Ultrasonic irrigation flows in root canals: effects of ultrasound power and file insertion depth.

Ultrasonic irrigation during root canal treatment can enhance biofilm disruption. The challenge is to improve the fluid flow so that the irrigant reaches areas inaccessible to hand instrumentation. The aim of this study is to experimentally investigate how the flow field and hydrodynamic forces induced by ultrasonic irrigation are influenced by the ultrasound power and file insertion depth. A root canal phantom was 3D printed and used as a mold for the fabrication of a PDMS channel. An ultrasonic instrument with a #15K-file provided the irrigation. The flow field was studied by means of Particle Image Velocimetry (PIV). The time averaged velocity and shear stress distributions were found to vary significantly with ultrasound power. Their maximum values increase sharply for low powers and up to a critical power level. At and above this setting, the flow pattern changes, from the high velocity and shear stress region confined in the vicinity of the tip, to one covering the whole root canal domain. Exceeding this threshold also induces a moderate increase in the maximum velocities and shear stresses. The insertion depth was found to have a smaller effect on the measured velocity and shear stresses. Due to the oscillating nature of the flow, instantaneous maximum velocities and shear stresses can reach much higher values than the mean, especially for high powers. Ultrasonic irrigation will benefit from using a higher power setting as this does produce greater shear stresses near the walls of the root canal leading to the potential for increased biofilm removal.

Improved biofilm removal using cavitation from a dental ultrasonic scaler vibrating in carbonated water.

The use of cavitation for improving biofilm cleaning is of great interest. There is no system at present that removes the biofilm from medical implants effectively and specifically from dental implants. Cavitation generated by a vibrating dental ultrasonic scaler tip can clean biomaterials such as dental implants. However, the cleaning process must be significantly accelerated for clinical applications. In this study we investigated whether the cavitation could be increased, by operating the scaler in carbonated water with different CO2 concentrations. The cavitation around an ultrasonic scaler tip was recorded with high speed imaging. Image analysis was used to calculate the area of cavitation. Bacterial biofilm was grown on surfaces and its removal was imaged with a high speed camera using the ultrasonic scaler in still and carbonated water. Cavitation increases significantly with increasing carbonation. Cavitation also started earlier around the tips when they were in carbonated water compared to non-carbonated water. Significantly more biofilm was removed when the scaler was operated in carbonated water. Our results suggest that using carbonated water could significantly increase and accelerate cavitation around ultrasonic scalers in a clinical situation and thus improve biofilm removal from dental implants and other biomaterials.

The effect of standoff distance and surface roughness on biofilm disruption using cavitation.

Effective biofilm removal from surfaces in the mouth is a clinical challenge. Cavitation bubbles generated around a dental ultrasonic scaler are being investigated as a method to remove biofilms effectively. It is not known how parameters such as surface roughness and instrument distance from biofilm affect the removal. We grew Strepotococcus sanguinis biofilms on coverslips and titanium discs with varying surface roughness (between 0.02-3.15 µm). Experimental studies were carried out for the biofilm removal using high speed imaging and image analysis to calculate the area of biofilm removed at varying ultrasonic scaler standoff distances from the biofilm. We found that surface roughness up to 2 µm does not adversely affect biofilm removal but a surface roughness of 3 µm caused less biofilm removal. The standoff distance also has different effects depending on the surface roughness but overall a distance of 1 mm is just as effective as a distance of 0.5 mm. The results show significant biofilm removal due to an ultrasonic scaler tip operating for only 2s versus 15-60s in previous studies. The technique developed for high speed imaging and image analysis of biofilm removal can be used to investigate physical biofilm disruption from biomaterial surfaces in other fields.

How does ultrasonic cavitation remove dental bacterial biofilm?

Bacterial biofilm accumulation is problematic in many areas, leading to biofouling in the marine environment and the food industry, and infections in healthcare. Physical disruption of biofilms has become an important area of research. In dentistry, biofilm removal is essential to maintain health. The aim of this study is to observe biofilm disruption due to cavitation generated by a dental ultrasonic scaler (P5XS, Acteon) using a high speed camera and determine how this is achieved. Streptococcus sanguinis biofilm was grown on Thermanox™ coverslips (Nunc, USA) for 4 days. After fixing and staining with crystal violet, biofilm removal was imaged using a high speed camera (AX200, Photron). An ultrasonic scaler tip (tip 10P) was held 2 mm away from the biofilm and operated for 2 s. Bubble oscillations were observed from high speed image sequences and image analysis was used to track bubble motion and calculate changes in bubble radius and velocity on the surface. The results demonstrate that most of the biofilm disruption occurs through cavitation bubbles contacting the surface within 2 s, whether individually or in cavitation clouds. Cleaning occurs through shape oscillating microbubbles on the surface as well as through fluid flow.

