Periodontal Therapy:Manual Scaling and Root planing

Erry Mochamad AriefSenior Lecturer in Periodontics

Objectives After periodontal instrumentation session, student should be able to demonstrate y Proper position of the patient and the operator (Accessibility)y Visibility, illumination and retraction y Condition of instruments (sharpness)y Maintaining a clean field y Instrument stabilization: Instrument grasp, Fulcrum or Finger resty Instrument activation: Adaptation, Angulation, Lateral pressure, and Strokey Selection of the proper instrumeny Technique for periodontal probing, determining attachment loss, using dental explorer,

furcation detectiony Technique for tooth mobility quantificationy Technique for using Chisel, Sickle and Wing shaped, Curettey Manual Scaling and root planing technique in different areas of the mouth

2 30/10/08

PHASES OF PERIODONTAL THERAPYy Phase I therapyy Started after E&D and treatment planningy Removal bacterial plaque and all irritants (periodontal instrumentation)y OH Instruction

y Maintenance phasey All patients that undergo periodontal therapyy Patients return to clinic for evaluation, periodontal instrumentation, and

reinforcement of OH techniques.

y Phase II therapyy Surgical (periodontal instrumentation)

All phases need periodontal instrumentation

3 30/10/08

Periodontal Instrumentationy Scaling: to remove plaque and calculusy Root planing: to remove plaque, calculus,

endotoxiny Stain removaly Surgery

4 30/10/08

Principles of Instrumentation1. Accessibility (positioning of patient and operator)2. Visibility, illumination and retraction3. Condition of instruments (sharpness)4. Maintaining a clean field5. Instrument stabilization6. Instrument activation7. Selection of the proper instrument

5 30/10/08

1. Positioning

y prevent clinician and patient from discomfort and injury

y permit a clear view, the best is direct vision

y allow easy access to the teeth

y efficient: time and energy

6 30/10/08

Clinical/Operator positionNeutral position

7 30/10/08

30/10/088

30/10/089

30/10/0810

30/10/0811

30/10/0812

13 30/10/08

30/10/0814

Patient Head Position

15 30/10/08

16

Supine patient position: The patients heels should be slightly higher than the tip of his or her nose

Adjust his/her head to provide best view: chin up/down, toward/straight/ away

30/10/08

Visibility, illumination and retractiony Direct vision with direct illuminationy Indirect vision by using mouth mirrory Indirect illumination by using mouth mirrory Retraction provides visibility, accessibility and

illumination by using mirror or fingersy Softening the lips with petroleum jelly/vaseline to

prevent cracking and bleeding

17 30/10/08

maxilla

mandibularDental light position

18 30/10/08

Sharpness

y When the instrument is sharp, the cutting edge is a fine liney Light reflected from the

rounded cutting edge of a dull instrument appears as a bright line.

19 30/10/08

Maintaining a clean fieldy From saliva, blood, and debrisy Pooling saliva interferes: visibility, firm finger rest

cannot be establishedy Blood and debris can be removed by wiping with

gauzey Operative field should be flushed occasionally with

water

20 30/10/08

Instrument stabilization

30/10/0821

y Instrument graspy Finger rest

Fulcrum (finger rest) y Stabilizes the clinicians hand during instrumentationy Intraoral and extraoral fulcrum

30/10/0822

Instrument activationyAdaptationyAngulationyLateral pressureyStrokes

23 30/10/08

Adaptation

y Is placing the first one or two millimeters of the side of the working end in contact with the tooth surface

Adapted Not-adapted

24 30/10/08

30/10/08Adapted Not-adapted25

Angulation

y Is the angle formed between the face of instrument and the tooth surfaces

30/10/0826

Incorrect

27 30/10/08

Subgingival scaling procedure.

A, Curette inserted with the face of the blade flush against the tooth.

B, Working angulation (45 to 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.

