Periodontology 2000, Vol. 71, 2016, 113–127 © 2016 John Wiley & Sons A/S.
iley & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Ultrasonic vs. hand
instrumentation in periodontal
therapy: clinical outcomes
R A N J I T H A K R I S H N A & J A M I E A. D E S T E F A N O
Periodontal disease
The initial culprits in periodontal disease are an array
of periodontal pathogens that can trigger dysregu-
lated immune and inflammatory responses in host
periodontal tissues, causing bone and periodontal
attachment loss (81, 125). Associated with the devel-
opment of periodontitis are endogenous and environ-
mental factors, such as poor oral hygiene, smoking,
stress, obesity, genetic variation and diabetes and
other systemic diseases (157). One goal of periodontal
nonsurgical therapy is to reduce the amount of tooth-
associated biofilms and their biological products,
such as endotoxins, antigens, enzymes and other
tissue-irritating substances (54). This can be
accomplished through changing the subgingival
environment by scaling and root planing or by root
debridement, with or without local delivery of antimi-
crobials and/or antiseptics, and/or the use of adjunc-
tive systemic antimicrobials. This initial therapy
usually does not target the microbial communities
associated with other extracellular or intracellular
mucosal niches within the mouth, or systemic colo-
nies (84, 92). Although studies have shown saliva,
cheek, tongue, tonsillar crypts and the palatal surface
microbial colonies as additional sources of cross-in-
fection to the periodontium within an individual, or
among individuals (43, 45, 168, 171), nonsurgical ther-
apy infrequently involves treating the whole mouth,
or the whole body, or treating others in close oral
contact with the patient, in an effort to control rein-
fection (11, 12). A statistically significant correlation
exists between the presence of disease and the quan-
tity and bacterial composition of dental plaque (11,
In memory of Dr Connie Drisko, an inspiration beyond measure.
PERIODONTOLOGY 2000
41, 42, 100, 156). Along with bacteria, cytomegalo-
virus, Epstein–Barr virus, papillomaviruses and her-
pes simplex virus may contribute to the pathogenesis
of periodontitis (152). Such dual infections have been
shown to be associated with more severe periodontal
disease, as herpesviruses in general can enhance
cytokine release, and Epstein–Barr virus, along with
cytomegalovirus, are associated with more severe
forms of periodontitis (24, 97, 140). Molecular meth-
ods have also revealed the presence of archaea and
fungi within the subgingival milieu (19, 143).
Halting the progression of
gingivitis
Plaque-induced gingivitis is an inflammatory change
caused by accumulation of a bacterial biofilm on the
tooth surface adjacent to the gingival tissues (98) and
is the most common oral disease in dentulous adults
(102, 123). Several studies have shown that this com-
monly occurring plaque-induced gingivitis is a pre-
cursor of periodontitis (94). Hugoson et al. (68)
observed, in a cross-sectional study conducted in
Sweden over a 30-year period, that improvements in
plaque control reduced the prevalence of both gin-
givitis and periodontitis.
According to the classic model proposed by Page &
Schroeder (124), the development of gingivitis and its
progression to periodontitis occurs in four stages.
Clinical signs of gingivitis start to appear in the ‘early
lesion’ (second stage). Up to the ‘established lesion’
(third stage), clinical signs of the disease can be
reversed by disrupting and removing the microbial
plaque biofilm.
The most predictable way of disrupting the micro-
bial plaque, reducing inflammation around the gingi-
val margins and thus preventing gingivitis, is by
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Krishna & De Stefano
mechanical disruption and removal of the microbial
plaque community. The effectiveness of this proce-
dure is highly dependent on the skill and ability of the
individual to remove plaque from all the tooth sur-
faces (70). Several studies have investigated how fre-
quently plaque needs to be removed to prevent
gingivitis and reached different conclusions. Lang
et al. (85) reported that brushing every 48 h prevents
gingivitis, whereas Kelner et al. (75) reported that
brushing every 24 h is consistent with gingival health.
In addition, Kelner et al. (75) reported that brushing
every 72 h does not prevent development of gingival
inflammation. The subjects in these studies were
dental students and their brushing technique was
supervised by a dental hygienist, resulting in more
plaque removal than average.
The European Workshop on Mechanical Plaque
control (86) recognized that meticulous plaque
removal every 24 h would be adequate to prevent gin-
givitis. However, because most people do not remove
all the plaque on their tooth surfaces every time they
brush, a higher frequency of toothbrushing will result
in better plaque removal (2, 70). In 1995, The Ameri-
can Dental Association made the recommendation for
toothbrushing to be performed at least twice a day
(30, 66). In a more recent study carried out by Pinto
et al. (128), participants were evaluated for gingival
inflammation at baseline, and 15 and 30 days after
performing mechanical removal of plaque with differ-
ent frequencies of 12, 24, 48 and 72 h; the authors
concluded that mechanical removal of plaque up to
every 24 h may prevent an increase in the severity of
gingival inflammation over a period of 30 days.
Disruption of microbial plaque every 12–24 h is
ideal for preventing gingivitis. However, in certain sit-
uations in which the thoroughness of plaque removal
is questionable, a higher frequency may be desirable.
Calculus: an important secondary
etiology
Calculus, defined as mineralized bacterial plaque, is a
gingival irritant, but bacterial plaque has a greater
pathogenic potential than calculus (33). Calculus has
both external irregularities and internal channels that
can promote the retention of periodontal pathogens
and therefore serves as a reservoir for inflammation-
inducing microbial products and components
(29, 162).
