Principles of scaling and root planing

Term scaling refers to the instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus, and stains from these surfaces 1. Root planing is defined as a treatment procedure  designed to remove cementum or surface dentin that is  rough, impregnated with calculus,  or contaminated  with toxins or microorganisms 2. It was Albucasis who designed a set of instruments to remove calculus around 1000 years ago. He believed that removal of calculus was essential for keeping the mouth healthy. Cleaning of tooth surfaces was also recommended by Pierre Fauchard (father of modern dentistry) to cure gum diseases and he designed specific instruments for this purpose. Riggs (1882)(1882) 3, stressed upon the importance of scaling in the treatment and prevention of periodontal diseases. He stated that if tartar is deposited over the tooth surfaces, the first principle of surgery demands that it should be removed and following its removal within three days a marked improvement is noticed.

Rationale for scaling

Numerous clinical and histopathological studies have demonstrated beneficial effects of calculus removal on gingival and periodontal health 4-10. Calculus present on enamel surface in supragingival areas can be easily removed, but calculus present in subgingival areas and interproximal areas is difficult to remove. It has been demonstrated that calculus deposited in supragingival areas has a much less physical hardness as compared to the underlying tooth structure which makes it easily removable 11. However, during calculus deposition on cementum surfaces, the apatite crystals may be deposited onto the cemental surfaces as well as into the calculus matrix. It brings the two structures in an intimate contact and makes calculus removal from the cemental surfaces more difficult as compared to that from enamel surfaces 12.

Another factor responsible for firm cementum and calculus attachment is increased the microscopic roughness of cementum surfaces facing periodontal pocket 13. During pocket formation, the Sharpey’s fiber insertion sites are exposed which may be responsible for increased micro roughness. Another reason for increased micro-roughness may be the resorption process on cementum surfaces during pocket formation.  Another major reason for difficult removal of cementum associated calculus is that the hardness of calculus is twice as that of cementum 11.

Rationale for root planing

As already stated, the cementum surface exposed to the periodontal pocket is rough as compared to non-exposed areas. The rough surfaces act as a reservoir for microorganisms and hence disease progression. The resorption defects formed on the cementum during pocket formation also serve as a reservoir for the plaque which may serve as foci of re-infection. Hence, removal of…………………..

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Daly (1982) 18 demonstrated that microorganisms associated with periodontal disease penetrated the cementum till the depth of cementodentinal junction and suggested removal of all the periodontally involved cementum. However, in the same year Nakib et al. 19 demonstrated that endotoxin adhered to the tooth surface without penetration into cementum of either periodontally healthy or diseased teeth, and binding of the endotoxin to the root surface appeared to be weak. Hence, the removal of all cementum was not recommended by the authors. These findings have been supported by many other studies 20-24. Researchers have advocated that extensive root planing is not essential for endotoxin removal from the root surface 22. Hence, while doing root planing a very thin layer of cementum needs to be removed to achieve a biologically acceptable root surface.

Scaling and root planing creates a layer of organic and mineralized debris known as the smear layer that covers the surface of the instrumented roots and occludes the dentin tubules 25-27. The average thickness of this layer is approximately 2-15 μm 28. This smear layer may act as a physical barrier between the healing periodontal tissues and the root surface.

Instruments used for scaling and root planing

Presently, a large number of hand instruments are available for scaling and root planing. A detailed description of these instruments is available in “Periodontal instruments” (chapter 49). The oldest instruments used for scaling are scalers or sickles. When adapted properly, the cutting edge of these instruments makes an angle of 90⁰ with the tooth surface. Some sickles are designed with their blade and shank in a straight line with the handle, while others (jacquette) have an angulated shank to facilitate access to various tooth surfaces. These are used for supra-gingival scaling.

Another instrument used for scaling is the hoe. It is used to remove calculus from the root surfaces and deep pockets. The angle between the outer cutting surface and the face of the hoe is about 70⁰. The working face of hoe should make a 90⁰ angle with the root surface. The shank of hoe is slightly bowed so that it can maintain a two-point contact on a convex tooth surface. At least four different hoes are required to get access to all circumferential tooth surfaces.

