Scaling and Root Planing: Key Concepts

• Scaling and root planing (S + RP) involves specific procedures with distinct aims in periodontal therapy

Scaling

• Scaling removes biofilm and calculus from both supragingival and subgingival tooth surfaces
• Supragingival scaling is the initial phase of debridement for patients with periodontal disease
• This facilitates subsequent subgingival scaling
• Supragingival calculus and gross overhang are removed first, followed by polishing the dentition
• Allows the patient to start a self-performed plaque control program
• Calculus itself doesn't induce inflammation, but its ability to provide an ideal surface for microbial colonization makes it harmful
• The rationale for removing calculus is to eliminate surface irregularities that harbor pathogenic bacteria

Root Planing

• Root planing removes residual embedded calculus and cementum portions to produce a smooth, hard, and clean surface
• Root planing instrumentation removes "contaminated" cementum and dentin
• Restores the biological compatibility of periodontally diseased root surfaces
• Initially, dentists performed root planing because they believed bacterial endotoxins penetrated the cementum
• Because of this, they thought it was necessary to remove biofilms, calculus, and the underlying cementum

S&RP Procedures

• S&RP are not separate
• Can be carried out in multiple visits
• The number of teeth included in each session for RP depends on the operator's skills and case severity
• Typically (4-6) teeth at each session
• The area is probed initially to identify the probing pocket depth (PPD)
• PPD measurement is the distance from the gingival margin to the most apical penetration of the periodontal probe

Root Surface Assessment

• Assess anatomy
• Identify location of deposits
• Insert the periodontal probe into the gingival crevice or periodontal pocket without pressure or force
• Measured in mm

Aims of Scaling and Root Planing

• Restore gingival health by completely removing elements that provoke gingival inflammation (biofilm, calculus & endotoxin) from the tooth surface
• Calculus deposits on root surfaces are frequently embedded in cemental irregularities
• Subgingival calculus is porous and harbors bacteria and endotoxin, therefore needing complete removal
• Biofilm bacteria may invade dentinal tubules when dentin is exposed
• Scaling alone is insufficient to remove them, and removing a portion of the root surface is necessary to eliminate these deposits
• The root surface is contaminated by toxic substances, notably endotoxins when exposed to biofilm and the pocket environment
• Evidence suggests these toxic substances are only superficially attached to the root and do not permeate it deeply
• Extensive removal of dentin and cementum is unnecessary to render the roots free of toxins
• The goal is to create a clean & hard root surface that is as smooth as possible
• Helps inhibit further plaque retention
• This promotes tissue healing, potentially with the formation of a long junctional epithelium, and aids soft tissue reattachment

Types of Subgingival Scaling & Root Planing

• Subgingival scaling & root planing are performed as either closed or open procedures under local anesthesia
• Closed procedure implies instrumentation subgingivally without displacing the gingiva
• Closed procedures often involve less trauma, pain, bleeding, and minimal recession
• Wound healing occurs more rapidly following closed procedures
• Closed therapy is the go too for mild and moderate periodontitis
• Represents the initial therapeutic approach before surgical intervention for complex & severe cases
• Closed therapy is limited by its performance without direct vision and good access for instruments
• Success depends on tactile sensation & knowledge of root morphology
• Experienced hygienists cannot always effectively treat all root surfaces, nor completely remove all plaque & calculus from all surfaces
• Ex: S+RP of poorly accessible, irregular root surfaces, in deep, narrow or distal pockets and substantial furcation involvement, even in patients with minimal mouth opening capacity & with expansively progressive disease
• Open procedure involves exposure of the affected root surface by displacing from the gingival tissue, via incision and reflection to facilitate instrument access and visibility for the operator
• Instruments used for scaling & root planing are Hand, Ultrasonic & sonic, Motor driven devices incorporating diamond-coated tips (reciprocating instruments), Rotating, and Laser-instruments. exert antimicrobial effects
• Laser devices have been introduced for various aspects of periodontal therapy, including S&RP Depending upon the wavelength and settings employed, some lasers ablate subgingival calculus and exert antimicrobial effects; however, recent guidelines do not suggest its use in periodontitis treatment due to low evidence available

Removal of Plaque-Retentive Factors

• Includes correction of the relation between faulty dentistry, (overhang fillings, defective crown margins, improperly situated clasps of P.D.) and periodontal disease due to its plaque-retentive property
• These conditions should be corrected either by correction or replacement of prostheses & restorations
• Prevents plaque accumulation & facilitates self-performed tooth cleaning and periodontal health

Corrections for Restorative Defects

• Recontouring defective restorations and crowns corrects restorative defects, which are plaque or biofilm retentive areas
• Recontouring is accomplished by smoothing the rough surfaces and removing overhangs from faulty restorations using burs or hand instruments, or complete replacement of the failing restorations
• These procedures can be completed concurrently with other Phase I procedures

