Effectiveness and Efficiency in Ultrasonic Scaling

Earn
5 CE credits
This course was
written for dental
hygienists, dentists,
and assistants.
Effectiveness and
Efficiency in
Ultrasonic Scaling
A Peer-Reviewed Publication
Written by Elizabeth (“Betsy”) Reynolds, RDH, MS
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Educational Objectives
Upon completion of this course, the clinician will be able
to do the following:
1. Understand the importance of biofilm and
calculus removal
2. Identify the advantages of ultrasonic scalers
compared to hand scalers
3. Understand the types of power scalers available,
their modes of action, and considerations in selecting
a power scaler
4. Be able to determine the clinically appropriate inserts
and tips for use in individual cases and the sequence
in which these should be used
5. Identify the ergonomic advantages and recent
advancements in ultrasonic scalers
6. Understand the types of tips that can be used
safely and effectively in implant maintenance, as
well as which materials are contraindicated for
scaling implants
Abstract
The standard non-surgical treatment for periodontal disease is supra- and subgingival scaling to disrupt and thoroughly remove biofilm, calculus deposits, periodontal
pathogens, and debris. Instrumentation options include
hand scalers and ultrasonic scalers. Considerations in the
choice of method include efficacy, efficiency, safety, patient comfort, and ergonomics. Ultrasonic devices have
enabled clinicians to effectively and efficiently remove
supragingival and subgingival hard deposits and biofilm.
When selected and used appropriately, they are clinician
and patient friendly. Scaling inserts have evolved to include slim, complementary tips which are curved right
and left, straight, beavertail, and angulated insert tips; as
well as specialty instruments, inserts and tips designed
for safe and effective implant care without altering the
integrity of implants. Instrumentation strategies used in
debriding implants must ensure that the instruments are
compatible with the implant surface. Plastic scaling instruments and plastic-tipped ultrasonic scalers have been
found to be safe and effective to use around implants.
The latest generation of ultrasonic scalers offers the
ability to thoroughly instrument deep pockets and furcation areas, and offers benefits over conventional hand
scalers which include improved operator ergonomics and
comfort, improved patient comfort, less tooth substance
removal and more efficient and effective treatment.
Introduction
Periodontal disease relies upon the presence of a mature
biofilm rich in periodontopathogens, and is evident
to varying degrees in the majority of U.S. adults.1 The
progression of periodontal disease is highly variable and
dependent largely upon the host response, with bacterial
2
variances between individuals accounting for only 20%
of cases progressing.2 Nonetheless, the removal of bacteria and their byproducts is essential to prevent and halt
periodontal disease. Home care oral hygiene measures
can be effective in removing supragingival biofilm when
properly performed. However, once a mature subgingival biofilm has developed, or dental calculus is present,
home care is ineffective and clinical care is required. In
the absence of clinical intervention, periodontal disease
progression in individual patients leads to soft tissue attachment loss and bone loss.
The relationship of biofilm, calculus, and
periodontal disease
Within 48 hours of dental biofilm formation, sufficient
numbers of periodontopathic anaerobes are established
for the onset of gingivitis. If the biofilm is not disrupted,
its maturation will result in a complex subgingival biofilm
three to twelve weeks after the biofilm starts to form. The
subgingival biofilm is highly structured, and contains
mainly gram-negative anaerobes.3 Research has found
that a small proportion of these anaerobic species form
complexes associated with periodontal disease.4 Mature
biofilm both harbors and protects bacteria by enveloping them in a well-structured and resistant biofilm. The
deepest regions of the biofilm harbor the most periodontopathogens, and are where the highest levels of bacterial
vitality are seen.5
The reversible gingivitis which develops 48 hours
after the formation of biofilm will transform to an active
process whereby the host responds by releasing antibodies, neutrophils, lymphocytes, and macrophages into
the adjacent tissue. Interleukin 1 and tumor necrosis
factor are cytokines produced by the leukocytes. These
inflammatory markers then stimulate the production
of matrix metalloproteinases (MMPs). The production
of cytokines, prostaglandins, and chemokines leads to
inflammation and bone loss.6
Dental calculus is present in the majority of adults
supra- and subgingivally, and is 70%-80% inorganic.7
Calculus formation results from calcification of dental
biofilm and exfoliated oral epithelial cells. The mineral
ions responsible for this originate in the saliva and additionally from the crevicular fluid.8 In addition, dental
calculus contains bacterial debris interspersed within
a mineral deposit of mainly calcium phosphate (Figure
1). Research has found that supragingival calculus also
has nonmineralized areas within it containing bacteria.9
Endotoxins are slowly released from dental calculus10
into the adjacent soft tissue, where they may become destructive to the soft and hard tissues of the periodontium.
The disruption and removal of subgingival biofilm and
calculus requires clinical intervention, and is typically
carried out by non-surgical periodontal treatment.
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Figure 1. Dental Calculus Formation
BIOFILM
CaPO4
CALCULUS
• 70%–80% inorganic
• Provides a site for biofilm
retention and growth
• Releases endotoxins
Bacterial debris
Exfoliated oral
epithelial cells
Goals of non-surgical periodontal treatment
The overall goals of periodontal treatment are to halt
disease progression and to obtain clinical attachment
gains. Supra- and subgingival scaling are the standard
non-surgical treatment for periodontal disease, and may
be supplemented with systemic or local antimicrobial
therapy or other adjunctive therapy.11,12,13 The objectives
of scaling are to disrupt the dental biofilm and to remove
the maximum possible amount of dental biofilm, dental
calculus, periodontal bacteria, and debris from the root
surfaces and soft tissue. A further objective is that the
root surfaces be biocompatibly smooth upon completion
of scaling, thereby reducing the risk of recolonization and
subgingival biofilm adhesion and retention on biocompatible surfaces. (As clarification – root planing is not indicated, and is both clinically unnecessary and damaging to
the root surface integrity.) Clinically, definitive removal
of dental calculus is important. Retained dental calculus
provides a distinct raised or rough site for the adhesion of
bacteria and for biofilm retention, and will also contain
endotoxins. While it has been suggested that removal of
dental calculus may not be key in periodontal treatment,14
based upon the potential impact of retained or residual
dental calculus this is not justified. As with dental biofilm,
the objective is thorough removal (Figure 2).
