Periodontal Treatment Planning & Phase I Therapy

Periodontal Treatment Planning
&
Phase I Therapy

After the diagnosis and prognosis have been established, the treatment is
planned.
 Treatment decisions are made with the diagnosis and prognosis of the
individual teeth and the overall dentition in mind.
 A properly formulated treatment plan is paramount to treating periodontal
disease, and obtaining long-term health.
The Treatment plan should have:
i. Immediate goals,
ii. Intermediate goals, and
iii. Long-term goals.
INTRODUCTION
Newman and Carranza’s Clinical Periodontology. 13th ed. 2019

 Elimination of all infectious and inflammatory processes that cause periodontal
and other oral problems that may hinder the patient’s general health and to bring
the oral cavity to a state of health.
 This may require patient education on infectious oral diseases and disease
prevention, periodontal procedures, endodontics, caries control, oral surgery, and
treatment of oral mucous membrane pathologies.
 Referral to other dental and medical specialties may be necessary.
 Elimination of root surface accretions along with pocket reduction and the
establishment of good gingival contours and mucogingival relationships
conducive to periodontal health.
 Extraction of hopeless teeth, restoration of carious lesions, and correction of poor
existing restorations may be necessary.
The Immediate Goals

The Intermediate Goals
❖ Reconstruction of a healthy dentition that fulfills all functional and aesthetic
requirements and lasts many years.
❖ Restoration of health, function, aesthetics, and longevity involves
endodontic, orthodontic, periodontal, and prosthodontic considerations as
well as the age, health, and desires of the patient.
❖ The financial impact of restoring the dentition to health, function, aesthetics,
and longevity requires careful consideration and understanding by the
patient.
❖ May be quickly achieved or require treatments over months or even years,
depending on the complexity of the case, the therapy involved, and the
financial status of the patient.

The Long-term Goals
 Maintenance of health through prevention and professional
supportive therapy.
 Once active disease has been controlled, all infectious and
inflammatory processes have been eliminated, and health has
been attained, health should be maintainable for the rest of
the patient’s life.
 Meticulous daily patient home care, and patient adherence to
professional recall maintenance at a regular interval.

Procedures required for the establishment and maintenance of oral health:
• Emergency treatment (pain, acute infections).
• Removal of nonfunctional and diseased teeth, and possibly strategic extraction of healthy teeth
to facilitate the prosthetic reconstruction of the patient.
• Treatment of periodontal diseases (surgical or nonsurgical, regenerative or resective).
• Endodontic therapy (necessary and intentional).
• Caries removal and placement of temporary and final restorations.
• Occlusal adjustment and orthodontic therapy.
• Replacement of missing teeth with removable or fixed dental prostheses or dental implants .
• Aesthetic demands.
• Sequence of therapy.
Treatment Plan is the BLUEPRINT for Case Management

Data Collection Diagnosis
Phase I
Therapy
Phase I
Evaluation
Recycle
Surgery
SPT
(recall)
Data Collection Diagnosis
Initial
Therapy
Evaluation
Initial Therapy
Retreatment
Surgery
SPT
(recall)

Periodontal Treatment Sequence
Periodontal Evaluation
 Comprehensive periodontal examination.
 Diagnosis and prognosis.
 Patient education:
• Clinical findings and disease status.
• Disease pathogenesis and prevention.
• Personalized oral hygiene instruction.
 Reduction of systemic and environmental
risk factors:
• Physician consultation.
• Smoking cessation.
Periodontal treatment plan:
 Oral hygiene assessment and education.
 Nonsurgical therapy.
 Periodontal reevaluation.
 Periodontal supportive maintenance.
Nonsurgical Therapy
 Oral hygiene assessment and education*
 Infection control:
• Nonsurgical periodontal therapy:
• Supragingival and subgingival Scaling and Root Planing (SRP)
• Extraction of hopeless teeth.
 Reduction of local risk factors:
• Removal or reshaping of overhangs and overcontoured restorations.
• Restoration of carious lesions.
• Restoration of open contacts.
Periodontal Reevaluation
 Inquiry of new concerns or problems.
 Inquiry of changes in patient’s medical and oral health status.
 Assessment of outcome of nonsurgical therapy.
 Determination of required additional nonsurgical and adjunctive therapy.
*Patient oral hygiene is critical to the overall short-term and long-term treatment outcome.
Therefore oral hygiene must be repeatedly assessed and reinforced.

Surgical Therapy
 Adjunct to nonsurgical therapy.
 Should only occur once patient demonstrates proficient biofilm
control.
 Objectives:
• Primary: Access for root instrumentation.
• Secondary: Pocket reduction through soft tissue resection, osseous
resection, or periodontal regeneration.
 Periodontal access surgery:
• Resective.
• Regenerative.
 Extraction of hopeless teeth.
 Periodontal plastic surgery:
• Mucogingival surgery.
• Aesthetic crown lengthening.
 Preprosthetic surgery:
• Prosthetic crown lengthening.
• Implant site preparation and implant placement.
Periodontal Treatment Sequence……..
Periodontal Maintenance Therapy
 Inquiry of new concerns or problems.
 Inquiry of changes in patient’s medical and oral health
status.
 Professional maintenance care:
• Supragingival and subgingival biofilm and calculus removal.
• Selective scaling and root planing.
 Assessment of recall interval and plan for next visit.
*Patient oral hygiene is critical to the overall short-term and long-term treatment outcome.
Therefore oral hygiene must be repeatedly assessed and reinforced.

Sequence of Periodontal Therapy (Preferred)

Periodontal Treatment Decision Tree

OBJECTIVES OF PERIODONTAL TREATMENT
❑ Restore tissue destroyed by disease.
❑ Reestablish the physiological contours necessary for preservation of periodontal health.
❑ Prevent recurrence of disease.
❑ Reduce tooth loss.
❑ Eliminate Pain.
❑ Eliminate gingival inflammation and bleeding.
❑ Reduce periodontal pockets and eliminate infection.
❑ Arrest the destruction of soft tissue and bone.
❑ Reduce the abnormal mobility.
❑ Establish optimal occlusal function.

Overall Treatment Plan
 The aim of the treatment plan is total treatment i.e.,
the coordination of all the immediate, intermediate,
and long-term goals for the purpose of creating a
well-functioning dentition in a healthy periodontal
environment.
 It is based on the diagnosis, prognosis, disease
severity, risk factors, and other factors.

Overall Treatment Plan …….
Extracting or Preserving a Tooth
Teeth on the borderline of a hopeless prognosis do not contribute
to the overall usefulness of the dentition. Such teeth become
sources of recurrent problems.
A tooth should be extracted under the following conditions:
• It is so mobile that function becomes painful.
• It can cause acute abscesses during therapy.
• There is no use for it in the overall treatment plan.

