Progress Notes

During her initial visit the patient was instructed on plaque control and oral hygiene home care. The patient brushed only once daily and did not use interproximal cleaning aids at the initial visit. An electric toothbrush with a two minute timer or a manual toothbrush for twice daily use was recommended for plaque control. Thin, waxed floss and a floss handle for improved access to posterior interproximal areas was provided and the patient was instructed with c‐shaped flossing technique. Use of a 0.12% chlorhexidine rinse was recommended twice daily after completion of scaling and root planing for two weeks. The patient consented to four quadrants of scaling and root planing with local anesthesia and nitrous oxide for pain and anxiety control. A three‐to‐four month maintenance recall was recommended upon completion of nonsurgical periodontal treatment. The patient appeared motivated to continue with efforts for further improvement of her oral health.

Discussion

The patient presents with generalized moderate biofilm, supra, and heavy interproximal subgingival calculus located in all four posterior quadrants. Upon effective removal of calculus and biofilm, and considering no tooth mobility, lack of furcation involvement, nonsmoking history, and a positively motivated patient, the periodontal prognosis for this patient is favorable.

The goal of periodontal instrumentation includes the removal of plaque and calculus, the elimination of bleeding upon probing, reduction in probing depths, reduction of inflammation, improvement in gingival health and appearance, and resolution of patient discomfort (Carnio et al. 2015; Kumar 2015). Any biofilm or calculus remaining on a tooth’s surface may increase the risk for future plaque retention and increased risk for attachment loss (Aspriello et al. 2011; Krishna and De Stefano 2016). Effective nonsurgical periodontal therapy involves the combination of both manual and ultrasonic instrumentation, including the selection of appropriate instruments. These depend upon periodontal probing depths, amount of calculus, and biofilm present, detection of root surface irregularities prior to scaling, and radiographic interpretation of tooth and root anatomy (Carnio et al. 2015; Krishna and De Stefano 2016; Kumar 2015; Wilkins 2009). Consideration of all of these factors prior to instrumentation allows the clinician to minimize risk for potential periodontal abscess formation and any alteration to the root surface structure. Years of inappropriate instrumentation and minor tooth structure removal may create cumulative damage to the root increasing the rate of plaque retention and toxin formation (Kumar 2015, p. 56). A number of factors contribute to root surface roughness including the type of ultrasonic tip, curette tip design, force applied, angulation, and duration of instrumentation (Henchman et al. 2016; Kumar 2015).

Manual instrumentation for scaling and root planing is the established protocol for successful treatment of periodontal disease and dental caries. This protocol provides the advantage of better instrument control and tactile perception for the clinician (Henchman et al. 2016; Kumar 2015). Universal curets, depending on their design, may be used in all areas of the mouth for scaling and root planing (Darby and Walsh 2003, p. 387). Area specific curets may be used in all areas of the mouth, but the clinician must assess the specific design for use on anterior versus posterior surfaces (Darby and Walsh 2003, p. 387). In general the more acute the angle and the greater the number of bends, the more access the instrument provides for posterior teeth (Darby and Walsh 2003, p. 387). A key to effective instrumentation includes the sharpness of an instrument’s cutting edge, with sharp instruments providing the clinician with more tactile sensitivity, more control for working efficiency and lateral pressure, and increased patient comfort (Darby and Walsh 2003, p. 397). Sharpening instruments at the first sign of dullness helps to ensure blade effectiveness while preserving the original contours and design (Darby and Walsh 2003, p. 396). Once appropriate instruments are selected, the clinician chooses the correct working end for nonsurgical manual instrumentation. For ideal calculus and biofilm removal, the angulation of the blade adapts from 45° to 90° with the tooth’s surface (Darby and Walsh 2003, p. 394). A more open angulation is recommended for a smoothing, root planing stroke, while a closer angulation grabs the root surface for heavy deposit removal (Darby and Walsh 2003, p. 394). However, manual instrumentation is timely, skill dependent, and with limitations when utilized in deep periodontal pockets or hard to navigate furcation areas (Henchman et al. 2016; Kumar 2015; Wilkins 2009).

Ultrasonic and power instrumentation provides less fatigue to the operator while effectively removing dental debris from difficult to reach areas (Kumar 2015; Wilkins 2009). The three modes of action for power instrumentation include mechanical action, cavitation, and acoustic mainstreaming (Darby and Walsh 2003, p. 473). The types of ultrasonic instrumentation, magnetostrictive and piezoelectric, refer to the range of acoustical vibrations that are a unit of frequency referred to as cycles per second (Darby and Walsh 2003, p. 474). Magnetostricitve tips act with alternating electromagnetic fields causing the tip of the insert to vibrate in an elliptical or orbital motion (Darby and Walsh 2003, p. 476). The piezoelectric units differ in that vibration occurs when alternating currents are applied to the transducer, creating a dimensional change transmitted to the tip where the tip moves in a linear pattern with only two sides of the tip activated to the adapted tooth surface (Darby and Walsh 2003, p. 481). Effective power and ultrasonic instrumentation requires deliberate, multidirectional strokes, keeping the tip constantly moving (Henchman et al. 2016, p. 137). Overlapping vertical, horizontal, and oblique strokes, in a cross‐hatching pattern and working circumferentially allow for effective removal of pathogens (Henchman et al. 2016, p. 137). A power or ultrasonic insert designed for subgingival periodontal debridement has a tip that is 40–47% thinner than the standard diameter tip with a longer shank that can reach 1 mm deeper than hand instruments, into subgingival areas, furcations, root concavities, and interproximal areas (Henchman et al. 2016, p. 136).

After complete patient assessment, the suggested treatment for nonsurgical periodontal instrumentation begins with use of the ultrasonic or other power driven scaler on high to medium power to remove heavy calculus deposits, moving to thinner insert tips on lower power settings for residual deposits and biofilm removal (Henchman et al. 2016; Wilkins 2009). The use of multidirectional, short overlapping strokes using vertical, horizontal, and oblique motions in a cross‐hatching pattern on the entire surface of tooth and root structure is necessary for removal of biofilm pathogens (Henchman et al. 2016, p. 137). The lavage and mechanical vibrations in addition to the use of ultrasonic scalers, act to disrupt biofilm and flush endotoxins from the sulcus (Henchman et al. 2016, p. 136). When debriding moderate to heavy supragingival calculus, a heavy insert tip set on moderate to high power allows for proper fragmenting of heavy calculus deposits (Henchman et al. 2016; Wilkins 2009). If used on a low setting, the heavy insert becomes more likely to burnish calculus or damage the existing tooth structure. Slim insert tips used on low to medium power are able to reach 1 mm deeper into subgingival pockets, furcations, and root concavities than hand instruments (Henchman et al. 2016, p. 136). When choosing an ultrasonic tip insert for instrumentation the clinician must adjust the power setting accordingly.

Take‐Home Hints

1. Effective removal of biofilm and calculus accumulation is necessary for successful nonsurgical periodontal therapy.
2. Ultrasonic or power driven scaler tips used on the incorrect power setting may damage existing tooth structure.
3. Goals for selecting appropriate instrumentation techniques include minimizing risks for root structure damage and improving tissue health.
4. Manual instrumentation provides greater instrument control and tactile sensitivity but is clinician skill dependent.