Periodontal instruments

Introduction:

Re-establishment and maintenance of periodontal health is the main objective of periodontal treatment. Local factors like plaque and calculus are the major factors for periodontal disease progression. Removal of these local factors to obtain a clean root surface is mandatory to achieve periodontal health. Periodontal instruments have been designed specifically to achieve this goal. Presently, there is a large range of instruments available for the removal of supra and subgingival calculus, including ultrasonic devices, sickles, hoes, chisels and curettes. Also, surgical instruments with various shapes, sizes and designs are available to help clinicians to efficiently perform the procedure.  A thorough knowledge instruments is mandatory for their appropriate usage. The following discussion is focused on various aspects of periodontal instrument designs and their specific uses.

Parts of an instrument:

An instrument can be broadly divided into three parts: handle, shank and working end. Handle of the instrument is used for grasping the instrument. Shank connects the handle to the working end & allows adaptation of working end to tooth surface. Working end does the work of the instruments. Instrument may be single ended or double ended. Double ended instruments with working-ends that are mirror images of each other have paired working-ends while instruments with two dissimilar working-ends have unpaired working-ends.

Parts of an instrument

Parts of an instrument

Following is the detailed description of these three parts of the instruments,

Handel:

Handle of the instrument is used for grasping the instrument. Presently, they are available in various weights, diameter and texture.

Weight:

Weight of the handle is determined by its diameter and its core (solid or hollow). Hollow handles are more widely used because of better tactile perception and minimized muscle fatigue. Handles with small diameter, heavy solid metal core and smooth flat texture are generally avoided.

Hollow handles: Increase tactile transfer & minimize fatigue

Solid handles: Reduce tactile transfer & increase fatigue

Various instrument handle designs

Handle  Designs

Diameter:

Small handles decrease control and increase muscle fatigue whereas large handles maximize control and reduce muscle fatigue but restrict movement in areas where access is limited.

Texture:

Serrated knurled handles maximize control and decrease hand fatigue whereas smooth handles decrease control and increase muscle fatigue.

Shank:

As already stated, shank connects the handle to the working end of the instrument. Shank can be functional or terminal as described in the image below. Functional shank extends from the working end to the shank bend closest to instrument handle. It can be short, long or intermediate. Terminal shank extends between blade & 1st bend. Long functional shank is needed to reach the tooth surfaces of posterior teeth or root surfaces of teeth with subgingival periodontal pockets whereas short functional shanks are used to remove supragingival calculus deposits or to reach the surface of anterior teeth. Shank can be rigid, moderately rigid or flexible.

Functional and terminal shank

Functional and terminal shank

Different shank types, their usage and examples

Shank type

Uses

Examples

Rigid

Removal of heavy calculus deposits.Limits tactile conduction so that calculus detection is difficult. Sickle scalerPeriodontal filesRigid Gracey curette

Moderate

Removal of moderate or light calculus deposits.Good tactile transfer allowing detection and removal of calculus. Universal curette

Flexible

Detection of subgingival calculus.Removal of fine calculus.Best tactile sensation. Gracey cuettesExplorers

 

Working end:

The working end or blade is made up of several components such as the face, cutting edge, back & toe.  A rounded working end is called toe whereas a pointed working end is called tip. Following diagram describes various parts of the working end.

Know more……………..

Balanced instrument:

A periodontal instrument is balanced if the working-ends are aligned with the long axis of the handle. This design ensures that finger pressure applied against handle is transferred to the working-end of the instrument. Also if an instrument is not balanced, it is difficult to use and stresses muscles of hand.

Balanced instrument

 

Classification of periodontal instruments:

Periodontal instruments can be divided into following categories,

  • Diagnostic Instruments
  • Scaling Instruments
  • Root planing & Curetting instruments
  • Periodontal Endoscope
  • Cleaning and polishing Instruments
  • Surgical Instruments

Following flow chart describes the periodontal instrument classification,

Classification of periodontal instruments

Classification of periodontal instruments

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Mouth mirror:

Mouth mirror has been used by dentists and professionals working in the oral health field for many years to assist in viewing inside a patient’s oral cavity. Mouth mirror or dental mirror, consists of a small, cylindrical, metal shaft with a metal disk attached at the end of it which holds the mirror. There are basically four types of mouth mirrors: the plane mirror/flat surface mirror, the front surface mirror, the concave mirror, and the double-sided mirror. A mirror may be designed for a single, disposable use or for repeated use.

Plane mirror/flat surface mirror:

Like a regular mirror, the reflecting surface of this mouth mirror is present on the back surface of the mirror glass. The problem with this mirror is formation of double image known as ghost image”. It is formed due to double reflecting surfaces. Hence, a clear image of the object is not seen during indirect vision.

Front Surface mirror:

To overcome the problem associated with plane mirror, the reflecting surface is placed on the front surface of the glass. It produces a clear mirror image with no distortion but the disadvantage is easy scratching of the reflecting surface. This mirror is most commonly used as it provides good quality clear images.

Concave mirror:

In these mirrors, the reflecting surface is on the front surface of the mirror lens which is concave. So, the image produced is larger in size as compared to its original size. It is used to see the enlarged image of areas where normal mirror does not display complete details. It is not recommended for routine use because magnification distorts the image.

Double-sided mirror:

It is used to retract the cheek or tongue. At the same time the opposite side of the mirror can be used to view the indirect image.

Mouth mirrors

Mouth mirrors

Sizes of Mouth Mirrors:

  • Size 1 -16 mm
  • Size 2 -18 mm
  • Size 3 – 20 mm
  • Size 4 – 22 mm
  • Size 5 – 24 mm

Most commonly used mouth mirrors are Size 4/ No.4 and Size 5/ No.5. The small size mirror usually Size 2/ No.2 allows a dentist to view areas in the mouth inaccessible by plain sight, such as the back teeth. 

Use:

Mouth mirror should be used with a light grip in order to prevent muscular or skeletal strain in the hands. It is also comfortable to the patient. The fogging of the mirror can be avoided by placing the reflective surface under warm water. Mouth mirrors can also serve as effective teaching tools about proper tooth care for young children and adults alike.

Uses of mouth mirror:

  • Indirect vision
  • Retraction
  • Indirect illumination
  • Transillumination

Periodontal probes:

Periodontal probing is the gold standard for periodontal assessment. The rationale behind periodontal probing is to detect and measure loss or gain of attachment level to determine the extent of previous or ongoing periodontal disease activity and to assess the efficacy of treatment done. It is used to accurately locate, assess, and measure the sulcus and pocket depth. Presently, various periodontal probes are available which vary in their markings, color coding, diameter, material, and angle.

