Periodontal Instrumentation Grasp, Fulcrum, Wrist Motion, Using the Periodontal Probe

Handle, Shank, Working End Head HANDLE Shank Shank HANDLE Shank

Use of the Dental Mirror Indirect vision Illumination Reflection of light Transillumination Reflection of light “through” the tooth surface Especially for calculus Retraction

Modified Pen Grasp Most efficient grasp Control – Stability Pivot Point

Modified Pen Grasp Thumb & Index finger opposite at junction of handle & shank Handle is between junction of the first and second joint of the index finger Pad of middle finger against the shank (side of pad) Fingers are a “unit” Left hand grasp Right hand grasp

Establishing a Finger Fulcrum Stability Activate instrument - stroke pivot Control - prevents injury Always on a stable oral structure Occlusal plane, mandible, zygoma Ring finger

Fulcrums Intraoral Intraoral As close to working areas as possible Approximately two teeth away Do not fulcrum on the same tooth Mandibular arch Maxillary anterior teeth

Extra-Oral Fulcrum Extraoral Maxillary arch Posterior teeth

Wrist Motion Side to side Up and down Activated by pivoting fulcrum finger Wrist must be straight to activate stroke - movement of instrument Will be demonstrated on the presenter

Instrument Identification Name, design number, manufacturer Determined by use Probes Explorers Curets Sickles Hoes Files Chisels

The Probe Primary instrument in the periodontal exam Assess gingival health Periodontal status Exploratory Requires skill development

Probe Design Vary in cross-sectional design Millimeter markings Rectangular in shape (flat) Oval Round Millimeter markings Calibrated at varying intervals

Marquis Probe Color coded 3, 6, 9, 12 mm markings Thin working end Key is to know the increments Type of probe being used

Use of the Probe Inserted to the Junctional epithelium Measures sulcus Periodontal pockets Gingival recession Attachment loss

Angulation Probe is parallel to long axis of tooth

Interproximal Angulation Slightly tilted Apical to the contact point Not enough angulation Correct angulation Too much angulation

Adaptation Working end is well-adapted to tooth surface

Technique Gently “walk” the probe

Readings Six readings Deepest reading within the designated areas Distal (DB & DL) Buccal (B) or Lingual (L) Mesial (MB & ML) Deepest reading within the designated areas

Gracey Curets

Gracey Series Anterior Teeth Posterior Teeth (next week) 5/6 all surfaces of anteriors/premolars Posterior Teeth (next week) 7/8 Buccal & Lingual Surfaces 11/12 Mesial Surfaces 13/14 Distal Surfaces 15/16 Mesial Surfaces 17/18 Distal Surfaces

Design Characteristics Standard or Finishing (non-rigids) Rigid Extra Rigid Extended Shanks Different Blade sizes Regular Mini

Design Characteristics Area specific Adapt to a specific area or tooth surface Two curved edges with a blade Only one cutting edge is used for calculus removal Lateral surface Face Back Cutting edge

Design Characteristics Working end is tilted in relationship to the terminal shank (offset by 70°) Makes one cutting edge lower than the other This lower end is the one that is used for instrumentation

Identification of the Cutting Edge Place shank perpendicular to floor Lower blade is the cutting edge Lower shank will be parallel to surface being scaled

Advantages of Design Characteristics Allows insertion into deep pockets Prevents tissue trauma Correct cutting edge to tooth surface angulation Easier adaptation Around convex tooth crowns to access root surfaces

Adapting the Curet Blade

Blade Adaptation to Tooth Surface 0° <45° 45-90° > 90° insertion Healthy tissue Plaque removal Ideal Calculus Removal Tissue Trauma

Adaptation of lower third of blade to tooth surface Correct Lower 1/3 Incorrect Toe 1/3 Incorrect Middle 1/3

Relationship of Lower Shank to Blade Angulation Too far Toe is coronal Lower shank parallel Lower shank To far forward

Calculus Removal “Channeling”

Review of Fundamentals of Instrumentation

Working Stroke oblique vertical horizontal circumferential

Basic Design Characteristics of the Working end of Instruments Lateral surface Face Back Cutting edge Lateral surface Cross section

Curet Toe vs Sickle Tip HEEL TIP TOE

Comparison of Curets & Sickle Blades

Sickle Scaler

Uses Supragingival calculus Stain Slightly subgingival (1-2mm)

Different Designs Anterior teeth Posterior teeth Modified shank Blade can vary in size & design

Design Characteristics Straight rigid shank Two cutting edges Straight or slightly curved Back of the instrument Pointed or rounded

Adaptation

Adaptation INCORRECT CORRECT

ANGULATION

Technique Mesial & Distal Divide tooth structure in 3rds Distal line angle towards interproximal Mesial line angle towards interproximal Labial or Lingual Surface Graceys or Universals Mesial & Distal Vertical stroke

Visual Guide to Instrumentation Anterior Teeth Handle extends upward/parallel to long axis of teeth when interproximal Does not apply to Facial or Lingual surfaces Oblique stroke is best Alternative instruments are better than sickle Prevent tissue trauma