Supra- and subgingival scaling can be performed with
hand instruments or with power scalers. An alternative
is a blended procedure combining the use of both hand
instruments and power scalers. Considerations in the
choice of method include efficacy, efficiency, safety, patient comfort, and ergonomics. The use of hand scalers
requires great care to achieve a satisfactory result, and
takes a considerable amount of time. It is now generally
held that hand scalers and ultrasonic scalers are similar
in their effectiveness in removing subgingival biofilm.15
However, standard Gracey curettes are known to be too
wide to enter the furcation in more than half of all maxillary and mandibular first molars,16 which have furcation
entrances as narrow as 0.63 mm wide while the minimum
width of the Gracey curettes is 0.76 mm.17 Hand scalers
have been found to be ineffective in removing calculus
deposits in furcation areas whether an open- or closedflap technique is used.18 Ultrasonic scalers are considered
superior to hand instruments for the treatment of moderate and severe furcations.19 The precision thin tips of ultrasonic scalers are significantly thinner than the working
end curettes, enabling them to enter narrow furcation areas. A further difference exists between hand scalers and
ultrasonic scalers with respect to their positioning for calculus removal (Figure 3). In the case of hand scalers such
Figure 2. Goals of Non-Surgical Periodontal Treatment
•
•
•
•
•
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Disruption of dental biofilm
Removal of dental biofilm
Removal of dental calculus
Removal of periodontal bacteria and debris
Smooth root surfaces upon completion of scaling
Halt disease progression
Clinical attachment gains
3
Figure 3. Comparison of Hand Scalers and Ultrasonic Scalers
Hand Scalers
Ultrasonic Scalers
Minimum width of tips
0.76 mm
0.55 mm
Slim inserts available
Yes - less slim than ultrasonic slim tips
Yes
Positioning of tips
Apical to the deposit
Coronal to the deposit
Deposit removal in furcations
Less effective
More effective
Lavage
None
Low to moderate
Patient comfort
Varies with clinical skill, tips used
Varies with clinical skill, tips used
Root surface damage
More than with ultrasonic scalers
Less than with hand scalers
Ergonomics
More wearing, fatigue
Less wearing, fatigue
Bacterial aerosol
If irrigation is used
Yes, minimize
as curettes, the scalers must be apical to the deposit prior
to its removal, while with ultrasonic scalers the insert is
positioned coronal to the deposit20 – resulting in easier
application of the instrument and potentially less tissue
distension. It has also been found that hand instruments
appear to cause more root surface damage than ultrasonic
scalers used at a medium power setting.21 Jacobson et al.
found that using hand scalers resulted in grooves and
cementum removal evident with SEM analysis, while the
use of ultrasonic scalers resulted in no detectable changes
to the root surface.22 Most recently, lasers have also been
used for scaling and root planing procedures. Clinical results using lasers have been variable, and while effective
in removing calculus deposits, in vitro testing found the
Er:YAG laser to be less efficient than ultrasonic scalers
and the lased root surface was found to be structurally
altered with the development of a surface microroughness after lasing.23
Hand instrumentation requires highly repetitive,
intricate, and complex hand movements, which can be
wearing and ergonomically unsatisfactory. Ultrasonic devices have enabled clinicians to effectively and efficiently
remove hard deposits and subgingival biofilm. When selected and used appropriately, they are also clinician and
patient friendly, and offer ergonomic benefits over hand
scaling. Ultrasonic scaling also reduces the time required
for thorough scaling compared to hand scaling, increasing efficiency for the office by reducing the time patients
must sit in the dental chair.
Types of ultrasonic scaling devices
Ultrasonic scalers have been in use since the 1950s, when
the first stand-alone ultrasonic scalers were introduced.
Since then they have been revolutionized with the introduction of ergonomically designed devices and tips, microtips, microprocessor controls, and other innovations.
Ultrasonic devices are available in the U.S. as magnetostrictive devices and as piezoelectric devices (Figure 4).
4
These are mechanically distinct in their mode of action
and method of use. In the U.S., the best known and most
used is the magnetostrictive ultrasonic scaler.
Figure 4
4a. Magnetostrictive
ultrasonic scaler
4b. Piezoelectric
ultrasonic scaler
Magnetostrictive ultrasonic scalers rely upon an elliptical movement of the ultrasonic tip. The magnetostrictive
stack in the insert converts energy from the handpiece
into mechanical oscillations that activate the insert tip
(Figure 5). The electronic system produces small strokes
of the insert that are microscopic and delivers from
25,000 to over 40,000 cycles (strokes) per second at the
tip. A second type of magnetostrictive device that is
less common (Odontoson) uses a ferrite rod to produce
a rotational rather than elliptical movement. Ultrasonic
devices are available with closed loops that automatically
adjust the tuning for the resonance of each tip, enabling
the clinician to successively insert different tips into the
handpiece without having to stop and adjust settings
each time.
When using magnetostrictive scalers, the insert must
be meticulously adapted to all areas of the tooth surface.
It is important to note that the most active area of the
insert’s tip is the point, followed by the concave face of
the insert, then the convex back, with the lateral surfaces
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Figure 5. Magnetostrictive Ultrasonic Insert
Magnetostrictive Movement
being the least active. The point of the insert should never
be directed into the tooth surface, and care should be taken
that the face of the insert is not adapted perpendicular to
the tooth’s surface. The majority of scaling will be accomplished with the back and lateral surfaces of the insert. The
length of the active tip area for scaling depends upon the
energy output and frequency at which the ultrasonic unit
operates. Magnetostrictive ultrasonic scalers operate at a
frequency ranging from 18 to 45 kHz, typically at 25 or
30 kHz. At a frequency of 25 kHz, the terminal 4.3 mm
of the tip is active, at 30 kHz 4.2 mm of the tip is active
(Figure 6, 7). A higher frequency of 50 kHz results in an
active area in the terminal 2.3 mm of the tip.24 The inserts
should be activated prior to insertion into the pockets and
used with a continual stroking motion in a horizontal, vertical, or oblique manner – offering the clinician flexibility
and choice. It is important to keep the tip moving and to
maintain the integrity of the contact between the active
area of the tip and the tooth surface for optimal results.