Historical aspect:

Periodontal probes have been used for last many years for diagnosis of periodontal diseases. probe” is a Latin word which means “to test”. Diagnosis of diseases and its importance in treatment planning goes back to the time of Hippocrates, who tried to systematically diagnose and treat various pathological conditions. Periodontal probe was first described as a periodontal diagnostic instrument by John W. Riggs in 1982 1.  

The diagnosis of pyorrhoea by measuring pocket depths using periodontal probe was described by F. V. Simonton in 1925. He emphasized that presence of pyorrhoea and its extent could only be determined by the presence and depths of periodontal pockets 2.  The basic shape of periodontal probe is same as was originally described.

The first systematic classification of periodontal probes was given by B. L. Pihlstrom in 1992 3 , who classified periodontal probes into three generations: First generation, Second generation and Third generation probes. Watts in year 2000 extended this classification by adding two more generations, the fourth and fifth generation of periodontal probes 4.

Generations of periodontal probes:

As already stated periodontal probes have been classified into five generations,

  • First generation
  • Second generation
  • Third generation
  • Fourth generation
  • Fifth generation

Following is the detailed description regarding these generations of periodontal probes,

First generation periodontal probes:

The first generation periodontal probes are the conventional or manual probes, made up of stainless steel or plastic. They have no pressure or force measuring device attached which can measure the pressure or force applied by the examined during probing. The working end of these probes is either round, tapered, flat, or rectangular with smooth rounded ends. Calibrations in millimetres are made at various intervals facilitating measurement of periodontal pocket depths. Working end of the probe may be curved to facilitate probing into the furcation areas. The diameter of the probe is important because if it more, it is difficult to insert it into the periodontal pocket and it may not reach the bottom of the pocket; if it is too thin, it may penetrate the junctional epithelium, giving a false reading.

Charles H.M. Williams 5 in 1936 introduced a graduated periodontal probe known as William’s probe. This probe is considered as the prototype for first generation periodontal probes. It is a stainless steel probe with a diameter of 1 mm, length of 13 mm and a blunt tip end. The graduations are present 1 mm, 2 mm, 3 mm, 5 mm, 7 mm, 8 mm, 9 mm, and 10 mm. The 4 mm and 6 mm readings are missing in this probe to improve visibility and avoid confusion in reading the markings. The angle between the handle and probe tip is 130⁰.

Another periodontal probe is Goldman-fox probe having similar markings as that of William’s but with flat tip. The Glickman probe has round tip with longer shank. Merritt A & B probes have round tip with single bend in shank. The University of michigan ‘o’ probe has round fine narrow diameter at tip with markings at 3, 6 & 8 mm. The University of North Carolina probe (UNC-15) has color coding for every mm marking and is longer in length (15 mm). It is preferred for clinical trials where conventional probe is required.

The Community Periodontal Index of Treatment Need (CPITN) is widely used for screening and monitoring the periodontal findings in patients. It was designed by Professors George S. Beagrie and Jukka Ainamo in 1978. This index is widely used in epidemiological studies. A specific probe i.e. CPITN probe (CPITN–E/ CPITN–C) has been designed for recording the periodontal findings while recording this index which has been recommended by WHO 6. The probes have a ball tip of 0.5 mm, with a black band between 3.5 mm and 5.5 mm, as well as black rings at 8.5 mm and 11.5 mm. The weight of the probe is 5 gms. The FDI World Dental Federation/WHO Joint Working Group 1 has advised the manufacturers of CPITN probes to identify the instruments as CPITN–E (epidemiologic), which have 3.5-mm and 5.5-mm markings, and CPITN–C (clinical), which have 3.5-mm, 5.5-mm, 8.5-mm, and 11.5-mm markings.

Periodontal probes

Periodontal probes

Marquis color coded probe 7 is another probe that has been designed to facilitate easy read out of pocket depth. It has makings at 3-3-3-3/ 3-3-2-3/ 2-2-2-2 mm intervals. It is available in both straight and curved designs, has the slimmest tip. The LL-20 probe (Hu-Friedy) has a tip of 0.5 mm diameter and rounded end marked in increments upto 20mm. To facilitate reading there are thick black markings at 4, 9, 14 & 19 mm 8. For probing around implants color coded polymeric probes have been designed to minimize the possibility of scratching the metal surface.

Naber’s probe is a curved probe, used for detecting and measuring horizontal periodontal furcation involvement in multi-rooted teeth. It has a curved working, a blunt tip and is double ended. The examples of non-calibrated, double ended smooth surface Naber’s furcation probe are 1 N and 2 N. variation of these include Naber’s 3 N furcation probe which is graduated with markings at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 mm and colour coded probe which has markings at 3, 6, 9, 12 mm.

Various periodontal probes and their features

Probe

Name

Markings

Color coding

Advantages

Disadvantages

 William's Probe

Williams

probe

1-2-3-5-7-8-9-10(4 and 6 missing) No 4 and 6 mm markings are missing which minimize confusion during reading. Difficult to read
 CPITN Probe

CPITN probe (WHO

Probe)

3.5-5.5-8.5-11.5 ( 0.5 mm ball-end) Present at 3.5-5.5 and 8.5-11.5 mm. Ball end minimizes connective tissue penetration.Useful for screening pourposes Not appropriate for precise pocket depth measurement.
 Marquis color coded probe

Marquis

Color coded probe

3-6-9-12 3 to 6 and 9 to 12 mm Easy to read.Thin shank allows access into tight fibrotic sulci Thin tip may penetrate Junctional epitheliumMarkings must be estimated between color bands. 
 Goldman-Fox Probe

GoldmanFox

probe

1-2-3-5-7-8-9-10(4 and 6 missing) No 4 and 6 mm markings are missing which minimize confusion during reading. Flat shank does not allow easy access into tight fibrotic pockets
 UNC-15 probe

UNC-15

probe

1-2-3-4-5-6-7- 8-9-10-11-12-13-14-15 Color coded at 5,10 and15 mm Thin shank allows access into tight fibrotic sulci.Suitable for use in deep periodontal pockets. Thin tip may penetrate Junctional epithelium 
 Merrittt B probe

Merritt

probe

1-2-3-5-7-8-9-10  No 4 and 6 mm markings are missing which minimize confusion during reading. Difficult to read
 Michigan O probe

Michigan ‘O’

probe

Marks at 3, 6, and 8 mm 3-6-8 mm N/A Not used to measure deep pockets as markings end at 8 mm.

Second generation periodontal probes:

There is no standardization of pressure applied in first generation probes. It has been shown that the pressure applied during probing affects the readings obtained, which may cause error in readings depending upon the pressure applied during probing by same or different operators 9, 10.

To overcome this problem second generation probes were developed to standardize and quantify the pressure used during probing. These probes are pressure sensitive, allowing for improved standardization of probing pressure. It has been shown that probing pressure should not exceed 0.2 N/mm2. 9, 10 These probes can be used easily in clinical practice without requirement of computerization of the operatory.

