all right let's look at hand activation or hand activated and ultrasonic instrumentation when we say hand activated what we're referring to is manual instrumentation so using our instruments that you guys learned in pre-clinic ultrasonic instrumentation that refers to cabitron or piezo so when we instrument or when we debride rather our clients so the main reason why we're debriding our client is for periodontal health we want their health their oral health to um be good and be healthy and and you know not have any disease no gingivitis no perio so hand instrumentation or actually any type of instrumentation is very important what i must say is that when we are determining what type of instrumentation to use whether it be hand versus um ultrasonic it's important that um let's say someone has like lots of heavy calculus in there in their mouth you want to use a mix okay so what i want you guys to understand is that we should just use cabbage on and that and not follow up with the manual hand department we must use a mix we can use completely you know all hand debridement that's fine we can use all manual instrumentation but if we choose to use a cavitron or a piezo we must supplement that with hand instrumentation so let's look at our basic instrument design we have a handle the handle is what you're holding we have a shank the shank is the area in between the handle and the working end and we also have the working end which is right here so again we have the handle the handle is the air at the area or the part that you are holding the shank is the area from in between the handle and the working end and the working end this is from the terminal shank and i'll go over the different types of shaft but the terminal shank to the the working and to the very tip or to the very toe this working end the working end is basically defined as the area that comes into contact to the um toot or the area that comes into contact with the teeth okay so that is your working end now when we're looking at the shank there are two types of shank there's a functional shank actually this whole thing is a shank and then there's also a functional shank and a terminal shank or the lower shank and the way to differentiate the functional shank from the lower or terminal shank is that this shank the functional shank starts from the first bend to the very end of the working end or to the very end of the of where the working end starts and the lower shank or the terminal shank starts at the last bend or the last curve up to the working end okay so functional shank is the first bend which we see here is the first bend all the way to the working end the lower shank or terminal shank is the last bend up to the working end now when we look at the handle you can see there's very different types of material that the handle can be made from some of them are very small some of them are very large some of them have texture or knurling some of them don't some of them are solid so they feel heavy some of them are hollow where it feels lighter so hollow is better it feels lighter it's it's less strenuous on our hands we like to see texture for knurling like this because it doesn't slip off of our hand as we're deep writing we like seeing large grips so this is a larger grip is better than a thin small type of handle because [Music] it's more comfortable to hold and it also leads to less cramping if you use a small one you're more prone to cramping your hand to cramp that is so here's a question for you guys which of the following instrument designed is best used for accessing a deep area pocket on the proximal surface of a maxillary permanent first roller so we're using we're looking at the maxillary first molar we want to access the proximal surface with the measles and distals which one is the bacteria in the deep here your pocket the answer is a the more angles your shank is the more bendy your shank is the better because when you have an angled shank with a complex bend it is easier to access the deep area pockets on the posterior teeth whatever you opposed to your teeth so the more posterior you go the more angled and complex bend you want if it's more in the anterior then the small you just need like uh you don't need an angle you can have a straight shank with you know one or one bend with a single bend if it's for anterior teeth but if it's for posterior teeth you want an angled shank where the shank is tilted or angled and complex bends so let me show you what that looks like so remember this is our shank and the lower shank is from the last band to the very tip of the very beginning of the working end and um just something to keep in mind is that we have this is our regular size shank and sometimes and i'll show you later on you can get um a long shank where what do you think this would be good for why would someone want to have an instrument with a long shank yeah the long shank if you're thinking is to access the deep pockets pair your pockets you would be correct if you want to go deeper in the sulcus you would probably want a longer shank so that you're able to go in a lot more deeper so this is a short shank this could be considered a long shank this long shank is good for deep perio probing depths even recession sometimes long times are good um even if you sometimes if you want to fulcrum um in an area you want to you want to debra attitude and falcon further away from that area so if you have a long distance from your fulcrum to the area instrumented you would want a long shank this is what it looks like with a simple shank where it's just bent in one place whereas a complex shank this could be bent in like one or two places and so complex shanks are good for posterior teeth like this premolar here where a simple shank is good for anterior teeth that we see over here when we look at the working end and remember the definition of the working end is is basically from the terminal shank to the end of the instrument that comes into contact with the um tooth or with the tissue and so this is the base right here which is the innermost surface of this curette the back is let me show