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Module no 3

Instrument sharpening
Problem identification
Robins Dhakal
Department of Periodontology & Oral Implantology
CODS, BPKIHS
CONTENTS
• 1. Introduction
• 2. Evaluation of sharpness
• 3. Preserving working end design
• 4. Instrument replacement
• 5. Instrument tip breakage
• 6. Instrument maintenance
• 7. Sharpening stones
• 8. Principles of sharpening
• 9. Sharpening methods
• 10. Problem identification
INTRODUCTION

Nothing in the technical


• In 1908, G. V. Black, stated that “
procedures of dental practice is more important than
the care of the cutting edges of instruments. The
student who can not, or will not learn this should
abandon the study of dentistry. ”
INTRODUCTION

• Effective periodontal instrumentation with hand-activated


instruments is possible only with properly maintained sharp
cutting edges
• As an instrument is used, minute particles of metal are worn
away from the working-end
• Loss of metal from the working-end changes the cutting edge
from a fine line to a rounded surface, resulting in a dull,
ineffective cutting edge
Evaluation of sharpness
The cutting edge of an instrument is a line formed by
the pointed junction of the instrument face and lateral
surface
When the instrument is sharp,
this junction is a fine line running
the length of the cutting edge
It has length but no width
A. Sickle Scaler in Cross Section.
B. Universal Curet in Cross Section.
C. Area-Specific Curet in Cross Section
Evaluation of sharpness

1. Visual 2. Tactile
1. Visual evaluation
A cutting edge is evaluated visually by holding the working end under a bright light
source, such as the dental light or a high-intensity lamp
The instrument face is held approximately perpendicular to the light beams.
a. A dull cutting edge will reflect light because it is rounded and thick. The
reflected light appears as a bright line running along the edge of the face.
b. A sharp cutting edge is a line—with no thickness—and does not reflect the
light.
Visual Detection of a Visual Detection of a
Dull Cutting Edge Sharp Cutting Edge.
• 2. Tactile evaluation

Performed by drawing the instrument lightly


across an acrylic rod known as a “sharpening test
stick.”
a. A dull cutting edge will slide over the surface of
the stick.
b. A sharp cutting edge will bite into—grab—the
surface of the test stick.
Preserving working end design
• The design of the lateral surfaces, back, toe, and tip must be maintained during
sharpening

The working-ends of some periodontal instruments have curved lateral surfaces,


whereas others have straight lateral surfaces.

• Sharpening the cutting edges in sections is a strategy that preserves the design
characteristics of any working-end
The sharpening stone is applied to only a third of the cutting
edge at a time to maintain a curved cutting edge.
• Sharpen the (1) heel-third, (2) middle third, and (3) toe- or
tip-third of the cutting edge.
If the instrument is a curette, (4) sharpen the toe.
Common sharpening errors

Unnecessary Metal Removal.


A. A new sickle scaler.
Alteration of Working-End Design. B. The working-end of this scaler has
A. A new universal curet. Note that curet A been excessively shortened in length by
has straight lateral surfaces and a rounded sharpening.
toe.
B. In sharpening the curet shown in A, the
clinician has altered its design
characteristics. It is thinner and shorter
than the original, and the curet toe has
been sharpened to a point.
Altered Shape.
Flattened Cutting Edge.
A. A new sickle scaler.
A. A new area-specific curette with curved
B. In this example, incorrect
cutting edges.
sharpening technique resulted in
B. In this example, incorrect sharpening
straight cutting edges, whereas
technique created a straight lateral surface
the cutting edges on the original
and a pointed tip. The original design
sickle were curved (flame-
characteristics of the instrument were
shaped).
curved lateral surfaces and a rounded toe.
Instrument replacement

Sickle scalers and curettes have a limited use-life and must eventually be
discarded

Frequent sharpening that preserves the working-end design combined with


care during handling and sterilization will prolong an instrument’s use-life

One research study reports that a 20% reduction in size results in a significant
reduction in working-end strength

Murray GH, Lubow RM, Mayhew RB, Summitt JB, Usseglio RJ. The effects of two sharpening
methods on the strength of a periodontal scaling instrument.J Periodontol . 1984;55:410–
413.
Instrument tip breakage
1. Maintenance for Prevention of Breakage.
• The instrument’s working-ends should be carefully inspected under magnification
after each use.
• a. Thin or improperly sharpened working-ends can break during calculus removal.

b. Frequent sharpening, correct sharpening technique, and discarding of
instruments with thin or poorly sharpened working-ends minimize the possibility
of a broken tip.
2. Management of a Broken Working-End

1. Stop instrumentation immediately, remain calm, and inform the patient of


the problem.

