Ultrasound in Med. & Biol Vol. 14, No. l, pp. 7-14, 1988 0301-5629/88 $3.00 + .

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Printed in the U.S.A. 1987 Pergamon Journals Ltd.

OOriginal Contribution

APPLICATIONS OF ULTRASOUND IN DENTISTRY

A. D. W A L M S L E Y
Department of Dental Prosthetics, The Dental School, St. Chad's Queensway, Birmingham, B4 6NN

(Received 11 February 1987; in revisedforrn 29 May 1987)

Abstract--An ultrasonic descaler working at kHz frequencies is used in dentistry to remove attached deposits
from the teeth. Such devices offer many advantages over conventional hand instruments by reducing both the
work and time involved in the clinical descaling process. Although it is a recognised clinical instrument, there has
been little attempt to standardise its acoustic power output. A parameter which may characterise adequately the
acoustic emission from these instruments is the displacement amplitude of the probe tip. Modification of the
ultrasonic descaler generator has led to the further use of the instrument in other dental areas. Diagnostic
applications of M H z ultrasound is limited by the structure and arrangement of the dental tissues. Therapeutic
ultrasound has been used to treat a variety of dentally related ailments, and ultrasonic cleaning baths are used to
clean both dental instruments and materials.

Key Words: Ultrasound, Dentistry, Clinical applications.

