Application of ultrasound in periodontics

J Indian Soc Periodontol. 2008 Sep-Dec; 12(3): 5561. doi: 10.4103/0972-124X.44096 Copyright Journal of Indian Society of Periodontology Vivek K. Bains,1 Ranjana Mohan,2 and Rhythm Bains3 1Senior Lecturer, Department of Periodontics, Saraswati Dental College and Hospital, Lucknow (UP), India 2Professor and Head, Department of Periodontics, Saraswati Dental College and Hospital, Lucknow (UP), India 3Senior Lecturer, Department of Conservative Dentistry, Career PG Institute of Dental Sciences and Hospital, Lucknow (UP), India Correspondence: Dr. Vivek Kumar Bains, #16/1317, Indiranagar, Lucknow 226 016 (UP), India. E-mail: doc_vivek76@yahoo.co.in Received October 19, 2008; Accepted November 4, 2008. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Ultrasound offers great potential in development of a noninvasive periodontal assessment tool that would offer great yield real time information, regarding clinical features such as pocket depth, attachment level, tissue thickness, histological change, calculus, bone morphology, as well as evaluation of tooth structure for fracture cracks. In therapeutics, ultrasonic instrumentation is proven effective and efficient in treating periodontal disease. When used properly, ultrasound-based instrument is kind to the soft tissues, require less healing time, and are less tiring for the operator. Microultrasonic instruments have been developed with the aim of improving root-surface debridement. The dye/paper method of mapping ultrasound fields demonstrated cavitational activity in an ultrasonic cleaning bath. Piezosurgery resulted in more favorable osseous repair and remodeling in comparison with carbide and diamond burs. The effect of ultrasound is not limited to fracture healing, but that bone healing after osteotomy or osteodistraction could be stimulated as well. Keywords: LIPUS, microstreaming, microultrasonics, piezosurgery, ultrasonic cleaner, ultrasound probe INTRODUCTION Catuna was first to use ultrasound technology in dentistry in 1953 for cavity preparation. Ultrasound was first introduced in periodontal procedure as ultrasonic scalers in 1955 by Zinner and has undergone many changes since then, and simple compact devices have replaced large, heavy units. The single, bulky universal tip has been replaced by a variety of site specific, slimmer tips (some of which have been coined as microultrasonic). PMCID: PMC2813560

Ultrasound offers great potential in development of a noninvasive periodontal assessment tool that would offer great yield real time information, regarding clinical features such as pocket depth, attachment level, tissue thickness, histological change, calculus, bone morphology, as well as evaluation of tooth structure for fracture cracks. Spranger was first to try ultrasonography in periodontology, he tried to determine height of alveolar crest in periodontal patients. Palou attempted to image the crest of alveolar bone by aiming ultrasound transducer perpendicular to long axis of tooth. Eger et al. assessed the measurement of gingival thickness using an ultrasonic device with a 5 MHz transducer. While these efforts proved the feasibility of ultrasonic imaging in dentistry, investigators showed that ultrasonic device measures echoes from the hard tissue of tooth surface, and periodontal attachment level can be inferred from these echoes. Periodontal structures mapping system using ultrasonic probe was invented at NASA by Companion under supervision of Joseph Heyman and patented in May 1998. Reports also suggest role of ultrasound in osteopromotion and in piezoelectric bone surgery. This paper is intended to review the various applications of ultrasound in periodontics. APPLICATION OF ULTRASOUND IN DIAGNOSIS Periodontal ultrasonography Roots for the ultrasound technology used in periodontal ultrasonography are in an ultrasoundbased time-of-flight technique used routinely in NASA Langley Research Center's NonDestructive Evaluation Sciences Laboratory to measure material thickness and, in some cases, length. The primary applications of that technology have been in aircraft skin thickness for corrosion detection and bolt length for bolt tension measurements. Ultrasound probe works somewhat like a sonogram. With a sonogram, the probe is pressed against the body and the beam penetrates the womb and the echoes that come back are recorded and displayed as an image of the fetal face. Same technology is adapted to image the periodontal structures, mainly by making the probe that sends the ultrasound signals and receives the echoes very small. Software in computer sorts out all of echoes and makes an image of attachment level pocket depth, etc. Automatically. Current method of diagnosing periodontal disease (walking probe) is invasive, uncomfortable, and inexact. Ultrasonography probe provides a mapping system for noninvasively making and recording differential measurements of depth of any patient's periodontal ligaments relative to a fixed point as cementoenamel junction. Mapping system uses ultrasound to detect top of ligaments at various points around each tooth and uses either ultrasound or an optical method to find CEJ at same points. Depth of sulcus is calculated as difference between the points. Periodontal ultrasonic probe It consists of transducer, which is housed within a contra angled handpiece at the base of hollow conical tip. This is responsible for emitting and receiving sound waves. Hollow tip focuses acoustic beam into periodontal tissue. Transducer is mounted at the base of a dual taper, convergentdivergent coupler in order to provide acoustically tapered interface with a throat area in order of 0.5 mm. A throat area of 1.5 mm represents an active area reduction from transducer element to aperture. Such a reduction is mandated by geometry and very small window offered by gingival margin. An added virtue of attaining a small tip size is ability of ultrasonic probe to examine interdental area

