrasonic Insert

D. Grip is a green color and used for the removal of light to moderate oral deposits.

16. Which of the following inserts is only used for large, heavy supragingival dental calculus deposits and cannot be used subgingivally? a. Cavitron Powerline 10 30K Ultrasonic Insert b. Cavitron Powerline 100 30K Ultrasonic Insert c. Cavitron Powerline 1000 30K Ultrasonic Insert d. Cavitron Powerline 3 30K Ultrasonic Insert 17. Which of the following Cavitron Slimline Ultrasonic Inserts is allowed to be used on high power? a. Cavitron Slimline 10 30K Ultrasonic Insert b. Cavitron Slimline 1000 30K Ultrasonic Insert c. Cavitron Slimline 10R 30K Ultrasonic Insert d. Cavitron Slimline 10L 30K Ultrasonic Insert 18. Which of the following inserts has a comparable thickness and tactile sensitivity as the handactivated ODU 11/12 explorer? a. Cavitron Powerline Ultrasonic Insert b. Cavitron Slimline Ultrasonic Insert c. Cavitron Thinsert 30K Ultrasonic Insert

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19. Which of the following is TRUE of the Cavitron Softip Implant 30K Ultrasonic Insert? a. The shank is made of carbon. b. The shank is made of Teflon. c. The active area is covered with a detachable Softip made of Polysulfone Amoco P-1700. d. The shank is impregnated with Polyether ether ketone (PEEK).

References

1. Partido, B. B., Webb, C., & Carr, M. P. (2018). Comparison of the efficiency of calculus detection between ultrasonic inserts and an explorer. Journal of Dental Hygiene, 92(6), 33–39.

20. True or False. The disposable Softip is placed on the Cavitron Softip Implant 30K Ultrasonic Insert with your fingers. a. True b. False

CHAPTER 14

HuFriedyGroup LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Distinguish HuFriedyGroup magnetostrictive ultrasonic products, parts, and accessories. 2. Recognize the design differences of inserts and select the best insert for the patient presentation. 3. Perform proper water-line maintenance. 4. Select the correct water flow and power setting for each insert. 5. Reprocess handpieces and inserts according to the manufacturer’s recommendations.

KEY TERMS

flow: internal water port that is positioned • Base closer to the grip of an insert shank. operation mode: high power mode that • Blue allows the user to select a power output of

2.5–10.0 on the SWERV ™3 . Direct flow: internal water port that is positioned closer to the terminal 4 mm of an insert shank. ENZYMAX™: HuFriedyGroup enzymatic cleaner that is safe for use on HuFriedyGroup inserts. Green operation mode: low power mode that allows the user to select a lower power output of 1–5 on the SWERV ™3 . STREAMLINE™: category of HuFriedyGroup inserts with base flow that do not have a nose cone and do not swivel. STREAMLINE™ Direct Flow: category of the HuFriedyGroup’s inserts with direct flow that do not have a nose cone and do not swivel. STREAMLINE™ PLUS: category of HuFriedyGroup inserts with direct flow, have an 18% wider grip, a beige nose cone, and do not swivel.

• • • • • •

Series: the name of HuFriedyGroup’s • SWERV magnetostrictive ultrasonic device. category of HuFriedyGroup inserts with • Swivel: base flow that swivel, have an 18% wider grip, and 3 ™

a black nose cone.

DIRECT FLOW : category of • SWIVEL HuFriedyGroup inserts with direct flow that swivel, ™

have an 18% wider grip, and a gray nose cone.

Introduction This chapter will explore magnetostrictive ultrasonic technology manufactured by HuFriedyGroup. Their company’s research and development teams have continued to evolve the field of magnetostrictive technology, releasing new and innovative devices and insert designs. Although there are other manufacturers of magnetostrictive ultrasonic technology, it would be too lengthy for this book to cover every single one. For this reason, the author has chosen to focus on two of the largest global magnetostrictive manufacturers. This chapter will present the HuFriedyGroup’s ultrasonic devices, handpieces, and insert portfolio. Detailed information for each insert with its clinical use, power settings, diameter, shape, length, and cross-section will be discussed. This knowledge will assist the oral health-care provider in implementing a contemporary approach to ultrasonic instrumentation.

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Chapter 14 HuFriedyGroup

This book will not discuss 25 kHz ultrasonic technology because this technology has been replaced by the 30 kHz market. As discussed in Chapter 3, to change the frequency of a magnetostrictive ultrasonic from 25 kHz to 30 kHz, the ferromagnetic laminate nickel plates are shortened, so a 25 kHz insert cannot be used in a 30 kHz device. HuFriedyGroup offers a single 25  kHz ultrasonic device with a limited selection of inserts. Newer inserts are now specifically designed for 30 kHz devices and not available in the older 25 kHz models.

HuFriedyGroup Magnetostrictive Ultrasonic Device The trade name for the HuFriedyGroup magnetostrictive ultrasonic device is SWERV ™3 . There are two analog models:

• SWERV • SWERV

3 ™ 3 ™

Figure 14-1  HuFriedyGroup SWERV ™3 30K Courtesy of HuFriedyGroup Mfg. Co., LLC.

Series, 25K Series, 30K

By the time of this book’s publication, the SWERV ™3 Series has been discontinued, but its presence in the industry still exists. The SWERV ™3 Series models are single mode without air polishing dual capability. They do not have an independent self-contained water reservoir—they use the dental unit’s water supply source.

Frequency

HuFriedyGroup offers a 25 kHz and 30 kHz model. Varying inserts are offered for both frequency models, with more options for the 30 kHz. A 25 kHz insert cannot be used in the 30 kHz model, and vice versa, due to the difference in the plate length. 3 SWERV™ 30K

The SWERV ™3 30K is shown in Figure 14-1 and has many user-friendly features such as:

• Two color-coded power settings. One is blue and • •

the other is green. Blue is for higher power output and green is for lower power output. Automatic purge: When activated, automatic purge provides a constant water flow for 45 seconds. Digital display.

Figure 14-2  HuFriedyGroup SWERV ™3 Series 30K Power

Control

Courtesy of HuFriedyGroup Mfg. Co., LLC.

Power

HuFriedyGroup’s magnetostrictive ultrasonic devices have a two-part system that controls the power output. There is no Boost mode option. The foot pedal activates and deactivates the device and delivers the power output selected by the provider.

Power Control The two-part system for power control consists of two color-coded operation modes as shown in Figure 14-2 that will illuminate when selected and 10 individual power levels controlled by the up and down arrows.

• Blue operation mode: high power mode that al-

lows the user to select a power output of 2.5–10.0.

HuFriedyGroup Magnetostrictive Ultrasonic Device

265

Table 14-1  HuFriedyGroup SWERV™3 Series 30K Power Settings SWERV™3 Series 30K

Illumination Color

Biofilm, Bacterial By-Products Stain

Low

1–3

Blue

Light

Medium

4–7

Blue

High

8–10

Red

Dental Calculus

Light

Light

Moderate, heavy

Moderate, heavy

Light, moderate

X

Moderate, heavy

Moderate, heavy

• Green operation mode: low power mode that

allows the user to select a lower power output of 1–5.

When blue operation mode is selected and the power output is at maximum 10, an automatic safety feature will engage after 10 minutes of use where the device automatically reduces the power output. Each insert is designed for specific power output levels and should never be used at a power output not approved by the manufacturer. This information can be found in the direction for use/instruction for use (DFU/IFU). Table 14-1 provides a summary of power settings.

• Low power: Used for the removal of light bio• •

film, bacterial by-products, stain, and dental calculus. Medium power: Used for the removal of moderate to heavy biofilm, bacterial by-products, stain, and light to moderate dental calculus. High power: Used for the removal of heavy stain and dental calculus.

Foot Pedal The foot pedal is round and tethered to the device by a cord. There is no Bluetooth technology available. Boost mode is not available. The pedal is depressed all the way to the floor to activate the device. If the foot pedal is continuously depressed for more than 20 minutes, the device will power down and make an audible beep sound. If this safety feature activates, the user must turn the unit off and then back on with the power on/off switch.

Water

There is one water control on a HuFriedyGroup magnetostrictive ultrasonic device. The water flow rate is selected based on the power output setting. If present, the water filter must be periodically checked and replaced at a specified interval by the manufacturer, which can be found in the DFU/IFU.

Figure 14-3  HuFriedyGroup SWERV ™3 Series 30K Water

Control

Courtesy of HuFriedyGroup Mfg. Co., LLC.

Water Control The water control is on the side of the machine (see Figure 14-3). Turn clockwise to turn the water down and counterclockwise to turn it up.

Water Flow Rate The water flow rate is chosen based on the power output setting.

• Low to medium power: Water flow rate is set for a •

rapid drip with a fine mist halo. See Figure 14-4a. High power: Water flow rate is turned up so the rapid drip disappears and a strong mist is expelled. See Figure 14-4b.

Water Filter The water filter should be inspected regularly to ensure it is not in need of replacement prior to its recommended replacement interval of 240 liters or one year. The filter should be replaced more frequently if the:

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Chapter 14 HuFriedyGroup

A

B

Figure 14-4  Water Settings: A. Low to medium power (Cavitron Slimline 10S 30K Ultrasonic Insert), B. High power

(Cavitorn Powerline 1000 30K Ultrasonic Insert) Reproduced with permission from Dentsply Sirona.

• Filter has particulate matter buildup. • Filter discolors from the original color. • Water flow in the line is reduced or inconsistent. Insert Water Port Inserts have an external or internal water port (see Figure 14-5a and b). Internal water ports are equipped with a small cannula tube embedded inside the shank that emerges from a small opening. The exact port position on the shank varies by insert and is presented later in the chapter. External water ports have a thin cannula tube attached above and parallel to the shank of the insert where the water expels from the canula and branches out in multiple directions.

Handpiece The SWERV ™3 30K handpiece is not autoclavable. The manufacturer recommends a disposable, single patient use barrier sleeve for the handpiece (see Figure 14-6). The handpiece does not rotate. The handpiece should be filled with water prior to seating an insert and the O-ring lubricated as described in Chapter 5 (see Figure 5-7).

• Hold the handpiece upright over a sink, then step •

on the pedal to fill with water until a dome of water appears on the brim. Allow any trapped air to exit the handpiece prior to seating an insert.

A

B

Figure 14-5  HuFriedyGroup Insert Water Port:

A. Internal Water Port (Swivel XT and After Five Straight), B. External Water Port (After Five) A: Reproduced with permission from HuFriedyGroup Mfg. Co., LLC. B: Courtesy of HuFriedyGroup Mfg. Co., LLC

• Lubricate the O-ring on the insert by rotating the O-ring 360 degrees over the water dome.

• Place the insert into the handpiece in an upright

position. Apply gentle pressure and use a pushtwist motion to fully seat the O-ring of the insert into the handpiece.

Insert Portfolio

267

Figure 14-7  Swivel (Power PLUS Standard Bevel 30K

Insert)

Courtesy of HuFriedyGroup Mfg. Co., LLC.

Figure 14-6  HuFriedyGroup SWERV ™3 30K Handpiece

Disposable Barrier

Figure 14-8  STREAMLINE™ (Beavertail 30K Insert) Courtesy of HuFriedyGroup Mfg. Co., LLC.

Courtesy of HuFriedyGroup Mfg. Co., LLC.

Insert Portfolio HuFriedyGroup manufactures a variety of shank shapes, diameters, cross-sections, and water ports for their SWERV ™3 30 kHz ultrasonic device, which supports a contemporary approach to ultrasonic instrumentation. All inserts have a color grip covering the connecting body, two green O-rings, and 15–16 ferromagnetic laminate nickel plates that vary by insert. The stacks are imprinted with the company name, lot number, and date of insert creation. O-rings are a wearand-tear items and should be replaced when worn. The color of the grip is a patented color specific for HuFriedyGroup inserts. All grips are textured to improve the provider’s grasp and decrease slipping. There are five categories of inserts, each with their own portfolio of choices. 1. SWIVEL DIRECT FLOW™ 2. Swivel 3. STREAMLINE™ Direct Flow 4. STREAMLINE™ 5. STREAMLINE™ PLUS The five categories are distinguished from one another in four ways: 1. Ability to rotate (Swivel) in the handpiece: Some inserts rotate in the handpiece and others do not. • The rotating inserts are termed Swivel and move 360 degrees. The rotating insert

categories are SWIVEL DIRECT FLOW™ and Swivel (see Figure 14-7). • The nonrotating insert categories are STREAMLINE™ Direct Flow, STREAMLINE™, and STREAMLINE™ PLUS (see Figure 14-8). When an insert rotates, the magnetostrictive grasp may need modification to control the insert adaptation, angulation, and orientation on the tooth surface. The index finger or thumb may need to be advanced closer to or on the insert grip (see Figure 14-9a and b). If the finger position is modified, the oral health-care provider will need to ensure that the handpiece stays positioned in the webbing between the thumb and index finger and that excessive lateral pressure is not applied as the fingers have advanced forward on the grip. 2. Position of the water port: HuFriedyGroup offers inserts with internal and external water ports. The selection of inserts with an external water port is smaller than that for internal. Internal water ports are positioned in one of two places on the shank and termed direct flow and base flow (see Figure 14-10). • Direct flow: internal water port positioned closer to the terminal 4 mm of the shank. The insert categories that use direct flow are SWIVEL DIRECT FLOW™, STREAMLINE™ Direct Flow, and STREAMLINE™ PLUS. See Figure 14-10a.

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Chapter 14 HuFriedyGroup

• Base flow: internal water port positioned close to the grip. The insert categories that use base flow are Swivel and STREAMLINE™. See Figure 14-10b. 3. Grip width: Grips come in a standard width size or an 18% wider grip width. The wider grip size decreases muscle strain and pinch force. The SWIVEL DIRECT FLOW™, Swivel, and STREAMLINE™ PLUS have an 18% greater width (see Figure 14-11). 4. Nose cone: SWIVEL DIRECT FLOW™, Swivel, and STREAMLINE™ PLUS have a colored nose cone. The SWIVEL DIRECT FLOW™ and STREAMLINE™ do not have a colored nose cone (see Figure 14-12).

A

Table 14-2

summarizes the five categories of inserts and their differences. HuFriedyGroup offers thick and thin diameter inserts in their five categories.

Thick Diameter Inserts Thick diameter inserts have the largest surface area of the shank. There are five thick diameter inserts that all have a straight shank and are pictured in Figure 14-13a to d.

B Figure 14-9  Magnetostrictive Grasp (HuFriedyGroup

Swivel XT 30K and Dentsply Sirona Cavitron Steri-Mate Sterilizable, Detachable Handpiece): A. Correct Grasp, B. Modified Grasp for Rotating Insert

1. #10 Universal 2. #1000 Triple Bend 3. Power PLUS Standard Conical 4. Power PLUS Standard Bevel 5. Beavertail

Courtesy of HuFriedyGroup Mfg. Co., LLC.

A

B

Figure 14-11  HuFriedyGroup Insert Grip Width. Thinner

Figure 14-10  HuFriedyGroup Internal Water Port

Position: A. Direct Flow, B. Base Flow

grip STREAMLINE™ Beavertail on left (yellow) and thicker grip STREAMLINE™ PLUS #10 on right (lavender with beige nose cone)

Courtesy of HuFriedyGroup Mfg. Co., LLC.

Courtesy of HuFriedyGroup Mfg. Co., LLC.

Insert Portfolio

269

There are no curved shank shapes in the thick diameter insert portfolio because their surface area is too large to access subgingivally in tightly adherent tissues to reach complex root anatomy. The thick diameter inserts have two options in the bend of the terminal 4 mm of the shank. All inserts are still considered a straight shape because the overall shank is still bent in one plane with small bends in the terminal 4 mm. The small bends change the cross-section and length of the shank.

• Cross-section: One-bended shanks have a rounded

Figure 14-12  HuFriedyGroup Insert Colored Nose Cones.

SWIVEL DIRECT FLOW™ After Five on left (gray nose cone with dark blue grip), STREAMLINE™ PLUS #1000 Triple Bend in middle (beige nose cone and orange grip), and Swivel Power PLUS Standard Conical (black nose cone and ocean blue grip) Courtesy of HuFriedyGroup Mfg. Co., LLC.

•

or circular cross-section, and three-bended shanks have a diamond cross-section. The Power PLUS inserts have either have a conical or beveled active area antinode. A bevel shank has a diamond cross-section, and a conical shank has a round or circular cross-section (see Figure 14-14a and b). Adaptation: The diamond cross-sections allow for easier adaption of the active area antinode to interproximal areas and line angles (see Figure 14-15a and b).

Table 14-2  HuFriedyGroup Insert Categories Name

Nose Cone

Nose Cone Color

Ability to Rotate

SWIVEL DIRECT FLOW



Gray

Swivel



STREAMLINE™ Direct Flow STREAMLINE™

™

™

STREAMLINE PLUS

A

B

Grip

Water Port



18% wider grip Textured

Direct flow

Black



18% wider grip Textured

Base flow







Textured

Direct flow







Textured

Base flow



Beige



18% wider grip Textured

Direct flow

C

D

Figure 14-13  HuFriedyGroup Thick Diameter Inserts: A. #10 Universal (STREAMLINE™ PLUS, lavender grip),

B. #1000 Triple Bend (STREAMLINE™ PLUS, orange grip), C. Power PLUS Standard Conical and Bevel (Swivel, ocean blue grip), D. Beavertail (STREAMLINE™, yellow grip) Courtesy of HuFriedyGroup Mfg. Co., LLC.

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Chapter 14 HuFriedyGroup

A A

B

Figure 14-14  HuFriedyGroup Power PLUS Standard

Inserts: A. Conical (Swivel Power PLUS Standard Conical), B. Bevel (Swivel Power PLUS Standard Bevel) Courtesy of HuFriedyGroup Mfg. Co., LLC.

• Length:

Shank lengths vary by insert. Shank lengths are short, standard, and extended (see Figure 14-16). The Power PLUS line has a 25% longer shank than the #10 Universal, which adds 2 mm in length. This allows access into deeper periodontal pockets.

Table 14-3 provides a summary of the insert name, color of the grip, number of bends in the terminal 4 mm of the shank, cross-section, and whether the active area antinode has a special conical or beveled shape for the thick diameter inserts.

Clinical Indications for Use. Thick diameter inserts other than the Beavertail:

• Used for the removal of moderate to heavy dental • •

calculus deposits and supragingival staining. If tissues are soft, spongy, and movable, they may be able to access subgingivally. When tissues are firm, hard, or tightly adherent, access may be restricted.

The Beavertail insert:

• Used for the removal of large, heavy supragingival •

dental calculus deposits. The provider will adapt the point directly onto the deposits for removal. Never use subgingivally due to its broad, flat, and blunt shank shape (see Figure 14-13d).

B Figure 14-15  Diamond Cross-Section Inserts Active

Area Antinode Adapted to the Curved Line Angle Anatomy of the Mandibular First Molar Buccal Surface: A. HuFriedyGroup Swivel Power PLUS Standard Bevel, B. HuFriedyGroup #1000 Triple Bend STREAMLINE™ PLUS

Power Settings. All thick diameter inserts can be used at all power settings without injury to the shank. Clinically, since they are used for the removal of moderate to heavy dental calculus and stain, a high power is typically used. Insert Category. #10 Universal and #1000 Triple Bend are offered in all five categories.

• The •

Power PLUS is offered only in the Swivel Category. The Beavertail is only offered in the STREAMLINE™ category.

Insert Portfolio

Thin Diameter Inserts

271

Thin diameter insert features:

Thin diameter inserts have a smaller surface area of the shank than thick diameter inserts and come in varying shank lengths. There are eight thin diameter inserts. ⎫ 1. #100 Thin ⎪ 2. After Five Straight ⎬ 40% thinner than #10 Univer3. After Five Right ⎪ sal (see Figure 14-17a to c) ⎭ 4. After Five Left ⎫ 24% thinner than #1000 Triple 5. XT ⎬ Bend (see Figure 14-18a and b) 6. XT Triple Bend ⎭ 7. Power PLUS Thin Conical (see Figure 14-19) 8. Power PLUS Thin Bevel

• The • •

#100 Thin, After Five Straight, After Five Right, and After Five Left are 40% thinner than the #10 Universal. The XT and XT Triple Bend are 24% thinner than the #1000 Triple Bend. Power PLUS Thin Conical and Bevel have a 25% longer shank than the #10 Universal, which adds 2 mm in length. Thin diameter shank shapes:

• Straight shank: #100 Thin, After Five Straight, •

XT, XT Triple Bend, Power PLUS Thin Conical, and Power PLUS Thin Bevel. Curved shank: After Five Right and After Five Left.

Table 14-4 provides a summary of the insert name, color of the grip, number of bends in the terminal 4 mm of the shank, cross-section, whether the active area antinode has a special conical or beveled shape, and the overall shank shape for the thin diameter inserts.

Figure 14-16  HuFriedyGroup Swivel Power PLUS

Standard Bevel (black nose cone and ocean blue grip) and SWIVEL DIRECT FLOW™ After Five Straight (beige nose cone and dark blue grip). Note the longer shank of the Swivel Power PLUS Standard Bevel

Clinical Indications for Use. All thin diameter inserts are used for the removal of light to moderate dental calculus, biofilm, bacterial by-­ products, and stain. The thinner shank diameter allows for subgingival access with little to no tissue distension. The After Five Inserts and Power PLUS have an extended shank to access deep periodontal pockets. The After Five Right and Left have a long and curved shank shape, which allows access and adaptation to complex root anatomy (concavity, convexity, furcation) and deep periodontal pockets. Power Settings. All thin inserts can be used on low and medium power because the connecting body does not support high power. When incorrect power

Table 14-3  HuFriedyGroup Thick Diameter Shank Inserts Name

Grip Color

Number of Bends in Terminal 4 mm of Shank

#10 Universal

Lavender

1

Round

Power PLUS Standard Conical

Ocean blue

1

Round

Power PLUS Standard Bevel

Ocean blue

1

Diamond

#1000 Triple Bend

Orange

3

Diamond

Beavertail

Yellow

1

Broad, flat, blunt

Cross-Section

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Chapter 14 HuFriedyGroup

B

A

C

Figure 14-17  HuFriedyGroup Thin Diameter Inserts (40% Thinner Than Universal #10):

A. #100 Thin (STREAMLINE™ PLUS, black grip), B. After Five Straight (Swivel, dark blue grip), C. After Five Left (Swivel, teal grip) and Right (Swivel, red grip) Courtesy of HuFriedyGroup Mfg. Co., LLC.

A

B

Figure 14-18  HuFriedyGroup Thin Diameter Inserts (24%

Thinner Than #1000 Triple Bend): A. XT (Swivel, purple grip), B. XT Triple Bend (STREAMLINE™ Direct Flow, purple grip)

Figure 14-19  HuFriedyGroup Swivel Power PLUS Thin

Courtesy of HuFriedyGroup Mfg. Co., LLC.

Courtesy of HuFriedyGroup Mfg. Co., LLC.

Conical

Reprocessing

273

Table 14-4  HuFriedyGroup Thin Diameter Shank Inserts Number of Bends in Terminal 4 mm of Shank

Name

Grip Color

Shape

#100 Thin

Black

Straight

1

Round

After Five Straight

Dark blue

Straight

1

Round

After Five Right

Red

Curved

1

Round

After Five Left

Teal

Curved

1

Round

XT

Purple

Straight

1

Round

XT Thin

Purple

Straight

3

Diamond

Power PLUS Thin Conical

Ocean blue

Straight

1

Round

Power PLUS Thin Bevel

Ocean blue

Straight

1

Diamond

settings are used, the risk for insert damage or shank breakage increases. Patient safety is at risk if the shank were to break in the mouth while in use. The patient could aspirate the broken shank. If it breaks subgingivally, a retrieval procedure may be required.

Cross-Section

Insert

Always use aseptic techniques during reprocessing that includes full personal protective equipment (PPE) and utility gloves when handling contaminated equipment to avoid cross-­contamination and operator injury.

Carefully remove the insert from the handpiece being sure not to strip the two O-rings or damage the ferromagnetic laminate nickle plates. Clean the insert with a manufacturer-approved enzymatic cleaner. HuFriedyGroup manufactures its own enzymatic cleaner (­ENZYMAX™) that is safe for use on its inserts. It is always best practice to use the manufacturer’s cleaner. The manufacturer will test its equipment with its own cleaner but will not necessarily test all other manufacturers’ products. Leave the enzyme cleaner in place on the insert for 3–5 minutes. Never use a metal brush or steel wool if manually cleaning the insert. Rinse all lumens of the insert five times with a single-use syringe (minimum 50 mL). The insert may be placed in an ultrasonic bath for 16 minutes with an approved solution per the manufacturer. Rinse the insert with low-­contaminated or deionized water. The insert may be placed in an automated instrument washer with an approved solution per the manufacturer. Prior to bagging for sterilization, ensure the insert is completely dry. Steam under pressure is recommended because cold liquid disinfection, chemical vapor, and dry heat sterilization have not been tested or validated for efficacy.

3 SWERV™ Device

Handpiece

Insert Category

• #100 Thin is offered in all five categories. • After Five Straight, Right, and™Left are offered in™ • • •

the SWIVEL DIRECT FLOW , STREAMLINE Direct Flow, and STREAMLINE™ PLUS. XT is offered in the Swivel and STREAMLINE™ Direct Flow. XT Triple Bend is offered in the SWIVEL DIRECT FLOW™, STREAMLINE™ PLUS, and STREAMLINE™ Direct Flow. Power PLUS is only offered in the Swivel.

Reprocessing

The power cord, waterline, handpiece cable, foot pedal and cord, and the device itself is not sterilizable but should be disinfected with an approved solution per the manufacturer, which you can find in the product directions for use/instructions for use (DFU/IFU).

Once the procedure is complete, remove the disposable barrier and throw it away in accordance with regulations. The handpiece should be disinfected with a manufacturer-approved solution found in the DFU/ IFU. The handpiece is not sterilizable.

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Chapter 14 HuFriedyGroup

CASE STUDY

A 24-year-old Hispanic male presents to the hygienist for a new patient appointment. He has not seen a dentist since he was 15 years old. He smokes eight cigarettes a day and has daily moderate alcohol intake. He has a metal tongue ring. He does not take any prescription or over-the-counter medications, has no known drug allergies, and his vitals are within normal limits. His chief complaint is “something feels weird on my lower front teeth, but nothing hurts” (see Figure 14-20). Periodontal findings: Generalized heavy biofilm and light to moderate dental calculus throughout. Probe depths are 3–4 mm generally with 85% bleeding upon probing. Gingival tissues are generally erythematous with localized edema mandibular anterior central and lateral incisors. No attachment loss is present except the mandibular central and lateral incisors, which also have heavy lingual, interproximal, and facial dental calculus. The patient has severe recession mandibular central incisors only on the lingual. Treatment plan: A periodontist performs the examination and recommends a nonsurgical periodontal debridement procedure followed by bone and gingival grafting for the mandibular anterior central incisors. The dental hygienist carries out phase one of the treatment and performs a nonsurgical periodontal debridement. Even with local anesthesia, the patient experienced pain upon instrumentation of the mandibular anterior central incisors, and the dental hygienist debrided to the best of their ability (see Figure 14-21).

Figure 14-20  Periapical radiograph and intraoral photograph of the mandibular

anterior teeth

Figure 14-21  Immediate post-operative intraoral

photograph of the mandibular anterior teeth

Reprocessing

275

Figure 14-22  Four Week Postoperative Intraoral Photographs of the Mandibular Anterior Teeth

The patient was seen four weeks post-nonsurgical periodontal debridement (see Figure 14-22). He reports severe pain for the first week after the procedure. The severe pain has subsided, but he still has occasional sensitivity to hot and cold on the mandibular anterior teeth.

Questions for Initial Nonsurgical Periodontal Debridement

1. Which of the following is not a likely cause of the localized severe attachment loss seen in Figure 14-20 and Figure 14-21? a. Attachment loss caused by natural aging processes b. Presence of a metal tongue ring c. Malocclusion with a traumatic bite d. The patient’s brushing habits 2. Which of the following inserts should be used to begin debridement of the mandibular anterior lingual central incisors pictured in Figure 14-20? a. #10 Universal b. #100 Thin c. XT d. Both B and C 3. What power setting should be used to begin debridement of the mandibular anterior lingual central incisors with the insert selected in question 2? a. High b. Medium c. Low 4. True or False: A tap stroke followed by an ultrasonic activation stroke should be initially used to debride the mandibular anterior lingual central incisors with the insert selected in question 2. a. True b. False 5. The #10 Universal insert reduces the size of the dental calculus from heavy to light. Which insert should the dental hygienist use next to remove the light deposits? a. Continue using the #10 Universal b. Change from a #10 Universal to a Power PLUS Thin Conical c. Change from a #10 Universal to a #100 Thin d. Change from a #10 Universal to an After Five Right 6. What power setting should be used with the insert selected in question 5? a. High b. Medium c. Low d. Both B and C

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Chapter 14 HuFriedyGroup

7. After the dental hygienist used the Power PLUS Thin Conical, there was still residual light dental calculus on the mesial-lingual line angle of the mandibular right central incisor. What insert would be the best selection to remove this deposit? a. XT Triple Bend b. Power PLUS Thin Bevel c. Universal #10 d. #1000 Triple Bend

Questions for Four-Week Follow-Up Appointment

1. Ultrasonic technology is contraindicated for the debridement of the mandibular right central incisor dental calculus as seen in Figure 4-22. a. True b. False 2. Which of the following inserts should be used to begin debridement of the mandibular anterior lingual central incisors pictured in Figure 14-22? a. Power PLUS Standard Conical b. Beavertail c. XT d. #1000 Triple Bend

Summary

HuFriedyGroup offers a variety of magnetostrictive technology that allow for a contemporary approach to ultrasonic instrumentation. Always read your product’s DFU/IFU prior to using it for the first time. There

Questions

is pertinent information for the safe handling and delivery of care that must be followed to avoid equipment damage and to keep your patients safe.

1. In which of the following scenarios would an oral health-care provider choose to use low power? a. Heavy dental calculus mandibular anterior lingual. b. Light biofilm generally throughout the mouth. c. Heavy stain maxillary anterior lingual. d. Low power is never indicated for use.

4. When should the water filter be replaced? a. Filter has particulate matter buildup or discolors. b. Water flow in the line is reduced or inconsistent. c. Annually or every 240 liters. d. All of the above.

2. On which power setting is the water flow rate set to a rapid drip with fine mist halo? a. Low b. Medium c. High d. Both A and B e. All of the above

5. True or False. The handpiece for the SWERV ™3 30K is not autoclavable. a. True b. False

3. Which of the following cross-sections of an insert allows for better adaptation to line angles and interproximal surfaces? a. Round b. Diamond c. Broad, flat, blunt

6. Which of the following insert categories will rotate in the handpiece? a. Swivel b. STREAMLINE™ Direct Flow c. STREAMLINE™ PLUS d. STREAMLINE™

Questions

277

7. Which of the following insert categories has a water port with base flow? a. Swivel b. STREAMLINE™ Direct Flow c. STREAMLINE™ d. Both A and C e. All of the above

15. Which of the following inserts is only used for large, heavy supragingival dental calculus deposits and cannot be used subgingivally? a. #10 Universal b. #1000 Triple Bend c. Power PLUS Standard Bevel d. Beavertail

8. Which of the following insert categories has an 18% wider grip width to decrease pinch force strain? a. Swivel b. SWIVEL DIRECT FLOW™ c. STREAMLINE™ PLUS d. All of the above

Match the following terms with their correct description for questions 16–19. There is only one correct answer for each question.

9. Which of the following insert categories has a beige nose cone? a. SWIVEL DIRECT FLOW™ b. STREAMLINE™ Direct Flow c. STREAMLINE™ d. STREAMLINE™ PLUS 10. Which of the following is a thick diameter insert? a. Power PLUS Standard Conical b. Power PLUS Thin Conical c. XT d. After Five Right 11. True or False. HuFriedyGroup manufactures a curved magnetostrictive insert with a thick and thin diameter. a. True b. False 12. What is the cross-section of a bevel and triplebended shank? a. Circular b. Round c. Diamond d. Trianglular 13. How much longer is the shank of a Power PLUS Standard Conical or Bevel insert compared to the Universal #10? a. 10% b. 20% c. 25% d. 35% 14. What power setting can the thick diameter inserts be used on? a. Low b. Medium c. High d. All of the above

16. #100 Thin

A. Grip is a teal color with a curved shank shape.

17. XT

B. Grip is a black color with one bend in the shank.

18. After Five Left

C. Grip is an ocean blue color with a 25% longer shank.

19. Power PLUS Thin Conical

D. Grip is a purple color that is 24% thinner than the #1000 triple bend

20. True or False. All After Five and Power PLUS inserts have an extended shank. a. True b. False 21. What power setting can the thin diameter inserts be used on? a. Low b. Medium c. High d. Both A and B 22. True or False. All insert designs are offered in each of the five categories of HuFriedyGroup inserts. a. True b. False 23. Which of the following inserts is offered in all five insert categories? a. #10 Universal b. #1000 Triple Bend c. #100 Thin d. All of the above

CHAPTER 15

Curved Inserts LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Identify a magnetostrictive insert as a right or left. 2. Recognize the indications for use and design variations for curved inserts. 3. Identify the correct adaptation and angulation of a curved right insert in vertical and transverse orientation. 4. Identify the correct adaptation and angulation of a curved left insert in vertical and transverse orientation. 5. Perform an ultrasonic activation stroke with right- and left-curved inserts.

Introduction Magnetostrictive curved shank inserts are multifunctional as they can debride subgingival deep periodontal pockets and complex root anatomy, as well as supragingival interproximal areas. The curved inserts function as a pair, with one debriding lingual surfaces and the other debriding facial/buccal surfaces. These inserts were developed in the 1990s, and by 2000, the American Academy of Periodontology (AAP) released a position paper supporting the use of thin diameter curved shanks over hand-­activated instruments for the debridement of Class II, Class III, and Class IV furcation defects (Drisko et al., 2000). There is a large body of literature supporting the use of curved shanks in furcation areas; however, curved inserts also assist the provider in safely debriding root

concavities, convexities, and interproximal surfaces both supragingivally and subgingivally. Their multifunctional capabilities make them a useful tool in many periodontal applications, from a general prophylaxis to surgical procedures.

Magnetostrictive Curved Insert Introduction Magnetostrictive curved inserts are used in both vertical and transverse orientations:

• Vertical orientation: Used to debride deep peri•

odontal pockets and complex root anatomy. The active area antinode is contacting cementum in this orientation (see Figure 15-1a and b). Transverse Orientation: Used to debride supragingival interproximal areas. The active area antinode is contacting enamel in this orientation unless recession is present, in which case, the shank may also contact dentin or cementum (see Figure 15-1).

When a vertical orientation is used to debride root anatomy, follow these rules for ultrasonic instrumentation to protect the less mineralized hard tissue cementum:

• Power: •

Low to medium power is used. High power increases the risk for cemental injury. Adaptation: Adapt back and lateral surfaces. The point and face have a higher displacement amplitude and should either be used with caution or avoided on cementum. See Chapter 9 for details on shank surface displacement amplitude.

279

280

Chapter 15 Curved Inserts

A

B

Figure 15-1  Curved insert orientation: A. Vertical orientation on the lingual of the mandibular right first molar,

B. Transverse orientation on the mesial-lingual of the mandibular right first molar.

B

A

Figure 15-2  Curved insert angulation: A. 0- to 15-degree angulation with back surface on the buccal of the mandibular

right first molar, B. 90-degree angulation with the point on the buccal of the mandibular right first molar.

• Angulation:

Use a 0- to 15-degree angulation. A  90-degree angulation is contraindicated because the point would be in contact with the cementum (see Figure 15-2a and b). Activation: Use an ultrasonic activation stroke. A tap stroke should be used with caution as the point is adapted.

has no influence on which insert is used on the facial/buccal or lingual surfaces. The correct insert will be the same for dominant right- or left-handed providers. As presented in Chapter 11, to correctly identify each insert as right or left:

Magnetostrictive curved inserts are used as a pair. The provider needs two inserts to debride a single tooth. These inserts are nicknamed rightcurved insert and left-curved insert. The left and right distinction refers to the direction of the shank bend and has nothing to do with how or where they are used in the mouth. The provider’s dominant hand

other in your nondominnant in front of your face hand so that the color grips are parallel to you. Turn the point surface away from you. Look at the curve of the shank coming out of the grip. If the shank curves to the right, it is the right curved insert and if it curves to the left, it is the left curved insert (see Figure 15-3).

•

• Hold one insert in your dominant hand and the • •

Magnetostrictive Curved Insert Adaptation

281

Left Curved Shank Right Curved Shank

Figure 15-4  Magnetostrictive curved insert adaptation Figure 15-3  Magnetostrictive curved inserts (Dentsply

Sirona Cavitron Slimline 10L and 10R Fitgrip 30K Ultrasonic Inserts).

vertical inserts (Dentsply Sirona Cavitron Slimline 10L and 10R 30K Ultrasonic Inserts). Reproduced with permission from Dentsply Sirona

Reproduced with permission from Dentsply Sirona

Magnetostrictive Curved Insert Adaptation Correct adaptation of curved magnetostrictive inserts is dependent on the shank orientation. For both vertical and transverse orientation, one curved insert is adapted to the facial/buccal surfaces of teeth in one quadrant and the other curved insert is adapted to the lingual (see Figure 15-4). Curved inert adaption is similar to the adaption of posterior area-specific hand-activated curettes. ­Area-specific curettes have one lower cutting edge on each side that adapts to either the mesial or distal of a posterior tooth. The provider must use two area-specific curettes to instrument all surfaces of one posterior tooth.

D

M

A

• One posterior area-specific curette adapts to the •

buccal/­ lingual and mesial surfaces of posterior teeth (see Figure 15-5a). The other posterior area-specific curette adapts to the distal surfaces of posterior teeth (see Figure 15-5b).

The provider will use two magnetostrictive curved inserts to instrument one tooth, just as they do with posterior area-specific curettes. Instead of a mesial or distal adaptation, magnetostrictive curved inserts have a facial/buccal or lingual adaptation.

Vertical Orientation

Vertical orientation is used to debride root surfaces. A curved insert will access a deep periodontal pocket

D

M

B Figure 15-5  Posterior area-specific Gracey curette:

A. Gracey 11/12 B. Gracey 13/14.

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Chapter 15 Curved Inserts

A

A

B Figure 15-7  Curved shank adaptation in vertical

orientation (HuFriedyGroup after Five Right): A. Active area antinode adapted at the Cementoenamel junction (CEJ), B. Active area antinode adapted subgingivally. B Figure 15-6  Vertical orientation curved insert (Dentsply

Sirona Cavitron Slimline 10R 30K Ultrasonic Insert): A. Back surface of the shank adapted to the mesial-buccal root of the mandibular first molar, B. Lateral surface of the shank adapted to the distal of the mandibular first molar.

with its long shank and conform to complex root anatomy such as concavities, convexities, and furcations (see Figure 15-6a and b). Due to the curvature of the shank, the back and lateral surfaces of the active area antinode will be adapted when in vertical orientation. A 0- to 15-degree angulation is used with an ultrasonic activation stroke on low to medium power.

Adaptation and Shank Position Vertical Orientation The provider cannot use the shank position in relationship to the long axis of the tooth as a visual cue to the correct adaptation in vertical orientation as is

used with straight shank inserts or hand-activated instruments.

• Right- and left-curved inserts have a shank that is • •

curved to a specific degree, which allows the back and lateral surfaces of the active area antinode to correctly adapt to complex root anatomy. The shank will never be parallel to the long axis of the tooth when the active area antinode is adapted correctly in vertical orientation. Figure 15-7a and b shows the correct adaptation of a curved insert on the mandibular right first molar distal periodontal pocket. Notice the visible shank is not parallel to the long axis of the tooth. It is curved across the buccal molar tooth surface.

Identifying Correct Adaptation for Vertical Orientation During active patient care, the provider can determine which curved insert is used on the facial/buccal and

Magnetostrictive Curved Insert Adaptation

lingual tooth surfaces without referencing a book. The steps for selecting the correct curved insert by area of the mouth are shown in Table 15-1. Table 15-1  Magnetostrictive Curved Insert

Selection Steps (Dentsply Sirona Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert) 1. With the insert not Correct activated, place the point on the occlusal of any posterior tooth in the quadrant to receive ultrasonic instrumentation. Ensure that the colored grip Incorrect is parallel to the occlusal plane of the teeth. If the grip is not parallel, this technique will not work.

283

Right-Curved Insert Adaptation Vertical Orientation Maxillary arch: Maxillary right lingual and maxillary left facial/ buccal (see Figure 15-8). Mandibular arch: Mandibular right facial/buccal and mandibular left lingual (see Figure 15-9). There is a pattern for correct adaptation of a curved insert. Look at the maxillary arch adaptation of the right curved insert. The right curved insert is adapted to the maxillary left facial/buccal and maxillary right lingual. If the insert is adapted on the facial/ buccal surface of one quadrant, it is also adapted to the lingual surface of the adjacent quadrant. The same holds true for the mandibular arch. The right insert is adapted to the mandibular right facial/buccal, so it is also adapted to the mandibular left lingual.

Left-Curved Insert Adaptation Vertical Orientation Maxillary arch: Maxillary right facial/buccal and maxillary left lingual (see Figure 15-10).

UR L

ingua

l

2. Move the point across the occlusal toward the buccal surface of the tooth.

3. Drop the shank off onto the Correct buccal surface. If the back surface is in contact with the buccal of the tooth, this is the correct insert for the surface. If the face is in contact with the buccal of the tooth, this is the incorrect insert for the surface. Incorrect

A

UL Buccal

B Figure 15-8  Axillary arch right-curved insert vertical

orientation: A. Maxillary right lingual, B. Maxillary left facial/buccal.

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Chapter 15 Curved Inserts

UR Buccal

LR Buccal

A

UL

A

Figure 15-10  Maxillary arch left-curved insert vertical

orientation: A. Maxillary right facial/buccal, B. Maxillary left lingual.

al

LL Li

ngua

l

ual

Ling

B

ingu

B Figure 15-9  Mandibular arch right-curved insert vertical

Mandibular arch: Mandibular right lingual and mandibular left facial/buccal (see Figure 15-11). The same pattern exists for the left-curved insert as it does for the right. The left insert is adapted to the maxillary right facial/buccal, so it is also adapted to the maxillary left lingual. The left insert adapts to the mandibular left facial/buccal, so it is also adapted on the mandibular right lingual. Table 15-2 and Figure 15-12 summarize the correct adaption for the maxillary arch of curved inserts in vertical orientation. Table 15-3 and Figure 15-13 summarize the correct adaption for curved inserts on the mandibular arch in vertical orientation.

LR L

orientation: A. Mandibular right facial/buccal, B. Mandibular left lingual.

A

B

LL Buccal

Figure 15-11  Mandibular arch left-curved insert vertical

orientation: A. Mandibular right lingual, B. Mandibular left facial/buccal.

Magnetostrictive Curved Insert Adaptation

Table 15-2  Maxillary Adaptation for Right and Left Curved Inserts in Vertical Orientation

285

Transverse Orientation

Right-Curved Insert (Gold)

Left-Curved Insert (Orange)

Transverse orientation is used to debride supragingival interproximal surfaces. Follow these rules for ultrasonic instrumentation in transverse orientation

Facial/ Buccal

UL

UR

• Adaptation: Back and lateral surfaces are adapted

Lingual

UR

UL

UR Facial/Buccal

(see Figure 15-14a). If the point and face are adapted, the provider has selected the incorrect insert (see Figure 15-14b). Unlike vertical orientation where the shank is not parallel to the long axis of the tooth, in transverse orientation, the terminal shank is parallel to the long axis of the tooth in correct adaptation while the active area antinode is at a right angle to the interproximal contact. (see Figure 15-14a).

UL Facial/Buccal

UR Lingual

UL Lingual

Figure 15-12  Vertical orientation right- and left-curved

insert adaptation for the maxillary arch.

Table 15-3  Mandibulr Adaptation for Right and Left Curved Inserts in Vertical Orientation Right-Curved Insert (Gold)

Left-Curved Insert (Orange)

Facial/Buccal

LR

LL

Lingual

LL

LR

LR Lingual

LL Lingual

A

B Figure 15-14  Transverse orientation curved insert

LR LL Facial/Buccal Facial/Buccal

Figure 15-13  Vertical orientation right- and left-curved

insert adaptation for the mandibular arch.

(Dentsply Sirona Cavitron Slimline 10L Fitgrip 30K Ultrasonic Insert): A. Correct adaptation. Lateral surface is adapted with 0-degree angulation of the active area antinode to the mandibular right first molar distalbuccal, B. Incorrect adaptation. Point and face active area antinode are adapted to the distal-lingual surface og the mandibular left first molar.

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Chapter 15 Curved Inserts

LR L

ingu al

UR Buccal

A A

al

ingu

UL L

LL Buccal B Figure 15-16  Mandibular arch right-curved insert

transverse orientation: A. Mandibular right lingual, B. Mandibular left facial/buccal.

B Figure 15-15  Maxillary arch right-curved insert

UR Lingual

transverse orientation: A. Maxillary right facial/buccal, B. Maxillary left lingual.

• Angulation: •

0- to 15-degree angulation (see ­ igure 15-14a). F Activation: An ultrasonic activation stroke or a tap stroke are used.

When mapping curved insert adaptation for transverse orientation, you will notice it is the opposite of vertical orientation.

A

Right-Curved Insert Adaptation

UL Buccal

Maxillary arch: Maxillary right facial/buccal and maxillary left lingual (see Figure 15-15). Mandibular arch: Mandibular right lingual and mandibular left facial/buccal (see Figure 15-16).

Left-Curved Insert Adaptation Maxillary arch: Maxillary right lingual and maxillary left facial/buccal (see Figure 15-17). Mandibular arch: Mandibular right facial/buccal and mandibular left lingual (see Figure 15-18).

B Figure 15-17  Maxillary arch left-curved insert transverse

orientation: A. Maxillary right lingual, B. Maxillary left facial/buccal.

Magnetostrictive Curved Insert Adaptation

UR Facial/Buccal

UL Facial/Buccal

UR Lingual

LR Buccal

287

UL Lingual

A

Figure 15-19  Transverse orientation right- and

left-curved insert adaptation for the maxillary arch.

Table 15-5  Adaptation for Right and Left Curved Right-Curved Insert (Gold)

Left-Curved Insert (Orange)

Facial/Buccal

LL

LR

Lingual

LR

LL

LL L

ingu

al

Inserts in Transverse Orientation

B Figure 15-18  Mandibular arch left-curved insert

transverse orientation: A. Mandibular right facial/ buccal, B. Mandibular left lingual.

LR Lingual

LL Lingual

Table 15-4  Maxillary Adaptation for Right and Left Curved Inserts in Transverse Orientation Right-Curved Insert (Gold)

Left-Curved Insert (Orange)

Facial/Buccal

UR

UL

Lingual

UL

UR

Table 15-4 and Figure 15-19 summarize the correct adaption for curved inserts on the maxillary arch in transverse orientation.

CASE STUDY

LR LL Facial/Buccal Facial/Buccal

Figure 15-20  Transverse orientation right- and

left-curved insert adaptation for the mandibular arch. Table 15-5 and Figure 15-20 summarize the correct adaption for the mandibular arch of curved inserts in transverse orientation.

A 52-year-old Caucasian male with a noncontributory medical history presents to your office with a chief complaint of “My teeth are starting to get loose and something on the lower left hurts. My teeth are sensitive to hot and cold temperatures.” The patient’s last dental visit was at the age of 17. The initial panoramic X-ray, left side bitewing, and periapical radiographs with intraoral camera photographs are shown on the next page. The mandibular left wisdom tooth was extracted the same day of the new patient appointment due to a deep periodontal abscess and patient reported pain. Periodontal assessment: 3- to 14-mm probe depths with 100% BOP, generalized moderate to severe recession, furcation Class II and III, mobility Class 1 and 2.

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Chapter 15 Curved Inserts

Mandibular anterior periapical. Panoramic radiograph.

Left premolar bitewing.

Left molar bitewing.

Mandibular right premolar and molar periapical.

A

B

Intraoral photographs: A. Anterior facial surfaces, B. Mandibular left canine, lateral incisor, and right central incisor lingual surfaces.

Magnetostrictive Curved Insert Adaptation

289

Treatment options included: 1. Full mouth rehabilitation with a prosthodontist. 2. Extractions and removable partial or full denture. 3. Nonsurgical periodontal debridement with informed consent—this procedure may not save the teeth. The patient is dentally anxious and selects treatment plan option number three. The mandibular left was debrided first. Postoperative radiographs and intraoral photographs are shown here.

Left bitewing.

Mandibular left premolar periapical.

Mandibular left molar periapical.

Mandibular left canine periapical with technique errors.

Mandibular anterior and premolar lingual surfaces.

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Chapter 15 Curved Inserts

Mandibular left anterior facial surfaces.

Mandibular left premolar lingual surfaces. 1. Describe the staged instrumentation approach the dental hygienist likely used to debride the mandibular left lateral incisor to completion. State the insert designs that were used and why. Also state the power level used with each stage of instrumentation. 2. What curved insert did the dental hygienist use to debride the root concavity on the mesial-lingual of the mandibular left first premolar? What orientation was used? 3. Describe how the dental hygienist debrided the deep distal root defect of the mandibular left second molar with staged instrumentation. State the insert designs that were used and why. Also state the power level used with each stage of instrumentation. 4. Why would the straight thin long shank insert not debride the mandibular left second molar distal area to completion? 5. What curved insert did the dental hygienist use to debride the buccal Class III furcation of the mandibular left first molar? What orientation was used? What surfaces of the insert were adapted?

Summary

This chapter presented the clinical use of magnetostrictive curved inserts. The curved inserts are used as a pair to debride complex root anatomy and interproximal supragingival surfaces in both vertical

Questions

and transverse orientations. Low to medium power with the back and lateral surfaces adapted with 0- to 15-degree angulation is used to protect less mineralized hard tissues such as dentin and cementum.

1. True or False. Magnetostrictive curved inserts can be used in both vertical and transverse orientation. a. True b. False

3. True or False. The same curved insert is used for a vertical and transverse orientation on the facial/buccal surfaces of the maxillary right. a. True b. False

2. True or False. The correct adaptation of right- and left-curved inserts is different for a dominant right-handed provider than a left-handed provider. a. True b. False

4. What power level is appropriate to use when debriding complex root anatomy such as a furcation with ultrasonic instrumentation? a. Low b. Medium c. High d. Both A and B

References

291

5. What surfaces of an insert should be adapted in vertical orientation subgingivally? a. Back b. Lateral c. Face d. Point e. Both A and B

9. Which insert would be the best selection to debride the mandibular left canine distal-facial 2–3 mm subgingival when the tooth has no attachment loss? a. Right-curved insert b. Left-curved insert c. Straight insert

6. Which of the following ultrasonic shank angulations is contraindicated when debriding apical of the CEJ? a. 0–5 degrees b. 5–10 degrees c. 10–15 degrees d. 90 degrees

10. Which insert would be the best selection to debride the maxillary left central incisor mesiallingual 2–3 mm subgingival when the tooth has no attachment loss? a. Right-curved insert b. Left-curved insert c. Straight insert

7. True or False. When debriding 6 mm under the gums with a curved insert in a vertical orientation, the portion of the shank the provider can see will be parallel to the long axis of the tooth. a. True b. False

11. Which insert would be the best selection to debride the maxillary left first and second molars distal-buccal 2–3 mm subgingival when the tooth has no attachment loss? a. Right-curved insert b. Left-curved insert c. Straight insert

8. Which insert would be the best selection to debride the maxillary right first premolar mesiallingual 3 mm subgingival when the tooth has no attachment loss? a. Right-curved insert b. Left-curved insert c. Straight insert

12. Which insert would be the best selection to debride a Class III furcation defect on the mandibular right first molar buccal? a. Right-curved tip b. Left-curved tip c. Straight tip

References

1. Drisko, C. L., Cochran, D. L., Blieden, T., Bouwsma, O. J., Cohen, R. E., Damoulis, P., Fine, J. B., Greenstein, G., Hinrichs, J., Somermman, M. J., Iacono, V., & Genco, R. J. (2000). Position paper: Sonic and ultrasonic scalers in

periodontics. Research, Science and Therapy Committee of the American Academy of Periodontology. Journal of Periodontology, 71(11), 1792–1801. https://doi.org/10.1902 /jop.2000.71.11.1792

CHAPTER 16

Curved Insert Technique Practice LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Perform an ultrasonic activation stroke with a curved insert using a correct grasp, finger rest, operator and patient positioning, instrument adaptation, angulation, and orientation. 2. Maintain proper ergonomics while performing ultrasonic instrumentation. 3. Transition from vertical and transverse orientations during ultrasonic instrumentation with a curved insert.

Introduction This chapter will combine all the building blocks of ultrasonic instrumentation using curved magnetostrictive inserts. You will combine grasp, finger rest, operator and patient chair positioning, instrument adaptation, angulation, orientation, and activation chairside in a simulated patient care experience. Ultrasonic instrumentation on complex root anatomy is best learned through practice and repetition. A strong working knowledge of root anatomy is required to prevent patient injury.

Skill Building: Vertical and Transverse Orientation You will need the following supplies: typodont, typodont pole, dental chair, ultrasonic device,

high-volume evacuation, ultrasonic handpiece, rightand left-curved ultrasonic inserts. Rationale: This exercise will incorporate ultrasonic instrumentation techniques of adaptation, angulation, orientation, and activation and combine them with aerosol control and patient and operator positioning to simulate an active patient treatment scenario with curved inserts. The goal of this exercise is to use curved inserts to correctly debride subgingival root anatomy with a vertical orientation and debride the interproximal contact space with a transverse orientation.

Setup

1. Mount the pole onto the dental chair. 2. Mount the typodont onto the pole. 3. Set up the ultrasonic device attaching the power, water, and/or air connectors. Turn on the device. 4. Attach an High-volume evacuation (HVE) to the suction system. 5. Flush the waterline for a minimum of 20–30 seconds. Always follow your clinic’s protocols for waterline maintenance, which may be different than a 20- to 30-second waterline flush. 6. Attach the sterile ultrasonic handpiece to the handpiece connector cord. 7. See Box 16-1. 8. Place the insert into the handpiece. Refer to ­Figure 5-7 for proper O-ring(s) lubrication. Fill the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360 ­degrees over the water dome until fully lubricated. Place the insert into the handpiece in the upright position. 293

294

Chapter 16 Curved Insert Technique Practice

Box 16-1 Dominant right-handed provider: Identify the mandibular right first molar buccal. Dominant left-handed provider: Identify the mandibular left first molar buccal. Dominant right-handed provider: Select the right-curved insert. The HuFriedyGroup right-curved insert has a red grip. Dominant left-handed provider: Select the left-curved insert. The HuFriedyGroup left-curved insert has a teal grip.

Buccal Furcation Debridement of the Mandibular First Molar Grasp the ultrasonic handpiece with your dominant hand. See Chapter 9 for details if needed.

Grasp the HVE with your nondominant hand. See Chapter 9 for details if needed.

Adapt the back or lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the buccal furcation entrance (see Figure 16-1).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port on the insert.

Select the operator positioning for direct vision. • Dominant right-handed provider: 8–11 o’clock • Dominant left-handed provider: 1–4 o’clock

Select the patient chair positioning for the mandibular arch. Patient chair supine, semi-supine, or in between supine and semi-supine with chin slightly down. Left curved insert

Right curved insert

Establish a finger rest intraoral or extraoral, ensuring correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps below.

9. Set the power control to low. See Dentsply Sirona Chapter 13 and HuFriedyGroup Chapter 14 for details if needed. 10. Set the water flow rate to a rapid drip with fine mist halo. See Dentsply Sirona Chapter 13 and HuFriedyGroup Chapter 14 for details if needed. 11. Confirm the correct insert has been selected for the buccal surface of the first molar using Table 15-1.

Figure 16-1  Buccal furcation debridement of the

mandibular first molar. Back surface of the active area antinode adapted coronal to the buccal furcation entrance.

Skill Building: Vertical and Transverse Orientation

295

1. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 16-2).

Figure 16-4  Buccal furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal surface of the mesial root. Figure 16-2  Buccal furcation debridement of the

mandibular first molar. Back surface of the active area antinode adapted coronal to the buccal furcation entrance.

6. Adapt the back or lateral surface to debride the mesial surface of the distal root with the active area antinode at a 0- to 15-degree angulation (see Figure 16-5).

2. Continue the ultrasonic activation stroke, moving toward the buccal furcation. 3. Be sure to maintain adaptation of the active area antinode with a 0- to 15-degree angulation as you approach the buccal furcation. 4. Enter the buccal furcation with the back or lateral surface of the active area antinode. Maintain a 0- to 15-degree angulation. Debride one-half of the furcation area. The other half will be debrided from the lingual (see Figure 16-3).

Figure 16-5  Buccal furcation debridement of the

mandibular first molar. Back surface of the active area antinode adapted to the mesial surface of the distal root.

7. Debridement of the mandibular first molar buccal furcation is now complete. Figure 16-3  Buccal furcation debridement of the

mandibular first molar. Back surface of the active area antinode adapted in the buccal furcation.

5. Adapt the back or lateral surface to debride the distal surface of the mesial root with the active area antinode at a 0- to 15-degree angulation (see Figure 16-4).

Mesial-Buccal Root Debridement of the Mandibular First Molar

1. Adapt the back or lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the mesial-buccal root distal surface (see Figure 16-6).

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Chapter 16 Curved Insert Technique Practice

3. Debride the entire mesial root by adapting the back or lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the distal surface of the mesial-buccal root toward the mesial surface of the mesial-­ buccal root, conforming to the root anatomy (see Figure 16-8a and b).

Figure 16-6  Mesial-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the mesial-buccal root distal surface.

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 16-7a and b).

A

A B Figure 16-8  Mesial-buccal root debridement of the

mandibular first molar: A. Lateral surface of the active area antinode adapted to the mesial-buccal root, B. Lateral surface of the active area antinode adapted to the mesial-buccal root.

B Figure 16-7  Mesial-buccal root debridement of the

mandibular first molar: A. Lateral surface of the active area antinode adapted coronal to the mesial-buccal root distal surface, B. Lateral surface of the active area antinode adapted on the mesial-buccal root distal surface.

4. Complete the mesial-buccal root debridement with the back or lateral surface of the active area antinode adapted to the direct mesial with a 0- to 15-degree angulation as if you are probing the mesial col (see Figure 16-9). 5. Debride one-half of the mesial interproximal area. The other half will be debrided from the lingual (see Figure 16-10a and b).

Skill Building: Vertical and Transverse Orientation

297

Interproximal Adaptation Tips and Tricks

• Curved

insert adaptation to the interproximal area should resemble the orientation used with a periodontal probe (see Figure 16-11).

Figure 16-9  Mesial-buccal root debridement of the

mandibular first molar. Back surface of the active area antinode adapted to the mesial.

Figure 16-11  Probing of the mesial col.

• Remember the ultrasonic shank will not be paral-

lel to the long axis of the tooth as it is for straight shank inserts and hand-activated instruments (see Figure 16-12).

A

Figure 16-12  Mesial-buccal root debridement of the

mandibular first molar. Back surface of the active area antinode adapted to the mesial subgingivally. Notice the shank visible to the provider is across the premolar buccal surface and not parallel to the long axis of the tooth.

• If you find interproximal insert adaptation chalB Figure 16-10  Mesial-buccal root debridement of the

mandibular first molar: A. Back surface of the active area antinode adapted to the mesial, B. Lateral surface of the active area antinode adapted to the mesial debriding one-half the mesial interproximal area.

lenging, just image the insert as a probe and pretend you are probing the col with the active area antinode to obtain correct adaptation, angulation, and orientation.

6. Debridement of the mandibular first molar mesial-buccal root is now complete.

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Chapter 16 Curved Insert Technique Practice

Distal-Buccal Root Debridement of the Mandibular First Molar

mesial surface of the distal-buccal root toward the distal surface of the distal-buccal root, conforming to the root anatomy (see Figure 16-15a and b).

1. Adapt the back or lateral surface of the active area antinode in a vertical orientation with a 0- to 15-degree angulation at the cervical third on the crown of the tooth coronal to the distal-buccal root mesial surface (see Figure 16-13).

A

Figure 16-13  Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the distal-buccal root mesial surface.

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 16-14a and b). 3. Debride the entire distal root by adapting the back or lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the

A

B Figure 16-15  Distal-buccal root debridement of the

mandibular first molar: A. Back surface of the active area antinode adapted on the distal-buccal root, B. Lateral surface of the active area antinode adapted on the distal-buccal root.

B

Figure 16-14  Distal-buccal root debridement of the mandibular first molar: A. Back surface of the active area antinode

adapted coronal to the distal-buccal root mesial surface just coronal to the furcation entrance, B. Back surface of the active area antinode adapted on the distal-buccal root mesial surface.

Skill Building: Vertical and Transverse Orientation

4. Complete the distal-buccal root debridement with the back or lateral surface of the active area antinode adapted to the direct distal with a 0- to 15-degree angulation as if you are probing the distal col (see Figure 16-16).

299

Lingual Debridement of the Mandibular First Molar Supragingival Interproximal Area

Dominant right- and left-handed providers: Continue debriding the same tooth with the same insert. Transverse orientation will be used for this exercise. Confirm the correct insert has been selected for transverse orientation (see Box 16-2). If a curved insert is adapted in a vertical orientation on the buccal surface of a tooth, it is adapted on the lingual surface in transverse orientation.

Figure 16-16  Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal.

5. Debride one-half of the distal interproximal area (see Figure 16-17). The other half will be debrided from the lingual. Use the same adaptation tips and tricks from the mesial-buccal interproximal debridement.

Box 16-2 Transverse Orientation Adaptation 1. Adapt the active area antinode to the distallingual interproximal contact of the mandibular first molar. In correct adaptation, the shank is parallel to the long axis of the tooth and is not wrapped around the tooth.

2. Adapt the active area antinode to the distalbuccal interproximal contact. This is incorrect adaptation as the shank is wrapping across the tooth and the point is in contact with the interproximal contact.