An early animal investigation showed that auto-
claved calculus is only a low-grade irritant, whereas
114
nonsterile calculus produces a granulomatous foreign
body reaction with a tendency for abscess formation
within connective tissue (5). In addition, Listgarten &
Ellegaard (96) found that lowering the toxicity of cal-
culus by treatment with chlorhexidine gluconate per-
mits the attachment of a junctional epithelium to
calculus.
It was once believed that plaque, calculus and
cementum contaminated with bacterial products and
components (e.g. endotoxin) required removal by
thorough scaling and root planing to achieve peri-
odontal health. Hatfield & Baumhammers (62) stated
that root surfaces exposed to periodontal disease are
toxic to growing cells in vitro, and Aleo et al. (3, 4)
showed that endotoxin from periodontally involved
teeth was toxic to fibroblasts, inhibiting their growth.
Nabers (112) advocated removing softened and con-
taminated root surface in order to obtain a smooth,
hard surface that would allow reattachment to occur,
and Jones & O’Leary (71) promoted root planing as
able to render diseased root surfaces approximately
as free of detectable endotoxin as uninvolved,
healthy root surfaces.
The current general consensus among clinicians
and clinical researchers is that cementum, although
difficult to retain during calculus removal, need not
be sacrificed for a good therapeutic outcome (117). It
appears that endotoxin adheres to root surfaces with-
out penetration into cementum, and its binding to
root surfaces appears to be weak (113).
Root planing with hand instrumentation is able to
remove root irregularities that harbor plaque and cal-
culus, and renders diseased root surfaces free of
detectable endotoxin (67, 71). However, it has been
shown that gentler techniques, utilizing sonic or
ultrasonic scalers, are as effective in removing plaque
and calculus (110).
Hand instrumentation vs. sonic/
ultrasonic instrumentation
Altering the subgingival microbiota to one compatible
with periodontal health, or reducing the bacterial
load and calculus deposits on tooth surfaces, can be
achieved with equal effectiveness by hand scalers and
curettes or ultrasonic scaling instruments (14, 15, 27,
46, 48).
Root debridement is often performed with a combi-
nation of sonic and ultrasonic instruments and hand
instruments (such as scalers and curettes), followed
by root planing with hand instruments. There are two

basic types of curettes – Universal and Gracey – with
most models requiring sharpening. These two types
of curette differ in the area-specificity, the number of
cutting edges, the curve of the cutting edge and the
angle of the face to the terminal shank.
The success of periodontal therapy depends on the
removal of hard and soft deposits from the root sur-
faces (16, 17, 65, 95). Reviews of various studies per-
formed under different conditions and in different
models have concluded that neither hand nor
mechanical instruments are superior in removing
subgingival deposits (36, 47, 88, 89, 118, 121, 159).
Ultrasonic instruments remove less root structure
than hand instruments (158, 164) but leave behind a
rougher surface (20). Hand instrumentation has been
recommended to smooth the root surface after ultra-
sonic use as a final finishing procedure in the treat-
ment of periodontitis-affected roots (139).
Most commercially available hand instruments
require sharpening on a regular basis. For decades it
has been accepted knowledge that periodontal
instruments must be re-sharpened frequently (37,
119, 161, 177). A few studies have compared changes
in root-surface morphology based on the cutting edge
of the instruments used (20, 21, 119, 138). O’Leary &
Kafrawy (119) recommended sharpening hand instru-
ments after every five working strokes, Coldiron et al.
(47) after every 10 strokes and Rees et al. (133) after
every 12 strokes. Zappa et al. (180) found that after
the first 20 strokes there was diminished hard-tissue
removal and an increase in pressure applied per
stroke. Even though all these studies show a decrease
in instrument sharpness and effectiveness, very few
clinicians sharpen their instruments every five to 20
strokes (180). Although instrument sharpening is the
deciding factor for clinical effectiveness in achieving a
clean and smooth root surface, sharpening the instru-
ment every five to 20 strokes is not very practical and
results in destruction of the original contour of these
expensive instruments. Re-sharpening can weaken
the scaler, causing breakage during function, or can
create metal tags that are potentially harmful to the
hard and soft tissues. All studies evaluated so far still
leave us with the question of how frequently we
should sharpen our instruments. How much is too
much and how much is too little? Most studies sug-
gest that depending on the quality of the alloy and
the pressure used for root planing, we may be able to
retain sharpness for a greater number of strokes than
originally thought.
Owing to the above problems with instrument
sharpening, clinicians and instrument manufacturers
have been seeking instruments that can achieve
Ultrasonic vs. hand instrumentation in periodontal therapy
better clinical effectiveness with less trauma to the
hard and soft tissues and can be used for prolonged
periods of time without sharpening. Several instru-
ments with “edge retention” properties have been
recently introduced to the market with the claims
that these instruments need little or no sharpening,
and allow unproblematic maintenance and display
long-term effectiveness. Different metal alloys,
including stainless steel, high-speed steel, carbon
steel and tungsten carbide, have been shown to influ-
ence the efficacy and life expectancy of the instru-
ment (160).
Sisera et al. (151) evaluated three different instru-
ments with edge-retention technology in comparison
with a standard curette made of stainless-steel alloy.
