Accepted: 17 April 2018

DOI: 10.1111/idh.12349

ORIGINAL ARTICLE

Root surface alterations following manual and mechanical

scaling: A comparative study

M Maritato1 | L Orazi1 | D Laurito1 | G Formisano2 | E Serra3 | M Lollobrigida1 |

A Molinari2 | A De Biase1

1
Department of Oral and Maxillo Facial
Sciences, Sapienza University of Rome,
Rome, Italy
2
National Center for Drug Research and
Evaluation, Istituto Superiore di Sanità,
Rome, Italy
3
ENEA Materials Technology Unit, Casaccia
Research Center, Rome, Italy
Correspondence
Alberto De Biase, Department of Oral and
Maxillofacial Sciences, Sapienza University
of Rome, Rome, Italy.
Email: alberto.debiase@uniroma1.it
Abstract
Objectives: The aim of this study was to investigate the morphological and surface
roughness changes in dental root samples following periodontal scaling by hand cu-
rette, piezoelectric ultrasonic devices or a combination of these.
Methods: Twenty-­four monoradicular teeth extracted as a result of periodontal disease
were divided into 4 groups: Group A was treated by piezoelectric ultrasonic scaler
Piezon® Master 400; Group P by piezoelectric ultrasonic scaler PiezoSmart®; Group C
using Gracey curette 7/8; Group AC by a combined technique of piezoelectric ultrasonic
scaler Piezon® Master 400 and Gracey curette 7/8. The treated samples were then ana-
lysed using a white light interferometer and scanning electron microscopy (SEM).
Results: Roughness analysis revealed major surface alterations in Group C
(Sa = 24.98 μm); the samples treated using the combined technique (Group AC)
showed reduced but still significant alteration (Sa = 14.48 μm), while samples treated
with the piezoelectric ultrasonic devices (Group A and Group P) presented the lowest
roughness values (Sa = 8.99 and Sa = 4.45 μm, respectively). A significant difference
was found between groups C and P (P = 0.036). SEM analysis confirmed the rough-
ness analysis revealing non-­homogeneous surfaces in Group C, while a less morpho-
logical alteration was noted in the other groups.
Conclusion: All periodontal devices used in this in vitro study produced a certain
degree of surface alteration. Hand curettes appear to have a major impact on surface
integrity compared with piezoelectric ultrasonic devices.

KEYWORDS
calculus removal, dental scaling, hand curette, root planing, surface roughness, ultrasonic
scaling

1 | I NTRO D U C TI O N self-­performed plaque control. 2 Scaling and root planing involve

Periodontitis is actually the most common inflammatory disease of
the oral cavity with worldwide distribution.1 Periodontal therapy is
intended to reduce tissue inflammation, allowing the periodontium
to repair and preventing further attachment loss. Basic periodontal
treatment aims at eliminating supra-­and subgingival plaque, bacte-
rial deposits and calculus from tooth surfaces to permit effective
both the cleaning and smoothening of the root surface. In the past,
the removal of dental plaque, calculus and altered cement was
performed using only hand-­held instruments, for example sickle,
curettes, chisel, files and hoes. Sonic and ultrasonic scalers are re-
ferred to as power-­driven scalers and are currently used for scaling
and root planing in conjunction with, or as an alternative to, hand-­
held instruments. Piezoelectric units operate in 25-­50 kHz range

