Periodontal instrumentation

According to periodontal diseases we can put the treatment into 2 major categories; surgical and non-surgical treatment.

-non surgical treatment which is the part that we will study and work with this semester and next semester: elimination of the inflammation by physical removal of the causes( plaque and calculus) by sub gingival scaling and root planing. To arrest progress of periodontal disease; plaque induced gingivitis, slight to moderate periodontitis( the sever cases have to go to surgery to open the access. non-surgical treatment always proceeds periodontal surgery. The non-surgical perio therapy divided into 3 parts: 1-oral hygiene measures 2-periodontal instrumentation 3 -chemical agents Definitions Scaling: consider instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus and stains. ,, we are scaling the tooth surface to get very very smooth surfaces which is later on will be able to reunite again with the periodontal ligaments(regeneration later on) Root planing: treatment processor design to remove surface dentin or cementum that is rough- indicated by calculus or contaminated with toxins and microorganisms. After deposition of plaque its convert to calculus then the bacteria will be able to affect the walls of cementum,, and I will get area of infected cementum(necrotic cementum) this layer has high percentage from bacteria with will prevent the reattachment with PDL.

SO the processor to remove the calculus is the scaling.(supra or sub gingival position). Scaling and root planing are not separable procedures( performed at the same time).

New terms,, just know this terms:

Periodontal debridement: Removal or disruption of bacterial plaque

biofilm, its byproducts, & plaque retentive calculus deposits from coronal tooth surfaces & tooth root surfaces(the whole surfaces) to the extent needed to reestablish periodontal health.

Growth debridement: removal of plaque or calculus just for full

charting-examination and diagnosis. Classification of periodontal instrument:- for nonsurgical treatment;

4 main categories:periodontal probes, explorers, scalars, instrument for polishing and cleansing.

Three major parts for each instrument: 1- handle(deferent types, forms),, 2- shank 3- blade(working ends).

PS: never ever lets the handle guide u to the instrument type, eg; sometimes curettes handle in DTC was blue in color, after while they bring to the center probes have blue handle,, then of course the students get confused Shank: 2 parts; functional shank,, terminal or the lower shank (the last straight part of the shank which is the nearest to the blade).

What's the importance of the shank:

its allow me to control the usage of instrument during the process of

scaling and planing especially in the posterior areas( so it has angles, carves, some be short, some long according to usage and name).
when we want to identify the instrument, make the terminal shank

perpendicular to the floor and the blade facing u. We should use instrument in the correct way keep the terminal shank parallel to the long axis of the tooth.

1-periodontal probe

In DTC; we use The University of Michigan "O" probe, with Williams markings (at 1, 2, 3, 5, 7, 8, 9, and 10 mm) "THE C IN THE PHOTO". -when we use probe we use "walking technique": insert the probe and walk without complete removal of the probe from the pocket (makes ups and downs) if we use the probe in straight way without ups and downs that will push the plaque down and may that lead to periodontal abscess.

Uses of the probe:

1- diagnosis of periodontal diseases(the most important); bleeding on probing( we inserted in the sulcus to detect if we have bleeding upon probing, so we have laceration in sulcular epithelium.

2- measurement of sulcus depth, amount of recession; any measurement can be done directly by using of the probe. 3- angulation: probe should be inserted parallel to the long axis of the tooth AND continuing considering the anatomy of the crown. 4-Reading; each tooth should have 6 reading(mid- buccal, mid- lingual, distobuccal, distolingual, mesiobuccal, mesiolingual) to make sure everything is okay,,,,,,, from this point we must conclude that the periodontal disease is a very localized disease.

We talked about straight probes,, we have another type of probe which is "nabers probes); for detection of furcation areas; inserted in the furcation area by 3mm 3mm.

Explorers

to explore presence of calculus or plaque or whatever within the sulcus, should insert the tip within the pocket and go to the deepest point then go up with very light force. ps; in Carranza's book say that we can use periodontal probes as explorers .