2. Maintain retraction and patient head position.

a. Do NOT use compressed air to attempt to locate the metal fragment.

b. Do NOT use suction to attempt to remove the metal fragment.

3. Examine the location where the fracture occurred, mucobuccal fold, and the
floor of the mouth. If the metal fragment is located on the surface of the tissue,
blot the area with a gauze square. The metal fragment will catch in the gauze
material for easy removal.
4. If the fragment cannot be located on the outer surfaces of the tissues, examine the
sulci or pockets in the area.

a. Insert a curette into the sulcus or pocket at the distofacial or distolingual line
angle and move slowly forward until the fragment is located.

b. Once located, use the curette like a scoop to remove the tip from beneath the
gingival margin and catch it with a gauze square.

5. If the fragment cannot be located, take a periapical radiograph of the area. If located, use
a curette as described above to remove the tip. If this fails, surgical removal of the metal
fragment.

6. If the fragment still cannot be located in the mouth, the patient should be referred for a
chest X-ray to ensure that the tip has not been aspirated into a lung. After referral, it is
important to follow up with the patient to confirm that a chest X-ray was obtained.
Planning for instrument maintenance
• When to sharpen ?
• Sickle scalers, curettes, and periodontal files should be sharpened after each use or
as needed during periodontal instrumentation.
1. Sharpening after Instrument Use
Ideally, instruments used for treatment should be sterilized before sharpening
to decrease the risk of disease transmission.
• Sterilized instruments are sharpened and sterilized a second time prior to use.

2. Sharpening during Treatment


Depends on the extent of calculus deposits present
Frequency of sharpening
Immediate Sharpening Infrequent Sharpening

• Maintained cutting edges need only a few light • Dull neglected cutting edges require many firm
sharpening strokes and minor recontouring. sharpening strokes and extensive recontouring.

•Calculus removal is easier for both clinician and • Calculus removal is difficult and tiring for both
patient. the clinician and patient.

• Instruments have a long use-life. • Instruments have a short use-life


J Periodontol. 1985 Sep;56(9):532-6.
Scanning electron microscope evaluation of wear of
dental curettes during standardized root planing.
Tal H, Panno JM, Vaidyanathan TK.
Abstract
• This study evaluated the sharpness and wear of some dental curettes
available in the market following standardized root planing procedures. Nine
working edges of nine Gracey No. 1/2 DE curettes, three each from three
different manufacturers, were used as controls.
• These unused factory-sharpened edges were examined by scanning electron microscope (SEM). Eighteen edges of nine curettes of the same brands were likewise
examined after root planing procedures. Root planing was carried out on extracted one-rooted teeth mounted in natural positions in manikin jaws. Working areas
measuring 3 X 5 mm were marked on root surfaces previously exposed by periodontitis. Root planing procedures included 15 vertical strokes done by either Side 1 or
Side 2 of each instrument in relation to a single working area of a tooth, and the same procedure repeated 3 times using the opposite side of the curette.
• All working edges were examined at points 1 and 2 mm from the tip under 500 times magnification. Edge deformation increased significantly from the control group
to the "15-stroke" group and from the "15-stroke" group to the "45-stroke" group. Factory-sharpened curettes (control) were sharp, with functional wire edges
.
present on 55% of the specimens

• After 15 strokes, nonfunctional wire edges and narrow edge deformations


with bevels measuring less than 15 mu were present. After 45 strokes eight
cutting edges (88.9%) showed bevels wider than 15 mu.
Advantages of sharpening
• Easier Calculus Removal
• Improved Stroke Control
• Reduced Number of Strokes/Working efficiency
• Increased Patient Comfort and Satisfaction
• Reduced Clinician Fatigue
Sharpening Armamentarium
• WORK AREA AND EQUIPMENT
A stable, flat work surface is essential
A good light source,
Sharpening equipment
• Sharpening stone(s)
• Plastic sharpening test stick
• Magnifying light, lens, or loops
• Gauze
• Lubricant
• Gloves
• Safety glasses
Sharpening stones
• A sharpening stone is used to remove metal from the lateral surfaces of the
working-end to restore a sharp, fine cutting edge

