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Instrumentation and Scaling Teeth
Sandy Gregory
M.Ed., RVT, VTS (Physical Rehab), CCRA

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Common Service
Most common services in a veterinary small animal practice are:
-Dental prophylaxis
-Periodontal treatments
-Tooth extractions
Oral surgery by the veterinarians

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Veterinary Technicians do most of these

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Properly Equip Your Dental Room
-The key to providing top quality oral care is to have the proper instruments and the skills to use them properly

-Without the proper equipment, the care is compromised

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AAHA Dental CareGuidelines
- “One size fits all” approach to dental equipment is inadequate
- Have various sizes of instruments and insets for mechanical scalers
- Must be working properly, need to be sharpened and repaired accordingly

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-All dental equipment MUST be autoclaved/sterilized
-Single use equipment must be discarded after each patient
-Instruments and equipment require routine maintenance and care

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Protect Yourself
-All kinds of bacteria, calculus, and fragments can be aerosolized
-Recommended to irrigate first with a 0.12% chlorhexidine solution to help minimize the bacterial aerosolization

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Personal Protective Equipment
- Protective clothing consists of gown (protective clothing), gloves, mask +/- face
shield, and cap/bonnet
- When dental radiographs are taken, make sure to wear appropriate PPE

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AAHA Recommendation
Instruments to Include in the Dental Surgical Pack
- Scalers
- Curettes
- Probe/explorer
- Sharpening materials
- Scalpel
- Extraction equipment ( e.g., periosteal elevators, luxating elevators, periodontal elevators, extraction forceps, root tip picks, root tip forceps)
- Thumb forceps
- Hemostats
- Iris, LaGrange, Mayo, or Metzenbaum scissors
- Needle holders
- Mouth mirror
- Retraction aid (e.g., University of Minnesota reactors)

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Dental Cleaning
- Performed on a patient with calculus and plaque on some of the teeth but otherwise is
healthy
- The idea is to prevent periodontal disease
- Must be performed by a licensed veterinarian, veterinary technician or a
trained assistant under supervision of the veterinarian

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Now What?
1. Perform an oral exam
2. Full mouth radiographs
(One study suggests that the radiographs showed important pathology in 27.8% dogs and 41.7% in cats when no abnormal findings showed on the initial exam) AND
(In abnormal findings, radiographs showed additional pathology in 50% of dogs and 53.9% of cats)!!!

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Next
3. Scale the teeth supragingivally and subgingivally
4. Polish the teeth
5. Irrigate subgingival
6. Apply sealants
7. Home care

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Make yourself comfortable
Let’s begin

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Hand Instruments
- Handle – grasping, part that you hold on to
- Working End- in contact with the tooth and has a heel middle and a toe
- Shank – in the middle of the handle and the working end

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What They Do
- Shank – allows adaptation of the working end to the tooth surface
- Shank – will help to conform to the area of use in the mouth
- Thick shank – stability to remove heavy calculus

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Keep Them Sharpened
- Sharpened instruments will make it easier to remove calculus
- Doesn’t slow you down
- More efficient
- Less Work for YOU

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Modified Pen Grip
- Reduces fatigue
- Allows fine motion
- Stabilizes hand onto a firm surface
- Pinkie rests on the ring finger
- Ring finger is a fulcrum
- Fingers are in a “C”

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Use 3 Fingers In A Tripod
Thumb and index finger provide rotation

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Periodontal Probes
- Evaluates gingival health
- Can check the subgingival pockets for abnormal pocket depth
- Depending on the health, there might be a little gingival bleeding and this is acceptable

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Motion
- Walk the probe around the entire tooth (ALL SURFACES)
- Probe should remain in contact with the tooth
- Keep it parallel to the tooth

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Measure Up
- Scored by bands or measurement markers
- Chart abnormal depths, attachment levels, hyperplastic gingiva, size of oral lesions and loss of bone in areas of furcation

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Gingival hyperplasia is a growth of excess gingival tissue and is measured in mm at the top of the gingival margin to the sulcus

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Normal
Pocket depth for a dog 0-3 mm
Pocket depth for a cat 0-1 mm

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Numbers Greater Than
Make sure to chart because they are a sign of dental disease

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Periodontal Probes

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Measure Recession

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Shepherd’s Hook
- Usually at the other end of the probe
- Also called an Explorer
1. Detects irregularities such as fractures
2. Caries (cavities)
3. Lesions

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4. Mobility
5. Calculus deposits
6. Enamel defects

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Shepherd’s Hook/Explorer

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Shepherd’s Hook/Explorer

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Scalers
- Use supragingival only
- Curved or straight
- Triangle in a cross section
- Has 2 cutting edges that converge to form a sharp point
- Useful for the developmental grooves in teeth (especially canine in Felines)

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Motion
- Use short coronal pull strokes
- Removes debris SUPRAGINGIVALLY
- Useful for finishing touches after the ultrasonic cleaning
- ALWAYS go away from the gingiva (coronally)

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Scalers

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Curette
- Can be used SUPRA and SUB GINGIVAL
- Rounded edge to protect the epithelium
- Useful in removing the subgingival plaque and calculus
- Smooth rounded heal opposite the cutting edge