Other important factors in tip use are the amount of lateral
force applied – which should be light – and the angulations
of the tips themselves to ensure that they are maintained
against the tooth surface. Magnetostrictive technology
Figure 6. Active Tip Area and Ultrasonic
Scaler Frequency
Frequency
Active Tip
25 kHz
Terminal 4.3 mm
30 kHz
Terminal 4.2 mm
50 kHz
Terminal 2.3 mm
Stack movement results in lengthening
and shortening of the insert, and an elliptical pattern movement of the active tip.
results in all surfaces of the insert being active. Since all
four surfaces of the inserts are active and used for scaling,
magnetostrictive ultrasonic technology offers more flexibility in adaptation to the tooth surface as well as ease of
use and more flexibility in technique.
The thoroughness with which scaling devices are used
is a key attribute for success. If the insert is applied incorrectly to remove biofi lm and calculus, the tooth surface
may be damaged. As with hand instruments, if inserts
are not used properly the removal of biofi lm and calculus
will not be definitive and will compromise the clinical results and the achievement of the goals of therapy. Studies
have shown that in comparing a sonic instrument (Periosonic), magnetostrictive ultrasonic (Cavitron®, Slimline
inserts), and hand curettes that all three were effective in
disrupting biofi lm and in removing biofi lm and calculus
deposits. It was found that use of the magnetostrictive ultrasonic scaler resulted in the least tooth substance loss.25
It is well recognized that residual calculus is difficult to
detect, with false negatives being commonplace – one
study estimated that 77% of surfaces with residual calculus had been scored as calculus-free.26 Regardless of the
type of instrumentation used, this can occur and is also
dependant upon individual clinical expertise. To ensure
that calculus is removed and that it is not burnished, it is
important to select appropriate tips and to use the correct
power setting based on patient need. Magnetostrictive ultrasonic units are available that are designed to definitively
remove calculus at low to moderate power settings, and
some incorporate a power booster which can momentarily
increase the power by up to 25% without further altering
the device’s settings. These features result in thorough re-
Figure 7. Ultrasonic Insert Design and Active Tip Terminal
Tip
Grip
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Shaft insert portion
5
moval of biofi lm and calculus deposits, while increasing
patient comfort and ergonomics for the clinician.
Piezoelectric ultrasonic scalers rely upon linear movement. The piezoelectric device uses aligned ceramic
discs to produce the straight micromovements of the tip
through alternating expansion and compression of the
ceramic discs when electricity flows over the surfaces of
the crystal (Figure 8). Piezoelectric ultrasonic units operate at a frequency ranging from 25 to 50 kHz. Given the
linear fashion in which the tip moves, with piezoelectric
devices the tip’s two lateral surfaces are most active. If
adaptation to the tooth’s surface is incorrect the tip will
sound different against the tooth, letting the clinician
know that the tip adaptation needs to be altered. Deposit
removal should be accomplished by utilizing the lateral
surfaces of a piezoelectric insert. Clinicians must develop
definitive techniques to maximize efficiency. The tip
must be held lateral to the tooth surface, which is often
achieved by pivoting the wrist. While clinical results are
Figure 8. Piezoelectric Ultrasonic Insert
Piezoelectric Movement
Crystal action of piezo results in a lateral
movement of the active tip.
similar to those obtained with the use of magnetostrictive
devices, the limitations of active surfaces afforded by a
piezoelectric scaler make it a much more technique-sensitive device. Without successful technique, the clinical
outcome of piezoelectric scaling may be compromised
– potentially resulting in root surface damage and incomplete deposit removal. In the same vein, clinicians using
magnetostrictive units should take care not to limit their
instrumentation to the instrument’s lateral surfaces.
Comparison of Magnetostrictive and
Piezoelectric Ultrasonic Units
The use of either magnetostrictive or piezoelectric ultrasonics requires great care and an overlapping movement
around the whole of the root surface to ensure biofi lm
and calculus removal. One in vitro study comparing
ultrasonic scalers and hand curettes found while the
piezoelectric device resulted in slightly faster instrumentation compared to the magnetostrictive device, both
were more efficient than hand curettes. In measuring the
tooth surface roughness (Ra), however, the tooth surface
was smoothest after use of the magnetostrictive device
and roughest following use of the piezoelectric device. In
comparing all three instrumentation methods, the hand
curette produced the smoothest surface but the most
tooth substance loss as measured by SEMs, and the magnetostrictive produced the least tooth substance loss.27
The efficacy of calculus removal from a root surface was
found to be the same with all three methods.
In comparing magnetostrictive and piezoelectric
devices, it has been suggested that piezoelectric devices
may be more comfortable for patients28 due to their linear rather than elliptical movement. However, for both
devices the adaptation of tips at the correct angle and
Figure 9. Comparison of Magnetostrictive and Piezoelectric Ultrasonic Units
6
Magnetostrictive Units
Piezoelectric Units
Mechanism
Metal stack or ferrite rod
Aligned ceramic discs
Tip Movement
Elliptical
Linear
Active Surfaces
Back, face, and lateral (4)
Lateral (2)
Positioning of Tips
Flexible
Must be lateral to surface
Slim Inserts Available
Yes
Yes
Inserts that Mimic Perio Probe Yes
Yes
Effective Calculus Removal
Yes
Yes
Coolant/Lavage Volume
Low to high, directional with some inserts Low to moderate
Patient Comfort
Varies with clinical skill, tips used
Varies with clinical skill, tips used
Technique Sensitive
+
+++
Learning Curve
+
+++
Flexibility of Technique
+++
+
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keeping the tip in motion when against the tooth helps
prevent discomfort. In this regard, adaptation is more
versatile with the magnetostrictive ultrasonic inserts,
which are active on four rather than two surfaces (Figure
9). Similarly, it is important to use only a very light grasp
and pressure. One study compared pain perception in
patients treated with either a magnetostrictive ultrasonic unit (Dentsply) or a piezoelectric unit (Vector). The
patients’ perception of pain was similar during and after
treatment, irrespective of the ultrasonic unit used.29 It
should be noted that pain may be associated with tissue
distension/manipulation or dentinal hypersensitivity
rather than with the movement of ultrasonic tips. Tissue
distension can be minimized through careful selection
of tips and technique (Figure 10). Where unavoidable,
the use of locally delivered topical anesthetics (Oraqix,
Dentsply) or local anesthetics may be necessary, and
peri-operative use of desensitizing agents helps relieve
hypersensitivity during treatment.
