A deeper look at low-frequency contact ultrasonic debridement in the clinical management of patients with diabetic foot ulcers.

The current study aimed to evaluate the dispersal of solution and microbes (aerosol) in the clinical environment during treatment with Low-frequency contact ultrasonic debridement (LFCUD) with or without suction attachment in patients with diabetic foot ulcers (DFUs). We performed 20 treatments in 10 patients divided into two groups to receive the proposed LFCUD modalities. We measured the microbial load of the environment pre-treatment (sample M1), during treatment with each LFCUD modality (sample M2) and post-treatment (sample M3). The use of LFCUD debridement without a suction attachment results in significantly higher immediate contamination of the clinic environment than the suction attachment, particularly during the procedure (1.70 ± 0.98 log 10 CFU/mL versus 0.77 ± 0.85 log 10 CFU/mL, p = 0.035). When suction is not applied, there are statistically significant differences depending on whether the DFUs are neuropathic or neuroischemic, finding a greater number of microorganisms with high loads in neuropathic DFUs. We found a statistically significant positive correlation between wound area (r = 0.450, p = 0.047) and TBI (r = 0.651, p = 0.006) with the bacterial load during the LFCUD. Based on our results, we recommend using the personal protective equipment required to protect staff members and patients during treatment with LFCUD and using a suction attachment where clinically possible to reduce clinic environmental pollution, especially in neuropathic DFUs and those with larger areas.

Use of low-frequency contact ultrasonic debridement with and without polyhexamethylene biguanide in hard-to-heal leg ulcers: an RCT.

OBJECTIVE: The primary aim of this research was to investigate the combination effect of polyhexamethylene biguanide (PHMB) and low-frequency contact ultrasonic debridement (LFCUD) on the bacterial load in hard-to-heal wounds in adults, compared with ultrasonic debridement alone. Secondary outcomes included wound healing, quality of life (QoL) and pain scores. METHOD: In this single-blinded, randomised, controlled trial participants were randomised to two groups. All participants received LFCUD weekly for six weeks, plus six weeks of weekly follow-up. The intervention group received an additional 15-minute topical application of PHMB post-LFCUD, at each dressing change and in a sustained dressing product. The control group received non-antimicrobial products and the wounds were cleansed with clean water or saline. Wound swabs were taken from all wounds for microbiological analysis at weeks 1, 3, 6 and 12. RESULTS: A total of 50 participants took part. The intervention group (n=25) had a lower bacterial load at week 12 compared with the control group (n=25) (p<0.001). There was no difference in complete wound healing between the groups (p=0.47) or wound-related QoL (p=0.15). However, more wounds deteriorated in the control group (44%) compared with the intervention group (8%, p=0.01). A higher proportion of wounds reduced in size in the intervention group (61% versus 12%, p=0.019). Pain was lower in the intervention group at week six, compared with controls (p=0.04). CONCLUSION: LFCUD without the addition of an antimicrobial agent such as PHMB, cannot be recommended. Further research requires longer follow-up time and would benefit from being powered sufficiently to test the effects of multiple covariates.

Hyperbaric oxygen therapy for the treatment of moderate to severe periodontitis: a clinical pilot study.

Objectives: To clinically and microbiologically evaluate the effects of hyperbaric oxygen (HBO2) therapy in addition to full-mouth ultrasonic subgingival debridement (FM-UD), in the initial treatment of chronic periodontitis. Methods: Twenty patients presenting moderate to severe generalized forms of chronic periodontitis were included in a three-month randomized, parallel-group, single-blinded, prospective study. At baseline patients were randomly assigned to two treatment groups [Test Group (FM-UD+HBO2) and Control Group (FM-UD)]. Both groups were treated with an FM-UD session. Ten HBO2 sessions (one session per day for 10 days at a pressure of 2.5 ATA) were additionally administered to the Test Group. Soft tissues parameters [probing pocket depth (PPD), bleeding on probing (BOP), clinical attachment level (CAL) and visible plaque index (VPI)] were assessed at baseline (immediately before FM-UD treatment), after two weeks, after six weeks and at three months. For each patient, a site presenting PPD ≥ 6mm and positive BOP was selected as a qualifying site (QS), to be monitored clinically (at T0, T1, T2 and T3) and microbiologically (at T0, T1 and T3). Results: There were no statistically significant differences between the two groups for any clinical parameter analyzed after three months, except for BOP, which was significantly (p < 0.05) reduced in the Test Group. Reductions in bacterial levels were detected in both groups after therapy. Faster bacterial recolonization occurred after three months in the Control Group. Conclusion: HBO2 therapy in combination with FM-UD may represent an efficacious approach to the treatment of moderate to severe forms of periodontitis.

