Scaling and root planing

Scaling and Root

Planing

Presented by: Presented to:

Apekshya Dhakal Dr. Nawaraj Lamdari

BDS 2nd Batch Dr. Lalbabu Kumait

Roll no. 10 Dept. of Periodontics

Contents

• Introduction

• Periodontal instruments

• Principles of instrumentation

• Principles of scaling and root planing

• Supragingival scaling technique

• Subgingival scaling technique

• Various approaches to instrumentation

• Conclusion

Introduction:

• Scaling is the process by which biofilm and calculus are removed from both supragingival and subgingival tooth surfaces.

• Root planing is the process by which residual embedded calculus and portions of cementum are removed from the roots to produce a smooth, hard, clean surface.

Classification of Periodontal Instruments

Periodontal instruments are classified according to the purposes they serve, as follows:

1. Periodontal probes

2. Explorers

3. Scaling, root-planing, and curettage instruments :

Sickle scaler

Hoe, chisel, and file scalers

Ultrasonic and sonic instruments

4. Periodontal endoscopes

5. Cleansing and polishing instruments

Periodontal probes:

• Used to locate, measure, and mark pockets, as well as determine their course on individual tooth surfaces.

• Tapered, rod like instrument calibrated in millimeters, with a blunt, rounded tip .

• The World Health Organization (WHO) probe has millimeter markings and a small, round ball at the tip.

• Furcation areas can best be evaluated with the curved, blunt Nabers probe .

• The shank should be aligned with the long axis of the tooth surface to be probed.

Explorers:

• They are used to locate subgingival calculus deposits and caries.

• Also used to check the smoothness of the root surfaces after root planing.

Scaling and Curettage Instruments:

Sickle Scalers:• Used primarily to remove supragingival

calculus.

• Have a flat surface and two cutting edges that converge in a sharply pointed tip.

• Sickle scalers are used with a pull stroke.

• Sickle scalers with straight shanks are designed for use on anterior teeth and premolars and those with contra-angled shanks adapt to posterior teeth.

Curettes:• Used for removing deep subgingival calculus, root planing altered

cementum, and removing the soft tissue lining the periodontal pocket.

• The curette is finer than the sickle scalers and does not have any sharp points or corners other than the cutting edges of the blade. Therefore curettes can be adapted and provide good access to deep pockets, with minimal soft tissue trauma.

There are two basic types of curettes:

1. Universal curettes

2. Area specific curettes

Universal curettes:

• Universal curettes have cutting edges that may be inserted in most areas of the dentition by altering and adapting the finger rest, fulcrum, and hand position of the operator.

• The face of the blade of every universal curette is at a 90-degree angle (perpendicular) to the lower shank when seen in cross-section from the tip.

Area-Specific Curettes:

Gracey Curettes:

• A set of several instruments designed and angled to adapt to specific anatomic areas of the dentition.

• They provide the best adaptation to complex root anatomy.

• Double-ended Gracey curettes are paired in the following manner:

Gracey #1-2 and 3-4: Anterior teeth

Gracey #5-6: Anterior teeth and premolars

Gracey #7-8 and 9-10: Posterior teeth: facial and lingual

Gracey #11-12: Posterior teeth: mesial

Gracey #13-14: Posterior teeth: distal

• Recent additions to the Gracey curette set:

Gracey #15-16 and 17-18.

The Gracey #15-16:

modification of the standard #11-12 and is designed for the mesial surfaces of posterior teeth.

Gracey #11-12 blade combined with the more acutely angled #13-14 shank

Gracey #17-18 :

modification of the #13-14.

It has a terminal shank elongated by 3 mm and a more accentuated angulation of the shank to provide complete occlusal clearance and better access to all posterior distal surfaces.

Extended-Shank Curettes:

• Are modifications of the standard Gracey curette design.

• The terminal shank is 3 mm longer, allowing extension into deeper periodontal pockets of 5 mm or more.

• Has a thinned blade for smoother subgingival insertion and reduced tissue distention.

Mini-Bladed Curettes.

