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Ultrasonics 101 (2020) 106035

Contents lists available at ScienceDirect

Ultrasonics
journal homepage: www.elsevier.com/locate/ultras

On the use of ultrasonic dental scaler tips as cleaning technique of T


microfiltration ceramic membranes
M.A. Bazána, V. Carpintero-Tepolea, E. Brito-de la Fuenteb, E. Driolic, G. Ascanioa,

a
Instituto de Ciencias Aplicadas y Tecnología, Universidad Nacional Autónoma de México, P.O. Box 70-186, 04510 CdMx, Mexico
b
Innovation & Development Product & Process Engineering Center, Pharmaceuticals Division, Fresenius Kabi Deutschland GmbH, Rathausplatz 12, D-61352 Bad Homburg,
Germany
c
Institute On Membrane Technology, ITM-CNR, c/o University of Calabria, Via P. Bucci, 17/C, I-87030 Rende, Cosenza, Italy

ARTICLE INFO ABSTRACT

Keywords: The use of ultrasonic dental scaler (UDS) tips has been investigated for cleaning ceramic membranes fouled when
Ultrasonic dental scaler tips filtering cactus juice. Thin and long tips having a larger coverage exhibited the best performance for removing
Ceramic membrane the cake layer deposited on the membrane surface. Such tips cleaned an area equivalent to almost one third of
Microfiltration total area of the membrane surface. However, the cleaned area could be increased notoriously if the membrane
were placed in rotatory disc holder. The resistance-in series model and atomic force microscopy (AFM) technique
helped to reveal the effect of the UDS tips as cleaning process of ceramic membranes. The reversible resistances
estimated for UDS tips were 58% and 17% lower than the ones obtained by chemical cleaning at transmembrane
pressures of 0.3 bar and 0.5 bar, respectively. This was corroborated by microscope images, which showed the
detachment of cake layer of the membrane surface. Results of this work showed that UDS tips are an innovative
option as cleaning strategy for filtration membranes.

1. Introduction to the cleaning techniques include chemical costs, waste disposal, and
significant capital investments for equipment.
Microfiltration (MF) is currently used for clarification and sterile Ultrasonic cleaning has attracted attention as a potential alternative
filtration of many pharmaceutical and biotechnological products [1]. or a supplementary technique to hydraulic and/or chemical cleaning
The main challenge of microfiltration, as a pressure-driven process, is [7]. The ultrasound technique has been studied on a variety of surfaces,
membrane fouling, which leads to a significant decline in permeate flux from delicate removal of particles on semiconductor wafers to removal
and changes in membrane selectivity overtime [2]. of scale and oxides from steel strips [8]. This technology generates
Fouling in MF processes are strongly dependent on the colloidal acoustic streaming and cavitation that can promote membrane vibra-
particles; fouling types include organic and inorganic fouling, bio- tion, disturb pollutant–to–membrane attachment, and possibly prolong
fouling and multi-fouling. Also, fouling can be residual, reversible or membrane life [4,8–11]. The effectiveness of ultrasound-assisted
irreversible; all of these increase the membrane filtration resistance and membrane filtration has been successfully applied during processing of
induce substantial decline in permeate flux [3]. systems such as dextran [12,13], waste waters [14], milk and bovine
A number of different chemical and physical methods are currently serum [15]. All these studies have been carried out using ultrasonic
used for cleaning filtration membranes [4]. Chemical cleaning is the baths or ultrasonic transducer elements integrated into membrane
most common method to recover permeability and performance of modules designed to allocate ultrasonic transducers. Flat sheets and
microfiltration membranes [5,6]. Chemical processes consume large tubular membranes have been the most used for these applications
volumes of expensive chemical reagents such as surfactants and caustic [15].
soda, which can themselves damage the membrane material and in turn An innovative option for cleaning fouled membranes is the use of
reduce the life span of the membrane. Physical cleaning methods, such ultrasonic dental scaler (UDS) tips, which have been successfully used
as back flushing and backwashing, are also applied to fouled mem- for removing plaque and calculus from teeth surface, periodontal
branes. However, these techniques interrupt the continuous filtration pockets and dental implants [11]. A transducer in the handpiece in-
process leading to longer processing time [4]. Other drawbacks related duces vibrations with frequencies in the ultrasonic range (25–30 kHz),


