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Treatment of Titanium Dental Implants With Three Piezoelectric

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					J Periodontol • September 2007




Treatment of Titanium Dental Implants
With Three Piezoelectric Ultrasonic
Scalers: An In Vivo Study
Hideyuki Kawashima,* Shuichi Sato,*† Mamoru Kishida,* Hiroaki Yagi,*
Kazuma Matsumoto,* and Koichi Ito*†


      Background: Dental implants require regular maintenance.
  It is crucial that the instrument used for maintenance be able to
  remove plaque and calculus from the implant surface effec-
  tively and efficiently, while causing minimal damage to its
  circumference. Some ultrasonic scalers may be useful for
  implant maintenance; however, no clinical study has exam-
  ined this. This study evaluated the treatment of titanium im-

                                                                                             P
                                                                                                   laque and calculus that accumu-
  plants with three piezoelectric scalers in vivo.                                                 late on the surface of a dental
      Methods: Fourteen patients underwent implant treatment                                       implant may damage the implant
  in which plaque and calculus were removed from the abut-                                   and lead to pocket formation around the
  ment surfaces with ultrasonic scalers. The abutments were                                  implant.1,2 Therefore, regular professional
  treated with scalers with carbon (VS; N = 7), plastic (PS; N =                             maintenance and preventative oral hy-
  7), or metallic (ES; N = 7) tips. The abutment surface charac-                             giene at home are crucial. Because
  teristics were examined after instrumentation using scanning                               implant circumference may be affected
  electron microscopy. The amount of plaque remaining and                                    by the accumulation of periodontal
  roughness were estimated using a modification of the remain-                                pathogenic bacteria,3 early plaque re-
  ing plaque and calculus score and the modified roughness                                    moval is essential for patients who have
  score, respectively. In addition, the abutment surfaces were                               undergone dental implant surgery.4 Un-
  imaged with a laser profilometer and a laser scanning electron                              fortunately, plaque removal may dam-
  microscope (SEM).                                                                          age the implant surface. Conventional
      Results: The remaining plaque and calculus scores did not                              sonic and ultrasonic scalers cause con-
  differ significantly among the VS, PS, and ES groups. VS and                                siderable changes to implant surfaces.5-7
  PS produced a significantly smoother abutment surface than                                  Therefore, the use of plastic curets,
  ES. The laser SEM three-dimensional images also demon-                                     graphite or nylon-type instruments, rub-
  strated that VS and PS produced smooth abutment surfaces,                                  ber polishing cups, brushes with abrasive
  whereas ES resulted in damaged surfaces.                                                   paste, and air-powder abrasive systems
      Conclusions: VS and PS produced clean, smooth abutment                                 have been recommended.5-20 A new
  surfaces. Piezoelectric scalers with non-metal tips are suitable                           ultrasonic scaler features a changed vi-
  for use in dental implant maintenance. J Periodontol 2007;78:                              bration direction and a tip with a novel
  1689-1694.                                                                                 composition and shape that seems to
                                                                                             reduce the damage caused to implant
  KEY WORDS
                                                                                             and root surfaces.21,22 Although ultra-
  Dental plaque; observation; titanium.                                                      sonic scalers are effective in rapid plaque
                                                                                             removal, they can damage implant sur-
                                                                                             faces.
  * Department of Periodontology, Nihon University School of Dentistry, Tokyo, Japan.
  † Division of Advanced Dental Treatment, Dental Research Center, Nihon University School      The value of ultrasonic scalers in
    of Dentistry.                                                                            implant maintenance remains unclear.
                                                                                             Previous reports suggested that non-
                                                                                             metallic ultrasonic tips or modified ul-
                                                                                             trasonic tips are effective in implant
                                                                                             maintenance;23,24 however, there is no
                                                                                             consensus as to which instrument is the

                                                                                             doi: 10.1902/jop.2007.060496


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In Vivo Removal of Plaque From a Titanium Surface                                                                                Volume 78 • Number 9




                                                                                most appropriate for use on an implant surface. Sato
                                                                                et al.21 reported that an ultrasonic scaler with a non-
                                                                                metal tip was superior to a plastic scaler in removing
                                                                                artificial debris, while minimizing the damage to the
                                                                                implant surface in vitro. Therefore, this study as-
                                                                                sessed the extent to which piezoelectric ultrasonic
                                                                                scalers removed plaque and calculus from dental im-
    Figure 1.
    Outline of the experimental schedule.                                       plants in vivo and the damage caused to the abutment
                                                                                surfaces.

