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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 1  |  Page : 24-29

Effect of visual enhancement on root surface instrumentation: An in vitro scanning electron microscope study


Dental Centre, Bhopal, India

Date of Submission04-Oct-2021
Date of Decision14-Nov-2021
Date of Acceptance27-Nov-2021
Date of Web Publication05-Apr-2022

Correspondence Address:
Sunil Kumar Goyal
Dental Centre, Bhopal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodd.jodd_60_20

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  Abstract 


Aim: The aim of this study was to compare the efficacy of various magnifying tools in periodontal mechanotherapy.
Materials and Methods: A total of 30 single-rooted extracted teeth were equally divided into six groups. The root surfaces were subjected to manual as well as ultrasonic instrumentation under unaided eye, magnifying loupes, and dental operating microscope (DOM). Then, the teeth samples were evaluated for the surface properties and for the presence of smear layer with a scanning electron microscope using magnification of ×100 and ×3000.
Statistical Analysis: Data were subjected to statistical analysis using Kruskal–Walli's Analysis of variance and Mann–Whitney's test.
Results: The mean roughness and loss of tooth substance index scores for the manual instrumentation performed under unaided, loupe, and surgical microscope were 1.8, 1, and 1, respectively. The mean scores for the power-driven instrumentation performed under unaided, loupe, and surgical microscope were 1.2, 1.2, and 1, respectively. Statistically significant (P < 0.05) difference was found when root planing was performed by hand instrumentation under DOM when compared to unaided vision. Comparison between manual and ultrasonic instrumentation was nonsignificant (P > 0.05) under magnification.
Conclusions: All treatment modalities were effective in mechanical debridement of the root surface. The result favored the use of ultrasonic instrumentation as compared to manual instrumentation under unaided vision. Whereas under magnification, both manual instrumentation and ultrasonic instrumentation produced similar root surface smoothness.

Keywords: Dental operating microscope, magnifying loupes, root planing and periodontal disease, vision enhancement


How to cite this article:
Goyal SK, Prasanna M P. Effect of visual enhancement on root surface instrumentation: An in vitro scanning electron microscope study. J Dent Def Sect. 2022;16:24-9

How to cite this URL:
Goyal SK, Prasanna M P. Effect of visual enhancement on root surface instrumentation: An in vitro scanning electron microscope study. J Dent Def Sect. [serial online] 2022 [cited 2022 May 18];16:24-9. Available from: http://www.journaldds.org/text.asp?2022/16/1/24/342650




  Introduction Top


Mechanical debridement of the root surface still remains as one of the cornerstones of successful periodontal therapy. Effective plaque and calculus removal from the root surface unequivocally determine the outcome of periodontal regenerative therapy.[1] Scaling and root planing (SRP) performed by traditional techniques results in extensive abrasion and gauging of the root surface.[2] One school of thought advocates extensive and aggressive scaling and root planing which is necessary to remove endotoxins previously thought to be deeply embedded into the root surfaces. Whereas other supports a gentle approach, an endotoxin is a weakly adherent surface phenomenon and that power-driven instruments can be used to accomplish definitive root detoxification without overinstrumentation of root and without extensive cementum removal.[3] Scaling and root planing performed with curettes and ultrasonic instrumentation induce several morphological changes such as smear layer and irregular surface with grooves on the root surface.[4]

Root surface treatment can be improved by magnification and illumination besides lasers and endoscope.[5] Commonly used magnification tools in periodontal practice are magnifying loupes (ML) and dental operating microscope (DOM).

Limited data are available in the literature regarding the efficacy of SRP using magnification also there are contradictory results when comparing hand instrumentation with ultrasonic instrumentation. Currently, no studies indicate whether magnification can enhance the effectiveness of periodontal calculus removal. Hence, the present research was undertaken to evaluate the root surface characteristics following root planing with hand-and power-driven instruments using magnifying tools based on the results of scanning electron microscopy (SEM) of the root surface.

Aim and objectives

The aim of this study was to compare the manual as well as ultrasonic instrumentation under magnification.

The objectives were

  1. To evaluate the root surface roughness and loss of tooth substance by root planing with manual and ultrasonic instrumentation under magnification
  2. To evaluate the presence of smear layer and opening of dentinal tubules by root planing with manual and ultrasonic instrumentation under magnification
  3. To compare the roughness and loss of tooth substance, presence of smear layer, and opening of dentinal tubules between manual and ultrasonic instrumentation using magnification.



  Materials and Methods Top


Collection and storage of teeth

The teeth selected for study were extracted from patients suffering from generalized chronic severe periodontitis and with hopeless prognosis from the outpatient department of the institute. The teeth were then washed with distilled water and treated with 2% sodium hypochlorite solution, and then stored in normal saline to avoid dehydration until further study.

