Ultrasonic instruments and antimicrobial agents in supportive periodontal treatment and retreatment of recurrent or refractory periodontitis

Ultrasonic debridement has been shown to successfully alter the etiology of periodontal disease by the removal of plaque, calculus and endotoxins from the subgingival area. Very few studies in the literature (38, 49) document the clinical outcomes of using ultrasonic instruments equipped with either standard or microultrasonic tips for supportive periodontal treatment; however, current evidence suggests that microultrasonic instrumentation may be successfully used for periodontal debridement and has many advantages over hand instruments and older, more traditional ultrasonic tips. Using curets or ultrasonic instruments to intentionally remove cementum and endotoxin appears to be unjustified given current information and might even be considered overtreatment. The availability of smaller diameter periodontal type tips has revolutionized the procedure referred to as scaling and root planing, creating a paradigm shift to a less aggressive procedure described as periodontal debridement (202). The aim of periodontal debridement is to treat the gingival and periodontal inflammation through mechanical removal of tooth and root surface irritants to the extent that the adjacent soft tissue can maintain or return to a healthy, noninflamed state (202). The advantages of ultrasonic instruments appear to outweigh the disadvantages; however, there is limited evidence regarding the relationship of root smoothness and the smear layer produced by ultrasonic instruments and the degree of wound healing that might be expected over a long period of time. Whether microultrasonic instruments will achieve equal or better long-term results than that of traditional ultrasonic instruments and hand scalers remains to be answered; however, clinical experience and some limited data (38, 49) suggest that subgingival debridement may be enhanced with the use of microultrasonic instruments. Very few, if any, in vitro or in vivo data are published on recently developed ultrasonic units and their respective tips (50, 112, 141, 146, 147). There is a critical need to study the local effects of many of these new instruments and tips, to provide clinicians with scientific data, rather than anecdotal data, relative to the safety and efficacy of these new products prior to their introduction on the market. Good clinical practice dictates that treatments that can potentially cause irreversible damage should be carefully evaluated and documented prior to their acceptance as a therapeutic regimen. The profession should demand the same pre-marketing standards for these cleaning devices, as is currently in place for other types of devices used in the treatment of periodontal disease.