Corresponding author.
E-mail address: gabriel.ascanio@icat.unam.mx (G. Ascanio).

https://doi.org/10.1016/j.ultras.2019.106035
Received 10 January 2018; Received in revised form 12 September 2019; Accepted 24 September 2019
Available online 24 September 2019
0041-624X/ © 2019 Elsevier B.V. All rights reserved.
M.A. Bazán, et al. Ultrasonics 101 (2020) 106035

Nomenclature Rtot total resistance (m−1)


TMP transmembrane pressure (bar)
AFM atomic force microscope UDS ultrasonic dental scaler
Jcactus permeate flux of cactus juice (L⋅m−2⋅h−1) Vx cross-flow velocity (m⋅s−1)
Jv permeate flux
P pressure (bar) Greek symbols
Rirr irreversible resistance (m−1)
Rm resistance of the cleaned membrane (m−1) µ dynamic viscosity (Pa.s)
Rrev reversible resistance (m−1)

and the free end side of the tip is placed on the tooth, allowing the 2.3. Experimental strategy
mechanical removal of deposits on the surface [16–18]. UDS tips per-
formance (frequency, vibration motion and bacterial biofilm disrup- Cactus juice (Opuntia ficus indica) was used as plugging fluid of
tion) has been studied to understand and improve dental specialists ceramic membranes. Firstly, cladodes were macerated during 24 h to
techniques during routine teeth cleaning [10,11]; Performance of such concentrate the mucilage at a viscosity of 0.045 Pa⋅s and then it was
devices depends on the tip shape and design, as well as on the generator filtered using two-0.8 μm ceramic membranes (M1 y M2) for 30 min.
power. Thin and long tips generate larger amplitude vibrations than The operating conditions of MF process were TMP = 0.3 and 0.5 bar,
short tips [11]. Several in vitro studies have demonstrated that the best Vx = 0.02 m/s and room temperature (20 °C ± 2 °C). Membranes M1
performance of UDS tips is obtained when placing the tip parallel to the and M2 were fully recovered with chemical reagents before every MF
teeth surface at a distance between 0.25 mm and 0.5 mm [10,19]. run.
At our knowledge, the use of UDS tips as cleaning method of mi- After processing the cactus juice, the fouled membrane M1 was
crofiltration ceramic membranes has not been reported in the literature. placed into the disc holder to begin the cleaning process by using
Therefore, the purpose of this work is to evaluate the cleaning perfor- chemical reagents. Firstly, NaOH 15 g/L concentration in water dis-
mance of UDS tips on a ceramic membrane fouled during microfiltra- tilled, TMP = 0.3 bar at 50 °C for 30 min; followed by rinsing with pure
tion of cactus juice (Opuntia ficus indica). UDS tips were tested on fo- water. Second, NHO3 1.5 mL/L concentration in distilled water,
uled membranes to investigate the role of ultrasonic factors controlling TMP = 0.3 bar at 80 °C for 15 min, followed by rinsing with pure water.
the mechanisms of membrane cleaning. For that purpose, the re- The membrane M2 was placed into the disc holder with UDS tips, they
sistance-in series model and atomic force microscopy (AFM) techniques were operated with distilled water (with / without flow) during 30 min
were used to reveal the effects of UDS tips as cleaning process of at a constant frequency of 29 kHz with activation intervals of 15 s and
ceramic membranes. resting times of 20 s. Membrane M2 was rotated 45° while UDS was in
standby.
After each experiment, the membranes were regenerated by the
2. Materials and methods procedure of chemical cleaning as suggested by the supplier. It should
be noted that only one membrane was used for chemical cleaning (M1)
2.1. Microfiltration membranes and only one for ultrasound cleaning (M2). Tests were performed by
triplicate and results are reported in terms of the mean value and their
Inside DISRAM™ ceramic membranes (ZrO2-TiO2) of 0.8 μm from standard deviation. The statistical analysis was carried out by the non-
Tami industries® having 2.5 mm thickness, 47 mm diameter and a total parametric test Mann-Whitney U using the statistical software NCSS 12.
filtration area of 13.1 cm2 were used in this work. Water permeability
of ceramic membranes was determined before and after every MF run
2.4. Analysis of resistances
with deionized water (18.2 MΩ cm, 0.056 µS/cm) under a transmem-
(
brane pressure (TMP = 1 2 2
P +P
) P3 ) of 0.3 and 0.5 bar at 20 ± 2 °C. Resistance-in-series were calculated for a better understanding of

