J Clin Periodontol 2002; 29(Suppl.

3): 72–81 Copyright # Blackwell Munksgaard 2002

Printed in Denmark. All rights reserved

ISSN 1600-2865

Review article

J. Tunkel1, A. Heinecke2 and

A systematic review of efficacy T. F. Flemmig1
1
Clinic of Periodontology and 2Department of
Medical Informatics and Biomathematics,

of machine-driven and manual University of Muenster, Germany

subgingival debridement in the

treatment of chronic periodontitis
Tunkel J, Heinecke A, Flemmig T.F: A systematic review of efficacy of machine-driven and
manual subgingival debridement in the treatment of chronic periodontitis. J Clin Periodontol
2002; 29(Suppl. 3): 72–81. # Blackwell Munksgaard, 2002.

Abstract
Objectives: The purpose of this systematic review was to determine the efficacy
of machine-driven compared with manual subgingival debridement in the
treatment of periodontitis.
Background: Mechanical debridement of the periodontal pocket plays a pivotal
role in the treatment of periodontitis.
Methods: A literature search for controlled clinical trials with at least 6 months’
follow-up comparing machine-driven instruments with hand instruments for
the treatment of chronic periodontitis was performed up to April 2001.
Screening of titles and abstracts as well as data extraction was conducted
independently by two reviewers (J.T. & T.F.F.). As primary outcome variable,
the prevention of tooth loss was used; secondary outcome variables were the
prevention of disease progression, the resolution of anatomical defects and the
resolution of gingival inflammation. Efficiency was assessed by mean time
needed to treat one tooth.
Results: From a total of 419 abstracts, 27 articles were included for the review.
The weighted kappa score for agreement between the two reviewers was 0.77,
95% CI: 0.65–0.89, indicating substantial agreement. No study reported on the
selected primary outcome variables. Using clinical attachment gain, probing
pocket depth reduction or bleeding on probing reduction as outcome variables,
there appeared to be no differences between ultrasonic/sonic and manual
debridement. No major differences in the frequency or severity of adverse
effects were found. However no meta-analysis could be performed on any of
the previously mentioned parameters. Ultrasonic/sonic debridement was found
to take significantly less time, i.e. 36.6%, than debridement using hand
instruments (P ¼ 0.0002, 95% CI of the standardized effect estimate:
0.39–1.37, heterogeneity P ¼ 0.77).
Conclusions: With respect to clinical outcome measures, the available data do not
indicate a difference between ultrasonic/sonic and manual debridement in the
treatment of chronic periodontitis for single-rooted teeth; however, the evidence
for this is not very strong. In addition, ultrasonic/sonic subgingival debridement
requires less time than hand instrumentation. Further research is needed to assess Key words: dental-scaling; meta-analysis;
the efficacy of machine-driven debridement on multirooted teeth and clinical periodontitis-therapy; sonication; subgingival
outcome variables having tangible benefit to the patients should be used. curettage; systematic review; ultrasonics

