Manual Periodontal Instrumentation Bailey1

Introduction
Periodontal
Instrumentation
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
30
37
68
106
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!
4
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
Session
Topic
Carrenza
Bailey et al
Pre-Class
Pre-Class
Intro-Lab Prep
Asepsis
Ch. 36
Bailey 7-10
Module 24 (handout)
Video-Christensen
Video-Modified Ultrasonics Bailey/Moody
March 6
Lecture
Mechanical Scal- Ch. 43

ers
Bailey 49-80
Module 21 (handout)
March 13
Spring Break
Party
Get a Tan
March 20
Clinical@Dr. B Ultrasonics
Office
March 27
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
April 3
Clinic
Risk Assessment
Oral Hygiene
Prophylaxis
Fluoride
April 10
Lecture
Hand Instrumentation
Lab-Sharpening
Patients
April 17
Clinic
April 26?
Comprehensive Observation
Final
Report Due
Have Fun
Module III-Pattison
Module IV-Pattison
5
Creighton University School of Dentistry

Freshman 2004-2005 Instrument List
Periodontics Instruments
Item
Unit
1.
1 each
Gracey Curettes G1/2 Ultra Handle
2.
1 each
Gracey Curettes #11/12 Ultra Handle
3.
1 each
Gracey Curettes #13/14 Ultra Handle
4.
1 each
PQ2N Black Coded Nabers Probe
5.
1 each
11/12 Explorer
6.
1 each
Black Coded Probe (3-6-9-12)
7.
1 each
McCall Curettes, #13/14 Ultra Handle
8.
1 each
McCall Curettes, #17/18 Ultra Handle
9.
1 each
H-6/7 Straight Sickle Scaler
10.
1 each
McBim Sharpening Stone, 2 sided
11.
1 each
Barnhart Curettes, 1/2 Ultra Handle
12.
1 each
Plastic Test Stick
13.
2 each
Double Sided Mirrors
Other
Description
Prophy angles, paste, handpiece, eye goggles,

lab coat, patient mirror, napkin clips
6
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
7
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.
Paper Clip
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!
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!
10
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
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!
WHO
Williams dia
WHO mark.
marks @3.5,
8.5,11.5,and
.05 ball @ end
Good diameter,
Large diameter
Screening Probes!
11
Specialty Probes
Furcation Probes
In addition to the general periodontal probes
May have markings
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.
#1N
#2N
These probes were developed by Dr Claude

Nabors and bear his name.
Non-Metallic
Plastic or plastic-like probes also exist. Many of these were designed to be discarded ie.
single use. Some practitioners prefer to use non-metallic instruments around dental
implants.
Plastic probe with a

pressure sensor
12
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!
13
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.
Smart Practice
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!
Image #1
Image #2
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.
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
14
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
Scaler
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.
Targeted mostly for Not as variable as

supragingival areas the curette
Generally heavier
shank/cutting edge
than curette
Most are pointed
H-6/H-7 Straight
sickle scaler
15
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
Area-Specific 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!
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.
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!
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
16
Gracey Series Curettes

Instrument
Where Used
1/2
Anterior areas
3/4
Anterior areas
5/6
Anterior and premolars
7/8
Posterior facial & lingual
9/10
Posterior facial & lingual
11/12
Posterior-mesial areas
13/14
Posterior-distal areas
15/16
Posterior-mesial areas
Note: As a general
rule, the low numbers
are for the anterior and
the higher numbers are
progressively for the
posterior 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!
Tip
Head
Area-Specific
Lateral
Tip
Blade is curved in
two directions--tipshank & left-right
(lateral edges)
Extended Shank
Designed for deeper pockets
After Five series
Small Bladed
Blades are 1/2 size
Mini-Five
Curvettes
Shank Differences
Rigid
Flex
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
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!
18
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
19
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!
20
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
Lateral Edge
Back
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
21
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!
Dull Edge
A broad surface area
mirrors back light. Appears
as a bright line or area.
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!
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!
22
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.
23
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.
24
25
26
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!
27
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
28
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!
29
Laboratory Scaling

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
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
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 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.
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.
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!
30

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!
31
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
Intact periodontal fibers
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)
32
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.
33
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.
34
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!
35
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).
36
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!
37
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!
38
Creighton Periodontal Chart
39
40
Example
March 22, 2000
Patient
eg. Doctoor Soon Tobee
Examining student
41
42
Example
43
For Clinical Use
44
For Clinical Use
45
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.
46
Oral Hygiene
Device/Method
Brand/Type
Show Patient
Patient Demo
List Method
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)
47
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
49
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.
50
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???
51
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
52
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
Microson
Manual/Auto Tune $599
ID595-MTAH
660
76
Not Available
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.
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.
53
54
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
Custom
Cost
$95
$100
$95
$130
$135
Comments
For the longest of time tips were
all that Tony made. Exceptional
quality*
$135
$145
$145
$125
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!
Customized large
$100
diameter tips to very
fine tips.*
*Note:
When ordering the above, be sure to specify ultrathin!
**Note:
Many of the above can be re-tipped at a fraction of original cost.