Figure 16-17  Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal to debride one-half the interproximal area.

6. Debridement of the mandibular first molar distalbuccal root is now complete.

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Chapter 16 Curved Insert Technique Practice

Grasp the ultrasonic handpiece with your dominant hand. See Chapter 9 for details if needed.

Grasp the HVE with your nondominant hand. See Chapter 9 for details if needed.

Adapt the lateral surface of the active area antinode in a transverse orientation at the distal-lingual interproximal contact supragingivally (see Figure 16-18).

1. Perform an ultrasonic activation stroke to debride one-half of the distal interproximal area. The other half will be debrided from the buccal. 2. Reposition the lateral surface of the active area antinode with a 0- to 15-degree angulation in a transverse orientation to the mesial-lingual interproximal contact supragingivally (see Figure 16-19).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port on the insert.

Select the operator positioning for direct vision. • Dominant right-handed provider: 1–4 o’clock • Dominant left-handed provider: 8–11 o’clock

Select the patient chair positioning for the mandibular arch. Patient chair supine, semi-supine, or in between supine and semi-supine with chin slightly down.

Establish a finger rest intraoral or extraoral, ensuring correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps listed next.

Figure 16-19  Lingual interproximal mandibular first

molar debridement. Lateral surface of the active area antinode adapted to the mesial-lingual interproximal contact supragingivally.

3. Perform an ultrasonic activation stroke to debride one-half of the mesial interproximal area. The other half will be debrided from the buccal. 4. Lingual debridement of the mandibular first molar  supragingival interproximal area is ­ complete.

Lingual Furcation Debridement of the Mandibular First Molar

Figure 16-18  Lingual interproximal mandibular first

molar debridement. Lateral surface of the active area antinode adapted to the distal-lingual interproximal contact supragingivally.

Dominant right-handed provider: Remove the right-curved insert and replace with the left-curved insert. HuFriedyGroup left-curved insert has a teal red grip. Continue debridement of the mandibular right first molar. Dominant left-handed provider: Remove the left-curved insert and replace with the right-curved insert. HuFriedyGroup right-curved insert has a red grip. Continue debridement of the mandibular left first molar. Confirm the correct insert has been selected for  the lingual surface of the first molar using Table 15-1­.

Skill Building: Vertical and Transverse Orientation Grasp the ultrasonic handpiece with your dominant hand. See Chapter 9 for details if needed.

301

2. Continue the ultrasonic activation stroke, moving toward the lingual furcation (see Figure 16-21).

Grasp the HVE with your nondominant hand. See Chapter 9 for details if needed.

Adapt the back or lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the lingual furcation entrance (see Figure 16-20).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port on the insert.

Figure 16-21  Lingual furcation debridement of the

mandibular first molar. Back surface of the active area antinode adapted coronal to the lingual furcation entrance.

3. Be sure to maintain adaptation of the active area antinode with a 0- to 15-degree angulation as you approach the lingual furcation (see Figure 16-22).

Select the operator positioning for direct vision. • Dominant right-handed provider: 1–4 o’clock • Dominant left-handed provider: 8–11 o’clock

Select the patient chair positioning for the mandibular arch. Patient chair supine, semi-supine, or in between supine and semi-supine with chin slightly down.

Establish a finger rest intraoral or extraoral, ensuring correct ultrasonic handpiece grasp is maintained.

Figure 16-22  Lingual furcation debridement of the Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps listed next.

mandibular first molar. Back surface of the active area antinode adapted coronal to the lingual furcation entrance.

4. Enter the lingual furcation with the back or lateral surface of the active area antinode. Maintain a 0- to 15-degree angulation. Debride one-half of the furcation area. The other half was debrided from the buccal (see Figure 16-23).

Figure 16-20  Lingual furcation debridement of the

mandibular first molar. Back surface of the active area antinode adapted coronal to the lingual furcation entrance.

1. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation.

Figure 16-23  Lingual furcation debridement of the

mandibular first molar. Back surface of the active area antinode adapted in the lingual furcation.

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Chapter 16 Curved Insert Technique Practice

5. Adapt the back or lateral surface to debride the distal surface of the mesial root with the active area antinode at a 0- to 15-degree angulation (see Figure 16-24).

Figure 16-26  Distal-lingual root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the distal-lingual root mesial surface.

Figure 16-24  Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal surface of the mesial root.

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 16-27a and b).

6. Adapt the back or lateral surface to debride the mesial surface of the distal root with the active area antinode at a 0- to 15-degree angulation (see Figure 16-25).

A

Figure 16-25  Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the mesial surface of the distal root.

7. Debridement of the mandibular first molar lingual furcation is now complete.

Distal-Lingual Root Debridement of the Mandibular First Molar

1. Adapt the lateral or back surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the distal-lingual root mesial surface (see Figure 16-26).

B Figure 16-27  Distal-lingual root debridement of the

mandibular first molar: A. Lateral surface of the active area antinode adapted coronal to the distal-lingual root mesial surface, B. Lateral surface of the active area antinode adapted on the distal-lingual root mesial surface.

3. Debride the entire distal root by adapting the back or lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the mesial surface of the distal-lingual root toward the distal surface of the distal-lingual root, conforming to the root anatomy (see Figure 16-28a and b).

Skill Building: Vertical and Transverse Orientation

303

5. Debride one-half of the distal interproximal area. The other half was debrided from the buccal. Use the same adaptation tips and tricks from the mesial-buccal interproximal debridement (see Figure 16-30a and b).

A

A

B Figure 16-28  Distal-lingual root debridement of the

mandibular first molar: A. Back surface of the active area antinode adapted to the distal-lingual root, B. Lateral surface of the active area antinode adapted to the distal-lingual root.

4. Complete the distal-lingual root debridement with the back or lateral surface of the active area antinode adapted to the direct distal with a 0- to 15-degree angulation as if you are probing the distal col (see Figure 16-29).

B Figure 16-30  Distal-lingual root debridement of the

mandibular first molar: A. Lateral surface of the active area antinode adapted to the distal, B. Lateral surface of the active area antinode adapted to the distal debriding one-half the distal interproximal area.

6. Debridement of the mandibular first molar distal-lingual root is now complete.

Mesial-Lingual Root Debridement of the Mandibular First Molar Figure 16-29  Distal-lingual root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal.

1. Adapt the back or lateral surface of the active area antinode in a vertical orientation with a 0- to 15-degree angulation at the cervical third on the crown of the tooth coronal to the mesial-lingual root distal surface (see Figure 16-31).

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Chapter 16 Curved Insert Technique Practice

3. Debride the mesial root by adapting the back or lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the distal surface of the mesial-lingual root toward the mesial surface of the mesial-lingual root, conforming to the root anatomy (see Figure 16-33a and b).

Figure 16-31  Mesial-lingual root debridement of the

mandibular first molar. Back surface of the active area antinode adapted coronal to the mesial-lingual root distal surface.

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 16-32a and b).

A

B A

Figure 16-33  Mesial-lingual root debridement of the

mandibular first molar: A. Lateral surface of the active area antinode adapted to the mesial-lingual root, B. Lateral surface of the active area antinode adapted to the mesial-lingual root.

4. Complete the mesial-lingual root debridement with the back or lateral surface of the active area antinode adapted to the direct mesial with a 0to 15-degree angulation as if you are probing the mesial col (see Figure 16-34).

B Figure 16-32  Mesial-lingual root debridement of the

mandibular first molar: A. Back surface of the active area antinode adapted coronal to the mesial-lingual root distal surface just coronal to the furcation entrance, B. Lateral surface of the active area antinode adapted on the mesial-lingual root distal surface.

Figure 16-34  Mesial-lingual root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the mesial.

Skill Building: Vertical and Transverse Orientation

5. Debride one-half of the mesial interproximal area. The other half was debrided from the buccal (see Figure 16-35a and b). Use the same adaptation tips and tricks from the mesial-buccal interproximal debridement.

305

6. Debridement of the mesial-lingual root is now complete.

Buccal Debridement of the Mandibular First Molar Supragingival Interproximal Area

Dominant right- and left-handed providers: Continue debriding the same tooth with the same insert. Transverse orientation will be used for this exercise. Confirm the correct insert has been selected for transverse orientation (see Box 16-3). If a curved insert is adapted in a vertical orientation on the lingual surface of a tooth, it is adapted on the buccal surface in transverse orientation.

Box 16-3

A

1. Adapt the active area antinode to the distalbuccal interproximal contact of the mandibular first molar. In correct adaptation, the shank is parallel to the long axis of the tooth and is not wrapped around the tooth.

2. Adapt the active area antinode to the distallingual interproximal contact. This is incorrect adaptation as the shank is wrapping across the tooth and the point is in contact with the interproximal contact.

B Figure 16-35  Mesial-lingual root debridement of the

mandibular first molar: A. Back surface of the active area antinode adapted to the mesial, B. Back surface of the active area antinode adapted to the mesial debriding one-half the mesial interproximal area.

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Chapter 16 Curved Insert Technique Practice

Grasp the ultrasonic handpiece with your dominant hand. See Chapter 9 for details if needed.

Grasp the HVE with your nondominant hand. See Chapter 9 for details if needed.

Adapt the lateral surface of the active area antinode in a transverse orientation at the distal-buccal interproximal contact supragingivally (see Figure 16-36).

1. Perform an ultrasonic activation stroke to debride one-half of the distal interproximal area. The other half was debrided from the lingual. 2. Reposition the lateral surface of the active area antinode with a 0- to 15-degree angulation in a transverse orientation to the mesial-buccal interproximal contact supragingivally (see Figure 16-37).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port on the insert.

Select the operator positioning for direct vision. • Dominant right-handed provider: 8–11 o’clock • Dominant left-handed provider: 1–4 o’clock

Select the patient chair positioning for the mandibular arch. Patient chair supine, semi-supine, or in between supine and semi-supine with chin slightly down.

Establish a finger rest intraoral or extraoral, ensuring correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps listed next.

Figure 16-36 Buccal interproximal mandibular first

molar debridement. Lateral surface of the active area antinode adapted to the distal-buccal interproximal contact supragingivally.

Figure 16-37  Buccal interproximal mandibular first

molar debridement. Lateral surface of the active area antinode adapted to the mesial-buccal interproximal contact supragingivally.

3. Perform an ultrasonic activation stroke to debride one-half of the mesial interproximal area. The other half was debrided from the lingual. 4. Buccal debridement of the mandibular first molar  supragingival interproximal area is ­ complete.

Summary

Summary

Magnetostrictive curved shank inserts are multifunctional because they can debride subgingival deep periodontal pockets and complex root anatomy, as well as supragingival interproximal areas. The curved inserts function as a pair, with one debriding lingual surfaces

307

and the other debriding facial/buccal surfaces. Continued repetitive ultrasonic instrumentation practice with curved inserts will increase your confidence with their use.

CHAPTER 17

EMS LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Identify EMS piezoelectric ultrasonic products, parts, and accessories. 2. Recognize the design differences of tips and select the best tip for the patient presentation. 3. Understand the operations of the foot pedal. 4. Perform proper waterline maintenance. 5. Select the correct water flow and power setting for each tip. 6. Reprocess handpieces and tips according to the manufacturer’s recommendations.

this product is not approved for use in the United States. Original Piezon Handpiece: handpiece without LED lighting manufactured by EMS. Original Piezon LED Handpiece: handpiece with LED lighting manufactured by EMS. Perio Tips: the name of thin (slim) diameter tips with straight and curved shanks manufactured by EMS. Piezon: the name of an EMS piezoelectric ultrasonic device. Scaling tips: the name of thick diameter tips with a straight shank manufactured by EMS.

• • • • •

KEY TERMS

the name of a dual mode piezoelectric • AIRFLOW: ultrasonic and air polishing device manufactured

by EMS. AIRFLOW Prophylaxis Master: the name of the newest dual mode model that provides both piezoelectric ultrasonic scaling and air polishing manufactured by EMS. CLIP+CLEAN: tool paced into the device’s water bottle receptacle for dust protection. CombiTorque: the name of the wrench manufactured by EMS. E-Series tip threader: tip threader with four flats manufactured by EMS. Light guide: located inside the Original Piezon LED handpiee provides Light Emitting Diode (LED) illumination during ultrasonic instrumentation that will need replacement over time. Night Cleaner: a solution manufactured by EMS with a combination of chemicals (ethylenediaminetetraacetate, p-hydroxybenzoic acid ester, polyhexamethylenebiguanide) that will prevent lime, algae, and biofilm formation in a waterline with its bactericidal and fungicidal actions. At the time of publication,

• • • • • •

Introduction This chapter will explore piezoelectric ultrasonic technology manufactured by EMS. The company’s research and development teams have continued to evolve the field of piezoelectric technology, releasing new and innovative devices and tip designs. Although there are other manufacturers of piezoelectric ultrasonic technology, it would be too lengthy for this book to cover every single one. For this reason, the author has chosen to focus on two of the largest global piezoelectric manufacturers. This chapter will present EMS’s ultrasonic devices, handpieces, and tip portfolio. Detailed information for each tip with its clinical use, power settings, diameter, shape, length, and coatings will be discussed. This knowledge will assist the oral health-care provider in implementing a contemporary approach to ultrasonic instrumentation. As discussed in other chapters, it is best practice to use the tips from the company that made your 309

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Chapter 17 EMS

ultrasonic device because there are many differences in manufacturing designs. Mismatching manufacturer technology is not recommended and has the potential to adversely affect efficiency and equipment performance, and possibly void the product’s warranty. Piezoelectric tips are designed with two different tip threaders that are specific to each ultrasonic manufacturer. Using an incorrect piezoelectric tip for the handpiece can strip and destroy the threader and possibly the horn of the handpiece. This causes irreversible damage, and the equipment must be discarded and replaced. EMS has created a unique approach to routine nonsurgical procedures that incorporates disclosing dyes, biofilm reduction and management with air polishing technology, and piezoelectric ultrasonic instrumentation for the removal of hard deposits. EMS has named this procedure Guided Biofilm Therapy (GBT). GBT technique will be presented in the air polishing section of the book.

A

EMS The trade name for EMS piezoelectric ultrasonic devices is Piezon. EMS has created many piezoelectric ultrasonic models over the years that offer a wide range of functionality and features, for example:

• Single

• •

models that provide piezoelectric ultrasonic scaling. There are three single mode P ­ iezon models termed Piezon 150, Piezon 250, and ­ Piezon 700. Two of them have an independent water b ­ottle delivery system, and one is connected to the water supply on the dental unit (see Figure 17-1a to c). Dual mode models that provide both piezoelectric ultrasonic scaling and air polishing. These devices are trade named AIRFLOW. Independent self-contained water reservoirs.

B

Frequency

The frequency used for all piezoelectric models manufactured by EMS is 32 kHz.

Emerging Technology

The newest dual mode model on the market is the AIRFLOW Prophylaxis Master (see Figure 17-2), which has many user-friendly features such as:

• •

Three handpieces: one for piezoelectric ultrasonic scaling and two for air polishing. Touch screen power control.

C Figure 17-1  EMS Piezon models: A. Piezon 150,

B. Piezon 250, C. Piezon 700.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

EMS

311

Figure 17-3  EMS Piezon 700 touch screen dial. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Piezon 700. Piezon 700 is sold with a touch screen circular dial (see Figure 17-3). There are no number markings. It is easier to distinguish power settings if we compare it to a standard clock that tells time with a first and second hand as seen in Figure 17-4. Figure 17-2  EMS AIRFLOW Prophylaxis Master. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

• Round • •

wireless foot pedal with Bluetooth technology. Boost mode. Independent fluid reservoir bottle. Air polishing technology uses the air from the dental unit and is discussed later in this book.

Power

EMS piezoelectric ultrasonic devices have three ways to change the power setting that varies by model. The foot pedal activates and deactivates the device and delivers the power level selected by the provider. Boost mode is an option on select models controlled through the foot pedal.

Power Control Power output options are low, medium, and high, controlled with a moveable knob, dial, or touch screen. Piezon 150 and Piezon 250.  Piezon 150 and Piezon 250 are sold with a movable knob with power range one through nine. One is on and nine is max.

• Low power: one to three. • Medium power: four to six. Four is the maximum •

power for periodontal procedures. High power: seven to nine.

• Power off: 6 o’clock. • Low power: 6-10 o’clock. • Medium power: 10-2 o’clock. • High power: 2-5 o-clock. The Piezon 700 has two modes that assist with optimizing power settings. The two modes are called Standard and Endo (see Figure 17-5).

• Standard mode: Mode used for ultrasonic scaling. • Endo mode: Mode used for deep cavity endodontics because it reduces the power curve to deliver a more delicate treatment.

After 15 minutes of inactivity, the unit will go into Standby mode. AIRFLOW Prophylaxis Master.  The power control for the AIRFLOW Prophylaxis Master is a touch screen numbering system. The power output options are 1 through 10 selected by sliding one’s finger on the groove panel below the number (see Figure 17-6a and b).

• 0 is water only with no cavitation delivery. • Low power (1–3). • Medium power (4–7). • High power (8–10). Ten is maximum power. After 60 minutes of inactivity, the unit will go into Standby mode. Table 17-1 provides a summary of power settings for the Piezon 150, Piezon 250, Piezon 700, and the AIRFLOW Prophylaxis Master.

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Chapter 17 EMS

12 o-clock 10 o-clock

2 o-clock

A

6 o-clock: off position

B Figure 17-5  EMS Piezon 700 Standard and End modes.

A. EMS Piezon 700 touch screen dial, B. Clock. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 17-4  EMS Piezon 700 touch screen dial. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A

B

Figure 17-6  EMS AIRFLO Prophylaxis Master Touchscreen Groove Panel: A. Touchscreen groove panel power

output set to one B. Touchscreen groove panel power output set to five. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

EMS

313

Table 17-1  EMS Power Settings AIRFLOW Prophylaxis Master

Piezon 700

Piezon Biofilm, Bacterial 150/250 By-Products

Stain

Dental Calculus

1–3

6-10 o’clock

1–3

Light

Light

Light

Medium 4–7

10-2 o’clock

4–6

Moderate, heavy

Moderate, heavy

Light, moderate

High

2-5 o’clock

7–9

X

Moderate, heavy

Moderate, heavy

Low

8–10

Boost: press in middle and all way to floor

4

3

Non-Boost: press lightly on side

1 2 Standard Mode

1

Irrigation + light

2

Ultrasound irrigation + light

3 4 (+ 2 )

Ultrasound + light (Dry work mode)

Endo Mode 1 2 3

Same as Standard mode

4

Inactive

*Temporary power increase of 30% (up to 100%)

Boost function* + light

Figure 17-7  EMS Piezon 700 foot pedal. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Foot Pedal

Figure 17-8  EMS AIRFLOW Prophylaxis Master foot

pedal.

Boost Mode The Piezon 700 and AIRFLOW Prophylaxis Master have Boost mode. Boost mode is controlled by the foot pedal. Boost allows for uninterrupted ultrasonic instrumentation. When boost mode is activated, the power output will increase. Boost is a useful feature during debridement when a larger oral deposit is encountered. The provider does not need to stop ultrasonic instrumentation to increase the power setting. To activate Boost:

The Piezon  150, Piezon  250, and Piezon  700 have foot pedals that are tethered to the ultrasonic device via a cord.

• Piezon Master 700: Depress the pedal control 4

• Round pedal: Piezon  150 and Piezon  250. No

•

•

Boost mode option. Four-setting pedal: Piezon  700. Boost mode is available (see Figure 17-7).

The AIRFLOW Prophylaxis Master has a wireless round foot pedal with Bluetooth technology that is not tethered to the device via a cord. The foot pedal is synched to the device by the manufacturer. There is no need for synchronization upon delivery.

and 2 at the same time. Boost mode will increase the power output by 30%. AIRFLOW Prophylaxis Master: Depress the middle of the pedal all the way to the floor. To operate without Boost, press the foot pedal lightly on the outer rim (see Figure 17-8). Boost mode will increase the power output as shown in Table 17-2.

Water

EMS piezoelectric ultrasonic devices have three different ways to change the water flow rate based on the

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Chapter 17 EMS

Table 17-2  EMS AIRFLOW Prophylaxis Master Boost Mode Power Increase Power setting

0

1

2

3

4

5

6

7

8

9

10

Boost mode

0

6

7

8

9

10

10

10

10

10

10

Reproduced with permission from EMS Electro Medical Systems

model. The water flow rate selected by the provider is based on the power output setting. If present, the water filter must be periodically checked and replaced at a specified interval by the manufacturer, which can be found in the direction for use or instruction for use (DFU/IFU). The water temperature can be changed in some models. A peristaltic water pump accompanies a device with an independent water bottle that needs replacement at a specified interval by the manufacturer that can be found in the DFU/IFU.

Water Control

• Piezon

• •

150 and Piezon 250: the water control is a knob located on the side of the unit (see Figure 17-9). Turn the knob clockwise to increase the water flow rate and counterclockwise to decrease. Piezon 700: the water control is on the handpiece connector (see Figure 17-10). AIRFLOW Prophylaxis Master: the water control is a spindle on the handpiece holder with settings 1 through 10 (see Figure 17-11a and b).

Figure 17-9  EMS Piezon 150 and Piezon 250 water

control grey knob on the left side of the device. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

MAX

Water Flow Rate EMS recommends a continuous water flow rate during active ultrasonic instrumentation because heat is produced. There are no tips used for oral deposit removal that have a dry work function. A few tips have this function and are used for endodontic and restorative procedures. Be sure to adhere to the instructions in the DFU/IFU for dry work function use. The water flow rate is selected based on the tip being used and listed in the DFU/IFU. The three tips EMS manufactures for natural teeth are the PS, PSR, ad PSL, which are all used with 70–100% water flow rate. The PI tip is used for dental implant debridement, and the water flow rate is medium to high.

Water Filter The water filter should be inspected monthly and replaced at minimum three times a year. If you own a dual device, replace the air filter annually (see Figure 17-12).

Figure 17-10  EMS Piezon 700 water control. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Water Temperature The AIRFLOW Prophylaxis Master allows for a change in water temperature. This is not a feature in other Piezon models. Heating the water can increase patient comfort, especially if the patient has dentinal hypersensitivity or they are not anesthetized while instrumenting less mineralized hard tissues. The device is set to 40°C/104° by default. To change the water temperature, follow these steps: 1. Press and hold 0 and 10 at the same time (see Figure 17-13a).

EMS

315

A

A

B

Figure 17-11  EMS AIRFLOW Prophylaxis Master water

control: A. Spindle set to zero, B. Spindle set to ten. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

B Figure 17-13  EMS AIRFLOW Prophylaxis Master:

A. Pressing 0 and 10 at the same time, B. Number illumination above the groove panel. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Water Bottles and Line Purging

Figure 17-12  EMS AIRFLOW Prophylaxis Master Water

Filter (blue) and Air Filter (white). Reproduced with permission from E.M.S. Electro Medical Systems S.A.

2. The numbers will change color (see Figure 17-13b). Numbers 0–4 are used to change the water temperature. • 0: no heat • 1: 25°C/77°F • 2: 30°C/86°F • 3: 35°C/95°F • 4: 40°C/104°F (default) 3. Press the On/Off button to save your setting.

The Piezon 150 does not have an independent water bottle. It derives its water source from the dental unit. The Piezon 250 and AIRFLOW Prophylaxis Master have one independent water bottle (see Figure 17-14a), and the Piezon 700 has two independent water bottles. Water bottles are equipped with an O-ring to prevent leakage and provide a tight seal (see Figure 17-14b). The O-ring will need to be replaced when it is worn. Remove the bottle with a straight pull motion and replace the same way. Do not twist the bottle when placing and removing. Anytime the water bottle is removed for long periods of time, place the CLIP∙CLEAN tool into the device’s water bottle receptacle for dust protection. The CLIP+CLEAN should be sterilized prior to use as unsterile use may contaminate the device. Refer to the DFU/IFU for compatible solutions that you can use in the independent water bottles. The Piezon 250 and Piezon 700 independent water

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Chapter 17 EMS

A

Figure 17-15  EMS AIRFLOW Prophylaxis Master Night

Cleaner bottle (blue) and product. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

B Figure 17-14  EMS AIRFLOW Prophylaxis Master:

A. Independent water bottle B. Red O-ring on the bottle cap.

different from the other models. In addition to daily cleaning, the water lines are to be treated once a week with a specialized Night Cleaner (see Figure 17-15). At the time of this book publication, Night Cleaner is not approved for use in the United States. EMS recommends other products for waterline maintenance. Contact EMS for any questions. The Night Cleaner is a solution with a combination of chemicals (ethylenediaminetetraacetate, p-hydroxybenzoic acid ester, polyhexamethylenebiguanide).  Night Cleaner is bactericidal and fungicidal and prevents lime and algae formation in the line. It contains a source of phenylalanine, which fights biofilm accumulation in the lines.

• Night Cleaner is placed in the Nighttime cleaner

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

bottles have specific maintenance recommendations in the DFU/IFU such as:

• Purge the line for 20 seconds at the beginning and • •

end of the day as well as between patients. At the end of the day, run a disinfectant solution through the line for 20 seconds, leave in place for 5 minutes, and then run distilled water through the line for 20 seconds. The waterline should be cleaned every 13 uses. Refer to DFU/IFU for compatible cleaning ­solutions and how long to run them through the line.

The AIRFLOW Prophylaxis Master independent water bottle has specific maintenance recommendations

• •

bottle, which is a blue color (see Figure 17-16a and b). Fill the Nighttime bottle with the Night Cleaner solution to the fill line. Set the water control to 10 on the device. Run the entire solution from the bottle through the line and leave it in place overnight (12 hours). The next morning, remove the Nighttime cleaner bottle and replace with a fully filled water bottle. Set the water control to 10 and flush the line to clear the solution away.

The AIRFLOW Prophylaxis Master has an automatic purge feature. Press the pedal once to activate the automatic purge. The numbers will illuminate blue and then change to white over a 1-minute purge (see Figure 17-17). Purge the waterline for a minimum of 20 seconds at the start of the day, between patients, and at the end of the day.

EMS

317

Figure 17-17  EMS AIRFLOW Prophylaxis Master

automatic line purge number illumination. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A

Figure 17-18  EMS Piezon Peristaltic Water Pump Reproduced with permission from E.M.S. Electro Medical Systems S.A.

B Figure 17-16  EMS AIRFLOW Prophylaxis Master:

A. Blue Nighttime cleaner bottle affixed to the device, B. Nighttime cleaner bottle labeled (“CLEANER”) on the cap. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Water Pump A peristaltic water pump will accompany a piezoelectric ultrasonic device that uses an independent water bottle (see Figure 17-18). The peristaltic water pump is a wear and tear item whose frequency of replacement can be found in the DFU/IFU. For example, the Piezon 700 water pump should be replaced every 18 months.

Tip Water Port All tips have an internal water port as described in Chapter 5. Internal water ports are equipped with a

small cannula tube embedded inside the shank that emerges from a small port opening at a specific position on the shank.

Handpiece EMS manufactures two Piezon handpieces (see ­Figure 17-19).

• Original Piezon Handpiece:

Handpiece with-

out LED lighting.

• Original Piezon LED Handpiece:

Handpiece with LED lighting (see Figure 17-19). The LED lighting initiates when the handpiece is removed from its holder (see Figure 17-20). The LED light will automatically turn off after 20 seconds once the foot pedal is released.

Both handpieces are made of a medical-grade resin body that is sterilized between patient use. They have a detachable nose cap and O-ring (see Figure 17-21a and b).

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Chapter 17 EMS

A

Figure 17-19  EMS Original Piezon LED Handpiece in

holder with attached tip inside the CombiTorque wrench. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

B Figure 17-21  EMS Detachable parts from handpiece:

A. Nose cap and light guide, B. Red O-ring and light source. Figure 17-20  EMS Original Piezon LED Handpiece

illuminated.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

The Original Piezon LED handpiece also has a detachable light guide (see Figure 17-21a). These items are removed prior to reprocessing and placed back into the handpiece prior to use.

Light Guide

The LED light guide provides illumination during active ultrasonic instrumentation for improved visibility. Light guides will need to be replaced over

time. It is recommended to check the transparency monthly. When the illumination reduces or the light guide changes color and becomes more opaque, it is time to replace. The handpiece can always be used without the light guide; the user will just lose the LED illumination. The light source inside the handpiece cannot be replaced (see Figure 17-21b)

O-Ring A black O-ring is present on the handpiece connector cord (see Figure 17-22). Periodically inspect the O-ring and evaluate for damage or wear and replace as indicated.

EMS Tip Portfolio

Figure 17-22  EMS handpiece connector cord with black

O-ring.

319

Figure 17-24  EMS E-Series tip threader with 4 flats.

2 flats are visible in this image. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 17-23  EMS handpiece and handpiece connector

cord.

Handpiece Connection When attaching the handpiece to the handpiece connector cable, ensure that the electrical connections align (see Figure 17-23). Be gentle when attaching and removing the handpiece from the connector to avoid damage to the connections.

EMS Tip Portfolio EMS manufacturers a variety of shank shapes, diameters, and coatings. The diamond tips are used during periodontal flap surgery and will not be covered in this book.

The tip threader is an E-Series, with four flats (see Figure 17-24). In Figure 17-24 two flats are visible from one side, and the other two flats are on the opposite side. Only use tips manufactured by EMS in their piezoelectric devices. Do not attach an S-Series tip to an EMS handpiece because they have two flats instead of four. This can cause stripping of the handpiece and tip. Once damaged, the equipment must be discarded and replaced. Tips are torqued into the handpiece with the wrench (see Figure 17-19). Follow these guidelines for proper torque that produces optimal tip performance:

• Do not force torquing beyond its stop point. • Tighten moderately with the wrench provided to • •

ensure optimal torque. Do not overtorque a tip because the risk for breakage or tip threader stripping increases. Never remove or place a tip into the handpiece when the device is activated.

Thick Diameter Tips

EMS used to manufacture three thick diameter tips with a straight shank. They had the largest surface area of the shank and were termed Scaling Tips. At the time of publication of this book, EMS has stopped manufacturing these tips. The tip name, shank shape, and cross-section are listed in Table 17-3 for institutions that may still have and use these tips.

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Chapter 17 EMS

Table 17-3  EMS Thick Diameter Shank Tips (Scaling Tips) Name

Shank Shape

Cross-section

A Instrument Straight

Round

B Instrument Straight

Broad, flat, blunt design

C Instrument Straight

Broad, flat, blunt design

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Table 17-4  EMS Thin Diameter Shank Tips (Scaling Tips) Tip Name

Shank Shape

Cross Section

PS (PerioSlim) Instrument

Straight

Round

PSR (Perio Slim Right) Instrument

Curved

Round

PSL (Perio Slim Left) Instrument

Curved

Round

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Clinical Indications for Use B and C Instruments are used for large, heavy supragingival dental calculus deposits.

• B Instrument: used on the lingual surfaces of an•

terior and posterior teeth. C Instrument: used on anterior teeth.

A Instrument is used for the removal of moderate to heavy dental calculus deposits and staining. Due to its thick shank diameter, A Instrument may not be able to access subgingivally when tissues are firm, hard, and tightly adherent. If tissues are soft, spongy, and moveable, A Instrument may be able to access subgingivally.

Power and Water Settings B and C Instruments can be used at all power levels, and A Instrument is used on medium or high. Clinically, since they are used for the removal of moderate to heavy dental calculus and stain, a high power is typically used. The water flow rate is medium to high.

Thin Diameter Tips

EMS used to manufacture seven thin diameter tips with a straight shank. At the time of publication of this book, EMS has stopped manufacturing four of  the seven tips in this category called Perio Tips. The three tips currently manufactured are the PS Instrument, PSR Instrument, and the PSL Instrument. The PS Instrument tip has a straight shank shape, and the PSR and PSL Instrument tips have a curved shank shape. All cross sections are round. Table 17-4 provides a summary of the tip name, shank shape, and cross-section. The discontinued tips are:

• Straight thin tips: P and PL3 Instruments have a •

round cross-section and one bend in the shank. Curved thin tips: PL1, PL2, PL4, and PL5 Instruments. PL4 and PL5 are curved with a ball point and PL1 and PL2 are curved without a ball point.

Table 17-5  EMS Perio Tip Power and Water Settings

Tip Name

Power Setting

Water Flow Rate

PS Instrument

30–100%

70–100%

PSR Instrument

10–60%

70–100%

PSL Instrument

10–60%

70–100%

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Clinical Indication for Use Perio Tips are used for the removal of light to moderate dental calculus, stain, and all levels of biofilm and bacterial by-products. Their thin diameter allows for subgingival access with little to no tissue distension (see Figure 17-25a and b).

• The curved PSR and PSL Instruments are use•

ful for interproximal and complex root anatomy debridement. They can debride down to 8  mm subgingivally. The PS Instrument can debride down to 10 mm subgingivally.

Power and Water Settings The water flow rate for Perio Tips is 70–100%. The power settings for the PS Instrument is 30–100%, and for the PSR and PSL Instruments is 10–60% (see­ Table 17-5). Always use the lowest power output possible to achieve the clinical goal.

Implant Tip

EMS manufactures a tip for implant debridement called the PI Instrument. The tip is coated with polyether ether ketone (PEEK) and is autoclavable (see Figure 17-26). As a reminder from Chapter 5, PEEK is a semicrystalline, high-temperature thermoplastic polymer that is

Reprocessing

321

coated onto the stainless-steel active area antinode for the debridement of a dental implant. The tip has a single bend and is designed to debride a dental implant, abutment, and prosthesis. The power setting is low to medium with a water flow rate that is medium to high.

Reprocessing Always use aseptic techniques during ­reprocessing that includes full Personal Protective Equipment (PPE) and utility gloves when handling contaminated equipment to avoid cross-contamination and operator injury.

Ultrasonic Device A

The power cord, air and water lines, handpiece cable, foot pedal and cord, and the device itself are not sterilizable but should be disinfected with an approved solution per the manufacturer, which you can find in the product DFU/IFU. Do not spray disinfectant solutions directly on system surfaces. Use a manufacturer-­ approved chemical wipe with correct contact time.

Tip, Wrench (EMS CombiTorque Wrench), and Handpiece

B Figure 17-25  EMS Perio Tips: A. PS Instrument, B. PSR

and PSL Instruments.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Carefully remove the tip from the handpiece with the wrench called a CombiTorque. Cleaning should occur within one hour ­after use. Manual and automatic cleaning instructions are found in the manufacturer’s DFU/IFU. The tip and CombiTorque can be placed in an ultrasonic bath and automated washer. Detach the handpiece from the handpiece connection cable with a gentle straight pull motion. Do not twist or turn the handpiece upon removal to avoid damage to the connections. Unscrew the nose cap, and remove the light guide (if applicable) and O-ring from the handpiece (as seen in Figure 17-27). Rinse the nose cap, light guide, O-ring, and handpiece under running water. The handpiece cannot be placed in an ultrasonic bath. Sterilization should occur directly after cleaning processes are complete. Steam under pressure sterilization is recommended because cold liquid disinfection, chemical vapor, and dry heat sterilization have not been tested or validated for efficacy. Do not exceed the maximum number of sterilization cycles.

Figure 17-27  EMS Original Piezon LED Handpiece with Figure 17-26  EMS PI Instrument.

removed red O-ring, light guide, and nose cap. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

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Chapter 17 EMS

CASE STUDY

A 24-year-old Hispanic male presents to the hygienist for a new patient appointment. He has not seen a dentist since he was 15 years old. He smokes eight cigarettes a day and has daily moderate alcohol intake. He has a metal tongue ring. He does not take any prescription or over-the-counter medications, has no known drug allergies, and his vitals are within normal limits. His chief complaint is “something feels weird on my lower front teeth, but nothing hurts” (see Figure 17-28). Periodontal findings: Generalized heavy biofilm and light to moderate dental calculus throughout. Probe depths are 3–4 mm generally with 85% bleeding upon probing. Gingival tissues are generally erythematous with localized edema mandibular anterior central and lateral incisors. No attachment loss is present except the mandibular central and lateral incisors, which also have heavy lingual, interproximal, and facial dental calculus. The patient has severe recession mandibular central incisors only on the lingual. Treatment plan: A periodontist performs the examination and recommends a nonsurgical periodontal debridement procedure followed by bone and gingival grafting for the mandibular anterior central incisors. The dental hygienist carries out phase one of the treatment and performs a nonsurgical periodontal debridement. Even with local anesthesia, the patient experienced pain upon instrumentation of the mandibular anterior central incisors, and the dental hygienist debrided to the best of their ability (see Figure 17-29).

Figure 17-28  Periapical radiograph and intraoral photograph of the

mandibular anterior teeth.

Figure 17-29  Immediate post-operative intraoral

photograph of the mandibular anterior teeth.

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323

Figure 17-30  Four Week Postoperative Intraoral Photographs of the Mandibular Anterior Teeth.

The patient was seen four weeks post-nonsurgical periodontal debridement (see Figure 17-30). He reports severe pain for the first week after the procedure. The severe pain has subsided, but he still has occasional sensitivity to hot and cold on the mandibular anterior teeth.

Questions for initial nonsurgical periodontal debridement

1. Which of the following is not a likely cause of the localized severe attachment loss seen in Figure 17-28 and Figure 17-29? a. Attachment loss caused by the natural aging processes b. Presence of a metal tongue ring c. Malocclusion with a traumatic bite d. The patient’s brushing habits 2. Which of the following tips should be used to begin debridement of the mandibular anterior lingual central incisors pictured in Figure 17-28? a. PS Instrument b. PSR Instrument c. PSL Instrument d. PI Instrument 3. What power setting should be used to begin debridement of the mandibular anterior lingual central incisors with the tip selected in question 2? a. 70–100% b. 30–40% c. 20–30% d. 10–20% 4. True or False: A tap stroke followed by an ultrasonic activation stroke should be initially used to debride the mandibular anterior lingual central incisors with the tip selected in question 2. a. True b. False 5. The PS Instrument removes the dental calculus from the straight lingual, but the provider is unable to adapt the lateral surfaces to the direct mesial interproximal area. What tip should the provider switch to? a. PSR/PSL Instruments b. PI Instrument

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Chapter 17 EMS

Questions for four-week follow-up appointment

1. Ultrasonic technology is contraindicated for the debridement of the mandibular right central incisor dental calculus as seen in Figure 17-30. a. True b. False 2. Which of the following tips should be used to begin debridement of the mandibular anterior lingual central incisors pictured in Figure 17-30? a. PS Instrument b. PSR Instrument c. PSL Instrument d. PI Instrument

Summary

EMS offers a variety of piezoelectric ultrasonic devices with differing functionality. Four tips are available, which include a thin straight tip, two curved tips, and one implant debridement tip. Handpieces are made with and without LED illumination. Guided Biofilm

Questions

1. Which of the following is the trade name for an EMS single mode piezoelectric ultrasonic device? a. AIRFLOW b. AIRFLOW Prophylaxis Master c. Piezon d. Night Cleaner 2. What is the frequency of an EMS piezoelectric ultrasonic device? a. 25 kHz b. 30 kHz c. 32 kHz d. 40 kHz 3. What power setting should be used to remove light biofilm on the enamel of teeth? a. Low b. Medium c. High 4. What power setting should be used to remove heavy dental calculus on the enamel of teeth? a. Low b. Medium c. High

Therapy, which includes ultrasonic instrumentation with the AIRFLOW Prophylaxis Master in its treatment protocols, is an approach to routine and nonsurgical periodontal procedures that will be discussed in detail in the air polishing section of this book.

5. When using the Piezon Master 700, what percentage increase of power occurs when Boost mode is activated? a. 10% b. 20% c. 25% d. 30% 6. How often should the water filter be replaced? a. Monthly b. Biannually c. Triannually d. Annually 7. What is the water temperature set to upon delivery of the AIRFLOW Prophylaxis Master? a. There is no water temperature control on the AIRFLOW Prophylaxis Master. b. 0 degrees Celsius c. 40 degrees Celsius d. 90 degrees Celsius 8. Which of the following is a wear and tear item that needs replacement? a. Independent bottle O-ring b. Handpiece connector cord O-ring c. Light guide d. Peristaltic pump e. All of the above

Questions

9. How long will the water purge when the automatic purge feature is activated on the AIRFLOW Prophylaxis Master? a. 1 minute b. 2 minutes c. 4 minutes d. 5 minutes 10. True or False. EMS manufactures tips with an S-Series threader. a. True b. False 11. Which tip currently manufactured by EMS is a straight thin tip? a. PS Instrument b. PSR Instrument c. PSL Instrument d. None of the above 12. Which of the following EMS tips can debride the deepest into a periodontal pocket? a. PS Instrument b. PSR Instrument c. PSL Instrument

325

13. What water flow rate should be used with PS, PSR, and PSL Instruments? a. 40–50% b. 50–60% c. 60–70% d. 70–100% 14. What is the maximum power that can be used with the PSR and PSL Instruments? a. 100% b. 60% c. 50% d. 30% 15. Which of the following tips is used for implant debridement? a. PS Instrument b. PI Instrument c. PSR Instrument d. PSL Instrument

CHAPTER 18

Acteon LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Identify Acteon piezoelectric ultrasonic products, parts, and accessories. 2. Recognize the design differences of tips and select the best tip for the patient presentation. 3. Understand the operations of the foot pedal. 4. Perform proper waterline maintenance. 5. Select the correct water flow and power setting for each tip. 6. Reprocess handpieces and tips according to the manufacturer’s recommendations. 7. Implement the Soprocare three-step program for routine and nonsurgical periodontal procedures.

KEY TERMS

power zone: high power range (11–16) that is • Blue used with prophylaxis tips. mode: setting on Soprocare camera • Caries manufactured by Acteon that detects areas of demineralization. Daylight mode: setting on Soprocare camera manufactured by Acteon that captures intraoral images with natural light. F.L.A.G. dye: fluorescein dye solution made of a mixture of glycerol and disodium 2-(3-oxo-6oxidoxanthen-9-yl) benzoate that stains plaque biofilm. Green power zone: low power range (1–6) that is used with periodontic tips. Implant care: the name of plastic and titanium tips manufactured by Acteon. Irrigation seal: O-rings present on an Acteon handpiece and the horn. Light Emitting Diode (LED) ring: ring located in the handpiece of the Newtron SLIM B.LED that provides illumination during ultrasonic instrumentation.

• • • • • •

the name of an Acteon piezoelectric • Newtron: ultrasonic device. SLIM: handpiece without LED lighting • Newtron manufactured by Acteon. SLIM B.LED: handpiece with LED • Newtron lighting manufactured by Acteon. mode: setting on Soprocare camera • Perio manufactured by Acteon that uses a blue LED ®

light and white LED light to illuminate the pigments present in oral deposits and the natural endogenous fluorophores present in hard and soft tissues. Periodontic tips: the name of ultra-thin diameter tips manufactured by Acteon. Prophylaxis tips: the name of thick and thin (slim) diameter tips manufactured by Acteon. Soprocare: the name of a proprietary threestep program created by Acteon for preventive nonsurgical procedures that uses the Soprocamera for patient education, F.L.A.G technology with ultrasonic instrumentation, and air polishing. Soprocare camera: the name of the camera manufactured by Acteon that has a daylight, caries, and perio mode to capture intraoral images. S-Series tip threader: tip threader with two flats manufactured by Acteon.

• • • • •

Introduction This chapter will explore piezoelectric ultrasonic technology manufactured by Acteon. The company’s research and development teams have continued to evolve the field of piezoelectric technology, releasing new and innovative devices and tip designs. Although there are other manufacturers of piezoelectric ultrasonic technology, it would be too lengthy for this 327

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Chapter 18 Acteon

book to cover every single one. For this reason, the author has chosen to focus on two of the largest global piezoelectric manufacturers. This chapter will present Acteon’s ultrasonic devices, handpieces, and tip portfolio. Detailed information for each tip, with its clinical use, power settings, diameter, shape, length, and coatings, will be discussed. This knowledge will assist the oral health-care provider in implementing a contemporary approach to ultrasonic instrumentation. As discussed in other chapters, it is best practice to use the tips from the company that made your ultrasonic device because there are many differences in manufacturing designs. Mismatching manufacturer technology is not recommended and has the potential to adversely affect efficiency and equipment performance, and possibly void the product’s warranty. Piezoelectric tips are designed with two different tip threaders that are specific to each ultrasonic manufacturer. Using an incorrect piezoelectric tip for the handpiece can strip and destroy the threader and possibly the horn of the handpiece. This causes irreversible damage, and the equipment must be discarded and replaced. Soprocare is a unique proprietary procedure created by Acteon for preventive nonsurgical procedures that consists of using the Soprocare camera, F.L.A.G. technology for B.LED with ultrasonic instrumentation, and air polishing that will be discussed in this chapter.

A

B

Acteon Piezoelectric Ultrasonic Devices The trade name for Acteon piezoelectric ultrasonic devices is Newtron. There are three generations of Newtron piezoelectric scalers termed Newtron Booster, Newtron P5 B.LED, and Newtron P5 XS B.LED (see Figure 18-1a to c). All are single mode models that deliver piezoelectric ultrasonic scaling. The Newtron P5 XS B.LED has an independent self-­contained water reservoir. The other two models connect to the water ­supply on the dental unit.

Frequency

The frequency range of the Newtron piezoelectric ultrasonic devices is 28–36 kHz. The oral health-care provider does not adjust the frequency—the device makes the adjustments on its own based on the tip torqued into the handpiece. Never use another manufacturer’s tip in an Acteon ultrasonic device or performance will be compromised and the risk for equipment damage increases.

C Figure 18-1  Acteon Newtron Piezoelectric ultrasonic

devices: A. Newtron Booster, B. Newtron P5 B.LED, C. Newtron P5 XS B.LED. Reproduced with permission from ACTEON.

Emerging Technology

The Newtron P5 XS B.LED offers many user-friendly features such as:

• Preconfiguration of power and irrigation settings •

that can be controlled through a tablet or smartphone app. A magnetic light indicator that illuminates when the device is on and corresponds to the power level (see Figure 18-2a to d). The light indicator panel is removable from the device for cleaning and disinfecting. It cannot be sterilized.

Acteon Piezoelectric Ultrasonic Devices

A

B

C

D

329

Figure 18-2  Acteon Newtron P5 XS B.LED light indicator: A. Green light (low power), B. Yellow light (medium power),

C. Blue light (high power), D. Orange light (very high power). Reproduced with permission from ACTEON.

Table 18-1  Acteon Newtron Power Settings Color

Power Range

Power Classification

Tips

Uses

Green

1–6

Low power

Periodontic, implant debridement

Periodontics

Yellow

6–11

Medium power

Endodontic

Root canal procedures

Blue

11–16

High power

Prophylaxis

Scaling

Orange

16–20

Very high power

Surgical

Implant loosening

Reproduced with permission from ACTEON

• Automatic water purge activated by a single de• • •

pression of the pedal. The device will automatically purge for 4 minutes and can be interrupted by a second press of the pedal. LED handpiece with white and blue light. Round foot pedal. Independent water reservoir with a 300 or 500 ml tank.

Power

Acteon piezoelectric ultrasonic devices use a magnetic detachable turntable knob to change the power

output setting that is color-coded. There is no Boost mode function. The foot pedal activates and deactivates the device and delivers the power output level selected by the provider.

Power Control The power settings are a color-coded system with a total power range of 1–20. Each tip is paired with a specified color-coded power range. Reference the directions for use or instructions for use (DFU/IFU) for this information. There are four colors: green, yellow, blue, and orange (see Table 18-1).

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Chapter 18 Acteon

Green Power Zone.  The green power zone is low power output. Acteon states the green power zone is for periodontics. It is used for the debridement of enamel, dentin, cementum, and dental implant structures. Periodontic tips have a green color band and are used in the green power zone. Always use the lowest power possible for the oral deposit level. For example, if you are debriding a root furcation with light dental calculus, then a lower setting in the green power zone should be used. If the furcation has moderate dental calculus, a slightly higher setting in the green power zone may be needed for removal. Blue Power Zone.  Blue power zone is high power output. Acteon states that the blue power zone is for scaling. It is used for the removal of oral deposits. Prophylaxis tips have a blue color band and are used in the blue power zone. Caution should be exercised using high blue power zone settings when debriding less mineralized hard tissues such as dentin or cementum. The highest level in the blue zone should only be used for heavy dental calculus removal. Light dental calculus, stain, or biofilm should be debrided with lower settings in the blue power zone.

Figure 18-3  Acteon Newtron P5 XS B.LED Water Control

in front of independent water bottle. Reproduced with permission from ACTEON.

Foot Pedal The foot pedal is tethered to the device via a cord.

• Round pedal: Newtron P5 B.LED and Newtron •

P5 XS B.LED. Rectangular pedal: Newtron Booster.

A

Water

The Newtron piezoelectric ultrasonic devices have a water control knob whose location varies by model. The water flow rate is selected based on the power level. All devices have a peristaltic water pump that is replaced annually.

Water Control The Newtron P5 XS B.LED has a dial water control in front of the water bottle (see Figure 18-3). The Newtron Booster and Newtron P5 B.LED have a water dial on the side of the device. Turn the dial clockwise to increase the water flow rate and counterclockwise to decrease.

Water Flow Rate Acteon recommends a continuous flow of water during active ultrasonic instrumentation. The water flow rate is chosen based on the power output setting.

B Figure 18-4  Water Settings (Newtron SLIM and Tip 1):

A. Low to medium power, B. High power.

• Low to medium power: Water flow rate is set for a rapid drip or a rapid drip with a fine mist halo (see Figure 18-4a).

Acteon Piezoelectric Ultrasonic Devices

331

• High power: The water flow rate is turned up, so

the rapid drip disappears, and a strong mist is expelled (see Figure 18-4b).

Figure 18-5  Newtron SLIM B.LED Handpiece with

detachable nose piece, optical guide, and LED ring.

Water Bottle and Line Purging The Newtron P5 XS B.LED has an independent water reservoir bottle (see Figure 18-3). The Newtron Booster and Newtron P5 B.LED derive their water source from the dental unit. The independent water reservoir bottle of the Newtron P5 XS B.LED is sold in 300 ml or 500 ml sizes. Refer to the DFU/IFU for compatible solutions that can be used in the independent water reservoir bottle. Remove the bottle with a straight pull motion and replace the same way. Do not twist the bottle when placing and removing. There are specific maintenance recommendations for independent water reservoir bottles found in the DFU/IFU such as:

• After installation and before first use, at the end

•

of the day, and following a period of prolonged nonuse, the irrigation system must be cleaned. Fill the independent water reservoir bottle with hypochlorite diluted to less than 3%. Purge the line for 2 minutes. Then refill the independent water reservoir bottle with demineralized, distilled, or drinking water. Purge the line for another 2 minutes to clear the diluted hypochlorite solution.

Water Pump A peristaltic water pump will accompany a piezoelectric ultrasonic device that uses an independent water reservoir bottle. The peristaltic water pump is a wear and tear item that must be replaced annually.

Tip Water Port All tips have an internal water port as described in Chapter 5. Internal water ports are equipped with a small cannula tube embedded inside the shank that emerges from a small port opening at a specific position on the shank.

Handpiece

Acteon manufacturers two handpieces for the Newtron piezoelectric ultrasonic devices that are removable and sterilizable between patients. Each handpiece has two O-rings and a detachable nose piece (see Figure 18-5). 1. Newtron SLIM: Handpiece without LED lighting (see Figure 18-6a).

Reproduced with permission from ACTEON.

A

B Figure 18-6  Acteon handpieces: A. Newtron SLIM,

B. Newtron SLIM B.LED. Reproduced with permission from ACTEON.

2. Newtron SLIM B.LED: Handpiece with LED lighting (see Figure 18-6b). There are two different lighting choices of white or blue/white light. The LED lighting initiates when the handpiece is removed from its holder. The LED light will automatically turn off a few seconds after the foot pedal is released. In addition to a detachable nose piece, the Newtron SLIM B.LED handpiece has an LED ring and optical guide (see Figure 18-5).

LED Ring

The LED ring provides illumination during active ultrasonic instrumentation for improved visibility. One LED ring provides white light only, and the other provides a mixture of white and blue light (see Figure 18-7). The blue light is used for fluorescent lighting, which is discussed later in this chapter.

O-Ring

There are two O-rings that Acteon terms irrigation seals. One is present on the metal shaft on the back

of the handpiece that should be lubricated with silicone paste prior to use to prolong its service life and prevent leaks (see Figure 18-8). The other is present on the horn. Periodically inspect the irrigation seals for damage or wear and replace as indicated. A thin plier can remove the seals and then use the purposedesigned kit provided by Acteon to put new irrigation seals into place.

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Chapter 18 Acteon

Handpiece Connection When attaching the handpiece to the handpiece connector cable, ensure that the electric connections align. Be gentle when attaching and removing the handpiece from the connector to avoid damage to the connections (see Figure 18-8).

Acteon Tip Portfolio

Figure 18-7  Acteon Handpiece LED ring. Reproduced with permission from ACTEON.

Acteon offers a wide variety of tips spanning multiple fields in dentistry that vary in shank shape, diameter, and coating. They manufacture nearly 80 tips categorized by prophylaxis, periodontics, implant care, endodontics, and prosthesis. This book will cover the first three: prophylaxis, periodontics, and implant care. Prophylaxis tips have a thicker diameter shank than periodontic tips. Diamond-coated tips are single-use tips and are not covered in this textbook because they are used for periodontal flap surgery. The tip threader is an S-Series with two flats and a color band just below the flats (see Figure 18-9). Only use tips manufactured by Acteon in their piezoelectric devices. Do not attach an E-Series tip to an Acteon handpiece because they have four flats instead of two. This can cause stripping of the tip threader and the horn of the handpiece. Once damaged, the equipment must be discarded and replaced.

Flat

Figure 18-8  Acteon handpiece on the left and handpiece

connector cable on the right.

Figure 18-9  Acteon tip H3. Green color band below the

visible flat. The second flat in on the opposite side.

Acteon Tip Portfolio

333

the shank, and Slim prophylaxis tips have the second largest surface area of the shank. All prophylaxis tips have a larger shank diameter than periodontic tips. Prophylaxis tips have a straight shank that is bent in one plane with a round cross-section. There are no curved shank shapes in the prophylaxis portfolio.

Power Settings Prophylaxis tips are all used in the blue power zone of 11–16, which is considered high power. For any procedure, always use the lowest possible power output to achieve the clinical goal. Never raise the power higher than 16.

Thick Diameter Prophylaxis Tips There are four (1, 10X, 2, 3) thick diameter prophylaxis tips. Tips 1 and 10X are used for supragingival removal of moderate to heavy calculus deposits because their large surface area is too thick to access subgingivally without tissue distension or injury.

A

• Tip 1: Single bend shank that adapts to all tooth surfaces supragingivally (see

Table 18-2).

Figure 18-11a

and

• Tip 10X: Single bend shank useful for debriding interproximal areas (see Figure 18-11b and Table 18-2).

B Figure 18-10  Acteon wrench: A. Wrench and tip 1,

B. Wrench and Newtron SLIM handpiece. Reproduced with permission from ACTEON.

Tips are torqued into the handpiece with the wrench (see Figure 18-10a and b). Replace wrenches annually. Follow these guidelines for proper torque to ensure the optimal tip performance:

• Do not force torquing beyond its stop point. • Tighten moderately with the wrench provided to • •

ensure optimal torque. Do not over-torque a tip because the risk for breakage or tip threader stripping increases. Never remove or place a tip into the handpiece when the device is activated.

Prophylaxis Tips

The prophylaxis tip portfolio offers thick and thin (Acteon term is Slim) diameter shanks with a blue stripe below the tip threader flats. The blue color stripe indicates the tip as a prophylaxis tip and corresponds to the power output setting. The thick diameter prophylaxis tips have the largest surface area of

There are two flat and blunt shank designs in the thick diameter prophylaxis portfolio. One has a blunted point, and the other has a rounded point. The point is adapted to the oral deposit during ultrasonic instrumentation.

• Tip 2: Useful for the removal of heavy dental cal-

•

culus supragingivally due to its broad and flat shank with a blunted point. Tip 2 is not used subgingivally due to its large surface area (see Figure 18-11c and Table 18-2). Tip 3: Useful for the removal of heavy to moderate dental calculus and staining supragingivally due to its broad and flat shank with a rounded point. Tip 3 is not used subgingivally due to its large surface area (see Figure 18-11d and Table 18-2).

Slim Prophylaxis Tips There are three (1S, 10P, 10Z) Slim prophylaxis tips. They are used to debride both supragingivally and subgingivally.

• Tip 1S: Useful for debriding supragingival and

subgingival interproximal areas due to its more active lateral surfaces. Its shank is longer than tip 1 (see Figure 18-12a and Table 18-3).

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Chapter 18 Acteon

B

A

C

D

Figure 18-11  Acteon thick prophylaxis tips: A. Tip 1, B. Tip 10X, C. Tip 2, D. Tip 3. Reproduced with permission from ACTEON.

Table 18-2  Acteon Thick Prophylaxis Tips

Table 18-3  Acteon Thin Prophylaxis Tips

Tip Name

Shank Shape

Cross Section

Tip Name

Shank Shape

Cross Section

1

Straight

Round

1S

Straight

Round

10X

Straight

Round

10P

Straight

Round

2

Straight

Broad, flat, blunt point

10Z

Straight

Round

3

Straight

Broad, flat, rounded point

Reproduced with permission from ACTEON

Reproduced with permission from ACTEON

A

B

C

Figure 18-12  Acteon Slim prophylaxis tips: A. Tip 1S, B. Tip 10P, C. Tip 10Z. Reproduced with permission from ACTEON.

Acteon Tip Portfolio

335

• Tip •

10P: Useful for debriding probe depths 2–3  mm ue to its fine round shank (see Figure 18-12b and Table 18-3). Tip 10Z: Useful for debriding pocket depths 2–4 mm. The tip has probe-like markings on its shank that are used to evaluate the depth of the pocket during ultrasonic instrumentation (see Figure 18-12c and Table 18-3).

Periodontic Tips

The periodontic tips portfolio has thin diameter shanks with a green stripe below the tip threader flats. The green color stripe indicates the tip as a periodontic tip and corresponds to the power output setting. Periodontic tip shanks are thinner than prophylaxis tips. There are two shank shape options of straight and curved. All periodontic tips have a round cross-section.

Power Settings

B

A

Periodontic tips are all used in the green power zone of 1–6, which is considered very low power. For any procedure, always use the lowest possible power output to achieve the clinical goal. Never raise the power higher than 6.

Straight Periodontic Tips There are three straight periodontic tips (H3, TK1-1S, TK1-1L) that are used for the removal of light dental calculus, stain, and all levels of biofilm and bacterial by-products.

• Tip H3: Adapts to anterior teeth (see Figure 18-13a •

and Table 18-4). Tips TK1-1S and TK1-1L: Designed with probe-like markings on the shank that are useful for evaluating the depth of periodontal pockets during ultrasonic instrumentation (see Figure 18-13b and C and Table 18-4). The TKI-1S has a shorter shank than the TK1-1L and is recommended for pocket depths of 4 mm and less. TKI-1L is used to debride pocket depths of 4 mm and greater.

C Figure 18-13  Acteon straight periodontic tips: A. Tip H3, B. Tip TK1-1S, C. Tip TK1-1L. Reproduced with permission from ACTEON.

Table 18-4  Acteon Straight Periodontic Tips

Curved Periodontic Tips

Tip Name

Shank Shape

Cross Section

There are three pairs of curved periodonitc tips (P2R/ P2L, TK2R/TK2L, H4R/H4L) that are used to debride light dental calculus, stain, and all levels of biofilm and bacterial by-products on complex root anatomy. The R stands for a right-curved shank and the L stands for a left-curved shank.

H3

Straight

Round

TK1-1S

Straight

Round

TK1-1L

Straight

Round

Reproduced with permission from ACTEON

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Chapter 18 Acteon

• Tips H4R/H4L: Contra-angled tips with a similar • •

design to a hand-activated curette. They are used on posterior teeth (see Figure 18-14a and Table 18-5). Tips TK2-1R/TK2-1L: Shank resembles a furcation probe. They are used on posterior teeth (see Figure 18-14b and Table 18-5). Tips P2R/P2L: Shank has a double-bend with a rounded micro-tip. The diameter is the thinnest of all periodontic curved tips. They are useful for debriding root structures when tissues are hard, firm, and tightly adherent. They are also useful for debriding difficult to access interproximal spaces. They are used on anterior and posterior teeth (see Figure 18-14c and Table 18-5).

Implant Tips

A

Acteon manufactures multiple tips used for the debridement of a dental implant, abutment, and prosthesis called implant care. There are two groups of tips: plastic micro-tipped and titanium. Implant care tips are used in the green power zone with a maximum power output of 3.

Plastic Micro-Tipped Plastic micro-tipped implant care tips are used to debride a dental implant, abutment, and prosthesis. They will remove biofilm and low adherence oral deposits. There are three plastic micro-tipped implant debridement tips.

• Tip PHI: straight shank shape that is adapted to •

anterior dental implants (see Figure 18-15a). Tips PH2R/PH2L: curved shank shape that is adapted to posterior dental implants. The shank resembles a hand-activated universal curette (see Figure 18-15b).

B

Titanium Titanium implant care tips are used to debride implant threads and valleys. There are five titanium implant care tips (see Table 18-6).

• Tip IP1: Straight shank with the widest diameter •

that is useful for debriding a dental implant with wide threads. Tips IP2R/IP2L: Curved shank shape with the second widest diameter. These tips are useful for debriding a dental implant with medium implant thread width. These tips are adapted the same as the curved tips for natural teeth, which will be shown in Chapter 20.

C Figure 18-14  Acteon curved periodontic tips: A. Tips

H4R/H4L, B. Tips TK2-1R/TK2-1L, C. Tips P2R/P2L. Reproduced with permission from ACTEON.

Reprocessing

337

Table 18-5  Acteon Curved Periodontic Tips Tip Name

Shank Shape

Tooth Adaptation

Cross Section

H4R/H4L

Curved

Posterior

Round

TK2-1R/TK2-1L

Curved

Posterior

Round

P2R/P2L

Curved

Anterior and posterior

Round

Reproduced with permission from ACTEON

A

B

Figure 18-15  Plastic micro-tipped implant debridement tips: A. PH1, B. PH2L/PH2R. Reproduced with permission from ACTEON.

