17: Instrumentation for Client Assessment and Care

Instrumentation for Client Assessment and Care

This chapter focuses on the use of periodontal instruments for assessment and nonsurgical periodontal instrumentation. The primary objective of nonsurgical periodontal instrumentation is to restore periodontal tissue to health by removing dental plaque biofilm, its byproducts, and plaque-retentive factors from tooth surfaces and from within the tooth pocket space. Successful professional care depends on reducing plaque biofilm to a level that is acceptable to the tissue; therefore, instructing and supervising the client’s daily self-care precedes, continues with, and follows instrumentation by the dental hygiene practitioner.

Instrument Design

Parts of an Instrument

Handle—the part of a periodontal instrument that the clinician holds; various shapes, weights, sizes, and surface serrations (smooth, ribbed, or knurled) exist

Shank—connects the working end with the handle; usually bent in one or more places to facilitate placement of the working end against the tooth surface

1. Functional shank—the part of the shank that allows the working end to be adapted to the tooth surface; begins below the working end and extends to the last bend in the shank nearest the handle

2. Lower (terminal) shank—the bent portion of the functional shank nearest to the working end (see Figure 17-1)

3. Extended lower shank—3 mm longer than a standard lower shank; provides additional leverage, acting like a fulcrum, and is ideal when using advanced levering techniques or for working in deep periodontal pockets

4. Simple shank—bent in one plane (front to back); used primarily on anterior teeth; also called a straight shank

5. Complex shank—bent in two planes (front to back and side to side) to facilitate instrumentation of posterior teeth; this design is necessary to reach around the crown and onto the root surface; also called an angled shank or curved shank

Working end—the part of the dental instrument that contacts the tooth or soft tissue to perform the work of the instrument; begins where the instrument shank ends; an instrument may have one or two working ends

1. Parts of the working end—identified as the face, back, lateral surfaces, toe, and tip; on a hand-activated debridement instrument, a cutting edge is formed by the union of a lateral surface and the face of the working end

2. Application of the working end—the tooth surfaces or areas of the mouth on which an instrument can be used

a. Anterior use—one single-ended instrument (e.g., anterior sickle scaler, such as a Jacquette 33) can be used to perform procedures on the facial, lingual, mesial, and distal surfaces of anterior teeth

b. Posterior use—one double-ended instrument (e.g., posterior sickle scaler, such as a Jacquette 34/35) can be used to perform procedures on the facial, lingual, mesial, and distal surfaces of posterior teeth

c. Universal use—one double-ended instrument (e.g., universal curet, such as a Columbia 13/14) can be used to perform procedures on both anterior and posterior teeth

d. Area-specific use—an instrument that can be applied only to specific surfaces and areas of the mouth; a set of area-specific instruments (e.g., area-specific curets, such as the Gracey series) is needed for procedures on the entire dentition

3. Function of the working end

Design Characteristics

Instrument balance—a balanced instrument has working ends that are aligned with the long axis of the handle

Instrument identification—the unique design name and number that identify each periodontal instrument

1. Design name—identifies the school or individual responsible for the original design or development of an instrument or group of instruments (e.g., ODU 11/12 periodontal explorer, in which the ODU stands for Old Dominion University; and the TU-17, in which TU stands for Tufts University School of Dental Medicine)

2. Design number—the number designation of the working end that, when combined with the design name, provides the exact identification of the working end (e.g., Gracey 11, in which Gracey is the design name, and 11 is the design number)

3. Identification of the working ends of a double-ended instrument—a double-ended instrument will have two design numbers, one number for each working end of the instrument

Hand-Activated Instruments

Classifications

Hand-activated nonsurgical periodontal instruments are classified as periodontal probes, explorers, sickle scalers, periodontal files, universal curets, area-specific curets, hoes, or chisels; hoes and chisels are rarely used because their functions have been largely replaced by mechanized instruments

Periodontal instruments are divided into classifications based on the specific design characteristics of the working end; design characteristics include:

1. Design of the cutting edges, back, lateral surfaces, and shank

2. Cross-section of the working end

3. Relationship of the face to the lower shank (Table 17-1)

TABLE 17-1

Use of Hand-Activated Instruments

image

From Nield-Gehrig JS: Fundamentals of periodontal instrumentation and advanced root instrumentation, ed 6, Philadelphia, 2008, Lippincott Williams & Wilkins.

