2. Introduction
Mechanical non-surgical therapy
Manual instruments
Sonic and ultrasonic instruments
Healing of periodontal tissues following scaling and root
planing
One stage full mouth disinfection
Pharmacotherapeutics
Systemic antibiotics
Local drug delivery
Host modulatory therapy
Lasers in nonsurgical therapy
Photodynamic therapy
Root biomodification
Growth factors
3. Dental plaque is the main etiological factor in the
pathogenesis of periodontal diseases.
The basic approach to periodontal infection is the
removal of supragingival and subgingival bacterial
deposits by scaling and root planing.
The primary goal of periodontal therapy is to
preserve the natural dentition by achieving and
maintaining a healthy periodontium.
4. Nonsurgical periodontal treatment is the cornerstone
of periodontal therapy and the first recommended
approach to the control of periodontal infections.
Nonsurgical periodontal therapy is still considered to
be the gold standard to which other treatment
methods are compared. (Cobb CM 1996)
Nonsurgical periodontal therapy still constitutes the
first step in controlling periodontal infections.
5. Consists of scaling and root planing and is an
important procedure in the treatment of periodontal
diseases.
Mechanical debridement can be performed with the
help of scalers.
Scalers can be divided into Manual, Power driven.
6. DEFINITIONS (1989 proceedings of World Workshop
in Clinical Periodontics)
Scaling - “Instrumentation of the crown and root
surfaces of the teeth to remove plaque, calculus and
stains from these surfaces.”
Root planing - “A definitive treatment procedure
designed to remove cementum or surface dentin that
is rough impregnated with calculus, or contaminated
with toxins or microorganisms. It was further stated
that when done in a thorough fashion, some
unavoidable soft tissue removal occurs.”
7. Scaling and root planing are not separate procedures.
The principles applicable to scaling equally apply to root
planing.
The difference between scaling and root planing is only a
matter of degree.
The nature of the tooth surface determines the degree to
which the tooth must be scaled or planed.
8. To restore gingival health by completely removing
elements that provoke gingival inflammation (i.e
plaque, calculus and endotoxin)
To secure biologically acceptable root surfaces
To resolve inflammation
To reduce probing depths
To facilitate oral hygiene procedures
To improve or maintain attachment levels
To prepare tissues for surgical procedures
9. Ideally, the goal of all periodontal therapy is to
reconstitute the periodontal tissues in their original
form and relationships. Such a result occurs
consistently only when the disease is completely
reversible, as in early marginal gingivitis, when no
connective tissue attachment of the periodontium to
the root has been lost.
Once a true periodontal pocket depth has developed,
reconstitution of the periodontium is only rarely
obtainable by deep scaling alone.
Thus, the objective of deep scaling in treatment of
periodontitis is to eliminate or reduce the size of
plaque retentive periodontal pockets by either tissue
shrinkage or "reattachment" to the tooth surface.
10. When deep scaling is used as the sole means of
treatment for a given periodontal pocket, the
procedure must be extremely thorough. The
technique is known as definitive deep scaling.
If the aim of scaling is to reduce gingival
inflammation in preparation for surgical procedures
in deeper pockets, the requirements are less
stringent, since good tissue tone can result from less
than perfect deep scaling. This procedure is
presurgical scaling.
11. Supragingival scaling - instrumentation is performed coronal
to the gingival margin
entails the removal of calculus generally less tenacious and
less calcified than subgingival calculus.
Subgingival scaling and Root Planning - more complex
and difficult to perform than supragingival scaling.
Subgingival calculus is usually harder than supragingival
calculus and is often locked into root surface irregularities,
making it more tenacious and therefore more difficult to
remove.
Curette is the choice for subgingival scaling and root planning
should be performed under local anesthesia.
Subgingival instrumentation aims at resolving the inflammation
in the gingiva and arresting the progressive destruction of the
attachment apparatus by removing the biofilm present in the
gingival pocket. It is the most important measure in the
treatment of periodontitis.
12. Marginal Gingivitis
Since the essential etiologic agent is bacterial plaque, effective
oral hygiene procedures are presupposed in all successful
therapy.
Necrotizing ulcerative gingivitis
in both its acute and moderately advanced sub-acute forms
responds well to deep scaling
Gentle debridement of the soft tissue and gentle scaling of the
hard tissue wall are all that is required for healing.
Moderate periodontitis (pocket depths to 7mm)
characterized by extensive gingival edema can undergo sizable
reductions of tissue dimensions after treatment. Pocket depth
reductions are dependent on the configuration of the pockets
around the teeth. Since pocket reduction is based primarily on
tissue shrinkage, circumferential pockets of relatively uniform
depths respond most completely.
13. Palatal surface pockets - undergo "closure" after
definitive deep scaling.
Since palatal tissue is fibrous and rarely undergoes
significant tissue shrinkage after scaling, the pocket
closure is most likely a reattachment, characterized by a
"long epithelial attachment' rather than a new
connective tissue attachment.
In this location, the reattachment is very stable over long
periods of time.
14. Facial surface pockets
The narrower the pocket, the greater the possibility for
success.
Since many of these pockets extend apical to the mucogingival
line, pocket closure can preclude the necessity of mucogingival
surgery.
Proximal deep pockets-
on anterior teeth and premolars have a fairly high rate of
pocket closure after definitive deep scaling.
Deep grooves on proximal surfaces, as are frequently
encountered on maxillary first premolars and the lingual
surface of maxillary anterior teeth, seem to be a deterrent to
successful pocket closure. This deterrence may be the result of
difficulties in properly curetting the deeper portions of such
vertical grooves.
