Manual Periodontal Instrumentation Bailey1

Periodontal Instrumentation
Introduction
George M Bailey,DDS Creighton School of Dentistry/ University of Utah
Table of Contents
Course Objectives 4 Schedule 5 Instrument List 6 Asepsis 7 Models 8 Instruments 10 Holding Instruments 18 Sharpening 20 Scaling on Models 27 Scaling v. Root Planing Exam/Risk Assessment Oral Hygiene 46 Tuneable Ultrasonics48 Advanced Ultrasonics Polish/Stain 80 Ergonomics 83 Scaling on Patients 88 Philosophy of Treatment
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Objectives--Periodontal Instrumentation
Periodontal instrumentation 132 is a pre-clinical course for the periodontal courses which will follow in the sophomore year, both clinical 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 (your lab partner, not dental patients). How well you learn these base principles is likely to determine your performance in the advanced courses to follow. Every effort will be expended to treat you as the doctor you will become. You will be treated with dignity, as a scholar trying to learn the principles and acquire the skills necessary to treat your patients-to-be at the level they deserve and demand and with the loving care they need. In return you will be expected to honor the subject matter as important and use your personal skills and intellectual abilities to learn and gain an appreciation for dentistry as a profession. The above will be accomplished in an environment which represents current thought, modern techniques, and consistent with the scientific method. Because the best type of learning comes when there is interest and enjoyment, 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 instruments you might acquire for your office. 2. Have basic periodontal diagnostic abilities and how to perform oral 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 Bailey Time: 8:00-11:50am Mondays Texts: Carrenza, Clinical Periodontology, 9th ed. Harris, Primary Preventive Dentistry, 6th ed. Bailey, G.M., Introduction to Perio Instrumentation Pattison/Pattison, Periodontal Instrumentation
Date Pre-Class Session Pre-Class Topic Intro-Lab Prep Asepsis Carrenza Ch. 36 Bailey et al Bailey 7-10 Module 24 (handout) Video-Christensen Video-Modified Ultrasonics Bailey/Moody Bailey 49-80 Module 21 (handout) Get a Tan
March 6 March 13 March 20
Lecture Spring Break
Mechanical Scal- Ch. 43 ers Party Have Fun
Clinical@Dr. B Ultrasonics Office Lecture Risk Assess-Perio Ch. 4 & 32 Bailey 38-46 Oral Exam pp. 451-452 Module 1&2-Pattison Instruments Oral Hygiene Harris Ch. 5-7 Prophylaxis Module V-Pattison Bailey 81-83 Harris Ch. 9 Fluoride Pre-Clinic Bailey 81-106 Risk Assessment Oral Hygiene Prophylaxis Fluoride Hand Instrumentation Lab-Sharpening Patients Module III-Pattison Module IV-Pattison
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March 27
April 3
Clinic
April 10
Lecture
April 17 April 26?
Clinic
Comprehensive Observation Final Report Due
Creighton University School of Dentistry Freshman 2004-2005 Instrument List

Periodontics Instruments Item
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Other
Unit
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
Description
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 Pathogens Standards, as it relates to dentistry. OSHA is that governmental agency which seeks to protect workers (employees) from hazardous work conditions. These are regulations imposed on the employer and carry the weight of law. Although technically the doctor (employer) is not bound personally by the regulations, by convention, the doctor is now assumed to be also bound by the same regulations as his (her) employees. It is assumed that the doctor will be compliant! The full document is fairly complex (as per usual with government things) with practice procedures, record keeping, and employee notification provisions being spelled out. As a doctor (employer) you will need to know and practice these principles. As relates to your position as dental students, the following will rigidly apply: Personal Protection
This refers to those practices employed to protect oneself from infectious contamination. Whenever one is in contact with a patient or body parts or fluids from another person, the dental student must: Wear gloves Patient Protection Wear a high filtration mask Sterilized instruments/devices Wear protective eye-ware Protective eye-ware Wear protective clothing An aseptic environment Employ frequent hand-washing Vaccinations (although not mandated, this is a near standard)
Note: A current video demonstrating these and other procedures

will 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 clinical practice. Therefore, prepare the model with care. The following will be necessary: An Arch of Extracted Teeth To qualify, the teeth must meet the following requirements: 1. Epithelial attachment migration--this can be determined because the remnants of the attachment fibers (softtissue) are still attached to the tooth 2. Subgingival calculus--a minimum of 5mm past the CEJ; calculus need not completely encircle the tooth in ringlike formation, but could exist as spiny nodules, fingerprojections, individual calculus islands or thin, smooth veneers. 3. Soft necrotic cementum (desirable, but difficult to find on extracted teeth). 4. Preferential selection should be given to upper first bicuspids because of their predisposition to retain calculus in the mesial marginal grove and to molars with furcation involvement. 5. A full-half arch--in order to make this model meaningful, a half arch (central incisor thru 2nd molar) is necessary
Technique Models
Making the Model

1. Make several retentive grooves in the root structure with a bur or disc, and /or drill a small hole at the apex of the root which will allow a paper-clip or wire to be inserted through the root. There are other methods, but the intent is to provide firm anchorage of the tooth into the plaster (stone) pour. Since considerable pressure will be put on the teeth during the scaling exercises, it is important to have the teeth firmly anchored. 2. Arrange the teeth in a natural arch form, with the teeth touching in a normal marginal ridge-to-ridge relationship (lute the teeth with wax). Using boxing wax , make a form the shape of the maxillary arch, about 2 inches deep. Suspend the luted arch of teeth so that the stone pour will cover only the roots (leave at least 6 mm of root uncovered by the stone). Allow stone to set at least 2 hours before removing the boxing wax--trim the model. 3. Keep the teeth moist--either submerge the crowns/roots in water or cover with glycerin. Do not let the water or glycerin contact the stone--it will weaken it and cause the teeth to fall out!
Paper Clip
6mm
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--Handle
Handles come in many sizes and configurations. It is well to try a variety before you make your final purchase for the office. Some things to consider: 1. Size-the instrument should be comfortable in your hand. 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 prefer a 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 End
The part that actually does the work and which is in contact with the tooth. The name of the instrument is usually derived from this part eg. probe. With periodontal cleaning instruments, this is called the blade.
C--Shank
Note: It is important to learn the above terms. This is how professionals communicate! The thin segment that joins the handle to the working end. The shape of the shank determines which area of the mouth the instrument was designed for ie. because of its shape, the Gracey 11/12 best fits in the posterior areas!
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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 diagnostic/screening tool for periodontal diseases by performing measurements. Therefore, 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 of diameter and markings.
Marquis
UNC
WHO
Williams dia WHO mark. marks @3.5, 8.5,11.5,and .05 ball @ end
Marquis diameter Mich O diameter Mich O diameter Mich O diameter Marquis marks Williams marks Williams marks Mich O marking 3mm spaced areas 1mm marks with @1mm with marks@3,5,7mm bands@ 5,10,15 space @ 3-5mm
Good diameter,hard to read markings with accuracy! Good diameter and easy to read! Good diameter, easy to read!
Good diameter, Large diameter Screening Probes! 11
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. #1N #2N
May have markings
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. Plastic probe with a pressure sensor
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Explorers
The 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 to the tooth with a very light touch since it is the very fine tip that is the detection tool. Pressing too hard on the instrument decreases the tactile sense. Explorer tips may be made of stainless steel, carbon steel, or an alloy, all with claims of superiority. See what works for you! Each periodontal instrument tray should have an explorer or two. Clinical Tip When using an explorer in a clinical setting to detect calculus use 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 flat plane mirror which reflects a double image, one on the apparent surface of the mirror and another that appears within the substance of the mirror. This type of mirror is difficult to use clinically because of the double images.
Image #1 Image #2
Smart Practice
Front Surface(Concave)--the most common type of mirror used. Gives a single, same-size image. As used in the mouth, the image is reversed. Practice is needed to use any mirror! There are many diameters available, with the #5 being the most common.
Concave--as with other mirrors and lenses, the concave shape produces a magnified image. The production of a magnified image and its usefulness is obvious.
Clinical Tip--to minimize mirror fogging, warm mirror surface against the patients alveolar mucosa of the cheek!
Other--there are many different shapes and mirror types available including double-sided mirrors which allow indirect vision and retraction at the same time.
Smart Practice
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Scaling/Root Planing Instruments