Int J Dent Hygiene. 2018;1–6. wileyonlinelibrary.com/journal/idh © 2018 John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
2 |
and are activated by dimensional changes in the crystals housed
within the hand-­
piece as electricity passes over their surfaces.
There is still some controversy about the effectiveness of available
treatment options. According to some authors, ultrasonic scalers
leave more contaminated cementum on the root surface compared
with curettes, and they for this reason consider them as adjuncts to
hand instruments for tooth surface debridement. 3 Further concern
has been raised concerning the effects of periodontal instrumen-
tation on root surfaces as several studies on plaque accumulation
found a positive correlation between root roughness and plaque
growth, with a greater amount of plaque on rougher than on smooth
surfaces.4 An ideal treatment should guarantee effective debride-
ment and the preservation of the integrity of the tooth structure.
The purpose of this in vitro study was to analyse the morphological
changes and the roughness on the root surface of extracted teeth
treated with hand curette and two different mechanical ultrasonic
devices.
2 | M ATE R I A L S A N D M E TH O DS
The experimental design used in this study has been developed
according to the CRIS Guidelines (Checklist for Reporting In-­vitro
Studies).5
2.1 | Sample preparation and instrumentation
Twenty-­four extracted monoradicular human teeth were selected
for the study. Inclusion criteria were the following: teeth extracted
as a result of severe periodontal disease (probing depth >6 mm),
tooth mobility (grade II or grade III), no root decay and no history of
periodontal treatment over the past 6 months. All specimens were
washed and cleaned to remove any residual soft tissue attached to
the root surface. Calculi were not removed during the sample prepa-
ration. After embedding in plaster casts, the samples were randomly
divided into 4 groups (n = 6 teeth per group) and the middle third of
the mesial and distal root surfaces of each tooth was instrumented
with the following devices (Figure 1):
1. Group A: Piezoelectric ultrasonic device Piezon Master 400 with
scaler tip “A” (E.M.S. Electro Medical Systems, Nyon, Switzerland);
2. Group P: Piezoelectric ultrasonic device PiezoSmart® alone with a
scaler tip “P1” (Mectron Medical Technology, Carasco, Italy);
(A) (B)
MARITATO et al.
3. Group C: Gracey curette 7/8 alone (Hu-Friedy Mfg. Co., Chicago,
USA);
4. Group AC: Piezoelectric ultrasonic device Piezon Master 400 with
scaler tip “A” followed by Gracey curette 7/8.
Each sample was instrumented until a smooth, calculus-­free sur-
face was obtained. One single operator performed the tests to ensure
the same working conditions and pressure applied during scaling.
Subsequently, 5 × 5 mm sections of each surface were cut (thus ob-
taining n = 12 sections per group) and sent for surface analysis.
2.2 | Sample characterization
After instrumentation, nine specimens per group were randomly se-
lected for topographic analysis using a white light interferometer
(NewView 5000 TM; Zygo, Middlefield, CT, USA). Samples were first
coated with aluminium (200 nm) using a vacuum deposition process to
optimize light reflection. Data were elaborated using MetroPro soft-
ware (Zygo, Middlefield, CT, USA), and different amplitude parameters
were evaluated: Sa, average surface height deviation amplitude (arith-
metic mean of the distances between the points of the surface and a
medium reference plane); St, distance between the highest peak and
the deepest valley within the measured area; Sq, root-­mean-­square
roughness (mean square of the distances between the points of the
surface and a medium reference plane). For each parameter, the arith-
metic mean, the standard deviation and maximum and minimum values
were recorded. Data were analysed with one-­way univariate ANOVA
