ARMAMENTARIUM

● Lab gown – face mask – gloves – head cap

● Clean tray, 4 basic instruments, perio instruments
● Micromotor with contra-angle, Polishing brush, Rubber cup
● Floss - waxed and unwaxed
● Disclosing solution
● Prophy paste and Pumice
● Cotton dispenser – waste receiver – 3 dappen
dish

INSTRUMENTS

● Mouth mirror - for visualization,illumination and retraction.

​ ▪ Indirect Vision–visualization of patients' mouths that cannot be seen directly.
​ ▪ Indirect illumination – reflection of light to dark areas of the mouth.
​ ▪ Transillumination – passing through light from the mouth mirror.
​ ▪ Retraction – of cheeks, lips and tongue.
● Cotton plier - used to pick and remove cotton and other materials in the oral cavity. For
insertion and withdrawal of small items to be placed in the mouth
● Dental explorer no. 23/17 - used to detect caries and calcular deposits.
CONCAVITY: caries, CONVEXITY: calcular deposits. You can also run in tooth surfaces
to check if there are still excess calcular deposits. Surface should be smooth.
▪ No. 23 (Shepherd’s hook) used in supragingival examinations, examining dental
caries.
▪ No. 17 (Orban Type) tip is bent at 90 degrees to lower shank which allows insertion to
narrow pockets.
● Periodontal explorer (ODU) Old dominion university 11/12 - for subgingival
-Has same angulation of gracey 11/12 difference is this is more accurate
-Has a “gritty” feel
● Spoon excavator - used to remove debris, Removal of carious dentin (or soft caries in
general)
● Periodontal probes - used to locate, measure, mark pocket depths, and clinical
attachment level. Probe tip is kept in contact with the tooth surface. Probe is positioned
parallel to the long axis of the tooth.

*Move the probe from one area to another by “walking the probe”
(ex. Mesial to distal in buccal OR lingual) to avoid missing deep
defect

▪ UNC15 (UNIVERSITY OF NORTH CARLONA) - used

for comprehensive periodontal examination
- 15mm length probe with markings from
 1-15mm, color coded markings at 5th, 10th & 15th. Preferred conventional probe in
clinical research.

​
▪ WHO (WORLD HEALTH ORGANIZATION) - used for
probing caries and periodontium. Has a ball tip that
minimizes connective tissue penetration and also
measures 0.5 mm, with black band markings at 3.5, 5.5,
8.5, 11.5. 1 dark band near the ball

▪ CPITN-C (Clinical) - has 2 black band

▪ CPITN- E (Epidemiological) - doesn’t have 8.5-11.5

marking, only 1 dark band and ball point end
*Both can be used in PSE (Periodontal Screening Record) used
for high foot traffic clinics. Will tell you if you have periodontitis but not the extent or severity
unlike comprehensive periodontal exam. Record only 1 tooth on UL, LL, UA, LA, UR, AND
LR. There is code to follow. All can be used in community.
Good qualities of probe:
● slender/ tapering
● Blunt
● Rod shaped
● Cross Sectionally, circular or rectangular working end
● Have accurate measurements
*When inserting a probe in a pocket, the long axis of the probe must be parallel to the root
surface. 5-10 degrees in relation to the contact area

● Naber’s Probe - for detection of furcation on

multirooted teeth and ideal for accessing the amount of
bone loss in furcation areas with color coded markings
at (every 3mm) 3mm – 12mm markings.

a) Nabers 1N Probe-specifically designed for mesial and distal

furcations on maxillary molar. with smooth non-calibrated
surface, and sharper, more defined curves/angles.
b) Nabers 2N Probe - accesses all buccal and lingual
furcations. It also facilitates access to any furcation with a long
root trunk and/or deep pocket. With smooth non-calibrated
surface, has a shallower curve at the working end.

● Sickle scaler - double ended scaler used to remove supragingival calculus. Tip third
should be adapted at 60-70 degrees. Working end is pointed because it’s for
supragingival only.
-Tip of scaler is used for removal of thick and tenacious calculus but not for SRP
 ▪ Vertical Strokes–anterior teeth,mesial and distal of posterior teeth.
▪ Oblique Strokes–facial and lingual of posterior.
▪ Horizontal Strokes–midline and line angles on the facial and lingual of post.