Ultrasonic debridement management of lower extremity wounds: retrospective analysis of clinical outcomes and cost.

OBJECTIVE: The aim of this study was to assess wound healing outcomes following direct, low-frequency, high-intensity, ultrasonic debridement as a surgical adjunct for non-healing lower extremity wounds. METHODS: A retrospective review was conducted for patients undergoing lower extremity wound treatment with direct, low-frequency (22.5 kHz), high-intensity (~60 W/cm2) ultrasonic debridement between January 2010 and January 2016. Clinical outcomes were assessed up to 180-days post-ultrasonic debridement. Descriptive statistics, cost and univariate analysis were performed. RESULTS: Overall, 82 wounds in 51 patients were included. Mean age was 57.0 years (range: 32-69), and average body mass index (BMI) was 30.8 kg/m². Patient comorbidities consisted of smoking (47%; n=24), hypertension (75%; n=38), diabetes (45%; n=23), and peripheral vascular disease (51%, n=26). Average wound age at initial presentation was 1013 days (range: 2-5475 days) with an average wound size of 9.0cm x 7.4cm. At 180-days post-debridement, 60% (n=49) of wounds had completely healed. Readmission (47%; n=24) and reoperation (45%; n=23) rates were characterised by the reason for readmission and reoperation respectively. Readmission for wound healing (70%, n=39) was primarily for further debridements (41%; n=16). Wound infection (30%; n=7) was the most common readmission for wound complications (30%; n=17). Reoperations primarily consisted of treatments for further wound healing 96% (n=51). Cost analysis showed a lower total treatment cost for patients with improved healing ($78,698), compared with non-improved wounds ($137,707). CONCLUSION: In a complex, heterogeneous cohort of chronic extremity wounds, the use of direct, low-frequency, high-intensity, ultrasonic debridement is a safe and reliable adjunctive therapy for the management of these wounds.

The Clinical Efficacy of Subgingival Debridement by Ultrasonic Instrumentation Compared With Subgingival Air Polishing During Periodontal Maintenance: A Systematic Review.

OBJECTIVE: The objective of this review was to evaluate the effect of subgingival debridement by ultrasonic debridement (UD) in comparison with subgingival air polishing (SubGAP) during periodontal maintenance. METHODS: A systematic search of electronic databases was conducted to identify publications from January 01, 2000, to December 21, 2018. Publication selection, data extraction, and risk of bias assessment were performed by two reviewers independently. The addressed problem-intervention-comparison-outcomes question was "For patients in the periodontal maintenance phase, is SubGAP more likely to result in better clinical outcomes than UD?" RESULTS: From a total of 435 articles identified, 6 studies were included. Although none of them was evaluated to have a low risk of bias, overall, the main reason was that blinding of personnel was almost impossible to achieve for the study design. Owing to the heterogeneity, the data from included studies could not be synthesized. Most of the included studies suggested no statistical difference in pocket-depth reduction, except for one which showed UD was superior to SubGAP. In terms of clinical attachment loss and gingival regression, no treatment was indicated to have more benefits than the other based on the present evidence. SubGAP had a preferable comfort level compared with UD, as reported. It must be noted that none of included studies' follow-up time was more than 1 year. CONCLUSION: The clinical efficacy of SubGAP compared with that of UD for periodontal maintenance remains inconclusive on account of limited evidence. To date, neither SubGAP nor UD showed superior clinical effect when compared. High-quality, well-designed clinical studies are still needed to ascertain the long-term clinical stability.