Overall Treatment Plan ……. Extracting or Preserving a Tooth
In some cases, a tooth can be retained temporarily, postponing the decision to
extract until after treatment is completed under the following conditions:
• It maintains posterior stops; the tooth can be removed after treatment, when it can
be replaced by an implant or another type of prosthesis.
• It maintains posterior stops and may be functional after implant placement in
adjacent areas. When the implant is restored, these teeth can be extracted.
• In the anterior aesthetic zone, a tooth can be retained during periodontal therapy
and removed when treatment is completed and a permanent restorative
procedure can be performed. The retention of this tooth should not jeopardize the
adjacent teeth. This approach avoids the need for temporary appliances during
therapy.
• Extraction of hopeless teeth can also be performed during periodontal surgery of
the adjacent teeth. This approach reduces the number of appointments needed for
surgery in the same area.

 In complex cases, interdisciplinary consultation with other specialty areas is
necessary before a final plan can be made.
 The opinions of orthodontists and prosthodontists are especially important for
the final decision in these patients.
 Occlusal evaluation and therapy may be necessary during treatment, which
may necessitate planning for occlusal adjustment, orthodontics, and splinting.
 The correction of bruxism and other occlusal habits may also be necessary.
 Systemic conditions should be carefully evaluated because they may require
special precautions during the course of periodontal treatment.
 Supportive periodontal care is also of paramount importance for case
maintenance.
Overall Treatment Plan ……. Extracting or Preserving a Tooth

Sequence of Therapy
 Periodontal therapy is an inseparable part of dental therapy, and all treatments must be well coordinated.
 Phase I, or the nonsurgical phase, is directed to the elimination of the etiologic factors of dental, gingival,
and periodontal diseases.
 Immediately after completion of phase I therapy, the patient should be placed on the maintenance phase
(phase IV) to preserve the results obtained and prevent any further deterioration and recurrence of
disease.
 On periodic evaluation the maintenance phase, the patient enters into the surgical phase (phase II) and
the restorative phase (phase III) of treatment.
 Phase I, or the Nonsurgical phase.
 Phase II, or the Surgical phase.
 Phase III, or the Restorative phase.
 Phase IV, or the Maintenance phase.

Explaining the Treatment Plan to the Patient
The following discussion includes suggestions for explaining the treatment plan to the
patient:
 Be specific. Tell your patient, “You have gingivitis” or “You have periodontitis,” then explain
exactly what the condition is.
 Avoid vague statements. Do not use statements such as “You have trouble with your gums”
or “Something should be done about your gums.”
 Begin your discussion on a positive note. Talk about the teeth that can be retained and the
long-term service they can be expected to render.
 Make it clear that every effort will be made to retain as many teeth as possible, but do not
dwell on the patient’s loose teeth.
 Present the entire treatment plan as a unit. Avoid creating the impression that treatment
consists of separate procedures, some or all of which may be selected by the patient.

Patients often seek guidance from the dentist with questions such as the following:
• “Are my teeth worth treating?”
• “Would you have them treated if you had my problem?”
• “Why don’t I just go along the way I am until the teeth really bother me and then have them all
extracted?”
Explaining the Treatment Plan to the Patient ………..
Explain that “doing nothing” or holding onto hopelessly diseased teeth as long as possible is inadvisable
for the following reasons:
1. Periodontal disease is a microbial infection, and it to be an important risk factor for severe life-threatening diseases
such as stroke, CVD, pulmonary disease, and diabetes, as well as for premature low-birth-weight babies in women of
childbearing age. Correcting the periodontal condition eliminates a serious potential risk of systemic disease, which
in some cases ranks as high on the danger list as smoking.
2. It is not feasible to place restorations or fixed bridges on teeth with untreated periodontal disease because the
usefulness of the restoration would be limited by the uncertain condition of the supporting structures.
3. Failure to eliminate periodontal disease not only results in the loss of teeth already severely involved, but also
shortens the life span of other teeth. With proper treatment, these teeth can serve as the foundation for a healthy,
functioning dentition.

Fig. 36.3 Sample treatment timeline. Following nonsurgical periodontal therapy, the patient is placed on periodontal
maintenance at regular intervals. Surgical and restorative treatments are scheduled between periodontal recalls.

Initial Therapy:
• Patient education.
• Oral hygiene instruction (OHI).
• Scaling and root planing (SRP)
• Other treatment as needed:
-Elimination of restorations overhangs.
- Restoring carious teeth.
- Removal of hopeless teeth.
- Occlusal adjustment.
- Temporary stabilization.
- Occlusal bite plane.

Oral Hygiene Instruction (OHI)
Initial Therapy …….
Patient information:
 Importance of daily disruption dental plaque.
 Share/discuss with the patient the findings of
periodontal charting, i.e. BOP, radiographs
(bone level).
 Illustrate the locations of plaque in the
dentition (disclosing solution).
 Review/modify patient’s tooth brushing
technique. Introduce additional oral hygiene
aids as needed, but in step by step fashion.
https://www.google.com/search?q=plaque+disclosing+agents https://www.google.com/search?q=tooth+brushing

https://www.google.com/search?q=removal+of+overhang+restorations https://www.aegisdentalnetwork.com/id/2006/12/clinical-uses-of-reciprocating-handpieces
Removal of iatrogenic factor
(amalgam overhang)
improves the oral hygiene
condition.
Reciprocating Motor-Driven
Handpieces and Abrasive Tips

Correction of Iatrogenic Irritants - Bridge Pontics
https://www.google.com/search?q=removal+of+overhang+restorations
Removal of Overextended Crown Margins

Extraction
https://www.google.com/search?q=removal+of+overhang+restorations
Odontoplasty
of grooves,
ridges,
irregularities..
Removal of Natural Plaque-retentive Areas

Removal of Supragingival Calculus and PolishingInitial Therapy …….
https://www.google.com/search?q=scaling+and+polishing

Scaling and Root Planing (SRP)
Definitions
Scaling:
Removal of plaque, calculus, and stain from the crown
and root surfaces.
Root planing:
Removal of cementum or surface dentin that is rough or
impregnated with calculus, toxins, or microorganisms.
Rationale
Limitations of supragingival plaque control:
▪ Effective for gingivitis.
▪ Limited effects on periodontitis.
▪ Does not alter the bacterial composition in pockets
> 5 mm.
Therefore, SUBGINGIVAL mechanical
instrumentation is necessary in addition
to personal oral hygiene to achieve
periodontal health.
Objectives
 Replacement of pathogenic microflora with
the sparse flora found in health.
 Conversion of inflamed pathologic pockets
to healthy gingival tissue.
 Shrinkage of the deepened pocket to a
shallow, healthy sulcus.

Scaling and Root Planing (SRP)Initial Therapy …….
Advantages
◆ Superior tactile sensitivity.
◆ Superior adaptation.
◆ No aerosol.
◆ Excellent access - different design.
◆ No heat generation.
◆ Better visibility.
Hand Instrumentations
Disadvantages
◆ Requires proper blade angulation.
◆ Requires sharpening of blade.
◆ Requires heavy lateral pressure.
◆ Tiring for clinician.
◆ More potential for carpal tunnel syndrome.