The prototype for these probes is, true pressure sensitive probe (TPS), introduced by Frank Hunter in 1994. These probes have a disposable probing head and a hemispheric probe tip with a diameter of 0.5 mm. This probe was designed to deliver the same 20 grams of force every time it was used 4. A rim surrounding the side of the ball tip helps in detection of cementoenamel junction, calculus or root surface irregularities. Controlled probing force to the probe tip was provided using a parallelogram. A visual sliding scale is present with two marks, which when meet indicate force application of 20 grams.

Historically, Gabathuler & hassell (1971) probably designed the 1st pressure sensitive probe with a constant force application. Another pressure sensitive probe holder was designed by Armitage in1977 to determine how a constant probing pressure of 25 pounds affected the connective-tissue attachment 11. Similarly, a pressure sensitive probe was designed by van der Velden in 1978, using a cylinder and piston connected to an air-pressure system 12. Their device was capable of recording force alteration from 0.1 N to 0.5 N, which is the range of clinical periodontal probing.

Tromp et al in 1979 13 introduced a pressure sensitive probe in which a torque spring was attached to a loose probe head that could rotate in a point bearing. By doing this they achieved a constant force application of about 15 grams which was independent for the force applied by the operator.

Vitek et al in 1979 14, introduces a leaf spring force controlled periodontal probe. This device delivered a force within 0.5 grams to Michigan ‘O’ probe tip with a terminal diameter of 0.35 ± 0.05 mm

Polson in 1980 15 introduced electronic pressure sensitive probe. This is also known as Vine Valley Probe (Vine Valley Research, NY USA). The probe design had a handpiece and a control base which allowed the examiner to control the probing pressure.  An electromagnetic device was designed to accurately measure the force applied. The force was pre-set and probing was performed. As the force was increased by the operator during probing, a ‘beep’ from the central box indicated that the pre-set force level has been achieved. 

Third-generation periodontal probes:

The limitations of second generation probes included errors in constant pressure application, errors in readings, errors in calculation of attachment loss as well as there was no automated recording system available to store the data obtained. Third-generation probes refer to automated probing systems where along with a constant pressure application the data is stored by computer. In these probes the examiner related errors are eliminated.

Foster-Miller (Alabama) probe:

This probe was devised by Jeffcoat et al 16 in 1986. It is considered as the prototype for third generation periodontal probes. Working at university of Alabama, they were able to build a device capable of providing controlled probing pressure and measuring the pocket depth along with detection of cementoenamel junction(CEJ); from which clinical attachment loss is automatically determined. The components of the probe included: a pneumatic cylinder, a linear variable differential transducer (LVDT), a force transducer, an accelerator, and a probe tip.

The detection of the cementoenamel junction (CEJ) is done by moving the ball tip of the probe on the root surface at a controlled speed and preset pressure. When it reaches the CEJ there is abrupt change in the acceleration which is indicated by the graph, hence the cementoenamel junction is detected. A major advantage of CEJ detection is that it is a better reference point as compared to the gingival margin because the later may change during period of time. Disadvantage of this probing system is that it may falsely locate CEJ in case of root surface irregularities.

Florida Probe:

The Florida Probe was developed following the criteria defined by the National Institute of Dental and Craniofacial Research for overcoming limitations of conventional probing. These criteria are 17,

  • Easy to use
  • Non-invasive
  • Constant and standardized force
  • Light-weight
  • Easy access to any location around all teeth
  • A guidance system to ensure proper angulation
  • Complete sterilization of all portions entering mouth
  • No biohazard from material or electric shock
  • Direct electronic reading and digital output.

It was developed by Gibbs et al 18 in 1988. The components of this probe include a probe handpiece and sleeve; a displacement transducer; a foot switch; and a computer interface/personal computer. The hemispheric probe tip has a diameter of 0.45 mm, and the sleeve has a diameter of 0.97 mm. This probing system provides a constant pressure of 15 grams and a precision of 0.2 millimeters, providing a highly accurate periodontal examination. Florida probe has three varients: the pocket probe, the disk probe, and a stent-based model (Florida Probe Corp., Gainesville, FL). The latter two probes use occlusal/incisal surface or a prefabricated stent for referencing. Advantages of this system include the precise electronic measurements and computer storage of data and disadvantages are lack of tactile sensitivity and inability to precisely record pocket depth in inflamed tissues 19.

Toronto automated probe:

McCulloch and Birek 20 in 1991 at University of Toronto, described a probe that, like the Florida disk probe, used the occlusal-incisal surface to measure gingival attachment levels (relative attachment loss). This probe was incorporated with a tilt sensor device in its handle which could identify changes in the angulation of the probe. The sulcus probing was done with a 0.5 mm nickel-titanium wire that is extended under air pressure.

Probing forces from 0.1 N to 0.9 N, corresponding to probing pressures from 0.51 N/mm2 to 4.58 N/mm2, can be generated by an electric torque motor contained in the length gauge 21.  Advantages of this automated probing system include an incorporated electronic guidance system to improve precision in probe angulation and it allows the estimation of biophysical integrity of the dentogingival junction by measuring intrapocket probing velocity 22. Disadvantages of this probing system are errors in probe positioning, difficulty in recording the pocket depths around second and third molars and to reproduce readings, patients have to position their heads in the same place 23.

Interprobe:

It is also known as the Perio Probe. This probing system uses fiber optic technology. Goodson and Kondon (1988) 24 used this technology in their controlled-force Accutek probe. Components of this probing system include a probe tip (disposable) which is attached to an optical encoder transducer element, a control unit, memory cards for recording the data and a foot switch. A fiber bundle transmits light to the transducer and reflected light to a signal processor. Probing depth is computed by comparison of the reflected light signal with the reference obtained from the zero position 9. A friction clutch mechanism is used to apply a controlled probing force at 0.4 N (4.16 N/mm2).

The interprobe is calibrated for a constant 0.3-N (1.26 N/mm2) probing force and uses a 0.55 mm diameter plastic filament. A plastic filament 0.55 mm in diameter with a rounded tip extends from a plastic sheath and measures pocket depths upto 10 mm in 0.5 mm increments. The information obtained about bleeding, loss of attachment, furcation involvement, suppuration and mobility are also recorded by this probing system.

Periprobe comp:

The Peri Probe Comp is a computerised electronic probe with a controlled pressure of 0.45 N in 2 mm pockets to 0.25 N in 13 mm pockets. The components of the probing system include a handpiece with a disposable probe sleeve unit and a small ball shaped 0.5 mm diameter end. The handpiece contains a closed in spring which controls the probing pressure. The unit is connected with a computer which records the data obtained by probing 25.