you the backdrop it's the opposite so the face isn't right here the back is on the opposite side and then this lateral surface these are the surfaces on either side of the base so this is there's one on this side and there's one also on the other side there's also a cutting edge the cutting edge is the sharp edge and the sharp edges where the lateral surface and the face meet then curette's toes at the end sickles have tips at the end we even have paired and unpaired instruments so look at this one this is unpaired because when you look at the working end it's very different right this is a second one this is another instrument another kind of intel probably a curette on this side so it's not the same this is paired with this instrument where this working end looks is the mirror image of the other working end so one side could be used on specific side of the mouth and the other side could be used on other sides of the of the client's mouth so it's just a mirror end of the working end which is considered paired unpaired is when you have two different instruments on each side now when you are classifying instruments you can classify them by assessment instrument which are these three over here we use a mirror we use a probe and we use explorer for assessment and then the other instruments are for treatment so this is what you're using for calculus removal scaling debriding root planing that's what all that is for so we can see here we have this is a file um this is a hole and we'll look at that basically to break down chunks of calculus then we have a sicko and we have a curette there are many different types of mirror there is the front surface mirror so it's like this which is um where the mirror reflection is on the front of a flat glass and it's like clear you see a clear reflection clear image there's no distortion it doesn't look you know magnified or it doesn't look like it's less not magnified so this is a front surface this the only disadvantage with this is that it does scratch easily this area can scratch easily the concave surface which is this one right here the mirror reflection is on front of a curved glass it's concave like it's like a curved glass and so when you're looking at the reflection it's magnified the teeth look bigger so it's a magnified image we also have the flat or the plain surface and this is where [Music] the mirror reflection is on the back of a flat glass and this one is actually pretty good because you don't really get any um scratching with this one so you do get scratching of the surface on the front surface but you don't really see scratching on the flat surface so mirrors are great because they have four different functions i'm going to show you those right here so we can see that this one the mirror is used to retract the buccal mucosa so retraction is one um thing that the mirror can do another thing americans do is indirect vision where if you can't see an area you look at the mirror to see the area so you're looking at it indirectly there is indirect illumination so illumination stands for light so here we can see light being shown in that area and then lastly we have trans illumination where you're basically making light travel through the t to see if there's any cavities for example sometimes you can see some shadows through the light so that's trans elimination so four different functions of the mouth we have explorers too and you can see here there's so many different types of explorers we have the pigtail we have the 11 12 which is the one you might be familiar with so many different types of um explorers and we know what they're used for right they're used to detect calculus they're used to detect carries they're used to see if there's any irregularities if the margins of the restoration the fillings are not smooth the explorer can detect that through tactile sensitivity we also have this previous slide said probe is another assessment um instrument unless there's actually a question on this so which of the following instruments is best designed for assessment of vocation involvement vocation involvement what probe do you use for vacation involvement yeah it's the neighbors probe okay so the neighbor's probe and i'll show you a picture of it it's a specialized probe that is used for um detection and also classification of locations it has like a curved shank it has shaded markings um it has a blunted tip so it's really good for sub-gingival insertion and it's also really good to you know figure out what classification of location your client has so let's look at the different types of probes so we have the marquis probe and if you look at this probe you can see that it's um spaced apart every three millimeters so we have three millimeters six millimeters nine millimeters and twelve millimeter marking the chip is very very thin so it's really important that one of the considerations it's saying here is that be very gentle because you can really poke or penetrate through the junctional epithelium if you put too much pressure so be very gentle because the tip is very thin we have the williams probe and i know this is not clear but there is measurements of um it goes like one two three and then there's no four and then it goes to five there's no six and it goes to seven and then it goes all the way down to ten so there is spaces between the three and five and the spaces between the five and the seven but the downside is really hard to read and you can kind of see that right like it's very hard for you to see the lines here the michigan probe is like this and it has um measurements of three six and eight so it ends at eight millimeters so if someone has a deeper pocket more than eight millimeter this might not be the good probe a good probe for it because it ends at eight millimeter then we have the unc um 12 and the unc 15 probe and when you look at this it has all the um markings here so if you look at the unc 12 one it has um it you can literally see all the lines from one all the way up to 12 and it's color coded you can see the dark black band at four millimeters and at nine millimeters but the unc 15 