28 30/10/08

Lateral pressurey Is the act of using the thumb and index finger to

engage (press) the cutting edge against the tooth surface or calculus deposity The amount of pressure must be varied according to

the nature of the calculus and according to whether the stroke is intended to remove calculus or to smooth the root surface.y Lateral pressure may be firm, moderate, or lighty The careful application of lateral pressure during

instrumentation is important

29 30/10/08

Wrist motion activationy Is the act of rotating the hand and wrist as a unity Similar with turning a doorknoby Recommended for calculus removal with hand activated

instr.y More powerful and less fatigue than digital motion

activation

30 30/10/08

Digital motion activationy Is moving the instrument by flexing the fingersy It may be used with periodontal probes, explorers, and

ultrasonic instruments or where movement is very restricted, such as in furcation areas

31 30/10/08

Instrumentation Strokesy Strokes Direction

32 30/10/08

Instrumentation for calculus removaly A, Calculus is removed by engaging the

apical or lateral edge of the deposit with the cutting edge of a scaler; vertical movement of the instrument will remove the fragment of calculus engaged by the instrument

y B, The instrument is moved laterally and again engages the edge of the calculus, overlapping the previous stroke to some extent

y C, The final portion of the deposit is engaged and removed. Note how the procedure is performed in an interdental space by entering facially and lingually.

33 30/10/08

30/10/0834

SCALING IN DIFFERENT AREAS OF THE MOUTH

y MAXILLARY TEETH

35 30/10/08

Maxillary right posterior sextant: facial aspect

y Operator: Side position (9 o'clock).

y Illumination: Direct. y Visibility: Direct (indirect for

distal surfaces of molars). y Retraction: Mirror or index

finger of the non-operating hand.

y Finger rest: Extraoral, palm up. Backs of the middle and fourth fingers on the lateral aspect of the mandible on the right side of the face.

36 30/10/08

Maxillary right posterior sextant: lingual aspect.

y Operator: Side position (9 oclock). y Illumination: Direct and

indirect. y Visibility: Direct or indirect. y Retraction: None. y Finger rest: Extraoral, palm

up. Backs of the middle and fourth fingers on the lateral aspect of the mandible on the right side of the face. 37 30/10/08

Maxillary anterior sextant: facial aspect, surfaces away from the operator

y Operator: Back position (12 oclock)y Illumination: Direct. y Visibility: Direct. y Retraction: Index finger of the

non-operating hand. y Finger rest: Intraoral, palm up.

Fourth finger on the incisal edges or occlusal surfaces of adjacent maxillary teeth

38 30/10/08

Maxillary anterior sextant: facial aspect, surfaces toward the operator

y Operator: Front position (8 oclock) y Illumination: Direct. y Visibility: Direct. y Retraction: Index finger of the

nonoperating hand. y Finger rest: Intraoral, palm

down. Fourth finger on the incisal edges or the occlusal or facial surfaces of adjacent maxillary teeth. 39 30/10/08

Maxillary anterior sextant: lingual aspect, surfaces away from the operator (surfaces toward the operator are scaled from a front position).

y Operator: Back position (12 oclock)y Illumination: Indirect. y Visibility: Indirect. y Retraction: None. y Finger rest: Intraoral, palm up.

Fourth finger on the incisal edges or the occlusal surfaces of adjacent maxillary teeth

40 30/10/08

Maxillary left posterior sextant: facial aspect

y Operator: Side position (9 oclock). y Illumination: Direct or

indirect. y Visibility: Direct or indirect. y Retraction: Mirror. y Finger rest: Intraoral, palm

up. Fourth finger on the incisal edges or the occlusal surfaces of adjacent maxillary teeth.

41 30/10/08

Maxillary left posterior sextant: lingual aspect

y Operator: Side position (9 oclock). y Illumination: Direct. y Visibility: Direct. y Retraction: None. y Finger rest: Intraoral, palm up.

Fourth finger on the occlusal surfaces of adjacent maxillary teeth.

42 30/10/08

Mandibular left posterior sextant: facial aspect

y Operator: Side position (9 oclock). y Illumination: Direct. y Visibility: Direct or indirect. y Retraction: Index finger or

mirror of the nonoperating hand. y Finger rest: Intraoral, palm

down. Fourth finger on the incisal edges or the occlusal or facial surfaces of adjacent mandibular teeth

43 30/10/08

Mandibular left posterior sextant: lingual aspect

y Operator: Side position (9 oclock). y Illumination: Direct and

indirect. y Visibility: Direct. y Retraction: Mirror retracts

tongue. y Finger rest: Intraoral, palm

down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent mandibular teeth.