All forms of periodontitis are asso-
ciated with a bacterial infection and
there is evidence that only some
bacterial species of the complex bio-
film adhering to the tooth surface
contribute to the disease (Clark &
Loe 1993, Haffajee & Socransky
1994, Socransky et al. 1998). The clin-
ical features of periodontitis include
clinical attachment loss, alveolar
bone loss, periodontal pockets and
gingival inflammation. In addition,
swelling or recession of the gingiva,
bleeding of the gingiva following
application of pressure, and increa-
sed mobility, drifting, and/or tooth
exfoliation may occur. With few excep-
tions, most forms of periodontitis are
chronic inflammations that may pro-
gress continuously or by bursts of
activity (Badersten et al. 1985, Claffey
et al. 1996, Flemmig 1999, Jeffcoat &
Reddy 1991, Machtei et al. 1993).
Left untreated, periodontitis has
been reported to be a major cause of
tooth extraction in adults living in the
industrialized world (Reich & Hiller
1993, Stephens et al. 1991).
Treatment of periodontitis is dir-
ected primarily towards the reduction
of pathogens embedded in the subgin-
gival biofilm (Slots 1979, Slots & Ting
1999). Mechanical debridement of the
periodontal pocket has been sug-
gested to significantly reduce the risk
of tooth loss, slow down the rate of
periodontal disease progression, and
improve gingival health (Axelsson &
Lindhe 1981, Knowles et al. 1979,
Lindhe & Nyman 1984). Hand instru-
ments such as curettes, hoes, and
scalers have traditionally been used
to scrape the subgingival biofilm
and calculus off the pathologically
exposed root surface. Since the vast
majority of clinical trials relating to
periodontitis therapy have been con-
ducted using curettes and/or scalers,
hand instrumentation is generally
regarded as the gold standard.
Although there is limited evidence of
clinical efficacy and safety, there is
an apparent trend among clinicians
to give preference to machine-
driven instruments for subgingival
debridement.
The purpose of this systematic
review was to compare the effect
of machine-driven instruments and
hand instruments in the treatment of
periodontitis using clinical outcome
variables.
Machine-driven and manual debridement
Material and methods
Development of the systematic review
protocol
Study selection
This was a systematic review of
randomized controlled clinical trials
with a follow-up period of at least
6 months. Six-month data were
required on clinical outcome variables
and had to be presented on a subject
basis. For time needed for treatment
and adverse effects there was no mini-
mal observation period and site-based
data were accepted. Studies in which
the operator was given a time limit for
the treatment were excluded from the
review. Subjects had to suffer from
chronic periodontitis that was treated
by means of mechanical debridement
with no adjunctive therapy. Periodon-
titis was defined by clinical attachment
loss or alveolar bone loss of 1 mm or
more and a pocket probing depth of
4 mm or more, and gingival inflamma-
tion was assessed by bleeding on prob-
ing or by a gingival index. Since the
definition of periodontitis is generally
not presented, studies were also
included that provided no information
on the criteria used for the diagnosis of
periodontitis. Studies on the treatment
of aggressive periodontitis, periodon-
titis as a manifestation of systemic dis-
eases, necrotizing periodontal diseases,
abscesses of the periodontal tissue, peri-
odontitis associated with endodontic
lesions, or developmental or acquired
deformities and conditions were excluded
from the review.
As test therapy for periodontitis,
supra- and subgingival debridement by
means of machine-driven instruments
was assessed. Machines currently used
for subgingival debridement generate
either an oscillating or a rotary working
motion. Thus, sonic scalers, piezo-
electric or magnetostrictive ultrasonic
scalers, oscillating files, and rotary
burs were included. As control therapy,
supra- and subgingival debridement
using hand instruments, i.e. all instru-
ments activated solely by the operator’s
hand, was assessed. Studies investi-
gating surgical interventions were
excluded.
It was intended to use the preven-
tion of tooth loss as primary outcome
variable. Tooth survival is of tangible
benefit to the subject as biopsycho-
social evaluations have indicated
(Locker & Slade 1994, Nuttall et al.
2001). However, in case only scant
73
data on the effect of the test therapy
on tooth loss due to periodontitis was
retrieved, the first (in the sequence
listed below) of the secondary out-
come variables with sufficient data
for a meaningful comparison was
used as the primary outcome variable.
The following surrogate parameters
were used as secondary outcome
variables. The order in which the
parameters are listed reflects their
descending value as a surrogate for
the primary outcome variable: pre-
vention of disease progression as
assessed by the incidence of a loss of
2 mm or more in clinical attachment
level (iCAL-L) or alveolar bone
(iAB-L); resolution of anatomical
defects associated with periodontitis
as assessed by mean gain in clinical
attachment level (mCAL-G) or mean
reduction in pocket probing depth
(mPPD-R); resolution of gingival
inflammation as assessed by the
reduction in mean bleeding on prob-
ing (mBOP-R) or mean gingival index
(mGI-R); prevention of acute exacer-
bations of periodontitis as assessed by
the incidence of periodontal abscesses
(iPA). Efficiency was assessed by the
mean time (in minutes) needed to
treat one tooth. As adverse effects,
the following parameters were assessed:
gingival recession (GR), soft tissue
trauma, root damage, root roughness,
and root hypersensitivity (mRH).
Searching
In free text the following search was
performed in the literature databases
MEDLINE (from 1966), Cochrane
Controlled Trials Register (from
1966), BIOSIS (from 1970),
EMBASE (from 1974), HEALTH
DEVICES ALERTS (from 1983),
MEDITEC (from 1968), RUSSMED
ARTICLES (from 1988), and SCI-
SEARCH (from 1974) up to and
including April 2001: (CLINICAL-
TRIAL [pt] OR (clinic* AND trial*)
OR (clinic* AND study*)) AND ((dent*
AND scal*) OR (root* AND plan*) OR
debrid* OR (root* AND instrument*)
OR (subging* AND curettag*) OR
(dent* AND deposit*) OR (dent*
AND plaque*) OR (dent* AND
calcul*)) AND (sonic* OR ultrasonic*
OR oscillat* OR reciprocat* OR rotat*
OR diamond* OR (air* AND abras*)