INTRODUCTION amount of aluminium slurry used during cutting

The common perception of the use of ultrasound
from a medical point of view is in its wide use in areas
such as diagnostic imaging and physiotherapy.
Within the wider aspects of medicine however ultra-
sound finds considerable uses in the practice of den-
tistry. One of the earliest references to its use in the
dental sphere was in 1952, where an industrial ultra-
sonic impact grinder was used to prepare cavities in
extracted h u m a n teeth (Balamuth, 1963). This
quickly caught the imagination of dentists and the
potential use of such an ultrasonic dental drill was
reported by Catuna (1953), with aa instrument being
introduced eventually for cavity preparation in the
teeth of patients (Nielsen and Richards, 1954; Roche,
1954; Oman and Applebaum, 1955). These early in-
struments operated at a frequency of around 29 kHz
using an abrasive slurry ofaluminium oxide particles
to assist in the cutting process. Tooth substance was
removed efficiently by this technique (Postle, 1958).
There was little patient discomfort and it was sug-
gested that cavity preparation could be performed
without recourse to local anaesthesia. Furthermore,
as a low contact load was employed in cutting, po-
tential traumatic effects on the underlying vascular
and nervous tissues of the dental pulp were reduced.
However, ultrasonic cavity preparation never became
popular due to poor visual access and the large
which required removal. As a result it was superseded
by the more effective high speed rotary drills (Street,
1959) which were developed around the same time.
The role of ultrasonics in dentistry did not disappear
altogether since previously Zinner (1955) had
adapted the original ultrasonic drill for use in the
removal of dental plaque and calculus from the sur-
face of the teeth (descaling). This process was first
demonstrated clinically by Johnson and Wilson
(1957) and is now a widely accepted clinical proce-
dure. By the seventies it was reported that within the
United States of America there were some 50,000 to
100,000 ultrasonic devices in use for descaling and
periodontal treatment (Lees, 1972; Frost, 1977). At
the present time the number of units is likely to be far
in excess of this number worldwide although accurate
figures do not exist.
The use of ultrasound in dentistry is not re-
stricted to the descaling of teeth, however, and its
application in other areas has been steadily increasing
(Balamuth, 1967). The ultrasonic descaler has been
modified for use also in root canal therapy (endo-
dontics), amalgam packing, extraction of teeth, and
displacing cemented restorations from teeth. Other
applications of ultrasound in dentistry include the
treatment of joint and muscle related ailments
around the face, the generalised cleaning of both in-
struments prior to sterilisation and dentures, and as a
8 Ultrasound in Medicineand Biology
diagnostic procedure to detect dental caries and peri-
odontal disease.
ULTRASONIC DESCALING
The supporting tissues of the natural human
tooth (Fig. 1) consist of the gingivae, the periodontal
ligament, and the alveolar bone, collectively termed
the periodontium. These tissues may be subject to
inflammatory change which, if left untreated may
lead to irreversible damage with subsequent loss of
the teeth. The primary etiological factor in periodon-
tal disease is the deposition and accumulation of
dental plaque on the surfaces of teeth (Lre et at.,
1965). Dental plaque is a soft tenacious bacterial de-
posit which forms on the surface of a tooth when oral
hygiene methods are ineffective or abandoned
(McHugh, 1970), and the control of plaque forma-
tion and its effective removal is an essential require-
metn for periodontal health (Lre, 1970).
If dental plaque is allowed to accumulate, depo-
sition of calcium salts in its matrix will result in the
formation of dental calculus, which consists mainly
of 80% inorganic matter mainly in the form of cal-
cium phosphate as hydroxyapatite, and inorganic
matter comprising mainly desquamated epithelial
cells and bacteria (Jenkins, 1966). Calculus acts as
tissue irritant by virtue of its roughness, bacterial
content, and by the accumulation of further dental
plaque deposits on its surface (Allen and Kerr, 1965;
Schroeder, 1969).
The main application of ultrasound in dentistry
therefore is to remove both dental plaque and cal-
~ ~ Enamel
Gn
i gvia
I~ Pupl
Denn
tie
Piearo
Lg i de
m onnttal
Root
Cemenutm
A
Bone r
v
l eoa
l monly used probes are shown in Fig. 3b. They range
Fig. 1. A schematic diagram of the constituents of the tooth
and its supporting tissue.
Volume14, Number 1, 1988
Fig. 2. The ultrasonic descaler being used clinically to re-
move attached deposits from the surfaces of the teeth.
culus deposits from the surfaces of teeth (Fig. 2) using
an ultrasonic descaler (Suppipat, 1974). These in-
struments operate at frequencies of 25-42 kHz and
are useful in that they reduce the mechanical effort
required by the clinician. Furthermore they are easy
to operate and there is a reduction in both the treat-
ment time and the level of discomfort to the patient.
These devices utilise a rigid metal probe which is
