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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
1689
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.
1690
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.
1691
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
1692
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-
REFERENCES ferent methods to clean titanium abutments. A scan-
˚
1. Ericsson I, Lekholm V, Branemark P-I, Lindhe J, ning electron microscopic study. Clin Oral Implants
Glantz P-O, Nyman S. A clinical evaluation of fixed- Res 1992;3:120-127.
1693
In Vivo Removal of Plaque From a Titanium Surface Volume 78 • Number 9
10. Hallmon WW, Waldrop TC, Meffert RM, Wade BW. 21. Sato S, Kishida M, Ito K. The comparative effect of
A comparative study of the effects of metallic, nonme- ultrasonic scalers on titanium surfaces: An in vitro
tallic and sonic instrumentation on titanium abutment study. J Periodontol 2004;75:1269-1273.
surfaces. Int J Oral Maxillofac Implants 1996;11:96-100. 22. Kawashima H, Sato S, Kishida M, Ito K. A comparison
11. Bain CA, Green S, Bain GB, Price D. Effect of various of root surface instrumentation using two piezoelectric
cleaning devices on dental implants. J Dent Res ultrasonic scalers and hand scalers in vivo. J Peri-
1993;72(Spec. Issue):287(Abstr. 1968). odontal Res 2007;42:90-95.
12. Bain CA. An in vitro and in vivo evaluation of various 23. Kwan JY, Zablotsky MH, Meffert RM. Implant mainte-
implant cleaning instruments. Quintessence Int 1998; nance using a modified instrument. J Dent Hyg 1990;
29:423-427. 64:422-430.
13. Fox SC, Moriarty JD, Kusy RP. The effects of scaling a 24. Gantes BG, Nilveus R. The effects of different hygiene
titanium implant surface with metal and plastic instru- instruments on titanium surfaces. SEM observa-
ments: An in vitro study. J Periodontol 1990;61:485-490. tions. Int J Periodontics Restorative Dent 1991;11:
14. Homiak AW, Cook PA, De Bore J. Effects of hygiene 225-239.
on titanium abutments: A scanning electron micros- 25. Lang NP, Lindhe J. Maintenance of the implant pa-
copy study. J Prosthet Dent 1992;67:364-369. tient. In: Lindhe J, Karring T, Lang NP, eds. Clinical
15. Matarasso S, Quaremba G, Vaia E, Coraggio F, Periodontology and Implant Dentistry, 4th ed. Oxford,
Cafeiero C, Lang NP. Maintenance of implants: An U.K.: Blackwell Munksgaard; 2003:1024-1030.
in vitro study of titanium implant surface modifica- 26. Ruhling A, Koeher T, Kreusch J, Plagmann HC.
¨
tions subsequent to the application of different prophy- Treatment of subgingival implant surfaces with Teflon-
laxis procedures. Clin Oral Implants Res 1996;7:64-72. coated sonic and ultrasonic scaler tips and various
16. Augthun M, Tinshert J, Huber A. In vitro studies on the implant curettes. An in vitro study. Clin Oral Implants
effect of cleaning methods on different implant sur- Res 1994;5:19-29.
faces. J Periodontol 1998;69:857-864. 27. Bailey GM, Gardner JS, Day MH, Kovanda BJ. Implant
17. Rapley JW, Swan RH, Hallmon WW, Mills MP. The surface alteration from nonmetallic ultrasonic tip. J
surface characteristics produced by various oral hy- West Soc Periodontol Periodontal Abstr 1998;46:69-73.
giene instruments and materials on titanium implant 28. Schwarz F, Papanicolau P, Rothamel D, Beck B,
abutment. Int J Oral Maxillofac Implants 1990;5:47-52. Herten M, Becker J. Influence of plaque biofilm re-
18. Mengel R, Buns CE, Mengel C, Flores-de-Jacoby L. An moval on reestablishment of the biocompatibility of
in vitro study of treatment of implant surface with dif- contaminated titanium surfaces. J Biomed Mater Res
ferent instruments. Int J Oral Maxillofac Implants 1998; A 2006;77:437-444.
13:91-96.
19. Orton GS, Steele DL, Wolinsky LE. Dental profes- Correspondence: Dr. Shuichi Sato, Department of Peri-
sional’s role in monitoring and maintenance of tissue- odontology, Nihon University School of Dentistry, 1-8-13,
integrated prostheses. Int J Oral Maxillofac Implants Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8310, Japan.
1989;4:305-310. Fax: 81-3-3219-8349; e-mail: sato-su@dent.nihon-u.ac.jp.
20. Balshi TJ. Hygiene maintenance procedures for
patients treated with tissue integrated prosthesis Submitted December 10, 2006; accepted for publication
(osseointegration). Quintessence Int 1986;17:95-102. March 14, 2007.
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