this one it's longer so you can go all the way up to 15. millimeters so it's called unc 15 because it goes up to 15 millimeters this is unc dash 12 because it goes up to 12 millimeters so 15 means it can go deeper you have a very deep deep pocket a client with a deep pocket significant attachment loss then this might be the one to use there is this type of probe right here the nova tech probe and you can see it's quite um angular it's like it has an angled bend it's mostly for the distal surfaces it kind of feels bulky because of this angulation that you see but it's only used for distal surfaces in the posterior side and then we have the psr and the psr is um the one that has a ball tip at the very end tip and it does have markings so the color-coded one is from 3.5 millimeters to 5.5 millimeters refer back to my period videos where i do go over how to use the psr probe this is the neighbor's vacation probe we can see the curved the round tapered and curved working end and then for implants we do have some plastic probes things to keep in mind is that with the plastic probe the markings do wear away so it's important that you replace or throw away these um plastic probes if it is worn away here we see a vocation probe a neighbor's probe that is used and you can goes in and remember if it goes in halfway then it is a class two so just review the classifications verification if you can't recall but remember the probe that i want you guys to know are is the neighbors probe and it's used in areas where there are two or more roots so your molars when we're looking at treatment instruments so we just looked at assessment instruments which included the mouth the explorer and the probe now we're looking at treatment instruments and the treatment instruments we typically use are um curettes they could be universal and they could be area specific and let's look look at um these type of instruments so the first thing i want you guys to know is let's look at the difference between a universal curette and compare it to an gracie curette or an area specific curette what you'll notice is in the universal look at the um the shank it is 90 degrees right the base the space right here this is the base of the curette is right alongside the um the shine so it's like a 90 degree right here and then it comes out so it's 90 degree right here but when you look at the um greasy what you'll notice is that this it's tilted right if you look at the base right here on the working end it does tilt it offsets a little bit and opposite attached to a 70 degree angle 70 degree angle to its shank one thing to note is with the universal you have double cutting edges you have this side is sharp on this side is strap so there's two cutting edges whereas with the area specific the gray circular you only have one cutting edge the lower side is your cutting edges the sharp side is the side you want adapted against your against the client's teeth so which of the following instruments treatment instruments are best designed for debriding very narrow and deep pair your pockets a keyword narrow and deep carrier pockets here are your options c is the correct answer micro mini five curette so let's look at what what all this so just to recap actually you know what let's look at all these type and then we'll come back to this question to understand why is the micro one and not any other ones this is the standard greasy curette look at the shank okay it's not as long as the other shanks when you look at the other the after five so when it says five by five it means it's a longer shank it is actually three millimeters longer compared to our regular greasy curette okay so this this is this size of the shank and this size when you have the five in the word it is three millimeters longer than this let's look at the actual five curette so the abstract accurate it is three millimeters longer than a standard greasy curette but if you look at the working end it is the same size as this the mini okay is we look at the working end it is mini it is smaller than our regular standard gray circuit and the micro mini means it's even more smaller than the um than the mini five so it gets even more smaller if you look at the working and here it gets even more smaller so when you have a narrow narrow pocket in a deep pocket you want one that says five because five means that it's a deeper pocket so it's a deeper shank it's a longer shank so you're able to get in deeper and then when it says narrow you want the most narrowest uh working end which is this one because you want it to go inside that very narrow pocket so the smallest or tiniest working end is the micro mini five so that's why this is the best answer because the micro mini 5 blade width is 20 smaller than the micro 5 sorry than the mini 5 carat um and it is actually 50 so the micro mini 5 is actually 50 smaller than the regular greasy curette and it also has a long terminal shank so this is your best one for narrow pockets this one would be good for deep pockets but if you want to help if you have a narrow pocket this would be more ideal in darby there are great tables so 28.4 to 28.8 these tables are really good actually let me show you them so this this is from darby this is a table from um darby table 28.4 and it talks about the universal curette where we know it's double ended um because there's the both sides have cutting edges so it tells you the main specifications or domain design that you find in all in all the universal curettes and then it shows you pictures of the various um universal curette and what they are used for so you'll notice here that they have like a short shank um and they're more rigid if you look at it's more thicker it's more rigid so it's good for anterior tooth surfaces and for shallow probing that's because they have a short shank but if you look at um these curettes they have a long lower shank so if they have a long lower shine we know and if it's more bendy the more bent the shank is it's easier to go more posterior right and tells you which ones are good for buccal and lingual so you can see that i would um actually encourage