44 30/10/08

Mandibular anterior sextant: facial aspect, surfaces toward the operator

y Operator: Front position (8 oclock) y Illumination: Direct. y Visibility: Direct. y Retraction: Index finger of the

nonoperating hand. y Finger rest: Intraoral, palm

down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent mandibular teeth45 30/10/08

Mandibular anterior sextant: facial aspect, surfaces away from the operator

y Operator: Back position (12 oclock) y Illumination: Direct. y Visibility: Direct. y Retraction: Index finger or

thumb of the nonoperating hand. y Finger rest: Intraoral, palm

down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent mandibular teeth

46 30/10/08

Mandibular anterior sextant: lingual aspect, surfaces away from the operator

y Operator: Back position (12 oclock) y Illumination: Direct and

indirect. y Visibility: Direct and indirect. y Retraction: Mirror retracts

tongue. y Finger rest: Intraoral, palm

down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent mandibular teeth

47 30/10/08

Mandibular anterior sextant: lingual aspect, surfaces toward the operator

y Operator: Front position (8 oclock) y Illumination: Direct and

indirect. y Visibility: Direct and indirect. y Retraction: Mirror retracts

tongue. y Finger rest: Intraoral, palm

down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent mandibular teeth

48 30/10/08

Mandibular right posterior sextant: facial aspect

y Operator Side position (9 oclock). y Illumination: Direct. y Visibility: Direct. y Retraction: Mirror or index

finger of the nonoperating hand. y Finger rest: Intraoral, palm

down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent mandibular teeth49 30/10/08

Mandibular right posterior sextant: lingual aspect

y Operator: Side position (9 oclock). y Illumination: Direct and

indirect. y Visibility: Direct and indirect. y Retraction: Mirror retracts

tongue. y Finger rest: Intraoral, palm

down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent mandibular teeth

50 30/10/08

Instruments for scaling and root planingy Universal curettesy Gracey curettes

51 30/10/08

Universal Curettes

y A, Columbia #4R-4L universal curette.y B, Younger-Good #7-8,

McCall's #17-18, and Indiana University #17-18 universal curettes.

52 30/10/08

Graceys curettes

y Gracey #5-6 (Yellow): For Anterior teeth and premolarsy Gracey #7-8 (Green): For Posterior teeth: facial and lingual y Gracey #11-12 (Orange): For Posterior teeth: mesialy Gracey #13-14 (Blue): For Posterior teeth: distal

53 30/10/08

30/10/0854

Chisel Wing-shaped Hygienist

y Push Scaler or Chisel.y A pushing instrument used parallel to the occlusal plane. This

instrument can be used supra-gingivally especially in the anterior. Great care need to be taken to avoid soft tissue damage.

y Hygienist Sickle.y Is a single-ended instrument can be used for mesial, distal,

facial, and lingual surfaces of supra and sub gingival calculus.Adaptation of Sickle scaler is important to prevent damage to the tissue

y Wing-shaped scalery This instrument has a wing blade shape and a sharply pointed

end. The mode of use is pull coronally for the supra and sub gingival area of the tooth

55 30/10/08

Conclusion: Principles of scaling and root planingy Determine the correct cutting edgey Finger resty Concentrate on using the lower third of the cutting

edge for calculus removal (adaptation)y Allow the hand-forearm to carry the burden of the

stroke, rather than flexing the fingers (digital motion activation)y Modulate lateral pressure

56 30/10/08

Calculus detectiony Supragingival calculus can be detected visually or

by using compressed air and dental mirrory Dry calculus has contrast visually with enamely Subgingival calculus are hidden beneath gingiva

57 30/10/08

technique to identify the presence of supra and subgingival calculus

58 30/10/08

Furcation involvement

59 30/10/08

y Occurs when periodontal infection invades the area between and around the roots of bifurcated or trifurcated teeth

y Access to furcation areay Mandibular molars (bifurcated)

examined from the facial and lingual surfaces

y Maxillary first premolar (bifurcated) from the mesial and distal surfaces

y Maxillary first molars (trifurcated) from the facial, mesial, distal surfaces

SCHEDULE FOR PERIODONTAL INSTRUMENTATION SKILLYear 3 2008/2009

Thursday8-10am Activities Venue(Supervisor)

8-9 am Lecture Periodontal Instrumentation DK 1 (ERRY)