Figure 10. Slim Tip Insert Provides Ease
of Access Into Pocket and Minimizes
Tissue Distension
The cavitational effect of ultrasonic devices aids
biofilm removal,30 and the acoustic effects of the water
lavage assist in the removal of calculus deposits. Similarly, the lavage obtained from power-driven scalers’
water/fluid coolant provides for continual flushing
and is believed to be of therapeutic benefit.31 While
lavage is considered beneficial, a balance is desirable
between no lavage and lavage that is copious and nondirectional. With overzealous lavage, the potential for
patient gagging and patient discomfort increases and
a longer treatment time is required as the amount of
suctioning necessary increases. This may result in the
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clinician having to stop while suction is used to evacuate
the water or chemotherapeutic used for lavage. Generally, piezoelectric ultrasonic units use less water than
magnetostrictive ultrasonic units. To decrease the fluid
necessary for proper lavage production, innovations in
magnetostrictive insert designs have allowed for a more
focused spray with minimal fluid volume. It is possible
to use a focused spray or drip of water delivered through
the insert and tip itself – enabling better visibility, more
directional control, increased patient comfort and a
decreased need for suction while still providing the
beneficial effects of lavage.
Ultrasonic tip and insert designs
Originally, ultrasonic tips were available only with extremely limited design options. By the 1990s clinicians
and manufacturers recognized the clinical limitations of
the bulky tip options on the market and a line of magnetostrictive inserts designed to improve subgingival and
furcation access was introduced. Slim tip inserts are designed to be approximately 30% slimmer than standard
inserts. The slimmer profile of the revised tips not only
resulted in improved access – in particular to the depths
of pockets greater than 4 mm depth – but also provided
improved patient comfort by reducing tissue manipulation and distension.
In one study in the early 1990s, hand instruments
failed to adequately reach the base of deep pockets on
75% of root surfaces, primarily due to the impediments
imposed by pocket morphology,32 yet the base of deep
pockets is exactly where higher levels of periodontal
pathogens are found.33 Slim tips available for both magnetostrictive and piezoelectric ultrasonic units are designed
to reach into deep pockets effectively and safely. They
are able to improve pocket access by 1 mm over hand
instrumentation, and to reach the base of 86% of pockets
3 to 6 mm deep.34 Slim tips designed to mimic the ends of
periodontal probes enable easier insertion and improved
tactility. This enables detection of remaining or residual
calculus, saving time by decreasing instrument exchange
during treatment.
When compared to the original cumbersome tip designs, the slimmer inserts decrease the amount of tooth
surface that is lost to instrumentation. In one study,
slim scaler tips were found to produce less substance
loss for both magnetostrictive slim tips (Slimline) and
Figure 11. Dentin Loss Using Slim Tips:
MR and PZE
Slim Tips (MR unit)
Slim Tips (PZE unit)
Width (in microns)
254.4
352
Depth (in microns)
6.3
12.1
Volume (in cubic microns)
22.5
56.4
7
piezoelectric slim tips (Perioprobe). In comparing
the slim scaler tips of both types of devices, dentin
loss was assessed using laser profilometry for depth,
width, and volume of defects. The magnetostrictive
device resulted in less gouging than the piezoelectric
device, with mean changes in the dentin of 254.4 microns, 6.3 microns and 22.5 cubic microns for width,
depth and volume versus 352.0 microns, 12.1 microns
and 56.4 cubic microns respectively (Figure 11). It was
also found that for both devices, changing the force
used from 0.3N to 0.7N increased the substance loss
twofold,35 underscoring the importance of using a light
to moderate instrumentation force.
Flemmig et al. studied slim inserts using a piezoelectric ultrasonic scaler and compared instrumentation
using varying angulations, lateral forces, various power
settings, and instrumentation time. It was found that
lateral force most influenced the total amount of root
substance loss, while tip angulation had the most effect
on the depth of the defect, with the greatest defect depth
and volume loss occurring when the angulation of instrumentation measured was 45 degrees with 2N lateral
force applied. The study concluded that “to prevent
severe root damage it is crucial to use the assessed scaler
at a tip angulation of close to 0 degrees”.36 In a separate
study assessing root substance loss when slim tips were
used in magnetostrictive ultrasonic units, Flemmig et
al. again found that the greatest influence on the volume
of tooth surface lost to improper instrumentation was
the lateral force applied. Angulations of 0, 45, and 90
degrees were used. Unlike the results in the piezoelectric study, severe root damage was not evident when the
angulation was 45 degrees, 0.5N lateral force, and the
power was set at up to a medium setting. This study
concluded that “the efficacy of the assessed magnetostrictive ultrasonic scaler may be adapted to the various
clinical needs by adjusting the lateral force, tip angulation, and power setting.”37
Figure 12. Standard diameter insert; slim tip
curved, left and right inserts
8
Figure 13. Advantages of Curved Left and
Right Ultrasonic Inserts
• Easier instrumentation of deeper pockets
• Superior adaptation to root morphology
• Slim tips are slimmer than narrowest furcation areas
• Proper instrumentation of:
• Furcations
• Full circumference of roots
• Ergonomically designed
Figure 14. Aspects for Use: Right and Left Inserts
Left Inserts
• Upper Right Buccal/Labial
• Upper Left Palatal
• Lower Left Buccal/Labial
• Lower Right Lingual
Right Inserts
• Upper Right Palatal
• Upper Left Buccal/Labial
• Lower Left Lingual
• Lower Right Buccal/Labial
As ultrasonics have evolved, new designs in straight
and curved tips have also included complementary
designs reflecting the site-specific benefits of Gracey
curettes (Figure 12). By using both right and left inserts
in deeper pockets (>4 mm deep) the full circumference
of the root, complex root anatomy and furcations can
be more easily and properly instrumented (Figure 13).
Right and left tip inserts are designed to adapt to the
root surface and furcation areas for optimal results,
with each of these used in specific areas of the mouth
and teeth – similar to Gracey curettes. When entering
the furcation, rotating the insert enables the tip to reach
the roof of the furcation (Figure 14).
The importance of superior access and adaptation
cannot be underestimated in deep pockets or furcations.
Furcation involvement is a leading cause of periodontally-induced tooth loss, and periodontal treatment
failure for molars with furcation involvement is more
than double the rate of treatment failure for molars with
no furcation involvement over an eight-year period.38
At their narrowest point, the roof of furcations can be
narrower than the width of hand instruments, making
them inaccessible or extremely difficult to instrument.