15. Abscesses –
Acute periodontal abscesses respond well to deep
scaling. The responsive nature of acutely inflamed tissues
seems to favorably predispose the tissue to regenerate
lost attachment and alveolar bone.
This reparative ability appears to occur most frequently
on single-rooted teeth or on one root of a multirooted
tooth.
Abscesses related to pockets within the furcations of
molars do not respond by regeneration.
Those abscessed pockets that can be readily evacuated
of pus are most responsive to deep scaling.
16. Gingivitis –
Gingivitis caused by systemic or non-correctable local
factors will not respond to deep scaling and root planing
to an acceptable degree.
Conditions such as hormonally induced desquamative
gingivitis, hyperplasia due to phenytoin (Dilantin)
sensitivity, gingival inflammation resulting from reduced
salivary flow, or the drying effects of mouth breathing
are examples of tissue reactions most resistant to
treatment by deep scaling alone.
17. Periodontitis –
Periodontitis that exhibits little gingival inflammation or
has thick, fibrous gingiva overlying the pockets is
relatively resistant to effective treatment by deep scaling
and root planing.
In the absence of inflammation, little pocket reduction by
tissue shrinkage can occur.
18. Pockets that extend into the bifurcation or trifurcation
area of molars or premolars, especially of grades II
and III, will not respond to deep scaling by shrinkage
or reattachment.
Deep proximal pockets associated with shallow or
nonexistent facial or lingual pockets on premolars
and molars will respond poorly.
The retromolar areas in the mandible and the thick
gingiva of the tuberosity of the maxilla will undergo
little shrinkage because of the nature of the adjacent
anatomic structures.
19. Deep, interdental bony craters associated with closely
approximating roots in periodontitis cases have poor
prospects. The most frequent area that exhibits this
change is the space between the distobuccal root of the
maxillary first molar and the mesiobuccal root of the
second molar. Deep scaling usually causes only slight
tissue reduction with no reattachment.
In cases of long-standing subacute necrotizing gingivitis,
deep and wide gingival and bony craters develop in the
molar areas. These craters do not readily exhibit soft
tissue regeneration as occurs elsewhere in the dentition.
Surgical intervention is required to eliminate the defect.
20. Rapidly formed pockets with attendant extensive
bone loss caused by root fractures and granulation
tissue enlargements are best treated by extraction
and surgical excision, respectively. The rapid
granulation lesion is best enucleated down to the
alveolar bone using a flap procedure to provide
access.
Deep pockets of >7 mm on any tooth surface as well
as those difficult to completely scale because of their
anatomy will persist. These latter pockets are
frequently circuitous or considerably wider at their
base than at the gingival margin. Open scaling of the
root surfaces is the preferred treatment.
21. Very aged Individuals
Medically compromised patients who cannot sustain the
trauma of surgery.
Psychologically unprepared patients who cannot accept
the psychic implications inherent in surgical techniques
that are essentially excisional
Esthetic considerations where severe recession In
anterior segments would be unacceptable
Extremely advanced cases wherein pocket eradication by
surgery would be impossible and where extractions of
many teeth and restorations are unacceptable to the
patient
23. HISTORY
JOHN W RIGGS in the 20th century designed a series of six
instruments, which were the first to have various instrument
designs for the different tooth surfaces to be treated.
Instruments were essentially sickles, were still large and
clumsy and not suitable for fine scaling.
William J Younger devised a set of instruments that included
curette style instruments with more delicate blades and
slender shanks. Tools lacked a contra angle.
Later Robert Good, Henry Jompkins, David D Smith, R.G.
Hutchinson all developed various instrument designs in
curettes and files all lacked contra angle.
C.M. Carr made major improvements in instrument design with
exact contra angle, two point contact, on the root surface of
instrument blade and shank.
24.
25. Uses -
Removal of supragingival calculus.
Useful for removal of gross calculus that is slightly below
the gingival margin when it is continuous with the
supragingival calculus and when the gingival tissue is
flaccid to permit easy insertion.
Limitations
Sickle scaler does not lend itself to subgingival insertion –
the pointed tip and back can cause tissue trauma.
Tactile sensitivity decreased with larger heavier blades.
Since face is perpendicular to the lower shank – level
cutting edges. Thus the lower shank must be tilted
slightly toward the tooth surface to establish correct
angulation.
26. Anterior scalers Posterior scalers
Straight shank & handle, shank &
working end in the same plane
Contrangle shank
Either single ended/double ended.
Usually pair 2 different working ends.
For eg U15 curved sickle paired with
33 straight sickle
Double ended / paired with ends that
are mirror images
Limit the clinicians ability to maintain
balanced posture
- cause excessive wrist bend
- limited to use on anterior sextant
Eg D-1 white side – 2 VSC -128,
Towner U-15 Goldman H6 and H7.
Allows the clinician to access all areas
of the mouth with one instrument while
maintaining a balanced posture.
Eg 204S, Jacquette 34/35, Ball 2/3,
Mecca 11/12 Catatonia 107/108.
27. An instrument having a sharp-spoon shaped edge
and rounded toe used for debridement of periodontal
pockets, tooth roots and bone.
It is the instrument of choice for removing deep
subgingival calculus, root planning altered
cementum and removing the soft tissue lining the
periodontal pocket.
28.
29.
30. Gracey Curette
Standard
Rigid, Extrarigid, Gracey prophy
Modification to Gracey curettes
After five / extended shank
Minifive / mini-bladed
Vision curvettes
Langer and mini-langer curettes
Turgeon modified gracey
Quetin furcation curettes
O’Hehir debridement curettes
31. representative of the area specific curette.