● Curettes – type of scaler designed for moderate calculus removal on supragingival and
subgingival surfaces, also for root planing.
-Terminal end is called a toe
● Universal curette - a double- ended instrument used for periodontal scaling, calculus
debridement and root planing. The purpose of the universal curette is to remove small or
medium size calculus deposits and can be used both supragingivally and subgingivally.
● Gracey curettes– Area-specific used to remove supra and subgingival calculus and for
root planing. Has only one cutting edge and the blade is angulated at 70 degrees from
the terminal shank. Working end is not pointed to avoid penetration of tissue.
- Working face - scaling and root planing
- None working face - removal of infected pocket lining (Difference of scaling and
polishing and scaling and root planing)
▪ 3/4-anterior teeth.
▪ 5/6–anterior premolars
▪ 7/8–facial and lingual posterior
▪ 11/12–mesial surface of posterior
▪ 13/14–distal surface of posterior

LOWER SHANK IS PARALLEL TO THE LONG AXIS OF THE TOOTH

▪ One Cutting Edge–because the cutting edge is used for subgingival scaling while the other
side is used for gingival curettage of serrated epithelium.

● Periodontal file- used to crush subgingival calculus

DIFFERENCES BETWEEN CURETTE AND SCALER

CURETTES SCALER

TIP NO SHARP POINT POINTED TIP

USE OF CUTTING EDGE ONE CUTTING EDGE TWO CUTTING EDGE

SHAPE CROSS SECTION SEMI CIRCULAR TRIANGULAR

BLADE ANGLE OFFSET BLADE, 70 NOT OFFSET BLADE,
DEGREES 90 DEGREES

DIFFERENCE BETWEEN GRACEY CURETTE AND UNIVERSAL CURETTE

GRACEY UNIVERSAL CURETTE

AREA OF USE SPECIFIC SURFACES ALL AREAS AND

SURFACES

USE OF CUTTING EDGE ONE CUTTING EDGE TWO CUTTING EDGE

CUTTING EDGE CURVED IN TWO PLANES CURVED IN ONE PLANE

CURVATURE

BLADE ANGLE OFFSET BLADE, 70 NOT OFFSET, 90

DEGREES DEGREES

STEPS IN SCALING AND POLISHING

1. DISCLOSING
2. SCALING
3. POLISHING
4. FLOSSING

CLINICAL PROCEDURE

1. Swab all the present teeth with cotton damped in disclosing solution
2. Scale the teeth in order of quadrants, starting from 1st quadrant (1st labial, 2nd labial,
2nd lingual, 1st lingual, 1st occ, 2nd occ)
3. When all the plaque and calcular deposits have been removed, brush all the surfaces of
the teeth with pumice powder
4. Polish the teeth with prophylaxis paste
 5. Floss all the interproximal areas with tight
contacts
6. Home-care: brush 3 times a day (after every
meal)
7. Follow up: reappoint after 6 months

TERMINOLOGY

▪ Plaque – host associated biofilm, soft accumulation. Needs to be remove because aside from
it’s a bacterial build up if left untreated it will progress to calcular deposit.

▪ Calculus – hard deposit that forms due to mineralized dental plaque. mineralized biofilm
covered by unmineralized biofilm. Cycle kaya kumakapal

▪ Furcation – anatomical area where roots divide.

▪ Gingivitis – inflammation of gingiva caused by bacterial buildup on teeth.

▪ Periodontitis – severe periodontal infection. Untreated gingivitis progresses to periodontitis.

Involves gingiva, alveolar bone, cementum, periodontal ligament. Where junctional epithelium of
gingiva migrates apically. Cementum will be exposed, biofilm will colonize cementum thus
altered cementum. Alveolar bone will recede. Destruction of PDL

▪ Biofilm - main culprit; colonies of microorganisms suspended in organic matrix. Much more
organized. Plaque induced gingivitis (even without bleeding)

▪ Materia Alba - Desquamated epithelial cells, traces of bacteria, Salivary glycoproteins and
food debris. Unorganized, thus can be easily displaced by water because it lacks proper
organization.