Other insert tips include diamond-coated ultrasonic
tips. Some manufacturers have designed and advocate
diamond-coated tips for non-surgical scaling. Other manufacturers advocate these tips specifically for difficult-toremove calculus during open-flap procedures, and not for
use with non-surgical scaling. Incorrect use of diamondcoated ultrasonic tips can lead to tooth substance loss and
soft tissue damage. Teflon-coated tips have been tested
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Figure 15. Insert Tips and Function
Scaler Insert Tip
Use
Standard
Removal of moderate-heavy deposits
Standard triple-bend
Aids access for removal of moderate-heavy deposits
Beavertail
Removal of heavy deposits and stains; anterior teeth
Chisel
Anterior teeth and premolars; overhanging margins
Perio probe
Shallow and deep pocket deposit removal;
Deeper subgingival lavage; calculus detection
Slim tips
Deposit removal in pockets 4 mm deep and greater
Straight
Superficial deposit removal
Curved and angulated
Aid access and adaptation
Curved right and left
Aid access and adaptation to root morphology; furcation areas
Right and left furcation
Deposit removal in root furcation areas
Fine-tipped
Aid access for deposit removal in narrow interdental spaces
Diamond-coated
Depends upon manufacturer Gross deposit removal; Surgical or non-surgical access
Removal of overhanging margins
Endodontic
Debridement of canals; removal of fractured endodontic instruments
and, while effective in disrupting and removing biofilm,
were found to be less effective in removing calculus than
conventional ultrasonic tips.39
Instrumentation sequence
Just as with hand instruments, different ultrasonic inserts are designed for specific tasks (Figure 15). Standard
ultrasonic inserts are designed for moderate to heavy
deposit removal, and slim inserts are designed for light
deposit removal. Standard inserts are not intended for use
in deep pockets nor are they designed for root adaptation
in deep pockets, and should not be regarded as a universal insert. Utilizing the appropriate ultrasonic inserts in
the correct sequence and at the appropriate power level
ensures good clinical results and comfort for the patient
and an ergonomic dental hygiene procedure (Figures 16,
17). In general, supragingival calculus deposits should be
removed using a standard diameter insert at a low to high
power setting as indicated by the patient’s oral condition.
Following use of standard diameter inserts, debridement
of pockets 4 mm deep or greater is achieved using slim
tipped inserts at a low power setting. Recent magnetostrictive innovations allow use of lower power settings
for thorough calculus debridement. The final stage of the
scaling procedure is the use of a slim insert at a low power
setting to remove the smear layer on the root surface.
Chemotherapeutic irrigants for lavage
Water is routinely used in ultrasonic units as a coolant
and has a lavage effect in the periodontal pockets. The
use of chemotherapeutics with ultrasonic inserts offers
lavage and cooling of the insert tip with the additional
benefit of placing the chemotherapeutic agent directly
into the periodontal pocket during the scaling procedure.
Over the years, various chemotherapeutic agents have
been used, including chlorhexidine, povidone-iodine
and sodium hypochlorite. An early study comparing use
of 0.12% chlorhexidine gluconate and sterile water for
Figure 16. Sequence for Instrumentation
Standard Inserts
• Removal of gross, superficial
deposits
• Suitable for pockets up to 3 mm
deep
• Medium-high power setting
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Slim Tip Inserts
• Debridement of pockets 4 mm and
deeper
• Lower power setting
• +/– hand instrumentation
Slim Tip Inserts
• Removal of smear layer from root
surface
• Low power setting
9
Figure 17
Figure 17a. Chisel insert for anterior regions
Figure 17b. Insert with a fine tip for use in areas
with narrow access
Figure 17c. Standard diameter insert with triplebend for removal of moderate-heavy deposits
Figure 17d. Insert that mimics the shape of a periodontal probe. Provides for good access into pockets
10
cooling and lavage found that the use of chlorhexidine
gluconate was beneficial in reducing clinical probing
depth 14 and 28 days post-scaling in pockets that were
initially 4–6 mm probing depth, but otherwise produced
clinically comparable results to the use of sterile water.40
A second study found that use of chlorhexidine as the
coolant resulted in significantly more sites with final
probing depths of 1–3 mm, rather than greater than
3 mm with use of water as the coolant. Chlorhexidine
coolant was found in this study to have a slight adjunctive effect.41 A more recent study found that use of
chlorhexidine (Eludril) or sodium hypochlorite as an irrigant during scaling and root planing resulted in slightly
more effective reduction in plaque index, gingival index,
and bleeding upon probing compared to water, with
the chlorhexidine being more effective than the sodium
hypochlorite. Probing depth reductions, however, were
found to be the same as with scaling alone.42 Research
has also been conducted using povidone iodine, with the
results suggesting that use of 10% povidone iodine as an
irrigant at the time of scaling was effective in reducing
the total count of periodontopathic bacteria and could
be a useful irrigant during therapy.43 It is important to
note, however, that use of chemotherapeutics as irrigants during ultrasonic scaling is not a substitute for
indicated adjunctive antimicrobial treatment such as locally-delivered sustained release agents and has not been
shown to have a long-term effect. It has also been found
that adjunctive daily use of chemotherapeutic irrigants
at home may help reduce inflammation.44 Another practice is to use water as a coolant during primary scaling,
followed by use of a chemotherapeutic during the final
phase of scaling and desmearing. It has been suggested
that the use of chlorhexidine for lavage will reduce the
bacterial count in the aerosol associated with ultrasonic
scaling; however, studies indicate that the most important factors in controlling the bacterial aerosol are the
use of appropriate suction and an ultrasonic unit utilizing sufficient but modest amounts of coolant delivered
directionally to the site.
Ergonomics
The primary objective of ergonomics is to prevent workrelated injuries.45 Dental procedures by their nature
expose clinicians to occupational health risks. Dental
hygiene procedures use particularly repetitive and
physically-demanding movements. Occupational risks
specific to delivering dental hygiene care include reduced
tactile sensitivity, carpal tunnel syndrome, neck and back
injuries, and hand and finger injuries due to muscle fatigue.46,47 Scaling involves pinch-grasp, force, vibratory
stimuli (if ultrasonic scalers are used), and potentially
awkward operator positions that can all result in workrelated musculoskeletal injuries.48
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Figure 18. Patient Seated in Ergonomic Position
Figure 19. Insert With Soft, Dimpled Handle
Scaling ergonomically requires a number of considerations. Selecting a position for the patient that
is comfortable for clinician and patient alike – usually seating the patient at a 45-degree angle – is the
first step; this angle should be adjusted as necessary.
