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POSTGRADUATE PERIODONTOLOGY - THEORY EXAMINATION NOTES

• Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation, 8th Edition (Gehrig, Sroda, Saccuzzo)
• Periodontology for the Dental Hygienist, 4th Edition (Perry, Beemsterboer, Essex)

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PART 1: ERGONOMICS AND PERIODONTAL INSTRUMENTATION

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1.1 MUSCULOSKELETAL DISORDERS (MSDs) IN DENTAL PRACTICE

Definition and Significance

• Musculoskeletal disorders (MSDs) are disorders of the muscles, nerves, tendons, ligaments, joints, cartilage, or spinal discs
• Dental hygienists are at high risk due to the nature of periodontal instrumentation
• Cumulative trauma disorders (CTDs) = MSDs caused by cumulative exposure to forceful, repetitive motions

Types of MSDs Relevant to Periodontal Instrumentation

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1.2 NEUTRAL POSITION (KEY EXAMINATION TERM)

Characteristics of Neutral Seated Clinician Position

• Neutral position is defined as the position in which the body is in a state of equilibrium and is least likely to be injured
• Head: Tilted slightly forward, not bent sharply downward; ears aligned over the shoulders
• Shoulders: Relaxed, not elevated; level with each other
• Upper arms: Close to the body; relaxed and hanging downward
• Elbows: Bent at approximately a 90-degree angle; at waist level
• Forearms: Parallel to the floor
• Wrists: Straight; not bent up, down, or to the side
• Back: Straight; not twisted or bent
• Thighs: Parallel to the floor when seated
• Feet: Flat on the floor

Examiner Note: "Neutral position" = position of equilibrium and least potential for injury. Head slightly forward, shoulders relaxed, elbows at 90 degrees at waist level, wrists straight, back straight, thighs parallel to floor, feet flat.

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1.3 CLINICIAN CLOCK POSITIONS

FLOWCHART: SEQUENCE FOR ESTABLISHING PATIENT/CLINICIAN POSITION

STEP 1: ME
    |
    v
Assume clock position for the treatment area
    |
    v
STEP 2: MY PATIENT
    |
    v
Establish patient chair and head position
    |
    v
STEP 3: MY EQUIPMENT
    |
    v
Adjust the unit light. Pause and self-check clinician, patient, and equipment position
    |
    v
STEP 4: MY NON-DOMINANT HAND
    |
    v
Place fingertips of non-dominant hand as shown for the clock position
    |
    v
STEP 5: MY DOMINANT HAND
    |
    v
Place fingertips of dominant hand as shown for the clock position

Clock Positions and Treatment Areas

Key Positioning Details

• Maxillary treatment: Patient chair in supine position; chin-up head position
• Mandibular treatment: Patient chair in semisupine position; chin-down head position
• The patient's open mouth should be below the point of the clinician's elbow
• Clinician's elbow should not be raised above waist level

Standing Position

• Used when: difficulty accessing the treatment area; patient cannot be placed in supine position due to medical or physical contraindications; working on mandibular treatment areas
• Correct standing position: shoulders relaxed, elbow of dominant hand at waist level, torso in neutral position, not leaning over the patient

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1.4 ANCILLARY EQUIPMENT

Coaxial Illumination (Dental Headlights)

• Coaxial illumination sources = spectacle-mounted or headband-mounted miniature lights that provide a beam of light parallel to the clinician's sight line
• Advantages:
  • Eliminates shadows produced by hands and instruments
  • Provides shadow-free light
  • Facilitates improved posture (clinician does not crane neck to adjust overhead light)

Magnification Loupes

• Mounted to spectacle frames or headband
• Improve visualization of subgingival areas and fine calculus deposits
• May reduce need for awkward neck and trunk posture

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1.5 FOUNDATIONAL BUILDING BLOCKS OF PERIODONTAL INSTRUMENTATION

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PART 2: INSTRUMENT GRASP

2.1 MODIFIED PEN GRASP

• The modified pen grasp is the recommended grasp for periodontal instrumentation
• Components of modified pen grasp:
  • Index finger: Curved; pad of the finger rests on the instrument handle
  • Thumb: Curved; pad of the thumb rests on the instrument handle, opposite to and not overlapping the index finger
  • Middle finger: Rests lightly on the shank (not on the handle); the pad and side of the finger contact the shank
  • Ring finger: The finger rest (fulcrum) finger; establishes contact with the tooth or oral structure
  • Little finger: Curled or resting; follows the ring finger

Examiner Note: In the modified pen grasp, the middle finger rests on the shank (not the handle). This differentiates it from a standard pen grasp.