• Sharpening stones are made of abrasive particles that are harder than the metal
of the instruments to be sharpened
Sharpening stones

2
SOURCES Sharpening stones. Left to right, A flat India
stone, a flat Arkansas stone, a cone-shaped
Arkansas stone, and a ceramic stone.
Type Grit Use Lubricant Sterilization

Ceramic Fine Routine sharpening of metal and Water All methods


synthetic stone some plastic implant instruments

Arkansas Fine Routine sharpening of metal Mineral oil All methods


natural stone instruments

Neivert — Routine sharpening of metal Water All methods


Whittler instruments

India synthetic Medium Sharpening of metal instruments Water or oil All methods
stone that are dull

Composition Coarse Sharpening of metal instruments Water All methods


synthetic that are extremely dull or that
stone need reshaping

Power devices Varies Routine sharpening and sharpening As directed by As directed by


and honing of instruments that are maker maker
machines extremely dull
Sharpening stones Particle size

Coarse stones
• Have larger particles and cut more rapidly
• Used on instruments that are dull
Finer stones
• Have smaller crystals and cut more slowly
• Reserved for final sharpening to produce a finer edge and for sharpening
instruments that are only slightly dull
Sharpening stones Method of use

• Mounted on a metal mandrel and used in a motor- • Rectangular with flat or grooved surfaces,
driven handpiece whereas others are cylindrical or cone
• Cylindrical, conical, or disc shaped shaped
• Not recommended for routine use • Used in two ways:
• are difficult to control precisely and can ruin the • the instrument may be stabilized
shape of the instrument, and held stationary while the stone is
• Tend to wear down the instrument quickly, and drawn across it,
• can generate considerable frictional heat, which • or the stone may be stabilized and held
may affect the temper of the stationary while the instrument is drawn
instrument across it.
Unmounted
Mounted stones
rotary stones
J Int Acad Periodontol. 2006 Jan;8(1):17-22.
Sharpening of periodontal instruments with different sharpening
stones and its influence upon root debridement—scanning
electronic microscopy assessment.
Silva MV, Gomes DA, Leite FR, Sampaio JE, de Toledo BE, Mendes AJ.
Abstract
• The objective of this study was to evaluate, through scanning electronic microscopy, the effect of sharpening with different sharpening stones on the cutting angle of periodontal curettes (Gracey 5-6), and the
influence on root surfaces after debridement and planing.
• The experimental model consisted of two different phases. In the first, the cutting angles of fifteen stainless steel Gracey 5-6 curettes were analyzed under a scanning electronic microscope after being sharpened
with different types of stones. In the second phase, the root surfaces of 25 newly extracted teeth were evaluated with a scanning electronic microscope after being debrided with curettes sharpened with different
stones.

• Analysis of the results showed that the synthetic stones (aluminum oxide and
carborundum) are more abrasive and produce more irregular cutting angles,
whereas Arkansas stones are less abrasive and produce smoother and more
defined cutting angles.
• There was no significant statistical differences among the five groups tested with
regard to the degree of irregularity of the root surfaces after instrumentation
LUBRICATION AND CARE OF STONES
1. Lubrication of Sharpening Stone
• A lubricant is a substance, such as water or oil, applied to the surface of
a sharpening stone to reduce friction between the stone and the
instrument.
• It prevents the metal shavings from sticking to the surface of the stone
LUBRICATION AND CARE OF STONES
2. Care of Sharpening Stone
• The sharpening stone should be cleaned in an ultrasonic cleaner or scrubbed
with a brush and hot water to remove metal particles from the surface of the
stone

• After cleaning, the stone should be dried on a paper towel and placed in an
autoclave bag or on an instrument cassette to be sterilized
Principles of sharpening
1. Choose a stone suitable for the instrument to be
sharpened—one that is of an appropriate shape and
abrasiveness.

