G. J. Smart', M.

Wilson^
The assessment of ultrasonic root E. H. Davies^ and J. B. Kieser^
Departments of 'Periodontology, ^Clinical
Pathology and Immunology and ^Biomaterials

surface debridement by Science, Institute of rental Surgery, 256 Grays

Inn Road, London, WC1X 8LD, UK

determination of residual
endotoxin ieveis .
Smart GJ, Wilson M, Davies EH and Kieser JB: Assessment of ultrasonic root
surfaee debridement by determination of residual endotoxin levels. J Clin Periodon-
tol 1990: 17: 174-178

Abstraet. Recent demonstrations of the superficial nature and ease of removal of

root-surface-associated cytotoxic materials suggest that extensive root-surface
instrutnentation is not warranted clinically. This in vitro investigation determined
the detoxifying effects of a conservative regime of ultrasonic root debridement,
using the Limulus amoebocyte lysate assay for lipopolysaccharide (LPS) as an
indication of the presence or absence of cytotoxic materials. 20 extracted peri-
odontally-involved single-rooted teeth, with no clinically detectable calculus de-
posits, were debrided with a Cavitron TF-10 tip. Light pressure, resulting from a
force application of approximately 50 g, lasting for 0.8 s/mm^ of root surface
was used and complete overlapping instrumentation ensured. The ftnding of
LPS levels of < 2.5 ng per root in 19 out of 20 teeth after such debridement was Key words: ultrasonic; debridement; lipopoly-
sacoharide; periodontitis; root surface.
comparable to LPS levels found on healthy, uninvolved control teeth, and thus
endorses the growing belief that root surface cleanliness can be readily achieved. Accepted for publication 19 March 1989

Root-surface instrurnentation has tra-
ditionally centred upon scaling and root
planing. Scaling relates to the "gross
subgingival accretions", and root plan-
ing to the "microbial flora on the root
surface or lying free in the pocket, all
flecks of calculus and all contaminated
cementum and dentine" (O'Leary 1986).
The long-held assumption of cementum
contatnination was reinforced by the
fmdings of Aleo et al. (1974, 1975) and
has promoted the use of root planing to
decontaminate such surfaces (Jones &
O'Leary 1978, Nishimine & O'Leary
1979). More irnportantly, operator diffi-
culties with subgingival root planing
and the assessrnent of its efficacy have
fostered the now widely practiced con-
cept of periodontal flap access surgery
(Axelsson & Lindhe 1981, Pihlstrom et
al. 1981, Frandsen 1983), notwithstand-
ing the comparable clinical results with
non-surgical techniques (Hill et al. 1981,
Pihlstrom et al. 1981, 1983, Lindhe et
al. 1982, 1984, Isidor et al. 1984, 1986,
Westfelt et al. 1985, Lindhe & Nyman
1985).
Recent research fmdings have ques-
tioned the extent of root surface con-
tamination and the ease of removal of
associated cytotoxic materials such as
bacterial lipopolysaccharide (LPS).
Thus LPS, shown to be consistently
present in periodontally-involved root
surface associated materials (Wilson et
al. 1986, Maidwell-Smith et al. 1987,
Cheetham et al. 1988), displays no sig-
nificant cemental penetration (Moore et
al. 1986, Hughes & Smales 1986,
Hughes et al. 1988). Moreover, the find-
ing in our own laboratory that virtually
all LPS detected could be removed in
vitro by rinsing and brushing alone
(Moore et al. 1986) may also apply to
other cytotoxic substances. This, cou-
pled with the fact that polishing of
periodontally involved root surfaces has
resulted in similar healing to that after
the complete rernoval of cementum at
the time of periodontal surgery (Nyman
et al. 1986, 1988), indicates that other
cytotoxic substances are removed equal-
ly readily. This in turn suggests that LPS
may be used as a reliable marker of the
presence of such substances and more
importantly of bacterial plaque itself in
investigations on root surface instru-
mentation.
The superficial nature of root surface
contamination has been further demon-
strated by thefindingthat all but minute
amounts of LPS present on perio-
dontally involved roots were removed
in vitro by only 15 light overlapping
hand instrument strokes per root sur-
face (Cheetham et al. 1988). Ultrasonic
devices are likely to be equally effective
in this respect for they have been shown
both clinically (Torfason et al. 1979,
Badersten et al. 1981, 1984, Oosterwaal
et al. 1987) and microbiologically
(Thornton and Garnick 1982, Leon and
Vogel 1987, Breininger et al. 1987) to
be as effective as hand instruments for
subgingival instrumentation. However,
the extent to which these devices must
be used to achieve such root surface
decontamination is unclear. The effi-
cacy of conservative hand instrument
and polishing regirnes described above,
coupled with the facility with which su-
pragingival staining encountered clin-
ically may be removed by the rnethodi-
cal light use of ultrasonic devices are
instructive in this context. Thus, corn-
parable subgingival root surface cleanli-
ness may be achieved by a similarly con-

