Power

Instrumentation

Academic Chair Dental Hygiene, Dental Assisting, and Surgical Technology at Dallas College
World Headquarters
Jones & Bartlett Learning
25 Mall Road
Burlington, MA 01803
978-443-5000
info@jblearning.com
www.jblearning.com
Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett
Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com.

Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional
associations, and other qualified organizations. For details and specific discount information, contact the special sales department at
Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com.

Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner.
The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett
Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or
otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC, and such reference shall
not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein.
Power Instrumentation for the Dental Professional, First Edition is an independent publication and has not been authorized, sponsored, or
otherwise approved by the owners of the trademarks or service marks referenced in this product.
There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities
represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and
scenarios featured in the case studies throughout this product may be real or fictitious but are used for instructional purposes only.
24877-7
Production Credits
Vice President, Product Management: Marisa R. Urbano Marketing Manager: Mark Adamiak
Vice President, Content Strategy and Implementation: Content Services Manager: Colleen Lamy
Christine Emerton VP, Manufacturing and Inventory Control: Therese Connell
Director, Product Management: Matthew Kane Composition: S4Carlisle Publishing Services
Product Manager: Bill Lawrensen Project Management: S4Carlisle Publishing Services
Director, Content Management: Donna Gridley Cover Design: Kristin E. Parker
Manager, Content Strategy: Carolyn Pershouse Text Design: Kristin E. Parker
Content Strategist: Ashley Malone Media Development Editor: Faith Brosnan
Director, Project Management and Content Services: Karen Scott Rights & Permissions Manager: John Rusk
Manager, Project Management: Jackie Reynen Cover Image (Title Page, Chapter Opener):
Project Manager: Brooke Haley © Liyao Xie/Moment/Getty Images
EBook Project Manager: Collen Lamy Printing and Binding: Lakeside Book Company
Digital Project Manager: Erin Bosco
Library of Congress Cataloging-in-Publication Data
Names: Mayo, Lisa (Dental hygienist), author.
Title: Power instrumentation for the dental professional / Lisa Mayo.
Description: First edition. | Burlington, MA : Jones & Bartlett Learning,
[2023] | Includes bibliographical references and index.
Identifiers: LCCN 2022026690 | ISBN 9781284235999 (hardcover)
Subjects: MESH: Dental Care--instrumentation | Dental Care--methods |
Dental Instruments
Classification: LCC RK681 | NLM WU 26 | DDC 617.600284--dc23/eng/20220906
LC record available at https://lccn.loc.gov/2022026690
6048
Printed in the United States of America
27 26 25 24 23   10 9 8 7 6 5 4 3 2 1
 Dedication

I would like to dedicate this book to three groups of people.

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

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

CHAPTER 2 Infection Prevention for Aerosol-Generating

Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

CHAPTER 3 Ultrasonic Physics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

CHAPTER 4 Ultrasonic Device and Attachments. . . . . . . . . . . . . . . . 47

CHAPTER 5 Ultrasonic Insert and Tip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

CHAPTER 6 Ultrasonic Mechanism of Action. . . . . . . . . . . . . . . . . . . . . 91

CHAPTER 7 Ultrasonic Historical and Contemporary

Clinical Applications and Contraindications. . . . . . 107

CHAPTER 8 Clinical Perspectives of Tooth Anatomy. . . . . . . . . . . . 131

CHAPTER 9 Grasp, Stabilization, and Positioning. . . . . . . . . . . . . . 149

CHAPTER 10 Adaptation, Angulation, and Orientation . . . . . . . . . . 171

CHAPTER 11 Activation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

CHAPTER 12 Ultrasonic Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

CHAPTER 13 Dentsply Sirona. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

CHAPTER 14 HuFriedyGroup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

CHAPTER 15 Curved Inserts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

CHAPTER 16 Curved Insert Technique Practice. . . . . . . . . . . . . . . . . . 293

iv
 Brief Contents v

CHAPTER 17 EMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

CHAPTER 18 Acteon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

CHAPTER 19 EMS Curved Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345

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

CHAPTER 21 Air Polishing Introduction. . . . . . . . . . . . . . . . . . . . . . . . . 391

CHAPTER 22 Air Polishing Powders and Clinical

Applications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

CHAPTER 23 Coronal to CEJ Air Polishing. . . . . . . . . . . . . . . . . . . . . . . 425

CHAPTER 24 Coronal and Apical to CEJ Air Polishing. . . . . . . . . . . 447

CHAPTER 25 Air Polishing Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . 483

CHAPTER 26 Implant Case Definitions and Assessment. . . . . . . . 525

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

CHAPTER 28 Nonmechanical Implant Maintenance . . . . . . . . . . . . . 571

Glossary 589
Index 599
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
The Integrated Learning and Teaching
Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Reviewers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi
CHAPTER 1 Dental Aerosols. . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Oral Flora. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Aerosols and Spatter Droplets. . . . . . . . . . . . . . . 3
Aerosol Particle Size . . . . . . . . . . . . . . . . . . . . . . . . . 3
Dental Aerosols. . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Sequence of Events of Dental Aerosol
Production and Movement in the
Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Pathogenic Dental Aerosols. . . . . . . . . . . . . . . . . 4
Acute Respiratory Infection. . . . . . . . . . . . . . . . . . 6
Dental Aerosols and the DHCP. . . . . . . . . . . . . . . 7
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
CHAPTER 2 Infection Prevention
for Aerosol-Generating
Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Dental Aerosol Management . . . . . . . . . . . . . . . 13
Maintenance of Dental Unit Lines. . . . . . . . . . . . . .
Personal Protective Equipment (PPE) . . . . . . . . . . .
Pre-Procedural Antimicrobial Rinses. . . . . . . . . . . .
Evacuation Devices. . . . . . . . . . . . . . . . . . . . . . . . .
Ventilation Systems. . . . . . . . . . . . . . . . . . . . . . . . .
Air Decontamination. . . . . . . . . . . . . . . . . . . . . . . .
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
vi
CHAPTER 3 Ultrasonic Physics. . . . . . 31
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Sound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Sound and Wave Theory. . . . . . . . . . . . . . . . . . . . . 32
Ultrasound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Dental Ultrasonic Device. . . . . . . . . . . . . . . . . . . 35
Active Medium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Transducer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Mechanical Energy . . . . . . . . . . . . . . . . . . . . . . . . . 36
Ultrasonic Sound Waves. . . . . . . . . . . . . . . . . . . . . 36
Piezoelectric Ultrasonic. . . . . . . . . . . . . . . . . . . . . . 36
Magnetostrictive Ultrasonic. . . . . . . . . . . . . . . . . . . 38
Ultrasonic Wave Antinodes and Nodes. . . . . . . . . . 40
Auditory Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
CHAPTER 4 Ultrasonic Device
and Attachments . . . . . . . . . . . . . . . . . . . . 47
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Direction for Use (DFU). . . . . . . . . . . . . . . . . . . . 48
Dental Ultrasonic Device. . . . . . . . . . . . . . . . . . . 48
Integrated Ultrasonic Device. . . . . . . . . . . . . . . . . . 48
Stand-Alone Ultrasonic Device . . . . . . . . . . . . . . . . 48
Foot Pedal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Integrated Ultrasonic Device. . . . . . . . . . . . . . . . . . 49
Stand-Alone Ultrasonic Device . . . . . . . . . . . . . . . . 50
Foot Pedal Design and Functionality. . . . . . . . . . . . 50
13 Water and Air Lines. . . . . . . . . . . . . . . . . . . . . . . 51
17 Water Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
23 Air Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
23 Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
25 Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
25 Ergonomics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

CHAPTER 5 Ultrasonic Insert
and Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Ultrasonic Insert and Tip Parts
and Terminology. . . . . . . . . . . . . . . . . . . . . . . . 62
Magnetostrictive . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Piezoelectric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Water Port . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Insert and Tip Shank. . . . . . . . . . . . . . . . . . . . . . 69
Shank Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Shank Anatomy and Activity. . . . . . . . . . . . . . . . . . 69
Shank Coating. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Shank Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Shank Clinical Selection Criteria. . . . . . . . . . . . . . . 72
Shank Movement . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Power Control and Shank Displacement
Amplitude. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Shank Wear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
CHAPTER 6 Ultrasonic
Mechanism of Action . . . . . . . . . . . . . . . . 91
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Mechanism of Action. . . . . . . . . . . . . . . . . . . . . . 92
Mechanical Mechanism of Action . . . . . . . . . . . . . . 92
Fluid Mechanism of Action. . . . . . . . . . . . . . . . . . . 92
Acoustic Cavitation. . . . . . . . . . . . . . . . . . . . . . . . . 92
Acoustic Microstreaming. . . . . . . . . . . . . . . . . . . . . 98
Liquid Jets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Coolant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Lavage and Irrigation. . . . . . . . . . . . . . . . . . . . . . . 101
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
CHAPTER 7 Ultrasonic Historical
and Contemporary ­Clinical
Applications and
Contraindications. . . . . . . . . . . . . . . . . . . 107
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Medical Clinical Applications of
Ultrasonics . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Dental Clinical Applications of
Ultrasonics . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Historical Clinical Applications. . . . . . . . . . . . . . . 109
Contemporary Clinical Applications. . . . . . . . . . . 111
Contents vii
Theoretical Approaches to Ultrasonic
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . 115
Traditionalist Approach to Ultrasonic
Instrumentation. . . . . . . . . . . . . . . . . . . . . . . . . 116
Contemporary Approach to Ultrasonic
Instrumentation. . . . . . . . . . . . . . . . . . . . . . . . . 116
Periodontal Debridement. . . . . . . . . . . . . . . . . 117
Periodontal Disease Pathogenesis. . . . . . . . . . . . . . 117
Periodontal Disease Statistics. . . . . . . . . . . . . . . . . 117
Preventive Clinical Treatment . . . . . . . . . . . . . . . . 118
Considerations and Contraindications. . . . . . . 120
Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . 121
Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
CHAPTER 8 Clinical
Perspectives of Tooth
Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Instrumentation Considerations. . . . . . . . . . . . 132
Hard Tissue Histology. . . . . . . . . . . . . . . . . . . . . . 132
Instrument Selection. . . . . . . . . . . . . . . . . . . . . . . 132
Instrumentation of Cementum . . . . . . . . . . . . . . . 133
Complex Root Anatomy. . . . . . . . . . . . . . . . . . . 134
Root Nomenclature. . . . . . . . . . . . . . . . . . . . . . . . 134
Root Concavity and Convexity . . . . . . . . . . . . . . . 135
Furcation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
CHAPTER 9 Grasp, Stabilization,
and Positioning . . . . . . . . . . . . . . . . . . . . . 149
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Grasp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Magnetostrictive Grasp. . . . . . . . . . . . . . . . . . . . . 150
Piezoelectric Grasp . . . . . . . . . . . . . . . . . . . . . . . . 151
Advanced Grasp . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Light Grasp. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Grasp Skill Building . . . . . . . . . . . . . . . . . . . . . . . 153
Stabilization. . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Intraoral Finger Rest. . . . . . . . . . . . . . . . . . . . . . . 155
Extraoral Finger Rest. . . . . . . . . . . . . . . . . . . . . . . 155
Operator and Patient Chair
Positioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Operator and Patient Positioning Selection. . . . . . 158
Aerosol Control. . . . . . . . . . . . . . . . . . . . . . . . . . . 160
viii Contents
Operator Chair Position by Area of
the Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Posterior Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Anterior Teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Comparison of Ultrasonic and
Hand-Activated Instrumentation. . . . . . . . . . 165
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
CHAPTER 10 Adaptation,
Angulation, and Orientation . . . . . . . 171
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Shank Surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Angulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
90-Degree Angulation. . . . . . . . . . . . . . . . . . . . . . 174
0- to 15-Degree Angulation. . . . . . . . . . . . . . . . . . 176
Orientation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Vertical Orientation. . . . . . . . . . . . . . . . . . . . . . . . 176
Transverse Orientation. . . . . . . . . . . . . . . . . . . . . 177
Skill Building Adaptation, Angulation,
and Orientation. . . . . . . . . . . . . . . . . . . . . . . . 179
Comparison of Ultrasonic and
Hand-Activated Instrumentation. . . . . . . . . . 193
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
CHAPTER 11 Activation. . . . . . . . . . . . . 197
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Activation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Finger Motion. . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Ultrasonic Activation Stroke . . . . . . . . . . . . . . . . . 198
Tap Stroke. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Comparison of Ultrasonic and
Hand-Activated Instrumentation. . . . . . . . . . 220
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
CHAPTER 12 Ultrasonic
Technique. . . . . . . . . . . . . . . . . . . . . . . . . . 223
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Ultrasonic Instrumentation Skill
Building With Operator and Patient
Positioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Maxillary Left Central Incisor . . . . . . . . . . . . . . . . 224
Mandibular Molar. . . . . . . . . . . . . . . . . . . . . . . . . 224
Mandibular First Molar Lingual. . . . . . . . . . . . . . . 224
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
CHAPTER 13 Dentsply Sirona. . . . . . 239
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Magnetostrictive Ultrasonic Devices . . . . . . . . 240
Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Emerging Technology . . . . . . . . . . . . . . . . . . . . . . 240
Digital Cavitron Ultrasonic Scaling Systems. . . . . . 240
Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Insert Portfolio. . . . . . . . . . . . . . . . . . . . . . . . . . 249
Thick Diameter Cavitron Powerline
Ultrasonic Inserts. . . . . . . . . . . . . . . . . . . . . . . . 249
Thin Diameter Cavitron Slimline Ultrasonic
Inserts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Ultra-Thin Diameter Cavitron Thinsert. . . . . . . . . 253
Implant Insert. . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Diamond-Coated Insert. . . . . . . . . . . . . . . . . . . . . 255
Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Cavitron Ultrasonic Scaler. . . . . . . . . . . . . . . . . . . 257
Insert. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
CHAPTER 14 HuFriedyGroup . . . . . . 263
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
HuFriedyGroup Magnetostrictive
Ultrasonic Device. . . . . . . . . . . . . . . . . . . . . . 264
Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
SWERV3 30K . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Insert Portfolio. . . . . . . . . . . . . . . . . . . . . . . . . . 267
Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 273
SWERV3 Device. . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Insert. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
CHAPTER 15 Curved Inserts . . . . . . . 279
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Magnetostrictive Curved Insert
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . 279

Magnetostrictive Curved Insert
Adaptation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Vertical Orientation. . . . . . . . . . . . . . . . . . . . . . . . 281
Transverse Orientation. . . . . . . . . . . . . . . . . . . . . 285
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
CHAPTER 16 Curved Insert
Technique Practice . . . . . . . . . . . . . . . . 293
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Skill Building: Vertical and Transverse
Orientation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Setup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Buccal Furcation Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . .
Mesial-Buccal Root Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . .
Distal-Buccal Root Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . .
Lingual Debridement of the Mandibular
First Molar Supragingival Interproximal
Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lingual Furcation Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . .
Distal-Lingual Root Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . .
Mesial-Lingual Root Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . .
Buccal Debridement of the Mandibular First
Molar Supragingival Interproximal Area. . . . . . .
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
CHAPTER 17 EMS . . . . . . . . . . . . . . . . . . 309
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
EMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Emerging Technology . . . . . . . . . . . . . . . . . . . . . .
Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EMS Tip Portfolio. . . . . . . . . . . . . . . . . . . . . . . . 319
Thick Diameter Tips. . . . . . . . . . . . . . . . . . . . . . . 319
Thin Diameter Tips. . . . . . . . . . . . . . . . . . . . . . . . 320
Implant Tip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Ultrasonic Device . . . . . . . . . . . . . . . . . . . . . . . . . 321
Tip, Wrench (EMS CombiTorque Wrench),
and Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . 321
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Contents ix
CHAPTER 18 Acteon . . . . . . . . . . . . . . . 327
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Acteon Piezoelectric Ultrasonic Devices. . . . . 328
Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Emerging Technology . . . . . . . . . . . . . . . . . . . . . . 328
Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Acteon Tip Portfolio. . . . . . . . . . . . . . . . . . . . . . 332
Prophylaxis Tips. . . . . . . . . . . . . . . . . . . . . . . . . . 333
Periodontic Tips . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Implant Tips. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 337
293 Ultrasonic Device . . . . . . . . . . . . . . . . . . . . . . . . . 337
Soprocare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
294
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
295 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
CHAPTER 19 EMS Curved Tips. . . . . 345
298
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
EMS Piezoelectric Curved Tip Introduction. . . 345
299
EMS Piezoelectric Curved Tip Adaptation. . . . 347
300 Identifying Correct Adaptation . . . . . . . . . . . . . . . 348
Skill Building: Debridement Curved Tips. . . . . 350
302 Setup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Buccal Furcation Debridement of the
303 Mandibular First Molar . . . . . . . . . . . . . . . . . . . 352
Mesial-Buccal Root Debridement of the
305 Mandibular First Molar . . . . . . . . . . . . . . . . . . . 353
Distal-Buccal Root Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . . 355
Lingual Furcation Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . . 356
Distal-Lingual Root Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . . 357
310 Mesial-Lingual Root Debridement of the
310 Mandibular First Molar . . . . . . . . . . . . . . . . . . . 359
311 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
313 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
CHAPTER 20 Acteon Curved Tips. . . 365
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Acteon Piezoelectric Curved
Tips Introduction. . . . . . . . . . . . . . . . . . . . . . . 365
Acteon Piezoelectric Curved Tip Adaptation. . . . 368
Identifying Correct Adaptation . . . . . . . . . . . . . . . 368
Skill Building: Debridement Curved Tips. . . . . 374
Setup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
x Contents
Buccal Furcation Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . . 375
Mesial-Buccal Root Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . . 377
Distal-Buccal Root Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . . 379
Lingual Furcation Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . . 380
Distal-Lingual Root Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . . 382
Mesial-Lingual Root Debridement of the
Mandibular First Molar . . . . . . . . . . . . . . . . . . . 384
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
CHAPTER 21 Air Polishing
Introduction . . . . . . . . . . . . . . . . . . . . . . . . 391
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
Tooth Polishing. . . . . . . . . . . . . . . . . . . . . . . . . . 392
Rotary Handpiece Polishing . . . . . . . . . . . . . . . 393
Provider Technique. . . . . . . . . . . . . . . . . . . . . . . . 396
Air Polishing. . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Air Polishing Devices. . . . . . . . . . . . . . . . . . . . . . . 397
Nozzle Design. . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Air Polishing Mechanism of Action. . . . . . . . . . . . 401
Rotary and APD Polishing
Comparison. . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Polishing Contraindications and
Considerations . . . . . . . . . . . . . . . . . . . . . . . . 404
Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . 405
Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
CHAPTER 22 Air Polishing
Powders and Clinical
Applications . . . . . . . . . . . . . . . . . . . . . . . . 411
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
APD Clinical Applications. . . . . . . . . . . . . . . . . 412
APD Powder Particle Size and Mohs
Hardness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Particle Size. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Mohs Hardness. . . . . . . . . . . . . . . . . . . . . . . . . . . 413
APD Powder Chemical Composition
and Clinical Applications. . . . . . . . . . . . . . . . 414
Sodium Bicarbonate Powder. . . . . . . . . . . . . . . . . 414
Aluminum Trihydroxide Powder. . . . . . . . . . . . . . 415
Calcium Sodium Phosphosilicate Powder. . . . . . . 415
Calcium Carbonate Powder. . . . . . . . . . . . . . . . . . 415
Glycine Powder. . . . . . . . . . . . . . . . . . . . . . . . . . . 415
Erythritol Powder. . . . . . . . . . . . . . . . . . . . . . . . . 415
Powder Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Air Polishing Literature. . . . . . . . . . . . . . . . . . . . . 416
APD Considerations. . . . . . . . . . . . . . . . . . . . . . 416
Gingival Status . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Sodium Bicarbonate Powder. . . . . . . . . . . . . . . . . 416
APD and Dental Materials. . . . . . . . . . . . . . . . . 417
Dental Materials: Safe Use of an APD. . . . . . . . . . . 418
Dental Materials: APD Use With Caution. . . . . . . . 418
Dental Materials: APD Use Contraindicated. . . . . . 419
Adverse Effects . . . . . . . . . . . . . . . . . . . . . . . . . 420
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
CHAPTER 23 Coronal to CEJ
Air Polishing . . . . . . . . . . . . . . . . . . . . . . . 425
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
Dentsply Sirona Air Polishing Devices. . . . . . . 426
Dentsply Sirona Polishing Powders. . . . . . . . . 427
Cavitron Prophy Jet Air Polishing System
and Cavitron Jet Plus Ultrasonic
Scaling and Air Polishing System. . . . . . . . . 427
Powder Bowl. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Powder Velocity Control. . . . . . . . . . . . . . . . . . . . 429
Prophy Mode Cycles. . . . . . . . . . . . . . . . . . . . . . . 430
Foot Pedal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Nozzle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Handpiece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 440
Air Polishing Device . . . . . . . . . . . . . . . . . . . . . . . 440
Handpiece and Nozzle Insert. . . . . . . . . . . . . . . . . 440
Clinical Technique. . . . . . . . . . . . . . . . . . . . . . . 440
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
CHAPTER 24 Coronal and
Apical to CEJ Air Polishing . . . . . . . . 447
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
Subgingival Air Polishing in Periodontal
Debridement. . . . . . . . . . . . . . . . . . . . . . . . . . 448
Overall Clinical Outcomes. . . . . . . . . . . . . . . . . . . 448
Delivery of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Hard and Soft Tissue Effects . . . . . . . . . . . . . . . . . 449
Microbiological. . . . . . . . . . . . . . . . . . . . . . . . . . . 449

EMS Air Polishing Devices . . . . . . . . . . . . . . . . 449
EMS Air Polishing Powders. . . . . . . . . . . . . . . . 449
EMS AIRFLOW One and AIRFLOW
Prophylaxis Master. . . . . . . . . . . . . . . . . . . . . 451
Powder Chambers. . . . . . . . . . . . . . . . . . . . . . . . .
Powder Velocity Control. . . . . . . . . . . . . . . . . . . .
Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Air. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EMS AIRFLOW Handy 3.0 . . . . . . . . . . . . . . . . . 458
Body. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
Powder Chamber. . . . . . . . . . . . . . . . . . . . . . . . . . 460
Foot Pedal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
EMS Handpiece and Nozzles . . . . . . . . . . . . . . 465
AIRFLOW Handpieces . . . . . . . . . . . . . . . . . . . . . 465
PERIOFLOW Handpiece. . . . . . . . . . . . . . . . . . . . 468
Reprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . 471
Air Polishing Devices. . . . . . . . . . . . . . . . . . . . . . . 471
Handpieces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
EMS Guided Biofilm Therapy (GBT) . . . . . . . . . 472
GBT Step 1: Assessment and infection
control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
GBT Step 2: Disclose, and GBT Step 3:
Motivate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
GBT Step 4: AIRFLOW Max. . . . . . . . . . . . . . . . .
Step 5: PERIOFLOW. . . . . . . . . . . . . . . . . . . . . . .
GBT Step 6: Piezon PS. . . . . . . . . . . . . . . . . . . . . .
GBT Step 7: Check . . . . . . . . . . . . . . . . . . . . . . . .
GBT Step 8: Recall. . . . . . . . . . . . . . . . . . . . . . . . .
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
CHAPTER 25 Air Polishing
Technique. . . . . . . . . . . . . . . . . . . . . . . . . . 483
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
Clinical Technique. . . . . . . . . . . . . . . . . . . . . . . 483
Grasp and Stabilization. . . . . . . . . . . . . . . . . . . . .
Aerosol Control. . . . . . . . . . . . . . . . . . . . . . . . . . .
Operator Chair Positioning. . . . . . . . . . . . . . . . . .
Patient Positioning. . . . . . . . . . . . . . . . . . . . . . . . .
Patient Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Skill Building: Air Polishing on Inanimate
Objects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Penny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
Quail Egg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Skill Building: Air Polishing with
Dentsply Sirona Device. . . . . . . . . . . . . . . . . . 489
Dentsply Sirona APD Setup. . . . . . . . . . . . . . . . . . 489
Air Polishing Posterior Occlusal Surfaces. . . . . . . . 493
Air Polishing Anterior Smooth Surfaces. . . . . . . . . 495
Contents xi
Air Polishing Posterior Smooth Surfaces . . . . . . . . 497
Dentsply Sirona APD Breakdown:. . . . . . . . . . . . . 499
Skill Building: Air Polishing with EMS
Guided Biofilm Therapy . . . . . . . . . . . . . . . . . 501
451 EMS AIRFLOW Prophylaxis Master Setup. . . . . . . 502
452 GBT Step 1: Assessment and infection control. . . . 504
454 GBT Step 2: Disclose, and GBT Step 3: Motivate. . . 504
458 GBT Step 4: AIRFLOW MAX. . . . . . . . . . . . . . . . . 504
GBT Step 5: PERIOFLOW. . . . . . . . . . . . . . . . . . . 513
GBT Step 6: Piezon PS, GBT Step 7: Check,
and GBT Step 8: Recall. . . . . . . . . . . . . . . . . . . 516
Skill Building: Air Polishing with EMS
AIRFLOW Handy 3.0 . . . . . . . . . . . . . . . . . . . . 516
AIRFLOW Handy 3.0 Perio. . . . . . . . . . . . . . . . . . 516
AIRFLOW Handy 3.0 Classic . . . . . . . . . . . . . . . . 520
AIRFLOW Handy 3.0 Perio and AIRFLOW
Handy 3.0 Classic Breakdown. . . . . . . . . . . . . . 521
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
CHAPTER 26 Implant Case
Definitions and Assessment. . . . . . . 525
472
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
472 Dental Implant Anatomy and Physiology. . . . . 526
474 Keratinized Outer Masticatory Mucosa . . . . . . . . . 528
474 Non-keratinized Inner Masticatory Mucosa. . . . . . 528
474 Mucosa Remodeling Factors . . . . . . . . . . . . . . . . . 528
474 Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
474 Implant Baseline. . . . . . . . . . . . . . . . . . . . . . . . . . 533
Peri-Implant Diseases and Conditions . . . . . . 533
Peri-Implant Health. . . . . . . . . . . . . . . . . . . . . . . . 533
Peri-Implant Mucositis . . . . . . . . . . . . . . . . . . . . . 534
Peri-Implantitis. . . . . . . . . . . . . . . . . . . . . . . . . . . 534
Peri-Implant Soft and Hard Tissue Deficiencies. . . . 534
Clinical Assessments . . . . . . . . . . . . . . . . . . . . 537
Visual and Palpatory Tissue Assessment . . . . . . . . 539
Periodontal Charting Assessment. . . . . . . . . . . . . . 539
Recall Recommendations. . . . . . . . . . . . . . . . . 543
483
484 Oral Hygiene Instructions. . . . . . . . . . . . . . . . . 544
484 Brushing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544
484 Interdental Aids. . . . . . . . . . . . . . . . . . . . . . . . . . . 544
484 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550
CHAPTER 27 Mechanical
Implant Maintenance. . . . . . . . . . . . . . 553
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
Implant Debridement Overview . . . . . . . . . . . . 553
Implant Debridement Goals . . . . . . . . . . . . . . . . . 554
xii Contents

Surface Topography. . . . . . . . . . . . . . . . . . . . . . 555 Nonmechanical Debridement. . . . . . . . . . . . . . 572

Implant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 Dental Lasers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
Abutment and Prosthesis. . . . . . . . . . . . . . . . . . . . 555 Chlorhexidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
Mechanical Debridement . . . . . . . . . . . . . . . . . 556 Ozone and Hydrogen Peroxide. . . . . . . . . . . . . . . 577
Hand-Activated Instrumentation. . . . . . . . . . . . . . 556 Locally Administered Antibiotics. . . . . . . . . . . . . . 580
Ultrasonic Instrumentation. . . . . . . . . . . . . . . . . . 557 Nonmechanical Debridement and
Air Polishing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558 Peri-Implantitis. . . . . . . . . . . . . . . . . . . . . . . . 581
Peri-Implant Mucositis Debridement. . . . . . . . 559 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584
Peri-Implant Mucositis Literature . . . . . . . . . . . . . 559 Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584
Peri-Implantitis Debridement. . . . . . . . . . . . . . 559 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
Implant Debridement . . . . . . . . . . . . . . . . . . . . . . 559
Mechanical Debridement Technique . . . . . . . . 561 Glossary 589
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566 Index 599
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567

CHAPTER 28 Nonmechanical
Implant Maintenance. . . . . . . . . . . . . . . 571
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
Implant Debridement Goals. . . . . . . . . . . . . . . 572
Preface
The field of dental ultrasonics and air polishing has
become mainstream as the technology has evolved.
Power Instrumentation for the Dental Professional aims to
bridge the gap of knowledge between education and
clinical practice by allowing the learner to acquire the
skills needed to implement power technology effec-
tively in patient care with a contemporary approach to
preventive, maintenance, and nonsurgical periodontal
procedures.
The first two chapters begin power instrumenta-
tion education with the infection prevention required
for the safe delivery of care. The middle of the book,
Chapters 3–20, focus on dental ultrasonic technol-
ogy and technique. Chapters 3–8 present ultrasonic
science, physics, mechanism of action, functionality,
and universal terminology. By Chapter 9, the learner
will be able to incorporate a contemporary approach
to ultrasonic instrumentation and identify ultrasonic
limitations, contraindications, and clinical indications
for use.
Ultrasonic instrumentation technique is taught
over Chapters 9–12. Skills are broken down into
building blocks starting with grasp and stabilization,
operator and patient positioning, and aerosol control
in Chapter 9. Chapters 10 and 11 add the building
blocks of adaptation, angulation, orientation, and ac-
tivation. Chapter 12 brings all the building blocks to-
gether with step-by-step hands-on practice exercises.
Chapters 13–16 present magnetostrictive ultrasonic
technology from Dentsply Sirona and ­HuFriedyGroup,
Chapters 17–20 present piezoelectric ultrasonic
technology from EMS and Acteon. Manufacturers’
specific terminology is introduced, and step-by-step
hands-on practice exercises are provided to further
develop technique.
Chapters 21–25 are dedicated to air polishing
education. Chapters 21 and 22 present the science,
physics, mechanism of action, functionality, uses, lim-
itations, contraindications, and universal terminology
for air polishing. Chapters 23 and 24 teach the equip-
ment, clinical technique, and manufacturers’ specific
terminology for air polishing coronal and apical to the
CE. Chapter 25 combines all the information learned
into multiple step-by-step hands-on practice exercises
for Dentsply Sirona and EMS technology.
Chapters 26–28 wrap up the text by discussing
dental implant maintenance with a focus on power
technology and instrumentation in three chapters.
Chapter 26 defines the case definitions of peri-­
implant health and disease based on a series of clinical
assessments. Chapters 27 and 28 teach the mechan-
ical and nonmechanical debridement techniques for
dental implants, abutments, and prosthesis using evi-
dence-based research and science.
As with any form of clinical practice, power in-
strumentation is best learned through continued rep-
etition. The exercises in this book allow the learner to
move at their own pace to gain proficiency. The videos
that accompany the text will provide visual and audi-
tory instruction that can be watched multiple times
while developing and honing clinical instrumentation
skills.
xiii
The Integrated Learning
and Teaching Package
Integrating the text with constructive instructor re-
sources is crucial to deriving their full benefit. Based
on feedback from instructors and students, Jones &
Bartlett Learning has made the following resources
available to qualified instructors:
• Test Bank with questions for every chapter.
• Slides in PowerPoint format.
• Instructor’s Manual, containing answers to the
in-text end-of-chapter and case study questions,
worksheets, teaching tips, and clinical rubrics.
• Image Bank, supplying key figures from the text.
• Skills-based videos that demonstrate various tech-
niques from the text.

xiv
Acknowledgments
Manufacturers
Thank you to the manufacturers, whose generos-
ity and support in providing imaging, reviews, and
equipment enhanced the content quality of this book
immensely:
• Dentsply Sirona: Gail Malone, RDH, BS; Rachel
Dorn, RDH, MS; and Michele Lash, RDH, BA.
• Acteon: Chip Vagnoni
• HuFriedyGroup: Janelle Armstead and Drew
Eschweiler
• EMS: Melissa Obrotka, RDH, BA.
Professors
Thank you to all the professors who seek to prepare
the next generation of oral health-care providers for
contemporary clinical practice. I hope you find this
book provides you with the tools necessary to en-
rich your institutions’ power instrumentation clin-
ical curriculum. Thank you for your dedication to
the dental field and student teaching. I welcome any
comments or suggestions you have for changes to fu-
ture editions.
Students
Students, you are the junior ambassadors to the dental
field. I give you my sincere appreciation and gratitude
for joining the profession I hold so dear. You represent
the next generation of oral health-care professionals
who will strike a path forward in improving patient
care and experiences through power instrumentation.
I thank you for your commitment to patient excel-
lence and welcome any comments or suggestions you
have for future editions.
xv
Reviewers
Cheri L. Barton, RDH, BSDH, MSDH
Lecturer/Senior Clinic Lead/Clinic Coordinator
Eastern Washington University and University of
Washington
Adjunct Faculty in the Periodontal Department
University of Washington School of Dentistry
Lisa Bilich, RDH, MSEd
Professor/Department Chair
Eastern Washington University
Donna L. Catapano, MD, DHSc, RDH, CDA
Clinical Assistant Professor
Department of Dental Hygiene and Dental Assisting,
NYU College of Dentistry
Christine A. Dominick, CDA, RDH, MEd
Associate Dean and Professor
Forsyth School of Dental Hygiene, Massachusetts
College of Pharmacy and Health Sciences
Deborah A. Graeff, MS, RDH
Professor/Retired
Erie Community College
Holly Houck, RDH, MSDH
Instructional Faculty; Dental Studies Department
Head
Pima Community College
Jena N. Iversen, RDH, MA
Faculty
Hudson Valley Community College
Brenda Kibbel, RDH, BSDH, MEd
Assistant Professor
Tennessee State University
Lisa M. Lavery, RDH, MPH
Instructor
Hudson Valley Community College
Jeffery V. McMinn, RDH, MA
Assistant Professor
Hudson Valley Community College
Martha Lynne Morgan. RDH, MS, MA
Adjunct Professor for Dental and Dental Hygiene
Continuing Education Director for Dental Hygiene
Divisions of Integrated Clinical Foundations and
Simulations
Dental Hygiene and Dental Hygiene Continuing
Education
University of Detroit Mercy School of Dentistry
Kristeen Perry, RDH, MSDH
Associate Professor
Forsyth School of Dental Hygiene, Massachusetts
College of Pharmacy and Health Sciences
Maryse Rodger, RDH, BSDH, MBA
Assistant Professor
Regis College
Windy Rothmund, RDH, MSDH
Assistant Professor
Department of Dental Hygiene, Eastern Washington
University
Irina Smilyanski, RDH, MSDH, DHS
Associate Professor of Dental Hygiene
Forsyth School of Dental Hygiene, Massachusetts
College of Pharmacy and Health Sciences
Laura Tubbs, RDH, MA
Assistant Professor
Department of Dental Hygiene, Hudson Valley
Community College
Tiffany Wilson DDS, MPH
Assistant Professor
Meharry Medical College School of Dentistry

Petal Leuwaisee, RDH, CHES, BSDH, MA

Associate Professor
Hostos Community College

xvi
 CHAPTER 1
Dental Aerosols
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Differentiate between oral symbiosis and
dysbiosis.
2. Define an aerosol and spatter droplet and
correlate particle size to potential health
hazards.
3. Understand the sequence of events of dental
aerosol production, release, and movement in
an environment.
4. Understand disease transmission risk when
performing a dental aerosol-generating
procedure.
5. Identify equipment capable of producing and
releasing large volumes of aerosols.
KEY TERMS
• Aerosol: small particle size (<50 µm) product
created and released into the environment during
a dental aerosol-generating procedure that stays
airborne for an extended period of time and
travels great distances.
• Acute respiratory infection (ARI): As defined by
the WHO is an infection capable of interfering with
•
respiratory system function (WHO, 2014).
Dental aerosol: man-made aerosol generated
by air-driven dental equipment that emits an
aqueous solution.
• Dental aerosol-generating procedure: any
procedure performed in a dental environment that
releases aerosols into the air.
• Dental equipment: machine and accessory used
in the practice of dentistry.
• Dental health-care personnel (DHCP): as defined
by the CDC is any “paid and unpaid personnel
in the dental health-care setting who might be
occupationally exposed to infectious materials,
including body substances and contaminated
supplies, equipment, environmental surfaces,
water, or air” (CDC, 2003).
• Diffusion: passive movement of a substance from
an area of higher concentration to an area of
lower concentration.
• Dysbiosis: imbalance of microbiota in the human
microbiome that disrupts homeostasis and has
the potenntail to cause diease, impairement, and
inflammation.
• Oral flora: the natural microbiome residents
that exist in the oral cavity such as bacteria,
fungi, protozoa, viruses, genetic material, and
environmental influences (nicotine, pollutants).
• Oral health-care provider: trained and licensed
DHCP who is involved in direct patient care,
treatment, and management of oral conditions
within their scope of practice.
• Pathogenic dental aerosol: airborne aerosol
created and released during a dental aerosol-
generating procedure that contains a pathogenic
organism (bacteria, viruses, fungi, protozoa)
capable of causing disease once the organism
•
enters the host.
Pathogenic organism: organisms capable of
causing disease.
• Spatter droplet: large particle size (>50 µm)
product created and released into the
environment during a dental aerosol-generating
•
procedure.
Symbiosis: balance of microbiota in the human
microbiome that leads to health, wellness, and
•
the promotion of homeostasis.
Zoonotic disease: an infectious disease that is
spread between animals and humans.
1
2 Chapter 1 Dental Aerosols

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

Oral Flora
The mouth has an extensive and diverse microbiome
composed of bacteria, fungi, protozoa, viruses, ­genetic
material, and environmental influences ­ (nicotine,
­pollutants) that make up the oral flora. B
• When these natural residents all live in harmony Figure 1-1 Oral dysbiosis A. Dental caries on a maxillary
with one another, a symbiotic environment ex- anterior tooth; B. Periodontal disease. Note the
ists, and the patient’s oral microbiome is balanced, inflammation of the gingiva and oral deposits on the
healthy, and homeostasis is maintained. anterior teeth

• When the residents do not live in harmony with
one another, a dysbiotic microbiome occurs in
which disease can manifest. The most common
oral diseases from a dysbiotic state are dental car-
ies (tooth decay, cavity) and periodontal disease
((inflammatory disease with resultant infection
and loss of the supportive apparatus of teeth) see
Figure 1-1). When disease is present, pathogenic
organisms (organisms capable of causing dis-
ease) are found in higher concentrations.
The term dental health-care personnel
(DHCP), as defined by the Centers for Disease Control
and Prevention (CDC, 2003), refers to “all paid and
unpaid personnel in the dental health-care setting who
might be occupationally exposed to infectious mate-
rials, including body substances and contaminated,
equipment, environmental surfaces, water, or air.”
Examples of DHCP per the CDC are listed in Box 1-1.
For the purposes of this book, the term oral
health-care provider is used to reference a trained
and licensed DHCP who is actively involved in direct
patient care, treatment, and management of oral condi-
tions within their scope of practice. Examples include,
but are not limited to, a dentist, specialist, dental hy-
gienist, or dental assistant. The oral health-care pro-
vider has the highest risk of exposure to a patient’s oral
flora residents as they work intimately in the mouth
with equipment that generates large volumes of aero-
sols, and studies have shown the highest exposure risk
zone to an oral health-care provider is 1–3 feet from the
patient’s mouth (Innes et al., 2021; Manish et al., 2020;
Muzzin et al., 1999; Zemouri, 2020).

Box 1-1 Dental Health-Care Personnel
■ Dentist
■ Dental hygienists
■ Dental assistants
■ Dental laboratory technicians
■ Student
■ Contractual personnel
■ Administrative staff
■ Housekeeping
■ Maintenance
■ Volunteer
Center for Disease Control. (2003, December 19). Guidelines for infection control in dental
health-care settings – 2003. MMWR, 52, RR-17, 1–76.
Reference to specific commercial products, manufacturers, companies, or trademarks
does not constitute its endorsement or recommendation by the U.S. Government,
Department of Health and Human Services, or Centers for Disease Control and Prevention.
Aerosols and Spatter
Droplets
An oral health-care provider uses air-driven equip-
ment during patient procedures. This equipment gen-
erates and expels aerosols and spatter droplets into
the dental environment.
• Aerosol: An aerosol is a small particle size
(<50 µm) product created and released from
equipment that emits water and air (Matys &
Grzech-Lesniak, 2020; Micik et al., 1968; Singh
et al., 2020). An aerosol will stay airborne for an
extended period of time and travel great distances
due to their small size (Micik et al.; Fennelly,
2020; Kumar & Subramanian, 2020). The smaller
the particle size, the longer the aerosol will remain
suspended in the air. See Table 1-1. Aerosols under
10 µm in size are naked to the human eye and
have an increased risk for human disease trans-
mission (CDC, 2020).
• Spatter droplet: A spatter droplet is a large par-
ticle size (>50 µm) product created and released
from equipment that emits water and air. Matys &
Grzech-Lesniak, 2020; Singh et al., 2020). Due
to its larger size, the spatter droplet will bounce
from surface to surface and land from the force of
gravity faster than an aerosol (CDC, 2003, 2020).
Spatter droplet can be seen with the naked eye,
but once dried on a surface, may be difficult to
detect (CDC, 2020).
An oral health-care provider has extreme close
contact with their patient and is exposed to large
­volumes of spatter droplets and aerosols throughout
Aerosols and Spatter Droplets 3
Table 1-1 Particle Size and Time
of Suspension in Air
Particle Size Average Time of Suspension in the Air*
100 µm 3–5.8 seconds
10 µm 4–8.2 minutes
1–3 µm 1–12 hours
*Time of air suspension will vary based on the amount of turbulence in the air from natural
ventilation (windows or doors opening and closing) and mechanical ventilation (heating,
air-conditioning, fans).
Data from Kulkarni, P., Baron, P.A., & Willeke, K. (2011). Aerosol measurement: Principles,
techniques, and applications. (3rd Ed.). Hoboken, NJ:Wiley.
BREAKOUT POINT
An aerosol is a small particle-size product that
stays suspended in the air for long periods of time
and will travel great distances from its source
of creation, increasing the potential for disease
transmission.
a workday. Aerosols and spatter droplets have the po-
tential to enter the human body through respiratory
inhalation (inhaling while breathing) or through ab-
sorption via the skin or eye. Humans are capable of
easily inhaling particle sizes under 100 µm (Thomas,
2013). If inhaled, these particles gain access to the
respiratory system and can cause an adverse health
effect when they contain pathogenic organisms gener-
ated from the oral microbiome.
BREAKOUT POINT
Aerosol and spatter droplet particles can be inhaled
or absorbed through the skin or eye, increasing the
risk for human-to-human disease transmission.
Aerosol Particle Size
Aerosol particle size plays a large role in the poten-
tial health hazard risk to humans. The process that
generated the particle dictates the size. A human
expels particle sizes under 1 µm during normal
breathing, talking, singing, and shouting (Kumar &
­Subramanian, 2020; Asadi et al., 2019; Fabian et al.,
2011). Thousands of aerosols and spatter droplets are
expelled with a human sneeze, pant, or cough and
can contain pathogenic organisms such as viruses
and bacteria. See Figure 1-2. Millions of aerosols are
4 Chapter 1 Dental Aerosols
Figure 1-2 Human Sneeze
© Hatcha/Shutterstock.
created and released during a dental aerosol-generating
procedure (defined later).
As seen in Table 1-1, the smaller the particle size
generated, the longer it will remain suspended in
the air because the aerosol particle moves by passive
diffusion in an environment. Diffusion is the move-
ment of a substance from an area of high concentra-
tion to low concentration throughout an environment.
A small-sized aerosol will remain suspended in the air
for minutes to hours depending on the amount of air
turbulence (air-conditioning, heating, open window,
fan) in the environment. Pathogenic aerosols can pose
a threat to a health-care facility’s ventilation system if
they gain access and circulate throughout the building
(Fennelly, 2020).
Dental Aerosols
A dental aerosol is a man-made aerosol generated
by air-driven dental equipment that emits an aque-
ous solution (most commonly used is water). Den-
tal equipment refers to any machine or accessory
used in the practice of dentistry. A dental aerosol-­
generating procedure is any procedure that pro-
duces and releases spatter droplets or aerosols into the
environment. Examples of air-driven equipment that
generate dental aerosols are:
• Dental drill. Commonly used for the removal of
tooth decay. See Figure 1-3a.
• Dental ultrasonic or air polisher used for the re-
moval of stain, biofilm, or dental calculus (see
Figure 1-3b and c).
• Air/water syringe used for drying and rinsing the
mouth (see Figure 1-3d).
Sequence of Events of
Dental Aerosol Production
and Movement in the
Environment
There are six steps in the production, release, and
movement of an aerosol in the environment.
1. Air-driven dental equipment emits water that is re-
leased into the mouth during active use and mixes
with the oral flora of the oral cavity (see Figure 1-4a).
2. A dental aerosol is formed and combines with the
water and oral flora mixture inside the mouth.
The aerosol becomes slightly ionized (charged)
when it combines with the water and oral flora
mixture (Asadi et al., 2019).
3. Slightly ionized aerosol particle leaves the mouth
and is forcefully expelled into the environment.
4. Water evaporates from the aerosol when it in-
teracts with ions in the ambient air (oxygen,
­carbon dioxide, hydrogen, nitrogen) and causes
the aerosol particle to become highly ionized (see
Figure 1-4b; Asadi et al., 2019).
5. The highly ionized aerosols react violently in
the environment with one another due to their
charged state. They repel off one another and ag-
gressively bounce around in the environment (see
Figure 1-4c; Asadi et al., 2019).
6. As the aerosol particles move about the environ-
ment, they begin to interact with ions in the air
and slowly start to deionize. When they lose their
charge, they become less reactive and will even-
tually fall to the ground. After 30 minutes, den-
tal aerosol particle movement is greatly reduced
(Asadi et al., 2019).
Pathogenic Dental
Aerosols
A pathogenic dental aerosol is a dangerous airborne
aerosol created and released during a dental aerosol-
generating procedure that contains a pathogenic or-
ganism (bacteria, viruses, fungi, protozoa) capable of
causing disease once the organism enters a host. When
inhaled, the pathogenic aerosol will penetrate the respi-
ratory system and can cause an adverse health event.
• Mycobacterium tuberculosis, pseudomonas aerugi-
nosa, influenza, coronaviruses, rhinovirus, and mea-
sles have been found in aerosols as small as 3–5 µm
particle size and can penetrate both the lower and
upper respiratory tract of a human (see Figure 1-4c;
 Pathogenic Dental Aerosols 5

A B

C D
Figure 1-3 Air-driven dental equipment: A. Dental drill; B. Dental ultrasonic (Dentsply Sirona Cavitron Slimline 1000
30K Ultrasonic Insert); C. Dental air polisher (EMS AIR-FLOW Max handpiece); D. Air/water syringe
A: © Milos Batinic/Shutterstock; B: Reproduced with permission from Dentsply Sirona.

H2O
Flora

Dental aerosol

A B C
Figure 1-4 Sequence of Events of Dental Aerosol Production and Behavior. A. Air-Driven
Equipment B. Aerosol Made of Water and Oral Flora. Water Evaporates and Aerosol Becomes
Ionized C. Aerosol Repel From One Another
A: © Milos Batinic/Shutterstock.
6 Chapter 1 Dental Aerosols

Table 1-2 Pathogen Size and Respiratory System

Penetration
Upper Nasal cavity
Pathogenic Aerosol Respiratory System respiratory Pharynx External
Size Penetration tract (throat) nose
Larynx
1–4 µm Lower and upper airway
Trachea
5–12 µm Upper airway

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

see Table 1-2; Fennelly, 2020; Kumar & Subramanian,

2020; Thomas, 2013). Bronchiole Alveoli
The respiratory system is divided into two r­ egions:
the upper and lower respiratory tract as depicted in
Figure 1-5.

• Upper respiratory tract: consists of the nose,

­nasal cavity, paranasal sinuses, and pharynx. See
Figure 1-5a.
• Lower respiratory tract: consists of the larynx, tra-
chea, bronchial tree and the lungs (see Figure 1-5a).
The bronchial tree, is made of primary, secondary,
and tertiary bronchi. The tertiary bronchi branch
into small bronchioles, which house air-filled sacs
called alveoli. See Figure 1-5b. When an organ-
ism gains access to the lower respiratory tract, in-
fections are challenging to treat and can become
life-threatening, especially in a vulnerable, med-
ically compromised individual (Vos et al., 2021).
Examples include, but are not limited to, pneumo-
nia, bronchitis, and tuberculosis (Vos et al., 2021).
BREAKOUT POINT
A small particle-size pathogenic dental aerosol can
invade the lower and upper respiratory tract of a
human and cause infection.
Acute Respiratory
Infection
An acute respiratory infection (ARI) is an infec-
tion capable of interfering with respiratory system
function, including breathing. According to the WHO
(2014), “ARIs are the leading cause of morbidity and
mortality from infectious diseases in the world” with
98% of death occurring due to viral and bacterial dis-
eases that invade the lower respiratory tract.
Figure 1-5 Respiratory System
ARIs with the potential to cause a public health
emergency at either a pandemic or epidemic level are:
• Severe acute respiratory syndrome coronavirus
(SARS-CoV): The virus is linked to a bat reservoir
as zoonotic infection, which emerged in 2002 and
disappeared by 2004 (WHO, 2014; National In-
stitute of Allergy and Infectious Disease, 2020). A
zoonotic disease is an infectious disease that is
spread between animals and humans. The duration
of infectivity for SARS-CoV is not well defined, and
an oral health-care provider should use extreme
caution when performing an aerosol-generating
procedure on a patient with a known SARS-CoV
infection within the last 81 days (WHO, 2014).
• Severe acute respiratory syndrome ­coronavirus two
(SARS-CoV-2): The virus that causes COVID-19
is linked to a bat reservoir as zoonotic infection
(WHO, 2018; National Institute of Allergy and
Infectious Disease, 2020). The duration of infec-
tivity of SARS-CoV-2 and its variants is not known
at the time of this book’s publication. It would be
prudent for the oral health-care provider to treat
a recovered SARS-CoV-2 patient in a similar man-
ner as a SARS-CoV patient because both illnesses
are caused by a coronavirus (WHO, 2014). For
now, there are no set guidelines from the WHO

on how long to avoid an aerosol-generating pro-
cedure for any patient with a known current or
previous SARS-CoV-2 infection (WHO, 2014).
• Middle East respiratory syndrome coronavirus
(MERS-CoV): The virus is linked to a camel res-
ervoir as zoonotic infection identified in 2012
(WHO, 2014; National Institute of Allergy and
Infectious Disease, 2020).
• Human influenza caused by a new subtype, in-
cluding human episodes of avian influenza (H5N1,
H7N9, H7N2, H9N2), are zoonotic infections from
birds. H7N9 first emerged in a human in 2013
(WHO, 2014). According to the WHO (2014), in-
fluenza A (H1N1) appeared in April 2009 and re-
sulted in a pandemic until August 2010.
Dental Aerosols
and the DHCP
Studies have shown a dental aerosol can travel as much
as six to nine feet away from the source (patient mouth)
and move in both a horizontal and vertical direction
(Innes et al., 2021; Kumar & Subramanian, 2020;
Dhand & Li, 2020; Milejczak & Bowden, 2005). This
means the aerosol travels up to the ceiling and down to
the floor while also moving left to right of the patient
(see Figure 1-6). Because aerosol concentration is highest
the first 10–30 minutes after a dental aerosol-generating
procedure and can stay suspended for hours in the air, a
DHCP should wear a mask to protect their airway.
Figure 1-6 Dental Aerosol Movement in Dental
Environment
Dental Aerosols and the DHCP 7
BREAKOUT POINT
Dental aerosols are at their highest concentration
10–30 minutes immediately following the conclusion
of a dental aerosol-generating procedure.
BREAKOUT POINT
A small particle-size dental aerosol will travel a
minimum of 6–9 feet away from the patient’s mouth
in both horizontal and vertical directions.
During a dental aerosol-generating procedure, the
highest exposure risk zone is 1–3 feet from the pa-
tient’s mouth (Innes et al., 2021; Manish et al., 2020;
Muzzin et al., 1999; Zemouri et al., 2020).
• The heaviest contamination to the oral health-care
provider is their mask, face shield, face, and arms
(Innes et al., 2021; Zemouri et al., 2020). Without
the use of aerosol appropriate PPE (presented in
Chapter 2), the provider is at higher risk for dis-
ease transmission from a pathogenic dental aero-
sol (see the practice exercise shown in Figure 1-7).
• The heaviest contamination to the patient is on their
face and chest (Innes et al., 2021; Zemouri et al.,
2020.
BREAKOUT POINT
Heaviest contamination during an aerosol-generating
procedure is on the provider’s mask, face shield,
face, and arms.
When a dental aerosol-generating procedure is per-
formed, there are specific infection prevention protocols
that must be followed. The next chapter will present a
six-tier multilayer approach to protecting all humans in
the dental environment. In addition, DHCPs should also:
1. Manually disinfect all surfaces and equipment within
a 10-foot radius of the dental aerosol-generating
equipment with an Environmental Protection
Agency (EPA)-­registered intermediate-level disin-
fectant. Refer to the products direction/instruction
for use (DFU/IFU) to ensure correct application and
contact time is followed. EPA-registered intermedi-
ate-level disinfectants vary in their:
• Contact times.
• Number of wipes and contact time when
using towelettes. Some are one-step while
­others are two-step wipe systems.
• Claims against specific bacterial microorgan-
isms and viruses.
8 Chapter 1 Dental Aerosols

Figure 1-7 Dental aerosol-generating procedure and

inappropriate PPE
What is wrong with this picture?
Both male and female oral health-care providers’ hair,
scalp, and skin of the face and neck are exposed with
no face shield or hair covering. The female’s arms and
torso are exposed with no gown. The male’s torso is
exposed with the gown open. The patient is missing
protective glasses.
© CandyBox Images/Shutterstock.
•When using towelettes, follow these
recommendations:
1. Use the correct number of wipes per the
manufacturer. Using fewer wipes than rec-
ommended will compromise disinfection
results.
2. Leave the solution untouched for the re-
quired contact time.
3. When wiping a large area, using larger-
sized towelettes may improve efficiency.
Many manufacturers sell different size
towelettes with varied scents.
4. Always close the lid tightly on a towelette
container to prevent towelettes from dry-
ing (see Figure 1-8).
2. Consider rescheduling any patient who presents
to an appointment with a fever or active infection.
Figure 1-8 Towelette Lid Left Open (Medicom
Pro-Surface)
Reproduced with permission from Medicom.
According to the WHO (2014), “There is a sig-
nificant research gap regarding the epidemiology
of ARI transmission from patients to health-care
workers during aerosol-generating procedures.”
Due to this knowledge gap, the dental office
should have strong protocols and regular train-
ing for staff on the risk for disease transmission
during a dental aerosol-generating procedure.
3. Remove carpet that is within 10 feet of aerosol-
generating equipment. Carpet allows aerosols to
recirculate in an environment, prolonging their
suspension time in the air (Organization for Safety,
Asepsis, and Protection, 2018). When a person
walks on carpet, they crush the fibers against
one another. If an aerosol is trapped in the carpet
­fibers, it will become airborne again as the carpet
fibers are crushed against one another (Organi-
zation for Safety, Asepsis, and Protection, 2018).

CASE STUDY
You are a practicing dental hygienist in a country where you work under the supervision of a licensed dentist. Your first
patient of the day presents for a procedure that will generate large volumes of dental aerosols. The patient reports they
tested positive for SARS-CoV-2 yesterday and today their temperature is 101.0 degrees Fahrenheit. You relay this infor-
mation to your supervisor who is not a licensed dentist. She tells you to proceed because the patient already prepaid for
their procedure and she does not want to deal with rescheduling or refunding the patient.
1. What are the potential consequences if you follow your supervisor’s order and proceed with treatment?
2. How should this situation be handled?
3. If you proceed with the procedure, could you be found guilty of a negligent tort?
 Questions 9

Summary
This chapter presented the dental equipment that cre-
ates and releases large volumes of dental aerosols into
the environment. Dental aerosol and spatter droplet
production, release, circulation, behavior, move-
ment, particle size, and pathogenicity were discussed.
Oral health-care providers are at an increased risk
for disease transmission because they provide direct
patient care in the highest risk zone of exposure 1–3
feet from the patient’s mouth. Aerosols are at their
highest concentration 10–30 minutes after a dental
aerosol-generating procedure is complete but can re-
main suspended in the air for hours and travel 6–9 feet
away from the source. DHCPs should protect them-
selves from this contaminated air by wearing a mask.

Questions
1. Which of the following is a natural resident of 7. Which DHCP has the highest risk for exposure
the oral flora? to the oral flora residents of a patient’s mouth?
a. Bacteria a. Oral health-care provider
b. Fungi b. Administrative staff
c. Protozoa c. Housekeeper
d. Genetic material d. Maintenance repair personnel
e. All of the above 8. Which particle size will stay airborne for the
Match the following terms to their correct definitions longest time?
for questions 2–5. There is only one correct answer a. 1,000 µm
for each term. b. 100 µm
2. Dysbiosis A. Balance of microbiota in the c. 50 µm
human microbiome that leads d. 5 µm
to health and wellness, and 9. Which of the following dental equipment will
promotes homeostasis. generate and release a dental aerosol?
3. Aerosol B. Large particle size (>50 µm) a. Air/water syringe
product created and released b. Dental drill
into the environment during c. Dental ultrasonic
a dental aerosol-generating d. All of the above
procedure that stays airborne 10. What size aerosol will penetrate the lower
for less time and an aerosol. respiratory tract when inhaled?
4. Spatter C. Small particle (<50 µm) a. 1 µm
when expelled into an b. 7 µm
environment stays airborne; c. 10 µm
for an extended period d. 50 µm
of time and travels great
11. Which of the following is an ARI with the
distances.
potential to cause a public health emergency at a
5. Symbiosis D. Imbalance of microbiota in pandemic or epidemic level?
the human microbiome that a. Severe acute respiratory syndrome
disrupts homeostasis and coronavirus
can result in dental caries or b. Severe acute respiratory syndrome
periodontal disease in the coronavirus two
mouth. c. Middle East respiratory syndrome
6. Which of the following is considered a dental coronavirus
health-care personnel (DHCP) as described by d. Human influenza linked to avian influenza
the CDC? e. All of the above
a. Dental hygienist
b. Housekeeper
c. Maintenance repair worker
d. All of the above
10 Chapter 1 Dental Aerosols
12. When are dental aerosols at their
highest concentration in the air after an
aerosol-generating procedure is concluded?
a. 10–30 minutes
b. 30–60 minutes
c. 2–3 hours
d. 1 day
13. True or False. Thirty minutes after an
aerosol-generating dental procedure, all aerosols
are gone from the environment and the oral
health-care provider can safely remove their
mask.
a. True
b. False
References
1. Asadi, S., Wexler, A. S., Cappa, C. D., Barneda, S., Bouvier,
N. M., & Ristenpart, W. D. (2019). Aerosol emission and
superemission during human speech increases with voice
loudness. Scientific Reports, 9(2348), 1–10. https://doi
.org/10.1038/s41598-019-38808
2. Centers for Disease Control and Prevention. (2003).
Guidelines for infection control in dental health-care
settings—2003. MMWR, 52(RR-17), 1–76.
3. Centers for Disease Control and Prevention. (2020).
Bloodborne pathogens and aerosols. https://www.cdc.gov
/oralhealth/infectioncontrol/faqs/bloodborne-exposures.html
4. Dhand, R., & Li, J. (2020). Coughs and sneezes: Their role
in transmission of respiratory viral infections, including
SARS-CoV-2. American Journal Respiratory Critical Care,
202(5), 651–659.
5. Fabian, P., Brain, J., Houseman, A., Gern, J., & Milton, D.
K. (2011). Origin of exhaled breath particles from healthy
and human rhinovirus-infected subjects. Journal of Aerosol
Medicine & Pulmonary Drug Delivery, 24(3), 137–149. https://
doi.org/10.1089/jamp. 2010.0815
6. Fennelly, K. (2020). Particle sizes of infectious aerosols:
Implications for infection control. The Lancet, 8, 914–924.
7. Innes, N., Johnson, I. G., Al-Yaseen, W., Harris, R., Jones,
R., KC, S., McGregor, S., Robertson, M., Wade, W. G., &
Gallagher, J. E. (2021). A systematic review of droplet
and aerosol generation in dentistry. Journal of Dentistry,
105(103556), 1–13.
8. Kulkarni, P., Baron, P. A., & Willeke, K. (2011). Aerosol
measurement: Principles, techniques, and applications (3rd ed.).
Wiley.
9. Kumar, P. S., & Subramanian, K. (2020). Demystifying the
mist: Sources of microbial bioload in dental aerosols. Journal
of Periodontology, 91, 1113–1122.
10. Manish, J., Mathur, A., Mukhi, P. U., Ahire, M., & Pingal,
C. (2020). Qualitative and quantitative analysis of bacterial
aerosols in dental clinical settings: Risk exposure towards
dentist, auxiliary staff, and patients. Journal Family Medicine
Primary Care, 9(2), 1003–1008. https://doi.org/10.4103
/jfmpc.jfmpc_863_19
11. Matys, J., & Grzech-Lesniak, K. (2020). Dental aerosol as
a hazard risk for dental workers. Materials, 13(22), 5109.
https://doi.org/10.3390/ma13225109
14. During a dental aerosol-generating procedure,
where is the highest exposure risk zone for the
oral health-care provider?
a. 11–15 feet from the patient’s mouth
b. 8–10 feet from the patient’s mouth
c. 5–7 feet from the patient’s mouth
d. 1–3 feet from the patient’s mouth
15. True or False. After a dental aerosol-generating
procedure, the DHCP only needs to manually
disinfect equipment that they touched with an
EPA-registered disinfectant.
a. True
b. False
12. Micik, R. E., Miller, R. L., Mazzarella, M. A., & Ryge, G.
(1968). Studies on dental aerobiology: I. Bacterial aerosols
generated during dental procedures. Journal Dental
Restorative, 48(1), 49–56.
13. Milejczak, C. B., & Bowden, C. (2005). Optimum travel
distance of dental aerosols in the dental hygiene practice.
Journal of Dental Hygiene, 79(4), 1–2.
14. Muzzin, K., King, T., & Berry, C. W. (1999). Assessing the
clinical effectiveness of an aerosol reduction device for
the air polisher. Journal American Dental Association, 130,
1354–1359.
15. National Institute of Allergy and Infectious Disease.
(2020). Coronavirus overview. https://www.niaid.nih.gov
/diseases-conditions/coronaviruses
16. Organization for Safety, Asepsis, and Protection. (2018).
Dental unit water quality: Organization for safety, asepsis
and prevention white paper and recommendations—2018.
Journal of Dental Infection Control and Safety, 1(1), 1–27.
17. Singh, S., Shah, S., Shetty, P., & Shetty, R. (2020). Combating
respiratory hazards in dentistry: A comprehensive review.
Journal of Dental Research and Review, 7(2), 1–5.
18. Thomas, R. J. (2013). Particle size and pathogenicity in the
respiratory tract. Virulence, 4(8), 847–858.
19. Vos, L. M., Bruyndonckx, R., Zuithoff, N. P. A., Little, P.,
Oosterheet, J. J., Broekhuizen, B. D. L., Lumens, C., Leons,
K., Viveen, M., Butler, C. C., Crook, D., Platea, K., Gooses,
H., Claws, E. C. J., Level, M., Van Loon, A. M., Verheij, T.
J. M., & Coenjaerts, F. E. J. (2021). Lower respiratory tract
infection in the community: Associations between viral
etiology and illness course. Clinical Microbiology Infect, 27(1),
96–104.
20. World Health Organization. (2014). Infection prevention
and control of epidemic-and pandemic prone acute respiratory
infections in health care. https://www.who.int/publications/i/item
/infection-prevention-and-control-of-epidemic-and-pandemic
-prone-acute-respiratory-infections-in-health-care
21. Zemouri, C., Volgenant, C. M. C., Buijs, M. J., Crielaard, W.,
Rosema, N. A. M., Brandt, B. W., Lahi, A. M. G. A., & De
Soot, J. J. (2020). Dental aerosols: Microbial composition
and spatial distribution. Journal of Oral Microbiology, 12(1),
1762040, 1–8. https://doi.org/10.1080/20002297.2020
.1762040
 CHAPTER 2
Infection Prevention
for Aerosol-Generating
Procedures
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Define a biofilm and recognize its impact on
dental unit line quality.
2. Implement a six-tier multilayer infection
prevention plan to protect everyone in the
dental environment from hazardous spatter
droplets and aerosols.
3. Select the personal protective equipment (PPE)
that provides the highest protection during a
dental aerosol-generating procedure.
4. Differentiate between surgical and particulate
filtering facepiece respirator masks and
identify which mask provides the best
protection during a dental aerosol-generating
procedure.
5. Identify intraoral and extraoral evacuation
devices and incorporate the technology in a
manner that maximizes protection for dental
health-care personnel (DHCP) during a dental
aerosol-generating procedure.
6. Recognize the positive impact engineering
controls such as high-quality ventilation and air
decontamination technology can have on the
dental environment.
KEY TERMS
• Air decontamination: also known as air
purification or no-touch decontamination. A device
that improves indoor air quality and reduces
contaminants.
• Air purification: see air decontamination.
• Anti-retraction device: a device that blocks fluids
from retracting backward into the dental unit line
tubing.
• Biofilm:
collection of microbial cells that bind
together on a surface and form an enclosed
matrix held together by polysaccharides that is
irreversibly bound to a surface.
• Bipolar air ionization: form of air decontamination
that releases clusters of bipolar ions in the
environment to change the polarity of aerosol
particles.
• Colony-forming unit (CFU): estimates the number
and concentrations of viable microorganism cells
in a test specimen.
• Dental device: instrument or machine including
components, parts, and accessories that is used
in the diagnosis, treatment, and prevention of
disease (Organization for Safety, Asepsis, and
Protection, 2018).
• Dental unit: combination of interconnected dental
equipment and dental instruments constituting
a functional assembly for use in the provision of
dental treatment (Organization for Safety, Asepsis,
and Protection, 2018).
• Electrostatic precipitator: form of air
decontamination that changes air ionization
through the release of charged particles and
electrostatic forces.
• Extraoral scavenging device: device positioned
outside the oral cavity to change the air flow
•
dynamics in the immediate treatment area.
Face shield: clear covering worn to protect
parts of the face from splashes, typically made
of a headband that holds the shield on the
user’s head.
11
12 Chapter 2 Infection Prevention for Aerosol-Generating Procedures

• Filtration: a form of air decontamination

where particles and pollutants from the air are
• Surgical mask: loose-fitting pleated flat materials
that cover the wearer’s respiratory portals of
physically or mechanically removed through entry (nose, mouth) whose design varies widely
diffusion, settling, and impaction. among manufacturers in the materials they are
• Gown: single-use disposable or non-disposable made of and efficiency of filtration.
reusable material worn by a DHCP that is
impenetrable to fluid and reaches to the neckline
• Ultraviolet-light germicidal irradiation (UVGI):
form of air decontamination where air is exposed
and knees and covers the torso and forearms. to short wavelength UV light to reduce aerosol
• Hair covering: single-use disposable or non- contamination through oxidizing reactions.
disposable reusable material worn by a DHCP
that is impenetrable to fluid and protects the
• Vacuum line: small plastic tubing that is affixed
with either a disposable or reusable sterilizable
scalp and hair from airborne particles. suction device to remove fluids from a patient’s
• Heterotrophic mesophilic water bacteria: bacteria
that require organic carbon nutrients for growth
mouth during treatment, which provides a
favorable environment for a biofilm’s growth.
and can exist in all types of water. • Water line: small plastic tubing that delivers
• High-efficiency particulate air (HEPA) filter:
a form of air decontamination that filters air
an aqueous solution that provides a favorable
environment for a biofilm’s growth.
particles, dust, pollen, mold, bacteria, and
airborne particles out of the environment.
• High-volume evacuation: intraoral evacuation
device with a large opening used for the removal
of fluid from the mouth and large volumes of air.
• Hydrogen peroxide (H2O2) system: form of
air decontamination where air is exposed to
Introduction
vaporized (gaseous) hydrogen peroxide to reduce This chapter will discuss infection prevention
contamination through oxidizing reactions.
•
protocols and interventions central to the use of
­
Low-volume evacuation: intraoral evacuation aerosol-­generating equipment. Oral health-care pro-
device with small openings used for the removal
viders who work in direct patient care are at high risk
of fluid from the mouth.
• National Institute for Occupational Safety and
Health (NIOSH): a component of the CDC within
for exposure to pathogenic dental aerosols and dis-
ease transmission. The recent COVID-19 pandemic
the US Department of Health and Human cause by the novel SARS-CoV-2 coronavirus and its
Services that certifies particulate filtering variants revealed the need for aerosol-protection best
facepiece respirators in the United States.
•
practice management strategies. Aerosol-generating
Non-NIOSH-approved filtering facepiece procedures received special attention from governing
respirators: a respirator mask manufactured
dental boards, which released new regulations to mit-
outside the United States in compliance with the
other country’s standards that protect from non-
igate the risks associated with the practice of dentistry
oil aerosols and are expected to provide similar during a pandemic caused by an acute respiratory
protection as a NIOSH-approved particulate ­infection (ARI).
filtering facepiece respirator mask. Specific infection prevention protocols are needed
• No-touch decontamination: see air decontamination.
•
when aerosol-generating procedures are performed in
Organization for Safety, Asepsis, and Prevention the dental environment. This chapter presents a six-
(OSAP): dentistry’s leading global agency advisor
tier multilayer approach to mitigate the risk for disease
for infection prevention education and training.
• Ozone air generator: form of air decontamination
where air is exposed to trioxygen to reduce
transmission during dental aerosol-generating proce-
dures, which includes the maintenance of dental unit
contamination through oxidizing reactions. lines, personal protective equipment (PPE) unique to
• Particulate filtering facepiece respirator mask:
tight fitting mask that covers the wearer’s
aerosol-­generating procedures, patient pre-procedural
antimicrobial rinsing, evacuation techniques that cap-
respiratory portals of entry (nose, mouth) and ture high volumes of aerosols, and employing engi-
forms a tight seal around the nose and mouth to
neering controls such as adequate ventilation and air
provide protection from airborne particles.
• Pre-procedural antimicrobial rinse: rinse given
to a patient prior to a procedure to reduce the
decontamination technology.
When a dental aerosol-generating procedure
number of viable organisms in the mouth. is performed, the oral health-care provider must
• Shoe covering: single-use disposable or non-
disposable reusable material worn by a DHCP
utilize PPE that provides protection from high vol-
umes of aerosols and spatter droplets. This includes
that is impenetrable to fluid and covers the shoe gloves with quality hand hygiene, gowns, hair cov-
and reaches to the ankle.
ering, eye protection, a face shield, and a particulate
 Dental Aerosol Management 13

filtering facepiece respirator mask. High-volume

evacuation is needed to reduce aerosol contamina-
tion by removing the contaminants from the source
before they have a chance to circulate in the air. For
an additional layer of protection engineering con-
trols such as adequate ventilation and air decon-
tamination may also be incorporated into an overall
prevention program.

Dental Aerosol
Management
The oral health-care provider should enter treatment
assuming every patient is infectious and utilize a six-
tier multilayer approach to protect the dental environ-
ment from aerosol and spatter droplet contamination.
The six tiers are:
1. Maintenance of dental unit lines
2. PPE
3. Pre-procedural antimicrobial rinses
Figure 2-1 Dental Unit
4. Evacuation devices
5. Ventilation systems
6. Air decontamination

Maintenance of Dental
Unit Lines
The Organization for Safety, Asepsis, and
­Prevention (OSAP) is dentistry’s leading global
advisor for infection prevention education and
training. It provides recommendations for best
practices in infection control that regulators use
in their ­standards. OSAP states a dental unit is a
“combination of interconnected dental equipment
and dental instruments constituting a functional as-
sembly for use in the provision of dental treatment”
(see Figure 2-1). A dental device is any instrument
or machine, including components, parts, and ac-
cessories, that is used in the diagnosis, treatment,
and prevention of disease (OSAP, 2018). Examples
of a dental device are a drill, dental ultrasonic, and
an air polisher. Figure 2-2 Dental Unit Plastic Tubing
As part of the dental unit, narrow diameter plas-
tic tubing is used to deliver water and air, and retract
fluids (see Figure 2-2). The plastic tubing will become variety of organisms. All they need for growth is mois-
contaminated with biofilm if it is not maintained and ture, nutrients, and a surface for adherence.
tested regularly (OSAP, 2018). • Natural biofilms are beneficial and a needed part
A biofilm is a collection of microbial cells that of the food chain. You can see visually see bio-
bind together on a surface and form an enclosed ma- film growth on rocks in fresh and salt water (see
trix held together by polysaccharides, which are not Figure 2-3).
easily removed by gentle rinsing from a surface (OSAP, • Industry biofilm is not beneficial and is problem-
2018). Biofilms are all around us. They are made of a atic when it grows inside piping or health-care
14 Chapter 2 Infection Prevention for Aerosol-Generating Procedures

Figure 2-4 Dental Unit Vacuum Line with Detachable

Evacuation Devices
Figure 2-3 Biofilm Growth on Rocks in Shallow Stagnant
Water
© Diane079F/Shutterstock.

tubing. Industry biofilm is dangerous when it

grows readily and unchecked inside dental tub-
ing because it is expelled into the air and into the
mouth of a patient, which increases the risk for an
adverse health effect.

BREAKOUT POINT
Plastic line tubing of a dental unit will become
contaminated with biofilm if the lines are not
properly maintained.

Figure 2-5 Molar Tooth with Dental Amalgam

Vacuum Line Tubing Filling

A dental unit vacuum line is made of narrow ­plastic recommended by the manufacturer. There are sit-
tubing that is affixed with either a disposable or re- uations where the manufacturer may recommend
usable sterilizable evacuation device to remove cleaning or disinfecting between patients. Refer to
­fluids from a patient’s mouth during treatment (see the directions or instructions for use (DFU/IFU).
Figure 2-4).
The vacuum line provides a moist environment
• Avoid oxidizing, foaming, or acidic line cleaning
solutions. Refer to the manufacturer’s DFU/IFU
favorable for a biofilm’s growth. The lines must be for approved solutions that are compatible with
maintained per manufacturer recommendations to your ultrasonic and air polishing device.
avoid biofilm accumulation. To mitigate the growth of
biofilm in the vacuum line, the DHCP should:
• For an office that removes, places, or extracts teeth
with dental amalgam materials, a pH neutral (6–8
• Run a cleaning or disinfecting solution through pH) solution that is nonoxidizing is required to avoid
all vacuum lines once per day, at minimum, to re- solubilizing mercury in the line (see Figure 2-5; US
move debris and deodorize the line. Use a solution Environmental Protection Agency [EPA], 2021).

Figure 2-6 Patient Closing Lips on Saliva Ejector
• Use anti-retraction devices on vacuum lines. The
vacuum line can become contaminated if the
provider allows a patient to fully close their lips
around a saliva ejector (see Figure 2-6). This ac-
tion applies a negative pressure inside the line
and can force the retraction of oral fluids back
into the tubing. This backflow fluid can then
­enter the next patient’s mouth when they close
on the line. To decrease the risk for retraction, an
­ nti-­retraction device can be permanently in-
a [CDC], 2003).
stalled onto the vacuum line valves or be fitted to
the evacuation line as a disposable single-use item
(see Figure 2-7). An anti-retraction device blocks
fluids from retracting backward into the line
during use. If the office is using a permanently
installed anti-retraction device, the valve needs to
be checked periodically for integrity and replaced
when faulty.
BREAKOUT POINT
A patient should not close their lips around a
saliva ejector to prevent retraction of fluid into the
evacuation line.
Water-Line Tubing
A dental unit water line is made of narrow plas-
tic tubing that delivers an aqueous solution (see
Figure 2-8a). Examples of equipment that deliver
Dental Aerosol Management 15
Figure 2-7 Disposable Single-Use Retraction Device
(HuFriedyGroup SafeFlo)
Courtesy of HuFriedyGroup Mfg. Co., LLC.
water from the dental unit to a patient’s mouth are the
air/water syringe, dental ultrasonic, and air polisher
(see Figure 2-8b).
A biofilm can readily bind to and build colonies
inside water line tubing because:
• Tubing is plastic with a very narrow lumen size.
• Tubing has inconsistent water flow rates.
• When not in use, water becomes stagnant inside
the tubing, proving a moist environment.
To decrease the risk of disease transmission from
a biofilm-contaminated water line, each office should
develop and implement a comprehensive water-line
maintenance plan that consists of regular moni-
toring, cleaning, and continuous treatment (OSAP,
2018; Centers for Disease Control and Prevention
Water-Line Monitoring. A water line contami-
nated with biofilm will release organisms into the envi-
ronment and the patient’s mouth. Water lines must be
tested regularly to ensure they are safe for human use
(OSAP, 2018; EPA, 2021). There are multiple tests on
the market for water-line evaluation. Some are done
chairside while others require a mail-in test result.
The results are reported as number of colony-­
forming units (CFUs) per mL. CFUs are the number
of separable cells in a sample. In the United States, the
CDC recommends dental offices follow the EPA’s accept-
able drinking water standards of less than 500 CFU/mL
of heterotrophic mesophilic water bacteria (bac-
teria that require complex organic compounds, such as
plant or animal, for food and metabolic s­ ynthesis) for
nonsurgical dental procedures (EPA, 2021).
• The CDC recommends dental offices use as low
as reasonably achievable levels of bacteria in their
water lines that do not exceed the EPA standard.
(CDC, 2003)
16 Chapter 2 Infection Prevention for Aerosol-Generating Procedures

A B
Figure 2-8 Dental unit water line: A. Air/water syringe on the left, piezoelectric handpiece
connector cable in the middle, high speed air turbine connector on right, B. Air/water syringe
expelling water into the low-volume evacuation device. Note the aerosols and spatter droplets
created by this action.

• For surgical procedures, sterile saline or sterile
water is used (CDC, 2003).
BREAKOUT POINT
Dental water lines should have less than 500 CFU/
mL of heterotrophic mesophilic water bacteria for
nonsurgical procedures.
If the number of CFUs exceeds the recommended
levels, disease transmission risk is increased through
direct contact in a patient’s mouth or in the form of a
pathogenic aerosol. The most serious adverse health
events that have been reported from contaminated
water lines above the CDC recommendations are:
• Community outbreaks of pseudomonas aerugi-
nosa, legionella, and nontuberculosis mycobacterium
linked to dental water-line biofilm contamination
(OSAP, 2018; CDC, 2003; Koletsi et al., 2020).
Some of these outbreaks were associated with
dental unit water lines with over 1 million hetero-
trophic mesophilic water bacteria CFU/mL. Un-
fortunately, some patients have lost their lives or
suffered serious chronic systemic health effects as
a result of ingesting the contaminated water that
exceeded the EPA standard (CDC, 2003).
• Water lines colonized with high levels of
gram-negative heterotrophic biofilms release lipo-
polysaccharides, which can activate a patient’s or
a DHCP’s preexisting respiratory condition such
as asthma (Pankhurst et al., 2005).
Water-Line Maintenance. Water-line cleaning
recommendations are provided by the manufacturer
and vary based on the type of water source. Recom-
mendations are different for systems that use ster-
ile water than those that derive their water from the
municipal water supply. Municipal water can be soft,
hard, or pumped from a well. The line cleaning rec-
ommendations will vary for each situation. Water lines
should be shocked periodically with an EPA-­registered,
manufacturer-approved solution to decrease biofilm
accumulation and remove debris. The manufacturer
determines the frequency and delivery method.
Water lines need continuous treatment to fight
biofilm accumulation in the line. A tablet, straw, car-
tridge, or liquid drop is used to decrease biofilm ac-
cumulation in water lines. Follow the manufacturer’s
recommendations for installation, maintenance, and
replacement. Some products are replaced once a year
while others are replaced daily. Some will deliver a
shock treatment automatically while others require a
manual shock.
 Dental Aerosol Management 17

Water-Line Maintenance Best Practice quality hand hygiene; gown, hair, and shoe coverings;
Recommendations. Best practice recommenda- eye protection; a face shield; and a particulate filtering
tions for dental unit water lines are: facepiece respirator mask.

• OSAP encourages manufacturers “to design den-

Hand Hygiene and Gloves
tal water systems that are passively non-­retracting
without the use of anti-retraction valves that re- Quality hand hygiene is needed to reduce the risk
quire periodic replacement or maintenance” of disease transmission, especially in any health-care
(OSAP, 2018). If this technology is not available ­setting (CDC, 2003). In the United States, the Food
on your unit, install an anti-retraction device onto and Drug Administration (FDA) regulates handwash-
any line that expels water (OSAP, 2018). ing products (handwash and rubs) used by health-care
• Use sterile handpieces, including ultrasonic and workers. The CDC Hand Hygiene Task Force provides
air polishing handpieces, for each patient. Multi- guidelines for proper hand hygiene in health-care.
ple studies have shown microbial contamination There are two methods for handwashing:
from retracted oral flora in the internal compo- 1. Antimicrobial hand soap and water.
nents of air-driven handpieces after a single use • This method is used when hands are visibly
(CDC, 2003; Chin et al., 2006; Herd et al., 2007). soiled.
• OSAP and the CDC recommend flushing any • Antimicrobial soaps should have bacterio-
water line connected to a dental device or dental static and bactericidal effects (CDC, 2002).
unit that enters a patient’s mouth for a minimum Non-antimicrobial soaps are not approved for
20-30 seconds at the start of the day, in between health-care use.
patients, and at the end of the day regardless of • Common agents used in health care are listed
the presence of an anti-retraction device (OSAP, in Table 2-1.
2018; CDC, 2003). This will assist in removing 2. Alcohol-based hand rub antiseptic
potentially retracted organisms in the line.
• This method is used when hands are not vis-
ibly soiled.
BREAKOUT POINT • Common agents used in health care are listed
Dental water lines should be flushed for a minimum in Table 2-2.
of 20–30 seconds at the start of the day, between • Concentrations 60–95% alcohol are most ef-
patients, and at the end of the day. fective (CDC, 2002).
• In a systematic review published in 2004 by Pi-
cheansathian et al. (2004), alcohol-based hand
Personal Protective antiseptics were recommended over handwash-
Equipment (PPE) ing with antimicrobial soap for routine hand hy-
When a dental aerosol-generating procedure is per- giene in health-care settings. The most effective
formed, aerosol-appropriate PPE is needed to protect combination found in the study was 61% etha-
DHCP. Aerosol appropriate PPE includes gloves with nol with 1% chlorhexidine antiseptic hand rub.

Table 2-1 Antimicrobial Hand Soaps Used in Health Care

Chemical Mechanism of Action Activity
Chloroxylenol Inactivates bacterial enzymes and Bactericidal
alters cell walls.
Hexachlorophene Inactivates bacterial enzymes. Bacteriostatic
Iodophors (common concentrations are 7.5–10% Inactivates cell cytoplasmic Bactericidal
povidone-iodine) membrane.
Quaternary ammonium compounds (most commonly used Absorbs cell cytoplasmic Bacteriostatic
is alkyl benzalkonium chlorides followed by benzethonium membranes and causes leakage. and fungistatic
chloride, cetrimide, and cetylpyridinium chloride)

Data from Center for Disease Control. (2002, October 25). Guideline for hand hygiene in health-care settings. MMWR, 51 (RR16), 1-44.
18 Chapter 2 Infection Prevention for Aerosol-Generating Procedures

Table 2-2 Alcohol-Based Hand Antiseptics

Chemical Additive Ingredients*
Isopropanol Hexachlorophene
Ethanol Quaternary ammonium compounds
N-propanol Povidone-iodine
Triclosan
Chlorhexidine gluconate (low
concentrations of 0.5–1.0%)

*Additive agents are available in some products that can increase

the antimicrobial or residual activity.

Figure 2-10 Glove Integrity Compromised with Tear on

Index Finger

Figure 2-9 Alcohol-Based Hand Antiseptic Dispenser

© zhihao/Moment/Getty Images.

• Volume of product used varies between for-

mulations and manufacturers. DHCPs should
reference the manufacturer’s instructions for
recommended volume. Many products are
sold with a dispensing method such as a
pump or automatic sensor, which is designed
to dispense the proper volume of product that
will optimize effects and prevent drying of the
skin (see Figure 2-9).
Once hand hygiene is complete, DHCP will
Figure 2-11 Healthcare Worker Wearing a Disposable
don well-fitting gloves. Gloves should be changed if Gown, Hair, and Shoe Coverings
cross-contamination occurs or the integrity of the glove
is compromised (see Figure 2-10). Wearing gloves does
at the end of each workday (see Figure 2-12b). Coun-
not negate the need for proper hand hygiene and both
tries vary in their rules and regulations for launder-
are imperative when performing any procedure.
ing. In some countries, the employer is responsible for
laundering staff reusable gowns, hair coverings, and
Gown, Hair, and Shoe Protection shoe coverings either in the office or with an off-site
A gown, hair, and shoe covering will offer protection for facility.
the oral health-care provider during a dental aerosol- A hair covering will protect the scalp and hair
generating procedure (see Figure 2-11 and 2-12a and b). from airborne particles. Those with facial hair such as
The materials should be impenetrable to fluid and are a full beard may consider covering this hair as long as
either disposable single-use or nondisposable reus- the covering does not interfere with the fit of the mask.
able. If nondisposable, the materials must be laundered A gown should reach the neckline and knees while
 Dental Aerosol Management 19

tract and covers the mouth and nose portal of en-

try. There are two categories of masks with multiple
manufacturer choices in each category. The two cat-
egories are surgical masks and particulate filtering
facepiece respirator masks (see Figure 2-13a and b).

A
A

B
Figure 2-12 Hair Covering: A. Disposable Hair Covering
B. Reusable Hair Covering

overing the torso and forearms. Shoe coverings

c­
should cover the entire shoe and reach to the ankle.
The gown, hair covering, and shoe coverings must be
changed when visibly soiled and removed prior to leav-
ing the active treatment area (US Department of Labor,
Occupational Safety and Health Administration, 2012).

Mask
Mask selection is one of the most important layers
of PPE protection during a dental aerosol-generating
procedure because it is the direct physical barrier
between a pathogen and the wearer’s respiratory
C
Figure 2-13 Masks: A. Surgical Mask (Medicom),
B. Particulate Filtering Facepiece Respirator Mask (3M),
C. Non-NIOSH-Approved Filtering Facepiece Respirator
A: Reproduced with permission from Medicom; B: © Liliboas/iStock/Getty Images Plus/Getty Images.
20 Chapter 2 Infection Prevention for Aerosol-Generating Procedures
The difference between the two categories is summa-
rized in Table 2-3.
A particulate filtering facepiece respirator mask
offers the highest level of protection from small,
particle-size aerosols. DHCPs should check with their
individual country and/or state rules and regulations
to determine if a specific mask is required when par-
ticipating in a dental aerosol-­generating procedure.
Selecting the appropriate mask based on procedure
is imperative to protect the DHCP from pathogenic
aerosols.
A dental aerosol-generating procedure has the po-
tential to wet the outside of a mask, which will de-
crease its effectiveness due to wicking. A mask that
becomes wet from splashes or secretions should be
immediately discarded and replaced (CDC, 2003).
A chin-length face shield will provide some protec-
tion to the outer layer of a mask from wetting. Fol-
low the manufacturer’s recommendations for when
to change a mask because recommendations vary be-
tween products.
A dental aerosol will travel over 6 feet away from
the source and stay suspended in the air for minutes
to hours with their highest concentrations in the
first 10–30 minutes immediately after an aerosol-­
generating procedure is complete. Any DHCP ex-
posed to this contaminated air should have a mask
on, even if the active patient care has ended.
Surgical Mask. A surgical mask is a pleated flat
material that cover the wearer’s respiratory portals
of entry (nose, mouth) whose design varies widely
among manufacturers in the materials they are made
Table 2-3 Surgical and Particulate Filtering
Facepiece Respirator Mask Comparison
Surgical Mask Respirator Mask
Regulation in the FDA NIOSH
United States
Fluid resistant Yes Yes
Fit Loose Tight
Fit and seal test No Yes
Protection from Some Higher level
dental aerosols protection
Data from US Food & Drug Administration. (2020, September 3). Face masks and surgical
masks for COVID-19: Manufacturing, purchasing, important, and donating masks during the
public health emergency. Accessed November 14, 2020 from https://www.fda.gov/medical
-devices/coronavirus-covid-19-and-medical-devices/face-masks-and-surgical-masks-covid
-19-manufacturing-purchasing-importing-and-donating-masks-during.
of and efficiency of filtration (FDA, 2020; WHO,
2014). Surgical masks are regulated by the FDA in
the United States (FDA, 2020). The FDA is a com-
ponent of the US Department of Health and Human
Services. When the provider is actively involved in a
dental aerosol-generating procedure that has the po-
tential to release pathogenic aerosols within 1–3 feet
of the patient’s mouth, a surgical mask may not be the
best practice for protection because designs, materi-
als, and processing vary among manufacturers with
no standardization of testing methods for mask filter
efficiency (WHO, 2014). The most common material
used in the manufacturing of a surgical mask is poly-
propylene fabricated by spunbonded, meltblown, or
wetlaid processes in either two or three layers.
• The CDC (2003) states, “Surgical masks are not
NIOSH-certified as respirators, do not protect the
user adequately from exposure to tuberculosis,
and do not satisfy OSHA requirements for respi-
ratory protection.”
• WHO (2014) states that surgical masks “do not
offer adequate respiratory protection against
small-particle aerosols” and these masks vary
widely in the efficiency of filtration.
BREAKOUT POINT
Surgical masks do not offer adequate respiratory
protection against small, particle-size aerosols.
The American Society for Testing and Materials
(ASTM) is a nonprofit organization and has set three
performance levels for surgical masks based on per-
cent filtration efficiency, bacterial filtration efficiency,
fluid resistance, breathability, flammability, and ISO
certification (see Table 2-4; ASTM, 2019).
Table 2-4 ASTM Ratings
Fluid Delta P
Resistance PFE BFE (mmH2O/cm2)
Level 1 Low ≥ 95% ≥ 95% <5.0
(80 mmHg)
Level 2 Moderate ≥98% ≥ 98% <6.0
(120 mmHg)
Level 3 High ≥98% ≥ 98% <6.0
(160 mmHg)
Reproduced with permission from American Society for Testing and Materials. (2021). Standard
specification for performance of material used in medial face masks ASTM F2100-21. ASTM
International, West Conshohocken, PA. doi: 10.1520/F2100-21.
 Dental Aerosol Management 21

• Percent filtration efficiency (PFE) measures the

percent efficiency of the mask to filter particulate
matter in pore sizes 0.1–1.0 microns. The higher
the PFE, the better protection the mask provides.
• Bacterial filtration efficiency (BFE) measures the
percent efficiency of the mask in filtering microor-
ganisms in pore sizes 1–5 microns. Staphylococcus
aureus is the bacteria used in the testing due to its
small size. The higher the BFE, the better protec-
tion the mask provides.
• Fluid resistance is measured by spraying synthetic
blood onto the mask and evaluating for penetra-
tion. The higher the fluid resistance, the better
protection the mask provides.
• Breathability of masks is reported as a Delta P
(differential pressure) parameter. The Delta P
shows how the pressure drops across a mask, A
which demonstrates its resistance to air flow.
Higher Delta P offers better protection but less
breathability.
A surgical mask should be worn per the manu-
facturer’s instructions. When wearing a surgical mask,
the nose and mouth should be completely covered
with no gapping between the skin and the mask to
prevent a portal of entry for pathogenic organisms. If
there is gapping, or the mask has a loose fit, do not
make alterations to how it is worn such as crisscross-
ing or knotting the ear loop ties because protection
can no longer be guaranteed (see Figure 2-14a and b).
This increases the risk for disease transmission and
leakage around the mask. The wearer should switch
to a different mask size or shape.

BREAKOUT POINT
Do not alter how a surgical mask is worn if it does
not fit. Select another brand, size, or shape.
B

Particulate Filtering Facepiece Respi-
rator Mask. A particulate filtering facepiece
respirator mask will provide the highest level of pro-
tection from small, particle-size aerosols. The WHO
(2014) recommends oral health-care providers wear
a particulate filtering facepiece respirator mask during
aerosol-generating procedures. A respirator mask
is certified by the National Institute for Occupa-
tional Safety and Health (NIOSH) in the United
States, which is component of the CDC within the US
Department of Health and Human Services. The mask
will form a tight seal around the wearer’s nose and
mouth.
Figure 2-14 Surgical Mask Fit: A. Correct Fit with
Edges of Mask Flush with the Skin, B. Incorrect Fit with
Gapping Between Mask and Skin with Crisscrossed Ear
Loops
NIOSH has seven classes of approved particu-
late filtering facepiece respirator masks denoted by
N, R, and P, which refer to the filter’s oil resistance
(see Table 2-5). In an industry where exposure to oil
may occur, it is important the wearer use a particu-
late filtering facepiece respirator that is oil resistant.
This is not a requirement for the practice of dentistry.
The field typically uses class N. The minimum level
22 Chapter 2 Infection Prevention for Aerosol-Generating Procedures

Table 2-5 Particulate Filtering Facepiece Table 2-6 Seal Test

Respirator Mask Classes
Positive Negative
Airborne Filtration Oil Pressure Seal Pressure Seal
Class Ability Resistance Check Check

N95 95% None Procedure Exhale gently Inhale sharply

Surgical N95 95%*
N99 99%
N100 99.97%
R95 95%
P95 95%
P99 99%
P100 99.97%
*Surgical N95 masks are also approved by the FDA as a surgical mask.
Data from Center for Disease Control. (2020, April 9) NIOSH approved particulate filtering
facepiece respirators. Accessed November 14, 2020 from https://www.cdc.gov/niosh/npptl
/topics/respirators/disp_part/default.html
of filtration approved by NIOSH is 95%, which refers
to the mask’s ability to filter 95% of particles with less
than 5% leakage into the mask.
In the United States, OSHA’s respiratory protection
standard requires any wearer to be fit and seal tested and
gain a medical clearance prior to wearing a particulate
filtering facepiece respirator mask (US Department of
Labor, Occupational Safety and Health Administration,
2011). Employers should maintain a log documenting
day, month, year, and name of the staff member who
received respirator training and the seal-and-fit test.
• Fit Testing: Performed to verify the fit, comfort,
model, and size needed for the user. Fit testing
should be performed and logged annually. Com-
mon testing is a pass or fail with a specific test
agent for taste or smell. The wearer needs to be
aware that facial hair has been shown to cause
20–1,000 times more leakage around a particulate
filtering facepiece respirator mask (CDC, 2018a).
• Seal Testing: A seal test should be performed by
the user each time they put on the mask. Positive
or negative pressure seal checks can be performed,
and users should refer to the manufacturer’s rec-
ommendations for the type of pressure seal test to
perform. See Table 2-6.
with hands with hands
None covering paths covering paths
None for air to for air to
escape over the escape over the
None mask. mask.
Somewhat
Passing test Facepiece Facepiece
Strong slightly collapses
pressurized slightly
Strong
Data from Center for Disease Control. (2018). Filtering out confusion: Frequently asked
Strong questions about respiratory protection: User seal test. Accessed May 12, 2021 from https://
www.cdc.gov/niosh/docs/2018-130/pdfs/2018-130.pdf?id=10.26616/NIOSHPUB 2018130.
Non-NIOSH-Approved Filtering Facepiece
Respirators (FFRs). In response to the SARS-
CoV-2 global pandemic, which began in 2019, the FDA
approved an Emergency Use Authorization (EUA) for
non-NIOSH-approved filtering facepiece respi-
rators manufactured outside the United States (FDA,
2020b). These masks are manufactured in compliance
with the other country’s standards, protect from non-oil
aerosols, and are expected to provide similar protection
as a NIOSH-approved particulate filtering facepiece res-
pirator mask (FDA, 2020a, 2020b). Examples include
KN/KP95, PFF2, P2, and DS/DL2 (see Figure 2-13c).
Face Shield and Protective Eyewear
For an aerosol-generating procedure, a chin-length
face shield and protective eyewear with side shields
is best practice. Eyewear with side shields protects the
eyes from splashes, spatter droplets, and aerosols but
does not cover all aspects of the face and does not pro-
tect the wearer’s mask. A chin-length face shield offers
some protection for the outer layer of the mask and
covers the wearer’s skin. A face shield is a clear cover-
ing worn to protect parts of the face from splashes; it
is typically made of a headband that holds the shield
on the user’s head. (see Figure 2-15). Face shields and
protective eyewear should be disinfected per the man-
ufacturer’s instructions if they are not single use, and

BREAKOUT POINT BREAKOUT POINT

A seal-and-fit test will ensure the respirator mask is A chin-length face shield will protect the outer layer
a good fit for the wearer. of the wearer’s mask from getting wet.

Figure 2-15 Chin-Length Face Shield
Box 2-1 Pre-Procedural Rinse Chemicals
Chlorhexidine
Essential oils (eucalyptol, menthol, methyl
salicylate, thymol-based)
Herbal products (aloe, sage, echinacea-based)
Oxygenating agents (hydrogen​peroxide)
Oxidizing agents (sodium hypochlorite)
Quaternary ammonium compounds (cetylpyridinium
chloride)
hand hygiene should be performed after removal. The
patient should also wear eye protection during all pro-
cedures, but especially during aerosol-­generating pro-
cedures, to avoid contamination or injury to their eyes.
Pre-Procedural Antimicrobial
Rinses
Pre-procedural antimicrobial rinses routinely
given to patients prior to a procedure to reduce the
number of viable organisms in the mouth. Although
specific chemicals can decrease microbial counts in
the mouth, it is unknown if prerinsing translates into
a decreased rate of infection for the DHCP (Marui
et al., 2019; Nagraj et al., 2020). Prerinsing does not
eliminate the risk for pathogenic aerosol disease trans-
mission and is just one of the six layers of protection
in an overall infection prevention program. For a list
of commonly used chemicals, see Box 2-1.
Evacuation Devices
One of the most important environmental controls for
reducing aerosol contamination is the use of an intra-
oral evacuation (suction) device. These devices will
Dental Aerosol Management 23
reduce the environmental contamination of aerosols
both free-floating in the air and on surfaces by remov-
ing the particles at the source. Particle sizes 20 µm and
larger are relatively easy to remove, but particles ≤0.1
µm are almost impossible to remove from a surface and
easily recirculate in the air for prolonged periods of time
(Kulkarni et al., 2011; Kumar & ­Subramanian, 2020).
Intraoral Device
The goal of an intraoral evacuation device used during
a dental aerosol-generating procedure is to remove
aerosolized particles at the source of release inside the
mouth. There are two types of intraoral evacuation
devices used in dentistry: low-volume evacuation
and high-volume evacuation.
Low-volume evacuation (LVE). An LVE removes
fluids in the mouth but does little for the displacement and
removal of air particles created during a dental aerosol-
generating procedure. The LVE saliva ejector hole open-
ings are too small to displace air and should only be used
in conjunction with an HVE (see Figure 2-16; Nagraj
et al., 2020; Harrel & Molinari, 2004).
BREAKOUT POINT
An LVE will not protect the dental environment from
aerosol contamination.
High-volume evacuation (HVE). An HVE must
be used during a dental aerosol-generating procedure
because it will remove large volumes of air from the
source. If used properly, an HVE will prevent over 90%
of aerosols from entering the environment (Nagraj et al.,
2020; Harrel & Molinari, 2004; Avasth, 2018). There
are many HVE choices on the market today. To be clas-
sified as an HVE, the equipment must remove 100 cu-
bic feet of air per minute when the provider is engaged
in a dental aerosol-­generating procedure (Nagraj et al.,
2020; Harrel & ­Molinari, 2004; Avasth, 2018). Air vol-
ume movement is measured in cubic feet per minute.
Providers should be aware there is equipment on the
market that attaches to an HVE vacuum line, but does
not 100 cubic feet of air per minute. Studies have shown:
• The evacuation line itself has little influence on
aerosol reduction (Holloman et al., 2015).
• The bore hole opening of a device has the greatest
influence in removing air particles at the source
(Holloman et al., 2015). Devices that remove
100 cubic feet of air per minute typically have an
8 mm bore hole opening (see Figure 2-17a to c;
Harrel & Molinari, 2004).
24 Chapter 2 Infection Prevention for Aerosol-Generating Procedures

C
Figure 2-16 Low-Volume Evacuation: A. Saliva Ejector—
Safco®, B. Isolite® Mouthpiece, Zyris, C. Ivory® ReLeafTM,
Kulzer®

B
BREAKOUT POINT
An HVE that removes 100 cubic feet of air per
minute will reduce more than 90% of aerosol
contamination in the environment.

It is the onus of the oral health care provider to

review product claims to ensure their HVE meets this
standard prior to implementing it into practice. The
HVE should be no more than 12 inches away from the
patient’s mouth for optimal aerosol reduction (Nagraj
et al., 2020; Kumar & ­Subramanian, 2020).
C
Figure 2-17 High-Volume Evacuation: A. HVE
Evacuator—Crosstex®, B. Purevac® HVE Mirror Tip,
Dentsply Sirona®, C. HVEsoloTM, Palmero Healthcare

Extraoral Scavenging Device
An extraoral scavenging device is used in con-
junction with an HVE for an added layer of environ-
mental protection. The device is positioned outside
the oral cavity and changes the airflow dynamics in
the immediate treatment area. An extraoral scaveng-
ing device will decrease spatter droplet and aerosol
levels better when used with an HVE than compared
to using an HVE alone (Shahdad et al., 2020).
A study published by Matys and Grzech-Lesniak
(2020) evaluated aerosol reduction of LVE, LVE with
an extraoral device, HVE, HVE with an extraoral de-
vice, and the Zirc (Isolite) appliance during high-speed
handpiece and ultrasonic use. The key results were:
• The wider HVE evacuation device (8 mm) re-
moved two to eight times more aerosols than
compared to an LVE plus an extraoral device.
• When HVE was used during an aerosol-­generating
procedure, the aerosol contamination in the en-
tire dental office was reduced.
• The greatest amount of aerosol reduction was
found with an HVE plus an extraoral device.
Ventilation Systems
A ventilation system is an engineering control in an
overall aerosol reduction program designed to im-
prove indoor air quality. In health-care facilities, the
heating, ventilation, and air-conditioning (HVAC)
system aims to control temperature, relative humid-
ity, and airflow to decrease viral, bacterial, and fun-
gal growth. Unfortunately, environments that are
comfortable for people are also favorable for microbe
growth. Buildings utilize both natural and mechanical
ventilation in their designs.
Natural Ventilation
Natural ventilation examples are windows and doors
that exchange indoor and outdoor air. This type of
engineering control is not always possible in a dental
office when windows and doors to the outside are not
part of the office design. The use of small cooling fans
in the dental operatory is not recommended when the
office does not utilize natural ventilation because they
recirculate aerosols, which keeps them suspended in
the environment for longer periods of time.
Natural ventilation is not recommended as the
sole mechanism for decontaminating air in a dental
office. It should be used in conjunction with mechan-
ical ventilation because simply opening a window or
door will not exchange large enough volumes of air to
reduce aerosol contamination.
Dental Aerosol Management 25
BREAKOUT POINT
A small cooling fan should not be used in a dental
operatory because it can recirculate aerosols.
Mechanical Ventilation
Mechanical ventilation examples are fans that are in-
stalled in air ducts, windows, or walls that circulate
air in a room or facility. Fans are used in positive and
negative pressure rooms found in hospital settings.
• Positive pressure room: leaks room air out through
openings.
• Negative pressure room: designed with less pres-
sure inside the room than outside to prevent con-
taminated air from escaping when the door is
opened. Uncontaminated filtered air flows into
the negative pressure room and contaminated air
escapes through the exhaust system.
A dental office can employ mechanical ventilation
techniques such as installing exhaust fans in rooms that
are designed to pull moisture, odors, circulating air, and
fumes from an area of the office and vent them outdoors.
The WHO included ventilation systems as an en-
gineering control in their guidelines for prevention of
ARIs in health-care settings. The following are WHO’s
(2009) summary points pertaining to ventilation:
• “Lack of ventilation or low ventilation rates are
associated with increased infection rates or out-
breaks of airborne diseases.”
• Higher ventilation rates can reduce the concentra-
tion of airborne pathogens and aid in the dilution
of pathogenic aerosols. At this time, The WHO
does not have a recommended minimum ventila-
tion flow rate.
• “The airflow from a contaminated source can lead
to infection further away from the source.”
Air Decontamination
Air decontamination is another engineering control
that is part of an overall aerosol reduction program. Air
decontamination, also known as air purification
or no-touch decontamination, includes devices
designed to improve indoor air quality and reduce the
risk of disease transmission from contaminated air. The
technology can be a stand-alone device or integrated
into the HVAC system. Devices reduce volatile organic
compounds (VOCs), particulate matter, and bioaero-
sols to varying degrees in the environment.
There are multiple technologies for air decon-
tamination such as filtration, technology that reacts
26 Chapter 2 Infection Prevention for Aerosol-Generating Procedures

with oxygen species, and technology that reacts with incapable of reproduction (Nagraj et al., 2020; Daniels,
charged particles. 2007). An ROS is produced during oxidation-redux
reactions. Oxidizing agents remove electrons from an-
Filtration other substance by acquiring it for themselves, leaving
the substance ionized (charged) and highly reactive.
Filtration is the physical or mechanical removal of
Examples of technologies that contain a chemi-
particles and pollutants from air through diffusion,
cal with oxidizing capability are ultraviolet (UV) light,
settling, and impaction. For smaller particle removal,
ozone generator, and a hydrogen peroxide system.
filtration is aided by electrostatic attraction where air
is forced through special filters that capture impurities
UV Light. UVC light is used as an air decontami-
(Cumbo, 2020; Daniels, 2007).
nant and surface disinfectant in health-care settings
A high-efficiency particulate air (HEPA)
because UVC light has germicidal capabilities. A short
filter is a common device used in air decontamination
wavelength is used for air decontamination. Depend-
(see Figure 2-18). HEPA filters reduce air particles, dust,
ing on the delivery method, humans may or may not
pollen, mold, bacteria, and airborne particles greater
be able to be in the room during UVC action (Cumbo
than 0.3 µm in diameter (Ehtezazi et al., 2021; Tepper
et al., 2020). Figure 2-19 is a low-dosage UVC that is
& Kessick, 2008). HEPA filters are divided into sev-
safe for human exposure.
eral classes denoted by capital letters (A, B, C, D, E, F).
In the United States, the FDA regulates radiation-
They vary in their minimum efficiency reporting value
emitting electronic products and uses standards ap-
(MERV), which should be evaluated prior to purchase.
plicable to UV radiation products. At the time of this
HEPA filters are composed of randomly arranged
writing, the WHO (2019) is “unable to make a recom-
and pleated fibers (Daniels, 2007). Higher levels use
mendation about the use of ultraviolet germicidal
activated carbon prefilters, which act as an absorbent
irradiation (UVGI) to reduce the risk of transmission
(Daniels, 2007). Filters need to be checked and re-
of pathogenic aerosols in health-care facilities”.
placed regularly per the manufacturer’s instructions.
Filters without activated carbon prefilters need to be
Ozone Generator. Ozone is an allotrope of oxygen
replaced more frequently. Some filtration devices are
called trioxygen (O3). It is a highly oxidative substance
passive (they do not affect circulation of air in a room)
that renders organisms harmless by destroying their
while others are active (they draw air into the device).
cell wall integrity and nucleic acid functionality (Nagraj
et al., 2020; Cumbo et al., 2020). Industrial ozone air
Reactions with Oxygen Species generators expel O3 into an empty room for air de-
Technologies that decontaminate the air through oxi- contamination and odor control and should not be in-
dizing reactions destroy microorganisms and control haled by humans (Cumbo et al., 2020; ­Daniels, 2007).
odors. These technologies generate photons and re-
active oxygen species (ROS) that decontaminate the Hydrogen Peroxide System. A hydrogen
environment by interfering with the nucleic acid pro- peroxide (H2O2) system releases a form of H2O2; a
duction of bacteria, viruses, and fungi, rendering them commonly used form is vapor or gaseous hydrogen

Figure 2-18 HEPA Device Figure 2-19 365DisInFxtTM by GE

© simpson33/iStock/Getty Images Plus/Getty Images. Reproduced with permission from Current Lighting Solutions, LLC.
 Dental Aerosol Management 27

Reactions with Charged Particles

Bipolar air ionization and electrostatic precipitation
are technologies that create air ionization and cause
reactions with charged particles.
• Bipolar air ionization produces clusters of bi-
polar (negative and positive) ions and releases
them into the air. This leads to the creation of
ROS and changes the polarity of aerosol particles.
Aerosolized particles are attracted to the negative
ions and become heavier, causing them to fall to
the surface faster and decrease circulation time
(Nagraj et al., 2020).
• An electrostatic precipitator will remove par-
ticles from the air through electrostatic forces. The
concept is similar to rubbing a balloon on the car-
pet and then sticking it to the wall. The balloon
stays on the wall due to electrostatic forces. An
electrostatic precipitator is made of wires and a se-
Figure 2-20 Gaseous hydrogen peroxide system with ries of metal collection plates. A voltage is applied
carbon-filter (Medical Guardian to the wires and metal plates and a charged aero-
Reproduced with permission from ActivePure Technologies, LLC.
sol is released into the environment, which inter-
acts with aerosol particles in the air and changes
their polarity. The ionized aerosol particles are
attracted to the collecting plates. Some machines
peroxide (see Figure 2-20). The system may or may produce ozone in this process and other ma-
not combine the hydrogen peroxide with silver ions chines are ozone-free (Tepper & Kessick, 2008).
(Nagraj et al., 2020; Cumbo et al., 2020). Hydrogen Electrospray machines spray a liquid jet into the
peroxide is an oxidizing agent that is highly reactive environment, which is unstable and breaks apart
and will destroy cellular structures (cell walls, pro- readily into charged liquid droplets that produce a
teins, lipids, nucleic acids, amino acids) and function. charged aerosol (Tepper & Kessick, 2008).

CASE STUDY
You are scheduled to perform a procedure that will generate large volumes of aerosols and spatter droplets. Your patient
arrives and informs you their jaw is sore today and they can only open their mouth in a limited capacity. They also inform
you they have a terrible gag reflex and state, “If you are planning on using that water instrument in my mouth, I am going
to gag on the water.” You are only given 60 minutes to complete this procedure, which is difficult to do on a patient without
a gag reflex and limited opening.
When you begin your procedure, you quickly realize you cannot hold the HVE in your nondominant hand while you
hold the ultrasonic handpiece in your dominant hand. Your nondominant hand must hold a mirror so you can see all ar-
eas of the mouth due to the patient’s limited opening. You must adjust your delivery of care to accommodate the patient’s
individual needs. For each adjustment, indicate whether or not it is appropriate and why.
1. Have the patient hold the LVE in their own mouth while you perform an aerosol-generating procedure holding your
mirror in one hand and the ultrasonic handpiece in another.
2. Twist the LVE saliva ejector so that it can hook on to the patient’s cheek and lip and balance intraorally. This allows
you to have both hands free to hold the mirror in your nondominant hand and the ultrasonic handpiece in the other.
You turn on the HVE, which is positioned 2 feet away from the patent’s mouth.
3. Reappoint the patient to a day when four-handed dentistry can be performed with the help of an assistant to make
the most comfortable experience for the patient, even if this adversely affects your daily production goal.
4. Render less treatment than planned and use the HVE while performing the aerosol-generating procedure.
5. Use the LVE and an extraoral scavenging device to complete the entire procedure.
6. If the procedure can be performed with equipment that does not emit air and water, switch to that equipment, even
if it slows you down and less treatment is rendered.
28 Chapter 2 Infection Prevention for Aerosol-Generating Procedures
Summary
This chapter demonstrated appropriate infection pre-
vention protocols for the dental environment where
large volumes of aerosols are generated each workday.
A six-tier multilayer infection prevention plan will de-
crease th risk of disease transmission during aerosol-
ized procedures. Aerosol-appropriate PPE should be
used, which includes gloves (after hand hygiene is per-
formed), gown, hair covering, shoe coverings, eye pro-
tection, face shield, and a particulate filtering facepiece
respirator mask. The patient can reduce the number
Questions
1. In the United States, what is the maximum
number of heterotrophic mesophilic water
bacteria CFU that is acceptable for nonsurgical
dental procedures?
a. 10,000 CFU/mL
b. 1,000 CFU/mL
c. 750 CFU/mL
d. 500 CFU/mL
2. Which of the following is an adverse health
event that has been linked to biofilm-
contaminated water lines?
a. Pseudomonas aeruginosa community outbreak
b. Legionella community outbreak
c. Nontuberculosis mycobacterium community
outbreak
d. All of the above
3. How long does the CDC and OSAP recommend
the DHCP flush all water lines connected to a
dental device or dental unit that enters a patient’s
mouth at the start of the day, between patients,
and at the end of the day?
a. 2 minutes
b. 1 minute
c. 20–30 seconds
d. The CDC and OSAP do not recommend
flushing water lines.
4. What type of hand hygiene is recommended
when hands are not visibly soiled?
a. Antimicrobial hand soap and water
b. Alcohol-based antiseptic
c. Non-antimicrobial hand soap and water
d. None of the above
5. Which of the following is a quaternary ammonium
compound used in antimicrobial hand soap?
a. Cetylpyridinium chloride
b. Isopropanol
c. Ethanol
d. n-propanol
of viable microorganisms in their oral flora with a pre-
procedural rinse. The oral health-care provider should
use an HVE and extraoral scavenging device for opti-
mal removal of aerosols from the source. The proper
maintenance and monitoring of dental unit lines will
reduce the risk of biofilm contamination. Employing
engineering controls such as adequate ventilation and
air decontamination technologies will offer another
layer of protection as part of an overall multilayer in-
fection prevention program.
6. When the oral health-care provider is
performing an aerosol-generating procedure,
which of the following PPE is best practice?
a. Gown that extends to the waist
b. Eyewear with side shields and no face shield
c. Surgical mask
d. Particulate filtering facepiece respirator mask
7. Which agency regulates surgical mask quality in
the United States?
a. Organization for Safety, Asepsis, and
Prevention (OSAP)
b. Food and Drug Administration (FDA)
c. Center for Disease Control (CDC)
d. American Dental Association (ADA)
8. Which of the following masks requires a seal-
and-fit test and a medical clearance in the
United States prior to wearing?
a. Surgical mask
b. N95 mask
c. N100 mask
d. Both B and C
e. All of the above
9. Which of the following is an acceptable
adjustment when a surgical mask does not fit
snugly on a provider’s face?
a. Loop the ear loops
b. Tie a knot in the ear loops to tighten the fit of
the mask
c. Discard the mask and put on a different size
or shape mask
d. Perform the procedure with the ill-fitting mask
10. True or False. A pre-procedural rinse will
eliminate the risk for pathogenic aerosol disease
transmission.
a. True
b. False

11. An HVE will remove how many cubic feet of air
per minute?
a. 10
b. 50
c. 75
d. 100
12. Which of the following is incorrect about a
dental aerosol-generating procedure?
a. Introduces large volumes of potentially
pathogenic dental aerosols into the
environment.
b. The use of an LVE alone is sufficient to
control aerosols.
c. The use of an HVE will prevent over 90%
of contaminated aerosols from entering the
environment.
d. If a scavenging device is used, it should be
used in conjunction with an HVE.
13. True or False. In a dental office without natural
ventilation, the oral health-care provider should
References
1. American Society for Testing and Materials. (2019). Standard
specification for performance of material used in medial face masks
F2100-19e1. https://doi.org/10.1520/F2100-19E01
2. Avasth, A. (2018, May 16). High volume evacuation (HVE) in
reducing aerosol—an exploration worth by clinicians. Journal
of Dental Health Oral Disorders & Therapy¸ 9(3), 165–166.
3. Centers for Disease Control and Prevention. (2002).
Guideline for hand hygiene in health-care settings. MMWR,
51(RR-16), 1–44.
4. Centers for Disease Control and Prevention. (2003).
Guidelines for infection control in dental health-care
settings—2003. MMWR, 52(RR-17), 1–76.
5. Centers for Disease Control and Prevention. (2018a). Filtering
out confusion: Frequently asked questions about respiratory
protection: Fit testing. https://www.cdc.gov/niosh/docs/2018-129
/pdfs/2018-129.pdf?id=10.26616.NIOSHPUB 2018129
6. Centers for Disease Control and Prevention. (2018b).
Filtering out confusion: Frequently asked questions about
respiratory protection: User seal test. https://www.cdc.gov
/niosh/docs/2018–130/pdfs/2018–130.pdf?id=10.26616
/NIOSHPUB 2018130
7. Centers for Disease Control and Prevention. (2020). NIOSH
approved particulate filtering facepiece respirators. https://www
.cdc.gov/niosh/npptl/topics/respirators/disp_part/default
.html
8. Chin, J. R., Miller, C. H., & Palenik, C. J. (2006). Internal
contamination of air-driven low-speed handpieces and
attached prophy angles. Journal of American Dental Association,
137, 1275–1280.
9. Cumbo, E., Gallina, G., Messine, P., & Scardina, G. A. (2020).
Alternative methods of sterilization in dental practices
against COVID–19. International Journal of Environmental
Research and Public Health, 17(16), 5736. https://doi.org
/10.3390ijerph17165736
References 29
use a small cooling fan to help reduce dental
aerosol circulation.
a. True
b. False
14. Which of the following air decontamination
technologies is defined as the physical or
mechanical removal of particles and pollutants
from the air through diffusion, settling, and
impaction?
a. Filtration
b. Ultraviolet (UV) light
c. Ozone generator
d. Hydrogen peroxide system
15. Which of the following forms of air
decontamination creates air ionization and
causes reactions with charged particles?
a. HEPA filter
b. Ultraviolet (UV) light
c. Electrostatic precipitator
d. Hydrogen peroxide system
10. Daniels, S. L. (2007). On the qualities of the air as affected
by radiant energies photocatalytic ionization processes for
remediation of indoor environments. Journal of Environmental
Engineering and Science, 6, 329–342. https://doi.org/10.1139
/S06–072
11. Ehtezazi, T., Evans, D. G., Jenkinson, I. D., Evans, P. A.,
Vadgama, V. V., Vadgama, J., Jarad, F., Grey, N., & Chilcott,
R. P. (2021). SARS-CoV-2: Characterisation and mitigation of
risks associated with aerosol generating procedures in dental
practices. British Dental Journal, 1–7.
12. Harrel, S., & Molinari, J. (2004). Aerosols and splatter in
dentistry. The Journal of the American Dental Association, 135,
429–437.
13. Herd, A., Chin, J., Palenik, C. J., & Ofner, S. (2007). The
in vivo contamination of air-driven low-speed handpieces
with prophylaxis angles. The Journal of the American Dental
Association, 138, 1360–1365.
14. Holloman, J. L., Mauriello, S. M., Pimenta, L., & Arnold, R.
R. (2015). Comparison of suction device with saliva ejector
for aerosol and spatter reduction during ultrasonic scaling.
The Journal of the American Dental Association, 146(1), 27–33.
15. Koletsi, D., Belibasakis, G. N., & Eliades, T. (2020).
Intervention to reduce aerosolized microbes in dental
practice: A systematic review with network meta–analysis of
randomized controlled trials. Journal of Dental Research, 99(11),
1228–1238. https://doi.org/10.1177/0022034520943574
16. Kulkarni, P., Baron, P. A., & Willeke, K. (2011). Aerosol
measurement: Principles, techniques, and applications (3rd ed.).
Wiley.
17. Kumar, P. S., & Subramanian, K. (2020). Demystifying the
mist: Sources of microbial bioload in dental aerosols. Journal
of Periodontology, 91, 1113–1122.
18. Marui, V. C., Souto, M. L. S., Rovai, E. S., Romito, G. A.,
Chambrone, L., & Pannuti, C. M. (2019). Efficacy of
30 Chapter 2 Infection Prevention for Aerosol-Generating Procedures
preprocedural mouth rinses in the reduction of microorganisms
in aerosol: A systematic review. Journal of the American Dental
Association, 150(12), 1015–1026. https://doi.org/10.1016/j
.adaj.2019.06.024
19. Matys, J., & Grzech-Lesniak, K. (2020). Dental aerosol as a
hazard for dental workers. Materials, 13(5109), 1–13. https://
doi.org/10.3390/mal13225109
20. Nagraj, K. S., Eachempati, P., Paisi, M., Nasser, M.,
Sivaramakrishnan, G., & Verbeek, J. H. (2020). Interventions
to reduce contaminated aerosols produced during dental
procedures for preventing infectious diseases (review).
Cochrane Database of Systematic Review, 10, Art No: CD013686.
https://doi.org/10.1002/14651858.CD013686.pub.2
21. OSAP. (2018). Dental unit water quality: Organization
for safety, asepsis and prevention white paper and
recommendations—2018. Journal of Dental Infection Control
and Safety, 1(1), 1–27.
22. Pankhurst C. L., Coulter W., & Philpott-Howard J. N. (2005).
Evaluation of the potential risk of occupational asthma in
dentists exposed to contaminated dental unit waterlines.
Primary Dental Care, 12(2), 53–59.
23. Picheansathian, W. (2004). Effectiveness of alcohol-based
solutions for hand hygiene: A systematic review. International
Journal of Nursing Practice, 10, 3–9.
24. Shahdad, S., Patel, T., Hindocha, A., Cagney, N., Mueller, J. D.,
Seoudi, N., Morgan, C., & Din, A. (2020). The efficacy of
an extraoral scavenging device on reduction of splatter
contamination during dental aerosol generating procedures:
An exploratory study. British Dental Journal, 1–10.
25. Tepper, G., & Kessick, R. (2008). A study of ionization and
collection efficiencies in electrospray–based electrostatic
precipitators. Journal of Aerosol Science, 39, 609–617.
26. US Department of Labor, Occupational Safety and Health
Administration. (2011). OSHA personal protective equipment
e–CFR Part 1910.134.
27. US Department of Labor, Occupational Safety and Health
Administration. (2012). OSHA instruction: Enforcement
procedures for the occupational exposure to bloodborne pathogens
e-CFR Part 1910.1030.
28. US Environmental Protection Agency. (2019). Indoor air quality.
https://www.epa.gov/indoor-air-quality-iaq/what-hepa
-filter-1#:~:text=HEPA%20is%20a%20type%20of,of%20
Energy
29. US Environmental Protection Agency. (2021). Electronic code
of federal regulations e-CFR 40 1N441. https://www.ecfr.gov
/cgi-bin/text-idx?SID=8cd479a3a836f1837caa08f7630d869
8&mc=true&node=pt40.32.441&rgn=div5
30. US Food and Drug Administration. (2020). FAQs on
the EUAs for non-NIOSH approved respirators during
the COVID-19 pandemic. https://www.fda.gov/medical
-devices/coronavirus-disease-2019-covid-19-emergency
-use-authorizations-medical-devices/faqs-euas-non-niosh
-approved-respirators-during-covid-19-pandemic
31. US Food and Drug Administration. (2020a). Face masks
and surgical masks for COVID-19: Manufacturing, purchasing,
important, and donating masks during the public health
emergency. https://www.fda.gov/medical-devices/coronavirus
-covid-19-and-medical-devices/face-masks-and-surgical
-masks-covid-19-manufacturing-purchasing-importing-and
-donating-masks-during
32. US Food and Drug Administration. (2020b). Personal
protective equipment EUAs. https://www.fda.gov/medical
-devices/coronavirus-disease-2019-covid-19-emergency
-use-authorizations-medical-devices/personal-protective
-equipment-euas#appendixa?fbclid=IwAR3Att1FHBvm0yS
TeWU3EJXM7EL_g3u1zXxzuYAu362MOcApuzSTsL-4KPQ
33. World Health Organization. (2009). Natural ventilation for
infection control in health-care settings. WHO Publications/
Guidelines, 1–133.
34. World Health Organization. (2014). Infection prevention
and control of epidemic and pandemic prone acute respiratory
infections in health care. https://www.who.int/publications
/i/item/infection-prevention-and-control-of-epidemic-and
-pandemic-prone-acute-respiratory-infections-in-health-care
 CHAPTER 3
Ultrasonic Physics
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Relate the ultrasonic field of study and sound
principles to medical and dental device
functionality.
2. Define wave frequency and amplitude and correlate
these concepts to the field of ultrasonics.
3. Compare and contrast piezoelectric and
magnetostrictive materials.
4. Identify the components of a magnetostrictive
and piezoelectric ultrasonic device and describe
how each produces an ultrasonic sound wave of
a set frequency.
5. Describe the steps of energy generation and
transfer in a magnetostrictive and piezoelectric
ultrasonic device.
6. Define and identify the clinical significance of
an ultrasonic wave pattern antinode and node.
7. Recognize potentially adverse auditory effects
of ultrasonics in the workplace and take
appropriate steps to reduce the risk of noise-
induced hearing loss (NIHL).
KEY TERMS
• Ablation: complete removal of a substance or
material through a chipping action.
• Active area antinode: the terminal 1.0-3.5mm on
an ultrasonic shank that performs the clinical
actions such as the removal of oral deposits.
• Active medium: part of a dental ultrasonic that
determines the speed and length of the ultrasonic
sound wave produced; it is made of nickel or
•
man-made ceramic crystals.
Antinode: formed when maximum positive and
maximum negative displcement of two ultrasonic
waves interface.
• Back driver: also known as back mass. Part of a
piezoelectric ultrasonic device located behind the
piezoceramic discs that distributes compressive
stress across the discs.
• Back mass: see back driver.
•
Decibel (dB): Unit of measurement for reporting
the loudness of sound.
• Ferromagnetic laminate nickel plate: the active
medium of a magnetostrictive ultrasonic device
that determines the speed and length of the
ultrasonic sound wave.
• Front driver: also known as front mass. Part of a
piezoelectric ultrasonic device located between
the horn and piezoceramic discs that optimizes
the maximum output and delivers the energy
from the transducer to the horn.
• Front mass: see front driver.
• Hertz (Hz): SI metric used for measuring and
reporting sound frequency, where 1 Hz equals 1
vibration cycle per second.
• High-range ultrasound: ultrasound used for
imaging in health care with a frequency range
above 1 MHz.
• Horn: Part of a piezoelectric ultrasonic device
coupled to the front driver, travels the length of
the handpiece, and is threaded to a piezoelectric
tip. The horn focuses and transmits the ultrasonic
sound wave to the tip and allows for a change in
the wave amplitude.
• Infrasound: sound frequency below the audible
range of human hearing (<20 Hz).
• Low-range ultrasound: ultrasound used in health
care with a frequency range of 20–100 kHz.
• Magnetostriction: also known as magnetostrictive
effect. The change of shape of a ferromagnetic
material when it is placed under a magnetically
induced strain.
• Magnetostrictive effect: see magnetostriction.
• Mechanical energy: energy created by the transfer
of electrical energy across an active medium by
a transducer and that leads to the production of
ultrasonic sound waves and provides the clinical
action of an insert and tip.
31
32 Chapter 3 Ultrasonic Physics

• Node: located on the terminal 3.5-5.0 mm of an

ultrasonic shank formed when the crest of one
audible range of human hearing such as a dog whistle.
Infrasound is a term used to describe the frequency
wave meets the trough of a second that results in pitch below the audible range of human hearing such
destructive interferences and causes the shank to
as an earthquake. A dental ultrasonic device exposes
have no clinical action.
• Noise-induced hearing loss (NIHL): temporary
or permanent hearing loss caused by damage of
the oral health-care provider to decibels that may pose
a risk for noise-induced hearing loss (NIHL) in a sus-
ear structures from either persistent exposure to ceptible individual.
loud noises or a one-time exposure to an intense In the dental field, two ultrasonic devices are
sound such as an explosion.
•
available termed magnetostrictive and piezoelectric.
Oral deposit: biofilm, dental calculus, stain, Magnetostrictive and piezoelectric dental ultrasonic
and bacterial by-product that colonize the oral
devices are made of different materials and differ from
environment.
• Piezoceramic discs: the active medium made
of lead-zirconate-titanate in a piezoelectric
one another in how they produce their clinical effects.
This chapter will discuss the technology used to man-
ultrasonic device that determines the speed and ufacture each ultrasonic device. To safely use a dental
length of the ultrasonic sound wave. ultrasonic device in a patient’s mouth, one must un-
• Piezoelectric effect: the production of an
electrical potential across materials when
derstand the materials it is made of and respect the
physic principles behind its functionality. This knowl-
mechanical stress is applied.
• Ultrasonics: field of study that explores the
acoustic frequency range of machines that
edge will enhance your clinical skills as you begin to
incorporate ultrasonics into your patient care.
are above the audible range of human hearing

•
(>20 kHz).
Ultrasound: sound frequency above the audible Sound
range of human hearing (>20 kHz).
• Transducer: device that converts one form of
energy into another.
The field of study that investigates the acoustic fre-
quency of a device above the human range of hearing
• Wave amplitude: distance between equilibrium
and a wave’s maximum negative or positive
is termed ultrasonics. Health care has advanced due
to the development of ultrasonic t­echnology. An ul-
displacement. trasonic device whose frequency is above the audible
• Wave crest: positive peak or point of largest
maximum displacement of a wave.
range of human hearing allows medical and dental

•
professionals to image structures inside the human
Wave equilibrium: state of a wave at rest or body to aid in diagnosing, monitoring, and treating
balance between opposing forces.
• Wave frequency: number of wave cycles
completed at one point on the wave in a given
diseases and conditions. Ultrasound imaging is used
by many specialties such as cardiovascular, gynecol-
time period. Measured in cycles per second. ogy, urology, hematology, ophthalmology, and oral
• Wave trough: negative peak or the point of largest
negative displacement of a wave.
and maxillofacial surgery (O’Daly et al., 2008).

• Wavelength: length of one cycle of a wave.

Introduction
The field of study that investigates the acoustic fre-
quency of a device above the human range of hearing
is termed ultrasonics. Ultrasonic technology is used
in many fields such as health care, chemistry, phys-
ics, engineering, the food industry, oceanography,
and seismology (study of earthquakes). To under-
stand ultrasonic technology and its safe clinical use,
one must become familiar with the theories of sound
propagation, measurement, and wave frequency. The
wave frequency determines which sounds a human
can hear and which ones they cannot. Ultrasound is
a term used to describe a frequency pitch above the
Sound and Wave Theory
To understand the field of ultrasonics, one must un-
derstand the principles of sound propagation. Sound
is produced by vibrating objects through a material
that creates a mechanical wave. The following terms
are used in the study of wave and sound propagation
and theories (see Figure 3-1):
• Wave equilibrium: state of a wave at rest or bal-
ance between opposing forces.
• Wave amplitude: distance between equilibrium
and a wave’s maximum displacement both posi-
tively and negatively. Describes how high or low
the wave is displaced from its equilibrium.
• Wave crest: the positive peak or point of largest
positive maximum displacement.
• Wave trough: the negative peak or the point of
largest negative displacement.
 Sound 33

• Wave frequency: number of wave cycles com- • Wavelength: denoted as (λ). Length of one cycle
pleted by one point on a wave in a given period of a wave measured from any two points. Figure 3-1
of time. Wave frequency is measured in cycles per shows the wavelength as the distance from one
second. When pressure is applied to a wave, its wave crest to the other.
frequency will increase.
To better understand these wave definitions, let us
use an analogy. Imagine you are at the beach. You walk
out into the ocean and stand knee-high in the water. You
Wavelength (λ) stand in place for one minute counting the number of
waves that hit you. The total number of waves that strike
you during the one-minute period is the frequency of
Wave Amplitude the waves. If it is a calm, light breezy day at the beach,
crest
the waves will be small (low amplitude) and less numer-
Equilibrium
ous during the one minute so the frequency and ampli-
tude will be low. If it is a stormy day where the waves
are larger (high amplitude) and more numerous, the
frequency and amplitude will be higher (see Table 3–1).
Wave trough When studying dental ultrasonics, the terms wave
frequency and amplitude are used to describe the de-
Figure 3-1 Wave Terminology vice output and functionality.

Table 3-1 Wave Frequency and Amplitude

Wave Frequency Wave Amplitude
Calm and non-breezy day 12 waves hit you over Waves are small and
one minute. calm.
Wave frequency = 12 Hz Amplitude = Low

Stormy day 60 waves hit you over Waves are large and
one minute. powerful.
Wave frequency = 60 Hz Amplitude = High

© bierchen/Shutterstock
34 Chapter 3 Ultrasonic Physics

Sound Measurement oral deposits from teeth (Baehni et al., 1992;

The SI (metric system Système Internationale) used
for measuring and reporting sound frequency
is hertz (Hz); 1 Hz equals 1 cycle per second, 1
kilohertz equals 1,000 cycles per second, and 1 mega-
hertz equals 1 million cycles per second (see Box 3-1).
Dental ultrasonic devices are reported in kilohertz,
and ultrasound imaging is reported in megahertz.
Lea & Walmsley, 2000; Walmsley et al., 2008;
see Figure 3-3b). An oral deposit is a term
used throughout the textbook and refers to
biofilm, dental calculus, stain, and bacterial
by-­product that colonize the mouth.

Sound Pitch and Frequency

In the theory of sound, the frequency is called
the pitch. Higher frequency vibrations equate to a
higher pitch, and lower frequency vibrations produce
lower pitches. Humans are capable of hearing wave
frequency pitches 20 Hz to 20 kHz (see Figure 3-2).
Two terms are used when referencing sound wave
­frequency and pitch: ultrasound and infrasound.

Ultrasound. Ultrasound describes a frequency

pitch that is above the audible range of human hear-
ing (>20 kHz) (see Figure 3-2). Dogs are capable of
hearing ultrasound pitches, which is why the dog
whistle cannot be heard by humans (Cheeke, 2012).
Health-care ultrasound devices are either low or high
range and serve different purposes.
• Low-range ultrasound: A low-range health-care
A
ultrasound device will use a wave frequency of
20–100 kHz. They emit decibels audible to hu-
man hearing. A decibel (dB) is the unit used for
measuring the intensity and loudness of sounds.
Examples include:
• Ultrasonic cleaners with a wave frequency range
of 20-100 kHz are used to remove bioburden
from instruments prior to the sterilization pro-
cess (Cheeke, 2012; see Figure 3-3a).
• A dental ultrasonic device with a wave
­frequency range of 25–42 kHz is used to remove

Box 3-1 Hertz

Hertz (Hz) 1 Hz wave cycle per second B

Kilohertz (kHz) 1,000 Hz cycles per second Figure 3-3 Low range ultrasound: A. Ultrasonic cleaner,
Megahertz (MHz) 1,000,000 Hz cycles per second B. Magnetostrictive dental ultrasonic device Cavitron 300
Series Ultrasonic Scaling System
Reproduced with permission from Dentsply Sirona

Infrasound <20 Hz Ultrasound >20 kHz

20 Hz–20 kHz Low frequency: 20–100 kHz
High frequency: ≥1 MHz

Figure 3-2 Sound Frequency and Pitch


• High-range ultrasound: A high-range health-care
ultrasound device uses a wave frequency above
1 MHz. It is used to image structures inside the
human body and is above the audible range of
human hearing.
BREAKOUT POINT
A dental ultrasonic device used for the removal of
oral deposits has a frequency range of 25–42 kHz.
Infrasound. Infrasound describes a frequency pitch
that is below the audible range of human hearing
(< 20Hz; see Figure 3-2). Animals such as elephants
and whales can hear infrasound pitches (Cheeke,
2012).
Ultrasound
The theory of ultrasound was first postulated by
Lazzaro Spallanzani in 1794 while he studied bats
(Cheeke, 2012). His research led to the discovery of a
bat’s innate ability to use echolocation, which allows
bats to emit sounds above the audible range of human
hearing to locate food and navigate in the dark. Bats
emit ultrasound waves from their mouth and nose
that bounce off objects in the environment and pro-
duce echoes. The bats use the echoes to fly in the dark
and locate prey (see Figure 3-4).
Since the 1800s, humans have learned to harness
the power of ultrasound wave frequency and create
Figure 3-4 Bat and Echolocation
Dental Ultrasonic Device 35
ultrasonic technology with numerous applications.
Ultrasonic devices are currently used in multiple
disciplines such as health care, chemistry, physics,
engineering, the food industry, oceanography, and
seismology (Cheeke, 2012). Ultrasonic devices are
used in the emulsification of paint pigments, cosmetic
products, dyes, and shoe polish. They are used in en-
gineering for the welding of metals and plastics, sol-
dering, and drilling. The food industry uses them for
food preservation and cleaning.
Dental Ultrasonic Device
A dental ultrasonic device produces a longitudinal
ultrasonic wave through the interaction of an active
medium and a transducer.
Active Medium
The active medium is made of either of the following:
1. Man-made ceramic crystals.
2. Nickel.
The active medium determines the speed and
length of the ultrasonic sound wave produced, which
translates to its clinical applications.
BREAKOUT POINT
The active medium of a dental ultrasonic device is
either man-made ceramic crystals or nickel.
Transducer
The transducer houses the active medium and
­allows for the conversion of energy. Transducers can
be electric, thermal, or mechanical. Dental transduc-
ers are either piezoelectric or magnetostrictive and
convert electrical energy into mechanical energy
in the form of two ultrasonic sound waves (Bains,
2008). The electric energy used by the transducer is
conveniently derived from an electrical wall outlet
(see Figure 3-5).
BREAKOUT POINT
A dental ultrasonic device is made of a
magnetostrictive or piezoelectric transducer, which
converts electrical energy into mechanical energy.
36 Chapter 3 Ultrasonic Physics
Figure 3-5 Dental ultrasonic and electrical supply
(Dentsply Sirona Cavitron Select SPS Ultrasonic Scaling
System)
Mechanical Energy
Mechanical energy is created through the transfer of
electrical energy across the active medium in a dental
ultrasonic device that leads to the production of two
ultrasonic sound waves. The mechanical energy cre-
ated provides the clinical action of the device such as
the removal of oral deposits from tooth surfaces. Oral
deposits are mechanically chipped away and a ­ blated
(complete removal of a substance or material through
a chipping action) by the dental ultrasonic device
(see Figure 3-6).
BREAKOUT POINT
The mechanical energy created by the transducer
provides the clinical actions of a dental ultrasonic
device.
Ultrasonic Sound Waves
As the ultrasonic sound waves travel through a den-
tal ultrasonic device, the particles that make up the
wave are disrupted from their wave equilibrium and
oscillate forward in an up and down wavelike motion.
The frequency of the ultrasonic sound wave produced
can be mathematically calculated as speed divided by
wavelength.
• Frequency = Speed / Wavelength
Figure 3-6 Dental ultrasonic ablation. Note the dental
calculus deposit mechanically chipped from the facial
surface of the mandibular right central incisor.
The ultrasonic sound wave frequency is dic-
tated by the active medium and transducer and is
an unchangeable parameter on a dental piezoelec-
tric and magnetostrictive ultrasonic device. Dental
ultrasonic devices produce a wave frequency in the
low-­frequency ultrasound range of 25–42 kHz.
BREAKOUT POINT
The active medium and transducer determine the
frequency range (25-42kHz) of the ultrasonic sound
waves produced by a dental ultrasonic device.
Piezoelectric Ultrasonic
The piezoelectric effect was discovered in the late
1880s. It was found that when mechanical stress was ap-
plied to specific materials, an electrical potential across
the materials was produced that was proportional to the
applied stress. The word piezo comes from the Greek
work piezin, which means to “press” or “squeeze.”
Transducer and Active Medium
The active medium in a dental piezoelectric ultrasonic
is man-made ceramic crystals compressed into piezoc-
eramic discs. The transducer is a piezoelectric Lan-
gevin transducer, so named after the man who created
the technology (Cheeke, 2012; Abdullah et al., 2009;
Lu et al., 2017). The Langevin transducer is made of

Horn
Front driver
Electrodes PZT discs
Back driver
Figure 3-7 Piezoelectric Transducer and Active Medium
Figure 3-8 Piezoelectric handpiece (Acteon SLIM
handpiece)
Reproduced with permission from ACTEON.
four parts and houses the active medium: back mass/
driver, piezoceramic discs, front mass/driver, and the
horn as depicted in Figure 3-7. The transducer and
active medium are housed in a piece of equipment
known as a handpiece (see Figure 3-8). The ultrasonic
sound waves are created inside the handpiece and exit
at the horn.
Back Mass/Driver. The back driver distrib-
utes compressive stress across the active medium
­(piezoceramic discs) and is made of either aluminum
alloy, titanium, or tungsten (Barava & Hossam, 2020).
It is located behind the piezoceramic discs as seen in
­Figure 3-7.
Piezoceramic Discs. The active medium
man-made ceramic crystals are shaped into hard
­ iezoceramic discs . The piezoceramic discs are po-
p crystals (Baines et al., 2008; Abdullah et al., 2009).
sitioned between the front and back drivers and are of
two basic types made of lead-zirconate-titanate called
Dental Ultrasonic Device 37
PZT4 and PZT8 (Cheeke, 2012; Abdullah et al., 2009;
Vives, 2008). Electrodes are inserted between adjacent
piezoceramic discs (Bowen, 2008; see Figure 3-7).
• Electrodes are thin, flat, and made of either nickel
foil or nickel-beryllium alloy (Barava & Hossam,
2020; Bhuyan et al., 2008).
• Electrodes provide the electric pathway to the
piezoceramic discs and have high thermal con-
ductivity with an ability to carry heat away from
the discs, which are poor heat conductors. (Bar-
ava & Hossam, 2020).
• Electrode activity is the reason a piezoelectric
handpiece does not give off as much heat as a
magnetostrictive handpiece when in use.
BREAKOUT POINT
A piezoelectric dental ultrasonic handpiece does
not give off as much heat as a magnetostrictive
handpiece when in use.
Front Mass/Driver. The front driver diameter is
narrower than the piezoceramic discs to optimize the
maximum output and deliver the energy to the horn
(Vjuginova, 2019). The front driver is typically made
of titanium or an aluminum alloy (Barava & Hossam,
2020). It is located behind the horn and in front of the
piezoceramic dicsc ­(Barava & Hossam, 2020).
Horn. The shape of the horn varies by manufacturer.
It is typically made of a solid metal rod that possesses
high dynamic fatigue strength and low acoustic loss,
such as a titanium alloy (O’Daly et al., 2008; Vives,
2008). The horn is coupled to the front mass/driver
disk and travels the length of the handpiece (see
­Figure 3-7). A piezoelectric tip is threaded into the
horn by the user (see Figure 3-9). The horn focuses
and transmits the ultrasonic sound waves to the tip
and allows for a change in the wave (Vives, 2008).
Ultrasonic Sound Wave Production
To produce ultrasonic sound waves, an external elec-
tric field (voltage) is applied to the piezoceramic discs
and electrodes inside the handpiece, which results in
constant static compressive stress.
• This stress causes a molecular change in the
crystalline structure of the man-made ceramic
­
When the voltage is stopped, the material returns
to its original crystalline shape (see Figure 3-10).
38 Chapter 3 Ultrasonic Physics

Box 3-2 Dental Ultrasonic Device Energy

Conversion

Piezoelectric Electrical Energy → Mechanical

Energy
Magnetostrictive Electrical Energy → Magnetic
­Energy → Mechanical Energy

Box 3-3 Dental Ultrasonic Frequency

Ranges

Piezoelectric 28–42 kHz

Magnetostrictive 25–30 kHz

Figure 3-9 Piezoelectric tip and handpiece (EMS

Original Piezon LED Handpiece and PS tip).

BREAKOUT POINT
Voltage
A dental piezoelectric ultrasonic device produces an
ultrasonic wave frequency range of 28–42 kHz.

BREAKOUT POINT
The frequency of a dental piezoelectric ultrasonic
device is set by the manufacturer. To change the
frequency, the piezoceramic discs and horn length
are changed.
Figure 3-10 Molecular Crystaline Structure of
Piezoelectirc Ceramic Crystals

Hossam, 2020; Zhao et al., 2019). Each manufacturer

• Physically, the piezoceramic discs and electrodes determines the wave frequency of its own device.
displace with equal lateral expansion. This con-
verts electric energy into mechanical energy in the
form of ultrasonic sound waves. Magnetostrictive Ultrasonic
Magnetostriction, also known as the magneto-
Piezoelectric devices convert low voltage
strictive effect, was discovered in the mid-1800s.
(≤ 200V) electrical energy directly into mechanical
When a ferromagnetic material, is exposed to a mag-
energy in one step, unlike magnetostrictive transduc-
netic field, it changes shape. Ferromagnetic materials
ers, which add a middle (magnetic) energy conversion
possess great magnetization when exposed to an ex-
step ­(Bhuyan et al., 2008; see Box 3-2). A dental piezo-
ternal magnetic field (Encyclopedia Britannica, 2014;
electric ultrasonic device produces a wave frequency
Sakon et al., 2019).
range of 28–42 kHz as noted in Box 3-3 (Baehni
et al., 1993; Lea & Walmsley, 2000; Walmsley et al.,
2008). To increase the wave frequency from 28 kHz Transducer and Active Medium
to 42 kHz, the manufacturer shortens the piezoce- The active medium of a dental magnetostric-
ramic disc and horn length (Lu et al., 2017; Barava & tive ultrasonic device is ferromagnetic nickel. The
 Dental Ultrasonic Device 39

A B
Figure 3-11 Magnetostrictive insert and handpiece: A. Insert with ferromagnetic laminate nickel plates to the
right of the blue grip (Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert), B. Handpiece with copper wire coils
visible
Reproduced with permission from Dentsply Sirona.

Magnetic

Electric

Energy

Copper coils produce Nickel elongates and shrinks Mechanical

magnetic field violently like an accordion Energy

Figure 3-12 Magnetostrictive Ultrasound Sound Wave Production

Reproduced with permission from Dentsply Sirona; © Sergiy Kuzmin/Shutterstock

ferromagnetic material is located on a piece of equip-

ment known as an insert (see Figure 3-11a). The nickel
is compressed into thin ferromagnetic laminate
nickel plates with a specific number (varies by man-
ufacturer) tightly stacked upon one another. The in-
sert is then placed into a piece of equipment known
as a handpiece that contains copper wire coils (see
Figure 3-11b). The copper wire coils are not visible to
the provider because they are covered by the hand-
piece material. Figure 3-11b shows the inside of the
handpiece so you can view the copper wire coils.

BREAKOUT POINT
Figure 3-13 Molecular Lattice Structure of
The active medium of a magnetostrictive ultrasonic Ferromagnetic Nickel
is ferromagnetic nickel, which is housed on an
insert.
runs through the handpiece and excites the copper
wire coils. The copper wire coils produce a magnetic
field that is applied to the ferromagnetic nickel active
BREAKOUT POINT medium and causes it to deform and change shape as
The transducer of a magnetostrictive ultrasonic
it becomes highly magnetized (see Figure 3-12; Clausse
is housed in the handpiece and contains copper et al., 2017; Kim & Kwon, 2015).
wire coils.
• This magnetization causes a molecular change in
the lattice structure of the nickel (see Figure 3-13).
When the magnetization is stopped, the mate-
Ultrasonic Sound Wave Production rial returns to its original shape. The ferromag-
To produce an ultrasonic sound wave in a netic nickel rotates in the direction of the field of
­magnetostrictive ultrasonic device, electrical energy ­magnetization (Clausse et al., 2017).
40 Chapter 3 Ultrasonic Physics
• Physically, the bulk ferromagnetic laminate nickel
plates will deform, which causes them to elongate and
shrink violently like an accordion (see Figure 3-12;
Clausse et al., 2017).
• Molecular and physical changes of the ferromag-
netic nickel from the magnetic field created by the
copper wire coils causes the production of ultrasonic
sound waves when the magnetic energy is trans-
formed into mechanical energy (see Figure 3-12;
Kim & Kwon, 2015).
Unlike a piezoelectric transducer, which will co-
vert electrical energy directly into mechanical energy, a
magnetostrictive transducer adds an additional step in
the ­middle by converting electrical energy into mag-
netic energy and then into mechanical energy (Clausse
et al., 2017; see Box 3-2). This action generates energy
that is lost in the form of heat, which can be felt in the
handpiece if sufficient cooling water is not used.
The highest achievable frequency for a magneto-
strictive ultrasonic dental device is 30 kHz because,
to increase the frequency, the ferromagnetic laminate
nickel plates are shortened (Kim & Kwon, 2015; see
Figure 3-14). If the mass becomes too small, the nickel
plates will not be able to achieve the elongation and
shrinking action needed to create productive ultra-
sonic sound waves. For this reason, a magnetostrictive
ultrasonic device has a lower frequency range than a
piezoelectric device of 25–30 kHz (see Box 3-3). Due
to the length difference between a 25 kHz and 30 kHz
insert, a 25 kHz insert cannot be used in a 30 kHz
device, and vice versa (see Figure 3-14).
BREAKOUT POINT
A dental magnetostrictive ultrasonic device produces
an ultrasonic wave frequency of 25–30 kHz.
Ultrasonic Wave Antinodes
and Nodes
When electrical energy encounters the transducer
and active medium in a dental ultrasonic device, it
Figure 3-14 Magnetostrictive inserts (Cavitron Slimline
10S 25K Ultrasonic Insert and Cavitron Slimline 10S
Fitgrip 30K Ultrasonic Insert,). Note the shorter length
of the ferromagnetic laminate plates on the 30K insert.
is eventually transformed into mechanical energy in
the form of two ultrasonic sound waves that are in
constant motion with one another. When the waves
cross paths with one another, two phenomena occur
called an antinode and a node, respectively, that have
a significant impact on the proper and safe clinical use
of dental ultrasonics.
Antinode
Each of the two ultrasonic waves have crests and troughs.
An a­ ntinode is formed when the maximum positive
and maximum negative displacement of the two waves
interface (see Figure 3-15 red and blue lines). When the
ultrasonic is in use, the two ultrasonic waves are in con-
stant motion, swinging up and down between maxi-
mum positive (crest) and maximum negative (trough)
displacements. Antinodes are created two ways:
1. When the crest of one wave meets the crest of a
second, large positive displacement occurs.
2. When the trough of one wave meets the trough
of a second, large negative displacement occurs.
An antinode produces the clinical actions ­(removal
of oral deposits) of a dental ultrasonic insert and tip
shank.
Node
A node is formed when the crest of one wave meets
the trough of a second (see Figure 3-15 orange
circles). They are the regions of wave patterns where
destructive interference occurs and the amplitude is at
equilibrium (rest). A node, or nodal point as they are
commonly referred to, are areas on an insert and tip
shank with no clinical activity. If adapted to a tooth
surface, oral deposits will not be removed.
BREAKOUT POINT
The nodal point has no clinical action and when
adapted to tooth surfaces, will not remove oral
deposits.
Figure 3-15 Ultrasonic sound waves. Antinodes
present at the crest and troughs of the waves. Node
present at equilibrium (orange circles on diagram).

Box 3-4 Antinode and Node Shank Location
Antinode Terminal Active area
1.0–3.5 mm antinode
Node 3.5–5.0 mm Site of no activity
Antinode 5.0–8.5 mm Length varies by
manufacturer
shank length
Location of Antinodes and Nodes
An ultrasonic insert and tip shank has two antinodes
and one node (see Box 3-4 for the exact position).
The active area antinode performs the clinical
action and is the area adapted to tooth surfaces for
the removal of oral deposits. If this region becomes
damaged, the insert and tip will no longer remove oral
deposits and the equipment must be discarded.
BREAKOUT POINT
When the active area antinode is adapted to tooth
surfaces, oral deposits will be removed.
Auditory Effects
The audible range for human sound is 20 Hz to
20 kHz. This means humans will hear the first
sub-harmonic of a dental ultrasound device up to 20
kHz. The frequency of an ultrasonic device ranges
from 25 kHz to 42 kHz, with decibels of 60–99 dB
(Sliwinska-Kowalska & Zaborowski, 2017; American
Dental Association, 2020).
• Long-term exposure to noise levels above 80 dB
increases the risk for hearing loss.
• In the United States, OSHA has set the occupational
threshold decibel level to 90 dB, and in Europe it is
80–87 dB for an 8-hour day (Sliwinska-Kowalska
& Zaborowski, 2017; Tikka et al., 2017;
­Smagowska & Pawlaczk-Tuszczynska, 2013).
• Exposure to 100 dB over a period of 10 years
raises the probability of hearing ­ impairment
Dental Ultrasonic Device 41
Box 3-5 NIHL Symptoms
Tinnitus (noise or ringing in the ears)
Balance disturbances
Dizziness
Fatigue
Nausea
Headache
Data from Smagowska, B., & Pawlaczyk-Luszczynska, M. (2013). Effects of ultrasonic
noise on the human body—a bibliographic review. International Journal of Occupational
Safety and Ergonomics, 19(2), 195–202
by 94.5–99.5% (Smagowska & ­ Pawlaczk-
Tuszczynska, 2013).
• Globally 16% of adult hearing loss has been
­attributed to occupational noise (Tikka et al., 2017).
• Approximately 9 million workers in the United
States have been exposed to sound levels above
85 dB (Tikka et al., 2017).
Noise-Induced Hearing Loss
Persistent occupational exposure to high decibels can
result in a hearing impairment called noise-induced
hearing loss (NIHL).
• NIHL occurs when the sensory hair cells ­(cochlea)
located in the outer and inner ear become damaged
by persistent or impulse (a single large sound such as
a bomb explosion) noise exposure (Lie et al., 2016).
• NIHL can be temporary or permanent and lead to
sensorineural hearing loss, which involves damage
to the auditory neuronal pathways and ­cochlear
cells (Sliwinska-Kowalska & Zaborowski, 2017;
Lie et al., 2016).
• Professions with the highest prevalence of NIHL
are miners, construction workers, and those
working in the manufacturing industry followed
by health-care professions (Tikka et al., 2017).
Other professions at risk for NIHL are pilots,
firefighters, musicians, and agriculture industry
workers (Lie et al., 2016).
• NIHL is the second most common self-reported
occupational illness or injury and can be min-
imized if noise levels are reduced below 80 dB
(Smagowska & Pawlaczk-Tuszczynska, 2013).
The most common symptoms of NIHL are listed
in Box 3-5. The major risk factors associated with the
development of NIHL according to the WHO are
(Sliwinska-­Kowalska & Zaborowski, 2017):
1. Intensity of noise measured in sound pressure
levels.
2. Length of exposure in years.
42 Chapter 3 Ultrasonic Physics

3. Impulsiveness of noise.
4. Individual susceptibility for developing NIHL.
Just because someone has occupational exposure
to noises above 80 dB does not mean they will
develop NIHL. There are many contributing fac-
tors such as genetics, age, or hearing damage and
impairment prior to occupational exposure. Hair
cells of the ears can also be damaged by medi-
cations, infections, or trauma (American Dental
Association, 2020).

Auditory Risks
Most hearing loss associated with occupational NIHL
Figure 3-16 Foam earplugs
occurs within the first 10 years of exposure (Lie et al.,
© DonGar/iStock/Getty Images Plus/Getty Images.
2016). Therefore, those susceptible to NIHL, who are
exposed to high decibel equipment, need to take pre-
ventive action early in their career. Helpful tips for
• Evaluate high-decibel equipment placement in
the dental operatory to maximize distance from
the oral health-care provider exposed to high decibel the generated noise.
equipment:
• Wear hearing protection (see Figure 3-16). A Co-
• Obtain a hearing test before entering the profes- chrane Review published by Tikka et al. (2017)
sion to determine baseline. found hearing protection devices can reduce noise
• Test hearing periodically after exposure to exposure by 20 dB but concluded that there is not
high-decibel equipment. enough evidence to support their use in providing
• Investigate noise levels produced by equipment. long-term hearing protection.

CASE STUDY
A novice student is using a dental ultrasonic device for the first time in a patient’s mouth. They are attempting to remove
the oral deposits pictured in Figure 3-17.
The dental calculus deposits are not coming off no matter how long the student spends on their removal. A professor
came by and told the student their adaptation of the shank to the tooth surface is incorrect. What is the student doing
wrong?

Figure 3-17 Mandibular right anterior lingual surfaces.

 Questions 43

Summary
This chapter presented the theories of sound and
wave propagation and movement as it relates to the
field of ultrasonics. Ultrasonics are used in many in-
dustries and serve multiple purposes. The dental field
uses magnetostrictive and piezoelectric ultrasonic
devices with distinct mechanisms of action. The ac-
tive medium and transducers are different in each de-
vice, which produces a wide range of ultrasonic wave
­frequencies of 25–42 kHz. The transducer in a mag-
netostrictive ultrasonic transfers electrical energy into
magnetic energy and then into mechanical energy.
The transducer in a piezoelectric ultrasonic trans-
fers electrical energy directly into mechanical energy.
Regardless of these differences, both dental ultrasonic
devices are used for the same clinical action of remov-
ing oral deposits from tooth surfaces.
The interaction of the two ultrasonic sound waves
produced by a dental ultrasonic device creates two
wave phenomena termed antinode and node. The ter-
minal 1.0–3.5 mm of the shank is the active area an-
tinode and is used for the removal of oral deposits.
Oral health-care providers who use a dental ultrasonic
device are exposed to decibels that may increase their
risk of NIHL. Any person susceptible to NIHL should
have their hearing tested regularly and take steps to
mitigate their risk.

Questions
1. Which field of study investigates the acoustic 8. Wavelength F. The positive peak or point
characteristics and frequency of a device above of largest maximum dis-
the audible range of human hearing? placement of a wave.
a. Ultrasonics
9. A dental ultrasonic device used for the removal
b. Infrasound
of oral deposits has what type of sound range?
c. Ultrasound
a. Low-range ultrasound
d. Frequency pitch
b. High-range ultrasound
2. What is the SI metric for measuring and c. Infrasound
reporting sound frequency? d. All of the above
a. Decibel
10. Which of the following dictates the frequency of
b. Gram
the ultrasonic sound wave produced in a dental
c. Hertz
ultrasonic device?
d. None of these
a. Active medium
Match the following terms related to wave theory with b. Transducer
their definition for questions 3–8. There is only one c. Handpiece
correct answer for each question. d. Both A and B
3. Wave A. Negative peak or the point Match the following to a piezoelectric or magnetostric-
amplitude of largest negative displace- tive ultrasonic device for questions 11–20. ­Answer A
ment of a wave. for magnetostrictive and B for piezoelectric. There is
4. Wave crest B. Number of wave cycles only one correct answer for each question.
completed at one point on 11. Horn
the wave in a given time
12. Handpiece that contains copper wire coils
period.
13. Insert
5. Wave C. Length of one cycle of a
frequency wave. 14. Tip
6. Wave D. Distance between equilib- 15. Ferromagnetic laminate nickel plate
equilibrium rium and a wave’s maxi-
16. Piezoceramic discs
mum negative or positive
displacement. 17. Electrical energy transferred to magnetic energy
and then to mechanical energy
7. Wave trough E. State of a wave at rest or
balance between opposing 18. Electrical energy transferred directly to
forces. mechanical energy
44 Chapter 3 Ultrasonic Physics

25. What structure inside the piezoelectric

19. Frequency range 28–42 kHz
handpiece is the tip threaded into?
20. Frequency range 25–30 kHz a. Front driver
b. Back driver
21. Which of the following focuses and transmits
c. Piezoceramic disc
the ultrasonic sound waves produced in a
d. Horn
piezoelectric ultrasonic device to the tip and
allows for a change in the wave amplitude? 26. True or False. A magnetostrictive transducer
a. Copper wire coils converts electrical energy into mechanical energy
b. Horn and then into magnetic energy.
c. Piezoceramic discs a. True
d. Ferromagnetic laminate nickel plates b. False
22. Which of the following will change the 27. True or False. A node is formed when the
ultrasonic wave frequency in a piezoelectric maximum positive and maximum negative
device? displacement of two ultrasonic sound waves
a. Shorten the piezoceramic disc and horn interface.
length. a. True
b. Shorten the ferromagnetic laminate nickel b. False
plate length. 28. True or False. The node is a site of no clinical
c. Remove the horn. activity where destructive interference occurs
d. The ultrasonic wave frequency cannot be between sound waves and the amplitude is at
changed in a piezoelectric device. equilibrium.
23. Which of the following will increase the a. True
ultrasonic wave frequency in a magnetostrictive b. False
ultrasonic? 29. Where is the node located on an insert or tip
a. Lengthen the ferromagnetic laminate nickel shank?
plate. a. Terminal 1.0–3.5 mm
b. Shorten the ferromagnetic ferromagnetic b. 3.5–5.0 mm
laminate nickel plate. c. 3.5–6.5 mm
c. Shorten the horn length. d. 5.0–8.0 mm
d. The ultrasonic wave frequency cannot be
changed in a magnetostrictive device. 30. Which of the following can decrease a DHCP’s
risk for NIHL?
24. True or False. A piezoelectric transducer a. Obtain a hearing test before entering the
converts low-voltage electrical energy directly profession to determine baseline.
into mechanical energy in one step. b. Test hearing periodically after exposure to
a. True high-decibel equipment.
b. False c. Wear a hearing protection device.
d. All of the above

References
1. Abdullah, A., Shahini, M., & Pak, A. (2009). An approach
to design a high power piezoelectric ultrasonic transducer.
Journal of Electroceramics, 22, 369–382. https://doi
.org/10.1007/s10832-007-9408-8
2. American Dental Association. (2020). Safety tips to prevent
hearing loss. https://success.ada.org/en/wellness/safety-tips-to
-avoid-hearing-loss#:~:text=Dentists%20are%20exposed
%20to%20the,levels%20of%2060% 2D99%20decibels
3. Baehni, P., Thilo, B., Chapuis, B., & Pernet, D. (1992). Effects
of ultrasonic and sonic scalers on dental plaque microflora
in vitro and in vivo. Journal of Clinical Periodontology, 19,
455–459.
4. Bains, V., Mohan, R., & Bains, R. (2008). Application of
ultrasound in periodontics: Part 1. Journal of Indian Society
of Periodontology, 12(2), 29–33. https://doi.org/10.4103
/0972-124X.44087
5. Baraya, M. Y., & Hossam, M. (2020). Design of an
electromagnetic system for measuring and monitoring micro-
ultrasonic amplitude of Langevin transducer. The International
Journal of Advanced Technology, 107, 2953–2965. http://doi
.org/10.1007/s00170-020-04922-w
6. Bhuyan, S., Hu, J., & Sun, C. Q. (2008). Wireless energy
transmission to piezoelectric components. Journal of Applied
Physics, 47(5), 4226–4230.