Numerical investigation of cavitation generated by an ultrasonic dental scaler tip vibrating in a compressible liquid.

Bacterial biofilm accumulation around dental implants is a significant problem leading to peri-implant diseases and implant failure. Cavitation occurring in the cooling water around ultrasonic scaler tips can be used as a novel solution to remove debris without any surface damage. However, current clinically available instruments provide insufficient cavitation around the activated tip surface. To solve this problem a critical understanding of the vibro-acoustic behaviour of the scaler tip and the associated cavitation dynamics is necessary. In this research, we carried out a numerical study for an ultrasound dental scaler with a curved shape tip vibrating in water, using ABAQUS based on the finite element method. We simulated the three-dimensional, nonlinear and transient interaction between the vibration and deformation of the scaler tip, the water flow around the scaler and the cavitation formation and dynamics. The numerical model was well validated with the experiments and there was excellent agreement for displacement at the free end of the scaler. A systematic parametric study has been carried out for the cavitation volume around the scaler tip in terms of the frequency, amplitude and power of the tip vibration. The numerical results indicate that the amount of cavitation around the scaler tip increases with the frequency and amplitude of the vibration. However, if the frequency is far from the natural frequency, the cavitation volume around the free end decreases due to reduced free end vibration amplitude.

Impact of scientific and technological advances.

Advancements in research and technology are transforming our world. The dental profession is changing too, in the light of scientific discoveries that are advancing biological technology-from new biomaterials to unravelling the genetic make-up of the human being. As health professionals, we embrace a model of continuous quality improvement and lifelong learning. Our pedagogical approach to incorporating the plethora of scientific-technological advancements calls for us to shift our paradigm from emphasis on skill acquisition to knowledge application. The 2017 ADEE/ADEA workshop provided a forum to explore and discuss strategies to ensure faculty, students and, ultimately, patients are best positioned to exploit the opportunities that arise from integrating new technological advances and research outcomes. Participants discussed methods of incorporating the impact of new technologies and research findings into the education of our dental students. This report serves as a signpost of the way forward and how to promote incorporation of research and technology advances and lifelong learning into the dental education curriculum.

Cleaning lateral morphological features of the root canal: the role of streaming and cavitation.

AIM: To investigate the effects of ultrasonic activation file type, lateral canal location and irrigant on the removal of a biofilm-mimicking hydrogel from a fabricated lateral canal. Additionally, the amount of cavitation and streaming was quantified for these parameters. METHODOLOGY: An intracanal sonochemical dosimetry method was used to quantify the cavitation generated by an IrriSafe 25 mm length, size 25 file inside a root canal model filled with filtered degassed/saturated water or three different concentrations of NaOCl. Removal of a hydrogel, demonstrated previously to be an appropriate biofilm mimic, was recorded to measure the lateral canal cleaning rate from two different instruments (IrriSafe 25 mm length, size 25 and K 21 mm length, size 15) activated with a P5 Suprasson (Satelec) at power P8.5 in degassed/saturated water or NaOCl. Removal rates were compared for significant differences using nonparametric Kruskal-Wallis and/or Mann-Whitney U-tests. Streaming was measured using high-speed particle imaging velocimetry at 250 kfps, analysing both the oscillatory and steady flow inside the lateral canals. RESULTS: There was no significant difference in amount of cavitation between tap water and oversaturated water (P = 0.538), although more cavitation was observed than in degassed water. The highest cavitation signal was generated with NaOCl solutions (1.0%, 4.5%, 9.0%) (P < 0.007) and increased with concentration (P < 0.014). The IrriSafe file outperformed significantly the K-file in removing hydrogel (P < 0.05). Up to 64% of the total hydrogel volume was removed after 20 s. The IrriSafe file typically outperformed the K-file in generating streaming. The oscillatory velocities were higher inside the lateral canal 3 mm compared to 6 mm from WL and were higher for NaOCl than for saturated water, which in turn was higher than for degassed water. CONCLUSIONS: Measurements of cavitation and acoustic streaming have provided insight into their contribution to cleaning. Significant differences in cleaning, cavitation and streaming were found depending on the file type and size, lateral canal location and irrigant used. In general, the IrriSafe file outperformed the K-file, and NaOCl performed better than the other irrigants tested. The cavitation and streaming measurements revealed that both contributed to hydrogel removal and both play a significant role in root canal cleaning.

