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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 8  |  Issue : 4  |  Page : 226-232

Comparison of nonsurgical periodontal therapy with hand scaler, conventional ultrasonic scaler, and vector™ ultrasonic system in patients with generalized chronic periodontitis


Department of Periodontology and Oral Implantology, Luxmi Bai Institute of Dental Sciences and Hospital, Patiala, Punjab, India

Date of Web Publication27-Dec-2016

Correspondence Address:
Ashutosh Nirola
Department of Periodontology and Oral Implantology, Luxmi Bai Institute of Dental Sciences and Hospital, Patiala - 147 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-4003.196813

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  Abstract 

Background: The purpose of the study was to compare clinical efficacy of nonsurgical periodontal therapy with hand scaler, conventional ultrasonic scaler, and Vector ultrasonic system in patients with generalized chronic periodontitis. Materials and Methods: Sixty patients with generalized chronic periodontitis fitting the inclusion and exclusion criteria were assigned to one of the three treatment groups (n = 20 in each group). Group I – hand scalers, Group II – conventional ultrasonic scalers, and Group III – Vector™ ultrasonic system. Before oral prophylaxis, clinical parameters (gingival index [GI], plaque index [PI], calculus index [CI], periodontal probing depth [PPD], clinical attachment loss [CAL], and hypersensitivity) were recorded. GI, PI, CI, and hypersensitivity were reevaluated at 1, 3, 6 and 12 weeks. PPD and CAL were reevaluated at 6 and 12 weeks. Results and Conclusion: The results showed that nonsurgical therapy with Vector ultrasonic system is clinically comparable in all the parameters, to hand and conventional ultrasonic scalers, suggesting that it can be used as a gentle root debridement device for supportive periodontal therapy, as an alternative to other ultrasonic or sonic scalers.

Keywords: Chronic periodontitis, debridement, dental scaling, root planing, ultrasonics


How to cite this article:
Nirola A, Batra P, Kaur S. Comparison of nonsurgical periodontal therapy with hand scaler, conventional ultrasonic scaler, and vector™ ultrasonic system in patients with generalized chronic periodontitis. Indian J Dent Sci 2016;8:226-32

How to cite this URL:
Nirola A, Batra P, Kaur S. Comparison of nonsurgical periodontal therapy with hand scaler, conventional ultrasonic scaler, and vector™ ultrasonic system in patients with generalized chronic periodontitis. Indian J Dent Sci [serial online] 2016 [cited 2019 Mar 25];8:226-32. Available from: http://www.ijds.in/text.asp?2016/8/4/226/196813


  Introduction Top


Periodontitis is a complex disease, in which disease expression involves intricate interactions of the biofilm with the host immune-inflammatory response and subsequent alterations in bone and connective tissue homeostasis.[1] Bacterial plaque and calculus are recognized etiological agents in the initiation and progression of periodontal disease, whose accumulation and attachment are facilitated by a roughened root surface.[2] Periodontal treatment thus focuses on the thorough removal of plaque, calculus, and plaque products.[3]

Conventional nonsurgical periodontal therapy consists of mechanical supra- and subgingival tooth debridement (using manual, rotating, and ultrasonic instruments) and instructions in self-administered oral health-care measures.[4] The most commonly used procedure for root surface debridement is mechanical scaling and root planing using hand instruments, for example, hand scalers and Gracey curettes.[5] Although beneficial results from this treatment modality have been reported in both clinical and microbial parameters, such instrumentation calls for clinical skills and sometimes despite them, the anatomy of the root often precludes the achievement of the desired biologically compatible root surface.[6]

To mechanize the procedure of scaling and root planing, power-driven instruments such as sonic and ultrasonic scalers were proposed. Although periodontal treatment with power-driven instruments offers indeed some interesting perspectives to the clinician, they come with certain drawbacks which include considerable heat development at the scaler's tip if the water cooling is inefficient, formation of pathogenic bacterial aerosols, and reduction in tactile sensation in comparison to hand instruments.[7]

Recently, a Vector™ scaler (Dürr Dental) was developed for use in scaling and root planing, and it has been shown to remove biofilms and subgingival calculus in a gentle manner.[8] It comprises a ring-shaped resonant body vibrated by an ultrasonic device (at 25,000 Hz) and is attached to the working end at an angle of 90°. This configuration eliminates ellipsoid vibrations of the instrument tip, which therefore moves in a plane parallel to the tooth surface, allowing minimally invasive instrumentation.[9]

Although many studies have been done comparing the efficacy of different hand scalers with conventional ultrasonic scalers, very few studies have compared the efficacy of hand scalers, conventional ultrasonic scalers, and Vector ultrasonic system with each other, in vivo.