Index Finger and Thumb Placement Rules

• Thumb and index finger are opposite each other on the handle and do not overlap each other on the handle
• Pads (not tips) of the thumb and index finger contact the handle

Grasp Pressure

• A light grasp is essential for tactile sensitivity; grip force should be just enough to maintain control of the instrument
• Heavy grasp pressure reduces tactile sensitivity and contributes to hand and wrist fatigue

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2.2 JOINT HYPERMOBILITY AND INSTRUMENTATION

• Hypermobile joints may cause problems:
  • Increased flexibility makes hands less stable; muscles must work harder to grip and manipulate objects
  • The joint of the thumb or index finger may hyperextend ("collapsed inward") during grasp
  • Since proprioceptive sensitivity may be reduced, the clinician must take care not to grip with too much force
  • Performing instrumentation with joints in a hyperextended position may cause injury by overstretching the hypermobile joint
• Interventions for hypermobility:
  • Silipos sleeve (Lycra or silicon sleeve): assists with proprioceptive retraining while grasping the instrument handle; may be worn under surgical gloves
  • Ring splints: help prevent joint hyperextension and retrain proprioceptivity (perception) of finger position (Brandfonbrener)
  • Orthopedic hand specialist evaluation recommended
  • Physical therapy and joint stabilizing devices

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2.3 FINGER RESTS (FULCRUMS)

Key Terms

• Fulcrum = the support point; in instrumentation, the finger rest that stabilizes the hand during stroke production
• Intraoral fulcrum = finger rest established on a tooth surface within the oral cavity
• Extraoral fulcrum = finger rest established outside the oral cavity (on the patient's face/chin)
• Advanced fulcrum = a fulcrum used when a conventional intraoral fulcrum cannot be established
• Support beam = the lower arm and wrist acting as a rigid unit during stroke activation
• Neutral wrist position = straight alignment of the wrist; not flexed, extended, or deviated

Intraoral Finger Rest Technique

• The ring finger is the finger rest (fulcrum) finger
• Ring finger rests on a stable tooth surface
• The finger rest should be close to the working area to provide maximum control
• A firm finger rest is needed - not a light touch

Finger Pad Placement

• Thumb and index finger: opposite each other on the handle; pads contact handle; do not overlap each other
• Middle finger: pad and side of finger rest lightly on the shank
• Ring finger: fingertip contacts the tooth surface for the finger rest
• Index, middle fingers: in a neutral position during instrumentation

Anterior Sextant Finger Rests

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PART 3: INSTRUMENT DESIGN AND CLASSIFICATION

3.1 PARTS OF A PERIODONTAL INSTRUMENT

FLOWCHART: INSTRUMENT ANATOMY

PERIODONTAL INSTRUMENT
        |
   _____|_____
  |           |
HANDLE      WORKING END
  |           |
Single-      Active portion of
ended or     instrument that
double-      contacts the tooth
ended        or tissue
        |
       SHANK
        |
   _____|_____
  |           |
LOWER       UPPER
SHANK       SHANK
(Terminal    (Between handle
shank -      and lower shank)
contacts
tooth)

Components Defined

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3.2 CLASSIFICATION OF PERIODONTAL INSTRUMENTS

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3.3 CURETS - DETAILED CLASSIFICATION

Universal Curets vs. Area-Specific Curets

Examiner Key Term: In area-specific curets, the correct cutting edge is the lower cutting edge - identified as the edge that is lower when the face of the blade is parallel to the floor and the toe points away from the clinician.

Gracey Curet Area Designations

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3.4 SICKLE SCALERS

• Design: Triangular cross-section; pointed toe; two cutting edges
• Use: Supragingival calculus removal; deposits slightly below the gingival margin
• NOT for deep subgingival instrumentation because pointed tip and rigid shank can damage soft tissue in deep pockets
• Types: Straight sickle scalers (anterior teeth), contra-angle sickle scalers (posterior teeth)

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PART 4: TECHNIQUE ESSENTIALS

4.1 ADAPTATION (KEY EXAMINATION TERM)

• Adaptation = the relationship of the working-end of an instrument to the tooth surface
• Correct adaptation: the first 1 to 2 mm (leading third) of the cutting edge is maintained in contact with the tooth surface
• For curets: the toe third of the working-end should contact the tooth
• Incorrect adaptation ("toe away"): only the middle or heel third of the blade contacts the tooth, resulting in trauma to the soft tissue

Examiner Note: "Correct adaptation" means maintaining the first 1-2 mm (toe-third) of the cutting edge against the tooth surface at all times during the stroke.

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4.2 ANGULATION (CRITICAL EXAMINATION TOPIC)

• Angulation = the angle formed between the face of the blade and the tooth surface
• Correct instrumentation angulation: 45 to 90 degrees (optimally 60 to 80 degrees)
• Less than 45 degrees: instrument face too close to tooth; cutting edge will not engage calculus (burnishing calculus instead of removing it)
• 90 degrees: cutting edge is perpendicular to tooth - traumatic, may lacerate tissue

Examiner Keyword: "Burnishing" = smoothing of calculus over the tooth surface without removal, resulting from too-closed angulation (less than 45 degrees). A burnished surface feels smooth to the explorer but calculus remains.

