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Introduction

PeriodontalInstrumentation

George M Bailey,DDS

Creighton School of Dentistry/

University of Utah


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Course Objectives 4

Schedule 5

Instrument List 6

Asepsis 7Models 8

Instruments 10

Holding Instruments 18

Sharpening 20

Scaling on Models 27

Scaling v. Root Planing 30

Exam/Risk Assessment 37

Oral Hygiene 46

Tuneable Ultrasonics 48

Advanced Ultrasonics 68

Polish/Stain 80

Ergonomics 83

Scaling on Patients 88Philosophy of Treatment 106

Table

ofContents


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Objectives--Periodontal Instrumentation

Periodontal instrumentation 132 is a pre-clinical course forthe periodontal courses which will follow in the sophomore year, bothclinical and didactic. Although it is billed as a pre-clinical course, there will

be significant use of the clinical facilities in a hands-on environment (yourlab partner, not dental patients). How well you learn these base principles islikely to determine your performance in the advanced courses to follow.

Every effort will be expended to treat you as the doctor you willbecome. You will be treated with dignity, as a scholar trying to learn the prin-ciples and acquire the skills necessary to treat your patients-to-be at the levelthey deserve and demand and with the loving care they need. In return youwill be expected to honor the subject matter as important and use your per-sonal skills and intellectual abilities to learn and gain an appreciation for den-tistry as a profession.

The above will be accomplished in an environment which representscurrent thought, modern techniques, and consistent with the scientific meth-od. Because the best type of learning comes when there is interest and enjoy-ment, the instructor will use a variety of presentation methods,

abundant clinical examples, and a heavy dose of humor.At the conclusion of this course you should (will) have or will be able

to do the following:1. Know the periodontal instruments, how to properly use them, how

to care for them, and have an understanding of what instrumentsyou might acquire for your office.

2. Have basic periodontal diagnostic abilities and how to performoral risk assessment.

3. Know the importance and the hows of oral hygiene instruction.4. Understand and demonstrate the use of mechanical scalers.5. Demonstrate to the instructor proper scaling techniques.6. Demonstrate the sum of the above in a clinical setting!

Knowledge truly is power, but it must be used with knowledge!

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PERIO INSTRUMENTATIONPER 132

SPRING 2006

Course Instructor: Dr. George M BaileyTime: 8:00-11:50am MondaysTexts: Carrenza, Clinical Periodontology, 9th ed.

Harris, Primary Preventive Dentistry, 6th ed.Bailey, G.M., Introduction to Perio InstrumentationPattison/Pattison, Periodontal Instrumentation

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Date Session Topic Carrenza Bailey et al

Pre-Class Pre-Class Intro-Lab PrepAsepsis Ch. 36 Bailey 7-10Module 24 (handout)Video-ChristensenVideo-Modified Ultra-sonics Bailey/Moody

March 6 Lecture Mechanical Scal-ers

Ch. 43 Bailey 49-80Module 21 (handout)

March 13 Spring Break Party Have Fun Get a Tan

March 20 Clinical@Dr. B

OfficeUltrasonics

March 27 Lecture Risk Assess-PerioOral ExamInstrumentsOral HygieneProphylaxis

FluoridePre-Clinic

Ch. 4 & 32pp. 451-452

Bailey 38-46Module 1&2-Pattison

Harris Ch. 5-7Module V-Pattison

Bailey 81-83

Harris Ch. 9

Bailey 81-106

April 3 Clinic Risk Assessment

Oral HygieneProphylaxisFluoride

April 10 Lecture Hand Instrumen-tation

Lab-Sharpening

Module III-Pattison

Module IV-Pattison

April 17 Clinic Patients

April 26? Comprehensive

Final

Observation

Report Due


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Creighton University School of Dentistry

Freshman 2004-2005 Instrument List

Periodontics Instruments

Item Unit Description

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

Other

1 each

1 each

1 each

1 each

1 each

1 each

1 each

1 each

1 each

1 each

1 each

1 each

2 each

Gracey Curettes G1/2 Ultra Handle

Gracey Curettes #11/12 Ultra Handle

Gracey Curettes #13/14 Ultra Handle

PQ2N Black Coded Nabers Probe

11/12 Explorer

Black Coded Probe (3-6-9-12)

McCall Curettes, #13/14 Ultra Handle

McCall Curettes, #17/18 Ultra Handle

H-6/7 Straight Sickle Scaler

McBim Sharpening Stone, 2 sided

Barnhart Curettes, 1/2 Ultra Handle

Plastic Test Stick

Double Sided Mirrors

Prophy angles, paste, handpiece, eye goggles,lab coat, patient mirror, napkin clips

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Dental Asepsis Standards

OSHA Mandates

In December of 1991, OSHA developed the Bloodborne Path-ogens Standards, as it relates to dentistry. OSHA is that governmentalagency which seeks to protect workers (employees) from hazardous workconditions. These are regulations imposed on the employer and carry theweight of law. Although technically the doctor (employer) is not bound

personally by the regulations, by convention, the doctor is now assumedto be also bound by the same regulations as his (her) employees. It is as-sumed that the doctor will be compliant!

The full document is fairly complex (as per usual with governmentthings) with practice procedures, record keeping, and employee notifica-tion provisions being spelled out. As a doctor (employer) you will need toknow and practice these principles. As relates to your position as dentalstudents, the following will rigidly apply:

Personal ProtectionThis refers to those practices employed to protect oneself frominfectious contamination. Whenever one is in contact with apatient or body parts or fluids from another person, the dentalstudent must:

Wear gloves

Wear a high filtration mask

Wear protective eye-ware

Wear protective clothing

Employ frequent hand-washing

Vaccinations (although not mandated, thisis a near standard)

Patient ProtectionSterilized instruments/devices

Protective eye-ware

An aseptic environment

Note: A current video demonstrating these and other procedureswill be shown

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Technique Models

You will need to make a technique model to practice instrumentation principles.

This model will be used during several sessions and will simulate actual clinicalpractice. Therefore, prepare the model with care. The following will be necessary:

An Arch of Extracted TeethTo qualify, the teeth must meet the following requirements:

1. Epithelial attachment migration--this can be determinedbecause the remnants of the attachment fibers (soft-tissue) are still attached to the tooth

2. Subgingival calculus--a minimum of 5mm past the CEJ;

calculus need not completely encircle the tooth in ring-like formation, but could exist as spiny nodules, finger-projections, individual calculus islands or thin, smoothveneers.

3. Soft necrotic cementum (desirable, but difficult to find onextracted teeth).

4. Preferential selection should be given to upper firstbicuspids because of their predisposition to retain

calculus in the mesial marginal grove and to molars withfurcation involvement.

5. A full-half arch--in order to make this model meaningful,a half arch (central incisor thru 2nd molar) is necessary

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Technique Models

Making the Model

1. Make several retentive grooves in the rootstructure with a bur or disc, and /or drill asmall hole at the apex of the root which willallow a paper-clip or wire to be insertedthrough the root.

There are other methods, but the intent is toprovide firm anchorage of the tooth into theplaster (stone) pour. Since considerablepressure will be put on the teeth during thescaling exercises, it is important to have theteeth firmly anchored.

2. Arrange the teeth in a natural arch form,with the teeth touching in a normal marginalridge-to-ridge relationship (lute the teethwith wax). Using boxing wax , make a formthe shape of the maxillary arch, about 2

inches deep. Suspend the luted arch of teethso that the stone pour will cover only theroots (leave at least 6 mm of root uncovered

by the stone). Allow stone to set at least 2hours before removing the boxing wax--trimthe model.

3. Keep the teeth moist--either submerge thecrowns/roots in water or cover withglycerin.Do not let the water or glycerin

contact the stone--it will weaken it and

cause the teeth to fall out!

Paper Cl

6mm

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Periodontal Instruments

General Instrument Design

All dental hand instruments have certain similarities even though the visual

design seems to be unique to that instrument. Each hand instrument can be

divided into three separate parts: handle, working end, and shank.

A--HandleHandles come in many sizes and configurations. It iswell to try a variety before you make your final pur-

chase for the office. Some things to consider:

1.Size-the instrument should be comfortable in yourhand. Much like a racket handle in tennis and

racquetball, your individual preferences should

be the final guide.

2. Grooved or smooth-some prefer having a grooved

surface which is less slippery, while others prefera smooth surface which allows quick changes in

instrument position.3.Hollow v. solid-again, personal choice. Try a

variety before the final choice!

B--Working EndThe part that actually does the work and which is incontact with the tooth. The name of the instrument is

usually derived from this part eg. probe. With perio-

dontal cleaning instruments, this is called the blade.

