1. Periodontal Instrumentation
Grasp, Fulcrum, Wrist Motion,
Using the Periodontal Probe

2. Handle, Shank, Working End
Head
HANDLE
Shank
Shank
HANDLE
Shank

3. Use of the Dental Mirror
Indirect vision
Illumination
Reflection of light
Transillumination
Reflection of light “through” the tooth surface
Especially for calculus
Retraction

4. Modified Pen Grasp Most efficient grasp Control – Stability
Pivot Point

5. Modified Pen Grasp
Thumb & Index finger opposite at junction of handle & shank
Handle is between junction of the first and second joint of the index finger
Pad of middle finger against the shank (side of pad)
Fingers are a “unit”
Left hand grasp
Right hand grasp

6. Establishing a Finger Fulcrum
Stability
Activate instrument - stroke
pivot
Control - prevents injury
Always on a stable oral structure
Occlusal plane, mandible, zygoma
Ring finger

7. Fulcrums Intraoral Intraoral As close to working areas as possible
Approximately two teeth away
Do not fulcrum on the same tooth
Mandibular arch
Maxillary anterior teeth

8. Extra-Oral Fulcrum
Extraoral
Maxillary arch
Posterior teeth

9. Wrist Motion Side to side Up and down
Activated by pivoting fulcrum finger
Wrist must be straight to activate stroke - movement of instrument
Will be demonstrated on the presenter

10. Instrument Identification
Name, design number, manufacturer
Determined by use
Probes
Explorers
Curets
Sickles
Hoes
Files
Chisels

11. The Probe Primary instrument in the periodontal exam
Assess gingival health
Periodontal status
Exploratory
Requires skill development

12. Probe Design Vary in cross-sectional design Millimeter markings
Rectangular in shape (flat)
Oval
Round
Millimeter markings
Calibrated at varying intervals

13. Marquis Probe Color coded 3, 6, 9, 12 mm markings Thin working end
Key is to know the increments
Type of probe being used

14. Use of the Probe Inserted to the Junctional epithelium Measures sulcus
Periodontal pockets
Gingival recession
Attachment loss

15. Angulation
Probe is parallel to long axis of tooth

16. Interproximal Angulation
Slightly tilted
Apical to the contact point
Not enough angulation
Correct
angulation
Too much
angulation

17. Adaptation
Working end is well-adapted to tooth surface

18. Technique
Gently “walk” the probe

19. Readings Six readings Deepest reading within the designated areas
Distal (DB & DL)
Buccal (B) or Lingual (L)
Mesial (MB & ML)
Deepest reading within the designated areas

20. Gracey Curets

21. Gracey Series Anterior Teeth Posterior Teeth (next week)
5/6 all surfaces of anteriors/premolars
Posterior Teeth (next week)
7/8 Buccal & Lingual Surfaces
11/12 Mesial Surfaces
13/14 Distal Surfaces
15/16 Mesial Surfaces
17/18 Distal Surfaces

22. Design Characteristics
Standard or Finishing (non-rigids)
Rigid
Extra Rigid
Extended Shanks
Different Blade sizes
Regular
Mini

23. Design Characteristics
Area specific
Adapt to a specific area or tooth surface
Two curved edges with a blade
Only one cutting edge is used for calculus removal
Lateral
surface
Face
Back
Cutting edge

24. Design Characteristics
Working end is tilted in relationship to the terminal shank (offset by 70°)
Makes one cutting edge lower than the other
This lower end is the one that is used for instrumentation

25. Identification of the Cutting Edge
Place shank perpendicular to floor
Lower blade is the cutting edge
Lower shank will be parallel to surface being scaled

26. Advantages of Design Characteristics
Allows insertion into deep pockets
Prevents tissue trauma
Correct cutting edge to tooth surface angulation
Easier adaptation
Around convex tooth crowns to access root surfaces

27. Adapting the Curet Blade

28. Blade Adaptation to Tooth Surface0°
<45°
45-90°
> 90°
insertion
Healthy tissue
Plaque removal
Ideal
Calculus
Removal
Tissue
Trauma

29. Adaptation of lower third of blade to tooth surface
Correct
Lower 1/3
Incorrect
Toe 1/3
Incorrect
Middle 1/3

30. Relationship of Lower Shank to Blade Angulation
Too far
Toe is coronal
Lower shank
parallel
Lower shank
To far forward

31. Calculus Removal “Channeling”

32. Review of Fundamentals of Instrumentation

33. Working Stroke
oblique
vertical
horizontal
circumferential

34. Basic Design Characteristics of the Working end of Instruments
Lateral
surface
Face
Back
Cutting edge
Lateral
surface
Cross section

35. Curet Toe vs Sickle Tip
HEEL
TIP
TOE

36. Comparison of Curets & Sickle Blades

37. Sickle Scaler

38. Uses
Supragingival calculus
Stain
Slightly subgingival (1-2mm)

39. Different Designs Anterior teeth Posterior teeth
Modified shank
Blade can vary in size & design

40. Design Characteristics
Straight rigid shank
Two cutting edges
Straight or slightly curved
Back of the instrument
Pointed or rounded

41. Adaptation

42. Adaptation
INCORRECT
CORRECT

43. ANGULATION

44. Technique Mesial & Distal Divide tooth structure in 3rds
Distal line angle towards interproximal
Mesial line angle towards interproximal
Labial or Lingual Surface
Graceys or Universals
Mesial & Distal
Vertical stroke

