Wonderful question,Nazanin! I will use your situation to elaborate on how we approach periodontal therapy on a patient with a Type IV or III classification as these strategies apply whether using ultrasonics or not.
My first question would be, do you have access to a piezoelectric device? If so, then problem solved, since piezoelectric ultrasonic devices do not pose any threat to cardiac pacemakers.
If not, then you will need to fall back on your hand instrumentation skills. Although shielded pacemakers used today have a lower potential for magnetic interference, the American Academy of Periodontology recommends that you avoid exposing patients with cardiac pacemakers to magnetostrictive devices such as Cavitrons.
Hand instrumentation for a patient with advanced disease status must be carefully planned, in terms of time allotment, armamentarium, and implementation. It goes without saying that instruments must be optimally sharpened and contoured, instrumentation fundamentals be applied with careful focus, and the patient be comfortably anesthetized with local/block anesthesia for your therapy to be successful.
Begin instrumenting only those teeth you are certain you can complete in the appointed time: this may be a quadrant, or a sextant, or - depending on the amount of calculus and the depth of pocketing - only two teeth. The major point here is to take full advantage of gaining access to the base of pockets. NOTE: This access is compromised once the coronal cuff of gingival tissue tightens in response to full mouth gross scaling/initial debridement whereby the ultrasonic is used throughout the mouth as a "first step" to periodontal therapy. This is NOT the initial step to periodontal therapy: Just Don't Do It.
Another detriment to initial FM ultrasonic debridement is that when the swelling and sensitivity calm down in response to gross scaling, many patients will question whether additional therapy is "really that important" since their whole mouth was treated and everything feels better. . . many patients will decide to not return and thus never receive the definitive therapy they are in serious need of receiving. Instrumenting to completion in segments will make the patient profoundly aware of the contrast between their current state of disease and where healing has occurred in response to your therapy, reinforcing the value of your work and obvious need for additional therapy until their treatment is complete.
The type of instruments used will make a big difference in your ability to tackle this case with success. I will include in this summary some of the hand instruments I would use in my perio practice, as this type of patient is the norm in our office, and we know what works and what does not!
The order of instrumentation is also important, as it will ensure your time is used to its maximum benefit for efficiency and also spare you the muscular fatigue of hand instrumentation without the benefit of power scaling. So use a prescribed order of sequence for your therapy, treating only those teeth in the segment you plan to complete that day that have been fully anesthetized.
I would begin with sickle scalers--both anterior and posterior. If there is heavy calculus in the posterior, use the IUFW 204 with wrist rock activations to crack off the bulk of deposit on proximal surfaces. The NEVI-4 is another wonderful instrument that has adequate shank rigidity for superior calculus removal. The idea here is to remove the bulk of deposit with the easiest and least fatiguing approach using instruments that offer the greatest leverage!
The next instrument classification we move to is the periodontal file, which is uniquely suited to provide this important first step of crushing and fracturing calculus in the depths of pockets where sickle scalers cannot access. Use Hirschfeld files (Hirschfeld 3/7 and 5/11), inserting them all the way to the base of the pocket; your periodontal probings and radiographs are essential to guide insertion depths and angulation in advanced perio therapy so display them for your reference during treatment. The periodontal file acts as a series of minute sickle scalers and if you are unfamiliar with this instrument, it can become your new best friend! Activate linear pull strokes that are parallel to the terminal shank of the instruments (perpendicular to the blades themselves).
Periodontal files are an essential instrument for dental hygienists because they are the one instrument that is effective on burnished calculus. Use them on any periodontal maintenance patient with areas that bleed upon probing--especially those areas with minute pinpoint bleeding, as that is an indication of burnished calculus. They can be used in any direction--vertical, oblique, and horizontal which is especially effective on the CEJ.
Because sickles and files are not definitive debridement instruments, they must be followed up with scaling and root planing using curets with blade curvatures that can access the many contours of teeth. (NOTE: This is also the reason why following ultrasonic instrumentation with hand instruments will produce more favorable clinical outcomes!)
Begin with universal curets, which provide better torque and leverage than Gracey curets. Again, the idea is to remove as much calculus as possible in the easiest way possible--the idea behind sequencing of instrumentation. My favorite universal curets for periodontal therapy are the Columbia 4R/4L, Barnhart 5/6 (rigid), McCall 17/18 and Younger-Good 7/8.
Gracey and mini-Gracey curets follow the use of universal curets and I recommend you use rigid Graceys whenever possible. The most essential Gracey instruments are #s 5/6, 7/8, 11/12, & 13/14, and mini-Gracey #s 5/6 and 13/14. Of course there are many more to choose from including micro-mini Graceys, but if you want a set of "bare bones" Graceys that will work well for periodontal therapy, these will suffice.
While Gracey curets are area-specific, they can also be used in many other applications in periodontal therapy; e.g., the Gracey 5/6 is very effective in posterior segments and the Gracey 13/14 is highly versatile and is not limited to distal surfaces. If you are interested in expanding your skills, look for a hands-on course in advanced periodontal instrumentation taught by Anna Pattison. I often assist with these courses and I also teach in-office hands-on courses in advanced instrumentation and perio therapy for those people interested in more focused, one-on-one instruction and follow-up. Anna also offers online subscriptions to DVD courses through the Pattison Institute that will expand to advanced instrumentation in the future. You can find them online at https://www.pattisoninstitute.com.
I hope this helps give you an idea of the strategies we use on advanced perio case types and I wish you best of luck! Stacy
204 INDIANA UNIVERSITY FORT WAYNE SCALER
4 NEVI® POSTERIOR SCALER
3/7 HIRSCHFIELD FILE SCALER
5/11 HIRSCHFIELD FILE SCALER
4R/4L COLUMBIA UNIVERSITY CURET
5/6 RIGID BARNHART CURET
17/18 MCCALL CURET
7/8 YOUNGER-GOOD CURET