The patient’s last dental examination, prophylaxis, and radiographic assessment occurred five years ago. The patient states she is dental phobic. Currently the patient brushes once daily with a manual, soft‐bristled toothbrush and does not use any interdental aides.
The patient and is currently breastfeeding after giving birth six months ago. She is in good health, taking no medications at this time. She reports no known allergies.
- Vital Signs:
- Blood pressure: 130/70 mmHg
- Pulse: 74 beats/min
- Respiratory Rate: 15 breaths/min
The patient is a nonsmoker and reports never using tobacco products. She drinks socially, having two to four glasses of wine per week. Her current diet includes starchy vegetables, carbohydrate rich foods, and caffeinated soda to help her stay awake and have energy for her newborn baby.
The extra‐ and intraoral examinations are within normal limits. The gingival examination reveals bright red, shiny gingiva with generalized moderate inflammation, and bleeding on probing for all sites. The gingival margins on the maxillary anterior sextant are rolled with blunted papilla between teeth #8 and #9. There is heavy generalized supragingival biofilm and calculus accumulation with heavy interproximal subgingival calculus in all posterior quadrants. Probing depths range from 3–5 mm. Localized gingival recession is present on the facial of #22 and #27. No tooth mobility or furcation involvement is detected.
Radiographs reveal slight generalized horizontal bone loss with a slight vertical bony defect on the mesial of tooth #31. Interproximal calculus appears radiographically in all four quadrants (see Figures 4.1.1, 4.1.2, 4.1.3, and 4.1.4).
Dental Hygiene Diagnosis
|Increased risk for periodontal disease||Dental neglect; moderate biofilm; once daily brushing without interproximal aids.
heavy interproximal calculus, bleeding upon probing, and probing depths >4 mm existing in all quadrants
|Increased risk for caries||Irregular dental care, starchy and carbohydrate diet, and soda|
|Generalized gingival sensitivity and possible gingival recession post‐dental hygiene treatment||Gingival inflammation related to biofilm accumulation, lack of proper oral hygiene instruction (OHI) and homecare|
Planned Dental Hygiene Interventions
|Clinical||Education||Oral Hygiene Instruction|
|Four quadrants scaling and root planing with ultrasonic and hand instrumentation
Use of local anesthesia and nitrous oxide for pain management and ease dental anxiety
Four to eight week (Segelnick and Weinberg 2006) re‐evaluation of periodontal tissue and probing depths
Three to four month periodontal maintenance appointments
|Progression and etiology of periodontal disease
Increased risk for dental caries
Reinforce importance of regular dental visits
Educate on techniques available to ease patient anxiety for future treatments
Follow‐up/review of OHI
|Electric, battery powered, or manual toothbrush with emphasis on two‐minute brushing at least twice daily
C‐shaped flossing or use of a floss handle for interdental cleaning or other interdental aides per patient preference
Use of antimicrobial rinse twice daily
Healthy snacks and beverages
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.
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.
- Effective removal of biofilm and calculus accumulation is necessary for successful nonsurgical periodontal therapy.
- Ultrasonic or power driven scaler tips used on the incorrect power setting may damage existing tooth structure.
- Goals for selecting appropriate instrumentation techniques include minimizing risks for root structure damage and improving tissue health.
- Manual instrumentation provides greater instrument control and tactile sensitivity but is clinician skill dependent.