Hand instrumentation: exploring your options: part 1.
The most difficult and critical nonsurgical periodontal therapy is root debridement involving scaling and root planing. (1) Achieving optimal gingival health after nonsurgical periodontal instrumentation begins with dental hygienists ensuring that the root surfaces are smooth and free of biofilm and calculus. Dental hygiene treatment has two main areas of focus: initial therapy and maintenance therapy. Modifications or additions to our traditional armamentarium may improve our abilities to identify and remove deposits during both phases of therapy. (2)
Nonsurgical periodontal therapy provided during initial therapy begins with the development of a dental hygiene treatment plan for patients based on information collected during the examination. This includes the medical and dental history, radiographic evaluation and periodontal assessment (probing, mobility, furcation involvement, gingival findings). One of the most important data collection processes is evaluation of the deposits present.
The dental hygienist must take the time to detect and assess the calculus deposits and can do so by using a variety of diagnostic instruments. Deposits cannot be removed if the dental hygienist cannot detect them. The explorer tip used to evaluate root surfaces can be larger than some of the edges of burnished calculus that need to be removed. (3) Therefore, the use of a very fine explorer tip with a shank that provides access to deep pockets is necessary. Periodontal probing should never be underestimated: it not only measures probing depth, but it also determines the topographical map of the pockets that are in need of treatment and is crucial to the clinical evaluation and treatment plan development. (4) An array of probes is available to improve the diagnostic skills of the clinician. Once the diagnosis has been completed and the dental hygiene treatment plan has been determined, deposit removal is initiated.
Effective calculus removal depends on initially accessing the deposits and then using a combination of firm lateral pressure and correct angulation of the blade against the tooth. Burnished calculus will result from inadequate pressure or an incorrect angle. To achieve the correct angle, a variety of instruments and reinforced hand positions should be considered, as well as extraoral or alternative fulcrums. These can provide increased power when using hand instruments. (5) Dental hygienists can occasionally review root morphology to refresh their knowledge of all of the developmental grooves, the heights of contour, developmental depressions, the location of the cementoenamel junction line of contour and the general anatomy of the furcations. A strong foundation in root morphology provides a highly developed understanding of where to find the potential challenges to effective instrumentation. All of these tools are important in helping visualize where the instrument blade is to be adapted and the texture of root surfaces when calculus/deposit free. Modifications to hand instruments have been made to facilitate blade adaptation once the deposits or root surface to be addressed has been determined.
Deposit removal will be neither time efficient nor technically successful no matter what instruments you have chosen, if they do not have a sharp cutting edge. Instruments require sharpening throughout the entire initial phase of treatment. (6), (7) Calculus will inevitably get burnished onto the tooth surface if dull instruments are used, and burnished calculus is more difficult to remove than the initial deposit. Removal of burnished calculus requires a different instrumentation approach than the initial technique used.
Power instrumentation plays a huge role in initial therapy. Because of the thinning and miniaturization of the tips, power instruments have become far more useful and beneficial in removing deposits subgingivally. While it is still possible to gouge roots and burnish calculus with power instruments, they nevertheless greatly reduce the effort required to remove deposits. (8) Ultrasonic instrumentation cannot completely remove subgingival deposits from all the surfaces of the roots and is limited in pockets over 4 mm. Follow-up with hand instruments is always required, especially on interproximal surfaces directly under the contact where the small active portion of a sonic or ultrasonic tip is difficult to adapt. Root coverage is very important, and only a very small portion of the ultrasonic tip is vibrating optimally for deposit removal, This active portion of the tip must touch the entire root surface to ensure thorough deposit removal. A combination of both hand and power instrumentation is the preferred approach.
Degree of root smoothness achieved during initial therapy will be one of the most important factors affecting subsequent maintenance therapy appointments. Root surface smoothness is the criterion for immediate evaluation of scaling and root planing and the most successful evaluation tool to determine complete removal of the calculus and accompanying pathogens. Complete removal of calculus gives the tissue the greatest opportunity to return to a healthy state. Rough root surfaces are very difficult to deplaque and detoxify. If the root surface is smooth, maintenance therapy can be carried out in a much more efficient manner. (9) Subsequent instrumentation and evaluation are straightforward.