you to look at these tables and see when you can use each type of universal curette there's also the area specific curette okay and we know the area specific curette is unique because they only have one working end one's the cutting edge rather and again if i show you some pictures here we go so the greasies are your area specific you can see that they in this table they go over what they're used for and what their advantages and disadvantages are and one thing i want you guys to know is the smaller the number that means the more anterior um when you have a smaller number it's good for anterior teeth but when you have a higher number like 11 12 15 16 13 14 17 18 that's good for posterior teeth so the higher the number is for posterior the lower the number it's for anterior so the one two that's the smallest number we have that is for anterior when you have something made away like the 5 6 7 eight perhaps that could be for premolars and then when you go to like 11 12 all the way to 17 18 that is for the posterior molars so again we see this here when you have small numbers it's more for um incisor teeth but when you have larger numbers then it could be used for more posteriority and they all have their unique surfaces that they have to work with so 1314 or 1718 are boarded distals 1112 or 1516 are for the mesial so that's important to note as well now when we're looking at sickles you'll notice that sickles have two cutting edges which means it's sharp on both sides so both sides could be adapted depending on where you are in the mouth um and it could be a straight circle it could be a curved sickle and they come in the shank so the shank which is this area here could be straight that's what i'm sorry that's what i was trying to say straight it could be um you know curved as well or contour angled so even the shank is different with sickles so there's lots of different circles that we see here there's files that you have to know about so files are the purpose of having files are to crush and break up any moderate or heavy sub-gingival calculus okay so that's what it is and it's very similar to a whole scalar vaporite so make sure you're adopted make sure they do have sharp corners here right so you want to make sure that you're correctly adapted uh when you're doing the activation when you're trying to crush and break up the sub g calculus these are the vacation instruments is the neighbor's probe okay it's never to use for removing calculus remember that it is to assess verification and you can see it has three millimeter markings so you can see how you know deep the frications are so every color code is three millimeter markings scalers for implants so this is a humidity one but there is like and this is made of titanium but um there are like it could be made out of plastic it could be made out of graphite gold this is titanium so they're all used to remove biofoam that's around the titanium implant and perhaps even calculus of that usually calculus don't really bind to implant but if it does these are the instruments that you can use tactile sensitivity is an important term to note because tactile sensitivity is um feeling the vibrations transmit from your fingers um to the handle actually it's basically you're saying you're sensing the vibrations from the instrument to uh to your to your kick to your fingers sorry not to the handle to the clinical clinician's fingers on the handle and that helps when you can check you know you can check to see is it smooth is it rough and the tactile sensitivity the vibrations help you feel that sharpening as we know is extremely extremely important we have to make sure the blade is sharp because when the blade is sharp it's going to decrease your your fatigue you're going to feel so much better you don't have to scrape at it so like you know for a long period of time we don't have to debride it at one area for a long period of time because if it's sharp it's going to come off easily the calculus or tartar will come off easily so it's the first sign of dullness if you notice that it's not sharp and you will notice as the more you practice the more you'll get this start sharpening your instrument or find a sharpened instrument and to sharpen instruments there are many stones there's the arkansas stone there's the india stone and there's the ceramic stone so um the main difference between these stones is that this stone right here the arkansas stone this is a natural stone refined texture so it's fine texture so it's good for people who are newbies over new hygienists um that aren't comfortable with sharpening because it's fine it won't it won't disrupt the instrument as much these ones right here the india stone one it's also a natural stone um it comes in medium texture and so sometimes what they do is they use this um stone purse and then they follow up with the arkansas stone to get a polished edge to their instruments and this is your ceramic stone when you are sharpening uh there are two techniques there is you could either move the instrument over the stone so this is where the stone is flat and you're just rubbing the instrument or moving the instrument along the stone this is um could be done by sickles but most of the time this is probably what you learned where you're sharpening by moving by literally moving the stone up and down so there are two methods you could depending on what instrument you have you could move the instrument up and down the sharpening stone or you could take the sharpening stone and move that up and down over the instrument the other thing it states over here is that there are lots of devices that can do um that can automatically you know sharpen your instruments but the ones that we learned in school the manual sharpening techniques which is typically this one when you test for sharpening um or when you just to see if your instrument is sharp remember the plastic stick that we use so it's important that you have a light when you're looking at it because the strong light helps to see if it's sharp also tactile test so when you you know put it on the hard plastic stick you want to