-We use explorer also after finish the treatment to detect if there is any rough area any deposits any calculus any plaque we can detect it by explorers (or periodontal probes).

instrument for scaling and root planing

- there is 5 types: 1-scalers , 2-currets, 3- chisel, 4- file, 5-hoe.
-Chisel: is the only instrument that we use it with pushing movements.
File:

Unfortunately,,, the Dr stopped here and said that what's remain from the chapter is required. I copied the remaining info from past year script;

The other manual instruments are the Hoe, chisel and file scalers. Used to remove tenacious subgingival calculus and altered cementum Their use is limited compared with that of curettes. Most instruments are made of stainless steel and are not suitable for use with implants. And we have titanium and plastic instruments used on titanium and other implant abutment materials to avoid scarring and permanent damage to the implants.

Scalers: Used primarily to remove large deposits of supra-gingival calculus and used supra-gingival only because it has a huge diameter and pointed tip (especially the one ended scaler) Exception are the ones that are fine scalers double ended and can be used up to 3mm sub-gingivaly without traumatizing the gingiva characteristic: They have triangular cross section and two straight cutting

edges and a pointed tip WE have different types of scalers : sickle scaler and interdental The correct adaptation: last third is the working end.

Curette:
Used to remove subgingival calculus, smooth rough root surfaces (root planing), and remove the diseased soft- tissue lining of the periodontal pocket (soft-tissue curettage)

Characteristic: they have Semicircular cross section and Converge in a rounded toe.

Now we compare between the Manual instruments ( scalers and curettes) And between the Curettes two types ( gracy and universal) Comparison between scalers and curettes

Comparison between the two types of Curettes:

Now we discuss Gracy instruments: Numbered from to 1- 14 and usually they come double ended (paired instruments) so each curette has two number, one corresponds to each end. - Gracy 1/2:

 Used for the buccal ( labial) surfaces of anterior teeth The handle, shank and blade are in one plane ( straight )
- Gracy 3/4:

Used for the lingual surfaces of anterior teeth The handle, shank and blade are also straight ( similar to gracy 1/2) Normally we use gracy 1/2 for the lingual surface of anterior teeth as well (so we can substitute gracy 3/4 with gracy 1/2) Note: anterior teeth include incisors and canines. - Gracy 5/6: Used for the buccal and lingual surfaces of premolars. Also in the kits sometimes they just have gracy 13/14 and can be used for premolars instead of gracy 5/6 - Gracy 7/8 + 9/10: Used for buccal and lingual surfaces of posterior teeth. And those also can be substituted with gracy 11/12 and 13/14
- Gracy 11/12:

Used for the mesial surfaces of posterior teeth. Its contra angled and less sharp than gracy 13/14. Gracy 13/14 : Used for the distal surfaces of posterior teeth. Its contra angles and has acute turn ( sharp angle ) to reach the distal surfaces of posterior teeth.

Gracy curette modification:

- Gracy 15/16:

Modification of gracy 11/12 = it has the shank of gracy 13/14 and the blade of 11/12
- Gracy 17/18:

 Modification of

gracy 13/14 = it has a elongated terminal shank by 3 mm and and accentuated angle of the blade.

Extended shank curretts ( after five curettes )

Their

shank is 3 mm longer, and their blade is thinner than gracy and have a large diameter and tapered shanks.
They are

available with all standard Gracy numbers except for 9/10

There are also Modifications of the After Five curettes

The Blades are half the length of the After Five or standard Gracey curettes (allows easier insertion and adaptation in Deep, narrow pockets, Furcations and Developmental grooves)

There are also Micro mini five Gracey curettes:

Blades that are 20% thinner and smaller than the Mini Five curettes Smallest of all curettes
Provide

exceptional access and adaptation to tight, deep, or narrow pockets; narrow furcations; developmental depressions; line angles; and deep pockets on facial, lingual, or palatal surfaces

Powered (mechanical) instruments:

Power instrumentation has the potential to make scaling less demanding, more time efficient, and more ergonomically friendly ( does not excust the hand while working)

 We have to use the manual instruments first to improve the tactile sensation then we will be allowed to use the powered instruments