C--ShankThe thin segment that joins the handle to the workingend. The shape of the shankdetermines which area ofthe mouth the instrument was designed for ie. because

of its shape, the Gracey 11/12 best fits in the posterior

areas!

Note: It is important to

learn the above terms. This

is how professionals

communicate! 10


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Periodontal Instrument Classification

Periodontal Probes

There is an almost staggering array of periodontal probes available, and more

added each year. The basic intent of the periodontal probe is to act as a diagnos-

tic/screening tool for periodontal diseases by performing measurements. There-

fore, the probe shape and markings should reflect its ability to measure. Although

there are many variations, periodontal probes can be divided into categories on

the basis ofdiameter and markings.

Marquis UNC O O WHOMarquis diameter Mich O diameter Mich O diameter Mich O diameter Williams dia

Marquis marks Williams marks Williams marks Mich O marking WHO mark.

3mm spaced areas 1mm marks with @1mm with marks@3,5,7mm marks @3.5,

bands@ 5,10,15 space @ 3-5mm 8.5,11.5,and

.05 ball @ endGood diameter,hard to read Good diameter and Good diameter, easy Good diameter, Large diameter

markings with accuracy! easy to read! to read! Screening Probes!11


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Specialty Probes

Furcation Probes

In addition to the general periodontal probes

previously described, specialty probes which

measure furcations are also available. The

shank on these probes is curved so as to allow

easy access into the separation point of the

roots. Some have calibrations which allow a

numerical value to be assigned to the furcation.

These probes were developed by Dr Claude

Nabors and bear his name.

Non-Metallic

Plastic or plastic-like probes also exist. Many of these were designed to be discarded ie.

single use. Some practitioners prefer to use non-metallic instruments around dental

implants.

#1N #2N

May have markings

Plastic probe with apressure sensor

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ExplorersThe main use of explorers in periodontics is threefold:

1.Calculus detection on the root surface

2.Caries detection

3. Determine texture, contour, and smoothness of the root surface

Explorers are therefore diagnostic aids that also determine the end-point of the cleaning process

ie. when the root is smooth, it is likely to be free of bacterial calculus.

Explorers should be applied tothe tooth with a very lighttouch since it is the very finetip that is the detection tool.Pressing too hard on the instru-ment decreases the tactilesense.

Explorer tips may be made ofstainless steel, carbon steel, oran alloy, all with claims ofsuperiority. See what works foryou!

Each periodontal instrumenttray should have an explorer ortwo.

Clinical TipWhen using an explorer in a

clinical setting to detect calculususe the side of the tip and not the

tip itself. The tactical sense is

much higher!

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Mouth Mirrors

Mouth mirrors are used constantly in dentistry as either instruments for indirect

vision, illumination, transillumination, or as a retracting device. As with other

instruments, mirrors come in a variety of types and sizes. When classified on the

basis of image produced, there are basically three types:

Plane Surface (flat)--this is a flatplane mirror which reflects a double

image, one on the apparent surfaceof the mirror and another that appears

within the substance of the mirror. This

type of mirror is difficult to useclinically because of the double images.

Image #1

Image #2

Front Surface(Concave)--the most

common type of mirror used. Gives a

single, same-size image. As used in themouth, the image is reversed. Practice

is needed to use any mirror! There are

many diameters available, with the #5being the most common.

Smart Practice

Smart Practice

Concave--as with other mirrors and

lenses, the concave shape produces amagnified image. The production of a

magnified image and its usefulness is

obvious.Other--there are many

different shapes andmirror types availableincluding double-sided

mirrors which allow

indirect vision and re-traction at the same

time.

Clinical Tip--to minimize mirrorfogging, warm mirror surface against

the patients alveolar mucosa of the

cheek!

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Scaling/Root Planing Instruments

The numbers and types of hand instruments used for cleaning teeth probably ex-

ceeds any other category of hand instruments. This is necessitated by the variety of teeth

present in the mouth, the varying shapes of teeth and roots, and the relative position of the

teeth themselves. Even with a wide variety of instruments, it seems that the practitioner

still needs an instrument that is not available. Each mouth is similar to, but distinctly dif-

ferent from all other mouths.

Tooth cleaning hand instruments can be divided into the two general categories:

curettes and scalers. However, some manufacturers code their instruments in a manner

which would indicate they are one-or-the-other, even though the physical characteristics of

the instrument would put it in another category! The chart below describes the general

characteristics of the curette v. scaler.

CuretteGeneral Definition

General use is forsubgingival clean-

ing.Has a tendencyto be delicate (how-ever, manyvariants)

ShankHighly variable

in diameter &

angulations. A

tendency to be for

use in a specific

area! 60-70

shank-to-blade

angle.

Cutting EdgeGenerally round-

ed

ExamplesGracey Series

#1/2,11/12,13/14

Scaler Targeted mostly forsupragingival areasGenerally heavier

shank/cutting edgethan curette

Not as variable asthe curette

Most are pointed H-6/H-7 Straightsickle scaler

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Design Differences

In addition to the general categories of scaler v. curette previously presented, the

curettes (and some scalers) can be catalogued on the basis of where in the mouth they

were designed to be used. Although the physical design of the instrument makes it most

suitable for a specific area or teeth, the clinician may find it useful in other areas. Howev-

er, it is important to understand the relationship of the cutting edge (working end) to the

tooth when deviating from the standard application. The design of the instrument auto-

matically puts the cutting edge in the most efficient angle to the tooth and deviations from

that may negate the effectiveness of the tool.Know your instrument well!

Universal Curettes

As the name implies, these instruments

were designed to adapt to all surfacesof all teeth in the mouth. The practicalreality is that they work in most areas

but limitations in opening the mouth,

teeth rotation, pocket depth, etc put

limits on the universality!

Although the blade size and the length

of shank vary, universal curettes (asviewed in cross section with the tip of

the instrument pointed towards you)

have a 90 shank-to-blade relationship.

Area-Specific Curettes

Originally designed by Dr Clayton

Gracey in the 1930s, the Graceycurettes are the most noted area-specificcurette series. These instruments areusually double-ended, but have only onecutting edgeper end.

The numbering system identifies the rec-ommended use sites (see table on follow-ing page).

The shank-to-blade relationship is anoffset orientation of 60-70. This allows

the blade to contact the tooth atthe proper angleprovided the

shank is parallel to the long ax-

is of the tooth! Unlike univer-sals, the blade is curved in twodirections

Shank

90

Blade

Also, universals have two

cutting edges & are

curved in one direction

from head to toe of the

blade!

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Gracey Series Curettes

Instrument Where Used

1/2 Anterior areas

3/4 Anterior areas

5/6 Anterior and premolars

7/8 Posterior facial & lingual

9/10 Posterior facial & lingual

11/12 Posterior-mesial areas

13/14 Posterior-distal areas

15/16 Posterior-mesial areas

Modifications of Standard

GraceyExtended Shank

Designed for deeper pocketsAfter Five series

Small BladedBlades are 1/2 size

Mini-Five

Curvettes

Shank Differences

RigidFlex

Blade Shape--Universal v. Area Specific

Universal

Curved only in

one direction

from the head totoe ie toe (tip) is

curved slightly

upward!

Tip

Head

Tip

Lateral

Area-Specific

Blade is curved intwo directions--tip-

shank & left-right

(lateral edges)

Note: Best way to determine the bladeDifferences, how to insert the instrumentinto the pocket, and which edge to sharp-en--point toe of instrument towardsyou!

Note: As a general

rule, the low numbers

are for the anterior and

the higher numbers are

progressively for the

posterior areas!

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Holding Periodontal Instruments

Grasp

Holding the dental instrument in a proper fashion is important for the following reasons:1. Instrument design--dental hand instruments were developed with the

supposition that they would be held in a certain manner. Therefore, holdingthem differently may negate their design and effectiveness.

2. Stability--holding periodontal hand instruments in a stable, defined relation-ship to the tooth is necessary in order to make it work properly.

3. Control--many hand instruments require significant forces be placed on them

to accomplish the goal eg. scaling teeth requires heavy, controlled forces toremove stubborn, dense calculus, or requires controlled, delicate motions so asnot to damage delicate tissues eg. probing.

There are three basic grips: pen grasp, modified pen grasp, and palm-thumb grasp!

Pen Grasp

Is the same as holding apen for writing (is pre-sented as a comparisonand is rarely used!

Modified Pen GraspThe most common way tohold dental instruments--

most stable, controlledgrasp.