The most important instrument used for subgingival scaling and root planing is a curette. A detailed description of the design of curettes, their classification and their method of application has been discussed in “Periodontal instruments” (chapter 49) and “Principles of instrumentation” (chapter 50). Area specific curettes are used for removal of calculus deposits on the root surfaces in different parts of the dentition. For root planing, an angle of……………………………………

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The instrument is activated by placing the flat side of the blade on the root surface with cutting edge engaging the calculus. Chisels are very useful in removing calculus in the mandibular anterior region from interproximal areas. The primary problems associated with their use are gouging and streaking and therefore should be used carefully.

Identification of calculus deposits

The first step in carrying out scaling and root planing is the detection of sites with calculus deposition. The areas with calculus deposition can be identified by visual examination under bright light. Both the supragingival calculus and calculus just below the gingival margin can be identified under good lighting and clean field. A jet of compressed air can be used to identify calculus deposits on the root surface facing periodontal pocket. The compressed air displaces the soft tissue away from the tooth surface, making deposits near the cervical area of root visible.  Use of explorers to detect sites with calculus deposits is a common method used by clinicians. This method requires a sharp and pointed explorer or probe which is moved in the subgingival areas on the root surface and changes in tactile sensation are observed. The instrument is held in the hand with a light but stable modified pen grasp. This grasp provides maximum tactile sensation. The pads of the fingers perceive slight vibrations conducted through the instrument through the instrument shank. The tip of the instrument is moved………………

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Initially, it is difficult to differentiate between fine calculus deposit and altered cementum but with experience, one can identify and differentiate between various changes on the cementum surface, root surface morphologies and calculus deposits on the root surface.

Clinical procedure for scaling and root planing

Scaling and root planing are the two basic procedures carried out in patients with accretions on the teeth and periodontal disease.  Scaling and root planing are not separate procedures, but a component of the initial periodontal therapy of complete periodontal treatment plan. The appointments required for procedures may vary according to the clinical presentation of the case. In patients with less calculus deposit and relatively healthy periodontium, only one appointment may be sufficient, whereas, in patients with a lot of calculus deposits and inflamed periodontal tissues, more appointments may be required for these procedures.

Supragingival scaling:

The supragingival calculus is clinically visible under good lighting and clean field. It is less tenacious and less calcified which makes it easily removable from the tooth surface. Because it is deposited above the gingival margins, there are a fewer chances of any damage to the soft tissue. The scaling instruments can be easily placed in a proper angulation because there is no hindrance from the soft tissue. The instruments used for supragingival scaling include sickles, curettes, sonic and ultrasonic power driven scalers and to a lesser extent chisels and hoes. The instrument is held in a modified pen grasp and finger rest is established. The cutting edge of the instrument is placed to engage the apical edge of the calculus with the face of the blade making an angulation of slightly less than 90⁰ with the tooth surface (Figure 51.1). After the instrument has been stabilized; short, powerful overlapping scaling strokes are activated in the coronal direction with a pull action. It must be noted that while using the sickles, their sharp tip may lacerate the soft tissue of the gingiva and gouge the exposed root surface, so care must be taken to properly adapt the instrument to the tooth surface and carefully activating the stroke.

Figure 51.1 The calculus is engaged at its apical portion and a pull stroke is given to remove it

The calculus is engaged at its apical portion and a pull  stroke  is  given  to  remove  it

Once all the visible calculus has been removed and the tooth surface is free of all the supragingival deposits, the areas just below the gingival margins should be inspected. If there is any visible calculus deposit, it should be removed using curettes or sickles (if the soft tissue is not injured). Finally, when all the surfaces of the teeth are free from calculus, polishing is done to smoothen out any surface irregularities, which may result due to instrumentation.

