Periodontal instrumentation

Presented by:
Navneet Randhawa
MDS 1st
year
Periodontology and Oral Implantology

CONTENTS
 Introduction
 Classification
 Principles of instrumentation
 Techniques and Position
 Sharpening of instruments

Introduction
 Periodontal intruments are designed for
specific purposes
 Those are:
 Removing calculus
 Root Planing
 Curetting
 Removing dead tissue

Periodontal Probes
 Purpose:
They are used to locate,mark,measure the
depth of periodontal pockets.
They are tapered rod like
instruments,calibrated in millimeters
 Furcation areas can be best evaluated with
curved, blunt Nabers probe.

 When measuring a pocket, the probe is
inserted with a firm gentle pressure to the
bottom of the pocket.
 Shank should be aligned with long axis of the
tooth surface to be probed.

TYPES OF PROBES
 Generations of probes:-
 First Generation
 Second Generation
 Third Generation
 Fourth Generation
 Fifth Generation

First Generation Probes
 Do not control for probing pressure and are
not suited for automatic data collection.
 These probes most commonly are used by
general dental practitioners as well as
periodontists.

WILLIAM’S PROBE:
 Invented in 1936 by Charles H.M. Williams.
 These probes have a thin stainless steel tip of 13 mm in length and a
blunt tip end with a diameter of 1 mm.
 The graduations on these probes are 1 mm, 2 mm, 3 mm, 5 mm, 7
mm, 8 mm, 9 mm, and 10 mm.
 The4-mm and 6-mm markings are absent to improve visibility and
avoid confusion in reading the markings.
 The probe tips and handles are enclosed at 130 degrees.

CPITN PROBES
• The Community Periodontal
Index of Treatment Need (CPITN)
was designed by Professors
George S. Beagrie and Jukka
Ainanio in 1978.
• CPITN probes are recommended
for use when screening and
monitoring patients with the
CPITN index.
• CPITN-E (epidemiologic), which
have 3.5-mm and 5.5-mm
markings
• CPITN-C (clinical), which have
3.5-mm, 5.5-mm, 8.5-mm, and
11.5-mm markings.

 CPITN probes have thin
handles and are
lightweight (5 gm).
 The probes have a ball
tip of 0.5 mm, with a
black band between 3.5
mm and 5.5 mm. as well
as black rings at 8.5 mm
and 11.5 mm.

University of Michigan ‘O’
Probes have markings at 3 mm. 6 mm, and 8 mm.
A modification of this probe with Williams‘ markings also is
available.
University of North Carolina-15 (UNC-15)
Probes are color-coded at every 5 millimeter demarcation.
They are the preferred probe in clinical research if conventional
probes are required.

NABER’S PROBE
 The Naber's probe is used to detect and
measure the involvement of furcal areas
by the periodontal disease process
in multirooted teeth.
 Naber's probe also is used in the assessment of more complex
clinical cases, including those with a restorative treatment.
 These probes can be color-coded or without demarcation.

SECOND GENERATION (CONSTANT PRESSURE)
PROBES
 Pressure sensitive, allowing for improved standardization
of probing pressure.
 The True Pressure Sensitive (TPS) probe is the prototype
for second-generation probes.
 Introduced by Hunter in 1994, these probes have a
disposable probing head and a hemispheric probe tip
with a diameter of 0.5 mm.
 A controlled probing pressure of 20 gm is usually applied.
 These probes have a visual guide and a sliding scale
where two indicator lines meet at a specified pressure.

 In 1977, Armitage designed a pressure sensitive probe
holder to standardize the insertion pressure and
determine how accurate probing pressure of 25 pounds
affected the connective-tissue attachment.
 In 1978, van der Velden devised a pressure-sensitive
probe with a cylinder and piston connected to an air-
pressure system.
 Subsequently, it was modified with a displacement
transducer for electronic pocket-depth reading

 The Electronic pressure-sensitive probe, allowing for
control of insertion pressure, was introduced by Polson
in 1980.
 This probe has a handpiece and a control base that
allows the examiner to control the probing pressure.
 The pressure is increased until an audio signal indicates
that the preset pressure has been reached.
 Yeaple probe, a modification of Polson’s probe design
which is used in studies of dentinal hypersensitivity.

THIRD GENERATION
(AUTOMATED)
 This generation includes computer-assisted
direct data capture to reduce examiner bias
and allows for greater probe precision.
 These probes require computerization of the
dental operatory and can be used by
periodontists and academic institutions for
research.

Foster-Miller probe (Foster-Miller, Inc,
Waltham, MA)
 Prototype of third-generation probes.
 Devised by Jefficoat et al in 1986, this probe has
controlled probing pressure and automated detection of
the cementoenamel junction (CEJ).
 The components of the probe are:
A pneumatic cylinder,
A linear variable
Differential transducer (LVDT),
A force transducer,
An accelerator
A probe tip.

 Main mechanism of action of the is by detection of the
CEJ.
 The ball tip moves or glides over the root surface at a
controlled speed and preset pressure.
 Abrupt changes in the acceleration of the probe
movement (recorded on a graph) indicate when it meets
the CEJ and when it is stopped at the base of the pocket

Advantage is the
 Automatic detection of the CEJ
Disadvantage is that
 it cannot deem root roughness or root surface
irregularities as the CEJ.

