Calculus Removal and Root Surface Roughness When Using the Er:YAG or Er,Cr:YSGG Laser Compared with Conventional Instrumentation Method: A Literature Review

Abstract

Objective:

The purpose of this literature review was to evaluate the effectiveness of using Er:YAG (erbium-doped yttrium/aluminum/garnet) laser or Er,Cr:YSGG (erbium, chromium-doped yttrium/scandium/gallium/garnet) laser on calculus removal and their effect on the topography and roughness of root surface in comparison with the conventional instruments in the nonsurgical periodontal therapy.

Background data:

One of the most challenging problems in treatment of periodontal disease is the elimination of plaque and calculus, leaving a clean and smooth root surface to decrease plaque and calculus retention, and for good gingival reattachment.

Materials and methods:

PubMed and Google Scholar were searched for available literature. The electronic search was limited to articles published in the period between January 2007 and April 2017, in the English language.

Results:

A total of 47 publications fulfilled the inclusion criteria of this systematic review and screened according to the research questions. Calculus removal using the ultrasonic instrument showed remaining calculus compared with the hand instrument, whereas, on the contrary, erbium lasers revealed no remaining calculus or smaller amounts compared with the conventional instruments when used in appropriate settings. The results of this review showed that ultrasonic instrumentation produced effects on the root surface almost similar to that of hand instrumentation. Er:YAG laser and Er,Cr:YSGG laser clarify a little more surface roughness when compared with conventional instruments.

Conclusions:

The present systematic review indicates that a combination of scaling and root planing (SRP) using the erbium lasers as an adjunctive therapy at certain parameters can be appropriate to remove residual debris from the root surface and at the same time have little or no negative thermal effect on the root surface. The Er:YAG laser also seems to be the most suitable for nonsurgical periodontal therapy. Additional new good-designed studies are needed to evaluate the effectiveness of erbium lasers with SRP in nonsurgical periodontal therapy.

Introduction

When the calculus and biofilm are on the enamel surface, scaling alone is sufficient to remove them completely from the enamel surface, leaving a smooth and clean surface, but when the calculus is on the root surface it is often embedded in the cementum irregularity. Therefore, scaling alone is unsatisfactory to remove it.¹ The superficial layer of root surface must be removed to eliminate the embedded part of the deposit, and in some cases where the cementum is thin, that may lead to unavoidable and recommended dentin exposure.² Sonic and ultrasonic devices were used to remove heavy calculus layers from supra and subgingival areas, with different types of tip design. Water was used to decrease heat generated from friction and to clean out the deposits from the pocket. Ultrasonic tip provides better access to the subgingival area than accessibility only with hand instrument.³ However, both methods of instrumentation give a good result when used to remove plaque and calculus or bacterial reduction and reduce the symptoms of periodontitis.⁴ It is well known that traditional treatment is useful to remove heavy deposits and stain more quickly with less trauma to the tissue, therefore resulting in less postoperative pain and discomfort. Many new technologies are being used for the periodontal procedure, including laser; laser was newly introduced, since three decades, in dentistry to be used for many therapies in hard and soft tissue.^5,6

In periodontology, laser has an indication in surgical therapy, in nonsurgical treatment of periodontal disease, and in pathological changing in all periodontal diseases. When applying a laser in periodontology, the following advantages can be incorporated into the treatment: enhance decreasing of bacteria, reduce bleeding, improve access to complex anatomical structures, as well as increased patient comfort and biostimulation of the healing process. Several types of laser are used, for example, Er:YAG (erbium-doped yttrium/aluminum/garnet) and Nd:YAG for nonsurgical periodontal therapy pockets of up to 8–10 mm. A randomized, double-blinded, clinical study compared the effect of scaling and root planing (SRP) alone versus SRP plus diode laser using clinical, microbiological, and inflammatory analyses in patients with aggressive periodontitis. The result showed significantly more improvement in probing depth levels and providing clinical attachment level (CAL) gain, after a single treatment, using SRP plus diode laser at 12 months compared with SRP alone. However, it did not significantly reduce the percentage of bleeding sites compared with SRP treatment alone.⁷

For good results, the surgical periodontal procedures use the Er:YAG laser for calculus removal as the first step and then use diode or Nd:YAG lasers to support decontamination, biostimulation, and de-epithelialization. A study proved that the wound-healing time after 980 nm diode laser-assisted surgical treatment of the lateral periodontal cyst was shorter than that with conventional surgical treatment. Furthermore, the study results showed a significant reduction in postoperative complications and improvement in the periodontal parameters assessed after a 12-month follow-up.⁸ Also, in people with uncontrolled diabetes, who are generally at danger for hyperglycemia, which can result in increased inflammation leading to an increased risk of periodontal disease, in a split-mouth study, the clinical benefits of photobiomodulation (808 nm GaAlAs diode laser with an energy density of 4.46 J/cm² on days 1, 2, and 7 after SRP), in type 2 Diabetes Mellitus (D.M.), in nonsurgical periodontal treatment were evaluated. In this study, it was pointed out that photobiomodulation acts as an adjunctive therapy to nonsurgical periodontal treatment, improving periodontal healing in type 2 D.M.⁹

Disinfection of periodontal pockets can be done very effectively using the neodymium laser.¹⁰ The advantage of the neodymium laser compared with diode lasers in periodontal treatment is the laser light penetration into the tissue of more than 10 mm. Hence, all microorganisms penetrating the marginal periodontium can be reached and killed. While the Er:YAG laser is a helpful tool used to remove plaque, calculus debride safely of the periodontal pockets.¹⁰ The purpose of this systematic review was to compare the effect of using Er:YAG laser or erbium, chromium-doped yttrium/scandium/gallium/garnet (Er,Cr:YSGG) laser and conventional instruments on calculus removal and their effect on the root surfaces after treatment.

Research questions

Is there a difference in the amount of plaque and calculus removed using Er:YAG laser or Er,Cr:YSGG laser in comparison with the conventional instruments?

Is there a difference between Er:YAG laser or Er,Cr:YSGG laser in comparison with conventional instruments regarding the effect on root surfaces after treatment?

Materials and Methods

Study selection strategy

PubMed and Google Scholar were searched for available literature. The electronic search was limited to articles published in the period between January 2007 and April 2017, in the English language.

The review should only consider studies that meet all inclusion criteria and do not violate any of the exclusion criteria to answer the research questions mentioned above.

Inclusion criteria

The inclusion criteria were as follows: (1) included were in vitro and human studies, (2) erbium lasers, hand, and ultrasonic periodontal instruments, (3) to answer the research questions, the search was just restricted to patients with periodontitis, (4) the systematic literature review was conducted in Google Scholar and PubMed, (5) the search was restricted to English articles and limited the time from 2007 to 2017, (6) 4 mm or more pocket probing depth and1 mm or more clinical attachment loss or alveolar bone loss, and (7) the following criteria: (i) efficiency of plaque and calculus removal of different periodontal instruments and (ii) the effect of use of different periodontal instruments on the topography and roughness of root surface.

Exclusion criteria

The exclusion criteria were as follows: (1) the exclusion included animal studies and literature reviews, (2) research articles in which patients with systemic diseases or conditions that affect healing, those smoking, and patients taking antibiotic therapy when there is a medical condition, (3) articles that did not have sufficient information on laser settings, (4) further excluded were such studies, despite calculus detection, (5) study outcomes with a specific focus on specific diseases such as studies on the treatment of periodontitis, abscesses, peri-implantitis, periodontitis associated with endodontic lesions, or developmental or acquired deformities were also ruled out, (6) studies considering surgical interventions (frenectomy, vestibuloplasty, excisional procedures, crown lengthening, incisions, and drainages; implant exposures during second-stage surgery) vestibuloplasty, (7) studies examining measures and interventions on damage occurring to the adjacent tissues such as bone by using the erbium lasers, (8) to answer the research questions, all types of publications were included, only the following criteria were excluded from the review: (i) pain and thermal side effects during and after periodontal therapy with erbium lasers and (ii) healing time required after treatment of periodontal disease.

Results

Original research articles resulted in a total of 2619 records. The literature search was carried out for articles between January 2007 and April 2017, using the following search keywords “nonsurgical periodontal therapy,” “root surface debridement,” “periodontitis therapy,” “ultrasonic periodontal instrumentation,” “Er,Cr:YSGG laser,” and “Er:YAG laser.” With an additional electronic database search in ResearchGate, electronic search was conducted by one reviewer (M.A.A.).

A total of 2619 records were found (Fig. 1). After reading, analyzing, and removing duplicates and assessing the titles of the publications, 193 titles could be included because they remained relevant to the research questions. By initial reviewing of the received abstracts of the remaining studies, 146 further publications were excluded. This exclusion was founded on 57 studies that presented data on clinical evaluation of periodontal disease probing pocket depth, CAL, and bleeding on probing. Thirty-one literature reviews were excluded as well as 44 animal studies; they did not meet the inclusion criteria. Fourteen were excluded from this review because they did not assemble the search criteria and the given information on antibacterial activity of the erbium lasers or conventional instruments. Forty-seven suitable full-text articles were read and evaluated independently by one author (M.A.A.) and confirmed by other authors (R.N. and N.G.).

FIG. 1.

Description of selection process of the included publications.

Assessment and evaluation criteria for the efficiency of calculus removal and the effect on the topography and roughness of root surface of different periodontal instruments were based on reviewing the collected results and conclusions from each reviewed study. Further, presenting all available evidence and scoring according to explained criteria. Individual estimation of the reviewer (M.A.A.) in this method is patently susceptible to inaccuracy. However, after taking great care to find all relevant studies, basically assess each study, combining the findings from individual studies in an unbiased manner (Tables 1 and 2). Two reviewers (R.N. and N.G.) evaluated all the included articles and assessed the proposal to make sure to minimize the risk of bias. Moreover, the previously defined inclusion and exclusion criteria were used to select the definitive studies to be included, and the Preferred Reporting Items for Systematic Reviews guideline was followed.

Table 1.