An evaluation of an ultrasonic debridement system in patients with diabetic foot ulcers: a case series.

OBJECTIVE: This study evaluated the use of ultrasonic debridement in patients with diabetic foot ulcers (DFU). METHOD: In this prospective, single-arm, open-label study, all patients with DFUs underwent wound debridement by ultrasonic debridement system (SonicOne OR Ultrasonic debridement system). Wherever possible, the edges were approximated by means of stitches. In other cases, the surgical breach healed by secondary intention, or a partial thickness skin graft (with or without Integra Dermal Regeneration Template or Integra Flowable Wound Matrix) was applied, and subsequently healed by primary intention. RESULTS: We assessed 15 patients with a DFU. The time required for debridement was short (an average 15.06±4.02 minutes). Complete wound healing (defined as 100% re-epithelialisation) was achieved in all 15 cases. Median time to heal was 39.20±16.05 days. The ultrasonic debridement system was found to show adequate debridement while preserving more viable tissue to promote rapid healing. CONCLUSION: Our findings show that the device demonstrates advantages in the reduction of debridement times, and efficacy in safely preserving the viable tissue, with a low complication rate in surgery of DFUs. A study that uses a larger cohort is required to fully evaluate the effectiveness, or otherwise, of the ultrasonic debridement system.

Effects of Ultrasonic Debridement on Oral Hygiene Status.

The aim of this randomized-controlled, single-blinded study was to compare the effects of mechanical tooth cleaning (MTC) and ultrasonic debridement (UD) on oral hygiene status in healthy young adults. Thirty-seven participants (mean age: 20.3±0.62 years) were divided into 3 groups after pre-examination: group A, receiving MTC; B, receiving MTC+UD using a universal insert (UDUI); and C, receiving MTC+UD using a probe-shaped insert (UDPI). All participants were required to abstain from oral hygiene for 24 hours after the allocated intervention, after which they were examined. A masked examiner determined the Quigley-Hein plaque index (PlI) and Silness and Löe gingival index (GI) scores before the interventions and after 24 hours of non-brushing. A significant increase in the PlI score was observed in group A (p<0.001) in comparison with that in group B (A: 0.311±0.26; B: -0.01±0.33; C: 0.13±0.27; p<0.05). A significant decrease in the GI score was observed in groups B and C (p<0.05), and the change in this score in group C significantly differed from that in group A or B (A: -0.04±0.25; B: -0.13±0.17; C: -0.33±0.2; p<0.05). Only MTC was insufficient to prevent plaque formation over a 24-hour period of non-brushing and decrease the GI score. Ultrasonic debridement was more effective in preventing plaque formation and decreasing the GI score, regardless of the type of insert used. The present results suggest that UD should be included as an important procedure in the provision of professional oral prophylaxis and that UDPI is as efficient for cleaning as UDUI.

Full-mouth ultrasonic debridement associated with povidone iodine rinsing in GAgP treatment: a randomised clinical trial.