FLORIDA PROBE
 Gibbs et al. in 1988.
 This probe consists of a
Probe handpiece and sleeve;
A displacement transducer;
A foot switch; and
A computer interface/personal computer.
 The hemispheric probe tip has a diameter of 0.45 mm,
and the sleeve has a diameter of 0.97 mm .
 Constant probing pressure of 15 gm is provided by coil
springs inside the handpiece.

 They also can record missing teeth, recession, pocket
depth, bleeding, suppuration, furcation involvement,
mobility, and plaque assessment.
 Each measurement is recorded with potentially 0.2-mm
accuracy.

TORONTO AUTOMATED PROBE
 Devised by McCulloch and Birek in 1991 at
University of Toronto, used the occlusoincisal
surface to measure relative clinical
attachment levels.
 The sulcus is probed with a 0.5-mm nickel-
titanium wire that is extended under air
pressure.
 It controls angular discrepancies by means of
a mercury tilt sensor that limits angulation
within ± 30°.

 This probe has the advantage of an incorporated
electronic guidance system to improve precision
in probe angulation.
 It also estimates the biophysical integrity of the
dentogingival junction by measuring intrapocket
probing velocity.
 The disadvantages are associated with
positioning:
It is difficult to measure second and third molars,
and patients have to position their heads in the
same place to reproduce readings.

FOURTH GENERATION PROBES
 These are three dimensional (3D) probes.
 These probes are aimed at recording
sequential probe positions along the gingival
sulcus.
 They are an attempt to extend linear probing
in a serial manner to take into account the
continuous and 3D pocket being examined.

FIFTH GENERATION PROBES
 Probes are being designed to be 3D and noninvasive: an
ultrasound or other device is added to a fourth-
generation probe.
 Fifth-generation probes aim to identify the attachment
level without penetrating it.
 The only fifth-generation probe available, the
UltraSonographic (US) probe (Visual Programs, Inc),
uses ultrasound waves to detect, image, and map the
upper boundary of the periodontal ligament and its
variation over time as an indicator of the presence of
periodontal disease.

EXPLORERS
 Used to locate subgingival deposits and carious areas.
 To check the smoothness of root surfaces after root
planing.
Shepherd Hook Explorer: for
supragingival examination of
caries and irregular restoration
Straight Explorer: for
supragingival examination of
caries and irregular
restoration margins.

Curved Explorer:
for calculus
detection and
shallow pockets.
Pigtail and Cowhorn Explorer:
For calculus detection and shallow pockets
not extending deep than cervical third of root.

SCALING AND CURETTAGE INSTRUMENTS
SICKLE SCALERS (SUPRAGINGIVAL SCALERS)
 Have flat surface and two cutting edges that converge in a
sharply pointed tip.
 Used to remove supragingival calculus.
 Used with a pull stroke.
 Scalers with straight shank: anterior teeth and premolars.
 Scalers with contra-angle shank: posterior teeth.

 U15/30 scalers: large.
 Jacquette sickle scalers #1,2,3 : medium sized
blades.
 Curved 204 sickle scaler: large, medium or small
blades.
 Nevi 2 posterior scaler: thin enough, can be inserted
few mm subgingivally.

CURETTES
 For removing deep subgingival calculus, root
planing, altered cementum and removing soft
tissue lining the pocket.
 Each working end has cutting edge on both sides
and a rounded toe.
 Finer than sickle scalers
 Can be adapted and provide good access to deep
pockets, with minimal soft tissue trauma.

UNIVERSAL CURETTES
 Have cutting ledges that may be inserted in most areas
of dentition by altering, adapting the finger rest,
fulcrum and hand position of operator.
 Face of blade is 90-degree angle to the lower shank.
 Blade is curved in one direction from head of the blade
to toe.
 Examples: Banhart curettes #1-2 and 5-6
Columbia curettes #13-14, 2R-2L. 4R-4L
Younger-Good #7-8
The McCall’s #17-18
Indiana University #17-18

 Offset blade: they are angled approx. 60-70 degrees
from lower shank. This allows the blade to be inserted in
precise position necessary for subgingival scaling and
root planing.
 These have curved blade. (curved from head to toe and
along the side of cutting edge).
 Only pull stroke can be used.

 Available with either “rigid” or “finishing” type
of shank.
 Rigid Gracey: larger, stronger and less flexible
shank and blade than finishing Gracey.
 Rigid shank allows removal of moderate to heavy
calculus.

GRACEY CURETTES
 Designed and angled to adapt specific anatomic areas of
dentition.
 Double ended curettes paired in this manner:
 Gracey #1-2 and 3-4: Anterior teeth
 Gracey #5-6: Anterior teeth and premolars.
 Gracey #7-8 and 9-10: Posterior teeth: Facial and lingual.
 Gracey #11-12 : Posterior teeth: Mesial
 Gracey #13-14: Posterior teeth: Distal

Gracey #15-16 : consists of Gracey #11-12 combined with more
acutely angled #13-14 shank.
Allows better adaptation to posterior mesial surfaces from a front
position with intraoral rests.
Modifications of Gracey Curettes

Gracey #17-18: modification of #13-14. has a terminal shank
elongated by 3mm and a more accentuated angulation of the
shank to provide complete occlusal clearence and better access to
all posterior distal teeth.