servative ultrasonic regime of limited
duration, using only light pressure and
complete overlapping of instrumen-
tation strokes. The aims of this in vitro
study were therefore to first establish
the feasibility of such debridement on
periodontally involved root surfaces
and then to assess its efficacy by deter-
mining the amounts of residual LPS by
a Limulus amoebocyte lysate/affinity
chromatography assay (Wilson et al.
1986).
Material and Methods
The pressures applied during ultrasonic
root surface instrumentation were first
assessed to establish a reproducible
technique and the instrumentation time
required to produce a clinically "clean"
surface when using light pressure. The
teeth selected for this and the sub-
sequent investigations had no clinically
discernible deposits of subgingival cal-
culus as determined by visual inspection
following extraction. This was designed
to exclude the possibly complicating ef-
fect of the removal of calculus (scaling)
which might have influenced the oper-
ator's efforts during the simpler exercise
of root surface debridement under con-
sideration.
Instrumentation pressure was assess-
ed on an Instron Materials Testing Ma-
chine* which is capable of detecting and
recording the characteristic of very
small loads (Fischel et al. 1982). The
crown of each tooth was fixed with self-
curing acrylic resin into a nylon retain-
ing tube and mounted in a specially con-
structed jig placed onto the Instron load
cell. An adjustable laboratory retort
stand and clamp provided a stable fin-
ger rest during instrumentation.
A Cavitron** 2002 Ultrasonic Dental
Unit was used with a TF-10 tip at an
angle of 15 to the root surface as re-
commended by the manufacturer, and
set at medium power (2.5) and 50%
water supplied from a pressurised con-
tainer. An operating amplitude of the
tip of 46 nm was measured at this setting
using a light microscope with a mi-
crometer eyepiece. This was the same
for each of the 6 previously unused in-
serts examined confirming the findings
of Walmsley et al. (1986).
* Instron Ltd., High Wycombe, Buck-
inghamshire, UK.
** Dentsply Ltd., Addlcstone, Weybridge,
Surrey, UK.
The possible pressure ranges that
could be applied when using an ultra-
sonic tip were first measured on a single
tooth. Clearly discernible ranges of
light, medium and heavy pressures
could be produced, of which the light
pressure of between 30-40 g selected for
the subsequent investigations, was
found to be most reproducible during
17 separate sequences of instrumen-
tation.
The duration of ultrasonic instru-
mentation to achieve visually clean peri-
odontally-involved root surfaces when
using this light pressure was then deter-
mined on 10 successive teeth. Root sur-
face cleanliness was judged by the re-
moval of both disease-induced staining
and staining produced by the appli-
cation of a disclosing agent, as described
by Eaton et al. (1984) and Poole et al.
(1984). Supplementary staining was
necessitated by the inconsistent pattern
of disease-induced staining encountered
on the roots.
The total area of the periodontally
involved root surfaces was established
using the formula:
pocket area =
mean pocket depth
X total root area,
mean root length
based on the method described by Ny-
man & Ericsson (1982) and mean root
surface areas (Jepsen 1963). This
method was chosen so as to minimize
the handling of the roots inherent in the
use of alternative planimetric methods,
and thereby to reduce the risk of ex-
traneous root surface contamination in
the subsequent main investigation. The
instrumentation time per unit area was
then calculated, based on the time taken
to achieve cleanliness and the total
periodontally involved root surface area
of each tooth. This was found to be 78
s/cm- of root surface and apportioned
accordingly to each of the 20 teeth se-
lected for the main investigation.
Collection and processing of teeth
Periodontally involved root surfaces
20 single-rooted teeth were extracted
from 17 patients presenting in the casu-
alty department of the Eastman Dental
Hospital (II male, 6 female, mean age
53.2 years+10.6 years) following a di-
agnosis of chronic inflammatory perio-
dontal disease. All teeth fulfilled the fol-