Subgingival scaling and root planing:

As already discussed, subgingival calculus is harder as compared to supragingival calculus and is difficult to remove due to its close adaptation to the cementum on the root surface. The subgingival instrumentation becomes more difficult due to the overlying tissue, which makes the adaptation of proper angulation of the instrument difficult. The clinician has to rely heavily on the tactile sensitivity because the vision is, most of the times, obscured by bleeding. The scaling instrument can easily extend beyond the junctional epithelium especially if…………………….

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The most common instruments used by most of the clinicians for subgingival scaling and root planing are curettes. Both universal and area specific curettes have been designed for subgingival scaling and root planing. Area specific curettes such as Gracey curettes have been designed to reach all the surfaces of dentition as closely as possible. As already described in the chapter 50 “Principles of instrumentation”, the instrument is held in a modified pen grasp and is stabilized by establishing a secure finger rest. An appropriate finger rest should allow keeping the lower shank of the instrument parallel to the long axis of the tooth and should allow the operator to use wrist arm motion to activate strokes (Figure 51. 2). The finger rest should be close to the working area so that appropriate instrumentation can be done. A finger rest established too far from the working area forces the clinician to separate the middle and ring finger due to which the stroke activation requires finger flexion. It adversely affects the scaling and root planing strokes and thus, the quality of the instrumentation. In certain posterior areas in the maxillary arch, opposite arch or extraoral fulcrums are required to stabilize the instrument.

Figure 51.2 While engaging the instrument on the root surface, the lower shank of the instrument is parallel to the long axis of the tooth

Placement of terminal shank of the instrument

As already stated, the lower shank of the instrument is kept parallel to the long axis of the tooth. The working end of the instrument is then inserted into the periodontal pocket, with close to 0⁰ angulation and after it reaches the base of the pocket and apical end of the calculus is engaged, a working angulation between 45⁰ and 90⁰ is established. Pressure is applied laterally against the lateral wall of the tooth and a series of controlled overlapping, short and powerful pull strokes are made to dislodge calculus from the root surface. The instrument should be closely adapted to the root surface during instrumentation. The instrument handle can be rolled between thumb and finger to adapt the cutting edge on line angles, development depressions and other changes on the root surface. The amount of lateral pressure applied depends on the nature of the calculus. More pressure is required to remove tenacious calculus. Small files may be used to remove heavy calculus to reduce its bulk and then curettes are used to remove remaining calculus. Files have a small head, so they can be inserted in the narrow, deep pocket to crush heavy calculus.

The excessive lateral pressure during subgingival scaling and root planing may result in loss of tooth structure and formation of nicks and gouges. Sometimes ditches may be formed on the root surface because of excessive removal of cementum from a particular area. To avoid these problems, short, powerful scaling strokes are used initially to remove calculus and as soon as calculus and root surface roughness has been eliminated longer root planing strokes with light pressure are applied.

The removal of calculus from the interproximal areas is difficult, especially if the contacts are wide. Scaling and root planing below the contact areas of the adjacent teeth is done by keeping the lower shank of the instrument parallel to the long axis of the tooth and extending the cutting edge as far as possible below the contact area. With lower shank parallel to the long axis of the tooth, the blade of the curette can reach the base of the pocket and instrument stroke can reach at least halfway across the proximal surface. If the lower shank is angled and tilted away from the tooth, the toe will move towards contact area and cutting edge won’t be able to engage the calculus. On the other hand, if the lower shank is tilted towards the contact area, application of scaling and root planing strokes will be hindered.