Efficiency of Plaque and Calculus Removal of Different Periodontal Instruments

N	Author (year)	Type/time	Design/samples	Purpose	Instrument		Finding
N	Author (year)	Type/time	Design/samples	Purpose	Laser type/parameters	Conventional instrument	Finding
1	Krause et al. (2007)²⁰	In vitro study	20 single-rooted freshly extracted human teeth	To evaluate the removal of subgingival calculus and dental hard tissues depending on the threshold level of a fluorescence feedback-controlled Er:YAG laser.	Er:YAG laser 2940 nm PE 140 mJ RR 10 Hz ED 17.2 J/cm² Chisel-shaped fiber tip TZ 0.4–1.65 mm WI 1 mL/min 15° IR A	Not reported	The amount of removed calculus depended on the laser fluorescence threshold level. Lowering of the laser fluorescence threshold values led to a reduction of the amount of residual calculus.
2	Ting et al. (2007)¹⁷	In vitro study Fixed with a 2% glutaraldehyde for 3–4 h, 1% osmium tetroxide for 2 h	22 noncarious, extracted, single-rooted teeth 1. C-G (n = 8) 2. NW-G (n = 39) 0.5 W: N = 10 1.0 W: N = 9 1.5 W: N = 8 2.0 W: N = 12 3. IW-G (n = 44) 0.5 W: N = 10 1.0 W: N = 10 1.5 W: N = 12 2.0 W: N = 12	Determine the appropriate power output setting for an Er,Cr:YSGG laser used in periodontal pocket irradiation by examining the morphologic alterations of the root surfaces and the efficiency of calculus removal.	Er,Cr:YSGG laser 2780 nm PD 140–200 μs RR 20 Hz Pa 0–6 W fiber-optic tube sapphire tip TD 600 μm 20% air and 10 water 0.5 W (25 mJ/pulse) 1.0 W (50 mJ/pulse), 1.5 W (75 mJ/pulse) 2.0 W (100 mJ/pulse)	Gracey curettes to remove soft tissue and calculus	At 1.5 and 2.0 W, Ra and Z in the IW group were statistically higher than in the NW group. Mean × values at 0.5 W were the lowest of any of the groups. No statistically significant difference was found between 1.0, 1.5, and 2.0 W in this study. 1.0-W power output is acceptably efficient for removing the calculus without any conspicuous morphologic alterations to the root surface. Melted RS and irregular ablation were observed at 1.5 and 2.0 W in the NW group, the same power outputs in the IW group resulted in smooth, deep ablation. In all of the laser-treated specimens, no smear layer was found on the root.
3	Kawashima et al. (2007)²¹	In vivo study	15 patients with advanced periodontal disease 3 experimental groups of 10 teeth	To compare the effectiveness of two PU scalers and a hand scaler for subgingival SRP.	Not reported	Two PU scalers, (vector scaler, enac scaler) hand instrument	Vector scaler produces a smooth root surface with minimal loss of tooth substance. The remaining calculus index did not differ significantly among the three groups. The roughness loss of tooth substance index was significantly lower for the vector scaler and enac scaler groups than for the hand scaler group.
4	Yukna et al. (2007)²³	In vitro study	139 tooth surfaces were used 49 t for DIs 50 t for PIs 40 t for HIs Extracted human teeth with moderate to severe calculus	To compare a new DI with a PI and hand curettes for calculus removal in vitro.	Not reported	Sharp Gracey curettes [HIs]. PIs DIs	Calculus removal with (DIs) was approximately two times faster than with hand curettes (His) and three times faster than with (PIs). Teeth treated with His showed significantly less calculus than those treated with (Pis) and (DIs). There was no difference between (DIs) and (PIs) in residual calculus. Teeth treated with PIs showed smoothest surfaces. Most of the cementum seemed intact.
5	Herrero et al. (2010)³²	An in vivo study	40 samples G-1: L-120 (10 teeth) KaVo Key II, 120 mJ and 10 Hz+US G-2: L-140 (10 teeth) KaVo Key II, 140 mJ and 10 Hz+US G-3: L-160 w/o FDBK (10 teeth) KaVo Key III, 160 mJ and 10 Hz w/o CDS+US. G-4: L-160 w/FDBK (10 teeth) KaVo Key III 160 mJ and 10 Hz, w/CDS+US Laser (15 mm² of left side of the root) US (15 mm² of right side of the root surface) Control (central area was left unscaled)	To evaluate the capacity of Er:YAG laser application to eliminate calculus from periodontally affected root surfaces compared with ultrasonic scaling.	Er:YAG laser 2940 nm RR 10 Hz PD 250 μs Fiber delivery system Contact handpiece WI 15 mL = min →For (KaVo Key II) E 120–140 mJ TZ insert tip of 0.5 × 1.65 mm ED 14.5–17 J/cm² →For (KaVo Key III) E 160 mJ TZ 0.4 × 1.65 mm ED 24.2 J/cm²	PU scaling (28,500 Hz, universal tip, medium power setting, water spray 15 mL = min)	No differences were identified as to the amount of residual calculus between the four different laser treatments and US. The capacity of the Er:YAG laser to remove calculus is comparable with US. Feedback control allows a selective removal of calculus without any modification of the root surface demonstrating complete calculus ablation and partial removal of the subjacent cementum. Er:YAG laser produces slightly rougher and more irregular surface than US. Ultrasonic-treated root surfaces were smooth w/o tissue alteration.
6	Rajiv et al. (2010)²⁴	An in vivo study	G-A instrumented with either Gracey curette or standard smooth ultrasonic tip G-B Gracey curette or diamond-coated ultrasonic tip 14 patients 20 incisors Teeth selected were divided into two working sides (mesial and distal)	To evaluate and compare the effectiveness of various root planing instruments, namely, the curette, standard smooth ultrasonic tip, and diamond-coated ultrasonic tip under conditions of nonsurgical root debridement.	Not reported	Gracey curette, standard smooth ultrasonic insert, diamond-coated ultrasonic insert	Better cleanliness for curette compared with standard smooth ultrasonic tip. Remaining calculus was significantly higher for standard smooth ultrasonic tip compared with curette. Diamond-coated ultrasonic tip showed greater roughness and loss of tooth substance.
7	Hakki et al. (2010)¹⁸	In vitro study	Buccal side of root surface Right side = Er,Cr:YSGG laser Left side = hand instrumentation Untreated sites = control Hand instruments (G) Curettes n = 8 Hand instruments+tetracycline-hydrochloride G+TetHCl, n = 8 Er,Cr:YSGG laser I n = 8 Er,Cr:YSGG laser II n = 8 32 human extracted teeth	To investigate the efficiency of hand instrumentation and laser irradiation on calculus removal from the root surfaces	Er,Cr:YSGG laser →Laser I, setting I Noncontact mode, 1.5 mm, 30° angle RR 10 Hz P 1.5 W E 150 mJ, 65% air, 55% w, H mode PD 140 μs Fiber optic tip, TD 600 μm, TL 14 mm →Laser II setting II Noncontact, mode, 1.5 mm, 30° angle RR 10 Hz, P 1.5 W E 150 mJ, 65% air, 55% water, S mode PD 400 μs Fiber optic tip, TD 600 μm, TL 14 mm	Hand instrumentation (Gracey curettes)	All treatments were efficient in calculus removal from the root surfaces. Thermal changes, including melting and carbonization, were not observed in either laser procedure. The surface was rougher in the laser groups than in the groups treated with hand instruments. Roughness was greater in the long-pulse laser setting than in the short-pulse setting. Laser procedures, when used in appropriate settings, are capable of performing SRP in the treatment of periodontitis.
8	Madan et al. (2011)²⁵	In vitro study	Mesial root surface was cleaned with a Gracey curette. Distal root surface was cleaned with Kermit piezoelectric scaler Single operator performed 20 human mandibular incisors	To evaluate the topography of root surfaces after using Gracey curettes and PU scaler.	Not reported	Gracey curette, piezoelectric scaler, power setting at medium level	It was observed that none of the root surfaces treated with any of the modalities was completely free of calculus. A greater amount of calculus remained on the root surfaces treated with ultrasonic scalers. Roughness and loss of tooth substance were more pronounced in root surfaces treated with Gracey curettes. Time taken to clean the root surfaces with ultrasonic scaler was certainly less than with hand instrumentation.
9	Etemadi et al. (2013)¹⁹	In vitro study	Calculus was divided into two almost equal segments and a hole was randomly made on top of one part of the calculus One side w/Er:YAG laser Other side w/Er,Cr:YSGG laser 32 periodontally hopeless teeth were used	To investigate the root morphology of teeth and efficiency of scaling after using Er:YAG laser and Er,Cr:YSGG laser.	2 mm D, 30° angle → Er:YAG laser E 200 mJ, P 2.4 W RR 12 Hz, PD 100 μs TD 1.1 mm, TL of 6 mm 60% water, 40% ED of 21 J/cm² → Er,Cr:YSGG laser E 50 mJ, P 1 W RR 20 Hz; PD 140 μs TD 600 μm, TL 4 mm 55% water,65% ED 17.7 J/cm²	Not reported	The efficiency of calculus removal in the Er:YAG laser group was significantly higher than in the Er,Cr:YSGG laser group. No carbonization or remaining calculus was found in samples from either group. All samples had craters. The number of craters in the Er,Cr:YSGG laser group was significantly higher than in the Er:YAG laser group. There was no significant difference in efficiency per power for calculus removal between the two groups. Er:YAG laser group appears to have an advantage in terms of time and efficiency of calculus removal and crater formation compared with the Er,Cr:YSGG laser.
10	Foroutan et al. (2013)³⁵	In vitro study	G-1 control G-2 manual G-3 ultrasonic G-4 manual Er:YAG laser Single-rooted extracted teeth suffering from acute periodontitis	The scaling effect using manual tools, ultrasonic machine, and (Er:YAG laser) on the connection of the human gums, connective tissue cells on the root surface of the teeth suffering from severe periodontitis.	Er:YAG laser 2940 nm E 100 mJ RR 10 Hz PD 230 very short Optic fiber system CS 0.5 × 1.65 mm 1.5 mm D and 15–20° angle Noncontact mode	Manual tools (scaled Gracey) Ultrasonic machine	The present study indicated that although various dental surface cleaning methods may be different in other aspects, the spread of fibroblast cells with filopodia was found.
11	Miremadi et al. (2014)³⁴	Experimental clinical trial in vivo and in vitro study 3 days after extraction. 64 teeth were divided into two subgroups	In vivo group 19 patients for L and US treatment followed by TE 32 teeth G-1 8 teeth—G-2 8 teeth G-3 8 teeth—G-4 8 teeth In vitro group of 32 teeth G-1 8 teeth—G-2 8 teeth G-3 8 teeth—G-4 8 teeth treated w/US on one side, laser debridement w/Er:YAG laser on the opposite side	To investigate the morphologic effects of different L settings versus US. To compare the exposure of dentinal tubules corresponding to tooth substance removal by different laser settings and US. To compare the treatment duration of laser debridement using different settings w/each other and to ultrasound.	Er:YAG laser 2940 nm Chisel fiber tip TZ 0.5 × 1.5 mm E 60 mJ ED 6.7 J/cm² E 100 mJ ED 12.0 J/cm² E 160 mJ ED 18.7 J/cm² E 250 mJ ED 30.7 J/cm² RR 10 Hz 70% water, 30% 20°–25° angle	Ultrasonic scaler using the two available tips (1-S and 10Z, Satelec P5 Newtron, Acteon, The group, Bilbao, Spain)	Laser debridement produced an irregular, rough and flaky surface free of carbonization. Ultrasound produced a relatively smoother surface. Laser treatments at 100, 160, and 250 mJ led to significantly more dentinal denudation than ultrasound. Er:YAG laser debridements at 60 and 250 mJ/pulse, respectively, are not appropriate for clinical use. Laser debridement at 100 and 160 mJ pulse seems more suitable for clinical application. Compared with ultrasound, the former is more time-consuming and the latter is more aggressive. The rough and irregular surface, free of carbonization and melting, found in all lasers. Calculus was effectively ablated along with partial or complete ablation of the underlying cementum in all samples.
12	Graetz et al. (2015)²⁶	Pilot in vitro study	Evaluation of the residual plaque on the tooth surface and the contaminated area was planimetrically assessed Sonic device (AIR) Ultrasonic scaler VEC Ultrasonic scaler TIG Dummy heads were equipped with periodontitis Models the modified model's simulated moderate periodontitis with horizontal bone loss and isolated	To investigate the efficacy of sub- and supragingival plaque removal with sonic and two ultrasonic devices as well as the health-risk for dental professionals during treatment.	Not reported	Ultrasonic TIG: Tigon+, W and H, Bürmoos, Austria VEC: Vector, Dürr, Bietigheim-Bissingen, Germany	The smallest amounts of residual plaque were found for the sonic device AIR. Significantly more plaque remained after the use of the ultrasonic Scaler VEC. AIR/TIG demonstrated equal residual amounts of plaque sub- as well as supragingival. The lowest HRI was found after using VEC. Sonic devices are as effective as ultrasonic devices in the removal of biofilm but bear a higher risk to the dental professionals.
13	Mittal et al. (2014)²⁷	A planimetric and profilometric study	14 participants, 40 single-rooted teeth 80 root surfaces for the analysis 3 experimental groups Control group (untreated, n = 10) G-1: PU group G-2: Magnetostrictive ultrasonic group G-3: Hand instrumentation group (curette)	To compare the effectiveness of different ultrasonic scalers and a periodontal curette on the root surfaces for calculus removal and root surface roughness.	Not reported	PU 25,000 Hz. PS tips Magnetostrictive ultrasonic 25,000 Hz. TFI p-10 tips Hand instrument (curette)	Residual deposits were similar in all experimental groups. SEM analysis revealed a similar root surface pattern for the ultrasonic devices. Curette showed many instrument scratches, gouges, and removal of a large amount of cementum. Curette produced rougher root surfaces than two ultrasonic devices. Piezoelectric devices produced minimum root surface roughness. The maximum amount of root substance removal, root surface cracks, and corrugations was seen after using hand instruments followed by PU devices and magnetostrictive ultrasonic devices.
14	Graetz et al. (2017)³¹	In vitro study	Standardized plastic teeth on manikins' heads 7 single-rooted and 5 multi-rooted teeth 7 experienced fully trained periodontists using sonic, ultrasonic devices (TIG), and double-Gracey curettes (GRA) 4 less experienced operators Undergraduate 4-year dental students (LO)	To differentially compare plaque removal efficacy and root surface roughening of newly developed sonic, ultrasonic scaler, and curettes in the hands of experienced versus less experienced operators.	Not reported	Ultrasonic devices (TIG) Double-Gracey curettes (GRA)	The surface roughness was higher with GRA followed by AIR then TIG regardless of operators' experience. The sonic device was most efficient in plaque removal. The ultrasonic device produced the least surface roughness. All three tested instruments seem effective in mechanical root debridement.