Guidelines for the Use of Ultrasonic Devices
 Use enough water to avoid
overheating the instrument and tooth
surface.
 Apply the side of the instrument (not
the tip) to the tooth surface.
 Move the tip continuously in a back-
and-forth brushing stroke avoiding
heavy pressure.
 Wear protective face mask and
glasses during use.
 Check completeness of deposit
removal with an appropriate explorer.
Do not use ultrasonic devices on patients
with cardiac pacemakers without
consultation with their cardiologist.
 Patients with infectious diseases such as AIDS,
tuberculosis and hepatitis should be treated with
great caution.
 Flush water line for at least 2 minutes before use to
decrease microbial contamination of the water
lines and reservoir.
 Ultrasonic devices should not be used near bonded
veneer and cemented restorations.

#1 point
#4 lateral
surfaces
#4 lateral surfaces
#2 concave front
surfaces
#3 convex back
surfaces
Magnetostrictive Ultrasonic device.
(Courtesy Dentsply Sirona, York, PA.)
Columbia #4R-4L
universal curette
Universal U15/30 scaler
Advantages and Disadvantages of Mechanized
Instruments Compared With Manual Instruments
Advantages
 Increased efficiency
 Multiple surfaces of tip are capable
of removing deposits.
 No need to sharpen.
 Less chance for repetitive stress
injuries.
 Large handpiece size.
 Reduced lateral pressure.
 Less tissue distention.
 Water.
 Lavage.
 Irrigation.
 Acoustic microstreaming.
Disadvantages
 More precautions and limitations.
 Client comfort (water spraying).
 Aerosol production.
 Temporary hearing shifts.
 Noise.
 Less tactile sensation.
 Reduced visibility.
 More root surface roughness.
From Darby ML, Walsh MM: Dental hygiene, ed 3,
St. Louis, 2010, Saunders.

Limitations
❑ Poor access to deep periodontal pockets.
❑ Presence of grooves, concavities in roots.
❑ Constricted access to furcations.
❑ Bacterial invasion of the gingiva (Aggressive P).

Clinical and Microbiological Responses
Clinically:
 Decreased gingival inflammation.
 Less BOP.
 Decreased PD, and gain in CAL.
Microbiologically:
 Shift in the composition of the subgingival
microflora.
 Decrease in Gram-negative organisms and
increased Gram-positives.
 Bacteroides species are reduced but not
eliminated.

Periodontal Treatment
Planning
Re-evaluation Phase

Objectives
Re-evaluation Phase
1. To assess tissue response to therapy:
a. Gingival Condition.
b. Pocket Depths, etc.
2. To assess patient’s compliance with OHI:
a. Plaque and Bleeding Index.
b. Review OHI.
3. To Assess need/advisability for further periodontal therapies.

Re-evaluation Phase ……
Components of the Re-evaluation Visit
a. Performed 4-8 weeks following the completion of the initial
phase of periodontal therapy.
b. All data collected in the initial visit should be recollected at
the revaluation visit:
- Gingival tissue assessment.
- Probing depth (PD)/clinical attachment level (CAL).
- Bleeding on probing (BOP).
- Mobility.
- Marginal tissue recessions.
- Plaque score.

Planning
Surgical Phase

Surgical Phase
Surgical Procedures
 Gingivectomy.
 Modified Widman Flap.
 Flap Approached Curettage.
 Apically-positioned Flap.
 Regenerative Procedures.
Re-evaluation.
Indications for Surgical Phase
 Inflammation subsequent to initial therapy.
 Persistent PDs.
 Osseous and Furcation defects.
 Gingival enlargement.
 Inadequate biologic width (BW).
 Muccogingival defects.

Planning
Restorative-Prosthetic Phase

Restorative-Prosthetic Phase
■ Pre-prosthetic Surgery
- Gingival Grafts.
- Ridge Augmentation.
- Crown Lengthening.
Re-evaluation.

Supportive Periodontal Therapy (SPT)
(Maintenance /Recall Phase)

Supportive Periodontal Therapy (SPT) (Maintenance /Recall Phase)
Maintenance Phase
 Procedures performed at selected interval to assist
patient in maintaining oral health.
 Patients can be maintained in stable periodontal
condition with a properly scheduled SPT program.
 Less attachment loss occurs and fewer teeth are lost
when patients maintain SPT schedule.

Maintenance Phase ……
Objectives
 To prevent the progression and recurrence of periodontal disease.
 To prevent the loss of dental implants after clinical stability has
been achieved.
 To reduce tooth loss by monitoring the dentition and any
prosthetic replacement of the natural teeth.
 To diagnose and manage, other diseases or conditions found
within the oral cavity.

Schedule and Extent of Need
 Started at the completion of active periodontal treatment.
 Progression of gingivitis to periodontitis has not accurately
predicted and thus periodic SPT in all cases can prevent further
progression of disease.
 Large percentage of population will benefit from regular SPT.

Compliance and its Role in Periodontal Therapy
◆ Compliance (adherence and therapeutic alliance) has been
defined as “the extent to which a person’s behavior coincides
with medical or health advice”.
◆ Compliance falls with time.
◆ Less threatening the patient perceives the problem, the lower
the compliance.
◆ More immediate and severe the threat, the greater the
likelihood of compliance.
Wilson TG. (1996) Periodontology 2000,12:11-115.

CONCLUSION
Examination → Diagnosis → Prognosis ↔ Treatment
• Diagnosis requires thorough and careful examination.
• Prognosis is based on accurate diagnosis.
• Treatment decisions are based on the prognosis.
• Treatment decisions are made to improve the prognosis.
• Diagnosis and prognosis will change with treatment.

Phase I therapy or cause-
related therapy is the first in
the chronologic sequence of
procedures that constitute
periodontal treatment.
Phase I Periodontal Therapy
Synonyms
 Initial Therapy
 Nonsurgical Periodontal Therapy
 Cause-related Therapy
Cause-related phase I periodontal therapy is the approach aimed at removal of
pathogenic biofilms, toxins, and calculus and the reestablishment of a biologically
acceptable root surface.

Phase I Periodontal Therapy ………
Rationale
Phase I therapy is defined by the evidence-based American Association of
Periodontology (AAP) practice guidelines:
◆ The initiation of a comprehensive daily plaque or biofilm control regimen.
◆ Management of periodontal-systemic interrelationships as needed.
◆ Thorough removal of supragingival and subgingival bacterial plaque or biofilm
and calculus.
◆ Other problems that must be managed include the use of chemotherapeutic
agents as necessary, and local factors such as elimination of defective
restorations and treatment of carious lesions.

Management of all contributing local factors is required in phase I therapy.
The following list of elements makes up phase I therapy:
1. Patient education and oral hygiene instruction (OHI).
2. Complete removal of supragingival calculus.
3. Correction or replacement of poorly fitting restorations and other prosthetic devices.
4. Restoration or temporization of carious lesions.
5. Orthodontic tooth movement.
6. Treatment of food impaction areas.
7. Treatment of occlusal trauma.
8. Extraction of hopeless teeth.
9. Possible use of antimicrobial agents, including necessary plaque or biofilm sampling and sensitivity testing.