test, and a statistical significance was assumed if P < .05.
Finally, three specimens for each group were analysed using a
field emission gun scanning electron microscope (FEG-­SEM) (Inspect
FTM; FEI Company, Hillsboro, OR, USA) at ×20 and ×200 magnifica-
tion with an acceleration voltage of 10 kV. For SEM analysis, samples
were fixed with 2% glutaraldehyde in 0.1 M cacodylate buffer (pH
7.4) at room temperature for 30 minutes, post-­fixed with 1% OsO4
in the same buffer, dehydrated through a graded ethanol series, crit-
ical point dried with CO2 (CPD 030 Balzers device; Bal-­Tec, Balzers)
and gold-­coated by sputtering (SCD040 Balzers device; Bal-­Tec).
3 | R E S U LT S
Interferometric analysis (Figure 2) with a three-­dimensional map-
ping revealed the residual roughness of the samples. The results
F I G U R E 1 A, Extracted tooth
embedded in a plaster model and treated
by piezoelectric device. B, Samples
sections covered with gold for scanning
electron microscopy (SEM) analysis
MARITATO et al.
F I G U R E 2 Illustrative image
showing the three-­dimensional surface
analysis performed using white light
interferometer
of Sa, S q and PV parameters are shown in Figure 3. As indicated
by S a values, the most pronounced roughness alterations were
observed in Group C (S a = 24.98 μm). Group AC also showed sig-
nificant surface alterations (Sa = 14.48 μm), while the piezoelectric
ultrasonic scalers used in groups A and P produced moderate peaks
and less surface modifications than the first two groups (Sa = 8.99
and Sa = 4.45 μm, respectively). A statistically significant difference
was found for S a and S q between groups C and P (P = .036 and .023,
respectively).
At SEM analysis (Figure 4), samples treated by hand curette
(Group C) revealed a non-­homogeneous surface with some deeper
and smooth portions. In the group treated with the combined tech-
nique (Group AC), some areas were characterized by major substance
loss and no well-­defined borders, presumably due to hand instru-
mentation. The root surfaces presented, however, a more homoge-
neous morphology compared with Group C. Finally, samples treated
by piezoelectric ultrasonic devices (groups A and P) presented only
superficial grooves distributed unevenly, within an almost uniform
cementum layer.
4 | D I S CU S S I O N
This study aimed to assess and to compare the effects on root
surface morphology of various mechanical and hand instruments
used in non-­s urgical periodontal therapy. Surface microscopic and
roughness analysis revealed differences between the study’s four
groups and highlighted the highest surface alterations in groups
treated with manual curette and the combination of manual
| 3
curette and piezoelectric device. Less-­p ronounced differences
could be noted between the two piezoelectric devices tested.
The degree of surface alteration after manual debridement is re-
lated to various factors, primarily the presence of a sharp cutting
edge and the moderate pressure necessary for calculus removal.
On the other hand, the mechanism of action of ultrasonic devices
is based on both the tip vibration and the cavitation effect, thus
requiring light pressure. 6 From the clinical perspective, an intact
non-­contaminated and toxin-­f ree cement layer leads to higher ad-
hesion of fibroblasts and epithelial binding to the tooth and rep-
resents a prerequisite in long-­term maintenance of periodontal
health.7 A smooth, hard surface is also believed to avoid further
accumulation of bacteria and calculus, although the exact role of
root surface roughness is still controversial. 8
Several authors have reported that manual instruments
leave a smoother surface as compared to ultrasonic devices.9
However, manual curettes have also been demonstrated to re-
move more cementum.10,11 Piezoelectric ultrasonic scalers, al-
though having similar efficacy in calculus removal, seem to be
more effective in preserving the tooth substance12 ; however,