• Mini-bladed curettes, such as the Hu-Friedy Mini Five curettes, are modifications of the After Five curettes.

• The Mini Five curettes feature blades that are half the length of the After Five or standard Gracey curettes

• The shorter blade allows easier insertion and adaptation in deep, narrow pockets; furcations; developmental grooves; line angles; and deep, tight, facial, lingual, or palatal pockets.

Langer and Mini-Langer Curettes.

• The Langer and Mini Langer curettes are a set of three curettes combining the shank design of the standard Gracey #5-6, 11-12, and 13-14 curettes with a universal blade honed at 90 degrees rather than the offset blade of the Gracey curette.

• The Langer #5-6 curette adapts to the mesial and distal surfaces of anterior teeth;

• The Langer #1-2 curette adapts to the mesial and distal surfaces of mandibular posterior teeth;

• The Langer #3-4 curette adapts to the mesial and distal surfaces of maxillary posterior teeth.

Hoe Scalers:Used for scaling of ledges or rings of calculus.

The blade is inserted to the base of the periodontal pocket so that it makes two-point contact with the tooth.

This stabilizes the instrument and prevents nicking of the root.

The instrument is activated with a firm pull stroke toward the crown.

Chisel Scalers:Designed for the proximal surfaces of teeth too

closely spaced to permit the use of other scalers.

It is a double-ended instrument with a curved shank at one end and a straight shank at the other.

The blades are slightly curved and have a straight cutting edge beveled at 45 degrees.

General Principles of Instrumentation

Accessibility: Positioning of Patient and Operator

• The position of the patient and operator should provide maximal accessibility to the area of operation.

The clinician’s position:

• His/her feet should be flat on the floor.

• The thighs parallel to the floor.

• Back straight and the head erect.

Patient’s position:

• Supine position and placed so that the mouth is close to the resting elbow of the clinician.

• For instrumentation of the maxillary arch, the patient should be asked to raise the chin.

• For instrumentation on the mandibular arch, the patient should be asked to lower the chin until the mandible is parallel to the floor.

Visibility, Illumination, and Retraction

• Whenever possible, direct vision with direct illumination from the dental light is most desirable.

• If this is not possible, indirect vision may be obtained by using the mouth mirror and indirect illumination may be obtained by using the mirror to reflect light to where it is needed.

• Retraction provides visibility, accessibility, and illumination.

• The mirror may be used for retraction of the cheeks or the tongue.

• The index finger is used for retraction of the lips or cheeks.

Condition and Sharpness of Instruments

• Before any instrumentation, all instruments should be inspected to make sure that they are clean, sterile, and in good condition.

• Sharp instruments:

Enhance tactile sensitivity and allow the clinician to work more precisely and efficiently .

• Dull instruments :

Incomplete calculus removal

Unnecessary trauma because of the excess force usually applied to compensate for their ineffectiveness.

Maintaining a Clean Field

• Despite good visibility, illumination, and retraction, instrumentation can be hampered if the operative field is obscured by saliva, blood, and debris.

• Adequate suction is essential.

• Blood and debris can be removed from the operative field with suction and by wiping or blotting with gauze squares.

Instrument Stabilization

The two factors of major importance in providing stability are the instrument grasp and the finger rest.

Instrument Grasp: A proper grasp is essential for precise control of movements made during periodontal instrumentation.

Modified pen grasp : The thumb, index finger, and middle finger are used to hold the instrument as a pen is held, but the pad of the middle finger rests on the shank.

Standard pen grasp:

The side of the middle finger rests on the shank.

The palm and thumb grasp:

Is useful for stabilizing instruments during sharpening and for manipulating air and water syringes

Finger Rest:

• The finger rest serves to stabilize the hand and the instrument by providing a firm fulcrum as movements are made to activate the instrument.

• The fourth (ring) finger is preferred by most clinicians for the finger rest.

Intraoral finger rest:

• Conventional: The finger rest is established on tooth surfaces immediately adjacent to the working area.

• Cross-arch: The finger rest is established on tooth surfaces on the other side of the same arch.