The numbers and types of hand instruments used for cleaning teeth probably exceeds 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 different 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.
Curette
General Definition General use is for subgingival cleaning.Has a tendency to be delicate (however, many variants)
Shank Cutting Edge Examples Highly variable Generally round- Gracey Series in diameter & ed #1/2,11/12,13/14 angulations. A tendency to be for use in a specific area! 60-70 shank-to-blade angle.
Most are pointed H-6/H-7 Straight sickle scaler
Scaler
Targeted mostly for Not as variable as supragingival areas the curette Generally heavier shank/cutting edge than curette
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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. However, 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 automatically 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 surfaces of all teeth in the mouth. The practical reality 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 (as viewed in cross section with the tip of the instrument pointed towards you) have a 90 shank-to-blade relationship.
Shank 90 Blade Also, universals have two cutting edges & are curved in one direction from head to toe of the blade!
Area-Specific Curettes
Originally designed by Dr Clayton Gracey in the 1930s, the Gracey curettes are the most noted area-specific curette series. These instruments are usually double-ended, but have only one cutting edge per end. The numbering system identifies the recommended use sites (see table on following page). The shank-to-blade relationship is an offset orientation of 60-70. This allows the blade to contact the tooth at the proper angle provided the shank is parallel to the long axis of the tooth! Unlike universals, the blade is curved in two directions
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Gracey Series Curettes

Instrument 1/2 3/4 5/6 7/8 9/10 11/12 13/14 15/16 Where Used Anterior areas Anterior areas Anterior and premolars Posterior facial & lingual Posterior facial & lingual Posterior-mesial areas
Posterior-distal areas
Note: As a general rule, the low numbers are for the anterior and the higher numbers are progressively for the posterior areas!
Posterior-mesial areas
Modifications of Standard Gracey

Blade Shape--Universal v. Area Specific Universal Curved only in one direction from the head to toe ie toe (tip) is curved slightly upward! Extended Shank Designed for deeper pockets After Five series Small Bladed Blades are 1/2 size Mini-Five Curvettes Shank Differences Rigid Flex
Tip
Head
Area-Specific
Lateral
Blade is curved in two directions--tipshank & left-right (lateral edges)
Note: Best way to determine the blade Differences, how to insert the instrument into the pocket, and which edge to sharpen--point toe of instrument towards you! 17
Tip
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, holding them differently may negate their design and effectiveness. 2. Stability--holding periodontal hand instruments in a stable, defined relationship 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 to remove stubborn, dense calculus, or requires controlled, delicate motions so as not to damage delicate tissues eg. probing. There are three basic grips: pen grasp, modified pen grasp, and palm-thumb grasp!
Note: Index bent at 2nd joint Extended middle finger

Pad far down the shank
Ring finger along side

Supports middle finger
Pen Grasp Is the same as holding a pen for writing (is presented as a comparison and is rarely used!
Modified Pen Grasp The most common way to hold dental instruments-most stable, controlled grasp. Palm-Thumb Grasp If used, generally to hold an instrument 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 Principles 1. 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 Sites Whenever possible, choose a fulcrum with the lowest number from the following list, since the list represents decreasing stability: # 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 precise and efficient manner with dull instruments.
Tactile sensitivity is reduced, because a dull instrument must be held more firmly and pressed against the tooth harder than a sharp instrument A dull blade crushes the calculus rather than removing it, leaving smoothed-over calculus which is then more difficult to detect and remove. This is called burnishing- a false sense of removal!
*The Heavy Handed Clinician--scaling does require firm lateral pressures. A dull instrument demands more pressure which increases patient discomfort (a dental euphemism for pain)! In addition, more pressure increases the possibility of slipping and lacerating dental tissues.
*A Time Waster--dull instruments

simply require more strokes to reach the end-point(a dental term used to describe when the final objective has been met). The scaling end-point is when the calculus has been removed and a smooth root surface created. Instrument sharpening is truly an art and a skill. It is not easily learned in a single session but requires working with many techniques and a variety of instruments. The benefits of a sharp instrument which was meant to be sharp are enormous. Keep at it!
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Evaluating Sharpness Obviously, the first step is to recognize when an instrument is both dull and sharp. Both can be accomplished by the same methods, but may be the opposite of each other. It is important to first understand what makes a sharp edge.
Face Cutting Edge Back
Lateral Edge
On a curette, a sharp edge is formed when the face intersects the lateral edge producing a very fine acute angle. If this angle becomes rounded, then the instrument has a dull edge!
The sharpness of an instrument is therefore a function of the face-to-lateraledge-angle. The duration of this sharpness may be modified by the metal of which it made, how it is used, and other factors such as sterilization! Objective of Sharpening Having described above what makes a sharp edge, the objective of sharpening an instrument is therefore: 1. Once again create the acute angle between the face and lateral edge 2. 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
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Evaluating Sharpness Contd

Visual The sharpness of an instrument can be determined by visually examining the instruments ability to reflect light at the sharpened edge. Magnification is almost a must for this evaluation! When a sharp edge exists, light will be not be reflected back since there is no reflecting surface.. (a strong illuminating source is necessary). A dull edge on the other hand is a rounded surface (actually two or more lines) which Sharp Edge have a flat surface No surface area to capable of reflecting reflect light, no visilight. ble light reflection! Tactile Determination 1. Test Stick or Thumbnail-a sharp instrument will bite and grab into either a thumbnail or commercially available plastic sticks which approximate the hardness of the nail. A dull instrument will not grab! This is the most frequently used clinical method for determining sharpness (see note below). 2. In Use--frequently, the final test is how it performs in the mouth removing calculus. Dont hesitate to pronounce an instrument dull if it doesnt perform, even if everything else says it is sharp!
Dull Edge A broad surface area mirrors back light. Appears as a bright line or area.
Note: One of the issues of using the thumbnail is the threat of contaminating the instrument. If used, instrument must be sterilized after sharpening!
When To Sterilize? Sterilizing does dull instruments! One of the unresolved issues is when to sharpen the instrument. In this day and age, sterility is more important than 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 occurring minerals which are harder than the metal they are sharpening. The two most common from this group are the Arkansas oil stone (generally a very fine smooth surface for fine sharpening. These stones have become rare and are likely to be comparatively expensive.) and the India oil stone ( a courser surface). Synthetic There is an almost staggering array of man-made sharpening stones. Carborundum, ruby, diamond impregnated, and ceramic are just a few types. Mechanical Sharpeners
There are several mechanical sharpeners available on the market. Properly used these devices can produce excellent sharp edges. Many of these devices have several different stones that can be used. Mounted Stones Most of the materials listed under sharpening stones can and have been formed around a mandrill which is inserted into the chuck of either a lathe or dental handpiece.
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Sharpening Methods
Text Your textbook by Carranza/Newman Clinical Periodontology, 9th edition has an excellent presentation on sharpening pp 586-593. This should be carefully studied. Other On the following pages, several scanned images from a variety of manufacturer pamphlets will be presented.
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Laboratory Scaling Exercises

Models
Retrieve the models you previously prepared. Remember, the extracted teeth are from human sources and must be treated as a biohazard! Whenever 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 on the counter-top. Secure it with tape. Place an additional paper towel or two down before placing the models. These papers will absorb any moisture and can be discarded at the end of each session. These paper items need to be rolled 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 scaling exercises. 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 for the oral cavity, the principles are the same.
General Principles for the Model