Treatment SessionsPhase I Periodontal Therapy ………
All the following conditions must be considered when determining the phase I
treatment plan:
• General health and tolerance of treatment.
• Number of teeth present.
• Amount of subgingival calculus.
• Probing pocket depths (PDs).
• Attachment loss (CAL).
• Furcation involvement (FI).
• Alignment of teeth.
• Margins of restorations.
• Developmental anomalies.
• Physical barriers to access the dentition (i.e., limited opening or tendency to gag).
• Patient cooperation and sensitivity to therapy (requiring use of anesthesia or
analgesia).
After careful analysis and
diagnosis of the specific
periodontal condition present,
the clinician must develop a
treatment plan that includes all
required procedures to treat the
periodontal involvement and an
estimate of the number of
appointments necessary to
complete phase I therapy.

Sequence of Procedures
Step 1: Plaque or Biofilm Control Instruction.
Step 2: Removal of Supragingival and Subgingival Plaque or
Biofilm and Calculus.
Step 3: Recontouring Defective Restorations and Crowns.
Step 4: Management of Carious Lesions.
Step 5: Tissue Reevaluation.

Sequence of ProceduresPhase I Periodontal Therapy ………
Step 1: Plaque or Biofilm Control Instruction
Plaque or biofilm control is an essential component of successful periodontal therapy, and
instruction should begin at the first treatment appointment.
 The explanation of the etiology of the disease must be presented to the patient.
 Once the patient understands the nature of periodontal disease and the etiology, it will be
easier to teach the hygiene that he or she must practice.
 The patient must be instructed on the correct technique to remove the plaque or biofilm;
[focusing on applying the bristles at the gingival third of the clinical crowns, where the tooth
meets the gingival margin). This technique is sometimes referred to as targeted oral hygiene
(Takei H: Personal communication, 2009) and is synonymous with the Bass technique].
Instructions are also initiated for interdental cleaning with dental floss and interdental brushes.

Step 2: Removal of Supragingival and Subgingival Plaque or Biofilm and Calculus
 Removal of calculus is accomplished using scalers, curettes, ultrasonic
instrumentation, or combinations of these devices during one or more
appointments.
 Most clinicians advocate the combination of hand instruments (scalers,
curettes) and ultrasonic devices.
 In addition to calculus and plaque or biofilm removal, cementum exposed to
the pocket environment should be removed.

Step 3: Recontouring Defective Restorations and Crowns
Corrections of restorative defects, which are plaque or biofilm
retentive areas, may be accomplished by smoothing the rough
surfaces and removing overhangs from the faulty restorations
with burs or hand instruments, or complete replacement of the
failing restorations may be necessary.

Step 4: Management of Carious Lesions
☻ Complete removal of carious tissue at or near g. m.
☻ Placement of final or temporary restoration.
N.B.: Carious lesion may work as a source of infection & hamper
a successful Periodontal therapy.

Step 5: Tissue Reevaluation
 Reexamination of periodontal tissues to determine further need of
periodontal therapy.
 Careful evaluation of PDs and all anatomical conditions for the
need of Surgical periodontal therapy.
 Effective Plaque control and gingival health must be ensured
before any surgery.
After SRP, and other phase I procedures, the periodontal
tissues require approximately 4 weeks to heal.

 SRP therapy have been studied extensively to evaluate their
effects on periodontal disease.
 Many studies have indicated that this treatment is both effective
and reliable.
 Studies ranging from 1 month to 2 years in length demonstrated
up to 80% reduction in BOP and mean PD reductions of 2 - 3 mm.
 Other studies demonstrated that the percentage of periodontal
pockets of 4-mm or deeper was reduced by more than 50% and
in many cases up to 80%.
Results

Results
Fig. 47.1 Results of phase I therapy, severe chronic periodontitis.
(A) A 45-year-old patient with deep probe depths, bone loss, severe swelling, and redness of the gingival
tissues.
(B) Results 3 weeks after the completion of phase I therapy. Note that the gingival tissue has returned to a
normal contour, with redness and swelling dramatically reduced.
A B

Phase I Periodontal Therapy ……… Results
A B
Fig. 47.2 Results of phase I
therapy, moderate chronic
periodontitis.
(A) A 52-year-old patient with
moderate attachment loss and
PDs in the 4- to 6-mm range.
Note that the gingiva appears
pink because it is fibrotic.
Inflammation is present in the
periodontal pockets but
disguised by the fibrotic tissue.
BOP present.
(B) Lingual view of the patient with
more visible inflammation and
heavy calculus deposits.
(C) and (D) At 18 months after phase
I therapy the same areas show
significant improvement in
gingival health. The patient
returned for regular maintenance
visits at 4-month intervals.
DC

Phase I Periodontal Therapy ……… Results
Fig. 47.3 Effects of overhanging amalgam margin on interproximal gingiva of maxillary first molar in otherwise
healthy mouth.
(A) Clinical appearance of rough, irregular, and overcontoured amalgam.
(B) Gentle probing of interproximal pocket.
(C) Extensive bleeding elicited by gentle probing indicating severe inflammation in the area.
A B C

Healing
 Reevaluation after 4 weeks of SRP.
 Reevaluation of Pt.’s OH procedures.
 A long JE formation rather than new CT attachment to the root
surfaces. (Repair of attachment epithelium by 1-2 wks.)
 Healing will show gradual reduction of inflam. cells, GCF increase,
repair of CT with decrease g. inflam. signs.
 Transient root hypersensitivity & GR (1-2 mm) may accompany the
healing process. (Needs pt. motivation).

Decision to Refer for Specialist TreatmentPhase I Periodontal Therapy ………
☻ Most periodontal problems can be managed by
a Genral Dentist pursuing Phase I thearpy.
☻ Advanced /complicated cases need Specialized
treatment.
☻ The 5-mm standard CAL is an obvious guideline
for Referral at Reevaluation phase.
☻ The 5-mm standard is based on the typical root
length as 13 mm.
(The concept of the critical probing depth of 5.4
mm has been advanced to assist in making the
determination to proceed to surgical intervention).
Fig. 47.4 The 5-mm standard for referral to a periodontist is based
on root length, probing depth, and clinical attachment loss. The
standard serves as a reasonable guideline to analyze the case for
referral for specialist care. CEJ, Cementoenamel junction.
(Redrawn with permission from Armitage G, editor: Periodontal maintenance therapy,
Berkeley, CA, 1974, Praxis.)