OBJECTIVE: This study evaluated the clinical, immunological and microbiological results of full-mouth ultrasonic debridement (FMUD) with 10 % povidone iodine (PVPI) as the cooling liquid in the treatment of generalised aggressive periodontitis (GAgP). MATERIAL AND METHODS: Twenty-eight patients presenting GAgP were randomly assigned to one of the following groups for evaluation: FMUD + SS (n = 14)--single session of FMUD with 0.9 % saline solution as cooling agent and FMUD + PVPI (n = 14)--single session of FMUD with PVPI solution as cooling agent. Probing depth (PD), relative clinical attachment level (RCAL), relative position of gingival margin, plaque index (FMPI) and bleeding score (FMBS), immunological (interleukin-10 and interleukin-1ß concentrations in gingival crevicular fluid) and microbiological (Aa and Pg amounts) parameters were evaluated at baseline, first, third and sixth months after treatment. RESULTS: The two groups presented reduction of FMPI and FMBS and had statistically significant PD reductions, RCAL gains and gingival recession (p < 0.05). Both therapies reduced Pg levels in deep and in moderate pockets (p < 0.05). FMUD + PVPI reduced Aa levels in deep pockets. However, no inter-group differences in clinical, immunological and microbiological parameters were observed (p > 0.05). CONCLUSIONS: It could be concluded that 10 % PVPI used as an irrigant solution in FMUD decreased Aa levels in deep pockets but had no additional benefits when compared with saline solution irrigation in terms of clinical, microbiological and immunological results. CLINICAL RELEVANCE: The FMUD is a valid option for the treatment of GAgP, but the use of 10 % PVPI did not improve the results of the periodontal therapy.

Effect of application of a PVP-iodine solution before and during subgingival ultrasonic instrumentation on post-treatment bacteraemia: a randomized single-centre placebo-controlled clinical trial.

BACKGROUND: To assess the effect of concomitant subgingival rinsing with 10% PVP-iodine during subgingival instrumentation on the prevalence and magnitude of bacteraemia of oral origin. MATERIALS AND METHODS: Subgingival instrumentation was performed with water or PVP-iodine rinse in patients with periodontitis. Prior to instrumentation, subjects gargled for 1 min with the allocated liquid. Pockets were then rinsed for 1 min and subgingivally instrumented with liquid-cooled (water/PVP-iodine) ultrasonic scalers (1 min). Two minutes later, a blood sample from the arm vein was drawn using a lysis centrifugation blood culture system for quantitative microbiological analysis. Non-parametric statistical tests were performed to assess differences in the prevalence and extent of bacteraemia between groups. RESULTS: Of the 19 samples in each group, oral-borne bacteraemia was detected in 10 of the control and 2 of the test samples. With an average of 3.0 [1; 5] colony forming units, significantly less bacteria and bacteraemia were found in the test group compared to the controls (12.2 [1; 46]) (p = 0.003). Anaerobic bacteria were not found in the test group. CONCLUSIONS: Bacteraemia after subgingival instrumentation with concomitant PVP-iodine rinsing is reduced but not eliminated. Therefore, it might be recommended for patients at a high risk of endocarditis or infection of endoprostheses. However, preventive antibiotic treatment should not be omitted.

A topical desiccant agent in association with ultrasonic debridement in the initial treatment of chronic periodontitis: a clinical and microbiological study.

Effective sub-gingival debridement is crucial to prevent serious systemic infections in hospitalized patients. Lack of compliance and the impracticality of repeated treatment in a short span of time are identified barriers to the performance of full mouth scaling and root planing (SRP). The aim of this randomized study was to evaluate the clinical and microbiological effects of the adjunctive administration of a locally delivered desiccant liquid with molecular hygroscopic properties (HYBENX® Oral Tissue Decontaminant™; HBX) in association with sub-gingival ultrasonic debridement (UD) in a hospital setting. Sixteen patients presenting moderate to severe chronic periodontitis were followed in a randomized 3 month, split mouth, single-blind, prospective study. At baseline (T1) control and test sides were treated with supra and subgingival UD with or without the association of a locally delivered desiccant liquid (HBX). Treatment was repeated after 6 weeks (T2). Clinical and microbiological parameters were assessed at T1, T2 and at 3 months (T3). The test group sites presented a significantly greater reduction in visible plaque index (VPI), bleeding on probing scores (BOP) and gingival index (GI) at T2 and T3 compared to the control group sites. HBX as monotherapy reached the same bacterial load reduction as UD. Compared to UD, a combined HBX-UD treatment resulted in a statistically significant greater bacterial load reduction immediately after treatment. A significantly lower anaerobic bacterial load was still present at T2. Data obtained show that decreased inflammatory signs and reduction of the bacterial load can be obtained in the short term by topical association of the desiccant agent HBX with UD.