Instrument Grasp Use and practice the modified pen grasp technique. As with any new physical exercise, your fingers are likely to tire quickly until you develop and tone the muscles involved. As lame as it sounds, picking up pencils, eating utensils (this will impress your significant others), etc on a regular basis will speed up the process. Remember, you will be doing this with every patient for many years to come! Finger Rest Remember the preference for fulcrums Even though this is a model and can be turned around, try to make this as real as possible. A proper fulcrum is part of the full action of grasp, finger action, and wrist movement. Each step depends on the others.
Preferred Fulcrum Sites Whenever possible, choose a fulcrum with the lowest number from the following list, since the list represents decreasing stability: # 1--Intra-oral 1--an adjacent tooth 2--cross-arch tooth 3--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 on pages 600-602. Not only are they principles of scaling, they are listed above in the sequential order of scaling ie. Adaptation first, angulation second, etc. Many of the diagrams in this chapter seem to indicate a perfect adaptation of the instrument on every tooth. This is wishful thinking 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 the orderly collection of clinical information that defines the degree of health/disease. Pocket depth, tissue quality/ quantity, radiographs, & visual parameters are recorded This is the removal of plaque and calculus from the tooth surfaces above the gingival margin. Because direct vision is possible, this is the starting place for learning techniques. End-Point--the collection of data is the aim. However, this data is used to determine therapy and prognosis. One cannot overvalue the importance of the exam!
Supragingival Scaling
End-Point--the tooth surfaces are free of plaque and calculus and are smooth and shiny as determined by visual and contact with an explorer. Use of prophy pastes is generally part of the process. End-Point--is determined by tactile sense since these surfaces cannot be visualized ie contacting the root surface with an explorer. The feel is of a glassy smooth surface. Technically difficult to achieve!
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Subgingival Scaling
The removal of bacterial deposits from the root surfaces below the gingival margin. Frequently, removal of diseased soft-tissue is part of the process. No direct vision is possible, so tactile senses need be employed. Most difficult of the cleaning procedures.
Scaling v. Root Planing Basically one which has a reduced bacterial population
Objectives of Scaling & Root Planing with reduced cytotoxins 1. Create a biologically acceptable root surface Patients really cannot properly 2. Resolve inflammation clean the teeth with rough calculus 3. Reduce pocket depths present! 4. Improve the ability of the patient to clean the teeth 5. Enhance attachment of biological structures 6. Prepare the tissues for additional procedures if needed eg surgery Do not underestimate the systemic effect 7. Reduce numbers and kinds of that a diseased mouth creates! Evidence bacteria from the oral cavity is accumulating almost daily! 8. Give the patient a psychological boost
The deeper the pocket the greater the probability of failure. Waerhaug
Limitations to Scaling and Root Planing 1. Anatomy of the root itself 2. Pocket depth--the deeper the pocket the less effective is the procedure 3. Tooth position/alignment 4. Inadequate instruments--even with the multitude of instruments available, this is always a concern--both diagnostic and cleaning 5. Access--limited opening, small mouth, etc 6. Personal technical ability--it is important to develop the highest level of competence possible 7. Time/frequency--these procedures do take time, may require multiple appointments, and may need to be repeated every few months!
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What is the Periodontal Root Surface Like?
Normal/Healthy Smooth, clean, shiny enamel surface
Diseased Plaque, calculus, stain, rough surface Dense calculus (rough)
Shallow pocket (sulcus) smooth surface Degenerating cementum (rough surface) Cavitated root surface Intact bone Bone loss Intact cementum Dense subgingival calculus (rough surface) Deep pocket (bleeds upon probing, instrumentation, pus, tender, soft tissue lining pocket is necrotic, bad smell)
Intact periodontal fibers
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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 formation better than a rough surface. This is generally true. The issue is to what degree must the root surface be smooth ie glassy or smoother than was? One camp indicates that the only way to determine complete calculus removal is if the probe feels a glassy-smooth surface. The other side questions the need to remove so much tooth structure to make it smooth. Probably, the answer is that a clean surface is more important 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 plaque produces enzymes/toxins that invade the root surface and retard the regeneration of a normal soft-tissue attachment. The unresolved question is to what degree does the root surface need to be planed in order 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 not excessively scraped as in the immediate past. However, although toned down, many texts continue to support the glassy-smooth root 2. Future--since the current issue requires touching the root surface with an instrument to determine the presence of calculus, better diagnostic devices are needed. Already available are in-operatory microscopes with high magnification. Lasers that can scan root surfaces for smoothness already exist for research purposes. Various dyes selective 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 are cleaned, they approach the color of enamel. 2. Drying--using air to dry the tooth enhances calculus detection 3. Transillumination--the mirror can be used to reflect light through the tooth which highlights the dense calculus deposits. A strong illuminating light such as a fiberoptic, is even better! 4. Disclosing Solutions (tablets)--there are several dyes currently available that are specific for plaque and calculus Tactile Clues The dentist (hygienist) is very dependant on the sense of touch since most of the root surfaces cannot be seen, but must be touched with an instrument. It is important to develop this sense to a high level As surfaces become calculus free, the feel becomes similar to the feel of stroking the instrument over enamel. Slide the explorer over many surfaces, both smooth and rough, to train the sense of touch. This is even more difficult and takes more time to develop because of the necessity of gloves.
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Auditory Clues As root planing nears completion, there is a change in sound. This is a combination of tactile and auditory- hear-feel. The scratchy sound (feel) which has a lower dull pitch, changes to higher pitch which does not resonate as much and is therefore quieter. Scrape enamel versus a fine emery paper.
Other Things Sharp Instruments There is a distinct difference in clues given about the presence or absence of calculus from an instrument which is dull versus one that is sharp . Dull scalers have a low resonating pitch whereas a sharp instrument glides over the surface with a higher pitch. Also, you should know that differences in blade and shank size can dramatically affect the clues given. It is important to know your instrument, train your senses, and practice, practice, practice!
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Scaling Review
Grasp--Use the modified pen
grasp.The instrument is held by the thumb and index finger with the pad of the middle finger placed on the shank to control and guide movement and to prevent slipping!
Fulcrum--Rest the ring finger on the

teeth whenever possible. Place it on, adjacent to, or as near as possible to the tooth being cleaned. A dry surface can be obtained by wiping the area with a 2x2 gauze. Intra-oral rests are best!
Angulation--angulation is the blade-totooth relationship. When this is correct, the calculus removal is efficient. Remember that when the shank connecting the blade (terminal shank) is parallel to the long axis of the root surface, then the blade is adjusted to the proper angle to the tooth. The design is meant to help you. Dont defeat its purpose!
Angulation Terminal Shank
Strokes--scaling strokes must be short, even,

and overlapping. Use a combination of vertical, oblique, and horizontal to ensure that all surfaces are contacted. Multiple strokes are needed to produce a smooth surface (research indicates that 20-40 strokes may be required).
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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 important to know and understand what you are to do before entering the clinic. Any clinical exercise should be practiced on models and/or in the mind before trying 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 treatment is instituted about the health or disease status of the patient. 2. Make a tentative opinion about the probability of success if treatment is performed. 3. Assign an orderly sequence to the process 4. 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 ability to 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 most important difference between doctor and patient. All the rest are technical 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 tray 4-5 2x2 gauzes Red/blue pencil Periodontal Charts (Use the For Clinical Use charts to gather data). 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), record findings on the Periodontal Examination Chart (For Clinical Exam) Mark missing teeth, crowns, restorations, bridges, veneers, and implants, broken fillings, fractured teeth, diastemas, etc. Using the red pencil, mark the position of the gingival margin on the Perio Exam Chart. Using the blue pencil, mark the position of the MJG (mucogingival junction) --be accurate, since you will need to reproduce these on the Mucogingival Examination Chart and hand both in Note: you may want to gather numerical data on the
Mucogingival Exam Chart & transpose it).
Using black ink, record the pocket probings, furcation measurements, presence of bleeding on probing (an * in the BP column),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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40
Example
March 22, 2000
Patient
eg. Doctoor Soon Tobee
Examining student
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42
Example
43
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, patient mirror, etc) Objectives The intent of this clinic session is to help you develop patient teaching 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 Patient
List Method
Patient Demo
Brush (two types) Brush (two methods Floss (two types)
Floss (two methods)

