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LATEST INSTRUMENTS FOR

PERIODONTAL
TREATMENT/SURGERY

DMD-6B: GROUP 3
MARASIGAN, MONCAYO, NACAR, NAGUIT, ORUGA, PENA
(PERIODONTICS)
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INTRODUCTION
Periodontitis is a chronic inflammatory disease linked to dysbiotic dental plaque biofilm, leading to tooth-supporting tissue
damage. Treatment involves a stepwise approach, including non-surgical (steps 1 and 2) and surgical therapy (step 3).
Subgingival instrumentation during step 2 is crucial for disease management, with a choice between hand or power-driven
instruments. However, power-driven scalers generate contaminated aerosols, posing challenges for infection control. The
COVID-19 pandemic further emphasized the need for precautions during aerosol-generating procedures. This systematic
review focuses on comparing the clinical efficacy of hand versus power-driven instruments for subgingival instrumentation
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during surgical therapy (step 3) for periodontitis. The goal is to determine the impact of different instruments on pocket
reduction post-surgical intervention, offering insights for future treatment guidelines and protocols, especially considering
reduced exposure to aerosol-generating procedures.
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METHODOLOGY
The research protocol was registered with PROSPERO and adhered to Cochrane Handbook guidelines. The
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework guided the
review. The inclusion criteria targeted adult patients with periodontitis undergoing surgery, comparing
power-driven and hand instruments. The outcomes covered PPD reduction, percentage of pocket closure,
clinical attachment level changes, bleeding on probing, plaque index changes, tooth survival, gingival
recession, radiographic changes, microbiota alterations, and patient-reported outcomes. The search
strategy involved multiple databases, including MEDLINE, Embase, Web of Science, and the Cochrane
Database. Data extraction, quality assessment, and risk of bias analysis were conducted
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RESULTS
Out of 1295 records, 4 studies met the inclusion criteria. The level of agreement between
reviewers was 93.3%, and Cohen’s kappa was 0.84. The studies, conducted in Brazil and
Germany, included a total of 50 participants per group. Both hand and power-driven instruments
demonstrated effectiveness in reducing PPD values, with no significant differences. Secondary
outcomes such as clinical attachment level, bleeding on probing, plaque accumulation, gingival
recession, and time requirement were also analyzed. Meta-analysis was not performed due to
study heterogeneity. The studies were considered at moderate risk of bias.
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CONCLUSION
Despite the limited number of studies and moderate risk of bias, this systematic review
concludes that both hand and power-driven instruments are effective in reducing probing pocket
depth after surgical treatment of periodontitis. Clinicians have the flexibility to choose
instruments based on a case-by-case situation, considering factors such as contamination risk,
clinician and patient preferences, and procedure time. The review highlights the need for further
research on different instruments, surgical techniques, and meaningful endpoints to better
inform clinical decision-making processes.
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INTRODUCTION:
The introduction underscores the critical first step in periodontal treatment, emphasizing the removal of bacterial deposits and
calculus while preserving healthy dental tissues. Traditional handheld instruments have been historically employed for this
purpose, but the advent of sonic and ultrasonic scalers marked a shift in the approach to gross scaling and calculus removal. The
review discusses the use of sonic and ultrasonic scalers in periodontal therapy, focusing on their role in removing subgingival
microbial biofilms to control inflammatory periodontal disease. The study explores the safety, efficacy, and potential side effects
of these power-driven instruments, covering topics such as scaling time, reduction of bacterial plaque, access to subgingival areas
and furcations, alterations on restorations, impact on implants, and effects on demineralized surfaces. The review also addresses
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safety concerns, including thermal effects, cavitation, vibration white finger phenomenon, and aerosol contamination. The
findings emphasize the importance of considering the potential deleterious side effects of sonic and ultrasonic instruments in
dental practice.
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ADVANTAGES:
The study underscores the advantages of sonic and ultrasonic scalers in terms of efficiency, safety, and their
role in reducing bacterial plaque in periodontal pockets. These instruments demonstrate efficacy in reducing
bacterial load in periodontal pockets, thereby aiding in the management of periodontopathogens. The
ultrasonic scaler's antimicrobial effect against non-periodontopathic bacteria has been demonstrated in vitro,
suggesting an additional advantage in promoting oral health beyond the removal of physical deposits.
Additionally, the study delves into the nuances of access to subgingival areas, furcations, and the impact on
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restorations and implants, providing comprehensive insights that contribute to informed clinical decision-
making.
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ADVANTAGES:
These power-driven instruments play a pivotal role in the mechanical removal of subgingival microbial
biofilms, which is crucial for halting periodontal infections and maintaining a healthy periodontium. The
periodic removal of these microbial biofilms is essential in controlling inflammatory periodontal diseases.
Sonic and ultrasonic scalers, characterized by their vibrational energy, effectively remove deposits from
dental surfaces, encompassing bacterial plaque, calculus, and endotoxin. The high-frequency oscillations
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(25,000–42,000 Hz) of scaler tips, combined with cavitational activity and constant flushing of the lavage
used for cooling, contribute to the disruption of weak and unattached subgingival plaque.
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CONCLUSION:
In conclusion, a comprehensive understanding of the techniques and instruments discussed in this study, particularly the
utilization of sonic and ultrasonic scalers in periodontal treatment, holds significant importance for dental practitioners. The
emphasis on the initial step of removing bacterial deposits and calculus while preserving healthy dental tissues underscores the
foundational role these procedures play in effective periodontal care. The evolution from traditional handheld instruments to
advanced power-driven scalers signifies a paradigm shift in approach, and knowledge of their mechanisms, frequencies, and
associated discomforting stimuli is crucial for informed decision-making in clinical practice. Furthermore, the historical context of
ultrasonic scaling development adds depth to this understanding. Recognizing the nuances between sonic and ultrasonic scalers,
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their respective advantages, and potential discomforts allows practitioners to tailor treatment approaches for optimal patient
outcomes. Ultimately, a thorough grasp of the study's insights enhances the overall quality of periodontal care, promoting efficient
plaque control, patient education, and successful management of periodontal conditions.
 INTRODUCTION
Non-surgical periodontal therapy using scaling and root surface debridement has been crucial in managing
periodontal issues for decades. This focuses on reducing inflammation and restoring gum health by
meticulously removing biofilm and calculus. Conventional non-surgical periodontal therapy (CNST) involves
power-driven and/or manual instrumentation to debride the root surfaces, and meticulous root planning is
necessary to remove diseased cementum by hand instruments, which was essential for periodontal healing.
However, recent findings challenge this notion, suggesting gentle and light-touch root surface
instrumentation to remove the plaque and calculus is sufficient. Minimally invasive non-surgical therapy
(MINST) utilizes specialized thin instruments for scaling and root surface debridement and magnification to
minimize tissue trauma and improve outcomes. Furthermore, this study compares MINST and CNST in
terms of clinical effects and patient comfort during initial periodontal treatment.
 METHODOLOGY
Patients with moderate to severe periodontitis were included in the study. Nine out of ten patients
were recruited and completed the post-treatment re-evaluation in this study. Randomized split-
mouth design, CNST and MINST on each side, was performed. Clinical parameters, including
periodontal probing depth (PD), gingival recession (REC), clinical attachment level (CAL), and
gingival bleeding on probing (BOP), were recorded on baseline, 1 month and 3 months post-
treatment. Non-parametric statistics were used for analysis.