Visual Guide to Instrumentation Lower shank is parallel to surface being scaled Vertical stroke

CLINIC DEMONSTRATION H6/7 Sickle Scaler Shank slightly curved Review on clinic floor 33 15 H6/7

Universal Curets

TYPES OF UNIVERSAL CURETTES Columbia Barnhart Bunting Goldman Younger-Good Langer (gracey shank)

Design Features Can adapt to all tooth surfaces 90 degree blade angulation shank curvature allows adaptation both cutting edges are used blade curved on only one plane

Blade Adaptation

Use of the Universal Curet: Anterior teeth Both instrument ends will be used Handle is parallel to long axis of tooth Adapt blade to mesial or distal Initiate by starting at the tooth midline Work towards the interproximal Refer to diagram on pages 183-184 in Pattison

Type of Stroke Used Oblique on buccal & lingual Vertical on Mesial & Distal

Use of the Universal Curet: Posterior Region Select the working end that adapts to the interproximal surface Lower Shank is parallel to mesial surface Select blade that is in contact with the mesial surface Use from the distal line angle towards mesial surface

Use of the Universal Curet: Posterior Region Using the same working end No flipping of instrument Select the opposite or “secondary” blade to scale the distal surface Note that the lower shank is parallel to the distal surface

Vertical Interproximal Stroke Vertical Stroke on Mesial and Distal Surfaces

Posterior Scaling with Gracey Instruments

Gracey Curets Area specific Each working end is a mirror image Shank design Blade design Each working end is a mirror image Blade identification Allows for correct working end Adaptation to surface being scaled

Lower third is used for calculus removal

7/8 Gracey Curet Buccal & Lingual Surfaces Posterior teeth Initiate stroke from the distal line angle Finish stroke at the mesial line angle Stroke used Oblique or horizontal Lower shank is not parallel stroke is “towards midline”

11/12 and 15/16 Gracey Curets Used on mesial surfaces of all posterior Initiate stroke at mesial line angle and continue towards the mesial-interproximal surface Each end is a mirror image

13/14 Gracey Curet Distal surfaces Initiate stroke at the distal line angle Continue towards interproximal (distal) Difficult to see blade use shank as visual cue Keep lower shank parallel to tooth surface

Exploratory vs Working Stroke Blade is less than 45° Grasp is lighter Tactile sensitivity is enhanced On the “down” stroke Objective is to identify depth of calculus Blade is 45-90° Calculus removal Firm grasp Engage blade by Adaptation or “bite” On the “up” stroke Vertical Oblique

Adaptation Degree of “how open” or “closed” the blade is upon insertion is dependent on: Type of tissue Fibrotic vs boggy or hemorrhagic tissue Severity of disease Retractable tissue Interproximal embrasure Tenacity of calculus

Difference in Technique Scaling short, precise, strokes, channeling calculus deposits Planing long even strokes Objective is to smooth the root surface Takes experience and time to obtain skill

How well have we scaled? At time of S/RP appointment After appointment Exploring, probing Smoothness of tooth surface After appointment Healthy periodontium Decreased bleeding, pocket depths, marginal bleeding

Limitations obscured vision from bleeding tactile sensitivity instruments selected direction & length of strokes confines of soft tissue - tissue type tooth anatomy clinical findings “mental image” based on visual, mental, and manual skills

Limitations Accurate treatment plan Severity of Disease progression Anesthesia, number of appointments Severity of Disease progression Local factors Systemic factors Pockets, furcas, anatomical characteristics, erosion, recession, mobility

Most common areas missed: most apical portion of pocket furcation areas & distal surfaces primary reason: not overlapping strokes

Effects of scaling & root planing reduction in inflammation pocket depth reduction-- avg.. 1.36mm .8mm in recession .52 in attachment attachment - maintained or slight gain decreased mobility - fibers reduction in gram-, spirochetes, bacteroides conflicting results with A. Actinocytemcomitans

Sequence to Periodontal Instrumentation Patient Assessment Local and systemic factors that influence periodontal condition Hx of smoking Periodontal Evaluation Severity of disease Periodontal tx plan Surgery, grafts, Overall objective of phase I therapy Calculus Assessment How difficult, tenacity, depth

Sequence to Periodontal Instrumentation Phase I Simple = 1 appointment Simple case, light calculus, little sensitivity, controlled periodontal condition, mild inflammation Phase I Intermediate – 2 appointments Overdue, early Periodontitis 4-5 mm pockets, Patient may require ½ mouth anesthesia (Lower & upper quads avoid same arch) Phase I Complex 4 appointment by quads with anesth, pockets, calculus, furcations Re-evaluation appointment

Sequence to Periodontal Instrumentation Full mouth Start in tooth sequence for plaque removal Assess where calculus is present Areas of inflammation Two appointment Anesthesia, upper & lower quad Complex Each quadrant with anesthesia