The original series was developed in the 1930’s by
Dr. Clayton Gracey – a periodontist at the University
of Michigan
designed to provide better access to root surfaces in
deep pockets.
32.
33. Rigid curettes
A rigid curette has a larger, stronger, less flexible shank and
working end.
Used to remove medium sized calculus deposits.
Rigid shank limits tactile information.
Advantages : No need of using additional heavy scalers
such as sickles and hoes.
Extra rigid curettes
Blades identical in size to standard gracey curettes.
Ideal for tenacions calculus removal gross scaling and initial
debridement.
Gracey prophy curettes
Blades are of same size as gracey standard curettes – shank is
shorter and more rigid for removal of subgingival deposits.
34.
35. • Blade length – 50% shorter.
Curved slightly upward – allows the curettes to adapt
more closely to the tooth surface.
Has a precision balanced blade tip in direct
alignment with the handle.
Blade tip perpendicular to the handle and shank
closer to parallel with the hand.
Lower shank has two raised bands at 5 and 10mm –
visually estimate pocket depth during instruments.
An identification mark (+) on the handle near the
junction of the shank – indicates lower cutting edge.
36.
37.
38. Set of 3 curettes combines the shank design of the
standard gracey # 5-6, # 11-12, # 13-14.
Langer # 5-6 - mesial and distal of anterior teeth
Langer # 1-2 curette (gracey 11-12 shank) – mesial
and distal of mandibular posterior teeth.
Langer # 3-4 curette (gracey 13-14 shank) – mesial
and distal of maxillary posterior teeth.
Types
Standard langer – for pockets 4mm or less in depth.
Rigid langer – for removal of tenacious deposits.
Extended shank langer – for pockets greater than 4mm.
Miniature shank langer – for access into deep narrow
pockets
39. Working end is narrower in size narrower therefore is
easier to insert
Cross section has been modified making it easier to
sharpen
40. Each miniature working end has a single straight
cutting edge
Corners of the cutting edges & back of the working
end are rounded to minimize the potential for
gouging the tooth surface
Working end is available in either 0.9mm or 1.3mm
size
41. Working end is a tiny circular disk
The entire circumference of the working end is the
cutting edge – can be used in pull or push stroke in
any direction
Extended lower shank
42. Blade is slightly bowed thus can maintain 2-point
contact.
Back of the blade is rounded and blade reduced to
minimal thickness.
Single straight cutting edge.
Blade turned at 99-100° angle to shank.
Cutting edge beveled at 45° angle to the end of the
blade.
43. Uses
Removes large accessible supragingival calculus.
Limitations
Causes tissue distention of the pocket wall.
Lack of adaptability to curved root surface.
Lack of tactile sensitivity – bulk of instrument.
44. Designed for proximal surfaces of teeth too closely
spaced to permit the use of other scalers.
Usually used in the anteriors
A double ended instrument with a curved shank at one
end and straight shank at the other.
blades are slightly curved and have a straight cutting
edge beveled at 45°.
Uses
Removal of supragingival calculus from exposed proximal
surfaces of anterior teeth where interdental gingiva is missing.
Full width of cutting edge should be applied as the sharp
corners can nick and groove the tooth surface.
45. It has a series of blades on a base, base is either
round oval or rectangular.
Multiple blades are at 90-105° angle with the shank.
Functions
Primary function is to fracture / crush tenacious calculus.
Used to remove overhanging margins of restorations
Disadvantages
It can easily gauge and roughen root surfaces.
46. Used for final finishing of root surfaces
Do not have cutting edges but are coated with very
fine grit diamond
Buccal-lingual instruments are used in furcations
47. Power driven instruments uses rapid energy
vibrations of a powered instrument tip to fracture
calculus from the tooth surface and clean the
environment of the periodontal pocket.
Electronically powered devices were developed with
the goal of making calculus removal easier and
faster with less patient discomfort and clinician
fatigue.
Power driven scalers
Sonic scalers
Ultrasonic scalers
Magnetostrictive scalers
Piezoelectric scalers
48. Other power driven instruments
Reciprocating scaler system (PER-IO-TOR)
Perioplaner & periopolisher system (EVA system)
Rotating motion (Intensiv, Desmoclean)
Periosonic system
49. The first electronically powered devices, were developed
in late 1950’s, these were bulky and limited to removing
heavy supragingival calculus deposits.
In 1980’s slim diameter instrument tips were developed
that are smaller in size than curettes.
The use of ultrasound in dentistry was proposed by
Catuna (1953) for the purpose of cutting teeth.
Zinner 1955 showed that ultrasound could be used to
remove deposits from the teeth.
Ultrasonic became an accepted procedure and it was
stated that in 1960 – that instruments were an acceptable
alternative to hand scalers and studies have come to the
conclusion that ultrasonic scalers are as effective as
hand instrumentation with regard to the clinical outcome.
(Sorrin and Swen 1965, Suppipat 1974, Torfason et al 1979,
Badersten et al 1981)
50. Various physical factors play a role
Frequency
Stroke
Water flow
Physiological effects of water may play a role in the
efficacy of power instruments
Frequency
“Number of times per sec an insert tip moves back &
forth during one cycle in an orbital, elliptical or linear
stroke path.
Determines the area of the tip considered active
Higher frequency – smaller active area
51. Stroke
Maximum distance the insert tip travels during one cycle
or stroke path
Amplitude = half the distance of the stroke
The power knob controls the stroke length of the insert
during one cycle
Increasing the power increases the distance the tip
travels while the frequency remains constant
52. Water flow
Ultrasonic scalers may be manually or automatically tuned
devices.