the specific impact of mechanical devices on surface roughness
is still unclear. In comparing a piezoelectric scaler with a magne-
tostrictive scaler and a manual curette, Busslinger et al.13 found
the highest R a values with the piezoelectric device. Conversely,
Kawashima et al.14 suggested that piezoelectric ultrasonic
scalers provide a smooth surface with minimal loss of tooth
substance. Similarly, Zafar et al.15 have observed only slight dif-
ferences in surface smoothening between ultrasonic scalers and
Gracey curettes.
4 |
F I G U R E 3 Graphs representing different roughness parameters
Sa, Sq and PV for each group. Sa and Sq: average surface height
deviation amplitude and root-­mean-­square roughness; PV: distance
between the highest peak and the deepest valley within the
measured area
In this study, significant differences in surface roughness
have been observed between Group C (hand curette) and Group
P (PiezoSmart ®). Moreover, in Group C surface microcracks were
also detectable. These results are in accordance with the study
MARITATO et al.
by Solís Moreno et al.,16 in which piezoelectric devices produced
the smoothest surface compared with manual curettes and dia-
mond burs. In another study, a greater amount of root substance
removal, more surface cracks and morphological alterations were
observed after using curettes (17-19). Other authors however re-
ported similar surface alterations using manual and ultrasonic in-
struments.9,20 Aspriello et al., 21 using both confocal laser scanning
microscopy and scanning electron microscopy (SEM), observed a
significant formation of smear layer on root surfaces treated with
hand curettes, which suggests combining both manual and me-
chanical instruments.
In conclusion, piezoelectric instruments seem to combine ef-
fective surface debridement with the preservation of cementum;
no difference could be noted between the results from the piezo-
electric instruments tested. Given that the impact of periodontal
treatments on surface roughness can be more pronounced and
less controllable in vivo, it would be then advisable to use ultra-
sonic devices to limit root damage. However, the clinical rele-
vance of these results should be further investigated with clinical
studies addressing post-­o perative sensitivity. This study presents
certain limitations, including the small sample size and the im-
possibility, for this kind of these studies, to blind the operator.
Results may have been influenced by the previous long-­s tanding
periodontal treatments and different roughness conditions.
Moreover, the manual pressure exerted by the experimenter,
even after specific training, cannot be considered replicable or
standardized.
5 | CO N C LU S I O N
The results of this study indicate that both mechanical and hand
professional instrumentation can have an impact on the tooth
surface. Hand curettes produced the most remarkable surface
alterations, modifying the root morphology and roughness, while
piezoelectric devices showed a limited but still present impact on
root surfaces. However, far from giving a definitive answer to the
question about the most effective periodontal instrumentation,
because the clinical implications of this and other in vitro studies
can be questionable, clinicians should be aware that, based on the
current knowledge, both manual and mechanical devices could
eventually damage the root surface as a result of an improper use.
6 | C LI N I C A L R E LE VA N C E
6.1 | Scientific rationale
Various periodontal scaling modalities, both manual and mechanic,
are currently described in the literature. However, it remains unclear
what kind of treatment is most effective in calculus and plaque re-
moval while at the same time preserving tooth substance. The aim
of this study was then to investigate the root surface alterations fol-
lowing different scaling procedures.
MARITATO et al. | 5

