Periodontology 2000, Vol.

55, 2011, 189–204  2011 John Wiley & Sons A/S

Printed in Singapore. All rights reserved PERIODONTOLOGY 2000

Calculus-detection technologies
and their clinical application
GRIT MEISSNER & THOMAS KOCHER

Subgingival calculus surfaces are usually covered thus may lead to the unwanted removal of cemen-
with a layer of unmineralized and metabolically tum, residual calculus, or both (6, 25, 27, 47, 57).
active bacteria. The essential component of conven- Clinicians are often uncertain about the nature of a
tional periodontal therapy is the effective removal of subgingival root surface while performing periodon-
these bacterial deposits from the root surface, along tal instrumentation. The correct evaluation of a
with calculus deposits, in order to create a biologi- cleaned surface is key to enable thorough and sub-
cally compatible root surface (10, 45, 63). stance-sparing debridement. To support the clini-
While numerous clinical studies have documented cian‘s decision to either stop or continue therapy, the
the beneficial effects of complete removal of sub- past few years have witnessed the development of
gingival calculus on the resolution of inflammation several calculus-detection techniques based on dif-
(11, 45, 63), others have found that gingival tissues ferent technologies. Current technologies for calculus
adjacent to root surfaces covered with small polished identification include detection-only systems (a
calculus spots might have a tendency to heal that is miniaturized endoscope, a device based on light
similar to tissues adjacent to thoroughly cleaned, reflection and a laser that activates the tooth surface to
calculus-free root surfaces (26, 44). Nevertheless, fluoresce) as well as combined calculus-detection and
periodontal destruction is clearly related to the very calculus-removal systems [an ultrasonic oscillation-
presence of calculus, which may extend the range of based system that analyzes impulses reflected from
damage associated with plaque microorganisms (36, the tooth surface, and a system combining erbium-
61, 64). doped yttrium aluminium garnet (Er:YAG) and diode
Calculus is a porous substance that can adsorb a lasers] (Tables 1 and 2). The aim of this article was to
variety of toxic products and retain significant levels provide a critical review of these devices based on
of endotoxin, which itself can damage tissue (64). currently available clinical and experimental data.
These toxins are located on, not within, periodontally
diseased root surfaces (7, 22, 43). It was therefore
deduced that extensive removal of cementum is not
necessary, and root surfaces should be treated
Detection-only systems
carefully during periodontal therapy in order to
Fiberoptic endoscopy-based technology
selectively remove subgingival calculus and biofilm
without removing the underlying cementum. The idea to modify a medical endoscope for peri-
Subgingival root debridement currently comprises odontal use has, to date, been realized in only one
the systematic treatment of all diseased root surfaces device (Perioscopy; Perioscopy Inc., Oakland, CA,
using hand-sonic and ⁄ or ultrasonic instruments, USA), which was introduced in the year 2000. Peri-
followed by tactile control with a periodontal probe, oscopy is a minimally invasive miniature periodontal
explorer or curette, until the root surface feels endoscope which is inserted into the periodontal
smooth and clean. However, traditional tactile per- pocket and permits visualization of the root surface
ception of the subgingival environment without vis- within the subgingival environment at magnifications
ible access before and after treatment frequently of 24–48· (Fig. 1). The system consists of a 1 mm,
lacks sensitivity, specificity and reproducibility, and 10,000-pixel fiberoptic bundle surrounded by multiple

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Table 1. Automated calculus-detection technologies

Treatment goal Technology Device name

Calculus detection only Fiberoptic endoscopy Perioscopy

Spectro-optical technology Detectar

Autofluorescence Diagnodent
Combined calculus detection and Ultrasound Perioscan
removal
Laser and autofluorescence Keylaser3

illumination fibers, a light source, an irrigation sys- sonic instruments until the root surface was found to
tem and a liquid crystal display monitor. Clinicians be clean, as assessed by either an explorer or the
can observe the subgingival root surface, tooth periodontal endoscope. After extraction, a higher
structure and residual calculus in real time. The percentage of residual calculus covering the root
magnified images can be viewed on the monitor in surface was detected microscopically in the explorer
real time, and images and videos can be captured and group than in the endoscope group (D = 2.1%). The
saved in computer files. The endoscope may help to difference was statistically significant only in deeper
identify, locate and treat calculus spots during pockets and in interproximal sites (pocket depth
instrumentation of residual calculus at the time of, or > 6 mm; D = 2.9%) compared with buccal sites
after, scaling. To be proficient in the endoscopic (pocket depth > 4 mm; D = 1.3%). A correlation was
technique a training period of at least 8 h is necessary found between shorter treatment time and increasing
to learn the procedure and practical experience is experience of the operator for treatment with the
required for up to 4 weeks subsequently (59, 60). endoscope, a finding confirmed by a companion
In the first clinical study, nonresponding peri- study (41). However, the treatment results of the
odontal sites (n = 44; probing depth 5–8 mm) were latter study showed some discrepancies. Out of 24
treated by subgingival root debridement with or patients, a total of 70 molars were treated in vivo
without use of the dental endoscope (5). No signifi- either by scaling and root planing only or by scaling
cant changes regarding pocket depth reduction were and root planing plus dental endoscopy, followed by
reported in either group, 1 and 3 months after extraction. Overall,1.2% less residual calculus cover-
treatment, compared with baseline. Moreover, the ing the root surface was found in the endoscopy
gingival crevicular fluid flow rate, prostaglandin E2 group (12.3%) compared with the scaling and root
and interleukin-1beta levels decreased without planing group (13,5%). No differences in residual
showing significant differences between the groups. calculus were found in deep pockets, furcation areas
Additionally, a rather long treatment time, of 45 min or on buccal ⁄ lingual surfaces. Only interproximal
per experimental site, was noted for the Perioscopy pockets with a depth of < 6 mm had significantly less
procedure. residual calculus in the endoscope group compared
In a study evaluating the histologic response to the with the scaling and root planing group. Thus, at least
removal of calculus and biofilm with the aid of the for multi-rooted teeth, the beneficial effect of the
dental endoscope (65), a total of 12 teeth from six endoscope-aided scaling and root planing remains
patients were extracted 6 months after endoscope- questionable.
aided scaling and root planing. Histological evidence Taken together, only one clinical study to date has
showed formation of a long junctional epithelium, investigated the clinical effects after the application of
bone repair and no signs of chronic inflammation. fiberoptic technology. No differences were found
However, a control group that received scaling and regarding pocket depth reduction between scaling and
root planing alone was not included and therefore root planing alone and endoscope-aided scaling and
the incremental effect attributable to the use of the root planing. Histologic healing, which was assessed
endoscope was not determined. on extracted teeth 6 months after endoscope-aided
A randomized, controlled, clinical study evaluated scaling and root planing, was not compared with
the percentage of residual calculus after tooth scaling and root planing alone in a randomized clinical
extraction (20) in 100 single-rooted teeth of 15 study. Microscopic analysis of root surfaces after
patients. The teeth were treated by hand- and ultra- endoscopy-aided scaling and root planing showed a