METHODOLOGY:
SPLIT-MOUTH AND INTERVENTION
CONVENTIONAL NON-SURGICAL
PERIODONTAL THERAPY (CNST)
It primarily utilized a power-driven piezo-electric
ultrasonic scaling device equipped with scaling
tips (Model P-10 and P-20, NSK, Tochigi, Japan)
for subgingival biofilm and calculus removal.
Additionally, manual standard Gracey curette
instruments (Gracey curette 1/2; 11/12; 13/14,
Hu-Friedy, Chicago, IL, USA) were employed to
refine any residual deposits from the root
surfaces.
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MINIMALLY INVASIVE NON-SURGICAL
PERIODONTAL THERAPY (MINST)
A minimally invasive technique delicately
cleaned tooth root surfaces using specific
thin piezo-electric scaling tips (Model P-26L,
P-26R, P-40, NSK, Tochigi, Japan) and
manual miniature periodontal curettes
(Micro Mini-Five Gracey curette 1/2, 11/12,
13/14, Hu-Friedy, Chicago, IL, USA).
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RESULTS
PD, REC, CAL, and BOP were improved after treatment in both CNST and
MINST groups. Comfort feedback and gingival recession showed better
outcomes in the MINST group than in the CNST group. No statistical
significance of parameters was found between CNST and MINST
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DISCUSSIONS
MANUAL STANDARD GRACEY
CURETTE INSTRUMENTS
Effectiveness of subgingival calculus removal in 35 non-molar
Relatively long and straight blade teeth between standard Gracey curettes, newly designed
Easily leaves some gaps without thorough longer shank and thinner blade Gracey curettes (After Five
debridement of the root surface Gracey curette, Hu-Friedy, Chicago, IL, USA), and untreated
Failure of total removal of dental calculus on control
treated root surfaces was found in several
PHASE 02
studies, especially in deep periodontal pockets. Results: significant treatment effect in terms of percentage of
NEWLY DEVELOPED GRACEY residual calculus compared to untreated teeth. Moreover, the
CURETTE INSTRUMENTS mesial tooth surfaces presented the least residual calculus.
However, there is no significant difference in percentage of
residual calculus between standard Gracey curettes and the
Longer shanks and thinner and smaller blades
Allow for better access to complicated root areas newly designed one.
Facilitate contamination debridement
Minimize hard and soft tissue trauma