Equipments required to run the probe include computer, monitor, keyboard, separate electron box for water pressure control, and foot pedal all mounted on large cart to transport conveniently. Probe tip incorporates a slight flow of water to ensure a good coupling of ultrasonic energy to tissues. Water can come either from a suspended IV-type sterile bag or plumbed from dental chair. Working of ultrasonic probe Ultrasonic probe tip is held in a vertical position, parallel to long axis of the tooth. Tip is gently placed on gingival margin until slight blanching of gingiva is visualized; ensuring the complete coupling of water into gingival sulcus, the probe is activated with a foot pedal. When foot pedals are engaged, a small stream of water will flow into sulcus along with a thin beam of ultrasound waves. Ultrasonic probe projects a narrow frequency (120 MHz) ultrasonic pulse into gingival sulcus or periodontal pocket and then detects echoes of returning wave. An ultrasonic beam entering the tissues is absorbed, reflected, or scattered. Reflected portion is received by machine and used for reconstruction of ultrasonic image. As these sound waves bounces of periodontal tissues, echoes are recorded by a tiny transducer in handpiece and analyzed simultaneously by computer attached to ultrasonic unit. As the examiner passes probe tip across the gingival margin, computer records incoming data which employs artificial intelligence algorithms to translate out data into estimates of probing depth in millimeters Unlike manual probing where measurements are obtained at six sites per tooth, ultrasound probe tip is gently placed on gingival margin then swept along entire gingival area. Thus, the probe is able to painlessly capture a series of observations (depth measurements and contour) across entire subgingival area as probe tip passes gingival margin so yielding more information. Though this noninvasive method for measuring pocket seems to be accurate long-term evidence-based studies are needed. APPLICATION OF ULTRASOUND IMAGING FOR PERIODONTAL ASSESSMENT A recent study using the ULTRADERM (Longport International Ltd, Silchester, U.K.) ultrasonic scanner that works at the frequency of 20 MHz in an animal (pig jaw) model had shown that periodontal ultrasonography can produce images suitable for the assessment of the periodontium as well as accurate measurement of the dimensional relationship between hard and soft structures.The technique of ultrasonography has also been applied in human subjects. In various studies the device was used to evaluate gingival thickness before and after mucogingival therapy for root coverage.It was also used to assess the dynamics of mucosal dimensions after root coverage with connective tissue grafts,bioresorbable barrier membranes, and for measurement of masticatory mucosa.Ultrasonic scanner provides satisfactory results both in terms of accuracy and repeatability. APPLICATION OF ULTRASOUND IN CALCULUS DETECTION There are a variety of subgingival calculus detection systems in the market as Detectar, Keylaser II, and Dental Endoscope and for in vitro studies. Meissner developed an ultrasound-based device for office use which was automatically able to detect subgingival calculus. They showed that dental surfaces may be discriminated by the analysis of tip oscillations of an ultrasonic instrument, which possesses computerized calculus detection (CCD) features. This system may help to judge other systems in vivo.