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Table 2. Studies reviewed in this article

Instrument Reference Design Sample size Method Results

Diagnodent (31) In vitro study 10 teeth, 271 sites Fluorescence was mea- A clean root surface was
sured at five teeth and indicated with a median
reproducibility was value of 6.2, in contrast to a
tested (at all five teeth) median value of 57.7 on
Effect of root the root where calculus was
debridement on found
fluorescence was tested Not influenced by the fluid
High reproducibility
Fluorescence values after root
debridement were similar to
those for a clean root surface
Diagnodent (17) In vitro study A total of 30 teeth, Fluorescence was Significant differences in
For each medium, measured in medium, fluorescence between calculus
10 teeth were air, saline solution and cementum in all fluids
included and blood Air: cementum, 0.4; calculus,
54.1
Saline solution: cementum,
0.4; calculus, 60.7
Blood: cementum, 2.1;
calculus, 39.6
Diagnodent (16) In vitro study A total of 40 teeth;Hand instrumentation Surface area of residual calculus
20 teeth were with and without Multirooted teeth:
included for each Diagnodent. In total, hand instrumentation:
treatment 120 surfaces were 0.5 ± 0.48 · 107 lm2
evaluated Diagnodent: 0.27 ± 0.43 · 107
lm2 (P = 0.02)
Single-rooted teeth:
hand instrumentation:
0.19 ± 0.37 · 107 lm2
Diagnodent:
0.11 ± 0.26 · 107 lm2
(P = 0.19)
Keylaser 3 (30) In vitro study Twenty teeth ERL (140 mJ per pulse, Threshold 5 [U]; the median
covered with 10 Hz), with a chisel- residual calculus was
subgingival calculus shaped glass-fiber tip 11 (0–78)%
were treated with (0.4 · 1.65 mm); water Threshold 1 [U]; the median
an ERL irrigation (1 ml ⁄ min) residual calculus was 0 (0–26)%
Fluorescence threshold Laser-treated cementum thick-
level of 5 [U] was reduced ness [median, 80 (0–250) mm]
at intervals of 1 [U] for Untreated opposite side [med-
every laser treatment ian, 90 (30–250) mm] (P < 0.05)
Keylaser 3 (53) Randomized, Twelve patients, Three teeth per patient Histologically, ERL produced
single-masked each with six were treated with an ERL homogeneous and smooth root
study periodont [ERL1, 100 mJ per pulse; surfaces
ally diseased ERL2, 120 mJ per pulse; Calculus was almost selectively
single-rooted teeth ERL3, 140 mJ per pulse; removed, no thermal damage,
10 Hz; water irrigation; no cementum loss, mean
chisel-shaped glass-fiber treatment time needed with
tip (0.4 · 1.65 mm); the ERL was comparable to that
transmission factor 0.85] for hand instrumentation
and three teeth per Hand instrumentation resulted
patient were treated in significantly higher values for
with the Vector system residual calculus and in more
or hand instrumentation, root surface damage than laser
or were untreated treatment
(control)

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Table 2. (Continued)