Oral hygiene reinforcement in the simplified periodontal treatment of 1 hour.

AIM: To compare the clinical and microbiological outcome of the 1-h ultrasonic debridement of chronic periodontitis patients (CPP) with and without frequent sessions of oral hygiene reinforcement. METHODS: Clinical measurements and subgingival plaque were collected from 44 CPP at baseline, 3- and 6-months. The control group received a single session of 1-h full-mouth ultrasonic debridement, while oral hygiene instructions (OHI) were reiterated over four visits. In the test group, OHI were limited in the 1-h treatment session. At 3-months, both groups received additional debridement and OHI. The "Checkerboard" DNA-DNA hybridization technique quantified Porphyromonas gingivalis, Tannerella forsythia and Treponema denticola in plaque. RESULTS: At three months, smaller reductions in plaque and bleeding indices, and in P. gingivalis numbers were noted in the test group, while these differences disappeared at six months. After the 3-month re-treatment visit, the test group presented with a greater probing pocket depth (PPD) reduction. Plaque negatively affected PPD in a similar manner after both treatment approaches. CONCLUSIONS: Lack of oral hygiene reinforcement in the 1-h full-mouth debridement resulted in higher plaque and bleeding scores and numbers of P. gingivalis at three months; professional removal of dental biofilm every three months is beneficial in subjects with compromised plaque control.

Radiofrequency ablation of varicose veins in combination with ultrasonic-assisted wound debridement and platelet-rich plasma as well as platelet-rich fibrin technologies in treatment of lower extremity venous ulcers in office-based surgery.

Introduction: for the treatment of varicose ulcer performed clinical and laboratory reasoning of the use of ultrasonic-assisted venous ulcer debridement and Platelet-rich plasma with radiofrequency ablation in an outpatient setting, was carried out. Methods: ultrasonic-assisted debridement of trophic ulcer were performed for 50 patients with lower extremity varicose veins at decompensation stage. The effectiveness of ultrasonic-assisted debridement was evaluated by indicators of bacteriological, morphological, cytological study and assessment of trophic ulcers according to the MEASURE system. After ultrasonic-assisted debridement, the patients were divided into two groups: 30 patients, who underwent combined Platelet-rich plasma to stimulate wound regeneration and 20 patients, for whom the Granuflex hydrocolloid bandage was applied for the same purpose. Results: a comparative analysis of ulcer regeneration in two groups of patients proved that in cases of platelet rich plasma the time of transition from inflammatory-regenerative type to regenerative one is much shorter than when using a hydrocolloid dressing. In 28 patients undergoing Platelet-rich plasma (PRP) and Platelet-rich fibrin (PRF), the radiofrequency ablation of the principal superficial and perforating veins was performed. Another 22 patients performed autodermoplasty of trophic ulcers after radiofrequency ablation. Conclusion: our experience has shown that in a one-day inpatient surgical clinic such a multidisciplinary approach to treatment of venous ulcers, including ultrasonic-assisted debridement that is stimulation of wounded process by Platelet-rich plasma with further surgeries to remove the causes of decompensated chronic insufficiency, is promising regarding low costs of treatment and rehabilitation of these patients.

Ultrasonic debridement with stem cell therapy of suspensory branch desmitis in an equine patient.

Ultrasonic debridement as a treatment for tendinopathy and desmitis is a relatively new approach in orthopedic surgery. Previously only used in limited cases, this procedure shows promise for treating ligament-bone and tendon-bone interface injuries. We present a case study of a 2-yr-old thoroughbred male horse, unable to train due to recalcitrant symptoms after extensive conservative management of suspensory branch desmitis. It was then treated with ultrasonic debridement and concurrent manubrial stem cell autograft injection, to treat the ultrasound visualized lesion. Post-surgically, the patient recovered quickly, began training within 16 wk, and went onto win several races. Repeat ultrasound imaging reveals a complete restoration of the internal fiber architecture of the ligament. With a 3-yr follow-up, there has been consistent training and race performance with no re-injury. This study is the first to document the successful outcome of ultrasonic debridement with concurrent stem cell injection in the treatment of equine desmitis.