Note:

Index bent at 2ndjoint

Extended middle fingerPad far down the shank

Ring finger along sideSupports middle finger

Palm-Thumb GraspIf used, generally to hold aninstrument for sharpening!

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Holding Perio Instru

Finger Rest (fulcrum)

Typically, significant forces are put on periodontal scaling hand

instruments. In addition to the modified pen grasp which helps retain the

instrument in the hand, the finger rest stabilizes the hand-instrument union

in a position in the mouth. This allows the cleaning motions to be effective

and prevent damage to the surrounding tissues. The actual fulcrum point is

dependant upon the instrument used, which area/surface of the mouth is

being cleaned, and modifying factors eg. tooth position, ability to open, etc.

The specific sites will be discussed in another section.

In general, the following factors are important relative to finger rests:

General Principles1. Use the ring finger to contact the fulcrum

point. Although other fingers can be used, they

are necessary in maintaining the grasp!

2.Keep the ring and middle finger close

together during scaling since this provides a

stable instrument-hand relationship.

Preferred Fulcrum SitesWhenever possible, choose

a fulcrum with the lowestnumber from the following

list, since the list repre-

sents decreasingstability:

# 1--Intra-oral

1--an adjacent tooth

2--cross-arch tooth

3--bone surface

4--finger-on-finger

#2--Extra-oral sites

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Principles of Sharpening

It is impossible to scale and root plane in a pre-cise and efficient manner with dull instruments.

Tactile sensitivity is reduced, because a dullinstrument must be held more firmly andpressed against the tooth harder than a sharpinstrument

A dull blade crushes the calculus rather thanremoving it, leaving smoothed-over calculuswhich is then more difficult to detect andremove. This is called burnishing- a falsesense of removal!

*The Heavy Handed Clinician--scaling does requirefirm lateral pressures. A dull instrument demands morepressure which increases patient discomfort (a dentaleuphemism for pain)! In addition, more pressure increases thepossibility of slipping and lacerating dental tissues.

*A Time Waster--dull instrumentssimply require more strokes to reachthe end-point(a dental term used to

describe when the final objective hasbeen met). The scaling end-point iswhen the calculus has been removedand a smooth root surface created.

Instrument sharpening is tru-ly an art and a skill. It is noteasily learned in a singlesession but requires workingwith many techniques and avariety of instruments. Thebenefits of a sharp instrument

which was meant to be sharpare enormous.Keep at it!

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Evaluating Sharpness

Obviously, the first step is to recognize when an instrument is both dulland sharp. Both can be accomplished by the same methods, but may be theopposite of each other. It is important to first understand what makes a sharpedge.

On a curette, a sharp edge is formedwhen the face intersects the lateraledge producing a very fine acute

angle. If this angle becomes round-ed, then the instrument has a dulledge!

The sharpness of an instrument istherefore a function of the face-to-lateral-edge-angle. The duration of this sharpnessmay be modified by the metal of which itmade, how it is used, and other factorssuch as sterilization!

Objective of Sharpening

Having described above what makes a sharp edge, the objective ofsharpening an instrument is therefore:

1. Once again create the acute angle between the face and lateral

edge2. Restore the edge to its manufactured shape (this of course

assumes it was precise to begin with)3. Do the above without excessive removal of metal

Face

Cutting

Edge

Back

Lateral Edge

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Evaluating Sharpness Contd

Visual

The sharpness of aninstrument can bedetermined by visuallyexamining the instru-ments ability to

reflect light at thesharpened edge.

Magnification is almost a must for this

evaluation! When a sharp edge exists, lightwill be not be reflected back since there is noreflecting surface.. (a strong illuminatingsource is necessary). A dull edge on the otherhand is a rounded surface (actually two ormore lines) whichhave a flat surfacecapable of reflectinglight.

Sharp EdgeNo surface area toreflect light, no visi-ble light reflection!

Dull Edge

A broad surface areamirrors back light. Appears

as a bright line or area.

Tactile Determination

1. Test Stick or Thumbnail--a sharp instrument willbite and grab into either a

thumbnail or commerciallyavailable plastic stickswhich approximate the

hardness of the nail. A dullinstrument will not grab!This is the most frequentlyused clinical method fordetermining sharpness (seenote below).

2. In Use--frequently, the finaltest is how it performs in themouth removing calculus.Dont hesitate to pronouncean instrument dull if it

doesnt perform, even ifeverything else says it issharp!

Note: One of the issues of usingthe thumbnail is the threat ofcontaminating the instrument. Ifused, instrument must be sterilizedafter sharpening!

When To Sterilize? Sterilizing does dull instruments! One of the unresolved issuesis when to sharpen the instrument. In this day and age, sterility is more importantthan sharpness. However, one can sharpen at chairside with a sterile stone!

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Sharpening Devices and General Principles

As has already been said, due to the large number of scaling instruments

available, there are an equally large number of devices and techniques available for

sharpening them. The following represents the general foundation. The specific

principles for the individual instruments will be given in the clinic.

Sharpening Stones

Natural-Quarried

These stones are naturally occurringminerals which are harder than the metalthey are sharpening. The two mostcommon from this group are theArkansas oil stone (generally a veryfine smooth surface for fine sharpening.These stones have become rare and arelikely to be comparatively expensive.)and the India oil stone ( a courser sur-face).

SyntheticThere is an almost staggering array ofman-made sharpening stones. Carborun-dum, ruby, diamond impregnated, andceramic are just a few types.

Mechanical Sharpeners

There are several mechanical sharpenersavailable on the market. Properly usedthese devices can produce excellent sharpedges. Many of these devices haveseveral different stones that can be used.

Mounted StonesMost of the materials listed under sharp-ening stones can and have been formedaround a mandrill which is inserted intothe chuck of either a lathe or dental hand-piece.

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Sharpening Methods

TextYour textbook by Carranza/Newman Clinical Periodontology, 9th edition hasan excellent presentation on sharpening pp 586-593. This should be carefullystudied.

Other

On the following pages, several scanned images from a variety of manufacturerpamphlets will be presented.

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Laboratory Scaling Exercises

Models

Retrieve the models you previously prepared. Remember, the extractedteeth are from human sources and must be treated as a biohazard! Whenev-er you touch them it is mandatory to be gloved and when you scale on the

model, you must use gloves, eye protection, and a surgical mask!

Counter-top preparation

Place either a newspaper or a section from the paper roll found in the lab onthe counter-top. Secure it with tape. Place an additional paper towel or twodown before placing the models. These papers will absorb any moisture andcan be discarded at the end of each session. These paper items need to berolled up and placed in the biohazard containers at the end of each session.The counter-top then needs to be wiped with a germicide.

Note: There is a tendency to eat

and study at the same lab space

that is used for the scalingexercises. Please be certain that

the space is asepticised before

using it for other purposes!

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Laboratory Scaling

Pre-Lab Reading

Read Chapter 41 in Clinical Periodontology. Although this is specific forthe oral cavity, the principles are the same.

General Principles for the Model

Instrument GraspUse and practice the modified pen grasp

technique. As with any new physical exercise,your fingers are likely to tire quickly until youdevelop and tone the muscles involved. Aslame as it sounds, picking up pencils, eatingutensils (this will impress your significantothers), etc on a regular basis will speed up the

process.Remember, you willbe doing this with every patient for many years

to come!

Finger RestRemember the preference for fulcrumsEven though this is a model and can beturned around, try to make this as realas possible. A proper fulcrum is part ofthe full action of grasp, finger action,and wrist movement. Each stepdepends on the others.

Preferred Fulcrum SitesWhenever possible, choosea fulcrum with the lowest

number from the following

list, since the list repre-sents decreasingstability:

# 1--Intra-oral

1--an adjacent tooth

2--cross-arch tooth3--opposite arch tooth

3--bone surface

4--finger-on-finger#2--Extra-oral sites

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Laboratory Scaling

Activating the Instrument

Adaptation, blade angulation, lateral pressure, and strokes

These are nicely covered in Clinical Periodontology 9th edition onpages 600-602. Not only are they principles of scaling, they are listedabove in the sequential order of scaling ie. Adaptation first, angulationsecond, etc. Many of the diagrams in this chapter seem to indicate a

perfect adaptation of the instrument on every tooth. This is wishfulthinking at best! However, the closer the principles are followed, the

higher the probability of success. Try to make it work!

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Laboratory Scaling

Scaling v. Root Planing

What are we trying to accomplish with scaling and root planing? The

following will show not only the orderly progression of therapy, but will also

define the various steps and indicate the end-point ie. What we want/need to

accomplish.