Fourth generation periodontal probes:

The fourth generation periodontal probes utilize 3 D technology with the aim of obtaining a precise and continuous reading of the base of the sulcus or pocket. These probes are currently under development.  These probes are aimed at recording sequential probe positions along the gingival sulcus. The 3 D visualization can provide us quite accurate information about periodontal pocket.

Fifth generation periodontal probes:

In addition to 3 D technology, these probes are designed to utilize ultrasound. These are non-invasive probes. The advantage of using ultrasound waves is accurate measurement of attachment levels without penetrating the junctional epithelium. The major disadvantage of conventional probes is the overestimation of pocket depth due to penetration of probe tip into the connective tissue especially in inflammation. The only available fifth-generation probe is Ultra Sonographic (US) probe (Visual Programs, Inc, www.usprobe.com )

Ultra Sonographic (US) probe:

The US Probe mapping system is a non-invasive periodontal probing technique which measures periodontal pocket depth with identification of junctional epithelial attachment and cemento-enamel junction (CEJ). It uses the same technology as used by NASA to detect cracks in airplanes. Ultrasound probe works somewhat like a sonogram. This probe was devised by Hinders et al. at the NASA Langley Research Center 26. Here, a very narrow beam of high-frequency (10-15 MHz) ultrasonic waves is passed into the gingival sulcus and echoes of returning waves, which are reflected back from tissues are recorded. Software in computer sorts out all of echoes and makes an image of attachment level pocket depth, etc. automatically 27. Various periodontal structures like top of periodontal ligament at various points around each tooth as well as the cementoenamel junction is identified by using ultrasound or an optical method at the same time in this probing system.

Components:

The components of the probe include transducer, which is housed within a contra angled handpiece at the base of hollow conical tip, computer to record and display the data, separate electron box for water pressure control, and a foot pedal. The hollow conical tip focuses acoustic beam into periodontal tissue and the transducer emits and receives sound waves.

Working:

While probing, the tip of the probe is kept vertically parallel to the long axis of the tooth and placed gently on gingival margin until slight blanching of gingiva is visualized. Now the probe is activated with foot paddle to introduce a small stream of water into sulcus along with a thin beam of ultrasound waves. The ultrasonic beam entering the tissues is either absorbed, reflected, or scattered. The reflected portion of the beam is received by machine and used for reconstruction of ultrasonic image. The transducer installed in the handpiece records the echoes and the computer analyses the data obtained. As the examiner passes probe tip across the gingival margin, computer records incoming data which employs artificial intelligence algorithms to translate out data into estimates of probing depth in millimetres 28. In this way a three dimensional information about periodontal hard and soft tissue is obtained which is very helpful for the clinicians to make an accurate treatment plan for a patient.

Know more………..Advantages and disadvantages of various generations of probe:First generation probes:

Advantages

Disadvantages

  • These are easily available and inexpensive.
  • Tactile sensation is preserved and easily navigated by operator.
  • Color coding allows precise reading.
  • Can be used even in presence of subgingival calculus
 

  • Probing force cannot be measured.
  • Heavy in weight.
  • Inter-examiner variation is high.
  • No computer capturing of data.
  • Errors may occur during reading.
  • Assistant is required to record the readings.

Second generation probes:

Advantages

Disadvantages

  • Constant pressure application.
  • Less inter-examiner variation.
  • Comfortable to the patient.
  • Penetration into inflamed connective tissue may occur.
  • Assistant is required to record the readings.

Third generation probes:

Advantages

Disadvantages

  • Constant pressure application.
  • Errors during data recording are minimal.
  • Computerized storage of data.
  • Printouts can be obtained.
 

  • Penetration into inflamed connective tissue may occur.
  • Less tactile sensitivity.

Fourth generation probes:

Advantages

Disadvantages

  • Allow three-dimensional measurement of pocket.
  • Sequential probe positions can be measured.
  • Computerized storage of data.
  • Printouts can be obtained.
  •  Under development.

Fifth generation probes:

Advantages

Disadvantages

  • Non-invasive.
  • Accurate measurement of pocket depth.
  • Ultrasound waves accurately detect various periodontal structures like upper boundary of periodontal ligament and other soft tissue structures.
  • Provides information regarding condition of the gingival tissues
  • Computerized storage of data.
  • Printouts can be obtained.
  • Technique sensitive.
  • Expensive
  • Operator training required for interpreting the images obtained.

 Explorers:

Dental explorers are diagnostic instruments used to conduct a tactile examination and appraisal of pits and fissures, carious lesions, smoothness of root surfaces, presence of calculus on root surface   and margins of restoration. Explorers have sharp point at the end which enhances the tactile sensation. Pointed working end that is referred to as the “explorer tip” is 1-2 mm in length.

Explorers are made up of flexible metal which helps in better tactile sensation when instrument is moved on the tooth surface. Only light exploratory strokes are applied to evaluate the surface smoothness. Side of the working end of explorer is used after periodontal debridement to evaluate calculus removal and root surface texture.

There are various types of explorers available having their own advantages and disadvantages. Following is description of each design with its use,

Straight explore:

It is one of the most commonly used explorers. It has a straight working end with a pointed tip. It used to diagnose dental caries and irregular restorations margins. It is not recommended for subgingival use because the pointed tip of the explorer can injure the soft tissue at the base of sulcus/pocket. The examples of straight explorer include No. 6, No. 6A, No. 6L and 6XL explorers.

Shepherd hook explorer:

The name shepherd hook is derived from a long stick with curved end which was used by shepherd to catch sheep. It is one of the most commonly used explores and is diagnose dental caries and irregular restoration margins. It is not recommended for subgingival use because the pointed tip of the explorer can injure the soft tissue at the base of sulcus/pocket. The examples of Shepherd hook explorers are No. 23 and No. 54 explorers.

Curved explorers:

Curved explorers are used to detect the presence of calculus on root surface. These are used with light stroke and moved on root surface in the horizontal direction. Care must be taken not to injure the soft tissue while using them sub-gingivally. The examples of curved explorers are No. 3 and No. 3A explorers.

Orban type explorer:

This is also a commonly used explore. It is designed in such a way that the tip of explore is at an angle of 90⁰ with the lower shank. Advantage of this design is that when inserted into the sulcus/pocket, the back of the tip comes in contact with the soft tissue rather than the tip, preventing soft tissue injury. Disadvantage of this design is difficulty in assessing the line angles and contact areas of teeth. The examples of Orban type explorers are No. 17 and No. 20 F explorers.

