Rationale for scaling and root Rationale for scaling and root planingplaning

Process by which Process by which plaque and calculus plaque and calculus are removed from are removed from both supra and both supra and subgingival tooth subgingival tooth surface.surface.

Process by which Process by which residual embedded residual embedded calculus and portion calculus and portion of cementum are of cementum are removed from the root removed from the root to produce a smooth, to produce a smooth, hard and clean hard and clean surfacesurface

ScalingScaling Root PlaningRoot Planing

Changes in root surfaces in Changes in root surfaces in periodontitisperiodontitis

A.A. Plaque and Calculus Plaque and Calculus deposition.deposition.

Supra and subgingival Supra and subgingival calculus have a rough calculus have a rough surface capable of surface capable of harboring plaque that harboring plaque that cannot be removed by cannot be removed by conventional oral conventional oral hygiene techniques.hygiene techniques.

Bauhammers et Bauhammers et

al,1973al,1973..

Changes in root surfaces in Changes in root surfaces in periodontitisperiodontitis

B. B. Alterations in exposed Alterations in exposed cementumcementum

Hypermineralized surface Hypermineralized surface zonezone

Changes in organic matrixChanges in organic matrix

Endotoxins cytotoxic in Endotoxins cytotoxic in tissue culture tissue culture

Aleo et al , Aleo et al , 19741974

Primary objectivePrimary objective

Restoration of gingival healthRestoration of gingival health

Scaling and root planing are not separable Scaling and root planing are not separable proceduresprocedures

Before Scaling & Root Before Scaling & Root PlaningPlaning

After Scaling & Root After Scaling & Root planingplaning

Scaling and root planingScaling and root planing are a prerequisite are a prerequisite for the arrest and cure of periodontal for the arrest and cure of periodontal disease; together with plaque control, they disease; together with plaque control, they constitute the major means by which the constitute the major means by which the disease is prevented.disease is prevented.

Careful subgingival scaling and root Careful subgingival scaling and root planing is an effective mean to eliminate planing is an effective mean to eliminate gingivitis and reduce the probing depth gingivitis and reduce the probing depth even at sites with initially deep periodontal even at sites with initially deep periodontal pockets.pockets.

Badersten, 1984Badersten, 1984

Subgingival scaling and root planing Subgingival scaling and root planing are measures which can be effective in:are measures which can be effective in:

Eliminating inflammationEliminating inflammation

Reducing probing depthsReducing probing depths

Improving clinical attachmentImproving clinical attachment

Objectives Of Root PlaningObjectives Of Root Planing

Securing biologically acceptable root surfacesSecuring biologically acceptable root surfaces

Resolving inflammationResolving inflammation

Decreasing pocket depthDecreasing pocket depth

Facilitating oral hygiene proceduresFacilitating oral hygiene procedures

Improving or maintaining attachment levelImproving or maintaining attachment level

Preparing the tissues for surgical proceduresPreparing the tissues for surgical procedures

Scaling and root planing is an integral part of Scaling and root planing is an integral part of periodontal therapy. The rationale for scaling periodontal therapy. The rationale for scaling and root planing is the following: and root planing is the following:

Removal of calculus and "infected" root Removal of calculus and "infected" root structure structure

Achievement of a smooth root surface which Achievement of a smooth root surface which is less prone to plaque accumulation is less prone to plaque accumulation

Rationale for root planingRationale for root planing

Garret in 1977Garret in 1977 set forth the rationale for set forth the rationale for root planingroot planing

Root SmoothnessRoot Smoothness

Removal of Diseased CementumRemoval of Diseased Cementum

Preparation for New AttachmentPreparation for New Attachment

Root SmoothnessRoot Smoothness

No biological evidence which relates No biological evidence which relates smooth root surfaces to decreased plaque smooth root surfaces to decreased plaque formation or increased ease of removal.formation or increased ease of removal.

It remains the only clinical indicator of It remains the only clinical indicator of calculus removal available at present.calculus removal available at present.

Recent data suggests Recent data suggests that root structure that root structure removal is not necessary. removal is not necessary. The end point of scaling The end point of scaling and root planing is and root planing is however a smooth root however a smooth root surface as rough surfaces surface as rough surfaces are more prone to plaque are more prone to plaque accumulation.accumulation.

Calculus can be seen in Calculus can be seen in radiographs or detected radiographs or detected clinically. clinically.