Instrument Reference Design Sample size Method Results

Keylaser 3 (55) Randomized Twenty-four peri- ERL, water irrigation Histologically, calculus was
clinical study odontally diseased [160 mJ per pulse and selectively removed No thermal
single-rooted teeth chisel-shaped tip damage
(1.65 · 0.5 mm); Results obtained following
calculated energy density treatment with the ERL were
19.4 J ⁄ cm2 per pulse; comparable to those obtained
10 Hz] vs. hand by hand instruments
instrumentation
Keylaser 3 (56) Randomized, Twenty patients, ERL, water irrigation Average treatment time in both
controlled, single-rooted teeth [160 mJ per pulse; 10 Hz; groups was 5 min for
split-mouth [n = 407 for laser chisel-shaped tip single-rooted teeth and 9 min
study treatment (ERL), (1.65 · 0.5 mm); calcu- for multirooted teeth
n = 383 for UI] lated energy density All clinical parameters
multirooted teeth 136 mJ per pulse; or investigated showed improve-
(n = 269 for laser chisel-shaped tip ment in both groups, which was
treatment, n = 247 (1.1 · 0.5 mm); calculated significant between baseline
for UI energy density 114 mJ and 6 months post-treatment
per pulse] Bleeding on probing:
ERL: baseline, 40%; 6 months,
17%
UI: baseline, 46%; 6 months,
15%
Clinical attachment level gain:
ERL: after 3 months, 1.48 ± 0.73;
after 6 months, 1.11 ± 0.59
UI: after 3 months, 1.53 ± 0.67;
after 6 months, 1.11 ± 0.46
There were no statistically
significant differences between
the groups
Keylaser 3 (62) Single masked, Twenty patients at Treatment either by ERL Baseline:
randomized, recall visit with at [160 mJ per pulse;10 Hz; Mean pocket depth: ERL, 6 mm;
controlled, least two residual water irrigation; UI, 5.8 mm
split-mouth pocket depths of chisel-shaped tips After 1 month significant differ-
design study > 5 mm in each jaw (0.5 · 1.1 mm)] or by a ences:
piezoelectric ultrasonic Mean pocket depth reduction:
scaler (UI) (Piezon Master ERL, 0.9 mm; UI, 0.5 mm
400; EMS, Nyon, (P < 0.05)
Switzerland) Mean clinical attachment
Clinical and microbiologic level gain: ERL, 0.5 mm; UI,
effects at 1 and 4 months 0.06 mm (P < 0.01)
post-treatment were After 4 months no significant
evaluated differences:
Mean pocket depth reduction:
ERL, 1.1 mm; UI, 1.0 mm
Mean clinical attachment level
gain: ERL, 0.6 mm; UI, 0.4 mm
Both treatment modalities
resulted in reduction of subgin-
gival microflora, with no
differences between the groups
The patientsÕ preference was
laser instrumentation

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Table 2. (Continued)

Instrument Reference Design Sample size Method Results

Keyaser 3 (13) Single-blinded, Seventy-two Treatment per quadrant: All four treatment modalities
randomized, patients with hand instruments resulted in a significant
controlled, periodontal (Gracey curettes reduction of Porphyromonas
specific quad- disease (Hu Friedy), feedback- gingivalis, Prevotella intermedia,
rant design controlled ERL (160 mJ Tannerella forsythia and
study per pulse;10 Hz; water Treponema denticola after
irrigation; chisel-shaped 3 months. Laser and sonic
tips of 0.5 · 1.65 and instrumentation failed to
0.5 · 1.1 mm), sonic reduce Aggregatibacter
scaler (SONICflexs system actinomycetemcomitans
LUX 2003 L; KaVo) significantly
and a piezoelectric The patientsÕ preference
ultrasonic scaler (Piezon was UI
Master 400, EMS)
Bacterial samples were
investigated at baseline,
and at 3 and 6 months
post-treatment

Perioscopy (5) Randomized Six patients on Group A: scaling and root Plaque index, bleeding on
patient maintenance planing plus explorer probing, clinical attachment
matched-site therapy, 44 sites Group B: scaling and root level gain: no significant
design study with pocket depth planing plus Perioscopy differences after 3 months
5–8 mm Treatment until root between the groups
surface was considered Pocket depth: decrease of
to be clean ‡ 2 mm in both groups, no
Evaluation of plaque significant differences
index, bleeding on prob- Treatment duration unrealistic
ing, clinical attachment for clinical use
level after 3 months
Perioscopy (20) Randomized Fifteen patients, a Group A: scaling and 2.1% more residual calculus in
clinical and total of 100 sites, root planing plus the explorer group
in vitro study Single-rooted teeth explorer Statistical significance only in
Group B: scaling and interproximal sites (pocket
root planing plus depth > 6 mm; 2.9%)
Perioscopy Treatment duration: endoscope
Treatment until root group showed a significant
surface was considered to decrease of time with
be clean increasing experience of the
Tooth extraction operator
immediately after therapy
Microscopic evaluation of
residual calculus
Perioscopy (41) Randomized Twenty-four Group A: scaling and root 1.2% more residual calculus in
clinical and patients, a total of planing plus explorer the explorer group
in vitro study 70 molars Group B: scaling and root Statistical significance only in
planing plus Perioscopy interproximal sites (pocket
Treatment until root depth < 6 mm; 2.6%)
surface was considered No differences in residual
to be clean calculus in deep pockets, furca-
Tooth extraction immedi- tion areas or on buccal ⁄ lingual
ately after therapy surfaces
Microscopic evaluation Treatment duration: endoscope
of residual calculus group showed a significant de-
crease of time with increasing
experience of the operator

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Table 2. (Continued)

Instrument Reference Design Sample size Method Results

Perioscopy (65) Clinical and Six patients, a Scaling and root planing Histologically: formation
histological total of 12 teeth plus Perioscopy of a long junctional epithelium,
study Tooth extraction evidence of bone repair,
6 months after therapy no signs of chronic
Histologic evaluation inflammation
No control group
DetecTar (23) Randomized, Eight patients, a Group A: no treatment, Group A: n = 96 surfaces;
single-masked total of 44 teeth calculus detection by 79.4% sensitivity and 95.1%
study (176 surfaces) DetecTar specificity
Teeth extracted Group B: scaling and Group B: n = 80 surfaces
immediately after root planing + DetecTar (n = 58 initially positive,
treatment until teeth were n = 22 initially negative)
Microscopic considered to be clean
evaluation Control of the detection:
results after extraction
DetecTar (24) Randomized, One-hundred Group A (n = 50): Detectar group:
controlled patients with supragingival Plaque index (baseline 57.5%,
clinical study plaque-associated debridement + oral after 4 weeks 27.1%)
gingivitis hygiene instruction Bleeding on probing
and motivation (baseline 19.1%, after
Group B (n = 50): 4 weeks 7.1%)
supragingival Control group:
debridement + oral Plaque index (baseline 60.5%,
hygiene instruction and after 4 weeks 41.9%)
motivation + Detectar Bleeding on probing (baseline
23.1%, after 4 weeks 14.5%)
DetecTar (32) In vitro ran- Twenty extracted Teeth were scanned: Specificity:
domized study periodontally (a) with different 100% in blood
involved, calculus- working tip 95-100% for all
covered teeth angulations of the angulations in saline
fibreoptic (0, 10, 45 solution
or 90) Sensitivity:
(b) with different ambient Nearly 100% for all
fluids (blood and saline angulations in saline solution
solution) In blood:
Results were compared 100% for 90 angulation
with clinical and 89% for 45 angulation
histological findings 70% for 10 to 0 angulation
Perioscan (39) In vitro study Ten teeth, 200 Detection results were Calculus and cementum were
measurements compared with visual distinguishable with a sensitivity
findings on calculus of 88% and a specificity of 76%
and cementum
surfaces
Perioscan (38) In vitro study Thirty-four teeth, Detection results were Calculus and cementum
1363 measurements compared with visual were distinguishable with a
findings, by moving the sensitivity of 76% and a
instrument tip over the specificity of 86%
calculus and cementum
surfaces
Perioscan (40) In vitro study Fifty extracted, Calculus was removed The smallest, recognizable
periodontally stepwise, in order to residual deposits had an average
involved, calculus- determine the discrimi- diameter of 219 mm, an area of
covered teeth native capability 21,600 mm2 and a circumfer-
ence of 748 mm; Sensitivity was
73% and specificity 80%