lowing criteria: (i) periodontal pocket-
ing and radiographic evidence of at least
30% bone loss; (ii) no history of pro-
Ultrasonic root surface debridement 175
fessional cleaning in the preceding 12
months; (iii) vital pulps, no root surface
restorations or caries; (iv) no history of
antibiotic therapy during the preceding
month.
Prior to extraction, the level of the
gingival margin was marked with a
sharp pencil. The extraction technique
and subsequent storage of the teeth
(Moore et al. 1986) ensured no contami-
nation from extraneous LPS. Contami-
nation was similarly avoided by adher-
ing strictly to the procedures described
by Wilson et al. (1986) during prepara-
tion of the teeth for debridement and
their subsequent management for LPS
assay.
Each tooth was first fixed into a ny-
lon retaining tube and then shallow cir-
cumferential grooves were cut immedi-
ately apical and coronal to the pre-ex-
traction gingival margin and the most
coronal periodontal ligament remnants,
respectively. The resulting demarcated
periodontally involved root surface area
was calculated and the total instrumen-
tation time computed for each tooth,
one quarter of which was appportioned
to each of the buccal, lingual, mesial
and distal root faces.
Periodontally uninvolved root surfaces
10 surgically removed totally unerupted
third molar teeth, obtained from 7 pa-
tients attending the Oral Surgery de-
partment were used as controls. These
teeth were handled as described above
but were not subjected to grooving.
Preparation of experimental material
Debridement technique
The retaining tube of each tooth was
fitted in turn into the Instron jig for
debridement. The individual root faces
were debrided with the ultrasonic in-
strument using a light pressure for the
prescribed time. A "cross-hatching"
pattern of instrumentation was carried
out in which the instrument tip was pas-
sed methodically with a continuous
overlapping action in an apico-coronal
plane and then from side to side to en-
sure optimal root surface coverage. This
regime was performed regardless of the
distribution of disease-induced staining
and any minor deposits of calculus pres-
ent. Similarly, any residual flecks of cal-
culus at the completion of instrumen-
tation were ignored. The entire root sur-
face of half (5) of the control teeth were
subjected to this debridement regime.
176 Smart et al.
Stripping attd LPS assay
The test root surfaces were then stripped
with a dental bur to a depth of 1 mm
ad modum Wilson et al. (1986) and the
material from each tooth collected sep-
arately for subsequent LPS assay. The
10 control teeth were similarly stripped
for assay, but as only half had been
debrided the extent of possible contami-
nation during instrumentation could be
established.
The material harvested from each in-
dividual tooth was subjected to a se-
quence of "Westphal" extraction, dialy-
sis and ultracentrifugation, followed by
Polymyxin B/Sepharose 4B affinity
chromatography and Limulus amoe-
bocyte lysate assay (Moore et al, 1986).
Results
The mean yield of LPS from the unin-
strumented control (periodontally-unin-
volved) teeth was 0,479 + 0,19 ng per
tooth (range: 0,29-0,703 ng per tooth).
The instrumented control teeth gave a
similar low yield of 0,209 + 0,15 ng per
tooth (range: 0-0,414 ng per tooth) im-
plying that the instrumentation per se
did not introduce an appreciable
amount of exogenous LPS, Following
instrumentation, the amount of residual
LPS on the periodontally-involved roots
ranged from <0,02 ng to 9,978 ng with
a mean value of 0,919 + 0,33 ng per
tooth (Fig, 1), 17 of the 20 teeth yielded
10.0-
9.9-
2.2'
1.5-
1-4
NET ^O
LPS
ng
0.5
TEST CONTROLS
1 2
Fig. 1. Scatter diagram showing the net re-
sidual LPS yield per root of the test (peri-
odontally-involved) teeth, and the control
(periodontally-uninvolved) teeth.
< 1,0 ng of LPS and 4 of these yielded mentation is currently being practiced,
less than 0,02 ng per tooth. a belief endorsed by Moore et al, (1986)
and Nyman et al, (1986, 1988) and by
the demonstrated efficacy of a conserva-
Discussion
tive method of nand instrutnentation
This in vitro investigation has shown (Cheetham et al, 1988), Controlled clin-
that very small amounts of LPS remain ical evaluations of such regimes are now
