Effect of Different Scaling Methods and Materials on the Enamel Surface Topography: An In Vitro SEM Study

Abstract

Aim: Scaling is important for maintenance of gingival and periodontal conditions. These procedures have a harmful effect on the dental hard tissues. The aim of this study was to investigate the effects of hand and ultrasonic instruments made of stainless and titanium on the surface properties of enamel. Materials and Methods: Forty extracted premolars were used in this in vitro study and were randomly divided into four groups (n = 10). Group I received ultrasonic scaling with stainless steel tip, group II received ultrasonic scaling with titanium tip, group III hand scaling with stainless steel tip, and group IV hand scaling with titanium tip. Scanning electron microscopy (SEM) was used to examine the enamel surface morphology. Surface roughness of enamel was measured at baseline and after the scaling simulation using atomic force microscopy (AFM). Differences between initial and final measurements of surface roughness (ΔRa) were analyzed using two-way analysis of variance (ANOVA) followed by post hoc pairwise comparisons between groups. Results: SEM revealed deeper scratches and more destructive changes on enamel surface in group IV, whereas other groups revealed less change. AFM revealed that a mean surface roughness difference (ΔRa) had the highest value with hand instruments using titanium curettes, whereas the lowest difference was found with ultrasonic tips using stainless-steel tips. Hand titanium curettes showed a statistically significant increase in ΔRa when compared to hand stainless steel curettes (P = 0.02) and ultrasonic titanium tips (P = 0.01). Hand stainless steel tips showed a statistically significant increase in ΔRa when compared to ultrasonic stainless steel tips (P = 0.02) and hand titanium curettes (P = 0.02). Conclusion: Scaling using ultrasonic stainless steel tips produce the least amount of surface roughness and damage to the tooth surface.

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Address for correspondence: Dr. Mahmoud Al Ankily,
14 A Kawala St. Abdeen, Cairo 11613, Egypt.
E-mail: mahmoud.ankily@bue.edu.eg
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How to cite this article: Al Ankily M, Makkeyah F, Bakr MM,
Shamel M.Effect of different scaling methods and materials on the
enamel surface topography: An in vitro SEM study. J Int Oral Health
2020;12:579‑85.
Original Research
Effect of Different Scaling Methods and Materials on the
Enamel Surface Topography: An In Vitro SEM Study
Mahmoud Al Ankily1, Fatma Makkeyah2, Mahmoud M. Bakr3, Mohamed Shamel1
1Department of Oral Biology, The British University in Egypt, Cairo, Egypt, 2Department of Fixed Prosthodontics, The British University in Egypt, Cairo, Egypt, 3Clinical
Education, School of Dentistry and Oral Health, Griffith University, Gold Coast, Queensland, Australia
Abstract
Aim: Scaling is important for maintenance of gingival and periodontal conditions. These procedures have a harmful effect on the dental hard tissues.
The aim of this study was to investigate the effects of hand and ultrasonic instruments made of stainless and titanium on the surface properties of
enamel. Materials and Methods: Forty extracted premolars were used in this in vitro study and were randomly divided into four groups (n= 10).
Group Ireceived ultrasonic scaling with stainless steel tip, group II received ultrasonic scaling with titanium tip, group III hand scaling with stainless
steel tip, and group IV hand scaling with titanium tip. Scanning electron microscopy (SEM) was used to examine the enamel surface morphology.
Surface roughness of enamel was measured at baseline and after the scaling simulation using atomic force microscopy (AFM). Differences between
initial and final measurements of surface roughness (ΔRa) were analyzed using two‑way analysis of variance (ANOVA) followed by post hoc pairwise
comparisons between groups. Results: SEM revealed deeper scratches and more destructive changes on enamel surface in group IV, whereas other
groups revealed less change. AFM revealed that a mean surface roughness difference (ΔRa) had the highest value with hand instruments using titanium
curettes, whereas the lowest difference was found with ultrasonic tips using stainless‑steel tips. Hand titanium curettes showed a statistically significant
increase in ΔRa when compared to hand stainless steel curettes (P=0.02) and ultrasonic titanium tips (P=0.01). Hand stainless steel tips showed a
statistically significant increase in ΔRa when compared to ultrasonic stainless steel tips (P=0.02) and hand titanium curettes (P=0.02). Conclusion:
Scaling using ultrasonic stainless steel tips produce the least amount of surface roughness and damage to the tooth surface.