The primary goal of maintenance or supportive periodontal therapy is to remove the bacterial microflora that has re-established since initial therapy. In the time between initial therapy and the first re-evaluation appointment, inflammation in the pocket wall is reduced, and the connective tissue fibres become healthier. As a result, the pocket wall becomes firmer and tighter, and a long junctional epithelium attachment forms. Very little actual bone or cementum is being redeposited, so the epithelial attachment is fragile. The recolonization of the pathogenic biofilm takes approximately three months, and as inflammation recurs, the tissue becomes looser and more flaccid, causing deterioration of the long junctional epithelial attachment. It's a balancing act: the maintenance appointment needs to occur before inflammation at the base of the pocket is re-established because, unless it does, there is a risk of continued loss of alveolar bone and connective tissue attachment. Patients must understand that their pockets haven't disappeared; instead, a nice healthy band of tissue is now hugging the tooth that can become loose again. The preservation of our patients' teeth depends on removing the bacterial microflora from the root surfaces within the pockets on a regular basis. Debridement and the motivation provided by the dental hygienists for their patients at regularly scheduled maintenance therapy appointments are what will make treatment successful.
The bacterial microflora that reforms is lightly adhered to the tooth, so only light instrumentation strokes are required. (9) Mechanical friction disorganizes the bacterial biofilm, and for thorough disorganization, the entire root surface must be contacted. If power instrumentation is selected, fine tips should be used on a very low power setting to prevent unnecessary removal of tooth structure, and the tip must contact the entire tooth surface. The blade of a hand instrument provides more surface area to contact the tooth surface and is therefore more efficient.
Whether power or hand instrumentation is used, thorough root debridement is accomplished using a series of careful, close, overlapping gentle strokes so that the entire root surface is deplaqued and detoxified. Hand instruments can be divided into sets identified for initial and maintenance therapy. A dull blade provides maximum surface area to contact the root surfaces, while sharp new blades are used for shearing off deposits during initial therapy. Older hand instruments demonstrating reduced blade width can be placed in maintenance therapy sets, while the new ones are used for initial therapy.
Dental hygienists need to have a sufficient armamentarium at their disposal to access all root surfaces and remove deposits. Following are some alternatives available in hand instruments to aid in complete deposit removal and the resulting tissue resolution, as well as some factors to consider when making instrument choices.
Instrument Use as Determined by Pocket Depth
There have been significant advancements in hand instruments and techniques over the years. "Development in instrument design and materials has furthered the dental hygienist's ability to scale tenacious calculus in deep pockets and furcations." (2) We can now provide nonsurgical periodontal therapy to greater depths and with increased predictability than our counterparts were able to in the past.
This review focuses on hand instruments used for the provision of dental hygiene treatment. Hand instruments can be grouped by their area of use for:
1. Supragingival instrumentation
2. Subgingival instrumentation
a. 1mm--4 mm
b. 4 mm to gingival attachment level
Hand instruments have been modified in many ways to provide improved access and adaptation for the different areas requiring instrumentation and to meet the challenges of a variety of potential deposit situations. These modifications include:
* Angulation of the blade to the shank
* Length of the shank
* Length of blade
* Shape of blade
* Location of blade on the shank
* Modifications that allow the practitioner to use various strokes
* Modifications that facilitate furcation instrumentation
There are many modified instruments that the clinician may find useful in practice. There are some assessment questions that can help the clinician evaluate case by case whether an instrument should be included in their armamentarium and what its benefit will be. Of course, intraoral trial and error and the resulting deposit removal are the true tests. The assessment questions that can be used to help focus a personal evaluation of instruments are:
* Access--Can the blade be positioned where it is to be adapted to tooth surfaces?
* Adaptability--Can the blade contact tooth surfaces where instrumentation is required? For example: under contact areas, within furcations or root concavities, etc.
* Activation--Can the blade be activated with the appropriate strokes? Some instruments are designed for heavy powerful stokes, while others are applied with light shaving strokes.
* Comfort--Does the instrument have any qualities that improve comfort for the clinician? For example: a light, large, round handle or grip.
* Modification (if applicable)--Does the instrument feature any modification to improve any qualities for the clinician while in use? For example: a longer terminal shank, shortened blade, etc.?
There have been technological modifications to address specific issues or to improve general comfort in use of the instrument. Examples are variations in handles (stainless steel, resin, etc.) and blades that require little sharpening (EverEdge[TM) and instruments for implants. Table I above and Table II on pages 32 and 33 are lists of some of the available instruments and are grouped by clinical diagnosis of pocket depth.