OR perioplan* OR periopolish* OR
rootshap* OR power-driven* OR
machine-driven*) NOT valv* NOT
74 Tunkel et al.
toothbrush* NOT canal* NOT
arthro*. Using MESH categories, a
search was performed in the literature
database MEDLINE (from 1966):
CLINICAL-TRIAL [pt] AND (dental-
scaling OR root-planing OR peri-
odontitis-therapy OR dental-deposits
OR dental-plaque-therapy OR subgingival
curettage OR dental-prophylaxis-
instrumentation OR dental-calculus-
therapy OR periodontal-pocket-therapy)
AND (ultrasonics OR sonication
OR air abrasion). In addition, the
reference lists from the selected art-
icles were checked for further studies
qualifying for the review. Only
articles written in English were
selected.
Validity assessment
Titles and abstracts from studies iden-
tified by the above search strategy
were screened by two reviewers inde-
pendently (J.T. and T.F.F.) for inclu-
sion in the review. Disagreements
were resolved by discussion. Full text
of studies selected by the screening
process were evaluated for inclusion
by two reviewers (J.T. and T.F.F.)
according to the inclusion and exclu-
sion criteria. Agreement was evalu-
ated by unweighted kappa scores on
a 2  2 contingency table. The selec-
tion criteria were applied to a subset
of potentially relevant studies to iden-
tify areas of disagreement and lack of
clarity in the selection criteria. Dis-
agreement regarding inclusion was
resolved by discussion. A kappa
score of >0.81 was regarded as almost
complete agreement, and a kappa
score of 0.61–0.80 as substantial
agreement.
The methodological quality of the
studies was assessed independently by
the two reviewers using a predeter-
mined appraisal form that focused
on the following issues: method of
randomization, allocation conceal-
ment, blindness of clinicians/exam-
iners and completeness of follow-up.
The randomization method (i.e. the
method used to generate the random-
ization sequence) was classified as
adequate when random number
tables, tossed coin or shuffled cards
were used. The method was deemed
inadequate when other randomiza-
tion methods were used, e.g. alternate
assignment, hospital number, odd/
even birth date, and it was considered
unclear when the randomization
method was not reported or
explained.
Allocation concealment, i.e. how
the randomization sequence was
concealed from the therapists, was
classified as adequate when examiners
were kept unaware of the random-
ization sequence, e.g. by means of
central randomization or sequentially
numbered opaque envelopes. Con-
cealment was deemed inadequate
when other allocation concealment
methods were used, e.g. alternate
assignment, hospital number or odd/
even birth date, and it was considered
unclear when the allocation conceal-
ment method was not reported or
explained.
In the present assessment, single
instead of double blinding was used
since it is unreasonable to assume that
a conscious subject could be blinded
with regard to machine-driven and
manual subgingival debridement. Thus,
blinding was used only for the
examiner assessing the treatment out-
come. Blindness of examiners with
regard to treatment alternatives used in
the trial was dichotomously determined
(yes/no). Completeness of follow-up
was assessed dichotomously (yes/no)
by answering the following questions
relating to the information provided
by the papers: Was the number of
subjects at baseline and at completion
of the follow-up interval reported
for both groups? Were reasons given
for individuals not completing the
study?
Quantitative data synthesis
The significance of discrepancies in
the estimates of the treatment effects
from different trials was assessed by
Cochran’s test of heterogeneity. In
the event of any significant hetero-
geneity (P < 0.1) being detected, it was
planned to reassess the significance
of the treatment effects by using a
random effects model. If heterogeneity
was not significant, it was continued
with a fixed effects model. The stand-
ardized difference was assessed as
estimator and the weighted mean of
these differences was used as estimator
for the overall effect according to
Fleiss (1993).
The protocol was peer reviewed
by members of the Cochrane Oral
Health Group prior to commencing
the review.
Results
Study characteristics
A total of 419 abstracts were screened:
391 were retrieved from the databases
and 28 from the reference lists of pre-
liminarily included articles. 27 articles
were then selected for inclusion (Fig. 1).
The weighted kappa score for agree-
ment between the two reviewers on
the inclusion of abstracts was 0.77,
95% CI: 0.650–0.891, indicating
substantial agreement. Disagreement
regarding inclusion was resolved by
discussion.
Sixteen of the 27 studies included
after screening of titles and abstracts
were initially excluded during verifi-
cation of study eligibility. Since the
data from these studies could not
answer the clinical question that
should be addressed, the eligibility
criteria were set to also include studies
that had used a site-based statistical
analysis. This resulted in the inclusion
of two further studies, i.e. a total of
13 studies have been included for the
final review (Table 1).
The machine-driven instruments
assessed included ultrasonic scalers
(Badersten et al. 1981, 1984, Belting
& Spjut 1964, Copulos et al. 1993,
Dragoo 1992, Johnston & De Marco
1974, Kerry 1967, Moskow & Bressman
1964, Stewart et al. 1967, Torfason et al.
1979, Yukna et al. 1997), sonic scalers
(Johnston & De Marco 1974, Kocher
et al. 2001, Laurell & Pettersson 1988),
an air-turbine driven 6-sided rotary
instrument, and a vibratory air-driven
handpiece (Belting & Spjut 1964). Only
ultrasonic/sonic scalers were assessed
with an oscillating motion that is per-
pendicular to the long axis of the work-
ing tip. No reports were found on
ultrasonic instruments with an oscillat-
ing motion that is parallel to the long
axis of the working tip.
Two studies (Boretti et al. 1995,
Oosterwaal et al. 1987) were excluded
because their data covered only 1 and
1.5 months, respectively, five reported
only qualitative data concerning
adverse effects (Ewen et al. 1976,
Garnick & Dent 1989, Jones et al.
1972, McCall & Szmyd 1960, Schaffer
et al. 1964), and three presented no
data for the desired types of outcome
measurements (Biagini et al. 1988,
Gellin et al. 1986, Sanderson 1966).
In one study the time needed for
treatment was only provided for
quadrants and not for a single tooth