2. Use a sterilized sharpening stone

3. Establish the proper angle between the sharpening stone and


the surface of the instrument
Principles of sharpening
Principles of sharpening

4. A stable, firm grasp of both the instrument and the


sharpening stone is maintained that ensures proper angulation

5. Avoid excessive pressure

6. Avoid the formation of a wire edge

7. Lubricate the stone during sharpening

8. Sharpen instruments at the fist sign of dullness


Sharpening methods
• (1) the moving stone technique
• (2) the moving instrument technique
• (3) a powered sharpening device
Removing Metal to Restore a Sharp Cutting
Edge
• Regardless of the sharpening method used, the process of restoring a sharp
cutting edge involves removing metal from the lateral surfaces of the working-
end

Metal is removed from a lateral surface until the junction with


the face is restored to a fine line with no width
RELATIONSHIP BETWEEN THE SHARPENING
STONE AND INSTRUMENT FACE
• A sharp cutting edge is restored by removing metal from the lateral surface while
maintaining the 70° to 80° internal junction between the face and the lateral
surface
angle greater than 80°, the angulation less than 70°, the
end result is a bulky end result is a working-end that
working-end that is difficult is weakened due to excessive
to adapt to the tooth surface removal of metal
The Moving Instrument Technique
 Involves removing metal from the lateral surface by moving the working-end
across the surface of a stabilized sharpening stone

Figure..Moving Instrument
Technique. For the moving
instrument technique, the
working-end is moved across
a stationary sharpening stone.
• Placing the sharpening stone on a flat countertop, it is not possible to view the
angle between the stone and the instrument face.

A new sharpening tool, called the Sharpening Horse which allows the clinician to
see the face-to-stone angulation is available while using the moving instrument
technique.
ESSENTIAL SKILL COMPONENTS

(1) using a modified pen grasp, (2) using the ring finger as a (3) sliding the ring finger along the top
support beam for the hand, of the Sharpening Horse tool during
and sharpening
SETTING UP THE SHARPENING
HORSE

Components of the Sharpening Horse System. • The sharpening horse system consists
of a metal device that holds a sharpening stone at a fixed angle, a ceramic sharpening
stone, and an acrylic test stick. The ceramic stone should be lubricated with water prior
to sharpening.
MOVING INSTRUMENT
TECHNIQUE: STEP-BY-STEP FOR CURETTES

1. Figure ..Grasp and


Finger Rest

2. Figure….Face-to-Stone
Angulation

Figure..Technique Check
4.Figure ..Sharpen Cutting Edge in
3. Figure..Begin with Sections.
Heel-Third.

6. Figure…Pivot
5.Figure….Slide the the Working-
Fulcrum along End.
the Beam
7. Figure …Pivot
the Working-End.

8. Figure…Pivot onto the Toe


9. Complete the Sharpening Process:

• Complete the sharpening process by recontouring the back of the working-end


on the top edge of the sharpening stone.

Turn the Sharpening Horse around to sharpen the opposite cutting edge of a
universal curet or sickle scaler.
For Sickle scalers

Figures …Sharpen Cutting Edge of a Sickle in Thirds. Using a similar


Adapt Sickle to Stone. Establish technique to that used for a curet, sharpen the heel-third, middle-
the correct face-to-stone third, and tip-third of a sickle scaler
angulation by positioning the face
parallel to the tabletop.
The Moving Stone Technique
• The moving stone technique involves removing metal from the working-end by
moving a sharpening stone over a lateral surface of a stabilized instrument

• Easy to see the angle formed between the face and the stone probably accounts
for the popularity of the moving stone method
Steps
• The moving stone technique involves grasping the instrument and
stabilizing it against a countertop.
• The sharpening stone is held in the clinician’s other
hand and is moved over the lateral surface of the
working-end

• The sharpening stone is positioned against the lateral


surface and moved up and down to remove metal from
the working-end.
1: Positioning the Instrument against a
Stable Surface

When positioned with the face parallel to the


countertop, the lower shank of an
area-specific curette is NOT perpendicular to
When positioned with the face parallel to the countertop, the the countertop.
lower shanks of these instruments are perpendicular to the •One cutting edge, the working cutting
countertop edge, is sharpened on each area-specific
curette.
Two cutting edges are sharpened on each working-end of a
sickle scaler or a universal curette.
2: Establishing
Angulation of the Stone
to the Instrument Face

Establish a 90° Angle.