In addition to the 5-mm PD criterion, other factors must be considered in the decision to refer to a periodontal specialist:
1. Extent of the disease and generalized or localized periodontal involvement. The amount of bone loss, even in localized
areas, suggests the need for specialized surgical techniques.
2. Root length. Short-rooted teeth are jeopardized to a greater extent by the 5-mm CAL criterion than teeth with long
roots.
3. Hypermobility. Excessive tooth mobility suggests that contributing factors may be responsible for the mobility. The
extent of mobility could mean that the prognosis for the tooth may be guarded to poor.
4. Difficulty of SRP. The presence of deep pockets and furcations makes instrumentation difficult, but the results can often
be improved with surgical access.
5. Restorability and importance of particular teeth for reconstruction. Long-term prognosis of each tooth is important when
considering extensive restorative work.
6. Age of the patient. Younger patients with extensive attachment loss are more likely to have aggressive forms of disease
that require advanced therapy.
7. Lack of resolution of inflammation after thorough plaque or biofilm removal and excellent SRP. If inflammation and
progressive deepening of the pocket continue, further therapy will be necessary. Such cases require an understanding of
the etiology to determine the best course of treatment.

Periodontal Instruments
&
Instrumentation

Classification of Periodontal Instruments
1. Periodontal probes
2. Explorers
3. Scaling, Root-planing, and Curettage instruments
4. Periodontal endoscopes
5. Cleansing and polishing instruments.

7/17/2020Prof. Zahid 66
Typical Universal Scaler (U 15/30) and Periodontal Probe
Tip
Shank
Handle

Types of Periodontal Probes
Fig. 50.3 Types of periodontal probes.
A, Marquis color-coded probe. Calibrations are in 3-mm
sections.
B, University of North Carolina 15 probe, a 15-mm long
probe marked at each millimeter and color coded at the
5th, 10th, and 15th millimeters.
C, University of Michigan “O” probe, with Williams
markings (at 1, 2, 3, 5, 7, 8, 9, and 10 mm).
D, Michigan “O” probe with markings at 3, 6, and 8 mm.
E, World Health Organization probe, which has a 0.5-mm
ball at the tip and markings at 3.5, 8.5, and 11.5 mm
and color coding from 3.5 to 5.5 mm.
A
B
C D
E

Fig. 50.4
Curved #2 Nabers probe for detection
of furcation areas, with color-coded
markings at 3, 6, 9, and 12 mm.
Curved #2 Nabers probe
Plastic probe:
Colorvue (Hu-Friedy, Chicago).

Explorers
Fig. 50.5 Five typical
explorers.
A, #17;
B, #23;
C, EXD11-12;
D, #3;
E, #3CH pigtail.
A
B C
D
E

Scaling, Root-planing, and Curettage instruments
i. Sickle scalers are heavy instruments used to remove supragingival calculus.
ii. Curettes are fine instruments used for subgingival scaling, root planing, and
removal of the soft tissue lining the pocket.
iii. Hoe, chisel, and file scalers are used to remove tenacious subgingival
calculus and altered cementum. Their use is limited compared with that of
curettes.
iv. Implant instruments are plastic or titanium scalers and curettes designed
for use on implants and implant restorations.
v. Ultrasonic and sonic instruments are used for scaling and cleansing tooth
surfaces and curetting the soft tissue wall of the periodontal pocket.

Types of
Basic
Scaling
Instruments

Periodontal Scaler (sickle shaped)
Fig. 50.11
Both ends of a U15/30 scaler
Fig. 50.12
Three
different
sizes of 204
Sickle
Scalers

Supragingival Scaling
Fig. 50.11
Both ends of a U15/30 scaler

Periodontal Chisel ScalerPeriodontal Hoe Scaler Periodontal File Scaler
Periodontal Scalers ………

Universal Sickle Scaler (U15/30)
Fig. 50.39
(A)Chisel scaler and
(B) File scaler
Fig. 50.41 Diamond files. (A) #1, #2 and (B) #3, #4. (Brasseler, Savannah, GA.)
(C) SDCN7, SDCM/D7. (Hu-Friedy, Chicago.) (Copyright A. Pattison.)
Combination of Sickle & Chisel Scaler

Periodontal
Hoe Scalers
 Hoe scalers are used for
scaling of ledges or rings of
calculus (Fig. 50.38).
 The blade is bent at a 99-
degree angle, and the
cutting edge is formed by
the junction of the flattened
terminal surface with the
inner aspect of the blade.
 The cutting edge is beveled
at 45 degrees.

Periodontal
Curettes

Universal & Area Specific
Curettes’ blades
90-degree
angle
60-70-degree
angle

Use of
Periodontal
Curettes

Columbia #4R-4L
universal curette. Younger-Good #7-8, McCall’s #17-18, and
Indiana University #17-18 universal curettes.
Universal Curette set

https://www.google.com/search?q=Gracey+curettes
Gracey
Curette set

Gracey Curette set
Reduced set of Gracey curettes.
Left to right, #5-6, #7-8, #11-12, and #13-14.
Fig. 50.20.
Gracey #13-14 curette.
For distal surfaces.
Gracey #11-12 curette. Note
the double turn of the shank.

Double-ended Gracey curettes are
paired in the following manner:
 Gracey #1-2 and 3-4: Anterior teeth.
 Gracey #5-6: Anterior teeth and premolars.
 Gracey #7-8 and 9-10: Posterior teeth
(facial and lingual).
 Gracey #11-12: Posterior teeth (mesial).
 Gracey #13-14: Posterior teeth (distal).
Use of Gracey Curettes
Gracey curette #15-16: modification of
the standard #11-12 and is designed for
the mesial surfaces of posterior teeth. It
consists of a Gracey #11-12 blade
combined with the more acutely angled
#13-14 shank.
Gracey #17-18: modification of the #13-
14. It has a terminal shank elongated
by 3 mm and a more accentuated
angulation of the shank to provide
complete occlusal clearance and better
access to all posterior distal surfaces.

Fig. 50.22 Gracey #15-16. New Gracey curette,
designed for mesioposterior surfaces,
combines a Gracey #11-12 blade with a
Gracey #13-14 shank. (Copyright A. Pattison.)
Fig. 50.25 Comparison of After Five
curette and Mini Five curette. The
shorter Mini Five blade (half the
length) allows increased access and
reduced tissue trauma.
Gracey Curette set ………
Fig. 50.23 After Five curettes. Note the extra 3 mm in the
terminal shank of After Five curettes compared with standard
Gracey curettes. A, #5-6; B, #7-8; C, #11-12; D, #13-14.
(Copyright A. Pattison.)
A B C
D

Fig. 50.27 Micro Mini Five Gracey curettes. Left to right,
#1-2, #7-8, #11-12, #13-14. (CopyrightA. Pattison.)
Micro Mini Five Gracey curettes (Hu-Friedy, Chicago, IL) have blades that are
20% thinner and smaller than the Mini Five curettes These are the smallest of
all curettes, and they provide exceptional access and adaptation to tight,
deep, or narrow pockets; narrow furcations; developmental depressions; line
angles; and deep pockets on facial, lingual, or palatal surfaces.
Gracey Curette set ………

eFig. 50.33 Subgingival scaling procedure. (A) Curette inserted with the face of the blade flush against the
tooth. (B) Working angulation (45 to 90 degrees) is established at the base of the pocket. (C) Lateral pressure
is applied, and the scaling stroke is activated in the coronal direction.
Subgingival Instrumentation using Curette

eFig. 50.31 Mini Five #13-14 curette adapted to
the palatal surface of a maxillary molar with the
toe directed distally. (CopyrightA. Pattison.)
Fig. 50.24 Comparison of
After Five curette with
standard Gracey curette.
Rigid Gracey #13-14
adapted to the distal surface
of the first molar and rigid
After Five #13-14 adapted to
the distal surface of the
second molar.
Notice the extralong shank
of the After Five curette,
which allows deeper
insertion and better access.