Sr. No. Gracey Curette Universal Curette
Area of Use Set of many curettes One curette designed for
designed for specific all areas and surfaces.
areas and surfaces.
Cutting Edge
Use One cutting edge used; Both cutting edge used;
work with outer edge work with either outer
only. Or inner edge.
Curvature Curved in two planes; Curved in one plane;blade
blade curves up and to curves up, not to the
Blade angle Offset blade; face of Blade not offset; face of
blade beveled at 60 blade beveled at 90
degrees to shank. degrees to shank.

EXTENDED SHANK CURETTES
AFTER-FIVE CURETTES.
 Terminal shank is 3mm longer, allowing extensions into the pockets
of 5mm or more.
 Thinned blade for smoother subgingival insertion and reduced
distention.
 Large-diameter, tapered shank.
 All standard Gracey numbers except #9-10 are available in After-
Five curettes.

 Rigid After-five curettes: removal of heavy or tenacious
calculus deposits.
 Finishing After-Five curettes: for light scaling or
deplaquing in a periodontal maintainence petient

MINI BLADED CURETTES
 These curettes feature blades that are half the length of After-Five or
standard Gracey curettes.
 Shorter blade allows easier insertion and adaptation in deep, narrow
pockets; furcations; developmental grooves; line angles; and deep
pockets.
 Can be used in areas where root morphology or tight tissue prevents full
insertion of other curettes.
 Used with vertical strokes.

GRACEY CURVETTES
 Another set of four Mini-bladed curettes:
Sub-0 and #1-2: Anterior teeth and premolars
#11-12: posterior mesial surfaces.
#13-14: posterior distal surfaces.
 Blade length is 50% shorter than conventional Gracey
curette, and blade has been curved slightly upward.
 Has a precision balanced tip in direct alignment with the
handle, a blade tip perpendicular to the handle, and a
shank closer to parallel with the handle.

LANGER AND MINI-LANGER
CURETTES
 These combine the shank design of the
standard gracey #5-6, 11-12 and 13-14 curettes
with a universal blade honed at 90 degrees
rather than offset blade.

 Langer #5-6: mesial and distal surfaces of
anterior teeth.
mandibular posterior teeth.
maxillary posterior teeth.

SCHWARTZ PERIOTRIEVERS
 Set of two double-ended, highly magnetized
instruments.
 Retrieval of broken instrument tips from periodontal
pockets.
 Indispensable when clinician has a broken curette tip in a
furcation or deep pocket

PLASTIC INSTRUMENTS FOR
IMPLANTS
 Instruments for use on titanium and other
implant abutment materials.
 Used to avoid scarring and permanent damage
to the implants.

HOE SCALERS
 Used for scaling of ledges or rings of calculus.
 The blade is bent at 99-degree angle
 Cutting edge is formed by the junction of flattened
terminal surface with the inner aspect of the blade.
 Cutting blade is beveled at 45 degrees.

 The blade is inserted to the base of the pocket so
that it makes a two point contact with the tooth.
This stabilized the instrument and prevents the
nicking of the root.
 The instrument is activated with a firm pull stroke
towards the crown, with every effort being made to
preserve the two point contact with the tooth.
 McCall’s #3,4,5,6,7 and 8 : access to all tooth
surfaces.

FILES
 Have series of blades on a base.
 Function: to fracture or crush large deposits of tenacious
calculus or burnished sheets of calculus.
 Can easily gauge and roughen root surfaces when used
improperly.
 Not suitable for fine scaling and root planing.
 Sometimes used for removing overhanging margins of
dental restoration.

CHISEL SCALERS
 Double ended instrument with a curved
shank at one end and a straight shank at other end.
 The blades are slightly curved and
have a straight cutting edge
beveled at 45 degrees.
 Inserted from facial surface.
 Curve of the blade allows it to stabilize against the proximal surface,
whereas the cutting edge engages the calculus.
 Activated by push motion.

QUETIN FURCATION CURETTES
 Actually hoes with a shallow, half moon radius that fits into the
roof or floor of furcation.
 Curvature of the tip fits into the developmental depressions of the
inner aspects of the root.
 Shanks are slightly curved for better access.
 They remove burnished calculus from recessed areas of furcation

DIAMOND COATED FILES
 Used for final finishing of root.
 Donot have cutting edges.
 Coated with very fine grit diamond.
 Sharply abrasive and should be used with light, even
pressure against the root surface to avoid gouging or
grooving.
 These can produce smooth, even, clean, highly polished
surfaces.

ULTRASONIC AND SONIC INSTRUMENTS
 Used for removing plaque, scaling, curetting and removing stain.
 Two types: MAGNETOSTRICTIVE AND PEIZOELECTRIC
 Alternating electric current generates oscillations in materials in the
handpiece that cause the scaler tip to vibrate.
 Vibrations range from 20,000 to 45,000 cycles per second.

 MAGNETOSTRICTIVE UNITS: the pattern of vibration
of the tip is elliptical i.e. all the sides of tip are active and
work when adapted to the tooth.
Generate heat and require water for cooling
 PEIZOELECTRIC UNITS: the pattern of vibration is
linear, or back and forth i.e. two sides of the tips are
most active.
Donot generate heat but still utilize water for cooling
frictional heat and flushing away debris.