11/12 type explorers:

The 11/12 explorer is a Universal assessment/diagnostic periodontal instrument. It has excellent subgingival adaptation. This explorer has been specifically designed to examine the proximal areas and deep periodontal pockets. It is circular in cross-section. The design of the shank is complex which helps in assessment of root surface in anterior as well as posterior teeth and shallow as well as deep pockets. The two ends of the instrument are mirror image of each other and a long flexible shank allows for subgingival adaptation into deep pockets areas. Examples of this type of explorers include: ODU 11/12 and 11/12 AF explorers.

Pigtail and Cowhorn explorers:

The name pigtail or cowhorn is because of shape of shank of the instrument that is used to examine teeth for calculus, caries, and restoration margins. It is used to explore the smoothness of the root surface only shallow pockets because its curved lower shank causes considerable displacement of soft tissue away from the root surface. Examples of pigtail or cowhorn include: 3CH, 3ML and 2A explorers. 

Explorers

Explorers

Scaling instruments:

These instruments are used to remove plaque and calculus from the tooth surface. Scaling instruments can be divided into two types: manual and power driven instruments. The manual instruments include: sickle scalers, curettes, files, hoes and chisels. The power driven instruments include sonic and ultrasonic scalers. Ultrasonic scalers can further of two types: piezoelectric and magnetostrictive. In the following section we shall discuss in detail various design features and usage of these instruments.

Manual scaling instruments:

Sickle scalers:

These are mainly used for supra-gingival scaling. They are designed for removal of moderate to heavy deposits. A sickle scaler has two cutting edges which are formed by the junction of the facial surface with the two lateral surfaces converging to a pointed tip. This design gives a triangular shape to the working end in cross section, with two cutting edges. This triangular cross section results in an almost pointed back. The facial surface of the blade is positioned at a 90 degree angle to the terminal shank. They have two blade designs: straight and curved.

Scalers

Scalers

Sickle scaler with straight blade:

It has two cutting edges on a straight blade ending at a sharp point. It is also known as Jacquette scaler. It is primarily used for scaling of broad facial and lingual surfaces and can also be used for scaling of interproximal areas.

Sickle scaler with curved blade:

It has two cutting edges on a curved blade ending at a sharp point. It is primarily used for scaling of interproximal areas. Presently, various types of sickle scales are available which include: university of south Carolina sickle scaler, Turner sickle scaler, Jacquette sickle scaler, Indiana university sickle scaler, U15/30 sickle scaler, Morse sickle scaler, 204 sickle scaler etc.

Sickle scalers of same design can be obtained in different sizes to be used in subgingival areas. Based on size the working end, U15/30 and Indiana university sickle scalers are large in size. Jacquette sickle scaler No.1, 2 and 3 have medium size. Curved 204 sickle scalers are available in large, medium and small size.

Design features of scalers and curettes

Design features of scalers and curettes

Curettes:

Curettes are instrument of choice for sub-gingival scaling. Details about the types, design and usage of curettes has been discussed later in Root planing & Curetting instruments.

File scalers:

File type scales are primarily used to fracture or crush the calculus. These are a group of 4 scales used for buccal, lingual, mesial and distal sites. The blade of the instrument is small so as to reach the deeper areas of periodontal pocket.

Hoe scalers:

These are primarily used for root planing and to remove calculus from base of the pockets. Similar to file type scalers, these are also available as a set of four scalers.

Chisel scalers:

These have been designed for scaling of proximal areas and are primarily used in the anterior areas of mouth. Therefore, their adaptation is limited.

Powered scaling instruments and equipment:

These include sonic and ultrasonic scaling units. These work with vibration  energy which is delivered to the working tip. This tip when applied to the surface of calculus, dislodges it from the root surface. This topic needs detailed discussion which has been given in “Sonic and ultrasonic scalers in periodontal treatment”.

Root planing & Curetting instruments:

These instruments are used for scaling and root planing in subgingival areas where scalers are not used because of their large size. These are broadly classified as universal and area specific curettes.

Universal curettes:

These are paired instruments having two cutting edges, designed to adapt to various areas in the dentition by altering the adaptation, figure rest, fulcrum and hand position. The face of the blade is perpendicular to the lower shank when seen in cross section of the tip. Both the cutting edges of the curette can be used. The examples of universal curettes include Langer curettes (Gracey shank), Columbia curettes, Indiana university curettes, Barnhart curettes, Bunting curettes, Gothernberg curettes, Younger good curettes, Mc call’s curettes.

Columbia curette 4R/4L

Columbia Curette

Design:

As already stated, universal curette blade has two parallel cutting edges that meet at a rounded toe. The curette has two cutting edges which are formed at the junction of the lateral surfaces with the facial surface. The facial surface of the blade is positioned at a 90 degree angle to the terminal shank.

Design features of universal and area specific curettes

Curette Design

Area-specific curettes:

These curettes have been designed to work on specific areas of dentition. The example of these curettes include Gracey curettes, Kramer Nevins series, Turgeon series, Hu-friedy after five series, Hu-friedy mini five series, Hu-friedy curvette series and furcation curettes. Gracey curettes are the most commonly used area specific curettes.

History of Gracey curettes:

In 1940’s Dr. Clayton Gracey, a dentist and educator at the University of Michigan invented Gracey curettes. He wanted to provide dentists instruments that could reach the deepest and least accessible periodontal pockets simply and without traumatic stretching of the gingiva. Because different shapes and positions of teeth in the arch it was not possible with the help of a single instrument. These curettes have a distinctive offset face of the blade making it a single cutting edge. Gracey and Hugo Friedman (Founder of Hu-Friedy), together developed a series of 14  area-specific curetes that are single-ended and are named after the designer and maker Dr. Gracey, hence Gracey curet 1/2, 3/4, 5/6, 7/8, 9/10, 11/12, 13/14. Presently, Gracey curettes are available as double-ended instruments with multiple handle choices. The shank of these curettes has been designed in such a way that while instrumentation clinician maintains a neutral position of the hand, wrist, and forearm by decreasing wrist flexion. The maintenance of a neutral wrist position is critical in the prevention of carpal tunnel syndrome 29. Gracey Curettes 1/2, 3/4, 5/6 are used on the anterior sextants of teeth. 7/8 and 9/10 are used on the buccal and lingual portions of posterior teeth. 11/12 and 15/16 are used on the mesial portions of posterior teeth. 13/14 and 17/18 are used on the distal portions of posterior teeth.