make sure that it is uh it you hear that click and it does you know catch does catch on that stick an auditory stance where you want to hear that click you want to hear that noise to show that it is sharp you don't want to just slide over if it does it's it's a dull instrument now what happens if actually by the way did you guys know explorer can also be sharpened so you could do two or three rotations around the tip of on the stone and it does explore can be sharpened now what if your instrument breaks what do you do remember if you're the if your instrument is too thin discard it because the last thing you want to do is for it to break in someone's mouth so it's be proactive and discard that instrument if it the chip has become too thin now here's a question about what can happen if some if something breaks if a tip breaks a dental hygienist is scaling the posterior mandibular right quadrant suddenly the tip of the working end of the instrument 1314 area specific curette breaks which of the following is not an appropriate part of the initial tip retrieval procedure so have a look and tell me what you think yeah it is v so um we can reinstrument that area with another curette and see if that the broken curette comes out so that's what that refers to we get another curette and see if we can scoop out the broken tip you could in you definitely have to tell your client about the breakage there are magnetic tip instruments such as a period which um a prayer retriever where you could it's magnetic so it's able to you know bring out the broken tip through a magnetic tip but you never want to dry the area with compressed air because what can happen the broken tip could move from that area where it is and it could the client could be pushed to the back of the client's mouth and the client can easily swallow or aspirate it and so finding it could be more difficult if you dry the area with compressed air so never do that when there's a broken tip inside in your client's mouth what you want to do is you want to tell your client stop using any low speed or high speed because what you want to do is you want the client to spit it out so give the client a cup and tell them to spit and we're hoping that it would come out in their saliva and then if it doesn't get recovered make sure you inform the client show the client so the client physically sees it and document it but there are times when you won't be able to um get it out let's say it doesn't come out then what do you do well then you could use a magnetic tip pair your treatments to draw and grab the tip fragment use some um if you're at a period office you might do an open blob periodontal surgery and find it in that gum you could use way too graphic imaging so take an x-ray and see if you can find where the missing tip is and then once you know then you can take it out and if you absolutely still can't find it then they need to do a chest radio grab a chest x-ray to make sure that they haven't aspirated that tip so then you must do a chest x-ray we still cannot find it after taking the radiographs actually looking visually after using the magnetic tip remover um to you know take out the tip so last resort chest radiograph but you have to find it that's some you have to find it and you have to document it so if you can't find it then you have to do a test radiograph or tell the client to do a test radiograph so document any instrument tip breakage by noting the specific tutor site um incident disclosure to the client with significant signature verifications to get them to sign um where you have you know and you disclose everything that happened what the client said so you want to note what the client's response was and if you're doing any follow-ups or referrals note that as well very important be as specific and detailed as possible this is the modified pen graphs which is the most common graph we use for hand activated instrument notice the c shape it's a nice comfortable you know relaxed c shape notice that the thumb pad is placed on the instrument handle the index finger is also placed on the instrument at a higher you know on the on the handle as well and the middle finger is placed on the shank towards the working end so this is the most common graph the standard grass we use for dental hygiene instrumentation um so fulcrum as you know is very important we must welcome at all times even when we're using a capture on our piezo we are always welcoming you could do an intraoral fulcrum where you're fulcruming inside the mouth or you could do an extra oral fulcrum where you're focusing outside the mouth now when we're looking at um instrument insertion so how you put the instrument inside your client's mouth we have to look at we have to understand these three terms angulation adaption adaptation sorry and activation so let's look at this first when you angle the instrument so when you put the instrument inside the sulcus the important thing is that insertion angle has to be close to zero degrees look at that the face is against the two the base of the instrument is against the two it is at zero degrees as we see here this is ideal for the insertion of working and once it is inserted then you can open the instrument and um it can be anywhere from 45 to let's say it's here anywhere from 45 um to 90 but ideally the best one is anywhere from 60 to 80. so 70. 