Similarly, instead of a clinician bending his or her neck
and back, it is important to have the patient turn his
or her head to the right or left and chin up or down to
improve access and visibility to awkward areas (Figure 18). Contrary to instinct, taking the time to have
patients do so will save time and result in less fatigue
and wear for the clinician without compromising the
patient’s comfort or the outcome.
The use of finger rests or fulcrum points helps reduce
the thumb pinch force and reduces hand muscle load
while utilizing hand instruments.49 Extra-oral and/or
hand-on-hand fulcrums are recommended with ultrasonics to assist with flexibility of movement. Beyond
these simple steps, the ergonomics of scaling is mostly
influenced by technique and instrument selection.
When hand scaling, it has been demonstrated that
dental hygienists reduce their tactile sensitivity in as little
as 45 minutes. In contrast, in dental hygienists using ultrasonic scalers tactile sensitivity increased and vibration
was insufficient to reduce tactile sensitivity.50
Handle instrument design influences hand muscle
load and pinch force. Lightweight hand instruments
with larger-diameter handles have been found to reduce
muscle load and pinch force when compared to heavy or
thin-handled instruments.51 Handle design also influences selection of ultrasonic inserts and tips. Thicker
handle insert designs that incorporate a thick, soft, and
dimpled rubber-like handle on the insert are available to
improve clinician comfort (Figure 19).
Softer and fatter grips also enable easier rotation and
reduce hand fatigue. These handle innovations do not
reduce or affect the wrist pivot required to position tips
properly during piezoelectric instrumentation. Originally,
ultrasonic handpieces were static and did not pivot during instrumentation. Currently, magnetostrictive units
are available with handpieces with swivel features, which
reduce discomfort, minimize line pinching, and enable
instrument manipulation in areas of difficult access (such
as furcations and distal root areas). Recent innovations in
magnetostrictive ultrasonic units include the incorporation
of a remote frequency wireless foot control. This technology enables the foot control position more flexibility, since
Figure 20. Ergonomics and Influencers
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Neck and Back Strain, Fatigue/Wear
Patient positioning
Operator positioning
Wireless foot controls
Tactile Sensitivity
Diminished by hand scaling
Increased by ultrasonic scaling
Hand Pinch/Grasp/Muscle Load
Problems, Discomfort
Reduced by use of finger rests/fulcrum points
Reduced by use of lighter handles and inserts
Reduced by use of fatter inserts and handles
Reduced by use of softer grips on inserts
Wrist Pivot Issues
Reduced by use of handpieces with swivel features
11
it is not tied to the unit by a cord, and also operate from
any side of the base. This offers ease of use and ergonomic
benefits since the clinician can position the foot control in
the most comfortable position without needing to consider
any cords (Figure 20).
Implant care
As dental implants continue to evolve into a routine
dental procedure, the need for improved scaling instruments and devices is increasing. Long-term implant
failure due to peri-implantitis occurs commonly in patients with poor oral hygiene and who do not attend periodic maintenance visits.52 Initially, biofilm formation
will result in peri-mucositis that is etiologically similar
to gingivitis in the natural dentition. If improved oral
hygiene procedures and professional maintenance care
are not initiated, this will progress to irreversible periimplantitis – inflammation of the tissue at the implant
site, with both soft tissue inflammation and bone loss.
Infected implant sites have six times the number of
gram-negative anaerobes compared to gram-positive
aerobes.53 Meticulous home care and regular clinical
maintenance visits are essential to prevent peri-implantitis. Inflammation of the implant site must be kept to a
minimum through soft and hard tissue deposit removal
while minimally impacting the surrounding tissues and
the implant. This includes the removal of biofilm and
calcified deposits at the implant site and on the implant
surface. Instrumentation strategies used in cleaning
implant(s) must ensure that the instruments used are
compatible with the implant surface. Implant damage
due to inappropriate instrumentation increases the likelihood of biofilm formation and maturation,54 anaerobic
colonization, and calculus formation.
Metal tip hand scalers, including titanium alloy
and stainless steel curettes, and metal ultrasonic tips,
have been found in studies to result in implant surface
roughness and to increase the surface roughness of ti-
Figure 21. Scaling and Implant Surfaces
• Plastic-tipped ultrasonic scalers are effective and safe
• Effectively remove soft and hard deposits
• Found not to increase the surface roughness of
titanium implants
• Metal tip scalers result in implant surface damage and roughness
• Including titanium alloy and stainless steel
instruments
• Implant surface alterations are influenced by the implant
• HA-coated implants are more susceptible to
alterations
• Plasma-coated implants are more susceptible to
alterations
tanium abutments.55, 56, 57 In addition to considerations
regarding the use of metal scalers, it has also been
found that HA-coated and plasma-coated implants are
susceptible to surface alterations during scaling and
more so than non-coated implants (Figure 21).58, 59
Plastic scaling instruments have been found to be
safe for use around implants and abutments, and not to
increase the surface roughness of the titanium.60, 61, 62 Sato
et al. concluded that ultrasonic inserts with non-metal
tips were suitable for implant maintenance.63 In vitro
research using scanning electron microscopy found that
use of disposable plastic tips over metal base tips left virtually no traces and did not destroy the surface integrity
of implants and abutments.64
Systems are available that use metal bases on specialty ultrasonic inserts with a single-use soft plastic
tip that fits over the metal base (Cavitron® SofTip™,
Dentsply Professional) (Figure 22). These plastic tips
are designed to effectively remove biofilm and light calculus deposits at implant sites as well as on the implants
Figure 22
Figure 22a. SofTip™ assembly into metal base insert
12
Figure 22b. Implant scaling using a SofTip™
ultrasonic insert
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and superstructures, without damaging the implant’s
surface or affecting the integrity of the peri-implant
mucosal cuff.
