The treatment plan for any Periodontal disease, starts with the PHASE-I Therapy, otherwise called Etiotrophic Phase. A thorough mechanical debridement, by Scaling and Root planing forms an integral part of this initial phase of therapy.
The advent of Power driven instruments, has proven to be a blessing for both the clinician and the patient, owing to its ease of use.
Though it is designed so as to make it least technique sensitive, there are certain guidelines to e followed.
The unit is assembled according to the manufacturer’s directions. The water lines of the unit should be flushed for no less than 2 minutes to reduce the microbial life that can exist within the dental unit’s water line. Bleeding the water lines for an additional 3 minutes will eliminate bubbles and reduce heat.
Thoroughly wipe the ultrasonic unit with a disinfectant use a sterile autoclavable handpiece or wipe the handpiece with disinfectant. Cover the unit and the handpiece with plastic or latex barriers.
The appropriate ultrasonic tip is selected and inserted into the handpiece. Once the tip is securely in place, the power & water settings are selected. The setting chosen should be low yet effective for the type of debridement to be completed. The water flow should be adjusted so that a mist of water surrounds the tip.
The patient’s health history should be reviewed to alert the clinician to any contra indications to the procedure. The procedure should be fully explained to the patient, and the patient should be asked to rinse with an antimicrobial mouth rinse. This reduces the bacterial load, and reduces the bacteremia created in the patient’s mouth during ultrasonic use. Patients should also wear safety glasses to protect their eyes from splattered debris. A fluid resistant drape can be used to protect the patient clothing from the water spray.
Suction, either high velocity evacuation or saliva ejector should be placed for elimination of water created by the ultrasonic unit.
Patients and operator positioning
Patient and operator positioning for sonic and ultrasonic instrumentation follow the same principles as for hand instrumentation.
For instrumentation of the upper arch, the patient is seated in a supine position with the chin slightly lifted up. The backrest of the dental chain should be approximately 450angulation to the floor, if treatment is carried out in the mandible. A slight lowering of the patients chin allows good visibility to the lingual aspects of the lower front teeth. Good patient positioning should allow the operator to be seated upright. Whenever necessary, indirect view or illumination by the use of dental mirror should be used.
Before each scaling procedure, the clinician should carry out a thorough evaluation of the sites to be treated,
- Probing pocket depth
- Root surface anatomy and morphology
- Interpretation of radiographic findings.
In combination with detailed anatomic knowledge, the operator should be able to develop a 3 dimensional picture of the periodontal pocket therapy.
Instrumental grasp and finger rest
To allow maximum instrument stabilization the instrument hand piece should be held using a modified pen grasp.
An intra oral finger rest is recommended for instrumentation of teeth in the lower arch and in the upper front segment. An extraoral palm rest should be chosen while instrumenting maxillary posterior teeth, with the back of the hand in the right maxillary area or with the palm of the hand in the left arch respectively.
The tip of the ultrasonic scaler is adapted to the tooth at approximately 10-15 degrees, angulation greater than 15 degrees can cause the tip to be positioned incorrectly and damage could result to the tooth surface.
In case of tips with left and right offset angulation, tip is inserted such that convex working surface is in contact with root surface.
Using the concave side as working surface bears the risk that the instrument tip will be applied perpendicular to the root surface leading to unnecessary gauging and root surface damage.
Instrumentation of maxillary teeth
The left bent tip is used for the instrumentation of the maxillary front teeth palatal aspect and the maxillary left palatal aspect. In addition, the contra lateral approximal tooth surfaces may be cleaned with the same left offset tip inserted in an almost oblique / horizontal position.
The right offset tip is used to instrument the remaining areas to be treated.
Instrumentation of mandibular teeth
For instrumentation in the mandible the left offset tip should be used for the right lingual molar area, the lower buccal frontal segment and the lower left buccal posterior area.
As in the maxilla, the right bent tip is used for the instrumentation of the corresponding sites remaining to be treated.
By using the systematic approach, a complete and efficient instrumentation of the entire dentition is attainable and both patient and operator will benefit from the use of sonic and ultrasonic scaler.
Ultrasonic instrumentation is accomplished with a light touch and light pressure, keeping the tip parallel to the tooth surface and constantly in motion.
Leaving the tip in one place for too long or using the point of the tip against the tooth can lead to gouging & roughening of the root surface or overheating of the tooth.
Using a lower power setting and applying only slight pressure reduces the volume & depth of tooth structure removed.
The working end of the ultrasonic instrument must come in contact with the calculus deposit to fracture & remove it. As with hand instruments, instrument adaptation to the tooth is critical to success. The working tip must contact all aspects of the root surface to thoroughly remove plaque & toxins.
Although as much as 10 mm or more of the length of the ultrasonic tip vibrates, only a small portion of it can be adapted to contact the curved root surface at any one time or point.
As with hand instruments, a series of rapid, overlapping strokes must be activated to ensure complete root coverage. However, the rapid, light strokes with a blunt, vibrating working end impair tactile sensitivity & the constant water spray necessary for the operation of the instrument hampers visibility for these reason, during ultrasonic instrumentation. The tooth surface should be frequently examined with an explorer to evaluate the completeness of debridement.
The response of the soft tissue to debridement is the best indicator of successful treatment. In addition, the surface must be evaluated for complete deposit removal. Clinicians may need to follow ultrasonic scaling with hand instrumentation to complete the debridement process.
Ultrasonic & sonic scalers produce an aerosol hence particular precautions are necessary when using these devices to avoid inhalation or direct contact with blood borne & air borne pathogens.
The dental team should be wearing well-fitting disposable mask at 95% filtration of particles, 3-5μm in size. Because aerosols from ultrasonic scalers can remain suspended in the air for up to 30 mins masks should be changed every 20 mins during instrumentation. This is recommended since moisture seeps in the mask & decreases efficacy.