In selecting an instrument for a specific task, one of the most important considerations is the classification of the working end

Dental Mirror

Characteristics

Uses

Probe

Characteristics

Types

Calibrations—millimeter marks at intervals that are specific for each probe design

1. Calibrated probes

a. Probe designs may differ in millimeter markings (Table 17-2); only certain millimeter increments may be indicated on the probe (e.g., 1—2—3—5—7—8—9—10 mm), or each millimeter may be indicated (e.g., 1—2—3—4—5—6—7—8—9—10—11—12—13—14—15 mm)

TABLE 17-2

Examples of Probe Markings

image

From Nield-Gehrig JS: Fundamentals of periodontal instrumentation and advanced root instrumentation, ed 6, Philadelphia, 2008, Lippincott Williams & Wilkins.

b. Color-coded probes are marked in bands (often black), with each band being several millimeters in width (e.g., 3–5 mm and 8–10 mm)

2. Furcation probes

Explorer

Characteristics

Design (Figure 17-2)

Types—available in a variety of design types; not all design types are well suited to subgingival use; therefore, the clinician must be knowledgeable about the recommended use of each design type

1. Shepherd hook (e.g., #23 and #54 explorers)—an unpaired explorer with a short, highly curved shank and a sharp point; used for supragingival examinations to detect irregular margins of restorations; not recommended for calculus detection because subgingival use could result in tissue trauma

2. Straight explorer (e.g., 6, 6A, 6L, 6XL)—an unpaired explorer with a short lower shank and a sharp point; used for examinations to detect irregular margins of restorations; not recommended for subgingival calculus detection

3. Curved explorer (e.g., 3, 3A)—an unpaired explorer with a curved shank and a sharp point; limited for use in examining normal sulci or shallow pockets; may be used for calculus detection; however, care must be taken not to injure the junctional epithelium when the working end is used subgingivally

4. Orban-type explorer (e.g., TU-17, Orban 20)—an unpaired explorer with a straight lower shank that can be used in deep pockets with only slight tissue displacement (stretching of the tissue wall away from the tooth); the explorer tip is bent at a 90-degree angle to the terminal shank, which allows the back of the tip (instead of the point) to be directed toward the junctional epithelium; useful for detecting subgingival calculus on anterior teeth or on the facial and lingual surfaces of posterior teeth; however, the straight lower shank makes it difficult to adapt to the line angles and proximal surfaces of posterior teeth

5. Pigtail or cowhorn explorer (e.g., 3MI, 3CH, 2A)—a paired universal explorer with a short, broadly curved lower shank and a sharp point; the curved lower shank causes considerable tissue displacement; useful for detecting calculus in normal sulci or shallow pockets extending no deeper than the cervical third of the root

6. The 11/12-type explorer (e.g., ODU 11/12, 11/12 AF)—a paired universal explorer with an extended lower shank and a tip that is bent at a 90-degree angle to the terminal shank; the tip design allows the back of the tip to be applied to the pocket base without lacerating the junctional epithelium; this effective explorer design adapts well to all surfaces throughout the mouth and is equally useful when exploring a shallow sulcus or a deep periodontal pocket

Sickle Scaler

Characteristics

Design (Figure 17-3)

Uses

Limitations

Periodontal File

Characteristics

Design

Uses

Limitations

Universal Curet

Characteristics

Design (Figure 17-4)

Uses

Limitations

Area-Specific Curet

Characteristics

Design (Figure 17-5)

Uses

Limitations

Hand Instruments for Root Debridement

Characteristics

Examples of advanced root debridement instruments—a variety of periodontal instruments have been developed to increase treatment effectiveness on root surfaces within deep periodontal pockets