• Opposite arch: The finger rest is established on tooth surfaces on the opposite arch.

• Finger on finger: The finger rest is established on the index finger or thumb of the non-operating hand .

Extraoral fulcrums:

• Palm up: By resting the backs of the middle and fourth fingers on the skin overlying the lateral aspect of the mandible on the right side of the face.

• Palm down: By resting the front surfaces of the middle and fourth fingers on the skin overlying the lateral aspect of the mandible on the left side of the face.

Instrument Activation

Adaptation:

• Adaptation refers to the manner in which the working end of a periodontal instrument is placed against the surface of a tooth.

• Precise adaptation :

To avoid trauma to the soft tissues and root surfaces

To ensure maximum effectiveness of instrumentation.

• Precise adaptation is maintained by carefully rolling the handle of the instrument against the index and middle fingers with the thumb. This rotates the instrument in slight degrees so that the toe or tip leads into concavities and around convexities.

Angulation:

• Angulation refers to the angle between the face of a bladed instrument and the tooth surface.

• It may also be called the tooth-blade relationship.

• For subgingival insertion of a bladed instrument such as a curette, angulation should be as close to 0 degree as possible.

• During scaling and root planing, optimal angulation is between 45 and 90 degrees .

• During scaling, angulation should be just less than 90 degrees so that the cutting edge “bites” into the calculus.

• With angulation of less than 45 degrees, the cutting edge will not bite into or engage the calculus properly. Instead, it will slide over the calculus, smoothing or “burnishing” it.

Lateral Pressure:

• Lateral pressure refers to the pressure created when force is applied against the surface of a tooth with the cutting edge of a bladed instrument.

• Lateral pressure may be firm, moderate, or light.

Strokes:

Three basic types of strokes are used during instrumentation:

I. The exploratory stroke,

II. The scaling stroke, and

III. The root planing stroke.

The exploratory stroke is a light, “feeling” stroke that is used with probes and explorers to evaluate the dimensions of the pocket and to detect calculus and irregularities of the tooth surface.

The scaling stroke is a short, powerful pull stroke that is used with bladed instruments for the removal of both supragingival and subgingival calculus.

The root-planing stroke is a moderate to light pull stroke that is used for final smoothing and planing of the root surface.

Principles of Scaling and Root Planing

• The primary objective of scaling and root planing is to restore gingival health by completely removing elements that provoke gingival inflammation (i.e., biofilm, calculus, and endotoxin) from the tooth surface.

• Scaling and root planing should not be viewed as separate procedures unrelated to the rest of the treatment plan.

• After careful analysis of a case, the number of appointments needed to complete this phase of treatment is estimated.

• Patients with small amounts of calculus and relatively healthy tissues can be treated in one appointment.

• The dentist should estimate the number of appointments needed on the basis of the number of teeth in the mouth, severity of inflammation, amount and location of calculus, depth and activity of pockets, presence of furcation invasions, patient’s comprehension of and compliance with oral hygiene instructions, and need for local anesthesia.

Detection Skills

• Good visual and tactile detection skills are required for the accurate initial assessment of the extent and nature of deposits and root irregularities before scaling and root planing.

• Light deposits of supragingival calculus are often difficult to see when they are wet with saliva.

• Compressed air may be used to dry supragingival calculus until it is chalky white and readily visible.

• Air also may be directed into the pocket in a steady stream to deflect the marginal gingiva away from the tooth so that subgingival deposits near the surface can be seen.

• Tactile exploration of the tooth surfaces in subgingival areas of pocket depth, furcations, and developmental depressions is much more difficult than visual examination of supragingival areas and requires the skilled use of a fine-pointed explorer or probe.

• The explorer or probe is held with a light but stable modified pen grasp.

• After a stable finger rest is established, the tip of the instrument is carefully inserted subgingivally to the base of the pocket.

• Light exploratory strokes are activated vertically on the root surface.

• When calculus is encountered, the tip of the instrument should be advanced apically over the deposit until the termination of the calculus on the root is felt.