Removal of Diseased CementumRemoval of Diseased Cementum

Removal of exposed cementum by root Removal of exposed cementum by root planing, the fibroblasts adhered to both planing, the fibroblasts adhered to both diseased and non diseased areas of the diseased and non diseased areas of the root.root.

Aleo et al, 1975.Aleo et al, 1975.

Deposits of calculus on root surfaces are Deposits of calculus on root surfaces are frequently embedded in cemental frequently embedded in cemental irregularities ( Zander,1953; Moskow, irregularities ( Zander,1953; Moskow, 1969)1969)

Scaling alone is therefore insufficient to Scaling alone is therefore insufficient to remove calculus. A portion of cementum remove calculus. A portion of cementum must be removed to eliminate these must be removed to eliminate these deposits.deposits.

Preparation for New AttachmentPreparation for New Attachment

Root planing plays an important role in Root planing plays an important role in preparing root surfaces for demineralization preparing root surfaces for demineralization and subsequent new attachment and subsequent new attachment

To determine efficacy of therapy, therapeutic To determine efficacy of therapy, therapeutic goals must first be established. In periodontal goals must first be established. In periodontal therapy, our objectives are as follows: therapy, our objectives are as follows:

Suppression or elimination of pathogenic Suppression or elimination of pathogenic bacteria bacteria

Establishment of a healthy root surface Establishment of a healthy root surface

Conversion of inflamed to healthy tissues Conversion of inflamed to healthy tissues

Reduction of periodontal pockets Reduction of periodontal pockets

Scaling and root planingScaling and root planing has both local has both local and systemic sequelae. and systemic sequelae.

Locally, the results of scaling and root Locally, the results of scaling and root planing are: planing are:

Debridement of bacteria and calculus Debridement of bacteria and calculus

Removal of infected cementum and dentin Removal of infected cementum and dentin

A shift in the microbial population A shift in the microbial population

Scaling and root are not Scaling and root are not always the only measures always the only measures that are required in order that are required in order to properly eliminate to properly eliminate subgingival infection in subgingival infection in deep pockets.deep pockets.

Waerhaug(1978)Waerhaug(1978)

If, following scaling and If, following scaling and root planing, signs of root planing, signs of “bleeding” on probing to “bleeding” on probing to the bottom of the pocket” the bottom of the pocket” persist, and if the clinical persist, and if the clinical attachment level fails to attachment level fails to improve, surgical therapy improve, surgical therapy should be considered should be considered since this treatment may since this treatment may facilitate more adequate facilitate more adequate root debridment .root debridment .

Caffesee etal (1986)Caffesee etal (1986)

The microbial shift is effected by two The microbial shift is effected by two mechanisms mechanisms The removal of bacteria by scaling and root The removal of bacteria by scaling and root planing planing The clinical outcome of scaling and root planing The clinical outcome of scaling and root planing which alters the environment favoring population which alters the environment favoring population by certain bacteria over others by certain bacteria over others – Decreased pocket depth Decreased pocket depth – Smooth root surfaces Smooth root surfaces – Reduction of inflammation Reduction of inflammation

Scaling and root planing also has systemic Scaling and root planing also has systemic effects. These are a bacteremia and a effects. These are a bacteremia and a host immune response host immune response

Incidence of Bacteremia During Different DentalIncidence of Bacteremia During Different Dental

Procedures Procedures Heimdahl, et al., 1990 Heimdahl, et al., 1990 Surgical Surgical ProcedureProcedure

% of Patients % of Patients with with BacteremiaBacteremia

%Viridans %Viridans group group streptococcistreptococci

% % AnaerobesAnaerobes

Dental Dental ExtractionExtraction

100100 8585 7575

Scaling and Scaling and Root Planing Root Planing

7070 5555 6565

Third Molar Third Molar Surgery Surgery

5555 4040 4545

Endodontic Endodontic Treatment Treatment

2020 1515 55

Bilateral Bilateral Tonsillectomy Tonsillectomy

5555 4040 4040

Based on this study it can Based on this study it can be seen that immediately be seen that immediately after undergoing scaling after undergoing scaling and root planing the and root planing the majority of patients (70%) majority of patients (70%) will have a bacteremia.will have a bacteremia.

The same study also The same study also showed that ten minutes showed that ten minutes after the procedure, the after the procedure, the incidence of bacteremia incidence of bacteremia is down to 30%. is down to 30%.