Ask the manufacturer.
55
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!
56
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.
57
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
Advantages
Clip-on Reading
Glasses
Least Costly
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
Disadvantages
Requires eyeglass frame
Eye-to-object distance frequently requires user to
bend the head downward.
Cost
Tend to be heavy but new
materials have helped fixed
magnification
Cost
Large, bulky arms
A major equipment purchase
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
Global
(303)306-9826
Skyler
$8,000-25,000
58
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.
60
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.
62
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!
63
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!
64
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!).
3.
Continue to adjust tuning as needed for debridement

and for patient comfort.
Note: Even with no deliberate changes,

occasional slight changes in tuning are
necessary to maintain cleaning efficiency.
65
DEBRIDEMENT CONTINUED
Initial Continuing
Power
Light Calculus
Lowest
Moderate Calculus Heavy Calculus

Lowest
Lowest
Tune
Minimal, can just

barely feel, no
auditory
Moderate, can feel,

hear, and see light
mist
High (tuned), feel, hear,

visual H20 spray
(rooster tail)
H2 0
Copious
Copious
Copious
Tip Orientation
Parallel to long axis

of tooth
Same
Same
Tip Movement on
Tooth
Occlusal-to-apical
and circumferential
Contacts all areas
of crown and rootthat are accessible
Same
Same
66
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.
Use in advanced periodontitis cases
2.
Use in soft-tissue curettage
3.
Incorporating ultrasonics, soft-tissue curettage, and anti-microbials

(Ultrasonic Bacterial Curettage UBC)
68
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.
Power Setting
Tuning
Recall Patient
Advanced Perio Patient
At lowest point
Usually at lowest point
Low
Frequently fully tuned
Tips
Universal R&L ultrathin
Same
H2 0
As much as can control
As much as can control (high

volume important to flush the
pockets)
Anesthetic
Generally not
Usually required
Magnification
Important
Approaching mandatory
69
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.
70
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.
71
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
72
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
73
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
Ultrasonic as Curette
1.
Instrument Shape
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.
2.
Constant Vibration
The frequency is constant so that cutting

forces produce uniform soft-tissue removal.
3.
Irrigation
The constant fluid flow flushes out the pocket

to remove tissue, calculus, bacterial products,
and enhances visibility.
4.
Superior Tactile Sensations
The ultrasonic actually enhances tactile feel

over hand instrumentation.
5.
Highly Variable
Frequency can be changed to remove tissue of

varying density.
6.
Decreased Hemorrhage
Uniform cutting and copious irrigation

decrease overall bleeding and post-op pain
74
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.
75
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
76
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.
77
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.
78
COMPARISON OF CHX V. H20

As Irrigant in Ultrasonic Debridement
H2 0
Chlorhexidine --CHX
Availability/Cost
Readily/Low
Limited/Moderate
Taste
None
Metallic/slightly objectionable
Effect on Units
None
* May harm some units

* Residual in units
Patient Acceptance
High
Low-requires prior explanations
Therapeutic Effects
Moderate
High
As usage of ultrasonic debridement increases, there will be increased research into 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
79
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
Therapeutic Benefits of Polishing
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!
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
80
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
81
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!
82
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!
87
Sequence For Learning Basic

Instrumentation Techniques
Sextants--Mandibular Arch
Right Handed Operator
Posterior Teeth:
Anterior Teeth:
Molars-Bicuspids
Cuspid-to-Cuspid
I.
A.
B.
Buccal SurfacesMandibular Right Posteriors

Lingual SurfacesMandibular Right Posteriors
II.
A.
B.
Labial SurfacesMandibular Anteriors

Lingual SurfacesMandibular Anteriors
III.
A.
B.
Buccal SurfacesMandibular Left Posteriors