DIs, diamond-coated ultrasonic inserts; HIs, hand instruments; Er,Cr:YSGG, erbium, chromium-doped yttrium/scandium/gallium/garnet; PIs, plain ultrasonic inserts; PU, piezoelectric ultrasonic; SEM, scanning electron microscope; US.

Table 2.

Effect of Using Different Periodontal Instruments on the Topography and Roughness of the Root Surface

N	Author (year)	Type/time	Design/samples	Purpose	Instrument		Finding
N	Author (year)	Type/time	Design/samples	Purpose	Laser type/parameters	Conventional instrument	Finding
1	Abed et al. (2007)⁴³	In vitro experimental study 15 human teeth	Samples were divided into mesial and distal halves Randomly divided into two equal groups G-1 = 15 surface Hand instrument SRP G-2 = Laser SRP	To demonstrate the in vitro capability of the Er:YAG laser for SRP in periodontitis.	Er:YAG laser E 160 mJ, RR 12 Hz ED 20 J/cm² Very long-pulse mode RO7 handpiece 2-mm distance TD 1 mm 30° angle Mirror-type transfer system	Two new universal curettes	The statistics reported that roughness was more evident in laser-treated surfaces than in hand instrument-treated surfaces. Er:YAG laser was not able to leave a smooth microscopic surface on the cementum. Very long pulses (750–1000 μs) of Er:YAG laser leave a smoother surface. Decreasing the energy to less than 22.6 mJ at the finishing period of root planing could give a completely smooth surface.
2	Noori et al. (2008)⁶⁷	In vitro study 30 human-extracted intact teeth	Samples divided into two equal parts Part for Er,Cr:YSGG laser Part for ultrasound instrument	To compare the histologic effects of Er,Cr:YSGG laser with ultrasound instruments during calculus-removing procedures.	Er,Cr:YSGG laser 2780 nm E 50 mJ P 1 W RR 20 Hz TL 6 mm TD 600 μm 65% air and 55% water spray 30° angle 1–2 mm distance	Ultrasound instrument (DENTSPLY CAVITRON) Medium power 15° water	The number of craters in two groups demonstrated a significant difference. 95% of laser, samples out of 20 samples in each group had craters. 40% of the ultrasound samples out of 20 samples in each group had craters. Craters were seen in each sample in the laser group. In the SEM evaluation, the surface structure of the laser-treated tooth was more similar to an ordinary tooth. Er,Cr:YSGG laser SRP has some advantages compared with ultrasound procedure.
3	Santos et al. (2008)⁴⁵	In vivo study 14 patients 35 single-rooted teeth 70 root surfaces	G-1 = PU device G-2 = magnetostrictive ultrasonic device G-3 = hand instrumentation Gracey curette G-4 = untreated teeth (control)	To compare root surfaces instrumented by piezoelectric and magnetostrictive ultrasonic devices in teeth exhibiting advanced periodontal disease.	Not reported	PU (29,000 Hz w/10p tip) Magnetostrictive ultrasonic (25,000 Hz w/P-10 tip) Hand instrument	There were statistically significant differences between control and all the experimental groups. The results showed that residual deposits were similar in all tested groups. SEM analysis revealed a similar root surface pattern for the ultrasonic devices. Root surfaces instrumented with curette were rougher and had more root surface tissue removed than with the ultrasonic. All the three instruments could not produce completely deposit-free surface.
4	Gomez et al. (2009)⁶¹	In vitro study Duration of the treatment was 1 min 18 extracted human multi-radicular teeth On the right side of the root w/Er:YAG laser or Nd:YAG On the left side of the root w/US	G-1 (3 teeth): Er:YAG laser, 80 mJ, 10 Hz. LS w/US G-2 (3 teeth): Er:YAG laser 100 mJ, 10 Hz. LS w/US G-3 (3 teeth): Er:YAG laser 120 mJ, 10 Hz. LS w/US G-4 (3 teeth) Nd:YAG laser 0.5 W, 10 Hz. LS w/US G-5 (3 teeth): Nd:YAG laser 1 W, 10 Hz. LS w/US G-6 (3 teeth): Nd:YAG laser 1.5 W, 10 Hz. LS w/US	To evaluate the effects of Er:YAG laser and Nd:YAG lasers on the morphology and chemical composition of root surfaces and compare them with those produced using ultrasonic instrumentation (US).	Er:YAG laser 2940 nm RR 10 Hz E 80, 100, and 120 mJ ED 16, 20, and 24 J/cm² PD 250 μs SS 0.8 mm D 1.5 cm Water cooling	Ultrasonic instrumentation (US) 28,500 Hz Medium power Standard tip	SEM examination of the areas treated with US showed a smooth appearance. In all groups treated with Er:YAG laser, entire cementum layers were removed and dentinal tubules were exposed. Root surfaces treated by Er:YAG laser at 120 mJ/pulse showed an increase in the peak intensities of calcium and phosphorus more than that seen with US treatment. US showed a smooth appearance. Loss of cementum was generally nonexistent or minimal with no signs of thermal side effects such as melting, cracking, or carbonization compared with Er:YAG laser and Nd:YAG laser treatment.
5	Zhou et al. (2009)⁴⁹	In vitro study Treatment for a total of 10 min 40 extracted human teeth due to periodontal disease	G-1 (10 teeth): HD G-2 (10 teeth): conventional ultrasonic system with an “IS” tip (Satelec) G-3 (10 teeth): VA and metal curette G-4 (10 teeth) VP and metal curette	To certify that the vector device, a recently introduced piezo-driven ultrasonic device has an efficacy comparable with conventional instrumentation and leads to a smoother root surface after debridement.	Not reported	Hand instrument Satelec ultrasonic system “IS” insert tip, at 25 kHz and w/hydroxyl-apatite containing polishing fluid (VP) or w/silicon-carbide containing abrasive fluid (VA)	The root surfaces in the VA and VP groups were smoother than, those in other groups. Scratches were obvious on the root treated by HD or the Satelec ultrasonic system. The calculus removal efficiency of VA did not differ from those of the HD and Satelec groups. The calculus removal efficiency of the VP group was significantly lower than those of HD and Satelec groups. Vector system as a novel means is a promising alternative for initial and maintenance therapy of periodontitis.
6	Casarin et al. (2009)⁵⁶	An in vitro study Each specimen was instrumented with 15 strokes 40 extracted mandibular and maxillary premolars	G-1 (10 teeth): hand instrument Gracey curettes (HD) G-2 (10 teeth): ultrasonic scaler at 10% power G-3 (10 teeth): ultrasonic scaler at 50% power G-4 (10 teeth) ultrasonic scaler at 100% power	To evaluate the root surface defect produced by hand curettes and ultrasonic tips with different power settings. The defect depth produced by the instrumentation.	Not reported	Hand instrument Gracey curettes Ultrasonic scaler	The values for the defect depth on root surface showed no statistically significant difference between hand instrumentation and ultrasonic scaling at 10%, 50%, or 100% power settings. Ultrasonic instrumentation produced a similar defect depth to that of hand instrumentation. The smaller contact area between the instrument and the root surface is independent of the power setting used for scaling.
7	Lea et al. (2009)⁵⁹	In vitro study Extracted human molar teeth	3 magnetostrictive scalers (Slimline) driven by a Cavitron 3 piezoelectric (P) scalers driven by a miniMaster generator	To investigate the degree of tooth damage caused by magnetostrictive (Slimline) and piezoelectric (P-style) ultrasonic scaler probes and relate it to an increased understanding of how the probes oscillate.	Not reported	Magnetostrictive (Slimline) probe (30 kHz, water flow rate 20 mL/min 10° angle load of 100, 200 g) Piezoelectric (P-style) ultrasonic scaler	Magnetostrictive probes oscillate with greater vibration displacement amplitude and cause significantly greater defect depths and volumes than piezoelectric. Magnetostrictive probe 1 produced significantly deeper defect depths than magnetostrictive probe 2. Both piezoelectric probes 2 and 3 also produced significantly greater defect volumes than all of the piezoelectric. Increasing power of all magnetostrictive and piezoelectric probes was shown to increase defect depth. Magnetostrictive probes oscillating with greater displacement amplitudes than piezoelectric probes, there were few differences in the resulting defect depths.
8	de Oliveira et al. (2010)⁶⁸	In vitro study 10 samples from each group were subjected to deposition of bloody tissue and the other 10 did not receive any type of treatment 45 teeth 25 teeth for the analysis of the morphology, attachment of blood components 20 teeth for the analysis of the roughness, root wear	G-1 (20 samples) Laser Er,Cr:YSGG laser-30° G-2 (20 samples) Laser Er,Cr:YSGG laser-45° G-3 (20 samples) Laser Er,Cr:YSGG laser-60° G-4 (20 samples) Laser Er,Cr:YSGG laser-90° G-5 (20 samples) SRP.	To evaluate the influence of the working tip angulation of the Er,Cr:YSGG laser on the morphology, attachment of blood components, roughness, and wear on irradiated root surfaces compared with SRP.	Er,Cr:YSGG laser 2780 nm PD 140–200 μs RR 20 Hz E 300 mJ P 0–6 W 29.99 J/cm² Sapphire-coated tip TD 600 μm TL 4 mm 10% air and 15% water Sweeping movements in contact IT 30 s	Manual curettes (5–6, Hu-Friedy)	The samples irradiated with the Er,Cr:YSGG laser were rougher than the samples scaled with manual instrument. The samples irradiated with a laser at an angulation of 60° were rougher than the samples irradiated with the laser at an angulation of 30°. Samples with a laser with a working angle of 90° were rougher than the samples irradiated with a laser at an angulation of 30° and 45°. The group that was irradiated with the Er,Cr:YSGG laser at an angle of 30° presented the least wear in comparison with all the other treatments. The root surfaces irradiated with the Er,Cr:YSGG laser working angulation tip of 45° and 60°, and the samples scaled with manual instruments presented greater attachment of blood components.