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4.3 LATERAL PRESSURE

• Lateral pressure = the pressure applied against the tooth surface by the cutting edge
• Assessment strokes (exploratory strokes): light lateral pressure to detect calculus and root irregularities
• Working strokes (scaling/root planing): moderate to firm lateral pressure to remove calculus

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4.4 INSTRUMENTATION STROKES

Stroke Directions

• Vertical strokes: Parallel to the long axis of the tooth; used on facial/lingual surfaces
• Oblique strokes: Diagonal to the long axis; most commonly used
• Horizontal strokes: Perpendicular to the long axis; used at the base of pockets and furcation areas

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4.5 SUPRAGINGIVAL VS. SUBGINGIVAL CALCULUS REMOVAL

FLOWCHART: CALCULUS REMOVAL SEQUENCE

ESTABLISH FINGER REST (FULCRUM)
            |
            v
ADAPT working-end to tooth surface
    (first 1-2 mm of cutting edge)
            |
            v
ANGULATE at 45-90 degrees (optimal 60-80°)
            |
            v
ACTIVATE STROKE with moderate-to-firm lateral pressure
            |
            v
DIRECT stroke AWAY from gingival margin (coronal direction)
            |
            v
OVERLAP strokes to ensure complete coverage
            |
            v
REASSESS with explorer for residual calculus

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PART 5: PERIODONTAL PROBES AND PROBING TECHNIQUE

5.1 PERIODONTAL PROBE DESIGN

• Periodontal probe = a thin, tapered, blunt-ended instrument used to measure the depth of the periodontal sulcus or pocket and assess the periodontal status
• Probe design: handle, shank, and working-end (the calibrated rod)
• Markings: Millimeter calibrations on working-end; most common markings: 1-2-3-5-7-8-9-10 mm or 3-6-9-12 mm

Types of Probes

Examiner Note: "Probing depth" = the distance from the gingival margin to the base of the pocket as measured with a periodontal probe. The term "probing depth" is more accurate than "sulcus depth" for the clinician because "sulcus depth" is a histologic term only.

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5.2 PROBING TECHNIQUE

Steps in Basic Probing

1. Hold probe with modified pen grasp
2. Establish a finger rest on nearby teeth
3. Insert probe at the distal line angle of the tooth with the probe parallel to the long axis of the tooth
4. Walk the probe around the tooth in 1-mm increments, maintaining contact with the root surface
5. Probe six sites per tooth: mesiobuccal, buccal (mid), distobuccal, mesiolingual, lingual (mid), distolingual
6. Keep the probe inside the sulcus or pocket throughout measurement
7. Read the probe at the level of the free gingival margin

Factors Affecting Probing Accuracy

• Inflammation: increased gingival crevicular fluid (GCF) flow with inflammation; edematous tissue may allow probe to penetrate beyond the junctional epithelium
• Probe diameter: thinner probes give more accurate subgingival measurements
• Probing force: standardized probing force of 0.25 N (25 g) recommended
• Angulation of probe: probe must remain parallel to the long axis of the tooth
• Calculus deposits: calculus can prevent full probe insertion

Examiner Keyword: "Walking the probe" = moving the probe in short, 1-mm overlapping steps along the entire circumference of the tooth while maintaining contact with the root surface within the pocket.

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5.3 EXPLORERS

• Explorer = a thin, wire-like instrument with a sharp tip used to detect subgingival calculus, caries, root irregularities, furcation involvement, and margin of restorations
• Uses tactile sensitivity transmitted through the shank and handle

Types of Explorers

Examiner Note: The ODU 11/12 explorer is the preferred instrument for subgingival calculus detection because the curved tip allows adaptation to root surfaces in deep periodontal pockets.

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PART 6: POWERED INSTRUMENTATION

6.1 INTRODUCTION TO POWERED INSTRUMENTATION

• Powered scalers = instruments that use mechanical vibration to disrupt and remove deposits from tooth surfaces
• Types:
  • Ultrasonic scalers: vibrate at 18,000 to 50,000 cycles per second (Hz)
  • Sonic scalers: vibrate at 2,000 to 6,500 cycles per second (Hz)

Types of Ultrasonic Scalers

Examiner Keyword: Magnetostrictive = elliptical motion (all sides active). Piezoelectric = linear motion (two sides active).

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6.2 POWERED WORKING-END DESIGN

• Working-end shapes: straight, curved, ball-end, perio (slim), furcation
• Slim (perio) tips: designed for subgingival use in periodontal pockets
• Power settings:
  • Low power: for biofilm disruption, stain removal, light deposits
  • Medium power: for moderate calculus
  • High power: for heavy, tenacious calculus (only)

Adaptation - Working-End Orientation

Examiner Note: Ultrasonic tips should NEVER be held perpendicular (90 degrees) to the tooth surface. The correct adaptation is with the tip at 0-15 degrees to the tooth surface.