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 Calculus-detection technologies

Table 2. (Continued)

Instrument Reference Design Sample size Method Results

Perioscan (37) In vivo Sixty-three buccal Teeth were scanned Calculus and cementum
randomized, subgingival tooth in situ were distinguishable with a
clinical study surfaces Detection results were sensitivity of 91% and a
compared with visual specificity of 82%
findings after extraction The positive predictive
value was 0.59 and the
negative predictive value
was 0.97

ERL, Er:YAG laser; UI, ultrasonic instrumentation.

Fig. 2. Spectro-optical technology. The DetecTar (Dents-

ply Professional, York, PA, USA) uses a light-emitting
diode and fiberoptic technology to detect calculus.

calculus, which is caused by absorption, reflection

and diffraction when irradiated by red light, is sensed
by an optical fiber and converted into an electrical
signal that is analyzed by a computer-processed
algorithm. The DetecTar device comes as a portable
cordless handpiece with a curved periodontal probe
that has millimeter markings to measure pocket
depths. Without any tactile pressure, the subgingival
root surface can be scanned by the instrument. As
soon as calculus is detected, the operator receives the
Fig. 1. Endoscopy-based technology. The Perioscopy
(Perioscopy Inc., Oakland, CA, USA) uses a minimally information on calculus localization by audible and
invasive miniature periodontal endoscope, which is luminous signals.
inserted into the periodontal pocket, to detect calculus. Only a few investigations have evaluated spectro-
optical technology as a diagnostic instrument in
small benefit only in interproximal sites, in particular periodontology. The ability to detect subgingival
in single-rooted teeth with deep pockets, and in calculus in vitro was tested in 20 freshly extracted
multirooted teeth with relatively shallow pockets. teeth affected by periodontitis, and the results were
compared with clinical and histological findings (32).
In addition, the influence of different working-tip
Spectro-optical technology
angulations (0, 10, 45 and 90) of the fiberoptic probe
The spectro-optical approach to calculus detection and of different ambient fluids (blood and saline
uses a light-emitting diode and fiberoptic technology, solution) were studied. The specificity was only
and is currently used by only one device, the Detec- slightly influenced by the type of irrigation fluid,
Tar (Dentsply Professional, York, PA, USA) (Fig. 2). being 100% in blood and 95-100% in saline solution
The characteristic spectral signature of subgingival for all angulations. The sensitivity in saline solution