▪ Biological width (supra crestal width) - combination of junctional epithelium and underlying
connective tissue. 2mm

▪ Clinical Attachment loss - apical migration of the junctional epithelium together with bone loss
- Clinical attachment loss is a defensive mechanism: preserves biologic seal to maintain the
2mm biological width. Double edged sword, even if it is a defensive mechanism, it still is
detrimental due to loss of PDL connection

▪ Pocket- same when measured to gingival margin to base, if GM TO BASE IS GREATER OR

EQUAL TO 4MM WITH OR WITHOUT CLINICAL ATTACHMENT LOSS, patient cant maintain
and bound to worsen overtime

▪ Gingival sulcus- 0 TO 3MM WITHOUT CLINICAL ATTACHMENT LOSS(CLINICALLY

HEALTHY) Patient can still maintain it.
▪ Scaling – non surgical procedure of removing plaque and calculus on the teeth.
- removal of biofilm, leads to altered cementum

▪ Root Planing – smoothing of root to remove infected tooth substances.

- removal of altered cementum and infected pocket lining to encourage periodontal
reattachment. Forming long junctional epithelium

▪ Curettage – scraping of gingival wall.

▪ Reduced periodontium– nagkaron ng periodontitis pero nagamot

Parts of the Periodontal Hand Instrument

1. Handle–the part of a periodontal instrument used for holding the instrument

2. Shank–a rod-shaped length of metal located between the handle and the working-end of a
dental instrument.

▪ Functional shank–begins below the working-end and extends to the last bend in the shank
nearest the handle
▪ Lowershank–the portion of the functional shank nearest to the working- end. It is important in
selecting the correct working end for the instrument.

3. Working-end–the part of the instrument that does the work of the instrument. The working end
begins where the shank ends.

CLASSIFICATION OF CEP

​ Grade 1: distinct change in CEJ contour with enamel projecting toward the
bifurcation (<1/3 of the root trunk)
​ Grade 2: CEP approaching the furcation but not actually making contact (>1/3)
​ Grade 3: (extending to the furcation proper)
​

DEGREE OF TOOTH MOBILITY

​ Degree 1 – horizontal movement is detected to 1mm

​ Degree 2 – horizontal movement ranges from 1-2mm
​ Degree 3 – horizontal and vertical movement is observed.
How to detect tooth mobility?
– by applying pressure to both ends of 2 dental instruments (dental mirrors) gently moving the
tooth buccu-lingually.

PERIODONTITIS AND GINGIVITIS

>Gingivitis is gum inflammation and, when left untreated, can progress to more serious
stages of periodontal disease, such as periodontitis.

>Periodontitis occurs when gingivitis is left untreated and periodontal disease advances.
When periodontitis develops, the inner layer of the gum and bone pulls away from the teeth
and periodontal pockets form with harmful bacteria. Plaque spreads and grows below the
gumline, which can lead to tooth and bone loss

Clinical signs of Periodontitis:

● Receding gums
● Tooth mobility
● Bleeding
● Pus formation
● Pocket formation
● Halitosis
● Swelling

BASIC PERIODONTAL EXAM

● Careful assessment of the periodontal tissues is an essential component of patient

management. The BPE is a simple and rapid screening tool that is used to indicate
the level of further examination needed and provide basic guidance on treatment
needed.
● Used as a basic screening method to check the periodontal status of a patient. It is
a simple procedure and should be done on all patients to quickly identify any
particular periodontal issues.
● This probe is specifically designed for this exam. The probe features a 0.5mm ball
on its tip. It then has a black band from 3.5mm to 5.5mm and another black band
from 8.5mm to 11.5mm. The first band is very useful when it comes to recording the
patient's BPE score.

0-4
0 - This indicates that there are no pockets >3.5mm (i.e. the black band is completely
visible), no bleeding and no calculus or plaque traps (e.g. overhanging restorations)

1 - This indicates that there are no pockets >3.5mm (i.e. the black band is completely
visible), no calculus or plaque traps (e.g. overhanging restorations) but there is bleeding
after probing

2 - This indicates that there are no pockets >3.5mm (i.e. the black band is completely
visible) but there is calculus or plaque traps present

3 - This indicates that probing depths between 3.5mm and 5.5mm have been found (i.e.
black band is partially visible)

4 - This indicates a probing depth of >5.5mm (i.e. black band is completely hidden in
pocket)

5 - Indicates furcation involvement

FURCATION INVOLVEMENT

● Furcation involvement refers to bone loss at the branching point of the roots.
● Furcation can only be present on multirooted teeth, not single-rooted teeth
● Diagnosis of the furcation involvement is based upon probing and visual
detection. Although a straight probe maybe used, detection of subgingival
furcation is facilitated by the use of the curved Nabers probe.
(mesial and distal roots) mandibular teeth (mesiobuccal, distobuccal, palatal
roots) maxillary

> Mandibular teeth : bifurcated (mesial and distal roots) Potential furcation detect on the
mid-facial and mid-lingual aspects of the tooth.