Preparation of teeth

A total of 30 single-rooted teeth were used in this study and equally divided into six groups with the following inclusion and exclusion criteria.

Inclusion criteria

  1. Chronic periodontitis with more than 5 mm attachment loss
  2. Radiographic evidence of advanced periodontal destruction.


Exclusion criteria

  1. Teeth with wasting diseases or cervical restorations
  2. Carious or endodontically involved teeth
  3. Periapical lesion
  4. History of SRP in the previous 6 months.


Group 1a: SRP was performed by hand instruments with sharp Gracey curettes (Hu-Friedy) without using any magnification device (unaided).

Group 1b: SRP was performed by hand instruments with sharp Gracey Curettes (Hu-Friedy) with the help of magnification loupe (ML) of magnification ×2.5 (Max View Loupes).

Group 1c: SRP was performed by hand instruments with sharp Gracey Curettes (Hu-Friedy) with DOM of magnification ×1.0 (AAOM-20/I).

Group 2a: SRP was performed by piezo ultrasonic scaler (EMS, Piezon) at 20,000 Hz unaided.

Group 2b: SRP was performed by piezo ultrasonic scaler (EMS, Piezon) at 20,000 Hz with the help of ML of magnification ×2.5 (Max View Loupes).

Group 2c: SRP performed by piezo ultrasonic scaler (EMS, Piezon) at 20,000 Hz with the help of DOM of magnification ×1.0 (AAOM-20/I).

After instrumentation, specimen were prepared for SEM study to compare the roughness and loss of tooth substance index (RLTSI),[6] presence or absence of smear layer, debris, and the opening of dentinal tubules.[7] The SEM photomicrographs at ×100 were used to compare the RLTSI and ×3500 to compare the presence or absence of smear layer, debris, and the opening of dentinal tubules. The SEM analysis was scored blindly by an independent investigator to eliminate bias.


  Results Top


Group 1

Measurement of surface roughness:

The SEM analysis shows definitely corrugated local areas where the cementum may be completely removed, although most of the cementum is still present for the unaided group under ×100. Whereas SEM analysis for loupes and surgical microscope shows even surface with slight roughness and no loss of tooth substance at ×100 [Table 1].
Table 1: Roughness and loss of tooth substance index for manual instrumentation

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Group 1a

The SEM analysis at ×100 shows wide instrumentation marks and loss of tooth substance.[Figure 1]a and presence of thick smear layer and no opening of dentinal tubules at ×3000 [Figure 1]d.
Figure 1: (a) Scanning electron microscopy photomicrograph at ×100 Manual instrumentation-unaided vision. (b) Scanning electron microscopy photomicrograph at ×100 Manual instrumentation-magnifying loupes. (c) Scanning electron microscopy photomicrograph at ×100 Manual instrumentation– surgical operating microscope. (d) Scanning electron microscopy photomicrograph at ×3000 Manual instrumentation-unaided vision. (e) Scanning electron microscopy photomicrograph at × 3000 Manual instrumentation-magnifying loupes. (f) Scanning electron microscopy photomicrograph at ×3000 Manual instrumentation– surgical operating microscope

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Group 1b

The SEM analysis at ×100 shows instrumentation marks and loss of tooth substance [Figure 1]b and presence of smear layer and no opening of dentinal tubules at ×3000 [Figure 1]e.

Group 1c

The SEM analysis at ×100 shows even root surface with slight roughness in local areas confined to cementum [Figure 1]c and the presence of smear layer and no opening of dentinal tubules at ×3000 [Figure 1]f.

Group 2

Measurement of surface roughness

SEM analysis shows slightly roughened or corrugated local areas confined to cementum at ×100 [Table 2].
Table 2: Roughness and loss of tooth substance index for ultrasonic instrumentation

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Group 2a

The SEM analysis at ×100 shows smooth, clean root surface, and slight loss of tooth substance [Figure 2]a, and presence of smear layer and no opening of dentinal tubules at ×3000 [Figure 2]d.
Figure 2: (a) Scanning electron microscopy photomicrograph at ×100 Ultrasonic instrumentation– unaided. (b) Scanning electron microscopy photomicrograph at ×100 Ultrasonic instrumentation– magnifying loupe. (c) Scanning electron microscopy photomicrograph at ×100 Ultrasonic instrumentation– surgical operating microscope. (d) Scanning electron microscopy photomicrograph at ×3000 Ultrasonic instrumentation– unaided. (e) Scanning electron microscopy photomicrograph at ×3000 Ultrasonic instrumentation– magnifying loupe. (f) Scanning electron microscopy photomicrograph at ×3000 Ultrasonic instrumentation– surgical operating microscope

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Group 2b

The SEM analysis at ×100 shows instrumentation marks and loss of tooth substance [Figure 2]b and presence of smear layer with visible debris and no opening of dentinal tubules at ×3000 [Figure 2]e.

