Rationale for scaling and root planing

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Rationale for scaling and root planing
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Scaling
Root Planing

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

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

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Changes in root surfaces in periodontitis

• Plaque and Calculus deposition.
• Supra and subgingival calculus have a rough
  surface capable of harboring plaque that cannot
  be removed by conventional oral hygiene
  techniques.
• Bauhammers et al,1973.

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Changes in root surfaces in periodontitis

• B. Alterations in exposed cementum
• Hypermineralized surface zone
• Changes in organic matrix
• Endotoxins cytotoxic in tissue culture
• Aleo et al , 1974

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Primary objective

• Restoration of gingival health
• Scaling and root planing are not separable
  procedures

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• Before Scaling Root Planing

• After Scaling Root planing

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

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• Careful subgingival scaling and root planing is
  an effective mean to eliminate gingivitis and
  reduce the probing depth even at sites with
  initially deep periodontal pockets.
• Badersten, 1984

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

• Eliminating inflammation
• Reducing probing depths
• Improving clinical attachment

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Objectives Of Root Planing

• Securing biologically acceptable root surfaces
• Resolving inflammation
• Decreasing pocket depth
• Facilitating oral hygiene procedures
• Improving or maintaining attachment level
• Preparing the tissues for surgical procedures

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• Scaling and root planing is an integral part of
  periodontal therapy. The rationale for scaling
  and root planing is the following
• Removal of calculus and "infected" root structure
  
• Achievement of a smooth root surface which is
  less prone to plaque accumulation

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Rationale for root planing

• Garret in 1977 set forth the rationale for root
  planing
• Root Smoothness
• Removal of Diseased Cementum
• Preparation for New Attachment

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Root Smoothness

• No biological evidence which relates smooth root
  surfaces to decreased plaque formation or
  increased ease of removal.
• It remains the only clinical indicator of
  calculus removal available at present.

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• Recent data suggests that root structure removal
  is not necessary. The end point of scaling and
  root planing is however a smooth root surface as
  rough surfaces are more prone to plaque
  accumulation.
• Calculus can be seen in radiographs or detected
  clinically.

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Removal of Diseased Cementum

• Removal of exposed cementum by root planing, the
  fibroblasts adhered to both diseased and non
  diseased areas of the root.
• Aleo et al, 1975.

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• Deposits of calculus on root surfaces are
  frequently embedded in cemental irregularities (
  Zander,1953 Moskow, 1969)
• Scaling alone is therefore insufficient to remove
  calculus. A portion of cementum must be removed
  to eliminate these deposits.

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Preparation for New Attachment

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

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• To determine efficacy of therapy, therapeutic
  goals must first be established. In periodontal
  therapy, our objectives are as follows
• Suppression or elimination of pathogenic bacteria
  
• Establishment of a healthy root surface
• Conversion of inflamed to healthy tissues
• Reduction of periodontal pockets

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• Scaling and root planing has both local and
  systemic sequelae.
• Locally, the results of scaling and root planing
  are
• Debridement of bacteria and calculus
• Removal of infected cementum and dentin
• A shift in the microbial population

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• Scaling and root are not always the only measures
  that are required in order to properly eliminate
  subgingival infection in deep pockets.
• Waerhaug(1978)

• If, following scaling and root planing, signs of
  bleeding on probing to the bottom of the
  pocket persist, and if the clinical attachment
  level fails to improve, surgical therapy should
  be considered since this treatment may
  facilitate more adequate root debridment .
• Caffesee etal (1986)

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

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

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Incidence of Bacteremia During Different Dental Procedures Heimdahl, et al., 1990 Incidence of Bacteremia During Different Dental Procedures Heimdahl, et al., 1990 Incidence of Bacteremia During Different Dental Procedures Heimdahl, et al., 1990 Incidence of Bacteremia During Different Dental Procedures Heimdahl, et al., 1990
Surgical Procedure of Patients with Bacteremia Viridans group streptococci Anaerobes
Dental Extraction 100 85 75
Scaling and Root Planing 70 55 65
Third Molar Surgery 55 40 45
Endodontic Treatment 20 15 5
Bilateral Tonsillectomy 55 40 40
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• Based on this study it can be seen that
  immediately after undergoing scaling and root
  planing the majority of patients (70) will have
  a bacteremia.
• The same study also showed that ten minutes after
  the procedure, the incidence of bacteremia is
  down to 30.

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

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The Efficacy of Scaling and Root Planing

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

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The Efficacy of Scaling and Root Planing
Effect of Scaling and Root Planing on Calculus RemovalBuchanan and Robertson, 1987 Effect of Scaling and Root Planing on Calculus RemovalBuchanan and Robertson, 1987 Effect of Scaling and Root Planing on Calculus RemovalBuchanan and Robertson, 1987 Effect of Scaling and Root Planing on Calculus RemovalBuchanan and Robertson, 1987
Treatment Probing Depth (mm) CPT CPS
None 6.0 2.6 100 82
S/RP 5.7 2.4 62 24
Even on treated teeth, a fairly high percentage
of calculus was remained after scaling and root
planing.
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• When comparing calculus removal by tooth type,
  tooth surface and probing depth, the results were
  fairly in keeping with logic .

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The Efficacy of Scaling and Root Planing
Calculus Positive Surfaces After S/RP by Tooth TypeBuchanan and Robertson, 1987 Calculus Positive Surfaces After S/RP by Tooth TypeBuchanan and Robertson, 1987 Calculus Positive Surfaces After S/RP by Tooth TypeBuchanan and Robertson, 1987 Calculus Positive Surfaces After S/RP by Tooth TypeBuchanan and Robertson, 1987
Treatment Anterior Teeth Premolars Molars
None 87 75 83
S/RP 19 29 26
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The Efficacy of Scaling and Root Planing
Calculus Positive Surfaces After S/RP by Tooth SurfaceBuchanan and Robertson, 1987 Calculus Positive Surfaces After S/RP by Tooth SurfaceBuchanan and Robertson, 1987 Calculus Positive Surfaces After S/RP by Tooth SurfaceBuchanan and Robertson, 1987 Calculus Positive Surfaces After S/RP by Tooth SurfaceBuchanan and Robertson, 1987 Calculus Positive Surfaces After S/RP by Tooth SurfaceBuchanan and Robertson, 1987
Treatment Mesial Distal Facial Lingual
None 91 96 64 77
S/RP 28 41 17 10
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The Efficacy of Scaling and Root Planing
Calculus Positive Surfaces by Probing DepthBuchanan and Robertson, 1987 Calculus Positive Surfaces by Probing DepthBuchanan and Robertson, 1987 Calculus Positive Surfaces by Probing DepthBuchanan and Robertson, 1987 Calculus Positive Surfaces by Probing DepthBuchanan and Robertson, 1987 Calculus Positive Surfaces by Probing DepthBuchanan and Robertson, 1987 Calculus Positive Surfaces by Probing DepthBuchanan and Robertson, 1987
Treatment 0-2 2.1-4 4.1-6 6.1-8 gt8
None 67 69 84 90 88
S/RP 2 14 24 36 45
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• These data indicate that generally calculus is
  harder to remove in the posterior teeth as
  compared to anterior teeth, or with proximal
  surfaces as compared to facial or lingual/palatal
  surfaces, and in deeper pockets as compared to
  more shallow pockets.
• An interesting point is that calculus removal by
  scaling and root planing was more efficient in
  the molar region than in the premolar region, but
  only slightly so.

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