x20 x200

Group A

Group P

Group C

Group AC

FIGURE 4 Scanning electron microscopy (SEM) photographs showing the surface morphology for each treatment group at ×20 and ×200

AC K N OW L E D G E M E N T
6.2 | Principle findings
The authors wish to acknowledge Dr. Serena Rufini for her scientific
In this study, piezoelectric instrumentation has been demonstrated
contribution to this work.
to preserve root morphology to a greater extent than using man-
ual curettes although all the tested instruments produced surface
alterations. C O N FL I C T O F I N T E R E S T

The authors declare that there is no conflict of interest regarding the

6.3 | Practical implication publication of this article.
The results of this study would favour the use of ultrasonic devices.
Be that as it may, clinicians should be aware of the potential damages
ORCID
on root surfaces related to scaling procedures, both manual and me-
chanical, and their clinical implication. A De Biase http://orcid.org/0000-0002-8475-463X
6 | MARITATO et al.

REFERENCES 13. Busslinger A, Lampe K, Beuchat M, Lehmann B. A comparative in

vitro study of a magnetostrictive and a piezoelectric ultrasonic scal-
1. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes
ing instrument. J Clin Periodontol. 2001;28:642‐649.
W. Global burden of severe periodontitis in 1990-­2010: a systematic
14. Kawashima H, Sato S, Kishida M, Ito K. A comparison of root sur-
review and meta-­regression. J Dent Res. 2014;93:1045‐1053.
face instrumentation using two piezoelectric ultrasonic scalers and
2. Arabaci T, Ciçek Y, Canakçi CF. Sonic and ultrasonic scalers in peri-
a hand scaler in vivo. J Periodontal Res. 2007;42:90‐95.
odontal treatment: a review. Int J Dent Hyg. 2007;5:2‐12.
15. Zafar MS. Comparing the effects of manual and ultrasonic in-
3. Yaghini J, Naghsh N, Attaei E, Birang R, Birang E. Root surface
strumentation on root surface mechanical properties. Eur J Dent.
roughness after scaling and root planing with Er:YAG laser com-
2016;10:517‐521.
pared to hand and ultrasonic instruments by profilometry. J Dent
16. Solís Moreno C, Santos A, Nart J, Levi P, Velásquez A, Sanz Moliner
(Tehran). 2015;12:899‐905.
J. Evaluation of root surface microtopography following the use
4. Kocher T, Langenbeck N, Rosin M, Bernhardt O. Methodology
of four instrumentation systems by confocal microscopy and
of three-­ dimensional determination of root surface roughness.
scanning electron microscopy: an in vitro study. J Periodontal Res.
J Periodontal Res. 2002;37:125‐131.
2012;47:608‐615.
5. Krithikadatta J, Gopikrishna V, Datta M. CRIS Guidelines (Checklist
17. Mittal A, Nichani AS, Venugopal R, Rajani V. The effect of various
for Reporting In-­vitro Studies): a concept note on the need for stan-
ultrasonic and hand instruments on the root surfaces of human sin-
dardized guidelines for improving quality and transparency in re-
gle rooted teeth: a Planimetric and Profilometric study. J Indian Soc
porting in-­vitro studies in experimental dental research. J Conserv
Periodontol. 2014;18:710‐717.
Dent. 2014;17:301‐304.
18. Santos FA, Pochapski MT, Leal PC, Gimenes-Sakima PP, Marcantonio
6. Rosales-Leal JI, Flores AB, Contreras T, Bravo M, Cabrerizo-Vílchez
E Jr. Comparative study on the effect of ultrasonic instruments on
MA, Mesa F. Effect of root planing on surface topography: an in-­vivo
the root surface in vivo. Clin Oral Invest. 2008;12:143‐150.
randomized experimental trial. J Periodontal Res. 2015;50:205‐210.
19. Dahiya P, Kamal R, Gupta R, Pandit N. Comparative evaluation of
7. Arora S, Lamba AK, Faraz F, Tandon S, Ahad A. Evaluation of the
hand and power-­ driven instruments on root surface character-
effects of Er, Cr:YSGG laser, ultrasonic scaler and curette on root
istics: a scanning electron microscopy study. Contemp Clin Dent.
surface profile using surface analyser and scanning electron micro-
2011;2:79‐83.
scope: an in vitro study. J Lasers Med Sci. 2016;7:243‐249.
20. Singh S, Uppoor A, Nayak D. A comparative evaluation of the ef-
8. Ko MJ, Cho CM, Jeong SN. Characteristics of the molar surface after
ficacy of manual, magnetostrictive and piezoelectric ultrasonic in-
removal of cervical enamel projections: comparison of three differ-
struments–an in vitro profilometric and SEM study. J Appl Oral Sci.
ent rotating instruments. J Periodontal Implant Sci. 2016;46:107‐115.
2012;20:21‐26.
9. Ribeiro FV, Casarin RC, Nociti Júnior FH, Sallum EA, Sallum AW,
21. Aspriello SD, Piemontese M, Levrini L, Sauro S. Ultramorphology
Casati MZ. Comparative in vitro study of root roughness after in-
of the root surface subsequent to hand-­ultrasonic simultaneous
strumentation with ultrasonic and diamond tip sonic scaler. J Appl
instrumentation during non-­surgical periodontal treatments: an in
Oral Sci. 2006;14:124‐129.
vitro study. J Appl Oral Sci. 2011;19:74‐81.
10. Ritz L, Hefti AF, Rateitschak KH. An in vitro investigation on the
loss of root substance in scaling with various instruments. J Clin
Periodontol. 1991;18:643‐647.
11. Mishra MK, Prakash S. A comparative scanning electron microscopy How to cite this article: Maritato M, Orazi L, Laurito D, et al.
study between hand instrument, ultrasonic scaling and erbium
Root surface alterations following manual and mechanical
doped: Yttrium aluminum garnet laser on root surface: a morpho-
logical and thermal analysis. Contemp Clin Dent. 2013;4:198‐205. scaling: A comparative study. Int J Dent Hygiene. 2018;00:1–6.
12. Taib H, Ling C, Khamis M, Arief E. Evaluation of the effects of differ- https://doi.org/10.1111/idh.12349
ent scaling modalities on the root surfaces: an in vitro study. J Oral
Health Res. 2017;8:5‐11.