Key highlights

• Why worn ultrasonic tips can significantly reduce scaling efficiency long before they appear damaged.
• How angulation, adaptation, and stroke length influence calculus removal and patient comfort.
• The practical differences between piezoelectric and magnetostrictive ultrasonic systems—and why technique should change accordingly.
• Common reasons clinicians compensate with excess pressure or power when equipment performance is actually the issue.
• How understanding the physics behind ultrasonic instrumentation can improve outcomes for patients while reducing operator fatigue.

Episode description

Ultrasonic instrumentation is a daily part of clinical practice, but many hygienists rarely have the opportunity to revisit the science behind how these devices actually work. In this episode, Jessica Atkinson and Dave Torres continue their conversation with Noel and Richard Paschke, exploring the connection between ultrasonic engineering, clinical technique, and patient care.

The discussion moves beyond product differences and focuses on practical questions hygienists face every day: How does tip wear affect efficiency? When should power settings be adjusted? Why do piezo and magnetostrictive systems require different approaches? And how can clinicians improve calculus removal while reducing fatigue and maintaining patient comfort? Through a combination of clinical experience and engineering insight, this episode offers a deeper understanding of the tools many hygienists rely on every day.

Episode transcript

Jessica Atkinson: Today we're going to delve even deeper into what the Paschkes have done for the profession of dental hygiene. We have with us Noel, who was the first dental hygienist at Johns Hopkins Hospital and the first RDH appointed to the medical school faculty. Today we're going to talk a little more about what it means to be a medical provider as a dental hygienist.

With her is Rich, the engineer who makes this medical provider's dreams come true. He has a master's degree in industrial engineering and a bachelor's degree in physics, which really makes a difference when it comes to ultrasonic engineering.

I want to start the conversation about being a medical provider. Rich, from the engineering side, and Noel, from the medical provider side, tell us a little about that connection.

Noel Paschke: My first position out of dental hygiene school was at Johns Hopkins Hospital in Baltimore. While I was at the University of Maryland, we had a rotation through the University of Maryland Hospital, and I always joke that the hospital bug bit me. I was fascinated by the idea of providing dental hygiene services in a hospital environment.

The challenge was that there weren't any dental hygiene positions available. I started thinking about what hospitals were well known in the Baltimore area and landed on Johns Hopkins. When I found out they didn't employ a dental hygienist, I wrote the job description myself. I met with the department head and explained why they needed a hygienist, especially because they were opening a bone marrow transplant center.

At that time, we didn't have salivary diagnostics or the tools we have today, but what I learned in hygiene school—almost fifty years ago—was that the mouth is connected to the rest of the body. That concept shaped my entire career.

I understood that patients undergoing bone marrow transplants would be profoundly immunosuppressed. Looking at the amount of bacterial plaque present in the mouth, I worried about what could happen when patients had no ability to fight infection. That realization reinforced the importance of what hygienists provide as healthcare professionals.

Next year I'll celebrate fifty years in the profession, and one of the most exciting developments I've seen is the growing recognition of hospital dental hygiene. It's fascinating work, and it's wonderful to see more hygienists becoming involved.

Jessica Atkinson: I love that you saw an opportunity where none existed and created it yourself.

Recently, legislation passed in Utah allowing dental hygienists to work in hospital settings, but there isn't yet a clear roadmap for how that happens. Your story is a reminder that hygienists can create opportunities, write job descriptions, meet with decision-makers, and explain the value they bring.

We're medical providers, not technicians. Our instrumentation reflects that reality. Rich, tell us why an ultrasonic isn't just a magic wand and why it should be viewed as a true medical device.

Designing medical devices around clinicians

Richard Paschke: My first job in dentistry was with Cavitron Corporation in Long Island City, New York. Before that, I worked in defense contracting. One of the engineers who interviewed me had actually worked with Oppenheimer at Los Alamos.

Interestingly, I turned down the position three times before finally deciding that maybe the dental field would be more meaningful and enjoyable.

One of my early projects was designing a radiofrequency scalpel used for shaping gingival tissue. As I worked on the design, my supervisor asked why it was taking so long. I told him, "Because this goes in somebody's mouth."