> Maxillary molars: trifurcated (mesiobuccal, distobuccal, palatal roots). Potential

furcation defect on the mid-buccal, mesial and distal aspects of the tooth.

>Maxillary first premolar: can be bifurcated (buccal and palatal roots). Potential furcation
defect on the mesial and distal aspects of the tooth.

How do you classify furcation involvement?

● Grade 1: incipient bone loss (1-3mm)

● Grade 2: Partial bone loss (4-6mm)
● Grade 3: through and through w/o gingival recession (>7mm)
 ● Grade 4: through and through with gingival recession (>7mm)
Markings are 3, 6, 9, 12mm

WHAT ARE THE CLASSES OF FURCATION (Glickman’s Classification)

Class I: Curvature of the concavity between the roots can be detected with the probe tip
but it cannot enter the space.

Class II: Probe penetrates into the furcation, but does not completely pass through to the
other side.

Class III: Probe passes completely through the furcation but is not clinically visible
because the soft issue still fills the furcation defect.

Class IV: Probe passes completely through the furcation and the entrance to the
furcation is clinically visible because of gingival recession.

Hamp Classification

Class 0 – No furcation involvement

Class 1 – Horizontal furcation involvement <3mm

Class 2 - Horizontal furcation involvement >3mm

Class 3 – Through and through furcation involvement

3 values by using UNC 15:

● bleeding index
● plaque index
● Level of gingival margin: gingival recession(GM is located apical to CEJ) and
gingival excess (GM is located coronal to CEJ)
*Clinical attachment loss/ level CEJ TO BASE OF POCKET (gingival recession +/-
pocket probing depth)
*pocket probing depth

Basis for diagnosing periodontitis: CLINICAL ATTACHMENT LOSS

Mild: 1-2mm CAL
Moderate: 3-4mm CAL
Severe: equals or more than 5mm CAL

Chronic Periodontitis:
Localized, less than 30%
Generalized, more than 30%

Non surgical periodontal therapy is gold standard, least invasive yet it can treat
mild, moderate and severe cases of periodontitis

HANDLING GRACEY CURETTES

● All gracey curettes when inserted should start at 0 degrees (the face of the
instrument and the tooth are touching)
● When removing the curettes, go back to 0 then wiggle out
● Shank and the tooth should always be parallel to get that 70 degree angle
● When using gracey curettes it is important to have good fulcrum and good
lateral pressure
● Stroke length should be short: 1-2mm
● All gracey curettes when inserted should start at 0 degrees (the face of the
instrument and the tooth are touching)
● When removing the curettes, go back to 0 then wiggle out
● Shank and the tooth should always be parallel to get that 70 degree angle
● When using gracey curettes it is important to have good fulcrum and good
lateral pressure
● Stroke length should be short: 1-2mm

INSTRUMENT INSERTION:

○ The instrument is inserted with its blade to tooth angle as close to 0

degree as possible
○ GOAL: maintain the blade as close to the root surface as possible
○ Correct angulation of insertion: 0 degrees
○ Correct angulation of scaling and root planing: 45-90 degrees

INSTRUMENT ADAPTATION:

○ 1-2mm of the terminal 1/3 of the working end is adapted to the tooth
surface
○ Terminal 1-2mm of the working end is adapted diagonally to the
calculus deposit

STROKES DURING INSTRUMENTATION:

○ Assessment stroke (exploratory stroke)

-USE: Used to evaluate root surface anatomy, surface irregularities,
 presence of calculus on root surface and other plaque retentive factors
-STROKE: These are light strokes to assess root surface conditions
-PRESSURE: Instrument is held with light pressure and is moved with
light pressure against the tooth surface (not to apply any lateral
pressure consciously)