Keywords: Atomic Force Microscopy, Electron Microscopy, Enamel, Scaling, Surface Roughness
Received: 05‑04‑2020, Revised: 06‑04‑2020, Accepted: 13‑07‑2020, Published: 30‑11‑2020.
IntroductIon
Bacterial plaque or biofilms are described as organized
structures consisting of microcolonies of bacterial
cells, distributed in a shaped matrix or glycocalyx.[1,2] In
relation to the oral cavity, it is termed dental plaque and
it subsequently mineralizes to form hard deposits termed
calculus.[3] The majority of patients suffer from gingival
inflammation in response to this plaque, which eventually
progresses to periodontitis. Bone destruction and tooth
loss are the main consequences following periodontitis
which is considered one of the most common oral
diseases.[4] Successful management of the periodontal
diseases is of great significance in preventing irreversible
bone destruction and tooth loss. This is based on regulating
the dental plaque and restriction of further progression of
the disease. Different treatment methods such as standard
nonsurgical strategies, gingival curettage, laser treatment,
and regenerative procedures can be used.[5‑10]
American Academy of Periodontology proposed that any
procedures to maintain the gingival and periodontal health
should be performed with minimally invasive techniques.[11]
These noninvasive treatment methods used to manage
periodontal problems include scaling, root planning, and
oral hygiene care and are extensively performed routinely
in dental practice. The scaling procedure necessitates
removal of bacterial plaque, hard calculus, and extrinsic
stains from the surfaces of crown and root.[12] Although
HeadA=HeadB=HeadA=HeadB/HeadA
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Al Ankily, etal.: Effect of different scaling methods and materials on the enamel
580 580 Journal of International Oral Health ¦ Volume 12 ¦ Issue 6 ¦ November‑December 2020
scaling is a very challenging procedure, its role in controlling
gingivitis and periodontitis is well‑documented.[13]
Scaling is carried out either with hand or ultrasonic scalers.
The advantage of hand scaling involves superior management
of the instruments and an improved tactile feedback to
the operator. It is skill‑dependent, time‑consuming, and
exhausting, whereas sonic and ultrasonic scalers allow access
to the furcation and deep pockets and are more time efficient
and less tiring to dental practitioners.[14,15]
The mechanism of ultrasonic scalers includes the vibrations
that aids in biofilm removal and the acoustic effects of water
lavage, and the mechanical chipping action of the oscillating
scaler probe when in contact with the tooth surface which
assists in the removal of calculus deposit.[16] However, it has
been reported that these power‑driven scalers can cause
roughness of enamel surfaces, a procedure that can be
affected by many factors such as procedure time, pressure,
and angulation of the scaling tip.[17,18]
Different materials of hand instruments and ultrasonic
tips such as stainless steel curettes, rubber cups, plastic
curettes, titanium curettes, and air‑power abrasive systems
have been used in removing plaque from tooth surfaces as
well as implants.[19] However, the scaling procedures with
these materials can increase surface roughness of tooth
surfaces and dental restorations, which will influence
color stability and microbial colonization and induce
plaque formation. Apositive correlation between surface
roughness and the rate of supragingival and subgingival
plaque deposition has been reported.[20]
Stainless steel curettes are most commonly used for tooth
scaling, whereas titanium‑coated curettes are specifically
made for dental implant debridement because they have
a similar hardness to the titanium surface and will not
scratch or mark the surface.[21] However, the effect of the
use of titanium instruments for tooth scaling has not been
investigated. The aim of this study was to investigate the
effect of different types of hand and ultrasonic instruments
used in scaling on surface properties of enamel.
MaterIals and Methods
Setting and design
This study was conducted to evaluate the effect of two
different scaling mechanisms: hand scaling and ultrasonic
scaling with scaling instrument material stainless steel and
titanium on the surface roughness and surface anatomy
of enamel by using atomic force microscopy (AFM) and
scanning electron microscopy (SEM).
Sampling criteria
Forty extracted sound human premolars were collected
from patients with an average age from 14 to 20years
undergoing extractions for orthodontic purposes.
Immediately after extraction, the teeth were scraped of
any residual tissue, washed under running tap water, and
examined for the presence of cracks or carious lesions and
were discarded if found any.
Study method
After removing the roots, the buccal surfaces were cleaned
with prophylactic paste (Dharma FL USA 58‑00030) to
ensure removal of extrinsic stains. Gypsum blocks were
used to mount the teeth by inserting the lingual half into
the blocks with the highest area of the specimen being the
middle third of the buccal aspect [Figure 1].