Group 2c

The SEM analysis at ×100 shows smooth and clean root surface [Figure 2]c and presence of smear layer with visible debris and no opening of dentinal tubules at ×3000 [Figure 2]f.

All observations were tabulated by a single observer and were subjected to statistical analysis using KruskalWalli's Analysis of variance and Mann–Whitney's test. The mean RLTSI scores for the manual instrumentation performed under unaided, loupe, and surgical microscope were 1.8, 1, and 1, respectively [Table 3]. The mean scores for the power-driven instrumentation performed under unaided, loupe, and surgical microscope were 1.2, 1.2, and 1, respectively [Table 3]. Statistically significant (P < 0.05) difference was found when root planing was performed by hand instrumentation under DOM when compared to unaided vision.
Table 3: Comparison between manual and ultrasonic instrumentation for roughness and loss of tooth substance

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On comparing between manual and ultrasonic instrumentation for roughness and loss of tooth substance for all three groups, i.e., unaided, loupes, and surgical microscope the results were statistically nonsignificant (P > 0.05) [Table 3] and [Figure 3].
Figure 3: Comparison between manual and ultrasonic instrumentation for roughness and loss of tooth substance

Click here to view



  Discussion Top


In the present study, the effect of magnification on the root surface instrumentation was evaluated by in vitro method for the purpose of standardization. This is difficult to achieve in vivo due to variations inaccessibility. The use of SEM can eliminate drawbacks associated with other techniques of examining root surfaces. Scanning electron microscope combines resolution with great depth of focus.[8],[9],[10]

On comparing manual with ultrasonic instrumentation by unaided vision, loupes, and surgical operating microscope, the roughness and loss of tooth substance index showed a statistically nonsignificant difference between two groups which indicates both manual and ultrasonic instrumentation show similar efficacy in terms of root surface smoothness. The findings of this study are similar to that of Drisko[11] who found similar results on comparing manual and ultrasonic instrumentation. There was more roughness and loss of tooth substance seen with manual instrumentation under unaided eye compared to ultrasonic instrumentation. Similarly, Ritz[12] and Dragoo[13] have also reported least tooth substance loss with ultrasonic instrumentation.

Ideally, scaling and root planing procedures should leave smooth root surfaces relatively free of smear layer and any associated calculus, bacteria, or endotoxin-contaminated root cementum.[14] In the present study, the root surface was smooth and clean with slight localized roughness when root planing was performed by either hand instrumentation or ultrasonic instrumentation done under surgical microscope which is in accordance with the Belcher,[15] Kotschy,[2] and Mamoun J[5] who emphasized the importance of the surgical operating microscope in definitive removal of calculus and improved smoothness of the root.

In the ultrasonic group, no statistically significant difference was found when comparing the root surface prepared under surgical operating microscope, loupe, or unaided vision even though it may be considered that the water cooling system in the ultrasonics can blur the operators view through the DOM.

Whereas under magnification, both manual as well as ultrasonic instrumentation were similar in surface characteristics which show magnification and illumination improve the visual acuity, thereby reducing force for the removal of calculus and enhances effectiveness of SRP by causing less abrasion and gauging of the root surface.

Instrumentation creates a layer of organic and mineralized debris known as the smear layer on the surface of the roots and occludes the dentinal tubules.[16] The smear layer is a layer of microcrystalline and organic particle debris, appears on the surface of teeth that have undergone instrumentation. The presence of smear layer after instrumentation may act as a physical barrier between the root surface and periodontal tissues.[17] Root conditioning has been proposed as a promising procedure for smear layer removal.[18] In the present study, smear layer was present in all the groups and no opening of dentinal tubules was present which is in accordance with the SEM study done by Aspriello SD,[4] which showed that curettes produced a compact and thick multilayered smear layer, while the morphology of the root surfaces after ultrasonic scaler treatment appearing irregular with few grooves and a thin smear layer.

The dentinal tubules were not exposed in any groups as no effort was made to remove the cementum to expose the underlying dentin during SRP. Cementum removal has been deemed generally unnecessary as it is stated that endotoxin is a superficial entity which is loosely adherent.[19]

Various factors such as instrument type, applied forces, time of instrumentation, and operator experience in the use of magnifying tools influence the results when evaluating manual and ultrasonic instrumentation under magnification. The use of surgical operating microscope can be cumbersome, and it may require long adjustment period for clinical proficiency. Further, loupes can be uncomfortable for the operator due to increased weight of the lens, eyestrain, and fatigue.[20] In our study, the intergroup comparisons between manual and ultrasonic instrumentation did not show any statistically significant results, which could be due to the small sample size. However, the surgical operating microscope had the lowest mean score for the index. Hence, according to this study, surgical operating microscope proved to be the best in all respects.