The Graduating European Dentist: Contemporaneous Methods of Teaching, Learning and Assessment in Dental Undergraduate Education.

It is often the case that good teachers just "intuitively" know how to teach. Whilst that may be true, there is now a greater need to understand the various processes that underpin both the ways in which a curriculum is delivered, and the way in which the students engage with learning; curricula need to be designed to meet the changing needs of our new graduates, providing new, and robust learning opportunities, and be communicated effectively to both staff and students. The aim of this document is to draw together robust and contemporaneous methods of teaching, learning and assessment that help to overcome some of the more traditional barriers within dental undergraduate programmes. The methods have been chosen to map specifically to The Graduating European Dentist, and should be considered in parallel with the benchmarking process that educators and institutions employ locally.

The Graduating European Dentist: A New Undergraduate Curriculum Framework.

With "The Graduating European Dentist", ADEE provides a new approach that reflects best academic practice for European undergraduate dental education. The new suite of documents sees increased emphasis on important curriculum components such as patient safety, working as a team and patient-centred care. There is also an increased emphasis on teaching excellence, student satisfaction and student preparedness and support. Guidance relating to methods of teaching and learning, and assessment (educational measurement), is also provided. It is anticipated that this new format will further increase accessibility and utility for educators, institutions, societies and regulators, across the sector.

Imaging and analysis of individual cavitation microbubbles around dental ultrasonic scalers.

Cavitation is a potentially effective and less damaging method of removing biofilm from biomaterial surfaces. The aim of this study is to characterise individual microbubbles around ultrasonic scaler tips using high speed imaging and image processing. This information will provide improved understanding on the disruption of dental biofilm and give insights into how the instruments can be optimised for ultrasonic cleaning. Individual cavitation microbubbles around ultrasonic scalers were analysed using high speed recordings up to a million frames per second with image processing of the bubble movement. The radius and rate of bubble growth together with the collapse was calculated by tracking multiple points on bubbles over time. The tracking method to determine bubble speed demonstrated good inter-rater reliability (intra class correlation coefficient: 0.993) and can therefore be a useful method to apply in future studies. The bubble speed increased over its oscillation cycle and a maximum of 27ms-1 was recorded during the collapse phase. The maximum bubble radii ranged from 40 to 80µm. Bubble growth was observed when the ultrasonic scaler tip receded from an area and similarly bubble collapse was observed when the tip moved towards an area, corresponding to locations of low pressure around the scaler tip. Previous work shows that this cavitation is involved in biofilm removal. Future experimental work can be based on these findings by using the protocols developed to experimentally analyse cavitation around various clinical instruments and comparing with theoretical calculations. This will help to determine the main cleaning mechanisms of cavitation and how clinical instruments such as ultrasonic scalers can be optimised.

Penetration of sub-micron particles into dentinal tubules using ultrasonic cavitation.

OBJECTIVES: Functionalised silica sub-micron particles are being investigated as a method of delivering antimicrobials and remineralisation agents into dentinal tubules. However, their methods of application are not optimised, resulting in shallow penetration and aggregation. The aim of this study is to investigate the impact of cavitation occurring around ultrasonic scalers for enhancing particle penetration into dentinal tubules. METHODS: Dentine slices were prepared from premolar teeth. Silica sub-micron particles were prepared in water or acetone. Cavitation from an ultrasonic scaler (Satelec P5 Newtron, Acteon, France) was applied to dentine slices immersed inside the sub-micron particle solutions. Samples were imaged with scanning electron microscopy (SEM) to assess tubule occlusion and particle penetration. RESULTS: Qualitative observations of SEM images showed some tubule occlusion. The particles could penetrate inside the tubules up to 60µm when there was no cavitation and up to ∼180µm when there was cavitation. CONCLUSIONS: The cavitation bubbles produced from an ultrasonic scaler may be used to deliver sub-micron particles into dentine. This method has the potential to deliver such particles deeper into the dentinal tubules. CLINICAL SIGNIFICANCE: Cavitation from a clinical ultrasonic scaler may enhance penetration of sub-micron particles into dentinal tubules. This can aid in the development of novel methods for delivering therapeutic clinical materials for hypersensitivity relief and treatment of dentinal caries.

