by Lynne H. Slim, RDH, BSDH, MSDH
Auto maintenance is something I know very little about, so I rely on my Honda mechanic, Tony, to advise me on servicing my 2008 Honda Accord. I handpicked Tony after seeing several mechanics at the local Honda dealership and what sold me on him was his attention to detail.
When I think about the importance of precision in dental hygiene instrumentation, Renee Marchant Turner immediately comes to mind. In addition to practicing four days a week in Northern California, Renee also lectures on ultrasonics and ergonomics, and she teaches hands-on ultrasonic, ergonomic, and laser workshops in California's Sonoma Valley wine country. These workshops are truly hands-on, using real mouths, not typodonts.
Dental hygiene clinicians everywhere are always hungry for instrumentation pointers, especially now that ultrasonic instruments have such a wide array of applications. Here are some questions I posed to Renee recently.
In looking back over the past 10 years in private practice, how has your instrumentation protocol changed?
After practicing for about 15 years, my instrumentation protocol changed from hand instruments as my primary instrumentation technique of choice to magnetostrictive ultrasonic instrumentation. In the 30 years since I graduated from dental hygiene school, technology and science have changed dramatically. My instrumentation style needed constant updating to keep current.
Patients have benefited from ultrasonic scaling due to its added advantage of water lavage, cavitation, reduced cementum removal over hand instrumentation, increased comfort – when ultrasonics are properly used – and more complete biofilm removal. The benefit for me personally is that I am still practicing and have not been forced into retirement from repetitive stress disorder.
Is there one mentor in particular who has influenced your ultrasonic debridement technique? If so, what did you learn from that mentor that made the biggest difference?
Oh yes, Dr. John Kwan and Peggy Hawkins were my mentors. In the early 1990s, they co-authored an article about this new way of using ultrasonic scalers, and they called it micro-ultrasonic scaling. They coined the phrase. This work was originally the brainchild of Dr. Thomas Holbrook.
Dr. Kwan and Ms. Hawkins taught the hands-on ultrasonic course that literally changed the way I practice. They taught me the nuances of proper ultrasonic technique that allowed me to reduce my hand instrumentation time to a very small percentage of the total time I devote to scaling.
The truth is that I could live without hand instruments, but I could not continue practicing without ultrasonic equipment. My body would not tolerate hand instrumentation, and I would feel my patients were not getting the best care I could provide.
Please don't think I am against hand instrumentation. I use hand scalers on just about all patients, but for a very limited amount of time. I also have certain patients for whom ultrasonic instrumentation is contraindicated due to COPD or an inability to handle even small amounts of water.
Dr. Kwan and Ms. Hawkins taught me that the best way to control ultrasonic scaling power, comfort, and water spray was to use tunable magnetostrictive equipment. When we control the frequency of vibration with a tuning knob, we can control patient comfort, speed of deposit removal, and remove or reduce water spray.
Some of the techniques taught in 1995 have changed, but not significantly. There are new machines and inserts; piezoelectric technology is another great form of ultrasonic instrumentation. To this day, Dr. Kwan and his dental hygienists use no hand instruments for periodontal debridement or maintenance. It's all done with tunable magnetostrictive instruments.
When instrumenting subgingivally with ultrasonics and knowing that you are working blind, what has perioscopy taught you about instrumentation that you didn't already know?
Perioscopy was certainly an eye opener. Again, my mentor, Dr. John Kwan, taught me how to use a Perioscope and let me borrow one to practice with. Being able to see into that 9 mm pocket with great magnification on a screen was a wonderful learning experience. I was able to see where I missed deposits and how to remove them while looking at a computer screen with about 24-power magnification. I changed my ultrasonic stroke from the original motion I learned in the 1990s where the motion was fast and almost like a tremor. I slowed it down and I now move very slowly using teeny-tiny strokes.
From what I have read, most calculus is missed at the line angles and the CEJ. When using perioscopy, I found my problem area was right at the epithelial attachment. Moving more slowly and almost dragging the insert along the root surface was the trick to complete removal, or as complete as a clinician can accomplish. I now teach these principles to my ultrasonic course participants.
Do you prefer magnetostrictive to piezoelectric ultrasonic instrumentation or vice a versa?
I love this question. Personally, I use both magnetostrictive and piezoelectric ultrasonics and have one stacked on top of the other in my operatory. Because I am so well versed in magnetostrictive ultrasonics, I use it more often. However, the more I use a piezo unit, the more I like it. They both have their place in ultrasonic instrumentation.
Piezoelectric ultrasonics pulverize deposits into slurry and magnetostrictive ultrasonics bang them off. Both are different, and both are efficient, and I could fill several pages about the differences.