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6.3 AIR POLISHING FOR BIOFILM MANAGEMENT

• Air polishing = a procedure that uses a slurry of pressurized air, water, and polishing powder to remove biofilm, soft deposits, and stain
• Supragingival air polishing: uses sodium bicarbonate powder (conventional, coarse) or newer glycine-based powder via standard nozzle
• Subgingival air polishing: uses glycine-based powder (fine, gentle) via:
  • Standard metal nozzle
  • Flexible plastic tip (subgingival delivery)

Powder Comparison

Clinical Evidence for Subgingival Air Polishing

• Glycine powder subgingival air polishing has been shown effective for disruption of subgingival biofilm in periodontal pockets
• Studies support its use as an adjunct to mechanical debridement

Posttreatment Precautions

• Patients with sodium-restricted diets (hypertension, renal disease): sodium bicarbonate powder is contraindicated
• Caution with patients who have respiratory conditions
• Patients with composite restorations: sodium bicarbonate can roughen composite surfaces

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PART 2: PERIODONTAL ANATOMY AND TISSUES

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2.1 NORMAL GINGIVA - CLINICAL CHARACTERISTICS

Examiner Keyword: "Stippling" = normal orange-peel texture of the attached gingiva; produced by connective tissue fiber bundles; loss of stippling is an early sign of gingival inflammation.

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2.2 GINGIVAL ANATOMY - COMPONENTS

FLOWCHART: REGIONS OF THE GINGIVA

GINGIVA
    |
    |-----> FREE GINGIVA (MARGINAL GINGIVA)
    |           |
    |           |---> Free gingival margin (coronal-most edge)
    |           |---> Gingival sulcus (space between free gingiva and tooth)
    |           |---> Free gingival groove (demarcates free from attached gingiva)
    |
    |-----> ATTACHED GINGIVA
    |           |
    |           |---> Bound apically to mucogingival junction
    |           |---> Stippled surface
    |           |---> Width varies (1-9 mm; widest maxillary anteriors)
    |
    |-----> INTERDENTAL (INTERPROXIMAL) GINGIVA
                |
                |---> Col area (non-keratinized; prone to disease)
                |---> Buccal papilla
                |---> Lingual papilla

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2.3 GINGIVAL SULCUS AND JUNCTIONAL EPITHELIUM

• Gingival sulcus = the space between the free gingiva and the tooth surface; lined by sulcular epithelium (non-keratinized)
• Histologic depth of the sulcus: 0-2 mm (average 1.8 mm) in health
• Clinical (probing) depth: distance from free gingival margin to the base of the pocket as measured by a probe; may differ from histologic depth
• Junctional epithelium (JE): the epithelium at the base of the sulcus that attaches to the tooth surface; forms the epithelial attachment
• The junctional epithelium attaches to the cementum on erupted teeth

Examiner Note: "Probing depth" is more accurate than "sulcus depth" for the clinician because "sulcus depth" is a histologic description only.

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2.4 GINGIVAL CREVICULAR FLUID (GCF)

• Gingival crevicular fluid (GCF) = a serum-like fluid that flows from the connective tissue through the epithelium and into the gingival sulcus
• Increases with: inflammation; mechanical stimulation; hormone levels (puberty, pregnancy); mastication of hard foods
• Composition: plasma proteins, electrolytes, metabolic byproducts, inflammatory mediators
• Clinical significance: GCF flow increases with inflammation; its measurement has been proposed as a method to assess periodontal disease activity

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2.5 PERIODONTAL LIGAMENT (PDL)

PDL Fiber Groups (Principal Fibers)

Examiner Note: The oblique fiber group is the most numerous and is the major load-bearing group; transfers occlusal stresses to bone.

Physiologic Mesial Migration (Drift)

• Definition: Normal tooth movement; probably the result of wear of proximal and occlusal tooth surfaces
• Movement is gradual, totaling no more than 1 cm during a lifetime
• Occurs in conjunction with gradual remodeling of alveolar bone:
  • Bone resorption (osteoclastic activity) increased along mesial surfaces (pressure areas)
  • New bone deposited (osteoblastic activity) along distal surfaces (tension areas)

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2.6 CEMENTUM

• Cementum is a calcified structure formed by cementoblasts; once encased, cementoblasts are called cementocytes
• Thickness: 20-50 µm near the CEJ; 50-200 µm at the apex
• Functions: Anchors the teeth; maintains occlusal relationships; provides a seal for dentinal tubules
• Contains extrinsic fibers = Sharpey's fibers = embedded portions of PDL fiber bundles that attach to the roots of the teeth
• No vascular or nerve connections in cementum; therefore, cementum cannot transmit pain sensations (not sensitive to scaling procedures)