1. The 11/12-type periodontal explorer—an 11/12 AF (After Five) explorer has an extended shank and is ideal for use in deep periodontal pockets

2. Advanced curet designs—several curets are ideal for instrumentation within deep periodontal pockets

a. Vision curvette curet series—have a working end that is shortened to half the length of a standard Gracey curet, a curved working end, and an extended lower shank

b. Modified Gracey curets

c. Quetin Furcation curets—specialized instruments that are used to debride furcation areas and root concavities; each miniature working end has a single, straight cutting edge with rounded corners; the working ends are available in either 0.9-mm or 1.3-mm size

d. O’Hehir debridement curets—area-specific curets that are designed to remove light residual calculus deposits and bacterial contaminants from root surfaces

e. Instruments with diamond-coated working ends

Principles of Instrumentation

Position of the Clinician

Neutral, seated position (Figure 17-6)

Relationship to the client and the dental unit

Stabilization During Instrumentation

Modified pen grasp—the recommended grasp for holding a periodontal instrument that allows precise control of the working end; precise placement of the fingers in the modified pen grasp is important to be successful in instrumentation technique

1. Finger placement and function (Figure 17-7)

2. Technique

3. Glove fit—proper fit of sterile gloves is important in avoiding muscle strain during instrumentation

Fulcrum and finger rest

1. Definitions

2. Types of fulcrums

3. Advanced fulcrum techniques

Angulation

Definition—the relationship between the face of a calculus removal instrument and the tooth surface to which the working end is applied

Principles

Activation

Definition—moving an instrument to produce a stroke; it is the action of an instrument in the performance of the task for which it was designed

Types

Stabilization and lateral pressure

1. Definitions

2. Stroke pressure

Maintaining adaptation during stroke production

Neutral wrist position—correct wrist position is important to avoid muscle discomfort and injury during the procedure; the wrist should be aligned with the long axis of the forearm; bending the wrist up, down, or to the side should be avoided

Instrumentation Strokes

Types of strokes

1. Placement stroke—used to position the working end at the base of the sulcus pocket or apical to a calculus deposit

2. Assessment strokes—used to evaluate the tooth surface or the health of periodontal tissue

3. Calculus removal work strokes—used to remove calculus deposits

4. Root debridement work strokes—used to remove residual calculus deposits, plaque biofilm, and plaque byproducts from root surfaces

Stroke direction

Stroke characteristics

1. Length—short, powerful stroke for calculus removal; longer, lighter stroke for root surface debridement

2. Overlap—strokes should overlap to ensure complete coverage; long ridges of calculus are treated in sections, in overlapping scaling zones

3. Pattern

Steps for Calculus Removal with Hand-Activated Instruments

Position the dental mirror, and establish a finger rest

Grasp the instrument in a modified pen grasp

Establish a finger rest

Adjust the hand–wrist–forearm as a unit

1. Position the thumb and the index finger across from each other on the instrument handle, near the junction of the handle and shank

2. Lightly rest one side of the middle finger pad on the instrument shank

3. Place the other side of the middle finger pad against the ring finger to allow the hand to function as a unit during the production of the stroke

4. Balance the tip of the ring finger on an occlusal or an incisal surface to support the weight of the hand and instrument

5. Position the wrist in a neutral position so that it is aligned with the long axis of the forearm (Figure 17-9)

Adapt the cutting edge

Stabilize the grasp, and apply lateral pressure

Activate a pulling stroke away from the junctional epithelium

Pause briefly at the end of a stroke

Check the instrumentation area frequently with an explorer

Instrumentation for Assessment

Assessments with Periodontal Probes

Purposes of the periodontal examination

1. Aid in planning dental care by determining gingival characteristics, probing depth, level of attachment, and presence of bone loss

2. Determine the extent of inflammation in conjunction with the probing depth and attachment level; bleeding resulting from probing is an early clinical sign of inflammation (Figure 17-10)

3. Evaluation of treatment outcomes according to:

Jan 1, 2015 | Posted by in Dental Hygiene | Comments Off on 17: Instrumentation for Client Assessment and Care
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