419 titles &
abstracts
27 full text
articles
16 studies excluded
2 studies re-included
after revision of inclusion criteria
Fig. 1. Numbers of articles screened and included for the systematic review.
(Forrest 1967). The study by Van
Volkinburg et al. (1976) was an in
vitro study, that by Suppipat (1974)
was a review article, and that by
Hou et al. (1987) could not be
retrieved as a full article. There was
no study comparing machine-driven
vs. manual subgingival debridement
on tooth survival or the prevention
of disease progression. Only four
studies were found to fulfill all criteria
of study eligibility and provided data
on mCAL-G, mPPD-R and BOP-R
(Badersten et al. 1981, 1984, Copulos
Table 1. Reasons for exclusion of studies
Study
Biagini et al. 1988
Boretti et al. 1995
Ewen et al. 1976
Forrest 1967
Garnick & Dent 1989
Gellin et al. 1986
Hou et al. (1987)
Jones et al. 1972
McCall & Szmyd 1960
Oosterwaal et al. 1987
Sanderson 1966
Schaffer et al. 1964
Suppipat (1974)
Van Volkinburg et al. 1976
Machine-driven and manual debridement
Included studies
1 data provided by Kocher et al. 2001
clinical outcome
2 A meta-analysis on clinical outcome
time
4 et al. 2001), treatment was performed
adverse effects
1
clinical outcome & time
3 (Badersten et al. 1981, 1984, Copulos
time & adverse effects
2 1997). Four trials investigated single-
clinical outcome, time &
adverse effects
et al. 1993, Kocher et al. 2001)
(Table 2). Three trials assessed only
single-rooted teeth (Badersten et al.
1981, Badersten et al. 1984, Kocher
et al. 2001). Both studies by Badersten
et al. (1981, 1984) were excluded from
meta-analysis since the site was used
as a statistical unit, no information
about standard deviations was pro-
vided, and the raw data could not be
retrieved from the authors. Mean
values and standard deviations for
mCAL-G, mPPD-R and BOP-R of
test and control groups were available
Reason for exclusion
No data for the desired types of outcome measurements
1-month data only
Only qualitative data for adverse effects
Time needed to treat for quadrants only
Only qualitative data for adverse effects
No data for the desired types of outcome measurements
Full article not available
Only qualitative data for adverse effects
Only qualitative data for adverse effects
1.5-month data only
No data for the desired types of outcome measurements
Only qualitative data for adverse effects
Review article
In vitro study
75
for two studies (Kocher et al. 2001,
Copulos et al. 1993). Unpublished
allowed calculation of mean values
and standard deviations of probing
depth for all groups combined.
variables was not performed since the
design of the available studies differed
substantially. In one study (Kocher
using a modified sonic scaler tip
during initial therapy and in another
study (Copulos et al. 1993), treatment
was performed during supportive
periodontal therapy (SPT).
Data on the time needed for treat-
ment was provided by eight studies
et al. 1993, Dragoo 1992, Laurell &
Pettersson 1988, Moskow & Bressman
1964, Torfason et al. 1979, Yukna et al.
rooted teeth only (Badersten et al.
1981, 1984, Torfason et al. 1979,
Yukna et al. 1997). All studies present-
ing data on the time needed to treat a
single tooth were included irrespective
of the study design, i.e. parallel group
or split-mouth, or whether the subject
or the site was used as a statistical
unit. It was assumed that these factors
would have only a negligible effect, if
any, on the time required for therapy.
Three studies providing data regarding
instrumentation time during initial
and supportive periodontal therapy
(Badersten et al. 1981, 1984, Torfason
et al. 1979) showed that, in general,
each operator used somewhat more
time for the treatment during initial
compared with supportive periodontal
therapy. Therefore, these data are pre-
sented separately. For initial therapy,
seven studies provided data (Badersten
et al. 1981, 1984, Dragoo 1992, Laurell
& Pettersson 1988, Moskow &
Bressman 1964, Torfason et al. 1979,
Yukna et al. 1997). From only two
studies could the standard deviations
be retrieved (Laurell & Pettersson
1988, Yukna et al. 1997). Hence only
these two studies were used for meta-
analysis. For supportive periodontal
therapy, five studies presented data
on the mean time required for one
tooth (Badersten et al. 1981, 1984,
Copulos et al. 1993, Torfason et al.
1979). Only one paper (Copulos et al.
1993) provided standard deviations.
Thus, a meta-analysis could not be
76 Tunkel et al.
performed for the time needed to treat
one tooth during supportive peri-
odontal therapy.
Adverse effects following machine-
driven and hand instrumentation were
reported in nine studies (Badersten et al.
1981, 1984, Belting & Spjut 1964,
Dragoo 1992, Johnston & De Marco
1974, Kerry 1967, Moskow & Bressman
1964, Stewart et al. 1967, Yukna et al.
1997). Five trials investigated single-
rooted teeth only (Badersten et al.
1981, 1984, Belting & Spjut 1964,
Kerry 1967, Yukna et al. 1997). No
meta-analysis could be performed
from the nine studies presenting data
on adverse effects. The methods of
determining adverse effects differed
considerably between trials. Adverse
effects were categorized as either more
severe or more frequent, depending on
the type of outcome measurement in
the test group, more in the control
group, or equal in both groups.
Little information was provided on
the experience of the operator. The
subgingival debridement in the study
by Stewart et al. (1967) was performed
by third- and fourth-year students.
Copulos et al. (1993) and Laurel &
Pettersson (1988) reported that instru-
mentation was rendered by dental
hygienists. Subgingival debridement
in the trial by Dragoo 1992 was per-
formed by five dentists, each with at
least 10 years of clinical experience. In
four papers (Badersten et al. 1981,
1984, Belting & Spjut 1964, Yukna
et al. 1997) the instrumentation was
rendered by one or more of the
authors. Yukna et al. (1997) described
the skill of the operating dentists as
ranging from ‘novice to 20 years of
experience’ (Table 2).
Methodological quality of included studies
Six of the 13 included studies were
described as randomized (Badersten
et al. 1981, 1984, Copulos et al.
1993, Johnston & De Marco 1974,
Laurell & Pettersson 1988, Yukna
et al. 1997). In all trials, however,
randomization methods remained
unclear. In none of the included
studies was allocation concealment
found. Examiner blinding was evident
in nine studies (Badersten et al. 1981,
1984, Copulos et al. 1993, Johnston &
De Marco 1974, Laurell & Pettersson
1988, Moskow & Bressman 1964,
Stewart et al. 1967, Torfason et al.
1979, Yukna et al. 1997). Information
about withdrawals and dropouts was
not provided in any of the included
studies except in that by Copulos et al.
(1993) who reported that all nine sub-
jects entering the study completed it.
In the study by Moskow & Bressman
(1964) five teeth were lost due to frac-
ture during extraction, but it
remained unclear in which group
these teeth were. Unpublished data