Periodontal

Examination

A periodontal exam is theorderly collection of clinicalinformation that defines thedegree of health/disease.Pocket depth, tissue quality/quantity, radiographs, &visual parameters arerecorded

End-Point--the collection ofdata is the aim. However,this data is used to determinetherapy and prognosis. Onecannot overvalue the im-portance of the exam!

Supragingival Scaling This is the removal ofplaque and calculus from thetooth surfaces above the gin-gival margin. Because directvision is possible, this is thestarting place for learningtechniques.

End-Point--the tooth surfac-es are free of plaque and cal-culus and are smooth andshiny as determined byvisual and contact with anexplorer. Use of prophypastes is generally part ofthe process.

Subgingival Scaling The removal of bacterialdeposits from the root surfaces

below the gingival margin.Frequently, removal ofdiseased soft-tissue is part ofthe process. No direct visionis possible, so tactile sensesneed be employed. Most diffi-cult of the cleaning procedures.

End-Point--is determinedby tactile sense since these

surfaces cannot be visual-ized ie contacting the rootsurface with an explorer.The feel is of a glassysmooth surface. Technicallydifficult to achieve!

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Basically one which has a reduced bacterial population

with reduced cytotoxins

Patients really cannot properly

clean the teeth with rough calculus

present!

Objectives of Scaling & Root Planing

1. Create a biologically acceptable rootsurface

2. Resolve inflammation3. Reduce pocket depths4. Improve the ability of the patient to

clean the teeth5. Enhance attachment of biological

structures6. Prepare the tissues for additional

procedures if needed eg surgery7. Reduce numbers and kinds of

bacteria from the oral cavity8. Give the patient a psychological

boost

Do not underestimate the systemic effect

that a diseased mouth creates! Evidenceis accumulating almost daily!

Limitations to Scaling and Root Planing1. Anatomy of the root itself2. Pocket depth--the deeper the pocket the

less effective is the procedure3. Tooth position/alignment4. Inadequate instruments--even with the

multitude of instruments available, thisis always a concern--both diagnosticand cleaning

5. Access--limited opening, small mouth,etc

6. Personal technical ability--it is im-portant to develop the highest level ofcompetence possible

7. Time/frequency--these procedures dotake time, may require multipleappointments, and may need to berepeated every few months!

The deeper the pocketthe greater the proba-bility of failure.

Waerhaug

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What is the Periodontal Root Surface Like?

Normal/Healthy

Smooth, clean, shinyenamel surface

Shallow pocket (sulcus)smooth surface

Intact periodontal fibers

Intact bone

Intact cementum

Diseased

Plaque, calculus, stain,rough surface

Dense calculus (rough)

Degenerating cementum(rough surface)

Cavitated root surface

Bone loss

Dense subgingivalcalculus (rough surface)

Deep pocket (bleeds up-on probing, instrumenta-tion, pus, tender, softtissue lining pocket isnecrotic, bad smell)

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Significance of a Smooth Root

A. The significance (necessity) of a smooth root has never been resolved. One

can find almost an equal number of research and clinical articles supporting

one as the other. The usual reasons given, with some comments, follow:

1. Smooth surface retards plaque/calculus formationbetter than arough surface. This is generally true. The issue is to what degree mustthe root surface be smooth ie glassy or smoother than was? One campindicates that the only way to determine complete calculus removal

is if the probe feels a glassy-smooth surface. The other sidequestions the need to remove so much tooth structure to make itsmooth.Probably, the answer is that a clean surface is moreimportant than a smooth surface--but how do you determine clean

with an explorer unless it is totally smooth?

2. Remove bacterial toxins. It is well known that bacterial plaqueproduces enzymes/toxins that invade the root surface and retard theregeneration of a normal soft-tissue attachment. The unresolvedquestion is to what degree does the root surface need to be planed inorder provide the most beneficial environment? Again, the answer

seems to be clean, but not excessively scraped.

B. So, what is the present and the future on this question?

1. Present--the general feeling is that the root should be clean but notexcessively scraped as in the immediate past. However, althoughtoned down, many texts continue to support the glassy-smooth root

2. Future--since the current issue requires touching the root surface withan instrument to determine the presence of calculus, better diagnosticdevices are needed. Already available are in-operatory microscopes

with high magnification. Lasers that can scan root surfaces forsmoothness already exist for research purposes. Various dyesselective for bacteria can be produced.

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Determining When Root Is Calculus Free

Visual

1. Color--frequently, necrotic root surfaces are dark in color. As they arecleaned, they approach the color of enam-el.

2. Drying--using air to dry the tooth

enhancescalculus detection3. Transillumination--the mirror can be

used to reflect light through the toothwhich highlights the dense calculus de-

posits. A strong illuminating light such asa fiberoptic, is even better!

4. Disclosing Solutions (tablets)--there areseveral dyes currently available that are specific for plaque and calculus

Tactile Clues

The dentist (hygienist) is very dependant on thesense of touch since most of the root surfacescannot be seen, but must be touched with aninstrument. It is important to develop this senseto a high level

As surfaces become calculus free, the feelbecomes similar to the feel of stroking the

instrument over enamel. Slide the explorer overmany surfaces, both smooth and rough, totrain the sense of touch. This is even more

difficult and takes more time to developbecause of the necessity of gloves.

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Auditory Clues

As root planing nears completion, there is achange in sound. This is a combination of tac-tile and auditory- hear-feel. The scratchysound (feel) which has a lower dull pitch,changes to higher pitch which does not reso-

nate as much and is therefore quieter. Scrapeenamel versus a fine emery paper.

Other Things

Sharp Instruments

There is a distinct difference in clues given about the presence orabsence of calculus from an instrument which is dull versus onethat is sharp . Dull scalers have a low resonating pitch whereasa sharp instrument glides over the surface with a higher pitch. Also,you should know that differences in blade and shank size candramatically affect the clues given. It is important to know yourinstrument, train your senses, and practice, practice, practice!

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Scaling Review

Grasp--Use the modified pengrasp.The instrument is held by thethumb and index finger with the padof the middle finger placed on theshank to control and guide movementand to prevent slipping! Fulcrum--Rest the ring finger on the

teeth whenever possible. Place it on,

adjacent to, or as near as possible to thetooth being cleaned. A dry surface canbe obtained by wiping the area with a2x2 gauze. Intra-oral rests are best!

Angulation--angulation is the blade-to-tooth relationship. When this is correct, thecalculus removal is efficient. Rememberthat when the shank connecting the blade

(terminal shank) is parallel to the long axisof the root surface, then the blade isadjusted to the proper angle to the tooth.

The design is meant to help you. Dont

defeat its purpose!

Strokes--scaling strokes must be short, even,and overlapping. Use a combination of vertical,oblique, and horizontal to ensure that all surfacesare contacted. Multiple strokes are needed to

produce a smooth surface (research indicates that20-40 strokes may be required).

TerminalShank

Angulation

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Periodontal Exam/

Risk Assessment

This exercise will be accomplished in the clinic with the exam/periodontal risk assessment performed on your lab partner. It is importantto know and understand what you are to do before entering the clinic. Anyclinical exercise should be practiced on models and/or in the mind beforetrying to apply them to a patient. This page will serve as a review.

Purpose of the Exam

To gather all possible information that will allow you to:1. Make as definitive a diagnosis as is possible before treat-

ment is instituted about the health or disease status of thepatient.

2. Make a tentative opinion about the probability of successif treatment is performed.

3. Assign an orderly sequence to the process4. Gather details that can then be relayed to the patient about

the above, plus, an indication of time needed, finances,disruption of patients daily schedule, possible discomfort,

possible consequences if treatment is not performed,possible complications, and etc.

Importance

The exam sets the entire tone for all treatment to follow. The abilityto perform the examination, to combine the data collected with

the totality of our knowledge (education), and provide the

patient with a comprehensive plan for their health is the single mostimportant difference between doctor and patient. All the rest aretechnical things which much of the population could learn and

institute.Acquire superior diagnostic skills!

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Periodontal Exam/Risk Assessment

Equipment/Materials Needed

Mirror, periodontal probe, Nabers probe, explorer (all sterilized)Instrument tray4-5 2x2 gauzesRed/blue pencilPeriodontal Charts (Use the For Clinical Use charts to gather da-

ta).Gloves, mask, eye protection, clean lab coat or scrubs

Reading Assignments (Pre-Entering Clinic)

*Module 8 of Pattison & Pattison Use of Periodontal Probes.

*Chapter 32 of Carranza / Newman Clinical Diagnosis.