The specimens were equally (10 in each group) and
randomly divided as follows:
Group I: Ultrasonic scaling with stainless steeltip
Group II: Ultrasonic scaling with titaniumtip
Group III: Hand scaling with stainless steeltip
Group IV: Hand scaling with titanium tip
Instruments
Ultrasonic instruments: Stainless steel ultrasonic G1 Scaler
tip (NSK, Japan).
Titanium nitride ultrasonic G1T Scaler Tip (Woodpecker,
Guilin, Guangxi, China).
Hand instruments: Stainless steel curette: Gracey no.7/8
Hu‑Friedy, Chicago, Illinois.
Titanium curette: TI 23 AS2 A. Deppeler Sa, Rolle,
Switzerland.
Scaling procedure
A customized apparatus was designed and fabricated to ensure
proper standardization of the scaling method. This scaling
apparatus consisted of a gearbox to control the speed of the
motor. Acrankshaft (two cycles/s) connecting rod which is fixed
Figure 1: Gypsum blocks specimen
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Al Ankily, etal.: Effect of different scaling methods and materials on theenamel
Journal of International Oral Health ¦ Volume 12 ¦ Issue 6 ¦ November‑December 2020 581
to a slider for changing the movement from rotation to linear
movement to deliver a consistent 5 mm horizontal movement,
double‑pane balance to simulate the forces used in manual, and
ultrasonic scaling[22] [Figure 2].
Hand scaling
The samples were mounted onto one side of the double‑pane
balance and attached in place using screws. Each instrument
was fixed in the arm using screws with the tip engaged at a
15° angle to the specimen. Aconstant force of 500 g was
applied to the instrument by the vertical movement of
counterweighted balance. Fifteen even strokes were made
with the hand scaling instruments across the surface of each
sample This representing 1year scaling every 3months (five
times) three successive movements each.[23]
Ultrasonic scaling
The samples were mounted onto one side of the double‑pane
balance and attached in place using screws. An ultrasonic
scaler handpiece was used intermediate power setting (level
5 of 14 grades). The scaling tips were angled 90° relative to
the surface of sample. Aconstant force of 30 g was applied
to the ultrasonic scalar tip by the vertical movement of a
counterweighed balance.[24] Astandardized 5 mm horizontal
movement for 30 seconds was achieved. Thirty strokes were
made with the ultrasonic handpiece at a speed of 2 Hz was
achieved and operated by the control box.[17]
Scanning electron microscopy analysis
Specimens from each group were mounted on the SEM
plate to examine their surfaces (Electron Microscopy
Sciences, Hatfield, Pennsylvania) using the model Quanta
FEG 250 (Field Emission Gun) with accelerating voltage
30 kV. All SEM images were randomized and each image
was given a unique code to ensure that image analysis
was performed blindly. Two research team members
examined each image independently. Both examiners were
initially calibrated by examining 10 SEM images (not
included in the results) collaboratively to moderate and
ensure consistency. The enamel surface morphology was
examined on each SEM image for samples from each group
after the simulated scaling procedure. Any abnormalities
and/or surface defects that are not consistent with normal
histological features. The intensity of surface defects was
also described on each image as fine, moderate, or deep.
Surface roughness measurement
Initial surface roughness was measured using AFM Auto
Probe CPResearch2 (Model: MLCT‑MT‑A) operated in
contact mode using non‑conductive silicon nitride probe,
at scan area of 25 μm, scan rate of 1 Hz and number
of data points 256× 256 m2 using proscan 1.8 software
for controlling the scan parameters and IP 2.1 software
for image analysis served as control. Surface roughness
differences (ΔRa) were calculated after measuring the
values after the scaling methods.
Statistical analysis
All data were analyzed using computer software SPSS
version 21 (SPSS Armonk, New York). Two‑way analysis
of variance (ANOVA) followed by post hoc pairwise
comparisons between groups were used to analyze surface
roughness differences (ΔRa). Ap‑value less than or equal
to 0.05 was considered statistically significant.
results
Scanning electron microscope examination
SEM of samples before scaling procedure revealed
normal enamel surface with normal surface structures
like perikymata and rod end. After scaling, group Iteeth
samples showed a relatively smooth enamel surface with
little fine scratches. Group II showed similar surface
morphology with greater change in enamel surface
manifested as deep and multiple scratches on enamel
surface in comparison to group I, whereas group III
showed little scratches became more obvious and deeper
than group I, also. Group IV samples revealed the
most aggressive effect in regards to the morphology of
the enamel surface in comparison to the other groups,
scratches are the deepest and more destructive [Figure 3].