by Kocher et al. (2001) revealed that
one subject failed to report for the
final 6-month examination.
Clinical outcome variables
The four pertinent studies including a
total of 50 subjects failed to demon-
strate a statistically significant differ-
ence between ultrasonic/sonic and
manual subgingival debridement in
the treatment of periodontitis when
mCAL-G, mPPD-R and mBOP-R
were used as variables. Since meta-
analysis could not be performed, the
comparisons were made within each
study (Tables 3–5).
Time needed to treat one tooth
The meta-analysis included only two
studies (Laurell & Pettersson 1988,
Yukna et al. 1997) (Table 6). For
initial therapy the debridement with
ultrasonic/sonic instruments took on
average 36.7% less time than the
treatment with hand instruments
(P ¼ 0.0002, 95% CI of the standard-
ized effect estimate: 0.39–1.3 L,
heterogeneity P ¼ 0.77). In SPT,
although no meta-analysis could be
performed, the data indicated that
subgingival debridement as part of
supportive periodontal therapy may
be performed in less time with
machine-driven instruments than
with hand instrument.
Adverse effects
No data were available on root sensi-
tivity. Utilizing the categorization, all
kinds of adverse effects were revealed
with similar frequency in both treat-
ment regimes (Table 7). Five studies
provided information on root damage
or root roughness (Belting & Spjut
1964, Dragoo 1992, Kerry 1967,
Moskow & Bressman 1964, Yukna
et al. 1997). Three studies found more
adverse effects in the machine-driven
group (Belting & Spjut 1964, Kerry
1967, Yukna et al. 1997), one trial
more damage in the hand instrumen-
tation group (Moskow & Bressman
1964) and one study no difference
between treatment methods (Dragoo
1992). Regarding soft tissue trauma,
one study found more adverse effects
in the hand instrumentation group
(Johnston & De Marco 1974), while
three found no difference between
treatment modalities (Badersten et al.
1981, 1984, Stewart et al. 1967).
Discussion
For the inclusion of studies in the
systematic review, stringent criteria
were employed resulting in only four
reports on clinical outcome variables.
Two of the studies reported data that
were analyzed based on the subject as
the statistical unit (Kocher et al. 2001,
Copulos et al. 1993) and in two, the
site was used for analysis (Badersten
et al. 1981, 1984). Since site-based
analysis did not show differences at
a significance level of P < 0.05, it
was considered reasonable to assume
that a subject-based analysis of the
same data would also fail to detect a
statistically significant difference.
Since tooth survival is of tangible
benefit to the subject (Locker & Slade
1994, Nuttall et al. 2001), it would be
desirable to evaluate which therapy is
superior in preventing tooth loss.
However, it is recognized that tooth
survival is difficult to assess in a pro-
spective manner due to the rare inci-
dence of spontaneous tooth loss and
confounding factors, e.g. extraction
by a dentist, large subject sample,
and long-term follow-up. Thus, it
was not surprising that no study
reported tooth survival rates.
If the maintenance of teeth is the
primary goal of subgingival debride-
ment, preventing further attachment
loss may be a valuable surrogate out-
come variable (Hujoel et al. 1999).
However, due to the short duration,
i.e. 6 months, of the included trials,
the effect of the assessed treatments
on periodontal disease progression
was not determined. Thus only
mCAL-G and mPPD-R as well as
mBOP-R representing the clinical
inflammatory status could be used as
surrogate outcome variables. In all
four included trials, mCAL-G,
mPPD-R, and mBOP-R were similar
following machine-driven and hand
instrumentation. Despite mPPD-R
being quite similar, the low mCAL-G
Table 2. Characterstics of included studies (*derived from figures)
Study Methods Participants Interventions Outcomes Notes
Badersten et al. RCT, split-mouth, 15 individuals, aged 22–60, instrumentation at baseline, secondary outcome variables: university-based, single-rooted
1981 2 treatment groups, aged 22–60, with moderately, after 2 and 6 months; 1) mCAL-G* teeth only, operators: authors, site-based
12 months’ duration advanced periodontal disease 1) Test: ultrasonic scaler Dentsply 2) mPPD-R* analysis
264 surfaces in each group Cavitron 600, TF1-10 tip 3) mBOP-R*
2) Control: Ash or Columbia 4) mean time needed to treat
curettes, as preferred by the one tooth
operator
Badersten et al. RCT, split-mouth, 16 individuals, aged 38–58, instrumentation at baseline, secondary outcome variables: university-based, single-rooted teeth only,
1984 2 treatment groups, 5 females, with severely after 3 and 6 months; 1) mCAL-G* operators: authors, site-based analysis
24 months’ duration advanced periodontal disease, 1) Test: ultrasonic scaler 2) mPPD-R*
426 surfaces in each group Dentsply Cavitron 600, 3) mBOP-R*
TF1-10 tip 4) mean time needed to treat
2) Control: Ash or Columbia one tooth
Curettes as preferred by the
operator
Belting & Spjut CT, parallel group design, 29 teeth in the control group, 1) Test 1: ultrasonic adverse effects: university-based, single-rooted teeth only,
1964 4 treatment groups, 30 in test groups 1 and 2, prophylaxis unit 1) root damage operator: author, site-based analysis
debridement of teeth 15 in test group 3, extraction 2) Test 2: air-turbine driven
prior to extraction indicated for various reasons 6-sided rotary instrument
3) Test 3: vibratory air-driven
hand piece
4) Control: curettes
Copulos et al. RCT, split-mouth, 9 individuals, aged 23–73 instrumentation at baseline, secondary outcome variables: university-based, operators: dental
1993 2 treatment groups, patients (mean 53.2), after 3 and 6 months; 1) mCAL-G hygienists, patient-based analysis, SPT
6 months’ duration 2 females, with 1) Test: modified ultrasonic 2) mPPD-R
history of periodontal disease, scaler Dentsply 3) mBOP-R
45 sites in each group 2) Control: Gracey curettes 4) mean time needed to treat
one tooth
Dragoo 1992 CT, parallel group design, 168 root surfaces altogether, 1) Test 1: ultrasonic scaler secondary outcome variables: private practice, operators: dentists
3 treatment groups, 74 surfaces in test group 1, 18 Cavitron (Dentsply) with 1) mean time needed to treat and dental hygienists (experienced),
debridement of teeth prior in test group 2 and 76 in the EW P10-tip one tooth site-based analysis
to extraction control group, extraction 2) Test 2: ultrasonic scaler adverse effects:
indicated for periodontal or Cavitron (Dentsply) with 1) root damage
prosthetic reasons modified EW P10-tip
3) Control: routine hand
instruments
Johnston & RCT, split mouth, 24 individuals, 1) Test 1: ultrasonic scaler adverse effects: university-based, site-based analysis
De Marco 1974 4 treatment groups, 48 teeth in each group Cavitron 600 (Dentsply) 1) soft tissue trauma (2 teeth per patient)
immediate results 2) Test 2: Orbison (laceration)
prophylaxis unit
3) Control: Gracey curettes
4) negative control:
no treatment
Machine-driven and manual debridement
77
 78