7. Bowen, C. R., Bradley, L. R., Almond, D. P., & Wilcox, P. D.
(2008). Flexible piezoelectric transducer for ultrasonic
inspection of non-planar components. Ultrasonics, 48, 367–375.
8. Cheeke, J. D. N. (2012). Fundamentals of applications of
ultrasonic waves (2nd ed.). Taylor & Francis.
9. Clausse, B., Lhemery, A., & Walasek, H. (2017). A model
to predict the ultrasonic field radiated by magnetostrictive
effects induced by EMAT in ferromagnetic parts. Journal of
Physics: Conference Series, 797(012004), 1–14. https://doi
.org/10.1088/1742-6596/797/1/012004
10. Encyclopedia Britannica. (2014). Ferromagnetism. https://
www.britannica.com/science/ferromagnetism
11. Kim, Y. Y., & Kwon, Y. E. (2015). Review of magnetostrictive
patch transducers and applications in ultrasonic nondestructive
testing of waveguides. Ultrasonics, 62, 3–19.
12. Lea, S. C., & Walmsley, A. D. (2000). Mechano-physical
and biophysical properties of power-driven scalers: Driving
the future of powered instrument design and evaluation.
Periodontology, 21(2009), 63–78.
13. Lie, A., Skogstad, M., Johannessen, H., A., Tynes, T., Mehlum,
I. S., Nordby, K. C., Engdahl, B., & Tambs, K. (2016).
Occupational noise exposure and hearing: A systematic
review. International Archives of Occupational and Environmental
Health, 89, 351–372. https://doi.org/10.1007/s00420-015
-1083-5
14. Lu, X., Hu, J., Peng, H., & Wang, Y. (2017). A new topological
structure for the Langevin-type ultrasonic transducer.
Ultrasonics, 75, 1–8.
15. O’Daly, B., Gavin, G., O’Bryne, J., & McGuinness, G. (2008).
High-power low-frequency ultrasound: A review of tissue
dissection and ablation in medicine and surgery. Journal of
Materials Technology, 200(1–3), 38–58.
16. Pecheva, E., Sammons, R. L., & Walmsley, A. D. (2016).
The performance characteristics of a piezoelectric ultrasonic
dental scaler. Medical Engineering and Physics, 38, 199–203.
References 45
17. Sakon, T., Yamasaki, Y., Kodama, H., Kanomata, T., Nojiri,
H., & Adachi, Y. (2019). The characteristic properties of
magnetostriction and magneto-volume effects of Ni2MnGa-
type ferromagnetic Heusler alloys. Materials, 12(3655), 1–13.
https://doi.org/10.3390/ma12223655
18. Sliwinska-Kowalska, M., & Zaborowski, K. (2017). World
Health Organization environmental noise guidelines for the
European region: A systematic review on environmental
noise and permanent hearing loss and tinnitus. International
Journal Environmental Research Public Health, 14, 1139.
https://doi.org/10.3390/ijerph14101139
19. Smagowska, B., & Pawlaczk-Tuszczynska, M. (2013). Effects
of ultrasonic noise on the human body—a bibliographic
review. International Journal of Occupational Safety and
Ergonomics, 19(2), 195–202.
20. Tikka, C., Verbeek, J. H., Kateman, E., Morata, T. C.,
Dreschler, W. A., & Ferrite S. (2017). Intervention to prevent
occupational noise-induced hearing loss. Cochrane Database
of Systematic Reviews, 7, Art. No. CD006396.
21. Vives, A. A. (2008). Advances in piezoelectric transducers
(2nd ed.). Springer Science & Business Media.
22. Vjuginova, A. A. (2019). Multifrequency Langevin-type
ultrasonic transducer. Russian Journal of Nondestructive
Testing, 55(4), 249–254.
23. Walmsley, A. D., Lea, S. C., Landini, G., & Moses, A. J. (2008).
Advances in power driven pocket/root instrumentation.
Journal of Clinical Periodontology, 35(8), 22–28. https://doi
.org/10.1111/j.1600-015X.2008.01258.x
24. Zhao, B., Chang, B., Wang, X., & Bie, W. (2019). System
design and experimental research on ultrasonic assisted
elliptical vibration grinding of Nano-ZrO2 ceramics. Ceramic
International, 45(18), 24865–24877.
 CHAPTER 4

Ultrasonic Device
and Attachments
preservation, specifications, and troubleshooting
LEARNING OBJECTIVES of the equipment.
After studying this chapter, you will be able to: • Foot pedal: device that activates a
magnetostrictive or piezoelectric ultrasonic
1. Identify the information included in a direction/ device.
instruction for use (DFU/IFU) and recognize its
importance.
• Handpiece: hard, durable, sterilizable piece of
equipment that securely attaches to a connector
2. Operate a stand-alone or integrated dental cable and accepts an insert or tip.
ultrasonic device and recognize foot pedal
functionality.
• Instruction for use (IFU): see direction for use
(DFU).
3. Safely deliver aqueous solutions during
ultrasonic instrumentation and properly
• Integrated ultrasonic device: ultrasonic device
that is wired inside a dental unit with controls on
maintenance water lines of a dental ultrasonic the unit itself.
device.
4. Understand the importance of maintaining
• Psi: acronym for pound force per square inch and
represents a unit of pressure from a force applied
quality water lines through purging, water filter to an area.
replacement, and monitoring.
5. Set the water flow rate of a dental ultrasonic
• Purge: a procedure that removes stagnant liquid
from a water line.
device and identify factors that adversely affect
water flow rates.
• Reprocessing: the act of cleaning, disinfecting,
and sterilizing reusable equipment in a detailed
6. Reprocess an ultrasonic handpiece in repeatable process.
accordance with CDC recommendations and
FDA regulations.
• Stand-alone ultrasonic device: ultrasonic device
that is not part of the dental unit itself but placed
on a flat surface inside the dental operatory within
easy reach of the user.
KEY TERMS
• Water-line attachment cord: cord provided by the
• Air-line attachment cord: cord provided by the
manufacturer for an ultrasonic device that
manufacturer for an ultrasonic device that does
not have its own independent water reservoir
bottle and connects to the dental unit water input.
has dual capability as an ultrasonic and an air
polishing system that attaches to the air input on • Water-line filter: filter installed on the water line
of an ultrasonic device that captures particles and
the dental unit.
• Direction for use (DFU): Also known as instruction
for use (IFU). Readable detailed information
biofilm.

packet provided by the manufacturer of a dental

ultrasonic device, part, or accessory that provides
pertinent content related to the use, maintenance,

47
48 Chapter 4 Ultrasonic Device and Attachments
Introduction
Dental ultrasonic technology has dramatically changed
since its inception almost 70 years ago. Manufacturers
provide a vast selection of equipment and accessories.
This chapter will provide a basic understanding of
magnetostrictive and piezoelectric ultrasonic device
functionality and attachments. In the United States,
a dental ultrasonic device is classified as a “medical
device” and is regulated by the US Food and Drug
Administration (FDA, 2020). The FDA requires a di-
rection for use (DFU), or sometimes referred to as in-
struction for use (IFU), to accompany the sale of a
dental ultrasonic device or any of its parts and acces-
sories. The DFU/IFU provides valuable information
that should be reviewed prior to implementing the
equipment into clinical practice.
A dental ultrasonic is either used as a stand-alone
device or integrated into the dental unit. This chap-
ter will provide an overview of the parts and acces-
sories that accompany the ultrasonic device and the
reprocessing and disinfecting recommendations by
the CDC. Inserts and tips are sold separately by man-
ufacturers and will be discussed in the next chapter.
A dental ultrasonic device must be handled with care
and all DFU/IFU instructions followed to avoid dam-
age, prevent patient injury, and prolong the life of the
equipment.
BREAKOUT POINT
Magnetostrictive and piezoelectric dental
ultrasonics are considered medical devices in the
United States and regulated by the FDA.
Direction for Use (DFU)
Manufacturers who sell dental ultrasonics, parts, and
accessories will provide a readable detailed informa-
tion packet (printed or electronic) for the equipment
called a direction for use (DFU). A DFU is sometimes
referred to as an instruction for use (IFU). The DFU/
IFU provides important information on equipment
specifications such as use, installation, maintenance,
and troubleshooting. Frequently asked questions can
be answered by referencing the product’s DFU/IFU.
• The DFU/IFU is updated regularly by manufac-
turers as industry standards and recommenda-
tions change. Many manufacturers offer their
most current DFU/IFU free of charge online.
• DHCPs should reference their product’s most cur-
rent DFU/IFU offered by the manufacturer on a
regular basis to ensure they are practicing with
the most current recommendations. This is es-
pecially important when using dental equipment
that connects to air and water lines as industry
standards, recommendations, and regulations for
maintenance and monitoring change over time.
Examples of information you will find in a DFU/
IFU for a dental ultrasonic are listed in Table 4-1.
Dental Ultrasonic Device
The two ultrasonic devices used in dentistry are
magnetostrictive and piezoelectric. The oral health-
care provider should familiarize themselves with the
most current DFU/IFU information prior to using the
equipment to prevent damage and patient injury.
Think of an ultrasonic device as a vehicle. Vehi-
cles need regular maintenance such as oil changes,
and replacement of wear-and-tear items such as tires
and brakes. The better care you take of your vehicle,
the better it will run and the longer it will last in good
condition. Mishandle your vehicle, never change the
oil, or put the wrong gas in the tank, the more prob-
lems the vehicle will have. Ultrasonic devices are no
different. With good handling, regular maintenance,
and care, the equipment will last longer. Just as a vehi-
cle only runs well for a set number of miles, an ultra-
sonic device only lasts for a specified number of uses
and then must be replaced. Refer to the manufactur-
er’s DFI/IFU for this information.
A dental ultrasonic is either used as a stand-alone
device or is integrated into the dental unit.
Integrated Ultrasonic Device
An integrated ultrasonic device is wired inside
a dental unit with controls on the unit itself (see
Figure 4-1). The manufacturer provides detailed in-
stallation guidelines. A skilled technician should be
charged with installing the device as a strong working
knowledge of the dental unit is needed to avoid dam-
age. The device is connected to an electrical power
outlet and to air and water lines inside the unit.
Stand-Alone Ultrasonic Device
A stand-alone ultrasonic device is not part of the
dental unit itself. The device is placed on a flat surface
inside the dental operatory within easy reach of the oral
health-care provider. The device power cord is con-
nected to an external electrical outlet. The air line is
 Foot Pedal 49

Table 4-1 Direction/Instructions for Use

Product overview and List of all equipment in the purchase delivery including accessories, parts, and
equipment list replacement intervals.
Packaging and storage: This is especially important for parts and accessories that
are reprocessed between patient use. Instructions for safe storage are provided to avoid
equipment damage.
Operational specifics for Examples include electric, air, water, weight, dimensions, operating frequency, and power
equipment supply for the equipment.
Installation Instructions for attaching the device to the dental unit water, air, and power lines.
Infection control and Handling, warnings, limitations of processing, and point-of-use recommendations.
reprocessing Chemical safety and recommendations for manual and automatic disinfecting and
cleaning and sterilization requirements.
Maintenance, Various accessories and parts in need of daily, weekly, or yearly maintenance, inspection,
inspection, and testing and testing.
recommendations
Indications for use Patient treatment indications.
Warnings Contraindications, considerations, precautions, and adverse reactions.
Operating instructions Power, water, and air settings. Controls and assembly for clinical use.
Disposal Equipment disposal requirements: sharps, community trash, or sent to an agency
licensed for specialized medical disposal.
Warranty Information Length of warranty, what voids a warranty, and what is not covered by the warranty.
Manufacturer contact Phone numbers and addresses of the manufacturer and technical support.

attached to the dental unit itself. The water line is ei-

ther attached to the dental unit, (see Figure 4-2a), or the
device may use its own independent water bottle res-
ervoir (see Figure 4-2b). The power cord, air line, and
water line are visible and should be positioned to avoid
damage from someone stepping on them, rolling a chair
over them, or tripping on them (see Figure 4-2).

Foot Pedal
The activation of the ultrasonic device is controlled
through a foot pedal. The operator depresses the
foot pedal to activate the device.

Integrated Ultrasonic Device

Figure 4-1 Integrated ultrasonic device (Acteon Newtron
SLIM handpiece with tip and wrench)
The foot pedal is the rheostat for an integrated ultra-
sonic device. The rheostat is tethered to the dental
unit via a cord (see Figure 4-3a). The foot pedal pro-
vided by the manufacturer is not used.
During active ultrasonic use, there is a constant
flow of aqueous solution that is expelled from the
insert and tip water port on the shank (discussed in
Chapter 5). When the provider releases their foot
from the rheostat, the action of the insert or tip ceases
50 Chapter 4 Ultrasonic Device and Attachments

BREAKOUT POINT
The rheostat serves as the foot pedal for an
integrated ultrasonic device.

immediately, but the water flow does not stop instan-

taneously. There is a few seconds of delay in the wa-
ter flow stopping. To avoid splashing the patient with
water, the provider should release their foot from the
rheostat, pause for 3–5 seconds, and then withdrawal
the insert or tip from the patient’s mouth.

Stand-Alone Ultrasonic Device

The foot pedal provided by the manufacturer is used
for a stand-alone device. The pedal can be tethered
to the ultrasonic device via a pedal cord or it can
be cord-free with the use of Bluetooth synchroniza-
tion depending on the manufacturer and model (see
Figure 4-3b and c). Cordless pedals offer the advan-
tage of easy maneuverability as the provider moves
their chair throughout a procedure.

A
BREAKOUT POINT
The foot pedal provided by the manufacturer is used
for a stand-alone ultrasonic device.

Foot Pedal Design

and Functionality
The foot pedal provided by the manufacturer comes
with a variety of designs and functionalities. There are
three enhancements of foot pedal designs offered by
some manufacturers.
1. Shape of foot pedal: A foot pedal is either round
or square (see Figure 4-3b and c). A round pedal
offers an ergonomic a­ dvantage over square. The
user can activate the device by depressing any
section of a round pedal, whereas a square pedal
B
must be depressed exactly in the middle for
Figure 4-2 Stand-alone ultrasonic device: A. Water activation.
line that will connect the ultrasonic device to the dental 2. Foot-free activation: Foot-free activation allows
unit water input, note the power cord and water inputs
the device to stay active during ultrasonic instru-
on the back of the device (Dentsply Sirona Cavitron 300
Ultrasonic Scaling System), B. Independent water bottle
mentation without continued depression of the
reservoir that will not connect to the dental unit water pedal. This allows the user to keep both feet flat
input (EMS AIRFLOW Prophylaxis Master) on the ground during ultrasonic instrumentation,
A: Reproduced with permission from Dentsply Sirona; B: Reproduced with permission from E.M.S. Electro Medical Systems S.A. which improves ergonomics.

A
B Figure 4-4a. One side of the cord is attached di-
C heat is generated during ultrasonic wave production.
Figure 4-3 Foot pedals: A. Integrated ultrasonic
rheostat foot pedal, B. Stand-alone ultrasonic device
corded foot pedal (Dentsply Sirona Cavitron Select SPS
Ultrasonic Scaling System), C. Stand-alone ultrasonic
devise cordless foot pedal (Dentsply Sirona Tap-on
technology wireless foot pedal)
C: Reproduced with permission from Dentsply Sirona.
Water and Air Lines 51
3. Power control: Some manufacturers offer the abil-
ity to increase the power output setting through
the foot pedal. This feature allows for uninter-
rupted ultrasonic instrumentation, which in-
creases the provider’s efficiency during active
treatment. The percentage of power increase
varies by manufacturer, make, and model, and is
provided in the DFU/IFU.
These enhancements are not available for an inte-
grated device because the rheostat is used as the foot
pedal.
Water and Air Lines
A dental ultrasonic uses a continuous flow of aque-
ous solution (most commonly used is water) during
instrumentation. An air input is required if the ultra-
sonic has a dual functionality as an air polisher. Water
and air lines must be properly maintained for safety.
Water Line
A dental ultrasonic device derives its liquid source in
one of two ways:
1. Connecting directly to the water input on a den-
tal unit. Manufacturers provide a water-line
attachment cord of their own color choosing
to connect to the dental unit. Some color this
cord blue to identify it as a water connector (see
rectly to the ultrasonic device and the other side
is connected to the dental unit water input (see
Figure 4-4a and 4-4b).
2. Use of an independent water bottle reservoir (see
Figure 4-5). A reservoir container accompanies
the ultrasonic device and is filled with an aqueous
solution of the provider’s choosing and placed in
its corresponding holder. A water-line attachment
cord is not needed.
Aqueous Solutions
When a dental ultrasonic device is in use, a constant
aqueous solution flow is required to prevent injury
to the patient and damage to the equipment because
Water is the most frequently used aqueous solution.
Alternate Medicaments. The oral health-care
provider should reference the DFU/IFU prior to us-
ing a solution other than water to determine com-
patibility and cleaning requirements. Medicaments
must be flushed from the line with a manufacturer
52 Chapter 4 Ultrasonic Device and Attachments

Figure 4-4 Water-line attachment cord: A. Ultrasonic water-line attached to the back
of the Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System,
B. Ultrasonic water-line attached to the dental unit water input.

recommended germicide, a­ ntimicrobial, conditioning concentrations to exert its action. Antimicrobial

system, or cleaner to prevent biofilm accumulation
and line damage (OSAP, 2018).
Box 4-1 lists common alternate medicaments used
during ultrasonic instrumentation. An oral health-
care provider may choose to use an alternate medica-
ment during active patient care for a variety of reasons
such as:
1. Antimicrobial effects: For an antimicrobial
agent to be effective, it must reach its target
site and be present long enough with sufficient
solutions can be used during ultrasonic instru-
mentation in times of infection and inflam-
mation. However, studies have shown that a
one-time irrigation delivery from a dental ultra-
sonic during periodontal therapy has not been
shown to produce statistically or clinically sig-
nificant improvement in treatment outcomes as
measured by bleeding, probing, plaque index,
or clinical attachment (Del Peloso Riberio et al.,
2006; Hallmon & Rees, 2003; Leonhardt et al.,
2006).
 Water and Air Lines 53

Water bottle

A
Figure 4-5 Ultrasonic independent water bottle
reservoir (EMS AIRFLOW Prophylaxis Master)
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Box 4-1 Alternate Medicaments for

Ultrasonic
Water filter
Cetylpyridinium chloride (CPC)
Chlorhexidine
Essential oils
Hydrogen peroxide
Povidone iodine
Sodium hypochlorite
Sterile saline
Sterile water B
Figure 4-6 Water line filters: A. Dentsply Sirona Cavitron
Jet Plus Ultrasonic Scaling and Air Polishing System
2. Surgical procedures: Sterile saline or sterile ­water, with water filter on the water line, B. EMS AIRFLOW
Prophylaxis Master with water filter under device
as noted in Box 4-1, is used during surgical pro-
(blue color).
cedures that incise, excise, or reflect tissues, and
expose sterile areas of the oral environment. The
CDC and OSAP recommend the use of sterile
solutions for surgical procedures (CDC, 2003; BREAKOUT POINT
OSAP, 2018).
An ultrasonic water filter must be replaced at a
frequency set by the manufacturer.
Water-Line Filters
A water-line filter is installed on the water line by
some manufacturers to capture particles and bio-
film in the water line of an ultrasonic device (see Water filters should be checked periodically and
Figure 4-6a and b). If present, the filter must be re-
changed more frequently if any of the following occur:
placed on a frequency cited in the DFU/IFU. The fre- • Filter has particulate matter buildup.
quency of replacement may vary based on the water • Filter discolors from original color.
supply source (municipal, hard, soft, well, distilled). • Water flow in the line is reduced or inconsistent.
54 Chapter 4 Ultrasonic Device and Attachments

Water Flow Rate

Water should be delivered to the ultrasonic device in a
smooth, continuous, noninterrupted flow at a rate se-
lected by the user. Inconsistent water flow could dam-
age equipment and cause injury to a patient. If water
flow is intermittent or inconsistent, the oral health-
care provider should terminate use and only resume
when the flow rate is corrected.

Inconsistent Flow Rate Factors. There are

many causes for an inconsistent water flow rate to an
ultrasonic such as:
• Clogged dental unit water supply or plumbing.
• Trapped air in the water line.
• Polluted water-line filter. A
• Low-quality municipal water.
• Incorrect psi of the dental unit. Psi stands for
pound force per square inch and is a unit of pres-
sure from a force applied to an area. Ultrasonic psi
requirements are found in the DFU/IFU.
• Using damaged equipment such as a handpiece,
insert, or tip.
• Clogged water port on the insert or tip shank (dis-
cussed in more detail in Chapter 5).
• Mixing of manufacturer ultrasonic equipment.
Ultrasonic equipment is not universal. Each man-
ufacturer designs its handpiece and insert or tip
to function optimally in its own ultrasonic device.
Using a handpiece, insert, or tip from one man-
ufacturer in the device of another will adversely
affect performance, cause inconsistent water flow
rates, and potentially void the warranty. Reference
the DFU/IFU for warranty terms

Water Control and Flow Rate. The wa- B

ter flow rate is adjusted with the water control (see
Figure 4-7a and b). Water flow rates are not standard-
ized among manufacturers so the user must learn the
control for their purchased ultrasonic device.
The water flow has many functions such as:
Figure 4-7 Water control: A. Turnable control on a
Dentsply Sirona handpiece connector cable, B. Turnable
black spindle next to the handpiece on the EMS
AIRFLOW Prophylaxis Master
B: Reproduced with permission from E.M.S. Electro Medical Systems S.A.

• Acts as a coolant to dissipate heat generated when

the transducer converts electrical energy into Purging of the Water Line
mechanical energy in both magnetostrictive and
The ultrasonic water line must be purged to remove
piezoelectric ultrasonic devices.
stagnant liquid from the ultrasonic water line. (CDC,
• Prevents overheating and damage to the equipment.
• Prevents patient injury.
The water flow rate is chosen based on the power BREAKOUT POINT
output selected by the user.
Ultrasonic high power output requires a higher
• Low and medium power output will require a
water flow rate, and low to medium power output
lower ­water flow rate. requires a lower water flow rate.
• High power output will require a higher flow rate.

2003; OSAP, 2018). Purging is performed either man-
ually or automatically depending on the ultrasonic
model (see Figure 4-8). The CDC (2003) recommends
at a minimum 20-30 second purge at the beginning
of the day, between patients, and at the end of the
day. Always follow your clinic’s protocols because its
purging recommendations may be longer than 20–30
seconds for a variety of reasons.
Figure 4-8 Automatic Water-Line purge feature on
the top left side of the touch screen (Dentsply Sirona
Cavitron Touch Ultrasonic Scaling System)
Reproduced with permission from Dentsply Sirona.
Handpiece 55
BREAKOUT POINT
Water-line purging removes stagnant liquid to
prevent biofilm accumulation.
Air Line
An air-line attachment cord will accompany a
stand-alone ultrasonic device with dual functionality
as an air polisher because the air polisher requires an
air source. One side of the cord is attached directly to
the device and the other side is connected to the den-
tal unit air input. Refer to the DFU/IFU for air input
compatibility and psi requirements.
The color of the cord varies by manufacturer.
Water- and air-line connectors on a dental unit are
typically near one another, as seen in Figure 4-9. It is
imperative that the water and air lines are connected
to their correct inputs on the dental unit. Mixing up
the cords could result in significant, and sometimes
irreversible, damage to equipment.
Handpiece
The dental ultrasonic handpiece is a hard, du-
rable sterilizable piece of equipment that at-
taches to a connector cable and accepts an insert
or tip (see Figure 4-10). To safely attach and
remove a handpiece from the handpiece connector
cable, do not twist, but gently pull the handpiece
straight out of its connector. Twisting upon re-
moval can damage the electrical attachments (see
Figure 4-11a and b).
Figure 4-9 Water and air connectors on a dental unit.
Water input is blue and air input is yellow on this unit.
56 Chapter 4 Ultrasonic Device and Attachments
Figure 4-10 Handpiece with insert attached (Dentsply
Sirona Powerline 10 Fitgrip 30K Ultrasonic Insert,
Cavitron Steri-Mate 360 Handpiece)
Reproduced with permission from Dentsply Sirona.
B process. Ultrasonic handpieces are sterilized after each
Figure 4-11 Handpiece and handpiece connector cable:
A. Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling
and Air Polishing System connector cable on left and
Jet-Mate Sterilizable, Detachable Handpiece on right,
B. Acteon Newtron connector cable on left and Newtron
SLIM handpiece on right.
The handpiece is held by the provider during
ultrasonic instrumentation (see Figure 4-12a and b).
For integrated ultrasonic devices, the connector cord
is part of the unit (Figure 4-13a) and for stand-alone
B
Figure 4-12 Handpiece grasp: A. Magnetostrictive
grasp (Dentsply Sirona Slimline 10S Fitgrip 30K
Ultrasonic Insert in Cavitron Steri-Mate 360 Handpiece),
B. Piezoelectric grasp (Acteon Tip 1 in Newtron SLIM
handpiece).
A: Reproduced with permission from Dentsply Sirona; B: Reproduced with permission from ACTEON.
devices, the connector cord is tethered to the machine
itself (Figure 4-13b).
Reprocessing
Reprocessing is the act of cleaning, disinfecting, and
sterilizing reusable equipment in a detailed repeatable
patient use as recommended by the CDC and required
by the FDA because the internal components can be-
come contaminated from retracted oral flora (CDC,
2003; Chin et al., 2006; Herd et al., 2007). These re-
tracted contaminants pose several risks such as:
1. They are then expelled in the form of a dental
aerosol during active use and adversely affect air
quality.
2. If the dental aerosol contains pathogenic organ-
isms, they can cause an adverse health event.
 Handpiece 57

3. The retracted fluids from one patient can

cross-contaminate into the mouth of another
during ultrasonic instrumentation.

CDC Recommendations
The CDC (2018) has specific guidelines and recom-
mendations for reprocessing dental handpieces.
• An ultrasonic handpiece that can be removed
from air and water lines should be sterilized be-
tween patients.
• An ultrasonic handpiece that cannot be removed
from air and water lines should not be used, and
the equipment should be retired and replaced.
• An ultrasonic handpiece that does not have FDA
clearance with validated instructions for repro-
cessing should not be used.

A
B
Figure 4-13 Handpiece connector cable: A. Integrated
unit Acteon Newtron SLIM handpiece and cable cord
connected to the dental unit, B. Stand alone device
handpiece connector cable and handpiece tethered
to the device (Dentsply Sirona Cavitron 300 Series
Ultrasonic Scaling System, Powerline 10 Fitgrip 30K
Ultrasonic Insert in Cavitron Steri-Mate 360 Handpiece).
A: Reproduced with permission from ACTEON; B: Reproduced with permission from Dentsply Sirona.
FDA Regulations
The FDA (2015) uses the Spaulding classification
(critical, semi-critical, non-critical) with modifica-
tions of its own to describe the “potential risk of infec-
tion caused by the device.”
• An ultrasonic handpiece is a semi-critical item,
which is defined as a “device that contacts intact
mucous membranes or non-intact skin but does
not penetrate tissues,” and as such, should be re-
processed by sterilization.
For an older generation ultrasonic device without a
detachable handpiece, the FDA states:
• The device is not consistent with state-of-the-art
science.
• The device cannot ensure it is cleaned, disin-
fected, or sterilized properly.
• The device should not be used and should be re-
placed (FDA, 2015).
Reprocessing Safety
The FDA requires manufacturers to provide repro-
cessing instructions in the DFU/IFU, which vary by
make and model. DHCPs responsible for reprocessing
an ultrasonic handpiece need to be familiar with the
DFU/IFU to avoid damage to costly parts and ensure
patient safety.

Ergonomics
BREAKOUT POINT It is ergonomically desirable to have the following
­features in handpiece design:
An ultrasonic handpiece is sterilized after each
patient use. • Thick diameter: decreases the pinch grip used by
the provider.
58 Chapter 4 Ultrasonic Device and Attachments

Figure 4-14 Moveable nose cone (Dentsply Sirona

Cavitron Steri-Mate 360 Handpiece).
Reproduced with permission from Dentsply Sirona.

• Light weight: decreases musculoskeletal strain

and stress.
• Moveable nose cone: decreases strain and fatigue
by preventing constant repositioning during ul-
trasonic instrumentation (see Figure 4-14).
• Lighting: Light Emitting Diode (LED) lighting im- Figure 4-15 LED lighting (EMS Original Piezon LED
proves visibility in the mouth during ultrasonic Handpiece and PS tip)
instrumentation (see Figure 4-15). Reproduced with permission from ACTEON.

CASE STUDY
A dental hygienist is temping in an office he has not been to before. His operatory is equipped with a piezoelectric ultra-
sonic device with a detachable handpiece. He uses the piezoelectric device for his first patient and detaches the hand-
piece and packages it for sterilization. He cannot find another sterile handpiece for the ultrasonic device, so he asks the
lead dental assistant where they are kept. The assistant tells him their dental hygienist does not sterilize the handpiece
at all. The hygienist uses a two-step disinfectant towelette to wipe down the handpiece after each use. This saves the
office money by not purchasing additional handpieces.
Is this office following the most current recommendations from the CDC? If not, what are the most current rec-
ommendations? Is this office following the most current regulations from the FDA? If not, what are the most current
recommendations? What choices does the dental hygienist have in this scenario?

Summary
This chapter presented an overview of stand-alone
and integrated dental ultrasonic devices and their at-
tachments. The power cord, foot pedal, water and air
line, water control, and handpiece work together to
produce the action of ultrasonic devices during in-
strumentation. The oral health-care provider should
read and reference the most current DFU/IFU prior
to use to avoid equipment damage and ensure they
are following current manufacturer recommenda-
tions. Compliance with CDC recommendations and
FDA regulations for reprocessing handpieces and
maintaining safe dental unit water-line quality is im-
perative to protect the DHCP and patient from cross-­
contamination and disease transmission.

Questions
1. All of the following are included in a DFU/IFU for 2. True or False. The oral health-care provider uses
a dental ultrasonic device EXCEPT which one? the foot pedal provided by the manufacturer in
a. Warranty information an integrated ultrasonic device.
b. Packing and storage a. True
c. Electrical requirements b. False
d. Reprocessing requirements
e. All of the above are included in the DFU/IFU

3. True or False. In the United States, a dental
ultrasonic device is classified as a medical device
by the CDC.
a. True
b. False
4. True or False. When a water cord is colored by the
manufacturer, yellow is the common color chosen.
a. True
b. False
5. True or False. Only water can be used as an
aqueous solution in a dental ultrasonic device.
a. True
b. False
6. True or False. A one-time irrigation delivery
from a dental ultrasonic during periodontal
therapy has been shown to produce statistically
significant improvements in treatment outcomes.
a. True
b. False
7. Which of the following medicaments is
commonly used in a dental ultrasonic device
during surgical procedures?
a. Sterile saline
b. Chlorhexidine
c. Hydrogen peroxide
d. Povidone iodine
8. True or False. Any aqueous solution can be
used inside a dental ultrasonic device and the
provider does not have to reference the DFU/IFU
for compatibility and cleaning requirements.
a. True
b. False
9. True or False. Water filter replacement frequency
is not the same for all devices and is determined
by the water supply source.
a. True
b. False
10. Where would a provider find the most current
information for water filter replacement
recommendations and frequency?
a. Printed manufacturer DFU/IFU
b. Online from a dentist’s blog site
References
1. Centers for Disease Control and Prevention. (2003).
Guidelines for infection control in dental health-care
settings—2003. MMWR, 52(RR-17), 1–76.
2. Centers for Disease Control and Prevention. (2018). CDC
statement on reprocessing dental handpieces. https://www.cdc
.gov/oralhealth/infectioncontrol/statement-on-reprocessing
-dental-handpieces.htm
References 59
c. Google search and open the first link that
appears
d. Online manufacturer DFU/IFU
11. A water-line filter must be replaced when which
of the following occurs?
a. It is the recommended change time interval
per the manufacturer.
b. Filter changes color from white to brown.
c. Water flow rate becomes inconsistent.
d. All of the above
12. True or False. The provider should not worry
about intermittent or inconsistent water flow
rates when the dental ultrasonic device is in use.
a. True
b. False
13. Which of the following can cause inconsistent
water flow rates to the dental ultrasonic device?
a. Trapped air in the water line
b. Low-quality municipal water
c. Clogged water cannula
d. All of the above
14. True or False. An air-line attachment cord is
needed for every ultrasonic device.
a. True
b. False
15. Which of the following is TRUE of an ultrasonic
handpiece?
a. An ultrasonic handpiece does not need to
be sterilized between patient use and can be
wiped with an EPA-registered intermediate
level disinfectant wipe.
b. The handpiece should be sterilized after a
single patient use.
c. A handpiece that is not detachable from the
ultrasonic device is okay to use until the
device breaks.
d. A handpiece is a non-critical item.
16. True or False. An ultrasonic handpiece that
cannot be removed from air and water lines
should not be used and the equipment should
be retired.
a. True
b. False
3. Chin, J. R., Miller, C. H., & Palenik, C. J. (2006). Internal
contamination of air-driven low-speed handpieces and
attached prophy angles. Journal of the American Dental
Association, 137, 1275–1280.
4. Del Peloso Riberio, E., Bittencourt, S., Ambrosano, G. M. B.,
Nociti, F. N., Sallum, E. A., Sallum, A. W., & Casati, M. Z.
(2006). Povidone-iodine used as an adjunct to non-surgical
60 Chapter 4 Ultrasonic Device and Attachments
treatment of furcation involvements. Journal of Periodontology,
77(2), 211–217. https://doi.org/10.1902/jop.2006.050095
5. Food and Drug Administration. (2020). CFR-Code of federal
regulations. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs
/cfcfr/CFRSearch.cfm?fr=872.4850
6. Hallmon, W., & Rees, T. D. (2003). Local anti-infective
therapy: Mechanical and physical approaches. A systematic
review. Annals of Periodontology, 8(1), 99–114. https://doi
.org/10.1902/annals.2003.8.1.99
7. Herd, A., Chin, J., Palenik, C. J., & Ofner, S. (2007). The in
vivo contamination of air-driven low-speed handpieces with
prophylaxis angles. Journal of the American Dental Association,
138, 1360–1365.
8. Leonhardt, A., Bergstrom, C., Krok, L., & Cardaropoli, G.
(2006). Healing following ultrasonic debridement and
PVP-iodine in individuals with severe chronic periodontal
disease: A randomized, controlled clinical study. Acta
Odontologica Scandinavica, 64, 262–266.
9. Organization for Safety, Asepsis, and Protection. (2018).
Dental unit water quality: Organization for safety, asepsis
and prevention white paper and recommendations—2018.
Journal of Dental Infection Control and Safety, 1(1), 1–27.
10. U.S. Food and Drugs Administration. (2015). Reprocessing
medical devices in health care settings: Validation methods and
labeling. FDA-2011-D-0293. https://www.fda.gov/regulatory
-information/search-fda-guidance-documents/reprocessing
-medical-devices-health-care-settings-validation-methods
-and-labeling
 CHAPTER 5
Ultrasonic Insert and Tip
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Identify the materials of a magnetostrictive
insert and piezoelectric tip.
2. Differentiate diameter, shape, length, and water
port position on an insert and tip shank.
3. Select the best shank design for a clinical
procedure based on oral deposit type, oral deposit
location, tooth topography, and tissue consistency.
4. Explain the shank movement of a
magnetostrictive insert and piezoelectric tip.
5. Define displacement amplitude and relate
displacement changes to the power output of
an ultrasonic device.
6. Identify shank loss of length and relate this
concept to insert and tip performance.
7. Evaluate a shank for wear and determine when
an insert or tip should be replaced.
KEY TERMS
• Connecting body: metal attachment between
the ferromagnetic laminate nickel plate and the
shank on a magnetostrictive insert whose design
influences the power output options of the insert.
• Curved shank: an ultrasonic insert or tip whose
shank is bent in more than one plane.
• Displacement amplitude: refers to the length
of stroke, or the distance the shank moves in a
vibratory elliptical pattern in one cycle.
• External water port: thin tube water port that
attaches above and parallel to the shank of an
insert or tip and expels an aqueous solution.
• Grip: colored portion of a magnetostrictive insert
that covers the connecting body.
• Insert: placed into a magnetostrictive handpiece
made of ferromagnetic laminate nickel plates,
connecting body, grip, O-ring(s), and stainless-
steel shank.
• Internal water port: small cannula water tube
embedded inside an insert and tip shank with a
small port opening that expels an aqueous solution.
• Loaded
shank: an insert or tip shank that is in
contact with a surface.
• Magnetostrictive stainless-steel shank: located
on a magnetostrictive insert and performs the
work or action.
• O-ring: silicone-based material that is located on a
magnetostrictive insert and piezoelectric handpiece.
• Piezoelectric stainless-steel shank: located on a
piezoelectric tip and performs the work or action.
• Polyether ether ketone (PEEK): a semicrystalline,
high-temperature thermoplastic polymer on an
ultrasonic shank for the debridement of a dental
implant.
• Polysulfone Amoco P-1700: high strength polymer
single-use disposable covering for an ultrasonic
shank manufactured by Dentsply Sirona called a
SofTip used for dental implant debridement.
• Power control: changes the shank displacement
amplitude of an insert and tip.
• Straight shank: an ultrasonic insert or tip whose
shank is bent in a single plane.
• Tip: placed into the horn of a piezoelectric
handpiece made of a stainless-steel shank.
• Tip threader: located at the base of a piezoelectric
tip that is torqued into the horn of the handpiece
for secure tip connection.
• Tissue consistency: the physical state of epithelial
tissues typically described as firm, hard, and
tightly adherent or soft, spongy, and movable.
• Tooth topography: and the features, parts, or
structures of a tooth’s surface.
• Unloaded shank: an insert or tip shank that is not
contacting a surface.
• Water port: port present on an insert and tip
that expels an aqueous solution used during
ultrasonic instrumentation.
• Wrench: houses a piezoelectric tip and torques
the tip into the horn of the handpiece.
61
62 Chapter 5 Ultrasonic Insert and Tip

Introduction
device in the mouth by delivering mechanical energy
to tooth surfaces.
Manufacturers offer a diversified portfolio of inserts • An insert is placed into a magnetostrictive
and tips to fit any clinical situation and patient pre- handpiece.
sentation. An insert is placed into a magnetostrictive • A tip is placed into a piezoelectric handpiece.
handpiece, and a tip is placed into a piezoelectric
handpiece. This chapter will provide an overview of
the materials, terminology, movement, clinical selec-
Magnetostrictive
tion criteria, and wear of inserts and tips. A magnetostrictive insert is made of ferromagnetic
The transducer and active medium produce the laminate nickel plates (active medium), connecting
two ultrasonic sound waves at a set frequency, which body, colored grip, O-ring(s), and a stainless-steel
causes an insert and tip to move in a vibratory ellip- shank.
tical motion. The user can change how large or small
the vibratory elliptical motion is through the power Ferromagnetic Laminate
control. The power output is selected based on the Nickel Plates
patient clinical presentation and procedure.
Nickel is the active medium used in a magnetostric-
The design of an insert or tip dictates its use in
tive ultrasonic device. The nickel is compressed into
the mouth. Inserts and tips are offered in a variety of
thin wafer laminate plates stacked tightly on top of
shank diameters, shapes, and lengths. For example, a
one another. The nickel stacks are soldered together
thicker diameter shank will remove heavy dental cal-
to form a tightly packed unit (see Figure 5-1).
culus while a thin diameter shank will remove lighter
Each manufacturer designs its active medium to
deposits. A longer shank design will allow access to
function optimally in its own transducer. There is
deeper periodontal pockets than a short shank. The
no industry standardization of ferromagnetic lam-
oral health-care provider uses multiple inserts and
inate nickel plate design. Manufacturers vary in the
tips during a procedure based on oral deposit type,
number of wafers, size, weight, length, and soldering
location, tooth topography, and tissue consistency.
method so it is important to use the insert from the
At the conclusion of this chapter, you will learn how
manufacturer of your ultrasonic device for optimal
to select an appropriate insert or tip for any clini-
performance.
cal situation. Future chapters will provide more de-
The ferromagnetic laminate nickel plates can eas-
tailed information on individual manufacturer inserts
ily become damaged if they are mishandled or an in-
and tips.
sufficient cooling solution is used during treatment. If
With time and use, the shank of an insert and
any of the nickel stacks warp, splay, separate, fracture,
tip will wear and lose length. With every millimeter
or bend, the insert will no longer properly magnetize
of shank loss, the performance of the equipment de-
and will need to be discarded (see Figure 5-2a and b).
creases, which adversely affects patient clinical out-
To avoid damage from mishandling, a metal carrier
comes. This chapter will teach you how to identify
can be used to store, transport, and reprocess the in-
wear and loss of shank length and when to discard
sert (see Figure 5-3).
the insert or tip.

Ultrasonic Insert and Tip

BREAKOUT POINT
Parts and Terminology
If the ferromagnetic nickel stack becomes damaged,
An ultrasonic insert or tip is placed into an ultrasonic it will no longer magnetize and must be discarded.
handpiece and contains a stainless-steel shank. The
shank performs the work or action of the ultrasonic

BREAKOUT POINT
A magnetostrictive insert is made of ferromagnetic
laminate nickel plates, connecting body and grip,
O-ring(s), and a stainless-steel shank.
Figure 5-1 Magnetostrictive insert with ferromagnetic
laminate nickel plates to the left (Dentsply Sirona®
Cavitron® Powerline® 10 Fitgrip® 30K Ultrasonic Insert).
 Ultrasonic Insert and Tip Parts and Terminology
B
Figure 5-2 Ferromagnetic laminate nickel plate injury:
A. Nickel plates with gapping and change of shape from
straight to wavy, B. Nickel plates with gapping.
Figure 5-3 Metal carrier (Dentsply Sirona Cavitron
Slimline 1000 30K Ultrasonic Insert and Powerline 10
30K Ultrasonic Insert).
Connecting Body and Colored Grip
The connecting body is a metal attachment be-
tween the ferromagnetic laminate nickel plates and
the stainless-steel shank on a magnetostrictive insert.
Connecting bodies vary in thickness, length, size, and
weight based on design characteristics of the shank
(see Figure 5-4). Each insert has a different connecting
body, which influences the power output settings that
can be used during active treatment. The manufacturer
63
Figure 5-4 Connecting body
Reproduced with permission from Dentsply Sirona.
Figure 5-5 Colored grip over connecting body
(HuFriedyGroup Swivel Direct Flow Power Plus Standard
Conical (ocean blue)and HuFriedyGroup Swivel Direct
Flow After Five Straight (dark blue).
Courtesy of HuFriedyGroup Mfg. Co., LLC
provides power setting recommendations and limita-
tions in the direction for use or instruction for use
(DFU/IFU) for each insert.
The connecting body is not visible because it is
covered by a colored grip that varies in design, tex-
turing, color, and thickness between manufacturers
(see Figure 5-5). There is no industry standardization
for the color of grips. Manufacturers select and patent
their color and design, leading to many variations on
the market today.
BREAKOUT POINT
The connecting body and stainless-steel shank
design dictate the power output settings that can be
used for an insert.
64 Chapter 5 Ultrasonic Insert and Tip

Figure 5-6 O-ring: Dentsply Sirona Cavitron Powerline

10 Fitgrip 30K Ultrasonic Insert with one O-ring and
HuFriedyGroup Swivel Direct Flow After Five Straight
with two O-rings.
Courtesy of HuFriedyGroup Mfg. Co., LLC

O-Ring A

The O-ring is located between the ferromagnetic lam-

inate nickel plates and the connecting body. Some
manufacturers have one O-ring while others use two
(see Figure 5-6). The O-ring is made of a silicone ma-
terial. When placing an insert into a handpiece, the
O-ring should advance all the way into the handpiece.

BREAKOUT POINT
The insert O-ring should be lubricated with water
prior to seating inside the handpiece.
B

O-Ring Function. The function of the O-ring on a

magnetostrictive insert is to:
• Hold the insert in the handpiece securely.
• Provide a seal-tight connection between the insert
and handpiece.
• Prevent water leakage from the handpiece.

O-Ring Lubrication. The O-ring is a wear-and-

tear item and will need periodic replacement based
on use, handling, and reprocessing. To prolong the
life of an O-ring, the provider should lubricate the sil-
icone O-ring prior to placing it inside the handpiece
to prevent drying and overheating (see Figure 5-7a to c
for the steps in proper lubrication and seating of the
insert into the handpiece).
O-Ring Replacement. The O-ring should be
checked periodically and replaced when:
• Water leaks from the handpiece when in use.
• Insert does not remain seated in the handpiece
when in use.
• It appears damaged, dry, cracked, or brittle.
C
Figure 5-7 O-ring lubrication (Dentsply Sirona Cavitron
Steri-Mate Sterilizable, Detachable Handpiece and
Cavitron Slimline 10L Fitgrip 30K Ultrasonic Insert): A. Fill
handpiece until a dome of water is visible at its opening,
B. Rotate the O-ring 360 degrees over the water dome
until fully lubricated, C. Place the insert into the handpiece
in an upright position until the O-ring is fully seated.
Reproduced with permission from Dentsply Sirona.
 Ultrasonic Insert and Tip Parts and Terminology
• It-ring is loose or movable.
• It-ring is missing.
Replacement recommendations:
• Never change the number of O-rings during re-
placement. If the insert has one O-ring, always
replace with a single O-ring. If it has two O-rings,
replace both.
• Always use the O-ring from the manufacturer of
the insert. Do not use an O-ring from one manu-
facturer on another’s insert. O-rings are not uni-
versal and vary in size, thickness, mass, material,
and fit.
• Refer to the DFU/IFU for O-ring replacement
steps to avoid damage to the ferromagnetic lami-
nate nickel plates.
Steps for replacement:
• Remove the worn O-ring.
• Use an O-ring replacement tool sold by the manu-
facturer to grab and slide the O-ring down the fer-
romagnetic laminate nickel plates (see Figure 5-8).
• If the manufacturer does not sell a replacement
tool, use a cotton plier to grab and slide the
O-ring down the ferromagnetic laminate nickel
plates (see Figure 5-9).
Figure 5-8 Dentsply Sirona O-ring Replacement Tool
(Dentsply Sirona Cavitron Powerline 1000 Fitgrip 30K
Ultrasonic Insert).
Reproduced with permission from Dentsply Sirona.
Figure 5-9 Cotton pliers for removal of O-ring.
Courtesy of HuFriedyGroup Mfg. Co., LLC
65
Stainless-Steel Shank
The magnetostrictive stainless-steel shank is
permanently attached to the insert by the connecting
body. The shank performs the work or action in the
mouth by delivering the mechanical energy of the de-
vice (see Figure 5-10).
Piezoelectric
A piezoelectric tip is made of a stainless-steel shank
and tip threader. It is placed into the handpiece with
a wrench. The handpiece is equipped with an O-ring
that must be replaced when worn or damaged.
Wrench
The piezoelectric wrench houses the piezoelectric tip
anytime it is not in use (see Figure 5-11a and b). The
tip is removable from the wrench. The wrench threads
the tip into the horn located inside the handpiece.
The wrench serves three functions:
1. Protects the tip from damage and the dental
health-care personnel (DHCP) from injury during
transport and reprocessing.
2. Reduces the risk for tip loss due to its small size.
3. Provides proper torque of the tip to the handpiece.
If a tip is over-torqued or under-torqued, it can
adversely affect tip movement and performance.
Manufacturers may color-code their wrenches for easy
identification of tip design. Some provide a carry case
for multiple tips (see Figure 5-12). There is no industry
standardization for color or design of wrenches. Man-
ufacturers select and patent their color and design,
leading to many variations on the market today.
Stainless-Steel Shank
and Tip Threader
The piezoelectric stainless-steel shank is
threaded into the horn located inside the handpiece
via a wrench. The tip performs the work or action of
the tip in the mouth by delivering mechanical energy
to tooth surfaces. At its base is a tip threader that is
threaded and torqued into the horn for secure con-
nection (see Figure 5-13).
Figure 5-10 Insert stainless steel shank and color grip
(Dentsply Sirona Cavitron Powerline 10 Fitgrip 30K
Ultrasonic Insert).
Reproduced with permission from Dentsply Sirona
66 Chapter 5 Ultrasonic Insert and Tip

Figure 5-13 Tip and tip threader (Acteon 1 with blue

stripe below threader and H3 with green stripe below
threader).
Reproduced with permission from ACTEON.

• There are two styles of tip threaders: S-Thread

B piece horn. Providers cannot use an E-Thread tip
Figure 5-11 Wrench (Acteon): A. Top view, B. Side view.
Reproduced with permission from ACTEON.
• Each manufacturer designs its tip threader to be
Steps for tip connection to to the handpiece:
Figure 5-12 Carry case for multiple wrenches and tips
(Acteon wrenches, tips, and Newtron SLIM handpiece).
Reproduced with permission from ACTEON.
• Some manufacturers provide a color ring on the
tip threader that corresponds to the power out-
put allowed for the tip or identifies specific design
variations (see Figure 5-13).
and E-Thread (so named after the manufacturer
who created the tips that differ in design). Each
thread style has a different number of flats that in-
terlock and correspond to the design of the hand-
in an S-compatible handpiece, and vice versa.
compatible with its handpiece. It is never recom-
mended to intermix one manufacturer’s tip with
another’s handpiece. Irreversible damage in the
form of stripping to the horn of the handpiece
and tip threader can occur. Once stripped, the
handpiece and tip must be discarded because
there is no way to reverse the damage inflicted on
the equipment. Refer to the manufacturer DFU/
IFU for compatibility details.
1. Place the tip inside the wrench if not already pres-
ent (see Figure 5-14a).
2. Place the tip threader into the handpiece (see
Figure 5-14b).
3. Rotate the wrench until the tip is fully torqued
(see Figure 5-14c). Some manufacturers provide a
wrench that makes an audible “click” sound when
the proper torque has been reached. Other manu-
facturers do not provide a “click” sound but have a
built-in safety feature that prevents over-torquing.
 Water Port 67

B C
Figure 5-14 Tip connection to handpiece (Acteon H3 Tip and Newtron SLIM handpiece): A. Tip placed inside wrench,
B. Wrench used to place tip threader into handpiece opening, C. Rotate wrench to torque tip into handpiece.
Reproduced with permission from ACTEON.

ultrasonic instrumentation. There are two types of

BREAKOUT POINT
Always use the tip from the manufacturer of the
piezoelectric device to avoid stripping and damage
to the tip threader and handpiece.
Water Port
A water port is present on every magnetostrictive
insert and piezoelectric tip because an aqueous solu-
tion (most commonly used is water) is needed during
water ports: external and internal.
1. External water port: An external water port
was the first type offered for an insert and tip. An
external water port is made of a thin tube attached
above and parallel to the shank of an insert or tip.
Water is expelled from the canula and branches
out in multiple directions (see Figure 5-15).
2. Internal water port: An internal water port
delivery is more commonly used today. An inter-
nal water port is made of a small cannula tube
embedded inside an insert and tip shank with a
68 Chapter 5 Ultrasonic Insert and Tip

Figure 5-15 External water port (Dentsply Sirona P

Series 10 Metal Grip 25K Ultrasonic Insert).
Reproduced with permission from Dentsply Sirona.

Figure 5-17 Internal water port unclogging tool

(Dentsply Sirona finger spreader).
Reproduced with permission from Dentsply Sirona.

Table 5-1 Water port advantages

and disadvantages
Flow Type Advantage Disadvantage
A External Less likely to clog. Tubing can be
water port easily damaged
from mishandling.
Water spray is
not focused,
decreasing
visualization of the
working field.
Water control.
Internal Water spray is Small port
water port focused, increasing openings may
visualization of the become clogged.
working field.
Water control.

Reproduced with permission from Dentsply Sirona.

B
Figure 5-16 Internal water ports (note the different sizes
and locations): A. Dentsply Sirona Cavitron Powerline 10
Fitgrip 30K Ultrasonic Insert, B. Acteon 1 and H3 tips.
small port opening that expels an aqueous solu-
tion that is more focused than an external water
port. The port position on the shank varies by
manufacturer (see Figure 5-16). If the water port
becomes clogged, insufficient water will be ex-
pelled, which can lead to equipment damage and
patient discomfort. If the internal water port be-
comes clogged, a cleaning tool provided by the
manufacturer can be used to unclog the canula.
(see Figure 5-17).
Table 5-1
summarizes the advantages and disad-
vantages of internal and external water ports.
 Insert and Tip Shank 69

Insert and Tip Shank

This section will cover shank damage, anatomy, activity,
design, clinical selection criteria, movement, and wear.
Shank Damage
The stainless-steel shank must be handled with care
to avoid damage. When a shank becomes damaged, it
cannot be fixed and should be discarded.
when a specified loss of length occurs, it must be
replaced.
• Mishandling during the transport, use, reprocess-
ing, or storing of the insert or tip, for example,
placing heavy equipment on top of the insert or
tip in the sterilizer or dropping the insert or tip
(see Figure 5-18a and b).
• Exposure to harmful chemicals during reprocess-
ing that are not compatible with the insert or tip.
This information is found in the product’s DFU/
IFU. See Figure 5-19 for a case example.

BREAKOUT POINT
When an insert or tip shank becomes damaged,
it must be discarded.
Common causes of shank damage are:
• Using an incorrect power output setting for the
insert or tip.
• Using an incorrect water flow rate for the insert
or tip.
• Applying excessive lateral force during instrumen-
tation. Further details are presented in Chapter 9.
• Using an insert or tip past its replacement rec-
ommendation. This increases the likelihood for
breakage. An insert or tip will wear with use, and
Shank Anatomy and Activity
Chapter 3 introduced the terms antinode and node.
The shank has two antinodes and one node (also
termed nodal point), which is produced when the two
ultrasonic sound waves interact with one another.
Table 5-2 demonstrates where the antinodes and node
are located on the shank, which ones are active, and
which ones are adapted to tooth surfaces during ultra-
sonic instrumentation.
BREAKOUT POINT
The active area antinode is adapted to tooth
structures for the removal of oral deposits.

A B
Figure 5-18 Shank damage from mishandling: A. Terminal 1-4mm of the shank is bent past 90-degrees
after being dropped on the floor. (Dentsply Sirona Cavitron Slimline 1000 Fitgrip30K Ultrasonic Insert),
B. Insert on left terminal 1-4mm of the shank is bent to 90-degree angle after being dropped on the
ground. Insert on right is not damaged. (Dentsply Sirona Slimline 1000 30K Ultrasonic Insert).
Reproduced with permission from Dentsply Sirona.
70 Chapter 5 Ultrasonic Insert and Tip

• Polyether ether ketone (PEEK) is a semicrystal-

BREAKOUT POINT line high-temperature thermoplastic polymer that
is coated onto the shank for the debridement of a
The nodal point is not adapted to tooth structures
because it does not remove oral deposits. dental implant (see Figure 5-20b).
• Polysulfone Amoco P-1700 is a high strength
polymer single-use disposable covering for the
shank manufactured by Dentsply Sirona called a
Shank Coating SofTip that ffixes to the Cavitron SofTip Implant
The ultrasonic shank can be coated with or made of a 30K Ultrasonic Insert for implant debridement.
different material for specialty care. • A diamond-coated shank is used for the removal of
• Titanium, carbon, and teflon shanks are used heavy dental calculus deposits, burnished calculus,
for the debridement of a dental implant. (see and tooth substances (Kocher et al., 2001; Vastardis
Figure 5-20a). et al., 2005; Yukna et al., 2007; see Figure 5-20c).
Reference the manufacturer DFU/IFU prior to use
because some diamond-coated shanks are only ap-
proved for use during periodontal surgeries when
the gums are flapped, and the provider can directly
see the root anatomy. The Food and Drug Adminis-
tration (FDA) (2021) considers a diamond-­coated
instrument to be single use unless the manufacturer
submits 501(k) validation data for reprocessing.
Check the manufacturer’s DFU/IFU for whether a
diamond-coated insert or tip is single use or ap-
proved for reprocessing. Providers should also ref-
erence their local and federal governing board laws
to determine if their scope of practice allows the
use of a diamond-coated instrument on root sur-
faces. Diamond-coated instruments must be han-
dled with care because if they are placed directly
on cementum, damage and removal will occur
quickly (Kocher et al., 2001; Vastardis et al., 2005).

Figure 5-19 Damage to stainless-steel shank and

BREAKOUT POINT
colored grip from non-compatible chemical exposure
(Dentsply Sirona Cavitron 10R Bellissima Grip 30K If an ultrasonic shank is coated or covered with
Ultrasonic Insert): Note the discoloration on the grip, titanium, carbon, telfon, PEEK, or Polysulfone
rust on the shank, and rust in and around the internal Amoco P-1700, the insert or tip may be safely used
water port. to debride a dental implant.
Reproduced with permission from Dentsply Sirona.

Table 5-2 Shank anatomy and activity

Adaptation to Tooth
Structures During
Name Position on the Shank Active Area Instrumentation
Active area Terminal 1.0–3.5 mm (Pecheva et al., 2016; Vyas Yes. Site of Yes
antinode et al., 2016) greatest activity.
Node (nodal point) 3.5–5.0 mm (Pecheva et al., 2016; Vyas et al., 2016) No No
Antinode 5–8 mm* (Pecheva et al., 2016; Vyas et al., 2016) Yes No

*Length varies by the overall length of the shank.

 Insert and Tip Shank 71

A B C
Figure 5-20 Specialty Ultrasonic Shanks A. Titanium tip (Acteon IP1), B. PEEK tip (EMS PI), C. Diamond-coated insert
(Dentsply Sirona Cavitron Diamondcoat Ultrasonic Insert).
A: Reproduced with permission from ACTEON. C: Reproduced with permission from Dentsply Sirona.

Shank Design diameter selection. For example, tissues that are

tightly adherent to the tooth root make it difficult to
Inserts and tips are offered in a variety of shank diam- adapt thicker or wider diameter instruments subgin-
eters, shapes, and lengths. The oral health-care pro- givally. Tooth anomalies such as fixed orthodontic
vider uses multiple inserts or tips to complete a full retainers, crowded teeth, and tight contacts between
mouth periodontal debridement. Design variations teeth are better debrided with thin and ultra-thin di-
are presented first, and then clinical selection criteria ameter shanks (see Figure 5-21a and b).
are presented second.
Shank Shape
Shank Diameter
Shank shape is selected based on the tooth anatomy
As a generality, there are three shank diameters: thick, being instrumented.
thin, and ultra-thin. There is no industry standardiza- There are two shank shapes: straight and curved.
tion for diameter width. Widths vary by manufacturer,
and not every manufacturer offers all three diameter 1. Straight shank: A straight shank is bent in a sin-
choices in their portfolio. gle plane. It is used to instrument noncomplex
The provider determines which diameter shank anatomical structures such as the crowns of teeth
to use clinically based on the oral deposit type (bio- or simple root anatomy (see Figure 5-22a and b).
film, dental calculus, stain), and level (heavy, mod- 2. Curved shank: A curved shank is bent in more
erate, light). Tissue consistency also plays a role in than one plane. It is used to instrument complex
anatomy such as root concavities and furcations
(see Figure 5-23a and b).

BREAKOUT POINT
BREAKOUT POINT
Oral deposit type, size, tissue consistency, and tooth
anomalies influence the shank diameter selected A straight shank shape is used to instrument
by the oral health-care provider during ultrasonic noncomplex anatomy, and a curved shank shape is
instrumentation. used for complex anatomy.
72 Chapter 5 Ultrasonic Insert and Tip
B
Figure 5-21 Thin and ultra-thin diameter shank use:
A. Fixed retainer on the mandibular anterior lingual
teeth, B. Mandibular anterior teeth with crowding.
Shank Length
A longer shank is used to access a deeper periodon-
tal pocket or longer clinical crowns. There is no uni-
versal industry standard for shank length. Insert and
tip shank length varies among manufacturers (see
Figure 5-24 for a case example).
BREAKOUT POINT
A longer shank length is used to debride deeper
periodontal pockets.
Shank Clinical Selection Criteria
Now that you are familiar with general shank design
variations, let’s tie those concepts into clinical selec-
tion. There are four clinical criteria used for insert and
tip selection: oral deposit type and size, oral deposit
location, tooth topography, and tissue consistency.
B
Figure 5-22 Straight shank: A. Insert shank bent in
one plane (Dentsply Sirona Slimline 10S Fitgrip 30K
Ultrasonic Insert), B. Noncomplex anatomy with straight
clinical crowns and no concavities or convexities on the
mandibular anterior facial surfaces.
A: Reproduced with permission from Dentsply Sirona.
BREAKOUT POINT
Oral deposit type and size, oral deposit
location, tooth topography, and tissue
consistency are the four clinical criteria used
for ultrasonic instrumentation insert and tip
selection.
Oral Deposit Type and Size
Oral deposit type (biofilm, bacterial by-products,
stain, dental calculus) can be different sizes (heavy,
moderate, light; see Figure 5-25a to d for examples).

B
Figure 5-23 Curved shape: A. Insert shank bent in
two planes (Dentsply Sirona Slimline 10R Fitgrip 30K
Ultrasonic Insert), B. Complex root anatomy. Root concavity
of the mandibular left second molar. Furcation defect with
root concavities on the mandibular left first molar.
Insert and Tip Shank 73
C
Figure 5-24 Shank length case example (Acteon tips):
A. The probe depth on this mandibular second premolar
buccal surface is shallow at 2 mm. The tooth has no
bone loss. The shank length needed to debride this
area is a short length (tip with blue stripe), B. The probe
depths on these maxillary left molars are 6–7 mm in the
interproximal areas. The bone loss is significant. The
shank length needed to debride this area is a longer
shank length (green stripe tip).
74 Chapter 5 Ultrasonic Insert and Tip

B C

D
Figure 5-25 Oral deposits: A. Light to moderate stain on the maxillary left lingual surfaces and the lower anterior
facial surfaces, B. Heavy biofilm on the mandibular right facial/buccal surfaces, C. Light to moderate dental calculus
on the mandibular anterior lingual surfaces, D. Heavy dental calculus maxillary right molar occlusal surfaces.
 Insert and Tip Shank 75

Deposits can be slightly adherent or tenaciously at-
tached to crown and root surfaces.
Table 5-3 matches the oral deposit type and size
with the shank diameter used for its removal.
• Thick diameter shank: removes heavy dental cal-
culus and stain (see Figure 5-25d).
• Thin and ultra-thin diameter shanks: removes
light to moderate dental calculus and stain as well
as all levels of biofilm and bacterial by-products
(see Figure 5-25a to c).
It is common for an oral health-care provider to
use a staged instrumentation approach to debride-
ment, for example:
• If heavy dental calculus is present, such as seen in
Figure 5-25d, the provider will begin ultrasonic
instrumentation with a thick diameter shank to
reduce the size of the dental calculus from heavy
to moderate or light.
• The provider will then switch from the thick
diameter shank to a thin or ultra-thin shank to
remove the remaining light to moderate dental
calculus.
Complete Mini Case Studies 1 and 2 for practice
in selecting the correct diameter shank for the clinical
presentation.
BREAKOUT POINT
A thick diameter shank is used to remove heavy
dental calculus and stain while a thin or ultra-thin
shank diameter will remove all levels of biofilm and
light to moderate dental calculus and stain.

Table 5-3 Oral deposit type and size and shank diameter
Shank Diameter Biofilm and Bacterial By-Products Dental Calculus Stain
Thick   
(Heavy) (Heavy)
Thin   
(Heavy, Moderate, Light) (Moderate, Light) (Moderate, Light)

Ultra-Thin   
(Heavy, Moderate, Light) (Moderate, Light) (Moderate, Light)

Mini Case Study 1: Oral Deposit Case Example

Maxillary right anterior facial surfaces

Maxillary left molar buccal surfaces

76 Chapter 5 Ultrasonic Insert and Tip

Maxillary left anterior facial surfaces

Oral deposit type and size

■ Dental calculus: generalized light to moderate
■ Biofilm: generalized heavy
■ Stain: generalized moderate
Which shank diameter(s) should the oral health-care provider select?
Answer: Thin or ultra-thin diameters
Justification: Thin or ultra-thin shank diameters will remove light to moderate dental calculus and stain as well as the
heavy biofilm. A thick shank diameter is not indicated due to the lack of heavy dental calculus and stain.

Mini Case Study 2: Oral Deposit Case Example

Mandibular anterior lingual surfaces

Maxillary right molar occlusal surfaces

 Insert and Tip Shank 77

Left premolar bitewing radiograph with dental calculus

in the interproximal surfaces.

Oral deposit type and size

■ Dental calculus: generalized heavy
■ Biofilm: generalized heavy
■ Stain: generalized moderate
Which shank diameter(s) should the oral health-care provider select?
Answer: Staged instrumentation is needed for this case. The oral health-care provider will begin with a thick diameter
shank and then switch to a thin or ultra-thin diameter shank.
Justification: Treatment begins with a thick shank diameter to remove the heavy dental calculus and reduce its size to
moderate to light. Then, the oral health-care provider will switch to a thin or ultra-thin shank diameter to remove the
remaining light to moderate dental calculus, all levels of biofilm and bacterial by-products, as well as any stain the thick
shank diameter left behind.

Oral Deposit Location
Oral deposits can be located on the enamel, dentin,
and cementum of anterior and posterior teeth both
supragingivally and subgingivally (see Figure 5-26).
Straight and curved shanks can be safely used on
enamel, dentin, and cementum for the removal of oral
deposits. When a procedure calls for the debridement
of complex root anatomy such as a furcation or root
concavity, a curved shank is used.
Tooth Topography
Topography is a term that refers to the physical fea-
ture of the surface of an object. Think of the surface
of a mountain. There are peaks and valleys along its
terrain (see Figure 5-27a). Teeth and roots are no dif-
ferent. Teeth have varied anatomy with pits, fissures,
concavities, convexities, depressions, and straight
clinical features (see Figure 5-27b). Dental instru-
ments, including ultrasonic inserts and tips, are de-
signed to contour to a specific tooth topography. For
example, straight ultrasonic shanks are designed to
contour and adapt to noncomplex tooth topography,
and curved shank designs are for complex tooth to-
pography (see Figure 5-28).
Tissue Consistency
Tissue consistency refers to the physical state ep-
ithelial tissues typically described as firm, hard, and
tightly adherent or soft, spongy, and movable.
• Hard, firm, tightly adherent tissue consistency:
A thick shank diameter may have too great a
surface area to access subgingivally when tissues
are hard, firm, and tightly adherent. Thin and
ultra-thin shank diameters can access subgingi-
vally with minimal to no tissue distension (see
Table 5-4).
• Soft, spongy, movable tissue consistency: all shank
diameters can access subgingivally when the tis-
sue consistency is soft, spongy, and movable (see
Table 5-4).
Shank Movement
When activated, a magnetostrictive insert and piezo-
electric tip shank move in a vibratory elliptical motion,
78 Chapter 5 Ultrasonic Insert and Tip

B
Figure 5-27 Topography: A. The peaks and valleys of
a mountain are an example of topography, B. Note
A the complex tooth topography of furcation areas,
depressions, concavities, convexities, and elevations of
these extracted molars.

B A
Figure 5-26 Oral deposits: A. Dental calculus, stain,
and biofilm seen visually on the enamel and dentin of
the mandibular right anterior facial surfaces, B. Dental
calculus on the cementum of the mandibular left molars
evident on this molar bitewing radiograph.

BREAKOUT POINT
A thick-diameter shank is unable to access
subgingvially when the tissue consistency is hard,
firm, or tightly adherent.
as confirmed by 3-D scanning laser vibrometer with
Doppler effect.
• Three-dimensional scanning laser vibrometry is
used in biomedical, mechanical, civil, aerospace,
and automotive engineering (Tabatabai, 2013).
B
Figure 5-28 Tooth topography and shank design:
A. Curved shank shape adapted to complex root anatomy
on this extracted mandibular second molar (Dentsply
Sirona Slimline 10L 30K Ultrasonic Insert), B. Straight
shank shape adapted to non-complex root anatomy on
the mandibular left central incisor facial surface (Dentsply
Sirona Slimline 10S Fitgrip 30K Ultrasonic Insert).

Table 5-4 Tissue consistency and shank diameter
Firm, Hard, Tightly Adherent
Diameter Insert/Tip
Thick  
Thin  
Ultra-Thin  
• The Doppler effect is used to describe how
light or sound wave frequency is changed
when the shank moves closer or farther away
from an object. The discovery of this tech-
nology allowed for more accurate viewing of
shank movement.
Historical Perspectives of Movement
Prior to the advent of 3-D technology for view-
ing shank movement, light-beam technology was
used. Light-beam evaluation was restricted and
did not allow observers to view both longitudinal
and lateral movements of ultrasonic shanks (Lea &
Walmsley, 2000; Lea et al., 2004). This led to
industry-­wide misinformation with claims that an
insert shank moved differently than the shank of a
tip. It was thought the shank of a tip moved in only
a lateral linear pattern and an insert shank moved in
an elliptical pattern.
Current Perspectives of Movement
When 3-D scanning laser vibrometry using the Dop-
pler effect technology was invented, it confirmed that
both an insert and tip shank move with vibratory el-
liptical patterns. The vibratory elliptical motion var-
ies slightly between the two. The slight differences
led piezoelectric manufacturers to create tips with a
smoother movement on tooth structures when lateral
surfaces of the shank are adapted. This will be dis-
cussed in more detail in later chapters.
Three-dimensional scanning laser vibrometry also
provided:
• Better visualization of node and antinode posi-
tions on an ultrasonic shank.
• More accurate viewing of the shank movement,
velocity, and frequency of oscillations.
Insert and Tip Shank 79
Soft, Spongy, Movable
BREAKOUT POINT
The shank of an insert and tip both move in a
vibratory elliptical motion.
Power Control and Shank
Displacement Amplitude
Dental ultrasonic devices are sold with changeable
power output settings. The oral health-care provider
selects the power output they wish to use during
a procedure through the power control. Power
controls are not universal, and manufacturers set
their own power output at each control setting (see
Figure 5-29a to c). As you can see in Figure 5-29, some
controls are touch screen while others are a dial. The
symbols and numbers are not universal and vary by
model and manufacturer. Later chapters teach the
power control for each individual ultrasonic device by
manufacturer.
The power control changes the shank displace-
ment amplitude. Displacement amplitude refers to
the length of stroke, or the distance the active area
antinode on the shank moves in one vibratory ellipti-
cal cycle. Amplitude describes how large or small the
displacement moves about its axis. When the power
output is increased, the forces put upon the active
medium increase, which lengthens the stroke dis-
placement amplitude (Pecheva et al., 2016; Lea et al.,
2003; see Figure 5-30).
• Low power output (low power control setting)
causes a smaller displacement amplitude of the
active area antinode on the shank. This means
the vibratory motion of the terminal antinode is
moving in smaller, tighter elliptical patterns (see
Figure 5-30—green circle). This power setting
80 Chapter 5 Ultrasonic Insert and Tip

Figure 5-30 Displacement Amplitude.

is commonly used for the removal of lighter oral

deposits.
• Medium power output (medium power control
A setting) causes an increase in displacement am-
plitude from low power output but not as great
as high power output. The vibratory motion of
the active area antinode is moving in larger ellip-
tical patterns than low power output (see Figure
5-30—orange circle). This power setting is com-
monly used for the removal of light and moderate
oral deposits.
• High power output (high power control setting)
causes a further increase in displacement ampli-
tude from a medium power output. This is the
largest displacement amplitude of the active area
B antinode. The vibratory motion of the active area
antinode is moving in the largest elliptical pat-
terns achievable (see Figure 5-30—red circle).
This power setting is commonly used for the re-
moval of heavier oral deposits.

BREAKOUT POINT
The power control changes the ultrasonic shank
displacement amplitude.

Although the power control changes the displace-

ment amplitude, there are many variables that influence
a shank’s displacement amplitude capability. The most
significant influences are power output setting and
shank diameter (Pecheva et al., 2016; Lea & Walmsley,
C 2000; Lea et al., 2009). Load, quantity of water, and
Figure 5-29 Power control: A. Touch screen power
shank wear are also factors affecting displacement am-
control on the Dentsply Sirona Cavitron Touch Ultrasonic plitude, but to a lesser extent than power output set-
Scaling System, B. Dial power control on the Acteon tings and shank diameter (Lea et al., 2009).
Newtron P5 XS B.LED, C. Touch groove panel on the
EMS AIR-FLOW Prophylaxis Master. • Power output settings: Shank stroke displacement
A: Reproduced with permission from Dentsply Sirona. B: Reproduced with permission from ACTEON. C: Reproduced with permission
amplitude does not increase in a predictable or
from E.M.S. Electro Medical Systems S.A. linear fashion with an increase in power output.

For example, increasing the power output from
low to medium may provide the user with a 20%
increase or a 50% increase, depending on the
manufacturer, device, and insert and tip design.
• Shank diameter
• Thick diameter: A thick diameter shank will
produce a more predictable displacement
amplitude at all power output settings with
a more stable vibratory elliptical motion than
thin and ultra-thin (Pecheva et al., 2016; Lea &
Walmsley, 2000; Lea et al., 2003; Lea &
Walmsley, 2003).
• Thin and ultra-thin diameter: Thin and
ultra-­ thin diameter shanks produce more
varied and unpredictable displacement
amplitudes than thick at all power out-
put settings (Pecheva et al., 2016; Lea &
Walmsley, 2000; Lea et al., 2003; Lea &
Walmsley, 2003). The thinner shanks have
more variability in their displacement ampli-
tude, which adds a learning curve for the user
in pairing power output correctly with thinner
shanks.
• Load
• Loaded shank : A shank is termed loaded
when it is contacting a tooth surface. A loaded
shank will produce a smaller displacement
amplitude at all power output settings than
one that is unloaded or not contacting a tooth
surface (Lea & Walmsley, 2000; Lea et al.,
2009). Loading has a greater effect on the dis-
placement amplitude of thin and ultra-thin
diameter shanks than thick. Chapter 9 will
teach you the lateral pressure used to cor-
rectly load a shank during ultrasonic instru-
mentation. Excessive pressure to the shank
will cause over-loading and leads to undesir-
able effects.
• Unloaded shank : A shank is unloaded when
it is free-floating and not contacting a tooth sur-
face. An unloaded shank has a greater degree
of displacement amplitude than loaded at all
power output settings which demonstrates the
effect loading has on the displacement ampli-
tude of the shank (Lea & Walmsley, 2000; Lea
et al., 2009.
• Quantity of water
• When the water flow is too high on a low or
medium power setting, the displacement am-
plitude of the shank will decrease (Pecheva
et al., 2016). This decreases equipment per-
formance and provider efficiency during ul-
trasonic instrumentation. For example, it will
Insert and Tip Shank 81
take longer to remove an oral deposit when
the water flow rate is too high while using a
low to medium power output (Pecheva et al.,
2016).
• When water flow is too high on a high power
setting, the displacement amplitude of the
shank is less affected (Pecheva et al., 2016).
• Loss of length: Over time the shank will become
worn and lose length. The displacement amplitude
will decrease with each millimeter lost, which also
decreases equipment performance and provider
efficiency during ultrasonic instrumentation.
The lowest power output that can achieve the
clinical goal should always be used. When the power
output is changed, the water flow rate must also be
changed.
• Increase power output = increase water rate flow
• Decrease power output = decrease water rate flow
Each insert and tip has power output require-
ments and restrictions. Some shank designs cannot
support higher power output settings and can break if
they are used on an unapproved setting by the man-
ufacturer. This leads to equipment damage and can
endanger the patient. Reference the DFU/IFU for this
information. Later chapters will provide this informa-
tion by manufacturer.
Shank Wear
The shank will naturally wear with use over time.
The shank will lose its length, which adversely im-
pacts the clinical efficiency of the insert and tip as
the active area antinode is worn away. Any wear
and loss of length causes a reduction in clinical per-
formance. Manufacturers provide wear guides to
assist the oral health-care provider in monitoring
their shank length. When a specific length has been
lost, which varies by manufacturer, the insert or tip
should be discarded.
Recommendations for monitoring shank length:
• The frequency of shank loss evaluation should be
determined based on frequency of use and care of
equipment.
• Always use your manufacturer’s wear guide as the
exact position of the nodal point on the shank can
vary by 0.5–1.0 mm between manufacturers. The
position of the nodal point influences replace-
ment recommendations. Manufacturers vary on
how they measure for loss of length. Some use
two lines on their wear guides while others use
three. The colors used for the lines also vary by
manufacturer (see Figure 5-31 and Figure 5-32).
82 Chapter 5 Ultrasonic Insert and Tip

A A

B
Figure 5-31 Dentsply Sirona and HuFriedyGroup
replacement wear guide—two lines on each insert that
are blue and red: A. Dentsply Sirona, B. HuFriedyGroup.
A: Reproduced with permission from Dentsply Sirona. B: Courtesy of HuFriedyGroup Mfg. Co., LLC

Follow the manufacturer’s directions for when

to retire an insert or tip based on loss of shank
length.
• Generally, when a shank loses approximately
2 mm in length (may vary up to 0.5–1.0 mm be-
tween manufacturers), it must be discarded (see
Table 5-5).
• With each millimeter lost, the oral deposit re- B
moval capability of the active area antinode
Figure 5-32 Acteon replacement wear guide: A. Three
decreases (Lea et al., 2006). When more than
lines on each tip that are green, yellow, and red, B. Two
3 mm is lost, the active area antinode is gone lines on each tip that are green and red.
and only the nodal point is being adapted on Reproduced with permission from ACTEON.
tooth surfaces, which produces no clinical effect
(see Figure 5-33). Remember, the nodal point will
not remove oral deposits.
BREAKOUT POINT
With each millimeter loss of shank length, the active Measuring Shank Wear
area antinode shortens, producing less clinical The steps for correctly measuring the shank for wear are:
activity. It will take longer to remove oral deposits
with each millimeter lost. 1. Obtain the insert wear guide from the manufac-
turer of your insert or tip.
 Insert and Tip Shank 83

2. Locate the correct insert or tip on the wear guide. 4. Determine how much wear, if any, is lost by the
3. Align the shank of the insert or tip to the wear shank length compared to the lines drawn on the
guide pictorial of the insert or tip. wear guide.

Rate of Shank Wear

Table 5-5 Replacement recommendations
The rate of shank wear is extremely variable and de-
Amount of Active pendent on many factors associated with provider
Area Lost Effect Discard use, such as:
1 mm* Reduction in clinical No
performance
• Frequency of use: The more an insert or tip is
used, the faster it will wear.
2 mm* Significant reduction in Yes • Improper technique: If the provider over-loads
performance the shank by applying excessive lateral pressure,
the insert or tip will wear faster. Chapter 9 will
*Represents an average. This figure could vary by 0.5–1.0 mm by
manufacturer based on exact position of the nodal point. teach the correct lateral pressure used during ul-
trasonic instrumentation.

Terminal 3.5 mm is always adapted to a tooth surface during ultrasonic instrumentation

No loss of active area antinode

3.5–
1 mm 2 mm 3.5 mm
4.5 mm

Entire active area antinode (3.5 mm) is adapted to tooth surfaces producing the clinical
actions of the shank. The nodal point is not adapted. Oral deposit removal is at 100%
efficiency.

1 mm loss of active area antinode

3.5–
2 mm 3.5 mm
4.5 mm

Active area antinode is reduced to 2.5 mm. Now 1 mm of the nodal point will be adapted
to maintain 3.5 mm adaptation to tooth surfaces during ultrasonic instrumentation. Oral
deposit removal efficiency is decreased by a minimum of 25%.

2 mm loss of length

3.5–
3.5 mm
4.5 mm

Active area antinode is reduced to 1.5 mm. Now 2 mm of the nodal point will be adapted
to maintain 3.5 mm adaptation to tooth surfaces during ultrasonic instrumentation. Oral
deposit removal efficiency is decreased by a minimum of 50%. It is time to discard and
retire the insert or tip.

3+ mm loss of length

3.5–
4.5 mm

Entire active area antinode is gone and only the nodal point is being adapted to tooth
surfaces. Oral deposit removal efficiency is 0%.

Figure 5-33 Shank wear and loss of length.

84 Chapter 5 Ultrasonic Insert and Tip

• Improper pairing with oral deposits: Using an in-
sert or tip on an oral deposit it is not designed
for will cause faster wear, for example, using a
thin-diameter shank for the removal of heavy
dental calculus. This type and size of deposit is
best removed with a thick-diameter shank.
• Improper power setting: Using a power setting
not allowed for an insert or tip will cause faster
wear and potential breakage of the shank.
• Manufacturer mix matching: Using an insert or
tip from one manufacturer in another’s ultrasonic
device can damage equipment, reduce efficiency,
and increase the rate of wear.
• Manufacturer insert and tip architectural de-
signs vary and are unique for their ultrasonic
device.
• Manufacturers vary on the power output of
their ultrasonic device. The user may un-
knowingly be using an incorrect power set-
ting for their insert or tip.

CASE STUDY
Your patient is a 28-year-old Caucasian female with a noncontributory medical history. The patient is not taking any over-
the-counter or prescription medications and has no drug allergies. Her Body Mass Index (BMI) is 22. She is a college
student, nonsmoker, with moderate alcohol intake on weekends.
Chief complaint: “My teeth do not feel clean and sometimes my gums bleed when I floss.”
Dental exam: occlusal caries present on the mandibular left first and second molars, which require composite res-
torations. See intraoral photographs. No previous orthodontics. Wisdom teeth were extracted a couple of months ago.
Occlusion: Class 1 bilateral with first molar relationship. Overbite of 4 mm. Mandibular anterior crowding.
Oral hygiene exam:
■ Disclosing solution revealed 92% of surfaces with biofilm and dental calculus (see intraoral photographs of the
maxillary right first and second molars, maxillary left premolars and first molar, and the maxillary left molars).
■ Generalized heavy biofilm.
■ Moderate supragingival dental calculus maxillary facial/buccal surfaces, mandibular lingual surfaces, and the
mandibular anterior facials. Light to moderate interproximal calculus throughout the mouth. Heavy biofilm
throughout. Mandibular right second molar has moderate subgingival calculus.
Periodontal exam:
■ Probe depths 2–3 mm generally except mandibular right second molar, which has 6 mm probe depths on all
surfaces.
■ Class II furcation involvement on the buccal and lingual of mandibular right second molar (see radiograph).
■ No bone loss is present except the mandibular right second molar, which has a vertical defect of 3 mm on the
distal. The dentist suspects the wisdom tooth was malpositioned and caused the boney defect.
■ No recession or mobility is present in the mouth.
■ 66% bleeding upon probing.
Tissue description:
■ Generalized loss of stippling, tissues generally erythematous.
■ Consistency is soft, spongy, and movable generally.
■ Bulbous gingiva mandibular right second molar, maxillary left anterior facial, and mandibular anterior facial and
lingual with additional rolling of the margins on the lingual.
 Insert and Tip Shank 85

Intraoral photograph: Mandibular anterior facial

surfaces

Intraoral photograph: Mandibular anterior lingual

surfaces

Intraoral photograph: Mandibular left anterior facial

surfaces
Intraoral photograph: Mandibular anterior facial
surfaces

Intraoral photograph: Maxillary right facial/buccal Intraoral photograph: Maxillary left anterior facial
surfaces surfaces

Intraoral photograph: Mandibular left molar occlusal Intraoral photograph: Maxillary right second molar
surfaces buccal surface
86 Chapter 5 Ultrasonic Insert and Tip

Intraoral photograph: Maxillary left premolar and molar

buccal and occlusal surfaces

Intraoral photograph: Maxillary right premolar and

molar occlusal surfaces

Intraoral photograph: Maxillary left molar buccal Intraoral photograph: Radiograph of the mandibular
surfaces right second molar

1. Based on the tissue consistency and oral deposit type, which diameter shank would you use subgingivally and why?
2. Based on the oral deposit level, what power output setting is not indicated and why?
3. What shank shape should be used on the mandibular right second molar and why?
4. What length shank should be used on the mandibular right second molar and why?
5. What shank shape and length should be used on all teeth except the mandibular right s­ econd molar and why?
6. What diameter shank would be the best selection to debride the supragingival interproximal areas on the
mandibular anterior and why?

Summary
A magnetostrictive insert and piezoelectric tip vary in
their materials and designs but have the same vibra-
tory elliptical motion of the active area antinode. Man-
ufacturers vary on their portfolio of inserts and tips
as well as power output. The power control changes
the displacement amplitude of the shank. The patient
clinical presentation dictates which diameter, shape,
and length of shank the oral health-care provider
Questions
1. Which of the following statements regarding
ferromagnetic laminate nickel plates is FALSE?
a. All magnetostrictive ferromagnetic laminate
nickel plates are manufactured the same.
b. Ferromagnetic laminate nickel plates can
become damaged if insufficient cooling water
is used during treatment.
c. Ferromagnetic laminate nickel plates can
become damaged from mishandling such as
placing a heavy item on top of them.
d. If any nickel plate becomes warped, splayed,
separated, fractured, or bent, the insert must
be dicarded.
2. Complete the sentence. Each insert has a
differently designed connecting body that
influences the _________ setting that can be used.
a. Stroke
b. Power
c. Water
d. Air
3. Which of the following is TRUE regarding a
magnetostrictive O-ring?
a. Manufacturers vary in the number of O-rings
present on an insert.
b. An O-ring should be lubricated with water
prior to each use.
c. A properly functioning O-ring will prevent
water leaking from the handpiece.
d. All of the above
4. Which of the following connects a tip to the
handpiece?
a. Wrench
b. Connecting body
c. O-ring
d. Shank
5. The piezoelectric stainless-steel shank tip
threader is torqued into what part of the
handpiece with a wrench?
a. Front driver
Questions 87
selects for procedures. The four clinical criteria used
for insert or tip selection is oral deposit type and size,
oral deposit location, tooth topography, and tissue
consistency. With use over time, the shank will wear
and lose length. The oral health-care provider must
monitor for this loss of length with the manufacturer’s
wear guide on a periodic basis.
b. Horn
c. Back driver
d. Piezoceramic discs
6. Which of the following is TRUE of a
piezoelectric tip?
a. All tips have the same tip threader design.
b. The shank performs the work or action of the
tip in the mouth.
c. The tip threader provides the proper torque
of the tip to the horn.
d. The piezoelectric stainless-steel shank is
torqued into the front driver.
7. Which of the following ultrasonic shank(s) is
used to debride a dental implant?
a. Titanium shank
b. Carbon shank
c. Diamond-coated shank
d. Both A and B
e. All of the above
8. Which of the following shank designs is used
for the debridement of complex anatomical
structures such as a furcation?
a. Thick straight shank
b. Thin straight shank
c. Thin curved shank
d. Ultra-thin straight shank
Match the following terms to the correct dental ul-
trasonic device for questions 9–15. Answer A for
magnetostrictive, B for piezoelectric, or C for both
magnetostrictive and piezoelectric. There is only one
correct answer choice for each question.
9. Wrench that houses the tip
10. Ferromagnetic nickel laminate plate
11. Stainless steel shank
12. Tip
13. Horn
88 Chapter 5 Ultrasonic Insert and Tip

23. Which diameter shank would be the best

14. Connecting body
choice for the removal of light dental calculus
15. Tip threader subgingivally with tissue consistency that is soft,
spongy, and movable?
Match the following clinical scenarios to the MOST
a. Thick diameter
correct shank design for questions 16–18. There is
b. Thin diameter
only one most correct answer for each question.
c. Ultra-thin diameter
16. Deep periodontal probe A. Longer shank d. Both B and C
depth with significant length e. All of the above
bone loss 24. True or False. A magnetostrictive insert and a
17. Heavy supragingival den- B. Thin-diameter piezoelectric tip shank both move in a vibratory
tal calculus shank elliptical motion.
a. True
18. Light to moderate dental C. Thick-diameter b. False
calculus shank
25. Decreasing the power output setting causes
19. Which of the following can damage a shank? which of the following to occur?
a. Dropping the insert or tip on the ground a. Frequency increases
b. Using incorrect power output settings b. Stroke length increases
c. Using an insert or tip past its recommended c. Displacement amplitude decreases
replacement time d. Vibratory elliptical motion stops
d. Applying excessive lateral pressure on the
26. You are using an ultrasonic for the removal of
shank when adapted to a tooth surface
heavy tenacious dental calculus. The oral deposit
e. All of the above
is not coming off on the low power output you
20. What type of water canula is made of a thin tube selected. You decide to turn up the power output
that attaches above and parallel to the shank of to high. What else do you need to do prior to
an insert or tip? resuming your ultrasonic instrumentation?
a. Internal water port a. Turn down the water flow rate
b. External water port b. Turn up the water flow rate
21. Which diameter shank would be the best choice c. Turn the water flow rate off
for the removal of heavy subgingival dental d. No adjustments are needed when you turn
calculus when tissues are soft, spongy, and the power output from low to high
movable? 27. Which of the following will cause the greatest
a. Thick diameter degree of displacement amplitude of the active
b. Thin diameter area antinode?
c. Ultra-thin diameter a. Low power setting
22. Which diameter shank would be the best b. Loading the insert or tip
choice for the removal of light dental calculus c. Unloading the insert or tip
subgingivally when tissues are firm, hard, and d. Insert or tip with loss of length
tightly adherent to the tooth root? 28. If the water flow rate is placed on the highest
a. Thick diameter level, at which power setting would the
b. Thin diameter displacement amplitude of the insert or tip
c. Ultra-thin diameter active area antinode be the least affected?
d. Both B and C a. Low
e. All of the above b. Medium
c. High

29. Which of the following has the greatest influence
on the displacement amplitude of an insert or
tip active area antinode?
a. Diameter of shank
b. Load
c. Quantity of water
d. Loss of length
30. Which diameter shank has the more predictable
displacement amplitude at all power output
settings with a more stable vibratory elliptical
motion?
a. Ultra-thin
b. Thin
c. Thick
d. All of the above
31. When an insert or tip shank ________ length
due to wear, the performance and cleaning
efficiency of the equipment _________.
References
1. Food and Drug Administration. (2021). Product classification.
https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpcd
/classification.cfm?id=1379
2. Kocher, T., Fanghanel, J., Sawaf, H. & Litz, R. (2001).
Substance loss caused by scaling with different sonic scaler
inserts: An in vitro study. Journal of Clinical Periodontology, 28,
9–15.
3. Lea, S. C., Felver, B., Landini, G., & Walmsley, A. D. (2009).
Three-dimensional analyses of ultrasonic scaler oscillations.
Journal of Clinical Periodontology, 36, 44–50. http://doi.org
/10.1111/j.1600-051X
4. Lea, S. C., Landini, G., & Walmsley, A. D. (2003).
Displacement amplitude of ultrasonic scaler inserts. Journal
of Clinical Periodontology, 30, 505–510.
5. Lea, S. C., Landini, G., & Walmsley, A. D. (2004). Assessing
the vibrations of dental ultrasonic scalers. Journal of Sound
and Vibration, 271, 1113–1120.
6. Lea, S. C., Landini, G., & Walmsley, A. D. (2006). The effect
of wear on ultrasonic scaler tip displacement amplitude.
Journal of Periodontology, 33, 37–41. http://doi.org/10.1111
/j.1600-015X.2005.00861.x
7. Lea, S. C., & Walmsley, A. D. (2000). Mechano-physical
and biophysical properties of power-driven scalers: Driving
References 89
a. Loses, increases
b. Loses, decreases
c. The shank length never changes.
32. When should an insert or tip be discarded?
a. When the shank loses 0.5 mm of length
b. When the shank loses 1 mm of length
c. When the shank loses 2 mm of length
d. Ultrasonic inserts and tips never need to be
discarded.
33. Which of the following can increase the rate of
insert and tip wear?
a. Increased frequency of use
b. Using a higher power setting than allowed for
the insert or tip per the manufacturer
c. Using a tip from one manufacturer in the
device of another
d. All of the above
the future of powered instrument design and evaluation.
Periodontology, 21(2009), 63–78.
8. Lea, S. C., & Walmsley, L. G. (2003). Ultrasonic scaler tip
performance under various load conditions. Journal of Clinical
Periodontology, 30, 876–881.
9. Pecheva, E., Sammons, R. L., & Walmsley, A. D. (2016).
The performance characteristics of a piezoelectric ultrasonic
dental scaler. Medical Engineering and Physics, 38, 199–203.
10. Tabatabai, H., Oliver, D. E., Rohrbaugh, J. W., & Papadopoulus,
C. (2013). Novel application of laser Doppler vibration
measurement to medical imaging. Sensing and Imaging, 14,
13–28. http://doi.org/10.1007/s11220-013-0077-1
11. Vastardis, S., Yukna, R. A., Rice, D. A., & Mercante, D.
(2005). Root surface removal and resultant surface texture
with diamond-coated ultrasonic inserts: An in vitro and SEM
study. Journal of Clinical Periodontology, 32, 467–473.
12. Vyas, N., Pecheva, E., Dehghani, H., Sammons, R. L.,
Wang Q. X., & Leppinen, D. (2016). High speed imaging
of cavitation around dental ultrasonic scaler tip. PLOS One,
11, 3, 1-12. http://doi.org/10.1371/journal.pone.0149804
13. Yukna, R. A., Vastardis, S., & Mayer, E. T. (2007). Calculus
removal with diamond-coated ultrasonic inserts in vitro.
Journal of Periodontology, 78(1), 122–126.
 CHAPTER 6
Ultrasonic Mechanism
of Action
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Describe the mechanical and fluid mechanism
of action of a dental ultrasonic device.
2. Define cavitation and acoustic cavitation and
understand the oral effects acoustic cavitation
produces in the mouth.
3. Explain the production, movement, and activity
of an acoustic cavitation vapor gas bubble.
4. Define acoustic microstreaming and explain
how its action contributes to acoustic cavitation
effects in the mouth.
5. Explain how a liquid jet is formed inside a vapor
gas bubble and list its advantages.
6. Understand the importance of using a coolant
during ultrasonic instrumentation.
7. Explain the clinical benefits of lavage and
irrigation during ultrasonic instrumentation.
KEY TERMS
• Acoustic cavitation: formation of vapor gas
bubbles in a sound wave at low-pressure regions
within a liquid when the liquid is accelerated to
high velocities and the bubbles implode when
they reach regions of higher pressure.
• Acoustic microstreaming: a fluid gradient, or
current, that transports acoustic cavitation
vapor gas bubbles away from their site of
release.
• Bernoulli’s principle: fluid dynamic principle of
liquid flow that states in a horizontal flow of fluid,
areas of higher velocity (speed) will have less
pressure.
• Cavitation: formation of a bubble in a liquid that
occurs when the liquid undergoes a rapid change
in velocity (speed).
•
Fluid: a liquid or gas substance that deforms
continuously when stresses are placed upon it
when in a fluid medium.
• Fluid dynamics: the study of fluids in motion.
• Hydrodynamic shear stress: force applied per
unit area in a fluid medium and results from the
friction between fluid particles, which causes
deformation of nearby substances.
• Irrigation: Application of a steady stream of fluid
to remove debris, or deliver a therapeutic agent
subgingivally.
• Kinetic energy: the energy an object or particle
possesses due to its motion.
• Lavage: the washing or flushing of fluid
subgingivally.
• Liquid jet: formation of a jet inside an acoustic
cavitation vapor gas bubble when the bubble
nears a solid surface.
• Mechanism of action: a device’s fundamental
physical processes responsible for an action.
• Oscillation: repeated back-and-forth rotational
movement about an equilibrium.
• Primary Bjerknes force: force that exists in any
sound field where there is a positive gradient
responsible for creating the oscillating motion of
an acoustic cavitation vapor gas bubble in a liquid
medium.
• Secondary Bjerknes force: a force that exists
between bubbles in the same sound field which
causes the bubbles to either repel or be attracted
to one another in a liquid medium.
• Viscosity: resistance of a substance to flow.
91
92 Chapter 6 Ultrasonic Mechanism of Action
Introduction
This chapter will present the mechanism of action pro-
duced by a dental ultrasonic device and relate these
concepts to clinical outcomes. A dental ultrasonic
device has profound microbiological effects in the
mouth through its mechanical and fluid mechanisms
of actions. When the active area antinode of the shank
contacts an oral deposit, its chipping action breaks the
bond from the tooth for removal. The fluid expelled
during active use serves multiple functions and pro-
duces direct and indirect effects. The fluid cools the
equipment from the heat dissipated during ultrasonic
wave production; provides a clear visual working field
for the operator; and changes the oral flora compo-
sition to promote a symbiotic environment through
acoustic cavitation, acoustic microstreaming, and liq-
uid jet production. This chapter will present both the
mechanical and fluid dynamic mechanisms of action
so the oral health-care provider understands the clin-
ical applications and limitations of dental ultrasonic
technology.
Mechanism of Action
Mechanism of action describes a device’s funda-
mental physical processes responsible for an action.
A dental ultrasonic will produce clinical effects in the
mouth through direct and indirect contact with oral
structures. The mechanical mechanism of action is
through direct contact and the fluid mechanism of ac-
tion is through indirect contact.
Mechanical Mechanism of
Action
As previously mentioned, a dental ultrasonic device
uses a transducer and active medium to convert elec-
trical energy into mechanical energy in the form of
two ultrasonic sound waves of a specific frequency.
The mechanical energy allows the device to perform
its work and clinical actions in the mouth. The ultra-
sonic sound waves cause the shank of an insert and
tip to vibrate in an elliptical motion that mechanically
chips away oral deposits upon direct contact.
Fluid Mechanism of Action
The study of fluids in motion is called fluid
­dynamics. A fluid is a liquid or a gas substance that
deforms continuously when stresses are placed upon
it in a fluid medium. When in use, a dental ultrasonic
delivers a constant flow of aqueous solution (most
commonly used is water), which is expelled into the
mouth and interacts with the oral environment in a
very dynamic way. The fluid contributes to the de-
vice’s mechanism of action in five ways:
1. Production of acoustic cavitation
2. Production of acoustic microstreaming
3. Production of liquid jets
4. Coolant
5. Lavage and irrigation
Through fluid dynamics of acoustic cavitation,
acoustic microstreaming, and the production of liquid
jets, profound microbiological changes occur in the
mouth. The fluid also functions as a coolant to dissi-
pate heat produced during ultrasonic instrumentation
and provides a lavage and irrigation for the provider.
Each of the five fluid dynamics is discussed next.
Acoustic Cavitation
Fluid dynamics tell us anytime a liquid undergoes a
rapid change in velocity (speed), cavitation occurs.
Cavitation is the formation of a bubble in a liquid.
For example:
• When you use a straw to blow air into a drink,
the bubbles that form on the surface are cavitation
bubbles (see Figure 6-1a).
• When waves break in an ocean, water flows over
boulders in a river, or a propeller on a boat cuts
through the water, the bubbles that form on the
surface are cavitation bubbles (see Figure 6-1b).
Humans can hear the cavitation bubbles in the
previous examples because the bubble formation and
size are within the audible range of human hearing
(20 Hz–20 kHz). Many industries, such as wastewa-
ter treatment, food processing, engineering and metal
casting, use technology that intentionally or unin-
tentionally produces cavitation bubbles (Fang et al.,
2018; Legay et al., 2011). For some industries, the
production of cavitation bubbles is a benefit, while for
others, it is a hazard.
• Hazard: In wastewater treatment, cavitation gas
bubbles will erode a pipe. Engineers intentionally
design equipment to avoid sudden changes in
fluid velocity and pressure to avoid the produc-
tion of cavitation bubbles.
• Benefit: In health care, dental and medical ultra-
sonic cleaners create cavitation gas bubbles to agi-
tate substances for the removal of bioburden prior
to sterilization (see Figure 6-2).
Cavitation also occurs in nature. For example,
a shrimp can produce a cavitation bubble when it

A
B on the Bernoulli principle, the larger diameter
Figure 6-1 Cavitation Bubbles. A. Blowing Air through
a Straw into a Glass of Milk. Note the Bubbles Forming
on the Surface. B. Driving a Boat Through Water. Note
the Bubbles Formed on the Water Surface Behind the
Propeller
B: © EmiliaUngur/Shutterstock.
Figure 6-2 Cavitation Gas Bubbles in an Ultrasonic
Cleaner
Mechanism of Action 93
moves fast enough underwater. The cavitation bubble
is used to kill its prey.
When cavitation is created in an environment of
sound waves (dental ultrasonic technology), the cav-
itational bubble formation is referred to as acoustic
cavitation (Legay et al., 2011). The fluid dynamic
of acoustic cavitation offers beneficial effects in the
mouth because it produces profound microbiological
changes. To understand the mechanism of action of
acoustic cavitation, you need to understand two prin-
ciples of water pressure and temperature first: the Ber-
noulli principle and water phase diagram.
Bernoulli Principle
In the field of fluid dynamics, the Bernoulli principle
relates the velocity (speed) of a fluid’s flow rate to the
pressure dynamic in the fluid medium. The Bernoulli
principle states that, in a horizontal flow of fluid, an
area of higher fluid velocity will exhibit less pressure.
Here is an example to help understand the
­Bernoulli principle of fluid dynamics:
• Refer to Figure 6-3. As the diameter of the system
increases in size, the water flow rate decreases be-
cause the fluid is contained in a larger area. Based
area with the slower fluid flow rate will have an
increase in fluid pressure.
• Refer to Figure 6-3. As the diameter of the sys-
tem decreases and becomes smaller, the water
flow rate increases. This is because the water is
contained in a smaller surface area. Based on
Bernoulli’s principle, the smaller diameter area
­
with the faster flowing fluid rate causes a decrease
in fluid pressure.
The change of pressure in response to the velocity
or flow rate of a fluid causes a release of energy called
kinetic energy. Kinetic energy is the energy an object
or particle possesses due to its motion (Encyclopedia
Britannica, 2017). In dental ultrasonic technology, ki-
netic energy is produced by changes in fluid velocity
Smaller diameter Increased diameter
leads to higher leads to slower
velocity or speed velocity or speed
of water flow of water flow
Figure 6-3 Bernoulli Principle
94 Chapter 6 Ultrasonic Mechanism of Action
and pressure. The kinetic energy released contributes
to the mechanism of action of an ultrasonic device.
Water Phase Diagram
Water changes from a solid, liquid, and gas with tem-
perature change. At ambient pressure, the melting
point of solid water (ice) is zero degrees Celsius, and
the boiling point of water is 100 degrees Celsius. These
changes in water phases are depicted in Figure 6-4.
Water can be made to change phases at tem-
peratures different than depicted in Figure 6-4 if the
A bubbles on a typodont that were produced during ul-
B diameter water-line tubing and the handpiece.
C uid vapor, and the kinetic energy generated
Figure 6-4 Water Phases with Temperature Change:
A. Solid Water (Ice), B. Solid Melting to Liquid, C. Gas
Vapor Water
C: © showcake/Shutterstock.
amount of pressure in an environment is altered. This
principle of temperature and pressure is typically de-
picted on a water phase diagram with temperature on
the x-axis and pressure on the y-axis (see Figure 6-5).
Notice the diagram shows liquid water turning to
gas vapor at temperatures below 100 degrees Celsius
(x-axis) when the pressure is decreased (y-axis).
Dental Ultrasonic Acoustic
Cavitation
Now that you understand the Bernoulli principle and
water phase diagram, let us come back to discussing
acoustic cavitation produced by a dental ultrasonic
device.
Dental Ultrasonic Acoustic Cavitation
Defined. Acoustic cavitation is defined as the
formation of vapor gas bubbles in a sound wave at
low-pressure regions within a fluid medium when the
liquid is accelerated to high velocities and the bubbles
implode when they reach regions of higher pressure
(Fang et al., 2018; Legay et al., 2011; National Institutes
of Health, 2000; Figure 6-6) shows acoustic cavitation
trasonic instrumentation. Humans are unable to hear
the implosion of acoustic cavitation bubbles produced
by a dental ultrasonic because the sound waves that
produce them are above the audible range of human
hearing (>20 kHz).
Acoustic cavitation is a fluid phenomenon that
takes advantage of the Bernoulli principle and the wa-
ter phase diagram. When in use, the dental ultrasonic
device has a constant flow of aqueous solution (most
commonly used is water) running through a narrow
• Based on the Bernoulli principle, an increase in
water flow velocity inside the dental water line
and handpiece will lead to a decrease in pressure
that generates and releases kinetic energy.
• When the water pressure falls below the vapor
pressure of water (see the water phase diagram
Figure 6-5), liquid water is converted to a vapor
gas bubble.
• The vapor gas bubble is released from the water
port on the shank into the mouth and is referred
to as the acoustic cavitation vapor gas bubble.
The bubble is a mixture of dissolved gases, liq-
from the change in fluid velocity and pressure
(Cheeke, 2002).
• The acoustic cavitation vapor gas bubble will im-
plode inside the mouth once it reaches an area

10 mPa
1 mPa
100 kPa
Pressure
10 kPa
1 kPa
100 Pa
10 Pa
–250 –200 –150 –100 –50
Temperature (°C)
Figure 6-5 Water Phase Diagram
Figure 6-6 Acoustic cavitation bubbles on dental
typodont (Dentsply Sirona Powerline 10 Fitgrip 30K
Ultrasonic Insert)
with higher pressure, above that of vapor gas.
With increasing pressure, water will convert from
a vapor gas back into a liquid (see the water phase
diagram Figure 6-5).
• When an acoustic cavitation vapor gas bubble im-
plodes in the mouth, it releases a shock wave that
has profound microbiological effects described
later in this chapter (Lauterborne & Ohl, 1997).
The shock wave is a result of two phenomena:
1. Release of stored kinetic energy inside the
bubble (Lauterborne & Ohl, 1997).
2. Changes in the activity of the water and fluid
immediately surrounding the acoustic cavi-
tation vapor gas bubble. The water immedi-
ately surrounding the bubble accelerates and
Mechanism of Action 95
0 50 100 150 200 250 300 350
Solid (ice)
Liquid (water)
Vapor (steam)
BREAKOUT POINT
An acoustic cavitation vapor gas bubble releases
a shock wave when it implodes inside the mouth,
causing profound microbiological effects.
deaccelerates violently, slamming into itself
because water is not compressible (Yamamoto
et al., 2021).
Acoustic Cavitation Vapor Gas Bubble
­Behavior. A dental ultrasonic releases many acous-
tic cavitation vapor gas bubbles in the mouth during
ultrasonic instrumentation that interact with one an-
other. The bubbles move in oscillating patterns in re-
sponse to the acoustic pressure (Stricker et al., 2013;
Zhang & Li, 2016). Oscillation is the repeated rota-
tional movement of the bubble about its equilibrium.
Imagine a tetherball game. In tetherball, a ball is
tethered to a metal pole by a cord (see Figure 6-7).
The pole is the ball’s equilibrium. The ball is swung
around the pole by the players. If you stop hitting the
ball, it will come to a stop and rest at its equilibrium
(pole). The bubble movement in acoustic cavitation
behaves in the same manner as the tetherball. The
bubble swings and rotates back and forth about its
equilibrium axis, eventually either imploding or com-
bining with a nearby bubble (see Figure 6-7).
There are two forces responsible for bubble oscil-
latory movement and the interactions bubbles have
with one another. The forces are termed primary and
secondary Bjerknes forces.
96 Chapter 6 Ultrasonic Mechanism of Action

B
Figure 6-8 Secondary Bjerknes forces: A. Bubble
repulsion (antiphase oscillation) that do not combine,
B. Bubble coalescence (in-phase oscillation) that
combine to make a larger bubble.

• Secondary Bjerknes forces: A secondary

A Tetherball
Oscillating acoustic cavitation gas vapor bubble
B of bacteria (Cheeke, 2002; Zhang & Li, 2016).
Figure 6-7 Acoustic Cavitation Vapor Gas Bubble
Movement: A. Tetherball, B. Oscillating Acoustic
Cavitation Gas Vapor Bubble
• Primary Bjerknes forces: A primary Bjerknes
force will exist in any sound field where there is
a positive gradient (Cheeke, 2002). When a bub-
ble in a liquid medium is subjected to a sound
field, it will interact with the sound field. Smaller
bubbles travel up the acoustic pressure gradient
while larger bubbles travel downward (Zhang &
Li, 2016; Leighton et al., 1990). This creates the
oscillatory movement of the bubble.
Bjerknes force explains the behavior of an acous-
tic cavitation vapor gas bubble in the sound field.
Once released in the mouth, each oscillating bub-
ble will interact with the other oscillating bubbles
in the environment in two ways:
1. The bubble will repel away from other bubbles
(Cheeke, 2002). Bubbles that oscillate in anti-
phase with one another (opposite directions)
will repel one another (Zhang & Li, 2016; see
Figure 6-8a). This action allows the bubble to
maintain its small spherical shape, which is
clinically desirable. When a bubble maintains
its shape integrity, it will implode and release a
productive and powerful shock wave capable of
causing microbiological changes in the mouth,
such as detaching and destroying biofilm com-
plexes on tooth surfaces and altering the cell walls
2. The bubble will be attracted to the other bub-
bles and want to combine with them (Cheeke,
2002). Bubbles that oscillate in phase with one
another (oscillating in the same direction) will
be attracted to each other and combine (Cheeke,
2002; Zhang & Li, 2016; Leighton et al., 1990;
see Figure 6-8b). This changes the shape, size,
and volume of the original bubble, making it
larger, which is not clinically desirable. When
bubble size increases beyond 10 µm, the bub-
ble loses its strong spherical shape, which de-
creases shock wave implosion effectiveness
(Cheeke, 2002; Stricker et al., 2013).

BREAKOUT POINT
It is clinically desirable to have an acoustic
cavitational vapor gas bubble maintain its small
spherical shape because it releases a productive
shock wave that can detach biofilm from tooth
surfaces and alter the cell walls of bacteria.
Acoustic Cavitation and Dental Ultra-
sonic Device. Acoustic cavitation occurs at the
antinodes of an ultrasonic shank, with the most sub-
stantial release at the active area antinode (terminal
1.0–3.5 mm; Vyas et al., 2016).
BREAKOUT POINT
The most substantial acoustic cavitation vapor gas
bubble release occurs at the active area antinode of
the ultrasonic shank.
The factors that influence the number of acoustic
cavitation vapor gas bubbles produced are:
• Power setting: A higher power output will pro-
duce a greater number of acoustic cavitation
­vapor gas bubbles than medium or low power
output (Vyas et al., 2016; Lea et al., 2005).
• Shank diameter: Thick, flat diameter shanks will
release less acoustic cavitation vapor gas bubbles
than thin and ultra-thin diameter shanks because
they have a smaller displacement amplitude at all
power output settings (Vyas et al, 2016). This is
beneficial because thin and ultra-thin shanks are
used subgingivally where periodontal infections
proliferate.
Acoustic Cavitation Oral Effects. When an
acoustic cavitation vapor gas bubble implodes and
releases its shock wave, profound microbiological
and physiological effects occur in the mouth. After
bubble implosion, the shock waves will extend out-
ward in a diverging wavelike pattern into the sur-
rounding environment of the mouth, where localized
pressure and temperature changes occur (National
Institutes of Health, 2000; Cheeke, 2002; Stricker
et al., 2013; see Figure 6-9a). The greatest effects o­ ccur
in the immediate area surrounding the bubble. The
fluid environment farther away from the bubble is af-
fected less. This is similar to skipping a rock on the
water: the biggest ripples in the water occur immedi-
ately around the rock on the first skip, and ripples are
smaller on subsequent skips. (see Figure 6-9b).
Mechanism of Action 97
A
B
Figure 6-9 Shock waves. A. Acoustic cavitation vapor
gas bubble implosion and shock wave release. Note the
shock wave greatest immediately outside the bubble,
B. Rock skipping in the water.
B: © Valley Journal/Shutterstock.
The acoustic cavitation vapor gas bubble shock
wave is capable of:
• Altering the oral flora bacterial composition of
the mouth by reducing motile rods, filaments,
and spirochetes and increasing cocci-shaped
bacteria (Baehni et al., 1992). These microbio-
logical changes promote a more symbiotic oral
microbiome.
• Disrupting the cell wall integrity of gram-positive
and gram-negative bacteria (National Institutes
of Health, 2000; Stricker et al., 2013). The shock
wave creates microfractures in the cell wall of bac-
teria. If the cell wall becomes compromised, the
bacteria will lyse and die. Gram-negative bacteria
have thinner cell walls than gram-positive bacte-
ria because they have less peptidoglycan. Gram-­
negative bacteria are more susceptible to cell wall
damage from the shock waves than gram-positive
because of their thinner cell walls. This is benefi-
cial in the treatment and long-term management
of gingival, periodontal, and peri-implant infec-
tions because many gram-negative species con-
tribute to disease pathogenesis (development of
disease), have negative effects in the mouth, and
contribute to dysbiosis.
98 Chapter 6 Ultrasonic Mechanism of Action
• Detaching adherent bacteria from a biofilm ma-
trix through changing the surface tension and ad-
hesion forces of the biofilm matrix (Vyas et al.,
2016; Gartenmann et al., 2017; Gomez-­Suzrez,
2001; Mueller et al., 2011; Pecheya et al., 2016).
This effect occurs through direct shank contact
with tooth surfaces and indirect contact. A bio-
film complex can be detached when the ultrasonic
shank is at a distance of 0.25–1.50 mm from the
biofilm (Pecheya et al., 2016). The etiological
agent of periodontal disease is plaque biofilm.
Through indirect contact, a dental ultrasonic will
decrease biofilm concentrations which promote
oral symbiosis.
BREAKOUT POINT
When an acoustic cavitation vapor gas bubble
implodes and releases its shock wave, the cell
wall integrity of bacteria is altered and biofilm is
detached from its surface. This is beneficial in the
treatment and management of gingival, periodontal,
and peri-implant infections.
Acoustic Microstreaming
In addition to acoustic cavitation vapor gas bubble
release in the mouth, another fluid phenomenon
­ site of release.
called acoustic microstreaming occurs during ultra-
sonic instrumentation. Fluid dynamics tell us that
acoustic microstreaming produces a fluid gradi-
ent, or current, that transports acoustic cavitation va-
por gas bubbles away from their site of creation and
release in the mouth. Imagine a waterfall in a river.
The river water flows in one direction toward the wa-
terfall, carrying any object floating on its surface, such
as a branch (see Figure 6-10). This is similar to acoustic
Figure 6-10 Waterfall
© Adib Zainal.MY/Shutterstock.
microstreaming, where the fluid gradient picks up and
carries acoustic cavitation vapor gas bubbles released
from an ultrasonic shank. This is a clinically desir-
able action because it allows acoustic cavitation vapor
gas bubbles to affect areas of the mouth distant from
the site of their creation and release. For ­example in
Figure 6-6:
• The provider is performing ultrasonic instrumen-
tation on the mandibular right first premolar buc-
cal surface where acoustic cavitation vapor gas
bubbles are being created and released from the
water port on the ultrasonic shank.
• The bubbles became trapped in the fluid gradient
created by acoustic microstreaming and traveled
forward to the mandibular right anterior facial
surfaces.
• When the bubbles reach an area with higher pres-
sure, above that of vapor gas in the mouth, they
will implode releasing their shock wave which af-
fects the oral environmental in that area.
BREAKOUT POINT
Acoustic microstreaming carries acoustic cavitation
vapor gas bubbles in a fluid gradient and allows
them to affect areas of the mouth distant from their
When fluid flow is on a large scale, it is termed
acoustic streaming, and when it is on a small scale,
such as produced by a dental ultrasonic device, it is
termed acoustic microstreaming. Acoustic streaming
and microstreaming can only occur in a viscous fluid
environment. Viscosity is defined as the resistance of
a substance to flow.
• Highly viscous fluid does not flow easily
(Wu, 2018).
• Low-viscosity fluid does flow easily (Wu, 2018).
• If an oral health-care provider is using an aque-
ous solution other than water in their dental
ultrasonic device, the viscosity of the fluid will
change. This may alter acoustic cavitation and
microstreaming effects and should be considered
in treatment decisions.
Acoustic Microstreaming Behavior
Once the acoustic microstreaming fluid gradient is
established, it will become more turbulent when
it approaches a solid surface such as a bacterial cell
wall. Think of the waterfall again. As the river water

Figure 6-11 Turbulent river water around a rock (solid
surface).
© Rexjaymes/Shutterstock.
Figure 6-12 Acoustic Cavitation Vapor Gas Bubble and
Acoustic Microstreaming Fluid Gradient
approaches the waterfall, its velocity and turbulence
increase. When faster flowing water encounters a
solid surface inside the river water, such as a rock,
it becomes extremely turbulent (see Figure 6-11). The
turbulence created by the acoustic microstreaming
fluid gradient during ultrasonic instrumentation is
helpful because it traps bacterial cells and draws them
closer into contact with the acoustic cavitation vapor
gas bubbles trapped inside the gradient.
• The fluid gradient flow is highest and most tur-
bulent immediately around the vapor gas bubble
and decreases in velocity (speed) and turbulence
farther away from the bubble (National Institutes
of Health, 2000; see Figure 6-12). Bacterial cells
are swept into the gradient and are immediately
drawn to the site of greatest turbulence and ve-
locity, which is immediately around the acoustic
cavitation vapor gas bubble (see Figure 6-13a).
• When bacteria are in close contact with the
acoustic cavitation vapor gas bubble, the acous-
tic micro­streaming fluid gradient will exert great
force on the side of the cell in closest proximity to
the bubble. The cell side farthest away from the
Mechanism of Action 99
Site furthest
from bubble
B
Site closest
to bubble
B
Figure 6-13 Acoustic microstreaming fluid gradient
and bacteria: A. Bacteria drawn into the fluid gradient’s
highest velocity site around an acoustic cavitation vapor
gas bubble, B. Bacteria cell wall closest to the bubble
has the greatest force exerted on it which leads to
hydrodynamic shear stress on the cell wall.
bubble will have less gradient forces placed upon
it (see Figure 6-13b).
• This repeated unequal distribution of forces on the
bacteria causes hydrodynamic shear stress on
the cell wall, leading to deformation, destruction,
and detachment from an adherent biofilm (Wu,
2018; Fabbri et al., 2016; Howlin et al., 2015).
Hydrodynamic shear stress is a force applied per
unit area in a fluid medium and results from the
friction between fluid particles.
BREAKOUT POINT
Hydrodynamic shear stress produced by acoustic
microstreaming destroys bacteria and detaches
biofilm from surfaces. This is helpful for preventive
and therapeutic procedures that remove oral deposits.
Acoustic Microstreaming Oral Effects
Acoustic microstreaming aids in the microbiologi-
cal and physical effects of acoustic cavitation in the
mouth. Acoustic microstreaming:
• Provides a transport for acoustic cavitation vapor
gas bubbles to circulate in the mouth and affect
areas distant from their site of creation and release
from the ultrasonic insert or tip shank.
100 Chapter 6 Ultrasonic Mechanism of Action
• Leads to hydrodynamic shear stress, which causes
a decreased ability for bacteria to store elastic en-
ergy and leads to detachment from an adherent
biofilm (Fabbri et al., 2016; Howlin et al., 2015).
Hydrodynamic shear stress deforms and destroys
bacterial cell walls and membranes (Wu, 2018).
Liquid Jets
The production of liquid jets contributes to a dental
ultrasonics’ fluid mechanism of action and provides
beneficial effects in the mouth.
Liquid Jets Defined
In addition to acoustic cavitation and microstreaming,
fluid dynamics also helps explain the formation of liq-
uid jets that occurs in the fluid medium created by
a dental ultrasonic. A liquid jet is formed inside an
acoustic cavitational vapor gas bubble when the bub-
ble is near a solid surface such as a bacterial cell wall or
the ultrasonic shank. A liquid jet enhances the effects
of acoustic cavitation and supplies energy for the for-
mation of additional vapor gas bubbles in the mouth.
Liquid Jet Formation
and Deformation
The steps for liquid jet formation and deformation are
listed here.
1. Acoustic cavitation vapor gas bubble nears a solid
surface such as a bacterial cell and the fluid gra-
dient becomes asymmetrical because the bacte-
ria (solid surface) is resisting fluid flow and the
bubble is not resisting fluid flow (see Figure 6-14a;
Cheeke, 2002; Lauterborne & Ohl, 1997).
2. The asymmetrical fluid flow causes an invagi-
nation on the top of the bubble and an internal
high-speed liquid jet will form (see Figure 6-14b;
Cheeke, 2002).
3. The liquid jet grows until it extends from one side
of the bubble to the other, forming a funnel like the
shape of a tornado (see Figure 6-14c; National Insti-
tutes of Health, 2000; Lauterborne & Ohl, 1997).
4. The liquid jet will cause the bubble to rotate until
its tail is pointing toward the solid surface (see
Figure 6-14d).
5. The liquid jet violently ejects from the bubble to
pierce the solid surface (bacteria), and the bub-
ble will snap back to its spherical shape. Upon its
ejection from the vapor gas bubble, the liquid jet
releases energy into the surrounding environment,
which is used to form additional vapor gas bubbles.
B
B
A B
B B
C D
Figure 6-14 Liquid Jet Formation and Deformation:
A. Acoustic Cavitation Vapor Gas Bubble Nears a
Bacteria Cell Wall, B. Top of Bubble Invaginates and
a Liquid Jet Begins to Form, C. Liquid Jet Extends
from One Side to the Other in a Funnel-Like Shape
resembling a tornado, D. Bubble Rotates So the Tail Is
Pointed Toward the Bacteria Cell Wall
Liquid Jet Effects in the Mouth
Liquid jets aid in the microbiological and physicolog-
ical effects of acoustic cavitation and acoustic micro­
streaming in the mouth by:
• Disrupting microbial cell wall integrity through
hydrodynamic shear stress (Bruian, 2004).
• Releasing energy in the environment that is used
to form new acoustic cavitation vapor gas bubbles
(National Institutes of Health, 2000).
BREAKOUT POINT
Liquid jets enhance the effects of acoustic cavitation
by aiding in bacterial reduction.
Coolant
The water, or any aqueous solution used during ul-
trasonic instrumentation, will act as a coolant during
active treatment. This prevents adverse effects to the
equipment and the patient. Thermal effects in the form
of heat are generated during ultrasonic use when:
1. The transducer converts electrical energy into me-
chanical energy (Legay et al., 2011).
2. Kinetic energy is produced as changes occur to
fluid velocity and pressure (Legay et al., 2011).
3. When an acoustic cavitation vapor gas bubble
implodes. This will cause temperature in the
surrounding fluid to rise (Legay et al., 2011;
Cheeke, 2002).
 Mechanism of Action 101

4. The velocity and turbulence of the acoustic mi-
crostreaming fluid gradient is increased (Legay
et al., 2011).
5. The ultrasonic shank is loaded onto a tooth sur-
face and frictional heat is generated. (Pecheya
et al., 2016).
The oral health-care provider is charged with
maintaining a correct liquid flow rate to avoid heat
damage to equipment and patient injury. The signs
too low a liquid flow rate was selected are:
• Handpiece feels hot: If the handpiece starts to feel
warm when performing ultrasonic instrumen-
tation, the liquid flow rate should be increased.
The handpiece should never feel hot to the touch
during instrumentation.
• Patient reports the liquid feels hot. It is normal for
the liquid to be warmer during ultrasonic instru-
mentation, but it should never feel hot or uncom-
fortable to the patient.
Lavage and Irrigation
The water released from the water port on the shank
will lavage and irrigate the mouth. Lavage refers to a
washing or flushing of the subgingival environment.
During times of gum inflammation, gingival crevic-
ular fluid volume will increase. The fluid contains a
mixture of organisms, inflammatory infiltrate, endo-
toxins, blood, and pus. Some manufacturers offer a
lavage function on their ultrasonic whereby only the
aqueous solution is expelled from the water port and
cavitation is turned off. In this function mode, the de-
vice will not remove oral deposits but will lavage the
subgingival environment.
Irrigation refers to the application of a steady
stream of fluid to remove debris, or deliver a thera-
peutic agent subgingivally. As presented in a previous
chapter, an oral health-care provider may choose to
deliver an alternate solution to water during ultra-
sonic instrumentation. For example, sterile saline is
used for surgical procedures and antimicrobials (CPC,
chlorhexidine, essential oil, hydrogen peroxide, po-
vidone iodine) may be delivered during times of
inflammation.
The continuous liquid flow from lavage and ir-
rigation produces a clearer visual working field
for the oral health-care provider during ultrasonic
instrumentation.

CASE STUDY
Case Presentation: Your patient is a 58-year-old Caucasian male with a non-contributory medical history. He is not tak-
ing any over-the-counter or prescription medications and has no drug allergies. His Body Mass Index (BMI) is 42 and he
is a nonsmoker with moderate alcohol intake.
Chief complaint: “The color of my teeth is changing and it looks like something is stuck to my two front lower teeth.”
Dental exam: No decay is found. Previous orthodontics as a teenager. Wisdom teeth have been extracted in the past.
Oral hygiene exam:
■ Disclosing solution revealed 99% of surfaces with biofilm and dental calculus.
■ Generalized heavy biofilm.
■ Moderate to heavy dental calculus and stain.
Periodontal exam:
■ Probe depths 2–3 mm generally with localized 4 mm on the mandibular anterior and two molars have 5 mm probe
depths on the distal. The 4–5 mm probe depths are bleeding.
■ No furcation involvement.
■ Recession and mobility cannot be accurately detected at the initial assessment.
■ 88% bleeding upon probing.
■ Slight horizontal bone loss mandibular anterior central and lateral incisors only.
1. Describe this patient’s gingiva on the mandibular anterior teeth.
2. Why can recession and mobility not be properly detected at the initial assessment?
3. What is this patient’s periodontal diagnosis based on the information provided?
4. What procedure should the dental hygienist perform based on the information provided?
5. Describe the patient’s occlusal classification and status.
6. What would be the best form of instrumentation (hand-activated or ultrasonic) for this patient and why? List the
advantages of your selection.
102 Chapter 6 Ultrasonic Mechanism of Action
Right bite Front bite
Mandibular right anterior lingual Mandibular anterior facial surfaces
surfaces
Summary
Through both mechanical and fluid mechanisms of ac-
tion, a dental ultrasonic will remove adherent oral de-
posits and free-floating organisms through direct and
indirect contact. The mechanical mechanism of action
allows for the removal of oral deposits through direct
contact. When the active area antinode is loaded onto
a tooth surface, the shank will physically chip away the
oral deposits for the oral health-care provider. The fluid
Questions
1. True or False. The mechanical mechanism of
action of a dental ultrasonic device occurs when
an insert or tip shank physically contacts an oral
deposit and, through its chipping action, breaks
the bond for removal.
a. True
b. False
Left bite
Mandibular anterior lingual surfaces
mechanism of action removes adherent biofilm and
free-floating organisms without direct contact. Acoustic
cavitation, acoustic microstreaming, and the production
of liquid jets cause profound microbiological changes in
the mouth, reducing pathogenic organisms and promot-
ing oral symbiosis. The aqueous solution expelled by an
ultrasonic device serves as a coolant and irrigant, and
maintains a clear visual working field for the provider.
2. Which of the following contributes to the
fluid dynamic mechanism of action of a dental
ultrasonic?
a. Acoustic cavitation
b. Acoustic microstreaming
c. Production of liquid jets
d. All of the above

Match the following fluid dynamic terms with their
correct definition for questions 3–7. There is only one
correct answer for each term.
3. Acoustic A. Formed inside a vapor
cavitation gas bubble when the
bubble is near a solid
surface and supplies
energy for the forma-
tion of additional vapor
gas bubbles in a fluid
medium.
4. Acoustic B. Formation of a bubble in
microstreaming a liquid that occurs when
the liquid undergoes a
rapid change in velocity
(speed).
5. Hydrodynamic C. Formation of vapor gas
shear stress bubbles in a sound wave
at low-pressure regions
within a liquid when
the liquid is accelerated
to high velocities and
implodes when they
reach regions of higher
pressure.
6. Cavitation D. A fluid gradient, or cur-
rent, that transports
acoustic cavitation vapor
gas bubbles away from
their site of creation and
release.
7. Liquid jet E. Force applied per unit area
in a fluid medium that
results from the friction
between fluid particles,
which causes deformation
of nearby substances such
as bacteria.
8. Fill in the blank. The fluid dynamic of the
Bernoulli principle states that in a horizontal
flow of fluid, as the velocity of a liquid’s flow rate
, the pressure will . another.
a. Increases, decrease
b. Decreases, decrease
c. Increase, increase
d. None of the above
Questions 103
9. What type of energy is created and transferred
to the acoustic cavitation vapor gas bubble when
the velocity of a liquid’s flow rate increases and
the pressure decreases, as supported by the
Bernoulli principle?
a. Magnetic
b. Electrical
c. Thermal
d. Kinetic
10. True or False. According to the water phase
diagram, at lower atmospheric pressure, a fluid can
vaporize as steam below its ambient boiling point.
a. True
b. False
11. Fill in the blank. The acoustic cavitation bubble
will implode inside the mouth and release a
shock wave. This action occurs when the bubble
reaches an area of pressure,
making the vapor gas convert back into a
.
a. Higher, liquid
b. Lower, liquid
c. Higher, solid
d. Lower, solid
Match the following definition of force to its cor-
rect description for questions 12–14. Answer A for
primary Bjerknes force, and answer B for secondary
Bjerknes force. There is only one correct answer for
each question.
12. Responsible for vapor gas bubbles repelling one
another.
13. Responsible for the oscillation movement of the
vapor gas bubble.
14. Responsible for vapor gas bubbles being
attracted to one another.
15. Which secondary Bjerknes force is desirable to
provide the most productive and effective shock
wave release from a vapor gas bubble implosion?
a. Bubbles that oscillate in antiphase with one
another.
b. Bubbles that oscillate in phase with one
c. Bubbles that repel one another.
d. Both A and C
e. All of the above.
104 Chapter 6 Ultrasonic Mechanism of Action
16. Which of the following will decrease acoustic
cavitation vapor gas bubble release from the
shank water port?
a. Using a low power setting
b. Using a thin ultrasonic insert or tip
c. Using a thick ultrasonic insert or tip
d. Both A and C
e. All of the above
17. Which of the following will occur in the mouth
when an acoustic cavitation vapor gas bubble
implodes and releases its shock wave?
a. The number of motile rods, filaments, and
spirochetes reduce.
b. Cell wall integrity of gram-positive and
gram-negative bacteria is altered.
c. Adherent bacteria in a biofilm are removed.
d. All of the above
18. True or False. When an acoustic microstreaming
fluid gradient approaches a solid surface, the
gradient becomes more turbulent.
a. True
b. False
19. Fill in the blank. The acoustic microstreaming
fluid gradient flow is immediately
around the vapor gas bubble and
in velocity (speed) farther away from the bubble.
a. Lowest, decreases
b. Highest, increases
c. Highest, decreases
d. Lowest, increases
20. Which of the following is true of acoustic
microstreaming effects in the mouth?
References
1. Baehni, P., Thilo, B., Chapuid, B., & Pernet, D. (1992). Effects
of ultrasonic and sonic scalers on dental plaque microflora in
vitro and in vivo. Journal of Clinical Periodontology, 19, 455–459.
2. Brujan, E. A. (2004). The role of cavitation microjets in the
therapeutic applications of ultrasound. Ultrasound in Medicine
and Biology, 30(3), 381–387. https://doi.org/10.1016/j
s.ultrasmedbio.2003.10.019
3. Cheeke, J. D. N. (2002). Fundamentals of applications of
ultrasonic waves. CRC Press.
4. Encyclopedia Britannica. (2017). Mechanical energy. http://
www.britannica.com/science/kinetic-energy
5. Fabbri, S., Johnston, D. A., Rmaile, A., Gottenbos, B.,
De Jager, M., Aspiras, M., Starke, E. M., Ward, M. T., &
Stoodley, P. (2016). Streptococcus mutans biofilm transient
viscoelastic fluid behavior during high-velocity microsprays.
Journal of the Mechanical Behavior of Biomedical Materials, 59,
197–206. https://doi.org/10.1016/j.jmbbm.2015.012
a. Transport and circulate acoustic cavitation
vapor gas bubbles in the mouth
b. Causes hydrodynamic shear stress that aids in
the detachment of biofilm
c. Release shock waves into the environment
d. Both A and B
e. All of the above
21. Which of the following is true of liquid jet
effects in the mouth?
a. Releases shock waves
b. Supplies energy for the formation of
additional vapor gas bubbles
c. Transports and circulates acoustic cavitation
vapor gas bubbles
d. Creates a fluid gradient
22. Why must an ultrasonic emit an aqueous
solution to serve as a coolant during ultrasonic
instrumentation?
a. Cool the oral fluid environment that is
heated from acoustic cavitation and acoustic
microstreaming.
b. Cool the surface of the tooth from the
frictional heat that is created from loading a
shank on a tooth surface.
c. Dissipate the heat generated when the
transducer converts electrical energy into
mechanical energy.
d. All of the above
23. Which of the following is NOT a function of the
fluid expelled from a dental ultrasonic device?
a. Coolant
b. Lavage and irrigation
c. Maintenance of a clear visual working field
d. All of the above
6. Fang, Y., Yamamoto, T., & Komarov, S. (2018). Cavitation
and acoustic streaming generated by different sonotrode tips.
Ultrasonics-Sonochemistry, 48, 79–87. https://doi.org/10.1016
/j.ultsonch.2018.05.011
7. Gartenmann, S. J., Thurnheer, T., Attin, T., & Schmidlin, P.
R. (2017). Influence of ultrasonic tip distance and orientation
on biofilm removal. Clinical Oral Investigations, 21(4),
1029–1036. https://doi.org/10.1007/s00784-016-1854-8
8. Gomez-Suzrez, C., Busscher, H., Henry, C., & Mei, V. D.
(2001). Analysis of bacterial detachment from substratum
surfaces by the passage of air-liquid interfaces. Applied and
Environmental Microbiology, 67(6), 2531–2537. https://doi
.org/10.1128/AEM.67.6.2531-2537.2001
9. Howlin, R. P., Fabbri, S., Offin, D. G., Symonds, N., Kiang,
K. S., Knee, R. J., Yoganantham, D. C., Webb, J. S., Birkin,
P. R., Leighton, T. G., & Stoodley, P. (2015). Removal of
dental biofilms with an ultrasonically activated water stream.

Journal of Dental Research, 94(9), 1303–1309. https://doi
.org/10.1177/0022034515589284
10. Lauterborne, W., & Ohl, C. D. (1997). Cavitation bubble
dynamics. Ultrasonic Sonochemistry, 4, 65–75.
11. Lea, S. C., Price, G. J., & Walmsley, A. D. (2005). A study to
determine whether cavitation occurs around dental ultrasonic
scaling instruments. Ultrasonics Sonochemistry, 12, 233–236.
https://doi.org/10.1016/j.ultsonch.2003.006
12. Legay, M., Gondrexon, N., Le Person, S., Boldo, P., &
Bontemps, A. (2011). Enhancement of heat transfer by
ultrasound: Review and recent advances. International
Journal of Chemical Engineering, 670108, 1–17. https://doi
.org/10.1155/2011/670108
13. Leighton, T. G., Walton, A. J, & Pickworth, M. J. W. (1990).
Primary Bjerknes forces. European Journal of Physics, 11,
47–50.
14. Mueller, P., Guggenheim, B., Attin, T., Marlinghaus, E., &
Schmidlin, P. R. (2011). Potential of shock waves to remove
calculus and biofilm. Clinical Oral Investigations, 15(6),
959–965. https://doi.org/10.1007/s00784-010-0462-2
15. National Institutes of Health. (2000). Section 2—Definitions
and description of nonthermal mechanisms. Journal
Ultrasound Medicine, 19(2), 77–168.
References 105
16. Pecheva, E., Sammons, R. L., & Walmsley, A. D. (2016).
The performance characteristics of a piezoelectric
ultrasonic dental scaler. Medical Engineering and Physics, 38,
199–203.
17. Stricker, L., Dollet, B., Rivas, D. F., & Lohse, D. (2013).
Interacting bubble clouds and their sonochemical production.
Journal Acoustic Society of American, 1854–1862. https://doi
.org/10.1121/1.4816412
18. Vyas, N., Pecheva, E., Dehghani, H., Sammons, R. L.,
Wang Q. X., & Leppinen, D. (2016). High speed imaging
of cavitation around dental ultrasonic scaler tip. PLOS
One, 11(3), e0149804. https://doi.org/10.1371/journal.pone
.014980400
19. Wu, J. (2018). Acoustic streaming and its applications. Fluids,
3, 108. https://doi.org/10.3390/fluids3040108
20. Yamamoto, T., Kubo, K., & Komarov, S. V. (2021). Characterization
of acoustic streaming in water and aluminum melt during
ultrasonic irradiation. Ultrasonics Sonochemistry, 71(105381),
1–8. https://doi.org/10.1016/j.ultrsonch.2020.105381
21. Zhang, Y., & Li, S. (2016). The secondary Bjerknes force
between two gas bubbles under dual-frequency acoustic
excitation. Ultrasonics Sonochemistry, 29, 129–145. https://doi
.org/10.1016/j.ultsonch.2015.08.22
 CHAPTER 7
Ultrasonic Historical
and Contemporary ­Clinical
Applications and
Contraindications
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Recognize the medical and dental clinical uses
of ultrasonic and ultrasound technology.
2. Relate the historical clinical applications of dental
ultrasonic technology and periodontal disease
pathogenesis to the equipment of that time.
3. Compare and contrast the traditionalist and
contemporary theoretical approaches to
ultrasonic instrumentation.
4. Understand current periodontal disease
pathogenesis and the advantages of
incorporating a contemporary approach to
ultrasonic instrumentation in patient treatment
and disease management.
5. Appraise the differences between ultrasonic
and hand-activated instrumentation for
periodontal debridement.
6. Recognize historical and contemporary
considerations and contraindications for
ultrasonic instrumentation.
KEY TERMS
• Burnished calculus: deposit that is incompletely
removed during instrumentation and when
present on a root, becomes tenaciously adherent
to cementum and can contribute to disease
pathogenesis.
• Consideration: a factor or variable that should
be taken into account and the potential
consequences weighed against the benefits prior
to implementing a technology or procedure into a
patient care plan.
• Contraindication: a situation when a patient
should not receive treatment because it may be
harmful.
• Cyst: pathologic sac or cavity lined with
epithelium and enclosed in a connective tissue
capsule (Ibsen & Phelan, 2018).
• Granuloma: mass of inflammatory tissue
consisting of macrophages, giant cells, and
lymphocytes (Ibsen & Phelan, 2018).
• Lymphadenopathy: disease of the lymph node
causing palpable enlargement.
• Pathogenesis: manner of disease development.
• Periodontal debridement: a procedure of
instrumentation that promotes tooth conservation
while removing oral deposits to decontaminate
periodontal pockets and the mouth.
• Sialadenitis: inflammation, swelling, or infection
of a salivary gland.
• Sialolith: salivary gland stone.
• Tumor: a benign or malignant swelling or
enlargement of tissue (Johns Hopkins Medicine,
2020).
• Work-related musculoskeletal disorders
(WMSDs): injuries of muscles, nerves, tendons,
joints, cartilage, and spinal discs that occur and
are made worse by a work environment.
107
108 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications
Introduction
The field of ultrasonics has technology spanning the
entire health-care spectrum with medical and dental
devices used for a variety of purposes. Dental ultrasonic
technology first came to the market in the 1950s and
was designed to meet the standards of clinical p ­ ractice
at that time. The procedure of periodontal ­debridement
did not exist, and dental hygiene procedures were
focused on the removal of dental calculus and root plan-
ing cementum to a “glassy-smooth” finish. Ultrasonic
instrumentation was viewed as an adjunct to hand-
activated instrumentation for decades as the traditional-
ist approach to ultrasonic instrumentation was practiced.
In the 1990s, as the theories on periodontal dis-
ease etiology began to shift away from dental calcu-
lus to plaque biofilm, the procedure of periodontal
debridement was born. The contemporary approach
to ultrasonic instrumentation began to take shape as
manufacturers developed new and improved ultrasonic
technology with insert and tip shank designs intended
for safe root debridement and access to complex anat-
omy such as furcations. Ultrasonic instrumentation was
found to cause less alterations and removal of cemen-
tum than hand-activated instrumentation.
While overall clinical outcomes are similar for
hand-activated and ultrasonic instrumentation, there
are stark differences in terms of subgingival penetra-
tion, microbial reduction, furcation access, cemental
alterations, efficiency, and ergonomics. Through dis-
covering the differences between hand-activated and
ultrasonic instrumentation, the oral health-care pro-
vider will be able to make educated and informed de-
cisions of which instrumentation technique is best for
their patient presentation.
This chapter will provide both a historical tradi-
tionalist and current contemporary approach to ul-
trasonic instrumentation and the considerations and
contraindications for each. A deeper understanding of
ultrasonic technology will be gained through recog-
nizing theories of the past and present.
A contemporary approach to ultrasonic in-
strumentation meets the standards of practicing
periodontal medicine as outlined in the “2018 Clas-
sification of periodontal and peri-implant diseases and
conditions” from the American Academy of Periodon-
tology and European Federation of Periodontology.
Periodontal medicine applies a multidimensional
view of periodontal disease and considers individ-
ual patient characteristics in diagnostic and treat-
ment recommendations. The goal of preventive and
maintenance procedures is to detoxify root structures
while conserving cementum through the removal of
oral deposits to promote oral symbiosis. This current
theoretical approach to periodontal disease etiology,
treatment, and management is vastly different than in
decades past and requires a contemporary approach
to instrumentation.
Medical Clinical
Applications of
Ultrasonics
Medicine has a diversified portfolio of ultrasonic use.
The following is a list of common examples:
• High-frequency (>1 MHz) ultrasound imaging is
used to view internal structures and monitor fetal
development.
• Low-frequency (20–60 kHz) ultrasonics are used
in surgical procedures for tissue cutting and ab-
lation in multiple disciplines such as orthopedic,
ophthalmic, surgical, gastrointestinal, oral maxil-
lofacial, urological, neurosurgery, and cardiovas-
cular (O’Daly et al., 2008; Zilonova et al., 2019).
• Drug and gene delivery can be enhanced through
ultrasonic acoustic cavitation and microstreaming
(Zilonova et al., 2019; Ng & Liu, 2002; Pitt et al.,
2004).
• Physical therapy uses ultrasonics to decrease mus-
cle and joint pain through ultrasound diathermy
(delivery of heat), which utilizes an ultrasound wave
frequency range of 800 kHz–1 MHz (Forfang et al.,
2013). Ultrasound is also used for rehabilitation ther-
apy of musculoskeletal injuries (Spratt et al., 2014).
• Orthopedic professionals use ultrasonics during
surgical procedures to determine when they are
cutting through bone cement and cortical bone
(Forfang et al., 2013; Novak et al., 2008). Ul-
trasonics are also used to enhance bone fracture
healing with extracorporeal shock wave therapy
(Forfang et al., 2013; Novak et al., 2008).
• Ultrasonic shock wave therapy is used to dis-
solve calcified tendonitis, break apart gallstones
and kidney stones, and remove fatty tissue during
lipoplasty (liposuction; Schoenfield et al., 1990;
Yang et al., 2019; Zocchi et al., 2020).
Dental Clinical
Applications of Ultrasonics
This section will discuss the historical and contempo-
rary clinical applications of dental ultrasonics. You will
gain an in-depth perspective of ultrasonic instrumen-
tation as you learn theories of the past and present.

Historical Clinical Applications
In the 1950s, clinical trials began showing an ultra-
sonic device with a frequency range of 20–60 kHz in
the presence of a water medium was capable of re-
moving oral deposits and hard and soft tissues in the
mouth (O’Daly et al., 2008; Arabaci et al., 2007). The
magnetostrictive ultrasonic device came to the dental
market first in the 1950s, followed by piezoelectric in
the 1970s.
Magnetostrictive Ultrasonic Devise
Dentsply Sirona was the first manufacturer to produce
a dental magnetostrictive ultrasonic device in 1957
called the Cavitron Model 30 Scaler (see Figure 7-1).
The device was first marketed as an instrument to
remove decay in operative dentistry but could not
compete with the efficiency and effectiveness of high-
and low-speed turbine drills (Bains et al., 2008; Chen
et al., 2013). The device was then explored for a
potential role in periodontics, and by the 1960s, was
rebranded for oral deposit removal.
The device was manufactured without a set ultra-
sonic sound wave frequency. The oral health-care pro-
vider had to manually “tune” the transducer and active
medium to produce the desired ultrasonic sound wave
frequency (see Figure 7-2). Tuning the device to a spe-
cific wave frequency was challenging and produced
great variability in ultrasonic treatment outcomes and
patient comfort.
Figure 7-1 Early magnetostrictive ultrasonic device—
Dentsply Sirona Cavitron Model 30 Scaler.
Reproduced with permission from Dentsply Sirona
Dental Clinical Applications of Ultrasonics 109
The original insert design was a short, straight,
thick-diameter shank with an external water port be-
cause it was originally designed for decay removal
(see Figure 7-3). Once the magnetostrictive ultrasonic
device was rebranded for the field of periodontics and
oral deposit removal, the single design of the insert
limited the use and functionality in the mouth. Access
subgingivally and adaptation to complex root anat-
omy was a challenge and not always possible.
Piezoelectric Ultrasonic Device
The first dental piezoelectric ultrasonic device was
marketed for oral deposit removal in 1970 and
then later developed for surgical procedures (Chen
et al., 2013). Satalec, now blanketed under Aceton,
was the first manufacturer to sell a dental piezoelec-
tric ultrasonic device (see Figure 7-4). Tip design op-
tions were similar to the original insert design, which
limited subgingival access and adaptation to complex
root anatomy.
Tuning knob
Figure 7-2 Dentsply Sirona Cavitron Model 30 Scaler
tuning knob top right.
Reproduced with permission from Dentsply Sirona
Figure 7-3 Early magnetostrictive insert (Dentsply
Sirona Cavitron P Series 10 Metal Grip 25K Ultrasonic
Insert.
Reproduced with permission from Dentsply Sirona
110 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications
Figure 7-4 Early piezoelectric ultrasonic device by
Satalec.
Reproduced with permission from ACTEON
Sonic Scaler
The sonic scaler is not an ultrasonic device and is not
covered in this textbook because its technology for
periodontal debridement is obsolete. The sonic scaler
was released to the dental market in the 1970s as a
less expensive alternative to ultrasonic technology for
scaling and root planing procedures (Lea & Walmsley,
2000). The sonic scaler does not have a transducer or
active medium but is an air-driven turbine unit with a
low-frequency range 2–6 kHz (Arabaci et al., 2007).
Tip movement produced by the low frequency range
is a circular orbital motion (Lea & Walmsley, 2000).
Ultrasonic devices have replaced the sonic scaler for
periodontal debridement because the sonic scaler:
• Does not produce acoustic cavitation, acous-
tic microstreaming, or liquid jets (Arabaci et al.,
2007; Lea & Walmsley, 2000).
• Causes increased cemental damage and rough-
ness compared to an ultrasonic device (Arabaci
et al., 2007; Lea & Walmsley, 2000).
• Does not remove oral deposits as efficiently or
effectively as an ultrasonic device.
• Causes more patient discomfort than an u­ ltrasonic
device due to its low-frequency range.
• Includes tip designs that are limited and bulkier
than an ultrasonic insert or tip, limiting its use
subgingivally.
Periodontal Therapy
From 1957 until the mid-1990s, ultrasonic instru-
mentation was used an adjunct to traditional hand-­
activated instrumentation because there was a lack
of ultrasonic insert and tip designs on the market.
The provider was taught to use aggressive and force-
ful scaling strokes with hand-activated instruments
to remove oral deposits, cementum, and diseased
epithelial tissue. Cementum was root planed to a
“glassy-smooth finish” and the focus of dental hygiene
procedures was on the removal of dental calculus. This
methodology of dental hygiene treatment stopped by
the mid-1990s when a paradigm shift in the identi-
fication, treatment, and management of periodontal
disease occurred.
In the early 1990s, dental biofilm and free-­floating
planktonic bacteria were discovered to be the etio-
logical agents of periodontal disease in a susceptible
host and not dental calculus. The term periodontal
debridement was introduced by Irene Woodall,
RDH, PhD, in 1993 as a procedure of instrumen-
tation that promotes tooth conservation while re-
moving oral deposits to decontaminate periodontal
pockets and the mouth (Hinchman et al., 2016).
Periodontal debridement taught the provider to con-
serve cementum during instrumentation and not
root plane it to a “glassy-smooth finish.” Debride-
ment focused on biofilm reduction and not dental
calculus removal.
BREAKOUT POINT
Periodontal debridement is a procedure of
instrumentation that promotes tooth conservation
while removing oral deposits to decontaminate
periodontal pockets.
This paradigm shift inspired dental ultrasonic
manufacturers to create a new portfolio of inserts and
tips in the 1990s. Thinner diameter, longer length,
and curved shank shapes were designed to access the
subgingival environment and conform to complex
root anatomy (see Figure 7-5a and b). Research was
demonstrating better root conservation and less ce-
mental injury, removal, alteration, and abrasion with
these new ultrasonic insert and tip designs compared
to hand-activated instruments.
By 1999, the American Academy of Periodontol-
ogy (AAP) had released a new classification system of
periodontal health and disease, which was used for the
next 19 years until 2018 when the AAP and the Eu-
ropean Federation of Periodontology launched a new
classification system called the “2018 classification
of periodontal and peri-implant diseases and condi-
tions” (Armitage, 2000). In 2000, the AAP released a
position paper supporting the use of a thin-diameter
curved shank shape for debriding furcation defects
due to their smaller diameter, longer reach, and ce-
mental conservation compared to hand-activated in-
struments (Drisko et al., 2000). The AAP also stated
that ultrasonic instrumentation was equally effective

B of a failed root canal (Chen et al., 2013; see
Figure 7-5 Thin diameter straight and curved shape
shanks: A. Dentsply Sirona Slimline 10L (curved), 10S
(straight), 10R (curved) Fitgrip 30K Ultrasonic Inserts,
B. Acteon P2R, P2L curved tips.
Reproduced with permission from Dentsply Sirona
in the removal of biofilm, calculus, and endotoxins
­compared to hand-activated instrumentation (Drisko
et al., 2000).
Contemporary Clinical
Applications
Today, magnetostrictive and piezoelectric ultrasonics
have a magnitude of clinical applications in the field
of dentistry.
Dental Clinical Applications of Ultrasonics 111
Figure 7-6 Periapical lesion on the maxillary right
lateral incisor.
Endodontics
The clinical applications of a dental ultrasonic device
in the field of endodontics includes:
• Debridement and smear layer removal during
root canal procedures through the effects of
acoustic cavitation, acoustic microstreaming,
and liquid jet production (Van der Sluis et al.,
2007).
• Delivery of chemical medicaments to the root ca-
nal space (Van der Sluis et al., 2007).
• Removal of existing materials such as gutta per-
cha, silver points, and posts during retreatment
Figure 7-6).
Operative Dentistry
The clinical applications of a dental ultrasonic device
in the field of operative dentistry includes (Nitovas
et al., 2017):
• Removal of demineralized hard tissue (see
Figure 7-7).
• Preservation of intact marginal ridges when prep-
ping for restoration placement.
• Beveling of inaccessible cervical margins (see
Figure 7-8).
• Finite finishing of crown or veneer margins to
avoid gingival injury with a rotary bur.
112 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications
Figure 7-7 Demineralization and staining in the pits and
fissures of two mandibular molar teeth.
Figure 7-8 Cervical facial decay of the maxillary
right canine.
Oral and Maxillofacial Surgery (OMS)
The clinical applications of a dental ultrasonic device
in the field of OMS includes:
• Cutting of bone (osteotomy) to section hard tis-
sues (Chen et al., 2013).
• Implant surgeries to aid in alveolar bone crest
augmentation, removal of a dental implant, bone
harvesting, crestal bone splitting, and maxillary
sinus floor elevation (Chen et al., 2013; see
Figure 7-9).
• Repositioning of the inferior alveolar nerve
(Mohan et al., 2015; see Figure 7-10).
• Disintegrating calcium deposits in salivary ducts
with extracorporeal shock wave therapy (Ntovas
et al., 2017).
OMS uses ultrasonography to image structures
inside the body with a frequency above 1 MHz. Imag-
ing is used for the viewing of:
Figure 7-9 Implant and maxillary sinus augmentation.
Note the maxillary sinus wall apical to the maxillary left
molar and premolar teeth.
Figure 7-10 Alveolar nerve repositioning. Note the
alveolar nerve outlined on the mandibular right.
• Soft-tissue lesions such as cysts (pathologic sac or
cavity lined with epithelium and enclosed in a con-
nective tissue capsule; Ibsen & Phelan, 2018), gran-
ulomas (mass of inflammatory tissue consisting of
macrophages, giant cells, and lymphocytes; Ibsen
& Phelan, 2018), and tumors (neoplastic swelling
or enlargement growth either benign or malignant;
Johns Hopkins Medicine, 2020; see Figure 7-11a to c).
• Infections in the superficial facial spaces such as
an abscess (Mohan et al., 2015).
• Periapical lesions caused by a bacterial infec-
tion of the root, pulp, or periodontal tissue (see
Figure 7-12; Chen et al., 2013).
• Assess bone healing post-surgery (Mohan et al.,
2015).
• Detect and aid in removal techniques of for-
eign bodies such as a broken dental instrument
(Mohan et al., 2015).
• Structures associated with the temporomandibular
joint (TMJ) such as the joint, discs, and adjacent
soft tissues to aid in the management and treat-
ment of temporomandibular disorder (TMD) and
 Dental Clinical Applications of Ultrasonics 113

Figure 7-12 Periapical lesion on the maxillary right

lateral incisor.

Figure 7-13 Temporomandibular joints visible on a

panoramic radiograph.

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

Orthodontics
C The clinical applications of a dental ultrasonic device
in the field of orthodontics includes:
Figure 7-11 Soft tissue lesions: A. Lesion on the buccal
mucosa, B. Lesion on the left retromolar pad, C. Left • Orthodontic bracket debonding and residual ce-
lateral border of the tongue lesion. ment removal (Chen et al., 2013).
114 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications

Periodontics and Dental Hygiene

The clinical applications of a dental ultrasonic device
in the field of periodontics and dental hygiene include:
• Removal of oral deposits.
• Biofilm reduction.
• Aid in periodontal surgeries.
• Removal of a small amalgam or composite res-
toration overhang. Figure 7-15 shows large over-
hangs where a rotatory bur would be the better
option for removal than an ultrasonic.
• Removal of small to medium-size retained cement
around a fixed prosthesis (crown, inlay, onlay) as

Figure 7-14 Salivary gland swelling left floor of the

mouth.

• Decreasing root resorption by decreasing osteo-

clast number and activity (Mehta et al., 2016).
• Decreasing orthodontic treatment time by accel-
A
erating alveolar bone remodeling (Mehta et al.,
2016).
Similar to OMS, the specialty of orthodontics uses
ultrasonography to image structures inside the body.
Imaging is used for:
• Tongue posture and swallowing patterns (Mehta
et al., 2016).
• Thickness of the masseter muscle, which influences
craniofacial growth patterns and malocclusion risk
(Chen et al., 2013; Patini et al., 2019). Orthodon-
tic appliances have the potential to change mus-
cle thickness and subsequently change the forces
transmitted to skeletal and dental tissues (Patini
et al., 2019).
• Facial structures to aid in appliance selection
(Mehta et al., 2016).
• Gingival soft tissue thickness to aid in temporary
anchorage device (TAD) positioning (Mehta et al.,
2016). TADs such as a miniscrew, miniplate, or im-
plant provide anchorage to aid in tooth movement
with appropriate forces to decrease undesired effects. B
TADs are used for many purposes such as to close Figure 7-15 Restoration overhangs: A. Overhang
spaces, intrude or extrude teeth, reposition teeth restoration on the distal of the mandibular right first
upright, and aid in erupting an impacted tooth, or molar, B. Overhang restoration on the distal of the
for palatal expansion (Uzuner & Aslan, 2015). mandibular left first premolar.
 Theoretical Approaches to Ultrasonic Instrumentation
B 1999 system. In 2017, the World Workshop took
Figure 7-16 Fixed prosthesis retained cement:
A. Cement on the mesial and distal of the maxillary left
first molar, B. Cement on the mesial of the mandibular
right second molar.
seen in Figure 7-16. If the cement is large, a ro-
tary bur is a better option for removal than an
ultrasonic.
• Removal of small to medium retained orthodon-
tic cement. If the cement is large, a rotary bur is
needed for removal.
• Direct and indirect removal of organisms to
promote oral symbiosis through acoustic cavi-
tation, acoustic microstreaming, and liquid jet
production.
• Removal of hard or soft tissue as the scope of
practice allows.
• Debridement of grooves, pits, and fissures prior to
sealant placement (see Figure 7-17).
115
Figure 7-17 Stained fissures and pits on the occlusal
surface of a premolar tooth.
Theoretical Approaches
to Ultrasonic
Instrumentation
In 2015–2017, the AAP, European Federation of Peri-
odontology, and more than 100 experts from Asia and
Australia came together to build a new classification
system for gingival health and diseases to replace the
place in Chicago, Illinois, and four case types were de-
fined and released as the “2018 Classification of Peri-
odontal and Peri-Implant Diseases and Conditions”
(Caton et al., 2018).
The new classification system provided another
paradigm shift in the field of dentistry. For the first
time, the term periodontal medicine was introduced to
the dental community. Periodontal medicine:
• Is the act of considering individual patient needs in
the diagnosing, strategizing, and treatment of gingi-
val and periodontal conditions (Caton et al., 2018).
• Identifies periodontal disease as a multidi-
mensional disorder with varying severity and
complexity factors contributing to disease man-
agement (Caton et al., 2018).
• Accepts the procedure of periodontal debridement
with root detoxification and conservation because it
can promote oral symbiosis and long-term patient
health and stability in managing disease processes.
116 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications

Table 7-1 Approaches to ultrasonic instrumentation

Traditionalist Approach Contemporary Approach
Insert and tip design Single thick or thin diameter Thick, thin, and ultra-thin diameters
Straight shank Straight and curved shanks
Short shank Short and long shanks
Number of inserts and tips used One Many
Supragingival/Subgingival access Supragingival (subgingival Supragingival and subgingival
­Complex Root Anatomy ­access limited with thick Can adapt to complex root anatomy
­diameter shanks)
Cannot adapt to complex root
anatomy
Primary patient criteria Dental calculus Biofilm
Stain Inflammation
Bacterial by-products
Secondary patient criteria None Dental calculus
Stain
Hand instrumentation required for full Yes No
mouth debridement

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

It is important to recognize the historical and con- instrumentation. Only one ultrasonic insert or tip
temporary approaches to periodontal management was used on all tooth surfaces and then significant
because they have influenced the development of ul- hand-activated instrumentation was followed. The in-
trasonic technology and the theoretical approaches to sert or tip design was a short, straight, thick or thin
instrumentation. There are two theoretical approaches diameter shank, which was unable to adapt into com-
to ultrasonic instrumentation that have developed plex root anatomy.
over the past 70 years: the traditionalist approach
and the contemporary approach. Both approaches are
summarized in Table 7-1. BREAKOUT POINT
The traditionalist approach uses dental calculus and
Traditionalist Approach to stain presence as the primary selection criteria for
Ultrasonic Instrumentation ultrasonic instrumentation.
The traditionalist approach to ultrasonic instrumen-
tation was used from the 1950s until the time peri-
odontal debridement was widely accepted in the Contemporary Approach to
mid-1990s. This approach was based on the method- Ultrasonic Instrumentation
ology that dental calculus was the etiological agent of The contemporary approach to ultrasonic instru-
periodontal disease and not plaque biofilm in a sus- mentation promotes the AAPs practice of peri-
ceptible host. odontal medicine and is widely used today. In the
The traditionalist approach used only one pri- contemporary approach, ultrasonic instrumentation
mary patient criterion for the use of ultrasonic is used to:
instrumentation:
• Primary criterion: presence of dental calculus
• Reduce oral biofilm and bacterial by-products.
and/or stain.
• Conserve cementum.
• Detoxify tooth structures.
A traditionalist provider used ultrasonic instru- • Preserve gingival integrity.
mentation as an adjunct to traditional hand-activated • Decrease inflammatory mediators.

