14

J . Dent. 1991; 19: 14-17

Review
Ultrasound in dentistry. Part l-
biophysical interactions
W. R. E. Laird and A. D. Walmsley
Department of Restorative Dentistry, Dental School, Birmingham, UK
ABSTRACT
Ultrasound has many applications in the field of dentistry. However, it is only recently that the applications
and effects of its physical properties have been rationalized and understood. Ultrasound may be generated by
either magnetostriction or piezoelectricity, although the former is more commonly used in dental applications.
Interactions of ultrasound with biological tissues may be caused by either thermal or mechanical mechanisms.
The mechanical forces produced may be a result of cavitation, acoustic microstreaming and radiation pressure
forces. An understanding of these interactions alloys a more knowledgeable appreciation of the effectiveness,
safety limitations and rationale of dental ultrasonic instrumentation.
KEY WORDS: Ultrasound, Dentistry, Review
J. Dent. 1991; 19: 14-l 7 (Received 26 July 1990; accepted 1 August 1990)
Correspondence should be addressed to: Professor W. FL E. Laird, Department of Restorative Dentistry, Dental
School, St Chads Queensway, Birmingham 84 6NN. UK.
INTRODUCTION
Ultrasound is sound which has a frequency of 16-20 kHz
and as such is unable to be detected by the human ear. Its
use in dentistry extends over three decades, although it
is only more recently that the application and effects of
its physical properties have been rationalized and
understood.
One of the earliest reported uses of ultrasound in
dentistry was in the form of an ultrasonic drill developed
for cavity preparation in human teeth (Catuna, 1953)
based on pioneering work by Balamuth (1963). The
ultrasonic drill operated at a frequency of 29 kHz and
required an abrasive slurry of aluminium oxide to assist
the process of cutting or grinding enamel and dentine
(Postle, 1958). Although it was possible to use this
instrument without recourse to local anaesthesia, it was
somewhat cumbersome with a relatively slow action. In
addition it required very efficient suction apparatus to
remove the volumes of slurry used in the grinding process.
Nevertheless it did receive favourable comment (Oman
and Applebaum, 1954; Nielsen et aI., 1955), particularly in
respect of the low loads employed during cutting and the
limitation of traumatic effects to the dental pulp (Postle,
1958). In spite of this, ultrasonic cavity preparation never
became popular, being superceded by the much more
@ 1991 Butterworth-Heinemann Ltd.
0300-5712/91/010014-04
effective and efficient high speed rotary drills (Street,
1959).
The potential use of ultrasound in dentistry however
was still recognized by Zinner (1955), who suggested that
the use of a modified ultrasonic instrument in conjunc-
tion with a water coolant might be effective in the removal
of plaque and calculus from human teeth. This instrument
used a probe design in the form of a modified scaling tip
based on that used with hand scaling instruments. The
scaling procedure using such an instrument was demon-
strated by Johnson and Wilson (1957) and the technique
has become established as a rapid and simple alternative
to hand instrumentation and now finds wide clinical
use.
The pattern of oscillation of the probe tip was also
recognized as having potential use in endodontic therapy
in the cleaning and preparation of root canals prior to
obturation (Martin, 1976) and this has given rise to the
technique of endosonics. Other uses of ultrasound have
been the removal of debris from instruments prior to
sterilization, cleaning of dentures by immersion in an
ultrasonic bath, debonding of restorations (Walmsley et
al., 1989a, b), the treatment of disorders of the temporo-
mandibular joint and the detection of early caries (Ng et
al., 1988).
Laird and Walmsley: Ultrasound in dentistry
15
In order to appreciate the action of ultrasound in
dentistry however, it is necessary to have some apprecia-
tion and understanding of its physical properties, together
with the possible biological effects on tissues.
ULTRASONIC WAVES
Ultrasonic waves are essentially a mechanical propagation
of energy through a suitable medium. The waves occur
when particles of the medium are energized causing them
to vibrate and transfer energy to adjacent particles, the
energy being transmitted in the form of a wave. In fluids
and solids, wave propagation may be either longitudinal
or transverse. In the former, vibration occurs in the
direction of the travelling wave whilst in the latter the
particle displacement is at right angles to the direction of
propagation. Transverse waves can travel efficiently only
in solids, where there are strong forces of attraction
between adjacent particles to ensure energy transfer. In
fluids however particles slide past each other with little
resistance and the energy is dissipated within the fluid. In
the human body hard tissues can transmit both longi-
tudinal and transverse waves, compared to soft tissues
which can only transmit longitudinal waves, with the
transverse waves being dissipated as heat.
