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Calculus-detection technologiesand their clinical application

GRIT MEISSNER & THOMAS KOCHER

Subgingival calculus surfaces are usually covered

with a layer of unmineralized and metabolically

active bacteria. The essential component of conven-

tional periodontal therapy is the effective removal of

these bacterial deposits from the root surface, along

with calculus deposits, in order to create a biologi-

cally compatible root surface (10, 45, 63).

While numerous clinical studies have documented

the beneficial effects of complete removal of sub-

gingival calculus on the resolution of inflammation

(11, 45, 63), others have found that gingival tissues

adjacent to root surfaces covered with small polished

calculus spots might have a tendency to heal that is

similar to tissues adjacent to thoroughly cleaned,

calculus-free root surfaces (26, 44). Nevertheless,

periodontal destruction is clearly related to the very

presence of calculus, which may extend the range of

damage associated with plaque microorganisms (36,

61, 64).

Calculus is a porous substance that can adsorb a

variety of toxic products and retain significant levels

of endotoxin, which itself can damage tissue (64).

These toxins are located on, not within, periodontally

diseased root surfaces (7, 22, 43). It was therefore

deduced that extensive removal of cementum is not

necessary, and root surfaces should be treated

carefully during periodontal therapy in order to

selectively remove subgingival calculus and biofilm

without removing the underlying cementum.

Subgingival root debridement currently comprises

the systematic treatment of all diseased root surfaces

using hand-sonic and or ultrasonic instruments,followed by tactile control with a periodontal probe,

explorer or curette, until the root surface feels

smooth and clean. However, traditional tactile per-

ception of the subgingival environment without vis-

ible access before and after treatment frequently

lacks sensitivity, specificity and reproducibility, and

thus may lead to the unwanted removal of cemen-

tum, residual calculus, or both (6, 25, 27, 47, 57).

Clinicians are often uncertain about the nature of a

subgingival root surface while performing periodon-

tal instrumentation. The correct evaluation of a

cleaned surface is key to enable thorough and sub-

stance-sparing debridement. To support the clini-

cians decision to either stop or continue therapy, the

past few years have witnessed the development of

several calculus-detection techniques based on dif-

ferent technologies. Current technologies for calculus

identification include detection-only systems (a

miniaturized endoscope, a device based on light

reflection and a laser that activates the tooth surface to

fluoresce) as well as combined calculus-detection and

calculus-removal systems [an ultrasonic oscillation-

based system that analyzes impulses reflected from

the tooth surface, and a system combining erbium-

doped yttrium aluminium garnet (Er:YAG) and diode

lasers] (Tables 1 and 2). The aim of this article was to

provide a critical review of these devices based on

currently available clinical and experimental data.

Detection-only systems

Fiberoptic endoscopy-based technology

The idea to modify a medical endoscope for peri-

odontal use has, to date, been realized in only one

device (Perioscopy; Perioscopy Inc., Oakland, CA,

USA), which was introduced in the year 2000. Peri-

oscopy is a minimally invasive miniature periodontal

endoscope which is inserted into the periodontal

pocket and permits visualization of the root surface

within the subgingival environment at magnifications

of 2448 (Fig. 1). The system consists of a 1 mm,10,000-pixel fiberoptic bundle surrounded by multiple

189

Periodontology 2000, Vol. 55, 2011, 189204

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PERIODONTOLOGY 2000

illumination fibers, a light source, an irrigation sys-

tem and a liquid crystal display monitor. Clinicians

can observe the subgingival root surface, tooth

structure and residual calculus in real time. The

magnified images can be viewed on the monitor in

real time, and images and videos can be captured and

saved in computer files. The endoscope may help to

identify, locate and treat calculus spots during

instrumentation of residual calculus at the time of, or

after, scaling. To be proficient in the endoscopic

technique a training period of at least 8 h is necessary

to learn the procedure and practical experience is

required for up to 4 weeks subsequently (59, 60).

In the first clinical study, nonresponding peri-

odontal sites (n = 44; probing depth 58 mm) were

treated by subgingival root debridement with or

without use of the dental endoscope (5). No signifi-

cant changes regarding pocket depth reduction were

reported in either group, 1 and 3 months after

treatment, compared with baseline. Moreover, the

gingival crevicular fluid flow rate, prostaglandin E2and interleukin-1beta levels decreased without

showing significant differences between the groups.

Additionally, a rather long treatment time, of 45 min

per experimental site, was noted for the Perioscopy

procedure.

In a study evaluating the histologic response to the

removal of calculus and biofilm with the aid of the

dental endoscope (65), a total of 12 teeth from six

patients were extracted 6 months after endoscope-

aided scaling and root planing. Histological evidence

showed formation of a long junctional epithelium,

bone repair and no signs of chronic inflammation.

However, a control group that received scaling and

root planing alone was not included and therefore

the incremental effect attributable to the use of the

endoscope was not determined.

A randomized, controlled, clinical study evaluated

the percentage of residual calculus after tooth

extraction (20) in 100 single-rooted teeth of 15

patients. The teeth were treated by hand- and ultra-

sonic instruments until the root surface was found to

be clean, as assessed by either an explorer or the

periodontal endoscope. After extraction, a higher

percentage of residual calculus covering the root

surface was detected microscopically in the explorer

group than in the endoscope group (D = 2.1%). Thedifference was statistically significant only in deeper

pockets and in interproximal sites (pocket depth

> 6 mm; D = 2.9%) compared with buccal sites(pocket depth > 4 mm; D = 1.3%). A correlation wasfound between shorter treatment time and increasing

experience of the operator for treatment with the

endoscope, a finding confirmed by a companion

study (41). However, the treatment results of the

latter study showed some discrepancies. Out of 24

patients, a total of 70 molars were treated in vivo

either by scaling and root planing only or by scaling

and root planing plus dental endoscopy, followed by

extraction. Overall,1.2% less residual calculus cover-

ing the root surface was found in the endoscopy

group (12.3%) compared with the scaling and root

planing group (13,5%). No differences in residual

calculus were found in deep pockets, furcation areas

or on buccal lingual surfaces. Only interproximalpockets with a depth of < 6 mm had significantly less

residual calculus in the endoscope group compared

with the scaling and root planing group. Thus, at least

for multi-rooted teeth, the beneficial effect of the

endoscope-aided scaling and root planing remains

questionable.