 Sonic Units: consists of a handpiece that attaches to
a compressed air-line and uses a variety of specially
designed tips.
 Vibrations range from 2000-6500cps, which
provides less power for calculus removal than
ultrasonic units.
 All tips are designed to operate in a wet field with a
water spray directed at the end of tip.

 Within water droplets of this spray mist are
tiny vaccuum bubbles that quickly collapse,
releasing energy in a process known as
cavitation.
 The cavitation water sprays serve to flush
calculus, plaque, and debris dislodged by
the vibrating tip from the pocket.

DENTAL ENDOSCOPE
 Used subgingivally for
diagnosis and treatment of
periodontal disease.
 The Perioscopy system
consists of a 0.99mm
diameter, reusable fibreoptic
endoscope over which are
fitted a disposable, sterile
sheath.
 The fibreoptic fits onto the
probes and instruments.

 The sheath delivers water irrigation that
flushes the pocket while the endoscope is
being used.
 The fibreoptic attaches to the CCD, which
produces the image.

 Allows clear visualization deeply into subgingival
pockets and furcations.
 Permits operators to detect the presence and location of
subgingival deposits.
 Magnification ranges from 24X to 46X.
 Used to evaluate the subgingival areas for caries,
defective restorations, root fractures and resorption.

EVA system (Enhanced Visual
Assessment)
 Most efficient and least traumatic instruments.
 Correcting overhanging or overcontoured proximal alloy
and resin restorations.
 Files made of Al in the shape of a wedge protruding form
the shaft; one side of wedge is diamond coated and
other side is smooth.
 The files can be mounted on a special dental handpiece
attachment that generates reciprocating strokes of
variable frequency.

 When the unit is activated interproximally with the
diamond coated site of the file touching the restoration
and the smooth side adjacent to papilla, the oscillating
file swiftly planes the contour of the restoration and
reduces it to the desired shape.

CLEANING AND POLISHING
INSTRUMENTS
RUBBER CUPS
 Consists of a rubber shell with or without webbed
configurations in the hollow interior.
 Used in the handpiece with a special prophylaxis angle.
 A good cleansing and polishing paste that contains fluoride
should be used and kept moist to minimize frictional heat as
the cup revolves.

Aggressive use of rubber cup with any abrasive may remove
the layer of cementum, which is thin in cervical area.

BRISTLE BRUSHES
 Used in prophylaxis angle with a polishing paste.
 Use of brush should be confined to the crown to avoid
injuring the cementum and the gingiva.

DENTAL TAPE
 Used for polishing proximal surfaces that are
inaccessible to other polishing instruments.
 The tape is passed interproximally while being kept at a
right angle to the long axis of the tooth and is activated
with a firm labiolingual motion.
 The area is cleansed with warm water to remove the
remnants of the paste.

AIR-POWDER POLISHING
 Prophy-Jet: introduced first in
early 1980s.
 Very effective for removal of
extrinsic stains and soft
deposits.
 Uses the slurry of warm
water and sodium
bicarbonate.
 The slurry removes stains
rapidly and efficiently by
mechanical abrasion and
provides warm water for
rinsing and lavage.

Disadvantages:
 Abrasion of tooth structure.
 Roughening of amalgam, composite resins, cements and nonmetallic
restorations.
Contraindications
 Patients with history of respiratory illness and hemodialysis.
 Hypertensive patients on sodium restricted diet or patients on
medications affecting electrolyte balance.
 Patients with infectious disease.

GENERAL PRINCIPLES OF INSTRUMENTATION
1. Accessibility: Positioning
of Patient and Operator
 Facilitates thoroughness
of instrumentation.
 Inadequte accessibility
impedes the
instrumentation, tires the
operator, diminishes his or
her effectiveness.
 Clinician’s feet flat and
thighs parallel to floor.
 Straight back and head
erect.

RIGHT-HANDED CLINICIAN LEFT-
HANDED CLINICIAN
• 7 o’ clock position to the • 5 o’ clock position, to
the
front of the patient’s head. front of the patient’s
head.
• 9 o’ clock position to the • 3 o’ clock position,
to the
side of the patient’s head. side of the patient’s
head.
• 10 to 11 o’ clock, to the • 2 to 10 o’ clock
position,
back of the patient’s head. to the back of the
patient’s
head.
• 12 o’ clock position, directly • 12 o’ clock position,
behind the patient’s behind the patient’s head.
head.

2. Visibility, Illumination and
Retraction
 Direct vision with direct
illumination from dental
light is most desirable.
 Indirect vision obtained
by using mouth mirror.
 Indirect illumination by
using retraction of
cheeks or tongue; index
finger used for retraction
of lips or cheeks.

FOLLOWING METHODS EFFECTIVE FOR RETRACTION:
Retraction of cheek using mouth mirror Retraction of lower lip using index finger
Retraction of tongue using mouth mirror

3. Condition and Sharpness of
Instruments
 Should be clean, sterile and in good condition.
 Working ends must be sharp.
 Dull instruments lead to incomplete calculus
removal and trauma.
 Advantages
- Easy removal.
- Improved stroke control and reduced number of strokes.
- Reduced clinician fatigue and increased patient comfort.