Mechanical Brushes
(two types) Show on model
Hygiene Aids
Floss threader Interproximal Brush Rubber Tip
Implant Care
Show on model
Pediatric Patient
(two years old)
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Tuneable Ultrasonics With Modified Tips
48
TUNEABLE ULTRASONICS
BASICS
OBJECTIVES
To understand the basic principles of tuneable ultrasonics and to initiate the use of tuneable ultrasonics in various clinical conditions. At the end of this segment, the participant should know and/or be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. Discuss the origins of the technique Understand and discuss the basic mechanics of ultrasonics Enumerate the equipment characteristics Describe the advantages and disadvantages of tuneable ultrasonics v. traditional ultrasonics and hand instruments Initiate preparatory procedures for tuneable ultrasonics Demonstrate clinical applications Determine the end-point of clinical applications Discuss the use of ultrasonics as a clinical therapeutic tool
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Tuneable Ultrasonics
Basics
Background Mechanical scalers have been an integral part of dentistry for decades. The first commercially available device was introduced by Dentsply/Cavitron in 1958. Scores of devices are currently available from a variety of manufacturers. 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 favor of automatic tuning. Dr Thomas Holbrook is one of the pioneers of using tuneable ultrasonics. His clinical application of tuneable ultrasonics and the modification of the of tips is commonly referred to as the Holbrook Technique. Overcoming the Biases The concept of using tuneable ultrasonics and modified tips as the primary or exclusive technique for scaling and root planing challenges many long-held dental principals. The composition of the root surface, the healing of the periodontal support structures, and long-term maintenance are part of a dental/hygiene schooling and clinical experience. Change comes slowly!
Being At Peace Whether of not the clinician uses this technique is likely related to being at peace with the technique and reconciling educational and clinical backgrounds.
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Lets Evaluate the Concerns (Biases)

Plaque and Calculus Removal The periodontal diseases are primarily caused by the destructive effects of bacterial plaque. Although calculus itself does not directly cause the disease process, bacterial accumulation on the rough surface, and the retention of endotoxins in the porous interior enhance the inflammatory sequence. Therefore, thorough removal of both plaque and calculus is essential in periodontal control. Numerous studies have demonstrated that ultrasonics are co-equal with hand instruments in plaque and calculus removal. What About Cementum?
It is thought that degenerating cementum harbors plaque and endotoxins which perpetuates the disease process. Some have advocated the complete removal of remaining cementum, claiming that cementum exposed to periodontal disease lacks an ability to regenerate. Others point out that like begets like and too vigorous removal eliminates cementum regeneration. The clinician is trapped between these two extremes and can only rely upon the tactile sense of smoothness to determine if cementum has been removed. Recent studies indicate that necrotic cementum must be removed but some viable cementum left to regenerate this important attachment entity. Therefore the glassy-smooth surface advocated in hand instrumentation has likely removed all cementum; whereas, a slight roughness, a velvety feel indicates necrotic cementum remaining. Ultrasonics generally produces the latter surface. Consider Is the glassy smooth surface what we really want? Its hard to give up long-standing clinical objectives isnt 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 more rapidly with ultrasonics than with hand instruments. The multiple strokes necessary to produce the glassy surface typically desired in hand instrumentation generally take longer than achieving the endpoint smoothness via ultrasonics.
PAINFUL
Most 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 overcome on devices possessing a tuneable control (see explanation in video). In addition, pre-heating the water flowing through the tip before clinical application can produce a suitable level of comfort for most clinical situations.
LOSS OF TACTILE SENSE

Because most subgingival deposits cannot be visualized, one must rely upon tactile senses to indicate when calculus has been removed. Standard diameter ultrasonic tips with uncontrolled vibration (nontuneable units) do significantly reduce the tactile fee. However, with thin/modified tips and manual tuning control, tactile sensitivity is excellent! Many practitioners experienced in this technique use the thin tips to feel irregularities on the root surface, similar to using an explorer.
ACCESS
If the clinician is at peace with the ability of ultrasonics to cleanse the tooth surfaces equal to hand instruments (noting the slight differences of tactile feel at the end-point) then a remaining issue relates to access. A severe 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 can readily 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 Abscesses Heavy calculus Ortho bands Everyone in this room
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EQUIPMENT
POWER UNIT We are truly sorry, but you must have a tuneable unit for this technique! Otherwise, only a limited use can be achieved in ultrasonics. The unit must be manually tuneable! This may represent a sizeable investment for the dental office. With care, this unit is likely to last a practice life-time. Enhanced therapy, done faster and kinder dental intangibles? Manufacturer Ultrasonic Services Inc. 7126 Mullins Dr. Houston, TX 77081 (800) 874-5332 jfine@usiultrasonics.com Jim Fines, Pres. Tony Riso Co. 2641 Northeast 186 Terrace North Miami, FL 33180 (305) 466-5681 tonyriso@yahoo.com J.H. Maliga (718) 871-1810 Parkell (800) 243-7446 parkell.com Dentsply/Cavitron (out of production) Unit 800 800-M USI-25M USI-25MPLC Flush Switch Ultra-weight Cord 2530 Cost $1280 $1775 $2145 $2735 $55 $50 $995 Comments Exceptional tuning range. The Rolls Royce of ultrasonics. Evaluate the differences between the foot controls. Unit is tuneable, auto-tuning, and accepts both 25 and 30k inserts.
Microson Manual/Auto Tune $599 ID595-MTAH 660 76 Not Available
Nice compact unit which has been manufactured for many years. Truly a comparative bargain. Not quite as finely tuneable as the others. One of the originals. If you can find one, dust it off!
Practice Hints Involve 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.
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TUNEABLE ULTRASONICS EQUIPMENT
MODIFIED TIPS
The second part of this technique is the modified tip. It can be readily demonstrated that the conventional tips are too large in diameter and have a curvature that prohibits entrance into most clinical pockets. Therefore, a modification (either custom produced or commercially manufactured) is necessary. Most practitioners will find the commercial products adequate to accomplish most of the intra-oral goals. In order to negotiate the pockets and allow contact with the variable root-surface anatomy both straight (universal) and R and L modifications are necessary.
Manufacturer Tony Riso Co
Tips P-100 P-100R, P-100L P-50 (Universal) Furcation (Ball tip) ITS (Implant titanium scaler) Ultrasonic Services 10UH (Universal) Inc. 10UHR, 10UHL 20 Series HeFriedy Slim-Line
Cost $95 $100 $95 $130 $135 $135 $145 $145 $125
Comments For the longest of time tips were all that Tony made. Exceptional quality*
Custom
Customized large $100 diameter tips to very fine tips.*
Good quality that has turned to exceptional with many innovations. Entered into a sales deal with Tony Riso to market his tip.* Caution with the plastic encased model (Slim-Flow). The plastic cracks rapidly. Almost a lost art, but can produce very delicate tips. Michele Mooney is the master!
*Note: **Note:
When ordering the above, be sure to specify ultrathin! Many of the above can be re-tipped at a fraction of original cost. Ask the manufacturer.
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EQUIPMENT
SPECIALIZED TIPS The incredible versatility of the modified thin tips can be enhanced even more by the use of other 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 fpr an enhanced ability to clean sub-gingivally. Note: R&Ls generally require less tuning than universals, so tune it down!
Calibrated Tips (Far Left Above) Some manufacturers are making tips with either Williams or Marquis markings. Great idea, but a combination of ultrasonic vibration and sterilization soon 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 has many other uses. Try it in the following places: -Distal of molars -Mesial fluting on maxillary 1st bicuspid -Generalized stain removal -Other
Implant Tip (Middle tip-photo at left) A neoprene (plastic) tip was developed by Tony Riso for use with implants. It will clean the visible supra-structure better than any device. It is exceedingly kind to the titanium surface and cleans quickly. Requires ITS insert from Tony Riso. Bailey,GM et al. Implant Surface Alterations 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 that role for an experienced hygienist than anything else. It is truly astounding what an enlarged view are can reveal.
Type
Clip-on Reading Glasses
Advantages
Least Costly
Disadvantages
Requires eyeglass frame Eye-to-object distance frequently requires user to bend the head downward.
Availability Cost
Gadjet stores, catalogues such as Sharper Image, Brookstone, Skymall, etc.. Pharmacy/optical section at Walmart, K-Mart, many local stores $18-36 $800-1,500
Optical
Microscope
Customizable for eye-toobject distance Can maintain good skeletal posture Excellent optics which enhance light gathering (make oral cavity less of a dark hole and less eyestrain) Multiple magnification available Can be outfitted with light source Multiple magnification Excellent light source
Cost Tend to be heavy but new materials have helped fixed magnification
Cost Large, bulky arms A major equipment purchase
Global (303)306-9826 Skyler $8,000-25,000
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1) Clip-On Reading Glasses This is a good starting point. See if this is for you!
2) Optical Other than cost, this is probably where you want to be. Consider a 2.0X magnification. Easier to learn and control.
3) Microscope For the future, a surgical microscope will be as common in the dental office as a panoramic machine!
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. 59
MECHANICS (PHYSICS) OF ULTRASONICS