The contemporary approach uses primary and
secondary patient criteria for the use of ultrasonic
instrumentation:
• Primary criteria: presence of biofilm, bacterial
by-products, and inflammation.
• Secondary criterion: presence of dental calculus
and/or stain.
In the contemporary approach, ultrasonic instru-
mentation is not used as an adjunct to hand-activated
instrumentation as is done in the traditionalist approach.
A full mouth debridement is completed with a variety
of insert and tip designs using staged instrumentation.
The conjunctive use of hand-activated instruments is
only utilized when the provider encounters a barrier for
ultrasonic instrumentation. Ultrasonic instrumentation
is performed on every patient to reduce biofilm and in-
flammatory mediators through the delivery of acoustic
cavitation, acoustic microstreaming, and liquid jets in
the mouth to promote oral symbiosis.
BREAKOUT POINT
The contemporary approach to ultrasonic
instrumentation allows for full mouth debridement
without the adjunctive use of hand-activated
instruments to remove biofilm, bacterial by-products,
dental calculus, and stain, and to reduce the overall
inflammatory burden of the mouth.
Periodontal Debridement
The clinical objective of periodontal debridement is to
remove the etiological agents of infection while con-
serving healthy enamel, dentin, and cementum by us-
ing the least aggressive instrumentation to achieve this
goal. Oral health-care providers perform supragingi-
val and subgingival instrumentation with hand-ac-
tivated instruments, ultrasonic instruments, and air
polishing systems to reduce biofilm levels to promote
a symbiotic oral microbiome.
Periodontal Disease
Pathogenesis
Pathogenesis is a term that describes the man-
ner of disease development. While there are mul-
tiple perspectives for the specific role of bacteria
in periodontal disease, it is widely recognized that
when specific pathogenic microbial species combine
in an oral biofilm complex, uncontrolled immune
reactions occur in a susceptible host that lead to
­attachment loss.
Periodontal Debridement 117
Table 7-2 Periodontal disease risk factors
Host risk A host risk factor is an attribute that
factors increases the risk of periodontal
disease and influences one’s ability
to control inflammatory mediators
such as:
■ Immunological and metabolic
genetic disorders (Albandar
et al., 2018).
■ Systemic diseases such as dia-
betes mellitus, cardiovascular
diseases, autoimmune diseases,
rheumatoid arthritis, osteoarthri-
tis, obesity, osteoporosis, AIDS,
and inflammatory diseases (Al-
bandar et al., 2018).
■ Oral risks: presence of periodon-
tal pockets, restorations, root
anatomy, tooth position (crowding
or spacing), traumatic occlusal
forces, ability of the patient to
properly cleanse their mouth, or
the presence of mucogingival de-
fects (gingival recession, lack of
keratinized gingiva; Albandar
et al., 2018; Lang & Bartold, 2017).
Microbiological There are over 700 organisms that
composition inhabit the oral cavity and up to 200
can be present in just one individual
patient (Aas et al., 2005). The host
composition of oral flora and the
presence of supragingival and sub-
gingival biofilm contribute to disease
susceptibility (Lang & Bartold, 2017).
Environmental Nicotine, medications, emotional
influences stress, mental illness (depression,
bipolar), diet, and nutrition contrib-
ute to disease susceptibility (Lang &
Bartold, 2017).
Periodontitis represents a dysbiotic oral state
characterized by progressive destruction of tooth
supporting apparatus structures mediated by host-
immune responses to microbial insults. Gingival,
periodontal, and peri-­implant diseases are multifacto-
rial and multidimensional, involving host risk factors,
and microbiological and environmental influences
(see Table 7-2).
Periodontal Disease Statistics
According to the WHO (2021), 10% of the global
population has severe periodontal disease, which may
result in tooth loss. Inequities are noted for those of
118 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications
a lower socioeconomic status. In the United States,
the Centers for Disease Control and Prevention (CDC)
(2013) reports the following statistics for periodontal
disease prevalence:
• 47.2% of adults 30 years and older have peri-
odontal disease.
• 70.1% of adults over the age of 65 have periodon-
tal disease.
• Those living below the federal poverty level and
those with less than a high school education have
prevalence rates above 65%.
It is clear from these statistics that a greater num-
ber of adults are living in a state of oral dysbiosis rather
than symbiosis. In times of inflammation, dysbiosis,
periodontal pocketing, and active infection, supragin-
gival and subgingival periodontal instrumentation is
needed to arrest disease progression and restore sym-
biosis. Ultrasonic instrumentation causes profound
microbiological change in the mouth through acous-
tic cavitation, acoustic microstreaming, and liquid jet
release and aids in the treatment of dysbiosis.
Preventive Clinical Treatment
Ultrasonic and hand-activated instrumentation differ
from each another in their delivery of care, but not
in overall clinical outcomes. There is a large body of
evidence dating back to the 1980s that has shown com-
parable periodontal debridement clinical o­utcomes
between hand-activated and ultrasonic instrumen-
tation as measured by the reduction of bleeding
and probe depths, as well as gains in clinical attach-
ment (Drisko et al., 2000; Barendgret et al., 2008;
D’Ercole et al., 2006; Khosravi et al., 2004; Muniz
et al., 2020; Oosterwaal et al., 1987; Timkel et al.,
2002; Walmsley et al., 2008). It is in the delivery of
care where dramatic differences are seen between the
two. The subgingival access, microbial reduction, fur-
cation access, cemental alterations, efficiency, and cli-
nician ergonomics are not the same for ultrasonic and
hand-activated instrumentation.
Figure 7-18 Tissue consistency that is firm, hard, and tightly adherent on the maxillary anterior lingual surfaces.
Subgingival Access
Thin and ultra-thin ultrasonic shanks are narrower in
diameter than a standard hand-activated instrument
blade, which allows them to access subgingivally
with minimal to no tissue distension. The advan-
tages of ultrasonic thin and ultra-thin shanks over
hand-activated instruments are:
• Improved access subgingivally when tissues are
firm, hard, and tightly adherent to the tooth root,
as seen in Figure 7-18 (Zhang et al., 2020).
• Less tissue injury while instrumenting tooth roots
(Zhang et al., 2020).
• Ease of access to deeper periodontal pockets
with thinner diameter, curved shape, and longer
shanks (Barendgret et al., 2008; Oosterwaal et al.,
1987; Zhang et al., 2020; Beuchat et al., 2001).
BREAKOUT POINT
Thin and ultra-thin ultrasonic diameter shanks are
slimmer than a standard hand-activated instrument
blade and access subgingivally with minimal to no
tissue distension.
Microbial Reduction
Dental ultrasonic acoustic cavitation, acoustic mi-
crostreaming, and liquid jet production change the
oral flora of the mouth by detaching adherent bio-
film; reducing the number of spirochetes, filaments,
gram-negative bacteria, and motile rods; and in-
creasing the number of coccoid bacteria (Baehni
et al., 1992; Gartenmann et al., 2017; Gomez-Suzrez
et al., 2001; Mueller et al., 2011; National Institutes of
Health, 2000; Pecheva et al., 2016; Stricker et al., 2013;
Thilo & Baehni, 1987). These changes favor a symbiotic
oral microbiome. A hand-activated instrument will only
remove organisms through direct blade contact and
does not produce microbiological effects through acous-
tic cavitation, acoustic microstreaming, or liquid jets.
 Periodontal Debridement 119

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

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

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

Cementum Alterations
An ultrasonic insert and tip shank causes less cemen-
tum injury, removal, alteration, and abrasion than a
hand-­activated instrument blade during oral deposit
removal (Drisko et al., 2000; Kawashina et al., 2006;
Kumar et al., 2015; Maritato et al., 2018; Mittal et al.,
2014; Ritz et al., 1991; Santos, et al., 2008; Singh B
et al., 2012). More detail on this topic will be pre-
Figure 7-19 Furcation entrance: A. Narrow furcation
sented in a later chapter.
entrances on the maxillary first premolar and
mandibular molar, B. Wide furcation entrance on a
mandibular molar.
BREAKOUT POINT
Ultrasonic instrumentation causes less alterations
to cementum than hand-activated instrumentation the bond between the deposit and the tooth, which
during oral deposit removal. is physically demanding and time-consuming, and
requires expert-level technique to avoid injury to ce-
mentum and tissue. An ultrasonic tip or insert me-
Efficiency chanically chips the deposit away from tooth structures
The removal of oral deposits with a hand-activated in- for the provider. Studies have demonstrated a 20.0–
strument is achieved through mechanically breaking 36.6% reduction in oral deposit removal time with the
120 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications
A Dental professionals are at an increased risk for work-
B
Figure 7-20 Instrument furcation access: A. Ultrasonic
active area antinode of the shank adapting and
easily accessing a narrow furcation entrance on the
mandibular second molar, B. Area-specific hand-
activated instrument blade unable to access a narrow
furcation entrance on the mandibular second molar.
use of a dental ultrasonic compared to hand-activated
instrumentation with similar treatment outcomes
(Muniz et al., 2020; Tunkel et al., 2002; Benchat
et al., 2001; Copulos et al., 1993).
BREAKOUT POINT
Ultrasonic instrumentation decreases total
treatment time by 20.0–36.6% when compared to
hand-activated instrumentation.
Contemporary health-care models for dentistry
and medicine have shortened the time a provider
spends with their patient but still demand high-
quality outcomes. The provider is expected to pro-
duce the same quality outcomes as in years past
with less time allotted for patient care. With these
time constraints on a patient appointment, the oral
health-care provider needs to use all available tech-
nology that maximizes efficiency and minimizes treat-
ment time.Ultrasonic instrumentation is an example
of this because it will decrease procedure time while
producing comparable clinical outcomes as hand-
activated instrumentation.
Ergonomics
related musculoskeletal disorders (WMSDs).
WMSDs are injuries of muscles, nerves, tendons, joints,
cartilage, and spinal discs that occur and are made
worse by the work environment (CDC, 2020). The in-
creased risk for WMSDs is attributed to (CDC, 2020):
• Sustained repetitive motions and tasks.
• Static posture and positioning for long periods of
time.
• Awkward positioning.
• Force put on small muscle groups and nerves
during procedures.
National Institute for Occupational Safety and
Health (NIOSH) has a Musculoskeletal Health Cross-
Sector Program aimed at reducing “the burden of
WMSD through a focused program of research and
prevention that protects workers” (CDC, 2019). The
program helps improve efficiency of workplace in-
terventions for health-care workers (CDC, 2019).
Ultrasonic instrumentation offers protection for oral
health-care providers by:
• Decreasing active patient treatment time.
• Allowing for more flexible operator chair
positioning.
• Mechanically chipping away oral deposits for the
provider, which decreases labor intensity..
• Allowing for a light and relaxed grasp when in-
strumenting, which reduces wrist, arm, and hand
fatigue.
Considerations
and Contraindications
A consideration is a factor or variable that should
be taken into account and the potential consequences
weighed against the benefits prior to implementing

a technology or procedure into a patient care plan.
A contraindication is a situation when a patient
should not receive treatment because it may be harm-
ful. There are considerations and contraindications
for ultrasonic instrumentation.
The field of ultrasonic technology has changed
dramatically from its inception. The considerations
and contraindications have also changed dramatically
as the technology has evolved. Caution should be ex-
ercised when referencing dated literature for consider-
ations and contraindications because this information
applied to technology of that time and may not repre-
sent the technology of today.
In the United States, a dental ultrasonic device is
classified as a “medical device” by the FDA (2020),
which requires scientific research and reporting for
considerations and contraindications. Considerations
and contraindications vary by model and manufac-
turer and can be referenced in the direction for use/
instruction for use (DFU/IFU). This section will dis-
cuss general considerations and contraindications for
ultrasonic use, but it is not a comprehensive list for
each manufacturer as there are too many devices on
the market to cite each one.
Contraindications
Dental ultrasonics are contraindicated for a patient
with an active communicable disease and are con-
traindicated for use on fixed and removable dental
materials.
Communicable Disease
Patients with active ARIs such as tuberculosis, coro-
navirus, or influenza should not be seen in the
dental office and certainly not be subjected to an
aerosol-generating procedure until they are recovered
from their active infection. This places the entire den-
tal environment at risk for disease transmission from
pathogenic aerosols. The patient is also put at risk for
further disease complications due to their compro-
mised immune state.
Fixed Dental Materials
An ultrasonic shank has the potential to scratch, chip,
or roughen fixed dental materials. This contributes to
poor esthetics, discoloration, and oral deposit accu-
mulation, which can increase the risk for secondary
caries and gingival inflammation. A stainless-steel
shank should not directly contact the following fixed
dental materials:
• Composite resin
• Glass ionomer cement
Considerations and Contraindications 121
• Sealant
• Dental ceramics (porcelain, alumina, zirconia)
• All-metal castings (gold, palladium, platinum)
• Porcelain bonded alloys (porcelain fused to a
metal crown)
• Stainless steel alloys (crowns commonly placed
on pediatric patients)
• Amalgam
BREAKOUT POINT
Avoid direct contact of a stainless-steel shank on a
fixed dental material.
Removable Dental Materials
A dental ultrasonic device may scratch, roughen,
puncture, or chip removable dental materials.
A ­stainless-steel shank should not directly contact the
following removable dental materials:
• Acrylic resins such as those used on dentures and
partials
• Denture teeth (acrylic, composite, porcelain)
• Denture liners
• Bruxism guard (hard, soft, Thermoguard)
Considerations
The following require special consideration or tech-
nique adjustments to ultrasonic instrumentation. The
risks versus benefits should be weighed prior to ultra-
sonic exposure.
Demineralized and Decayed Hard
Tissues
All forms of instrumentation (hand-activated and
ultrasonic) should be used with caution on demin-
eralized or carious hard tissue. This hard tissue has
an increased risk for further loss and destruction,
which may contraindicate all forms of instrumenta-
tion depending on the level of demineralization (see
Figure 7-21a to c for examples).
Dental Implant
There are ultrasonic inserts and tips specifically de-
signed for safe dental implant debridement, as seen
in Chapter 5 (see Figure 7-22). A stainless-steel shank
is not designed for direct contact on a dental implant,
abutment, prosthesis, or superstructure.
122 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications

A B

C
Figure 7-21 Demineralized hard tissue: A. Cervical facial demineralization and caries of the maxillary right canine;
instrumentation should be used with caution to avoid further breakdown of the hard tissue, B. Interproximal
demineralization and carious lesions on the maxillary left central and lateral incisors; instrumentation should be used
with caution to avoid further breakdown the of the hard tissues; C. Advanced carious lesion occlusal of a maxillary molar;
instrumentation is contraindicated.

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


Dentin Hypersensitivity
If a patient has active dentinal hypersensitivity from
exposed root structures, as seen in Figure 7-23a and b,
all forms of instrumentation will be challenged. Instru-
mentation technique will need to be modified when
working on a patient with dentinal hypersensitivity to
avoid eliciting a painful stimulus. These modifications
include, but are not limited to:
• Application of a desensitization product prior to
instrumentation.
A •
B
Figure 7-23 Recession and dentin exposure:
A. Recession on the maxillary left first molar buccal
surface, B. Recession on mandibular anterior facial
surfaces.
Considerations and Contraindications 123
• Ultrasonic modifications: Use low power output
settings with correct water flow rate. Adapt less
active surfaces of the shank (back, lateral) to the
tooth surface (described in Chapter 9).
• Provide breaks during instrumentation.
• Administer injectable local anesthesia.
If the patient is experiencing active dentinal hy-
persensitivity on a tooth that cannot be controlled
through these technique modifications, then all forms
of instrumentation may be completely contraindicated.
HIV
The oral health-care provider may want to obtain the
patient’s CD4+ T-lymphocyte count or viral load count
prior to performing an aerosol-generating procedure.
If the risk for a bacteremia is low and the risk for envi-
ronmental contamination of pathogenic aerosols is low,
ultrasonic instrumentation may be safely performed.
Individual Patient Factors
Dental ultrasonics should be used with caution for pa-
tients who present with:
• Increased risk of aspiration
• Difficulty swallowing
• Respiratory challenges
Challenged airway (see Figure 7-24)
• Persistent or violent coughing
• Exaggerated gag reflex
Figure 7-24 Challenged airway. Notice the patient’s
tongue covers their airway when they open.
124 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications

Ultrasonic instrumentation may be possible for
these patients if the provider can manage the com-
plication with positioning and evacuation techniques.
Using semi-supine or upright patient positioning,
stand-up operator positioning, low to medium power
output with lower water flow rates, or four-handed
dentistry, may provide a manageable work-around for
these patients with limiting factors.
Pediatric Patients
The American Academy of Pediatric Dentistry (2020)
published a policy on the role of dental prophylaxis
in Pediatric Dentistry and listed the dental ultra-
sonic as a recommended device to remove biofilm,
stain, and dental calculus on pediatric patients. In
the past, the ultrasonic device was thought to be
contraindicated because of the larger pulp cham-
ber size in younger children and the concern for
potential discomfort. The provider can safely use a
dental ultrasonic device on a pediatric patient with
modifications such as avoiding high power output
settings, using correct water flow rates, and adapt-
ing less active surfaces of the shank (back, l­ateral)
to the tooth surface (described in Chapter 9).
Today’s ultrasonic devices have improved dissipation
of heat, which improves patient comfort and decreases
the risk for a pupal response.
Orthodontic Appliances
Ultrasonic instrumentation is indicated for debrid-
ing tooth and root surfaces around orthodontic ap-
pliances with modifications such as avoiding high
power ­output settings and avoiding placing the shank
directly on the bonded material around brackets to
prevent chipping (see Figure 7-25a and b).
Pacemaker
The presence of a pacemaker is not an absolute con-
traindication for ultrasonic instrumentation. The oral
health-care provider should reference the manufac-
turer’s DFU/IFU for specific recommendations and
warnings on ultrasonic use and cardiac pacemakers
prior to instrumentation. The patient may also consult
with their medical specialist for questions regarding
dental procedures.

B
Figure 7-25 Bonded orthodontic brackets: A. Bonded brackets on the maxillary anterior teeth facial surfaces
B. Bonded brackets on the mandibular anterior teeth facial surfaces.
 Considerations and Contraindications 125

that minimizes current flow and preserves battery

BREAKOUT POINT
The presence of a pacemaker is not an absolute
contraindication for ultrasonic instrumentation.
Patients with arrhythmias or heart failure may
have an implanted cardiac pacemaker. A pacemaker is
a pulse generator with electronics and leads that travel
to the heart and deliver depolarizing pulses. The bat-
tery has a specified life-span but does not typically last
a lifetime. Older models were unable to sense intrinsic
cardiac activity and were pacing only, but contempo-
rary models sense and pace with a patient’s intrinsic
cardiac activity for improved performance (National
Institutes of Health, 2021).
There are different types of pacemakers such
as wired transvenous, epicardial, and wireless
(Mulpuru et al., 2017). There are also numerous
manufacturers of pacemakers. One of the largest
manufacturers is Medtronic, which released the first
pacemaker in 1957 (National Institutes of Health,
2021). Each manufacturer provides a detailed list
of household items and medical and dental equip-
ment and procedures that have the potential to in-
terfere with the function of their pacemaker. Best
practice would be to obtain of a copy of the pa-
tient’s pacemaker card and place in their permanent
record. This will assist with completeness of infor-
mation for future appointments.
In the past, electromagnetic interferences from
the environment were a concern to the functional-
ity of a pacemaker. With the improvements of pace-
maker designs in shielding, electrode optimization
life, noise protection algorithms, bipolar pacing,
and nonphysiological signal rejection interference,
electromagnetic interference from cell phones,
medical and dental equipment is less of a concern
(National Institutes of Health, 2021; Conde-Mir
et al., 2018).
The following is an example list from three pace-
maker manufacturers of the potential for electromag-
netic interference from dental equipment:
• Medtronic (2018) states, “Dental apex locator,
dental drills, dental ultrasonic scaler or clean-
ers, dental x-rays, and dental pulp tester have no
known risk to pacemaker function.”
• Boston Scientific (2021) states, “Dental drills,
dental ultrasonic cleaning equipment, diagnostic
x-rays, and diagnostic ultrasound are procedures
that will not affect pacemaker function.”
• Biotronik (2017) states, “Ultrasonic dental clean-
ing should be kept at a minimum distance of
15cm (0.49 feet) from the pacemaker.”
Numerous studies have been conducted in the
dental field on an ultrasonics’ potential to interfere
with a cardiac pacemaker. A recent in vivo study by
Conde-Mir et al. (2018) found no potential electro-
magnetic interferences when using a dental ultrasonic
scaler, dental electric pulp tester, or dental electronic
apex locator for patients with a pacemaker.
Surgical Procedures
Reference the manufacturer’s DFU/IFU for the surgi-
cal applications (if any) of the ultrasonic device. Some
ultrasonics can be used for surgical procedures while
others cannot.

CASE STUDY
A dental hygienist is seeing a new patient at ten o’clock in the morning. The 58-year-old patient arrives late and takes a
long time to complete the medical and dental history form. By the time the patient is ready to go back into the treatment
room, the hygienist is already 30 minutes into an 80-minute appointment. The hygienist neglects to review the medical
history and proceeds directly into radiographs and periodontal probing, trying to make up time. A prophylaxis is indicated,
and the hygienist asks the patient if they have any medical issues while they are setting up the ultrasonic for the prophy-
laxis. The patient states he had a heart attack seven months ago and a pacemaker was placed. The hygienist is in a hurry
due to starting late and decides since the pacemaker is so new there is probably nothing to worry about when using an
ultrasonic scaler. The rest of the appointment proceeds without any issues.
Were the actions of the hygienist right or wrong? Was the patient at risk for an adverse health event because of
the hygienist's actions? What should have been done differently during this appointment?
126 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications
Summary
This chapter explored the use of ultrasonic technology in
both the medical and dental field. Historical and contem-
porary theoretical approaches to dental ultrasonic instru-
mentation were introduced and related to periodontal
disease treatment, management, and pathogenesis. His-
torical and contemporary ultrasonic considerations and
contraindications for instrumentation were reviewed.
Questions
1. A magnetostrictive ultrasonic device was first
marketed for which type of dental procedure?
a. Removal of oral deposits
b. Removal of decay
c. Endodontic procedures
d. Orthodontic procedures
2. Which of the following procedures can a dental
hygienist perform with a dental ultrasonic device
if it is within their scope of practice?
a. Removal of a small restoration overhang
b. Removal of retained orthodontic cement
c. Removal of oral deposits
d. All of the above
3. Which of the following is TRUE of the
dental magnetostrictive ultrasonic devices
manufactured in the 1950s?
a. The operator had to manually tune the
ultrasonic to set the wave frequency.
b. Both external and internal water port designs
were an option on an insert.
c. Insert diameter options were thick and thin.
d. Insert design allowed for easy access
subgingivally.
4. Which of the following is TRUE of
contemporary periodontal debridement
procedures?
a. Cementum should be root planed to a
glassy-smooth finish.
b. Root structures should be conserved during
oral deposit removal.
c. Debridement is focused on reducing biofilm
and decontaminating periodontal pockets.
d. Both B and C
Match the following descriptions to the correct the-
oretical approach to ultrasonic instrumentation for
questions 5–9. Answer A for the traditionalist ap-
proach and B for the contemporary approach. There
is only one correct answer for each question.
Understanding the general differences between hand-­
activated and ultrasonic instrumentation assists the
provider in making the best treatment decision for their
patient’s needs. Complete periodontal debridement with
ultrasonic instrumentation supports the practice of peri-
odontal medicine and improves clinical efficiency which
may offer some protection from WMSDs.
5. Complete debridement is possible without
the adjunctive use of hand-activated
instrumentation.
6. Ultrasonic instrumentation can be performed
using a variety of insert and tip diameters
(thick, thin, ultra-thin) and shapes (straight,
curved).
7. Dental calculus and stain presence if the primary
criteria for ultrasonic instrumentation.
8. Biofilm and inflammation presence is the
primary criteria for ultrasonic instrumentation.
9. One ultrasonic shank shape and diameter can be
used for a whole mouth procedure.
10. True or False. Hand-activated and ultrasonic
instrumentation produce comparable
periodontal debridement clinical outcomes
as measured by bleeding and probe depth
reduction and gains in clinical attachment.
a. True
b. False
11. Ultrasonic instrumentation is preferred over
hand-activated instrumentation in which of the
following patient case scenarios?
a. Shallow pocket depth with tightly adherent
gingival tissues
b. Furcation entrance with a narrow width
c. Procedure with limited time
d. All of the above
12. Which of the following puts an oral health-care
provider at an increased risk for work-related
musculoskeletal disorders?
a. Sustained repetitive motion and tasks
b. Static postures for a long period of time
c. Force put on small muscle groups and nerves
during procedures
d. All of the above

13. Which of the following is a contraindication for
ultrasonic use?
a. Porcelain crown
b. Sealant
c. Patient with active influenza
d. All of the above
14. Which of the following can be safely debrided
with a stainless-steel ultrasonic shank?
a. Denture tooth
b. Dental implant abutment
c. Dentin with active hypersensitivity
d. A stainless-steel shank cannot be used in any
of these situations
References
1. Aas, J. A., Paster, B. J., Stokes, L. N., Olsen, I., & Dewhirst,
F. E. (2005). Defining the normal bacterial flora of the oral
cavity. Journal Clinical Microbiology, 43(11), 5721–5723.
2. Albandar, J., Susin, C., & Hughes, F. (2018). Manifestations
of systemic diseases and conditions that affect the periodontal
attachment apparatus: Case definitions and diagnostic
considerations. Journal of Periodontology, 89(1), S183–S203.
https://doi.org/10.1002/JPER.16-0480
3. American Academy of Pediatric Dentistry. (2020). Policy
on the role of dental prophylaxis in pediatric dentistry. Oral
Health Policies, 62–63.
4. Arabaci, T., Cicek, Y., & Canakci, C. F. (2007). Sonic and
ultrasonic scalers in periodontal treatment: A review.
International Journal of Dental Hygiene, 5, 2–12.
5. Armitage, G. C. (2000). Periodontal diagnosis and classification
of periodontal diseases. Periodontology, 24(2004), 9–21.
6. Asadoorian, J., Bobtyl, D., & Goulding, M. J. (2015). Dental
hygienists’ perception of preparation and use for ultrasonic
instrumentation. International Journal of Dental Hygiene, 13,
30–41.
7. Baehni, P., Thilo, B., Chapuis, B., & Pernet, D. (1992). Effects
of ultrasonic and sonic scalers on dental plaque microflora
in vitro and in vivo. Journal of Clinical Periodontology, 19,
455–459.
8. Bains, V., Mohan, R., & Bains, R. (2008). Application
of ultrasound in periodontics: Part 1. Journal Indian
Society of Periodontology, 12(2), 29–33. https://doi.org
/10.4103/0972-124X.44087
9. Barendgret, D. S., Van der Velden, U., Timmerman, M. F.,
& Van der Weijden, F. (2008). Penetration depth with
an ultrasonic mini insert compared with a conventional
curette in patients with periodontitis and in periodontal
maintenance. Journal of Clinical Periodontology, 35, 31–36.
https://doi.org/10.1111/j.1600-051X.2007.01169.x
10. Beuchat, M., Busslinger, A., Schmidlin, P. R., Michel, B.,
Lehmann, B., & Lutz, F. (2001). Clinical comparison of the
effectiveness of novel sonic instruments and curettes for
periodontal debridement after two months. Journal of Clinical
Periodontology, 28, 1145–1150.
11. Biotronik. (2017). Electromagnetic compatibility of BIOTRONIK
cardiac pacemakers, ICDs and CRT devices. https://biotronik
.cdn.mediamid.com/cdn_bio_doc/bio23016/8207
/bio23016.pdf
References 127
15. Which of the following is a consideration that
could influence the use of a dental ultrasonic?
a. Patient with a gag reflex
b. Patient with persistent and violent cough
c. Patient with HIV
d. Patient with a pacemaker
e. All of the above
12. Boston Scientific. (2021). Medical and dental procedures.
https://www.bostonscientific.com/en-US/patients/about
-your-device/pacemakers/living-with-a-pacemaker/medical
-and-dental-procedures.html
13. Caton, J. G., Armitage, G., Berglundh, T., Chapple, I. C.,
Jepsen, S., Kornman, K., Mealey, B. L., Papapanou, P. N.,
Sanz, M., & Tonetti, M. S. (2018). A new classification
scheme for periodontal and peri-implant diseases and
conditions—introduction and key changes from the 1999
classification. Journal of Periodontology, 89(1), S1–S8. https://
doi.org/10.1002/JPER.18-0157
14. Centers for Disease Control and Prevention. (2013).
Oral health. https://www.cdc.gov/oralhealth/conditions
/periodontal-disease.html
15. Centers for Disease Control and Prevention. (2019).
Musculoskeletal health program. https://www.cdc.gov/niosh
/programs/msd/default.html
16. Centers for Disease Control and Prevention. (2020).
Work-related musculoskeletal disorders & ergonomics. https://
www.cdc.gov/workplacehealthpromotion/health-strategies
/musculoskeletal-disorders/index.html
17. Chen, Y. L., Chang, H. H., Chiang, Y. C., & Lin, C. P. (2013).
Application and development of ultrasonics in dentistry.
Journal of the Formosan Medical Association, 112, 659–665.
https://doi.org/10.1016/j.jfma.2013.05.007
18. Conde-Mir, I., Miranda-Ruis, J., Trucco, E., Lahor-Soler, E.,
Brunet-Llobet, L., Domingo, R., Tolsana, J. M., & Mont, L.
(2018). European Journal of Oral Sciences, 126, 307–315.
19. Copulos, T. A., Low, S. B., Walker, C. B., Trebilock, Y. Y., &
Hefti, A. F. (1993). Comparative analysis between a modified
ultrasonic tip and hand instruments on clinical parameters
of periodontal disease. Journal of Periodontology, 64(8),
694–700.
20. D’Ercole, S., Piccolomini, R., Capaldo, G., Catamo, G., Perinetti,
G., & Guida, L. (2006). Effectiveness of ultrasonic instruments
in the therapy of severe periodontitis: A comparative
clinical-microbiological assessment with curettes. New
Microbiology, 29(2), 101–110.
21. Dragoo, M. R. (1992). A clinical evaluation of hand and
ultrasonic instruments in subgingival debridement, Part
1. With unmodified and modified ultrasonic inserts.
International Journal of Periodontics & Restorative Dentistry,
12(4), 311–323.
128 Chapter 7 Ultrasonic Historical and Contemporary ­Clinical Applications and Contraindications
22. Drisko, C. L., Cochran, D. L., Blieden, T., Bouwsma, O.
J., Cohen, R. E., Damoulis, P., Fine, J. B., Greenstein, G.,
Hinrichs, J., Somermman, M. J., Iacono, V., & Genco, R.
J. (2000). Position paper: Sonic and ultrasonic scalers in
periodontics. Journal of Periodontology, 71(11), 1792–1801.
https://doi.org/10.1902/jop.2000.71.11.1792
23. Food and Drug Administration. (2020). CFR—Code of
Federal Regulations. https://www.accessdata.fda.gov/scripts
/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=872.4850
24. Forfang, W., You, B. H., & Song, I. H. (2013). Ultrasonic
dental therapy: Trends and prospects. European International
Journal of Science and Technology, 2(1), 1–6.
25. Gartenmann, S. J., Thurnheer, T., Attin, T., & Schmidlin, P.
R. (2017). Influence of ultrasonic tip distance and orientation
on biofilm removal. Clinical Oral Investigations, 21(4),
1029–1036. https://doi.org/10.1007/s00784-016-1854-8
26. Gomez-Suzrez, C., Busscher, H., Henry, C., & Mei, V. D.
(2001). Analysis of bacterial detachment from substratum
surfaces by the passage of air-liquid interfaces. Applied and
Environmental Microbiology, 67(6), 2531–2537. https://doi
.org/10.1128/AEM.67.6.2531-2537.2001
27. Hinchman, S. S., Funk, A., DeBiase, C., & Frere, C. (2016).
Ultrasonic instrumentation instruction in dental hygiene
programs in the United States. Journal of Dental Hygiene,
90(2), 135–142.
28. Ibsen, O., & Phelan, J. (2018). Oral pathology for the dental
hygienist with general pathology introductions (7th ed.). Elsevier.
29. Johns Hopkins Medicine. (2020). What is cancer? http://
pathology.jhu.edu/pc/BasicTypes1.php
30. Kawashima, H., Sata, S., Kishida, M., & Ito, K. (2006). A
comparison of root surface instrumentation using two
piezoelectric ultrasonic scalers and a hand scaler in vivo.
Journal of Periodontal Research, 42, 90–95.
31. Khosravi, M., Bahrami, Z. S., Atabaki, M. S. J., Shokrgozar,
M. A., & Shokri, F. (2004). Comparative effectiveness of
hand and ultrasonic instruments in root surface planing in
vitro. Journal of Clinical Periodontology, 31, 160–165.
32. Kumar, P., Das, S. J., Sonowal, S. T., & Chawla, J. (2015).
Comparison of root surface roughness produced by hand
instruments and ultrasonic scalers: An in vitro study. Journal
of Clinical and Diagnostic Research, 9(11), ZC56–ZC60. https://
doi.org/10.7860/ JCDR/2015/13744.6828
33. Lang, N., & Bartold, P. (2017). Periodontal health. Journal
of Periodontology, 89(1), S9–16. https://doi.org/10.1002
/JPER.16-0517
34. Lea, S. C., & Walmsley, A. D. (2000). Mechano-physical
and biophysical properties of power-driven scalers: Driving
the future of powered instrument design and evaluation.
Periodontology, 51(2009), 63–78.
35. Leon, L. E., & Vogel, R. I. (1987). A comparison of the
effectiveness of hand scaling and ultrasonic debridement in
furcations as evaluated by differential dark-field microscopy.
Journal of Periodontology, 58(2), 86–94.
36. Maritato, M., Orazi, L., Laurito, D., Formisano, G., Serra, E.
Lollobrigida, M., Molinari, A., & De Biase, A. (2018). Root
surface alterations following manual and mechanical scaling:
A comparative study. International Journal of Dental Hygiene,
16, 553–558. https://doi.org/10.1111/idh.12349
37. Medtronic. (2018). Medical and dental procedures
electromagnetic compatibility guide for implantable cardiac devises.
https://www.medtronic.com/us-en/patients/electromagnetic
-guide/medical-dental.html
38. Mehta, P., Sagarkar, R. M., Silju, M., Prashantha, G. S.,
& Srijan, S. (2016). Review ultrasonics: Applications of
ultrasound in orthodontics. Journal of Dental & Oro-facial
Research, 12(1), 30–32.
39. Mittal, A., Nichani, A. S., Venugopal, R., & Rajani, V. (2014).
The effect of various ultrasonic and hand instruments on the
root surfaces of human single rooted teeth: A planimetric and
profilometric study. Journal of Indian Society of Periodontology,
18(6), 710–717.
40. Mohan, K. R., Rao, N. K., Krishna, G. L., Kumar, V. S.,
Ranaganath, N., & Lakshmi, U. V. (2015). Role of
ultrasonography in oral and maxillofacial surgery: A review
of literature. Journal Maxillofacial Oral Surgery, 14(2),
162–170. https://doi.org/10.1007/s12663-014-0616-x
41. Mueller, P., Guggenheim, B., Attin, T., Marlinghaus, E., &
Schmidlin, P. R. (2011). Potential of shock waves to remove
calculus and biofilm. Clinical Oral Investigations, 15(6),
959–965. https://doi.org/10.1007/s00784-010-0462-2
42. Mulpuru, S. K., Madhavan, M., McLeod, C. J., Cha, Y. M.,
& Friedman, P. A. (2017). Journal of the American College of
Cardiology, 69(2), 189–210.
43. Muniz, F. W. M. G., Langa, G. P. J., Pimentel, R. P., Martins,
J. R., Pereira, D. H., & Rosing, C. K. (2020). Comparison
between hand and sonic/ultrasonic instruments for periodontal
treatment: Systematic review with meta-analysis. Journal of
International Academy of Periodontology, 22(4), 187–204.
44. National Institutes of Health. (2000). Section 2—Definitions
and description of nonthermal mechanisms. Journal of
Ultrasound in Medicine, 19(2), 77–168.
45. National Institutes of Health. (2021). Pacemakers. https://
www.nhlbi.nih.gov/health-topics/pacemakers
46. Ng, K., & Liu, Y. (2002). Therapeutic ultrasound: Its application
in drug delivery. Medicinal Research Reviews, 22(2), 204–223.
47. Novak, K. F., Govindaswami, M., Ebersole, J. L., Schadan,
W., House, N., & Novak, M. J. (2008). Effects of low-energy
shock waves on oral bacteria. Journal of Dental Research, 87(10),
928–931.
48. Ntovas, P., Doukoudakis, S., Tzoutzas, J., & Lagouvardos,
P. (2017). Evidence provided for the use of oscillating
instruments in restorative dentistry: A systematic review.
European Journal of Dentistry, 11(2), 268–273. https://doi
.org/10.4103/ejd.ejd_232_16
49. Oda, S., & Ishikawa, I. (1989). In vitro effectiveness of a
newly-designed ultrasonic scaler tip for furcation areas.
Journal of Periodontology, 60(11), 634–639.
50. O’Daly, B., Gavin, G., O’Bryne, J., & McGuinness, G. (2008).
High-power low-frequency ultrasound: A review of tissue
dissection and ablation in medicine and surgery. Journal of
Materials Technology, 200(1–3), 38–58.
51. Oosterwaal , P. J. M., Matee, M. I., Mikx, F. H. M, Van’t Hof,
M. A., & Renggli, H. H. (1987). The effect of subgingival
debridement with hand and ultrasonic instruments on the
subgingival microflora. Journal of Clinical Periodontology, 14,
528–533.
52. Patini, R., Gallenzi, P., Lione, R., Cozza, P., & Cordaro,
M. (2019). Ultrasonographic evaluation of the effects of
orthodontic or functional orthopaedic treatment on masseter
muscles: A systematic review and meta-analysis. Medicina,
55(256), 3–15. https://doi.org/10.3390/medicina55060256
53. Pecheva, E., Sammons, R. L., & Walmsley, A. D. (2016).
The performance characteristics of a piezoelectric ultrasonic
dental scaler. Medical Engineering and Physics, 38, 199–203.

54. Pitt, W. G., Husseini, G., & Staples, B. J. (2004). Ultrasonic
drug delivery—a general review. Expert Opinion on Drug
Delivery, 1(1), 37–56.
55. Ritz, L., Hefti, A. F., & Rateitschak, K. H. (1991). An in
vitro investigation on the loss of root substance in scaling
with various instruments. Journal of Clinical Periodontology,
18(9), 643–647. https://doi.org/10.1111/j.1600-051x.1991.
tb00104.x
56. Santos, F. A., Pohapski, M. T., Leal, P. C., Gimenes-Sakima, P. P.,
& Marcantonio, E. (2008). Comparative study on the effect
of ultrasonic instruments on the root surface in vivo. Clinical
Oral Investigation, 12, 143–150. https://doi.org/10.1007
/s00784-007-0167-3
57. Schoenfield, L. J., Berci, G., Carnovale, R. L., Casarella, W.,
Caslowitz, P., Chumley, D., Davis, R. C., Gillenwater, J. Y.,
Johnson, C., Jones, S., Jordan, L. G., Kafonek, D. R., Laufer, I.,
Lillemoe, K. D., Lu, S., Maglinte, D., Maher, J. W., Malet, P. F.,
Malt, R. A., . . . Torres, W. E. (1990). The effect of ursodiol on the
efficacy and safety of extracorporeal shock-wave lithotripsy of
gallstones. New England Journal of Medicine, 323(18), 1239–1245.
58. Singh, S., Uppoor, A., & Nayak, D. (2012). A comparative
evaluation of the efficacy of manual, magnetostrictive and
piezoelectric ultrasonic instruments—an in vitro profilometric
and SEM study. Journal of Applied Oral Science, 20(1), 21–26.
59. Spratt, H., Levine, D., & Tillamn, L. (2014). Physical therapy
clinic therapeutic ultrasound equipment as a source for bacterial
contamination. Physiotherapy Theory and Practice, 30(7), 507–
511. https://doi.org/10.3109/09593985.2014.900836
60. Stricker, L., Dollet, B., Rivas, D. F., & Lohse, D. (2013).
Interacting bubble clouds and their sonochemical production.
Journal of the Acoustical Society of America, 1854–1862. https://
doi.org/10.1121/1.4816412
61. Thilo, B. E., & Baehni, P. C. (1987). Effect of ultrasonic
instrumentation on dental plaque microflora in vitro. Journal
of Periodontal Research, 22, 518–521.
62. Tunkel, J., Heinecke, A., & Flemming, T. F. (2002).
A systematic review of efficacy of machine-driven and
References 129
manual subgingival debridement in the treatment of chronic
periodontitis. Journal of Clinical Periodontology, 29(3), 72–81.
63. Uzuner, F. D., & Aslan, B. I. (2015). Miniscrew Applications in
Orthodontics, Current Concepts in Dental Implantology. https://
doi.org/10.5772/59879
64. Van der Sluis, L. W., Versluis, M., Wu, M. K., & Wesselink, P. R.
(2007). Passive ultrasonic irrigation of the root canal: A review
of the literature. International Endodontic Journal, 40(6),
415–426. https://doi.org/10.1111/j.1365-2591.2007.01243.x
65. Walmsley, A. D., Lea, S. C. Landini, G., & Moses, A. J. (2008).
Advances in power driven pocket/root instrumentation.
Journal of Clinical Periodontology, 35(8), 22–28. https://doi
.org/10.1111/j.1600-015X.2008.01258.x
66. World Health Organization. (2021). Oral health. https://www
.who.int/news-room/fact-sheets/detail/oral-health
67. Yang, Y., Wen, Y., Chen, K., & Chen, C. (2019).
Ultrasound-guided versus fluoroscopy-guided percutaneous
nephrolithotomy: A systematic review and meta-analysis.
World Journal of Urology, 37, 777–788.
68. Yusa, H., Yoshida, H., & Ueno, E. (1999). Ultrasonographic
criteria for diagnosis of cervical lymph node metastasis of
squamous cell carcinoma in the oral and maxillofacial region.
Journal of Oral Maxillofacial Surgery, 57(1), 41–48. https://
doi.org/10.1016/s0278-2391(99)90631-6
69. Zhang, X., Hu, Z., Zhu, X., Li, W., & Chen, J. (2020).
Treating periodontitis—a systematic review and meta-
analysis comparing ultrasonic and manual subgingival
scaling at different probing pocket depths. BMC
Oral Health, 20(176), 1–16. https://doi.org/10.1186
/s12903-020-01117-3
70. Zilonova, E. M., Solovchuk, M., & Sheu, T. W. H. (2019).
Simulation of cavitation enhanced temperature elevation in
soft tissue during high-intensity focused ultrasound thermal
therapy. Ultrasonics Sonochemistry, 53, 11–24.
71. Zocchi, M. L., Vincenzo, V., & Bassetto, F. (2020). 32 years
of ultrasonic-assisted lipoplasty (U.A.L.): From aesthetic to
obesity. Aesthetic Plastic Surgery, 44, 1230–1240.
 CHAPTER 8

Clinical Perspectives
of Tooth Anatomy
LEARNING OBJECTIVES • Extraneous variable: a factor in a research design
that influences a change in study results.
After studying this chapter, you will be able to: • Furcation: anatomical division between tooth
roots present on multi-rooted teeth.
1. Explain the histological differences in dental
hard tissues and relate this to conservative and
• Furcation defect: pathological condition where the
furcation is no longer filled in with alveolar bone.
safe instrumentation. Also referred to as furcation involvement.
2. Identify the ultrasonic insert or tip that should
• Furcation involvement: see furcation defect.
be selected for use on complex and noncomplex
root anatomy.
• Glickman Index: furcation index with four grades
that report on furcation defect severity and extent.
3. Identify the presence of root concavities,
convexities, and furcations on anterior and
• Morphology: the study of the parts of an organism
and the relationships between structures.
posterior teeth.
4. Identify the average position of a furcation on
• Root concavity: linear concave indentation in
cementum. Also referred to as a root depression
the root trunk of bifurcated and trifurcated or groove.
teeth.
• Root convexity: a curved bulge in cementum.
5. Utilize periodontal probing, exploration, and
• Root depression: see root concavity.
radiographs for the assessment of a furcation
• Root groove:
Root see root concavity.
defect as well as its anatomy, topography,
position on the root trunk, and entrance width.
• entrance of the furcation.
trunk: area on a tooth root from the CEJ to

6. Recognize two-dimensional radiographic

limitations in the identification of a furcation
• Tooth root: the area on a tooth root that is covered
by cementum from the CEJ to the root apex.
defect.
7. Describe the advantages of a curved thin
• Trifurcation: tooth root with three roots.
diameter ultrasonic shank in the debridement
of a furcation defect as compared to a
hand-activated instrument.

Introduction
KEY TERMS
The goal of periodontal instrumentation is to remove
• Bifurcation: tooth root with two roots.
• Cementoenamel
oral deposits and diseased structures while conserv-
junction (CEJ): junction between ing healthy tooth structures. Hard tissues of teeth
the cementum and dentin that is not visible in
differ in their mineralized content. Cementum is the
health and is visible in the presence of bone loss,
recession, or previous crown lengthening. least mineralized and enamel is the most mineralized
• Confounding variable: an extraneous variable not
accounted or controlled for in a study design that
hard tissue. Over-instrumentation of cementum will
cause injury and removal, which adversely affects the
affects results. periodontium's health. This chapter will discuss hard

131
132 Chapter 8 Clinical Perspectives of Tooth Anatomy
tissue composition and provide research-based evi-
dence that ultrasonic instrumentation causes less alter-
ations and removal of cementum than hand-activated
instrumentation.
Root anatomy and topography is complex with
concavities, convexities, and furcations. A strong
working knowledge of root anatomy is needed to
prevent cemental injury during instrumentation. De-
briding complex root anatomy subgingivally poses a
significant challenge for the oral health-care provider
because they cannot visually see these structures.
They must rely on their root anatomy knowledge and
assessments such as periodontal charting, explorer
evaluation, and radiographs to assist them in safe
instrumentation. This chapter will strengthen your
knowledge of complex root anatomy so you can per-
form safe ultrasonic instrumentation.
Instrumentation
Considerations
A tooth is made of multiple hard tissues that vary in
their histology, anatomy, and topography. These dif-
ferences influence periodontal instrumentation tech-
nique and instrument selection by the oral health-care
provider. The goal of periodontal debridement is to
remove oral deposits and diseased structures while
preserving healthy structures.
Hard Tissue Histology
During periodontal instrumentation, the oral health-
care provider is routinely debriding oral deposits from
enamel, dentin, and cementum both supragingivally
and subgingivally. Histologically enamel, dentin, and
cementum vary in their mineral, protein, and water
content. See Table 8-1. It is important for the pro-
vider to recognize these histological differences so the
best instrument can be selected for safe oral deposit
removal.
Table 8-1 Hard Tissue Content
Enamel Dentin
Percentage calcified 96%* 70%*
(mineralized) tissue
Percentage proteins 4%* 30%*
and water
*These percentage values represent an average and are not an absolute.
Nedoklan et al. (2021), Sheldahl & Yapp (2020)
Enamel has the greatest percentage of calcified
content, and cementum has the least. This means
cementum is more prone to injury during periodon-
tal instrumentation than enamel due its lower min-
eralized content. The goal of instrumentation with
hand-activated or ultrasonic instruments is to remove
disease contributors without scratching, gouging, al-
tering, removing, or injuring healthy structures.
BREAKOUT POINT
Cementum is more prone to injury during
periodontal instrumentation than enamel.
Instrument Selection
The oral health-care provider selects which instru-
ment to use for oral deposit removal based on the fol-
lowing criteria:
• Tooth tissue histology: Dentin and cementum are
less mineralized than enamel. The instruments and
technique used on enamel are not the same for den-
tin and cementum as they are more prone to injury.
• Tooth anatomy and topography: Teeth vary in
their anatomy and topography. Instruments are
specially designed to adapt to these differences.
For example, multi-rooted teeth have furcations
and deeper concavities, and the hand-activated
instruments designed for this anatomy have lon-
ger, more complex shanks. The ultrasonic shank
designed for this root anatomy is a thin diameter
curved shape.
• Oral deposit characteristics: Oral deposits can be
lightly adherent or tenaciously attached to the
crowns and roots of teeth. Deposits vary in thick-
ness (light, moderate, heavy). Hand-activated and
ultrasonic instruments with thicker diameters are
designed for heavier deposits while thinner diam-
eters are designed for lighter deposits.
• Tissue consistency: Tissue consistency varies
from patient to patient. Tissues can be firm, hard,
avascularized, and tightly adherent to tooth roots
or soft, spongy, swollen, and movable. Wide di-
ameter instruments are unable to access subgingi-
Cementum val areas with tightly adherent tissues.
45–50%*
BREAKOUT POINT
50%*
Tooth tissue histology, anatomy, topography, oral
deposit type and level, and tissue consistency all
influence which instrument the provider chooses to
use for oral deposit removal.

Instrumentation of Cementum
Careful consideration for instrument selection must
be exercised when debriding cementum. Uninten-
tional cementum removal through incorrect instru-
ment selection or technique can cause permanent
root topography change and contributes to disease
processes (Tunkel et al., 2002).
Cementum has a regulatory and reattachment
role in periodontal disease management. Chronic
over-instrumentation leads to damage that compro-
mises tooth survival (Tunkel et al., 2002). Diseased
cementum loses its biocompatibility with gingival
fibers through hypermineralization and degenera-
tion of collagen matrix (Khosravi et al., 2004). These
pathogenic changes occur in the outer superficial
layers of the cementum, so the removal of multiple
outer or any inner layer of cementum is not nec-
essary during debridement to promote periodon-
tal health (Tunkel et al., 2002). While a toxin-free
cemental surface will allow for proper fibroblast
adhesion and epithelial binding to the tooth root,
over-instrumentation has a negative and adverse ef-
fect (Khosravi et al., 2004).
There is an extensive body of literature, spanning
multiple decades, evaluating root alterations during
hand-activated and ultrasonic instrumentation.
Drawing definitive conclusions and making mean-
ingful comparisons from studies is a challenge due to
many factors, such as:
• Study design end points: Studies vary in their
designs and end points. Some end points are the
total elimination of dental calculus deposits while
others are the root alterations based on a specific
number, pressure, and length of strokes applied
to cementum by the researcher.
• Controlling for variables: Controlling for extra-
neous variables (factors that influence change
in study results) and confounding variables
(extraneous variables not accounted or controlled
for in a study design that affect results) is difficult
in clinical instrumentation studies. Some com-
mon examples of these variables in root alteration
studies include:
• Clinical technique: Variations exist between
examiners in their adaptation, angulation,
and orientation of instruments. Applied
stroke forces and lateral pressure are impossi-
ble to calibrate between examiners.
• Amount and extent of oral deposits in the
study.
• Model of ultrasonic device or hand instru-
ment used is not always reported.
Instrumentation Considerations 133
• Ultrasonic power settings and water flow
rates are not the same between manufacturers
and are not always reported.
• Insert and tip displacement amplitude, diam-
eter, and shank design vary between manu-
facturers and are not always reported.
• Instrument contact time is not always reported
or accounted for.
Regardless of varied study designs and confound-
ing and extraneous variables, decades of studies have
reported two constant outcomes when comparing
hand-activated to ultrasonic instrumentation of ce-
mental root surfaces:
1. Ultrasonic instrumentation of the cemental sur-
face produces on average 50% less removal,
alteration, and injury than hand-activated instru-
mentation during oral deposit removal (Drisko
et al., 2000; Kawashima et al., 2006; Kumar et al.,
2015; Maritato et al., 2018; Mittal et al., 2014;
Ritz et al., 1991; Santos et al., 2008; Singh et al.,
2012).
2. Hand and ultrasonic instrumentation will both
remove oral deposits and diseased cementum,
but hand-activated instruments produce a more
glassy-smooth cemental finish (Drisko et al.,
2000; Kawashima et al., 2006; Kumar et al.,
2015; Maritato et al., 2018; Mittal et al., 2014;
Ritz et al., 1991; Santos et al., 2008; Singh et
al., 2012). If you recall from Chapter 7, glassy-
smooth cemental surfaces are not a desirable out-
come of instrumentation.
BREAKOUT POINT
Ultrasonic instrumentation produces, on average,
50% less alteration to cemental surfaces than
hand-activated instrumentation.
Ultrasonic instrumentation matches the goal of
periodontal debridement in removing oral deposits,
decontaminating periodontal pockets, and removing
diseased cementum while conserving healthy cemen-
tum with the use of:
• Thin and ultra-thin shank diameters that can ac-
cess subgingival spaces with minimal to no tissue
distension.
• Thin, curved ultrasonic shanks adapt to complex
root anatomy and debride root concavities and
furcations with less alteration to the cementum
(Drisko et al., 2000; Dragoo, 1992).
134 Chapter 8 Clinical Perspectives of Tooth Anatomy

Complex Root Anatomy

A strong working knowledge of tooth root anatomy is
needed to safely debride and detoxify structures with-
out damaging cementum. When alveolar bone loss
occurs due to disease processes, the provider is forced
to instrument in and around extremely complex and
variable root anatomy.
Root Nomenclature
Common root nomenclature is listed in Table 8-2.

Table 8-2 Root Nomenclature

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

Tooth root Area on a tooth root that is covered by cementum

from the CEJ to the root apex.

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

Root concavity A linear, concave indentation in cementum. Also

referred to as a root depression or groove.

Root convexity
Furcation
Bifurcation
Trifurcation
Furcation defect
Root Concavity and Convexity
Root concavities and convexities are a part of normal
root anatomy that are routinely debrided. In the pres-
ence of alveolar bone loss, additional concavities and
convexities must be debrided, which can pose a chal-
lenge for safe instrument adaptation. A thin, curved
ultrasonic shank will safely debride root concavities
Complex Root Anatomy 135
A curved bulge in cementum.
Anatomical division between tooth roots present on
multi-rooted teeth.
Tooth root with two roots.
Tooth root with three roots.
A pathological condition where the furcation is no
longer filled in with alveolar bone. Also referred to as
furcation involvement.
and convexities. Its thin diameter shank allows sub-
gingival access with minimal to no tissue distension,
and the curved shape will adapt to complex root anat-
omy with ease. A straight shank is not designed to
conform to concave and convex anatomy and will
either damage the cementum or leave behind depos-
its (Tunkel et al., 2002; Oda & Ishikawa, 1989; see
Figure 8-1).
136 Chapter 8 Clinical Perspectives of Tooth Anatomy

A B

C D
Figure 8-1 Straight and curved shanks: A. Straight thin diameter shank. Notice the gap
in adaptation of the active area antinode on the mesial root. B. Curved thin diameter
shank. Notice the complete adaptation of the active area antinode on the mesial root
anatomy. C. Straight thin diameter shank. Notice the gap in adaptation of the active
area antinode on the distal root. D. Curved thin diameter shank. Notice the complete
adaptation of the active area antinode on the distal root anatomy.

BREAKOUT POINT The most common root concavities and con-

vexities on anterior teeth are listed in Table 8-3. Pre-
A thin, curved ultrasonic shank is used to debride
molar teeth are in Table 8-4, and molar teeth are in
a root concavity and convexity because it will adapt
Table 8-5. These tables show areas where the use of a
correctly and safely to complex root anatomy.
thin, curved shank is useful for debridement.
 Complex Root Anatomy 137

Table 8-3 Root Concavities and Convexities—Anterior Teeth

Facial Lingual Mesial Distal
Maxillary central incisor Convex Convex Shallow concavity Convex
but cannot be felt
until bone loss is
in the middle third
of the root.

Maxillary lateral incisor Convex Not common, but Inconsistent Convex

can have accessory root concavity
groove from lingual presence.
fossa onto the root
surface.

Mandibular central and lateral Convex Convex Concavity Concavity deeper

incisors than mesial.
All canines
138 Chapter 8 Clinical Perspectives of Tooth Anatomy

Table 8-4 Root Concavities and Convexities—Premolar Teeth

Facial Lingual Mesial Distal
Maxillary first Convex Convex Deep mesial root concavity Concavity
premolar that begins on the crown and
*Bifurcated root extends past the CEJ onto the
root. Deeper than distal.

Maxillary second Convex Convex Concavity, but cannot be
premolars felt until bone loss is in the
middle third of the root.
Mandibular Convex Convex First premolar: Shallow
first and second concavity but cannot be
premolar felt until bone loss is in the
middle third of the root.
Second premolar: no
concavity.
Concavity, but cannot
be felt until bone loss
is in the middle third
of the root. Deeper
than mesial.
Concavity, but cannot
be felt until bone loss
is in the middle third
of the root. Deeper
than mesial.

Table 8-5 Root Concavities and Convexities—Molar Teeth

Facial Lingual Mesial Distal
Maxillary first Concavity between Maxillary first lingual Convex MB root. Concavity from CEJ to
and second mesiobuccal and root convex shaped like entrance of furcation.
molar distobuccal root. a banana and may have
*Trifurcated root longitudinal depression
on straight lingual. MB L

DB MB
L DB

MB root: concavity
mesial and distal
surfaces. Second molar lingual
root straighter.

DB MB
L
 Complex Root Anatomy 139

Facial Lingual Mesial Distal

DB root: mesial
concavity and
convex distal.

DB MB

Mandibular Concavity between Concavity between Deep concavity mesial Concavity mesial
first and second mesial and distal mesial and distal roots. surface of mesial surface distal root and
molar. roots. root and even deeper inconsistent concavity
*Bifurcated root concavity on distal distal surface distal
surface of mesial root. root.

D M

Third molars are left out of the table due to a vast number of anatomic variations such as (Scheid & Weiss, 2017):
■ Maxillary third molars are usually trifurcated and mandibular molars may have one or more extra roots than first

and second mandibular molars.

■ Roots of third molars are shorter and frequently fused together.
■ Root trunks are longer and furcation is located in the apical third of the root.

Furcation Knowledge of the furcation position on a root trunk

A furcation is the anatomical division between tooth
roots that is only present on multi-rooted teeth. In
health, the alveolar bone fills in the furcation area.
A furcation defect, also known as furcation involve-
ment, is a pathological condition where furcation is
no longer filled in with alveolar bone. The provider
will debride a furcation defect at each preventive ap-
pointment. Instrument selection and knowledge of
furcation anatomy is imperative to safely and fully de-
bride a defect.
will guide the provider in instrument selection and
instrumentation technique. In general, mandibu-
lar teeth have less variation than maxillary teeth.
Table 8-6 provides a summary of multi-rooted teeth
and their average root trunk length. Keep in mind, the
root trunk length provided is an average, and patients
may present with longer or shorter root trunks.
BREAKOUT POINT

Furcation Anatomy Knowledge of the position of a furcation entrance on

the root trunk will guide the provider in instrument
There are great variations in root trunk length, fur- selection and debridement technique.
cation width, and position of the furcation entrance.
140 Chapter 8 Clinical Perspectives of Tooth Anatomy

Table 8-6 Multi-Rooted Teeth and Furcations

Number of Furcation Entrance Root Trunk Length (Distance from
Tooth Roots and Detection (15) CEJ–Entrance of Furcation)*
Maxillary first premolar Bifurcated: Mid-mesial 7.5 mm*
Buccal root Mid-distal
Lingual root

Photo demonstrates the variability in

root trunk length.
Maxillary molars Trifurcated Mid-buccal Buccal 5 4 mm*
Lingual root Mesiolingual 1st molar mesial 5 4.5 mm*
Mesiobuccal Distolingual 2nd molar mesial 5 5.5 mm*
Distobuccal 1st molar distal 5 4.5 mm*
2nd molar distal 5 4 mm*

Photo demonstrates the variability in

root trunk length.
Mandibular molars Bifurcated Mid-buccal 1st molar buccal 5 3.0–3.5 mm*
Mesial root Mid-lingual 1st molar lingual 5 5.5 mm*
Distal root 2nd molar buccal 5 4 mm*
2nd molar lingual 5 3.5–4.0 mm*

Photo demonstrates the variability in

root trunk length.

* Ranges vary 1–9 mm for each tooth, and this number represents an average.
Dababneh et al. (2011); Kadovic et al. (2017); Kerns et al. (1999)

(see Figure 8-2). Knowledge of the probing depth

Furcation Assessment
Before debriding a furcation with a thin, curved ul-
trasonic shank, the oral health-care provider will per-
form three assessments to determine the degree of
furcation defect, length of root trunk, and root topog-
raphy: periodontal charting, explorative evaluation,
and radiographic evaluation.
Periodontal Charting. During periodontal
charting, a curved periodontal probe is used to iden-
tify a furcation defect depth and aids in classification
and classification provides valuable information that
is useful for instrumentation. There are over a dozen
classification systems for detecting and recording
furcation involvement on a periodontal chart. The
first, and most widely used, was released in 1953 by
Glickman (termed Glickman Index) and divides
furcation involvement into four grades (denoted
I–IV) based on furcation defect severity and extent
(Glickman, 1972; Pilloni & Rojas, 2018).
Many other classification systems have been re-
leased since Glickman’s that add more anatomic detail
 Complex Root Anatomy 141

BREAKOUT POINT
A curved periodontal probe will identify the depth
and classification of a furcation defect to assist the
provider in instrument selection and debridement
technique.
to provide guidance on treatment recommendations
and long-term prognosis. For example, some systems
identify:
• Bone loss between varying surfaces on a tooth
(facial, lingual, proximal).
• Number of remaining boney walls.
• Morphology of existing bone. Morphology is a
term that describes the study of the parts of an or-
ganism and the relationships between structures.
• Root trunk length variations. Length is then re-
lated to bone loss patterns (horizontal versus
vertical).
• Radiographic evidence of furcation lesions.
Exploration Evaluation. The dental explorer is
used to assess the anatomy and topography of a furca-
tion. The explorer will identify the furcation entrance
position on the root trunk, width of the entrance,
presence of a concavity and convexity, and presence
or absence of oral deposits. There is wide variability in
furcation anatomy, topography, entrance widths, and
length of root trunk. Furcation entrance widths can
be as narrow as under a millimeter or well over (see
Figure 8-3).

BREAKOUT POINT
An explorer will identify the anatomy, topography,
entrance width, and presence of oral deposits of a
furcation defect to aid the provider in debridement
technique.

Radiographic Evaluation. A dental radiograph

Figure 8-2 Furcation Probe (P2N6 Naber’s Probe by
HuFriedyGroup)
Courtesy of HuFriedyGroup Mfg. Co., LLC
will reveal important anatomy that is useful during
instrumentation (see Figure 8-4). Not all furcation de-
fects will appear on a two-dimensional image because
facial and lingual structures are superimposed on one
another (see Figure 8-5a and b). Cone-beam computer
tomography (CBCT) provides a three-dimensional
view of a tooth with more tooth anatomy detail and
alveolar bone positioning (see Figure 8-6).

Length root 4 mm 7 mm 2 mm 6 mm 3 mm
trunk
Width furca Under 1 mm Under 1 mm Under 1 mm 1 mm 4 mm
entrance

Figure 8-3 Furcation width and root trunk.

142 Chapter 8 Clinical Perspectives of Tooth Anatomy
Figure 8-4 Radiograph furcation appearance.
Mandibular left first molar shows a radiolucent lesion in
the furcation entrance with loss of lamina dura.
Furcation Debridement
Once all furcation assessments are complete, the next
step is instrument selection and debridement. Debrid-
ing a furcation defect is challenging because of the
variable anatomy, position, and topography. The goal
of periodontal instrumentation is to ensure the furca-
tion defect is debrided without altering cementum to
prevent further alveolar bone and attachment loss. A
furcation may be clinically visible in the presence of
gingival recession (see Figure 8-7a) or hidden under
the gums (see Figure 8-7b).
In the 1940s, prior to the advent of dental ul-
trasonic technology, hand-activated area-specific cu-
rettes were developed. The single cutting edge with
a toe blade on a more complex and longer shank al-
lowed for better adaptation into deeper periodontal
pockets on the tooth root while protecting the gin-
giva from injury. However, when it came to furca-
tion debridement, the blade was too thick to access
narrow furcation entrance widths (see Figure 8-8a).
The solution to this instrument challenge came with
the development of thin, curved ultrasonic shanks
whose width is only 0.5 mm, allowing them to ac-
cess even the narrowest of furcation entrances (see
Figure 8-8b).
B
Figure 8-5 Maxillary molar furcation case: A. Maxillary
right first molar has a through-and-through furcation
defect from the buccal. The curved furcation probe was
able to strike the palatal root when inserted from the
buccal midline. The radiograph is underreporting
the furcation severity due to the superimposition of
the palatal root on the two-dimensional digital image.
However, the image still shows anatomy that is helpful
for the provider such as root trunk length and alveolar
bone position. B. Maxillary right first molar shows a
significant vertical bone defect on the mesial of the tooth
and horizontal bone loss on the distal (see red lines).
This two-dimensional digital image does not show the
direct mesial or distal of the tooth, making accurate
radiographic furcation assessment challenging. The
blue arrows are pointing to the furcation entrances on
the proximal surface.
BREAKOUT POINT
A thin, curved ultrasonic insert or tip allows access
to narrow furcation entrances during debridement.

Figure 8-6 CBCT.
A
B
Figure 8-7 Furcation: A. Furcation entrance visible on
mandibular left first molar, B. Furcation entrance not
visible on maxillary right first molar intraoral camera
photo. Radiograph reveals vertical bone loss on mesial.
This tooth has furcation involvement straight buccal and
mesial.
Complex Root Anatomy 143
A
B
Figure 8-8 Furcation entrance: A. Hand-activated
area-specific posterior Gracey curette: note the width of
the blade does not allow access to the narrow furcation
entrance, B. Ultrasonic curved thin insert: the narrow
shank allows access to the narrow furcation entrance.
144 Chapter 8 Clinical Perspectives of Tooth Anatomy

A B
Figure 8-9 Straight and curved shank: A. Straight shank: Improper furcation adaptation of the active area antinode
that will lead to cementum damage. (Dentsply Sirona Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert),
B. Curved shank: Proper furcation adaptation of the active area antinode that will not cause cemental damage
(Dentsply Sirona Cavitron Slimline 10L 30K Ultrasonic Insert).

A straight ultrasonic shank is not designed to
debride furcation anatomy and has been found to
cause cemental damage (Tunkel et al., 2002; Oda &
Ishikawa, 1989). As you will learn in later chapters,
certain surfaces of the active area antinode on the
shank have higher displacement amplitudes than
others. These surfaces are more likely to damage
BREAKOUT POINT
A straight ultrasonic shank should not be used
to debride furcation defects; a thin, curved shank
should be used.
cementum. A straight shank will adapt these more ac-
tive surfaces on a furcation defect, and a curved shank
will not (see Figure 8-9).
In summary, a thin, curved ultrasonic insert or tip
is the instrument of choice for debriding furcation de-
fects because of the following:
• Narrow diameter that allows for access to narrow
furcation entrances (Drisko et al., 2000).
• Longer shank that allows for access to deeper
periodontal pockets where furcation defects are
found (Dragoo, 1992; Leon & Vogel, 1987).
• Detoxification ability through acoustic cavitation,
acoustic microstreaming, and liquid jet production.
• Improved time efficiency of debridement (Tunkel
et al., 2002).

CASE STUDY 1
You are working for a dental office that schedules two nonsurgical periodontal debridement procedures per day. The
office has many hand-activated instrument choices such as sickle scalers, universal curettes, and area-specific cu-
rettes for anterior and posterior teeth. They also provide a magnetostrictive ultrasonic device in each operatory with a
thick and thin straight insert. You are given 90 minutes to perform a half-mouth nonsurgical periodontal debridement
on each patient. You find yourself struggling to finish in the time allotted and notice you are spending a lot of time
hand-instrumenting posterior teeth furcations and interproximal root concavities. What are some solutions and educa-
tional points you should present to your employer to solve this dilemma?
 Questions 145

CASE STUDY 2
You are performing a periodontal debridement on the distal of the mandibular right first molar pictured here. Vertical
bone loss is present, revealing a large distal root concavity that must be debrided.

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

Summary
Dental ultrasonic technology has revolutionized the
treatment and management of periodontal disease
through improved access to and complete debride-
ment of complex root anatomy such as furcation
defects, root concavities, and root convexities. Thin,
curved ultrasonic shanks will allow for correct active
area antinode adaptation in and around furcation de-
fects and root concavities while conserving cementum.
Through the production of acoustic cavitation, acous-
tic microstreaming, and liquid jets, dental ultrasonic
technology removes adherent pathogenic biofilm, and
its direct-contact chipping action removes tenacious
deposits in the subgingival environment. These ac-
tions promote a symbiotic oral environment and ward
off disease processes.

Questions
1. Which of the following hard tissues has the 2. Which of the following hard tissues is
highest percentage of mineralized structure? most prone to injury from periodontal
a. Enamel instrumentation?
b. Dentin a. Enamel
c. Cementum b. Dentin
c. Cementum
146 Chapter 8 Clinical Perspectives of Tooth Anatomy

Match the following terms to their correct definitions 14. Lingual root of maxillary first molar.
for questions 3–7. There is one correct answer for 15. Mesial of mandibular first molar.
each term.
16. True or False. In health, alveolar bone fills in the
3. Furcation A. Tooth root with two roots. furcation area.
4. Root concavity B. Linear concave a. True
indentation in the root. b. False
5. Furcation defect C. A pathological condition
where the furcation is 17. True or False. There is one universal
no longer filled in with classification system for furcation involvement.
alveolar bone. a. True
6. Bifurcation D. Area on a tooth root b. False
measured from the CEJ 18. On average, how much bone loss must occur
to the entrance of the before a furcation defect can be detected on the
furcation. maxillary first premolar?
7. Root trunk E. Anatomical division a. 7.5 mm
between tooth roots. b. 4.5 mm
8. True or False. Both hand-activated and c. 3 mm
ultrasonic instrumentation will remove d. 2 mm
oral deposits from cemental surfaces, but
19. On average, how much bone loss must occur
hand-activated instruments produce less
before a furcation defect can be detected on the
gouging and removal of cementum than
mesial of the maxillary first molar?
ultrasonic instrumentation.
a. 1 mm
a. True
b. 2 mm
b. False
c. 3 mm
9. Which periodontal instrument is the best d. 4.5 mm
selection for the removal of oral deposits in a
20. On average, how much bone loss must occur
narrow furcation?
before a furcation defect can be detected on the
a. Thin, straight ultrasonic shank
buccal of the mandibular first molar?
b. Thin, curved ultrasonic shank
a. 1 mm
c. Area-specific curette
b. 2 mm
d. Posterior sickle scaler
c. 3.0–3.5 mm
10. For which of the following would the use of a d. The mandibular first molar does not have a
thin, curved ultrasonic shank be useful? furcation.
a. Mesial root of maxillary first premolar
21. True or False. With alveolar bone loss, a
b. Distal root of the mandibular canine
furcation defect can occur and will always appear
c. Distal furcation involvement maxillary first
radiographically on a two-dimensional image.
molar
a. True
d. All of the above
b. False
Determine if the following have a root concavity or
22. Which of the following is an advantage of
root convexity for questions 11–15. Answer A for root
thin, curved ultrasonic shanks in furcation
concavity and B for root convexity. There is only one
debridement?
correct answer for each question.
a. Narrow width
11. Buccal mandibular second premolar. b. Longer shank for reaching deeper pockets
12. Distal mandibular central incisor. c. Detoxification and biofilm removal through
acoustic cavitation, acoustic microstreaming,
13. Mesial mandibular first premolar with bone loss and liquid jet release
into the middle third. d. All of the above

References
1. Dababneh, R., Samara, R., Abul-Ghanam, M. A., Obeidat, L., &
Shudifat, N. (2011, March). Root trunk: Types and dimension
and their influence on the diagnosis and treatment of
periodontally involved first molars. Journal of the Royal Medical
Services, 18(1), 45–51.
2. Dragoo, M. R. (1992). A clinical evaluation of hand
and ultrasonic instruments in subgingival debridement,
Part 1. With unmodified and modified ultrasonic inserts.
International Journal of Periodontics & Restorative Dentistry,
12(4), 311–323.
3. Drisko, C. L., Cochran, D. L., Blieden, T., Bouwsma, O. J.,
Cohen, R. E., Damoulis, P., Fine, J. B., Greenstein, G.,
Hinrichs, J., Somermman, M. J., Iacono, V., & Genco, R. J.
(2000). Position paper: Sonic and ultrasonic scalers in
periodontics. Research, Science and Therapy Committee
of the American Academy of Periodontology. Journal of
Periodontology, 71(11), 1792–1801. https://doi.org/10.1902
/jop.2000.71.11.1792
4. Glickman, I. (1972). Clinical periodontology: Prevention,
diagnosis, and treatment of periodontal disease in the practice of
general dentistry (4th ed., pp. 242–245). Saunders.
5. Kadovic, J., Novakovic, N., Jovanovic, M., Dordevic, V.,
Petrovic, V., Stojcev-Stajcic, L., & Cakic, S. (2017).
Anatomical characteristics of the furcation area and root
surfaces of multi-rooted teeth: Epidemiological study.
Military-Medical and Pharmaceutical Review, 76(00), 1–34.
https://doi.org/10.2298/VSP170308149K
6. Kawashima, H., Sata, S., Kishida, M., & Ito, K. (2006). A
comparison of root surface instrumentation using two
piezoelectric ultrasonic scalers and a hand scaler in vivo.
Journal of Periodontal Research, 42, 90–95.
7. Kerns, D., Greenwell, H., Wittwer, J., Drisko, C.,
Williams, J. N., & Kerns, L. L. (1999). Root trunk dimensions
of 5 different tooth types. The International Journal of
Periodontics & Restorative Dentistry, 19(1), 83–91.
8. Khosravi, M., Bahrami, Z. S., Atabaki, M. S. J.,
Shokrgozar, M. A., & Shokri, F. (2004). Comparative
effectiveness of hand and ultrasonic instruments in root
surface planing in vitro. Journal of Clinical Periodontology, 31,
160–165.
9. Kumar, P., Das, S. J., Sonowal, S. T., & Chawla, J. (2015).
Comparison of root surface roughness produced by hand
instruments and ultrasonic scalers: An invitro study. Journal of
Clinical and Diagnostic Research, 9(11), ZC56–ZC60. https://
doi.org/10.7860/JCDR/2015/13744.6828
10. Leon, L. E., & Vogel, R. I. (1987). A comparison of the
effectiveness of hand scaling and ultrasonic debridement in
furcations as evaluated by differential dark-field microscopy.
Journal of Periodontology, 58(2), 86–94.
References 147
11. Maritato, M., Orazi, L., Laurito, D., Formisano, G., Serra, E.
Lollobrigida, M., Molinari, A., & De Biase, A. (2018). Root
surface alterations following manual and mechanical scaling:
A comparative study. International Journal of Dental Hygiene,
16, 553–558. https://doi.org/10.1111/idh.12349
12. Mittal, A., Nichani, A. S., Venugopal, R., & Rajani, V. (2014).
The effect of various ultrasonic and hand instruments on the
root surfaces of human single rooted teeth: A planimetric and
profilometric study. Journal of Indian Society of Periodontology,
18(6), 710–717.
13. Nedoklan, S., Knezovic, Z., Knezovic, N., & Sutlovic, D.
(2021). Nutrition and mineral content in human teeth
through the centuries. Archives of Oral Biology, 124
(105075), 1–9.
14. Oda, S., & Ishikawa, I. (1989). In vitro effectiveness of a
newly-designed ultrasonic scaler tip for furcation areas.
Journal of Periodontology, 60(11), 634–639.
15. Pilloni, A., & Rojas, M. A. (2018). Furcation involvement
classification: A comprehensive review and a new system
proposal. Dentistry Journal, 6(3), 1–22. https://doi.org/10
.3390/dj6030034
16. Ritz, L., Hefti, A. F., & Rateitschak, K. H. (1991). An in
vitro investigation on the loss of root substance in scaling
with various instruments. Journal of Clinical Periodontology,
18(9), 643–647. https://doi.org/10.1111/j.1600-051x.1991
.tb00104.x
17. Santos, F. A., Pohapski, M. T., Leal, P. C., Gimenes-Sakima, P. P., &
Marcantonio, E. (2008). Comparative study on the effect of
ultrasonic instruments on the root surface in vivo. Clinical Oral
Investigations, 12, 143–150. https://doi.org/10.1007/s00784
-007-0167-3
18. Scheid, R. C., & Weiss, G. (2017). Woelfel’s dental anatomy
(9th ed.). Wolters Kluwer.
19. Sheldahl, L. C., & Yapp, R. A. (2020). Histology and embryology
for the dental hygienist. Open Oregon Publishing. https://
openoregon.pressbooks.pub/histologyandembryology
/chapter/chapter-4-histology-of-the-teeth-and-periodontal
-tissue/#4teeth
20. Singh, S., Uppoor, A., & Nayak, D. (2012). A comparative
evaluation of the efficacy of manual, magnetostrictive
and piezoelectric ultrasonic instruments—an in vitro
profilometric and SEM study. Journal of Applied Oral Science,
20(1), 21–26.
21. Tunkel, J., Heinecke, A., & Flemming, T. F. (2002). A
systematic review of efficacy of machine-driven and manual
subgingival debridement in the treatment of chronic
periodontitis. Journal of Clinical Periodontology, 29(Suppl 3),
72–81.
 CHAPTER 9
Grasp, Stabilization,
and Positioning
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Grasp a magnetostrictive and piezoelectric
ultrasonic handpiece correctly.
2. Identify the function of each finger of the
dominant hand in an ultrasonic grasp.
3. Demonstrate intraoral and extraoral finger
rests used for ultrasonic instrumentation.
4. Demonstrate operator chair positioning for
posterior and anterior teeth during ultrasonic
instrumentation.
5. Understand the use and positioning of the High
volume evacuation (HVE) during ultrasonic
instrumentation.
KEY TERMS
• Cheek finger rest: extraoral stabilization
technique where the operator’s finger rest is on
the cheek while the ultrasonic shank is positioned
inside the mouth on a tooth surface.
• Chin finger rest: extraoral stabilization technique
where the operator’s finger rest is on the chin
while the ultrasonic shank is positioned inside the
mouth on a tooth surface.
• Cross-arch finger rest: intraoral stabilization
technique where the operator’s finger rest is on
the adjacent arch as the position of the ultrasonic
shank on a tooth surface.
• Extraoral finger rest: stabilization technique
where a finger rest of the operator’s dominant
hand is outside the mouth during ultrasonic
instrumentation.
• Finger rest: stabilization with the ring and pinkie
fingers during ultrasonic instrumentation.
• Grasp: the act of holding a dental device in a specific
manner that promotes high-quality ergonomics.
• Intraoral finger rest: a stabilization technique
where the operator’s dominant hand is inside the
mouth during ultrasonic instrumentation.
• Opposite-arch finger rest: intraoral stabilization
technique where the operator’s finger rest is on
the same side of the mouth but opposite arch as
the position of the ultrasonic shank on a tooth
surface.
• Purevac HVE: a high-volume evacuation system
manufactured by Dentsply Sirona.
• Purevac HVE Connector: a part of the Dentsply
Sirona Purevac HVE system that connects the
mirror tip to the HVE hose and rotates 360 degrees.
• Purevac HVE Hose: five-foot long hose that
attaches to the HVE line on a dental unit that
is part of the Dentsply Sirona Purevac HVE
system.
• Purevac HVE Mirror Tip: an 8 mm bore hole HVE
with affixed mirror that is part of the Dentsply
Sirona Purevac HVE system.
• Same quadrant intraoral finger rest: intraoral
stabilization technique where the operator’s
finger rest is three or more teeth away in the
same quadrant as the position of the ultrasonic
shank on a tooth surface.
Introduction
This is the first chapter in Section 3 that will teach
ultrasonic instrumentation technique. Correct ul-
trasonic technique is taught as a series of building
blocks as depicted in Figure 9-1. Chapter 9 covers
149
150 Chapter 9 Grasp, Stabilization, and Positioning

Pinkie Ring Middle Index Thumb

Grasp and
stabilization

Operator and
patient positioning

Aerosol control

Adaptation

Angulation

Orientation

Activation

Figure 9-1 Ultrasonic Instrumentation Building Blocks

the green topics, Chapter 10 covers the blue, and

Chapter 11 covers the orange. Chapter 12 puts all
the building blocks together with chairside tech-
nique practice.
This chapter will introduce the building blocks of
grasp, finger rests, and operator and patient chair po-
sitioning required for proper ultrasonic instrumenta-
tion. Ultrasonic instrumentation utilizes a relaxed and
light grasp with an intraoral or extraoral finger rest for
stabilization. This differs from hand-activated instru-
mentation, which requires a tight, pinch-grip grasp on
the instrument with a secure fulcrum for stabilization.
A wrist rock with lateral pressure applied to the fin-
gers and forearm is required to physically break the
oral deposit bond from the tooth surface during hand-­
activated instrumentation. A dental ultrasonic shank
will mechanically chip the oral deposit from the tooth
for the oral health-care provider, allowing for a relaxed
grasp with no lateral pressure to muscle groups. Small
finger movements are used to position the active area
antinode of the shank on tooth surfaces.
Operator chair and patient positioning are fluid
and flexible during ultrasonic instrumentation. The
provider uses direct vision whenever possible because
both hands are used simultaneously. The nondomi-
nant hand grasps the HVE, and the dominant hand
grasps the ultrasonic handpiece. The HVE is used
during ultrasonic instrumentation to control aerosols,
remove fluid from the patient’s mouth, and retract oral
structures for visibility. Direct vision is made possible
through the use of bilateral chair positioning utilizing
both the right and left sides of the patient chair regard-
less of the operator’s dominant hand. Intraoral and
extraoral finger rests are used to accommodate direct
vision, bilateral chair positioning, and a relaxed grasp.
Figure 9-2 Fingers for the ultrasonic grasp
Grasp
The operator grasp refers to the hand and finger
positioning around an instrument that promotes
high-quality ergonomics. The oral health-care pro-
vider will grasp the ultrasonic handpiece in their
dominant hand with a light and relaxed grasp.
• The thumb, index finger, and middle finger are
used to stabilize the handpiece in the grasp (see
Figure 9-2—red circles). Their exact position on
the handpiece is different for a magnetostrictive
than a piezoelectric.
• The ring and pinkie finger are used as a finger rest
(see Figure 9-2—blue circles). Finger rests are the
same for magnetostrictive and piezoelectric ultra-
sonic instrumentation.
Magnetostrictive Grasp
A magnetostrictive ultrasonic is grasped with the
thumb and index finger equidistant from one another
on either side of the handpiece. The middle finger is
advanced forward onto the colored grip of the insert.
The handpiece itself lays in the webbing bet­ween the
thumb and index finger (see Figure 9-3). The posi-
tioning of the handpiece in the webbing is important
and should not be compromised as the oral health-
care provider is working. This grasp will promote
optimal ergonomics by balancing the weight of the
handpiece in the hand.
 Grasp 151

Figure 9-3 Correct Magnetostrictive Handpiece Grasp

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

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

Hand and Finger Size

Small palm size and short fingers (see Figure 9-4a):
• Thumb and index finger will grasp lower on the
handpiece closer to the grip, but both fingers re-
main on the handpiece.
• Middle finger will be higher on the grip, farther
away from the shank.
B
Figure 9-4 Hand and finger size in magnetostrictive
grasp (Dentsply Sirona Cavitron Steri-Mate 360
Handpiece and Cavitron Slimline 10S Fitgrip 30K
Ultrasonic Insert): A. Small Hand and Short Fingers,
B. Large Hand and Long Fingers
Reproduced with permission from Dentsply Sirona

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

• Thumb and index finger will grasp higher on the
handpiece, farther away from the grip than a pro-
vider with small palms and short fingers.
• Middle finger will be lower on the grip closer to
the shank than a provider with short fingers.
Regardless of hand size, the middle finger should
never be advanced forward within the terminal ½ inch
of the grip (see Figure 9-5). This is to prevent exces-
sive lateral pressure from being applied to the grasp Figure 9-5 Terminal 1/2 Inch of Insert Grip (Dentsply
and reduces the risk for shank breakage. Sirona Powerline 10 30K Ultrasonic Insert)
Note: If using an insert that rotates, the magneto-
strictive grasp may need to be modified to control
the insert. The index finger or thumb may need to be Piezoelectric Grasp
advanced closer to or on the insert grip. If the finger A piezoelectric is grasped with the thumb and index
position is modified, the oral health-care provider will finger equidistant from one another on either side
need to ensure: of the handpiece. The middle finger is touching and
• The handpiece position stays in the webbing tucked behind the index finger. The handpiece lays in
­between the thumb and index finger. the webbing between the thumb and index finger to
• Excessive lateral pressure is not applied to the promote optimal ergonomics by balancing the weight
­fingers in the grasp. of the handpiece in the hand (see Figure 9-6).
152 Chapter 9 Grasp, Stabilization, and Positioning

Figure 9-6 Piezoelectric Handpiece Grasp

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

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

Advanced Grasp
In an advanced ultrasonic grasp, the provider will
move the handpiece from the webbing between the
thumb and index finger to the second joint of the in-
dex finger (see Figure 9-7a and b). This grasp is useful
in the following situations:
• Areas of the mouth that are challenging to see and
access, such as terminal molars.
• When using curved shank shapes.
• When the operator position is moved to their
nondominant side of the patient chair.
B
This grasp is not an alternative to the primary ultra-
Figure 9-7 Advanced Handpiece Grasp:
sonic grasp described previously. The palm of the A. Magnetostrictive advanced grasp (Dentsply Sirona
hand and carpel tunnel are put under strain in an ad- Cavitron Steri-Mate 360 Handpiece ad Cavitron Slimline
vanced grasp, so it is to be used as a last resort and 10S Fitgrip 30K Ultrasonic Insert), B. Piezoelectric
temporarily. The provider should reestablish an ultra- advanced grasp (Acteon Newtron Slim Handpiece and
sonic grasp as soon as possible. Tip 1)
A: Reproduced with permission from Dentsply Sirona; B: Reproduced with permission from ACTEON

Light Grasp
The oral health-care provider uses a light, relaxed
grasp with no lateral pressure applied to the fingers
when the shank is loaded onto tooth surfaces during
ultrasonic instrumentation. This is unlike hand-­
activated instrumentation where a firm, pinch-grip,
engaged grasp with lateral pressure transmitted to
the fingers is required to produce a productive scal-
ing stroke. The difference in grasp is attributed to the
functionality of the equipment.
The provider applies 0–10 g of lateral pressure in
an ultrasonic grasp (Nagraj et al., 2020). The goal is
to use as light a grasp as possible. When more than
10 g is used, increased pressure from the grasp will
transmit to a loaded ultrasonic shank, which can lead
to multiple adverse effects:
• Loss of tactile sensitivity: Inability of the oral
health-care provider to feel the tooth anatomy
during ultrasonic instrumentation.
 Stabilization 153

• Displacement amplitude of the shank will decrease.

This decreases the effectiveness and efficiency of
oral deposit removal.
• Removal of oral deposits will take longer, increasing
labor intensity and fatigue of the oral health-care
provider.
• Increased risk for incomplete removal of oral
deposits. This can lead to the incidental burnishing
of dental calculus onto crown and root surfaces.
Burnished calculus occurs when the outer portion
of a dental calculus mass is removed and the inner
layer is left behind on the tooth crown or root.
This is not a desired clinical outcome.
• Equipment damage
• An insert and tip will wear faster, causing
the shank to lose length. This decreases the
equipment’s life expectancy and efficiency.
• The risk for shank breakage increases. Ultra-
sonic shanks are not designed for more than
10 g of lateral pressure and will break at their Figure 9-8 Lateral Pressure Skill Building (Dentsply
weakest structure, which is typically at one Sirona Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert)
Reproduced with permission from Dentsply Sirona
of the bends in the shank. If the breakage
occurs during active ultrasonic instrumen-

tation, the risk for an adverse patient event
increases. The patient may aspirate or swal-
low the broken shank, which will require a
medical referral. If the shank breaks subgin-
givally, the broken piece may become lodged
in the tissue, requiring a retrieval procedure.
BREAKOUT POINT
Stabilization
During ultrasonic instrumentation, a provider uses a
finger rest to stabilize their hand and provide sup-
port for the shank active area antinode on tooth struc-
tures. The ring and pinkie fingers are used in a finger
rest. Both fingers are relaxed. In a stable ultrasonic
finger rest:

In an ultrasonic grasp, 0–10 g of lateral pressure
is applied to a loaded ultrasonic shank.
Grasp Skill Building
You will need the following supplies: small kitchen
scale, ultrasonic insert or tip, ultrasonic handpiece.
Rationale: This exercise will provide a kinetic learn-
ing experience to practice lateral pressure. You will
be able to evaluate and feel 0–10 g of lateral pressure
transmitted to the insert or tip shank.
Steps:
1. Place an insert or tip in the handpiece.
2. Place the kitchen scale on a flat surface.
3. Grasp the ultrasonic handpiece correctly.
4. Place the point of the insert or tip on the scale.
5. Apply lateral pressure until 10 g is reached (see
Figure 9-8).
6. Repeat the exercise until 0–10 g of pressure is ap-
plied with each placement.
• The ring or pinkie finger may be used inde-
pendently (Figure 9-9a) or together (Figure 9-9b).
• The ring and pinkie fingers do not have to touch
one another (see Figure 9-9a).
• The ring finger can touch or not touch the mid-
dle finger (see Figure 9-10). A gapping between
the middle and ring finger is useful to maintain
proper grasp in many situations during ultrasonic
instrumentation. Gapping the fingers can assist
with maintaining the handpiece in the webbing
between the thumb and index finger.
• The pad or side of the finger may be used in a
finger rest (see Figure 9-11a and b).
• The ring and pinkie finger may be inside or out-
side the oral cavity.
Unlike hand-activated instrumentation, a stable
and secure fulcrum with all fingers touching is not
needed with ultrasonic instrumentation because the
provider is not using lateral pressure, stroke force, or a
wrist rock to manually break oral deposits from tooth
surfaces (see Figure 9-12a and b).
154 Chapter 9 Grasp, Stabilization, and Positioning

Figure 9-10 Finger rest gap Between Middle and Index

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

B
Figure 9-9 Finger rest ring and Pinkie Fingers (Dentsply
Sirona Cavitron Steri-Mate Sterilizable, Detachable
Handpiece and Cavitron Powerline 10 30K Ultrasonic
Insert): A. Ring and Pinkie Finger Separated and Used
Independently, B. Ring and Pinkie Finger Touching and
Used Together
A: Reproduced with permission from Dentsply Sirona

B
BREAKOUT POINT
Figure 9-11 Finger Rest (Dentsply Sirona Cavitron Steri-
In an ultrasonic finger rest, the middle, ring, and Mate 360 Handpiece and Cavitron Slimline 10S Fitgrip
pinkie fingers may separate. 30K Ultrasonic Insert): A. Side of Finger, B. Pad of Finger
Reproduced with permission from Dentsply Sirona

B
Figure 9-12 Fulcrum and finger rest comparison:
A. Hand-activated Instrument Fulcrum (HuFriedyGroup
SH6/7 Anterior Sickle Scaler), B. Ultrasonic Finger Rest
(Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and
Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert)
Intraoral Finger Rest
An intraoral finger rest is when the dominant hand
finger rest is placed inside the mouth for ultrasonic in-
strumentation stabilization. There are three intraoral
finger rest options:
1. Same quadrant finger rest: The finger rest
is inside the mouth on the same quadrant as
the shank active area antinode (see Figure 9-13).
Due to the grasp used in ultrasonic instrumenta-
tion, the finger rest will be more than three teeth
away from the position of the shank. This is un-
like hand-activated instrumentation where the
Stabilization 155
Figure 9-13 Intraoral same quadrant finger rest. The
shank is adapted to the mandibular right first molar and
the finger rest is on the mandibular right lateral incisor.
Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and
Cavitron Slimline 10L Fitgrip 30K Ultrasonic Insert
and Purevac HVE)
Reproduced with permission from Dentsply Sirona
fulcrum finger is one to three teeth away from the
placement of the blade.
2. Cross-arch finger rest: The finger rest is inside
the mouth on the adjacent arch as the shank ac-
tive area antinode (see Figure 9-14).
3. Opposite-arch finger rest: The finger rest is in-
side the mouth on the same side of the mouth but
opposite arch as the shank active area antinode
(see Figure 9-15).
Extraoral Finger Rest
An extraoral finger rest is when the dominant hand
finger rest is placed outside the mouth for ultrasonic
instrumentation stabilization. The pads or side of the
ring or pinkie finger can be used. Fingers can be split
apart or together. There are two extraoral finger rests.
1. Cheek finger rest: Finger rest is on the outside
of the mouth on the cheek as the shank active area
antinode is adapted to tooth structures inside the
mouth (see Figure 9-16).
156 Chapter 9 Grasp, Stabilization, and Positioning

A B
Figure 9-14 Intraoral Cross-Arch Finger Rest (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron
Powerline 10 Fitgrip 30K Ultrasonic Insert): A. Shank active area antinode is adapted to the maxillary right canine
and the finger rest is on the maxillary left canine, B. Shank active area antinode is adapted to the mandibular left first
premolar and the finger rest is on the mandibular right canine.
Reproduced with permission from Dentsply Sirona

A B
Figure 9-15 Intraoral Opposite-Arch Finger Rest (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron
Powerline 10 Fitgrip 30K Ultrasonic Insert): A. Shank active area antinode is adapted to the maxillary right first
premolar and the finger rest is on the mandibular right lateral incisor, B. Shank active area antinode is adapted to the
maxillary left second premolar and the finger rest is on the mandibular left canine.
Reproduced with permission from Dentsply Sirona

Figure 9-16 Extraoral Cheek Finger Rest (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Thinsert
Fitgrip Ultrasonic Insert and Purevac HVE)
Reproduced with permission from Dentsply Sirona
 Operator and Patient Chair Positioning 157

Figure 9-18 Simultaneous use of dominant and non-

Figure 9-17 Extraoral Chin Finger Rest (Dentsply
dominant hands during ultrasonic instrumentation
Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron
(Dentsply Sirona Steri-Mate 360 Handpiece, Cavitron
Powerline 10 Fitgrip 30K Ultrasonic Insert and
Thinsert Fitgrip 30K Ultrasonic Insert, Purevac HVE,
Purevac HVE)
Cavitron 300 Ultrasonic Scaling System)
Reproduced with permission from Dentsply Sirona
Reproduced with permission from Dentsply Sirona

2. Chin finger rest: Finger rest is on the outside of

the mouth on the chin as the shank active area
antinode is adapted to tooth structures inside the
mouth (see Figure 9-17).

BREAKOUT POINT
An intraoral or extraoral finger rest is used during
ultrasonic instrumentation.

Operator and Patient

Chair Positioning
Operator chair and patient positioning are fluid and Figure 9-19 Maxillary anterior lingual indirect vision
flexible during ultrasonic instrumentation. Both hands (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece,
are used simultaneously during active patient treat- Cavitron Thinsert Fitgrip 30K Ultrasonic Insert, and
Purevac HVE)
ment. The dominant hand is grasping the ultrasonic
Reproduced with permission from Dentsply Sirona
handpiece and the nondominant hand is grasping the
HVE (see Figure 9-18). The provider uses bilateral op-
erator chair positioning, regardless of being dominant
right- or left-handed, to use direct vision for all areas BREAKOUT POINT
of the mouth. The only area where indirect vision is re-
Bilateral operator chair positioning is used during
quired is the maxillary anterior lingual surfaces and the ultrasonic instrumentation.
maxillary posterior occlusal surfaces (see Figure 9-19).
158 Chapter 9 Grasp, Stabilization, and Positioning

A B C
Figure 9-20 Patient Chair Positioning (Dentsply Sirona Cavitron Steri-Mate 360 Handpiece and Cavitron Powerline
10 Fitgrip 30K Ultrasonic Insert and Purevac HVE). A. Maxillary ultrasonic instrumentation: Patient is supine with
chin slightly tilted upward. B. Mandibular ultrasonic instrumentation: Patient is semi-supine with chin slightly tilted
downward. C. Mandibular ultrasonic instrumentation: Patient is in between supine and semi-supine with chin slightly
downward.

Flexible bilateral operator chair positioning is an

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

• Maxillary arch: Patient positioning is typically

supine, or in between supine and semi-supine,
with the patient’s chin slightly tilted upward (see
Figure 9-21).
• Mandibular arch: Patient positioning is either
supine, in between supine and semi-supine, or
semi-supine, with the patient’s chin slightly tilted
downward (see Figure 9-22).
When direct vision is challenged in the seated posi-
tion, changing to a stand-up operator positioning may
resolve the issue (see Figure 9-23).
Figure 9-21 Maxillary Ultrasonic Instrumentation
Patient Chair Positioning (Dentsply Sirona Cavitron
Steri-Mate 360 Handpiece and Cavitron Powerline
10 Fitgrip 30K Ultrasonic Insert and Purevac HVE)
Operator and Patient
Positioning Selection
The operator and patient positioning must not com-
promise ergonomics. If ergonomics becomes compro-
mised, the operator has selected an incorrect chair

Figure 9-22 Mandibular Ultrasonic Instrumentation
Patient Chair Positioning (Dentsply Sirona Cavitron
Steri-Mate 360 Handpiece and Cavitron Powerline 10
Fitgrip 30K Ultrasonic Insert and Purevac HVE)
Figure 9-23 Ultrasonic Instrumentation with Operator
Stand-Up Positioning (Dentsply Sirona Cavitron Steri-
Mate 360 Handpiece and Cavitron Powerline 10 Fitgrip
30K Ultrasonic Insert and Purevac HVE)
position for ultrasonic instrumentation. The shoulder,
torso, back, legs, and arms should be in neutral posi-
tioning. The handpiece grasp, HVE position, and shank
placement on the tooth must be correct. Unique patient
factors may influence chair positioning such as a lim-
ited opening, restricted airway, gag reflex, or Temporo-
mandibular Disorder (TMD).
There is no one correct operator chair position for
each area of the mouth. The operator chair position
Operator and Patient Chair Positioning 159
will be different for each provider as human beings
are built differently. Individual operator factors that
influence appropriate chair positioning are:
• Height
• Girth
• Arm length
• Leg length
• Palm size
• Finger length
For example, a taller individual with longer arms will
position their operator chair farther away from the
patient than a shorter individual. An individual with
smaller palm size and finger length grasps the hand-
piece slightly different than an individual with a larger
palm size and finger length. The difference in grasp
influences the position of the finger rest. One individ-
ual may prefer an intraoral finger rest while another
prefers extraoral while instrumenting the same tooth.
Dental equipment also influences operator and
patient chair positioning.
• Loupes and lighting. If the provider has a light
affixed to their loupes, they have more freedom
in operator chair positioning. Using the overhead
light attached to the dental unit restricts position-
ing. The provider must sit in a location where the
dominant and nondominant hand positioning
does not block the overhead light.
• Dental chair characteristics such as headrest posi-
tion, height of dental chair, and maneuverability
of the dental chair (ability to move the chair right
and left). For example, if the dental chair will not
raise high enough to perform stand-up operator
positioning, this restricts the provider. If the pa-
tient headrest does not move, this will influence
patient chair positioning and chin tilts.
• Dental operatory design. If the operatory design
does not allow the provider passage from the left
to the right side of the chair, direct vision in all
areas of the mouth during ultrasonic instrumenta-
tion is not possible. In this situation, the use of an
HVE with an affixed mirror is needed for indirect
vision capability. If an HVE with affixed mirror is
not available, the provider will be forced to switch
to hand instrumentation to debride areas of the
mouth where indirect vision is required. This will
increase overall patient treatment time. The HVE
is always used during ultrasonic instrumentation
to reduce the quantity of aerosols and spatter
droplets released into the environment. The pro-
vider may not switch to an LVE to accommodate
for operatory design limitations because this con-
taminates the environment and reduces air quality.
160 Chapter 9 Grasp, Stabilization, and Positioning
Aerosol Control
An HVE is used during ultrasonic instrumentation
and serves three functions:
1. Reduce aerosol and splatter droplet contamina-
tion of the dental environment.
2. Remove oral fluids from the patient’s mouth.
3. Retract oral structures to improve visibility.
HVE Positioning
The HVE should be positioned 0.5–6.0 inches from
the water port on the shank (see Figure 9-24). This
distance allows for optimal aerosol removal and fluid
control while allowing the water to produce its mech-
anisms of action.
A sists of:
B
Figure 9-24 HVE Position (Dentsply Sirona Cavitron
Steri-Mate 360 Handpiece and Cavitron Powerline
10 Fitgrip 30K Ultrasonic Insert) A. HVE 0.5-6 inches
away from the water port on the shank B. HVE
greater than 12 inches away from the water port on the
shank
B. Reproduced with permission from Dentsply Sirona
• If the HVE is positioned greater than 12 inches
away from the water port, excessive aerosol and
spatter droplet contamination will enter the envi-
ronment, and fluid will accumulate in the patient’s
mouth (Nagraj et al., 2020; see Figure 9-24).
• If the HVE is too close to the active area an-
tinode (< 0.5 inches), the water will be evacu-
ated into the HVE before it has an opportunity to
perform its fluid dynamic mechanisms of actions
in the mouth, as learned in Chapter 6.
BREAKOUT POINT
The HVE should be positioned 0.5–6.0 inches from
the water port on the shank for optimal aerosol and
fluid control.
HVE Grasp
The HVE is grasped differently depending on the de-
vice and the area of the mouth the provider is work-
ing. This textbook only presents an HVE that has the
ability to remove 100 cubic feet of air per minute as
this has been shown to reduce aerosol contamination
over 90% (Nagraj et al., 2020; Avasth, 2018; Harrel &
Molinari, 2004; Holloman et al., 2015). These de-
vices typically have a large (8 mm) bore hole opening.
Any device without a verified claim as an HVE is not
presented.
Manufacturers offer a variety of design options for
an HVE. They can be short, long, angled, or affixed
with a mirror (see Figure 9-25). They all attach to the
HVE line of a dental unit.
The Purevac HVE manufactured by Dentsply
Sirona is a high-volume evacuation system that con-
• Mirror tip: Sterilizable 8 mm bore hole opening
HVE evacuation device. The mirror tip has an af-
fixed mirror that allows the provider to use in-
direct vision during ultrasonic instrumentation.
The mirror tip is slightly angled (see Figure 9-26a
and b).
• Connector: Connects the mirror tip to the
HVE hose. The connector has a 360-degree
swivel capability for provider ergonomics (see
Figure 9-26c).
• Hose: A 5-foot long hose that attaches to the
HVE line on the dental unit (see Figure 9-26c).
The hose is 69% lighter weight than a stan-
dard HVE hose, which decreases strain on the
provider’s nondominant hand and improves
­
ergonomics.
 Operator and Patient Chair Positioning 161

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

A B C
Figure 9-26 Dentsply Sirona Purevac System: A. Mirror tip, B. Mirror tip from the side. Notice the angulation. C. Hose
and 360-degree swivel connector with attached mirror tip
Reproduced with permission from Dentsply Sirona

The Purevac HVE system emits less noise than a stan-

dard dental unit HVE. The HVE is grasped in a simi-
lar manner as the ultrasonic handpiece in a pen grasp
with the mirror tip laying in the webbing between the
thumb and index finger. The angulation of the mir-
ror tip assists with this grasp. The provider can grasp
lower or higher on the mirror tip depending on the
clinical need (see Figure 9-27a and b). Ensure the fin-
gers do not cover the port hole openings on the front
of the mirror tip during use or the functionality may
be decreased.
You can grasp a standard HVE in three ways:
1. Pen grasp: A pen grasp similar to an ultrasonic
handpiece grasp. The HVE lays between the
webbing of the thumb and index finger (see
Figure 9-28a). This is the dominant grasp used for
ultrasonic instrumentation because it decreases
provider strain for improved ergonomics.
2. Alternate pen grasp. A variation of the pen grasp
may be needed for various areas of the mouth
depending on the weight of the HVE cord, HVE
162 Chapter 9 Grasp, Stabilization, and Positioning

suction design, visibility, and patient positioning.

The HVE is moved to the second joint of the in-
dex finger (see Figure 9-28b). This grasp should
be used only when necessary. The provider should
return to a pen grasp as soon as possible for opti-
mal ergonomics.

B
Figure 9-27 Dentsply Sirona Purevac Grasp: A. Fingers
C
More Forward on Mirror Tip in Grasp, B. Fingers Farther
Back on Mirror Tip in Grasp Figure 9-28 HVE Grasp: A. Pen Grasp, B. Alterante Pen
Reproduced with permission from Dentsply Sirona Grasp, C. Palm Grasp
 Operator Chair Position by Area of the Mouth 163

3. Palm grasp. The thumb is collapsed on top of the • Mandibular right buccal
index finger and the HVE is resting in the palm • Mandibular left lingual
(see Figure 9-28c). This grasp may be needed The operator chair position and patient head
for various posterior areas of the mouth when ­position is listed in Table 9-1.
visibility is challenged and the HVE is needed
for retraction. This grasp should be used only Surfaces Away. The posterior surfaces away
when necessary. The provider should return for the dominant right-handed provider are (see
to a pen grasp as soon as possible for optimal Figure 9-30):
ergonomics.
• Maxillary right lingual
The sequence of steps for selecting correct opera- • Maxillary left buccal
tor and patient chair positioning are as follows • Mandibular right lingual
• Mandibular left buccal
Grasp ultrasonic handpiece with the dominant hand The operator chair position and patient head
­position is listed in Table 9-2.

Grasp the HVE with the nondominant hand

Place the shank active area antinode on the tooth surface

to be instrumented

Position HVE 0.5–6.0 inch from the water port

Select operator positioning for direct vision

Select patient chair positioning

Select an intraoral or extraoral finger rest

Begin instrumentation

Figure 9-29 Posterior Teeth Surface Toward Dominant

Right-Handed
Operator Chair Position
by Area of the Mouth
Posterior Teeth Table 9-1 Posterior Teeth Surface Toward
Dominant Right-Handed
Dominant Right-Handed
Surfaces Toward. The posterior surfaces toward Direct Vision
for the dominant right-handed provider are (see Operator chair 8–11 o’clock
Figure 9-29): clock position
• Maxillary right buccal Patient head Turned away from the provider
• Maxillary left lingual
164 Chapter 9 Grasp, Stabilization, and Positioning

Figure 9-30 Posterior Teeth Surface Away Dominant

Right-Handed

Figure 9-31 Posterior Teeth Surface Toward Dominant

Table 9-2 Posterior Teeth Surface Away Left-Handed
Dominant Right-Handed
Direct Vision Indirect Vision
Operator chair 1–4 o’clock 8–11 o’clock Table 9-3 Posterior Teeth Surface Toward
clock position Dominant Left-Handed
Patient head Turned away from Turned toward Direct Vision
the provider the provider
Operator chair clock 1–4 o’clock
position
Patient head Turned away from the
Dominant Left-Handed provider
Surfaces Toward. The posterior surfaces t­oward
for the dominant left-handed provider are (see
Figure 9-31):

• Maxillary right lingual • Mandibular right buccal

• Maxillary left buccal • Mandibular left lingual
• Mandibular right lingual The operator chair position and patient head
• Mandibular left buccal ­position is listed in Table 9-4.
The operator chair position and patient head
­position is listed in Table 9-3. Anterior Teeth
Dominant Right- and Left-Handed
Surfaces Away. The posterior surfaces away The maxillary and mandibular canines may require
for the dominant left-handed provider are (see operator chair positioning for posterior teeth depend-
Figure 9-32):
ing on the patient’s curve of Spee (exaggerated or ex-
• Maxillary right buccal cessive, narrow, or anatomically normal), opening,
• Maxillary left lingual and chair position (supine, semi-supine, upright).
 Comparison of Ultrasonic and Hand-Activated Instrumentation 165

Figure 9-32 Posterior Teeth Surface Awya Dominant

Left-Handed

Table 9-4 Posterior Teeth Surface Away

Dominant Left-Handed B
Direct Vision Indirect Vision Figure 9-33 Mandibular Anterior Surfaces Dominant
Right- and Left-Handed: A. Facial, B. Lingual
Operator chair 8–11 o’clock 1–4 o’clock
clock position
Patient head Turned away from Turned toward
the provider the provider Table 9-5 Mandibular Arch
Direct Vision
Operator chair clock position 11–1 o’clock
Patient head position Chin down
Mandibular Anterior Teeth. Dominant right-
and left-handed providers will use 11-1 o’clock operator
chair positioning with the patient chin down for facial
Comparison of Ultrasonic
and linugal surfaces (see Figure 9-33 and Table 9-5).

Maxillary Anterior Teeth. Dominant right- and and Hand-Activated

left-handed providers will use 11-1 o’clock operator
chair positioning with the patient chin down for facial
and linugal surfaces (see Figure 9-34). The maxillary
lingual surfaces require indirect vision for instrumen-
tation (see Table 9-6).
Instrumentation
Table 9-7 summarizes the differences between ultra-
sonic and hand-activated grasp, stabilization, and op-
erator positioning.
166 Chapter 9 Grasp, Stabilization, and Positioning

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

Table 9-6 Maxillary Arch

Direct Vision Indirect Vision
Operator chair clock position 11–1 o’clock 11–1 o’clock
Teeth surface Facial Lingual
Patient head position Chin up Chin up

Table 9-7 Hand-Activated Versus Ultrasonic Instrumentation

Hand-Activated Instrumentation
Grasp Tight, firm, pinch-grip. All fingers
touching.
Lateral pressure Strong lateral pressure utilized to
manually break the bond between the oral
deposit and tooth surface with a scrapping
motion of the blade.
Stabilization Stable and secure fulcrum.
Intraoral fulcrum predominates.
Advanced intraoral and extraoral fulcrums
require provider to use finger motion
instead of the ergonomically desired
wrist-rock.
Aerosol and spatter droplet None.
production
Operator positioning Stringent operator chair positioning
required for proper adaptation, angulation,
and activation of instruments. Mastery
of indirect vision, fulcrums, wrist rock,
and grasp required to avoid fatigue and
musculoskeletal injury.
Ultrasonic Instrumentation
Light, relaxed. Fingers do not have to
touch.
No lateral pressure utilized as
the shank active area antinode
mechanically chips the oral deposit
from the tooth surface.
Relaxed finger rest intraoral and
extraoral.
Large volumes produced.
Flexible bilateral operator chair
positioning with direct vision
predominately used.
 Questions 167

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

CASE STUDY 2
A dental hygienist is temping in a dental office for the first time. The dentist owns a piezoelectric ultrasonic. The hygienist
has never used a piezoelectric device and grasps the handpiece the same way as a magnetostrictive. This feels awkward
to the hygienist who applies over 10 grams of lateral pressure when in use. What consequences can occur due to the
hygienist’s technique error?

Summary
During ultrasonic instrumentation, the oral health-
care provider grasps the handpiece lightly with no
lateral pressure transmitted to the fingers. Bilateral
operator chair positioning and flexible patient chair
positioning is used with intraoral and extraoral fin-
ger rests made possible by the ultrasonic device
mechanically chipping away oral deposits through
the vibratory elliptical motion of the insert and tip
shank. Oral health-care providers have the freedom
to choose their own individual positioning based
on their body type as long as ergonomics are not
compromised.

Questions
1. In an ultrasonic instrumentation grasp, what 3. True or False. An oral health-care provider with
finger(s) are used for a finger rest? a small palm size and short fingers will grasp a
a. Index finger magnetostrictive handpiece the same as someone
b. Middle finger with a large palm size and long fingers.
c. Ring finger a. True
d. Pinkie finger b. False
e. Both C and D 4. Fill in the blank. Regardless of hand size, in a
2. In a magnetostrictive ultrasonic grasp, which magnetostrictive grasp, the middle finger should
finger is placed on the insert grip? never advance forward on the grip within the
a. Thumb terminal ____ inch of the grip.
b. Index finger a. ½
c. Middle finger b. 1
d. Ring finger c. 1½
d. 2
168 Chapter 9 Grasp, Stabilization, and Positioning

5. In an ultrasonic grasp of a magnetostrictive or 12. What is the ideal distance of the HVE from the
piezoelectric, which finger is on the handpiece? water port on the shank?
a. Index finger a. 1–2 mm
b. Middle finger b. 3–6 mm
c. Ring finger c. 0.5–6.0 inches
d. Pinkie finger d. 1–2 feet
6. What is the maximum lateral pressure that can 13. What is the maximum distance an HVE can be
be applied to the fingers in an ultrasonic grasp? from the water port on the shank in order to
a. 10 g control the number of aerosols that enter the
b. 20 g environment?
c. 25 g a. 15 inches
d. 50 g b. 12 inches
7. Which of the following can occur when a c. 10 inches
provider uses excessive lateral pressure in an d. 6 inches
ultrasonic grasp? 14. True or False. There is one exact operator chair
a. Removal of oral deposits takes longer. position for each area of the mouth during
b. Incomplete removal of oral deposits. ultrasonic instrumentation.
c. Insert or tip shank breakage. a. True
d. All of the above b. False
8. True or False. In an ultrasonic instrumentation 15. A dominant right- and left-handed oral health-
finger rest, all the fingers must be touching one care provider uses what clock position to
another. perform ultrasonic instrumentation of the
a. True mandibular anterior central incisors?
b. False a. 8–11 o’clock
9. Which of the following finger rests can be used b. 11–1 o’clock
during ultrasonic instrumentation? c. 1–4 o’clock
a. Intraoral finger rest 1–2 teeth away from the d. 12 o’clock only
insert or tip shank placement on a tooth 16. For a right-handed provider to perform
b. Extraoral cheek rest ultrasonic instrumentation on the posterior teeth
c. Intraoral cross-arch surfaces toward them, what clock positions
d. Both B and C should be used?
e. All of the above a. 8–11 o’clock
10. Which of the following is a function of the HVE b. 11–1 o’clock
used during ultrasonic instrumentation? c. 1–4 o’clock
a. Reduce aerosol contamination of the dental d. 12 o’clock only
environment. 17. For a left-handed provider to perform ultrasonic
b. Remove oral fluids from the patient’s mouth. instrumentation on the posterior teeth surfaces
c. Retract the cheek and lip. toward them, what clock positions should be
d. All of the above. used?
11. True or False. If the dental operatory design a. 8–11 o’clock
does not allow the oral health-care provider to b. 11–1 o’clock
use bilateral operator chair positioning during c. 1–4 o’clock
ultrasonic instrumentation, it is acceptable to d. 12 o’clock only
use the LVE instead of the HVE so an instrument
mirror can be used for indirect vision.
a. True
b. False
 References 169

18. For a left-handed provider to perform ultrasonic Match the following to either hand instrumentation
instrumentation on the posterior teeth surfaces or ultrasonic instrumentation for questions 20–27.
away from them, what clock positions are an Answer A for hand instrumentation and B for ultra-
option? sonic instrumentation. There is only one correct an-
a. 8–11 o’clock swer for each question.
b. 11–1 o’clock 20. Firm pinch grip with a stable and secure
c. 1–4 o’clock fulcrum.
d. 12 o’clock only
e. Both A and C 21. Relaxed finger rest.
19. For a right-handed provider to perform 22. Large volumes of aerosols and spatter droplets
ultrasonic instrumentation on the posterior teeth are created.
surfaces away from them, what clock positions 23. Wrist-rock movement of the instrument.
are an option?
24. No lateral pressure in grasp.
a. 8–11 o’clock
b. 11–1 o’clock 25. Small finger motion to move the instrument.
c. 1–4 o’clock
d. 12 o’clock only
e. Both A and C

References
1. Avasth, A. (2018). High volume evacuator (HVE) in reducing
aerosol—an exploration worth by clinicians. Journal of Dental
Health Oral Disorders & Therapy¸ 9(3), 165–166.
2. Harrel, S., & Molinari, J. (2004). Aerosols and splatter in
dentistry. Journal American Dental Association, 135, 429–437.
3. Holloman, J. L., Mauriello, S. M., Pimenta, L., & Arnold, R. R.
(2015). Comparison of suction device with saliva ejector
for aerosol and spatter reduction during ultrasonic scaling.
Journal American Dental Association, 146(1), 27–33.
4. Nagraj, K. S., Eachempati, P., Paisi, M., Nasser, M.,
Sivaramakrishnan, G., & Verbeek, J. H. (2020). Interventions
to reduce contaminated aerosols produced during dental
procedures for preventing infectious diseases: Review.
Cochrane Database of Systematic Review, 10, Art No: CD013686.
https://doi.org/10.1002/14651858.CD013686.pub.2
 CHAPTER 10

Adaptation, Angulation,
and Orientation
LEARNING OBJECTIVES • Angulation: degree of tilt an instrument has when
adapted to the surface of a tooth.
After studying this chapter, you will be able to: • Back surface: the convex surface of a shank with
the third highest displacement amplitude.
1. Identify the four surfaces of an ultrasonic
shank.
• Face surface: the concave surface of a shank with
the second highest displacement amplitude.
2. Compare and contrast the four surfaces of an
ultrasonic shank to one another, identifying
• Lateral surface: the sides of a shank with the
lowest displacement amplitude.
which surfaces have the highest displacement
amplitude and which have the least.
• Orientation: the position an instrument has in
association with a structure.
3. Understand how to safely instrument tooth
structures with the varying ultrasonic shank
• Point surface: the end of a shank with the highest
displacement amplitude.
surfaces.
4. Correctly adapt the ultrasonic active area
• Transverse orientation: the active area antinode
of the shank is placed at a right angle to the long
antinode to the crown and root surfaces. axis of the tooth.
5. Safely angle the shank active area antinode
to the tooth surface in a 90-degree and 0- to
• Vertical orientation: the active area antinode of the
shank is placed vertical to the long axis of the tooth.
15-degree angulation.
6. Understand the clinical applications of the
90-degree and 0- to 15-degree angulation.
7. Adapt and angle the ultrasonic shank active
area antinode in a vertical orientation.
8. Adapt and angle the ultrasonic shank active Introduction
area antinode in a transverse orientation.
After learning the building blocks of grasp, finger rest,
operator and patient chair positioning, and aerosol
control in Chapter 9, the next steps to learn are shank
KEY TERMS adaptation, angulation, and orientation in this chapter
• 0-shank
to 15-degree angulation: angulation of the
active area antinode to the tooth surface
(see Figure 10-1). Chapter 11 will add the last building
block of activation.
that is between 0- and 15-degrees that adapts the There are four surfaces of an ultrasonic shank: the
face, back, and lateral surfaces.
•
point, face, back, and congruent lateral surfaces. The
90-degree angulation: angulation of the shank
point and face have the highest displacement ampli-
active area antinode to the tooth surface at a
90-degree angle that adapts the point or just
tude, making them the most active surfaces on the
offset from the point. shank. Their adaptation onto dentin and cementum
• Adaptation: placement of an instrument against
the surface of a tooth.
should be used with extreme caution as they could
damage less mineralized hard tissues.

171
172 Chapter 10 Adaptation, Angulation, and Orientation

Grasp and
stabilization

Operator and
patient positioning

Aerosol control

Adaptation

Angulation

Orientation

A
Activation

Figure 10-1 Ultrasonic instrumentation building blocks.

Two angulations are utilized for ultrasonic in-

strumentation. A 90-degree angulation is used less
frequently than a 0- to 15-degree angulation; a
90-degree angulation is used for the debridement
of heavy dental calculus and occlusal pits and fis-
sures. A 0- to 15-degree angulation is used for the
debridement of supragingival and subgingival tooth
surfaces.
Two orientations are used for ultrasonic instru-
mentation. An ultrasonic shank may be positioned in
a vertical or transverse orientation. A vertical orienta-
tion is used for supragingival and subgingival debride-
ment. A transverse orientation is used for debriding
the interproximal spaces between teeth supragingi-
vally. Transverse orientation is not used subgingivally. B
This chapter will provide instruction on the ad-
aptation, angulations, and orientations used during
ultrasonic instrumentation. These instrumentation
techniques will prepare you for the next building
block of instrumentation, which is activation.

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

Shank Surfaces
There are four surfaces on the shank of an insert
and tip: point, face, back, and two congruent lateral
sides (see Table 10-1). The four surfaces have different
C
Figure 10-2 Ultrasonic active area antinode adaptation:
A. Active area antinode, B. Active area antinode
adapted subgingivally, C. Active area antinode adapted
supragingivally.
 Adaptation 173

Table 10-1 Four Surfaces of an Ultrasonic Shank

Displacement
Surface Photo Amplitude Capability
Point Greatest

Face 2nd greatest

Back 3rd greatest

Congruent Least
lateral
surfaces

Dentsply Sirona Cavitron Powerline 10 30K Ultrasonic Insert and Acteon Tip 1S

Reproduced with permission from Dentsply Sirona

174 Chapter 10 Adaptation, Angulation, and Orientation

displacement amplitude capabilities at comparable adapting the congruent lateral surfaces of a tip to the
power settings. tooth surfaces for a smoother ultrasonic instrumenta-
tion experience. Reference the manufacturer directions
• Point: At all power settings, the point has the
for use/instructions for use (DFU/IFU) for these details.
greatest displacement amplitude, making it the
most powerful surface (Pecheva et al., 2016). It is
located at the end of the shank (see Table 10-1a).
The point is useful for breaking apart large dental
Angulation
calculus deposits or when debriding occlusal pits Angulation refers to the degree of tilt an instrument
and fissures. Extreme caution should be exercised has when adapted to the surface of a tooth. During
and the risk versus benefit weighed prior to using ultrasonic instrumentation, the active area is angled
the point on less mineralized hard tissues such as to the tooth surface with either a 90-degree angulation
cementum and dentin. or 0- to 15-degree angulation.
• Face: The face has the second greatest displace-
ment amplitude, making it less powerful than the 90-Degree Angulation
point but still quite powerful (Pecheva et al., 2016).
A 90-degree angulation is used selectively and in-
The face is the concave surface of the shank (see
frequently during ultrasonic instrumentation. This
Table 10-1b). The face is useful for the removal of
angulation is only used supragingivally. The point, or
supragingival interproximal dental calculus depos-
just offset from the point, is adapted to the tooth sur-
its on enamel. Caution should be exercised and the
face at a 90-degree angle (see Figure 10-3).
risk versus benefit weighed prior to using the face
on less mineralized hard tissues such as cementum
and dentin.
• Back: The back has the third greatest displacement
amplitude and is adapted to all supragingival and
subgingival areas on enamel, dentin, or cementum
(Pecheva et al., 2016). The back is the convex sur-
face of the shank (see Table 10-1c).
• Lateral: The two lateral congruent surfaces
have the least displacement amplitude and are
adapted to all supragingival and subgingival areas
on enamel, dentin, or cementum (Pecheva et al.,
2016). The lateral surfaces are on either side of
the shank (see Table 10-1d).
A

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

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

As discussed previously, all surfaces of a magne-
tostrictive insert shank and piezoelectric tip shank are
active when powered on. All surfaces can be adapted
for ultrasonic instrumentation. However, some piezo-
electric manufacturers recommend predominately
B
Figure 10-3 90-degree angulation (Dentsply Sirona
Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert):
A. Point directly adapted to occlusal surface, B. Shank
tilted slightly toward the buccal, making the point
slightly offset on the occlusal surface.
 Angulation 175

A B

C
Figure 10-4 A. Heavy dental calculus deposit on occlusal, interproximal, and lingual surfaces of the maxillary right
terminal molars, B. Stain on the occlusal surface of mandibular molars, C. Stain on the incisal surfaces of anterior teeth.

A 90-degree angulation is useful in the following placement. Enamel is much thicker on the occlu-
patient scenarios: sal surface of a tooth than on smooth surfaces.
The use of the point on the occlusal is safe unless
• To fracture heavy dental calculus deposits, as
the enamel is damaged by significant erosion, at-
seen in Figure 10-4a. Care should be used to
stop the ultrasonic instrumentation when the trition, or demineralization, as seen in Figure 10-5.
heavy dental calculus breaks apart to avoid
over-instrumentation with the high displacement
amplitude of the point. BREAKOUT POINT
• To remove stain and decontaminate the pits and
A 90-degree angulation is useful for debriding heavy
fissures on the occlusal surface of teeth, as seen in dental calculus and stain.
Figure 10-4b and c. This is useful prior to sealant
176 Chapter 10 Adaptation, Angulation, and Orientation

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

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

anatomy of the tooth. There is no gap between
the active area and the tooth structure (see
Figure 10-6a).
• 15-degree: Active area antinode is slightly angled
to the anatomy of the tooth. There is a slight gap
between the active area and the tooth structure
(see Figure 10-6b).
If the active area is over-angled (>15 degrees),
damage to gingival tissues and incidental removal of
healthy tooth structures will occur as the point begins
to adapt to tooth surfaces (see Figure 10-6c and d).

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

Orientation
Orientation describes the position an instrument
has in association with a tooth structure. In ultrasonic
instrumentation, there are two orientations of the ac-
tive area antinode to a tooth or tooth root: vertical
orientation and transverse orientation.

Vertical Orientation
In vertical orientation, the active area antinode of
the shank is placed vertically to the long axis of the
tooth. This orientation resembles that of a periodontal
probe orientation (see Figure 10-7). Vertical orienta-
tion is used for debriding supragingival and subgingi-
val tooth surfaces.

Figure 10-5 Contraindication for use of point: Attrition, • The back and congruent lateral surfaces of the
fracture, demineralization, and erosion on premolar and shank can be adapted to tooth surfaces in vertical
anterior teeth. orientation.
 Orientation 177

A B

C D
Figure 10-6 Active area antinode shank angulation: A. 0-degree angulation, B. 15-degree angulation, C. 45-degree
angulation, D. 70-degree angulation.

BREAKOUT POINT
Vertical orientation is used for debriding
supragingival and subgingival tooth surfaces.
• The back and lateral surfaces are used on cemen-
tum and dentin as they are less active than the
face or point.
Transverse Orientation
In transverse orientation, the active area antinode
of the shank is placed at a right angle to the long axis
of the tooth. This orientation resembles the orienta-
tion of a sickle scaler (see Figure 10-8). Transverse ori-
entation is only used for supragingival interproximal
debridement (see Table 10-2).
• The face, back, and congruent lateral surfaces
of the shank can be adapted to tooth surfaces in
transverse orientation when adapting to enamel.
178 Chapter 10 Adaptation, Angulation, and Orientation

• If recession is present and dentin is exposed, the

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

B B
Figure 10-7 Vertical orientation: A. Periodontal probe, Figure 10-8 Transverse orientation: A. Posterior sickle
B. Ultrasonic (Dentsply Sirona Cavitron Slimline 10S scaler, B. Ultrasonic (Dentsply Sirona Cavitron Slimline
Fitgrip 30K Ultrasonic Insert). 10S Fitgrip 30K Ultrasonic Insert).

Table 10-2 Vertical and Transverse Orientation

Supragingival/Subgingival Shank Resembles Debridement Uses
Vertical Supragingival Parallel to the long axis of Probe Shallow and deep
orientation Subgingival tooth periodontal pockets
Transverse Supragingival Right angle to the long axis Posterior sickle Interproximal areas
orientation of tooth scaler under contacts
 Skill Building Adaptation, Angulation, and Orientation 179

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

Skill Building Adaptation,

Angulation, and
Orientation
You will need the following supplies: typodont, ul-
trasonic handpiece, straight thin or ultra-thin insert
or tip.
Rationale: This exercise will provide a kinetic learn-
ing experience to practice the building blocks of ul-
trasonic instrumentation learned in this chapter. You
will experience instrument adaptation, angulation,
and both vertical and transverse orientations of the
shank active area antinode on tooth surfaces.
Insert and handpiece pictured: Dentsply Sirona Cav-
itron Slimline 10S Fitgrip 30K Ultrasonic Insert,
Dentsply Sirona Cavitron Steri-Mate 360 Handpiece.
Exercise 1: Posterior Tooth Vertical Orientation
• Adaptation: Lateral and back surface
• Angulation: 0- to 15-degree
• Orientation: Vertical

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

2. Position the typodont on a flat surface.

3. Correctly grasp the handpiece with the dominant hand and maintain the grasp
throughout the exercise.
180 Chapter 10 Adaptation, Angulation, and Orientation

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

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

5. Establish a finger rest: intraoral same quadrant or cross-arch depending on

the length of your fingers.

6. Dominant right-handed provider: Place the active area antinode lateral RT

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

D DB B MB M

LF
 Skill Building Adaptation, Angulation, and Orientation 181

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

angulation. Return to a 0-degree angulation.

LF

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

Correct.

9. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

active area antinode and slowly advance subgingivally to a depth of 3 mm.
182 Chapter 10 Adaptation, Angulation, and Orientation

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

D DB B MB M

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

angulation. Return to a 0-degree angulation.

12. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

active area antinode and slowly advance to the gumline.

13. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

active area antinode and slowly advance subgingivally to a depth of 3 mm.

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

D DB B MB M

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

angulation. Return to a 0-degree angulation.
 Skill Building Adaptation, Angulation, and Orientation 183

16. Maintain lateral or back surface adaptation with a 0- to 15-degree angulation

of the active area antinode and slowly advance to the gumline.

17. Maintain lateral or back surface adaptation with a 0- to 15-degree angulation

of the active area antinode and slowly advance subgingivally to a depth of
3 mm.

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

D DB B MB M

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

angulation. Return to a 0-degree angulation.

20. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

active area antinode and slowly advance to the gumline.

21. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

active area antinode and slowly advance subgingivally to a depth of 3 mm.

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

D DB B MB M
184 Chapter 10 Adaptation, Angulation, and Orientation

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

angulation. Return to a 0-degree angulation.

24. Maintain back or lateral surface adaptation with a 0- to 15-degree angulation

of the active area antinode and slowly advance to the gumline.

25. Maintain back or lateral surface adaptation with a 0- to 15-degree angulation

of the active area antinode and slowly advance subgingivally to a depth of
3 mm.

Exercise 2: Posterior Tooth Transverse Orientation

• Adaptation: Lateral and face surfaces
• Angulation: 0-degree
• Orientation: Transverse

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

2. Position the typodont on a flat surface.

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

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

buccal surface.
Dominant left-handed provider: Identify the mandibular left first molar buccal
surface.
 Skill Building Adaptation, Angulation, and Orientation 185

5. Establish a finger rest: intraoral same quadrant or cross-arch depending on RT

the length of your fingers.

Middle, index, and pinkie finger

do not have to touch.

LF

6. Dominant right-handed provider: Place the lateral surface active area

­antinode on the distal of the mandibular right first molar in a transverse
­orientation with 0-degree angulation.
Dominant left-handed provider: Place the lateral surface active area antinode
on the distal of the mandibular left first molar in a transverse orientation with
0-degree angulation.
186 Chapter 10 Adaptation, Angulation, and Orientation

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

8. Magnetostrictive insert: Change adaptation to the face surface and adapt

directly under the distal contact, maintaining transverse orientation and a
0-degree angulation of the active area antinode.
Piezoelectric tip: skip this step.

Exercise 3: Anterior Tooth Vertical Orientation

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

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

2. Position the typodont on a flat surface.

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

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

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

facial surface.
Dominant left-handed provider: Identify the maxillary right central incisor
facial surface.
 Skill Building Adaptation, Angulation, and Orientation 187

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

LF

7. Dominant right-handed provider: Place the active area antinode lateral

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

D DF F MF M

8. Establish a 0-degree angulation.

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

188 Chapter 10 Adaptation, Angulation, and Orientation

10. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

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

11. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

active area antinode and slowly advance subgingivally to a depth of 3 mm.

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

D DF F MF M

13. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

active area antinode and slowly advance to the gumline.
 Skill Building Adaptation, Angulation, and Orientation 189

14. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

active area antinode and slowly advance subgingivally to a depth of 3 mm.

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

D DF F MF M

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

angulation. Return to a 0-degree angulation. Maintain lateral or back surface
adaptation with a 0- to 15-degree angulation of the active area antinode and
slowly advance to the gumline.
190 Chapter 10 Adaptation, Angulation, and Orientation

17. Maintain lateral or back surface adaptation with a 0- to -15-degree angulation

of the active area antinode and slowly advance subgingivally to a depth of
3 mm.

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

D DF F MF M

19. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

active area antinode and slowly advance to the gumline.

20. Maintain lateral surface adaptation with a 0- to 15-degree angulation of the

active area antinode and slowly advance subgingivally to a depth of 3 mm.
 Skill Building Adaptation, Angulation, and Orientation 191

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

LF

D DF F MF M

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

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

LF

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

LF
192 Chapter 10 Adaptation, Angulation, and Orientation

Exercise 4: Anterior Tooth Transverse Orientation

• Adaptation: Lateral, back, and face surfaces
• Angulation: 0-degree
• Orientation: Transverse

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

2. Position the typodont on a flat surface.

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

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

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

LF

6. Magnetostrictive insert: Dominant right-handed provider, place the active

area antinode lateral or face surface on the distal of the left central incisor
in a transverse orientation with 0-degree angulation. Dominant left-handed
provider, place the active area antinode lateral or face surface on the distal of
the left central incisor in a transverse orientation with 0-degree angulation.
Piezoelectric tip: Dominant right-handed provider, place the active area
antinode lateral surface on the distal of the left central incisor in a transverse
orientation with 0-degree angulation. Dominant left-handed provider, place
the active area antinode lateral surface on the distal of the right central
incisor in a transverse orientation with 0-degree angulation. Face surface adaptation
pictured
 Comparison of Ultrasonic and Hand-Activated Instrumentation 193

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

Face surface adaptation

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

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

Back surface adaptation

pictured

Comparison of Ultrasonic Table 10-3 Hand-activated versus ultrasonic

and Hand-Activated instrumentation

Instrumentation Hand-Activated
Instruments
Ultrasonic
Instruments
Table 10-3 summarizes the differences between Adaptation 1–2 mm of the blade 1.0–3.5 mm
hand-activated and ultrasonic instrumentation adap- adapted to the tooth active area
tation, angulation, and orientation. surface. antinode
adapted to the
tooth surface.
Angulation 60- to 80-degree 90- or 0- to
angulation of blade 15-degree
to the tooth surface. angulation of
Angulation technique active area
varies based on antinode to
instrument design of the the tooth
blade, number of cutting surface.
edges, and internal and
external angles.
Orientation Vertical or transverse Vertical or
transverse
194 Chapter 10 Adaptation, Angulation, and Orientation

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

Mandibular anterior facial surface Maxillary right buccal and facial surfaces

Maxillary right second molar occlusal Maxillary left buccal and facial surfaces

Oral hygiene exam:

■ Generalized moderate to heavy supragingival and subgingival dental calculus.
■ Generalized heavy biofilm.
■ Generalized heavy stain.
■ The patient reports brushing every other day or every two days. She never flosses her teeth because it “hurts and
takes too long.”
Periodontal exam:
■ Probe depths 4–7 mm generally.
■ Horizontal bone loss scattered throughout the mouth.
■ No recession or mobility is present in the mouth.
■ Bleeding upon probing is present on 100% of surfaces.
Tissue description:
■ Punched out papillae mandibular anterior with a pseudomembrane once wiped away reveals fiery-red gingiva.
■ Generalized rolled and bulbous tissues.
■ Generalized erythema and edema.

Diagnosis: The patient is diagnosed with necrotizing periodontitis and will receive an initial nonsurgical periodontal
debridement with injectable local anesthesia. The patient does not appear to have active decay; however, another exam-
ination will be performed once the heavy oral deposits are removed.
1. What diameter shank should the provider select to begin the procedure and why?
2. What power setting should the provider use with this diameter shank and why?
 Questions 195

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

Summary
During ultrasonic instrumentation, the point, face,
back, and congruent lateral surfaces of the shank ac-
tive area antinode are used to remove oral deposits.
Care should be exercised when debriding dentin and
cementum due to their less mineralized content. The
active area antinode is angled 0 to 15 degrees during
supragingival and subgingival debridement in a ver-
tical orientation. A 90-degree angulation is used to
selectively remove heavy dental calculus deposits or
debride the occlusal pits and fissures of teeth with the
point. Transverse orientation is only used interprox-
imally on supragingival structures. Mastering adap-
tation, angulation, and orientation will prepare you
for the last building block of ultrasonic instrumenta-
tion, which is activation and is presented in the next
chapter.

Questions
1. Fill in the blank. The active area antinode is 6. Which of the following surfaces of the shank
located at the terminal of an ultrasonic should be used with caution on dentin and
shank and is used to remove oral deposits. cementum?
a. 1–5 mm a. Point
b. 1–6 mm b. Face
c. 1.0–3.5 mm c. Back
d. 2–6 mm d. Lateral
Match the following shank surfaces to their correct e. There is more than one correct answer.
descriptors for questions 2–5. There is one correct an- 7. A 90-degree angulation is used in which of the
swer for each question. following patient scenarios?
a. Remove stain and dental calculus on the
2. Point A. Used on supragingival and occlusal surface of teeth
subgingival tooth surfaces. b. Remove heavy dental calculus deposits
3. Face B. Highest amplitude displacement. supragingivally
c. Remove heavy dental calculus deposits
4. Back C. Lowest amplitude displacement. subgingivally on cementum
5. Lateral D. Used in a transverse orientation d. Both A and B
for the removal of supragingival e. All of the above
interproximal dental calculus
deposits on enamel but is used
with caution on dentin or
cementum.
196 Chapter 10 Adaptation, Angulation, and Orientation

8. What degree angulation can be safely used on all 10. Used for debriding interproximal supragingival
hard tissues? surfaces at a right angle to the long axis of the
a. 0–15 degrees tooth.
b. 20–45 degrees 11. Used supragingivally and subgingivally.
c. 60–80 degrees
d. 90 degrees 12. Useful for debriding deep periodontal pockets.
Match the following orientation to its correct descrip- 13. Active area antinode is parallel to the long axis
tion for questions 9–14. Select A for vertical orien- of the tooth.
tation and B for transverse orientation. There is only 14. Orientation is similar to the orientation of a
one correct answer for each question. periodontal probe.
9. Used supragingivally only.

References
1. Pecheva, E., Sammons, R. L., & Walmsley, A. D. (2016).
The performance characteristics of a piezoelectric ultrasonic
dental scaler. Medical Engineering and Physics, 38, 199–203.
 CH APTER 11

Activation
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Define ultrasonic activation.
2. Understand the clinical indications for an
ultrasonic activation stroke.
3. Perform and describe the two movements,
horizontal and top-down, that produce an
ultrasonic activation stroke.
4. Perform an ultrasonic activation stroke with
an insert or tip while maintaining proper
adaptation, angulation, and orientation of the
active area antinode of the shank.
5. Understand the clinical indications for a tap
stroke.
6. Perform a tap stroke while maintaining proper
adaptation, angulation, and orientation of the
shank active area antinode.
KEY TERMS
• Ultrasonic activation stroke: a combination of
horizontal and top-down movement patterns
of the active area antinode on the shank used
simultaneously to produce the activation required
for ultrasonic instrumentation.
Introduction
This chapter will add the final building block of acti-
vation for ultrasonic instrumentation technique (see
Figure 11-1).
There are two ultrasonic activation techniques,
an ultrasonic activation stroke and a tap stroke. An
ultrasonic activation stroke is a combination of two
movements called horizontal and top-down. This
stroke is used for the removal of oral deposits su-
pragingivally and subgingivally. The active area an-

• Activation:
tinode is kept in a constant 2-mm back-and-forth
the pattern of movement an motion called h­orizontal movement. The active area
instrument has on a structure.
• Finger motion: the use of the thumb and
index and middle fingers to move the active
antinode is placed coronal to an oral deposit and ad-
vanced apically for removal. This is referred to as the
area antinode of the shank during ultrasonic since horizontal movement is italicized in this para-
instrumentation. grap, please add italics to top-down movement. A tap
• Horizontal movement: a component of the
ultrasonic activation stroke where the active
stroke is used for the removal of heavy dental calculus
deposits. In this chapter you will learn both activation
area antinode of the shank is moved back and patterns and have an opportunity to practice them
forth in 2-mm increments at a steady consistent
pace, with each horizontal cycle lasting 0.5–1.0
with step-by-step kinetic exercises.
second.
• Tap stroke: a tapping activation with the ultrasonic
point, or just offset from the point, to remove a Activation
large dental calculus deposit.
• Top-down movement: a component of the
ultrasonic activation stroke where the active area
Activation describes the pattern of movement an in-
strument has on a tooth structure. The activation used
antinode of the shank is moved from the most for hand instrumentation is quite different than ultra-
incisal/occlusal position (top) on a tooth surface sonic instrumentation. Hand-activated instrumenta-
to the most apical (down). tion requires the provider to manually break the oral
197
198 Chapter 11 Activation
Grasp and
stabilization
Operator and
patient positioning
Aerosol control
Adaptation
Angulation
Orientation
Activation
Figure 11-1 Ultrasonic instrumentation building blocks.
deposit bond from the tooth surface with significant
lateral pressure and a scraping motion of the blade.
The active area antinode on an ultrasonic insert and
tip will mechanically chip oral deposits off tooth sur-
faces for the provider so no lateral pressure or scrap-
ping motions are required.
Let’s use an analogy to demonstrate:
• Hand-activated instrumentation is comparable
to brushing teeth with a manual toothbrush. The
operator must manually move the bristles in a
specific pattern with an applied force to cleanse
the tooth. To produce an activation stroke with
a hand instrument, the provider applies lateral
pressure to the fingers in the grasp and uses a
tight pinch grip. A strong and secure fulcrum is
required as the blade is locked apical (under) the
oral deposit, and a wrist-rock motion is used to
manually scrape the blade against the deposit for
removal. The blade is moved in a coronal direc-
tion with short, sharp, biting strokes. Multiple
overlapping and multidirectional strokes are re-
quired to physically break the bond between the
oral deposit and the tooth surface.
• Ultrasonic instrumentation is comparable to
brushing teeth with an electric toothbrush. The
operator simply positions the bristles on the tooth
with no added pressure, and the electronic mo-
tion of the bristles cleanses the tooth. To produce
an activation stroke with an ultrasonic shank,
the active area antinode is placed on the deposit
and lightly moved with small finger motions
and no lateral pressure. The active area antinode
mechanically chips the deposit from the tooth
surface for the provider with less overlapping
and multidirectional strokes compared to hand
instrumentation.
Finger Motion
During ultrasonic instrumentation, the provider will
use their dominant-hand thumb and index and mid-
dle fingers to move the active area antinode of the
shank along tooth surfaces. This is termed finger
motion. A wrist rock is not used in ultrasonic in-
strumentation as is needed during hand-activated
instrumentation. Once the ultrasonic active area an-
tinode is adapted, angled, and oriented to the tooth
structure, the provider will activate by depressing the
foot pedal. The shank will instantaneously move in a
vibratory elliptical motion with a displacement am-
plitude selected by the provider through the power
control. When activated, the active area antinode is
moved with a continuous fluid movement with finger
motion.
There are two types of activation used for ultra-
sonic instrumentation: ultrasonic activation stroke
and tap stroke.
Ultrasonic Activation Stroke
The ultrasonic activation stroke is a combination
of two movement patterns used simultaneously to
produce the activation required for ultrasonic instru-
mentation. The two movement patterns are: horizon-
tal movement and top-down movement.
Horizontal Movement
In horizontal movement, the active area an-
tinode is moved back and forth horizontally in
2-mm increments at a steady consistent pace,
with each horizontal cycle lasting 0.5–1.0 sec-
ond depending on the oral deposit type and level.
­Multiple overlapping horizontal cycles are used to
cover every surface of the tooth during ultrasonic
instrumentation.
BREAKOUT POINT
The horizontal movement of an ultrasonic activation
stroke is produced by moving the active area 2 mm
back and forth at a pace of 0.5–1.0 second.
 Activation 199

Skill Building: Horizontal Movement of the Ultrasonic Activation Stroke

You will need the following supplies: graph paper, black pen, red and blue crayons.

Rationale: This exercise will provide a kinetic learning experience to practice the horizontal movement of the
ultrasonic activation stroke. You can transfer what you learn from this simulation of horizontal movement into
active patient treatment.
Steps:

1. Draw a maxillary central incisor on a piece of graph paper with the black pen. Include
12 boxes for the crown of the tooth.

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

A
12

B
121212121212

(continues)
200 Chapter 11 Activation

Skill Building: Horizontal Movement of the Ultrasonic Activation Stroke (continued)

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

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

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

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

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

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

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

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

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

1 2 1 2 1 2 1 2 1 2 1 2
 Activation 201

Top-Down Movement oral deposit and then moved in a coronal direction

(top) with a short, sharp, biting stroke. An ultrasonic
Top-down movement is performed simultaneously
activation stroke starts coronal to the oral deposit and
with horizontal movement to produce an ultrasonic
moves in an apical direction.
activation stroke. The active area antinode of the
shank is placed at the most incisal/occlusal position
(top) on a tooth surface and then moved in an apical BREAKOUT POINT
direction (down) while continuous horizontal cycles
The top-down movement of an ultrasonic activation
are performed (see Figure 11-2). The top-down move-
stroke moves the active area antinode in an apical
ment is the opposite of hand-activated instrumenta- direction.
tion where the blade is placed apical (down) to an

A B C

Figure 11-2 Ultrasonic top-down movement (Dentsply Sirona Cavitron Slimline 10S Fitgrip 30K Ultrasonic Insert): A.
Active area antinode positioned at the incisal-third of the maxillary right central incisor, B. Active area antinode moved
apical and now positioned at the middle-third of the tooth, C. Active area antinode moved further apically and now
positioned at the cervical-third of the tooth.

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

Activation Stroke
You will need the following supplies: graph paper with the maxillary central incisor used in the horizontal
movement skill-building exercise, and a red crayon.

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

(continues)
202 Chapter 11 Activation

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

Activation Stroke (continued)

Steps:

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

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

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

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

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

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

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

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

5. Continue until all vertical lines are colored.

1 2 1 2 1 2 1 2 1 2 1 2
 Activation 203

Skill Building: Ultrasonic Instrumentation Candle Exercise

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

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

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

(continues)
204 Chapter 11 Activation

Skill Building: Ultrasonic Instrumentation Candle Exercise (continued)

5. Select a thick diameter insert or tip.

• Magnetostrictive Dentsply Sirona Cavitron Powerline 10, Cavitron Powerline 100, or Cavitron Powerline 1000
Ultrasonic Inserts
• Magnetostrictive HuFriedyGroup: #10 Universal, #1000 Triple Bend, Power PLUS Standard Conical, or Power
PLUS Standard Bevel
• Piezoelectric Acteon: Prophylaxis thick tips #1 or #10X
• Piezoelectric EMS: Instrument A (This is a discontinued item, but if the institution has this tip, then you can
use it in this section of the exercise. If not, then skip steps 5–15.)
6. Connect the thick diameter insert or tip to the ultrasonic handpiece.
• Magnetostrictive Dentsply Sirona and HuFriedyGroup: Refer to Figure 5-7 for proper O-ring(s) lubrication.
Fill the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360 degrees
over the water dome until fully lubricated. Place the insert into the handpiece in the upright position.
• Piezoelectric Acteon: Lubricate the O-ring with silicone paste. Torque the tip into the handpiece with the
wrench provided by the manufacturer.
• Piezoelectric EMS: Torque the tip into the handpiece with the wrench provided by the manufacturer.
7. Set the power level to high.
• Magnetostrictive Dentsply Sirona: Dial control set to 2 o’clock or digital touch screen 60–75 (see Dentsply
Sirona chapter 13 for details if needed).
• Magnetostrictive HuFriedyGroup: Select operation mode blue and use numbers 8–10 (see HuFriedyGroup
chapter 14 for details if needed).
• Piezoelectric Acteon: Numbers 11–16 (blue color zone) (see Acteon chapter 18 for details if needed).
• Piezoelectric EMS: Piezon 150 and 250 numbers 7–9, Piezon 700 dial set 12–2 o’clock on standard mode,
AIRFLOW Prophylaxis Master numbers 8–10 (See EMS chapter 17 for details if needed,)
8. Set the water flow rate.
• Magnetostrictive Dentsply Sirona and HuFriedyGroup: strong mist with no rapid drip (see Dentsply Sirona
chapter 13 and HuFriedyGroup chapter 14 for details if needed).
• Piezoelectric Acteon: strong mist with no rapid drip (see Acteon chapter 18 for details if needed).
• Piezoelectric EMS: 70–100% (see EMS chapter 17 for details if needed).
9. Grip the candle at its base over a sink or trash can with your nondominant hand.
 Activation 205

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

Dentsply Sirona Cavitron Steri-Mate 360

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

Dentsply Sirona Cavitron

Steri-Mate 360 Handpiece and
Cavitron Powerline 10 30K Dentsply Sirona Cavitron Steri-Mate 360 Handpiece
change to Ultrasonic Insert and Cavitron Powerline 10 30K Ultrasonic Insert
12. Depress the foot pedal to activate. Do not activate Boost mode if this is available on your device. Perform an
ultrasonic activation stroke with horizontal movement from one side of the white stripe to the other. Once
the white stripe begins to remove, advance the active area antinode downward (top-down) with continuous
fluid overlapping horizontal movements at a pace of 0.5–1.0 second per horizontal cycle. Maintain active area
antinode adaptation with 0-degree angulation while performing an ultrasonic activation stroke. Do not adapt
the nodal point because the white stripe will not remove. Be sure to move the shank and not the candle.

(continues)
206 Chapter 11 Activation

Skill Building: Ultrasonic Instrumentation Candle Exercise (continued)

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

14. Remove the top third white stripe while trying to avoid injuring the solid color under the white stripe.
 Activation 207

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

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

(continues)
208 Chapter 11 Activation

Skill Building: Ultrasonic Instrumentation Candle Exercise (continued)

21. Grasp the ultrasonic handpiece with your dominant hand, with no lateral pressure transmitted to the fingers,
as learned in chapter 9.
22. Adapt the lateral surface of the active area antinode of the thin diameter shank to the white stripe where
the thick diameter shank left off on the middle third of the candle. Use a vertical orientation with 0-degree
angulation.

Dentsply Sirona Cavitron Slimline 10S

Fitgrip 30K Ultrasonic Insert
23. Depress the foot pedal to activate. Do not activate Boost mode if this is available on your device. Perform an
ultrasonic activation stroke with horizontal movement from one side of the white stripe to the other. Once
the white stripe begins to remove, advance the active area antinode downward (top-down) with continuous
fluid overlapping horizontal movement at a pace of 0.5–1.0 second per horizontal cycle. Maintain active area
antinode adaptation with 0-degree angulation while performing an ultrasonic activation stroke. Do not adapt
the nodal point because the white stripe will not remove. Be sure to move the shank and not the candle.
24. Remove the middle third white stripe while trying to avoid injuring the solid color under the white stripe.
 Activation 209

25. Remove the thin diameter insert or tip from the handpiece and record your observations.
Observations: Record your observations for the thin diameter shank on medium power candle exercise.
1. What overall clinical changes did you observe with a change in power setting? Was it easier to control the
removal of the white stripe? Why or why not?
2. What overall clinical changes did you observe with a change in shank diameter? Was it easier to remove
the white stripe without damaging the color portion of the candle? Why or why not?
3. Did the white stripe remove faster or slower with the thin diameter shank compared to the thick diameter
shank? Why?
4. Did the white stripe lift off easily without breaking or was it pulverized by the thin diameter shank on
medium power? Did this differ from the thick diameter at high power? Why?
Complete steps 26–34 and record your observations.
26. Select an ultra-thin diameter insert or tip.
• Magnetostrictive Dentsply Sirona: Cavitron Thinsert Ultrasonic Insert
• Magnetostrictive HuFriedyGroup: XT or XT Triple Bend
• Piezoelectric Acteon: Periodontic tips H3, TK1-1S, or TK1-1L
• Piezoelectric EMS: If no ultra-thin tips are available, skip steps 26–34.
27. Connect the insert or tip to the handpiece.
• Magnetostrictive Dentsply Sirona and HuFriedyGroup: Refer to Figure 5-7 for proper O-ring(s) lubrication.
Fill the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360
degrees over the water dome until fully lubricated. Place the insert into the handpiece in the upright
position.
• Piezoelectric Acteon: Lubricate the O-ring with silicone paste. Torque the tip into the handpiece with the
wrench provided by the manufacturer.
28. Set the power level to low.
• Magnetostrictive Dentsply Sirona: Dial control 8–10 o’clock or digital touch screen set to 10–30 (see
Dentsply Sirona chapter 13 for details if needed).
• Magnetostrictive HuFriedyGroup: Select operation mode green and use numbers 1–3 (see HuFriedyGroup
chapter 14 for details if needed).
• Piezoelectric Acteon: Numbers 1–6 (green color zone). (see Acteon chapter 18 for details if needed).
29. Set the water flow rate.
• Magnetostrictive Dentsply Sirona and HuFriedyGroup: rapid drip with fine mist halo (see Dentsply Sirona
chapter 13 and HuFriedyGroup chapter 14 for details if needed).
• Piezoelectric Acteon: rapid drip with fine mist halo (see Acteon chapter 18 for details if needed).
30. Grip the candle at its base over a sink or trash can with your nondominant hand.
31. Grasp the ultrasonic handpiece with your dominant hand with no lateral pressure transmitted to the fingers,
as learned in chapter 9.
32. Adapt the lateral surface of the active area antinode of the ultra-thin diameter shank to the white stripe where the
thin diameter shank left off on the bottom third of the candle. Use a vertical orientation with 0-degree angulation.

Dentsply Sirona Cavitron Thinsert 30K Ultrasonic Insert

(continues)
210 Chapter 11 Activation

Skill Building: Ultrasonic Instrumentation Candle Exercise (continued)

33. Depress the foot pedal to activate. Do not activate Boost mode if this is available on your device. Perform an
ultrasonic activation stroke with horizontal movement from one side of the white stripe to the other. Once
the white stripe begins to remove, advance the active area antinode downward (top-down) with continuous
fluid overlapping horizontal movement at a pace of 0.5–1.0 second per horizontal cycle. Maintain active area
adaptation with 0-degree angulation while performing an ultrasonic activation stroke. Do not adapt the nodal
point because the white stripe will not remove. Be sure to move the shank and not the candle.
34. Remove the bottom third white stripe trying to avoid injuring the solid color under the white stripe. Remove the
ultra-thin diameter insert or tip from the handpiece and record your observations.

Observations: Record your observations for the ultra-thin diameter shank on low power candle exercise.
1. What overall clinical changes did you observe with a change in power setting? Was it easier to control the
removal of the white stripe? Why or why not?
2. What overall clinical changes did you observe with a change in shank diameter? Was it easier to remove
the white stripe without damaging the color portion of the candle? Why or why not?
3. Did the white stripe remove faster or slower when compared to the thick and thin diameter shanks? Why?
4. Did the white stripe lift off easily without breaking or was it pulverized by the ultra-thin shank on low
power? Why?
Complete steps 35–41 and record your observations.
35. Select a hand-activated sickle scaler (anterior sickle preferred) and use the second candle.
36. Hold the candle at the base in your nondominant hand so that is parallel in your hand as pictures here.
 Activation 211

37. Grasp the hand scaler with a modified pen grasp. Establish a fulcrum with the ring finger behind the candle
and ensure all fingers are touching one another. Do not allow the fulcrum finger to separate from the
middle finger.

38. Select a white stripe to scale in the top third of the candle. Adapt the 1–2 mm of the working end (blade) 1/2
inch from the top of the white stripe.

(continues)
212 Chapter 11 Activation

Skill Building: Ultrasonic Instrumentation Candle Exercise (continued)

39. Establish a 60- to 80-degree angle of the blade to the candle white stripe and produce a scaling stroke moving
from apical to coronal with sharp, short, biting movements with a wrist rock to remove the white stripe.

40. Continue scaling until the white stripes in the top third of the candle are removed.

41. Record your observations.

Observations: Record your observations for the hand-activated sickle scaler candle exercise.
1. What differences did you notice between the ultrasonic inserts and tips and the hand-activated instrument
for the removal of the white stripe?
2. Which instrumentation technique took less time: ultrasonic or hand-activated? Why?
3. Which instrumentation technique was more labor intensive? Why?
4. Which instrumentation technique caused more damage to the solid color under the white stripe? Why?
 Activation 213

Skill Building: Curved Shank Ultrasonic Instrumentation Spoon Exercise

You will need the following supplies: 2 clear spoons, Wite-Out, ultrasonic device, ultrasonic handpiece, thin curved
shank insert or tip, thin or ultra-thin straight shank insert or tip, sink or trash can to collect water.

Rationale: This exercise will provide a kinetic learning experience to practice ultrasonic instrumentation
with a curved ultrasonic shank. You will experience curved shank adaptation, angulation, and orientation while
performing an ultrasonic activation stroke. You will use a straight and curved shank to remove Wite-Out from the
concave surface of a plastic spoon. The concave spoon is simulating a root concavity. This will allow you to feel the
difference between the two shank shapes (straight, curved) for adaptation into complex root anatomy such as a
concavity.
Goal of This Exercise: The goal of this exercise is to remove all the Wite-Out on the spoon without puncturing
the spoon.
Prior to Use: Apply a thin layer of Wite-Out on the inside center portion of the clear spoon and allow it to dry.

Identify a curved insert and tip.

■ To correctly identify a right and left insert or tip, hold one insert/tip in your dominant hand and the other in your
nondominant hand directly in front of your face so that the color grips or tip threaders are parallel to you.
■ Look at the curve of the shank coming out of the grip. If the shank curves to the right, it is the right-curved
insert/tip and if it curves to the left, it is the left-curved insert/tip.

(continues)
214 Chapter 11 Activation

Skill Building: Curved Shank Ultrasonic Instrumentation Spoon Exercise (continued)

Dentsply Sirona Cavitron

Slimline 10R and 10L Fitgrip
30K Ultrasonic Insert Acteon tips H4L and H4R
Complete steps 1–14 with the curved shank and record your observations.
1. Set up the ultrasonic device, attaching the power, water, and/or air connectors. Turn on the device.
2. Flush the waterline for a minimum of 20–30 seconds. Always follow your clinic’s protocols for waterline
maintenance, which may be different than a 20- to 30-second waterline flush.
3. Attach a sterile handpiece to the ultrasonic handpiece connector.
4. Select the thin curved insert or tip from the list below:
• Dominant right-handed provider: Magnetostrictive
• Dentsply Sirona Cavitron Slimline 10R Ultrasonic Insert
• HuFriedyGroup After Five Right
• Dominant right-handed provider: Piezoelectric
• Aceton periodontic tips P2L, TK2-1L, H4L
• EMS PSR
• Dominant left-handed provider: Magnetostrictive
• Dentsply Sirona Cavitron Slimline 10L Ultrasonic Insert
• HuFriedyGroup After Five Left
• Dominant left-handed provider: Piezoelectric
• Acteon periodontic tips P2R, TK2-1R, H4R
• EMS PSL
5. Connect the thin curved insert or tip to the ultrasonic handpiece.
• Magnetostrictive Dentsply Sirona and HuFriedyGroup: Refer to Figure 5-7 for proper O-ring(s) lubrication.
Fill the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360 degrees
over the water dome until fully lubricated. Place the insert into the handpiece in the upright position.
• Piezoelectric Acteon: Lubricate the O-ring with silicone paste. Torque the tip into the handpiece with the
wrench provided by the manufacturer.
• Piezoelectric EMS: Torque the tip into the handpiece with the wrench provided by the manufacturer.
6. Set the power level allowed for the curved insert or tip.
• Magnetostrictive Dentsply Sirona: Low to medium power with the dial 8 o’clock to 2 o’clock or digital touch
screen 10–60 (see Dentsply Sirona chapter 13 for details if needed).
• Magnetostrictive HuFriedyGroup: Low to medium power. Operation blue mode numbers number 3–7 or
operation green mode numbers 1–5. (see HuFriedyGroup chapter 14 for details if needed).
• Piezoelectric Acteon: Low power numbers 1–6 (green color zone) (see Acteon chapter 18 for details if
needed).
• Piezoelectric EMS: 10–60% (see EMS chapter 17 for details if needed).
 Activation 215

7. Set the water flow rate.

• Magnetostrictive Dentsply Sirona and HuFriedyGroup: rapid drip with fine mist halo (see Dentsply Sirona
chapter 13 and HuFriedyGroup chapter 14 for details if needed).
• Piezoelectric Acteon: rapid drip with fine mist halo (see Acteon chapter 18 for details if needed).
• Piezoelectric EMS: 70–100% (see EMS chapter 17 for details if needed).
8. Dominant right-handed provider: Grip the stem of the spoon over a sink or trash can with your left hand, with
the spoon’s Wite-Out facing you.
Dominant left-handed provider: Grip the stem of the spoon over a sink or trash can with your right hand, with
the spoon’s Wite-Out facing you.

9. Do not move the spoon during this activity. The active area antinode of the shank is moved and not the spoon.
10. Grasp the ultrasonic handpiece with your dominant hand, with no lateral pressure transmitted to the fingers,
as learned in chapter 9.

Dentsply Sirona Steri-Mate 360 Handpiece and

Cavitron Powerline 10 30K Ultrasonic Insert

(continues)
216 Chapter 11 Activation

Skill Building: Curved Shank Ultrasonic Instrumentation Spoon Exercise (continued)

11. Magnetostrictive: Adapt the back surface of the active area antinode with 0-degree angulation in a vertical
orientation at the top of the spoon on the Wite-Out farthest to the left.

HuFriedyGroup Curved Insert

After Five Right
Piezoelectric: Adapt the lateral surface of the active area antinode with 0-degree angulation in a vertical
orientation at the top of the spoon on the Wite-Out farthest to the left.

Acteon tip P2L

 Activation 217

12. Depress the foot pedal to activate. Do not activate Boost mode if this is available on your device. Perform
an ultrasonic activation stroke with 2-mm increment horizontal movements. Once the Wite-Out begins to
remove, advance the active area antinode of the shank downward (top-down) with continuous fluid overlapping
horizontal movements at a pace of 0.5–1.0 second per horizontal cycle. Maintain active area antinode
adaptation with 0-degree angulation while performing an ultrasonic activation stroke. Do not adapt the nodal
point because the Wite-Out will not remove. Be sure to move the shank and not the spoon.

13. When the first 2-mm segment of the Wite-Out is removed, repeat the steps on the next 2 mm of the Wite out.

  
HuFriedyGroup Curved Insert After
Five Right

  
(continues)
218 Chapter 11 Activation

Skill Building: Curved Shank Ultrasonic Instrumentation Spoon Exercise (continued)

14. When all the Wite-Out is removed, the curved shank practice is complete. Record your observations.
Observations: Record your observations for the curved shank on low-medium power spoon exercise.
1. Did the curved shank maintain adaptation of the lateral or back surface as the active area antinode was
advanced into the concave surface of the spoon?
2. Did the curved shank maintain 0-degree angulation when the active area antinode was adapted into the
concave surface of the spoon as shown here?

HuFriedyGroup Curved Insert After Five Left

3. Was all the Wite-Out removed with the curved shank?
Complete steps 15–24 with the straight insert or tip and record your observations.
15. Remove the curved insert or tip from the handpiece.
16. Connect the thin or ultra-thin insert or tip to the ultrasonic handpiece.
• Magnetostrictive Dentsply Sirona and HuFriedyGroup: Refer to Figure 5-7 for proper O-ring(s) lubrication. Fill
the handpiece with water until a dome of water is visible at its opening. Rotate the O-ring(s) 360 degrees over
the water dome until fully lubricated. Place the insert into the handpiece in the upright position.
• Piezoelectric Acteon: Lubricate the O-ring with silicone paste. Torque the tip into the handpiece with the
wrench provided by the manufacturer.
• Piezoelectric EMS: Torque the tip into the handpiece with the wrench provided by the manufacturer.
17. Do not change the power level or water flow rate.
18. Dominant right-handed provider: Grip the stem of the spoon over a sink or trash can with your left hand, with
the spoon’s Wite-Out facing you.
Dominant left-handed provider: Grip the stem of the spoon over a sink or trash can with your right hand, with
the spoon’s Wite-Out facing you.
19. Do not move the spoon during this activity. The active area antinode of the shank is moved and not the spoon.
20. Grasp the ultrasonic handpiece with your dominant hand, with no lateral pressure transmitted to the fingers,
as learned in chapter 9.
21. Magnetostrictive: Adapt the back or lateral surface of the active area antinode with 0-degree angulation in a
vertical orientation at the top of the spoon on the Wite-Out farthest to the left.

HuFriedyGroup Staright Insert After Five

 Activation 219

Piezoelectric: Adapt the lateral surface of the active area antinode with 0-degree angulation in a vertical
orientation at the top of the spoon on the Wite-Out farthest to the left.
22. Depress the foot pedal to activate. Do not activate Boost mode if this is available on your device. Perform
an ultrasonic activation stroke with 2-mm increment horizontal movements. Once the Wite-Out begins to
remove, advance the active area antinode of the shank downward (top-down) with continuous fluid overlapping
horizontal movement at a pace of 0.5–1.0 second per horizontal cycle. Maintain active area antinode
adaptation with 0-degree angulation while performing an ultrasonic activation stroke with either the back
or lateral surfaces. Do not adapt the nodal point because the Wite-Out will not remove. Be sure to move the
shank and not the spoon. Do not adapt the face or point. Do not increase the angulation of the active area
antinode.
23. When you have removed all the Wite-Out you can in the first 2-mm segment, repeat the steps on the next
2 mm of the Wite-Out.
24. When all Wite-Out that can be removed is done, the straight shank practice is complete. Record your
observations.
Observations: Record your observations for the straight shank on the low-medium power spoon exercise.
1. Did the straight shank maintain adaptation of the lateral or back surface as the active area was advanced
into the concave surface of the spoon? Why or why not?
2. Did the straight shank maintain 0-degree angulation of the lateral or back surfaces when the active area
antinode was adapted into the concave surface of the spoon? Why or why not? See the image that follows.

3. Was all the Wite-Out removed with the straight shank? Why or why not?
4. What were the limitations of the straight shank compared to the curved shank?

Tap Stroke return to an ultrasonic activation stroke for three

The tap stroke is useful for breaking apart large dental
calculus deposits (see Figure 11-3a to c). The provider
uses the point, or just offset from the point, and gently
touches the deposit for 1–2 seconds, then removes the
point for 1–2 seconds (see Figure 11-4). This movement
is repeated until the dental calculus deposit fractures.
The active area antinode is angled 90-degrees to adapt
the point on the dental calculus deposit.
Beginner Tap Stroke
When using a tap stroke clinically for the first time,
it is best to tap on the deposit three times and then
passes. This technique will prevent the provider
from unintentionally injuring a crown or root sur-
face with the point. The sequence for a beginner tap
stroke is:
1. Tap-tap-tap on the point or just offset from the
point.
2. Ultrasonic activation stroke-stroke-stroke on the
lateral, back, or face surfaces.
3. Repeat steps 1 and 2 until the large dental calcu-
lus deposit fractures.
A tap stroke can be used on any tooth surface
with heavy dental calculus deposits. Once the dental
220 Chapter 11 Activation

A B C

Figure 11-3 Tap stroke is useful for the following patient scenarios: A. Mandibular right anterior lingual surfaces with
moderate to heavy dental calculus and stain, B. Maxillary right first and second molar occlusal surfaces with heavy dental
calculus, C. Mandibular anterior lingual surfaces with heavy dental calculus and stain.

Figure 11-4 Tap stroke (Dentsply Sirona Cavitron Powerline 10 30K Ultrasonic Insert): A. Point in
contact, B. Point not in contact.

Comparison of Ultrasonic
calculus fractures, the tap stroke is stopped, and an and Hand-Activated
ultrasonic activation stroke is resumed. Care must
be exercised not to contact the point directly on
Instrumentation
the crown or root surface once the dental calculus Table 11-1summarizes the differences between ultra-
fractures. sonic and hand-activated instrumentation.
 Comparison of Ultrasonic and Hand-Activated Instrumentation 221

Table 11-1 Hand-Activated Instruments versus Ultrasonic Instruments

Hand-Activated Instrumentation Ultrasonic Instrumentation
Stroke Scaling stroke: Short, sharp, biting with Ultrasonic activation stroke
significant lateral pressure. Many forceful Tap stroke
overlapping and multidirectional strokes. No lateral pressure, light grasp, and
overlapping multidirectional strokes.
Movement of the Wrist rock Finger motion
working end
Removal of oral Provider manually breaks the bond between Ultrasonic mechanically chips the oral
deposit the oral deposit and tooth with a scraping deposit from the tooth surface with a vibratory
motion of the blade. elliptical motion of the shank.

CASE STUDY
You are performing a nonsurgical periodontal debridement on your patient from the previous chapter shown here.

Maxillary right buccal and facial surfaces

Mandibular anterior facial surface

Maxillary left buccal and facial surfaces

Maxillary right second molar occlusal.

222 Chapter 11 Activation

1. What activation stroke would you use first on the mandibular anterior facial surfaces, the maxillary right second
molar occlusal surface, and the maxillary left facial and buccal surfaces?
2. Explain the shank angulation and technique you need to use for the stroke in question 1.
3. Explain why this stroke is used first.
4. What activation stroke would you use second on the mandibular anterior facial surfaces, the maxillary right second
molar occlusal surface, and the maxillary left facial and buccal surfaces?
5. Explain the shank angulation and technique you need to use for the stroke in question 4.
You remove the heavy dental calculus with a thick diameter shank using a combination of tap and ultrasonic
activation strokes on the mandibular anterior facial surfaces, the maxillary right second molar occlusal surface, and
the maxillary left facial and buccal surfaces. Now, a light layer of dental calculus remains on all supragingival tooth
surfaces.
6. What diameter shank would you use to remove the light supragingival dental calculus?
7. Which activation stroke would you use to remove the light supragingival dental calculus?
8. What power level would you use to remove the light supragingival dental calculus?

Summary
During ultrasonic instrumentation, an ultrasonic acti-
vation stroke or tap stroke can be used with either a
90-degree or 0- to 15-degree angulation for oral de-
posit removal. A tap stroke is used for the removal of
heavy dental calculus deposits. An ultrasonic activa-
tion stroke is produced through a combination of a
horizontal 2-mm back-and-forth continuous motion
of the active area antinode in a top-down approach.