APPLICATION OF ULTRASOUND IN SCALING AND ROOT PLANING The mechanism of removing calculus Cavitation was assumed to be able to liberate some energy for the removal of deposits. However, it has been found that using only the cavitation without the touch of the vibrating tip is not sufficient to remove the calculus, and that a direct contact between the vibrating tip and the calculus is necessary. Therefore, it is now generally accepted that the mechanical energy produced by the vibrating tip (chipping action) along with cavitation is responsible for the removal of deposits. Mechanism of removing biofilm or plaque Cavitational activity has an adverse effect on bacteria within dental plaque. The effect of this cavitational activity disrupts bacterial cell wall and subgingival microbial environment. Microstreaming or acoustic mainstreaming, generated by ultrasound in the presence of a fluid environment, also is effective in removing bacterial plaque. Ultreo (Inc. today) is a revolutionary power toothbrush that combines ultrasound waveguide technology with precisely tuned sonic bristle action for a deep, gentle, long-lasting feeling of clean. Clinical studies prove that Ultreo can remove up to 95% of plaque from hard-to-reach areas in the first minute of brushing. Endotoxin removal and root detoxification Currently, it is understood that endotoxin (LPS) is a surface substance which is superficially associated with the cementum and calculus and that it is easily removed by washing, brushing, light scaling, or polishing the contaminated root surface. Heat automatically generated from magnetostrictive units may assist in endotoxin removal or detoxification, as a result, areas of the tooth where the tip does not touch may inadvertently be detoxified as well. Cautions while using ultrasonics in scaling and root planing As with any dental procedures universal precautions consists of wearing protective eyewear and/of face shield, mask and gloves. In the beginning of the day, hold the handpiece over a sink or drain, set power to low, activate the foot control, and flush the water line of unit at maximum water-flow for at least 2 minutes to clear stagnant water and reduce water films in tubing. All the inserts are autoclavable and should be sterilized before every use. Having the patient rinse with approved antimicrobials, and high vacuum suction, helps to minimize aerosols. An aerosol reduction device (ARD) that is attached to the ultrasonic handpiece has been shown to reduce contamination cloud by placing suction in close proximity to the ultrasonic tip. Harrel showed a high volume evacuator attachment to an ultrasonic handpiece significantly reduced the detectable aerosols splatter produced during ultrasonic scaling by 93%. Veksler reported 30-second rinse with an essential oil mouthrinse before instrumentation reduces bacterial count in the aerosol by 92.1% and salivary bacterial level by about 50% for up to 40 minutes and 97% reduction for up to 60 minutes following two 30second rinses with 0.12% chlorhexidine. Aerosols can be suspended in air for up to 30 minutes after using power-driven scalers, so, infection control is to be maintained even after the procedure is finished. Lightest amount of lateral pressure possible while still maintaining control of instrument and proper adaptation of tip is necessary for calculus removal. Increasing the pressure decreases the mechanical vibrations, the chipping action, and ultimately the effectiveness of ultrasonics. To prevent root damage in SRP the assessed magnetostrictive ultrasonic scaler should be the used at 0.5 N lateral pressure, low or medium

