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G. J. Smart', M.

Wilson^
The assessment of ultrasonic root E. H. Davies^ and J. B. Kieser^
Departments of 'Periodontology, ^Clinical
Pathology and Immunology and ^Biomaterials

surface debridement by Science, Institute of rental Surgery, 256 Grays


Inn Road, London, WC1X 8LD, UK

determination of residual
endotoxin ieveis .
Smart GJ, Wilson M, Davies EH and Kieser JB: Assessment of ultrasonic root
surfaee debridement by determination of residual endotoxin levels. J Clin Periodon-
tol 1990: 17: 174-178

Abstraet. Recent demonstrations of the superficial nature and ease of removal of


root-surface-associated cytotoxic materials suggest that extensive root-surface
instrutnentation is not warranted clinically. This in vitro investigation determined
the detoxifying effects of a conservative regime of ultrasonic root debridement,
using the Limulus amoebocyte lysate assay for lipopolysaccharide (LPS) as an
indication of the presence or absence of cytotoxic materials. 20 extracted peri-
odontally-involved single-rooted teeth, with no clinically detectable calculus de-
posits, were debrided with a Cavitron TF-10 tip. Light pressure, resulting from a
force application of approximately 50 g, lasting for 0.8 s/mm^ of root surface
was used and complete overlapping instrumentation ensured. The ftnding of
LPS levels of < 2.5 ng per root in 19 out of 20 teeth after such debridement was Key words: ultrasonic; debridement; lipopoly-
sacoharide; periodontitis; root surface.
comparable to LPS levels found on healthy, uninvolved control teeth, and thus
endorses the growing belief that root surface cleanliness can be readily achieved. Accepted for publication 19 March 1989

Root-surface instrurnentation has tra- tamination and the ease of removal of The superficial nature of root surface
ditionally centred upon scaling and root associated cytotoxic materials such as contamination has been further demon-
planing. Scaling relates to the "gross bacterial lipopolysaccharide (LPS). strated by thefindingthat all but minute
subgingival accretions", and root plan- Thus LPS, shown to be consistently amounts of LPS present on perio-
ing to the "microbial flora on the root present in periodontally-involved root dontally involved roots were removed
surface or lying free in the pocket, all surface associated materials (Wilson et in vitro by only 15 light overlapping
flecks of calculus and all contaminated al. 1986, Maidwell-Smith et al. 1987, hand instrument strokes per root sur-
cementum and dentine" (O'Leary 1986). Cheetham et al. 1988), displays no sig- face (Cheetham et al. 1988). Ultrasonic
The long-held assumption of cementum nificant cemental penetration (Moore et devices are likely to be equally effective
contatnination was reinforced by the al. 1986, Hughes & Smales 1986, in this respect for they have been shown
fmdings of Aleo et al. (1974, 1975) and Hughes et al. 1988). Moreover, the find- both clinically (Torfason et al. 1979,
has promoted the use of root planing to ing in our own laboratory that virtually Badersten et al. 1981, 1984, Oosterwaal
decontaminate such surfaces (Jones & all LPS detected could be removed in et al. 1987) and microbiologically
O'Leary 1978, Nishimine & O'Leary vitro by rinsing and brushing alone (Thornton and Garnick 1982, Leon and
1979). More irnportantly, operator diffi- (Moore et al. 1986) may also apply to Vogel 1987, Breininger et al. 1987) to
culties with subgingival root planing other cytotoxic substances. This, cou- be as effective as hand instruments for
and the assessrnent of its efficacy have pled with the fact that polishing of subgingival instrumentation. However,
fostered the now widely practiced con- periodontally involved root surfaces has the extent to which these devices must
cept of periodontal flap access surgery resulted in similar healing to that after be used to achieve such root surface
(Axelsson & Lindhe 1981, Pihlstrom et the complete rernoval of cementum at decontamination is unclear. The effi-
al. 1981, Frandsen 1983), notwithstand- the time of periodontal surgery (Nyman cacy of conservative hand instrument
ing the comparable clinical results with et al. 1986, 1988), indicates that other and polishing regirnes described above,
non-surgical techniques (Hill et al. 1981, cytotoxic substances are removed equal- coupled with the facility with which su-
Pihlstrom et al. 1981, 1983, Lindhe et ly readily. This in turn suggests that LPS pragingival staining encountered clin-
al. 1982, 1984, Isidor et al. 1984, 1986, may be used as a reliable marker of the ically may be removed by the rnethodi-
Westfelt et al. 1985, Lindhe & Nyman presence of such substances and more cal light use of ultrasonic devices are
1985). importantly of bacterial plaque itself in instructive in this context. Thus, corn-
investigations on root surface instru- parable subgingival root surface cleanli-
Recent research fmdings have ques- mentation. ness may be achieved by a similarly con-
tioned the extent of root surface con-
Ultrasonic root surface debridement 175