When an ultrasound wave encounters an interface
between different media, as will occur with the tissues of
the teeth for instance, part of it will be reflected back into
the original medium and the remainder reflected into the
new medium at a velocity which is dependent upon the
transmission properties of the medium. The ratio of the
reflected to refracted waves is termed the acoustic
impedance, and there is greater energy transfer across
boundaries where acoustic impedances are similar. Large
impedance mismatches occur between solids to liquids to
gases and consequently little energy is transferred.
GENERATION OF ULTRASOUND
For clinical purposes ultrasound is generated by trans-
ducers which convert electrical energy into ultrasonic
waves. This is usually achieved by magnetostriction or
piezoelectricity, with the former being more common in
the generation of the low frequency ultrasound oscillations
used in dentistry.
Magnetostrictive devices undergo changes in their
physical dimension when a magnetic field is applied to
them. This is usually achieved by placing a ferromagnetic
stack within a solenoid through which is passed a direct
current. This produces stresses leading to a change in
shape of the material. When an alternating current is
passed through the solenoid the stack will then change its
shape at twice the frequency of the applied magnetic field.
Magnetostriction with a laminated ferromagnetic stack is
used commonly in the design of ultrasonic scaling
instruments as it is a robust and easily manufactured
system.
The piezoelectric system is based on the fact that certain
crystalline structures such as quartz will be subject to a
shape change when placed within an electrical field. If an
alternating voltage at an ultrasonic frequency is applied
across a piezoelectric crystal, it will result in an oscillating
shape change of the crystal at the frequency applied. This
is then passed onto the working tip. Piezoelectric genera-
tors are more efficient at frequencies in the MHz rather
than the kHz range, although some have been developed
for use in dentistry. However, the crystalline structure has
poor shock resistance and such instruments are more
fragile than their magnetostrictive counterparts.
When the input energy to a system is in phase with the
natural frequency of oscillation of that system it is said to
be in resonance. This will maintain or increase the
amplitude of oscillation of a probe tip and allow it to work
at maximum efficiency, if the tip and the generating stack
are cut to resonant length, which is usually one-half
wavelength or multiples thereof.
BIOLOGICAL EFFECTS OF ULTRASOUND
When an ultrasonic wave passes through a biological
system changes may occur in that system. These may be
due to heat, cavitational activity, acoustic microstreaming
or radiation forces. All are important when considering
the use of ultrasonic instrumentation in dentistry.
THERMAL EFFECTS
As a wave of ultrasound passes through tissues its energy
is reduced and is dissipated as heat, leading to an
elevation of tissue temperature. The effects of this on the
tissues are dependent upon the size of temperature rise,
the time over which it is maintained and the thermal
sensitivity of the tissue. In most tissues the normal
physiological response will be an alteration in the blood
flow in the region due to reflex relaxation of the arterioles.
The resultant increase in blood flow through the area will
tend to control heating effects within a limited increase in
temperature, with a temperature rise of less than 1 C
resulting only in a minor overall increase in local
metabolic rate. Excessively high temperatures however
will lead inevitably to tissue damage.
CAVITATION
Cavitational activity in relation to ultrasound encompas-
ses a continuous spectrum of bubble activity in a liquid
medium. It ranges from gentle linear pulsation of gas-
tilled bodies in low amplitude sound fields (stable
cavitation) to violent and destructive behaviour of vapour-
filled cavities (transient cavitation) in high amplitude
sound fields (Flynn, 1964; Nyborg, 1977; Williams, 1983).