Table I. Suprgingival Modified Instruments Name Product code Blade description Modification/Details and area of use Nevi 1 * (SCNEVI1) Nevi Scalers- Can be used with a push or pull Disc end Anterior stroke in all directions Easy use sharpening with a Bates-style channel stone Nevi Scalers - Super-thin anterior curved Sickle end sickle Ideal for interproximal Anteior use and curved anterior deposit removal Nevi 2 * (SCNEI2) Posterior use Super-thin posterior curved sickle scaler Unique contra-angle design Great for interproximal reach and ergonomic hand positioning SN135 * Posterior use Posterior use scaler Improved interproximal access for posterior scaling Rounded back for less trauma Pointed toe for hard-to-reach under-contact areas Y-ME Curette * Anterior/Premoler Contra-angle petite shank SYME9 use design coupled with a 70[degrees] offset single cutting edge provides optimal tooth-to-blade angulation Beneficial for line angle access and pedodontic dentition [ILLUSTRATION OMITTED] 2 Gillette/15 Anterior Use Disc-shaped end that may be Younger-Good used in a push or pull stroke m Scaler * all directions Super-thin anterior curved sickle scaler with a reduced blade length Ideal for lingual stain and calculus removal Montana Jack ** Posterior Use This scaler is narrower than Nevi 4 * typical scalers with a contra-angled sweeping blade. It comes in a Rigid shank design. ** [ILLUSTRATION OMITTED] SN137 *HS-L5 ** Anterior Use Replaces two instruments It has Scaler curette a universal curette on one end combination and a sickle scaler on the other It also comes with a mini curette end and the scaler. Reduced time searching More adaptation needed to really effectively use * Hu-Friedy ** PDT *** American Eagle
This column, part 1, includes instruments modified for supragingival and subgingival use in periodontal pockets to 4 mm in depth. A continuation, part 2, will include instruments modified for subgingival use in periodontal pockets over 4 mm in depth to the gingival attachment level and technological modifications of hand instruments to improve comfort or blade integrity.
Subgingival Instruments for Use in Pocket Depths of 1mm - 4mm
Universal and Gracey curettes are the instruments of choice in sulci of normal depth. In shallow sulci, the root surface is broad and generally flat, and a regular blade length is appropriate to adapt to all surfaces. There are concavities and depressions on the root surfaces, but they are generally shallow and can be accessed with the regular dental hygiene armamentarium such as the traditional Gracey and Universal curettes.
Problems can arise when calculus has been previously burnished, whether by hand or ultrasonic instrumentation. Additional instruments will be required to provide a variety of strokes and improve access and adaptability of the blade to provide the force necessary to crush the burnished calculus. Universal curettes are popular instruments of choice in pockets of 1-4 mm. As pocket depths increase when the blade is adapted at the correct angle, the terminal shank compensates and loses the parallel relationship to the surface being instrumented when using universal curettes. The compensation in retaining the parallelism of the terminal shank results in the loss of the ability to access the base of the pocket, and other instrument choices must be made.
Table II. Subgingival Instruments 1-4 mm Name Blade Modification/Details description and area of use Nabers Furcation Diagnostic Modified terminal shank in a curved Probe shape to adapt into furcations with (Color-coded) 2 mm markings on the probe Designed for furcation detection <1mm Class I >1mm Class II Class III furcations connect and covered with soft tissue Class IV furcations connect and clinically exposed EXD 11/12 Explorer Diagnostic Old Dominion University explorer utilizing the shank design of a Gracey 11/12; tip is curved like the 11/12. For subgingival deposit detection. This is ideal for posterior calculus detection. [ILLUSTRATION OMITTED] Columbia 4R/4L Universal Blade at 90 degrees to terminal Curette shank so two cutting surfaces can be utilized Moderate shank length for crown clearance and enhanced access Columbia 13/14 Universal Blade at 90 degrees to terminal Curette shank so two cutting surfaces can be utilized Moderate shank length for crown clearance and enhanced access McCalls 13/14 Universal Blade at 90 degrees to terminal Curette shank so two cutting surfaces can be utilized Designed with enhanced rigidity for removal of challenging deposits Barnhart 1/2, 5/6 Universal Blade at 90 degrees to terminal Curette shank so two cutting surfaces can be utilized Barnhart 1/2: longer terminal shank for extended reach, crown clearance Barnhart 5/6: shorter terminal shank, longer blade length Younger-Good 7/8 Universal Blade at 90 degrees