2.2. Microfiltration system

Fig. 1 shows the experimental setup used for filtering cactus juice
(Opuntia ficus indica). The membrane was installed into a 316-stainless
steel disc holder (maximum pressure: 4 bar) under the cross-flow con-
figuration. Fluid velocity was varied by means of a 75211-60 Micro-
pump™ having a flow rate from 0 to 1590 L/h. Pressure sensors (Cole-
Parmer®) were installed on the feed (P1), retentate (P2) and permeate
(P3) lines and the desired TMP was adjusted with clamp valves (Cole-
Parmer®). The feed volume was 500 mL and the TMP was adjusted from
0.2 a 0.5 bar. The permeate flow rate was measured by means of a di-
gital balance (Scout Ohaus® SPX6201) connected to a data acquisition
card, so that the mass rate was continuously registered.
The schematic diagram of ultrasonic scaler tip configuration into the
membrane holder is shown in Fig. 2. UDS tips used were 1 and 10P (P5
Booster Suprasson®), which provide a maximum power of 40 W and a
frequency ranging from 27 to 32 kHz. They were installed into the disc
holder at 0.75 mm from membrane surface, keeping the same distance
from the cell top. The cleaning process was carried out without and
with flow at low cross-flow velocity (Vx = 0.02 m/s). Fig. 1. Experimental setup used for filtering cactus juice.

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M.A. Bazán, et al. Ultrasonics 101 (2020) 106035

Fig. 2. Schematic diagram of UDS tips configuration into the membrane holder: (a) Top view; (b) cross section view.

the mechanisms of flux decline and the cleaning effect of UDS tips on 2.5. Membrane micrographs by atomic force microscopy
the ceramic membranes. According to the resistance-in-series model
[20,21], the permeate flux can be expressed as follows: To explain the flux decline and the cleaning power of UDS tips on
TMP the ceramic membranes, micrographs by atomic force microscopy
Jv = (AFM) were taken. Five membranes were studied, namely; M1 chemi-
µRtot (1)
cals cleaning; M2 UDS cleaning; M3 virgin; M4 fouled with cactus juice;
where Jv is the permeate flux (m/s), TMP is the transmembrane pres- and M5 damage by exceeding exposure time of UDS tip 10P. The
sure (kPa), Rtot is the total resistance (m−1) and μ is the fluid viscosity membrane section observed was 20 × 20 μm using a 100× optical
(Pa⋅s) at 20 °C. The total resistance Rtot could be defined as: magnification by means of a WITec Alpha300 RA Atomic Force
Rtot = Rm + Rrev + Rirr (2) Microscope. The micrograms of the membrane were obtained at a
constant force of 0.2 N/m and at a frequency of 13 kHz.
where Rm is the resistance of the cleaned membrane, Rrev the reversible
resistance including concentration polarization and cake layer re-
sistances, and Rirr the irreversible resistance, which consists of the ad- 3. Results
sorption and pore blocking of mucilage on the membrane that cannot
be removed by cleaning processes [12]. 3.1. Cleaning effect of UDS tips on ceramic membranes
Experimentally, the resistances were determined using the experi-
mental flux data as described by Simon et al. [13] and Cai et al. [12] by Fig. 3 shows the surfaces cleaned by using UDS tips 1 and 10P op-
following the next steps: erating at 29 kHz. Surfaces estimated by means of the drawing software
AutoCAD® (2017) were 83 mm2 and 7 mm2 using UDS tips 10P and 1,
1. Pure water flux was determined using a clean membrane to obtain respectively. UDS tip 10P having a thin and long design provided higher
Rm. amplitude vibrations resulting in a larger clean surface, which is in
2. The permeate flux (Jcactus) of cactus juice was measured after fil- good agreement with the findings reported elsewhere [11].
tering about 30 min to obtain Rtot. It should be noted that the active layer of ceramic membrane (TiO2-
3. The fouled membrane was cleaned using chemical methods and UDS ZrO2) was damaged when the operation time exceeded 30 min, which is
to remove the deposited cake. The chemical cleaning consisted of shown in Fig. 4 using the tip 10P at frequency of 29 kHz for more than
using chemical reagents (NaOH and NHO3) at high temperatures (50 30 min. As pointed out by Pecheva et al. [11] the use of thin and long
and 80 °C), followed by rinsing with pure water. On the other hand, UDS tips generate high vibrations resulting in stronger cavitation ef-
UDS tips were operated during 30 min at 29 kHz. Finally, the water fects. Each cavitation bubble acts as a localized “hot spot” generating
flux was measured with distilled water to obtain Rm + Rirr. temperatures of about 4000–6000 K and pressures of 100–200 MPa.
4. Rrev is obtained with Eq. (2). Bubble implosions occur with lifetimes shorter than 10 μs [15].
Therefore, operation time must be controlled to achieve the best