He looked at me and said, "That's ironic. You used to make bombs."

My response was, "Yes, but this is a little more personal."

When I design a medical device, I start by asking what the device is supposed to accomplish and who will be using it. Only after defining those things do I determine which technology is appropriate. Too often, people apply overly complex technology to simple problems.

The simpler a device is to use, the easier it is for clinicians to focus on patient care rather than the equipment itself.

Throughout my career I worked in research and development, manufacturing engineering, technology management, and product development. One of the biggest challenges is taking a product through a corporate approval process without losing sight of the original purpose it was designed to serve.

Piezo vs. magnetostrictive: Understanding the basics

Dave Torres: Most of us use ultrasonics every day, but if I'm being honest, the last time I really studied the differences between piezo and magnetostrictive systems was hygiene school. Can you walk us through it again?

Noel Paschke: One thing both technologies share is that they operate through frequency and amplitude. Those terms sound technical, but they have direct clinical relevance.

Both systems are ultrasonic technologies. Many hygienists were trained on only one type, so understanding how each functions is important.

Frequency refers to how often the tip moves back and forth. Amplitude refers to the distance it moves. Understanding those concepts helps clinicians make better decisions about adaptation, angulation, power settings, and patient comfort.

Why precision matters more than power

Richard Paschke: In dentistry, ultrasonic frequencies generally range from about 18 to 50 kilohertz. Frequency refers to the number of times the tip moves back and forth each second.

Amplitude, sometimes called sweep, refers to the distance the tip travels. For most ultrasonic tips, that distance is approximately the thickness of a business card.

Noel Paschke: That's an important concept to pause and think about.

Sometimes clinicians imagine that they can place the tip subgingivally, move it around, and somehow the calculus will magically disappear. In reality, we're working with an extremely refined instrument.

When you consider that the maximum movement may only equal the thickness of a business card, it becomes obvious how much precision is required. We need to understand root anatomy, furcations, concavities, and adaptation.

This isn't a matter of simply turning on a device and hoping it works. As healthcare professionals, we're making clinical decisions every second to maximize patient comfort, safety, and treatment effectiveness.

Jessica Atkinson: That's why continuing education matters. We need reminders that these are sophisticated medical devices requiring critical thinking and skill.

The hidden cost of worn ultrasonic tips

Dave Torres: Let's talk about tip wear because every hygienist eventually finds themselves explaining to an office manager why new inserts are necessary.

How much does wear actually matter?

Richard Paschke: It matters a great deal.

Both piezo and magnetostrictive systems remove calculus primarily through mechanical motion. When a traditional tip loses just one millimeter of length, sweep can decrease by approximately twenty-five percent.

At two millimeters of wear, you can lose roughly half of the original sweep.

Think of a space shuttle sitting on a launch pad. The rockets must generate enough force to overcome gravity before lift-off occurs. In the same way, an ultrasonic tip must generate enough mechanical energy to overcome the fracture potential of calculus.

When the tip wears, that energy decreases. Eventually, instead of removing calculus, you begin burnishing it.

Noel Paschke: That's where we see what I call a triple threat.

First, the patient may not receive the treatment they believe they're receiving because the calculus isn't being effectively removed.

Second, clinicians often respond by gripping harder and applying more pressure, increasing physical strain and the risk of musculoskeletal injury.

Third, there are implications for the practice itself. If equipment isn't functioning properly, questions arise about effectiveness, workplace safety, and the quality of care being delivered.

As clinicians, we need to recognize that worn instruments simply cannot perform as intended.

Common technique errors and how to correct them

Jessica Atkinson: One thing clinicians often struggle with is angulation. What are some common mistakes?

Noel Paschke: With piezo technology especially, clinicians often use it as though it were a magnetostrictive insert.

If the tip is tilted too far, you'll begin contacting the back surface. That's when patients hear the loud, uncomfortable sound that makes them think something is wrong or that treatment will be painful.

For piezo systems, angulation is generally around zero to five degrees. For magnetostrictive systems, it's typically five to fifteen degrees.