Caries Control

• Dental caries, particularly root caries, is a problem for periodontal patients because of attachment loss and exposed root surfaces
• Fluoride is primarily effective topically to prevent and reverse the caries process whether in enamel, cementum, or dentin
• All periodontal patients should be encouraged to use fluoride-containing toothpaste daily
• Patients at high risk for caries should use a higher-concentration fluoride toothpaste or gel
• A lower concentration can be used during maintenance therapy
• A periodic chlorhexidine rinsing regimen to control cariogenic oral bacteria is part of the caries risk management program for high-risk individuals
• You should evaluate other considerations in caries control such as diet and reduced salivary flow, and modifications should be made where possible

Risk Factor Control

• Smoking and diabetes are two proven risk factors in the etiopathogenesis of periodontitis
• The control two risk factors should be an component in periodontitis treatment

Evaluation of Cause-Related Thearpy

• A thorough evaluation of Phase I therapy effects happen no less than 1-3 months (sometimes 9 months) after phase I therapy completion
• Reevaluation of the patient's periodontal conditions & caries activity should be performed no earlier than 4 weeks after the last S + RP procedures
• This provides time for tissues to heal by forming a long junctional epithelium
• Sufficient practice with oral hygiene skills helps the process
• Immediate evaluation by both scaling and root planning follows evaluation via tissue response
• Clinical evaluation of the soft tissue response to scaling and root planing, including probing, should not be conducted earlier than 2 weeks postoperatively
• Re-epithelialization of the wounds created during instrumentation takes 1-2 weeks
• Until then, gingival bleeding can be expected, even when calculus has been completely removed, due to the incompletely epithelialized tissue wound
• Gingival bleeding on probing noted after the interval is more likely the persistent inflammation from residual deposits or inadequate plaque control
• Clinical changes after instrumentation continue for weeks or months
• A longer evaluation period may be indicated before deciding whether to intervene with further instrumentation or surgery
• Reevaluation of the periodontal condition includes repeat probing of the entire mouth
• Evaluates calculus, root caries, defective restorations, and signs of persistent inflammation

Signs of Resolution

• Increased resistance of periodontal tissues to probing and a lack of bleeding indicate resolution of the inflammatory lesion related to sufficient biofilm/calculus removal
• Clinical endpoints of treatment success are defined as 1) no bleeding on pocket probing and 2) "pocket closure" or reduction, a PPD of ≤4mm
• Clinical improvement is less pronounced at molars, particularly furcation sites, than single-rooted teeth
• Smoking negatively effects periodontal therapies, so if the patient is a smoker, smoking cessation should be considered as an adjunctive measure
• The initial therapy phase is completed with analysis of the results
• The treatment deals with self-performed plaque control, plaque level (OLeary index), gingival inflammation resolution including less bleeding, shrinkage of the gingival soft tissue (recession), increased resistance to probe tip penetration by the tissues at the base of the pocket, probing pocket depth reduction, and, changes in probing attachment level, and reduced tooth mobility
• BOP measurement: insert a periodontal probe to the bottom of the gingival crevice or periodontal pocket at six points around the tooth surface; bleeding within 30 seconds gives score(1), non-bleeding gives score (0)
• Clinical attachment level (CAL) is the distance from the cementoenamel junction (CEJ) to where the periodontal probe tip reaches

Treatment Evaluation Outcomes

• Patients with improved oral hygiene, lacking gingival inflammation, lacking bleeding on probing with a marked reduction in probing pocket depth ≤4 mm need no further periodontal treatment and are advanced to the maintenance phase of periodontal therapy (supportive periodontal therapy)
• Patients with proper oral hygiene but sites of bleeding on probing with no significant probing depth reduction may require advancement to the corrective phase, including periodontal surgery (PPD≥6 mm or PPD> 4mm with BOP)
• Patients with inadequate oral hygiene need re-motivation and re-instruction to improve their oral hygiene because the periodontal oral hygiene can not be improved with the periodontal hygiene disease will recurrent with periodontal surgery

Chemical Plaque Control

• Influenced by compliance and dexterity, chemical plaque control acts as an adjunctive means to overcome inadequacies of mechanical cleaning

Mechanism of Action

• Achieved by quantitative reduction of the number of microorganisms and/or qualitative alteration of biofilm vitality

Characteristics of Chemical Plaque Control Agents :

• Specificity: Demonstrate a wide spectrum of action (bacteria, viruses, and yeasts) limiting antibiotics to prevention of bacteraemia, at-risk patients, and treatment of some periodontal conditions
• Efficacy: Antimicrobial capacity must combat microorganisms implicated in gingivitis and periodontitis.
• Substantivity: Is the duration of the antimicrobial and as a measurement of the contact time between the agent and the substrate in a defined medium
• Safety: Demonstrated in animal models before human use, minimizing secondary effects because of the chronicity of the conditions to be prevented and the foreseeable long-term use
• Stability: Agents remain stable at room temperature for an extended period, avoiding formulation interferences
• The action of chemicals fit into four categories: Anti-adhesive, Antimicrobial, Plaque Removal, and Anti-pathogenic

Characteristics of Chemical Plaque Control Agents (cont.)