DISCUSSIONS
MANUAL STANDARD GRACEY
CURETTE INSTRUMENTS
Relatively long and straight blade
Easily leaves some gaps without thorough
debridement of the root surface
Failure of total removal of dental calculus on
treated root surfaces was found in several
PHASE 02
studies, especially in deep periodontal pockets.
NEWLY DEVELOPED GRACEY
CURETTE INSTRUMENTS
Longer shanks and thinner and smaller blades
Allow for better access to complicated root areas
Facilitate contamination debridement
Minimize hard and soft tissue trauma
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109 teeth were treated with either conventional standard
Gracey curettes or with newly designed small-sized Mini-Five
Gracey curettes (Hu-Friedy, Chicago, IL, USA). They found that
the use of Mini-Five Gracey curettes resulted in greater PD
reduction and lower gingival recession. Regarding power-
driven devices, a recent randomized clinical trial compared
three different sizes of piezoelectric ultrasonic scaler tips for
in vitro and clinical analyses.
Results showed that using a slim-designed scaler tip caused
less tooth substance loss and less pain experience for
patients than a conventional wide scaler tip. These studies
supported that treating root surfaces with slim and small
instruments might facilitate better outcomes than
conventional instruments.
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DISCUSSION
In this study, teeth of the MINST groups were treated by Micro Mini-Five Gracey
curettes, which were designed to have an elongated terminal shank and 50% shorter
blade than standard Gracey curettes. In addition, the thickness of the Micro Mini-Five
Gracey curettes is 20% thinner than the Mini-Five Gracey curettes. The results in the
present study also revealed a similar trend of more favorable clinical outcomes from
using small-diameter instruments versus conventional ones.
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CONCLUSION
Given the constraints, minimally invasive non-surgical periodontal
therapy (MINST) might serve as an alternative to the conventional
non-surgical periodontal therapy (CNST). However, additional
research is necessary to define its clinical protocol and gather more
evidence supporting MINST's effectiveness.
 INTRODUCTION
Air Polishing Device
Air Polishing uses a targeted jet of compressed Ir that is mixed with water and glycine powders to efficiently
remove biofilm, without causing damage to the periodontal soft tissues or tooth and root structure.
Comparable clinical and microbiological results have been demonstrated in several studies with regard to standard
procedures such as ultra/sonic instrumentation or the use of hand instruments
The main advantages of subgingival air polishing are lower abrasiveness and less time required for treatment. In
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addition, the method was rated as more comfortable compared to alternative methods (hand instruments or sonic
scaling) by the majority of patients in several studies
STUDY DESIGN
Two nonadjacent single-rooted teeth with a periodontal pocket (5–9
mm) from the same jaw were chosen to serve either as the test or
control group. While the test group received subgingival
instrumentation using a new air polishing device with a conical shaped
tip, the control group was treated using sonic scaling. While one
blinded clinician (ABK) performed all measures, a second clinician
(BJW) did subgingival instrumentation using different procedures.