Types of Powered instruments: I.Sonic:

Work Use Tips

at a frequency of 2000 to 6500 cycles per second

a high or low speed air source from the dental unit are large in diameter and universal in design an elliptical or orbital stroke pattern

Tip travels in

II.Ultra Sonic scalers: Works by converting very high

frequency sound waves into mechanical energy in the form of very rapid vibrations
A spray of

water at the tip prevents the buildup of heat and provides a continuous flushing of debris and bacteria from the base of the pocket

Magnetostrictive Ultrasonic Work in a frequency range of 18,000 to 50,000 cycles Metal stacks Vibrations Tips

per second

that change dimension when electrical energy is applied

travel from the metal stack to a connecting body that causes the vibration of the working tip move in an elliptical or orbital stroke pattern

Piezoelectric Ultrasonic Work in a frequency range of 18,000 to 50,000 cycles Have

per second

ceramic discs that are located in the hand piece & change in dimension as electrical energy is applied
Move in

a linear pattern, giving the tip two active surfaces.

Tip Designs

 Large diameter

tips in the Universal design and are indicated for the removal of large, and tenacious deposits
Thinner diameter

tips may be site specific in design of Straight instruments and Right and left contra-angled instruments (allow for greater access and adaptation to root morphology) Mechanized Instruments as Compared with Manual Instruments

Mechanized Instruments Precautions

Unshielded pacemakers

( some patients dont know if they have shielded or not shielded pacemakers so its more cautious to not use ultrasonic if they mention that they have pacemaker)
Infectious

diseases:human immunodeficiency virus to protect our selves since the virus is in the saliva and the blood. ( manual instrumentation is indicated for patients with infectious disease since there is no aerosol while manual instrumentation)
Immune

suppression from disease or chemotherapy (to protect the

patient)

 Demineralized

tooth surface& exposed dentin (especially associated with sensitivity) because using ultrasonic cause pitting df the deminerlized surfaces.
Restorative

materials (porcelain, amalgam, gold, composite) abutments unless using special tips.

Titanium implant Children

(primary teeth)

Mechanized Instruments Contraindications

Chronic

pulmonary disease: asthma, emphysema, cystic fibrosis, pneumonia

Cardiovascular disease

with secondary pulmonary disease because of the water sprays.

Swallowing difficulty (dysphagia)

Clinical outcomes of power-driven instruments.

Remove biofilm bacteria, and calculus through mechanical action, especially In the furcation area, because it has smaller diameter tips compared with the manual instrument. -The point of a sonic instrument removes bacterial plaque more efficiently

Tt of chronic periodontitis
single-rooted teeth No difference in the efficacy of subgingival debridement using ultrasonic/sonic scalers vs hand instruments multirooted teeth: A benefit for ultrasonic could not be determined because of a lack of clinical data

-no difference in outcomes between the three types of the power driven instruments: sonic, magnetostrictive, and piezoelectric scalers.

III.Polishing Instruments Polishing can reduce sonic scaling

root surface roughness

 It

also removes any pigmentation left by smoke, food and drugs (chlorhexidine)

different procedures ( clean more than one tooth at once ) Rubber cups: used with the base supraginigval to avoid injury to cementum Bristle brushes (stiff so should be confined to the crown, to avoid injuring the cementum and the gingiva)
They could be disposable or

reusable.

(C)Rotary Instruments ( diamond Bur )

Also used to remove natural plaque- retentive areas (odontoplasty of grooves (upper lateral), ridges, irregularities) so to reduce the plaque retention areas and used to prepare prostatic abutment teeth for crowns or bridges.

(D) Alternating Movement Instruments

useful in

removing calculus and planing the approximal surfaces of the

roots
also

used to remove the excess contours of iatrogenic interproximal fillings ( over hanged restoration )
Strip

holders Used for over hanged restorations Eva System -Used in the inter-proximal areas and the overhang restorations and the over-contouring to prepare access for the oral hygiene maintenance.
DONE BY: asma'a almawas .