○ Calculus removal stroke (scaling stroke)

-USE: Lateral pressure is applied on the cutting edge of the instrument
to remove supra- or subgingival calculus deposited on the tooth/root
surface
-Aside from removing calculus, this is also used to remove overhanging
restoration margins
-STROKE/PRESSURE: Lateral Pressure
-Pressure is applied on the finger rest on the tooth on which the finger
rest has been established
-Index finger and thumb are flexed slightly to exert pressure on the
instrument
-The pressure must be distributed evenly by index finger and thumb to
not lose control over the instrumentation grasp
-Firm movement in the coronal direction is made to dislodge the
calculus
-“Channeling” – the procedure by which the calculus deposit is removed
piece by piece. It is done by application of controlled and powerful wrist
generated strokes. Strokes are approx. 1mm.
○ Root planning stroke
-USE: Light to moderate pressure strokes used to remove residual
calculus after scaling strokes + final smoothening and planning of the
root surface and to remove bacterial plaque and bacterial endotoxins
from the root surface
-STROKES/PRESSURE: Light to moderate pressure strokes
-These strokes are multidirectional

*the 3 above-mentioned strokes can be activated in 3 directions: VERTICAL,

HORIZONTAL, and OBLIQUE. (VERTICAL and OBLIQUE are more common)

DIRECTION OF INSTRUMENT STROKE:

● Direction of the instrument is designated by its relation to the long axis

of the tooth
● Instrument stroke may be: Vertical, Oblique, Horizontal, or
Circumferential
● Vertical or Oblique: moderate to high pressure
 ● Horizontal: Light pressure directed towards tissue
● Instrument strokes may be described as: Pull, Push, and Walking
● Pull Stroke: most common, it is used during scaling after
calculus has been engaged
● Push Stroke: rarely used, apically moved towards the
gingiva
● Walking Stroke: Uses both coronal and apical movement
of the working end of the instrument

CONCLUSION:

● Goal of instrumentation: ensure a clean root surface which is

biologically acceptable
● Unnecessary removal of the root cementum should be avoided
ADDITIONAL QUESTIONS:

What instrument is used for subgingival scaling?

-Curettes/Gracey Curettes. Scalers shouldn’t be used because it could traumatize the
tissue during scaling and curettes are more preferable

When do you use UNC 15 probe?

-Used on patients with periodontal problems and the markings are more accurate.
Used in clinical set up

When do you use WHO probe?

-Used for excavation because the distance of the markings are different and farther
away from each other. Used in community set up

Naber’s probe?
-Used to detect furcal involvement in multirooted teeth. The markings indicate how
many mm of bone has been destroyed

How do you use an explorer to detect calcular deposits?

- The surface is not smooth. There is a “jumping” sensation due to the roughness of
the deposits.

How do you use an explorer to detect caries?

- There will be a “catch” when you explore the surfaces of the tooth.

What does 0 degree mobility mean?

- 0 degree – normal physiologic movement
-There is a slight displacement of the clinical crown under the application of moderate
pressure
-Normal physiologic tooth movement: 0.25mm

Why is there normal physiologic movement?

- There is normal movement because tooth is not directly fused to the bone of the jaw,
but the sockets of the periodontal ligament

What do you call it when it is directly fused to the bone?

- Ankylosis

What is the difference between a gracey curette and a universal/sickle scaler?

- Area: Gracey curettes are area specific, while scalers can be used on all surfaces
and areas
- Cutting edge: Gracey curettes have one cutting edge (outer part), Scalers have two
cutting edges (either outer or inner)—since scalers have two cutting edges, it is more
prone to damaging tissues during subgingival scaling, which is why curettes are used
during SRP.
- Blade angle: Gracey curette has an offset blade of 70 degrees (cutting edge curved
in two planes), Scaleers are not offset and has a 90 degree blade angle (cutting edge
curved in one plane)
- Cross section shape: GC is semicircular in x-section (rounded), Scalers are triangular
in shape (pointed)
- Calculus removal: GCs are used to remove subgingival calcular deposits and for root
planning, Scalers are used for supragingival scaling

Why gracey curettes are more adaptable compared with scalers?

- GC has a different shank design and angle, making it more adaptable