Questions
1. How far back and forth does the provider move
the shank active area antinode in a horizontal
movement of an ultrasonic activation stroke?
a. 8 mm
b. 5 mm
c. 3 mm
d. 2 mm
2. True or False. In the ultrasonic activation stroke,
the active area antinode is placed apical to an
oral deposit and moved in a coronal direction
with continuous horizontal cycles.
a. True
b. False
3. True or False. The tap stroke is produced by
moving the active area in a 2-mm back-and-
forth continuous horizontal pattern with a top-
down approach.
a. True
b. False
4. In which patient scenario is a tap stroke
indicated?
a. To break apart heavy dental calculus deposits
b. To remove light stain and dental calculus
from the smooth surfaces of teeth
c. For biofilm reduction on the root surface
d. All of the above
Match the following to either hand instrumentation
or ultrasonic instrumentation for questions 5–12.
­Answer A for hand instrumentation and B for ul-
trasonic instrumentation. There is only one correct
­answer for each question.
5. Manually breaking the bond between the tooth
surface and an oral deposit.
6. Chipping action removes oral deposits from
tooth surfaces.
7. Forceful scaling stroke with significant lateral
pressure.
8. Light grasp with use of ultrasonic activation
stroke or tap stroke.
9. Wrist rock to move the working end.
10. Finger motion to move the active area antinode.
11. Activation direction is coronal to apical.
12. Stroke direction is apical to coronal.
 CHAPTER 12
Ultrasonic Technique
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Perform an ultrasonic activation stroke on
anterior and posterior teeth with correct grasp,
finger rest, operator and patient positioning,
instrument adaptation, angulation, orientation,
and activation.
2. Maintain proper ergonomics while performing
ultrasonic instrumentation.
3. Transition from vertical and transverse
orientation during ultrasonic instrumentation.
Introduction
This chapter will combine all the building blocks of
ultrasonic instrumentation learned in ­ Chapters 9
through 11. You will combine grasp, finger rest, oper-
ator and patient chair positioning, adaptation, angula-
tion, orientation, and activation in a simulated patient
care experience.
Ultrasonic instrumentation, like hand-activated
instrumentation, is best learned through repetition
and practice because there are many technique de-
mands placed on the oral health-care provider. When
mastered, ultrasonic instrumentation conserves root
structures, reduces pathogens, and improves ergo-
nomics through decreased labor intensity and time
for procedures. This chapter will provide you with a
kinetic learning experience that you can transfer into
live patient care.
Ultrasonic
Instrumentation Skill
Building With Operator
and Patient Positioning
You will need the following supplies: typodont,
­typodont pole, dental chair, ultrasonic device, nail
polish or Wite-Out, high-volume evacuation, ultra-
sonic handpiece, and a thin or thick ultrasonic insert
or tip.
Rationale: This exercise will provide a kinetic
learning experience that incorporates ultrasonic in-
strumentation techniques of adaptation, angulation,
orientation, and activation with aerosol control and
patient and operator positioning to simulate an active
patient treatment scenario.
The goal of this exercise is to remove the nail
polish or Wite-Out from the painted teeth while con-
trolling fluid and aerosols using proper patient and
operator positioning.
Setup:
1. Paint nail polish, Wite-Out on the entire facial/
buccal, lingual, and interproximal surfaces on the
following teeth:
• Maxillary left central incisor.
• Mandibular right first molar for dominant
right-handed provider and mandibular left
first molar for dominant left-handed provider.
Instructors may add teeth to this exercise as they
see fit.
2. Mount pole onto dental chair.
223
224 Chapter 12 Ultrasonic Technique

3. Mount typodont onto pole.

4. Set up ultrasonic device attaching the power,
­water, and/or air connectors. Ensure psi’s of the
dental unit is compatible with the ultrasonic
­device. Turn on the device.
5. Attach an High-volume evacuation (HVE) to the
suction system.
6. Flush the water line for a minimum of 20 to
30 seconds. Always follow your clinic’s pro-
tocols for water-line maintenance, which may
be ­different than a 20- to 30-second water-
line flush.
7. Attach a sterile handpiece to the ultrasonic hand-
piece connector cord.
8. Select a thin or thick diameter shank and connect
to the ultrasonic handpiece.
• Magnetostrictive Dentsply Sirona and
­HuFriedyGroup: Position the handpiece ver-
tically over a sink or trash can and fill with D DF F MF M
water until a water dome appears over the
brim. Lubricate the O-ring(s) by rotating the
O-ring(s) over the water dome until all as-
pects of the O-ring(s) have been coated. Then Figure 12-1 Maxillary Left Central Incisor Facial Divided
in 2 mm Segments
place the insert into the handpiece ensuring
the O-ring(s) is/are firmly seated. See Chapter
5 for details. Maxillary Left Central Incisor Facial
• Piezoelectric Acteon: Lubricate the O-ring Divide the maxillary left central incisor in 2 mm seg-
with silicone paste. Torque the tip into the ments on the facial: distal, distal-facial, facial midline,
handpiece with the wrench provided by the mesial-facial, mesial (see Figure 12-1).
manufacturer.
• Piezoelectric EMS: The O-ring on the hand- Maxillary Left Central Incisor Lingual
piece does not require lubrication. Torque the Divide the maxillary left central incisor in 2 mm
tip into the handpiece with the wrench pro- segments: distal, distal-lingual, lingual midline,
vided by the manufacturer. ­mesial-­lingual, mesial (see Figure 12-2).
9. Set the power level to low or medium.
10. Set the water flow period at end of sentence
missing Mandibular Molar
Dominant right-handed provider: perform ultrasonic
• Magnetostrictive Dentsply Sirona and Hu-
instrumentation on the mandibular right first molar.
FriedyGroup: rapid drip with fine mist
Dominant left-handed provider: perform ultrasonic
halo (see Dentsply Sirona, Chapter 13, and
instrumentation on the mandibular left first molar.
HuFriedyGroup, Chapter 14, for details if
needed).
• Piezoelectric Acteon: rapid drip with fine mist Mandibular First Molar Facial
halo (see Acteon, Chapter 18, for details if Divide the mandibular molar in 2 mm segments on
needed). the buccal: distal, distal-buccal, distal-buccal midline,
• Piezoelectric EMS: 70–100% (see EMS, buccal, mesial-buccal midline, mesial-buccal, mesial
­Chapter 17, for details if needed). (see Figure 12-3).

Maxillary Left Central Incisor Mandibular First Molar Lingual

Dominant right- and left-handed providers will per- Divide posterior teeth in 2 mm segments: distal, distal-­
form ultrasonic instrumentation on the maxillary left lingual, distal-lingual midline, lingual, mesial-­lingual
central incisor. midline, mesial-lingual, mesial (see Figure 12-4).
 Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning 225

Grasp the ultrasonic handpiece with your dominant hand.See Chapter 9 for details.
• Magnetostrictive: Thumb and index finger equidistant from one another on either side of the handpiece. The middle
finger is advanced forward onto the colored grip of the insert. The handpiece lays in the webbing between the thumb
and index finger.
• Piezoelectric: Thumb and index finger equidistant from one another on either side of the handpiece. The middle finger
is tucked behind the index finger. The handpiece lays in the webbing between the thumb and index finger.

Grasp the HVE with your nondominant hand. See Chapter 9 for details.

Place the active area antinode on the tooth surface at the facial.
• Position the lateral surface of the active area antinode in a vertical orientation at the
incisal edge of the facial midline of the maxillary left central incisor.
• Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port of the insert or tip.

Select the operator positioning for direct vision: 11–1 o’clock for dominant right- and left-handed providers.

Select the patient chair positioning for the maxillary arch. Patient chair supine with chin slightly upward.

Establish a finger rest intraoral or extraoral ensuring correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps in Table12-1.

Table 12-​1 Ultrasonic Instrumentation of the Maxillary Left Central Incisor Facial Surfaces
Depress the foot pedal to activate the insert or tip.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the
nail polish or Wite-Out on the facial midline. Advance the active area antinode in an apical
direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you
move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation.
■ Do not allow the active area to lose contact with the tooth surface.
■ Do not allow the shank to roll onto the nodal point (3.5–5.0 mm) as no action occurs and the nail
polish or Wite-Out will not be removed.
■ Remove all the nail polish or Wite-Out from the facial midline surfaces incisal to the gum line.

D DF F MF M

(continues)
226 Chapter 12 Ultrasonic Technique

Table 12-​1 Ultrasonic Instrumentation of the Maxillary Left Central Incisor Facial Surfaces (continued)
■ Reposition the lateral surface of the active area antinode at the incisal edge of the mesial-facial
line angle in a vertical orientation with 0- to 15-degree angulation.
■ Reposition the HVE as needed.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the
nail polish or Wite-Out on the mesial-facial line angle. Advance the active area antinode in an
apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as
you move apically to maintain contact with the tooth surface at a 0- to15-degree angulation.
■ Remove all the nail polish or Wite-Out from the mesial-facial line angle surfaces incisal to the
gum line.
D DF F MF M

■ Dominant right-handed magnetostrictive insert: Reposition the back surface of the active area
antinode at the incisal edge of the straight mesial in a vertical orientation with 0- to 15-degree
angulation as if you were going to probe the mesial col.
■ Dominant right-handed piezoelectric tip: Reposition the lateral surface of the active area
antinode at the incisal edge of the straight mesial in a vertical orientation with a 0- to 15-degree
angulation as if you were going to probe the mesial col.
■ Dominant left-handed magnetostrictive insert and piezoelectric tip: Reposition the lateral
surface of the active area antinode at the incisal edge of the straight mesial in a vertical
orientation with 0- to 15-degree angulation as if you were going to probe the mesial col.
■ Reposition the HVE as needed. D DF F MF M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the
nail polish or Wite-Out on the mesial. Advance the active area antinode in an apical direction at
a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically
to maintain contact with the tooth surface at a 0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the mesial surfaces incisal to the gum line.
■ Magnetostrictive insert: Transition to a transverse orientation with the back, lateral, or
face surface with a 0- to 15-degree angulation to debride the mesial interproximal contact
supragingivally.
■ Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a
0- to 15-degree angulation to debride the mesial interproximal contact supragingivally.
■ Debride one-half of the mesial interproximal space. The other half is debrided from the lingual.
■ Reposition the HVE as needed.
■ Remove all the nail polish or Wite-Out from one-half of the mesial interproximal space.

D DF F MF M

■ Reposition the lateral surface of the active area antinode at the incisal edge of the distal-facial
line angle in a vertical orientation with 0- to 15-degree angulation.
■ Reposition the HVE as needed.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the
nail polish or Wite-Out on the distal-facial line angle. Advance the active area antinode in an
apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as
you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the distal-facial line angle surfaces incisal to the
gum line.
D DF F MF M
 Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning 227

■ Dominant right-handed magnetostrictive insert and piezoelectric tip: Reposition the lateral
surface of the active area antinode at the incisal edge of the straight distal in a vertical
orientation with a 0- to 15-degree angulation as if you were going to probe the distal col.
■ Dominant left-handed magnetostrictive insert: Reposition the back surface of the active area
antinode at the incisal edge of the straight distal in a vertical orientation with 0- to 15-degree
angulation as if you were going to probe the distal col.
■ Dominant left-handed piezoelectric tip: Reposition the lateral surface of the active area antinode
at the incisal edge of the straight distal in a vertical orientation with a 0- to 15-degree angulation
as if you were going to probe the distal col.
■ Reposition the HVE as needed. D DF F MF M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the
nail polish or Wite-Out on the distal. Advance the active area antinode in an apical direction at a
pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically
to maintain contact with the tooth surface at a 0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the distal surfaces incisal to the gum line.
■ Magnetostrictive insert: Transition to a transverse orientation with the back, lateral, or
face surface with a 0- to 15-degree angulation to debride the distal interproximal contact
supragingivally.
■ Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a
0- to 15-degree angulation to debride the distal interproximal contact supragingivally.
■ Debride one-half of the distal interproximal space. The other half is debrided from the lingual.
■ Reposition the HVE as needed.
■ Remove all the nail polish or Wite-Out from one-half of the distal interproximal space.

D DF F MF M

D DL L ML M

Figure 12-2 Maxillary Left Central Incisor Lingual

Divided in 2 mm Segments
228 Chapter 12 Ultrasonic Technique

Grasp the ultrasonic handpiece with your dominant hand.

Grasp the HVE with affixed mirror with your nondominant hand. If an HVE with an affixed mirror
is not available, skip the lingual surfaces of the maxillary left central incisor.

Place active area antinode on the tooth surface at the lingual midline.
• Position the lateral surface of the active area antinode in a vertical orientation at the
incisal edge of the lingual midline of the maxillary left central incisor.
• Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port of the insert or tip.

Select the operator positioning for indirect vision: 11-1 o’clock for dominant right- and left-handed providers.

Select the patient chair positioning for the maxillary arch. Patient chair supine with chin slightly upward.

Establish a finger rest intraoral or extraoral ensuring correct handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps in Table12-2.

Table 12-2 Ultrasonic Instrumentation of the Maxillary Left Central Incisor Lingual Surfaces
Depress the foot pedal to activate the insert or tip.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the
nail polish or Wite-Out on the lingual midline. Advance the active area antinode in an apical
direction at a pace of 0.5–1.0 second per horizontal cycle. Rotate the active area antinode as
you move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation
■ Do not allow the active area to lose contact with the tooth surface.
■ Do not allow the shank to roll onto the nodal point (3.5–5.0 mm) as no action occurs and the
nail polish or Wite-Out will not be removed.
■ Remove all the nail polish or Wite-Out from the lingual midline surfaces incisal to the gum line.

D DL L ML M
 Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning 229

■ Reposition the lateral surface of the active area antinode at the incisal edge of the mesial-
lingual line angle in a vertical orientation with a 0- to 15-degree angulation.
■ Reposition the HVE as needed.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the
nail polish or Wite-Out on the mesial-lingual line angle. Rotate the active area antinode as you
move apically to maintain contact with the tooth surface at a 0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the mesial-lingual line angle surfaces incisal to
the gum line.

D DL L ML M

■ Dominant right-handed magnetostrictive insert: Reposition the back surface of the active
area antinode at the incisal edge of the straight mesial in a vertical orientation with a
0- to 15-degree angulation as if you were going to probe the mesial col.
■ Dominant right-handed piezoelectric tip: Reposition the lateral surface of the active area
antinode at the incisal edge of the straight mesial in a vertical orientation with a 0- to
15-degree angulation as if you were going to probe the mesial col.
■ Dominant left-handed magnetostrictive insert and piezoelectric tip: Reposition the lateral
surface of the active area antinode at the incisal edge of the straight mesial in a vertical
orientation with a 0- to 15-degree angulation as if you were going to probe the mesial col.
■ Reposition the HVE as needed. D DL L ML M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the
nail polish or Wite-Out on the mesial. Advance the active area antinode in an apical direction
at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move
apically to maintain contact with the tooth surface at a 0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the mesial surfaces incisal to the gum line.
■ Magnetostrictive insert: Transition to a transverse orientation with the back, lateral, or
face surface with a 0- to 15-degree angulation to debride the mesial interproximal contact
supragingivally.
■ Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a
0- to 15-degree angulation to debride the mesial interproximal contact supragingivally.
■ Debride one-half of the mesial interproximal space. The other half was debrided from the
facial.
■ Reposition the HVE as needed.
■ Remove all the nail polish or Wite-Out from one-half of the mesial interproximal space.
D DL L ML M

■ Reposition the lateral surface of the active area antinode at the incisal edge of the distal-
lingual line angle in a vertical orientation with a 0- to 15-degree angulation.
■ Reposition the HVE as needed.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the distal-lingual line angle. Advance the active area antinode
in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area
antinode as you move apically to maintain contact with the tooth surface at a 0- to 15-degree
angulation.
■ Remove all the nail polish or Wite-Out from the distal-lingual line angle surfaces incisal to the
gum line. D DL L ML M

(continues)
230 Chapter 12 Ultrasonic Technique

Table 12-2 Ultrasonic Instrumentation of the Maxillary Left Central Incisor Lingual Surfaces (continued)
■ Dominant right-handed magnetostrictive insert and piezoelectric tip: Reposition the
lateral surface of the active area antinode at the incisal edge of the straight distal in a
vertical orientation with a 0- to 15-degree angulation as if you were going to probe the
distal col.
■ Dominant left-handed magnetostrictive insert: Reposition the back surface of the active area
antinode at the incisal edge of the straight distal in a vertical orientation with a 0- to 15-degree
angulation as if you were going to probe the distal col.
■ Dominant left-handed piezoelectric tip: Reposition the lateral surface of the active area at the
incisal edge of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if
you were going to probe the distal col. D DL L ML M
■ Reposition the HVE as needed.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove the
nail polish or Wite-Out on the distal. Advance the active area antinode in an apical direction at a
pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode as you move apically
to maintain contact with the tooth surface at a 0- to 15-degree angulation.
■ Remove all the Wite-Out from the distal surfaces incisal to the gum line.
■ Magnetostrictive insert: Transition to a transverse orientation with the back, lateral, or
face surface with a 0- to 15-degree angulation to debride the distal interproximal contact
supragingivally.
■ Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a
0- to 15-degree angulation to debride the distal interproximal contact supragingivally.
■ Debride one-half of the distal interproximal space. The other half was debrided from
the facial.
■ Reposition the HVE as needed.
■ Remove all the Wite-Out from one-half of the distal interproximal space. D DL L ML M

MB midline
DB midline

D DB B MB M

Figure 12-3 Mandibular First Molar Buccal Divided in 2 mm Segments.

 Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning 231

Grasp the ultrasonic handpiece with your dominant hand. See Chapter 9 for details.
• Magnetostrictive: Thumb and index finger equidistant from one another on either side of the handpiece. The middle
finger is advanced forward onto the colored grip of the insert. The handpiece lays in the webbing between the
thumb and index finger.
• Piezoelectric: Thumb and index finger equidistant from one another on either side of the handpiece. The middle
finger is tucked behind the index finger. The handpiece lays in the webbing between the thumb and index finger.

Grasp the HVE with your nondominant hand. See Chapter 9 for details.

Place the active area antinode on the tooth surface at the straight buccal.
• Position the lateral surface of the active area antinode in a vertical orientation at the
occlusal-third on the straight buccal of the mandibular first molar.
• Establish a 0- to 15-degree angulation.

Establish a 0- to 15-degree angulation.

Select the operator positioning for direct vision.

• Dominant right-handed provider: 8–11 o’clock.
• Dominant left-handed provider: 1–4 o’clock.

Select the patient chair positioning for the mandibular arch.

• Supine, semi-supine, or in between supine and semi-supine.
• Patient chin slightly downward.
• Head slightly away from the provider depending on operator positioning.

Establish a finger rest intraoral or extraoral ensuring correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps in Table12-3.

Table 12-3 Ultrasonic Instrumentation of the Mandibular First Molar Buccal Surfaces
Depress the foot pedal to activate the insert or tip.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the straight buccal. Advance the active area antinode in
MB midline
DB midline

an apical direction at a pace of 0.5–1.0 second per horizontal cycle. Rotate the active D DB B MB M
area antinode as you move apically to maintain contact with the tooth surface at a 0- to
15-degree angulation.
■ Do not allow the active area to lose contact with the tooth surface.
■ Do not allow the shank to roll onto the nodal point (3.5–5.0 mm) as no action occurs and the
nail polish or Wite-Out will not be removed.
■ Remove all the nail polish or Wite-Out from the straight buccal surfaces occlusal to the
gum line.

(continues)
232 Chapter 12 Ultrasonic Technique

■ Reposition the lateral surface of the active area antinode at the occlusal-third of the
mesial-buccal midline in a vertical orientation with a 0- to 15-degree angulation.

MB midline
DB midline
■ Reposition the HVE as needed. D DB B MB M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the mesial-buccal midline. Advance the active area antinode
in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active
area antinode as you move apically to maintain contact with the tooth surface at a
0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the mesial-buccal midline surfaces occlusal to
the gum line.

■ Reposition the lateral surface of the active area antinode at the occlusal-third of the
mesial-buccal in a vertical orientation with a 0- to 15-degree angulation.

MB midline
DB midline
■ Reposition the HVE as needed. D DB B MB M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the mesial-buccal. Advance the active area antinode in
an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area
antinode as you move apically to maintain contact with the tooth surface at a
0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the mesial-buccal occlusal to the gum line.

■ Magnetostrictive insert: Reposition the back or lateral surface active area antinode at
the occlusal-third of the straight mesial in a vertical orientation with a 0- to 15-degree

MB midline
DB midline
angulation as if you were going to probe the mesial col. D DB B MB M
■ Piezoelectric tip: Reposition the lateral surface of the active area antinode at the occlusal-
third of the straight mesial in a vertical orientation with a 0- to 15-degree angulation as if
you were going to probe the mesial col.
■ Reposition the HVE as needed.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the mesial. Advance the active area antinode in an apical
direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode
as you move apically to maintain contact with the tooth surface at a 0- to 15-degree
angulation.
■ Remove all the nail polish or Wite-Out from the mesial surfaces occlusal to the gum line.
■ Magnetostrictive insert: Transition to a transverse orientation with the lateral or back
surface with a 0- to 15-degree angulation to debride the mesial interproximal contact
MB midline
DB midline

supragingivally. D DB B MB M
■ Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a
0- to 15-degree angulation to debride the mesial interproximal contact supragingivally.
■ Debride one-half of the mesial interproximal space. The other half is debrided from the
lingual.
■ Reposition the HVE as needed.
■ Remove all the nail polish or Wite-Out from one-half of the mesial interproximal space.
 Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning 233

■ Reposition the lateral surface of the active area antinode at the occlusal-third of the distal-
buccal midline in a vertical orientation with a 0- to 15-degree angulation.

MB midline
DB midline
■ Reposition the HVE as needed. D DB B MB M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the distal-buccal midline. Advance the active area antinode
in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active
area antinode as you move apically to maintain contact with the tooth surface at a
■ 0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the distal-buccal midline surfaces occlusal to
the gum line.

■ Reposition the lateral surface of the active area antinode at the occlusal-third of the distal-
buccal in a vertical orientation with a 0- to 15-degree angulation.

MB midline
DB midline
■ Reposition the HVE as needed. D DB B MB M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the distal-buccal. Advance the active area antinode in
an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area
antinode as you move apically to maintain contact with the tooth surface at a
0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the distal-buccal surfaces occlusal to the
gum line.

■ Magnetostrictive insert: Reposition the back or lateral surface of the active area antinode
at the occlusal-third of the straight distal in a vertical orientation with a 0- to 15-degree

MB midline
DB midline
angulation as if you were going to probe the distal col. D DB B MB M
■ Piezoelectric tip: Reposition the lateral surface of the active area antinode at the occlusal-
third of the straight distal in a vertical orientation with a 0- to 15-degree angulation as if you
were going to probe the distal col.
■ Reposition the HVE as needed.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the distal. Advance the active area antinode in an apical
direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode
as you move apically to maintain contact with the tooth surface at a 0- to 15-degree
angulation.
■ Remove all the nail polish or Wite-Out from the distal surfaces occlusal to the gum line.
■ Magnetostrictive insert: Transition to a transverse orientation with the lateral or back
surface with a 0- to 15-degree angulation to debride the distal interproximal contact MB midline
DB midline

supragingivally. D DB B MB M
■ Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a
0- to 15-degree angulation to debride the distal interproximal contact supragingivally.
■ Debride one-half of the distal interproximal space. The other half is debrided from the
lingual.
■ Reposition the HVE as needed.
■ Remove all the nail polish or Wite-Out from one-half of the distal interproximal space.
234 Chapter 12 Ultrasonic Technique

ML midline
DL midline
D DL L ML M

Figure 12-4 Mandibular First Molar Lingual Divided in 2 mm Segments

Grasp the ultrasonic handpiece with your dominant hand. An advanced grasp (moving the handpiece to the
second joint of the index finger) may be needed because the provider will be on their non-dominant
side of the patient chair. See Chapter 9 for details.

Grasp the HVE with your nondominant hand.

Place the active area antinode on the tooth surface at the straight lingual.
• Position the lateral surface of the active area antinode in a vertical orientation at the
occlusal-third on the straight lingual of the mandibular first molar.
• Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water port of the insert or tip.

Select operator positioning for direct vision.

• Right-handed provider: 1–4 o’clock.
• Left-handed provider: 8–11 o’clock.

Select the patient chair positioning for the mandibular arch

• Supine, semi-supine, or in between supine and semi-supine.
• Patient chin slightly downward.
• Head slightly away from the provider depending on operator positioning.

Establish a finger rest intraoral or extraoral ensuring correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE. Begin instrumentation with the steps in Table12-4.
 Ultrasonic Instrumentation Skill Building With Operator and Patient Positioning 235

Table 12-4 Ultrasonic Instrumentation of the Mandibular First Molar Lingual Surfaces
Depress the foot pedal to activate the insert or tip.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the straight lingual. Advance the active area antinode in

ML midline
DL midline
an apical direction at a pace of 0.5–1.0 second per horizontal cycle. Rotate the active area D DL L ML M
antinode as you move apically to maintain contact with the tooth surface at a
0- to 15-degree angulation.
■ Do not allow the active area to lose contact with the tooth surface.
■ Do not allow the shank to roll onto the nodal point (3.5–5.0 mm) as no action occurs and
the nail polish or Wite-Out will not be removed.
■ Remove all the nail polish or Wite-Out from the straight lingual occlusal to the gum line.

■ Reposition the lateral surface of the active area antinode at the occlusal-third of the
mesial-lingual midline in a vertical orientation with a 0- to 15-degree angulation.

ML midline
DL midline
■ Reposition the HVE as needed. D DL L ML M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the mesial-lingual midline. Advance the active area
antinode in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the
active area antinode as you move apically to maintain contact with the tooth surface at a
0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the mesial-lingual midline surfaces occlusal
to the gum line.

■ Reposition the lateral surface of the active area antinode at the occlusal-third of the
mesial-lingual in a vertical orientation with a 0- to 15-degree angulation.

ML midline
DL midline
■ Reposition the HVE as needed. D DL L ML M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the mesial-lingual. Advance the active area antinode
in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active
area antinode as you move apically to maintain contact with the tooth surface at a
0- to 15-degree angulation.
■ Remove all the Wite-Out from the mesial-lingual surfaces occlusal to the gum line.

■ Magnetostrictive insert: Reposition the back or lateral surface of the active area antinode
at the occlusal-third of the straight mesial in a vertical orientation with 0- to 15-degree
ML midline
DL midline

angulation as if you were going to probe the mesial col. D DL L ML M

■ Piezoelectric tip: Reposition the lateral surface of the active area antinode at the
occlusal-third of the straight mesial in a vertical orientation with 0- to 15-degree
angulation as if you were going to probe the mesial col.
■ Reposition the HVE as needed.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the mesial. Advance the active area antinode in an apical
direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode
as you move apically to maintain contact with the tooth surface at a 0- to 15-degree
angulation.
■ Remove all the Wite-Out from the mesial surfaces occlusal to the gum line.

(continues)
236 Chapter 12 Ultrasonic Technique

■ Magnetostrictive insert: Transition to a transverse orientation with the lateral or back

surface with a 0- to 15-degree angulation to debride the mesial interproximal contact

ML midline
DL midline
supragingivally. D DL L ML M
■ Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a
0- to 15-degree angulation to debride the mesial interproximal contact supragingivally.
■ Debride one-half of the mesial interproximal space. The other half was debrided from
the buccal.
■ Reposition the HVE as needed.
■ Remove all the nail polish or Wite-Out from one-half of the mesial interproximal space.

■ Reposition the lateral surface of the active area antinode at the occlusal-third of the
distal-lingual midline in a vertical orientation with a 0- to 15-degree angulation.

ML midline
DL midline
■ Reposition the HVE as needed. D DL L ML M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the distal-lingual midline. Advance the active area antinode
in an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active
area antinode as you move apically to maintain contact with the tooth surface at a
0- to 15-degree angulation. Remove all the Wite-Out from the distal-lingual midline
surfaces occlusal to the gum line.

■ Reposition the lateral surface of the active area antinode at the occlusal-third of the
distal-lingual in a vertical orientation with a 0- to 15-degree angulation.

ML midline
DL midline
■ Reposition the HVE as needed. D DL L ML M
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the distal-lingual. Advance the active area antinode in
an apical direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active
area antinode as you move apically to maintain contact with the tooth surface at a
0- to 15-degree angulation.
■ Remove all the nail polish or Wite-Out from the distal-lingual surfaces occlusal to the
gum line.

■ Magnetostrictive insert: Reposition the back or lateral surface of the active area antinode
at the occlusal-third of the straight distal in a vertical orientation with a 0- to 15-degree
ML midline
DL midline

angulation as if you were going to probe the distal col. D DL L ML M

■ Piezoelectric tip: Reposition the lateral surface of the active area antinode at the
occlusal-third of the straight distal in a vertical orientation with a 0- to 15-degree
angulation as if you were going to probe the distal col.
■ Reposition the HVE as needed.
■ Perform an ultrasonic activation stroke (2 mm horizontal movement top-down) to remove
the nail polish or Wite-Out on the distal. Advance the active area antinode in an apical
direction at a pace of 0.5–1 second per horizontal cycle. Rotate the active area antinode
as you move apically to maintain contact with the tooth surface at a 0- to 15-degree
angulation.
■ Remove all the nail polish or Wite-Out from the distal surfaces occlusal to the gum line.
 Summary 237

Table 12-4 Ultrasonic Instrumentation of the Mandibular First Molar Lingual Surfaces (continued)
■ Magnetostrictive insert: Transition to a transverse orientation with the lateral or face
surface with a 0- to 15-degree angulation to debride the distal interproximal contact

ML midline
DL midline
supragingivally. D DL L ML M
■ Piezoelectric tip: Transition to a transverse orientation with the lateral surface with a
0- to 15-degree angulation to debride the distal interproximal contact supragingivally.
■ Debride one-half of the distal interproximal space. The other half was debrided from the
buccal.
■ Reposition the HVE as needed.
■ Remove all the nail polish or Wite-Out from one-half of the distal interproximal space.

Summary
Ultrasonic instrumentation is a safe and effective
method to remove oral deposits. Continuous prac-
tice is required to achieve proficiency with the tech-
nique demands of the technology. When mastered,
ultrasonic instrumentation conserves root structures,
reduces pathogens, and improves ergonomics through
decreased labor intensity and time for procedures.
 CHAPTER 13

Dentsply Sirona
LEARNING OBJECTIVES • Cavitron Steri-Mate Sterilizable, Detachable
Handpiece: non-rotating nose-cone, detachable
After studying this chapter, you will be able to: handpiece for single mode ultrasonic scaling
devices manufactured by Dentsply Sirona.
1. Identify Dentsply Sirona magnetostrictive
ultrasonic products, parts, and accessories.
• Cavitron Thinsert 30K Ultrasonic Insert: the name
of the ultra-thin diameter insert manufactured by
2. Recognize the design differences of inserts Dentsply Sirona.
and select the best insert for the patient
presentation.
• Cavitron Ultrasonic Scaling System: the name of a
Dentsply Sirona magnetostrictive ultrasonic device.
3. Understand the operations of the foot pedal.
4. Perform proper water-line maintenance.
• Fitgrip: the name of an insert grip with larger
width and rippled texturing manufactured by
5. Select the correct water flow and power setting Dentsply Sirona.
for each insert.
6. Reprocess handpieces and inserts according to
• Jet-Mate Sterilizable, Detachable Handpiece:
handpiece for dual mode ultrasonic scaling
the manufacturer’s recommendations. devices that provide both magnetostrictive
ultrasonic scaling and air polishing manufactured
by Dentsply Sirona.
KEY TERMS
• Softip: blue disposable single-use Polysulfone
• Boost mode: a power mode option activated
through the foot pedal that delivers additional
Amoco P-1700 tip that is placed onto the Dentsply
Sirona Cavitron Softip Implant 30K Ultrasonic
Insert for dental implant debridement.
•
power output.
Cavitron Diamondcoat 30K Ultrasonic Insert: • Tap-On technology: a feature in a Dentsply Sirona
magnetostrictive ultrasonic device that allows the
the name for the diamond-coated shank
manufactured by Dentsply Sirona. system to deliver active cavitation to the insert
• Cavitron Powerline Ultrasonic Insert: the name
for thick diameter inserts manufactured by
without a constant depression of the foot pedal.

Dentsply Sirona.
• Cavitron Slimline Ultrasonic Insert: the name of
thin diameter inserts manufactured by Dentsply
Sirona. Introduction
• Cavitron Softip Disposable Prophy Tip Removal
Wrench: autoclavable wrench used to apply This chapter will explore magnetostrictive ultrasonic
and remove the disposable single-use Softip technology manufactured by Dentsply Sirona. The com-
on the shank of the Cavitron Softip Implant 30K pany’s research and development teams have ­continued
Ultrasonic Insert manufactured by Dentsply to evolve the field of magnetostrictive technology, re-
Sirona.
•
leasing new and innovative devices and insert designs
Cavitron Softip Implant 30K Ultrasonic Insert:
since 1957. Although there are other manufacturers of
the name for the implant insert manufactured by
Dentsply Sirona. magnetostrictive ultrasonic technology, it would be too
• Cavitron Steri-Mate 360 Handpiece: handpiece
with a 360-degree rotating nose cone
lengthy for this book to cover every single one. For this
reason, the author has chosen to focus on two of the
manufactured by Dentsply Sirona. largest global magnetostrictive manufacturers.
239
240 Chapter 13 Dentsply Sirona
This chapter will present Dentsply Sirona ultra-
sonic devices, handpieces, and insert portfolio. De-
tailed information for each insert with its clinical use,
power settings, diameter, shape, length, cross-section,
and coatings will be discussed. This knowledge will
assist the oral health-care provider in implementing
a contemporary approach to ultrasonic instrumenta-
tion. As discussed in other chapters, it is best practice
to use the inserts from the company that made your
ultrasonic device because there are many differences
in manufacturing designs. Mismatching manufacturer
technology is not recommended and has the potential
to adversely affect efficiency and equipment perfor-
mance, and possibly void the product’s warranty.
This book will not discuss 25 kHz ultrasonic tech-
nology because this technology has been replaced by
the 30 kHz market. As discussed in Chapter 3 to change
the frequency of a magnetostrictive ultrasonic from
25 kHz to 30 kHz, the ferromagnetic laminate nickel
plates are shortened, so a 25 kHz insert cannot be used
in a 30 kHz device. Dentsply Sirona offers a single 25
kHz ultrasonic device with a limited selection of inserts.
Newer inserts are now specifically designed for 30 kHz
devices and not available in the older 25 kHz models.
Magnetostrictive
Ultrasonic Devices
The trade name for the Dentsply Sirona magneto-
strictive ultrasonic device is Cavitron Ultrasonic
Scaling System. Dentsply Sirona has been manufac-
turing magnetostrictive ultrasonic devices for the den-
tal market since 1957, with many models developed
over the years that offer a wide range of functionality
and features, for example:
• Single mode models that provide magnetostric-
tive ultrasonic scaling.
• Dual-mode models that provide both magneto-
strictive ultrasonic scaling and air polishing.
• Independent self-contained water reservoirs.
• Digital touch screen magnetostrictive ultrasonic
scalers.
Frequency
Original models from the 1950s required the provider
to manually tune a Cavitron Ultrasonic Scaling de-
vice to a specific frequency (see Chapter 7). By the
1980s, Cavitron Ultrasonic Scaling models had been
sold with a set frequency. Many 30 kHz Cavitron Ul-
trasonic Scaling models have been released since the
1980s, each with improvements to the technology. The
Figure 13-1 Dentsply Sirona Cavitron Slimline 10S 25K
Ultrasonic Insert Cavitron Slimline 10S Fitgrip 30K
Ultrasonic Insert
Reproduced with permission from Dentsply Sirona.
30 kHz models have replaced the antiquated 25 kHz
models, and newer inserts have been developed spe-
cifically for 30 kHz Cavitron Ultrasonic Scaling mod-
els, making the selection of inserts for a 25 kHz device
different than 30 kHz. Due to the difference in length,
a 25 kHz insert cannot be used in a 30 kHz ultrasonic
device, and vice versa (see Figure 13-1).
Emerging Technology
The newest Cavitron Ultrasonic Scaling systems re-
leased by Dentsply Sirona are the Cavitron 300 ­Series
Ultrasonic Scaling System and Cavitron Touch Ultra-
sonic Scaling System. They are the first digital mag-
netostrictive ultrasonic devices with touch screen
technology. All previous models are analog.
• Analog ultrasonic scaling system: An analog ultra-
sonic scaler harnesses the energy produced by the
ultrasonic sound waves from equilibrium to the
crest of the wave (positive energy; see Figure 13-2a).
The energy produced from the wave’s equilibrium
to the trough (negative energy) is not used to drive
the handpiece action and dissipates as heat, as
seen in Figure 13-2a (dotted lines).
• Digital ultrasonic scaling system: A digital ultra-
sonic scaler harnesses and delivers both the pos-
itive and negative energy of the ultrasonic sound
waves (see Figure 13-2b). Less heat is produced in
this system so the provider can opt to lower the
water flow rate during active instrumentation for
improved visibility and aerosol control. Through
harnessing all positive and negative energy cre-
ated by the ultrasonic sound waves, lower power
settings can be used to remove oral deposits, im-
proving efficiency and patient comfort.
Digital Cavitron Ultrasonic
Scaling Systems
Digital Cavitron Ultrasonic Scaling Systems have
many user-friendly features (as seen in Figure 13-3).
 Magnetostrictive Ultrasonic Devices 241

Positive energy

Negative energy

Positive energy

Negative energy

B
Figure 13-2 Analog and Digital Ultrasonic Scaling
A
Systems: A. Analog Ultrasonic Scaling System, B. Digital
Ultrasonic Scaling System

Figure 13-3 Cavitron 300 Series Ultrasonic Scaling System

Reproduced with permission from Dentsply Sirona.

• Touch screen: Allows for a change in a setting
without the use of a dial, as is used in analog mod-
els. This allows for more precise control.
• Automatic purge: When activated, auto-
matic purge provides a constant water flow for
two minutes. This timer can be stopped early
by touching the control on the screen (see
Figure 13-4a and b).
• Rinse: Provides an aqueous lavage flow from
the insert without cavitation. The rinse feature
is located under the purge button (as seen in
Figure 13-4a).
• Settings icon: Located at the bottom left of the
screen (see Figure 13-5). Settings allow for an
B
Figure 13-4 Dentsply Sirona Cavitron Touch Ultrasonic
Scaling System Icons: A. Left side of screen, top icon is
purge and second from the top icon is rinse, B. Purge
Countdown for 120 Seconds. To Interrupt Automatic
Purge, Touch the Icon (Scale) Next to the Counter
Reproduced with permission from Dentsply Sirona.
adjustment in foot pedal settings and screen
brightness.
• Preset power mode options: There are three pro-
gramable preset power options. This allows for
a quick touch selection during treatment. Icons
are located on the right side of the screen. See
­Figure 13-5.
242 Chapter 13 Dentsply Sirona

Figure 13-5 Dentsply Sirona Cavitron Touch Ultrasonic A

Scaling System Icons
Reproduced with permission from Dentsply Sirona.

• Lock/unlock screen: The user can lock and unlock

the screen. The light will diminish when the screen
is locked. Simply hold the button for three sec-
onds to activate and deactivate (see F
­ igure 13-5).
• Foot pedal: Round, cord-free foot pedal with
Bluetooth and Tap-On technology accompanies
the device. The screen displays the battery level
on the menu screen, similar to a smartphone with
four bars (see Figure 13-6a).
• Four bars: 75–100% charged B
• Three bars: 50–75% charged
Figure 13-6 Battery Display and USB Charger Dentsply
• Two bars: 25–50% charged
Sirona Cavitron Touch Ultrasonic Scaling System:
• One bar: 0–25% charged A. Green battery display is on the top right, B. Foot pedal
The battery is charged via a USB cord that con- charging is on the left
nects the pedal to the front of the device (see Reproduced with permission from Dentsply Sirona.
Figure 13-6b).
• Handpiece: Detachable and sterilizable Cavitron
Steri-Mate 360 Handpiece is used with digital
ultrasonic scaling systems. The handpiece has a
rotating nose cone for improved ergonomics by
decreasing operator repositioning and finger rest
adjustments during active patient treatment (see Figure 13-7 Rotating Nose Cone, Dentsply Sirona
Figure 13-7). Cavitron Steri-Mate 360 Handpiece
• Handpiece cord: The handpiece cord rotates Reproduced with permission from Dentsply Sirona.

during use and is lighter than analog models.

• Water control: Control is on the handpiece con-
nector cord.
• Water filter: An icon will appear on the device
when the water filter needs to be replaced.
Power
The power output is controlled by either a dial or touch
screen depending on the model. The foot pedal activates

and deactivates the device and delivers the power level
selected by the provider. Boost mode is an option on
select models controlled through the foot pedal.
Power Control
Power output options are low, medium, and high,
controlled through a dial or touch screen.
• Dial: Analog scalers are sold with a movable dial
that has varied color markings, depending on the
model. It is easier to distinguish power settings on
an analog movable dial if we compare it to a stan-
dard clock that tells time with a first and second
hand (see Figure 13-8).
A promised (see Figure 13-10). Each insert is designed
B
Figure 13-8 Dentsply Sirona Cavitron Analog Dial
(Cavitron Jet Plus Ultrasonic Scaling and Air Polishing
System): A. Dial, B. Clock
Magnetostrictive Ultrasonic Devices 243
• Power off: 6 o’clock
• Low power: approximately 6 to 10 o’clock
• Medium power: approximately 10 to 12 o’clock
• High power: approximately 12 to 2 o’clock
• Dual models with air polishing and ultrasonic
scaling have one dial to control both functions.
Moving the dial past 2 o’clock will activate air
polishing. The section may read, “Prophy Mode,”
with a gray or purple color. The colors and mark-
ing vary by model (see Figure 13-9).
• Touch screen: Digital models are a touch screen
with numbers 0–100. The power output is dis-
played in the middle of the screen (see Table 13-1).
Table 13-2 provides a summary of power settings
for both analog and digital technology.
• Low power: Used for the removal of light biofilm,
bacterial by-products, stain, and dental calculus.
• Medium power: Used for the removal of moderate
to heavy biofilm, bacterial by-products, stain, and
light to moderate dental calculus.
• High power: Used for the removal of heavy stain
and dental calculus.
Power settings past 2 o’clock on an analog model
or over 75 on a digital model are generally not used
for ultrasonic instrumentation because the displace-
ment amplitude of the insert becomes so great that the
effectiveness of oral deposit removal becomes com-
for specific power out levels and should never be used
at a power output not approved by the manufacturer.
This information can be found in the instruction for
use (IFU).
Figure 13-9 Dentsply Sirona Cavitron Jet Plus Ultrasonic
Scaling and Air Polishing System with Purple “Prophy
Mode” on the Dial
Reproduced with permission from Dentsply Sirona.
244 Chapter 13 Dentsply Sirona

Table 13-1 Power Settings (Dentsply Sirona Cavitron Touch Ultrasonic Scaling System)
Low power Approximately 0–30

         
Medium power Approximately 30–60

              
High power Approximately 60+

Reproduced with permission from Dentsply Sirona.

Table 13-2 Dentsply Sirona Power Settings

Digital Cavitron Analog Cavitron Biofilm, Bacterial Dental
Ultrasonic Scaling* Ultrasonic Scaling* By-Products Stain Calculus
Low 0–30 Off position to Light Light Light
10 o’clock
Medium 30–60 10–12 o’clock Moderate, heavy Moderate, Light,
heavy moderate
High 60+ 12–2 o’clock X Moderate, Moderate,
heavy heavy

*Power levels are approximations.

Reproduced with permission from Dentsply Sirona.

Boost Mode
Many, but not all, models have a Boost mode option.
Refer to the model IFU to determine if Boost mode is
available. Boost mode is controlled by the foot pedal,
which is depressed all the way to the floor to acti-
vate, also called second position. Boost allows for un-
interrupted ultrasonic instrumentation. When Boost
mode is activated, the power output will increase by
­approximately 25%.
Boost is a useful feature during debridement when
a larger oral deposit is encountered. The provider
does not need to stop ultrasonic instrumentation to
increase the power setting. They simply depress the
pedal to its second position (all the way down) to
activate Boost and increase the power to remove the
larger deposit. See Figure 13-13a. The pedal is then
returned to its first position (half-way down) to deac-
tivate Boost. See Figure 13-13b.
• Analog Ultrasonic Scaling Systems: when Boost
mode is activated, the light on the front of the
device will change from green (on) to orange
­
(Boost; see Figure 13-11a).
• Digital Ultrasonic Scaling Systems: touch screen
will display the word BOOST in orange above
the power output level selected by the user when
­activated (see Figure 13-11b).
 Magnetostrictive Ultrasonic Devices 245

A
B
Figure 13-10 Maximum Power Settings: A. Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling
and Air Polishing System dial set to 2 o’clock, B. Dentsply Sirona Cavitron Touch Ultrasonic Scaling
System set to 75.
Reproduced with permission from Dentsply Sirona.

A B C
Figure 13-11 Dentsply Sirona Cavitron Ultrasonic Scaling System Boost Mode: A. Green light ‘on’ (Dentsply Sirona
Cavitron Select SPS Ultrasonic Scaling System), B. Orange light ‘Boost mode”, C. Orange BOOST display (Dentsply
Sirona Cavitron Touch Ultrasonic Scaling system).
Reproduced with permission from Dentsply Sirona.

Foot Pedal • Round foot pedal: Allows the provider to depress

Original models had a square foot pedal and newer
models have a round foot pedal (see Figure 13-12a and b).
Wireless Bluetooth technology, Boost, and Tap-On
technology are available in specific models. Refer to
the IFU to determine which features your model has.
the pedal anywhere for activation.
• Boost: Activated by depressing the foot pedal to
its second position to deliver an approximately
25% increase in power output (see Figure 13-13a).
• Tap-On technology: Tap-On technology wire-
less foot pedal eliminates the need to hold the
246 Chapter 13 Dentsply Sirona

A
A

B
B Figure 13-13 Dentsply Sirona Tap-On technology
Figure 13-12 Dentsply Sirona Cavitron Foot Pedals:
wireless foot pedal: A. Boost (pedal depressed to second
A. Round (Tap-On Technology Wireless Foot Pedal), position which is all the way down), B. Tap-on (pedal
B. Square depressed to the first position which is half-way down)
Reproduced with permission from Dentsply Sirona.

foot pedal down during active treatment. This al- Digital Cavitron Ultrasonic Scaling
lows the provider to relax their foot on the floor System
during ultrasonic instrumentation, which de-
1. Turn the power on.
creases strain on the leg, hips, and back. To acti-
2. Stand within 10 feet of the unit.
vate Tap-On technology, the foot pedal is pressed
3. Press and hold the settings icon on the touch
to its first position and then quickly released
screen (see Figure 13-5).
(see Figure 13-13b). A digital Ultrasonic Scaling
4. Press the sync icon. The icon will begin to rotate.
System can also enable tap-on from the settings
5. On the bottom of the foot pedal, press and hold
screen. The length of time the device stays active
the red button for three seconds.
varies based on the model purchased and is listed
6. The sync icon will stop rotating on the touch
in the IFU. Tap-On technology only activates
screen when the pedal is synchronized.
when a handpiece and insert is attached.
• Wireless Bluetooth technology: Allows ease of
maneuverability for the provider as the pedal is Analog Cavitron Ultrasonic Scaling
not tethered to the ultrasonic device. System
The foot pedal must be synched to the ultrasonic de- 1. Turn the power on.
vice upon delivery. The steps for synchronization follow. 2. Stand within 10 feet of the unit.

3. Press the purge button (see Figure 13-14).
4. Graphics will blink for 5–6 seconds. During this
time, on the bottom of the foot pedal, press and
hold the red button for three seconds.
5. All graphics will blink at the same time upon suc-
cessful synchronization.
Water
The water flow rate is controlled either with the
handpiece connector or with a dial depending on
the model. The water flow rate is selected based
on the power output setting. If present, the water filter
must be periodically checked and replaced at a speci-
fied interval by the manufacturer, which can be found
in the IFU.
Water Control
An analog device has a water control either on the
handpiece connector cable or as a dial, depending
on the model purchased. A digital model has a water
control on the handpiece connector cable. The hand-
piece connector water display has either numbers or
symbols depending on the model.
• Numbers: the lower the number, the lower the
water flow rate (see Figure 13-15).
• Symbols: One water droplet has a lower water
flow rate than three water droplets.
Figure 13-14 Purge button in blue (Dentsply Sirona
Cavitron Jet Plus Ultrasonic Scaling and Air Polishing
System)
Reproduced with permission from Dentsply Sirona.
Magnetostrictive Ultrasonic Devices 247
Water Flow Rate
The water flow rate is chosen based on the power out-
put setting.
• Low to medium power: Water flow rate is set for a
rapid drip with a fine mist halo (see Figure 13-16a).
• High power: The water flow rate is turned up, so
the rapid drip disappears, and a strong mist is ex-
pelled (see Figure 13-16b).
Water Filter
If using a model with a water filter, the filter should
be inspected regularly to ensure it is not in need of
replacement prior to its recommended replacement
interval. Replacement intervals are based on the wa-
ter supply source being run through the unit (see
Table 13-3 for details). The filter should be replaced
more frequently if the:
• Filter has particulate matter buildup.
• Filter discolors from the original color.
• Water flow in the line is reduced or inconsistent.
Insert Water Port
Inserts have an internal water port as described in
Chapter 5. Internal water ports are equipped with a
small cannula tube embedded inside the shank that
emerges from a small opening. The port position on
the shank varies for each insert.
Figure 13-15 Dentsply Sirona Cavitron Ultrasonic
Scaling System Water Control Number 1-6
248 Chapter 13 Dentsply Sirona

Mist with droplets Fine mist

Low-med power High power

A B
Figure 13-16 Water Settings: A. Low to medium power (Cavitron Slimline 10S 30K Ultrasonic Insert), B. High power
(Cavitorn Powerline 1000 30K Ultrasonic Insert)
Reproduced with permission from Dentsply Sirona.

Table 13-3 Dentsply Sirona Cavitron Ultrasonic Scaling Water Filter Replacement

(Reproduced with permission from Dentsply Sirona)

Water Source Municipal Well Hard Soft Bottle Systems

Replacement timing 1 × month 2 × month 2 × month 1 × month 2 × month

Reproduced with permission from Dentsply Sirona.

Handpiece called the Jet-Mate Sterilizable, Detachable

Handpieces have evolved over the years to maintain
compliance with changing Centers for Disease Con-
trol and Prevention (CDC) recommendations for
handpiece reprocessing. The IFU will list the specific
handpiece that is compatible with the model pur-
chased. The provider must purchase the handpiece
that is compatible with their model. Current models
use a sterilizable handpiece.
• Dual mode Ultrasonic Scaling Systems that pro-
vide both magnetostrictive ultrasonic scaling and
air polishing have a handpiece that is equipped for
both an ultrasonic insert and air polishing nozzle
Handpiece (see Figure 13-17a).
• Analog Ultrasonic Scaling Systems use a non-­
rotating nose-cone, detachable handpiece
(see Figure 13-17b) called the Cavitron Steri-
Mate Sterilizable, Detachable Handpiece
• Digital Ultrasonic Scaling Systems use the Cavit-
ron Steri-Mate 360 Handpiece that features a ro-
tating nosecone as seen in Figure 13-17c.
Connect the handpiece to the handpiece connec-
tor cable by aligning the electrical connections. Be
gentle when attaching and removing the handpiece
from the connector to avoid damage to the connec-
tions (see Figure 13-18).

A
B
C
Figure 13-17 Dentsply Sirona Cavitron Ultrasonic
Handpieces: A. Dual Model Jet-Mate Sterilizable,
Detachable Ultrasonic Handpiece, B. Cavitron Steri-
Mate Sterilizable, Detachable Handpiece, C. Cavitron
Steri-Mate 360 Handpiece
Reproduced with permission from Dentsply Sirona.
Figure 13-18 Dentsply Sirona handpiece connector cable
on left and Jet-Mate Sterilizable, Detachable Ultrasonic
Handpiece on the right
The handpiece should be filled with water prior
to seating an insert and the O-ring lubricated as de-
scribed in Chapter 5 (see Figure 5-7).
• Hold the handpiece upright over a sink, then step
on the pedal to fill the handpiece with water until
a dome of water appears on the brim.
• Allow any trapped air to exit the handpiece prior
to seating an insert.
• Lubricate the O-ring on the insert by rotating the
O-ring 360 degrees over the water dome.
• Place the insert into the handpiece in an upright
position. Apply gentle pressure and use a push-
twist motion to fully seat the O-ring of the insert
into the handpiece.
Insert Portfolio 249
Insert Portfolio
Dentsply Sirona manufactures a variety of shank
shapes, diameters, cross-sections, and coatings for its
analog and digital 30K Cavitron Ultrasonic Scaling
Systems, which supports a contemporary approach to
ultrasonic instrumentation.
All inserts have a color grip covering the connect-
ing body; one O-ring; and 16 ferromagnetic laminate
nickel plates with markings of the company name, lot
number, and date of insert creation. The O-ring is a
wear-and-tear item and should be replaced when worn.
The color of the grip is a patented color specific
for Dentsply Sirona ultrasonic inserts. There are five
color grips:
1. Thick diameter shank: Cavitron Powerline Ultra-
sonic Insert with a blue grip.
2. Thin diameter shank: Cavitron Slimline ­Ultrasonic
Insert with a green grip.
3. Ultra-thin shank: Cavitron Thinsert 30K Ultra-
sonic Insert with a purple grip.
4. Implant insert: Cavitron Softip Implant 30K Ultra-
sonic Insert with a yellow grip.
5. Diamond insert: Cavitron DiamondCoat 30K Ul-
trasonic Insert with an orange grip.
In 2014, a new style grip was released named
Fitgrip. The Fitgrip has a larger width with rippled
texturing (see Figure 13-19). Thicker grips improve
ergonomics by decreasing muscle strain and pinch
force. The texturing improves the provider’s grasp and
decreases slipping.
Thick Diameter Cavitron
Powerline Ultrasonic Inserts
Thick diameter inserts have the largest surface area
of the shank and are termed Cavitron Powerline
­Ultrasonic Inserts (see Figure 13-20a to d). They
have a blue grip color. There are four Cavitron Pow-
erline Ultrasonic Inserts that all have a straight shank.
There are no curved shank shapes in the thick diam-
eter insert portfolio because their surface area is too
large to access subgingivally in tightly adherent tissues
to reach complex root anatomy.
The Cavitron Powerline Ultrasonic Insert portfo-
lio offers a variety of bends in the terminal 4 mm of the
shank. All inserts are still considered a straight shape
because the overall shank is still bent in one plane
with small bends in the terminal 4 mm. The small
bends change the cross-section and length of the
shank. Table 13-4 provides a summary of cross-section
and number of bends.
250 Chapter 13 Dentsply Sirona

• Cross-section: A one- and two-bended shank has to interproximal areas and line angles (see
a round or circular cross-section, and a three- Figure 13-21).
bended shank has a diamond cross-section. • Length: Every time the terminal 4 mm of the
• Adaptation: The diamond cross-section allows shank is bent, the shank length changes slightly.
for easier adaption of the active area antinode This is only clinically relevant if accessing deeper
periodontal pockets.

Table 13-4 Dentsply Sirona Cavitron Powerline

Ultrasonic Inserts
Number of Bends
in Terminal 4 mm Cross-
Name of Shank Section
Cavitron Powerline 10 1 Round
30K Ultrasonic Insert
Cavitron Powerline 100 2 Round
30K Ultrasonic Insert
Cavitron Powerline 3 Diamond
1000 30K Ultrasonic
Insert
Cavitron Powerline 3 1 Broad,
30K Ultrasonic Insert flat, blunt
design
Figure 13-19 Dentsply Sirona Fitgrip and Standard Grip Memory trick: The number of zeros indicate the number of bends in
(Cavitron Powerline 10 Fitgrip 30K Ultrasonic Insert on left the terminal 4 mm of the shank.
and Cavitron Powerline 10 30K Ultrasonic Insert on right)
Reproduced with permission from Dentsply Sirona.

A B C D
Figure 13-20 Dentsply Sirona Powerline Ultrasonic Inserts: A. Cavitron
Powerline 10 Fitgrip 30K Ultrasonic Insert, B. Cavitron Powerline 100
Fitgrip 30K Ultrasonic Insert, C. Cavitron Powerline 1000 Fitgrip 30K
Ultrasonic Insert, D. Cavitron Powerline 3 Fitgrip 30K Ultrasonic Insert
Reproduced with permission from Dentsply Sirona.

Figure 13-21 Dentsply Sirona Cavitron Powerline
1000 30k Ultrasonic Insert Adapted to the Line Angle of
the Mandibular First Molar Buccal Surface. Diamond
Cross-Section Inserts Adapted to the Curved Line Angle
Anatomy of the Mandibular First Molar Buccal Surface.
Notice the Active Area Antinode is in Contact With the
Curved Line Angle Anatomy of the Mandibular First
Molar Buccal Surface
Clinical Indications for Use
Cavitron Powerline 10, 100, 1000 30K Ultrasonic
Inserts:
• Used for the removal of moderate to heavy dental
calculus deposits and supragingival staining.
• If tissues are soft, spongy, and movable, they may
be able to access subgingivally.
• When tissues are firm, hard, or tightly adherent,
access may be restricted.
Cavitron Powerline 3 30K Ultrasonic Insert:
• Used for the removal of large, heavy supragingival
dental calculus deposits. The provider will adapt
the point directly onto the deposits for removal.
• Never used subgingival due to its broad, flat, and
blunt shank shape (see Figure 3-20d).
Power Settings
Cavitron Powerline Ultrasonic Inserts can be used at all
power settings without injury to the shank. Clinically,
since they are used for the removal of moderate to heavy
dental calculus and stain, a high power is typically used.
Thin Diameter Cavitron Slimline
Ultrasonic Inserts
Cavitron Slimline Ultrasonic Inserts have a shank
diameter that is 30% thinner than the Cavitron
Insert Portfolio 251
Figure 13-22 Cavitron Slimline 10S Fitgrip 30K Ultrasonic
Insert on the left and Dentsply Sirona Cavitron Powerline
Fitgrip 30K 10 Ultrasonic Insert on the right
Reproduced with permission from Dentsply Sirona.
Powerline 10, 100, 1000 30K Ultrasonic Inserts
(see Figure 3-22).
They have a green color grip. Dentsply Sirona
manufactures four Cavitron Slimline Ultrasonic In-
serts listed in Table 13-5 (see Figure 13-23a to c).
• Straight shank shape: Cavitron Slimline 10S and
1000 30K Ultrasonic Inserts.
• Curved shank shape: Cavitron Slimline 10R and
10L 30K Ultrasonic Inserts.
Clinical Indications for Use
Cavitron Slimline Ultrasonic Inserts are used for the
removal of light to moderate dental calculus and
stain as well as all levels of biofilm and bacterial by-­
products. The 30% thinner shank diameter allows for
subgingival access with little to no tissue distension.
The Cavitron Slimline 10R and 10L 30K Ultrasonic
Inserts have a long and curved shank shape, which al-
lows access and adaptation to complex root anatomy
(concavity, convexity, furcation) and deep periodontal
pockets.
Power Settings
Cavitron Slimline Ultrasonic Inserts vary on the power
settings that can be safely used without injury to the
shank. This is because the connecting body under
the grip varies in design. Table 13-6 summarizes the
power settings for each insert.
252 Chapter 13 Dentsply Sirona

Table 13-5 Dentsply Sirona Cavitron Slimline Ultrasonic Inserts

Number of Bends in Terminal Cross-Section Shank
Name 4 mm of Shank Shape Shape
Cavitron Slimline 10S 30K Ultrasonic Insert 1 Round Straight
Cavitron Slimline 1000 30K Ultrasonic Insert 3 Diamond Straight
Cavitron Slimline 10R 30K Ultrasonic Insert 1 Round Curved
Cavitron Slimline 10L 30K Ultrasonic Insert 1 Round Curved

A B C
Figure 13-23 Dentsply Sirona Cavitron Slimline Ultrasonic Inserts: A. Cavitron Slimline 10S
Fitgrip 30K Ultrasonic Insert, B. Cavitron Slimline 1000 Fitgrip 30K Ultrasonic Insert, C.
Cavitron Slimline 10L/10R Fitgrip 30K Ultrasonic Inserts
Reproduced with permission from Dentsply Sirona.

• All power settings: Cavitron Slimline 1000 30K Table 13-6 Dentsply Sirona Cavitron Slimline
Ultrasonic Insert can be used on low, medium, Ultrasonic Inserts Power Settings
and high power.
Insert Power Setting
• Low to medium power: Cavitron Slimline 10S,
10R, 10L 30K Ultrasonic Inserts are used on low Cavitron Slimline 10S 30K Low, medium
and medium power because the connecting body Ultrasonic Insert
does not support the use of high power. Cavitron Slimline 1000 30K Low, medium, high
Ultrasonic Insert
When incorrect power settings are used, the risk
for insert damage or shank breakage increases. Patient Cavitron Slimline 10R 30K Low, medium
safety is at risk if the shank were to break in the mouth Ultrasonic Insert
while in use. The patient could aspirate the broken Cavitron Slimline 10L 30K Low, medium
shank. If it breaks subgingivally, a retrieval procedure Ultrasonic Insert
may be required.

Ultra-Thin Diameter Cavitron
Thinsert
The Cavitron Thinsert 30K Ultrasonic Insert has
a diameter shank that is 47% thinner than ­Cavitron
Slimline Ultrasonic Inserts (see Figure 13-24a). The grip
is a purple color. This insert has a similar thickness to
an ODU11/12 periodontal explorer with similar tac-
tile sensitivity (Partido et al., 2018; see Figure 13-24b).
Clinical Indications for Use
The Cavitron Thinsert 30K Ultrasonic Insert is used
for the removal of light to moderate dental calculus
A vider could turn up the power to medium-high and
B
Figure 13-24 Dentsply Sirona Cavitron Thinsert 30K
Ultrasonic Insert: A. Cavitron Thinsert 30K Ultrasonic
Insert and Slimline 10S Fitgrip 30K Ultrasonic Insert,
B. Cavitron Thinsert 30K Ultrasonic Insert and
HuFriedyGroup 11/12 Old Dominion University (ODU)
Explorer
Reproduced with permission from Dentsply Sirona.
Insert Portfolio 253
deposits, staining, biofilm, and bacterial by-­products.
The Cavitron Thinsert 30K Ultrasonic Insert is useful
for:
• Adapting to tooth roots under the gums in firm,
avascularized, tight epithelial tissue. The in-
sert causes little to no tissue distension (see
Figure 13-25).
• Accessing tight interproximal spaces when teeth
are crowded (see Figure 13-26a to c).
• Debriding around a fixed orthodontic appliance
such as a retainer (see Figure 13-27).
• Exploration to detect residual oral deposits
during active ultrasonic instrumentation. A
study by Partido et al. (2018) found an inactive
Cavitron Thinsert 30K Ultrasonic Insert and a
hand-activated ODU 11/12 explorer produced
similar results in calculus detection. The advan-
tage of using a Cavitron Thinsert 30K Ultrasonic
Insert for exploration is the provider does not
have to put down their ultrasonic handpiece and
pick up an explorer to detect for residual oral de-
posits. This increases efficiency by not changing
instruments.
Power Settings
The Cavitron Thinsert 30K Ultrasonic Insert may be
used at all power settings without injury to the shank.
Clinically, because the insert is commonly used for
the removal of light to moderate dental calculus de-
posits and biofilm, low and medium power are com-
monly used. Since an inactive Cavitron Thinsert 30K
Ultrasonic Insert can also be used as an explorer, if
a dental calculus deposit were encountered, the pro-
use the Cavitron Thinsert 30K Ultrasonic Insert for its
removal without damage to the shank.
Figure 13-25 Firm, Avascularized, Tight Epithelial
Tissue of a Patient Who Smokes Cigarettes
254 Chapter 13 Dentsply Sirona
C
Figure 13-26 Crowded Teeth: A. Mandibular
arch, B. Mandibular anterior and premolar teeth,
C. Mandibular anterior and premolar teeth.
Implant Insert
The Cavitron Softip Implant 30K Ultrasonic
­Insert has a yellow color grip with an inactive shank.
The inactive shank is covered with a blue disposable
single-use Softip made of Polysulfone Amoco P-1700,
which is a high-strength polymer. The disposable
Softip cannot be placed on any insert other than the
Cavitron Softip Implant 30K Ultrasonic Insert because
the Softip may break or fall off while in use.
Figure 13-27 Fixed lingual retainer on the mandibular
anterior lingual surfaces
Figure 13-28 Dentsply Sirona Cavitron Softip Disposable
Prophy Tip Removal Wrench, Softip (blue), and Cavitron
Softip Implant 30K Ultrasonic Insert (yellow grip)
An autoclavable wrench called the Cavitron
Softip Disposable Prophy Tip Removal Wrench
is used to apply and remove the disposable single-use
Softip on the shank of the Cavitron Softip Implant
30K Ultrasonic Insert (see Figure 13-28).
Use aseptic technique for attaching the blue Softip
to the shank to avoid cross-contamination. Use gloves

A
B 3. Gently push the Cavitron Softip Implant 30K
C ing, liquid jet production, tissue lavage, and irrigation
Figure 13-29 Attaching Softip to the Cavitron Softip
Implant 30K Ultrasonic Insert: A. Round opening of the
Cavitron Softip Disposable Prophy Tip Removal Wrench,
B. Place Softip into the wrench opening, C. Place Cavitron
Softip Implant 30K Ultrasonic Shank into Softip opening
Reproduced with permission from Dentsply Sirona.
Insert Portfolio 255
when handling equipment and ensure the insert and
wrench have been sterilized prior to use.
The following are steps for attaching the single
use disposable blue Softip to the shank of the Cavit-
ron Softip Implant 30K Ultrasonic Insert:
1. Place the blue-colored Softip into the round
opening on the top of the Cavitron Softip Dis-
posable Prophy Tip Removal Wrench (see
Figure 13-29a and b).
2. Place the Cavitron Softip Implant 30K U ­ ltrasonic
Insert shank into the Softip opening (see
Figure 13-29c).
3. Turn the insert one-quarter turn and remove the
Softip from the Cavitron Softip Disposable Pro-
phy Tip Removal Wrench.
4. Verify the Softip is in place by gently tugging on
the blue Softip with your fingers.
Use aseptic technique when detaching the blue
Softip from the shank to avoid cross-contamination.
The following are steps for detaching the blue
Softip from the shank of the Cavitron Softip Implant
30K Ultrasonic Insert:
1. Place the Softip, which is still affixed to the Cavitron
Softip Implant 30K Ultrasonic Insert shank, into
the slot opening on the Cavitron Softip Disposable
Prophy Tip Removal Wrench (see Figure 13-30a).
2. Place your thumb and index finger over the Softip
(see Figure 13-30b).
Ultrasonic Insert downward to disengage the
­
Softip.
4. Dispose of the used Softip in accordance with the
standards of biohazard material.
5. Reprocess the Cavitron Softip Implant 30K Ultra-
sonic Insert and Cavitron Softip Disposable Pro-
phy Tip Removal Wrench as directed in the IFU.
Clinical Indications for Use
and Power Settings
Low power is used when debriding a dental implant.
The Cavitron Softip Implant 30K Ultrasonic Insert
can be safely used to debride implant structures (see
Figure 13-31a to c). The insert provides the benefit of
delivering acoustic cavitation, acoustic microstream-
around peri-implant tissues.
Diamond-Coated Insert
The Cavitron Diamondcoat 30K Ultrasonic I­nsert
is an orange color with an impregnated diamond
256 Chapter 13 Dentsply Sirona

B
Figure 13-30 Detaching Softip from the Cavitron Softip
Implant 30K Ultrasonic Insert: A. Softip placed into slot
opening of the Cavitron Softip Disposable Prophy Tip
Removal Wrench, B. Thumb and index finger over the C
Softip
Reproduced with permission from Dentsply Sirona.
Figure 13-31 Dental implants: A. Dental implants
mandibular right molars, B. Dental implant-supported
crowns mandibular right molars, C. Dental implant
retention for an overdenture
coating of the active area antinode of the shank (see
Figure 13-32). The Cavitron Diamondcoat 30K Ultra-
sonic Insert is used for:
• Removal of restoration overhangs and recontour-
ing of dental restorations (amalgam, gold, com-
• Removal of extremely tenacious deposits of calcu- posite, acrylic, and porcelain) in both nonsurgical
lus in both nonsurgical and surgical procedures. and surgical procedures (see Figure 13-33).

Figure 13-32 Dentsply Sirona Cavitron Diamondcoat
Ultrasonic Insert
Figure 13-33 Distal amalgam overhang on the
mandibular right first molar
The Cavitron DiamondCoat Ultrasonic Insert is
not intended for:
• Use by a dental hygienist during nonsurgical pro-
cedures because the insert is very abrasive.
• General ultrasonic prophylaxis procedures be-
cause damage to soft and hard tissues may result.
• The recontouring of metallic dental crowns be-
cause premature wear of the diamond coating will
occur.
Reprocessing 257
Reprocessing
Always use aseptic techniques during reprocessing that
include full Personal Protective Equipment (PPE) and
utility gloves when handling contaminated equipment
to avoid cross-­contamination and operator injury.
Cavitron Ultrasonic Scaler
The power cord, air and water lines, handpiece cable,
foot pedal and cord, and the device itself is not ster-
ilizable but should be disinfected with an approved
solution per the manufacturer, which you can find in
the product IFU. Do not spray disinfectant solutions
directly on the Ultrasonic Scaling System surfaces. Use
a manufacturer approved chemical wipe with correct
contact time. Keep analog models away from direct
sunlight to prevent discoloration.
Insert
Carefully remove the insert from the handpiece, being
sure not to strip the O-ring or damage the ferromagnetic
laminate nickel plates. Clean any soil on the insert with
a disposable cloth under running water and place in an
ultrasonic bath for 15 minutes with an approved solu-
tion by the manufacturer. It is always best practice to
use the manufacturer’s cleaner to ­ensure compatibility.
The insert may be placed in an automated in-
strument washer with an approved solution per the
­manufacturer. Prior to bagging for sterilization, ensure
the insert is completely dry. Do not use a chemical
disinfectant on inserts. Steam under pressure steril-
ization is recommended because cold liquid disinfec-
tion, chemical vapor, and dry heat sterilization have
not been tested or validated for efficacy.
Handpiece
Detach the handpiece from the unit with a gentle
straight pull motion. Do not twist or turn the hand-
piece upon removal to avoid damage to the con-
nectors. Automatic and manual cleaning directions
are provided in the product’s IFU. Do not place the
handpiece in an ultrasonic bath. Prior to bagging for
sterilization, ensure the handpiece is completely dry.
Sterilize with a steam under pressure sterilizer.
258 Chapter 13 Dentsply Sirona

CASE STUDY
A 24-year-old Hispanic male presents to the hygienist for a new patient appointment. He has not seen a dentist since he was
15 years old. He smokes eight cigarettes a day and has daily moderate alcohol intake. He has a metal tongue ring. He does not
take any prescription or over-the-counter medications, he has no known drug allergies, and his vitals are within normal limits.
His chief complaint is “something feels weird on my lower front teeth, but nothing hurts” (see Figure 13-34).
Periodontal findings: Generalized heavy biofilm and light to moderate dental calculus throughout. Probe depths are
3–4 mm generally with 85% bleeding upon probing. Gingival tissues are generally erythematous with localized edema
mandibular anterior central and lateral incisors. No attachment loss is present except the mandibular central and lat-
eral incisors, which also have heavy lingual, interproximal, and facial dental calculus. The patient has severe recession
mandibular central incisors only on the lingual.
Treatment plan: A periodontist performs the examination and recommends a nonsurgical periodontal debridement
procedure followed by bone and gingival grafting for the mandibular anterior central incisors. The dental hygienist car-
ries out phase one of the treatment and performs a nonsurgical periodontal debridement. Even with local anesthesia,
the patient experienced pain upon instrumentation of the mandibular anterior central incisors, and the dental hygienist
debrided to the best of their ability (see Figure 13-35).

Figure 13-34 Periapical radiograph and intraoral photograph of the mandibular anterior teeth

Figure 13-35 Immediate post-operative intraoral

photograph of the mandibular anterior teeth
 Reprocessing 259

Figure 13-36 Four Week Postoperative Intraoral Photographs of the Mandibular Anterior Teeth

The patient was seen four-weeks post-nonsurgical periodontal debridement (see Figure 13-36). He reports severe
pain for the first week after the procedure. The severe pain has subsided, but he still has occasional sensitivity to hot and
cold on the mandibular anterior teeth.

Questions for Initial Nonsurgical Periodontal Debridement

1. Which of the following is not a likely cause of the localized severe attachment loss seen in Figure 13-34 and
Figure 13-35?
a. Attachment loss caused by natural aging processes
b. Presence of a metal tongue ring
c. Malocclusion with a traumatic bite
d. The patient’s brushing habits
2. Which of the following inserts should be used to begin debridement of the mandibular anterior lingual central
incisors pictured in Figure 13-34?
a. Cavitron Powerline Ultrasonic Insert
b. Cavitron Slimline Ultrasonic Insert
c. Cavitron Thinsert 30K Ultrasonic Insert
d. Both B and C
3. What power setting should be used to begin debridement of the mandibular anterior lingual central incisors with
the insert selected in question 2?
a. High
b. Medium
c. Low
4. True or False: A tap stroke followed by an ultrasonic activation stroke should be initially used to debride the
mandibular anterior lingual central incisors with the insert selected in question 2.
a. True
b. False
5. The Cavitron Powerline Ultrasonic Insert reduces the size of the dental calculus from heavy to light. Which insert
should the dental hygienist use next to remove the light deposits?
a. Continue using the Cavitron Powerline Ultrasonic Insert
b. Change from a Cavitron Powerline Ultrasonic Insert to the Cavitron Slimline1000 30K Ultrasonic Insert
c. Change from a Cavitron Powerline Ultrasonic Insert to the Slimline10S 30K Ultrasonic Insert
d. Change from a Cavitron Powerline Ultrasonic Insert to the Slimline10R 30K Ultrasonic Insert
260 Chapter 13 Dentsply Sirona

6. What power setting should be used with the insert selected in question 5?
a. High
b. Medium
c. Low
d. Both B and C
7. After the dental hygienist used the Cavitron Powerline Ultrasonic Insert and Cavitron Slimline 10S Ultrasonic
Insert, there was still residual light dental calculus on the distal-facial line angle of the mandibular left central
incisor. What insert would be the best selection to remove this deposit?
a. Cavitron Slimline 1000 30K Ultrasonic Insert
b. Cavitron Thinsert 30K Ultrasonic Insert
c. Cavitron Powerline 100 30K Ultrasonic Insert
d. Cavitron Powerline 1000 30K Ultrasonic Insert
8. What power level can be used for the insert selected in question 7?
a. Low
b. Medium
c. High
d. All of the above

Questions for Four-Week Follow-Up Appointment

1. Ultrasonic technology is contraindicated for the debridement of the mandibular right central incisor dental
calculus as seen in Figure 13-36.
a. True
b. False
2. Which of the following inserts should be used to begin debridement of the mandibular anterior lingual central
incisors pictured in Figure 13-36?
a. Cavitron Powerline Ultrasonic Insert
b. Cavitron Slimline Ultrasonic Insert
c. Cavitron Thinsert 30K Ultrasonic Insert
d. Both B and C

Summary
Dentsply Sirona offers a variety of magnetostrictive
technologies that allows for a contemporary approach
to ultrasonic instrumentation. Always read your prod-
uct’s direction for use/instruction for use (DFU/IFU)
prior to using it for the first time. There is pertinent
information for the safe handling and delivery of care
that must be followed to avoid equipment damage
and to keep your patient safe.

Questions
1. In which of the following scenarios would an d. Both A and B
oral health-care provider choose to use low e. All of the above
power? 3. Which of the following cross-sections of an
a. Heavy dental calculus mandibular anterior insert allows for better adaptation to line angles
lingual. and interproximal surfaces?
b. Light biofilm generally throughout the a. Round
mouth. b. Diamond
c. Heavy stain maxillary anterior lingual. c. Broad, flat, blunt
d. Low power is never indicated for use.
4. True or False. Dentsply Sirona manufactures a
2. On which power setting is the water flow rate curved magnetostrictive insert with a thick and
set to a rapid drip with fine mist halo? thin diameter?
a. Low a. True
b. Medium b. False
c. High
 Questions 261

5. Which of the following is TRUE of the grip? 11. True or False. The Cavitron Steri-Mate 360
a. A thinner grip will reduce pinch force. Handpiece can be used on any Cavitron
b. Texturing improves the grasp. Ultrasonic Scaling System.
c. No texturing will reduce the chance of a. True
slipping. b. False
d. None of the above. Match the following terms with their correct de-
6. True or False. A digital ultrasonic scaling scription. There is only one correct answer for each
system will produce more heat than an analog question.
ultrasonic scaling.
a. True 12. Cavitron Powerline A. Grip is a purple color
b. False Ultrasonic Insert and can be used at all
power settings.
7. When using a Cavitron Ultrasonic Scaling
Analog System that has a dial to control the 13. Cavitron Slimline B. Grip is a blue color
power, what clock position range is medium Ultrasonic Insert and used for the
power? removal of heavy
a. Approximately 6–10 o’clock dental calculus.
b. Approximately 10–12 o’clock 14. Cavitron Thinsert C. Grip is a yellow color
c. Approximately 12–2 o’clock 30K Ultrasonic and used to debride
8. When using a Cavitron Ultrasonic Scaling Digital Insert dental implants.
System that has a touch screen to control the 15. Cavitron Softip D. Grip is a green color
power, what number range is medium power? Implant 30K and used for the
a. Approximately 0–30 Ultrasonic Insert removal of light
b. Approximately 30–60 to moderate oral
c. Approximately 60+ deposits.
9. Which of the following is TRUE of the Boost
16. Which of the following inserts is only used
mode in a Cavitron Ultrasonic Scaling System?
for large, heavy supragingival dental calculus
a. The Cavitron 300 Series will display the word
deposits and cannot be used subgingivally?
Boost in orange when activated on the screen.
a. Cavitron Powerline 10 30K Ultrasonic Insert
b. Increases the power output by
b. Cavitron Powerline 100 30K Ultrasonic Insert
approximately 25%.
c. Cavitron Powerline 1000 30K Ultrasonic
c. Activated by depressing the foot pedal to
Insert
its second position
d. Cavitron Powerline 3 30K Ultrasonic Insert
d. Allows for uninterrupted ultrasonic
instrumentation when a larger oral deposit 17. Which of the following Cavitron Slimline
is encountered. Ultrasonic Inserts is allowed to be used on high
e. All of the above are true. power?
a. Cavitron Slimline 10 30K Ultrasonic Insert
10. How often should a Dentsply Sirona water
b. Cavitron Slimline 1000 30K Ultrasonic Insert
filter be replaced if the office is using a bottle
c. Cavitron Slimline 10R 30K Ultrasonic Insert
water system with a Cavitron Ultrasonic
d. Cavitron Slimline 10L 30K Ultrasonic Insert
Scaling System whose water supply is from the
dental unit? 18. Which of the following inserts has a comparable
a. Annually thickness and tactile sensitivity as the hand-
b. One time per month activated ODU 11/12 explorer?
c. Two times per month a. Cavitron Powerline Ultrasonic Insert
d. The water filter never needs to be replaced b. Cavitron Slimline Ultrasonic Insert
c. Cavitron Thinsert 30K Ultrasonic Insert
262 Chapter 13 Dentsply Sirona

19. Which of the following is TRUE of the Cavitron 20. True or False. The disposable Softip is placed
Softip Implant 30K Ultrasonic Insert? on the Cavitron Softip Implant 30K Ultrasonic
a. The shank is made of carbon. Insert with your fingers.
b. The shank is made of Teflon. a. True
c. The active area is covered with a detachable b. False
Softip made of Polysulfone Amoco P-1700.
d. The shank is impregnated with Polyether
ether ketone (PEEK).

References
1. Partido, B. B., Webb, C., & Carr, M. P. (2018). Comparison of
the efficiency of calculus detection between ultrasonic inserts
and an explorer. Journal of Dental Hygiene, 92(6), 33–39.
 CHAPTER 14

HuFriedyGroup
LEARNING OBJECTIVES • SWERV 3
™ Series: the name of HuFriedyGroup’s
magnetostrictive ultrasonic device.
After studying this chapter, you will be able to: • Swivel: category of HuFriedyGroup inserts with
base flow that swivel, have an 18% wider grip, and
1. Distinguish HuFriedyGroup magnetostrictive a black nose cone.
ultrasonic products, parts, and accessories.
2. Recognize the design differences of inserts and
• SWIVEL ™
DIRECT FLOW : category of
HuFriedyGroup inserts with direct flow that swivel,
select the best insert for the patient presentation. have an 18% wider grip, and a gray nose cone.
3. Perform proper water-line maintenance.
4. Select the correct water flow and power setting
for each insert.
5. Reprocess handpieces and inserts according to
the manufacturer’s recommendations.
Introduction
KEY TERMS This chapter will explore magnetostrictive ultra-
sonic technology manufactured by HuFriedyGroup.
• Base flow: internal water port that is positioned
closer to the grip of an insert shank.
Their company’s research and development teams

• Blue
have continued to evolve the field of magnetostric-
operation mode: high power mode that tive technology, releasing new and innovative devices
allows the user to select a power output of
and insert designs. Although there are other manu-
2.5–10.0 on the SWERV ™3 .
• Direct flow: internal water port that is positioned
closer to the terminal 4 mm of an insert shank.
facturers of magnetostrictive ultrasonic technology, it
would be too lengthy for this book to cover every
• ENZYMAX™: HuFriedyGroup enzymatic cleaner
that is safe for use on HuFriedyGroup inserts.
single one. For this reason, the author has chosen to
focus on two of the largest global magnetostrictive
• Green operation mode: low power mode that
allows the user to select a lower power output of
manufacturers.
This chapter will present the HuFriedyGroup’s
1–5 on the SWERV ™3 .
• STREAMLINE™: category of HuFriedyGroup
inserts with base flow that do not have a nose
ultrasonic devices, handpieces, and insert portfolio.
Detailed information for each insert with its clin-
cone and do not swivel. ical use, power settings, diameter, shape, length,
• STREAMLINE™ Direct Flow: category of the
HuFriedyGroup’s inserts with direct flow that do
and cross-section will be discussed. This knowl-
edge will assist the oral health-care provider in im-
not have a nose cone and do not swivel.
•
plementing a contemporary approach to ultrasonic
STREAMLINE™ PLUS: category of HuFriedyGroup instrumentation.
inserts with direct flow, have an 18% wider grip, a
beige nose cone, and do not swivel.

263
264 Chapter 14 HuFriedyGroup

This book will not discuss 25 kHz ultrasonic

technology because this technology has been replaced
by the 30 kHz market. As discussed in Chapter 3, to
change the frequency of a magnetostrictive ultrasonic
from 25 kHz to 30 kHz, the ferromagnetic laminate
nickel plates are shortened, so a 25 kHz insert cannot
be used in a 30 kHz device. HuFriedyGroup offers
a single 25 kHz ultrasonic device with a limited se-
lection of inserts. Newer inserts are now specifically
designed for 30 kHz devices and not available in the
older 25 kHz models.

HuFriedyGroup
Magnetostrictive
Ultrasonic Device
Figure 14-1 HuFriedyGroup SWERV ™3 30K
The trade name for the HuFriedyGroup magnetostric- Courtesy of HuFriedyGroup Mfg. Co., LLC.
tive ultrasonic device is SWERV ™3 . There are two an-
alog models:
• SWERV ™3 Series, 25K
• SWERV ™3 Series, 30K
By the time of this book’s publication, the SWERV ™3
Series has been discontinued, but its presence in the
industry still exists. The SWERV ™3 Series models are
single mode without air polishing dual capability.
They do not have an independent self-contained wa-
ter reservoir—they use the dental unit’s water supply
source.

Figure 14-2 HuFriedyGroup SWERV ™3 Series 30K Power

Frequency Control
Courtesy of HuFriedyGroup Mfg. Co., LLC.
HuFriedyGroup offers a 25 kHz and 30 kHz model.
Varying inserts are offered for both frequency models,
with more options for the 30 kHz. A 25 kHz insert
Power
cannot be used in the 30 kHz model, and vice versa,
due to the difference in the plate length. HuFriedyGroup’s magnetostrictive ultrasonic devices
have a two-part system that controls the power out-
put. There is no Boost mode option. The foot pedal
SWERV™
3
30K activates and deactivates the device and delivers the
power output selected by the provider.
The SWERV ™3 30K is shown in Figure 14-1 and has
many user-friendly features such as:
Power Control
• Two color-coded power settings. One is blue and
The two-part system for power control consists of two
the other is green. Blue is for higher power output
and green is for lower power output. color-coded operation modes as shown in Figure 14-2
that will illuminate when selected and 10 individual
• Automatic purge: When activated, automatic
power levels controlled by the up and down arrows.
purge provides a constant water flow for 45
seconds. • Blue operation mode: high power mode that al-
• Digital display. lows the user to select a power output of 2.5–10.0.
 HuFriedyGroup Magnetostrictive Ultrasonic Device 265

Table 14-1 HuFriedyGroup SWERV™3 Series 30K Power Settings

Biofilm, Bacterial
SWERV™3 Series 30K Illumination Color By-Products Stain Dental Calculus
Low 1–3 Blue Light Light Light
Medium 4–7 Blue Moderate, heavy Moderate, heavy Light, moderate
High 8–10 Red X Moderate, heavy Moderate, heavy

• Green operation mode: low power mode that

allows the user to select a lower power output
of 1–5.
When blue operation mode is selected and the power
output is at maximum 10, an automatic safety feature
will engage after 10 minutes of use where the device
automatically reduces the power output. Each insert is
designed for specific power output levels and should
never be used at a power output not approved by the
manufacturer. This information can be found in the
direction for use/instruction for use (DFU/IFU).
Table 14-1 provides a summary of power settings.

• Low power: Used for the removal of light bio-

film, bacterial by-products, stain, and dental
calculus. Figure 14-3 HuFriedyGroup SWERV ™3 Series 30K Water
• Medium power: Used for the removal of moderate Control
to heavy biofilm, bacterial by-products, stain, and Courtesy of HuFriedyGroup Mfg. Co., LLC.

light to moderate dental calculus.

• High power: Used for the removal of heavy stain
and dental calculus.
Foot Pedal
The foot pedal is round and tethered to the device
by a cord. There is no Bluetooth technology available.
Boost mode is not available. The pedal is depressed
all the way to the floor to activate the device. If the
foot pedal is continuously depressed for more than
20 minutes, the device will power down and make an
audible beep sound. If this safety feature activates, the
user must turn the unit off and then back on with the
power on/off switch.
Water
There is one water control on a HuFriedyGroup mag-
netostrictive ultrasonic device. The water flow rate is
selected based on the power output setting. If pres-
ent, the water filter must be periodically checked and
replaced at a specified interval by the manufacturer,
which can be found in the DFU/IFU.
Water Control
The water control is on the side of the machine
(see Figure 14-3). Turn clockwise to turn the water
down and counterclockwise to turn it up.
Water Flow Rate
The water flow rate is chosen based on the power out-
put setting.
• Low to medium power: Water flow rate is set for a
rapid drip with a fine mist halo. See Figure 14-4a.
• High power: Water flow rate is turned up so the
rapid drip disappears and a strong mist is ex-
pelled. See Figure 14-4b.
Water Filter
The water filter should be inspected regularly to en-
sure it is not in need of replacement prior to its rec-
ommended replacement interval of 240 liters or one
year. The filter should be replaced more frequently
if the:
266 Chapter 14 HuFriedyGroup

A B
Figure 14-4 Water Settings: A. Low to medium power (Cavitron Slimline 10S 30K Ultrasonic Insert), B. High power
(Cavitorn Powerline 1000 30K Ultrasonic Insert)
Reproduced with permission from Dentsply Sirona.

• Filter has particulate matter buildup.

• Filter discolors from the original color.
• Water flow in the line is reduced or inconsistent.

Insert Water Port

Inserts have an external or internal water port
(see Figure 14-5a and b). Internal water ports are
equipped with a small cannula tube embedded in-
side the shank that emerges from a small opening.
The exact port position on the shank varies by insert
and is presented later in the chapter. External water
ports have a thin cannula tube attached above and
parallel to the shank of the insert where the water
expels from the canula and branches out in multiple
directions.

Handpiece
The SWERV ™3 30K handpiece is not autoclavable. The
manufacturer recommends a disposable, single patient
use barrier sleeve for the handpiece (see Figure 14-6).
The handpiece does not rotate. The handpiece
should be filled with water prior to seating an insert
and the O-ring lubricated as described in Chapter 5
(see Figure 5-7).
• Hold the handpiece upright over a sink, then step
on the pedal to fill with water until a dome of wa-
ter appears on the brim.
• Allow any trapped air to exit the handpiece prior
to seating an insert.
A B
Figure 14-5 HuFriedyGroup Insert Water Port:
A. Internal Water Port (Swivel XT and After Five
Straight), B. External Water Port (After Five)
A: Reproduced with permission from HuFriedyGroup Mfg. Co., LLC. B: Courtesy of HuFriedyGroup Mfg. Co., LLC
• Lubricate the O-ring on the insert by rotating the
O-ring 360 degrees over the water dome.
• Place the insert into the handpiece in an upright
position. Apply gentle pressure and use a push-
twist motion to fully seat the O-ring of the insert
into the handpiece.

Figure 14-6 HuFriedyGroup SWERV ™3 30K Handpiece
Disposable Barrier
Courtesy of HuFriedyGroup Mfg. Co., LLC.
Insert Portfolio
HuFriedyGroup manufactures a variety of shank shapes,
diameters, cross-sections, and water ports for their
SWERV ™3 30 kHz ultrasonic device, which supports a
contemporary approach to ultrasonic instrumentation.
All inserts have a color grip covering the connect-
ing body, two green O-rings, and 15–16 ferromagnetic
laminate nickel plates that vary by insert. The stacks
are imprinted with the company name, lot num-
ber, and date of insert creation. O-rings are a wear-
and-tear items and should be replaced when worn.
The color of the grip is a patented color specific for
HuFriedyGroup inserts. All grips are textured to im-
prove the provider’s grasp and decrease slipping.
There are five categories of inserts, each with their
own portfolio of choices.
1. SWIVEL DIRECT FLOW™
2. Swivel
3. STREAMLINE™ Direct Flow
4. STREAMLINE™
5. STREAMLINE™ PLUS
The five categories are distinguished from one an-
other in four ways:
1. Ability to rotate (Swivel) in the handpiece: Some
inserts rotate in the handpiece and others do not.
• The rotating inserts are termed Swivel and
move 360 degrees. The rotating insert
Insert Portfolio 267
Figure 14-7 Swivel (Power PLUS Standard Bevel 30K
Insert)
Courtesy of HuFriedyGroup Mfg. Co., LLC.
Figure 14-8 STREAMLINE™ (Beavertail 30K Insert)
Courtesy of HuFriedyGroup Mfg. Co., LLC.
categories are SWIVEL DIRECT FLOW™ and
Swivel (see Figure 14-7).
• The nonrotating insert categories are
STREAMLINE™ Direct Flow, STREAMLINE™,
and STREAMLINE™ PLUS (see Figure 14-8).
When an insert rotates, the magnetostrictive
grasp may need modification to control the in-
sert adaptation, angulation, and orientation on
the tooth surface. The index finger or thumb may
need to be advanced closer to or on the insert grip
(see Figure 14-9a and b). If the finger position is
modified, the oral health-care provider will need
to ensure that the handpiece stays positioned in
the webbing between the thumb and index finger
and that excessive lateral pressure is not applied
as the fingers have advanced forward on the grip.
2. Position of the water port: HuFriedyGroup offers
inserts with internal and external water ports. The
selection of inserts with an external water port
is smaller than that for internal. Internal water
ports are positioned in one of two places on the
shank and termed direct flow and base flow (see
Figure 14-10).
• Direct flow: internal water port positioned
closer to the terminal 4 mm of the shank.
The insert categories that use direct flow are
SWIVEL DIRECT FLOW™, STREAMLINE™
Direct Flow, and STREAMLINE™ PLUS. See
Figure 14-10a.
268 Chapter 14 HuFriedyGroup
A STREAMLINE™ PLUS have a colored nose cone. The
B 3.
Figure 14-9 Magnetostrictive Grasp (HuFriedyGroup
Swivel XT 30K and Dentsply Sirona Cavitron Steri-Mate
Sterilizable, Detachable Handpiece): A. Correct Grasp,
B. Modified Grasp for Rotating Insert
Courtesy of HuFriedyGroup Mfg. Co., LLC.
A B
Figure 14-10 HuFriedyGroup Internal Water Port
Position: A. Direct Flow, B. Base Flow
Courtesy of HuFriedyGroup Mfg. Co., LLC.
• Base flow: internal water port positioned
close to the grip. The insert categories that
use base flow are Swivel and STREAMLINE™.
See Figure 14-10b.
3. Grip width: Grips come in a standard width size or
an 18% wider grip width. The wider grip size de-
creases muscle strain and pinch force. The SWIVEL
DIRECT FLOW™, Swivel, and STREAMLINE™
PLUS have an 18% greater width (see Figure 14-11).
4. Nose cone: SWIVEL DIRECT FLOW™, Swivel, and
SWIVEL DIRECT FLOW™ and STREAMLINE™ do
not have a colored nose cone (see Figure 14-12).
Table 14-2
summarizes the five categories of in-
serts and their differences. HuFriedyGroup offers
thick and thin diameter inserts in their five categories.
Thick Diameter Inserts
Thick diameter inserts have the largest surface area
of the shank. There are five thick diameter inserts
that all have a straight shank and are pictured in
Figure 14-13a to d.
1. #10 Universal
2. #1000 Triple Bend
Power PLUS Standard Conical
4. Power PLUS Standard Bevel
5. Beavertail
Figure 14-11 HuFriedyGroup Insert Grip Width. Thinner
grip STREAMLINE™ Beavertail on left (yellow) and
thicker grip STREAMLINE™ PLUS #10 on right (lavender
with beige nose cone)
Courtesy of HuFriedyGroup Mfg. Co., LLC.
 Insert Portfolio 269

There are no curved shank shapes in the thick

Figure 14-12 HuFriedyGroup Insert Colored Nose Cones.
SWIVEL DIRECT FLOW™ After Five on left (gray nose cone with
dark blue grip), STREAMLINE™ PLUS #1000 Triple Bend in
middle (beige nose cone and orange grip), and Swivel Power
PLUS Standard Conical (black nose cone and ocean blue grip)
Courtesy of HuFriedyGroup Mfg. Co., LLC.
diameter insert portfolio because their surface area is
too large to access subgingivally in tightly adherent
tissues to reach complex root anatomy.
The thick diameter inserts have two options in the
bend of the terminal 4 mm of the shank. All inserts
are still considered a straight shape because the over-
all shank is still bent in one plane with small bends
in the terminal 4 mm. The small bends change the
cross-section and length of the shank.
• Cross-section: One-bended shanks have a rounded
or circular cross-section, and three-bended shanks
have a diamond cross-section. The Power PLUS
inserts have either have a conical or beveled ac-
tive area antinode. A bevel shank has a diamond
cross-section, and a conical shank has a round or
circular cross-section (see Figure 14-14a and b).
• Adaptation: The diamond cross-sections al-
low for easier adaption of the active area an-
tinode to interproximal areas and line angles
(see Figure 14-15a and b).

Table 14-2 HuFriedyGroup Insert Categories

Name Nose Cone Nose Cone Color Ability to Rotate Grip Water Port
™
SWIVEL DIRECT FLOW  Gray  18% wider grip Direct flow
Textured
Swivel  Black  18% wider grip Base flow
Textured
STREAMLINE™ Direct Flow    Textured Direct flow
STREAMLINE™    Textured Base flow
™
STREAMLINE PLUS  Beige  18% wider grip Direct flow
Textured

A B C D
Figure 14-13 HuFriedyGroup Thick Diameter Inserts: A. #10 Universal (STREAMLINE™ PLUS, lavender grip),
B. #1000 Triple Bend (STREAMLINE™ PLUS, orange grip), C. Power PLUS Standard Conical and Bevel
(Swivel, ocean blue grip), D. Beavertail (STREAMLINE™, yellow grip)
Courtesy of HuFriedyGroup Mfg. Co., LLC.
270 Chapter 14 HuFriedyGroup

A B
Figure 14-14 HuFriedyGroup Power PLUS Standard
Inserts: A. Conical (Swivel Power PLUS Standard
Conical), B. Bevel (Swivel Power PLUS Standard Bevel)
Courtesy of HuFriedyGroup Mfg. Co., LLC.

• Length: Shank lengths vary by insert. Shank

lengths are short, standard, and extended
(see Figure 14-16). The Power PLUS line has a 25%
longer shank than the #10 Universal, which adds
2 mm in length. This allows access into deeper
periodontal pockets.
Table 14-3 provides a summary of the insert name,
color of the grip, number of bends in the terminal
4 mm of the shank, cross-section, and whether the
active area antinode has a special conical or beveled
shape for the thick diameter inserts.
Clinical Indications for Use. Thick diameter
inserts other than the Beavertail:
• Used for the removal of moderate to heavy dental
calculus deposits and supragingival staining.
• If tissues are soft, spongy, and movable, they may
be able to access subgingivally.
• When tissues are firm, hard, or tightly adherent,
access may be restricted.
The Beavertail insert:
• Used for the removal of large, heavy supragingival
dental calculus deposits. The provider will adapt
the point directly onto the deposits for removal.
• Never use subgingivally due to its broad, flat, and
blunt shank shape (see Figure 14-13d).
B
Figure 14-15 Diamond Cross-Section Inserts Active
Area Antinode Adapted to the Curved Line Angle
Anatomy of the Mandibular First Molar Buccal Surface:
A. HuFriedyGroup Swivel Power PLUS Standard Bevel,
B. HuFriedyGroup #1000 Triple Bend STREAMLINE™
PLUS
Power Settings. All thick diameter inserts can be
used at all power settings without injury to the shank.
Clinically, since they are used for the removal of mod-
erate to heavy dental calculus and stain, a high power
is typically used.
Insert Category. #10 Universal and #1000 Triple
Bend are offered in all five categories.
• The Power PLUS is offered only in the Swivel
Category.
• The Beavertail is only offered in the STREAMLINE™
category.
 Insert Portfolio 271

Thin Diameter Inserts Thin diameter insert features:

Thin diameter inserts have a smaller surface area of • The #100 Thin, After Five Straight, After Five
the shank than thick diameter inserts and come in Right, and After Five Left are 40% thinner than
varying shank lengths. There are eight thin diameter the #10 Universal.
inserts. • The XT and XT Triple Bend are 24% thinner than
1. #100 Thin ⎫ the #1000 Triple Bend.
⎪ • Power PLUS Thin Conical and Bevel have a 25%
2. After Five Straight ⎬ 40% thinner than #10 Univer-
3. After Five Right ⎪ sal (see Figure 14-17a to c) longer shank than the #10 Universal, which adds
⎭ 2 mm in length.
4. After Five Left
5. XT ⎫ 24% thinner than #1000 Triple
⎬ Bend (see Figure 14-18a and b) Thin diameter shank shapes:
6. XT Triple Bend ⎭
7. Power PLUS Thin Conical (see Figure 14-19) • Straight shank: #100 Thin, After Five Straight,
8. Power PLUS Thin Bevel XT, XT Triple Bend, Power PLUS Thin Conical,
and Power PLUS Thin Bevel.
• Curved shank: After Five Right and After Five
Left.
Table 14-4 provides a summary of the insert name,
color of the grip, number of bends in the terminal
4 mm of the shank, cross-section, whether the active
area antinode has a special conical or beveled shape,
and the overall shank shape for the thin diameter
inserts.

Clinical Indications for Use. All thin diame-

Figure 14-16 HuFriedyGroup Swivel Power PLUS
Standard Bevel (black nose cone and ocean blue grip)
and SWIVEL DIRECT FLOW™ After Five Straight (beige
nose cone and dark blue grip). Note the longer shank of
the Swivel Power PLUS Standard Bevel
ter inserts are used for the removal of light to moder-
ate dental calculus, biofilm, bacterial by-­ products,
and stain. The thinner shank diameter allows for
subgingival access with little to no tissue distension.
The After Five Inserts and Power PLUS have an ex-
tended shank to access deep periodontal pockets.
The After Five Right and Left have a long and curved
shank shape, which allows access and adaptation to
complex root anatomy (concavity, convexity, furca-
tion) and deep periodontal pockets.
Power Settings. All thin inserts can be used on
low and medium power because the connecting body
does not support high power. When incorrect power

Table 14-3 HuFriedyGroup Thick Diameter Shank Inserts

Number of Bends in Terminal
Name Grip Color 4 mm of Shank Cross-Section
#10 Universal Lavender 1 Round
Power PLUS Standard Conical Ocean blue 1 Round
Power PLUS Standard Bevel Ocean blue 1 Diamond
#1000 Triple Bend Orange 3 Diamond
Beavertail Yellow 1 Broad, flat, blunt
272 Chapter 14 HuFriedyGroup

A B C
Figure 14-17 HuFriedyGroup Thin Diameter Inserts (40% Thinner Than Universal #10):
A. #100 Thin (STREAMLINE™ PLUS, black grip), B. After Five Straight (Swivel, dark blue grip),
C. After Five Left (Swivel, teal grip) and Right (Swivel, red grip)
Courtesy of HuFriedyGroup Mfg. Co., LLC.

A B
Figure 14-18 HuFriedyGroup Thin Diameter Inserts (24%
Thinner Than #1000 Triple Bend): A. XT (Swivel, purple grip), Figure 14-19 HuFriedyGroup Swivel Power PLUS Thin
B. XT Triple Bend (STREAMLINE™ Direct Flow, purple grip) Conical
Courtesy of HuFriedyGroup Mfg. Co., LLC. Courtesy of HuFriedyGroup Mfg. Co., LLC.
 Reprocessing 273

Table 14-4 HuFriedyGroup Thin Diameter Shank Inserts

Number of Bends in Terminal
Name Grip Color Shape 4 mm of Shank Cross-Section
#100 Thin Black Straight 1 Round
After Five Straight Dark blue Straight 1 Round
After Five Right Red Curved 1 Round
After Five Left Teal Curved 1 Round
XT Purple Straight 1 Round
XT Thin Purple Straight 3 Diamond
Power PLUS Thin Conical Ocean blue Straight 1 Round
Power PLUS Thin Bevel Ocean blue Straight 1 Diamond

settings are used, the risk for insert damage or shank

breakage increases. Patient safety is at risk if the shank
were to break in the mouth while in use. The patient
could aspirate the broken shank. If it breaks subgingi-
vally, a retrieval procedure may be required.
Insert Category
• #100 Thin is offered in all five categories.
• After Five Straight, Right, and Left are offered in
the SWIVEL DIRECT FLOW™, STREAMLINE™
Direct Flow, and STREAMLINE™ PLUS.
• XT is offered in the Swivel and STREAMLINE™
Direct Flow.
• XT Triple Bend is offered in the SWIVEL DIRECT
FLOW™, STREAMLINE™ PLUS, and STREAM-
LINE™ Direct Flow.
• Power PLUS is only offered in the Swivel.
Reprocessing
Always use aseptic techniques during reprocessing that
includes full personal protective equipment (PPE) and
utility gloves when handling contaminated equipment
to avoid cross-­contamination and operator injury.
Insert
Carefully remove the insert from the handpiece being
sure not to strip the two O-rings or damage the ferromag-
netic laminate nickle plates. Clean the insert with a man-
ufacturer-approved enzymatic cleaner. HuFriedyGroup
manufactures its own enzymatic cleaner (­ENZYMAX™)
that is safe for use on its inserts. It is always best practice
to use the manufacturer’s cleaner. The manufacturer will
test its equipment with its own cleaner but will not nec-
essarily test all other manufacturers’ products. Leave the
enzyme cleaner in place on the insert for 3–5 minutes.
Never use a metal brush or steel wool if manually clean-
ing the insert. Rinse all lumens of the insert five times
with a single-use syringe (minimum 50 mL).
The insert may be placed in an ultrasonic bath for
16 minutes with an approved solution per the man-
ufacturer. Rinse the insert with low-­contaminated or
deionized water. The insert may be placed in an auto-
mated instrument washer with an approved solution
per the manufacturer. Prior to bagging for steriliza-
tion, ensure the insert is completely dry. Steam un-
der pressure is recommended because cold liquid
disinfection, chemical vapor, and dry heat steriliza-
tion have not been tested or validated for efficacy.

SWERV™
3
Device
The power cord, waterline, handpiece cable, foot pedal
and cord, and the device itself is not sterilizable but
should be disinfected with an approved solution per
the manufacturer, which you can find in the product
directions for use/instructions for use (DFU/IFU).
Handpiece
Once the procedure is complete, remove the dispos-
able barrier and throw it away in accordance with reg-
ulations. The handpiece should be disinfected with a
manufacturer-approved solution found in the DFU/
IFU. The handpiece is not sterilizable.
274 Chapter 14 HuFriedyGroup

CASE STUDY
A 24-year-old Hispanic male presents to the hygienist for a new patient appointment. He has not seen a dentist since he was
15 years old. He smokes eight cigarettes a day and has daily moderate alcohol intake. He has a metal tongue ring. He does not
take any prescription or over-the-counter medications, has no known drug allergies, and his vitals are within normal limits.
His chief complaint is “something feels weird on my lower front teeth, but nothing hurts” (see Figure 14-20).
Periodontal findings: Generalized heavy biofilm and light to moderate dental calculus throughout. Probe depths are
3–4 mm generally with 85% bleeding upon probing. Gingival tissues are generally erythematous with localized edema
mandibular anterior central and lateral incisors. No attachment loss is present except the mandibular central and lat-
eral incisors, which also have heavy lingual, interproximal, and facial dental calculus. The patient has severe recession
mandibular central incisors only on the lingual.
Treatment plan: A periodontist performs the examination and recommends a nonsurgical periodontal debridement
procedure followed by bone and gingival grafting for the mandibular anterior central incisors. The dental hygienist car-
ries out phase one of the treatment and performs a nonsurgical periodontal debridement. Even with local anesthesia,
the patient experienced pain upon instrumentation of the mandibular anterior central incisors, and the dental hygienist
debrided to the best of their ability (see Figure 14-21).

Figure 14-20 Periapical radiograph and intraoral photograph of the mandibular

anterior teeth

Figure 14-21 Immediate post-operative intraoral

photograph of the mandibular anterior teeth
 Reprocessing 275

Figure 14-22 Four Week Postoperative Intraoral Photographs of the Mandibular Anterior Teeth

The patient was seen four weeks post-nonsurgical periodontal debridement (see Figure 14-22). He reports severe
pain for the first week after the procedure. The severe pain has subsided, but he still has occasional sensitivity to hot and
cold on the mandibular anterior teeth.

Questions for Initial Nonsurgical Periodontal Debridement

1. Which of the following is not a likely cause of the localized severe attachment loss seen in Figure 14-20
and Figure 14-21?
a. Attachment loss caused by natural aging processes
b. Presence of a metal tongue ring
c. Malocclusion with a traumatic bite
d. The patient’s brushing habits
2. Which of the following inserts should be used to begin debridement of the mandibular anterior lingual central
incisors pictured in Figure 14-20?
a. #10 Universal
b. #100 Thin
c. XT
d. Both B and C
3. What power setting should be used to begin debridement of the mandibular anterior lingual central incisors with
the insert selected in question 2?
a. High
b. Medium
c. Low
4. True or False: A tap stroke followed by an ultrasonic activation stroke should be initially used to debride the
mandibular anterior lingual central incisors with the insert selected in question 2.
a. True
b. False
5. The #10 Universal insert reduces the size of the dental calculus from heavy to light. Which insert should the dental
hygienist use next to remove the light deposits?
a. Continue using the #10 Universal
b. Change from a #10 Universal to a Power PLUS Thin Conical
c. Change from a #10 Universal to a #100 Thin
d. Change from a #10 Universal to an After Five Right
6. What power setting should be used with the insert selected in question 5?
a. High
b. Medium
c. Low
d. Both B and C
276 Chapter 14 HuFriedyGroup

7. After the dental hygienist used the Power PLUS Thin Conical, there was still residual light dental calculus on the
mesial-lingual line angle of the mandibular right central incisor. What insert would be the best selection to remove
this deposit?
a. XT Triple Bend
b. Power PLUS Thin Bevel
c. Universal #10
d. #1000 Triple Bend

Questions for Four-Week Follow-Up Appointment

1. Ultrasonic technology is contraindicated for the debridement of the mandibular right central incisor dental
calculus as seen in Figure 4-22.
a. True
b. False
2. Which of the following inserts should be used to begin debridement of the mandibular anterior lingual central
incisors pictured in Figure 14-22?
a. Power PLUS Standard Conical
b. Beavertail
c. XT
d. #1000 Triple Bend

Summary
HuFriedyGroup offers a variety of magnetostrictive
technology that allow for a contemporary approach
to ultrasonic instrumentation. Always read your prod-
uct’s DFU/IFU prior to using it for the first time. There
is pertinent information for the safe handling and de-
livery of care that must be followed to avoid equip-
ment damage and to keep your patients safe.

Questions
1. In which of the following scenarios would an oral 4. When should the water filter be replaced?
health-care provider choose to use low power? a. Filter has particulate matter buildup or
a. Heavy dental calculus mandibular anterior discolors.
lingual. b. Water flow in the line is reduced or
b. Light biofilm generally throughout the mouth. inconsistent.
c. Heavy stain maxillary anterior lingual. c. Annually or every 240 liters.
d. Low power is never indicated for use. d. All of the above.
2. On which power setting is the water flow rate 5. True or False. The handpiece for the SWERV ™3
set to a rapid drip with fine mist halo? 30K is not autoclavable.
a. Low a. True
b. Medium b. False
c. High 6. Which of the following insert categories will
d. Both A and B rotate in the handpiece?
e. All of the above a. Swivel
3. Which of the following cross-sections of an b. STREAMLINE™ Direct Flow
insert allows for better adaptation to line angles c. STREAMLINE™ PLUS
and interproximal surfaces? d. STREAMLINE™
a. Round
b. Diamond
c. Broad, flat, blunt
 Questions 277

7. Which of the following insert categories has a 15. Which of the following inserts is only used
water port with base flow? for large, heavy supragingival dental calculus
a. Swivel deposits and cannot be used subgingivally?
b. STREAMLINE™ Direct Flow a. #10 Universal
c. STREAMLINE™ b. #1000 Triple Bend
d. Both A and C c. Power PLUS Standard Bevel
e. All of the above d. Beavertail
8. Which of the following insert categories has an Match the following terms with their correct descrip-
18% wider grip width to decrease pinch force tion for questions 16–19. There is only one correct
strain? answer for each question.
a. Swivel
b. SWIVEL DIRECT FLOW™ 16. #100 Thin A. Grip is a teal color
c. STREAMLINE™ PLUS with a curved shank
d. All of the above shape.
9. Which of the following insert categories has a 17. XT B. Grip is a black color
beige nose cone? with one bend in the
a. SWIVEL DIRECT FLOW™ shank.
b. STREAMLINE™ Direct Flow 18. After Five Left C. Grip is an ocean blue
c. STREAMLINE™ color with a 25%
d. STREAMLINE™ PLUS longer shank.
10. Which of the following is a thick diameter 19. Power PLUS D. Grip is a purple color
insert? Thin Conical that is 24% thinner
a. Power PLUS Standard Conical than the #1000 triple
b. Power PLUS Thin Conical bend
c. XT
d. After Five Right 20. True or False. All After Five and Power PLUS
inserts have an extended shank.
11. True or False. HuFriedyGroup manufactures a
a. True
curved magnetostrictive insert with a thick and
b. False
thin diameter.
a. True 21. What power setting can the thin diameter inserts
b. False be used on?
a. Low
12. What is the cross-section of a bevel and triple-
b. Medium
bended shank?
c. High
a. Circular
d. Both A and B
b. Round
c. Diamond 22. True or False. All insert designs are offered in
d. Trianglular each of the five categories of HuFriedyGroup
inserts.
13. How much longer is the shank of a Power PLUS
a. True
Standard Conical or Bevel insert compared to
b. False
the Universal #10?
a. 10% 23. Which of the following inserts is offered in all
b. 20% five insert categories?
c. 25% a. #10 Universal
d. 35% b. #1000 Triple Bend
c. #100 Thin
14. What power setting can the thick diameter
d. All of the above
inserts be used on?
a. Low
b. Medium
c. High
d. All of the above
 CHAPTER 15
Curved Inserts
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Identify a magnetostrictive insert as a right or
left.
2. Recognize the indications for use and design
variations for curved inserts.
3. Identify the correct adaptation and angulation of
a curved right insert in vertical and transverse
orientation.
4. Identify the correct adaptation and angulation
of a curved left insert in vertical and transverse
orientation.
5. Perform an ultrasonic activation stroke with
right- and left-curved inserts.
Introduction
Magnetostrictive curved shank inserts are multifunc-
tional as they can debride subgingival deep periodon-
tal pockets and complex root anatomy, as well as
supragingival interproximal areas. The curved inserts
function as a pair, with one debriding lingual surfaces
and the other debriding facial/buccal surfaces.
These inserts were developed in the 1990s, and
by 2000, the American Academy of Periodontology
(AAP) released a position paper supporting the use
of thin diameter curved shanks over hand-­activated
instruments for the debridement of Class II, Class III,
and Class IV furcation defects (Drisko et al., 2000).
There is a large body of literature supporting the use
of curved shanks in furcation areas; however, curved
inserts also assist the provider in safely debriding root
concavities, convexities, and interproximal surfaces
both supragingivally and subgingivally. Their mul-
tifunctional capabilities make them a useful tool in
many periodontal applications, from a general pro-
phylaxis to surgical procedures.
Magnetostrictive Curved
Insert Introduction
Magnetostrictive curved inserts are used in both verti-
cal and transverse orientations:
• Vertical orientation: Used to debride deep peri-
odontal pockets and complex root anatomy. The
active area antinode is contacting cementum in
this orientation (see Figure 15-1a and b).
• Transverse Orientation: Used to debride su-
pragingival interproximal areas. The active area
antinode is contacting enamel in this orientation
unless recession is present, in which case, the
shank may also contact dentin or cementum (see
Figure 15-1).
When a vertical orientation is used to debride
root anatomy, follow these rules for ultrasonic instru-
mentation to protect the less mineralized hard tissue
cementum:
• Power: Low to medium power is used. High
power increases the risk for cemental injury.
• Adaptation: Adapt back and lateral surfaces. The
point and face have a higher displacement ampli-
tude and should either be used with caution or
avoided on cementum. See Chapter 9 for details
on shank surface displacement amplitude.
279
280 Chapter 15 Curved Inserts

A B

Figure 15-1 Curved insert orientation: A. Vertical orientation on the lingual of the mandibular right first molar,
B. Transverse orientation on the mesial-lingual of the mandibular right first molar.

A B
Figure 15-2 Curved insert angulation: A. 0- to 15-degree angulation with back surface on the buccal of the mandibular
right first molar, B. 90-degree angulation with the point on the buccal of the mandibular right first molar.

• Angulation: Use a 0- to 15-degree angulation.
A 90-degree angulation is contraindicated be-
cause the point would be in contact with the ce-
mentum (see Figure 15-2a and b).
• Activation: Use an ultrasonic activation stroke.
A tap stroke should be used with caution as the
point is adapted.
Magnetostrictive curved inserts are used as a
pair. The provider needs two inserts to debride a
single tooth. These inserts are nicknamed right-
curved insert and left-curved insert. The left and right
distinction refers to the direction of the shank bend
and has nothing to do with how or where they are
used in the mouth. The provider’s dominant hand
has no influence on which insert is used on the
facial/buccal or lingual surfaces. The correct insert
will be the same for dominant right- or left-handed
providers.
As presented in Chapter 11, to correctly identify
each insert as right or left:
• Hold one insert in your dominant hand and the
other in your nondominnant in front of your face
hand so that the color grips are parallel to you.
• Turn the point surface away from you.
• Look at the curve of the shank coming out of the
grip. If the shank curves to the right, it is the right
curved insert and if it curves to the left, it is the
left curved insert (see Figure 15-3).
 Magnetostrictive Curved Insert Adaptation 281

Left Curved
Shank

Right Curved
Shank

Figure 15-4 Magnetostrictive curved insert adaptation

vertical inserts (Dentsply Sirona Cavitron Slimline 10L
Figure 15-3 Magnetostrictive curved inserts (Dentsply and 10R 30K Ultrasonic Inserts).
Sirona Cavitron Slimline 10L and 10R Fitgrip 30K Reproduced with permission from Dentsply Sirona

Ultrasonic Inserts).
Reproduced with permission from Dentsply Sirona

Magnetostrictive Curved
Insert Adaptation
Correct adaptation of curved magnetostrictive inserts
is dependent on the shank orientation. For both ver-
tical and transverse orientation, one curved insert is
adapted to the facial/buccal surfaces of teeth in one
quadrant and the other curved insert is adapted to
the lingual (see Figure 15-4).
Curved inert adaption is similar to the adap- D M
tion of posterior area-specific hand-activated curettes.
­Area-specific curettes have one lower cutting edge on
each side that adapts to either the mesial or distal of a A
posterior tooth. The provider must use two area-specific
curettes to instrument all surfaces of one posterior tooth.
• One posterior area-specific curette adapts to the
buccal/­lingual and mesial surfaces of posterior
teeth (see Figure 15-5a).
• The other posterior area-specific curette adapts
to the distal surfaces of posterior teeth (see
Figure 15-5b).

The provider will use two magnetostrictive curved

inserts to instrument one tooth, just as they do with
posterior area-specific curettes. Instead of a mesial D M
or distal adaptation, magnetostrictive curved inserts
have a facial/buccal or lingual adaptation.

Vertical Orientation B

Vertical orientation is used to debride root surfaces. Figure 15-5 Posterior area-specific Gracey curette:
A curved insert will access a deep periodontal pocket A. Gracey 11/12 B. Gracey 13/14.
282 Chapter 15 Curved Inserts
B
Figure 15-6 Vertical orientation curved insert (Dentsply
Sirona Cavitron Slimline 10R 30K Ultrasonic Insert):
A. Back surface of the shank adapted to the mesial-buccal
root of the mandibular first molar, B. Lateral surface of the
shank adapted to the distal of the mandibular first molar.
with its long shank and conform to complex root
anatomy such as concavities, convexities, and furca-
tions (see Figure 15-6a and b). Due to the curvature of
the shank, the back and lateral surfaces of the active
area antinode will be adapted when in vertical orien-
tation. A 0- to 15-degree angulation is used with an
ultrasonic activation stroke on low to medium power.
Adaptation and Shank Position
Vertical Orientation
The provider cannot use the shank position in rela-
tionship to the long axis of the tooth as a visual cue
to the correct adaptation in vertical orientation as is
Figure 15-7 Curved shank adaptation in vertical
orientation (HuFriedyGroup after Five Right): A. Active
area antinode adapted at the Cementoenamel junction
(CEJ), B. Active area antinode adapted subgingivally.
used with straight shank inserts or hand-activated
instruments.
• Right- and left-curved inserts have a shank that is
curved to a specific degree, which allows the back
and lateral surfaces of the active area antinode to
correctly adapt to complex root anatomy.
• The shank will never be parallel to the long axis of
the tooth when the active area antinode is adapted
correctly in vertical orientation.
• Figure 15-7a and b shows the correct adaptation
of a curved insert on the mandibular right first
molar distal periodontal pocket. Notice the visible
shank is not parallel to the long axis of the tooth.
It is curved across the buccal molar tooth surface.
Identifying Correct Adaptation
for Vertical Orientation
During active patient care, the provider can determine
which curved insert is used on the facial/buccal and
 Magnetostrictive Curved Insert Adaptation 283

lingual tooth surfaces without referencing a book. The Right-Curved Insert Adaptation
steps for selecting the correct curved insert by area of
Vertical Orientation
the mouth are shown in Table 15-1.
Maxillary arch: Maxillary right lingual and maxillary
left facial/ buccal (see Figure 15-8).
Table 15-1 Magnetostrictive Curved Insert Mandibular arch: Mandibular right facial/buccal
Selection Steps (Dentsply Sirona Cavitron Slimline and mandibular left lingual (see Figure 15-9).
10S Fitgrip 30K Ultrasonic Insert) There is a pattern for correct adaptation of a
1. With the insert not Correct curved insert. Look at the maxillary arch adaptation
activated, place the of the right curved insert. The right curved insert is
point on the occlusal of adapted to the maxillary left facial/buccal and maxil-
any posterior tooth in lary right lingual. If the insert is adapted on the facial/
the quadrant to receive buccal surface of one quadrant, it is also adapted to
ultrasonic instrumentation.
the lingual surface of the adjacent quadrant. The same
Ensure that the colored grip
is parallel to the occlusal Incorrect holds true for the mandibular arch. The right insert is
plane of the teeth. If the adapted to the mandibular right facial/buccal, so it is
grip is not parallel, this also adapted to the mandibular left lingual.
technique will not work.
Left-Curved Insert Adaptation
Vertical Orientation
Maxillary arch: Maxillary right facial/buccal and max-
illary left lingual (see Figure 15-10).

2. Move the point across the

occlusal toward the buccal
surface of the tooth.
l
ingua
UR L

3. Drop the shank off onto the Correct

buccal surface.
If the back surface is in contact
with the buccal of the tooth, A
this is the correct insert for the
surface.
If the face is in contact with the UL Buccal
buccal of the tooth, this is the
incorrect insert for the surface. Incorrect

Figure 15-8 Axillary arch right-curved insert vertical

orientation: A. Maxillary right lingual, B. Maxillary left
facial/buccal.
284 Chapter 15 Curved Inserts

UR Buccal

A
LR Buccal

UL
Ling
ual
B
l
ngua

Figure 15-10 Maxillary arch left-curved insert vertical

orientation: A. Maxillary right facial/buccal, B. Maxillary
left lingual.
LL Li

al

B
ingu

Figure 15-9 Mandibular arch right-curved insert vertical

orientation: A. Mandibular right facial/buccal,
LR L

B. Mandibular left lingual.

Mandibular arch: Mandibular right lingual and

mandibular left facial/buccal (see Figure 15-11).
The same pattern exists for the left-curved insert A
as it does for the right. The left insert is adapted to the
maxillary right facial/buccal, so it is also adapted to
the maxillary left lingual. The left insert adapts to the
mandibular left facial/buccal, so it is also adapted on
the mandibular right lingual.
Table 15-2 and Figure 15-12 summarize the correct
adaption for the maxillary arch of curved inserts in LL Buccal
vertical orientation. B
Table 15-3 and Figure 15-13 summarize the correct Figure 15-11 Mandibular arch left-curved insert vertical
adaption for curved inserts on the mandibular arch in orientation: A. Mandibular right lingual, B. Mandibular
vertical orientation. left facial/buccal.
 Magnetostrictive Curved Insert Adaptation 285

Table 15-2 Maxillary Adaptation for Right and Transverse Orientation

Left Curved Inserts in Vertical Orientation Transverse orientation is used to debride supragingi-
Right-Curved Left-Curved Insert val interproximal surfaces. Follow these rules for ul-
Insert (Gold) (Orange) trasonic instrumentation in transverse orientation
Facial/ UL UR • Adaptation: Back and lateral surfaces are adapted
Buccal (see Figure 15-14a). If the point and face are
adapted, the provider has selected the incorrect
Lingual UR UL
insert (see Figure 15-14b). Unlike vertical orienta-
tion where the shank is not parallel to the long
axis of the tooth, in transverse orientation, the
terminal shank is parallel to the long axis of the
tooth in correct adaptation while the active area
UR UL
Facial/Buccal Facial/Buccal antinode is at a right angle to the interproximal
contact. (see Figure 15-14a).

UR UL
Lingual Lingual

Figure 15-12 Vertical orientation right- and left-curved

insert adaptation for the maxillary arch.

Table 15-3 Mandibulr Adaptation for Right and

Left Curved Inserts in Vertical Orientation
Right-Curved Left-Curved
Insert (Gold) Insert (Orange)
Facial/Buccal LR LL
A
Lingual LL LR

LR LL
Lingual Lingual B

Figure 15-14 Transverse orientation curved insert

LR LL
Facial/Buccal Facial/Buccal
Figure 15-13 Vertical orientation right- and left-curved
insert adaptation for the mandibular arch.
(Dentsply Sirona Cavitron Slimline 10L Fitgrip 30K
Ultrasonic Insert): A. Correct adaptation. Lateral surface
is adapted with 0-degree angulation of the active area
antinode to the mandibular right first molar distal-
buccal, B. Incorrect adaptation. Point and face active
area antinode are adapted to the distal-lingual surface
og the mandibular left first molar.
286 Chapter 15 Curved Inserts

UR Buccal

al
ingu
LR L
A

LL Buccal
UL L

B
ingu

Figure 15-16 Mandibular arch right-curved insert

transverse orientation: A. Mandibular right lingual,
al

B. Mandibular left facial/buccal.

Figure 15-15 Maxillary arch right-curved insert

transverse orientation: A. Maxillary right facial/buccal,
B. Maxillary left lingual.
UR Lingual

• Angulation: 0- to 15-degree angulation (see

­Figure 15-14a).
• Activation: An ultrasonic activation stroke or a tap
stroke are used.
When mapping curved insert adaptation for
transverse orientation, you will notice it is the oppo-
site of vertical orientation. A

Right-Curved Insert Adaptation UL Buccal

Maxillary arch: Maxillary right facial/buccal and max-
illary left lingual (see Figure 15-15).
Mandibular arch: Mandibular right lingual and
mandibular left facial/buccal (see Figure 15-16).

Left-Curved Insert Adaptation

Maxillary arch: Maxillary right lingual and maxillary B
left facial/buccal (see Figure 15-17). Figure 15-17 Maxillary arch left-curved insert transverse
Mandibular arch: Mandibular right facial/buccal orientation: A. Maxillary right lingual, B. Maxillary left
and mandibular left lingual (see Figure 15-18). facial/buccal.
 Magnetostrictive Curved Insert Adaptation 287

UR UL
Facial/Buccal Facial/Buccal

UR UL
LR Buccal Lingual Lingual

Figure 15-19 Transverse orientation right- and

left-curved insert adaptation for the maxillary arch.

Table 15-5 Adaptation for Right and Left Curved

Inserts in Transverse Orientation
al

Right-Curved Left-Curved
ingu

Insert (Gold) Insert (Orange)

LL L

Facial/Buccal LL LR
Lingual LR LL

B
Figure 15-18 Mandibular arch left-curved insert
transverse orientation: A. Mandibular right facial/
buccal, B. Mandibular left lingual. LR LL
Lingual Lingual

Table 15-4 Maxillary Adaptation for Right and

Left Curved Inserts in Transverse Orientation
LR LL
Right-Curved Left-Curved Facial/Buccal Facial/Buccal
Insert (Gold) Insert (Orange)
Facial/Buccal UR UL
Figure 15-20 Transverse orientation right- and
Lingual UL UR left-curved insert adaptation for the mandibular arch.

Table 15-4 and Figure 15-19 summarize the correct Table 15-5 and Figure 15-20 summarize the correct
adaption for curved inserts on the maxillary arch in adaption for the mandibular arch of curved inserts in
transverse orientation. transverse orientation.

CASE STUDY
A 52-year-old Caucasian male with a noncontributory medical history presents to your office with a chief complaint of
“My teeth are starting to get loose and something on the lower left hurts. My teeth are sensitive to hot and cold tempera-
tures.” The patient’s last dental visit was at the age of 17. The initial panoramic X-ray, left side bitewing, and periapical
radiographs with intraoral camera photographs are shown on the next page. The mandibular left wisdom tooth was
extracted the same day of the new patient appointment due to a deep periodontal abscess and patient reported pain.
Periodontal assessment: 3- to 14-mm probe depths with 100% BOP, generalized moderate to severe recession,
furcation Class II and III, mobility Class 1 and 2.
288 Chapter 15 Curved Inserts

Mandibular anterior periapical.

Panoramic radiograph.

Left premolar bitewing. Left molar bitewing.

Mandibular right premolar and molar periapical.

A B
Intraoral photographs: A. Anterior facial surfaces, B. Mandibular left canine, lateral incisor, and right central incisor
lingual surfaces.
 Magnetostrictive Curved Insert Adaptation 289

Treatment options included:

1. Full mouth rehabilitation with a prosthodontist.
2. Extractions and removable partial or full denture.
3. Nonsurgical periodontal debridement with informed consent—this procedure may not save the teeth.
The patient is dentally anxious and selects treatment plan option number three. The mandibular left was debrided
first. Postoperative radiographs and intraoral photographs are shown here.

Mandibular left premolar periapical.

Left bitewing.

Mandibular left molar periapical.

Mandibular left canine periapical with technique errors.

Mandibular anterior and premolar lingual surfaces.

290 Chapter 15 Curved Inserts

Mandibular left anterior facial surfaces.

Mandibular left premolar lingual surfaces.

1. Describe the staged instrumentation approach the dental hygienist likely used to debride the mandibular left
lateral incisor to completion. State the insert designs that were used and why. Also state the power level used with
each stage of instrumentation.
2. What curved insert did the dental hygienist use to debride the root concavity on the mesial-lingual of the
mandibular left first premolar? What orientation was used?
3. Describe how the dental hygienist debrided the deep distal root defect of the mandibular left second molar with
staged instrumentation. State the insert designs that were used and why. Also state the power level used with each
stage of instrumentation.
4. Why would the straight thin long shank insert not debride the mandibular left second molar distal area to completion?
5. What curved insert did the dental hygienist use to debride the buccal Class III furcation of the mandibular left first
molar? What orientation was used? What surfaces of the insert were adapted?

Summary
This chapter presented the clinical use of magneto-
strictive curved inserts. The curved inserts are used
as a pair to debride complex root anatomy and in-
terproximal supragingival surfaces in both vertical
and transverse orientations. Low to medium power
with the back and lateral surfaces adapted with 0- to
15-degree angulation is used to protect less mineral-
ized hard tissues such as dentin and cementum.

Questions
1. True or False. Magnetostrictive curved inserts 3. True or False. The same curved insert is used
can be used in both vertical and transverse for a vertical and transverse orientation on the
orientation. facial/buccal surfaces of the maxillary right.
a. True a. True
b. False b. False
2. True or False. The correct adaptation of 4. What power level is appropriate to use when
right- and left-curved inserts is different for debriding complex root anatomy such as a
a dominant right-handed provider than a furcation with ultrasonic instrumentation?
left-handed provider. a. Low
a. True b. Medium
b. False c. High
d. Both A and B
 References 291

5. What surfaces of an insert should be adapted in 9. Which insert would be the best selection to
vertical orientation subgingivally? debride the mandibular left canine distal-facial
a. Back 2–3 mm subgingival when the tooth has no
b. Lateral attachment loss?
c. Face a. Right-curved insert
d. Point b. Left-curved insert
e. Both A and B c. Straight insert
6. Which of the following ultrasonic shank 10. Which insert would be the best selection to
angulations is contraindicated when debriding debride the maxillary left central incisor mesial-
apical of the CEJ? lingual 2–3 mm subgingival when the tooth has
a. 0–5 degrees no attachment loss?
b. 5–10 degrees a. Right-curved insert
c. 10–15 degrees b. Left-curved insert
d. 90 degrees c. Straight insert
7. True or False. When debriding 6 mm under 11. Which insert would be the best selection to
the gums with a curved insert in a vertical debride the maxillary left first and second
orientation, the portion of the shank the molars distal-buccal 2–3 mm subgingival when
provider can see will be parallel to the long axis the tooth has no attachment loss?
of the tooth. a. Right-curved insert
a. True b. Left-curved insert
b. False c. Straight insert
8. Which insert would be the best selection to 12. Which insert would be the best selection to
debride the maxillary right first premolar mesial- debride a Class III furcation defect on the
lingual 3 mm subgingival when the tooth has no mandibular right first molar buccal?
attachment loss? a. Right-curved tip
a. Right-curved insert b. Left-curved tip
b. Left-curved insert c. Straight tip
c. Straight insert

References
1. Drisko, C. L., Cochran, D. L., Blieden, T., Bouwsma, O.
J., Cohen, R. E., Damoulis, P., Fine, J. B., Greenstein, G.,
Hinrichs, J., Somermman, M. J., Iacono, V., & Genco, R.
J. (2000). Position paper: Sonic and ultrasonic scalers in
periodontics. Research, Science and Therapy Committee
of the American Academy of Periodontology. Journal of
Periodontology, 71(11), 1792–1801. https://doi.org/10.1902
/jop.2000.71.11.1792
 CHAPTER 16
Curved Insert Technique
Practice
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Perform an ultrasonic activation stroke with a
curved insert using a correct grasp, finger rest,
operator and patient positioning, instrument
adaptation, angulation, and orientation.
2. Maintain proper ergonomics while performing
ultrasonic instrumentation.
3. Transition from vertical and transverse
orientations during ultrasonic instrumentation
with a curved insert.
Introduction
This chapter will combine all the building blocks of
ultrasonic instrumentation using curved magneto-
strictive inserts. You will combine grasp, finger rest,
operator and patient chair positioning, instrument
adaptation, angulation, orientation, and activation
chairside in a simulated patient care experience.
Ultrasonic instrumentation on complex root anat-
omy is best learned through practice and repetition.
A strong working knowledge of root anatomy is re-
quired to prevent patient injury.
Skill Building: Vertical and
Transverse Orientation
You will need the following supplies: typodont,
typodont pole, dental chair, ultrasonic device,
high-volume evacuation, ultrasonic handpiece, right-
and left-curved ultrasonic inserts.
Rationale: This exercise will incorporate ultra-
sonic instrumentation techniques of adaptation, an-
gulation, orientation, and activation and combine
them with aerosol control and patient and operator
positioning to simulate an active patient treatment
scenario with curved inserts.
The goal of this exercise is to use curved inserts
to correctly debride subgingival root anatomy with
a vertical orientation and debride the interproximal
contact space with a transverse orientation.
Setup
1. Mount the pole onto the dental chair.
2. Mount the typodont onto the pole.
3. Set up the ultrasonic device attaching the power,
water, and/or air connectors. Turn on the device.
4. Attach an High-volume evacuation (HVE) to the
suction system.
5. Flush the waterline for a minimum of 20–30 seconds.
Always follow your clinic’s protocols for water-
line maintenance, which may be different than a
20- to 30-second waterline flush.
6. Attach the sterile ultrasonic handpiece to the
handpiece connector cord.
7. See Box 16-1.
8. Place the insert into the handpiece. Refer to
­Figure 5-7 for proper O-ring(s) lubrication. Fill the
handpiece with water until a dome of water is visi-
ble at its opening. Rotate the O-ring(s) 360 ­degrees
over the water dome until fully lubricated. Place the
insert into the handpiece in the upright position.
293
294 Chapter 16 Curved Insert Technique Practice

Box 16-1
Buccal Furcation Debridement
of the Mandibular First Molar
Dominant right-handed provider: Identify the
mandibular right first molar buccal.
Grasp the ultrasonic handpiece with your dominant hand.
Dominant left-handed provider: Identify the See Chapter 9 for details if needed.
mandibular left first molar buccal.
Dominant right-handed provider: Select the
right-curved insert. The HuFriedyGroup right-curved
Grasp the HVE with your nondominant hand.
insert has a red grip. See Chapter 9 for details if needed.
Dominant left-handed provider: Select the
left-curved insert. The HuFriedyGroup left-curved
insert has a teal grip. Adapt the back or lateral surface of the active area antinode in
a vertical orientation at the cervical third on the crown of the
tooth coronal to the buccal furcation entrance
(see Figure 16-1).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water

port on the insert.

Select the operator positioning for direct vision.

• Dominant right-handed provider: 8–11 o’clock
• Dominant left-handed provider: 1–4 o’clock

Select the patient chair positioning for the mandibular arch.

Patient chair supine, semi-supine, or in between supine and
semi-supine with chin slightly down.
Left curved Right curved
insert insert
Establish a finger rest intraoral or extraoral, ensuring
correct ultrasonic handpiece grasp is maintained.

Ensure the foot pedal is within reach. Turn on the HVE.

Begin instrumentation with the steps below.

9. Set the power control to low. See Dentsply Sirona

Chapter 13 and HuFriedyGroup Chapter 14 for
details if needed.
10. Set the water flow rate to a rapid drip with fine
mist halo. See Dentsply Sirona Chapter 13 and Figure 16-1 Buccal furcation debridement of the
HuFriedyGroup Chapter 14 for details if needed. mandibular first molar. Back surface of the active
11. Confirm the correct insert has been selected for the area antinode adapted coronal to the buccal furcation
buccal surface of the first molar using Table 15-1. entrance.
 Skill Building: Vertical and Transverse Orientation 295

1. Perform an ultrasonic activation stroke. Rotate

the active area antinode as you move apically to
maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 16-2).

Figure 16-4 Buccal furcation debridement of the

mandibular first molar. Lateral surface of the active
area antinode adapted to the distal surface of the
mesial root.

Figure 16-2 Buccal furcation debridement of the

mandibular first molar. Back surface of the active 6. Adapt the back or lateral surface to debride the
area antinode adapted coronal to the buccal furcation mesial surface of the distal root with the active
entrance. area antinode at a 0- to 15-degree angulation (see
Figure 16-5).
2. Continue the ultrasonic activation stroke, moving
toward the buccal furcation.
3. Be sure to maintain adaptation of the active area
antinode with a 0- to 15-degree angulation as you
approach the buccal furcation.
4. Enter the buccal furcation with the back or lat-
eral surface of the active area antinode. Maintain
a 0- to 15-degree angulation. Debride one-half of
the furcation area. The other half will be debrided
from the lingual (see Figure 16-3).

Figure 16-5 Buccal furcation debridement of the

mandibular first molar. Back surface of the active
area antinode adapted to the mesial surface of the
distal root.

7. Debridement of the mandibular first molar buccal

furcation is now complete.

Figure 16-3 Buccal furcation debridement of the

mandibular first molar. Back surface of the active area
antinode adapted in the buccal furcation.
5. Adapt the back or lateral surface to debride the
distal surface of the mesial root with the active
area antinode at a 0- to 15-degree angulation (see
Figure 16-4).
Mesial-Buccal Root
Debridement of the
Mandibular First Molar
1. Adapt the back or lateral surface of the active area
antinode in a vertical orientation at the cervical
third on the crown of the tooth coronal to the
mesial-buccal root distal surface (see Figure 16-6).
296 Chapter 16 Curved Insert Technique Practice

3. Debride the entire mesial root by adapting the

back or lateral surface of the active area antinode
with a 0- to 15-degree angulation and mov-
ing from the distal surface of the mesial-buccal
root toward the mesial surface of the mesial-­
buccal root, conforming to the root anatomy (see
Figure 16-8a and b).

Figure 16-6 Mesial-buccal root debridement of the

mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the mesial-buccal root
distal surface.

2. Perform an ultrasonic activation stroke. Rotate

the active area antinode as you move apically to
maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 16-7a and b).

B
Figure 16-8 Mesial-buccal root debridement of the
mandibular first molar: A. Lateral surface of the active
area antinode adapted to the mesial-buccal root,
B. Lateral surface of the active area antinode adapted to
the mesial-buccal root.

4. Complete the mesial-buccal root debridement

with the back or lateral surface of the active area
B antinode adapted to the direct mesial with a
0- to 15-degree angulation as if you are probing
Figure 16-7 Mesial-buccal root debridement of the
mandibular first molar: A. Lateral surface of the active
the mesial col (see Figure 16-9).
area antinode adapted coronal to the mesial-buccal 5. Debride one-half of the mesial interproximal area.
root distal surface, B. Lateral surface of the active area The other half will be debrided from the lingual
antinode adapted on the mesial-buccal root distal surface. (see Figure 16-10a and b).
 Skill Building: Vertical and Transverse Orientation 297

Interproximal Adaptation Tips

and Tricks
• Curved insert adaptation to the interproximal
area should resemble the orientation used with a
periodontal probe (see Figure 16-11).

Figure 16-9 Mesial-buccal root debridement of the

mandibular first molar. Back surface of the active area
antinode adapted to the mesial.

Figure 16-11 Probing of the mesial col.

• Remember the ultrasonic shank will not be paral-

lel to the long axis of the tooth as it is for straight
shank inserts and hand-activated instruments
(see Figure 16-12).

Figure 16-12 Mesial-buccal root debridement of the

mandibular first molar. Back surface of the active area
antinode adapted to the mesial subgingivally. Notice
the shank visible to the provider is across the premolar
buccal surface and not parallel to the long axis of
the tooth.

• If you find interproximal insert adaptation chal-

B
Figure 16-10 Mesial-buccal root debridement of the
mandibular first molar: A. Back surface of the active
area antinode adapted to the mesial, B. Lateral surface
of the active area antinode adapted to the mesial
debriding one-half the mesial interproximal area.
lenging, just image the insert as a probe and pre-
tend you are probing the col with the active area
antinode to obtain correct adaptation, angulation,
and orientation.
6. Debridement of the mandibular first molar
mesial-buccal root is now complete.
298 Chapter 16 Curved Insert Technique Practice

Distal-Buccal Root Debridement mesial surface of the distal-buccal root toward the
distal surface of the distal-buccal root, conform-
of the Mandibular First Molar ing to the root anatomy (see Figure 16-15a and b).
1. Adapt the back or lateral surface of the active
area antinode in a vertical orientation with a 0- to
15-degree angulation at the cervical third on the
crown of the tooth coronal to the distal-buccal
root mesial surface (see Figure 16-13).

Figure 16-13 Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the distal-buccal root
mesial surface.

2. Perform an ultrasonic activation stroke. Rotate

the active area antinode as you move apically to
maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 16-14a and b).
3. Debride the entire distal root by adapting the back
or lateral surface of the active area antinode with a
0- to 15-degree angulation and moving from the
B
Figure 16-15 Distal-buccal root debridement of the
mandibular first molar: A. Back surface of the active
area antinode adapted on the distal-buccal root,
B. Lateral surface of the active area antinode adapted on
the distal-buccal root.

A B
Figure 16-14 Distal-buccal root debridement of the mandibular first molar: A. Back surface of the active area antinode
adapted coronal to the distal-buccal root mesial surface just coronal to the furcation entrance, B. Back surface of the
active area antinode adapted on the distal-buccal root mesial surface.
 Skill Building: Vertical and Transverse Orientation
4. Complete the distal-buccal root debridement
with the back or lateral surface of the active area
antinode adapted to the direct distal with a 0- to
15-degree angulation as if you are probing the
distal col (see Figure 16-16).
Figure 16-16 Distal-buccal root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted to the distal.
5. Debride one-half of the distal interproximal area
(see Figure 16-17). The other half will be debrided
from the lingual. Use the same adaptation tips
and tricks from the mesial-buccal interproximal
debridement.
Figure 16-17 Distal-buccal root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted to the distal to debride one-half
the interproximal area.
6. Debridement of the mandibular first molar distal-
buccal root is now complete.
299
Lingual Debridement
of the Mandibular First
Molar Supragingival
Interproximal Area
Dominant right- and left-handed providers: Continue
debriding the same tooth with the same insert. Trans-
verse orientation will be used for this exercise.
Confirm the correct insert has been selected for
transverse orientation (see Box 16-2). If a curved insert
is adapted in a vertical orientation on the buccal sur-
face of a tooth, it is adapted on the lingual surface in
transverse orientation.
Box 16-2 Transverse Orientation
Adaptation
1. Adapt the active area antinode to the distal-
lingual interproximal contact of the mandibular
first molar. In correct adaptation, the shank is
parallel to the long axis of the tooth and is not
wrapped around the tooth.
2. Adapt the active area antinode to the distal-
buccal interproximal contact. This is incorrect
adaptation as the shank is wrapping across
the tooth and the point is in contact with the
interproximal contact.
300 Chapter 16 Curved Insert Technique Practice
Grasp the ultrasonic handpiece with your dominant hand.
See Chapter 9 for details if needed.
Grasp the HVE with your nondominant hand.
See Chapter 9 for details if needed.
Adapt the lateral surface of the active area antinode in a
transverse orientation at the distal-lingual interproximal
contact supragingivally
(see Figure 16-18).
Establish a 0- to 15-degree angulation.
Position the HVE 0.5–6.0 inches from the water
port on the insert.
Select the operator positioning for direct vision.
• Dominant right-handed provider: 1–4 o’clock
• Dominant left-handed provider: 8–11 o’clock
Select the patient chair positioning for the mandibular arch.
Patient chair supine, semi-supine, or in between supine and
semi-supine with chin slightly down.
Establish a finger rest intraoral or extraoral, ensuring
correct ultrasonic handpiece grasp is maintained.
Ensure the foot pedal is within reach. Turn on the HVE.
Begin instrumentation with the steps listed next.
Figure 16-18 Lingual interproximal mandibular first
molar debridement. Lateral surface of the active area
antinode adapted to the distal-lingual interproximal
contact supragingivally.
1. Perform an ultrasonic activation stroke to debride
one-half of the distal interproximal area. The
other half will be debrided from the buccal.
2. Reposition the lateral surface of the active area
antinode with a 0- to 15-degree angulation in
a transverse orientation to the mesial-lingual
interproximal contact supragingivally (see
Figure 16-19).
Figure 16-19 Lingual interproximal mandibular first
molar debridement. Lateral surface of the active area
antinode adapted to the mesial-lingual interproximal
contact supragingivally.
3. Perform an ultrasonic activation stroke to debride
one-half of the mesial interproximal area. The
other half will be debrided from the buccal.
4. Lingual debridement of the mandibular first
molar supragingival interproximal area is
­
complete.
Lingual Furcation
Debridement of the
Mandibular First Molar
Dominant right-handed provider: Remove the
right-curved insert and replace with the left-curved
insert. HuFriedyGroup left-curved insert has a teal
red grip. Continue debridement of the mandibular
right first molar.
Dominant left-handed provider: Remove the
left-curved insert and replace with the right-curved
insert. HuFriedyGroup right-curved insert has a red
grip. Continue debridement of the mandibular left
first molar.
Confirm the correct insert has been selected
for the lingual surface of the first molar using
Table 15-1­.
 Skill Building: Vertical and Transverse Orientation 301

Grasp the ultrasonic handpiece with your dominant hand.

2. Continue the ultrasonic activation stroke, moving
See Chapter 9 for details if needed. toward the lingual furcation (see Figure 16-21).

Grasp the HVE with your nondominant hand.

See Chapter 9 for details if needed.

Adapt the back or lateral surface of the active area antinode in

a vertical orientation at the cervical third on the crown of the
tooth coronal to the lingual furcation entrance
(see Figure 16-20).

Figure 16-21 Lingual furcation debridement of the

Establish a 0- to 15-degree angulation. mandibular first molar. Back surface of the active area
antinode adapted coronal to the lingual furcation entrance.

Position the HVE 0.5–6.0 inches from the water 3. Be sure to maintain adaptation of the active area
port on the insert. antinode with a 0- to 15-degree angulation as you
approach the lingual furcation (see Figure 16-22).
Select the operator positioning for direct vision.
• Dominant right-handed provider: 1–4 o’clock
• Dominant left-handed provider: 8–11 o’clock

Select the patient chair positioning for the mandibular arch.

Patient chair supine, semi-supine, or in between supine and
semi-supine with chin slightly down.

Establish a finger rest intraoral or extraoral, ensuring

correct ultrasonic handpiece grasp is maintained.

Figure 16-22 Lingual furcation debridement of the

mandibular first molar. Back surface of the active area
Ensure the foot pedal is within reach. Turn on the HVE.
Begin instrumentation with the steps listed next. antinode adapted coronal to the lingual furcation entrance.

4. Enter the lingual furcation with the back or lat-

eral surface of the active area antinode. Maintain
a 0- to 15-degree angulation. Debride one-half of
the furcation area. The other half was debrided
from the buccal (see Figure 16-23).

Figure 16-20 Lingual furcation debridement of the

mandibular first molar. Back surface of the active
area antinode adapted coronal to the lingual furcation
entrance.

1. Perform an ultrasonic activation stroke. Rotate

the active area antinode as you move apically to Figure 16-23 Lingual furcation debridement of the
maintain contact with the root surface at a 0- to mandibular first molar. Back surface of the active area
15-degree angulation. antinode adapted in the lingual furcation.
302 Chapter 16 Curved Insert Technique Practice

5. Adapt the back or lateral surface to debride the

distal surface of the mesial root with the active
area antinode at a 0- to 15-degree angulation (see
Figure 16-24).

Figure 16-26 Distal-lingual root debridement of the

mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the distal-lingual root
mesial surface.

2. Perform an ultrasonic activation stroke. Rotate

Figure 16-24 Lingual furcation debridement of the
mandibular first molar. Lateral surface of the active area
antinode adapted to the distal surface of the mesial root.
the active area antinode as you move apically to
maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 16-27a and b).

6. Adapt the back or lateral surface to debride the

mesial surface of the distal root with the active
area antinode at a 0- to 15-degree angulation (see
Figure 16-25).

Figure 16-25 Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active area
antinode adapted to the mesial surface of the distal root.

7. Debridement of the mandibular first molar lin-
gual furcation is now complete.
Distal-Lingual Root
Debridement of the
Mandibular First Molar
1. Adapt the lateral or back surface of the active
area antinode in a vertical orientation at the
cervical third on the crown of the tooth coro-
nal to the distal-lingual root mesial surface (see
Figure 16-26).
B
Figure 16-27 Distal-lingual root debridement of the
mandibular first molar: A. Lateral surface of the active
area antinode adapted coronal to the distal-lingual root
mesial surface, B. Lateral surface of the active area
antinode adapted on the distal-lingual root mesial surface.
3. Debride the entire distal root by adapting the back
or lateral surface of the active area antinode with a
0- to 15-degree angulation and moving from the
mesial surface of the distal-lingual root toward the
distal surface of the distal-lingual root, conform-
ing to the root anatomy (see Figure 16-28a and b).
 Skill Building: Vertical and Transverse Orientation
B
Figure 16-28 Distal-lingual root debridement of the
mandibular first molar: A. Back surface of the active
area antinode adapted to the distal-lingual root,
B. Lateral surface of the active area antinode adapted to
the distal-lingual root.
4. Complete the distal-lingual root debridement
with the back or lateral surface of the active area
antinode adapted to the direct distal with a 0- to
15-degree angulation as if you are probing the
distal col (see Figure 16-29).
Figure 16-29 Distal-lingual root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted to the distal.
303
5. Debride one-half of the distal interproximal area.
The other half was debrided from the buccal.
Use the same adaptation tips and tricks from the
mesial-buccal interproximal debridement (see
Figure 16-30a and b).
B
Figure 16-30 Distal-lingual root debridement of the
mandibular first molar: A. Lateral surface of the active
area antinode adapted to the distal, B. Lateral surface of
the active area antinode adapted to the distal debriding
one-half the distal interproximal area.
6. Debridement of the mandibular first molar
distal-lingual root is now complete.
Mesial-Lingual Root
Debridement of the Mandibular
First Molar
1. Adapt the back or lateral surface of the active
area antinode in a vertical orientation with a 0- to
15-degree angulation at the cervical third on the
crown of the tooth coronal to the mesial-lingual
root distal surface (see Figure 16-31).
304 Chapter 16 Curved Insert Technique Practice

3. Debride the mesial root by adapting the back or

lateral surface of the active area antinode with a
0- to 15-degree angulation and moving from the
distal surface of the mesial-lingual root toward the
mesial surface of the mesial-lingual root, conform-
ing to the root anatomy (see Figure 16-33a and b).

Figure 16-31 Mesial-lingual root debridement of the

mandibular first molar. Back surface of the active area
antinode adapted coronal to the mesial-lingual root
distal surface.

2. Perform an ultrasonic activation stroke. Rotate

the active area antinode as you move apically to
maintain contact with the root surface at a 0- to A
15-degree angulation (see Figure 16-32a and b).

B
Figure 16-33 Mesial-lingual root debridement of the
A mandibular first molar: A. Lateral surface of the active
area antinode adapted to the mesial-lingual root,
B. Lateral surface of the active area antinode adapted to
the mesial-lingual root.

4. Complete the mesial-lingual root debridement

with the back or lateral surface of the active area
antinode adapted to the direct mesial with a 0-
to 15-degree angulation as if you are probing the
mesial col (see Figure 16-34).

B
Figure 16-32 Mesial-lingual root debridement of the
mandibular first molar: A. Back surface of the active
area antinode adapted coronal to the mesial-lingual
root distal surface just coronal to the furcation entrance, Figure 16-34 Mesial-lingual root debridement of the
B. Lateral surface of the active area antinode adapted on mandibular first molar. Lateral surface of the active
the mesial-lingual root distal surface. area antinode adapted to the mesial.
 Skill Building: Vertical and Transverse Orientation
5. Debride one-half of the mesial interproximal area.
The other half was debrided from the buccal (see
Figure 16-35a and b). Use the same adaptation tips
and tricks from the mesial-buccal interproximal
debridement.
A wrapped around the tooth.
B
Figure 16-35 Mesial-lingual root debridement of the
mandibular first molar: A. Back surface of the active
area antinode adapted to the mesial, B. Back surface of
the active area antinode adapted to the mesial debriding
one-half the mesial interproximal area.
305
6. Debridement of the mesial-lingual root is now
complete.
Buccal Debridement
of the Mandibular First
Molar Supragingival
Interproximal Area
Dominant right- and left-handed providers: Continue
debriding the same tooth with the same insert. Trans-
verse orientation will be used for this exercise.
Confirm the correct insert has been selected for
transverse orientation (see Box 16-3). If a curved insert
is adapted in a vertical orientation on the lingual sur-
face of a tooth, it is adapted on the buccal surface in
transverse orientation.
Box 16-3
1. Adapt the active area antinode to the distal-
buccal interproximal contact of the mandibular
first molar. In correct adaptation, the shank is
parallel to the long axis of the tooth and is not
2. Adapt the active area antinode to the distal-
lingual interproximal contact. This is incorrect
adaptation as the shank is wrapping across
the tooth and the point is in contact with the
interproximal contact.
306 Chapter 16 Curved Insert Technique Practice

Grasp the ultrasonic handpiece with your dominant hand.

1. Perform an ultrasonic activation stroke to debride
See Chapter 9 for details if needed. one-half of the distal interproximal area. The
other half was debrided from the lingual.
2. Reposition the lateral surface of the active
Grasp the HVE with your nondominant hand. area antinode with a 0- to 15-degree angulation
See Chapter 9 for details if needed.
in a transverse orientation to the mesial-buccal
interproximal contact supragingivally (see
Figure 16-37).
Adapt the lateral surface of the active area antinode in a
transverse orientation at the distal-buccal interproximal
contact supragingivally (see Figure 16-36).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water

port on the insert.

Select the operator positioning for direct vision.

• Dominant right-handed provider: 8–11 o’clock
• Dominant left-handed provider: 1–4 o’clock

Select the patient chair positioning for the mandibular arch.

Patient chair supine, semi-supine, or in between supine and
semi-supine with chin slightly down.
Figure 16-37 Buccal interproximal mandibular first
molar debridement. Lateral surface of the active area
antinode adapted to the mesial-buccal interproximal
contact supragingivally.
Establish a finger rest intraoral or extraoral, ensuring
correct ultrasonic handpiece grasp is maintained.

3. Perform an ultrasonic activation stroke to debride

one-half of the mesial interproximal area. The
Ensure the foot pedal is within reach. Turn on the HVE.
Begin instrumentation with the steps listed next.
other half was debrided from the lingual.
4. Buccal debridement of the mandibular first
molar supragingival interproximal area is
­
complete.

Figure 16-36 Buccal interproximal mandibular first

molar debridement. Lateral surface of the active area
antinode adapted to the distal-buccal interproximal
contact supragingivally.

Summary
Magnetostrictive curved shank inserts are multifunc-
tional because they can debride subgingival deep peri-
odontal pockets and complex root anatomy, as well as
supragingival interproximal areas. The curved inserts
function as a pair, with one debriding lingual surfaces
Summary 307
and the other debriding facial/buccal surfaces. Con-
tinued repetitive ultrasonic instrumentation practice
with curved inserts will increase your confidence with
their use.
 CHAPTER 17

EMS
this product is not approved for use in the
LEARNING OBJECTIVES United States.
After studying this chapter, you will be able to: • Original Piezon Handpiece: handpiece without
LED lighting manufactured by EMS.
1. Identify EMS piezoelectric ultrasonic products,
parts, and accessories.
• Original Piezon LED Handpiece: handpiece with
LED lighting manufactured by EMS.
2. Recognize the design differences of tips and
select the best tip for the patient presentation.
• Perio Tips: the name of thin (slim) diameter tips
with straight and curved shanks manufactured
3. Understand the operations of the foot pedal. by EMS.
4. Perform proper waterline maintenance.
5. Select the correct water flow and power setting
• Piezon: the name of an EMS piezoelectric
ultrasonic device.
for each tip.
6. Reprocess handpieces and tips according to the
• Scaling tips: the name of thick diameter tips with
a straight shank manufactured by EMS.
manufacturer’s recommendations.

KEY TERMS
• AIRFLOW: the name of a dual mode piezoelectric
ultrasonic and air polishing device manufactured Introduction
by EMS.
• AIRFLOW Prophylaxis Master: the name of the
newest dual mode model that provides both
This chapter will explore piezoelectric ultrasonic
technology manufactured by EMS. The company’s
piezoelectric ultrasonic scaling and air polishing research and development teams have continued to
manufactured by EMS. evolve the field of piezoelectric technology, releas-
• CLIP+CLEAN: tool paced into the device’s water
bottle receptacle for dust protection.
ing new and innovative devices and tip designs. Al-

•
though there are other manufacturers of piezoelectric
CombiTorque: the name of the wrench ultrasonic technology, it would be too lengthy for this
manufactured by EMS.
• E-Series tip threader: tip threader with four flats
manufactured by EMS.
book to cover every single one. For this reason, the
author has chosen to focus on two of the largest global
• Light guide: located inside the Original Piezon
LED handpiee provides Light Emitting Diode (LED)
piezoelectric manufacturers.
This chapter will present EMS’s ultrasonic devices,
illumination during ultrasonic instrumentation handpieces, and tip portfolio. Detailed information
that will need replacement over time.
•
for each tip with its clinical use, power settings, di-
Night Cleaner: a solution manufactured ameter, shape, length, and coatings will be discussed.
by EMS with a combination of chemicals
This knowledge will assist the oral health-care pro-
(ethylenediaminetetraacetate, p-hydroxybenzoic
acid ester, polyhexamethylenebiguanide)
vider in implementing a contemporary approach to
that will prevent lime, algae, and biofilm ultrasonic instrumentation.
formation in a waterline with its bactericidal As discussed in other chapters, it is best prac-
and fungicidal actions. At the time of publication, tice to use the tips from the company that made your

309
310 Chapter 17 EMS

ultrasonic device because there are many differences

in manufacturing designs. Mismatching manufacturer
technology is not recommended and has the poten-
tial to adversely affect efficiency and equipment per-
formance, and possibly void the product’s warranty.
Piezoelectric tips are designed with two different tip
threaders that are specific to each ultrasonic manu-
facturer. Using an incorrect piezoelectric tip for the
handpiece can strip and destroy the threader and pos-
sibly the horn of the handpiece. This causes irrevers-
ible damage, and the equipment must be discarded
and replaced.
EMS has created a unique approach to routine
nonsurgical procedures that incorporates disclosing
dyes, biofilm reduction and management with air pol- A
ishing technology, and piezoelectric ultrasonic instru-
mentation for the removal of hard deposits. EMS has
named this procedure Guided Biofilm Therapy (GBT).
GBT technique will be presented in the air polishing
section of the book.

EMS
The trade name for EMS piezoelectric ultrasonic de-
vices is Piezon. EMS has created many piezoelectric
ultrasonic models over the years that offer a wide
range of functionality and features, for example:
• Single models that provide piezoelectric ultra-
sonic scaling. There are three single mode P­ iezon
models termed Piezon 150, Piezon 250, and
­
Piezon 700. Two of them have an independent
B
water b­ottle delivery system, and one is con-
nected to the water supply on the dental unit (see
Figure 17-1a to c).
• Dual mode models that provide both piezoelectric
ultrasonic scaling and air polishing. These devices
are trade named AIRFLOW.
• Independent self-contained water reservoirs.

Frequency
The frequency used for all piezoelectric models man-
ufactured by EMS is 32 kHz.

Emerging Technology
The newest dual mode model on the market is the
AIRFLOW Prophylaxis Master (see Figure 17-2),
which has many user-friendly features such as: C
• Three handpieces: one for piezoelectric ultrasonic Figure 17-1 EMS Piezon models: A. Piezon 150,
scaling and two for air polishing. B. Piezon 250, C. Piezon 700.
• Touch screen power control. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 17-2 EMS AIRFLOW Prophylaxis Master.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
• Round wireless foot pedal with Bluetooth
technology.
• Boost mode.
• Independent fluid reservoir bottle. Air polishing
technology uses the air from the dental unit and
is discussed later in this book.
Power
EMS piezoelectric ultrasonic devices have three ways
to change the power setting that varies by model.
The foot pedal activates and deactivates the device
and delivers the power level selected by the provider.
Boost mode is an option on select models controlled
through the foot pedal.
Power Control
Power output options are low, medium, and high, con-
trolled with a moveable knob, dial, or touch screen.
Piezon 150 and Piezon 250. Piezon 150 and
Piezon 250 are sold with a movable knob with power
range one through nine. One is on and nine is max.
• Low power: one to three.
• Medium power: four to six. Four is the maximum
power for periodontal procedures.
• High power: seven to nine.
EMS 311
Figure 17-3 EMS Piezon 700 touch screen dial.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
Piezon 700. Piezon 700 is sold with a touch screen
circular dial (see Figure 17-3). There are no number
markings. It is easier to distinguish power settings if
we compare it to a standard clock that tells time with
a first and second hand as seen in Figure 17-4.
• Power off: 6 o’clock.
• Low power: 6-10 o’clock.
• Medium power: 10-2 o’clock.
• High power: 2-5 o-clock.
The Piezon 700 has two modes that assist with
optimizing power settings. The two modes are called
Standard and Endo (see Figure 17-5).
• Standard mode: Mode used for ultrasonic scaling.
• Endo mode: Mode used for deep cavity endodon-
tics because it reduces the power curve to deliver
a more delicate treatment.
After 15 minutes of inactivity, the unit will go into
Standby mode.
AIRFLOW Prophylaxis Master. The power
control for the AIRFLOW Prophylaxis Master is a
touch screen numbering system. The power output
options are 1 through 10 selected by sliding one’s
finger on the groove panel below the number (see
Figure 17-6a and b).
• 0 is water only with no cavitation delivery.
• Low power (1–3).
• Medium power (4–7).
• High power (8–10). Ten is maximum power.
After 60 minutes of inactivity, the unit will go into
Standby mode.
Table 17-1 provides a summary of power settings
for the Piezon 150, Piezon 250, Piezon 700, and the
AIRFLOW Prophylaxis Master.
312 Chapter 17 EMS

12 o-clock

10 o-clock

2 o-clock

6 o-clock: off position

B
Figure 17-5 EMS Piezon 700 Standard and End modes.
A. EMS Piezon 700 touch screen dial, B. Clock.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 17-4 EMS Piezon 700 touch screen dial.

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A B
Figure 17-6 EMS AIRFLO Prophylaxis Master Touchscreen Groove Panel: A. Touchscreen groove panel power
output set to one B. Touchscreen groove panel power output set to five.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
 EMS 313

Table 17-1 EMS Power Settings

AIRFLOW Piezon Biofilm, Bacterial
Prophylaxis Master Piezon 700 150/250 By-Products Stain Dental Calculus
Low 1–3 6-10 o’clock 1–3 Light Light Light
Medium 4–7 10-2 o’clock 4–6 Moderate, heavy Moderate, heavy Light, moderate
High 8–10 2-5 o’clock 7–9 X Moderate, heavy Moderate, heavy

Boost: press in middle and all way to floor

Non-Boost:
press lightly
on side
3 1

Standard Mode Endo Mode

1 Irrigation + light Same as Figure 17-8 EMS AIRFLOW Prophylaxis Master foot
1 2 3
Standard mode pedal.
Ultrasound
2
irrigation + light
4 Inactive

3
Ultrasound + light
*Temporary power increase of 30%
(Dry work mode)
4 (+ 2 ) Boost function*
+ light
Figure 17-7 EMS Piezon 700 foot pedal.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
Foot Pedal
The Piezon 150, Piezon 250, and Piezon 700 have
foot pedals that are tethered to the ultrasonic device
via a cord.
• Round pedal: Piezon 150 and Piezon 250. No
Boost mode option.
• Four-setting pedal: Piezon 700. Boost mode is
available (see Figure 17-7).
The AIRFLOW Prophylaxis Master has a wireless
round foot pedal with Bluetooth technology that is
not tethered to the device via a cord. The foot pedal
is synched to the device by the manufacturer. There is
no need for synchronization upon delivery.
Boost Mode
(up to 100%)
The Piezon 700 and AIRFLOW Prophylaxis Master
have Boost mode. Boost mode is controlled by the
foot pedal. Boost allows for uninterrupted ultrasonic
instrumentation. When boost mode is activated, the
power output will increase. Boost is a useful feature
during debridement when a larger oral deposit is en-
countered. The provider does not need to stop ultra-
sonic instrumentation to increase the power setting.
To activate Boost:
• Piezon Master 700: Depress the pedal control 4
and 2 at the same time. Boost mode will increase
the power output by 30%.
• AIRFLOW Prophylaxis Master: Depress the mid-
dle of the pedal all the way to the floor. To operate
without Boost, press the foot pedal lightly on the
outer rim (see Figure 17-8). Boost mode will in-
crease the power output as shown in Table 17-2.
Water
EMS piezoelectric ultrasonic devices have three differ-
ent ways to change the water flow rate based on the
314 Chapter 17 EMS

Table 17-2 EMS AIRFLOW Prophylaxis Master Boost Mode Power Increase
Power setting 0 1 2 3 4 5 6 7 8 9 10
Boost mode 0 6 7 8 9 10 10 10 10 10 10

Reproduced with permission from EMS Electro Medical Systems

model. The water flow rate selected by the provider

is based on the power output setting. If present, the
water filter must be periodically checked and replaced
at a specified interval by the manufacturer, which can
be found in the direction for use or instruction for use
(DFU/IFU). The water temperature can be changed in
some models. A peristaltic water pump accompanies
a device with an independent water bottle that needs
replacement at a specified interval by the manufac-
turer that can be found in the DFU/IFU.