Fig. 50.32 Periodontal
maintenance Gracey
curettes (Hu-Friedy) Shorter,
thinner three-quarter–sized Gracey
curettes with modified rigid shanks.
Left to right, Pattison Gracey Lite
#1-2, Pattison Gracey Lite #7-8,
Pattison Gracey Lite #11-12,
Pattison Gracey Lite #13-14.
(CopyrightA. Pattison.) Introduced in
November 2015 .
Gracey curettes for Periodontal Maintenance Therapy

Langer Curettes
Fig. 50.33 Langer curettes combine Gracey-type
shanks with universal curette blades. Left to right,
#5-6, #1-2, and #3-4. (Copyright A. Pattison.)
 Langer #5-6 curette adapts to the mesial and distal
surfaces of anterior teeth.
 Langer #1-2 curette (Gracey #11-12 shank) adapts to
the mesial and distal surfaces of mandibular posterior
teeth.
 Langer #3-4 curette (Gracey #13-14 shank) adapts to
the mesial and distal surfaces of maxillary posterior
teeth (Fig. 50.33).
 These instruments can be adapted to both mesial and
distal tooth surfaces without changing instruments.
 Standard Langer curette shanks are heavier than a
finishing Gracey but less rigid than the rigid Gracey.

Fig. 50.40 Quétin furcation curettes: BL2 (larger)
and BL1 (smaller). (Copyright A. Pattison.)
Quétin furcation curettes
are actually hoes with a
shallow, half-moon radius
that fits into the roof or
floor of the furcation.
Furcation Curettes

Newman and Carranza’s Clinical
Periodontology. 13th ed. 2019
Subgingival
Instrumentation

Plastic and Titanium
Instruments for Dental
Implants

Fig. 50.35 (A) Plastic probe: Colorvue. (B) New Implacare IIBarnhart #5-6
cone socket plastic curette tips that screw into an autoclavable stainless
steel handle. (Courtesy Hu-Friedy, Chicago, IL.)
B
A
Plastic and
Titanium
Instruments
for Dental
Implants

Fig. 50.36 New Mini titanium implant scalers (Hu-Friedy, Chicago). Left to right, Mini Five Gracey #1-2,
Mini Five Gracey #11-12, Langer #1-2, Mini Five Gracey #13-14, 204SDSickle Scaler.
Plastic and Titanium Instruments
for Dental Implants …….

Fig. 50.37 (A) Micro Mini titanium implant curettes (Paradise Dental
Technologies, Missoula, MT). Left to right, Gracey #1-2 Micro Mini, Gracey
#11-12 Micro Mini, Gracey #13-14 Micro Mini. (B) Mini-bladed titanium implant
curettes (LM Instruments, Parainen, Finland) : Mini universal curette, Mini
Gracey #1-2, Mini Gracey #13-14, Mini Gracey #11-12.
A B
Plastic and Titanium
Instruments for Dental
Implants …….

SONIC &
ULTRASONIC
Instruments Fig. 51.9 Pen grasp of tip.
(Courtesy Hu-Friedy, Chicago, IL.)

Mechanism of Action of Power Scalers
Various physical factors play a role in the mechanism of action of power scalers
that includes frequency, stroke, and water flow.
In addition, water contributes to three physiologic effects:
i. Acoustic steaming is unidirectional fluid flow caused by ultrasound waves.
ii. Acoustic turbulence is created when the movement of the tip causes the
coolant to accelerate, producing an intensified swirling effect. This turbulence
continues until cavitation occurs.
iii. Cavitation is the formation of bubbles in water caused by the high turbulence.
The bubbles implode and produce shock waves in the liquid, thus creating
further shock waves throughout the water to disrupt biofilm.

Type and Benefit of Power Instruments
⧫ Sonic units work at a frequency of 2000 to 6500 cycles per
second and use a high- or low-speed air source from the
dental unit.
⧫ Water is delivered via the same tubing used to deliver
water to a dental handpiece.
⧫ Sonic scaler tips are large in diameter and universal in
design.
⧫ A sonic scaler tip travels in an elliptical or orbital stroke
pattern. This stroke pattern allows the instrument to be
adapted to all tooth surfaces.

Type and Benefit of Power Instruments ......
⧫ Magnetostrictive ultrasonic devices work
in a frequency range of 18,000 to 50,000
cycles per second (Figs. 51.1 and 51.2).
⧫ Metal stacks that change dimension when
electrical energy is applied power the
magnetostrictive technology.
⧫ Vibrations travel from the metal stack to a
connecting body that causes the vibration of
the working tip.
⧫ Tips move in an elliptical or orbital stroke
pattern. This gives the tip four active working
surfaces (Fig. 51.3).
Lateral
Surface
Point
Lateral
Surface
Concave
Front
Surface
Convex
Back
Surface
Fig. 51.1 Magnetostrictive ultrasonic
device. (Courtesy Dentsply Sirona, York, PA.)

Type and Benefit of Power Instruments ......
⧫ Piezoelectric ultrasonic units work
in a frequency range of 18,000 to
50,000 cycles per second (Fig. 51.4).
⧫ Ceramic disks located in the
handpiece power the piezoelectric
technology and change in dimension
as electric energy is applied.
⧫ Piezoelectric tips move primarily in a
linear pattern, giving the tip two
active surfaces (Fig. 51.5).
⧫ Various insert tip designs and shapes
are available for use.
Fig. 51.4 A piezoelectric ultrasonic
device. (Courtesy Hu-Friedy, Chicago, IL.)
Fig. 51.5 Working sides of a
piezoelectric tip.
Fig. 51.8 Site-specific
designed insert. (Courtesy
Dentsply Sirona, York, PA.)
Fig. 51.6 An ultrasonic insert with
universal design.
(Courtesy Dentsply Sirona, York, PA.)

Indications, Precautions, and Contraindications for
Use of Mechanized Instruments
Indications
• Supragingival debridement of
dental calculus and extrinsic
stains.
• Subgingival debridement of
calculus, oral biofilm, root surface
constituents, and periodontal
pathogens.
• Removal of orthodontic cement.
• Gingival and periodontal conditions
and diseases.
• Surgical interventions.
• Margination (reduces amalgam
overhangs).
Precautions
• Unshielded pacemakers.
• Infectious diseases: HIV, hepatitis, tuberculosis
(active stages).
• Demineralized tooth surface.
• Exposed dentin (especially associated with
sensitivity).
• Restorative materials (porcelain, amalgam, gold,
composite).
• Titanium implant abutments unless using special
insert (e.g., Quixonic SofTip Prophy Tips).
• Children (primary teeth).
• Immunosuppression from disease or chemotherapy.
• Uncontrolled DM.
Contraindications
• Chronic pulmonary
disease: asthma,
emphysema, cystic
fibrosis, pneumonia.
• CVD with secondary
pulmonary disease.
• Swallowing difficulty
(dysphagia)
From Darby ML, Walsh MM: Dental
hygiene, ed 3, St. Louis, 2010, Saunders.