The Immediate and Delayed Post-Debridement Effects on Tissue Bacterial Wound Counts of Hypochlorous Acid Versus Saline Irrigation in Chronic Wounds.

Introduction: Wound debridement is considered essential in chronic wound management. Hypochlorous acid has been shown to be an effective agent in reducing wound bacterial counts in open wounds. Ultrasound-enabled wound debridement is an effective and efficient method of debridement. This study compared ultrasound irrigation with hypochlorous acid versus saline irrigation for wound debridement on pre- and postoperative wounds and determined regrowth of bacteria over 1 week period of time. Finally, the outcome of definitive wound closure of the clinically clean-appearing wounds was recorded. Methods: Seventeen consenting adult patients with chronic open wounds were randomly selected for study. The patients were randomly divided into the hypochlorous acid irrigation or saline irrigation group. All patients provided pre- and postoperative tissue samples for qualitative and quantitative bacteriology. For the time (7 days) between the debridement procedure and the definitive closure procedure, the wounds were dressed with a silver-impregnated dressing and a hydroconductive dressing. Results: Both types of irrigation in the ultrasonic system initially lowered the bacterial counts by 4 to 6 logs. However, by the time of definitive closure, the saline-irrigated wounds had bacterial counts back up to 105 whereas the hypochlorous acid-irrigated wounds remained at 102 or fewer. More than 80% of patients in the saline group had postoperative closure failure compared with 25% of patients in the hypochlorous acid group. Conclusions: Hypochlorous acid irrigation with ultrasound debridement reduced bacterial growth in chronic open wounds more efficiently than saline alone. Postoperative wound closure outcomes suggest a remarkable reduction in wound complications after wound debridement using hypochlorous acid irrigation with ultrasound versus saline alone.

Ultrasound-assisted treatment of sternocutaneous fistula in post-sternotomy cardiac surgery patients.

OBJECTIVES: Using an ultrasonic debridement system (low frequency, 25 kHz), we aimed to completely remove bacterial biofilms and preserve vital sternal tissue and to compare this procedure with conventional surgical therapy. METHODS: In this retrospective study, we evaluated 37 consecutive patients (25 males) between April 2011 and June 2013 in whom sternocutaneous fistula (SCF) was treated with the ultrasound-assisted wound (UAW) system (Group A, n = 18) or with conventional surgical therapy (Group B, n = 19). Treatment in Group A consisted of a complete dissection of the SCF followed by a multistep UAW debridement session after an interval of 3 days. Our final step in both groups was secondary wound closure with a musculocutaneous flap. RESULTS: Patients in both groups were categorized as high risk with respect to several of the known SCF risk factors. In both groups, a similar variety of bacteria were isolated: 61% were gram-positive species, 16.5% were gram-negative species and 10.5% were Candida albicans. Time to secondary wound closure following eradication was significantly shorter in Group A (10 ± 5.4 vs 15 ± 7.1 days in Group B, P = 0.012). Postoperative antibiotic treatment time (16 ± 9.3 vs 22 ± 10.7 days in Group B, P = 0.078) showed a trend in favour of Group A, but the mean hospitalization time (22 ± 12.0 vs 26 ± 14.3 days in Group B, P = 0.34) did not differ between groups. Recurrence of SCF tended to be less frequent in Group A (6 vs 21% in Group B, P = 0.46). In Group B, one infection-related death was noted. The mean follow-up time was 8 ± 2.7 (Group A) and 10 ± 5.7 (Group B) months. CONCLUSIONS: Ultrasonic debridement is a promising adjunct to SCF treatment. In combination with adequate surgical and antimicrobial therapy, we documented good mid-term results in our trial group.