Clinical Data Gathering

Gather data & do the following on your patient (lab partner), recordfindings on the Periodontal Examination Chart (For Clinical Exam)

Mark missing teeth, crowns, restorations, bridges, veneers, andimplants, broken fillings, fractured teeth, diastemas, etc.Using the red pencil, mark the position of the gingival margin onthe Perio Exam Chart. Using the blue pencil, mark the position ofthe MJG (mucogingival junction) --be accurate, since you willneed to reproduce these on the Mucogingival Examination Chartand hand both in Note: you may want to gather numerical data on theMucogingival Exam Chart & transpose it).

Using black ink, record the pocket probings, furcation measure-ments, presence of bleeding on probing (an * in the BP col-umn),and mobility.Make the chart pretty (photocopy chart and redo), hand in for

grading--both Perio and Mucogingival!

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Creighton Periodontal Chart

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Example

Patient eg. Doctoor Soon Tobee Examining student

March 22, 2000

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Example

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For Clinical Use

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For Clinical Use

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Oral Hygiene

Pre-Clinical

1. Review the section on Oral Hygiene given in Preventive Dentistry

2. Assemble the oral hygiene devices that you will need

3. Set up your clinical tray (mirror, probe, Nabers, explorer, patientmirror, etc)

Objectives

The intent of this clinic session is to help you develop patientteaching skills for oral hygiene by actually teaching your lab partner the

basics that he (she) will need to maintain a healthy mouth.

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Oral Hygiene

Device/Method Brand/Type

Show PatientList Method

Patient Demo

Brush (two types)

Brush (two methods

Floss (two types)

Floss (two methods)

Mechanical Brushes(two types)

Show on model

Hygiene AidsFloss threader

Interproximal Brush

Rubber Tip

Implant Care

Show on model

Pediatric

Patient

(two years old)

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Tuneable Ultrasonics

With

Modified Tips

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TUNEABLE ULTRASONICS

BASICS

OBJECTIVESTo understand the basic principles of tuneable ultrasonics and to initiate the use of tuneableultrasonics in various clinical conditions. At the end of this segment, the participant shouldknow and/or be able to do the following:

1. Discuss the origins of the technique2. Understand and discuss the basic mechanics of ultrasonics3. Enumerate the equipment characteristics4. Describe the advantages and disadvantages of tuneable ultrasonics v. traditional

ultrasonics and hand instruments5. Initiate preparatory procedures for tuneable ultrasonics

6. Demonstrate clinical applications7. Determine the end-point of clinical applications8. Discuss the use of ultrasonics as a clinical therapeutic tool

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Basics

BackgroundMechanical scalers have been an integral part of dentistry for decades. Thefirst commercially available device was introduced by Dentsply/Cavitron in1958. Scores of devices are currently available from a variety of manufac-turers. It is interesting to note that the first device had a variable tune(frequency) control, but that this control was or has been eliminated in fa-vor of automatic tuning. Dr Thomas Holbrook is one of the pioneers ofusing tuneable ultrasonics. His clinical application of tuneable ultrasonics

and the modification of the of tips is commonly referred to as theHolbrook Technique.

Overcoming the BiasesThe concept of using tuneable ultrasonicsand modified tips as the primary orexclusive technique for scaling and root

planing challenges many long-held dental

principals. The composition of the rootsurface, the healing of the periodontalsupport structures, and long-termmaintenance are part of a dental/hygieneschooling and clinical experience. Changecomes slowly!

Being At Peace

Whether of not the clinician uses this techniqueis likely related to being at peace with the

technique and reconciling educational and clin-ical backgrounds.

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Lets Evaluate the Concerns (Biases)

Plaque and Calculus Removal

The periodontal diseases are primarily caused by the destructive effects ofbacterial plaque. Although calculus itself does not directly cause the diseaseprocess, bacterial accumulation on the rough surface, and the retention ofendotoxins in the porous interior enhance the inflammatory sequence. There-fore, thorough removal of both plaque and calculus is essential in periodontalcontrol. Numerous studies have demonstrated that ultrasonics are co-equalwith hand instruments in plaque and calculus removal.

What About Cementum?It is thought that degenerating cementumharbors plaque and endotoxins whichperpetuates the disease process. Some haveadvocated the complete removal of remainingcementum, claiming that cementum exposed toperiodontal disease lacks an ability to regenerate.Others point out that like begets like and toovigorous removal eliminates cementum regener-ation. The clinician is trapped between these twoextremes and can only rely upon the tactile senseof smoothness to determine if cementum hasbeen removed. Recent studies indicate that ne-crotic cementum must be removed but some via-ble cementum left to regenerate this importantattachment entity. Therefore the glassy-smoothsurface advocated in hand instrumentation haslikely removed all cementum; whereas, a slightroughness, a velvety feel indicates necroticcementum remaining. Ultrasonics generallyproduces the latter surface.

ConsiderIs the glassy smooth surface what we really want?Its hard to give up long-standing clinical objectivesisnt it? But maybe they were wrong???

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OTHER THINGS

TOO SLOW

Several recent studies indicate that the end point of the cleaning procedure may be reached morerapidly with ultrasonics than with hand instruments. The multiple strokes necessary to produce theglassy surface typically desired in hand instrumentation generally take longer than achieving the end-point smoothness via ultrasonics.

PAINFULMost ultrasonic devices have no control over the frequency with which the tip moves through its arch-of-movement (tuning) and can only change the size of the arch (power). This limitation can be over-come on devices possessing a tuneable control (see explanation in video). In addition, pre-heating thewater flowing through the tip before clinical application can produce a suitable level of comfort formost clinical situations.

LOSS OF TACTILE SENSEBecause most subgingival deposits cannot be visualized, one must rely upon tactile senses to indicatewhen calculus has been removed. Standard diameter ultrasonic tips with uncontrolled vibration (non-tuneable units) do significantly reduce the tactile fee. However, with thin/modified tips and manualtuning control, tactile sensitivity is excellent! Many practitioners experienced in this technique usethe thin tips to feel irregularities on the root surface, similar to using an explorer.

ACCESSIf the clinician is at peace with the ability of ultrasonics to cleanse the tooth surfaces equal to handinstruments (noting the slight differences of tactile feel at the end-point) then a remaining issue re-lates to access. Asevere limitation of hand instrumentation is gaining access to subgingival deposits.Narrow but deep pockets, fibrotic tissue, limited mouth opening, anatomy eg. distal of terminal

molars, and furcations severely limit cleaning via hand instruments. Thin modified ultrasonic tips canreadily fit into most pockets, thus cleaning areas that are not accessible to hand instruments.

DISADVANTAGES/ADVANTAGES LIST

Better Than Hand Equal to Hand Worse Than Hand

Deep narrow pockets Everything else None to date

Thick tissue

Thin tissue

All 3rd

molars

Distal all 2nd

molars

Around C & B

AbscessesHeavy calculus

Ortho bands

Everyone in this room

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EQUIPMENT

POWER UNITWe are truly sorry, but you must have a tuneableunit for this technique! Otherwise, only a limiteduse can be achieved in ultrasonics. The unit mustbe manually tuneable! This may represent a sizeableinvestment for the dental office. With care, this unitis likely to last a practice life-time. Enhanced therapy,done faster and kinderdental intangibles?

Practice HintsInvolve the entire office in the purchase decision.* Rational for purchase* Device most appropriate* A commitment to use

* Make sure patients know about this better,quicker, kinder cleaning device.

Manufacturer Unit Cost Comments

Ultrasonic Services Inc.7126 Mullins Dr.Houston, TX 77081(800) [email protected] Fines, Pres.

800800-MUSI-25MUSI-25MPLCFlush SwitchUltra-weight Cord

$1280$1775$2145$2735$55$50

Exceptional tuning range. TheRolls Royce of ultrasonics. Evalu-ate the differences between thefoot controls.

Tony Riso Co.2641 Northeast 186 TerraceNorth Miami, FL 33180(305) [email protected]

2530 $995 Unit is tuneable, auto-tuning, andaccepts both 25 and 30k inserts.

J.H. Maliga(718) 871-1810 Microson Nice compact unit which has beenmanufactured for many years.

Parkell(800) 243-7446parkell.com

Manual/Auto TuneID595-MTAH

$599 Truly a comparative bargain. Notquite as finely tuneable as the oth-ers.

Dentsply/Cavitron(out of production)

66076

Not Available One of the originals. If you canfind one, dust it off!

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EQUIPMENT

MODIFIED TIPSThe second part of this technique is the modified tip. It can be readily demonstrated that theconventional tips are too large in diameter and have a curvature that prohibits entrance intomost clinical pockets. Therefore, a modification (either custom produced or commerciallymanufactured) is necessary. Most practitioners will find the commercial products adequate toaccomplish most of the intra-oral goals.