4. Maintaining a Clean Field
 Pooling of saliva interferes with visibility and impedes control.
 A firm finger rest could not be established.
 Adequate suction is essential.
• Blood and debris can be removed from the operative field with suction
and by wiping or blotting with gauze squares.
• The operative field should also be flushed occasionally with water.
• Compressed air and gauze square can be used to facilitate visual
inspection of tooth surfaces just below the gingival margin during
instrumentation.
• Retractable tissue can also be deflected away from the tooth by gently
packing the edge of gauze square into the pocket with the back of a
curette.

5. Instrumental Stabilization
INSTRUMENT GRASP
 Most effective is : MODIFIED PEN GRASP

 The thumb, index and middle finger are used to hold the
instrument, but the middle finger is positioned so that
the side of the pad next to the fingernail is resting on the
instrument shank.
 The index finger is bent on the second joint and
positioned well above the middle finger on same side of
handle.
 Pad of thumb placed midway between the middle and
index finger on opposite side of handle, hence creates
the ‘tripod effect’.

PALM AND THUMB GRASP
 Useful for stabilizing
instruments during
sharpening.
 Manipulating air and water
syringes, but it is not
recommended for
periodontal instrumentation.
 Manoeuvrability and tactile
sensitivity are so inhibited by
this grasp that it is unsuitable
for the precise, controlled
movements necessary during
periodontal procedures.

 The fourth finger is preferred for finger rest.
 Although it is possible to use third finger, but it is not
recommended as it restricts the arc of movement
during the activation of strokes.
 Maximal control is achieved when middle finger is kept
between shank and fourth finger.
 Hence these two fingers are used as a one-unit fulcrum
during scaling.

INTRAORAL FINGER REST
CONVENTIONAL :
The fourth finger rests on the
occlusal surfaces of adjacent
teeth.
CROSS-ARCH:
incisal surfaces of teeth on the
opposite side of the same arch.

OPPOSITE –ARCH :
mandibular teeth while the
maxillary posterior teeth are
instrumented.
FINGER ON FINGER:
The fourth finger rests on
index finger of the non
operating hand.

EXTRAORAL FINGER REST
 Allow optimal access and angulation while providing adequate
stabilization.
 Extraoral fulcrums are not “finger rests” in the literal sense, because the
tips or pads of the fingers are not used for extraoral fulcrums as they
are for intraoral finger rests.
PALM-UP:
Backs of the fingers rest on the right
lateral aspect of the mandible while the
maxillary right posterior teeth are
instrumented.
PALM-DOWN:
The front surfaces of finger rests on the
mandible while maxillary left posterior teeth
are instrumented.

INDEX-FINGER
REINFORCED REST:
The index finger is placed
on the shank for pressure
and control in maxillary left
posterior lingual region.
THUMB-REINFORCED
REST:
The thumb is placed on the
handle for control in the
maxillary right posterior
lingual region.

6. INSTRUMENT ACTIVATION
 ADAPTATION
Refers to the manner in which the working end of an
instrument is placed against the surface of a tooth.

The tip and side of the probe should be flush
against the tooth surface as vertical strokes are
activated within the crevice.
The lower third of the working end must be kept
in constant contact with the tooth while it is
moving over varying tooth contours.

 If only the middle third of the working end is adapted on
a convex surface so that the blade contacts the tooth at a
tangent, the toe or sharp tip will jut out into soft tissue,
causing trauma and discomfort.
 If it is adapted so that only the toe or tip is in contact ,
the soft tissue can be distended or compressed by the
back of the working end, also causing trauma and
discomfort.

INSTRUMENT ANGULATION
 It refers to the angle between the face of bladed
instrument and tooth surface.
 Also called tooth-blade relationship.

Blade angulation. A, 0 degrees: correct angulation for blade insertion.
B, 45 to 90 degrees: correct angulation for scaling and root planing.
C, Less than 45 degrees: incorrect angulation for scaling and root
planing.
D, More than 90 degrees: incorrect angulation for scaling and root
planing, correct angulation for gingival curettage.

Angulation less than 45 degrees, the
cutting edge will slide over the calculus,
smoothening or burnishing it.
Angulation more than 90 degrees, lateral
surface will be against the tooth and
calculus will be burnished
Angulation should be just
less than 90 degrees so that
cutting edge bites into
calculus.

LATERAL PRESSURE
 Refers to the pressure created when force is applied
against the surface of a tooth with the cutting edge of a
bladed instrument.
 May be firm, moderate or light.

STROKES
Three Basic strokes used:
 Exploratory Stroke
 Scaling Stroke
 Root planing Stroke
 Any of these strokes are activated in a vertical, horizontal
or oblique direction.

EXPLORATORY STROKE
Light feeling stroke used with probes or explorers
 Evaluate the dimension of the pocket
 To detect calculus and irregularities of the tooth surface.
 Grasped lightly and adapted with light pressure to
achieve maximal tactile sensitivity.

SCALING STROKE
 Short, powerful pull stroke.
 Removal of supragingival and
subgingival calculus.
 The cutting edge engages the
apical border of calculus and
dislodges it with a firm
movement in coronal
direction.
 Finger flexing is indicated for
precise control over stroke in
line angles and lingual or
facial aspects of narrow
rooted teeth.

ROOT PLANING STROKE
 Moderate to light pull stroke.
 Used for final smoothening
and planing of root surface.
 Curette is adapted to the
tooth surface with even,
lateral pressure.
 A continuous series of long,
overlapping shaving strokes
is activated.