                                                                                               MATERIALS AND METHODS
                                                                                               Fourteen patients (four men and 10
                                                                                               women; aged 47.5 – 9.7 years) under-
                                                                                               went implant treatment (21 implants)
                                                                                               in the mandibular molar region. From
                                                                                               3 to 9 months after the initial surgery,
                                                                                               healing abutments‡ (diameter = 4.5
                                                                                               mm; height = 5 mm) were fixed to each
                                                                                               implant. Two weeks after the second
                                                                                               surgery, the sutures were removed,
                                                                                               and the abutments were changed to a
                                                                                               control abutment. The patients were in-
                                                                                               structed to brush the abutments using
                                                                                               a soft toothbrush. After 1 week, each
                                                                                               abutment was replaced with a test abut-
                                                                                               ment (Fig. 1). Before taking impres-
                                                                                               sions of the upper structures, the test
                                                                                               abutments were treated with ultrasonic
                                                                                               scalers with a carbon§ (VS; N = 7; Fig.
                                                                                               2A), plastici (PS; N = 7; Fig. 2B), or me-
                                                                                               tallic¶ (ES; N = 7; Fig. 2C) tip. The three
    Figure 2.                                                                                  scalers were set at medium power, and a
    The three piezoelectric ultrasonic scalers used: A) VS; B) PS; and C) ES.
                                                                                               single experienced examiner (SS) re-
                                                                                               moved the plaque and calculus for 60
                                                                                               seconds. Instrumentation of the subgin-
                                                                                gival area was performed meticulously to avoid injury
                                                                                to the peri-implant tissue. All patients who partici-
                                                                                pated in the study signed an informed consent state-
                                                                                ment approved by the Nihon University Committee on
                                                                                the Protection of Human Subjects.
                                                                                   The abutments were irrigated with saline, stored in
                                                                                2.5% glutaraldehyde, dehydrated in an ascending
                                                                                ethanol series, processed with a critical point dryer,#
                                                                                and gold-coated with an ion coater.**
                                                                                   The abutment surface characteristics were exam-
                                                                                ined after instrumentation using a scanning electron
                                                                                microscope (SEM). The amounts of remaining plaque
                                                                                and calculus were estimated using the modified re-
                                                                                maining plaque and calculus score developed by
                                                                                Speelman et al.9 The score is ranked from 0 to 5 as
                                                                                follows: 0 = untreated abutments, no pellicle, debris,
                                                                                ‡    Ti-6A1-4V, HL, Steri-Oss, Nobel Biocare, Yorba Linda, CA.
                                                                                §    Vector, Durr Dental, Bietigheim-Bissingen, Germany.
                                                                                              ¨
                                                                                i    Suprasson P-MAX, Satelec Acteon Group, Merignac, France.
    Figure 3.                                                                   ¶    Enac, Osada, Tokyo, Japan.
    Abutment under SEM observation. MPA = mesial proximal area.                 #    HCP-2, Hitachi, Tokyo, Japan.
                                                                                **   JFC-1100, JEOL, Tokyo, Japan.


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J Periodontol • September 2007                                                                    Kawashima, Sato, Kishida, Yagi, Matsumoto, Ito




                                                                                                      third of the treated surface covered
                                                                                                      with thin layers of (a), (b), or (c);
                                                                                                      4 = surface moderately unclean,
                                                                                                      one-third of the treated surface
                                                                                                      covered with thick layers of (a),
                                                                                                      (b), or (c); and 5 = surface very un-
                                                                                                      clean; the surface is clearly rough
                                                                                                      at a low magnification, and thick
                                                                                                      calculus is present.
                                                                                                         The surface alterations were
                                                                                                      evaluated using the modified rough-
                                                                                                      ness score developed by Hallmon
                                                                                                      et al.10 and determined by three
                                                                                                      masked investigators. The surface
                                                                                                      alterations were scored as follows:
                                                                                                      0 = smooth, comparable to un-
                                                                                                      treatedtitaniumsurfaces;1= slightly
                                                                                                      rough; 2 = moderately rough; and
                                                                                                      3 = extremely rough.
                                                                                                         SEM images at magnifications
 Figure 4.                                                                                            ·500 and ·1,000 were evaluated.
 SEM images: A) VS; B) PS; C) ES; and D) control. All of the scalers removed the visible plaque
                                                                                                      The mesial surface of the apical
 successfully. A and B show no damage to the abutments, whereas C shows some damage to the
 abutments; D shows plaque accumulation. (Original magnification ·500.)                                third of the healing abutments was
                                                                                                      observed randomly at five points
                                                                                                      (Fig. 3). The SEM images of the
                                                                                                      abutments were scored by the
                                                                                                      three masked examiners. If there
                                                                                                      were differences between the ex-
                                                                                                      aminers, the results were discussed
                                                                                                      until agreement was reached.
                                                                                                         Three-dimensional (3D) surface
                                                                                                      images were obtained using a la-
                                                                                                      ser SEM.††
                                                                                                      Statistical Analysis
                                                                                                      All data are presented as mean –
                                                                                                      SD. The data were analyzed using
                                                                                                      Kruskal-Wallis and Bonferroni tests.
                                                                                                      A significance level of P <0.05 was
                                                                                                      assumed for all analyses. A statis-
                                                                                                      tical program‡‡ was used for all
                                                                                                      analyses.