RESULTS
After 6 months, clinical data from 44 participants were collected for
analysis
PD and CAL decreased significantly for both groups
PD = control T0 5.96, T2 4.75; experimental T0 5.96, T2 4.8
CAL = control T0 7.38, T2 5.84; experimental T0 7.28, T2 6.34
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BOP = control 42.5%; experimental 46.5%
Pain Perception = control 28.8, experimental 12.56
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SUMMARY
A new tool called the perioscope has made it much easier to remove calculus from below
the gumline during periodontal therapy.
Calculus is a hard deposit that builds up on teeth and can lead to periodontal disease. The
perioscope is a small camera that is inserted under the gumline to allow the dentist to see
the calculus and remove it more effectively.
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The perioscope was originally designed to help dentists diagnose periodontal disease, but
it has since been found to be a valuable tool for treatment as well.
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SUMMARY
By using the perioscope, dentists can remove calculus more precisely and avoid damaging
the tooth's root. This can help to improve the outcome of periodontal therapy and prevent the
disease from recurring.
The perioscope is a minimally invasive tool that can be used in both non-surgical and surgical
periodontal therapy. www.reallygreatsite.com
In non-surgical therapy, the perioscope is used to remove calculus from shallow pockets
below the gumline. In surgical therapy, the perioscope can be used to guide the dentist during
surgery.
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SUMMARY
Studies have shown that periodontal therapy is more effective when the
perioscope is used. The perioscope helps to ensure that all of the calculus is
removed and that the tooth's root is not damaged.
Overall, the perioscope is a valuable tool for the treatment of periodontal disease.
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It is a minimally invasive tool that can be used to improve the success rates of
periodontal therapy.
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PARTS OF PERIOSCOPE
1. FIBRE-OPTIC STRAND
A perioscope is made up of a sheath and a 0.5 mm fibre-optic strand.
At the end of a two meters long fused fibre-optic bundle with 10,000 individual
light-directing fibre pixels, a gradient index lens is installed.
Fifteen huge core plastic fibre-optic strands surround the fused bundle and
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lens, providing light to the operating site from distance bulb
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PARTS OF PERIOSCOPE
2. STERILE SHEATH
The subgingival region is the seat of infection in a periodontitis patient, the
fibre-optic strand’s distal tip must be sterilised with sterile disposable sheath if
it comes into direct contact with any of the subgingival tissues.
The fibre-optic strand is enclosed in a sterile disposable sheath that may be
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discarded after each use and acts as a barrier against subgingval infection.
The fibre-optic wire can be clearly seen through the sapphire glass in the
sheath
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PARTS OF PERIOSCOPE
3. PERISTALTIC PUMP
There is a risk of bleeding within the gingival pocket because the subgingival
region of a pocket is inflammatory and bleeding will hinder vision from the
perioscope.
The perioscope contains a pulsatile peristaltic pump that keeps continuous water
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spray maintaining the working field free of blood and debris.
A separate water tube connects the sheath to a peristaltic pump, which drives
water from the strand to the strand’s end, irrigating the working field
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PARTS OF PERIOSCOPE
3. PERISTALTIC PUMP
There is a risk of bleeding within the gingival pocket because the subgingival
region of a pocket is inflammatory and bleeding will hinder vision from the
perioscope.
The perioscope contains a pulsatile peristaltic pump that keeps continuous water
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spray maintaining the working field free of blood and debris.
A separate water tube connects the sheath to a peristaltic pump, which drives
water from the strand to the strand’s end, irrigating the working field
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PARTS OF PERIOSCOPE
4. CHARGE COUPLED DEVICE CAMERA
This CCD is a video camera that uses a camera coupler to magnify and focus the
image onto the CCD sensor.
The camera’s control unit digitises and converts the CCD’s electric impulses into a
standard S-video output, which is presented on an active matrix Liquid Crystal Display-
Thin Film Transistor (LCD-TFT) monitor.
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The objective lens has a field of view of 70o in air, but it is reduced to 53o in water and
other less-than-ideal environments [5]. The image of the root and pocket on the LCD
panel is improved with magnifications ranging from 22 to 48
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PARTS OF PERIOSCOPE
5. MICROSURGICAL INSTRUMENTS
A gingival retractor (soft tissue shield) is now linked to the curette blade. The gingival
tissue is kept away from the endoscope’s tip using this retractor, to see the curette
blade and tooth surface visibly.
The distal tip features a gingival retractor fashioned into it. The ultrasonic adapter is
made up of a collar, a strut, and awww.reallygreatsite.com
tube, all of which are stainless steel
The scaler tip as well as surrounding tooth surface are viewed through the endoscope
window sheath. The distal tip of the tube is also fixed up for irrigating fluid, while
gingival tissue retraction ensures an unobstructed view of the active tip
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INDICATIONS OF PERIOSCOPY PROCEDURE