Water Control
• Piezon 150 and Piezon 250: the water control
is a knob located on the side of the unit (see
Figure 17-9). Turn the knob clockwise to increase
the water flow rate and counterclockwise to Figure 17-9 EMS Piezon 150 and Piezon 250 water
decrease. control grey knob on the left side of the device.
• Piezon 700: the water control is on the handpiece Reproduced with permission from E.M.S. Electro Medical Systems S.A.

connector (see Figure 17-10).

• AIRFLOW Prophylaxis Master: the water control
is a spindle on the handpiece holder with settings
MAX
1 through 10 (see Figure 17-11a and b).

Water Flow Rate

EMS recommends a continuous water flow rate during
active ultrasonic instrumentation because heat is pro-
duced. There are no tips used for oral deposit removal
that have a dry work function. A few tips have this
function and are used for endodontic and restorative
procedures. Be sure to adhere to the instructions in
the DFU/IFU for dry work function use.
The water flow rate is selected based on the tip
being used and listed in the DFU/IFU. The three tips
EMS manufactures for natural teeth are the PS, PSR,
ad PSL, which are all used with 70–100% water flow
rate. The PI tip is used for dental implant debride-
ment, and the water flow rate is medium to high.
Water Filter
The water filter should be inspected monthly and re-
placed at minimum three times a year. If you own a dual
device, replace the air filter annually (see Figure 17-12).
Figure 17-10 EMS Piezon 700 water control.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
Water Temperature
The AIRFLOW Prophylaxis Master allows for a
change in water temperature. This is not a feature in
other Piezon models. Heating the water can increase
patient comfort, especially if the patient has dentinal
hypersensitivity or they are not anesthetized while in-
strumenting less mineralized hard tissues. The device
is set to 40°C/104° by default.
To change the water temperature, follow these
steps:
1. Press and hold 0 and 10 at the same time (see
Figure 17-13a).
 EMS 315

A B
Figure 17-11 EMS AIRFLOW Prophylaxis Master water
control: A. Spindle set to zero, B. Spindle set to ten.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

B
Figure 17-13 EMS AIRFLOW Prophylaxis Master:
A. Pressing 0 and 10 at the same time, B. Number
illumination above the groove panel.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Water Bottles and Line Purging

The Piezon 150 does not have an independent wa-
ter bottle. It derives its water source from the den-
tal unit. The Piezon 250 and AIRFLOW Prophylaxis
Master have one independent water bottle (see
Figure 17-14a), and the Piezon 700 has two indepen-
dent water bottles. Water bottles are equipped with
an O-ring to prevent leakage and provide a tight seal
Figure 17-12 EMS AIRFLOW Prophylaxis Master Water
Filter (blue) and Air Filter (white). (see Figure 17-14b). The O-ring will need to be replaced
Reproduced with permission from E.M.S. Electro Medical Systems S.A. when it is worn. Remove the bottle with a straight pull
motion and replace the same way. Do not twist the
2. The numbers will change color (see Figure 17-13b). bottle when placing and removing. Anytime the water
Numbers 0–4 are used to change the water bottle is removed for long periods of time, place the
temperature. CLIP∙CLEAN tool into the device’s water bottle
• 0: no heat receptacle for dust protection. The CLIP+CLEAN
• 1: 25°C/77°F should be sterilized prior to use as unsterile use may
• 2: 30°C/86°F contaminate the device.
• 3: 35°C/95°F Refer to the DFU/IFU for compatible solutions
• 4: 40°C/104°F (default) that you can use in the independent water bottles.
3. Press the On/Off button to save your setting. The Piezon 250 and Piezon 700 independent water
316 Chapter 17 EMS
A
B fights biofilm accumulation in the lines.
Figure 17-14 EMS AIRFLOW Prophylaxis Master:
A. Independent water bottle B. Red O-ring on the
bottle cap.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
bottles have specific maintenance recommendations
in the DFU/IFU such as:
• Purge the line for 20 seconds at the beginning and
end of the day as well as between patients.
• At the end of the day, run a disinfectant solution
through the line for 20 seconds, leave in place for
5 minutes, and then run distilled water through
the line for 20 seconds.
• The waterline should be cleaned every 13 uses. Re-
fer to DFU/IFU for compatible cleaning ­solutions
and how long to run them through the line.
The AIRFLOW Prophylaxis Master independent
water bottle has specific maintenance recommendations
Figure 17-15 EMS AIRFLOW Prophylaxis Master Night
Cleaner bottle (blue) and product.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
different from the other models. In addition to
daily cleaning, the water lines are to be treated
once a week with a specialized Night Cleaner (see
Figure 17-15). At the time of this book publication,
Night Cleaner is not approved for use in the United
States. EMS recommends other products for water-
line maintenance. Contact EMS for any questions.
The Night Cleaner is a solution with a combi-
nation of chemicals (ethylenediaminetetraacetate,
p-hydroxybenzoic acid ester, polyhexamethylen-
ebiguanide). Night Cleaner is bactericidal and fun-
gicidal and prevents lime and algae formation in the
line. It contains a source of phenylalanine, which
• Night Cleaner is placed in the Nighttime cleaner
bottle, which is a blue color (see Figure 17-16a
and b). Fill the Nighttime bottle with the Night
Cleaner solution to the fill line.
• Set the water control to 10 on the device. Run the
entire solution from the bottle through the line
and leave it in place overnight (12 hours).
• The next morning, remove the Nighttime cleaner
bottle and replace with a fully filled water bottle.
Set the water control to 10 and flush the line to
clear the solution away.
The AIRFLOW Prophylaxis Master has an auto-
matic purge feature. Press the pedal once to activate
the automatic purge. The numbers will illuminate
blue and then change to white over a 1-minute purge
(see Figure 17-17). Purge the waterline for a minimum
of 20 seconds at the start of the day, between patients,
and at the end of the day.

B small cannula tube embedded inside the shank that
Figure 17-16 EMS AIRFLOW Prophylaxis Master:
A. Blue Nighttime cleaner bottle affixed to the device,
B. Nighttime cleaner bottle labeled (“CLEANER”) on
the cap.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
Water Pump
A peristaltic water pump will accompany a piezoelec-
tric ultrasonic device that uses an independent water
bottle (see Figure 17-18). The peristaltic water pump is
a wear and tear item whose frequency of replacement
can be found in the DFU/IFU. For example, the Piezon
700 water pump should be replaced every 18 months.
Tip Water Port
All tips have an internal water port as described in
Chapter 5. Internal water ports are equipped with a
EMS 317
Figure 17-17 EMS AIRFLOW Prophylaxis Master
automatic line purge number illumination.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
Figure 17-18 EMS Piezon Peristaltic Water Pump
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
emerges from a small port opening at a specific posi-
tion on the shank.
Handpiece
EMS manufactures two Piezon handpieces (see
­Figure 17-19).
• Original Piezon Handpiece: Handpiece with-
out LED lighting.
• Original Piezon LED Handpiece: Handpiece
with LED lighting (see Figure 17-19). The LED
lighting initiates when the handpiece is removed
from its holder (see Figure 17-20). The LED light
will automatically turn off after 20 seconds once
the foot pedal is released.
Both handpieces are made of a medical-grade resin
body that is sterilized between patient use. They have a
detachable nose cap and O-ring (see Figure 17-21a and b).
318 Chapter 17 EMS
Figure 17-19 EMS Original Piezon LED Handpiece in
holder with attached tip inside the CombiTorque wrench.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
Figure 17-20 EMS Original Piezon LED Handpiece
illuminated.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
The Original Piezon LED handpiece also has a detach-
able light guide (see Figure 17-21a). These items are
removed prior to reprocessing and placed back into the
handpiece prior to use.
Light Guide
The LED light guide provides illumination during
active ultrasonic instrumentation for improved vis-
ibility. Light guides will need to be replaced over
A
B
Figure 17-21 EMS Detachable parts from handpiece:
A. Nose cap and light guide, B. Red O-ring and light
source.
time. It is recommended to check the transparency
monthly. When the illumination reduces or the light
guide changes color and becomes more opaque, it is
time to replace. The handpiece can always be used
without the light guide; the user will just lose the LED
illumination. The light source inside the handpiece
cannot be replaced (see Figure 17-21b)
O-Ring
A black O-ring is present on the handpiece connec-
tor cord (see Figure 17-22). Periodically inspect the
O-ring and evaluate for damage or wear and replace
as indicated.

Figure 17-22 EMS handpiece connector cord with black
O-ring.
Figure 17-23 EMS handpiece and handpiece connector
cord.
Handpiece Connection
When attaching the handpiece to the handpiece con-
nector cable, ensure that the electrical connections
align (see Figure 17-23). Be gentle when attaching and
removing the handpiece from the connector to avoid
damage to the connections.
EMS Tip Portfolio
EMS manufacturers a variety of shank shapes, diame-
ters, and coatings. The diamond tips are used during
periodontal flap surgery and will not be covered in
this book.
EMS Tip Portfolio 319
Figure 17-24 EMS E-Series tip threader with 4 flats.
2 flats are visible in this image.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
The tip threader is an E-Series, with four flats
(see Figure 17-24). In Figure 17-24 two flats are visi-
ble from one side, and the other two flats are on the
opposite side.
Only use tips manufactured by EMS in their
piezoelectric devices. Do not attach an S-Series tip to
an EMS handpiece because they have two flats instead
of four. This can cause stripping of the handpiece and
tip. Once damaged, the equipment must be discarded
and replaced.
Tips are torqued into the handpiece with the
wrench (see Figure 17-19). Follow these guidelines for
proper torque that produces optimal tip performance:
• Do not force torquing beyond its stop point.
• Tighten moderately with the wrench provided to
ensure optimal torque.
• Do not overtorque a tip because the risk for break-
age or tip threader stripping increases.
• Never remove or place a tip into the handpiece
when the device is activated.
Thick Diameter Tips
EMS used to manufacture three thick diameter tips
with a straight shank. They had the largest surface
area of the shank and were termed Scaling Tips. At
the time of publication of this book, EMS has stopped
manufacturing these tips. The tip name, shank shape,
and cross-section are listed in Table 17-3 for institu-
tions that may still have and use these tips.
320 Chapter 17 EMS

Table 17-3 EMS Thick Diameter Shank Tips Table 17-4 EMS Thin Diameter Shank Tips
(Scaling Tips) (Scaling Tips)
Shank Tip Name Shank Shape Cross Section
Name Shape Cross-section
PS (PerioSlim) Straight Round
A Instrument Straight Round Instrument
B Instrument Straight Broad, flat, blunt design PSR (Perio Slim Curved Round
Right) Instrument
C Instrument Straight Broad, flat, blunt design
PSL (Perio Slim Left) Curved Round
Reproduced with permission from E.M.S. Electro Medical Systems S.A. Instrument

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Clinical Indications for Use

B and C Instruments are used for large, heavy su-
pragingival dental calculus deposits. Table 17-5 EMS Perio Tip Power and Water
Settings
• B Instrument: used on the lingual surfaces of an-
Tip Name Power Setting Water Flow Rate
terior and posterior teeth.
• C Instrument: used on anterior teeth. PS Instrument 30–100% 70–100%
A Instrument is used for the removal of moderate PSR Instrument 10–60% 70–100%
to heavy dental calculus deposits and staining. Due
PSL Instrument 10–60% 70–100%
to its thick shank diameter, A Instrument may not
be able to access subgingivally when tissues are firm, Reproduced with permission from E.M.S. Electro Medical Systems S.A.
hard, and tightly adherent. If tissues are soft, spongy,
and moveable, A Instrument may be able to access
subgingivally. Clinical Indication for Use
Perio Tips are used for the removal of light to moder-
Power and Water Settings ate dental calculus, stain, and all levels of biofilm and
bacterial by-products. Their thin diameter allows for
B and C Instruments can be used at all power levels,
subgingival access with little to no tissue distension
and A Instrument is used on medium or high. Clini-
(see Figure 17-25a and b).
cally, since they are used for the removal of moderate
to heavy dental calculus and stain, a high power is • The curved PSR and PSL Instruments are use-
typically used. The water flow rate is medium to high. ful for interproximal and complex root anatomy
debridement. They can debride down to 8 mm
Thin Diameter Tips subgingivally.

EMS used to manufacture seven thin diameter tips

with a straight shank. At the time of publication of
this book, EMS has stopped manufacturing four
of the seven tips in this category called Perio Tips.
The three tips currently manufactured are the PS In-
strument, PSR Instrument, and the PSL Instrument.
The PS Instrument tip has a straight shank shape, and
the PSR and PSL Instrument tips have a curved shank
shape. All cross sections are round. Table 17-4 pro-
vides a summary of the tip name, shank shape, and
cross-section. The discontinued tips are:
• Straight thin tips: P and PL3 Instruments have a
round cross-section and one bend in the shank.
• Curved thin tips: PL1, PL2, PL4, and PL5 Instru-
ments. PL4 and PL5 are curved with a ball point
and PL1 and PL2 are curved without a ball point.
• The PS Instrument can debride down to 10 mm
subgingivally.
Power and Water Settings
The water flow rate for Perio Tips is 70–100%. The
power settings for the PS Instrument is 30–100%,
and for the PSR and PSL Instruments is 10–60% (see­
Table 17-5). Always use the lowest power output pos-
sible to achieve the clinical goal.
Implant Tip
EMS manufactures a tip for implant debridement called
the PI Instrument. The tip is coated with polyether ether
ketone (PEEK) and is autoclavable (see Figure 17-26).
As a reminder from Chapter 5, PEEK is a semicrystal-
line, high-temperature thermoplastic polymer that is
 Reprocessing 321

coated onto the stainless-steel active area antinode for

the debridement of a dental implant. The tip has a sin-
gle bend and is designed to debride a dental implant,
abutment, and prosthesis. The power setting is low to
medium with a water flow rate that is medium to high.

Reprocessing
Always use aseptic techniques during ­reprocessing that
includes full Personal Protective Equipment (PPE) and
utility gloves when handling contaminated equipment
to avoid cross-contamination and operator injury.

Ultrasonic Device
The power cord, air and water lines, handpiece cable,
foot pedal and cord, and the device itself are not ster-
A ilizable but should be disinfected with an approved
solution per the manufacturer, which you can find in
the product DFU/IFU. Do not spray disinfectant solu-
tions directly on system surfaces. Use a manufacturer-­
approved chemical wipe with correct contact time.

Tip, Wrench (EMS CombiTorque

Wrench), and Handpiece
Carefully remove the tip from the handpiece with the
wrench called a CombiTorque. Cleaning should oc-
cur within one hour ­after use. Manual and automatic
cleaning instructions are found in the manufacturer’s
DFU/IFU. The tip and CombiTorque can be placed in
an ultrasonic bath and automated washer.
Detach the handpiece from the handpiece connec-
tion cable with a gentle straight pull motion. Do not twist
or turn the handpiece upon removal to avoid damage to
B the connections. Unscrew the nose cap, and remove the
light guide (if applicable) and O-ring from the handpiece
Figure 17-25 EMS Perio Tips: A. PS Instrument, B. PSR
(as seen in Figure 17-27). Rinse the nose cap, light guide,
and PSL Instruments.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
O-ring, and handpiece under running water.
The handpiece cannot be placed in an ultrasonic
bath. Sterilization should occur directly after cleaning
processes are complete. Steam under pressure steril-
ization is recommended because cold liquid disinfec-
tion, chemical vapor, and dry heat sterilization have
not been tested or validated for efficacy. Do not exceed
the maximum number of sterilization cycles.

Figure 17-27 EMS Original Piezon LED Handpiece with

removed red O-ring, light guide, and nose cap.
Figure 17-26 EMS PI Instrument. Reproduced with permission from E.M.S. Electro Medical Systems S.A.
322 Chapter 17 EMS

CASE STUDY
A 24-year-old Hispanic male presents to the hygienist for a new patient appointment. He has not seen a dentist since he
was 15 years old. He smokes eight cigarettes a day and has daily moderate alcohol intake. He has a metal tongue ring.
He does not take any prescription or over-the-counter medications, has no known drug allergies, and his vitals are within
normal limits.
His chief complaint is “something feels weird on my lower front teeth, but nothing hurts” (see Figure 17-28).
Periodontal findings: Generalized heavy biofilm and light to moderate dental calculus throughout. Probe depths are
3–4 mm generally with 85% bleeding upon probing. Gingival tissues are generally erythematous with localized edema
mandibular anterior central and lateral incisors. No attachment loss is present except the mandibular central and lat-
eral incisors, which also have heavy lingual, interproximal, and facial dental calculus. The patient has severe recession
mandibular central incisors only on the lingual.
Treatment plan: A periodontist performs the examination and recommends a nonsurgical periodontal debridement
procedure followed by bone and gingival grafting for the mandibular anterior central incisors. The dental hygienist car-
ries out phase one of the treatment and performs a nonsurgical periodontal debridement. Even with local anesthesia,
the patient experienced pain upon instrumentation of the mandibular anterior central incisors, and the dental hygienist
debrided to the best of their ability (see Figure 17-29).

Figure 17-28 Periapical radiograph and intraoral photograph of the

mandibular anterior teeth.

Figure 17-29 Immediate post-operative intraoral

photograph of the mandibular anterior teeth.
 Reprocessing 323

Figure 17-30 Four Week Postoperative Intraoral Photographs of the Mandibular Anterior Teeth.

The patient was seen four weeks post-nonsurgical periodontal debridement (see Figure 17-30). He reports severe
pain for the first week after the procedure. The severe pain has subsided, but he still has occasional sensitivity to hot and
cold on the mandibular anterior teeth.

Questions for initial nonsurgical periodontal debridement

1. Which of the following is not a likely cause of the localized severe attachment loss seen in Figure 17-28 and
Figure 17-29?
a. Attachment loss caused by the natural aging processes
b. Presence of a metal tongue ring
c. Malocclusion with a traumatic bite
d. The patient’s brushing habits
2. Which of the following tips should be used to begin debridement of the mandibular anterior lingual central incisors
pictured in Figure 17-28?
a. PS Instrument
b. PSR Instrument
c. PSL Instrument
d. PI Instrument
3. What power setting should be used to begin debridement of the mandibular anterior lingual central incisors with
the tip selected in question 2?
a. 70–100%
b. 30–40%
c. 20–30%
d. 10–20%
4. True or False: A tap stroke followed by an ultrasonic activation stroke should be initially used to debride the
mandibular anterior lingual central incisors with the tip selected in question 2.
a. True
b. False
5. The PS Instrument removes the dental calculus from the straight lingual, but the provider is unable to adapt the
lateral surfaces to the direct mesial interproximal area. What tip should the provider switch to?
a. PSR/PSL Instruments
b. PI Instrument
324 Chapter 17 EMS

Questions for four-week follow-up appointment

1. Ultrasonic technology is contraindicated for the debridement of the mandibular right central incisor dental
calculus as seen in Figure 17-30.
a. True
b. False
2. Which of the following tips should be used to begin debridement of the mandibular anterior lingual central incisors
pictured in Figure 17-30?
a. PS Instrument
b. PSR Instrument
c. PSL Instrument
d. PI Instrument

Summary
EMS offers a variety of piezoelectric ultrasonic devices
with differing functionality. Four tips are available,
which include a thin straight tip, two curved tips, and
one implant debridement tip. Handpieces are made
with and without LED illumination. Guided Biofilm
Therapy, which includes ultrasonic instrumentation
with the AIRFLOW Prophylaxis Master in its treat-
ment protocols, is an approach to routine and non-
surgical periodontal procedures that will be discussed
in detail in the air polishing section of this book.

Questions
1. Which of the following is the trade name for an 5. When using the Piezon Master 700, what
EMS single mode piezoelectric ultrasonic device? percentage increase of power occurs when Boost
a. AIRFLOW mode is activated?
b. AIRFLOW Prophylaxis Master a. 10%
c. Piezon b. 20%
d. Night Cleaner c. 25%
2. What is the frequency of an EMS piezoelectric d. 30%
ultrasonic device? 6. How often should the water filter be replaced?
a. 25 kHz a. Monthly
b. 30 kHz b. Biannually
c. 32 kHz c. Triannually
d. 40 kHz d. Annually
3. What power setting should be used to remove 7. What is the water temperature set to upon
light biofilm on the enamel of teeth? delivery of the AIRFLOW Prophylaxis Master?
a. Low a. There is no water temperature control on the
b. Medium AIRFLOW Prophylaxis Master.
c. High b. 0 degrees Celsius
4. What power setting should be used to remove c. 40 degrees Celsius
heavy dental calculus on the enamel of teeth? d. 90 degrees Celsius
a. Low 8. Which of the following is a wear and tear item
b. Medium that needs replacement?
c. High a. Independent bottle O-ring
b. Handpiece connector cord O-ring
c. Light guide
d. Peristaltic pump
e. All of the above
 Questions 325

9. How long will the water purge when the 13. What water flow rate should be used with PS,
automatic purge feature is activated on the PSR, and PSL Instruments?
AIRFLOW Prophylaxis Master? a. 40–50%
a. 1 minute b. 50–60%
b. 2 minutes c. 60–70%
c. 4 minutes d. 70–100%
d. 5 minutes 14. What is the maximum power that can be used
10. True or False. EMS manufactures tips with an with the PSR and PSL Instruments?
S-Series threader. a. 100%
a. True b. 60%
b. False c. 50%
11. Which tip currently manufactured by EMS is a d. 30%
straight thin tip? 15. Which of the following tips is used for implant
a. PS Instrument debridement?
b. PSR Instrument a. PS Instrument
c. PSL Instrument b. PI Instrument
d. None of the above c. PSR Instrument
12. Which of the following EMS tips can debride the d. PSL Instrument
deepest into a periodontal pocket?
a. PS Instrument
b. PSR Instrument
c. PSL Instrument
 CHAPTER 18

Acteon
LEARNING OBJECTIVES • Newtron: ®
the name of an Acteon piezoelectric
ultrasonic device.
After studying this chapter, you will be able to: • Newtron SLIM: handpiece without LED lighting
manufactured by Acteon.
1. Identify Acteon piezoelectric ultrasonic
products, parts, and accessories.
• Newtron SLIM B.LED: handpiece with LED
lighting manufactured by Acteon.
2. Recognize the design differences of tips and
select the best tip for the patient presentation.
• Perio mode: setting on Soprocare camera
manufactured by Acteon that uses a blue LED
3. Understand the operations of the foot pedal. light and white LED light to illuminate the
4. Perform proper waterline maintenance. pigments present in oral deposits and the natural
5. Select the correct water flow and power setting endogenous fluorophores present in hard and soft
for each tip. tissues.
6. Reprocess handpieces and tips according to the
manufacturer’s recommendations.
• Periodontic tips: the name of ultra-thin diameter
tips manufactured by Acteon.
7. Implement the Soprocare three-step program
for routine and nonsurgical periodontal
• Prophylaxis tips: the name of thick and thin (slim)
diameter tips manufactured by Acteon.
procedures.
• Soprocare: the name of a proprietary three-
step program created by Acteon for preventive
KEY TERMS nonsurgical procedures that uses the
Soprocamera for patient education, F.L.A.G
• Blue power zone: high power range (11–16) that is
used with prophylaxis tips.
technology with ultrasonic instrumentation, and
air polishing.
• Caries mode: setting on Soprocare camera • Soprocare camera: the name of the camera
manufactured by Acteon that has a daylight,
manufactured by Acteon that detects areas of
demineralization. caries, and perio mode to capture intraoral
• Daylight mode: setting on Soprocare camera images.
manufactured by Acteon that captures intraoral • S-Series tip threader: tip threader with two flats
manufactured by Acteon.
images with natural light.
• F.L.A.G. dye: fluorescein dye solution made of
a mixture of glycerol and disodium 2-(3-oxo-6-
oxidoxanthen-9-yl) benzoate that stains plaque
biofilm.
• Green power zone: low power range (1–6) that is
used with periodontic tips.
Introduction
• Implant care: the name of plastic and titanium
tips manufactured by Acteon.
This chapter will explore piezoelectric ultrasonic

•
Irrigation seal: O-rings present on an Acteon
handpiece and the horn.
• Light Emitting Diode (LED) ring: ring located
in the handpiece of the Newtron SLIM B.LED
that provides illumination during ultrasonic
instrumentation.
technology manufactured by Acteon. The company’s
research and development teams have continued to
evolve the field of piezoelectric technology, releas-
ing new and innovative devices and tip designs. Al-
though there are other manufacturers of piezoelectric
ultrasonic technology, it would be too lengthy for this
327
328 Chapter 18 Acteon

book to cover every single one. For this reason, the

author has chosen to focus on two of the largest global
piezoelectric manufacturers.
This chapter will present Acteon’s ultrasonic de-
vices, handpieces, and tip portfolio. Detailed informa-
tion for each tip, with its clinical use, power settings,
diameter, shape, length, and coatings, will be dis-
cussed. This knowledge will assist the oral health-care
provider in implementing a contemporary approach
to ultrasonic instrumentation.
A
As discussed in other chapters, it is best practice
to use the tips from the company that made your ul-
trasonic device because there are many differences in
manufacturing designs. Mismatching manufacturer
technology is not recommended and has the potential to
adversely affect efficiency and equipment performance,
and possibly void the product’s warranty. Piezoelectric
tips are designed with two different tip threaders that
are specific to each ultrasonic manufacturer. Using an
incorrect piezoelectric tip for the handpiece can strip
and destroy the threader and possibly the horn of the
handpiece. This causes irreversible damage, and the
equipment must be discarded and replaced. Soprocare
is a unique proprietary procedure created by Acteon B
for preventive nonsurgical procedures that consists of
using the Soprocare camera, F.L.A.G. technology
for B.LED with ultrasonic instrumentation, and air pol-
ishing that will be discussed in this chapter.

Acteon Piezoelectric
Ultrasonic Devices
The trade name for Acteon piezoelectric ultrasonic
devices is Newtron. There are three generations of
Newtron piezoelectric scalers termed Newtron Booster,
Newtron P5 B.LED, and Newtron P5 XS B.LED (see
Figure 18-1a to c). All are single mode models that de-
liver piezoelectric ultrasonic scaling. The Newtron
P5 XS B.LED has an independent self-­contained water
reservoir. The other two models connect to the water
­supply on the dental unit.
Frequency
The frequency range of the Newtron piezoelectric ul-
trasonic devices is 28–36 kHz. The oral health-care
provider does not adjust the frequency—the device
makes the adjustments on its own based on the tip
torqued into the handpiece. Never use another
manufacturer’s tip in an Acteon ultrasonic device or
performance will be compromised and the risk for
equipment damage increases.
C
Figure 18-1 Acteon Newtron Piezoelectric ultrasonic
devices: A. Newtron Booster, B. Newtron P5 B.LED,
C. Newtron P5 XS B.LED.
Reproduced with permission from ACTEON.
Emerging Technology
The Newtron P5 XS B.LED offers many user-friendly
features such as:
• Preconfiguration of power and irrigation settings
that can be controlled through a tablet or smart-
phone app.
• A magnetic light indicator that illuminates when
the device is on and corresponds to the power
level (see Figure 18-2a to d). The light indicator
panel is removable from the device for cleaning
and disinfecting. It cannot be sterilized.
 Acteon Piezoelectric Ultrasonic Devices 329

A B

C D
Figure 18-2 Acteon Newtron P5 XS B.LED light indicator: A. Green light (low power), B. Yellow light (medium power),
C. Blue light (high power), D. Orange light (very high power).
Reproduced with permission from ACTEON.

Table 18-1 Acteon Newtron Power Settings

Color Power Range Power Classification Tips Uses
Green 1–6 Low power Periodontic, implant debridement Periodontics
Yellow 6–11 Medium power Endodontic Root canal procedures
Blue 11–16 High power Prophylaxis Scaling
Orange 16–20 Very high power Surgical Implant loosening
Reproduced with permission from ACTEON

• Automatic water purge activated by a single de-
pression of the pedal. The device will automati-
cally purge for 4 minutes and can be interrupted
by a second press of the pedal.
• LED handpiece with white and blue light.
• Round foot pedal.
• Independent water reservoir with a 300 or 500 ml
tank.
Power
Acteon piezoelectric ultrasonic devices use a mag-
netic detachable turntable knob to change the power
output setting that is color-coded. There is no Boost
mode function. The foot pedal activates and deacti-
vates the device and delivers the power output level
selected by the provider.
Power Control
The power settings are a color-coded system with a
total power range of 1–20. Each tip is paired with a
specified color-coded power range. Reference the di-
rections for use or instructions for use (DFU/IFU) for
this information. There are four colors: green, yellow,
blue, and orange (see Table 18-1).
330 Chapter 18 Acteon

Green Power Zone. The green power zone is

low power output. Acteon states the green power zone
is for periodontics. It is used for the debridement of
enamel, dentin, cementum, and dental implant struc-
tures. Periodontic tips have a green color band and are
used in the green power zone. Always use the lowest
power possible for the oral deposit level. For example,
if you are debriding a root furcation with light dental
calculus, then a lower setting in the green power zone
should be used. If the furcation has moderate dental
calculus, a slightly higher setting in the green power
zone may be needed for removal.

Blue Power Zone. Blue power zone is high Figure 18-3 Acteon Newtron P5 XS B.LED Water Control
power output. Acteon states that the blue power zone in front of independent water bottle.
Reproduced with permission from ACTEON.
is for scaling. It is used for the removal of oral depos-
its. Prophylaxis tips have a blue color band and are
used in the blue power zone. Caution should be ex-
ercised using high blue power zone settings when de-
briding less mineralized hard tissues such as dentin or
cementum. The highest level in the blue zone should
only be used for heavy dental calculus removal. Light
dental calculus, stain, or biofilm should be debrided
with lower settings in the blue power zone.

Foot Pedal
The foot pedal is tethered to the device via a cord.
• Round pedal: Newtron P5 B.LED and Newtron
P5 XS B.LED. A
• Rectangular pedal: Newtron Booster.

Water
The Newtron piezoelectric ultrasonic devices have a
water control knob whose location varies by model.
The water flow rate is selected based on the power
level. All devices have a peristaltic water pump that is
replaced annually.

Water Control
The Newtron P5 XS B.LED has a dial water control
in front of the water bottle (see Figure 18-3). The
Newtron Booster and Newtron P5 B.LED have a water
dial on the side of the device. Turn the dial clockwise
to increase the water flow rate and counterclockwise B
to decrease.
Figure 18-4 Water Settings (Newtron SLIM and Tip 1):
A. Low to medium power, B. High power.
Water Flow Rate
Acteon recommends a continuous flow of water • Low to medium power: Water flow rate is set for
during active ultrasonic instrumentation. The water a rapid drip or a rapid drip with a fine mist halo
flow rate is chosen based on the power output setting. (see Figure 18-4a).

• High power: The water flow rate is turned up, so
the rapid drip disappears, and a strong mist is ex-
pelled (see Figure 18-4b).
Water Bottle and Line Purging
The Newtron P5 XS B.LED has an independent wa-
ter reservoir bottle (see Figure 18-3). The Newtron
Booster and Newtron P5 B.LED derive their water
source from the dental unit.
The independent water reservoir bottle of the
Newtron P5 XS B.LED is sold in 300 ml or 500 ml
sizes. Refer to the DFU/IFU for compatible solutions
that can be used in the independent water reservoir
bottle. Remove the bottle with a straight pull motion
and replace the same way. Do not twist the bottle
when placing and removing. There are specific main-
tenance recommendations for independent water res-
ervoir bottles found in the DFU/IFU such as:
• After installation and before first use, at the end
of the day, and following a period of prolonged
nonuse, the irrigation system must be cleaned.
Fill the independent water reservoir bottle with
hypochlorite diluted to less than 3%. Purge the
line for 2 minutes.
• Then refill the independent water reservoir bottle
with demineralized, distilled, or drinking water.
Purge the line for another 2 minutes to clear the
diluted hypochlorite solution.
Water Pump
A peristaltic water pump will accompany a piezoelec-
tric ultrasonic device that uses an independent water
reservoir bottle. The peristaltic water pump is a wear
and tear item that must be replaced annually.
Tip Water Port
All tips have an internal water port as described in
Chapter 5. Internal water ports are equipped with a
small cannula tube embedded inside the shank that
emerges from a small port opening at a specific posi-
tion on the shank.
Handpiece
Acteon manufacturers two handpieces for the Newtron
piezoelectric ultrasonic devices that are removable and
sterilizable between patients. Each handpiece has two
O-rings and a detachable nose piece (see Figure 18-5).
1. Newtron SLIM: Handpiece without LED lighting
(see Figure 18-6a).
Acteon Piezoelectric Ultrasonic Devices 331
Figure 18-5 Newtron SLIM B.LED Handpiece with
detachable nose piece, optical guide, and LED ring.
Reproduced with permission from ACTEON.
A
B
Figure 18-6 Acteon handpieces: A. Newtron SLIM,
B. Newtron SLIM B.LED.
Reproduced with permission from ACTEON.
2. Newtron SLIM B.LED: Handpiece with LED
lighting (see Figure 18-6b). There are two differ-
ent lighting choices of white or blue/white light.
The LED lighting initiates when the handpiece is
removed from its holder. The LED light will au-
tomatically turn off a few seconds after the foot
pedal is released. In addition to a detachable nose
piece, the Newtron SLIM B.LED handpiece has an
LED ring and optical guide (see Figure 18-5).
LED Ring
The LED ring provides illumination during active
ultrasonic instrumentation for improved visibil-
ity. One LED ring provides white light only, and the
other provides a mixture of white and blue light (see
Figure 18-7). The blue light is used for fluorescent
lighting, which is discussed later in this chapter.
O-Ring
There are two O-rings that Acteon terms irrigation
seals. One is present on the metal shaft on the back
of the handpiece that should be lubricated with sili-
cone paste prior to use to prolong its service life and
prevent leaks (see Figure 18-8). The other is present
on the horn. Periodically inspect the irrigation seals
for damage or wear and replace as indicated. A thin
plier can remove the seals and then use the purpose-
designed kit provided by Acteon to put new irrigation
seals into place.
332 Chapter 18 Acteon
Figure 18-7 Acteon Handpiece LED ring.
Reproduced with permission from ACTEON.
Figure 18-8 Acteon handpiece on the left and handpiece
connector cable on the right.
Handpiece Connection
When attaching the handpiece to the handpiece con-
nector cable, ensure that the electric connections
align. Be gentle when attaching and removing the
handpiece from the connector to avoid damage to the
connections (see Figure 18-8).
Acteon Tip Portfolio
Acteon offers a wide variety of tips spanning multiple
fields in dentistry that vary in shank shape, diameter,
and coating. They manufacture nearly 80 tips catego-
rized by prophylaxis, periodontics, implant care, end-
odontics, and prosthesis. This book will cover the first
three: prophylaxis, periodontics, and implant care.
Prophylaxis tips have a thicker diameter shank than
periodontic tips. Diamond-coated tips are single-use
tips and are not covered in this textbook because they
are used for periodontal flap surgery.
The tip threader is an S-Series with two flats
and a color band just below the flats (see Figure 18-9).
Only use tips manufactured by Acteon in their piezo-
electric devices. Do not attach an E-Series tip to an
Acteon handpiece because they have four flats instead
of two. This can cause stripping of the tip threader
and the horn of the handpiece. Once damaged, the
equipment must be discarded and replaced.
Flat
Figure 18-9 Acteon tip H3. Green color band below the
visible flat. The second flat in on the opposite side.

A cause their large surface area is too thick to access
B
Figure 18-10 Acteon wrench: A. Wrench and tip 1,
B. Wrench and Newtron SLIM handpiece.
Reproduced with permission from ACTEON.
Tips are torqued into the handpiece with the
wrench (see Figure 18-10a and b). Replace wrenches
annually. Follow these guidelines for proper torque to
ensure the optimal tip performance:
• Do not force torquing beyond its stop point.
• Tighten moderately with the wrench provided to
ensure optimal torque.
• Do not over-torque a tip because the risk for
breakage or tip threader stripping increases.
• Never remove or place a tip into the handpiece
when the device is activated.
Prophylaxis Tips
The prophylaxis tip portfolio offers thick and thin
(Acteon term is Slim) diameter shanks with a blue
stripe below the tip threader flats. The blue color
stripe indicates the tip as a prophylaxis tip and corre-
sponds to the power output setting. The thick diam-
eter prophylaxis tips have the largest surface area of
Acteon Tip Portfolio 333
the shank, and Slim prophylaxis tips have the second
largest surface area of the shank. All prophylaxis tips
have a larger shank diameter than periodontic tips.
Prophylaxis tips have a straight shank that is bent in
one plane with a round cross-section. There are no
curved shank shapes in the prophylaxis portfolio.
Power Settings
Prophylaxis tips are all used in the blue power zone
of 11–16, which is considered high power. For any
procedure, always use the lowest possible power out-
put to achieve the clinical goal. Never raise the power
higher than 16.
Thick Diameter Prophylaxis Tips
There are four (1, 10X, 2, 3) thick diameter prophy-
laxis tips. Tips 1 and 10X are used for supragingival
removal of moderate to heavy calculus deposits be-
subgingivally without tissue distension or injury.
• Tip 1: Single bend shank that adapts to all tooth
surfaces supragingivally (see Figure 18-11a and
Table 18-2).
• Tip 10X: Single bend shank useful for debriding in-
terproximal areas (see Figure 18-11b and Table 18-2).
There are two flat and blunt shank designs in
the thick diameter prophylaxis portfolio. One has a
blunted point, and the other has a rounded point. The
point is adapted to the oral deposit during ultrasonic
instrumentation.
• Tip 2: Useful for the removal of heavy dental cal-
culus supragingivally due to its broad and flat
shank with a blunted point. Tip 2 is not used
subgingivally due to its large surface area (see
Figure 18-11c and Table 18-2).
• Tip 3: Useful for the removal of heavy to moderate
dental calculus and staining supragingivally due
to its broad and flat shank with a rounded point.
Tip 3 is not used subgingivally due to its large sur-
face area (see Figure 18-11d and Table 18-2).
Slim Prophylaxis Tips
There are three (1S, 10P, 10Z) Slim prophylaxis tips.
They are used to debride both supragingivally and
subgingivally.
• Tip 1S: Useful for debriding supragingival and
subgingival interproximal areas due to its more
active lateral surfaces. Its shank is longer than tip
1 (see Figure 18-12a and Table 18-3).
334 Chapter 18 Acteon

A B C D
Figure 18-11 Acteon thick prophylaxis tips: A. Tip 1, B. Tip 10X, C. Tip 2, D. Tip 3.
Reproduced with permission from ACTEON.

Table 18-2 Acteon Thick Prophylaxis Tips Table 18-3 Acteon Thin Prophylaxis Tips
Tip Name Shank Shape Cross Section Tip Name Shank Shape Cross Section
1 Straight Round 1S Straight Round
10X Straight Round 10P Straight Round
2 Straight Broad, flat, blunt point 10Z Straight Round
3 Straight Broad, flat, rounded point Reproduced with permission from ACTEON
Reproduced with permission from ACTEON

A B C
Figure 18-12 Acteon Slim prophylaxis tips: A. Tip 1S, B. Tip 10P, C. Tip 10Z.
Reproduced with permission from ACTEON.
 Acteon Tip Portfolio 335

• Tip 10P: Useful for debriding probe depths

2–3 mm ue to its fine round shank (see
Figure 18-12b and Table 18-3).
• Tip 10Z: Useful for debriding pocket depths
2–4 mm. The tip has probe-like markings on its
shank that are used to evaluate the depth of the
pocket during ultrasonic instrumentation (see
Figure 18-12c and Table 18-3).

Periodontic Tips
The periodontic tips portfolio has thin diameter
shanks with a green stripe below the tip threader
flats. The green color stripe indicates the tip as a
periodontic tip and corresponds to the power output
setting. Periodontic tip shanks are thinner than pro-
phylaxis tips. There are two shank shape options of
straight and curved. All periodontic tips have a round
cross-section.
B
Power Settings A
Periodontic tips are all used in the green power zone
of 1–6, which is considered very low power. For any
procedure, always use the lowest possible power out-
put to achieve the clinical goal. Never raise the power
higher than 6.

Straight Periodontic Tips

There are three straight periodontic tips (H3, TK1-1S,
TK1-1L) that are used for the removal of light dental
calculus, stain, and all levels of biofilm and bacterial
by-products.
• Tip H3: Adapts to anterior teeth (see Figure 18-13a
and Table 18-4).
• Tips TK1-1S and TK1-1L: Designed with
probe-like markings on the shank that are
useful for evaluating the depth of periodontal
pockets during ultrasonic instrumentation (see C
Figure 18-13b and C and Table 18-4). The TKI-1S
Figure 18-13 Acteon straight periodontic tips: A. Tip H3,
has a shorter shank than the TK1-1L and is B. Tip TK1-1S, C. Tip TK1-1L.
recommended for pocket depths of 4 mm and Reproduced with permission from ACTEON.
less. TKI-1L is used to debride pocket depths of
4 mm and greater.
Table 18-4 Acteon Straight Periodontic Tips
Curved Periodontic Tips Tip Name Shank Shape Cross Section
There are three pairs of curved periodonitc tips (P2R/ H3 Straight Round
P2L, TK2R/TK2L, H4R/H4L) that are used to debride
TK1-1S Straight Round
light dental calculus, stain, and all levels of biofilm
and bacterial by-products on complex root anatomy. TK1-1L Straight Round
The R stands for a right-curved shank and the L stands Reproduced with permission from ACTEON
for a left-curved shank.
336 Chapter 18 Acteon

• Tips H4R/H4L: Contra-angled tips with a similar

design to a hand-activated curette. They are used
on posterior teeth (see Figure 18-14a and Table 18-5).
• Tips TK2-1R/TK2-1L: Shank resembles a furca-
tion probe. They are used on posterior teeth (see
Figure 18-14b and Table 18-5).
• Tips P2R/P2L: Shank has a double-bend with a
rounded micro-tip. The diameter is the thinnest
of all periodontic curved tips. They are useful for
debriding root structures when tissues are hard,
firm, and tightly adherent. They are also useful for
debriding difficult to access interproximal spaces.
They are used on anterior and posterior teeth (see
Figure 18-14c and Table 18-5).

Implant Tips A
Acteon manufactures multiple tips used for the de-
bridement of a dental implant, abutment, and pros-
thesis called implant care. There are two groups of
tips: plastic micro-tipped and titanium. Implant care
tips are used in the green power zone with a maxi-
mum power output of 3.

Plastic Micro-Tipped
Plastic micro-tipped implant care tips are used to
debride a dental implant, abutment, and prosthesis.
They will remove biofilm and low adherence oral
deposits.
There are three plastic micro-tipped implant de-
bridement tips.
• Tip PHI: straight shank shape that is adapted to
anterior dental implants (see Figure 18-15a).
• Tips PH2R/PH2L: curved shank shape that is
adapted to posterior dental implants. The shank B
resembles a hand-activated universal curette (see
Figure 18-15b).

Titanium
Titanium implant care tips are used to debride im-
plant threads and valleys. There are five titanium im-
plant care tips (see Table 18-6).
• Tip IP1: Straight shank with the widest diameter
that is useful for debriding a dental implant with
wide threads.
• Tips IP2R/IP2L: Curved shank shape with the
second widest diameter. These tips are useful for
debriding a dental implant with medium implant C
thread width. These tips are adapted the same as Figure 18-14 Acteon curved periodontic tips: A. Tips
the curved tips for natural teeth, which will be H4R/H4L, B. Tips TK2-1R/TK2-1L, C. Tips P2R/P2L.
shown in Chapter 20. Reproduced with permission from ACTEON.

Table 18-5 Acteon Curved Periodontic Tips
Tip Name Shank Shape
H4R/H4L Curved
TK2-1R/TK2-1L Curved
P2R/P2L Curved
Reproduced with permission from ACTEON
A B
Figure 18-15 Plastic micro-tipped implant debridement tips: A. PH1, B. PH2L/PH2R.
Reproduced with permission from ACTEON.
• Tips IP3R/IP3L: Curved shank shape with the
narrowest diameter. These tips are useful for de-
briding a dental implant with narrow implant
thread width. These tips are adapted the same as
the curved tips for natural teeth, which will be
shown in Chapter 20.
Reprocessing
Always use aseptic techniques during reprocessing that
includes full Personal Protective Equipment (PPE) and
utility gloves when handling contaminated equipment
to avoid cross-contamination and operator injury.
Ultrasonic Device
The power cord, air and water lines, handpiece ca-
ble, foot pedal and cord, and the device itself are not
Reprocessing 337
Tooth Adaptation Cross Section
Posterior Round
Posterior Round
Anterior and posterior Round
sterilizable but should be disinfected with an approved
solution per the manufacturer, which you can find in
the product DFU/IFU. Do not spray disinfectant solu-
tions directly on system surfaces. Use a manufacturer-
approved chemical wipe with correct contact time.
Tip
Carefully remove the tip from the handpiece with the
wrench. Manual and automatic cleaning instructions are
found in the manufacturer’s DFU/IFU. The tip and wrench
may be placed in an ultrasonic bath for 10 minutes and
an automated instrument washer with manufacturer-­
approved solutions. Prior to bagging for sterilization,
ensure that the tip and wrench are completely dry.
Do not use a chemical disinfectant on tips. Steam un-
der pressure sterilization is recommended because
cold liquid disinfection, chemical vapor, and dry heat
sterilization have not been tested or validated for efficacy.
338 Chapter 18 Acteon

Table 18-6 Titanium-Tipped Implant Debridement Tips

Wide Implant Threads Medium Implant Threads Narrow Implant Threads
IP1 IP2R/IP2L IP3R/IP3L

Reproduced with permission from ACTEON


Handpiece
Detach the handpiece from the handpiece con-
nector cable with a gentle straight pull motion.
Do not twist or turn the handpiece upon removal
to avoid damage to the connections. Unscrew the
nose piece, remove the optical guide (if applicable),
and LED ring (if applicable). Manual and automatic
cleaning instructions are found in the manufactur-
er’s DFU/IFU.
The handpiece should be cleaned no more than
2 hours after use and cannot be placed in an ultra-
sonic bath. Only the nose piece disassembled from
the handpiece may be immersed in an ultrasonic bath
for no more than 2 minutes. The equipment may be
run through an automated instrument washer with
an approved solution and contact time per the man-
ufacturer. Refer to the DFU/IFU for approved solu-
tions. Prior to bagging for sterilization, ensure that the
handpiece is completely dry. Use only a steam under
pressure form of sterilization.
Soprocare
Soprocare is a proprietary three-step program from
Acteon for preventive nonsurgical procedures that
consists of using the Soprocare camera, F.L.A.G.
Figure 18-17 Acteon Soprocare camera images: Daylight mode of the maxillary left anterior facial surfaces.
Perio mode of the maxillary left anterior facial surfaces.
Soprocare 339
technology for B.LED with ultrasonic instrumenta-
tion, and air polishing.
1. Use the Soprocare camera to identify dental
plaque biofilm and gingival inflammation (see
Figure 18-16). This first step assists with patient
education. The patient is able to visually see in-
flammation and oral deposits in their mouth. The
camera is equipped with three modes:
1. Daylight mode: captures intraoral images.
See Figure 18-17.
2. Caries mode: aids in the detection of demin-
eralization and can capture the image.
3. Perio mode: Uses a blue LED and white LED
light to illuminate the pigments present in oral
deposits and the natural endogenous fluoro-
phores present in hard and soft tissues. Plaque
biofilm will appear as grainy white, ­immature
dental calculus appears yellow, and mature
dental calculus appears dark orange (see
Figure 18-17). The image can be captured by
the camera.
Figure 18-16 Acteon Soprocare camera.
340 Chapter 18 Acteon
Figure 18-18 Air-N-Go Easy.
Reproduced with permission from ACTEON.
2. Guided treatment with the use of F.L.A.G. tech-
nology for B.LED. This second step enables you
to detect and visibly see immature and mature
biofilm during active ultrasonic instrumentation.
A F.L.A.G. solution fluorescein dye is either added
to the independent water reservoir bottle of the
Newton P5 XS B.LED piezoelectric ultrasonic or
can be applied directly onto tooth surfaces with a
brush. The solution is a mixture of glycerol and di-
sodium 2-(3-oxo-6-oxidoxanthen-9-yl) ­benzoate.
The solution will dye biofilm and will not stain the
gingiva. When the Newtron SLIM B.LED hand-
piece with the LED blue/white light guide is used,
the F.L.A.G. solution glows even brighter.
3. Full mouth air polishing completes the Soprocare
program treatment. Acteon manufactures a porta-
ble handheld air polisher called the Air-N-Go Easy,
which is used to remove any residual biofilm and
stain supragingivally and subgingivally with spe-
cialized powders and nozzles (see Figure 18-18).
Air polishing is extensively covered in Section 5
of this book.
 Soprocare 341

CASE STUDY
A 24-year-old Hispanic male presents to the hygienist for a new patient appointment. He has not seen a dentist since he
was 15 years old. He smokes eight cigarettes a day and has daily moderate alcohol intake. He has a metal tongue ring.
He does not take any prescription or over-the-counter medications, has no known drug allergies, and his vitals are within
normal limits.
His chief complaint is “something feels weird on my lower front teeth, but nothing hurts” (see Figure 18-19).
Periodontal findings: Generalized heavy biofilm and light to moderate dental calculus throughout. Probe depths are
3–4 mm generally with 85% bleeding upon probing. Gingival tissues are generally erythematous with localized edema
mandibular anterior central and lateral incisors. No attachment loss is present except the mandibular central and lat-
eral incisors, which also have heavy lingual, interproximal, and facial dental calculus. The patient has severe recession
mandibular central incisors only on the lingual.
Treatment plan: A periodontist performs the examination and recommends a nonsurgical periodontal debridement
procedure followed by bone and gingival grafting for the mandibular anterior central incisors. The dental hygienist car-
ries out phase one of the treatment and performs a nonsurgical periodontal debridement. Even with local anesthesia,
the patient experienced pain upon instrumentation of the mandibular anterior central incisors, and the dental hygienist
debrided to the best of their ability (see Figure 18-20).

Figure 18-19 Periapical radiograph and intraoral photograph of the mandibular

anterior teeth.

Figure 18-20 Immediate post-operative intraoral

photograph of the mandibular anterior teeth.
342 Chapter 18 Acteon

Figure 18-21 Four Week Postoperative Intraoral Photographs of the Mandibular Anterior Teeth.

The patient was seen four weeks post-nonsurgical periodontal debridement (see Figure 18-21). He reports severe
pain for the first week after the procedure. The severe pain has subsided, but he still has occasional sensitivity to hot and
cold on the mandibular anterior teeth.

Questions for initial nonsurgical periodontal debridement

1. Which of the following is not a likely cause of the localized severe attachment loss seen in Figure 18-19 and
Figure 18-20?
a. Attachment loss caused by the natural aging processes
b. Presence of a metal tongue ring
c. Malocclusion with a traumatic bite
d. The patient’s brushing habits
2. Which of the following tips should be used to begin debridement of the mandibular anterior lingual central incisors
pictured in Figure 18-19 ?
a. 1
b. 1S
c. H3
d. TK1-1S
3. What power setting should be used to begin debridement of the mandibular anterior lingual central incisors with
the tip selected in question 2?
a. Blue power zone 11–12
b. Blue power zone 15–16
c. Green power zone 1–2
d. Green power zone 5–6
4. True or False: A tap stroke followed by an ultrasonic activation stroke should be initially used to debride the
mandibular anterior lingual central incisors with the tip selected in question 2.
a. True
b. False
5. Tip 1 reduces the size of the dental calculus from heavy to light. Which tip should the dental hygienist use next to
remove the light deposits?
a. Continue using the 1.
b. Change from a 1 to a TK1-1S.
c. Change from a 1 to a TK1-1L.
d. Change from a 1 to a P2R.
 Questions 343

6. What power setting should be used with the tip selected in question 5?
a. Blue power zone 15–16
b. Blue power zone 11–12
c. Green power zone 3–4
d. Orange power zone 16–17

Questions for four-week follow-up appointment

1. Ultrasonic technology is contraindicated for the debridement of the mandibular right central incisor dental
calculus, as seen in Figure 18-21.
a. True
b. False
2. Which of the following tips should be used to begin debridement of the mandibular anterior lingual central incisors
pictured in Figure 18-21?
a. 1
b. 2
c. 10X
d. H3

Summary
Acteon offers a variety of piezoelectric ultrasonic de-
vices with differing functionality. They manufacture a
wide variety of tips that span multiple specialties of
dentistry to fit any patient presentation. Handpieces
are made with and without LED illumination. So-
procare is a proprietary three-step program used for
preventive and nonsurgical periodontal procedures
that allows the provider to educate their patient with
Soprocare camera technology, visualize plaque biofilm
with F.L.A.G. technology for B.LED during ultrasonic
instrumentation, and complete the patient procedure
with air polishing.

Questions
1. Which of the following is an Acteon 4. What size water bottle is available for the
piezoelectric ultrasonic device? Newtron P5 XS B.LED?
a. Newtron a. 100 ml
b. Irrigation seal b. 300 ml
c. Newtron SLIM c. 500 ml
d. F.L.A.G. d. Both B and C
2. What is the frequency range of an Acteon Match the following power color zone to its correct
piezoelectric device? description for questions 5–8. There is only one cor-
a. 25–30 kHz rect answer for each question.
b. 30–40 kHz
c. 28–36 kHz 5. Green power zone A. High power
d. 35–40 kHz 6. Yellow power B. Used with periodontic
3. How long will the automatic purge feature stay zone tips
active in the Newtron P5 XS B.LED piezoelectric 7. Blue power zone C. Power range 16–20
ultrasonic device?
a. 1 minute 8. Orange power D. Used with endod­
b. 2 minutes zone ontic tips
c. 3 minutes
d. 4 minutes
344 Chapter 18 Acteon

9. What power setting should be used with a 18. IP2L

periodontic tip when light biofilm is present on 19. P2L
the enamel of teeth?
a. Green power zone 1 20. True or False. Thick diameter and slim diameter
b. Green power zone 6 tips are available in the prophylaxis portfolio of
c. Blue power zone 11 tips.
d. Blue power zone 16 a. True
b. False
10. What power setting should be used with a
prophylaxis tip when heavy dental calculus is 21. Which of the following is a slim prophylaxis tip
present on the enamel of teeth? with markings similar to a probe that can reach
a. Green power zone 1 up to 4 mm during debridement?
b. Green power zone 6 a. 10Z
c. Blue power zone 11 b. 10P
d. Blue power zone 16 c. 1
d. P2S
11. Which of the following is a wear and tear item
that will need replacement over time? 22. Which of the following is a curved periodontic
a. Irrigation seal tip?
b. Wrench a. P2R
c. Peristaltic water pump b. TK1-1S
d. All of the above c. H3
d. 10X
12. How often should the peristaltic water pump be
replaced? 23. True or False. Acteon manufactures curved
a. Monthly implant tips that vary in diameter to debride
b. Biannually different implant thread widths.
c. Annually a. True
d. Biennially b. False
13. True or False. Acteon manufactures tips with an 24. In which step in the Soprocare program does
E-Series threader. ultrasonic instrumentation take place?
a. True a. Step one
b. False b. Step two
c. Step three
Match the following tips to their correct tip family for d. Step four
questions 14–19. Answer A for prophylaxis tips, B for
periodontic tips, and C for implant tips. There is only 25. Which Soprocare camera setting uses a blue
one correct answer for each question. LED and white LED light to illuminate the
pigments present in oral deposits and the natural
14. TK2-1S endogenous fluorophores present in hard and
15. PH1 soft tissues?
16. 10X a. Daylight mode
b. Caries mode
17. 1S c. Perio mode
 CHAPTER 19
EMS Curved Tips
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Identify an EMS curved tip as right or left.
2. Recognize the clinical uses for EMS curved
tips.
3. Identify the correct adaptation and angulation of
an EMS curved right tip in vertical orientation.
4. Identify the correct adaptation and angulation of
an EMS curved left tip in vertical orientation.
5. Perform an ultrasonic activation stroke
with EMS curved tips using correct grasp,
finger rest, operator and patient positioning,
instrument adaptation, angulation, and
orientation.
6. Maintain proper ergonomics while
performing ultrasonic instrumentation with
EMS curved tips.
Introduction
This chapter will present the clinical use of piezoelectric
curved tips manufactured by EMS. The curved tips are
used as a pair to debride complex root anatomy. The
curved tips function as a pair, with one debriding lingual
surfaces and the other debriding facial/buccal surfaces.
Low to medium power with the lateral surfaces adapted
at a 0- to 15-degree angulation is used with a vertical
orientation. A step-by-step exercise is presented to en-
hance your clinical technique with EMS curved tips.
Curved shanks were developed in the 1990s,
and by 2000, the American Academy of Periodon-
tology (AAP) released a position paper supporting
the use of thin diameter curved shanks over hand-
activated instruments for the debridement of Class II,
Class III, and Class IV furcation defects (Drisko et al.,
2000). There is a large body of literature supporting
the use of curved shanks in furcation areas; however,
curved shanks also assist the provider in safely de-
briding root concavities, convexities, and interprox-
imal surfaces both supragingivally and subgingivally.
Their multifunctional capabilities make them a useful
tool in many periodontal applications, from a general
prophylaxis to surgical procedures.
EMS Piezoelectric Curved
Tip Introduction
The EMS curved tips are used in vertical orientation
to debride complex root anatomy in deep periodontal
pockets up to 8 mm. The active area antinode is contact-
ing cementum in this orientation (see Figure 19-1a and b).
When debriding root anatomy with a curved EMS
tip in a vertical orientation, follow these rules for
ultrasonic instrumentation to protect the less mineral-
ized hard tissue cementum:
• Power: Low to medium power is used. High power
increases the risk for cemental injury.
• Adaptation: Adapt lateral surfaces. The point and
face have a higher displacement amplitude and
should either be used with caution, or avoided,
on cementum. See Chapter 9 for details on shank
surface displacement amplitude.
• Angulation: Use a 0- to 15-degree angulation. A
90-degree angulation is contraindicated because
the point would be in contact with the cementum
(see Figure 19-2a and b).
• Activation: Use an ultrasonic activation stroke.
A tap stroke should be used with caution as the
point is adapted.
Piezoelectric curved tips are used as a pair. The
provider needs two tips to debride a single tooth.
345
346 Chapter 19 EMS Curved Tips

A B
Figure 19-1 EMS Vertical Orientation Curved Tip (PSR/PRL): A. Lateral surface adapted to the distal of the mandibular
left first molar, B. Lateral surface adapted to the buccal of the mandibular left first molar.

A B
Figure 19-2 EMS curved tip angulation (PSR/PSL): A. 0- to 15-degree angulation with lateral surface, B. 90-degree
angulation with the point.

The tips are nicknamed right- and left-curved tips.
The left and right distinction refers to the direction
of the shank bend and has nothing to do with how
or where they are used in the mouth. The provid-
er’s dominant hand has no influence on which tip
is used on the facial/buccal or lingual surfaces. The
correct tip will be the same for dominant right- or
left-handed providers.
As presented in Chapter 11, to correctly identify
each tip as right or left:
• Hold one tip in your dominant hand and the
other in your nondominant hand so the shanks
are parallel in front of your face.
• Turn the point surface away from you.
• Look at the curve of the shank. If the shank curves
to the right, it is the right-curved tip, and if it curves
to the left, it is the left-curved tip (see Figure 19-3).
EMS now only manufacturers two curved tips:
PSL Instrument and PSR Instrument. PSL is the
left-curved tip and PSR is the right-curved tip.

EMS Piezoelectric Curved
Tip Adaptation
EMS curved tips are used as a pair. One curved tip
is adapted to the facial/buccal surfaces of the teeth in
one quadrant, and the other curved tip is adapted to
the lingual (see Figure 19-4).
Curved tip adaption is similar to the adaption
of posterior area-specific hand-activated curettes.
Left (PSL) Right (PSR)
Figure 19-3 EMS Photoelectric Curved Tips (PSR and
PSL Instruments).
A B
Figure 19-5 Posterior Area-specific Gracey curette: A. Gracey 11/12, B. Gracey 13/14.
EMS Piezoelectric Curved Tip Adaptation 347
Area-specific curettes have one lower cutting edge on
each side that adapts to either the mesial or distal of a
posterior tooth. The provider must use two area-specific
curettes to instrument all surfaces of one posterior tooth.
• One posterior area-specific curette adapts to the
buccal/lingual and mesial surfaces of posterior
teeth (see Figure 19-5a).
• The other posterior area-specific curette adapts
to the distal surfaces of posterior teeth (see
Figure 19-5b).
Figure 19-4 EMS Piezoelectric Curved Tip Adaptation
Vertical Orientation (PSR/PSL Instruments).
348 Chapter 19 EMS Curved Tips

The provider will use two piezoelectric curved
tips to instrument one tooth, just as they do with pos-
terior area-specific curettes. Instead of a mesial or dis-
tal adaptation, piezoelectric curved tips have a facial/
buccal or lingual adaptation.
Identifying Correct Adaptation
During active patient care, the provider can deter-
mine which curved tip is used on the facial/buccal
and lingual without referencing a book. EMS curved
piezoelectric tips are adapted correctly when the
shank is parallel to the long axis of the tooth, with
the lateral surface in contact with the tooth surface.
This is similar to the adaptation of hand-activated
instruments.
• Figure 19-6a: Notice the terminal shank is parallel
to the long axis of the mandibular left first molar,
with the tip lateral surface adapted. This is correct
adaptation.
• Figure 19-6b: Notice the terminal shank is wrap-
ping around the buccal of the mandibular left first
molar, with the tip lateral surface adapted. This is
incorrect adaptation.
EMS Right-Curved Tip (PSR
Instrument) Adaptation
• Maxillary arch: Maxillary right facial/buccal and
maxillary left lingual (see Figure 19-7a and b).
• Mandibular arch: Mandibular right lingual and man-
dibular left facial/buccal (see Figure 19-8a and b).
There is a pattern for correct adaptation of the
EMS curved tips. Look at the maxillary arch adapta-
tion of the PSR Instrument. The tip is adapted to the

A B
Figure 19-6 Curved tip adaptation: A. Correct adaptation of the PSR Instrument, B. Incorrect adaptation of the PSL
Instrument.

A B
Figure 19-7 Maxillary Arch PSR Instrument: A. Maxillary right facial/buccal, B. Maxillary left lingual.
 EMS Piezoelectric Curved Tip Adaptation 349

A B
Figure 19-8 Mandibular Arch PSR Instrument: A. Mandibular right lingual, B. Mandibular left facial/buccal.

maxillary right facial/buccal and maxillary left lingual.

If the tip is adapted on the facial/buccal surfaces of
one quadrant, it is also adapted to the lingual surfaces
of the adjacent quadrant. The same holds true for the
mandibular arch. The right tip is adapted on the man-
dibular right lingual, so it is also adapted to the man-
dibular left facial/buccal.
EMS Left-Curved Tip (PSL Instrument)
Adaptation
• Maxillary arch: Maxillary right lingual and maxil-
lary left facial/buccal (see Figure 19-9a and b).
• Mandibular arch: Mandibular right facial/buccal
and mandibular left lingual (see Figure 19-10a and b).

A B
Figure 19-9 Maxillary Arch PSL Instrument: A. Maxillary right lingual, B. Maxillary left facial/buccal.

A B
Figure 19-10 Mandibular Arch PSL Instrument: A. Mandibular right facial/buccal, B. Mandibular left lingual.
350 Chapter 19 EMS Curved Tips

The same pattern exists for the PRL Instrument as

it does for the PSR Instrument. The PRL Instrument
is adapted to the maxillary right lingual, so it is also
adapted to the maxillary left facial/buccal. The PSL
Instrument adapts to the mandibular left lingual, so it LR LL
is also adapted on the mandibular right facial/buccal. Lingual Lingual
Table 19-1 and Figure 19-11 summarize the correct
adaption for the PSR and PSL Instruments on the
maxillary arch in vertical orientation. LR LL
Facial/Buccal Facial/Buccal
Table 19-2 and Figure 19-12 summarize the cor-
rect adaption for the PSR and PSL Instruments on the
mandibular arch in vertical orientation.
Figure 19-12 Vertical Orientation PSR and PSL
Instrument Adaptation for the Mandibular Arch.

Table 19-1 Maxillary Adaptation for EMS PSR

and PSL Instruments in Vertical Orientation Skill Building:
PSR Instrument
(Orange)
PSL Instrument
(Gold)
Debridement Curved Tips
You will need the following supplies: typodont, ty-
Facial/Buccal UR UL
podont pole, dental chair, ultrasonic device, high-
Lingual UL UR volume evacuation, ultrasonic handpiece, PSR and
PSL Instruments.
Rationale: This exercise will incorporate ultrasonic in-
strumentation techniques of adaptation, angulation,
orientation, and activation and combine them with
UR UL aerosol control and patient and operator positioning
Facial/Buccal Facial/Buccal to simulate an active patient treatment scenario with
curved tips.
The goal of this exercise is to correctly debride
UR UL subgingival root anatomy with curved tips in a verti-
Lingual Lingual
cal orientation.

Setup
1. Mount the pole onto the dental chair.
2. Mount the typodont onto the pole.
Figure 19-11 Vertical Orientation PSR and PSL
Instrument Adaptation for the Maxillary Arch. 3. Set up the ultrasonic device, attaching the
power, water, and/or air connectors. Turn on the
device.
4. Attach an High-volume evacuation (HVE) to the
Table 19-2 Mandibular Adaptation for EMS PSR suction system.
and PSL Instruments in Vertical Orientation 5. Flush the waterline for a minimum of 20–30 sec-
onds. Always follow your clinic’s protocols for wa-
PSR Instrument PSL Instrument
terline maintenance, which may be different than a
(Orange) (Gold)
20- to 30-second waterline flush.
Facial/Buccal LL LR 6. Attach a sterile ultrasonic handpiece to the hand-
Lingual LR LL piece connector cord.
7. See Box 19-1.
 Skill Building: Debridement Curved Tips 351

Box 19-1
Dominant right-handed provider: Identify the mandibular right first molar buccal.
Dominant left-handed provider: Identify the mandibular left first molar buccal.
Dominant right-handed provider: Select the PSL Instrument.
Dominant left-handed provider: Select the PSR Instrument.

8. Use the CombiTorque wrench to torque the tip
into the horn of the handpiece.
9. Set the power control to 10–60%. See EMS
Chapter 17 for details if needed.
10. Set the water control to 70–100%. See EMS
Chapter 17 for details if needed.
11. Confirm the correct tip has been selected for the
buccal surface of the first molar by identifying if
the shank is parallel to the long axis of the tooth
(see Figure 19-6a).
352 Chapter 19 EMS Curved Tips

Buccal Furcation Debridement 1. Perform an ultrasonic activation stroke. Rotate

of the Mandibular First Molar
Grasp the ultrasonic handpiece with your dominant hand.
See Chapter 9 for details if needed.
the active area antinode as you move apically to
maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 19-14).

Grasp the HVE with your nondominant hand.

See Chapter 9 for details if needed.

Adapt the lateral surface of the active area antinode in a vertical

orientation at the cervical third on the crown of the tooth coronal
to the buccal furcation entrance (see Figure 19-13).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water

port on the trip.

Figure 19-14 Buccal debridement of the mandibular

Select the operator positioning for direct vision. first molar. Lateral surface of the active area antinode
• Dominant right-handed provider: 8–11 o’clock adapted coronal to the buccal furcation entrance.
• Dominant left-handed provider: 1–4 o’clock

2. Continue the ultrasonic activation stroke, moving

Select the patient chair positioning for the mandibular arch.
Patient chair supine, semi-supine, or in between supine and
semi-supine with chin slightly down.
Establish a finger rest intraoral or extraoral, ensuring
correct ultrasonic handpiece grasp is maintained.
Ensure the foot pedal is within reach. Turn on the HVE.
Begin instrumentation with the steps below.
toward the buccal furcation.
3. Be sure to maintain adaptation of the active area
antinode with a 0- to 15-degree angulation as you
approach the buccal furcation.
4. Enter the buccal furcation with the lateral sur-
face of the active area antinode (see Figure 19-15).
Maintain 0- to 15-degree angulation. Debride
one-half of the furcation area. The other half will
be debrided from the lingual.

Figure 19-13 Buccal furcation debridement of the Figure 19-15 Buccal surface debridement of the
mandibular first molar. Lateral surface of the active area mandibular first molar. Lateral surface of the active area
antinode adapted coronal to the buccal furcation entrance. antinode adapted in the buccal furcation.
 Skill Building: Debridement Curved Tips 353

5. Adapt the lateral surface to debride the distal surface 7. Debridement of the mandibular first molar buccal
of the mesial root with the active area antinode at a furcation is now complete.
0- to 15-degree angulation (see Figure 19-16).

Mesial-Buccal Root
Debridement of the Mandibular
First Molar
1. Adapt the lateral surface of the active area antinode
in a vertical orientation at the cervical third on the
crown of the tooth coronal to the mesial-buccal
root distal surface (see Figure 19-18).

Figure 19-16 Buccal surface debridement of the

mandibular first molar. Lateral surface of the active
area antinode adapted to the distal surface of the
mesial root.
6. Adapt the opposite lateral surface to debride the
mesial surface of the distal root with the active
area antinode at a 0- to 15-degree angulation (see
Figure 19-17).

Figure 19-18 Mesial-buccal root debridement of the

mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the mesial-buccal root
distal surface.

2. Perform an ultrasonic activation stroke. Rotate

Figure 19-17 Buccal surface debridement of the the active area antinode as you move apically to
mandibular first molar. Lateral surface of the active area maintain contact with the root surface at a 0- to
antinode adapted to the mesial surface of the distal root. 15-degree angulation (see Figure 19-19a and b).

A B
Figure 19-19 Mesial-buccal root debridement of the mandibular first molar. A. Lateral surface of the active
area antinode adapted coronal to the mesial-buccal root distal surface, B. Lateral surface of the active area
antinode adapted on the mesial-buccal root distal surface.
354 Chapter 19 EMS Curved Tips

3. Debride the entire mesial root by adapting the surface of the mesial-buccal root toward the me-
lateral surface of the active area with a 0- to sial surface of the mesial-buccal root, conforming
15-degree angulation and moving from the distal to the root anatomy (see Figure 19-20a and b).

A B
Figure 19-20 Mesial-buccal root debridement of the mandibular first molar. A. Lateral surface of the active area
antinode adapted to the mesial-buccal root, B. Lateral surface of the active area antinode adapted to the mesial-buccal
root.

4. Complete the mesial-buccal root debridement
with the lateral surface of the active area antinode
adapted to the direct mesial with a 0- to 15-degree
angulation as if you are probing the mesial col
(see Figure 19-21a).
5. Debride one-half of the mesial interproximal area.
The other half will be debrided from the lingual
(see Figure 19-21b).
6. Debridement of the mandibular first molar
mesial-buccal root is now complete.

A B
Figure 19-21 Mesial-buccal root debridement of the mandibular first molar: A. Lateral surface of the active area
antinode adapted to the mesial, B. Lateral surface of the active area antinode adapted to the mesial debriding one-half
the interproximal area.

Distal-Buccal Root Debridement
of the Mandibular First Molar
1. Adapt the lateral surface of the active area antinode
in a vertical orientation with a 0- to 15-degree an-
gulation at the cervical third on the crown of the
tooth coronal to the distal-buccal root mesial sur-
face (see Figure 19-22).
Figure 19-22 Distal-buccal root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the distal-buccal root
mesial surface.
2. Perform an ultrasonic activation stroke. Rotate
the active area antinode as you move apically to
maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 19-23).
Figure 19-23 Distal-buccal root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted on the distal-buccal root mesial
surface.
Skill Building: Debridement Curved Tips 355
3. Debride the entire distal root by adapting the lat-
eral surface of the active area antinode with a 0- to
15-degree angulation and moving from the mesial
surface of the distal-buccal root toward the distal
surface of the distal-buccal root, conforming to
the root anatomy.
4. Complete the distal-buccal root debridement
with the lateral surface of the active area antinode
adapted to the direct distal with a 0- to 15-degree
angulation as if you were probing the distal col
(see Figure 19-24).
Figure 19-24 Distal-buccal root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted to the distal.
5. Debride one-half of the distal interproximal area.
The other half will be debrided from the lingual
(see Figure 19-25).
Figure 19-25 Distal-buccal root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted to the distal to debride one-half
the interproximal area.
6. Debridement of the mandibular first molar
distal-buccal root is now complete.
356 Chapter 19 EMS Curved Tips

Lingual Furcation Debridement

of the Mandibular First Molar
Dominant right-handed provider: Remove the PSL
Instrument and replace with PSR Instrument. C
­ ontinue
debridement of the mandibular right first molar.
Dominant left-handed provider: Remove the PSR In-
strument and replace with PSL Instrument. Continue
debridement of the mandibular left first molar.
Confirm the correct tip has been selected for the
lingual surface of the first molar by identifying if the
shank is parallel to the long axis of the tooth (see
Figure 19-6a).

Grasp the ultrasonic handpiece with your dominant hand.

See Chapter 9 for details if needed.

Figure 19-26 Lingual furcation debridement of the

Grasp the HVE with your nondominant hand. mandibular first molar. Lateral surface of the active area
See Chapter 9 for details if needed. antinode adapted coronal to the lingual furcation entrance.

1. Perform an ultrasonic activation stroke. Rotate

Adapt the lateral surface of the active area antinode in a vertical the active area antinode as you move apically to
orientation at the cervical third on the crown of the tooth coronal
to the lingual furcation entrance (see Figure 19-26). maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 19-27).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water

port on the trip.

Select the operator positioning for direct vision.

• Dominant right-handed provider: 1–4 o’clock
• Dominant left-handed provider: 8–11 o’clock

Select the patient chair positioning for the mandibular arch.

Patient chair supine, semi-supine, or in between supine and
semi-supine with chin slightly down.

Establish a finger rest intraoral or extraoral, ensuring

correct ultrasonic handpiece grasp is maintained.

Figure 19-27 Lingual furcation debridement of the

Ensure the foot pedal is within reach. Turn on the HVE.
mandibular first molar. Lateral surface of the active
Begin instrumentation with the steps below. area antinode adapted coronal to the lingual surface
furcation entrance.

2. Continue the ultrasonic activation stroke, moving
toward the lingual furcation.
3. Be sure to maintain adaptation of the active area
antinode with a 0- to 15-degree angulation as you
approach the lingual furcation.
4. Enter the lingual furcation with the lateral sur-
face of the active area antinode. Maintain a 0- to
15-degree angulation. Debride one-half of the fur-
cation area. The other half was debrided from the
buccal (see Figure 19-28).
Figure 19-28 Lingual furcation debridement of the
mandibular first molar. Lateral surface of the active area
antinode adapted in the lingual furcation.
5. Adapt the lateral surface to debride the distal sur-
face of the mesial root with the active area antinode
at a 0- to 15-degree angulation (see Figure 19-29).
Figure 19-29 Lingual furcation debridement of the
mandibular first molar. Lateral surface of the active area
antinode adapted to the distal surface of the mesial root.
Skill Building: Debridement Curved Tips 357
6. Adapt the opposite lateral surface to debride the
mesial surface of the distal root with the active
area antinode at a 0- to 15-degree angulation
(see Figure 19-30).
Figure 19-30 Lingual furcation debridement of the
mandibular first molar. Lateral surface of the active area
antinode adapted to the mesial surface of the distal root.
7. Debridement of the mandibular first molar lin-
gual furcation is now complete.
Distal-Lingual Root
Debridement of the Mandibular
First Molar
1. Adapt the lateral surface of the active area antinode
in a vertical orientation at the cervical third on the
crown of the tooth coronal to the distal-lingual
root mesial surface (see Figure 19-31).
Figure 19-31 Distal-lingual root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the distal-lingual root
mesial surface.
358 Chapter 19 EMS Curved Tips

2. Perform an ultrasonic activation stroke. Rotate maintain contact with the root surface at a 0- to
the active area antinode as you move apically to 15-degree angulation (see Figure 19-32a and b).

A B
Figure 19-32 Distal-lingual root debridement of the mandibular first molar: A. Lateral surface
of the active area antinode adapted coronal to the distal-lingual root mesial surface, B. Lateral
surface of the active area antinode adapted on the distal-lingual root mesial surface.

3. Debride the entre distal root by adapting the lat-
eral surface of the active area antinode with a 0- to
15-degree angulation and moving from the mesial
surface of the distal-lingual root toward the distal
surface, conforming to the root anatomy.
4. Complete the distal-lingual root debridement
with the lateral surface of the active area antinode
adapted to the direct distal with a 0- to 15-degree
angulation as if you were probing the distal col
(see Figure 19-33a).
5. Debride one-half of the distal interproximal area.
The other half was debrided from the buccal (see
Figure 19-33b).
6. Debridement of the mandibular first molar
distal-lingual root is now complete.

A B
Figure 19-33 Distal-lingual root debridement of the mandibular first molar: A. Lateral surface of the active area
antinode adapted to the distal, B. Lateral surface of the active area antinode adapted to the distal debriding one-half
the distal interproximal area.
 Skill Building: Debridement Curved Tips 359

Mesial-Lingual Root
Debridement of the Mandibular
First Molar
1. Adapt the lateral surface of the active area antinode
in a vertical orientation with a 0- to 15-degree an-
gulation at the cervical third on the crown of the
tooth coronal to the mesial-lingual root distal sur-
face (see Figure 19-34).
A

Figure 19-34 Mesial-lingual root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the mesial-lingual root
distal surface.
B
Figure 19-35 Mesial-lingual root debridement of the
mandibular first molar: A. Lateral surface of the active
area antinode adapted on the mesial-lingual root distal
surface, B. Lateral surface of the active area antinode
adapted on the mesial-lingual root.

2. Perform an ultrasonic activation stroke. Rotate
the active area antinode as you move apically to
maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 19-35a).
3. Debride the mesial root by adapting the lateral
surface of the active area antinode with a 0- to
15-degree angulation and moving from the distal
surface of the mesial-lingual root toward the me-
sial surface of the mesial-lingual root, conforming
to the root anatomy (see Figure 19-35b).
4. Complete the mesial-lingual root debridement
with the lateral surface of the active area antinode
adapted to the direct mesial with a 0- to 15-degree
angulation as if you were probing the mesial col
(see Figure 19-36a).
5. Debride one-half of the mesial interproximal area.
The other half was debrided from the buccal (see
Figure 19-36b).
6. Debridement of the mesial-lingual root is now
complete.

A B
Figure 19-36 Mesial-lingual root debridement of the mandibular first molar: A. Lateral surface of the
active area antinode adapted to the mesial, B. Lateral surface of the active area antinode adapted to the
mesial debriding one-half the mesial interproximal area.
360 Chapter 19 EMS Curved Tips

CASE STUDY
A 52-year-old Caucasian male with a noncontributory medical history presents to your office with a chief complaint of
“My teeth are starting to get loose and something on the lower left hurts. My teeth are sensitive to hot and cold tempera-
tures.” The patient’s last dental visit was at the age of 17. The initial panoramic X-ray and left side bitewing and periapical
radiographs with intraoral camera photographs are shown here. The mandibular left wisdom tooth was extracted the
same day of the new patient appointment due to a deep periodontal abscess and patient reported pain.
Periodontal assessment: 3–14 mm probe depths with 100% BOP, generalized moderate to severe recession, furca-
tion Class II and III, mobility Class 2 and 3.
Treatment options included:

Panoramic radiograph.

Mandibular anterior periapical.

Left premolar bitewing. Left molar bitewing.

 Skill Building: Debridement Curved Tips 361

Mandibular right premolar and molar periapical.

A B
Intraoral photographs: A. Anterior facial surfaces, B. Mandibular left canine, lateral incisor, and right central incisor
lingual surfaces.

1. Full-mouth rehabilitation with a prosthodontist.

2. Extractions and removable partial or full denture.
3. Nonsurgical periosdontal debridement with informed consent (this procedure may not save the teeth).
The patient is dentally anxious and selects treatment plan option number three. The mandibular left was debrided first.
Post-operative radiographs and intraoral photographs are shown here.

Left bitewing. Mandibular left premolar periapical.

362 Chapter 19 EMS Curved Tips

Mandibular left molar periapical.

Mandibular left canine periapical with technique errors.

Mandibular anterior and premolar lingual surfaces.

Mandibular anterior and premolar facial surfaces. Mandibular left premolar lingual surfaces.

1. Describe the staged instrumentation approach the dental hygienist likely used to debride the mandibular left
lateral incisor to completion. State the tip designs that were used and why. Also state the power level used with
each stage of instrumentation.
2. What curved tip did the dental hygienist use to debride the root concavity on the mesial-lingual of the mandibular
left first premolar? What orientation was used?
3. Describe how the dental hygienist debrided the deep distal root defect of the mandibular left second molar with
staged instrumentation. State the tip designs that were used and why. Also state the power level used with each
stage of instrumentation.
4. Why would the straight long shank tip not debride the mandibular left second molar distal area to completion?
5. What curved tip did the dental hygienist use to debride the buccal Class III furcation of the mandibular left first
molar? What orientation was used?
 References 363

Summary
This chapter presented the clinical use of piezoelectric
curved tips manufactured by EMS. The curved tips are
used as a pair to debride complex root anatomy. Low
to medium power with the lateral surfaces adapted in
vertical orientation with a 0- to 15-degree angulation
is used to protect less mineralized hard tissues such as
dentin and cementum.

Questions
1. True or False. The correct adaptation of right- and c. Lateral
left-curved tips is different for a dominant right- d. None of these
handed provider than a left-handed provider. 7. Which tip would be the best selection to debride
a. True the maxillary right first premolar mesial-lingual
b. False 2–3 mm subgingival when the tooth has no
2. What power level is appropriate to use when attachment loss?
debriding complex root anatomy such as a a. PSR Instrument
furcation with ultrasonic instrumentation? b. PSL Instrument
a. Low c. PS Instrument
b. Medium 8. Which tip would be the best selection to debride
c. High the mandibular left canine distal-facial 2–3 mm
d. Both A and B subgingival when the tooth has no attachment
3. What surfaces of the PSR and PSL Instruments loss?
should be adapted in vertical orientation a. PSR Instrument
subgingivally? b. PSL Instrument
a. Lateral c. PS Instrument
b. Face 9. Which tip would be the best selection to debride
c. Point the maxillary left central incisor mesial-lingual
4. Which of the following ultrasonic shank 2–3 mm subgingival when the tooth has no
angulations is contraindicated when debriding attachment loss?
apical of the Cementoenamel junction (CEJ)? a. PSR Instrument
a. 0–5 degrees b. PSL Instrument
b. 5–10 degrees c. PS Instrument
c. 10–15 degrees 10. Which tip would be the best selection to debride
d. 90 degrees the maxillary left first and second molars distal-
5. True or False. When debriding 6 mm under buccal 2–3 mm subgingival when the tooth has
the gums with the PSR or PSL Instrument in a no attachment loss?
vertical orientation, the provider can see a shank a. PSR Instrument
that will be parallel to the long axis of the tooth. b. PSL Instrument
a. True c. PS Instrument
b. False 11. Which tip would be the best selection to debride
6. When adapting into a furcation, which tip a Class III furcation defect on the mandibular
surface should be in contact with the cementum right first molar buccal?
in the furcation entrance? a. PSR Instrument
a. Face b. PSL Instrument
b. Point c. PS Instrument

References
1. Drisko, C. L., Cochran, D. L., Blieden, T., Bouwsma, O. of the American Academy of Periodontology. Journal of
J., Cohen, R. E., Damoulis, P., Fine, J. B., Greenstein, G., Periodontology, 71(11), 1792–1801. https://doi.org/10.1902
Hinrichs, J., Somermman, M. J., Iacono, V., & Genco, R. J. /jop.2000.71.11.1792
(2000). Position paper: Sonic and ultrasonic scalers in
periodontics. Research, Science and Therapy Committee
 CHAPTER 20
Acteon Curved Tips
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Identify an Acteon curved piezoelectric tip as
right or left.
2. Recognize the indications for use and the
design variations for Acteon curved tips.
3. Identify the correct adaptation and angulation
of an Acteon curved right tip in vertical
orientation.
4. Identify the correct adaptation and angulation of
an Acteon curved left tip in vertical orientation.
5. Perform an ultrasonic activation stroke with a
right- and left-curved tip using correct grasp,
finger rest, operator and patient positioning,
instrument adaptation, angulation, and
orientation.
6. Maintain proper ergonomics while performing
ultrasonic instrumentation with a right- and
left-curved tip.
Introduction
This chapter will present the clinical use of piezoelectric
curved tips manufactured by Acteon. The curved tips
are used as a pair to debride complex root anatomy. The
curved tips function as a pair, with one debriding lin-
gual surfaces and the other debriding facial/buccal sur-
faces. Low to medium power with the lateral surfaces
adapted at a 0- to 15-degree angulation is used with a
vertical orientation. A step-by-step exercise is presented
to enhance your clinical technique with curved tips.
Curved shanks were developed in the 1990s, and by
2000, the American Academy of Periodontology (AAP)
released a position paper supporting the use of thin di-
ameter curved shanks over hand-activated instruments
for the debridement of Class II, Class III, and Class IV
furcation defects (Drisko et al., 2000). There is a large
body of literature supporting the use of curved shanks
in furcation areas; however, curved shanks also assist the
provider in safely debriding root concavities, convexi-
ties, and interproximal surfaces both supragingivally
and subgingivally. Their multifunctional capabilities
make them a useful tool in many periodontal applica-
tions, from a general prophylaxis to surgical procedures.
Acteon Piezoelectric
Curved Tips Introduction
Piezoelectric curved tips are used in vertical orientation
to debride complex root anatomy in deep periodontal
pockets. The active area antinode is contacting cemen-
tum in this orientation (see Figure 20-1a and b). The
curved tip will access a deep periodontal pocket with
its long shank and conform into complex root anat-
omy such as a root concavity, convexity, and furcation.
When debriding root anatomy with a curved Ac-
teon tip in a vertical orientation, follow these rules for
ultrasonic instrumentation to protect the less mineral-
ized hard tissue cementum:
• Power: Low to medium power is used. High
power increases the risk for cemental injury.
• Adaptation: Adapt lateral surfaces. The point and
face have a higher displacement amplitude and
should either be used with caution, or avoided,
on cementum. See Chapter 9 for details on shank
surface displacement amplitude.
• Angulation: Use a 0- to 15-degree angulation. A
90-degree angulation is contraindicated because
the point would be in contact with the cementum
(see Figure 20-2a and b).
365
366 Chapter 20 Acteon Curved Tips

A B
Figure 20-1 Acteon Vertical Orientation Curved Tip: A. Lateral surface adapted to the distal of the mandibular right
first molar, B. Lateral surface adapted to the buccal of the mandibular right first molar.

A B
Figure 20-2 Acteon Curved Tip Angulation: A. 0-to 15- degree angulation with the lateral surface on the buccal of the
mandibular right first molar, B. 90-degree angulation with the point on the buccal of the mandibular right first molar.

• Activation: Use an ultrasonic activation stroke.
A tap stroke should be used with caution as the
point is adapted.
Piezoelectric curved tips are used as a pair. The
provider needs two tips to debride a single tooth. The
tips are nicknamed right-curved tips and left-curved
tips. The left and right distinction refers to the direc-
tion of the shank bend and has nothing to do with
how or where they are used in the mouth. The pro-
vider’s dominant hand has no influence on which tip
is used on the facial/buccal or lingual surfaces. The
correct tip will be the same for dominant right- or left-
handed providers.
As presented in Chapter 11, to correctly identify
each tip as right or left:
• Hold one tip in your dominant hand and the
other in your nondominant hand so the shanks
are parallel in front of your face.
• Turn the point surface away from you.
• Look at the curve of the shank. If the shank curves
to the right, it is the right-curved tip, and if it curves
to the left, it is the left-curved tip (see Figure 20-3).
 Acteon Piezoelectric Curved Tips Introduction 367

LF RT
RT

LF

A B
Figure 20-3 Acteon piezoelectric curved tips: A. P2L/P2R tips, B. H4L/H4R tips.

Acteon manufactures multiple curved tips. This
book will not cover the diamond-coated tips because
they are used predominately during periodontal sur-
gery procedures. Chapter 18 presented the curved
tips selection manufactured by Acteon.
• Tips H4R/H4L, TK2-1R/TK2-1L, and P2R/
P2L are used for natural teeth debridement
(see Figure 20-4a to c). H4R/H4L and TK2-1R/
TK2-1L debride posterior teeth. P2R/P2L debride
anterior and posterior teeth.
• Tips PH2R/PH2L, IP2R/IP2L, IP3R/IP3L are used
for dental implant debridement. PH2R/PH2L are
designed to debride a posterior dental implant,
abutment, and prosthesis. IP2R/IP2L and IP3R/IP3L
are designed to debride implant threads and val-
leys. These tips are adapted the same as the curved
tips for natural teeth that are shown in this chapter.

LF RT

RT
LF

C
Figure 20-4 Acteon curved tips; A. H4L/H4L, B. TK2-1L/TK2-1R, C. P2L/P2R.
Reproduced with permission from ACTEON
368 Chapter 20 Acteon Curved Tips

Acteon Piezoelectric
Curved Tip Adaptation
Acteon curved tips are used as a pair. One curved tip
is adapted to the facial/buccal surfaces of the teeth in
one quadrant and the other curved tip is adapted to
the lingual (see Figure 20-5).
Curved tip adaption is similar to the adaption
of posterior area-specific hand-activated curettes.
Area-specific curettes have one lower cutting edge
on each side that adapts to either the mesial or dis-
tal of a posterior tooth. The provider must use two
area-specific curettes to instrument all surfaces of one
posterior tooth.
• One posterior area-specific curette adapts to the
buccal/lingual and mesial surfaces of posterior
teeth (see Figure 20-6a).
• The other posterior area-specific curette adapts
to the distal surfaces of posterior teeth (see
Figure 20-6b).

The provider will use two piezoelectric curved

tips to instrument one tooth, just as they do with pos-
terior area-specific curettes. Instead of a mesial or dis-
tal adaptation, piezoelectric curved tips have a facial/
buccal or lingual adaptation.

Identifying Correct Adaptation

Figure 20-5 Acteon Piezoelectric Curved Tip Adaptation
Vertical Orientation (P2L/P2R).
During active patient care, the provider can deter-
mine which curved tip is used on the facial/buc-
cal and lingual without referencing a book. Acteon
curved piezoelectric tips are adapted correctly when
the shank is parallel to the long axis of the tooth with
the lateral surface in contact with the tooth surface.
This is similar to the adaptation of hand-activated
instruments.

A B
Figure 20-6 Posterior Area-specific Gracey Curette: A. Gracey 11/12, B. Gracey 13/14.
 Acteon Piezoelectric Curved Tip Adaptation 369

• Figure 20-7a and Figure 20-8a: Notice the termi- • Figure 20-7b and Figure 20-8b: Notice the termi-
nal shank is parallel to the long axis of the man- nal shank is wrapping around the buccal of the
dibular right first molar with the tip lateral surface mandibular right first molar with the tip lateral
adapted. This is correct adaptation. surface adapted. This is incorrect adaptation.

A B
Figure 20-7 H4L tip adaptation: A. Correct adaptation, B. Incorrect adaptation.

A B
Figure 20-8 P2L adaptation: A. Correct adaptation, B. Incorrect adaptation.

Acteon Right-Curved Tips for

Posterior Teeth (H4R and TK2-1R)
Adaptation
• Maxillary arch: Maxillary right buccal and maxil-
lary left lingual (see Figure 20-9a and b).
• Mandibular arch: Mandibular right lingual and
mandibular left buccal (see Figure 20-10a and b).
There is a pattern for correct adaptation of Acteon
posterior curved tips. Look at the maxillary arch ad-
aptation of the right-curved tips. The right-curved tips
are adapted to the maxillary right buccal and maxillary
370 Chapter 20 Acteon Curved Tips

UR Buccal

UL
Ling
ual
A B
Figure 20-9 Maxillary Arch H4R and TK2-1R Tips: A. Maxillary right buccal, B. Maxillary left lingual.
l
ingua
LR L

LL Buccal

A B
Figure 20-10 Mandibular Arch H4R and TK2-1R Tips: A. Mandibular right lingual, B. Mandibular left buccal.

left lingual. If the tips are adapted on the buccal sur-
faces of one quadrant, they will also adapt to the lin-
gual surfaces of the adjacent quadrant. The same holds
true for the mandibular arch. The right-curved tips are
adapted to the mandibular left buccal, so they are also
adapted to the mandibular right lingual.
Acteon Left Curved Tips for Posterior
Teeth (H4L and TK2-1L) Adaptation
• Maxillary arch: Maxillary right lingual and maxil-
lary left buccal (see Figure 20-11a and b).
• Mandibular arch: Mandibular right buccal and
mandibular left lingual (see Figure 20-12a and b).

UL Buccal
gual
UR Lin

A B
Figure 20-11 Maxillary Arch H4L and TK2-1L Tips: A. Maxillary right lingual, B. Maxillary left buccal.
 Acteon Piezoelectric Curved Tip Adaptation 371

gual
LL Lin
LR Buccal

A B
Figure 20-12 Mandibular Arch H4L and TK2-1L Tips: A. Mandibular right buccal, B. Mandibular left lingual.

The same pattern exists for the left-curved tips as
it does for the right. The left-curved tips are adapted
to the maxillary left buccal, so they are also adapted
to the maxillary right lingual. The left tips adapt to
the mandibular right buccal, so they also adapt to the
mandibular left lingual.
Table 20-1 and Figure 20-13 summarize the correct
adaption for posterior curved tips on the maxillary
arch in vertical orientation.
Table 20-2 and Figure 20-14 summarize the cor-
rect adaption for posterior curved tips on the mandib-
ular arch in vertical orientation.

Table 20-1 Maxillary Adaptation for Acteon Table 20-2 Mandibular Adaptation for Acteon
H4R/H4L and TK2-1R/TK2-1L Tips in Vertical H4R/H4L and TK2-1R/TK2-1L Tips in Vertical
Orientation Orientation
Right-Curved Right-Curved Tips Left-Curved Tips
Tips (H4R and Left-Curved Tips (H4L (H4R and TK2-1R) (H4L and TK2-1L)
TK2-1R) (Gold) and TK2-1L) (Orange) (Gold) (Orange)
Buccal UR UL Buccal LL LR
Lingual UL UR Lingual LR LL

LR LL
Lingual Lingual
Posterior Posterior
LR LL
Buccal Buccal
Posterior Posterior
UR UL
Buccal Buccal
Posterior Posterior
UR UL
Lingual Lingual
Posterior Posterior

Figure 20-13 Vertical orientation H4R/H4L and Figure 20-14 Vertical orientation H4R/H4L and
TK2-1R/TK2-1L adaptation for the maxillary arch. TK2-1R/TK2-1L adaptation for the mandibular arch.
372 Chapter 20 Acteon Curved Tips

Acteon Right-Curved Tip for Anterior • Mandibular arch: Mandibular right posterior lin-
gual, mandibular left posterior buccal, and man-
and Posterior Teeth (P2R) Adaptation
dibular anterior facial (see Figure 20-16a and b).
• Maxillary arch: Maxillary right posterior buccal,
maxillary left posterior lingual, and maxillary an-
terior lingual (see Figure 20-15a and b).

UR Posterior buccal

Anterior Lingual

UL P
oste
r
ior L
ingu
al
A B
Figure 20-15 Maxillary Arch P2R Tip: A. Maxillary right posterior buccal, B. Maxillary left posterior lingual
and anterior lingual.
Lingua rior
ste
l
LR Po

Anterior Buccal
LL Posterior Buccal

B
Figure 20-16 Mandibular Arch P2R Tip: A. Mandibular right posterior lingua,l B. Mandibular left posterior
buccal and anterior facial.
 Acteon Piezoelectric Curved Tip Adaptation 373

Acteon Left-Curved Tip for Anterior • Mandibular arch: Mandibular right posterior buc-
cal, mandibular left posterior lingual, and man-
and Posterior Teeth (P2L) Adaptation
dibular anterior lingual (see Figure 20-18a and b).
• Maxillary arch: Maxillary right posterior lingual,
maxillary left posterior buccal, and maxillary an-
terior facial (see Figure 20-17a and b).

rior
UR Poste
Lingual
A

LR Posterior Buccal

UL Posterior Buccal

B
Figure 20-17 Maxillary Arch P2L Tip: A. Maxillary right posterior lingual, B. Maxillary left posterior buccal and
anterior facial.

Anterior Lingual
terior
LL Pos
l
Lingua

LR PosteriorBuccal

A B
Figure 20-18 Mandibular Arch P2L Tip: A. Mandibular right posterior buccal, B. Mandibular left posterior lingual and
anterior lingual.
374 Chapter 20 Acteon Curved Tips

Table 20-3 and Figure 20-19 summarize the cor-

rect adaption for P2R and P2L tips on the maxillary LR LL
arch in vertical orientation. Lingual Lingual
Posterior Posterior
Table 20-4 and Figure 20-20 summarize the cor- LR LL
Buccal Buccal
rect adaption for P2R and P2L tips on the mandibular Posterior Posterior
arch in vertical orientation.
Anterior
Lingual

Anterior
Table 20-3 Maxillary Adaptation for Acteon P2R Facial
and P2L Tips in Vertical Orientation
Right-Curved Tip Left-Curved Tip P2L Figure 20-20 Vertical orientation P2R and P2L
P2R (Gold) (Orange) adaptation for the mandibular arch

Facial/ UR posterior UL posterior and

Buccal anterior
Lingual UL posterior and UR posterior
Skill Building:
anterior Debridement Curved Tips
You will need the following supplies: typodont, ty-
podont pole, dental chair, ultrasonic device, high-
volume evacuation, ultrasonic handpiece, right- and
left-curved ultrasonic tips.
Anterior Rationale: This exercise will incorporate ultrasonic in-
Facial
strumentation techniques of adaptation, angulation,
orientation, and activation and combine them with
Anterior
Lingual
aerosol control and patient and operator positioning
UR UL to simulate an active patient treatment scenario with
Buccal Buccal
Posterior Posterior curved tips.
UR UL
Lingual Lingual The goal of this exercise is to correctly debride
Posterior Posterior
subgingival root anatomy with curved tips in a verti-
cal orientation.

Figure 20-19 Vertical orientation P2R and P2L Setup

adaptation for the maxillary arch.
1. Mount the pole onto the dental chair.
2. Mount the typodont onto the pole.
3. Set up the ultrasonic device, attaching the power,
water, and/or air connectors. Turn on the device.
4. Attach an High-volume evacuation (HVE) to the
Table 20-4 Mandibular Adaptation for Acteon
P2R and P2L Tips in Vertical Orientation suction system.
5. Flush the waterline for a minimum of
Right-Curved Left-Curved Tip P2L 20–30 seconds. Always follow your clinic’s protocols
Tip P2R (Gold) (Orange)
for waterline maintenance, which may be different
Facial/ LL posterior LR posterior than a 20- to 30-second waterline flush.
Buccal and anterior 6. Attach a sterile ultrasonic handpiece to the hand-
Lingual LR posterior LL posterior and anterior piece connector cord.
7. See Box 20-1.
 Skill Building: Debridement Curved Tips 375

Box 20-1
Buccal Furcation Debridement
of the Mandibular First Molar
Dominant right-handed provider: Identify the
mandibular right first molar buccal. Grasp the ultrasonic handpiece with your dominant hand.
See Chapter 9 for details if needed.
Dominant left-handed provider: Identify the
mandibular left first molar buccal.
Dominant right-handed provider: Select H4L, P2L,
or TK2-1L curved tip. Grasp the HVE with your nondominant hand.
Dominant left-handed provider: Select H4R, P2R, or See Chapter 9 for details if needed.
TK2-1R curved tip.

Adapt the lateral surface of the active area antinode in a vertical

orientation at the cervical third on the crown of the tooth coronal
to the buccal furcation entrance (see Figure 20-21).

Establish a 0- to 15-degree angulation.

Position the HVE 0.5–6.0 inches from the water

port on the trip.

Select the operator positioning for direct vision.

• Dominant right-handed provider: 8–11 o’clock
• Dominant left-handed provider: 1–4 o’clock

Select the patient chair positioning for the mandibular arch.

Patient chair supine, semi-supine, or in between supine and
Left Curved Right Curved semi-supine with chin slightly down.
Tip Tip

Establish a finger rest intraoral or extraoral, ensuring

correct ultrasonic handpiece grasp is maintained.

Ensure that the foot pedal is within reach. Turn on the HVE.
Begin instrumentation with the steps below.

8. Lubricate the handpiece O-ring with silicone paste.

Use the wrench to torque the tip to the handpiece.
9. Set the power control to the green zone (1-6). See
Acteon Chapter 18 for details if needed.
10. Set the water flow rate to a rapid drip with fine mist
halo. See Acteon Chapter 18 for details if needed.
11. Confirm the correct tip has been selected for the
buccal surface of the first molar by identifying if
the shank is parallel to the long axis of the tooth
(see Figure 20-7a and Figure 20-8a).
Figure 20-21 Buccal furcation debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the buccal furcation
entrance.
376 Chapter 20 Acteon Curved Tips

1. Perform an ultrasonic activation stroke. Rotate 4. Enter the buccal furcation with the lateral surface of
the active area antinode as you move apically to the active area antinode (see Figure 20-22a and b).
maintain contact with the root surface at a 0- to Maintain a 0- to 15-degree angulation. Debride
15-degree angulation (see Figure 20-21). one-half of the furcation area. The other half will
2. Continue the ultrasonic activation stroke, moving be debrided from the lingual.
toward the buccal furcation.
3. Be sure to maintain adaptation of the active area
antinode with a 0- to 15-degree angulation as you
approach the buccal furcation.

A B
Figure 20-22 Buccal furcation debridement of the mandibular first molar: A. Lateral surface of the active area
antinode adapted just coronal to the buccal furcation entrance, B. Lateral surface of the active area antinode adapted
in the buccal furcation.

5. Adapt the lateral surface to debride the dis- 6. Adapt the opposite lateral surface to debride the
tal surface of the mesial root with the active mesial surface of the distal root with the active
area antinode at a 0- to 15-degree angulation area antinode at a 0- to 15-degree angulation
(see Figure 20-23). (see Figure 20-24).

Figure 20-23 Buccal furcation debridement of the Figure 20-24 Buccal furcation debridement of the
mandibular first molar. Lateral surface of the active area mandibular first molar. Lateral surface of the active area
antinode adapted to the distal surface of the mesial root. antinode adapted to the mesial surface of the distal root.
 Skill Building: Debridement Curved Tips 377

7. Debridement of the mandibular first molar buccal 2. Perform an ultrasonic activation stroke. Rotate
furcation is now complete. the active area antinode as you move apically to
maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 20-26).
Mesial-Buccal Root
Debridement of the Mandibular
First Molar
1. Adapt the lateral surface of the active area antinode
in a vertical orientation at the cervical third on the
crown of the tooth coronal to the mesial-buccal
root distal surface (see Figure 20-25).

Figure 20-26 Mesial-buccal root debridement of the

mandibular first molar. A. Lateral surface of the active
area antinode adapted on the mesial-buccal root
surface.

3. Debride the entire mesial root by adapting the lat-

Figure 20-25 Mesial-buccal root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the mesial-buccal root
distal surface.
eral surface of the active area antinode with a 0- to
15-degree angulation and moving from the distal
surface of the mesial-buccal root toward the me-
sial surface of the mesial-buccal root, conforming
to the root anatomy (see Figure 20-27a and b).

A B
Figure 20-27 Mesial-buccal root debridement of the mandibular first molar:
A. Lateral surface of the active area antinode adapted to the mesial-buccal
root, B. Lateral surface of the active area antinode adapted to the mesial.
378 Chapter 20 Acteon Curved Tips

4. Complete the mesial-buccal root debridement
with the lateral surface of the active area antinode
adapted to the direct mesial with a 0- to 15-degree
angulation as if you are probing the mesial col
(see Figure 20-28a).
5. Debride one-half of the mesial interproximal area.
The other half will be debrided from the lingual
(see Figure 20-28a to c).
6. Debridement of the mandibular first molar
mesial-buccal root is now complete.

A B

C
Figure 20-28 Mesial-buccal root debridement of the mandibular first molar:
A. Lateral surface of the active area antinode adapted to the mesial, B. Lateral
surface of the active area antinode debriding one-half the mesial, C. Lateral
surface of the active area antinode debriding one-half the interproximal area.
 Skill Building: Debridement Curved Tips 379

Distal-Buccal Root
Debridement of the
Mandibular First Molar
1. Adapt the lateral surface of the active area antinode
in a vertical orientation with a 0- to 15-degree an-
gulation at the cervical third on the crown of the
tooth coronal to the distal-buccal root mesial sur-
face (see Figure 20-29).

Figure 20-29 Distal-buccal root debridement of the

mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the distal-buccal root
mesial surface.

2. Perform an ultrasonic activation stroke. Rotate

the active area antinode as you move apically
to maintain contact with the root surface at a
0- to 15-degree angulation (see Figure 20-30a
and b).
3. Debride the entire distal root by adapting the lat-
eral surface of the active area antinode with a 0- to
15-degree angulation and moving from the mesial B
surface of the distal-buccal root toward the distal
Figure 20-30 Distal-buccal root debridement of the
surface of the distal-buccal root, conforming to mandibular first molar: A. Lateral surface of the
the root anatomy. active area antinode adapted on the distal-buccal root,
4. Complete the distal-buccal root debridement B. Lateral surface of the active area antinode adapted on
with the lateral surface of the active area antinode the distal-buccal root.
380 Chapter 20 Acteon Curved Tips
adapted to the direct distal with a 0- to 15-degree
angulation as if you are probing the distal col
(see Figure 20-31).
Figure 20-31 Distal-buccal root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted to the distal.
5. Debride one-half of the distal interproximal area.
The other half will be debrided from the lingual
(see Figure 20-32).
6. Debridement of the mandibular first molar
distal-buccal root is now complete.
Figure 20-32 Distal-buccal root debridement of the
mandibular first molar. Lateral surface of the active
area antinode adapted to the distal to debride one-half
the interproximal area.
Lingual Furcation Debridement
of the Mandibular First Molar
Dominant right-handed provider: Remove the H4L,
P2L, or TK2-1L tip and replace with H4R, P2R, or
TK2-1R.
Dominant left-handed provider: Remove the
H4R, P2R, or TK2-1R tip and replace with H4L, P2L,
or TK2-1L.
Grasp the ultrasonic handpiece with your dominant hand.
See Chapter 9 for details if needed.
Grasp the HVE with your nondominant hand.
See Chapter 9 for details if needed.
Adapt the lateral surface of the active area antinode in a vertical
orientation at the cervical third on the crown of the tooth coronal
to the lingual furcation entrance (see Figure 20-33).
Establish a 0- to 15-degree angulation.
Position the HVE 0.5–6.0 inches from the water
port on the trip.
Select the operator positioning for direct vision.
• Dominant right-handed provider: 1–4 o’clock
• Dominant left-handed provider: 8–11 o’clock
Select the patient chair positioning for the mandibular arch.
Patient chair supine, semi-supine, or in between supine and
semi-supine with chin slightly down.
Establish a finger rest intraoral or extraoral, ensuring
correct ultrasonic handpiece grasp is maintained.
Ensure that the foot pedal is within reach. Turn on the HVE.
Begin instrumentation with the steps below.
 Skill Building: Debridement Curved Tips 381

2. Continue the ultrasonic activation stroke moving

toward the lingual furcation.
3. Be sure to maintain adaptation of the active area
antinode with a 0- to 15-degree angulation as you
approach the lingual furcation.
4. Enter the lingual furcation with the lateral sur-
face of the active area antinode. Maintain a 0- to
15-degree angulation. Debride one-half of the fur-
cation area. The other half was debrided from the
buccal (see Figure 20-35).

Figure 20-33 Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the lingual furcation
entrance.

1. Perform an ultrasonic activation stroke. Rotate

the active area antinode as you move apically to Figure 20-35 Lingual furcation debridement of the
maintain contact with the root surface at a 0- to mandibular first molar. Lateral surface of the active area
15-degree angulation (see Figure 20-34). antinode adapted in the lingual furcation entrance.

5. Adapt the lateral surface to debride the distal sur-

face of the mesial root with the active area antinode
at a 0- to 15-degree angulation (see Figure 20-36).

Figure 20-34 Lingual furcation debridement of the

mandibular first molar. Lateral surface of the active Figure 20-36 Lingual furcation debridement of the
area antinode adapted coronal to the lingual furcation mandibular first molar. Lateral surface of the active area
entrance. antinode adapted to the distal surface of the mesial root.
382 Chapter 20 Acteon Curved Tips

6. Adapt the opposite lateral surface to debride the

mesial surface of the distal root with the active
area antinode at a 0- to 15-degree angulation (see
Figure 20-37).
Distal-Lingual Root
Debridement of the Mandibular
First Molar
1. Adapt the lateral surface of the active area antinode
in a vertical orientation at the cervical third on the
crown of the tooth coronal to the distal-lingual
root mesial surface (see Figure 20-38).

Figure 20-38 Distal-lingual root debridement of the

Figure 20-37 Lingual furcation debridement of the
mandibular first molar. Lateral surface of the active area
antinode adapted to the mesial surface of the distal root.
7. Debridement of the mandibular first molar lin-
gual furcation is now complete.
mandibular first molar. Lateral surface of the active
area antinode adapted coronal to the distal-lingual root
mesial surface.
2. Perform an ultrasonic activation stroke. Rotate
the active area antinode as you move apically to
maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 20-39a and b).

A B
Figure 20-39 Distal-lingual root debridement of the mandibular first molar: A. Lateral
surface of the active area antinode adapted to the distal-lingual root mesial surface,
B. Lateral surface of the active area antinode adapted to the distal-lingual root.
 Skill Building: Debridement Curved Tips 383

3. Debride the entire distal root by adapting the lat-
eral surface of the active area antinode with a 0- to
15-degree angulation and moving from the mesial
surface of the distal-lingual root toward the distal
surface, conforming to the root anatomy.
4. Complete the distal-lingual root debridement
with the lateral surface of the active area antinode
adapted to the direct distal with a 0- to 15-degree
angulation as if you were probing the distal col
(see Figure 20-40a).
5. Debride one-half of the distal interproximal area.
The other half was debrided from the buccal (see
Figure 20-40b and c).
6. Debridement of the mandibular first molar
distal-lingual root is now complete.

A B

C
Figure 20-40 Distal-lingual root debridement of the mandibular first molar: A. Lateral surface of the active area
antinode adapted to the distal, B. Lateral surface of the active area antinode adapted to the distal debriding, C. Lateral
surface of the active area antinode adapted to the distal debriding one-half the interproximal area.
384 Chapter 20 Acteon Curved Tips

Mesial-Lingual Root
Debridement of the Mandibular
First Molar
1. Adapt the lateral surface of the active area antinode
in a vertical orientation with a 0- to 15-degree an-
gulation at the cervical third on the crown of the
tooth coronal to the mesial-lingual root distal sur-
face (see Figure 20-41).

Figure 20-41 Mesial-lingual root debridement of the

mandibular first molar. Lateral surface of the active
area antinode adapted coronal the mesial-lingual root
distal surface.

2. Perform an ultrasonic activation stroke. Rotate

the active area antinode as you move apically to
maintain contact with the root surface at a 0- to
15-degree angulation (see Figure 20-42a and b).
3. Debride the mesial root by adapting the lateral sur-
face of the active area antinode with a 0- to 15-degree
angulation and moving from the distal surface of the
mesial-lingual root toward the mesial surface of the
mesial-lingual root, conforming to the root anatomy.
B
Figure 20-42 Mesial-lingual root debridement of the
mandibular first molar: A. Lateral surface of the active
area antinode adapted on the mesial-lingual root distal
surface, B. Lateral surface of the active area antinode
adapted on the mesial-lingual root distal surface.
 Skill Building: Debridement Curved Tips 385

4. Complete the mesial-lingual root debridement
with the lateral surface of the active area antinode
adapted to the direct mesial with a 0- to 15-degree
angulation as if you were probing the mesial col
(see Figure 20-43a and b).
5. Debride one-half of the mesial interproximal area.
The other half was debrided from the buccal.
6. Debridement of the mesial-lingual root is now
complete.

A B
Figure 20-43 Mesial-lingual root debridement of the mandibular first molar: A. Lateral surface of the active
area antinode adapted to the mesial debriding one-half the mesial interproximal area, B. Lateral surface of the
active area antinode adapted to the mesial.

CASE STUDY
A 52-year-old Caucasian male with a noncontributory medical history presents to your office with a chief complaint of
“My teeth are starting to get loose and something on the lower left hurts. My teeth are sensitive to hot and cold tempera-
tures.” The patient’s last dental visit was at the age of 17. The initial panoramic X-ray and left side bitewing and periapical
radiographs with intraoral camera photographs are shown here. The mandibular left wisdom tooth was extracted the
same day of the new patient appointment due to a deep periodontal abscess and patient reported pain.
Periodontal assessment: 3–14 mm probe depths with 100% BOP, generalized moderate to severe recession, furca-
tion Class II and III, mobility Class 2 and 3.

Panoramic radiograph.
386 Chapter 20 Acteon Curved Tips

Mandibular anterior periapical.

Left premolar bitewing. Left molar bitewing.

Mandibular right premolar and molar periapical.

A B
Intraoral photographs: A. Anterior facial surfaces, B. Mandibular left canine, lateral incisor, and right central
incisor lingual surfaces.
 Skill Building: Debridement Curved Tips 387

Treatment options include:

1. Full-mouth rehabilitation with a prosthodontist.
2. Extractions and removable partial or full denture.
3. Nonsurgical periodontal debridement with informed consent (this procedure may not save the teeth).
The patient is dentally anxious and selects treatment plan option number three. The mandibular left was debrided first.
Post-operative radiographs and intraoral photographs are shown here.

Left bitewing. Mandibular left premolar periapical.

Mandibular left molar periapical. Mandibular left canine periapical with technique errors.
388 Chapter 20 Acteon Curved Tips

Mandibular anterior and premolar lingual surfaces. Mandibular left anterior facial surfaces.

Mandibular left premolar lingual surfaces.

1. Describe the staged instrumentation approach the dental hygienist likely used to debride the mandibular left
lateral incisor to completion. State the tip designs that were used and why. Also state the power level used with
each stage of instrumentation.
2. What curved tip did the dental hygienist use to debride the root concavity on the mesial-lingual of the mandibular
left first premolar? What orientation was used?
3. Describe how the dental hygienist debrided the deep distal root defect of the mandibular left second molar with
staged instrumentation. State the tip designs that were used and why. Also state the power level used with each
stage of instrumentation.
4. Why would the straight long shank tip not debride the mandibular left second molar distal area to completion?
5. What curved tip did the dental hygienist use to debride the buccal Class III furcation of the mandibular left first
molar? What orientation was used?
 References 389

Summary
This chapter presented the clinical use of piezoelec-
tric curved tips manufactured by Acteon. The curved
tips are used as a pair to debride complex root anat-
omy. Low to medium power with the lateral surfaces
adapted in a vertical orientation with a 0- to 15-degree
angulation is used to protect less mineralized hard tis-
sues such as dentin and cementum.

Questions
1. True or False. The correct adaptation of right- and 7. Which tip would be the best selection to debride
left-curved tips is different for a dominant right- the maxillary right first premolar mesial-lingual
handed provider than a left-handed provider. 2-3 mm subgingivally when the tooth has no
a. True attachment loss?
b. False a. Right-curved tip
2. What power level is appropriate to use when b. Left-curved tip
debriding complex root anatomy such as a c. Straight tip
furcation with ultrasonic instrumentation? 8. Which tip would be the best selection to debride
a. Low the mandibular left canine distal-facial 2–3 mm
b. Medium subgingivally when the tooth has no attachment
c. High loss?
d. Both A and B a. Right-curved tip
3. What surfaces of curved piezoelectric tips b. Left-curved tip
should be adapted in vertical orientation c. Straight tip
subgingivally? 9. Which tip would be the best selection to debride
a. Lateral the maxillary left central incisor mesial-lingual
b. Face 2–3 mm subgingivally when the tooth has no
c. Point attachment loss?
4. Which of the following ultrasonic shank a. Right-curved tip
angulations is contraindicated when debriding b. Left-curved tip
apical of the Cementoenamel junction (CEJ)? c. Straight tip
a. 0–5 degrees 10. Which tip would be the best selection to debride
b. 5–10 degrees the maxillary left first and second molars
c. 10–15 degrees distal-buccal 2–3 mm subgingivally when the
d. 90 degrees tooth has no attachment loss?
5. True or False. When debriding 6 mm under the a. Right-curved tip
gums with a curved tip in a vertical orientation, b. Left-curved tip
the shank that the provider can see will be c. Straight tip
parallel to the long axis of the tooth. 11. Which tip would be the best selection to debride
a. True a Class III furcation defect on the mandibular
b. False right first molar buccal?
6. When adapting into a furcation, which surface a. Right-curved tip
should be in contact with the cementum in the b. Left-curved tip
furcation entrance? c. Straight tip
a. Face
b. Point
c. Lateral
d. None of these

References
1. Drisko, C. L., Cochran, D. L., Blieden, T., Bouwsma, O. J.,
Cohen, R. E., Damoulis, P., Fine, J. B., Greenstein, G.,
Hinrichs, J., Somermman, M. J., Iacono, V., and Genco, R. J.
(2000). Position paper: Sonic and ultrasonic scalers in
periodontics. Research, Science and Therapy Committee
of the American Academy of Periodontology. Journal of
Periodontology, 71(11), 1792–1801. https://doi.org/10.1902
/jop.2000.71.11.1792
 CHAPTER 21
Air Polishing Introduction
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Select the best tooth polishing procedure for
a patient that will pair an appropriate level of
abrasion for their needs.
2. Identify tooth polishing techniques that increase
the risk for over-abrasion and hard tissue
alteration and removal.
3. Compare and contrast rotary handpiece
polishing and air polishing.
4. Appraise the differences between stand-alone,
portable, single-power, and multipower air
polishing devices.
5. Recognize the clinical indications for the use of
a standard and subgingival nozzle.
6. Describe the two mechanisms of action of an
air polishing device.
7. Identify individual patient polishing
contraindications and considerations.
KEY TERMS
• Abrasion: the process of wearing something away.
• Air polishing device (APD): device that delivers
a slurry mixture of compressed air, powder
particles, and water to the crown and root
surfaces of teeth.
• Cleaning agent: non-abrasive chemical applied
to tooth and restorative materials with a rotary
•
handpiece.
Extrinsic exogeneous stain: stain present on the
surface of a tooth that originated from an external
•
source.
Mohs hardness: a scale of measurement that lists
a mineral’s surface resistance to scratching or
abrasion.
• Multipower delivery air polishing device:
commonly found on stand-alone APDs that will
expel the slurry mixture from the nozzle with
changeable powder velocity settings.
• Over-abrasion: unintentional or intentional
excessive wearing away of hard tissues or
restorative materials during tooth polishing.
• Polishing agent: abrasive chemical applied to
tooth and restorative materials with a rotary
handpiece.
• Portable handheld air polishing device: ADP that
attaches to the air turbine connector on a dental
unit and does not require an electrical outlet
connection.
• Powder chamber: part of an APD that holds the
powder.
• Single-power delivery air polishing device:
commonly found on portable handheld APDs
that expel the slurry mixture from the nozzle at
a set powder velocity that is not adjustable.
• Stand-alone air polishing device: APD that
requires an electric outlet connection, attaches to
the air connector on a dental unit, and either uses
an independent water reservoir or attaches to the
water connector on a dental unit.
• Standard nozzle: reusable nozzle with a larger
diameter lumen opening than a subgingival
nozzle that delivers the slurry mixture to the
crown and root surfaces of teeth.
• Subgingival nozzle: single-use flexible narrow
tapered nozzle with a smaller diameter lumen
opening than a standard nozzle that delivers
the slurry mixture subgingivally into deeper
periodontal pockets.
• Tooth polishing: procedure to mechanically
remove extrinsic exogeneous staining and biofilm
from the surface of a tooth.
• Venturi effect: a principle of fluid dynamics
where the velocity of a fluid passing through
a constricted area will increase with resultant
decrease in pressure.
391
392 Chapter 21 Air Polishing Introduction

Introduction
Air polishing has been a part of preventive care for de-
cades. The initial discovery of air devices is attributed
to Dr. Robert Black, who invented the Air Dent in
1945. The Air Dent combined compressed air and
water with a highly abrasive powder (aluminum ox-
ide) for decay removal. This technique was, and still
is, referred to as air abrasion. Air abrasion gave way to
a new type of air technology known as air polishing in
the 1970s that was used in routine preventive proce-
dures for supragingival stain removal.
The literature presented in this chapter will
demonstrate that air polishing causes less tooth surface
alteration and removal compared to rotary handpiece
A
polishing with a polishing agent. Air polishing offers
a more conservative and efficient approach for biofilm
management and stain removal than alternative pol-
ishing techniques. Air polishing devices (APDs) are
either stand-alone or portable with single-power and
multipower functionality An APD delivers a slurry
mixture of compressed air, powder particles, and wa-
ter to the crown and root surfaces of teeth. There are
two nozzle designs with varied clinical applications.
This chapter provides an introductory overview of the
equipment used in air polishing with a comparison to
rotary handpiece polishing that will enable you to se-
lect the method of delivery that will provide the most
conservative and safe treatment for your patient. B
Figure 21-1 Nicotine Staining: A. Nicotine staining on
the maxillary right anterior lingual surfaces B. Nicotine
Tooth Polishing staining on mandibular anterior lingual surfaces.

Tooth polishing is a procedure to mechanically re-
move extrinsic exogeneous staining and biofilm from
the surface of a tooth (Lamont et al., 2018). ­Extrinsic
exogeneous stain occurs on the surface of a tooth
that originates from an external source. Common
sources of extrinsic exogenous stain include, but are
not limited to:
• Environmental exposures to nicotine, prescription
medications, industry metals, and dark-colored
beverages (see Figure 21-1a and b and Figure 21-2).
• Chemical exposures to ingredients found in
mouth rinses and dentifrices such as stannous flu-
oride and chlorhexidine (see Figure 21-3a and b).
Polishing tooth surfaces is accomplished by two
different mechanisms:
1. Application of a polishing or cleaning agent with
a rubber cup, rubber point, or stiff bristle point
affixed to a rotary handpiece.
2. Exposure to a slurry mixture of compressed air,
powder particles, and water delivered by an APD.
Both mechanisms produce their clinic actions by
a process termed abrasion. Abrasion is the process of
wearing something away. In terms of tooth polishing,
abrasion wears away unwanted materials such as bio-
film and extrinsic exogeneous stain from hard tissues.
Over-abrasion is an excessive wearing away of tooth
surfaces that is damaging to hard tissues (enamel,
dentin, cementum). Over-abrasion can be intentional
or unintentional. Unintentional over-abrasion occurs
due to many reasons such as incorrect provider tech-
nique or incorrect delivery selection.
BREAKOUT POINT
Tooth polishing removes unwanted materials from
tooth surfaces through abrasion.

Figure 21-2 Coffee Staining. Coffee staining on mandibular anterior and premolar lingual surfaces.
A
B
Figure 21-3 Chemical Staining: A. Chlorhexidine staining
on mandibular anterior lingual surfaces, B. Stannous
fluoride staining on mandibular anterior facial surfaces.
Rotary Handpiece
Polishing
Rotary handpiece polishing produces intentional,
selective, and controlled wear to hard tissues (Boyd
et al., 2021) using a rubber cup, rubber point, or stiff
bristle brush laden with a polishing or cleaning agent
(see Figure 21-4a to c). The provider should use the
Rotary Handpiece Polishing 393
least abrasive agent for the patient presentation and
selectively polish hard tooth surfaces with extrinsic
exogeneous stain and/or biofilm.
Cleaning and polishing agents are applied to
hard tissue surfaces and dental materials with a rotary
handpiece (see Figure 21-5a and b). Cleaning agents
are nonabrasive chemicals that are safe for use on hard
tissues and restorative materials. Polishing agents
are routinely used to remove extrinsic exogeneous
staining and biofilm from tooth surfaces during pre-
ventive procedures
• Polishing agents: The most common agents used for
routine tooth polishing are calcium carbonate and
flour of pumice (Sawai et al., 2015). Other chem-
icals such as aluminum oxide, aluminum silicate,
boron, emery, feldspar, garnet, perlite, silica, silicon
carbide, silicon dioxide, tin oxide, zirconium oxide,
or zirconium silicate are used for polishing hard tis-
sues and dental materials (Sawai et al., 2015).
• Polishing agents and dental materials: Polishing
agents are abrasive, with the potential to scratch
dental materials depending on multiple factors
such as the delivery method, provider technique,
and abrasiveness of the agent. Polishing agents
should not be used on certain dental materi-
als such as dental ceramics (porcelain, alumina,
zirconia), and porcelain-bonded alloys because
they irreversibly increase surface roughness and
decrease restoration gloss (Salawai et al., 2015;
Covey et al., 2011; Monaco et al., 2020; Sugiyama
et al., 2017).
• Polishing agent particle design: There is no indus-
try standardization for particle shape, size, hard-
ness, and abrasiveness. Manufacturers determine
their particle design for coarse, medium, fine, and
ultrafine. This places the burden on the provider
to be familiar with each manufacturer’s polish-
ing agent in the office and then correctly pair the
agent to their patient’s needs.
394 Chapter 21 Air Polishing Introduction

B
Figure 21-5 Polishing agent and rubber cup: A. Dentsply
Sirona Nupro Prophy Paste, B. Dentsply Sirona Nupro
C Freedom Disposable Prophy Angle with polishing paste.
Figure 21-4 Rotary handpiece polisher and rubber cup:
Reproduced with permission from Dentsply Sirona

A. Dentsply Sirona Nupro Freedom Cordless Prophy

system, B. Corded polisher: Dentsply Sirona Midwest low Polishing agents have a larger, more irregu-
speed handpiece and disposable prophy angle, C. Dentsply lar shape than air polishing powders, increasing
Sirona Nupro Freedom disposable prophy angles. their abrasive effects when the rotary cup pushes
Reproduced with permission from Dentsply Sirona. the particle into hard tissues and dental materials

(Covey et al., 2011; Christensen & Bangerter, 1987)
(see Figure 21-6a and b) Polishing agent characteristics
that increases abrasion effects are (Sawai et al., 2015;
Christensen & Bangerter, 1987):
• Larger particle sizes.
• Higher Mohs hardness (described later).
• Irregular shapes with sharp edges.
BREAKOUT POINT
There is no industry standardization for polishing
agents’ particle shape, size, hardness, and
abrasiveness.
A
B
Figure 21-6 Polishing agents: A. Nupro coarse and flour
of pumice polishing agents under SEM 500x. Note the
large irregular-shaped particles with sharp edges.
B. SEM of enamel, dentin, and Cementoenamel
junction (CEJ) after rotary handpiece polishing of
enamel and dentin for 5 seconds, 2,500 revolutions
per minute, and 150 g of pressure. Notice the “enamel
scratches appeared mostly on the cervical one-third of
crowns. Dentin scratches covered entire exposed root”
(Christensen & Bangerter, 1987).
Used with permission from Dr. Rella Christensen, PhD
Rotary Handpiece Polishing 395
Mohs Hardness
The Mohs hardness scale measures a mineral’s
surface resistance to scratching or abrasion and was
invented by a German mineralogist in the 1800s
named Friedrich Mohs (Encyclopaedia Britannica,
2017). The Mohs hardness scale ranks minerals
1 through 10. A 10 (diamond) is the most resistant
mineral to scratching while 1 (talc) is the lowest.
The Mohs hardness scale is not a linear scale. For
example, a 4 on the Mohs hardness scale is 25%
more resistant to abrasion than a 3, and a 10 is
300% more resistant to abrasion than a 9 (Encyclo-
paedia Britannica, 2017). Oral hard tissues, dental
materials, polishing agents, and powders delivered
by an APD have a Mohs hardness rating as seen
in Table 21-1.
Polishing agents have a Mohs hardness rating
of 5.5–8.0 (depending on the chemical composi-
tion); Boyd et al., 2021) while air polishing powders
range from 2.0 to 4.0 (Chowdhary & Mohan, 2018;
Johnson et al., 2014). The goal of polishing is to use
a material that is softer than the structure it is applied
to, to avoid over-abrasion. Over-abrasion will occur
when a higher Mohs hardness material is used on a
lower Mohs hardness structure (Arabaci et al., 2007;
Graumann et al., 2013; Janiszewska-Olszowska et al.,
2020). For example, using a polishing agent on dentin
or cementum has the potential to cause over-abrasion
due to the higher Mohs rating of the polishing agent.
BREAKOUT POINT
Air polishing powders have a lower Mohs hardness
rating than polishing agents.
Table 21-1 Mohs Hardness
Mohs Hardness
Polishing agent (calcium
carbonate, flour of pumice) 5.5–8.0
Enamel 5.0
Dentin 3.0–4.0
Cementum 2.5–3.0
APD powders 2.0–4.0
Boyd et al. (2021), Chowdhary & Mohan (2018), Johnson et al. (2014)
396 Chapter 21 Air Polishing Introduction

Provider Technique
It is difficult to calibrate provider technique during
rotary handpiece polishing. Variables such as the
speed used for rotary cup rotation, the pressure ap-
plied to the rotary cup, the cup angulation, contact
time, and the quantity of paste used during polishing
influence abrasion effects (Graumann et al., 2013).
The risk for over-abrasion increases in the follow-
ing situations (Sawai et al., 2015; Graumann et al.,
2013):

• Higher speed of rotary cup rotation.

• Heavier lateral pressure applied to the rotary cup. A
• Incorrect rubber cup angulation to the tooth
surface.
• Increased quantity of polishing agent applied.
• Increased stiffness of the rubber cup, rubber
point, or bristle point. The stiffness of these ma-
terials is not industry standardized and varies by
manufacturer.
Polishing all hard tissues with an abrasive polish-
ing agent is not recommended (Sawai et al., 2015).
The American Dental Hygienists’ Association (1998)
endorses selective polishing to limit the removal of
hard tissues, especially for less mineralized hard tis-
sues such as dentin and cementum, whose Mohs B
hardness is only 3–4. Nonselective polishing can lead
to the following adverse effects:
• Removal of microns of enamel (Christensen &
Bangerter, 1987; Pence et al., 2011). Cervical
enamel is more prone to removal than the oc-
clusal because occlusal enamel is thicker. A pol-
ishing agent with a high Mohs hardness should
not be used on tooth surfaces with active caries
or enamel with erosion, attrition, abrasion, or de-
mineralization to avoid further breakdown (Sawai
et al., 2015; see Figure 21-7a to c).
• Removal and over-abrasion of less mineralized
hard tissues such as dentin and cementum (Sawai
et al., 2015). Cementum in the cervical region of
teeth is very thin, ranging from 20 to 50 µm in
thickness (Sauro et al., 2010). This area of a tooth
has an increased risk for over-abrasion when ex-
posed to materials high on the Mohs hardness
scale (Sauro et al., 2010) (see Figure 21-6b).
• Removal of the outer fluoride rich layer on C
the enamel (Boyd et al., 2021; Christensen &
Figure 21-7 Hard Tissue Injury: A. Cervical
Bangerter, 1987; Gutmann, 1998).
demineralization and decay on the facial of the maxillary
• Increase dentinal hypersensitivity through the re- right canine, B. Erosion and attrition on the lingual
moval of the smear layer when not using a ther- surfaces of the maxillary right first premolar and
apeutic polishing agent such as Novamin that anterior teeth, C. Recurrent decay on the cervical-buccal
occludes dentin tubules (Sawai et al., 2015). of a mandibular molar.
 Air Polishing 397

Air Polishing
Air polishing is accomplished with the use of a
stand-alone or portable device equipped with a noz-
zle. Powder is placed inside a powder chamber of
the device. The powder chamber is a specialized con-
tainer that holds powder particles. When an ADP is
activated, compressed air and water runs through the
nozzle and mixes with the powder from the powder
chamber. A slurry mixture is expelled from the nozzle
opening.

Air Polishing Devices

APDs are sold as stand-alone devices or portable
handheld devices.
• Stand-alone air polishing device: A stand- A
alone APD requires an electric outlet connection,
attaches to the air connector on a dental unit, and
either uses an independent water reservoir or at-
taches to the water connector on a dental unit (see
Figure 21-8a). The device has a detachable hand-
piece with either an affixed or detachable nozzle
(see Figure 21-8b).
• Portable handheld air polishing device: A
portable handheld APD attaches to the air turbine
B
connector on a dental unit and does not require
an electrical outlet connection (see Figure 21-9a). Figure 21-8 Stand-alone air polishing device:
The powder chamber is smaller than a stand- A. Dentsply Sirona Cavitron Jet-Plus, B. Dentsply Sirona
Jet-Mate Ultrasonic handpiece with detachable Cavitron
alone device. The device has a detachable hand- Jet Air Polishing Insert.
piece with either an affixed or detachable nozzle Reproduced with permission from Dentsply Sirona
(see Figure 21-9b and c).
Each device has psi requirements for the air and
at a set powder velocity that is not adjustable. The
water flow that are specified in the manufacturer di-
powder is placed into the powder chamber, and
rections for use or instructions for use (DFU/IFU).
compressed air is forced into the chamber, mix-
Psi is a unit of pressure and stands for pound force per
ing with the powder. An internal control regulates
square inch. In general, the higher the psi, the higher
the amount of powder used and velocity of the ex-
the level of abrasion capability. When using a portable
pelled slurry, which is largely dependent on the vol-
or stand-alone APD, the psi of the dental unit water
ume of powder in the chamber (Donnet et al., 2021;
and air may need to be adjusted to the specifications
Petersilka, 2000).
found in the product’s DFU/IFU. Using incorrect wa-
A portable handheld APD is an example of a
ter and air psi settings will alter the velocity of slurry
single-power delivery system. It attaches to the
expulsion and increases the risk for over-abrasion
air-turbine connector on a dental unit and has a
(Kozlovsky et al., 2005; Petersilka et al., 2003).
smaller powder chamber than a stand-alone APD.
Smaller powder chambers deplete their powder faster
APD Design than a larger chamber. When the powder volume
There are two designs for an APD: single-power deliv- decreases, the risk for inconsistent powder parti-
ery or multipower delivery. cle expulsion increases. Powder fluctuations lead to
undesired changes such as over-abrasion, decreased
Single-Power Delivery. A single-power delivery efficiency, and compromised patient outcomes
air polishing device expels the slurry mixture of (Kozlovsky et al., 2005; Petersilka et al., 2003; Donnet
compressed air, powder, and water from its nozzle et al., 2021; Petersilka, 2000).
398 Chapter 21 Air Polishing Introduction
A deposit, decreasing the risk for over-abrasion.
B Figure 21-11a and b).
C
Figure 21-9 Portable handheld air polishing device:
A. EMS AIRFLOW Handy 3.0 Perio and AIR-FLOW
Handpiece, B. EMS AIRFLOW Handy 3.0 Perio without
nozzle attached, C. EMS AIRFLOW Handy 3.0 Perio with
attached PERIOFLOW nozzle.
Reproduced with permission from HuFriedyGroup Mfg. Co., LLC.
BREAKOUT POINT
Small powder chambers deplete their power
faster than a large powder chamber and can cause
inconsistent powder particle expulsion.
Multipower Delivery. A multipower delivery
air polishing device expels the slurry mixture of
compressed air, powder, and water from its nozzle at
variable velocities selected by the provider through the
powder velocity control. The powder velocity control
changes the amount of powder used and the speed
of powder discharged from the chamber. Powder is
placed into a powder chamber, and compressed air
is forced into the chamber, mixing with the powder
(see Figure 21-10a to c). When activated by the user, the
slurry mixture is expelled from the nozzle at a velocity
determined by the powder velocity selection. This is
beneficial because the provider can pair the velocity of
powder expulsion to the level of oral deposits present
on tooth surfaces, decreasing the risk for over-abrasion.
BREAKOUT POINT
A multipower APD allows the provider to correctly
pair the powder expulsion to the level of oral
Stand-alone APDs are typically multipower with
a larger powder chamber than the one on a portable
handheld APD. A multipower delivery APD is designed
with a rounded powder chamber that has an open nar-
row tube inside and is sealed with a removable cap (see
• The tube is in the center of the powder chamber
(Figure 21-11a) and has a series of small holes at
its base (Figure 21-11c).
• When the device is activated, a stream of com-
pressed air is forced into and through the tube.
• The powder in the chamber is agitated and drawn
into the small holes at its base.
• The air powder stream is projected upward
toward the cap.
• The air powder mixture exits through its outlet
at the upper part of the chamber and is pumped
through the handpiece connector cable and into
the handpiece affixed with a nozzle, where it is
expelled onto tooth surfaces.
The provider fills the chamber with powder.
• The chamber should be filled so the powder level
does not completely deplete while in use or incon-
sistent powder emissions will occur, decreasing the
efficiency of the device and increasing the risk for
over-abrasion (Kozlovsky et al., 2005; Petersilka
et al., 2003; Donnet et al., 2021; Petersilka, 2000).
• The powder level should never cover the opening
of the tube.
 Air Polishing 399

A B C
Figure 21-10 Stand-alone multipower APD powder holding chamber: A. Dentsply Sirona Cavitron Jet-Plus
non-detachable powder bowl, B. EMS AIRFLOW Prophylaxis Master detachable powder chamber. C. EMS powder
chamber removed from the device.
A: Reproduced with permission from Dentsply Sirona; B and C: Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Cap

Powder

Tube
Air line
A B C
Figure 21-11 Multipower powder chamber: A. Dentsply Sirona Cavitron Jet-Plus powder bowl with inner tube,
B. Removable cap (Dentsply Sirona Cavitron Jet-Plus powder bowl cap), C. Powder chamber

Nozzle Design (see Figure 21-12a and b). The nozzle expels the slurry
mixture from the APD. Standard nozzle has two concen-
A nozzle expels the slurry into the mouth. There are
tric openings (see Figure 21-13):
two nozzle designs: a standard nozzle and a subgingival
nozzle. Individual design characteristics of both, such • Outer opening: Expels water.
as the size, shape, length, angulation, lumen diameter • Inner opening: Expels powder and compressed
opening, and the materials they are made of, vary by air mixture. The compressed air causes the wa-
manufacturer. ter and powder to mix upon contact, creating a
slurry.
Standard Nozzle A standard nozzle will deliver the slurry mixture
A standard nozzle is reusable and has a larger di- supragingivally, and if the APD allows for subgingival
ameter lumen opening than a subgingival nozzle use, a standard nozzle will expel the slurry into shallow
400 Chapter 21 Air Polishing Introduction

Subgingival Nozzle
A subgingival nozzle is a single-use, flexible,
narrow-tapered nozzle with a smaller diameter lumen
opening than a standard nozzle. The nozzle will de-
liver the slurry mixture subgingivally into deeper peri-
A odontal pockets (. 4mm; Ng, 2018). The nozzle has
multiple small lumen diameter orifices or outlets at
its end that expel the water and compressed air pow-
der particles (see Figure 21-14). Manufacturers vary on
the number of orifices at the end, ranging from one
to three (Ng, 2018; Moene et al., 2010). The water
B
pressure is lower than a standard nozzle (Ng, 2018;
Figure 21-12 Standard nozzle: A. EMS AIRFLOW Max Moene et al., 2010). The powder and water exit hori-
handpiece, B. Dentsply Sirona Jet-Mate Ultrasonic zontally on the lateral aspects of the nozzle where they
handpiece and Cavitron JET Air Polishing Insert. mix together (Petersilka, 2000; Ng, 2018; Flemmig
A: Reproduced with permission from E.M.S. Electro Medical Systems S.A; B: Reproduced with permission from Dentsply Sirona
et al., 2012).

BREAKOUT POINT
A subgingival nozzle delivers the expressed slurry
into deep periodontal pockets.

A subgingival nozzle is made of a flexible, narrow

thermoplastic elastomer that is tapered at its end, with
an average thickness of 0.7 mm (varies by the manu-
facturer) to allow for subgingival access with minimal
tissue distention (Ng, 2018; Flemmig et al., 2012).
Some manufacturers place probe-like markings on

Figure 21-13 Nozzle Opening (Dentsply Sirona

Cavitron JET Air Polishing Insert) Inner opening expel
compressed air and powder particles. Outer opening
expels water.

(,4 mm) pockets (Ng, 2018). There are six different

powder selections that are presented in Chapter 22.
The powder selected influences whether the nozzle
delivers the slurry supragingivally or subgingivally.

BREAKOUT POINT
Figure 21-14 Subgingival nozzle with 3 orifices/
A standard nozzle has a larger diameter lumen outlets (EMS PERIOFLOW handpiece with single-use
opening than a subgingival nozzle. PERIOFLOW subgingival nozzle).
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
 Air Polishing 401

Figure 21-15 Subgingival nozzle (EMS PERIOFLOW

subgingival nozzle with probe-like markings).

the nozzle to assist the provider in correct subgingival

placement (see Figure 21-15).
Studies have indicated that a subgingival nozzle
can biofilm reduce periodontal pockets up to 9 mm
(Kozlovsky et al., 2005; Moene et al., 2010). In the
United States, a subgingival nozzle has Food and Drug
Administration (FDA) approval to reduce biofilm up
to 5 mm because some studies have shown biofilm
Figure 21-16 Ventiru effect. Thumb placed over the
removal efficiency slightly decreases in depths beyond opening of a water hose.
5 mm (Kozlovsky et al., 2005; Moene et al., 2010).

Subgingival Nozzle Mechanism of Action. Air Polishing Mechanism

A subgingival nozzle expels its slurry directly into the
periodontal pocket creating a vacuum-like environ-
ment through the Venturi effect. The Venturi effect
is a principle in fluid dynamics similar to Bernoulli’s
principle presented in Chapter 6.
• The Venturi effect occurs when a fluid (slurry mix-
ture) is forced into a constricted area (periodontal
pocket). As the fluid flow through a constricted
area, the velocity will increase which decreases
the pressure.
• In times of gingival inflammation, the volume of
gingival crevicular fluid (GCF) increases due to
the presence of inflammatory infiltrate, increased
blood flow, and invading organisms. The subgin-
gival nozzle introduces the slurry mixture into this
subgingival environment, which activates the fluid.
• The subgingival fluid is essentially vacuumed out
of the pocket by the Venturi effect, resulting in a
reduction in pathogenic organisms and biofilm in
the environment.
You have seen the Venturi effect before; you just
might not have known it. Anytime you place your
thumb over the opening of a garden hose and the wa-
ter jet stream velocity increases, you have witnessed
the Venturi Effect (see Figure 21-16).
of Action
Air polishing removes biofilm and extrinsic exoge-
nous stain through two mechanisms of action: fluid
dynamics and abrasion.
Fluid Dynamics
The water expelled from the APD nozzle causes the
release of kinetic energy. Kinetic energy is created
when the velocity of water is increased, which de-
creases environmental fluid pressure as proven by
Bernoulli’s principle. See Chapter 6 for a review if
needed. This change of pressure in response to an
increase in fluid velocity (speed) causes the release of
kinetic energy.
The water interacts with the APD powder in the
following ways (Petersilka et al., 2003):
1. The kinetic energy produced by the water frag-
ments the powder particles, reducing their size
before they contact the tooth surface.
2. The water dampens the impact of the powder par-
ticle that strikes the tooth surface.
These two effects produce a slurry mixture that is
less abrasive to tooth surfaces than a rotary handpiece
polisher with a polishing agent.
402 Chapter 21 Air Polishing Introduction
BREAKOUT POINT
Fluid dynamics of an APD fragment and dampened
powder particles before they strike a tooth surface,
which decreases the risk for over-abrasion.
Abrasion
The abrasion produced by an APD is beneficial in
the wearing away and removal of unwanted materi-
als such as biofilm, extrinsic exogeneous stains, and
immature dental calculus. There are many factors that
play a role in the abrasion capability of an APD such
as the delivery system, nozzle design, and provider
technique.
BREAKOUT POINT
An APD will remove biofilm, extrinsic exogeneous
stain, and immature dental calculus from tooth
surfaces through abrasion.
Delivery System. An APD that delivers the most
constant and consistent powder and water flow pro-
duces superior abrasion surface effects with less risk
for over-abrasion (Graumann et al., 2013; Kozlovsky
et al., 2005; Petersilka et al., 2003; Donnet et al.,
2021; Petersilka, 2000). Box 21-1 demonstrates the se-
quence of events that can cause over-abrasion from
inconsistent water flow rates.
Incorrect water flow rates can cause over-abrasion
or under-abrasion (Graumann et al., 2013; Kozlovsky
Box 21-1
Inconsistent water flow rate
↓ be too high for the level of extrinsic exogeneous
Decreases kinetic energy released
↓
Less fragmenting of powder particles
↓
Larger, more abrasive powder particles reach the
tooth surface
↓ ter flow rate to the level of extrinsic exogeneous
Increased risk for over-abrasion
et al., 2005; Petersilka et al., 2003; Donnet et al.,
2021; Petersilka, 2000):
• Over-abrasion: Insufficient water will cause
over-abrasion because powder particles are not
fragmented correctly and contact structures as a
larger size from less kinetic energy.
• Under-abrasion: Excessive water will cause
under-abrasion because the powder volume is de-
creased, and its particle size is dampened.
Inconsistent powder flow rates can cause
over-abrasion or under-abrasion (Kozlovsky et al.,
2005; Petersilka et al., 2003):
• Over-abrasion: too high powder flow will cause
over-abrasion (Graumann et al., 2013; Kozlovsky
et al., 2005; Petersilka et al., 2003; Donnet et al.,
2021; Petersilka, 2000).
• Under-abrasion: too little powder flow will cause
under-abrasion (Graumann et al., 2013; Kozlovsky
et al., 2005; Petersilka et al., 2003; Donnet et al.,
2021; Petersilka, 2000).
The volume of powder in the chamber influences
abrasion effects:
• When powder levels are too low inside the cham-
ber, an inconsistent amount of powder is deliv-
ered, which decreases efficiency and compromises
patient outcomes (Graumann et al., 2013; Kozlovsky
et al., 2005; Petersilka et al., 2003; Donnet et al.,
2021; Petersilka, 2000).
• The size of the APD powder chamber influences
powder flow rates. Larger powder chambers
allow for more consistent powder emissions
during active use because they do not deplete
as fast as smaller chambers (Graumann et al., 2013;
Kozlovsky et al., 2005; Petersilka et al., 2003;
Donnet et al., 2021; Petersilka, 2000).
APD single-power delivery or multipower deliv-
ery influences abrasion effects. A multipower device
with adjustable power settings is more ideal than one
without (Donnet et al., 2021):
• Single-power delivery APDs are always delivering
maximum powder and water flow rates that may
stain and biofilm (Donnet et al., 2021). This
causes excessive abrasion than what is necessary
for the patient presentation (Buhler et al., 2015).
• Multipower delivery APDs allow the provider
to correctly pair the powder emission and wa-
stain and biofilm in the mouth. This will prevent
over-abrasion.

Nozzle Design. Individual nozzle characteristics
such as length, diameter, lumen diameter size of the
opening, and shape influence the efficiency of slurry de-
livered. There is no industry standardization for nozzle
designs, so the provider needs to be trained in proper
use for their device. Some nozzles deliver a more focused
slurry while others deliver a more turbulent expulsion.
• A more focused slurry expulsion increases effi-
ciency and decreases contact time and the risk for
over-abrasion (see Figure 21-17a).
• A more turbulent expulsion allows the slurry to
spray in unwanted directions, decreasing effi-
ciency and increasing the risk for over-abrasion
(see Figure 21-17b).
Provider Technique. Correct provider technique
is important for the safe delivery of any form of polish-
ing. Air polishing technique is complicated by the lack
of industry standardization, so the provider needs to
be trained in the proper use of their device. Technique
A BREAKOUT POINT
B •
Figure 21-17 Slurry Spray (Dentsply Sirona Cavitron JET
Air Polishing Insert) A. Focused spray B. Turbulent spray
Rotary and APD Polishing Comparison 403
errors can cause over-abrasion or under-abrasion,
both of which complicate patient outcomes.
• Incorrect angulation of the nozzle to the tooth or
gingiva can lead to over-abrasion (Petersilka, 2000).
• Incorrect movement of the nozzle across tooth
surfaces. Moving too slow will cause over-abrasion
and moving too fast will cause under-abrasion.
• Using the powder from one manufacturer in the
device of another. Manufacturer handpieces, noz-
zles, and powders are specially designed for their
APD. Equipment is not interchangeable without
industry standardization. Patient outcomes be-
come compromised, and equipment damage will
occur that may void your warranty when you
inter-mix manufacturer products. Refer to the
DFU/IFU for situations that void a warranty.
Manufacturers recommend a specific distance of
the nozzle from the tooth surface during active air
polishing. Exceeding this distance will cause the fol-
lowing adverse effects:
• Less focused spray whose slurry strikes more struc-
tures in the mouth than desired, causing a decrease
in efficiency, and an increase in aerosolization, soft
tissue irritation, and potential soft tissue trauma
(Buhler et al., 2015; see Figure 21-18a and b).
• Decreased water jet velocity. When water jet
velocity is decreased, powder particles are not
fragmented properly prior to striking the tooth,
leading to over-abrasion.
• Decreased effectiveness of the slurry that forces
the provider to increase contact time, leading to
over-treatment and over-abrasion (Petersilka et al.,
2000; Buhler et al., 2015).
Over-abrasion risk decreases when correct water
and powder flow rates are used, a more focused
slurry is expelled from the nozzle, and correct
provider technique is used.
Rotary and APD Polishing
Comparison
Air polishing is less abrasive to tooth structures than
using a rotary handpiece with a polishing agent
(Gutmann, 1998; Cochis et al., 2013; Ovard, 2018)
for the following reasons:
APD power particles have a lower Mohs hardness
rating than polishing agents (Boyd et al., 2021;
Chowdhary & Mohan, 2018; Arabaci et al., 2007;
404 Chapter 21 Air Polishing Introduction

Table 21-2 Rotary Handpiece Polishing and Air

Polishing Comparison
Rotary
Handpiece Air
Polishing Polishing
Agents with lower Mohs  
Rating (Boyd et al., 2021;
Chowdhary & Mohan, 2018)
Less alteration and removal of  
hard tissues (Johnson et al.,
2004; Buhler et al., 2015)
Can be safely used on less  
mineralized hard
tissues such as dentin and
cementum
More uniform-shaped particle  
A with less sharp edges
Less operator fatigue  
(Chowdhary & Mohan, 2018)
More efficient stain removal  
(Park et al., 2020)
Less aerosol production  

• Rotary handpiece polishing presses larger, more

irregular-shaped polishing agents into the tooth
surface (Christensen & Bangerter, 1987) while
APDs deliver a slurry mixture with fragmented
particles.
Due to their delivery with compressed air and
water, APDs remove supragingival biofilm and ex-
trinsic exogeneous stain more efficiently than rotary
handpieces (Graumann et al., 2013; Gutmann, 1998;
Park et al., 2020). APDs are also able to deliver their
slurry in difficult to access areas such as interproxi-
mal surfaces, crowded teeth, and orthodontic appli-
B
ances (Park et al., 2020).
Figure 21-18 Nozzle distance from tooth: A. Incorrect Table 21-2 summarizes the differences between ro-
nozzle distance (too far away)—less focused spray,
tary handpiece polishing and air polishing.
B. Correct nozzle distance with proper focused spray.

Graumann et al., 2013; Janiszewska-Olszowska

et al., 2020).
• APD powder particles are smaller in size than pol-
ishing agents (Boyd et al., 2021).
• APD powder particle shape is more uniform, with
fewer gagged and sharp edges than polishing
agents.
• APD power particle size is reduced prior to con-
tacting structures in the mouth due to the mixture
with water and the kinetic energy released.
Polishing
Contraindications
and Considerations
Tooth polishing with a rotary handpiece or APD is a
very safe procedure and routinely performed in the
dental setting. There are times when polishing is con-
traindicated or when special considerations should be
exercised.
 Polishing Contraindications and Considerations 405

Contraindications
A contraindication, as presented in Chapter 7, is a sit-
uation when a device should not be used because it
may harm the patient. Absolute contraindications for
polishing with a rotary handpiece or an APD include:
• Allergy to ingredients or flavoring agents.
• Tooth structures with demineralization, ero-
sion, attrition, abrasion, or active caries (see
Figure 21-19a and b). Air polishing can still be
administered on other teeth in the mouth, but it
should be avoided on these defects.
• Denuded root surfaces.

Considerations
A consideration, as presented in Chapter 7, is a situa-
tion when the provider must weigh the potential con-
A
sequences against the benefits when deciding to use a
specific technology in patient care. Patients should con-
sult their physician prior to undergoing routine teeth
polishing (rotary handpiece or air polishing) if they
present with any of the following medical conditions:
• Active or poorly controlled respiratory disease
where daily breathing is challenged. Examples
include, but are not limited to, those with un-
controlled or poorly controlled asthma, Chronic
Obstructive Pulmonary Disease (COPD), cystic
fibrosis, or lung cancer.
• Communicable disease. Examples include, but
are not limited to, active infection with coronavi- B
rus, influenza, tuberculosis, or herpes. Figure 21-19 Hard Tissue Injury: A. Cavitated molar
• Any medical condition that causes immunosuppres- cervical surface, B. Attrition on mandibular anterior
sion where the risk for a bacteremia is increased. incisal surfaces.

CASE STUDY
Patient is a 68-year-old Caucasian female with prediabetes taking metformin. Her Body Mass Index (BMI) is 28. She does
not have any known allergies or drug allergies. She is retried, she is a nonsmoker, does not drink alcohol, and likes to
drink hot tea multiple times a day. She has no chief complaints.
Dental exam: No treatment needs.
Occlusion: Class I bilateral with first molar relationship. Crowding of the mandibular anterior teeth.
Oral hygiene exam:
■ Disclosing solution revealed 85% of surfaces with biofilm and dental calculus.
■ Generalized moderate extrinsic exogeneous stain, biofilm, and dental calculus.
Periodontal exam:
■ Probe depths generalized 3–5 mm with bleeding upon probing 62% of the mouth.
■ Class I and II furcation involvement on all molars and Class IV furcation on the maxillary right first molar as seen in
the intraoral photograph.
■ Generalized bone loss in the coronal third.
■ Localized vertical bone loss in the apical-third on the distal of the maxillary right first molar.
■ Generalized recession.
406 Chapter 21 Air Polishing Introduction

Tissue description:
■ Generalized firm, coral pink, stippled attached gingiva.
■ Localized loss of interdental papillae due to recession with Class II embrasure spaces.

Intraoral Photograph: Maxillary right posterior teeth Intraoral Photograph: Mandibular anterior teeth facial
buccal surfaces. surfaces

1. What type of polishing (rotary handpiece with polishing agent or air polishing) should be performed on the
maxillary right first molar? Justify your answer.
2. What type of polishing (rotary handpiece with polishing agent or air polishing) should be performed on the
mandibular anterior teeth? Justify your answer.
3. If the air polisher left behind residual stain in the interproximal area of the mandibular right lateral incisor, what
ultrasonic shank diameter would be the best option for its removal? Justify your answer.
4. What could be causing the stain seen in the intraoral camera photograph of the mandibular anterior facial and
interproximal surfaces?
5. Is it likely air polishing can remove the dental calculus pictured in the intraoral photographs? Why or why not?
6. Can air polishing remove the dark color on the cervical area of the maxillary right posterior buccal surfaces? Why
or why not?
7. The dental hygienist chooses to deliver an air polishing powder that can be used supragingivally and subgingivally.
What nozzle(s) will the dental hygienist need for this case? Justify your answer.

Summary
This chapter introduced air polishing equipment and
provided a thorough comparison to rotary handpiece
polishing. Air polishing causes less alterations to hard
tissue surfaces than rotary handpiece polishing due to
its overall delivery with compressed air, fluid dynam-
ics, and powder particle design. There are various air
polishing market choices for the provider, including
stand-alone, portable handheld, single-power, and
multipower delivery. Subgingival nozzles deliver the
slurry mixture into deeper periodontal pockets, which
is useful in times of gingival inflammation around nat-
ural teeth and dental implants.

Questions
1. Which of the following can cause extrinsic
exogeneous staining on tooth surfaces?
a. Nicotine
b. Stannous fluoride
c. Chlorhexidine
d. All of the above
2. Which of the following is TRUE of air polishing?
a. The kinetic energy produced by the water
released from the nozzle of an APD fragments
the powder particles and decreases their size
before reaching structures inside the mouth.
b. Polishing agents have a lower Mohs hardness
than air polishing powders.
c. Provider technique has no effect on the
abrasion effects on tooth surfaces.
d. Over-abrasion is a desired effect of tooth
polishing.
3. Which of the following is TRUE of a polishing
agent applied with a rotary handpiece?
a. Polishing agents have a higher Mohs hardness
than dentin and cementum.
b. Polishing agents have the potential to scratch
dental materials.
c. Polishing agents can alter and remove oral
hard tissues.
d. All of the above
4. Which of the following is a correct Mohs order
from highest rating to lowest?
a. Enamel, APD powder, dentin, polishing agent
b. Enamel, polishing agent, APD powder, dentin
c. Polishing agent, enamel, dentin, APD powder
d. Polishing agent, enamel, APD powder, dentin
5. Which of the following increase(s) the risk for
over-abrasion when using a rotary handpiece
with a polishing agent?
a. Using less lateral pressure
b. Higher speed of cup rotation
c. Stiffer rubber cup
d. Using less polishing agent
e. Both B and C
6. Which of the following is an adverse effect of
nonselective rotary handpiece polishing with a
nontherapeutic polishing agent?
a. Unintentional removal of cementum
b. Unintentional removal of hard tissue in a
demineralized area
c. Removal of the outer fluoride rich layer of
enamel
d. Increased dentinal hypersensitivity through
the removal of the smear layer.
Questions 407
e. All of the above
7. Where do you connect a portable handheld air
polishing device on the dental unit?
a. Air/water syringe
b. Air-turbine connector
c. High-speed evacuation line
d. A portable handheld device does not connect
to the dental unit
8. True or False. The psi for all air polishing
devices is the same.
a. True
b. False
9. True or False. It is desirable to have an APD that
produces a more consistent power flow rate than
one that does not.
a. True
b. False
10. Which APD nozzle uses the Venturi effect for its
mechanism of action?
a. Standard nozzle
b. Subgingival nozzle
For questions 11 to 13, match the following statement
to the correct mechanism of action for an APD. An-
swer A for fluid dynamic and B for abrasion. There is
only one correct answer for each question.
11. Decreases the powder particle size with kinetic
energy.
12. Wears away and removes unwanted materials
such as extrinsic exogeneous stain and biofilm.
13. Dampens the impact of powder particles on the
tooth surface.
Match the following APD delivery changes to whether
it will cause over-abrasion or under-abrasion for ques-
tions 14–21. Answer A for over-abrasion and B for
under-abrasion. There is only one correct answer for
each question.
14. Too little water
15. Excessive water
16. Too high powder flow rate
17. Too low powder flow rate
18. Incorrect angulation of the nozzle
19. Moving the nozzle too slowly
20. Moving the nozzle too fast
21. Slurry spray that is less focused and more
turbulent
408 Chapter 21 Air Polishing Introduction
22. True or False. Smaller powder chambers of an
APD allow for more consistent powder emission
during active use because they deplete their
powder faster.
a. True
b. False
23. Which of the following provider technique(s)
can increase the abrasion effects on tooth
surfaces when using an APD?
a. Increased contact time of the slurry on tooth
surfaces
b. Decreased working distance of the nozzle to
the tooth surface
c. Incorrect nozzle angulation
d. Incorrect nozzle movement across tooth
surfaces
e. All of the above
Match the following statements to the correct response
for questions 24–29. Answer A for air polishing and
References
1. American Dental Hygienists’ Association. (1998). American
Dental Hygienists’ Association position paper on the oral prophylaxis.
https://www.adha.org/resources-docs/7115_Prophylaxis
_Postion_Paper.pdf
2. Arabaci, T., Cicek, Y., Ozgoz, M., Canakci, V., Canakci, C.
F., & Eltas, A. (2007). The comparison of the effects of three
types of piezoelectric ultrasonic tips and air polishing system
on the filling materials: An in vitro study. International Journal
of Dental Hygiene, 5, 205–210.
3. Boyd, L. D., Mallonee, L. F., & Wyche, C. J. (2021). Wilkins’
clinical practice of the dental hygienist (13th ed.). Jones &
Bartlett Learning.
4. Buhler, J., Anato, M., Weiger, R., & Walter, C. (2015).
A systematic review on the effects of air polishing on oral
tissues. International Journal of Dental Hygiene, 14, 15–28.
5. Chowdhary, Z., & Mohan, R. (2018). Efficiency of three
different polishing methods on enamel and cementum: A
scanning electron microscope study. Journal of Indian Society
of Periodontology, 22(1), 1–6.
6. Christensen, R. P., & Bangerter, V. W. (1987). Immediate and
long-term in vivo effects of polishing on enamel and dentin.
Journal of Prosthetic Dentistry, 57(2), 150–160.
7. Cochis, A., Fini, M., Carrassi, A., Migliario, M., Visai, L., &
Rimondini, L. (2013). Effect of air polishing with glycine
powder on titanium abutment surfaces. Clinical Oral Implant
Research, 24, 904–909.
8. Covey, D. A., Barnes, C., Watanabe, H., & Johnson, W. W.
(2011). Effects of a paste-free prophylaxis polishing cup and
various prophylaxis polishing pastes on tooth enamel and
restorative materials. General Dentistry, 59(6), 466–473.
9. Donnet, M., Fournier, M., Schmidlin, P. R., & Lussi, A. (2021).
A novel method to measure the powder consumption of dental
air-polishing devises. Applied Science, 11(1101), 1–11.
10. Encyclopaedia Britannica. (2017). Mohs hardness. https://
www.britannica.com/science/Mohs-hardness
B for rotary handpiece polishing. There is only one
correct answer for each question.
24. Lower Mohs rating
25. Powder particle shape is more uniform and less
irregular
26. Smaller particle size
27. Less aerosol production
28. Less efficient stain removal
29. Can be safely used on dentin and cementum
30. Which of the following is a patient consideration
for polishing?
a. Poorly controlled asthma
b. Active communicable disease such as
coronavirus
c. High blood pressure
d. Both A and B
11. Flemmig, T. F., Arushanov, D., Daubert, D., Rothen, M.,
Muller, G., & Leroux, B. G. (2012). Randomized controlled
trial assessing efficacy and safety of glycine powder air
polishing in moderate-to-deep periodontal pockets. Journal
of Periodontology, 83(4), 444–452.
12. Graumann, S. J., Sensat, M. L., & Stoltenberg, J. L. (2013).
Air polishing: A review of current literature. Journal of Dental
Hygiene, 87(4), 173–180.
13. Gutmann, M. E. (1998). A comprehensive review of the
literature. Journal of Dental Hygiene, 72(3), 47–56.
14. Janiszewska-Olszowska, J., Drozdzik, A., Tandecka, K., &
Grocholewicz, K. (2020). Effect of air-polishing on surface
roughness of composite dental restorative material—
comparison of three different air-polishing powders. BMC
Oral Health, 20(30), 1–7.
15. Johnson, W. W., Barnes, C. M., Covey, D. A., Walker, M. P.,
& Ross, J. A. (2004). The effects of a commercial aluminum
air polishing powder on dental restorative materials. Journal
of Prosthodontics, 13(3), 166–172.
16. Kozlovsky, A., Artzi, Z., Nemcovsky, C. E., & Hirshberg,
A. (2005). Effect of air-polishing devices on the gingiva:
Histologic study in the canine. Journal of Clinical
Periodontology, 32, 329–334.
17. Lamont, T., Worthington, H. V., Clarkson, J. E., & Beirne,
P. V. (2018). Routine scale and polish for periodontal health
in adults (Review). Cochrane Library Database of Systematic
Reviews, 12(CD004625), 1–59.
18. Moene, R., Decaillet, F., Andersen, E., & Mombelli, A. (2010).
Subgingival plaque removal using a new air-polishing device.
Journal of Periodontology, 81(1), 79–88.
19. Monaco, C., Arena, A., Scheda, L., Di Fiore, A., &
Zucchelli, G. (2020). In vitro 2D and 3D roughness and
spectrophotometric and gloss analyses of ceramic materials
after polishing with different prophylaxis pastes. Journal of
Prosthetic Dentistry, 124(6), 787e1–787e8.