• Tips

IP3R/IP3L: Curved shank shape with the narrowest diameter. These tips are useful for debriding a dental implant with narrow implant thread width. These tips are adapted the same as the curved tips for natural teeth, which will be shown in Chapter 20.

Reprocessing Always use aseptic techniques during reprocessing that includes full Personal Protective Equipment (PPE) and utility gloves when handling contaminated equipment to avoid cross-contamination and operator injury.

Ultrasonic Device

The power cord, air and water lines, handpiece cable, foot pedal and cord, and the device itself are not

sterilizable but should be disinfected with an approved solution per the manufacturer, which you can find in the product DFU/IFU. Do not spray disinfectant solutions directly on system surfaces. Use a manufacturerapproved chemical wipe with correct contact time.

Tip Carefully remove the tip from the handpiece with the wrench. Manual and automatic cleaning instructions are found in the manufacturer’s DFU/IFU. The tip and wrench may be placed in an ultrasonic bath for 10 minutes and an automated instrument washer with manufacturer-­ approved solutions. Prior to bagging for sterilization, ensure that the tip and wrench are completely dry. Do not use a chemical disinfectant on tips. Steam under pressure sterilization is recommended because cold liquid disinfection, chemical vapor, and dry heat sterilization have not been tested or validated for efficacy.

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Chapter 18 Acteon

Table 18-6  Titanium-Tipped Implant Debridement Tips Wide Implant Threads

Medium Implant Threads

Narrow Implant Threads

IP1

IP2R/IP2L

IP3R/IP3L

Reproduced with permission from ACTEON

Soprocare

Handpiece Detach the handpiece from the handpiece connector cable with a gentle straight pull motion. Do not twist or turn the handpiece upon removal to avoid damage to the connections. Unscrew the nose piece, remove the optical guide (if applicable), and LED ring (if applicable). Manual and automatic cleaning instructions are found in the manufacturer’s DFU/IFU. The handpiece should be cleaned no more than 2  hours after use and cannot be placed in an ultrasonic bath. Only the nose piece disassembled from the handpiece may be immersed in an ultrasonic bath for no more than 2 minutes. The equipment may be run through an automated instrument washer with an approved solution and contact time per the manufacturer. Refer to the DFU/IFU for approved solutions. Prior to bagging for sterilization, ensure that the handpiece is completely dry. Use only a steam under pressure form of sterilization.

technology for B.LED with ultrasonic instrumentation, and air polishing. 1. Use the Soprocare camera to identify dental plaque biofilm and gingival inflammation (see Figure 18-16). This first step assists with patient education. The patient is able to visually see inflammation and oral deposits in their mouth. The camera is equipped with three modes: 1. Daylight mode: captures intraoral images. See Figure 18-17. 2. Caries mode: aids in the detection of demineralization and can capture the image. 3. Perio mode: Uses a blue LED and white LED light to illuminate the pigments present in oral deposits and the natural endogenous fluorophores present in hard and soft tissues. Plaque biofilm will appear as grainy white, ­immature dental calculus appears yellow, and mature dental calculus appears dark orange (see Figure 18-17). The image can be captured by the camera.

Soprocare Soprocare is a proprietary three-step program from

Acteon for preventive nonsurgical procedures that consists of using the Soprocare camera, F.L.A.G.

Figure 18-16  Acteon Soprocare camera.

Figure 18-17  Acteon Soprocare camera images: Daylight mode of the maxillary left anterior facial surfaces.

Perio mode of the maxillary left anterior facial surfaces.

339

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Chapter 18 Acteon

Figure 18-18  Air-N-Go Easy. Reproduced with permission from ACTEON.

2. Guided treatment with the use of F.L.A.G. technology for B.LED. This second step enables you to detect and visibly see immature and mature biofilm during active ultrasonic instrumentation. A F.L.A.G. solution fluorescein dye is either added to the independent water reservoir bottle of the Newton P5 XS B.LED piezoelectric ultrasonic or can be applied directly onto tooth surfaces with a brush. The solution is a mixture of glycerol and disodium 2-(3-oxo-6-oxidoxanthen-9-yl) ­benzoate. The solution will dye biofilm and will not stain the

gingiva. When the Newtron SLIM B.LED handpiece with the LED blue/white light guide is used, the F.L.A.G. solution glows even brighter. 3. Full mouth air polishing completes the Soprocare program treatment. Acteon manufactures a portable handheld air polisher called the Air-N-Go Easy, which is used to remove any residual biofilm and stain supragingivally and subgingivally with specialized powders and nozzles (see Figure 18-18). Air polishing is extensively covered in Section 5 of this book.

Soprocare

CASE STUDY

341

A 24-year-old Hispanic male presents to the hygienist for a new patient appointment. He has not seen a dentist since he was 15 years old. He smokes eight cigarettes a day and has daily moderate alcohol intake. He has a metal tongue ring. He does not take any prescription or over-the-counter medications, has no known drug allergies, and his vitals are within normal limits. His chief complaint is “something feels weird on my lower front teeth, but nothing hurts” (see Figure 18-19). Periodontal findings: Generalized heavy biofilm and light to moderate dental calculus throughout. Probe depths are 3–4 mm generally with 85% bleeding upon probing. Gingival tissues are generally erythematous with localized edema mandibular anterior central and lateral incisors. No attachment loss is present except the mandibular central and lateral incisors, which also have heavy lingual, interproximal, and facial dental calculus. The patient has severe recession mandibular central incisors only on the lingual. Treatment plan: A periodontist performs the examination and recommends a nonsurgical periodontal debridement procedure followed by bone and gingival grafting for the mandibular anterior central incisors. The dental hygienist carries out phase one of the treatment and performs a nonsurgical periodontal debridement. Even with local anesthesia, the patient experienced pain upon instrumentation of the mandibular anterior central incisors, and the dental hygienist debrided to the best of their ability (see Figure 18-20).

Figure 18-19  Periapical radiograph and intraoral photograph of the mandibular

anterior teeth.

Figure 18-20  Immediate post-operative intraoral

photograph of the mandibular anterior teeth.

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Chapter 18 Acteon

Figure 18-21  Four Week Postoperative Intraoral Photographs of the Mandibular Anterior Teeth.

The patient was seen four weeks post-nonsurgical periodontal debridement (see Figure 18-21). He reports severe pain for the first week after the procedure. The severe pain has subsided, but he still has occasional sensitivity to hot and cold on the mandibular anterior teeth.

Questions for initial nonsurgical periodontal debridement 1. Which of the following is not a likely cause of the localized severe attachment loss seen in Figure 18-19 and Figure 18-20? a. Attachment loss caused by the natural aging processes b. Presence of a metal tongue ring c. Malocclusion with a traumatic bite d. The patient’s brushing habits 2. Which of the following tips should be used to begin debridement of the mandibular anterior lingual central incisors pictured in Figure 18-19 ? a. 1 b. 1S c. H3 d. TK1-1S 3. What power setting should be used to begin debridement of the mandibular anterior lingual central incisors with the tip selected in question 2? a. Blue power zone 11–12 b. Blue power zone 15–16 c. Green power zone 1–2 d. Green power zone 5–6 4. True or False: A tap stroke followed by an ultrasonic activation stroke should be initially used to debride the mandibular anterior lingual central incisors with the tip selected in question 2. a. True b. False 5. Tip 1 reduces the size of the dental calculus from heavy to light. Which tip should the dental hygienist use next to remove the light deposits? a. Continue using the 1. b. Change from a 1 to a TK1-1S. c. Change from a 1 to a TK1-1L. d. Change from a 1 to a P2R.

Questions

343

6. What power setting should be used with the tip selected in question 5? a. Blue power zone 15–16 b. Blue power zone 11–12 c. Green power zone 3–4 d. Orange power zone 16–17

Questions for four-week follow-up appointment 1. Ultrasonic technology is contraindicated for the debridement of the mandibular right central incisor dental calculus, as seen in Figure 18-21. a. True b. False 2. Which of the following tips should be used to begin debridement of the mandibular anterior lingual central incisors pictured in Figure 18-21? a. 1 b. 2 c. 10X d. H3

Summary

Acteon offers a variety of piezoelectric ultrasonic devices with differing functionality. They manufacture a wide variety of tips that span multiple specialties of dentistry to fit any patient presentation. Handpieces are made with and without LED illumination. Soprocare is a proprietary three-step program used for

Questions

1. Which of the following is an Acteon piezoelectric ultrasonic device? a. Newtron b. Irrigation seal c. Newtron SLIM d. F.L.A.G. 2. What is the frequency range of an Acteon piezoelectric device? a. 25–30 kHz b. 30–40 kHz c. 28–36 kHz d. 35–40 kHz 3. How long will the automatic purge feature stay active in the Newtron P5 XS B.LED piezoelectric ultrasonic device? a. 1 minute b. 2 minutes c. 3 minutes d. 4 minutes

preventive and nonsurgical periodontal procedures that allows the provider to educate their patient with Soprocare camera technology, visualize plaque biofilm with F.L.A.G. technology for B.LED during ultrasonic instrumentation, and complete the patient procedure with air polishing.

4. What size water bottle is available for the Newtron P5 XS B.LED? a. 100 ml b. 300 ml c. 500 ml d. Both B and C Match the following power color zone to its correct description for questions 5–8. There is only one correct answer for each question. 5. Green power zone

A. High power

6. Yellow power zone

B. Used with periodontic tips

7. Blue power zone

C. Power range 16–20

8. Orange power zone

D. Used with endod­ ontic tips

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Chapter 18 Acteon

9. What power setting should be used with a periodontic tip when light biofilm is present on the enamel of teeth? a. Green power zone 1 b. Green power zone 6 c. Blue power zone 11 d. Blue power zone 16 10. What power setting should be used with a prophylaxis tip when heavy dental calculus is present on the enamel of teeth? a. Green power zone 1 b. Green power zone 6 c. Blue power zone 11 d. Blue power zone 16 11. Which of the following is a wear and tear item that will need replacement over time? a. Irrigation seal b. Wrench c. Peristaltic water pump d. All of the above 12. How often should the peristaltic water pump be replaced? a. Monthly b. Biannually c. Annually d. Biennially 13. True or False. Acteon manufactures tips with an E-Series threader. a. True b. False Match the following tips to their correct tip family for questions 14–19. Answer A for prophylaxis tips, B for periodontic tips, and C for implant tips. There is only one correct answer for each question. 14. TK2-1S 15. PH1 16. 10X 17. 1S

18. IP2L 19. P2L 20. True or False. Thick diameter and slim diameter tips are available in the prophylaxis portfolio of tips. a. True b. False 21. Which of the following is a slim prophylaxis tip with markings similar to a probe that can reach up to 4 mm during debridement? a. 10Z b. 10P c. 1 d. P2S 22. Which of the following is a curved periodontic tip? a. P2R b. TK1-1S c. H3 d. 10X 23. True or False. Acteon manufactures curved implant tips that vary in diameter to debride different implant thread widths. a. True b. False 24. In which step in the Soprocare program does ultrasonic instrumentation take place? a. Step one b. Step two c. Step three d. Step four 25. Which Soprocare camera setting uses a blue LED and white LED light to illuminate the pigments present in oral deposits and the natural endogenous fluorophores present in hard and soft tissues? a. Daylight mode b. Caries mode c. Perio mode

CHAPTER 19

EMS Curved Tips LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Identify an EMS curved tip as right or left. 2. Recognize the clinical uses for EMS curved tips. 3. Identify the correct adaptation and angulation of an EMS curved right tip in vertical orientation. 4. Identify the correct adaptation and angulation of an EMS curved left tip in vertical orientation. 5. Perform an ultrasonic activation stroke with EMS curved tips using correct grasp, finger rest, operator and patient positioning, instrument adaptation, angulation, and orientation. 6. Maintain proper ergonomics while performing ultrasonic instrumentation with EMS curved tips.

Introduction This chapter will present the clinical use of piezoelectric curved tips manufactured by EMS. The curved tips are used as a pair to debride complex root anatomy. The curved tips function as a pair, with one debriding lingual surfaces and the other debriding facial/buccal surfaces. Low to medium power with the lateral surfaces adapted at a 0- to 15-degree angulation is used with a vertical orientation. A step-by-step exercise is presented to enhance your clinical technique with EMS curved tips. Curved shanks were developed in the 1990s, and by 2000, the American Academy of Periodontology (AAP) released a position paper supporting the use of thin diameter curved shanks over handactivated instruments for the debridement of Class II, Class III, and Class IV furcation defects (Drisko et al.,

2000). There is a large body of literature supporting the use of curved shanks in furcation areas; however, curved shanks also assist the provider in safely debriding root concavities, convexities, and interproximal surfaces both supragingivally and subgingivally. Their multifunctional capabilities make them a useful tool in many periodontal applications, from a general prophylaxis to surgical procedures.

EMS Piezoelectric Curved Tip Introduction The EMS curved tips are used in vertical orientation to debride complex root anatomy in deep periodontal pockets up to 8 mm. The active area antinode is contacting cementum in this orientation (see Figure 19-1a and b). When debriding root anatomy with a curved EMS tip in a vertical orientation, follow these rules for ultrasonic instrumentation to protect the less mineralized hard tissue cementum:

• Power: Low to medium power is used. High power increases the risk for cemental injury.

• Adaptation: Adapt lateral surfaces. The point and

• •

face have a higher displacement amplitude and should either be used with caution, or avoided, on cementum. See Chapter 9 for details on shank surface displacement amplitude. Angulation: Use a 0- to 15-degree angulation. A 90-degree angulation is contraindicated because the point would be in contact with the cementum (see Figure 19-2a and b). Activation: Use an ultrasonic activation stroke. A tap stroke should be used with caution as the point is adapted.

Piezoelectric curved tips are used as a pair. The provider needs two tips to debride a single tooth. 345

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Chapter 19 EMS Curved Tips

A

B

Figure 19-1  EMS Vertical Orientation Curved Tip (PSR/PRL): A. Lateral surface adapted to the distal of the mandibular

left first molar, B. Lateral surface adapted to the buccal of the mandibular left first molar.

A

B

Figure 19-2  EMS curved tip angulation (PSR/PSL): A. 0- to 15-degree angulation with lateral surface, B. 90-degree

angulation with the point.

The tips are nicknamed right- and left-curved tips. The left and right distinction refers to the direction of the shank bend and has nothing to do with how or where they are used in the mouth. The provider’s dominant hand has no influence on which tip is used on the facial/buccal or lingual surfaces. The correct tip will be the same for dominant right- or left-handed providers. As presented in Chapter 11, to correctly identify each tip as right or left:

• Hold • •

one tip in your dominant hand and the other in your nondominant hand so the shanks are parallel in front of your face. Turn the point surface away from you. Look at the curve of the shank. If the shank curves to the right, it is the right-curved tip, and if it curves to the left, it is the left-curved tip (see Figure 19-3).

EMS now only manufacturers two curved tips: PSL Instrument and PSR Instrument. PSL is the left-curved tip and PSR is the right-curved tip.

EMS Piezoelectric Curved Tip Adaptation

EMS Piezoelectric Curved Tip Adaptation

Area-specific curettes have one lower cutting edge on each side that adapts to either the mesial or distal of a posterior tooth. The provider must use two area-specific curettes to instrument all surfaces of one posterior tooth.

EMS curved tips are used as a pair. One curved tip is adapted to the facial/buccal surfaces of the teeth in one quadrant, and the other curved tip is adapted to the lingual (see Figure 19-4). Curved tip adaption is similar to the adaption of posterior area-specific hand-activated curettes.

Left (PSL)

• One posterior area-specific curette adapts to the •

buccal/lingual and mesial surfaces of posterior teeth (see Figure 19-5a). The other posterior area-specific curette adapts to the distal surfaces of posterior teeth (see Figure 19-5b).

Right (PSR)

Figure 19-3  EMS Photoelectric Curved Tips (PSR and

Figure 19-4  EMS Piezoelectric Curved Tip Adaptation

PSL Instruments).

A

347

Vertical Orientation (PSR/PSL Instruments).

B

Figure 19-5  Posterior Area-specific Gracey curette: A. Gracey 11/12, B. Gracey 13/14.

348

Chapter 19 EMS Curved Tips

The provider will use two piezoelectric curved tips to instrument one tooth, just as they do with posterior area-specific curettes. Instead of a mesial or distal adaptation, piezoelectric curved tips have a facial/ buccal or lingual adaptation.

Identifying Correct Adaptation

During active patient care, the provider can determine which curved tip is used on the facial/buccal and lingual without referencing a book. EMS curved piezoelectric tips are adapted correctly when the shank is parallel to the long axis of the tooth, with the lateral surface in contact with the tooth surface. This is similar to the adaptation of hand-activated instruments.

•

Figure 19-6a:

Notice the terminal shank is parallel to the long axis of the mandibular left first molar,

A

•

with the tip lateral surface adapted. This is correct adaptation. Figure 19-6b: Notice the terminal shank is wrapping around the buccal of the mandibular left first molar, with the tip lateral surface adapted. This is incorrect adaptation.

EMS Right-Curved Tip (PSR Instrument) Adaptation

• Maxillary arch: Maxillary right facial/buccal and •

maxillary left lingual (see Figure 19-7a and b). Mandibular arch: Mandibular right lingual and mandibular left facial/buccal (see Figure 19-8a and b).

There is a pattern for correct adaptation of the EMS curved tips. Look at the maxillary arch adaptation of the PSR Instrument. The tip is adapted to the

B

Figure 19-6  Curved tip adaptation: A. Correct adaptation of the PSR Instrument, B. Incorrect adaptation of the PSL

Instrument.

A

B

Figure 19-7  Maxillary Arch PSR Instrument: A. Maxillary right facial/buccal, B. Maxillary left lingual.

EMS Piezoelectric Curved Tip Adaptation

A

349

B

Figure 19-8  Mandibular Arch PSR Instrument: A. Mandibular right lingual, B. Mandibular left facial/buccal.

maxillary right facial/buccal and maxillary left lingual. If the tip is adapted on the facial/buccal surfaces of one quadrant, it is also adapted to the lingual surfaces of the adjacent quadrant. The same holds true for the mandibular arch. The right tip is adapted on the mandibular right lingual, so it is also adapted to the mandibular left facial/buccal.

A

EMS Left-Curved Tip (PSL Instrument) Adaptation

• Maxillary arch: Maxillary right lingual and maxillary left facial/buccal (see Figure 19-9a and b).

• Mandibular arch: Mandibular right facial/buccal and mandibular left lingual (see Figure 19-10a and b).

B

Figure 19-9  Maxillary Arch PSL Instrument: A. Maxillary right lingual, B. Maxillary left facial/buccal.

A

B

Figure 19-10  Mandibular Arch PSL Instrument: A. Mandibular right facial/buccal, B. Mandibular left lingual.

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Chapter 19 EMS Curved Tips

The same pattern exists for the PRL Instrument as it does for the PSR Instrument. The PRL Instrument is adapted to the maxillary right lingual, so it is also adapted to the maxillary left facial/buccal. The PSL Instrument adapts to the mandibular left lingual, so it is also adapted on the mandibular right facial/buccal. Table 19-1 and Figure 19-11 summarize the correct adaption for the PSR and PSL Instruments on the maxillary arch in vertical orientation. Table 19-2 and Figure 19-12 summarize the correct adaption for the PSR and PSL Instruments on the mandibular arch in vertical orientation.

LR Lingual

LL Lingual

LR Facial/Buccal

LL Facial/Buccal

Figure 19-12  Vertical Orientation PSR and PSL

Instrument Adaptation for the Mandibular Arch.

Table 19-1  Maxillary Adaptation for EMS PSR and PSL Instruments in Vertical Orientation PSR Instrument (Orange)

PSL Instrument (Gold)

Facial/Buccal

UR

UL

Lingual

UL

UR

UR Facial/Buccal

UL Facial/Buccal

UR Lingual

UL Lingual

Skill Building: Debridement Curved Tips You will need the following supplies: typodont, typodont pole, dental chair, ultrasonic device, highvolume evacuation, ultrasonic handpiece, PSR and PSL Instruments. Rationale: This exercise will incorporate ultrasonic instrumentation techniques of adaptation, angulation, orientation, and activation and combine them with aerosol control and patient and operator positioning to simulate an active patient treatment scenario with curved tips. The goal of this exercise is to correctly debride subgingival root anatomy with curved tips in a vertical orientation.

Setup Figure 19-11  Vertical Orientation PSR and PSL

Instrument Adaptation for the Maxillary Arch.

Table 19-2  Mandibular Adaptation for EMS PSR and PSL Instruments in Vertical Orientation PSR Instrument (Orange)

PSL Instrument (Gold)

Facial/Buccal

LL

LR

Lingual

LR

LL

1. Mount the pole onto the dental chair. 2. Mount the typodont onto the pole. 3. Set up the ultrasonic device, attaching the power, water, and/or air connectors. Turn on the device. 4. Attach an High-volume evacuation (HVE) to the suction system. 5. Flush the waterline for a minimum of 20–30 seconds. Always follow your clinic’s protocols for waterline maintenance, which may be different than a 20- to 30-second waterline flush. 6. Attach a sterile ultrasonic handpiece to the handpiece connector cord. 7. See Box 19-1.

Skill Building: Debridement Curved Tips

351

Box 19-1 Dominant right-handed provider: Identify the mandibular right first molar buccal. Dominant left-handed provider: Identify the mandibular left first molar buccal. Dominant right-handed provider: Select the PSL Instrument. Dominant left-handed provider: Select the PSR Instrument.

8. Use the CombiTorque wrench to torque the tip into the horn of the handpiece. 9. Set the power control to 10–60%. See EMS Chapter 17 for details if needed. 10. Set the water control to 70–100%. See EMS Chapter 17 for details if needed.

11. Confirm the correct tip has been selected for the buccal surface of the first molar by identifying if the shank is parallel to the long axis of the tooth (see Figure 19-6a).

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Chapter 19 EMS Curved Tips

Buccal Furcation Debridement of the Mandibular First Molar Grasp the ultrasonic handpiece with your dominant hand. See Chapter 9 for details if needed.

1. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 19-14).

Grasp the HVE with your nondominant hand. See Chapter 9 for details if needed.

Adapt the lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the buccal furcation entrance (see Figure 19-13).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port on the trip.

Figure 19-14  Buccal debridement of the mandibular Select the operator positioning for direct vision. • Dominant right-handed provider: 8–11 o’clock • Dominant left-handed provider: 1–4 o’clock

Select the patient chair positioning for the mandibular arch. Patient chair supine, semi-supine, or in between supine and semi-supine with chin slightly down.

Establish a finger rest intraoral or extraoral, ensuring correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps below.

Figure 19-13  Buccal furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the buccal furcation entrance.

first molar. Lateral surface of the active area antinode adapted coronal to the buccal furcation entrance.

2. Continue the ultrasonic activation stroke, moving toward the buccal furcation. 3. Be sure to maintain adaptation of the active area antinode with a 0- to 15-degree angulation as you approach the buccal furcation. 4. Enter the buccal furcation with the lateral surface of the active area antinode (see Figure 19-15). Maintain 0- to 15-degree angulation. Debride one-half of the furcation area. The other half will be debrided from the lingual.

Figure 19-15  Buccal surface debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted in the buccal furcation.

Skill Building: Debridement Curved Tips

5. Adapt the lateral surface to debride the distal surface of the mesial root with the active area antinode at a 0- to 15-degree angulation (see Figure 19-16).

353

7. Debridement of the mandibular first molar buccal furcation is now complete.

Mesial-Buccal Root Debridement of the Mandibular First Molar

1. Adapt the lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the mesial-buccal root distal surface (see Figure 19-18).

Figure 19-16  Buccal surface debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal surface of the mesial root.

6. Adapt the opposite lateral surface to debride the mesial surface of the distal root with the active area antinode at a 0- to 15-degree angulation (see Figure 19-17).

Figure 19-18  Mesial-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the mesial-buccal root distal surface.

Figure 19-17  Buccal surface debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the mesial surface of the distal root.

A

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 19-19a and b).

B

Figure 19-19  Mesial-buccal root debridement of the mandibular first molar. A. Lateral surface of the active

area antinode adapted coronal to the mesial-buccal root distal surface, B. Lateral surface of the active area antinode adapted on the mesial-buccal root distal surface.

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Chapter 19 EMS Curved Tips

3. Debride the entire mesial root by adapting the lateral surface of the active area with a 0- to 15-degree angulation and moving from the distal

A

surface of the mesial-buccal root toward the mesial surface of the mesial-buccal root, conforming to the root anatomy (see Figure 19-20a and b).

B

Figure 19-20  Mesial-buccal root debridement of the mandibular first molar. A. Lateral surface of the active area

antinode adapted to the mesial-buccal root, B. Lateral surface of the active area antinode adapted to the mesial-buccal root.

4. Complete the mesial-buccal root debridement with the lateral surface of the active area antinode adapted to the direct mesial with a 0- to 15-degree angulation as if you are probing the mesial col (see Figure 19-21a).

A

5. Debride one-half of the mesial interproximal area. The other half will be debrided from the lingual (see Figure 19-21b). 6. Debridement of the mandibular first molar mesial-buccal root is now complete.

B

Figure 19-21  Mesial-buccal root debridement of the mandibular first molar: A. Lateral surface of the active area

antinode adapted to the mesial, B. Lateral surface of the active area antinode adapted to the mesial debriding one-half the interproximal area.

Skill Building: Debridement Curved Tips

Distal-Buccal Root Debridement of the Mandibular First Molar

1. Adapt the lateral surface of the active area antinode in a vertical orientation with a 0- to 15-degree angulation at the cervical third on the crown of the tooth coronal to the distal-buccal root mesial surface (see Figure 19-22).

355

3. Debride the entire distal root by adapting the lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the mesial surface of the distal-buccal root toward the distal surface of the distal-buccal root, conforming to the root anatomy. 4. Complete the distal-buccal root debridement with the lateral surface of the active area antinode adapted to the direct distal with a 0- to 15-degree angulation as if you were probing the distal col (see Figure 19-24).

Figure 19-22  Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the distal-buccal root mesial surface.

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 19-23).

Figure 19-24  Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal.

5. Debride one-half of the distal interproximal area. The other half will be debrided from the lingual (see Figure 19-25).

Figure 19-25  Distal-buccal root debridement of the

Figure 19-23  Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted on the distal-buccal root mesial surface.

mandibular first molar. Lateral surface of the active area antinode adapted to the distal to debride one-half the interproximal area.

6. Debridement of the mandibular first molar distal-buccal root is now complete.

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Chapter 19 EMS Curved Tips

Lingual Furcation Debridement of the Mandibular First Molar

Dominant right-handed provider: Remove the PSL Instrument and replace with PSR Instrument. C ­ ontinue debridement of the mandibular right first molar. Dominant left-handed provider: Remove the PSR Instrument and replace with PSL Instrument. Continue debridement of the mandibular left first molar. Confirm the correct tip has been selected for the lingual surface of the first molar by identifying if the shank is parallel to the long axis of the tooth (see Figure 19-6a).

Grasp the ultrasonic handpiece with your dominant hand. See Chapter 9 for details if needed.

Figure 19-26  Lingual furcation debridement of the Grasp the HVE with your nondominant hand. See Chapter 9 for details if needed.

Adapt the lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the lingual furcation entrance (see Figure 19-26).

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the lingual furcation entrance.

1. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 19-27).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port on the trip.

Select the operator positioning for direct vision. • Dominant right-handed provider: 1–4 o’clock • Dominant left-handed provider: 8–11 o’clock

Select the patient chair positioning for the mandibular arch. Patient chair supine, semi-supine, or in between supine and semi-supine with chin slightly down.

Establish a finger rest intraoral or extraoral, ensuring correct ultrasonic handpiece grasp is maintained.

Figure 19-27  Lingual furcation debridement of the Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps below.

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the lingual surface furcation entrance.

Skill Building: Debridement Curved Tips

2. Continue the ultrasonic activation stroke, moving toward the lingual furcation. 3. Be sure to maintain adaptation of the active area antinode with a 0- to 15-degree angulation as you approach the lingual furcation. 4. Enter the lingual furcation with the lateral surface of the active area antinode. Maintain a 0- to 15-degree angulation. Debride one-half of the furcation area. The other half was debrided from the buccal (see Figure 19-28).

357

6. Adapt the opposite lateral surface to debride the mesial surface of the distal root with the active area antinode at a 0- to 15-degree angulation (see Figure 19-30).

Figure 19-30  Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the mesial surface of the distal root.

7. Debridement of the mandibular first molar lingual furcation is now complete.

Figure 19-28  Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted in the lingual furcation.

5. Adapt the lateral surface to debride the distal surface of the mesial root with the active area antinode at a 0- to 15-degree angulation (see Figure 19-29).

Figure 19-29  Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal surface of the mesial root.

Distal-Lingual Root Debridement of the Mandibular First Molar

1. Adapt the lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the distal-lingual root mesial surface (see Figure 19-31).

Figure 19-31  Distal-lingual root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the distal-lingual root mesial surface.

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Chapter 19 EMS Curved Tips

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to

A

maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 19-32a and b).

B

Figure 19-32  Distal-lingual root debridement of the mandibular first molar: A. Lateral surface

of the active area antinode adapted coronal to the distal-lingual root mesial surface, B. Lateral surface of the active area antinode adapted on the distal-lingual root mesial surface.

3. Debride the entre distal root by adapting the lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the mesial surface of the distal-lingual root toward the distal surface, conforming to the root anatomy. 4. Complete the distal-lingual root debridement with the lateral surface of the active area antinode adapted to the direct distal with a 0- to 15-degree

A

angulation as if you were probing the distal col (see Figure 19-33a). 5. Debride one-half of the distal interproximal area. The other half was debrided from the buccal (see Figure 19-33b). 6. Debridement of the mandibular first molar distal-lingual root is now complete.

B

Figure 19-33  Distal-lingual root debridement of the mandibular first molar: A. Lateral surface of the active area

antinode adapted to the distal, B. Lateral surface of the active area antinode adapted to the distal debriding one-half the distal interproximal area.

Skill Building: Debridement Curved Tips

359

Mesial-Lingual Root Debridement of the Mandibular First Molar 1. Adapt the lateral surface of the active area antinode in a vertical orientation with a 0- to 15-degree angulation at the cervical third on the crown of the tooth coronal to the mesial-lingual root distal surface (see Figure 19-34). A

B Figure 19-34  Mesial-lingual root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the mesial-lingual root distal surface.

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 19-35a). 3. Debride the mesial root by adapting the lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the distal surface of the mesial-lingual root toward the mesial surface of the mesial-lingual root, conforming to the root anatomy (see Figure 19-35b).

A

Figure 19-35  Mesial-lingual root debridement of the

mandibular first molar: A. Lateral surface of the active area antinode adapted on the mesial-lingual root distal surface, B. Lateral surface of the active area antinode adapted on the mesial-lingual root.

4. Complete the mesial-lingual root debridement with the lateral surface of the active area antinode adapted to the direct mesial with a 0- to 15-degree angulation as if you were probing the mesial col (see Figure 19-36a). 5. Debride one-half of the mesial interproximal area. The other half was debrided from the buccal (see Figure 19-36b). 6. Debridement of the mesial-lingual root is now complete.

B

Figure 19-36  Mesial-lingual root debridement of the mandibular first molar: A. Lateral surface of the

active area antinode adapted to the mesial, B. Lateral surface of the active area antinode adapted to the mesial debriding one-half the mesial interproximal area.

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Chapter 19 EMS Curved Tips

CASE STUDY

A 52-year-old Caucasian male with a noncontributory medical history presents to your office with a chief complaint of “My teeth are starting to get loose and something on the lower left hurts. My teeth are sensitive to hot and cold temperatures.” The patient’s last dental visit was at the age of 17. The initial panoramic X-ray and left side bitewing and periapical radiographs with intraoral camera photographs are shown here. The mandibular left wisdom tooth was extracted the same day of the new patient appointment due to a deep periodontal abscess and patient reported pain. Periodontal assessment: 3–14 mm probe depths with 100% BOP, generalized moderate to severe recession, furcation Class II and III, mobility Class 2 and 3. Treatment options included:

Panoramic radiograph.

Mandibular anterior periapical.

Left premolar bitewing.

Left molar bitewing.

Skill Building: Debridement Curved Tips

361

Mandibular right premolar and molar periapical.

A

B

Intraoral photographs: A. Anterior facial surfaces, B. Mandibular left canine, lateral incisor, and right central incisor lingual surfaces.

1. Full-mouth rehabilitation with a prosthodontist. 2. Extractions and removable partial or full denture. 3. Nonsurgical periosdontal debridement with informed consent (this procedure may not save the teeth). The patient is dentally anxious and selects treatment plan option number three. The mandibular left was debrided first. Post-operative radiographs and intraoral photographs are shown here.

Left bitewing.

Mandibular left premolar periapical.

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Chapter 19 EMS Curved Tips

Mandibular left molar periapical.

Mandibular left canine periapical with technique errors.

Mandibular anterior and premolar lingual surfaces.

Mandibular anterior and premolar facial surfaces.

Mandibular left premolar lingual surfaces.

1. Describe the staged instrumentation approach the dental hygienist likely used to debride the mandibular left lateral incisor to completion. State the tip designs that were used and why. Also state the power level used with each stage of instrumentation. 2. What curved tip did the dental hygienist use to debride the root concavity on the mesial-lingual of the mandibular left first premolar? What orientation was used? 3. Describe how the dental hygienist debrided the deep distal root defect of the mandibular left second molar with staged instrumentation. State the tip designs that were used and why. Also state the power level used with each stage of instrumentation. 4. Why would the straight long shank tip not debride the mandibular left second molar distal area to completion? 5. What curved tip did the dental hygienist use to debride the buccal Class III furcation of the mandibular left first molar? What orientation was used?

References

Summary

This chapter presented the clinical use of piezoelectric curved tips manufactured by EMS. The curved tips are used as a pair to debride complex root anatomy. Low to medium power with the lateral surfaces adapted in

Questions

1. True or False. The correct adaptation of right- and left-curved tips is different for a dominant righthanded provider than a left-handed provider. a. True b. False

2. What power level is appropriate to use when debriding complex root anatomy such as a furcation with ultrasonic instrumentation? a. Low b. Medium c. High d. Both A and B 3. What surfaces of the PSR and PSL Instruments should be adapted in vertical orientation subgingivally? a. Lateral b. Face c. Point 4. Which of the following ultrasonic shank angulations is contraindicated when debriding apical of the Cementoenamel junction (CEJ)? a. 0–5 degrees b. 5–10 degrees c. 10–15 degrees d. 90 degrees 5. True or False. When debriding 6 mm under the gums with the PSR or PSL Instrument in a vertical orientation, the provider can see a shank that will be parallel to the long axis of the tooth. a. True b. False 6. When adapting into a furcation, which tip surface should be in contact with the cementum in the furcation entrance? a. Face b. Point

References

1. Drisko, C. L., Cochran, D. L., Blieden, T., Bouwsma, O. J., Cohen, R. E., Damoulis, P., Fine, J. B., Greenstein, G., Hinrichs, J., Somermman, M. J., Iacono, V., & Genco, R. J. (2000). Position paper: Sonic and ultrasonic scalers in periodontics. Research, Science and Therapy Committee

363

vertical orientation with a 0- to 15-degree angulation is used to protect less mineralized hard tissues such as dentin and cementum.

c. Lateral d. None of these 7. Which tip would be the best selection to debride the maxillary right first premolar mesial-lingual 2–3 mm subgingival when the tooth has no attachment loss? a. PSR Instrument b. PSL Instrument c. PS Instrument 8. Which tip would be the best selection to debride the mandibular left canine distal-facial 2–3 mm subgingival when the tooth has no attachment loss? a. PSR Instrument b. PSL Instrument c. PS Instrument 9. Which tip would be the best selection to debride the maxillary left central incisor mesial-lingual 2–3 mm subgingival when the tooth has no attachment loss? a. PSR Instrument b. PSL Instrument c. PS Instrument 10. Which tip would be the best selection to debride the maxillary left first and second molars distalbuccal 2–3 mm subgingival when the tooth has no attachment loss? a. PSR Instrument b. PSL Instrument c. PS Instrument 11. Which tip would be the best selection to debride a Class III furcation defect on the mandibular right first molar buccal? a. PSR Instrument b. PSL Instrument c. PS Instrument

of the American Academy of Periodontology. Journal of Periodontology, 71(11), 1792–1801. https://doi.org/10.1902 /jop.2000.71.11.1792

CHAPTER 20

Acteon Curved Tips LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Identify an Acteon curved piezoelectric tip as right or left. 2. Recognize the indications for use and the design variations for Acteon curved tips. 3. Identify the correct adaptation and angulation of an Acteon curved right tip in vertical orientation. 4. Identify the correct adaptation and angulation of an Acteon curved left tip in vertical orientation. 5. Perform an ultrasonic activation stroke with a right- and left-curved tip using correct grasp, finger rest, operator and patient positioning, instrument adaptation, angulation, and orientation. 6. Maintain proper ergonomics while performing ultrasonic instrumentation with a right- and left-curved tip.

Introduction This chapter will present the clinical use of piezoelectric curved tips manufactured by Acteon. The curved tips are used as a pair to debride complex root anatomy. The curved tips function as a pair, with one debriding lingual surfaces and the other debriding facial/buccal surfaces. Low to medium power with the lateral surfaces adapted at a 0- to 15-degree angulation is used with a vertical orientation. A step-by-step exercise is presented to enhance your clinical technique with curved tips. Curved shanks were developed in the 1990s, and by 2000, the American Academy of Periodontology (AAP) released a position paper supporting the use of thin diameter curved shanks over hand-activated instruments

for the debridement of Class II, Class III, and Class IV furcation defects (Drisko et al., 2000). There is a large body of literature supporting the use of curved shanks in furcation areas; however, curved shanks also assist the provider in safely debriding root concavities, convexities, and interproximal surfaces both supragingivally and subgingivally. Their multifunctional capabilities make them a useful tool in many periodontal applications, from a general prophylaxis to surgical procedures.

Acteon Piezoelectric Curved Tips Introduction Piezoelectric curved tips are used in vertical orientation to debride complex root anatomy in deep periodontal pockets. The active area antinode is contacting cementum in this orientation (see Figure 20-1a and b). The curved tip will access a deep periodontal pocket with its long shank and conform into complex root anatomy such as a root concavity, convexity, and furcation. When debriding root anatomy with a curved Acteon tip in a vertical orientation, follow these rules for ultrasonic instrumentation to protect the less mineralized hard tissue cementum:

• Power: •

•

Low to medium power is used. High power increases the risk for cemental injury. Adaptation: Adapt lateral surfaces. The point and face have a higher displacement amplitude and should either be used with caution, or avoided, on cementum. See Chapter 9 for details on shank surface displacement amplitude. Angulation: Use a 0- to 15-degree angulation. A 90-degree angulation is contraindicated because the point would be in contact with the cementum (see Figure 20-2a and b). 365

366

Chapter 20 Acteon Curved Tips

A

B

Figure 20-1  Acteon Vertical Orientation Curved Tip: A. Lateral surface adapted to the distal of the mandibular right

first molar, B. Lateral surface adapted to the buccal of the mandibular right first molar.

A

B

Figure 20-2  Acteon Curved Tip Angulation: A. 0-to 15- degree angulation with the lateral surface on the buccal of the

mandibular right first molar, B. 90-degree angulation with the point on the buccal of the mandibular right first molar.

• Activation:

Use an ultrasonic activation stroke. A tap stroke should be used with caution as the point is adapted.

Piezoelectric curved tips are used as a pair. The provider needs two tips to debride a single tooth. The tips are nicknamed right-curved tips and left-curved tips. The left and right distinction refers to the direction of the shank bend and has nothing to do with how or where they are used in the mouth. The provider’s dominant hand has no influence on which tip is used on the facial/buccal or lingual surfaces. The

correct tip will be the same for dominant right- or lefthanded providers. As presented in Chapter 11, to correctly identify each tip as right or left:

• Hold • •

one tip in your dominant hand and the other in your nondominant hand so the shanks are parallel in front of your face. Turn the point surface away from you. Look at the curve of the shank. If the shank curves to the right, it is the right-curved tip, and if it curves to the left, it is the left-curved tip (see Figure 20-3).

Acteon Piezoelectric Curved Tips Introduction

LF

RT

367

RT LF

A

B

Figure 20-3  Acteon piezoelectric curved tips: A. P2L/P2R tips, B. H4L/H4R tips.

Acteon manufactures multiple curved tips. This book will not cover the diamond-coated tips because they are used predominately during periodontal surgery procedures. Chapter 18 presented the curved tips selection manufactured by Acteon.

• Tips

H4R/H4L, TK2-1R/TK2-1L, and P2R/ P2L are used for natural teeth debridement (see  Figure 20-4a to c). H4R/H4L and TK2-1R/

LF

•

TK2-1L debride posterior teeth. P2R/P2L debride anterior and posterior teeth. Tips PH2R/PH2L, IP2R/IP2L, IP3R/IP3L are used for dental implant debridement. PH2R/PH2L are designed to debride a posterior dental implant, abutment, and prosthesis. IP2R/IP2L and IP3R/IP3L are designed to debride implant threads and valleys. These tips are adapted the same as the curved tips for natural teeth that are shown in this chapter.

RT

A

LF

RT

B

C Figure 20-4  Acteon curved tips; A. H4L/H4L, B. TK2-1L/TK2-1R, C. P2L/P2R. Reproduced with permission from ACTEON

368

Chapter 20 Acteon Curved Tips

Acteon Piezoelectric Curved Tip Adaptation Acteon curved tips are used as a pair. One curved tip is adapted to the facial/buccal surfaces of the teeth in one quadrant and the other curved tip is adapted to the lingual (see Figure 20-5).

Curved tip adaption is similar to the adaption of posterior area-specific hand-activated curettes. Area-specific curettes have one lower cutting edge on each side that adapts to either the mesial or distal of a posterior tooth. The provider must use two area-specific curettes to instrument all surfaces of one posterior tooth.

• One posterior area-specific curette adapts to the •

buccal/lingual and mesial surfaces of posterior teeth (see Figure 20-6a). The other posterior area-specific curette adapts to the distal surfaces of posterior teeth (see Figure 20-6b).

The provider will use two piezoelectric curved tips to instrument one tooth, just as they do with posterior area-specific curettes. Instead of a mesial or distal adaptation, piezoelectric curved tips have a facial/ buccal or lingual adaptation.

Identifying Correct Adaptation

Figure 20-5  Acteon Piezoelectric Curved Tip Adaptation

Vertical Orientation (P2L/P2R).

A

During active patient care, the provider can determine which curved tip is used on the facial/buccal and lingual without referencing a book. Acteon curved piezoelectric tips are adapted correctly when the shank is parallel to the long axis of the tooth with the lateral surface in contact with the tooth surface. This is similar to the adaptation of hand-activated instruments.

B

Figure 20-6  Posterior Area-specific Gracey Curette: A. Gracey 11/12, B. Gracey 13/14.

Acteon Piezoelectric Curved Tip Adaptation

369

• Figure 20-7a and Figure 20-8a: Notice the termi-

• Figure 20-7b and Figure 20-8b: Notice the termi-

A

B

nal shank is parallel to the long axis of the mandibular right first molar with the tip lateral surface adapted. This is correct adaptation.

nal shank is wrapping around the buccal of the mandibular right first molar with the tip lateral surface adapted. This is incorrect adaptation.

Figure 20-7  H4L tip adaptation: A. Correct adaptation, B. Incorrect adaptation.

A

B

Figure 20-8  P2L adaptation: A. Correct adaptation, B. Incorrect adaptation.

Acteon Right-Curved Tips for Posterior Teeth (H4R and TK2-1R) Adaptation

• Maxillary arch: Maxillary right buccal and maxillary left lingual (see Figure 20-9a and b).

• Mandibular

arch: Mandibular right lingual and mandibular left buccal (see Figure 20-10a and b).

There is a pattern for correct adaptation of Acteon posterior curved tips. Look at the maxillary arch adaptation of the right-curved tips. The right-curved tips are adapted to the maxillary right buccal and maxillary

370

Chapter 20 Acteon Curved Tips

UR Buccal

UL ual Ling

A

B

LR L

ingua

l

Figure 20-9  Maxillary Arch H4R and TK2-1R Tips: A. Maxillary right buccal, B. Maxillary left lingual.

LL Buccal

A

B

Figure 20-10  Mandibular Arch H4R and TK2-1R Tips: A. Mandibular right lingual, B. Mandibular left buccal.

left lingual. If the tips are adapted on the buccal surfaces of one quadrant, they will also adapt to the lingual surfaces of the adjacent quadrant. The same holds true for the mandibular arch. The right-curved tips are adapted to the mandibular left buccal, so they are also adapted to the mandibular right lingual.

Acteon Left Curved Tips for Posterior Teeth (H4L and TK2-1L) Adaptation

• Maxillary arch: Maxillary right lingual and maxil•

lary left buccal (see Figure 20-11a and b). Mandibular arch: Mandibular right buccal and mandibular left lingual (see Figure 20-12a and b).

UR Lin gual

UL Buccal

A

B

Figure 20-11  Maxillary Arch H4L and TK2-1L Tips: A. Maxillary right lingual, B. Maxillary left buccal.

371

LL Lin gual

Acteon Piezoelectric Curved Tip Adaptation

LR Buccal

B

A

Figure 20-12  Mandibular Arch H4L and TK2-1L Tips: A. Mandibular right buccal, B. Mandibular left lingual.

The same pattern exists for the left-curved tips as it does for the right. The left-curved tips are adapted to the maxillary left buccal, so they are also adapted to the maxillary right lingual. The left tips adapt to the mandibular right buccal, so they also adapt to the mandibular left lingual.

Table 20-1 and Figure 20-13 summarize the correct adaption for posterior curved tips on the maxillary arch in vertical orientation. Table 20-2 and Figure 20-14 summarize the correct adaption for posterior curved tips on the mandibular arch in vertical orientation.

Table 20-1  Maxillary Adaptation for Acteon

Table 20-2  Mandibular Adaptation for Acteon

H4R/H4L and TK2-1R/TK2-1L Tips in Vertical Orientation Right-Curved Tips (H4R and TK2-1R) (Gold)

Left-Curved Tips (H4L and TK2-1L) (Orange)

Buccal

UR

UL

Lingual

UL

UR

H4R/H4L and TK2-1R/TK2-1L Tips in Vertical Orientation Right-Curved Tips (H4R and TK2-1R) (Gold)

Left-Curved Tips (H4L and TK2-1L) (Orange)

Buccal

LL

LR

Lingual

LR

LL

LR Lingual Posterior

UR Buccal Posterior

UR Lingual Posterior

UL Buccal Posterior

LR Buccal Posterior

LL Lingual Posterior

LL Buccal Posterior

UL Lingual Posterior

Figure 20-13  Vertical orientation H4R/H4L and

TK2-1R/TK2-1L adaptation for the maxillary arch.

Figure 20-14  Vertical orientation H4R/H4L and

TK2-1R/TK2-1L adaptation for the mandibular arch.

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Chapter 20 Acteon Curved Tips

Acteon Right-Curved Tip for Anterior and Posterior Teeth (P2R) Adaptation

• Maxillary arch: Maxillary right posterior buccal,

• Mandibular arch: Mandibular right posterior lingual, mandibular left posterior buccal, and mandibular anterior facial (see Figure 20-16a and b).

maxillary left posterior lingual, and maxillary anterior lingual (see Figure 20-15a and b).

UR Posterior buccal Anterior Lingual

r oste UL P al

ingu ior L

A

B

Figure 20-15  Maxillary Arch P2R Tip: A. Maxillary right posterior buccal, B. Maxillary left posterior lingual

LR Po ste Lingua rior l

and anterior lingual.

A

LL Posterior Buccal

Anterior Buccal

B Figure 20-16  Mandibular Arch P2R Tip: A. Mandibular right posterior lingua,l B. Mandibular left posterior

buccal and anterior facial.

Acteon Piezoelectric Curved Tip Adaptation

Acteon Left-Curved Tip for Anterior and Posterior Teeth (P2L) Adaptation

373

• Mandibular arch: Mandibular right posterior buccal, mandibular left posterior lingual, and mandibular anterior lingual (see Figure 20-18a and b).

• Maxillary arch: Maxillary right posterior lingual,

UR Poste rior Lingual

maxillary left posterior buccal, and maxillary anterior facial (see Figure 20-17a and b).

A LR Posterior Buccal UL Posterior Buccal

B Figure 20-17  Maxillary Arch P2L Tip: A. Maxillary right posterior lingual, B. Maxillary left posterior buccal and

anterior facial.

LL Pos terior Lingua l

Anterior Lingual

LR PosteriorBuccal

A

B

Figure 20-18  Mandibular Arch P2L Tip: A. Mandibular right posterior buccal, B. Mandibular left posterior lingual and

anterior lingual.

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Chapter 20 Acteon Curved Tips

Table 20-3 and Figure 20-19 summarize the correct adaption for P2R and P2L tips on the maxillary arch in vertical orientation. Table 20-4 and Figure 20-20 summarize the correct adaption for P2R and P2L tips on the mandibular arch in vertical orientation.

LR Lingual Posterior

LL Lingual Posterior

LR Buccal Posterior

LL Buccal Posterior

Anterior Lingual Anterior Facial

Table 20-3  Maxillary Adaptation for Acteon P2R and P2L Tips in Vertical Orientation Right-Curved Tip P2R (Gold)

Left-Curved Tip P2L (Orange)

Facial/ Buccal

UR posterior

UL posterior and anterior

Lingual

UL posterior and anterior

UR posterior

Figure 20-20  Vertical orientation P2R and P2L

adaptation for the mandibular arch

Skill Building: Debridement Curved Tips You will need the following supplies: typodont, typodont pole, dental chair, ultrasonic device, highvolume evacuation, ultrasonic handpiece, right- and left-curved ultrasonic tips.

Anterior Facial

UR Buccal Posterior

Anterior Lingual

UL Buccal Posterior

UL Lingual Posterior

UR Lingual Posterior

Figure 20-19  Vertical orientation P2R and P2L

adaptation for the maxillary arch.

Table 20-4  Mandibular Adaptation for Acteon P2R and P2L Tips in Vertical Orientation Right-Curved Tip P2R (Gold)

Left-Curved Tip P2L (Orange)

Facial/ Buccal

LL posterior and anterior

LR posterior

Lingual

LR posterior

LL posterior and anterior

Rationale: This exercise will incorporate ultrasonic instrumentation techniques of adaptation, angulation, orientation, and activation and combine them with aerosol control and patient and operator positioning to simulate an active patient treatment scenario with curved tips. The goal of this exercise is to correctly debride subgingival root anatomy with curved tips in a vertical orientation.

Setup

1. Mount the pole onto the dental chair. 2. Mount the typodont onto the pole. 3. Set up the ultrasonic device, attaching the power, water, and/or air connectors. Turn on the device. 4. Attach an High-volume evacuation (HVE) to the suction system. 5. Flush the waterline for a minimum of 20–30 seconds. Always follow your clinic’s protocols for waterline maintenance, which may be different than a 20- to 30-second waterline flush. 6. Attach a sterile ultrasonic handpiece to the handpiece connector cord. 7. See Box 20-1.

Skill Building: Debridement Curved Tips

Box 20-1 Dominant right-handed provider: Identify the mandibular right first molar buccal. Dominant left-handed provider: Identify the mandibular left first molar buccal. Dominant right-handed provider: Select H4L, P2L, or TK2-1L curved tip. Dominant left-handed provider: Select H4R, P2R, or TK2-1R curved tip.

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Buccal Furcation Debridement of the Mandibular First Molar Grasp the ultrasonic handpiece with your dominant hand. See Chapter 9 for details if needed.

Grasp the HVE with your nondominant hand. See Chapter 9 for details if needed.

Adapt the lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the buccal furcation entrance (see Figure 20-21).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port on the trip.

Select the operator positioning for direct vision. • Dominant right-handed provider: 8–11 o’clock • Dominant left-handed provider: 1–4 o’clock

Left Curved Tip

Right Curved Tip

Select the patient chair positioning for the mandibular arch. Patient chair supine, semi-supine, or in between supine and semi-supine with chin slightly down.

Establish a finger rest intraoral or extraoral, ensuring correct ultrasonic handpiece grasp is maintained.

Ensure that the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps below.

8. Lubricate the handpiece O-ring with silicone paste. Use the wrench to torque the tip to the handpiece. 9. Set the power control to the green zone (1-6). See Acteon Chapter 18 for details if needed. 10. Set the water flow rate to a rapid drip with fine mist halo. See Acteon Chapter 18 for details if needed. 11. Confirm the correct tip has been selected for the buccal surface of the first molar by identifying if the shank is parallel to the long axis of the tooth (see Figure 20-7a and Figure 20-8a). Figure 20-21  Buccal furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the buccal furcation entrance.

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1. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 20-21). 2. Continue the ultrasonic activation stroke, moving toward the buccal furcation. 3. Be sure to maintain adaptation of the active area antinode with a 0- to 15-degree angulation as you approach the buccal furcation.

A

4. Enter the buccal furcation with the lateral surface of the active area antinode (see Figure 20-22a and b). Maintain a 0- to 15-degree angulation. Debride one-half of the furcation area. The other half will be debrided from the lingual.

B

Figure 20-22  Buccal furcation debridement of the mandibular first molar: A. Lateral surface of the active area

antinode adapted just coronal to the buccal furcation entrance, B. Lateral surface of the active area antinode adapted in the buccal furcation.

5. Adapt the lateral surface to debride the distal surface of the mesial root with the active area antinode at a 0- to 15-degree angulation (see Figure 20-23).

Figure 20-23  Buccal furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal surface of the mesial root.

6. Adapt the opposite lateral surface to debride the mesial surface of the distal root with the active area antinode at a 0- to 15-degree angulation (see Figure 20-24).

Figure 20-24  Buccal furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the mesial surface of the distal root.

Skill Building: Debridement Curved Tips

7. Debridement of the mandibular first molar buccal furcation is now complete.

Mesial-Buccal Root Debridement of the Mandibular First Molar

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2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 20-26).

1. Adapt the lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the mesial-buccal root distal surface (see Figure 20-25).

Figure 20-26  Mesial-buccal root debridement of the

mandibular first molar. A. Lateral surface of the active area antinode adapted on the mesial-buccal root surface.

Figure 20-25  Mesial-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the mesial-buccal root distal surface.

A

3. Debride the entire mesial root by adapting the lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the distal surface of the mesial-buccal root toward the mesial surface of the mesial-buccal root, conforming to the root anatomy (see Figure 20-27a and b).

B

Figure 20-27  Mesial-buccal root debridement of the mandibular first molar:

A. Lateral surface of the active area antinode adapted to the mesial-buccal root, B. Lateral surface of the active area antinode adapted to the mesial.

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Chapter 20 Acteon Curved Tips

4. Complete the mesial-buccal root debridement with the lateral surface of the active area antinode adapted to the direct mesial with a 0- to 15-degree angulation as if you are probing the mesial col (see Figure 20-28a).

5. Debride one-half of the mesial interproximal area. The other half will be debrided from the lingual (see Figure 20-28a to c). 6. Debridement of the mandibular first molar mesial-buccal root is now complete.

B

A

C Figure 20-28  Mesial-buccal root debridement of the mandibular first molar:

A. Lateral surface of the active area antinode adapted to the mesial, B. Lateral surface of the active area antinode debriding one-half the mesial, C. Lateral surface of the active area antinode debriding one-half the interproximal area.

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Distal-Buccal Root Debridement of the Mandibular First Molar

1. Adapt the lateral surface of the active area antinode in a vertical orientation with a 0- to 15-degree angulation at the cervical third on the crown of the tooth coronal to the distal-buccal root mesial surface (see Figure 20-29).

A

Figure 20-29  Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the distal-buccal root mesial surface.

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 20-30a and b). 3. Debride the entire distal root by adapting the lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the mesial surface of the distal-buccal root toward the distal surface of the distal-buccal root, conforming to the root anatomy. 4. Complete the distal-buccal root debridement with the lateral surface of the active area antinode

B Figure 20-30  Distal-buccal root debridement of the

mandibular first molar: A. Lateral surface of the active area antinode adapted on the distal-buccal root, B. Lateral surface of the active area antinode adapted on the distal-buccal root.

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Chapter 20 Acteon Curved Tips

adapted to the direct distal with a 0- to 15-degree angulation as if you are probing the distal col (see Figure 20-31).

Lingual Furcation Debridement of the Mandibular First Molar

Dominant right-handed provider: Remove the H4L, P2L, or TK2-1L tip and replace with H4R, P2R, or TK2-1R. Dominant left-handed provider: Remove the H4R, P2R, or TK2-1R tip and replace with H4L, P2L, or TK2-1L.

Grasp the ultrasonic handpiece with your dominant hand. See Chapter 9 for details if needed.

Grasp the HVE with your nondominant hand. See Chapter 9 for details if needed.

Figure 20-31  Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal.

5. Debride one-half of the distal interproximal area. The other half will be debrided from the lingual (see Figure 20-32). 6. Debridement of the mandibular first molar distal-buccal root is now complete.

Adapt the lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the lingual furcation entrance (see Figure 20-33).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port on the trip.

Select the operator positioning for direct vision. • Dominant right-handed provider: 1–4 o’clock • Dominant left-handed provider: 8–11 o’clock

Select the patient chair positioning for the mandibular arch. Patient chair supine, semi-supine, or in between supine and semi-supine with chin slightly down.

Establish a finger rest intraoral or extraoral, ensuring correct ultrasonic handpiece grasp is maintained.

Ensure that the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps below.

Figure 20-32  Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal to debride one-half the interproximal area.

Skill Building: Debridement Curved Tips

381

2. Continue the ultrasonic activation stroke moving toward the lingual furcation. 3. Be sure to maintain adaptation of the active area antinode with a 0- to 15-degree angulation as you approach the lingual furcation. 4. Enter the lingual furcation with the lateral surface of the active area antinode. Maintain a 0- to 15-degree angulation. Debride one-half of the furcation area. The other half was debrided from the buccal (see Figure 20-35).

Figure 20-33  Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the lingual furcation entrance.

1. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 20-34).

Figure 20-35  Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted in the lingual furcation entrance.

5. Adapt the lateral surface to debride the distal surface of the mesial root with the active area antinode at a 0- to 15-degree angulation (see Figure 20-36).

Figure 20-34  Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the lingual furcation entrance.

Figure 20-36  Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the distal surface of the mesial root.

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Chapter 20 Acteon Curved Tips

6. Adapt the opposite lateral surface to debride the mesial surface of the distal root with the active area antinode at a 0- to 15-degree angulation (see Figure 20-37).

Distal-Lingual Root Debridement of the Mandibular First Molar

1. Adapt the lateral surface of the active area antinode in a vertical orientation at the cervical third on the crown of the tooth coronal to the distal-lingual root mesial surface (see Figure 20-38).

Figure 20-38  Distal-lingual root debridement of the Figure 20-37  Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted to the mesial surface of the distal root.

7. Debridement of the mandibular first molar lingual furcation is now complete.

A

mandibular first molar. Lateral surface of the active area antinode adapted coronal to the distal-lingual root mesial surface.

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 20-39a and b).

B

Figure 20-39  Distal-lingual root debridement of the mandibular first molar: A. Lateral

surface of the active area antinode adapted to the distal-lingual root mesial surface, B. Lateral surface of the active area antinode adapted to the distal-lingual root.

Skill Building: Debridement Curved Tips

3. Debride the entire distal root by adapting the lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the mesial surface of the distal-lingual root toward the distal surface, conforming to the root anatomy. 4. Complete the distal-lingual root debridement with the lateral surface of the active area antinode adapted to the direct distal with a 0- to 15-degree

383

angulation as if you were probing the distal col (see Figure 20-40a). 5. Debride one-half of the distal interproximal area. The other half was debrided from the buccal (see Figure 20-40b and c). 6. Debridement of the mandibular first molar distal-lingual root is now complete.

B

A

C Figure 20-40  Distal-lingual root debridement of the mandibular first molar: A. Lateral surface of the active area

antinode adapted to the distal, B. Lateral surface of the active area antinode adapted to the distal debriding, C. Lateral surface of the active area antinode adapted to the distal debriding one-half the interproximal area.

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Chapter 20 Acteon Curved Tips

Mesial-Lingual Root Debridement of the Mandibular First Molar

1. Adapt the lateral surface of the active area antinode in a vertical orientation with a 0- to 15-degree angulation at the cervical third on the crown of the tooth coronal to the mesial-lingual root distal surface (see Figure 20-41).

A

Figure 20-41  Mesial-lingual root debridement of the

mandibular first molar. Lateral surface of the active area antinode adapted coronal the mesial-lingual root distal surface.

2. Perform an ultrasonic activation stroke. Rotate the active area antinode as you move apically to maintain contact with the root surface at a 0- to 15-degree angulation (see Figure 20-42a and b). 3. Debride the mesial root by adapting the lateral surface of the active area antinode with a 0- to 15-degree angulation and moving from the distal surface of the mesial-lingual root toward the mesial surface of the mesial-lingual root, conforming to the root anatomy.

B Figure 20-42  Mesial-lingual root debridement of the

mandibular first molar: A. Lateral surface of the active area antinode adapted on the mesial-lingual root distal surface, B. Lateral surface of the active area antinode adapted on the mesial-lingual root distal surface.

Skill Building: Debridement Curved Tips

4. Complete the mesial-lingual root debridement with the lateral surface of the active area antinode adapted to the direct mesial with a 0- to 15-degree angulation as if you were probing the mesial col (see Figure 20-43a and b).

A

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5. Debride one-half of the mesial interproximal area. The other half was debrided from the buccal. 6. Debridement of the mesial-lingual root is now complete.

B

Figure 20-43  Mesial-lingual root debridement of the mandibular first molar: A. Lateral surface of the active

area antinode adapted to the mesial debriding one-half the mesial interproximal area, B. Lateral surface of the active area antinode adapted to the mesial.