to terminal Curette shank so two cutting surfaces can be utilized Blade shape is narrower at the heel, pronounced rounded toe Subtle transition from terminal shank to working end 15/16 Gracey Posterior The terminal shank is modified to Curette (SGR sextants reflect the 13/14 angle of terminal 15/16) Modified Buccal, shank with he 11/12 blade angle for Gracey Curette lingual and mesial surfaces. It is used to mesial improve adaptation to the mesial surfaces of surfaces of posterior teeth by premolars, improving fulcrum capabilities. It molars compares to using the 11/12 Gracey Curette but has a more dramatic terminal shank angle. It reaches intraorally to posterior teeth and allows for improved blade angle to the mesial posterior teeth surfaces. 15/16 Rigid Gracey Area-specific Rigid Gracey Curettes reflect a Curette (SGR designs modified terminal shank. The shank 15/16) Modified Scaling when is thickened to reduce instrument Gracey Curette less flexion spring when removing tenacious is preferred calculus deposits. They have the identical blade size as standard Graceys 15/16 Extra Rigid Extra-Rigid Gracey Curettes reflect Gracey Curette a modified terminal shank. The (SGR 15/16) shank is extra thickened to further Modified Gracey reduce instrument spring when Curette removing tenacious calculus deposits and also has the identical blade size as standard Graceys. 17/18 Gracey Posterior The 17/18 has a modified terminal Curette (SGR Sextants shank and blade. The terminal shank 17/18) Distal is modified to reflect a more surfaces of dramatic angle to improve premolars, adaptation to the distal surfaces molars of posterior teeth. It also has a thickened shank to reduce instrument spring when removing tenacious calculus deposits. It has a reduced blade length. The 17/18 compares to the 13/14 Gracey curette. 17/18 Gracey Area-specific Rigid Gracey Curettes See 15/16 Curette (SR 17/18) designs Rigid Scaling when less flexion is preferred 17/18 Gracey Extra-Rigid Gracey Curettes See Curette (SR 17/18) 15/16 Extra-Rigid Langer Curettes Area-specific They have a universal blade with designs Gracey shank design. They have two blades on each end. A set of the instruments is required. The SL 3/4 completes the scaling of the maxillary posteriors, the SL 1/2 instrument the mandibular posteriors and the SL 5/6 is used to instrument the mandibular and maxillary anteriors. Millennium Area-specific Less tissue distension Handles Curettes 3D - SRP designs color-coded to area of use The Trisha O'Hehir unique 3D design presents a blade with a cutting area of approximately 310 degrees and can be utilized in either a push or pull motion, vertically, laterally or diagonally. Debridement Area-specific Small disc-shaped blades Entire Curettes 1/2 designs edge of the blade is a cutting edge Buccal - Lingual enabling a push or pull stroke in (Posterior) 3/4 all directions Extended shank for Mesial - Distal access (Posterior) 5/6--Anterior 7/8 Extended--Anterior Turgeon Curettes Area-specific Modified blade is triangular in designs cross-section Back of blade is thinned to provide a sharper blade that is easier to sharpen Numbers are the same as traditional Gracey curette Quetin Curette Area-specific Quetin Curette - SQBL, SQMD designs Modified blade is on the tip of the instrument Needs to be sharpened right around the tip Available in blade widths of 1.3 mm and 0.9 mm DeMarco Curettes Area-specific Modified blade is disc-shaped to designs adapt to root concavities and furcations Adapt to labial and lingual surfaces SDM1 Large disc blade SDM2 Smaller disc blade Hirschfeld/Orban Area-specific Crush burnished calculus Files designs Emargination--excess amalgam removal Files are difficult to sharpen.
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(9.) Pattison AM. The use of hand instruments in supportive periodontal treatment. Periodontol 2000. 1996; 12: 71-89.
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(11.) Rosling B, Serino G, Hellstrom MK et al, Longitudinal periodontal tissue alterations during supportive therapy. J Clin Periodontol. 2001; 28(3): 241-9.
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This column was made possible by an educational grant sponsored by Hu-Friedy Mfg. Co.,Inc.
Barbara Long, SDT, RDH, CACE, BGS, is currently a lecturer and clinical instructor at the College of Dentistry, University of Saskatchewan and provides professional development programs for dental hygienists. Designer of dental instruments, she holds the patent for the "Vision Curvettes." Registrar-executive eirector of the Saskatchewan Dental Hygienists' Association, she has made significant contributions to the dental hygiene profession through research, clinical experience and active membership in professional associations.
By Barbara Long, SDT, RDH, CACE, BGS