Establish a 75° Angle

This position gives you a visual


starting point from which to
establish the correct
angulation
3: Sharpen the Cutting Edge in
Sections
4: Removing Metal Burs from
the Cutting Edge

Sharpening can produce minute metal burs that project from the cutting edge

A cutting edge with metal burs is


sometimes termed a wire edge because
the metal burs are like tiny wire B. Burs can be prevented by finishing
projections. The use of a wire edge on with a down stroke of the sharpening
the root surfaces can result in gouging stone toward the cutting edge
of the cementum.
5. Recontouring the Toe and
Back of the Working-End

Recontouring is the process of removing metal from the toe and


back to restore the curved surfaces of a curette

Figure….Recontouring the
Figure…Recontouring the Back
Toe
Sharpening a Periodontal File
• To sharpen a file, the clinician will need to use a metal file known as a tanged file .

• The file on a countertop is stabilized by our nondominant hand and tanged file with
our dominant hand.
• The tanged file is laid in a horizontal position against the
first cutting edge and the file is moved back and forth across
the cutting edge
EFFECTIVENESS OF THE TECHNIQUES
Scanning electron microscope assessment of several resharpening techniques
on the cutting edges of Gracey curettes The journal of contemporary dental
practice 8(7):70-7 · November 2007Roberto Antonio Andrade Acevedo, José Eduardo Cezar Sampaio, Jamil
Awad Shibli


Sharpening
with rotary
devices
produced
extremely
irregular
cutting edges.

the moving instrument technique produced a the moving stone technique produced a bevel
precise, defined cutting edge with an exact junction and wire edges between the coronal (C)
between the coronal (C) surface—instrument face— surface—instrument face—and the lateral (L)
and the lateral (L) surface. surface
Basic principles similar to instruments

Preparation for the moving stone technique includes (1) positioning the face parallel to the
countertop and (2) establishing a 70° to 80° angle between the face and the stone
Differences between instruments with these
techniques
• Two sharpening edges per working-end are sharpened for universal curettes and
sickle scalers

• Only one cutting edge per working-end—the lower cutting edge—is sharpened
on an area-specific curette

• The rounded toe and back should be recontoured on area-specific and universal
curettes
Mechanical Sharpeners
• The Rx Honing Machine (Rx Honing Machine Corp, Mishawaka, IN) is an
example of a mechanical sharpener
• This instrument moves a hone in a reciprocating motion at a slow speed,
while the instrument is held at the appropriate angulation and supported
by a rest
• Interchangeable aluminum oxide hones of different shapes and coarseness
are available to accommodate the various instrument sizes, shapes, and
degrees of dullness
Advantages
• Restoration of the cutting edge is accomplished more easily and in less
time than by other sharpening methods.

Other examples : PerioStar 3000™ by Kerr Dental Specialities, Sidekick® Sharpener by Hu-Friedy
Additional Information on
Instruments and Equipment
for Tooth Preparation
Terrence E. Donovan, R. Scott
Eidson
Problem Identification:
Difficulties in
Instrumentation
Can’t see the treatment area

Cause
Wrong “clock position” for treatment area

Patient positioned too high Maintenance of


proper operator
Solution
Patient head position and patient
Not using indirect vision position

Finger rest too close to surface to be


instrumented
Can’t locate the calculus

Cause
Middle finger not resting on shank

Using middle finger to hold the instrument

Solution Use of modified pen


Using “death grasp” on handle grasp
Too few strokes, not overlapping strokes When working subgingivally, use instrumentation
zones and overlapping strokes to cover the entire root
surface.

Not detecting calculus at line angles on Position the working-end distal to the line angle with
posterior teeth the explorer tip aimed toward the junctional epithelium
(but NOT touching the junctional epithelium) and make
short horizontal strokes “around” the line angle toward
the front of the mouth.

Not detecting calculus at midlines of Make small, controlled horizontal strokes at the midline
anterior teeth on facial or lingual surfaces
Poor Illumination of Treatment Area
Cause Solution

Unit light too close to mouth Light should be an arm’s length above or in front of the
clinician.

Not using mirror for indirect Use mirror to direct light onto the treatment area.
illumination
Can’t Adapt Cutting Edge to Tooth Surface
Cause
Trying to adapt the middle-third of cutting edge

1.Using the tip 3rd


Using the wrong cutting edge for the tooth surface
2. Identifying the
Solution correct working end
Using the wrong instrument for the task or area of the
mouth

Finger rest too far away

Lower shank not parallel to facial or lingual surface of


posterior tooth
Can’t Maintain Adaptation
Cause Solution

Incorrect grasp; not rolling instrument Sloppy technique with grasp makes it difficult to
handle control the instrument.
As we work around the circumference of the tooth, roll
the handle between our index finger and thumb to
maintain adaptation.