45. Visual Guide to Instrumentation Anterior Teeth
Handle extends upward/parallel to long axis of teeth when interproximal
Does not apply to Facial or Lingual surfaces
Oblique stroke is best
Alternative instruments are better than sickle
Prevent tissue trauma

46. Visual Guide to Instrumentation
Lower shank is parallel to surface being scaled
Vertical stroke

47. CLINIC DEMONSTRATION H6/7 Sickle Scaler Shank slightly curved
Review on clinic floor 33 15
H6/7

48. Universal Curets

49. TYPES OF UNIVERSAL CURETTES
Columbia
Barnhart
Bunting
Goldman
Younger-Good
Langer (gracey shank)

50. Design Features Can adapt to all tooth surfaces
90 degree blade angulation
shank curvature allows adaptation
both cutting edges are used
blade curved on only one plane

52. Blade Adaptation

53. Use of the Universal Curet: Anterior teeth
Both instrument ends will be used
Handle is parallel to long axis of tooth
Adapt blade to mesial or distal
Initiate by starting at the tooth midline
Work towards the interproximal
Refer to diagram on pages in Pattison

54. Type of Stroke Used Oblique on buccal & lingual
Vertical on Mesial & Distal

55. Use of the Universal Curet: Posterior Region
Select the working end that adapts to the interproximal surface
Lower Shank is parallel to mesial surface
Select blade that is in contact with the mesial surface
Use from the distal line angle towards mesial surface

56. Use of the Universal Curet: Posterior Region
Using the same working end
No flipping of instrument
Select the opposite or “secondary” blade to scale the distal surface
Note that the lower shank is parallel to the distal surface

57. Vertical Interproximal Stroke
Vertical Stroke on Mesial and Distal Surfaces

58. Posterior Scaling with Gracey Instruments

59. Gracey Curets Area specific Each working end is a mirror image
Shank design
Blade design
Each working end is a mirror image
Blade identification
Allows for correct working end
Adaptation to surface being scaled

60. Lower third is used for calculus removal

61. 7/8 Gracey Curet Buccal & Lingual Surfaces
Posterior teeth
Initiate stroke from the distal line angle
Finish stroke at the mesial line angle
Stroke used
Oblique or horizontal
Lower shank is not parallel
stroke is “towards midline”

62. 11/12 and 15/16 Gracey Curets Used on mesial surfaces of all posterior
Initiate stroke at mesial line angle and continue towards the mesial-interproximal surface
Each end is a mirror image

63. 13/14 Gracey Curet Distal surfaces
Initiate stroke at the distal line angle
Continue towards interproximal (distal)
Difficult to see blade use shank as visual cue
Keep lower shank parallel to tooth surface

64. Exploratory vs Working Stroke
Blade is less than 45°
Grasp is lighter
Tactile sensitivity is enhanced
On the “down” stroke
Objective is to identify depth of calculus
Blade is 45-90°
Calculus removal
Firm grasp
Engage blade by
Adaptation or “bite”
On the “up” stroke
Vertical
Oblique

65. Adaptation
Degree of “how open” or “closed” the blade is upon insertion is dependent on:
Type of tissue
Fibrotic vs boggy or hemorrhagic tissue
Severity of disease
Retractable tissue
Interproximal embrasure
Tenacity of calculus

66. Difference in Technique
Scaling
short, precise, strokes, channeling calculus deposits
Planing
long even strokes
Objective is to smooth the root surface
Takes experience and time to obtain skill

67. How well have we scaled? At time of S/RP appointment After appointment
Exploring, probing
Smoothness of tooth surface
After appointment
Healthy periodontium
Decreased bleeding, pocket depths, marginal bleeding

68. Limitations obscured vision from bleeding tactile sensitivity
instruments selected
direction & length of strokes
confines of soft tissue - tissue type
tooth anatomy
clinical findings
“mental image” based on visual, mental, and manual skills

69. Limitations Accurate treatment plan Severity of Disease progression
Anesthesia, number of appointments
Severity of Disease progression
Local factors
Systemic factors
Pockets, furcas, anatomical characteristics, erosion, recession, mobility

70. Most common areas missed:
most apical portion of pocket
furcation areas & distal surfaces
primary reason: not overlapping strokes

71. Effects of scaling & root planing
reduction in inflammation
pocket depth reduction-- avg mm
.8mm in recession
.52 in attachment
attachment - maintained or slight gain
decreased mobility - fibers
reduction in gram-, spirochetes, bacteroides
conflicting results with A. Actinocytemcomitans

72. Sequence to Periodontal Instrumentation
Patient Assessment
Local and systemic factors that influence periodontal condition
Hx of smoking
Periodontal Evaluation
Severity of disease
Periodontal tx plan
Surgery, grafts,
Overall objective of phase I therapy
Calculus Assessment
How difficult, tenacity, depth

73. Sequence to Periodontal Instrumentation
Phase I Simple = 1 appointment
Simple case, light calculus, little sensitivity, controlled periodontal condition, mild inflammation
Phase I Intermediate – 2 appointments
Overdue, early Periodontitis 4-5 mm pockets,
Patient may require ½ mouth anesthesia (Lower & upper quads avoid same arch)
Phase I Complex
4 appointment by quads with anesth, pockets, calculus, furcations
Re-evaluation appointment

74. Sequence to Periodontal Instrumentation
Full mouth
Start in tooth sequence for plaque removal
Assess where calculus is present
Areas of inflammation
Two appointment
Anesthesia, upper & lower quad
Complex
Each quadrant with anesthesia