20. Ng, E. (2018). The efficacy of air polishing devises in
supportive periodontal therapy: A systematic review and
meta-analysis. Quintessence International, 49, 453–467.
https://doi.org/10.3290/j.qi.a40341
21. Ovard, C. F. (2018). Tooth polishing. The Gale encyclopedia of
nursing and allied health, 6(4), 3545.
22. Park, B., Kim, M., Park, J., Jeong, J., & Noh, H. (2020).
Research on dental plaque removal methods for efficient oral
prophylaxis: With a focus on air polishing and rubber cup
polishing. International Journal of Dental Hygiene, 19(3), 1–7.
https://doi.org/10.1111/idh.12481
23. Pence, S. D., Chambers, D. A., Van Tets, I. G., Wolf, R., &
Pfeiffer, D. C. (2011). Repetitive coronal polishing yields
minimal loss. Journal of Dental Hygiene, 85(4), 348–357.
24. Petersilka, G. (2000). Subgingival air-polishing in the treatment
of periodontal biofilm infections. Periodontology, 55, 124–142.
References 409
25. Petersilka, G. J., Bell, M., Mehl, A., Hickel R., & Flemmig,
T. F. (2003). Root defects following air polishing. Journal of
Clinical Periodontology, 30, 165–170.
26. Sauro, S., Watson, T. F., & Thompson, I. (2010). Dentine
desensitization induced by prophylactic and air-polishing
procedures: An in vitro dentine permeability and confocal
microscopy study. Journal of Dentistry, 38, 411–422.
27. Sawai, M., Bhardwaj, A., Jafri, Z., Sultan, N., & Daing, A.
(2015). Tooth polishing: The current status. Journal of Indian
Society of Periodontology, 19(4), 375–380.
28. Sugiyama, T., Kameyama, A., Enokuchi, T., Haruyama,
A., Chiba, A., Sugiyama, S., Hosaka, M., & Takahashi, T.
(2017). Effect of professional dental prophylaxis on the
surface gloss and roughness of CAD/CAM restorative
materials. Journal of Clinical Experimental Dentistry, 9(6),
772–778.
 CHAPTER 22

Air Polishing Powders

and Clinical Applications
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. List the clinical applications of an air polishing
device (APD).
2. Compare and contrast air polishing powder
particle size, Mohs hardness, and chemical
composition.
3. Identify powders that are used coronal to the
Cementoenamel junction (CEJ) and powders
that are used coronal and apical to the CEJ.
4. Select the appropriate powder for the patient
clinical presentation.
5. Identify individual patient air polishing
considerations.
6. Deliver safe air polishing that does not
adversely affect dental materials.
KEY TERMS
• Aluminum trihydroxide powder: APD powder
made of aluminum and hydroxide that is
• Erythritol powder: APD powder made of erythritol
and 0.3% chlorhexidine that is soluble in water
and administered coronal and apical to the CEJ.
•
Erythritol powder air polishing (EPAP): A clinical
air polishing procedure where erythritol powder is
administered.
• Glycine powder: APD powder made of glycine
and silicic acids that is soluble in water and
administered coronal and apical to the CEJ.
• Glycine powder air polishing (GPAP): A clinical
air polishing procedure where glycine powder is
administered.
• Sodium bicarbonate powder: APD powder made
of sodium bicarbonate, with or without added
tricalcium phosphate or silicon oxide that is soluble
in water and administered coronal to the CEJ.
• Subcutaneous facial emphysema: sudden facial
swelling and crepitus upon palpitation caused
by the introduction of air into subcutaneous
connective tissue.

Introduction
insoluble in water and administered coronal to
the CEJ.
• Calcium carbonate powder: APD powder made of
calcium and carbonate that is insoluble in water
Air polishing devices have a variety of clinical ap-
and administered coronal to the CEJ. plications. New powders continue to be developed
• Calcium sodium phosphosilicate powder: APD
powder made of calcium, phosphorus, silica, and
and released to the market, providing both preven-
tive and therapeutic functionality. APDs are used for
sodium that is soluble in water and will dentinal the removal of extrinsic stain, biofilm, and immature
tubules.
•
dental calculus both coronal and apical to the CEJ.
Cytokines: large group of proteins, peptides, They decontaminate surfaces prior to sealant place-
or glycoproteins that are secreted by specific
immune cells.
ment, are used in the management gingival inflamma-
• Dyspnea: difficult or labored breathing,
sometimes referred to as having shortness of
tion around natural teeth and dental implants, in the
management of dentinal hypersensitivity, and in the
breath. process of debriding orthodontic appliances.
411
412 Chapter 22 Air Polishing Powders and Clinical Applications

There are six powders on the market that vary
in their chemical composition, Mohs hardness, and
particle size, all of which determine the clinical ap-
plications of each powder. Providers must use the
powder sold by the manufacturer of their APD to
avoid equipment damage and patient injury. As with
dental ultrasonic devices, APDs release large volumes
of aerosolized particles into the dental environment
that must be controlled with appropriate infection
prevention protocols presented in Chapter 2. There
are considerations for air polishing that vary by pow-
der and manufacturer. Providers should reference the
directions for use or instructions for use (DFU/IFU)
prior to use to ensure patient safety.
procedure, or sealant placement (see Figure 22-2).
APDs provide superior microbial reduction and
depth of penetration into pits and grooves of teeth
than compared to a rotary handpiece rubber cup or
bristles with a prophylaxis agent, which improves
the bond strength of the dental material (Barnes
et al., 2014; Botti et al., 2010; Graumann et al.,
2013; Lenzi et al., 2013; Tamura et al., 2017).
• Dentinal desensitization through occluding ex-
posed tubules (see Figure 22-3). Not all APD
powders are capable of dentinal desentization.
This chapter will present which powders possess
chemicals capable of occluding dentinal tubules.

APD Clinical Applications

APDs have many clinical applications depending on
the delivery system and powder composition. An APD
will not remove firmly established dental calculus but
has been shown to remove immature or early form-
ing dental calculus. An APD will remove all levels of
biofilm and extrinsic stain from the smooth surface,
interproximal spaces, and pits and fissures of teeth.
Air polishing clinical applications include:
• Biofilm, stain, and immature dental calculus re-
moval for routine preventive and therapeutic pro-
cedures (see Figure 22-1). This clinical application
aids in the treatment and management of peri-
odontal and peri-implant diseases.
• Debridement of orthodontic appliances. A
• Surface preparation prior to orthodontic bracket
placement, direct restoration placement, bonding
or cementing indirect restorations (inlay, onlay,
crown, veneer), fluoride application, whitening

Figure 22-1 Biofilm, calculus, stain, and immature and
mature dental calculus on mandibular anterior lingual
surfaces.
B
Figure 22-2 Occlusal contamination: A. Biofilm and
dental calculus present in the occlusal pits and fissures
of a premolar tooth, B. Stain present in the occlusal pits
and fissures of a premolar and molar tooth.
 APD Powder Particle Size and Mohs Hardness 413

Table 22-1 APD Powder Administration to Tooth

Surfaces
Powder Coronal to CEJ Apical to CEJ
Aluminum  
trihydroxide
Calcium carbonate  
Sodium bicarbonate  
Glycine  
Erythritol
Figure 22-3 Recession of the mandibular anterior
 
central incisor facial surfaces.

Table 22-2 APD Powder Particle Size

APD Powder Particle Size
Powder Particle Size
and Mohs Hardness
Aluminum trihydroxide 80–325 µm*
There are six powders on the market for air polish-
Sodium bicarbonate 40–250 µm*
ing. Two can be administered coronal and apical to
the CEJ, and three are administered coronal to the Calcium sodium phosphosilicate 25–120 µm*
CEJ (see Table 22-1). Calcium sodium phosphosilicate Calcium carbonate 45–55 µm*
is not listed in Table 22-1 because it is only used as
a therapeutic powder in the management of dentinal Glycine 20–63 µm*
hypersensitivity and will be discussed later. Erythritol 14 µm

Particle Size
The six powders in Table 22-1 have different particle
size ranges. Table 22-2 lists the powders from largest
particle size to the smallest.
Powders vary in their chemical composition,
which determines their Mohs hardness rating and
particle size. Manufacturers may sell the same pow-
der, but due to slight chemical composition changes,
each varies in Mohs hardness, particle size, particle
volume, and clinical applications. For example, one
manufacturer sells a 64-μm particle size sodium bi-
carbonate powder while another sells a 177-μm parti-
cle size. This can be confusing for the buyer if they are
unaware of particle size differences. This is one of the
many reasons why a provider cannot mix and match
manufacturer powders in an APD. Mixing manufac-
turer powders may void the warranty and increases
the chance of permanent damage of the APD, leading
to costly repairs or full replacement (see Figure 22-4).
Each powder sold by a manufacturer comes with spe-
cific claims, indications, considerations, contraindi-
cations, and approved clinical use, which is found in
the DFU/IFU.
In general, the larger the particle size, the higher
the abrasive capability of the powder (Graumann et al.,
2013; Arabaci et al., 2007; Janiszewska-Olszowska
et al., 2020). Larger particle sizes will remove biofilm,
*Particle size varies by manufacturer. Refer to the powder DFU/IFU for further information.
stain, and immature dental calculus with less contact
time than smaller particle sizes; however, they may
not be suitable for less mineralized hard tissues such
as cementum and dentin.
BREAKOUT POINT
Manufacturers vary in air polishing powder chemical
composition, particle size, particle volume, and
Mohs hardness, each of which changes the clinical
applications.
Mohs Hardness
APD powders have different Mohs hardness ratings
ranging from 2 to 4. Table 22-3 lists the powders from
the highest Mohs rating to the lowest. Calcium so-
dium phosphosilicate is not listed in Table 22-3 be-
cause its Mohs hardness is not comparable to the
other powders owing to its clinical application of
dentinal desentization. In general, the higher the
Mohs rating, the higher the abrasive capability of the
powder (Graumann et al., 2013; Arabaci et al., 2007;
Janiszewska-Olszowska et al., 2020).
414 Chapter 22 Air Polishing Powders and Clinical Applications

A B
Figure 22-4 Equipment damage: A. EMS powder used in a Dentsply Sirona APD—note the powder present
outside the powder chamber (powder bowl), B. Dentsply Sirona APD powder chamber (powder bowl) without
damage.
Reproduced with permission from Dentsply Sirona

Table 22-3 APD Powder Mohs Hardness APD Powder Chemical

Powder Mohs Hardness Composition and Clinical
Aluminum trihydroxide 3–4* Applications
Calcium carbonate 3
Sodium Bicarbonate Powder
Sodium bicarbonate 2–3* Sodium bicarbonate powder is made of sodium
Glycine 2 and bicarbonate with or without added tricalcium
phosphate or silicon oxide to improve its flow char-
Erythritol 2
acteristics (Kozlovsky et al., 2005; Petersilka, 2000).
*Mohs hardness varies by manufacturer. Refer to the powder DFU/IFU for further information. The chemical symbol is NaHCO3. Sodium bicar-
bonate powder is soluble in water. It was the first
air polishing powder to be developed in the 1970s
and was initially sold with much higher particle sizes
(250 µm) than used today. The particle size range is
BREAKOUT POINT 40–250 µm with a Mohs hardness of 2–3 that varies
among manufacturers (Petersilka, 2000; Petersilka
Glycine and erythritol have a smaller particle size et al., 2003).
and lower Mohs hardness than the other APD
Clinically, sodium bicarbonate powder is admin-
powders, which allows them to be administered
coronal and apical to the CEJ. istered coronal to the CEJ. The slurry spray should be
avoided on soft tissues to prevent irritation. Sodium
 APD Powder Chemical Composition and Clinical Applications
bicarbonate powder can be used in the management of
dentinal hypersensitivity because it will occlude den-
tin tubules (Banerjee et al., 2010). Sodium bicarbonate
with added tricalcium phosphate has higher substan-
tivity on the dentin tubule than sodium bicarbonate
without tricalcium phosphate (Banerjee et al., 2010).
Aluminum Trihydroxide Powder
Aluminum trihydroxide powder was the second
air polishing powder released to the market as an alter-
native to sodium bicarbonate. It is made of aluminum
and hydroxide. The chemical symbol is Al(OH)3. Alu-
minum trihydroxide is insoluble in water. The particle
size range is 80–325 µm with a Mohs hardness of 3–4
that varies among manufacturers. Clinically, aluminum
trihydroxide is administered coronal to the CEJ.
Calcium Sodium
Phosphosilicate Powder
Calcium sodium phosphosilicate powder is a bio-
active glass with a chemical composition of calcium,
phosphorus, silica, and sodium (Graumann et al.,
2013). Its chemical symbol is CaNaO6PSi. Silicon di-
oxide is added to aid in powder flow characteristics.
Calcium sodium phosphosilicate is soluble in water.
The particle size is in the range of 25–120 µm and
the Mohs hardness is 6, which varies among manu-
facturers. The powder is used therapeutically to aid in
the management of dentinal hypersensitivity because
it will deposit hydroxycarbonate apatite (HCA) onto
exposed tubules to occlude them and decrease their
lumen diameter size.
Calcium Carbonate Powder
Calcium carbonate is a natural substance found on
rocks, sea shells, and pearls (Barnes et al., 2014).
Pharmacologically, is used as an antacid to subside
heartburn. Its chemical symbol is CaCO3. Calcium
carbonate powder is insoluble in water. It has a
particle range of 44–55 µm that varies among man-
ufacturers, and a Mohs hardness of 3. Clinically, it is
administered coronal to CEJ.
Glycine Powder
Glycine is a simple, nonessential amino acid in the
human body that is an important component of most
polypeptides. It acts as an inhibitory neurotransmitter
in the nervous system. Glycine is used in the food in-
dustry as a flavoring and preservative.
415
Glycine powder is made of glycine and silicic
acids. Silicic acids are added to improve powder flow
characteristics (Petersilka, 2000). Glycine powder is
soluble in water. The particle size range is 20–63 µm,
which varies among manufacturers, and the Mohs
hardness is 2.Clinically, glycine is administered coro-
nal and apical to the CEJ. When glycine is used during
an air polishing procedure, it is referred to as glycine
powder air polishing (GPAP).
Glycine powder will not occlude dentin tubules
like sodium bicarbonate, calcium carbonate, or calcium
sodium phosphosilicate. It has been shown to increase
dentin hypersensitivity if the smear layer is removed
(Moene et al., 2010; Sauro et al., 2010). Glycine is a
useful adjunctive aid in the management of subgingi-
val biofilm and gingival inflammation around natural
teeth and dental implants for the following reasons:
• Glycine powder is postulated to have anti-
inflammatory effects through inhibiting inflam-
matory cell activation and immunomodulatory
effects through decreasing cytokines and toxic
medicators such as free radicals (Moene et al.,
2010). Gingival diseases and inflammation oc-
cur when the immune system sends cells such
as polymorphonuclear leukocytes, macrophages,
T-lymphocytes, and B-lymphocytes to the gingi-
val sulcus in response to pathogenic organisms
crossing into the connective tissue. Several of
these inflammatory mediators release cytokines,
which are a large group of proteins, peptides, or
glycoproteins that contribute to the inflammatory
effects of the gingiva. Glycine powder interacts
with these cells and proteins to decrease inflam-
mation (Moene et al., 2010).
• Glycine powder inhibits the synthesis of a pep-
tidoglycan component necessary to maintain cell
wall integrity of bacteria (Cochis et al., 2013). If
the cell wall integrity becomes compromised, the
bacteria will not survive.
BREAKOUT POINT
Glycine and erythritol are useful adjunctive aids in
the management of subgingival biofilm and gingival
inflammation.
Erythritol Powder
Erythritol is a hydrogenated form of carbohydrate
called a polyol or sugar alcohol (Hashino et al., 2013).
It has a sweet taste and is used as a natural sweetener
in the food industry as a sugar substitute.
416 Chapter 22 Air Polishing Powders and Clinical Applications
Erythritol powder is made of erythritol with the
addition of 0.3% chlorhexidine that improves powder
flow characteristics and provides antimicrobial action.
It is soluble in water. Erythritol powder has the low-
est particle size of all powders at 14 µm. The Mohs
hardness is 2. Clinically, erythritol is administered
coronal and apical to the CEJ. When erythritol is used
during an air polishing procedure, it is referred to as
­ rythritol powder air polishing (EPAP).
e
Erythritol powder is a useful adjunctive aid in the
management of subgingival biofilm and gingival in-
flammation around natural teeth and dental implants
for the following reasons:
• Erythritol powder has been postulated in the lit-
erature to have an inhibitory effect on bacterial
replication by decreasing nucleic acid synthesis
and amino acids (Hashino et al., 2013).
• Erythritol powder has been shown to slow down
the extracellular matrix biosynthesis by bacteria,
thus disrupting the structural integrity of an oral
biofilm (Hashino et al., 2013; Drago et al., 2014).
These results have been confirmed through the
decrease of specific bacterial pathogens when
exposed to erythritol in studies (Hashino et al.,
2013; Park et al., 2020).
• The addition of chlorhexidine provides an antimi-
crobial action other powders do not possess.
BREAKOUT POINT
Erythritol powder is the only powder with added
chlorhexidine for antimicrobial effects.
Powder Care
Powders and powder containers cannot be exposed
to moisture, high temperatures, or humidity as they
spoil and clump. If this occurs, the powder should
be discarded. Powders have an expiration date and
should be discarded when they reach this matura-
tion time.
Powder containers should be stored:
1. In well-sealed containers with a tight-fitting lid.
2. In a well-ventilated room.
3. In dry, cool conditions protected from humidity.
4. Away from liquids.
Prior to filling an APD powder chamber, shake the
powder container to loosen powder particles and
break apart clumps.
Air Polishing Literature
There is an extensive body of literature spanning de-
cades that has reviewed the abrasiveness and efficiency
of APDs and powders. Drawing definitive conclusions
and making meaningful comparisons between stud-
ies and technologies is challenging, if not impossible,
because of the lack of industry standardization and
variability between manufacturers’ products such as:
• Delivery systems that operate at different psi’s.
• Varied nozzle designs.
• Varied powder chamber sizes.
• Varied powder chemical composition, parti-
cle size, particle volume, Mohs hardness, and
additives.
Caution should be exercised when appraising
dated literature because the results may not be reflec-
tive of today’s technology. APD devices and powders
have changed dramatically over the last decade with
improved delivery systems, nozzle designs, powder
chambers, operating system psi, and powder com-
position. When studies do not report or account for
powder particle size, delivery system, or provider
technique (contact time, nozzle distance, and angu-
lation), results should be interpreted with caution.
Providers should be aware of these variables when
critically appraising the literature.
APD Considerations
Each powder has different patient considerations,
which vary by manufacturer. It would be impossible
to cover every consideration for each manufacturer’s
product in this book. A general overview of consider-
ations is provided next. For further details, reference
the manufacturer’s DFU/IFU.
Gingival Status
If a patient presents with severe gingival inflammation
or a recent post-surgical procedure, air polishing may
be contraindicated, or caution should be exercised to
avoid further trauma or gingival erosion (Kozlovsky
et al., 2005; see Figure 22-5a and b). If gingival injury
occurs during air polishing, it will heal uneventfully
on its own within six days post-procedure but may
cause the patient transient postoperative discomfort
(Kozlovsky et al., 2005; Flemmig et al., 2007).
Sodium Bicarbonate Powder
Sodium bicarbonate powder has received special
attention in the literature over the years owing to

B
Figure 22-5 Gingival status considerations for air polishing: A. Maxillary anterior teeth post-
surgical procedure with stitches, B. Severe gingival inflammation from a necrotizing disease on
the maxillary left facial/buccal surfaces.
its water solubility and dissociation into a sodium
cation (Na+) and bicarbonate (HCO3−) anion inside
the body. Concerns have been raised that the ad-
dition of these charged elements could disrupt the
acid/base balance in the body for a patient with a
metabolic disorder, adrenal gland dysfunction, or
renal disease, or a patient taking a diuretic medica-
tion, steroid, or potassium supplement. It was also
suggested a patient on a sodium-restricted diet or
saltless diet should not receive sodium bicarbonate
air polishing.
Recent literature has shown the actual amount
of powder ingested by a patient during a one-time
APD exposure to sodium bicarbonate is minimal and
causes clinically insignificant changes to blood pH, or
to sodium, chloride, and potassium levels through-
out the body (Petersilka et al., 2000). However, some
manufacturers still recommend using an alternate
powder for a patient who fits any of the previously
APD and Dental Materials 417
listed criteria. Best practice may be to avoid sodium
bicarbonate powder in these patients or consult with
their physician prior to use.
APD and Dental Materials
APD powders have the potential to scratch, dull, or
roughen specific dental materials depending on the
powder and delivery system, but they have never
been shown to crack, chip, remove, or crater materials
when used correctly per the manufacturer’s directions
(Pelka et al., 2010). A roughened or scratched dental
material is undesirable because it may discolor or con-
tribute to oral deposit accumulation, which increases
the risk for secondary caries and gingival inflamma-
tion. The goal of restorative dentistry is to place res-
torations with a smooth glazed finish, and the goal of
preventive procedures is not to alter this finish.
418 Chapter 22 Air Polishing Powders and Clinical Applications
There is an extensive body of literature that has
evaluated the effects of various APDs and powders on
dental materials. Again, exercise caution when refer-
encing dated literature because their results may no
longer be reflective of today’s current technology. It is
best to follow the manufacturer’s DFU/IFU for dental
material considerations and contraindications rather
than an individual publication.
Dental Materials:
Safe Use of an APD
• Dental ceramics and porcelain bonded alloys:
APD powders have not been shown to cause sur-
face alterations to dental ceramics such as por-
celain, alumina, zirconia, and porcelain-bonded
alloys (porcelain fused to metal crown) (Arabaci
et al, 2007; Petersilka, 2000; Cooley et al., 1988;
Johnson et al., 2004; see Figure 22-6).
A (see Figure 22-8).
B •
Figure 22-6 Safe use of an APD: A. Dental ceramics and
porcelain bonded alloys on the maxillary and mandibular
right anterior and posterior teeth, B. Porcelain bonded
alloys on the maxillary anterior teeth.
• Orthodontic appliances: APD powders are safe
and indicated for oral deposit removal around
fixed orthodontic appliances (Petersilka, 2000;
see Figure 22-7).
BREAKOUT POINT
Air polishing is safe for dental ceramics, porcelain-
bonded alloys, and orthodontic appliances.
Dental Materials:
APD Use With Caution
For the materials listed in this section, it is best prac-
tice for you to reference the manufacturer’s DFU/IFU
and follow their recommendations. Literature has re-
ported APD use should proceed with caution for:
• Composite resins: The literature is mixed on the
effects APD powders have on composite resins.
Studies have found powders cause significant sur-
face roughness, little surface roughness, and no
surface roughness (Botti et al., 2010; Janiszewska-­
Olszowska, 2020; Pelka et al., 2010; Cooley et al.,
1988; Lubow et al., 1996). Glycine and erythritol
powders cause less surface alteration than other
powders, likely owing to their chemical com-
position, lower particle size, and lower Mohs
hardness (Giacomelli et al., 2011; Salerno et al.,
2010). Composite resins that experience loss of
smoothness due to natural deterioration in the
mouth over time are more susceptible to abrasion
effects than composites without loss of structure
• Amalgams: APD powders may cause a discolor-
ation, dulling, or change to surface characteristics
of amalgam restorations (Graumann et al., 2013;
Lubow & Cooley, 1996; see Figure 22-9).
• All-metal cast and stainless-steel alloys: The liter-
ature is mixed on the effects APD powders have
on all-metal castings such as gold, palladium,
platinum, and stainless-steel alloys (crowns com-
monly used in pediatric patients) over time. Some
studies show a discoloration, matte finish, or ero-
sion while others do not (Barnes et al., 2014; Pe-
tersilka, 2000; Cooley et al., 1988; Johnson et al.,
2004; see Figure 22-10).
Removable appliances (partial, dentures: Erythri-
tol and glycine can be safely used on removable
appliances, while powders with a higher particle
size may be contraindicated. Refer to the manu-
facturer’s DFU/IFU for details.
 APD and Dental Materials 419

B
Figure 22-7 Safe use of an APD: A. Fixed orthodontic appliances on the mandibular anterior
lingual surfaces, B. Orthodontic brackets and wires on the mandibular anterior facial surfaces.

A B
Figure 22-8 APD use with caution: A. Fractured composite resin on a mandibular molar,
B. Composite resins on molars.

Dental Materials:
BREAKOUT POINT
APD Use Contraindicated
Providers should reference the manufacturer’s
DFU/IFU prior to air polishing a composite resin,
• Adhesives: Air polishing with sodium bicarbonate
or calcium carbonate prior to operative dentistry
amalgam, all-metal cast and stainless-steel alloy,
or a removable appliance. has been shown in some studies to negatively af-
fect the bond strength of a dental adhesive, while
420 Chapter 22 Air Polishing Powders and Clinical Applications
Figure 22-9 APD use with caution. Amalgam restoration
on a molar with fracture lines.
Figure 22-11 APD use contraindicated. Luting agents under restoration margins of
these crowns.
the use of glycine did not (Petersilka, 2000). It
is postulated this occurs due to the varied effects
these powders have on dentin. Glycine will not
occlude dentin tubules and can remove the smear
layer on dentin, unlike sodium bicarbonate and
calcium carbonate powders that bond to and oc-
clude tubules (Moene et al., 2010).
• Glass ionomer cement and sealant: It would be
best practice to avoid direct use of an APD pow-
der on a glass ionomer cement and sealant due to
the risk for substance loss and surface alteration
(Graumann et al., 2013; Pelka et al., 2010; John-
son et al., 2004). Studies vary in their reports,
with some showing less surface alteration with
glycine and erythritol than other powders (Barnes
et al., 2014; Johnson et al., 2004). Refer to the
manufacturer’s DFU/IFU for details.
• Luting cements: sodium bicarbonate, aluminum
trihydroxide, calcium sodium phosphosilicate,
and calcium carbonate may remove luting ce-
ments, and their use should be avoided on the
direct margins of restorations (Cooley et al., 1988;
Johnson et al., 2004; see Figure 22-11).
Figure 22-10 APD use with caution. All-metal cast alloys
on maxillary molars and maxillary right premolars.
Adverse Effects
Air polishing is a routine procedure that is very safe.
The most serious adverse effect is subcutaneous
­facial emphysema whose incidence is extremely rare
(Petersilka, 2000; Flemmig et al., 2007; ­Karmakar &
Kamath, 2017). There have only been nine air emphy-
semas and three air embolisms reported as a sequela
from subcutaneous facial emphysema from 1977 to
2001, which all healed uneventfully without medical in-
tervention and were attributed to improper technique on
the part of the provider during air polishing (Petersilka,
2000; Flemmig et al., 2007; Karmakar & Kamath, 2017).
Subcutaneous facial emphysema is most com-
monly associated with head and neck surgery, trauma,
intubation, mechanical ventilation, or an infectious
process (Yang et al., 2006). The most common dental
procedure linked to subcutaneous facial emphysema
is an extraction when air is introduced into the loose
surrounding connective tissue by an air-turbine drill
or air/water syringe (Yang et al., 2006).
Subcutaneous facial emphysema is character-
ized by sudden facial swelling and crepitus upon
 Adverse Effects 421

palpation within 24–36 hours after the dental proce-
dure (Petersilka, 2000; Karmakar & Kamath, 2017;
Yang et al., 2006). It can spread to the throat, heart,
eye, or ear. Typically, subcutaneous facial emphysema
resolves on its own within 1–3 days (Karmakar &
Kamath, 2017). In the event the patient experiences
thoracic pain, has issues with swallowing, dyspnea
(difficult or labored breathing), or changes in vi-
sion or hearing, medical attention should be sought
(Karmakar & Kamath, 2017).

CASE STUDY
Your patient is a 77-year-old Caucasian female with poorly controlled high blood pressure, high cholesterol, diabetes,
osteoarthritis, and osteopenia. She is taking hydrochlorothiazide, metoprolol, and losartan for her blood pressure; ator-
vastatin for her high cholesterol; metformin and Lantus for her diabetes; and Mobic and risedronate for osteoarthritis
and osteopenia. Her Body Mass Index (BMI) is 18. She does not have any known allergies or drug allergies. She is retried.
Her last HbA1c was 9.2.
Her chief complaint is: “I don’t like the stains on my teeth and the color.”
Dental exam: Chipped tooth maxillary left central incisor (see intraoral photograph). No history of orthodontics.

Front bite. Left bite.

Right bite. Posterior teeth mandibular arch.

Posterior teeth maxillary arch

422 Chapter 22 Air Polishing Powders and Clinical Applications

Occlusion: Class 1 bilateral with first molar relationship. Crowding anterior teeth with an overjet.
Oral hygiene exam:
■ Generalized moderate biofilm
■ Localized light stain
■ Light dental calculus throughout with moderate supragingival calculus mandibular anterior
Periodontal exam:
■ Probe depths generally 3–5 mm
■ Class I and II furcation involvement on most molars
■ Generalized recession
■ Class 1 mobility maxillary central and lateral incisors
■ Bleeding upon probing 12% of the mouth
Tissue description:
■ Generalized firm, pink, stippled attached gingiva.
■ Loss of interdental papillae due to recession with Class 2 embrasure spaces generally.

Case Study Questions

1. List the type of dental materials present in this patient’s mouth.
2. Which dental material(s) present in this patient’s mouth have a consideration or contraindication for air polishing?
3. What air polishing powder(s) should be selected for this patient and why?
4. The maxillary left central incisor is treatment planned for a composite restoration on the mesial facial lingual
incisal. What considerations or contraindications does this restoration have for air polishing?
5. Does the patient have anything in her medical history that would be a contraindication for air polishing?
6. Does the patient have anything in her medical history that is a consideration for air polishing?
7. Does the patient have any tooth or gingival condition that is a contraindication or consideration for air polishing?
8. Based on your observations of the mandibular anterior facial and interproximal surfaces, what powder should
you use to remove the extrinsic exogeneous stain and biofilm when the patient does not report dentinal
hypersensitivity? Justify your answer.
9. Which nozzle should be used for this patient to deliver glycine or erythritol subgingivally? Justify your answer.
10. List the reasons why air polishing should be selected over a rotary handpiece with a polishing agent for this
patient.

Summary
APDs are used for the removal of biofilm, extrinsic
stains, and immature dental calculus from smooth
surfaces, interproximal spaces, and pits and fissures
of teeth. They are used times of gingival inflammation
around natural teeth and dental implants, to decontam-
inate orthodontic appliance, and for surface preparation
prior to sealant placement. Glycine and erythritol can
be administered coronal and apical to the CEJ. Calcium
sodium phosphosilicate is used in the therapeutic man-
agement of dentinal hypersensitivity. Sodium bicarbon-
ate, aluminum trihydroxide, and calcium carbonate are
administered coronal to the CEJ. Providers should ref-
erence their manufacturer’s powder and APD DFU/IFU
for considerations and contraindications of use.

Questions
1. Which of the following can be removed with an 2. Which of the following is a clinical indication for
APD? use of an APD?
a. Biofilm a. Debridement of a dental implant
b. Firmly established dental calculus b. Subgingival debridement
c. Intrinsic staining c. Debridement of pits and fissures prior to
d. None of the above sealant placement
d. Dentinal desensitization
e. All of the above
 References 423

3. True or False. All air polishing powders are 12. True or False. Powders that can be administered
manufactured the same and can be used in any apical to the CEJ have a lower particle size than
APD. powders administered coronal to the CEJ.
a. True a. True
b. False b. False
Match the following powder to its correct description 13. Which of the following APD powders is
for questions 4–9. There is only one correct answer postulated to have anti-inflammatory and
for each powder. immunomodulatory effects in the mouth by
4. Sodium bicarbonate A. Administered decreasing cytokines and toxic medicators such
coronal and apical as free radicals?
to the CEJ a. Sodium bicarbonate
b. Erythritol
5. Glycine B. Administered c. Glycine
coronal to the CEJ d. Aluminum trihydroxide
with a particle
14. Which of the following APD powders is
size range of
postulated to have antimicrobial effects by
80–325 µm
inhibiting bacterial replication through effects on
6. Aluminum C. Mohs hardness nucleic acid and amino acid synthesis that can
trihydroxide of 3 affect the structural integrity of an oral biofilm?
7. Erythritol D. Administered a. Sodium bicarbonate
coronal to the CEJ, b. Erythritol
water-soluble, c. Glycine
particle size d. Aluminum trihydroxide
40–250 µm 15. Which of the following is TRUE?
a. Powder containers do not need to be sealed
8. Calcium sodium E. Occludes dentin
after use.
phosphosilicate tubules
b. Powder containers should be shaken prior
9. Calcium carbonate F. 0.3% to use.
chlorhexidine c. Powders may be used past their expiration date.
added to this sugar d. Moisture and humidity will not affect the
alcohol for an integrity of an APD powder.
antimicrobial effect
16. Which of the following is TRUE of an APD and
10. Which of the following powders can be powders?
administered apical to the CEJ? a. An APD should be used with caution in times
a. Sodium bicarbonate of severe gingival inflammation.
b. Aluminum trihydroxide b. All powders should be avoided for a patient
c. Glycine on a sodium-restricted diet.
d. Erythritol c. APD powders should never be used on a
e. Both C and D porcelain crown.
f. All of the above d. APD powders are safe for use on a glass
ionomer and sealant.
11. Which powder has the smallest particle size?
a. Sodium bicarbonate 17. True or False. Air polishing runs a high risk for
b. Aluminum trihydroxide causing a subcutaneous facial emphysema.
c. Glycine a. True
d. Erythritol b. False

References
1. Arabaci, T., Cicek, Y., Ozgoz, M., Canakci, V., Canakci, C. F., &
Eltas, A. (2007). The comparison of the effects of three types
of piezoelectric ultrasonic tips and air polishing system on
the filling materials: An in vitro study. International Journal of
Dental Hygiene, 5, 205–210.
2. Banerjee, A., Headmost-Sani, M., Farrell, S., & Thompson, I.
(2010). A clinical evaluation and comparison of bioactive
glass and sodium bicarbonate air-polishing powders. Journal
of Dentistry, 38, 475–479.
424 Chapter 22 Air Polishing Powders and Clinical Applications
3. Barnes, C. M., Covery, D., Watanabe, H., Simetich, B.,
Schulte, J. R., & Chen, H. (2014). An in vitro comparison
of the effects of various air polishing powders on enamel
and selected esthetic restorative materials. Journal of Clinical
Dentistry, 4(25), 76–87.
4. Botti, R. H., Bossu, M., Zallocco, N., Vestri, A., & Polimeni, A.
(2010). Effectiveness of plaque indicators and air polishing
for the sealing of pits and fissures. European Journal of
Paediatric Dentistry, 11(1), 15–18.
5. Cochis, A., Fini, M., Carrassi, A., Migliario, M., Visai, L., &
Rimondini, L. (2013). Effect of air polishing with glycine
powder on titanium abutment surfaces. Clinical Oral Implant
Research, 24, 904–909.
6. Cooley, R. L., Lubow, R. M., & Brown, F. H. (1988). Effect
of air-powder abrasive instrument on porcelain. Journal of
Prosthetic Dentistry, 60(4), 440–444.
7. Drago, L., Fabbro, M. D., Bortolin, M., Vassena, C., Vecchi, E. D.,
Taschieri, S. (2014). Biofilm removal and antimicrobial
activity of two different air-polishing powders: An in vitro
study. Journal of Periodontology, 85(11), e363–e369.
8. Flemmig, T. F., Hetzel, M., Topoll, H., Gerss, J., Haeberlein, I., &
Petersilka, G. (2007). Subgingival debridement efficacy of
glycine powder air polishing. Journal of Periodontology, 78(6),
1002–1010.
9. Giacomelli, L., Salerno, M., Derchi, G., Genovesi, A.,
Paganin, P. P., & Covani, U. (2011). Effect of air polishing
with glycine and bicarbonate powders on a nanocomposite
used in dental restorations: An in vitro study. International
Journal Periodontics Restorative Dentistry, 31, e51–e56.
10. Graumann, S. J., Sensat, M. L., & Stoltenberg, J. L. (2013).
Air polishing: A review of current literature. Journal of Dental
Hygiene, 87(4), 173–180.
11. Hashino, E., Kuboniwa, M., Alghamdi, S. A., Yamaguchi, M.,
Yamamoto, R., Cho, H., & Amano, A. (2013). Erythritol
alters microstructure and metabolomic profiles of biofilm
composed of Streptococcus gordonii and Porphyromonas
gingivalis. Molecular Oral Microbiology, 28, 435–451.
12. Janiszewska-Olszowska, J., Drozdzik, A., Tandecka, K., &
Grocholewicz, K. (2020). Effect of air-polishing on surface
roughness of composite dental restorative material: Comparison
of three different air-polishing powders. BMC Oral Health,
20(30), 1–7.
13. Johnson, W. W., Barnes, C. M., Covey, D. A., Walker, M. P., &
Ross, J. A. (2004). The effects of a commercial aluminum air
polishing powder on dental restorative materials. Journal of
Prosthodontics, 13(3), 166–172.
14. Karmakar, S., & Kamath, D. G. (2017). Subgingival
airpolishing: A simple and cost effective medical insurance.
Journal of Pharmaceutical Sciences and Research, 9(2),
199–201.
15. Kozlovsky, A., Artzi, Z., Nemcovsky, C. E., & Hirshberg, A.
(2005). Effect of air-polishing devices on the gingiva:
Histologic study in the canine. Journal of Clinical
Periodontology, 32, 329–334.
16. Lenzi, T. L., Menezes, L. B. R., Soares, F. Z. M., & Rocha, R. O.
(2013). Effect of air abrasion and polishing on primary
molar fissures. European Archives of Paediatric Dentistry, 14,
117–120. https://doi.org/10.1007/s40368-013-0023-x
17. Lubow, R. M., & Cooley, R. L. (1996). Effect of air-powder
abrasive instrument on restorative materials. Journal of
Prosthetic Dentistry, 55(4), 462–465.
18. Moene, R., Decaillet, F., Andersen, E., & Mombelli, A. (2010).
Subgingival plaque removal using a new air-polishing device.
Journal of Periodontology, 81(1), 79–88.
19. Park, B., Kim, M., Park, J., Jeong, J., & Noh, H. (2020).
Research on dental plaque removal methods for efficient oral
prophylaxis: With a focus on air polishing and rubber cup
polishing. International Journal of Dental Hygiene, 19(3), 1–7.
https://doi.org/10.1111/idh.12481
20. Pelka, M. A., Altmaier, K., & Lohbauer, U. (2010). The effect of
air-polishing abrasives on wear of direct restoration materials.
Journal of the American Dental Association, 141, 63–70.
21. Petersilka, G. (2000). Subgingival air-polishing in the
treatment of periodontal biofilm infections. Periodontology,
55, 124–142.
22. Petersilka, G. J., Bell, M., Mehl, A., Hickel R., & Flemmig, T. F.
(2003). Root defects following air polishing. Journal of Clinical
Periodontology, 30, 165–170.
23. Salerno, M., Giacomelli, L., Derchi, G., Patra, N., & Dispro, A.
(2010). Atomic force microscopy in vitro study of surface
roughness and fractal character of a dental restoration composite
after air-polishing. BioMedical Engineering OnLine, 9, 59.
24. Sauro, S., Watson, T. F., & Thompson, I. (2010). Dentine
desensitization induced by prophylactic and air-polishing
procedures: An in vitro dentine permeability and confocal
microscopy study. Journal of Dentistry, 38, 411–422.
25. Tamura, Y., Takamizawa, T., Shimamura, Y., Akiba, S., Iman, A.,
Tsujimoto, A., Kurokawa, H., & Miyazaki, M. (2017).
Influence of air-powder polishing on bond strength and
surface-free energy of universal adhesive systems. Dental
Materials Journal, 36(6), 762–769.
26. Yang, S. C., Chiu, T. H., Lin, T. J., & Chan, H. M. (2006).
Subcutaneous emphysema and pneumomediastinum
secondary to dental extraction: A case report and literature
review. Journal of Medical Science, 22, 641–645.
27. Zhong, A., Wheeler, M. D., Li, X., Froh, M., Schemmer, P.,
Yin, M., Bunzendaul, H., Bradford, B., Lemasters, J. J. (2003).
L-glycine: A novel anti-inflammatory, immunomodulatory,
and cytoprotective agent. Current Opinion in Clinical Nutrition
and Metabolic Care, 2, 229–240.
 CHAPTER 23
Coronal to CEJ Air
Polishing
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Identify Dentsply Sirona air polishing devices,
parts, and accessories.
2. Identify Dentsply Sirona powder selections
and their clinical indications, applications, and
considerations.
3. Use a Dentsply Sirona air polishing device with
proper power settings, water flow rate, and
nozzle angulations.
KEY TERMS
• Auto-cycle Prophy mode: preprogrammed
automatic cycles on a Dentsply Sirona APD that
delivers a slurry discharge followed by a water
•
rinse.
Cavitron Jet Air Polishing Insert: the name
of the air polishing insert with affixed nozzle
•
manufactured by Dentsply Sirona.
Cavitron Jet Fresh Prophy Powder: the name of
the aluminum trihydroxide powder manufactured
by Dentsply Sirona.
• Cavitron Jet Plus Ultrasonic Scaling and Air
Polishing System: the name of a dual-function
APD plus ultrasonic scaling device manufactured
by Dentsply Sirona.
• Cavitron Prophy Jet Handpiece Cleaning Tool:
sterilizable narrow solid metal wire used to
dislodge residual powder in the powder delivery
port of the Dentsply Sirona Jet-Mate Sterilizable,
Detachable Handpiece.
• Cavitron Prophy Jet Nozzle Cleaning Tool:
sterilizable narrow solid metal wire with an
affixed white holder used to dislodge residual
powder in the nozzle delivery tube of a Dentsply
Sirona Cavitron Jet Air Polishing Insert.
•
Cavitron Prophy Jet Prophy Powder: the name of
the sodium bicarbonate powder manufactured by
Dentsply Sirona.
• Heater rod: a part of the Cavitron Jet Air Polishing
Insert that is placed into the Jet-Mate Sterilizable,
Detachable Handpiece insert port opening that
heats the water for improved patient comfort;
manufactured by Dentsply Sirona.
• Insert port: larger opening on the soft nozzle
grip of the Jet-Mate Sterilizable, Detachable
Handpiece manufactured by Dentsply Sirona that
house the heater rod of the removable Cavitron
•
Jet Air Polishing Insert.
Jet-Mate Sterilizable, Detachable Handpiece:
the name of the air polishing handpiece
manufactured by Dentsply Sirona.
• Manual Prophy mode cycle: cycle on a Dentsply
Sirona APD where the provider controls the water
and slurry discharge through the foot pedal.
• Nozzle tube: terminal portion on the Dentsply
Sirona Cavitron Jet Air Polishing Insert with
two concentric openings to deliver water and
•
compressed air powder mixture.
Powder bowl: the name of the powder chamber
manufactured by Dentsply Sirona.
• Powder bowl cap: the name of the powder
•
chamber cap manufactured by Dentsply Sirona.
Powder delivery port: smaller opening on the
soft nozzle grip of the Jet-Mate Sterilizable,
Detachable Handpiece manufactured by Dentsply
Sirona that house the prophy powder delivery
tube of the removable Cavitron Jet Air Polishing
Insert
425
426 Chapter 23 Coronal to CEJ Air Polishing

• Powder flow control dial: dial located on the

powder bowl cap that changes the powder velocity
and flow; sometimes referred to as a daisy wheel;
manufactured by Dentsply Sirona.
• Prophy mode cycle dial: present on the front of an
APD manufactured by Dentsply Sirona that allows
the provider to choose between manual or auto-
cycle Prophy modes.
• Prophy powder delivery tube: part of the Dentsply
Sirona Cavitron Jet Air Polishing Insert that is
placed into the Jet-Mate Sterilizable, Detachable
Handpiece powder delivery port and delivers the
compressed air and powder mixture.
• Soft nozzle grip: a replaceable wear and tear
item located on the terminal end of the Jet-
Mate Sterilizable, Detachable Handpiece with
two port hole openings; manufactured by Dentsply
Sirona.

Figure 23-1 Cavitron Prophy Jet Air Polishing System.

Introduction
Reproduced with permission from Dentsply Sirona

Air polishing coronal to the CEJ is a safe and efficient

method for removing stain, biofilm, and immature
dental calculus. While there are multiple manufac-
turers of air polishing technology, this chapter will
focus on Dentsply Sirona APDs because covering ev-
ery manufacturer of APD technology would be too
lengthy for this book.
Dentsply Sirona has been manufacturing air pol-
ishing devices for use coronal to the CEJ since 1997.
They manufacturer stand-alone multipower delivery
APDs with two powder choices of sodium bicarbonate
and aluminum trihydroxide. Do not use another man-
ufacturer’s powder in a Dentsply Sirona APD because
the chemical composition, Mohs hardness, particle
size, particle volume, and clinical applications of the
powder may not be compatible. This chapter will pres-
ent Dentsply Sirona air polishing devices, parts, and
accessories. The clinical techniques used to deliver safe Figure 23-2 Cavitron Jet Plus Ultrasonic Scaling and Air
air polishing to tooth surfaces will be demonstrated. Polishing System.
Reproduced with permission from Dentsply Sirona

Dentsply Sirona Air

Polishing Devices
Dentsply Sirona manufactures two different air pol-
ishing systems:
1. Single stand-alone APD released in 2013 called
the Cavitron Prophy Jet Air Polishing System
(see Figure 23-1).
2. Dual functionality device as a magnetostrictive
ultrasonic scaler and APD. There have been three
models released since 1997. The most current
model, and the one featured in this book, is the
Cavitron Jet Plus ­Ultrasonic Scaling and
Air Polishing System released in 2012 (see
Figure 23-2).
There are specific air and water pressure psi
(pound force per square inch) required for each de-
vice, which can be referenced in the product’s direc-
tion for use or instruction for use (DFU/IFU).
 Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling 427

Dentsply Sirona Powder Bowl

Polishing Powders Each device has a large powder bowl with a remov-
able powder bowl cap (see Figure 23-5). The pow-
Dentsply Sirona sells two powders—sodium bicar- der bowl cap is designed with threads that allow a
bonate and aluminum trihydroxide—for air polishing
coronal to the CEJ. Cavitron Prophy Jet Prophy
Powder is sodium bicarbonate, and Cavitron Jet
Fresh Prophy Powder is aluminum trihydroxide
(see Figure 23-3). Both powders are not to be directed
subgingivally into a gingival sulcus.

Cavitron Prophy Jet

Air Polishing System
and Cavitron Jet Plus
Ultrasonic Scaling and Air
Polishing System
The powder chamber, called the powder bowl by
Dentsply Sirona, is large (see Figure 23-4a and b).
There are three powder velocity settings. There are
two Prophy mode selections called manual and au-
to-cycle prophy modes.

Figure 23-4 Powder bowl (Cavitron Jet Plus Ultrasonic

Scaling and Air Polishing System).
Reproduced with permission from Dentsply Sirona

Powder flow
control dial

Powder bowl
cap

Powder bowl

A B
Figure 23-3 Dentsply Sirona powders: A. Cavitron
Prophy Jet Prophy Powder, B. Cavitron Jet Fresh Prophy
Powder.
Reproduced with permission from Dentsply Sirona
Figure 23-5 Powder bowl, powder bowl cap, and powder
flow control dial (Cavitron Jet Plus Ultrasonic Scaling
and Air Polishing System).
428 Chapter 23 Coronal to CEJ Air Polishing

secure connection to the powder bowl to prevent air powder in the window of the powder flow control
or powder from leaking. Use care when attaching and dial (see Figure 23-8). If you do not see this white
removing the powder bowl cap from the powder bowl circle of powder, the device did not pressurize
to avoid stripping the threads. This could irreversibly
damage the equipment. The powder bowl is emptied
at the conclusion of each workday to prevent mois-
ture contamination and clogging.
The powder bowl cap has a powder flow
­control dial that allows for a change in powder flow
velocity. This is sometimes referred to as a daisy wheel
(see Figure 23-5).
To fill the powder bowl:
1. With the device off, unscrew the powder bowl cap.
2. Shake the powder bottle to break up clumps.
3. Pour the powder into the powder bowl (see
Figure 23-6). Do not fill past the top of the inner
tube.
4. Close the lid tightly on the powder bottle to pre-
vent moisture contamination.
5. With a soft disposable cloth, clear away powder
on the threads of the powder bowl and powder
bowl cap (see Figure 23-7).
6. Thread the powder bowl cap back onto the pow-
der bowl, ensuring that threads are not stripped.
7. Turn the power on. The chamber powder bowl
will pressurize. You will see a small white circle of

Figure 23-7 Cleaning threads with a disposable soft

cloth (Cavitron Jet Plus Ultrasonic Scaling and Air
Polishing System).

Figure 23-6 Pouring powder into the powder bowl

(Cavitron Jet Plus Ultrasonic Scaling and Air Polishing
System). Figure 23-8 Powder flow control dial (Cavitron Jet Plus
Reproduced with permission from Dentsply Sirona Ultrasonic Scaling and Air Polishing System).
 Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling
Figure 23-9 Removal of the powder bowl and powder
bowl cap (Cavitron Jet Plus Ultrasonic Scaling and Air
Polishing System).
Reproduced with permission from Dentsply Sirona
correctly. Turn the device off, check for a clog, and
verify an adequate powder level is present in the
powder bowl.
To empty the powder bowl:
1. Turn the APD off. The powder bowl will depres-
surize in a few seconds. Do not attempt to remove
the powder bowl cap during this time.
2. Once full depressurization has occurred, re-
move the power bowl cap carefully to avoid
stripping the threads. Set the cap aside (see
Figure 23-9).
3. Lift and remove the powder bowl from the device
carefully (see Figure 23-9 and 23-10). Do not dam-
age the cords under the chamber.
4. Discard all unused powder from the powder
bowl in the trash. Emptying the powder bowl
will ­reduce moisture absorption and prevent
clogging.
5. Place the powder bowl back into its holder and
ensure that the cords to the powder bowl are not
pinched or smashed. Do not place the powder
bowl cap back on the powder bowl.
6. Do not position your face directly over the pow-
der bowl, and turn the device on for 15 seconds.
This will eliminate any residual powder or mois-
ture in the powder bowl.
7. Turn the device off.
429
Figure 23-10 Removal of the powder bowl (Cavitron Jet
Plus Ultrasonic Scaling and Air Polishing System).
Reproduced with permission from Dentsply Sirona
8. Remove the seal ring on the powder bowl cap with-
out damaging the seal ring (see Figure 23-11a and b).
An instrument without a sharp cutting edge can
be used, such as a dull explorer.
9. Use a soft disposable cloth to remove any powder
residue from the seal ring (see Figure 23-12). Do
not scratch, bend, or damage the seal ring.
10. Use a soft disposable cloth to remove residual
powder from the inside of the powder bowl cap
and the powder bowl threads (see Figure 23-13). If
residual powder remains, use a soft bristle tooth-
brush with light strokes to dislodge powder parti-
cles (see Figure 23-13).
11. Place the seal ring back onto the powder bowl cap
(see Figure 23-14).
12. Place the powder bowl cap on the powder bowl
without stripping the threads.
Powder Velocity Control
There are three powder flow velocity options of low,
medium, and high set by the powder flow control dial
on the powder bowl cap. The powder flow control
430 Chapter 23 Coronal to CEJ Air Polishing

A B
Figure 23-11 Removal of the seal ring on the powder bowl cap. A. Dull explorer placed under the seal ring B. Dull
explorer lifting up and removing the seal ring

• High powder flow velocity is only used for excep-

tionally difficult to remove stains such as beetle
nut or heavy tobacco staining. Once the heavy
stain is removed, return to a low or medium
setting.
To change a powder flow velocity setting, turn the
powder flow control knob to the indicated letter on
the powder bowl: L is for low, M is for medium, and H
is for high (see Figure 23-16a to c).

Prophy Mode Cycles

A Prophy mode cycle dial is present on the front
of the device. The dial allows the provider to choose
between two cycle options of manual or auto-cycle
prophy modes.
• Manual Prophy mode cycle: Manual mode
requires the provider to press the foot pedal to
discharge the slurry mixture and release the foot
Figure 23-12 Removal of residual powder from the
pedal to stop it (see Figure 23-17a). When the pedal
seal ring. is pressed all the way to the floor (second posi-
tion), the slurry will discharge (see Figure 23-17b).
When the pedal is pressed halfway to the floor
dial has a small, raised, clear, round indicator for set- (first position), water only will discharge (see
ting the powder flow (see Figure 23-15). Figure 23-17c). Patient comfort during air polish-
• Low and medium powder flow velocity are used ing can be improved if a water rinse is provided
for most procedures. after slurry exposure. This will remove residual
 Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling 431

A B
Figure 23-13 Residual powder removal (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System): A. Powder
removal on the threads of the power bowl, B. Powder removal on the threads of powder bowl cap.

Figure 23-14 Powder bowl cap and seal ring.

Figure 23-15 Powder flow control dial round indicator
(Cavitron Jet Plus Ultrasonic Scaling and Air Polishing
System).
powder from soft and hard tissues. Manual mode
is termed None or Manual on the dial depending
on the model (see Figure 23-18). slurry discharge followed by a water rinse. The three
• Auto-cycle Prophy mode: Auto-cycle has three auto-cycle options are termed Short, Medium, and
preprogrammed automatic cycles that deliver a Long. They vary in their time of water and slurry
432 Chapter 23 Coronal to CEJ Air Polishing

A B C
Figure 23-16 Low, medium, high powder flow velocity settings (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing
System): A. L: Low, B. M: Medium, C. H: High.

B C
Figure 23-17 Foot pedal (Tap-On technology wireless foot pedal): A. Foot pedal (Cavitron tap-on foot pedal),
B. Pedal depressed all the way to the floor will discharge the slurry mixture, C. Pedal depressed halfway to
the floor will discharge water only.
Reproduced with permission from Dentsply Sirona
 Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling 433

discharge from the nozzle (see ­
Table 23-1 lists the length of time of slurry and water
discharge for auto-cycle Prophy mode.
Figure 23-18). The dial color pattern is different for the single
stand-alone APD and dual functionality APD.
• Single stand-alone: The Cavitron Prophy Jet Air
Polishing System has one dial that is a purple
color (see Figure 23-1).
• Dual functionality: The Cavitron Jet Plus Ultra-
sonic Scaling and Air Polishing System has a dial
with blue, gray, and purple colors (see Figure 23-2).
The blue and gray are for ultrasonic instrumen-
tation, and the purple is used to set the Prophy
mode cycle for air polishing.

Figure 23-18 Prophy mode cycle dial set to ‘Manual’
(Cavitron Prophy Jet Air Polishing System).
Reproduced with permission from Dentsply Sirona
Foot Pedal
Dentsply Sirona APDs have an indicator on the device
panel that displays the battery level of the foot pedal.
The foot pedal is also equipped with Tap-On technol-
ogy while using the auto-cycle prophy mode. Tap-On
technology eliminates the need to hold the pedal
down while in active use. This allows the provider to
relax their foot on the floor, which decreases strain on
the leg, hips, and back. To activate Tap-On technol-
ogy, the foot pedal is pressed halfway to the floor (first
position) and quickly released. The device will stay
active for 4 minutes and deliver the auto-cycle prophy
mode selected by the user.

Table 23-1 Auto-Cycle Prophy Mode Wireless Bluetooth Technology

Cycle Name Slurry Expulsion Water Rinse The pedal has wireless Bluetooth technology. The
pedal must be synchronized with the device upon de-
Short 0.75 second 1.25 seconds livery. To synchronize:
Medium 2.0 seconds 1.0 second 1. Turn on the power to the device. The on button is
Long 3.0 seconds 2.0 seconds located under the front of the unit (see Figure 23-19).
2. Stand within 10 feet of the unit.

Figure 23-19 Power button (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System).
Reproduced with permission from Dentsply Sirona
434 Chapter 23 Coronal to CEJ Air Polishing

Figure 23-21 Blue water line.

Figure 23-20 Blue purge button (Cavitron Jet Plus

Ultrasonic Scaling and Air Polishing System).
Reproduced with permission from Dentsply Sirona

3. Press the Purge button (see Figure 23-20).

4. Graphics will blink for 5–6 seconds. During this
time, on the bottom of the foot pedal, press and
hold the red button for three seconds.
5. All graphics will blink at the same time upon suc-
cessful synchronization.

Water
Dentsply Sirona APDs are connected to the water
input on the dental unit. The waterline is blue (see
Figure 23-21). Water is used continuously during ac-
tive air polishing. A high water setting is used for air
polishing to obtain a productive slurry consistency.
Waterlines and filters (see Figure 23-22) must be
maintained per the manufacturer’s recommendations
Figure 23-22 Water filter on the water line.
to ensure patient safety (see Chapter 13 for water fil-
ter replacement frequency). One end of the waterline
is connected to the back of the APD, and the other degrees while in use to decrease the need for finger
end is attached to the dental unit water input (see rest repositioning and to prevent coiling of the line.
Figure 23-23a and b).

Water Control
The water control is on the handpiece connector
cord (see Figure 23-24). The flow rate selections are
1 through 6. The lowest water flow rate is 1, and the
highest is 6. The handpiece connector cord rotates 330
Water Purge
Dentsply Sirona APDs have an automatic purge (see
Figure 23-20). To activate, press the Purge button
once, and the waterline will automatically purge for
2 minutes. To deactivate the purge mid-cycle, press
the Purge button again.
 Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling 435

Air
Dentsply Sirona APDs are connected to the air in-
put on the dental unit. The air line is black with a
replaceable filter that should be checked periodically
(see Figure 23-25 and Figure 23-26). Refer to the DFU/
IFU for replacement steps. A filter mounting bracket
is used to hang the air filter in a downward position
to allow for moisture separation and drainage of water
from the filter.
One end of the air line is connected to the back of
the APD, and the other end is attached to the dental
unit air input (see Figure 23-27a and b). Water and air
line connectors on a dental unit are typically near one
another. Use care to ensure the water and air lines are
connected to their correct inputs on the dental unit.
Mixing up the cords could result in significant, and
A
sometimes irreversible, damage to the equipment.

B patient use. There are markings on the air polishing
Figure 23-23 Water connection: A. Waterline connected
to the back of the APD, B. Waterline connected to the
dental unit.
Nozzle
The Cavitron Jet Air Polishing Insert is the name of
the air polishing insert with an affixed nozzle man-
ufactured by Dentsply Sirona. The insert is a silver
color with a green O-ring that is placed into the hand-
piece. The opening on the insert expels the slurry. The
Cavitron Jet Air Polishing Insert is sterilized after each
insert with the company’s name and date of creation.
There are four parts to the Cavitron Jet Air Polishing
Insert, as seen in Figure 23-28.

A B C
Figure 23-24 Water control: A. Handpiece connector (Cavitron Jet Plus Ultrasonic Scaling and Air Polishing System),
B. Handpiece connected to the handpiece connector (Jet-Mate Sterilizable, Detachable Handpiece), C. Water control
numbers 1–6 on the handpiece connector.
Reproduced with permission from Dentsply Sirona
436 Chapter 23 Coronal to CEJ Air Polishing

A
Figure 23-25 Black air line.

B
Figure 23-27 Air connection: A. Air line connected to
the back of the APD, B. Air (yellow), water (blue), and
electric input on a dental unit.

Prophy powder delivery tube Heater Rod

Figure 23-26 Air filter on the black air line cord.

1. Heater rod: Long solid metal rod that heats the

water for patient comfort.
2. Single green O-ring: Water seal to prevent leakage.
The O-ring is a wear and tear item and should be
replaced when worn. Nozzle Tube O-Ring
3. Prophy powder delivery tube: Delivers the
compressed air and powder mixture to the nozzle Figure 23-28 Cavitron Jet Air Polishing Insert.
tube.
4. Nozzle tube: Terminal portion of the Cavit-
ron Jet Air Polishing Insert with two concentric
openings. The outer opening expels water, and Cleaning Tool
the inner opening expels the compressed air and The Cavitron Prophy Jet Nozzle Cleaning Tool is
powder mixture (see Figure 23-29). The nozzle is a sterilizable narrow solid metal wire with an affixed
slightly angled for ease of use. white holder used to dislodge residual powder in the
 Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling 437

Inner circle:
air/powder

Outer circle:
water

Figure 23-29 Nozzle tube openings. Inner opening

expels compressed air and powder. Outer opening
expels water.
A B
Figure 23-31 Cavitron Prophy Jet Nozzle Cleaning Tool
A. Cavitron Prophy Jet Nozzle Cleaning Tool inserted
into the nozzle delivery tube of the Cavitron Jet Air
Polishing Insert, B. Cavitron Prophy Jet Nozzle Cleaning
Tool and Cavitron Jet Air Polishing Insert correctly
bagged for reprocessing.

Figure 23-30 Cavitron Prophy Jet Nozzle Cleaning tool.

nozzle delivery tube of the Cavitron Jet Air Polishing

Insert (see Figure 23-30). The steps for proper use are
below:
• Remove the Cavitron Jet Air Polishing Insert from
the Jet-Mate Sterilizable, Detachable Handpiece.
• Place the Cavitron Prophy Jet Nozzle Cleaning Figure 23-32 Dentsply Sirona Jet-Mate Sterilizable,
Tool inside the nozzle delivery tube on the Cavit- Detachable Handpiece and Soft Nozzle Grip.
ron Jet Air Polishing Insert. Reproduced with permission from Dentsply Sirona

• Slide the tool in and out until there is no resis-

tance. The wire will pierce all the way through the
nozzle delivery tube (see Figure 23-31a).
• Remove the Cavitron Prophy Jet Nozzle Cleaning
Tool from the nozzle delivery tube and reprocess
(see Figure 23-31b). If the Cavitron Prophy Jet
Nozzle Cleaning Tool is left in the delivery tube,
sterility cannot be guaranteed.
Handpiece
The Jet-Mate Sterilizable, Detachable Handpiece
is the name of the air polishing handpiece manufactured
by Dentsply Sirona. The handpiece has a detach-
able soft nozzle grip. The soft nozzle grip is a wear
and tear item that will need periodic replacement
(see Figure 23-32).There are two port hole openings
on the soft nozzle grip, the powder delivery port
and the insert port (see Figure 23-33).
• Powder delivery port: Smaller opening on the soft
nozzle grip. The prophy powder delivery tube
on the Cavitron Jet Air Polishing Insert is placed
in this port, which has an airtight seal for slurry
delivery.
438 Chapter 23 Coronal to CEJ Air Polishing
Figure 23-33 Soft nozzle grip powder delivery (smaller
opening) and insert port (larger opening).
• Insert port: Larger opening on the soft nozzle
grip.The heater rod on the Cavitron Jet Air Pol-
ishing Insert is placed in this port.
Cleaning Tool
The Cavitron Prophy Jet Handpiece Cleaning
Tool is a sterilizable narrow solid metal wire used to
dislodge residual powder in the powder delivery port
on the Jet-Mate Sterilizable, Detachable Handpiece.
The steps for proper use are below:
• Remove the Cavitron Jet Air Polishing Insert from
the Jet-Mate Sterilizable, Detachable Handpiece.
• Place the Cavitron Prophy Jet Handpiece Clean-
ing Tool inside the powder delivery port on the
Jet-Mate Sterilizable, Detachable Handpiece (see
Figure 23-34).
• Slide the tool in and out until there is no resistance.
• Remove the Cavitron Prophy Jet Handpiece
Cleaning Tool from the powder delivery port and
reprocess. If the Cavitron Prophy Jet Handpiece
Cleaning Tool is left in the powder delivery port,
sterility cannot be guaranteed.
Jet-Mate Sterilizable, Detachable
Handpiece and Cavitron Jet Air
Polishing Insert Assembly
1. Align the electrical connections of the Jet-Mate
Sterilizable, Detachable Handpiece and the
Figure 23-34 Cavitron Prophy Jet Handpiece Cleaning
Tool placed inside the powder delivery port on the
Jet-Mate Sterilizable, Detachable Handpiece
Reproduced with permission from Dentsply Sirona
Figure 23-35 Handpiece connector (left) and Jet-Mate
Sterilizable, Detachable Handpiece (right).
Reproduced with permission from Dentsply Sirona
handpiece connector cable and gently attach
them (see Figure 23-35).
2. Hold the Jet-Mate Sterilizable, Detachable Hand-
piece upright over a sink, step on the pedal to
fill with water, and allow trapped air to exit. Al-
low a dome of water to remain at the Jet-Mate
Sterilizable, Detachable Handpiece opening (see
Figure 23-36).
3. Lubricate the green O-ring of the Cavitron Jet
Air Polishing Insert on the water dome by ro-
tating the O-ring 360 degrees on the water (see
Figure 23-37).
4. Place the Cavitron Jet Air Polishing Insert into the
opening on the Jet-Mate Sterilizable, Detachable
Handpiece, ensuring the heater rod is aligned
with the larger insert port opening, and the pro-
phy powder delivery tube is aligned with the
powder delivery port (see Figure 23-38a and b).
 Cavitron Prophy Jet Air Polishing System and Cavitron Jet Plus Ultrasonic Scaling
Figure 23-36 Jet-Mate Sterilizable, Detachable
Handpiece with a dome of water.
Figure 23-37 O-ring lubrication on the Cavitron Jet Air
Polishing Insert.
5. Ensure that the O-ring is fully seated. Do not
twist the nozzle in the handpiece to assist with
O-ring seating (see Figure 23-29a and b). Use a
firm straight push motion.
439
A B
Figure 23-38 Jet-Mate Sterilizable, Detachable
Handpiece and Cavitron Jet Air Polishing Insert:
A. Heater rod placed into the insert port opening and
prophy powder delivery tube aligned with the powder
delivery port, B. Prophy powder delivery tube placed into
the powder delivery port.
A B
Figure 23-39 Jet-Mate Sterilizable, Detachable
Handpiece and Cavitron Jet Air Polishing Insert:
A. O-ring not fully seated, B. O-ring fully seated.
440 Chapter 23 Coronal to CEJ Air Polishing

Jet-Mate Sterilizable, Detachable Clinical Technique

Handpiece and Cavitron Jet Air
Polishing Insert Removal Steps
1. Remove the Cavitron Jet Air Polishing Insert from
the Jet-Mate Sterilizable, Detachable Handpiece.
2. Use the Cavitron Prophy Jet Nozzle Cleaning Tool
and the Cavitron Prophy Jet Handpiece Cleaning
Tool to dislodge residual powder. Remove both
cleaning tools..
3. Use a gentle straight pull motion to remove the
Jet-Mate Sterilizable, Detachable Handpiece from
the handpiece connector cable. Do not twist the
handpiece to prevent damage to the electrical
connections.
4. Follow automatic and manual cleaning direc-
tions, as well as sterilization protocols in the
product’s instruction for use (IFU).
1. Use the lowest powder velocity flow rate possible
to achieve the clinical goal.
2. Position the nozzle 2–4 mm away from the middle
of the tooth surface (see Figure 23-40).The noz-
zle should never directly contact tooth surfaces
during air polishing. Placing the nozzle closer
than 2–4 mm can cause over-abrasion. Placing
the nozzle farther away than 2–4 mm decreases
effectiveness and can cause under-abrasion.
3. Expose each tooth surface to 1–2 seconds of the
slurry mixture. Use the shortest contact time
required to achieve the clinical goal. Move the
nozzle in small, circular, continuous, fluid over-
lapping motions as the slurry is expelled.
4. After 2–3 teeth have been exposed to the slurry, a
rinse of equal length should be provided for im-
proved patient comfort.

Reprocessing Nozzle angulation varies by tooth surface.

Always use aseptic techniques during reprocess-

• Smooth and interproximal surfaces
• Anterior teeth: 60-degree angulation of the noz-
ing that includes full personal protective equipment zle to tooth surface (see Figure 23-41a and b).
(PPE) and utility gloves when handling contaminated • Posterior teeth: 80-degree angulation of the
equipment to avoid cross-contamination and operator nozzle to tooth surface angled slightly distally
injury. (see Figure 23-42a and b).
• Incisal and occlusal surfaces
Air Polishing Device • 90-degree angulation of the nozzle to tooth
The power cord, air line, waterline, handpiece ca- surface (see Figure 23-43a and b).
ble, foot pedal and cord, and the device itself is not
sterilizable. Remove powder from all fixtures with
a disposable soft nonabrasive cloth prior to using a
manufacturer-approved disinfectant, which you can
find in the product’s IFU. Do not spray disinfectant
solutions directly on APD system surfaces. Use a
­manufacturer-approved chemical wipe with correct
contact time. Keep APDs away from direct sunlight to
prevent discoloration.

Handpiece and Nozzle Insert

Remove the cleaning tools from the Jet-Mate Steril-
izable, Detachable Handpiece and Cavitron Jet Air
Polishing Insert. Automatic and manual cleaning
directions as well as sterilization protocols are pro-
vided in the product’s IFU. The Jet-Mate Sterilizable,
Detachable Handpiece, Cavitron Jet Air Polishing
Insert, and cleaning tools should be completely dry
before packaging for sterilization. Steam under pres-
sure sterilization is recommended because cold liquid
disinfection, chemical vapor, and dry heat steriliza- Figure 23-40 Nozzle 2–4 mm from the tooth surface of
tion have not been tested or validated for efficacy. the mandibular right first molar facial.
 Clinical Technique 441

A B
Figure 23-41 Anterior nozzle angulation on the maxillary left central incisor facial surface: A. Incorrect 90-degree
angulation, B. Correct 60-degree angulation.

A B
Figure 23-42 Posterior nozzle angulation on the mandibular right first molar buccal surface: A. Incorrect 90-degree
angulation, B. Correct 80-degree angulation.

A B C
Figure 23-43 Occlusal and Incisal air polishing: A. 90-degree nozzle angulation to the occlusal of the mandibular right
first molar, B. Staining on the occlusal of a premolar that can be air polished with a 90-degree anuglation, C. Staining
on the incisal of maxillary anterior teeth that can be air polished with a 90-degree anuglation.
442 Chapter 23 Coronal to CEJ Air Polishing

CASE STUDY
Your patient is a 58-year-old Indian male with a noncontributory medical history. The patient is not taking any
over-the-counter or prescription medications and has no drug allergies. Body Mass Index (BMI) is 25.
His chief complaint is “I don’t like the color of my teeth.”
Dental exam: Patient had orthodontics in the past and lost the mandibular left second molar a few years ago due to
a failed root canal. The dentist recommended a dental implant for the edentulous space. The maxillary left third
molar is treatment planned for extraction due to decay.
Occlusion: Class I bilateral with first molar relationship. Overbite of 6 mm. Mandibular anterior crowding.
Oral hygiene exam:
■ Disclosing solution revealed 95% of surfaces with biofilm and dental calculus.
■ Generalized heavy biofilm.
■ Generalized moderate supragingival dental calculus on smooth surfaces. Generalized light to moderate
interproximal dental calculus.
■ Generalized moderate to heavy staining.
Periodontal exam:
■ Probe depths 3–6 mm generally with bleeding upon probing 37% of the mouth. Localized 7 mm probe depth on the
maxillary left wisdom tooth mesial-lingual surface. This tooth has significant mesial decay.
■ Localized recession and furcation involvement on molars Class I and II.

Mandibular right anterior lingual surfaces Mandibular anterior lingual surfaces

Mandibular anterior and premolar lingual surfaces Mandibular left anterior lingual surfaces
 Clinical Technique 443

Maxillary right anterior lingual surfaces Maxillary left anterior lingual surfaces

First premolar occlusal. Second premolar occlusal.

First molar occlusal.

444 Chapter 23 Coronal to CEJ Air Polishing

Periodontal charting.

Full-mouth series radiographs.

1. Can air polishing remove the dental calculus pictured on the mandibular anterior lingual surfaces? Why or
why not?
2. What nozzle angulation, distance, and powder velocity flow rate would you use to remove the stain seen on the
molar and premolar teeth?
3. What nozzle angulation, distance, and powder velocity flow rate would you use to remove the stain seen on the
maxillary and mandibular anterior lingual and interproximal surfaces?
4. What air polishing powder should be used for this patient with a Dentsply Sirona APD and why?

Summary
Air polishing with a Dentsply Sirona APD is a safe an
effective procedure for the removal and reduction of
biofilm, immature dental cal­culus, and extrinsic ex-
ogeneous staining. There are two powder options
of sodium bicarbonate and aluminum trihydroxide.
The Cavitron Jet Air Polishing Insert; Cavitron Pro-
phy Jet Nozzle Cleaning Tool; Jet-Mate Sterilizable,
Questions
1. True or False. Dentsply Sirona manufactures a
stand-alone and dual functionality APD.
a. True
b. False
2. Which of the following powders are
manufactured by Dentsply Sirona and
compatible with their APDs?
a. Cavitron Prophy Jet Prophy Powder
b. Cavitron Jet Fresh Prophy Powder
c. Glycine
d. Both A and B
3. How do you change the powder flow velocity
from low to medium?
a. Turn the dial on the handpiece connector.
b. Turn the powder flow control dial on the
powder bowl cap.
c. Turn the Prophy mode cycle dial.
d. The powder flow velocity cannot be changed.
4. What powder flow velocity is used infrequently
and only for the removal of exceptionally heavy
and difficult to remove stains such as beetle nut
staining or heavy tobacco stain?
a. Low
b. Medium
c. High
d. All of the above
5. Which of the following is TRUE?
a. Powder in the powder bowl does not need to
be emptied at the end of a workday.
b. The powder bowl is filled with powder to
completely submerge the inner tube.
c. The provider can tell the device is pressurized
when a small white circle of powder can
be seen in the window of the powder flow
control dial.
d. When the APD is turned off, it will
immediately depressurize, and the powder
bowl cap can be easily removed.
Questions 445
Detachable Handpiece; and Cavitron Prophy Jet
Handpiece Cleaning Tool should be sterilized after
each patient use. The clinical technique and noz-
zle angulation vary by tooth surface. A step-by-step
hands-on exercise with a Dentsply Sirona APD is pre-
sented in Chapter 25.
6. True or False. When delivering air polishing, a
water rinse is not needed.
a. True
b. False
7. Which auto-cycle Prophy mode dispenses
the slurry for 2 seconds and then provides a
1-second water rinse?
a. Short
b. Medium
c. Long
8. How are a water lavage rinse and the auto-cycles
activated in a Dentsply Sirona APD?
a. Press the pedal all the way to the floor.
b. Activate Boost mode.
c. Press the pedal halfway to the floor.
9. How long will water dispense from the waterline
when the automatic purge is activated in a
Dentsply Sirona APD?
a. 1 minute
b. 2 minutes
c. 3 minutes
d. 4 minutes
10. Which of the following is FALSE?
a. The Cavitron Prophy Jet Handpiece Cleaning
Tool and Cavitron Prophy Jet Nozzle
Cleaning Tool are used to dislodge residual
powder.
b. The Cavitron Prophy Jet Handpiece Cleaning
Tool and Cavitron Prophy Jet Nozzle
Cleaning Tool are left inside the nozzle and
handpiece during sterilization.
c. The prophy powder delivery tube is inserted
into the powder delivery port of the Jet-Mate
Sterilizable, Detachable Handpiece.
d. The nozzle heater rod is placed into the insert
port of the Jet-Mate Sterilizable, Detachable
Handpiece.
446 Chapter 23 Coronal to CEJ Air Polishing

11. How far away should the nozzle be from the Match the following tooth surface to the correct noz-
surface of a tooth? zle angulation for questions 12–14. There is only one
a. 2–4 mm correct answer for each question.
b. 5–6 mm 12. Anterior A. 80 degrees
c. 7–8 mm
d. 9–10 mm 13. Posterior B. 90 degrees
14. Occlusal C. 60 degrees
 CHAPTER 24
Coronal and Apical to CEJ
Air Polishing
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Recognize the benefits of subgingival air
polishing during periodontal debridement.
2. Identify EMS air polishing devices, parts, and
accessories.
3. Identify EMS powder selections and their
clinical indications, applications, and
considerations.
4. Use an EMS air polishing device with proper
powder velocity settings, water flow rate, and
nozzle angulations.
5. Implement EMS Guided Biofilm Therapy (GBT)
in clinical practice.
KEY TERMS
• AIRFLOW Classic powder: the name of sodium
•
bicarbonate powder manufactured by EMS.
AIRFLOW Handpiece: the name of the air
polishing handpiece that delivers the slurry
mixture supragingival and in shallow (<4 mm)
pockets; manufactured by EMS.
• AIRFLOW Handy: the name of the portable
handheld APDs manufactured by EMS.
• AIRFLOW Handy 3.0 Classic: the name of the
portable handheld APD with a blue powder
chamber that delivers AIRFLOW Classic
powder (sodium bicarbonate); manufactured
by EMS.
• AIRFLOW Handy 3.0 Perio: the name of the
portable handheld APD with a pink powder
chamber that delivers AIRFLOW Perio powder
(glycine) and AIRFLOW Plus powder (erythritol);
manufactured by EMS.
• AIRFLOW One: the name of a single stand-alone
APD manufactured by EMS.
• AIRFLOW Perio powder: the name of glycine
powder manufactured by EMS.
• AIRFLOW Plus powder: the name of erythritol
powder manufactured by EMS.
• AIRFLOW Prophylaxis Master: the name of a dual-
functional APD plus ultrasonic scaling device
manufactured by EMS.
• BacterX Pro mouthwash: mouthrinse that contain
chlorhexidine digluconate 0.1%, cetylpyridinium
chloride 0.05%, and sodium fluoride 0.01%
(fluoride 0.0005%).
• Body: part of the portable handheld AIRFLOW
Handy 3.0 that houses the powder chamber and
inner tube; manufactured by EMS.
• Cord adaptor: part of the portable handheld
AIRFLOW Handy 3.0 that attaches to a dental unit
air turbine connector.
• Dynamic pressure regulator: control on the
AIRFLOW One and AIRFLOW Prophylaxis Master
that automatically sets the optimal pressure
range based on the powder velocity setting for
•
each powder chamber.
Easy Clean Tool: tool for cleaning EMS
AIRFLOW and PERIFLOW handpieces prior to
sterilization.
• Guided Biofilm Therapy (GBT): the name of
a proprietary multi-step program created by
EMS for preventive non-surgical procedures
that combines disclosing solution, air polishing
for biofilm reduction subgingivally and
supragingivally, and piezoelectric ultrasonic
instrumentation.
447
448 Chapter 24 Coronal and Apical to CEJ Air Polishing
• Nozzle extractor: tool used to remove the single-
use disposable subgingival nozzle from the
PERIOFLOW handpiece.
• PERIOFLOW Handpiece: the name of the air
polishing handpiece that delivers the slurry
mixture into deeper (>4 mm) periodontal pockets;
manufactured by EMS.
Introduction
Subgingival air polishing is a safe and efficient method
to remove and reduce plaque biofilm, the etiological
agent of gingival, periodontal, and peri-implant dis-
eases. The powders delivered subgingivally are gly-
cine and erythritol. These powders have a low particle
size and Mohs hardness, as discussed in Chapter 22.
Literature commonly refers to the clinical procedures
performed with glycine and erythritol as glycine pow-
der air polishing (GPAP) and erythritol powder air
polishing (EPAP).
The literature presented in this chapter will
show glycine and erythritol have been proven
safe for use on less mineralized hard tissues such
as dentin and cementum without causing harmful
effects. Subgingival slurry penetration with EMS
technology is possible with a standard and subgin-
gival nozzle.
There are multiple manufacturers of air polish-
ing technology; this chapter will focus on two EMS
devices because covering every manufacturer of
APD technology would be too lengthy for this book.
Guided Biofilm Therapy (GBT) is a unique propri-
etary multi-step program created by EMS for preven-
tive non-surgical procedures that combines disclosing
solution, air polishing for biofilm reduction subgingi-
vally and supragingivally, and piezoelectric ultrasonic
instrumentation.This chapter will present GBT with
the AIRFLOW Prophylaxis Master.
Subgingival Air
Polishing in Periodontal
Debridement
As discussed previously, the clinical objective of
periodontal debridement is to remove the etiologi-
cal agents of periodontal infections while conserving
healthy enamel, dentin, and cementum by using the
least aggressive instrumentation to achieve this goal.
Oral health-care providers perform supragingival and
subgingival instrumentation with hand-activated in-
struments, ultrasonic instruments, and air polishing
devices to reduce biofilm levels to promote a symbi-
otic oral environment.
Subgingival air polishing has been investigated
in the literature for its clinical outcomes, safety of
­delivery, and microbiological effects. There is a grow-
ing body of evidence showing comparable over-
all clinical outcomes for periodontal debridement
with hand-activated and ultrasonic instrumentation
with and without the adjunctive use of subgingival
air polishing. However, the evidence does show dif-
ferences in the delivery of care, alterations and ef-
fects to hard and soft tissues, and microbiological
changes when s­ ubgingival air polishing is used during
debridement.
Overall Clinical Outcomes
• Subgingival air polishing is used in conjunc-
tion with either hand-activated or ultrasonic in-
strumentation when firmly established dental
calculus deposits are present because the slurry
mixture will not remove firmly established calcu-
lus deposits. Air polishing will remove all levels
of biofilm and immature or early forming dental
calculus.
• Studies have shown similar treatment outcomes
when air polishing is used during nonsurgical peri-
odontal debridement along with hand-activated
or ultrasonic instrumentation in shallow and deep
periodontal pockets (Buhler et al., 2015; Cosgarea
et al., 2021; Hagi et al., 2015; Kargas et al., 2015;
Mensi et al., 2021; Moene et al., 2010; Muller
et al., 2014; Ng, 2018; Park et al., 2018; Sculean
et al., 2013).
• Ultrasonic instrumentation, GPAP, and EPAP re-
duce plaque biofilm and gingival inflammation
similarly, but the ultrasonic can simultaneously
remove firmly established dental calculus, while
GPAP and EPAP cannot (Sculean et al., 2013).
A randomized controlled trial by Muller et al.
(2014) evaluated the reduction in probe depths
over 4 mm in periodontal maintenance patients
over a 12-month period between participants
who received ultrasonic instrumentation only and
a group that received ultrasonic instrumentation
followed by subgingival air polishing with eryth-
ritol 0.3% chlorhexidine. Both groups demon-
strated comparable results in reduction of probe
depths over 4 mm when patients received each
treatment at 3-, 6-, and 9-month intervals (Muller
et al., 2014).

Delivery of Care
• Subgingival air polishing is safe for hard and soft
tissues if used as directed by the manufacturer
(Moene et al., 2010; Sculean et al., 2013; ­Flemmig
et al., 2007, 2012; Petersilka et al., 2008).
• Time efficiency of biofilm reduction subgin-
givally is improved with air polishing when
compared to hand-activated instrumentation,
with studies reporting three to five times faster
biofilm removal (Moene et al., 2010; Sculean
et al., 2013; Flemmig et al., 2012; Wennstrom
et al., 2011).
• Studies report that patient comfort during biofilm
reduction is improved with subgingival air polish-
ing compared to other forms of instrumentation
(Moene et al., 2010; Muller et al., 2014; Sculean
et al., 2013; Petersilka et al., 2008; Wennstrom
et al., 2011; Petersilka, 2000).
Hard and Soft Tissue Effects
• Studies have shown glycine and erythritol p ­ owder
do not have harmful effects on cementum and
dentin and cause less alterations to root structures
and dental materials than other powders ­(Flemmig
et al., 2012; Petersilka, 2000; Pelka et al., 2010;
Petersilka et al., 2003).
• Erythritol and glycine powders cause less epithe-
lial damage and erosions to soft tissues during
biofilm removal compared to hand-­ activated
instrumentation (Petersilka et al., 2008; Flem-
mig et al., 2012; Petersilka, 2000). Although
epithelial tissue damage will heal on its own un-
eventfully within 6 days after the injury, these
findings show GPAP and EPAP improve patient
comfort and decrease post-­procedure discom-
fort (Flemmig et al., 2007; Kozlovsky et al.,
2005). A recent systematic review by Buehler
et al. (2015) found air polishing caused simi-
lar effects on root roughness as ultrasonic in-
strumentation. Hand-activated instrumentation
caused significantly higher root roughening
than both ultrasonic and air polishing forms of
instrumentation.
Microbiological
• Subgingival air polishing reduces biofilm lev-
els in shallow (1–3 mm) and deep (≥4 mm)
periodontal pockets significantly more com-
­ the AIRFLOW Plus powder (see Table 24-1 and
pared to hand-­ activated instrumentation
(Sculean et al., 2013; Flemmig et al., 2007,
­ piece was developed to deliver AIRFLOW Perio powder
2012; Petersilka, 2000).
EMS Air Polishing Powders 449
• When subgingival air polishing is used in con-
junction with hand-activated instrumentation,
Porphyromonas gingivalis levels are reduced sig-
nificantly more compared to hand scaling only
(Park et al., 2018; Flemmig et al., 2012; Hashino
et al., 2013). Other periodontal pathogens such
as T. forsythia, C. rectus, E. corrodens, F. nucleatum,
P. intermedia, and T. ­denticola investigated in the
literature did not have the same levels of reduc-
tion as P. ­gingivalis (Park et al., 2018; Flemmig
et al., 2012; Hashino et al., 2013). An in vitro
study published in 2014 by Drago et al. (2014),
tested Staphylococcus aureus, Bacteroides fragilis,
and Candida albicans susceptibility to glycine
and erythritol with 0.3% chlorhexidine. Both
powders had an inhibitory effect by decreasing
the number of surviving cells of all three strains.
Glycine was less effective against Staphylococcus
aureus than Bacteroides fragilis and Candida albi-
cans. Erythritol was more effective than glycine
on all three strains (Drago et al., 2014).
EMS Air Polishing Devices
EMS manufactures three different air polishing
systems:
1. Single stand-alone APD called the the AIRFLOW
One (see Figure 24-1a). This is ideal for offices
that already have an ultrasonic device and only
need to purchase an air polisher.
2. Dual functionality device as a piezoelectric ul-
trasonic scaler and APD called the AIRFLOW
­Prophylaxis Master (see Figure 24-1b).
3. Portable handheld APD called the AIRFLOW
Handy (see Figure 24-1c).
There is a specific air and water pressure psi
(pound force per square inch) required for each de-
vice, which you can find in the product’s direction for
use or instruction for use (DFU/IFU).
EMS Air Polishing
Powders
EMS began selling AIRFLOW in 1982 for su-
pragingival air polishing. Currently, EMS manufac-
tures three different powders called the AIRFLOW
­Classic ­powder, AIRFLOW Perio powder, and
Figure 24-2a and b). In 2003, the PERIOFLOW hand-
(glycine) into deeper (>4 mm) periodontal pockets.
450 Chapter 24 Coronal and Apical to CEJ Air Polishing

B
A

C
Figure 24-1 EMS devices: A. AIRFLOW One, B. AIRFLOW Prophylaxis Master, C. AIRFLOW Handy 3.0 Perio.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Table 24-1 EMS Powders In 2012, EMS added AIRFLOW Plus powder
(erythritol).
Powder EMS Name Particle Size
Today, both the AIRFLOW Perio Powder ­(glycine)
Sodium AIRFLOW Classic Powder 40 µm and AIRFLOW Plus Powder (erythritol) are delivered
bicarbonate both supragingivally and subgingivally. AIRFLOW
Glycine AIRFLOW Perio Powder 25 µm Classic Powder (sodium bicarbonate) is only deliv-
ered coronal to the CEJ owing to its larger particle size
Erythritol AIRFLOW Plus Powder 14 µm and Mohs hardness. Never use another manufacturer’s
Reproduced with permission from E.M.S. Electro Medical Systems S.A. powder in an EMS APD because this can cause equip-
ment damage and possibly void the warranty.
 EMS AIRFLOW One and AIRFLOW Prophylaxis Master 451

A B
Figure 24-2 EMS powder bottles: A. AIRFLOW Plus powder, B. AIRFLOW
Classic powder.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

EMS AIRFLOW
One and AIRFLOW
Prophylaxis Master
This section will cover the powder chambers, change-
able powder velocity settings, and water and air re-
quirements for the AIRFLOW One and AIRFLOW
Prophylaxis Master.

Powder Chambers
A powder chamber is provided for each powder
type and has a color-coded lid. The correct powder
must be placed in its correct powder chamber to
avoid equipment damage.
• Gray: AIRFLOW Classic powder (sodium
bicarbonate) is placed into the gray chamber.
­
This powder is delivered coronal to the CEJ (see
Figure 24-3).
• Red: AIRFLOW Perio powder (glycine) or
AIRFLOW Plus powder (erythritol) is placed into
the red chamber. These powders are delivered
coronal and apical to the CEJ (see Figure 24-4).
The powder chambers are equipped with an integ­ Figure 24-3 Gray powder chamber (EMS AIRFLOW
rated dynamic pressure regulator that automatically Prophylaxis Master).
452 Chapter 24 Coronal and Apical to CEJ Air Polishing
Figure 24-4 Red powder chamber (EMS AIRFLOW
Prophylaxis Master).
sets the optimal pressure range based on the powder
velocity setting for each powder chamber.
To fill the powder chamber:
1. With the device off, remove the powder cham-
ber from its magnetic connection to the APD (see
Figure 24-5).
2. Shake the powder bottle to break up clumps.
3. Pour the powder into its corresponding powder
chamber. Do not fill past the max fill line indi-
cated on the powder chamber (see Figure 24-3
and Figure 24-4).
4. Close the lid tightly on the powder bottle to pre-
vent moisture contamination.
5. Place the powder chamber into its holder on the
APD. Ensure that the magnetic connection is secure.
6. Turn the device on (see Figure 24-5).
7. Press the dynamic pressurization button (see
Figure 24-6a).A white light will illuminate when
the powder chamber is turned on and pressur-
ized (see Figure 24-6b). If the device is not used
for 1 hour, the unit will go into off-mode standby
where the powder chamber automatically depres-
surizes and the white light turns off.
To empty the powder bowl:
1. Turn the APD off.
2. Allow the powder chamber to fully depres-
surize. Ensure that the handpiece is not facing
Figure 24-5 EMS AIRFLOW Prophylaxis Master on/off
control.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
upward or toward you to avoid injury from the
spraying of purged air and residual powder (see
Figure 24-7a).
3. Remove the powder chamber from its magnetic
holder without twisting or rotating the chamber
(see Figure 24-7b).
4. Discard all unused powder from the powder
chamber in the trash.
5. Clean the connections with compressed air from
the A/W syringe and place on a dry surface.
Powder Velocity Control
Powder velocity control settings are 0 through 10.
Zero will deliver water only, and 10 delivers maximum
air pressure output. The powder velocity is changed
by sliding your finger on the groove panel below the
number (see Figure 24-8).
The air pressure increases incrementally from
1 through 10. The gray powder chamber with
AIRFLOW Classic powder (sodium bicarbonate) will
output a higher dynamic air pressure at all power set-
tings than the red powder chamber with AIRFLOW
Perio powder (glycine) or AIRFLOW Plus powder
(erythritol). Sodium bicarbonate is used for heavier,
more tenacious stains coronal to the CEJ, and a higher
air pressure is needed for removal. Glycine and eryth-
ritol are used coronal and apical to the CEJ. A lower
 EMS AIRFLOW One and AIRFLOW Prophylaxis Master 453

A B
Figure 24-6 Dynamic pressure regulator (EMS AIRFLOW Prophylaxis Master): A. Dynamic pressure
regulator control, B. Illuminated powder chamber.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A B
Figure 24-7 EMS AIRFLOW handpiece and powder chamber: A. EMS AIRFLOW MAX handpiece
nozzle pointed downward, B. Removal of the powder chamber.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
454 Chapter 24 Coronal and Apical to CEJ Air Polishing

air pressure is desired when delivering a slurry mix-
ture on less mineralized hard tissues such as dentin
and cementum (see Table 24-2).
Foot Pedal
The AIRFLOW One and AIRFLOW Prophylaxis Mas-
ter have a wireless foot pedal with Bluetooth technol-
ogy (see Figure 24-9). The foot pedal is synched to
the device by the manufacturer. There is no need for
synchronization prior to use.
The foot pedal is pressed on the outer side with
a light pressure. If the middle of the pedal is pressed
all the way to the floor, the device will activate Boost
mode (see the next section). When the foot pedal is
released, there is a 0.2-second delay in the slurry stop-
ping. Be sure to keep the nozzle in the patient’s mouth
during this time to avoid splashing.
Boost Mode. Boost mode is controlled by the foot
pedal. When activated, Boost mode will increase the
air pressure incremental to the powder velocity set-
ting (see Table 24-3).
Water
A continuous water flow rate is needed anytime the
APD is in use. A high water flow rate is used to ob-
tain a productive slurry consistency and to avoid ex-
pulsion of a cloud of powder into the air. Waterlines
and filters must be maintained per the manufacturer’s
recommendations to ensure patient safety. Refer to the
DFU/IFU for details. Some models allow for a change
in water temperature.
Water Control
The water control is a black spindle located next to
the handpiece holder with options 1 through 10 (see
Figure 24-10).

Boost: press
in middle and
all way to floor

Non-Boost:
press lightly on
side

Figure 24-9 EMS AIRFLOW One and AIRFLOW

Prophylaxis Master foot pedal. Boost: press middle
of pedal to floor. Non-boost: press pedal lightly on
Figure 24-8 Powder velocity control (EMS AIRFLOW the side
Prophylaxis Master). Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Table 24-2 Dynamic Air Pressure by Powder Chamber

Power Setting 0 1 2 3 4 5 6 7 8 9 10
Classic Powder Water only 1.9 2.1 2.3 2.6 2.8 3.0 3.2 3.5 3.7 3.9
Perio and Plus Powders Water only 1.5 1.7 1.9 2.0 2.2 2.4 2.6 2.7 2.9 3.1

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Table 24-3 EMS AIRFLOW One and AIRFLOW Prophylaxis Master Boost Mode
Power Setting 0 1 2 3 4 5 6 7 8 9 10
Boost 0 6 7 8 8 8 9 10 10 10 10

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

 EMS AIRFLOW One and AIRFLOW Prophylaxis Master 455

Figure 24-10 Water control spindle (EMS AIRFLOW MAX

handpiece)
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Water Temperature
The water temperature can be adjusted to improve
patient comfort. The AIRFLOW One and AIRFLOW
Prophylaxis Master are preset to 40°C/104oF by de-
fault. A higher water temperature may be desired for
air polishing, especially on less mineralized hard tis-
sues such as cementum and dentin that are more re-
sponsive to temperature fluctuations.
To change the water temperature:
B
Figure 24-11 Changing water temperature (EMS
AIRFLOW Prophylaxis Master): A. Press and hold 1
and 10 at the same time, B. Illuminated colors on
numbers.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

1. Press and hold 0 and 10 at the same time (see

Figure 24-12b). The water bottle has an O-ring at the
Figure 24-11a).
bottom that will need to be replaced when worn (see
2. The numbers will illuminate with varied col-
Figure 24-13). Anytime the water bottle is removed for
ors. Use numbers 0–4 to change the water tem-
long periods of time, place the CLIP+CLEAN tool
perature (see Figure 24-11b). Numbers 6–10 will
into the device’s independent water bottle receptacle for
change the sound the machine emits.
dust protection. See Chapter 17 for details if needed.
• 0: no heat
Regular cleaning of the waterline is required to
• 1: 25°C/77oF
prevent biofilm accumulation. Refer to the DFU/IFU
• 2: 30°C/86oF
for approved cleaners. In addition to daily clean-
• 3: 35°C/95oF
ing, the waterlines should be treated once a week
• 4: 40°C/104oF (default)
with the specialized Night Cleaner. At the time
3. Press the On/Off button to save your setting.
of this book publication, Night Cleaner is not ap-
proved for use in the United States. EMS recom-
Water Bottles mends other products for waterline maintenance.
The APDs have an independent water bottle reservoir Contact EMS for any questions. The cleaner is a
(see Figure 24-12a). Remove the bottle with a straight solution with a combination of chemicals (eth-
pull motion and replace it the same way (see ylenediaminetetraacetate, p-­ hydroxybenzoic acid
456 Chapter 24 Coronal and Apical to CEJ Air Polishing

Figure 24-13 Red O-ring on water bottle.

A Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 24-14 EMS AIRFLOW Night Cleaner bottle (blue)

B
Figure 24-12 Independent water bottle reservoir:
A. Water bottle, B. AIRFLOW Prophylaxis Master water
bottle receptacle.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
ester, polyhexamethylenebiguanide; see Figure 24-14).
Night Cleaner is bactericidal and fungicidal and pre-
vents lime and algae formation in the line. It contains
and product.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
a source of phenylalanine, which fights biofilm accu-
mulation in lines.
• Night Cleaner is placed in the blue Nighttime
cleaner bottle (see Figure 24-15 and Figure 24-16).
Fill the Nighttime bottle with the Night Cleaner
solution to the fill line.
 EMS AIRFLOW One and AIRFLOW Prophylaxis Master 457

Figure 24-16 Nighttime cleaner bottle label

Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 24-15 Blue Nighttime cleaner bottle (EMS

AIRFLOW Prophylaxis Master).
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

• Set the water control spindle to 10. Run the en-

tire contents of the Nighttime cleaner bottle
through the line and leave it in place overnight
(12 hours).
• The next morning, remove the Nighttime cleaner
bottle and replace with a fully filled indepen-
dent water reservoir bottle. Set the water con-
trol spindle to 10 and flush the line to clear the
solution away.

Water Filter
The APDs have a transparent water filter located on
the bottom of the device next to the air filter (see
Figure 24-17). The manufacturer recommends inspect-
ing the water filter monthly. The water filter should be
replaced three times a year. If the water filter needs re- Figure 24-17 EMS AIRFLOW Prophylaxis Master air
placement more than three times per year, the quality (white) and water (blue) filters.
of the water should be evaluated.
end of the day. To activate line purging with the
Water Purge AIRFLOW ONE, press the pedal and then release
Purge the waterline for a minimum of 20 seconds when complete. The AIRFLOW Prophylaxis Master
at the start of the day, between patients, and at the has an automatic purge feature. Press the pedal once
458 Chapter 24 Coronal and Apical to CEJ Air Polishing

Figure 24-18 Automatic purge illuminated numbers

(EMS AIRFLOW Prophylaxis Master).
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

to activate automatic purge. The numbers above the

groove panel will illuminate and de-illuminate over a
1-­minute purge countdown cycle (see Figure 24-18).
B

Air Figure 24-19 AIRFLOW Handy 3.0: A. AIRFLOW Handy

3.0 Perio (pink powder chamber), B. AIRFLOW Handy
An air line accompanies both APDs and is connected 3.0 Classic (blue powder chamber).
to the dental unit. A transparent air filter is located on Reproduced with permission from E.M.S. Electro Medical Systems S.A.
the bottom of the device next to the water filter (see
Figure 24-17). The manufacturer recommends monthly Powder Powder
filter inspection. The air filter should be replaced annu- chamber chamber cap

ally or more frequently if the color darkens.

EMS AIRFLOW Handy 3.0

EMS has been manufacturing portable handheld APDs
since 1995. The latest release is the AIRFLOW Handy
3.0 that connects to the air turbine attachment on a
dental unit. Portable handheld APDs are designed for Handpiece Body Cord adaptor
occasional and isolated use due to their smaller pow-
der chambers. There are two AIRFLOW Handy 3.0
portable devices, each designed for a specific powder
with individual air and water psi requirements. Figure 24-20 AIRFLOW Handy 3.0 anatomy.
1. AIRFLOW Handy 3.0 Perio: Pink powder cham- Reproduced with permission from E.M.S. Electro Medical Systems S.A.

ber that accepts AIRFLOW Perio powder (­ glycine)

and AIRFLOW Plus powder (­erythritol) (see
Figure 24-19a). The AIRFLOW and ­PERIOFLOW
handpiece attach to this device. Do not use
­AIRFLOW Classic powder (sodium bicarbonate)
in this portable handheld APD.
2. AIRFLOW Handy 3.0 Classic: Blue powder
chamber that accepts AIRFLOW Classic powder
(sodium bicarbonate) (see Figure 24-19b). The
AIRFLOW handpiece attaches to this device. The
PERIOFLOW handpiece is not used because so-
dium bicarbonate is not delivered subgingivally
into periodontal pockets. Do not use AIRFLOW
Perio powder (glycine) or AIRFLOW Plus powder
(erythritol) in this portable handheld APD.
Body
The body of the AIRFLOW Handy 3.0 houses the
powder chamber and its inner tube (see Figure 24-20).
 EMS AIRFLOW Handy 3.0 459

The body has a series of O-rings that allow for a se-
cure connection to the handpiece and need periodic
replacement when worn.
Figure 24-21 AIRFLOW Handy 3.0 grasp.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
The provider grasps the body while in use. The
body is balanced and designed to rest securely in the
webbing between the thumb and index finger (see
Figure 24-21).
At its base, the body has a cord adaptor that is
securely connected to the dental unit air turbine con-
nector (see Figure 24-20 and Figure 24-22a to d). There
are O-rings on the turbine connector on the dental
unit that need to be well maintained and replaced
when worn to avoid air leakage during air polishing.
It is best to adjust the psi and water flow rate of
the dental unit air turbine connector prior to attaching
the AIRFLOW Handy 3.0. All parts of the AIRFLOW
Handy 3.0 and the air turbine connector must be dry
and free of moisture to avoid clumping of powder,

A B

C D
Figure 24-22 AIRFLOW Handy 3.0 Perio: A. Air turbine connector on left and AIRFLOW cord adaptor on the right (note
the black O-ring), B. Aligning connectors, C. Rotate air turbine connector until fully secure on the AIRFLOW cord
adaptor, D. Attached AIRFLOW Handy 3.0 Perio to dental unit.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
460 Chapter 24 Coronal and Apical to CEJ Air Polishing

blockage of the air/powder channels, and equipment

damage.

Powder Chamber
The powder chamber of a portable handheld device
is smaller than the powder chamber of a stand-alone
APD. Because the powder chamber is small, the
provider must closely monitor the level of powder
throughout the procedure.
• Chapter 21 discussed the internal controls that
regulate the amount of powder expelled by a por-
table APD, which is partially dependent on the
amount of powder inside the chamber (Petersilka,
2000; Donnet et al., 2021).
• The powder velocity cannot be changed on a
handheld portable APD. The provider cannot pair
powder velocity with the level of oral deposits No o-ring
present. The portable handheld device will always
deliver maximum powder velocity.
• When powder levels decrease in the chamber,
the risk for inconsistent powder particle expul-
sion ­increases (Petersilka, 2000; Donnet et al.,
2021).
• When an inconsistent powder flow rate occurs,
the APD’s mechanism of action changes and the
risk for over-abrasion increases.
The power chamber has a cap with threads that
align with the powder chamber threads. The cap
has a ring that should be replaced annually as it is a
wear and tear item (see Figure 24-23).
To fill the powder bowl:
1. Turn off the master switch to the dental unit.
2. Check the O-rings on the air turbine connec-
tor cord and the AIRFLOW cord adaptor to
ensure that they are in good condition (see Black o-ring
A
Figure 24-24a and b).

B
Figure 24-23 AIRFLOW Handy 3.0 powder chamber cap Figure 24-24 O-rings: A. AIRFLOW Handy 3.0 Perio
and ring. black O-ring, B. Air turbine connector.

3. Blow compressed air with the A/W syringe into
the air turbine connector on the dental unit and
the cord adaptor on the AIRFLOW Handy 3.0
(see Figure 24-25a and b).
B
Figure 24-25 Delivering compressed air: A. Air turbine
connector, B. AIRFLOW Handy 3.0 Perio cord adaptor.
4. Remove the powder chamber cap on the powder
chamber (see Figure 24-26).
5. Select the correct powder for the AIRFLOW
Handy 3.0 being used. Be sure to pair the pow-
der and AIRFLOW Handy 3.0 correctly because
EMS AIRFLOW Handy 3.0 461
Figure 24-26 Powder chamber cap removed
from the powder chamber on the AIRFLOW Handy
3.0 Perio.
using an incorrect powder can cause clogging
and equipment damage, and may void the
warranty.
6. Shake the powder bottle to break up clumps.
Take the cap off and place the powder dispenser
on the bottle (see Figure 24-27a to c).
7. Point the AIRFLOW Handy 3.0 downward (see
Figure 24-28).
8. Connect the powder bottle dispenser with the
powder chamber opening (see Figure 24-29a).
Dispense powder into the chamber by pumping
the dispenser lightly. Do not fill past the inner
tube (see Figure 24-29b).
9. Remove the dispenser from the powder bot-
tle and place the lid back on the bottle imme-
diately to prevent moisture contamination and
clumping.
10. With a soft disposable cloth, clear away residual
powder on the threads of the powder chamber
and cap (see Figure 24-30a and b).
11. Secure the powder chamber cap tightly on the
powder chamber without stripping the threads.
Do not shake the AIRFLOW Handy 3.0 once the
cap is securely placed. This could cause powder
to settle into the inner tube.
12. Turn the master switch of the dental unit on
(see Figure 24-31a and b). Air should not be es-
caping from the AIRFLOW Handy 3.0 or from
the cord adaptor attachment to the air turbine.
462 Chapter 24 Coronal and Apical to CEJ Air Polishing
A B
Figure 24-27 Powder bottle and dispenser assembly: A. Powder bottle with cap on and dispenser to the right,
B. Powder bottle cap removed, C. Dispenser affixed to the powder bottle.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
Figure 24-28 AIRFLOW Handy 3.0 Perio without powder
chamber cap angled downward.
If this occurs, check the O-rings and reclean the
threads to remove any residual powder contam-
ination. The powder chamber cap has an O-ring
that should be replaced periodically when it is
worn. Ensure that attachments are secure and
tightened correctly.
To empty the powder bowl:
1. Turn the master switch to the dental unit off. The
AIRFLOW Handy 3.0 will depressurize over a few
C
seconds. Do not attempt to remove the powder
chamber cap during depressurization.
2. Remove the powder chamber cap carefully to avoid
damaging the threads of the powder c­hamber
or the powder chamber cap. Set the cap aside.
3. Discard all unused powder in the trash. Emp-
tying the powder chamber will reduce mois-
ture ­ absorption and prevent clogging (see
Figure 24-32a and b).
4. Use an High volume evacuation (HVE) to re-
move residual powder from the chamber (see
Figure 24-33).
5. Remove the cap ring without damaging the ring.
Use an instrument without a sharp cutting edge
such as a dull explorer (see Figure 24-34a).
6. Use a soft disposable cloth to remove residual
powder from the cap ring and the threads of the
powder chamber and powder chamber cap (see
Figure 24-34b).
7. Clean the threads of the powder chamber and
powder chamber cap with alcohol (ethanol, iso-
propanol) and then allow to dry completely.
8. Place the cap ring back into the cap.
9. Affix the powder chamber cap back onto the
powder chamber for storage until the next use.
This will keep the internal components of the
body free from moisture contamination and dust.
 EMS AIRFLOW Handy 3.0 463

A B
Figure 24-29 Filling the powder chamber of the AIRFLOW Handy 3.0 Perio: A. Powder
bottle connected to the opening of the powder chamber, B. Powder in the powder
chamber not filled past the inner tube.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A B
Figure 24-30 Removal of residual powder from the AIRFLOW Handy 3.0 Perio:
A. Soft disposable cloth cleaning on the threads of the powder chamber, B. Soft
disposable cloth on the threads of the powder chamber cap.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

A B
Figure 24-31 Example of a master switch on a dental unit: A. Master switch off, B. Master switch on.
464 Chapter 24 Coronal and Apical to CEJ Air Polishing

Figure 24-33 Removal of residual powder in the powder

chamber with an HVE.

A A

B
Figure 24-34 Powder chamber cap: A. Cap ring
removed, B. Removal of residual powder on cap ring.

Foot Pedal
The rheostat on the dental unit activates and deac-
tivates the AIRFLOW Handy 3.0 (see Figure 24-35).
When the rheostat is released, keep the nozzle in the
B patient’s mouth for a few seconds until depressuriza-
Figure 24-32 Discarding unused powder: A. Emptying tion has occurred to avoid splashing as there is a delay.
unused powder in a receptacle, B. View of empty powder Ensure that the HVE remains on during this time to
chamber. control aerosols.
 EMS Handpiece and Nozzles 465

B
Figure 24-36 EMS handpieces: A. AIRFLOW handpiece,
B. AIRFLOW MAX handpiece.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

Figure 24-35 Rheostat.

EMS Handpiece
and Nozzles
EMS manufactures two classes of handpieces for the Figure 24-37 PERIOFLOW Handpiece.
AIRFLOW One, AIRFLOW Prophylaxis Master, and Reproduced with permission from E.M.S. Electro Medical Systems S.A.

the AIRFLOW Handy 3.0:

1. AIRFLOW Handpiece: There are two hand-
pieces in this class. The AIRFLOW hand-
piece and the AIRFLOW MAX handpiece. This
class of handpiece delivers supragingival and
­shallow (1–3 mm) subgingival air polishing (see
Figure 24-36a and b). At the time of publication,
A
EMS is no longer manufacturing the AIRFLOW
handpiece. However, this book discusses the
handpiece as institutions may still be using the
equipment.
2. PERIOFLOW Handpiece: This class of hand-
piece delivers deep (>4 mm) subgingival air pol-
ishing (see Figure 24-37).
Both classes of handpieces are made of a
B
medical-grade resin body that is sterilized between
patient use. All APDs have O-rings on the handpiece Figure 24-38 EMS O-rings on the handpiece connector
connector cord that will need to be replaced when cord: A. Black O-rings on the AIRFLOW Prophylaxis
worn (see Figure 24-38a and b). When attaching the Master, B. Black O-rings on the AIRFLOW Handy
3.0 Perio.
handpiece to the handpiece connector cable, ensure
that connectors align and use a gentle straight push
the mouth (see Figure 24-36a and b). The handpiece
motion to avoid damaging the parts
nozzle delivers the slurry both supragingivally and
subgingivally in shallow pockets (1–3 mm). The end
AIRFLOW Handpieces of the nozzle has two concentric openings. The outer
Both AIRFLOW handpieces have an affixed nozzle with opening expels water, and the inner opening expels
a 120-degree angulation for ease of use throughout the air and powder mixture (see Figure 24-39).
466 Chapter 24 Coronal and Apical to CEJ Air Polishing

Inner opening:
air/powder

Outer opening:
water

Figure 24-39 EMS AIRFLOW Max handpiece nozle. Figure 24-40 EMS AIRFLOW MAX handpiece with
guided laminar AIRFLOW technology.

Both AIRFLOW handpieces deliver any pow-

der manufactured by EMS. If using the AIRFLOW
Handy 3.0 Classic with AIRFLOW Classic powder
(sodium bicarbonate), the nozzle is not to be directed
apical to the CEJ. The differences between the two
handpieces are:
• The AIRFLOW MAX has a wider outlet, slimmer
handpiece width diameter, and reduced noise and
weight than the AIRFLOW handpiece.
• The AIRFLOW MAX has a patented hexagon design
at the nozzle opening equipped with guided lami-
nar AIRFLOW technology that improves the travel
pattern of the powder and water. The slurry travels
in a more organized fashion in straight paths instead
of turbulent nonorganized paths (see Figure 24-40).
This decreases powder and water from spraying in Figure 24-41 AIRFLOW nozzle 3–5 mm from the tooth
unwanted directions and minimizes aerosols. surface.

AIRFLOW and AIRFLOW Max
Handpiece Technique
The AIRFLOW and AIRFLOW Max nozzle is placed
3–5 mm from the tooth surface, moving in constant
overlapping circular movements as the slurry is ex-
pelled (see Figure 24-41).
Each tooth surface will receive 5–10 seconds of
slurry exposure to remove biofilm, stain, an dimma-
ture dental calculus, depending on the amount of oral
deposits and the powder being used. Manufactur-
ers recommend, and studies have confirmed, a 5- to
10-second, no more than 20-­second, slurry exposure
per tooth is sufficient for complete biofilm and stain
removal during GPAP and EPAP (Hagi et al., 2015;
Flemmig et al., 2012; Petersilka, 2000; Kozlovsky
et al., 2005; Karmakar & Kamath, 2017).
The nozzle angulation depends on the powder
being delivered.

A
B surfaces such as seen in Figure 24-44.
Figure 24-42 AIRFLOW Max nozzle angulation:
A. Coronal to the CEJ angulation, B. Apical to the CEJ
angulation.
• AIRFLOW Classic (sodium bicarbonate) nozzle is
angled coronal to the CEJ (see Figure 24-42a).
• AIRFLOW Perio (glycine) and Plus (erythritol)
are angled coronal and apical of the CEJ (see
Figure 24-42b).
The degree of nozzle angulation varies by tooth
surface.
• Smooth surface and interproximal: 30- to 60-degree
angulation between the nozzle and the tooth sur-
face (see Figure 24-42a and b).
EMS Handpiece and Nozzles 467
B
Figure 24-43 Incisal/occlusal nozzle to surface
angulation: A. Incorrect 90-degree angulation,
B. Correct 60-degree angulation.
• Incisal and occlusal surfaces: 60-degree angu-
lation of the nozzle to the tooth surface (see
Figure 24-43a and b). This angulation is used for
oral deposit removal in the pits, fissures, and
grooves of anterior incisal and posterior occlusal
Powder Velocity and Water Setting
The water flow rate is always set to 10 (100%) during
air polishing. The powder velocity can be changed on
the AIRFLOW One and the AIRFLOW Prophylaxis
Master. The powder velocity control setting is se-
lected based on the level of oral deposit and whether
the slurry is being expelled supragingivally or sub-
gingivally. Heavier oral deposits will require a higher
setting, and lighter deposits will require a lower set-
ting. The lowest powder velocity setting with the
shortest contact time is used to achieve the goal of
stain, biofilm, and immature dental calculus removal.
• Coronal to the CEJ: The powder velocity setting
options are 3 through 10 (30–100%).
468 Chapter 24 Coronal and Apical to CEJ Air Polishing
B Subgingival Nozzle
Figure 24-44 Oral deposits: A. Staining on the incisal of
maxillary anterior teeth, B. Staining on the occlusal of a
premolar.
• Apical to the CEJ, around dental implants, and
orthodontic brackets: The powder velocity setting
options are 3 through 6 (30–60%).
PERIOFLOW Handpiece
The PERIOFLOW handpiece is compatible with the
AIRFLOW One, AIRFLOW Prophylaxis Master, and
the AIRFLOW Handy 3.0 Perio. The AIRFLOW
B
Figure 24-45 EMS PERIOFLOW subgingival nozzle:
A. Nozzle with no probe-like markings, B. Nozzle with
probe-like markings.
Handy 3.0 Classic delivers sodium bicarbonate pow-
der coronal to the CEJ, so a PERIOFLOW handpiece
would not be used.
A detachable single-use subgingival nozzle is placed
on the terminal portion of the PERIOFLOW hand-
piece (see Figure 24-45a and b and Figure 24-46a).
• The nozzle is disposed at the conclusion of a pa-
tient procedure or after 20 sites of debridement.
• The nozzle will access deeper periodontal pockets
(>4 mm) (see Figure 24-46b).
• The newest nozzle is the third generation and is
25% slimmer with improved flexibility.
• There are two options for nozzle styles. One style
is all white, and the other has probe-like markings
of 3 mm, 5 mm, 7 mm, and 9 mm to assist the
provider in recognizing how deep the nozzle has

A
B
Figure 24-46 EMS PERIOFLOW handpiece:
A. PERIOFLOW handpiece with affixed single-use
disposable subgingival nozzle, B. Subgingival nozzle on
the maxillary right first molar root.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
EMS Handpiece and Nozzles 469
Figure 24-47 EMS PERIOFLOW subgingival nozzle
trilateral powder-outlet and apical water-only spray.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
been inserted subgingivally (see Figure 24-45a
and b and Figure 24-46b).
• A trilateral powder-outlet and apical water-only
spray is expelled from the end of the subgingival
nozzle (see Figure 24-47).
Subgingival Nozzle Placement
and Removal from the Handpiece
• To place a disposable subgingival nozzle on the
PERIOFLOW handpiece, align the nozzle with
the notches on the terminal portion of the hand-
piece and gently push on a hard surface to fully
engage (see Figure 24-48a to c). Ensure that the
nozzle is securely attached prior to use by gently
pulling with your fingers.
• The nozzle is removed with the nozzle ­extractor
that accompanies the handpiece. Do not remove
the subgingival nozzle by pulling it off with
your fingers to avoid stripping and damaging
the handpiece. Line the extractor with the base
of the nozzle and then gently push upward (see
Figure 24-49a to c).
PERIOFLOW Nozzle Technique
The subgingival nozzle is inserted into the peri-
odontal pocket parallel to the long axis of the tooth
with a similar orientation to a periodontal probe (see
Figure 24-50a and b).
470 Chapter 24 Coronal and Apical to CEJ Air Polishing

A B C
Figure 24-48 EMS PERIOFLOW subgingival nozzle placement: A. Align the subgingival nozzle with the notch on the
PERIOFLOW handpiece, ensuring the closed section of the nozzle is at the top, B. Gently push the subgingival nozzle
downward with your fingers, C. Gently push the top of the subgingival nozzle on a hard surface such as a countertop to
secure the connection.

A B C
Figure 24-49 EMS PERIOFLOW subgingival nozzle removal: A. Align the nozzle extractor with the subgingival nozzle,
B. Push the nozzle extractor upward, C. Remove the subgingival nozzle with the nozzle extractor.

A B
Figure 24-50 EMS PERIOFLOW handpiece subgingival nozzle insertion: A. Nozzle insertion on the mandibular left second
molar distal-buccal surface, B. Nozzle insertion on the mandibular left second molar distal surface.

Figure 24-51 Subgingival nozzle inserted subgingivally
3 mm from the crest of the alveolar bone.
The nozzle is advanced subgingivally to the depth
of the periodontal pocket and then retracted 2–3 mm.
• This will position the nozzle more than 3 mm
away from the crest of the alveolar bone, which
EMS recommends (see Figure 24-51).
• Because the crest of the alveolar bone is 1–2 mm
from the junctional epithelium, retracting the
nozzle from the base of the pocket by 2–3 mm
will ensure correct distance from the crest of the
alveolar bone.
• Do not apply force as the nozzle is inserted sub-
gingivally because this could injure the patient.
• Deliver the slurry into the pocket for a maximum
of 5 seconds, making continuous slow vertical os-
cillations (up, down, rotational) along the pocket
(Tastepe et al., 2017). It is not advised to keep the
nozzle static once the slurry is being delivered in
a periodontal pocket because cleaning efficiency
decreases (Tastepe et al., 2017).
When using a subgingival nozzle, it is important
the APD delivers a constant continuous air, powder,
and water emission to avoid over-abrasion of less
­mineralized cemental surfaces (Donnet et al., 2021).
• If the air and powder emission is greater than the
water emission, the cementum could be damaged
or denuded.
• An in vitro study by Tastepe et al. (2017) found
higher powder flow caused excessive powder ac-
cumulation on tooth and implant surfaces, which
Reprocessing 471
4.35 mm
6.53 mm
Figure 24-52 Width of slurry exposure (Tastepe et al., 2017).
decreased cleaning ability. Simply increasing the
water flow was not always enough to dissolve the
excess powder (Tastepe et al., 2017).
Powder Velocity and Water Setting
• The water flow rate is always set to 10 (100%)
with the PERIOFLOW handpiece.
• The powder velocity setting is selected based
on the level of oral deposit in the periodontal
pocket. Powder velocity settings 5 through 10
(50–100%) are used around natural teeth and
dental implants.
• Tastepe et al. (2017) reported that higher air
pressure in deeper periodontal pockets cleaned
the surface area better than lower pressure.
Higher pressures cleaned 6.53 mm width in
pockets, and low pressure only dispersed to a
width of 4.35 mm (see Figure 24-52). The study
recommended using the device’s highest sub-
gingival mode setting based on these findings
­(Tastepe et al., 2017).
Reprocessing
Always use aseptic techniques during reprocess-
ing that includes full Personal Protective Equipment
(PPE) and utility gloves when handling contaminated
equipment to avoid cross-contamination and operator
injury.
Air Polishing Devices
The power cord; air lines; waterlines; hand-
piece cable; foot pedal; and the bodies of each of
the ­ AIRFLOW Handy 3.0, AIRFLOW One, and
­AIRFLOW Prophylaxis Master devices themselves
are not sterilizable. Remove powder from all fix-
tures with a disposable, soft nonabrasive cloth prior
to using a manufacturer-approved disinfectant,
which can be found in the product’s DFU/IFU. Do
not spray disinfectant solutions directly on system
surfaces. Use a manufacturer-approved disinfectant
with correct contact time.
472 Chapter 24 Coronal and Apical to CEJ Air Polishing
A B
Figure 24-53 Easy Clean tool: A. Easy Clean tool being inserted into the handpiece, B. Easy Clean tool connected to
the handpiece, C. Area of connection with the disposable syringe.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
Handpieces
Full manual and automatic cleaning and disinfect-
ing instructions are found in the product’s DFU/IFU.
The AIRFLOW and AIRFLOW MAX handpieces are to
be cleaned with the Easy Clean tool provided by the
manufacturer immediately after use.
• Place one opening of the Easy Clean tool in the
handpiece (see Figure 24-53a and b).
• Then attach a disposable syringe filled with more
than 2 ml of drinking water to the opposite end of
the Easy Clean tool (see Figure 24-53c).
• Dispense the liquid from the disposable syringe
through the central lumina of the handpiece for
20 seconds.
• Blow compressed air twice through both o­ penings
of the handpiece to dry internal components.
The PERIOFLOW handpiece has specific manual
and automatic cleaning instructions that are different
than AIRFLOW handpieces and can be found in the
product’s DFU/IFU.
Never place handpieces into an ultrasonic bath.
Automated-washer disinfector may be used. Ensure
that the handpiece is free of visible stains. Hand-
pieces and the Easy Clean tool should be completely
dry before packaging for sterilization. Sterilize the
handpiece and Easy Clean tool with steam under a
pressure sterilizer. Once the maximum number of
sterilization cycles has been reached, as stated in
the DFU/IFU, the handpiece should be retired and
replaced.
C
EMS Guided Biofilm
Therapy (GBT)
EMS has developed a proprietary eight-step program
for preventive non-surgical procedures called Guided
Biofilm Therapy (GBT). EMS states, “GBT consists
of treatment protocols based on individual patient
diagnosis and risk assessment in order to achieve
optimal results. The treatment is provided in the
­
least invasive way, with the highest level of comfort,
safety and efficiency” (EMS, 2022). The eight steps are
presented next.
GBT Step 1: Assessment
and infection control
The patient will pre-rinse with BacterX Pro
­mouthwash. The mouthrinse contains a combina-
tion of three chemicals: chlorhexidine digluconate
0.1%, cetylpyridinium chloride 0.05%, and sodium
fluoride 0.01% (fluoride 0.0005%). See Chapter 2 for
a review of pre-rinsing if needed. The provider will
then complete all clinical assessments.
GBT Step 2: Disclose, and GBT
Step 3: Motivate
Step 2 is to apply a two-tone dye on tooth surfaces
to reveal biofilm presence. Making biofilm visible
will enhance patient education and oral-hygiene in-
structions. Disclosing can improve patient motivation
 EMS Guided Biofilm Therapy (GBT) 473

to maintain healthy oral behaviors. EMS lists the fol-

lowing benefits in applying the two-tone dye prior to
debridement:

• Identify hard and soft deposits to improve ef-

ficiency of removal by the provider with the
AIRFLOW Prophylaxis Master. The dye will guide
the provider during instrumentation.
• Allow for selective cleaning of contaminated
surfaces for a more conservative approach to
debridement.
• Avoid unnecessary abrasion and instrumen­tation.
A
• Improve identification of oral deposits in hard
to access areas such as crowded teeth, fixed
orthodontic appliances, tight contacts between
­
teeth, and the distal surface of terminal molars.
• Identify oral deposits in the pit and fissures
of teeth that require removal prior to sealant
placement.
• Identify oral deposits on removable appliances
such as dentures and partials, which can be hard
to see with the naked eye.
• Improve patient education and motivation.
B
A recent large systematic review by Oliveira et al.
(2021) found the use of a plaque disclosing agent led
to significant improvements in oral hygiene habits for
patients in active orthodontic therapy.

• Indirect evidence showed patients may expe-

rience faster habit formation with the use of a
plaque disclosing agent compared to oral hygiene
instruction and supervised brushing technique
adjustments.
• The systematic review recommended plaque-
disclosing agents as a standard for orthodontic
patients and as an adjunct for those without ap-
pliances (Oliveira et al., 2021). C
The disclosing solution provided by EMS is a Figure 24-54 Disclosing solution: A. Red stained areas
two-tone dye on presoaked pellets. The solution is on the anterior teeth, B. Red stained areas on the right
applied with a pair of cotton pliers, and one pellet is side of the mouth, C. Red stained areas on the left side
of the mouth.
used per treatment.

• Tooth surfaces that stain red identify immature

biofilm (see Figure 24-54a to c).
• Tooth surfaces that stain blue identify mature
biofilm.
Precautions for the two-tone dye:
• Avoid contact with eyes, skin, clothing, and
equipment.
• May stain dental restorative materials or or-
thodontic brackets. If the discoloration is not
removed during treatment, it will disappear on its
own after a few days.
• Do not swallow.
Contraindications for the two-tone dye:
• Do not use the two-tone dye is the patient has an
allergy to any of the ingredients: aqua, glycerin,
CI 45430 (erythrosine), ethylparaben, CI 42051
(patent blue), aroma, CPC.
474 Chapter 24 Coronal and Apical to CEJ Air Polishing

GBT Step 4: AIRFLOW Max pockets. Air polishing technique is presented

in Chapter 25.
Administer full-mouth supragingival and shallow
(1–3 mm) subgingival air polishing (EMS terms
­AIRFLOWING) with the AIRFLOW Max handpiece and GBT Step 6: Piezon PS
AIRFLOW Plus powder (erythritol) for biofilm, stain,
GBT shortens the patient treatment time needed
and immature dental calculus reduction and removal.
with the piezoelectric ultrasonic device because bio-
Air polishing technique is presented in Chapter 25.
film, stain, and immature dental calculus is already
The erythritol powder can also be used to remove
removed. The ultrasonic is used to remove residual,
biofilm from soft tissues such as the buccal mucosa,
firmly established dental calculus. EMS recommends
free and attached gingiva, palate, and tongue. Al-
ultrasonic instrumentation with the PS tip for nat-
though air polishing will not remove mature, firmly
ural teeth and the PI tip for dental implants. See
established dental calculus, it will still remove the
Chapter 17 for details.
biofilm and stain on and around the dental calculus
(Flemmig et al., 2007). The presence of firmly es-
tablished dental calculus deposits that cannot be re-
moved with air polishing does not adversely affect the
GBT Step 7: Check
efficiency and results of the air polishing procedure Perform a final check for remaining biofilm, ensure
(Petersilka, 2000). that hard deposits are fully removed, accurately diag-
nose caries (only for providers whose scope of prac-
tice allows for oral diagnosing), protect with fluoride,
Step 5: PERIOFLOW and do not polish with a rotary handpiece.
Administer subgingival air polishing (EMS terms
­AIRFLOWING) with the P ­ ERIOFLOW handpiece
and AIRFLOW Plus powder (erythritol) for bio- GBT Step 8: Recall
film, stain, and immature dental calculus reduc- Select a recall frequency based on risk factors and ask
tion and removal in deeper (>4 mm) periodontal for feedback from the patient on the procedure.

CASE STUDY
Your patient is a 58-year-old Indian male with a noncontributory medical history. The patient is not taking any
over-the-counter or prescription medications and has no drug allergies. Body Mass Index (BMI) is 25.
His chief complaint is “I don’t like the color of my teeth.”
Dental exam: Patient had orthodontics in the past and lost the mandibular left second molar a few years ago due to
a failed root canal. The dentist recommended a dental implant for the edentulous space. The maxillary left third
molar is treatment planned for extraction due to decay.
Occlusion: Class I bilateral with first molar relationship. Overbite of 6 mm. Mandibular anterior crowding.
Oral hygiene exam:
■ Disclosing solution revealed 95% of surfaces with biofilm and dental calculus.
■ Generalized heavy biofilm.
■ Generalized moderate supragingival dental calculus on smooth surfaces. Generalized light to moderate
interproximal dental calculus.
■ Generalized moderate to heavy staining.
Periodontal exam:
■ Probe depths 3–6 mm generally with bleeding upon probing 37% of the mouth. Localized 7 mm probe depth on the
maxillary left wisdom tooth mesial-linugal surface. This tooth has significant mesial decay.
■ Localized recession and furcation involvement on molars Class I and II.
 EMS Guided Biofilm Therapy (GBT) 475

Mandibular anterior lingual surfaces.

Mandibular right anterior lingual surfaces.

Mandibular anterior and premolar lingual surfaces Mandibular left anterior lingual surfaces.

Intraoral photographs: Maxillary right anterior lingual Intraoral photographs: Maxillary left anterior lingual
surfaces. surfaces.
476 Chapter 24 Coronal and Apical to CEJ Air Polishing

First premolar occlusal surface.

Second premolar occlusal surface.

First molar occlusal surface.

 EMS Guided Biofilm Therapy (GBT) 477

Periodontal charting.

Full mouth series radiographs.

478 Chapter 24 Coronal and Apical to CEJ Air Polishing

1. Can air polishing remove the dental calculus pictured on the mandibular anterior lingual surfaces? Why or
why not?
2. The provider performs GBT for all routine and nonsurgical periodontal therapy procedures. What are the first
three steps the provider carries out?
3. The provider moves to the fourth step of GBT. What powder and handpiece does the provider use? Describe
the clinical delivery and what oral deposits will be removed by in this step. Include nozzle distance, angulation,
movement, time of exposure, air pressure power setting, and water flow rate.
4. After the fourth step of GBT, stain persists on the lower anterior lingual. What could the provider use for its
removal? Hint: There are two correct answers.
5. After the fourth step of GBT, stain persists on the molar and premolar occlusal grooves and pits. What is the best
powder selection for its removal?
6. What air pressure powder velocity setting is needed for your selection in question 5?
7. Is the fifth step of GBT indicated for this patient? Why or why not?
8. Can the PERIOFLOW handpiece and subgingival nozzle reach to the depth of this patient’s pockets?
9. Describe the clinical delivery of subgingival air polishing to pocket depths deeper than 4 mm. Include which
handpiece is used, nozzle distance, angulation, movement, time of exposure, air pressure powder velocity
settings, and water flow rate.
10. Will the provider use one or two subgingival nozzles? Why?
11. Will GBT step 6 be necessary for this patient? Why or why not?

Summary
Air polishing with an EMS APD is a safe and effective
procedure for the removal and reduction of biofilm,
immature dental cal­culus, and extrinsic exogeneous
staining. Sodium bicarbonate powder should only be
used on structures coronal to the CEJ. Glycine and
erythritol powders are used on tooth structures coro-
nal and apical to the CEJ. GBT is a proprietary eight-
step program for preventive non-surgical procedures
developed by EMS. Step-by-step, hands-on exercises
for air polishing are presented in the next chapter.

Questions
1. Which of the following will air polishing 4. Which EMS powder(s) can be used
remove? supragingivally and subgingivally?
a. Immature dental calculus a. AIRFLOW Classic powder
b. Firmly established dental calculus b. AIRFLOW Perio powder
c. Biofilm c. AIRFLOW Plus powder
d. Both A and C d. Both B and C
e. All of the above 5. Which EMS powder has a particle size of 14 µm
2. What is the name of an EMS non-portable and is used during GBT?
handheld air polishing device? a. AIRFLOW Classic powder
a. AIRFLOW b. AIRFLOW Perio powder
b. PERIOFLOW c. AIRFLOW Plus powder
c. AIRFLOW MAX 6. Which EMS powder is used for heavier, more
d. Handy tenacious stain?
3. Which EMS powder has a particle size of a. AIRFLOW Classic powder
40 µm? b. AIRFLOW Perio powder
a. AIRFLOW Classic powder c. AIRFLOW Plus powder
b. AIRFLOW Perio powder
c. AIRFLOW Plus powder
 Questions 479

7. What color is the powder chamber for 13. Which of the following is FALSE about the
AIRFLOW Classic powder in the AIRFLOW One AIRFLOW Prophylaxis Master?
and AIRFLOW Prophylaxis Master? a. To activate Boost mode, press the pedal in the
a. Black middle all the way to the floor.
b. White b. The outer part of the pedal will deliver the
c. Gray powder velocity setting selected by the
d. Red provider.
8. What color is the powder chamber for c. When Boost mode is activated, a 30%
AIRFLOW Perio powder and AIRFLOW Plus increase in power will occur regardless of
powder in the AIRFLOW One and AIRFLOW the powder velocity setting selected by the
Prophylaxis Master? provider.
a. Black d. Water flow is required at all times while the
b. White APD is in use.
c. Gray 14. True or False. The AIRFLOW One and
d. Red AIRFLOW Prophylaxis Master APDs have
9. True or False. When the provider turns off adjustable water temperatures 0 through
the AIRFLOW APD, it will depressurize 40 degrees Celsius.
immediately, and the powder chamber bottles a. True
can be removed. b. False
a. True 15. How often should the water filter be replaced for
b. False the AIRFLOW One and AIRFLOW Prophylaxis
10. What powder velocity setting only delivers Master?
water with no slurry in the AIRFLOW One and a. Annually
AIRFLOW Prophylaxis Master? b. Twice per year
a. 0 c. Three times per year
b. 1 d. Monthly
c. 8 16. How often should the air filter be replaced for
d. 10 the AIRFLOW One and AIRFLOW Prophylaxis
11. Which powder chamber will deliver a higher Master?
dynamic air pressure at all powder settings in a. Annually
the AIRFLOW One and AIRFLOW Prophylaxis b. Twice per year
Master c. Three times per year
a. Gray d. Monthly
b. Red 17. Automatic purging is available on the AIRFLOW
c. Black Prophylaxis Master. How long will the line purge
d. White when activated?
12. Which of the following is TRUE of the a. 30 seconds
AIRFLOW One and AIRFLOW Prophylaxis b. 1 minute
Master? c. 2 minutes
a. The foot pedal must be synched prior to the d. 4 minutes
first use. 18. True or False. The AIRFLOW Handy 3.0 has a
b. The foot pedal is pressed all the way to the smaller powder chamber than the AIRFLOW
floor to deliver the slurry at the powder stand-alone devices.
velocity selected. a. True
c. There is a 0.2-second delay in the slurry b. False
stopping upon release of the foot pedal.
d. Both devices have a Boost mode option.
480 Chapter 24 Coronal and Apical to CEJ Air Polishing
19. What color is the AIRFLOW Handy 3.0 for
Classic powder body?
a. Pink
b. Blue
c. Gray
d. Red
20. What is the maximum, or deepest subgingival
depth the AIRFLOW and AIRFLOW MAX
handpieces can reach when delivering
AIRFLOW Perio and Plus powders?
a. 3 mm
b. 4 mm
c. 5 mm
d. 6 mm
21. Which of the following handpieces can deliver
an air polishing slurry deeper than 4 mm?
a. AIRFLOW handpiece
b. AIRFLOW MAX handpiece
c. PERIOFLOW handpiece
22. How many millimeters should the AIRFLOW
and AIRFLOW MAX handpieces be from the
tooth surface during supragingival air polishing?
a. 3–5 mm
b. 5–6 mm
c. 6–7 mm
d. 7–8 mm
23. Which of the following angulations is correct
when delivering AIRFLOW Classic powder to
the smooth surfaces of teeth?
a. 30 to 60 degrees apical to the CEJ
b. 30 to 60 degrees coronal to the CEJ
c. 10 to 30 degrees apical to the CEJ
d. 10 to 30 degrees coronal to the CEJ
24. Which of the following angulations can be used
when delivering AIRFLOW Perio and AIRFLOW
Plus powders to the smooth surfaces of teeth?
a. 30 to 60 degrees apical to the CEJ
b. 30 to 60 degrees coronal to the CEJ
c. 10 to 30 degrees apical to the CEJ
d. 10 to 30 degrees coronal to the CEJ
e. Both A and B
25. Which of the following nozzle angulations
is used when debriding occlusal surfaces of
posterior teeth and incisal surfaces of anterior
teeth?
a. 30-degree angulation
b. 50-degree angulation
c. 90-degree angulation
d. 60-degree angulation
26. What water flow rate is used when air polishing
with an EMS APD?
a. 100%
b. 50%
c. 30%
d. 10%
27. What powder velocity setting is used when
delivering AIRFLOW Perio or Plus powders
subgingivally with the AIRFLOW handpiece?
a. 30–60%
b. 50–100%
c. 30–100%
d. 60–100%
28. How many millimeters should an EMS
subgingival nozzle be from the crest of the
alveolar bone?
a. 1–2 mm
b. >3 mm
c. 0.5–1.0 mm
d. There is no rule for the distance of a subgingival
nozzle to the crest of the alveolar bone.
29. True or False. When delivering an air polishing
slurry with a subgingival nozzle, the provider
inserts the nozzle into the pocket and holds the
nozzle in place to deliver 5 seconds of a slurry.
a. True
b. False
30. Which of the following is FALSE?
a. A subgingival nozzle should be replaced after
debriding 20 periodontal pocket sites.
b. A subgingival nozzle never needs to be
during debridement.
c. The water flow rate when using the
PERIOFLOW handpiece is 100%.
d. The powder velocity settings for the
PERIOFLOW handpiece is 50–100%
31. In which of the following situations would
the use of the EMS GBT two-tone dye be
contraindicated?
a. The patient has an allergy to erythrosine.
b. The patient has an allergy to patent blue.
c. The patient has an allergy to Cetylpyridinium
chloride (CPC).
d. All of the above.

References
1. Buhler, J., Amato, M., Weiger, R., & Walter, C. (2015). A
systematic review on the effects of air polishing devices on
oral tissues. International Journal of Dental Hygiene, 14, 15–28.
2. Cosgarea, R., Jepsen, S., Fimmers, R., Bodea, A., Eick, S., &
Schulean, A. (2021). Clinical outcomes following periodontal
surgery and root surface decontamination by erythritol-based
air polishing: A randomized, control, clinical pilot study.
Clinical Oral Investigations, 25, 627–635.
3. Donnet, M., Fournier, M., Schmidlin, P., & Lussi, A. (2021). A
novel method to measure the powder consumption of dental
air-polishing devices. Applied Sciences¸ 11(1101), 2–11.
4. Drago, L., Fabbro, M. D., Bortolin, M., Vassena, C.,
Vecchi, E. D., & Taschieri, S. (2014). Journal of Periodontology,
85(11), e363–e369.
5. EMS (2022). What is GBT? https://www.ems-dental.com/en
/guided-biofilm-therapy
6. Flemmig, T. F., Arushanov, D., Daubert, D., Rothen, M.,
Muller, G., & Leroux, B. G. (2012). Randomized controlled
trial assessing efficacy and safety of glycine powder air
polishing in moderate-to-deep periodontal pockets. Journal
of Periodontology, 83(4), 444–452.
7. Flemmig, T. F., Hetzel, M., Topoll, H., Gerss, J., Haeberlein,
I., & Petersilka, G. (2007). Subgingival debridement efficacy
of glycine powder air polishing. Journal of Periodontology,
78(6), 1002–1010.
8. Hagi, T. T., Hofmanner, P., Eick, S., Donnet, M., Salvi, G.
E., Sculean, A., & Ramseier, C. A. (2015). The effects of
erythritol air-polishing powder on microbiological and
clinical outcomes during supportive periodontal therapy:
Six-month results of a randomized controlled clinical trial.
Quintessence International, 46(1), 31–41.
9. Hashino, E., Kuboniwa, M., Alghamdi, S. A., Yamaguchi,
M., Yamamoto, R., Cho, H., & Amano, A. (2013). Erythritol
alters microstructure and metabolomic profiles of biofilm
composed of Streptococcus gordonii and Porphyromonas
gingivalis. Molecular Oral Microbiology, 28, 435–451.
10. Kargas, K., Tsalikis, L., Sakellari, D., Menexes, G., &
Konstantinidis, A. (2015). Pilot study on the clinical and
microbiological effect of subgingival glycine powder air
polishing using a cannula-like jet. International Journal of
Dental Hygiene, 13, 161–169.
11. Karmakar, S., & Kamath, D. G. (2017). Subgingival
airpolishing: A simple and cost effective medical insurance.
Journal of Pharmacology & Research, 9(2), 199–201.
12. Kozlovsky, A., Artzi, Z., Nemcovsky, C. E., & Hirshberg,
A. (2005). Effect of air-polishing devices on the gingiva:
Histologic study in the canine. Journal of Clinical
Periodontology, 32, 329–334.
13. Mensi, M., Scotti, E., Sordillo, A., Calza, S., Guarnelli, M. E.,
Fabbri, C., Farina, R., & Trombelli, L. (2021). Efficacy of the
additional use of subgingival air polishing with erythritol
powder in the treatment of periodontitis patients: A randomized
controlled clinical trial. Clinical Oral Investigations, 25, 729–736.
14. Moene, R., Decaillet, F., Andersen, E., & Mombelli, A. (2010).
Subgingival plaque removal using a new air-polishing device.
Journal of Periodontology, 81(1), 79–88.
References 481
15. Muller, N., Moene, R., Cancela, J. A., & Mombelli, A. (2014).
Subgingival air-polishing with erythritol during periodontal
maintenance: Randomized clinical trial of twelve months.
Journal of Clinical Periodontology, 41, 883–889.
16. Ng, E. (2018). The efficacy of air polishing devices in
supportive periodontal therapy: A systematic review and
meta-analysis. Quintessence International, 49, 453–467.
https://doi.org/10.3290/j.qi.a40341
17. Oliveira, L. M., Pazinatto, J., & Zanatta, F. B. (2021). Are
oral hygiene instructions with aid of plaque-disclosing
methods effective in improving self-performed dental
plaque control? A systematic review of randomized
controlled trials. International Journal of Dental Hygiene, 19,
239–254.
18. Park, E. J., Kwon, E. Y., Kim, H. J., Lee, J. Y., Choi, J., &
Joo, J. Y. (2018). Clinical and microbiological effects of the
supplementary use of an erythritol powder air-polishing
device in non-surgical periodontal therapy: A randomized
clinical trial. Journal of Periodontal Implant Science, 48(5),
295–304.
19. Pelka, M., Trautmann, S., Petschelt, A., & Lohbauer, U.
(2010). Influence of air-polishing devices and abrasives on
root dentin—An in vitro confocal laser scanning microscope
study. Quintessence International, 44(7), e141–e148.
20. Petersilka, G. (2000). Subgingival air-polishing in the
treatment of periodontal biofilm infections. Periodontology,
55, 124–142.
21. Petersilka, G. J., Bell, M., Haberlein, I., Mehl, A., & Flemmig,
T. F. (2003). In vitro evaluation of novel low abrasive air
polishing powders. Journal of Clinical Periodontology, 30,
9–13.
22. Petersilka, G., Faggion, C. M., Stratmann, U., Gerss, J.,
Ehmke, B., Haeberlein, I., & Flemmig, T. F. (2008). Effect
of glycine powder air-polishing on the gingiva. Journal of
Clinical Periodontology, 35, 324–332.
23. Petersilka, G. J., Tunkel, J., Barakos, K., Heinecke, A.,
Haberlein, I., & Flemmig, T. F. (2003). Subgingival plaque
removal at interdental sites using a low-abrasive air polishing
powder. Journal of Periodontology, 74(3), 307–311.
24. Sculean, A., Bastendorf, K. D., Becker, C., Bush, B., Einwag,
J., Lanoway, C., Platzer, U., Schmage, P., Schoeneich, B.,
Walter, C., Wennstrom, J. L., & Flemmig, T. F. (2013).
A paradigm shift in mechanical biofilm management?
Subgingival air polishing: A new way to improve mechanical
biofilm management in the dental practice. Quintessence
International, 44(7), 475–477.
25. Tastepe, C. S., Lin, X., Donnet, M., Wismeijer, D., &
Liu, Y. (2017). Parameters that improve cleaning efficiency
of subgingival air polishing in titanium implant surfaces:
An in vitro study. Journal of Periodontology, 88(4),
407–414.
26. Wennstrom, J. L., Dahlen, G., & Ramberg, P. (2011).
Subgingival debridement of periodontal pockets by air
polishing in comparison with ultrasonic instrumentation
during maintenance therapy. Journal of Clinical Periodontology,
38, 820–827.
 CHAPTER 25
Air Polishing Technique
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Set up and break down an air polishing device.
2. Deliver safe, effective, and efficient air polishing.
3. Use the correct techniques for supragingival
and subgingival air polishing.
4. Control aerosols with optimal High volume
evacuation (HVE) positioning during active air
polishing.
Introduction
The clinical technique for air polishing is similar to
ultrasonic instrumentation with regard to aerosol con-
trol, HVE positioning, patient and operator position-
ing, grasp, and finger rest. As with dental ultrasonic
devices, APDs release large volumes of aerosolized
product into the environment, which must be con-
trolled with appropriate infection prevention proto-
cols discussed in Chapter 2.
This chapter offers a step-by-step chairside prac-
tice in air polishing techniques for Dentsply Sirona
and EMS APDs. You will combine grasp, finger rest,
operator and patient chair positioning, nozzle angula-
tion and distance, and HVE positioning. Air polishing,
like ultrasonic instrumentation, is best learned through
repetition and practice because there are many tech-
nique demands placed on the oral health-care provider.
When mastered, air polishing improves the efficiency
of procedures. The combination of air polishing and ul-
trasonic instrumentation provides a more conservative
approach to oral deposit removal and promotes oral
symbiosis with minimal alterations to tooth structures.
Clinical Technique
The clinical techniques of air polishing are simi-
lar to ultrasonic instrumentation. This section will
discuss grasp, stabilization, aerosol control, patient
and ­ operator positioning, and patient care best
practices.
Grasp and Stabilization
The same grasp for the piezoelectric ultrasonic hand-
piece (described in Chapter 9) is used for a stand-
alone air polishing handpiece (see Figure 25-1a and b).
• The dominant hand lightly holds the air polishing
handpiece with a relaxed grasp.
• The thumb and index finger are equidistant from
each other on either side of the handpiece.
• The middle finger is touching and tucked behind
the index finger.
• The handpiece lays in the webbing between the
thumb and index finger to promote optimal ergo-
nomics by balancing the weight of the handpiece
in the hand.
The grasp for a portable handheld device is differ-
ent than a stand-alone device.
• The body rests in the webbing between the thumb
and index finger (see Figure 25-2).
• The thumb and index finger are equidistant from
each other on either side of the handpiece.
• The middle finger is touching and tucked behind
the index finger.
• No lateral pressure is used during air polishing.
A standard nozzle does not contact tooth surfaces
during air polishing, so lateral pressure is not
used.
483
484 Chapter 25 Air Polishing Technique
A
B The same patient positioning used for ultrasonic in-
Figure 25-1 Air polishing handpiece grasp (Dentsply
Sirona Jet-Mate Ultrasonic Handpiece and Cavitron
Jet Air Polishing Insert): A. Right-handed provider,
B. Left-handed provider.
Reproduced with permission from Dentsply Sirona
Figure 25-2 Air polishing portable device handpiece
grasp (EMS AIRFLOW Handy 3.0 Perio).
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
• Subgingival nozzle: the nozzle contacts root sur-
faces, but no lateral pressure is used as the slurry
mixture is expelled.
The same stabilization finger rests (intraoral, ex-
traoral) used in ultrasonic instrumentation are also
used for air polishing (see Chapter 9 for details).
Aerosol Control
The same aerosol control techniques learned for ultra-
sonic instrumentation, including HVE grasp, are used
for air polishing. The HVE is positioned 0.5–6.0 inches
away from the nozzle for proper environmental aerosol
control. Air polishing does not produce acoustic cavi-
tation, acoustic microstreaming, or liquid jets, so the
slurry may be suctioned immediately after it contacts
the tooth surface.
Operator Chair Positioning
Flexible bilateral operator chair positioning with di-
rect vision is used, and indirect vision is only required
for the maxillary anterior lingual surfaces and the
maxillary posterior occlusal surfaces.
The provider may use any clock position on the
left or right side of the patient chair, regardless of their
dominant hand, so direct vision can be utilized. The
provider chooses the operator chair positioning that
allows for proper ergonomics and direct vision. If er-
gonomics becomes compromised, the provider has se-
lected an incorrect chair positioning for air polishing.
Patient Positioning
strumentation is also used for air polishing, as de-
scribed in Chapter 9. Patient chair positioning is
flexible, with supine, semi-supine, upright, or any po-
sition in between. When direct vision is challenged in
a seated position, standup provider positioning may
resolve the issue. For seated instrumentation:
• Maxillary arch: Patient positioning is typically su-
pine, or in between supine and semi-supine, with
the patient’s chin slightly tilted upward.
• Mandibular arch: Patient positioning is either
supine, in between supine and semi-supine, or
semi-supine, with the patient’s chin slightly tilted
downward.
Patient Care
• As in ultrasonic instrumentation, the patient
should rinse with a pre-procedural antimicrobial
solution.
• The provider should evaluate the patient record
to ensure that there are no considerations or con-
traindications to air polishing.
 Skill Building: Air Polishing on Inanimate Objects 485

Figure 25-3 Lip and cheek retractor (OptraGate Ivoclar,

EMS AIRFLOW MAX Handpiece, Dentsply Sirona Purevac
HVE Mirror Tip.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

• A lip lubricant may be used to prevent drying of

the lips from slurry exposure. Ensure the prod-
uct chosen will not affect the integrity of the pro-
vider’s gloves. Common agents used are vitamin
E–based products or cocoa butter.

Lip and Cheek Retraction

The lip and cheek can be retracted with the HVE or
with the assistance of a lip-and-cheek retractor. De-
pending on its design, a lip-and-cheek retractor can
improve the patient experience by preventing the
powder slurry from landing on external structures
immediately around the oral cavity (see Figure 25-3).
Lubricate the patient’s lips prior to placing a lip and
cheek retractor for improved comfort.
Face Drapes
Face drapes prevent the slurry from settling on the
patient’s face during air polishing. They are not re-
quired for air polishing but may improve the patient
experience. They are sold as single-use disposable or
reusable nondisposable (see Figure 25-4a and b). Pa-
tient protective eyewear is still required when using a
face drape to prevent splashes into the eyes.
Skill Building: Air
Polishing on Inanimate
Objects
You will need the following supplies:
• Tarnished penny, hard-boiled quail egg, APD,
HVE, container to collect water.
• Dentsply Sirona: Jet-Mate Sterilizable, Detach-
able Handpiece, Cavitron Jet Air Polishing Insert,
B
Figure 25-4 Face cover/drape (ProSafe Products):
A. Blue reusable face drape, B. White reusable drape.
Cavitron Prophy Jet Prophy powder ­(sodium bi-
carbonate) or Cavitron JET-Fresh Prophy ­powder
(aluminum trihydroxide).
• EMS: AIRFLOW or AIRFLOW MAX hand-
piece, AIRFLOW Classic powder (sodium bi-
carbonate), AIRFLOW Perio powder (glycine),
AIRFLOW Plus powder (erythritol).
Rationale: This exercise will provide a kinetic
learning experience with an APD simulating the re-
moval of biofilm and stain and with a fluid continuous
movement of the nozzle. If the APD is a multipower
device, various powder velocity settings will be prac-
ticed. These techniques can then be transferred to ac-
tive patient treatment.
486 Chapter 25 Air Polishing Technique
A B
Figure 25-5 Quail eggs: A. Carton of quail eggs, B. Hard-boiled quail egg.
Figure 25-6 Tarnished and shiny pennies.
The goal of this exercise is to remove the tarnish
off the penny to produce a shiny surface and remove
the stain from the outer shell of a hard-boiled quail egg.
Purchase and boil quail eggs the night be-
fore the exercise and collect tarnished pennies (see
Figure 25-5a and b and Figure 25-6).
Penny
Complete steps 1–12 and then record your observa-
tions for questions 1–4.
1. Set up the APD, handpiece, and nozzle per the
manufacturer’s directions. Ensure that the psi
(pound force per square inch) of the dental unit
water and air is correct for the device. Any pow-
der compatible with your APD can be used for air
polishing the penny.
2. Turn on the APD and flush the waterline for a
minimum of 20–30 seconds. Always follow your
clinic’s protocols for waterline maintenance, which
may be different than a 20- to 30-second water-
line flush.
3. If using a multipower delivery APD, set the ­control
to low or medium. Set the water flow rate to high
following manufacturer recommendations.
4. Adjust the water and/or powder velocity until an
effective slurry is expelled from the nozzle. A pro-
ductive slurry will have an equal mixture of air,
powder, and water with minimal powder expul-
sion in the form of an aerosol cloud.
5. Place the penny on a solid surface and hold it
steady with your nondominant hand.
6. Provide fluid control such as having a collection
container under the surface and/or having some-
one else hold the HVE close to your working area.
Turn on the HVE.
7. Grasp the APD handpiece with your dominant
hand.
8. Position the nozzle at the appropriate distance
from the penny (Dentsply Sirona APD 2–4 mm,
EMS APD 3–5 mm). Activate the APD by press-
ing the pedal. Expose one side of the penny to
the slurry, moving the nozzle in small, circular,
continuous, overlapping motions until you re-
veal the penny’s underlying shiny surface (see
Figure 25-7a to c).
 Skill Building: Air Polishing on Inanimate Objects 487

A B

C
Figure 25-7 Slurry exposure to a tarnished penny: A. Dentsply Sirona Cavitron Jet Air Polishing Insert 2–4 mm nozzle
to penny distance, B. EMS AIRFLOW MAX handpiece 3–5 mm nozzle to penny distance slurry exposure on the penny,
C. EMS AIRFLOW MAX handpiece removing the tarnish on the penny.

9. Flip the penny over. 11. Activate the APD and expose the new side of the
10. Increase nozzle distance from the penny to 12 mm penny to the slurry. Move the nozzle in slow, fluid,
(see Figure 25-8). continuous movements over the penny until you
reveal the underlying shiny surface.
12. Record your observations for questions 1–4.
Observations for the penny exercise:
1. At what distance was the tarnish removed from
the penny the fastest? Why?
2. What happened to the stain removal capability
when you increased the nozzle–penny distance
from 2–5 mm to 12 mm? Why?
3. Was it challenging to control the aerosols expelled
from the APD? At what distance was aerosol con-
trol the most difficult? Explain your answer.
4. Was it challenging to produce an effective slurry?
What changes did you make to produce an effec-
tive slurry?

Quail Egg
Figure 25-8 Nozzle distance from penny 12 mm Divide your quail egg into 4 equal sections (see
(Dentsply Sirona Cavitron Jet Air Polishing Insert). Figure 25-9).
488 Chapter 25 Air Polishing Technique

Figure 25-10 APD handpiece grasp (Dentsply Sirona

Jet-Mat Sterilizable, Detachable Handpiece and Cavitron
Jet Air Polishing Insert)
Reproduced with permission from Dentsply Sirona

(see Figure 25-11). Activate the APD by pressing

Figure 25-9 Quail egg divided into 4 sections. the pedal. Expose the first section of the quail egg
to the slurry, moving the nozzle in small, circular,
continuous, overlapping motions until the stains
on the outer shell are removed.
Use sodium bicarbonate or aluminum trihydrox-
ide powders for steps 13–24. Complete steps 13–24
and then record your observations for questions 5–8.
If you do not have access to sodium bicarbonate or alu-
minum trihydroxide powders, then skip steps 13–24
and observation questions 5–8.
13. Select the first section of your quail egg.
14. Fill your APD with either sodium bicarbonate or
aluminum trihydroxide powder.
15. If using a multipower delivery APD, set the con-
trol to high.
16. Adjust the water and/or powder velocity until an
effective slurry is expelled from the nozzle. A pro-
ductive slurry will have an equal mixture of air,
powder, and water with minimal powder expul-
sion in the form of an aerosol cloud. Figure 25-11 EMS AIRFLOW MAX handpiece 3–5 mm
17. Grasp the quail egg in your non-dominant hand. from the outer shell surface of a quail egg.
18. Provide fluid control such as having a collec-
tion container under the quail egg and/or having
someone else hold the HVE close to your working 21. Move to section two of your quail egg if using a
area. Turn on the HVE. multipower delivery APD. Turn the control down
19. Grasp the APD handpiece with your dominant to medium. If you are not using a multipower
hand (see Figure 25-10). device, skip steps 21–23.
20. Position the nozzle at the appropriate dis- 22. Grasp the handpiece with your dominant hand.
tance from the quail egg (Dentsply Sirona APD 23. Position the nozzle at the appropriate dis-
2–4 mm, EMS APD 3–5 mm) on the first section tance from the quail egg (Dentsply Sirona APD
 Skill Building: Air Polishing with Dentsply Sirona Device
2–4 mm, EMS APD 3–5 mm) on the second sec-
tion. Activate the APD by pressing the pedal.
Expose the second section of the quail egg to
the slurry, moving the nozzle in small, circu-
lar, continuous, overlapping motions until the
stains on the outer shell are removed.
24. Record your observations for questions 5–8.
Observations for sodium bicarbonate or alumi-
num trihydroxide powder::
5. Were the stains on the outer shell of the quail egg
difficult to remove? Why or why not?
6. If using a multipower delivery APD, when you
decreased the powder velocity, were the stains
easier or more difficult to remove? Which powder
velocity setting removed the stain the fastest?
7. If using a multipower delivery APD, was there a
change in aerosol production between high and
medium powder velocity? Why or why not?
8. If using a multipower delivery APD, which setting
did you prefer for stain removal? Why?
Use glycine or erythritol powders for steps 25–34
and then record your observations for questions 9–12.
Complete steps 25–34 and then record your observa-
tions for questions 9–12. If you do not have access to
glycine or erythritol powders, then skip steps 25–34
and observation questions 9–12.
25. Fill your APD with either glycine or erythritol
powder.
26. If using a multipower delivery APD, set the con-
trol to medium.
27. Adjust the water and/or powder velocity until an
effective slurry is expelled from the nozzle. A pro-
ductive slurry will have an equal mixture of air,
powder, and water with minimal powder expul-
sion in the form of an aerosol cloud.
28. Grasp the quail egg in your nondominant hand.
29. Provide fluid control such as having a collec-
tion container under the quail egg and/or having
someone else hold the HVE close to your working
area. Turn on the HVE.
30. Grasp the APD handpiece with your dominant
hand.
31. Position the nozzle at the appropriate distance
from the quail egg (EMS APD 3–5 mm) on the
third section (see Figure 25-11). Activate the APD
by pressing the pedal. Expose the third section of
the quail egg to the slurry, moving the nozzle in
small, circular, continuous, overlapping motions
until the stains on the outer shell are removed.
32. If using a multipower delivery APD, turn the con-
trol down to low.
489
33. Position the nozzle at the appropriate distance from
the quail egg (EMS APD 3–5 mm) on the fourth
section (see Figure 25-11). Activate the APD by
pressing the pedal. Expose the fourth section of
the quail egg to the slurry, moving the nozzle in
small, circular, continuous, overlapping motions
until the stains on the outer shell are removed.
34. Record your observations for questions 9–12.
Observations for glycine or erythritol powders:
9. Were the stains on the outer shell of the quail egg
difficult to remove? Why or why not?
10. If using a multipower velocity device, what pow-
der velocity control setting removed the staining
faster? Why?
11. If using a multipower velocity device, was there
a change in aerosol production between the two
powder velocity control settings? Why or why not?
12. If using a multipower velocity device, which pow-
der velocity control setting did you prefer for stain
removal? Why?
Skill Building: Air
Polishing with Dentsply
Sirona Device
You will need the following supplies: APD; sterile
Cavitron Jet Air Polishing Insert; sterile Jet-Mate Ster-
ilizable, Detachable Handpiece; Cavitron Prophy Jet
Prophy powder (sodium bicarbonate) or Cavitron
Jet Fresh Prophy powder (aluminum trihydroxide);
HVE: A/W syringe; gauze; cotton roll; lip and cheek
retractor (if applicable); lip lubricant (if applicable);
typodont; typodont pole; dental chair.
Rationale: This exercise will provide a kinetic learning
experience with the Dentsply Sirona APD on either a
live patient or typodont. The air polishing techniques
of nozzle angulation, aerosol control, and patient and
operator positioning are simulated.
The goal of this exercise is to administer air pol-
ishing to tooth surfaces coronal to the Cementoe-
namel junction (CEJ).
Dentsply Sirona APD Setup
1. Don Personal Protective Equipment (PPE) for this
aerosol-generating procedure.
2. Evaluate the psi of the water and air on the dental
unit to ensure compatibility with the device’s spec-
ifications from in the instruction for use (IFU).
3. Connect the water and air lines from the APD to
the dental unit (see Figure 25-12).
490 Chapter 25 Air Polishing Technique

Figure 25-12 Dental unit with black air cord attached

to the yellow air input, water cord attached to the blue
water input, powder cord attached the electrical outlet.

4. Connect the power cord (see Figure 25-12).

5. With the power off, remove the powder bowl cap
from the powder bowl (see Figure 25-13).
Figure 25-14 Turning the APD on with powder bowl cap
off (Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling
and Air Polishing System).
Reproduced with permission from Dentsply Sirona

8. Turn the device off.

9. Select either the Cavitron Prophy Jet Prophy Pow-
der (sodium bicarbonate) or the Cavitron Prophy
Powder (aluminum trihydroxide) and shake the
powder bottle to break up any clumps.
10. Fill the powder bowl. Do not fill past the inner
tube (see Figure 25-15).

Figure 25-13 Removal of powder bowl cap from

the powder bowl (Dentsply Sirona Cavitron Jet Plus
Ultrasonic Scaling and Air Polishing System).
Reproduced with permission from Dentsply Sirona

6. Look in the powder bowl and verify it is empty.

7. Do not position your face directly over the pow-
der bowl, and turn the device on for 15 seconds. Figure 25-15 Filling the powder bowl (Dentsply Sirona
This will eliminate any residual powder or mois- Cavitron Jet Plus Ultrasonic Scaling and Air Polishing
ture in the powder bowl (see Figure 25-14). System).
 Skill Building: Air Polishing with Dentsply Sirona Device 491

11. Visually inspect the powder bowl cap and ensure

that powder is not present on the threads or the
seal ring. Use a soft disposable cloth to remove
residual powder if present.
12. Gently twist and secure the powder bowl cap on
the powder bowl without stripping the threads
(see Figure 25-16).

Figure 25-17 Powder flow control (Dentsply Sirona

Cavitron Jet Plus Ultrasonic Scaling and Air Polishing
System)

15. Purge the line for a minimum of 20–30 seconds

per the Centers for Disease Control and Preven-
tion (CDC). Always follow your clinic’s protocols
for waterline maintenance, which may be differ-
ent than a 20- to 30-second waterline flush. You
can use the automatic purge feature and the water
line will purge for 2 minutes (see Figure 25-18).