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Meissner & Kocher

was nearly 100% for all angulations. In blood, the enables the detection of calculus, and several in vitro
sensitivity decreased with smaller tip angulations studies have examined the autofluorescence of dental
(100% sensitivity with angulation 90, 89% sensitivity root surfaces and calculus (8, 12, 18, 26, 30, 45). Oral
with angulation 45 and 70% sensitivity with angu- microorganisms and their metabolites (metal-free
lation 10–0). The combination of saline solution as porphyrins, metalloporphyrins and other chromato-
the ambient fluid and a working-tip angulation of 90 phores) are assumed to contain the fluorophores that
– which, however, cannot be achieved in the are emitted from dental calculus and from carious
periodontal pocket – resulted in the most accurate lesions (14, 21, 29). Several distinct fluorescence
measurements. bands between 570 and 730 nm were identified on
A recent clinical study sought to determine the calculus specimens, which could be elicited with light
utility of the spectro-optical technology for subgingi- of wavelength 400–420 nm, but could not be found
val calculus removal (23). A total of 44 teeth (176 on clean root surfaces (9). Another study found
surfaces) were included in the study. In an untreated characteristic autofluorescence emission peaks for
control group, a total of 96 untreated surfaces were calculus and dentin caries at 700 and 720 nm,
scanned in vivo using the DetecTar. In the treatment respectively, which were elicited by light of wave-
group, treatment was initiated upon obtaining posi- lengths 635 and 655 nm, respectively (33). On
tive signals from the spectro-optical device, and the surfaces covered by bacterial cells or blood, the
treatment was continued until no signal was elicited. autofluorescence intensity was reduced.
Clinical calculus findings were documented by visual In order to differentiate calculus from the healthy
and microscopic examination after tooth extraction. tooth surface, a fluorescence-ratio method based on
The control group showed a sensitivity of only 79.4% autofluorescence induced by a blue light-emitting
and a specificity of 95.1%. Of 58 tooth surfaces that diode of 405 nm has been developed (48). Calculus
initially showed calculus and which were conse- and healthy tooth surfaces exposed to light wave-
quently treated until they tested negative for calculus, lengths of 487 and 628–685 nm were used to create a
10 (17%) remained partly covered with calculus, calculus parameter, R, which was selected to define a
whereas 48 (83%) were completely calculus-free. relationship between the integrated intensities spe-
Nevertheless, nine (41%) of the 22 surfaces that were cific for calculus and for healthy teeth in the 628 to
initially identified as calculus-free (and therefore 685- and the 477 to 497-nm wavelength regions,
untreated) did, in fact, harbor calculus. However, the respectively. A cut-off threshold of R = 0.2 was able to
number of false-negative readings may have been distinguish dental calculus from healthy teeth with
caused by incomplete surface scanning as a result of 100% sensitivity and 100% specificity under various
limited access of the instrument and problems with experimental conditions in vitro.
guiding the instrument. No sensitivity or specificity A diagnostic instrument, based on different auto-
data for the treatment group were calculated from fluorescence intensities after stimulation with red
the published results. Additionally, the study only light, claims to distinguish healthy from carious tooth
recorded the clinical presence or absence of subgin- substance (Diagnodent; KaVo, Biberach, Germany)
gival calculus deposits for each surface (without exact (Fig. 3). An indium gallium arsenide phosphate
localization on the respective surface), and a highly (InGaAsP)-based red laser diode (< 1 mW) sends light
heterogeneous group of surfaces, with pocket depths with a wavelength of 655 nm through an optical fiber
ranging from 1 to 10 mm, was evaluated. Therefore, onto the root surface, which is then induced to
false-negative results may have been caused by an fluoresce. The emitted fluorescent light returning
incomplete scanning process, technological limits of from the tooth tissue is captured by surrounding
the device, or a combination of both. These aspects optical fibers and transmitted to an integrated photo
cannot be discriminated in vivo if the exact location of diode, which serves as the fluorescence detector.
the device during scanning is not definitively known. Optical effects caused by reflected light and ambient
Altogether, the utility of the spectro-optical light are eliminated by a band-pass filter and mod-
technology for calculus detection has not yet been ulation of the fluorescent light, respectively. The
thoroughly investigated. device was primarily developed for caries diagnosis
and launched as a stand-alone device about 10 years
ago. Based on a multitude of clinical studies, it is
Autofluorescence-based technology
considered to be a reliable caries detector on occlusal
The ability of calculus to emit fluorescent light fol- and smooth surfaces, showing high levels of sensi-
lowing irradiation with light of a certain wavelength tivity (92.1%) and specificity (100%), a high level of

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fluorescence values in air (cementum, 0.4; calculus,

54.1), in saline solution (cementum, 0.4; calculus,
60.7) and in blood (cementum, 2.1; calculus, 39.6).
With a cut-off value of 5, sensitivity and specificity in
all three media were 100% (17). Another study sim-
ulated a clinical situation based on a mannequin
model and compared the effectiveness of root-
surface instrumentation when supported by the
application of two different diagnostic instruments
(the autofluorescence-based system vs. a conven-
tional explorer) (16). Forty extracted periodontally
involved teeth (120 surfaces for each diagnostic
group) were treated with conventional Gracey
curettes until this method indicated a clean root
surface. For multirooted teeth, calculus detection
Fig. 3. Autofluorescence-based technology. The Diagno-
dentTM Pen (KaVo, Biberach, Germany) is based on the using autofluorescence resulted in a significantly
detection of different autofluorescence intensities after smaller total area covered with residual calculus than
stimulation with red light. if diagnostics was based on a conventional explorer.
However, in single-rooted teeth, the two study groups
reproducibility (kappa value: in vitro, 0.9; in vivo, revealed a comparable amount of residual calculus.
0.9) and a good interexaminer and intra-examiner In summary, when used in vitro, the autofluores-
agreement (21, 34, 35, 42, 46, 49, 58). cence-based system could differentiate between cal-
Later, the device was further refined to enable cal- culus and cementum with great reproducibility. In a
culus detection. The fluorescence intensities are preclinical situation, a superior effect of the system
measured, transformed and shown on a digital dis- compared with manual use of an explorer could be
play as relative calculus-detection values from 0-99. shown only on molars. The diagnostic value of the
According to the manufacturer, values of ‡ 40 indicate autofluorescence-based system needs to be assessed
mineralized deposits, whereas values of between 5 in the clinical setting, and its effect on treatment
and 40 indicate very small calcified plaque sites (not outcomes determined.
further specified) or residual calculus following partial
cleaning, and values of £ 5 indicate a clean root sur-
face. Values indicating calculus are indicated by a Combined detection ⁄ treatment
beep with an increasing audiotone frequency as the
display value increases. The manufacturer thus pro-
devices
vides a small-size device, which is claimed to be able
Ultrasonic technology
to detect both caries and calculus, and which can be
handled easily with no further training required. Ultrasonic calculus-detection technology is based on
The autofluorescence-based device for calculus a conventional piezo-driven ultrasonic scaler and is
detection has been evaluated only in in vitro studies similar to the way that one might tap on the rim of a
so far, with any patient-derived clinical evidence glass with a spoon to identify cracks acoustically (28,
lacking. Surfaces of extracted periodontally involved 60). An insert at a conventional dental ultrasound
teeth, which were partly covered with calculus and scaler receives short, weak impulses with a frequency
moistened with saline solution or blood, were scan- of about 50 Hz, which make the insertÕs distal tip
ned using the device (17, 31). The fluorescence oscillate at a frequency that is dependent upon the
signals detected were compared with visual and surface characteristics. The oscillations are con-
histological findings. The presence of calculus was ducted into the piezo-ceramic discs, which transform
significantly correlated with a higher intensity of the oscillations into voltage. The voltage level repre-
fluorescence (17, 31). A median value of 6.2 was sents the intensity of the tip oscillation, while the
obtained for clean root surfaces and a median value frequency stays the same. The overall signal, con-
of 57.7 was obtained for calculus, which was not sisting of both the impulse stimulus and the impulse
influenced by the presence of fluid. Additionally, high response, is evaluated using a computerized system,
reproducibility for measurements after 6 and 24 h thereby generating information about a given surface
could be shown (31). The second study found relative characteristic.