Lingual SurfacesMandibular Left Posteriors
88
Mandibular Arch
I. Mandibular Right Posterior:
A.
(MolarsBicuspids)
Buccal Approach
Operator Position: 8-9 oclock
Patient Position:
Head turned slightly toward operator.
Mirror:
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
b.
Use direct vision.
a.
4th finger rest on occlusal surfaces of

mandibular right bicuspids.
b.
Move finger rest to the incisal surfaces

of the mandibular anterior teeth as you
progress forward.
Fulcrum:
89
Mandibular Right Posterior Contd
B.
Lingual Approach
Operator Position: 8 oclock (try 11 oclock also)
Patient Position:
Head turned toward operator.
Mirror:
a.
4th finger rest on the occlusal surface of

the cross-arch teeth.
b.
Retract tongue with mirror in other hand
c.
Reflect light.
d.
Use indirect or direct vision.
Fulcrum:
a.
b.
4th finger rest on the labial-incisal

surfaces of mandibular anteriors
Move finger rest as you progress
forward.
90
Mandibular Arch Contd
Mandibular Anterior: (Cuspid-Cuspid)

A.
Labial Approach
I.
Surfaces Toward The Patients Right

Operator Position: 8 oclock (11 oclock)
Patient Position:
Head straight, turn head toward operator as

needed.
Mirror:
a.
None (place on bracket tray or tuck in

left hand).
b.
Retract lower lip with left index finger.
c.
Use direct vision.
Fulcrum:
4th finger rest on labial-incisal surfaces of

adjacent teeth--occlusal surfaces if in
11 oclock position.
91
Mandibular Anterior Contd
II A. Labial Approach (Surfaces Toward The Patients Left)

Operator Position: 11 oclock or 8 oclock
Patient Position:
Head straight, turn head toward operator as

needed.
Mirror:
a.
None.
b.
Retract lower lip with left index finger.
c.
Use direct vision.
Fulcrum:
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
92
Mandibular Anterior Contd
II.
B. Lingual Approach (Mandibular Anterior)

I.
Surfaces Toward Patients Right

Operator Position: 8 oclock (try 11 oclock also)
Patient Position:
Head turned toward operator, lower chin.
Mirror:
a.
4th finger rest on handle of the mirror.
b.
4th finger rest on the buccal-occlusal of

the mandibular right bicuspid to lateral
area.
c.
Retract tongue with mirror
d.
Reflect light.
e.
Use indirect vision.
Fulcrum:
4th finger rest on the incisal surfaces of

adjacent teeth
93
Mandibular Anterior Condtd
II.
B.
Lingual Approach (Surfaces Toward Patients Left )

Operator Position: 11 oclock ( try 8 oclock also)
Patient Position:
Head slightly turned toward operator, chin

lowered.
Mirror:
a.
4th finger rest on the buccal surfaces of

mandibular left bicuspid-cuspid area.
b.
Retract tongue with mirror
c.
Reflect light.
d.
Use direct or indirect vision.
Fulcrum:
4th finger rest on incisal surfaces of adjacent

teeth to the patients right of area being
instrumented left if in 8 oclock position).
94
Mandibular Arch Contd
III.
Mandibular Left Posterior (Molars-Bicuspids)

A.
Buccal Approach
Operator Position: 11 oclock (8 oclock)
Patient Position:
Mirror:
a.
4th finger rest on shank of mirror.
b.
Retract buccal mucosa with mirror.
c.
Use direct vision.

Note: For distals of 2nd & 3rd molars, use
mirror for indirect vision when necessary.
a.
4th finger rest on buccal-occlusal surfaces of

mandibular left bicuspid-cuspid area.
b.
Move finger rest to incisal surfaces of

mandibular anterior teeth as you progress
forward.
Fulcrum:
95
Mandibular Left Posterior Contd
III.
B. Lingual Approach (Mandibular Left Posterior)

Operator Position: 8-9 oclock
Patient Position:
Head straight or slightly away.
Mirror:
a.
4th finger rest on mirror handle
b.
Retract tongue with mirror surface.
c.
Use direct vision.
d.
May use indirect vision for distals.
a.
4th finger rest on buccal-occlusal

surfaces of mandibular left bicuspids.
b.
Move finger rest to the labial-incisal

surfaces of the mandibular left anteriors
as you progress forward.
Fulcrum:
96
Sequence For Learning Basic