Mechanized vs Manual Instruments
Aerosol Production?
 Power-driven devices produce bioaerosols and splatter,
which can contaminate the operator and remain in the
air for up to 30 minutes.
 Good infection control practices can minimize the
hazard.
 Preprocedural rinsing with 0.12% chlorhexidine and high-
speed evacuation are the most efficient ways to reduce
bioaerosols.
(Discussed in Treatment Planning section)

Home and Self-Applied Irrigation
7/17/2020
Emerging evidence indicates that the oral irrigator effectively removes
biofilm and is as effective as dental floss when added to toothbrushing.
Fig. 51.10 Pulsation creates
two zones of hydrokinetic
activity: the impact zone
and the flushing zone.
(Courtesy Water Pik, Inc., Fort
Collins, CO.)
Fig. 51.11 A dental water jet with 1200
ppm and a pressure setting that
ranges from 20 to 90 psi. (Courtesy
Water Pik, Inc., Fort Collins, CO.)
Fig. 51.12 A cordless
dental water jet, which
also has 1200 ppm.
(Courtesy Water Pik, Inc., Fort
Collins, CO.)
Jet tip
Tip with soft
tapered
bristles
Site-
specific
tip
Tip with soft
filaments
(Courtesy Water Pik, Inc., Fort Collins, CO.)

Ultrasonic Scaler tips
Or
INSERTS

Rotary Scaler (fine burs)

Fig. 50.45 Metal prophylaxis angle with rubber cup and brush.
Fig. 50.46 Disposable plastic prophylaxis
angle with rubber cup and with brush.
Bristle Brushes:
Bristle brushes are available in wheel and cup shapes
(see Fig. 50.45). The brush is used in the prophylaxis
angle with a polishing paste. Because the bristles are
stiff, use of the brush should be confined to the crown
to avoid injuring the cementum and the gingiva.
Cleansing and
Polishing
instruments

Latest Diagnostic Aid
Fig. 50.42 Perioscopy
system, dental endoscope.
(Courtesy Perioscopy, Inc.,
Oakland, CA.)
Fig. 50.44 Perioscopic instrumentation permits deep
subgingival visualization in pockets and furcations.
(Courtesy Perioscopy, Inc., Oakland, CA.)

Periodontal Sharpening Instruments
eFig. 50.62
(A) Using a palm grasp, the operator holds the
universal curette so that the face of the blade is
parallel to the floor. The stone makes a 100- to
110-degree angle with the face of the blade.
(B) Sharpening the universal curette with a diamond
sharpening card: Hold the curette so that the face
of the blade is parallel to the floor. The
sharpening card makes a 100- to 110 degree
angle with the face of the blade.
A
B

1. Accessibility:
- Patient’s position.
- Operator’s position.
2. Visibility, Illumination & Retraction.
3. Condition and Sharpness of Instruments.
4. Maintaining a Clean Field.
5. Instrument Stabilization.
6. Instrument Activation.
Basic Principles of Periodontal
Instrumentation

eFig. 50.1
Direct vision and
direct illumination in
the mandibular left
premolar area.
eFig. 50.2
Indirect vision using the
mirror for the lingual
surfaces of the mandibular
posterior teeth.Newman and Carranza’s Clinical

eFig. 50.3
Indirect illumination using
the mirror to reflect light
onto the maxillary left
posterior lingual region.
eFig. 50.4
Combination of indirect
illumination and indirect vision
for the lingual surfaces of the
maxillary anterior teeth.

eFig. 50.7
Retracting the tongue with the
mirror.
eFig. 50.5
Retracting the cheek with the mirror.
eFig. 50.6
Retracting the lip with the index
finger of the nonoperating
hand.Newman and Carranza’s Clinical

eFig. 50.8
Modified pen grasp. The pad of
the middle finger rests on the
shank. (Copyright A. Pattison.)
eFig. 50.9
Standard pen grasp. The side of the
middle finger rests on the shank.
eFig. 50.10
Palm and thumb
grasp, used for
stabilizing instruments
during sharpening.
Grasping the Instrument

Finger Rest
eFig. 50.11 Intraoral conventional finger
rest. The fourth finger rests on the
occlusal surfaces of adjacent teeth.
eFig. 50.12 Intraoral cross-arch finger
rest. The fourth finger rests on the
incisal surfaces of teeth on the
opposite side of the same arch.
eFig. 50.13 Intraoral opposite-arch
finger rest. The fourth finger rests on
the mandibular teeth while the maxillary
posterior teeth are instrumented.
eFig. 50.14 Intraoral finger-on-finger
rest. The fourth finger rests on the index
finger of the nonoperating hand.
eFig. 50.15 Extraoral palm-up fulcrum.
The backs of the fingers rest on the
right lateral aspect of the mandible
while the maxillary right posterior teeth
are instrumented.
eFig. 50.16 Extraoral palm-down
fulcrum. The front surfaces of the
fingers rest on the left lateral aspect of
the mandible while the maxillary left
posterior teeth are instrumented.
eFig. 50.17 Index finger–reinforced rest.
The index finger is placed on the shank
for pressure and control in the maxillary
left mesial and lingual region.
eFig. 50.18 Thumb-reinforced rest. The
thumb is placed on the handle for control in
the maxillary right posterior lingual region.

6. Instrument Activation:
Strokes:

Working Positions
of the Operator

eFig. 50.27
Gracey #5-6
curette adapted to
an anterior tooth.
(CopyrightA. Pattison.)
eFig. 50.28
Gracey #7-8 curette
adapted to the
facial surface of a
posterior tooth.
eFig. 50.29
Gracey #11-12
curette adapted to
the mesial surface
of a posterior tooth.
eFig. 50.30
Gracey #13-14
curette adapted to
the distal surface of
a posterior tooth.

eFig. 50.25
Correct cutting edge of a Gracey
curette adapted to the tooth.
eFig. 50.26
Incorrect cutting edge of a Gracey
curette adapted to the tooth.

eFig. 50.40
Maxillary anterior
sextant: facial
aspect, surfaces
away from the
operator.
eFig. 50.41
Maxillary anterior
sextant: facial
aspect, surfaces
toward the
operator.
Maxillary anterior sextant: Facial aspect,
surfaces away from the operator (eFig.
50.40).
Operator position: Back position.
Illumination: Direct.
Visibility: Direct.
Retraction: Index finger of the nonoperating
hand.
Finger rest: Intraoral, palm up. Fourth finger on
the incisal edges or occlusal surfaces of
adjacent maxillary teeth.
Maxillary anterior sextant: Facial aspect,
surfaces toward the operator (eFig. 50.41).
Operator position: Front position.
Visibility: Direct.
Retraction: Index finger of the nonoperating
hand.
Finger rest: Intraoral, palm down. Fourth finger on
the incisal edges or the occlusal or facial
surfaces of adjacent maxillary teeth.