Fig. 3. Surfaces cleaned by UDS tips: (a) tip 1; (b) tip 10P; (c) comparison between tips 1 and 10P, red area is 83 mm2 and blue area is 7 mm2. The areas were
calculated with AutoCAD®. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

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M.A. Bazán, et al. Ultrasonics 101 (2020) 106035

Table 1
Mean values of the fouled area, the cleaned area and the cleaning efficiency.
Test Fouled area [mm2] Cleaned area [mm2] Cleaning efficiency [%]

1 979.79 408.09 41.65


2 1310.00 887.87 67.78
3 1310.00 643.40 49.11
Mean 1199.92 ± 190.65 646.45 ± 239.90 52.85 ± 13.46

cleaning performance while avoiding damage of membrane surface.


The next step consisted of cleaning the fouled membrane (M2) by
rotating it in steps of 45° until completing 360° by keeping fixed the tip.
Three membranes before and after ultrasonic cleaning are shown in
Fig. 5a and b, respectively, and the cactus juice residue area calculated
by using the drawing software AutoCAD® is shown in Fig. 5c. Such an
area is likely caused by the heterogenous distribution of the fouling
cake on the membrane. Anyway, a part of the pattern obtained at a
given position, for instance as the one shown in Fig. 3c, could be su-
perposed with the next one after rotating the membrane 45°. The main
Fig. 4. Damaged surface of a 0.8 μm ceramic membrane produced by a UDS tip drawback of the MF systems is the membrane modules size, which is
10P excessing the exposure time (longer than 30 min). very compact, so that the space for UDS tips is very limited. Such a

Fig. 5. Cleaning surface on three ceramic membranes of 0.8 µm using a UDS tip 10P: (a) membrane before ultrasonic cleaning; the non-fouled area, which was
subtracted from the total membrane area, is delimited by the red oval; (b) membrane after ultrasonic cleaning; (c) blue line is the cactus juice residue area calculated
with AutoCAD®. The membrane was rotated in steps of 45° by means a rotatory disc holder. (For interpretation of the references to colour in this figure legend, the
reader is referred to the web version of this article.)

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M.A. Bazán, et al. Ultrasonics 101 (2020) 106035