• The distance between the apical edge of the calculus and the bottom of the pocket usually ranges from 0.2 to 1.0 mm.

• The tip is adapted closely to the tooth to ensure the greatest degree of tactile sensitivity and avoid tissue trauma.

Supragingival Scaling Technique

• Supragingival calculus is generally less tenacious and less calcified than subgingival calculus.

• Sickles, curettes, and ultrasonic and sonic instruments are most often used for the removal of supragingival calculus.

• The sickle or curette is held with a modified pen grasp, and a firm finger rest is established on the teeth adjacent to the working area.

• The blade is adapted with an angulation of slightly less than 90 degrees to the surface being scaled.

• The cutting edge should engage the apical margin of the supragingival calculus while short, powerful, overlapping scaling strokes are activated coronally in a vertical or an oblique direction.

Subgingival Scaling and Root-Planing Technique

• Subgingival calculus is usually harder than supragingival calculus and is often locked into root irregularities, making it more tenacious and therefore more difficult to remove.

• Vision is obscured by the bleeding that inevitably occurs during instrumentation and by the tissue itself.

• In addition, the adjacent pocket wall limits the direction and length of the strokes.

• The curette is preferred by most clinicians for subgingival scaling and root planing because of the advantages afforded by its design.

• Its curved blade, rounded toe, and curved back allow the curette to be inserted to the base of the pocket and adapted to variations in tooth contour with minimal tissue displacement and trauma.

• Sickles, hoes, files, and ultrasonic instruments also are used for subgingival scaling of heavy calculus.

• Some small files may be inserted to the base of the pocket to crush or initially fracture tenacious deposits.

• The curette is held with a modified pen grasp, and a stable finger rest is established.

• The correct cutting edge is slightly adapted to the tooth, with the lower shank kept parallel to the tooth surface.

• The lower shank is moved toward the tooth so that the face of the blade is nearly flush with the tooth surface.

• The blade is then inserted under the gingiva and advanced to the base of the pocket by a light exploratory stroke. When the cutting edge reaches the base of the pocket, a working angulation of between 45 and 90 degrees is established, and pressure is applied laterally against the tooth surface.

• Calculus is removed by a series of controlled, overlapping, short, powerful strokes primarily using wrist-arm motion.

• As calculus is removed, resistance to the passage of the cutting edge diminishes until only a slight roughness remains.

• Longer, lighter root-planing strokes are then activated with less lateral pressure until the root surface is completely smooth and hard.

• Scaling and root-planing strokes should be confined to the portion of the tooth where calculus or altered cementum is found; this area is known as the instrumentation zone.

• Sweeping the instrument over the crown where it is not needed wastes operating time, dulls the instrument, and causes loss of control.

• If heavy lateral pressure is continued after the bulk of calculus has been removed and the blade is repeatedly readapted with short, choppy strokes, the result will be a roughened root surface, resembling the rippled surface of a washboard.

• If heavy lateral pressure is continued with long, even strokes, the result will be excessive removal of root structure, producing a smooth but “ditched” or “riffled” root surface.

• To avoid these hazards of over instrumentation, a deliberate transition from short, powerful scaling strokes to longer, lighter root-planing strokes must be made as soon as the calculus and initial roughness have been eliminated.

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.

Various approaches to instrumentation:Maxillary right posterior sextant: facial aspect

• Operator position: Side position.

• Illumination: Direct.

• Visibility: Direct (indirect for distal surfaces of molars).

• Retraction: Mirror or index finger of the nonoperating hand.

• Finger rest: Extraoral, palm up.

Maxillary right posterior sextant, premolar region only: Facial aspect.

• Operator position: Side or back position.


• Visibility: Direct.


• Finger rest: Intraoral, palm up. Fourth finger on the occlusalsurfaces of the adjacent maxillary posterior teeth.

Maxillary right posterior sextant: Lingual aspect

• Operator position: Side or front position.

• Illumination: Direct and indirect.

• Visibility: Direct or indirect.

• Retraction: None.

• 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.

Maxillary right posterior sextant: Lingual aspect

• Operator position: Front position.




