Scaling and Root Planing – The expression nonsurgical therapy suggests that the nonsurgical procedure so designated is performed in a closed environment and, therefore, is not invasive (eg, it does not break the epithelial seal of the sulcular or junctional epithelium). While the concept of scaling and root planing may be, indeed, nonsurgical, the gingival soft tissue is often inadvertently invaded. Local anesthesia will often be required for patient comfort during Scaling and root planing procedures.
Oral hygiene and local antimicrobial procedures, the removal of iatrogenic factors, occlusal therapy, and systemic antibiotic procedures are not invasive and, therefore, conform to nonsurgical concepts.
The term surgical treatment is reserved for those periodontal procedures that are performed in a deliberately open environment where incisions are made, periodontal soft tissue is elevated to expose tooth roots and alveolar bone, and the soft tissue is either replaced or repositioned over the roots and bone. During surgical access, resective or regenerative procedures may be performed on the bony defects produced by periodontitis.
SCALING AND ROOT PLANING
Scaling and root planing are the cornerstones of almost all initial therapy treatment plans for periodontitis and may be the only mechanical therapy required for the management of mild (1-2 mm clinical attachment loss) chronic periodontits. While scaling and root planing procedures are utilized routinely, they remain among the most technically demanding procedures performed in periodontics. When performed with optimal access and skill, scaling and root planing will produce a decrease in gingival inflammation, a reduction in periodontal probing depths, and a gain in periodontal attachment. With less than optimal access and skill, the out comes from scaling and root planing will, by extension, be less than optimal.
What Is Scaling and Root Planing? What Are the Goals and Objectives of Scaling and Root Planing?
Scaling and root planing are two technically similar periodontal procedures. Both involve the mechanical application of hand- and/or power-driven instruments to tooth surfaces to remove plaque, stain, and calculus. Clinically, it is frequently difficult to separate one from the other. Scaling may be performed on either coronal or radicular surfaces in periodontitle cases, but in gingivitis cases, scaling should be limited to coronal surfaces. Root planing is only performed on root surfaces that have been denuded of periodontal attachments . In addition to the removal of plaque, stain, and calculus, it also includes the removal of diseased cementum containing imbedded calculus, and toxic bacterial debris such as endotoxin.
The goals and objectives of scaling and root planing are both technical and biologic. The technical goals and objectives of scaling and root planing (the mindset of the clinician at the time), are to produce hard, smooth tooth surfaces free of calculus and cementum affected with endotoxin and/or other bacterial contaminants. In the process, the bacterial load adjacent to periodontal tissues is reduced.
The biologic goals and objectives of scaling and root planing are to produce a tooth surface and sulcular ecosystem that is biocompatible with periodontal epithelial cell and connective tissue adhesion. Decreases in gingival inflammation, reductions in periodontal probing depths, the presence of Gram- positive beneficial bacterial species, and gains in periodontal attachment are the outcomes by which effective scaling and root planing are measured.
What Is Disease-Affected Cementum? What Is Endotoxin and Where Does it Come From?
Disease-affected cementum is cementum that has been stripped of periodontal attachment by periodontitis and has been exposed to the septic contents of the periodontal pocket. It contains remnants of embedded calculus, whole bacteria, and the products of microbial life. The most studied of these is bacterial endotoxin. Endotoxin and whole bacteria may be found as deep as 12 microns beneath the cemental surface.
Endotoxin is the lipopolysaccharide component of the outer membrane of Gram-negative cell walls. It is exported as membrane vesicles during the lifespan of most Gram-negative bacteria. The biologic activity of endotoxin includes attraction of inflammatory cells, activation of the complement system, stimulation of bone resorption, fibroblast cytotoxicity, pyrogenicity, and mitogenic activity with B-lymphocytes. Endotoxin will produce a severe local inflammatory reaction when injected experimentally in tissue.
What Are the Instruments Used in Scaling and Root Planing? What Techniques Are Employed?
Calculus detection and removal are learned skills that gradually improve with experience. Exquisite tactile sensitivity, mediated by hand, sonic, and ultrasonic instruments is essential. Correct instrumentation is then an essential prerequisite to detection and removal. There are many different instruments specifically designed for scaling and root planing, and there are probably as many personal preferences for instruments as there are instruments. The following is a guide to the four general categories of instruments used in scaling and root planing.
Periodontal probes and explorers are used to detect calculus deposits. Probes will also confirm that deposits have been removed and that the roots have been planed to hard and smooth surfaces. The ultralight Motfitt-Maryland periodontal probe with Williams markings is an excellent choice for subgingival calculus detection. The 3A curved explorer or the Nabers furcation probe may also be used for calculus detection and are particularly helpful in root concavities or furcation invasions.