Figure 25-16 Placing the powder bowl cap onto the

powder bowl. (Dentsply Sirona Cavitron Jet Plus
Ultrasonic Scaling and Air Polishing System).
Reproduced with permission from Dentsply Sirona

13. Turn on the power to the device. Ensure that air is

not leaking from the powder bowl or the powder
bowl cap after it pressurizes. If air is leaking, turn
the device off and clean all threads.
14. Verify the powder bowl is pressurized by look-
ing into the window on the powder flow control.
If powder flow (small white circle of powder)
is seen, the device is pressurized correctly. If
no flow is seen, turn the device off, check for a Figure 25-18 Automatic purge feature activated on the
clog, and ensure that adequate powder level is Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and
present in the powder bowl (see Figure 25-17). Air Polishing System.
492 Chapter 25 Air Polishing Technique
16. Connect the Jet-Mate Sterilizable, Detachable
Handpiece to the handpiece cable. Be sure to
align the attachments correctly to avoid damage
to the equipment (see Figure 25-19).
Figure 25-19 Attaching the Jet-Mate Sterilizable,
Detachable Handpiece to the handpiece cable (Dentsply
Sirona Cavitron Jet Plus Ultrasonic Scaling and Air
Polishing System.
Reproduced with permission from Dentsply Sirona
17. Position the handpiece vertically over a sink and
fill with water until a water dome appears over
the brim and all air bubbles are released (see
Figure 25-20).
Figure 25-20 Water dome visible in handpiece opening.
18. Lubricate green O-ring on the Cavitron JET Air
Polishing Insert by rotating the O-ring 360 de-
grees over the water dome (see Figure 25-21).
Figure 25-21 O-ring lubrication: Rotate the O-ring
360 degrees over the water dome until fully lubricated.
19. Keep the handpiece in a vertical position and align
the heater rod and nozzle tube with the openings
on the handpiece. Place the nozzle into the hand-
piece. Make sure the O-ring is fully seated (see
Figure 25-22).
Figure 25-22 Cavitron JET Air Polishing Insert placed
into the Jet-Mate Sterilizable, Detachable Handpiece.
20. Set the water flow rate to high.
21. Select low or medium powder velocity emission
with the powder flow control on the powder bowl
cap. High powder emission is seldom used in
 Skill Building: Air Polishing with Dentsply Sirona Device 493

clinical practice and is indicated only for the removal
of heavy tenacious stains. Rotate the powder flow
control to ‘L’ or ‘M’ on the device (see Figure 25-23).
their consent to continue. If applicable, lubricate
the patient’s lips, insert a lip and cheek retractor
into the patient’s mouth. Affix a patient napkin,
put on safety goggles, use a face drape or a hair
covering if applicable.

Air Polishing Posterior

Occlusal Surfaces
Begin on the mandibular occlusal surfaces of your domi-
nant side. Beginning on the occlusal surface can improve
the patient experience by allowing them to experience
the feel of air polishing prior to exposing smooth and in-
terproximal surfaces that are closer to the lips and cheeks.
• Dominant right-handed provider: mandibular right
terminal molar occlusal surface.
• Dominant left-handed provider: mandibular left
terminal molar occlusal surface.

Insert a lip and cheek retractor (if applicable).

Figure 25-23 Setting the powder flow control (Dentsply
Sirona Cavitron Jet Plus Ultrasonic Scaling and Air
Polishing System).
Grasp the air polishing handpiece with your dominant hand.
22. Use the dial to select manual prophy mode cycle
for this exercise. Auto-cycle prophy mode is use-
ful after you become more proficient in air polish-
Grasp the HVE with your nondominant hand.
ing techniques (see Figure 25-24).

Position the nozzle 2–4 mm from the occlusal of the

mandibular terminal molar of your dominant side
at a 90-degree angle (see Figure 25-25).

Position the HVE 0.5–6.0 inches from the nozzle

Select the operator positioning for direct vision.

• Dominant right-handed provider: 8–11 o’clock
• Dominant left-handed provider: 1–4 o’clock

Figure 25-24 Dial set to manual prophy mode cycle

(Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling
and Air Polishing System).
23. Adjust the water and/or powder velocity until an
effective slurry is expelled from the nozzle. A pro-
ductive slurry will have an equal mixture of air,
powder, and water with minimal powder expul-
sion in the form of an aerosol cloud.
24. Evaluate the patient record to ensure there are no
considerations or contraindications to air polish-
ing. Explain the procedure to the patient and gain
Select the patient chair positioning for the mandibular arch.
• Supine, semi-supine, or in between supine and
semi-supine.
• Patient chin slightly downward
Establish a finger rest intraoral or extraoral,
ensuring correct handpiece grasp is maintained.
Ensure that the foot pedal is within reach. Turn on the HVE.
Begin air polishing the following steps.
494 Chapter 25 Air Polishing Technique

3. Rinse both molars by pressing the pedal halfway

to the floor to expel only water.
4. Move to the second premolar of your dominant
side.
5. Position the nozzle 2–4 mm from the occlusal
­surface at a 90-degree angle (see Figure 25-27).

Figure 25-25 Nozzle at a 2- to 4-mm distance and

at a 90-degree angle to the occlusal surface of the
mandibular right second molar.

1. Depress the foot pedal all the way to the floor to

expel the slurry. Expose the mandibular occlu-
sal terminal molar of your dominant side to 1–2
­seconds (varies based on the level of biofilm and
stain present) of the slurry using continuous,
overlapping, circular movements.
2. Move to the next molar of your dominant
side and repeat the slurry exposure, keeping
the HVE 0.5–6.0 inches from the nozzle (see
Figure 25-26).

Figure 25-27 Nozzle at a 2- to 4-mm distance and

at a 90-degree angle to the occlusal surface of the
mandibular right second premolar.

6. Reposition the HVE 0.5–6.0 inches from the

nozzle.
7. Press the foot pedal all the way to the floor to
expel the slurry. Expose the occlusal of the sec-
ond premolar to 1–2 seconds (varies based on
the level of biofilm and stain present) of the
slurry using continuous, overlapping, circular
movements.
8. Move to the first premolar of your dominant
Figure 25-26 Nozzle at a 2- to 4-mm distance and side and repeat the slurry exposure, keeping
at a 90-degree angle to the occlusal surface of the the HVE 0.5–6.0 inches from the nozzle (see
mandibular right first molar. Figure 25-28).
 Skill Building: Air Polishing with Dentsply Sirona Device 495

Grasp the air polishing handpiece with your dominant hand.

Grasp the HVE with your nondominant hand.

Position the nozzle 2–4 mm from the middle-third distal-facial

of the maxillary canine on your dominant side
at a 60-degree angle (see Figure 25-29).

Position the HVE 0.5–6.0 inches from the nozzle.

Select the operator positioning for direct vision.

• Dominant right-handed provider: 8–1 o’clock
• Dominant left-handed provider: 11–4 o’clock

Select patient chair positioning for the maxillary arch.

Patient chair supine with chin slightly upward.

Figure 25-28 Nozzle at a 2- to 4-mm distance and Establish a finger rest intraoral or extraoral,
ensuring correct handpiece grasp is maintained.
at a 90-degree angle to the occlusal surface of the
mandibular right first premolar.

Ensure that the foot pedal is within reach. Turn on

the HVE. Begin air polishing with the following steps.
9. Rinse both premolars by pressing the pedal half-
way to the floor to expel only water.
10. Repeat all steps on the mandibular occlusal sur-
faces of your nondominant side and both max-
illary arches. Upper arches will require indirect
vision. If an HVE with affixed mirror is not avail-
able, then four-handed assisted dentistry will be
needed. If neither are available, then do not air
polish the maxillary occlusal surfaces because an
HVE must be used during air polishing.

Air Polishing Anterior

Smooth Surfaces
Begin on the maxillary facial canine of your dominant
side.
• Dominant right-handed provider: maxillary right
canine facial surface. Figure 25-29 Nozzle at a 2- to 4-mm distance and at a
• Dominant left-handed provider: maxillary left ca- 60-degree angle to the middle-third distal-facial of the
nine facial surface. maxillary right canine.
496 Chapter 25 Air Polishing Technique

1. Press the foot pedal all the way to the floor to expel
the slurry. Expose the distal-facial of the maxillary
canine of your dominant side to 1–2 seconds of
slurry, then the midline-facial 1–2 seconds, and
then the mesial-facial 1–2 seconds using continu-
ous, overlapping circular movements.
2. Move to the maxillary lateral incisor of your domi-
nant side and repeat the slurry exposure on the distal-
facial, midline-facial, and mesial-facial, keeping
the HVE 0.5–6.0 inches from the nozzle (see
Figure 25-30).

Figure 25-31 Nozzle at a 2- to 4-mm distance and at a

60-degree angle to the middle-third midline-facial of the
maxillary right central incisor.

7. Move to the maxillary central incisor of your non-

dominant side and repeat the slurry exposure on
the mesial-facial, midline-facial, and distal-facial,
keeping the HVE 0.5–6.0 inches from the nozzle
(see Figure 25-32).

Figure 25-30 Nozzle at a 2- to 4-mm distance and at a

60-degree angle to the middle-third distal-facial of the
maxillary right lateral incisor.

3. Rinse the canine and lateral incisor by pressing

the pedal halfway to the floor to expel only water.
4. Move to the maxillary central incisor of your
dominant side.
Position the nozzle 2–4 mm from the middle-third
distal-facial of the maxillary central incisor on your
dominant side at a 60-degree angle.
5. Reposition the HVE 0.5–6.0 inches from the
nozzle.
6. Press the foot pedal all the way to the floor to expel
the slurry. Expose the distal-facial of the central inci-
sor of your dominant side to 1–2 seconds of slurry,
then the midline-facial 1–2 seconds, and then the Figure 25-32 Nozzle at a 2- to 4-mm distance and at a
mesial-facial 1–2 seconds using continuous, over- 60-degree angle to the middle-third midline-facial of the
lapping circular movements (see Figure 25-31). maxillary left central incisor.
 Skill Building: Air Polishing with Dentsply Sirona Device
8. Rinse both centrals by pressing the pedal halfway
to the floor to expel only water.
9. Move the maxillary lateral incisor of your non-
dominant side. Position the nozzle 2–4 mm from
the middle-third mesial-facial of the maxillary
lateral incisor on your non-dominant side at a
60-degree angle.
10. Position the HVE 0.5–6.0 inches from the nozzle.
11. Press the foot pedal all the way to the floor to ex-
pel the slurry. Expose the mesial-facial of the lateral
incisor of your nondominant side to 1–2 seconds
of slurry, then the midline-facial 1–2 seconds,
and then the distal-facial 1–2 seconds using con-
tinuous, overlapping circular movements (see
Figure 25-33).
Figure 25-33 Nozzle at a 2- to 4-mm distance and at a
60-degree angle to the middle-third midline-facial of the
maxillary left lateral incisor.
12. Move to the maxillary canine of your nondom-
inant side and repeat the slurry exposure on
the mesial-facial, midline-facial, and distal-facial,
keeping the HVE 0.5–6.0 inches from the nozzle.
13. Rinse the lateral and canine tooth on your
non-dominant side by pressing the pedal halfway
to the floor to expel only water.
497
14. Repeat all steps on the lingual surfaces of the
maxillary anterior teeth with indirect vision. If
an HVE with affixed mirror is not available, then
four-handed assisted dentistry will be needed. If
neither are available, then do not air polish upper
anterior lingual surfaces because an HVE must be
used during air polishing.
15. Repeat all steps on the facial and lingual surfaces
of the mandibular anterior teeth.
Air Polishing Posterior
Smooth Surfaces
Begin on the maxillary buccal terminal molar of your
dominant side.
• Dominant right-handed provider: maxillary right
terminal molar buccal surface.
• Dominant left-handed provider: maxillary left ter-
minal molar buccal surface.
Grasp the air polishing handpiece with your dominant hand.
Grasp the HVE with your nondominant hand.
Position the nozzle 2–4 mm pointed slightly distally from the
middle third distal-buccal of the maxillary terminal molar
of your dominant side at an 80-degree angle (see Figure 25-34).
Position the HVE 0.5–6.0 inches from the nozzle.
Select the operator position for direct vision.
• Dominant right-handed provider: 8–11 o’clock
• Dominant left-handed provider: 1–4 o’clock
Select the patient chair positioning for the maxillary arch:
patient chair supine with the chin slightly upward.
Establish a finger rest intraoral or extraoral, ensuring correct
handpiece grasp is maintained.
Ensure that the foot pedal is within reach. Turn on
the HVE. Begin air polishing with the steps below.
498 Chapter 25 Air Polishing Technique

3. Rinse all molars by pressing the pedal halfway to

the floor to expel water only.
4. Move to the maxillary second premolar of your
dominant side.
5. Position the nozzle 2–4 mm pointed slightly dis-
tally from the middle third distal-buccal of the
maxillary second premolar of your dominant side
at an 80-degree angle (see Figure 25-36).

Figure 25-34 Nozzle at a 2- to 4-mm distance and

pointed slightly distally at an 80-degree angle to the
buccal surface of the maxillary right second molar.

1. Press the foot pedal all the way to the floor to expel
the slurry. Expose the distal-buccal of the terminal
molar of your dominant side to 1–2 seconds of
slurry, then the midline-buccal 1–2 seconds, and
then the mesial-buccal 1–2 seconds using contin-
uous, overlapping circular movements.
2. Move to the next molar(s) of your dominant side
and repeat the slurry exposure on the distal-buccal,
midline-buccal, and mesial-buccal, keeping the HVE
0.5–6.0 inches from the nozzle (see Figure 25-35).

Figure 25-36 Nozzle at a 2- to 4-mm distance and

pointed slightly distally at an 80-degree angle to the
distal-buccal surface of the maxillary right second
premolar.

6. Reposition the HVE 0.5–6.0 inches from the

nozzle.
7. Press the foot pedal all the way to the floor to expel
the slurry. Expose the distal-buccal of the second
premolar of your dominant side to 1–2 seconds of
slurry, then the midline-buccal 1–2 seconds, and
then the mesial-buccal 1–2 seconds using contin-
uous, overlapping circular movements.
8. Move to the maxillary first premolar of your dom-
inant side and repeat the slurry exposure on the
distal-buccal, midline-buccal, and mesial-buccal,
Figure 25-35 Nozzle at a 2- to 4-mm distance and keeping the HVE 0.5–6.0 inches from the nozzle.
pointed slightly distally at an 80-degree angle to the Angle the HVE to capture the aerosols and slurry
distal-buccal surface of the maxillary right first molar. released by the nozzle (see Figure 25-37).
 Skill Building: Air Polishing with Dentsply Sirona Device 499

3. Use the Cavitron Prophy Jet Nozzle Cleaning Tool

to dislodge residual powder in the nozzle delivery
tube. Remove the cleaning tool when complete
(see Figure 25-39).

Figure 25-37 Nozzle at a 2- to 4-mm distance and

pointed slightly distally at an 80-degree angle to the
distal-buccal surface of the maxillary right first premolar.

9. Rinse both premolars by pressing the pedal half-

way to the floor to expel water only.
10. Repeat all steps on the lingual surfaces of the max-
illary posterior teeth of your dominant side, mov-
ing your operator chair position for direct vision.
• Dominant right-handed provider: 1–4 o’clock
• Dominant left-handed provider: 8–11 o’clock
11. Repeat all steps on the maxillary posterior teeth
of your non-dominant side and the mandibular
Figure 25-39 Cavitron Prophy Jet Nozzle Cleaning
teeth both buccal and lingual surfaces.
Tool in the nozzle delivery tube of the Cavitron Jet Air
Polishing Insert.
Dentsply Sirona APD
4. Remove the Jet-Mate Sterilizable, Detachable
Breakdown Handpiece from the handpiece connector cable
1. Turn the APD off and allow the powder bowl to with a straight pull motion. (see Figure 25-40).
depressurize.
2. Remove the Cavitron Jet Air Polishing Insert from
the handpiece (see Figure 25-38).

Figure 25-38 Removal of the Cavitron Jet Air Polishing
Insert from the Jet-Mate Sterilizable, Detachable
Handpiece (Dentsply Sirona Cavitron Jet Plus Ultrasonic
Scaling and Air Polishing System).
Reproduced with permission from Dentsply Sirona
Figure 25-40 Removal of the Jet-Mate Sterilizable,
Detachable Handpiece from the handpiece connector
cable (Dentsply Sirona Cavitron Jet Plus Ultrasonic
Scaling and Air Polishing System).
Reproduced with permission from Dentsply Sirona
500 Chapter 25 Air Polishing Technique

5. Use the Cavitron Prophy Jet Handpiece Cleaning 8. Lift and remove the powder bowl from the de-
Tool to dislodge residual powder in the powder vice carefully. Do not damage the cords under the
delivery port of the handpiece. Remove the clean- bowl (see Figure 25-43).
ing tool when complete (see Figure 25-41).

Figure 25-41 Cavitron Prophy Jet Handpiece Cleaning

Tool inside the powder delivery port of the the Jet-Mate
Sterilizable, Detachable Handpiece (Dentsply Sirona
Cavitron Jet Plus Ultrasonic Scaling and Air Polishing
System).
Reproduced with permission from Dentsply Sirona

Figure 25-43 Removal of the powder bowl from the

6. Disinfect the device, cords, and the pedal with a
manufacturer-approved disinfectant solution and
technique. Refer to the IFU.
7. Carefully remove the powder bowl cap to avoid
damage to the threads. Set the cap aside (see
Figure 25-42).
Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling and
Air Polishing System.
Reproduced with permission from Dentsply Sirona
9. Discard all unused powder from the powder bowl
(see Figure 25-44).

Figure 25-42 Dentsply Sirona Cavitron Jet Plus Figure 25-44 Removing powder from the powder bowl
Ultrasonic Scaling and Air Polishing System with powder (Dentsply Sirona Cavitron Jet Plus Ultrasonic Scaling
bowl cap removed. and Air Polishing System).
Reproduced with permission from Dentsply Sirona Reproduced with permission from Dentsply Sirona
 Skill Building: Air Polishing with EMS Guided Biofilm Therapy
10. Place the powder bowl back into its holder and
ensure that the cords to the powder bowl are not
pinched or smashed. Do not place the powder
bowl cap back on the powder bowl.
11. Do not position your face directly over the pow-
der bowl, and turn the device on for 15 seconds.
This will eliminate any residual powder or mois-
ture in the powder bowl.
12. Turn the device off.
13. Remove the seal ring on the powder bowl cap
without damaging the seal ring. An instrument
without a sharp cutting edge can be used, such as
a dull explorer (see Figure 25-45).
Figure 25-45 Removal of the seal ring from the powder
bowl cap with a dull explorer.
14. Use a soft disposable cloth to wipe the seal ring to
remove residual powder. Do not scratch, bend, or
damage the seal ring (see Figure 25-46).
Figure 25-46 Soft disposable cloth wiping the seal ring
of the powder bowl cap.
501
15. Use a soft disposable cloth to wipe the threads
of the powder bowl cap and the powder bowl.
If powder will not remove, use a soft toothbrush
with light strokes to dislodge powder particles
(see Figure 25-47).
Figure 25-47 Soft disposable cloth wiping the threads of
the powder bowl.
16. Place the seal ring back onto the powder
bowl cap.
17. Place the powder bowl cap on the powder bowl
without stripping the threads.
18. Reprocess the Cavitron Jet Air Polishing Insert;
Cavitron Prophy Nozzle Cleaning Tool; Jet-Mate
Sterilizable, Detachable Handpiece; and the
Cavitron Prophy Jet Handpiece Cleaning Tools
according to the manufacturer’s directions in
­
the IFU.
Skill Building: Air Polishing
with EMS Guided Biofilm
Therapy
You will need the following supplies: APD, red powder
chamber, sterile AIRFLOW handpieces (AIRFLOW
handpiece or AIRFLOW MAX), PERIOFLOW hand-
piece, PERIOFLOW subgingival nozzle, AIRFLOW
Plus powder (GBT uses erythritol powder for its patented
procedure), HVE, A/W syringe, gauze, cotton roll, lip
502 Chapter 25 Air Polishing Technique

and cheek retractor (if applicable), lip lubricant (if ap-

plicable), live patient, dental chair.
Rationale: This exercise simulates the GBT proce-
dure proprietary to EMS. This exercise will provide a
kinetic learning experience on a live patient. You will
use the air polishing techniques of nozzle angulation,
aerosol control, and patient and operator positioning.
The goal of this exercise is to administer the clini-
cal technique steps of GBT on a live patient.

EMS AIRFLOW Prophylaxis

Master Setup
1. Don PPE for this aerosol-generating procedure.
2. Evaluate the psi of the water and air on the den-
tal unit to ensure compatibility with the device’s
specifications.
3. Connect the air line from the APD to the dental unit.
4. Connect the power cord.
5. Fill the independent water bottle reservoir and
Figure 25-49 Filling the red powder chamber with
place it into the device (see Figure 25-48).
AIRFLOW Plus powder.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

7. Place the red powder chamber into the device, en-

suring a magnetic connection (see Figure 25-50).

Figure 25-48 Independent water bottle reservoir placed

into its receptacle on the AIRFLOW Prophylaxis Master.

6. Fill the red powder chamber with AIRFLOW Plus Figure 25-50 Red powder chamber placed into its
powder (erythritol) not to exceed the maximum receptacle on the AIRFLOW Prophylaxis Master.
fill line (see Figure 25-49). Reproduced with permission from E.M.S. Electro Medical Systems S.A.
 Skill Building: Air Polishing with EMS Guided Biofilm Therapy
8. Turn the device on (see Figure 25-51).
Figure 25-51 On/off and dynamic pressure regulator
controls on the AIRFLOW Prophylaxis Master.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
9. Press the dynamic pressure regulator and verify
the unit is pressurized by evaluating for powder
chamber illumination (see Figure 25-52).
Figure 25-52 Powder chamber illuminates after
pressing the dynamic pressure regulator on the
AIRFLOW Prophylaxis Master.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
503
10. Set the water control to 10 with the spindle next
to the handpiece (see Figure 25-53).
Figure 25-53 Spindle water control set to 10 (AIRFLOW
Max handpiece).
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
11. Adjust the water temperature if desired. The de-
fault setting is 40°C/104°F. See Chapter 24 for
details.
12. Purge the ultrasonic and air polishing lines for
20–30 seconds. Always follow your clinic’s proto-
cols for waterline maintenance, which may be dif-
ferent than a 20- to 30-second waterline flush. The
air ­polishing line is pictured in Figure 25-54.
Figure 25-54 Air polishing line of the AIRFLOW
Prophylaxis Master.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
504 Chapter 25 Air Polishing Technique

• AIRFLOW One: Press the pedal to purge the
line and then release when complete.
• AIRFLOW Prophylaxis Master: Press the pedal
once to activate the automatic purge. The blue
numbers will change to white as a one-minute
purge completes (see Figure 25-55).
3. Perform a plaque index and show the patient their
results in a hand mirror (see Figure 25-56).
4. Provide oral hygiene instructions to motivate the
patient. See Chapter 24 for details.

Figure 25-56 Disclosing solution. Red stained areas

indicating biofilm presence.

GBT Step 4: AIRFLOW MAX

1. Blow air through the interior of the AIRFLOW MAX
handpiece from both sides to eliminate moisture.
2. Connect the sterile AIRFLOW MAX handpiece to
the handpiece connector cable. Be sure to align
the attachments correctly to avoid damage to the
equipment (see Figure 25-57).

Figure 25-55 Automatic purge illuminated numbers

(EMS AIRFLOW Prophylaxis Master).
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

GBT Step 1: Assessment

and infection control
1. Have the patient rinse with BacterX Pro mouth-
wash. See Chapter 24 for details.
2. Evaluate the patient record to ensure that there
are no considerations or contraindications to air
polishing and disclosing solution. See Chapters
22 and 24 for details.
3. Explain the procedure to the patient and gain
their consent to continue.
4. Lubricate the patient’s lips.
5. Insert a lip and cheek retractor into the patient’s Figure 25-57 Attaching the AIRFLOW MAX handpiece
mouth. to the handpiece connector cable on the AIRFLOW
6. Affix a patient napkin, put on safety goggles, use a Prophylaxis Master.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
face drape or a hair covering if applicable.
3. Set the powder velocity control for air polishing.
GBT Step 2: Disclose, and GBT • 30–60% is used for coronal and apical to CEJ
Step 3: Motivate surfaces.
1. Use cotton pliers and apply the two-tone dye to • If heavier or more tenacious stain is present
all tooth surfaces using a presoaked pellet. See coronal to the CEJ, the powder velocity can
Chapter 24 for details. be increased to 60–100%.
2. Rinse the patient’s mouth thoroughly and do not • Do not use over 60% for surfaces apical to
allow the patient to swallow the disclosing solution. the CEJ.
 Skill Building: Air Polishing with EMS Guided Biofilm Therapy 505

4. Set the water flow rate to 10 (100%).

5. Adjust the water and/or powder velocity until an
effective slurry is expelled from the nozzle. A pro-
ductive slurry will have an equal mixture of air,
powder, and water with minimal powder expul-
sion in the form of an aerosol cloud.

Air Polishing (EMS terms AIRFLOWING)

Posterior Occlusal Surfaces
Begin GBT air polishing on the mandibular occlusal
surfaces of your dominant side. Beginning on the oc-
clusal surface can improve the patient experience by
allowing them to experience the feel of air polishing
prior to exposing smooth and interproximal surfaces
that are closer to the lips and cheeks.
Figure 25-58 Nozzle at a 3- to 5-mm distance and
• Dominant right-handed provider: mandibular right
at a 60-degree angle to the occlusal surface of the
terminal molar occlusal surface. mandibular right second molar.
• Dominant left-handed provider: mandibular left
terminal molar occlusal surface.
1. Depress the foot pedal on the side to expel the
slurry. Do not activate Boost mode. See ­Chapter 24
Grasp the air polishing handpiece with your dominant hand. for details. Expose the mandibular occlusal termi-
nal molar of your dominant side to the slurry us-
ing continuous, overlapping circular movements.
Exposure time is dependent on the level of oral
Grasp the HVE with your nondominant hand. deposits and is typically 5–10 seconds, no more
than 20 seconds.
2. Move to the next molar of your dominant
Position the nozzle 3–5 mm from the occlusal surface of the
side and repeat the slurry exposure, keeping
mandibular terminal molar on your dominant side the HVE 0.5–6.0 inches from the nozzle (see
at a 60-degree angle (see Figure 25-58). Figure 25-59).

Position the HVE 0.5–6.0 inches from the nozzle.

Select the operator position for direct vision.

• Dominant right-handed provider: 8–11 o’clock
• Dominant left-handed provider: 1–4 o’clock

Select the patient chair positioning for the mandibular arch.

• Supine, semi-supine, or in between supine and
semi-supine.
• Patient chin slightly downward.

Establish a finger rest intraoral or extraoral,

ensuring correct handpiece grasp is maintained.

Figure 25-59 Nozzle at a 3- to 5-mm distance and

Ensure that the foot pedal is within reach. Turn on
the HVE. Begin air polishing with the following steps. at a 60-degree angle to the occlusal surface of the
mandibular right first molar.
506 Chapter 25 Air Polishing Technique

3. Continue moving forward in the mouth, exposing

Grasp the air polishing handpiece with your dominant hand.
the mandibular premolar occlusal surfaces and
the anterior incisal surfaces of your dominant side
(see Figure 25-60).
Grasp the HVE with your non-dominant hand.

Position the nozzle 3–5 mm from the middle third distal-facial

pointed away from the gum line of the maxillary canine of your
dominant side at a 30- to 60-degree angle (see Figure 25-61).

Position the HVE 0.5–6.0 inches from the nozzle.

Select the operator position for direct vision.

• Dominant right-handed provider: 8–1 o’clock
• Dominant left-handed provider: 11–4 o’clock

Select patient chair positioning for the maxillary arch.

patient chair supine with chin slightly upward.

Establish a finger rest intraoral or extraoral,

Figure 25-60 Nozzle at a 3- to 5-mm distance and
at a 60-degree angle to the occlusal surface of the
mandibular right first premolar.
ensuring correct handpiece grasp is maintained.
Ensure that the foot pedal is within reach. Turn on the HVE.
begin air polishing with the following steps.

4. Repeat all steps on the mandibular occlusal

surfaces of your non-dominant side and both
maxillary arches. Maxillary arches will require
indirect vision. If an HVE with affixed mirror
is not available, then four-handed assisted den-
tistry will be needed. If neither are available,
then do not air polish the maxillary occlusal
surfaces because an HVE must be used during
air polishing.

Air Polishing (EMS terms AIRFLOWING)

Anterior Smooth Surfaces
Air polishing of surfaces coronal to the CEJ will be
completed first and then air polishing of the surfaces
apical to the CEJ will be completed.

Surfaces Coronal to the CEJ. Begin on the

maxillary facial canine of your dominant side.
• Dominant right-handed provider: maxillary right
canine facial surface.
• Dominant left-handed provider: maxillary left ca-
nine facial surface.
Figure 25-61 Nozzle at a 3- to 5-mm distance and at a
30- to 60-degree angle to the middle-third distal-facial
of the maxillary right canine pointed away from the gum
line.
 Skill Building: Air Polishing with EMS Guided Biofilm Therapy 507

1. Press the foot pedal on the side to expel the slurry.

Do not activate Boost mode. Expose the distal-fa-
cial of the maxillary canine of your dominant side
to 5–10 seconds, no more than 20 seconds, of
slurry, then the midline-facial, and then the me-
sial-facial using continuous, overlapping circular
movements.
2. Move to the maxillary lateral incisor of your dom-
inant side and repeat the slurry exposure on the
distal-facial, midline-facial, and mesial-facial,
keeping the HVE 0.5–6.0 inches from the nozzle
(see Figure 25-62).

Figure 25-62 Nozzle at a 3- to 5-mm distance and at a

30- to 60-degree angle to the middle-third distal-facial
of the maxillary right lateral incisor pointed away from
the gum line.

3. Repeat all steps on the remaining maxillary an-

terior facial surfaces, maintaining the nozzle
3–5 mm from the middle third facial and pointed
away from the gum line at a 30- to 60-degree an-
gle. Continue to adjust the HVE to capture the
aerosols and slurry expelled by the nozzle (see
Figure 25-63a to d).
B
Figure 25-63 Nozzle at a 3- to 5-mm distance and at a
30- to 60-degree angle to the facial middle-third pointed
away from the gum line on the: A. Maxillary right central
incisor midline-facial, B. Maxillary left central incisor
midline-facial.
508 Chapter 25 Air Polishing Technique
C 2. Press the foot pedal on the side to expel the
D
Figure 25-63 (Continued) C. Maxillary left lateral incisor
mesial-facial, D. Maxillary left canine mesial-facial.
4. Repeat all steps on the maxillary anterior lingual
smooth and interproximal surfaces coronal to the
CEJ. Maxillary anterior lingual surfaces will require
indirect vision. If an HVE with affixed mirror is not
available, then four-handed assisted dentistry will
be needed. If neither are available, then do not air
polish the maxillary anterior lingual surfaces be-
cause an HVE must be used during air polishing.
5. Repeat all steps on the mandibular anterior facial
and lingual surfaces.
Surfaces Apical to the CEJ. Begin on the max-
illary facial canine of your dominant side.
• Dominant right-handed provider: maxillary right
canine facial surface.
• Dominant left-handed provider: maxillary left ca-
nine facial surface.
1. Position the nozzle 3–5 mm from the middle
third distal-facial pointed toward the gum line of
the maxillary canine of your dominant side at a
30- to 60-degree angle. Position the HVE 0.5–6.0
inches from the nozzle.
slurry. Do not activate Boost mode. Expose
the distal-facial of the maxillary canine of your
dominant side to 5–10 seconds, no more than
20 ­seconds, of slurry, then the midline-facial, and
then the mesial-facial using continuous, overlap-
ping circular movements (see Figure 25-64).
Figure 25-64 Nozzle at a 3- to 5-mm distance and at a
30- to 60-degree angle to the middle-third midline-facial
of the maxillary right canine pointed toward the
gum line.
 Skill Building: Air Polishing with EMS Guided Biofilm Therapy 509

3. Move to the maxillary lateral incisor of your

dominant side and repeat the slurry exposure on
the distal-facial, midline-facial, and mesial-facial,
keeping the HVE 0.5–6.0 inches from the nozzle
(see Figure 25-65).

Figure 25-65 Nozzle at a 3- to 5-mm distance and at a

30- to 60-degree angle to the middle-third midline-facial
of the maxillary right lateral incisor pointed toward the
gum line.

4. Repeat all steps on the remaining maxillary an-

terior facial surfaces, maintaining the nozzle
3–5 mm from the middle-third facial and pointed
toward the gum line at a 30- to 60-degree an-
gle. Continue to adjust the HVE to capture the
aerosols and slurry expelled by the nozzle (see
Figure 25-66a to d).
5. Repeat all steps on the maxillary anterior lingual
smooth and interproximal surfaces apical to the
CEJ. Maxillary anterior lingual surfaces will re-
quire indirect vision. If an HVE with affixed mir-
ror is not available, then four-handed assisted
dentistry will be needed. If neither are available, B
then do not air polish the maxillary anterior
Figure 25-66 Nozzle at a 3- to 5-mm distance and at a
lingual surfaces because an HVE must be used 30- to 60-degree angle to the facial middle-third pointed
during air polishing. toward from the gum line on the: A. Maxillary right
6. Repeat all steps on the mandibular anterior facial central incisor midline-facial, B. Maxillary left central
and lingual surfaces. incisor midline-facial.
510 Chapter 25 Air Polishing Technique
C
D
Figure 25-66 (Continued) C. Maxillary left lateral incisor
mesial-facial, D. Maxillary left canine midline-facial.
Air Polishing (EMS terms AIRFLOWING)
Posterior Smooth Surfaces
Air polishing of surfaces coronal to the CEJ will be
completed first, and then air polishing of the surface
apical to the CEJ will be completed.
Surfaces Coronal to the CEJ. Begin on the ter-
minal mandibular molar buccal surface of your dom-
inant side.
• Dominant right-handed provider: mandibular right
molar buccal surface.
• Dominant left-handed provider: mandibular left
molar buccal surface.
Grasp the air polishing handpiece with your dominant hand.
Grasp the HVE with your non-dominant hand.
Position the nozzle 3–5 mm from the middle third distal-buccal
pointed away from the gum line of the terminal mandibular molar of
your dominant side at a 30- to 60-degree angle (see Figure 25-67).
Position the HVE 0.5–6.0 inches from the nozzle.
Select the operator position for direct vision.
• Dominant right-handed provider: 8–11 o’clock
• Dominant left-handed provider: 1–4 o’clock
Select patient chair positioning for the mandibular arch.
• Supine, semi-supine, or in between supine
and semi-supine.
• Patient chin slightly downward.
Establish a finger rest intraoral or extraoral,
ensuring correct handpiece grasp is maintained.
Ensure that the foot pedal is within reach. Turn on
the HVE. Begin air polishing with the following steps.
Figure 25-67 Nozzle at a 3- to 5-mm distance and at
a 30- to 60-degree angle to the middle-third midline-
buccal of the mandibular right second molar pointed
away from the gum line.
 Skill Building: Air Polishing with EMS Guided Biofilm Therapy 511

1. Press the foot pedal on the side to expel the slurry.
Do not activate Boost mode. Expose the distal-­
buccal of the terminal mandibular molar on your
dominant side to 5–10 seconds, no more than
20 seconds, of slurry, then the midline-buccal,
and then the mesial-buccal using continuous
overlapping circular movements.
2. Move to the next molar(s) of your dominant
side and repeat the slurry exposure on the
distal-buccal, midline-buccal, and mesial-buccal,
keeping the HVE 0.5–6.0 inches from the nozzle
(see Figure 25-68).

Figure 25-68 Nozzle at a 3- to 5-mm distance and at a

30- to 60-degree angle to the middle-third midline-buccal
of the mandibular right first molar pointed away from the
gum line.

3. Continue moving forward in the quadrant to the Continue to adjust the HVE to capture the aero-
premolar teeth, maintaining the nozzle 3–5 mm sols and slurry expelled by the nozzle (see
from the middle third buccal and pointed away Figure 25-69a and b).
from the gum line at a 30- to 60-degree angle.

A B
Figure 25-69 Nozzle at a 3- to 5-mm distance and at a 30- to 60-degree angle to the buccal
middle-third pointed away from the gum line on the: A. Mandibular right second premolar distal-
buccal surface, B. Mandibular right first premolar on the midline-buccal surface.
512 Chapter 25 Air Polishing Technique
4. Repeat all steps on the mandibular lingual smooth
and interproximal surfaces coronal to the CEJ on
your dominant side. Adjust your operator chair
position for direct vision.
• Dominant right-handed provider: 1–4 o’clock
• Dominant left-handed provider: 8–11 o’clock
5. Repeat all steps on the mandibular posterior buc-
cal and lingual smooth and interproximal surfaces
coronal to the CEJ surfaces of your non-dominant
side.
6. Repeat all steps on the maxillary posterior buccal
and lingual smooth and interproximal surfaces
coronal to the CEJ.
Surfaces Apical to the CEJ. Begin on the ter-
minal mandibular molar buccal surface of your dom-
inant side.
• Dominant right-handed provider: mandibular right
molar buccal surface.
• Dominant left-handed provider: mandibular left
molar buccal surface.
1. Position the nozzle 3–5 mm from the middle third
distal-buccal and pointed toward the gum line of
the terminal mandibular molar on your dominant
side at a 30- to 60-degree angle (see Figure 25-70).
Figure 25-71 Nozzle at a 3- to 5-mm distance and at
a 30- to 60-degree angle to the middle-third midline-
buccal of the mandibular right first molar pointed
toward the gum line.
Figure 25-70 Nozzle at a 3- to 5-mm distance and at
a 30- to 60-degree angle to the middle-third midline-
buccal of the mandibular right second molar pointed
toward the gum line.
2. Position the HVE 0.5–6.0 inches from the nozzle.
3. Press the foot pedal on the side to expel the
slurry. Do not activate Boost mode. Expose the
distal-buccal of the mandibular terminal molar
of your dominant side to 5–10 seconds, no more
than 20 seconds, of slurry, then the midline-buc-
cal, and then the mesial-buccal using continuous,
overlapping circular movements.
4. Move to the next molar(s) of your dominant
side and repeat the slurry exposure on the
distal-buccal, midline-buccal, and mesial-buccal,
keeping the HVE 0.5–6.0 inches from the nozzle
(see Figure 25-71).
5. Continue moving forward in the quadrant to the
premolar teeth, maintaining the nozzle 3–5 mm
from the middle third buccal and pointed toward
the gum line at a 30- to 60-degree angle. Continue
to adjust the HVE to capture the aerosols and
slurry expelled by the nozzle (see Figure 25-72a
and b).
6. Repeat all steps on the mandibular lingual smooth
and interproximal surfaces apical to the CEJ on
your dominant side. Adjust your operator chair
position for direct vision.
• Dominant right-handed provider: 1–4 o’clock
• Dominant left-handed provider: 8–11 o’clock
7. Repeat all steps on the mandibular posterior buc-
cal and lingual smooth and interproximal surfaces
apical to the CEJ surfaces of your non-dominant
side.
8. Repeat all steps on the maxillary posterior buccal
and lingual smooth and interproximal surfaces
apical to the CEJ.
 Skill Building: Air Polishing with EMS Guided Biofilm Therapy 513

A B
Figure 25-72 Nozzle at a 3- to 5-mm distance and at a 30- to 60-degree angle to the buccal middle-third pointed
toward the gum line on the: A. Mandibular right second premolar midline-buccal surface, B. Mandibular right first
premolar midline-buccal surface.

GBT Step 5: PERIOFLOW 4. Secure a subgingival nozzle into the handpiece.

Align the single-use disposable subgingival noz-
1. With the ADP on, but your foot released from zle with the notch on the PERIOFLOW hand-
the pedal, remove the AIRFLOW MAX handpiece piece, ensuring that the closed section of the
from the handpiece connector cable and set aside. nozzle is at the top, and gently push the subgin-
2. Blow air through the interior of the PERIOFLOW gival nozzle downward with your fingers (see
handpiece from both sides to eliminate any Figure 25-74).
moisture.
3. Attach the PERIOFLOW handpiece to the hand-
piece connector cable. Be sure to align the attach-
ments correctly to avoid damage to the equipment
(see Figure 25-73).

Figure 25-73 Attaching PERIOFLOW handpiece to

handpiece connector cable on the AIRFLOW Prophylaxis
Master. Figure 25-74 Subgingival nozzle attachment to the
Reproduced with permission from E.M.S. Electro Medical Systems S.A. PERIOFLOW handpiece.
514 Chapter 25 Air Polishing Technique

5. Place the subgingival nozzle on a hard sur- Periodontal Pocket Treatment

face and push downward until the subgingival
nozzle is fully seated onto the handpiece (see Grasp the air polishing handpiece with your dominant hand.
Figure 25-75).

Grasp the HVE with your nondominant hand.

Position the nozzle on the tooth surface with the periodontal

pocket to receive subgingival treatment.

Position the HVE 0.5–6.0 inches from the nozzle.

Select the operator position for direct vision.

Select the patient chair positioning.

Establish a finger rest intraoral or extraoral,

ensuring correct handpiece grasp is maintained.

Ensure that the foot pedal is within reach. Turn on

Figure 25-75 Place the end of the subgingival nozzle the HVE. Begin air polishing with the following steps.
on a hard surface and push to fully seat the disposable
subgingival nozzle into the PERIOFLOW handpiece.
1. Insert the subgingival nozzle to the depth of the
periodontal pocket and then retract 2–3 mm from
6. Determine the sites of the mouth that have probe the base of the pocket to maintain at least a 3-mm
depths >4 mm for use with the PERIOFLOW distance from the crest of the alveolar bone. The
subgingival nozzle and handpiece. nozzle is inserted parallel to the long axis of the
7. Set the powder velocity control for subgingival air tooth (see Figure 25-76).
polishing of 5 through 10 (50–100%). The pow-
der velocity setting is selected based on the oral
deposit level.
8. Set the water flow rate to 10 (100%).
9. Adjust the water and/or powder velocity until an
effective slurry is expelled from the nozzle. A pro-
ductive slurry will have an equal mixture of air,
powder, and water with minimal powder expul-
sion in the form of an aerosol cloud.
10. Select the first periodontal pocket to be treated.

Figure 25-76 Subgingival nozzle inserted into the buccal

periodontal pocket on the mandibular right first molar.
 Skill Building: Air Polishing with EMS Guided Biofilm Therapy 515

2. Press the pedal and deliver the slurry for a maxi-
mum of 5 seconds in the periodontal pocket while
making continuous, slow vertical oscillations (up,
down, rotational) along the pocket.
3. Lift your foot off the pedal to stop the slurry expul-
sion and wait until the spray stops to retract the
subgingival nozzle from the periodontal pocket.
4. Repeat steps 1–3 on additional periodontal pock-
ets >4 mm. Change the subgingival nozzle after
20 sites have been treated.
5. Remove the subgingival nozzle with the nozzle
extractor. Line the extractor with the base of the
subgingival nozzle and then gently push upward
(see Figure 25-77a to c).

A B

C
Figure 25-77 EMS PERIOFLOW subgingival nozzle removal: A. Align the nozzle extractor with the subgingival nozzle,
B. Push the nozzle extractor upward, C. Remove the subgingival nozzle with the nozzle extractor.

EMS AIRFLOW Prophylaxis Master fully depressurize for 10 seconds. Ensure that the
handpiece is not facing upward or toward you to
Air Polishing Breakdown
avoid injury from the spraying of purged air and
1. Turn the APD off and allow the powder chamber residual powder (see Figure 25-78a and b).
to depressurize. Allow the powder chamber to

A B
Figure 25-78 EMS AIRFLOW Prophylaxis Master breakdown: A. Turn off
unit, B. Turn PERIOFLOW nozzle downward.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
516 Chapter 25 Air Polishing Technique
2. Remove the detachable handpiece (see Figure 25-79).
Figure 25-79 Removing the PERIOFLOW handpiece
from the handpiece connector cable.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
3. Use the Easy Clean tool with attached disposable
syringe filled with more than 2 ml of drinking
­water to irrigate the AIRFLOW MAX handpiece
opening for 20 seconds. See Chapter 24 for details.
4. Blow air twice through both openings of the
AIRFLOW MAX handpiece when rinsing is
complete.
5. Remove powder from the device, cords, and pedal
fixtures with a disposable soft nonabrasive cloth
prior to using a manufacturer-approved disinfec-
tant solution. Do not spray disinfectant solutions
directly on system surfaces.
6. Remove the powder chamber from its magnetic
holder without twisting or rotating the bottle.
7. Discard all unused powder in the trash can. Emp-
tying the powder chamber will reduce moisture
absorption and prevent clogging.
8. Clean the connections with compressed air from
the A/W syringe and place on a dry surface.
9. Reprocess the handpieces and Easy Clean tool per
the manufacturer’s directions in the DFU/IFU.
GBT Step 6: Piezon PS, GBT Step 7:
Check, and GBT Step 8: Recall
Perform piezoelectric ultrasonic instrumentation
with the techniques shown in the ultrasonic chap-
ters for remaining hard deposits. Visually evaluate for
­remaining oral deposits in need of removal and estab-
lish an a­ ppropriate recall for the patient based on risk
factors.
Skill Building: Air Polishing
with EMS AIRFLOW
Handy 3.0
You will need the following supplies: portable hand-
held devices AIRFLOW Handy 3.0 Perio, AIRFLOW
Handy 3.0 Classic, AIRFLOW Perio powder,
AIRFLOW Plus powder, AIRFLOW Classic powder,
AIRFLOW handpiece or AIRFLOW MAX handpiece,
PERIOFLOW handpiece, single-use disposable sub-
gingival nozzle, HVE, A/W syringe, gauze, cotton roll,
lip and cheek retractor (if applicable), typodont, ty-
podont pole, and dental chair.
Rationale: This exercise will provide a kinetic learning
experience with the EMS Handy 3.0 on a typodont or
a live patient. The air polishing techniques of nozzle
angulation, aerosol control, and patient and operator
positioning are simulated, which can then be trans-
ferred to live patient treatment.
The goal of this exercise is to administer air pol-
ishing coronal and apical to the CEJ with a standard
and subgingival nozzle.
The AIRFLOW Handy 3.0 Perio is compatible
with AIRFLOW Perio powder (glycine) or AIRFLOW
Plus powder (erythritol) used for air polishing coronal
and apical to the CEJ. AIRFLOW Handy 3.0 Classic is
compatible with AIRFLOW Classic powder (sodium
bicarbonate) used for air polishing heavier or tena-
cious stains coronal to the CEJ.
This exercise will demonstrate AIRFLOW Handy
3.0 Perio and then AIRFLOW Handy 3.0 Classic.
Skip the steps for the device your institution does
not own.
AIRFLOW Handy 3.0 Perio
AIRFLOW Handy 3.0 Perio Setup
1. Turn on the master switch to the dental unit (see
Figure 25-80).
Figure 25-80 Example of a dental unit master switch
turned on.
 Skill Building: Air Polishing with EMS AIRFLOW Handy 3.0 517

2. Don PPE for an aerosol-generating procedure. 4. Check the O-rings on the air turbine connector
3. Evaluate the psi of the water and air on the dental cord of the dental unit and the cord adaptor on
unit to ensure compatibility with the specifica- the AIRFLOW Handy 3.0 Perio to ensure that they
tions of the AIRFLOW Handy 3.0 Perio device. are in good condition (see Figure 25-81a and b).

A B
Figure 25-81 O-rings: A. Dental unit air turbine O-rings, B. Cord adaptor of the AIRFLOW Handy 3.0 Perio.

5. Blow compressed air with the A/W syringe into the cord adaptor on the AIRFLOW Handy 3.0
the air turbine connector on the dental unit and Perio (see Figure 25-82a and b).

A B
Figure 25-82 A/W syringe blowing compressed air on: A. Dental unit air turbine connector, B. Cord adaptor on the
AIRFLOW Handy 3.0 Perio.
518 Chapter 25 Air Polishing Technique

6. Turn off the master switch to the dental unit (see 7. Remove the powder chamber cap and set aside
Figure 25-83). (see Figure 25-84).

Figure 25-83 Example of a dental unit master switch

turned off.

Figure 25-84 Powder chamber cap removed from the

powder chamber on the AIRFLOW Handy 3.0 Perio.

8. Shake the AIRFLOW Perio or AIRFLOW Plus 9. Point the AIRFLOW Handy 3.0 Perio downward
powder bottle to break up clumps. Take the cap (see Figure 25-85b).
off and place the powder dispenser on the bottle
(if applicable) (see Figure 25-85a).

A B
Figure 25-85 Preparing to fill the powder chamber of the AIRFLOW Handy 3.0 Perio: A. AIRFLOW Plus powder bottle
with the cap on and the dispenser to the left, B. AIRFLOW Handy 3.0 Perio pointed downward.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
 Skill Building: Air Polishing with EMS AIRFLOW Handy 3.0 519

10. Connect the powder bottle dispenser with the
powder chamber opening. Pour the AIRFLOW
Perio or AIRFLOW Plus powder into the powder
chamber with the body pointed downward. Do
not fill past the inner tube (see Figure 25-86).
11. Remove the dispenser from the powder bottle
and place the cap back on immediately to prevent
moisture contamination (see Figure 25-87).

Figure 25-86 Powder in the powder chamber of Figure 25-87 Powder bottle cap on the AIRFLOW Plus
the AIRFLOW Handy 3.0 Perio not filled past the powder bottle.
inner tube. Reproduced with permission from E.M.S. Electro Medical Systems S.A.

12. With a soft disposable cloth, clear away powder c­ hamber and powder chamber cap (see
residual powder on the threads of the Figure 25-88a and b).

A B
Figure 25-88 Removal of residual powder from the AIRFLOW Handy 3.0 Perio: A. Soft disposable cloth cleaning the
threads of the powder chamber, B. Soft disposable cloth cleaning the threads of the powder chamber cap.
520 Chapter 25 Air Polishing Technique
13. Secure the powder chamber cap tightly on the
powder chamber without stripping the threads.
Do not shake the AIRFLOW Handy 3.0 Perio
once the cap is securely placed to avoid powder
settling into the inner tube.
14. Turn on the master switch to the dental unit. Air
should not be escaping from the cord adaptor or
the air turbine connection. If this occurs, check
the O-rings and reclean the threads to remove any
residual powder contamination.
15. Connect the sterile AIRFLOW handpiece or
AIRFLOW MAX handpiece to the body of the
AIRFLOW Handy 3.0 Perio (see Figure 25-89).
Figure 25-89 AIRFLOW MAX handpiece connected to the
AIRFLOW Handy 3.0 Perio body.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
16. Adjust the water flow rate until an effective slurry
is expelled from the nozzle. The powder veloc-
ity cannot be adjusted on a portable handheld
device. A productive slurry will have an equal
mixture of air, powder, and water with minimal
powder expulsion in the form of an aerosol cloud.
Air Polishing
1. Follow all steps for GBT Step 4 (AIRFLOW MAX),
skipping the step for changing the powder veloc-
ity control setting. Be sure to the use the correct
grasp as seen in Figure 25-2.
2. Follow all steps for GBT Step 5 (PERIOFLOW),
skipping the step for changing the powder veloc-
ity control setting. Be sure to the use the correct
grasp as seen in Figure 25-2.
AIRFLOW Handy 3.0 Classic
AIRFLOW Handy 3.0 Classic Setup
1. Turn off the master switch to the dental unit (see
Figure 25-83).
2. Remove the AIRFLOW Handy 3.0 Perio from the
air turbine on the dental unit.
3. Evaluate the psi of the water and air on the dental
unit to ensure compatibility with the specifica-
tions of the AIRFLOW Handy 3.0 Classic.
4. Check the O-rings on the air turbine connector
cord of the dental unit and the cord adaptor on the
AIRFLOW Handy 3.0 Classic to ensure that they
are in good condition (see Figure 25-81a and b).
5. Turn on the master switch to the dental unit and
blow compressed air with the A/W syringe into the
air turbine connector on the dental unit and the
cord adaptor on the AIRFLOW Handy 3.0 Classic
(see Figure 25-80 and Figure 25-82a and b).
6. Turn off the master switch to the dental unit.
7. Remove the powder chamber cap and set aside
(see Figure 25-84).
8. Shake the AIRFLOW Classic powder bottle to
break up clumps. Take the cap off and place the
powder dispenser on the bottle (if applicable; see
Figure 25-85a).
9. Point the AIRFLOW Handy 3.0 Classic down-
ward (see Figure 25-85b).
10. Connect the powder bottle dispenser with the
powder chamber opening. Pour the AIRFLOW
Classic powder into the powder chamber. Do not
fill past the inner tube (see Figure 25-86).
11. Remove the dispenser from the powder bottle
and place the cap back on immediately to prevent
moisture contamination (see Figure 25-87).
12. With a soft disposable cloth, clear away residual
powder on the threads of the powder chamber and
powder chamber cap (see Figure 25-88a and b).
13. Secure the powder chamber cap tightly on the
powder chamber without stripping the threads.
Do not shake the AIRFLOW Handy 3.0 Classic
once the cap is securely placed to avoid powder
settling into the inner tube.
14. Turn on the master switch to the dental unit. Air
should not be escaping from the cord adaptor or
the air turbine connection. If this occurs, check
the O-rings and reclean the threads to remove any
residual powder contamination.
15. Connect the sterile AIRFLOW handpiece or
AIRFLOW MAX handpiece to the body of the
AIRFLOW Handy 3.0 Classic (see Figure 25-89).
16. Adjust the water flow rate until an effective slurry
is expelled from the nozzle. The powder veloc-
ity cannot be adjusted on a portable handheld
device. A productive slurry will have an equal
mixture of air, powder, and water with minimal
powder expulsion in the form of an aerosol cloud.
Air Polishing
1. Follow the steps for GBT step 4 (AIRFLOW MAX)
surfaces coronal to the CEJ. Skip the steps for
changing the powder velocity control setting. Skip
the steps for surfaces apical to the CEJ. Be sure to
the use the correct grasp as seen in Figure 25-2.
 Skill Building: Air Polishing with EMS AIRFLOW Handy 3.0
AIRFLOW Handy 3.0 Perio
and AIRFLOW Handy 3.0 Classic
Breakdown
1. Remove the detachable handpiece (see Figure 25-90a
and b).
B 6. Remove residual powder from the device, cords,
Figure 25-90 AIRFLOW Handy 3.0 Removal of
Detachable Handpiece: A. AIRFLOW Handy 3.0 Perio
with the handpiece removed from the body, B. AIRFLOW
handpiece.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
2. Use the Easy Clean tool with attached dispos-
able syringe filled with more than 2 ml of drink-
ing water to irrigate the AIRFLOW or AIRFLOW
MAX handpiece opening for 20 seconds (see
Chapter 24 for details; see Figure 25-91).
Figure 25-91 Easy clean tool placed into the handpiece
opening. Disposable syringe is placed into the opening
on the Easy Clean tool.
521
3. Blow air twice through both openings of the
handpiece when rinsing is complete.
4. Turn off the master switch to the dental unit.
When the device is turned off, the powder cham-
ber takes a few seconds to depressurize.
5. Remove the AIRFLOW Handy 3.0 from the
air turbine connector on the dental unit (see
Figure 25-92).
Figure 25-92 Removal of the cord adaptor from the air
turbine connection.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.
and pedal fixtures with a disposable soft nonabra-
sive cloth.
7. Disinfect the device, cords, and pedal fixtures
with a manufacturer-approved disinfectant solu-
tion. Do not spray disinfectant solutions directly
on system surfaces.
8. Gently remove the powder chamber cap after de-
pressurization without stripping the threads. Set
the cap aside (see Figure 25-93).
Figure 25-93 Powder chamber cap removed from the
powder chamber on the AIRFLOW Handy 3.0 Perio.
522 Chapter 25 Air Polishing Technique

9. Discard all unused powder in the trash. Empty- 11. Remove the cap ring without damaging the ring.
ing the powder chamber will reduce moisture ab- Use an instrument without a sharp cutting edge
sorption and prevent clogging. such as a dull explorer (see Figure 25-95).
10. Turn on the master switch to the dental unit and
use the HVE to remove residual powder from the
chamber (see Figure 25-94).

Figure 25-94 Removal of residual powder in the powder Figure 25-95 Ring removed from the powder
chamber with an HVE. chamber cap.

12. Use a soft disposable cloth to remove residual powder chamber and powder chamber cap (see
powder from the cap ring and the threads of the Figure 25-96a to c).

A B

C
Figure 25-96 Cleaning of the AIRFLOW Handy 3.0 with soft disposable cloth: A. Cleaning of the
powder chamber threads, B. Cleaning of the powder chamber cap threads, C. Cleaning the cap ring.
Reproduced with permission from E.M.S. Electro Medical Systems S.A.

13. Clean the threads of the powder chamber and
powder chamber cap with alcohol (ethanol, iso-
propanol) and then allow to dry completely.
14. Place the cap ring back into the powder chamber cap.
Summary
Air polishing is a safe and effective procedure for the
removal and reduction of biofilm, immature dental cal-
culus, and extrinsic exogeneous staining. Many of the
same techniques used for ultrasonic instrumentation are
transferrable to air polishing such as the grasp, finger rest,
aerosol control, and operator and patient positioning.
Summary 523
15. Affix the powder chamber cap back onto the
powder chamber.
16. Reprocess handpieces according to the manufac-
turer’s directions in the DFU/IFU.
Lip and cheek retractors, lip lubricant, and face drapes
can increase patient comfort during air polishing pro-
cedures. The use of an HVE is required to reduce envi-
ronmental aerosols during air polishing. Repetition and
practice will increase your skills and clinical proficiency
in supragingival and subgingival air polishing.
 CHAPTER 26

Implant Case Definitions

and Assessment
LEARNING OBJECTIVES • Overdenture: implant-supported removable
partial or complete denture with built-in copings
that attach to an implant structure.
•
After studying this chapter, you will be able to:
Peri-implant health: a dental implant with
1. Identify a dental implant by its case definition absence of active disease.
as peri-implant health, peri-implant mucositis,
peri-implantitis, or peri-implant hard and soft
• Peri-implantitis: a dental implant with active
disease and loss of attachment.
tissue deficiency.
2. Identify the structures associated with a dental
• Peri-implant mucositis: a dental implant with
active disease of the peri-implant mucosa,
implant and implant suprastructure. with resultant inflammation in the absence of
3. Recognize the anatomy and physiology of continuing loss of attachment.
peri-implant mucosa and bone.
4. Perform implant clinical assessments that
• Prosthesis: dental material (fixed or removable)
visible in the mouth that interconnects to any
include visual and palpatory tissue inspection, dental implant device.
periodontal charting, radiographs, occlusion
status, and prosthesis inspection.
• Supracrestal connective tissue attachment: term
used to describe the junctional epithelium and
supracrestal connective tissue surrounding a
dental implant or natural tooth.
KEY TERMS
• Abutment: metal (titanium, gold) or non-metal
(high-strength ceramics such as alumina or
zirconia) biomaterial placed directly into the
dental implant that provides support for a fixed,
Introduction
fixed-detachable, or removable dental prosthesis.
• Bone remodeling: period of time after implant
placement into maxillary or mandibular bone
In 2015–2017, the American Academy of Periodon-
tology, European Federation of Periodontology, and
required for full osseointegration where immature more than 100 experts from Asia and Australia came
bone is replaced by mature bone. together to build a new classification system for gin-
• Dental implant: surgically placed biomaterial
made of stainless steel, cobalt-based alloy,
gival health and diseases to replace the 1999 system.
In 2017, the World Workshop took place in Chicago,
titanium, or titanium-based alloy placed directly Illinois, and four case types were defined and re-
into the maxillary or mandibular bone.
• Implant baseline: radiographic bone level and
6-point probe depth around a dental implant
leased as the “2018 Classification of Periodontal and
Peri-Implant Diseases and Conditions.”
12 months post-implant placement. The implant category is the first of its kind to clas-
• Osseointegration: mechanical and physiological
integration, anchorage, and fusion of a dental
sify and case define peri-implant health, peri-implant
disease, and peri-implant deficiency. Implant dentistry
implant with the maxillary or mandibular bone. has become a major component of patient treatment
525
526 Chapter 26 Implant Case Definitions and Assessment

planning and care since the last World Workshop was

held in 1999. The number of dental implants placed
today far exceeds the numbers placed prior to 1999,
so a new classification system specific to dental im-
plants was developed.
The four categories in the implant classification
system are peri-implant health, peri-implant mu-
cositis, peri-implantitis, and peri-implant hard and
soft tissue deficiency. This chapter will review the
implant classification category and the clinical as- A
sessments needed to identify the status of a dental
implant. This information will guide you in your de-
bridement technique, maintenance protocols, and
recommendations.

Dental Implant Anatomy

and Physiology
A dental implant can be used to replace a single tooth
with an implant-supported single crown or replace
multiple missing teeth with an implant-supported fixed B
partial or complete arch prosthesis, implant-supported
fixed-detachable partial or complete arch prosthesis,
or implant-supported removable partial or complete
arch prosthesis, also referred to as an overdenture
(see Figure 26-1a to c).
A dental implant is comprised of three parts: an
implant, abutment, and prosthesis; see Figure 26-2).

• Dental implant: Surgically placed biomaterial

made of stainless steel, cobalt-based alloy, tita-
nium, or titanium-based alloy placed directly
into the maxillary or mandibular bone (Anjum
& Rajasekar, 2021; De Avila et al., 2014; see
Figure 26-2). A dental implant becomes function-
ally ankylosed into the bone through a remod-
eling process mediated by osteoblasts. A healing
cap is placed onto the dental implant while bone
remodeling (defined later in this chapter) and tis-
sue healing are occurring (see Figure 26-3).
• Abutment: Biomaterial placed directly into the
dental implant that provides support for a fixed,
fixed-detachable, or removable dental prosthe-
sis (see Figure 26-2). The abutment is a made of
metal (titanium, gold) or nonmetal (high strength
ceramics alumina, or zirconia) dental materials
(De Avila et al., 2014; Pandoleon et al., 2019;
Sailer et al., 2009; Sanz-Sanchez et al., 2018).
• Prosthesis: Dental material (fixed or remov-
able) visible in the mouth that interconnects to
any dental implant device (see Figure 26-2 and
Figure 26-4).
C
Figure 26-1 Dental Implants: A. Maxillary and
mandibular implant-supported fixed dental
prosthesis, B. Maxillary and mandibular implant-
supported complete arch removable dental prosthesis
(overdenture), C. Mandibular right first molar single-
tooth implant.
Although dental implants replace natural teeth,
they do not possess the same anatomy and physiology
as natural teeth. It is important for the oral health-care
provider to recognize the anatomical difference be-
tween a dental implant and a natural tooth because
the differences influence debridement technique,
long-term maintenance, recall interval recommenda-
tions, and self-care.
Implant teeth do not have:
• Bundle bone (alveolar bone process).
• Cementum or inserting Sharpey’s fibers.
 Dental Implant Anatomy and Physiology 527

Prosthesis

Abutment

Implant

Figure 26-2 Dental implant structures (implant, abutment, and prosthesis).

Reproduced with permission from Dentsply Sirona

Figure 26-3 Implant healing caps/collars on the A

maxillary arch.

• Five principle fiber groups (alveolar crest, hori-

zontal, oblique, apical, interradicular) of the peri-
odontal ligament.
• Gingival fiber groups: alveologingival, dentogin-
gival, periosteogingival, intergingival, interpapil-
lary, transgingival, and transseptal.
Implant teeth do have connective tissue fiber
bundles oriented parallel and circumferential to the
implant and abutment (see Figure 26-5).
These anatomical differences make the pathogenesis
(manner of disease development) different for a dental
implant than for a natural tooth. Attachment and bone B
loss occur more rapidly around an implant than a nat- Figure 26-4 Prosthesis: A. Implant retention for
ural tooth, and the loss tends to occur circumferentially overdenture, B. Coping bar.
528 Chapter 26 Implant Case Definitions and Assessment
Figure 26-5 Illustration of the connective tissue fiber
bundles oriented parallel and circumferential to the
implant and abutment on a maxillary left lateral incisor
single-tooth replacement dental implant.
(Berglundh et al., 2018). These findings should be taken
into consideration by the provider when peri-implant
disease is identified. A wait-and-see approach to treat-
ment planning is not in the patient’s best interest and
leads to further destruction, increasing the risk for im-
plant failure.
BREAKOUT POINT
A dental implant has connective tissue fiber bundles
oriented parallel and circumferential to the implant
and abutment.
Keratinized Outer
Masticatory Mucosa
The structural composition of the keratinized outer
masticatory mucosa is 85% collagen fibers and ma-
trix elements, 3% fibroblasts, and 5% vascular units
(Araujo & Lindhe, 2018).
Orthokeratinized squamous epithelium extends
from the margin of the peri-implant mucosa to the
movable lining of the oral mucosa (Heitz-Mayfield &
Salvi, 2018; see Figure 26-6).
Figure 26-6 Keratinized outer masticatory mucosa
example on a maxillary right central incisor dental implant.
Controversy exists in the literature for the rec-
ommended width of keratinized mucosa necessary to
decrease the risk of implant failure and disease. Sys-
tematic reviews have shown that when the width of
keratinized mucosa is less than 2 mm, poorer plaque
biofilm control and increased biofilm accumulation oc-
curs due to discomfort with brushing with more fragile
thinner tissue (Cortellini & Bissada, 2018; Schwartz
et al., 2018). This will increase the risk for peri-im-
plant disease.
Non-keratinized Inner
Masticatory Mucosa
• Basal lamina and hemidesmosomes face the den-
tal implant surface and are inside the outer kerati-
nized mucosa. This area is invaded by pathogens
and inflammatory mediators first in peri-implant
disease (Heitz-Mayfield & Salvi, 2018).
• Connective tissue 40 µm in width contacts the
implant surface (Araujo & Lindhe, 2018).
• The barrier sulcular epithelium is similar to the
junctional epithelium around natural teeth and is
predominately made of collagen fibers 160 µm in
width (Araujo & Lindhe, 2018).
Mucosa Remodeling Factors
There are many factors that influence the remodeling
of keratinized and non-keratinized mucosa around a
dental implant after placement such as:
• Abutment and prosthesis design: There are many
designs for an abutment and prosthesis that vary
among manufacturers. The vast market selection
adds a challenge to providers who are charged
with implant maintenance because abutments
and prostheses vary in their width, shape, and
height (see Figure 26-7a to d for case examples).
 Dental Implant Anatomy and Physiology 529

B C

D
Figure 26-7 Abutment and prosthesis: A. Narrow, tapered abutment and wide prosthesis on the maxillary left
first molar and mandibular first molar, B. Abutment is narrower than the implant and prosthesis on the maxillary
right first molar, C. Abutment similar width as prosthesis on the mandibular left second premolar, D. Note
abutment design differences from others on this maxillary left first premolar.
530 Chapter 26 Implant Case Definitions and Assessment

The provider must customize and change their
debridement techniques to accommodate design
variations.
Abutment and prosthesis design have an in-
fluence on the epithelial and connective tissue
attachment. For example, if restorative margins
infringe on the supracrestal connective tissue
attachment, inflammation and/or loss of attach-
ment can occur (Jepsen et al., 2018). Supracrestal
connective tissue attachment replaced the term bio-
logical width and is the term now used to describe
the junctional epithelium and supracrestal con-
nective tissue surrounding a dental implant or
natural tooth (Jepsen et al., 2018; see Figure 26-8).
• Adjacent teeth position of the gingiva: If recession
is present around adjacent teeth, the dental implant
interdental papillae height will be adversely af-
fected (Heitz-Mayfield & Salvi, 2018; Hammerle &
Tarnow, 2018; see Figure 26-9 for a case example).
• Malpositioning of the surgically placed implant: If
the implant is too close or far away from the adja-
cent tooth, peri-implant mucosa can be adversely
affected. The minimum distance for biologically
acceptable health between two implants is 3 mm
(Berglundh et al., 2018; Hammerle & Tarnow,
2018). The minimum distance for biologically ac-
ceptable health between an implant and a natural
tooth is 1.5 mm (Berglundh et al., 2018; Hammerle
& Tarnow, 2018). See Figure 26-10 and ask your-
self if the distance between the dental implants
and the distance between the dental implant and
natural tooth follows these recommendations.
• Lack of keratinized tissue or lack of buccal bone
when the implant is placed. A patient with a thin-
ner buccal bone plate, thin scalloped biotype, or
less keratinized tissue width has an increased risk
for bone and tissue remodeling issues (Cortellini
& Bissada, 2018; Hammerle & Tarnow, 2018; see
Figure 26-11a to c).

Figure 26-8 Restorative margin infringing on the
supracrestal connective tissue attachment of the
maxillary central incisors. Note the rolled and inflamed
gingiva due to the placement of the porcelain crowns.
Bone
Dental implants are functionally ankylosed into the
bone through osseointegration (see Figure 26-12).
Osseointegration is the mechanical and physiological
integration, anchorage, and fusion of a dental implant
with the maxillary or mandibular bone.

Figure 26-9 Gingiva positioning: This maxillary right second premolar is an implant-supported prosthesis. The first
molar is a natural tooth with a porcelain-fused-to-metal crown with gingival recession. The arrow is demonstrating an
open embrasure space with missing interdental papilla on the distal of the implant-supported prosthesis due to the
existing recession and lack of papilla of the adjacent natural molar.
 Dental Implant Anatomy and Physiology 531

Figure 26-10 Implant positioning around an

implant-supported, fixed prosthesis on the maxillary
left posterior.

After a dental is placed into bone, a bone

remodeling process begins. Bone remodeling is the
period of time after implant placement into maxillary
or mandibular bone required for full osseointegration B
where immature bone is replaced by mature bone
(Da Silva Mello et al., 2016).
• First 1–3 months post-implant placement, woven
bone will form on the surface of the implant and then
be replaced by lamellar and marrow bone (Araujo &
Lindhe, 2018; Da Silva Mello et al., 2016). This neo-
formed (immature) bone exhibits characteristics of
spongy bone (Da Silva Mello et al., 2016).
• After 3 months, the spongy bone will be replaced
by compact bone (Da Silva Mello et al., 2016).
This phase of bone remodeling varies by patient
based on many variables such as the existing bone
and tissue status of the surgical site, type of im-
plant placed, and patient medical health status.
During the bone remodeling process, the crestal
bone height will naturally be reduced. Any crestal bone
height loss greater than 2 mm after the first year of
implant placement is associated with peri-implantitis C
(Renvert et al., 2018). The amount of reduction varies Figure 26-11 Buccal bone and thin scalloped biotype:
for each patient based on a variety of factors such as: A. Thin buccal bone plate due to long-term edentulism
and bone resorption, B. Thin scalloped biotype as
• Manufacturer design variances in implant surfaces, evident by blanching of tissue with gentle probing (under
characteristics, size, shape, and abutment-implant 0.25 N), C. Thin scalloped biotype as evident by probe
interface (Berglundh et al., 2018; Schwartz et al., transparency through the tissue upon gentle probing
2018; see Figure 26-13a to c). (under 0.25 B).
532 Chapter 26 Implant Case Definitions and Assessment

• Provider technique with prosthetic connections

(Berglundh et al., 2018; Schwartz et al., 2018).
• Lack of keratinized gingiva (Schwartz et al., 2018).
• Patient local and systemic factors (Berglundh
et al., 2018).
• Surgical loading (Berglundh et al., 2018).
• Surgical implant positioning: The minimum amount
of buccal bone needed to maintain the proper
long-term support of a dental implant is 2 mm
(Berglundh et al., 2018; Hammerle & Tarnow, 2018;
see Figure 26-14).

BREAKOUT POINT
Implant crestal bone height loss less than 2 mm is
Figure 26-12 Osseointegration, fully osseointegrated considered biologically acceptable.
dental implant on the mandibular right first molar.

A B

C
Figure 26-13 Manufacturer design variations: A. Less tapered abutment with a smooth crown
connection on the maxillary left first molar, B. Abutment is tapered and more narrow than prosthesis
on the right lateral incisor, C. Wider prosthesis than the abutment on the mandibular left first molar.

A
B edema, or suppuration.
Figure 26-14 Buccal bone and dental implants: A. More
than 2 mm of buccal bone width on this maxillary left
central incisor, B. Less than 2 mm of buccal bone
width on the maxillary dental implants supporting this
fixed-detachable hybrid complete arch prosthesis.
Peri-Implant Diseases and Conditions 533
Implant Baseline
A new term, implant baseline, was defined in the
“2018 Classification of Periodontal and Peri-Implant
Diseases and Conditions.” Implant baseline is deter-
mined 12 months post-implant placement when bone
remodeling is complete (Berglundh et al., 2018). The
provider will take a radiograph to assess osseointe-
gration and crestal bone height and acquire a six-
point probing around the implant (Berglundh et al.,
2018). These findings are the implant baseline. All
future periodontal charting and radiographs should
remain consistent with baseline readings. Loss of bone
or increased probe depths from baseline are not nor-
mal, and peri-implant disease should be suspected
(Berglundh et al., 2018).
BREAKOUT POINT
Implant baseline is acquired 12 months after
placement and consists of a 6-point probing and
radiographic bone position.
In the absence of implant baseline, the provider
should suspect peri-implantitis when (Berglundh
et al., 2018; Renvert et al., 2018):
• Probe depths are ≥6 mm with bleeding and/or
suppuration of gingival tissues.
• Bone level is ≥3 mm apical to the most coronal
portion of the implant.
Peri-Implant Diseases
and Conditions
This section will discuss the “Peri-Implant Diseases
and Conditions” of the “2018 Classification of Peri-
odontal and Peri-Implant Diseases and Conditions.”
Peri-Implant Health
Peri-implant health (Berglundh et al., 2018) is a
term used to describe a dental implant with the ab-
sence of active disease. See Table 26-1 for a summary.
• Peri-implant soft tissues do not have erythema,
• There is no attachment loss.
• Radiographic bone height and quality have not
changed from baseline. In the absence of base-
line, the crestal bone height has not been reduced
over 2 nn.
534 Chapter 26 Implant Case Definitions and Assessment
• Probe depths have not increased from baseline. In
the absence of baseline, the probe depths are un-
der 6 mm with absence of bleeding upon probing.
• The dental implant has no mobility.
• The patient has no discomfort.
BREAKOUT POINT
Implant probe depths 5 mm and below without
bleeding or suppuration are considered biologically
healthy.
Health can be reestablished around a dental im-
plant with decreased bone and soft tissue support
just as with natural teeth. An implant can return to
a state of health on a reduced support periodontium
once attachment loss has been arrested and stabilized
with surgical or nonsurgical interventions (Berglundh
et al., 2018; Renvert et al, 2018).
Peri-Implant Mucositis
Peri-implant mucositis (Berglundh et al., 2018) is
a term used to describe a dental implant with active
disease of the peri-implant mucosa, with resultant in-
flammation in the absence of continuing loss of at-
tachment. See Table 26-1 for a summary.
• Peri-implant soft tissues have erythema, edema,
and/or suppuration.
• There is no radiographic bone loss from baseline.
In the absence of baseline, the crestal bone height
has not been reduced over 2 mm.
• Probe depths may have increased from baseline
due to gingival swelling and decreased probe re-
sistance. Bleeding upon probing is present.
• The patient may or may not have soreness.
BREAKOUT POINT
Peri-implant mucositis is reversible with treatment.
Peri-implant mucositis can reoccur around a den-
tal implant with previous peri-implant health on a
reduced but stable periodontium. Mucositis is revers-
ible with nonsurgical therapy. After therapy, resolu-
tion and return to peri-implant health can take up to
3 weeks (Berglundh et al., 2018). Since peri-implant
mucositis precedes peri-implantitis, it must be treated
immediately with proper interventions to resolve the
disease process (Berglundh et al., 2018).
Peri-Implantitis
Peri-implantitis is a state of active disease and loss
of attachment around a dental implant. The progres-
sion of bone loss in the absence of tissue inflamma-
tion and previous peri-implant mucositis is very rare
(Berglundh et al., 2018). See Table 26-1 for a summary.
• Peri-implant soft tissues have erythema, edema,
and/or suppuration.
• There is increased radiographic bone loss from
baseline with more than 2mm crestal bone height
loss. In the absence of baseline, crestal bone
height loss greater than 2mm would indicate
peri-implantitis.
• Probe depths may have increased from base-
line with bleeding upon probing.When baseline
probe depths are unknown, any probe depth
6 mm and greater with bleeding would indicate
peri-implantitis (Berglundh et al., 2018).
• Mobility may be present.
• Patient soreness and discomfort is present.
• The dental implant itself may be exposed to the
oral cavity.
BREAKOUT POINT
Peri-implantitis is a state of active disease and loss
of attachment around a dental implant that is in
need of immediate treatment.
Peri-implantitis should be staged and graded with
immediate referral to a specialist for evaluation. When
peri-implantitis is successfully treated and arrested,
the dental implant can return to a state of peri-implant
health on a reduced periodontium.
Peri-Implant Soft and Hard
Tissue Deficiencies
Hard and soft tissue deficiencies can be present prior
to, during, or after implant placement. They can
complicate and compromise implant survival (Ham-
merle & Tarnow, 2018). The most common etiology
of peri-implant hard and soft tissue deficiencies is re-
lated to (Hammerle & Tarnow, 2018):
• Systemic diseases and conditions of the patient.
• Systemic medications.
 Peri-Implant Diseases and Conditions 535

Table 26-1 Peri-Implant Health, Peri-Implant Mucositis, Peri-Implantitis Comparison

Peri-Implant Health Peri-Implant Mucositis Peri-Implantitis
Tissues No erythema, edema, Erythema, edema, and/or Erythema, edema, and/or
suppuration suppuration suppuration
Radiographic No RBL from baseline and No RBL from baseline and Increased RBL from baseline OR
Bone Loss #2 mm crestal bone loss* #2 mm crestal bone loss $3 mm crestal bone loss in the
(RBL) (Renvert et al., 2018) (Renvert et al., 2018) absence of baseline
Attachment None* None Present
Loss
Probe Depth No increases from baseline Increases from baseline due to Increase PD from baseline
(PD) and #5 mm (Renvert et al., gingival swelling or decreased OR $6 mm in the absence of
2018) probe resistance baseline
BOP None Present Present
Mobility None None Present
Patient None Possible Present
Soreness

*Does not represent a dental implant with peri-implant health on a reduced periodontium.
Berglundh et al. (2018)

• Processes of tissue healing.

• Tissue turnover and response to clinical interven-
tions.
• Trauma to orofacial structures.
• Local diseases affecting teeth, periodontium, bone,
and mucosa.
• Biomechanical factors.
• Tissue morphology and phenotype (thin scalloped
biotypes).
• Iatrogenic factors.
There are many factors that contribute to hard
and soft tissue deficiencies around a dental implant.
Providers should be aware of these risk factors and ad-
just clinical treatment and management as indicated.
Figure 26-15 Bone resorption on the mandibular right
edentulous ridge.
Hard Tissue Deficiencies Prior to
Implant Placement
• Edentulous ridges with natural resorption that re- • Bone loss due to periodontitis, endodontic infec-
quire bone augmentation for implant placement tions, longitudinal root fractures, or general trauma
(Hammerle & Tarnow, 2018; see Figure 26-15). (Hammerle & Tarnow, 2018; see Figure 26-16).
• Traumatic tooth extraction with damage to sur- • Bone height in the posterior maxilla can com-
rounding bone that adversely affects healing. plicate dental implant placement because of the
Crestal bone height loss around adjacent teeth presence of the maxillary sinus. The posterior
and loss of buccal bone can challenge the place- teeth are usually buccal to the sinus separated
ment of a dental implant (Hammerle & Tarnow, by a thin plate of bone, but due to radiographic
2018). angulation and superimposition, the maxillary
536 Chapter 26 Implant Case Definitions and Assessment

Figure 26-16 Root fracture of the maxillary right central

incisor.

second premolar and molars may appear to proj-

ect into the sinus (see Figure 26-17a). Sinus pneu-
matization after tooth extraction changes the
height of the maxillary bone in the posterior re-
gion. The bone can become insufficient for the
placement of a dental implant (see Figure 26-18).
The bone may also become insufficient for a stan-
dard-length dental implant, increasing the risk of
boney defects (see Figure 26-17b and Figure 26-19;
Hammerle & Tarnow, 2018).
B
Figure 26-17 Maxillary posterior teeth: A. Maxillary right
premolar periapical where the maxillary sinus appears
superimposed over the apices of the premolar and
molar teeth, B. Dental implants with varying heights
and widths.
B: Reproduced with permission from Dentsply Sirona

Hard Tissue Deficiencies after

Implant Placement
• Defects in healthy situations can occur after tooth
removal and implant placement such as dehis-
cence, fenestration, and infraboney defects (Ham-
merle & Tarnow, 2018).
• Malpositioning of implants: If an implant is placed
too far buccally with less than 2 mm of buccal
bone width, the risk for mucosal recession and Figure 26-18 Maxillary right first molar edentulous
narrow keratinized tissue increases (Hammerle & spaces where the maxillary bone is insufficient for
Tarnow, 2018). implant placement.
 Clinical Assessments 537

Soft Tissue Deficiencies Prior

to Implant Placement
• Tooth loss will cause a reduction of the alveo-
lar ridge and soft tissues (Hammerle & Tarnow,
2018; see Figure 26-20).
• Periodontal or systemic diseases that reduce bone
height. When bone augmentation is required, the
available soft tissue may be insufficient to cover
the new bone volume (Hammerle & Tarnow,
2018).

A Soft Tissue Deficiencies after

Implant Placement
• Lack of buccal bone can be the result of trau-
matic extraction or natural bone resorption af-
ter tooth loss. Lack of buccal bone can lead to
mucosal recession around the dental implant
over time (Hammerle & Tarnow, 2018; see
Figure 26-20).
• Interdental papilla height can be compromised
based on implant position and whether the im-
plant is placed next to another implant or a
natural tooth (Hammerle & Tarnow, 2018; see
Figure 26-21 and Figure 26-22).
• Keratinized tissue width over 2 mm is more ideal
than under 2 mm for the long-term health of a
dental implant (Hammerle & Tarnow, 2018).
B
• Migration of teeth and lifelong skeletal changes:
Figure 26-19 Maxillary dental implants: A. Radiographic Maxillary and mandibular anatomy changes and
measurements of the maxillary right first molar for teeth placement shifts throughout a lifetime. This
bone width, sinus position, and prosthesis clearance, can cause “discrepancies of facial tissue heights
B. Shorter height dental implants of the maxillary right
between an implant crown and the natural tooth”
second premolar and first molar.
(Hammerle & Tarnow, 2018).

• Previous peri-implantitis with loss of peri-implant

hard and soft tissues at implant sites ­(Hammerle &
Tarnow, 2018).
BREAKOUT POINT
• Limited evidence supports mechanical overload
as a potential for interference with osseointegra- An implant can remain healthy and stable with
tion (Hammerle & Tarnow, 2018). a soft and hard tissue deficiency; however, these
• Systemic diseases and medications such as pro- deficiencies increase the risk for long-term
longed bisphosphonates, radiotherapy, and os- complications.
teogenesis imperfecta can lead to bone damage
(Hammerle & Tarnow, 2018).
• Tissue phenotype: Thinner scalloped biotype can
lead to greater marginal bone loss than when an
implant is placed into thick biotype tissues (Cor-
Clinical Assessments
tellini & Bissada, 2018; Hammerle & Tarnow, Now that you are familiar with peri-implant case defi-
2018). Table 26-2 provides a tissue phenotype nitions, let’s tie those concepts with clinical practice.
example. There are a series of clinical assessments providers
538 Chapter 26 Implant Case Definitions and Assessment

Table 26-2 Tissue Phenotype

Tissue phenotype is a thin scalloped biotype as evident
by the probe being visible through the tissue upon
gentle probing with less than 0.25 N of pressure. Thin
phenotypes are at higher risk for mucogingival de-
fects (Cortellini & Bissada, 2018).
Thin phenotypes typically have slender triangular
shaped teeth, interproximal contacts closer to incisal
edge (red dot), thin buccal bone, and a narrow zone of
keratinized tissue width (Cortellini & Bissada, 2018).

Tissue phenotype is a thick biotype. The probe will not

be visible through the tissue when probing. Thick
phenotypes are at lower risk for mucogingival defects
(Cortellini & Bissada, 2018).
Thick phenotypes typically have square-shaped teeth,
interproximal contacts more apical (red dot), thicker
buccal bone, and a broad zone of keratinized tissue
width (Cortellini & Bissada, 2018).

should perform each time the patient presents for
their regular recall appointment when they have an
implant restoration. The clinical assessments re-
quired for proper implant evaluation include visual
and palpatory tissue inspection, periodontal charting,
radiographs, occlusion status, and prosthesis health
inspection.
BREAKOUT POINT
Clinical assessments of a dental implant should be
performed at each recall appointment and should
include visual and palpatory tissue inspection,
periodontal charting, radiographs, occlusion status,
and prosthesis health inspection.

Figure 26-20 Alveolar bone resorption of edentulous
maxillary right first molar.
Figure 26-21 Lack of buccal bone and keratinized tissue
after a traumatic extraction that led to buccal recession
and reduced height of the mesial interdental papilla of
this mandibular right first molar.
Figure 26-22 Embrasure space between the maxillary
left central incisor dental implant and the maxillary left
lateral incisor natural tooth.
Clinical Assessments 539
Visual and Palpatory
Tissue Assessment
1. Visually inspect implant tissues for signs of
disease.
2. Visually inspect the level of oral deposit accu-
mulation and perform a plaque index because
oral deposits contribute to disease pathogenesis
­(Berglundh et al., 2018; Schwartz et al., 2018).
The patients in Figure 26-23 are in need of at-
home oral hygiene instructions and motivation.
3. Palpate the outer keratinized masticatory mucosa
to determine if the tissue has adequate width. If
the tissue is tender upon palpation, or the threads
of the implant can be felt, this could be a sign of
active disease or the potential for an increased risk
of disease. The dental implant itself should not
be visible. If the threads are visible, this is either
a sign of active disease or previously arrested dis-
ease. A referral to a specialist for evaluation may
be indicated.
4. Palpate and visually inspect the prosthesis to en-
sure that it is not loose or fractured.
BREAKOUT POINT
Visually inspect and palpate a dental implant and
prosthesis at each recall appointment.
Periodontal Charting
Assessment
A dental implant periodontal charting assessment
consists of recording a 6-point probe with bleeding
points, gingival margin position, clinical attachment,
and mobility.
Probe Depths
Perform a 6-point probe with bleeding points at mini-
mum annually, but best practice would be to probe at
each recall appointment (Renvert et al., 2018; Lang &
Bartold, 2017). If the dental implant was recently
placed, you may want to consult with the specialist
prior to probing for the first time. There is a length of
time during bone and soft tissue remodeling when the
implant should not be probed to avoid injury.
The maximum pressure for probing natural teeth
is 0.25 N or 25 g (Lang & Bartold, 2017). Peri-im-
plant non-keratinized mucosa is less vascularized
in the zone between the bone crest and the barrier
sulcular epithelium compared to natural teeth, and
because of this, the provider should use as minimal
540 Chapter 26 Implant Case Definitions and Assessment

A B

C
Figure 26-23 Oral deposit accumulation: A. Dental biofilm and calculus present under mandibular implant-supported
fixed dental prosthesis, B. Plaque biofilm and material present around a coping bar, C. Dental calculus present under
mandibular implant-supported fixed prosthesis and the mandibular implant-supported fixed-detachable hybrid
prosthesis.

amount of pressure as possible to obtain the correct Gingival Margin

depth, but never to exceed 25 g (Berglundh et al.,
2018). If too much pressure is applied when prob-
ing a dental implant, false pocket depths and bleed-
ing can occur, which overestimate the disease state
(Lang & B ­ artold, 2017). Probe depths 5 mm and un-
der that do not bleed are considered biologically ac-
ceptable and healthy (Berglundh et al., 2018; Renvert
et al., 2018).
BREAKOUT POINT
A dental implant should be probed at each recall
appointment with a maximum probing pressure of
0.25 N or 25 g.
The gingival margin position should be evaluated
during periodontal charting. Providers should deter-
mine if the gingival margin is coronal or apical to its
correct position around the abutment and prosthesis.
• Coronal to its correct position: This could be due
to tissue inflammation or a restorative margin that
infringes on the supracrestal connective tissue
attachment.
• Apical to its correct position: Peri-mucosa re-
cession can be caused by nonpathologic and
pathologic conditions. If the dental implant has
peri-mucosa recession, the provider should in-
vestigate the cause to determine if any action is
needed.
 Clinical Assessments 541

Peri-Mucosa Recession. Peri-mucosa recession

can be part of the nonpathologic healing process or
caused by a pathologic condition (see Figure 26-21).
Providers need to identify the etiology of the
peri-mucosa recession to determine if this is a natural
healing process or a sign of active disease. The simple
existence of peri-mucosa recession does not indicate
disease.

BREAKOUT POINT
Figure 26-24 Dental implant mobility test under an
The presence of peri-mucosa recession does not implant-supported fixed-detachable hybrid maxillary
always indicate disease presence. prosthesis.

The interproximal papillae height around a dental

implant is many times shorter than a natural tooth
and does not always indicate disease (Berglundh et al.,
2018).
• When a dental implant is placed next to a natural
tooth, the papillae height is largely determined by
the periodontal tissues surrounding the natural
tooth (Hammerle & Tarnow, 2018).
• When a dental implant is placed next to another im-
plant, the papillae height is largely determined by the
bone crest between the two implants (Hammerle &
Tarnow, 2018).
Peri-mucosa recession is attributed to many fac-
tors such as (Berglundh et al., 2018):
• Surgical malposition of the implant.
• Implant placed into the bone with a hard tissue
deficiency.
• Implant placed into the tissue with an existing
soft tissue deficiency. Figure 26-25 Mobility test for implant-supported
• Thin tissue phenotype with a thinner width of ke- prosthesis on the mandibular right second premolar.
ratinized tissue.
• Lack of buccal bone (≤2 mm).
• Status of attachment of adjacent teeth. If recession Testing for dental abutment mobility:
is present in adjacent teeth, peri-mucosa recession 1. Place an implant-appropriate instrument under
is more likely. the prosthesis.
• Surgical trauma. 2. Gently push back and forth to determine if the
abutment screw is loose.
Mobility Testing for implant-supported prosthesis mobility:
Mobility should be tested and recorded in the peri- 1. Place an implant-appropriate blunt instrument on
odontal chart. either side of the prosthesis (see Figure 26-25).
Testing for dental implant mobility: 2. Gently press side to side.
1. Place an implant-appropriate instrument under the A dental implant, abutment, and prosthesis should
prosthesis in the embrasure space (see Figure 26-24). never be mobile. If mobility is present, immediately
2. Apply gentle pressure to determine the presence refer for evaluation. If the dental implant is mobile,
of mobility of the implant. you should suspect peri-implantitis.
542 Chapter 26 Implant Case Definitions and Assessment
BREAKOUT POINT
Check for mobility of the implant, abutment, and
prosthesis at each recall appointment.
Radiographic Assessment
Radiographs are an important assessment of the sta-
bility and health of a dental implant. Radiographic
assessment is recommended within the first year of
prosthesis delivery, and subsequent radiographic fre-
quency should be based on individual patient risk fac-
tors (Hernandez & Katsaros, 2018).
• In the first year, radiographic frequency is based
on the clinical patient presentation and should
occur more frequently than it does natural teeth
(Berglundh et al., 2018).
• After the first year, minimum annual radiographic
assessment is recommended (Berglundh et al.,
2018).
• If a patient has two or more dental implants, a
panoramic radiograph is recommended more fre-
quently (Berglundh et al., 2018; see Figure 26-26a).
• If the patient has five or more dental implants, a
panoramic radiograph or a Cone-beam computer
tomography (CBCT) is recommended more fre-
quently (Berglundh et al., 2018; see Figure 26-26b).
A
B
Figure 26-26 Multiple dental implants: A. Three dental
implants seen on a panoramic radiograph, B. More than
five dental implants seen on a panoramic radiograph.
BREAKOUT POINT
A dental implant requires minimum annual
radiographs, and when two or more implants are
present, panoramic and/or CBCT imaging is needed
more frequently than it is for natural teeth.
Occlusion Assessment
Occlusion is dynamic and constantly changes over
time. A balanced occlusal scheme is important for a
patient with any type of dental implant. An occlusal
evaluation with articulating paper should be per-
formed at each recall appointment to evaluate for
occlusal trauma (see Figure 26-27). Occlusal forces
should be evenly distributed over teeth in both arches
to prevent implant injury or prosthesis damage from
occlusal trauma (Fischer & Stenberg, 2013).
Occlusal overload is noted as a possible contrib-
utor to implant failure, but evidence is inconclusive
at this time (Berglundh et al., 2018; Schwartz et al.,
2018). If a removable occlusal device (guard) is indi-
cated to protect the implant-borne fixed restoration,
the provider should follow these recommendations
(Bidra, Daubert, Garcia, Kosinski, et al., 2016; Bidra,
Daubert, Garcia, Gauthier, et al., 2016):
• Evaluate the device at each recall appointment for
fit and function.
• Professionally clean the device at each recall
appointment.
• Provide patient education on use and proper storage.
• Educate the patient on self-care and cleansing with
manufacturer-approved solutions and chemicals.
Prosthesis Health
Providers should evaluate the health of the prosthesis
and/or removable appliances at each recall appoint-
ment. Check the prosthesis for:
• Fractures, chips, or cracks (see Figure 26-28)
• Loss of retention or loosening.
Figure 26-27 Occlusal evaluation with articulating
paper markings.

Figure 26-28 Fractured porcelain-fused-to-metal crown
on the mandibular right first molar lingual surface.
• Bio-corrosion.
• Surface topography changes.
• Loose screws or attachments.
• Screw fracture.
If an implant supported fixed-detachable partial
or complete arch prosthesis is removed for repair or
replacement, new prosthetic screws should be placed
(Bidra, Daubert, Garcia, Gauthier, et al., 2016). A
removable prosthesis may need adjustments, repair,
replacement, or a remake if any of the prosthetic
components becomes compromised (Bidra, Daubert,
Garcia, Gauthier, et al., 2016). Patients should receive
oral hygiene education on the proper care and mainte-
nance of a removable appliance as well as professional
cleaning at each recall appointment (Bidra, Daubert,
Garcia, Kosinski, et al., 2016; see Figure 26-29a
and b).
Recall Recommendations
The American College of Prosthodontists has es-
tablished clinical practice guidelines for recall and
maintenance of patients with tooth-borne and
implant-borne dental restorations. They state the
guidelines “are intended to provide clinicians with
guidance in diagnosis, treatment planning, and clinical
decision-making” (Bidra, Daubert, Garcia, Gauthier,
Recall Recommendations 543
Figure 26-29 Removable appliances: A. Implant-
supported removable maxillary overdenture.
et al., 2016). Patients with implant-borne restorations
require lifelong well-structured maintenance recall
appointments (Bidra, Daubert, Garcia, Kosinski,
et al., 2016; Bidra, Daubert, Garcia, Gauthier, et al.,
2016; Pjetursson, Thomas, et al., 2012; Pjetursson,
Helbling, et al., 2012).
Since peri-implantitis typically occurs within the
first few years after implant placement, it is prudent
for the provider to place a patient on a more frequent
recall (Berglundh et al., 2018; Renvert et al., 2018).
The American Academy of Periodontology (AAP)
states, “There is no predictable model or algorithm
to predict the progression of peri-implantitis based
on diagnostic methodologies currently available in
daily practice,” so close monitoring and thorough
assessments are imperative for long-term implant
stability and health (Berglundh et al., 2018; Renvert
et al., 2018).
Recall timing should be based on individual pa-
tient risk assessments. The American College of Pro­
sthodontists’ Clinical Practice Guidelines recommend
at minimum a 6-month recall for a patient with an
implant-borne restoration, and for those patients
at “higher risk based on age, ability to perform oral
self-care, biological or mechanical complications of
remaining natural teeth, tooth-borne restorations, or
implant-borne restorations,” a more frequent recall
may be required (Bidra, Daubert, Garcia, Gauthier,
et al., 2016). Patients with a high susceptibility or
BREAKOUT POINT
A patient with a dental implant should be seen at
minimum every 6 months for recall appointments
and more frequently based on individual risk
assessments.
544 Chapter 26 Implant Case Definitions and Assessment
history of active periodontitis, may need a more fre-
quent recall than periodontally stable patients as their
risk for peri-implantitis is higher (Berglundh et al.,
2018; Schwartz et al., 2018; Pjetursson, Thomas,
et al., 2012; Pjetursson, Helbling, et al., 2012).
Patients with lack of regular preventive main-
tenance care and poor plaque biofilm control as in-
dicated by a high plaque index have a significantly
higher risk for developing peri-implant mucositis and
peri-implantitis (Berglundh et al., 2018; Schwartz
et al., 2018; Costa et al., 2012). It is of utmost impor-
tance that patients with implant-borne restorations be
seen regularly for maintenance recall appointments
based on individual risk factors and have oral self-care
that promotes peri-implant health.
Oral Hygiene Instructions
Lifelong oral self-care with professional guidance is
needed to maintain peri-implant health and stability
(Bidra, Daubert, Garcia, Gauthier, et al., 2016).
Oral hygiene aids for a patient with an implant-
borne restoration include, but are not limited to:
• Oral topical agents, such as neutral-sodium flu-
oride with 0.3% triclosan or 5,000 ppm fluoride
toothpaste should be recommended for those pa-
tients with increased caries risk (Bidra, Daubert,
Garcia, Kosinski, et al., 2016; Bidra, Daubert,
Garcia, Gauthier, et al., 2016).
• When antimicrobial action is required to reduce
inflammation, chlorhexidine (gel, mouth rinse,
spray) should be used short-term because it
will not adversely affect osseointegration (Bidra,
Daubert, Garcia, Gauthier, et al., 2016; Figuero
et al., 2014; Lupi et al., 2017; Schou et al.,
2013).
• A patient with an implant-borne restoration can
benefit from an electric toothbrush, dental floss,
and a water or air flosser. Interdental aid recom-
mendations should be customized based on the
interdental papilla height (Bidra, Daubert, G
­ arcia,
Kosinski, et al., 2016; Bidra, Daubert, Garcia,
Gauthier, et al., 2016).
• For a patient with an implant-supported re-
movable partial or complete overdenture, the
patient should be educated to remove the ap-
pliance at night and cleanse the appliance twice
daily with a soft denture brush and denture
cleaning agent.
For the patient with a thin tissue phenotype, lack
of keratinized tissue, or lack of buccal bone, or if the
peri-implant mucosa is tender or sore, the following
may be helpful:
• Extra soft manual brush using a light Stillman or
Bass method.
• Electric toothbrush with a low-frequency option.
• Waterpik or air flosser with a low-speed option.
• Antimicrobial chlorhexidine.
BREAKOUT POINT
Chlorhexidine, neutral-sodium fluoride with 0.3%
triclosan, and 5,000 ppm neutral-sodium fluoride
can be safely recommended for a patient with an
implant-borne restoration (Bidra, Daubert, Garcia,
Kosinski, et al., 2016).
Brushing
• Swierkot et al. (2013) found no significant differ-
ences between electric and manual toothbrushing
on plaque reduction around dental implants and
peri-implant soft tissues.
• Brushing with a manual or electric toothbrush
is safe and effective for natural and implant-
supported prosthesis when dexterity and com-
mitment and motivation to oral hygiene care is
not an issue (Vandekerckhove et al., 2004).
Interdental Aids
Missing or blunted interdental papillae or wide inter-
dental spaces are difficult to clean with toothbrush
bristles alone because patients may not be able to ac-
cess the interproximal spaces thoroughly. The use of
interdental aids is helpful to properly de-plaque the
interproximal space around a dental implant to pre-
vent biofilm accumulation and subsequent gingival
inflammation (Swierkot et al., 2013; Corbella et al.,
2011). Common interdental aids include:
• Water or air flossers.
• Soft-Pick with elastomeric fingers (see
Figure 26-30a).
• Rubber tip stimulator (see Figure 26-30b).
• End tuft toothbrush (see Figure 26-30c).
• Interdental brush without a metal core (see
Figure 26-31a and b). There are many different
lengths, shapes (straight, curved), and thickness
of bristles. Customize your selection based on the
patient presentation.
Dental Floss
Patients with dental implants can use waxed, tufted,
or woven floss depending on the abutment and pros-
thesis. The technique for proper flossing is different
 Oral Hygiene Instructions 545

C
Figure 26-30 Interdental aids: A. GUM Soft-Pick,
B. Rubber tip stimulator, C. Sulcabrush.
B
Figure 26-31 GUM Interdental aid: A. GUM go-between,
B. GUM Instructions, note number three states “not for
use around implants.”
A and B: Used with permission from Sunstar Americas, Inc.
546 Chapter 26 Implant Case Definitions and Assessment

Figure 26-32 Flossing a dental implant.

than it is for natural teeth. The patient performs

vertical C-shaped flossing and then places the floss BREAKOUT POINT
in both interproximal spaces of the dental implant,
A dental implant is not flossed the same as a
crisscross the floss, and shoeshines back and forth natural tooth.
(see Figure 26-32).

CASE STUDY
The patient is a 64-year-old Caucasian female with a history of ulcerative colitis and occasional back pain and is taking
meloxicam 15 mg bid. All vitals are within normal limits and Body Mass Index (BMI) is 20. The patient lives with her hus-
band of 36 years, is a nonsmoker, does not drink alcohol, and has a gluten-free diet due to her ulcerative colitis.
Her chief complaint is “I have temporomandibular disorder (TMD) and I clench frequently.”
Dental exam: Patient wears a nightguard when she sleeps that was fabricated by a dentist. No previous orthodontics.
Recurrent decay present maxillary right second molar and mandibular right second premolar. Mandibular left first
premolar occlusal is fractured.
Occlusion: Class I bilateral with first molar relationship.
Oral hygiene exam: Scattered light biofilm with a plaque biofilm index of 13%.
Periodontal exam: see periodontal chart below.
Tissue description: Generalized loss of stippling, tissues generally coral pink. Only areas of marginal erythema were
found on the probe depths that had bleeding. Edema present maxillary left first molar dental implant and maxillary
right second molar.
 Oral Hygiene Instructions 547

Full mouth series radiograph.

Periodontal chart.
548 Chapter 26 Implant Case Definitions and Assessment

1. What is the patient’s implant classification for the mandibular right first molar based on the information provided?
a. Peri-implant health
b. Peri-implant mucositis
c. Peri-implantitis
d. Peri-implant soft and hard tissue deficiency
2. What is the patient’s implant classification for the maxillary left first molar based on the information provided?
a. Peri-implant health
b. Peri-implant mucositis
c. Peri-implantitis
d. Peri-implant soft and hard tissue deficiency
3. Which of the following could have contributed to the peri-implantitis of the maxillary left first molar implant?
Select all that apply.
a. Poor plaque control
b. Patient’s smoking habit
c. Patient’s meloxicam use
d. Sinus pneumatization
e. Submucosal cement
f. Clenching parafunctional habit
g. Poor surgical implant placement
h. Previous debridement that caused stripping and removal of implant threads
4. After assessment and diagnosis, what should be planned for the mandibular right first molar?
a. Debride and schedule the patient for the next recall.
b. Refer immediately to a specialist for evaluation.
c. Do nothing; an implant does not need to be debrided at each recall appointment if it is healthy.
d. Take a radiograph of the tooth and do not debride.
5. After assessment and diagnosis, what should be planned for the maxillary left first molar?
a. Debride and check again in 3 months.
b. Debride and check again in 6 months.
c. Refer immediately to a specialist for evaluation.
d. Nothing needs to be planned for this tooth.
6. How often should a radiograph be taken of the mandibular right first molar and why?
7. The maxillary left first molar implant is surgically removed, and a new implant placed. The patient is then referred
back to your office for routine recall and maintenance. How often should you radiograph the new implant within
the first year after placement? Explain your answer.

Summary
Dental implants require lifelong maintenance to
prevent peri-implant disease. Providers need a
strong working knowledge of the case definitions
for peri-implant health, peri-implant mucositis,
peri-implantitis, and peri-implant hard and soft tis-
sue deficiency to correctly classify a patient’s im-
plant status and provide appropriate interventions.
A dental implant can reestablish health on a reduced
periodontium upon successful surgical or nonsurgical
interventions. Providers should perform visual and
palpatory inspection, periodontal charting, radio-
graphs, and occlusion status evaluation, and check
prosthesis status at each recall appointment. Patients
should receive professional oral hygiene instruc-
tions that are customized to their needs at each recall
appointment.

Questions
1. Which of the following is present around a 2. Which of the following is TRUE of the
dental implant? non-keratinized inner masticatory mucosa of a
a. Sharpey’s fibers dental implant?
b. Periodontal ligament a. Basal lamina and hemidesmosomes face the
c. Connective tissue fiber bundles oriented dental implant surface and are inside the
parallel and circumferential outer keratinized mucosa.
d. Transgingival fibers
 Questions 549

b. Direct implant surface is contacted by 9. Peri-implantitis C. Bleeding upon probing

connective tissue predominately made of and suppuration around
fibroblasts that is 40 µm in width. a dental implant without
c. The barrier sulcular epithelium is similar loss of bone from baseline.
to the junctional epithelium around natural 10. Peri-implant soft D. Loss of bone and probe
teeth and is predominately made of collagen and hard tissue depths over 6 mm with
fibers 160 µm in width. deficiency bleeding upon probing.
d. All of the above.
11. True or False. Peri-implant health can be
3. At what month will spongy bone be replaced by reestablished around a dental implant with
compact bone during natural bone remodeling attachment loss from past disease processes that
after implant placement? have been arrested.
a. 1 month a. True
b. 2 months b. False
c. 3 months
d. None of the above 12. Which of the following conditions is
reversible?
4. How much crestal bone height reduction has been
a. Peri-implant mucositis
shown to be associated with peri-implantitis?
b. Peri-implantitis
a. 0.5 mm
c. Peri-implant soft tissue deficiency
b. 1.0 mm
d. Peri-implant hard tissue deficiency
c. 1.5 mm
d. >2.0 mm 13. What is the minimal amount of buccal
5. After implant placement, when is implant bone recommended to support a dental
baseline determined? implant and decrease the risk for future
a. 3 months peri-implantitis?
b. 6 months a. 0.5 mm
c. 12 months b. 1.0 mm
d. 24 months c. 2.0 mm
d. 4.0 mm
6. In the absence of implant baseline, the provider
should suspect peri-implantitis when which of 14. What is the minimum distance an implant
the following occur(s)? should be placed adjacent to a natural tooth?
a. Bleeding upon probing and/or suppuration of a. 1.5 mm
gingival tissues with probe depth ≥5 mm b. 2.0 mm
b. Bleeding upon probing and/or suppuration of c. 3.0 mm
gingival tissues with probe depth ≥6 mm d. 4.0 mm
c. Crestal bone height loss of 1 mm 15. Complete the sentence. A dental implant is at
d. Crestal bone height loss of 1.5 mm greater risk for failure and bone remodeling
Match the following terms to their correct description issues when only of keratinized mucosa
for questions 7–10. There is only one correct answer is present.
for each term. a. 1 mm
b. 4 mm
7. Peri-implant A. Dental implant with ab-
c. 5 mm
health sence of bleeding where
d. 6 mm
probe depths and the crest
of alveolar bone have not 16. Which of the following clinical assessments
changed since baseline. should be performed at each recall appointment
8. Peri-implant B. Implant placed into for a patient with a dental implant?
mucositis compromised bone from a. Visual inspection
previous periodontitis, b. Palpatory inspection
endodontic infection, lon- c. Periodontal charting
gitudinal root fracture, or d. Occlusion evaluation
general trauma. e. All of the above
550 Chapter 26 Implant Case Definitions and Assessment
17. What is the maximum pressure that should
be applied when probing a dental implant or
natural tooth?
a. 10 g
b. 15 g
c. 20 g
d. 25 g
18. True or False. Peri-implantitis is present if
gingival recession is found around a dental
implant.
a. True
b. False
19. Which of the following can contribute to
peri-mucosa recession?
a. Surgical malposition of the implant.
b. Recession is present on adjacent teeth.
c. Surgical trauma.
d. All of the above.
20. Which of the following radiographs is
recommended more frequently when a patient
has five or more dental implants?
a. Periapical
b. Bitewing
References
1. Alqahtari, S., Alsheraimi, A., Alshareef, A., Alsaban, R.,
Alqahtani, A., Almgran, M., Eldesouky, M., & Al-Omar, A.
(2020). Maxillary sinus pneumatization following extractions
in Riyadh, Saudi Arabia: A cross-sectional study. Cureus
Journal of Medical Science, 12(1), e6611.
2. Anjum, S., & Rajasekar, A. (2021). Surface modification of
dental implants—A review. Journal of Evolution of Medical and
Dental Sciences, 10(17), 1246–1250.
3. Araujo, M., & Lindhe, J. (2018). Peri-implant health. Journal
of Periodontology, 89(Suppl 1), S249–S256. https://doi.org
/10.1002/JPER.16-0424
4. Berglundh, T., Armitage, G., Araujo, M., Avila-Ortiz, G.,
Blanco, J., Camargo, P., Chen, S., Cochran, D., Derks, J.,
Figuero, E., Hammerle, C., Heitz-Mayfield, L., Huynh-Ba, G.,
Iacono, V., Koo, K., Lambert, F., McCauley, L., Quirynen, M.,
Renvert, S., Salvi, G., Schwarz, F., Tarnow, D., Tomasi, C.,
Wang, H., & Zitzmann, N. (2018). Peri-implant diseases
and conditions: Consensus report of workgroup 4 of the
2017 World Workshop on the classification of periodontal
and peri-implant diseases and conditions. Journal of
Periodontology, 89 (Suppl 1), S313–S318. https://doi.org
/10.1002/JPER.17-0739
5. Bidra, A. S., Daubert, D. M., Garcia, L. T., Gauthier, M. F.,
Kosinski, T. F., Nenn, C. A., Olsen, J. A., Platt, J. A.,
Wingrove, S. S., Chandler, N. D., & Curtis, D. A. (2016). A
systematic review of recall regimen and maintenance regimen
of patients with dental restorations. Part 2: Implant-borne
restorations. Journal of Prosthodontics, 25, S16–S31.
6. Bidra, A., Daubert, D. M., Garcia, L. T., Kosinski, T. F.,
Nenn, C. A., Olsen, J. A., Platt, J. A., Wingrove, S. S.,
c. Panoramic
d. Radiographs are not needed for a dental
implant
21. Which of the following should the provider do
at each recall appointment for a patient who
wears an occlusal device (guard)?
a. Evaluate the device at each recall
appointment for fit and function.
b. Professionally clean the device at each recall
appointment.
c. Provide patient education on use and proper
storage.
d. Educate the patient on self-care and cleansing
with manufacturer-approved solutions and
chemicals.
e. All of the above.
22. True or False. Every patient with an implant-
borne restoration should be placed on a
three-month recall appointment.
a. True
b. False
Chandler, N. D., & Curtis, D. A. (2016). Clinical practice
guidelines for recall and maintenance of patients with tooth-
borne and implant-borne dental restorations. Journal of
Prosthodontics, 25, S32–S40.
7. Corbella, S., Del Fabbro, M., Taschieri, S., De Siena, F., &
Francetti, L. (2011). Clinical evaluation of an implant
maintenance protocol for the prevention of peri-implant
diseases in patients treated with immediately loaded full-arch
rehabilitations. International Journal of Dental Hygiene, 9,
216–222.
8. Cortellini, P., & Bissada, N. (2018). Mucogingival conditions
in the natural dentition: Narrative review, case definitions,
and diagnostic consideration. Journal of Periodontology,
89(Suppl 1), S204–S213. https://doi.org/10:10.1002/JPER
.16-0671
9. Costa, F. O., Takenaka-Martinez, S., Cota, L. O. M.,
Ferreira, S. D., Silva, G. L. M., & Costa, J. E. (2012).
Peri-implant disease in subjects with and without preventive
maintenance: A 5-year follow-up. Journal of Clinical
Periodontology, 39, 173–181.
10. Da Silva Mello, A. S., Dos Santos, P. L., Marquesi, A.,
Queiroz, T. P., Margonar, R., & De Souza Faloni, A. P.
(2016). Some aspects of bone remodeling around dental
implants. Clinical Journal of Periodontics, Implantology and Oral
Rehabilitation. https://doi.org/10.1016/j.piro.2015.12.001
11. De Avila, E. D., De Molon, R. S., Vergani, C. E., De Assis
Mollo, F., & Salih, V. (2014). The relationship between
biofilm and physical-chemical properties of implant
abutment materials for successful dental implants. Materials,
7, 3651–3662.

12. Degidi, M., Scarano, A., Piattelli, M., Perrotti, V., & Piattelli, A.
(2005). Bone remodeling in immediately loaded and unloaded
titanium dental implants: A histologic and histomorphometric
study in humans. Journal of Oral Implantology, 31(1), 18–24.
13. Figuero, E., Graziani, F., Sanz, I., Herrera, D., & Sanz, M. (2014).
Management of peri-implant mucositis and peri-implantitis.
Periodontology, 2000(66), 255–273.
14. Fischer, K., & Stenberg, T. (2013). Prospective 10-year
cohort study based on a randomized, controlled trial (RCT)
on implant-supported full-arch maxillary prosthesis. Part
II: Prosthetic outcomes and maintenance. Clinical Implant
Dentistry and Related Research, 15(4), 498–508.
15. Hammerle, C., & Tarnow, D. (2018). The etiology of hard-and
soft-tissue deficiencies at dental implants: A narrative review.
Journal of Periodontology¸ 89(Suppl 1), S291–S303. https://
doi.org/10.1002/JPER.16-0810
16. Heitz-Mayfield, L., & Salvi, G. (2018). Peri-implant
mucositis. Journal of Periodontology, 89(Suppl 1), S257–S266.
https://doi.org/10.1002/JPER.16-0488
17. Hernandez, M., & Katsaros, T. (2018). Overview of the new
peri-implant and periodontal disease classification system. https://
decisionsindentistry.com/article/ce-sponsored-by-colgate-in
-partnership-with-the-american-academy-of-periodontology
-overview-of-the-new-peri-implant-and-periodontal-disease
-classification-system/
18. Jepsen, S., Canton, J. G., Albandar, J. M., Bissada, N. F.,
Bouchard, P., Cortellini, P., Demirel, K., De Sanctis, M.,
Ercoli, C., Fan, J., Geurs, N. C., Hughes, F. J., Jin, L.,
Kanatarci, A., Lalla, E., Madianos, P. N., Matthews, D.,
McGuire, M. K., Mills, M. P., Preshaw, P. M., Reynolds, M. A.,
Sculean, A., Susin, C., West, N. X., & Yamazaki, K. (2018).
Periodontal manifestations of systemic diseases and
developmental and acquired conditions: Consensus report of
workshop 3 of the 2017 World Workshop on the Classification
of Periodontal and Peri-Implant Diseases and Conditions.
Journal of Periodontology, 89(Suppl 1), S237–S248.
19. Lang, N., & Bartold, P. (2017). Periodontal health. Journal of
Periodontology, 89(Suppl 1), S9–S16. https://doi.org/10.1002
/JPER.16-0517
20. Lombardi, T., Bernardello, F., Berton, F., Porrelli, D., Rapani, A.,
Piloni, A. C., Fiorillo, L., Di Lenarda, R., & Stacchi, C.
(2018). Efficacy of alveolar ridge preservation after maxillary
molar extraction in reducing crestal bone resorption and
sinus pneumatization: A multicenter prospective case-control
study. BioMed Research International, 1–9. https://doi.org/10
.1155/2018/9352130
21. Lupi, S. M., Granati, M., Butera, A., Collesano, V.,
Rodriguez, R., & Baena, Y. (2017). Air-abrasive debridement
with glycine powder versus manual debridement and
chlorhexidine administration for the maintenance of
peri-implant health status: A six-month randomized clinical
trial. International Journal of Dental Hygiene, 15, 287–294.
22. Pandoleon, P., Bakopoulou, A., Papadopoulou, L., &
Koidis, P. (2019). Evaluation of the biological behaviour of
References 551
various dental implant abutment materials on attachment
and viability of human gingival fibroblasts. Dental Materials,
35, 1053–1063.
23. Pjetursson, B. E., Helbling, C., Weber, H. P., Matuliene G.,
Salvi, G. E., Bragger, U., Schmidlin, K., Zwahlen, M., &
Lang, N. P. (2012). Peri-implantitis susceptibility as it relates
to periodontal therapy and supportive care. Clinical Oral
Implants Research, 23, 888–894.
24. Pjetursson, B. E., Thomas, D., Jung, R., Zwahlen, M., &
Zembic, A. (2012). A systematic review of the survival
and complication rates of implant-supported fixed dental
prostheses (FDPs) after a mean observation period of at least
5 years. Clinical Oral Implants Research, 23(6), 22–38.
25. Renvert, S., Persson, G., Pirih, F., & Camargo, P. (2018).
Peri-implant health, peri-implant mucositis, and peri-
implantitis: Case definitions and diagnostic considerations.
Journal of Periodontology, 89(Suppl 1), S304–S312. https://
doi.org/10.1002/JPER.17-0588
26. Sailer, I., Philipp, A., Zembic, A., Pjetursson, B. E.,
Hammerle, C. H. F., & Zwahlen, M. (2009). A systematic
review of the performance of ceramic and metal implant
abutments supporting fixed implant reconstructions. Clinical
Oral Implants Research, 20(4), 4–31.
27. Sanz-Sanchez, I., Sanz-Martin, I., De Albornoz, A. C.,
Figuero, E., & Sanz, M. (2018). Biological effect of the
abutment material on the stability of peri-implant marginal
bone levels: A systematic review and meta-analysis. Clinical
Oral Implants Research, 28(Suppl 18), 124–144.
28. Schou, S., Holmstrup, P., Jorgensen, T., Skovgaard, L. T.,
Stoltze, K., Hjorting-Hansen, E., & Wenzel, A. (2003).
Implant surface preparation in the surgical treatment of
experimental peri-implantitis with autogenous bone graft
and ePTFE membrane in cynomolgus monkeys. Clinical Oral
Implants Research, 14, 412–422.
29. Schwartz, F., Derks, J., Monje, A., & Wang, H. (2018).
Peri-implantitis. Journal of Periodontology, 89(Suppl 1),
S267–S290. https://doi.org/10.1002/JPER.16-0350
30. Sharan, A., & Madjar, D. (2008). Maxillary sinus
pneumatization following extractions: A radiographic study.
Quintessence, 23(1), 48–56.
31. Swierkot, K., Brusius, M., Leismann, D., Nonnenmacher, C.,
Nusing, R., Lubbe, D., Schade-Brittinger, C., & Mengel, R.
(2013). Manual versus sonic-powered toothbrushing for
plaque reduction in patients with dental implants: An
exploratory randomized controlled trial. European Journal of
Oral Implantology, 6(2), 133–144.
32. Vandekerckhove, B., Quirynen, M., Warren, P. R., Strate, J., &
Van Steenberghe, D. (2004). The safety and efficacy of a
powered toothbrush on soft tissues in patient with implant-
supported fixed prosthesis. Clinical Oral Investigations, 8,
206–210.
 CHAPTER 27
Mechanical Implant
Maintenance
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Appraise, compare, and contrast dental
technology used in the debridement and
maintenance of a dental implant.
2. Identify the surface topography of a dental
implant, abutment, and prosthesis.
3. Select the appropriate debridement technique
based on implant, abutment, and prosthesis
presentation.
4. Recognize the clinical indications, limitations,
and contraindications of mechanical
debridement technology and techniques for
a dental implant, abutment, and prosthesis.
KEY TERMS
• Mechanical implant debridement: removal
of oral deposits through direct contact with
hand-activated instrumentation, ultrasonic
instrumentation, or air polishing technologies.
• Nonmechanical implant debridement: removal
of oral deposits through direct or indirect
contact with dental lasers, chlorhexidine,
low-concentration (<3%) hydrogen peroxide,
ozone (O3), or locally administered antibiotics and
antimicrobials.
Introduction
Patients with implant-borne removable, fixed-
detacahable, and fixed prostheses require lifelong well-
structured recall maintenance to promote biological
(bone and soft tissue) health customized to their in-
dividual needs, which may be different than patients
of the same age without implant-borne restorations
(Bidra, Daubert, ­Garcia, Kosinski, et al., 2016; Bidra,
Daubert, ­Garcia, Gauthier, et al., 2016; C
­ orbella et al.,
2011; ­Pjetursson et al., 2012). Improper treatment
planning, failure to identify risk factors, inappropri-
ate maintenance recall recommendations, and incom-
plete debridement can lead to peri-implant disease
in a susceptible host (Corbella et al., 2011; Saneja
et al., 2020).
This chapter will discuss the nonsurgical imple-
mentation phase of implant care with mechanical de-
bridement techniques after clinical assessments and
diagnosis are complete. The goal of implant debride-
ment is to mechanically or nonmechanically disrupt
and remove supragingival and subgingival oral depos-
its and reduce the quantity of pathogenic organisms to
promote immunological health of implant-supported
bone and soft tissues without adversely altering the
surface characteristics of the implant, abutment, or
prosthesis to maintain biocompatibility. This chapter
will discuss the surface characteristics and topogra-
phy of a dental implant, abutment, and prosthesis and
then relate that information to mechanical debride-
ment technology.
Implant Debridement
Overview
Implant maintenance follows assessment, diagnosis,
planning, implementation, and evaluation (ADPIE)
of the patient process of care. ADPIE assists providers
553
554 Chapter 27 Mechanical Implant Maintenance
Box 27-1 Patient Dental Implant Case
The maxillary left first molar dental implant has bone loss and peri-implantitis while the mandibular right first
molar dental implant has peri-implant health. Both diagnoses should be entered into the patient’s record.
in rendering a systematic, repeatable approach to
­patient care that ensures pertinent diagnoses are not
missed.
• Assessment: Clinical assessments presented in
Chapter 26 of visual and palpatory tissue inspec-
tion, periodontal charting, radiographs, occlusion
status, and prosthesis inspection reveal the status
of a dental implant.
• Diagnosis: A diagnosis (by those providers whose
scope of practice allows) of peri-implant health,
peri-implant mucositis, peri-implantitis, or peri-­
implant soft and hard tissue deficiency is made
based on assessment findings. The diagnosis is re-
corded in the patient record and discussed with
the patient. If the patient has more than one dental
implant, a diagnosis should be made for each im-
plant because they can differ (see Box 27-1).
• Planning: Appropriate nonsurgical and/or sur-
gical interventions should be treatment planned
based on the implant diagnosis.
• Implementation: A dental implant should be
debrided at each recall appointment along with
professional oral self-care education. This chap-
ter and the next will cover the nonsurgical imple-
mentation phase of implant care.
• Evaluation: Continued evaluation at each recall
appointment is needed to determine if interven-
tions were successful in either maintaining health
or resolving active disease.
BREAKOUT POINT
Implant maintenance follows ADPIE of the patient
process of care to ensure that the provider does not
miss a pertinent diagnosis.
Implant Debridement Goals
The goal of implant debridement is to mechanically
or nonmechanically disrupt and remove supragingival
and subgingival oral deposits and reduce the number
of pathogenic organisms to promote immunological
health of implant-supported bone and soft tissues
without adversely altering the surface characteristics of
the implant, abutment, or prosthesis to maintain bio-
compatibility (see Table 27-1 for mechanical and non-
mechanical debridement approaches to implant care).
Biofilm promotes disruption of the peri-implant
non-keratinized and keratinized mucosa, which protects

Table 27-1 Debridement Approach
Mechanical Nonmechanical
■ Hand-activated ■ Dental lasers
instrumentation ■ Chlorhexidine
■ Ultrasonic ■ Low-concentration (<3%)
instrumentation hydrogen peroxide
■ Air polishing ■ Ozone (O3)
■ Locally administered
antibiotics and
antimicrobials
the bone surrounding the implant (Berglundh et al.,
2018; De Almeida et al., 2017). Biofilm removal and
control is necessary to maintain peri-implant health
because its presence leads to peri-implant mucositis
and subsequent peri-implantitis (Berglundh et al.,
2018; De Almeida et al., 2017).
Surface Topography
The terms rough and smooth are commonly used when
describing the surface topography of a dental implant,
abutment, and prosthesis. Each structure is designed
with a different topography that promotes healing and
long-term health.
Implant
The implant is not meant to be exposed to the oral
cavity as it is placed directly into bone. It has a rough
surface topography designed to promote osteoblastic
activity during the early healing phases of bone re-
modeling (Anjum & Rajasekar, 2021; Balshe et al.,
2008; Bowers et al., 1992; Gustumhaugen et al., 2014;
Konenen et al., 1992). Implant manufacturers inten-
tionally create a rough surface topography through
various engineering techniques such as acid etching,
anodic oxidation, blasting, or coating with various
chemicals (Anjum & Rajasekar, 2021; Balshe et al.,
2008; Bowers et al., 1992; Konenen et al., 1992).
BREAKOUT POINT
A dental implant is designed with a rough surface
topography.
Abutment and Prosthesis
The abutment and prosthesis are meant to be exposed
to the oral cavity and have a smooth, finely textured sur-
face topography designed to inhibit bacterial adhesion
Surface Topography 555
and promote fibroblastic activity and attachment
(Blazquez-Hinarejos et al., 2017; Roehling et al.,
2017). Through complex chemical interactions in the
mouth between the surface of the abutment and the
composition of saliva, studies have shown titanium
abutments are more susceptible to biofilm accumu-
lation than zirconia (Nakamura et al., 2009; Roehling
et al., 2017; Sailer et al., 2009; Scarano et al., 2004;
Sanz-Martin et al., 2017; Sanz-Sanchez et al., 2018).
This is important information for the oral health-care
provider who is charged with maintaining a patient’s
dental implant throughout a lifetime with customized
recall and self-care instructions.
BREAKOUT POINT
An abutment and prosthesis are designed with a
smooth surface topography.
Debridement
Mechanical implant debridement of a dental im-
plant, abutment, and prosthesis is performed with
hand-activated instrumentation, ultrasonic instrumen-
tation, and air polishing that will physically remove
oral deposits through direct contact. Non­mechanical
implant debridement of a dental implant, abut-
ment, and prosthesis is performed with dental lasers,
chlorhexidine, low-concentration (<3%) hydrogen
peroxide, ozone (O3), or locally administered antibi-
otics and antimicrobials. Nonmechanical techniques
are frequently used as an adjunct, meaning in com-
bination with mechanical techniques, and will re-
move oral deposits and organisms through direct or
indirect contact.
BREAKOUT POINT
Mechanical debridement of a dental implant is
performed with hand-activated instrumentation,
ultrasonic instrumentation, and air polishing.
The dental implant should be fully embedded in
bone and not exposed to debridement procedures.
When bone loss is present, the dental implant will
need to be debrided. The abutment and prosthesis
are not embedded in bone and require regular me-
chanical and nonmechanical debridement to remove
accumulated oral deposits. Debridement recommen-
dations are different for a rough implant surface than
a smooth abutment and prosthesis surface.
556 Chapter 27 Mechanical Implant Maintenance
BREAKOUT POINT
A dental implant is embedded in bone and not
debrided unless bone loss has exposed the implant
to the oral cavity.
Ideally, debridement of the abutment and pros-
thesis should not change its smooth topography, and
debridement of the implant, if exposed to the oral
cavity, should not change its rough topography. In
clinical reality, debridement will cause a change in the
original surface topography, but how much change
leads to adverse effects is still under debate. There is
an extensive body of literature that has evaluated sur-
face topography change with mechanical and nonme-
chanical debridement.
If the smooth topography of an abutment
or prosthesis experiences a composition change
through corrosion or roughening, the structures may
have an increased risk for biofilm accumulation and
subsequent inflammation, which can lead to loss
of biocompatibility (Bowers et al., 1992; ­Konenen
et al., 1992; Dmytiyk et al., 1990; Moharrami et al.,
2019).
• Studies have found a surface roughness thresh-
old value of 0.20 µm or less does not appear to
increase bacterial colonization and enables good
soft-tissue adhesion (Moharrami et al., 2019;
­Biazussi et al., 2019; Bollen et al., 1997; De Avila
et al., 2014; Louropoulou et al., 2012).
• Roughening a smooth surface more than 0.20 µm
promotes bacterial adhesion in the micropits
created and protects them from dislodgement
during self-care (De Avila et al., 2014; Al-Ahmad
et al., 2010).
BREAKOUT POINT
Mechanical debridement should not cause more
than 0.20 µm of surface change to the abutment or
prosthesis.
Mechanical Debridement
This section will present the three forms of mechan-
ical implant debridement: hand-activated instrumen-
tation, ultrasonic instrumentation, and air polishing.
Hand-Activated
Instrumentation
This book does not cover hand-activated instrumenta-
tion, but these tools are worth mentioning in the con-
text of implant debridement because they are used for
the removal of biofilm, stain, and dental calculus from
a dental implant, abutment, and prosthesis. Many
hand-activated instruments have been developed
over the years for implant debridement. Examples in-
clude carbon, graphite, plastic, Teflon, and titanium.
Hand-activated instruments should either be the same
hardness or softer than the surface they are scaling to
avoid alterations. Titanium-coated instruments have
a similar hardness to titanium surfaces (De Almeida
et al., 2017; Duarte et al., 2009; see Figure 27-1).
• It is widely known through evidence-based re-
search that the use of a metal stainless-steel,
hand-activated instrument will adversely alter (re-
move, roughen, corrode) the original surface of a
dental implant, abutment, and prosthesis, with se-
verity based on contact time, number of strokes,
pressure, and number of treatments (Moharrami
et al., 2019; ­Louropoulou et al., 2012; Duarte et al.,
2009; Figuero et al., 2014; Mann et al., 2012; Schou
et al., 2003). For this reason, metal stainless-steel,
hand-activated instruments are contraindicated for
use on a dental implant, abutment, or prosthesis.
Figure 27-1 Hand-activated implant scaling kit with
titanium scalers and plastic probe.
Courtesy of Susan Wingrove
 Mechanical Debridement 557

BREAKOUT POINT
Metal stainless-steel, hand-activated instruments
are contraindicated for the mechanical debridement
of a dental implant, abutment, and prosthesis.

• A systematic review published by Louropoilou

et al. (2012), concluded that hand-activated in-
struments “may result in ineffective plaque re-
moval due to their design and size which prevents
accessibility to tight spaces and deeper periodon-
tal pockets.”
• Hand-activated instruments make it difficult to
access tight spaces and adequately debride probe
depths over 4 mm due to their blade width and
shape (De Almeida et al., 2017).
• A study by Lupi et al. (2017) evaluated a hand-­ A
activated plastic scaler with a one-time 0.1% ch-
lorhexidine irrigation and a 1% chlorhexidine gel
application subgingivally compared to Glycine
powder air polishing (GPAP) with a subgingival
nozzle in the debridement capability around an
abutment and prosthesis. The GPAP group had
statistically significant better probe depths and
plaque index scores than the plastic scaler group
and was found to be more effective in main-
taining peri-implant health at 3 and 6 months
post-treatment.

Ultrasonic Instrumentation
An ultrasonic insert or tip specifically designed
for implant debridement is covered with Polysul-
fone Amoco P-1700, or is made of titanium, car-
bon, Teflon, or Polyether ether ketone (PEEK) (see
Figure 27-2). Ultrasonic technology will remove bio-
film, stain, and dental calculus.
• Evidence-based research has shown that the use
of a stainless-steel ultrasonic insert and tip will
adversely alter (remove, roughen, corrode) the
original surface of a dental implant, abutment,
and prosthesis if the shank makes contact with
structures (Moharrami et al., 2019; Louropoulou
et al., 2012; Duarte et al., 2009; Figuero et al.,
2014; Mann et al., 2012; Schon et al., 2003).
BREAKOUT POINT
A stainless-steel ultrasonic shank should not
make contact with a dental implant, abutment, or
prosthesis.
B
Figure 27-2 Ultrasonic technology for implant
debridement: A. EMS PI tip; B. Dentsply Sirona Cavitron
SofTip Implant 30K Ultrasonic Insert with SofTip.
• PEEK, as defined in Chapter 5, is a semicrystalline
high-temperature thermoplastic polymer that is
coated on the stainless-steel active area antinode.
Studies have shown that PEEK tips may leave
behind remnants on the implant and abutment
during debridement, with larger remnants on the
threads of an implant (Mann et al., 2012; Cha
et al., 2019; Harrel et al., 2019; Tong et al., 2021).
However, it is not known if this leads to benefi-
cial, adverse, or no change in long-term outcomes
(Cha et al., 2019; Tong et al., 2021).
558 Chapter 27 Mechanical Implant Maintenance
• When an implant-appropriate ultrasonic insert or
tip is used directly on an implant that is exposed
to the oral cavity due to bone loss, it can cause mi-
croscopic alterations to its surface, can potentially
release titanium particles, and has been found
to ineffectively debride the valleys between the
threads (Cha et al., 2019; Sahrmann et al., 2021).
• Ultrasonic instrumentation of a dental implant
offers the advantage of providing acoustic cav-
itation, acoustic microstreaming, and liquid
jet production for the reduction of biofilm and
bacteria (see Chapter 6). Lavage and irrigation
are useful in times of peri-mucosa inflammation
(see Chapter 6).
BREAKOUT POINT
Hand-activated and ultrasonic instrumentation
will remove biofilm, stain, and dental calculus on
a dental implant, abutment, and prosthesis.
Air Polishing
Air polishing of dental implants has been more exten-
sively studied with sodium bicarbonate (low particle
size of 40–63 µm), glycine, and erythritol.
• APDs will remove biofilm, stain, and early-forming
immature dental calculus on a dental implant,
abutment, and prosthesis. They will not remove
mature, firmly established dental calculus.
• After air polishing, powder remnants have been
found on the dental implant, abutment, and pros-
thesis, but it is unknown if this leads to beneficial,
adverse, or no changes in long-term outcomes
(Duarte et al., 2009; Cha et al., 2019; Tong et al.,
2021; Furtsey & Zeer, 2020).
BREAKOUT POINT
Air polishing will remove biofilm, stain, and early-
forming immature dental calculus on a dental
implant, abutment, and prosthesis.
• Subgingival powders (glycine and erythritol) cause
less surface alterations to a dental implant, abut-
ment, and prosthesis than low particle size so-
dium bicarbonate; however, sodium bicarbonate
will produce a cleaner surface (Moharrami et al.,
2019; Biazussi et al., 2019; Duarte et al., 2009;
Cochis et al., 2013; Drago et al., 2014; ­Petersilka,
2000; Matsubara et al., 2020; Wei et al., 2017).
This information is important to the provider
when selecting a powder based on oral deposit
level and location. For example:
• If heavier biofilm and early-forming imma-
ture dental calculus are present coronal to the
CEL, low particle size sodium bicarbonate
may be the better selection for debridement.
• If heavier biofilm is present subgingivally,
then glycine or erythritol should be used
because sodium bicarbonate cannot be used
apical to the CEJ.
• Studies on glycine and erythritol either report
no surface change to the abutment or prosthesis
(Moharrami et al., 2019; Biazussi et al., 2019;
Louropoulou et al., 2012; Lupi et al., 2017; Cha
et al., 2019; Petersilka, 2000; De Sinea et al.,
2015; Sahm et al., 2011) or only a slight in-
crease in surface roughness (Biazussi et al.,
2019; De Avila et al., 2014) depending on pow-
der particle size, device, provider technique,
and contact time.
• In a systematic review by Moharrami et al.
(2019), air polishing with a medium setting was
found to alter surfaces comparable to plastic
hand-activated instruments, polishing cups, and
an erbium laser.
• A systematic review published by Barootchi et al.
(2020) concluded that air polishing is equally ef-
fective in removing plaque biofilm as ultrasonic
instrumentation. Glycine and erythritol also offer
the benefit of antimicrobial and antibiofilm ac-
tivity that can be useful in the treatment of peri-­
implant disease.
Studies have found erythritol with 0.3% chlorhexi-
dine produces a superior antimicrobial and antibio-
film effect than other powders (De Almeida et al.,
2017; Duarte et al., 2009).
• A study by Mensi et al. (2018) found erythritol
with 0.3% chlorhexidine produced superior re-
sults for inhibiting the regrowth of biofilm after
treatment compared to sodium bicarbonate.
• A study by Drago et al. (2014) tested the mi-
crobial effects of glycine and erythritol around
implants with peri-implantitis. Erythritol with
0.3% chlorhexidine displayed better bactericidal
effects and reduced microbes tested two to three
times more than glycine. Both powders reduced
microbes and removed biofilm, but erythritol had
stronger antimicrobial and antibiofilm activity
than glycine.

BREAKOUT POINT
Glycine and erythritol provide antimicrobial and
antibiofilm actions, with erythritol producing more
superior results.
Peri-Implant Mucositis
Debridement
As peri-implant mucositis is a precursor to peri-
implantitis, its presence should be addressed imme-
diately with appropriate nonsurgical and at-home
therapies customized to each individual patient
presentation.
• A recent systematic review published by Schwartz
et al. (2015) concluded that mechanical instru-
mentation is effective in treating peri-implant
mucositis.
• Patients should be reevaluated frequently after
treatment to ensure resolution of inflammation.
• If mechanical approaches with improved self-
care at home do not resolve the inflammation in
a timely manner, then nonmechanical adjunctive
methods should be employed with a more fre-
quent recall interval until all signs and symptoms
of peri-implant mucositis are resolved.
BREAKOUT POINT
Peri-implant mucositis requires immediate
treatment with mechanical debridement.
Peri-Implant Mucositis
Literature
• A study by De Sinea et al. (2015) evaluated the
difference in clinical outcomes when debriding
dental implants with peri-implant mucositis with
hand-activated Teflon scalers and rubber cup pol-
ishing compared to the use of subgingival GPAP.
Six months post-procedure, the subgingival GPAP
group had statistically significant decreases in
probe depths, bleeding index, and plaque index
compared to the hand-activated scaler and rubber
cup group.
• A study by Riben et al. (2015) evaluated the dif-
ference in clinical outcomes of debriding den-
tal implants with peri-implant mucositis with a
piezoelectric ultrasonic PEEK tip versus subgingi-
val GPAP. Both groups had statistically significant
Peri-Implantitis Debridement 559
reductions in mean plaque scores, probe depths,
bleeding upon probing, and percentage of dis-
eased sites. Both modalities were found effective
in treating peri-implant mucositis.
Peri-Implantitis
Debridement
Debriding implants with peri-implantitis is far more
complex than debriding an abutment and prosthesis
because an endosteal implant is made of threads and
valleys is difficult to debride to completion without
altering the surface topography. The recommenda-
tions for debriding an implant vary in the literature
with no clear superior method, which has led to
industry-­wide confusion (Riben-­Grundstrom et al.,
2015; Mussano et al., 2013). There is also no one clear
protocol for the overall treatment of peri-­implantitis
(Furtsey & Zeer, 2020; Esposito et al., 2012). A sys-
tematic review by Schwartz et al. (2015) concluded
that adjunctive nonmechanical approaches in com-
bination with mechanical instrumentation and/or
surgical interventions are needed in the treatment of
peri-implantitis.
BREAKOUT POINT
Debridement of a dental implant is far more complex
than debridement of an abutment or prosthesis.
Implant Debridement
Implant debridement should remove oral deposits
without changing the surface topography. A dental
implant has raised threads and depressed valleys be-
tween the threads (see Figure 27-3). The valleys pose
a significant challenge to instrumentation and are
the most difficult area to debride (Cha et al., 2019;
­Matsubara et al., 2020).
The surface topography is rough with multiple
micropores. Unfortunately, these design characteris-
tics promote bacterial adhesion and biofilm formation
and make their removal challenging for the provider
(Moharrami et al., 2019; Cha et al., 2019; Matsubara
et al., 2020; Gustumhaugen et al., 2014.
Hand-Activated and Ultrasonic
Instrumentation
Implant-appropriate hand-activated scalers and ul-
trasonic inserts and tips are limited in their ability to
560 Chapter 27 Mechanical Implant Maintenance
Valley
Thread
Figure 27-3 Endosteal dental implant with threads and
valleys.
Reproduced with permission from Dentsply Sirona
access deeper periodontal pockets and fully debride
implant threads and valleys (De Almeida et al., 2017;
Louropoulou et al., 2012; Cha et al., 2019; Tong et al.,
2021; Matsubara et al., 2020; G ­ ustumhaugen et al.,
2014; Persson et al., 2010). Acteon manufactures tita-
nium piezoelectric tips with varied designs specifically
for dental implant thread and valley debridement.
Each one is intended for different thread widths. See
Chapter 18 for details.
• A study by Persson et al. (2010) evaluated the de-
bridement capability of a hand-activated titanium
scaler compared to a PEEK ultrasonic piezoelec-
tric tip in peri-implantitis. No differences were
reported between the two in the reduction of
bleeding upon probing or probe depths. The mi-
crobiota evaluated was not significantly reduced
in the periodontal pockets, demonstrating inade-
quate debridement of both techniques.
• A study by Renvert et al. (2009) evaluated the de-
bridement capability of a hand-activated titanium
scaler with rubber cup prophylaxis paste com-
pared to an ultrasonic carbon-coated piezoelectric
ultrasonic tip. No differences were reported be-
tween the two in the reduction of bleeding upon
probing, probe depths, bacterial counts, or plaque
scores, demonstrating inadequate debridement in
both techniques.
Air Polishing
Studies have demonstrated subgingival air polishing
can reach the base of deeper periodontal pockets and
fully debride implant threads and valleys with simi-
lar or less surface topography changes than ultrasonic
and hand-activated instrumentation (Cha et al., 2019;
Tong et al., 2021). Studies have shown subgingival
powders may be capable of smoothing the roughened
surface of a dental implant so using recommended ex-
posure times, lower powder particle sizes, and correct
technique is imperative to avoid significant topogra-
phy changes (Moharrami et al., 2019; Biazussi et al.,
2019; Louropoulou et al., 2012; Tong et al., 2021).
• A study by Cha et al. (2019) evaluated the de-
bridement capability of GPAP, PEEK piezoelectric
ultrasonic tip, and a hand-activated metal scaler
on the threads and valleys of a pristine implant
surface. Only GPAP was able to fully debride the
threads and valleys of the implant and caused less
surface topography changes than the PEEK ultra-
sonic tip and metal scaler. The metal scaler caused
the most significant changes to the implant sur-
face, decreasing thread height and width. The
PEEK ultrasonic tip only caused slight alterations
to the threads. All modalities decreased surface
roughness in the areas they were able to access.
• A study by Furtsev and Zeer (2020) evaluated
surface topography changes with EPAP and found
the erythritol powder had a high capacity to clean
contaminated implant surfaces without changing
the roughness or altering the microporosities of
the surface.
• A study by Sahm et al. (2011) evaluated the de-
bridement capability of a hand-activated carbon
scaler plus irrigation with 0.1% chlorhexidine
and submucosal placement of 1% chlorhexidine
gel to subgingival GPAP. Both groups demon-
strated reductions in probe depths and gains of
clinical attachment, but the GPAP group pro-
duced significantly better reductions in bleeding
upon probing at the 3- and 6-month postopera-
tive evaluations.
Peri-Implantitis
and Titanium Particles
Studies have found titanium particles embedded in
the peri-implant soft tissues adjacent to a dental im-
plant with peri-implantitis. The etiology of embedded
titanium particles is multi-factorial. Frictional wear
during implant placement, corrosion from improper,
exogeneous sources such as oral products (toothpaste,
 Mechanical Debridement Technique 561

mouth rinse), an acidic oral environment from diet,

and biofilm presence can all cause the release of ti- Box 27-2 Oral Deposits Around
tanium particles that can embed into peri-implant Implant-Supported Prosthetics
mucosa. (Eger et al., 2017; Pettersson et al., 2017;
Heavy, mature, firmly established dental calculus
Surez-Lopez del Amo et al., 2018; Rodriguez et al., deposits under a mandibular implant-supported
2013). Higher concentrations are associated with fixed dental prosthesis.
the activation of the inflammatory response and dis-
ruption of epithelial health, and have been found in
close proximity to failing implants (Eger et al., 2017;
Pettersson et al., 2017; Surez-Lopez del Amo et al.,
2018; Rodriguez et al., 2013). Based on these find-
ings, it is hypothesized that increased titanium parti-
cles released from an implant surface that embed into
adjacent tissue is an indicator of increased risk for
peri-implant disease.
• A study by Harrel et al. (2019) evaluated a hand-­
activated stainless-steel scaler, a hand-activated ti- A
tanium scaler, and a PEEK ultrasonic tip and their Heavy biofilm and materia alba without mature,
potential to release titanium particles and change firmly established dental calculus deposits under a
the surface of a pristine dental implant. All three coping bar.
modalities showed metallic particles shed from
the titanium implant surface during debride-
ment, and all three caused surface topography
changes. The surface changes were not quantified
in the study.

Mechanical Debridement
Technique
As this chapter has demonstrated, there is no one-
size-fits-all or one superior method for implant, abut-
ment, and prosthesis mechanical debridement and
decontamination. Debridement approaches should
be customized for each individual patient presenta-
tion. Patient individual risk factors for building oral
deposits based on medical status (presence of sys-
temic ­disease), self-care quality at home, and hab-
its ­
(smoking) should be considered in mechanical
debridement selection and for establishing recall
frequency.
The oral deposit type (biofilm, calculus, stain)
and level (light, moderate, heavy) influences instru-
mentation selection. The provider should select the
best biofilm control method that will cause the least
alterations to surface topography.
• If mature, firmly established dental calculus
deposits are present, hand-activated or ultra-
sonic technology is required for its removal (see
Box 27-2a).
• If biofilm and early-forming immature dental
calculus is present, hand-activated, ultrasonic,
B
or air polishing technologies can be used (see
Box 27-2b).
There are hundreds of implant brands with mul-
tiple manufacturers, which has led to a wide variety
of choices on the implant market. Abutment and
prosthesis design variations, coupled with a patient’s
lack of knowledge on proper self-care, can hinder
the removal of biofilm and increase the risk for peri-­
implant disease (De Almeida et al., 2017). Implants,
abutments, and prostheses are made of a variety of
materials with various surface modifications, shapes,
lengths, and widths (Anjum & Rajasekar, 2021).
These differences pose an instrumentation chal-
lenge for providers who render routine maintenance
procedures.
562 Chapter 27 Mechanical Implant Maintenance

A B
Figure 27-4 Abutment and prosthesis design: A. Narrow tapered abutment with wider prosthesis on the maxillary right
lateral incisor, B. Wider prosthesis than abutment on the maxillary left first molar.

A B
Figure 27-5 Interdental papillae height case example: A. Implant-supported crowns on the
maxillary lateral incisors with tightly adherent gingival tissue with papilla that fills in the
interdental space, B. Radiographs of single tooth dental implants on the maxillary lateral
incisors showing adequate crestal bone height.

• When an abutment is narrower and more tapered
than the prosthesis, the provider must adjust their
instrumentation adaptation and angulation (see
Figure 27-4a and b). Once an instrument is in-
serted subgingivally, the provider must over-angle
(tilt) the instrument for correct adaptation.
• The position of the interdental papilla and the po-
sition of a dental implant in relation to the natural
teeth influence which mechanical debridement
equipment should be used. See the case example
in Figure 27-5a and b.
B and ask yourself which form of mechanical de-
bridement is needed for this patient?
Answer: Air polishing with glycine or erythri-
tol will remove the light biofilm supragingivally and
subgingivally. The tissues are tightly adherent, with
absence of inflammation and papilla fills in the in-
terdental space. Air polishing subgingivally will not
cause tissue distension or injury. Hand-activated and
ultrasonic instrumentation is not the best option
due to the lack of mature, firmly established den-
tal calculus and the status of the tissue. Subgingival
 Mechanical Debridement Technique 563

A B C
Figure 27-6 Horizontal circumferential strokes on a mandibular second premolar dental implant (Dentsply Sirona
Cavitron SofTip Implant 30K Ultrasonic Insert and SofTip): A. Insert placed on the dental implant distal-buccal,
B. Insert moved horizontally to the buccal-midline, C. Insert moved horizontally to the mesial-buccal.

access with implant-appropriate hand-activated and Figure 27-6).Vertical strokes should be avoided, espe-
ultrasonic shanks will be challenging due to their cially when debriding the implant itself.
thicker widths.
Mechanical debridement with hand-activated
and ultrasonic instrumentation should be performed BREAKOUT POINT
in a horizontal circumferential movements with light
Circumferential light horizontal strokes with an
strokes. This will reduce the risk of surface alter-
ultrasonic or hand-activated instrument are used to
ations and the release of titanium particles while im- debride a dental implant, abutment, and prosthesis.
proving debridement of the threads and valleys (see

CASE STUDY
The patient is a 44-year-old Caucasian female with a history of GERD and is taking omeprazole 20 mg bid. All vitals are
within normal limits, and Body Mass Index (BMI) is 35. Patient lives with her husband and two children, is a nonsmoker,
and drinks alcohol on weekends with friends. She does not have a chief complaint.
Dental exam: The patient wears a nightguard when she sleeps that was fabricated by a dentist. She has had previous
orthodontics and wears a retainer on her mandibular arch at night. No restorative needs. The mandibular right first
molar implant was placed 10 years earlier and after a traumatic extraction. The implant was placed into an area
with an existing hard tissue deficiency as a result of the traumatic extraction.
Occlusion: Class I bilateral with first molar relationship.
Oral hygiene exam: Scattered light biofilm with a plaque biofilm index of 12%. No dental calculus is present.
Periodontal exam: 2–3 mm probe depths generally with generalized slight recession. No bleeding upon probing or
mobility. The dental implant probe depths are 3–4 mm with no bleeding upon probing or suppuration. Keratinized
gingiva width is less than 2 mm. Buccal bone is exactly 2 mm in width.
Implant baseline: Baseline is known and probe depths were 3–4 mm with 1.8 mm loss of crestal bone height due to the
hard tissue deficiency. There is little to no interdental papilla due to this deficiency.
Tissue description: Generalized tight, pink, stippled attached gingiva.
564 Chapter 27 Mechanical Implant Maintenance

Full mouth series radiographs.

Panoramic radiograph.

Right molar vertical bitewing.

 Mechanical Debridement Technique 565

Right molar periapical. Lingual surfaces of mandibular right first molar

(implant crown) and second molar (zirconia crown).

Buccal surface mandibular right second molar (zirconia

crown), first molar (implant crown), and distal-buccal
surface of second premolar (zirconia crown).

1. What is this patient’s ASA classification? Explain your answer.

2. What is the patient’s implant classification for the mandibular right first molar based on the information provided?
3. Is the recession present on the buccal of the dental implant a sign of current active disease? Why or why not?
4. What factors increase this dental implant’s risk for future peri-implant disease?
5. Upon provider palpation of the implant from the buccal, the top implant thread can be felt as well as the abutment.
The patient reports this area is tender to palpation. Would you tell this patient their implant has active disease?
Why or why not?
6. Which of the three mechanical debridement approaches would be the best for this implant? Explain your answer.
7. What air polishing powder would you use to debride the prosthesis and abutment? Explain your answer.
8. What oral hygiene aids would you recommend for this patient? Explain your answer.

Questions at the next recall appointment

9. At the next recall appointment, the peri-implant tissue is erythematous, edematous, and bleeding upon probing,
with no increase in probe depth from baseline. The radiographic bone level remains constant with no change from
baseline. What is the classification of the dental implant at this appointment?
566 Chapter 27 Mechanical Implant Maintenance

10. Is the diagnosis in the previous question reversible?

11. The abutment has mature, firmly established dental calculus deposits and moderate biofilm at this recall
appointment that is contributing to the peri-mucosa inflammation and bleeding. What mechanical debridement
approach should be used to remove the dental calculus? Explain your answer.
12. You remove the mature, firmly established dental calculus. What air polishing powder and technique would you
use for biofilm reduction and removal? Explain your answer.
13. What additional oral hygiene aids would you recommend at this appointment that you did not recommend at the
last appointment? Explain your answer.
14. What recall interval would you recommend for the next appointment? Explain your answer.

Summary
Mechanical debridement is necessary in the mainte-
nance of dental implants to remove and reduce bio-
film to a level that promotes immunological health
of implant-supported bone and soft tissues. The
three mechanical forms of implant debridement are
hand-activated instruments, ultrasonic instrumen-
tation, and air polishing. Hand-activated and ultra-
sonic instrumentation will remove biofilm, stain,
and dental calculus, and air polishing will remove
biofilm, stain, and early-forming immature dental
calculus. Air polishing causes less surface alter-
ations compared to other forms of debridement and
is useful for difficult to access areas such as exposed
implant threads. Debridement selection should be
based on individual patient presentation and car-
ried out with the form of instrumentation that
causes the least surface alterations to the smooth
surface topography of the abutment and prosthesis
and the rough surface topography of the implant.

Questions
1. What step of ADPIE does implant debridement 6. In times of peri-implant health with no previous
occur? or current bone loss, what structure(s) are
a. Assessment routinely debrided during implant maintenance?
b. Diagnosis a. Abutment
c. Planning b. Implant
d. Implementation c. Prosthesis
e. Evaluation d. Both A and C
2. Which of the following is a mechanical e. All of the above
debridement approach used in implant 7. What surface roughness threshold have studies
maintenance? found does not increase bacterial colonization
a. Air polishing and enables good soft-tissue adhesion around a
b. Laser therapy dental implant?
c. Chlorhexidine administration a. 0.20 µm
d. Local delivery of an antibiotic b. 1.0 µm
Match the following structures with their natural sur- c. 2.0 µm
face topography produced by manufacturers for ques- d. 3.0 µm
tions 3–5. Answer A for smooth topography and B for 8. Which of the following hand-activated
rough topography. There is only one correct answer instruments is not safe and should not be used for
for each question. implant, abutment, or prosthesis debridement?
3. Implant a. Carbon
b. Graphite
4. Abutment c. Titanium
5. Prosthesis d. Metal stainless steel

9. Which of the following ultrasonic inserts and
tips is not safe and should not be used, for
implant, abutment, or prosthesis debridement?
a. Carbon
b. PEEK
c. Titanium
d. Stainless steel
10. Which of the following cannot remove mature,
firmly established dental calculus on the surface
of an implant, abutment, or prosthesis?
a. PEEK ultrasonic insert or tip
b. Titanium hand-activated instrument
c. Air polishing with glycine or erythritol
d. Titanium ultrasonic insert or tip
11. Which of the following can leave behind
remnants on the surface of a dental implant
during debridement?
a. GPAP
b. EPAP
c. PEEK ultrasonic insert or tip
d. All of the above
Match the following powders to their correct descrip-
tion for questions 12–14. There is only one correct
answer for each powder.
12. Sodium A. Produces a superior cleaner
bicarbonate surface but causes more
surface alteration.
13. Glycine B. Achieves superior anti-
microbial and antibiofilm
effects compared to other
powders.
References
1. Al-Ahmad, A., Weidmann-Al-Ahmad, M., Faust, J., Bachle, M.,
Follo, M., Wolkewitz, M., Hannig, C., Hellwig, E., Carvalho, C., &
Kohal, R. (2010). Biofilm formation and composition on
different implant materials in vivo. Journal of Biomedical
Materials Research Part B: Applied Biomaterials, 95B, 101–109.
2. Anjum, S., & Rajasekar, A. (2021). Surface modification of
dental implants—A review. Journal of Evolution of Medical and
Dental Sciences, 10(17), 1246–1250.
3. Balshe, A. A., Eckert, S. E., Koka, S., Assad, D. A., & Weaver,
A. L. (2008). The effects of smoking on the survival of
smooth- and rough-surface dental implants. International
Journal of Oral Maxillofacial Implants, 23(6), 1117–1122.
4. Barootchi, S., Ravida, A., Lavelli, L., & Wang, H. L. (2020).
Nonsurgical treatment for peri-implant mucositis: A
systematic review and meta-analysis. International Journal of
Oral Implantology, 13(2), 123–139.
5. Berglundh, T., Armitage, G., Araujo, M., Avila-Ortiz, G.,
Blanco, J., Camargo, P., Chen, S., Cochran, D., Derks, J.,
Figuero, E., Hammerle, C., Heitz-Mayfield, L., Huynh-Ba, G.,
References 567
14. Erythritol C. Provides little to no surface
with 0.3% alterations to the surface of
chlorhexidine an abutment.
15. Which of the following mechanical debridement
techniques have studies shown is superior to
debriding the treads and valleys of a dental
implant?
a. Hand-activated instrumentation
b. Ultrasonic instrumentation
c. Air polishing
d. All methods are equally effective in debriding
threads and valleys
16. True or False. Higher concentrations of titanium
particles have been found in peri-implant soft
tissues in close proximity to a failing implant
associated with inflammation and disruption of
epithelial health.
a. True
b. False
17. Which of the following can cause the release
of titanium particles from an implant that can
embed in peri-implant soft tissues?
a. Frictional wear during implant placement
b. Corrosion from debridement
c. Exogeneous sources such as oral products
d. All of the above
18. True or False. Vertical strokes are used when
debriding a dental implant with hand-activated
or ultrasonic instrumentation.
a. True
b. False
Iacono, V., Koo, K., Lambert, F., McCauley, L., Quirynen, M.,
Renvert, S., Salvi, G., Schwarz, F., Tarnow, D., Tomasi, C.,
Wang, H., & Zitzmann, N. (2018). Peri-implant diseases
and conditions: Consensus report of Workgroup 4 of the
2017 World Workshop on the classification of periodontal
and peri-implant diseases and conditions. Journal of
Periodontology, 89(Suppl 1), S313–S318. https://doi.org
/10.1002/JPER.17-0739
6. Biazussi, B. R., Perrotti, V., D’Arcamgelo, C., Elias, C. N.,
Bianchini, M. A., Tumedei, M., & De Vasconcellos, D. K. (2019).
Evaluation of the effect of air polishing with different abrasive
powders on the roughness of implant abutment surface: An in
vitro study. Journal of Oral Implantology, 45(3), 202–206.
7. Bidra, A. S., Daubert, D. M., Garcia, L. T., Gauthier, M. F.,
Kosinski, T. F., Nenn, C. A., Olsen, J. A., Platt, J. A., Wingrove,
S. S., Chandler, N. D., & Curtis, D. A. (2016). A systematic
review of recall regimen and maintenance regimen of patients
with dental restorations. Part 2: Implant-borne restorations.
Journal of Prosthodontics, 25, S16–S31.
568 Chapter 27 Mechanical Implant Maintenance
8. Bidra, A., Daubert, D. M., Garcia, L. T., Kosinski, T. F., Nenn,
C. A., Olsen, J. A., Platt, J. A., Wingrove, S. S., Chandler,
N. D., & Curtis, D. A. (2016). Clinical practice guidelines
for recall and maintenance of patients with tooth-borne and
implant-borne dental restorations. Journal of Prosthodontics,
25, S32–S40.
9. Blazquez-Hinarejos, M., Ayuso-Montero, R., Jane-Salas, E., &
Lopez-Lopez, J. (2017). Influence of surface modified dental
implant abutments on connective tissue attachment: A
systematic review. Archives of Oral Biology, 80, 185–192.
10. Bollen, C. M. L., Lambrechts, P., & Quirynen, M. (1997).
Comparison of surface roughness of oral hard materials to the
threshold surface roughness for bacterial plaque retention: A
review of the literature. Dental Materials, 13, 258–269.
11. Bowers, K. T., Keller, J. C., Randolph, B. A., Wick, D. G., &
Michaels, C. M. (1992). Optimization of surface micro­
morphology for enhanced osteoblast response in vitro.
International Journal of Oral Maxillofacial Implants, 7(3),
302–310.
12. Cha, J. K., Paeng, K., Jung, U. W., Choi, S. H., Sanz, M., &
Martin, I. S. (2019). The effect of five mechanical
instrumentation protocols on implant surface topography
and roughness: A scanning electron microscope and confocal
laser scanning microscope analysis. Clinical Oral Implant
Research, 30, 578–587.
13. Cochis, A., Fini, M., Carrassi, A., Migliario, M., Visai, L., &
Rimondini, L. (2013). Effect of air polishing with glycine
powder on titanium abutment surfaces. Clinical Oral Implant
Research, 24, 904–909.
14. Corbella, S., Del Fabbro, M., Taschieri, S., De Siena, F., &
Francetti, L (2011). Clinical evaluation of an implant
maintenance protocol for the prevention of peri-implant
diseases in patients treated with immediately loaded full-
arch rehabilitations. International Journal of Dental Hygiene, 9,
216–222.
15. De Almeida, J. M., Matheus, H. R., Gusman, D. J. R., Faleiros, P. L.,
De Araujo, N. J., & Novaes, V. C. N. (2017). Effectiveness of
mechanical debridement combined with adjunctive therapies
for nonsurgical treatment of periimplantitis: A systematic
review. Implant Dentistry, 26(1), 137–144.
16. De Avila, E. D., De Molon, R. S., Vergani, C. E., De Assis Mollo,
F., & Salih, V. (2014). The relationship between biofilm and
physical-chemical properties of implant abutment materials
for successful dental implants. Materials, 7, 3651–3662.
17. De Sinea, F., Corbella, S., Taschieri, S., Del Fabbro, M., &
Francetti, L. (2015). Adjunctive glycine powder air-polishing
for the treatment of peri-implant mucositis: An observational
clinical trial. International Journal of Dental Hygiene, 13,
170–176.
18. Dmytiyk, J. J., Fox, S. C., & Moriarty, J. D. (1990). The effects
of scaling titanium implant surfaces with metal and plastic
instruments on cell attachment. Journal of Periodontology, 61,
491–496.
19. Drago, L., Fabbro, M. D., Bortolin, M., Vassena, C., Vecchi,
E. D., & Taschieri, S. (2014). Biofilm removal and
antimicrobial activity of two different air-polishing powders:
An in vitro study. Journal of Periodontology, 85(11), e363–e369.
20. Duarte, P. M., Reis, A. F., De Freitas, P. M., & Ota-Tsuzuki,
C. O. (2009). Bacterial adhesion on smooth and rough
titanium surfaces after treatment with different instruments.
Journal of Periodontology, 80, 1824–1832.
21. Eger, M., Sterer, N., Liron, T., Kohavi, D., & Gabet, Y. (2017).
Scaling of titanium implants entrains inflammation-induced
osteolysis. Scientific Reports, 7, 39612. https://doi.org/10.1038
/srep39612
22. Esposito, M., Grusovin, M. G., & Worthington, H. V. (2012).
Treatment of peri-implantitis: What interventions are
effective? A Cochrane systematic review. European Journal of
Oral Implantology, 5, S21–S41.
23. Figuero, E., Graziani, F., Sanz, I., Herrera, D., & Sanz, M.
(2014). Management of peri-implant mucositis and peri-
implantitis. Periodontology, 2000(66), 255–273.
24. Furtsev, T. V., & Zeer, G. M. (2020). Efficiency of cleaning the
various types of dental implants’ surfaces (Tiu-Nite, Sla, Rbm)
using the air-flow erythritol method. Journal of International
Dental and Medical Research, 13(2), 448–452.
25. Gustumhaugen, E., Lonn-Stensrud, J., Scheie, A. A.,
Lyngstadaas, S. P., Ekfeldt, A., & Taxt-Lamolle, S. (2014).
Effect of chemical and mechanical debridement techniques
on bacterial re-growth on rough titanium surfaces: An in vitro
study. Clinical Oral Implants Research, 25, 707–713.
26. Harrel, S., Wilson, T. G., Pandya, M., & Diekwisch, T. G. H.
(2019). Titanium particles generated during ultrasonic
scaling of implants. Journal of Periodontology, 90, 241–246.
27. Konenen, M., Hormia, M., Kivilahti, J., Hautaniemi, J., &
Thesleff, I. (1992). Effect of surface processing on the
attachment, orientation, and proliferation of human gingival
fibroblasts on titanium. Journal of Biomedical Materials
Research, 26, 1325–1341.
28. Louropoulou, A., Slot, D. E., & Van der Weijden, F. A. (2012).
Titanium surface alterations following the use of different
mechanical instruments: A systematic review. Clinical Oral
Implants Research, 23, 643–658.
29. Lupi, S. M., Granati, M., Butera, A., Collesano, V., Rodriguez,
R., & Baena, Y. (2017). Air-abrasive debridement with glycine
powder versus manual debridement and chlorhexidine
administration for the maintenance of peri-implant health
status: A six-month randomized clinical trial. International
Journal of Dental Hygiene, 15, 287–294.
30. Mann, M., Parmar, D., Walmsley, A. D., & Lea, S. C. (2012).
Effect of plastic-covered ultrasonic scalers on titanium
implant surfaces. Clinical Oral Implants Research, 23, 76–82.
31. Matsubara, V. H., Leong, B. W., Leong, M. J. L., Lawrence, Z.,
Becker, T., & Quaranta, A. Q. (2020). Cleaning potential of
different air abrasive powders and their impact on implant
surface roughness. Clinical Implant Dentistry and Related
Research, 22, 96–104.
32. Mensi, M., Cochis, A., Sordillo, A., Ubertia, F., & Rimondini, L.
(2018). Biofilm removal and bacterial re-colonization
inhibition of a novel erythritol/chlorhexidine air-polishing
powder on titanium disks. Materials, 11(1510), 1–13.
33. Moharrami, M., Perrotti, V., Iaculli, F., Love, R. M., &
Quaranta, A. (2019). Effects of air abrasive decontamination
on titanium surfaces: A systematic review of in vitro studies.
Clinical Oral Implants Research, 21, 398–421.
34. Mussano, F., Rovasio, S., Schlieren, G., Bali, I., & Carossa, S.
(2013). The effect of glycine-powder airflow and hand
instrumentation on peri-implant soft tissues: A split-mouth
pilot study. International Journal of Prosthodontics, 26, 42–22.
35. Nakamura, K., Kanno, T., Milleding, P., & Ortengren, U.
(2009). Zirconia as a dental implant abutment material: A
systematic review. International Journal of Prosthodontics,
23(4), 299–309.
36. Persson, G. R., Samuelsson, E., Lindalh, C., & Renvert, S.
(2010). Mechanical non-surgical treatment of peri-implantitis:
A single-blinded randomized longitudinal clinical study. II.