The energy generated within these bubbles may result in
shock waves or hydrodynamic shear fields which may
disrupt biological tissues, and it is the production of these
16 J . Dent. 1991; 19: No.1
1
A
3
A
2
b 4
Fig. 7. Diagrammatic representation of possible bubble
collapse. a, A free bubble collapsing to smaller fragments
and radiating shock waves. b: 1, bubble on a solid surface; 2,
undergoing deformation; 3, producing a high velocity liquid
jet; 4, jet pierces bubble and damages solid surface.
large disruptive forces which are of use in the removal of
plaque and calculus during ultrasonic scaling (Balamuth,
1963).
The occurrence of cavitation requires the presence of
gaseous bodies or bubbles in the medium, which have
been termed cavitation nuclei (Williams, 1983). In the
presence of an ultrasound field a bubble will grow and will
undergo breathing pulsation in response to the applied
pressure oscillations set up by the field (Nyborg, 1977). As
the bubble pulsates transverse waves are set up on its
surface (Lamb, 1945) which become distorted and unstable
as the ultrasonic amplitude increases. Microbubbles will
occur around the original bubble (Nyborg and Rogers,
1967) and will act as new sites for cavitational activity
(Neppiras and Fill, 1969). Formation of microbubbles is
associated with the onset of transient cavitation, where the
bubbles show a collapse phenomenon (Flynn, 1964) with
the temperature of the gas in the bubble reaching
thousands of degrees Celsius and several thousand
atmospheres of pressure (Noltingk and Neppiras, 1956).
The demanding effects of transient cavitation are due to
the shock waves radiated during the final stages of bubble
collapse (Nyborg, 1977) or high velocity liquid jets (Fig. I)
from non-linear motions of the bubble face (Crum, 1982).
At low ultrasound frequencies in the order of 20-40 Wz
growth of micronuclei and subsequent transient cavita-
tion occur readily (Esche, 1952).
Cavitation occurring in human blood can result in a
thrombogenic effect (Chater and Williams, 1982) and
cause lysis of erythrocytes and platelets. This may explain
reduction in haemorrhage when using ultrasonic surgical
instruments and dental scalers (Ewen, 1960; Goliamina,
1974).
ACOUSTIC MICROSTREAMING
The rapid cyclical volume pulsation of a gas bubble
results in the formation of a complex steady state
streaming pattern within the liquid close to the bubble
surface. This is termed acoustic microstreaming and can
be demonstrated around an oscillating solid cylinder
within a fluid or a stationary cylinder within an oscillating
fluid (Fig. 2).
The dimensions of the patterns demonstrate a rapid
rate of change of streaming velocity with distance
(Nyborg, 1977). Therefore although the velocities them-
selves are only of the order of a few centimetres per second
(Williams, 1983) the gradients due to the rate of change of
velocity will produce large hydrodynamic shear stresses
close to the oscillating object (i.e. probe or gas bubble)
which may disrupt or damage biological cells or tissues.
These most probably contribute to the efficiency of
endosonic instrumentation (Lumley et al., 1990). Acoustic
microstreaming may also result in the disruption of blood
flow and cells such as human platelets exposed to probes
operating at 20 kHz (the level used in dentistry). At higher
Fig. 2. A theoretical prediction of the acoustic microstreaming
field generated around a solid cylinder oscillating within a
stationary fluid (modified from Holtzmark et al., 1954).
Laird and Walmsley: Ultrasound in dentistry 1 7
amplitudes gelatinous aggregates of platelets can form as
emboli resulting in possible blood vessel occlusion
(Walmsley et al., 1987).
RADIATION FORCES
Any medium or object in the path of an ultrasonic beam is
subjected to a radiation force which tends to push the
material in the direction of the propagation wave (Wells,
1977). This force is small, but in a standing wave field may
be enhanced and act over a short distance, so that dense
particles in the medium are driven to regions of maximum
acoustic pressure amplitude. In blood vessels this may
cause local aggregation of blood cells leading to stasis
(Dyson et al ., 1968). Radiation forces may also enhance
cavitational activity within a standing wave field (Nyborg,
1977).
OCONCLUSION
The physical properties and biological effects of ultra-
sound are of importance in dentistry where low frequency
ultrasound instrumentation is used. From a theoretical
extrapolation this may be both beneficial and damaging.
The understanding of the basis of ultrasound and
methods of its clinical use allows us to consider more fully
the effectiveness, safety limitations, and rationale of
dental ultrasonic instrumentation.
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