Gracey curettes

Gracey Curettes

Design:

Each Gracey blade is offset at 70˚. This creates one cutting edge which is referred to as the lower edge. Because of this blade angulation, curette can be used on a particular tooth surface. This angulation is in comparison to universal curettes where the blade angulation is 90 ˚. These are also available as rigid & extra rigid curettes in which shank diameter is wider and blade width is same as that of standard Gracey curettes. Different usage of standard, rigid and extra rigid curettes are as follows,

Use Standard Curettes:

  1. For light to moderate calculus removal
  2. For fine scaling and root planing
  3. As a finishing curette

Use Rigid Curettes:

  1. For moderate to heavy calculus removal
  2. For root planing
  3. For recall scaling appointments

Use Extra Rigid Curettes:

  1. For tenacious calculus removal
  2. For gross scaling and root planing
  3. For initial debridement

Gracey Curette 1/2 & 3/4: Used for the removal of subgingival plaque, calculus and root planing in the upper and lower anterior areas.

Gracey Curette 5/6: Used for of subgingival plaque, calculus and root planing in anterior teeth and premolars.

Gracey Curette 7/8 and 9/10: Used for of subgingival plaque, calculus and root planing in posterior teeth: facial and lingual surfaces.

Gracey Curettes 11/12: Used for the removal of subgingival plaque, calculus and root planing of the mesial surfaces in the premolar and molar areas.

Gracey Curettes 13/14: Used for the removal of subgingival plaque, calculus and root planing of the distal surfaces in the premolar and molar areas.

Since the introduction of Gracey curettes, a lot of modifications have been done and designs like 15/16 and 17/18 to access molars with correct angulations, After Five curettes with a longer terminal shank and thinned blade, Mini Five curettes with After Five features and a shorter blade, Micro Mini Five and biogent curettes have been introduced.

The 15/16 and 17/18 curettes:

The design of the 15/16 curette is a modification 11/12 curette. This curette has been designed for mesial surfaces of the difficult to reach posterior teeth. The curette has been designed in such a way that it permits an intraoral fulcrum close to the working area while instrumenting the molar teeth.

The Gracey 17/18 is a modified version of the 13/14 Gracey curette. It has been designed to reach the distal surfaces of the posterior teeth. The shank of 17/18 has been accentuated so that it can be used for instrumentation of difficult to reach areas, especially the mandibular second and third molars. 29

After Five Gracey curettes:

In these curettes the terminal shank is 3 mm longer than standard Gracey curettes which allow better access to deep pockets and areas with recession. The blade of the curette is 10% thinner than standard Gracey curettes to allow for less tissue distention when accessing deeper pockets. Main advantage of these curettes is superior access to root contours and pockets 5mm or more in depth. These are available in all standard Gracey numbers except # 9-10.

Mini Five Gracey curettes:

In mini five Gracey curettes, the terminal shank is 3mm longer than Standard Gracey and the blade is 50% shorter and 10% thinner. It is used for scaling in deep, narrow pockets. These are available in all standard Gracey numbers except # 9-10.

Micro Mini Five Gracey:

These have an extended terminal shank with 20% thinner blade as compared to Mini Five Gracey which helps in reducing tissue distension and ease gingival insertion designed to access deep periodontal pockets.

After five and mini five curettes

After five and mini five curettes

Biogent Curettes (Hu-Friedy):

These are recent advances in curette design where a shorter and thinner blade has been designed. There are different angulation between the shank and the working end providing more tissue friendly approach and enhanced pocket access.

Clinical procedure:

The curette is inserted into the pocket keeping the face of the curette almost parallel to tooth surface i.e. closed angle position. After reaching the base of the pocket, the face of the curette is positioned in angulation for calculus removal which is 60⁰ to 80⁰. The blade of a Gracey curette is adapted with lower cutting edge against the tooth, and the terminal shank parallel to the tooth surface being scaled. Lateral pressure is applied against the tooth (root) and a pull stroke is given maintaining the shank of the curette parallel to the long axis of the tooth.

Diagrammatic representation of curette activation

Curette activation

Diagrammatic representation of curette angulation with tooth surface

Curette angulation

Comparison between different types of Gracey curettes available

Type

Shank design and diameter

Blade length

Blade width

Available instruments

Standard

Standard

Standard

Standard

1/2, 3/4, 5/6,7/8, 9/10, 11/12, 13/14, 15/16, 17/18

Rigid standard

Increased shank diameter

Standard

Standard

1/2, 3/4, 5/6,7/8, 9/10, 11/12, 13/14, 15/16, 17/18

After five

Standard diameter with longer terminal shank

Standard

Decreased by 10% compared to  Standard

1/2, 3/4, 5/6, 7/8, 11/12, 15/16, 13/14

Rigid After five

Increased diameter with longer terminal shank

Standard

Decreased by 10% compared to Standard

1/2, 3/4, 5/6, 7/8, 11/12, 15/16, 13/14

Mini Five

Standard diameter with longer terminal shank

Decreased by 50% compared to Standard

Decreased by 10% compared to Standard

1/2, 3/4, 5/6, 7/8, 11/12, 15/16, 13/14, 17/18

Rigid Mini Five

Increased diameter with longer terminal shank

Decreased by 50% compared to Standard

Decreased by 10% compared to Standard

1/2, 3/4, 5/6, 7/8

11/12, 15/16, 13/14, 17/18

Micro

Mini Five

Increased diameter with longer terminal shank

Decreased by 50% compared to Standard

Decreased by 20% compared to mini five

1/2, 7/8, 11/12, 13/14

Biogent

Designed specifically

Shorter than the Standard

Thinner than the Standard

1/2, 7/8, 11/12, 13/14

 

Differences between Area specific and Universal curettes

 

Area specific curettes

Universal curettes

Area of use Specific surfaces All areas and surfaces
Use of cutting edge One cutting edge Two cutting edge
Cutting edge curvature Curved in two planes Curved in one plane
Blade angle Offset blade at 60-70⁰ Not Offset , 90⁰

Gracey curvettes:

These are a series of four minibalded curettes, in which the blade length is 50% shorter than that of the conventional Gracey currets with blade curved slightly upwards. It allows better adaptation on the root surface especially on the anterior teeth and the line angles. In the anterior instruments the shank is relatively straighter. Because of their design, curvettes are precisely balanced which further improves their efficacy. It should be noted that because of design of the blade while using posterior curvetts (#11/12 and #13/14), they may cause “grooving” into the proximal root surfaces of the posterior teeth. Following is the list of curvettes with their indicated areas of usage,

Instrument

Area of use

Curvette sub-zero Anterior teeth and premolars(facial and lingual surfaces)
Curvette 1/2 Anterior teeth and premolars(interproximal surfaces)
Curvette 11/12 Mesial surface of molars
Curvette 13/14 Distal surface of molars

Langer curettes:

These were designed in consultation with Dr. Burton Larger. These have combined features of Gracey shank and universal curette blade design. Because of the universal blade design both cutting edges of the blade are used allowing their use on both mesial and distal surfaces. These are set of four instruments,

1/2 Langer: Mandibular posterior

3/4 Langer: Maxillary posterior

5/6 Langer: Anterior teeth

17/18 Langer: Posterior teeth

Langer curettes

Langer curettes

The 1/2 Langer curette is used in mandibular posterior areas. The shank is similar to Gracey 11/12 curette. The shank should be kept less parallel to the tooth surface while scaling with universal blade. The 3/4 Langer curette has shank similar to 13/14 Gracey curette which allows its usage in maxillary posterior teeth. The 5/6 Langer curette has similar shank as that of Gracey 5/6 curette and is suitable for scaling of anterior teeth and premolars. 17/18 Langer curettes has shank design similar to 17/18 Gracey curette allowing its usage in second and third molar areas.