This indicates that the This indicates that the host immune response is host immune response is effective in eliminating the effective in eliminating the bacteria from the bacteria from the bloodstream, resulting in bloodstream, resulting in the rapid decline in the the rapid decline in the recovery of bacteria. For recovery of bacteria. For this reason, it is referred this reason, it is referred to as a to as a transient transient bacteremia. bacteremia.

The Efficacy of Scaling and Root The Efficacy of Scaling and Root PlaningPlaning

A study published in 1987, by Buchanan and A study published in 1987, by Buchanan and Robertson, examined teeth (treatment planned Robertson, examined teeth (treatment planned for extraction) that were scaled and root planed for extraction) that were scaled and root planed for 12-15 minutes each, subsequently extracted for 12-15 minutes each, subsequently extracted and examined microscopically for residual and examined microscopically for residual calculus. Results were recorded as percentages calculus. Results were recorded as percentages of calculus positive teeth (CPT) and calculus of calculus positive teeth (CPT) and calculus positive surfaces (CPS). These were compared positive surfaces (CPS). These were compared to similarly examined teeth that received no to similarly examined teeth that received no treatment prior to extraction. treatment prior to extraction.

The Efficacy of Scaling and Root PlaningThe Efficacy of Scaling and Root Planing Effect of Scaling and Root Planing on Calculus Effect of Scaling and Root Planing on Calculus

RemovalRemovalBuchanan and Robertson, 1987 Buchanan and Robertson, 1987

TreatmentTreatment Probing Depth (mm)Probing Depth (mm) % CPT% CPT % CPS% CPS

None None 6.0 ± 2.6 6.0 ± 2.6 100100 8282

S/RP S/RP 5.7 ± 2.4 5.7 ± 2.4 6262 2424

Even on treated teeth, a fairly high percentage of Even on treated teeth, a fairly high percentage of calculus was remained after scaling and root planing.calculus was remained after scaling and root planing.

When comparing calculus removal by When comparing calculus removal by tooth type, tooth surface and probing tooth type, tooth surface and probing depth, the results were fairly in keeping depth, the results were fairly in keeping with logic .with logic .

The Efficacy of Scaling and Root The Efficacy of Scaling and Root Planing Planing

% Calculus Positive Surfaces After S/RP by Tooth % Calculus Positive Surfaces After S/RP by Tooth TypeType

Buchanan and Robertson, 1987 Buchanan and Robertson, 1987

TreatmentTreatment Anterior TeethAnterior Teeth PremolarsPremolars MolarsMolars

None None 8787 7575 8383

S/RP S/RP 19 19 2929 2626

The Efficacy of Scaling and Root The Efficacy of Scaling and Root PlaningPlaning

% Calculus Positive Surfaces After S/RP by Tooth % Calculus Positive Surfaces After S/RP by Tooth SurfaceSurface

Buchanan and Robertson, 1987 Buchanan and Robertson, 1987

TreatmentTreatment MesialMesial DistalDistal Facial Facial LingualLingual

None None 9191 9696 6464 7777

S/RP S/RP 2828 4141 1717 1010

The Efficacy of Scaling and Root The Efficacy of Scaling and Root Planing Planing

% Calculus Positive Surfaces by Probing Depth% Calculus Positive Surfaces by Probing DepthBuchanan and Robertson, 1987 Buchanan and Robertson, 1987

TreatmentTreatment 0-20-2 2.1-42.1-4 4.1-64.1-6 6.1-86.1-8 >8>8

None None 6767 6969 8484 9090 8888

S/RP S/RP 22 1414 2424 3636 4545

These data indicate that generally These data indicate that generally calculus is calculus is harder to remove in the posterior teeth as harder to remove in the posterior teeth as compared to anterior teethcompared to anterior teeth, or with , or with proximal proximal surfaces as compared to facial or lingual/palatal surfaces as compared to facial or lingual/palatal surfacessurfaces, and in , and in deeper pockets as compared to deeper pockets as compared to more shallow pockets. more shallow pockets.

An interesting point is that calculus removal by An interesting point is that calculus removal by scaling and root planing was more efficient in the scaling and root planing was more efficient in the molar region than in the premolar region, but molar region than in the premolar region, but only slightly so. only slightly so.

The endpoint of clinical therapy is the The endpoint of clinical therapy is the elimination of inflammationelimination of inflammation. To achieve this, . To achieve this, open debridement may be required in addition open debridement may be required in addition to scaling and root planing, and treatment may to scaling and root planing, and treatment may be aided by chemotherapeutic agents. be aided by chemotherapeutic agents.