limitation could be overcome using a rotatory disc holder, through (Al2O3, ZrO2, TiO2, the fouling degree (reversible and irreversible), the
which the UDS tip could cover a filtration surface up to 1150 mm2. cleaning protocol (alkaline, alkaline + acid, alka-
Table 1 shows the mean values of the fouled area, the cleaned area line + acid + disinfectant) and the type of chemical reagent (NaOH,
and the cleaning efficiency of the tests shown in Fig. 5. It is important to ultrasil, HNO3, HCl, etc.) [22–24].
point out that the fouled area to be cleaned in test 1 has been calculated Table 2 shows the mean scores with their standard deviation and the
by subtracting the non-fouled area, delimited by the red oval, from the variance coefficient of the fluxes after chemical and ultrasonic cleaning.
total membrane surface (1310 mm2) as shown in Fig. 5a (see Eq. (3)). There was a significant difference between the two cleaning processes
The non-fouled area calculated with the software AutoCAD® was at both pressures (p < 0.05). Likewise, the M2 fluxes represented the
330.21 mm2. 25.6% and 32.26% of the M1 fluxes at TMP 0.3 bar and TMP 0.5 bar,
respectively.
Cleanedarea = fouledareabeforecleaning fouledareaaftercleaning (3)
Membrane resistance is also used to evaluate the performance of the
Looking at test 2, both the cleaned area and its efficiency are hi cleaning processes applied. Fig. 8 shows the resistances values obtained
gher compared to the other tests. On the other hand, it is also im- at a TMP of 0.3 and 0.5 bar and the corresponding means values with
portant to point out the large values of the standard deviation. When their standard deviations are shown in Table 3. Rtot and Rrev increased
filtering the cactus juice, the cake layer deposited on the membrane with increasing TMP from 0.3 to 0.5 bar for both membranes (M1 and
surface is not uniformly distributed. As the cake layer is deposited the M2). An increase of TMP can enhance the convective flow of particle
pressure downstream drops noticeably, so that the flow rate is reduced. towards the membrane, which subsequently enhances the polarization
If the cleaning process is performed under the same fouled conditions, and deposition of particles [25]. It should be noted that the Rrev re-
once the pressure on the downstream side drops to a certain value, the sistances obtained with chemicals reagents were bigger than resistances
standard deviation will be less scattered. obtained by the UDS tips at both pressures (0.3 and 0.5 bar). One reason
On the other hand, with the aim of evaluating the recovery of the for this could be that the membrane regeneration is more effective
membrane, the water flux was measured before processing the cactus when ultrasonic scaler tip is used. The acoustic streaming and cavita-
juice and after the cleaning process (chemical cleaning M1 vs. UDS tip tion produced by the ultrasonic tip promotes the membrane vibration
10P M2) to evaluate the recovery of the membrane. Figs. 6 and 7 show and lifts up the particles accumulated on the membrane.
the water flux of the membranes before and after cleaning, which were At 0.3 bar, the Rrev resistances obtained by the ultrasonic scaler were
fouled when filtering cactus juice at TMP of 0.3 bar and 0.5 bar, re- 58.4% lower than resistances obtained with chemicals, and the Rirrev
spectively. Results show that the water flux after cleaning with ultra- resistances obtained by the ultrasonic scaler were 1.6% higher than
sound was lower (74.4% at 0.3 bar and 67.74% at 0.5 bar) than the resitances obtained with chemicals. On other hand, the Rrev resistances
water flux obtained by chemical cleaning. On the other hand, the water values with ultrasonic scaler were 17.2% lower than resistances ob-
flux values after ultrasonic and chemical cleaning were lower than the tained with chemicals, and the Rirrev resistances obtained by the ultra-
initial water flux. At TMP = 0.3 bar, the decrease of the water flux sonic scaler were 12.3% higher than resistances obtained with chemi-
values were 83.06% and 48.82% for M2 and M1 membranes, respec- cals, at 0.5 bar TMP. This was indeed atributted to the fact that only
tively; while these were 83.47% and 48.82% for M2 and M1 mem- 37.3% of total membrane surface was cleaned by tip 10P. Also, it is
branes, respectively at 0.5 bar. important to point out that ultrasound removes mainly the top layer
The reduction of water flux after ultrasonic cleaning could be ex- deposited on the membrane surface, but hardly the subsequent ones.
plained by the fact that only 37.3% of the total membrane surface is
recovered after using the UDS tip 10. However, chemical cleaning could 3.2. Atomic force microscopy (AFM)
cause a reduction of water permeability due to structural changes
(changes of pore size, pore distribution, porority and zeta potential) in Fig. 9 shows AFM micrographs and 3D images, which corroborated
ceramic membranes during the cleaning protocol (basic + acid) [22]. the cleaning effect of UDS tip on the fouled ceramic membrane. As
Membranes regeneration will depend on the membrane chemistry Fig. 9(a) shows, a relief structure is observed on the membrane surface

Fig. 6. Fluxes before and after cleaning at TMP = 0.3 bar. M1 was cleaned with chemical reagents and M2 was cleaned with ultrasound.

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M.A. Bazán, et al. Ultrasonics 101 (2020) 106035

Fig. 7. Fluxes before and after cleaning at TMP = 0.5 bar. M1 was cleaned with chemical reagents and M2 was cleaned with ultrasound.