Manual : clinician can control frequency
Water, tuning and power knobs
Auto-tuned: maintain stable frequency
Water and power knobs
Water contributes to three physiologic effects that
enhance the efficacy of power scalers
Acoustic streaming
Unidirectional fluid flow caused by ultrasound waves
Acoustic turbulence
When the movement of the tip causes the coolant to
accelerate, producing an intensified swirling effect within the
periodontal pocket
disrupts the plaque biofilm.
A flow rate of atleast 14ml/min to 23ml/min is needed to
prevent thermal damages in periodontal pocket.
53. Cavitation
Within the water droplets of the spray mist are tiny
vacuum bubbles that quickly collapse releasing energy
that destroy bacteria by affecting the bacterial cell walls.
The combination of acoustic streaming, acoustic
turbulance and cavitation – disrupt microflora
54. Sonic scaler hand piece invented during 1960’s.
Operate by compressed air from the dental unit.
The hand piece is composed of a hollow – rod, a
rotor and several rubber O – rings.
Compressed air is forced through the hollow rod in
the hand piece.
The rotor is a 6mm wide thin metal ring that encircles
the hollow rod above a series of scientifically angled
holes.
The air escapes through the holes and the rotor
vibrate – triggers the entire rod to vibrate.
55. Frequency of vibration is 6000 Hz – 9000 Hz.
Depending on the air pressure input – vibrations are
conducted to the scaler tip – which oscillates with an
amplitude of upto 1000μm in an elliptical motion.
Due to this oscillation – plaque and calculus are
removed by a tapping motion.
Eg : Densonic, Titan S, Kavo Sonic, Flex sonic scaler tips.
Tip design is based on the task to be performed and
specific tooth anatomy.
Most tips are designed to simulate curet and sickle
scalers & are active on all 4 sides.
56. FLUID
Water cooling is not necessary with most brands of sonic
handpieces; water cooling is indicated however to obtain the
benefits of the flushing action of water lavage.
Cannot be used with antimicrobial solutions.
Water coolant flows directly through the working end.
TIP VIBRATION FREQUENCY
Ranges from 3,000 to 8,000 cycles/second.
Operate at frequencies within the audible range. Some
clinicians & patients find the noise generated by the sonic tip
to be annoying.
TIP MOTION
Active tip area ranges from 2.5- 3.5mm for both 25KHz & 30
KHz instruments
Vibrates in an orbital motion
TIP FREQUENCY & POWER - preset
57. Diamond coated ultrasonic tip - developed by Yukna et
al.
Results indicated that after being used on single rooted
teeth with probing depths of 5-12mm in removal of
subgingival calculus, the diamond coated ultrasonic tips
were much more efficient than the conventional tip. But
these diamond coated tips left the roughest root surface
after instrumentation (Kocher et al 1997)
A plastic tip was developed by Gauter et al.
Made of a strong plastic material for use with a sonic
scaler.
It was concluded that the new plastic tip might be useful
especially for maintenance therapy with less risk for
iatrogenic effects on root surfaces.
58. Teflon coated sonic inserts – by Kocher et al
Employed for maintenance treatment of residual
pockets.
Periosonic –
is a modified version of endodontic system – designed for
root debridement.
It has 2 types of files inserted in a sonic hand piece.
Periosonic 1 file
- resembles a reamer with 16mm working tip.
- used to remove heavy supra and subgingival calculus.
Periosonic 2 file
- more flexible and less aggressive than periosonic 1.
- designed for subgingival debridement, where the
smooth part of the file faces the soft tissue wall.
59. Kocher et al on comparing teflon coated sonic
inserts and Periotor with conventional U/s
scalers found more areas covered with plaque &
calculus and concluded that these instruments
may be suitable for removal of soft deposits not
calculus.
Tooth substance loss greater with diamond
coated tips than hand instruments. (Kocher et al
1998)
Hand versus sonic scalers – combination more
effective than either alone (Gellin et al 1986)
60. Two types
Magnetostrictive
Piezoelectric
Magnetostrictive
Introduced in 1950’s.
Magnetostrictive transducer comes attached with the
working tip to constitute a hand piece insert.
Either driven by a metal stack consisting of Nickel – iron
alloy strips or a Ferrite – insert inserted into a hand piece.
Alternating electric current generates oscillations in
materials in the hand piece that cause the scaler tip to
vibrate.
61. A live coil within the hand piece generates alternating
electro magnetic field.
Expansion or contraction of the ferro magnetic field and
vibrations are transmitted to the working tip causing
oscillations with amplitude of 13-72 μm.
Tip of magnetostrictive scalers moves in an elliptical
pattern at frequencies of 20,000 H3 to 45,000 H3 – all tips
are active.
Depending on the angulation of the scaler tip a
hammering or scraping motion pattern will result. Eg :
Dentsply, cavitron, odontosson.
62. Magneto strictive inserts
Most of the magnetostrictive devices have removable
instrument inserts that fit into the hand piece, the
components are
Metal stack – converts electrical power into mechanical
vibrations.
O-ring – a seal that keeps water flowing through the
insert rather than out of the hand piece.
Handle grip.
Water out let – provides water to the instrument tip.
Working end – used for calculus removal and deplaquing.
63.
64. In the piezo electric scaler, the transducer contained
within the hand piece and not connected to the
working tip insert.
Small working tip and easily inserted into the hand
piece.
Alternative electrical current applied to reactive
crystals causes a dimensional changes and then
transmitted to the working tip as ultrasonic
vibrations.
Oscillations is of linear pattern with frequency 20,000
– 45,000 Hz amplitudes upto 72 μm.
65. In vitro studies evaluated surface roughness
between the different power driven scalers.