                                                                                                     RESULTS
                                                                                                     The abutments treated with the
  Figure 5.                                                                                          VS and PS had essentially clean
  SEM images: A) VS; B) PS; C) ES; and D) control. (Original magnification ·1,000.)                   and smooth surfaces. No calculus
                                                                                                     was observed, although some
                                                                                                     small particles of amorphous ma-
calculus, or bacteria; 1 = clean surface, some small                          terial were seen (Figs. 4A, 4B, 5A, and 5B). The abut-
particles of amorphous material, no visible calculus,                         ments treated with the ES also had clean surfaces with
some spread bacteria or bacteria colonies; 2 = rela-                          no calculus. Some irregularities and defects were ob-
tively clean surface, less than one-third of the treated                      served (Figs. 4C and 5C). The controls showed plaque
surface covered with thin layers of (a) amorphous ma-                         accumulation (Figs. 4D and 5D).
terial, (b) calculus, smoothened or not, or (c) bacterial                     †† ERA-8800FE, ELIONIX, Tokyo, Japan.
colonies; 3 = surface slightly unclean, more than one-                        ‡‡ SPSS Base 10.0J, SPSS Japan, Tokyo, Japan.


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In Vivo Removal of Plaque From a Titanium Surface                                                      Volume 78 • Number 9




     The modified remaining plaque and calculus                  nium implant surfaces effectively and efficiently.23,24 In
  scores differed significantly when the VS, PS, and             this study, the titanium surfaces were cleaned thor-
  ES groups were compared to controls. However, no              oughly with no damage after ultrasonic debridement
  significant differences were observed among the VS,            using a carbon or plastic tip in vivo.
  PS, and ES groups (Fig. 6).                                       The shape and composition of the scaler tip may
     The surface roughness did not differ between the VS        be factors in plaque removal. Sato et al.21 compared
  and PS groups, whereas the ES group had significantly          the effectiveness of two ultrasonic scalers at removing
  rougher surfaces (Fig. 7).                                    artificial debris from titanium surfaces. The investiga-
     The laser SEM 3D surface images showed that VS             tors hypothesized that the probe type would be a de-
  and PS produced smooth surfaces similar to a pristine         terminant in the effective removal of debris from the
  abutment, whereas ES produced damaged surfaces                simulated subgingival area of a dental implant. How-
  with grooves (Fig. 8).                                        ever, we did not observe any difference in plaque
                                                                removal that could be attributed to the shape or com-
                                                                position of the scaler tip. All of the implant sulci mea-
  DISCUSSION
                                                                sured <3 mm (data not shown). Therefore, all of the
  We compared the surface characteristics of titanium           instruments appeared able to reach the subgingival
  abutments following treatment with three different            area, regardless of the shape or composition of the
  piezoelectric ultrasonic scalers. All three instruments       tip. In general, areas with probing depths that do not
  successfully removed plaque from the abutment sur-            exceed 3 mm should not undergo therapeutic mea-
  faces. The advantage of using ultrasonic instruments          sures.25 Instrumentation in the subgingival area
  is that they can remove plaque and calculus from tita-        should be performed meticulously. All instrumenta-
                                                                tion removed the plaque completely after treatment
                                                                for 60 seconds by one experienced examiner. How-
                                                                ever, the instrumentation could not be standardized
                                                                because this was an in vivo study. Inconsistencies in
                                                                instrumentation among the patients in our study
                                                                might have affected the results.
                                                                    Speelman et al.9 reported that no scaling methods
                                                                created clean titanium surfaces. However, their sub-
                                                                jects were dogs, and the investigators allowed plaque
                                                                to accumulate for 16 weeks, after which some deposits
                                                                appeared to have mineralized. In our study, the quan-
                                                                tity and quality of plaque accumulation on the healing
                                                                abutments varied among individuals. Furthermore, as
                                                                an ethical consideration, we instructed patients to
                                                                brush around healing abutments using soft tooth-
    Figure 6.
    The modified remaining plaque and calculus scores for each   brushes after their sutures were removed. As a result,
    instrument tested. *P <0.05.                                our study focused on the subgingival mesial proximal
                                                                area to avoid the effect of brushing.
                                                                    In vitro studies showed that instruments used to
                                                                clean teeth caused varying degrees of damage to im-
                                                                plant surfaces.9-17 Sonic and ultrasonic scalers with
                                                                metal tips caused fairly substantial changes to im-
                                                                plant surfaces.5-7 Scalers with Teflon-coated, plastic,
                                                                or carbon tips caused minimal damage to implant sur-
                                                                faces.26,27 Schwarz et al.28 evaluated biocompatibil-
                                                                ity after plaque removal from titanium disk surfaces
                                                                using an ultrasonic scaler with a fiber tip. They showed
                                                                that the ultrasonic scaler produced a biocompatible
                                                                titanium surface. In the present study, three piezoelectric
                                                                ultrasonic scalers were used: one with a carbon tip,
                                                                one with a plastic tip, and one with a metallic tip. Ac-
                                                                cording to SEM observations, the metallic tip caused
    Figure 7.                                                   substantial damage to the titanium surfaces, whereas
    The surface roughness scored by each examiner after SEM     the scalers with the carbon and plastic tips caused
    observation. *P <0.05.
                                                                minimal damage. The laser SEM 3D surface images