70 would be the perfect way so you you put the instrument in you insert it the instrument is closed right against the tooth then you open the instrument so that it's at 60 to 70 60 to 80 so 70 degree angle if you do 45 degree angle that is too close to remove calculus and burnishing you'll burnish the um calculus if you do 90 degree angle that is too open and you could damage the tissues on the other side so 70 degree or 60 to 80 degree is your best type of angulation for removing calculus and that's what we see here here's the tooth surface this is at 70 degree angle 6280 and anywhere in that shaded area is good for you to remove the calculus that's sitting there so when inserting a curette into a pair of pocket what is the ideal angle between the cutting edge of the blade of the instrument and the tooth yeah it is zero zero to ten degrees so you want it to be as close to the toot as possible upon insertion what about what degree of angulation should be established between the roots sorry between the tooth surface and the cutting edge of the instrument blade when calculus is removed so for calculus removal what is the degree of angulation we want 70 degrees right or 60 to 80 degrees this is what we want this is perfect to remove calculus this 45 is not good because it will burnish the calculus 90 is too open it's going to damage the adjacent tissues so 70 or 60 to 80 is your best one adaptation so we look at angulation adaptation is just it means touch like how the instrument touches d2 so just the touch adaptation is a fancy word for touch and activation is the actual activation the actual movement that you're doing when you are debriding okay so when you're using your your forearm your wrist your hand and your fingers all of it as one you're using it as a one um it's all you know one movement that you're using when you're doing the instrument activation so you could have an exploratory stroke which is really really light stroke where and this is typical when you use an explorer or a probe you can have a scaling stroke this is used to scale off calculus and you could have a root planing stroke and replaning basically means you're removing calculus that has been embedded into the cementum or you're smoothing out the roots okay so scaling is when you're removing calculus root planing is when you're removing cutlass from the cementum that has been embedded into the cementum all right so how do you know what curette to use here's one question for you which of the following instruments is the best choice for light to moderate sub-gingival calculus removal so key word light to moderate sub g-com universal curette that is what's designed for light to moderate so many times we just have very little um you know light calculus or light to moderate calculus a universal curette would do sicko is for supra so she's saying sub a chisel this actually here is a chisel and a chisel is um used for dislodging large bridges of calculus especially in the interproximal area so that's what it's for and it's not for a source for large bridges of cutless that has nothing to do with light to moderate sub-gingival calculus universal is the best one for just light to moderate sub-g cal calculus but what about this one the dental hygienist is scaling a sextant teeth number 28 through 31. in fdi that is four four two four seven the areas have five to six millimeter pocket light sub g calculus and bleeding on probing which of the following is the best instrument would be the best instrument to use to deprive the pockets in this area same options as before but here what we have are pockets that are deep bleeding on probing so this person is probably has perio right because when you see deep pockets they're definitely they definitely half period any time when you have four millimeter pockets or more with bleeding there they are a pair you'll find so if you have a perio client a client who's periodontally involved what type of scale it would be best the area is specific that is good for period clients so slight just to be a period of clients who we see who require scaling and root planning this is good okay this one is for someone who maybe you know we don't have enough information to say that they have paleo or not so universal cured is our first type of instrument to use if they have light to moderate subgcal and then if they're more perio involved then we use the area specific purat and again darby has this a table 28.5 which tells you exactly what instrument to use depending on what type of calculus someone has so i do encourage you to look at that and when you are instrumentation when you are doing instrumentation remember um these things if the fulcrum doesn't feel right find a different fulcrum so it's okay to alter your fulcrum um and with experience adjustments are made within seconds because remember when you're probing let's say you're probing a um so you're probing a tooth on this side you could have a three millimeter pocket or probing up and on this side you could have on the distal you could have a 10 millimeter probing up so remember that probing depths do change and so when you have in an area that is more periodontally involved like this 10 millimeter side you're gonna have to fulcrum further away from the working side so it's you know it's really important that you are comfortable with your fulcrum because sometimes you need to focus further away from the the actual toot especially if they're more periodontally involved this is a dental um perioscopy and this is actually really cool what happens here is that they have like a light that is attached to a dental and endoscope and and it's and there's a camera and you can actually go in with that endoscope with the perioscopy and you can actually see in the camera where exactly the calculus is so it allows for sub-gingival visualization of where the calculus is so it's really cool technology has come a long way now let's look at ultrasonic instrumentation and what i'll do here is i'll just look at the questions we'll do some questions so that you're able to understand and grasp the important concepts that you should know so here's our first question all of the following are contraindications for the use of mechanic mechanized instrument except one which one is the exception so when do you not have to um worry when you're using a cavitron or a so your answer oh sorry that was circled too big but your answer is b so when someone has a pulmonary disease a pulmonary disease is think of like like asthma emphysema cystic fibrosis pneumonia anything that puts them at risk anything where the lungs are involved you don't want to use cavitron or piezo so you don't want to use ultrasonic what does this speak that especially i mean difficulty swallowing so if someone has difficulty swallowing you're not going to use the cavity because with cavitron there's lots of water that is