Table 2 Table 3
Mean scores of the fluxes after chemical and ultrasonic cleaning process for two Mean scores of the resistances after cleaning with chemicals and ultrasound.
pressures.
Resistance M1
M1 M2
TMP = 0.3 bar TMP = 0.5 bar
TMP (bar) JM1 (L m-2h−1) %VC JM2 (L m−2h−1) %VC
Rm 1.31E+11 ± 0.00 9.60E+10 ± 1.87E-05
0.30 537.22 ± 38.98 7.25 137.48 ± 20.33 14.78 Rtot 2.04E+12 ± 2.99E-04 3.45E+12 ± 0.00
0.50 968.74 ± 90.35 9.32 312.58 ± 49.25 15.75 Rrev 1.84E+12 ± 5.83E+09 3.26E+12 ± 9.54E+09
RIrrv 7.43E+10 ± 5.83E+0.9 9.34E+10 ± 9.54E+09

provided by its active layer (TiO2-ZrO2), which is the virgin membrane Resistance M2

M3. However, after filtering cactus juice, 3D images reveal deposits of


TMP = 0.3 bar TMP = 0.5 bar
foulants on the membrane M4 surface (Fig. 9b). The use of UDS tip 10P
contributed to remove such foulants resulting in a clean surface. The Rm 1.47E+11 ± 0.00 1.01E+11 ± 0.00
benefits of ultrasound can be observed when comparing the surface Rtot 2.04E+12 ± 2.99E-04 3.45E+12 ± 0.00
Rrev 1.24E+12 ± 1.54E+11 2.87E+12 ± 7.77E+10
cleaned by using the scaler (Fig. 9d) with the intact surface (Fig. 9a).
RIrrv 6.56E+11 ± 1.54E+11 4.79E+11 ± 7.77E+10
Moreover, Fig. 9(e) shows the central zone of membrane M2 that was

Fig. 8. Cleaning methods and TMP effect on the hydraulic resistances.

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M.A. Bazán, et al. Ultrasonics 101 (2020) 106035

not cleaned by UDS tip 10P. flushing and/or back-pulsing), which could help to increase the process
Results suggest that the use of UDS tips is an innovative option as performance (sustainable flux). In the future, the use of the ultrasound
cleaning strategy; however, the operating parameters must be con- techniques for cleaning processes will result in less consumption of
trolled, such as the operating time, to avoid surface damage. Exposure chemical reagents, while increasing the membrane lifetime and redu-
times longer than 30 min caused the irreversible removal of the active cing process stops for membrane cleaning.
layer (ZrO2-TiO2) of the ceramic membrane. Therefore, the character-
istic reliefs on the membrane surface disappeared to give rise to a 4. Conclusions
deeper flat surface as shown in Fig. 9(f).
It should be noted that, due to technical limitations (i.e., size and The use of dental scaler tips has been investigated as concept test for
position of probes) only a part of the fouled region can be treated by cleaning fouled ceramic membranes. Results showed than thin and long
ultrasound and the rest will not exposed to the probe. However, this UDS tips providing larger amplitude vibrations resulted in larger
drawback could be overcome by using a rotatory system, whose design cleaned surfaces; however, operating parameters, particularly the ex-
has been proposed. Also, it would expect to get better results when posure time should be carefully controlled to avoid irreversible surface
combining ultrasound scalers with other anti-fouling techniques (back- damage resulting in low membrane selectivity. Under the operating

Fig. 9. 3D AFM images (left) and surfaces images (right) of the membrane: (a) Intact surface, virgin membrane M3; (b) fouled surface M4; (c) surface cleaned with
chemicals M1; (d) surface cleaned by tip 10P M2; (e) fouled surface, center of membrane M2; (f) damaged surface M5 by tip 10P.

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M.A. Bazán, et al. Ultrasonics 101 (2020) 106035

Fig. 9. (continued)

conditions used, the exposure time of UDS to fouled membranes should Ms. Fabiola Rodriguez and Nancy Reyna for the technical support, to
be shorter than 30 min. On the other hand, reversible resistances with MSc. José G. Bañuelos for the AFM images and Dr. Isadora Martínez for
UDS were 58% and 17% lower than the ones with chemical reagents at her advices in the statistical analysis.
pressures of 0.3 and 0.5 bar, respectively. Microscope images corrobo-
rated the detachment of cake layer of the membrane surface. Findings Appendix A. Supplementary material
of this work showed that UDS tips are an innovative clean technique for
filtration membranes and better results could be obtained when com- Supplementary data to this article can be found online at https://
bining ultrasound with other techniques reported such as back flow or doi.org/10.1016/j.ultras.2019.106035.
back pulse.
References
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