on the surface of single-rooted peri- clearly necessary.
odontally-involved teeth (which had no Since technically simpler subgingival
clinically detectable calculus) following instrumentation may be as effective as
a conservative ultrasonic instrumen- root planing, more specific terminology
tation regime consisting of light press- is warranted. The term "root surface
ure for a short period of time ensuring debridement" is suggested for a con-
overlapping instrumentation. This re- servative instrumentation regime of
sidual LPS in all but one instance overlapping strokes and light pressure
amounted to <2,2 ng and in 65% of utilized for only a limited time period.
the teeth was less than 0,5 ng. Such The consistent fmding of only minute
quantities are negligible, bearing in amounts of residual LPS following such
mind that the initial LPS levels would a regime is of interest, despite the inci-
have been in the order of several hun- dental observation of residual flecks of
dred ng (Moore et al, 1986, Maidwell- calculus in some instances. This is being
Smith et al. 1987), The consistency and investigated further using the experi-
efficacy of root surface decontami- mental model developed here.
nation demonstrated under the simu- Finally, the results of this investiga-
lated clinical conditions can no doubt
tion endorse our earlier observations re-
be reproduced clinically. However, the
garding both the superficial distribution
influence of an additional possible cavi-
tational cleansing effect occurring in the of LPS and its ease of removal from
laboratory (Walmsley et al, 1984, 1988) periodontally involved root surfaces.
which might not apply elsewhere cannot Furthermore, although these investiga-
be discounted. tions have been concerned only with
LPS, the contention that our findings
Although the Instron unit ensured a also hold true for other root surface
more reproducible standardized regime contaminants would seem to be re-
than the rather subjective instrumen- inforced by the equal facility with which
tation pressures used by others, the 50 such substances could be removed by
g (approximately) used in the main in- polishing alone (Nyman et al, 1986,
vestigation proved to be slightly greater 1988), and warrants the continued use
than the "light" mean pressure of 36 of LPS as a representative marker of
g10 g determined in the pilot study. root surface contaminants.
Nevertheless, this is similar to the In conclusion, the findings of this in
"light" pressure as determined by vitro investigation indicate that, in the
Bjorn & Lindhe (1962), and it lies be- absence of clinically detectable deposits
tween that of 6 g+:3 g as measured on of calculus, a conservative regime of
a trip balance by Walmsley et al, (1984), ultrasonic root debridement is highly ef-
and that of 75 g when using a counter- fective in removing LPS and possibly
balanced scale by Clark et al, (1968), also other cytotoxic substances from
The mechanical limitations of these periodontally involved root surfaces.
relatively unstable balance mechanisms This does in turn question the rationale
compared to the Instron unit must how- for root planing and has far reaching
ever be borne in mind. clinical implications, with particular ref-
The mean instrumentation time of 78 erence to surgical access for instrumen-
s per root corresponds to less than 1 s/ tation,
mm^ of root surface. Moreover, the
mean instrumentation time was very Zusammenfassung
much less than the 5-12 min considered
necessary for clinically effective ultra- Die Beurteilung der Ultrasehallreinigung der
sonic instrumentation (Badersten et al, Wurzeloberflaehe durch die Bestimmung von
1984, 1985), even allowing for the inevi- Residual-Endotoxin Niveaus
tably greater expenditure of time by vir- Die kiirzlich beschriebene Oberflachenbe-
tue of the subgingival location of the schaffenheit und das leichte Enlfernen zur
Wurzelflache gehorender, zytoloxischer Stof-
root surfaces and the likely presence of fe legt nahe, dass umfassende instrumentelle
calculus deposits. This in turn implies Behandlung der Wurzeloberflaehe klinisch
that a considerable degree of overinstru- nicht berechtigt erscheint. Die hier vorliegen-