Split grasp Keep fingers together in the correct grasp position.

Fulcrum too close or too far away from tooth to be Finger rest should be near (but not on) the tooth to be
instrumented instrumented.
Fulcrum finger lifts off of the tooth as Fulcrum finger should be maintained in a straight,
stroke is made upright position throughout the stroke (acting as a
“support beam”).
Press down against the tooth with your fulcrum finger
so finger can act as a “brake” to stop the stroke

Tilting the instrument face away from Maintain correct face-to-tooth surface angulation as
the tooth surface during stroke (so we use a pull stroke to move the working-end in a
lateral surface or back of working-end coronal direction.
contacts tooth) Handle position should stay parallel to the tooth
surface as we make strokes (it should not tilt away
from the tooth
surface).

Not pivoting on finger rest On posterior teeth, pivot at line angles to maintain
adaptation.
In anterior sextants, as we work toward ourself, our
hand and arm should gradually pivot closer to our
body.
Uncontrolled or Weak Calculus Removal Stroke
Cause Solution

Instrument handle is supported solely Handle should rest against the index finger or hand for
by index finger and thumb support.

Fulcrum finger is relaxed and bent Fulcrum finger should be straight and apply pressure
against rest point on tooth (acting as a “support
beam”).

Stroke not stabilized; no lateral pressure with cutting During a work stroke, the index finger and thumb
edge against tooth surface should apply equal pressure against the instrument
handle, and the fulcrum finger applies pressure
against the tooth surface.

Wrist and arm not in neutral position Assess patient position, clinician position, and arm
position.
Missed Calculus Deposits! Deposits Missed at
Midlines of Anterior Teeth
Cause Solution

Not using horizontal strokes at midline Position the curette to the side of the midline with the toe
of facial or lingual surface aiming toward the junctional epithelium (but not touching
the junctional epithelium).
Make a series of short controlled horizontal strokes

Not overlapping vertical strokes at Position the working-end so that strokes will overlap for
midline surfaces toward and away

Not using a specialized instrument when indicated Use an area-specific curette with a miniature working-end
at midlines.
Missed Calculus Deposits! Deposits Missed at
Line Angles of Posterior Teeth
Cause Solution

Not using horizontal strokes at the Position the curette distal to the line angle with the
line angles toe aiming toward the junctional epithelium (but not
touching the junctional epithelium). Make a series of
short strokes around the line angle.

Not rolling handle to maintain As we work around a line angle, it is necessary to roll
adaptation to line angle the instrument handle between the index finger and
thumb to
maintain adaptation.
Missed Calculus Deposits! Deposits Missed
on Proximal Surfaces
Cause Solution
Not using indirect vision Use of indirect vision is vital for proximal surfaces.

Not rotating reflecting surface to view This problem is common on lingual surfaces of anterior
proximal surfaces teeth.
First, angle the mirror to view the surfaces toward us, and
then turn the mirror to view the surfaces away from us.

Not rolling handle to maintain adaptation As we work around a line angle and onto the proximal
surface, make small, continuous adjustments in adaptation
by rolling the handle.
Strokes not extended under contact Instrument at least one-half of a proximal surface from
area the facial and lingual aspects
Place curette between the papilla and the tooth surface.
Adapt the working-end to the tooth surface and insert it
to the junctional epithelium.

Working-end not “aimed” toward For distal surfaces of posterior teeth, the toe should aim
surface to be instrumented toward the back of the mouth.
Don’t try to “back the working-end” onto the distal
surface.
Conclusion
 The goal of instrument sharpening is to restore a fine, sharp cutting edge to a dull
working-end. To be successful, a sharpening technique should remove a minimum
amount of metal from the instrument and maintain the original design characteristics of
the working-end

 A sharp instrument allows the clinician to use less force, making the instrumentation
process more comfortable for the patient

Problems during instrumentation are likely to occur which should be identified and
corrected accordingly
References
• 1. Jill S. Nield-Gehrig, Fundamentals of periodontal instrumentation
and advanced root instrumentation, 7th edition, Lipincott Williams &
Wilkin
• 2. Fermin A. Carranza, Michael G. Newman, Perry R. Klokkevold,
Henry H. TAKEI, Clinical periodontology , 12th edition, Elsevier