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The ultrasonic device currently available (Perio- The only available study involving the clinical
scan; Sirona, Bensheim, Germany) (Fig. 4) provides application of this ultrasound tool tested the
a detection mode to discriminate between calculus accuracy by which calculus was detected (37).
deposits and clean roots, along with a treatment In vivo calculus detection was determined on 63
mode that allows conventional ultrasonic treatment subgingival surfaces and compared with visual
at different power levels. When the ultrasonic tip findings after tooth extraction. A prevalence of
touches the tooth surface, the detection results are calculus of 22.3% was found on the scanned sur-
indicated by a light signal integrated both in the faces, and calculus and cementum were discrimi-
handpiece and in a display of the table unit (green nated with a sensitivity of 91% and a specificity of
indicates cementum and blue indicates calculus). 82%. The positive and negative predictive values
When calculus is detected, an additional acoustic were 0.59 and 0.97, respectively. The combined
signal sounds. The detection mode is only activated application of the calculus-detection mode and
when no scaling treatment is performed. The detec- the ultrasonic removal of calculus remain to be
tion and treatment modes can be used successively investigated.
on the surface of the same tooth. If calculus deposits To sum up, the combined detection-and-treatment
are found, the root surface can be treated with a technology using ultrasound is a promising tool for
higher power setting, whereas in the absence of cal- minimally invasive debridement (retaining cemen-
culus (thus requiring the systematic removal only of tum) and selective calculus removal, as shown by a
biofilm), instrumentation can be performed at a study employing an in vivo and ex vivo reconstruc-
lower power setting. A prototype of the ultrasonic tion technique. However, the long-term clinical out-
device evaluated the calculus-detection capability come has not yet been investigated.
under laboratory conditions both in static tests
(yielding a sensitivity of 75% and a specificity of
Laser-based technology
82%) and during movements of the probing tip
(yielding a sensitivity of 88% and a specificity of The benefit of laser application in nonsurgical peri-
76%) (38, 39). The detection limit was further eval- odontal therapy is still a matter of debate among
uated by gradually removing calculus from 50 ex- clinicians (4, 12, 51). Lately, out of a variety of other
tracted teeth until the system stopped discriminating types of lasers, the Er:YAG laser has been considered
calculus deposits. Diameter, circumference and area to be the most promising for periodontal therapy (2,
of the smallest recognizable deposit, and of the no 3, 19). Its ability to ablate soft and hard tissue without
longer recognizable deposit, were measured, and a major thermal side effects qualifies the use of this
cut-off point was determined. It could be demon- laser for periodontal therapy, and Er:YAG lasers at
strated that calculus deposits with a diameter of different energy levels have been studied in various
0.2 mm could still be recognized with a sensitivity of in vitro and clinical trials. Er:YAG lasers are solid-
73% and a specificity of 80% (40). state lasers that emit pulsed infrared light with a

Fig. 4. Ultrasound-based calculus-

detection technology: Perioscan
(Sirona Dental Systems GmbH,
Bensheim, Germany). The principle
includes a fuzzy-logic-based detec-
tion mode employing ultrasound
90% root feedback analysis and adds a treat-
10% calculus ment mode to the automated
calculus detection, which uses the
same tip.

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 Calculus-detection technologies

wavelength of 2940 nm, which is strongly absorbed

by virtually all biological tissues containing water.
The effect of Er:YAG lasers is based on photoablation.
The light-induced tissue evaporation results in water
release and a concomitant cooling effect on the sur-
rounding tissue. However, when applied to dental
hard tissue, which contains a lower amount of water,
increased thermal effects can occur, and therefore
water irrigation is required (2).
The treatment effect of Er:YAG lasers (Keylaser 1 or
2; Kavo, Biberach, Germany) (Fig. 5) with regard to
calculus removal has been shown to be comparable
to conventional root debridement. No major thermal
damage was found if the laser was applied at lower
energy levels (radiation energy, 50–160 mJ) and with
concomitant water irrigation (2, 15, 18, 19, 54). A
number of in vivo and in vitro studies have shown the
potential of Er:YAG lasers to create a biocompatible
root surface by removing the smear layer and lipo-
polysaccharides from the tooth surface, by promoting
the attachment of periodontal ligament fibroblasts
and by decreasing the bacterial load (1, 52, 66). By
contrast, studies have also reported increased tissue
removal, roughened surfaces and a lower yield of
calculus removal compared with hand instrumenta-
tion (3, 15, 18, 19). The effectiveness of calculus
removal seems to be dependent on the irradiation
energy level. However, the application of high energy
levels is also associated with increased and undesir-
able root-substance loss if applied to a healthy tooth
structure (2, 18, 19).
The only commercially available device (Keyla-
ser3TM; KaVo) combines detection and treatment in a
feedback-controlled manner for selective removal of
calculus. The integrated calculus-detection device is
based on a 655-nm InGaAs diode laser for autofluo-
rescence-based calculus detection (described above
as a stand-alone diagnostic tool), whereas a 2940-nm
Er:YAG laser is used for treatment. The Er:YAG laser is
only activated to emit light if a preselected autoflu-
orescence threshold value for the diagnostic laser on Fig. 5. Laser-based combined detection and treatment
a scale of 0–99 is exceeded. As soon as the value falls technology. The Keylaser 3 (KaVo, Biberach, Germany)
employs the same detection method depicted in Fig. 3, but
below the threshold, the Er:YAG laser turns off. This adds a treatment mode to it.
combination of a diagnostic and a therapeutic laser
was designed to optimize calculus removal while
minimizing the undesired side effects of the Er:YAG apical direction in contact irradiation mode with
laser. pulsed infrared radiation [wavelength of 2.940 mm,
The feedback-controlled Er:YAG laser was recently a chisel-shaped glass-fiber application tip (size
evaluated in in vitro and clinical studies to determine 0.4 · 1.65 mm), 140 mJ per pulse, 10 Hz and calcu-
how different fluorescence-classification thresholds lated energy density of 17.2 mJ ⁄ cm2) (30). The fluo-
would influence the extent of calculus and cement rescence threshold varied between 5 (recommended
removal. Twenty teeth partly covered with calculus by the manufacturer as the lowest threshold value)
and irrigated with water were treated from coronal to and 1 in order to potentially increase sensitivity. Not

