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Implementation: debridement basics

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Margit Strobl

on 22 November 2016

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Transcript of Implementation: debridement basics

Implementation: deposit removal
1. Differentiate between scaling, root planing, and debridement and discuss the concept of non-surgical periodontal therapy..

7. Explain the rationale for a systematic approach to debridement.

5. Differentiate between the strokes used for assessment and working.
8. Explain and demonstrate the most logical order of instrumentation for effective time management and motion economy in the clinical setting.

Scaling/root planing
Scaling - removal of deposits from crown and/or root surfaces
Root Planing – instrumentation of periodontally involved teeth to remove rough or contaminated( with harmful bacterial products) cementum

Periodontal debridement – the removal of bacterial plaque biofilms and calculus deposits from crown and/or root surfaces and from within pocket space.
Includes instrumentation of root surfaces to remove calculus and biofilm but not aggressive removal of cementum
Goal is conservation of cementum

Scaling/root planing vs debridement
The term debridement first appeared in 1994 in Irene Woodall's text "Comprehensive Dental Hygiene Care"
Increased scientific knowledge about periodontal disease has inspired changes in the terminology associated with calculus and biofilm removal during instrumentation
Conservation of cementum is now the goal of periodontal debridement vs aggressive removal of cementum to remove toxins and achieve glassy smooth roots during root planing
Scaling and root planing are now outdated terms

Developing a systematic approach is similar to that dental hygiene students practicing sequencing during when learning instrumentation. Sequencing will:
Increase efficiency and time management
Minimize the likelihood of missed areas of deposits
Reduce the risk of interrupting the healing process
Systematic approach to debridement
Effects of partial treatment
Incomplete debridement in an area could result in the interruption of the healing process
Could also create a periodontal abscess

Paradigm has shifted to non-surgical treatment of periodontal disease instead of scaling and root planing – this is intended to address pathogenic bacteria, the pocket space, the pocket wall, underlying tissues, and the patient's immune response. In other words, debridement therapy deals with the control of a bacterial infection

Purposes of non surgical periodontal therapy are to:
Eliminate/suppress infectious microorganisms
Eliminate/control infection to prevent reinfection
Establish an environment that helps resolve inflammation
Modify host and environmental risk factors for perio disease
Employ antimicrobial agents when indicated

According to Darby/Walsh...
Goals of periodontal debridement are:
Arresting the process of perio disease by removing bacterial plaque biofilms and calculus deposits
Creating an environment that assists in maintaining tissue health or permits the gingival tissue to heal, therefore eliminating inflammation
Increasing the effectiveness of patient self-care by eliminating areas of biofilm retention that are difficult or impossible for a patient to clean
And according to Gehrig...
And finally, the Journal of Periodontology
“The goals of periodontal therapy are to alter or eliminate the microbial etiology and contributing risk factors for periodontitis, thereby arresting the progression of disease and preserving the dentition in a state of health, comfort, and function with appropriate esthetics; and to prevent the recurrence of periodontitis.”
Journal of Periodontology May 2000 supplement
Patients who are not periodontally involved will generally require debridement on the crowns of the teeth only
Treatment becomes more comprehensive if the patient is periodontally involved

Requires highly developed instrumentation skills because you are working with patients who are periodontally involved
Debridement is part of the overall comprehensive treatment for a client
Involves the removal & disruption of all bacterial plaque, endotoxins, plaque retentive deposits
Root morphology is an important consideration; emphasis must be on least amount of root removal &/or damage to the root
Instrument selection is left to the clinician & based on what the client presents with relative to deposits and tissue health

Overview of Debridement
Differentiating between the different strokes
Assessment strokes:
Used to evaluate the tooth surface
Used with explorers to locate calculus deposits
Characteristics of an assessment stroke:
Flowing, feather-light stroke of moderate length
Contacts the tooth, but no pressure is applied against the tooth surface for this stroke

Working strokes:
Used to lift calculus deposits off of the tooth
Used with curets, sickle scalers, and periodontal files
Characteristics of a working stroke:
Brief, tiny, biting stroke used to snap a calculus deposit from tooth
Moderate pressure is applied against the tooth during this brief stroke
Root debridement stroke
Used to remove residual calculus deposits, bacterial plaque and byproducts from (1) root surfaces that are exposed in the mouth due to gingival recession and (2) root surfaces within deep periodontal pockets
Characteristics of a root debridement stroke:
Lighter, shaving stroke of moderate length
Used with curets
Light pressure is applied against the tooth surface during this stroke