Probing pocket depth of greater than 4 mm

Abnormal root deformities and anatomical changes can be detected
Provides some benefit to the treatment outcomes of non surgical
periodontal therapy www.reallygreatsite.com
Cases of teeth with a poor prognosis and limited access to
abnormalities
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PERIOSCOPY PROCEDURE
On the LCD screen, the periodontist can see the magnified root surface at
a magnification of 24X to 48X and around 3 mm of the root is checked at
a time.
The perioscope is held with left hand by the clinician and debridement
instrument is held in the right. Periodontal Endoscopy (PE) is a minimally
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invasive method that improves dental practitioners’ ability to detect and
remove calculus by allowing them to see the periodontal area more clearly
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PERIOSCOPY PROCEDURE
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ADVANTAGES OF PERIOSCOPY

A perioscope allows the periodontist to observe the subgingival morphology

in the least invasive method possible, for diagnosis and improved
management strategies for root and soft tissue debridement
Accurate visualisation of the root surface under magnification allows the
most effective instrumentation possible
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The level of perceived pain or discomfort with the periodontal endoscope

was significantly less than that experienced during periodontal probing
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DISADVANTAGES OF PERIOSCOPY
The time element is perioscope’s first and greatest disadvantage
A small percentage of patients feel discomfort without anaesthesia and
hence, require the same level of anaesthesia as traditional periodontal
surgical treatments
Use of a perioscope necessitates distinct clinical abilities, and achieving
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expertise requires training and time to become accustomed to the