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J Periodontol • September 2007                                                                 Kawashima, Sato, Kishida, Yagi, Matsumoto, Ito




 Figure 8.
 Three-dimensional laser SEM images: A) VS; B) PS; C) ES; and D) pristine abutment. A and B show smooth surfaces, whereas C shows a roughened
 surface compared to D. Arrows in C indicate the damaged groove.


confirmed these findings. However, roughness (Ra                                   bridge restoration supported by the combination of
and Rz) was not assessed because the curved abut-                                teeth and osseointegrated titanium implants. J Clin
                                                                                 Periodontol 1986;13:307-312.
ment surface was difficult to measure accurately. Fur-
                                                                            2.   Lekholm U, Adell R, Lindhe J, et al. Marginal tissue
thermore, the pressure of the instrumentation applied                            reaction at osseointegrated titanium fixtures. (2). A
to the abutments was inconstant and may have af-                                 cross-sectional retrospective study. Int J Oral Maxillofac
fected the amount of damage caused to the implant                                Surg 1986;15:53-61.
surfaces.                                                                   3.   Ericsson I, Berglundh T, Marinello C, Liljenberg B,
                                                                                 Lindhe J. Longstanding plaque and gingivitis at im-
   The limitations of this study included the small sam-
                                                                                 plants and teeth in the dog. Clin Oral Implants Res
ple number and inconsistencies in treatment among                                1992;3:99-103.
the patients. Piezoelectric ultrasonic scalers with                         4.   Quirynen M, van Steenberghe D. Bacterial adhesion to
non-metal tips removed the plaque from titanium im-                              oral implants and assessment of attachment and mar-
plants in vivo, while causing minimal surface damage.                            ginal bone level. Dtsch Zahnarztl Z 1993;48:158-160.
                                                                            5.   Thomson-Neal D, Evans GH, Meffert RM. Effects of
Further studies are required to confirm these findings.
                                                                                 various prophylactic treatments on titanium, sapphire
                                                                                 and hydroxyapatite-coated implants: A SEM study. Int
ACKNOWLEDGMENTS                                                                  J Periodontics Restorative Dent 1989;9:300-311.
The authors are deeply indebted to Prof. Masashi                            6.   Stefani LA. The care and maintenance of the dental
                                                                                 implant patient. J Dent Hyg 1988;62:447, 464-466.
Miyazaki and Dr. Naoshi Hirohata, Department of                             7.   Brough Muzzin KM, Jonson R, Carr P, Daffron P. The
Restorative Dentistry, Nihon University School of Den-                           dental hygienist’s role in the maintenance of osseointe-
tistry, for their technical support. Drs. Kawashima,                             grated dental implants. J Dent Hyg 1988;62:448-453.
Sato, Kishida, Yagi, Matsumoto, and Ito report no con-                      8.   Yukna RA. Optimizing clinical success with implants:
flicts of interest related to this study.                                         Maintenance and care. Compend Suppl 1993;(15):
                                                                                 S554-S561; quiz S565-S566.
                                                                            9.   Speelman JA, Collaert B, Klinge B. Evaluation of dif-
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