enrolled but a communicable disease like hepatitis tb strep throat covariate respiratory infections yes they could be transmitted with air through aerosols and we use standard precautions to meet the infection control guidelines but basically the point here is that when you have a client with communicable disease don't treat them don't treat them until you talk to a doctor because it's contagious so um the thing here is that we're not going to treat them regardless they're not necessarily contraindications it's just we're not going to treat them but the other ones are contraindications because the lungs are involved or they have difficulty swallowing this one is your the answer here that's if someone has a communicable disease we don't do any deprivement until the disease has been treated for an appropriate length of time as determined by the doctor when you have an ultrasonic um when you're using an ultra sonic instrumentation there are four mechanisms of action there's the mechanical the actual physical movement of the cabochon so when you're moving the cabbage on that's the mechanical physical movement that's what that's referring to irrigation is the water the water is flushing out um any you know it's flushing out it could be flushing out blood it could be flushing out biofilm it could be flushing out debris but irrigation is the water that is used with the ultrasonic instrument and the reason why we use water is to counteract the heat that is generated from the instrument tip cavitation is when you have a bubble that gets popped and that and when it when it pops it gets released um it forces the basically it forces there's a there's a there's an act there's a forceful act that comes on on the surface it's like a jet basically and so cavitation is with the collapse of a bubble that does the work for ultrasonic instrumentation and then we have acoustic micro streaming and that's basically the the swirling of the water the vigorous swirling of the water um that's happening here and that is very helpful with you um with debridement okay so we have mechanical which is the physical remove the physical action of using a cavitron we have irrigation where the water comes out uh to counteract the heat we have cavitation which is the bubbles that get popped with microscopic bubbles that get popped and does the action and we have acoustic micro streaming which is where you get the movement in the liquid when magnostrictive when magnetostrictive ultrasonic instrumentation is used the function of the water that circulates through the handpiece and exits as a spray at the working end is which of the following so why do we have water yeah we have water to um cool down the tip and so if your client is saying that oh it feels so hot up the water intake the water there probably isn't enough water water doesn't help with lubricating the instrument itself doesn't need lubrication the water flow doesn't reduce bleeding uh sorry reduces bleeding like you you'll wash away the bleeding but it doesn't stop the bleeding and the water doesn't destroy or disrupt bacteria acoustic micro streaming is a term that describes the potential to destroy or disrupt bacteria so water is a bipro the water basically is needed to cool the system down one of the major differences between the piezo ultrasonic instrument and the magnesium ultrasonic instrument is which of the following yes the answer is b so the activated surface of the working end is different so let me show you what that means this is a cabochon this is a piezo with a cavitron all surfaces are active so the lateral side of the surfaces the back the face all of those work so if you have any side of the cavitron adapted to the t it will work it will remove the calculus but the piezo only the lateral side so only the sides are active which means that when you adapt it when you touch when you keep the instrument or bring the instrument and touch it towards the tooth the side has to be adapted only the sides not the back not the base only the sides can can work this over here is saying the stroke pattern is you know how there's like movements that are happening here so the movement that is happening is elliptical here where it looks like this and here the movement is side to side linear that's the movement that's being transmitted in the ultrasonic this right over here frequency what this refers to is how many times the vibration is happening in per minute so for example 20 k8 said which is kilohertz it stands for there is 20 000 strokes per second so imagine that so any of the magma structure the amount of strokes that's happening is quite um you know it's anywhere from 20 to 40 000 strokes per second per second i should say and piezo is 29 to 50 so it's higher um kilohertz which means that there could be up to 50 000 strokes per in per second so a lot of movement a lot of strokes is happening um when we're using a ph that can go up to 50 which is you know quite impressive all right so when we're looking at ultrasonic tips it could be standard it could be thin or it could be a size slim or it could be ultra slim and i have a question on that and then we're gonna look at pictures of these the three different types of tips precision thin inserts are designed and indicated for which of the following so the answer is light perio periodontal root defragment so sometimes you can just look at it through process of elimination where um if you see heavy calculus and fcc or those cements you know that's quite heavy um so it can't be these two because they're they're kind of similar what you're looking for here is when you have a thin insert you don't want to use a thin insert for heavy calculus because you could you know break that insert and ortho cement that's quite strong a thin insert won't remove or throw cement because it could break and extrinsic tooth stain extrinsic tooting you could use a standard insert you don't need to use a thin insert for the staining but when you have light perio root debridements you have light calculus a thin insert will do thin inserts are designed for light period debridement they're good for you