Thus, the aim of our study was to compare the clinical efficacy of hand scaler, conventional ultrasonic scaler, and Vector ultrasonic system in patients of generalized chronic periodontitis.


  Materials and Methods Top


Sixty patients showing clinical evidence of generalized chronic periodontitis were selected from among the patients visiting our department. Patients were explained about the study purpose, and a signed written consent from the patient was obtained. The study was approved by the Ethical Committee of our Institute.

Inclusion criteria

  1. Patients suffering from generalized chronic periodontitis
  2. No history of periodontal treatment in the past 6 months
  3. Patients with periodontal pocket depth ≥4 mm
  4. Patients with calculus index (CI) (calculus component of oral hygiene index-simplified [OHI-S]) having the scoring criteria of 2
  5. Cooperative patients showing acceptable oral hygiene.


Exclusion criteria

  1. Patients who were immunocompromised or were on any long-term immunosuppressant drugs
  2. Patients on long-term use of local and systemic antibiotics within the last 6 months
  3. Any type of uncontrolled systemic illness such as diabetes, arthritis, cancer, cardiovascular disorders, bleeding disorders, and renal diseases.
  4. Any anticoagulant therapy or undergoing radiotherapy
  5. Teeth that had apical lesions, caries, and pulpitis
  6. Pregnant women or lactating mothers
  7. Smokers.


Methods

The patients were randomly divided into three groups of twenty patients each – (i) Group I – hand scalers (Gracey curette #5/6 used). Canines and premolars were used as index teeth for assessing probing depth (PD) and clinical attachment level, and since Gracey #5/6 is area specific for that region, it was used in our study [Photograph 1]. (ii) Group II – conventional ultrasonic scaler (Satelec P5 Newtron XS – frequency of 31 kHz, used at medium power setting corresponding with number 14). The H3 curette tip was used for periodontal debridement and H1 tip for supragingival scaling, [Photograph 2] and (iii) Group III – Vector Ultrasonic System (frequency 25 kHz, at 70% power setting corresponding to first four light-emitting diode lights lighting up on the display) [Photograph 3]. The bent curette-shaped tip was used for the proximal surfaces, and straight probe was used for the buccal and lingual surfaces.



Before oral prophylaxis, clinical parameters, i.e., Gingival index (GI) (Loe and Silness, 1963), plaque index (PI) (Turesky-Gilmore-Glickman modification of the Quigley-Hein and Elliot PI, 1970), CI (Calculus component of OHI-S, 1964), periodontal PD (PPD) (using William's calibrated periodontal probe), clinical attachment loss (CAL) (using standardized acrylic stent), and hypersensitivity (using Verbal Rating Scale) were recorded for each patient. Although hypersensitivity was not used as an inclusion criterion, few patients in all three groups had some sensitive teeth at baseline. Routine scaling and root planing was then carried out after each patient received proper instructions in oral hygiene procedures.

PD and CAL were assessed on the index teeth with the help of standardized stent. Clinical parameters of GI, PI, CI, and hypersensitivity were assessed for the entire dentition. GI, PI, CI, and hypersensitivity were again recorded at 1, 3, 6, and 12 weeks, postscaling and root planing. PPD and CAL were recorded again at 6 and 12 weeks. Oral hygiene instructions were reinforced. The scoring and assessment were performed by a single clinician.

The data thus collected were compiled and put into statistical analysis.


  Results Top


Sixty patients were enrolled in the study and underwent one of the three treatment modalities. The results obtained in this study were statistically analyzed using mean, standard deviation, ANOVA, and Kruskal–Wallis test for intergroup comparison and Paired t-test and Wilcoxon test for intragroup comparison.

Clinical parameters

The clinical parameters of GI, PI, CI, and hypersensitivity were recorded at baseline before oral prophylaxis and re-evaluated at 1, 3, 6, and 12 weeks. PPD and CAL were recorded at baseline before oral prophylaxis and reevaluated at 6 and 12 weeks.

GI, PI, and CI [Table 1] and [Figure 1],[Figure 2],[Figure 3] – the mean GI scores and PI scores in all three groups showed a statistically significant reduction from day 0 to week 12 (Group I, Group II, and Group III, P < 0.001). The intergroup comparison showed no significant difference in the reduction of scores among the three groups at various recall intervals. The mean calculus scores in all three groups were reduced to zero after prophylaxis (Group I, Group II, and Group III, P < 0.001). Isolated incidents were reported in a few patients in all three groups, wherein flecks of calculus were seen at the 6 and 12 weeks recall. The intergroup comparison showed no significant difference in the reduction of scores between the three groups.
Table 1: Intergroup comparison of reduction in mean gingival, plaque, and calculus index scores between Groups I, II, and III at different time intervals

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Figure 1: Intergroup comparison of reduction in mean gingival index scores between Groups I, II, and III at different time intervals.