driven to oscillate in its longitudinal mode. It is this
vibratory motion that provides the "chipping" action
which removes the attached deposits from the teeth.
A magnetostrictive or a piezoelectric transducer
within the handpiece is used to produce the ultra-
sonic vibrations. In magnetostrictive designs, the
metal probe is attached to a laminated ferromagnetic
stack (Fig. 3a). Each probe has its own integral stack
being known as an "insert" and this is powered by the
same generator via coils in the handpiece. Piezoelec-
tric devices are much simpler in design in that the
different probes are interchangeable with the one
transducer. Both designs utilise a flow of cooling
water which is passed through the handpiece and
onto the oscillating tip. The cooling water serves to
reduce frictional heating at the tooth/tip interface
and in magnetostrictive transducers it also is used to
cool the ferromagnetic stack.
On reaching the tip, cavitational activity occurs
within the water (Walmsley et al., 1986a), and thus
may also contribute to the removal of the attached
deposits (Balamuth 1967; Walmsley et al., 1984).
A variety of probe tip designs are used in the
descaling process and examples of the more com-
from straight or sickle probe tips approximately 2-3
cm long and 0.2 cm broad at the tip to angled/blade
designs incorporating a 0.5 by 1 cm blade tip. Such
designs are used for different clinical tasks such as
 Applications of ultrasound in dentistry A. D. WALMSLEY
(a)
(b)
Fig. 3(a). An example of inserts for a magnetostrictive gen-
erator are shown; (b) Three commonly used designs of de-
scaling probe tips: A, straight; B, angled blade, and C,
sickle.
general descaling and root planing (which will be dis-
cussed below). They are all based on conventional
hand-held instrument designs as it is assumed by both
manufacturers and clinicians that both forms of de-
scaling achieve the same result.
During oscillation, clinicians anticipate that the
oscillatory movement of the descaling tip will occur
along the longitudinal axis of the instrument (John-
son & Wilson, 1957). The direction of oscillation ob-
served, however invariably occurs at an angle O to the
longitudinal axis of the instrument (Fig. 4). This
angle is approximately 5 for the straight probe de-
signs and 30 for sickle/angled designs (Walmsley el
al., 1986b). Although most designs exhibit a true lon-
gitudinal motion, some of the more complex probe
tips demonstrate an open elliptical motion.
Comparison to conventional instrumentation
Although ultrasonic descaling is effective in the
removal of dental plaque and calculus, the use of
9
hand instruments may also achieve similar clinical
results. Therefore the majority of clinical investiga-
tions in relation to the ultrasonic descaler have been
concerned with its efficiency when compared to man-
ual methods and to assess which, if any, is superior.
Clinical studies on the quality of the descaling
process show that both manual and ultrasonic instru-
mentation remove the attached calculus from the
tooth surface efficiently with no apparent differences
between either technique (McCall and Szmyd, 1960;
Stende and Schaffer, 1961; Moskow and Bressman,
1964). These initial findings were followed by scan-
ning electron microscope studies of the enamel and
dentinal surfaces following routine descaling proce-
dures. This suggested that ultrasonic devices tended
to remove the calculus in small fragments with bur-
nishing of the remaining deposits, whilst hand instru-
ments removed the calculus in much larger fragments
(Jones et al., 1972). However, calculus removal by
the ultrasonic descaler was superior from those teeth
where there was good access.
In patients suffering from periodontal disease
there is often a surface layer of necrotic cementum
overlying the root. This necrotic cementum contains
bacterial products which may be irritant to the peri-
odontal tissues (Hatfield and Baumhammers, 1971;
Aleo et al.. 1974) and the removal of this surface layer
of cementum (root planing) is an established part of
the descaling process (Rosenberg and Ash, 1974;
Robinson, 1975).
After a course of descaling and root planing,
Torfason et al. (1979) showed that both hand and
ultrasonic instrumentation produced similar rates of
resolution of inflamed periodontal tissues. However,
this result has been disputed by Nishimine and
O'Leary (1979) who reported that, in root planing,
hand instruments were superior to ultrasonic de-
scalers. A generalised conclusion from the above
studies is that for either root planing or areas of the
mouth where access is difficult, ultrasonic descalers
are relatively ineffective (Stende and Schaffer, 1961;
Suppipat, 1974; Nishimine and O'Leary, 1979) and a
further course of descaling with hand instruments is
usually required to achieve a clinically satisfactory
Longitudinal
Axis
Fig. 4. A diagrammatic representation of the probe oscilla-
tions which occur at an angle (O) to the longitudinal axis of
the instrument.
10 Ultrasound in Medicineand Biology
result. This is generally related to both the lack of
operator tactile sensitivity when utilising the instru-
ment and poor visibility created by the associated