PRINCIPLES OF SCALING AND ROOT
PLANING
DETECTION SKILLS
Visual examination
 Compressed air may be used to dry supragingival
calculus until it is chalky white and readily visible.
 Air also may be directed into the pocket in a steady
stream to deflect the marginal gingiva away from the
tooth so that subgingival deposits near the surface can
be seen.

Tactile exploration
 The explorer or probe is
held with a light but stable
modified pen grasp.
 When calculus is
encountered, the tip of the
instrument should be
advanced apically over the
deposit until the
termination of the calculus
on the root is felt.

 The distance between the apical edge of the calculus and
the bottom of the pocket usually ranges from 0.2 to 1.0 mm.
 The tip is adapted closely to the tooth to ensure the greatest
degree of tactile sensitivity and avoid tissue trauma.
 When a proximal surface is being explored, strokes must be
extended at least halfway across that surface past the
contact area to ensure complete detection of inter-proximal
deposits.
 When an explorer is used at line angles, convexities, and
concavities, the handle of the instrument must be rolled
slightly between the thumb and fingers to keep the tip
constantly adapted to the changes in tooth contour.

SUPRAGINGIVAL SCALING
TECHNIQUE
 Sickles, curettes, and ultrasonic and sonic instruments are most
often used for the removal of supragingival calculus; hoes and
chisels are less frequently used.
 The sickle or curette is held with a modified pen grasp, and a firm
finger rest is established on the teeth adjacent to the working area.

 The blade is adapted with an angulation of slightly
less than 90 degrees to the surface being scaled.
 The cutting edge should engage the apical margin
of the supragingival calculus while short, powerful,
overlapping scaling strokes are activated coronally
in a vertical or an oblique direction.

The tooth surface is instrumented until it is visually
and tactilely free of all supragingival deposits.

SUBGINGIVAL SCALING AND ROOT
PLANING
 The curette is preferred by most clinicians for subgingival
scaling and root planing because of the advantages
afforded by its design.
 Its curved blade, rounded toe, and curved back allow
the curette to be inserted to the base of the pocket and
adapted to variations in tooth contour with minimal
tissue displacement and trauma.

 The curette is held with a
modified pen grasp, and a
stable finger rest is established.
 The correct cutting edge is
slightly adapted to the tooth,
with the lower shank kept
parallel to the tooth surface.
 The blade is then inserted under
the gingiva and advanced to the
base of the pocket by a light
exploratory stroke.

 When the cutting edge
reaches the base of the
pocket, a working
angulation of between 45
and 90 degrees is
established, and pressure
is applied laterally against
the tooth surface.
 Calculus is removed by a
series of controlled,
overlapping, short,
powerful strokes primarily
using wrist-arm motion.
SUBGINGIVAL SCALING PROCEDURE.
A Curette inserted with the face of the blade
flush against the tooth.
B Working angulation (45-90 degrees) is
established at the base of the pocket.
C Lateral pressure is applied, and the scaling
stroke is activated in the coronal direction.

 Longer, lighter root-planing strokes are then activated
with less lateral pressure until the root surface is
completely smooth and hard.
 The instrument handle must be rolled carefully between
the thumb and fingers to keep the blade adapted closely
to the tooth surface as line angles, developmental
depressions, and other changes in tooth contour are
followed.

 The amount of lateral pressure applied to the tooth surface
depends on the nature of the calculus and whether the strokes
are for initial calculus removal or final root planing.
 If heavy lateral pressure is continued after the bulk of calculus
has been removed and the blade is repeatedly readapted with
short, choppy strokes, the result will be a root surface
roughened by numerous nicks and gouges, resembling the
rippled surface of a washboard.
 If heavy lateral pressure is continued with long, even strokes,
the result will be excessive removal of root structure, producing
a smooth but “ditched” or “riffled” root surface.

INSTRUMENTATION IN PROXIMAL
SURFACES
 A common error in is failing to reach the midproximal
region apical to the contact.
 This area is relatively inaccessible, and the technique
requires more skill than instrumentation of buccal or
lingual surfaces.
 With properly designed curettes, this can be
accomplished by keeping the lower shank of the curette
parallel with the long axis of the tooth.
 The blade of the curette will reach the base of the
pocket and the toe will extend beyond the midline as
strokes are advanced across the proximal surface.

 If the lower shank is angled or tilted away from the tooth,
the toe will move toward the contact area.
 Because this prevents the blade from reaching the base
of the pocket, calculus apical to the contact will not be
detected or removed.
A, Correct shank position, parallel with
the long
axis of the tooth. B, Incorrect shank
position, tilted away from the tooth. C,
Incorrect shank
position, tilted too far toward the tooth.

axillary right posterior sextant: facial aspect. Maxillary right posterior sextant,
premolar region only: facial aspect
Maxillary right posterior sextant: lingual
aspect.
Maxillary anterior sextant: facial aspect

Maxillary anterior sextant: lingual aspect Maxillary left posterior sextant: facial aspec
axillary left posterior sextant: facial aspect.Maxillary left posterior sextant: lingual aspe

Mandibular left posterior sextant: facial
aspect.
Mandibular left posterior sextant:
lingual aspect.
andibular anterior sextant: facial aspect Mandibular anterior sextant: lingual aspect

Mandibular right posterior sextant:
facial aspect.
Mandibular right posterior sextant: lingua
aspect.