Instrumentation Techniques
Sextants--Maxillary Arch
Right Handed Operator
Posterior Teeth:
Anterior Teeth:
Molars-Bicuspids
Cuspid-To-Cuspid
IV.
A.
B.
Buccal SurfacesMaxillary Right Posteriors

Lingual SurfacesMaxillary Right Posteriors
V.
A.
B.
Labial SurfacesMaxillary Anteriors

Lingual SurfacesMaxillary Anteriors
VI.
A.
B.
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:
Head turned slightly away from operator.
Mirror:
a.
4th finger placed on shank of mirror.
b.
Retract buccal mucosa either with mirror

or index finger of non-operating hand
c.
Use direct vision.
d.
Indirect vision for distals of molars.
a.
4th finger rest may be on the labialincisal surfaces of bicuspid-cuspid area.

Move finger rest anteriorly as you
progress forward.
Fulcrum:
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:
a.
4th finger rest on labial surfaces of the

maxillary left lateral-cuspid area.
b.
Reflect light.
c.
Use direct vision.
d.
Use indirect vision for details.
Fulcrum:
4th finger rest on occlusal surface of tooth

being instrumented or adjacent teeth.
99
V.
Maxillary Anterior:
(Cuspid-Cuspid)
A.
Labial Approach
I.
Surfaces Toward Patients Right

Operator Position: 8 oclock (11 oclock also)
Patient Position:
Head straight. Turn head slightly toward

operator as you progress to left cuspid.
Mirror:
a.
No mirror, use direct vision.
b.
Left index finger retracting upper lip.
100
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.
Mirror:
a.
None. Use direct vision.
b.
Left index finger retracting upper lip.
Fulcrum:
4th finger rest on incisal surface to the

patients left of the area or on the tooth
being instrumented.
101
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
102
Maxillary Anterior Lingual Contd
V.
Maxillary Anterior Lingual Approach

B. Lingual
II. Surfaces Toward Patients Left
Patient Position:
Head turned toward operator, chin

raised
Mirror:
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
103
Maxillary Arch Contd
VI. Maxillary Left Posterior

A. Buccal Approach
Patient Position:
Head turned toward operator
Mirror:
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.
104
Maxillary Left Posterior Contd
VI.
B.
Maxillary Left Posterior Lingual Approach

Operator Position: 8 oclock and 11 0clock
Patient Position:
Head turned slightly away from operator, chin

raised.
Mirror:
a.
4th finger rest on labial of maxillary

right cuspid.
b.
Reflect light.
c.
Use direct vision.
Fulcrum:
4th finger rest on buccal-occlusal surface of

tooth being instrumented or slightly posterior
to area being instrumented.
105
A Philosophy of Patient Treatment
106

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Introduction

PERIO INSTRUMENTATIONPER 132

Mechanical Scal- Ch. 43

Risk Assess-Perio Ch. 4 & 32 Bailey 38-46

Creighton University School of Dentistry

Gracey Curettes G1/2 Ultra Handle

Gracey Curettes #11/12 Ultra Handle

Gracey Curettes #13/14 Ultra Handle

PQ2N Black Coded Nabers Probe

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,

Dental Asepsis Standards

Note: A current video demonstrating these and other procedures

Making the Model

2. Arrange the teeth in a natural arch form,

The thin segment that joins the handle to the working

Periodontal Instrument Classification

Marquis diameter Mich O diameter Mich O diameter Mich O diameter

Good diameter and

Good diameter, easy

May have markings

previously described, specialty probes which

These probes were developed by Dr Claude

Plastic probe with a

Explorers should be applied to

Concave--as with other mirrors and

Clinical Tip--to minimize mirror

Front Surface(Concave)--the most

Other--there are many

Scaling/Root Planing Instruments

Targeted mostly for Not as variable as

Most are pointed

As the name implies, these instruments

Originally designed by Dr Clayton

Although the blade size and the length

Also, universals have two

Gracey Series Curettes

Anterior and premolars

Posterior facial & lingual

Posterior facial & lingual

Note: Best way to determine the blade

Holding Periodontal Instruments

Ring finger along side

Modified Pen Grasp

Holding Perio Instru

Finger Rest (fulcrum)

Preferred Fulcrum Sites

*The Heavy Handed Clinician--scaling does require

*A Time Waster--dull instruments

On a curette, a sharp edge is formed

The sharpness of an instrument is

Evaluating Sharpness Contd

Note: One of the issues of using

Sharpening Devices and General Principles

There are several mechanical sharpeners

Laboratory Scaling Exercises

General Principles for the Model