CASE STUDY

A 52-year-old Caucasian male with a noncontributory medical history presents to your office with a chief complaint of “My teeth are starting to get loose and something on the lower left hurts. My teeth are sensitive to hot and cold temperatures.” The patient’s last dental visit was at the age of 17. The initial panoramic X-ray and left side bitewing and periapical radiographs with intraoral camera photographs are shown here. The mandibular left wisdom tooth was extracted the same day of the new patient appointment due to a deep periodontal abscess and patient reported pain. Periodontal assessment: 3–14 mm probe depths with 100% BOP, generalized moderate to severe recession, furcation Class II and III, mobility Class 2 and 3.

Panoramic radiograph.

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Chapter 20 Acteon Curved Tips

Mandibular anterior periapical.

Left premolar bitewing.

Left molar bitewing.

Mandibular right premolar and molar periapical.

A

B

Intraoral photographs: A. Anterior facial surfaces, B. Mandibular left canine, lateral incisor, and right central incisor lingual surfaces.

Skill Building: Debridement Curved Tips

387

Treatment options include: 1. Full-mouth rehabilitation with a prosthodontist. 2. Extractions and removable partial or full denture. 3. Nonsurgical periodontal debridement with informed consent (this procedure may not save the teeth). The patient is dentally anxious and selects treatment plan option number three. The mandibular left was debrided first. Post-operative radiographs and intraoral photographs are shown here.

Left bitewing.

Mandibular left premolar periapical.

Mandibular left molar periapical.

Mandibular left canine periapical with technique errors.

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Chapter 20 Acteon Curved Tips

Mandibular anterior and premolar lingual surfaces.

Mandibular left anterior facial surfaces.

Mandibular left premolar lingual surfaces.

1. Describe the staged instrumentation approach the dental hygienist likely used to debride the mandibular left lateral incisor to completion. State the tip designs that were used and why. Also state the power level used with each stage of instrumentation. 2. What curved tip did the dental hygienist use to debride the root concavity on the mesial-lingual of the mandibular left first premolar? What orientation was used? 3. Describe how the dental hygienist debrided the deep distal root defect of the mandibular left second molar with staged instrumentation. State the tip designs that were used and why. Also state the power level used with each stage of instrumentation. 4. Why would the straight long shank tip not debride the mandibular left second molar distal area to completion? 5. What curved tip did the dental hygienist use to debride the buccal Class III furcation of the mandibular left first molar? What orientation was used?

References

Summary

This chapter presented the clinical use of piezoelectric curved tips manufactured by Acteon. The curved tips are used as a pair to debride complex root anatomy. Low to medium power with the lateral surfaces

Questions

1. True or False. The correct adaptation of right- and left-curved tips is different for a dominant righthanded provider than a left-handed provider. a. True b. False

2. What power level is appropriate to use when debriding complex root anatomy such as a furcation with ultrasonic instrumentation? a. Low b. Medium c. High d. Both A and B 3. What surfaces of curved piezoelectric tips should be adapted in vertical orientation subgingivally? a. Lateral b. Face c. Point 4. Which of the following ultrasonic shank angulations is contraindicated when debriding apical of the Cementoenamel junction (CEJ)? a. 0–5 degrees b. 5–10 degrees c. 10–15 degrees d. 90 degrees 5. True or False. When debriding 6 mm under the gums with a curved tip in a vertical orientation, the shank that the provider can see will be parallel to the long axis of the tooth. a. True b. False 6. When adapting into a furcation, which surface should be in contact with the cementum in the furcation entrance? a. Face b. Point c. Lateral d. None of these

References

1. Drisko, C. L., Cochran, D. L., Blieden, T., Bouwsma, O. J., Cohen, R. E., Damoulis, P., Fine, J. B., Greenstein, G., Hinrichs, J., Somermman, M. J., Iacono, V., and Genco, R. J. (2000). Position paper: Sonic and ultrasonic scalers in

389

adapted in a vertical orientation with a 0- to 15-degree angulation is used to protect less mineralized hard tissues such as dentin and cementum.

7. Which tip would be the best selection to debride the maxillary right first premolar mesial-lingual 2-3 mm subgingivally when the tooth has no attachment loss? a. Right-curved tip b. Left-curved tip c. Straight tip 8. Which tip would be the best selection to debride the mandibular left canine distal-facial 2–3 mm subgingivally when the tooth has no attachment loss? a. Right-curved tip b. Left-curved tip c. Straight tip 9. Which tip would be the best selection to debride the maxillary left central incisor mesial-lingual 2–3 mm subgingivally when the tooth has no attachment loss? a. Right-curved tip b. Left-curved tip c. Straight tip 10. Which tip would be the best selection to debride the maxillary left first and second molars distal-buccal 2–3 mm subgingivally when the tooth has no attachment loss? a. Right-curved tip b. Left-curved tip c. Straight tip 11. Which tip would be the best selection to debride a Class III furcation defect on the mandibular right first molar buccal? a. Right-curved tip b. Left-curved tip c. Straight tip

periodontics. Research, Science and Therapy Committee of the American Academy of Periodontology. Journal of Periodontology, 71(11), 1792–1801. https://doi.org/10.1902 /jop.2000.71.11.1792

CHAPTER 21

Air Polishing Introduction LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Select the best tooth polishing procedure for a patient that will pair an appropriate level of abrasion for their needs. 2. Identify tooth polishing techniques that increase the risk for over-abrasion and hard tissue alteration and removal. 3. Compare and contrast rotary handpiece polishing and air polishing. 4. Appraise the differences between stand-alone, portable, single-power, and multipower air polishing devices. 5. Recognize the clinical indications for the use of a standard and subgingival nozzle. 6. Describe the two mechanisms of action of an air polishing device. 7. Identify individual patient polishing contraindications and considerations.

KEY TERMS

the process of wearing something away. • Abrasion: polishing device (APD): device that delivers • Air a slurry mixture of compressed air, powder

particles, and water to the crown and root surfaces of teeth. Cleaning agent: non-abrasive chemical applied to tooth and restorative materials with a rotary handpiece. Extrinsic exogeneous stain: stain present on the surface of a tooth that originated from an external source. Mohs hardness: a scale of measurement that lists a mineral’s surface resistance to scratching or abrasion. Multipower delivery air polishing device: commonly found on stand-alone APDs that will

•

expel the slurry mixture from the nozzle with changeable powder velocity settings. Over-abrasion: unintentional or intentional excessive wearing away of hard tissues or restorative materials during tooth polishing. Polishing agent: abrasive chemical applied to tooth and restorative materials with a rotary handpiece. Portable handheld air polishing device: ADP that attaches to the air turbine connector on a dental unit and does not require an electrical outlet connection. Powder chamber: part of an APD that holds the powder. Single-power delivery air polishing device: commonly found on portable handheld APDs that expel the slurry mixture from the nozzle at a set powder velocity that is not adjustable. Stand-alone air polishing device: APD that requires an electric outlet connection, attaches to the air connector on a dental unit, and either uses an independent water reservoir or attaches to the water connector on a dental unit. Standard nozzle: reusable nozzle with a larger diameter lumen opening than a subgingival nozzle that delivers the slurry mixture to the crown and root surfaces of teeth. Subgingival nozzle: single-use flexible narrow tapered nozzle with a smaller diameter lumen opening than a standard nozzle that delivers the slurry mixture subgingivally into deeper periodontal pockets. Tooth polishing: procedure to mechanically remove extrinsic exogeneous staining and biofilm from the surface of a tooth. Venturi effect: a principle of fluid dynamics where the velocity of a fluid passing through a constricted area will increase with resultant decrease in pressure.

• • •

• • • • •

•

•

•

•

•

391

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Chapter 21 Air Polishing Introduction

Introduction Air polishing has been a part of preventive care for decades. The initial discovery of air devices is attributed to Dr. Robert Black, who invented the Air Dent in 1945. The Air Dent combined compressed air and water with a highly abrasive powder (aluminum oxide) for decay removal. This technique was, and still is, referred to as air abrasion. Air abrasion gave way to a new type of air technology known as air polishing in the 1970s that was used in routine preventive procedures for supragingival stain removal. The literature presented in this chapter will demonstrate that air polishing causes less tooth surface alteration and removal compared to rotary handpiece polishing with a polishing agent. Air polishing offers a more conservative and efficient approach for biofilm management and stain removal than alternative polishing techniques. Air polishing devices (APDs) are either stand-alone or portable with single-power and multipower functionality An APD delivers a slurry mixture of compressed air, powder particles, and water to the crown and root surfaces of teeth. There are two nozzle designs with varied clinical applications. This chapter provides an introductory overview of the equipment used in air polishing with a comparison to rotary handpiece polishing that will enable you to select the method of delivery that will provide the most conservative and safe treatment for your patient.

Tooth Polishing

A

B Figure 21-1  Nicotine Staining: A. Nicotine staining on

the maxillary right anterior lingual surfaces B. Nicotine staining on mandibular anterior lingual surfaces.

Tooth polishing is a procedure to mechanically re-

2. Exposure to a slurry mixture of compressed air, powder particles, and water delivered by an APD.

• Environmental exposures to nicotine, prescription

Both mechanisms produce their clinic actions by a process termed abrasion. Abrasion is the process of wearing something away. In terms of tooth polishing, abrasion wears away unwanted materials such as biofilm and extrinsic exogeneous stain from hard tissues. Over-abrasion is an excessive wearing away of tooth surfaces that is damaging to hard tissues (enamel, dentin, cementum). Over-abrasion can be intentional or unintentional. Unintentional over-abrasion occurs due to many reasons such as incorrect provider technique or incorrect delivery selection.

move extrinsic exogeneous staining and biofilm from the surface of a tooth (Lamont et al., 2018). ­Extrinsic exogeneous stain occurs on the surface of a tooth that originates from an external source. Common sources of extrinsic exogenous stain include, but are not limited to:

•

medications, industry metals, and dark-colored beverages (see Figure 21-1a and b and Figure 21-2). Chemical exposures to ingredients found in mouth rinses and dentifrices such as stannous fluoride and chlorhexidine (see Figure 21-3a and b).

Polishing tooth surfaces is accomplished by two different mechanisms: 1. Application of a polishing or cleaning agent with a rubber cup, rubber point, or stiff bristle point affixed to a rotary handpiece.

BREAKOUT POINT Tooth polishing removes unwanted materials from tooth surfaces through abrasion.

Rotary Handpiece Polishing

393

Figure 21-2  Coffee Staining. Coffee staining on mandibular anterior and premolar lingual surfaces.

least abrasive agent for the patient presentation and selectively polish hard tooth surfaces with extrinsic exogeneous stain and/or biofilm. Cleaning and polishing agents are applied to hard tissue surfaces and dental materials with a rotary handpiece (see Figure 21-5a and b). Cleaning agents are nonabrasive chemicals that are safe for use on hard tissues and restorative materials. Polishing agents are routinely used to remove extrinsic exogeneous staining and biofilm from tooth surfaces during preventive procedures

• Polishing agents: The most common agents used for A

•

B Figure 21-3  Chemical Staining: A. Chlorhexidine staining

on mandibular anterior lingual surfaces, B. Stannous fluoride staining on mandibular anterior facial surfaces.

Rotary Handpiece Polishing Rotary handpiece polishing produces intentional, selective, and controlled wear to hard tissues (Boyd et al., 2021) using a rubber cup, rubber point, or stiff bristle brush laden with a polishing or cleaning agent (see Figure 21-4a to c). The provider should use the

•

routine tooth polishing are calcium carbonate and flour of pumice (Sawai et al., 2015). Other chemicals such as aluminum oxide, aluminum silicate, boron, emery, feldspar, garnet, perlite, silica, silicon carbide, silicon dioxide, tin oxide, zirconium oxide, or zirconium silicate are used for polishing hard tissues and dental materials (Sawai et al., 2015). Polishing agents and dental materials: Polishing agents are abrasive, with the potential to scratch dental materials depending on multiple factors such as the delivery method, provider technique, and abrasiveness of the agent. Polishing agents should not be used on certain dental materials such as dental ceramics (porcelain, alumina, zirconia), and porcelain-bonded alloys because they irreversibly increase surface roughness and decrease restoration gloss (Salawai et al., 2015; Covey et al., 2011; Monaco et al., 2020; Sugiyama et al., 2017). Polishing agent particle design: There is no industry standardization for particle shape, size, hardness, and abrasiveness. Manufacturers determine their particle design for coarse, medium, fine, and ultrafine. This places the burden on the provider to be familiar with each manufacturer’s polishing agent in the office and then correctly pair the agent to their patient’s needs.

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Chapter 21 Air Polishing Introduction

A

A

B

B Figure 21-5  Polishing agent and rubber cup: A. Dentsply

C Figure 21-4  Rotary handpiece polisher and rubber cup:

A. Dentsply Sirona Nupro Freedom Cordless Prophy system, B. Corded polisher: Dentsply Sirona Midwest low speed handpiece and disposable prophy angle, C. Dentsply Sirona Nupro Freedom disposable prophy angles. Reproduced with permission from Dentsply Sirona.

Sirona Nupro Prophy Paste, B. Dentsply Sirona Nupro Freedom Disposable Prophy Angle with polishing paste. Reproduced with permission from Dentsply Sirona

Polishing agents have a larger, more irregular shape than air polishing powders, increasing their abrasive effects when the rotary cup pushes the particle into hard tissues and dental materials

Rotary Handpiece Polishing

(Covey et al., 2011; Christensen & Bangerter, 1987) (see Figure 21-6a and b) Polishing agent characteristics that increases abrasion effects are (Sawai et al., 2015; Christensen & Bangerter, 1987): • Larger particle sizes. • Higher Mohs hardness (described later). • Irregular shapes with sharp edges.

BREAKOUT POINT There is no industry standardization for polishing agents’ particle shape, size, hardness, and abrasiveness.

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Mohs Hardness

The Mohs hardness scale measures a mineral’s surface resistance to scratching or abrasion and was invented by a German mineralogist in the 1800s named Friedrich Mohs (Encyclopaedia Britannica, 2017). The Mohs hardness scale ranks minerals 1 through 10. A 10 (diamond) is the most resistant mineral to scratching while 1 (talc) is the lowest. The Mohs hardness scale is not a linear scale. For example, a 4 on the Mohs hardness scale is 25% more resistant to abrasion than a 3, and a 10 is 300% more resistant to abrasion than a 9 (Encyclopaedia Britannica, 2017). Oral hard tissues, dental materials, polishing agents, and powders delivered by an APD have a Mohs hardness rating as seen in Table 21-1. Polishing agents have a Mohs hardness rating of 5.5–8.0 (depending on the chemical composition); Boyd et al., 2021) while air polishing powders range from 2.0 to 4.0 (Chowdhary & Mohan, 2018; Johnson et al., 2014). The goal of polishing is to use a material that is softer than the structure it is applied to, to avoid over-abrasion. Over-abrasion will occur when a higher Mohs hardness material is used on a lower Mohs hardness structure (Arabaci et al., 2007; Graumann et al., 2013; Janiszewska-Olszowska et al., 2020). For example, using a polishing agent on dentin or cementum has the potential to cause over-abrasion due to the higher Mohs rating of the polishing agent.

A

BREAKOUT POINT Air polishing powders have a lower Mohs hardness rating than polishing agents.

Table 21-1  Mohs Hardness B Figure 21-6  Polishing agents: A. Nupro coarse and flour

of pumice polishing agents under SEM 500x. Note the large irregular-shaped particles with sharp edges. B. SEM of enamel, dentin, and Cementoenamel junction (CEJ) after rotary handpiece polishing of enamel and dentin for 5 seconds, 2,500 revolutions per minute, and 150 g of pressure. Notice the “enamel scratches appeared mostly on the cervical one-third of crowns. Dentin scratches covered entire exposed root” (Christensen & Bangerter, 1987). Used with permission from Dr. Rella Christensen, PhD

Mohs Hardness Polishing agent (calcium carbonate, flour of pumice)

5.5–8.0

Enamel

5.0

Dentin

3.0–4.0

Cementum

2.5–3.0

APD powders

2.0–4.0

Boyd et al. (2021), Chowdhary & Mohan (2018), Johnson et al. (2014)

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Chapter 21 Air Polishing Introduction

Provider Technique

It is difficult to calibrate provider technique during rotary handpiece polishing. Variables such as the speed used for rotary cup rotation, the pressure applied to the rotary cup, the cup angulation, contact time, and the quantity of paste used during polishing influence abrasion effects (Graumann et al., 2013). The risk for over-abrasion increases in the following situations (Sawai et al., 2015; Graumann et al., 2013):

• Higher speed of rotary cup rotation. • Heavier lateral pressure applied to the rotary cup. • Incorrect rubber cup angulation to the tooth • •

A

surface. Increased quantity of polishing agent applied. Increased stiffness of the rubber cup, rubber point, or bristle point. The stiffness of these materials is not industry standardized and varies by manufacturer.

Polishing all hard tissues with an abrasive polishing agent is not recommended (Sawai et al., 2015). The American Dental Hygienists’ Association (1998) endorses selective polishing to limit the removal of hard tissues, especially for less mineralized hard tissues such as dentin and cementum, whose Mohs hardness is only 3–4. Nonselective polishing can lead to the following adverse effects:

B

• Removal of microns of enamel (Christensen &

•

• •

Bangerter, 1987; Pence et al., 2011). Cervical enamel is more prone to removal than the occlusal because occlusal enamel is thicker. A polishing agent with a high Mohs hardness should not be used on tooth surfaces with active caries or enamel with erosion, attrition, abrasion, or demineralization to avoid further breakdown (Sawai et al., 2015; see Figure 21-7a to c). Removal and over-abrasion of less mineralized hard tissues such as dentin and cementum (Sawai et al., 2015). Cementum in the cervical region of teeth is very thin, ranging from 20 to 50 µm in thickness (Sauro et al., 2010). This area of a tooth has an increased risk for over-abrasion when exposed to materials high on the Mohs hardness scale (Sauro et al., 2010) (see Figure 21-6b). Removal of the outer fluoride rich layer on the enamel (Boyd et al., 2021; Christensen & Bangerter, 1987; Gutmann, 1998). Increase dentinal hypersensitivity through the removal of the smear layer when not using a therapeutic polishing agent such as Novamin that occludes dentin tubules (Sawai et al., 2015).

C Figure 21-7  Hard Tissue Injury: A. Cervical

demineralization and decay on the facial of the maxillary right canine, B. Erosion and attrition on the lingual surfaces of the maxillary right first premolar and anterior teeth, C. Recurrent decay on the cervical-buccal of a mandibular molar.

Air Polishing

397

Air Polishing Air polishing is accomplished with the use of a stand-alone or portable device equipped with a nozzle. Powder is placed inside a powder chamber of the device. The powder chamber is a specialized container that holds powder particles. When an ADP is activated, compressed air and water runs through the nozzle and mixes with the powder from the powder chamber. A slurry mixture is expelled from the nozzle opening.

Air Polishing Devices

APDs are sold as stand-alone devices or portable handheld devices.

• Stand-alone air polishing device:

•

A standalone APD requires an electric outlet connection, attaches to the air connector on a dental unit, and either uses an independent water reservoir or attaches to the water connector on a dental unit (see Figure 21-8a). The device has a detachable handpiece with either an affixed or detachable nozzle (see Figure 21-8b). Portable handheld air polishing device: A portable handheld APD attaches to the air turbine connector on a dental unit and does not require an electrical outlet connection (see Figure 21-9a). The powder chamber is smaller than a standalone device. The device has a detachable handpiece with either an affixed or detachable nozzle (see Figure 21-9b and c).

Each device has psi requirements for the air and water flow that are specified in the manufacturer directions for use or instructions for use (DFU/IFU). Psi is a unit of pressure and stands for pound force per square inch. In general, the higher the psi, the higher the level of abrasion capability. When using a portable or stand-alone APD, the psi of the dental unit water and air may need to be adjusted to the specifications found in the product’s DFU/IFU. Using incorrect water and air psi settings will alter the velocity of slurry expulsion and increases the risk for over-abrasion (Kozlovsky et al., 2005; Petersilka et al., 2003).

APD Design There are two designs for an APD: single-power delivery or multipower delivery. Single-Power Delivery. A single-power delivery air polishing device expels the slurry mixture of compressed air, powder, and water from its nozzle

A

B Figure 21-8  Stand-alone air polishing device:

A. Dentsply Sirona Cavitron Jet-Plus, B. Dentsply Sirona Jet-Mate Ultrasonic handpiece with detachable Cavitron Jet Air Polishing Insert. Reproduced with permission from Dentsply Sirona

at a set powder velocity that is not adjustable. The powder is placed into the powder chamber, and compressed air is forced into the chamber, mixing with the powder. An internal control regulates the amount of powder used and velocity of the expelled slurry, which is largely dependent on the volume of powder in the chamber (Donnet et al., 2021; Petersilka, 2000). A portable handheld APD is an example of a single-power delivery system. It attaches to the air-turbine connector on a dental unit and has a smaller powder chamber than a stand-alone APD. Smaller powder chambers deplete their powder faster than a larger chamber. When the powder volume decreases, the risk for inconsistent powder particle expulsion increases. Powder fluctuations lead to undesired changes such as over-abrasion, decreased efficiency, and compromised patient outcomes (Kozlovsky et al., 2005; Petersilka et al., 2003; Donnet et al., 2021; Petersilka, 2000).

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Chapter 21 Air Polishing Introduction

Multipower Delivery. A multipower delivery air polishing device expels the slurry mixture of compressed air, powder, and water from its nozzle at variable velocities selected by the provider through the powder velocity control. The powder velocity control changes the amount of powder used and the speed of powder discharged from the chamber. Powder is placed into a powder chamber, and compressed air is forced into the chamber, mixing with the powder (see Figure 21-10a to c). When activated by the user, the slurry mixture is expelled from the nozzle at a velocity determined by the powder velocity selection. This is beneficial because the provider can pair the velocity of powder expulsion to the level of oral deposits present on tooth surfaces, decreasing the risk for over-abrasion. BREAKOUT POINT A

A multipower APD allows the provider to correctly pair the powder expulsion to the level of oral deposit, decreasing the risk for over-abrasion.

Stand-alone APDs are typically multipower with a larger powder chamber than the one on a portable handheld APD. A multipower delivery APD is designed with a rounded powder chamber that has an open narrow tube inside and is sealed with a removable cap (see Figure 21-11a and b).

B

• The tube is in the center of the powder chamber • • • •

C Figure 21-9  Portable handheld air polishing device:

A. EMS AIRFLOW Handy 3.0 Perio and AIR-FLOW Handpiece, B. EMS AIRFLOW Handy 3.0 Perio without nozzle attached, C. EMS AIRFLOW Handy 3.0 Perio with attached PERIOFLOW nozzle. Reproduced with permission from HuFriedyGroup Mfg. Co., LLC.

The provider fills the chamber with powder.

• The chamber should be filled so the powder level

BREAKOUT POINT Small powder chambers deplete their power faster than a large powder chamber and can cause inconsistent powder particle expulsion.

(Figure 21-11a) and has a series of small holes at its base (Figure 21-11c). When the device is activated, a stream of compressed air is forced into and through the tube. The powder in the chamber is agitated and drawn into the small holes at its base. The air powder stream is projected upward toward the cap. The air powder mixture exits through its outlet at the upper part of the chamber and is pumped through the handpiece connector cable and into the handpiece affixed with a nozzle, where it is expelled onto tooth surfaces.

•

does not completely deplete while in use or inconsistent powder emissions will occur, decreasing the efficiency of the device and increasing the risk for over-abrasion (Kozlovsky et al., 2005; Petersilka et al., 2003; Donnet et al., 2021; Petersilka, 2000). The powder level should never cover the opening of the tube.

399

Air Polishing

A

B

C

Figure 21-10  Stand-alone multipower APD powder holding chamber: A. Dentsply Sirona Cavitron Jet-Plus

non-detachable powder bowl, B. EMS AIRFLOW Prophylaxis Master detachable powder chamber. C. EMS powder chamber removed from the device. A: Reproduced with permission from Dentsply Sirona; B and C: Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Cap

Tube

Powder

Air line

A

B

C

Figure 21-11  Multipower powder chamber: A. Dentsply Sirona Cavitron Jet-Plus powder bowl with inner tube,

B. Removable cap (Dentsply Sirona Cavitron Jet-Plus powder bowl cap), C. Powder chamber

Nozzle Design

A nozzle expels the slurry into the mouth. There are two nozzle designs: a standard nozzle and a subgingival nozzle. Individual design characteristics of both, such as the size, shape, length, angulation, lumen diameter opening, and the materials they are made of, vary by manufacturer.

Standard Nozzle

A standard nozzle is reusable and has a larger diameter lumen opening than a subgingival nozzle

(see Figure 21-12a and b). The nozzle expels the slurry mixture from the APD. Standard nozzle has two concentric openings (see Figure 21-13):

• Outer opening: Expels water. • Inner opening: Expels powder and compressed air mixture. The compressed air causes the water and powder to mix upon contact, creating a slurry.

A standard nozzle will deliver the slurry mixture supragingivally, and if the APD allows for subgingival use, a standard nozzle will expel the slurry into shallow

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Chapter 21 Air Polishing Introduction

Subgingival Nozzle

A

B Figure 21-12  Standard nozzle: A. EMS AIRFLOW Max

handpiece, B. Dentsply Sirona Jet-Mate Ultrasonic handpiece and Cavitron JET Air Polishing Insert.

A: Reproduced with permission from E.M.S. Electro Medical Systems S.A; B: Reproduced with permission from Dentsply Sirona

A subgingival nozzle is a single-use, flexible, narrow-tapered nozzle with a smaller diameter lumen opening than a standard nozzle. The nozzle will deliver the slurry mixture subgingivally into deeper periodontal pockets (. 4mm; Ng, 2018). The nozzle has multiple small lumen diameter orifices or outlets at its end that expel the water and compressed air powder particles (see Figure 21-14). Manufacturers vary on the number of orifices at the end, ranging from one to three (Ng, 2018; Moene et al., 2010). The water pressure is lower than a standard nozzle (Ng, 2018; Moene et al., 2010). The powder and water exit horizontally on the lateral aspects of the nozzle where they mix together (Petersilka, 2000; Ng, 2018; Flemmig et al., 2012). BREAKOUT POINT A subgingival nozzle delivers the expressed slurry into deep periodontal pockets.

A subgingival nozzle is made of a flexible, narrow thermoplastic elastomer that is tapered at its end, with an average thickness of 0.7 mm (varies by the manufacturer) to allow for subgingival access with minimal tissue distention (Ng, 2018; Flemmig et al., 2012). Some manufacturers place probe-like markings on

Figure 21-13  Nozzle Opening (Dentsply Sirona

Cavitron JET Air Polishing Insert) Inner opening expel compressed air and powder particles. Outer opening expels water.

(,4 mm) pockets (Ng, 2018). There are six different powder selections that are presented in Chapter 22. The powder selected influences whether the nozzle delivers the slurry supragingivally or subgingivally. BREAKOUT POINT A standard nozzle has a larger diameter lumen opening than a subgingival nozzle.

Figure 21-14  Subgingival nozzle with 3 orifices/

outlets (EMS PERIOFLOW handpiece with single-use PERIOFLOW subgingival nozzle). Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Air Polishing

401

Figure 21-15  Subgingival nozzle (EMS PERIOFLOW

subgingival nozzle with probe-like markings).

the nozzle to assist the provider in correct subgingival placement (see Figure 21-15). Studies have indicated that a subgingival nozzle can biofilm reduce periodontal pockets up to 9 mm (Kozlovsky et al., 2005; Moene et al., 2010). In the United States, a subgingival nozzle has Food and Drug Administration (FDA) approval to reduce biofilm up to 5 mm because some studies have shown biofilm removal efficiency slightly decreases in depths beyond 5 mm (Kozlovsky et al., 2005; Moene et al., 2010).

Figure 21-16  Ventiru effect. Thumb placed over the

opening of a water hose.

Subgingival Nozzle Mechanism of Action.  A subgingival nozzle expels its slurry directly into the periodontal pocket creating a vacuum-like environment through the Venturi effect. The Venturi effect is a principle in fluid dynamics similar to Bernoulli’s principle presented in Chapter 6.

Air Polishing Mechanism of Action

• The Venturi effect occurs when a fluid (slurry mix-

Fluid Dynamics

•

•

ture) is forced into a constricted area (periodontal pocket). As the fluid flow through a constricted area, the velocity will increase which decreases the pressure. In times of gingival inflammation, the volume of gingival crevicular fluid (GCF) increases due to the presence of inflammatory infiltrate, increased blood flow, and invading organisms. The subgingival nozzle introduces the slurry mixture into this subgingival environment, which activates the fluid. The subgingival fluid is essentially vacuumed out of the pocket by the Venturi effect, resulting in a reduction in pathogenic organisms and biofilm in the environment.

You have seen the Venturi effect before; you just might not have known it. Anytime you place your thumb over the opening of a garden hose and the water jet stream velocity increases, you have witnessed the Venturi Effect (see Figure 21-16).

Air polishing removes biofilm and extrinsic exogenous stain through two mechanisms of action: fluid dynamics and abrasion.

The water expelled from the APD nozzle causes the release of kinetic energy. Kinetic energy is created when the velocity of water is increased, which decreases environmental fluid pressure as proven by Bernoulli’s principle. See Chapter 6 for a review if needed. This change of pressure in response to an increase in fluid velocity (speed) causes the release of kinetic energy. The water interacts with the APD powder in the following ways (Petersilka et al., 2003): 1. The kinetic energy produced by the water fragments the powder particles, reducing their size before they contact the tooth surface. 2. The water dampens the impact of the powder particle that strikes the tooth surface. These two effects produce a slurry mixture that is less abrasive to tooth surfaces than a rotary handpiece polisher with a polishing agent.

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Chapter 21 Air Polishing Introduction

BREAKOUT POINT Fluid dynamics of an APD fragment and dampened powder particles before they strike a tooth surface, which decreases the risk for over-abrasion.

et al., 2005; Petersilka et al., 2003; Donnet et al., 2021; Petersilka, 2000):

• Over-abrasion: •

Abrasion The abrasion produced by an APD is beneficial in the wearing away and removal of unwanted materials such as biofilm, extrinsic exogeneous stains, and immature dental calculus. There are many factors that play a role in the abrasion capability of an APD such as the delivery system, nozzle design, and provider technique.

Inconsistent powder flow rates can cause over-abrasion or under-abrasion (Kozlovsky et al., 2005; Petersilka et al., 2003):

• Over-abrasion: too high powder flow will cause •

BREAKOUT POINT An APD will remove biofilm, extrinsic exogeneous stain, and immature dental calculus from tooth surfaces through abrasion.

Delivery System. An APD that delivers the most constant and consistent powder and water flow produces superior abrasion surface effects with less risk for over-abrasion (Graumann et al., 2013; Kozlovsky et al., 2005; Petersilka et al., 2003; Donnet et al., 2021; Petersilka, 2000). Box 21-1 demonstrates the sequence of events that can cause over-abrasion from inconsistent water flow rates. Incorrect water flow rates can cause over-abrasion or under-abrasion (Graumann et al., 2013; Kozlovsky

Box 21-1 Inconsistent water flow rate ↓ Decreases kinetic energy released ↓ Less fragmenting of powder particles ↓ Larger, more abrasive powder particles reach the tooth surface ↓ Increased risk for over-abrasion

Insufficient water will cause over-abrasion because powder particles are not fragmented correctly and contact structures as a larger size from less kinetic energy. Under-abrasion: Excessive water will cause under-abrasion because the powder volume is decreased, and its particle size is dampened.

over-abrasion (Graumann et al., 2013; Kozlovsky et al., 2005; Petersilka et al., 2003; Donnet et al., 2021; Petersilka, 2000). Under-abrasion: too little powder flow will cause under-abrasion (Graumann et al., 2013; Kozlovsky et al., 2005; Petersilka et al., 2003; Donnet et al., 2021; Petersilka, 2000).

The volume of powder in the chamber influences abrasion effects:

• When powder levels are too low inside the cham-

•

ber, an inconsistent amount of powder is delivered, which decreases efficiency and compromises patient outcomes (Graumann et al., 2013; Kozlovsky et al., 2005; Petersilka et al., 2003; Donnet et al., 2021; Petersilka, 2000). The size of the APD powder chamber influences powder flow rates. Larger powder chambers allow for more consistent powder emissions during active use because they do not deplete as fast as smaller chambers (Graumann et al., 2013; Kozlovsky et al., 2005; Petersilka et al., 2003; Donnet et al., 2021; Petersilka, 2000).

APD single-power delivery or multipower delivery influences abrasion effects. A multipower device with adjustable power settings is more ideal than one without (Donnet et al., 2021):

• Single-power delivery APDs are always delivering

•

maximum powder and water flow rates that may be too high for the level of extrinsic exogeneous stain and biofilm (Donnet et al., 2021). This causes excessive abrasion than what is necessary for the patient presentation (Buhler et al., 2015). Multipower delivery APDs allow the provider to correctly pair the powder emission and water flow rate to the level of extrinsic exogeneous stain and biofilm in the mouth. This will prevent over-abrasion.

Rotary and APD Polishing Comparison

Nozzle Design.  Individual nozzle characteristics such as length, diameter, lumen diameter size of the opening, and shape influence the efficiency of slurry delivered. There is no industry standardization for nozzle designs, so the provider needs to be trained in proper use for their device. Some nozzles deliver a more focused slurry while others deliver a more turbulent expulsion.

• A more focused slurry expulsion increases effi•

errors can cause over-abrasion or under-abrasion, both of which complicate patient outcomes.

• Incorrect angulation of the nozzle to the tooth or • •

ciency and decreases contact time and the risk for over-abrasion (see Figure 21-17a). A more turbulent expulsion allows the slurry to spray in unwanted directions, decreasing efficiency and increasing the risk for over-abrasion (see Figure 21-17b).

Provider Technique. Correct provider technique is important for the safe delivery of any form of polishing. Air polishing technique is complicated by the lack of industry standardization, so the provider needs to be trained in the proper use of their device. Technique

gingiva can lead to over-abrasion (Petersilka, 2000). Incorrect movement of the nozzle across tooth surfaces. Moving too slow will cause over-abrasion and moving too fast will cause under-abrasion. Using the powder from one manufacturer in the device of another. Manufacturer handpieces, nozzles, and powders are specially designed for their APD. Equipment is not interchangeable without industry standardization. Patient outcomes become compromised, and equipment damage will occur that may void your warranty when you inter-mix manufacturer products. Refer to the DFU/IFU for situations that void a warranty.

Manufacturers recommend a specific distance of the nozzle from the tooth surface during active air polishing. Exceeding this distance will cause the following adverse effects:

• Less focused spray whose slurry strikes more struc-

• •

A

403

tures in the mouth than desired, causing a decrease in efficiency, and an increase in aerosolization, soft tissue irritation, and potential soft tissue trauma (Buhler et al., 2015; see Figure 21-18a and b). Decreased water jet velocity. When water jet velocity is decreased, powder particles are not fragmented properly prior to striking the tooth, leading to over-abrasion. Decreased effectiveness of the slurry that forces the provider to increase contact time, leading to over-treatment and over-abrasion (Petersilka et al., 2000; Buhler et al., 2015).

BREAKOUT POINT Over-abrasion risk decreases when correct water and powder flow rates are used, a more focused slurry is expelled from the nozzle, and correct provider technique is used.

Rotary and APD Polishing Comparison Air polishing is less abrasive to tooth structures than using a rotary handpiece with a polishing agent (Gutmann, 1998; Cochis et al., 2013; Ovard, 2018) for the following reasons: B Figure 21-17  Slurry Spray (Dentsply Sirona Cavitron JET

Air Polishing Insert) A. Focused spray B. Turbulent spray

• APD power particles have a lower Mohs hardness rating than polishing agents (Boyd et al., 2021; Chowdhary & Mohan, 2018; Arabaci et al., 2007;

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Chapter 21 Air Polishing Introduction

Table 21-2  Rotary Handpiece Polishing and Air Polishing Comparison

Rotary Handpiece Air Polishing Polishing Agents with lower Mohs Rating (Boyd et al., 2021; Chowdhary & Mohan, 2018)













More uniform-shaped particle with less sharp edges





Less operator fatigue (Chowdhary & Mohan, 2018)





More efficient stain removal (Park et al., 2020)





Less aerosol production





Less alteration and removal of hard tissues (Johnson et al., 2004; Buhler et al., 2015) Can be safely used on less mineralized hard tissues such as dentin and cementum A

• Rotary handpiece polishing presses larger, more

irregular-shaped polishing agents into the tooth surface (Christensen & Bangerter, 1987) while APDs deliver a slurry mixture with fragmented particles.

B Figure 21-18  Nozzle distance from tooth: A. Incorrect

nozzle distance (too far away)—less focused spray, B. Correct nozzle distance with proper focused spray.

• • •

Graumann et al., 2013; Janiszewska-Olszowska et al., 2020). APD powder particles are smaller in size than polishing agents (Boyd et al., 2021). APD powder particle shape is more uniform, with fewer gagged and sharp edges than polishing agents. APD power particle size is reduced prior to contacting structures in the mouth due to the mixture with water and the kinetic energy released.

Due to their delivery with compressed air and water, APDs remove supragingival biofilm and extrinsic exogeneous stain more efficiently than rotary handpieces (Graumann et al., 2013; Gutmann, 1998; Park et al., 2020). APDs are also able to deliver their slurry in difficult to access areas such as interproximal surfaces, crowded teeth, and orthodontic appliances (Park et al., 2020). Table 21-2 summarizes the differences between rotary handpiece polishing and air polishing.

Polishing Contraindications and Considerations Tooth polishing with a rotary handpiece or APD is a very safe procedure and routinely performed in the dental setting. There are times when polishing is contraindicated or when special considerations should be exercised.

Polishing Contraindications and Considerations

405

Contraindications

A contraindication, as presented in Chapter 7, is a situation when a device should not be used because it may harm the patient. Absolute contraindications for polishing with a rotary handpiece or an APD include:

• Allergy to ingredients or flavoring agents. • Tooth structures with demineralization,

•

erosion, attrition, abrasion, or active caries (see Figure 21-19a and b). Air polishing can still be administered on other teeth in the mouth, but it should be avoided on these defects. Denuded root surfaces.

Considerations

A consideration, as presented in Chapter 7, is a situation when the provider must weigh the potential consequences against the benefits when deciding to use a specific technology in patient care. Patients should consult their physician prior to undergoing routine teeth polishing (rotary handpiece or air polishing) if they present with any of the following medical conditions:

A

• Active

• •

or poorly controlled respiratory disease where daily breathing is challenged. Examples include, but are not limited to, those with uncontrolled or poorly controlled asthma, Chronic Obstructive Pulmonary Disease (COPD), cystic fibrosis, or lung cancer. Communicable disease. Examples include, but are not limited to, active infection with coronavirus, influenza, tuberculosis, or herpes. Any medical condition that causes immunosuppression where the risk for a bacteremia is increased.

B Figure 21-19  Hard Tissue Injury: A. Cavitated molar

cervical surface, B. Attrition on mandibular anterior incisal surfaces.

CASE STUDY

Patient is a 68-year-old Caucasian female with prediabetes taking metformin. Her Body Mass Index (BMI) is 28. She does not have any known allergies or drug allergies. She is retried, she is a nonsmoker, does not drink alcohol, and likes to drink hot tea multiple times a day. She has no chief complaints. Dental exam: No treatment needs. Occlusion: Class I bilateral with first molar relationship. Crowding of the mandibular anterior teeth. Oral hygiene exam: ■ ■

Disclosing solution revealed 85% of surfaces with biofilm and dental calculus. Generalized moderate extrinsic exogeneous stain, biofilm, and dental calculus.

Periodontal exam: ■ ■ ■ ■ ■

Probe depths generalized 3–5 mm with bleeding upon probing 62% of the mouth. Class I and II furcation involvement on all molars and Class IV furcation on the maxillary right first molar as seen in the intraoral photograph. Generalized bone loss in the coronal third. Localized vertical bone loss in the apical-third on the distal of the maxillary right first molar. Generalized recession.

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Chapter 21 Air Polishing Introduction

Tissue description: ■ ■

Generalized firm, coral pink, stippled attached gingiva. Localized loss of interdental papillae due to recession with Class II embrasure spaces.

Intraoral Photograph: Maxillary right posterior teeth buccal surfaces.

Intraoral Photograph: Mandibular anterior teeth facial surfaces

1. What type of polishing (rotary handpiece with polishing agent or air polishing) should be performed on the maxillary right first molar? Justify your answer. 2. What type of polishing (rotary handpiece with polishing agent or air polishing) should be performed on the mandibular anterior teeth? Justify your answer. 3. If the air polisher left behind residual stain in the interproximal area of the mandibular right lateral incisor, what ultrasonic shank diameter would be the best option for its removal? Justify your answer. 4. What could be causing the stain seen in the intraoral camera photograph of the mandibular anterior facial and interproximal surfaces? 5. Is it likely air polishing can remove the dental calculus pictured in the intraoral photographs? Why or why not? 6. Can air polishing remove the dark color on the cervical area of the maxillary right posterior buccal surfaces? Why or why not? 7. The dental hygienist chooses to deliver an air polishing powder that can be used supragingivally and subgingivally. What nozzle(s) will the dental hygienist need for this case? Justify your answer.

Summary

This chapter introduced air polishing equipment and provided a thorough comparison to rotary handpiece polishing. Air polishing causes less alterations to hard tissue surfaces than rotary handpiece polishing due to its overall delivery with compressed air, fluid dynamics, and powder particle design. There are various air

polishing market choices for the provider, including stand-alone, portable handheld, single-power, and multipower delivery. Subgingival nozzles deliver the slurry mixture into deeper periodontal pockets, which is useful in times of gingival inflammation around natural teeth and dental implants.

Questions

Questions

1. Which of the following can cause extrinsic exogeneous staining on tooth surfaces? a. Nicotine b. Stannous fluoride c. Chlorhexidine d. All of the above 2. Which of the following is TRUE of air polishing? a. The kinetic energy produced by the water released from the nozzle of an APD fragments the powder particles and decreases their size before reaching structures inside the mouth. b. Polishing agents have a lower Mohs hardness than air polishing powders. c. Provider technique has no effect on the abrasion effects on tooth surfaces. d. Over-abrasion is a desired effect of tooth polishing. 3. Which of the following is TRUE of a polishing agent applied with a rotary handpiece? a. Polishing agents have a higher Mohs hardness than dentin and cementum. b. Polishing agents have the potential to scratch dental materials. c. Polishing agents can alter and remove oral hard tissues. d. All of the above 4. Which of the following is a correct Mohs order from highest rating to lowest? a. Enamel, APD powder, dentin, polishing agent b. Enamel, polishing agent, APD powder, dentin c. Polishing agent, enamel, dentin, APD powder d. Polishing agent, enamel, APD powder, dentin 5. Which of the following increase(s) the risk for over-abrasion when using a rotary handpiece with a polishing agent? a. Using less lateral pressure b. Higher speed of cup rotation c. Stiffer rubber cup d. Using less polishing agent e. Both B and C 6. Which of the following is an adverse effect of nonselective rotary handpiece polishing with a nontherapeutic polishing agent? a. Unintentional removal of cementum b. Unintentional removal of hard tissue in a demineralized area c. Removal of the outer fluoride rich layer of enamel d. Increased dentinal hypersensitivity through the removal of the smear layer.

407

e. All of the above 7. Where do you connect a portable handheld air polishing device on the dental unit? a. Air/water syringe b. Air-turbine connector c. High-speed evacuation line d. A portable handheld device does not connect to the dental unit 8. True or False. The psi for all air polishing devices is the same. a. True b. False 9. True or False. It is desirable to have an APD that produces a more consistent power flow rate than one that does not. a. True b. False 10. Which APD nozzle uses the Venturi effect for its mechanism of action? a. Standard nozzle b. Subgingival nozzle For questions 11 to 13, match the following statement to the correct mechanism of action for an APD. Answer A for fluid dynamic and B for abrasion. There is only one correct answer for each question. 11. Decreases the powder particle size with kinetic energy. 12. Wears away and removes unwanted materials such as extrinsic exogeneous stain and biofilm. 13. Dampens the impact of powder particles on the tooth surface. Match the following APD delivery changes to whether it will cause over-abrasion or under-abrasion for questions 14–21. Answer A for over-abrasion and B for under-abrasion. There is only one correct answer for each question. 14. Too little water 15. Excessive water 16. Too high powder flow rate 17. Too low powder flow rate 18. Incorrect angulation of the nozzle 19. Moving the nozzle too slowly 20. Moving the nozzle too fast 21. Slurry spray that is less focused and more turbulent

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Chapter 21 Air Polishing Introduction

22. True or False. Smaller powder chambers of an APD allow for more consistent powder emission during active use because they deplete their powder faster. a. True b. False

B for rotary handpiece polishing. There is only one correct answer for each question.

23. Which of the following provider technique(s) can increase the abrasion effects on tooth surfaces when using an APD? a. Increased contact time of the slurry on tooth surfaces b. Decreased working distance of the nozzle to the tooth surface c. Incorrect nozzle angulation d. Incorrect nozzle movement across tooth surfaces e. All of the above

26. Smaller particle size

Match the following statements to the correct response for questions 24–29. Answer A for air polishing and

References

1. American Dental Hygienists’ Association. (1998). American Dental Hygienists’ Association position paper on the oral prophylaxis. https://www.adha.org/resources-docs/7115_Prophylaxis _Postion_Paper.pdf 2. Arabaci, T., Cicek, Y., Ozgoz, M., Canakci, V., Canakci, C. F., & Eltas, A. (2007). The comparison of the effects of three types of piezoelectric ultrasonic tips and air polishing system on the filling materials: An in vitro study. International Journal of Dental Hygiene, 5, 205–210. 3. Boyd, L. D., Mallonee, L. F., & Wyche, C. J. (2021). Wilkins’ clinical practice of the dental hygienist (13th ed.). Jones & Bartlett Learning. 4. Buhler, J., Anato, M., Weiger, R., & Walter, C. (2015). A systematic review on the effects of air polishing on oral tissues. International Journal of Dental Hygiene, 14, 15–28. 5. Chowdhary, Z., & Mohan, R. (2018). Efficiency of three different polishing methods on enamel and cementum: A scanning electron microscope study. Journal of Indian Society of Periodontology, 22(1), 1–6. 6. Christensen, R. P., & Bangerter, V. W. (1987). Immediate and long-term in vivo effects of polishing on enamel and dentin. Journal of Prosthetic Dentistry, 57(2), 150–160. 7. Cochis, A., Fini, M., Carrassi, A., Migliario, M., Visai, L., & Rimondini, L. (2013). Effect of air polishing with glycine powder on titanium abutment surfaces. Clinical Oral Implant Research, 24, 904–909. 8. Covey, D. A., Barnes, C., Watanabe, H., & Johnson, W. W. (2011). Effects of a paste-free prophylaxis polishing cup and various prophylaxis polishing pastes on tooth enamel and restorative materials. General Dentistry, 59(6), 466–473. 9. Donnet, M., Fournier, M., Schmidlin, P. R., & Lussi, A. (2021). A novel method to measure the powder consumption of dental air-polishing devises. Applied Science, 11(1101), 1–11. 10. Encyclopaedia Britannica. (2017). Mohs hardness. https:// www.britannica.com/science/Mohs-hardness

24. Lower Mohs rating 25. Powder particle shape is more uniform and less irregular 27. Less aerosol production 28. Less efficient stain removal 29. Can be safely used on dentin and cementum 30. Which of the following is a patient consideration for polishing? a. Poorly controlled asthma b. Active communicable disease such as coronavirus c. High blood pressure d. Both A and B

11. Flemmig, T. F., Arushanov, D., Daubert, D., Rothen, M., Muller, G., & Leroux, B. G. (2012). Randomized controlled trial assessing efficacy and safety of glycine powder air polishing in moderate-to-deep periodontal pockets. Journal of Periodontology, 83(4), 444–452. 12. Graumann, S. J., Sensat, M. L., & Stoltenberg, J. L. (2013). Air polishing: A review of current literature. Journal of Dental Hygiene, 87(4), 173–180. 13. Gutmann, M. E. (1998). A comprehensive review of the literature. Journal of Dental Hygiene, 72(3), 47–56. 14. Janiszewska-Olszowska, J., Drozdzik, A., Tandecka, K., & Grocholewicz, K. (2020). Effect of air-polishing on surface roughness of composite dental restorative material— comparison of three different air-polishing powders. BMC Oral Health, 20(30), 1–7. 15. Johnson, W. W., Barnes, C. M., Covey, D. A., Walker, M. P., & Ross, J. A. (2004). The effects of a commercial aluminum air polishing powder on dental restorative materials. Journal of Prosthodontics, 13(3), 166–172. 16. Kozlovsky, A., Artzi, Z., Nemcovsky, C. E., & Hirshberg, A. (2005). Effect of air-polishing devices on the gingiva: Histologic study in the canine. Journal of Clinical Periodontology, 32, 329–334. 17. Lamont, T., Worthington, H. V., Clarkson, J. E., & Beirne, P. V. (2018). Routine scale and polish for periodontal health in adults (Review). Cochrane Library Database of Systematic Reviews, 12(CD004625), 1–59. 18. Moene, R., Decaillet, F., Andersen, E., & Mombelli, A. (2010). Subgingival plaque removal using a new air-polishing device. Journal of Periodontology, 81(1), 79–88. 19. Monaco, C., Arena, A., Scheda, L., Di Fiore, A., & Zucchelli, G. (2020). In vitro 2D and 3D roughness and spectrophotometric and gloss analyses of ceramic materials after polishing with different prophylaxis pastes. Journal of Prosthetic Dentistry, 124(6), 787e1–787e8.

References 20. Ng, E. (2018). The efficacy of air polishing devises in supportive periodontal therapy: A systematic review and meta-analysis. Quintessence International, 49, 453–467. https://doi.org/10.3290/j.qi.a40341 21. Ovard, C. F. (2018). Tooth polishing. The Gale encyclopedia of nursing and allied health, 6(4), 3545. 22. Park, B., Kim, M., Park, J., Jeong, J., & Noh, H. (2020). Research on dental plaque removal methods for efficient oral prophylaxis: With a focus on air polishing and rubber cup polishing. International Journal of Dental Hygiene, 19(3), 1–7. https://doi.org/10.1111/idh.12481 23. Pence, S. D., Chambers, D. A., Van Tets, I. G., Wolf, R., & Pfeiffer, D. C. (2011). Repetitive coronal polishing yields minimal loss. Journal of Dental Hygiene, 85(4), 348–357. 24. Petersilka, G. (2000). Subgingival air-polishing in the treatment of periodontal biofilm infections. Periodontology, 55, 124–142.

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25. Petersilka, G. J., Bell, M., Mehl, A., Hickel R., & Flemmig, T. F. (2003). Root defects following air polishing. Journal of Clinical Periodontology, 30, 165–170. 26. Sauro, S., Watson, T. F., & Thompson, I. (2010). Dentine desensitization induced by prophylactic and air-polishing procedures: An in vitro dentine permeability and confocal microscopy study. Journal of Dentistry, 38, 411–422. 27. Sawai, M., Bhardwaj, A., Jafri, Z., Sultan, N., & Daing, A. (2015). Tooth polishing: The current status. Journal of Indian Society of Periodontology, 19(4), 375–380. 28. Sugiyama, T., Kameyama, A., Enokuchi, T., Haruyama, A., Chiba, A., Sugiyama, S., Hosaka, M., & Takahashi, T. (2017). Effect of professional dental prophylaxis on the surface gloss and roughness of CAD/CAM restorative materials. Journal of Clinical Experimental Dentistry, 9(6), 772–778.

CHAPTER 22

Air Polishing Powders and Clinical Applications LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. List the clinical applications of an air polishing device (APD). 2. Compare and contrast air polishing powder particle size, Mohs hardness, and chemical composition. 3. Identify powders that are used coronal to the Cementoenamel junction (CEJ) and powders that are used coronal and apical to the CEJ. 4. Select the appropriate powder for the patient clinical presentation. 5. Identify individual patient air polishing considerations. 6. Deliver safe air polishing that does not adversely affect dental materials.

KEY TERMS

trihydroxide powder: APD powder • Aluminum made of aluminum and hydroxide that is

insoluble in water and administered coronal to the CEJ. Calcium carbonate powder: APD powder made of calcium and carbonate that is insoluble in water and administered coronal to the CEJ. Calcium sodium phosphosilicate powder: APD powder made of calcium, phosphorus, silica, and sodium that is soluble in water and will dentinal tubules. Cytokines: large group of proteins, peptides, or glycoproteins that are secreted by specific immune cells. Dyspnea: difficult or labored breathing, sometimes referred to as having shortness of breath.

• • • •

powder: APD powder made of erythritol • Erythritol and 0.3% chlorhexidine that is soluble in water

and administered coronal and apical to the CEJ. Erythritol powder air polishing (EPAP): A clinical air polishing procedure where erythritol powder is administered. Glycine powder: APD powder made of glycine and silicic acids that is soluble in water and administered coronal and apical to the CEJ. Glycine powder air polishing (GPAP): A clinical air polishing procedure where glycine powder is administered. Sodium bicarbonate powder: APD powder made of sodium bicarbonate, with or without added tricalcium phosphate or silicon oxide that is soluble in water and administered coronal to the CEJ. Subcutaneous facial emphysema: sudden facial swelling and crepitus upon palpitation caused by the introduction of air into subcutaneous connective tissue.

• • •

• •

Introduction Air polishing devices have a variety of clinical applications. New powders continue to be developed and released to the market, providing both preventive and therapeutic functionality. APDs are used for the removal of extrinsic stain, biofilm, and immature dental calculus both coronal and apical to the CEJ. They decontaminate surfaces prior to sealant placement, are used in the management gingival inflammation around natural teeth and dental implants, in the management of dentinal hypersensitivity, and in the process of debriding orthodontic appliances. 411

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Chapter 22 Air Polishing Powders and Clinical Applications

There are six powders on the market that vary in their chemical composition, Mohs hardness, and particle size, all of which determine the clinical applications of each powder. Providers must use the powder sold by the manufacturer of their APD to avoid equipment damage and patient injury. As with dental ultrasonic devices, APDs release large volumes of aerosolized particles into the dental environment that must be controlled with appropriate infection prevention protocols presented in Chapter 2. There are considerations for air polishing that vary by powder and manufacturer. Providers should reference the directions for use or instructions for use (DFU/IFU) prior to use to ensure patient safety.

•

procedure, or sealant placement (see Figure 22-2). APDs provide superior microbial reduction and depth of penetration into pits and grooves of teeth than compared to a rotary handpiece rubber cup or bristles with a prophylaxis agent, which improves the bond strength of the dental material (Barnes et  al., 2014; Botti et  al., 2010; Graumann et  al., 2013; Lenzi et al., 2013; Tamura et al., 2017). Dentinal desensitization through occluding exposed tubules (see Figure 22-3). Not all APD powders are capable of dentinal desentization. This chapter will present which powders possess chemicals capable of occluding dentinal tubules.

APD Clinical Applications APDs have many clinical applications depending on the delivery system and powder composition. An APD will not remove firmly established dental calculus but has been shown to remove immature or early forming dental calculus. An APD will remove all levels of biofilm and extrinsic stain from the smooth surface, interproximal spaces, and pits and fissures of teeth. Air polishing clinical applications include:

• Biofilm, stain, and immature dental calculus re-

• •

moval for routine preventive and therapeutic procedures (see Figure 22-1). This clinical application aids in the treatment and management of periodontal and peri-implant diseases. Debridement of orthodontic appliances. Surface preparation prior to orthodontic bracket placement, direct restoration placement, bonding or cementing indirect restorations (inlay, onlay, crown, veneer), fluoride application, whitening

A

B Figure 22-1  Biofilm, calculus, stain, and immature and

mature dental calculus on mandibular anterior lingual surfaces.

Figure 22-2  Occlusal contamination: A. Biofilm and

dental calculus present in the occlusal pits and fissures of a premolar tooth, B. Stain present in the occlusal pits and fissures of a premolar and molar tooth.

APD Powder Particle Size and Mohs Hardness

413

Table 22-1  APD Powder Administration to Tooth Surfaces Powder

Figure 22-3  Recession of the mandibular anterior

Coronal to CEJ

Apical to CEJ

Aluminum trihydroxide





Calcium carbonate





Sodium bicarbonate





Glycine





Erythritol





central incisor facial surfaces.

APD Powder Particle Size and Mohs Hardness There are six powders on the market for air polishing. Two can be administered coronal and apical to the CEJ, and three are administered coronal to the CEJ (see Table 22-1). Calcium sodium phosphosilicate is not listed in Table 22-1 because it is only used as a therapeutic powder in the management of dentinal hypersensitivity and will be discussed later.

Particle Size

The six powders in Table 22-1 have different particle size ranges. Table 22-2 lists the powders from largest particle size to the smallest. Powders vary in their chemical composition, which determines their Mohs hardness rating and particle size. Manufacturers may sell the same powder, but due to slight chemical composition changes, each varies in Mohs hardness, particle size, particle volume, and clinical applications. For example, one manufacturer sells a 64-μm particle size sodium bicarbonate powder while another sells a 177-μm particle size. This can be confusing for the buyer if they are unaware of particle size differences. This is one of the many reasons why a provider cannot mix and match manufacturer powders in an APD. Mixing manufacturer powders may void the warranty and increases the chance of permanent damage of the APD, leading to costly repairs or full replacement (see Figure 22-4). Each powder sold by a manufacturer comes with specific claims, indications, considerations, contraindications, and approved clinical use, which is found in the DFU/IFU. In general, the larger the particle size, the higher the abrasive capability of the powder (Graumann et al., 2013; Arabaci et  al., 2007; Janiszewska-Olszowska et al., 2020). Larger particle sizes will remove biofilm,

Table 22-2  APD Powder Particle Size Powder

Particle Size

Aluminum trihydroxide

80–325 µm*

Sodium bicarbonate

40–250 µm*

Calcium sodium phosphosilicate

25–120 µm*

Calcium carbonate

45–55 µm*

Glycine

20–63 µm*

Erythritol

14 µm

*Particle size varies by manufacturer. Refer to the powder DFU/IFU for further information.

stain, and immature dental calculus with less contact time than smaller particle sizes; however, they may not be suitable for less mineralized hard tissues such as cementum and dentin. BREAKOUT POINT Manufacturers vary in air polishing powder chemical composition, particle size, particle volume, and Mohs hardness, each of which changes the clinical applications.

Mohs Hardness

APD powders have different Mohs hardness ratings ranging from 2 to 4. Table 22-3 lists the powders from the highest Mohs rating to the lowest. Calcium sodium phosphosilicate is not listed in Table 22-3 because its Mohs hardness is not comparable to the other powders owing to its clinical application of dentinal desentization. In general, the higher the Mohs rating, the higher the abrasive capability of the powder (Graumann et al., 2013; Arabaci et al., 2007; Janiszewska-Olszowska et al., 2020).

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Chapter 22 Air Polishing Powders and Clinical Applications

A

B

Figure 22-4  Equipment damage: A. EMS powder used in a Dentsply Sirona APD—note the powder present

outside the powder chamber (powder bowl), B. Dentsply Sirona APD powder chamber (powder bowl) without damage. Reproduced with permission from Dentsply Sirona

Table 22-3  APD Powder Mohs Hardness Powder Aluminum trihydroxide

Mohs Hardness 3–4*

Calcium carbonate

3

Sodium bicarbonate

2–3*

Glycine

2

Erythritol

2

*Mohs hardness varies by manufacturer. Refer to the powder DFU/IFU for further information.

BREAKOUT POINT Glycine and erythritol have a smaller particle size and lower Mohs hardness than the other APD powders, which allows them to be administered coronal and apical to the CEJ.

APD Powder Chemical Composition and Clinical Applications Sodium Bicarbonate Powder

Sodium bicarbonate powder is made of sodium

and bicarbonate with or without added tricalcium phosphate or silicon oxide to improve its flow characteristics (Kozlovsky et al., 2005; Petersilka, 2000). The chemical symbol is NaHCO3. Sodium bicarbonate powder is soluble in water. It was the first air polishing powder to be developed in the 1970s and was initially sold with much higher particle sizes (250 µm) than used today. The particle size range is 40–250 µm with a Mohs hardness of 2–3 that varies among manufacturers (Petersilka, 2000; Petersilka et al., 2003). Clinically, sodium bicarbonate powder is administered coronal to the CEJ. The slurry spray should be avoided on soft tissues to prevent irritation. Sodium

APD Powder Chemical Composition and Clinical Applications

bicarbonate powder can be used in the management of dentinal hypersensitivity because it will occlude dentin tubules (Banerjee et al., 2010). Sodium bicarbonate with added tricalcium phosphate has higher substantivity on the dentin tubule than sodium bicarbonate without tricalcium phosphate (Banerjee et al., 2010).

Aluminum Trihydroxide Powder

Aluminum trihydroxide powder was the second

air polishing powder released to the market as an alternative to sodium bicarbonate. It is made of aluminum and hydroxide. The chemical symbol is Al(OH)3. Aluminum trihydroxide is insoluble in water. The particle size range is 80–325 µm with a Mohs hardness of 3–4 that varies among manufacturers. Clinically, aluminum trihydroxide is administered coronal to the CEJ.

Calcium Sodium Phosphosilicate Powder

Glycine powder is made of glycine and silicic

acids. Silicic acids are added to improve powder flow characteristics (Petersilka, 2000). Glycine powder is soluble in water. The particle size range is 20–63 µm, which varies among manufacturers, and the Mohs hardness is 2.Clinically, glycine is administered coronal and apical to the CEJ. When glycine is used during an air polishing procedure, it is referred to as glycine powder air polishing (GPAP). Glycine powder will not occlude dentin tubules like sodium bicarbonate, calcium carbonate, or calcium sodium phosphosilicate. It has been shown to increase dentin hypersensitivity if the smear layer is removed (Moene et al., 2010; Sauro et al., 2010). Glycine is a useful adjunctive aid in the management of subgingival biofilm and gingival inflammation around natural teeth and dental implants for the following reasons:

• Glycine

Calcium sodium phosphosilicate powder is a bio-

active glass with a chemical composition of calcium, phosphorus, silica, and sodium (Graumann et  al., 2013). Its chemical symbol is CaNaO6PSi. Silicon dioxide is added to aid in powder flow characteristics. Calcium sodium phosphosilicate is soluble in water. The particle size is in the range of 25–120  µm and the Mohs hardness is 6, which varies among manufacturers. The powder is used therapeutically to aid in the management of dentinal hypersensitivity because it will deposit hydroxycarbonate apatite (HCA) onto exposed tubules to occlude them and decrease their lumen diameter size.