device
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CONCLUSION
The root surface area is remarkably cleaned and devoid of debris
and calculus after perioscope-assisted periodontal debridement.
The most significant purpose to utilise a perioscope is to improve
treatment outcomes by minimising PPD and enhancing root
surface attachment gains.
This is beneficial to the tissues in the local area. Because of the
magnification, the periodontist may diagnose and rectify
abnormalities earlier than with traditional treatment approaches.
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Early management reduces treatment times and slows disease
progression, avoiding the need for advanced periodontal surgery.
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INTRODUCTION
PiezoSurgery is an innovative technique for osteotomy and osteoplasty that employs ultrasonic vibration
through a specialized device with modulated frequency and controlled tip vibration. Rooted in the
longstanding use of ultrasound in medicine, early ultrasonic dental instruments were limited to scaling
and root planing. However, in the 1980s, the integration of ultrasonics in odontostomatologic surgery
faced challenges in bone surgery due to insufficient strength and temperature-related issues. Over the
last decade, the Piezosurgery Device by Mectron Medical Technology, a power ultrasonic device, has
addressed these limitations. It features a piezoelectric ultrasonic transducer and resonant cutting
inserts, offering increased precision, safety, and faster recovery after bone surgery. This advancement,
utilizing controlled linear microvibrations, marks a significant improvement over traditional instruments
and micromotors, ensuring safety and precision in various anatomical situations for enhanced surgical
outcomes.
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PIEZOSURGERY IN PERIODONTICS:
Piezosurgery in periodontics utilizes ultrasonic vibration for diverse procedures, employing inserts
categorized by coatings and tip types. Titanium nitrate-coated inserts are effective for osteoplasty and
bone chip harvesting due to their cutting efficiency and corrosion resistance. Diamond-coated inserts,
with sharp, smooth, and blunt tips, serve various applications such as precise osteotomy, delicate
structure preparation, and soft tissue work. The frequency in piezoelectric ultrasonic devices is
generated by deforming piezoceramic rings, producing vibrations for osseous tissue shattering at the
handpiece tip. The transducer's piezoelectric effect facilitates the conversion of electrical pulses to
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mechanical vibrations. In periodontics, piezosurgery is applied in procedures like scaling, root planning,
pocket lavage, crown lengthening, soft tissue debridement, resective surgeries, and regenerative
surgeries for autogenous grafts in intrabony defects. The implementation of piezosurgery enhances
precision and effectiveness in periodontal treatment.
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CONCLUSION:
Piezosurgery is a transformative tool that simplifies critical operations, particularly in
challenging-to-reach areas, reducing risks to soft and neurovascular tissues. With variable
frequency and power, multipurpose piezosurgery units find applications in Periodontology,
Implantology, and various oral surgical procedures, making them highly effective in clinical
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practice. However, the technique demands professional skill and training, as it typically requires
longer surgical times compared to conventional rotary and oscillating saws.
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SUMMARY OF LATEST INSTRUMENTS FOR PERIODONTAL
TREATMENT/SURGERY
1. Piezo-electric ultrasonic scaling device equipped with scaling tips
(Model P-10 and P-20, NSK, Tochigi, Japan)
2. Manual standard Gracey curette instruments (Gracey curette
1/2; 11/12; 13/14, Hu-Friedy, Chicago, IL, USA)
3. Thin piezo-electric scaling tips (Model P-26L, P-26R, P-40, NSK,
Tochigi, Japan) and manual miniature periodontal curettes
(Micro Mini-Five Gracey curette 1/2, 11/12, 13/14, Hu-Friedy,
Chicago, IL, USA).
4. 5/6 and 13/14 Gracey curettes, Barnhartt curette (Hu-friedy)
5. 7/8, 11/12, and 13/14 Gracey curettes, and Barnhartt curette (Hu-
friedy)
6. Diamond-sonic sonic scaler
7. Ultrasonic device (Multisonic Gnatus)
8. H3 Tip, ultrasonic device (MultiSonic Gnatus)
USES/FUNCTION
1-2. Manual instrument: For subgingival
biofilm and calculus removal
3. Newly developed instruments: Minimally
invasive technique delicately cleaned tooth
root surfaces
4. Used for anterior teeth and premolars and
for posterior distal surfaces
5. Used for posterior teeth (facial & lingual
surfaces) and Posterior distal surfaces
6-7. Used for root surface and created a
rougher surface compared to the curette and
standard smooth ultrasonic tip
8. H3 ultrasonic tip is ideal for starting
periodontal treatments on anterior teeth.
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SUMMARY OF LATEST INSTRUMENTS FOR PERIODONTAL
TREATMENT/SURGERY
USES/FUNCTION

9. Air polishing with trelahose powder 9. for subgingival biofilm and calculus
removal

10. Perioscopy 10. a treatment that combines a small

dental endoscope with advanced video,
11. Piezosurgery illumination, and magnification technologies
for subgingivaly imaging

11. They are effective for osteoplasty

technique or for harvesting bone chips
because they have the maximum cutting
efficiency, avoid corrosion, and increase
working life.
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REFERENCES
Cavalli, N., Calciolari, E., Goldoni, M., & Donos, N. (2022). Clinical
efficacy of hand and power-driven instruments for subgingival
instrumentation during periodontal surgical therapy: a systematic
review. Clinical Oral Investigations. https://doi.org/10.1007/s00784-
022-04759-5
Chung, Wen-Chen, Chiung-Fang Huang, and Sheng-Wei Feng. (2022).
"Clinical Benefits of Minimally Invasive Non-Surgical Periodontal Therapy
as an Alternative of Conventional Non-Surgical Periodontal Therapy—A
Pilot Study" International Journal of Environmental Research and Public
Health 19, no. 12: 7456. https://doi.org/10.3390/ijerph19127456

Arabacı, T., Çiçek, Y., & Canakci, C. (2007). Sonic and RATHOD,A.D.,JAISWAL,P.G.,MASURKAR,D.A.(2022).
ultrasonic scalers in periodontal treatment: a review. Enhanced Periodontal Debridement with Periodontal
International Journal of Dental Hygiene, 5(1), 2–12. Endoscopy (Perioscopy) for Diagnosis and Treatment in
https://doi.org/10.1111/j.1601-5037.2007.00217.x Periodontal Therapy

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Piezosurgery in periodontics: A new paradigm for traditional approaches: polishing devices in supportive periodontal therapy: Clinical,
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