I am having difficulty accessing deep calculus located directly on the distal of all posterior molars, especially when those teeth have crowns in place and tissues are tight. What is the best way to remove it and which instruments work best? I greatly look forward to your advise. THANK YOU!
Hello Georgina - - great question!
Calculus deposits on posterior distals can be challenging for a number of reasons: access can be difficult, especially with deep deposits underlying tight fibrotic tissue. With crowns in place, vertical strokes need to be well controlled--i.e., stopping short of the crown margin.
The best way to approach the scenario you describe is to use Hirschfeld files (Hirschfeld 3/7 and 5/11) to initially crush and fracture the calculus. Hirschfeld files are tiny and have a very narrow profile in both width and thickness. More importantly, they will easily reach the base of deep pockets, even when the tissue is fibrotic--in fact, often they are the only instrument that will work!
Additionally, if you have attempted to scale and root plane these surfaces, the calculus that is present is likely partially scaled or burnished, making it more difficult to detect and remove. The initial use of Hirschfeld files solves this problem since they are one of very few instruments effective on burnished calculus.
Insert the Hirschfeld periodontal file on distal surfaces and make short, well controlled strokes in a variety of directions (oblique, vertical, and horizontal if possible). Then follow up with curets to actually remove the deposits.
A universal curet gives you the most leverage and torque, if it will fit. Following universals (or in lieu of, if they don't fit), move to a mini-bladed Gracey 13/14, which will provide superior adaptation to deeper root concavities on distal surfaces. Use a vertical stroke with firm lateral pressure to cleanly remove the deposit.
Check the texture of the root using a Hu-Friedy 3A periodontal explorer with the lightest pressure. This explorer will access the deepest pockets with ease, giving you the information you need to determine whether additional instrumentation is necessary.
I hope this helps!