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2.7 ALVEOLAR BONE

• Alveolar process = the portion of the jaw bone that supports the teeth
• Alveolar bone proper = the thin plate of bone lining the tooth socket; also called the lamina dura on radiographs
• Supporting alveolar bone = trabecular (cancellous) bone surrounding the alveolar bone proper

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PART 3: DENTAL PLAQUE BIOFILM

3.1 DEFINITION AND IMPORTANCE

• Dental plaque is now referred to as dental plaque biofilm - the preferred contemporary term
• A biofilm is a structured community of microorganisms enclosed in a self-produced polymeric matrix, adherent to an inert or living surface

Recent Terminology Change: "Dental plaque" is now more precisely called "dental plaque biofilm" to reflect its community structure and properties.

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3.2 SUPRAGINGIVAL PLAQUE BIOFILM FORMATION

Inhibitors of Supragingival Plaque Biofilm

• Salivary components coat bacterial surfaces and inhibit binding
• Self-cleansing mechanisms of swallowing and salivary flow help wash bacteria away from teeth

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3.3 SUBGINGIVAL PLAQUE BIOFILM

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3.4 THEORIES OF DENTAL PLAQUE BIOFILM (KEY EXAMINATION TOPIC)

Examiner Note: The current prevailing theory is the Specific Plaque Hypothesis - recognizing that specific microorganisms (a limited number) are responsible for periodontal disease and that quantity of plaque alone does not determine pathogenicity.

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3.5 MICROBIAL CHANGES IN GINGIVITIS (LÖE'S EXPERIMENTAL GINGIVITIS MODEL)

• Löe's experimental gingivitis model: dental plaque was allowed to accumulate along the gingival margin for 10 to 21 days
• All subjects went from healthy state to localized inflammation characterized by red, edematous tissue
• Microbial succession in gingivitis:
  • Initial: gram-positive cocci and rods, gram-negative cocci
  • After accumulation: substantial increase in filamentous bacteria such as Actinomyces
  • Further succession toward: gram-negative anaerobes

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PART 4: CALCULUS

4.1 DEFINITION AND COMPOSITION

• Dental calculus = mineralized (calcified) dental plaque biofilm
• Composed primarily of calcium phosphate crystals deposited in an organic matrix
• NOT a primary cause of periodontal disease; calculus is significant because its rough, porous surface provides an ideal environment for living plaque biofilm to adhere

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4.2 TYPES OF CALCULUS

Examiner Keywords: Supragingival calculus mineral source = saliva. Subgingival calculus mineral source = gingival crevicular fluid (serum). Subgingival calculus = also called "serumal calculus."

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4.3 CALCULUS FORMATION RATE

• Plaque shows evidence of mineral precipitation in 1 to 14 days (can occur as quickly as within 4 hours)
• Calcifying plaques may become:
  • Up to 50% mineralized in 2 days
  • 60% to 90% mineralized in 12 days

Factors Associated with Increased Calculus Formation Rate (Mandel)

1. Elevated salivary pH
2. Concentration of calcium in saliva
3. Concentration of salivary bacterial protein and lipid
4. Lower individual inhibitory factors
5. Higher salivary urea and protein from the submandibular glands
6. Higher total salivary lipid levels

• Light calculus formers have higher levels of parotid pyrophosphate (similar to the chemical found in tartar control toothpastes)
• Heavy calculus formers: smokers and betel nut chewers had more calculus than nonsmokers

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4.4 CALCULUS AND PERIODONTAL DISEASE - LONGITUDINAL DATA

TABLE 5-1: Calculus Formation in Adult Male Populations (Anerud, Löe, and Boysen)

Examiner Note: The Sri Lankan/Norwegian data emphasized the importance of calculus removal and maintenance therapy for long-term gingival health.

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PART 5: CLASSIFICATION OF PERIODONTAL DISEASES

5.1 1999 CLASSIFICATION SYSTEM (AAP/EFP)

I. Gingival Diseases

• A. Dental plaque-induced gingival diseases
• B. Non-plaque-induced gingival lesions

II. Chronic Periodontitis

• Localized (< 30% of sites affected)
• Generalized (≥ 30% of sites affected)

III. Aggressive Periodontitis

• Localized
• Generalized

IV. Periodontitis as a Manifestation of Systemic Diseases

• Associated with hematological disorders
• Associated with genetic disorders

V. Necrotizing Periodontal Diseases

• Necrotizing Ulcerative Gingivitis (NUG)
• Necrotizing Ulcerative Periodontitis (NUP)