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Figure 2: Intergroup comparison of reduction in mean plaque index scores between Groups I, II, and III at different time intervals.

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Figure 3: Intergroup comparison of reduction in mean calculus index scores between Groups I, II, and III at different time intervals.

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PPD and CAL [Table 2] and [Figure 4] and [Figure 5] – the mean PPD scores and CAL scores in all three groups showed a statistically significant reduction from day 0 to week 12 (Group I, Group II, and Group III, P < 0.001). The intergroup comparison showed no significant difference in the reduction of scores among the three groups at various recall intervals.
Table 2: Intergroup comparison of reduction in mean periodontal probing depth and clinical attachment loss scores between Groups I, II, and III at different time intervals

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Figure 4: Intergroup comparison of reduction in mean periodontal probing depth scores between Groups I, II, and III at different time intervals.

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Figure 5: Showing intergroup comparison of reduction in mean clinical attachment loss scores between Groups I, II, and III at different time intervals.

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Hypersensitivity [Table 3] and [Figure 6] - the mean hypersensitivity scores in all three groups showed a statistically significant reduction from day 0 to week 12 (Group I, Group II, and Group III, P = 0.006). The scores showed no significant improvement from day 0 to week 1. The hypersensitivity scores exhibited improvement post 2 weeks of oral prophylaxis after which improvement was noted in all three groups. The intergroup comparison showed no significant difference in the reduction of scores among the three groups at various recall intervals.
Table 3: Intergroup comparison of reduction in mean hypersensitivity scores between Groups I, II, and III at different time intervals

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Figure 6: Intergroup comparison of reduction in mean hypersensitivity scores between Groups I, II, and III at different time intervals.

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  Discussion Top


Periodontitis is an infectious inflammatory destructive disease initiated by the microbial biofilm in a susceptible host.[10] Bacterial plaque has been shown to be a primary etiological factor for periodontal disease.[11] The cementum of roots exposed to plaque-infected periodontal pockets undergoes several changes including hypermineralization and adsorption of endotoxins, antigen–antibody complexes, and products of microbial metabolism, and such surfaces are, therefore not biocompatible with adjacent periodontal cells, the proliferation of which is pivotal for periodontal wound healing.[12],[13]

Hatfield and Baumhammers (1971) first described the cytotoxic effect of diseased root surfaces in cell cultures, whereas Aleo et al. (1974) demonstrated the presence of bacterial endotoxins on diseased roots and that human gingival fibroblasts did not adhere in vitro to a root surface contaminated with lipopolysaccharides. It was, therefore, concluded that the complete removal of the affected cementum and other etiological factors was critical to the success of periodontal therapy.[14]

Since long, the hand instruments were the first choice of clinicians. It was believed that these instruments produced a smooth root surface; however, considerable manual dexterity is required for their effective use, they are more time consuming, and unable to reach deeper root surfaces where pockets are more than 4 mm deep.[15],[16],[17]

Various powered instruments are also available to the clinician for mechanical root preparation including sonic, ultrasonic, and rotary instruments.[7] The advantages of power-driven instruments are less operator fatigue, ease in use, and a simultaneous flushing effect by coolant.[18] However, these instruments come with their own set of disadvantages that include decreased tactile sensitivity, uncontrolled damage to the root surfaces, aerosol contamination, vibrational hazards, and inadequate edge retention.[11]

Recently, a Vector scaler (Dürr Dental) was developed for use in scaling and root planing and has been shown to remove biofilms and subgingival calculus in a gentle manner (Klinger et al. 2000).[8] The Vector ultrasonic scaling system is characterized by a resonating ring, which converts the generated horizontal oscillation (frequency: 25 kHz) into pure vertical movements with an amplitude of about 30 µm along the longitudinal axis of the instrument tip. Thus, the instrument tip moves only parallel to the root surface.[19]

A refillable water container (120 ml) is provided in the base station. The coolant is applied to the working tip by intermittent pulsation at a flow rate of 6 ml/min. The suspension is not sprayed in an aerosol by the instrument but is held hydrodynamically on the instrument tip. The working tips result in minimally invasive instrumentation (by virtue of their nonelliptical vibration pattern and small amplitude of vibrations) and are comparable in dimensions to a manual probe or periodontal curette (Guentsch and Preshaw 2006b). Both metal and carbon fiber inserts are available with the Vector system.[9]

In the present study, the patients were examined at baseline for parameters – PI, GI, CI, PPD, CAL, and hypersensitivity. GI, PI, CI, and hypersensitivity were reevaluated at 1, 3, 6, and 12 weeks, whereas the PPD and CAL were reevaluated at 6 and 12 weeks.