Surface roughness was most strongly affected by
the shape of the tip.
Maximum roughness with angulated working tip
Lateral force influenced surface roughness
Decreased with increased lateral force
Higher instrument power – higher roughness
Magnetostrictive – more roughness than curettes.
(Folwaczny 2004)
66. Time needed for SRP more with curettes
Magnetostrictive – least tooth substance loss
Curettes – smoothest surface but extensive tooth loss
Piezoelectric fastest but left root surface rougher
(Busslinger 2001)
Ultrasonics used on medium power – less damage to root
surface than hand or sonic scalers (Jacobson et al 1994,
Dragoo 1992)
67. Size & shape of tips
Effect of cavitation on plaque removal
Effectiveness on all surfaces
Better access to furcations
Effectiveness with any stroke
Used with light touch
No firm finger rest required
Less soft tissue distention
Increased tactile sensitivity
Possible bactericidal effect
Less soft tissue trauma
Faster wound healing
68. Pocket irrigation
Washed field visibility
Removes amalgam overhangs
Disintegrates excess dental cement
Requires less time
No sharpening
Increased pt comfort & acceptance
Less tiring for the operator
Delivery of antimicrobial agents with debridement
69. 1996 world workshop in periodontics states that the
best instrumentation results are probably achieved
by the combined use of electronically powered
devices and hand activated instrumentation.
1) Removal of calculus.
2) Removal of plaque – powered instruments are
especially effective in deplaquing – disruption and
removal of the subgingival plaque biofilm from root
surfaces and pocket space.
3) Access to furcation – slim diameter instrument tips
are effective in treating class II and class III
furcation.
70. 4) Conservation of cementum – power driven used on
low-medium power settings seem to do less damage to
the root surface than hand instruments.
5) Pocket penetration – slim diameter tips penetrate
deeper into periodontal pockets.
6) Irrigation – water irrigation of the pocket washes toxic
products and free floating bacteria from the pocket and
provides better vision during instrumentations.
7) Bactericidal effect – the fluid stream flowing produces
2 effects that are unique to powered instruments –
cavitation and acoustic turbulence.
71. 1) Aerosol production
- Generate high level of contaminated aerosols.
- Microbes survive in aerosol for up to 24 hours.
- Communicable diseases can be disseminated. Dental
unit water lines may become significantly contaminated
with microorganisms, this is delivered to electronically
powered instruments dental hand pieces, air water
syringes.
72. Options to control water tubing contamination
Self-contained reservoir
An ultrasonic unit with a self contained reservoir bottle that
requires no waterline hook up.
Point of use filter
Install a filter in the dental unit waterline to physically reduce
the numbers of microorganism in the water flowing over the
instrument tip.
Flush the water tubing
Flush for a minimum of 2 minutes at the start of the day and
for 30s between patients.
2) Effect on unshielded cardiac pacemakers
In a recent position paper – American Academy of
periodontology recommends – to avoid exposing patients with
cardiac pacemakers to magnetostrictive ultrasonic devices.
Peizoelectric devices do not generate a magnetic field and do
not interfere with the functioning.
73. 3) Reduced Tactile Sensitivity
4) Age
Primary and newly erupted teeth of young children have large
pulp chambers that are more susceptible to damage from the
vibrations and heat.
5) Patients with demineralized tooth structure /
exposed dentinal surface.
6) Patients with composite or porcelain restorative
materials.
Infection control
Can be compromised because some powered scalers have
components that cannot be sterilized
74. 1. Communicable disease- Individuals with
communicable diseases that can be disseminated by
aerosols (e.g., hepatitis, tuberculosis, respiratory
infections, or HIV positive).
2. High susceptibility to infection- Individuals with a
high susceptibility to opportunistic infection that can be
transmitted by contaminated dental unit water or
aerosols, such as those with uncontrolled diabetes or
organ transplants, debilitated individuals with chronic
medical conditions, or immunosuppressed individuals.
3. Respiratory risk- Individuals with respiratory disease
or difficulty in breathing (e.g., those with a history of
emphysema, cystic fibrosis, asthma).This patient would
have a high risk of infection if he or she were to aspirate
septic material or microorganisms from dental plaque into
the lungs.
75. 4. Pacemaker- The American Academy of Periodontology
recommends that dental healthcare workers avoid exposing
patients with cardiac pacemakers to magnetostrictive devices.
Piezoelectric ultrasonic devices do not interfere with
pacemaker functioning.
5. Difficulty in swallowing or prone to gagging- Individuals
with multiple sclerosis, amyotrophic lateral sclerosis, muscular
dystrophy, or paralysis may experience difficulty in swallowing
or be prone to gagging.
6. Age- Primary and newly erupted teeth of young children
have large pulp chambers that are more susceptible to
damage from the vibrations and heat produced by ultrasonic
instrumentation.
7. Oral conditions- Avoid contact of instrument tip with
hypersensitive teeth, porcelain crowns, composite resin
restorations, demineralized enamel surfaces, or exposed
dentinal surfaces. Not for use in those with titanium implants,
unless the working-end of the powered instrument is covered
with a specially designed plastic sleeve.
76. Rotating instruments such as fine grained diamonds
(or sonic scalers with diamond coated inserts) can
be used, rotosonic scalers mounted on air turbine
(hexagon pyramid shaped bur).
Care should be taken to avoid excessive removal of
tooth substance with such cutting procedures.
Used to debride root furrows, furcation areas and
root surfaces in deep narrow infrabony pockets.
Use of rotosonic scalers and diamond points is
limited - excessive removal of tooth substance.
77. Serge Dibart (2004) – No.12 fluted carbide bur more
effective in removing debris & plaque than Gracey.