Calcium Carbonate Powder

Calcium carbonate is a natural substance found on rocks, sea shells, and pearls (Barnes et  al., 2014). Pharmacologically, is used as an antacid to subside heartburn. Its chemical symbol is CaCO3. Calcium carbonate powder is insoluble in water. It has a particle range of 44–55 µm that varies among manufacturers, and a Mohs hardness of 3. Clinically, it is administered coronal to CEJ.

Glycine Powder

Glycine is a simple, nonessential amino acid in the human body that is an important component of most polypeptides. It acts as an inhibitory neurotransmitter in the nervous system. Glycine is used in the food industry as a flavoring and preservative.

415

•

powder is postulated to have antiinflammatory effects through inhibiting inflammatory cell activation and immunomodulatory effects through decreasing cytokines and toxic medicators such as free radicals (Moene et  al., 2010). Gingival diseases and inflammation occur when the immune system sends cells such as polymorphonuclear leukocytes, macrophages, T-lymphocytes, and B-lymphocytes to the gingival sulcus in response to pathogenic organisms crossing into the connective tissue. Several of these inflammatory mediators release cytokines, which are a large group of proteins, peptides, or glycoproteins that contribute to the inflammatory effects of the gingiva. Glycine powder interacts with these cells and proteins to decrease inflammation (Moene et al., 2010). Glycine powder inhibits the synthesis of a peptidoglycan component necessary to maintain cell wall integrity of bacteria (Cochis et al., 2013). If the cell wall integrity becomes compromised, the bacteria will not survive.

BREAKOUT POINT Glycine and erythritol are useful adjunctive aids in the management of subgingival biofilm and gingival inflammation.

Erythritol Powder

Erythritol is a hydrogenated form of carbohydrate called a polyol or sugar alcohol (Hashino et al., 2013). It has a sweet taste and is used as a natural sweetener in the food industry as a sugar substitute.

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Chapter 22 Air Polishing Powders and Clinical Applications

Erythritol powder is made of erythritol with the

addition of 0.3% chlorhexidine that improves powder flow characteristics and provides antimicrobial action. It is soluble in water. Erythritol powder has the lowest particle size of all powders at 14 µm. The Mohs hardness is 2. Clinically, erythritol is administered coronal and apical to the CEJ. When erythritol is used during an air polishing procedure, it is referred to as ­ rythritol powder air polishing (EPAP). e Erythritol powder is a useful adjunctive aid in the management of subgingival biofilm and gingival inflammation around natural teeth and dental implants for the following reasons:

• Erythritol powder has been postulated in the lit•

•

erature to have an inhibitory effect on bacterial replication by decreasing nucleic acid synthesis and amino acids (Hashino et al., 2013). Erythritol powder has been shown to slow down the extracellular matrix biosynthesis by bacteria, thus disrupting the structural integrity of an oral biofilm (Hashino et al., 2013; Drago et al., 2014). These results have been confirmed through the decrease of specific bacterial pathogens when exposed to erythritol in studies (Hashino et  al., 2013; Park et al., 2020). The addition of chlorhexidine provides an antimicrobial action other powders do not possess.

BREAKOUT POINT Erythritol powder is the only powder with added chlorhexidine for antimicrobial effects.

Powder Care

Powders and powder containers cannot be exposed to moisture, high temperatures, or humidity as they spoil and clump. If this occurs, the powder should be discarded. Powders have an expiration date and should be discarded when they reach this maturation time. Powder containers should be stored: 1. In well-sealed containers with a tight-fitting lid. 2. In a well-ventilated room. 3. In dry, cool conditions protected from humidity. 4. Away from liquids. Prior to filling an APD powder chamber, shake the powder container to loosen powder particles and break apart clumps.

Air Polishing Literature

There is an extensive body of literature spanning decades that has reviewed the abrasiveness and efficiency of APDs and powders. Drawing definitive conclusions and making meaningful comparisons between studies and technologies is challenging, if not impossible, because of the lack of industry standardization and variability between manufacturers’ products such as:

• Delivery systems that operate at different psi’s. • Varied nozzle designs. • Varied powder chamber sizes. • Varied powder chemical composition, parti-

cle size, particle volume, Mohs hardness, and additives.

Caution should be exercised when appraising dated literature because the results may not be reflective of today’s technology. APD devices and powders have changed dramatically over the last decade with improved delivery systems, nozzle designs, powder chambers, operating system psi, and powder composition. When studies do not report or account for powder particle size, delivery system, or provider technique (contact time, nozzle distance, and angulation), results should be interpreted with caution. Providers should be aware of these variables when critically appraising the literature.

APD Considerations Each powder has different patient considerations, which vary by manufacturer. It would be impossible to cover every consideration for each manufacturer’s product in this book. A general overview of considerations is provided next. For further details, reference the manufacturer’s DFU/IFU.

Gingival Status

If a patient presents with severe gingival inflammation or a recent post-surgical procedure, air polishing may be contraindicated, or caution should be exercised to avoid further trauma or gingival erosion (Kozlovsky et al., 2005; see Figure 22-5a and b). If gingival injury occurs during air polishing, it will heal uneventfully on its own within six days post-procedure but may cause the patient transient postoperative discomfort (Kozlovsky et al., 2005; Flemmig et al., 2007).

Sodium Bicarbonate Powder

Sodium bicarbonate powder has received special attention in the literature over the years owing to

APD and Dental Materials

417

A

B Figure 22-5  Gingival status considerations for air polishing: A. Maxillary anterior teeth post-

surgical procedure with stitches, B. Severe gingival inflammation from a necrotizing disease on the maxillary left facial/buccal surfaces.

its water solubility and dissociation into a sodium cation (Na+) and bicarbonate (HCO3−) anion inside the body. Concerns have been raised that the addition of these charged elements could disrupt the acid/base balance in the body for a patient with a metabolic disorder, adrenal gland dysfunction, or renal disease, or a patient taking a diuretic medication, steroid, or potassium supplement. It was also suggested a patient on a sodium-restricted diet or saltless diet should not receive sodium bicarbonate air polishing. Recent literature has shown the actual amount of powder ingested by a patient during a one-time APD exposure to sodium bicarbonate is minimal and causes clinically insignificant changes to blood pH, or to sodium, chloride, and potassium levels throughout the body (Petersilka et al., 2000). However, some manufacturers still recommend using an alternate powder for a patient who fits any of the previously

listed criteria. Best practice may be to avoid sodium bicarbonate powder in these patients or consult with their physician prior to use.

APD and Dental Materials APD powders have the potential to scratch, dull, or roughen specific dental materials depending on the powder and delivery system, but they have never been shown to crack, chip, remove, or crater materials when used correctly per the manufacturer’s directions (Pelka et al., 2010). A roughened or scratched dental material is undesirable because it may discolor or contribute to oral deposit accumulation, which increases the risk for secondary caries and gingival inflammation. The goal of restorative dentistry is to place restorations with a smooth glazed finish, and the goal of preventive procedures is not to alter this finish.

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Chapter 22 Air Polishing Powders and Clinical Applications

There is an extensive body of literature that has evaluated the effects of various APDs and powders on dental materials. Again, exercise caution when referencing dated literature because their results may no longer be reflective of today’s current technology. It is best to follow the manufacturer’s DFU/IFU for dental material considerations and contraindications rather than an individual publication.

Dental Materials: Safe Use of an APD

• Dental

ceramics and porcelain bonded alloys: APD powders have not been shown to cause surface alterations to dental ceramics such as porcelain, alumina, zirconia, and porcelain-bonded alloys (porcelain fused to metal crown) (Arabaci et al, 2007; Petersilka, 2000; Cooley et al., 1988; Johnson et al., 2004; see Figure 22-6).

• Orthodontic

appliances: APD powders are safe and indicated for oral deposit removal around fixed orthodontic appliances (Petersilka, 2000; see Figure 22-7).

BREAKOUT POINT Air polishing is safe for dental ceramics, porcelainbonded alloys, and orthodontic appliances.

Dental Materials: APD Use With Caution

For the materials listed in this section, it is best practice for you to reference the manufacturer’s DFU/IFU and follow their recommendations. Literature has reported APD use should proceed with caution for:

• Composite resins: The literature is mixed on the

A

• •

B Figure 22-6  Safe use of an APD: A. Dental ceramics and

porcelain bonded alloys on the maxillary and mandibular right anterior and posterior teeth, B. Porcelain bonded alloys on the maxillary anterior teeth.

•

effects APD powders have on composite resins. Studies have found powders cause significant surface roughness, little surface roughness, and no surface roughness (Botti et al., 2010; Janiszewska-­ Olszowska, 2020; Pelka et al., 2010; Cooley et al., 1988; Lubow et al., 1996). Glycine and erythritol powders cause less surface alteration than other powders, likely owing to their chemical composition, lower particle size, and lower Mohs hardness (Giacomelli et al., 2011; Salerno et al., 2010). Composite resins that experience loss of smoothness due to natural deterioration in the mouth over time are more susceptible to abrasion effects than composites without loss of structure (see Figure 22-8). Amalgams: APD powders may cause a discoloration, dulling, or change to surface characteristics of amalgam restorations (Graumann et al., 2013; Lubow & Cooley, 1996; see Figure 22-9). All-metal cast and stainless-steel alloys: The literature is mixed on the effects APD powders have on all-metal castings such as gold, palladium, platinum, and stainless-steel alloys (crowns commonly used in pediatric patients) over time. Some studies show a discoloration, matte finish, or erosion while others do not (Barnes et al., 2014; Petersilka, 2000; Cooley et al., 1988; Johnson et al., 2004; see Figure 22-10). Removable appliances (partial, dentures: Erythritol and glycine can be safely used on removable appliances, while powders with a higher particle size may be contraindicated. Refer to the manufacturer’s DFU/IFU for details.

APD and Dental Materials

419

A

B Figure 22-7  Safe use of an APD: A. Fixed orthodontic appliances on the mandibular anterior

lingual surfaces, B. Orthodontic brackets and wires on the mandibular anterior facial surfaces.

A

B

Figure 22-8  APD use with caution: A. Fractured composite resin on a mandibular molar,

B. Composite resins on molars.

BREAKOUT POINT Providers should reference the manufacturer’s DFU/IFU prior to air polishing a composite resin, amalgam, all-metal cast and stainless-steel alloy, or a removable appliance.

Dental Materials: APD Use Contraindicated

• Adhesives: Air polishing with sodium bicarbonate

or calcium carbonate prior to operative dentistry has been shown in some studies to negatively affect the bond strength of a dental adhesive, while

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Chapter 22 Air Polishing Powders and Clinical Applications

Figure 22-9  APD use with caution. Amalgam restoration

on a molar with fracture lines.

Figure 22-10  APD use with caution. All-metal cast alloys

on maxillary molars and maxillary right premolars.

Figure 22-11  APD use contraindicated. Luting agents under restoration margins of

these crowns.

•

•

the use of glycine did not (Petersilka, 2000). It is postulated this occurs due to the varied effects these powders have on dentin. Glycine will not occlude dentin tubules and can remove the smear layer on dentin, unlike sodium bicarbonate and calcium carbonate powders that bond to and occlude tubules (Moene et al., 2010). Glass ionomer cement and sealant: It would be best practice to avoid direct use of an APD powder on a glass ionomer cement and sealant due to the risk for substance loss and surface alteration (Graumann et al., 2013; Pelka et al., 2010; Johnson et  al., 2004). Studies vary in their reports, with some showing less surface alteration with glycine and erythritol than other powders (Barnes et  al., 2014; Johnson et  al., 2004). Refer to the manufacturer’s DFU/IFU for details. Luting cements: sodium bicarbonate, aluminum trihydroxide, calcium sodium phosphosilicate, and calcium carbonate may remove luting cements, and their use should be avoided on the direct margins of restorations (Cooley et al., 1988; Johnson et al., 2004; see Figure 22-11).

Adverse Effects Air polishing is a routine procedure that is very safe. The most serious adverse effect is subcutaneous ­facial emphysema whose incidence is extremely rare (Petersilka, 2000; Flemmig et  al., 2007; ­Karmakar & Kamath, 2017). There have only been nine air emphysemas and three air embolisms reported as a sequela from subcutaneous facial emphysema from 1977 to 2001, which all healed uneventfully without medical intervention and were attributed to improper technique on the part of the provider during air polishing (Petersilka, 2000; Flemmig et al., 2007; Karmakar & Kamath, 2017). Subcutaneous facial emphysema is most commonly associated with head and neck surgery, trauma, intubation, mechanical ventilation, or an infectious process (Yang et al., 2006). The most common dental procedure linked to subcutaneous facial emphysema is an extraction when air is introduced into the loose surrounding connective tissue by an air-turbine drill or air/water syringe (Yang et al., 2006). Subcutaneous facial emphysema is characterized by sudden facial swelling and crepitus upon

Adverse Effects

palpation within 24–36 hours after the dental procedure (Petersilka, 2000; Karmakar & Kamath, 2017; Yang et al., 2006). It can spread to the throat, heart, eye, or ear. Typically, subcutaneous facial emphysema resolves on its own within 1–3 days (Karmakar &

421

Kamath, 2017). In the event the patient experiences thoracic pain, has issues with swallowing, dyspnea (difficult or labored breathing), or changes in vision or hearing, medical attention should be sought (Karmakar & Kamath, 2017).

CASE STUDY

Your patient is a 77-year-old Caucasian female with poorly controlled high blood pressure, high cholesterol, diabetes, osteoarthritis, and osteopenia. She is taking hydrochlorothiazide, metoprolol, and losartan for her blood pressure; atorvastatin for her high cholesterol; metformin and Lantus for her diabetes; and Mobic and risedronate for osteoarthritis and osteopenia. Her Body Mass Index (BMI) is 18. She does not have any known allergies or drug allergies. She is retried. Her last HbA1c was 9.2. Her chief complaint is: “I don’t like the stains on my teeth and the color.” Dental exam: Chipped tooth maxillary left central incisor (see intraoral photograph). No history of orthodontics.

Front bite.

Left bite.

Right bite.

Posterior teeth mandibular arch.

Posterior teeth maxillary arch

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Chapter 22 Air Polishing Powders and Clinical Applications

Occlusion: Class 1 bilateral with first molar relationship. Crowding anterior teeth with an overjet. Oral hygiene exam: ■ ■ ■

Generalized moderate biofilm Localized light stain Light dental calculus throughout with moderate supragingival calculus mandibular anterior

Periodontal exam: ■ ■ ■ ■ ■

Probe depths generally 3–5 mm Class I and II furcation involvement on most molars Generalized recession Class 1 mobility maxillary central and lateral incisors Bleeding upon probing 12% of the mouth

Tissue description: ■ ■

Generalized firm, pink, stippled attached gingiva. Loss of interdental papillae due to recession with Class 2 embrasure spaces generally.

Case Study Questions 1. 2. 3. 4.

List the type of dental materials present in this patient’s mouth. Which dental material(s) present in this patient’s mouth have a consideration or contraindication for air polishing? What air polishing powder(s) should be selected for this patient and why? The maxillary left central incisor is treatment planned for a composite restoration on the mesial facial lingual incisal. What considerations or contraindications does this restoration have for air polishing? 5. Does the patient have anything in her medical history that would be a contraindication for air polishing? 6. Does the patient have anything in her medical history that is a consideration for air polishing? 7. Does the patient have any tooth or gingival condition that is a contraindication or consideration for air polishing? 8. Based on your observations of the mandibular anterior facial and interproximal surfaces, what powder should you use to remove the extrinsic exogeneous stain and biofilm when the patient does not report dentinal hypersensitivity? Justify your answer. 9. Which nozzle should be used for this patient to deliver glycine or erythritol subgingivally? Justify your answer. 10. List the reasons why air polishing should be selected over a rotary handpiece with a polishing agent for this patient.

Summary

APDs are used for the removal of biofilm, extrinsic stains, and immature dental calculus from smooth surfaces, interproximal spaces, and pits and fissures of teeth. They are used times of gingival inflammation around natural teeth and dental implants, to decontaminate orthodontic appliance, and for surface preparation prior to sealant placement. Glycine and erythritol can

Questions

1. Which of the following can be removed with an APD? a. Biofilm b. Firmly established dental calculus c. Intrinsic staining d. None of the above

be administered coronal and apical to the CEJ. Calcium sodium phosphosilicate is used in the therapeutic management of dentinal hypersensitivity. Sodium bicarbonate, aluminum trihydroxide, and calcium carbonate are administered coronal to the CEJ. Providers should reference their manufacturer’s powder and APD DFU/IFU for considerations and contraindications of use.

2. Which of the following is a clinical indication for use of an APD? a. Debridement of a dental implant b. Subgingival debridement c. Debridement of pits and fissures prior to sealant placement d. Dentinal desensitization e. All of the above

References

423

3. True or False. All air polishing powders are manufactured the same and can be used in any APD. a. True b. False

12. True or False. Powders that can be administered apical to the CEJ have a lower particle size than powders administered coronal to the CEJ. a. True b. False

Match the following powder to its correct description for questions 4–9. There is only one correct answer for each powder.

13. Which of the following APD powders is postulated to have anti-inflammatory and immunomodulatory effects in the mouth by decreasing cytokines and toxic medicators such as free radicals? a. Sodium bicarbonate b. Erythritol c. Glycine d. Aluminum trihydroxide

4. Sodium bicarbonate

A. Administered coronal and apical to the CEJ

5. Glycine

B. Administered coronal to the CEJ with a particle size range of 80–325 µm

6. Aluminum trihydroxide

C. Mohs hardness of 3

7. Erythritol

D. Administered coronal to the CEJ, water-soluble, particle size 40–250 µm

8. Calcium sodium phosphosilicate

E. Occludes dentin tubules

9. Calcium carbonate

F. 0.3% chlorhexidine added to this sugar alcohol for an antimicrobial effect

10. Which of the following powders can be administered apical to the CEJ? a. Sodium bicarbonate b. Aluminum trihydroxide c. Glycine d. Erythritol e. Both C and D f. All of the above 11. Which powder has the smallest particle size? a. Sodium bicarbonate b. Aluminum trihydroxide c. Glycine d. Erythritol

References

1. Arabaci, T., Cicek, Y., Ozgoz, M., Canakci, V., Canakci, C. F., & Eltas, A. (2007). The comparison of the effects of three types of piezoelectric ultrasonic tips and air polishing system on the filling materials: An in vitro study. International Journal of Dental Hygiene, 5, 205–210.

14. Which of the following APD powders is postulated to have antimicrobial effects by inhibiting bacterial replication through effects on nucleic acid and amino acid synthesis that can affect the structural integrity of an oral biofilm? a. Sodium bicarbonate b. Erythritol c. Glycine d. Aluminum trihydroxide 15. Which of the following is TRUE? a. Powder containers do not need to be sealed after use. b. Powder containers should be shaken prior to use. c. Powders may be used past their expiration date. d. Moisture and humidity will not affect the integrity of an APD powder. 16. Which of the following is TRUE of an APD and powders? a. An APD should be used with caution in times of severe gingival inflammation. b. All powders should be avoided for a patient on a sodium-restricted diet. c. APD powders should never be used on a porcelain crown. d. APD powders are safe for use on a glass ionomer and sealant. 17. True or False. Air polishing runs a high risk for causing a subcutaneous facial emphysema. a. True b. False

2. Banerjee, A., Headmost-Sani, M., Farrell, S., & Thompson, I. (2010). A clinical evaluation and comparison of bioactive glass and sodium bicarbonate air-polishing powders. Journal of Dentistry, 38, 475–479.

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Chapter 22 Air Polishing Powders and Clinical Applications

3. Barnes, C. M., Covery, D., Watanabe, H., Simetich, B., Schulte, J. R., & Chen, H. (2014). An in vitro comparison of the effects of various air polishing powders on enamel and selected esthetic restorative materials. Journal of Clinical Dentistry, 4(25), 76–87. 4. Botti, R. H., Bossu, M., Zallocco, N., Vestri, A., & Polimeni, A. (2010). Effectiveness of plaque indicators and air polishing for the sealing of pits and fissures. European Journal of Paediatric Dentistry, 11(1), 15–18. 5. Cochis, A., Fini, M., Carrassi, A., Migliario, M., Visai, L., & Rimondini, L. (2013). Effect of air polishing with glycine powder on titanium abutment surfaces. Clinical Oral Implant Research, 24, 904–909. 6. Cooley, R. L., Lubow, R. M., & Brown, F. H. (1988). Effect of air-powder abrasive instrument on porcelain. Journal of Prosthetic Dentistry, 60(4), 440–444. 7. Drago, L., Fabbro, M. D., Bortolin, M., Vassena, C., Vecchi, E. D., Taschieri, S. (2014). Biofilm removal and antimicrobial activity of two different air-polishing powders: An in vitro study. Journal of Periodontology, 85(11), e363–e369. 8. Flemmig, T. F., Hetzel, M., Topoll, H., Gerss, J., Haeberlein, I., & Petersilka, G. (2007). Subgingival debridement efficacy of glycine powder air polishing. Journal of Periodontology, 78(6), 1002–1010. 9. Giacomelli, L., Salerno, M., Derchi, G., Genovesi, A., Paganin, P. P., & Covani, U. (2011). Effect of air polishing with glycine and bicarbonate powders on a nanocomposite used in dental restorations: An in vitro study. International Journal Periodontics Restorative Dentistry, 31, e51–e56. 10. Graumann, S. J., Sensat, M. L., & Stoltenberg, J. L. (2013). Air polishing: A review of current literature. Journal of Dental Hygiene, 87(4), 173–180. 11. Hashino, E., Kuboniwa, M., Alghamdi, S. A., Yamaguchi, M., Yamamoto, R., Cho, H., & Amano, A. (2013). Erythritol alters microstructure and metabolomic profiles of biofilm composed of Streptococcus gordonii and Porphyromonas gingivalis. Molecular Oral Microbiology, 28, 435–451. 12. Janiszewska-Olszowska, J., Drozdzik, A., Tandecka, K.,  & Grocholewicz, K. (2020). Effect of air-polishing on surface roughness of composite dental restorative material: Comparison of three different air-polishing powders. BMC Oral Health, 20(30), 1–7. 13. Johnson, W. W., Barnes, C. M., Covey, D. A., Walker, M. P., & Ross, J. A. (2004). The effects of a commercial aluminum air polishing powder on dental restorative materials. Journal of Prosthodontics, 13(3), 166–172. 14. Karmakar, S., & Kamath, D. G. (2017). Subgingival airpolishing: A simple and cost effective medical insurance. Journal of Pharmaceutical Sciences and Research, 9(2), 199–201.

15. Kozlovsky, A., Artzi, Z., Nemcovsky, C. E., & Hirshberg, A. (2005). Effect of air-polishing devices on the gingiva: Histologic study in the canine. Journal of Clinical Periodontology, 32, 329–334. 16. Lenzi, T. L., Menezes, L. B. R., Soares, F. Z. M., & Rocha, R. O. (2013). Effect of air abrasion and polishing on primary molar fissures. European Archives of Paediatric Dentistry, 14, 117–120. https://doi.org/10.1007/s40368-013-0023-x 17. Lubow, R. M., & Cooley, R. L. (1996). Effect of air-powder abrasive instrument on restorative materials. Journal of Prosthetic Dentistry, 55(4), 462–465. 18. Moene, R., Decaillet, F., Andersen, E., & Mombelli, A. (2010). Subgingival plaque removal using a new air-polishing device. Journal of Periodontology, 81(1), 79–88. 19. Park, B., Kim, M., Park, J., Jeong, J., & Noh, H. (2020). Research on dental plaque removal methods for efficient oral prophylaxis: With a focus on air polishing and rubber cup polishing. International Journal of Dental Hygiene, 19(3), 1–7. https://doi.org/10.1111/idh.12481 20. Pelka, M. A., Altmaier, K., & Lohbauer, U. (2010). The effect of air-polishing abrasives on wear of direct restoration materials. Journal of the American Dental Association, 141, 63–70. 21. Petersilka, G. (2000). Subgingival air-polishing in the treatment of periodontal biofilm infections. Periodontology, 55, 124–142. 22. Petersilka, G. J., Bell, M., Mehl, A., Hickel R., & Flemmig, T. F. (2003). Root defects following air polishing. Journal of Clinical Periodontology, 30, 165–170. 23. Salerno, M., Giacomelli, L., Derchi, G., Patra, N., & Dispro, A. (2010). Atomic force microscopy in vitro study of surface roughness and fractal character of a dental restoration composite after air-polishing. BioMedical Engineering OnLine, 9, 59. 24. Sauro, S., Watson, T. F., & Thompson, I. (2010). Dentine desensitization induced by prophylactic and air-polishing procedures: An in vitro dentine permeability and confocal microscopy study. Journal of Dentistry, 38, 411–422. 25. Tamura, Y., Takamizawa, T., Shimamura, Y., Akiba, S., Iman, A., Tsujimoto, A., Kurokawa, H., & Miyazaki, M. (2017). Influence of air-powder polishing on bond strength and surface-free energy of universal adhesive systems. Dental Materials Journal, 36(6), 762–769. 26. Yang, S. C., Chiu, T. H., Lin, T. J., & Chan, H. M. (2006). Subcutaneous emphysema and pneumomediastinum secondary to dental extraction: A case report and literature review. Journal of Medical Science, 22, 641–645. 27. Zhong, A., Wheeler, M. D., Li, X., Froh, M., Schemmer, P., Yin, M., Bunzendaul, H., Bradford, B., Lemasters, J. J. (2003). L-glycine: A novel anti-inflammatory, immunomodulatory, and cytoprotective agent. Current Opinion in Clinical Nutrition and Metabolic Care, 2, 229–240.

CHAPTER 23

Coronal to CEJ Air Polishing LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Identify Dentsply Sirona air polishing devices, parts, and accessories. 2. Identify Dentsply Sirona powder selections and their clinical indications, applications, and considerations. 3. Use a Dentsply Sirona air polishing device with proper power settings, water flow rate, and nozzle angulations.

KEY TERMS

affixed white holder used to dislodge residual powder in the nozzle delivery tube of a Dentsply Sirona Cavitron Jet Air Polishing Insert. Cavitron Prophy Jet Prophy Powder: the name of the sodium bicarbonate powder manufactured by Dentsply Sirona. Heater rod: a part of the Cavitron Jet Air Polishing Insert that is placed into the Jet-Mate Sterilizable, Detachable Handpiece insert port opening that heats the water for improved patient comfort; manufactured by Dentsply Sirona. Insert port: larger opening on the soft nozzle grip of the Jet-Mate Sterilizable, Detachable Handpiece manufactured by Dentsply Sirona that house the heater rod of the removable Cavitron Jet Air Polishing Insert. Jet-Mate Sterilizable, Detachable Handpiece: the name of the air polishing handpiece manufactured by Dentsply Sirona. Manual Prophy mode cycle: cycle on a Dentsply Sirona APD where the provider controls the water and slurry discharge through the foot pedal. Nozzle tube: terminal portion on the Dentsply Sirona Cavitron Jet Air Polishing Insert with two concentric openings to deliver water and compressed air powder mixture. Powder bowl: the name of the powder chamber manufactured by Dentsply Sirona. Powder bowl cap: the name of the powder chamber cap manufactured by Dentsply Sirona. Powder delivery port: smaller opening on the soft nozzle grip of the Jet-Mate Sterilizable, Detachable Handpiece manufactured by Dentsply Sirona that house the prophy powder delivery tube of the removable Cavitron Jet Air Polishing Insert

• • •

Prophy mode: preprogrammed • Auto-cycle automatic cycles on a Dentsply Sirona APD that

•

•

•

•

•

•

• • •

delivers a slurry discharge followed by a water rinse. Cavitron Jet Air Polishing Insert: the name of the air polishing insert with affixed nozzle manufactured by Dentsply Sirona. Cavitron Jet Fresh Prophy Powder: the name of the aluminum trihydroxide powder manufactured by Dentsply Sirona. Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System: the name of a dual-function APD plus ultrasonic scaling device manufactured by Dentsply Sirona. Cavitron Prophy Jet Handpiece Cleaning Tool: sterilizable narrow solid metal wire used to dislodge residual powder in the powder delivery port of the Dentsply Sirona Jet-Mate Sterilizable, Detachable Handpiece. Cavitron Prophy Jet Nozzle Cleaning Tool: sterilizable narrow solid metal wire with an

• •

425

426

Chapter 23 Coronal to CEJ Air Polishing

flow control dial: dial located on the • Powder powder bowl cap that changes the powder velocity

and flow; sometimes referred to as a daisy wheel; manufactured by Dentsply Sirona. Prophy mode cycle dial: present on the front of an APD manufactured by Dentsply Sirona that allows the provider to choose between manual or autocycle Prophy modes. Prophy powder delivery tube: part of the Dentsply Sirona Cavitron Jet Air Polishing Insert that is placed into the Jet-Mate Sterilizable, Detachable Handpiece powder delivery port and delivers the compressed air and powder mixture. Soft nozzle grip: a replaceable wear and tear item located on the terminal end of the JetMate Sterilizable, Detachable Handpiece with two port hole openings; manufactured by Dentsply Sirona.

• • •

Introduction Air polishing coronal to the CEJ is a safe and efficient method for removing stain, biofilm, and immature dental calculus. While there are multiple manufacturers of air polishing technology, this chapter will focus on Dentsply Sirona APDs because covering every manufacturer of APD technology would be too lengthy for this book. Dentsply Sirona has been manufacturing air polishing devices for use coronal to the CEJ since 1997. They manufacturer stand-alone multipower delivery APDs with two powder choices of sodium bicarbonate and aluminum trihydroxide. Do not use another manufacturer’s powder in a Dentsply Sirona APD because the chemical composition, Mohs hardness, particle size, particle volume, and clinical applications of the powder may not be compatible. This chapter will present Dentsply Sirona air polishing devices, parts, and accessories. The clinical techniques used to deliver safe air polishing to tooth surfaces will be demonstrated.

Figure 23-1  Cavitron Prophy Jet Air Polishing System. Reproduced with permission from Dentsply Sirona

Figure 23-2  Cavitron Jet Plus Ultrasonic Scaling and Air

Polishing System.

Reproduced with permission from Dentsply Sirona

Dentsply Sirona Air Polishing Devices Dentsply Sirona manufactures two different air polishing systems: 1. Single stand-alone APD released in 2013 called the Cavitron Prophy Jet Air Polishing System (see Figure 23-1). 2. Dual functionality device as a magnetostrictive ultrasonic scaler and APD. There have been three

models released since 1997. The most current model, and the one featured in this book, is the Cavitron Jet Plus ­ Ultrasonic Scaling and Air Polishing System released in 2012 (see Figure 23-2).

There are specific air and water pressure psi (pound force per square inch) required for each device, which can be referenced in the product’s direction for use or instruction for use (DFU/IFU).

Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling

Dentsply Sirona Polishing Powders Dentsply Sirona sells two powders—sodium bicarbonate and aluminum trihydroxide—for air polishing coronal to the CEJ. Cavitron Prophy Jet Prophy Powder is sodium bicarbonate, and Cavitron Jet Fresh Prophy Powder is aluminum trihydroxide (see Figure 23-3). Both powders are not to be directed subgingivally into a gingival sulcus.

427

Powder Bowl

Each device has a large powder bowl with a removable powder bowl cap (see Figure 23-5). The powder bowl cap is designed with threads that allow a

Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System The powder chamber, called the powder bowl by Dentsply Sirona, is large (see Figure 23-4a and b). There are three powder velocity settings. There are two Prophy mode selections called manual and auto-cycle prophy modes.

Figure 23-4  Powder bowl (Cavitron Jet Plus Ultrasonic

Scaling and Air Polishing System). Reproduced with permission from Dentsply Sirona

Powder flow control dial

Powder bowl cap

Powder bowl

A

B

Figure 23-3  Dentsply Sirona powders: A. Cavitron

Prophy Jet Prophy Powder, B. Cavitron Jet Fresh Prophy Powder. Reproduced with permission from Dentsply Sirona

Figure 23-5  Powder bowl, powder bowl cap, and powder

flow control dial (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System).

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Chapter 23 Coronal to CEJ Air Polishing

secure connection to the powder bowl to prevent air or powder from leaking. Use care when attaching and removing the powder bowl cap from the powder bowl to avoid stripping the threads. This could irreversibly damage the equipment. The powder bowl is emptied at the conclusion of each workday to prevent moisture contamination and clogging. The powder bowl cap has a powder flow ­control dial that allows for a change in powder flow velocity. This is sometimes referred to as a daisy wheel (see Figure 23-5). To fill the powder bowl:

powder in the window of the powder flow control dial (see Figure 23-8). If you do not see this white circle of powder, the device did not pressurize

1. With the device off, unscrew the powder bowl cap. 2. Shake the powder bottle to break up clumps. 3. Pour the powder into the powder bowl (see Figure 23-6). Do not fill past the top of the inner tube. 4. Close the lid tightly on the powder bottle to prevent moisture contamination. 5. With a soft disposable cloth, clear away powder on the threads of the powder bowl and powder bowl cap (see Figure 23-7). 6. Thread the powder bowl cap back onto the powder bowl, ensuring that threads are not stripped. 7. Turn the power on. The chamber powder bowl will pressurize. You will see a small white circle of Figure 23-7  Cleaning threads with a disposable soft

cloth (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System).

Figure 23-6  Pouring powder into the powder bowl

(Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System). Reproduced with permission from Dentsply Sirona

Figure 23-8  Powder flow control dial (Cavitron Jet Plus

Ultrasonic Scaling and Air Polishing System).

Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling

429

Figure 23-9  Removal of the powder bowl and powder

bowl cap (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System). Reproduced with permission from Dentsply Sirona

correctly. Turn the device off, check for a clog, and verify an adequate powder level is present in the powder bowl.

Figure 23-10  Removal of the powder bowl (Cavitron Jet

Plus Ultrasonic Scaling and Air Polishing System). Reproduced with permission from Dentsply Sirona

To empty the powder bowl: 1. Turn the APD off. The powder bowl will depressurize in a few seconds. Do not attempt to remove the powder bowl cap during this time. 2. Once full depressurization has occurred, remove the power bowl cap carefully to avoid stripping  the  threads. Set the cap aside (see Figure 23-9). 3. Lift and remove the powder bowl from the device carefully (see Figure 23-9 and 23-10). Do not damage the cords under the chamber. 4. Discard all unused powder from the powder bowl in the trash. Emptying the powder bowl will  ­ reduce moisture absorption and prevent clogging. 5. Place the powder bowl back into its holder and ensure that the cords to the powder bowl are not pinched or smashed. Do not place the powder bowl cap back on the powder bowl. 6. Do not position your face directly over the powder bowl, and turn the device on for 15 seconds. This will eliminate any residual powder or moisture in the powder bowl. 7. Turn the device off.

8. Remove the seal ring on the powder bowl cap without damaging the seal ring (see Figure 23-11a and b). An instrument without a sharp cutting edge can be used, such as a dull explorer. 9. Use a soft disposable cloth to remove any powder residue from the seal ring (see Figure 23-12). Do not scratch, bend, or damage the seal ring. 10. Use a soft disposable cloth to remove residual powder from the inside of the powder bowl cap and the powder bowl threads (see Figure 23-13). If residual powder remains, use a soft bristle toothbrush with light strokes to dislodge powder particles (see Figure 23-13). 11. Place the seal ring back onto the powder bowl cap (see Figure 23-14). 12. Place the powder bowl cap on the powder bowl without stripping the threads.

Powder Velocity Control

There are three powder flow velocity options of low, medium, and high set by the powder flow control dial on the powder bowl cap. The powder flow control

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Chapter 23 Coronal to CEJ Air Polishing

A

B

Figure 23-11  Removal of the seal ring on the powder bowl cap. A. Dull explorer placed under the seal ring B. Dull

explorer lifting up and removing the seal ring

• High powder flow velocity is only used for excep-

tionally difficult to remove stains such as beetle nut or heavy tobacco staining. Once the heavy stain is removed, return to a low or medium setting.

To change a powder flow velocity setting, turn the powder flow control knob to the indicated letter on the powder bowl: L is for low, M is for medium, and H is for high (see Figure 23-16a to c).

Prophy Mode Cycles

A Prophy mode cycle dial is present on the front of the device. The dial allows the provider to choose between two cycle options of manual or auto-cycle prophy modes.

• Manual Prophy mode cycle: Figure 23-12  Removal of residual powder from the

seal ring.

dial has a small, raised, clear, round indicator for setting the powder flow (see Figure 23-15).

• Low and medium powder flow velocity are used for most procedures.

Manual mode requires the provider to press the foot pedal to discharge the slurry mixture and release the foot pedal to stop it (see Figure 23-17a). When the pedal is pressed all the way to the floor (second position), the slurry will discharge (see Figure 23-17b). When the pedal is pressed halfway to the floor (first position), water only will discharge (see Figure 23-17c). Patient comfort during air polishing can be improved if a water rinse is provided after slurry exposure. This will remove residual

Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling

A

431

B

Figure 23-13  Residual powder removal (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System): A. Powder

removal on the threads of the power bowl, B. Powder removal on the threads of powder bowl cap.

Figure 23-14  Powder bowl cap and seal ring.

Figure 23-15  Powder flow control dial round indicator

(Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System).

•

powder from soft and hard tissues. Manual mode is termed None or Manual on the dial depending on the model (see Figure 23-18). Auto-cycle Prophy mode: Auto-cycle has three preprogrammed automatic cycles that deliver a

slurry discharge followed by a water rinse. The three auto-cycle options are termed Short, Medium, and Long. They vary in their time of water and slurry

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Chapter 23 Coronal to CEJ Air Polishing

C

B

A

Figure 23-16  Low, medium, high powder flow velocity settings (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing

System): A. L: Low, B. M: Medium, C. H: High.

A

B

C

Figure 23-17  Foot pedal (Tap-On technology wireless foot pedal): A. Foot pedal (Cavitron tap-on foot pedal),

B. Pedal depressed all the way to the floor will discharge the slurry mixture, C. Pedal depressed halfway to the floor will discharge water only. Reproduced with permission from Dentsply Sirona

Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling

discharge from the nozzle (see ­ Figure  23-18). Table 23-1 lists the length of time of slurry and water discharge for auto-cycle Prophy mode.

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The dial color pattern is different for the single stand-alone APD and dual functionality APD.

• Single stand-alone: The Cavitron Prophy Jet Air •

Polishing System has one dial that is a purple color (see Figure 23-1). Dual functionality: The Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System has a dial with blue, gray, and purple colors (see Figure 23-2). The blue and gray are for ultrasonic instrumentation, and the purple is used to set the Prophy mode cycle for air polishing.

Foot Pedal

Reproduced with permission from Dentsply Sirona

Dentsply Sirona APDs have an indicator on the device panel that displays the battery level of the foot pedal. The foot pedal is also equipped with Tap-On technology while using the auto-cycle prophy mode. Tap-On technology eliminates the need to hold the pedal down while in active use. This allows the provider to relax their foot on the floor, which decreases strain on the leg, hips, and back. To activate Tap-On technology, the foot pedal is pressed halfway to the floor (first position) and quickly released. The device will stay active for 4 minutes and deliver the auto-cycle prophy mode selected by the user.

Table 23-1  Auto-Cycle Prophy Mode

Wireless Bluetooth Technology

Figure 23-18  Prophy mode cycle dial set to ‘Manual’

(Cavitron Prophy Jet Air Polishing System).

Cycle Name

Slurry Expulsion

Water Rinse

Short

0.75 second

1.25 seconds

Medium

2.0 seconds

1.0 second

Long

3.0 seconds

2.0 seconds

The pedal has wireless Bluetooth technology. The pedal must be synchronized with the device upon delivery. To synchronize: 1. Turn on the power to the device. The on button is located under the front of the unit (see Figure 23-19). 2. Stand within 10 feet of the unit.

Figure 23-19  Power button (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System). Reproduced with permission from Dentsply Sirona

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Chapter 23 Coronal to CEJ Air Polishing

Figure 23-21  Blue water line.

Figure 23-20  Blue purge button (Cavitron Jet Plus

Ultrasonic Scaling and Air Polishing System). Reproduced with permission from Dentsply Sirona

3. Press the Purge button (see Figure 23-20). 4. Graphics will blink for 5–6 seconds. During this time, on the bottom of the foot pedal, press and hold the red button for three seconds. 5. All graphics will blink at the same time upon successful synchronization.

Water

Dentsply Sirona APDs are connected to the water input on the dental unit. The waterline is blue (see Figure 23-21). Water is used continuously during active air polishing. A high water setting is used for air polishing to obtain a productive slurry consistency. Waterlines and filters (see Figure 23-22) must be maintained per the manufacturer’s recommendations to ensure patient safety (see Chapter 13 for water filter replacement frequency). One end of the waterline is connected to the back of the APD, and the other end is attached to the dental unit water input (see Figure 23-23a and b).

Water Control The water control is on the handpiece connector cord (see Figure 23-24). The flow rate selections are 1 through 6. The lowest water flow rate is 1, and the highest is 6. The handpiece connector cord rotates 330

Figure 23-22  Water filter on the water line.

degrees while in use to decrease the need for finger rest repositioning and to prevent coiling of the line.

Water Purge Dentsply Sirona APDs have an automatic purge (see Figure 23-20). To activate, press the Purge button once, and the waterline will automatically purge for 2  minutes. To deactivate the purge mid-cycle, press the Purge button again.

Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling

435

Air

A

Dentsply Sirona APDs are connected to the air input on the dental unit. The air line is black with a replaceable filter that should be checked periodically (see Figure 23-25 and Figure 23-26). Refer to the DFU/ IFU for replacement steps. A filter mounting bracket is used to hang the air filter in a downward position to allow for moisture separation and drainage of water from the filter. One end of the air line is connected to the back of the APD, and the other end is attached to the dental unit air input (see Figure 23-27a and b). Water and air line connectors on a dental unit are typically near one another. Use care to ensure the water and air lines are connected to their correct inputs on the dental unit. Mixing up the cords could result in significant, and sometimes irreversible, damage to the equipment.

Nozzle

B Figure 23-23  Water connection: A. Waterline connected

to the back of the APD, B. Waterline connected to the dental unit.

A

The Cavitron Jet Air Polishing Insert is the name of the air polishing insert with an affixed nozzle manufactured by Dentsply Sirona. The insert is a silver color with a green O-ring that is placed into the handpiece. The opening on the insert expels the slurry. The Cavitron Jet Air Polishing Insert is sterilized after each patient use. There are markings on the air polishing insert with the company’s name and date of creation. There are four parts to the Cavitron Jet Air Polishing Insert, as seen in Figure 23-28.

B

C

Figure 23-24  Water control: A. Handpiece connector (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System),

B. Handpiece connected to the handpiece connector (Jet-Mate Sterilizable, Detachable Handpiece), C. Water control numbers 1–6 on the handpiece connector. Reproduced with permission from Dentsply Sirona

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Chapter 23 Coronal to CEJ Air Polishing

A

Figure 23-25  Black air line.

B Figure 23-27  Air connection: A. Air line connected to

the back of the APD, B. Air (yellow), water (blue), and electric input on a dental unit.

Figure 23-26  Air filter on the black air line cord.

1. Heater rod: Long solid metal rod that heats the water for patient comfort. 2. Single green O-ring: Water seal to prevent leakage. The O-ring is a wear and tear item and should be replaced when worn. 3. Prophy powder delivery tube: Delivers the compressed air and powder mixture to the nozzle tube. 4. Nozzle tube: Terminal portion of the Cavitron Jet Air Polishing Insert with two concentric openings. The outer opening expels water, and the inner opening expels the compressed air and powder mixture (see Figure 23-29). The nozzle is slightly angled for ease of use.

Prophy powder delivery tube

Nozzle Tube

Heater Rod

O-Ring

Figure 23-28  Cavitron Jet Air Polishing Insert.

Cleaning Tool

The Cavitron Prophy Jet Nozzle Cleaning Tool is a sterilizable narrow solid metal wire with an affixed white holder used to dislodge residual powder in the

Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling

437

Inner circle: air/powder Outer circle: water

Figure 23-29  Nozzle tube openings. Inner opening

expels compressed air and powder. Outer opening expels water.

A

B

Figure 23-31  Cavitron Prophy Jet Nozzle Cleaning Tool

A. Cavitron Prophy Jet Nozzle Cleaning Tool inserted into the nozzle delivery tube of the Cavitron Jet Air Polishing Insert, B. Cavitron Prophy Jet Nozzle Cleaning Tool and Cavitron Jet Air Polishing Insert correctly bagged for reprocessing.

Figure 23-30  Cavitron Prophy Jet Nozzle Cleaning tool.

nozzle delivery tube of the Cavitron Jet Air Polishing Insert (see Figure 23-30). The steps for proper use are below:

• Remove the Cavitron Jet Air Polishing Insert from the Jet-Mate Sterilizable, Detachable Handpiece.

• Place the Cavitron Prophy Jet Nozzle Cleaning • •

Tool inside the nozzle delivery tube on the Cavitron Jet Air Polishing Insert. Slide the tool in and out until there is no resistance. The wire will pierce all the way through the nozzle delivery tube (see Figure 23-31a). Remove the Cavitron Prophy Jet Nozzle Cleaning Tool from the nozzle delivery tube and reprocess (see Figure 23-31b). If the Cavitron Prophy Jet Nozzle Cleaning Tool is left in the delivery tube, sterility cannot be guaranteed.

Handpiece

The Jet-Mate Sterilizable, Detachable Handpiece is the name of the air polishing handpiece manufactured

Figure 23-32  Dentsply Sirona Jet-Mate Sterilizable,

Detachable Handpiece and Soft Nozzle Grip. Reproduced with permission from Dentsply Sirona

by Dentsply Sirona. The handpiece has a detachable soft nozzle grip. The soft nozzle grip is a wear and tear item that will need periodic replacement (see  Figure 23-32).There are two port hole openings on the soft nozzle grip, the powder delivery port and the insert port (see Figure 23-33).

• Powder delivery port: Smaller opening on the soft

nozzle grip. The prophy powder delivery tube on the Cavitron Jet Air Polishing Insert is placed in this port, which has an airtight seal for slurry delivery.

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Chapter 23 Coronal to CEJ Air Polishing

Figure 23-34  Cavitron Prophy Jet Handpiece Cleaning

Tool placed inside the powder delivery port on the Jet-Mate Sterilizable, Detachable Handpiece Reproduced with permission from Dentsply Sirona

Figure 23-33  Soft nozzle grip powder delivery (smaller

opening) and insert port (larger opening).

• Insert

port: Larger opening on the soft nozzle grip.The heater rod on the Cavitron Jet Air Polishing Insert is placed in this port.

Cleaning Tool

The Cavitron Prophy Jet Handpiece Cleaning Tool is a sterilizable narrow solid metal wire used to dislodge residual powder in the powder delivery port on the Jet-Mate Sterilizable, Detachable Handpiece. The steps for proper use are below:

• Remove the Cavitron Jet Air Polishing Insert from • • •

the Jet-Mate Sterilizable, Detachable Handpiece. Place the Cavitron Prophy Jet Handpiece Cleaning Tool inside the powder delivery port on the Jet-Mate Sterilizable, Detachable Handpiece (see Figure 23-34). Slide the tool in and out until there is no resistance. Remove the Cavitron Prophy Jet Handpiece Cleaning Tool from the powder delivery port and reprocess. If the Cavitron Prophy Jet Handpiece Cleaning Tool is left in the powder delivery port, sterility cannot be guaranteed.

Jet-Mate Sterilizable, Detachable Handpiece and Cavitron Jet Air Polishing Insert Assembly 1. Align the electrical connections of the Jet-Mate Sterilizable, Detachable Handpiece and the

Figure 23-35  Handpiece connector (left) and Jet-Mate

Sterilizable, Detachable Handpiece (right). Reproduced with permission from Dentsply Sirona

handpiece connector cable and gently attach them (see Figure 23-35). 2. Hold the Jet-Mate Sterilizable, Detachable Handpiece upright over a sink, step on the pedal to fill with water, and allow trapped air to exit. Allow a dome of water to remain at the Jet-Mate Sterilizable, Detachable Handpiece opening (see Figure 23-36). 3. Lubricate the green O-ring of the Cavitron Jet Air Polishing Insert on the water dome by rotating the O-ring 360 degrees on the water (see Figure 23-37). 4. Place the Cavitron Jet Air Polishing Insert into the opening on the Jet-Mate Sterilizable, Detachable Handpiece, ensuring the heater rod is aligned with the larger insert port opening, and the prophy powder delivery tube is aligned with the powder delivery port (see Figure 23-38a and b).

Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling

Figure 23-36  Jet-Mate Sterilizable, Detachable

Handpiece with a dome of water.

A

439

B

Figure 23-38  Jet-Mate Sterilizable, Detachable

Handpiece and Cavitron Jet Air Polishing Insert: A. Heater rod placed into the insert port opening and prophy powder delivery tube aligned with the powder delivery port, B. Prophy powder delivery tube placed into the powder delivery port.

Figure 23-37  O-ring lubrication on the Cavitron Jet Air

Polishing Insert.

5. Ensure that the O-ring is fully seated. Do not twist the nozzle in the handpiece to assist with O-ring seating (see Figure 23-29a and b). Use a firm straight push motion.

A

B

Figure 23-39  Jet-Mate Sterilizable, Detachable

Handpiece and Cavitron Jet Air Polishing Insert: A. O-ring not fully seated, B. O-ring fully seated.

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Chapter 23 Coronal to CEJ Air Polishing

Jet-Mate Sterilizable, Detachable Handpiece and Cavitron Jet Air Polishing Insert Removal Steps 1. Remove the Cavitron Jet Air Polishing Insert from the Jet-Mate Sterilizable, Detachable Handpiece. 2. Use the Cavitron Prophy Jet Nozzle Cleaning Tool and the Cavitron Prophy Jet Handpiece Cleaning Tool to dislodge residual powder. Remove both cleaning tools.. 3. Use a gentle straight pull motion to remove the Jet-Mate Sterilizable, Detachable Handpiece from the handpiece connector cable. Do not twist the handpiece to prevent damage to the electrical connections. 4. Follow automatic and manual cleaning directions, as well as sterilization protocols in the product’s instruction for use (IFU).

Reprocessing Always use aseptic techniques during reprocessing that includes full personal protective equipment (PPE) and utility gloves when handling contaminated equipment to avoid cross-contamination and operator injury.

Air Polishing Device

The power cord, air line, waterline, handpiece cable, foot pedal and cord, and the device itself is not sterilizable. Remove powder from all fixtures with a disposable soft nonabrasive cloth prior to using a manufacturer-approved disinfectant, which you can find in the product’s IFU. Do not spray disinfectant solutions directly on APD system surfaces. Use a ­manufacturer-approved chemical wipe with correct contact time. Keep APDs away from direct sunlight to prevent discoloration.

Clinical Technique 1. Use the lowest powder velocity flow rate possible to achieve the clinical goal. 2. Position the nozzle 2–4 mm away from the middle of the tooth surface (see Figure 23-40).The nozzle should never directly contact tooth surfaces during air polishing. Placing the nozzle closer than 2–4 mm can cause over-abrasion. Placing the nozzle farther away than 2–4 mm decreases effectiveness and can cause under-abrasion. 3. Expose each tooth surface to 1–2 seconds of the slurry mixture. Use the shortest contact time required to achieve the clinical goal. Move the nozzle in small, circular, continuous, fluid overlapping motions as the slurry is expelled. 4. After 2–3 teeth have been exposed to the slurry, a rinse of equal length should be provided for improved patient comfort. Nozzle angulation varies by tooth surface.

• Smooth and interproximal surfaces

•

• Anterior teeth: 60-degree angulation of the nozzle to tooth surface (see Figure 23-41a and b). • Posterior teeth: 80-degree angulation of the nozzle to tooth surface angled slightly distally (see Figure 23-42a and b). Incisal and occlusal surfaces • 90-degree angulation of the nozzle to tooth surface (see Figure 23-43a and b).

Handpiece and Nozzle Insert

Remove the cleaning tools from the Jet-Mate Sterilizable, Detachable Handpiece and Cavitron Jet Air Polishing Insert. Automatic and manual cleaning directions as well as sterilization protocols are provided in the product’s IFU. The Jet-Mate Sterilizable, Detachable Handpiece, Cavitron Jet Air Polishing Insert, and cleaning tools should be completely dry before packaging for sterilization. Steam under pressure sterilization is recommended because cold liquid disinfection, chemical vapor, and dry heat sterilization have not been tested or validated for efficacy.

Figure 23-40  Nozzle 2–4 mm from the tooth surface of

the mandibular right first molar facial.

Clinical Technique

A

441

B

Figure 23-41  Anterior nozzle angulation on the maxillary left central incisor facial surface: A. Incorrect 90-degree

angulation, B. Correct 60-degree angulation.

B

A

Figure 23-42  Posterior nozzle angulation on the mandibular right first molar buccal surface: A. Incorrect 90-degree

angulation, B. Correct 80-degree angulation.

A

B

C

Figure 23-43  Occlusal and Incisal air polishing: A. 90-degree nozzle angulation to the occlusal of the mandibular right

first molar, B. Staining on the occlusal of a premolar that can be air polished with a 90-degree anuglation, C. Staining on the incisal of maxillary anterior teeth that can be air polished with a 90-degree anuglation.

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Chapter 23 Coronal to CEJ Air Polishing

CASE STUDY

Your patient is a 58-year-old Indian male with a noncontributory medical history. The patient is not taking any over-the-counter or prescription medications and has no drug allergies. Body Mass Index (BMI) is 25. His chief complaint is “I don’t like the color of my teeth.” Dental exam: Patient had orthodontics in the past and lost the mandibular left second molar a few years ago due to a failed root canal. The dentist recommended a dental implant for the edentulous space. The maxillary left third molar is treatment planned for extraction due to decay. Occlusion: Class I bilateral with first molar relationship. Overbite of 6 mm. Mandibular anterior crowding. Oral hygiene exam: ■ ■ ■ ■

Disclosing solution revealed 95% of surfaces with biofilm and dental calculus. Generalized heavy biofilm. Generalized moderate supragingival dental calculus on smooth surfaces. Generalized light to moderate interproximal dental calculus. Generalized moderate to heavy staining.

Periodontal exam: ■ ■

Probe depths 3–6 mm generally with bleeding upon probing 37% of the mouth. Localized 7 mm probe depth on the maxillary left wisdom tooth mesial-lingual surface. This tooth has significant mesial decay. Localized recession and furcation involvement on molars Class I and II.

Mandibular right anterior lingual surfaces

Mandibular anterior lingual surfaces

Mandibular anterior and premolar lingual surfaces

Mandibular left anterior lingual surfaces

Clinical Technique

Maxillary right anterior lingual surfaces

Maxillary left anterior lingual surfaces

First premolar occlusal.

Second premolar occlusal.

First molar occlusal.

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Chapter 23 Coronal to CEJ Air Polishing

Periodontal charting.

Full-mouth series radiographs. 1. Can air polishing remove the dental calculus pictured on the mandibular anterior lingual surfaces? Why or why not? 2. What nozzle angulation, distance, and powder velocity flow rate would you use to remove the stain seen on the molar and premolar teeth? 3. What nozzle angulation, distance, and powder velocity flow rate would you use to remove the stain seen on the maxillary and mandibular anterior lingual and interproximal surfaces? 4. What air polishing powder should be used for this patient with a Dentsply Sirona APD and why?

Questions

Summary

Air polishing with a Dentsply Sirona APD is a safe an effective procedure for the removal and reduction of biofilm, immature dental cal­culus, and extrinsic exogeneous staining. There are two powder options of sodium bicarbonate and aluminum trihydroxide. The Cavitron Jet Air Polishing Insert; Cavitron Prophy Jet Nozzle Cleaning Tool; Jet-Mate Sterilizable,

Questions

445

Detachable Handpiece; and Cavitron Prophy Jet Handpiece Cleaning Tool should be sterilized after each patient use. The clinical technique and nozzle angulation vary by tooth surface. A step-by-step hands-on exercise with a Dentsply Sirona APD is presented in Chapter 25.

1. True or False. Dentsply Sirona manufactures a stand-alone and dual functionality APD. a. True b. False

6. True or False. When delivering air polishing, a water rinse is not needed. a. True b. False

2. Which of the following powders are manufactured by Dentsply Sirona and compatible with their APDs? a. Cavitron Prophy Jet Prophy Powder b. Cavitron Jet Fresh Prophy Powder c. Glycine d. Both A and B

7. Which auto-cycle Prophy mode dispenses the slurry for 2 seconds and then provides a 1-second water rinse? a. Short b. Medium c. Long

3. How do you change the powder flow velocity from low to medium? a. Turn the dial on the handpiece connector. b. Turn the powder flow control dial on the powder bowl cap. c. Turn the Prophy mode cycle dial. d. The powder flow velocity cannot be changed. 4. What powder flow velocity is used infrequently and only for the removal of exceptionally heavy and difficult to remove stains such as beetle nut staining or heavy tobacco stain? a. Low b. Medium c. High d. All of the above 5. Which of the following is TRUE? a. Powder in the powder bowl does not need to be emptied at the end of a workday. b. The powder bowl is filled with powder to completely submerge the inner tube. c. The provider can tell the device is pressurized when a small white circle of powder can be seen in the window of the powder flow control dial. d. When the APD is turned off, it will immediately depressurize, and the powder bowl cap can be easily removed.

8. How are a water lavage rinse and the auto-cycles activated in a Dentsply Sirona APD? a. Press the pedal all the way to the floor. b. Activate Boost mode. c. Press the pedal halfway to the floor. 9. How long will water dispense from the waterline when the automatic purge is activated in a Dentsply Sirona APD? a. 1 minute b. 2 minutes c. 3 minutes d. 4 minutes 10. Which of the following is FALSE? a. The Cavitron Prophy Jet Handpiece Cleaning Tool and Cavitron Prophy Jet Nozzle Cleaning Tool are used to dislodge residual powder. b. The Cavitron Prophy Jet Handpiece Cleaning Tool and Cavitron Prophy Jet Nozzle Cleaning Tool are left inside the nozzle and handpiece during sterilization. c. The prophy powder delivery tube is inserted into the powder delivery port of the Jet-Mate Sterilizable, Detachable Handpiece. d. The nozzle heater rod is placed into the insert port of the Jet-Mate Sterilizable, Detachable Handpiece.

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Chapter 23 Coronal to CEJ Air Polishing

11. How far away should the nozzle be from the surface of a tooth? a. 2–4 mm b. 5–6 mm c. 7–8 mm d. 9–10 mm

Match the following tooth surface to the correct nozzle angulation for questions 12–14. There is only one correct answer for each question. 12. Anterior

A. 80 degrees

13. Posterior

B. 90 degrees

14. Occlusal

C. 60 degrees

CHAPTER 24

Coronal and Apical to CEJ Air Polishing LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Recognize the benefits of subgingival air polishing during periodontal debridement. 2. Identify EMS air polishing devices, parts, and accessories. 3. Identify EMS powder selections and their clinical indications, applications, and considerations. 4. Use an EMS air polishing device with proper powder velocity settings, water flow rate, and nozzle angulations. 5. Implement EMS Guided Biofilm Therapy (GBT) in clinical practice.

KEY TERMS

• •

AIRFLOW Classic powder: the name of sodium bicarbonate powder manufactured by EMS. AIRFLOW Handpiece: the name of the air polishing handpiece that delivers the slurry mixture supragingival and in shallow (4 mm) periodontal pockets; manufactured by EMS.

Introduction Subgingival air polishing is a safe and efficient method to remove and reduce plaque biofilm, the etiological agent of gingival, periodontal, and peri-implant diseases. The powders delivered subgingivally are glycine and erythritol. These powders have a low particle size and Mohs hardness, as discussed in Chapter 22. Literature commonly refers to the clinical procedures performed with glycine and erythritol as glycine powder air polishing (GPAP) and erythritol powder air polishing (EPAP). The literature presented in this chapter will show glycine and erythritol have been proven safe for use on less mineralized hard tissues such as dentin and cementum without causing harmful effects. Subgingival slurry penetration with EMS technology is possible with a standard and subgingival nozzle. There are multiple manufacturers of air polishing technology; this chapter will focus on two EMS devices because covering every manufacturer of APD technology would be too lengthy for this book. Guided Biofilm Therapy (GBT) is a unique proprietary multi-step program created by EMS for preventive non-surgical procedures that combines disclosing solution, air polishing for biofilm reduction subgingivally and supragingivally, and piezoelectric ultrasonic instrumentation.This chapter will present GBT with the AIRFLOW Prophylaxis Master.

Subgingival Air Polishing in Periodontal Debridement As discussed previously, the clinical objective of periodontal debridement is to remove the etiological agents of periodontal infections while conserving healthy enamel, dentin, and cementum by using the least aggressive instrumentation to achieve this goal. Oral health-care providers perform supragingival and

subgingival instrumentation with hand-activated instruments, ultrasonic instruments, and air polishing devices to reduce biofilm levels to promote a symbiotic oral environment. Subgingival air polishing has been investigated in the literature for its clinical outcomes, safety of ­delivery, and microbiological effects. There is a growing body of evidence showing comparable overall clinical outcomes for periodontal debridement with hand-activated and ultrasonic instrumentation with and without the adjunctive use of subgingival air polishing. However, the evidence does show differences in the delivery of care, alterations and effects to hard  and soft tissues, and microbiological changes when s­ ubgingival air polishing is used during debridement.