Taken together, only one clinical study to date has

investigated the clinical effects after the application of

fiberoptic technology. No differences were found

regarding pocket depth reduction between scaling and

root planing alone and endoscope-aided scaling and

root planing. Histologic healing, which was assessed

on extracted teeth 6 months after endoscope-aided

scaling and root planing, was not compared with

scaling and root planing alone in a randomized clinical

study. Microscopic analysis of root surfaces after

endoscopy-aided scaling and root planing showed a

Table 1. Automated calculus-detection technologies

Treatment goal Technology Device name

Calculus detection only Fiberoptic endoscopy Perioscopy

Spectro-optical technology Detectar

Autofluorescence Diagnodent

Combined calculus detection and

removal

Ultrasound Perioscan

Laser and autofluorescence Keylaser3

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Meissner & Kocher

Table 2. Studies reviewed in this article

Instrument Reference Design Sample size Method Results

Diagnodent (31) In vitro study 10 teeth, 271 sites Fluorescence was mea-

sured at five teeth and

reproducibility was

tested (at all five teeth)

Effect of root

debridement on

fluorescence was tested

A clean root surface was

indicated with a median

value of 6.2, in contrast to a

median value of 57.7 on

the root where calculus was

found

Not influenced by the fluid

High reproducibility

Fluorescence values after root

debridement were similar to

those for a clean root surface

Diagnodent (17) In vitro study A total of 30 teeth,

For each medium,

10 teeth were

included

Fluorescence was

measured in medium,

air, saline solution

and blood

Significant differences in

fluorescence between calculus

and cementum in all fluids

Air: cementum, 0.4; calculus,

54.1

Saline solution: cementum,

0.4; calculus, 60.7

Blood: cementum, 2.1;

calculus, 39.6

Diagnodent (16) In vitro study A total of 40 teeth;

20 teeth were

included for each

treatment

Hand instrumentation

with and without

Diagnodent. In total,

120 surfaces were

evaluated

Surface area of residual calculus

Multirooted teeth:

hand instrumentation:

0.5 0.48 107 lm2

Diagnodent: 0.27 0.43 107

lm2 (P = 0.02)Single-rooted teeth:

hand instrumentation:

0.19 0.37 107 lm2

Diagnodent:

0.11 0.26 107 lm2

(P = 0.19)

Keylaser 3 (30) In vitro study Twenty teeth

covered with

subgingival calculus

were treated with

an ERL

ERL (140 mJ per pulse,

10 Hz), with a chisel-

shaped glass-fiber tip

(0.4 1.65 mm); waterirrigation (1 ml min)Fluorescence threshold

level of 5 [U] was reduced

at intervals of 1 [U] for

every laser treatment

Threshold 5 [U]; the median

residual calculus was

11 (078)%

Threshold 1 [U]; the median

residual calculus was 0 (026)%

Laser-treated cementum thick-

ness [median, 80 (0250) mm]

Untreated opposite side [med-

ian, 90 (30250) mm] (P < 0.05)

Keylaser 3 (53) Randomized,

single-masked

study

Twelve patients,

each with six

periodont

ally diseased

single-rooted teeth

Three teeth per patient

were treated with an ERL

[ERL1, 100 mJ per pulse;

ERL2, 120 mJ per pulse;

ERL3, 140 mJ per pulse;

10 Hz; water irrigation;

chisel-shaped glass-fiber

tip (0.4 1.65 mm);transmission factor 0.85]

and three teeth per

patient were treated

with the Vector system

or hand instrumentation,

or were untreated

(control)

Histologically, ERL produced

homogeneous and smooth root

surfaces

Calculus was almost selectively

removed, no thermal damage,

no cementum loss, mean

treatment time needed with

the ERL was comparable to that

for hand instrumentation

Hand instrumentation resulted

in significantly higher values for

residual calculus and in more

root surface damage than laser

treatment

191

Calculus-detection technologies

Table 2. (Continued)


Keylaser 3 (55) Randomized

clinical study

Twenty-four peri-

odontally diseased

single-rooted teeth

ERL, water irrigation

[160 mJ per pulse and

chisel-shaped tip

(1.65 0.5 mm);calculated energy density

19.4 J cm2 per pulse;10 Hz] vs. hand

instrumentation

Histologically, calculus was

selectively removed No thermal

damage

Results obtained following

treatment with the ERL were

comparable to those obtained

by hand instruments

Keylaser 3 (56) Randomized,

controlled,

split-mouth

study

Twenty patients,

single-rooted teeth

[n = 407 for laser

treatment (ERL),

n = 383 for UI]

multirooted teeth

(n = 269 for laser

treatment, n = 247

for UI

ERL, water irrigation

[160 mJ per pulse; 10 Hz;

chisel-shaped tip

(1.65 0.5 mm); calcu-lated energy density

136 mJ per pulse; or

chisel-shaped tip

(1.1 0.5 mm); calculatedenergy density 114 mJ

per pulse]

Average treatment time in both

groups was 5 min for

single-rooted teeth and 9 min

for multirooted teeth

All clinical parameters

investigated showed improve-

ment in both groups, which was

significant between baseline

and 6 months post-treatment

Bleeding on probing:

ERL: baseline, 40%; 6 months,

17%

UI: baseline, 46%; 6 months,

15%

Clinical attachment level gain:

ERL: after 3 months, 1.48 0.73;

after 6 months, 1.11 0.59

UI: after 3 months, 1.53 0.67;

after 6 months, 1.11 0.46

There were no statistically

significant differences between

the groups

Keylaser 3 (62) Single masked,

randomized,

controlled,

split-mouth

design study

Twenty patients at

recall visit with at

least two residual

pocket depths of

> 5 mm in each jaw

Treatment either by ERL

[160 mJ per pulse;10 Hz;

water irrigation;

chisel-shaped tips

(0.5 1.1 mm)] or by apiezoelectric ultrasonic

scaler (UI) (Piezon Master

400; EMS, Nyon,

Switzerland)