• Finger rest: Intraoral, palm up, finger on finger.

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

• Operator position: Back position.



• Retraction: Index finger of the nonoperating hand.

• Finger rest: Intraoral, palm up. Fourth finger on the incisal edges or occlusal surfaces of adjacent maxillary teeth.

Maxillary anterior sextant: Facial aspect, surfaces toward the operator




• Retraction: Index finger of the nonoperating hand.

• Finger rest: Intraoral, palm down. Fourth finger on the incisal edges or the occlusal or facial surfaces of adjacent maxillary teeth.

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


• Illumination: Indirect.

• Visibility: Indirect.


• Finger rest: Intraoral, palm up. Fourth finger on the incisal edges or the occlusal surfaces of adjacent maxillary teeth

Maxillary left posterior sextant: Facial aspect.


• Illumination: Direct or indirect.


• Retraction: Mirror.

• Fingear rest: Extraoral, palm down. Front surfaces of the middle and fourth fingers on the lateral aspect of the mandible on the left side of the face.

Maxillary left posterior sextant: Facial aspect

• Operator position: Back or side position.

• Illumination: Direct or indirect.


• Retraction: Mirror.

• Finger rest: Intraoral, palm up. Fourth finger on the incisal edges or the occlusal surfaces of adjacent maxillary teeth

Maxillary left posterior sextant: Lingual aspect





• Finger rest: Intraoral, palm down, opposite arch, reinforced. Fourth finger on the incisal edges of the mandibularanterior teeth or the facial surfaces of the mandibular premolars, reinforced with the index finger of the nonoperating hand.




• Visibility: Direct and indirect.


• Finger rest: Extraoral, palm down. Front surfaces of the middle and fourth fingers on the lateral aspect of the mandible on the left side of the face. The nonoperating hand holds the mirror for indirect illumination.






• Finger rest: Intraoral, palm up. Fourth finger on the occlusal surfaces of adjacent maxillary teeth.

Mandibular left posterior sextant: Facial aspect




• Retraction: Index finger or mirror of the non-operating hand.

• Finger rest: Intraoral, palm down. Fourth finger on the incisal edges or the occlusal or facial surfaces of adjacent mandibular teeth.

Mandibular left posterior sextant: Lingual aspect

• Operator position: Front or side position.



• Retraction: Mirror retracts tongue.

• Finger rest: Intraoral, palm down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent mandibular teeth.

Mandibular anterior sextant: Facial aspect, surfaces toward the operator.




• Retraction: Index finger of the non-operating hand.


Mandibular anterior sextant: Facial aspect, surfaces away from the operator.




• Retraction: Index finger or thumb of the nonoperating hand.


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






Mandibular anterior sextant: Lingual aspect, surfaces toward the operator.





• Finger rest: Intraoral, palm down. Fourth finger on the incisal edges or the occlusalsurfaces of adjacent mandibular teeth.

Mandibular right posterior sextant: Facial aspect.






Mandibular right posterior sextant: Lingual aspect.





• Finger rest: Intraoral, palm down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent mandibularteeth.

conclusion

• Scaling and root planing is one of the most effective ways to treat gum disease before it becomes severe.

• Proper instrumentation technique and chair positions helps the operator to complete the procedure without delaying and also reduces the chances of future musculoskeletal problems.

“You don’t have to lose teeth to periodontal diseases. They often can be treated successfully.”

Thank you.

References:

• Carranza, F. A., Takei, H. H., Klokkevold, P. R., & Newman, M. G. (2012). Carranzas clinical periodontology (12th ed.). St. Louis (Mo): Saunders Elsevier.

• Treating periodontal diseases. (2005). The Journal of the American Dental Association, 136(1), 127. doi:10.14219/jada.archive.2005.0036

• Caffesse, R. G., Sweeney, P. L., & Smith, B. A. (1986). Scaling and root planing with and without periodontal flap surgery. Journal of Clinical Periodontology J Clin Periodontol, 13(3), 205-210. doi:10.1111/j.1600-051x.1986.tb01461.x

Education

Scaling and root planing