Overall Clinical Outcomes

• Subgingival

•

•

air polishing is used in conjunction with either hand-activated or ultrasonic instrumentation when firmly established dental calculus deposits are present because the slurry mixture will not remove firmly established calculus deposits. Air polishing will remove all levels of biofilm and immature or early forming dental calculus. Studies have shown similar treatment outcomes when air polishing is used during nonsurgical periodontal debridement along with hand-activated or ultrasonic instrumentation in shallow and deep periodontal pockets (Buhler et al., 2015; Cosgarea et al., 2021; Hagi et al., 2015; Kargas et al., 2015; Mensi et al., 2021; Moene et  al., 2010; Muller et al., 2014; Ng, 2018; Park et al., 2018; Sculean et al., 2013). Ultrasonic instrumentation, GPAP, and EPAP reduce plaque biofilm and gingival inflammation similarly, but the ultrasonic can simultaneously remove firmly established dental calculus, while GPAP and EPAP cannot (Sculean et al., 2013). A  randomized controlled trial by Muller et al. (2014) evaluated the reduction in probe depths over 4  mm in periodontal maintenance patients over a 12-month period between participants who received ultrasonic instrumentation only and a group that received ultrasonic instrumentation followed by subgingival air polishing with erythritol 0.3% chlorhexidine. Both groups demonstrated comparable results in reduction of probe depths over 4  mm when patients received each treatment at 3-, 6-, and 9-month intervals (Muller et al., 2014).

EMS Air Polishing Powders

Delivery of Care

• Subgingival air polishing is safe for hard and soft •

•

tissues if used as directed by the manufacturer (Moene et al., 2010; Sculean et al., 2013; ­Flemmig et al., 2007, 2012; Petersilka et al., 2008). Time efficiency of biofilm reduction subgingivally is improved with air polishing when compared to hand-activated instrumentation, with studies reporting three to five times faster biofilm removal (Moene et al., 2010; Sculean et al., 2013; Flemmig et al., 2012; Wennstrom et al., 2011). Studies report that patient comfort during biofilm reduction is improved with subgingival air polishing compared to other forms of instrumentation (Moene et al., 2010; Muller et al., 2014; Sculean et al., 2013; Petersilka et al., 2008; Wennstrom et al., 2011; Petersilka, 2000).

Hard and Soft Tissue Effects

• Studies have shown glycine and erythritol p­ owder

•

do not have harmful effects on cementum and dentin and cause less alterations to root structures and dental materials than other powders ­(Flemmig et al., 2012; Petersilka, 2000; Pelka et al., 2010; Petersilka et al., 2003). Erythritol and glycine powders cause less epithelial damage and erosions to soft tissues during biofilm removal compared to hand-­ activated instrumentation (Petersilka et al., 2008; Flemmig et  al., 2012; Petersilka, 2000). Although epithelial tissue damage will heal on its own uneventfully within 6 days after the injury, these findings show GPAP and EPAP improve patient comfort and decrease post-­procedure discomfort (Flemmig et  al., 2007; Kozlovsky et  al., 2005). A recent systematic review by Buehler et al. (2015) found air polishing caused similar effects on root roughness as ultrasonic instrumentation. Hand-activated instrumentation caused significantly higher root roughening than both ultrasonic and air polishing forms of instrumentation.

Microbiological

• Subgingival

air polishing reduces biofilm levels in shallow (1–3 mm) and deep (≥4 mm) periodontal pockets significantly more com­ pared to hand-­ activated instrumentation (Sculean et al., 2013; Flemmig et al., 2007, ­ 2012; Petersilka, 2000).

449

• When subgingival air polishing is used in con-

junction with hand-activated instrumentation, Porphyromonas gingivalis levels are reduced significantly more compared to hand scaling only (Park et al., 2018; Flemmig et al., 2012; Hashino et al., 2013). Other periodontal pathogens such as T. forsythia, C. rectus, E. corrodens, F. nucleatum, P. intermedia, and T. ­denticola investigated in the literature did not have the same levels of reduction as P.  ­gingivalis (Park et al., 2018; Flemmig et al., 2012; Hashino et al., 2013). An in vitro study published in 2014 by Drago et al. (2014), tested Staphylococcus aureus, Bacteroides fragilis, and Candida albicans susceptibility to glycine and erythritol with 0.3% chlorhexidine. Both powders had an inhibitory effect by decreasing the number of surviving cells of all three strains. Glycine was less effective against Staphylococcus aureus than Bacteroides fragilis and Candida albicans. Erythritol was more effective than glycine on all three strains (Drago et al., 2014).

EMS Air Polishing Devices EMS manufactures three different air polishing systems: 1. Single stand-alone APD called the the AIRFLOW One (see Figure 24-1a). This is ideal for offices that already have an ultrasonic device and only need to purchase an air polisher. 2. Dual functionality device as a piezoelectric ultrasonic scaler and APD called the AIRFLOW ­Prophylaxis Master (see Figure 24-1b). 3. Portable handheld APD called the AIRFLOW Handy (see Figure 24-1c). There is a specific air and water pressure psi (pound force per square inch) required for each device, which you can find in the product’s direction for use or instruction for use (DFU/IFU).

EMS Air Polishing Powders EMS began selling AIRFLOW in 1982 for supragingival air polishing. Currently, EMS manufactures three different powders called the AIRFLOW ­Classic ­powder, AIRFLOW Perio powder, and the AIRFLOW Plus powder (see Table 24-1 and Figure 24-2a and b). In 2003, the PERIOFLOW handpiece was developed to deliver AIRFLOW Perio powder (glycine) into deeper (>4 mm) periodontal pockets.

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Chapter 24 Coronal and Apical to CEJ Air Polishing

B A

C Figure 24-1  EMS devices: A. AIRFLOW One, B. AIRFLOW Prophylaxis Master, C. AIRFLOW Handy 3.0 Perio. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Table 24-1  EMS Powders Powder

EMS Name

Particle Size

Sodium AIRFLOW Classic Powder 40 µm bicarbonate Glycine

AIRFLOW Perio Powder

25 µm

Erythritol

AIRFLOW Plus Powder

14 µm

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

In 2012, EMS added AIRFLOW Plus powder (erythritol). Today, both the AIRFLOW Perio Powder ­(glycine) and AIRFLOW Plus Powder (erythritol) are delivered both supragingivally and subgingivally. AIRFLOW Classic Powder (sodium bicarbonate) is only delivered coronal to the CEJ owing to its larger particle size and Mohs hardness. Never use another manufacturer’s powder in an EMS APD because this can cause equipment damage and possibly void the warranty.

EMS AIRFLOW One and AIRFLOW Prophylaxis Master

A

B

Figure 24-2  EMS powder bottles: A. AIRFLOW Plus powder, B. AIRFLOW

Classic powder.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

EMS AIRFLOW One and AIRFLOW Prophylaxis Master This section will cover the powder chambers, changeable powder velocity settings, and water and air requirements for the AIRFLOW One and AIRFLOW Prophylaxis Master.

Powder Chambers

A powder chamber is provided for each powder type and has a color-coded lid. The correct powder must be placed in its correct powder chamber to avoid equipment damage.

• Gray: •

AIRFLOW Classic powder (sodium ­icarbonate) is placed into the gray chamber. b This powder is delivered coronal to the CEJ (see Figure 24-3). Red: AIRFLOW Perio powder (glycine) or AIRFLOW Plus powder (erythritol) is placed into the red chamber. These powders are delivered coronal and apical to the CEJ (see Figure 24-4).

The powder chambers are equipped with an integ­ rated dynamic pressure regulator that automatically

Figure 24-3  Gray powder chamber (EMS AIRFLOW

Prophylaxis Master).

451

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Chapter 24 Coronal and Apical to CEJ Air Polishing

Figure 24-5  EMS AIRFLOW Prophylaxis Master on/off Figure 24-4  Red powder chamber (EMS AIRFLOW

Prophylaxis Master).

sets the optimal pressure range based on the powder velocity setting for each powder chamber. To fill the powder chamber: 1. With the device off, remove the powder chamber from its magnetic connection to the APD (see Figure 24-5). 2. Shake the powder bottle to break up clumps. 3. Pour the powder into its corresponding powder chamber. Do not fill past the max fill line indicated on the powder chamber (see Figure 24-3 and Figure 24-4). 4. Close the lid tightly on the powder bottle to prevent moisture contamination. 5. Place the powder chamber into its holder on the APD. Ensure that the magnetic connection is secure. 6. Turn the device on (see Figure 24-5). 7. Press the dynamic pressurization button (see Figure 24-6a).A white light will illuminate when the powder chamber is turned on and pressurized (see Figure 24-6b). If the device is not used for 1 hour, the unit will go into off-mode standby where the powder chamber automatically depressurizes and the white light turns off. To empty the powder bowl: 1. Turn the APD off. 2. Allow the powder chamber to fully depressurize. Ensure that the handpiece is not facing

control.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

upward or toward you to avoid injury from the spraying of purged air and residual powder (see Figure 24-7a). 3. Remove the powder chamber from its magnetic holder without twisting or rotating the chamber (see Figure 24-7b). 4. Discard all unused powder from the powder chamber in the trash. 5. Clean the connections with compressed air from the A/W syringe and place on a dry surface.

Powder Velocity Control

Powder velocity control settings are 0 through 10. Zero will deliver water only, and 10 delivers maximum air pressure output. The powder velocity is changed by sliding your finger on the groove panel below the number (see Figure 24-8). The air pressure increases incrementally from 1 through 10. The gray powder chamber with AIRFLOW Classic powder (sodium bicarbonate) will output a higher dynamic air pressure at all power settings than the red powder chamber with AIRFLOW Perio powder (glycine) or AIRFLOW Plus powder (erythritol). Sodium bicarbonate is used for heavier, more tenacious stains coronal to the CEJ, and a higher air pressure is needed for removal. Glycine and erythritol are used coronal and apical to the CEJ. A lower

EMS AIRFLOW One and AIRFLOW Prophylaxis Master

A

B

Figure 24-6  Dynamic pressure regulator (EMS AIRFLOW Prophylaxis Master): A. Dynamic pressure

regulator control, B. Illuminated powder chamber. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A

B

Figure 24-7  EMS AIRFLOW handpiece and powder chamber: A. EMS AIRFLOW MAX handpiece

nozzle pointed downward, B. Removal of the powder chamber. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

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Chapter 24 Coronal and Apical to CEJ Air Polishing

air pressure is desired when delivering a slurry mixture on less mineralized hard tissues such as dentin and cementum (see Table 24-2).

air pressure incremental to the powder velocity setting (see Table 24-3).

Water

Foot Pedal

A continuous water flow rate is needed anytime the APD is in use. A high water flow rate is used to obtain a productive slurry consistency and to avoid expulsion of a cloud of powder into the air. Waterlines and filters must be maintained per the manufacturer’s recommendations to ensure patient safety. Refer to the DFU/IFU for details. Some models allow for a change in water temperature.

The AIRFLOW One and AIRFLOW Prophylaxis Master have a wireless foot pedal with Bluetooth technology (see Figure 24-9). The foot pedal is synched to the device by the manufacturer. There is no need for synchronization prior to use. The foot pedal is pressed on the outer side with a light pressure. If the middle of the pedal is pressed all the way to the floor, the device will activate Boost mode (see the next section). When the foot pedal is released, there is a 0.2-second delay in the slurry stopping. Be sure to keep the nozzle in the patient’s mouth during this time to avoid splashing.

Water Control The water control is a black spindle located next to the handpiece holder with options 1 through 10 (see Figure 24-10).

Boost Mode. Boost mode is controlled by the foot pedal. When activated, Boost mode will increase the

Boost: press in middle and all way to floor

Non-Boost: press lightly on side

Figure 24-9  EMS AIRFLOW One and AIRFLOW

Prophylaxis Master foot pedal. Boost: press middle of pedal to floor. Non-boost: press pedal lightly on the side

Figure 24-8  Powder velocity control (EMS AIRFLOW

Prophylaxis Master).

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Table 24-2  Dynamic Air Pressure by Powder Chamber Power Setting

0

1

2

3

4

5

6

7

8

9

10

Classic Powder

Water only

1.9

2.1

2.3

2.6

2.8

3.0

3.2

3.5

3.7

3.9

Perio and Plus Powders

Water only

1.5

1.7

1.9

2.0

2.2

2.4

2.6

2.7

2.9

3.1

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Table 24-3  EMS AIRFLOW One and AIRFLOW Prophylaxis Master Boost Mode Power Setting

0

1

2

3

4

5

6

7

8

9

10

Boost

0

6

7

8

8

8

9

10

10

10

10

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

EMS AIRFLOW One and AIRFLOW Prophylaxis Master

455

A

Figure 24-10  Water control spindle (EMS AIRFLOW MAX

handpiece)

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Water Temperature The water temperature can be adjusted to improve patient comfort. The AIRFLOW One and AIRFLOW Prophylaxis Master are preset to 40°C/104oF by default. A higher water temperature may be desired for air polishing, especially on less mineralized hard tissues such as cementum and dentin that are more responsive to temperature fluctuations. To change the water temperature: 1. Press and hold 0 and 10 at the same time (see Figure 24-11a). 2. The numbers will illuminate with varied colors. Use numbers 0–4 to change the water temperature (see Figure 24-11b). Numbers 6–10 will change the sound the machine emits. • 0: no heat • 1: 25°C/77oF • 2: 30°C/86oF • 3: 35°C/95oF • 4: 40°C/104oF (default) 3. Press the On/Off button to save your setting.

Water Bottles The APDs have an independent water bottle reservoir (see Figure 24-12a). Remove the bottle with a straight pull motion and replace it the same way (see

B Figure 24-11  Changing water temperature (EMS

AIRFLOW Prophylaxis Master): A. Press and hold 1 and 10 at the same time, B. Illuminated colors on numbers. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 24-12b). The water bottle has an O-ring at the bottom that will need to be replaced when worn (see Figure 24-13). Anytime the water bottle is removed for long periods of time, place the CLIP+CLEAN tool into the device’s independent water bottle receptacle for dust protection. See Chapter 17 for details if needed. Regular cleaning of the waterline is required to prevent biofilm accumulation. Refer to the DFU/IFU for approved cleaners. In addition to daily cleaning, the waterlines should be treated once a week with the specialized Night Cleaner. At the time of this book publication, Night Cleaner is not approved for use in the United States. EMS recommends other products for waterline maintenance. Contact EMS for any questions. The cleaner is a solution with a combination of chemicals (ethylenediaminetetraacetate, p-­ hydroxybenzoic acid

456

Chapter 24 Coronal and Apical to CEJ Air Polishing

A

Figure 24-13  Red O-ring on water bottle. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 24-14  EMS AIRFLOW Night Cleaner bottle (blue)

B Figure 24-12  Independent water bottle reservoir:

A. Water bottle, B. AIRFLOW Prophylaxis Master water bottle receptacle. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

ester, polyhexamethylenebiguanide; see Figure 24-14). Night Cleaner is bactericidal and fungicidal and prevents lime and algae formation in the line. It contains

and product.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

a source of phenylalanine, which fights biofilm accumulation in lines.

• Night

Cleaner is placed in the blue Nighttime cleaner bottle (see Figure 24-15 and Figure 24-16). Fill the Nighttime bottle with the Night Cleaner solution to the fill line.

EMS AIRFLOW One and AIRFLOW Prophylaxis Master

457

Figure 24-16  Nighttime cleaner bottle label Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 24-15  Blue Nighttime cleaner bottle (EMS

AIRFLOW Prophylaxis Master).

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

• Set the water control spindle to 10. Run the en•

tire contents of the Nighttime cleaner bottle through  the line and leave it in place overnight (12 hours). The next morning, remove the Nighttime cleaner bottle and replace with a fully filled independent water reservoir bottle. Set the water control spindle to 10 and flush the line to clear the solution away.

Water Filter The APDs have a transparent water filter located on the bottom of the device next to the air filter (see Figure 24-17). The manufacturer recommends inspecting the water filter monthly. The water filter should be replaced three times a year. If the water filter needs replacement more than three times per year, the quality of the water should be evaluated.

Water Purge Purge the waterline for a minimum of 20 seconds at the start of the day, between patients, and at the

Figure 24-17  EMS AIRFLOW Prophylaxis Master air

(white) and water (blue) filters.

end of the day. To activate line purging with the AIRFLOW ONE, press the pedal and then release when complete. The AIRFLOW Prophylaxis Master has an automatic purge feature. Press the pedal once

458

Chapter 24 Coronal and Apical to CEJ Air Polishing

A

Figure 24-18  Automatic purge illuminated numbers

(EMS AIRFLOW Prophylaxis Master). Reproduced with permission from E.M.S. Electro Medical Systems S.A.

to activate automatic purge. The numbers above the groove panel will illuminate and de-illuminate over a 1-­minute purge countdown cycle (see Figure 24-18).

Air

An air line accompanies both APDs and is connected to the dental unit. A transparent air filter is located on the bottom of the device next to the water filter (see Figure 24-17). The manufacturer recommends monthly filter inspection. The air filter should be replaced annually or more frequently if the color darkens.

B Figure 24-19  AIRFLOW Handy 3.0: A. AIRFLOW Handy

3.0 Perio (pink powder chamber), B. AIRFLOW Handy 3.0 Classic (blue powder chamber). Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Powder chamber

Powder chamber cap

EMS AIRFLOW Handy 3.0 EMS has been manufacturing portable handheld APDs since 1995. The latest release is the AIRFLOW Handy 3.0 that connects to the air turbine attachment on a dental unit. Portable handheld APDs are designed for occasional and isolated use due to their smaller powder chambers. There are two AIRFLOW Handy 3.0 portable devices, each designed for a specific powder with individual air and water psi requirements. 1. AIRFLOW Handy 3.0 Perio: Pink powder chamber that accepts AIRFLOW Perio powder (­ glycine) and AIRFLOW Plus powder (­erythritol) (see Figure 24-19a). The AIRFLOW and ­PERIOFLOW handpiece attach to this device. Do not use ­AIRFLOW Classic powder (sodium bicarbonate) in this portable handheld APD. 2. AIRFLOW Handy 3.0 Classic: Blue powder chamber that accepts AIRFLOW Classic powder (sodium bicarbonate) (see Figure 24-19b). The AIRFLOW handpiece attaches to this device. The

Handpiece

Body

Cord adaptor

Figure 24-20  AIRFLOW Handy 3.0 anatomy. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

PERIOFLOW handpiece is not used because sodium bicarbonate is not delivered subgingivally into periodontal pockets. Do not use AIRFLOW Perio powder (glycine) or AIRFLOW Plus powder (erythritol) in this portable handheld APD.

Body

The body of the AIRFLOW Handy 3.0 houses the powder chamber and its inner tube (see Figure 24-20).

EMS AIRFLOW Handy 3.0

459

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

The provider grasps the body while in use. The body is balanced and designed to rest securely in the webbing between the thumb and index finger (see Figure 24-21). At its base, the body has a cord adaptor that is securely connected to the dental unit air turbine connector (see Figure 24-20 and Figure 24-22a to d). There are O-rings on the turbine connector on the dental unit that need to be well maintained and replaced when worn to avoid air leakage during air polishing. It is best to adjust the psi and water flow rate of the dental unit air turbine connector prior to attaching the AIRFLOW Handy 3.0. All parts of the AIRFLOW Handy 3.0 and the air turbine connector must be dry and free of moisture to avoid clumping of powder,

A

B

The body has a series of O-rings that allow for a secure connection to the handpiece and need periodic replacement when worn.

Figure 24-21  AIRFLOW Handy 3.0 grasp.

C

D

Figure 24-22  AIRFLOW Handy 3.0 Perio: A. Air turbine connector on left and AIRFLOW cord adaptor on the right (note

the black O-ring), B. Aligning connectors, C. Rotate air turbine connector until fully secure on the AIRFLOW cord adaptor, D. Attached AIRFLOW Handy 3.0 Perio to dental unit. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

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Chapter 24 Coronal and Apical to CEJ Air Polishing

blockage of the air/powder channels, and equipment damage.

Powder Chamber

The powder chamber of a portable handheld device is smaller than the powder chamber of a stand-alone APD. Because the powder chamber is small, the provider must closely monitor the level of powder throughout the procedure.

• Chapter 21 discussed the internal controls that

•

• •

regulate the amount of powder expelled by a portable APD, which is partially dependent on the amount of powder inside the chamber (Petersilka, 2000; Donnet et al., 2021). The powder velocity cannot be changed on a handheld portable APD. The provider cannot pair powder velocity with the level of oral deposits present. The portable handheld device will always deliver maximum powder velocity. When powder levels decrease in the chamber, the risk for inconsistent powder particle expulsion  ­increases (Petersilka, 2000; Donnet et al., 2021). When an inconsistent powder flow rate occurs, the APD’s mechanism of action changes and the risk for over-abrasion increases.

No o-ring

The power chamber has a cap with threads that align with the powder chamber threads. The cap has a ring that should be replaced annually as it is a wear and tear item (see Figure 24-23). To fill the powder bowl: 1. Turn off the master switch to the dental unit. 2. Check the O-rings on the air turbine connector cord and the AIRFLOW cord adaptor to ensure that they are in good condition (see Figure 24-24a and b).

Black o-ring

A

B Figure 24-23  AIRFLOW Handy 3.0 powder chamber cap

and ring.

Figure 24-24  O-rings: A. AIRFLOW Handy 3.0 Perio

black O-ring, B. Air turbine connector.

EMS AIRFLOW Handy 3.0

461

3. Blow compressed air with the A/W syringe into the air turbine connector on the dental unit and the cord adaptor on the AIRFLOW Handy 3.0 (see Figure 24-25a and b).

A Figure 24-26  Powder chamber cap removed

from the powder chamber on the AIRFLOW Handy 3.0 Perio.

B Figure 24-25  Delivering compressed air: A. Air turbine

connector, B. AIRFLOW Handy 3.0 Perio cord adaptor.

4. Remove the powder chamber cap on the powder chamber (see Figure 24-26). 5. Select the correct powder for the AIRFLOW Handy 3.0 being used. Be sure to pair the powder and AIRFLOW Handy 3.0 correctly because

using an incorrect powder can cause clogging and equipment damage, and may void the warranty. 6. Shake the powder bottle to break up clumps. Take the cap off and place the powder dispenser on the bottle (see Figure 24-27a to c). 7. Point the AIRFLOW Handy 3.0 downward (see Figure 24-28). 8. Connect the powder bottle dispenser with the powder chamber opening (see Figure 24-29a). Dispense powder into the chamber by pumping the dispenser lightly. Do not fill past the inner tube (see Figure 24-29b). 9. Remove the dispenser from the powder bottle and place the lid back on the bottle immediately to prevent moisture contamination and clumping. 10. With a soft disposable cloth, clear away residual powder on the threads of the powder chamber and cap (see Figure 24-30a and b). 11. Secure the powder chamber cap tightly on the powder chamber without stripping the threads. Do not shake the AIRFLOW Handy 3.0 once the cap is securely placed. This could cause powder to settle into the inner tube. 12. Turn the master switch of the dental unit on (see Figure 24-31a and b). Air should not be escaping from the AIRFLOW Handy 3.0 or from the cord adaptor attachment to the air turbine.

462

Chapter 24 Coronal and Apical to CEJ Air Polishing

A

B

C

Figure 24-27  Powder bottle and dispenser assembly: A. Powder bottle with cap on and dispenser to the right,

B. Powder bottle cap removed, C. Dispenser affixed to the powder bottle. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 24-28  AIRFLOW Handy 3.0 Perio without powder

chamber cap angled downward.

If this occurs, check the O-rings and reclean the threads to remove any residual powder contamination. The powder chamber cap has an O-ring that should be replaced periodically when it is worn. Ensure that attachments are secure and tightened correctly. To empty the powder bowl: 1. Turn the master switch to the dental unit off. The AIRFLOW Handy 3.0 will depressurize over a few

seconds. Do not attempt to remove the powder chamber cap during depressurization. 2. Remove the powder chamber cap carefully to avoid damaging the threads of the powder c­hamber or the powder chamber cap. Set the cap aside. 3. Discard all unused powder in the trash. Emptying the powder chamber will reduce moisture ­ absorption and prevent clogging (see Figure 24-32a and b). 4. Use an High volume evacuation (HVE) to remove residual powder from the chamber (see Figure 24-33). 5. Remove the cap ring without damaging the ring. Use an instrument without a sharp cutting edge such as a dull explorer (see Figure 24-34a). 6. Use a soft disposable cloth to remove residual powder from the cap ring and the threads of the powder chamber and powder chamber cap (see Figure 24-34b). 7. Clean the threads of the powder chamber and powder chamber cap with alcohol (ethanol, isopropanol) and then allow to dry completely. 8. Place the cap ring back into the cap. 9. Affix the powder chamber cap back onto the powder chamber for storage until the next use. This will keep the internal components of the body free from moisture contamination and dust.

EMS AIRFLOW Handy 3.0

A

B

Figure 24-29  Filling the powder chamber of the AIRFLOW Handy 3.0 Perio: A. Powder

bottle connected to the opening of the powder chamber, B. Powder in the powder chamber not filled past the inner tube. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A

B

Figure 24-30  Removal of residual powder from the AIRFLOW Handy 3.0 Perio:

A. Soft disposable cloth cleaning on the threads of the powder chamber, B. Soft disposable cloth on the threads of the powder chamber cap. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A

B

Figure 24-31  Example of a master switch on a dental unit: A. Master switch off, B. Master switch on.

463

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Chapter 24 Coronal and Apical to CEJ Air Polishing

Figure 24-33  Removal of residual powder in the powder

chamber with an HVE.

A

A

B Figure 24-34  Powder chamber cap: A. Cap ring

removed, B. Removal of residual powder on cap ring.

Foot Pedal

B Figure 24-32  Discarding unused powder: A. Emptying

unused powder in a receptacle, B. View of empty powder chamber.

The rheostat on the dental unit activates and deactivates the AIRFLOW Handy 3.0 (see Figure 24-35). When the rheostat is released, keep the nozzle in the patient’s mouth for a few seconds until depressurization has occurred to avoid splashing as there is a delay. Ensure that the HVE remains on during this time to control aerosols.

EMS Handpiece and Nozzles

465

A

B Figure 24-36  EMS handpieces: A. AIRFLOW handpiece,

B. AIRFLOW MAX handpiece.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 24-35  Rheostat.

EMS Handpiece and Nozzles EMS manufactures two classes of handpieces for the AIRFLOW One, AIRFLOW Prophylaxis Master, and the AIRFLOW Handy 3.0: 1. AIRFLOW Handpiece: There are two handpieces in this class. The AIRFLOW handpiece and the AIRFLOW MAX handpiece. This class of handpiece delivers supragingival and ­shallow (1–3 mm) subgingival air polishing (see Figure 24-36a and b). At the time of publication, EMS is no longer manufacturing the AIRFLOW handpiece. However, this book discusses the handpiece as institutions may still be using the equipment. 2. PERIOFLOW Handpiece: This class of handpiece delivers deep (>4 mm) subgingival air polishing (see Figure 24-37). Both classes of handpieces are made of a medical-grade resin body that is sterilized between patient use. All APDs have O-rings on the handpiece connector cord that will need to be replaced when worn (see Figure 24-38a and b). When attaching the handpiece to the handpiece connector cable, ensure that connectors align and use a gentle straight push motion to avoid damaging the parts

AIRFLOW Handpieces

Both AIRFLOW handpieces have an affixed nozzle with a 120-degree angulation for ease of use throughout

Figure 24-37  PERIOFLOW Handpiece. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A

B Figure 24-38  EMS O-rings on the handpiece connector

cord: A. Black O-rings on the AIRFLOW Prophylaxis Master, B. Black O-rings on the AIRFLOW Handy 3.0 Perio.

the mouth (see Figure 24-36a and b). The handpiece nozzle delivers the slurry both supragingivally and subgingivally in shallow pockets (1–3 mm). The end of the nozzle has two concentric openings. The outer opening expels water, and the inner opening expels the air and powder mixture (see Figure 24-39).

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Chapter 24 Coronal and Apical to CEJ Air Polishing

Inner opening: air/powder Outer opening: water

Figure 24-39  EMS AIRFLOW Max handpiece nozle.

Figure 24-40  EMS AIRFLOW MAX handpiece with

guided laminar AIRFLOW technology.

Both AIRFLOW handpieces deliver any powder manufactured by EMS. If using the AIRFLOW Handy 3.0 Classic with AIRFLOW Classic powder (sodium bicarbonate), the nozzle is not to be directed apical to the CEJ. The differences between the two handpieces are:

• The AIRFLOW MAX has a wider outlet, slimmer •

handpiece width diameter, and reduced noise and weight than the AIRFLOW handpiece. The AIRFLOW MAX has a patented hexagon design at the nozzle opening equipped with guided laminar AIRFLOW technology that improves the travel pattern of the powder and water. The slurry travels in a more organized fashion in straight paths instead of turbulent nonorganized paths (see Figure 24-40). This decreases powder and water from spraying in unwanted directions and minimizes aerosols.

AIRFLOW and AIRFLOW Max Handpiece Technique The AIRFLOW and AIRFLOW Max nozzle is placed 3–5 mm from the tooth surface, moving in constant overlapping circular movements as the slurry is expelled (see Figure 24-41). Each tooth surface will receive 5–10 seconds of slurry exposure to remove biofilm, stain, an dimmature dental calculus, depending on the amount of oral

Figure 24-41  AIRFLOW nozzle 3–5 mm from the tooth

surface.

deposits and the powder being used. Manufacturers recommend, and studies have confirmed, a 5- to 10-second, no more than 20-­second, slurry exposure per tooth is sufficient for complete biofilm and stain removal during GPAP and EPAP (Hagi et al., 2015; Flemmig et al., 2012; Petersilka, 2000; Kozlovsky et al., 2005; Karmakar & Kamath, 2017). The nozzle angulation depends on the powder being delivered.

EMS Handpiece and Nozzles

467

A

A

B Figure 24-43  Incisal/occlusal nozzle to surface

angulation: A. Incorrect 90-degree angulation, B. Correct 60-degree angulation.

• Incisal

and occlusal surfaces: 60-degree angulation of the nozzle to the tooth surface (see Figure 24-43a and b). This angulation is used for oral deposit removal in the pits, fissures, and grooves of anterior incisal and posterior occlusal surfaces such as seen in Figure 24-44.

B Figure 24-42  AIRFLOW Max nozzle angulation:

A. Coronal to the CEJ angulation, B. Apical to the CEJ angulation.

• AIRFLOW Classic (sodium bicarbonate) nozzle is •

angled coronal to the CEJ (see Figure 24-42a). AIRFLOW Perio (glycine) and Plus (erythritol) are angled coronal and apical of the CEJ (see Figure 24-42b).

The degree of nozzle angulation varies by tooth surface.

• Smooth surface and interproximal: 30- to 60-degree angulation between the nozzle and the tooth surface (see Figure 24-42a and b).

Powder Velocity and Water Setting The water flow rate is always set to 10 (100%) during air polishing. The powder velocity can be changed on the AIRFLOW One and the AIRFLOW Prophylaxis Master. The powder velocity control setting is selected based on the level of oral deposit and whether the slurry is being expelled supragingivally or subgingivally. Heavier oral deposits will require a higher setting, and lighter deposits will require a lower setting. The lowest powder velocity setting with the shortest contact time is used to achieve the goal of stain, biofilm, and immature dental calculus removal.

• Coronal to the CEJ: The powder velocity setting options are 3 through 10 (30–100%).

468

Chapter 24 Coronal and Apical to CEJ Air Polishing

A

A

B Figure 24-45  EMS PERIOFLOW subgingival nozzle:

A. Nozzle with no probe-like markings, B. Nozzle with probe-like markings.

Handy 3.0 Classic delivers sodium bicarbonate powder coronal to the CEJ, so a PERIOFLOW handpiece would not be used. B Figure 24-44  Oral deposits: A. Staining on the incisal of

maxillary anterior teeth, B. Staining on the occlusal of a premolar.

Subgingival Nozzle A detachable single-use subgingival nozzle is placed on the terminal portion of the PERIOFLOW handpiece (see Figure 24-45a and b and Figure 24-46a).

• The nozzle is disposed at the conclusion of a pa• Apical to the CEJ, around dental implants, and orthodontic brackets: The powder velocity setting options are 3 through 6 (30–60%).

PERIOFLOW Handpiece

The PERIOFLOW handpiece is compatible with the AIRFLOW One, AIRFLOW Prophylaxis Master, and the AIRFLOW Handy 3.0 Perio. The AIRFLOW

• • •

tient procedure or after 20 sites of debridement. The nozzle will access deeper periodontal pockets (>4 mm) (see Figure 24-46b). The newest nozzle is the third generation and is 25% slimmer with improved flexibility. There are two options for nozzle styles. One style is all white, and the other has probe-like markings of 3 mm, 5 mm, 7 mm, and 9 mm to assist the provider in recognizing how deep the nozzle has

EMS Handpiece and Nozzles

469

Figure 24-47  EMS PERIOFLOW subgingival nozzle

trilateral powder-outlet and apical water-only spray. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A

•

been inserted subgingivally (see Figure 24-45a and b and Figure 24-46b). A trilateral powder-outlet and apical water-only spray is expelled from the end of the subgingival nozzle (see Figure 24-47).

Subgingival Nozzle Placement and Removal from the Handpiece

• To place a disposable subgingival nozzle on the

•

B Figure 24-46  EMS PERIOFLOW handpiece:

A. PERIOFLOW handpiece with affixed single-use disposable subgingival nozzle, B. Subgingival nozzle on the maxillary right first molar root. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

PERIOFLOW handpiece, align the nozzle with the notches on the terminal portion of the handpiece and gently push on a hard surface to fully engage (see Figure 24-48a to c). Ensure that the nozzle is securely attached prior to use by gently pulling with your fingers. The nozzle is removed with the nozzle ­extractor that accompanies the handpiece. Do not remove the subgingival nozzle by pulling it off with your fingers to avoid stripping and damaging the handpiece. Line the extractor with the base of the nozzle and then gently push upward (see Figure 24-49a to c).

PERIOFLOW Nozzle Technique The subgingival nozzle is inserted into the periodontal pocket parallel to the long axis of the tooth with a similar orientation to a periodontal probe (see Figure 24-50a and b).

470

A

Chapter 24 Coronal and Apical to CEJ Air Polishing

B

C

Figure 24-48  EMS PERIOFLOW subgingival nozzle placement: A. Align the subgingival nozzle with the notch on the

PERIOFLOW handpiece, ensuring the closed section of the nozzle is at the top, B. Gently push the subgingival nozzle downward with your fingers, C. Gently push the top of the subgingival nozzle on a hard surface such as a countertop to secure the connection.

A

B

C

Figure 24-49  EMS PERIOFLOW subgingival nozzle removal: A. Align the nozzle extractor with the subgingival nozzle,

B. Push the nozzle extractor upward, C. Remove the subgingival nozzle with the nozzle extractor.

A

B

Figure 24-50  EMS PERIOFLOW handpiece subgingival nozzle insertion: A. Nozzle insertion on the mandibular left second

molar distal-buccal surface, B. Nozzle insertion on the mandibular left second molar distal surface.

Reprocessing

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4.35 mm 6.53 mm

Figure 24-52  Width of slurry exposure (Tastepe et al., 2017).

decreased cleaning ability. Simply increasing the water flow was not always enough to dissolve the excess powder (Tastepe et al., 2017).

Powder Velocity and Water Setting

• The water flow rate is always set to 10 (100%) • Figure 24-51  Subgingival nozzle inserted subgingivally

3 mm from the crest of the alveolar bone.

The nozzle is advanced subgingivally to the depth of the periodontal pocket and then retracted 2–3 mm.

• This will position the nozzle more than 3 mm •

• •

away from the crest of the alveolar bone, which EMS recommends (see Figure 24-51). Because the crest of the alveolar bone is 1–2 mm from the junctional epithelium, retracting the nozzle from the base of the pocket by 2–3 mm will ensure correct distance from the crest of the alveolar bone. Do not apply force as the nozzle is inserted subgingivally because this could injure the patient. Deliver the slurry into the pocket for a maximum of 5 seconds, making continuous slow vertical oscillations (up, down, rotational) along the pocket (Tastepe et al., 2017). It is not advised to keep the nozzle static once the slurry is being delivered in a periodontal pocket because cleaning efficiency decreases (Tastepe et al., 2017).

When using a subgingival nozzle, it is important the APD delivers a constant continuous air, powder, and water emission to avoid over-abrasion of less ­mineralized cemental surfaces (Donnet et al., 2021).

• If the air and powder emission is greater than the •

water emission, the cementum could be damaged or denuded. An in vitro study by Tastepe et al. (2017) found higher powder flow caused excessive powder accumulation on tooth and implant surfaces, which

•

with the PERIOFLOW handpiece. The powder velocity setting is selected based on the level of oral deposit in the periodontal pocket. Powder velocity settings 5 through 10 (50–100%) are used around natural teeth and dental implants. Tastepe et al. (2017) reported that higher air pressure in deeper periodontal pockets cleaned the surface area better than lower pressure. Higher pressures cleaned 6.53 mm width in pockets, and low pressure only dispersed to a width of 4.35 mm (see Figure 24-52). The study recommended using the device’s highest subgingival mode setting based on these findings ­(Tastepe et al., 2017).

Reprocessing Always use aseptic techniques during reprocessing that includes full Personal Protective Equipment (PPE) and utility gloves when handling contaminated equipment to avoid cross-contamination and operator injury.

Air Polishing Devices

The power cord; air lines; waterlines; handpiece cable; foot pedal; and the bodies of each of the ­ AIRFLOW Handy 3.0, AIRFLOW One, and ­AIRFLOW Prophylaxis Master devices themselves are not sterilizable. Remove powder from all fixtures with a disposable, soft nonabrasive cloth prior to using a manufacturer-approved disinfectant, which can be found in the product’s DFU/IFU. Do not spray disinfectant solutions directly on system surfaces. Use a manufacturer-approved disinfectant with correct contact time.

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Chapter 24 Coronal and Apical to CEJ Air Polishing

A

B

C

Figure 24-53  Easy Clean tool: A. Easy Clean tool being inserted into the handpiece, B. Easy Clean tool connected to

the handpiece, C. Area of connection with the disposable syringe. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Handpieces

Full manual and automatic cleaning and disinfecting instructions are found in the product’s DFU/IFU. The AIRFLOW and AIRFLOW MAX handpieces are to be cleaned with the Easy Clean tool provided by the manufacturer immediately after use.

• Place one opening of the Easy Clean tool in the • • •

handpiece (see Figure 24-53a and b). Then attach a disposable syringe filled with more than 2 ml of drinking water to the opposite end of the Easy Clean tool (see Figure 24-53c). Dispense the liquid from the disposable syringe through the central lumina of the handpiece for 20 seconds. Blow compressed air twice through both o­ penings of the handpiece to dry internal components.

The PERIOFLOW handpiece has specific manual and automatic cleaning instructions that are different than AIRFLOW handpieces and can be found in the product’s DFU/IFU. Never place handpieces into an ultrasonic bath. Automated-washer disinfector may be used. Ensure that the handpiece is free of visible stains. Handpieces and the Easy Clean tool should be completely dry before packaging for sterilization. Sterilize the handpiece and Easy Clean tool with steam under a pressure sterilizer. Once the maximum number of sterilization cycles has been reached, as stated in the DFU/IFU, the handpiece should be retired and replaced.

EMS Guided Biofilm Therapy (GBT) EMS has developed a proprietary eight-step program for preventive non-surgical procedures called Guided Biofilm Therapy (GBT). EMS states, “GBT consists of treatment protocols based on individual patient diagnosis and risk assessment in order to achieve optimal results. The treatment is provided in the ­ least invasive way, with the highest level of comfort, safety and efficiency” (EMS, 2022). The eight steps are presented next.

GBT Step 1: Assessment and infection control

The patient will pre-rinse with BacterX Pro ­mouthwash. The mouthrinse contains a combination of three chemicals: chlorhexidine digluconate 0.1%, cetylpyridinium chloride 0.05%, and sodium fluoride 0.01% (fluoride 0.0005%). See Chapter 2 for a review of pre-rinsing if needed. The provider will then complete all clinical assessments.

GBT Step 2: Disclose, and GBT Step 3: Motivate

Step 2 is to apply a two-tone dye on tooth surfaces to reveal biofilm presence. Making biofilm visible will  enhance patient education and oral-hygiene instructions. Disclosing can improve patient motivation

EMS Guided Biofilm Therapy (GBT)

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to maintain healthy oral behaviors. EMS lists the following benefits in applying the two-tone dye prior to debridement:

• Identify • • • • • •

hard and soft deposits to improve efficiency of removal by the provider with the AIRFLOW Prophylaxis Master. The dye will guide the provider during instrumentation. Allow for selective cleaning of contaminated surfaces for a more conservative approach to debridement. Avoid unnecessary abrasion and instrumen­tation. Improve identification of oral deposits in hard to access areas such as crowded teeth, fixed orthodontic appliances, tight contacts between ­ teeth, and the distal surface of terminal molars. Identify oral deposits in the pit and fissures of teeth  that require removal prior to sealant placement. Identify oral deposits on removable appliances such as dentures and partials, which can be hard to see with the naked eye. Improve patient education and motivation.

A recent large systematic review by Oliveira et al. (2021) found the use of a plaque disclosing agent led to significant improvements in oral hygiene habits for patients in active orthodontic therapy.

A

B

• Indirect

•

evidence showed patients may experience faster habit formation with the use of a plaque disclosing agent compared to oral hygiene instruction and supervised brushing technique adjustments. The systematic review recommended plaquedisclosing agents as a standard for orthodontic patients and as an adjunct for those without appliances (Oliveira et al., 2021).

The disclosing solution provided by EMS is a two-tone dye on presoaked pellets. The solution is applied with a pair of cotton pliers, and one pellet is used per treatment.

C Figure 24-54  Disclosing solution: A. Red stained areas

on the anterior teeth, B. Red stained areas on the right side of the mouth, C. Red stained areas on the left side of the mouth.

• Tooth surfaces that stain red identify immature •

biofilm (see Figure 24-54a to c). Tooth surfaces that stain blue identify mature biofilm.

Precautions for the two-tone dye:

• Avoid •

contact with eyes, skin, clothing, and equipment. May stain dental restorative materials or orthodontic brackets. If the discoloration is not

•

removed during treatment, it will disappear on its own after a few days. Do not swallow. Contraindications for the two-tone dye:

• Do not use the two-tone dye is the patient has an

allergy to any of the ingredients: aqua, glycerin, CI 45430 (erythrosine), ethylparaben, CI 42051 (patent blue), aroma, CPC.

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Chapter 24 Coronal and Apical to CEJ Air Polishing

GBT Step 4: AIRFLOW Max

Administer full-mouth supragingival and shallow (1–3 mm) subgingival air polishing (EMS terms ­AIRFLOWING) with the AIRFLOW Max handpiece and AIRFLOW Plus powder (erythritol) for biofilm, stain, and immature dental calculus reduction and removal. Air polishing technique is presented in Chapter 25. The erythritol powder can also be used to remove biofilm from soft tissues such as the buccal mucosa, free and attached gingiva, palate, and tongue. Although air polishing will not remove mature, firmly established dental calculus, it will still remove the biofilm and stain on and around the dental calculus (Flemmig et al., 2007). The presence of firmly established dental calculus deposits that cannot be removed with air polishing does not adversely affect the efficiency and results of the air polishing procedure (Petersilka, 2000).

Step 5: PERIOFLOW

Administer subgingival air polishing (EMS terms ­AIRFLOWING) with the P ­ ERIOFLOW handpiece and  AIRFLOW Plus powder (erythritol) for biofilm, stain, and immature dental calculus reduction and removal in deeper (>4 mm) periodontal

pockets. Air polishing technique is presented in Chapter 25.

GBT Step 6: Piezon PS

GBT shortens the patient treatment time needed with the piezoelectric ultrasonic device because biofilm, stain, and immature dental calculus is already removed. The ultrasonic is used to remove residual, firmly established dental calculus. EMS recommends ultrasonic instrumentation with the PS tip for natural teeth and the PI tip for dental implants. See Chapter 17 for details.

GBT Step 7: Check

Perform a final check for remaining biofilm, ensure that hard deposits are fully removed, accurately diagnose caries (only for providers whose scope of practice allows for oral diagnosing), protect with fluoride, and do not polish with a rotary handpiece.

GBT Step 8: Recall

Select a recall frequency based on risk factors and ask for feedback from the patient on the procedure.

CASE STUDY

Your patient is a 58-year-old Indian male with a noncontributory medical history. The patient is not taking any over-the-counter or prescription medications and has no drug allergies. Body Mass Index (BMI) is 25. His chief complaint is “I don’t like the color of my teeth.” Dental exam: Patient had orthodontics in the past and lost the mandibular left second molar a few years ago due to a failed root canal. The dentist recommended a dental implant for the edentulous space. The maxillary left third molar is treatment planned for extraction due to decay. Occlusion: Class I bilateral with first molar relationship. Overbite of 6 mm. Mandibular anterior crowding. Oral hygiene exam: ■ ■ ■ ■

Disclosing solution revealed 95% of surfaces with biofilm and dental calculus. Generalized heavy biofilm. Generalized moderate supragingival dental calculus on smooth surfaces. Generalized light to moderate interproximal dental calculus. Generalized moderate to heavy staining.

Periodontal exam: ■ ■

Probe depths 3–6 mm generally with bleeding upon probing 37% of the mouth. Localized 7 mm probe depth on the maxillary left wisdom tooth mesial-linugal surface. This tooth has significant mesial decay. Localized recession and furcation involvement on molars Class I and II.

EMS Guided Biofilm Therapy (GBT)

Mandibular right anterior lingual surfaces.

Mandibular anterior lingual surfaces.

Mandibular anterior and premolar lingual surfaces

Mandibular left anterior lingual surfaces.

Intraoral photographs: Maxillary right anterior lingual surfaces.

Intraoral photographs: Maxillary left anterior lingual surfaces.

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Chapter 24 Coronal and Apical to CEJ Air Polishing

First premolar occlusal surface. Second premolar occlusal surface.

First molar occlusal surface.

EMS Guided Biofilm Therapy (GBT)

Periodontal charting.

Full mouth series radiographs.

477

478

Chapter 24 Coronal and Apical to CEJ Air Polishing

1. Can air polishing remove the dental calculus pictured on the mandibular anterior lingual surfaces? Why or why not? 2. The provider performs GBT for all routine and nonsurgical periodontal therapy procedures. What are the first three steps the provider carries out? 3. The provider moves to the fourth step of GBT. What powder and handpiece does the provider use? Describe the clinical delivery and what oral deposits will be removed by in this step. Include nozzle distance, angulation, movement, time of exposure, air pressure power setting, and water flow rate. 4. After the fourth step of GBT, stain persists on the lower anterior lingual. What could the provider use for its removal? Hint: There are two correct answers. 5. After the fourth step of GBT, stain persists on the molar and premolar occlusal grooves and pits. What is the best powder selection for its removal? 6. What air pressure powder velocity setting is needed for your selection in question 5? 7. Is the fifth step of GBT indicated for this patient? Why or why not? 8. Can the PERIOFLOW handpiece and subgingival nozzle reach to the depth of this patient’s pockets? 9. Describe the clinical delivery of subgingival air polishing to pocket depths deeper than 4 mm. Include which handpiece is used, nozzle distance, angulation, movement, time of exposure, air pressure powder velocity settings, and water flow rate. 10. Will the provider use one or two subgingival nozzles? Why? 11. Will GBT step 6 be necessary for this patient? Why or why not?

Summary

Air polishing with an EMS APD is a safe and effective procedure for the removal and reduction of biofilm, immature dental cal­culus, and extrinsic exogeneous staining. Sodium bicarbonate powder should only be used on structures coronal to the CEJ. Glycine and

Questions

1. Which of the following will air polishing remove? a. Immature dental calculus b. Firmly established dental calculus c. Biofilm d. Both A and C e. All of the above 2. What is the name of an EMS non-portable handheld air polishing device? a. AIRFLOW b. PERIOFLOW c. AIRFLOW MAX d. Handy 3. Which EMS powder has a particle size of 40 µm? a. AIRFLOW Classic powder b. AIRFLOW Perio powder c. AIRFLOW Plus powder

erythritol powders are used on tooth structures coronal and apical to the CEJ. GBT is a proprietary eightstep program for preventive non-surgical procedures developed by EMS. Step-by-step, hands-on exercises for air polishing are presented in the next chapter.

4. Which EMS powder(s) can be used supragingivally and subgingivally? a. AIRFLOW Classic powder b. AIRFLOW Perio powder c. AIRFLOW Plus powder d. Both B and C 5. Which EMS powder has a particle size of 14 µm and is used during GBT? a. AIRFLOW Classic powder b. AIRFLOW Perio powder c. AIRFLOW Plus powder 6. Which EMS powder is used for heavier, more tenacious stain? a. AIRFLOW Classic powder b. AIRFLOW Perio powder c. AIRFLOW Plus powder

Questions

7. What color is the powder chamber for AIRFLOW Classic powder in the AIRFLOW One and AIRFLOW Prophylaxis Master? a. Black b. White c. Gray d. Red 8. What color is the powder chamber for AIRFLOW Perio powder and AIRFLOW Plus powder in the AIRFLOW One and AIRFLOW Prophylaxis Master? a. Black b. White c. Gray d. Red 9. True or False. When the provider turns off the AIRFLOW APD, it will depressurize immediately, and the powder chamber bottles can be removed. a. True b. False 10. What powder velocity setting only delivers water with no slurry in the AIRFLOW One and AIRFLOW Prophylaxis Master? a. 0 b. 1 c. 8 d. 10 11. Which powder chamber will deliver a higher dynamic air pressure at all powder settings in the AIRFLOW One and AIRFLOW Prophylaxis Master a. Gray b. Red c. Black d. White 12. Which of the following is TRUE of the AIRFLOW One and AIRFLOW Prophylaxis Master? a. The foot pedal must be synched prior to the first use. b. The foot pedal is pressed all the way to the floor to deliver the slurry at the powder velocity selected. c. There is a 0.2-second delay in the slurry stopping upon release of the foot pedal. d. Both devices have a Boost mode option.

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13. Which of the following is FALSE about the AIRFLOW Prophylaxis Master? a. To activate Boost mode, press the pedal in the middle all the way to the floor. b. The outer part of the pedal will deliver the powder velocity setting selected by the provider. c. When Boost mode is activated, a 30% increase in power will occur regardless of the powder velocity setting selected by the provider. d. Water flow is required at all times while the APD is in use. 14. True or False. The AIRFLOW One and AIRFLOW Prophylaxis Master APDs have adjustable water temperatures 0 through 40 degrees Celsius. a. True b. False 15. How often should the water filter be replaced for the AIRFLOW One and AIRFLOW Prophylaxis Master? a. Annually b. Twice per year c. Three times per year d. Monthly 16. How often should the air filter be replaced for the AIRFLOW One and AIRFLOW Prophylaxis Master? a. Annually b. Twice per year c. Three times per year d. Monthly 17. Automatic purging is available on the AIRFLOW Prophylaxis Master. How long will the line purge when activated? a. 30 seconds b. 1 minute c. 2 minutes d. 4 minutes 18. True or False. The AIRFLOW Handy 3.0 has a smaller powder chamber than the AIRFLOW stand-alone devices. a. True b. False

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Chapter 24 Coronal and Apical to CEJ Air Polishing

19. What color is the AIRFLOW Handy 3.0 for Classic powder body? a. Pink b. Blue c. Gray d. Red

26. What water flow rate is used when air polishing with an EMS APD? a. 100% b. 50% c. 30% d. 10%

20. What is the maximum, or deepest subgingival depth the AIRFLOW and AIRFLOW MAX handpieces can reach when delivering AIRFLOW Perio and Plus powders? a. 3 mm b. 4 mm c. 5 mm d. 6 mm

27. What powder velocity setting is used when delivering AIRFLOW Perio or Plus powders subgingivally with the AIRFLOW handpiece? a. 30–60% b. 50–100% c. 30–100% d. 60–100%

21. Which of the following handpieces can deliver an air polishing slurry deeper than 4 mm? a. AIRFLOW handpiece b. AIRFLOW MAX handpiece c. PERIOFLOW handpiece 22. How many millimeters should the AIRFLOW and AIRFLOW MAX handpieces be from the tooth surface during supragingival air polishing? a. 3–5 mm b. 5–6 mm c. 6–7 mm d. 7–8 mm 23. Which of the following angulations is correct when delivering AIRFLOW Classic powder to the smooth surfaces of teeth? a. 30 to 60 degrees apical to the CEJ b. 30 to 60 degrees coronal to the CEJ c. 10 to 30 degrees apical to the CEJ d. 10 to 30 degrees coronal to the CEJ 24. Which of the following angulations can be used when delivering AIRFLOW Perio and AIRFLOW Plus powders to the smooth surfaces of teeth? a. 30 to 60 degrees apical to the CEJ b. 30 to 60 degrees coronal to the CEJ c. 10 to 30 degrees apical to the CEJ d. 10 to 30 degrees coronal to the CEJ e. Both A and B 25. Which of the following nozzle angulations is used when debriding occlusal surfaces of posterior teeth and incisal surfaces of anterior teeth? a. 30-degree angulation b. 50-degree angulation c. 90-degree angulation d. 60-degree angulation

28. How many millimeters should an EMS subgingival nozzle be from the crest of the alveolar bone? a. 1–2 mm b. >3 mm c. 0.5–1.0 mm d. There is no rule for the distance of a subgingival nozzle to the crest of the alveolar bone. 29. True or False. When delivering an air polishing slurry with a subgingival nozzle, the provider inserts the nozzle into the pocket and holds the nozzle in place to deliver 5 seconds of a slurry. a. True b. False 30. Which of the following is FALSE? a. A subgingival nozzle should be replaced after debriding 20 periodontal pocket sites. b. A subgingival nozzle never needs to be during debridement. c. The water flow rate when using the PERIOFLOW handpiece is 100%. d. The powder velocity settings for the PERIOFLOW handpiece is 50–100% 31. In which of the following situations would the use of the EMS GBT two-tone dye be contraindicated? a. The patient has an allergy to erythrosine. b. The patient has an allergy to patent blue. c. The patient has an allergy to Cetylpyridinium chloride (CPC). d. All of the above.

References

References

1. Buhler, J., Amato, M., Weiger, R., & Walter, C. (2015). A systematic review on the effects of air polishing devices on oral tissues. International Journal of Dental Hygiene, 14, 15–28. 2. Cosgarea, R., Jepsen, S., Fimmers, R., Bodea, A., Eick, S., & Schulean, A. (2021). Clinical outcomes following periodontal surgery and root surface decontamination by erythritol-based air polishing: A randomized, control, clinical pilot study. Clinical Oral Investigations, 25, 627–635. 3. Donnet, M., Fournier, M., Schmidlin, P., & Lussi, A. (2021). A novel method to measure the powder consumption of dental air-polishing devices. Applied Sciences¸ 11(1101), 2–11. 4. Drago, L., Fabbro, M. D., Bortolin, M., Vassena, C., Vecchi, E. D., & Taschieri, S. (2014). Journal of Periodontology, 85(11), e363–e369. 5. EMS (2022). What is GBT? https://www.ems-dental.com/en /guided-biofilm-therapy 6. Flemmig, T. F., Arushanov, D., Daubert, D., Rothen, M., Muller, G., & Leroux, B. G. (2012). Randomized controlled trial assessing efficacy and safety of glycine powder air polishing in moderate-to-deep periodontal pockets. Journal of Periodontology, 83(4), 444–452. 7. Flemmig, T. F., Hetzel, M., Topoll, H., Gerss, J., Haeberlein, I., & Petersilka, G. (2007). Subgingival debridement efficacy of glycine powder air polishing. Journal of Periodontology, 78(6), 1002–1010. 8. Hagi, T. T., Hofmanner, P., Eick, S., Donnet, M., Salvi, G. E., Sculean, A., & Ramseier, C. A. (2015). The effects of erythritol air-polishing powder on microbiological and clinical outcomes during supportive periodontal therapy: Six-month results of a randomized controlled clinical trial. Quintessence International, 46(1), 31–41. 9. Hashino, E., Kuboniwa, M., Alghamdi, S. A., Yamaguchi, M., Yamamoto, R., Cho, H., & Amano, A. (2013). Erythritol alters microstructure and metabolomic profiles of biofilm composed of Streptococcus gordonii and Porphyromonas gingivalis. Molecular Oral Microbiology, 28, 435–451. 10. Kargas, K., Tsalikis, L., Sakellari, D., Menexes, G., & Konstantinidis, A. (2015). Pilot study on the clinical and microbiological effect of subgingival glycine powder air polishing using a cannula-like jet. International Journal of Dental Hygiene, 13, 161–169. 11. Karmakar, S., & Kamath, D. G. (2017). Subgingival airpolishing: A simple and cost effective medical insurance. Journal of Pharmacology & Research, 9(2), 199–201. 12. Kozlovsky, A., Artzi, Z., Nemcovsky, C. E., & Hirshberg, A. (2005). Effect of air-polishing devices on the gingiva: Histologic study in the canine. Journal of Clinical Periodontology, 32, 329–334. 13. Mensi, M., Scotti, E., Sordillo, A., Calza, S., Guarnelli, M. E., Fabbri, C., Farina, R., & Trombelli, L. (2021). Efficacy of the additional use of subgingival air polishing with erythritol powder in the treatment of periodontitis patients: A randomized controlled clinical trial. Clinical Oral Investigations, 25, 729–736. 14. Moene, R., Decaillet, F., Andersen, E., & Mombelli, A. (2010). Subgingival plaque removal using a new air-polishing device. Journal of Periodontology, 81(1), 79–88.

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15. Muller, N., Moene, R., Cancela, J. A., & Mombelli, A. (2014). Subgingival air-polishing with erythritol during periodontal maintenance: Randomized clinical trial of twelve months. Journal of Clinical Periodontology, 41, 883–889. 16. Ng, E. (2018). The efficacy of air polishing devices in supportive periodontal therapy: A systematic review and meta-analysis. Quintessence International, 49, 453–467. https://doi.org/10.3290/j.qi.a40341 17. Oliveira, L. M., Pazinatto, J., & Zanatta, F. B. (2021). Are oral hygiene instructions with aid of plaque-disclosing methods effective in improving self-performed dental plaque control? A systematic review of randomized controlled trials. International Journal of Dental Hygiene, 19, 239–254. 18. Park, E. J., Kwon, E. Y., Kim, H. J., Lee, J. Y., Choi, J., & Joo, J. Y. (2018). Clinical and microbiological effects of the supplementary use of an erythritol powder air-polishing device in non-surgical periodontal therapy: A randomized clinical trial. Journal of Periodontal Implant Science, 48(5), 295–304. 19. Pelka, M., Trautmann, S., Petschelt, A., & Lohbauer, U. (2010). Influence of air-polishing devices and abrasives on root dentin—An in vitro confocal laser scanning microscope study. Quintessence International, 44(7), e141–e148. 20. Petersilka, G. (2000). Subgingival air-polishing in the treatment of periodontal biofilm infections. Periodontology, 55, 124–142. 21. Petersilka, G. J., Bell, M., Haberlein, I., Mehl, A., & Flemmig, T. F. (2003). In vitro evaluation of novel low abrasive air polishing powders. Journal of Clinical Periodontology, 30, 9–13. 22. Petersilka, G., Faggion, C. M., Stratmann, U., Gerss, J., Ehmke, B., Haeberlein, I., & Flemmig, T. F. (2008). Effect of glycine powder air-polishing on the gingiva. Journal of Clinical Periodontology, 35, 324–332. 23. Petersilka, G. J., Tunkel, J., Barakos, K., Heinecke, A., Haberlein, I., & Flemmig, T. F. (2003). Subgingival plaque removal at interdental sites using a low-abrasive air polishing powder. Journal of Periodontology, 74(3), 307–311. 24. Sculean, A., Bastendorf, K. D., Becker, C., Bush, B., Einwag, J., Lanoway, C., Platzer, U., Schmage, P., Schoeneich, B., Walter, C., Wennstrom, J. L., & Flemmig, T. F. (2013). A paradigm shift in mechanical biofilm management? Subgingival air polishing: A new way to improve mechanical biofilm management in the dental practice. Quintessence International, 44(7), 475–477. 25. Tastepe, C. S., Lin, X., Donnet, M., Wismeijer, D.,  & Liu,  Y. (2017). Parameters that improve cleaning efficiency of subgingival air polishing in titanium implant surfaces: An in vitro study. Journal of Periodontology, 88(4), 407–414. 26. Wennstrom, J. L., Dahlen, G., & Ramberg, P. (2011). Subgingival debridement of periodontal pockets by air polishing in comparison with ultrasonic instrumentation during maintenance therapy. Journal of Clinical Periodontology, 38, 820–827.

CHAPTER 25

Air Polishing Technique LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Set up and break down an air polishing device. 2. Deliver safe, effective, and efficient air polishing. 3. Use the correct techniques for supragingival and subgingival air polishing. 4. Control aerosols with optimal High volume evacuation (HVE) positioning during active air polishing.

Introduction The clinical technique for air polishing is similar to ultrasonic instrumentation with regard to aerosol control, HVE positioning, patient and operator positioning, grasp, and finger rest. As with dental ultrasonic devices, APDs release large volumes of aerosolized product into the environment, which must be controlled with appropriate infection prevention protocols discussed in Chapter 2. This chapter offers a step-by-step chairside practice in air polishing techniques for Dentsply Sirona and EMS APDs. You will combine grasp, finger rest, operator and patient chair positioning, nozzle angulation and distance, and HVE positioning. Air polishing, like ultrasonic instrumentation, is best learned through repetition and practice because there are many technique demands placed on the oral health-care provider. When mastered, air polishing improves the efficiency of procedures. The combination of air polishing and ultrasonic instrumentation provides a more conservative approach to oral deposit removal and promotes oral symbiosis with minimal alterations to tooth structures.

Clinical Technique The clinical techniques of air polishing are similar to ultrasonic instrumentation. This section will discuss grasp, stabilization, aerosol control, patient and  ­ operator positioning, and patient care best practices.

Grasp and Stabilization

The same grasp for the piezoelectric ultrasonic handpiece (described in Chapter 9) is used for a standalone air polishing handpiece (see Figure 25-1a and b).