SHARPENING OF INSTRUMENTS
 With use against the tooth
surface, the metal is worn
away from the cutting
edge until it becomes a
rounded surface instead of
a fine line.
 A dull cutting edge is a
rounded junction between
the face and lateral
surface of instrument.

EVALUATING SHARPNESS
 Visual Examination
 A dull cutting egde reflects
light as it is rounded and
thick, whereas sharp edge
doesn’t.
 Tactile Examination
 Use of a sharpness stick
test.
 A dull cutting egde slides
over the surface of the
stick while the sharp egde
scratches the stick

SHARPENING STONES
MOUNTED STONES
 Mounted on a metal mandrel and used in a motor-driven
handpiece.
 They may be cylindrical, conical, or disc shaped.
 These stones are generally not recommended for routine
use because they
(1) are difficult to control precisely and can ruin the shape of
the instrument,
(2) Tend to wear down the instrument quickly, and
(3) can generate considerable frictional heat, which may affect
the temper of the instrument.

UNMOUNTED STONES
 Some are rectangular with
flat or grooved surfaces,
whereas others are
cylindrical or cone shaped.
 Unmounted stones may be
used in two ways: the
instrument may be
stabilized and held
stationary while the stone
is drawn across it, or the
stone may be stabilized
and held stationary while
the instrument is drawn
across it.
Top to bottom, A flat India stone, a flat
Arkansas stone, a cone-shaped
Arkansas stone, and a ceramic stone.

PRINCIPLES OF SHARPENING
 Choose an appropriate stone.
 Sterilization of the stone.
 Establish the proper angle between the stone and
surface of the instrument.
The stone makes a 100- to 110-degree
angle with the face of the blade.
The stone meets the blade at an
angle of 100 to 110 degrees.

When the entire bevel on a chisel
contacts the sharpening stone, the
angle between the
instrument and the stone is 45 degrees.
Back-action chisels and hoes are
sharpened with a pull stroke.
As with the curette, the sickle has an
angle of 70 to 80 degrees between the
face of the blade and the lateral surface.

 Avoid heavy pressure as it may lead to quick grinding of
the surface by the stone.
 Avoid the formation of a “wire edge,” characterized by
minute filamentous projections of metal extending as a
roughened ledge from the sharpened cutting edge.
 A wire edge is produced when the direction of the
sharpening stroke is away from, rather than into or
toward, the cutting edge.
 Lubricate the stone during sharpening. This minimizes
clogging of the abrasive surface of the sharpening stone
with metal particles removed from the instrument.

ULTRASONIC AND SONIC INSTRUMENTATION

Mechanism of Action
 Various physical factors play a role in the
mechanism:
FREQUENCY
 Number of times per second an insert tip moves back
and forth during one cycle in an orbital, elliptical or linear
stroke path.
 Determines the area of the insert tip that is considered
active.
 Higher frequency results in a smaller active area of an
insert tip.

STROKE
 It is the maximum distance an insert tip
travels during one cycle or stroke path.
 Amplitude is equal to one-half the distance of
the stroke.
 High power settings produce a longer stroke
pattern and vice versa.

WATER FLOW
 Water contributes to the three physiological effects that
enhance the efficacy of scalers:
 Acoustic Streaming: unidirectional fluid flow caused by
ultrasound waves.
 Acoustic turbulence: created when the movement of the
tip causes the coolant to accelerate, produces an
intensified swirling effect.
 Cavitation: formation of the bubbles in the water caused
by high turbulence. The bubbles implode and produce
shock waves in the liquid.

Types of POWERED INSTRUMENTS
SONIC SCALERS
 Air-driven scalers in which
frequency produces a vibration
of the insert tip.
 Use a high-speed or low speed
air source from the dental unit.
 Tips are large in diameter and
universal in design.
 Elliptical to orbital stroke
pattern, which allows the tip to
adapt to all tooth surfaces.

ULTRASONIC SCALERS
PEIZOELECTRIC:
 Ceramic discs located in the handpiece.
 Can change the dimension as electric energy is applied to
the tip.
 Move in a linear pattern
 Two active surfaces of the tip.

MAGNETOSTRICTIVE
 Metal stacks that change dimension when electrical
energy is applied power magnetostrictive technology.
 Vibrations travel from the metal stack to a connecting
body, causing the vibration of the tip.
 Elliptical or orbital stroke pattern.
 Four active working surfaces.

EFFICACY AND CLINICAL OUTCOMES
1. Plaque and Calculus Removal
 Remove heavy subgingival calculus deposits.
 Both deplaquing of root surfaces and subgingival
scaling may be accomplished.

 Clifford et al. found that both traditional ultrasonic and
microultrasonic inserts were effective in disrupting the apical
plaque border.
 Gagnot et al.found that ultrasonic miniinserts were more effective
in the apical plaque zone than curettes.
 Garnick and Dent showed that both hand and ultrasonic
instrumentation removed plaque equally well.
 Busslinger et al. found that hand and ultrasonic instrumentation
with either a magnetostrictive or a piezoelectric insert were equally
effective in calculus removal.
 Patterson et al. found sonic and ultrasonic scalers removed similar
amounts of calculus.