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Meissner & Kocher

surprisingly, the amount of residual calculus de- of three energy levels: 100, 120 or 140 mJ per pulse,
pended on the laser fluorescence threshold levels. At 10 Hz), the Vector ultrasound system, conventional
a threshold of 5, the median residual amount of cal- hand instruments, or remained untreated. Teeth
culus related to the baseline amount of calculus was were instrumented in vivo under local anesthesia until
11% (minimum, 0%; maximum, 78%), whereas at a they were considered to be clean and then immediately
threshold of 1, it was reduced to 0% (minimum, 0%; extracted for analysis. The ultrasound system left sig-
maximum, 26%). However, the laser-treated residual nificantly smaller areas of residual calculus than the two
cementum was significantly thinner (median, 80 lm) other therapies, but needed a significantly longer
than the untreated residual cementum (median, 90 lm; instrumentation time than the laser and the hand
P < 0.05). Thus, by reducing the threshold level to 1, the instruments. However, treatment with the feedback-
sensitivity was increased at the expense of a reduced controlled Er:YAG laser still resulted in significantly less
specificity, as indicated by the increase of undesired residual calculus and less root-surface alterations than
substance loss. hand instrumentation.
A different study compared the clinical and histo- A clinical study compared the microbiological
logical effects of conventional hand instrumentation effects of the Er:YAG laser, hand instruments, sonic
with fluorescence-controlled Er:YAG laser irradiation scalers and ultrasonic scalers (13). The controlled,
at different device settings (55). Twenty-four peri- randomized, single-blinded clinical trial included 72
odontally involved single-rooted teeth were treated periodontal patients who had at least one site per
in vivo and extracted after therapy. Laser treatment quadrant with a pocket depth of > 4 mm, bleeding
consisted of fluorescence-controlled Er:YAG laser on probing and bone loss of at least 33%. The four
irradiation under water irrigation (160 mJ per pulse, quadrants per patient were randomly assigned to one
chisel-shaped tip of 1.65 · 0.5 mm, calculated energy of the following four debridement modalities: hand
density 19.4 J ⁄ cm2 per pulse, 10 Hz). All mesial root instruments, a feedback-controlled Er:YAG laser
surfaces were treated in vivo under local anesthesia (Keylaser3; 160 mJ per pulse, 10 Hz, water irrigation,
until they were considered to be clean. After extraction, chisel-shaped tips of 0.5 · 1.65 and 0.5 · 1.1 mm), a
the distal root surfaces were treated in vitro for com- sonic scaler (SONICflexs system LUX 2003 L; KaVo)
parison. Hand-instrumented teeth were treated accord- or a piezoelectric ultrasonic scaler (Piezon Master
ingly. Clinically, the use of the Er:YAG laser in vivo 400; EMS, Nyon, Switzerland). Subgingival plaque
produced homogeneous and nearly smooth root surfaces samples were obtained at baseline and at 3 and
without visible traces of the tip. Histologically, calculus 6 months postoperatively. All four treatments re-
had been selectively removed and no thermal damage sulted in a significant reduction in the amounts of
could be observed. The results were comparable to those Porphyromonas gingivalis, Prevotella intermedia,
seen after the use of hand instruments. The treatments Tannerella forsythia and Treponema denticola after
with the Er:Yag laser and with the hand instruments 3 months. Laser and sonic instrumentation failed to
were found to be more effective in vitro than in vivo. significantly reduce the amount of Aggregatibacter
Laser treatment also resulted in the removal of an in- actinomycetemcomitans. Six months post-treatment,
creased amount of cementum in vitro compared with the amount of test bacteria had increased in all study
in vivo, whereas for hand instrumentation the in vitro groups.
and in vivo results were comparable The reason for less Another set of clinical trials compared the clinical
substance removal in vivo was assumed to be caused by outcome of periodontal treatment by a feedback-
the restaining of the pocket tissue with blood and sulcus controlled Er:YAG laser or ultrasonic instrumenta-
fluid, which may have influenced the autofluorescence of tion (56). Single-rooted and multirooted teeth with
the dental hard tissue in vivo. However, by contrast, pocket depths of > 4 mm were randomly treated in
different media (including blood and saline solution) did a split-mouth design either by a feedback-controlled
not influence the autofluorescence intensity in vitro (17). Er:YAG laser (160 mJ per pulse, 10 Hz, chisel-shaped
Another clinical study compared the clinical tip of 1.65 · 0.5 mm, calculated energy density
benefit of autofluorescence-controlled Er:YAG laser 136 mJ per pulse; or chisel-shaped tip of 1.1 ·
radiation with that of a special ultrasonic device 0.5 mm, calculated energy density 114 mJ per pulse)
with vertical vibrations of the working tip (Vec- or by an ultrasonic device (Cavitron Select; Dents-
torTM; Dürr, Bietigheim-Bissingen, Germany), and ply, Konstanz, Germany) (56). At baseline, and 3 and
with hand instrumentation (53). Seventy-two single- 6 months post-treatment, plaque index, bleeding on
rooted teeth that were scheduled for extraction from probing, pocket depth, gingival recession and clini-
12 patients were randomly treated by the laser (at one cal attachment level were measured at six sites per

