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April 27, 2009  Photo: Hu-Friedy Power vs. Manual: Scaling Since its introduction, the ultrasonic scaler has been stealing the spotlight from hand instruments — is it justified? We can all agree: Ultrasonic scalers are here to stay. While there are some people who claim ultrasonics “don’t work for them,” with the right training and equipment, ultrasonics can work for anyone. And, while hand instrumentation remains an important part of an effective scaling combo, it does not make sense clinically or ergonomically for manual scaling to be the primary method for care. The most vocal experts on the merits of power scaling are dental hygienists, many of whom have been able to extend their career longevity by making the switch. One such expert is Renée Marchant-Turner, RDH. “Ultrasonic scaling and other ergonomic equipment saved my own career over 15 years ago,” Marchant-Turner said, which not only freed her up for a longer career in clinical practice, but also prompted her to embrace teaching ultrasonic instrumentation and ergonomic workshops. “Using hand instrumentation is not passe by any means. Using what works best for that patient, that day, with that clinician is variable. [But], the more time spend with ultrasonic instrumentation in an appointment, the less time necessary with hand instrumentation.” For example, while Marchant-Turner no longer needs hand instruments, she does still use them for various areas or reasons, such as with patients who cannot tolerate water at the back of their throats or dealing with the risk of certain airborne diseases. Nancy Miller, RDH, who has been coaching clinicians through her business, Ultraconcepts, since 1992 and now works with Jameson Management Inc., wholeheartedly agrees. “The idea is not to discard one method for the other, but to use them symbiotically throughout the mouth,” Miller said. A hurdle she’s observed, however, is that many clinicians aren’t using ultrasonic equipment as effectively as they could. “They use the ultrasonic [to go] around the whole mouth, then go back and pick up their hand instruments and reinstrument every surface again. This lends itself to less efficiency.” She advocates, instead, for what she calls the “Miller Method.” Finish one quadrant at a time, starting with the thorough use of the ultrasonic. “An ultrasonic is not an excuse to go ‘whipping’ through the mouth and calling it a day,” Miller explained. “All debris needs removal, but after practice with an ultrasonic—just like we did with hand instruments—the average use should be about 90% ultrasonic and 10% hand instrument on a routine continuing care patient.” Both Miller and Marchant-Turner underscored the need for proper training and equipment in order to get the full benefits of ultrasonic instrumentation. Since some technologies can potentially roll or plane over old, tenacious calculus, knowing how to address such hurdles is something that comes with time, training and technique—just like hand instrumentation. When used correctly, ultrasonics can improve the quality of care. “Cavitation and acoustic microstreaming occur in the lavage fluid while using the ultrasonic scaler in a pocket,” Miller said. “There is evidence that this disrupts biofilm and debris, and flushes it away more efficiently than using a hand instrument alone.” One of the most compelling arguments for ultrasonic instrumentation is enhanced ergonomics. “With hand instrumentation the wrist must move forcefully with every stroke,” Marchant-Turner pointed out. “Ultrasonic instrumentation allows for a neutral wrist as long as the proper insert or tips are being used for access to deep, irregular topography.” Other benefits include Ultrasonic instrumentation eliminates the tight, pinching grasp of hand instruments and the need for heavy lateral pressure to activate the action of a hand instrument blade. According to Miller, this leads to a more relaxed grasp and less microtrauma of the finger and hand musculature. When properly used, ultrasonic instrumentation allows for a relaxed neck posture since the arms and hands can be relaxed. According to Bethany Valachi, PT, MS, CEAS, a physical therapist, dental ergonomic consultant, and author of the book, Practice Dentistry Pain-Free: Evidence-based Strategies to Prevent Pain and Extend Your Career, “these ergonomic advantages put ultrasonics in the forefront, in some cases overshadowing manual instruments as artifacts of the past.” Even with the ergonomic emphasis she contends that, “the importance of precision manual scaling in delivering quality dental care cannot be overstated. The effectiveness of quality advanced periodontal instrumentation is often hard to match with an ultrasonic unit.” Patients can benefit too According to Miller, slender working tips on ultrasonic instruments can slide easily into a pocket without much tissue distension. This can be more comfortable for the patient. In addition, the lighter pressure required for ultrasonics won’t aggravate the root surface or periodontal ligament.
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