Areas for Langer curettes application 

Areas for Langer curettes application

The shank of Langer curettes heavier than a finishing Gracey but less rigid than the rigid Gracey. Langer curettes are available in rigid or flexible shanks. Other modification available are extended shank (After Five) and mini-bladed (Mini Five) versions of Langer curettes.

Quetin Furcation Curettes:

Furcation curettes are specifically designed for the removal of calculus and plaque in the furcation areas. These are small hoe-like instruments used to access into the ceiling or floor of the furcation as well as the depressions of roots inside furcations. Their main advantage is that they remove burnished calculus without removing much root surface.

Quetin Furcation Curette

Quetin Furcation Curette

Hirschfeld Files:

These are helpful in breaking up heavy calculus especially sheet-like burnished calculus. The application of curettes or diamond files should follow to smoothen the root surface.

Hirschfeld File

Hirschfield File

Periodontal endoscope:

Endoscopy has been used extensively in medicine allowing visualization and access to various parts of the body through minimally invasive surgical techniques. The components of an endoscopic unit include fiberoptic bundles, electronic video technology and fostered smaller-bore (viewing tubes) endoscopes of 2 mm and less, proving access into smaller cavities and anatomical spaces of the body.

Periodontal endoscope Perioscopy (Dental View, Irvine, CA) provides view of subgingival area helping the clinicians in diagnosis and treatment of periodontal diseases. It helps us to visualize deep pockets and furcation areas in detecting calculus, prosthetics, odontogenic aberrations, root fractures, resorption, and anatomic abnormalities.

It consists of a small bore with 0.99 mm diameter and 24x to 48x magnification, a powerful illuminating source, and an effective irrigation system to allow optimal visualization during minimally invasive periodontal surgical treatment. The fiberoptic is carried to subgingival area in a sterile sheath called as “explorer”. This sheath consists of two tubes: one isolating the fiberoptic from the oral environment and the other which delivers water to the end of fiber or camera lens.

Indication for use of periodontal endoscope:

  • Site which do not respond to traditional non-surgical periodontal therapy.
  • In cases where gingiva is chronically inflamed in spite of proper periodontal therapy.
  • In cases of suspected subgingival pathology.
  • In cases of root fracture, perforation or resorption.
  • Litigation cases which require documentation.

Cleaning and polishing instruments:

These instruments are used to clean and polish the tooth surface after scaling. The rationale for polishing is to leave a smooth, slippery clean tooth surface that is minimally plaque retentive and to make ongoing plaque control easier. Cleaning is the process of removing plaque biofilm and extrinsic stain from tooth surfaces remaining after scaling using a latex-free cup and/or bristle brush with the help of slow speed contra angle handpiece. Polishing is the process of achieving a smooth, mirror-like enamel surface that reflects light and is characterized as having a high luster.  It is done with the help of fine to extra fine grit abrasive agent. Due to fineness of the abrasive particles, the surface scratches are smaller than the wavelength of visible light (<0.05 µm) producing a highly reflective surface.

Rubber cups:

These are routinely used for polishing of the tooth surface after scaling. These are made up of a rubber shell with hollow interior. The rubber shell may or may not be webbed. These are attached to contra-angle micromotor handpiece used at low speed on the tooth surface. A fine paste should be used during polishing. It should not feel gritty when rubbed between thumb and finger. A medium or coarse paste can scour (scratch) the tooth surface and make it rougher which is not desired. The production of frictional heat should be minimized which can lead to pulp inflammation and if severe, can result in subsequent pulp necrosis.

The precautions during using rubber cups are,

  • Only low speed (less than 3,000rpm) should be used while using rubber cups, so that heat production is minimized.
  • Light pressure should be exerted at all times during polishing.
  • It should be used for a few seconds on a particular tooth surface.
  • Plenty of paste should be used so that it does not dry on tooth surface.

Bristle brushes:

The bristle bushes are available in natural and nylon bristles. These are attached to a wheel or cup shaped attachment, which can attach to a contra angle handpiece. These are also used with polishing pastes. While using these brushes, it is important to keep them away from the cementum or dentin surface because of their stiffness which may damage these structures.

Dental tape:

Dental tape is used for polishing interproximal tooth surfaces. It is made up of materials like spun silk, nylon, or teflon. It is used with polishing paste to polish interproximal areas. A piece of tape 12-18 ” long should be of sufficient length to polish all proximal tooth surfaces. Technique of using dental tape is same as that of dental floss. While polishing the entire proximal tooth surface, care should be taken not to traumatizing the interdental papilla or free gingival margins.

Air-powder polishing:

In this process, the cleaning and polishing of the dentition is achieved by a device that mixes air and water pressure with an abrasive agent such as sodium bicarbonate powder, aluminum trihydroxide, calcium sodium phosphosilicate powder, or calcium carbonate powder to remove extrinsic stain remaining after scaling.

Prophy-jet is commercially available device which uses air-powder polishing for removal of extrinsic stains and cleaning. Various studies have been done to evaluate the effectiveness and loss of tooth structure. Studies have shown significant loss of tooth substance when this procedure was done on cementum and dentin 30, 31.

Along with this studies have demonstrated that restorations such as amalgam, composite, cements and other non-metallic materials can be roughened with the use of these air abrasives 32-34.  This system can be safely used on titanium implants surfaces 35, 36.

It is important not to direct the air polishing stream at soft tissue or into the sulcus. Tissue emphysema has been reportedly caused when the air/water/powder stream was directed at the soft tissues or into the sulcus. Also, a direct contact of prophy powder with surfaces and marginal areas of dental restorations should be avoided.

Contraindications:

  • It is not recommended for patients on a sodium-restricted diet.
  • Patients who have severe respiratory illness.
  • Patients with known allergies to the components of abrasive powers used for air polishing.
  • On restorations like gold, composites and cements.
  • Areas with thin or deficient enamel, dentine or cementum.
  • Areas with hypersensitivity.
  • Areas with caries susceptibility such as white spots and demineralized enamel.