They simulated clinical conditions in the laboratory
using bovine central incisors. The concurrent removal
of dental hard tissue, at predetermined intervals (i.e.
number of strokes), was evaluated to monitor the
effectiveness and hard-tissue damage caused by the
instruments. The surface roughness after use was also
assessed. The influence of the sterilization process,
which may harm the curette material by changing the
structural components, was also assessed. Of the
three instruments tested, two had titanium nitride
coating and one was made of cryogenically treated
stainless steel. Instruments and the root surfaces were
evaluated at baseline, after 500, 1000 and 1010
strokes, and after sterilization. The authors found no
statistically significant difference between the differ-
ent instruments at different time points regarding the
amount of tooth structure removed. After 1010
strokes and five sterilization cycles, the dentin
removal significantly decreased for all curettes
(P ≤ 0.05). It was concluded that although the manu-
facturers’ claim for the titanium nitride-coated
instruments and the tempered stainless-steel instru-
ment about not requiring frequent sharpening over
multiple usage was true, it was also true for the con-
trol curette, which was made of untreated stainless
steel alloy. All instruments lost efficacy after being
repeatedly treated with thermal and chemical steril-
ization. Another recent study examined the effect of
repeated dry-heat sterilization and autoclave cycles
on carbon-steel and stainless-steel curettes during
scaling and root planing. Carbon-steel curettes were
more likely to be affected by surface corrosion prod-
ucts and edge deterioration than were stainless-steel
curettes. Using 2% sodium nitrite to inhibit corrosion
before sterilization greatly reduced the oxidation of
the metal surface (129).
Recently, diamond-coated curettes have been
introduced for scaling and root planing with conven-
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Krishna & De Stefano
tional curettes. Eick et al. (50) evaluated the efficacy
of an additional use of diamond-coated Gracey cur-
ettes on surface roughness, adhesion of periodontal
ligament fibroblasts and detection of Streptococcus
gordonii in vitro after conventional root planing. The
curettes used were diamond coated at the working
ends with a 15 lm grit size of natural diamond granu-
late. The authors found that the additional instru-
mentation with the diamond-coated curettes resulted
in a two-fold increase in the number of attached peri-
odontal ligament fibroblasts but not in the numbers
of adhered bacteria. The authors concluded that con-
ventional root planing with Gracey curettes followed
by subsequent polishing with diamond-coated cur-
ettes, may result in a root surface that provides favor-
able conditions for adhesion of periodontal ligament
fibroblasts without increasing microbial adhesion
(50). However, this study did not evaluate the instru-
ments for their ability to remove calculus, but rather
evaluated the effect of the instruments on root-sur-
face properties.
Only a limited number of studies have examined
the differences, between instruments, in retention of
the cutting edge (151, 160, 161). Several studies have
compared stainless-steel instruments with those of
carbon steel, to see how the alloy mix affects the
hardness of the cutting edge, and have reported con-
flicting results. In the study carried out by Tal and
coworkers (160, 161), the stainless-steel curettes
showed significant edge attrition after 45 strokes
compared with the high-speed steel, cemented-car-
bide steel and high-carbon steel instruments. Goro-
khovsky et al. (57) showed significantly less wear on
instruments with a 10 multilayer titanium nitride/ti-
tanium coating compared with uncoated high-chro-
mium stainless-steel scalers – wear resistance of the
former was increased by at least 12.5 times and clini-
cal usefulness extended from 3 months to 6–
11 months, depending on the rate of use. They also
found that steam sterilization at 260°C for 30 min and
215 cycles of ultrasonic cleaning had no negative
effects on either the titanium-coated or stainless-steel
curettes.
Dentin removal and surface roughness have been
examined in earlier instrumentation studies (51, 72,
105, 107, 126, 167, 178). Benfenati et al. (20) analyzed
scanning electron microscopy images of root surfaces
and found that blunt instruments produced smoother
root surfaces compared with sharp instruments, even
though they did not completely remove all the depos-
its on the root surface. A damaged curette created
deep scratches on the root surface. In more recent
studies, curettes have proven to create a relatively
116
smooth surface morphology, as determined by pro-
filometric findings (145, 169).
Powered scalers utilized in debridement proce-
dures are classified into sonic and ultrasonic instru-
ments according to their working frequencies. The
frequency (or speed) and the amplitude (or length) of
the stroke are important parameters to consider
when using ultrasonic scalers. The power setting that
is normally tuned manually controls the length of the
stroke, or amplitude. It has been shown that vibration
displacement amplitude at the scaling tip is equally
effective in scaling efficiency at half power or full
power (69). However, the chipping action, which not
only removes calculus but can damage root structure,
is greater at higher power settings (87). Also, the tip
displacement amplitude at a medium power setting
of 5 or 6 is higher with piezoelectric scalers than with
magnetostrictive units. This observation supports the
findings of Busslinger et al. that piezoelectric devices
create a higher degree of root damage compared with
magnetostrictive scalers running at the same power
setting (28, 52, 53). The greater the frequency, the
higher the energy output but the smaller the active
area of the tip. A lower frequency, of 25 kHz, results
in an active area of 4.3 mm at the terminal tip,
whereas a higher frequency, of 50 kHz, will result in
an active area of only 2.3 mm. At low frequency
under a load of 25 g, the active area of the tip is
increased, allowing deeper pocket depths to be
reached with diminished generation of heat, thus pre-
venting thermal damage and patient discomfort (88).