Microbiological results. Journal of Clinical Periodontology, 37,
563–573.
37. Petersilka, G. (2000). Subgingival air-polishing in the
treatment of periodontal biofilm infections. Periodontology,
55, 124–142.
38. Pettersson, M., Kelk, P., Belibasakis, G. N., Bylund, D.,
Thoren, M. M., & Johansson, A. (2017). Titanium ions form
particles that activate and execute interleukin-1β release
from lipopolysaccharide-primed macrophages. Journal of
Periodontology Research, 52, 21–32.
39. Pjetursson, B. E., Helbling, C., Weber, H. P., Matuliene G.,
Salvi, G. E., Bragger, U., Schmidlin, K., Zwahlen, M., &
Lang, N. P. (2012). Peri-implantitis susceptibility as it related
to periodontal therapy and supportive care. Clinical Oral
Implants Research, 23, 888–894.
40. Renvert, S., Samuelsson, E., Lindahl, C., & Persson, G. R.
(2009). Mechanical non-surgical treatment of peri-implantitis:
A double-blind randomized longitudinal clinical study.
I: Clinical results. Journal of Clinical Periodontology, 36,
604–609.
41. Rezk, F. A., Trimpou, G., Lauer, H. C., Weigl, P., & Krockow, N.
(2018). Response of soft tissue to different abutment materials
with different surface topographies: A review of the literature.
Journal of General Dentistry, 66(1), 18–25.
42. Riben-Grundstrom, C., Norderyd, O., Andre, U., & Renvert, S.
(2015). Treatment of peri-implant mucositis using a glycine
powder air-polishing or ultrasonic device: A randomized
clinical trial. Journal of Clinical Periodontology, 42, 462–469.
43. Rodriguez, D. C., Valderrama, P., Wilson, T. G., Palmer, K.,
Thomas, A., Sridhar, S. Adapalli, A., Burbano, M., &
Wadhwani, C. (2013). Titanium corrosion mechanisms
in the oral environment: A retrieval study. Materials, 6,
5258–5274.
44. Roehling, S., Astasov-Frauenhoffer, M., Hauser-Gerspach, I.,
Braissant, O., Woelfler, H., Waltimo, T., Kniha, H., &
Gahlert, M. (2017). In vitro biofilm formation on titanium
and zirconia implant surfaces. Journal of Periodontology, 88,
298–307.
45. Sahm, N., Becker, J., Santel, T., & Schwarz, F. (2011).
Non-surgical treatment of peri-implantitis using an air-
abrasive device or mechanical debridement and local
application of chlorhexidine: A prospective, randomized,
controlled clinical study. Journal of Clinical Periodontology, 38,
872–878.
46. Sahrmann, P., Winkler, S., Gubler, A., & Attin, T. (2021).
Assessment of implant surface and instrument insert changes
due to instrumentation with different tips for ultrasonic-driven
debridement. BMC Oral Health, 21(25), 1–11.
References 569
47. Sailer, I., Philipp, A., Zembic, A., Pjetursson, B. E.,
Hammerle, C. H. F., & Zwahlen, M. (2009). A systematic
review of the performance of ceramic and metal implant
abutments supporting fixed implant reconstructions. Clinical
Oral Implants Research, 20(4), 4–31.
48. Saneja, R., Bhattacharjee, B., Bhatnagar, A., Verna, K., &
Verna, A. (2020). Efficacy of different lasers of various
wavelengths in treatment of peri-implantitis and peri-implant
mucositis: A systematic review and meta-analysis. Journal of
Indian Prosthodontic Society, 20(4), 353–360.
49. Sanz-Martin, I., Sanz-Sanchez, I., De Albornoz, A. C.,
Figuero, E., & Sanz, M. (2017). Effects of modified abutment
characteristics on peri-implant soft tissue health: A systematic
review and meta-analysis. Clinical Oral Implants Research, 29,
118–129.
50. Sanz-Sanchez, I., Sanz-Martin, I., De Albornoz, A. C.,
Figuero, E., & Sanz, M. (2018). Biological effect of the
abutment material on the stability of peri-implant marginal
bone levels: A systematic review and meta-analysis. Clinical
Oral Implants Research, 28(S18), 124–144.
51. Scarano, A., Patellid, M., Capot, S., Favre, G. A., & Piattelli, A.
(2004). Bacterial adhesion on commercially pure titanium
and zirconium oxide disks: An in vivo human study. Journal
of Periodontology, 75, 292–296.
52. Schou, S., Holmstrup, P., Jorgensen, T., Skovgaard, L. T.,
Stoltze, K., Hjorting-Hansen, E., & Wenzel, A. (2003).
Implant surface preparation in the surgical treatment of
experimental peri-implantitis with autogenous bone graft
and ePTFE membrane in cynomolgus monkeys. Clinical Oral
Implants Research, 14, 412–422.
53. Schwartz, F., Schmucker, A., & Becker, J. (2015). Efficacy of
alternative or adjunctive measures to conventional treatment
of peri-implant mucositis and peri-implantitis: A systematic
review and meta-analysis. International Journal of Implant
Dentistry, 1(22), 2–34.
54. Surez-Lopez del Amo, F., Garaicoa-Pazmino, C., Fretwurst, T.,
Castilho, R. M., & Squarize, C. H. (2018). Dental implants-
associated release of titanium particles: A systematic review.
Clinical Oral Implants Research, 29, 1085–1100.
55. Tong, Z., Fu, R., Zhu, W., Shi, J., Yu, M., & Si, M. (2021).
Changes in the surface topography and element proportion
of clinically failed SLA implants after in vitro debridement
by different methods. Clinical Oral Implant Research, 32,
263–273.
56. Wei, M. C. T., Tran, C., Meredith, N., & Walsh, L. J. (2017).
Effectiveness of implant surface debridement using particle
beams at differing air pressures. Clinical and Experimental
Dental Research, 3, 148–153.
 CHAPTER 28
Nonmechanical Implant
Maintenance
LEARNING OBJECTIVES
After studying this chapter, you will be able to:
1. Appraise, compare, and contrast
nonmechanical debridement technologies used
in the maintenance of a dental implant.
2. Select the appropriate debridement technique
based on implant, abutment, and prosthesis
presentation.
3. Recognize the clinical indications, limitations,
and contraindications of nonmechanical
debridement technology and techniques.
KEY TERMS
• Arestin: 1 mg minocycline hydrochloride
applied into a periodontal pocket with sustained
controlled release over a specified period of time.
• Atridox: 10% concentration doxycycline hyclate
applied into a periodontal pocket with sustained
controlled release over a specified period of time.
• Catalase: enzyme present in obligate aerobe
bacteria, facultative anaerobic bacteria, and
human cells that catalyzes the reactions of
hydrogen peroxide, decomposing it to water and
oxygen
• Chlorhexidine: a cationic biguanide microbicide
solution with a broad spectrum of action against
fungi, gram positive bacteria, and gram negative
bacteria.
• Dental laser: a device used in the practice of
dentistry that emits an intense narrow beam
of non-ionizing nondivergent monochromatic
electromagnetic radiation of one coherent
wavelength that is used on either a cutting or
non-cutting mode.
• Ethylenediaminetetraacetic acid (EDTA): a
polyaminocarboxylic acid that decalcifies dentin
and removes the smear layer, making it a useful
chelating agent in endodontic procedures.
• Facultative anaerobic bacteria: bacteria that grow
in the presence or absence of oxygen.
• Hydrogen peroxide (H2O2): a highly reactive,
strong oxidizing chemical compound with
an unpaired electron, capable of damaging
cellular lipids, proteins, nucleic acids, and cell
membranes, leading to increased permeability
and death.
• Obligate aerobic bacteria: bacteria that require
oxygen to live and grow.
• Obligate anaerobic bacteria: bacteria whose
growth stops in the presence of oxygen.
• Ozone (O3): an allotropic modification of the
oxygen molecule, mixing pure oxygen with pure
ozone to make a chain of three atoms of oxygen
that is delivered in the dental field as a gas or a
liquid (ozonated water, oil, or saline).
• Perio Gel: the name of a proprietary prescription
1.7% hydrogen peroxide gel patented and
manufacturer by Perio Protect.
• Perio Protect: trade name of the company that
delivers the proprietary prescription Perio Gel in
a Perio Tray for at-home use in the treatment of
•
gingival inflammation.
Perio Tray: the name of a proprietary custom
lab-made fabricated prescription tray fabricated
of an ethylene vinyl acetate (EVA) elastomer
material with an internal peripheral seal
manufactured by Perio Protect.
• PerioChip: 2.5 mg of chlorhexidine gluconate
in a biodegradable matrix of hydrolyzed
gelatin (cross-linked with glutaraldehyde),
glycerin, and purified water that is locally
571
572 Chapter 28 Nonmechanical Implant Maintenance

administered into periodontal pockets with

sustained controlled release over a specified Table 28-1 Debridement Approaches
period of time.
• Peroxidase: group of enzymes that act as a
catalyst in reactions in which hydrogen peroxide is
Mechanical
■ Hand-activated
Nonmechanical
■ Dental lasers
reduced. instrumentation Chlorhexidine
•
■

Photodynamic therapy (PDT): procedure performed ■ Ultrasonic ■ Low-concentration (<3%)

with a dental laser in a non-cutting mode that uses instrumentation hydrogen peroxide
the laser wavelength energy to decontaminate, ■ Air polishing ■ Ozone (O3)
increase osteoblastic and fibroblastic activity, ■ Locally administered
decrease inflammation, and provide analgesia. antibiotics and antimicrobials
• Substantivity: a solution’s persistence of effect, or
resistance of removal, determined by its chemical
bonding to a surface, substrate, or structure.
• Tetracycline: broad-spectrum class of antibiotics
with bacteriostatic properties against both gram
Table 28-2 Nonmechanical Debridement
negative and gram positive bacteria. Techniques
Nonmechanical Debridement In-Office At-Home
Technique Therapy Therapy
Dental lasers  
Introduction Chlorhexidine  

Patients with implant-borne removable and fixed Low-concentration (<3%)  

prostheses require lifelong well-structured recall
maintenance to promote biological (bone and soft
tissue) health customized to their individual needs,
which may be different than patients of the same age
without implant-borne restorations (Bidra, Daubert,
Garcia, Kosinski, et al., 2016; Bidra, Daubert, Garcia,
Gauthier, et al., 2016; Corbella et al., 2011; ­Pjetursson
et al., 2012). Improper treatment planning, failure to
identify risk factors, inappropriate maintenance re-
call recommendations, and incomplete debridement
can lead to peri-implant disease in a susceptible host
(Corbella et al., 2011; Saneja et al., 2020).
This chapter will discuss nonmechanical debride-
ment technology used in implant maintenance. This
technology is commonly used as an adjunct to me-
chanical debridement techniques presented in the last
chapter. Adjunctive technology is especially useful
when managing peri-implant diseases. The goal of im-
plant debridement is to mechanically or nonmechani-
cally disrupt and remove supragingival and subgingival
oral deposits and reduce the number of pathogenic or-
ganisms to promote immunological health of implant-
hydrogen peroxide
Ozone (O3)  
Locally administered  
antibiotics and antimicrobials
number of pathogenic organisms to promote im-
munological health of implant-supported bone and
soft tissues without adversely altering the surface
characteristics of the implant, abutment, or pros-
thesis to maintain biocompatibility (see Table 28-1
for mechanical and nonmechanical debridement
approaches to implant care).
Nonmechanical technology is employed when
peri-implant disease and inflammation is present to
reduce biofilm and pathogenic organisms to a level
that promotes immunological health. Some nonme-
chanical debridement approaches are administered in
the office while others are used by the patient at home
(see Table 28-2).

supported bone and soft tissues without adversely
altering the surface characteristics of the implant, abut-
ment, or prosthesis to maintain biocompatibility.
Implant Debridement Goals
The goal of implant debridement is to mechanically
or nonmechanically disrupt and remove supragin-
gival and subgingival oral deposits and reduce the
Nonmechanical
Debridement
Nonmechanical debridement techniques are typically,
but not always, used as an adjunct to mechanical
debridement. Nonmechanical debridement approaches
include dental lasers, chlorhexidine, low-concentration
(<3%) hydrogen peroxide, ozone (O3), or locally
administered antibiotics and antimicrobials.
 Nonmechanical Debridement 573

These agents are part of a comprehensive treatment Laser Defined

plan for patients with active peri-implant disease. Ac-
The word laser is an acronym that stands for light ampli-
cording to the American Academy of Periodontology,
fication by stimulated emission of radiation. A dental
adjunctive agents such as non-mechanical debride-
laser is a device used in the practice of dentistry that
ment techniques “can be helpful in deep periodontal
emits an intense narrow beam of non-ionizing non-
pockets, anatomical defects, non-responsive sites, un-
divergent monochromatic electromagnetic radiation
resolved inflammation, and overall biofilm reduction
of one coherent wavelength that is used on either a
and control” (American Academy of Periodontology,
cutting or non-cutting mode (see Figure 28-2.) A den-
2006). For an adjunctive agent to be effective, it must
tal laser is classified as a medical laser device by the
(American Academy of Periodontology, 2006):
US Food and Drug Administration (FDA; n.d.) in the
1. Reach the base of the periodontal pocket. United States.
2. Possess bacteriostatic or bactericidal properties. Dental laser energy is of one wavelength (expressed
3. Remain in place long enough to exert its action. as nm) dependent on where the laser energy falls on
According to a systematic review published the electromagnetic spectrum (see Figure 28-3). Den-
by Hallstrom et al. (2017), a onetime irrigation of tal laser wavelengths are in the visible and infrared
a solution during nonsurgical periodontal ther- portion of the electromagnetic spectrum, which is
apy provided no additional benefit to patient out- non-ionizing energy. The laser wavelength energy in-
comes because irrigant medicaments do not possess teracts with hard and soft tissues in the mouth.
long-lasting substantivity in the sulcus or peri-
odontal pocket. Substantivity refers to a solution’s
persistence of effect, or resistance of removal, de-
termined by its chemical bonding to a surface, sub-
strate, or structure. Substantivity tells us how long
a product remains active to produce its effects in
the mouth.

Dental Lasers
There are many dental lasers on the market being
used as either an adjunct to the mechanical debride-
ment of dental implants or as a monotherapy (single)
approach (see Figure 28-1). A laser is used by a trained
oral health-care provider and delivered in-office. In
the United States, each state has specific rules and
regulations for lase use by a dentist or dental hygien-
ist. Check with your individual state dental board for
further information. Figure 28-1 Dental laser (Dentsply Sirona Siro Laser Blue).

Figure 28-2 Electromagnetic spectrum—ionizing energy (left visible light); nonionizing energy (right visible light).
© AIexVector/Shutterstock.
574 Chapter 28 Nonmechanical Implant Maintenance
Erbium
2,700–3,200 nm
Diode Carbon Dioxide
600–980 nm 9,000 nm+
Neodymium
1,064–1,340 nm
Figure 28-3 Dental lasers in the infrared zone of the
electromagnetic spectrum.
• Wavelengths high (carbon dioxide) and low
(neodymium, diode) in the infrared zone inter-
act with some hard tissue components like hy-
droxyapatite but are highly attracted to soft tissue
components such as water, melanin, and hemo-
globin (Gutierrez-Corrales et al., 2020; Parker,
2007). They are predominately used in soft tissue
procedures.
• Wavelengths in the middle of the infrared
(erbium) interact with some soft tissue components
and additional hard tissue components such as
hydroxyapatite (Gutierrez-Corrales et al., 2020;
Parker, 2007; Pagano et al., 2020). They are used
for both hard and soft tissue procedures.
Lasers are made of various materials and
when stimulated, produce a specific wavelength
(Gutierrez-Corrales et al., 2020). The carbon diox-
ide laser is made of gas. Diode, neodymium, and er-
bium lasers are made of a combination of metals or
semiconductor crystals such as aluminum, arsenic,
gallium, indium, scandium, and yttrium to which an
element such as chromium, neodymium, or erbium is
doped (added).
Laser Mechanism of Action
Lasers produce photothermal effects in the mouth
by converting their light energy into heat, which al-
lows them to optimize various photobiological effects
in the mouth. Wavelengths higher in the infrared
zone of the electromagnetic spectrum produce more
thermal emissions (heat), which allow them to cut
through tissues efficiently. The carbon dioxide laser is
an example of this and is frequently used in surgical
procedures (Matthews et al., 2010; Zue et al., 2021).
Lasers are used in cutting and non-cutting modes.
Each mode is used for different procedures.
Non-Cutting Mode. In a non-cutting mode, a
dental laser can:
• Decontaminate the mouth through bactericidal
actions (Giannopoulou et al., 2012; Salvi et al.,
2020; Soukos & Goodson, 2011; Tateno et al.,
2020).
• Increase osteoblastic and fibroblastic activity to
accelerate bone and tissue healing (Giannopoulou
et al., 2012; Salvi et al., 2020; Soukos & Goodson,
2011).
• Decrease inflammation through changes in inflam-
matory and immune mediators (Convissar, 2016;
Giannopoulou et al., 2012; Salvi et al., 2020;
Soukos & Goodson, 2011).
• Provide analgesia post-procedure or in the man-
agement of painful conditions such as temporo-
mandibular disorder (TMD), burning mouth,
ulcers, oral candidiasis, or stomatitis (Convissar
et al., 2016; Giannopoulou et al., 2012; Salvi
et al., 2020; Soukos & Goodson, 2011).
A specific procedure termed ­ photodynamic
therapy (PDT), also referred to as photobiomodula-
tion, low-level laser therapy, cold laser therapy, ther-
apeutic l­aser therapy, or soft laser therapy, is used
to produce the effects listed above (Convissar
et al., 2016).
• PDT utilizes a low-energy wavelength (visible red,
near-visible infrared, or low infrared) dental la-
ser in a non-cutting mode (Convissar et al., 2016;
Giannopoulou et al., 2012; Salvi et al., 2020;
Soukos & Goodson, 2011).
• PDT is used with or without (depending on the
manufacturer) a photosensitizer such as tolui-
dine blue, methylene blue, or malachite green
(Convissar er al., 2016; Salvi et al., 2020;
Soukos & Goodson, 2011). The photosensitizer
absorbs the laser wavelength and generates a
free radical or singlet oxygen, which is toxic to
microorganisms (Salvi et al., 2020; Soukos &
Goodson, 2011).
Cutting Mode. Dental lasers used in a cutting
mode physically ablate hard and soft tissues. Abla-
tion, as defined in Chapter 3, is the complete removal
of a substance or material through erosion, chipping,
or vaporization actions. The clinical application of a
cutting mode laser spans every specialty of dentistry.
For example, they are used to cut soft and hard tis-
sues in surgical procedures, remove diseased epi-
thelial tissue in nonsurgical procedures, and remove
carious lesions.
Lasers and Dental Implants
Lasers can be used as a monotherapy or adjunctive
therapy in the debridement of dental implants.

• Adjunctive therapy: As an adjunct to mechanical
debridement, laser actions are useful in times of
clinical challenges such as deep probe depths and
tissue inflammation, or for the debridement of ex-
posed implant threads.
• Monotherapy: Erbium lasers are the most com-
monly used as monotherapy owing to some man-
ufacturers’ claims that the wavelength can remove
dental calculus and plaque biofilm without the
adjunctive use of mechanical instrumentation
(Salvi et al., 2020; Figuero et al, 2014; Schwart
et al., 2015; Schwartz et al., 2008).
BREAKOUT POINT
A dental laser is useful in times of peri-implant
inflammation because it will decontaminate
periodontal pockets, decrease inflammation,
increase osteoblastic and fibroblastic activity to
decrease post-treatment pain, and decrease healing
time.
Laser Literature
• A systematic review published by Chala et al.
(2020) the adjunct use of dental lasers in non-­
surgical treatment of peri-implant mucositis and
peri-implantitis provide better results only in the
short term (3 months) and that all wavelengths
presented similar results.
• A systematic review published by Saneja et al.
(2020) concluded that laser treatment as an
adjunctive therapy or monotherapy in peri-­
implantitis did not show any superior effects than
conventional measures.
• Studies show at 1 to 9 months post-treatment, la-
ser test groups had better reductions in bleeding
upon probing than controls (Chala et al., 2020;
Aimetti et al., 2019; Bassetti et al., 2014; Persson
et al., 2011; Renvert et al., 2011; Sanchez-Martos
et al., 2020; Schar et al., 2012; Schwartz et al.,
2005, 2006, 2011).
• Studies evaluating the long-term results (≥12
months) found lasers did not produce any ad-
ditional benefits to treatment outcomes (reduc-
tion of probe depth, gain of clinical attachment)
compared to mechanical debridement with
hand-­ activated instruments, ultrasonic instru-
mentation, or subgingival air polishing (Saneja
et al., 2020; Aimetti et al., 2019; Bassetti et al.,
2014; Persson et al., 2011; Renvert et al., 2011;
Nonmechanical Debridement 575
Sanchez-Martos et al., 2020; Schar et al., 2012;
Schwartz et al., 2005, 2006, 2011).
Adverse Effects
Dental laser adverse effects are typically related to pro-
vider errors such as using improper settings or incor-
rect clinical technique (Saneja et al., 2020).
• Improper settings: Using improper settings such
as peak laser power, power density, or emission
modes (continuous, free-running, pulsed, gated,
chopped) can adversely affect a natural tooth or
dental implant.
• Improper clinical technique: using improper
technique such as duration of exposure, con-
tact with materials, and whether the optic fiber
tip is initiated (cutting mode) or non-initiated
(non-cutting mode) can adversely affect a natural
tooth or implant.
Studies have shown that titanium absorbs irra-
diation produced from infrared wavelengths (Chala
et al., 2020), so using proper settings and technique is
imperative to avoid adverse outcomes.
Chlorhexidine
When antimicrobial action is needed in times of
peri-implant tissue inflammation, the American
College of Prosthodontists recommend at-home
short-term use of chlorhexidine (Bidra, Daubert, Gar-
cia, Kosinski, et al., 2016). Chlorhexidine is a cationic
biguanide microbicide solution with a broad spectrum
of action against fungi, gram-positive bacteria, and
gram-­negative bacteria (Backhouse, 2016; Jenkins et
al., 1988; Kuyyakanond & Quesnel, 1992; Sahrmann
et al., 2019; Tsourounakis et al., 2013). Chlorhexi-
dine binds to cell membranes and causes permeability
of the intracellular components (Tsourounakis et al.,
2013). It can be delivered as a mouth rinse, gel, or
spray, or locally administered in the office by a trained
professional. Concentrations vary for all methods of
delivery and there is no one industry recommendation
for a specific concentration or delivery system.
• A study by Ready et al. (2015) found a 0.2% con-
centration chlorhexidine significantly reduced the
numbers of viable bacteria on the titanium surface
of a dental implant.
• A study by Paolantonio et al. (2008) found re-
duced bacterial colonization of a dental implant
over a 6-month period when a 1% chlorhexidine
gel was placed in the internal cavity of an implant
prior to placement.
576 Chapter 28 Nonmechanical Implant Maintenance
BREAKOUT POINT
The American College of Prosthodontists
recommends chlorhexidine when antimicrobial
action is needed for peri-mucosa inflammation.
Chlorhexidine produces good substantivity
compared to other medicaments, and it displays im-
mediate bactericidal effects in the mouth (Jenkins
et al., 1988; Tsourounakis et al., 2013). This is then
followed by a longer-lasting bacteriostatic action
through chlorhexidine’s attachment or absorption to
the acquired pellicle. These actions allow chlorhexi-
dine to inhibit new plaque biofilm formation on tooth
surfaces (Jenkins et al., 1988).
Chlorhexidine effects on cell death and fibroblasts
have been studied over the past few decades. A study
by Tsourounakis et al. (2013) found chlorhexidine ef-
fects on cell death and fibroblasts are concentration
and exposure dependent.
• Cell death: 1% chlorhexidine exposure caused
50% bacterial cell death while a 5% concentration
caused 95% bacterial cell death.
• Fibroblasts: <10% concentration produced no
significant reduction in viability of fibroblasts
while a 15–20% concentration produced a lethal
effect. A 5% concentration of 3-minute exposure
produced 60% fibroblast death up to 7 days after
exposure. This information is clinically relevant
when a procedure such as nonsurgical periodon-
tal therapy is performed, and increased fibroblas-
tic activity is desired postoperatively.
Locally Administered Chlorhexidine
Chlorhexidine can be manufactured as a locally ad-
ministered antimicrobial that is professionally applied
into periodontal pockets in the office. A common
example is PerioChip, which contains 2.5 mg of
chlorhexidine gluconate in a biodegradable matrix
of hydrolyzed gelatin (cross-linked with glutaralde-
hyde), glycerin, and purified water (FDA, 2012b).
When correctly placed in the pocket, the 2.5-mg gel-
atin remains in the subgingival environment for an
increased length of time, prolonging its action (see
Figure 28-4).
• A study by Sahrmann et al. (2019) evaluated
the adjunctive use of 1% chlorhexidine gel ver-
sus PerioChip for implants with peri-implant
mucositis. Patients received a rubber cup and
polishing paste along with a one-time irrigation
Figure 28-4 PerioChip.
Reproduced with permission from Perio Chip
with liquid chlorhexidine. One group received
a subgingival application of a 1% chlorhexidine
gel, and the other received PerioChip. Procedures
were repeated 3 months later. At the 6-month
postoperative evaluation, both groups displayed
reductions in probe depths and bleeding upon
probing; however, the PerioChip group had sig-
nificantly greater reductions in probe depth and
bleeding upon probing, with decreased tissue
inflammation.
Chlorhexidine Gel, Mouth Rinse,
and Spray Studies
Studies have been done on varied concentrations,
delivery, and exposure time with chlorhexidine. As
a commonality, studies have failed to demonstrate a
statistically significant difference in overall clinical
outcomes with the adjunctive use of chlorhexi-
dine in times of peri-implant mucositis and peri-
implantitis; however, short-term benefits have been
noted in some studies (Hallstrom et al., 2017; Menezes
et al., 2016; Porras et al., 2002; De Siena et al.,
2013; Thone-Muhling et al., 2010). The following is
a summary of five different studies that evaluated var-
ied deliveries, concentrations, and exposure times of
chlorhexidine.
• Hallstrom et al. (2017) evaluated the adjunctive
use of a 0.2% chlorhexidine gel over a short pe-
riod of time (12 weeks) for implants with peri-­
implant mucositis. Two groups received implant
debridement with titanium curettes, rubber cup

polishing, and oral hygiene instructions. One
group brushed twice daily with 0.2% chlorhex-
idine gel with neutral sodium fluoride. The sec-
ond group brushed with a placebo paste (neutral
sodium fluoride and methylparaben preserva-
tive). No statistically significant differences in
plaque scores or probe depths were noted at the
conclusion of the study; however, bleeding upon
probing was significantly improved in the chlor-
hexidine group after 4 and 12 weeks.
• Menezes et al. (2016) evaluated the adjunc-
tive use of 0.12% chlorhexidine effects for im-
plants with peri-implant mucositis. Two groups
received nonsurgical periodontal therapy with
plastic curettes along with oral hygiene instruc-
tions. One group used 0.12% chlorhexidine daily
at home, brushing the dorsum of the tongue for
1 minute and then gargling the liquid for the
last 10 ­seconds, followed by subgingival irriga-
tion. The second group did not use chlorhexi-
dine at home. Six months post-procedure, both
groups showed statistically significant reduc-
tions in plaque scores, gingival bleeding index,
probe depths, and bleeding upon probing with
no statistically significant differences between the
groups, indicating the addition of chlorhexidine
as it was delivered in the study did not enhance
clinical outcomes.
• Porras et al. (2002) evaluated the adjunctive use
of 0.12% chlorhexidine effects for implants with
peri-implant mucositis. Two groups received me-
chanical debridement with plastic scalers, rubber
cup polishing with prophylaxis paste, and oral
hygiene instructions. One group received an ad-
ditional one-time irrigation of 0.12% chlorhexi-
dine and a one-time topical 0.12% chlorhexidine
gel application followed by twice daily rinsing
(30 seconds) at home with a 0.12% chlorhexidine
mouth rinse for 10 days. The second group did
not use chlorhexidine. Both groups demonstrated
statistically significant decreases in probe depths,
improvements in clinical attachment level, and a
decrease in peri-implant mucositis with no statis-
tically significant differences between the groups,
indicating the addition of chlorhexidine as it was
delivered in the study did not enhance clinical
outcomes.
• Siena et al. (2013) evaluated the adjunctive use of
0.2% chlorhexidine mouth rinse and 1% chlor-
hexidine gel effects for implants with peri-implant
mucositis. Two groups received mechanical de-
bridement followed by oral hygiene instructions.
One group rinsed with 0.2% chlorhexidine twice
Nonmechanical Debridement 577
daily for 10 days and the other applied 1% ch-
lorhexidine gel subgingivally for 10 days. Three
months post-procedure, both groups demon-
strated reductions in probe depths and inflamma-
tion. Plaque levels were significantly reduced in
both groups, but only for the first month.
• Thone et al. (2010) evaluated the effects of ad-
junctive use of chlorhexidine alongside mechan-
ical debridement for implants with peri-implant
mucositis. Two groups received oral hygiene in-
struction, full mouth mechanical debridement,
and implant debridement with a Polyether ether
ketone (PEEK) piezoelectric ultrasonic tip and
plastic hand-activated scaler. One group was pro-
vided additional chlorhexidine in the form of a
one-time 1% gel applied subgingivally around the
dental implant, 1% gel brushed onto the tongue,
and a 0.2% spray on the tonsils. Patients were pro-
vided a 0.12% mouth rinse to use twice daily for
14 days. The second group did not use chlorhex-
idine. Eight months post-procedure, both groups
demonstrated a statistically significant decrease
in probe depths, improvements in clinical attach-
ment level, decrease in bleeding, and improved
gingival indexes with no statistically significant
differences between the groups, indicating the ad-
dition of chlorhexidine as it was delivered in the
study did not enhance clinical outcomes.
Ozone and Hydrogen Peroxide
Ozone and hydrogen peroxide have an antimicrobial
effect on bacteria, viruses, and fungi because they are
strong oxidizers. They are powerful decontaminants
and antiseptics with bactericidal effects.
Bacteria can be classified by their susceptibility to
grow or die in the presence of oxygen.
• Obligate aerobes: bacteria that require oxygen
to live and grow.
• Obligate anaerobes: bacteria whose growth
stops in the presence of oxygen.
• Facultative anaerobes: bacteria that can grow
in the presence or absence of oxygen; however,
they grow best in the presence of oxygen.
Obligate aerobes, facultative anaerobes, and obli-
gate anaerobes all display a susceptibility to the effects
of ozone and hydrogen peroxide, with obligate anaer-
obes having the most toxic reaction. In the treatment
of gingival and periodontal diseases, ozone and hy-
drogen peroxide decrease viable bacteria and inhibit
the accumulation of biofilm (Keller & B ­ uechel, 2017a;
Hossainian et al., 2011; Putt & Proskin, 2010).
578 Chapter 28 Nonmechanical Implant Maintenance

­ uman cells are not harmed because they have protec-

H Hydrogen Peroxide
tive enzymes, proteins, and nutrients that neutralize
the oxidative effects of ozone and hydrogen peroxide
(Nandi et al., 2019).
BREAKOUT POINT
Hydrogen peroxide and ozone have bactericidal
actions in the mouth.
Ozone
Ozone has been used in medicine since the 1930s
(Gupta & Mansi, 2012; Kumar et al., 2014; Tonon et al.,
2021). Ozone (O3) is an allotropic modification of
the oxygen molecule mixing pure oxygen with pure
ozone to make a chain of three atoms of oxygen that
is delivered in dentistry as a gas or a liquid (ozonated
water, oil, or saline; Gupta & Mansi, 2012; Kumar
et al., 2014; Tonon et al., 2021; Gallo & Scribante,
2021; Srikanth et al., 2013). Ozone is applied in-­
office by a trained professional.
• Ozone is used as a disinfectant and wound healer
in the mouth because of its antioxidant, anti-
inflammatory, analgesic, and immune-stimulating
effects (Gupta & Mansi, 2012; Tonon et al., 2021;
Gallo & Scribante, 2021).
BREAKOUT POINT
Ozone has antioxidant, anti-inflammatory, analgesic,
and immune-stimulating effects in the mouth.
Hydrogen peroxide (H2O2) is a highly reactive, strong
oxidizing chemical compound with an unpaired elec-
tron. It will damage cellular lipids, proteins, nucleic
acids, and cell membranes, leading to increased per-
meability and death (Boyd, 1989; Boyd et al., 2021;
Lazarchik & Haywood, 2010; Pedziwiatr et al., 2018).
Human cells, obligate aerobic bacteria, and facultative
anaerobic bacteria possess enzymes called catalase
and peroxidase. These enzymes neutralize hydro-
gen peroxide, decomposing it to water and oxygen
in the mouth. This decomposition can be physically
seen when hydrogen peroxide is poured onto a skin
wound and oxygen bubbles form on the surface as it is
debriding and disinfecting the area (see Figure 28-5).
Obligate anaerobic bacteria are unable to neutral-
ize the oxidization effects of hydrogen peroxide and
are destroyed when exposed. These microbiological
properties make hydrogen peroxide a useful chemical
agent in the fight against gingival diseases, inflamma-
tion, halitosis, and oral infections caused by obligate
anaerobe invasion. Hydrogen peroxide is recognized
by the FDA as an oral wound healing agent whose
ability to reduce gingival inflammation dates back to
the 1960s (Lazarchik & Haywood, 2010; FDA, 2020).
BREAKOUT POINT
Obligate anaerobic bacteria in the mouth have the
most toxic reaction to low-concentration hydrogen
peroxide.

• Ozone promotes fibroblastic activity; reduces cy-

tokines, interleukins, and prostaglandins; and can
alter the cytoplasm, cell wall, and enzymatic func-
tion of bacterial and fungal cells (Kumar et al.,
2014; Gallo & Scribante, 2021).
• Ozonated water, oil, or saline is used to irrigate
periodontal pockets, to irrigate intracanals during
endodontic procedures, and in caries risk reduction
by oxidizing pyruvic acid produced by cariogenic
bacteria; as an oral wound healer (herpes, aph-
thous ulcer, candidiasis, lichen planus, stomatitis);
used alongside dental lasers for post-surgical pain
in oral surgery procedures; and in the manage-
ment of TMD pain (Kumar et al., 2014; Tonon
et al., 2021; Gallo & Scribante, 2021; Srikanth
et al., 2013. Figure 28-5 Hydrogen peroxide on a wound.
 Nonmechanical Debridement 579

Low-concentration hydrogen peroxide (<3%) patient’s disease as reported in the periodontal

is found in over-the-counter at-home mouth rinses, charting and intraoral camera photographs.
dentifrices, and antiseptic gels. Low-concentration • Perio Protect is used in the management of gingi-
hydrogen peroxide delivered in a tray carrier for val inflammation associated with oral inflamma-
at-home use can also be prescribed by a trained oral tory processes.
health-care provider.
The patient wears the tray and gel for a specific
• Perio Protect is the name of a company number of times per day (protocol established by Perio
that formulated a prescription proprietary Protect) based on their level of inflammation.
1.7% hydrogen peroxide gel (Perio Gel; see
Figure 28-6a and b) delivered in an FDA-cleared
• When the contact time of hydrogen peroxide is
increased in the mouth, biofilm complexes are
medical device lab-made custom-fabricated pre- destroyed, and the pathology and virulence of
scription tray (Perio Tray; see Figure 28-7a and b). the subgingival environment is reduced through
• Perio Tray is classified as a medical device in the
United States by the FDA, which defines it as a
“custom sit tray requiring an impression from a
licensed dentist that is sent to a specialized dental
laboratory.” The FDA states that the tray is “used
to place Perio Gel solution into gingival crevices
or periodontal pockets and permits the placement
of solutions deeper into the crevice/pocket than
possible with traditional fluoride trays” (FDA,
2004). The tray is fabricated from an ethylene vi-
nyl acetate (EVA) elastomer material in a dental
laboratory and customized with an internal pe-
ripheral seal according to the magnitude of the

B B
Figure 28-6 Perio Gel by Perio Protect: A. Perio Gel Figure 28-7 Perio Tray by Perio Protect: A. Perio Tray on
package; B. Perio Gel application into a Perio Tray. a cast model, B. Perio Tray on a cast model.
Reproduced with permission from Perio Protect, LLC. Reproduced with permission from Perio Protect, LLC.
580 Chapter 28 Nonmechanical Implant Maintenance
hydrogen peroxide’s bactericidal and toxic effects
on cells (Hossainian et al., 2011; Putt & Proskin,
2010; Boyd, 1989; Keller & Buechel, 2017a).
• Scanning electron microscope and DNA analysis
have shown that Perio Gel can alter the micro-
biological state of the subgingival environment
through increasing subgingival oxygen saturation,
which is toxic to obligate anaerobic and faculta-
tive anaerobic bacteria (Keller & Buechel, 2017a,
2017b; Dunlap et al., 2011).
BREAKOUT POINT
Subgingival low-concentration hydrogen peroxide
destroys biofilm and reduces the number of bacteria
present in the gingival crevicular fluid.
Ozone and Hydrogen
Peroxide Literature
• A study published by Tonon et al. (2021) evalu-
ated ozonized saline solution and chlorhexidine
effects on peri-implant-related biofilm. Research-
ers found both chemicals produced similar anti-
biofilm effects and were capable of significantly
reducing the microbes investigated.
• A study published by McKenna et al. (2013) eval-
uated subgingival ozone and subgingival hydro-
gen peroxide effects on the plaque index, bleeding
index, and gingival index of dental implants with
peri-implant mucositis. Ozone plus hydrogen
peroxide produced the best gingival health scores
and was the most effective therapy in controlling
bleeding and reducing plaque scores.
Locally Administered
Antibiotics
Systemic antibiotics are no longer a standard of care,
and not routinely used, for the treatment and manage-
ment of periodontal and peri-implant diseases due to
multiple reasons such as:
• The benefits of the antibiotics would have to
outweigh the risk of contributing to the world-
wide public health crisis of antibiotic resistance
(Gehrig et al., 2019; Toledano et al., 2021).
• The antibiotic dose required to penetrate through
a biofilm matrix to access individual bacterial
cells is so high it would kill the patient (Keller &
Buechel, 2017a; Gehrig et al., 2019). The protec-
tive matrix around the biofilm shields the struc-
ture from antibiotic penetration.
In the rare situation where a systemic antibiotic
is indicated, the subgingival environment should be
cultured first so the correct medication is adminis-
tered. Antibiotics may be indicated for a patient with
systemic fever and malaise associated with a dental in-
fection, patients who are nonresponsive to initial ther-
apy, during surgical procedures and interventions, or
for a patient who is medically compromised.
BREAKOUT POINT
Systemic antibiotics are not routinely prescribed
in the treatment and management of peri-implant
diseases.
A common class of antibiotics used for local ad-
ministration into a periodontal pocket are tetracy-
clines. Tetracyclines are a class of antibiotics with
broad-spectrum bacteriostatic properties against both
gram-negative and gram-positive bacteria. Doxycycline
and minocycline are second-generation semisynthetic
tetracyclines that are used for delivery into a periodon-
tal pocket with sustained released that prolongs their
duration of action.
• Doxycycline: Atridox (Tolmar Therapeutics, Inc.)
is a controlled release doxycycline product (7 days)
with a two-syringe mixture of “450 mg A ­ TRIGEL
Delivery System, which is a bioabsorbable, flow-
able polymeric formulation composed of 36.7%
poly(DLlactide) (PLA) dissolved in 63.3%
N-methyl-2-pyrrolidone (NMP)” and “50 mg of
doxycycline hyclate which is equivalent to 42.5 mg
doxycycline” (FDA, 2011) (see Figure 28-8). The
constituted product has a concentration of 10% of
doxycycline hyclate (FDA, 2011).
• Minocycline: Arestin (Orapharma Bausch Health
Companies, Inc.) it is a controlled and sustained
release minocycline product with “1 mg minocy-
cline hydrochloride incorporated into a bioresorb-
able polymer, Poly or PGLA” (FDA, 2012a) (see
Figure 28-9). As per Orapharma, Arestin is not ap-
proved for use in the treatment of peri-implantitis.
A systematic review by Toledano et al. (2021),
evaluated the adjunctive use of locally administered
antibiotics that permit high concentrations to be main-
tained in a dental implant boney and soft tissue defect.
• The conclusion of the systematic review was that
“the local antibiotic administration does reduce,
without adverse effects, both peri-implant prob-
ing depths and bleeding on probing in patients
affected by peri-implantitis, if compared to con-
trol groups without local antibiotic application.”
 Nonmechanical Debridement and Peri-Implantitis
Figure 28-8 Atridox, Tolmar Therapeutics, Inc.
Reproduced with permission from Den-Mat Holdings, LLC.
Figure 28-9 Arestin Orapharma Bausch Health
Companies, Inc.
Reproduced with permission from OraPharma, a division of Bausch Health US, LLC.
• When locally administered antibiotics were not
used, there was a twofold increase in the likeli-
hood of continued bleeding.
Doxycycline
A study by Butcher et al. (2004) evaluated adjunc-
tive use of Atridox for dental implants with active
peri-implantitis.
• Two groups received mechanical debridement
with plastic hand-activated scalers, 0.2% chlor-
hexidine irrigation, and oral hygiene instructions.
One group received additional Atridox, and the
second group did not.
581
• Eighteen-weeks post-procedure, both groups
demonstrated significant reductions in probe
depths and bleeding. Four months post-procedure,
the group that received Atridox displayed 50%
greater reductions in probe depths and bleeding
upon probing.
Minocycline
A study by Bassetti et al. (2014) evaluated adjunctive
use of Arestin and laser therapy for dental implants
with active peri-implantitis.
• Two groups received debridement with titanium
hand-activated scalers combined with GPAP. One
group received additional laser therapy (photody-
namic therapy) while the second group received
Arestin.
• At 12 months post-procedure, both groups dis-
played statistically significant reductions in bleeding
upon probing, probe depths, and microbial counts.
A study by Renvert et al. (2006) evaluated the ad-
junctive use of Arestin for dental implants displaying
active infection over a 12-month period.
• Two groups received debridement with carbon
hand-activated instruments and oral hygiene in-
structions. One group received Arestin, and the
second group received 1 ml of 1% chlorhexidine
gel placed subgingivally.
• Twelve months post-procedure, both groups
demonstrated reductions in probe depth, bleed-
ing upon probing, and microbial counts; how-
ever, the group that received Arestin displayed
significantly greater reductions in probe depth
and bleeding upon probing.
Nonmechanical
Debridement
and Peri-Implantitis
Due to the limitations of mechanical debridement of
a dental implant (see Chapter 27), adjunctive nonme-
chanical technology may be needed to resolve disease
progression (Schwartz et al., 2015). The following is
a summary of three different studies that evaluated
various non-mechanical debridement approaches for
dental implants with peri-implantitis:
• A study by Persson et al. (2011) evaluated and
compared clinical outcomes with an erbium la-
ser used as monotherapy to EPAP. Both groups
demonstrated similar reductions in probe depths,
bleeding upon probing, and suppuration with
582 Chapter 28 Nonmechanical Implant Maintenance

similar changes to radiographic bone level. Mi-
crobial testing was performed on 74 species, and
both groups decreased overall bacterial counts.
EPAP produced significantly lower Pseudomonas
aeruginosa, Staphylococcus aureus, and Staphylococ-
cus anaerobius, while the erbium laser produced
significantly lower levels of Fusobacterium nuclea-
tum naviforme and Fusobacterium nucleatum nu-
cleatum. Six months post-procedure, probe depths
≥6 mm had higher microbial counts of 15 spe-
cies than probe depths <6 mm. It can be inferred
that the combination of EPAP and erbium laser
therapy may be beneficial in the management of
peri-­implant disease because they appear to sig-
nificantly reduce different species of microbes.
• A study by Gustumhaugen et al. (2014) evaluated
the effects of biofilm to 3% hydrogen peroxide,
ethylenediaminetetraacetic acid (EDTA), sa-
line, and a suspension of titanium dioxide pow-
der mixed with 3% hydrogen peroxide. EDTA is
a common chelating agent used in endodontic
procedures for irrigation (Moharrami et al., 2019;
Tong et al., 2021). EDTA is a polyaminocarbox-
ylic acid that decalcifies dentin and can remove
a smear layer (Moharrami et al., 2019). EDTA is
also used to irrigate periodontal pockets around
dental implants (Tong et al., 2021). In the study,
all surfaces were debrided with a titanium brush
prior to irrigation with solutions. The implants
treated with titanium brush debridement and
hydrogen peroxide produced significantly less
overall biofilm regrowth than all other chemicals.
EDTA combined with mechanical debridement
significantly reduced the amount of biofilm com-
pared to EDTA alone.
• A study by Tong et al. (2021) evaluated the oral de-
posit removal capability on failing dental implants
with both soft and hard deposits. The research-
ers evaluated GPAP, GPAP plus EDTA irrigation,
PEEK piezoelectric tip, and PEEK tip plus EDTA
irrigation. All modalities reduced contamination
on the implant. Only the PEEK piezoelectric tip
was able to remove the hard deposits (mature,
firmly established dental calculus). GPAP pro-
duced the best overall reduction of contamination
but was unable to remove all hard deposits. EDTA
did not improve the removal of contaminants. All
modalities caused surface topography changes
with no significant differences between groups in
surface roughness reduction.

CASE STUDY
Your patient is a 55-year-old African American female with a history of high blood pressure, high cholesterol, and type 2
diabetes taking Metformin, Lantus, Metoprolol, Simvastatin, and Celebrex. Her blood pressure is stage one, and all other
vitals are within normal limits. Her Body Mass Index (BMI) is 50, and her last HbA1c was 9.0. The patient lives on her
own and has not been to the dentist in 11 years. She is a nonsmoker, only drinks socially, and has a diet rich in complex
carbohydrates.
Her chief complaint is “I am scared of the dentist and I hate coming here. I do not have any pain in my mouth, but I
am worried what you might find.”
Dental exam: Carious lesions are present on four teeth that need composite restorations. The maxillary left second
molar has a periapical lesion associated with a previously treated root canal.
Occlusion: Class II bilateral with first molar relationship with an 8-mm overjet.
Oral hygiene exam: Scattered light biofilm with a plaque biofilm index of 93%.
Periodontal exam: Generalized 3- to 6-mm probe depths with generalized bleeding upon probing. The mandibular
anterior lingual teeth cannot be probed due to the presence of heavy dental calculus. The mandibular right first
molar implant has 6- to 8-mm probe depths with immediate heavy bleeding and suppuration upon probing with
Class 2 mobility. Tissues are erythematous and edematous, and the patient reports discomfort when this tooth
is probed. The mandibular anterior central incisor dental implants have 5- to 6-mm probe depths on the facial.
Mobility cannot be accurately assessed due to the presence of heavy supragingival and subgingival dental calculus.
Radiographs: The mandibular right first molar radiograph is below. The mandibular anterior central incisors have
6-mm crestal bone height loss associated with the dental implants. The natural teeth also have horizontal bone
loss into the middle third of the root.
 Nonmechanical Debridement and Peri-Implantitis 583

Mandibular right first molar periapical radiograph Mandibular anterior lingual surfaces

1. What is this patient’s ASA classification? Explain your answer.

2. Is there anything in the patient’s medical history that predisposes her for periodontal inflammation? If so, which
condition(s)?
The following are questions the dental hygienist asked the patient and the patient responses.
a. Do you know what year your dental implants were placed? Patient response: no idea.
b. Do you know how old you were when the dental implants were placed? Were they all placed at the same time?
Patient response: I think the front two were placed at the same time when I was in the twenties, and the back
one was placed when I was older.
c. Do you know what doctor placed the implants so we can get your records (the hygienist is wanting to evaluate
implant baseline)? Patient response: no idea.
d. Why did you need these implants? Congenitally missing, periodontal disease, caries, broken teeth, endodontic
infections? Patient response: I was born missing the front two. I can’t remember why I needed the back one.
e. Were the implants healthy at your last appointment 11 years ago? Patient response: No idea.Patient response:
No idea.
3. Based on the patient’s responses and the information provided, what is the classification of the mandibular right
first molar implant? Explain your answer.
4. Based on the patient’s responses and the information provided, what is the implant classification of the
mandibular anterior central incisors? Explain your answer.
5. Should the dental hygienist immediately debride the dental implants or have a dentist or specialist evaluate the
dental implants first? Explain your answer.
6. The patient sees a periodontist who directs the dental hygienist to remove the oral deposits from the mandibular
anterior teeth. What mechanical debridement approach should the dental hygienist use first to remove the oral
deposits seen on the mandibular left central and lateral incisor implants in the intraoral photograph? Explain
your answer.
7. What nonmechanical debridement approach could assist with the removal of the dental calculus on the
mandibular anterior central incisors? Explain your answer.
8. After the dental calculus is removed, what air polishing powder can be used with a subgingival nozzle for biofilm
reduction and removal?
9. After oral deposit removal, what nonmechanical adjunctive aids can be used in the office around all the implants?
Explain your answer.
10. Which non-mechanical in-office adjunctive aid can be used in the office to provide post-treatment analgesia and
promote osteoblastic and fibroblastic activity? Explain your answer.
11. After oral deposit removal, which nonmechanical adjunctive aid can be given to the patient for at-home use to
control inflammation?
584 Chapter 28 Nonmechanical Implant Maintenance
Summary
The use of nonmechanical debridement adjunctive
aids can be beneficial in the management of peri-­
implant inflammation. A dental specialist should al-
ways evaluate any implant with active peri-implantitis
prior to mechanical and nonmechanical debridement.
Nonmechanical approaches in-office include laser
therapy, ozone, and locally administered antibiotics
and antimicrobials. At-home use of low-­concentration
hydrogen peroxide or chlorhexidine can assist with
Questions
1. Which of the following nonmechanical
debridement approaches to implant maintenance
can be used as an at-home adjunctive aid?
a. Dental laser therapy
b. Subgingival hydrogen peroxide
c. Subgingival ozone
d. Locally administered Atridox or Arestin
2. Which of the following criteria does an
adjunctive aid need to meet to be effective
according to the American Academy of
Periodontology?
a. Reach the base of a periodontal pocket
b. Possess bacteriostatic or bactericidal
properties
c. Remain in place long enough to exert its
action
d. All of the above
3. Which of the following materials is used in the
production of a dental laser?
a. Carbon dioxide gas
b. Semiconductor crystals
c. Neodymium
d. Erbium
e. All of the above
4. Which dental laser has the highest wavelength
and produces more thermal emissions to cut
through tissues efficiently?
a. Diode
b. Erbium
c. Carbon dioxide
d. Neodymium
5. True or False. A dental laser can be used in a
cutting and non-cutting mode.
a. True
b. False
decreasing inflammation and biofilm reaccumulation
after professional interventions in the office. Non-
mechanical debridement approaches support the
goal of implant maintenance in reducing and remov-
ing biofilm to a level that promotes immunological
health of implant-supported bone and soft tissues
without adversely altering the surface characteristics
of the implant, abutment, or prosthesis to maintain
biocompatibility.
6. Which of the following is a function of a dental
laser when used in a non-cutting mode?
a. Ablate diseased tissue
b. Increase osteoblastic and fibroblastic activity
c. Used as an analgesia
d. Both B and C
7. Which of the following is TRUE of PDT?
a. PDT utilizes a laser wavelength energy in a
cutting mode to produce its therapeutic effects.
b. PDT is always used with a photosensitizer.
c. PDT is performed with a wavelength high in
the infrared zone.
d. The photosensitizer used by PDT absorbs the
laser wavelength and generates a free radical
or singlet oxygen.
8. A dental laser in a cutting mode can be used in
which of the following procedures?
a. Removal of carious lesion
b. Removal of diseased epithelial tissue
c. Ablation of hard and soft tissues
d. All of the above
9. Which of the following organisms is susceptible
to the actions of chlorhexidine?
a. Fungi
b. Gram-positive bacteria
c. Gram-negative bacteria
d. All of the above
Match the following products to their correct chem-
ical composition for questions 10–14. There is only
one correct answer for each product.
10. Perio Protect A. Pure oxygen mixed with
pure ozone to make O3.
11. PerioChip B. 10% doxycycline hyclate.
12. Arestin C. 1.7% hydrogen peroxide
gel delivered in a custom
lab-made tray.

13. Atridox D. 2.5 mg chlorhexidine
gluconate in a biodegrad-
able matrix of hydrolyzed
gelatin, glycerin, and
purified water.
14. Ozone E. 1 mg minocycline
hydrochloride in a
bioresorbable polymer.
15. Which of the following is not administered as
a locally applied agent by an oral health-care
provider into the periodontal pocket?
a. PerioChip
b. Atridox
c. Arestin
d. Perio Gel
16. Which of the following is TRUE of
chlorhexidine?
a. Chlorhexidine has poor substantivity.
b. Chlorhexidine is bactericidal.
c. Chlorhexidine is bacteriostatic.
d. Both B and C
e. All of the above
17. Which of the following is TRUE of ozone used
in the office?
a. Promotes fibroblastic activity.
b. Is a wound healer.
References
1. Aimetti, M., Mariani, G. M., Ferrarotti, F., Ercoli, E., Liu, C. C., &
Romano, F. (2019). Adjunctive efficacy of diode laser in the
treatment of peri-implant mucositis with mechanical therapy:
A randomized clinical trial. Clinical Oral Implants Research,
30, 429–438.
2. Albandar, J., Susin, C., & Hughes, F. (2018). Manifestations
of systemic diseases and conditions that affect the periodontal
attachment apparatus: Case definitions and diagnostic
considerations. Journal of Periodontology, 89(Suppl 1), S183–
S203. https://doi.org/10.1002/JPER.16-0480
3. American Academy of Periodontology. (2006). American
Academy of Periodontology statement on the local
delivery of sustained or controlled release antimicrobials
as adjunctive therapy in the treatment of periodontitis.
Journal of Periodontology, 77, 1458. https://doi.org/10.1902
/jop.2006.068001
4. Backhouse, R. (2016). Chlorhexidine: An effective adjunct
alongside treatment for peri-implant mucositis. Dental
Health, 55(3), 25–32.
5. Bassetti, M., Schar, D., Wicki, B., Eick, S., Ramseier, C.
A., Arweiler, N. B., Sculean, A., & Salvi, G. E. (2014).
Anti-infective therapy of peri-implantitis with adjunctive
local drug delivery or photodynamic therapy: 12-month
outcomes of a randomized controlled clinical trial. Clinical
Oral Implants Research, 25, 279–287.
6. Bidra, A. S., Daubert, D. M., Garcia, L. T., Gauthier, M. F.,
Kosinski, T. F., Nenn, C. A., Olsen, J. A., Platt, J. A., Wingrove,
References 585
c. Reduces cytokines.
d. All of the above.
18. Which of the following has the most toxic
reaction to hydrogen peroxide?
a. Obligate aerobe
b. Facultative anaerobe
c. Obligate anaerobe
d. All are equally susceptible to the effects of
hydrogen peroxide
19. Which of the following is TRUE for the use of
systemic antibiotics in the treatment of active
peri-implantitis?
a. Systemic antibiotics are a standard of care in
the treatment of peri-implantitis.
b. A standard systemic antibiotic dose is
effective in killing the bacteria in a biofilm
matrix.
c. Systemic antibiotics may be used for patients
who are nonresponsive to initial therapy after
the subgingival environment is cultured.
d. Systemic antibiotics are never used in the
treatment of peri-implantitis.
20. True or False. Peri-implantitis is reversible and
can be treated with mechanical debridement by
a trained oral health-care provider.
a. True
b. False
S. S., Chandler, N. D., & Curtis, D. A. (2016). A systematic
review of recall regimen and maintenance regimen of patients
with dental restorations. Part 2: Implant-borne restorations.
Journal of Prosthodontics, 25, S16–S31.
7. Bidra, A., Daubert, D. M., Garcia, L. T., Kosinski, T. F., Nenn, C.
A., Olsen, J. A., Platt, J. A., Wingrove, S. S., Chandler, N. D., &
Curtis, D. A. (2016). Clinical practice guidelines for recall and
maintenance of patients with tooth-borne and implant-borne
dental restorations. Journal of Prosthodontics, 25, S32–S40.
8. Boyd, R. L. (1989). Effects on gingivitis of daily rinsing with
1.5% H2O2. Journal of Clinical Periodontology, 16, 557–562.
9. Boyd, L. A., Mallonee, L. F., & Wyche, C. J. (2021). Wilkins’
clinical practice of the dental hygienist (13th ed.). Jones &
Bartlett Learning.
10. Buchter, A., Meyer, U., Kruse-Losler, B., Joos, U., &
Kleinheinz, J. (2004). Sustained release of doxycycline for the
treatment of peri-implantitis: Randomised controlled trial.
British Journal of Oral and Maxillofacial Surgery, 42, 439–444.
11. Chala, M., Anagnostaki, E., Mylona, V., Chalas, A., Parker, S.,
& Lynch, E. (2020). Adjunctive use of laser in peri-implant
mucositis and per-implantitis treatment: A systematic review.
Dentistry Journal, 8(68), 1–19.
12. Convissar, R. A. (2016). Principles and practice of laser dentistry
(2nd ed.). Elsevier.
13. Corbella, S., Del Fabbro, M., Taschieri, S., De Siena, F.,
& Francetti, L. (2011). Clinical evaluation of an implant
maintenance protocol for the prevention of peri-implant
586 Chapter 28 Nonmechanical Implant Maintenance
diseases in patients treated with immediately loaded full-
arch rehabilitations. International Journal of Dental Hygiene, 9,
216–222.
14. De Siena, F., Francetti, L., Corbella, S., Taschieri, S., & Del
Fabbro, M. (2013). Topical application of 1% chlorhexidine
gel versus 0.2% mouthwash in the treatment of peri-implant
mucositis: An observational study. International Journal of
Dental Hygiene, 11, 41–47.
15. Dunlap, T., Keller, D, Marshall, M. V., Costerton, J. W.,
Schaudinn, C., Sindelar, B., & Cotton, J. R. (2011).
Subgingival delivery of oral debriding agents: A proof of
concept. Journal of Clinical Dentistry, 22(22), 5, 149–158.
16. Figuero, E., Graziani, F., Sanz, I., Herrera, D., & Sanz,
M. (2014). Management of peri-implant mucositis and
peri-implantitis. Periodontology 2000, 66, 255–273.
17. Gallo, S., & Scribante, A. (2021). Ozone therapy in dentistry:
From traditional applications towards innovative ones: A
review of the literature. Earth and Environmental Science, 707,
012001. https://doi.org/10.1088/1755-1315/707/1/012001
18. Gehrig, J. S., Shin, D. E., & Willmann, D. E. (2019).
Foundations of periodontics for the dental hygienist (5th ed.).
Wolters Kluwer.
19. Giannopoulou, C., Cappuyns, I., Cancela, J., Cionca, N., &
Mombelli, A. (2012). Effect of photodynamic therapy, diode
laser, and deep scaling on cytokine and acute-phase protein
levels in gingival crevicular fluid of residual periodontal
pockets. Journal of Periodontology, 83, 1018–1027.
20. Gupta, G., & Mansi, B. (2012). Ozone therapy in periodontics.
Journal of Medicine and Life, 5(1), 59–67.
21. Gustumhaugen, E., Lonn-Stensrud, J., Scheie, A. A.,
Lyngstadaas, S. P., Ekfeldt, A., & Taxt-Lamolle, S. (2014).
Effect of chemical and mechanical debridement techniques
on bacterial re-growth on rough titanium surfaces: An in vitro
study. Clinical Oral Implants Research, 25, 707–713.
22. Gutierrez-Corrales, A., Rizcala-Orlando, Y., Montero-Miralles,
P., Volland, G., Gutierrez-Perez, J. L., Torres-Lagares, D., &
Serra-Figallo, A. (2020). Comparison of diode laser—Oral
tissue interaction to different wavelengths: In vitro study of
porcine periodontal pockets and oral mucosa. Medicina Oral
Patologia Oral y Cirugia Bucal, 25(2), e224–e232.
23. Hallstrom, H., Lindgren, S., & Twetman, S. (2017). Effect
of a chlorhexidine-containing brush-on gel on peri-implant
mucositis. International Journal of Dental Hygiene, 15,
149–153.
24. Hossainian, N., Slot, D. E., Afennich, F., & Van der Weijden,
G. A. (2011). The effects of hydrogen peroxide mouthwashes
on the prevention of plaque and gingival inflammation: A
systematic review. International Journal of Dental Hygiene, 9,
171–181. https://doi.org/10.1111/j.1601-5037.2010.00492.x
25. Jenkins, S., Addy, M., & Wade, W. (1988). The mechanism of
action of chlorhexidine: A study of plaque growth on enamel
inserts in vivo. Journal of Clinical Periodontology, 15, 415–424.
26. Keller, D.C., & Buechel. (2017a). Direct medication
delivery modifies the periodontal biofilm. Oral Biology and
Dentistry, 5, 1, 1-7. doi: 10.7243/2053-5775-5-1.
27. Keller, D.C., & Buechel, M. (2017b). Periodontal treatment
with direct medication delivery of hydrogen peroxide and
oxygen. Oral Health Case Reports, 3, 1, 1-6. doi:10.4172
/2471-8726.1000133.
28. Kumar, A., Bhagawati, S., Tyagi, P., & Kumar, P. (2014).
Current interpretations and scientific rationale of the ozone
usage in dentistry: A systematic review of the literature.
European Journal of General Dentistry, 3(3), 175–180.
29. Kuyyakanond, T., & Quesnel, L. B. (1992). The mechanism
of action of chlorhexidine. FEMS Microbiology Letters, 100,
211–216.
30. Lazarchik, D. A., & Haywood, V. B. (2010). Use of tray-applied
10 percent carbamide peroxide gels for improving oral health
in patients with special-care needs. Journal of the American
Dental Association, 141(6), 639–646.
31. Matthews, D. C. (2010). Seeing the light: The truth about soft
tissue lasers and nonsurgical periodontal therapy. Journal of
the American Dental Association, 76(2), 1–5.
32. McKenna, D. F., Borzabadi-Farahani, A., & Lynch, E. (2013).
The effect of subgingival ozone and/or hydrogen peroxide on
the development of peri-implant mucositis: A double-blind
randomized controlled trial. The International Journal of Oral
& Maxillofacial Implants, 28(6), 1483–1489.
33. Menezes, K. M., Fernandes-Costa, A. N., Silva-Neto, R.
D., Calderon, P. S., & Gurgel, B. C. V. (2016). Efficacy of
0.12% chlorhexidine gluconate for non-surgical treatment
of peri-implant mucositis. Journal of Periodontology, 87,
1305–1313.
34. Moharrami, M., Perrotti, V., Iaculli, F., Love, R. M., &
Quaranta, A. (2019). Effects of air abrasive decontamination
on titanium surfaces: A systematic review of in vitro studies.
Clinical Oral Implants Research, 21, 398–421.
35. Nandi, A., Yan, L. J., Jana, C. K., & Das, N. (2019). Role of catalase
in oxidative stress- and age-associated degenerative diseases.
Oxidative Medicine and Cellular Longevity, 2019(9613090), 1–19.
36. Pagano, S., Lombardo, G., Orso, M., Abraha, I., Capobianco,
B., & Cianetti, S. (2020). Lasers to prevent dental caries: A
systematic review. BMJ, 10(e038638), 1–11.
37. Paolantonio, M., Perinetti, G., D’Ercole, S., Graziani, F.,
Catamo, G., Sammartino, G., & Piccolomini, R. (2008).
Internal decontamination of dental implants: An in vivo
randomized microbiologic 6-month trial on the effects of a
chlorhexidine gel. Journal of Periodontology, 79, 1419–1425.
38. Parker, S. (2007). Surgical lasers and hard dental tissue.
British Dental Journal, 202(8), 445–454.
39. Pedziwiatr, P., Mikotajczyk, F., Zawadzki, D., Mikotajczyk,
K., Bedka, A., & Oktan, S. K. N. (2018). Decomposition of
hydrogen peroxide: Kinetics and review of chosen catalysts.
Acta Innovations, 26, 45–52.
40. Persson, G. R., Roos-Jansaker, A. M., Lindahl, C., & Renvert, S.
(2011, September). Microbiological results after non-surgical
erbium-doped: Yttrium, aluminum, and garnet laser or air-
abrasive treatment of peri-implantitis: A randomized clinical
trial. Journal of Periodontology, 82, 9, 1267–1278.
41. Pjetursson, B. E., Helbling, C., Weber, H. P., Matuliene G.,
Salvi, G. E., Bragger, U., Schmidlin, K., Zwahlen, M., &
Lang, N. P. (2012). Peri-implantitis susceptibility as it relates
to periodontal therapy and supportive care. Clinical Oral
Implants Research, 23, 888–894.
42. Porras, R., Anderson, G. B., Caffesse, R., Narendran, S., &
Trejo, P. M. (2002). Clinical response to 2 different
therapeutic regimens to treat peri-implant mucositis. Journal
of Periodontology, 73(10), 1118–1125.
43. Putt, M. S., & Proskin, H. M. (2010). Custom tray application
of peroxide gel as an adjunct to scaling and root planing in
the treatment of periodontitis: A randomized, controlled three-
month clinical trial. Journal of Clinical Dentistry, 23(23), 2,
48–56.
44. Ready, D., Theodoridis, G., Green, I., Ciric, L., Pratten, J.,
Tay, W., & McDonald, A. (2015). In vitro evaluation of the
antibiofilm properties of chlorhexidine and delmopinol on

dental implant surfaces. International Journal of Antimicrobial
Agents, 45, 662–666.
45. Renvert, S. Lessem, J., Dahlen, G., Lindahl, C., & Svensson,
M. (2006). Topical minocycline microspheres versus topical
chlorhexidine gel as an adjunct to mechanical debridement
of incipient peri-implant infections: A randomized clinical
trial. Journal of Clinical Periodontology, 33, 362–369.
46. Renvert, S., Lindahl, C., Jansaker, A. M. R., & Persson, G. R.
(2011). Treatment of peri-implantitis using an ER:YAG laser
or an air-abrasive device: A randomized clinical trial. Journal
of Clinical Periodontology, 38, 65–73.
47. Sahrmann, P., Bettschart, C., Wiedemeier, D. B., Al-Majid, A.,
Attin, T., & Schmidlin, P. R. (2019). Treatment of peri-implant
mucositis with repeated application of chlorhexidine chips or
gel during supportive therapy: A randomized clinical trial.
Dentistry Journal, 7(115), 2–14.
48. Salvi, G. E., Stahli, A., Schmidt, J. C., Ramseier, C. A.,
Sculean, A., & Walter, C. (2020). Adjunctive laser or
antimicrobial photodynamic therapy to non-surgical
mechanical instrumentation in patients with untreated
periodontitis: A systematic review and meta-analysis. Journal
of Clinical Periodontology, 47, 176–198.
49. Sanchez-Martos, R., Samman, A., Bouazza-Juanes, K.,
Diaz-Fernandez, J. M., & Arias-Herrera, S. (2020). Clinical
effect of diode laser on peri-implant tissues during non-
surgical peri-implant mucositis therapy: Randomized
controlled clinical study. Journal of Clinical and Experimental
Dentistry, 12(1), e13–e21.
50. Saneja, R., Bhattacharjee, B., Bhatnagar, A., Verna, K., &
Verna, A. (2020). Efficacy of different lasers of various
wavelengths in treatment of peri-implantitis and peri-implant
mucositis: A systematic review and meta-analysis. The Journal
of Indian Prosthodontic Society, 20(4), 353–360.
51. Schar, D., Ramseier, C. A., Eick, S., Arweiler, N. B., Sculean, A.,
& Salvi, G. E. (2012). Anti-infective therapy of peri-implantitis
with adjunctive local drug delivery or photodynamic therapy:
Six-month outcomes of a prospective randomized clinical trial.
Clinical Oral Implants Research, 24, 104–110.
52. Schwartz, F., Aoki, A., Becker, J., & Sculean, A. (2008). Laser
application in non-surgical periodontal therapy: A systematic
review. Journal of Clinical Periodontology, 25(S8), 29–44.
53. Schwartz, F., Bieling, K., Bonsmann, M., Latz, T., & Becker,
J. (2006). Nonsurgical treatment of moderate and advanced
periimplantitis lesions: A controlled clinical study. Clinical
Oral Investigations, 10, 279–288.
54. Schwartz, F., Sahm, N., Iglhaut, G., & Becker, J. (2011). Impact
of the method of surface debridement and decontamination
on the clinical outcome following combined surgical therapy
of peri-implantitis: A randomized controlled clinical study.
Journal of Clinical Periodontology, 38, 276–284.
55. Schwartz, F., Schmucker, A., & Becker, J. (2015). Efficacy of
alternative or adjunctive measures to conventional treatment
of peri-implant mucositis and peri-implantitis: A systematic
review and meta-analysis. International Journal of Implant
Dentistry, 1(22), 2–34.
56. Schwartz, F., Sculean, A., Rothamel, D., Schwenzer, K.,
Georg, T., & Becker, J. (2005). Clinical evaluation of an
References 587
ER-YAG laser for nonsurgical treatment of peri-implantitis: A
pilot study. Clinical Oral Implants Research, 16, 44–52.
57. Soukos, N., & Goodson, J. M. (2011). Photodynamic
therapy in the control of oral biofilms. Periodontology 2000,
55, 143–166.
58. Srikanth, A., Sathish, M., & Harsha, A. V. S. (2013).
Application of ozone in the treatment of periodontal disease.
Journal of Pharmacy and Bioallied Sciences, 5(1), S89–S95.
59. Tateno, R. Y., Plama, L. F., Sendyk, W. R., & Campos, L.
(2020). Laser and antimicrobial photodynamic therapy for
the management of delayed healing following multiple dental
extractions in a post-radiotherapy patient. Photodiagnosis and
Photodynamic Therapy, 30(101764), 1–3.
60. Thone-Muhling, M., Swierkot, K., Nonnenmacher, C.,
Mutters, R., Flores-de-Jacoby, L., & Mengel, R. (2010).
Comparison of two full-mouth approaches in the treatment
of peri-implant mucositis: A pilot study. Clinical Oral Implants
Research, 21, 504–512.
61. Toledano, M., Osorio, M. T., Vallecillo-Rivas, M.,
Toledano-Osorio, M., Rodriguez-Archilla, A., Toledano, R.,
& Osorio, R. (2021). Efficacy of local antibiotic therapy in
the treatment of peri-implantitis: A systematic review and
meta-analysis. Journal of Dentistry, 113(103790), 1–9.
62. Tong, Z., Fu, R., Zhu, W., Shi, J., Yu, M., & Si, M. (2021).
Changes in the surface topography and element proportion
of clinically failed SLA implants after in vitro debridement by
different methods. Clinical Oral Implant Research, 32, 263–273.
63. Tonon, C. C., Panariello, B. H. D., Spolidorio, D. M. P.,
Gossweiler, A. G., & Duarte, S. (2021). Antibiofilm effect of
ozonized physiological saline solution on peri-implant-related
biofilm. Journal of Periodontology, 92, 1151–1162.
64. Tsourounakis, I., Palaiologou-Gallis, A. A., Stoute, D.,
Maney, P., & Lallier, T. E. (2013). Effect of essential oil and
chlorhexidine mouthwashes on gingival fibroblast survival
and migration. Journal of Periodontology¸ 84, 1211–1220.
65. US Food and Drug Administration. (2004). 510(k) summary
for Perio Protect tray. https://www.accessdata.fda.gov/cdrh
_docs/pdf3/K031809.pdf
66. US Food and Drug Administration. (2011). Atridox
(doxycycline hyclate) 10%. https://www.accessdata.fda.gov
/drugsatfda_docs/label/2011/050751s015lbl.pdf
67. US Food and Drug Administration. (2012a). Arestin (minocycline
hydrochloride) microspheres. https://www.accessdata.fda.gov
/drugsatfda_docs/label/2012/050781s019lbl.pdf
68. US Food and Drug Administration. (2012b). PerioChip 2.5mg
(chlorhexidine gluconate). https://www.accessdata.fda.gov
/drugsatfda_docs/ label/2012/020774s012lbl.pdf
69. US Food and Drug Administration. (2020). CFR—Code of
federal regulation title 21. https://www.accessdata.fda.gov
/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=310.534
70. US Food and Drug Administration. (n.d.). Medical
lasers. https://www.fda.gov/radiation-emitting-products
/surgical-and-therapeutic-products/medical-lasers
71. Xue, V. W., Zhao, I. S., Yin, I. X., Niu, J. Y., Lo, E. C. M., &
Chu, C. H. (2021). Effects of 9,300nm carbon dioxide laser
on dental hard tissue: A concise review. Clinical, Cosmetic and
Investigational Dentistry, 13, 155–161.
Glossary
0- to 15-degree angulation angulation of the shank ac-
tive area antinode to the tooth surface that is between 0 and
15 degrees and that adapts the face, back, and lateral surfaces.
90-degree angulation angulation of the shank active
area antinode to the tooth surface at a 90-degree angle that
adapts the point or just offset from the point.
A APDs manufactured by EMS.
Ablation complete removal of a substance or material
through a chipping action.
Abrasion the process of wearing something away.
Abutment metal (titanium, gold) or non-metal (high-
strength ceramics such as alumina or zirconia) biomaterial
placed directly into the dental implant that provides support
for a fixed, fixed-detachable, or removable dental prothesis.
Acoustic cavitation formation of vapor gas bubbles in
a sound wave at low-pressure regions within a liquid when
the liquid is accelerated to high velocities and implode
when they reach regions of higher pressure.
Acoustic microstreaming a fluid gradient, or cur-
rent, that transports acoustic cavitation vapor gas bubbles
away from their site of release.
Activation the pattern of movement an instrument has
on a structure.
Active area antinode the terminal 1.0–3.5 mm on an
ultrasonic shank that performs the clinical actions such as
the removal of oral deposits.
Active medium part of a dental ultrasonic that deter-
mines the speed and length of the ultrasonic sound wave
made of nickel or man-made ceramic crystals.
Acute respiratory infection (ARI) as defined by
the World Health Organization is an infection capable of
­interfering with respiratory system function (WHO, 2014).
Adaptation placement of an instrument against the sur-
face of a tooth.
Aerosol small particle size (<50 µm) product cre-
ated and released into the environment during a dental
­aerosol-generating procedure that stays airborne for an ex-
tended period of time and travels great distances.
Air decontamination also known as air purification or
no-touch decontamination. A device that improves indoor air
quality and reduces contaminants.
AIRFLOW the name of a dual mode piezoelectric ultra-
sonic and air polishing device manufactured by EMS.
AIRFLOW Classic powder the name of sodium bicar-
bonate powder manufactured by EMS.
AIRFLOW Handpiece the name of the air polishing
handpiece that delivers the slurry mixture supragingival
and in shallow (<4 mm) pockets, manufactured by EMS.
AIRFLOW Handy the name of the portable handheld
AIRFLOW Handy 3.0 Classic the name of the portable
handheld APD with a blue powder chamber that delivers
AIRFLOW Classic powder (sodium bicarbonate) manufac-
tured by EMS.
AIRFLOW Handy 3.0 Perio the name of the portable
handheld APD with a pink powder chamber that delivers
AIRFLOW Perio powder (glycine) and AIRFLOW Plus
powder (erythritol), manufactured by EMS.
AIRFLOW One the name of a single stand-alone APD
manufactured by EMS.
AIRFLOW Perio powder the name of glycine powder
manufactured by EMS.
AIRFLOW Plus powder the name of erythritol powder
manufactured by EMS.
AIRFLOW Prophylaxis Master the name of the
newest dual mode model that provides both piezoelec-
tric ­
ultrasonic scaling and air polishing, manufactured
by EMS.
Airline attachment cord cord provided by the manu-
facturer for an ultrasonic device that has dual capability as
an ultrasonic and an air polishing system that attaches to
the air input on the dental unit.
Air polishing device (APD) device that delivers a
slurry mixture of compressed air, powder particles, and
water to the crown and root surfaces of teeth.
Air purification see air decontamination.
Aluminum trihydroxide powder APD powder
made of aluminum and hydroxide that is insoluble in water
and administered coronal to the CEJ.
Angulation degree of tilt an instrument has when
adapted to the surface of a tooth.
Antinode formed when maximum positive and max-
imum negative displacement of two ultrasonic waves
interface.
Anti-retraction device a device that blocks fluids
from retracting backward into the dental unit line tubing.
589
590 Glossary
Arestin 1 mg minocycline hydrochloride applied into a
periodontal pocket with sustained controlled release over a
specified period of time.
Atridox 10% concentration doxycycline hyclate applied
into a periodontal pocket with sustained controlled release
over a specified period of time.
Auto-cycle Prophy mode preprogrammed automatic
cycles on a Dentsply Sirona APD that delivers a slurry dis-
charge followed by a water rinse.
B
Back driver also known as back mass. Part of a piezoelec-
tric ultrasonic device located behind the piezoceramic discs
that distribute compressive stress across the discs.
Back mass see back driver.
Back surface the convex surface of a shank with the
third highest displacement amplitude.
BacterX Pro mouthwash mouthrinse that contains
chlorhexidine digluconate 0.1%, cetylpyridinium chloride
0.05%, and sodium fluoride 0.01% (fluoride 0.0005%),
manufactured by EMS.
Base flow internal water port that is positioned
closer to the grip of an insert shank, manufactured by
HuFriedyGroup.
Bernoulli’s principle fluid dynamic principle of liquid
flow that states in a horizontal flow of fluid, areas of higher
velocity (speed) will have less pressure.
Bifurcation tooth root with two roots.
Biofilm collection of microbial cells that bind to-
gether on a surface and form an enclosed matrix held
­together by ­polysaccharides that is irreversibly bound to
a surface.
Bipolar air ionization form of air decontamination
that releases clusters of bipolar ions in the environment to
change the polarity of aerosol particles.
Blue operation mode high power mode that al-
lows the user to select a power output of 2.5–10.0 on the
­HuFriedyGroup SWERV3.
Blue power zone high power range (11–16) that is
used with prophylaxis tips manufactured by Acteon.
Body part of the portable handheld AIRFLOW Handy 3.0
that houses the powder chamber and inner tube, manufac-
tured by EMS.
Bone remodeling period of time after implant place-
ment into maxillary or mandibular bone required for full
osseointegration where immature bone is replaced by ma-
ture bone.
Boost mode a power mode option activated through the
foot pedal that delivers additional power output.
Burnished calculus deposit that is incompletely re-
moved during instrumentation and, when present on a
root, becomes tenaciously adherent to cementum and can
contribute to disease pathogenesis.
C
Calcium carbonate powder APD powder made of
calcium and carbonate that is insoluble in water and ad-
ministered coronal to the CEJ.
Calcium sodium phosphosilicate powder APD
powder made of calcium, phosphorus, silica, and so-
dium that is soluble in water and will occlude dentinal
tubules.
Caries mode setting on Soprocare camera manufactured
by Acteon that detects areas of demineralization.
Catalase enzyme present in obligate aerobe bacteria, fac-
ultative anaerobic bacteria, and human cells that catalyzes
the reactions of hydrogen peroxide, decomposing it to wa-
ter and oxygen.
Cavitation formation of a bubble in a liquid that oc-
curs when the liquid undergoes a rapid change in velocity
(speed).
Cavitron Diamondcoat 30K Ultrasonic Insert the
name for the diamond-coated shank manufactured by
Dentsply Sirona.
Cavitron Jet Air Polishing Insert the name of the
air polishing insert with affixed nozzle manufactured by
Dentsply Sirona.
Cavitron Jet Fresh Prophy Powder the name of
aluminum trihydroxide powder manufactured by Dentsply
Sirona.
Cavitron Jet Plus Ultrasonic Scaling and Air
­Polishing System the name of a dual-function APD
plus ultrasonic scaling device manufactured by Dentsply
Sirona.
Cavitron Powerline Ultrasonic Insert the name for
thick diameter inserts manufactured by Dentsply Sirona.
Cavitron Prophy Jet Air Polishing System the
name of a single stand-alone APD manufactured by
Dentsply Sirona.
Cavitron Prophy Jet Handpiece Cleaning
Tool sterilizable narrow solid metal wire used to dislodge
residual powder in the powder delivery port of the Dentsply
Sirona Jet-Mate Sterilizable, Detachable Handpiece.
Cavitron Prophy Jet Nozzle Cleaning Tool ster-
ilizable narrow solid metal wire with an affixed white
holder used to dislodge residual powder in the nozzle de-
livery tube of a Dentsply Sirona Cavitron Jet Air Polishing
Insert.
Cavitron Prophy Jet Prophy Powder the name of
sodium bicarbonate powder manufactured by Dentsply
Sirona.
Cavitron Slimline Ultrasonic Insert the name of
thin diameter inserts manufactured by Dentsply Sirona.
Cavitron Softip Disposable Prophy Tip Removal
Wrench autoclavable wrench used to apply and remove
the disposable single-use Softip on the shank of the Cavit-
ron Softip Implant 30K Ultrasonic Insert manufactured by
Dentsply Sirona.

Cavitron Softip Implant 30K Ultrasonic
­Insert the name for the implant insert manufactured by
Dentsply Sirona.
Cavitron Steri-Mate 360 Handpiece handpiece
with a 360-degree rotating nose cone manufactured by
Dentsply Sirona.
Cavitron Steri-Mate Sterilizable, Detachable
Handpiece non-rotating nose-cone, detachable hand-
piece for single mode ultrasonic scaling devices manufac-
tured by Dentsply Sirona.
Cavitron Thinsert 30K Ultrasonic Insert the name
of the ultra-thin diameter insert manufactured by Dentsply
Sirona.
Cavitron Ultrasonic Scaling System the name of a
Dentsply Sirona magnetostrictive ultrasonic device.
Cementoenamel junction (CEJ) junction between
the cementum and dentin that is not visible in health and is
visible in the presence of bone loss, recession, or previous
crown lengthening.
Cheek finger rest extraoral stabilization technique
where the operator’s finger rest is on the cheek while the
ultrasonic shank is positioned inside the mouth on a tooth
surface.
Chin finger rest extraoral stabilization technique
where the operator’s finger rest is on the chin while the
ultrasonic shank is positioned inside the mouth on a tooth
surface.
Chlorhexidine a cationic biguanide microbicide solu-
tion with a broad spectrum of action against fungi, gram
positive bacteria, and gram negative bacteria.
Cleaning agent non-abrasive chemical applied to tooth
and restorative materials with a rotary handpiece.
CLIP+CLEAN tool paced into the device’s water bottle re-
ceptacle for dust protection.
Colony-forming unit (CFU) estimates the number
and concentrations of viable microorganism cells in a test
specimen.
CombiTorque the name of the wrench manufactured
by EMS.
Confounding variable an extraneous variable not
accounted or controlled for in a study design that affects
results.
Connecting body metal attachment between the ferro-
magnetic laminate nickel plates and the shank on a magne-
tostrictive insert whose design influences the power output
options of the insert.
Consideration a factor or variable that should be taken
into account and the potential consequences weighed
against the benefits prior to implementing a technology or
procedure into a patient care plan.
Contraindication a situation when a patient should
not receive treatment because it may be harmful.
Cord adaptor part of the portable handheld AIRFLOW
Handy 3.0 manufactured by EMS that attaches to a dental
unit air turbine connector.
Glossary 591
Cross-arch finger rest intraoral stabilization tech-
nique where the operator’s finger rest is on the adjacent arch
as the position of the ultrasonic shank on a tooth surface.
Curved shank an ultrasonic insert or tip whose shank is
bent in more than one plane.
Cyst pathologic sac or cavity lined with epithelium and
enclosed in a connective tissue capsule (Ibsen & Phelan,
2018).
Cytokines large group of proteins, peptides, or glyco-
proteins that are secreted by specific immune cells.
D
Daylight mode setting on Soprocare camera manufac-
tured by Acteon that captures intraoral images with natural
light.
Decibel (dB) Unit of measurement for reporting the
loudness of sound.
Dental aerosol man-made aerosol generated by
­air-driven dental equipment that emits an aqueous solution.
Dental aerosol-generating procedure any pro-
cedure performed in a dental environment that releases
­aerosols into the air.
Dental device instrument or machine, including com-
ponents, parts, and accessories, that is used in the diagno-
sis, treatment, and prevention of disease (Organization for
Safety, Asepsis, and Protection, 2018).
Dental equipment machine and accessory used in the
practice of dentistry.
Dental health-care personnel (DHCP) as de-
fined by the Center for Disease Control is any “paid and
unpaid personnel in the dental health-care setting who
might be occupationally exposed to infectious materials,
including body substances and contaminated supplies,
­equipment, ­environmental surfaces, water, or air” (CDC,
2003).
Dental implant surgically placed biomaterial made of
stainless steel, cobalt-based alloy, titanium, or titanium-­
based alloy placed directly into the maxillary or mandib-
ular bone.
Dental laser a device used in the practice of dentistry
that emits an intense narrow beam of non-ionizing non-
divergent monochromatic electromagnetic radiation of one
coherent wavelength that is used on either a cutting or
non-cutting mode.
Dental unit combination of interconnected dental
equipment and dental instruments constituting a func-
tional assembly for use in the provision of dental treatment
(Organization for Safety, Asepsis, and Protection, 2018).
Diffusion passive movement of a substance from an area
of higher concentration to an area of lower concentration.
Direct flow internal water port that is positioned closer
to the terminal 4 mm of an insert shank, manufactured by
HuFriedyGroup.
592 Glossary
Direction for use (DFU) also known as instruction for
use (IFU). Readable detailed information packet provided
by the manufacturer of a dental ultrasonic device, part, or
accessory that provides pertinent content related to the
use, maintenance, preservation, specifications, and trou-
bleshooting of the equipment.
Displacement amplitude refers to the length of
stroke, or the distance the shank moves in a vibratory ellip-
tical pattern in one cycle.
Dynamic pressure regulator control on the
­AIRFLOW One and AIRFLOW Prophylaxis Master manu-
factured by EMS that automatically sets the optimal pres-
sure range based on the powder velocity setting for each
powder chamber.
Dysbiosis imbalance of microbiota in the human micro-
biome that disrupts homeostasis and has the potential to
cause disease, impairment, and inflammation.
Dyspnea difficult or labored breathing, sometimes re-
ferred to as having shortness of breath.
E
Easy Clean Tool tool for cleaning EMS AIRFLOW and
PERIFLOW handpieces prior to sterilization.
Electrostatic precipitator form of air decontami-
nation that changes air ionization through the release of
charged particles and electrostatic forces.
Enzymax HuFriedyGroup enzymatic cleaner that is safe
for use on HuFriedyGroup inserts.
Erythritol powder APD powder made of erythritol and
0.3% chlorhexidine that is soluble in water and adminis-
tered coronal and apical to the CEJ.
Erythritol powder air polishing (EPAP) a clin-
ical air polishing procedure where erythritol powder is
administered.
E-Series tip threader tip threader with four flats man-
ufactured by EMS.
Ethylenediaminetetraacetic acid (EDTA) a poly-
aminocarboxylic acid that decalcifies dentin and removes
the smear layer, making it a useful chelating agent in end-
odontic procedures.
External water port thin tube water port that attaches
above and parallel to the shank of an insert or tip and ex-
pels an aqueous solution.
Extraneous variable a factor in a research design that
influences a change in study results.
Extraoral finger rest stabilization technique where a
finger rest of the operator’s dominant hand is outside the
mouth during ultrasonic instrumentation.
Extraoral scavenging device positioned outside the
oral cavity to change the air flow dynamics in the immedi-
ate treatment area.
Extrinsic exogeneous stain stain present on the sur-
face of a tooth that originated from an external source.
F
Face shield clear covering worn to protect parts of the
face from splashes, typically made of a headband that holds
the shield on the user’s head.
Face surface the concave surface of a shank with the
second highest displacement amplitude.
Facultative anaerobic bacteria bacteria that grow
in the presence or absence of oxygen.
Ferromagnetic laminate nickel plate the ac-
tive medium of a magnetostrictive ultrasonic device that
­determines the speed and length of the ultrasonic sound
wave.
Filtration a form of air decontamination where particles
and pollutants from the air are physically or mechanically
removed through diffusion, settling, and impaction.
Finger motion the use of the thumb and index and mid-
dle fingers to move the active area antinode of the shank
during ultrasonic instrumentation.
Finger rest stabilization with the ring and pinkie fingers
during ultrasonic instrumentation.
Fitgrip the name of an insert grip with larger width and
rippled texturing manufactured by Dentsply Sirona.
F.L.A.G. dye fluorescein dye solution made of a mixture
of glycerol and disodium 2-(3-oxo-6-oxidoxanthen-9-yl)
benzoate that stains plaque biofilm, manufactured by
Acteon.
Fluid a liquid or gas substance that deforms continuously
when stresses are placed upon it when in a fluid medium.
Fluid dynamics the study of fluids in motion.
Foot pedal activates a magnetostrictive or piezoelectric
ultrasonic device.
Front driver also known as front mass. Part of a piezo-
electric ultrasonic device located between the horn and
piezoceramic discs that optimizes the maximum output
and delivers the energy from the transducer to the horn.
Front mass see front driver.
Furcation anatomical division between tooth roots pres-
ent on multi-rooted teeth.
Furcation defect pathological condition where the fur-
cation is no longer filled in with alveolar bone. Also referred
to as furcation involvement.
Furcation involvement see furcation defect.
G
Glickman Index furcation index with four grades that
report on furcation defect severity and extent.
Glycine powder APD powder made of glycine and si-
licic acids that is soluble in water and administered coronal
and apical to the CEJ.
Glycine powder air polishing (GPAP) A clinical air
polishing procedure where glycine powder is administered.

Gown single-use disposable or non-disposable reusable
material worn by a Dental Heathcare Provider (DHCP) that
is impenetrable to fluid and reaches to the neckline and
knees and covers the torso and forearms.
Granuloma mass of inflammatory tissue consisting
of macrophages, giant cells, and lymphocytes (Ibsen &
Phelan, 2018).
Grasp the act of holding a dental device in a specific man-
ner that promotes high-quality ergonomics.
Green operation mode low power mode that allows
the user to select a lower power output of 1–5 on the
SWERV3 manufactured by HuFriedyGroup.
Green power zone low power range (1–6) that is used
with periodontic tips manufactured by Acteon.
Grip colored portion of a magnetostrictive insert that cov-
ers the connecting body.
Guided Biofilm Therapy (GBT) the name of a pro-
prietary multi-step program created by EMS for preventive
non-surgical procedures that combines disclosing solution,
air polishing for biofilm reduction subgingivally and su-
pragingivally, and piezoelectric ultrasonic instrumentation.
H Implant care the name of plastic and titanium tips man-
Hair covering single-use disposable or non-disposable
reusable material worn by a Dental Healthcare Provider
(DHCP) that is impenetrable to fluid and protects the scalp
and hair from airborne particles.
Handpiece hard, durable, sterilizable piece of equip-
ment that securely attaches to a connector cable and ac-
cepts an insert or tip.
Heater rod a part of the Cavitron Jet Air Polishing In-
sert that is placed into the Jet-Mate Sterilizable, Detachable
Handpiece insert port opening that heats the water for im-
proved patient comfort, manufactured by Dentsply Sirona.
Hertz (Hz) SI metric used for measuring and reporting
sound frequency where 1 Hz equals 1 vibration cycle per
second.
Heterotrophic mesophilic water bacteria bacte-
ria that require organic carbon nutrients for growth and can
exist in all types of water.
High-efficiency particulate air (HEPA) filter a
form of air decontamination that filters air particles, dust,
pollen, mold, bacteria, and airborne particles out of the
environment.
High-range ultrasound ultrasound used for imaging
in health care with a frequency range above 1 MHz.
High-volume evacuation intraoral evacuation device
with a large opening used for the removal of fluid from the
mouth and large volumes of air.
Horizontal movement a component of the ultrasonic
activation stroke where the active area antinode of the shank is
moved back and forth in 2-mm increments at a steady consis-
tent pace, with each horizontal cycle lasting 0.5–1.0 second.
Glossary 593
Horn Part of a piezoelectric ultrasonic device coupled to
the front driver, travels the length of the handpiece, and is
threaded to a piezoelectric tip. The horn focuses and trans-
mits the ultrasonic sound wave to the tip and allows for a
change in the wave amplitude.
Hydrodynamic shear stress force applied per unit
area in a fluid medium and results from the friction be-
tween fluid particles, which causes deformation of nearby
substances.
Hydrogen peroxide (H2O2) system form of air de-
contamination where air is exposed to vaporized (gaseous)
hydrogen peroxide to reduce contamination through oxi-
dizing reactions.
Hydrogen peroxide (H2O2) a highly reactive strong ox-
idizing chemical compound with an unpaired electron capa-
ble of damaging cellular lipids, proteins, nucleic acids, and
cell membranes, leading to increased permeability and death.
I
Implant baseline radiographic bone level and 6-point
probe depth around a dental implant 12 months post-­
implant placement.
ufactured by Acteon.
Infrasound sound frequency below the audible range of
human hearing (<20 Hz).
Insert placed into a magnetostrictive handpiece made
of ferromagnetic laminate nickel plates, connecting body,
grip, O-ring(s), and stainless-steel shank.
Insert port larger opening on the soft nozzle grip of the
Jet-Mate Sterilizable, Detachable Handpiece manufactured
by Dentsply Sirona that houses the heater rod of the remov-
able Cavitron Jet Air Polishing Insert.
Instruction for use (IFU) see direction for use (DFU).
Integrated ultrasonic device ultrasonic device that
is wired inside a dental unit with controls on the unit itself.
Internal water port small cannula water tube embed-
ded inside an insert and tip shank with a small port open-
ing that expels an aqueous solution.
Intraoral finger rest a stabilization technique where
the operator’s dominant hand is inside the mouth during
ultrasonic instrumentation.
Irrigation application of a steady stream of fluid to re-
move debris or deliver a therapeutic agent subgingivally.
Irrigation seal O-rings present on an Acteon handpiece
and on the horn.
J
Jet-Mate Sterilizable, Detachable Hand-
piece handpiece for dual mode ultrasonic scaling devices
that provides both magnetostrictive ultrasonic scaling and
air polishing, manufactured by Dentsply Sirona.
594 Glossary
K
Kinetic energy the energy an object or particle pos-
sesses due to its motion.
L
Lateral surface the sides of a shank with the lowest dis-
placement amplitude.
Lavage the washing or flushing of fluid subgingivally.
LED ring ring located in the handpiece of the Newtron
SLIM B.LED that provides illumination during ultrasonic
instrumentation, manufactured by Acteon.
Light guide located inside the Original Piezon LED
handpiece that provides LED illumination during
­ultrasonic ­instrumentation that will need replacement over
time.
Liquid jet formation of a jet inside an acoustic cavitation
vapor gas bubble when the bubble nears a solid surface.
Loaded shank an insert or tip shank that is in contact
with a surface.
Low-range ultrasound ultrasound used in health care
with a frequency range of 20–100 kHz.
Low-volume evacuation intraoral evacuation device
with small openings used for the removal of fluid from the
mouth.
Lymphadenopathy disease of the lymph node causing
palpable enlargement.
M
Magnetostriction also known as magnetostrictive effect.
The change of shape of a ferromagnetic material when it is
placed under a magnetically induced strain.
Magnetostrictive effect see magnetostriction.
Magnetostrictive stainless-steel shank located
on a magnetostrictive insert and performs the work or
action.
Manual Prophy mode cycle cycle on a Dentsply
Sirona APD where the provider controls the water and
slurry discharge through the foot pedal.
Mechanical energy energy created by the transfer
of electrical energy across an active medium by a trans-
ducer and that leads to the production of ultrasonic
sound waves and provides the clinical action of an insert
and tip.
Mechanical implant debridement removal of oral
deposits through direct contact with hand-activated in-
strumentation, ultrasonic instrumentation, or air polishing
technologies.
Mechanism of action a device’s fundamental physical
processes responsible for an action.
Mohs hardness a scale of measurement that lists a min-
eral’s surface resistance to scratching or abrasion.
Morphology the study of the parts of an organism and
the relationships between structures.
Multipower delivery air polishing device com-
monly found on stand-alone APDs that will expel the slurry
mixture from the nozzle with changeable powder velocity
settings.
N
National Institute for Occupational Safety
and Health (NIOSH) a component of the Center for
Disease Control (CDC) within the United States De-
partment of Health and Human Services that certifies
­particulate ­filtering facepiece respirators in the United
States.
Newtron the name of an Acteon piezoelectric ultrasonic
device.
Newtron SLIM handpiece without LED lighting manu-
factured by Acteon
Newtron SLIM B.LED handpiece with LED lighting
manufactured by Acteon.
Night Cleaner a solution manufactured by EMS with
a combination of chemicals (ethylenediaminetetraacetate,
p-hydroxybenzoic acid ester, polyhexamethylenebigua-
nide) that will prevent lime, algae, and biofilm formation
in a waterline with its bactericidal and fungicidal actions.
At the time of publication, this product is not approved for
use in the United States.
Node located on the terminal 3.5–5.0 mm of an ultra-
sonic shank formed when the crest of one wave meets the
trough of a second that results in destructive interferences
and causes the shank to have no clinical action.
Noise-induced hearing loss (NIHL) temporary or
permanent hearing loss caused by damage of ear struc-
tures from either persistent exposure to loud noises or
a one-time exposure to an intense sound such as an
explosion.
Nonmechanical implant debridement removal of
oral deposits through direct or indirect contact with dental
lasers, chlorhexidine, low-concentration (<3%) hydrogen
peroxide, ozone (O3), or locally administered antibiotics
and antimicrobials.
Non-NIOSH-approved filtering facepiece
­respirator a respirator mask manufactured out-
side the United States in compliance with the other
country’s standards that protect from non-oil aero-
­
sols and is ­expected to provide similar protection as a
NIOSH-­approved ­particulate filtering facepiece respirator
mask.
No-touch decontamination see air decontamination.
Nozzle extractor tool used to remove the single-use
disposable subgingival nozzle from the PERIOFLOW
handpiece.

Nozzle tube terminal portion on the Dentsply Sirona
­ avitron Jet Air Polishing Insert with two concentric ­openings
C
to deliver water and compressed air powder mixture.
O
Obligate aerobic bacteria bacteria that require
­oxygen to live and grow.
Obligate anaerobic bacteria bacteria whose growth
stops in the presence of oxygen.
Opposite-arch finger rest intraoral stabilization
technique where the operator’s finger rest is on the same
side of the mouth but opposite arch as the position of the
ultrasonic shank on a tooth surface.
Oral deposit biofilm, dental calculus, stain, and bacte-
rial by-products that colonize the oral environment.
Oral flora the natural microbiome residents that exist in
the oral cavity such as bacteria, fungi, protozoa, viruses,
genetic material, and environmental influences (nicotine,
pollutants).
Oral health-care provider trained and licensed Den-
tal Healthcare Personnel (DHCP) who is involved in direct
patient care, treatment, and management of oral conditions
within their scope of practice.
Organization for Safety, Asepsis, and ­Prevention
(OSAP) dentistry’s leading global agency adviser for infec-
tion prevention education and training.
Orientation the position an instrument has in associa-
tion with a structure.
Original Piezon Handpiece handpiece without LED
lighting manufactured by EMS.
Original Piezon LED Handpiece handpiece with
LED lighting manufactured by EMS.
O-ring silicone-based material that is located on a magne-
tostrictive insert and piezoelectric handpiece.
Oscillation repeated back-and-forth rotational move-
ment about an equilibrium.
Osseointegration mechanical and physiological inte-
gration, anchorage, and fusion of a dental implant with the
maxillary or mandibular bone.
Over-abrasion unintentional or intentional excessive
wearing away of hard tissues or restorative materials during
tooth polishing.
Overdenture implant-supported removable partial or
complete denture with built-in copings that attach to an
implant structure.
Ozone (O3) an allotropic modification of the oxygen
molecule mixing pure oxygen with pure ozone to make
a chain of three atoms of oxygen that is delivered in the
dental field as a gas or a liquid (ozonated water, oil, or
saline).
Ozone air generator form of air decontamination
where air is exposed to trioxygen to reduce contamination
through oxidizing reactions.
Glossary 595
P
Particulate filtering facepiece respirator
mask tight fitting mask that covers the wearer’s respira-
tory portals of entry (nose, mouth) and forms a tight seal
around the nose and mouth to provide protection from air-
borne particles.
Pathogenesis manner of disease development.
Pathogenic dental aerosol airborne aerosol created
and released during a dental aerosol-generating procedure
that contains a pathogenic organism (bacteria, viruses,
fungi, protozoa) capable of causing disease once the organ-
ism enters the host.
Pathogenic organism organism capable of causing
disease.
Peri-implant health a dental implant with absence of
active disease.
Peri-implantitis a dental implant with active disease
and loss of attachment.
Peri-implant mucositis a dental implant with active
disease of the peri-implant mucosa with resultant inflam-
mation in the absence of continuing loss of attachment.
PerioChip 2.5 mg of chlorhexidine gluconate in a bio-
degradable matrix of hydrolyzed gelatin (cross-linked with
glutaraldehyde), glycerin, and purified water that is locally
administered into periodontal pockets with sustained con-
trolled release over a specified period of time.
Periodontal debridement a procedure of instrumen-
tation that promotes tooth conservation while removing
oral deposits to decontaminate periodontal pockets and the
mouth.
Periodontic tips the name of ultra-thin diameter tips
manufactured by Acteon.
PERIOFLOW Handpiece the name of the air polish-
ing handpiece that delivers the slurry mixture into deeper
(>4 mm) periodontal pockets, manufactured by EMS.
Perio Gel the name of a proprietary prescription 1.7%
hydrogen peroxide gel patented and manufacturer by Perio
Protect.
Perio mode setting on Soprocare camera manufactured
by Acteon that uses a blue LED and white LED light to
illuminate the pigments present in oral deposits and the
natural endogenous fluorophores present in hard and soft
tissues.
Perio Protect trade name of the company that delivers
the proprietary prescription Perio Gel in a Perio Tray for at-
home use in the treatment of gingival inflammation.
Perio Tips the name of thin (slim) diameter tips with
straight and curved shanks manufactured by EMS.
Perio Tray the name of a proprietary custom lab-made
fabricated prescription tray made of an ethylene vinyl ac-
etate (EVA) elastomer material with an internal peripheral
seal, manufactured by Perio Protect.
Peroxidase group of enzymes that act as a catalyst in
reactions in which hydrogen peroxide is reduced.
596 Glossary
Photodynamic therapy (PDT) procedure performed
with a dental laser in a non-cutting mode that uses the laser
wavelength energy to decontaminate, increase osteoblastic
and fibroblastic activity, decrease inflammation, and pro-
vide analgesia.
Piezoceramic discs the active medium made of
lead-zirconate-titanate in a piezoelectric ultrasonic device
that determines the speed and length of the ultrasonic
sound wave.
Piezoelectric effect the production of an electrical po-
tential across materials when mechanical stress is applied.
Piezoelectric stainless-steel shank located on a
piezoelectric tip and performs the work or action.
Piezon the name of an EMS piezoelectric ultrasonic
device.
Point surface the end of a shank with the highest dis-
placement amplitude.
Polishing agent abrasive chemical applied to teeth and
restorative materials with a rotary handpiece.
Polyether ether ketone (PEEK) a semicrystalline
high-temperature thermoplastic polymer on an ultrasonic
shank for the debridement of a dental implant.
Polysulfone Amoco P-1700 high strength polymer
single-use disposable covering for an ultrasonic shank
manufactured by Dentsply Sirona called a SofTip used for
dental implant debridement.
Portable handheld air polishing device ADP that
attaches to the air turbine connector on a dental unit and
does not require an electrical outlet connection.
Powder bowl the name of the powder chamber manu-
factured by Dentsply Sirona.
Powder bowl cap the name of the powder chamber
cap manufactured by Dentsply Sirona.
Powder chamber part of an APD that holds the powder.
Powder delivery port smaller opening on the soft
nozzle grip of the Jet-Mate Sterilizable, Detachable Hand-
piece manufactured by Dentsply Sirona that houses the
prophy powder delivery tube of the removable Cavitron Jet
Air Polishing Insert.
Powder flow control dial dial located on the powder
bowl cap that will change the powder velocity and flow,
sometimes referred to as a daisy wheel, manufactured by
Dentsply Sirona.
Power control control that changes the shank displace-
ment amplitude of an insert and tip.
Pre-procedural antimicrobial rinse rinse given to a
patient prior to a procedure to reduce the number of viable
organisms in the mouth.
Primary Bjerknes force force that exists in any sound
field where there is a positive gradient, responsible for cre-
ating the oscillating motion of an acoustic cavitation vapor
gas bubble in a liquid medium.
Prophylaxis tips the name of thick and thin (slim) di-
ameter tips manufactured by Acteon.
Prophy mode cycle dial present on the front of an
APD manufactured by Dentsply Sirona that allows the
provider to choose between manual or auto-cycle Prophy
modes.
Prophy powder delivery tube part of the Dentsply
Sirona Cavitron Jet Air Polishing Insert that is placed into
the Jet-Mate Sterilizable, Detachable Handpiece powder
delivery port and delivers the compressed air and powder
mixture.
Prosthesis dental material (fixed or removable) visi-
ble in the mouth that interconnects to any dental implant
device.
Psi acronym for pound force per square inch and rep-
resents a unit of pressure from a force applied to an area.
Purevac HVE a high-volume evacuation system manu-
factured by Dentsply Sirona.
Purevac HVE Connector a part of the Dentsply Sirona
Purevac HVE system that connects the mirror tip to the
HVE hose and rotates 360 degrees.
Purevac HVE Hose five-foot long hose that attaches to
the HVE line on a dental unit that is part of the Dentsply
Sirona Purevac HVE system.
Purevac HVE Mirror Tip an 8-mm bore hole HVE with
affixed mirror that is part of the Dentsply Sirona Purevac
HVE system.
Purge a procedure that removes stagnant liquid from a
water line.
R
Reprocessing the act of cleaning, disinfecting, and ster-
ilizing reusable equipment in a detailed repeatable process.
Root concavity linear concave indentation in cemen-
tum. Also referred to as a root depression or groove.
Root convexity a curved bulge in cementum.
Root depression see root concavity.
Root groove see root concavity.
Root trunk area on a tooth root from the CEJ to the
­entrance of the furcation.
S
Same quadrant intraoral finger rest intraoral sta-
bilization technique where the operator’s finger rest is three
or more teeth away in the same quadrant as the position of
the ultrasonic shank on a tooth surface.
Scaling tips the name of thick diameter tips with a
straight shank, manufactured by EMS.
Secondary Bjerknes force a force that exists between
bubbles in the same sound field and that causes the bub-
bles to either repel or be attracted to one another in a liquid
medium.

Shoe covering single-use disposable or non-disposable
reusable material worn by a Dental Healthcare Personnel
(DHCP) that is impenetrable to fluid and covers the shoe
and reaches to the ankle.
Sialadenitis inflammation, swelling, or infection of a
salivary gland.
Sialolith salivary gland stone.
Single-power delivery air polishing device com-
monly found on portable handheld APDs that will expel
the slurry mixture from the nozzle at a set powder velocity
and is not adjustable.
Sodium bicarbonate powder APD powder made
of sodium, bicarbonate, with or without added tricalcium
phosphate or silicon oxide, that is soluble in water and ad-
ministered coronal to the CEJ.
Softip blue disposable single-use Polysulfone Amoco
P-1700 tip that is placed onto the Dentsply Sirona Cavit-
ron Softip Implant 30K Ultrasonic Insert for dental implant
debridement.
Soft nozzle grip a replaceable wear and tear item lo-
cated on the terminal end of the Jet-Mate Sterilizable,
Detachable Handpiece with two port hole openings, manu-
factured by Dentsply Sirona.
Soprocare the name of a proprietary three-step pro-
gram created by Acteon for preventive nonsurgical pro-
cedures that uses the Soprocamera for patient education,
F.L.A.G technology with ultrasonic instrumentation, and air
polishing.
Soprocare camera the name of the camera manufac-
tured by Acteon that has a daylight, caries, and perio mode
to capture intraoral images.
Spatter droplet large particle size (>50 µm) product
created and released into the environment during a dental
aerosol-generating procedure.
S-Series tip threader tip threader with two flats man-
ufactured by Acteon.
Stand-alone air polishing device APD that requires
an electric outlet connection, attaches to the air connec-
tor on a dental unit, and either uses an independent w ­ ater
­reservoir or attaches to the water connector on a dental
unit.
Stand-alone ultrasonic device ultrasonic device
that is not part of the dental unit itself but placed on a flat
surface inside the dental operatory within easy reach of the
user.
Standard nozzle reusable nozzle with a larger diam-
eter lumen opening than a subgingival nozzle that deliv-
ers the slurry mixture to the crown and root surfaces of
teeth.
Straight shank an ultrasonic insert or tip whose shank
is bent in a single plane.
Streamline category of HuFriedyGroup inserts
with base flow that do not have a nose cone and do not
swivel.
Glossary 597
Streamline Direct Flow category of the HuFriedy-
Group inserts with direct flow that do not have a nose cone
and do not swivel.
Streamline Plus category of HuFriedyGroup inserts
with direct flow, have an 18% wider grip, a beige nose cone,
and do not swivel.
Subcutaneous facial emphysema sudden facial
swelling and crepitus upon palpitation caused by the intro-
duction of air into subcutaneous connective tissue.
Subgingival nozzle single-use flexible narrow tapered
nozzle with a smaller diameter lumen opening than a stan-
dard nozzle that delivers the slurry mixture subgingivally
into deeper periodontal pockets.
Substantivity a solution’s persistence of effect, or resis-
tance of removal, determined by its chemical bonding to a
surface, substrate, or structure.
Supracrestal connective tissue attachment term
used to describe the junctional epithelium and supracrestal
connective tissue surrounding a dental implant or natural
tooth.
Surgical mask loose-fitting pleated flat material that
covers the wearer’s respiratory portals of entry (nose,
mouth) whose design varies widely among manufacturers
in the materials they are made of and efficiency of filtration.
SWERV3 Series the name of HuFriedyGroup’s magne-
tostrictive ultrasonic device.
Swivel category of HuFriedyGroup inserts with base
flow that swivel, have an 18% wider grip, and a black nose
cone.
Swivel Direct Flow category of HuFriedyGroup inserts
with direct flow that swivel, have an 18% wider grip, and
a gray nose cone.
Symbiosis balance of microbiota in the human micro-
biome that leads to health, wellness, and the promotion of
homeostasis.
T
Tap-On technology a feature in a Dentsply Sirona
magnetostrictive ultrasonic device that allows the system
to deliver active cavitation to the insert without a constant
depression of the foot pedal.
Tap stroke a tapping activation with the ultrasonic
point, or just offset from the point, to remove a large dental
calculus deposit.
Tetracycline broad-spectrum class of antibiotics with
bacteriostatic properties against both gram negative and
gram positive bacteria.
Tip placed into the horn of a piezoelectric handpiece
made of a stainless-steel shank.
Tip threader located at the base of a piezoelectric tip
that is torqued into the horn of the handpiece for secure
tip connection.
598 Glossary
Tissue consistency the physical state of epithelial tis-
sues typically described as firm, hard, and tightly adherent
or soft, spongy, and movable.
Tooth polishing procedure to mechanically remove ex-
trinsic exogeneous staining and biofilm from the surface of
a tooth.
Tooth root the area on a tooth root that is covered by
cementum from the CEJ to the root apex.
Tooth topography describes the features, parts, or
structures of a tooth’s surface.
Top-down movement a component of the ultrasonic
activation stroke where the active area antinode of the
shank is moved from the most incisal/occlusal position
(top) on a tooth surface to the most apical (down).
Transducer device that converts one form of energy into
another.
Transverse orientation the active area antinode of
the shank is placed at a right angle to the long axis of the
tooth.
Trifurcation tooth root with three roots.
Tumor a benign or malignant swelling or enlargement of
tissue (Johns Hopkins Medicine, 2020).
U Wave amplitude distance between equilibrium and a
Ultrasonic activation stroke a combination of
­orizontal and top-down movement patterns of the
h displacement of a wave.
active area antinode on the shank used simultane-
ously to ­produce the activation required for ultrasonic
instrumentation.
Ultrasonics field of study that explores the acoustic fre-
quency range of machines that are above the audible range
of human hearing (>20 kHz).
Ultrasound sound frequency above the audible range of
human hearing (>20 kHz).
Ultraviolet-light germicidal irradiation (UVGI)
form of air decontamination where air is exposed to short
wavelength UV light to reduce aerosol contamination
through oxidizing reactions.
Unloaded shank an insert or tip shank that is not con-
tacting a surface.
V
Vacuum line small plastic tubing that is affixed with
either a disposable or reusable sterilizable suction device
to remove fluids from a patient’s mouth during treatment,
which provides a favorable environment for a biofilm’s
growth.
Venturi effect a principle of fluid dynamic where the
velocity of a fluid passing through a constricted area in-
creases with resultant decrease in pressure.
Vertical orientation the active area antinode of the
shank is placed vertical to the long axis of the tooth.
Viscosity resistance of a substance to flow.
W
Water line small plastic tubing that delivers an aqueous
solution that provides a favorable environment for a bio-
film’s growth.
Water-line attachment cord cord provided by the
manufacturer for an ultrasonic device that does not have its
own independent water reservoir bottle and connects to the
dental unit water input.
Water-line filter filter installed on the water line of an
ultrasonic device that captures particles and biofilm.
Water port port present on an insert and tip that
expels an aqueous solution used during ultrasonic
instrumentation.
wave’s maximum negative or positive displacement.
Wave crest positive peak or point of largest maximum
Wave equilibrium state of a wave at rest or balance be-
tween opposing forces.
Wave frequency number of wave cycles completed at
one point on the wave in a given time period. Measured in
cycles per second.
Wavelength length of one cycle of a wave.
Wave trough negative peak or the point of largest nega-
tive displacement of a wave.
Work-related musculoskeletal disorder (WMSD)
injuries of muscles, nerves, tendons, joints, cartilage, and
spinal discs that occur and are made worse by a work
environment.
Wrench a device that houses a piezoelectric tip and torques
the tip into the horn of the handpiece.
Z
Zoonotic disease an infectious disease that is spread
between animals and humans.
Index
Note: Page numbers followed by ‘f’ and ‘t’ indicate figures and tables respectively.

A
water, 330–331 top-down movement, 201–202
water bottle and line purging, 331 ultrasonic instrumentation candle
water control, 330 exercise, 203–212
ablation, 36 water flow rate, 330–331 ultrasonic versus hand-activated in-
abrasion, 392, 402–403 water pump, 331 strumentation, 220–221, 221t
abutment, 526, 529 Acteon curved tips, 365–389 active area antinode, 41
abutment and prosthesis, 555–556 adaptation, 368–374, 374f active medium, 35
acoustic cavitation Acteon left-curved tip for anterior acute respiratory infection (ARI),
Bernoulli principle, 93–94, 93f and posterior teeth (P2L) 6–7, 6f
defined, 94 adaptation, 373–374 COVID-19 pandemic and, 2
dental, 94–98 Acteon left-curved tips for posterior adaptations, 172–174. See also under
dental ultrasonic device and, 96 teeth (H4L and TK2-1L) individual entries
oral effects, 96–97 adaptation, 370–371 shank surfaces, 172–174, 173t
primary Bjerknes forces, 96 Acteon right-curved tip for anterior skill building, 179–193
secondary Bjerknes forces, 96, 96f and posterior teeth (P2R) ultrasonic versus hand-activated in-
vapor gas bubble behavior, 95–96 adaptation, 372 strumentation, 193
water phase diagram, 94, 94f Acteon right-curved tips for adjunctive therapy, 575
acoustic microstreaming, 98–100 posterior teeth (H4R and advanced grasp, 152, 152f
behavior, 98–99 TK2-1R) adaptation, 369–370 aerosol control, 160–162, 484
defined, 98 identifying correct, 368–374, 374f HVE grasp, 160–162
oral effects, 99–100 case study, 385–388 HVE positioning, 160
Acteon, 327–344, 328–331 debridement with, 374–385 aerosols, dental, 1–10. See also dental
case study, 341–343 buccal furcation debridement of aerosol
emerging technology, 328–329 mandibular first molar, 375–377, acute respiratory infection, 6–7
foot pedal, 330 375f–376f defined, 3
frequency, 328 distal-buccal root debridement of DHCP and, 7–8
handpiece, 331–332 mandibular first molar, 379–380, oral flora, 2
LED ring, 331, 332f 379f–380f overview, 2, 4
O-ring, 331 distal-lingual root debridement of particle size, 3–4, 3t
overview, 327–328 mandibular first molar, 382–383, pathogenic, 4–6, 5f
power, 329–330 382f–383f spatter droplets and, 3
reprocessing, 337–339 lingual furcation debridement of air, 458
handpiece, 339 mandibular first molar, 380–382, air decontamination, infection
tip, 337 380f–382f prevention and, 25–27
ultrasonic device, 337–339 mesial-buccal root debridement of bipolar air ionization, 27
Soprocare, 339–340 mandibular first molar, 377–378, electrostatic precipitator, 27
caries mode, 339 377f–378f filtration, 26
daylight mode, 339 mesial-lingual root debridement of hydrogen peroxide system, 26–27, 27f
perio mode, 339 mandibular first molar, 384–385, ozone generator, 26
tip portfolio, 332–337 384f–385f reactions with charged particles, 27
curved periodontic tips, 335–336, setup, 374–375 reactions with oxygen species, 26–27
336f, 337t overview, 365–367 UV Light, 26
implant tips, 336–337 activation, 197–222 air-driven dental equipment, 3, 4, 5f
periodontic tips, 335–336 defined, 197–198 AIRFLOW, 310
plastic micro-tipped, 336, 337f finger motion, 198 AIRFLOW Handy 3.0 Classic, 521–523,
prophylaxis tips, 333–335 overview, 197 521f–523f
slim prophylaxis tips, tap stroke, 219–220 AIRFLOW Handy 3.0 Perio, 521–523,
333–335, 334f ultrasonic activation stroke, 198–220 521f–523f
straight periodontic tips, 35t, 335 curved shank ultrasonic AIRFLOW Classic powder, 449
thick diameter prophylaxis tips, 333 instrumentation spoon exercise, AIRFLOW handpieces, 465–468,
titanium, 336–337, 338t 213–219 466f–468f
tip water port, 331 horizontal movement, 198–202 AIRFLOW Handy, 449, 450f
599
600 Index
AIRFLOW Handy 3.0, 458f, 516
body, 458f–459f, 458–460
foot pedal, 464, 465f
powder chamber, 460–464, 460f–464f
AIRFLOW Handy 3.0 Classic, 458,
458f, 520
AIRFLOW Handy 3.0 Perio, 458, 458f,
516–520, 516f–520f
AIRFLOW Max, 504–513,
504f–513f
air polish anterior smooth surfaces,
506–509, 507f–510f
air polish posterior occlusal surfaces,
505–506, 505f–506f
air polish posterior smooth surfaces,
510–512, 511f–513f
AIRFLOW One, 449, 450f
air, 458
foot pedal, 454, 454f, 454t
powder chambers, 451–452,
451f–453f
powder velocity control, 452, 454,
454f, 454t
water, 454–458, 458f
AIRFLOW Perio powder, 449
AIRFLOW Plus powder, 449
AIRFLOW Prophylaxis Master,
310, 449, 450f
air, 458
foot pedal, 454, 454f, 454t
powder chambers, 451–452,
451f–453f
powder velocity control, 452, 454,
454f, 454t
water, 454–458, 458f
air-line attachment cord, 55, 55f
air lines, ultrasonic devices and, 55
air polishing, 559, 560. See also CEJ air
polishing
AIRFLOW Handy 3.0 Classic Break
Down, 521–523, 521f–523f
AIRFLOW Handy 3.0 Perio, 521–523,
521f–523f
AIRFLOW Handy 3.0, 516
AIRFLOW Handy 3.0 Classic, 520
AIRFLOW Handy 3.0 Perio, 516–520,
516f–520f
case study, 405–406
clinical technique
aerosol control, 484
grasp and stabilization, 483–484, 484f
operator chair positioning, 484
patient care, 484–485, 485f
patient positioning, 484
considerations, 405
contraindications, 405
with Dentsply Sirona Device
air polish anterior smooth surfaces,
495–497, 496f–497f
air polish posterior occlusal sur-
faces, 493–495, 494f–495f
air polish posterior smooth surfaces,
497–501, 498f–502f
setup, 489–493, 490f–493f
devices, 397–401
design, 397–398, 399f
multipower delivery air polishing
device, 398
nozzle design, 399–401, 403
portable handheld air polishing
device, 397
rotary versus, 403–404
single-power delivery air polishing
device, 397
stand-alone air polishing device, 397
standard nozzle, 399–400, 400f
subgingival nozzle, 400–401,
400f–401f
with EMS guided biofilm therapy
AIRFLOW Max, 504–513,
504f–513f
assessment and infection control, 504
check, 516
disclose, 504, 504f
motivate, 504, 504f
PERIOFLOW, 513–516, 513f–516f
Piezon PS, 516
recall, 516
setup, 502f–504f
on inanimate objects, 485–486, 486f
penny, 486–487, 487f
quail egg, 487–489, 488f
mechanism of action, 401–403
abrasion, 402–403
fluid dynamics, 401
Mohs hardness, 395, 395t
overview, 392, 397
provider technique, 396, 403
rotary handpiece polishing, 393–395,
395f
tooth polishing, 392–393, 394f
air polishing devices (APDs), 392,
411–412
adverse effects, 420–421
clinical applications, 412f–413f
considerations
gingival status, 416, 417f
sodium bicarbonate power,
416–417
and dental materials, 417–418
contraindication, 419–420, 420f
safe use, 418f–419f
use with caution, 418, 419f–420f
powder
air polishing literature, 416
aluminum trihydroxide
powder, 415
calcium carbonate powder, 415
calcium sodium phosphosilicate
powder, 415
chemical composition and clinical
applications, 414–416
erythritol powder, 415–416
glycine powder, 415
Mohs hardness, 413–414, 414t
particle size, 413, 413t, 414f
powder care, 416
sodium bicarbonate powder,
414–415
air purification, 25. See also air
decontamination, infection
prevention and
aluminum trihydroxide powder, 415
Amalgam, 418, 420f
angulations, 172, 174–176
defined, 174
90-degree angulation, 174–175, 174f
skill building, 179–193
0- to 15-degree angulation, 176, 177f
ultrasonic versus hand-activated
instrumentation, 193
antibiotics, locally administered,
580–581, 581f
antinode, 40
active area, 41
anti-retraction device, 15
applications, ultrasonic. See ultrasonic
applications
aqueous solutions, 51–53
Arestin, 580, 581f
Atridox, 580, 581f
auditory effects, 41–42
auditory risks, 42
auto-cycle Prophy mode, 431, 433
B
back, 174
back driver, 36
BacterX Pro mouthwash, 472
base flow, 268
Bernoulli principle, 93
biofilm, 13
bipolar air ionization, 27
Bjerknes forces, 96
blue operation mode, 264
Blue power zone, 330
body, 458f–459f, 458–460
bone, 530–532, 533f
bone remodeling, 531
boost mode, 313
brushing, 544
buccal debridement of mandibular
first molar supragingival
interproximal area
technique practice, curved inserts,
305–306, 306f
buccal furcation debridement of
mandibular first molar, 352–353
Acteon curved tips, 375–377,
375f–376f
EMS curved tips, 352–353
technique practice, curved inserts,
294–295, 295f
burnishing of dental calculus, 153
C
calcium carbonate powder, 415
calcium sodium phosphosilicate powder,
415
catalase, 578
cavitation, 92
Cavitron Diamondcoat 30K Ultrasonic
Insert, 255

Cavitron Jet Air Polishing Insert, 435,
438–440
Cavitron Jet Fresh Prophy Powder, 427
Cavitron Jet Plus Ultrasonic Scaling and
Air Polishing System, 426, 426f
air, 435, 436f
foot pedal, 433f–433f, 433–434
handpiece, 437f–439f, 437–440
nozzle, 435–437, 436f–437f
powder bowl, 427–429, 427f–431f
powder velocity control, 429–430,
431f–432f
Prophy mode cycles, 430–433,
432f–433f, 433t
water, 434f–435f
control, 434, 435f
purge, 434
Cavitron Powerline Ultrasonic Inserts,
249, 250f
Cavitron Prophy Jet Air Polishing
System, 426, 426f
air, 435, 436f
foot pedal, 433f–433f, 433–434
handpiece, 437f–439f, 437–440
nozzle, 435–437, 436f–437f
powder bowl, 427–429, 427f–431f
powder velocity control, 429–430,
431f–432f
Prophy mode cycles, 430–433,
432f–433f, 433t
water, 434f–435f
control, 434, 435f
purge, 434
Cavitron Prophy Jet Handpiece Cleaning
Tool, 438
Cavitron Prophy Jet Nozzle Cleaning
Tool, 436
Cavitron Prophy Jet Prophy Powder, 427
Cavitron Slimline Ultrasonic Inserts,
251, 252t
Cavitron Softip Disposable Prophy Tip
Removal Wrench, 254
Cavitron Softip Implant 30K Ultrasonic
Insert, 254
Cavitron Steri-Mate 360 Handpiece, 242
Cavitron Steri-Mate Sterilizable,
Detachable Handpiece, 248
Cavitron Thinsert 30K Ultrasonic
Insert, 253
Cavitron ultrasonic scaling system, 240
CDC recommendations, reprocessing
and, 57
CEJ air polishing, EMS AIR–FLOW One
and AIR–FLOW Prophylaxis
Master
Cavitron Prophy Jet Air Polishing
System, 427–440
air, 435, 436f
foot pedal, 433f–433f, 433–434
handpiece, 437f–439f, 437–440
nozzle, 435–437, 436f–437f
powder bowl, 427–429, 427f–431f
powder velocity control, 429–430,
431f–432f
Prophy mode cycles, 430–433,
432f–433f, 433t
water, 434f–435f
clinical technique, 440, 441f–442f
Dentsply Sirona air polishing
devices, 426, 426f
powders, 427, 427f
EMS AIR-FLOW Handy 3.0, 458f
body, 458f–459f, 458–460
foot pedal, 464, 465f
powder chamber, 460–464,
460f–464f
EMS AIR-FLOW One and AIR-FLOW
Prophylaxis Master
air, 458
foot pedal, 454, 454f, 454t
powder chambers, 451–452,
451f–453f
powder velocity control, 452, 454,
454f, 454t
water, 454–458, 458f
EMS air polishing devices, 449, 450f
EMS air polishing powders, 449–450,
450t, 451f
EMS guided biofilm therapy
AIR-FLOW Max, 474
assessment and infection
control, 472
check, 474
disclose, 472–474, 474f
motivate, 472–474, 474f
PERIOFLOW, 474
Piezon PS, 474
recall, 474
EMS handpiece and nozzles, 465f
AIR-FLOW handpieces, 465–468,
466f–468f
PERIOFLOW handpiece, 468–471,
468f–471f
in periodontal debridement
delivery of care, 449
hard and soft tissue effects, 449
microbiological, 449
overall clinical outcomes, 448
reprocessing
air polishing device, 440
air polishing devices, 471
handpiece and nozzle
insert, 440
handpieces, 472, 472f
cell death, 576
cementum
alterations, 119
instrumentation of, 133
charged particles, reactions with, 27
cheek finger rest, 155
chlorhexidine, 575–576
gel, mouth rinse, and spray studies,
576–577
locally administered, 576
PerioChip, 576, 576f
cleaning agents, 393
CLIP+CLEAN tool, 315
colony-forming units (CFUs), 15
colored grip, 63
CombiTorque, 321
communicable disease, 121
complex root anatomy, 134–144
Index 601
furcation anatomy, 139, 140t
furcation assessment, 140–141, 142f
furcation debridement, 142–144
root concavity and convexity, 135,
136f, 137t–139t
root nomenclature, 134t–135t
Composite resins, 418
confounding variables, 133
connecting body, 63
consideration, 120
contraindication, 120
coolant, 100–101
cord adaptor, 459
COVID-19 pandemic, acute respiratory
infection and, 2
cross-arch finger rest, 155
curved inserts, 279–291
magnetostrictive, 279–280, 281f
adaptation, 281
adaptation and shank position
vertical orientation, 282
identifying correct adaptation for
vertical orientation, 282–283
left-curved insert adaptation
transverse orientation,
286, 287t
left-curved insert adaptation vertical
orientation, 283–284, 285t
right-curved insert adaptation
transverse orientation, 286, 287t
right-curved insert adaptation
vertical orientation, 283, 285t
selection steps, 283t
transverse orientation, 285–287
vertical orientation,
281–284, 285t
overview, 279
technique practice, vertical and
transverse orientation,
293–306
buccal debridement of mandibular
first molar supragingival inter-
proximal area, 305–306, 306f
buccal furcation debridement of
mandibular first molar, 294–295,
295f
distal-buccal root debridement of
mandibular first molar, 298–299,
298f
distal-lingual root debridement of
mandibular first molar, 302–303,
302f–303f
lingual debridement of mandibular
first molar supragingival
interproximal area, 299–300, 300f
lingual furcation debridement of
mandibular first molar, 300–302,
301f
mesial-buccal root debridement
of the mandibular first molar,
295–297, 296f–297f
mesial-lingual root debridement
of the mandibular first molar,
303–305, 304f
overview, 293
setup, 293–294
602 Index

curved periodontic tips, 335–336, 336f, mechanism of action, 574
337t dental materials
curved shank, 71 air polishing device, 417–418
curved tips. See EMS curved tips contraindication, 419–420, 420f
cysts, 112 safe use, 418f–419f
cytokines, 415 use with caution, 418, 419f–420f
dental ultrasonic device, 35–40
dental unit, defined, 13
distal-buccal root debridement of
mandibular first molar, 355, 355f
Acteon curved tips, 379–380,
379f–380f
EMS curved tips, 355, 355f
technique practice, curved inserts,
298–299, 298f
distal-lingual root debridement of

D
dental unit lines, maintenance mandibular first molar, 357–358,
of, 13–17, 13f 357f–358f
best practice recommendation, water Acteon curved tips, 382–383,
daisy wheel, 428 lines and, 17 382f–383f
debridement, 142–144 vacuum line tubing, 14–15, 14f curved inserts, technique practice,
decibel (dB), 34 water-line maintenance, 16 302–303, 302f–303f
demineralized and decayed water-line monitoring, 15–16 EMS curved tips, 357–358, 357f–358f
hard tissues, 121 water-line tubing, 15–17, 16f doxycycline, 580, 581
dental aerosol. See also aerosols dentinal desensitization, 413f dynamic pressure regulator, 451
defined, 4 dentin hypersensitivity, 123 dysbiosis, 2, 2f
management, 13–27 Dentsply Sirona, 239–262, dyspnea, 421
management, infection prevention 240–248
and, 13–27.See also infection, air polishing and

prevention of
movement, 7f
pathogenic, 4
production and behavior, 5f
dental aerosol-generating procedure,
4, 8f
infection prevention.Seeinfection,
prevention of
dental clinical applications, 108–115
endodontics, 111
magnetostrictive ultrasonic devise,
109
operative dentistry, 111, 112f
oral and maxillofacial surgery,
112–113, 112f–113f
orthodontics, 113–114
periodontal therapy, 110–111, 111f
periodontics and dental hygiene,
114–115, 114f
piezoelectric ultrasonic device, 109,
110f
sonic scaler, 110
dental device, 13
dental equipment, 4
dental floss, 544, 546, 546f
Dental health-care personnel (DHCP)
aerosol and, 7–8
defined, 2
dental implant, 121, 122f, 526
anatomy and physiology, 526–528,
526f–528f
bone, 530–532, 533f
implant baseline, 533
keratinized outer masticatory
mucosa, 528, 528f
mucosa remodeling factors,
528–530, 529f–531f
non-keratinized inner masticatory
mucosa, 528
dental lasers, 573–574, 573f
adverse effects, 575
laser
defined, 573–574, 574f–575f
and dental implants, 574–575
literature, 575
E
air polish anterior smooth surfaces,
495–497, 496f–497f
air polish posterior occlusal sur-
faces, 493–495, 494f–495f Easy Clean tool, 472
air polish posterior smooth surfaces, Electromagnetic spectrum, 573f–574f
497–501, 498f–502f electrostatic precipitator, 27
devices, 426, 426f EMS, 309–325
powders, 427, 427f emerging technology, 310–311
setup, 489–493, 490f–493f frequency, 310
analog Cavitron ultrasonic scaling handpiece, 317–319
system, 246–247 connection, 319
boost mode, 244, 245f light guide, 318
digital Cavitron ultrasonic scaling O-ring, 318, 319f
system, 246 overview, 309–310
digital Cavitron ultrasonic scaling power, 311–313, 313t
systems, 240–242, 241f AIRFLOW Prophylaxis Master, 311,
emerging technology, 240 312f
foot pedal, 245–247, 246f boost mode, 313
frequency, 240 foot pedal, 313
handpiece, 248 Piezon 150, 311
insert portfolio, 249–256 Piezon 250, 311
diamond-coated insert, Piezon 700, 311, 312f
255–256, 257f reprocessing, 321
implant insert, 254–255 tip, wrench, and handpiece, 321
thick diameter Cavitron powerline ultrasonic device, 321
ultrasonic inserts, 249–251 tip portfolio, 319–321
thin diameter Cavitron slimline implant tip, 320–321
ultrasonic inserts, 251–252 thick diameter tips, 319–320
ultra-thin diameter Cavitron thin diameter tips, 320
thinsert, 253–254 water, 313–317
insert water port, 247 bottles, 315–316, 317f
overview, 239–240 control, 314, 314f
power control, 243–244, 243f, 244t filter, 314
reprocessing, 257 flow rate, 314
Cavitron ultrasonic scaler, 257 line purging, 315–316, 317f
handpiece, 257 pump, 317
insert, 257 temperature, 314–315
water, 247–248 tip water port, 317
water control, 247 EMS air polishing devices, 449, 450f
water filter, 247, 248f EMS air polishing powders, 449–450,
water flow rate, 247 450t, 451f
diffusion, 4 EMS curved tips, 345–364
direct flow, 267 adaptation, 347–350
direction for use (DFU), 48, 49t EMS left-curved tip (PSR
displacement amplitude, 79–81 instrument) adaptation, 349–350
 Index 603

EMS right-curved tip (PSR
instrument) adaptation, 348–349
identifying correct, 348–350
debridement with, 350–359
buccal furcation debridement of
mandibular first molar, 352–353
distal-buccal root debridement of
mandibular first molar, 355, 355f
distal-lingual root debridement of
mandibular first molar, 357–358,
evacuation devices, infection prevention
and, 23–25, 24f
high-volume evacuation, 23
low-volume evacuation, 23
extraneous variables, 133
extraoral finger rest, 155
extraoral scavenging device, 25
extrinsic exogeneous stain, 392
Green power zone, 330
guided biofilm therapy (GBT). See EMS
guided biofilm therapy
gum margin, 540–541
H
hair protection, 18–19
hand-activated instrumentation,

357f–358f
lingual furcation debridement of
mandibular first molar, 356–357,
356f–357f
mesial-buccal root debridement of
mandibular first molar,
353–354
mesial-lingual root debridement of
mandibular first molar, 359
setup, 350–353
overview, 345–346, 347f
EMS guided biofilm therapy
AIRFLOW Max, 504–513, 504f–513f
air polish anterior smooth surfaces,
506–509, 507f–510f
air polish posterior occlusal sur-
faces, 505–506, 505f–506f
air polish posterior smooth surfaces,
510–512, 511f–513f
assessment and infection control, 504
CEJ air polishing
AIR-FLOW Max, 474
assessment and infection
control, 472
check, 474
disclose, 472–474, 474f
motivate, 472–474, 474f
PERIOFLOW, 474
Piezon PS, 474
recall, 474
check, 516
disclose, 504, 504f
motivate, 504, 504f
PERIOFLOW, 513–516, 513f–516f
Piezon PS, 516
F
face, 174
face drapes, 485, 485f
face shield, 22–23, 23f
facultative anaerobes, 577
facultative anaerobic bacteria, 578, 580
FDA regulations, reprocessing and, 57
ferromagnetic laminate nickel plates, 39
fibroblasts, 576
filtration, 26
finger motion, 198
finger rest, 153
fixed dental materials, 121
F.L.A.G. technology, 339
fluid, 92
fluid dynamics, 92, 401
fluid mechanism, 92
foot pedal, ultrasonic devices and
design and functionality, 50–51
integrated ultrasonic device, 49–50
stand-alone ultrasonic device, 50
frequency, 34–35, 34f
front driver, 36, 37
furcation
anatomy, 139, 140t
assessment, 140–141, 142f
debridement, 142–144
exploration evaluation, 141
periodontal charting, 140–141
radiographic evaluation, 141, 142f
furcation access, 119
556–557, 556f, 559–560
hand-activated versus ultrasonic
instrumentation, 166t
hand hygiene, 17–18, 17t, 18f
handpiece
HuFriedyGroup, 266, 267f
ultrasonic devices, 55–56, 56f
hard tissue
deficiencies after implant placement,
536–537, 538t
deficiencies prior to implant
placement, 535–536,
535f–536f
hard tissue histology, 132, 132t
heater rod, 436
hertz (Hz), 34
heterotrophic mesophilic water
bacteria, 15
high-efficiency particulate air (HEPA)
filter, 26
high-volume evacuation, 23–24, 24f
HIV, 123
horizontal movement, ultrasonic
activation stroke, 198–202
horn, 36, 37
HuFriedyGroup, 263–277
handpiece, 266, 267f
insert portfolio, 267–273
categories, 269t
thick diameter inserts,
268–270, 271t
thin diameter inserts, 271–273,
272f, 273t
magnetostrictive ultrasonic device,
264–266

G
recall, 516
frequency, 264
setup, 502f–504f
power, 264–265
EMS handpiece and nozzles, 465f
SWERV3 30K, 264, 264f
AIR-FLOW handpieces, 465–468, gingival status, 416, 417f
water, 265–266
466f–468f Glickman Index, 140
overview, 263–264
PERIOFLOW handpiece, 468–471, gloves, 17–18, 17t, 18f
reprocessing, 273
468f–471f glycine powder, 415
handpiece, 273
EMS left-curved tip (PSR instrument) glycine powder air polishing
insert, 273
adaptation, 349–350 (GPAP), 415
SWERV Device, 273
EMS right-curved tip (PSR instrument) gown, 18–19
HVE grasp, 160–162
adaptation, 348–349 granulomas, 112
HVE positioning, 160
endodontics, 111 grasp, 150–152, 150f
hydrodynamic shear stress, 99
Enzymax, 273 advanced grasp, 152, 152f
hydrogen peroxide (H2O2), 26–27, 27f,
ergonomics, ultrasonic devices and, defined, 150
578f–589f
57–58 light grasp, 152–153
erythritol powder, 415–416 magnetostrictive grasp, 150–151

I
erythritol powder air polishing hand and finger size, 151, 151f
(EPAP), 416 piezoelectric grasp, 151, 152f
E-Series, 319 skill building, 153, 153f
ethylenediaminetetraacetic grasp and stabilization, 483–484, 484f implant baseline, 533
acid (EDTA), 582 green operation mode, 265 implant care, 336
604 Index
implant case definitions and assessment,
525–526
clinical assessments, 537–538
gum margin, 540–541
mobility, 541, 541f
occlusion assessment, 542, 542f
periodontal charting assessment,
539–543
probe depths, 539–540
prosthesis health, 542–543, 543f
radiographic assessment, 542, 542f
visual and palpatory tissue assess-
ment, 539, 540f
dental implant anatomy and physiol-
ogy, 526–528, 526f–528f
bone, 530–532, 533f
implant baseline, 533
keratinized outer masticatory mu-
cosa, 528, 528f
mucosa remodeling factors,
528–530, 529f–531f
non-keratinized inner masticatory
mucosa, 528
oral hygiene
brushing, 544
interdental aids, 544–546,
545f–546f
peri-implant diseases and conditions
peri-implant health, 533–534
peri-implantitis, 534, 535t
peri-implant mucositis, 534
peri-implant soft and hard
tissue deficiencies, 534–537,
535f–537f, 538t
recall recommendations, 543–544
implant debridement, 553–554, 554b
mechanical implant
goals, 554–555, 555t
peri-implant mucositis treatment,
559–561, 560f
nonmechanical implant, 572, 572t
infection, prevention of, 11–29
air decontamination, 25–27
bipolar air ionization, 27
electrostatic precipitator, 27
filtration, 26
hydrogen peroxide system,
26–27, 27f
ozone generator, 26
reactions with charged particles, 27
reactions with oxygen species, 26–27
UV Light, 26
dental aerosol management, 13–27
dental unit lines, maintenance of,
13–17, 13f
best practice recommendation,
water lines and, 17
vacuum line tubing, 14–15, 14f
water-line maintenance, 16
water-line monitoring, 15–16
water-line tubing, 15–17, 16f
evacuation devices, 23–25, 24f
extraoral scavenging device, 25
high-volume evacuation, 23–24, 24f
intraoral device, 23–24
low-volume evacuation, 23, 24f
overview, 12–13
personal protective equipment, 17–23
face shield and protective eyewear,
22–23, 23f
gown, hair, and shoe protection,
18–19
hand hygiene and gloves, 17–18,
17t, 18f
mask, 19–20, 19f
non-NIOSH-approved filtering
facepiece respirators, 22–23
particulate filtering facepiece
respirator mask, 20t, 21–22, 22t
surgical mask, 20–21, 21f
pre-procedural antimicrobial
rinses, 23
ventilation systems, 25
mechanical ventilation, 25
natural ventilation, 25
infrasound, 35
insert, 62. See also curved inserts;
ultrasonic insert/tip
insert port, 437
insert portfolio. See also curved inserts;
ultrasonic insert/tip
Dentsply Sirona, 249–256
diamond-coated insert, 255–256, 257f
implant insert, 254–255
thick diameter Cavitron powerline
ultrasonic inserts, 249–251
thin diameter Cavitron slimline
ultrasonic inserts, 251–252
ultra-thin diameter Cavitron
thinsert, 253–254
HuFriedyGroup, 267–273
thick diameter inserts, 268–270, 271t
thin diameter inserts, 271–273,
272f, 273t
integrated ultrasonic device, 48
foot pedal, 49–50
interdental aids, 544, 545f
dental floss, 544, 546, 546f
intraoral device, 23–24
intraoral finger rest, 155
irrigation, 101
irrigation seals, 331
J
Jet-Mate sterilizable, detachable
handpiece, 248, 249f, 437,
438–440
K
keratinized outer masticatory mucosa,
528, 528f
kinetic energy, 93
L
laser. See also dental lasers
defined, 573–574, 574f–575f
and dental implants, 574–575
literature, 575
mechanism of action, 574
lateral surfaces, 174
lavage, 101
LED lighting, 58, 58f
LED ring, 331
light grasp, 152–153
light guide, 318
lingual debridement of mandibular
first molar supragingival
interproximal area
curved inserts, technique practice,
299–300, 300f
lingual furcation debridement of
mandibular first molar, 356–357,
356f–357f
Acteon curved tips, 380–382,
380f–382f
curved inserts, technique practice,
300–302, 301f
EMS curved tips, 356–357, 356f–357f
lip and cheek retraction, 485, 485f
liquid jets, 100, 100f
defined, 100
effects in mouth, 100
formation and deformation, 100
loaded shrank, 81
locally administered antibiotics,
580–581, 581f
low-volume evacuation, 23, 24f
lymphadenopathy, 113
M
magnetostriction, 38
magnetostrictive effect, 38
magnetostrictive grasp, 150–151
magnetostrictive stainless-steel
shank, 65
magnetostrictive ultrasonic, 38–40, 39f
magnetostrictive ultrasonic devices, 109
Dentsply Sirona.SeeDentsply Sirona
HuFriedyGroup, 264–266
frequency, 264
power, 264–265
manual Prophy mode cycle, 430–431
mask, 19–20, 19f
mechanical debridement
555, 561-563, 561b, 562f–563f
air polishing, 559
hand-activated instrumentation,
556–557, 556f
ultrasonic instrumentation, 557–558,
557f
mechanical energy, 36
mechanical implant maintenance
implant debridement, 553–554, 554b,
559–561, 560f
goals, 554–555, 555t
mechanical debridement
air polishing, 559
hand-activated instrumentation,
556–557, 556f

ultrasonic instrumentation,
557–558, 557f
mechanical debridement technique
561-563, 561b, 562f–563f
peri-implantitis treatment, 559–561,
560f
peri-implant mucositis
literature, 559
treatment, 559
surface topography
abutment and prosthesis, 555–556
implant, 555
mechanical ventilation, 25
mechanism of action, ultrasonic, 92–104
acoustic cavitation, 92–97, 93f
Bernoulli principle, 93–94
dental, 94–98
dental ultrasonic device and, 96
oral effects, 96–97
primary Bjerknes forces, 96
secondary Bjerknes forces, 96, 96f
vapor gas bubble behavior, 95–96
water phase diagram, 94
acoustic microstreaming, 98–100
behavior, 98–99
oral effects, 99–100
case study, 101–102
coolant, 100–101
defined, 92
fluid mechanism, 92
lavage and irrigation, 100
liquid jets, 100, 100f
defined, 100
effects in mouth, 100
formation and deformation, 100
mechanical mechanism, 92
medical clinical applications, 108
mesial-buccal root debridement of
mandibular first molar,
353–354
Acteon curved tips, 377–378,
377f–378f
curved inserts, technique practice,
295–297, 296f–297f
EMS curved tips, 353–354
technique practice, curved inserts,
295–297, 296f–297f
mesial-lingual root debridement of
mandibular first molar,
359
Acteon curved tips, 384–385,
384f–385f
curved inserts, technique practice,
303–305, 304f
EMS curved tips, 359
microbial reduction, 118
minocycline, 580, 581
mobility, 541, 541f
Mohs hardness, 395, 395t, 413–414,
414t
monotherapy, 575
morphology, 141
mucosa remodeling factors, 528–530,
529f–531f
multipower delivery air polishing
device, 398
N
National Institute for Occupational
Safety and Health (NIOSH), 21
natural ventilation, 25
Newtron, 328
Newtron SLIM, 331
Newtron SLIM B.LED, 331
Night Cleaner, 316, 455, 456
90-degree angulation, 174–175, 174f
nodes, 40
noise-induced hearing loss (NIHL), 41
non-keratinized inner masticatory
mucosa, 528
nonmechanical debridement, 572–573,
581–582
chlorhexidine, 575–577, 576f
dental lasers, 573f–574f, 573–575
implant debridement, 560f
air polishing, 560
hand-activated and ultrasonic
instrumentation, 559–560
peri-implantitis and titanium
particles, 560–561
locally administered antibiotics,
580–581, 581f
ozone and hydrogen peroxide,
577–580, 578f–589f
nonmechanical debridement/
peri-implantitis, 581–582
nonmechanical implant
maintenance, 555
implant debridement goals,
572, 572t
nonmechanical debridement,
572–573
chlorhexidine, 575–577, 576f
dental lasers, 573f–574f,
573–575
locally administered antibiotics,
580–581, 581f
ozone and hydrogen peroxide,
577–580, 578f–589f
nonmechanical debridement/
peri-implantitis, 581–582
non-NIOSH-approved filtering
facepiece respirators, 22–23
no-touch decontamination, 25. See also
air decontamination, infection
prevention and
nozzle design, air polishing,
399–401, 403
nozzle extractor, 469
nozzle tube, 436
O
obligate aerobes, 577
obligate aerobic bacteria, 578
obligate anaerobes, 577
obligate anaerobic bacteria, 578
occlusal contamination, 421f
occlusion assessment, 542, 542f
operative dentistry, 111, 112f
Index 605
operator and patient chair positioning.
See operator chair position,
by area of mouth; positioning,
operator and patient chair
operator chair position, by area of
mouth, 163–165. See also
positioning, operator and patient
chair
anterior teeth, 164–165, 165–166f
dominant right- and left-handed,
164–165, 165–166f
mandibular anterior teeth, 165,
165f
maxillary anterior teeth, 165, 166f
posterior teeth, 163–164
dominant left-handed, 164, 164t
dominant right-handed, 163, 163t
operator chair positioning, 484
opposite-arch finger rest, 155
oral and maxillofacial surgery, 112–113,
112f–113f
oral deposit
case example, 75–77
location, 77
type and size, 72–77
oral deposits, 34
oral flora, 2
oral health-care provider, 2
oral hygiene
brushing, 544
interdental aids, 544–546, 545f–546f
Organization for Safety, Asepsis, and
Prevention (OSAP), 13
orientations, 172, 176–178, 178t
defined, 176
skill building, 179–193
transverse, 177–178, 178f, 178t
ultrasonic versus hand-activated
instrumentation, 193
vertical, 176–177, 178f, 178t
O-ring, 64
function, 64
lubrication, 64, 64f
replacement, 64–65
orthodontic appliances, 124
orthodontics, 113–114
oscillation, 95
osseointegration, 530
over-abrasion, 392
overdenture, 526, 526f
oxygen species, reactions with, 26–27
ozone, 578, 580
ozone air generator, 26
P
pacemaker, 124–125
particulate filtering facepiece respirator
mask, 20t, 21–22, 22t
pathogenic dental aerosol, 4
pathogenic organisms, 2
patient care, 484–485, 485f
patient positioning, 484
PEEK, 557
606 Index
penny, 486–487, 487f
peri-implant health, 533–534, 535t
peri-implantitis, 534, 535t
peri-implantitis treatment, 581–582
implant debridement, 560f
air polishing, 560
hand-activated and ultrasonic
instrumentation, 559–560
peri-implantitis and titanium
particles, 560–561
peri-implant mucositis, 534, 535t
literature, 559
treatment, 559
peri-mucosa recession, 541
PerioChip, 576, 576f
periodontal charting, 140–141
assessment
gum margin, 540–541
mobility, 541, 541f
occlusion assessment, 542, 542f
probe depths, 539–540
prosthesis health, 542–543, 543f
radiographic assessment, 542, 542f
periodontal debridement, 117–120
delivery of care, 449
hard and soft tissue effects, 449
microbiological, 449
overall clinical outcomes, 448
pathogenesis, 117
preventive clinical treatment, 118–120
cementum alterations, 119
efficiency, 119–120
ergonomics, 120
furcation access, 119
microbial reduction, 118
subgingival access, 118
statistics, 117–118
periodontal therapy, 110–111, 111f
periodontics and dental hygiene,
114–115, 114f
periodontic tips, 335–336
PERIOFLOW, 513–516, 513f–516f
PERIOFLOW handpiece, 465, 468–471,
468f–471f
nozzle technique, 469–471, 470f–471f
powder velocity and water setting,
471, 471f
subgingival nozzle, 468–469,
468f–469f
subgingival nozzle placement and
removal from handpiece, 469, 470f
Perio Gel, 579, 579f
Perio Protect, 579
Perio tips, 320
Perio Tray, 579
peroxidase, 578
personal protective equipment (PPE),
infection prevention and, 17–23
face shield and protective eyewear,
22–23, 23f
gown, hair, and shoe protection, 18–19
hand hygiene and gloves, 17–18, 17t,
18f
mask, 19–20, 19f
particulate filtering facepiece
respirator mask, 20t, 21–22, 22t
R
surgical mask, 20–21, 21f
photodynamic therapy (PDT), 574
piezoceramic discs, 37, 38f
piezoelectric curved tips. See EMS radiographic assessment, 542, 542f
curved tips removable dental materials, 121
piezoelectric effect, 36 reprocessing
piezoelectric grasp, 151, 152f Acteon, 337–339
piezoelectric stainless-steel handpiece, 339
shank, 65 tip, 337
piezoelectric ultrasonic, 36, 37f ultrasonic device, 337–339
piezoelectric ultrasonic devices, 109, Dentsply Sirona, 257
110f Cavitron ultrasonic scaler, 257
Acteon and.See Acteon handpiece, 257
EMS and.SeeEMS insert, 257
Piezon, 310 EMS, 321
Piezon 150, 311 tip, wrench, and handpiece, 321
Piezon Handpiece, 317 ultrasonic device, 321
Piezon LED Handpiece, 317 ultrasonic devices, 56–57
point, 174 CDC recommendations, 57
polishing agents, 393 FDA regulations, 57
portable handheld air polishing safety, 57
device, 397 retraction
positioning, operator and patient chair, lip and cheek, 485, 485f
157–162. See also operator chair root concavity and convexity, 135, 136f,
position, by area of mouth 137t–139t
aerosol control, 160–162 root nomenclature, 134t–135t
HVE grasp, 160–162 rotary handpiece polishing,
HVE positioning, 160 393–395, 395f
selection, 158–159
powder bowl, 427–429, 427f–431f
S
powder bowl cap, 427, 427f
powder care, 416
powder chambers, 397, 451–452,
451f–453f same quadrant finger rest, 155
powder delivery port, 437 scaling tips, 319
powder flow control dial, 428 shank, 69–84. See also technique practice
powder velocity clinical selection criteria
control, 452, 454, 454f, 454t oral deposit location, 77
and water setting, 467–468 oral deposit type and size, 72–77
powder velocity control, 429–430, tissue consistency, 77
431f–432f tooth topography, 77
power. See under individual entries coating, 70
power control, 79–81 curved, 71
pre-procedural antimicrobial damage, 69
rinses, 23 design
probe depths, 539–540 curved, 71
prophylaxis tip, 333 diameter, 71, 79t
Prophy mode cycle dial, 430 length, 72
Prophy mode cycles, 430–433, shape, 71
432f–433f, 433t straight, 71
Prophy powder delivery tube, 436 displacement amplitude, 79–81
prosthesis, 526, 526f, 529f length, 72
health, 542–543, 543f loaded, 81
protective eyewear, 22–23, 23f movement, 77–79
Psi (pound force per square), 54, 397 current perspectives of, 79
ptich, 34–35, 34f historical perspectives of
Purevac HVE connector, 160 movement, 79
Purevac HVE hose, 160 power control, 79–81
Purevac HVE mirror tip, 160 straight, 71
purge, 54 unloaded, 81
wear, 81–84
measuring, 82–83
Q
rate of, 83–84
shock waves, 97, 97f
shoe protection, 18–19
quail egg, 487–489, 488f sialadenitis, 113

sialolith, 112
single-power delivery air polishing
device, 397
slim prophylaxis tips, 333–335, 334f
sneeze, 4f
sodium bicarbonate powder, 414–417
Softip, 254
soft nozzle grip, 437
soft tissue
deficiencies after implant placement,
537, 539f
deficiencies prior to implant
placement, 537, 539f
sonic scaler, 110
Soprocare camera, 328, 339
S-Series, 332
stabilization, 153–157, 154f
extraoral finger rest, 155–157,
156f–157f
cheek finger rest, 155, 156f
chin finger rest, 157, 157f
intraoral finger rest, 155, 155f
cross-arch finger rest, 155, 156f
opposite-arch finger rest,
155, 156f
same quadrant finger rest, 155, 155f
stand-alone air polishing device, 397
stand-alone ultrasonic device, 48, 49f
foot pedal, 50
standard nozzle, 399–400, 400f
straight periodontic tips, 35t, 335
straight shank, 71
Streamline, 267
Streamline direct flow, 267
Streamline Plus, 267
subcutaneous facial emphysema, 420
subgingival access, 118
subgingival nozzle, 400–401, 400f–401f
substantivity, 573
supracrestal connective tissue
attachment, 530
surface topography
abutment and prosthesis, 555–556
implant, 555
surgical mask, 20–21, 21f
SWERV3, 264
Swivel direct flow, 267
symbiosis, 2
T
Tap-On technology, 245
tap stroke, 219–220
technique practice, curved inserts. See
also ultrasonic technique
buccal debridement of mandibular
first molar supragingival inter-
proximal area, 305–306, 306f
buccal furcation debridement of man-
dibular first molar, 294–295,
295f
distal-buccal root debridement of
mandibular first molar,
298–299, 298f
distal-lingual root debridement of
mandibular first molar, 302–303,
302f–303f
lingual debridement of mandibular
first molar supragingival
interproximal area, 299–300,
300f
lingual furcation debridement of
mandibular first molar, 300–302,
301f
mesial-buccal root debridement of the
mandibular first molar, 295–297,
296f–297f
mesial-lingual root debridement of the
mandibular first molar, 303–305,
304f
setup, 293–294
tetracyclines, 580
thick diameter prophylaxis tips, 333
tip, 62. See also ultrasonic insert/tip
tip portfolio
Acteon, 332–337
curved periodontic tips, 335–336,
336f, 337t
implant tips, 336–337
periodontic tips, 335–336
plastic micro-tipped, 336, 337f
prophylaxis tips, 333–335
slim prophylaxis tips,
333–335, 334f
straight periodontic tips, 35t, 335
thick diameter prophylaxis tips, 333
titanium, 336–337, 338t
EMS, 319–321
implant tip, 320–321
thick diameter tips, 319–320
thin diameter tips, 320
tip threader, 65
tissue consistency, 77, 79
titanium, 336–337, 338t
titanium particles, 560–561
tooth anatomy, clinical perspectives of,
131–146
case studies, 144–145
complex root anatomy, 134–144
furcation anatomy, 139, 140t
furcation assessment,
140–141, 142f
furcation debridement, 142–144
root concavity and convexity, 135,
136f, 137t–139t
root nomenclature, 134t–135t
furcation
anatomy, 139, 140t
assessment, 140–141, 142f
debridement, 142–144
exploration evaluation, 141
periodontal charting, 140–141
radiographic evaluation, 141, 142f
instrumentation considerations,
132–133
cementum, instrumentation of, 133
hard tissue histology, 132, 132t
instrument selection, 132
overview, 131–132
tooth polishing, 392
Index 607
top-down movement, ultrasonic
activation stroke, 201–202
topography, 77, 78f
transverse orientations, 177–178, 178f,
178t
tumors, 112
U
ultrasonic, defined, 32
ultrasonic activation stroke, 198–220
curved shank ultrasonic
instrumentation spoon exercise,
213–219
horizontal movement, 198–202
top-down movement, 201–202
ultrasonic instrumentation candle
exercise, 203–212
ultrasonic applications, 107–127. See
also periodontal debridement;
ultrasonic instrumentation
case study, 125
in dental clinical, 108–115
endodontics, 111
magnetostrictive ultrasonic
devise, 109
operative dentistry, 111, 112f
oral and maxillofacial surgery,
112–113, 112f–113f
orthodontics, 113–114
periodontal therapy, 110–111, 111f
periodontics and dental hygiene,
114–115, 114f
piezoelectric ultrasonic device,
109, 110f
sonic scaler, 110
in medical clinical, 108
ultrasonic devices, 47–59
air lines, 55
direction for use, 48
ergonomics, 57–58
foot pedal
design and functionality, 50–51
integrated ultrasonic device,
49–50
stand-alone ultrasonic device, 50
handpiece, 55–56
integrated ultrasonic device, 48
foot pedal, 49–50
overview, 48
reprocessing, 56–57
CDC recommendations, 57
FDA regulations, 57
safety, 57
stand-alone ultrasonic device, 48, 49f
foot pedal, 50
water lines, 51–55
alternate medicaments, 51–52
aqueous solutions, 51–53
control and flow rate, 54
filters, 53
flow rate, 54
inconsistent flow rate factors, 54
purging of, 54–55
608 Index
ultrasonic insert/tip, 61–89. See also
insert portfolio
magnetostrictive, 62–65
connecting body and
colored grip, 63
ferromagnetic laminate nickel
plates, 62, 63f
O-ring, 64–65, 64f
stainless-steel shank, 65
piezoelectric, 65–67
stainless-steel shank, 65–66,
66f–67f
wrench, 65
shank, 69–84
anatomy and activity, 69, 70t
coating, 70
current perspectives of movement,
79
damage, 69
diameter, 71
displacement amplitude, 79–81
historical perspectives of move-
ment, 79
length, 72
loaded, 81
measuring wear, 82–83
movement, 77–79
oral deposit location, 77
oral deposit type and size, 72–77
power control, 79–81
rate of wear, 83–84
shape, 71
tissue consistency, 77
topography, tooth, 77
unloaded, 81
wear, 81–84
water port, 67–68, 68f, 68t
ultrasonic instrumentation, 557–558,
557f, 559–560. See also
periodontal debridement;
ultrasonic applications; ultrasonic
technique
considerations, 121–125
demineralized and decayed hard
tissues, 121
dental implant, 121, 122f
dentin hypersensitivity, 123
HIV, 123
individual patient factors, 123–124
orthodontic appliances, 124
pacemaker, 124–125
pediatric patient, 124
surgical procedure, 125
contraindications, 121
communicable disease, 121
fixed dental materials, 121
removable dental materials, 121
hand-activated versus, 166t
of mandibular first molar buccal
surfaces, 231t–234t
of mandibular first molar lingual
surfaces, 235t–236t
of maxillary left central incisor facial
surfaces, 225t–228t
of maxillary left central incisor lingual operator and patient positioning,
surfaces, 228t–231t 223–224
theoretical approaches, overview, 223
115–117, 116t ultrasound, 34–35, 35f
contemporary approach, unloaded shrank, 81
116–117 UV Light, 26
traditionalist approach, 116
ultrasonic mechanism of action. See
mechanism of action, ultrasonic
ultrasonic physics, 31–44
V
active medium, 35–39 vacuum line tubing, 14–15, 14f
antinodes, 40–41, 41t ventilation systems, infection prevention
auditory effects, 41–42 and, 25
auditory risks, 42 mechanical ventilation, 25
back driver, 37 natural ventilation, 25
case study, 41 Venturi effect, 401
dental ultrasonic device, 35–40 vertical orientations, 176–177, 178f,
front driver, 37 178t
horn, 37 visual and palpatory tissue
magnetostrictive ultrasonic, 38–40, assessment, 539, 540f
39f
mechanical energy, 36
nodes, 40–41
noise-induced hearing loss, 41 W
overview, 32
piezoceramic discs, 37, 38f water. See under individual entries
piezoelectric ultrasonic, 36, 37f water flow rate, 54
sound, 32–35 water-line, defined, 15. See also water-
infrasound, 35 line tubing
measurement, 34 water-line attachment cord, 51, 52f
ptich and frequency, 34–35, 34f water-line filters, 53
ultrasound, 34–35 water-line maintenance, 16
wave amplitude, 32, 33t water-line monitoring, 15–16
wave crest, 32 water lines, ultrasonic devices and,
wave equilibrium, 32 51–55
wave frequency, 33, 33t alternate medicaments, 51–52
wavelength, 33 aqueous solutions, 51–53
wave theory, 32–35, 33f control and flow rate, 54
wave trough, 32 filters, 53
transducer, 35 flow rate, 54
ultrasonic sound waves, inconsistent flow rate factors, 54
35–41, 36f purging of, 54–55
production, 37–38 water-line tubing, 15–17, 16f
ultrasound, 35, 35f water port, 67–68, 68f, 68t
ultrasonic technique, 223–237. external, 67, 68f
See also technique practice, internal, 67, 68f
curved inserts; ultrasonic wave amplitude, 32, 33t
instrumentation wave crest, 32
mandibular first molar buccal wave equilibrium, 32
surfaces, 231t–234t wave frequency, 33, 33t
mandibular first molar facial, 224 wavelength, 33
mandibular first molar lingual, 224 wave theory, 32–35, 33f
mandibular first molar lingual wave trough, 32
surfaces, 235t–236t, 237t wireless bluetooth technology,
mandibular molar, 224 433f–433f, 433–434
maxillary left central incisor, 224 work-related musculoskeletal disorders
maxillary left central incisor (WMSDs), 120
facial, 224 wrench, 65
maxillary left central incisor
Z
lingual, 224
maxillary left central incisor facial
surfaces, 225t–228t
maxillary left central incisor lingual 0- to 15-degree angulation, 176, 177f
surfaces, 228t–231t zoonotic disease, 6