VI. Abscesses of the Periodontium

• A. Gingival abscess
• B. Periodontal abscess
• C. Pericoronal abscess

VII. Periodontitis Associated with Endodontic Lesions

• Combined periodontal-endodontic lesions

VIII. Developmental or Acquired Deformities and Conditions

• A. Localized tooth-related factors that modify or predispose to plaque-induced diseases:
  1. Tooth anatomic factors
  2. Dental restorations or appliances
  3. Root fractures
  4. Cervical root resorption and cemental tears
• B. Mucogingival deformities and conditions around teeth:
  1. Gingival or soft tissue recession (facial/lingual; interproximal)
  2. Lack of keratinized gingiva
  3. Decreased vestibular depth
  4. Aberrant frenum/muscle position
  5. Gingival excess (pseudopocket; inconsistent gingival margin; excessive gingival display; gingival enlargement)
  6. Abnormal color
• C. Mucogingival deformities on edentulous ridges
• D. Occlusal trauma:
  1. Primary occlusal trauma
  2. Secondary occlusal trauma

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5.2 CHRONIC PERIODONTITIS - DETAILED

• Most common form of periodontal disease
• When clinicians say "periodontitis" or "periodontal disease," they are typically referring to chronic periodontitis
• Preclinical onset: may occur in adolescence
• Unless halted by therapy, appears to progress for the life of the individual
• Characterized by bone resorption that progresses slowly and predominantly in a horizontal direction
• Not usually significant clinically until about age 35 years
• NOT associated with systemic disease or abnormalities in host defense
• Progression occurs in episodic bursts of activity causing attachment loss
• Disease activity halts when host resistance controls the process through therapy or natural defenses

Severity Classification (Chronic Periodontitis)

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5.3 AGGRESSIVE PERIODONTITIS

• Distinguished from chronic periodontitis by: rapid rate of progression, familial aggregation, absence of large amounts of calculus relative to the severity of destruction
• Patients are otherwise systemically healthy

Localized Aggressive Periodontitis (LAgP)

• Onset: around puberty
• Localized to: first molars and incisors
• Key pathogen: Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans)

Generalized Aggressive Periodontitis (GAgP)

• Usually affects persons under 30 years of age
• Generalized interproximal attachment loss affecting at least three teeth other than first molars and incisors

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5.4 NECROTIZING PERIODONTAL DISEASES

Necrotizing Ulcerative Gingivitis (NUG)

• Also known as: "Vincent's disease" or "trench mouth"
• Historical term: "Vincent's angina" (because of the two microorganisms found: fusiform bacillus and spirochete = "Vincent's organisms")

Clinical Features of NUG (Cardinal Signs)

Microbiology

• Two organisms consistently present: fusiform bacillus and spirochete
• Authorities believe spirochetes may play an important role in the infection, but direct causative effect has NOT been proven

Treatment of NUG

• Debride plaque completely from tissues
• Begin home regimen of excellent plaque control
• Although gingival tissues are tender: careful scaling with curettes or ultrasonic scalers over two or more appointments
• Postoperative rinsing with dilute solution of hydrogen peroxide and warm water
• Antibiotics (penicillin, metronidazole): only if systemic symptoms (fever, severe malaise)
• Repeated bouts of NUG may cause permanent gingival deformation and higher risk for periodontal disease

FLOWCHART: NUG → NUP PROGRESSION

NUG (Necrotizing Ulcerative Gingivitis)
        |
        v
Extension of gingival infection into deeper tissues
        |
        v
NUP (Necrotizing Ulcerative Periodontitis)
        |
        v
BONE LOSS + ATTACHMENT LOSS
(The relationship between NUG and NUP is not clear;
may be consequence of extension OR a separate entity)

NOTE: NUG and NUP are grouped under the
single category of NECROTIZING PERIODONTAL DISEASES

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5.5 GINGIVAL DISEASES OF VIRAL ORIGIN

• May resemble plaque-induced gingivitis
• Primary herpetic infection (herpesvirus infection):
  • Highly contagious
  • Very common
  • Can be transmitted to the dental hygienist
  • Secondary forms (cold sores, fever blisters): also highly contagious; do not resemble gingivitis

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PART 6: EPIDEMIOLOGY AND RISK FACTORS

6.1 EPIDEMIOLOGY OF PERIODONTAL DISEASE

• 10% or more of the population has periodontal disease; proportion increases with age
• American Academy of Periodontology position: 5-20% of the U.S. population has periodontal disease; much higher percentage having slight or moderate disease
• Recent NHANES analysis using different criteria: 47.2% of adults aged 30 or more had periodontitis
• 1987 survey of employed persons: edentulism is decreasing; gingival bleeding is very common; calculus is present in most adults and almost all seniors

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6.2 RISK FACTORS FOR PERIODONTAL DISEASE

Tobacco (Smoking)

• Smokers have a higher prevalence of periodontal pathogenic species in plaque
• Smoking suppresses the vascular reaction, resulting in masking of the signs of gingival inflammation
• Smoking suppresses bleeding in periodontal disease
• Smoking may reduce granulocyte function, contributing to the decreased inflammatory signs noted in smokers
• Localized gingival recession: commonly seen in oral areas where smokeless tobacco is held

Examiner Keyword: Smoking masks signs of inflammation - reduced bleeding on probing does NOT indicate health in smokers.