Sonic powered instruments operate at frequencies in
the sonic range of 2–8 kHz (cycles per second) and
are driven to vibrate by compressed air striking a
metal rod within the handpiece to produce audible
oscillations that travel down to the attached scaling
tip. The vibrating tip produces elliptical to orbital
motions with all sides of the tip able to adapt to the
root surface (55, 93). The two types of ultrasonic sca-
lers are based on either magnetostrictive (e.g. Cavit-
ronâ) or piezoelectric (e.g. Piezon Master 400â,
Symmetry IQâ) mechanisms. The magnetostrictive
ultrasonic instruments are driven to vibrate by an
electric current supplied to either a wire coil, metal
stacks made of nickel–iron alloy, or to a ferrous rod in
the handpiece, producing a magnetic field that causes
the oscillation generator to change shape or dimen-
sion, creating the high vibrational energy that travels
to the scaler tip (10, 47). The piezoelectric scalers use
electrical energy to electrosize crystals housed within
the handpiece. The dimensional changes of these
crystals cause the generation of high vibrational
energy that travels to the tip (53). Magnetostrictive

ultrasonic scalers have elliptical tip movement and
operate between 18,000 and 45,000 cycles/second,
much faster than sonic scalers, with an amplitude
that ranges from 10 to 100 lm. All surfaces of the tip –
front, side and back – are simultaneously active with
the elliptical vibratory movement (53). The metal
stack in the magnetostrictive scaler generates heat,
and to prevent overheating it requires plenty of irriga-
tion during scaling. It is recommended that the flow
rate be at least 20–30 ml/min to prevent a tempera-
ture increase of more than 5°C that could potentially
damage the pulp and dentin (115). Piezoelectric
devices do not generate much heat and require less
irrigant; however, the cooler water might cause more
sensitivity during the procedure. Magnetostrictive
scalers have tips that are interchangeable as long as
the unit is of the same frequency, whereas piezoelec-
tric tips are of proprietary design and therefore are
not interchangeable. When using the magnetostric-
tive ultrasonic scaler to remove heavy calculus depos-
its on supra- and subgingival sites, it is best to use a
large tip on medium to high power. In subgingival
sites, the tip should be introduced to the base of the
pocket, moving coronally with paintbrush and light-
pressure strokes that are parallel to the long axis of
the tooth. At the feel of a calculus ledge, the tip
should be moved to the coronal aspect of the calculus
and tapped in an apical direction to break it away
from the surface of the root. Thin tips on medium to
high power are used to remove hard calculus from
furcations, concavities and deeper pockets. Thin tips
made of especially filtered titanium nitride/stainless-
steel alloy can sustain high power without breaking. It
is important to follow power debridement with sharp
hand instruments, such as Gracey curettes, to remove
any residual calculus and smooth the root surface.
Piezoelectric ultrasonic scalers produce a linear
vibratory movement that permits two lateral sides of
the tip to be active, operating at 25,000–50,000 cycles/
second, with amplitude of 12–72 lm. The recom-
mended technique for using the piezoelectric scaler is
from a coronal to apical direction. The crown of the
tooth should be paintbrushed, with the tip held lat-
eral to the tooth surface, using light pressure and
overlapping strokes moving down to the base of the
pocket, always with the lateral side of the tip as paral-
lel as possible to the long axis of the tooth. The vibra-
tion patterns and frequency of piezoelectric and
magnetostrictive scalers facilitate the dispersal,
crushing and removal of calculus with a continuous
water coolant (88). Although the primary mode of
operation is the physical vibratory action of the oscil-
lating tip, the irrigant not only provides cooling at the
Ultrasonic vs. hand instrumentation in periodontal therapy
treatment site, but creates acoustic turbulence,
streaming and cavitation. Extreme conditions of pres-
sure and temperature that destroy cell walls and kill
bacteria are produced by the cavitation resulting from
the formation and break down of microscopic bub-
bles (cavities) created as water passes through the
handpiece. Water exiting the tip creates acoustic
microstreaming and turbulence, further agitating and
disrupting the content of the pocket. Microjets that
impact on the tooth surface aid in the removal of pla-
que and stain but can also produce pitting in an area
of 0.66 mm2 (47, 83, 172–175).
Increased loading with tips contacting the tooth at
0.25–1.0 N (or 25–100 g) demonstrated a nonlinear
increase in displacement amplitude, which was sig-
nificantly different from the unloaded tip response,
suggesting high variability associated with ultrasonic
inserts because specific power levels are required for
different tips to achieve the same level of calculus
and plaque removal (87).
Another explanation for variability in tip perfor-
mance is reduction in tip length from repeated clini-
cal use and wear. A 1 mm reduction in wear results in
close to 25% loss of efficiency, whilst a 2 mm reduc-
tion in wear reduces the vibration displacement
amplitude by approximately 50%, requiring immedi-
ate tip replacement. Scaler tip wear is reduced by dia-
mond coating. The diamond tips have been shown to
remove calculus rapidly, especially at furcation areas.
However, they also lead to increased overall root-sur-
face removal (169).
Even though earlier studies have shown that ultra-
sonic scaling was enhanced by irrigation with povi-
done iodine, resulting in attachment gains of 50%
more than those receiving either ultrasonic debride-
ment alone or periodontal surgery, randomized clini-
cal trials by Del Peloso Ribeiro et al. (42) and
Leonhardt et al. (91) found no additional benefits in
using either a 0.5% or a 10% solution of povidone
iodine as an irrigant during debridement with ultra-
sonic devices. A study describing the use of 0.12%
chlorhexidine gluconate as an irrigant during subgin-
gival ultrasonic scaling demonstrated no enhanced
clinical outcomes (31), and a second study showed a
significant reduction in pocket depth at a 28-day
recall examination, suggesting that certain antimicro-
bial irrigants may enhance ultrasonic debridement
(134). No studies have been published using 0.5%
sodium hypochlorite as an adjunct irrigant during
ultrasonic debridement.