de in Vitro-Untersuchung bestimmt die ent-
giftcnde Wirkung eines konservativcn Vor-
gens mit Ultraschall-Wurzclreinigung, durch
Anwendung der Limulus - Ambobozyten -
Lysate Priifung fur Liposaccharide (LPS) aLs
Indikator fur das Vorhandensein oder das
Fehlen von zytotoxischen Stoffen. 20 extra-
hierte, parodontal crkrankte einwurzelige
Zahne ohne klinisch erkennbare Zahnslein-
ablagerung wurden mil ciner Cavition TF-IO
Spilze gesauberl, Eine, die Wurzelobcrfla-
chen vollstiindig deckende Behandlung mit
dicsem Instrument wurde, bei Anwendung
des leichten Druckes von etwa 50 Gramm
und einer Dauer von 0.8 Sekunden pro mm"
Wurzeloberflaehe, sichergestellt. Die Befunde
der LPS-Niveaus von <2,5 ng pro Wurzel
bei 19 der 20 Ziihne nach einer solchen Reini-
gung, waren mit den LPS-Niveaus bei gesun-
den, nicht in krankhaftes Gesehehen einbezo-
genen Kontrollzahnen vergleichbar und vcr-
stiirkten also die wachsende Einsichl, dass die
Sauberkeit der Wurzeloberflaehe leieht er-
reicht werden kann.
Resume
Evaluation du debridement ultrasonique de la
surface radiculaire par determination des ni-
veau.x residuels d'endotoxine
Les demonstrations recentes de la nature su-
perficielle du material cytotoxique au niveau
de la surfaee radiculaire et de la faeilite a
l'enlever suggerenl qu'un neltoyage parfait
de la surface radiculaire n'est pas justifie cli-
niquement. Celtc etude in vitro a determine
les effets detoxifiants d'un regime conserva-
teur de debridement ultrasonique de la surfa-
ce radiculaire en utilisant l'essai de Limulus
amoebocyte lysate pour lipopolysaccharides
(LPS) comme indicateur de la presenee ou
de I'absenee de materiel cytotoxique. Vingt
dents uniradieulees extraites pour raison de
parodonlite mais sans tartre decelable clini-
quement ont ete nettoyees avec un embout
Cavitron TF-10, Une pression legere d'envi-
ron 50 g a ete utilisee pendant 0.8
s/mm- de surface radiculaire. Un chevauche-
ment complet de toule la surface a ete realise.
Des niveaux de LPS < 2.5 ng par racine dans
19 des 20 dents traitees etaient comparables
a ceux trouves au niveau de dents controles
saines indiquanl que le netloyage de la surfa-
ce dentaire peul aisement etre accompli.
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Address:
Graham J Smart
Institute of Dental Health and Training
Royal Air Force, Halton
Aylesbury
Buckinghamshire HP22 5PG
UK