Reiner Mengel et al – 5 rotating instruments (Desmo-
clean, Perio-set, Viking set, 40μm & 15μm diamond
finishers – manual instruments superior
- Desmo-clean & 15μm diamond – performance almost
equal to manual
78. • The profin directional system offers a specially designed
hand piece – with a 1.2mm reciprocating motion of the
working tips set in self steering or fixed mode.
A recommended speed of 10,000 – 15,000 rpm will give
20,000-30,000 tip strokes per minute.
Specially designed working tips called PER-IO-TOR
instruments will optimize cleaning and planning of rough
root cementum surfaces and prevent further removal of
root cementum once the surface is clean and smooth.
79. Mengel et al (1994) evaluated the PER-IO-TOR
instruments and stated that they have similar
planning properties as manual hand instruments,
but cause minimal removal of tooth structures.
80. EVA system
introduced in 1969
Motor driven diamond files of the EVA prophylaxis
system are most efficient for correcting overhanging
proximal alloy & resin restorations
These files are made of aluminium in the shape of wedge
protruding from a shaft, one side of which is diamond
coated & the other smooth.
81. The Profin Directional system offers a specially
designed handpiece (a second generation of the so
called EVA system) with a 1.2 mm reciprocating
motion of the working tips set in self-steering or
fixed mode.
A recommended engine speed of 10,000 - 15,000
rpm will give 20,000 - 30,000 tip strokes per
minute. Specially designed working tips have
been developed for the Profin Directional system
(Axelsson, 1993).
82. Three relatively recent adjunctive modifications to
traditional Instrumentation for scaling and root
planing are worthy of note.
First, Johnson et al. incorporated the use of a fiber-optic
probe for illumination of the tooth surface after surgical
reflection of the papillary gingiva to facilitate sonic
scaling. Compared to untreated controls and traditional
closed sonic scaling without illumination, augmentation
with fiber optics and papillary reflection resulted in a
significant reduction in surface area of residual calculus in
4 to 6 mm pockets. Controls exhibited 39.36% calculus
versus closed sonic scaling at 5.26% versus fiber-optic
augmented scaling at 1.99%
83. The second modification concerns delivery through the
tip-end of ultrasonic inserts of a liquid antimicrobial
Instead of water for cooling and irrigation effects.
Nosal et al. have reported that the irrigation effect was
equal to the depth of instrument tip penetration and that
pocket depth had little if any effect However, they did
note that there was little lateral distribution of the lavage
effect beyond the tip.
The third modification features sonic scalers fitted with
plastic tips. An in vitro study using SEM by Gantes et al
indicated that the use of plastic tips results in less
removal of root structure and produced a smoother
surface than either manual curettes, rubber cup and
polishing paste or sonic scaler fitted with a metal tip.
84. characterized by a different working principle from
conventional ultrasonics, and utilizes tips that
oscillate in a linear fashion parallel to the root
surface.
The Working Principle
In 1999, Durr (Bietigheim-Bissingen, Germany) developed
a new generation of ultrasonic instruments named
Vector.
85. This instrument comprises a ring shaped resonant body
vibrated by an ultrasonic drive (at 25,000 Hz), which is
attached to the working end at an angle of 900
This configuration eliminates ellipsoid vibrations of the
instrument tip, which therefore moves in a plane parallel to
the tooth surface, in contrast to the laterally directed
vibrations typical of conventional ultrasonic scalers (Hahn
2000).
86. The amplitude of movement of the working tip
ranges from 30–35 mm, which is considerably less
than that observed in conventional ultrasonic scalers
(which typically have an amplitude of 10–100 mm).
In order to cool the working tip during function, a
coolant is supplied as part of the Vector system. A
refillable water container (120 ml) is provided in the
base station. The mobile base station also contains
the fluid bags (200 ml) that can be added during
treatment.
The coolant is applied to the working tip by
intermittent pulsation at a flow rate of 6 ml/min.
87. A polish fluid, which includes hydroxyl apatite particles of
<10 mm is added to the liquid film for root planing.
The suspension is not sprayed in an aerosol by the
instrument, but is held hydrodynamically on the
instrument tip.
The working tips result in minimally invasive
instrumentation (by virtue of their non-elliptical vibration
pattern and small amplitude of vibration) and are
comparable in dimensions to a manual probe or
periodontal curette (Guentsch et al. 2006b).
Both metal and carbon fibre inserts are available with the
Vector system. Straight inserts are typically used for
facial/buccal sites and curved inserts for the interproximal
tooth surfaces. Furcations inserts are also included in the
instrument set.
88. Braun et al (2003) – Vector causes less pain than
hand or conventional ultrasonics during treatment of
periodontal lesions
Effectiveness of subgingival calculus removal is
similar for Vector, manual instruments, and
conventional ultrasonic instruments. (Guentsch et al
)
Braun et al (2005) – less root substance removal
than hand or conventional ultrasonics
Thus, it has been demonstrated that the non-
elliptical oscillation of the Vector tip results in the
removal of only 2 ± 3 mm of cementum in
comparison with a conventional ultrasonic system
(24 ±18 mm of cementum removal) or
instrumentation with hand instruments (20 ±15 mm
of cementum removal) (Rupf et al. 2005).
89. Miliauskaite et al. 2005 reported that 10 min. were
required for the treatment of a multirooted tooth with
Vector compared with 12 min. for Gracey curettes to
achieve the endpoint of tactile smoothness.
On single-rooted teeth, the time was 6 min. in the
Vector group and 8 min. when using hand
instruments (Sculean et al. 2004).