30/10/089-10 am Putting Artificial Calculus on Frasaco model

MDL (HT, ERRY, WW, RARA, AKH, SLA)

8-9 am Demo Scaling and Root planning on real teeth (All supervisor)

6/11/08

9-10 am

Mounting 16 real teeth* on POP

PROSTHO LAB (HT, ERRY, WW, RARA, AKH, SLA)

13/11/08 KKKK

60 30/10/08

Activity: Supra and Subgingival scaling of artificial calculus on maxillary teeth, manuallySupra and Subgingival scaling of artificial calculus on mandibulary teeth, manually

Activity Grade* Signature

Preparation:a. Tray set up and cleanlinessb. Identification of instruments

Probing and exploring techniquea. Correct probing techniqueb. Correct exploring technique

Ergonomic position:Appropriate positioning of dummyCorrect working position of operator

Scaling technique:Use of appropriate instrumentUse appropriate technique

Calculus free: Teeth are free from calculus*Grading: 1=poor, 2=average, 3=good

61 30/10/08

Week 5Activity: Scaling and root planing on 16 real teeth, manually

Activity Grade* Signature

1.Scaling: Use of appropriate instrument and appropriate site (anterior and posterior) and good finger rest (left and right)

1.Exploring technique

1.Ergonomic position:a. Appropriate positioning of dummyb. Correct working position of operator

1.Scaling technique:a. Use of appropriate instrumentb. Use appropriate technique

1.Root Planing:a. Use of appropriate instrumentb. Use appropriate technique

1.Removal of calculus: Teeth are free from calculus*Grading: 1=poor, 2=average, 3=good

62 30/10/08

63 30/10/08

Positioning for the anterior sextant

Anterior surface toward

Turn slightly toward the clinician chin-down position

Turn slightly toward the clinician chin-up position

64 30/10/08

30/10/0865

chin-down position

chin-up position

30/10/0866

Positioning for the posterior sextant

Posterior aspects facing toward

Turned slightly away from the clinician chin-down position

Turned slightly away from the clinician chin-up position

30/10/0867

Positioning for the posterior sextant

Posterior aspects facing away

Turned slightly away from the clinician chin-down position

Turned slightly away from the clinician chin-up position

68 30/10/08

Periodontal Therapy:Manual Scaling and Root planingObjectivesPHASES OF PERIODONTAL THERAPYPeriodontal InstrumentationPrinciples of Instrumentation1. PositioningClinical/Operator positionNeutral positionPatient Head PositionVisibility, illumination and retractionSharpnessMaintaining a clean fieldInstrument stabilizationFulcrum (finger rest)Instrument activationAdaptationAngulationIncorrectLateral pressureWrist motion activationDigital motion activationInstrumentation StrokesInstrumentation for calculus removalSCALING IN DIFFERENT AREAS OF THE MOUTHMaxillary right posterior sextant: facial aspectMaxillary right posterior sextant: lingual aspect.Maxillary anterior sextant: facial aspect, surfaces away from the operatorMaxillary anterior sextant: facial aspect, surfaces toward the operatorMaxillary anterior sextant: lingual aspect, surfaces away from the operator (surfaces toward the operator are scaled from a frMaxillary left posterior sextant: facial aspectMaxillary left posterior sextant: lingual aspectMandibular left posterior sextant: facial aspectMandibular left posterior sextant: lingual aspectMandibular anterior sextant: facial aspect, surfaces toward the operatorMandibular anterior sextant: facial aspect, surfaces away from the operatorMandibular anterior sextant: lingual aspect, surfaces away from the operatorMandibular anterior sextant: lingual aspect, surfaces toward the operatorMandibular right posterior sextant: facial aspectMandibular right posterior sextant: lingual aspectInstruments for scaling and root planingUniversal CurettesGraceys curettesConclusion: Principles of scaling and root planingCalculus detectiontechnique to identify the presence of supra and subgingival calculusFurcation involvementSCHEDULE FOR PERIODONTAL INSTRUMENTATION SKILLYear 3 2008/2009Activity: Supra and Subgingival scaling of artificial calculus on maxillary teeth, manually Supra and Subgingival scaling ofWeek 5 Activity: Scaling and root planing on 16 real teeth, manually