An 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. This movement is 3-dimensional and so a definable 3-dimensional image is produced. The size of this form is determined by the power (amplitude) allowed to act on the tip. More power produces a greater tip movement (faster cleaning but more patient discomfort); whereas, less power produces the 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 largely set by the power control. This movement time is called frequency. In addition to the oscillations/time controlled by the tune control, the movement of the tip is further defined by phasing, basically harmonics. When successive mechanical tip movements (waves) are coordinated, we refer to this as being in phase. The clinical cleaning is highly efficient but the patient discomfort may be high. When the tip movements are out-of-phase, detuned, then cleaning is less efficient but with comfort being high.
TIPS
The general mechanics are as previously described. In addition, there are many characteristics of the tip itself which alter the movement patterns and intensity. The diameter, length, arc-of-curvature, and the metallic composition all affect the tip movements. Thus, an alteration of any tip characteristics will change cleaning abilities and/or patient comfort. Each tip needs to be individually tuned to accomplish the clinical goals.
CLINICAL USE OF ULTRASONIC PHYSICS-Arc-Of-Movement

Most tuneable ultrasonic units and associated modified tips produce a 3-dimensional elliptical pattern when activated. Because of this 3-dimensional movement, the entire circumference of the tip (all surfaces) as well as much of the tips length can be used for cleaning. This enhances the versatility of the ultrasonic, allowing the various surfaces of the tip to contact the anatomical surfaces of the root structure.
TUNING
Detuning (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, alternations in frequency (tuning) decrease the arc of movement but may actually increase the movement in this arc. These vibrations do not have the high auditory pitch or clanking of the tip the practitioner associates with power, but do have a high cleaning ability.
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PRE-CLINICAL PREPARATION
There 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 ultrasonic use suggests that water be run through the unit before placing the insert. Do not 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 Pacemakers Pacemakers produced in the past were sensitive to any electromagnetic variations. Current generation pacemakers appear to be little affected by dental ultrasonic cleaners. The major pacemaker manufacturers indicate in their patient education literature that dental ultrasonic probes (scalers) are unlikely to 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 over the chest area. Warming the H0 Although the dental delivery system may have selfcontained water heaters, the water issuing from the ultrasonic tip can be warmed further by the methods indicated in the video. Patient comfort is often more related to the water temperature than to the tip vibrations. Ultrasonic Tip Examination The thin modified tips should be occasionally examined for nicks or wear since both can alter clinical efficiency. The external water tube should be 1mm off the tips surface. Damping of the vibrations will occur (decreasing cleaning efficiency) if the water tubing contacts the tip. Damping also occurs if the knurls which hold the tip and water tube in position are loose. These should be firmly tightened.
Note: With proper care, your power unit should last many years. The tips will need to be re-tipped (not replaced) approximately every 2 years. 61
CLINICAL APPLICATIONS
PREPATORY PROCEDURES ON/OFF Turn the unit power on. With most units, it is important to turn the unit off when not in direct clinical use! INSERT/HANDPIECE Place the tip into the handpiece with an inward twisting motion. Contrary to traditional instructions, water should not be run through the handpiece, without an insert in place. Ultrasonics is such that even short activation of the foot control can produce significant damage to the handpiece. FOOT CONTROL The foot control should be placed in a position which is ergonomically comfortable. Activate the foot control so that enough water flows to eliminate any line debris or trapped air.
Note: Although the weight of the cord is minimal, the increased weight drag of the cord over time can become significant. Consider buying a soft, light cord.
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ADJUSTING H20 FLOW/H20 WARMTH Power to maximum Engage 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 pointed upward, there is approximately a 1 water stream from the tip Continue until the H20 is warm to the touch
What Are We Doing? Power to maximum! Energy to the handpiece but without vibration = Heat Why? To warm the H2O so it is comfortable
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 Note: Be certain H2O conduit is centered over the tip and within 1mm of contacting the tip! Note: The above procedure must be repeated at each change of tip!
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WATER CONTROL
One of the supposed disadvantages of ultrasonics is the need to use water. Some have suggested that it is too annoying to the patient to use on a regular basis. The advantages of a wash field are significant. The best way to control water in the oral cavity is by experimentation. See Michele Mooneys suggestions in the section under Hygiene in the video Tuneable Ultrasonics with Modified Tips. (CPSeminars) Be position and caring!
WATER Flushes away organic debris, toxins, and blood. Enhanced Therapy! Provides a clear, viewable area. Enhanced Therapy! Helps reach end-point more quickly. Enhanced Therapy! Less post-procedure pain. Enhanced Therapy!
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THE DEBRIDEMENT PROCESS 1. At the settings previously determined, orient the tip parallel with the long axis of the tooth surface and touch the side of the tip to an area of nonsensitive enamel. 2. Adjust the tuning until plaque and calculus can be removed, but is still comfortable for the patient (not the power, which should remain at minimum!). Continue to adjust tuning as needed for debridement and for patient comfort.
3.
Note: Even with no deliberate changes, occasional slight changes in tuning are necessary to maintain cleaning efficiency.
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DEBRIDEMENT CONTINUED
Initial Continuing Power Tune
Light Calculus Lowest Minimal, can just barely feel, no auditory Copious Parallel to long axis of tooth Occlusal-to-apical and circumferential Contacts all areas of crown and rootthat are accessible
Moderate Calculus Heavy Calculus Lowest Lowest Moderate, can feel, hear, and see light mist Copious Same Same High (tuned), feel, hear, visual H20 spray (rooster tail) Copious Same Same
H2 0 Tip Orientation Tip Movement on Tooth
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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 energy has been applied. In this illustration, there is equal movement along the length of the rod, but a concentration of energy at the end.
Energy concentrated at the tip!
Energy
Concentrated Energy
If the straight rod is bent to the shape of a universal ultrasonic tip, high energy remains at the end and is also concentrated on the inside curve.
Most-To-Least Energy Tip Movement * Tip of insert * Inside curve * Lateral surfaces * Back (outside curve) Note I: Although the foregoing is true in physics, frequently the clinician cannot apply the best energy surface of the tip to the tooth because of anatomy, ie tooth position, gingiva, access, etc
This knowledge can help determine which portion of the tip is in contact with the tooth. However, there is a reciprocal relationship between energy (cleaning ability) and comfort (discomfort) ie, as one goes up, the other goes down.
Note II: Rarely should the end of the tip be applied to the tooth, too much energy which hurts and can damage the tooth. Note III: The most efficient and yet most comfortable part of the tip to contact the tooth is the lateral border at the anterior portion of the tip, approximately 2mm behind the end.
CPSeminars 67
ADVANCED ULTRASONICS
Objectives
To provide clinically useable information in the following situations: 1. 2. 3. Use in advanced periodontitis cases Use in soft-tissue curettage Incorporating ultrasonics, soft-tissue curettage, and anti-microbials (Ultrasonic Bacterial Curettage UBC)
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THE TOUGH PERIO CASE