In order to negotiate the pockets and allow contact with the variable root-surface anatomyboth straight (universal) and R and L modifications are necessary.

*Note: When ordering the above, be sure to specify ultrathin!

**Note: Many of the above can be re-tipped at a fraction of original cost.Ask the manufacturer.

Manufacturer Tips Cost Comments

Tony Riso Co P-100P-100R, P-100LP-50 (Universal)Furcation (Ball tip)ITS (Implant titanium

scaler)

$95$100$95$130$135

For the longest of time tips wereall that Tony made. Exceptionalquality*

Ultrasonic ServicesInc.

10UH (Universal)10UHR, 10UHL20 Series

$135$145$145

Good quality that has turned toexceptional with many innova-tions.

HeFriedy Slim-Line $125 Entered into a sales deal withTony Riso to market his tip.*Caution with the plastic encasedmodel (Slim-Flow). The plasticcracks rapidly.

Custom Customized largediameter tips to very

fine tips.*

$100 Almost a lost art, but can pro-duce very delicate tips. Michele

Mooney is the master!

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EQUIPMENT

SPECIALIZED TIPSThe incredible versatility of the modified thin tips can be enhanced even more by the use ofother modifications already commercially available. More versatility, better therapy!

R&L Modifications* Excellent! for furcations* Use also inter-proximally* Try also parallel with long axis of the tooth

with the outside curve against the tooth fpran enhanced ability to clean sub-gingivally.

Note: R&Ls generally require less tuning thanuniversals, so tune it down!

Calibrated Tips (Far Left Above)Some manufacturers are making tips with eitherWilliams or Marquis markings. Great idea, but

a combination of ultrasonic vibration and sterilizationsoon remove the paint!

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SPECIALIZED TIPS CONTD

Tip With Ball At End (Far right in photo)(Furcation Tips)

Designed for furcations (excellent) but hasmany other uses.Try it in the following places:

-Distal of molars

-Mesial fluting on maxillary 1stbicuspid-Generalized stain removal

-Other

Implant Tip (Middle tip-photo at left)A neoprene (plastic) tip was developed byTony Riso for use with implants. It will cleanthe visible supra-structure better than anydevice. It is exceedingly kind to the titaniumsurface and cleans quickly. Requires ITSinsert from Tony Riso.Bailey,GM et al. Implant Surface Altera-

tions From a Non-Metallic Ultrasonic Tip.

Periodontal Abstracts 46:69.

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MAGNIFICATION

Want to improve your role as a therapist?Magnification is more likely to fill thatrole for an experienced hygienist thananything else. It is truly astounding whatan enlarged view are can reveal.

Type Advantages Disadvantages Availability Cost

Clip-on ReadingGlasses

Least Costly Requires eyeglass frame

Eye-to-object distance fre-quently requires user tobend the head downward.

Gadjet stores, catalogues

such as Sharper Image,Brookstone, Skymall, etc..

Pharmacy/optical section atWalmart, K-Mart, many localstores

$18-36

Optical Customizable for eye-to-object distance

Can maintain good skele-tal posture

Excellent optics which

enhance light gathering(make oral cavity less ofa dark hole and less eye-strain)

Multiple magnificationavailable

Can be outfitted withlight source

Cost

Tend to be heavy but newmaterials have helped fixedmagnification

$800-1,500

Microscope Multiple magnification

Excellent light source

Cost

Large, bulky arms

A major equipment pur-chase

Global(303)306-9826

Skyler

$8,000-25,000

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REALITY CHECK

1. Usually requires 6 months to become use to and use magnification properly.

2. Be positive!

3. Try for short periods initially.

4. Tell the patient what you are doing and why. Everyone is impressed with

better therapy.

5.

1) Clip-On Reading Glasses

This is a good starting point.See if this is for you!

2) OpticalOther than cost, this is probablywhere you want to be. Considera 2.0X magnification.Easier tolearn and control.

3) MicroscopeFor the future, a surgical microscopewill be as common in the dental officeas a panoramic machine!

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MECHANICS (PHYSICS) OF ULTRASONICSAn understanding of the basics of ultrasonics mechanics helps the practitioner utilize the devices(power source and tips) to a clinical advantage. A detailed discussion is not possible in this article

and, due to brevity, there are some over-simplifications.

POWER (AMPLITUDE)In terms of ultrasonics, power refers to amplitude,defined as the arc-of-movement of the tip. Thismovement is 3-dimensional and so a definable3-dimensional image is produced. The size ofthis form is determined by the power (amplitude)allowed to act on the tip. More power producesa greater tip movement (faster cleaning but morepatient discomfort); whereas, less power producesthe opposite effect in both cleaning efficiency and

comfort.

TUNE (FREQUENCY)The tune knob controls the movement per unit time that the tip moves within the boundaries largelyset by the power control. This movement time is called frequency. In addition to the oscillations/timecontrolled by the tune control, the movement of the tip is further defined by phasing, basically har-monics. When successive mechanical tip movements (waves) are coordinated, we refer to this as be-

ing in phase. The clinical cleaning is highly efficient but the patient discomfort may be high. Whenthe tip movements are out-of-phase, detuned, then cleaning is less efficient but with comfort beinghigh.

TIPS

The general mechanics are as previously described. In addition, there are many characteristics of thetip itself which alter the movement patterns and intensity. The diameter, length, arc-of-curvature, andthe metallic composition all affect the tip movements. Thus, an alteration of any tip characteristicswill change cleaning abilities and/or patient comfort. Each tip needs to be individually tuned to ac-complish the clinical goals.

CLINICAL USE OF ULTRASONIC PHYSICS-Arc-Of-MovementMost tuneable ultrasonic units and associated modified tips produce a 3-dimensional elliptical patternwhen activated. Because of this 3-dimensional movement, the entire circumference of the tip (all sur-faces) as well as much of the tips length can be used for cleaning. This enhances the versatility ofthe ultrasonic, allowing the various surfaces of the tip to contact the anatomical surfaces of the rootstructure.

TUNINGDetuning (out-of-phase adjustment of the tune control) lessens vibrations which often confuses(concerns) the practitioner as to the cleaning ability. Relying upon the discussion above, alternationsin frequency (tuning) decrease the arc of movement but may actually increase the movement in thisarc. These vibrations do not have the high auditory pitch or clanking of the tip the practitioner as-sociates with power, but do have a high cleaning ability.

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PRE-CLINICAL PREPARATIONThere are very few clinical contraindications for the proper use of the modified ultrasonics.

Occasionally, concern has been expressed about the following:

Clearing Stagnant H0/Trapped Air - One of the misconceptions about ultra-sonic use suggests that water be run through the unit before placing the insert. Donot do this! The unit can be damaged quickly.

Place insert in sheath

Power at lowest letting

Activate root control until H0 flows freely with no air

PacemakersPacemakers produced in the past were sensitive to any electro-

magnetic variations. Current generation pacemakers appear to be little affected bydental ultrasonic cleaners. The major pacemaker manufacturers indicate in theirpatient education literature that dental ultrasonic probes (scalers) are unlikelyto interfere with your pacemakers. Since the electromagnetic intensity is high in

the cord from the unit to the tip, one should avoid draping the cord directly overthe chest area.

Warming the H0Although the dental delivery system may have self-contained water heaters, the water issuing from the ultrasonic tip can be warmedfurther by the methods indicated in the video. Patient comfort is often more relat-ed to the water temperature than to the tip vibrations.

Ultrasonic Tip ExaminationThe thin modified tips should be occasionallyexamined for nicks or wear since both can alter clinical efficiency. The externalwater tube should be 1mm off the tips surface. Damping of the vibrations willoccur (decreasing cleaning efficiency) if the water tubing contacts the tip. Damp-ing also occurs if the knurls which hold the tip and water tube in position areloose. These should be firmly tightened.

Note: With proper care, your power unitshould last many years. The tips will needto be re-tipped (not replaced) approximatelyevery 2 years.

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CLINICAL APPLICATIONS

PREPATORY PROCEDURES

ON/OFF

Turn the unit power on.With most units, it is important to turn the unit offwhen not in direct clinical use!

INSERT/HANDPIECEPlace the tip into the handpiece with an inwardtwisting motion. Contrary to traditional instructions,water should not be run through the handpiece, without

an insert in place. Ultrasonics is such that even shortactivation of the foot control can produce significantdamage to the handpiece.

FOOT CONTROLThe foot control should be placed in a position whichis ergonomically comfortable. Activate the foot controlso that enough water flows to eliminate any line debrisor trapped air.

