Rationale for scaling and root

planing

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

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

Changes in root surfaces in

periodontitis
A. 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.

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

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

Before Scaling & Root

Planing

After Scaling & Root

planing

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.

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

Subgingival scaling and root planing

are measures which can be effective in:
Eliminating inflammation
Reducing probing depths
Improving clinical attachment

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

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

Rationale for root planing

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

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.

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.

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.

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.

Preparation for New Attachment

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

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

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

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)

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

Scaling and root planing also has

systemic effects. These are a bacteremia
and a host immune response

Incidence of Bacteremia During Different Dental

Procedures Heimdahl, et al., 1990
Surgical
Procedure

% of Patients
with
Bacteremia

%Viridans
%
group
Anaerobes
streptococci

100

85

75

Scaling and
Root Planing

70

55

65

Third Molar
Surgery

55

40

45

Endodontic
Treatment

20

15

Bilateral
Tonsillectomy

55

40

40

Dental
Extraction

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.

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.

The Efficacy of Scaling and Root Planing

Effect of Scaling and Root Planing on Calculus
Removal
Buchanan 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.

When comparing calculus removal by

tooth type, tooth surface and probing
depth, the results were fairly in keeping
with logic .

The Efficacy of Scaling and Root

Planing
% Calculus Positive Surfaces After S/RP by Tooth
Type
Buchanan and Robertson, 1987
Treatment Anterior Teeth

Premolars Molars

None

87

75

83

S/RP

19

29

26

The Efficacy of Scaling and Root

Planing
% Calculus Positive Surfaces After S/RP by Tooth
Surface
Buchanan and Robertson, 1987
Treatment Mesial Distal

Facial

Lingual

None

91

96

64

77

S/RP

28

41

17

10

The Efficacy of Scaling and Root

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

0-2

2.1-4

4.1-6

6.1-8

>8

None

67

69

84

90

88

S/RP

14

24

36

45

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.

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.