• The dominant hand lightly holds the air polishing handpiece with a relaxed grasp.

• The thumb and index finger are equidistant from • •

each other on either side of the handpiece. The middle finger is touching and tucked behind the index finger. The handpiece lays in the webbing between the thumb and index finger to promote optimal ergonomics by balancing the weight of the handpiece in the hand.

The grasp for a portable handheld device is different than a stand-alone device.

• The body rests in the webbing between the thumb • • •

and index finger (see Figure 25-2). The thumb and index finger are equidistant from each other on either side of the handpiece. The middle finger is touching and tucked behind the index finger. No lateral pressure is used during air polishing. A standard nozzle does not contact tooth surfaces during air polishing, so lateral pressure is not used. 483

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Chapter 25 Air Polishing Technique

The same stabilization finger rests (intraoral, extraoral) used in ultrasonic instrumentation are also used for air polishing (see Chapter 9 for details).

Aerosol Control

The same aerosol control techniques learned for ultrasonic instrumentation, including HVE grasp, are used for air polishing. The HVE is positioned 0.5–6.0 inches away from the nozzle for proper environmental aerosol control. Air polishing does not produce acoustic cavitation, acoustic microstreaming, or liquid jets, so the slurry may be suctioned immediately after it contacts the tooth surface. A

Operator Chair Positioning

Flexible bilateral operator chair positioning with direct vision is used, and indirect vision is only required for the maxillary anterior lingual surfaces and the maxillary posterior occlusal surfaces. The provider may use any clock position on the left or right side of the patient chair, regardless of their dominant hand, so direct vision can be utilized. The provider chooses the operator chair positioning that allows for proper ergonomics and direct vision. If ergonomics becomes compromised, the provider has selected an incorrect chair positioning for air polishing.

Patient Positioning

B Figure 25-1  Air polishing handpiece grasp (Dentsply

Sirona Jet-Mate Ultrasonic Handpiece and Cavitron Jet Air Polishing Insert): A. Right-handed provider, B. Left-handed provider. Reproduced with permission from Dentsply Sirona

The same patient positioning used for ultrasonic instrumentation is also used for air polishing, as described in Chapter 9. Patient chair positioning is flexible, with supine, semi-supine, upright, or any position in between. When direct vision is challenged in a seated position, standup provider positioning may resolve the issue. For seated instrumentation:

• Maxillary arch: Patient positioning is typically su•

Figure 25-2  Air polishing portable device handpiece

grasp (EMS AIRFLOW Handy 3.0 Perio).

Patient Care

• As

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

• Subgingival nozzle: the nozzle contacts root sur-

faces, but no lateral pressure is used as the slurry mixture is expelled.

pine, or in between supine and semi-supine, with the patient’s chin slightly tilted upward. Mandibular arch: Patient positioning is either supine, in between supine and semi-supine, or semi-supine, with the patient’s chin slightly tilted downward.

•

in ultrasonic instrumentation, the patient should rinse with a pre-procedural antimicrobial solution. The provider should evaluate the patient record to ensure that there are no considerations or contraindications to air polishing.

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Figure 25-3  Lip and cheek retractor (OptraGate Ivoclar,

EMS AIRFLOW MAX Handpiece, Dentsply Sirona Purevac HVE Mirror Tip. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A

• A lip lubricant may be used to prevent drying of

the lips from slurry exposure. Ensure the product chosen will not affect the integrity of the provider’s gloves. Common agents used are vitamin E–based products or cocoa butter.

Lip and Cheek Retraction The lip and cheek can be retracted with the HVE or with the assistance of a lip-and-cheek retractor. Depending on its design, a lip-and-cheek retractor can improve the patient experience by preventing the powder slurry from landing on external structures immediately around the oral cavity (see Figure 25-3). Lubricate the patient’s lips prior to placing a lip and cheek retractor for improved comfort.

Face Drapes Face drapes prevent the slurry from settling on the patient’s face during air polishing. They are not required for air polishing but may improve the patient experience. They are sold as single-use disposable or reusable nondisposable (see Figure 25-4a and b). Patient protective eyewear is still required when using a face drape to prevent splashes into the eyes.

Skill Building: Air Polishing on Inanimate Objects You will need the following supplies:

• Tarnished •

penny, hard-boiled quail egg, APD, HVE, container to collect water. Dentsply Sirona: Jet-Mate Sterilizable, Detachable Handpiece, Cavitron Jet Air Polishing Insert,

B Figure 25-4  Face cover/drape (ProSafe Products):

A. Blue reusable face drape, B. White reusable drape.

•

Cavitron Prophy Jet Prophy powder ­(sodium bicarbonate) or Cavitron JET-Fresh Prophy ­powder (aluminum trihydroxide). EMS: AIRFLOW or AIRFLOW MAX handpiece, AIRFLOW Classic powder (sodium bicarbonate), AIRFLOW Perio powder (glycine), AIRFLOW Plus powder (erythritol).

Rationale: This exercise will provide a kinetic learning experience with an APD simulating the removal of biofilm and stain and with a fluid continuous movement of the nozzle. If the APD is a multipower device, various powder velocity settings will be practiced. These techniques can then be transferred to active patient treatment.

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Chapter 25 Air Polishing Technique

A

B

Figure 25-5  Quail eggs: A. Carton of quail eggs, B. Hard-boiled quail egg.

Figure 25-6  Tarnished and shiny pennies.

The goal of this exercise is to remove the tarnish off the penny to produce a shiny surface and remove the stain from the outer shell of a hard-boiled quail egg. Purchase and boil quail eggs the night before the exercise and collect tarnished pennies (see Figure 25-5a and b and Figure 25-6).

Penny

Complete steps 1–12 and then record your observations for questions 1–4. 1. Set up the APD, handpiece, and nozzle per the manufacturer’s directions. Ensure that the psi (pound force per square inch) of the dental unit water and air is correct for the device. Any powder compatible with your APD can be used for air polishing the penny.

2. Turn on the APD and flush the waterline for a minimum of 20–30 seconds. Always follow your clinic’s protocols for waterline maintenance, which may be different than a 20- to 30-second waterline flush. 3. If using a multipower delivery APD, set the ­control to low or medium. Set the water flow rate to high following manufacturer recommendations. 4. Adjust the water and/or powder velocity until an effective slurry is expelled from the nozzle. A productive slurry will have an equal mixture of air, powder, and water with minimal powder expulsion in the form of an aerosol cloud. 5. Place the penny on a solid surface and hold it steady with your nondominant hand. 6. Provide fluid control such as having a collection container under the surface and/or having someone else hold the HVE close to your working area. Turn on the HVE. 7. Grasp the APD handpiece with your dominant hand. 8. Position the nozzle at the appropriate distance from the penny (Dentsply Sirona APD 2–4 mm, EMS APD 3–5 mm). Activate the APD by pressing the pedal. Expose one side of the penny to the slurry, moving the nozzle in small, circular, continuous, overlapping motions until you reveal the penny’s underlying shiny surface (see Figure 25-7a to c).

Skill Building: Air Polishing on Inanimate Objects

A

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B

C Figure 25-7  Slurry exposure to a tarnished penny: A. Dentsply Sirona Cavitron Jet Air Polishing Insert 2–4 mm nozzle

to penny distance, B. EMS AIRFLOW MAX handpiece 3–5 mm nozzle to penny distance slurry exposure on the penny, C. EMS AIRFLOW MAX handpiece removing the tarnish on the penny.

9. Flip the penny over. 10. Increase nozzle distance from the penny to 12 mm (see Figure 25-8).

11. Activate the APD and expose the new side of the penny to the slurry. Move the nozzle in slow, fluid, continuous movements over the penny until you reveal the underlying shiny surface. 12. Record your observations for questions 1–4. Observations for the penny exercise: 1. At what distance was the tarnish removed from the penny the fastest? Why? 2. What happened to the stain removal capability when you increased the nozzle–penny distance from 2–5 mm to 12 mm? Why? 3. Was it challenging to control the aerosols expelled from the APD? At what distance was aerosol control the most difficult? Explain your answer. 4. Was it challenging to produce an effective slurry? What changes did you make to produce an effective slurry?

Quail Egg Figure 25-8  Nozzle distance from penny 12 mm

(Dentsply Sirona Cavitron Jet Air Polishing Insert).

Divide your quail egg into 4 equal sections (see Figure 25-9).

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Chapter 25 Air Polishing Technique

Figure 25-10  APD handpiece grasp (Dentsply Sirona

Jet-Mat Sterilizable, Detachable Handpiece and Cavitron Jet Air Polishing Insert) Reproduced with permission from Dentsply Sirona

Figure 25-9  Quail egg divided into 4 sections.

(see Figure 25-11). Activate the APD by pressing the pedal. Expose the first section of the quail egg to the slurry, moving the nozzle in small, circular, continuous, overlapping motions until the stains on the outer shell are removed.

Use sodium bicarbonate or aluminum trihydroxide powders for steps 13–24. Complete steps 13–24 and then record your observations for questions 5–8. If you do not have access to sodium bicarbonate or aluminum trihydroxide powders, then skip steps  13–24 and observation questions 5–8. 13. Select the first section of your quail egg. 14. Fill your APD with either sodium bicarbonate or aluminum trihydroxide powder. 15. If using a multipower delivery APD, set the control to high. 16. Adjust the water and/or powder velocity until an effective slurry is expelled from the nozzle. A productive slurry will have an equal mixture of air, powder, and water with minimal powder expulsion in the form of an aerosol cloud. 17. Grasp the quail egg in your non-dominant hand. 18. Provide fluid control such as having a collection container under the quail egg and/or having someone else hold the HVE close to your working area. Turn on the HVE. 19. Grasp the APD handpiece with your dominant hand (see Figure 25-10). 20. Position the nozzle at the appropriate distance from the quail egg (Dentsply Sirona APD 2–4 mm, EMS APD 3–5 mm) on the first section

Figure 25-11  EMS AIRFLOW MAX handpiece 3–5 mm

from the outer shell surface of a quail egg.

21. Move to section two of your quail egg if using a multipower delivery APD. Turn the control down to medium. If you are not using a multipower device, skip steps 21–23. 22. Grasp the handpiece with your dominant hand. 23. Position the nozzle at the appropriate distance from the quail egg (Dentsply Sirona APD

Skill Building: Air Polishing with Dentsply Sirona Device

2–4 mm, EMS APD 3–5 mm) on the second section. Activate the APD by pressing the pedal. Expose the second section of the quail egg to the slurry, moving the nozzle in small, circular, continuous, overlapping motions until the stains on the outer shell are removed. 24. Record your observations for questions 5–8. Observations for sodium bicarbonate or aluminum trihydroxide powder:: 5. Were the stains on the outer shell of the quail egg difficult to remove? Why or why not? 6. If using a multipower delivery APD, when you decreased the powder velocity, were the stains easier or more difficult to remove? Which powder velocity setting removed the stain the fastest? 7. If using a multipower delivery APD, was there a change in aerosol production between high and medium powder velocity? Why or why not? 8. If using a multipower delivery APD, which setting did you prefer for stain removal? Why? Use glycine or erythritol powders for steps 25–34 and then record your observations for questions 9–12. Complete steps 25–34 and then record your observations for questions 9–12. If you do not have access to glycine or erythritol powders, then skip steps 25–34 and observation questions 9–12. 25. Fill your APD with either glycine or erythritol powder. 26. If using a multipower delivery APD, set the control to medium. 27. Adjust the water and/or powder velocity until an effective slurry is expelled from the nozzle. A productive slurry will have an equal mixture of air, powder, and water with minimal powder expulsion in the form of an aerosol cloud. 28. Grasp the quail egg in your nondominant hand. 29. Provide fluid control such as having a collection container under the quail egg and/or having someone else hold the HVE close to your working area. Turn on the HVE. 30. Grasp the APD handpiece with your dominant hand. 31. Position the nozzle at the appropriate distance from the quail egg (EMS APD 3–5 mm) on the third section (see Figure 25-11). Activate the APD by pressing the pedal. Expose the third section of the quail egg to the slurry, moving the nozzle in small, circular, continuous, overlapping motions until the stains on the outer shell are removed. 32. If using a multipower delivery APD, turn the control down to low.

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33. Position the nozzle at the appropriate distance from the quail egg (EMS APD 3–5 mm) on the fourth section (see Figure 25-11). Activate the APD by pressing the pedal. Expose the fourth section of the quail egg to the slurry, moving the nozzle in small, circular, continuous, overlapping motions until the stains on the outer shell are removed. 34. Record your observations for questions 9–12. Observations for glycine or erythritol powders: 9. Were the stains on the outer shell of the quail egg difficult to remove? Why or why not? 10. If using a multipower velocity device, what powder velocity control setting removed the staining faster? Why? 11. If using a multipower velocity device, was there a change in aerosol production between the two powder velocity control settings? Why or why not? 12. If using a multipower velocity device, which powder velocity control setting did you prefer for stain removal? Why?

Skill Building: Air Polishing with Dentsply Sirona Device You will need the following supplies: APD; sterile Cavitron Jet Air Polishing Insert; sterile Jet-Mate Sterilizable, Detachable Handpiece; Cavitron Prophy Jet Prophy powder (sodium bicarbonate) or Cavitron Jet Fresh Prophy powder (aluminum trihydroxide); HVE: A/W syringe; gauze; cotton roll; lip and cheek retractor (if applicable); lip lubricant (if applicable); typodont; typodont pole; dental chair. Rationale: This exercise will provide a kinetic learning experience with the Dentsply Sirona APD on either a live patient or typodont. The air polishing techniques of nozzle angulation, aerosol control, and patient and operator positioning are simulated. The goal of this exercise is to administer air polishing to tooth surfaces coronal to the Cementoenamel junction (CEJ).

Dentsply Sirona APD Setup

1. Don Personal Protective Equipment (PPE) for this aerosol-generating procedure. 2. Evaluate the psi of the water and air on the dental unit to ensure compatibility with the device’s specifications from in the instruction for use (IFU). 3. Connect the water and air lines from the APD to the dental unit (see Figure 25-12).

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Chapter 25 Air Polishing Technique

Figure 25-12  Dental unit with black air cord attached

to the yellow air input, water cord attached to the blue water input, powder cord attached the electrical outlet.

4. Connect the power cord (see Figure 25-12). 5. With the power off, remove the powder bowl cap from the powder bowl (see Figure 25-13).

Figure 25-14  Turning the APD on with powder bowl cap

off (Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System). Reproduced with permission from Dentsply Sirona

8. Turn the device off. 9. Select either the Cavitron Prophy Jet Prophy Powder (sodium bicarbonate) or the Cavitron Prophy Powder (aluminum trihydroxide) and shake the powder bottle to break up any clumps. 10. Fill the powder bowl. Do not fill past the inner tube (see Figure 25-15).

Figure 25-13  Removal of powder bowl cap from

the powder bowl (Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System). Reproduced with permission from Dentsply Sirona

6. Look in the powder bowl and verify it is empty. 7. Do not position your face directly over the powder bowl, and turn the device on for 15 seconds. This will eliminate any residual powder or moisture in the powder bowl (see Figure 25-14).

Figure 25-15  Filling the powder bowl (Dentsply Sirona

Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System).

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491

11. Visually inspect the powder bowl cap and ensure that powder is not present on the threads or the seal ring. Use a soft disposable cloth to remove residual powder if present. 12. Gently twist and secure the powder bowl cap on the powder bowl without stripping the threads (see Figure 25-16).

Figure 25-17  Powder flow control (Dentsply Sirona

Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System)

15. Purge the line for a minimum of 20–30 seconds per the Centers for Disease Control and Prevention (CDC). Always follow your clinic’s protocols for waterline maintenance, which may be different than a 20- to 30-second waterline flush. You can use the automatic purge feature and the water line will purge for 2 minutes (see Figure 25-18).

Figure 25-16  Placing the powder bowl cap onto the

powder bowl. (Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System). Reproduced with permission from Dentsply Sirona

13. Turn on the power to the device. Ensure that air is not leaking from the powder bowl or the powder bowl cap after it pressurizes. If air is leaking, turn the device off and clean all threads. 14. Verify the powder bowl is pressurized by looking into the window on the powder flow control. If powder flow (small white circle of powder) is seen, the device is pressurized correctly. If no flow is seen, turn the device off, check for a clog, and ensure that adequate powder level is present in the powder bowl (see Figure 25-17).

Figure 25-18  Automatic purge feature activated on the

Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System.

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Chapter 25 Air Polishing Technique

16. Connect the Jet-Mate Sterilizable, Detachable Handpiece to the handpiece cable. Be sure to align the attachments correctly to avoid damage to the equipment (see Figure 25-19).

18. Lubricate green O-ring on the Cavitron JET Air Polishing Insert by rotating the O-ring 360 degrees over the water dome (see Figure 25-21).

Figure 25-19  Attaching the Jet-Mate Sterilizable,

Detachable Handpiece to the handpiece cable (Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System. Reproduced with permission from Dentsply Sirona

17. Position the handpiece vertically over a sink and fill with water until a water dome appears over the brim and all air bubbles are released (see Figure 25-20).

Figure 25-21  O-ring lubrication: Rotate the O-ring

360 degrees over the water dome until fully lubricated.

19. Keep the handpiece in a vertical position and align the heater rod and nozzle tube with the openings on the handpiece. Place the nozzle into the handpiece. Make sure the O-ring is fully seated (see Figure 25-22).

Figure 25-22  Cavitron JET Air Polishing Insert placed

into the Jet-Mate Sterilizable, Detachable Handpiece.

Figure 25-20  Water dome visible in handpiece opening.

20. Set the water flow rate to high. 21. Select low or medium powder velocity emission with the powder flow control on the powder bowl cap. High powder emission is seldom used in

Skill Building: Air Polishing with Dentsply Sirona Device

clinical practice and is indicated only for the removal of heavy tenacious stains. Rotate the powder flow control to ‘L’ or ‘M’ on the device (see Figure 25-23).

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their consent to continue. If applicable, lubricate the patient’s lips, insert a lip and cheek retractor into the patient’s mouth. Affix a patient napkin, put on safety goggles, use a face drape or a hair covering if applicable.

Air Polishing Posterior Occlusal Surfaces

Begin on the mandibular occlusal surfaces of your dominant side. Beginning on the occlusal surface can improve the patient experience by allowing them to experience the feel of air polishing prior to exposing smooth and interproximal surfaces that are closer to the lips and cheeks.

• Dominant right-handed provider: mandibular right terminal molar occlusal surface.

• Dominant left-handed provider: mandibular left terminal molar occlusal surface.

Insert a lip and cheek retractor (if applicable).

Figure 25-23  Setting the powder flow control (Dentsply

Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System).

22. Use the dial to select manual prophy mode cycle for this exercise. Auto-cycle prophy mode is useful after you become more proficient in air polishing techniques (see Figure 25-24).

Grasp the air polishing handpiece with your dominant hand.

Grasp the HVE with your nondominant hand.

Position the nozzle 2–4 mm from the occlusal of the mandibular terminal molar of your dominant side at a 90-degree angle (see Figure 25-25).

Position the HVE 0.5–6.0 inches from the nozzle

Select the operator positioning for direct vision. • Dominant right-handed provider: 8–11 o’clock • Dominant left-handed provider: 1–4 o’clock

Figure 25-24  Dial set to manual prophy mode cycle

(Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System).

23. Adjust the water and/or powder velocity until an effective slurry is expelled from the nozzle. A productive slurry will have an equal mixture of air, powder, and water with minimal powder expulsion in the form of an aerosol cloud. 24. Evaluate the patient record to ensure there are no considerations or contraindications to air polishing. Explain the procedure to the patient and gain

Select the patient chair positioning for the mandibular arch. • Supine, semi-supine, or in between supine and semi-supine. • Patient chin slightly downward

Establish a finger rest intraoral or extraoral, ensuring correct handpiece grasp is maintained.

Ensure that the foot pedal is within reach. Turn on the HVE. Begin air polishing the following steps.

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3. Rinse both molars by pressing the pedal halfway to the floor to expel only water. 4. Move to the second premolar of your dominant side. 5. Position the nozzle 2–4 mm from the occlusal ­surface at a 90-degree angle (see Figure 25-27).

Figure 25-25  Nozzle at a 2- to 4-mm distance and

at a 90-degree angle to the occlusal surface of the mandibular right second molar.

1. Depress the foot pedal all the way to the floor to expel the slurry. Expose the mandibular occlusal terminal molar of your dominant side to 1–2 ­seconds (varies based on the level of biofilm and stain present) of the slurry using continuous, overlapping, circular movements. 2. Move to the next molar of your dominant side and repeat the slurry exposure, keeping the HVE 0.5–6.0 inches from the nozzle (see Figure 25-26). Figure 25-27  Nozzle at a 2- to 4-mm distance and

at a 90-degree angle to the occlusal surface of the mandibular right second premolar.

Figure 25-26  Nozzle at a 2- to 4-mm distance and

at a 90-degree angle to the occlusal surface of the mandibular right first molar.

6. Reposition the HVE 0.5–6.0 inches from the nozzle. 7. Press the foot pedal all the way to the floor to expel the slurry. Expose the occlusal of the second premolar to 1–2 seconds (varies based on the level of biofilm and stain present) of the slurry using continuous, overlapping, circular movements. 8. Move to the first premolar of your dominant side and repeat the slurry exposure, keeping the HVE  0.5–6.0 inches from the nozzle (see Figure 25-28).

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Grasp the air polishing handpiece with your dominant hand.

Grasp the HVE with your nondominant hand.

Position the nozzle 2–4 mm from the middle-third distal-facial of the maxillary canine on your dominant side at a 60-degree angle (see Figure 25-29).

Position the HVE 0.5–6.0 inches from the nozzle.

Select the operator positioning for direct vision. • Dominant right-handed provider: 8–1 o’clock • Dominant left-handed provider: 11–4 o’clock

Select patient chair positioning for the maxillary arch. Patient chair supine with chin slightly upward.

Figure 25-28  Nozzle at a 2- to 4-mm distance and

at a 90-degree angle to the occlusal surface of the mandibular right first premolar.

9. Rinse both premolars by pressing the pedal halfway to the floor to expel only water. 10. Repeat all steps on the mandibular occlusal surfaces of your nondominant side and both maxillary arches. Upper arches will require indirect vision. If an HVE with affixed mirror is not available, then four-handed assisted dentistry will be needed. If neither are available, then do not air polish the maxillary occlusal surfaces because an HVE must be used during air polishing.

Establish a finger rest intraoral or extraoral, ensuring correct handpiece grasp is maintained.

Ensure that the foot pedal is within reach. Turn on the HVE. Begin air polishing with the following steps.

Air Polishing Anterior Smooth Surfaces

Begin on the maxillary facial canine of your dominant side.

• Dominant right-handed provider: maxillary right •

canine facial surface. Dominant left-handed provider: maxillary left canine facial surface.

Figure 25-29  Nozzle at a 2- to 4-mm distance and at a

60-degree angle to the middle-third distal-facial of the maxillary right canine.

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Chapter 25 Air Polishing Technique

1. Press the foot pedal all the way to the floor to expel the slurry. Expose the distal-facial of the maxillary canine of your dominant side to 1–2 seconds of slurry, then the midline-facial 1–2 seconds, and then the mesial-facial 1–2 seconds using continuous, overlapping circular movements. 2. Move to the maxillary lateral incisor of your dominant side and repeat the slurry exposure on the distalfacial, midline-facial, and mesial-facial, keeping the HVE 0.5–6.0 inches from the nozzle (see Figure 25-30).

Figure 25-31  Nozzle at a 2- to 4-mm distance and at a

60-degree angle to the middle-third midline-facial of the maxillary right central incisor.

7. Move to the maxillary central incisor of your nondominant side and repeat the slurry exposure on the mesial-facial, midline-facial, and distal-facial, keeping the HVE 0.5–6.0 inches from the nozzle (see Figure 25-32).

Figure 25-30  Nozzle at a 2- to 4-mm distance and at a

60-degree angle to the middle-third distal-facial of the maxillary right lateral incisor.

3. Rinse the canine and lateral incisor by pressing the pedal halfway to the floor to expel only water. 4. Move to the maxillary central incisor of your dominant side. Position the nozzle 2–4 mm from the middle-third distal-facial of the maxillary central incisor on your dominant side at a 60-degree angle. 5. Reposition the HVE 0.5–6.0 inches from the nozzle. 6. Press the foot pedal all the way to the floor to expel the slurry. Expose the distal-facial of the central incisor of your dominant side to 1–2 seconds of slurry, then the midline-facial 1–2 seconds, and then the mesial-facial 1–2 seconds using continuous, overlapping circular movements (see Figure 25-31).

Figure 25-32  Nozzle at a 2- to 4-mm distance and at a

60-degree angle to the middle-third midline-facial of the maxillary left central incisor.

Skill Building: Air Polishing with Dentsply Sirona Device

8. Rinse both centrals by pressing the pedal halfway to the floor to expel only water. 9. Move the maxillary lateral incisor of your nondominant side. Position the nozzle 2–4 mm from the middle-third mesial-facial of the maxillary lateral incisor on your non-dominant side at a 60-degree angle. 10. Position the HVE 0.5–6.0 inches from the nozzle. 11. Press the foot pedal all the way to the floor to expel the slurry. Expose the mesial-facial of the lateral incisor of your nondominant side to 1–2 seconds of slurry, then the midline-facial 1–2  seconds, and then the distal-facial 1–2 seconds using continuous, overlapping circular movements (see Figure 25-33).

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14. Repeat all steps on the lingual surfaces of the maxillary anterior teeth with indirect vision. If an HVE with affixed mirror is not available, then four-handed assisted dentistry will be needed. If neither are available, then do not air polish upper anterior lingual surfaces because an HVE must be used during air polishing. 15. Repeat all steps on the facial and lingual surfaces of the mandibular anterior teeth.

Air Polishing Posterior Smooth Surfaces

Begin on the maxillary buccal terminal molar of your dominant side.

• Dominant right-handed provider: maxillary right •

terminal molar buccal surface. Dominant left-handed provider: maxillary left terminal molar buccal surface.

Grasp the air polishing handpiece with your dominant hand.

Grasp the HVE with your nondominant hand.

Position the nozzle 2–4 mm pointed slightly distally from the middle third distal-buccal of the maxillary terminal molar of your dominant side at an 80-degree angle (see Figure 25-34).

Position the HVE 0.5–6.0 inches from the nozzle.

Figure 25-33  Nozzle at a 2- to 4-mm distance and at a

60-degree angle to the middle-third midline-facial of the maxillary left lateral incisor.

12. Move to the maxillary canine of your nondominant side and repeat the slurry exposure on the mesial-facial, midline-facial, and distal-facial, keeping the HVE 0.5–6.0 inches from the nozzle. 13. Rinse the lateral and canine tooth on your non-dominant side by pressing the pedal halfway to the floor to expel only water.

Select the operator position for direct vision. • Dominant right-handed provider: 8–11 o’clock • Dominant left-handed provider: 1–4 o’clock

Select the patient chair positioning for the maxillary arch: patient chair supine with the chin slightly upward.

Establish a finger rest intraoral or extraoral, ensuring correct handpiece grasp is maintained.

Ensure that the foot pedal is within reach. Turn on the HVE. Begin air polishing with the steps below.

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3. Rinse all molars by pressing the pedal halfway to the floor to expel water only. 4. Move to the maxillary second premolar of your dominant side. 5. Position the nozzle 2–4 mm pointed slightly distally from the middle third distal-buccal of the maxillary second premolar of your dominant side at an 80-degree angle (see Figure 25-36).

Figure 25-34  Nozzle at a 2- to 4-mm distance and

pointed slightly distally at an 80-degree angle to the buccal surface of the maxillary right second molar.

1. Press the foot pedal all the way to the floor to expel the slurry. Expose the distal-buccal of the terminal molar of your dominant side to 1–2 seconds of slurry, then the midline-buccal 1–2 seconds, and then the mesial-buccal 1–2 seconds using continuous, overlapping circular movements. 2. Move to the next molar(s) of your dominant side and repeat the slurry exposure on the distal-buccal, midline-buccal, and mesial-buccal, keeping the HVE 0.5–6.0 inches from the nozzle (see Figure 25-35).

Figure 25-36  Nozzle at a 2- to 4-mm distance and

pointed slightly distally at an 80-degree angle to the distal-buccal surface of the maxillary right second premolar.

Figure 25-35  Nozzle at a 2- to 4-mm distance and

pointed slightly distally at an 80-degree angle to the distal-buccal surface of the maxillary right first molar.

6. Reposition the HVE 0.5–6.0 inches from the nozzle. 7. Press the foot pedal all the way to the floor to expel the slurry. Expose the distal-buccal of the second premolar of your dominant side to 1–2 seconds of slurry, then the midline-buccal 1–2 seconds, and then the mesial-buccal 1–2 seconds using continuous, overlapping circular movements. 8. Move to the maxillary first premolar of your dominant side and repeat the slurry exposure on the distal-buccal, midline-buccal, and mesial-buccal, keeping the HVE 0.5–6.0 inches from the nozzle. Angle the HVE to capture the aerosols and slurry released by the nozzle (see Figure 25-37).

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3. Use the Cavitron Prophy Jet Nozzle Cleaning Tool to dislodge residual powder in the nozzle delivery tube. Remove the cleaning tool when complete (see Figure 25-39).

Figure 25-37  Nozzle at a 2- to 4-mm distance and

pointed slightly distally at an 80-degree angle to the distal-buccal surface of the maxillary right first premolar.

9. Rinse both premolars by pressing the pedal halfway to the floor to expel water only. 10. Repeat all steps on the lingual surfaces of the maxillary posterior teeth of your dominant side, moving your operator chair position for direct vision. • Dominant right-handed provider: 1–4 o’clock • Dominant left-handed provider: 8–11 o’clock 11. Repeat all steps on the maxillary posterior teeth of your non-dominant side and the mandibular teeth both buccal and lingual surfaces.

Dentsply Sirona APD Breakdown

1. Turn the APD off and allow the powder bowl to depressurize. 2. Remove the Cavitron Jet Air Polishing Insert from the handpiece (see Figure 25-38).

Figure 25-39  Cavitron Prophy Jet Nozzle Cleaning

Tool in the nozzle delivery tube of the Cavitron Jet Air Polishing Insert.

4. Remove the Jet-Mate Sterilizable, Detachable Handpiece from the handpiece connector cable with a straight pull motion. (see Figure 25-40).

Figure 25-38  Removal of the Cavitron Jet Air Polishing

Figure 25-40  Removal of the Jet-Mate Sterilizable,

Reproduced with permission from Dentsply Sirona

Reproduced with permission from Dentsply Sirona

Insert from the Jet-Mate Sterilizable, Detachable Handpiece (Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System).

Detachable Handpiece from the handpiece connector cable (Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System).

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Chapter 25 Air Polishing Technique

5. Use the Cavitron Prophy Jet Handpiece Cleaning Tool to dislodge residual powder in the powder delivery port of the handpiece. Remove the cleaning tool when complete (see Figure 25-41).

8. Lift and remove the powder bowl from the device carefully. Do not damage the cords under the bowl (see Figure 25-43).

Figure 25-41  Cavitron Prophy Jet Handpiece Cleaning

Tool inside the powder delivery port of the the Jet-Mate Sterilizable, Detachable Handpiece (Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System). Reproduced with permission from Dentsply Sirona

6. Disinfect the device, cords, and the pedal with a manufacturer-approved disinfectant solution and technique. Refer to the IFU. 7. Carefully remove the powder bowl cap to avoid damage to the threads. Set the cap aside (see Figure 25-42).

Figure 25-43  Removal of the powder bowl from the

Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System. Reproduced with permission from Dentsply Sirona

9. Discard all unused powder from the powder bowl (see Figure 25-44).

Figure 25-42  Dentsply Sirona Cavitron Jet Plus

Figure 25-44  Removing powder from the powder bowl

Reproduced with permission from Dentsply Sirona

Reproduced with permission from Dentsply Sirona

Ultrasonic Scaling and Air Polishing System with powder bowl cap removed.

(Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System).

Skill Building: Air Polishing with EMS Guided Biofilm Therapy

10. Place the powder bowl back into its holder and ensure that the cords to the powder bowl are not pinched or smashed. Do not place the powder bowl cap back on the powder bowl. 11. Do not position your face directly over the powder bowl, and turn the device on for 15 seconds. This will eliminate any residual powder or moisture in the powder bowl. 12. Turn the device off. 13. Remove the seal ring on the powder bowl cap without damaging the seal ring. An instrument without a sharp cutting edge can be used, such as a dull explorer (see Figure 25-45).

501

15. Use a soft disposable cloth to wipe the threads of the powder bowl cap and the powder bowl. If powder will not remove, use a soft toothbrush with light strokes to dislodge powder particles (see Figure 25-47).

Figure 25-47  Soft disposable cloth wiping the threads of Figure 25-45  Removal of the seal ring from the powder

bowl cap with a dull explorer.

14. Use a soft disposable cloth to wipe the seal ring to remove residual powder. Do not scratch, bend, or damage the seal ring (see Figure 25-46).

the powder bowl.

16. Place the seal ring back onto the powder bowl cap. 17. Place the powder bowl cap on the powder bowl without stripping the threads. 18. Reprocess the Cavitron Jet Air Polishing Insert; Cavitron Prophy Nozzle Cleaning Tool; Jet-Mate Sterilizable, Detachable Handpiece; and the Cavitron Prophy Jet Handpiece Cleaning Tools according to the manufacturer’s directions in ­ the IFU.

Skill Building: Air Polishing with EMS Guided Biofilm Therapy

Figure 25-46  Soft disposable cloth wiping the seal ring

of the powder bowl cap.

You will need the following supplies: APD, red powder chamber, sterile AIRFLOW handpieces (AIRFLOW handpiece or AIRFLOW MAX), PERIOFLOW handpiece, PERIOFLOW subgingival nozzle, AIRFLOW Plus powder (GBT uses erythritol powder for its patented procedure), HVE, A/W syringe, gauze, cotton roll, lip

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Chapter 25 Air Polishing Technique

and cheek retractor (if applicable), lip lubricant (if applicable), live patient, dental chair. Rationale: This exercise simulates the GBT procedure proprietary to EMS. This exercise will provide a kinetic learning experience on a live patient. You will use the air polishing techniques of nozzle angulation, aerosol control, and patient and operator positioning. The goal of this exercise is to administer the clinical technique steps of GBT on a live patient.

EMS AIRFLOW Prophylaxis Master Setup

1. Don PPE for this aerosol-generating procedure. 2. Evaluate the psi of the water and air on the dental unit to ensure compatibility with the device’s specifications. 3. Connect the air line from the APD to the dental unit. 4. Connect the power cord. 5. Fill the independent water bottle reservoir and place it into the device (see Figure 25-48).

Figure 25-49  Filling the red powder chamber with

AIRFLOW Plus powder.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

7. Place the red powder chamber into the device, ensuring a magnetic connection (see Figure 25-50).

Figure 25-48  Independent water bottle reservoir placed

into its receptacle on the AIRFLOW Prophylaxis Master.

6. Fill the red powder chamber with AIRFLOW Plus powder (erythritol) not to exceed the maximum fill line (see Figure 25-49).

Figure 25-50  Red powder chamber placed into its

receptacle on the AIRFLOW Prophylaxis Master. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Skill Building: Air Polishing with EMS Guided Biofilm Therapy

8. Turn the device on (see Figure 25-51).

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10. Set the water control to 10 with the spindle next to the handpiece (see Figure 25-53).

Figure 25-53  Spindle water control set to 10 (AIRFLOW Figure 25-51  On/off and dynamic pressure regulator

controls on the AIRFLOW Prophylaxis Master. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

9. Press the dynamic pressure regulator and verify the unit is pressurized by evaluating for powder chamber illumination (see Figure 25-52).

Figure 25-52  Powder chamber illuminates after

Max handpiece).

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

11. Adjust the water temperature if desired. The default setting is 40°C/104°F. See Chapter 24 for details. 12. Purge the ultrasonic and air polishing lines for 20–30 seconds. Always follow your clinic’s protocols for waterline maintenance, which may be different than a 20- to 30-second waterline flush. The air ­polishing line is pictured in Figure 25-54.

pressing the dynamic pressure regulator on the AIRFLOW Prophylaxis Master.

Figure 25-54  Air polishing line of the AIRFLOW

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Prophylaxis Master.

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Chapter 25 Air Polishing Technique

• AIRFLOW One: Press the pedal to purge the line and then release when complete. • AIRFLOW Prophylaxis Master: Press the pedal once to activate the automatic purge. The blue numbers will change to white as a one-minute purge completes (see Figure 25-55).

3. Perform a plaque index and show the patient their results in a hand mirror (see Figure 25-56). 4. Provide oral hygiene instructions to motivate the patient. See Chapter 24 for details.

Figure 25-56  Disclosing solution. Red stained areas

indicating biofilm presence.

GBT Step 4: AIRFLOW MAX

1. Blow air through the interior of the AIRFLOW MAX handpiece from both sides to eliminate moisture. 2. Connect the sterile AIRFLOW MAX handpiece to the handpiece connector cable. Be sure to align the attachments correctly to avoid damage to the equipment (see Figure 25-57).

Figure 25-55  Automatic purge illuminated numbers

(EMS AIRFLOW Prophylaxis Master). Reproduced with permission from E.M.S. Electro Medical Systems S.A.

GBT Step 1: Assessment and infection control

1. Have the patient rinse with BacterX Pro mouthwash. See Chapter 24 for details. 2. Evaluate the patient record to ensure that there are no considerations or contraindications to air polishing and disclosing solution. See Chapters 22 and 24 for details. 3. Explain the procedure to the patient and gain their consent to continue. 4. Lubricate the patient’s lips. 5. Insert a lip and cheek retractor into the patient’s mouth. 6. Affix a patient napkin, put on safety goggles, use a face drape or a hair covering if applicable.

GBT Step 2: Disclose, and GBT Step 3: Motivate

1. Use cotton pliers and apply the two-tone dye to all tooth surfaces using a presoaked pellet. See Chapter 24 for details. 2. Rinse the patient’s mouth thoroughly and do not allow the patient to swallow the disclosing solution.

Figure 25-57  Attaching the AIRFLOW MAX handpiece

to the handpiece connector cable on the AIRFLOW Prophylaxis Master. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

3. Set the powder velocity control for air polishing. • 30–60% is used for coronal and apical to CEJ surfaces. • If heavier or more tenacious stain is present coronal to the CEJ, the powder velocity can be increased to 60–100%. • Do not use over 60% for surfaces apical to the CEJ.

Skill Building: Air Polishing with EMS Guided Biofilm Therapy

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4. Set the water flow rate to 10 (100%). 5. Adjust the water and/or powder velocity until an effective slurry is expelled from the nozzle. A productive slurry will have an equal mixture of air, powder, and water with minimal powder expulsion in the form of an aerosol cloud.

Air Polishing (EMS terms AIRFLOWING) Posterior Occlusal Surfaces Begin GBT air polishing on the mandibular occlusal surfaces of your dominant side. Beginning on the occlusal surface can improve the patient experience by allowing them to experience the feel of air polishing prior to exposing smooth and interproximal surfaces that are closer to the lips and cheeks.

• Dominant right-handed provider: mandibular right •

terminal molar occlusal surface. Dominant left-handed provider: mandibular left terminal molar occlusal surface.

Grasp the air polishing handpiece with your dominant hand.

Grasp the HVE with your nondominant hand.

Position the nozzle 3–5 mm from the occlusal surface of the mandibular terminal molar on your dominant side at a 60-degree angle (see Figure 25-58).

Figure 25-58  Nozzle at a 3- to 5-mm distance and

at a 60-degree angle to the occlusal surface of the mandibular right second molar.

1. Depress the foot pedal on the side to expel the slurry. Do not activate Boost mode. See ­Chapter 24 for details. Expose the mandibular occlusal terminal molar of your dominant side to the slurry using continuous, overlapping circular movements. Exposure time is dependent on the level of oral deposits and is typically 5–10 seconds, no more than 20 seconds. 2. Move to the next molar of your dominant side and repeat the slurry exposure, keeping the HVE 0.5–6.0 inches from the nozzle (see Figure 25-59).

Position the HVE 0.5–6.0 inches from the nozzle.

Select the operator position for direct vision. • Dominant right-handed provider: 8–11 o’clock • Dominant left-handed provider: 1–4 o’clock

Select the patient chair positioning for the mandibular arch. • Supine, semi-supine, or in between supine and semi-supine. • Patient chin slightly downward.

Establish a finger rest intraoral or extraoral, ensuring correct handpiece grasp is maintained.

Ensure that the foot pedal is within reach. Turn on the HVE. Begin air polishing with the following steps.

Figure 25-59  Nozzle at a 3- to 5-mm distance and

at a 60-degree angle to the occlusal surface of the mandibular right first molar.

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Chapter 25 Air Polishing Technique

3. Continue moving forward in the mouth, exposing the mandibular premolar occlusal surfaces and the anterior incisal surfaces of your dominant side (see Figure 25-60).

Grasp the air polishing handpiece with your dominant hand.

Grasp the HVE with your non-dominant hand.

Position the nozzle 3–5 mm from the middle third distal-facial pointed away from the gum line of the maxillary canine of your dominant side at a 30- to 60-degree angle (see Figure 25-61).

Position the HVE 0.5–6.0 inches from the nozzle.

Select the operator position for direct vision. • Dominant right-handed provider: 8–1 o’clock • Dominant left-handed provider: 11–4 o’clock

Select patient chair positioning for the maxillary arch. patient chair supine with chin slightly upward.

Establish a finger rest intraoral or extraoral, ensuring correct handpiece grasp is maintained.

Figure 25-60  Nozzle at a 3- to 5-mm distance and

at a 60-degree angle to the occlusal surface of the mandibular right first premolar.

Ensure that the foot pedal is within reach. Turn on the HVE. begin air polishing with the following steps.

4. Repeat all steps on the mandibular occlusal surfaces of your non-dominant side and both maxillary arches. Maxillary arches will require indirect vision. If an HVE with affixed mirror is not available, then four-handed assisted dentistry will be needed. If neither are available, then do not air polish the maxillary occlusal surfaces because an HVE must be used during air polishing.

Air Polishing (EMS terms AIRFLOWING) Anterior Smooth Surfaces Air polishing of surfaces coronal to the CEJ will be completed first and then air polishing of the surfaces apical to the CEJ will be completed. Surfaces Coronal to the CEJ.  Begin on the maxillary facial canine of your dominant side.

• Dominant right-handed provider: maxillary right •

canine facial surface. Dominant left-handed provider: maxillary left canine facial surface.

Figure 25-61  Nozzle at a 3- to 5-mm distance and at a

30- to 60-degree angle to the middle-third distal-facial of the maxillary right canine pointed away from the gum line.

Skill Building: Air Polishing with EMS Guided Biofilm Therapy

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1. Press the foot pedal on the side to expel the slurry. Do not activate Boost mode. Expose the distal-facial of the maxillary canine of your dominant side to 5–10 seconds, no more than 20 seconds, of slurry, then the midline-facial, and then the mesial-facial using continuous, overlapping circular movements. 2. Move to the maxillary lateral incisor of your dominant side and repeat the slurry exposure on the distal-facial, midline-facial, and mesial-facial, keeping the HVE 0.5–6.0 inches from the nozzle (see Figure 25-62).

A

Figure 25-62  Nozzle at a 3- to 5-mm distance and at a

30- to 60-degree angle to the middle-third distal-facial of the maxillary right lateral incisor pointed away from the gum line.

3. Repeat all steps on the remaining maxillary anterior facial surfaces, maintaining the nozzle 3–5 mm from the middle third facial and pointed away from the gum line at a 30- to 60-degree angle. Continue to adjust the HVE to capture the aerosols and slurry expelled by the nozzle (see Figure 25-63a to d).

B Figure 25-63  Nozzle at a 3- to 5-mm distance and at a

30- to 60-degree angle to the facial middle-third pointed away from the gum line on the: A. Maxillary right central incisor midline-facial, B. Maxillary left central incisor midline-facial.

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Chapter 25 Air Polishing Technique

polish the maxillary anterior lingual surfaces because an HVE must be used during air polishing. 5. Repeat all steps on the mandibular anterior facial and lingual surfaces. Surfaces Apical to the CEJ. Begin on the maxillary facial canine of your dominant side.

• Dominant right-handed provider: maxillary right •

C

canine facial surface. Dominant left-handed provider: maxillary left canine facial surface.

1. Position the nozzle 3–5 mm from the middle third distal-facial pointed toward the gum line of the maxillary canine of your dominant side at a 30- to 60-degree angle. Position the HVE 0.5–6.0 inches from the nozzle. 2. Press the foot pedal on the side to expel the slurry. Do not activate Boost mode. Expose the distal-facial of the maxillary canine of your dominant side to 5–10 seconds, no more than 20 ­seconds, of slurry, then the midline-facial, and then the mesial-facial using continuous, overlapping circular movements (see Figure 25-64).

D Figure 25-63  (Continued) C. Maxillary left lateral incisor

mesial-facial, D. Maxillary left canine mesial-facial.

4. Repeat all steps on the maxillary anterior lingual smooth and interproximal surfaces coronal to the CEJ. Maxillary anterior lingual surfaces will require indirect vision. If an HVE with affixed mirror is not available, then four-handed assisted dentistry will be needed. If neither are available, then do not air

Figure 25-64  Nozzle at a 3- to 5-mm distance and at a

30- to 60-degree angle to the middle-third midline-facial of the maxillary right canine pointed toward the gum line.

Skill Building: Air Polishing with EMS Guided Biofilm Therapy

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3. Move to the maxillary lateral incisor of your dominant side and repeat the slurry exposure on the distal-facial, midline-facial, and mesial-facial, keeping the HVE 0.5–6.0 inches from the nozzle (see Figure 25-65).

A

Figure 25-65  Nozzle at a 3- to 5-mm distance and at a

30- to 60-degree angle to the middle-third midline-facial of the maxillary right lateral incisor pointed toward the gum line.

4. Repeat all steps on the remaining maxillary anterior facial surfaces, maintaining the nozzle 3–5 mm from the middle-third facial and pointed toward the gum line at a 30- to 60-degree angle. Continue to adjust the HVE to capture the aerosols and slurry expelled by the nozzle (see Figure 25-66a to d). 5. Repeat all steps on the maxillary anterior lingual smooth and interproximal surfaces apical to the CEJ. Maxillary anterior lingual surfaces will require indirect vision. If an HVE with affixed mirror is not available, then four-handed assisted dentistry will be needed. If neither are available, then do not air polish the maxillary anterior lingual surfaces because an HVE must be used during air polishing. 6. Repeat all steps on the mandibular anterior facial and lingual surfaces.

B Figure 25-66  Nozzle at a 3- to 5-mm distance and at a

30- to 60-degree angle to the facial middle-third pointed toward from the gum line on the: A. Maxillary right central incisor midline-facial, B. Maxillary left central incisor midline-facial.

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Chapter 25 Air Polishing Technique

Grasp the air polishing handpiece with your dominant hand.

Grasp the HVE with your non-dominant hand.

Position the nozzle 3–5 mm from the middle third distal-buccal pointed away from the gum line of the terminal mandibular molar of your dominant side at a 30- to 60-degree angle (see Figure 25-67).

C

Position the HVE 0.5–6.0 inches from the nozzle.

Select the operator position for direct vision. • Dominant right-handed provider: 8–11 o’clock • Dominant left-handed provider: 1–4 o’clock

Select patient chair positioning for the mandibular arch. • Supine, semi-supine, or in between supine and semi-supine. • Patient chin slightly downward.

Establish a finger rest intraoral or extraoral, ensuring correct handpiece grasp is maintained.

Ensure that the foot pedal is within reach. Turn on the HVE. Begin air polishing with the following steps.

D Figure 25-66  (Continued) C. Maxillary left lateral incisor

mesial-facial, D. Maxillary left canine midline-facial.

Air Polishing (EMS terms AIRFLOWING) Posterior Smooth Surfaces Air polishing of surfaces coronal to the CEJ will be completed first, and then air polishing of the surface apical to the CEJ will be completed. Surfaces Coronal to the CEJ. Begin on the terminal mandibular molar buccal surface of your dominant side.

• Dominant right-handed provider: mandibular right •

molar buccal surface. Dominant left-handed provider: mandibular left molar buccal surface.

Figure 25-67  Nozzle at a 3- to 5-mm distance and at

a 30- to 60-degree angle to the middle-third midlinebuccal of the mandibular right second molar pointed away from the gum line.

Skill Building: Air Polishing with EMS Guided Biofilm Therapy

1. Press the foot pedal on the side to expel the slurry. Do not activate Boost mode. Expose the distal-­ buccal of the terminal mandibular molar on your dominant side to 5–10 seconds, no more than 20  seconds, of slurry, then the midline-buccal, and then the mesial-buccal using continuous overlapping circular movements.

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2. Move to the next molar(s) of your dominant side and repeat the slurry exposure on the distal-buccal, midline-buccal, and mesial-buccal, keeping the HVE 0.5–6.0 inches from the nozzle (see Figure 25-68).

Figure 25-68  Nozzle at a 3- to 5-mm distance and at a

30- to 60-degree angle to the middle-third midline-buccal of the mandibular right first molar pointed away from the gum line.

3. Continue moving forward in the quadrant to the premolar teeth, maintaining the nozzle 3–5 mm from the middle third buccal and pointed away from the gum line at a 30- to 60-degree angle.

A

Continue to adjust the HVE to capture the aerosols and slurry expelled by the nozzle (see Figure 25-69a and b).

B

Figure 25-69  Nozzle at a 3- to 5-mm distance and at a 30- to 60-degree angle to the buccal

middle-third pointed away from the gum line on the: A. Mandibular right second premolar distalbuccal surface, B. Mandibular right first premolar on the midline-buccal surface.

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Chapter 25 Air Polishing Technique

4. Repeat all steps on the mandibular lingual smooth and interproximal surfaces coronal to the CEJ on your dominant side. Adjust your operator chair position for direct vision. • Dominant right-handed provider: 1–4 o’clock • Dominant left-handed provider: 8–11 o’clock 5. Repeat all steps on the mandibular posterior buccal and lingual smooth and interproximal surfaces coronal to the CEJ surfaces of your non-dominant side. 6. Repeat all steps on the maxillary posterior buccal and lingual smooth and interproximal surfaces coronal to the CEJ.

2. Position the HVE 0.5–6.0 inches from the nozzle. 3. Press the foot pedal on the side to expel the slurry. Do not activate Boost mode. Expose the distal-buccal of the mandibular terminal molar of your dominant side to 5–10 seconds, no more than 20 seconds, of slurry, then the midline-buccal, and then the mesial-buccal using continuous, overlapping circular movements. 4. Move to the next molar(s) of your dominant side and repeat the slurry exposure on the distal-buccal, midline-buccal, and mesial-buccal, keeping the HVE 0.5–6.0 inches from the nozzle (see Figure 25-71).

Surfaces Apical to the CEJ.  Begin on the terminal mandibular molar buccal surface of your dominant side.

• Dominant right-handed provider: mandibular right molar buccal surface.

• Dominant left-handed provider: mandibular left molar buccal surface.

1. Position the nozzle 3–5 mm from the middle third distal-buccal and pointed toward the gum line of the terminal mandibular molar on your dominant side at a 30- to 60-degree angle (see Figure 25-70).

Figure 25-71  Nozzle at a 3- to 5-mm distance and at

a 30- to 60-degree angle to the middle-third midlinebuccal of the mandibular right first molar pointed toward the gum line.

Figure 25-70  Nozzle at a 3- to 5-mm distance and at

a 30- to 60-degree angle to the middle-third midlinebuccal of the mandibular right second molar pointed toward the gum line.

5. Continue moving forward in the quadrant to the premolar teeth, maintaining the nozzle 3–5 mm from the middle third buccal and pointed toward the gum line at a 30- to 60-degree angle. Continue to adjust the HVE to capture the aerosols and slurry expelled by the nozzle (see Figure 25-72a and b). 6. Repeat all steps on the mandibular lingual smooth and interproximal surfaces apical to the CEJ on your dominant side. Adjust your operator chair position for direct vision. • Dominant right-handed provider: 1–4 o’clock • Dominant left-handed provider: 8–11 o’clock 7. Repeat all steps on the mandibular posterior buccal and lingual smooth and interproximal surfaces apical to the CEJ surfaces of your non-dominant side. 8. Repeat all steps on the maxillary posterior buccal and lingual smooth and interproximal surfaces apical to the CEJ.

Skill Building: Air Polishing with EMS Guided Biofilm Therapy

A

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B

Figure 25-72  Nozzle at a 3- to 5-mm distance and at a 30- to 60-degree angle to the buccal middle-third pointed

toward the gum line on the: A. Mandibular right second premolar midline-buccal surface, B. Mandibular right first premolar midline-buccal surface.

GBT Step 5: PERIOFLOW

1. With the ADP on, but your foot released from the pedal, remove the AIRFLOW MAX handpiece from the handpiece connector cable and set aside. 2. Blow air through the interior of the PERIOFLOW handpiece from both sides to eliminate any moisture. 3. Attach the PERIOFLOW handpiece to the handpiece connector cable. Be sure to align the attachments correctly to avoid damage to the equipment (see Figure 25-73).

4. Secure a subgingival nozzle into the handpiece. Align the single-use disposable subgingival nozzle with the notch on the PERIOFLOW handpiece, ensuring that the closed section of the nozzle is at the top, and gently push the subgingival nozzle downward with your fingers (see Figure 25-74).

Figure 25-73  Attaching PERIOFLOW handpiece to

handpiece connector cable on the AIRFLOW Prophylaxis Master. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 25-74  Subgingival nozzle attachment to the

PERIOFLOW handpiece.

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Chapter 25 Air Polishing Technique

5. Place the subgingival nozzle on a hard surface and push downward until the subgingival nozzle is fully seated onto the handpiece (see Figure 25-75).

Periodontal Pocket Treatment Grasp the air polishing handpiece with your dominant hand.

Grasp the HVE with your nondominant hand.

Position the nozzle on the tooth surface with the periodontal pocket to receive subgingival treatment.

Position the HVE 0.5–6.0 inches from the nozzle.

Select the operator position for direct vision.

Select the patient chair positioning.

Establish a finger rest intraoral or extraoral, ensuring correct handpiece grasp is maintained.

Figure 25-75  Place the end of the subgingival nozzle

on a hard surface and push to fully seat the disposable subgingival nozzle into the PERIOFLOW handpiece.

6. Determine the sites of the mouth that have probe depths >4 mm for use with the PERIOFLOW subgingival nozzle and handpiece. 7. Set the powder velocity control for subgingival air polishing of 5 through 10 (50–100%). The powder velocity setting is selected based on the oral deposit level. 8. Set the water flow rate to 10 (100%). 9. Adjust the water and/or powder velocity until an effective slurry is expelled from the nozzle. A productive slurry will have an equal mixture of air, powder, and water with minimal powder expulsion in the form of an aerosol cloud. 10. Select the first periodontal pocket to be treated.

Ensure that the foot pedal is within reach. Turn on the HVE. Begin air polishing with the following steps.

1. Insert the subgingival nozzle to the depth of the periodontal pocket and then retract 2–3 mm from the base of the pocket to maintain at least a 3-mm distance from the crest of the alveolar bone. The nozzle is inserted parallel to the long axis of the tooth (see Figure 25-76).

Figure 25-76  Subgingival nozzle inserted into the buccal

periodontal pocket on the mandibular right first molar.

Skill Building: Air Polishing with EMS Guided Biofilm Therapy

2. Press the pedal and deliver the slurry for a maximum of 5 seconds in the periodontal pocket while making continuous, slow vertical oscillations (up, down, rotational) along the pocket. 3. Lift your foot off the pedal to stop the slurry expulsion and wait until the spray stops to retract the subgingival nozzle from the periodontal pocket.

A

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4. Repeat steps 1–3 on additional periodontal pockets >4 mm. Change the subgingival nozzle after 20 sites have been treated. 5. Remove the subgingival nozzle with the nozzle extractor. Line the extractor with the base of the subgingival nozzle and then gently push upward (see Figure 25-77a to c).

B

C Figure 25-77  EMS PERIOFLOW subgingival nozzle removal: A. Align the nozzle extractor with the subgingival nozzle,

B. Push the nozzle extractor upward, C. Remove the subgingival nozzle with the nozzle extractor.

EMS AIRFLOW Prophylaxis Master Air Polishing Breakdown

fully depressurize for 10 seconds. Ensure that the handpiece is not facing upward or toward you to avoid injury from the spraying of purged air and residual powder (see Figure 25-78a and b).

1. Turn the APD off and allow the powder chamber to depressurize. Allow the powder chamber to

A

B

Figure 25-78  EMS AIRFLOW Prophylaxis Master breakdown: A. Turn off

unit, B. Turn PERIOFLOW nozzle downward. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

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Chapter 25 Air Polishing Technique

2. Remove the detachable handpiece (see Figure 25-79).

Skill Building: Air Polishing with EMS AIRFLOW Handy 3.0 You will need the following supplies: portable handheld devices AIRFLOW Handy 3.0 Perio, AIRFLOW Handy 3.0 Classic, AIRFLOW Perio powder, AIRFLOW Plus powder, AIRFLOW Classic powder, AIRFLOW handpiece or AIRFLOW MAX handpiece, PERIOFLOW handpiece, single-use disposable subgingival nozzle, HVE, A/W syringe, gauze, cotton roll, lip and cheek retractor (if applicable), typodont, typodont pole, and dental chair.

Figure 25-79  Removing the PERIOFLOW handpiece

from the handpiece connector cable. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

3. Use the Easy Clean tool with attached disposable syringe filled with more than 2 ml of drinking ­water to irrigate the AIRFLOW MAX handpiece opening for 20 seconds. See Chapter 24 for details. 4. Blow air twice through both openings of the AIRFLOW MAX handpiece when rinsing is complete. 5. Remove powder from the device, cords, and pedal fixtures with a disposable soft nonabrasive cloth prior to using a manufacturer-approved disinfectant solution. Do not spray disinfectant solutions directly on system surfaces. 6. Remove the powder chamber from its magnetic holder without twisting or rotating the bottle. 7. Discard all unused powder in the trash can. Emptying the powder chamber will reduce moisture absorption and prevent clogging. 8. Clean the connections with compressed air from the A/W syringe and place on a dry surface. 9. Reprocess the handpieces and Easy Clean tool per the manufacturer’s directions in the DFU/IFU.

Rationale: This exercise will provide a kinetic learning experience with the EMS Handy 3.0 on a typodont or a live patient. The air polishing techniques of nozzle angulation, aerosol control, and patient and operator positioning are simulated, which can then be transferred to live patient treatment. The goal of this exercise is to administer air polishing coronal and apical to the CEJ with a standard and subgingival nozzle. The AIRFLOW Handy 3.0 Perio is compatible with AIRFLOW Perio powder (glycine) or AIRFLOW Plus powder (erythritol) used for air polishing coronal and apical to the CEJ. AIRFLOW Handy 3.0 Classic is compatible with AIRFLOW Classic powder (sodium bicarbonate) used for air polishing heavier or tenacious stains coronal to the CEJ. This exercise will demonstrate AIRFLOW Handy 3.0 Perio and then AIRFLOW Handy 3.0 Classic. Skip the steps for the device your institution does not own.

AIRFLOW Handy 3.0 Perio

AIRFLOW Handy 3.0 Perio Setup 1. Turn on the master switch to the dental unit (see Figure 25-80).

GBT Step 6: Piezon PS, GBT Step 7: Check, and GBT Step 8: Recall

Perform piezoelectric ultrasonic instrumentation with the techniques shown in the ultrasonic chapters for remaining hard deposits. Visually evaluate for ­remaining oral deposits in need of removal and establish an a­ ppropriate recall for the patient based on risk factors.

Figure 25-80  Example of a dental unit master switch

turned on.

Skill Building: Air Polishing with EMS AIRFLOW Handy 3.0

2. Don PPE for an aerosol-generating procedure. 3. Evaluate the psi of the water and air on the dental unit to ensure compatibility with the specifications of the AIRFLOW Handy 3.0 Perio device.

A

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4. Check the O-rings on the air turbine connector cord of the dental unit and the cord adaptor on the AIRFLOW Handy 3.0 Perio to ensure that they are in good condition (see Figure 25-81a and b).

B

Figure 25-81  O-rings: A. Dental unit air turbine O-rings, B. Cord adaptor of the AIRFLOW Handy 3.0 Perio.

5. Blow compressed air with the A/W syringe into the air turbine connector on the dental unit and

A

the cord adaptor on the AIRFLOW Handy 3.0 Perio (see Figure 25-82a and b).

B

Figure 25-82  A/W syringe blowing compressed air on: A. Dental unit air turbine connector, B. Cord adaptor on the

AIRFLOW Handy 3.0 Perio.

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Chapter 25 Air Polishing Technique

6. Turn off the master switch to the dental unit (see Figure 25-83).

7. Remove the powder chamber cap and set aside (see Figure 25-84).

Figure 25-83  Example of a dental unit master switch

turned off.

Figure 25-84  Powder chamber cap removed from the

powder chamber on the AIRFLOW Handy 3.0 Perio.

8. Shake the AIRFLOW Perio or AIRFLOW Plus powder bottle to break up clumps. Take the cap off and place the powder dispenser on the bottle (if applicable) (see Figure 25-85a).

A

9. Point the AIRFLOW Handy 3.0 Perio downward (see Figure 25-85b).

B

Figure 25-85  Preparing to fill the powder chamber of the AIRFLOW Handy 3.0 Perio: A. AIRFLOW Plus powder bottle

with the cap on and the dispenser to the left, B. AIRFLOW Handy 3.0 Perio pointed downward. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Skill Building: Air Polishing with EMS AIRFLOW Handy 3.0

519

10. Connect the powder bottle dispenser with the powder chamber opening. Pour the AIRFLOW Perio or AIRFLOW Plus powder into the powder chamber with the body pointed downward. Do not fill past the inner tube (see Figure 25-86).

11. Remove the dispenser from the powder bottle and place the cap back on immediately to prevent moisture contamination (see Figure 25-87).