Table 2. Continued
Study Methods Participants Interventions Outcomes Notes
Tunkel et al.

Kerry 1967 CT, parallel group design, 36 teeth in each treatment 1) Test 1: ultrasonic scaler adverse effects: university-based, single-rooted teeth only,
3 treatment groups, group, extraction indicated for Cavitron (Dentsply) with 1) root roughness scaling performed on the cervical third of
debridement of teeth prior various reasons, individuals EW PP-tip the root surfaces only, operators: three
to extraction aged 22–70 (mean 47.4) 2) Test 2: ultrasonic scaler operators, site-based analysis
Cavitron (Dentsply) with EW P10-tip
3) Control: Bunting curettes
Kocher et al. CT, split-mouth, 10 individuals, aged 35–61 instrumentation at baseline ; secondary outcome variables: university-based, single-rooted teeth only,
2001 4 treatment groups, (mean 46), with moderate to and after 3 months 1) mCAL-G patient-based analysis
6 months’ duration advanced periodontal disease, 1) Test 1: KaVo Sonicflex 2) mPPD-R
20 teeth in each group 2000 with Teflon-coated tip 3) mBOP-R
(prototype) at both instrumentations
2) Control: Gracey Curettes
(HU Friedy) at both
instrumentations
Laurell & RCT, split mouth, 12 individuals, aged 36–55, 1) Test: Titan S sonic scaler secondary outcome variables: university-based, patient-based analysis
Pettersson 1988 2 treatment groups, 7 females, with moderately 2) Control: hand instruments 1) mean time needed to treat
debridement of teeth prior advanced periodontal disease one tooth
to extraction
Moskow & CT, parallel group design, 53 teeth in test group, 42 teeth 1) Test: ultrasonic scalers secondary outcome variables: university-based, site-based analysis
Bressman 1964 2 treatment groups, in control group, extraction (nos. P-7, P-41, P-4r, P-9) 1) mean time needed to treat
3 months’ duration indicated for prosthetic or 2) Control: Columbia and one tooth
periodontal reasons McCall curettes adverse effects:
1) root damage
Stewart et al. CT, split mouth, 92 individuals aged 18–66, 1) Test: ultrasonic instrument adverse effects: university-based, operators: 3rd-year and
1967 2 treatment groups, 96 quadrants altogether 2) Control: hand instruments 1) soft tissue trauma assessed 4th-year students, patient-based analysis
immediate results by gingival bleeding
Torfason et al. CT, split-mouth, 18 individuals, aged 19–61 instrumentation at baseline secondary outcome variables: university-based, single-rooted teeth only,
1979 2 treatment groups, (mean 44), with periodontal 1) Test: ultrasonic scaler 1) mean time needed to treat operators: four operators, site-based
2 months’ duration disease, 51 teeth and 306 Dentsply Cavitron 600, one tooth analysis
measuring points in each group P-10 tip
2) Control: Ash or Gracey
curettes as preferred by the operator
Yukna et al. RCT, split-mouth, 15 individuals, 1) Test 1: plain ultrasonic secondary outcome variables: university-based, single-rooted teeth only,
1997 4 treatment groups, 20 teeth in each group 2) Test 2: fine grit diamond 1) mean time needed to treat operators: three operators from novice to
immediate results coated ultrasonic one tooth 20 years experience, site-based analysis
3) Test 3: medium grit diamond adverse effects:
coated ultrasonic 1) root roughness
4) Control: hand curettes
 Machine-driven and manual debridement 79