Logical order of instrumentation
Order of instrumentation can be looked at in two ways:
Order of debridement
Scaling to completion should be done first
Root planing follows
Debridement appointments
If more than one appointment is needed then debridement can be completed in sextants, quadrants or 2 quadrants of the same side

Debridement basics
Class activities
group discussion to add further information and clarify content
discussion of approach to debridement
Darby M, Walsh M. Dental Hygiene Theory and Practice.4th Ed. St Louis, Missouri: Saunders; 2015
Nield-Gehrig, Fundamentals of Periodontal Instrumentation. 7th Ed. Philadelphia PA: Lippincott Williams & Wilkins; 2013.
Barkerville, a gold rush town in the Cariboo region ( close to Quesnel)
6. Discuss the concept of lateral pressure.
4. Briefly discuss the concept of tactile sense and its importance in subgingival instrumentation.
3. Explain the process for inserting an instrument subgingivally in preparation for deposit removal.
What is the difference between scaling and root planing and debridement?
2. Relate a general overview of debridement.
Inserting an instrument subgingivally
To date in the clinic the focus has been on grasp, fulcrum, angulation, adaption, and activation.

We are just now encouraging students to go subgingivally with explorers. What do you do when you want to take a working instrument subgingivally? It is bigger and bulkier so there is a certain way in which this is done.

The process is as follows:
select the appropriate instrument
select the correct working end for the area to be instrumented
close the face between 0 and 40 degrees to the tooth surface (usually closer to 0)
gently slide the working end into the sulcus/pocket to prevent injury to the tissue
open the face to 60-80 degrees in preparation for assessment strokes
activate the cutting edge for removal of deposit

Tactile sensitivity
Definition: the ability to distinguish between roughness and smoothness on a tooth surface typically with an explorer or probe
It is just as important to be able to determine light calculus on an almost completely debrided tooth as it is to detect heavy calculus that has been burnished. These are prerequisites for developing tactile sensitivity
As the instrument glides over the tooth, differences such as calculus, restorations, and caries will create a vibration that travels through the shank and is felt in the fingertips
Calculus is not a cause of periodontal disease but because there is always a layer of plaque biofilm covering a calculus deposit, calculus plays a significant role in contributing to periodontal disease. Therefore, in order to control gingivitis and periodontitis, it is important that a dental hygienist develop good tactile sensitivity. This is particularly important for subgingival areas where the dental hygienist must depend on tactile sense to find the deposits
Lateral Pressure
Definition: the act of applying equal pressure with the index finger and thumb inward against the instrument handle to press the tip third of the cutting edge against a calculus deposit or tooth surface prior to and throughout an instrumentation stroke
The task and the instrument classification will determine how much lateral pressure is needed during instrumentation
Assessment- requires a feather light touch against the tooth surface
Calculus removal- requires firm lateral pressure against the tooth surface
Root debridement- requires less lateral pressure than a calculus removal stroke
More pressure applied against the handle, and by the fulcrum finger against the tooth, results in more pressure against the tooth surface or calculus deposit
Lateral pressure will range from light to firm; however heavy pressure is never recommended.

The amount of pressure also depends on the the tenacity of the deposit and will change as the deposit is removed. For example, the initial few strokes may be firmer but as the deposit breaks up, the lateral pressure becomes lighter
There are many ways in which to approach the debridement of any given area of the mouth. It requires some careful thought with consideration to ergonomics, economy of motion, minimizing the risk of forgetting areas and time available
The dental hygienist must also consider how much can realistically be completed in a limited amount of time. For example, if the dental hygienist had 40 minutes in which to debride, she/he would have to figure out how many teeth could be done in that time. Furthermore, consideration must be given to which areas should be completed first. The area with the most calculus or the most periodontally involved area?
Wilkins E. Clinical Practice of the Dental Hygienist. 12th Ed. Philadelphia: Wolter-Klower; 2017.
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