9	de Oliveira et al. (2010)⁶⁸	In vitro study 4 patients 15 teeth 60 root surface (4 surfaces from each tooth)	G-1 (20 surfaces): SRP G-2 (20 surfaces): Er,Cr:YSGG laser G-3 (20 surfaces): SRP and Er,Cr:YSGG laser	To evaluate the effects of Er,Cr:YSGG laser irradiation on root surfaces for adhesion of blood components and morphology,	Er,Cr:YSGG laser 2780 nm P 1.0 W, RR 20 Hz PD (140–150 μs) Sapphire tip TD 600 μm, TL 4 mm 45° angle 10% air and 15% water IT 30 s ED (29.99 J/cm²) Noncontact mode	Manual curette (Gracey curette)	Morphological analysis disclosed that all root surfaces irradiated by Er,Cr:YSGG laser (100%) were rougher than surfaces that were not irradiated. Er,Cr:YSGG laser irradiation produced rougher root surfaces than treatment by SRP. Er,Cr:YSGG laser did not interfere with the adhesion of blood components to the root surfaces. No statistical differences for adhesion of blood components to root surfaces were found between the groups.
10	Abed et al. (2010)⁶²	An in vitro study Each procedure was performed for 120 s 15 freshly extracted premolars due to existing periodontal problems Tooth was sectioned into halves	45 root surface sections. The same tooth as all three methods were applied on different halves of the same tooth G-1: Er:YAG laser G-2: Ultrasonic device G-3: Hand instrument	To compare the root surface roughness following scaling by Er:YAG laser with the conventional ultrasonic and hand instruments.	Er:YAG laser E 120 mJ RR 12 Hz PD 75–100 μs VSP mode Ro7 handpiece Water cooling	Ultrasound system TFI10 handpiece, 25 Hz Hand instrument sharp new curette	A minimal surface roughness was observed under SEM in samples treated by Er:YAG laser. Laser use was not superior to the other two methods of ultrasonic and hand instrumentation. Very little (mild) roughness seen in laser-irradiated group. The difference was not significant when ultrasonic and laser groups were compared. To produce little surface roughness based on the laser settings.
11	Tsurumaki et al. (2011)⁶⁹	An in vitro study 25 single- or multi-rooted teeth 10 samples from each group were used for analysis of root morphology 10 were used for analysis of adhesion of blood components on the root surface	G-1 (20 samples) hand curettes (Gracey curette) G-2 (20 samples) PU scaler G-3 (20 samples) Curettes plus PU scaler G-4 (20 samples) Er,Cr:YSGG laser G-5 (20 samples) Curettes plus Er,Cr:YSGG laser	To evaluate the morphology and adhesion of blood components on root surfaces instrumented by curettes, PU scaler, and Er,Cr:YSGG laser.	Er,Cr:YSGG laser 2780 nm P 1.0 W RR 20 Hz PD 140–150 μs Sapphire tip TD 600 μm TL 4 mm 10% air 15% water 45° angle IT 30 s ED 29.99 J/cm² Noncontact mode	Hand curettes (Gracey curette) PU scaler w/RS3 tip, standard mode, 30 kHz, water rate 30 mL/min, 30 s	The group treated with curettes showed smoother surfaces. Ultrasonic instrumentation and Er,Cr:YSGG laser irradiation produced rougher root surfaces than the curettes. In group 1 (SRP), the SEM micrographs showed smooth root surfaces in most cases and all samples showed the formation of smear layer and grooves without exposure of dentin tubules. In group 2 (PU scaler), the root surface is rougher with the presence of a smear and occluded tubules. In group 3, the pattern in this group was similar to that found in group 2. In group 4 (Er,Cr:YSGG laser), all root surfaces were rough, with no smear layer, with open dentin tubules, and the absence of thermal damage. In group 5 (SRP+Er,Cr:YSGG laser), the SEM micrographs were similar to group 4.
12	Aspriello et al. (2011)⁴⁸	An in vitro study Teeth were stored in a sterile saline solution at 4°C for 1 month Specimens stored for no longer than 5 days in distilled water 30 single-rooted human teeth 15 HF and 15 HNF	G-A instrumentation w/curettes G-B instrumentation w/piezoelectric w/titanium nitride coated tip G-C, combined technique with curette/ultrasonic piezoelectric instrumentation	To investigate the ultramorphology of the root surfaces induced by mechanical instrumentation performed using conventional curettes or piezoelectric scalers when used single handedly or w/combined technique.	Not reported	Gracey curette hand scaler	Periodontal SRP performed with curettes, ultrasonic, or combined instrumentation induced several morphological changes on the root surface. Curette presented a smoother surface than those treated using the ultrasonic tip. Curette, ultrasonic simultaneous instrumentation may combine the beneficial effects of each instrument in a single technique creating a root surface relatively free from the physical barrier of smear layer.
13	Dahiya et al. (2011)⁷⁷	An SEM study 20 single-rooted teeth	n = 2 Control group: untreated. G-1 (n = 6) Root planing by (HD) Gracey curettes G-2 (n = 6) Root planing by ultrasonic tip G-3 (n = 6) Root planing by rotary bur	To compare root surface characteristics following root planing with various hand and power-driven instruments.	Not reported	1–2 and 3–4 Gracey curettes (Hu-Friedy) PU scaling unit (perio, PS ultrasonic tip, water spray, medium power setting)	All the three instruments, namely Gracey curette, ultrasonic tip, and rotary bur were effective in mechanical debridement of the root surface. Rotary instruments produced the smoothest surface followed by ultrasonic tips and hand curette. Nonsignificant differences were found while comparing Gracey curettes and ultrasonic groups. The use of rotary instrument was more time-consuming, which might limit its use in clinical practice.
14	Oliveira et al. (2012)⁷⁵	An in vitro evaluation 15 extracted, single-rooted, periodontally diseased human teeth 60 samples of human teeth	G-1 (20 samples) (control group) no treatment G-2 (20 samples) Er,Cr:YSGG laser irradiation G-3 (20 samples) Er:YAG laser irradiation	To evaluate by SEM, the adhesion of blood components on root surfaces irradiated with Er,Cr:YSGG laser (2.78 μm) or Er:YAG laser (2.94 μm), and of the irradiation effects on root surface morphology.	→ Er,Cr:YSGG laser 2.780 nm RR 20 Hz Optical fiber tip TD 600 μm E 100 mJ ED 35.71 J/cm² Focused without contact Water cooling IT 15 s → Er:YAG laser 2.940 nm RR 10 Hz E 100 mJ ED 12.9 J/cm² 1.1 × 0.5 mm tip Focused without contact Water cooling IT 15 s	Manual instruments (Gracey-curette)	The root surfaces irradiated with Er:YAG laser and Er,Cr:YSGG laser presented greater roughness than those in the control group. Lower degree of adhesion in G2 than in G1 and G3. The Er:YAG laser and Er,Cr:YSGG laser treatments caused more extensive root surface changes. The Er:YAG laser treatment promoted a greater degree of blood component adhesion to root surfaces, compared with the Er,Cr:YSGG laser treatment. G1 samples showed smooth and leveled root surfaces, a smear layer was formed and grooves with dentinal tubule exposure were observed. Er,Cr:YSGG laser irradiation showed irregular root surface with the presence of microroughness, with open dentinal tubules and no smear layer. Er:YAG laser irradiation showed irregular root surface with the presence of craters, with open dentinal tubules and without a smear layer.
15	Singh et al. (2012)⁴⁶	An in vitro study 30 periodontally involved extracted human teeth The surfaces were examined for Damage Scratches Gouges Cracks Remnants of debris	G-A: new universal hand curette G-B: Cavitron (FSI–SLI) ultrasonic device with focused spray slimline inserts G-C: (EMS) PU device with prototype modified PS inserts	To comparatively evaluate the efficacy of manual, magnetostrictive, and PU instrumentation on periodontally involved extracted teeth using profile-meter and SEM.	Not reported	New universal hand curette Cavitron (FSI–SLI) ultrasonic device (EMS) PU device	No significant difference was observed in the three experimental groups. Manual, magnetostrictive, and PU instruments produce the same surface roughness and their efficacy for creating a biologically compatible surface of periodontally diseased teeth is similar. The overall surface roughness was greater after the piezoelectric instrumentation than the other two instruments.
16	Amid et al. (2012)⁷¹	Comparative in vitro SEM study 60 single-rooted maxillary and mandibular teeth	G-1: conventional hand curette G-2: ultrasonic device G-3: roots after scaling by hand instrumentation were treated by Er:YAG laser G-4: roots were prepared by the ultrasonic scaler and consequently were treated by laser	To describe the ultrastructural changes that happened after treatment of the root surfaces with ultrasonic and hand devices followed by Er:YAG laser irradiation.	Er:YAG laser 2940 nm E 50 mJ RR 10 Hz Very short pulse PD 320 μs 50–50% air/water Swiping motion 20° angle	Manual curette Ultrasonic scaler, moderate power, high water irrigation, 0°–20° angle	There were no severe morphologic changes, such as melting and charring, in any group. There were no signs of major thermal changes such as melting and carbonization in any laser-treated samples. The samples treated by laser irradiation showed more irregularities and distortions. Samples treated with ultrasonic devices showed rougher surfaces with few depths and laser irradiated were most irregular. Root surface irregularities were more pronounced in laser-treated groups compared with hand instruments. Er:YAG laser setting at 50 mJ/pulse, as an adjunct to traditional scaling and root planning, did not induce severe damages to root surfaces. All treatment modalities could remove dental calculus completely.