Clinical and microbiologic

effects at 1 and 4 months

post-treatment were

evaluated

Baseline:

Mean pocket depth: ERL, 6 mm;

UI, 5.8 mm

After 1 month significant differ-

ences:

Mean pocket depth reduction:

ERL, 0.9 mm; UI, 0.5 mm

(P < 0.05)

Mean clinical attachment

level gain: ERL, 0.5 mm; UI,

0.06 mm (P < 0.01)

After 4 months no significant

differences:

Mean pocket depth reduction:

ERL, 1.1 mm; UI, 1.0 mm

Mean clinical attachment level

gain: ERL, 0.6 mm; UI, 0.4 mm

Both treatment modalities

resulted in reduction of subgin-

gival microflora, with no

differences between the groups

The patients preference waslaser instrumentation

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Meissner & Kocher



Keyaser 3 (13) Single-blinded,

randomized,

controlled,

specific quad-

rant design

study

Seventy-two

patients with

periodontal

disease

Treatment per quadrant:

hand instruments

(Gracey curettes

(Hu Friedy), feedback-

controlled ERL (160 mJ

per pulse;10 Hz; water

irrigation; chisel-shaped

tips of 0.5 1.65 and0.5 1.1 mm), sonic

scaler (SONICflexs system

LUX 2003 L; KaVo)

and a piezoelectric

ultrasonic scaler (Piezon

Master 400, EMS)

Bacterial samples were

investigated at baseline,

and at 3 and 6 months

post-treatment

All four treatment modalities

resulted in a significant

reduction of Porphyromonas

gingivalis, Prevotella intermedia,

Tannerella forsythia and

Treponema denticola after

3 months. Laser and sonic

instrumentation failed to

reduce Aggregatibacter

actinomycetemcomitans

significantly

The patients preferencewas UI

Perioscopy (5) Randomized

patient

matched-site

design study

Six patients on

maintenance

therapy, 44 sites

with pocket depth

58 mm

Group A: scaling and root

planing plus explorer

Group B: scaling and root

planing plus Perioscopy

Treatment until root

surface was considered

to be clean

Evaluation of plaque

index, bleeding on prob-

ing, clinical attachment

level after 3 months

Plaque index, bleeding on

probing, clinical attachment

level gain: no significant

differences after 3 months

between the groups

Pocket depth: decrease of

2 mm in both groups, nosignificant differences

Treatment duration unrealistic

for clinical use


clinical and

in vitro study

Fifteen patients, a

total of 100 sites,

Single-rooted teeth

Group A: scaling and

root planing plus

explorer

Group B: scaling and

root planing plus

Perioscopy


surface was considered to

be clean

Tooth extraction

immediately after therapy

Microscopic evaluation of

residual calculus

2.1% more residual calculus in

the explorer group

Statistical significance only in

interproximal sites (pocket

depth > 6 mm; 2.9%)

Treatment duration: endoscope

group showed a significant

decrease of time with

increasing experience of the

operator


clinical and

in vitro study

Twenty-four

patients, a total of

70 molars

Group A: scaling and root

planing plus explorer

Group B: scaling and root

planing plus Perioscopy


surface was considered

to be clean

Tooth extraction immedi-

ately after therapy

Microscopic evaluation

of residual calculus

1.2% more residual calculus in

the explorer group

Statistical significance only in

interproximal sites (pocket

depth < 6 mm; 2.6%)

No differences in residual

calculus in deep pockets, furca-

tion areas or on buccal lingualsurfaces

Treatment duration: endoscope

group showed a significant de-

crease of time with increasing

experience of the operator

193




Perioscopy (65) Clinical and

histological

study

Six patients, a

total of 12 teeth

Scaling and root planing

plus Perioscopy

Tooth extraction

6 months after therapy

Histologic evaluation

No control group

Histologically: formation

of a long junctional epithelium,

evidence of bone repair,

no signs of chronic

inflammation

DetecTar (23) Randomized,

single-masked

study

Eight patients, a

total of 44 teeth

(176 surfaces)

Teeth extracted

immediately after

treatment

Microscopic

evaluation

Group A: no treatment,

calculus detection by

DetecTar

Group B: scaling and

root planing + DetecTar

until teeth were

considered to be clean

Control of the detection:

results after extraction

Group A: n = 96 surfaces;

79.4% sensitivity and 95.1%

specificity

Group B: n = 80 surfaces

(n = 58 initially positive,

n = 22 initially negative)

DetecTar (24) Randomized,

controlled

clinical study

One-hundred

patients with

plaque-associated

gingivitis

Group A (n = 50):

supragingival

debridement + oral

hygiene instruction

and motivation

Group B (n = 50):

supragingival

debridement + oral

hygiene instruction and

motivation + Detectar

Detectar group:

Plaque index (baseline 57.5%,

after 4 weeks 27.1%)

Bleeding on probing

(baseline 19.1%, after

4 weeks 7.1%)

Control group:

Plaque index (baseline 60.5%,

after 4 weeks 41.9%)

Bleeding on probing (baseline

23.1%, after 4 weeks 14.5%)

DetecTar (32) In vitro ran-

domized study

Twenty extracted

periodontally

involved, calculus-

covered teeth

Teeth were scanned:

(a) with different

working tip

angulations of the

fibreoptic (0, 10, 45

or 90)(b) with different ambient

fluids (blood and saline

solution)

Results were compared

with clinical and

histological findings

Specificity:

100% in blood

95-100% for all

angulations in saline

solution

Sensitivity:

Nearly 100% for all

angulations in saline solution

In blood:

100% for 90 angulation89% for 45 angulation

70% for 10 to 0 angulation

Perioscan (39) In vitro study Ten teeth, 200

measurements

Detection results were

compared with visual

findings on calculus

and cementum

surfaces

Calculus and cementum were

distinguishable with a sensitivity

of 88% and a specificity of 76%

Perioscan (38) In vitro study Thirty-four teeth,

1363 measurements



findings, by moving the

instrument tip over the

calculus and cementum

surfaces

Calculus and cementum

were distinguishable with a

sensitivity of 76% and a

specificity of 86%

Perioscan (40) In vitro study Fifty extracted,

periodontally

involved, calculus-

covered teeth

Calculus was removed

stepwise, in order to

determine the discrimi-

native capability

The smallest, recognizable

residual deposits had an average

diameter of 219 mm, an area of

21,600 mm2 and a circumfer-

ence of 748 mm; Sensitivity was

73% and specicity 80%

194

Meissner & Kocher

small benefit only in interproximal sites, in particular

in single-rooted teeth with deep pockets, and in

multirooted teeth with relatively shallow pockets.

Spectro-optical technology

The spectro-optical approach to calculus detection

uses a light-emitting diode and fiberoptic technology,

and is currently used by only one device, the Detec-

Tar (Dentsply Professional, York, PA, USA) (Fig. 2).

The characteristic spectral signature of subgingival

calculus, which is caused by absorption, reflection

and diffraction when irradiated by red light, is sensed

by an optical fiber and converted into an electrical

signal that is analyzed by a computer-processed

algorithm. The DetecTar device comes as a portable

cordless handpiece with a curved periodontal probe

that has millimeter markings to measure pocket

depths. Without any tactile pressure, the subgingival

root surface can be scanned by the instrument. As

soon as calculus is detected, the operator receives the

information on calculus localization by audible and

luminous signals.

Only a few investigations have evaluated spectro-

optical technology as a diagnostic instrument in

periodontology. The ability to detect subgingival

calculus in vitro was tested in 20 freshly extracted

teeth affected by periodontitis, and the results were

compared with clinical and histological findings (32).

In addition, the influence of different working-tip

angulations (0, 10, 45 and 90) of the fiberoptic probeand of different ambient fluids (blood and saline

solution) were studied. The specificity was only

slightly influenced by the type of irrigation fluid,

being 100% in blood and 95-100% in saline solution

for all angulations. The sensitivity in saline solution



Perioscan (37) In vivo

randomized,

clinical study

Sixty-three buccal

subgingival tooth

surfaces

Teeth were scanned

in situ



findings after extraction

Calculus and cementum

were distinguishable with a

sensitivity of 91% and a

specificity of 82%

The positive predictive

value was 0.59 and the

negative predictive value

was 0.97

ERL, Er:YAG laser; UI, ultrasonic instrumentation.

Fig. 1. Endoscopy-based technology. The Perioscopy

(Perioscopy Inc., Oakland, CA, USA) uses a minimally

invasive miniature periodontal endoscope, which is

inserted into the periodontal pocket, to detect calculus.

Fig. 2. Spectro-optical technology. The DetecTar (Dents-

ply Professional, York, PA, USA) uses a light-emitting

diode and fiberoptic technology to detect calculus.

195


was nearly 100% for all angulations. In blood, the

sensitivity decreased with smaller tip angulations

(100% sensitivity with angulation 90, 89% sensitivitywith angulation 45 and 70% sensitivity with angu-lation 100). The combination of saline solution asthe ambient fluid and a working-tip angulation of 90 which, however, cannot be achieved in the

periodontal pocket resulted in the most accurate

measurements.

A recent clinical study sought to determine the

utility of the spectro-optical technology for subgingi-

val calculus removal (23). A total of 44 teeth (176

surfaces) were included in the study. In an untreated

control group, a total of 96 untreated surfaces were

scanned in vivo using the DetecTar. In the treatment

group, treatment was initiated upon obtaining posi-

tive signals from the spectro-optical device, and the

treatment was continued until no signal was elicited.

Clinical calculus findings were documented by visual

and microscopic examination after tooth extraction.

The control group showed a sensitivity of only 79.4%

and a specificity of 95.1%. Of 58 tooth surfaces that

initially showed calculus and which were conse-

quently treated until they tested negative for calculus,

10 (17%) remained partly covered with calculus,

whereas 48 (83%) were completely calculus-free.

Nevertheless, nine (41%) of the 22 surfaces that were

initially identified as calculus-free (and therefore

untreated) did, in fact, harbor calculus. However, the

number of false-negative readings may have been

caused by incomplete surface scanning as a result of

limited access of the instrument and problems with

guiding the instrument. No sensitivity or specificity

data for the treatment group were calculated from

the published results. Additionally, the study only

recorded the clinical presence or absence of subgin-

gival calculus deposits for each surface (without exact

localization on the respective surface), and a highly

heterogeneous group of surfaces, with pocket depths

ranging from 1 to 10 mm, was evaluated. Therefore,

false-negative results may have been caused by an

incomplete scanning process, technological limits of

the device, or a combination of both. These aspects

cannot be discriminated in vivo if the exact location of

the device during scanning is not definitively known.

Altogether, the utility of the spectro-optical

technology for calculus detection has not yet been

thoroughly investigated.

Autofluorescence-based technology

The ability of calculus to emit fluorescent light fol-

lowing irradiation with light of a certain wavelength

enables the detection of calculus, and several in vitro

studies have examined the autofluorescence of dental

root surfaces and calculus (8, 12, 18, 26, 30, 45). Oral

microorganisms and their metabolites (metal-free

porphyrins, metalloporphyrins and other chromato-

phores) are assumed to contain the fluorophores that

are emitted from dental calculus and from carious

lesions (14, 21, 29). Several distinct fluorescence

bands between 570 and 730 nm were identified on

calculus specimens, which could be elicited with light

of wavelength 400420 nm, but could not be found

on clean root surfaces (9). Another study found

characteristic autofluorescence emission peaks for

calculus and dentin caries at 700 and 720 nm,

respectively, which were elicited by light of wave-

lengths 635 and 655 nm, respectively (33). On

surfaces covered by bacterial cells or blood, the

autofluorescence intensity was reduced.