Scalers are the instruments of choice for Scaling and root planing. Scalers have a bulky working end and a rigid shank. Both tend to limit their tactile sensitivity. In cross section, the most popular scalers (sickle scalers) have a triangle shaped blade with 2 opposed cutting edges. Scalers should not be used in deep (>4 mm) pockets so as to minimize injury to gingival tissues.
Hoes and files belong with scalers as instruments whose cutting edges are designed to function at right angles to the tooth surface and they should be used almost exclusively for heavy supragingival deposit removal. Frequently, calculus removal with scalers, hoes, and files will be incomplete, and more delicate instruments with greater tactile sensitivity and access capability will be required to remove residual deposits and smooth cementum or dentin. Scalers, hoes, and files are used with a vertical pull-type stroke.
Curettes are the instruments of choice for scaling and root planing. They are generally smaller than scalers and are designed to permit a traumatic entry to the subgingival space. The tactile sensitivity of most curettes is greater than scalers and, as such, curettes are well suited for subgingival calculus detection, calculus removal, and root planing. Area specific curettes (Gracey and Goldman-Fox) have a single cutting edge at 60° to the root surface and are designed to instrument specific tooth surfaces in specific regions of the mouth. For example, the Gracey 13/14 is designed to instrument the distal surfaces of molar and premolar teeth, while the Gracey 9/10 is designed to instrument the buccal or lingual surfaces of the same posterior teeth. Gracey curettes have been modified for improved access and reduced tissue injury. Universal curettes (Crane- Kaplan 6, McCalls 17s/1 8s, Columbia 4R/4L) have 2 culling edges at 90° to the root surface and may be used in any region of the mouth. Curettes may be used with vertical, oblique, horizontal, or circumferential pull-type strokes.
What Are Power-Driven Scalers? How Are They Used for Scaling and root planing ?
Power-driven scalers are usually used to provide a rapid calculus and stain removal with a minimum of discomfort to the patient or trauma to hard or soft tissues. Power-driven scalers use either ultrasonic or sonic energy for debridement.
Ultrasonic instruments use either magnetostrictive or piezoelectric technology to convert electrical energy to physical energy at the instrument tip for scaling and root planing . Instrument tips vibrate from 25,000-40,000 cycles per second at an amplitude between 10-30 pm. The heat generated by magnetostrictive instruments requires copious amounts of water for cooling. In the cooling process, water cavitation (similar to the effect produced by a propeller in water) occurs which releases dissolved gases. The resulting spray, along with the water itself facilitates the removal of dislodged debris. Recent advances in ultrasonic instrument design, such as thinner ultrasonic tips, have improved access in deep pockets and provide subgingival delivery of antimicrobial agents.
Sonic instruments are classified as air-turbine instruments. They use the air pressure from high-speed handpiece lines to produce tip vibrations from 2,000-6,000 cycles per second.
Power-driven instruments may be used for scaling and root planing in both supragingival arid sutigingival areas. It is recommended that the instrument be kept adequately cooled, that the instruments be kept in constant motion, and that the side (not the tip) of the instrument be used against tooth structure at all times. Many ultrasonic units may be used with a variety of irrigants such as chlorhexidine or povidone-iodine.
Are There Any Medical Risks to the Patient and or the Provider When Power-Driven Instruments Are Used to Scaling and root planing?
Magnetostrictive ultrasonic instruments may de-program some cardiac pacemakers. As it is not in the province of dental health professionals to decide whether or not a patient with a cardiac pacemaker may be at such a risk, it is recommended that a medical consultation be obtained before magnetostrictive ultrasonic instrumentation is performed.
Cultivable oral bacteria are present in aerosols created by sonic and ultrasonic instruments, and there seems to be no difference in the number of colony-forming units produced from aerosols generated by magnetostrictive, piezoelectric, or turbine driven instruments. Antimicrobial mouthrinses before power-driven instrumentation will reduce the number of cultivable bacteria in aerosols.
It is beyond the intended scope of this manual to describe the technical aspects of scaling and root planing. It is recommended that the reader consult one of the textbooks devoted to the subject listed in the Selected Readings section.
How Do Power-Driven Instruments Perform When Compared to Conventional Hand Instruments for Scaling and root planing ?
Comparison studies of the performance of power-driven instruments with hand instruments on extracted teeth have produced equivocal data. Both are partially effective in removing calculus and cementum while scaling and root planing . Tests on extracted teeth suggest that both methods are equally effective in removing debris from teeth, but that hand instruments alone, or following power-driven instrumentation, produced the smoothest tooth surface. Other reports have presented contrasting data indicating the superiority of power-driven instruments in producing smooth tooth surfaces while scaling and root planing.
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