A dentist wouldn’t place an implant using a composite kit. Why do so many hygienists settle for an augmented prophy setup when performing an SRP or periodontal maintenance? Adding a few choice instruments into your perio-fighting arsenal will give you greater access to pockets, remove more calculus, cause less tissue trauma, and likely improve your periodontal outcomes.1
Start with the Basics
Your periodontal setup should include a sharp set of standard Gracey curettes plus your favorite go-to instruments. All working ends should be well-maintained and sharp. Don’t skip out on the 17/18 Gracey, if possible. The distals of molars are notorious for accumulating calculus that may go undetected, even on routine prophy patients.
After you’ve got your basic kit, it’s time to add some key players.
Powered instruments − Whether piezo or magneto, having an array of tips is crucial when accessing deeper pockets. Standard, slim, and curved slim tips are the working-end design options.
Curved tips, right and left tips, and paired tips are all interchangeable terms. No matter what you call them, they should be an indispensable part of your periodontal armamentarium. Curved tips can be intimidating, if unfamiliar, but they should be standard-of-care for treating periodontitis, much the same way a Gracey is. They’re invaluable for almost every area in the mouth. After the initial debridement with a standard straight tip, they’re the second thing I reach for.
Curved tips adapt especially well to root curvatures, concavities, and furcation areas. They’re great for reaching calculus deposits below the contact areas of posterior teeth. Because of their design, I find I can maintain better ergonomics for longer periods of time when using curved tips as opposed to straight tips or some hand instruments.
Modified Gracey curette − Design modifications to area-specific Gracey’s were intended to facilitate treatment into pockets deeper than 4 mm as well as access deep, narrow pockets. The effectiveness of instrumentation decreases with advancing probe depths, especially pockets in excess of 5 mm.
Research has also concluded that root instrumentation causes trauma to the base of pockets. Choosing appropriate modified instruments may help aid in effective periodontal treatment while lessening tissue trauma.1 The modified Graceys can be used on the same tooth surfaces and with the same techniques as the original curettes.
The extended shank curette is not only 3 mm longer than a standard Gracey curette, but it also has a working-end width that’s 10% thinner, which facilitates insertion beneath the gingival margin and reducing tissue distention. Consider this instrument for those deeper, hard-to-reach pockets where a little extra length can make all the difference.
The miniature working-end curette is still 3 mm longer than a standard Gracey curette, yet the working-end length is half that of the standard, making it ideal for narrow pockets. It’s an optimal choice for furcation areas, line angles, and midlines of anterior roots. Miniature curettes are not intended to replace standard or extended curettes, but rather supplement them.
Diamond-coated instruments − Who doesn’t love diamonds? Diamond-coated instruments are truly unique as they have no cutting edges; instead, they have a working-end curvature coated in a very fine diamond grit. The curvature is similar to a Nabers furcation probe and is considered a finishing instrument, used to polish root surfaces, not remove heavy calculus.
They’re used like an emery board in that they remove small, embedded remnants of calculus that remain after instrumentation. It should be noted that only very light pressure should be applied as over-instrumentation of root surfaces is possible.
Activation is both a push and pull stroke with very light pressure, using multiple directions. Diamond-coated instruments are ideal for burnished calculus, class III furcations, deep pockets, and class IV furcations, including the furcation roof.
A file’s main purpose is to prepare heavy calculus so it can be removed by another instrument. A file can crush and roughen, prior to instrumentation. On especially bulky deposits, it’s worth considering using files as a supplement to prevent burnished calculus.
As periodontal files are limited in both design and function, they are considered area-specific; therefore, a set of files is needed to instrument the entire mouth.
Other Instruments Worth Considering
The O’Hehir Debridement curette has a working-end that’s a tiny circular disk, acting as one continuous cutting edge. Using a push or pull stroke in any direction, this unique instrument easily adapts to furcations, developmental grooves, concavities, and line angles.
With its extended lower shank, it can access deeper pockets and is designed to smooth root surfaces and remove small residual deposits after instrumentation. The O’Hehir 7/8 curette has a 15 mm-long shank that can provide access to even the deepest periodontal pocket of the mandibular anterior teeth.
A Quentin (pronounced kee-tan) furcation curette has a working-end shaped like a miniature hoe. The corners of the cutting edge are rounded, as is the back of the working-end to reduce possible gouging of root-surfaces. This instrument’s very specific design is intended to remove calculus from recessed areas of the furcation where other curettes (even miniature Graceys) may fail to reach, including on the inner aspects of the roots. They’re available in facial-lingual and mesial-distal and can be used on both posterior and anterior teeth.1
A subgingival dental endoscope is used to view and examine the inside of the periodontal pocket using an attached fiber-optic light and video camera. Images from inside the pocket are transmitted from the endoscope and projected onto a monitor. From there, the clinician has a highly magnified picture of subgingival conditions. Imagine seeing deposits, rather than detecting them with an explorer.
The technique takes time and effort to master, but according to the Journal of Dental Hygiene, significant more calculus is detected using endoscopes vs. tactile exploring.2
The subgingival endoscope is considered too time-consuming for routine subgingival instrumentation; however, it’s ideal for patients in whom periodontal surgical therapy is contraindicated, and also maintenance patients with areas of chronic inflammation or increasing pockets.
Hygienists too often seem to make do with limited instruments in situations they frequently find themselves in for a variety of reasons. Having the appropriate instruments for periodontally involved patients is a necessity, not a luxury. Building and maintaining a productive office centers, in part, around the hygiene department, and periodontal cases can contribute to growth and opportunity. To attain high ethical standards, it’s imperative to invest in and maintain periodontal instruments that meet the needs of your patients. This can be done by gradually adding one or two instruments into your armamentarium each month or each quarter.
What are your instruments of choice in your perio set-up? How does your office incorporate new instruments into the budget?
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- Gehrig, J.S., Sroda, R., Saccuzzo, D. (2017). Fundamentals of Periodontal Instrumentation and Advanced Root Instrumentation. Philadelphia: Wolters Kluwer.
- Osborn, J.B., et al. “Endoscope vs. Tactile Evaluation of Subgingival Calculus.” Journal of Dental Hygiene. Aug: 2014.