aerosol spray.
The efficiency of any descaling technique may
also be assessed by the eventual healing and resolu-
tion of the periodontal tissues. In clinical studies,
most investigators agree that tissues surrounding
teeth that are subjected to ultrasonic descaling show
more rapid resolution to health, as demonstrated by a
larger reduction in the tissue inflammation, than
where a hand instrument was used (Goldman, 1961 ;
Schaffer et al., 1964; Sanderson, 1966; Walsh and
Waite, 1978). This may be due to an increased rate of
collagen production stimulated by the ultrasonic de-
scaler (Bhasker et al., 1972). However, at these fre-
quencies the effect of the ultrasound may chiefly be
hormetic (Williams, 1983), that is, a beneficial or
stimulating effect resulting from the application of a
small "dose" of a harmful or irritating agent. Gener-
ally, most investigators cite the presence of a water
spray, with its lavage action irrigating the tissues, as
the major reason for the superiority of the ultrasonic
descaler (Clark, 1969; Bhasker, et al., 1972; D'Silva et
al., 1979). However, no consideration was given in
any of the above reports to the role of cavitational
activity within that water supply and its potential
cleaning action.
Clinical evaluation
The main advantage claimed for the use of an
ultrasonic descaler is that calculus removal is accom-
plished more rapidly than with conventional hand
instruments (Johnson and Wilson, 1957; Torafason
et al., 1979) and time savings of 20% (Forrest, 1967)
to 50% (Donz~ et al., 1973) have also been reported.
However, it appears that for efficient removal of cal-
culus, the same amount of time is involved regardless
of the technique used (Burman et al., 1958), although
ultrasonic descaling may be quicker for mandibular
teeth (Stewart et al., 1967).
During clinical treatment the majority of pa-
tients appear to prefer ultrasonic descaling to hand
instrumentation (Johnson and Wilson, 1957; Forrest,
1967; Donz6 et al., 1973) and this may be attributed
to a reduction in discomfort (Johnson and Wilson,
1957). Clearly this is an advantage in situations where
the tissues may be unduly susceptible to pain in the
presence of infection (Wilson, 1958).
In addition, many clinicians prefer using the ul-
trasonic descaler (Stewart et al., 1967) which may be
related to a reduction in both physical effort and
complex manipulation. However, the possible loss of
tactile sensation when using the device makes it diffi-
Volume14, Number 1, 1988
cult to be sure that all calculus has been removed
completely, a problem that does not appear to exist
when using hand instruments (Burman et al., 1958;
Moskow and Bressman, 1964; Schaffer, 1967).
I n s t r u m e n t standardisation
Many investigations into the performance of the
ultrasonic descaler, may be criticised due to the fact
that there was inadequate standardisation of the
operating instrument. The clinical settings of the
working ultrasonic descaler have ranged from the use
of either "medium" or "high" power levels used in
conjunction with a free flow of water (Moskow and
Bressman, 1964; Jones et al., 1972; D'Silva et al.,
1979) to a power setting and flow of cooling water
adjusted to the "operator's preference" with the pre-
cise conditions not being reported (Sanderson, 1966;
Torfason et al., 1979). Some investigators gave no
details of the working conditions of their instrument
(McCall and Szmyd, 1960; Goldman, 1961; Stende
and Schaffer, 1961; Donz~ et al., 1973). Other vari-
ables which are not adequately described are the time
spent and the application loads used during opera-
tion. Interpretation and comparison of the results
obtained from different workers is difficult, therefore,
due to these discrepancies in the instrument standar-
disation.
Although there are various methods used to
measure the acoustic power output emitted from
medical transducers operating at MHz frequencies
(Wells, 1977), there is no commonly agreed tech-
nique used for representing the power output from
ultrasonic descalers working in the kHz range. The
majority of these instruments are designed with a
control dial enabling the operator to vary the amount
of electrical power input to the transducer, and an
estimate of this is displayed on an arbitrary linear
scale. This scale, however does not provide a mean-
ingful estimate of any relevant acoustic emission
from the probe tip.
A parameter which adequately characterises the
acoustic emission is the displacement amplitude of
the oscillating tip (Walmsley et al., 1986a). The dis-
placement amplitude may be measured using a trav-
elling light microscope at an overall magnification of
100. This provides a direct measure of the "chip-
ping" action of the probe tip when used clinically.
Displacement amplitudes for the descaling tips
range from 18-27 gm for straight probes and from
27-65 um for sickle probes (Walmsley et al., 1986b).
It has been shown that differing designs of the descal-
ing tip exhibit different displacement amplitudes at
the same nominal power output from the same gener-
ator. Furthermore, different generators from the
 Applications of ultrasound in dentistry A. D. WALMSLFY 11