eFig. 50.42
Maxillary anterior sextant: lingual aspect, surfaces
away from the operator (surfaces toward the operator
are scaled from a front position).
Maxillary anterior sextant: Lingual
aspect, surfaces away from the
operator (surfaces toward the
operator are scaled from a front
position) (eFig. 50.42).
Illumination: Indirect.
Visibility: Indirect.
Retraction: None.
Finger rest: Intraoral, palm up. Fourth
finger on the incisal edges or the occlusal
surfaces of adjacent maxillary teeth.

eFig. 50.36
Maxillary right
posterior sextant:
facial aspect.
eFig. 50.37 Maxillary
right posterior
sextant, premolar
region only: facial
aspect.
Maxillary right posterior sextant: Facial aspect
(eFig. 50.36).
Operator position: Side position.
Visibility: Direct (indirect for distal surfaces of molars).
Retraction: Mirror or index finger of the nonoperating
hand.
Finger rest: Extraoral, palm up. Backs of the middle
and fourth fingers on the lateral aspect of the
mandible on the right side of the face.
Maxillary right posterior sextant, premolar
region only: Facial aspect (eFig. 50.37).
Operator position: Side or back position.
Visibility: Direct.
Retraction: Mirror or index finger of the nonoperating
hand.
Finger rest: Intraoral, palm up. Fourth finger on the
occlusal surfaces of the adjacent maxillary posterior
teeth.

eFig. 50.38
Maxillary right
posterior sextant:
lingual aspect.
eFig. 50.39
Maxillary right
posterior
sextant: lingual
aspect.
Maxillary right posterior sextant: Lingual aspect
(eFig. 50.38).
Operator position: Side or front position.
Illumination: Direct and indirect.
Visibility: Direct or indirect.
Retraction: None.
Finger rest: Extraoral, palm up. Backs of the middle
and fourth fingers on the lateral aspect of the
mandible on the right side of the face.
Maxillary right posterior sextant: Lingual aspect
(eFig. 50.39).
Visibility: Direct.
Retraction: None.
Finger rest: Intraoral, palm up, finger on finger. Index
finger of the nonoperating hand on the occlusal
surfaces of the maxillary right posterior teeth; fourth
finger of the operating hand or the index finger of the
nonoperating hand.

eFig. 50.43 Maxillary
left posterior sextant:
facial aspect.
eFig. 50.44 Maxillary left
posterior sextant: facial
aspect.
Maxillary left posterior sextant: Facial
aspect (eFig. 50.43).
Illumination: Direct or indirect.
Retraction: Mirror.
Finger rest: Extraoral, palm down. Front
surfaces of the middle and fourth fingers on
the lateral aspect of the mandible on the left
side of the face.
Maxillary left posterior sextant: Facial
Operator position: Back or side position.
Illumination: Direct or indirect.
Retraction: Mirror.
Finger rest: Intraoral, palm up. Fourth finger on
the incisal edges or the occlusal surfaces of

eFig. 50.45
Maxillary left
posterior sextant:
lingual aspect.
eFig. 50.46
Maxillary left
posterior sextant:
lingual aspect.
Maxillary left posterior sextant: Lingual aspect
(eFig. 50.45).
Visibility: Direct.
Retraction: None.
Finger rest: Intraoral, palm down, opposite arch,
reinforced. Fourth finger on the incisal edges of the
mandibular anterior teeth or the facial surfaces of the
mandibular premolars, reinforced with the index finger
of the nonoperating hand.
Maxillary left posterior sextant: Lingual aspect
(eFig. 50.46).
Visibility: Direct and indirect.
Retraction: None.
Finger rest: Extraoral, palm down. Front surfaces of the
middle and fourth fingers on the lateral aspect of the
mandible on the left side of the face. The nonoperating
hand holds the mirror for indirect illumination.

eFig. 50.47
Maxillary left posterior sextant: lingual aspect.
Maxillary left posterior sextant:
Lingual aspect (eFig. 50.47).
Visibility: Direct.
Retraction: None.
Finger rest: Intraoral, palm up. Fourth
finger on the occlusal surfaces of

eFig. 50.48 Mandibular
left posterior sextant:
facial aspect. Mandibular left posterior sextant: Facial
Retraction: Index finger or mirror of the
nonoperating hand.
Finger rest: Intraoral, palm down. Fourth finger
on the incisal edges or the occlusal or facial
surfaces of adjacent mandibular teeth.
Mandibular left posterior sextant: Lingual
Operator position: Front or side position.
Visibility: Direct.
Retraction: Mirror retracts tongue.
Finger rest: Intraoral, palm down. Fourth finger
on the incisal edges or the occlusal surfaces of
adjacent mandibular teeth.
eFig. 50.49 Mandibular left
posterior sextant: lingual
aspect.

eFig. 50.50
Mandibular anterior
sextant: facial
aspect, surfaces
toward the operator.
eFig. 50.51
Mandibular
anterior sextant:
facial aspect,
surfaces away
from the operator.
Mandibular anterior sextant: Facial aspect,
Visibility: Direct.
Retraction: Index finger of the nonoperating hand.
Mandibular anterior sextant: Facial aspect,
surfaces away from the operator (eFig. 50.51).
Visibility: Direct.
Retraction: Index finger or thumb of the
nonoperating hand.

eFig. 50.52
Mandibular anterior
sextant: lingual
aspect, surfaces away
from the operator.
eFig. 50.53
Mandibular anterior
sextant: lingual
aspect, surfaces
toward the operator.
Mandibular anterior sextant: Lingual aspect,
surfaces away from the operator (eFig.
50.52).
Mandibular anterior sextant: Lingual aspect,

eFig. 50.54 Mandibular
right posterior sextant:
facial aspect.
eFig. 50.55
Mandibular right
posterior sextant:
lingual aspect.
Mandibular right posterior sextant: Facial
Visibility: Direct.
Retraction: Mirror or index finger of the
nonoperating hand.
Finger rest: Intraoral, palm down. Fourth
Mandibular right posterior sextant:
Lingual aspect (eFig. 50.55).
Finger rest: Intraoral, palm down. Fourth

References:
1. Principal Source: Newman and Carranza’s Clinical Periodontology. 13th ed. 2019.
2. https://www.google.com/search?q=plaque+disclosing+agents
3.https://www.google.com/search?q=tooth+brushing
4.https://www.google.com/search?q=removal+of+overhang+restorations
5. https://www.aegisdentalnetwork.com/id/2006/12/clinical-uses-of-reciprocating-handpieces
6. https://www.google.com/search?q=scaling+and+polishing
7. https://www.google.com/search?q=Gracey+curettes
Disclaimer: This ppt presentation is purely for Educational purpose. No Financial relationship is involved.

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