  Conclusions Top


Ultrasonic instrumentation proved to be better as compared to manual instrumentation when surface roughness and loss of tooth substance is compared. DOM proved to be the best aid when root smoothness is considered, suggesting the superiority of surgical operating microscope in the treatment of root surfaces. Further, how much optical magnification influence the outcome of periodontal therapy is required to be seen by conducting this study on patients with wider parameters and long-term follow-up, as in vitro study cannot be directly related to the clinical situation.

Acknowledgments

We are grateful to Dr. AK Sikder, Associate Director, High Energy material Research Laboratory for his valuable help in making the SEM photographs of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lindhe J, Nyman S, Karring T. Scaling and root planing in shallow pockets. J Clin Periodontol 1982;9:415-8.  Back to cited text no. 1
    
2.
Kotschy P. Optimal root cleaning and microinvasive periodontal pocket surgery with microscope controlled glass bead blasting. Int J Microdent 2010;2:48-55.  Back to cited text no. 2
    
3.
Drisko CH. Root instrumentation. Power-driven versus manual scalers, which one? Dent Clin North Am 1998;42:229-44.  Back to cited text no. 3
    
4.
Aspriello SD, Piemontese M, Levrini L, Sauro S. Ultramorphology of the root surface subsequent to hand-ultrasonic simultaneous instrumentation during non-surgical periodontal treatments: An in vitro study. J Appl Oral Sci 2011;19:74-81.  Back to cited text no. 4
    
5.
Mamoun J. Use of high-magnification loupes or surgical operating microscope when performing prophylaxes, scaling or root planing procedures. N Y State Dent J 2013;79:48-52.  Back to cited text no. 5
    
6.
Lie T, Laknes KN. Evaluation of the effect on root surface of air turbine scalers and ultrasonic instrumentation. J Periodontol 1985;56:522-13.  Back to cited text no. 6
    
7.
Dibart S, Capri D, Casavecchia P, Nunn M, Skobe Z. Comparison of the effectiveness of scaling and root planing in vivo using hand vs. rotary instruments. Int J Periodontics Restorative Dent 2004;24:370-7.  Back to cited text no. 7
    
8.
Allen EF, Rhoads RH. Effect of high speed periodontal instruments on tooth surface. J Periodontol 1963;34:352-60.  Back to cited text no. 8
    
9.
Ellman IA. Comparative safety of the rotosonic scaler and the curette. J Periodontol 1964;35:410-7.  Back to cited text no. 9
    
10.
Moskow BS, Bressman E. Cemental response to ultrasonic and hand instrumentation. J Am Dent Assoc 1964;68:698-703.  Back to cited text no. 10
    
11.
Drisko CL. Scaling and root planing without overinstrumentation: Hand versus power-driven scalers. Curr Opin Periodontol 1993;78-88.  Back to cited text no. 11
    
12.
Ritz L, Hefti AF, Rateitschak KH. An in vitro investigation on the loss of root substance in scaling with various instruments. J Clin Periodontol 1991;18:643-7.  Back to cited text no. 12
    
13.
Dragoo MR. A clinical evaluation of hand and ultrasonic instruments on subgingival debridement. 1. With unmodified and modified ultrasonic inserts. Int J Periodontics Restorative Dent 1992;12:310-23.  Back to cited text no. 13
    
14.
Drisko CH. Nonsurgical periodontal therapy. Periodontol 2000 2001;25:77-88.  Back to cited text no. 14
    
15.
Belcher JM. A perspective on periodontal microsurgery. Int J Periodontics Restorative Dent 2001;21:191-6.  Back to cited text no. 15
    
16.
Kawashima H, Sato S, Kishida M, Ito K. A comparison of root surface instrumentation using two piezoelectric ultrasonic scalers and a hand scaler in vivo. J Periodontal Res 2007;42:90-5.  Back to cited text no. 16
    
17.
Hanes P, Polson A, Frederick T. Citric acid treatment of periodontitis-affected cementum. A scanning electron microscopic study. J Clin Periodontol 1991;18:567-75.  Back to cited text no. 17
    
18.
Silva AC, Moura CC, Ferreira JA. Biological effects of a root conditioning treatment on periodontally affected teeth – An in vitro analysis. Braz Dent J 2016;27:2.  Back to cited text no. 18
    
19.
Kwan JY. Enhanced periodontal debridement with the use of micro ultrasonic, periodontal endoscopy. J Calif Dent Assoc 2005;33:241-8.  Back to cited text no. 19
    
20.
Caplan SA. Magnification in dentistry. J Esthet Dent 1990;2:17-21.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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