Some patients prefer one over the other, but I can't always judge which they will prefer until I try both. I always prefer the piezo for harder deposits and for root debridement. Piezoelectric ultrasonic units come with great bladed tips that remove deposits more quickly and leave a smooth surface.
I have read posts by hygienists on Web chat rooms who feel that magneto instrumentation is faster or piezo is more comfortable or piezo does not remove as well as magneto. I suppose each clinician will have their own favorite after using them both long enough to become proficient. So using them both to figure out which one you prefer is imperative.
Personally, I think both are very effective in deposit removal. Each has a personality and each clinician needs to use both properly to determine which will work best in their hands. Just like hand instruments, we all have our personal favorites.
Which inserts/tips and hand instruments do you use with periodontal maintenance and root debridement cases?
Ultrasonic Services Incorporated (USI) makes my favorite inserts for magnetostrictive ultrasonics. These inserts are very precise and last a very long time, but they are rather pricey at $200 apiece. I also like Hu-Friedy external water inserts in the P-100 size that are straight, left, and right styles. Parkell makes my essential Parkell Burnett Power Tip for heavy, tenacious deposits.
For piezo ultrasonic scaling, I think Hu-Friedy's tips are great. These are a bit thinner than some other brands and allow superior access. The Hu-Friedy basket/wrench works well and helps reduce loss of these tiny instrument tips. For healthy patients, I use Hu-Friedy After Five tips, which are very thin. For periodontal maintenance patients, I use Hu-Friedy 100 Universal or 3 Perio (P-3). For root debridement I use the Hu-Friedy 3 Perio, Right Perio, and Left Perio (4R and 4L).
I may choose not to use any hand instruments on maintenance cases after ultrasonic scaling depending on how the root surface feels with exploration. If I need to do a quick scaling here and there, I use an H6/7 and my favorite universal, UC 3/4. For root debridement cases, I might add a Gracey 7/8, 13/14, 15/16 in regular and mini sizes. My favorite hand instruments are XP by American Eagle which do not need sharpening. I also like Hu-Friedy and PDT because they sharpen nicely and hold an edge well.
Which ultrasonic machines do you like?
Answering this question could take a while, so I will offer a brief commentary. USI makes an incredible magnetostrictive machine for the ultrasonic aficionado. It's expensive, but worth every penny. I personally own two, one for each office. I am not a fan of automatic magneto machines because I have never found one that is not over-powered, so my list reflects this bias.
My next favorite magnetostrictive machine is Parkell's Auto/Manual Tune Ultrasonic Scaler, and you can purchase it at a great price and warranty. It can be used in both manual tune mode and auto tune, so it is good for offices with clinicians who may not know how to tune ultrasonic equipment.
Hu-Friedy makes my favorite piezoelectric machine, Symmetry IQ. It has a very low power range which is great for easy cases and sensitive patients, but also has a very high power range for difficult and tenacious deposits. Plus, the lighted handle can be removed for sterilization. Piezoelectric handles, unlike magnetostrictive handles, have a deep hole (more than 15 mm) where the tips screw into and it should be sterilized since there is no way to disinfect this deep cavernous area. This is a pet peeve of mine with manufacturers who do not have removable piezoelectric handpieces. Parkell is coming out with a new Integra piezoelectric unit that has removable handpieces and I believe it's a great machine complete with two fluid reservoirs.
Do you have any specific tips for clinicians who are performing periodontal maintenance instrumentation on patients with dentinal hypersensitivity?
For hypersensitivity, I always pre-polish with GC America MI Paste. I leave it on for about five minutes and then scale with an ultrasonic. It works every time with a huge or complete reduction in sensitivity.
When using magnetostrictive equipment, pre-warm the water for your patient in this way: Have a Dixie cup on your instrument tray, run the ultrasonic into the cup with the water turned down to a very slow trickle, run on medium or medium-high power for a few seconds until the water warms from the insert friction, then turn the water up to the desired amount and it will stay warm for your patient! Works wonderfully and your patient will love you for it.
Also, I find many patients have sensitive roots on the buccal of the bicuspids from over-brushing or clenching or who knows what. Anyway, I also find these areas to be plaque- and calculus-free, so why scale them if they are sensitive? I teach my hands-on ultrasonic participants to leave these areas alone. No need to scale if it's already clean.
Piezoelectric tips will not warm water like magnetostricitive does. Piezo does not produce friction, so water will not warm. If you have a system with water bottles, you can warm the water in a microwave before scaling a patient.
On another note, keep your eyes peeled for a new piezoelectric unit from Parkell that is modeled after their magnetostrictive Integra machine. It has two reservoirs for water and medicaments and it's another great little machine.
Lynne Slim, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.
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