Systemic Disease

Genetic Factors

• Rare periodontal diseases in systemic conditions with genetic etiology:
  • Papillon-Lefèvre syndrome
  • Chédiak-Higashi syndrome
  • Leukocyte adhesion deficiency
• Twin studies suggest susceptibility to chronic periodontitis may also be genetically linked
• No specific genes identified for chronic periodontitis

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PART 7: PHARMACOLOGICAL MANAGEMENT IN PERIODONTAL DISEASE

7.1 SYSTEMIC ANTIBIOTICS

Examiner Note: Tetracyclines are uniquely beneficial in periodontal treatment because they are: (1) concentrated in GCF, (2) effective against A. actinomycetemcomitans, and (3) inhibit collagenase activity (not only antimicrobial but also anti-collagenase effect).

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7.2 LOCAL DRUG DELIVERY

• Rationale: Apply antibiotic directly to the site of infection within the pocket
• Types of locally delivered antimicrobials:
  • Tetracycline fiber (Actisite): placed directly into pocket
  • Minocycline microspheres (Arestin): placed in periodontal pocket
  • Doxycycline gel (Atridox): injectable gel placed in pocket
  • Chlorhexidine chip (PerioChip): placed in pocket

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PART 8: INSTRUMENT SHARPENING

8.1 PRINCIPLES OF SHARPENING

• Sharp instruments are essential for:
  • Effective calculus removal
  • Tactile sensitivity
  • Reduced clinician fatigue
  • Reduced number of strokes needed
  • Reduced patient discomfort
• Dull instrument signs: instrument face appears shiny (light reflects as a line from the cutting edge); slips over calculus without engaging it

Test for Sharpness

• Acrylic test stick: a sharp instrument will grab into the acrylic test stick without slipping; a dull instrument will reflect light (shiny edge) and slide over the test stick

Examiner Keyword: "Light reflection test" = a dull instrument edge reflects a line of light along the cutting edge when held under a light source; a sharp edge does not reflect light.

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8.2 SHARPENING TECHNIQUES

Sharpening a Curet

• Angle between stone face and instrument face: 100 to 110 degrees (to maintain the internal angle of the blade at 70-80 degrees)
• Stone is positioned at the lower third of the blade
• Work from heel to toe in overlapping strokes

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PART 9: PAIN CONTROL DURING PERIODONTAL INSTRUMENTATION

9.1 STRATEGIES FOR PAIN CONTROL

FLOWCHART: PAIN CONTROL STRATEGIES

STRATEGIES TO ALLAY FEAR OF PAIN DURING PERIODONTAL INSTRUMENTATION
                    |
        ____________|____________
        |                       |
NON-PHARMACOLOGIC          PHARMACOLOGIC
        |                       |
- Patient communication     Local anesthesia
- Building rapport          - Infiltration
- Distraction               - Nerve blocks
- Nitrous oxide             Topical anesthesia
                            - Applied before probing
                            - Applied before instrumentation

Local Anesthesia Indications for Periodontal Instrumentation

• Deep periodontal pockets (> 4-5 mm)
• Heavy, tenacious subgingival calculus
• Hyperreactive/sensitive patients
• Patients with a low pain threshold

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PART 10: ADVANCED TOPICS

10.1 FURCATION INVOLVEMENT - ASSESSMENT AND INSTRUMENTATION

Furcation Definitions

• Furcation = the anatomical area of a multirooted tooth where the roots diverge from the root trunk
• Furcation involvement = the extension of periodontal disease into the furcation area

Furcation Classification (Hamp, Nyman, Lindhe)

Instruments for Furcation Examination

• Nabers probe (furcation probe): curved instrument designed specifically for assessing furcation involvement
• Pig-tail (cowhorn) explorer: for detection of furcation in posterior teeth

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10.2 ROOT ANATOMY AND INSTRUMENTATION CHALLENGES

• Root concavities: depressions on root surfaces that are most difficult areas to instrument
• Root trunk: the portion of the root between the CEJ and the furcation entrance
• Root branches: the individual roots of a multirooted tooth apical to the furcation

Root Surface Features Relevant to Instrumentation

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10.3 ABSCESSES OF THE PERIODONTIUM