Table 3. Mean attachment level gain (mCAL-G) following machine-driven instrumentation and mBOP-R reported by Copulos
(MDI) and hand instrumentation (HI) as presented in the included studies; SD: standard et al. (1993) compared with that
deviation; Stat. analysis: Statistical analysis based on a subject or site basis reported by Badersten et al. (1981,
Statistical mCAL-G mCAL-G 1984) and Kocher et al. (2001) may
Study Treatment phase analysis SD HI (mm) SD MDI (mm) be explained by the difference in
Badersten et al. 1981 Initial therapy Site 0.30 0.50 study design. Copulos et al. (1993)
Badersten et al. 1984 Initial therapy Site 0.50 0.20 assessed the treatments in subjects
Kocher et al. 2001 Initial therapy Subject 0.53  1.16 0.71  1.07 receiving supportive periodontal ther-
Copulos et al. 1993 SPT Subject 0.10  1.71 0.20  1.34 apy, whereas the other authors used
subjects with untreated periodontitis.
Regarding multirooted teeth, the
Table 4. Mean pocket probing depth reduction (mPPD-R) following machine-driven presented data should be inter-
instrumentation (MDI) and hand instrumentation (HI) as presented in the included studies; preted with caution since three trials
SD: standard deviation; Stat. analysis: Statistical analysis based on a subject or site basis
(Badersten et al. 1981, 1984, Kocher
Statistical mCAL-G mCAL-G et al. 2001) investigated only single-
Study Treatment phase analysis SD H1 (mm) SD MDI (mm)
rooted teeth, whereas in the study by
Badersten et al. 1981 Initial therapy Site 1.00 1.20 Copulos et al. (1993) the type of teeth
Badersten et al. 1984 Initial therapy Site 1.40 1.20 included remains unclear. Anatomical
Kocher et al. 2001 Initial therapy Subject 0.77  0.80 1.10  0.70 studies revealed that most furcation
Copulos et al. 1993 SPT Subject 0.72  1.09 0.75  1.20
entrances are too small to be access-
ible to regular hand instruments
(Bower 1979). Thus the effectiveness
Table 5. Mean reduction of bleeding on probing (mBOP-R) following machine-driven of the small sonic and ultrasonic
instrumentation (MDI) and hand instrumentation (HI) as presented in the included studies; scaler tips might be favorable in
SD: standard deviation; Stat. analysis: Statistical analysis based on a subject or site basis
molar furcation areas, as indicated
Statistical
Study Treatment phase analysis mBOP-R MDI (%) mBOP-R HI (%)
by in vitro and in vivo studies (Leon
& Vogel 1987, Oda & Ishikawa 1989).
Badersten et al. 1981 Initial therapy Site 64 63 Due to the lack of clinical data, the
Badersten et al. 1984 Initial therapy Site 51 52 potential benefit of machine-driven
Kocher et al. 2001 Initial therapy Subject 42.7 56.9
Copulos et al. 1993 SPT Subject 5.5 2.2
instruments concerning healing out-
come of multirooted teeth could not
be evaluated.
The time required to complete a
Table 6. Mean time needed to treat one tooth during initial or supportive periodontal therapy treatment has a direct effect on the
of the machine-driven instrumentation (MDI) and hand instrumentation (HI) as presented in
the included studies; SD: standard deviation cost–benefit ratio. Therefore, if there
Time Time
is no difference between two therapies
Study Treatment phase SD MDI (min) SD HI (min) in clinical benefit, the one that can be
performed in less time may be prefer-
Badersten et al. 1981 Initial therapy 5.35 6.15 able. The present meta-analysis
Badersten et al. 1984 Initial therapy 6.85 6.85
Dragoo 1992 Initial therapy 7.55 9.60
clearly revealed that ultrasonic/sonic
Laurell & Pettersson 1988 Initial therapy 8.00  3.0 12.00  5.0 subgingival debridement can be com-
Moskow & Bressman 1964 Initial therapy 3.30 3.80 pleted in less time than subgingival
Torfason et al. 1979 Initial therapy 3.00 3.80 debridement using hand instruments.
Yukna et al. 1997 Initial therapy 2.80  1.3 4.80  3.2 Studies assessing both time needed for
Badersten et al. 1981 SPT 0.35 0.40
Badersten et al. 1984 SPT 1.35 1.30
treatment and clinical outcome vari-
Copulos et al. 1993 SPT 3.90  1.20 5.90  2.10 ables consistently demonstrated that
Torfason et al. 1979 SPT 2.10 2.40 although ultrasonic/sonic instruments
require less time in subgingival debride-
ment than hand instruments, the clin-
Table 7. Categorization of the different reported adverse effects into more adverse effects in ical effects are similar (Badersten et al.