17	Solís Moreno et al. (2012)⁵⁰	Comparative, in vitro, blinded study 20 teeth 40 interproximal root surfaces	G-1: Gracey curettes with 15 vertical strokes G-2: diamond burs (40 μm) at 3000 r.p.m. G-3: piezoceramic ultrasonic scaler G-4: piezo-surgery ultrasonic scaler with a power of two	To analyze and to compare the root surface roughness after using Gracey curettes, termination diamond burs (40 μm), a piezoceramic ultrasonic scaler, and a piezo-surgery ultrasonic scaler using confocal microscopy and SEM.	Not reported	Gracey curettes Piezo-surgery ultrasonic scaler Diamond burs Piezoceramic ultrasonic scaler	Curettes, piezoceramic ultrasonic scaler, and piezo-surgery ultrasonic scaler left a smoother surface than termination diamond burs. Statistically significant differences were observed in roughness between piezo-surgery and termination diamond burs. No statistically significant differences were between piezo-surgery and Gracey curettes and between piezo-surgery and piezoceramic ultrasonic scalers. Piezo-surgery ultrasonic scaler produced the smoothest surface. The termination diamond burs (40 μm) produced a rougher surface than the ultrasonic instruments and the hand curettes.
18	Amid et al. (2013)⁷²	A profile-meter study 60 single-rooted maxillary and mandibular teeth Samples were divided into four groups	G-1 (15 roots): manual curette G-2 (15 roots): ultrasonic scaler G-3 (15 roots): hand instrumentation+Er:YAG laser G-4 (15 roots): ultrasonic scaler+Er:YAG laser	To measure root surface roughness in teeth with periodontitis by a profilometer following root planning with ultrasonic and hand instruments with and without Er:YAG laser irradiation.	Er:YAG laser RR 10 Hz E 50 mJ P 50 W Very short pulse mode 50–50% air/water 20° angle IT 45 s	Manual curette Ultrasonic scaler medium position, high water irrigation, 0°–20° angle	Significant differences were detected in terms of surface roughness and surface distortion before and after treatment. No significant differences among the four groups were found. Root planning with a manual curette is the most effective method for reduction of surface roughness. Ultrasonic instrumentation showed the highest changes in this respect. The least significant changes occurred in samples treated with an ultrasonic instrument followed by laser irradiation. Er:YAG laser as an adjunct to traditional scaling and root planning reduces root surface roughness. However, the surface ultrastructure is more irregular than when using conventional methods.
19	Eick et al. (2013)⁷⁸	An in vitro study 30 specimens were used for three experiments (surface roughness, adhesion PDL fibroblasts, and adhesion of S. gordonii)	G-1 (15 roots): the standardized specimens as a control G-2 (15 roots): Gracey curettes G-3 (15 roots): Additional instrumentation after treatment with Gracey curettes by using diamond coated	To evaluate the efficacy of an additional usage of a diamond-coated curette on surface roughness, adhesion of periodontal ligament (PDL) fibroblasts, and of Streptococcus gordonii in vitro	Not reported	Gracey curettes (11GC12 Gracey curette, 13GC14 Gracey curette) Diamond-coated curettes (intensiv PerioDiaC rett PDC11/12, PDC13/14)	Instrumentation with conventional Gracey curettes reduced surface roughness. After application of Gracey curettes, the surface was smooth, although a smear layer was visible. The additional usage of diamond-coated curettes resulted in a more homogenous wave-like pattern with nearly no smear layer. The number of attached PDL fibroblasts did not change the following scaling with Gracey curettes. The additional instrumentation with the diamond-coated curettes resulted in a twofold increase in the number of attached PDL fibroblasts but not in the numbers of adhered bacteria.
20	Almehdi et al. (2013)⁶⁵	An in vitro study 40 extracted intact human molar and premolar teeth 11 cementum plates of dimension 4 × 4 × 1 mm were prepared from teeth	Each cementum surface has been divided into longitudinal thirds. The first one-third (ultrasonic instrumentation) The middle one-third (Er:YAG laser) The last one-third (CO₂ laser)	To precisely analyze the alterations of root cementum treated with the Er:YAG laser and the CO₂ lasers, using nondecalcified thin histological sections.	Er:YAG laser 2940 nm PD 250 μs E 40 mJ RR 25 Hz P 1 W ED 14.2 J/cm² 80° curved angle contact tip TD 600 μm Water spray IT 2 s 30° angle	PU scaler universal tip, water spray, moderate pressure, 4 power setting, 30° angulation	Stereomicroscopy ultrasonic scaler-treated cementum surface had a relatively smooth and glossy surface with small defects created by the ultrasonic vibration of the tip. SEM (low magnification) Ultrasonically treated cementum surface exhibited a shallow groove with a polished appearance. Er:YAG laser-treated cementum showed a fine microrough surface with no smear layer. SEM (moderate, high magnification). The ultrasonically treated cementum presented a smooth surface with an appearance of round-shaped structures. The Er:YAG laser-lased cementum showed a characteristic grass-like or flaky appearance.
21	do Nascimento Tsurumaki et al. (2013)⁵¹	An in vitro study 10 teeth single-rooted or multi-rooted teeth Proximal surface divided into four areas 20 samples, 10 to analyze morphology, 10 to analyze adhesion of blood components	G-1 untreated control group G-2 scaling with manual instrument, Gracey curette G-3 scaling with ultrasound PU scaler G-4 scaling with manual instruments+ultrasound	To evaluate the morphology and adhesion of blood components on root surfaces instrumented with PU Piezon Master Surgery.	Not reported	Manual instrument, Gracey curette Ultrasound PU scaler (Piezon Master Surgery), RS3 tip, standard mode, 30 kHz power, 30 mL/min irrigation, 30 s	Group 2 presented a smoother surface compared with Group 1 and groups instrumented with ultrasound. The instrumentation with PU presented a higher degree of irregularities than the surface profile of roots treated with manual curettes. The samples presented a smooth pattern with the presence of smear layer. In manual instrumentation group, all the samples of this group presented smooth aspect, with presence of smear layer and occluded dentinal tubules. In ultrasonic scaler group, an irregular root surface, with the presence of grooves promoted by the ultrasonic tip; the presence of smear layer and occluded dentinal tubules. In manual+ultrasonic scaler group, the pattern observed in this group was similar to that observed in the ultrasonic.
22	Belal and Watanabe (2014)⁶⁶	An in vitro study 45 periodontally affected single-rooted teeth 5 specimens in each group for surface topographic examination. The remaining 10 specimens in each group for human periodontal ligament cell suspension.	45 root specimens divided into 3 groups G-1 (15 specimens): untreated control group G-2 (15 specimens): SRP+Co₂ laser G-3 (15 specimens): SRP+Er:YAG laser	To compare the conditioning effects of the CO₂ or Er:YAG laser on periodontally diseased root surfaces following SRP in terms of the alteration of morphologies as well as the attachment of periodontal ligament cells.	Er:YAG laser 0.6 mm tip E 40 mJ RR 10 Hz ED 14.2 J/cm² Slight contact mode IT 45 s Under air/water spray	Ultrasonic scaler for 35 s	The Er:YAG laser-lased specimens showed the significantly highest number of attached cells, mostly in flat form, and did not show distinct thermal damage. SRP+Er:YAG laser-treated surface showing some areas with charring layers but other areas with multiple projections and the opening of dentinal tubules. SRP+CO₂ laser-treated surface showing some areas affected with surface charring and cracking. The Er:YAG laser may constitute a more useful conditioning tool for enhancing periodontal cell attachment to periodontally diseased root surfaces, with fewer undesirable thermal side effects.
23	Rosales‐Leal et al. (2015)⁵⁵	In vivo randomized experimental trial study 19 patients 44 single-rooted teeth	G-1 (n = 10): no treatment control group G-2 (n = 11): manual root planing with a curette G-3 (n = 10): root planing with a PU scraper G-4 (n = 13): root planing with a VOU scraper (Vector System)	To compare the topography of untreated single-rooted teeth planed in vivo with a curette, a PU scraper, or a VOU scraper.	Not reported	Manual instrumentation with a Gracey curette PU device G1 tip, water cooling, medium speed VOU device, metal tips	Surface morphology was similar after the three treatments and was less irregular than in the untreated group. The remaining roughness parameters were similar among all treatment groups. Both ultrasonic devices reduce the roughness, producing a similar topography to that observed after manual instrumentation with a curette. A similar surface morphology was observed after each treatment, whereas the surface was more irregular in the untreated group. A lower roughness value was obtained with the VOU device than with the other two instruments. Ultrasonic devices therefore appear to represent a valid alternative to manual instrumentation with a curette.
24	Casarin et al. (2015)⁵⁷	An in vitro study 90 extracted human teeth	G-1 control group (w/o instrumentation) G-2 curette instrumentation G-3 ultrasonic instrumentation w/low power G-4 ultrasonic instrumentation w/medium power G-5 ultrasonic instrumentation w/high power	To evaluate root roughness after ultrasonic instrumentation with different power settings and compared it with curette instrumentation.	Not reported	Gracey curettes Ultrasonic scaler w/0° angulation	The mean roughness values of the treated roots were higher than the nontreated roots. Roots treated by ultrasonic instrumentation had higher roughness means than roots treated by curettes. Ultrasonic instrumentation with a high-power setting produced a rougher root surface than ultrasonic instrumentation with a lower power setting. Manual instrumentation with curettes produced lower roughness than ultrasonic instrumentation independent of power setting.