In order to differentiate calculus from the healthy

tooth surface, a fluorescence-ratio method based on

autofluorescence induced by a blue light-emitting

diode of 405 nm has been developed (48). Calculus

and healthy tooth surfaces exposed to light wave-

lengths of 487 and 628685 nm were used to create a

calculus parameter, R, which was selected to define a

relationship between the integrated intensities spe-

cific for calculus and for healthy teeth in the 628 to

685- and the 477 to 497-nm wavelength regions,

respectively. A cut-off threshold of R = 0.2 was able to

distinguish dental calculus from healthy teeth with

100% sensitivity and 100% specificity under various

experimental conditions in vitro.

A diagnostic instrument, based on different auto-

fluorescence intensities after stimulation with red

light, claims to distinguish healthy from carious tooth

substance (Diagnodent; KaVo, Biberach, Germany)

(Fig. 3). An indium gallium arsenide phosphate

(InGaAsP)-based red laser diode (< 1 mW) sends light

with a wavelength of 655 nm through an optical fiber

onto the root surface, which is then induced to

fluoresce. The emitted fluorescent light returning

from the tooth tissue is captured by surrounding

optical fibers and transmitted to an integrated photo

diode, which serves as the fluorescence detector.

Optical effects caused by reflected light and ambient

light are eliminated by a band-pass filter and mod-

ulation of the fluorescent light, respectively. The

device was primarily developed for caries diagnosis

and launched as a stand-alone device about 10 years

ago. Based on a multitude of clinical studies, it is

considered to be a reliable caries detector on occlusal

and smooth surfaces, showing high levels of sensi-

tivity (92.1%) and specificity (100%), a high level of

196

Meissner & Kocher

reproducibility (kappa value: in vitro, 0.9; in vivo,

0.9) and a good interexaminer and intra-examiner

agreement (21, 34, 35, 42, 46, 49, 58).

Later, the device was further refined to enable cal-

culus detection. The fluorescence intensities are

measured, transformed and shown on a digital dis-

play as relative calculus-detection values from 0-99.

According to themanufacturer, values of 40 indicatemineralized deposits, whereas values of between 5

and 40 indicate very small calcified plaque sites (not

further specified) or residual calculus following partial

cleaning, and values of 5 indicate a clean root sur-face. Values indicating calculus are indicated by a

beep with an increasing audiotone frequency as the

display value increases. The manufacturer thus pro-

vides a small-size device, which is claimed to be able

to detect both caries and calculus, and which can be

handled easily with no further training required.

The autofluorescence-based device for calculus

detection has been evaluated only in in vitro studies

so far, with any patient-derived clinical evidence

lacking. Surfaces of extracted periodontally involved

teeth, which were partly covered with calculus and

moistened with saline solution or blood, were scan-

ned using the device (17, 31). The fluorescence

signals detected were compared with visual and

histological findings. The presence of calculus was

significantly correlated with a higher intensity of

fluorescence (17, 31). A median value of 6.2 was

obtained for clean root surfaces and a median value

of 57.7 was obtained for calculus, which was not

influenced by the presence of fluid. Additionally, high

reproducibility for measurements after 6 and 24 h

could be shown (31). The second study found relative

fluorescence values in air (cementum, 0.4; calculus,

54.1), in saline solution (cementum, 0.4; calculus,

60.7) and in blood (cementum, 2.1; calculus, 39.6).

With a cut-off value of 5, sensitivity and specificity in

all three media were 100% (17). Another study sim-

ulated a clinical situation based on a mannequin

model and compared the effectiveness of root-

surface instrumentation when supported by the

application of two different diagnostic instruments

(the autofluorescence-based system vs. a conven-

tional explorer) (16). Forty extracted periodontally

involved teeth (120 surfaces for each diagnostic

group) were treated with conventional Gracey

curettes until this method indicated a clean root

surface. For multirooted teeth, calculus detection

using autofluorescence resulted in a significantly

smaller total area covered with residual calculus than

if diagnostics was based on a conventional explorer.

However, in single-rooted teeth, the two study groups

revealed a comparable amount of residual calculus.

In summary, when used in vitro, the autofluores-

cence-based system could differentiate between cal-

culus and cementum with great reproducibility. In a

preclinical situation, a superior effect of the system

compared with manual use of an explorer could be

shown only on molars. The diagnostic value of the

autofluorescence-based system needs to be assessed

in the clinical setting, and its effect on treatment

outcomes determined.

Combined detection treatmentdevices

Ultrasonic technology

Ultrasonic calculus-detection technology is based on

a conventional piezo-driven ultrasonic scaler and is

similar to the way that one might tap on the rim of a

glass with a spoon to identify cracks acoustically (28,

60). An insert at a conventional dental ultrasound

scaler receives short, weak impulses with a frequency

of about 50 Hz, which make the inserts distal tiposcillate at a frequency that is dependent upon the

surface characteristics. The oscillations are con-

ducted into the piezo-ceramic discs, which transform

the oscillations into voltage. The voltage level repre-

sents the intensity of the tip oscillation, while the

frequency stays the same. The overall signal, con-

sisting of both the impulse stimulus and the impulse

response, is evaluated using a computerized system,

thereby generating information about a given surface

characteristic.

Fig. 3. Autofluorescence-based technology. The Diagno-

dentTM Pen (KaVo, Biberach, Germany) is based on the

detection of different autofluorescence intensities after

stimulation with red light.

197


The ultrasonic device currently available (Perio-

scan; Sirona, Bensheim, Germany) (Fig. 4) providesa detection mode to discriminate between calculus

deposits and clean roots, along with a treatment

mode that allows conventional ultrasonic treatment

at different power levels. When the ultrasonic tip

touches the tooth surface, the detection results are

indicated by a light signal integrated both in the

handpiece and in a display of the table unit (green

indicates cementum and blue indicates calculus).