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Post-treatment problems and care after scaling and root planing:

The patient may experience discomfort or pain following scaling and root planing, depending on the severity of gingival inflammation, which usually lasts anywhere from a few hours to 3 days. If the discomfort is more, it can be controlled with ibuprofen or acetaminophen (Tylenol). Another common problem faced after scaling and root planing is tooth sensitivity (hot/cold/sweet). The sensitivity may be intense at first, but generally, resolves within a few days to a few weeks. The patient may experience minor gingival bleeding while brushing immediately after scaling and root planing which disappears within a few days as the healing progresses. In some cases, the patient may experience minor discomfort while chewing hard food, which may be caused due to deep periodontal pockets and inflammation. This problem also subsides within a few weeks as the healing progresses. Although persistent bleeding after scaling and root planing is rare, but if the patient complains about it, he/she must be recalled to the dental office to find out the cause of bleeding. To reduce these post-operative problems, the patient is asked to follow the following instructions,

  • The patient should be asked to perform gentle and thorough plaque removal 2-3 times daily with a toothbrush (manual or mechanical), dental floss and/or other health care instruments recommended.
  • The patient should be asked to rinse the oral cavity with warm salt water few days following the treatment and mild analgesics may be used to reduce the discomfort during this period.
  • Chlorhexidine mouthwash may be prescribed to reduce inflammation and bleeding.
  • If the patient is experiencing sensitivity, desensitizing agents may be prescribed.

Healing after scaling and root planing

In most of the cases, immediately after scaling and root planing the epithelial attachment is severed and junctional and sulcular epithelium is partially removed 29, 32, 33. If the gingival tissue is severely inflamed, the scaling instruments often extend beyond the epithelial attachment and create tears in the connective tissue. Under the microscope………………………

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After 24 hours intense mitotic activity within the epithelium can be observed and within 48 hours the entire gingival crevice is covered with epithelium. In the next 4-5 days, the formation of new epithelial attachment takes place. Depending on the extent and severity of inflammation the complete healing of the epithelium takes place within 1-2 weeks.

In one investigation done on monkeys 34, the authors observed following changes during healing after scaling,

  1. The newly formed epithelial cells are derived primarily from the remaining cells of the junctional and crevicular epithelium.
  2. The regeneration of the epithelium reaches its peak 1-2 days following scaling.
  3. The healing of connective tissue reaches its peak 2-3 days after scaling.
  4. A new epithelial attachment may be established as early as 4-5 days after scaling.

Some less detailed studies on humans 6, 33 also demonstrate similar events of healing except that the time interval for various healing processes may vary. The complete healing of the epithelium may take as long as 9 months or more flowing scaling and root planing 35.

Studies have been done to investigate the re-colonization of bacteria in periodontal pocket following scaling and root planing. It has been observed that there is a significant change in bacterial flora after scaling and root planing. There is a significant reduction in Gram –ve microorganisms, motile rods and spirochetes 36, 37.  The re-colonization of these organisms may take place within 1-2 months in the absence of good oral hygiene 38 or may take several months with good oral hygiene 39, 40. One study has demonstrated that repeated scaling and root planing every 3 months may prevent the re-colonization of bacteria 41.

Changes observed after scaling and root planing

The most important change observed after scaling and root planing is the resolution of gingival inflammation due to which the gingiva attains a uniform color, gingival tissue bulk is reduced and tissue density is increased, tendency for bleeding on probing is reduced and the reduction in crevicular depth is observed. Reduction in probing depth is also a significant finding following scaling and root planing. In one study, it was observed that for pockets 4-6 mm deep, an average reduction in probing depth of 1 mm is expected following scaling and root planing and for pockets 7 mm or deeper, the expected reduction in probing depth is 2 mm 42.  This reduction in probing depth is observed partly due to the recession in the gingival margin and partly due to gain in attachment level.

Conclusion

The elimination of plaque and calculus from the tooth surfaces is the basic requirement of a successful periodontal treatment. There is enough evidence which suggests that scaling and root planing followed by adequate plaque control can dramatically improve the condition of periodontal tissues. In areas with deep pockets, surgical intervention is required to get complete access to the root surfaces so that all the calculus can be removed and effective root planing can be done. It has been well established that periodic scaling and root planing are the cornerstones of periodontal maintenance therapy following an active periodontal treatment.

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References:

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Periobasics: A textbook of periodontics and implantology

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