25	Kumar et al. (2015)⁵⁸	An in vitro study 35 healthy extracted premolars	G-1 performed no instrumentation, regarded as control G-2 performed SRP using Gracey curettes No.5/6 G-3 ultrasonic instrumentation w/low power G-4 ultrasonic instrumentation w/medium power G-5 ultrasonic instrumentation w/high power	To compare the root surface roughness after root planing performed with Gracey curette and by ultrasonic scalers (Satelec P-5 Booster) set at different power modes.	Not reported	Gracey curettes No 5/6 ultrasonic scaler copious irrigation, N2 insert, and 0° angulation	The mean roughness was found to be the highest in a group where SRP was performed using ultrasonic scaler at low-power mode. The lowest surface roughness was seen on the samples where SRP was performed using ultrasonic scaler at medium-power mode. The surface roughness in group where SRP was performed with ultrasonic scaler at high-power mode was found to be similar to that of the group in which root planing was carried out using curette.
26	Yaghini et al. (2015)⁷³	Experimental study 56 extracted sound single-rooted teeth	G-1: SRP with Er:YAG laser G-2: performed SRP using Gracey curette No. 3–4 G-3: ultrasonic instrumentation G-4: considered the control group	To evaluate the root surface roughness after SRP with Er:YAG laser compared with ultrasonic and hand instruments.	Er:YAG laser 2940 nm E 100 mJ P 1 W RR 10 Hz VSP and contact mode 50% water and air R 14 Handpiece Chisel tip 20°–30° angle	Hand instrument Gracey curette No. 3–4 ultrasonic device universal tip, moderate power, high water irrigation, little less than 90°	The surface roughness was higher in laser and lower in the ultrasonic group compared with other groups. There was a significant difference in surface roughness between the laser and ultrasonic groups. Surface roughness after SRP with Er:YAG laser was not higher than that after manual SRP, but the former value was higher than that after SRP with the ultrasonic instrument.
27	Müller et al. (2016)⁶⁰	An in vitro study 12 teeth Teeth were instrumented with new Gracey curettes (Gracey 5/6 from different brands)	G-1 (n = 2) Control, no instrumentation G-2 (n = 2) (GC); carbon steel G-3 (n = 2) (CSN); stainless steel Neumar G-4 (n = 2) (SSN); stainless steel Millenium G-5 (n = 2) (SSM); premium steel Neumar G-6 (n = 2) (PSN); Hu-Friedy (HF)	To verify the root surface after mechanical scaling with different Gracey curettes, steel, through SEM and superficial roughness analyses.	Not reported	Gracey curettes (PSN) premium steel Neumar (SSM) stainless steel Millenium (SSN) stainless steel Neumar (CSN) carbon steel Neumar (HF) Hu-Friedy	The specimens showed a decrease in roughness after instrumentation by curettes in all groups. Group SSM demonstrated a homogenous root surface and better smoothness in rugosimetry analysis. The group of curettes that provided better smoothness of root surface after scaling was SSM.
28	Solomon et al. (2016)⁵²	An in vitro study (AFM study) 30 human extracted teeth 3 groups Gracey curette (G), ultrasonic tip (US), and Periotor tip (PP)	G-1 (G), scaling w/manual instrument Gracey curette G-2 (US), ultrasonic scaling w/periodontal tip mounted on an ultrasonic handpiece G-3 (PP), scaling w/reciprocating contrast angle handpiece with Periotor tips	To compare the root surface morphology after scaling with Gracey curette, ultrasonic tip, Periotor insert, using atomic force microscopy (AFM)	Not reported	Gracey curette appropriate amount of pressure 60–70° angle Ultrasonic scaling periodontal tip, handpiece 25 kHz, 15 s, 90° angle water irrigation.	More appropriate surface morphology obtained after scaling with Periotor inserts, followed by Gracey curette and ultrasonic tip. Periotor device and Gracey scalers conducted at the almost similar roughness of the root surface. Surface morphology obtained after instrumentation with Periotor inserts is similar to that obtained by instrumentation with Gracey curette. In the first place, the ultrasonic technique determined surfaces with the lowest average of root means square.
29	Zafar (2016)⁵³	An in vitro study 40 Freshly extracted teeth	G-1 (n = 20) Gracey curettes (Gracey curettes No. 11/12, Hu-Friedy) G-2 (n = 20) Ultrasonic scaler (PIEZO-soft ultrasonic scaler)	To analyze the surface profiles of healthy and periodontal-treated roots. In addition, manual and ultrasonic instrumentation methods have been compared in terms of surface mechanical properties of root surfaces, including surface roughness, hardness, and elastic modulus.	Not reported	Gracey curettes (11/12 Gracey curettes, Hu-Friedy) Ultrasonic scaler (PIEZO-soft ultrasonic scaler), PIEZO scaler Tip 201, 30 kHz.	Gracey curettes and ultrasonic scalers are capable of significantly reducing the roughness following root planing. Group 1 showed better surface roughness compared with Group 2. Gracey curettes produced smoother surfaces than ultrasonic scalers.
30	Amid et al. (2016)⁷⁹	An in vitro study 50 extracted single-rooted premolars	G-1 (n = 10) control group: untreated. G-2 (n = 10) (HD) Gracey curettes 7 and 8 G-3 (n = 10) Er,Cr:YSGG laser group I: (HD)+laser W/of 120 mJ, 10 Hz. G-4 (n = 10) Er,Cr:YSGG laser group II: (HD)+laser W/of 160 mJ, 15 Hz. G-5 (n = 10) Ultrasonic group: ultrasonic scaler	To evaluate in vitro viability and attachment, configuration of human gingival fibroblasts on root surfaces treated with hand instruments, ultrasonic scalers and Er,Cr:YSGG laser using MTT assay and SEM observation.	Er,Cr:YSGG 2.79 μm 20°–25° angle Chisel-shaped glass fiber tip 0.5 × 1.65 mm Noncontact 1.5 mm IT 45–60 s Air/water spray → Er,Cr:YSGG laser Group I E 120 mJ RR 10 Hz → Er,Cr:YSGG laser Group II E 160 mJ RR 15 Hz	(HD) Hand instrumentation Gracey curettes 7 and 8 Ultrasonic scaler (piezo-surgery), 60 s	SEM observation revealed higher irregularity on the root surface. Abnormal and apoptotic fibroblasts were also more prevalent in the lased groups. The lased specimens showed the highest irregularity. Hand instrumentation and ultrasonic scaler root surfaces showed more regular patterns than the laser groups. The Er,Cr:YSGG laser did not reveal any satisfactory outcomes in terms of fibroblast attachment and survival at an output power of 1.2 and 1.6 watts.
31	George et al. (2016)⁷⁴	An in vitro study A total of 30 extracted noncarious nonrestored human teeth The data obtained were analyzed for remaining calculus index, loss of tooth substance index, and roughness	G-1 (n = 10) Hand instrumentation w/Gracey curette No. 1/2 (Hu- Friedy) G-2 (n = 10) PU scaling unit G-3 (n = 10) Hand instrumentation w/Gracey curette No. 1/2 (Hu-Friedy)+diode L	To compare the efficacy of calculus removal as well as to compare the roughness and loss of tooth substance caused after instrumentation with (1) hand instrument, (2) ultrasonic scaler, and (3) hand instrument+diode laser application.	Not reported	Hand instrumentation w/Gracey curette No. 1/2 (Hu-Friedy) PU scaling unit	No statistically significant differences were found between the three groups. Efficacy of calculus removal of ultrasonic scaler was marginally better, whereas the roughness caused after laser application was more when compared with the other groups. All three instruments could be used for routine debridement of the root surfaces, ultrasonic scalers were found to be more efficient than hand scalers. Diode laser may be routinely used as an adjunct to SRP as the surface alterations caused were minimal.
32	Arora et al. (2016)⁷⁰	An in vitro study 30 freshly extracted premolars Mesial surface of each root was divided into four parts Analyzed for the surface roughness, presence of smear layer, cracks, craters, and melting of the surface	Part A (n = 30) Control group: untreated. Part B (n = 30) irradiated by (Er,Cr:YSGG laser) laser Part C (n = 30) PU scaler Part D (n = 30) Gracey curette	To evaluate and compare the surface characteristics of roots treated with conventional instrumentation and those irradiated with Er,Cr:YSGG laser using SEM and profilometer.	Er,Cr:YSGG laser 2780 nm P 1 W RR 20 Hz 10% air and 15% water Noncontact mode Z6 laser tip TD 600 μm TL 6 mm IT 20 s	Hand instrumentation Gracey curette (#11–12, Hu-Friedy) PU scaler (medium power, BS-1 tip, air 65% and water 55%, for 20 s)	Er,Cr:YSGG laser group showed maximum surface roughness compared with the ultrasonic scaler and curette group where the smoothest surface was seen in group D (hand instrumentation). Surface with smear layer was found to be maximum (50%) in curette-treated samples and minimum (20%) in laser-treated ones. The maximum cracks (83.34%) were produced by ultrasonic scaler and the minimum (43.33%) by curettes. Crater formation was maximum (50%) in laser-treated samples and minimum (3.33%) in curette-treated ones. 63.33% samples treated by laser demonstrated melting of the root surface, followed by ultrasonic scaler and curettes.
33	Bozbay et al. (2016)⁸⁰	Clinical study 27 patients 48 caries-free, single-rooted teeth Measurement of the amount of and surface characteristics	G-1 PU scalers (U) G-2 PU scalers following air polishing (U+AP) G-3 AP alone G-4 HC	To evaluate the effects of three distinct periodontal treatment methods in comparison with hand instrumentation on residual cementum of periodontal-diseased teeth.	Not reported	Hand instruments (HC) (Gracey curettes 5/6, 11/12, 13/14 PU scaler (U) [Piezon Instrument Tip (PS), medium power settings, water cooling]	The smoothest root surfaces were produced by the HC followed by the AP. Root surfaces instrumented by U or U+AP presented grooves and scratches. The percentage of coronal cementum remaining following subgingival instrumentation was 84% for U, 80% for U+AP, 94% for AP, and 65% for HC. The amount of retained cementum with AP was still significantly greater than with HC. AP was superior to U devices in preserving cementum, whereas HC were the most effective instruments in removing cementum.