2. Bacterial reduction and cementum
removal
 Ultrasonic instruments using high-speed action produce cavitational activity and acoustic
microstreaming that may facilitate the disruption of the bacteria in subgingival biofilms.
 Some in vitro studies have shown that cavitational activity and acoustic microstreaming
may enhance cleaning efficacy and increase plaque reduction.
 O’Leary et al. found that up to 5 minutes of ultrasonic activation resulted in significant
killing of Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis. However, the
investigators acknowledged that increased temperature caused by “sonication” may have
contributed to the reduction.
 Conversely, Schenk et al. found that neither sonic nor ultrasonic scaling was capable of
killing A. actinomycetemcomitans or P. gingivalis.

 Leon and Vogel, found that ultrasonic instrumentation in
class II and class III furcations was more effective in
reducing bacteria and keeping bacterial at a healthy level
longer than hand instrumentation.
 Renvert et al. demonstrated that neither root
debridement with ultrasonic scaling nor osseous flap
surgery eliminated A. actinomycetemcomitans.
 Oosterwaal et al. studied subgingival plaque samples
after scaling using ultrasonic or hand instruments and
found that both reduced subgingival microbiota to a level
consistent with periodontal health.

3. Furcation Access
 Leon et al. demonstrated that ultrasonic scalers were equal to hand
scalers in reducing the bacteria in class I furcations but more effective
in class II and III furcations.
 Sugaya et al. found that an ultrasonic tip specifically designed for
furcations was more effective in debriding either class II furcations or
furcations with a horizontal probing depth greater than 2 mm.
 Patterson et al. found that both ultrasonic and sonic tips were similar
in their ability to remove calculus in furcations.
 Diamond-coated sonic tips have also been shown to be effective in
furcation debridement but are generally recommended for open
debridement.

4. Reduced Time
 Reduce the amount of time needed for scaling and root
planing, a benefit for both the practitioner and the
patient.
 Copulos et al. found that instrumentation time per tooth
with an ultrasonic scaler was 3.9 minutes versus 5.9
minutes for hand instruments.
 Kocher and Plagmann found that a diamond-coated
sonic scaler used to debride furcations during flap
surgery reduced treatment time by 50% over hand
instrumentation.

Disadvantages
1. Aerosol Production
 Barnes et al. demonstrated that the aerosol produced
by the in vivo use of an ultrasonic scaler on periodontally
involved teeth was contaminated with blood and that
the contamination occurred regardless of the level of
inflammation.
 Rivera-Hidalgo et al. compared focused-spray and
standard-spray ultrasonic inserts and found that each
produced an equal amount of aerosol contamination.

 Harrel and Molinari recommend three levels of defense
in the reduction of dental aerosols:
(1) personal protective barriers, such as a mask, gloves, and
safety glasses;
(2) routine use of a preprocedural antiseptic rinse; and
(3) use of a highspeed evacuation device by a dental
assistant or attached to the instrument being used.
 High-speed evacuation, aerosol reduction devices
attached to the ultrasonic scaler, and antiseptic rinsing
have all been shown to reduce aerosol contamination.

2. Patients with cardiac pacemakers
 Miller et al. found atrial and ventricular pacing was
inhibited by electromagnetic interference produced by a
magnetostrictive ultrasonic scaler.
 A sonic scaler was also tested but did not produce the
same effect.

 A modified pen grasp is used with an ultrasonic scaler,
together with an extraoral fulcrum.
 The extraoral fulcrum allows the operator to maintain a
light grasp and easier access physically and visually to the
oral cavity.
 Alternate fulcrums using cross-arch or opposite-arch finger
rests are acceptable alternatives.
 Light pressure is needed with a power instrument. The tip is
traveling at a set frequency in a set stroke pattern. Increased
pressure by the clinician on the tip causes decreased clinical
efficacy.

 Sonic/ultrasonic instrumentation requires removal from the
coronal to the apical portion of the deposit.
 This stroke pattern allows the insert to work at its optimal stroke
pattern and frequency for quick, effective removal of deposits.
 A deplaquing stroke should be used when the focus is removal of
biofilm and soft debris for the resolution of gingival inflammation.
 This stroke entails accessing every square millimeter of the tooth
surface during ultrasonic deplaquing because of the limited
lateral dispersion of the lavage subgingivally.

ACTIVE TIP AREA
 Portion of instrument tip that is capable of doing work.
 It is the vibration energy of a powered instrument tip that is
responsible for calculus removal.
 Active tip area ranges from 2 to 4 mm of length of the instrument
tip.
 Higher the frequency of instrument, shorter the active tip area.

Adaptation
 Point of Tip: should never be adapted on the tooth
surface. The high energy output could damage the
tooth.
 Face of Tip: Should not be adapted to tooth surface
due to high energy output.
 Back of Tip: Most effective in debridement in
magnetostrictive units. The back can be adapted to
tooth surfaces.
 Lateral Surfaces of Tip: Adaptation is
recommended with all sonic, peizoelectric and
magnetostrictive units.

 The tip is kept in constant contact to the tooth.
 Calculus removal: gentle tapping motion.
 Subgingival deplaquing: gentle sweeping motion.

INSTRUMENT TIP WEAR AND
REPLACEMENT
 A rule of thumb is that 1mm of wear results in
approximately 25% of the tip wear.
 Approx. 50% loss of efficiency occurs at 2mm of
wear and tip should be discarded at this point.

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