Figure 25-86  Powder in the powder chamber of

Figure 25-87  Powder bottle cap on the AIRFLOW Plus

the AIRFLOW Handy 3.0 Perio not filled past the inner tube.

powder bottle.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

12. With a soft disposable cloth, clear away residual powder on the threads of the

A

powder c­ hamber and powder chamber cap (see Figure 25-88a and b).

B

Figure 25-88  Removal of residual powder from the AIRFLOW Handy 3.0 Perio: A. Soft disposable cloth cleaning the

threads of the powder chamber, B. Soft disposable cloth cleaning the threads of the powder chamber cap.

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Chapter 25 Air Polishing Technique

13. Secure the powder chamber cap tightly on the powder chamber without stripping the threads. Do not shake the AIRFLOW Handy 3.0 Perio once the cap is securely placed to avoid powder settling into the inner tube. 14. Turn on the master switch to the dental unit. Air should not be escaping from the cord adaptor or the air turbine connection. If this occurs, check the O-rings and reclean the threads to remove any residual powder contamination. 15. Connect the sterile AIRFLOW handpiece or AIRFLOW MAX handpiece to the body of the AIRFLOW Handy 3.0 Perio (see Figure 25-89).

Figure 25-89  AIRFLOW MAX handpiece connected to the

AIRFLOW Handy 3.0 Perio body. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

16. Adjust the water flow rate until an effective slurry is expelled from the nozzle. The powder velocity cannot be adjusted on a portable handheld device. A productive slurry will have an equal mixture of air, powder, and water with minimal powder expulsion in the form of an aerosol cloud.

Air Polishing 1. Follow all steps for GBT Step 4 (AIRFLOW MAX), skipping the step for changing the powder velocity control setting. Be sure to the use the correct grasp as seen in Figure 25-2. 2. Follow all steps for GBT Step 5 (PERIOFLOW), skipping the step for changing the powder velocity control setting. Be sure to the use the correct grasp as seen in Figure 25-2.

AIRFLOW Handy 3.0 Classic

AIRFLOW Handy 3.0 Classic Setup 1. Turn off the master switch to the dental unit (see Figure 25-83). 2. Remove the AIRFLOW Handy 3.0 Perio from the air turbine on the dental unit. 3. Evaluate the psi of the water and air on the dental unit to ensure compatibility with the specifications of the AIRFLOW Handy 3.0 Classic. 4. Check the O-rings on the air turbine connector cord of the dental unit and the cord adaptor on the

AIRFLOW Handy 3.0 Classic to ensure that they are in good condition (see Figure 25-81a and b). 5. Turn on the master switch to the dental unit and blow compressed air with the A/W syringe into the air turbine connector on the dental unit and the cord adaptor on the AIRFLOW Handy 3.0 Classic (see Figure 25-80 and Figure 25-82a and b). 6. Turn off the master switch to the dental unit. 7. Remove the powder chamber cap and set aside (see Figure 25-84). 8. Shake the AIRFLOW Classic powder bottle to break up clumps. Take the cap off and place the powder dispenser on the bottle (if applicable; see Figure 25-85a). 9. Point the AIRFLOW Handy 3.0 Classic downward (see Figure 25-85b). 10. Connect the powder bottle dispenser with the powder chamber opening. Pour the AIRFLOW Classic powder into the powder chamber. Do not fill past the inner tube (see Figure 25-86). 11. Remove the dispenser from the powder bottle and place the cap back on immediately to prevent moisture contamination (see Figure 25-87). 12. With a soft disposable cloth, clear away residual powder on the threads of the powder chamber and powder chamber cap (see Figure 25-88a and b). 13. Secure the powder chamber cap tightly on the powder chamber without stripping the threads. Do not shake the AIRFLOW Handy 3.0 Classic once the cap is securely placed to avoid powder settling into the inner tube. 14. Turn on the master switch to the dental unit. Air should not be escaping from the cord adaptor or the air turbine connection. If this occurs, check the O-rings and reclean the threads to remove any residual powder contamination. 15. Connect the sterile AIRFLOW handpiece or AIRFLOW MAX handpiece to the body of the AIRFLOW Handy 3.0 Classic (see Figure 25-89). 16. Adjust the water flow rate until an effective slurry is expelled from the nozzle. The powder velocity cannot be adjusted on a portable handheld device. A productive slurry will have an equal mixture of air, powder, and water with minimal powder expulsion in the form of an aerosol cloud.

Air Polishing 1. Follow the steps for GBT step 4 (AIRFLOW MAX) surfaces coronal to the CEJ. Skip the steps for changing the powder velocity control setting. Skip the steps for surfaces apical to the CEJ. Be sure to the use the correct grasp as seen in Figure 25-2.

Skill Building: Air Polishing with EMS AIRFLOW Handy 3.0

AIRFLOW Handy 3.0 Perio and AIRFLOW Handy 3.0 Classic Breakdown

1. Remove the detachable handpiece (see Figure 25-90a and b).

521

3. Blow air twice through both openings of the handpiece when rinsing is complete. 4. Turn off the master switch to the dental unit. When the device is turned off, the powder chamber takes a few seconds to depressurize. 5. Remove the AIRFLOW Handy 3.0 from the air turbine connector on the dental unit (see Figure 25-92).

A Figure 25-92  Removal of the cord adaptor from the air

turbine connection.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

B Figure 25-90  AIRFLOW Handy 3.0 Removal of

Detachable Handpiece: A. AIRFLOW Handy 3.0 Perio with the handpiece removed from the body, B. AIRFLOW handpiece. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

2. Use the Easy Clean tool with attached disposable syringe filled with more than 2 ml of drinking water to irrigate the AIRFLOW or AIRFLOW MAX handpiece opening for 20  seconds (see Chapter 24 for details; see Figure 25-91).

Figure 25-91  Easy clean tool placed into the handpiece

opening. Disposable syringe is placed into the opening on the Easy Clean tool.

6. Remove residual powder from the device, cords, and pedal fixtures with a disposable soft nonabrasive cloth. 7. Disinfect the device, cords, and pedal fixtures with a manufacturer-approved disinfectant solution. Do not spray disinfectant solutions directly on system surfaces. 8. Gently remove the powder chamber cap after depressurization without stripping the threads. Set the cap aside (see Figure 25-93).

Figure 25-93  Powder chamber cap removed from the

powder chamber on the AIRFLOW Handy 3.0 Perio.

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Chapter 25 Air Polishing Technique

9. Discard all unused powder in the trash. Emptying the powder chamber will reduce moisture absorption and prevent clogging. 10. Turn on the master switch to the dental unit and use the HVE to remove residual powder from the chamber (see Figure 25-94).

11. Remove the cap ring without damaging the ring. Use an instrument without a sharp cutting edge such as a dull explorer (see Figure 25-95).

Figure 25-94  Removal of residual powder in the powder

Figure 25-95  Ring removed from the powder

chamber with an HVE.

chamber cap.

12. Use a soft disposable cloth to remove residual powder from the cap ring and the threads of the

A

powder chamber and powder chamber cap (see Figure 25-96a to c).

B

C Figure 25-96  Cleaning of the AIRFLOW Handy 3.0 with soft disposable cloth: A. Cleaning of the

powder chamber threads, B. Cleaning of the powder chamber cap threads, C. Cleaning the cap ring. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Summary

13. Clean the threads of the powder chamber and powder chamber cap with alcohol (ethanol, isopropanol) and then allow to dry completely. 14. Place the cap ring back into the powder chamber cap.

Summary

Air polishing is a safe and effective procedure for the removal and reduction of biofilm, immature dental calculus, and extrinsic exogeneous staining. Many of the same techniques used for ultrasonic instrumentation are transferrable to air polishing such as the grasp, finger rest, aerosol control, and operator and patient positioning.

523

15. Affix the powder chamber cap back onto the powder chamber. 16. Reprocess handpieces according to the manufacturer’s directions in the DFU/IFU.

Lip and cheek retractors, lip lubricant, and face drapes can increase patient comfort during air polishing procedures. The use of an HVE is required to reduce environmental aerosols during air polishing. Repetition and practice will increase your skills and clinical proficiency in supragingival and subgingival air polishing.

CHAPTER 26

Implant Case Definitions and Assessment LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Identify a dental implant by its case definition as peri-implant health, peri-implant mucositis, peri-implantitis, or peri-implant hard and soft tissue deficiency. 2. Identify the structures associated with a dental implant and implant suprastructure. 3. Recognize the anatomy and physiology of peri-implant mucosa and bone. 4. Perform implant clinical assessments that include visual and palpatory tissue inspection, periodontal charting, radiographs, occlusion status, and prosthesis inspection.

KEY TERMS

metal (titanium, gold) or non-metal • Abutment: (high-strength ceramics such as alumina or

zirconia) biomaterial placed directly into the dental implant that provides support for a fixed, fixed-detachable, or removable dental prosthesis. Bone remodeling: period of time after implant placement into maxillary or mandibular bone required for full osseointegration where immature bone is replaced by mature bone. Dental implant: surgically placed biomaterial made of stainless steel, cobalt-based alloy, titanium, or titanium-based alloy placed directly into the maxillary or mandibular bone. Implant baseline: radiographic bone level and 6-point probe depth around a dental implant 12 months post-implant placement. Osseointegration: mechanical and physiological integration, anchorage, and fusion of a dental implant with the maxillary or mandibular bone.

• • • •

implant-supported removable • Overdenture: partial or complete denture with built-in copings

that attach to an implant structure. Peri-implant health: a dental implant with absence of active disease. Peri-implantitis: a dental implant with active disease and loss of attachment. Peri-implant mucositis: a dental implant with active disease of the peri-implant mucosa, with resultant inflammation in the absence of continuing loss of attachment. Prosthesis: dental material (fixed or removable) visible in the mouth that interconnects to any dental implant device. Supracrestal connective tissue attachment: term used to describe the junctional epithelium and supracrestal connective tissue surrounding a dental implant or natural tooth.

• • • • •

Introduction In 2015–2017, the American Academy of Periodontology, European Federation of Periodontology, and more than 100 experts from Asia and Australia came together to build a new classification system for gingival health and diseases to replace the 1999 system. In 2017, the World Workshop took place in Chicago, Illinois, and four case types were defined and released as the “2018 Classification of Periodontal and Peri-Implant Diseases and Conditions.” The implant category is the first of its kind to classify and case define peri-implant health, peri-implant disease, and peri-implant deficiency. Implant dentistry has become a major component of patient treatment 525

526

Chapter 26 Implant Case Definitions and Assessment

planning and care since the last World Workshop was held in 1999. The number of dental implants placed today far exceeds the numbers placed prior to 1999, so a new classification system specific to dental implants was developed. The four categories in the implant classification system are peri-implant health, peri-implant mucositis, peri-implantitis, and peri-implant hard and soft tissue deficiency. This chapter will review the implant classification category and the clinical assessments needed to identify the status of a dental implant. This information will guide you in your debridement technique, maintenance protocols, and recommendations.

A

Dental Implant Anatomy and Physiology A dental implant can be used to replace a single tooth with an implant-supported single crown or replace multiple missing teeth with an implant-supported fixed partial or complete arch prosthesis, implant-supported fixed-detachable partial or complete arch prosthesis, or implant-supported removable partial or complete arch prosthesis, also referred to as an overdenture (see Figure 26-1a to c). A dental implant is comprised of three parts: an implant, abutment, and prosthesis; see Figure 26-2).

B

• Dental implant:

•

•

Surgically placed biomaterial made of stainless steel, cobalt-based alloy, titanium, or titanium-based alloy placed directly into the maxillary or mandibular bone (Anjum & Rajasekar, 2021; De Avila et al., 2014; see Figure 26-2). A dental implant becomes functionally ankylosed into the bone through a remodeling process mediated by osteoblasts. A healing cap is placed onto the dental implant while bone remodeling (defined later in this chapter) and tissue healing are occurring (see Figure 26-3). Abutment: Biomaterial placed directly into the dental implant that provides support for a fixed, fixed-detachable, or removable dental prosthesis (see Figure 26-2). The abutment is a made of metal (titanium, gold) or nonmetal (high strength ceramics alumina, or zirconia) dental materials (De  Avila et al., 2014; Pandoleon et al., 2019; Sailer et al., 2009; Sanz-Sanchez et al., 2018). Prosthesis: Dental material (fixed or removable) visible in the mouth that interconnects to any dental implant device (see Figure 26-2 and Figure 26-4).

C Figure 26-1  Dental Implants: A. Maxillary and

mandibular implant-supported fixed dental prosthesis, B. Maxillary and mandibular implantsupported complete arch removable dental prosthesis (overdenture), C. Mandibular right first molar singletooth implant.

Although dental implants replace natural teeth, they do not possess the same anatomy and physiology as natural teeth. It is important for the oral health-care provider to recognize the anatomical difference between a dental implant and a natural tooth because the differences influence debridement technique, long-term maintenance, recall interval recommendations, and self-care. Implant teeth do not have:

• Bundle bone (alveolar bone process). • Cementum or inserting Sharpey’s fibers.

Dental Implant Anatomy and Physiology

Prosthesis

Abutment

Implant

Figure 26-2  Dental implant structures (implant, abutment, and prosthesis). Reproduced with permission from Dentsply Sirona

Figure 26-3  Implant healing caps/collars on the

maxillary arch.

A

• Five principle fiber groups (alveolar crest, hori•

zontal, oblique, apical, interradicular) of the periodontal ligament. Gingival fiber groups: alveologingival, dentogingival, periosteogingival, intergingival, interpapillary, transgingival, and transseptal.

Implant teeth do have connective tissue fiber bundles oriented parallel and circumferential to the implant and abutment (see Figure 26-5). These anatomical differences make the pathogenesis (manner of disease development) different for a dental implant than for a natural tooth. Attachment and bone loss occur more rapidly around an implant than a natural tooth, and the loss tends to occur circumferentially

B Figure 26-4  Prosthesis: A. Implant retention for

overdenture, B. Coping bar.

527

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Chapter 26 Implant Case Definitions and Assessment

Figure 26-6  Keratinized outer masticatory mucosa

example on a maxillary right central incisor dental implant.

Figure 26-5  Illustration of the connective tissue fiber

bundles oriented parallel and circumferential to the implant and abutment on a maxillary left lateral incisor single-tooth replacement dental implant.

(Berglundh et al., 2018). These findings should be taken into consideration by the provider when peri-implant disease is identified. A wait-and-see approach to treatment planning is not in the patient’s best interest and leads to further destruction, increasing the risk for implant failure. BREAKOUT POINT A dental implant has connective tissue fiber bundles oriented parallel and circumferential to the implant and abutment.

Keratinized Outer Masticatory Mucosa

The structural composition of the keratinized outer masticatory mucosa is 85% collagen fibers and matrix elements, 3% fibroblasts, and 5% vascular units (Araujo & Lindhe, 2018). Orthokeratinized squamous epithelium extends from the margin of the peri-implant mucosa to the movable lining of the oral mucosa (Heitz-Mayfield & Salvi, 2018; see Figure 26-6).

Controversy exists in the literature for the recommended width of keratinized mucosa necessary to decrease the risk of implant failure and disease. Systematic reviews have shown that when the width of keratinized mucosa is less than 2 mm, poorer plaque biofilm control and increased biofilm accumulation occurs due to discomfort with brushing with more fragile thinner tissue (Cortellini & Bissada, 2018; Schwartz et  al., 2018). This will increase the risk for peri-implant disease.

Non-keratinized Inner Masticatory Mucosa

• Basal lamina and hemidesmosomes face the den-

• •

tal implant surface and are inside the outer keratinized mucosa. This area is invaded by pathogens and inflammatory mediators first in peri-implant disease (Heitz-Mayfield & Salvi, 2018). Connective tissue 40 µm in width contacts the implant surface (Araujo & Lindhe, 2018). The barrier sulcular epithelium is similar to the junctional epithelium around natural teeth and is predominately made of collagen fibers 160 µm in width (Araujo & Lindhe, 2018).

Mucosa Remodeling Factors

There are many factors that influence the remodeling of keratinized and non-keratinized mucosa around a dental implant after placement such as:

• Abutment and prosthesis design: There are many

designs for an abutment and prosthesis that vary among manufacturers. The vast market selection adds a challenge to providers who are charged with implant maintenance because abutments and prostheses vary in their width, shape, and height (see Figure 26-7a to d for case examples).

Dental Implant Anatomy and Physiology

529

A

C

B

D Figure 26-7  Abutment and prosthesis: A. Narrow, tapered abutment and wide prosthesis on the maxillary left

first molar and mandibular first molar, B. Abutment is narrower than the implant and prosthesis on the maxillary right first molar, C. Abutment similar width as prosthesis on the mandibular left second premolar, D. Note abutment design differences from others on this maxillary left first premolar.

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Chapter 26 Implant Case Definitions and Assessment

The provider must customize and change their debridement techniques to accommodate design variations. Abutment and prosthesis design have an influence on the epithelial and connective tissue attachment. For example, if restorative margins infringe on the supracrestal connective tissue attachment, inflammation and/or loss of attachment can occur (Jepsen et al., 2018). Supracrestal connective tissue attachment replaced the term biological width and is the term now used to describe the junctional epithelium and supracrestal connective tissue surrounding a dental implant or natural tooth (Jepsen et al., 2018; see Figure 26-8).

• Adjacent teeth position of the gingiva: If recession

•

•

is present around adjacent teeth, the dental implant interdental papillae height will be adversely affected (Heitz-Mayfield & Salvi, 2018; Hammerle & Tarnow, 2018; see Figure 26-9 for a case example). Malpositioning of the surgically placed implant: If the implant is too close or far away from the adjacent tooth, peri-implant mucosa can be adversely affected. The minimum distance for biologically acceptable health between two implants is 3 mm (Berglundh et al., 2018; Hammerle & Tarnow, 2018). The minimum distance for biologically acceptable health between an implant and a natural tooth is 1.5 mm (Berglundh et al., 2018; Hammerle & Tarnow, 2018). See Figure 26-10 and ask yourself if the distance between the dental implants and the distance between the dental implant and natural tooth follows these recommendations. Lack of keratinized tissue or lack of buccal bone when the implant is placed. A patient with a thinner buccal bone plate, thin scalloped biotype, or less keratinized tissue width has an increased risk for bone and tissue remodeling issues (Cortellini & Bissada, 2018; Hammerle & Tarnow, 2018; see Figure 26-11a to c).

Bone Figure 26-8  Restorative margin infringing on the

supracrestal connective tissue attachment of the maxillary central incisors. Note the rolled and inflamed gingiva due to the placement of the porcelain crowns.

Dental implants are functionally ankylosed into the bone through osseointegration (see Figure 26-12). Osseointegration is the mechanical and physiological integration, anchorage, and fusion of a dental implant with the maxillary or mandibular bone.

Figure 26-9  Gingiva positioning: This maxillary right second premolar is an implant-supported prosthesis. The first

molar is a natural tooth with a porcelain-fused-to-metal crown with gingival recession. The arrow is demonstrating an open embrasure space with missing interdental papilla on the distal of the implant-supported prosthesis due to the existing recession and lack of papilla of the adjacent natural molar.

Dental Implant Anatomy and Physiology

531

A

Figure 26-10  Implant positioning around an

implant-supported, fixed prosthesis on the maxillary left posterior.

After a dental is placed into bone, a bone remodeling process begins. Bone remodeling is the period of time after implant placement into maxillary or mandibular bone required for full osseointegration where immature bone is replaced by mature bone (Da Silva Mello et al., 2016).

B

• First 1–3 months post-implant placement, woven

•

bone will form on the surface of the implant and then be replaced by lamellar and marrow bone (Araujo & Lindhe, 2018; Da Silva Mello et al., 2016). This neoformed (immature) bone exhibits characteristics of spongy bone (Da Silva Mello et al., 2016). After 3 months, the spongy bone will be replaced by compact bone (Da Silva Mello et al., 2016). This phase of bone remodeling varies by patient based on many variables such as the existing bone and tissue status of the surgical site, type of implant placed, and patient medical health status.

During the bone remodeling process, the crestal bone height will naturally be reduced. Any crestal bone height loss greater than 2  mm after the first year of implant placement is associated with peri-implantitis (Renvert et al., 2018). The amount of reduction varies for each patient based on a variety of factors such as:

• Manufacturer design variances in implant surfaces, characteristics, size, shape, and abutment-implant interface (Berglundh et al., 2018; Schwartz et al., 2018; see Figure 26-13a to c).

C Figure 26-11  Buccal bone and thin scalloped biotype:

A. Thin buccal bone plate due to long-term edentulism and bone resorption, B. Thin scalloped biotype as evident by blanching of tissue with gentle probing (under 0.25 N), C. Thin scalloped biotype as evident by probe transparency through the tissue upon gentle probing (under 0.25 B).

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Chapter 26 Implant Case Definitions and Assessment

• Provider technique with prosthetic connections • • • •

(Berglundh et al., 2018; Schwartz et al., 2018). Lack of keratinized gingiva (Schwartz et al., 2018). Patient local and systemic factors (Berglundh et al., 2018). Surgical loading (Berglundh et al., 2018). Surgical implant positioning: The minimum amount of buccal bone needed to maintain the proper long-term support of a dental implant is 2 mm (Berglundh et al., 2018; Hammerle & Tarnow, 2018; see Figure 26-14).

BREAKOUT POINT Figure 26-12  Osseointegration, fully osseointegrated

dental implant on the mandibular right first molar.

A

Implant crestal bone height loss less than 2 mm is considered biologically acceptable.

B

C Figure 26-13  Manufacturer design variations: A. Less tapered abutment with a smooth crown

connection on the maxillary left first molar, B. Abutment is tapered and more narrow than prosthesis on the right lateral incisor, C. Wider prosthesis than the abutment on the mandibular left first molar.

Peri-Implant Diseases and Conditions

533

Implant Baseline

A

A new term, implant baseline, was defined in the “2018 Classification of Periodontal and Peri-Implant Diseases and Conditions.” Implant baseline is determined 12 months post-implant placement when bone remodeling is complete (Berglundh et al., 2018). The provider will take a radiograph to assess osseointegration and crestal bone height and acquire a sixpoint probing around the implant (Berglundh et al., 2018). These findings are the implant baseline. All future periodontal charting and radiographs should remain consistent with baseline readings. Loss of bone or increased probe depths from baseline are not normal, and peri-implant disease should be suspected (Berglundh et al., 2018).

BREAKOUT POINT Implant baseline is acquired 12 months after placement and consists of a 6-point probing and radiographic bone position.

In the absence of implant baseline, the provider should suspect peri-implantitis when (Berglundh et al., 2018; Renvert et al., 2018):

• Probe depths are ≥6 mm with bleeding and/or •

suppuration of gingival tissues. Bone level is ≥3 mm apical to the most coronal portion of the implant.

Peri-Implant Diseases and Conditions This section will discuss the “Peri-Implant Diseases and Conditions” of the “2018 Classification of Periodontal and Peri-Implant Diseases and Conditions.”

Peri-Implant Health

Peri-implant health (Berglundh et al., 2018) is a

term used to describe a dental implant with the absence of active disease. See Table 26-1 for a summary. B Figure 26-14  Buccal bone and dental implants: A. More

than 2 mm of buccal bone width on this maxillary left central incisor, B. Less than 2 mm of buccal bone width on the maxillary dental implants supporting this fixed-detachable hybrid complete arch prosthesis.

• Peri-implant soft tissues do not have erythema, • •

edema, or suppuration. There is no attachment loss. Radiographic bone height and quality have not changed from baseline. In the absence of baseline, the crestal bone height has not been reduced over 2 nn.

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Chapter 26 Implant Case Definitions and Assessment

• Probe depths have not increased from baseline. In

immediately with proper interventions to resolve the disease process (Berglundh et al., 2018).

• •

Peri-Implantitis

the absence of baseline, the probe depths are under 6 mm with absence of bleeding upon probing. The dental implant has no mobility. The patient has no discomfort.

BREAKOUT POINT Implant probe depths 5 mm and below without bleeding or suppuration are considered biologically healthy.

Health can be reestablished around a dental implant with decreased bone and soft tissue support just as with natural teeth. An implant can return to a state of health on a reduced support periodontium once attachment loss has been arrested and stabilized with surgical or nonsurgical interventions (Berglundh et al., 2018; Renvert et al, 2018).

Peri-Implant Mucositis

Peri-implant mucositis (Berglundh et al., 2018) is

a term used to describe a dental implant with active disease of the peri-implant mucosa, with resultant inflammation in the absence of continuing loss of attachment. See Table 26-1 for a summary.

• Peri-implant soft tissues have erythema, edema, and/or suppuration.

• There is no radiographic bone loss from baseline. • •

In the absence of baseline, the crestal bone height has not been reduced over 2 mm. Probe depths may have increased from baseline due to gingival swelling and decreased probe resistance. Bleeding upon probing is present. The patient may or may not have soreness.

BREAKOUT POINT Peri-implant mucositis is reversible with treatment.

Peri-implant mucositis can reoccur around a dental implant with previous peri-implant health on a reduced but stable periodontium. Mucositis is reversible with nonsurgical therapy. After therapy, resolution and return to peri-implant health can take up to 3 weeks (Berglundh et al., 2018). Since peri-implant mucositis precedes peri-implantitis, it must be treated

Peri-implantitis is a state of active disease and loss

of attachment around a dental implant. The progression of bone loss in the absence of tissue inflammation and previous peri-implant mucositis is very rare (Berglundh et al., 2018). See Table 26-1 for a summary.

• Peri-implant soft tissues have erythema, edema, •

•

• • •

and/or suppuration. There is increased radiographic bone loss from baseline with more than 2mm crestal bone height loss. In the absence of baseline, crestal bone height loss greater than 2mm would indicate peri-implantitis. Probe depths may have increased from baseline with bleeding upon probing.When baseline probe depths are unknown, any probe depth 6 mm and greater with bleeding would indicate peri-implantitis (Berglundh et al., 2018). Mobility may be present. Patient soreness and discomfort is present. The dental implant itself may be exposed to the oral cavity.

BREAKOUT POINT Peri-implantitis is a state of active disease and loss of attachment around a dental implant that is in need of immediate treatment.

Peri-implantitis should be staged and graded with immediate referral to a specialist for evaluation. When peri-implantitis is successfully treated and arrested, the dental implant can return to a state of peri-implant health on a reduced periodontium.

Peri-Implant Soft and Hard Tissue Deficiencies

Hard and soft tissue deficiencies can be present prior to, during, or after implant placement. They can complicate and compromise implant survival (Hammerle & Tarnow, 2018). The most common etiology of peri-implant hard and soft tissue deficiencies is related to (Hammerle & Tarnow, 2018):

• Systemic diseases and conditions of the patient. • Systemic medications.

Peri-Implant Diseases and Conditions

535

Table 26-1  Peri-Implant Health, Peri-Implant Mucositis, Peri-Implantitis Comparison Peri-Implant Health

Peri-Implant Mucositis

Peri-Implantitis

Tissues

No erythema, edema, suppuration

Erythema, edema, and/or suppuration

Erythema, edema, and/or suppuration

Radiographic Bone Loss (RBL)

No RBL from baseline and #2 mm crestal bone loss* (Renvert et al., 2018)

No RBL from baseline and #2 mm crestal bone loss (Renvert et al., 2018)

Increased RBL from baseline OR $3 mm crestal bone loss in the absence of baseline

Attachment Loss

None*

None

Present

Probe Depth (PD)

No increases from baseline and #5 mm (Renvert et al., 2018)

Increases from baseline due to gingival swelling or decreased probe resistance

Increase PD from baseline OR $6 mm in the absence of baseline

BOP

None

Present

Present

Mobility

None

None

Present

Patient Soreness

None

Possible

Present

*Does not represent a dental implant with peri-implant health on a reduced periodontium. Berglundh et al. (2018)

• Processes of tissue healing. • Tissue turnover and response to clinical interven• • • • •

tions. Trauma to orofacial structures. Local diseases affecting teeth, periodontium, bone, and mucosa. Biomechanical factors. Tissue morphology and phenotype (thin scalloped biotypes). Iatrogenic factors.

There are many factors that contribute to hard and soft tissue deficiencies around a dental implant. Providers should be aware of these risk factors and adjust clinical treatment and management as indicated.

Hard Tissue Deficiencies Prior to Implant Placement

Figure 26-15  Bone resorption on the mandibular right

edentulous ridge.

• Edentulous ridges with natural resorption that re-

• Bone loss due to periodontitis, endodontic infec-

•

•

quire bone augmentation for implant placement (Hammerle & Tarnow, 2018; see Figure 26-15). Traumatic tooth extraction with damage to surrounding bone that adversely affects healing. Crestal bone height loss around adjacent teeth and loss of buccal bone can challenge the placement of a dental implant (Hammerle & Tarnow, 2018).

tions, longitudinal root fractures, or general trauma (Hammerle & Tarnow, 2018; see Figure 26-16). Bone height in the posterior maxilla can complicate dental implant placement because of the presence of the maxillary sinus. The posterior teeth are usually buccal to the sinus separated by a thin plate of bone, but due to radiographic angulation and superimposition, the maxillary

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Chapter 26 Implant Case Definitions and Assessment

A

Figure 26-16  Root fracture of the maxillary right central

incisor.

second premolar and molars may appear to project into the sinus (see Figure 26-17a). Sinus pneumatization after tooth extraction changes the height of the maxillary bone in the posterior region. The bone can become insufficient for the placement of a dental implant (see Figure 26-18). The bone may also become insufficient for a standard-length dental implant, increasing the risk of boney defects (see Figure 26-17b and Figure 26-19; Hammerle & Tarnow, 2018).

B Figure 26-17  Maxillary posterior teeth: A. Maxillary right

premolar periapical where the maxillary sinus appears superimposed over the apices of the premolar and molar teeth, B. Dental implants with varying heights and widths. B: Reproduced with permission from Dentsply Sirona

Hard Tissue Deficiencies after Implant Placement

• Defects in healthy situations can occur after tooth •

removal and implant placement such as dehiscence, fenestration, and infraboney defects (Hammerle & Tarnow, 2018). Malpositioning of implants: If an implant is placed too far buccally with less than 2 mm of buccal bone width, the risk for mucosal recession and narrow keratinized tissue increases (Hammerle & Tarnow, 2018).

Figure 26-18  Maxillary right first molar edentulous

spaces where the maxillary bone is insufficient for implant placement.

Clinical Assessments

537

Soft Tissue Deficiencies Prior to Implant Placement

• Tooth loss will cause a reduction of the alveo•

lar ridge and soft tissues (Hammerle & Tarnow, 2018; see Figure 26-20). Periodontal or systemic diseases that reduce bone height. When bone augmentation is required, the available soft tissue may be insufficient to cover the new bone volume (Hammerle & Tarnow, 2018).

Soft Tissue Deficiencies after Implant Placement

A

• Lack of buccal bone can be the result of trau-

•

• B Figure 26-19  Maxillary dental implants: A. Radiographic

measurements of the maxillary right first molar for bone width, sinus position, and prosthesis clearance, B. Shorter height dental implants of the maxillary right second premolar and first molar.

•

matic extraction or natural bone resorption after tooth loss. Lack of buccal bone can lead to mucosal recession around the dental implant over time (Hammerle & Tarnow, 2018; see Figure 26-20). Interdental papilla height can be compromised based on implant position and whether the implant is placed next to another implant or a natural tooth (Hammerle & Tarnow, 2018; see Figure 26-21 and Figure 26-22). Keratinized tissue width over 2 mm is more ideal than under 2 mm for the long-term health of a dental implant (Hammerle & Tarnow, 2018). Migration of teeth and lifelong skeletal changes: Maxillary and mandibular anatomy changes and teeth placement shifts throughout a lifetime. This can cause “discrepancies of facial tissue heights between an implant crown and the natural tooth” (Hammerle & Tarnow, 2018).

• Previous peri-implantitis with loss of peri-implant • • •

hard and soft tissues at implant sites ­(Hammerle & Tarnow, 2018). Limited evidence supports mechanical overload as a potential for interference with osseointegration (Hammerle & Tarnow, 2018). Systemic diseases and medications such as prolonged bisphosphonates, radiotherapy, and osteogenesis imperfecta can lead to bone damage (Hammerle & Tarnow, 2018). Tissue phenotype: Thinner scalloped biotype can lead to greater marginal bone loss than when an implant is placed into thick biotype tissues (Cortellini & Bissada, 2018; Hammerle & Tarnow, 2018). Table 26-2 provides a tissue phenotype example.

BREAKOUT POINT An implant can remain healthy and stable with a soft and hard tissue deficiency; however, these deficiencies increase the risk for long-term complications.

Clinical Assessments Now that you are familiar with peri-implant case definitions, let’s tie those concepts with clinical practice. There are a series of clinical assessments providers

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Chapter 26 Implant Case Definitions and Assessment

Table 26-2  Tissue Phenotype Tissue phenotype is a thin scalloped biotype as evident by the probe being visible through the tissue upon gentle probing with less than 0.25 N of pressure. Thin phenotypes are at higher risk for mucogingival defects (Cortellini & Bissada, 2018). Thin phenotypes typically have slender triangular shaped teeth, interproximal contacts closer to incisal edge (red dot), thin buccal bone, and a narrow zone of keratinized tissue width (Cortellini & Bissada, 2018).

Tissue phenotype is a thick biotype. The probe will not be visible through the tissue when probing. Thick phenotypes are at lower risk for mucogingival defects (Cortellini & Bissada, 2018). Thick phenotypes typically have square-shaped teeth, interproximal contacts more apical (red dot), thicker buccal bone, and a broad zone of keratinized tissue width (Cortellini & Bissada, 2018).

should perform each time the patient presents for their regular recall appointment when they have an implant restoration. The clinical assessments required for proper implant evaluation include visual and palpatory tissue inspection, periodontal charting, radiographs, occlusion status, and prosthesis health inspection.

BREAKOUT POINT Clinical assessments of a dental implant should be performed at each recall appointment and should include visual and palpatory tissue inspection, periodontal charting, radiographs, occlusion status, and prosthesis health inspection.

Clinical Assessments

539

Visual and Palpatory Tissue Assessment

Figure 26-20  Alveolar bone resorption of edentulous

maxillary right first molar.

1. Visually inspect implant tissues for signs of disease. 2. Visually inspect the level of oral deposit accumulation and perform a plaque index because oral deposits contribute to disease pathogenesis ­(Berglundh et al., 2018; Schwartz et al., 2018). The patients in Figure 26-23 are in need of athome oral hygiene instructions and motivation. 3. Palpate the outer keratinized masticatory mucosa to determine if the tissue has adequate width. If the tissue is tender upon palpation, or the threads of the implant can be felt, this could be a sign of active disease or the potential for an increased risk of disease. The dental implant itself should not be visible. If the threads are visible, this is either a sign of active disease or previously arrested disease. A referral to a specialist for evaluation may be indicated. 4. Palpate and visually inspect the prosthesis to ensure that it is not loose or fractured. BREAKOUT POINT Visually inspect and palpate a dental implant and prosthesis at each recall appointment.

Periodontal Charting Assessment Figure 26-21  Lack of buccal bone and keratinized tissue

after a traumatic extraction that led to buccal recession and reduced height of the mesial interdental papilla of this mandibular right first molar.

A dental implant periodontal charting assessment consists of recording a 6-point probe with bleeding points, gingival margin position, clinical attachment, and mobility.

Probe Depths

Figure 26-22  Embrasure space between the maxillary

left central incisor dental implant and the maxillary left lateral incisor natural tooth.

Perform a 6-point probe with bleeding points at minimum annually, but best practice would be to probe at each recall appointment (Renvert et al., 2018; Lang & Bartold, 2017). If the dental implant was recently placed, you may want to consult with the specialist prior to probing for the first time. There is a length of time during bone and soft tissue remodeling when the implant should not be probed to avoid injury. The maximum pressure for probing natural teeth is 0.25 N or 25 g (Lang & Bartold, 2017). Peri-implant non-keratinized mucosa is less vascularized in the zone between the bone crest and the barrier sulcular epithelium compared to natural teeth, and because of this, the provider should use as minimal

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Chapter 26 Implant Case Definitions and Assessment

A

B

C Figure 26-23  Oral deposit accumulation: A. Dental biofilm and calculus present under mandibular implant-supported

fixed dental prosthesis, B. Plaque biofilm and material present around a coping bar, C. Dental calculus present under mandibular implant-supported fixed prosthesis and the mandibular implant-supported fixed-detachable hybrid prosthesis.

amount of pressure as possible to obtain the correct depth, but never to exceed 25 g (Berglundh et  al., 2018). If too much pressure is applied when probing a dental implant, false pocket depths and bleeding can occur, which overestimate the disease state (Lang & B ­ artold, 2017). Probe depths 5 mm and under that do not bleed are considered biologically acceptable and healthy (Berglundh et al., 2018; Renvert et al., 2018). BREAKOUT POINT A dental implant should be probed at each recall appointment with a maximum probing pressure of 0.25 N or 25 g.

Gingival Margin The gingival margin position should be evaluated during periodontal charting. Providers should determine if the gingival margin is coronal or apical to its correct position around the abutment and prosthesis.

• Coronal to its correct position: This could be due •

to tissue inflammation or a restorative margin that infringes on the supracrestal connective tissue attachment. Apical to its correct position: Peri-mucosa recession can be caused by nonpathologic and pathologic conditions. If the dental implant has peri-mucosa recession, the provider should investigate the cause to determine if any action is needed.

Clinical Assessments

541

Peri-Mucosa Recession. Peri-mucosa recession can be part of the nonpathologic healing process or caused by a pathologic condition (see Figure 26-21). Providers need to identify the etiology of the peri-mucosa recession to determine if this is a natural healing process or a sign of active disease. The simple existence of peri-mucosa recession does not indicate disease. BREAKOUT POINT The presence of peri-mucosa recession does not always indicate disease presence.

Figure 26-24  Dental implant mobility test under an

implant-supported fixed-detachable hybrid maxillary prosthesis.

The interproximal papillae height around a dental implant is many times shorter than a natural tooth and does not always indicate disease (Berglundh et al., 2018).

• When a dental implant is placed next to a natural •

tooth, the papillae height is largely determined by the periodontal tissues surrounding the natural tooth (Hammerle & Tarnow, 2018). When a dental implant is placed next to another implant, the papillae height is largely determined by the bone crest between the two implants (Hammerle & Tarnow, 2018).

Peri-mucosa recession is attributed to many factors such as (Berglundh et al., 2018):

• Surgical malposition of the implant. • Implant placed into the bone with a hard tissue • • • • •

deficiency. Implant placed into the tissue with an existing soft tissue deficiency. Thin tissue phenotype with a thinner width of keratinized tissue. Lack of buccal bone (≤2 mm). Status of attachment of adjacent teeth. If recession is present in adjacent teeth, peri-mucosa recession is more likely. Surgical trauma.

Mobility

Figure 26-25  Mobility test for implant-supported

prosthesis on the mandibular right second premolar.

Testing for dental abutment mobility: 1. Place an implant-appropriate instrument under the prosthesis. 2. Gently push back and forth to determine if the abutment screw is loose. Testing for implant-supported prosthesis mobility:

Mobility should be tested and recorded in the periodontal chart. Testing for dental implant mobility:

1. Place an implant-appropriate blunt instrument on either side of the prosthesis (see Figure 26-25). 2. Gently press side to side.

1. Place an implant-appropriate instrument under the prosthesis in the embrasure space (see Figure 26-24). 2. Apply gentle pressure to determine the presence of mobility of the implant.

A dental implant, abutment, and prosthesis should never be mobile. If mobility is present, immediately refer for evaluation. If the dental implant is mobile, you should suspect peri-implantitis.

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Chapter 26 Implant Case Definitions and Assessment

BREAKOUT POINT

BREAKOUT POINT

Check for mobility of the implant, abutment, and prosthesis at each recall appointment.

A dental implant requires minimum annual radiographs, and when two or more implants are present, panoramic and/or CBCT imaging is needed more frequently than it is for natural teeth.

Radiographic Assessment Radiographs are an important assessment of the stability and health of a dental implant. Radiographic assessment is recommended within the first year of prosthesis delivery, and subsequent radiographic frequency should be based on individual patient risk factors (Hernandez & Katsaros, 2018).

• In the first year, radiographic frequency is based • • •

on the clinical patient presentation and should occur more frequently than it does natural teeth (Berglundh et al., 2018). After the first year, minimum annual radiographic assessment is recommended (Berglundh et al., 2018). If a patient has two or more dental implants, a panoramic radiograph is recommended more frequently (Berglundh et al., 2018; see Figure 26-26a). If the patient has five or more dental implants, a panoramic radiograph or a Cone-beam computer tomography (CBCT) is recommended more frequently (Berglundh et al., 2018; see Figure 26-26b).

Occlusion Assessment Occlusion is dynamic and constantly changes over time. A balanced occlusal scheme is important for a patient with any type of dental implant. An occlusal evaluation with articulating paper should be performed at each recall appointment to evaluate for occlusal trauma (see Figure 26-27). Occlusal forces should be evenly distributed over teeth in both arches to prevent implant injury or prosthesis damage from occlusal trauma (Fischer & Stenberg, 2013). Occlusal overload is noted as a possible contributor to implant failure, but evidence is inconclusive at this time (Berglundh et al., 2018; Schwartz et al., 2018). If a removable occlusal device (guard) is indicated to protect the implant-borne fixed restoration, the provider should follow these recommendations (Bidra, Daubert, Garcia, Kosinski, et al., 2016; Bidra, Daubert, Garcia, Gauthier, et al., 2016):

• Evaluate the device at each recall appointment for • • •

fit and function. Professionally clean the device at each recall appointment. Provide patient education on use and proper storage. Educate the patient on self-care and cleansing with manufacturer-approved solutions and chemicals.

Prosthesis Health

A

Providers should evaluate the health of the prosthesis and/or removable appliances at each recall appointment. Check the prosthesis for:

• Fractures, chips, or cracks (see Figure 26-28) • Loss of retention or loosening.

B Figure 26-26  Multiple dental implants: A. Three dental

implants seen on a panoramic radiograph, B. More than five dental implants seen on a panoramic radiograph.

Figure 26-27  Occlusal evaluation with articulating

paper markings.

Recall Recommendations

543

Figure 26-29  Removable appliances: A. Implant-

supported removable maxillary overdenture.

Figure 26-28  Fractured porcelain-fused-to-metal crown

on the mandibular right first molar lingual surface.

• Bio-corrosion. • Surface topography changes. • Loose screws or attachments. • Screw fracture. If an implant supported fixed-detachable partial or complete arch prosthesis is removed for repair or replacement, new prosthetic screws should be placed (Bidra, Daubert, Garcia, Gauthier, et al., 2016). A removable prosthesis may need adjustments, repair, replacement, or a remake if any of the prosthetic components becomes compromised (Bidra, Daubert, Garcia, Gauthier, et al., 2016). Patients should receive oral hygiene education on the proper care and maintenance of a removable appliance as well as professional cleaning at each recall appointment (Bidra, Daubert, Garcia, Kosinski, et al., 2016; see Figure 26-29a and b).

et al., 2016). Patients with implant-borne restorations require lifelong well-structured maintenance recall appointments (Bidra, Daubert, Garcia, Kosinski, et al., 2016; Bidra, Daubert, Garcia, Gauthier, et al., 2016; Pjetursson, Thomas, et al., 2012; Pjetursson, Helbling, et al., 2012). Since peri-implantitis typically occurs within the first few years after implant placement, it is prudent for the provider to place a patient on a more frequent recall (Berglundh et al., 2018; Renvert et al., 2018). The American Academy of Periodontology (AAP) states, “There is no predictable model or algorithm to predict the progression of peri-implantitis based on diagnostic methodologies currently available in daily practice,” so close monitoring and thorough assessments are imperative for long-term implant stability and health (Berglundh et al., 2018; Renvert et al., 2018). Recall timing should be based on individual patient risk assessments. The American College of Pro­ sthodontists’ Clinical Practice Guidelines recommend at minimum a 6-month recall for a patient with an implant-borne restoration, and for those patients at “higher risk based on age, ability to perform oral self-care, biological or mechanical complications of remaining natural teeth, tooth-borne restorations, or implant-borne restorations,” a more frequent recall may be required (Bidra, Daubert, Garcia, Gauthier, et al., 2016). Patients with a high susceptibility or

Recall Recommendations The American College of Prosthodontists has established clinical practice guidelines for recall and maintenance of patients with tooth-borne and implant-borne dental restorations. They state the guidelines “are intended to provide clinicians with guidance in diagnosis, treatment planning, and clinical decision-making” (Bidra, Daubert, Garcia, Gauthier,

BREAKOUT POINT A patient with a dental implant should be seen at minimum every 6 months for recall appointments and more frequently based on individual risk assessments.

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Chapter 26 Implant Case Definitions and Assessment

history of active periodontitis, may need a more frequent recall than periodontally stable patients as their risk for peri-implantitis is higher (Berglundh et  al., 2018; Schwartz et al., 2018; Pjetursson, Thomas, et al., 2012; Pjetursson, Helbling, et al., 2012). Patients with lack of regular preventive maintenance care and poor plaque biofilm control as indicated by a high plaque index have a significantly higher risk for developing peri-implant mucositis and peri-implantitis (Berglundh et al., 2018; Schwartz et al., 2018; Costa et al., 2012). It is of utmost importance that patients with implant-borne restorations be seen regularly for maintenance recall appointments based on individual risk factors and have oral self-care that promotes peri-implant health.

Oral Hygiene Instructions Lifelong oral self-care with professional guidance is needed to maintain peri-implant health and stability (Bidra, Daubert, Garcia, Gauthier, et al., 2016). Oral hygiene aids for a patient with an implantborne restoration include, but are not limited to:

• Oral topical agents, such as neutral-sodium flu-

•

•

•

oride with 0.3% triclosan or 5,000 ppm fluoride toothpaste should be recommended for those patients with increased caries risk (Bidra, Daubert, Garcia, Kosinski, et al., 2016; Bidra, Daubert, Garcia, Gauthier, et al., 2016). When antimicrobial action is required to reduce inflammation, chlorhexidine (gel, mouth rinse, spray) should be used short-term because it will not adversely affect osseointegration (Bidra, Daubert, Garcia, Gauthier, et al., 2016; Figuero et  al., 2014; Lupi et al., 2017; Schou et al., 2013). A patient with an implant-borne restoration can benefit from an electric toothbrush, dental floss, and a water or air flosser. Interdental aid recommendations should be customized based on the interdental papilla height (Bidra, Daubert, G ­ arcia, Kosinski, et  al., 2016; Bidra, Daubert, Garcia, Gauthier, et al., 2016). For a patient with an implant-supported removable partial or complete overdenture, the patient should be educated to remove the appliance at night and cleanse the appliance twice daily with a soft denture brush and denture cleaning agent.

For the patient with a thin tissue phenotype, lack of keratinized tissue, or lack of buccal bone, or if the

peri-implant mucosa is tender or sore, the following may be helpful:

• Extra soft manual brush using a light Stillman or • • •

Bass method. Electric toothbrush with a low-frequency option. Waterpik or air flosser with a low-speed option. Antimicrobial chlorhexidine.

BREAKOUT POINT Chlorhexidine, neutral-sodium fluoride with 0.3% triclosan, and 5,000 ppm neutral-sodium fluoride can be safely recommended for a patient with an implant-borne restoration (Bidra, Daubert, Garcia, Kosinski, et al., 2016).

Brushing

• Swierkot et al. (2013) found no significant differ•

ences between electric and manual toothbrushing on plaque reduction around dental implants and peri-implant soft tissues. Brushing with a manual or electric toothbrush is safe and effective for natural and implantsupported prosthesis when dexterity and commitment and motivation to oral hygiene care is not an issue (Vandekerckhove et al., 2004).

Interdental Aids

Missing or blunted interdental papillae or wide interdental spaces are difficult to clean with toothbrush bristles alone because patients may not be able to access the interproximal spaces thoroughly. The use of interdental aids is helpful to properly de-plaque the interproximal space around a dental implant to prevent biofilm accumulation and subsequent gingival inflammation (Swierkot et al., 2013; Corbella et al., 2011). Common interdental aids include:

• Water or air flossers. • Soft-Pick with elastomeric

fingers

(see

Figure 26-30a).

• Rubber tip stimulator (see Figure 26-30b). • End tuft toothbrush (see Figure 26-30c). • Interdental brush without a metal core

(see and b). There are many different lengths, shapes (straight, curved), and thickness of bristles. Customize your selection based on the patient presentation. Figure 26-31a

Dental Floss Patients with dental implants can use waxed, tufted, or woven floss depending on the abutment and prosthesis. The technique for proper flossing is different

Oral Hygiene Instructions

545

A

A

B

B C Figure 26-30  Interdental aids: A. GUM Soft-Pick,

B. Rubber tip stimulator, C. Sulcabrush.

Figure 26-31  GUM Interdental aid: A. GUM go-between,

B. GUM Instructions, note number three states “not for use around implants.” A and B: Used with permission from Sunstar Americas, Inc.

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Chapter 26 Implant Case Definitions and Assessment

Figure 26-32  Flossing a dental implant.

than it is for natural teeth. The patient performs vertical C-shaped flossing and then places the floss in both interproximal spaces of the dental implant, crisscross the floss, and shoeshines back and forth (see Figure 26-32).

BREAKOUT POINT A dental implant is not flossed the same as a natural tooth.

CASE STUDY

The patient is a 64-year-old Caucasian female with a history of ulcerative colitis and occasional back pain and is taking meloxicam 15 mg bid. All vitals are within normal limits and Body Mass Index (BMI) is 20. The patient lives with her husband of 36 years, is a nonsmoker, does not drink alcohol, and has a gluten-free diet due to her ulcerative colitis. Her chief complaint is “I have temporomandibular disorder (TMD) and I clench frequently.” Dental exam: Patient wears a nightguard when she sleeps that was fabricated by a dentist. No previous orthodontics. Recurrent decay present maxillary right second molar and mandibular right second premolar. Mandibular left first premolar occlusal is fractured. Occlusion: Class I bilateral with first molar relationship. Oral hygiene exam: Scattered light biofilm with a plaque biofilm index of 13%. Periodontal exam: see periodontal chart below. Tissue description: Generalized loss of stippling, tissues generally coral pink. Only areas of marginal erythema were found on the probe depths that had bleeding. Edema present maxillary left first molar dental implant and maxillary right second molar.

Oral Hygiene Instructions

Full mouth series radiograph.

Periodontal chart.

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Chapter 26 Implant Case Definitions and Assessment

1. What is the patient’s implant classification for the mandibular right first molar based on the information provided? a. Peri-implant health b. Peri-implant mucositis c. Peri-implantitis d. Peri-implant soft and hard tissue deficiency 2. What is the patient’s implant classification for the maxillary left first molar based on the information provided? a. Peri-implant health b. Peri-implant mucositis c. Peri-implantitis d. Peri-implant soft and hard tissue deficiency 3. Which of the following could have contributed to the peri-implantitis of the maxillary left first molar implant? Select all that apply. a. Poor plaque control b. Patient’s smoking habit c. Patient’s meloxicam use d. Sinus pneumatization e. Submucosal cement f. Clenching parafunctional habit g. Poor surgical implant placement h. Previous debridement that caused stripping and removal of implant threads 4. After assessment and diagnosis, what should be planned for the mandibular right first molar? a. Debride and schedule the patient for the next recall. b. Refer immediately to a specialist for evaluation. c. Do nothing; an implant does not need to be debrided at each recall appointment if it is healthy. d. Take a radiograph of the tooth and do not debride. 5. After assessment and diagnosis, what should be planned for the maxillary left first molar? a. Debride and check again in 3 months. b. Debride and check again in 6 months. c. Refer immediately to a specialist for evaluation. d. Nothing needs to be planned for this tooth. 6. How often should a radiograph be taken of the mandibular right first molar and why? 7. The maxillary left first molar implant is surgically removed, and a new implant placed. The patient is then referred back to your office for routine recall and maintenance. How often should you radiograph the new implant within the first year after placement? Explain your answer.

Summary

Dental implants require lifelong maintenance to prevent peri-implant disease. Providers need a strong working knowledge of the case definitions for peri-implant health, peri-implant mucositis, peri-implantitis, and peri-implant hard and soft tissue deficiency to correctly classify a patient’s implant status and provide appropriate interventions. A dental implant can reestablish health on a reduced

Questions

1. Which of the following is present around a dental implant? a. Sharpey’s fibers b. Periodontal ligament c. Connective tissue fiber bundles oriented parallel and circumferential d. Transgingival fibers

periodontium upon successful surgical or nonsurgical interventions. Providers should perform visual and palpatory inspection, periodontal charting, radiographs, and occlusion status evaluation, and check prosthesis status at each recall appointment. Patients should receive professional oral hygiene instructions that are customized to their needs at each recall appointment.

2. Which of the following is TRUE of the non-keratinized inner masticatory mucosa of a dental implant? a. Basal lamina and hemidesmosomes face the dental implant surface and are inside the outer keratinized mucosa.

Questions

b. Direct implant surface is contacted by connective tissue predominately made of fibroblasts that is 40 µm in width. c. The barrier sulcular epithelium is similar to the junctional epithelium around natural teeth and is predominately made of collagen fibers 160 µm in width. d. All of the above. 3. At what month will spongy bone be replaced by compact bone during natural bone remodeling after implant placement? a. 1 month b. 2 months c. 3 months d. None of the above 4. How much crestal bone height reduction has been shown to be associated with peri-implantitis? a. 0.5 mm b. 1.0 mm c. 1.5 mm d. >2.0 mm 5. After implant placement, when is implant baseline determined? a. 3 months b. 6 months c. 12 months d. 24 months 6. In the absence of implant baseline, the provider should suspect peri-implantitis when which of the following occur(s)? a. Bleeding upon probing and/or suppuration of gingival tissues with probe depth ≥5 mm b. Bleeding upon probing and/or suppuration of gingival tissues with probe depth ≥6 mm c. Crestal bone height loss of 1 mm d. Crestal bone height loss of 1.5 mm Match the following terms to their correct description for questions 7–10. There is only one correct answer for each term. 7. Peri-implant health

8. Peri-implant mucositis

A. Dental implant with absence of bleeding where probe depths and the crest of alveolar bone have not changed since baseline. B. Implant placed into compromised bone from previous periodontitis, endodontic infection, longitudinal root fracture, or general trauma.

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9. Peri-implantitis

C. Bleeding upon probing and suppuration around a dental implant without loss of bone from baseline. 10. Peri-implant soft D. Loss of bone and probe and hard tissue depths over 6 mm with deficiency bleeding upon probing. 11. True or False. Peri-implant health can be reestablished around a dental implant with attachment loss from past disease processes that have been arrested. a. True b. False 12. Which of the following conditions is reversible? a. Peri-implant mucositis b. Peri-implantitis c. Peri-implant soft tissue deficiency d. Peri-implant hard tissue deficiency 13. What is the minimal amount of buccal bone recommended to support a dental implant and decrease the risk for future peri-implantitis? a. 0.5 mm b. 1.0 mm c. 2.0 mm d. 4.0 mm 14. What is the minimum distance an implant should be placed adjacent to a natural tooth? a. 1.5 mm b. 2.0 mm c. 3.0 mm d. 4.0 mm 15. Complete the sentence. A dental implant is at greater risk for failure and bone remodeling issues when only of keratinized mucosa is present. a. 1 mm b. 4 mm c. 5 mm d. 6 mm 16. Which of the following clinical assessments should be performed at each recall appointment for a patient with a dental implant? a. Visual inspection b. Palpatory inspection c. Periodontal charting d. Occlusion evaluation e. All of the above

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Chapter 26 Implant Case Definitions and Assessment

17. What is the maximum pressure that should be applied when probing a dental implant or natural tooth? a. 10 g b. 15 g c. 20 g d. 25 g 18. True or False. Peri-implantitis is present if gingival recession is found around a dental implant. a. True b. False 19. Which of the following can contribute to peri-mucosa recession? a. Surgical malposition of the implant. b. Recession is present on adjacent teeth. c. Surgical trauma. d. All of the above. 20. Which of the following radiographs is recommended more frequently when a patient has five or more dental implants? a. Periapical b. Bitewing

References

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c. Panoramic d. Radiographs are not needed for a dental implant 21. Which of the following should the provider do at each recall appointment for a patient who wears an occlusal device (guard)? a. Evaluate the device at each recall appointment for fit and function. b. Professionally clean the device at each recall appointment. c. Provide patient education on use and proper storage. d. Educate the patient on self-care and cleansing with manufacturer-approved solutions and chemicals. e. All of the above. 22. True or False. Every patient with an implantborne restoration should be placed on a three-month recall appointment. a. True b. False

Chandler, N. D., & Curtis, D. A. (2016). Clinical practice guidelines for recall and maintenance of patients with toothborne and implant-borne dental restorations. Journal of Prosthodontics, 25, S32–S40. 7. Corbella, S., Del Fabbro, M., Taschieri, S., De Siena, F.,  & Francetti, L. (2011). Clinical evaluation of an implant maintenance protocol for the prevention of peri-implant diseases in patients treated with immediately loaded full-arch rehabilitations. International Journal of Dental Hygiene, 9, 216–222. 8. Cortellini, P., & Bissada, N. (2018). Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic consideration. Journal of Periodontology, 89(Suppl  1), S204–S213. https://doi.org/10:10.1002/JPER .16-0671 9. Costa, F. O., Takenaka-Martinez, S., Cota, L. O. M., Ferreira,  S.  D., Silva, G. L. M., & Costa, J. E. (2012). Peri-implant disease in subjects with and without preventive maintenance: A 5-year follow-up. Journal of Clinical Periodontology, 39, 173–181. 10. Da Silva Mello, A. S., Dos Santos, P. L., Marquesi, A., Queiroz,  T. P., Margonar, R., & De Souza Faloni, A. P. (2016). Some aspects of bone remodeling around dental implants. Clinical Journal of Periodontics, Implantology and Oral Rehabilitation. https://doi.org/10.1016/j.piro.2015.12.001 11. De Avila, E. D., De Molon, R. S., Vergani, C. E., De Assis Mollo,  F., & Salih, V. (2014). The relationship between biofilm and physical-chemical properties of implant abutment materials for successful dental implants. Materials, 7, 3651–3662.

References 12. Degidi, M., Scarano, A., Piattelli, M., Perrotti, V., & Piattelli, A. (2005). Bone remodeling in immediately loaded and unloaded titanium dental implants: A histologic and histomorphometric study in humans. Journal of Oral Implantology, 31(1), 18–24. 13. Figuero, E., Graziani, F., Sanz, I., Herrera, D., & Sanz, M. (2014). Management of peri-implant mucositis and peri-implantitis. Periodontology, 2000(66), 255–273. 14. Fischer, K., & Stenberg, T. (2013). Prospective 10-year cohort study based on a randomized, controlled trial (RCT) on implant-supported full-arch maxillary prosthesis. Part II: Prosthetic outcomes and maintenance. Clinical Implant Dentistry and Related Research, 15(4), 498–508. 15. Hammerle, C., & Tarnow, D. (2018). The etiology of hard-and soft-tissue deficiencies at dental implants: A narrative review. Journal of Periodontology¸ 89(Suppl 1), S291–S303. https:// doi.org/10.1002/JPER.16-0810 16. Heitz-Mayfield, L., & Salvi, G. (2018). Peri-implant mucositis. Journal of Periodontology, 89(Suppl 1), S257–S266. https://doi.org/10.1002/JPER.16-0488 17. Hernandez, M., & Katsaros, T. (2018). Overview of the new peri-implant and periodontal disease classification system. https:// decisionsindentistry.com/article/ce-sponsored-by-colgate-in -partnership-with-the-american-academy-of-periodontology -overview-of-the-new-peri-implant-and-periodontal-disease -classification-system/ 18. Jepsen, S., Canton, J. G., Albandar, J. M., Bissada, N.  F., Bouchard, P., Cortellini, P., Demirel, K., De Sanctis,  M., Ercoli,  C., Fan, J., Geurs, N. C., Hughes, F. J., Jin,  L., Kanatarci,  A., Lalla, E., Madianos, P. N., Matthews, D., McGuire, M. K., Mills, M. P., Preshaw, P. M., Reynolds, M. A., Sculean, A., Susin, C., West, N. X., & Yamazaki, K. (2018). Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workshop 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. Journal of Periodontology, 89(Suppl 1), S237–S248. 19. Lang, N., & Bartold, P. (2017). Periodontal health. Journal of Periodontology, 89(Suppl 1), S9–S16. https://doi.org/10.1002 /JPER.16-0517 20. Lombardi, T., Bernardello, F., Berton, F., Porrelli, D., Rapani, A., Piloni, A. C., Fiorillo, L., Di Lenarda, R., & Stacchi, C. (2018). Efficacy of alveolar ridge preservation after maxillary molar extraction in reducing crestal bone resorption and sinus pneumatization: A multicenter prospective case-control study. BioMed Research International, 1–9. https://doi.org/10 .1155/2018/9352130 21. Lupi, S. M., Granati, M., Butera, A., Collesano, V., Rodriguez, R., & Baena, Y. (2017). Air-abrasive debridement with glycine powder versus manual debridement and chlorhexidine administration for the maintenance of peri-implant health status: A six-month randomized clinical trial. International Journal of Dental Hygiene, 15, 287–294. 22. Pandoleon, P., Bakopoulou, A., Papadopoulou, L., & Koidis,  P. (2019). Evaluation of the biological behaviour of

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CHAPTER 27

Mechanical Implant Maintenance LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Appraise, compare, and contrast dental technology used in the debridement and maintenance of a dental implant. 2. Identify the surface topography of a dental implant, abutment, and prosthesis. 3. Select the appropriate debridement technique based on implant, abutment, and prosthesis presentation. 4. Recognize the clinical indications, limitations, and contraindications of mechanical debridement technology and techniques for a dental implant, abutment, and prosthesis.

KEY TERMS

implant debridement: removal • Mechanical of oral deposits through direct contact with

hand-activated instrumentation, ultrasonic instrumentation, or air polishing technologies. Nonmechanical implant debridement: removal of oral deposits through direct or indirect contact with dental lasers, chlorhexidine, low-concentration (