Note: Although the weight of thecord is minimal, the increased weightdrag of the cord over time can becomesignificant. Consider buying a soft,light cord.

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ADJUSTING H20 FLOW/H20 WARMTH

Power to maximumEngage foot control

Detune (adjust the tune knob so that the tip vibration is at a minimum

Increase H20 flow at the tip so that when the tip is horizontal and pointedupward, there is approximately a 1 water stream from the tip

Continue until the H20 is warm to the touch

Keeping a horizontal position turn the tip so it points downward

Turn power to minimum

Turn tune until tip just vibrates (creates a light mist with a rapid H20 drip)

Maintain H20 stream

What Are We Doing?

Energy to the handpiece butwithout vibration = Heat

Why?

To warm the

H2O so it is comfortable

Note: Be certain H2O conduitis centered over the tip and

within 1mm of contacting thetip!

Note: The above proceduremust be repeated at each

change of tip!

Power to maximum!

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WATER CONTROL

One of the supposed disadvantages of ultrasonics

is the need to use water. Some have suggested thatit is too annoying to the patient to use on a regularbasis. The advantages of a wash field are significant.The best way to control water in the oral cavity is byexperimentation. See Michele Mooneys suggestionsin the section under Hygiene in the video TuneableUltrasonics with Modified Tips. (CPSeminars)Be position and caring!

WATER

Flushes away organic debris, toxins,and blood.Enhanced Therapy!

Provides a clear, viewable area.En-hanced Therapy!

Helps reach end-point more quickly.Enhanced Therapy!

Less post-procedure pain.EnhancedTherapy!

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THE DEBRIDEMENT PROCESS1. At the settings previously determined, orient the

tip parallel with the long axis of the tooth surfaceand touch the side of the tip to an area ofnon-sensitive enamel.

2. Adjust the tuning until plaque and calculus can beremoved, but is still comfortable for the patient(not the power, which should remain at minimum!).

3. Continue to adjust tuning as needed for debridementand for patient comfort.

Note: Even with no deliberate changes,occasional slight changes in tuning arenecessary to maintain cleaning efficiency.

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DEBRIDEMENT CONTINUED

Initial Continuing Light Calculus Moderate Calculus Heavy Calculus

Power Lowest Lowest Lowest

Tune Minimal, can just Moderate, can feel, High (tuned), feel, hear,barely feel, no hear, and see light visual H20 sprayauditory mist (rooster tail)

H20 Copious Copious Copious

Tip Orientation Parallel to long axis Same Sameof tooth

Tip Movement on Occlusal-to-apical Same SameTooth and circumferential

Contacts all areasof crown and root-that are accessible

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TIP/TOOTH RELATIONSHIP

To understand which portion of the tip to use, consider the tip as a straight rod to which en-

ergy has been applied.

In this illustration, there is equal movement along the length of the rod, but a concentrationof energy at the end.

If the straight rod is bent to the shape of auniversal ultrasonic tip, high energy remainsat the end and is also concentrated on the insidecurve.

This knowledge can help determine whichMost-To-Least Energy portion of the tip is in contact with the tooth.Tip Movement However, there is a reciprocal relationship* Tip of insert between energy (cleaning ability) and* Inside curve comfort (discomfort) ie, as one goes up,* Lateral surfaces the other goes down.* Back (outside curve)

Note I: Although the foregoing is true Note II: Rarely should the end of the tip be applied toin physics, frequently the clinician cannot the tooth, too much energy which hurts and can damageapply the best energy surface of the tip to the tooth.

the tooth because of anatomy, ie toothposition, gingiva, access, etc Note III: The most efficient and yet most comfortable

part of the tip to contact the tooth is the lateral borderat the anterior portion of the tip, approximately 2mmbehind the end.

CPSeminars

Energy

Energy concentratedat the tip!

ConcentratedEnergy

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ADVANCED ULTRASONICS


Objectives

To provide clinically useable information in the following situations:

1. Use in advanced periodontitis cases

2. Use in soft-tissue curettage

3. Incorporating ultrasonics, soft-tissue curettage, and anti-microbials(Ultrasonic Bacterial CurettageUBC)

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THE TOUGH PERIO CASE

Now that you are feeling more comfortable with your abilities and the capabilities of tunea-ble ultrasonics, it is time to consider the advanced periodontal case. The good news is thateverything you have learned to this point does apply. The bad news is that the skill level justtook a quantum leap.

The main difference between the recall

case and the advanced perio case is that

we must concentrate more on the therapy

while advancing our skills of technique.

Recall Patient Advanced Perio Patient

Power Setting At lowest point Usually at lowest point

Tuning Low Frequently fully tuned

Tips Universal R&L ultrathin Same

H20 As much as can control As much as can control (high

volume important to flush thepockets)

Anesthetic Generally not Usually required

Magnification Important Approaching mandatory

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INITIAL

Start calculus removal at the coronal end of the pocket (contrast this with hand instrumenta-tion which starts at the apical end) and at the tooth-to-calculus interface. This most common-ly allows the removal of large calculus chunks and speeds up the process. Proceed slowlytoward the pocket apex with multiple, slow (gentle pressure), sweeping movements.

Frequently described as an erasuremotion, the tip should contact the entiresurface of the tooth.

With the universal tip, most tip-to-tooth contact is parallel to the long-axis of the root. Resist

the urge to increase the power or to tune the tip too high. A tip with too much energy produc-es erratic movements and actually decreases the efficiency.

USE OF R & L MODIFICATIONS

Remove all the deposits possible with the universal tip before changing to the R & L tips.The R & Ls can add more efficient cleaning in furcations, inter-proximal areas, and distalmolar areas. The tip-to-tooth angle of R & Lsis likely to be perpendicular to the root surface asoften as parallel. The energy efficiency of the

R & Ls frequently requires de-tuning lower than Note: Remember that every surface ofwith the universals. the tip can be used for cleaninglikehaving many instruments in one.

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CLINICAL TIP

Talk positively about the process. Talk abouthow it is quicker, kinder, and more efficient.Present it as new technology. Patientsrespond well to this approach. Toothscraping has been considered by most asun-fun.

CLINICAL TIP

Pain Control/Practice AdministrationTry thisgive an analgesic (either OTC orprescription) 1 hour before or in the chair.Most research indicates it is easier to

prevent pain than play catch-up. See if thisisnt a positive idea.

Gatt, et al

AM J Sport Med 1998

July-Aug 26(4):524-9.

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TUNEABLE ULTRASONICSSOFT-TISSUE CURETTAGE

Therapy v. Cleaning

The dominantaim of hygiene is to clean the tooth. There is an infinite number of articleswhich demonstrate the therapeutic benefits of removing necrotic cementum and calculusfrom the root surfaces. Hygiene education keys in heavily on training hygienists to cleanthe tooth. As important as this process is, it is only a part of therapy.

The health of the soft-tissue has largely beenattributed to cleaning the disease off the root

(tooth) surface. However, many cases demandmore attention to the infection within the soft-tissue that cannot be eliminated solely bycleaning the tooth orresolution is just too slow.This is the role of soft-tissue curettage.

Therapy(thara pe)

[G. therapeia]The treatment of disease or disorderby various methods.

Stedmans Medical Dictionary

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CURETTAGEA REVIEW

Each practitioner needs to develop (in many cases re-develop) an appreciation for thebenefits of curetting soft-tissues. As

one of the least utilized and yet most mounting research indicates that the numberbeneficial therapeutic methods available of pathogens which actively invade theto the practitioner, is soft-tissue curettage. soft-tissue is increasing, we need to focusThese benefits were first downgraded by more on therapies which will remove theseresearch of suspect quality, adopted by pathogens from the soft-tissues. A list of]the insurance industry as unnecessary potential benefits follows:therapies, and almost eliminated byeducational institutions.CPSeminars

Benefits of Soft-Tissue Curettage

Reduce overall healing time Higher probability of new or re-attachment Elimination of pathogens from soft-tissue Removal of necrotic tissues De-epithelialization of pocket Rapid elimination of abscesses Decreased pain Elimination of caclulus shards in tissue Better access for root cleaning

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ULTRASONICS IN CURETTAGE

Many are surprised to find that the tip in an ultrasonic device is an effective curette. Hereto-fore most applications of ultrasonics have been applied to cleaning the tooth and root surfac-es. There are even a few advantages to the ultrasonic tip over the conventional hand instru-ment. The following discusses the ultrasonic as a soft-tissue cruet:

Hand Curette Ultrasonic as Curette

1. Instrument Shape By using the outside curve of the ultrasonic tipa constant shape is applied to the soft-tissuewall minimizing soft-tissue perforations andallowing uniform tissue removal.