A systematic review of controlled clinical trials, with
6 months or more of follow up, assessed the differ-
ences between ultrasonic, sonic and manual debride-
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Krishna & De Stefano
ment for the treatment of chronic periodontitis. It
was found that the mean gain in clinical attachment
level, the mean reduction in probing depth and the
mean reduction in bleeding on probing were similar
for both machine-driven and hand instruments. Pro-
cedures using machine-driven instruments, however,
took significantly less time (36.6% less than hand
instrumentation) and caused less soft-tissue trauma
but more root damage (165). A second systematic
review, carried out by Needlemann et al. (114),
assessed supragingival and subgingival plaque
removal using hand instruments (scalers and cur-
ettes) and powered instruments (sonic, ultrasonic,
rotating devices and air-polishing devices). They
found that repeated oral-hygiene instructions showed
similar effects to professional mechanical plaque
removal using either technique.
Early investigations demonstrated that hand instru-
mentation by curettes, as well as by very fine rotating
diamonds, created the smoothest root surfaces,
whereas “vibrating” instruments, such as sonic and
ultrasonic scalers, as well as coarse diamonds, tended
to roughen the root surface (144). Cobb (35) found
manual curettes more technique sensitive and time
consuming but more efficient with increased probing
depths. Equivalent clinical outcomes, however, have
been shown in studies comparing ultrasonic units
with hand scaling. A mean probing-depth reduction
of 1.2–2.7 mm was observed with the use of ultra-
sonic instruments, and values similar to those were
obtained with conventional hand instrumentation,
showing a reduction of 1.29 mm for moderate pock-
ets and 2.16 mm for deep pockets (36, 47). According
to a systematic review conducted by Van der Weijden
& Timmerman (166), subgingival mechanical instru-
mentation resulted in a mean attachment gain of
0.30–1.02 mm in pockets with an initial depth of up
to 4 mm and a mean attachment gain of up to
1.58 mm in pockets with an initial depth of ≥7 mm.
The literature on the physical effects of magne-
tostrictive and piezoelectric ultrasonic scaling devices
on tooth surfaces has shown varying results. For
example, Flemmig et al. (52) reported that use of a
magnetostrictive scaler for root debridement resulted
in a rougher root surface compared with use of a
piezoelectric device. By contrast, Busslinger et al. (28)
showed that after root instrumentation, a piezoelec-
tric device left a rougher surface than a magnetostric-
tive device. A recent study showed that root surfaces
treated with a piezoelectric scaler using 200 g of lat-
eral force were smoother than those treated with a
magnetostrictive device with the same lateral force
(179).
118
Comparison of root-surface instrumentation using
manual curettes, magnetostrictive ultrasonic scalers
and rotary instruments demonstrated nonsignificant
differences between the three groups in the amount
of calculus remaining, loss of tooth substance and
roughness of root surface after root planing; however,
magnetostrictive ultrasonic scaling showed the lowest
mean scores for the roughness/loss of tooth sub-
stance index, indicating less removal of cementum
and fewer marks of instrumentation on the dentin
surface (101). Kawashima et al. (74) compared the
effectiveness of two piezoelectric ultrasonic scalers
and a hand scaler for subgingival scaling and root
planing in vivo and found similar results, showing
that the remaining calculus index did not differ signif-
icantly among the groups but the roughness/loss of
tooth substance index was significantly lower for the
groups treated with the piezoelectric ultrasound unit.
Manual and ultrasonic scalers have been shown to
be equally effective in subgingival plaque removal.
Oosterwaal et al. (121) showed equal outcomes in
reducing the counts of rods, spirochetes and motile
organisms with either manual or ultrasonic magne-
tostrictive scaling on the subgingival microbiota in
periodontal pockets with probing depths of 6–9 mm.
Baehni et al. (18) compared the effects, on the sub-
gingival microbiota, of scaling using a piezoelectric
instrument with scaling using a sonic instrument and
reported no differences between the two techniques
in microscopy or culture observations.
The efficacy of ultrasonic scalers on the removal of
endotoxin has also been investigated. Nishimine &
O’Leary (116) found that ultrasonic scaling resulted in
average residual endotoxin values (i.e. 16.8 ng/ml)
approximately eight times higher than those after
hand scaling (i.e. 2.09 ng/ml). Smart et al. found
endotoxin levels of <2.5 ng per root after debride-
ment with a magnetostrictive ultrasound unit, which
was enough to allow fibroblast reattachment (155).
Several investigators have reported that ultrasonic
instruments can save 20–50% of time used for peri-
odontal debridement (32, 35, 49), and cause less dis-
comfort to the patient, while showing equal healing
responses of the affected periodontium (145, 165,
176). In addition, debridement using ultrasonic
instrumentation has been shown to be more effective
in areas of limited access, such as in furcations, deep
vertical defects or any area with limited access (49).
Comparison between hand instruments and sonic
and ultrasonic scalers did not show a clear advantage
for the machine-driven instruments (165), and tissue
trauma was similar with both instruments (6). Hand
instruments yielded greater improvements in clinical

parameters, such as bleeding on probing, compared
with instrumentation using an ultrasonic system (34).
Use of conventional Gracey curettes may result in
higher substance loss, but significantly better calculus
removal (26, 79, 145) and smoother surfaces, com-
pared with sonic and ultrasonic instrumentation (26,
79, 80, 135).