same manufacturer produce a different range of dis-
placement amplitudes when the same probe design is
used (Walmsley et al., 1986b).
The displacement amplitude not only gives a
measure of the amount of"chipping" action but also
gives a direct measure of cavitational activity occur-
ring within the associated cooling water (Walmsley et
al., 1986a). When measured by chemical dosimetry
methods, an apparent "threshold" for the onset of
cavitational activity occurs at displacement ampli-
tude of 12 um. It is then found to increase in a linear
manner with increasing displacement amplitude of
the probe (Walmsley et al., 1986a).
A measure &electrical power input to the trans-
ducer is meaningless (using the manufacturers con-
trol dial) because the transduction process is ineffi-
cient. This is demonstrated by a nonlinear increase in
the displacement amplitude with increasing power
setting (Walmsley et al., 1986a; 1986b). As the dis-
placement amplitude appears to be a satisfactory
method of determining the efficiency of an ultrasonic
descaling tip, measurements for the individual probes
in relation to acoustic power output should be dis-
played in manufacturers literature. This is necessary
in order to regularize and improve clinical perfor-
mance and allow meaningful comparison of results
between different clinical investigators.
file (Fig. 5). This oscillating file is placed within the
root canal of the tooth and abrades the walls remov-
ing contaminated organic and inorganic material. An
antiseptic solution (usually sodium hypochlorite) is
often passed over the oscillating tip to aid in the
cleaning process (Cunningham et al., 1982; Griffiths
and Stock, 1986). The occurrence of acoustic micro-
streaming fields developed around small irregularities
protruding from the file surface increases the effec-
tiveness of the disinfectant (Ahmad et al., 1987).
Cavitational activity has been shown not to occur
along the oscillating file and this is probably related to
the relatively low displacement amplitudes produced
when it is oscillating within the canal (Ahmad et al.,
1987).
These instruments have been subject to investi-
(a)
L
T