servative ultrasonic regime of limited The possible pressure ranges that fessional cleaning in the preceding 12
duration, using only light pressure and could be applied when using an ultra- months; (iii) vital pulps, no root surface
complete overlapping of instrumen- sonic tip were first measured on a single restorations or caries; (iv) no history of
tation strokes. The aims of this in vitro tooth. Clearly discernible ranges of antibiotic therapy during the preceding
study were therefore to first establish light, medium and heavy pressures month.
the feasibility of such debridement on could be produced, of which the light Prior to extraction, the level of the
periodontally involved root surfaces pressure of between 30-40 g selected for gingival margin was marked with a
and then to assess its efficacy by deter- the subsequent investigations, was sharp pencil. The extraction technique
mining the amounts of residual LPS by found to be most reproducible during and subsequent storage of the teeth
a Limulus amoebocyte lysate/affinity 17 separate sequences of instrumen- (Moore et al. 1986) ensured no contami-
chromatography assay (Wilson et al. tation. nation from extraneous LPS. Contami-
1986). The duration of ultrasonic instru- nation was similarly avoided by adher-
mentation to achieve visually clean peri- ing strictly to the procedures described
odontally-involved root surfaces when by Wilson et al. (1986) during prepara-
Material and Methods
using this light pressure was then deter- tion of the teeth for debridement and
The pressures applied during ultrasonic mined on 10 successive teeth. Root sur- their subsequent management for LPS
root surface instrumentation were first face cleanliness was judged by the re- assay.
assessed to establish a reproducible moval of both disease-induced staining Each tooth was first fixed into a ny-
technique and the instrumentation time and staining produced by the appli- lon retaining tube and then shallow cir-
required to produce a clinically "clean" cation of a disclosing agent, as described cumferential grooves were cut immedi-
surface when using light pressure. The by Eaton et al. (1984) and Poole et al. ately apical and coronal to the pre-ex-
teeth selected for this and the sub- (1984). Supplementary staining was traction gingival margin and the most
sequent investigations had no clinically necessitated by the inconsistent pattern coronal periodontal ligament remnants,
discernible deposits of subgingival cal- of disease-induced staining encountered respectively. The resulting demarcated
culus as determined by visual inspection on the roots. periodontally involved root surface area
following extraction. This was designed The total area of the periodontally was calculated and the total instrumen-
to exclude the possibly complicating ef- involved root surfaces was established tation time computed for each tooth,
fect of the removal of calculus (scaling) using the formula: one quarter of which was appportioned
which might have influenced the oper- to each of the buccal, lingual, mesial
ator's efforts during the simpler exercise pocket area =
mean pocket depth and distal root faces.
of root surface debridement under con- X total root area,
sideration. mean root length
Instrumentation pressure was assess- based on the method described by Ny- Periodontally uninvolved root surfaces
ed on an Instron Materials Testing Ma- man & Ericsson (1982) and mean root 10 surgically removed totally unerupted
chine* which is capable of detecting and surface areas (Jepsen 1963). This third molar teeth, obtained from 7 pa-
recording the characteristic of very method was chosen so as to minimize tients attending the Oral Surgery de-
small loads (Fischel et al. 1982). The the handling of the roots inherent in the partment were used as controls. These
crown of each tooth was fixed with self- use of alternative planimetric methods, teeth were handled as described above
curing acrylic resin into a nylon retain- and thereby to reduce the risk of ex- but were not subjected to grooving.
ing tube and mounted in a specially con- traneous root surface contamination in
structed jig placed onto the Instron load the subsequent main investigation. The
cell. An adjustable laboratory retort instrumentation time per unit area was Preparation of experimental material
stand and clamp provided a stable fin- then calculated, based on the time taken Debridement technique
ger rest during instrumentation. to achieve cleanliness and the total The retaining tube of each tooth was
A Cavitron** 2002 Ultrasonic Dental periodontally involved root surface area fitted in turn into the Instron jig for
Unit was used with a TF-10 tip at an of each tooth. This was found to be 78 debridement. The individual root faces
angle of 15 to the root surface as re- s/cm- of root surface and apportioned were debrided with the ultrasonic in-
commended by the manufacturer, and accordingly to each of the 20 teeth se- strument using a light pressure for the
set at medium power (2.5) and 50% lected for the main investigation. prescribed time. A "cross-hatching"
water supplied from a pressurised con- pattern of instrumentation was carried
tainer. An operating amplitude of the out in which the instrument tip was pas-
Collection and processing of teeth
tip of 46 nm was measured at this setting sed methodically with a continuous
using a light microscope with a mi- Periodontally involved root surfaces overlapping action in an apico-coronal
crometer eyepiece. This was the same 20 single-rooted teeth were extracted plane and then from side to side to en-
for each of the 6 previously unused in- from 17 patients presenting in the casu- sure optimal root surface coverage. This
serts examined confirming the findings alty department of the Eastman Dental regime was performed regardless of the
of Walmsley et al. (1986). Hospital (II male, 6 female, mean age distribution of disease-induced staining
53.2 years+10.6 years) following a di- and any minor deposits of calculus pres-
agnosis of chronic inflammatory perio- ent. Similarly, any residual flecks of cal-
dontal disease. All teeth fulfilled the fol- culus at the completion of instrumen-
* Instron Ltd., High Wycombe, Buck- tation were ignored. The entire root sur-
inghamshire, UK.
lowing criteria: (i) periodontal pocket-
** Dentsply Ltd., Addlcstone, Weybridge, ing and radiographic evidence of at least face of half (5) of the control teeth were
Surrey, UK. 30% bone loss; (ii) no history of pro- subjected to this debridement regime.
176 Smart et al.