Small adjustments in angulation can dramatically improve patient comfort and treatment efficiency.

Jessica Atkinson: If you had to identify three things clinicians could improve immediately, what would they be?

Noel Paschke: First, identify which technology you're using and understand its requirements.

Second, pay close attention to angulation and adaptation. With piezo systems, remember that you're primarily using the lateral surfaces.

Third, evaluate power settings appropriately for the clinical situation.

If the instrument isn't working well, don't automatically press harder. Ask yourself whether the tip is worn or whether another factor is limiting performance.

Should hygienists be tapping?

Jessica Atkinson: As an educator, I've taught clinicians to tap and then sweep. From an engineering standpoint, what are your thoughts on tapping?

Richard Paschke: From a physics perspective, tapping doesn't make much sense.

The instrument is most effective when it remains in contact with the calculus. Every time you intentionally break contact, you're reducing the amount of time energy is being transferred.

I haven't seen strong clinical evidence demonstrating that tapping is more effective than maintaining controlled contact with the deposit.

The more variables you introduce, the more difficult it becomes to control angulation and adaptation.

Jessica Atkinson: So what I'm hearing is that slowing down may actually make clinicians more efficient.

Richard Paschke: Exactly.

Jessica Atkinson: What about stroke length?

Noel Paschke: Precision is the key. Shorter strokes are generally more effective because they concentrate energy where it's needed.

Large sweeping motions reduce precision and make it harder to transfer energy effectively to the calculus. Even at high power, the tip is moving only a very small distance.

Ultrasonic instrumentation requires the same level of anatomical knowledge and precision as hand instrumentation. Understanding root anatomy and maintaining proper adaptation remain essential regardless of the technology you're using.

Power settings, energy transfer, and clinical decision-making

Jessica Atkinson: When we increase power, are we increasing frequency or amplitude?

Richard Paschke: Only amplitude.

The frequency remains fixed. Adjusting the power control changes the sweep distance, not the frequency of vibration.

Noel Paschke: Using the business card analogy again, think of high power as approaching the full thickness of that business card. Lower power settings produce much smaller movements.

That reinforces the need for overlapping strokes, proper adaptation, and precise technique. Ultrasonics aren't about placing a tip in the pocket and hoping something happens. Success depends on thoughtful, controlled instrumentation.

Richard Paschke: It's also important to remember that worn tips don't necessarily regain effectiveness when power is increased. As tips wear, they lose efficiency in multiple ways.

Turning up the power may not restore lost performance. Often it simply leads to more clinician fatigue and more patient discomfort.

Practical Piezo tips every hygienist should know

Dave Torres: I work in multiple offices and sometimes assistants set up the equipment for me. What should clinicians know about piezo tips and handpieces?

Noel Paschke: One important concept involves thread compatibility.

Different piezo systems use different thread designs. These are not interchangeable. Attempting to use the wrong tip can damage the handpiece and reduce performance.

Clinicians should know which system they are using and confirm compatibility before installation.

The other key point is ensuring that tips are tightened properly. If the connection isn't secure, energy transfer is compromised and performance suffers.

Richard Paschke: Tip wear affects more than sweep. It also reduces energy transfer efficiency.

Manufacturers often recommend reordering tips when they reach one millimeter of wear, but in reality that level of wear already represents a significant performance loss.

From an engineering standpoint, one millimeter should be viewed as a replacement point, not merely a reminder to reorder.

A professional responsibility

Noel Paschke: Imagine a surgeon telling a patient, "The instruments I'll be using today are twenty-five to fifty percent less effective than they were designed to be. Is that okay?"

Most patients would immediately say no.

Yet clinicians sometimes continue using worn instruments without fully appreciating the impact on treatment outcomes.

We need to be mindful of the tools we use and recognize that every instrument has limits. Maintaining those instruments is part of providing quality care.

Jessica Atkinson: That's a powerful reminder. These are medical devices, and we are medical professionals.

The more we understand the science behind the equipment we use every day, the better we can serve our patients and practice ethically, effectively, and confidently.

Thank you both for sharing your expertise and helping elevate our profession.