When calculus is detected, an additional acoustic

signal sounds. The detection mode is only activated

when no scaling treatment is performed. The detec-

tion and treatment modes can be used successively

on the surface of the same tooth. If calculus deposits

are found, the root surface can be treated with a

higher power setting, whereas in the absence of cal-

culus (thus requiring the systematic removal only of

biofilm), instrumentation can be performed at a

lower power setting. A prototype of the ultrasonic

device evaluated the calculus-detection capability

under laboratory conditions both in static tests

(yielding a sensitivity of 75% and a specificity of

82%) and during movements of the probing tip

(yielding a sensitivity of 88% and a specificity of

76%) (38, 39). The detection limit was further eval-

uated by gradually removing calculus from 50 ex-

tracted teeth until the system stopped discriminating

calculus deposits. Diameter, circumference and area

of the smallest recognizable deposit, and of the no

longer recognizable deposit, were measured, and a

cut-off point was determined. It could be demon-

strated that calculus deposits with a diameter of

0.2 mm could still be recognized with a sensitivity of

73% and a specificity of 80% (40).

The only available study involving the clinical

application of this ultrasound tool tested the

accuracy by which calculus was detected (37).

In vivo calculus detection was determined on 63

subgingival surfaces and compared with visual

findings after tooth extraction. A prevalence of

calculus of 22.3% was found on the scanned sur-

faces, and calculus and cementum were discrimi-

nated with a sensitivity of 91% and a specificity of

82%. The positive and negative predictive values

were 0.59 and 0.97, respectively. The combined

application of the calculus-detection mode and

the ultrasonic removal of calculus remain to be

investigated.

To sum up, the combined detection-and-treatment

technology using ultrasound is a promising tool for

minimally invasive debridement (retaining cemen-

tum) and selective calculus removal, as shown by a

study employing an in vivo and ex vivo reconstruc-

tion technique. However, the long-term clinical out-

come has not yet been investigated.

Laser-based technology

The benefit of laser application in nonsurgical peri-

odontal therapy is still a matter of debate among

clinicians (4, 12, 51). Lately, out of a variety of other

types of lasers, the Er:YAG laser has been considered

to be the most promising for periodontal therapy (2,

3, 19). Its ability to ablate soft and hard tissue without

major thermal side effects qualifies the use of this

laser for periodontal therapy, and Er:YAG lasers at

different energy levels have been studied in various

in vitro and clinical trials. Er:YAG lasers are solid-

state lasers that emit pulsed infrared light with a

90% root10% calculus

Fig. 4. Ultrasound-based calculus-

detection technology: Perioscan

(Sirona Dental Systems GmbH,

Bensheim, Germany). The principle

includes a fuzzy-logic-based detec-

tion mode employing ultrasound

feedback analysis and adds a treat-

ment mode to the automated

calculus detection, which uses the

same tip.

198

Meissner & Kocher

wavelength of 2940 nm, which is strongly absorbed

by virtually all biological tissues containing water.

The effect of Er:YAG lasers is based on photoablation.

The light-induced tissue evaporation results in water

release and a concomitant cooling effect on the sur-

rounding tissue. However, when applied to dental

hard tissue, which contains a lower amount of water,

increased thermal effects can occur, and therefore

water irrigation is required (2).

The treatment effect of Er:YAG lasers (Keylaser 1 or

2; Kavo, Biberach, Germany) (Fig. 5) with regard to

calculus removal has been shown to be comparable

to conventional root debridement. No major thermal

damage was found if the laser was applied at lower

energy levels (radiation energy, 50160 mJ) and with

concomitant water irrigation (2, 15, 18, 19, 54). A

number of in vivo and in vitro studies have shown the

potential of Er:YAG lasers to create a biocompatible

root surface by removing the smear layer and lipo-

polysaccharides from the tooth surface, by promoting

the attachment of periodontal ligament fibroblasts

and by decreasing the bacterial load (1, 52, 66). By

contrast, studies have also reported increased tissue

removal, roughened surfaces and a lower yield of

calculus removal compared with hand instrumenta-

tion (3, 15, 18, 19). The effectiveness of calculus

removal seems to be dependent on the irradiation

energy level. However, the application of high energy

levels is also associated with increased and undesir-

able root-substance loss if applied to a healthy tooth

structure (2, 18, 19).

The only commercially available device (Keyla-

ser3TM; KaVo) combines detection and treatment in a

feedback-controlled manner for selective removal of

calculus. The integrated calculus-detection device is

based on a 655-nm InGaAs diode laser for autofluo-

rescence-based calculus detection (described above

as a stand-alone diagnostic tool), whereas a 2940-nm

Er:YAG laser is used for treatment. The Er:YAG laser is

only activated to emit light if a preselected autoflu-

orescence threshold value for the diagnostic laser on

a scale of 099 is exceeded. As soon as the value falls

below the threshold, the Er:YAG laser turns off. This

combination of a diagnostic and a therapeutic laser

was designed to optimize calculus removal while

minimizing the undesired side effects of the Er:YAG

laser.

The feedback-controlled Er:YAG laser was recently

evaluated in in vitro and clinical studies to determine

how different fluorescence-classification thresholds

would influence the extent of calculus and cement

removal. Twenty teeth partly covered with calculus

and irrigated with water were treated from coronal to

apical direction in contact irradiation mode with

pulsed infrared radiation [wavelength of 2.940 mm,

a chisel-shaped glass-fiber application tip (size

0.4 1.65 mm), 140 mJ per pulse, 10 Hz and calcu-lated energy density of 17.2 mJ cm2) (30). The fluo-rescence threshold varied between 5 (recommended

by the manufacturer as the lowest threshold value)

and 1 in order to potentially increase sensitivity. Not

Fig. 5. Laser-based combined detection and treatment

technology. The Keylaser 3 (KaVo, Biberach, Germany)

employs the same detection method depicted in Fig. 3, but

adds a treatment mode to it.