These studies suggest that root surface
instrumentation tends to be quicker when using
Vector compared with conventional instruments,
unless gross calculus deposits are to be removed, in
which case conventional ultrasonic instruments are
quicker.
90. Following scaling and root planing, loss of clinical
attachment at sites with initially shallow pockets (1 to 3 mm)
may be due to mechanical trauma from instrumentation
and/or aggressive oral hygiene procedures and gain in
scores of plaque, bleeding and probing depth are supportive
in predicting probing attachment loss attachment level for
deeper pockets.
Ramfjord and Kiester were the first to report on loss of
clinical attachment levels subsequent to scaling and root
planing of shallow pockets.
91. Claffey and Stanley noted that loss of attachment
level in was related to buccolingual gingival
thickness, loss in clinical attachment level may
occur in shallow sites damaged during
instrumentation of immediately adjacent to
damaged during instrumentation of immediately
adjacent to deeper sited or during post-therapy
remodeling of periodontal tissues- a
phenomenon termed “leveling” by Fleszar et al.
92. There is a direct relationship between probing depth and expected
gains in clinical attachment levels following mechanical non-surgical
therapy.
It is interesting to note a paradox of attachment level measurements
exists: in that the major emphasis placed on such data by
researchers and the lack of emphasis by the clinician. Two factors
may explain this attitude: first the problems in obtaining accurate
measurements, second and most important, although the gains in
clinical attachment levels are statistically significant but clinically
insignificant increasing depths of periodontal pocket are directly
related to increased difficulty of accomplishing adequate
debridement (Osborn et al 1990)
Mechanical nonsurgical therapy has repeatedly been shown to be
effective at reducing probing depth in moderately deep 4 to 6mm and
deep ≥7 mm. (Claffey et al 1989)
93. Hammerle et al showed that, initial probing depth of
≥4mm accounted for 57% of all sites. 63.2% of these
baseline sites exhibited bleeding on probing which
was reduced to 16.6% at the final examination after
4 weeks of professional teeth cleaning.
Haffajee et al showed reduction in bleeding on
probing and mean gain in attachment level after
scaling and root planing.
94. Renvert et al demonstrated that root debridement
resulted in reduction of periodontal pocket depth and
bleeding on probing at sites.
Lavanchy D et al studied that scaling and root
planing clinically induces reduction in periodontal
pocket depth, decrease in gingival bleeding on
probing and attachment level gain.
95. Subgingival scaling and root planing reduces the
percentage of black pigmented microbes and
spirochetes. There is a shift from gram negative (-) to
gram positive (+) subgingival microbiota (Havanchy et al
1983)
Haffajee et al 1997 examined the levels of 40 bacterial
species including Actinobacillus
Actinomycetumcomitance, Porphyromonas gingivalis,
Prevotella intermedia and Treponema denticola using
checker boarder DNA-DNA hybridization before and after
scaling and root planing in adult pesiodontitis patients.
Mean prevalence and levels of P.gingivalis, T denticola
and Tannerella forsythia were significantly reduced
whereas the levels of Actinomyces were increased.
96. Dongudomdacha et al 2001 reported the number of
P gingivalis was positively associated with
periodontal pocket depth and attachment loss in
adult periodontitis. Further more, they showed none
of the species was eradicated and attachment levels
and bleeding on probing were not improved, but the
number of P gingivalis, P intermedia and A
actinomycetemcomitans decreased and pocket
depth improved after scaling and root planing
threshold number of P.gingivalis associated with
early clinical signs of disease may be 2.6x104.
However Haffajee et al had previously reported the
threshold to be 6x105.
97. According to Derby et al 2001 investigated the
effects of scaling and root planning on subgingival
microbial microflora. PCR was used to determine the
presence of Aa and Pg T Forsythia, P intermedia and
T-denticola in PDL disease and after treatment.
There was significant reduction in P Intermedia. T.
forsythia and T. denticola.
98. Furcations are less responsive and more difficult to
adequately treat using mechanical root therapy.
Molars with furcation involvement respond less
favorably to scaling and root planing than do molars
without furcations lesions or single rooted teeth.
Several factors inherent to molar furcations are likely
to play a major role in the response of molars to non-
surgical therapy (Fleischer HC et al 1989)
99. Changes in the subgingival microbial flora of molars
with and without furcations lesions following scaling
and root planing have been evaluated by Loos et al
at 12 months post therapy reductions in spirochetes
and P. gingivalis were significantly less to those
without.
This suggests that the less favorable clinical
response to mechanical non-surgical therapy, typical
of molar furcations lesions is related to furcal
Anatomy, lack of access and the persistence of a
pathologic microbial flora (Loos B et al 1988)
100. Ritz et al compared four different but commonly used
types of instrumentation: manual curette, ultrasonic
and sonic scalers, and rotating diamond burs. They
reported the following ascending order of mean root
substance removal after 12 strokes: ultrasonic scaler
(11.6 μm) < sonic scaler (93.5 μm) < manual curet
(108.9 μm) < rotating diamond bur (118.7 μm).
Cementum removal during scaling and root planing
with manual scalers was reported to be 60μm with
20 strokes by Coldiron et al.
101. Ishizuka et al reported that the root surface removal
by gracey curettes was 3-9 μm with 750g lateral
pressure for 50strokes. The amount of root surface
removal increased with force used.
While comparing manual scalers with ultrasonic
scalers, manual scalers removes more root
substance, whereas others reported that ultrasonic
scalers do so. According to these studies, the root
substance removal with one stroke was 1-20μm and
it varied depending on the site of the tooth, the
power of the power driven scaler, the shape of the tip
and root surface was exposed or not.