A quantitative method to measure biofilm removal efficiency from complex biomaterial surfaces using SEM and image analysis.

Biofilm accumulation on biomaterial surfaces is a major health concern and significant research efforts are directed towards producing biofilm resistant surfaces and developing biofilm removal techniques. To accurately evaluate biofilm growth and disruption on surfaces, accurate methods which give quantitative information on biofilm area are needed, as current methods are indirect and inaccurate. We demonstrate the use of machine learning algorithms to segment biofilm from scanning electron microscopy images. A case study showing disruption of biofilm from rough dental implant surfaces using cavitation bubbles from an ultrasonic scaler is used to validate the imaging and analysis protocol developed. Streptococcus mutans biofilm was disrupted from sandblasted, acid etched (SLA) Ti discs and polished Ti discs. Significant biofilm removal occurred due to cavitation from ultrasonic scaling (p < 0.001). The mean sensitivity and specificity values for segmentation of the SLA surface images were 0.80 ± 0.18 and 0.62 ± 0.20 respectively and 0.74 ± 0.13 and 0.86 ± 0.09 respectively for polished surfaces. Cavitation has potential to be used as a novel way to clean dental implants. This imaging and analysis method will be of value to other researchers and manufacturers wishing to study biofilm growth and removal.

Evaluating denture cleanliness of patients in a regional dental hospital.

Aims To evaluate the quality of clinical record keeping and determine quality of denture cleanliness; record baseline denture cleanliness for 60 patients; introduce denture hygiene instruction (DHI); and then re-assess the patients for improvement and enhanced record keeping.Methods Analysis of patients' denture hygiene instruction record keeping (n = 60) was undertaken retrospectively. The Denture Cleanliness Index (DCI) was utilised to assess denture cleanliness (best score 0, worst score 4). Baseline DCI scores were taken and individual DHI was delivered. After one month, patients were reviewed and scored, with record keeping quality analysed.Results At baseline, 11.7% (n = 7) of patients had DCI scores of ≤2, improving to 93.8% (n = 45) after one month, demonstrating short-term improvement in denture cleanliness. Only 63% (n = 38) of patients had evidence of a record of DHI within their notes at baseline, improving to 100% at recall.Conclusions New patient information leaflet and clinical guidelines on denture hygiene have been written and implemented. The results of this study suggest that this may be a relatively straightforward method to achieve a short-term improvement in denture cleanliness. The implementation of a DCI score is helpful in allowing patients to improve denture hygiene and its wider use is supported.

The performance characteristics of a piezoelectric ultrasonic dental scaler.

The objective of this work was to investigate the performance characteristics of a piezoelectric ultrasonic dental scaler using scanning laser vibrometry. The vibration characteristics of three standard piezoelectric tips were assessed with scanning laser vibrometry under various conditions: unconstrained, under a stream of flowing water, in a water tank, as well as subjected to loads to simulate clinical conditions. Subsequently, the tips were used to disrupt an in-vitro biofilm model of dental plaque, developed using a non-pathogenic Gram-negative species of Serratia (NCIMB40259). The laser vibrometry data showed that the oscillation pattern of the ultrasonic tip depends primarily on its shape and design, as well as on the generator power. Thin tips and high power settings induce the highest vibrations. Water irrigation of the tip and loads influence the tip performance by diminishing its vibration, while water volume increases it. Serratia biofilm was disrupted by the cavitation bubbles occurring around the scaler tip. The most effective biofilm removal occurred with the thinner tip. Understanding how the ultrasonic tip oscillates when in use and how it removes dental plaque is essential for gaining more knowledge regarding the cleaning mechanisms of the ultrasonic system. Cavitation may be used to remove plaque and calculus without a mechanical contact between the dental tip and the teeth. Better knowledge would enable dental specialists to understand and improve their techniques during routine cleaning of teeth. It will also lead to improving tip design and to the production of more effective instruments for clinical use.