Now that you are feeling more comfortable with your abilities and the capabilities of tuneable ultrasonics, it is time to consider the advanced periodontal case. The good news is that everything you have learned to this point does apply. The bad news is that the skill level just took 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 Power Setting Tuning Tips H2 0 At lowest point Low Universal R&L ultrathin As much as can control
Advanced Perio Patient Usually at lowest point Frequently fully tuned Same As much as can control (high volume important to flush the pockets) Usually required Approaching mandatory
Anesthetic Magnification
Generally not Important
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INITIAL
Start calculus removal at the coronal end of the pocket (contrast this with hand instrumentation which starts at the apical end) and at the tooth-to-calculus interface. This most commonly allows the removal of large calculus chunks and speeds up the process. Proceed slowly toward the pocket apex with multiple, slow (gentle pressure), sweeping movements.
Frequently described as an erasure motion, the tip should contact the entire surface 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 produces 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 distal molar areas. The tip-to-tooth angle of R & Ls is likely to be perpendicular to the root surface as often as parallel. The energy efficiency of the R & Ls frequently requires de-tuning lower than Note: Remember that every surface of with the universals. the tip can be used for cleaninglike
having many instruments in one.
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CLINICAL TIP Talk positively about the process. Talk about how it is quicker, kinder, and more efficient. Present it as new technology. Patients respond well to this approach. Tooth scraping has been considered by most as un-fun.
CLINICAL TIP Pain Control/Practice Administration Try thisgive an analgesic (either OTC or prescription) 1 hour before or in the chair. Most research indicates it is easier to prevent pain than play catch-up. See if this isnt a positive idea.
Gatt, et al AM J Sport Med 1998 July-Aug 26(4):524-9.
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TUNEABLE ULTRASONICS SOFT-TISSUE CURETTAGE

Therapy v. Cleaning
The dominant aim of hygiene is to clean the tooth. There is an infinite number of articles which demonstrate the therapeutic benefits of removing necrotic cementum and calculus from the root surfaces. Hygiene education keys in heavily on training hygienists to clean the tooth. As important as this process is, it is only a part of therapy. The health of the soft-tissue has largely been attributed to cleaning the disease off the root (tooth) surface. However, many cases demand more attention to the infection within the softtissue that cannot be eliminated solely by cleaning the tooth or resolution is just too slow. This is the role of soft-tissue curettage.
Therapy (thara pe) [G. therapeia] The treatment of disease or disorder by various methods.
Stedmans Medical Dictionary
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CURETTAGE A REVIEW
Each practitioner needs to develop (in many cases re-develop) an appreciation for the benefits of curetting soft-tissues. As one of the least utilized and yet most mounting research indicates that the number beneficial therapeutic methods available of pathogens which actively invade the to the practitioner, is soft-tissue curettage. soft-tissue is increasing, we need to focus These benefits were first downgraded by more on therapies which will remove these research 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 by educational 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. Heretofore most applications of ultrasonics have been applied to cleaning the tooth and root surfaces. There are even a few advantages to the ultrasonic tip over the conventional hand instrument. The following discusses the ultrasonic as a soft-tissue cruet:
Hand Curette 1. Instrument Shape
Ultrasonic as Curette By using the outside curve of the ultrasonic tip a constant shape is applied to the soft-tissue wall minimizing soft-tissue perforations and allowing uniform tissue removal. The frequency is constant so that cutting forces produce uniform soft-tissue removal. The constant fluid flow flushes out the pocket to remove tissue, calculus, bacterial products, and enhances visibility. The ultrasonic actually enhances tactile feel over hand instrumentation. Frequency can be changed to remove tissue of varying density. Uniform cutting and copious irrigation decrease overall bleeding and post-op pain
2. 3.
Constant Vibration Irrigation
4. 5. 6.
Superior Tactile Sensations Highly Variable Decreased Hemorrhage
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ULTRASONIC CURETTAGE TECHNIQUES

Soft-tissue curettage is usually a procedure that is accomplished at the same time as root-surface debridement. This frees the patient from two separate procedures and offers a better overall healing result. Curettage Sub-gingival curettage refers to scraping of the inner surface of the gingival wall of the periodontal pocket to clean out, separate, and remove diseased soft-tissue.
Glossary of Terms J Periodontal (suppl) 48:1,1977
Ultrasonics can be used for both procedures where the following describes the technique for soft-tissue curettage:
Instruments Note: Curettage with a mechanical device is restricted exclusively to ultrasonics. Subsonic devices have a frequency that is too low to perform soft-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 * Other device readily available for tuning changes Tips * Universal *R&L * All in good working order Clinical Application * Anesthetic * Clean tooth first * Apply outside curve of tip to inner lining of pocket * Gentle pressure to a free finger to outside surface of pocket * Gentle sweeping motion of tip End Point * Pocket wall removed * Root surface clean Post-Op * Hemorrhage control with 2x2 gauze and digital pressure * Patient institutes oral hygiene same day * Appropriate analgesics
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The foregoing represents one of the fastest ways to resolve highly inflamed pockets and abscesses. It combines the therapeutic effects of debridement (scaling) with the removal of the diseased inner soft-tissue wall and thorough irrigation of the pocket to eliminate unattached bacteria, calculus, plaque, and immune response by-products.
Clinical Tip In a chronic case, epithelium generally lines the pocket wall and inhibits healing. Try removing this inner wall with ultrasonic curettage for better pocket 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 these solutions rather than water as the ultrasonic irrigant may enhance the overall results. The standard for oral rinses are chlorhexidine (CHX) based compounds. Most research shows that CHX is significantly superior to other products in anti-bacterial activity. Therefore, it appears that CHX is the fluid of choice to replace water in the ultrasonic unit.
CHX irrigation resulted in a significant reduction in CPD than did H20 among sites initially probing 4-6mm Reynolds. J Clin Periodontal 1992 Sept; 19(8):595-600
Part of the better resolution of CHX v. H20 is undoubtedly due to CHX and its antibacterial activity. An under-investigated area is whether CHX is a better conductor of cavitation waves than those produced by H20 alone ie the cavitation activity may be enhanced by the addition of CHX (see research of Walmsley, AD), who has extensively studied ultrasonics.
It may be concluded that cavitational activity within the cooling water supply of the ultrasonic scaler results in a superficial removal of root surface constituents. Walmsley. J Clin Periodontal 1990 May;17(5):306-312.
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COMPARISON OF CHX V. H20