12
13
Summary
Research over the last two decades has resulted in new
insights into periodontal disease. While it is the host response that is generally responsible for the progression
of periodontal disease, gram-negative bacteria found in
mature biofilm are essential for periodontal disease to
exist and progress. The standard non-surgical treatment
for periodontal disease is supra- and subgingival scaling to disrupt and thoroughly remove biofilm, calculus
deposits, periodontal pathogens, and debris. Instrumentation options include hand scalers and ultrasonic
scalers. Ultrasonic scalers available in the U.S. include
both magnetostrictive and piezoelectric units, with the
magnetostrictive ultrasonic unit being more frequently
used. Scaling inserts have evolved to include slim, complimentary curved right and left, straight, beavertail and
angulated insert tips as well as specialty instruments,
inserts, and tips designed for safe and effective implant
care without altering the integrity of implants. The latest
generation of ultrasonic scalers offers the ability to thoroughly instrument deep pockets and furcation areas, and
offers benefits over conventional hand scalers including
improved operator ergonomics and comfort, improved
patient comfort, as well as more efficient and more
effective treatment.
14
Acknowledgement
26
Biofilm image courtesy of Dr. Gary Carr, Pacific Endodontic Research Foundation.
27
References
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and plastic instruments: an in vitro study. J Periodontol. 1990;61(8):485-490.
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and plastic instruments: an in vitro study. J Periodontol. 1990;61(8):485-490.
61 Homiak AW, et al. Effect of hygiene instrumentation on titanium abutments: a scanning
electron microscopy study. J Prosthet Dent. 1992;67(3):364-369.
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different instruments. Int J Oral Maxillofac Implants. 2004;19(2):232-238.
14
63 Sato S, Kishida M, Ito K. The comparative effect of ultrasonic scalers on titanium surfaces:
an in vitro study. J Periodontol. 2004;75(9):1269-1273.
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Author Profile
Elizabeth (“Betsy”) Reynolds, RDH, MS
Ms. Betsy Reynolds has been a practicing hygienist for over twenty years and has been involved with
several private practices stressing comprehensive periodontal care for patients seeking treatment. Betsy has
reinforced her love of the microbiological aspects of
periodontal therapy by maintaining teaching positions
emphasizing the dental sciences at numerous dental
and dental hygiene schools.
Betsy lectures extensively nationally and internationally on subjects that include biologic basis for
disease prevention, advanced instrumentation technique, current dental therapeutic modalities, pharmacological considerations for the dental professional,
microbiological and immunological aspects of dental
disease, the impact of oral disease on systemic health,
evidenced-based decision-making and scientific developments affecting oral health care delivery. Additionally, she has authored numerous articles and book
chapters on a variety of oral healthcare concerns. Betsy
holds a Master of Science Degree in Oral Biology from
the University of Washington.
Living in Boise, Idaho amidst the beauty of the
Rocky Mountains and the magnificent untamed waters of the Salmon River, Betsy enjoys spending time
outdoors with her husband, Mike, and their two dogs,
Lucy and Nellie.
Disclaimer
The author of this course has no commercial ties with the
sponsors or the providers of the unrestricted educational
grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at
www.ineedce.com.
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Questions
1.The removal of _____ is
essential to halt and prevent
periodontal disease.
a. Bacteria
b.Pellicle
c. Crevicular fluid
d.None of the above
2.Interleukin 1 is a _____ produced
by leukocytes.
a. Enzyme
b.Cytokine
c. Prostaglandin
d.None of the above
3.Dental calculus contains
calcified_____.
a. Biofilm
b.Exfoliated oral epithelial cells
c. Saliva
d.a and b
4.Subgingival calculus is typically
removed by _____.
a. Brushing
b.Non-surgical periodontal treatment
c. Subgingival irrigation
d.None of the above
5.Overall goals of non-surgical
periodontal treatment are _____.
a. To halt disease progression
b.To reduce bleeding
c. To obtain clinical attachment gains
d.a and c
6.Hand scalers have been found
to be ineffective in removing
calculus in _____.
a. Narrow interproximal areas
b.Furcation areas
c. Mesial root surfaces
d.All of the above
7.Furcation entrances can be as
narrow as _____.
a. 0.45 mm
b.0.63 mm
c. 0.75 mm
d.0.92 mm
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8.Ultrasonic scalers are considered superior to hand scalers in
_____ furcations.
a. All
b.Moderate and severe
c. Wider
d.No
9.Ultrasonic scalers are available
as _____.
a. Magnetostrictive units
b.Piezoelectric units
c. Supersonic units
d.a and b
10.Elliptical movement is obtained
using a _____ ultrasonic device.
a. Piezoelectric
b.Piezomechanical
c. Magnetostrictive
d.a and c
11.Magnetostrictive ultrasonic
units can use a _____ to
convert energy.
a. Stack
b.Cell
c. Ferrite rod
d.a and c
12.Piezoelectric ultrasonic units
use _____ to convert energy.
a. Ceramic rods
b.Ceramic discs
c. Metallic discs
d.Any of the above
13.The majority of scaling using
magnetostrictive ultrasonic
inserts will be accomplished
with ______________.
a. The point
b.The face
c. The lateral and convex back surfaces
d.The face and lateral surfaces
14.The available active area in
the terminal part of ultrasonic
inserts depends upon _____.
a. The frequency at which the ultrasonic
scaler operates
b.The length of the insert
c. The force applied using the insert against
the tooth
d.None of the above
15.Slim tip inserts are designed to
be approximately ______ than
standard inserts.
a. 20% slimmer
b.30% slimmer
c. 15% shorter
d.None of the above
16.What part of the insert
should never be directed
at the tooth surface?
a. The lateral surface
b.The tip
c. The point of the tip
d.The circumference
17.Important factors in tip use
are_____.
a. Keeping the tip moving continually
b.Applying a light lateral force
c. Angulations of the tips to ensure they are
against the tooth surface
d.All of the above
18.False negatives for the presence of residual calculus have
been found in up to _____ of
root surfaces.
a. 45 percent
b.55 percent
c. 77 percent
d.83 percent
19.Piezoelectric ultrasonic
units rely upon what type
of movement?
a. Rotational
b.Elliptical
c. Linear
d.All of the above
20.With piezoelectric ultrasonic
units, _____surfaces of the
insert’s tip are the most active.
a. All
b.The lateral
c. The front and back
d.Only the back
15
Questions
21.Hand curettes have been found 28.The efficacy of magnetostricto be less efficient in scaling
tive ultrasonics can be adapted
procedures than _____.
by adjusting _____.
a. Irrigation
b.Magnetostrictive ultrasonic scalers
c. Piezoelectric ultrasonic scalers
d.b and c
22.In a study comparing magnetostrictive and piezoelectric
ultrasonic scaling, patients’
perception of discomfort was
found to be _____.