• Anti-adhesive agents act at the pellicle surface, preventing initial attachment of primary plaque-forming bacteria and the development of biofilms
• Anti-microbial agents inhibit plaque formation via inhibiting bacterial proliferation, working at the pellicle-coated tooth surface before the primary plaque formation bacteria attach or attachment of the biofilm
• Plaque removal agents in mouth rinses reach all tooth surfaces and remove bacteria (chemical toothbrush, e.g., Hypochlorite's)
• Anti-pathogenic agents inhibit plaque microorganisms' pathogenicity without destroying them and approach to altering plaque ecology to a less pathogenic flora, e.g., Antimicrobial agents with bacteriostatic effect

Chemical Delivery Systems

• Chemical Delivery Systems exist in Tooth pastes-mouth rinses-spray-irrigators-chewing gum-varnishes,gel,chips
• These agents should have persistent hours-measured action/substantivity depending on absorption, antimicrobial maintenance, and slow release from the oral tissues
• Chlorhexidine (CHX) is the best chemical supra-gingival plaque control agent, Bisquanide antiseptic used as a mouth rinse (o. 2% or 0.12% w/v), gel, spray, varnishes, lozenges
• Chlorhexidine (CHX) is incorporated into tooth paste, chewing gum, slow sustained release vehicles (perio chip), periodontal packs and sub-gingival irrigation

Chlorhexidine CHX

• Characteristics: Nontoxic when digested, broad antimicrobial action, effective against fungi, yeast (Candida), viruses (human immunodeficiency virus, hepatitis B virus); bacterial resistance is undocumented
• Antimicrobial Effect: Mode of action is dependent upon the drug's access to bacterial cell walls, facilitated by electrostatic forces (chlorhexidine is positively charged; bacterial cell walls carry negative charges), disrupting the osmotic barrier, interfering and disturbing membrane transport, and induces bacteriostasis
• Depending on concentration, low concentrations can increase permeability of the plasmatic membrane, leading to a bacteriostatic effect
• Chlorhexidine can precipitate cytoplasm proteins and cell death, thus having a bactericidal effect
• Chlorhexidine has been demonstrated the capacity to penetrate and actively alter biofilm,
• Rinsing with chlorhexidine reduces oral bacteria in saliva by 50-90%; A reduction of 95% occurs around 5 days (overall reduction of is 70-80% at 40 days)
• Plaque inhibitory effect: CHX molecules adhere to the tooth surface, interfering with bacterial adhesion, and interacting to reduce the bacterial ability to stick to the tooth surface.
• Alters glycoprotein and reduces salivary pellicle formation, CHX reduces affects the activity of enzyme bacterial glucan production (glycosyl transferase C)
• Substantivity: CHX molecules bind reversibly to oral tissues, for sustained antimicrobial effects for up to 12 hours An After a 1-minute 0.2% chlorhexidine (10ml) mouth rinse, approximately 30% of the drug is retained, and half will have bonded to

Chlorhexidine Uses

• Contraindications include hypersensitivity to CHX.
• Single use to reduce the bacterial load, decrease the risk of bacteremia and infection in the surgical area
• Short term, the prevention of dental formation after subgingival, periodontal instrumentation or implants
• Use as implant therapy for gingivitis therapy, candidiasis therapy(denture stomatitis), and peri-implant mucositis therapy
• Long term reduces risk of long-term biofilm formation, disabilities, gingival, periodontitis, implants, infections, oral mucositis, caries, candidiasis, recurrent aphthous ulcers, and halitosis
• Side effects: Brown discoloration of teeth, taste perturbation, calculus formation, and parotid swelling
• To avoid the prolonged use of for CHX, the patient should be oral hygiene patient
• Rinsing CHX prevents gingivitis by inhibiting plaque regrowth where as the tooth paste may prevent its effectiveness for its chlorhexidine additives.

Mouth Rinses

• CHX mouth rinse adsorbed to the pellicle-coated enamel surface of the tooth surface
• CHX mouth rinse products includes, Nonprescription Essential Oil Rinse
• Nonprescription Essential Oil Rinse preparations (Listerine contains thymol, eucalyptol, menthol, and methyl salicylate) can reduce plaque (20-35%) and gingivitis (35.5-25%), however it is only as daily usage to prevent daily safety

The Products available

• Triclosan (toothpaste) reduces reduce plaque biofilm and gingivitis, other include stannous fluoride, cetylpyridinium chloride quaternary ammonium, and sanguinarine, but the results are not as effective with CHX Products

Explore essential principles of scaling and root planing in periodontal therapy. Understand the goals, targets, and factors influencing treatment outcomes. Learn about root surface contamination and biofilm effects.