Around implant abutments, studies have observed
that the use of plastic and titanium curettes resulted
in smoother surfaces compared with the use of steel
curettes (106). Several studies have confirmed the
finding that hand instrumentation produced much
smoother surfaces with fewer irregularities and
grooves compared with sonic and ultrasonic instru-
ments (13, 107).
Apart from producing a smooth surface free of bac-
teria, another goal of scaling and root planing is to
facilitate fibroblast cell attachment on the root sur-
face. Studies have shown that a very low number of
fibroblasts attach on untreated root surfaces with
periodontal disease (15, 76). Studies in which diode
lasers were used did not report an increase in the
numbers of attached cells after scaling and root plan-
ing (82).
Ultrasonic scaling in combination with a CO2 laser
was compared with hand scaling and root planing;
more pronounced fibroblast attachment was found
with the additional use of a CO2 laser (39). Similar
results of increased fibroblast attachment were also
found in a study investigating the effect of using
erbium-doped yttrium aluminium garnet (Er:YAG)
lasers (149). In contrast, some studies have found no
difference between rotary instruments and hand scal-
ing (77). In the study by Eick et al. (50) the number of
fibroblasts attached doubled when the surface was
treated with diamond-coated curettes. The fibroblast
orientation suggested that moderate roughness of the
root surface was beneficial for cell attachment. Eick
et al. (50) did not find any additional bacterial adhe-
sion after instrumentation with diamond-coated cur-
ettes compared with Gracey curettes alone. More
studies are needed to evaluate the relationship
between bacterial adhesion and the attachment of
fibroblast cells on root-surface roughness.
The roughness of the root surface after a scaling
procedure is a factor to consider for maintenance
because it has been shown that bacterial plaque
adheres more easily to rough root surfaces than to
smooth root surfaces (78, 89). Studies have shown
that initial bacterial adhesion always occurs on sur-
face irregularities (130). However, a study comparing
hand instrumentation with Er:YAG lasers and ultra-
sonics showed that the roughest root surface with the
Ultrasonic vs. hand instrumentation in periodontal therapy
greatest amount of adhesion of Streptococcus san-
guinis was obtained after hand instrumentation (122).
Schwarz et al. (146) published a systematic review
that discussed the clinical effect of laser application
compared with mechanical debridement in patients
undergoing nonsurgical periodontal therapy. They
also reviewed existing literature in relation to the
safety of laser applications. Owing to the heterogene-
ity of the different articles reviewed, they were not
able to perform a meta-analysis. However, based on
the limited evidence available, they concluded that
both Er:YAG lasers and mechanical debridement
yielded similar results, both short term and long term
(up to 24 months). Miyazaki et al. (108) compared
the effect of CO2 and neodymium-doped yttrium alu-
minium garnet (Nd:YAG) laser monotherapy with that
of ultrasonic scaling, and reported significant reduc-
tions in probing depths in all treatment groups after
1, 4 and 12 weeks of healing. However, only the Nd:
YAG group and the ultrasonic group showed signifi-
cant reductions in bleeding on probing and gain in
clinical attachment level. Aoki et al. (7) reported that
neither CO2 nor Nd:YAG lasers were able to remove
root surface calculus satisfactorily and that they pro-
duced root-surface alterations as a result of heat gen-
erated during irradiation. Studies evaluating Er:YAG
laser monotherapy for initial (38, 44, 147, 148, 150) or
maintenance (163) therapy have shown considerable
improvements in all periodontal clinical parameters
after treatment. The microbiological results reported
by Schwarz et al. (147, 148) indicate that subgingival
bacteria repopulate periodontal pockets 3–6 months
after treatment with Er:YAG lasers, indicating that
there are no additional benefits of using lasers over
conventional therapy.
Bower (25) has shown that in 81% of maxillary and
mandibular molars the furcation entrance is 1.0 mm
or less, and in 58% the diameter is 0.75 mm or less.
The blade face-width of curettes used in scaling and
root planing ranges from 0.75 mm to 1.10 mm, limit-
ing movement of the blade within a space of the same
size (25). Leon & Vogel (90) showed that in Class I fur-
cations, hand scaling and ultrasonic debridement
have equivalent access and consequent effects on
microbial outcome, whereas in Class II and Class III
furcations, ultrasonic debridement is significantly
more effective than hand scaling in decreasing the
counts of motile rods and spirochetes and in main-
taining decreased bacterial counts in these sites. Sig-
nificantly thinner ultrasonic tips, measuring
0.55 mm, are smaller than the working ends of the
smallest curettes, making them a superior choice for
calculus removal at moderate and severe furcation
119
Krishna & De Stefano
sites. In favor of sonic or ultrasonic instruments, a
reduction in the quantity of bacteria will create a bal-
ance between the host response and the residual
organisms, leading to good therapeutic outcome (27).
Traditional periodontal therapy involves scaling
and root planing, one quadrant at a time, with a 1-
week interval between appointments. This kind of
treatment, whilst effective, does not reduce the over-
all burden of microbes in the oral cavity and there is
always a chance of cross-infection between treated
and untreated sites. To address this problem, in 1995,
Quirynen et al. (131) introduced the concept of full-
mouth disinfection. In this procedure, full-mouth
scaling and root debridement were performed within
a 24-h period, subgingival irrigation (repeated three
times within a 10-min period) was carried out with
1% chlorhexidine gel, the tongue was brushed with
1% chlorhexidine gel and the mouth was rinsed with
0.2% chlorhexidine. Quirynen et al. (131) showed that
this yielded a better short-term result than the con-
ventional treatment protocol for periodontal disease.