Er:YAG, erbium-doped yttrium/aluminum/garnet; HC, hand curettes; HD, hand instrument debridement; SRP, scaling and root planning; VA, vector system with abrasive fluid; VOU, vertically oscillating ultrasonic; VP, vector system with polishing fluid.

Study evaluation

Articles were evaluated based on the same idea as in the study by M.A.A., R.N., and N.G. Antibacterial effect of using the Er:YAG laser or Er,Cr:YSGG laser compared with conventional instrumentation method—a literature review. Lasers in Dental Science 2017.¹¹

The data were recorded using the following indices:

Remaining calculus and roughness or loss of tooth substance index (Figs. 2 and 3).^12,13

FIG. 2.

Efficiency of plaque and calculus removal.

FIG. 3.

Effect of different periodontal instruments on the root surface.

3 = No calculus remaining on the root surface and smooth, or even root surface without loss of tooth substance.

2 = Small amount of material probably consisting of calculus and slightly roughened or corrugated local areas confined to the cementum.

1 = Definite amount of calculus confined to smaller areas and definitely rough areas where the cementum may be completely removed, although most of the cementum is still present.

0 = Considerable amount of remaining calculus appearing on the treated surface and high roughness with considerable loss of tooth substance.

Discussion

Efficiency of plaque and calculus removal of different periodontal instruments

The basic treatment of periodontal disease is the removal of the underlying problem of causing the disease. The elimination of plaque and calculus is considered an essential aim in the treatment of periodontal disease, and the success of healing of this disease depends on the amount of plaque and biofilm efficiently eliminated from the root surface.

First, in nonsurgical periodontal therapy, hand instrument scaling was most used until studies showed an increasing amount of evidence that ultrasonic instruments were effective in removing calculus, with significantly less time required to remove the calculus from root surfaces and leave the treated root surfaces smoother for better healing and reattachment. In the recent past was reported that Er:YAG laser and Er,Cr:YSGG laser could offer sufficient removal of subgingival calculus without thermal side effects in the level that appears to be the same to that yielded by ultrasonic scaler and hand instrument.^14,15 In agreement with the current findings, the Er:YAG laser demonstrated a relevant difference in efficiency of calculus removal compared with the Er,Cr:YSGG laser.¹⁶

Efficiency of plaque and calculus removal using Er,Cr:YSGG laser

Laser treatment for periodontal disease reduces patient trauma, postoperative complications, and healing time. It was concluded that the use of Er,Cr:YSGG laser for root scaling with a 1.0-W power output setting may be done without any morphological change of root surface and with the acceptable efficient removal of calculus.¹⁷ Data from an in vitro study have also shown that both hand instrumentation and erbium laser treatments were effective in calculus removal from root surfaces without any observed thermal changes in the form of melting or carbonization, when the effectiveness of erbium, Cr:YSGG laser and conventional treatment on calculus removal was examined. The results of this study recommended that the laser procedures, when used in appropriate parameters, are able to achieve SRP in the treatment of periodontitis.¹⁸

Efficiency of plaque and calculus removal using Er:YAG laser

The objective of using laser in nonsurgical periodontal therapy is to be at least as effective as the conventional treatment to clean the root surface especially in the periodontal pocket area. Studies evaluated the removal of subgingival calculus. In the first study with fluorescence feedback-controlled Er:YAG laser, they found that the amount of remaining calculus following laser irradiation depends on the fluorescence threshold level for a feedback-controlled Er:YAG laser. By lowering the laser fluorescence threshold, the amount of remaining calculus decreased. The second study demonstrated that the erbium laser compared with the Er,Cr:YSGG laser appears to have an advantage in terms of time and efficiency of periodontal disease treatment.^19,20

Efficiency of plaque and calculus removal using conventional instruments

The effectiveness of two ultrasonic devices (two piezoelectric ultrasonic Scalers) was compared with the hand instrument and it was found the remaining calculus index did not differ significantly among the three instrument groups.²¹ Ultrasonic scaling is as effective as hand instrumentation in plaque removal.²² In an attempt to increase the speed and efficiency of deposit removal, an in vitro study was done to see the difference in speed and efficiency between hand instrument and magnetostrictive ultrasonic instrument with plain inserts (PIs) and diamond-coated inserts (DIs) and found that the surfaces treated with hand instrument show less residual calculus, but on the contrary, the DIs were faster in calculus removal followed by sharp Gracey curettes [hand instruments (HIs)] and PIs.²³ In the same context, data from an in vitro study have shown that all the three instruments were effective in removing calculus and achieving a clean root surface; Gracey curette left a cleaner surface compared with the standard smooth ultrasonic tip. DIs were equal to the Gracey curette in the removal of calculus from the root surface. Root surface irregularity and damage of tooth hard substance with diamond-coated ultrasonic tip were significantly greater in contrast to the other two instruments.²⁴ Further, it was observed in a study that none of the root surfaces treated with any of the modalities of hand and ultrasonic instruments was completely free of calculus, but hand scaling with Gracey curettes gives better outcomes in terms of remaining calculus on the root surface.²⁵ Relatively more plaque was residual in the ultrasonic scaler (VEC) and little remaining plaque was found after use of the sonic device (AIR) and the ultrasonic scaler (TIG).²⁶ A study pointed out that using ultrasonic scalers for periodontal disease treatment is more efficient in the treatment of periodontal pocket but unable to remove complete endotoxins from root surfaces to achieve regeneration.²⁷ It is commonly assumed that less experienced operators tend to work with a higher power level of the powered device or to apply higher pressure to get higher efficacy.²⁸ Numerous factors may influence the efficiency of calculus removal such as the extent of periodontal disease, the instruments used, and the experience and skills of the operator.^29,30 An in vitro study has been different, comparing the periodontal disease treatment by use of conventional treatment in the hands of experienced versus less experienced. The study has shown that the Gracey curette, a piezoceramic ultrasonic scaler, and a sonic scaler were effective in mechanical root debridement, and surface roughness was higher with Gracey curettes followed by a sonic scaler and then a piezoceramic ultrasonic scaler, regardless of operators' experience.³¹

Comparing the efficiency of plaque and calculus removal using different periodontal instruments

The objectives of periodontal pocket debridement are not only for cleaning but also for disinfection. For this reason, the efficiency of scaling after applying erbium laser and Er,Cr:YSGG laser was investigated and despite the general acceptance of surface roughening after laser treatment, several other studies applying erbium:YAG laser at 40–160 mJ and 10 Hz showed a similar periodontal pocket treatment competence of both laser and ultrasonic debridement.^16,32 The results of a study showed that erbium laser with feedback control allows a selective elimination of calculus without any alteration of the root surface, with more capacity to remove calculus.³² Moreover, prior studies have usually not succeeded in presenting a general conclusion, and the outcomes of laser efficiency in root surface cleaning are not similar considering the extensiveness of laser types.³³ In an in vivo and in vitro study, calculus was efficiently removed with Er:YAG laser, but compared with ultrasonic scaler, the Er:YAG laser leaves a more rough and irregular surface, free of carbonization and melting.³⁴ In another study, by comparing the scaling effect utilizing manual instruments, ultrasonic tools, and Er:YAG laser on the reattachment of connective tissue cells of the gums to the root surface of the severe periodontitis diseased teeth, it was shown that although several dental surface cleaning procedures may differ in other aspects, they are the same regarding fibroblast morphology.³⁵

Effect of using various periodontal instruments on the root surface

The roughness of the root surface can affect the calculus and plaque accumulation. Therefore, smooth root surfaces are required to minimize plaque accumulation, reducing the occurrence of periodontitis.^36,37 Regardless of the instrument used for SRP treatment, conservation of tooth structure is very important. Because of the eradication of cementum layers and sometimes dentin layers, this leads to other complications in scaling procedure.³⁸ It is well accepted that roughness of the root surface does not negatively influence periodontal healing after periodontal treatment.^39,40 The degree of roughness, after calculus elimination, is not very important, but after root planing, it is very important to obtain healthy surfaces with minimal craters and holes after treatment, which will facilitate bacterial colonization and plaque formation on the root surface.⁴¹

Effect of Er:YAG laser on the topography and roughness of root surface

Effects of laser irradiation depend on the wavelength, power output, pulse duration, spot size, and irradiation time, also dependent on the optical density, structure, and maximal absorption of tissue.⁴² The potentiality of the Er:YAG laser in SRP was investigated, very long pulses (750–1000 μs) of Er:YAG laser give a smoother surface in general and provide a superior efficiency compared with a pulse duration of 140–400 μs, with the same energy densities. In this study, it has been irradiated with high power, and the water irrigation was not clear. Also, to get a completely smooth surface by just decreasing the energy to less than 22.6 mJ at the finishing period of treatment.⁴³

Effect of conventional instruments on the topography and roughness of the root surface

The production of smooth root surface with less alterations is the essential goal of SRP, which can be obtained with ultrasonic and hand instruments.⁴⁴ To examine the performance of different conventional ultrasonic debridements (piezoelectric ultrasonic device, magnetostrictive ultrasonic device, hand instrument) on the root surface, studies were conducted, which concluded that the devices were similar. The root surfaces appeared unequal, just the loss of dentine substance was observed with piezoelectric devices less than with magnetostrictive. Also, rougher root surfaces were found after treatment with curettes and more root surface tissue was removed than with the ultrasonic device.^45,46

Generally recognized as the gold standard of therapy in the management of periodontal diseases is the mechanical debridement of calcified deposits from the root surface. Sonic and conventional ultrasonic debridements were first designed for the periodontal pocket treatment and extrinsic stains.¹⁹ When manual and ultrasonic instrumentations were combined, the root morphology was totally different from that observed when they were single handedly resulting in some cases in the complete removal of the smear layer and the exposure of collagen fibrils.⁴⁷ That will promote the integration between the healed connective tissue and root surface, and assist in the attachment of gingival fibroblasts.⁴⁸

In one investigation, it was established that the efficiency of calculus removal of the vector system with abrasive fluid (VA) and metal curette did not differ significantly from that of the HI, and conventional ultrasonic system with an “IS” tip. Root surfaces were smoother in the VA and vector system with metal curette insert and with hydroxylapatite containing polishing fluid (VP) groups than those in HD and Satelec groups; on the contrary, the calculus removal effectiveness of the (VP) and metal curette groups was significantly less compared with the HD and Satelec groups, because some scratches were clear on the root surfaces treated by HD or the Satelec ultrasonic system.⁴⁹ Another study evaluated and compared using confocal microscopy and scanning electron microscopy (SEM), the root surface roughness after using Gracey curettes, diamond burs, a piezoceramic ultrasonic scaler, and a piezosurgery ultrasonic scaler. Also was found that a smoother root surface was left after using the piezoceramic ultrasonic scaler and piezosurgery ultrasonic scaler; the diamond burs produced a rougher surface than the ultrasonic instruments and hand curettes, and the piezosurgery ultrasonic scaler created the smoothest surface.⁵⁰