As Irrigant in Ultrasonic Debridement
H2 0 Availability/Cost Taste Effect on Units Patient Acceptance Therapeutic Effects Readily/Low None None High Moderate
Chlorhexidine --CHX Limited/Moderate Metallic/slightly objectionable * May harm some units * Residual in units Low-requires prior explanations High
As usage of ultrasonic debridement increases, there will be increased research into the precise role of irrigants other than water. For the moment, the major therapeutic effect of CHX is in highly inflamed pockets of moderate-severe depth and in obvious abscesses.
Necrotic wall of inflamed 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 frequently, just prophy. These are synonymous terms which invariably mean the same thing. Why Polish?
Aesthetics We live in a world where people are increasingly more conscious about their appearance--both as how they appear to themselves & their perception of how they appear to others! A probable very small minority truly dont care how they look or are perceived. The patient who says I really dont care how my teeth look, is highly likely to be concerned about a spot of dark stain left on a tooth after the polishing process. Most paying customers expect glistening white teeth after a dental visit! Therapeutic Benefits of Polishing The polishing agents used have the ability to remove dental plaque as well as stain. This removal is a part of therapy! Elimination of bacterial plaque from tooth surfaces (and hence from the oral cavity) is a oral health maintenance necessity! Selective Coronal Polishing Some advocate only polishing those tooth surfaces which have stain or visible plaque. They cite studies which show a few microns of fluoride rich enamel are removed with each prophy. Since plaque is frequently a microscopic entity and not easily seen and since bacteria seed other intra-oral sites, the complete removal is the desired goal. F2 can be replenished by topical application
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Polishing/Stain Removal
Materials As with most high-use items in dentistry, there are many different prophylaxis pastes and prophy angles commercially available. The photo at the right shows an extremely small sample. More and more, sealed, single-use items are becoming the standard. Polishing Procedure 1. Set up the operatory in an OSHA approved manner. Both doctor and patient should be protected. 2. Attach the slow speed handpiece to the dental tubing 3. Attach the prophy angle to the handpiece (for this exercise we will use the disposable angle) 4. Attach the rubber cup to the prophy angle 5. Dip the rubber cup into the prophy paste and fill the interior of the rubber cup with paste 6. Contact the tooth and engage the foot control so that the cup rotates at a slow speed 7. 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 the abrasive paste that cleans! An empty cup tends to overheat the tooth. 9. Subgingival--gently slip the edge of the rubber cup under the gingival margin while cup is rotating. 10.Interproximal--the flexible cup can be eased into the contact area 11. Thoroughly rinse abrasive out of the mouth with water 12.Fluoride--replenish the loss of surface F2 by topically applying fluoride
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Polish/Stain Removal
Apply slight pressure against tooth to flare the cup,allowing the edge to slip under the gingivaSlight
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) [<Gk.ergon.work].The applied science of equipment design intended to reduce operator fatigue and discomfort.
As we evolve more into a society that sits and does repetitive tasks, the more important will become the principles of proper body posture and body support. There are already governmental forces pushing to mandate set conditions for body support in the dental office. That aside, it is already evident that we must be sensitive to ergonomics. Although you are at the mercy of equipment already in place in the dental school, it is important that you use that equipment to the best advantage for your body. When you equip your own office, long hours of evaluation will go into choosing equipment. Since most of you are young, there is a tendency to believe the adage youth think they are immortal. Immortality has a way of proving its fragility within only a few years. Dentistry can be damaging to your body unless you protect yourself at the very start! Vision & Ergonomics In dentistry, we stare into a black hole called the oral cavity. This is roughly equivalent to squinting while looking into a darkened mine shaft on a bright sun-shiny day. The difference is that we do this for several hours each day! Protect yourself by doing the following:
Wear Protective Eyewear Keep irritating things out of your eyes Blink Frequently A well-known fact among ophthalmologists is that dentists tend to stare a long time at the object they are working on. Eyes become very dry. Use Proper Lighting Generally, the more you can illuminate the oral cavity, the less strain on the eyes Magnification It does reduce eye strain!!!
83
Ergonomics
Hearing Protection--Huh? The constant high pitched whine of the dental handpiece, the high decibel rating of the high speed evacuator, and the nearly imperceptible sound of the ultrasonic scaler, in a small enclosed room, all contribute to potential hearing loss. Studies do indicate that dentists and hygienists are at risk for hearing loss--beyond that of the general population. Hearing can be protected by wearing small in-the-ear devices. Huh?
84
Ergonomics
Protecting the Musculoskeletal System Man was not meant to walk upright. Heard that one before? With all the back problems present, it almost sounds like a truism. Dentists/dental hygienists spend much time in positions which are strenuous on the musculoskeletal system. Proper posture and proper support while seated are essential. You must take care of this body system or it will rapidly become a plague in your practice life! Proper equipment and proper use of that equipment will minimize problems. Consider the following:
Using the Proper Equipment Properly
Feet flat on the floor Equal pressure on chair
Small of back supported
85
Ergonomics
Oh, the poor body!
Great Footwork! But what is it doing to the bod? Next time you are in a dental office, quietly note the foot positions. Anything other than flat on the floor is torquing the skeletal system. Dont believe that you do it? See what happens the next time you get under stress!
Flying Nun The Slouch Note: All of us do strange things when we are operating from the dental chair. The key is to know what is proper and then minimize the amount of time we spend doing them! 86
By the Clock
This area is Reserved for the assistant. A good assistant will fight you for it--and win!
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Sequence For Learning Basic Instrumentation Techniques

Sextants--Mandibular Arch
Right Handed Operator
Posterior Teeth: Anterior Teeth:
Molars-Bicuspids Cuspid-to-Cuspid
I. II. III.
A. B. A. B. A. B.
Buccal SurfacesMandibular Right Posteriors Lingual SurfacesMandibular Right Posteriors Labial SurfacesMandibular Anteriors Lingual SurfacesMandibular Anteriors Buccal SurfacesMandibular Left Posteriors Lingual SurfacesMandibular Left Posteriors
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Mandibular Arch
I. Mandibular Right Posterior: A. Buccal Approach Operator Position: 8-9 oclock Patient Position: Mirror: Head turned slightly toward operator. a. To retract buccal mucosa, 4th finger placed on shank of mirror. Insert mirror parallel to the floor of the mouth, move it to the side gently pulling the cheek away from the teeth or index finger of other hand to retract Use direct vision. 4th finger rest on occlusal surfaces of mandibular right bicuspids. Move finger rest to the incisal surfaces of the mandibular anterior teeth as you progress forward. (MolarsBicuspids)
b. Fulcrum: a. b.
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Mandibular Right Posterior Contd
B.
Lingual Approach Operator Position: 8 oclock (try 11 oclock also) Patient Position: Mirror: Head turned toward operator. a. b. c. d. Fulcrum: a. b. 4th finger rest on the occlusal surface of the cross-arch teeth. Retract tongue with mirror in other hand Reflect light. Use indirect or direct vision. 4th finger rest on the labial-incisal surfaces of mandibular anteriors Move finger rest as you progress forward.
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Mandibular Arch Contd
Mandibular Anterior: (Cuspid-Cuspid) A. Labial Approach I. Surfaces Toward The Patients Right Operator Position: 8 oclock (11 oclock) Patient Position: Mirror: Head straight, turn head toward operator as needed. a. b. c. Fulcrum: None (place on bracket tray or tuck in left hand). Retract lower lip with left index finger. Use direct vision.
4th finger rest on labial-incisal surfaces of adjacent teeth--occlusal surfaces if in 11 oclock position.
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Mandibular Anterior Contd
II A. Labial Approach (Surfaces Toward The Patients Left) Operator Position: 11 oclock or 8 oclock Patient Position: Mirror: Head straight, turn head toward operator as needed. a. b. c. Fulcrum: None. Retract lower lip with left index finger. Use direct vision.
4th finger rest on the labial-incisal surfaces of adjacent teeth to the patients left of the area being instrumented ( or patients right if using the 8 oclock position).
8 oclock position
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Mandibular Anterior Contd
II.
B. Lingual Approach (Mandibular Anterior) I. Surfaces Toward Patients Right Operator Position: 8 oclock (try 11 oclock also) Patient Position: Mirror: Head turned toward operator, lower chin. a. b. 4th finger rest on handle of the mirror. 4th finger rest on the buccal-occlusal of the mandibular right bicuspid to lateral area. Retract tongue with mirror Reflect light. Use indirect vision.
c. d. e. Fulcrum:
4th finger rest on the incisal surfaces of adjacent teeth
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Mandibular Anterior Condtd
II.
B.
Lingual Approach (Surfaces Toward Patients Left ) Operator Position: 11 oclock ( try 8 oclock also) Patient Position: Mirror: Head slightly turned toward operator, chin lowered. a. b. c. d. Fulcrum: 4th finger rest on the buccal surfaces of mandibular left bicuspid-cuspid area. Retract tongue with mirror Reflect light. Use direct or indirect vision.
4th finger rest on incisal surfaces of adjacent teeth to the patients right of area being instrumented left if in 8 oclock position).
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Mandibular Arch Contd
III.
Mandibular Left Posterior (Molars-Bicuspids) A. Buccal Approach Operator Position: 11 oclock (8 oclock) Patient Position: Mirror: a. b. c. Head turned toward operator. 4th finger rest on shank of mirror. Retract buccal mucosa with mirror. Use direct vision. Note: For distals of 2nd & 3rd molars, use mirror for indirect vision when necessary. 4th finger rest on buccal-occlusal surfaces of mandibular left bicuspid-cuspid area. Move finger rest to incisal surfaces of mandibular anterior teeth as you progress forward.
Fulcrum:
a. b.
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Mandibular Left Posterior Contd
III.
B. Lingual Approach (Mandibular Left Posterior) Operator Position: 8-9 oclock Patient Position: Mirror: Head straight or slightly away. a. b. c. d. Fulcrum: a. b. 4th finger rest on mirror handle Retract tongue with mirror surface. Use direct vision. May use indirect vision for distals. 4th finger rest on buccal-occlusal surfaces of mandibular left bicuspids. Move finger rest to the labial-incisal surfaces of the mandibular left anteriors as you progress forward.
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Sequence For Learning Basic Instrumentation Techniques