However, conflicting findings have been reported
regarding the benefits of scaling and root planing, or
root debridement, according to quadrants, over a
number of visits, compared with one-stage
full-mouth instrumentation. It has been shown that
nonsurgical instrumentation performed in one visit,
or quadrant scaling performed in days, or weeks,
had no significant impact on the treatment outcome
(8, 141).
The limited additional benefits of full-mouth
debridement include a shorter treatment time and
use of less material in the clinic, but at the expense of
time needed to optimize home oral-hygiene protocols
and to develop a strong patient/practice relationship
to encourage patient compliance with oral-hygiene
protocols. It is well established that the absence of
good oral hygiene will result in the repopulation of
deep pockets 4–8 weeks following subgingival instru-
mentation. Hence, good plaque control can suppress
repopulation of previously treated subgingival sites
and affect the microbial populations in periodontally
involved sites that were not treated. Optimal oral
hygiene is key to successful nonsurgical therapeutic
outcomes (99, 111).
Can antimicrobial therapy be
effective if the biofilm is not
mechanically disrupted?
Studies have shown that bacterial resistance is much
higher in biofilms. Several authors have also
120
suggested that the minimum inhibitory concentration
profiles are different for bacteria in biofilm than for
bacteria in the planktonic state (22, 120, 181). This
could be a result of the fact that bacteria in biofilm
exist in different physiological stages of their life
cycle. The biofilm also contains different species of
bacteria, protozoa, fungi and viruses; communities
composed of hundreds of interacting species that,
once established, survive in the crevicular environ-
ment and challenge the innate, inflammatory and
adaptive immune responses that are unable to clear
or completely remove the biofilm (9, 109). Also, the
biofilm matrix is composed of complex polymers
inhibiting penetration and distribution of molecules
toward the central region containing the most viable
bacteria. The disruption of biofilm by mechanical
debridement and the establishment of daily oral-hy-
giene practices are central features of effective non-
surgical periodontal therapy, possibly by rendering
this intricate biofilm community more susceptible to
adjunctive approaches (9).
A systematic review (60) that focused on the use of
antimicrobials as an adjunct to mechanical debride-
ment and surgical therapy, as well as when used as a
monotherapy, concluded that the use of antimicro-
bials as a monotherapy did not produce any signifi-
cant improvements in clinical outcomes and
concluded that “there was insufficient evidence to
support the use of antibiotics as a monotherapy in
periodontitis patients”. The American Academy of
Periodontology position paper on systemic antibiotics
in 1996 suggested that based on the concept of “good
medical practice”, mechanical debridement should
always precede medications (1). This conclusion was
also supported in a review by Slots (153). A systematic
review conducted in 2008 (63), which attempted to
assess the benefits of prescribing antibiotics during
the nonsurgical therapy phase vs. the surgical phase,
remained inconclusive. However, two studies (58, 73)
that were not included in the above review showed
better clinical outcomes when a combination of
amoxicillin and metronidazole was given to a group
of patients with generalized aggressive periodontitis
during the initial therapy phase, and a synergistic
effect against the causative bacteria, Aggregatibacter
actinomycetemcomitans, has been noted in vitro
with a combination of metronidazole and
amoxicillin (127).
Periodontitis is an infection and the causitive
microorganisms often invade other tissues in the
body. These microbes adhere to the surfaces of teeth
in a very organized and complex manner to form a
biofilm called dental plaque. At the 5th European

Workshop of Periodontology, it was concluded that
“Dental plaque displays properties that are typical of
biofilms and microbial communities in general, a
clinical consequence of which is a reduced suscepti-
bility to antimicrobial agents as well as pathologic
synergism” (104). In a systematic review presented at
the European Workshop in 2002, Herrera et al. (64)
concluded that in certain clinical situations, such as
in patients with deep pockets, with progressive or
refractory disease, or with specific microbiological
profiles, the use of adjunctive systemic antimicrobials
may be beneficial. In another systematic review, pre-
sented at the World Workshop in 2003, Haffajee et al.
(60) concluded that even though systemic antibiotic
therapy could somewhat help conventional peri-
odontal therapy, because of the absence of a well-de-
fined protocol, it was prudent to stick to conventional
mechanical therapy alone.
Povidone-iodine, dilute sodium hypochlorite and
chlorhexidine gluconate have been used for pocket
irrigation during, or following, root-debridement pro-
cedures with the intent of applying bactericidal agent
in areas where root planing is less than ideal as a
result of anatomy or local factors. Locally applied
antimicrobial systems containing minocycline, doxy-
cycline, tetracycline, metronidazole and chlorhexi-
dine have been used with the intent of reducing the
numbers of viable pathogens in biofilms and sup-
pressing the reformation of biofilms (23, 56, 59). The
delivery of local antimicrobial therapy, alone, or in
conjuction with scaling and root planing, has been
reviewed in a meta-analysis by Hanes & Purvis (61).