the machine-driven instrumentation (MDI) group, more in the hand instrumentation (HI) 1981, 1984, Laurell & Pettersson 1988,
group, and no difference between the two groups Torfason et al. 1979).
Adverse effects Assuming two treatment modalities
Study Measurement More MDI More HI No difference to be equally effective, possible
adverse effects become more import-
Badersten et al. 1981 gingival recession + ant, especially if they influence subject
Badersten et al. 1984 gingival recession + comfort. The adverse effects evalu-
Stewart et al. 1967 gingival bleeding +
Johnston & De Marco 1974 soft tissue laceration (scale) + ated in this review have an impact
Belting & Spjut 1964 root damage (category) + on anatomical structures but do not
Dragoo 1992 root damage (scale) + influence the subject’s well-being.
Kerry 1967 root roughness score + The effect on clinical outcome
Moskow & Bressman 1964 root grooving + can be assumed to be minimal since
Yukna et al. 1997 root roughness (category) +
root roughness appears to have no
80 Tunkel et al.
influence on healing after debride-
ment procedures (Oberholzer &
Rateitschak 1996). Nonetheless, a
possible cumulative effect of substance
removal might become a serious prob-
lem regarding tooth survival over
time, as indicated by in vitro studies
(Flemmig et al. 1997, 1998a, 1998b,
Zappa et al. 1991). Adverse effects
regarding soft tissue trauma seem to
be equally distributed between the
two treatment modalities or slightly
more pronounced when utilizing hand
instruments. Histological trials have
indicated that, except for possible sub-
ject discomfort, the clinical effect of
soft tissue trauma as investigated in
the included trials can be assumed to
be minimal (Biagini et al. 1988, Ewen
et al. 1976).
The methodological quality of the
13 included studies revealed that none
of the trials provided sufficient infor-
mation concerning methods of ran-
domization, allocation concealment,
blindness of examiners and complete-
ness of follow-up. It is recommended
that investigators and authors prepar-
ing and reporting controlled clinical
trials should follow the CONSORT
guidelines (Begg et al. 1996, CON-
SORT 2001, Moher et al. 2001)
which provide clear-cut guidance on
design and presentation of trial
reports.
Conclusions
Implications for practice
* There appeared to be no difference
in the efficacy of subgingival debride-
ment using ultrasonic/sonic and
hand instruments in the treatment
of chronic periodontitis in single-
rooted teeth.
* For multirooted teeth, no evidence
on the efficacy of machine-driven
instruments was found.
* Subgingival debridement may be
completed in less time with ultra-
sonic/sonic than with hand instru-
ments.
* There appeared to be no major
difference in the frequency and
severity of adverse effects follow-
ing the two treatment modalities;
however, the evidence supporting
this is weak.
* No information on the clinical
efficacy of rotary burs or oscillating
files compared with hand
instrumentation could be retrieved.
* No information on any of the
assessed parameters was found for
ultrasonic instruments with an
oscillating motion parallel to the
long axis of the working tip.
Implications for research
1 High quality controlled randomized
clinical trials are needed to assess
the clinical efficacy of machine-
driven subgingival debridement.
These should include the assessment
of:
* periodontal disease progression
or tooth survival as primary out-
come variables;
* multirooted teeth
biopsychosocial aspects (e.g. com-
*
fort, esthetics);
* adverse effects (e.g. root sensi-
tivity, pain);
* health and safety of the operator.
2 Cost-effectiveness of different
modes of subgingival debridement
should be determined.
3 When designing and reporting
studies, researchers and authors
should pay greater attention to
improved study quality with refer-
ence to the CONSORT guidelines.
This would facilitate evaluation of
these studies after publication.
Acknowledgments
The authors are indebted to Dr. Ian
Needleman and Dr. Helen Worthington
for their guidance in preparing the
systemic review and to Dr. Oliver Obst,
Muenster University Library, for his
help in developing the search strategy.
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Address:
Thomas F. Flemmig, Prof. Dr med. dent.
Department of Periodontology
University Clinic Muenster
Waldeyerstr. 30
48149 Muenster
Germany
Tel: þ49 251 83 47059
Fax: þ49 251 83 47134
e-mail: flemmig@uni-muenster.de