A marked reduction in the periodontal inflammatory parameters such as gingival and PI is an important clinical indicator for successful subgingival debridement.[20] These were thus included in our study to evaluate the efficacy of instrumentation.

Histologic studies have shown that successful cause-related nonsurgical therapy results in the formation of a long junctional epithelium, independent of the method used.[17],[21],[22] Clinically, this is indicated by an increase in tissue resistance to periodontal probing.[23] Thus, PD and CAL were used as clinical parameters for evaluation in our study.

As a parameter for the patient's discomfort, all patients were asked about the occurrence of postoperative hypersensitivity using the verbal rating scale [19] at baseline and after 1, 3, 6, and 12 weeks.

The present study has shown that nonsurgical periodontal treatment with hand scalers, conventional ultrasonic scalers, and Vector ultrasonic system may lead to clinically and statistically significant reduction in clinical parameters of inflammation and hypersensitivity and gain in clinical attachment levels.

Mechanical nonsurgical periodontal therapy is known to predictably reduce the levels of gingival inflammation, and although meticulous supragingival plaque control leads to some reduction of the periodontal inflammation, the majority of the reduction in inflammation is only obtained following the subgingival instrumentation.[23],[24] The present study showed a reduction in individual GI in all three instrumentation groups, with no significant difference among the three groups. These results are in accordance with the studies of Hunter et al. 1984, Nishimine and O'Leary 1979, and Copulos et al. 1993.[5],[25],[26]

The plaque scores also showed an overall reduction in the three instrumentation groups, with no significant difference among the three groups. Our results are in accordance with the studies of Hunter et al. 1984, Nishimine and O'Leary 1979, and Copulos et al. 1993.[5],[25],[26]

The concept of removing all subgingival calculus and contaminated cementum has been shown to be unrealistic and quite likely unnecessary.[27] Further, it appears that a clinically acceptable level of gingival wound healing occurs, despite the presence of microscopic aggregates of residual root calculus.[24] Our study showed no significant difference in the reduction of calculus scores between the three instrumentation groups, suggesting that no instrument was statistically superior in removing calculus from the root surfaces. Similar results were also obtained by Thornton and Garnick 1982, Badersten et al. 1984a, 1984b, Copulos et al. 1993, and Kawashima et al. (2007a).[5],[8],[28],[29]

In the present study, clinical parameters of PPD and CAL were evaluated 6 weeks after instrumentation and then again at 12 weeks. The results show a highly significant reduction in both parameters from day 0 to week 12 (Group I, II, and III, P = 0.001) in all the three instrumentation groups, due to a combination of gain in clinical attachment and gingival recession, following resolution of inflammation.

Our results are in accordance with the studies of Torfason et al.,[30] who reported no statistically significant difference between ultrasonic and hand instrumentation. Badersten et al. (1981)[28] reported a mean PD decrease of 1.3 mm after 13 months for both ultrasonic and hand instrumentation (baseline PD: 4.2 mm), suggesting that the response to nonsurgical therapy is uniform in both the groups; Sculean et al., 2004 and Rupf et al., 2005 also demonstrated similar improvement in reduction of clinical parameters of PD and CAL while comparing Vector ultrasonic system with manual instrumentation and ultrasonics.[7],[31]

Besides, an effective pocket debridement, other aspects, such as the required treatment time and unwanted side effects (postoperative hypersensitivity and pain), are also important for the clinician and the patient.

Microscopic observations have confirmed that root surfaces, when kept free from plaque during maintenance, become highly mineralized and display mineral depositions at the peripheral ends of the tubules (Selvig 1969, Hiatt and Johansen 1972).[32],[33],[34]

In the present study, none of the patients reported subjective hypersensitivity, independent of the treatment method used, after subgingival debridement. There was a generalized trend of decrease in the preoperative hypersensitivity levels postdebridement in all the three treatment groups, but only after week 3 and statistically nonsignificant reduction in the preoperative hypersensitivity levels from day 0 to 1 week (Group I, II, and III, P = 0.317). This is in accordance with the study of Tammaro et al. 2000.[34] who reported that hypersensitivity peaked between 2.8 h and 2 weeks posttherapy and there was a reduction in the intensity of hypersensitivity during later phase of the follow-up period.

In our study, significant improvement was seen in all the clinical parameters in the three treatment groups; however, intergroup comparisons revealed clinically comparable but statistically nonsignificant results.


  Conclusion Top


In conclusion, our results indicate that the Vector system may be used preferably as a gentle root debridement device for supportive periodontal therapy owing to its nonelliptical vibration pattern and small amplitude of vibrations, as an alternative to other ultrasonic or sonic scalers.

Acknowledgment

We would like to thank Mr. Sudeep Jaisawal, Durr Dental India, for his help with the Vector ultrasonic system.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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