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- Less trauma to soft tissue
- Loose free flowing plaque in the periodontal pockets causes more disease than adhering plaque
- Used for root planing

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Motion
- Modified open grip, parallel to the tooth surface
- Working end goes into the sulcus (Direct the curette into the pocket with the blade parallel to the root surface)

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-If calculus is deep in the pocket, the curette may damage the periodontal
attachment
- Pull the instrument
- Repeat in overlapping strokes coronolly

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Motion Of Curette
Alexander Reiter, John Lewis and Colin Harvey

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Curette

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Say NO To Mouth Gags

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Cause Of Blindness
- Possibly anesthesia agents
- Hypoxia
- Latest loaded mouth gags

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Studies
Cerebral Ischemia
Study 2012 showed a possible connection
- 16 out of 20 had used mouth gags,
- 14 recovery of vision and 4 cats remained blind

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Even More
- Study 2014 – looked at functional and structural changes related to artery flow in the maxilla for cats
- Looked at CT – the maxillary artery runs along the angular process of the mandible and along the tympanic bulla. The distance was less between these when the mouth was open

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One More
- Veterinarians are finding more TMJ issues with dogs and cats
- Mouth gags can intensify that discomfort
- Use dental mirrors
- Curling rods

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Anesthesia Free Scaling
- Dental scaling is only achieved through proper ultrasonic scaling and hand instrumentation with sharpened working edges
- On an awake patient, even the slightest of movement can cause tissue damage from the instruments

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Get Real
- The patient will not hold still
- The veterinary professional can get bit
- You can not get to all the surfaces of the teeth especially the premolars
and molars

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50% of the tooth surface is below the gum line and realistically no one can get to that unless they are anesthetized

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More Reasons
- Access to the subgingival surface is impossible on an awake patient.
- If about 50% of the tooth is below the gum line, and you can’t use instruments subgingival, how do you care for it?
- You wont be able to take radiographs

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And More
- You can’t prevent aspiration like you can with a cuffed endotracheal tube
- Intravenous catheters help with administration of pain medication

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Ultrasonic Scaling
- Removes the least amount of cementum
- Provides water lavage that flushes out debris from the pockets
- Irrigates tissue to improve cleanign and wound healing (Bactericidal)
- There are no cutting edges so reduces possible lacerations like a curette might

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Ultrasonic Scaling
- Reduces fatigue on your hands
- Decreases iatrogenic attachment injury
- No need to sharpen
- Do need to monitor the tips for wear

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Tips
Tips WILL wear down
1 mm loss can result in 25 % less efficiency
2 mm loss can result in 50 % less efficiency

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Measure Up
- Tips extends beyond blue line
Optimum Efficiency (Scale Away)
- Tips touches blue line
25 % Efficiency loss (Recorder)
- Tips touches red line
50 % Efficiency loss (Discard)

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Scaling
- Need to see a generous cloud/mist of water coming from the tip
- Heat is generated – water cools the tip
- Once you have the proper mist, touch it to the tooth and start

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Motion
- Use a finger rest to brace your hand
- Use feather like strokes back and forth across the tooth
- Spend about 10 seconds per tooth at a time (time varies depending on machine)
- Use the sides of the tip !!!! ONLY
- Vibration “shatters” the calculus

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#1 point
#2 concave front surfaces
#3 convex back surfaces
#4 lateral surfaces
#4 lateral surfaces

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Types
- Ultrasonic scalers convert sound waves into mechanical vibration
a. Magnetostrictive :tip vibrates in an elliptical motion
18,000-29,000 cycles per second

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b. Piezoelectric : tip vibrates linearly
Converts alternating currents into 40,000 cycles per second through a crystal in the hand piece

c. Ferromagnetostrictive - tip is circular
Operates at 42 kHz frequency. Even with water flow, it is easy to heat the tooth up so be careful

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Converts Air Into Mechanical Vibration
- Sonic – tip vibrates in an elliptical motion Up to 18,000 cycles per second
- Rotary – rotoburs are inserted into the high speed hand piece - 6 sided burrs used
Spin at 3000,000-4000,000 rpm

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Ultrasonic

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Epulus

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Polishing
- Uses small prophy cups with “gobs” of paste
- Keep it moving – ALL surfaces
- Will smooth out the micro etching that has occurred
- Decreases the sensitivity
- Rinse off all the polish, debris, fragments and blood
- Treat teeth to seal the treatment

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Polishing

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Polishing

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Maintenance
- Know your manual
- Oil level of compressors need to be checked weekly or depending on the amount of use
- Prophy heads that are not self lubricating, need to be checked weekly
- Water levels should be drained daily to prevent bacterial build up

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- Clean biofilm from water lines and tubing
- Filtration units are available to treat the dental water
- Properly store equipment
*****Sharpen instruments before sterilizing******

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Tech Tips
- Take the collar off
- Cover the eyes with a towel
- Folded towel underneath the head to absorb water
- Change the towel under the head when changing sides
- Wipe off the face and comb out the hair
- Be careful of the senior dogs and cats

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Brushing At Home Is Still #1