Surgical instruments:

Various instruments are used during periodontal surgical procedures. These are broadle classified as follows,

  • Excisional and incisional instruments.
  • Periosteal elevators.
  • Electrosurgical instruments.
  • Surgical curettes and sickles.
  • Surgical chisels and hoes.
  • Surgical files.
  • Scissors and nippers.
  • Haemostats and tissue forceps.
  • Needle holders.

Excisional and incisional instruments:

These include periodontal knives, interdental knives and surgical blades.

Periodontal knives (gingivectomy knives):

These are single ended or double ended instruments with a kidney shaped margin of the cutting edge. These are used for initial bevel incision for gingivectomy or gingivoplasty procedures. Kirkland knife  is commonly used as gingivectomy knife.

Interdental knives:

These are single ended or double ended spear shaped periodontal knives. These have cutting edges on both sides of the blade which is used in the interdental areas. The examples of the knives include Orban’s knife #1-2, Merrifield knife # 1, 2, 3, 4 and Waerhaug knife.

Kirkland knife and Orban’s knife

Kirkland knife and Orban knife

Surgical blades:

These are used to put incision during periodontal surgical procedures. Most commonly used surgical blades during periodontal surgery are 12D, 15 and 15C. These are mounted on Bard- Parker handles carefully before use.

12D blade: It is a double edged blade, sharpened along both sides of the crescent shaped curve. It is made up of carbon steel and is used for cutting gingival tissue and making surgical incisions.

15 blade: It has a small curved cutting edge and is the most popular blade shape ideal for making short and precise incisions.

15C blade: This blade has a longer cutting edge than the traditional No.15 blade. Because of longer, more extended cutting edge, the 15C provides additional reach for carrying out periodontal procedures.

Surgical blades

Surgical blades

These blades are attached to bard parker handles which may be straight or contra-angle. These designs help in performing procedures in different parts of oral cavity. 

Bard parker handles

BP Handle

Electrosurgery:

Electrosurgery equipment uses a high-frequency electric current to cut tissue. The electrode attachment used will depend on the extent of the tissue removal required. One advantage of using the electrosurgery is coagulation and the control of bleeding. Detailed description of electrosurgery has been given in “Electrosurgery and its use in periodontal therapy”.

Periosteal elevators:

Periosteal elevators are used to reflect the full thickness flap during periodontal surgery. Purpose of flap elevation is to get access to the underlying bony defects. Various periosteal elevators have been designed out of which most commonly used in periodontal surgical procedures are: Goldman-Fox 14, Glickman 24G, Woodson and Prichard periosteal elevators.

Periosteal elevator

Surgical curettes and sickles:

The surgical curettes and sickles have a wide and heavier blade which makes them suitable for removal of granulation tissue, fibrous interdental tissue and tenacious subgingival deposits during periodontal surgical procedures. Langer and Kramer curettes #1, 2, 3 are widely used surgical curettes. Other examples include Prichard curettes and Kirkland surgical instruments which are heavy curettes whereas Ball scaler #B2-B3 are heavy scaler.

Chisels:

Use of the periodontal chisel scaler is extremely limited. It is used solely for the removal of heavy supragingival calculus deposits that bridge open interproximal spaces of anterior teeth.  

Ochsenbein Chisel

Hoes:

Periodontal hoe scalers are usually limited to removal of large ledges of calculus located supragingivally and slightly subgingivally. For example, calculus that rings the tooth on the facial, lingual, and distal surfaces of teeth that have no adjacent posterior teeth can be removed with the hoe.

Files:

Periodontal files are strong instruments used to crush large calculus deposits and to smooth the tooth surface at the cementoenamel junction when the dentist is root planing.

File

Bone File

Scissors and nippers:

These are used to remove tabs of tissues during gingivectomy, to trim the margins of periodontal flap, to remove muscle attachments during mucogingival surgeries and to enlarge the incision during periodontal abscess drainage. Various types of designs are available and selection depends upon individual preference. Examples include, Goldman-Fox #16 scissor which has a curved, bevelled blade with serrations.

Curved Scissors

Curved Scissors

Castroviejo Scissors 

Castroviejo Scissors

Needle holders:

These are used to hold the needle during suturing the flap. In addition to regular needle holders, Castroviejo needle holders are used in delicate and precise suturing in periodontal surgical procedures especially root coverage procedures.

Needle holder

Needle Holder

Lasers:

The word LASER is an acronym for Light Amplification by Stimulated Emission of Radiation. The use of lasers for treatment has become a common phenomenon in the medical field. An application of lasers in clinical dentistry has provided us with a new treatment modality. The use of lasers in periodontal treatment has been explored in following areas,

  • To treat dentinal hypersensitivity.
  • Removal of diseased pocket lining epithelium.
  • Bactericidal effects of lasers on pocket organisms.
  • Removal of calculus deposits and root surface detoxification.

This topic requires an elaborated discussion which is available in “Applications of Lasers in periodontal therapy”.

Dental implant maintenance and scaling instruments:

These instruments are specially designed for maintenance of dental implants. Because implants have a metallic surface, it may get adversely affected by application of metallic instruments.  These instruments are made up of plastic or non-metallic materials. These have been especially designed for cleaning the abutments of dental implants. The special material enables optimum cleaning without damaging the abutment surface. Metal scalers and curettes or untrasonic tips should never be used to clean the implant surface, because they may damage the surface of the implant. Several versions of implant scales are available to permit access in all situations.

Universal scaler: Can be used in most areas to clean the abutment surfaces and apical portion of the framework

Lingual scaler: Designed for cleaning the lingual side of the abutment.

Posterior scaler: Designed to enable access to the posterior lingual abutment surfaces.

Buccal scaler: Cleans the buccal surface of the abutment.

Polymeric periodontal probe for probing around implants

polymeric periodontal probe

Conclusion:

The aim of periodontal therapy is to remove all the local factors responsible for disease progression and make periodontal tissue architecture conducive for self oral hygiene maintenance. These goals are achieved by non-surgical and surgical periodontal therapy. An efficiently done non-surgical/surgical periodontal therapy is fundamental requirement of good clinical results.

Correct knowledge of instruments is mandatory before their clinical usage. A detailed description of instruments used in non-surgical and surgical periodontal treatment has been discussed above. One must read the “Principals of instrumentation” for appropriate clinical application of these instruments.

WARNING

Any unauthorized use or reproduction of periobasics.com content for commercial or any purposes is strictly prohibited and constitutes copyright infringement liable to legal action.

Acknowledgement:

I am very thankful to all the instrument manufacturing companies who have provided us with wonderful instruments without which our field is incomplete. Design of the instrument and its precise shape help clinicians to deliver best of their operative skills. The images of the instruments demonstrated in above discussion belong to various instrument manufacturing companies which are as follows,

  • Hu-Friedy.
  • Premier.
  • Miltex.
  • API.

References:

Please contact author for references

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