In this analysis, they compared 19 studies that used
adjunctive local-delivery antimicrobials, such as
minocycline gel, microencapsulated minocycline,
chlorhexidine chips and doxycycline gel, and found
significant probing-depth reduction and clinical
attachment gain when compared with scaling and
root planing alone. The use of sustained-release anti-
infective agents has been shown to reduce probing
depths and bleeding on probing in some populations,
similarly to that achieved by scaling and root planing
alone (24, 61). The use of antimicrobial irrigants or
anti-infective sustained-release systems did not show
any significant adverse effects on patients. Although
some studies have shown that chlorhexidine irriga-
tion during scaling and root planing, compared with
scaling and root planing alone, did not have a positive
adjunctive effect (40, 132), povidone-iodine (Be-
tadineâ, Iodopaxâ) showed positive adjunctive
effects, both in clinical indices and microbial parame-
ters. In addition, use of sodium hypochlorite (0.1–
0.5%) showed an 80-fold reduction of root endotoxin
Ultrasonic vs. hand instrumentation in periodontal therapy
in teeth with periodontal disease, to a level compara-
ble with that of periodontally healthy teeth (142). A
study performed in dogs showed that irrigation with
sodium hypochlorite resulted in histological signs of
increased osteoblastic activity, even though overall
healing and pocket-depth reduction was equal to that
obtained by scaling and root planing alone (170). It is
important to note that chlorhexidine has the poten-
tial to induce a dose-dependent reduction in fibrob-
last proliferation and, at lower concentrations, to
alter the production of collagen and noncollagen pro-
tein by these cells (103). A potentially adverse effect of
povidone-iodine is that it can interfere with thyroid
metabolism, especially in patients with thyroid dys-
function. Prolonged exposure to iodine can cause goi-
ter, alter synthesis of thyroid hormones, or induce
myxedema or hyperthyroidism (154). A mixture of
sodium bicarbonate, sodium chloride, and hydrogen
peroxide, in conjunction with scaling and root plan-
ing, has been shown to reduce the microbiota and
arrest the breakdown of periodontal tissues, and to
promote early periodontal healing with gain in
attachment levels and gain in alveolar bone mass
(136, 137).
When sites of inflammation have not responded to
initial periodontal therapy, advanced periodontal
therapy and/or periodontal maintenance therapy,
locally delivered antibiotics can be used. Locally
delivered antimicrobials are placed in a periodontal
pocket with a delivery system and released in a con-
trolled manner, allowing the minimum inhibitory
concentration of the antimicrobial to be achieved for
a prolonged period of time. Local antimicrobials
include: Atridoxâ, a 10% doxycycline gel in a bioab-
sorbable mixture that, when placed below the gingi-
val margin, flows to the bottom of the pocket, adapts
to the root surface and releases active drug over a
period of 21 days; PerioChipâ, a 2.5 mg chlorhexidine
biodegradable chip that is placed in the periodontal
pocket and maintains activity for up to 7–10 days;
and Arestinâ, a powder containing 1 mg of minocy-
cline spheres that remain active in the pocket for up
to 14 days. A 2003 workshop on periodontitis found
statistically significant improvement in clinical
attachment levels with adjunctive use of Atridox or
the PerioChip combined with scaling and root plan-
ing (61) and Grossi et al. (59) found that compared
with scaling and root planing alone, the use of
minocycline microspheres significantly improved
probing depths, clinical attachment levels and
bleeding on probing, and resulted in a reduction of
red complex bacteria in smokers with chronic
periodontitis.
121
Krishna & De Stefano
Concluding remarks
Nonsurgical periodontal therapy involves mechanical
removal and disruption of bacterial colonies from the
tooth and root surfaces. This can be accomplished by
hand, sonic and ultrasonic scalers. Root planing with
hand instruments render remove the root irregulari-
ties that harbor plaque and calculus. Root planing
with sonic and ultrasonic instruments remove less of
the tooth structure, but leave behind a rough surface.
However, both techniques are equally effective in
removing plaque and calculus deposits.
Sharp hand instruments are the key factor for clini-
cal effectiveness. It is recommended that the hand
instruments be sharpened every five to 20 strokes.
However, this is not practical, creates metal tags and
changes the original contour of the instruments.
Instruments also lose their efficacy after repeated
thermal and chemical sterilization. In view of these
problems, instruments with “edge retention” proper-
ties have recently gained popularity.
Powered scalers increase the efficiency during non-
surgical periodontal therapy by reducing operator
fatigue and removing calculus more quickly than
hand instrumentation. However, powered instru-
ments create a rough root surface and increase root
sensitivity. Powered instruments are classified as
sonic and ultrasonic based on their working frequen-
cies. The frequency, speed and amplitude are impor-
tant parameters to consider whilst using the power-
driven scalers. Higher frequencies require higher
energy output, but result in a smaller active area
around the tip. Ultrasonic devices can be piezoelec-
tric or magnetostrictive. Understanding their mecha-
nism of action helps the clinician use them optimally
and reduces the damage to the tooth structures and
surrounding tissues.
Chemical irrigation with antimicrobials as an
adjunctive therapy has been shown to have added
benefits during nonsurgical periodontal therapy.
Antimicrobial agents, such as povidine-iodine, dilute
sodium hypochlorite and chlorhexidine gluconate,
have been used for pocket irrigation during, or follow-
ing, root debridement because of their potential
bactericidal effect. Other local antimicrobials used
include minocycline, doxycycline and metronidazole.
Nonsurgical therapy can be accomplished in a sin-
gle visit or in multiple visits. The advantages of using
a multivisit approach are that the clinician has
multiple opportunities to observe and correct the
oral-hygiene practices of the patient and to evaluate
and treat any sites needing additional therapy. A
122
single-visit full-mouth disinfection procedure before
scaling and root planing, quadrant by quadrant, helps
to reduce the overall bacterial load and has been
shown to have additional benefits.
Nonsurgical treatment is the keystone to successful
treatment of any patient with periodontal disease. It
is important for the clinician to understand the differ-
ent instruments used, adjunctive therapies available
and the best practices established in order to achieve
optimal results.
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