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tooth. Deep pockets showed a tendency to experi- conditions. Histological and microscopic findings
ence more gingival recession, to gain more clinical after in vivo use point to the potential for some of
attachment level and to retain more residual pocket these technologies to support or replace conventional
depth compared with moderately deep pockets. subgingival scaling. Published studies evaluating
Bleeding on probing and clinical attachment level clinical parameters, however, exist only for the
improved significantly in both treatment groups ultrasound- and laser-based devices, which combine
after 6 months compared with baseline. However, calculus detection and treatment. Moreover, con-
statistically significant differences could not be trolled randomized clinical trials are lacking for all
observed between the two types of treatment, sug- currently commercially available dental devices that
gesting that treatment with the Er:YAG laser was are used to identify and selectively remove dental
comparable with, but probably not superior to, calculus.
ultrasonic instrumentation (56). This conclusion is All studies starting out with teeth treated in vivo
in agreement with a subsequent clinical study that and then investigated after extraction have the same
compared the microbiological and short-term clini- problem in common, namely that clinical parameters
cal effects after Er:YAG laser debridement vs. ultra- such as pocket depth, gingival recession and clinical
sonic treatment (62). Twenty patients with at least attachment level are assumed to be associated with a
two pockets with a depth of > 5 mm in each jaw comparable prevalence of calculus. This might not
were included in the study. The pockets were ran- always be the case and therefore a bias of uncertain
domized to receive either feedback-controlled magnitude is introduced, especially if different stud-
Er:YAG laser treatment (160 mJ per pulse, 10 Hz, ies and methods are compared. Moreover, it is
chisel-shaped tip of 1.1 · 0.5 mm, water irrigation) questionable whether the claimed improvement in
or piezoelectric ultrasonic treatment (Piezon Master calculus detection in fact has resulted in selective
400; EMS). Clinical attachment level gain and pocket calculus removal and a concomitant preservation of
depth reduction after 1 month were significantly cementum. Without histologic examination, it is
higher in the laser group (mean pocket depth impossible to decide whether cementum has actually
reduction, 0.9 mm; mean clinical attachment level also been removed (50). In the case of the laser-based
gain, 0.5 mm) than in the ultrasonic group [mean detection and treatment device, for instance, histo-
pocket depth reduction, 0.5 mm (P < 0.05); mean logical analysis unveiled that the thorough removal of
clinical attachment level gain, 0.06 mm (P < 0.01)], calculus also resulted in an unwanted increase in the
whereas 4 months after retreatment, no significant amount of cementum removed.
differences were detected between the two treat- A common problem of the stand-alone diagnostic
ment modalities (mean pocket depth reduction: devices is that the application of these instruments
laser, 1.1 mm; ultrasonic, 1.0 mm; and mean clinical requires the systematic scanning of the entire sub-
attachment level gain: laser, 0.6 mm; ultrasonic, gingival tooth surface, and, in the case of positive
0.4 mm). Both treatment modalities yielded a simi- calculus detection, the detected calculus has to be
lar reduction of the subgingival microflora after located using the therapeutic scaling instrument.
4 months. Identifying the exact location of the calculus may be
In conclusion, clinical and histological studies have difficult, thus potentially leading to over-treatment or
shown that laser-based detection and treatment of under-treatment. This problem relates to the skills of
calculus can effectively remove subgingival calculus the clinician rather than to features of the instru-
and preserve root substance. However, the results ment. The combined detection and treatment
were comparable with hand and ultrasonic debride- instruments aim to overcome this problem.
ment, and controlled long-term clinical studies are The influence of operator skills on the outcome
lacking. variable has been shown previously and should
always be considered when evaluating the utility of a
particular method of scaling (8). Two different sce-
Summary narios are conceivable: an experienced and trained
clinician will manage more easily the application of
A number of different technologies have been advanced diagnostic procedures, such as the endos-
incorporated into dental devices for the purpose of copy-based system, and thus obtain better results
identifying and selectively removing dental calculus. than an inexperienced operator. Alternatively, a cli-
Some of these new approaches for calculus removal nician who is highly experienced in traditional scal-
show promising results under optimum in vitro ing methods may achieve less additional benefit by

201
Meissner & Kocher

using supportive detection devices than a beginner or Clinical studies are necessary to assess if the use of
a modestly skilled clinician, who may overcome a these devices can improve long-term treatment out-
lack of manual dexterity by using a supportive diag- come, with consequences of smaller residual probing
nostic system. These aspects have not been ad- depth, a reduced need for periodontal surgery and
dressed in the published literature. less hypersensitivity after treatment.
The fiberoptic detection technology shows poten-
tial to be a helpful tool in periodontal therapy, but
needs to be studied in clinical studies in direct Acknowledgment
comparison with established scaling techniques. The
fiberoptic device currently available is somewhat The work on Perioscan was supported by grants from
difficult to handle and requires additional time and the Bundesministerium für Bildung und Forschung
skills of the operator, especially when used simulta- (BMBF 01 EZ 0025, BMBF 01 EZ 0026) and
neously with scaling and root planing. from Sirona, Bensheim, Germany. T. Kocher and
Data on the clinical utility of a spectro-optical G. Meissner have served as consultants to Sirona.
device for scaling and root planing are scarce.
Promising results were shown regarding the sensi-
tivity and specificity of calculus detection in vitro.
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