199


surprisingly, the amount of residual calculus de-

pended on the laser fluorescence threshold levels. At

a threshold of 5, the median residual amount of cal-

culus related to the baseline amount of calculus was

11% (minimum, 0%; maximum, 78%), whereas at a

threshold of 1, it was reduced to 0% (minimum, 0%;

maximum, 26%). However, the laser-treated residual

cementum was signicantly thinner (median, 80 lm)than the untreated residual cementum (median, 90 lm;P < 0.05). Thus, by reducing the threshold level to 1, the

sensitivity was increased at the expense of a reduced

specificity, as indicated by the increase of undesired

substance loss.

A different study compared the clinical and histo-

logical effects of conventional hand instrumentation

with fluorescence-controlled Er:YAG laser irradiation

at different device settings (55). Twenty-four peri-

odontally involved single-rooted teeth were treated

in vivo and extracted after therapy. Laser treatment

consisted of fluorescence-controlled Er:YAG laser

irradiation under water irrigation (160 mJ per pulse,

chisel-shaped tip of 1.65 0.5 mm, calculated energydensity 19.4 J cm2 per pulse, 10 Hz). All mesial rootsurfaces were treated in vivo under local anesthesia

until they were considered to be clean. After extraction,

the distal root surfaces were treated in vitro for com-

parison. Hand-instrumented teeth were treated accord-

ingly. Clinically, the use of the Er:YAG laser in vivo

produced homogeneous and nearly smooth root surfaces

without visible traces of the tip. Histologically, calculus

had been selectively removed and no thermal damage

could be observed. The results were comparable to those

seen after the use of hand instruments. The treatments

with the Er:Yag laser and with the hand instruments

were found to be more effective in vitro than in vivo.

Laser treatment also resulted in the removal of an in-

creased amount of cementum in vitro compared with

in vivo, whereas for hand instrumentation the in vitro

and in vivo results were comparable The reason for less

substance removal in vivo was assumed to be caused by

the restaining of the pocket tissue with blood and sulcus

fluid, which may have influenced the autofluorescence of

the dental hard tissue in vivo. However, by contrast,

different media (including blood and saline solution) did

not influence the autofluorescence intensity in vitro (17).

Another clinical study compared the clinical

benefit of autofluorescence-controlled Er:YAG laser

radiation with that of a special ultrasonic device

with vertical vibrations of the working tip (Vec-

torTM; Durr, Bietigheim-Bissingen, Germany), and

with hand instrumentation (53). Seventy-two single-

rooted teeth that were scheduled for extraction from

12 patients were randomly treated by the laser (at one

of three energy levels: 100, 120 or 140 mJ per pulse,

10 Hz), the Vector ultrasound system, conventional

hand instruments, or remained untreated. Teeth

were instrumented in vivo under local anesthesia until

they were considered to be clean and then immediately

extracted for analysis. The ultrasound system left sig-

nificantly smaller areas of residual calculus than the two

other therapies, but needed a significantly longer

instrumentation time than the laser and the hand

instruments. However, treatment with the feedback-

controlled Er:YAG laser still resulted in significantly less

residual calculus and less root-surface alterations than

hand instrumentation.

A clinical study compared the microbiological

effects of the Er:YAG laser, hand instruments, sonic

scalers and ultrasonic scalers (13). The controlled,

randomized, single-blinded clinical trial included 72

periodontal patients who had at least one site per

quadrant with a pocket depth of > 4 mm, bleeding

on probing and bone loss of at least 33%. The four

quadrants per patient were randomly assigned to one

of the following four debridement modalities: hand

instruments, a feedback-controlled Er:YAG laser

(Keylaser3; 160 mJ per pulse, 10 Hz, water irrigation,

chisel-shaped tips of 0.5 1.65 and 0.5 1.1 mm), asonic scaler (SONICflexs system LUX 2003 L; KaVo)

or a piezoelectric ultrasonic scaler (Piezon Master

400; EMS, Nyon, Switzerland). Subgingival plaque

samples were obtained at baseline and at 3 and

6 months postoperatively. All four treatments re-

sulted in a significant reduction in the amounts of

Porphyromonas gingivalis, Prevotella intermedia,

Tannerella forsythia and Treponema denticola after

3 months. Laser and sonic instrumentation failed to

significantly reduce the amount of Aggregatibacter

actinomycetemcomitans. Six months post-treatment,

the amount of test bacteria had increased in all study

groups.

Another set of clinical trials compared the clinical

outcome of periodontal treatment by a feedback-

controlled Er:YAG laser or ultrasonic instrumenta-

tion (56). Single-rooted and multirooted teeth with

pocket depths of > 4 mm were randomly treated in

a split-mouth design either by a feedback-controlled

Er:YAG laser (160 mJ per pulse, 10 Hz, chisel-shaped

tip of 1.65 0.5 mm, calculated energy density136 mJ per pulse; or chisel-shaped tip of 1.1 0.5 mm, calculated energy density 114 mJ per pulse)

or by an ultrasonic device (Cavitron Select; Dents-

ply, Konstanz, Germany) (56). At baseline, and 3 and

6 months post-treatment, plaque index, bleeding on

probing, pocket depth, gingival recession and clini-

cal attachment level were measured at six sites per

200

Meissner & Kocher

tooth. Deep pockets showed a tendency to experi-

ence more gingival recession, to gain more clinical

attachment level and to retain more residual pocket

depth compared with moderately deep pockets.