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PART 11: DENTAL HYGIENE PROFESSION AND PERIODONTAL THERAPY

11.1 HISTORICAL PERSPECTIVES (Key Examiner Context)

• Alfred C. Fones: The "father of dental hygiene"; taught his dental assistant cousin Irene Newman in 1906 to clean and treat patients
• His customized educational program was presented publicly at the National Dental Association Meeting in Cleveland in July 1911
• First dental hygiene school: established by Fones in Bridgeport, Connecticut, 1913
• Colleges and universities began to train dental hygienists in 1916
• Newman's first patients were children; she initially only polished teeth; later began to scale teeth but was only permitted to remove gross deposits
• Robin Adair of Atlanta: presented "The Introduction of Oral Prophylaxis into Dental Practice" to the Florida State Dental Society in June 1911; opened the fourth dental hygiene program in 1917 in Atlanta
• Dental hygiene began as a profession in 1913

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11.2 PROFESSIONAL ROLES OF THE DENTAL HYGIENIST (ADHA)

• Clinician
• Educator
• Researcher
• Administrator/Manager
• Advocate
• Public health practitioner

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SUMMARY TABLE: HIGH-YIELD EXAMINATION POINTS

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EXAMINER NOTE ON RECENT TERMINOLOGY:

1. "Dental plaque" → now called "dental plaque biofilm"
2. "Sulcus depth" → clinical measurement correctly called "probing depth" (sulcus depth is histologic)
3. "Root planing" and "scaling" are now often grouped as "periodontal debridement" or "non-surgical periodontal therapy (NSPT)"
4. "Localized juvenile periodontitis (LJP)" → now "Localized Aggressive Periodontitis (LAgP)"
5. "Generalized early-onset periodontitis" → now "Generalized Aggressive Periodontitis (GAgP)"

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• Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation, 8th Edition (Gehrig, Sroda, Saccuzzo)
• Periodontology for the Dental Hygienist, 4th Edition (Perry, Beemsterboer, Essex)

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INSTRUMENT GRASP - COMPLETE NOTES FROM SOURCE

Source Confirmation (Direct Textbook Statement)

"The modified pen grasp — as shown in Figure 3-1 — is the recommended method for holding a periodontal instrument." (Module 3, Section 1, p. 72)

"Module 3 introduces the modified pen grasp for holding a periodontal instrument. The correct instrument grasp — called the modified pen grasp — allows precise control of the working-end of a periodontal instrument, permits a wide range of movement, and facilitates good tactile conduction." (Module Overview, p. 69)

• Modified pen grasp

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Why Only Modified Pen Grasp Is Covered

"Note the finger placement for a modified pen grasp differs from that used when writing [standard pen grasp]." (Table 3-2, Fine-Tuning Your Grasp, p. 75)

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COMPLETE MODIFIED PEN GRASP - ALL DETAILS FROM SOURCE

Table 3-1 / Table 3-2: Correct Finger Placement and Function

Handle resting zone: The instrument handle rests against the hand anywhere between the second and third knuckles. (This is the handle resting zone.)

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Characteristics of Correct Modified Pen Grasp (Summarized from Source)

1. Modified pen grasp facilitates:
   • Precise control of the instrument as it moves over the tooth
   • Detection of rough areas on the tooth surface (tactile sensitivity)
   • Lessened musculoskeletal stress to the clinician's fingers
2. Thumb and index finger placement rules (verbatim from source):
   • Finger pads rest opposite each other at or near the junction of the handle and shank
   • The fingers do NOT overlap; there is a tiny space between them
   • The fingers hold the handle in a relaxed manner - "If your fingers are blanched, you are holding too tightly"
3. Middle finger rule (verbatim from source):
   • "Not used to hold the instrument. You should be able to lift your middle finger off the shank without dropping the instrument. If you drop the instrument, then you are incorrectly using the middle finger to help hold the instrument."
4. Ring finger rule (verbatim from source):
   • "The ring finger of the dominant hand advances ahead of the other fingers in the grasp. It is held upright and rigid to act as a strong support beam for the hand. The finger should not feel tense, but it should not be held limply against a tooth."

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Section 2: Grasp Variations (Impact of Finger Length on Grasp)

• A clinician's finger length determines the location where he or she grasps the instrument handle and stabilizes the hand in the mouth
• Clinicians with shorter fingers: knuckles in a more curved (knuckles up) position; grasp the instrument higher on the handle
• Clinicians with longer fingers: knuckles in a flatter (knuckles flat) position; grasp the instrument nearer to the junction of the handle and the shank

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Glove Fit and Its Effect on Grasp

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Fingernail Length and Grasp

• Fingernails extending any length beyond the fingertips result in decreased pinch grip strength
• Nails 1 or 2 cm in length result in decreased ability to manipulate the fingers and limited flexion of metacarpophalangeal joints
• Long fingernails interfere with: (1) correct grasp, (2) finger rest technique, (3) stabilization of the hand, and (4) patient comfort (may pinch soft tissues)

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CONCLUSION - DIRECT ANSWER TO YOUR QUESTION