Stripping attd LPS assay < 1,0 ng of LPS and 4 of these yielded mentation is currently being practiced,
The test root surfaces were then stripped less than 0,02 ng per tooth. a belief endorsed by Moore et al, (1986)
with a dental bur to a depth of 1 mm and Nyman et al, (1986, 1988) and by
ad modum Wilson et al. (1986) and the the demonstrated efficacy of a conserva-
Discussion
material from each tooth collected sep- tive method of nand instrutnentation
arately for subsequent LPS assay. The This in vitro investigation has shown (Cheetham et al, 1988), Controlled clin-
10 control teeth were similarly stripped that very small amounts of LPS remain ical evaluations of such regimes are now
for assay, but as only half had been on the surface of single-rooted peri- clearly necessary.
debrided the extent of possible contami- odontally-involved teeth (which had no Since technically simpler subgingival
nation during instrumentation could be clinically detectable calculus) following instrumentation may be as effective as
established. a conservative ultrasonic instrumen- root planing, more specific terminology
The material harvested from each in- tation regime consisting of light press- is warranted. The term "root surface
dividual tooth was subjected to a se- ure for a short period of time ensuring debridement" is suggested for a con-
quence of "Westphal" extraction, dialy- overlapping instrumentation. This re- servative instrumentation regime of
sis and ultracentrifugation, followed by sidual LPS in all but one instance overlapping strokes and light pressure
Polymyxin B/Sepharose 4B affinity amounted to <2,2 ng and in 65% of utilized for only a limited time period.
chromatography and Limulus amoe- the teeth was less than 0,5 ng. Such The consistent fmding of only minute
bocyte lysate assay (Moore et al, 1986). quantities are negligible, bearing in amounts of residual LPS following such
mind that the initial LPS levels would a regime is of interest, despite the inci-
have been in the order of several hun- dental observation of residual flecks of
Results dred ng (Moore et al, 1986, Maidwell- calculus in some instances. This is being
The mean yield of LPS from the unin- Smith et al. 1987), The consistency and investigated further using the experi-
strumented control (periodontally-unin- efficacy of root surface decontami- mental model developed here.
volved) teeth was 0,479 + 0,19 ng per nation demonstrated under the simu- Finally, the results of this investiga-
tooth (range: 0,29-0,703 ng per tooth). lated clinical conditions can no doubt
tion endorse our earlier observations re-
The instrumented control teeth gave a be reproduced clinically. However, the
garding both the superficial distribution
similar low yield of 0,209 + 0,15 ng per influence of an additional possible cavi-
tooth (range: 0-0,414 ng per tooth) im- tational cleansing effect occurring in the of LPS and its ease of removal from
plying that the instrumentation per se laboratory (Walmsley et al, 1984, 1988) periodontally involved root surfaces.