MODIFICATIONS OF THE
ULTRASONIC DESCALER
Apart from the routine descaling procedures, the
basic principles of the ultrasonic descaler have found
use in other areas of dentistry. Generally the genera-
tor remains unchanged but different shaped inserts
are used to perform the particular clinical task that is
required.

Endodontics
Ultrasonic vibrations may be used to prepare
and clean the root canal of nonvital teeth before fill-
ing is commenced (Richman, 1957; Martin, 1976;
Nehammer and Stock, 1985). The development of
such instruments was pioneered by Martin in the
early 1970s (Martin, 1976) and is now a well recog-
nised and documented technique which is rapidly
growing in popularity. These instruments are essen-
tially a direct adaptation of the ultrasonic descaler Fig. 5(a). A diagrammatic representation of the ultrasonic
where a rigid metal rod is driven to oscillate in its endodontic instrument showing the main longitudinal
longitudinal mode. However, unlike the descaling in- oscillation (L) occurring along the main axis. The metal file
struments, a small file is attached near the end of the is at right angles to the main instrument and a transverse
main driver and is set at an angle of 60-90 to the oscillation (T) is set up along its length; (b) The transverse
oscillation of the metal file consists of nodes (N) and anti-
main longitudinal axis. Accordingly, during opera- nodes (A). The tip of the file being unconstrained exhibits a
tion a transverse wave is set up along the length of the large oscillation (from Walmsley, 1987).
12 Ultrasound in Medicineand Biology
gations which are mainly related to the clinical effi-
ciency of the instrument. The advantages claimed for
such treatment over conventional methods include
cleaner root canals with increased debris removal and
a reduction in bacterial contamination (Martin et al.,
1980; Cunningham et al., 1982). The majority of in-
vestigators have not adequately standardised their in-
struments, making comparison between different
workers difficult. The operating characteristics of
these instruments suggest that the transversely oscil-
lating files (which may influence clinical perfor-
mance) are highly susceptible to loading (Walmsley,
1987). This results in the file tip being constrained
within the root canal. Clearly, further work is neces-
sary in this area of endosonics to assess adequately
the mechanism of action of these instruments.
Surgical applications
The ultrasonic descaler has also been adapted for
use in dental surgical procedures such as removal of
the apical portions of roots of teeth (Richman, 1957)
and surgical extraction of teeth (Horton et al., 1981).
The clinical advantages of such techniques appear to
be related to good haemorrhage control and field visi-
bility. No adverse effects have been reported so far by
such uses of ultrasound and healing appears unevent-
ful with minimal patient discomfort. The potential
hazards of utilising ultrasonic vibrations in these sur-
gical situations has not been fully assessed.
Other dental uses
In conservative dentistry the adapted ultrasonic
descaler has been used for the condensation of amal-
gam restorations (Skinner and Mizera, 1958) together
with restoration contouring and elimination of inter-
proximal ledges (Forrest, 1967; Gaffney et al., 1981).
The condensation of amalgam restorations in the
prepared tooth cavity is a dangerous practice as it
may produce increased levels of mercury vapour in
the surrounding air (Chandler et al., t971) and
should be discouraged. It may also be used during
orthodontic treatment to remove interdental contacts
between teeth, cemented orthodontic brackets, and
superficial decalcification of enamel (Gorelick and
Tascher, 1967; Cooke and Wreakes, 1978). The ul-
trasonic descaler may also be used to remove frac-
tured metal posts from teeth by breaking the cement
seal (Krell et al., 1985).
DIAGNOSTIC ULTRASOUND
The use of ultrasound in the MHz range as a
potential clinical diagnostic device has been investi-
gated. Lees ( 1971 ) has demonstrated that it is possible
to measure the size and shape of the pulp chamber of
Volume14, Number 1, 1988
teeth using an ultrasound pulse echo system. This has
also been used to diagnose areas of early enamel de-
mineralisation following acid attack (Lees et al.,
1973). However such diagnostic usage of ultrasound
is limited by both the high acoustic impedance mis-
matches between the various interfaces (enamel,
dentine, and pulpal tissues) and the anatomical ar-
rangement and geometry of the tooth. Consequently,
it is still at an early stage of development.
Other potential uses of diagnostic ultrasound in-
clude the mapping out of the oral soft tissues overly-
ing the alveolar bone (Daly and Wheeler, 1971). This
technique has been adapted to assess the thickness of
the oral mucosa in patients wearing complete den-
tures (Kydd et al., 1971). Furthermore, Spranger
(1971) has shown that diagnostic ultrasound may be
used to provide similar information to that obtained
from periapical radiographs in the monitoring of
periodontal disease.
THERAPEUTIC ULTRASOUND
Ultrasound in the MHz frequency range has
been used therapeutically to the head and neck to
treat a variety of inflammatory disorders ranging
from temporomandibular joint dysfunction (Espo-
sito et al., 1984) to improving the rate of healing after
removal of wisdom teeth (El Hag et al., 1985).
The anti-inflammatory effects of such treatment
may be largely placebo in action, with the beneficial
results related to patient motivation during treatment
(Roman 1960; Walmsley, 1984; E1 Hag et al., 1985).
Recent work to investigate this placebo effect has
utilised the removal of the lower wisdom tooth as a
model of acute inflammation. The use of low inten-
sity ultrasound (3 MHz, 0.1 W cm -2, 2 ms pulses with
8 ms spaces, 5 min duration) was found to produce a
major placebo effect and this could be related to an
inhibition in the release of inflammatory mediators
from cells (Hashish et al., 1986).
ULTRASONIC CLEANING BATHS
Ultrasound is often used commercially in the
cleaning of solid objects by the immersion in liquid
and subsequent exposure to the mechanical effects of
cavitational activity and acoustic microstreaming.
This is also applicable in dentistry. Ultrasonic clean-
ing baths operating at frequencies of 18-100 kHz
(Repacholi, 1981 ) are used in dentistry for removing
debris from instruments prior to sterilisation (Gor-
don, 1973), calculus and staining from dentures
(Abelson, 1981), and disinfecting rubber base im-
pressions prior to casting (Lorton et al., 1978).
 Applications of ultrasound in dentistry A. D. WALMSLEY
SUMMARY
Since its introduction in the early 1950s, ultra-
sound is now widely used within dentistry. Unfortu-
nately, this increased usage does not appear to have
produced any similar awareness of the potential bio-
logical hazards of ultrasound (Walmsley, 1988).
Other problems exist in that little standardisa-
tion of the instruments such as the ultrasonic descaler
has been carried out.
It is important that such standardisation is car-
fled out so that the instruments may be used effec-
tively with the minimum of potential damage to as-
sociated biological structures.
Acknowledgements--The author would like to thank Professor
W. R. E. Laird and Dr. A. R. Williams for their assistance in the
preparation of this article.
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