Sextants--Maxillary Arch
Right Handed Operator
Posterior Teeth: Anterior Teeth:
Molars-Bicuspids Cuspid-To-Cuspid
IV. V. VI.
A. B. A. B. A. B.
Buccal SurfacesMaxillary Right Posteriors Lingual SurfacesMaxillary Right Posteriors Labial SurfacesMaxillary Anteriors Lingual SurfacesMaxillary Anteriors Buccal SurfacesMaxillary Left Posteriors Lingual SurfacesMaxillary Left Posteriors
97
Maxillary Arch
IV. Maxillary Right Posterior: (Molars-Bicuspids) A. Buccal Approach Operator Position: 8-9 oclock (also try 11 oclock) Patient Position: Mirror: Head turned slightly away from operator. a. b. c. d. Fulcrum: a. 4th finger placed on shank of mirror. Retract buccal mucosa either with mirror or index finger of non-operating hand Use direct vision. Indirect vision for distals of molars. 4th finger rest may be on the labialincisal surfaces of bicuspid-cuspid area. Move finger rest anteriorly as you progress forward. OR b. At 9 oclock position: 4th finger rest on lingual-occlusal surface of tooth being instrumented or adjacent teeth.
98
Maxillary Right Posterior Contd
IV.
B.
Lingual Approach (Maxillary Right Posterior) Operator Position: 8 or 9 oclock (try 11 oclock also) Patient Position: Mirror: Head turned toward operator. a. b. c. d. Fulcrum: 4th finger rest on labial surfaces of the maxillary left lateral-cuspid area. Reflect light. Use direct vision. Use indirect vision for details.
4th finger rest on occlusal surface of tooth being instrumented or adjacent teeth.
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V.
Maxillary Anterior: A. I. Labial Approach
(Cuspid-Cuspid)
Surfaces Toward Patients Right Operator Position: 8 oclock (11 oclock also) Patient Position: Mirror: Head straight. Turn head slightly toward operator as you progress to left cuspid. a. b. No mirror, use direct vision. Left index finger retracting upper lip.
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Maxillary Anterior Contd
V.
A.
Maxillary Anterior Labial Approach Surfaces Toward Patients Left Operator Position: 8 oclock Patient Position: Head turned slightly toward operator. Turn head to straight position as you progress back to the left cuspid. a. b. Fulcrum: None. Use direct vision. Left index finger retracting upper lip.
Mirror:
4th finger rest on incisal surface to the patients left of the area or on the tooth being instrumented.
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V.
Maxillary Anterior B. Lingual Approach I. Toward Patients Right Operator Position 9-10 oclock Patient Position Head turned toward operator. Turn head more as you progress toward the left cuspid.
Mirror: a. 4th finger on buccal surfaces of maxillary left bicuspid-cuspid area b. Reflect light c. Use indirect vision Fulcrum: ` 4th finger on the incisal surfaces to the patients right of area being instrumented
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Maxillary Anterior Lingual Contd
V.
Maxillary Anterior Lingual Approach B. Lingual II. Surfaces Toward Patients Left Operator Position: 11 oclock Patient Position: Mirror: Head turned toward operator, chin raised a. 4th finger on buccal or occlusal surfaces of maxillary left bicuspid-cuspid area b. Reflect light c. Indirect vision Fulcrum: 4th finger on incisal surfaces of adjacent teeth to the right or on tooth being instrumented
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Maxillary Arch Contd
VI. Maxillary Left Posterior A. Buccal Approach Operator Position: 10 oclock Patient Position: Mirror: Head turned toward operator a. 4th finger rest on shank of mirror b. Retract buccal mucosa with mirror c. Direct vision--indirect for distals Fulcrum: 4th finger rest on lingual-occlusal surfaces of adjacent teeth anterior to tooth being instrumented.
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Maxillary Left Posterior Contd
VI.
B.
Maxillary Left Posterior Lingual Approach Operator Position: 8 oclock and 11 0clock Patient Position: Mirror: Head turned slightly away from operator, chin raised. a. b. c. Fulcrum: 4th finger rest on labial of maxillary right cuspid. Reflect light. Use direct vision.
4th finger rest on buccal-occlusal surface of tooth being instrumented or slightly posterior to area being instrumented.
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A Philosophy of Patient Treatment
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Manual Periodontal Instrumentation Bailey1

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Periodontal Instrumentation

George M Bailey,DDS Creighton School of Dentistry/ University of Utah

March 6 March 13 March 20

Lecture Spring Break

Mechanical Scal- Ch. 43 ers Party Have Fun

April 17 April 26?

Comprehensive Observation Final Report Due

Creighton University School of Dentistry Freshman 2004-2005 Instrument List

Dental Asepsis Standards

Note: A current video demonstrating these and other procedures

Making the Model

Periodontal Instrument Classification Periodontal Probes

Good diameter, Large diameter Screening Probes! 11

May have markings

Scaling/Root Planing Instruments

Gracey Series Curettes

Modifications of Standard Gracey

Blade is curved in two directions--tipshank & left-right (lateral edges)

Holding Periodontal Instruments

Note: Index bent at 2nd joint Extended middle finger

Ring finger along side

Holding Perio Instru

Finger Rest (fulcrum)

*A Time Waster--dull instruments

Evaluating Sharpness Contd

Sharpening Devices and General Principles

Laboratory Scaling Exercises

General Principles for the Model

Activating the Instrument

Scaling v. Root Planing

Scaling v. Root Planing

What is the Periodontal Root Surface Like?

Normal/Healthy Smooth, clean, shiny enamel surface

Diseased Plaque, calculus, stain, rough surface Dense calculus (rough)

Intact periodontal fibers

Scaling v. Root Planing

Significance of a Smooth Root

Scaling v. Root Planing

Determining When Root Is Calculus Free

Scaling v. Root Planing

Scaling v. Root Planing

Fulcrum--Rest the ring finger on the

Strokes--scaling strokes must be short, even,

Periodontal Exam/ Risk Assessment

Periodontal Exam/Risk Assessment

Creighton Periodontal Chart

eg. Doctoor Soon Tobee

For Clinical Use

For Clinical Use

Brush (two types) Brush (two methods Floss (two types)

Floss (two methods)

Tuneable Ultrasonics With Modified Tips

Lets Evaluate the Concerns (Biases)

OTHER THINGS TOO SLOW

LOSS OF TACTILE SENSE

Microson Manual/Auto Tune $599 ID595-MTAH 660 76 Not Available

TUNEABLE ULTRASONICS EQUIPMENT

Manufacturer Tony Riso Co

Customized large $100 diameter tips to very fine tips.*

SPECIALIZED TIPS CONTD

Cost Large, bulky arms A major equipment purchase

Global (303)306-9826 Skyler $8,000-25,000

MECHANICS (PHYSICS) OF ULTRASONICS

CLINICAL USE OF ULTRASONIC PHYSICS-Arc-Of-Movement