power setting, and tip close to zero degree angulation with tooth. Increasing the power also increases aerosol formation, which results in reduced water cooling and cavitational effect and can increase patient sensitivity. Chapple showed that use of half power setting was as effective as using the ultrasonic scaler at full power. Ultrasonic tips are now shaped more like probes. Insert the tip vertically, parallel to long axis of tooth, walk the tip into proximal surfaces, keeping the tip adapted to tooth-like probe. To ensure patient comfort, keep the tip moving at all the times when in contact with tooth. Direct vision is preferred when using ultrasonics, as indirect vision is compromised by mist of irrigant. Ultrasonic tips do not last forever. As tip wear, scaling efficiency decreases. One millimeter of tip wear results in approximately 25% loss of efficiency and 2 mm of wear results in approximately 50% loss of efficiency and at this point tip should be replaced. Clinicians who retain their inserts for years may find their instrument tips become reduced in length through wear, potentially leading to a detrimental change in performance of scaling system. The instrument should be kept away from bone to avoid possibility of necrosis and sequestration. APPLICATION OF ULTRASOUND IN CURETTAGE Ultrasound is effective for debriding the epithelial lining of periodontal pockets resulting in microcauterization. Morse scaler-shaped and rod-shaped ultrasonic instruments are used for this purpose. Investigators found ultrasonic instruments to be as effective as manual curettage and less inflammation and less removal of connective tissue. APPLICATION OF ULTRASOUND AS A MICROULTRSONICS Kwan and Peggy Hawkins coined the term microultrasonics in early 1990s as a generic term that identifies the refined use of powered instrumentation in supragingival and gross debridement. Microultrasonics is innovative, power-driven (magnetostrictive or piezoelectric) scaler products featuring thinner tips and varied shapes. These are small, approximating the size of a periodontal probe and can be used for supra and subgingival treatment at low to high power, with less to no water spray, and little or no adjunctive use of hand instrumentation. Tips of microultransonic instruments measure about 0.20.6 mm in diameter. These are powered to move up to ultrasonic speeds (25000 to more than 40000 cycles per second), with active working sides on all surfaces of vibrating instrument and provide ultrasonically activated lavage in working field. Ultrasonic motors need no deceleration mechanism because they have high torque output in low rotation speed. Microultrasonic instruments are less likely to overinstrument roots because they are neither sharp nor abrasive. The periodontal endoscope allows for visual access to root surfaces with great magnification, lessening the need for surgical intervention. Combined with a simple array of microultrasonic instruments, endoscopic debridement can be accompanied in a nonsurgical, minimally invasive way by the dentist or periodontist. APPLICATION OF ULTRASOUND AS ULTRASONIC CLEANER The dye/paper method of mapping ultrasound fields demonstrated cavitational activity in an ultrasonic cleaning bath. The ultrasonic cavitation implosion effect is incredibly effective in displacing the saturated layer of contaminant, allowing fresh cleaning solvent to come in contact with the unsaturated surface to attack and dissolve the remaining contaminant. It is especially effective on unsmooth and out-of-reach surfaces that are normally inaccessible through conventional means such as brushing. It has been shown to speed and enhance the effect of numerous chemical reactions. The most probable reason for this enhancement is due

to the levels of high energy created by the high temperatures and pressure emitted by millions of individual cavitation bubble implosions .In view of the use of such baths as a part of the process of controlling cross-infection in dentistry, it is suggested that manual cleaning of reusable instruments may be necessary as well. Figure 1 Ultrasonic periodontal probe with probe tip at the gingival margin and ultrasound projected into the periodontal pocket. The echoes returning from the crest of the periodontal ligament are shown (Hinders M And Companion J; www.acoustics.org) Figure 2 The hand piece contains a probe tip, which is small enough to permit scanning of the area between teeth. The ultrasonic transducer is mounted in a probe tip shell, which has a throat diameter small enough to project

Figure 3 Ultrasonographic periodontal probe in use; (as.wm.edu/Faculty/Hinders/NDE-Projects.html)

Figure 4 Ultrasonic device (B) measuring gingival thickness at a grafted recession site. (Muller H P, Stahl M, Eger T; 1999)

Figure 5 Camera and micro ultrasonics for endoscopic instrumentation; (Kwan J Y; 2005)

Figure 6 Scaler, probe and microultrasonic insert. (Kwan J Y; 2005)

CONCLUSION Diagnostic application of mega Hertz ultrasound includes use of ultrasonography for dimensional assessment of periodontal structures. The advantage of using noninvasive assessments without ionizing radiations could lead to applications in the evaluation of soft and hard tissue healing after periodontal surgery (regenerative, mucogingival, or implant surgery) as well as for clinical assessment and treatment planning prior to implant placement. In therapeutics, ultrasonic instrumentation is proven effective and efficient in treating periodontal disease. When used properly, ultrasound is kind to the soft tissues, requires less healing time, and is less tiring for the operator. LIPUS seems to play an effective role in repair and healing, still their role in periodontal regeneration needs to be investigated. Though ultrasound application in both diagnosis and periodontal therapy seems to present promising results, long-term evidence-based studies are required to use ultrasound in routine periodontal practice.

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