Surface roughness
Figure 4 shows the atomic force images before and after
scaling procedures for eachgroup.
Ultrasonic stainless steel tips clearly resulted in scraping
of the enamel surfaces and loss of their original texture,
leading to increased surface roughness. Its surface
roughness was increased by 3.58 after scaling [Figure4‑I].
Ultrasonic titanium tips showed more aggressive and
deeper scratches than the ultrasonic stainless steel tips.
Its surface roughness was increased by 6.67 after scaling
[Figure 4‑II]. Manual stainless steel scaling showed more
number of shallow irregularities than the ultrasonic
stainless steel scaling. Its surface roughness was increased
by 5.34 after scaling [Figure 4‑III]. Manual titanium
scaling caused the deepest scratches and highest change in
surface roughness. Its surface roughness was increased by
8.97 after scaling [Figure 4‑IV].
Two‑way ANOVA revealed a statistically significant
interaction in ΔRa among all groups (P=0.042) [Table 1].
Figure 2: A schematic diagram showing the custom-made scaling
and apparatus: (A) gear box, (B) instrument holder, (C) double-pane
balance, (D) samples-holding pane, and (E) weight-holding pane
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Al Ankily, etal.: Effect of different scaling methods and materials on the enamel
582 582 Journal of International Oral Health ¦ Volume 12 ¦ Issue 6 ¦ November‑December 2020
Comparisons between different experimental groups are
summarized in Table 2.
Effect of materials used on ΔRa
For both ultrasonic scaling and hand methods, ΔRa of
titanium curettes showed a statistically significant higher
difference from that of stainless steel curettes (P=0.03
and 0.02, respectively).
Effect of scaling methods used on ΔRa
For both stainless steel and titanium curettes, ΔRa of
hand instruments showed a higher value and a statistically
Figure 3: SEM micrographs of normal enamel surface before scaling (A) with normal structures like rod end (B). Experimental groups after the
scaling procedure: group I showed smooth enamel surface with little fine scratches (arrows). Group II showed deep and multiple scratches on enamel
surface (arrows), whereas group III little scratches became more obvious and deeper than group I, also. Group IV samples revealed that scratches
are the deepest and more destructive (arrows). Magnification ×2500
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Al Ankily, etal.: Effect of different scaling methods and materials on theenamel
Journal of International Oral Health ¦ Volume 12 ¦ Issue 6 ¦ November‑December 2020 583
significant difference from that of ultrasonic tips (P=0.02
and 0.01), respectively.
dIscussIon
Scaling is a vital part of professional dental cleaning
that is practiced by dentists and oral hygienist on a daily
basis.[25,26] It is executed using hand and power‑driven
ultrasonic instruments.[27] Casarin et al.[28] reported that
ultrasonic scalers can cause roughness of tooth surfaces,
a process that can be affected by working factors such as
procedure time, pressure, and angulation of the scaling
tip. Oral bacterial adhesion and retention is affected by
the surface roughness of any hard surfaces in the oral
cavity and has a significant outcome on the formation
and progression of dental plaque as well as influencing
discoloration of esthetic restorations..[29‑31] Consequently,
this in vitro study has been performed to detect the effect
of routine scaling using hand or ultrasonic tips on the
enamel surface roughness(Ra).
Instrumentation of the tooth, until it is clean, is highly
operator‑dependent and many operating parameters such
as load and contact angle might affect the outcome.[32] In
this study, instrumentation was performed using a specially
designed apparatus to control all variables (time, pressure,
and tip angulation), whereas testing other factors which
are the material and method of scaling procedure.
The use of SEM for evaluating surface topography and
assessing the state of dental tissues surfaces has been
widely used in previous studies.[21,32‑35] For, high‑resolution
surface investigation, AFM was used. AFM analysis was
proposed to provide qualitative and quantitative data on
the detailed description of various dental materials.[36]
AFM recreate a 3‑dimensional image of the surface
topography in real time. Analysis of these data sets can be
used with specific software to obtain all the relevant data
related to the examined surface in a quantitative form.
Moreover, another important feature of AFM is that it
allows the surface features to be visualized in an enhanced
with better details.[36]
In this study, surface roughness increased in all specimens
after scaling procedure. Group IV (hand scaling using
titanium curettes) showed the highest mean surface
roughness difference (ΔRa), whereas group I (ultrasonic
scaling using stainless steel tips) showed the least ΔRa.