2. Constant Vibration The frequency is constant so that cuttingforces produce uniform soft-tissue removal.

3. Irrigation The constant fluid flow flushes out the pocketto remove tissue, calculus, bacterial products,and enhances visibility.

4. Superior Tactile Sensations The ultrasonic actually enhances tactile feelover hand instrumentation.

5. Highly Variable Frequency can be changed to remove tissue ofvarying density.

6. Decreased Hemorrhage Uniform cutting and copious irrigationdecrease overall bleeding and post-op pain

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ULTRASONIC CURETTAGETECHNIQUES

Soft-tissue curettage is usually a procedure that isaccomplished at the same time as root-surface Curettagedebridement. This frees the patient from two Sub-gingival curettage refersseparate procedures andoffers a better overall to scraping of the inner surfacehealing result. of the gingival wall of the

periodontal pocket to clean out,separate, and remove diseasedsoft-tissue.

Glossary of TermsJ Periodontal (suppl) 48:1,1977

Ultrasonics can be used for both procedures where the following describes the technique forsoft-tissue curettage:

Instruments

Note: Curettage with a mechanicaldevice is restricted exclusively toultrasonics. Subsonic devices have

a frequency that is too low to performsoft-tissue curettage.

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SOFT-TISSUE CURETTAGE

CHECK LIST

Armamentarium * Power at lower setting

* Tuning at moderate intensity

* H20 at copious level

* Tubing/hand-piece balanced

* Otherdevice readily available for tuningchanges

Tips * Universal

* R & L

* All in good working order

Clinical Application * Anesthetic

* Clean tooth first

* Apply outside curve of tip to inner lining ofpocket

* Gentle pressure to a free finger to outsidesurface of pocket

* Gentle sweeping motion of tip

End Point * Pocket wall removed

* Root surface clean

Post-Op * Hemorrhage control with 2x2 gauze anddigital pressure

* Patient institutes oral hygiene same day

* Appropriate analgesics

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The foregoing represents one of the fastest ways to resolve highly inflamedpockets and abscesses. It combines the therapeutic effects of debridement

(scaling) with the removal of the diseased inner soft-tissue wall and thoroughirrigation of the pocket to eliminate unattached bacteria, calculus, plaque, andimmune response by-products.

Clinical Tip

In a chronic case, epithelium generally lines thepocket wall and inhibits healing. Try removingthis inner wall with ultrasonic curettage for betterpocket resolution.

Note: Higher tuning is frequently needed.

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ULTRASONIC BACTERIAL CURETTAGE

(UBC)There are several solutions which have demonstrated anti-plaque activity. Using one of thesesolutions rather than water as the ultrasonic irrigant may enhance the overall results. Thestandard for oral rinses are chlorhexidine (CHX) based compounds. Most research showsthat CHX is significantly superior to other products in anti-bacterial activity. Therefore, itappears that CHX is the fluid of choice to replace water in the ultrasonic unit.

Part of the better resolution of CHX v. H20CHX irrigation resulted in a is undoubtedly due to CHX and its anti-significant reduction in CPD than bacterial activity. An under-investigateddid H20 among sites initially probing area is whether CHX is a better conductor4-6mm of cavitation waves than those produced

by H20 alone ie the cavitation activity mayReynolds. J Clin Periodontal be enhancedby the addition of CHX (see1992 Sept; 19(8):595-600 research of Walmsley, AD), who has

extensively studied ultrasonics.

It may be concluded that cavitationalactivity within the cooling water supplyof the ultrasonic scaler results in a super-ficial removal of root surface constituents.

Walmsley. J Clin Periodontal 1990May;17(5):306-312.

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COMPARISON OF CHX V. H20As Irrigant in Ultrasonic Debridement

H20 Chlorhexidine --CHX

Availability/Cost Readily/Low Limited/Moderate

Taste None Metallic/slightly objectionable

Effect on Units None * May harm some units

* Residual in units

Patient Acceptance High Low-requires prior explanations

Therapeutic Effects Moderate High

As usage of ultrasonic debridement increases, there will be increased research into theprecise role of irrigants other than water. For the moment, the major therapeutic effect ofCHX is in highly inflamed pockets of moderate-severe depth and in obvious abscesses.

Necrotic wall ofinflamed pocket

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Polish/Stain Removal

Introduction

Polishing the visible tooth structure is variously called polishing, oral

prophylaxis, dental prophylaxis, coronal polishing (prophylaxis), or fre-quently, just prophy. These are synonymous terms which invariably

mean the same thing.

Why Polish?

Aesthetics

We live in a world where people areincreasingly more conscious about

their appearance--both as how theyappear to themselves & their percep-tion of how they appear to others! Aprobable very small minority trulydont care how they look or are

perceived. The patient who says Ireally dont care how my teeth look,

is highly likely to be concerned abouta spot of dark stain left on a toothafter the polishing process. Mostpaying customers expect glistening

white teeth after a dental visit!

Therapeutic Benefits of Polishing

The polishing agents used have theability to remove dental plaque as well

as stain. This removal is a part oftherapy! Elimination of bacterial plaquefrom tooth surfaces (and hence from theoral cavity) is a oral health maintenancenecessity!

Selective Coronal PolishingSome advocate only polishing thosetooth surfaces which have stain or vis-ible plaque. They cite studies whichshow a few microns of fluoride rich

enamel are removed with each prophy.Since plaque is frequently a microscopicentity and not easily seen and sincebacteria seed other intra-oral sites, thecomplete removal is the desired goal. F2can be replenished by topical application

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Polishing/Stain Removal

Materials

As with most high-use items indentistry, there are many different

prophylaxis pastes and prophyangles commercially available.The photo at the right shows anextremely small sample. Moreand more, sealed, single-use itemsare becoming the standard.

Polishing Procedure

1. Set up the operatory in anOSHA approved manner. Both doctor and patient should be protected.

2. Attach the slow speed handpiece to the dental tubing3. Attach the prophy angle to the handpiece (for this exercise we will use

the disposable angle)4. Attach the rubber cup to the prophy angle5. Dip the rubber cup into the prophy paste and fill the interior of the

rubber cup with paste6. Contact the tooth and engage the foot control so that the cup rotates at a

slow speed7. Keep the prophy cup moving against the tooth with light, intermittent

pressure (lowest speed possible without stalling)8. Contact the entire supragingival tooth surface. Surface should be shiny

and free of plaque.Note: Keep the rubber cup full of paste. It is theabrasive paste that cleans! An empty cup tends to overheat the tooth.

9. Subgingival--gently slip the edge of the rubber cup under the gingivalmargin while cup is rotating.

10.Interproximal--the flexible cup can be eased into the contact area11. Thoroughly rinse abrasive out of the mouth with water12.Fluoride--replenish the loss of surface F2by topically applying fluoride

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Apply slight pressure against tooth to flare the

cup,allowing the edge to slip under the gingivaSlight

Polish/Stain Removal

Different types of webbing in cup.Meant to retain the abrasive

Gentle, but thorough!

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Ergonomics and the Dental Therapist

Er.go.nom.ics (r'g-nmks)[


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Ergonomics

Hearing Protection--Huh?The constant high pitched whine of thedental handpiece, the high decibel rating ofthe high speed evacuator, and the nearlyimperceptible sound of the ultrasonicscaler, in a small enclosed room, allcontribute to potential hearing loss. Studiesdo indicate that dentists and hygienists areat risk for hearing loss--beyond that of thegeneral population.Hearing can be

protected by wearingsmall in-the-eardevices. Huh?

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Ergonomics

Protecting the Musculoskeletal System

Man was not meant to walk upright. Heard that one before? With all the back prob-lems present, it almost sounds like a truism. Dentists/dental hygienists spend muchtime in positions which are strenuous on the musculoskeletal system. Proper postureand proper support while seated are essential. You must take care of this body systemor it will rapidly become a plague in your practice life! Proper equipment and properuse of that equipment will minimize problems. Consider the following:

Using the Proper Equipment Properly

Feet flat on the floorEqual pressure on chair

Small of back supported

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Ergonomics

Oh, the poor body!

Great Footwork!But what is it doing tothe bod? Next time youare in a dental office,

quietly note the footpositions. Anything oth-er than flat on the flooris torquing the skeletalsystem. Dont believe

that you do it? See whathappens the next timeyou get under stress!

The Slouch

Flying Nun

Note: All of us do strange things when we areoperating fr

manual periodontal instrumentation bailey1

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