The presence of smear layer production and irregular root surface affects periodontal attachment. A third study came to the same results when evaluating the morphology and adhesion of blood components on root surfaces instrumented with piezoelectric ultrasonic and hand instrument; piezoelectric ultrasonic showed irregularities of root surface with the presence of smear layer more than with manual curette treatment.⁵¹ One of the most important criteria to explain the success of the different periodontal treatments is the evaluation of root surface roughness. Results of an experiment are in contradiction to other studies that have confirmed that approximately similar roughness on the root surface was earned after scaling with Periotor inserts, followed by Gracey curette and ultrasonic tip.⁵² In contradiction to that, a uniformly smooth surface is likely to facilitate better adhesion and healing of periodontal tissues following mechanical debridement. After estimation of the surface profiles of healthy and periodontal treated roots, it was found that after manual and ultrasonic instrumentation following root planing treatment, the Gracey curettes and ultrasonic scaler are capable of reducing roughness critically, although Gracey curettes yielded smoother surfaces than ultrasonic scalers.⁵³ Extensive cementum and dentin removal appear to be not necessary to achieve efficient healing.⁵⁴ Damage to the root surface is a major concern of the dentist. If the dentist removed the root surface, a new environment may be created for retention of subgingival plaque. The topography of untreated single-rooted teeth was compared in vivo with a root planing with a curette, a piezoelectric ultrasonic scaler (PU) or a vertically oscillating ultrasonic scaler (VOU). The device (VOU) achieves a lower roughness value than the other two instruments, and it is concluded that ultrasonic devices are therefore a valid alternative to manual instrumentation with a curette.⁵⁵

Another study investigated the surface roughening of root produced by hand and conventional ultrasonic instrumentation with different power settings (10%, 50%, and 100%). The result showed no difference between manual and conventional ultrasonic instrumentation at 10%, 50%, and 100% power settings; manual instrumentation produced a similar defect on the root surface to that of ultrasonic instrumentation.⁵⁶ Recently, the same author reported that ultrasonic instrumentation with a high-power parameter produced a rougher root exterior than ultrasonic instrumentation with a lower power parameter, also manual SRP with curettes creates lower roughness than ultrasonic instrumentation independent of power parameters.⁵⁷ The conclusion of this study did not support the observation of another study which observed that the lowest surface roughness was seen on the samples where SRP was accomplished with ultrasonic scaler at medium-power parameters. In the group where SRP was with ultrasonic scaler at high-power parameters, the root surface roughness was almost similar to that when SRP was carried out with a curette.⁵⁸ The technique by which the adherent material on root surfaces can be eliminated with the ultrasonic scaler instrumentation is through the mechanical chipping action, when in contact with the root surface. However, the oscillating probe may also harm the tooth surface, especially in visibly restricted regions.⁵⁹ Magnetostrictive probes oscillate with greater vibration displacement amplitude and cause significantly greater defect depths and volumes than piezoelectric probes.⁵⁹ The efficiency of SRP conventionally, with various hand instruments, was examined. A similar research was also examined and compared hand devices, as the specimen was instrumented with new Gracey curettes 5/6 from many different brands (carbon steel, stainless steel Neumar, stainless steel Millenium, premium steel Neumar, Hu-Friedy). They determined, according to the methodology applied, the group of curettes that presented a high-grade smoothness of root surface following the SRP was premium steel Neumar.⁶⁰

Comparing the effect of different periodontal instruments on the topography and roughness of the root surface

The effects of erbium laser and neodymium laser on the surfaces of root were evaluated. Also compared them with those produced by using conventional ultrasonic debridement; in all groups treated with Er:YAG laser (RR 10 Hz, E 80, 100, and 120 mJ, PD 250 μs) dentin tubules were exposed and cementum layers were removed.⁶¹ Evaluation of root surface irregularity following scaling by Er:YAG laser (120 mJ, 12 Hz, 75–100 μs, VSP mode, Ro7 handpiece, water cooling) was by the ultrasonic device and hand instruments. It was noted that a minimal surface roughness was inspected under SEM in specimens managed by Er:YAG laser and discussed that to create less surface roughness, it depends basically on the laser settings.⁶²

In the majority of studies that state the influences of Er:YAG laser irradiation, the Er:YAG laser may ablate not only dental calculus but also the external part of the underlying cementum in such investigations, the resulting surface topography was similar to microscopic acid etching.^63,64 The water cooling applied with Er:YAG laser irradiation can lead to minimal cementum ablation and thermal changes with characteristic microstructure and degradation of the external layer.⁶⁵ Examination of the conditioning effects of the CO₂ or Er:YAG laser on periodontally unhealthy root surfaces following SRP in terms of the morphological alterations. In a comparison between CO₂ laser and erbium laser for the treatment of peritoneal pocket and effect on the root surface, it was found that the CO₂ laser has some deleterious effects on root surfaces, but Er:YAG laser may constitute a useful conditioning significant tool to periodontal pocket treatment by enhancing the periodontal ligament cells without notable undesirable effects.⁶⁶ To study the microscopic effects of Er,Cr:YSGG laser, when applied on root surface tissues with different energy settings, a study was performed and pointed out that Er,Cr:YSGG laser SRP has some advantages compared with the conventional treatment procedure and this was statistically significant. The teeth also resemble the microscopic surface structure of an intact tooth. The disadvantage was increased surface roughness of the root surface due to use of high peak power density; moreover, not enough water spray during the treatment procedure.⁶⁷ Checking the effects of Er,Cr:YSGG laser irradiation on the root surfaces resulted that in SRP, all specimens had a smear layer and scratches, but in the majority, smooth (90%), only (10%) of specimens had a very rough surface without exposure of dentinal tubules. In Er,Cr:YSGG laser and in SRP-assisted Er,Cr:YSGG laser, the photomicrographs showed that all (100%) specimens were very rough, without the presence of a smear layer.⁶⁸ The root surface morphology of the teeth instrumented by curettes, piezoelectric ultrasonic scaler, and Er,Cr:YSGG laser was assessed. Samples from this curette group showed smooth root surfaces in most cases. The samples treated with piezoelectric ultrasonic scaler or curettes+piezoelectric ultrasonic scaler revealed that the root surface was rough with the presence of grooves produced by the instrument, smear layer, and blocked dentin tubules were also present. In groups managed with Er,Cr:YSGG laser or curettes+Er,Cr:YSGG laser, it was determined that all samples of the root surface were rough, with no smear layer, with open dentin tubules, and the absence of thermal damage.⁶⁹

A recent in vitro study reported that all modalities, that is, curettes, ultrasonic scalers, and the Er,Cr:YSGG laser, increase root surface irregularity. In addition, the laser has generated rougher surfaces and most changes in the root surface profile; on the other hand, the smoothest surface was observed after hand instrumentation.⁷⁰ A secondary consequence is the elimination of cementum and exposure of dentinal tubule after periodontal disease treatment. Even though the mass of cementum on the root surface is very variable and depends on factors such as patient age and previous periodontal treatments, this enabled us to analyze and compare more precisely the influence of both Er:YAG laser and ultrasonic scaling on the root surface. Ultrastructural alterations, which appeared after treatment of the root surfaces with ultrasonic and hand devices followed by Er:YAG laser irradiation, determined that the root surface changes were more clear in laser-treated groups compared with hand instruments and ultrasonic scaler and the hand instrumented samples were smoother than other groups.⁷¹

Morphological examination and roughness analysis were accomplished and showed also in conclusion that root planing with a manual curette is the most efficient method to reduce surface roughness, but they also showed that Er:YAG laser as an adjunctive therapy to conventional SRP can reduce root surface roughness.⁷² The received results of another study showed the same, that application of Er:YAG laser for SRP was not different from the hand instrument in terms of surface roughness, but led to greater surface roughness compared with the ultrasonic system.⁷³ Root surface roughness and loss of tooth substance were created after instrumentation with (1) hand instrument, (2) ultrasonic scaler, and (3) hand instrument+diode laser application. It was revealed that despite all the three instruments being used for routine debridement of root surfaces, ultrasonic scalers were found to be more efficient than hand scalers. Whereas the roughness caused after laser application was more when compared with the other groups, significant roughness was made on irradiation.⁷⁴ SEM provides valuable data regarding root surface morphology after SRP treatment. In the previous years, laser radiation has been presented as an alternative or a coadjutant to conventional, mechanical root surface debridement. The effects on root surface morphology irradiated with Er,Cr:YSGG laser (2.78 μm) or Er:YAG laser (2.94 μm) laser were assessed by SEM; it was found that Er,Cr:YSGG laser-irradiated specimens showed irregular root surface with the appearance of microroughness, with exposed dentinal tubules and no smear layer. The same in the samples irradiated with Er:YAG laser irradiation showed irregular root surface with craters, with exposed dentinal tubules and without a smear layer.⁷⁵ The appearance of the smear layer on the treated root surfaces can act as a physical barrier between the periodontal tissues and the root surface inadequate for reattachment of the periodontal tissue.⁷⁶

Conclusions

Based on the systematic review results, it can be concluded that the beneficial effects of erbium lasers as an adjunct to SRP have been established. Although all periodontal instruments were efficient in calculus removal from the root surfaces, hand instrument showed much less remaining calculus compared with an ultrasonic instrument. Whereas, on the contrary, calculus removal using the ultrasonic instrument was approximately faster compared with the hand instrument. Erbium lasers revealed no remaining calculus or smaller amounts compared with the conventional instruments when used in appropriate settings. The ability of the Er:YAG laser to eliminate the calculus is comparable with ultrasonic and hand instruments. The efficiency of calculus removal with Er:YAG laser seems to be much higher compared with Er,Cr:YSGG laser. The results showed that ultrasonic instrumentation produced effects on the root surface almost similar to that of hand instrumentation. Er:YAG laser clarifies a little more surface roughness when compared with conventional instruments. Er,Cr:YSGG laser exhibits also rougher surfaces than conventional instruments. The erbium laser-treated root surface was relatively rougher than the conventionally scaled root without important thermal elevation. However, in comparison with conventional instruments, there is an increase in amount of cementum removed when erbium lasers are used.

Further, according to the severity and progression of periodontal disease, the settings of erbium lasers can be adjusted. The results of this review indicate using erbium lasers as an adjunctive therapy to SRP with the following parameters:

Er:YAG laser: 2940 nm, power output of 0.5–1.8 W (50–120 mJ and 10–15 Hz), pulse duration “200 to 400 μs,” 1.5–2 mm noncontact mode, 10°–40° tip angle to the root surface, and 50% air and 70% water irrigation.

Er,Cr:YSGG laser: 2790 nm, power output range of 1.25–1.5 W, short pulse duration “140 to 200 μs,” 1.5–2 mm distance noncontact mode, radial firing tip, 10°–40° tip angle to the root surface, 30–50% air/water irrigation.

These parameters according to this review can be appropriate to remove residual debris from the root surface and at the same time have little or no negative thermal effect on the root surface.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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