Bleeding on probing and clinical attachment level

improved significantly in both treatment groups

after 6 months compared with baseline. However,

statistically significant differences could not be

observed between the two types of treatment, sug-

gesting that treatment with the Er:YAG laser was

comparable with, but probably not superior to,

ultrasonic instrumentation (56). This conclusion is

in agreement with a subsequent clinical study that

compared the microbiological and short-term clini-

cal effects after Er:YAG laser debridement vs. ultra-

sonic treatment (62). Twenty patients with at least

two pockets with a depth of > 5 mm in each jaw

were included in the study. The pockets were ran-

domized to receive either feedback-controlled

Er:YAG laser treatment (160 mJ per pulse, 10 Hz,

chisel-shaped tip of 1.1 0.5 mm, water irrigation)or piezoelectric ultrasonic treatment (Piezon Master

400; EMS). Clinical attachment level gain and pocket

depth reduction after 1 month were significantly

higher in the laser group (mean pocket depth

reduction, 0.9 mm; mean clinical attachment level

gain, 0.5 mm) than in the ultrasonic group [mean

pocket depth reduction, 0.5 mm (P < 0.05); mean

clinical attachment level gain, 0.06 mm (P < 0.01)],

whereas 4 months after retreatment, no significant

differences were detected between the two treat-

ment modalities (mean pocket depth reduction:

laser, 1.1 mm; ultrasonic, 1.0 mm; and mean clinical

attachment level gain: laser, 0.6 mm; ultrasonic,

0.4 mm). Both treatment modalities yielded a simi-

lar reduction of the subgingival microflora after

4 months.

In conclusion, clinical and histological studies have

shown that laser-based detection and treatment of

calculus can effectively remove subgingival calculus

and preserve root substance. However, the results

were comparable with hand and ultrasonic debride-

ment, and controlled long-term clinical studies are

lacking.

Summary

A number of different technologies have been

incorporated into dental devices for the purpose of

identifying and selectively removing dental calculus.

Some of these new approaches for calculus removal

show promising results under optimum in vitro

conditions. Histological and microscopic findings

after in vivo use point to the potential for some of

these technologies to support or replace conventional

subgingival scaling. Published studies evaluating

clinical parameters, however, exist only for the

ultrasound- and laser-based devices, which combine

calculus detection and treatment. Moreover, con-

trolled randomized clinical trials are lacking for all

currently commercially available dental devices that

are used to identify and selectively remove dental

calculus.

All studies starting out with teeth treated in vivo

and then investigated after extraction have the same

problem in common, namely that clinical parameters

such as pocket depth, gingival recession and clinical

attachment level are assumed to be associated with a

comparable prevalence of calculus. This might not

always be the case and therefore a bias of uncertain

magnitude is introduced, especially if different stud-

ies and methods are compared. Moreover, it is

questionable whether the claimed improvement in

calculus detection in fact has resulted in selective

calculus removal and a concomitant preservation of

cementum. Without histologic examination, it is

impossible to decide whether cementum has actually

also been removed (50). In the case of the laser-based

detection and treatment device, for instance, histo-

logical analysis unveiled that the thorough removal of

calculus also resulted in an unwanted increase in the

amount of cementum removed.

A common problem of the stand-alone diagnostic

devices is that the application of these instruments

requires the systematic scanning of the entire sub-

gingival tooth surface, and, in the case of positive

calculus detection, the detected calculus has to be

located using the therapeutic scaling instrument.

Identifying the exact location of the calculus may be

difficult, thus potentially leading to over-treatment or

under-treatment. This problem relates to the skills of

the clinician rather than to features of the instru-

ment. The combined detection and treatment

instruments aim to overcome this problem.

The influence of operator skills on the outcome

variable has been shown previously and should

always be considered when evaluating the utility of a

particular method of scaling (8). Two different sce-

narios are conceivable: an experienced and trained

clinician will manage more easily the application of

advanced diagnostic procedures, such as the endos-

copy-based system, and thus obtain better results

than an inexperienced operator. Alternatively, a cli-

nician who is highly experienced in traditional scal-

ing methods may achieve less additional benefit by

201


using supportive detection devices than a beginner or

a modestly skilled clinician, who may overcome a

lack of manual dexterity by using a supportive diag-

nostic system. These aspects have not been ad-

dressed in the published literature.

The fiberoptic detection technology shows poten-

tial to be a helpful tool in periodontal therapy, but

needs to be studied in clinical studies in direct

comparison with established scaling techniques. The

fiberoptic device currently available is somewhat

difficult to handle and requires additional time and

skills of the operator, especially when used simulta-

neously with scaling and root planing.

Data on the clinical utility of a spectro-optical

device for scaling and root planing are scarce.

Promising results were shown regarding the sensi-

tivity and specificity of calculus detection in vitro.

Whether or not a spectro-optical device is useful for

calculus detection needs to be evaluated in a clinical

setting. To our knowledge, a spectro-optical device is

not currently available for dental use.

To date, published data on autofluorescence-based

detection technology are only available from in vitro

and mannequin model studies. The autofluores-

cence-based system was found to be superior to

scaling and root planing alone only for multirooted

teeth, possibly because of their complicated root

configuration, which makes conventional diagnostics

more difficult. Calculus removal in single-rooted

teeth yielded similar results with and without the use

of the autofluorescence-based system. Its effective-

ness in clinical situations and its impact on clinical

parameters remains to be investigated.

It may be easy for clinicians to learn how to use

and apply the ultrasonic-driven combined detection

and treatment device because it is similar to the

familiar scaling technique. To provide reliable data

on the benefits of the device, clinical studies are

necessary to investigate changes in pocket depth,

clinical attachment level, bleeding on probing and

occurrence of hypersensitivity after treatment com-

pared with conventional methods.

The laser-based calculus-detection and treatment

technology has shown promising results with respect

to histology and certain clinical parameters in one

study, which, however, was limited to single-rooted

teeth. As the total number of cases in the published

literature is still small, additional studies are neces-

sary to evaluate the clinical benefit of this technology.

Taken together, despite promising laboratory

research results, the new technology-assisted

periodontal treatments have yet to show clinical

superiority in comparison with conventional scaling.

Clinical studies are necessary to assess if the use of

these devices can improve long-term treatment out-

come, with consequences of smaller residual probing

depth, a reduced need for periodontal surgery and

less hypersensitivity after treatment.

Acknowledgment

The work on Perioscan was supported by grants from

the Bundesministerium fur Bildung und Forschung

(BMBF 01 EZ 0025, BMBF 01 EZ 0026) and

from Sirona, Bensheim, Germany. T. Kocher and

G. Meissner have served as consultants to Sirona.

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