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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
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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
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Periodontal Instrumentationy Scaling: to remove plaque and calculusy Root planing: to remove plaque, calculus,
endotoxiny Stain removaly Surgery
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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
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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
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Clinical/Operator positionNeutral position
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Patient Head Position
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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
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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
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maxilla
mandibularDental light position
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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.
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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
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Instrument stabilization
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y Instrument graspy Finger rest
Fulcrum (finger rest) y Stabilizes the clinicians hand during instrumentationy Intraoral and extraoral fulcrum
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Instrument activationyAdaptationyAngulationyLateral pressureyStrokes
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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
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30/10/08Adapted Not-adapted25
Angulation
y Is the angle formed between the face of instrument and the tooth surfaces
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Incorrect
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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.
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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
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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
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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
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Instrumentation Strokesy Strokes Direction
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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.
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SCALING IN DIFFERENT AREAS OF THE MOUTH
y MAXILLARY TEETH
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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.
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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
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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
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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.
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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.
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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
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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.
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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
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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
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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
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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
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Instruments for scaling and root planingy Universal curettesy Gracey curettes
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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.
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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
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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
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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
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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
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technique to identify the presence of supra and subgingival calculus
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Furcation involvement
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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
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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
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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
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Positioning for the anterior sextant
Anterior surface toward
Turn slightly toward the clinician chin-down position
Turn slightly toward the clinician chin-up position
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chin-down position
chin-up position
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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
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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
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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