102. Badersten et al compared the clinical effects of subgingival
debridement using manual and ultrasonic instruments and reported
no differences in terms of probing depth, clinical attachment level
and gingival recession, after 2 years. However, they pointed out that
manual instrumentation took linger to achieve the same clinical
outcome.
Loos et al compared the effects of a single episode of supra and
subgingival debridement using either a sonic or an ultrasonic scaler
in 10 adult periodontitis patients. There was no difference in clinical
response the average time of active instrumentation was
4.0min/tooth with the sonic scaler and 3.3 min/tooth with ultrasonic
instrument. Manual scalers require more time in scaling and root
planing than power driven scalers.
Sherman et al evaluated the calculus removing efficiency of an
ultrasonic scaler (Cavitron with P -10 universal tip) and a Gracey
curette Total time spent for instrumentation per tooth is 3.9 min with
the ultrasonic scaler and 5.8 min with the manual scaler.
103. Scaling and root planing should remove plaque
calculus, and surface absorbed toxins with only
minimal removal of root structure and production of
surface roughness (Leknes K, et al 1991)
Instrument induced root surface roughness results in
increased surface free energy, increased surface
area, promotion of microbial adherence and
colonization and therefore plaque maturation and
compromised plaque removal (Leknes KN et al
1994)
104. Quiery and Bollen (1995) showed that surface free –
energy and roughness play major roles in the initial
adhesion and retention of oral microbes. Both
colonization and maturation of microbes were
increased in the presence of high surface energy
and increasing roughness. High energy surfaces are
known to collect more plaque, bind plaque more
strongly, and to select specific microbes.
105. The direct correlation between increasing surface
free energy and roughness with increasing rates of
plaque colorization and maturation appear to have
been substantiated in animal study by Leknes et al
they compared root surface treated by curette and/or
rotary diamond bur for plaque recolonization at 90
days post treatment.
The curette treated surfaces were consistently
smooth and exhibited significantly fewer numbers of
plaque colonies at all levels of the root surface within
the periodontal pocket. (Leknes 1994)
106. Studies have reported that manual curettes produce
either smoother root surfaces or a rougher surface
than ultrasonic instrumentation or the degree of
roughness is essentially equal regardless of
instrument choice. When comparing sonic versus
ultrasonic instrumentation, they were either
equivalent or the ultrasonic scaler was superior at
producing a smooth root surface.
Regardless of instrument choice inter proximal
areas, furcas, the cemento-enamel junction and
multirooted teeth in general are most likely to exhibit
residual calculus after treatment. (Breininger et al
1987)
107. Newly designed ultrasonic inserts allow greater
access to the base of deeper pockets and furcations.
When comparing manual curettes and ultrasonic
instruments, the curette appears slightly more
efficient but requires more effort, time and
experience. (Hunter et al 1984) The best results are
probably obtained by combining sonic/ultrasonic
instrumentation with manual scaling (Gellin et al
1986)
Recently Sculean et al demonstrated that non-
surgical periodontal therapy with a vector system
may lead to clinical improvements comparable to
those obtained with conventional hand instruments.
108.
109. Histological & clinical responses to SRP have been well
documented (Stahl et al, 1972, Lindhe et al 1982)
Difference in response to ultrasonic & hand instrumentation
are slight. Both result in removal of cementum from the root
surface & removal of epithelial lining of the pocket (Torfason et
al 1979)
Within 1 wk following subgingival debridement, a marked
reduction in the inflammatory infiltrate is the most striking
histologic observation.(Tagge et al 1975)
Subsequently apical migration of the junctional epithelium
occurs along the root surface extending till the level of
instrumentation. This epithelium is adherent to the root
surface.
The formation of long junctional epithelium does not fulfill the
criteria for regeneration & is considered a form of tissue repair.
110. For SRP to be considered effective, the patient
must be maintained at a level of periodontal
health that will prevent reinfection.
Criteria for assessing proper wound healing over
time –
One to two weeks after root planing
Resolution of edema
Shrinkage of gingival margin
Colour about normal
Moderate pocket depth may be present but no or
little bleeding from the base of the pocket
111. No suppuration
No obvious calculus
Oral hygiene excellent
Histologically, epithelialization about complete
Two to three weeks after SRP
Normal colour
Firm consistency
No bleeding from base of pocket
Decreased tooth mobility
Subgingival flora free from pathogens
Histologically CT maturation continues for 21 to
28 days, final gingival contours seen at 3 to 6
months.
112. Traditionally the end points of SRP have been the inability
of the clinician to mechanically or visibly detect remaining
calculus and the perception of smooth root surfaces in all
directions.
These end points are subjective.
Studies have confirmed the inability to completely
remove calculus with traditional SRP procedures.
(Sherman et al 1990). In spite of this in many cases a
positive healing response of the periodontium occurs.
113. Robertson states that “while total elimination of
etiologic factors is the appropriate treatment goal,
reduction of plaque & calculus below the threshold level
that is acceptable to the host appears to control the
infection process & improve the clinical signs of
inflammation.
Based on this hypothesis, the therapeutic end point
should be the evaluation of healing response of the
periodontal tissues following completion of therapy.
If tissue healing progresses to completion with no
remaining signs of inflammation, one has achieved a
successful end point. If signs of inflammation remain,
additional treatment is indicated. (David Cochran)
114. Monitoring the suppression or eradication of
pathogenic periodontal microbiota after SRP is a
valuable adjunct as an end point to SRP. (Walter
Cohen)
115. One stage full mouth disinfection
Pharmacotherapeutics
Systemic antibiotics
Local drug delivery
Host modulatory therapy