Regarding the effect of the material of instrument on the
surface roughness (ΔRa) readings; titanium instruments
caused a statistically significant increase in mean surface
roughness than the stainless steel instruments in both
hand (P=0.02) and ultrasonic (P=0.03) groups. This was
qualitatively confirmed by SEM analysis which showed
enamel specimens of the titanium groups to have deep
surface scratches and grooves. This may be attributed
to the increased hardness of the titanium instruments
(~751.9 MPa) compared to the stainless‑steel instruments
(~591.6 MPa)[37] which in return causes more deleterious
effect on enamel. Tamura et al.[38] reported that the
Vickers hardness of titanium nitride was 1300. This was
in contradiction to Vigolo et al.[39] who recorded equal
increase in the median surface roughness profile value for
both steel curette and titanium curette.
As for the effect of scaling method, this study revealed
that hand scaling method caused more increase in enamel
roughness and more harmful changes to enamel surface
than that of ultrasonic scaling method. The increase
in mean surface roughness was statistically significant
for the titanium instruments and for the stainless steel
instruments. SEM analysis revealed larger scratches on
the enamel surface of specimens of the hand instruments
groups. This difference might hereby be explained by the
higher pressure usually used for hand instrumentation[40]
than that used for ultrasonic scaling,[41] to simulate the
clinical situation. This results in deep scratches as well
as striae in the hand group. Coinciding results were
found in previous investigations.[42,43] Graetz etal.,[33] in a
comparative assessment of the possible efficacy, benefits
and harms of newly developed double gracey curettes
(GRA) and sonic (AIR) and ultrasonic instruments (TIG)
Figure 4: Atomic force images of all groups before and after scaling
procedure
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Al Ankily, etal.: Effect of different scaling methods and materials on the enamel
584 584 Journal of International Oral Health ¦ Volume 12 ¦ Issue 6 ¦ November‑December 2020
where the surface roughness was higher with GRA than
the AIR and TIG. This increase in surface roughness was
attributed to the repetitive overlapping working strokes,
which can cause irregular patterns and deep scratches on
the surface. Also Mittal etal.[44] in a comparison of the
effectiveness of different ultrasonic (a piezoelectric device
and a magnetostrictive ultrasonic device) and a periodontal
curette on calculus removal and surface roughness where
the curette produced the rougher surfaces than ultrasonic
devices, many instrument scratches, and deep gouges were
observed and a significant amount of the dentine layer was
removed, the surface cracks were maximum in thisgroup.
The results of this study suggest changes in the enamel
surface topography and roughness after using titanium
and stainless steel instruments for prophylactic periodontal
treatment. Moreover, different methods of scaling, hand,
and ultrasonic, resulted in changes in the morphology and
roughness of enamel surface. Therefore titanium curettes
and tips are not suitable for the use in scaling procedures
on enamel surface.
Further studies, including clinical trials, of the effects of
novel periodontal instruments onto hard dental tissues
topography and into the most desirable approach for
intraoral debridement would be desirable to clarify the
significance of the observations made in this in vitrostudy.
Conclusion
Scaling using ultrasonic stainless steel tips produced the
least amount of surface roughness and damage, whereas
titanium curettes and tips produced more aggressive
changes on the enamel surface in vitro.
Acknowledgement
Not applicable.
Financial support and sponsorship
Not applicable.
Conflicts of interest
There are no conflicts of interest.
Ethical policy and Institutional Review board statement
Ethical approval was obtained from the Research Ethics
Committee at Suez Canal University (Suez‑ REC 54/2018).
Data availability statement
The data that support the findings of this study are
available from the corresponding author, on reasonable
request.
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Table 2: Mean ΔRa and P values comparing different
experimental groups
Group Mean difference P Value
Group Ivs. Group II –3.09 P=0.03*
Group Ivs. Group III –1.76 P=0.02*
Group Ivs. Group IV –5.39 P=0.01*
Group II vs. Group III 1.33 P=0.42
Group II vs. Group IV –2.30 P=0.01*
Group III vs. Group IV –3.63 P=0.02*
*Signicant at P<0.05
Table 1: Mean and standard deviation of surface roughness before and after scaling and the mean difference (ΔRa) of all groups
Scaling
method
Material Mean ΔRa SD df 95% Confidence interval for
mean
ANOVA
P Value
Between
groups
Within groups Total Lower Bound Upper Bound
Ultrasonic Stainless steel 3.58 0.3 3 36 39 3.31 3.84 0.042*
Titanium 6.67 0.25 6.36 6.97
Hand Stainless steel 5.34 0.42 5.01 5.66
Titanium 8.97 0.76 8.70 9.23
*Signicant at P<0.05
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