did not introduce an appreciable which might not apply elsewhere cannot Furthermore, although these investiga-
be discounted. tions have been concerned only with
amount of exogenous LPS, Following LPS, the contention that our findings
instrumentation, the amount of residual Although the Instron unit ensured a also hold true for other root surface
LPS on the periodontally-involved roots more reproducible standardized regime contaminants would seem to be re-
ranged from <0,02 ng to 9,978 ng with than the rather subjective instrumen- inforced by the equal facility with which
a mean value of 0,919 + 0,33 ng per tation pressures used by others, the 50 such substances could be removed by
tooth (Fig, 1), 17 of the 20 teeth yielded g (approximately) used in the main in- polishing alone (Nyman et al, 1986,
vestigation proved to be slightly greater 1988), and warrants the continued use
than the "light" mean pressure of 36 of LPS as a representative marker of
g10 g determined in the pilot study. root surface contaminants.
10.0- Nevertheless, this is similar to the In conclusion, the findings of this in
9.9- "light" pressure as determined by vitro investigation indicate that, in the
2.2' Bjorn & Lindhe (1962), and it lies be- absence of clinically detectable deposits
tween that of 6 g+:3 g as measured on of calculus, a conservative regime of
1.5- a trip balance by Walmsley et al, (1984), ultrasonic root debridement is highly ef-
and that of 75 g when using a counter- fective in removing LPS and possibly
1-4
balanced scale by Clark et al, (1968), also other cytotoxic substances from
NET ^O The mechanical limitations of these periodontally involved root surfaces.
LPS relatively unstable balance mechanisms This does in turn question the rationale
ng compared to the Instron unit must how- for root planing and has far reaching
ever be borne in mind. clinical implications, with particular ref-
The mean instrumentation time of 78 erence to surgical access for instrumen-
0.5 s per root corresponds to less than 1 s/ tation,
mm^ of root surface. Moreover, the
mean instrumentation time was very Zusammenfassung
much less than the 5-12 min considered
necessary for clinically effective ultra- Die Beurteilung der Ultrasehallreinigung der
sonic instrumentation (Badersten et al, Wurzeloberflaehe durch die Bestimmung von
TEST CONTROLS 1984, 1985), even allowing for the inevi- Residual-Endotoxin Niveaus
1 2 tably greater expenditure of time by vir- Die kiirzlich beschriebene Oberflachenbe-
tue of the subgingival location of the schaffenheit und das leichte Enlfernen zur
Wurzelflache gehorender, zytoloxischer Stof-
Fig. 1. Scatter diagram showing the net re-
sidual LPS yield per root of the test (peri-
root surfaces and the likely presence of fe legt nahe, dass umfassende instrumentelle
odontally-involved) teeth, and the control calculus deposits. This in turn implies Behandlung der Wurzeloberflaehe klinisch
(periodontally-uninvolved) teeth. that a considerable degree of overinstru- nicht berechtigt erscheint. Die hier vorliegen-
Ultrasonic root surface debridetnent 177

