CHAPTER 12 Instrumentation
The purpose of clinical instrumentation is to create an oral environment where periodontal health is maintained and tissues can return to health. It is accomplished by debridement (or scaling) of the teeth to remove hard deposits to discourage dental biofilm (dental plaque) attachment, such as calculus and/or stain during an oral prophylaxis or nonsurgical periodontal therapy (NSPT), as well as periodontal maintenance (PM). Manual instruments, power-driven instruments, or combination of the two can be used to effectively debride (scale) the teeth and accomplish this goal. Loupes and a headlight are BOTH useful for improving instrumentation. Use of the dental endoscope (Perioscope) creates further opportunity for successful NSPT or PM by offering a tool to aid in definitive instrumentation.
Any instrument that means removal of endotoxins (altered cementum) or by-products of microorganisms from root surface is controversial, and use of other means for removal of dental biofilm is now stressed. Also controversial is the use of traditional root planing with removal of root structure to produce a smooth, glasslike root surface. In addition, soft tissue curettage with removal of the pocket lining is no longer recommended for health of the tissue. Section on polishing in this chapter covers the selective method. Discussion of all these issues is included to allow for changes in testing materials over time. The term “operator” may be used here instead of “clinician” when discussing instrumentation. The Centers for Disease Control and Prevention (CDC) recommends antimicrobial mouthrinse before any instrumentation.
The CORRECT positioning of BOTH patient and clinician during instrumentation is critical to long-term comfort and effectiveness of clinician. Takes into account ergonomic principles and incorporation of neutral positioning (see later discussion). Transfer of instruments is not discussed here, except to emphasize that to prevent injury to patient, instruments should never be passed over the patient’s face or eyes. Also not discussed is concept of work zones that are set up like a “clock” around the patient (review from class texts).
Scenario: A dental hygienist is on the first day of his new position at a large dental clinic. Before taking this new position, he was the only dental hygienist for over 10 years at the same small dental practice after graduating top of his class at age 20. He notices that he is unable to put his feet on the floor when he sits on the stool provided for him. He also has trouble instrumenting the lower arch; it just seems there is not enough overhead light, especially on the lingual of the anteriors. He also wants to get closer to his patients; he has forgotten what the effective distance to a patient’s mouth is. At the end of the day he notices that his back hurts. He is worried about what this means to his future in his profession.
Manual (hand) instruments are classified as either assessment or treatment instruments. However, many treatment instruments can also be used for assessment during treatment. Manual instruments include mirrors, explorers, probes, scalers, curets, hoes, files, chisels; available in BOTH basic designs and types and those for specific functions.
Basic manual instrument design determines the intended purpose and location of use. Specific selections are also based on personal preference and/or ergonomic concerns. Instrumentation with manually activated instruments, BOTH for assessment and for treatment, requires high degree of precision and control and in some cases power and force. CORRECT use of instruments can BEST be accomplished with consistent application of basic principles of instrumentation.
Figure 12-3 Periodontal probes (from left to right): Nabor’s is curved for furcations, PCP12 with Marquis markings on modified shank, Williams markings at 1-2-3-5-7-8-9-10, Marquis with 3-6-9 markings, WHO with ball tip used to record PSR.
Figure 12-6 Comparison of universal and area-specific curets. Universal curets have a 90° angle between the face and the terminal shank, which gives them two functional cutting edges. Area-specific curets have offset angle with a 70° angle between the face and the terminal shank. This makes lower cutting edge the only one that is used for debridement.
|Gracey curet||Designated area of use|
|Gracey 1-2 and 3-4||Anterior teeth|
|Gracey 5-6||Anterior or premolar teeth|
|Gracey 7-8 and 9-10||Posterior teeth buccal and lingual surfaces|
|Gracey 11-12 and 15-16||Posterior teeth mesial surfaces|
|Gracey 13-14 and 17-18||Posterior teeth distal surfaces|