a. Similar
b.Very different
c. Less with piezoelectric ultrasonic scaling
d.Less with magnetostrictive
ultrasonic scaling
23.Tissue distension can be
minimized through _____.
a. Technique
b.Careful selection of tips
c. a and b
d.Local anesthesia
24.The cavitational effect of
ultrasonic scalers aids _____.
a. Biofilm removal
b.Bacterial resistance
c. Saliva production
d.a and b
25.Reducing the amount of water
sprayed from inserts _____.
a. Improves visibility
b.Improves patient comfort
c. Reduces the need for suction
d.All of the above
26.Patient comfort varies
with _____.
a. The specific insert tips used
b.Clinical skill
c. The patient’s ability to sit upright
d.a and b
27.The flexibility of scaling technique is greatest with _____.
a. Piezoelectric ultrasonic units
b.Magnetostrictive ultrasonic units
c. Lasers
d.a and b
16
a. Tip angulation
b.Lateral force
c. Power setting
d.All of the above
29.The full circumference of deep
pockets and root morphology
can be properly instrumented
using _____.
a. Beavertail inserts
b.Right and left inserts
c. Straight inserts
d.Any of the above
30.Teflon-coated tips have
been found to be _____than
conventional ultrasonic tips.
a. As effective
b.More effective
c. Less effective
d.Quicker
31.Inserts are available for
ultrasonic units with
_____tips.
a. Straight
b.Angulated
c. Curved left and right
d.All of the above
32.Standard size straight
ultrasonic inserts are designed
for _______.
a. Moderate to heavy deposit removal in
probing depths less than 4 mm
b.Deposit removal in pockets deeper than
6 mm only
c. Biofilm removal only
d.a and b
33.Debridement of pockets
4 mm deep or greater is
achieved by _____.
a. Using straight inserts and a low
power setting
b.Using slim inserts and a high
power setting
c. Using slim inserts and a low
power setting
d.a or b
34.Liquids used for lavage
include_____.
a. Water
b.Chlorhexidine
c. Sodium hypochlorite
d.All of the above
35.Scaling ergonomically
includes_____.
a. Selecting a position for the patient that is
comfortable for the clinician
b.The use of finger rests or fulcrum points
c. Careful selection of instruments
d.All of the above
36.Hand muscle load and pinch
force are influenced by _____.
a. The diameter of the handle
b.The weight of the handle
c. The positioning of the patient
d.a and b
37.The use of handpieces with
swivel features___________.
a. Minimizes line pinching
b.Enables instrument manipulation in
areas of difficult access.
c. Restricts patient positioning
d.a and b
38.Implant surface roughness can
result from the use of _____.
a. Stainless steel curettes
b.Titanium alloy curettes
c. Chlorhexidine mouthrinses
d.a and b
39.Disposable plastic tips
designed for specialty inplant
inserts have been found
to_____.
a. Safely and effectively remove deposits
b.Disturb the integrity of the implant site
c. Be ineffective
d.b and c
40.Compared to hand scalers,
benefits of the latest ultrasonic
scalers include _____.
a. Improved patient comfort
b.Improved operator ergonomics
c. More effective treatment
d.All of the above
www.ineedce.com
ANSWER SHEET
Effectiveness and Efficiency in Ultrasonic Scaling
Name:
Title:
Address:
E-mail:
City:
State:
Telephone: Home (
)
Office (
Specialty:
ZIP:
)
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 5 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
Mail completed answer sheet to
Educational Objectives
1.
Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp.
Understand the importance of biofilm and calculus removal
2.
Identify the advantages of ultrasonic scalers compared to hand scalers
3.
Understand the types of power scalers available, their modes of action, and considerations in selecting a power scaler
4.
Be able to determine the clinically appropriate inserts and tips for use in individual cases and the sequence in which
these should be used
5.
Identify the ergonomic advantages and recent advancements in ultrasonic scalers
6.
Understand the types of tips that can be used safely and effectively in implant maintenance, as well as which
materials are contraindicated for scaling implants
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
For immediate results, go to www.ineedce.com
and click on the button “Take Tests Online.” Answer
sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
P ayment of $64.00 is enclosed.
(Checks and credit cards are accepted.)
If paying by credit card, please complete the
following:
MC
Visa
AmEx
Discover
Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
Acct. Number: _______________________________
1. Were the individual course objectives met?Objective #1: Yes No
Objective #2: Yes No
Objective #3: Yes No
Objective #4: Yes No
Objective #5: Yes No
Objective #6: Yes No
Exp. Date: _____________________
2. To what extent were the course objectives accomplished overall?
5
4
3
2
1
0
3. Please rate your personal mastery of the course objectives.
5
4
3
2
1
0
4. How would you rate the objectives and educational methods?
5
4
3
2
1
0
5. How do you rate the author’s grasp of the topic?
5
4
3
2
1
0
6. Please rate the instructor’s effectiveness.
5
4
3
2
1
0
7. Was the overall administration of the course effective?
5
4
3
2
1
0
8. Do you feel that the references were adequate?
Yes
No
9. Would you participate in a similar program on a different topic?
Yes
No
Charges on your statement will show up as PennWell
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
___________________________________________________________________
12. What additional continuing dental education topics would you like to see?
___________________________________________________________________
___________________________________________________________________
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. AGD Code 495
AUTHOR DISCLAIMER
The author of this course have no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant. No
manufacturer or third party has had any input into the development of course content.
All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected].
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the
survey included with the course. Please e-mail all questions to: [email protected].
www.ineedce.com
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70% (answering 28 or more questions correctly) on the
examination will receive a verification form verifying 5 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
credit. Please contact PennWell for current term of acceptance. Participants are urged to
contact their state dental boards for continuing education requirements. PennWell is a
California Provider. The California Provider number is 3274. The cost for courses ranges
from $49.00 to $110.00.
Many PennWell self-study courses have been approved by the Dental Assisting National
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet
DANB’s annual continuing education requirements. To find out if this course or any other
PennWell course has been approved by DANB, please contact DANB’s Recertification
Department at 1-800-FOR-DANB, ext. 445.
RECORD KEEPING
PennWell maintains records of your successful completion of any exam. Please contact our
offices for a copy of your continuing education credits report. This report, which will list
all credits earned to date, will be generated and mailed to you within five business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
© 2008 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell
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