de in Vitro-Untersuchung bestimmt die ent- Badersten, A,, Nilveus, R. & Egelberg, J. Jepsen, A, (1963) Root surface measurement
giftcnde Wirkung eines konservativcn Vor- (1981) Effect of nonsurgical periodontal and a method for x-ray determination of
gens mit Ultraschall-Wurzclreinigung, durch therapy. 1. Moderately advanced perio- rool surface area, Acta Odontologica Scan-
Anwendung der Limulus - Ambobozyten - dontitis. Journal of Clinical Periodontology dinavica 21, 3 5 ^ 6 .
Lysate Priifung fur Liposaccharide (LPS) aLs 8, 57-72. Jones, W. A. & O'Leary, T J. (1978) The
Indikator fur das Vorhandensein oder das Badersten, A., Nilveus, R. & Egelberg, J. effectiveness of in vivo root planing in re-
Fehlen von zytotoxischen Stoffen. 20 extra- (1984) Effect of nonsurgical periodontal moving bacterial endotoxin from the roots
hierte, parodontal crkrankte einwurzelige therapy. 11. Severely advanced perio- of periodonlally involved teeth. Journal of
Zahne ohne klinisch erkennbare Zahnslein- dontitis. Journal of Clinical Periodontologv Periodontology 49, 337-342.
ablagerung wurden mil ciner Cavition TF-IO 11,63-76. Leon, L. E. & Vogel, R. I. (1987) A compari-
Spilze gesauberl, Eine, die Wurzelobcrfla- Badersten, A., Nilveus, R. & Egelberg, J. son of the effectiveness of hand scaling and
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dicsem Instrument wurde, bei Anwendung therapy, (IV). Operator variability. Journal evaluated by differential dark-field miero-
des leichten Druckes von etwa 50 Gramm of Clinical Periodontology 12, 190-200. scopy. Journal of Periodontology 58, 86-94.
und einer Dauer von 0.8 Sekunden pro mm" Bjorn, H. & Lindhe, J. (1962) The influence Lindhe, J., Westfelt, E,, Nyman, S., Socran-
Wurzeloberflaehe, sichergestellt. Die Befunde of periodontal instruments on the tooth sky, S., Heijl, L. & Bratthall, G. (1982)
der LPS-Niveaus von <2,5 ng pro Wurzel surface. A methodological study. Odonto- Healing following surgical/non-surgical
bei 19 der 20 Ziihne nach einer solchen Reini- logi.ik Revy 13, 355-369. treatment of periodonlal disease. A clinical
gung, waren mit den LPS-Niveaus bei gesun- Breininger, D. R., O'Leary, T, J. & Blumen- study. Journal of Clinical Periodontology 9,
den, nicht in krankhaftes Gesehehen einbezo- shine, R. V. H. (1987) Comparative effec- 115-128,
genen Kontrollzahnen vergleichbar und vcr- tiveness of ultrasonic and hand scaling for Lindhe, J,, Westfeld, E., Nyman, S., Socran-
stiirkten also die wachsende Einsichl, dass die the removal of subgingival plaque and cal- sky, S. & Haffajee, A. D. (1984) Long-term
Sauberkeit der Wurzeloberflaehe leieht er- culus. Journal of Periodontology 58, 9-18. effect of surgical/non-surgical treatment of
reicht werden kann. Cheetham, W. A., Wilson, M. & Kieser, J. B, periodontal disease. Jourtial of Clinical
(1988) Root surface debridement in vitro. Periodontology 11, 448-458.
Journal of Clinical Periodontology 15, Maidwell-Smitii, M., Wilson, M. & Kieser, J.
Resume
288-292. B. (1987) Lipopolysaccharide (endoloxin)
Evaluation du debridement ultrasonique de la Clark, S. M., Grupe, H. E. & Mahler, D. B. from periodontally involved teeth. Journal
surface radiculaire par determination des ni- (1968) The effect of ultrasonic instrumen- of Clinical Periodontology 14, 453^56.
veau.x residuels d'endotoxine tation on root surfaces. Journal of Peri- Moore, J., Wilson, M. & Kieser, J. B. (1986)
Les demonstrations recentes de la nature su- odontology 39, 135-137, The distribution of bacterial lipopolysac-
perficielle du material cytotoxique au niveau Eaton, K, A., Kieser, J, B, & Davies, R, M. charide (endotoxin) in relation to perio-
de la surfaee radiculaire et de la faeilite a (1985) The removal of root surface de- dontally involved rool surfaces. Journal of
l'enlever suggerenl qu'un neltoyage parfait posits. Journal of Clinical Periodontologv Clinieal Periodontology 13, 748-751.
de la surface radiculaire n'est pas justifie cli- 12, 141-152, Nishimine, D. & O'Leary, T. J. (1979) Hand
niquement. Celtc etude in vitro a determine Fischel, H. R, Boyd, D. W. C. & Davies, E, instrumentation versus ultrasonics in the
les effets detoxifiants d'un regime conserva- H. (1982) Setting characteristics and po- removal of endoloxins from rool surfaces.
teur de debridement ultrasonique de la surfa- rosity of a composite resin. Quintessence Journal of Periodontology 50, 345-349.
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