Maintaining dental implants--do general dental practitioners have the necessary knowledge?

OBJECTIVE: The aim of this study was to understand the opinion of general dental practitioners about the current level of implant education at both undergraduate and postgraduate levels. MATERIALS AND METHODS: A questionnaire was sent to the general dental practitioners working in a group of practices in the West Midlands, UK. The completed responses were analysed. RESULTS: Ninety-one out of 101 dentists responded to the questionnaires (95.6%). Sixty-seven (77%) dentists stated that they learnt only theoretical aspects of dental implants during their undergraduate training. The majority of them stated that the training they received was not adequate. In addition, few barriers in dental implant provision by general dentists were also identified in the survey. The main barriers were risk of failures (56.3%), to avoid complications (65.5%) and the cost of learning (51.7%). The results were correlated to the implant competences set by the regulatory organisations such as General Dental Council and Association of Dental Education Europe. CONCLUSION: The present study confirmed that the current implant education at both undergraduate and postgraduate levels in the UK does not instil confidence to the GDPs to provide and maintain dental implants.

Dental students' uptake of mobile technologies.

AIM: The aim of this study was to understand how new mobile technologies, such as smartphones and laptops, are used by dental students. MATERIALS AND METHODS: A questionnaire was distributed to undergraduate dental students from years 1 to 4, at the University of Birmingham Dental School. Questionnaires were completed between February and April 2013. RESULTS: Two hundred and seventy questionnaires were completed. Laptops 55% (145) and smartphones 34% (88) were the most popular choice of device for connecting to the net and searching information. Laptops were preferred in first and second year. Students in year 3 preferred mobile phones, and by year 4 the use of mobile phones and laptops was similar. The top two application ideas chosen by students as the most useful on their smart phones were a dictionary for dental education (56%) and multiple choice questions (50%). Students who chose smartphones as their first choice or second choice of device strongly agreed that having the Internet on their smartphones had a positive impact on their dental education (55%). With laptops (48%), students preferred to be at home when using them while for smartphones (31%) they used them anywhere with a connection. E-mail (47%) and social networks (44%) were the top two Internet communication tools used most on laptops. Instant messaging was popular on smartphones (17%). CONCLUSIONS: Depending on the year in the course, laptops and smartphones are the most popular choice of device and desktop computers are the least popular. Applications on smartphones are very popular and instant messaging is an upcoming form of communication for students.

A novel methodology providing insights into removal of biofilm-mimicking hydrogel from lateral morphological features of the root canal during irrigation procedures.

AIM: To introduce and characterize a reproducible hydrogel as a suitable biofilm mimic in endodontic research. To monitor and visualize the removal of hydrogel from a simulated lateral canal and isthmus for the following: I) Ultrasonic-Activated Irrigation (UAI) with water, ii) UAI with NaOCl and iii) NaOCl without UAI. METHODOLOGY: A rheometer was used to characterize the viscoelastic properties and cohesive strength of the hydrogel for suitability as a biofilm mimic. The removal rate of the hydrogel from a simulated lateral canal or isthmus was measured by high-speed imaging operating at frame rates from 50 to 30,000 fps. RESULTS: The hydrogel demonstrated viscoelastic behaviour with mechanical properties comparable to real biofilms. UAI enhanced the cleaning effect of NaOCl in isthmi (P < 0.001) and both NaOCl and water in lateral canals (P < 0.001). A greater depth of cleaning was achieved from an isthmus (P = 0.009) than from a lateral canal with UAI and also at a faster rate for the first 20 s. NaOCl without UAI resulted in a greater depth of hydrogel removal from a lateral canal than an isthmus (P < 0.001). The effect of UAI was reduced when stable bubbles were formed and trapped in the lateral canal. Different removal characteristics were observed in the isthmus and the lateral canal, with initial highly unstable behaviour followed by slower viscous removal inside the isthmus. CONCLUSIONS: The biofilm-mimicking hydrogel is reproducible, homogenous and can be easily applied and modified. Visualization of its removal from lateral canal anatomy provides insights into the cleaning mechanisms of UAI for a biofilm-like material. Initial results showed that UAI improves hydrogel removal from the accessory canal anatomy, but the creation of stable bubbles on the hydrogel-liquid interface may reduce the cleaning rate.