know substance you can access subjectively easily if clients find it more comfortable and even with tactile sensitivity you're able to trend the vibration you're able to feel so thin inserts are narrow and um in than standard design they're narrow in diameter and they generally use less power and frequency than the standard inserts so let me show you this picture this is let's see here these are our um the ones the tips you can see they're a little thicker they're they're designed the standard one you could say they are designed for um heavier deposits but when you have the slim insert like this and we also have another thin insert like that you can see that it's a lot more thinner this is actually very thin this is 30 thinner than the regular insert this is good for sub gingival calculus for light to moderate calculus this also is really good for just you know plaque just biofilm and even light calculus as well but when you have moderate to heavy calculus you want to use a thicker chip because it's able to remove the deposit more effectively let's look at another question which of the following best describes the water spray that is recommended when precision thin inserts are used for non-surgical periodontal therapy non-surgical periodontal therapy refers to debridement okay when you think of this word think of debridement i know it also refers to education as well and nutritional counseling tobacco cessation all that but non-surgical period therapy in this case is referring to debridement so what is the best water spray that we want to see when we're using our ultrasonic this is the answer we want very fine droplets of water and a very fine mister spray okay it's kind of it's known as outer phase tuning um so the water spray is adjusted out of basic and it should appear as a fine mist with a water drip this is how clinician knows that the tip is not tuned to resonance frequency for maximum energy output i'm just reading the rationale for you here um basically you just want very fine drops you don't want large droppers of water you don't want a narrow steady stream of water because you want a steady stream with droplets of water okay so you shouldn't just see a stream you need to see droplets plus a stream and you don't need a narrow stream of water covering a large area that means the client's whole face is going to get wet it doesn't have to be a large area it can just be in a small area of spray in which of the following ways could an ultrasonic tip cause an undesirable surface alteration think about when it can um like maybe damage the root what could happen for it what could you do to damage the root to damage the surface what do you think yeah it is c so um if the point of the end of the insert of the tip is adapted to the tooth and then you could basically gouge the roots you could gouge like a bad area and you know and that that can cause damage the point is not you know your point should not be adapted it should be the side or if you're using a piezo for example it should be the lateral sides if the power setting is too low that's not going to damage anything if the water spray is too great i mean it'll make you wet but it's not going to damage water doesn't damage the surface if you use light pressure you're not going to damage the surface heavy pressure yes it'll damage it but if you use a point the tip of the insert it can definitely gouge the root one thing to note is when you are looking at the ultrasonic tip if you see two millimeter of the tip length has been lost throw it away replace it okay so that's how you know when to change an ultrasonic tip when two millimeter of the tip length is lost here's another question which of the following is an indication for using a standard ultrasonic insert i'll let you read it and you tell me what you think the answer is b so moderate to heavy super gingival calculus in a young adult accompanied by tobacco steam this is when you want to use a standard ultrasonic insert all the other ones are when you want to use thin inserts so for example if they have light calculus a thin insert will do you don't need a standard heavy thick one if they have fine deposit a thin one will do if they have light stain and fine sub g cup um so substitute calculus a thin instance will do right so this is process of elimination you can see that this one has the word light sub sub-gingival calculus this one has the word fine sub-gingiva calculus this one also has the word fine so it can't be these these ones says moderate too heavy none of the other ones said moderate to heavy so therefore it has to be b so standard ultrasonic inserts are good for moderate to heavy sub gingival calculus when you're using an ultrasonic instrumentation when you insert the tip what you want to do is you want to be as close to the tooth as possible anywhere from 0 to 15 degrees but the closer the better so zero degrees is ideal okay so you want to be as close to the tooth as possible so it's zero degree angulation is ideal just like a probe when you're probing you're using the same type of movement with the probe you're very close to the two zero to 15 degrees this is for manual instrumentation so anywhere from 45 to 90 degree but typically you want to be right in the middle so 70 degrees 60 to 70 degree is your ideal angulation for manual instrumentation for ultrasonics is anywhere from zero to fifteen ideally zero when you're using ultrasonic instrumentation it is recommended by darby that you do second bisector it's more efficient than doing it by quadrant because you're not changing um your position your operator's position you're not really changing the tips as option as well so work section by second it's easier on you and also advanced toward operators so what that means is start with the tooth that's furthest away from you and then come closer to you so if you're starting start with the third molar then go to the second roller then the first smaller than the premolar so you're working farther away from you more you're looking at a treatment area that is most distance from you and then it's going to come closer in advance towards you