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Treatment of Periodontal Disease with Scaling and Root Planing

Natalie Mick
Kirkwood Community College

Periodontal disease is one of the most common diseases found in adults in the United
States, affecting about one third of the population. Like most diseases, it is preventable but a
lack of knowledge leads to its prevalence. While there are a few treatment options, there is no
way to reverse the damage periodontal disease creates in the oral cavity. With the help of the
dental team, it is possible to slow the progression and restore gingival health, ultimately
saving the patients teeth. The dentist and the dental hygienist play a very important role in a
patients oral health, which is very closely related to their overall health.
Periodontal disease is a condition in which the gum tissue becomes infected with
bacteria and results in soft tissue damage, attachment loss, and bone loss. The condition
generally begins as gingivitis and the presence of bacteria in the gingival sulcus. If this
bacterial plaque is not cleaned out on a regular basis, the gingiva begins to swell and bleeding
is common. Gingivitis then leads to periodontal disease if it is left unresolved and the
bacterial presence increases. There is a change in the bacteria present in the oral cavity with
periodontitis. The most predominant bacteria are anaerobic gram-negative bacteria such as
Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Tannerella
forsythensis (Wilkins, 2014). These bacteria cause a periodontal infection and work to
destroy bone and tissue. Some predisposing factors for periodontal disease are poor oral
hygiene, poor nutrition, smoking, diabetes, older age, and decreased immunity (Clark, 2015).
These factors do not automatically destine a patient for periodontal disease. In fact, with
proper oral hygiene and regular dental cleanings, periodontal disease can be avoided or at
least present only in a mild form.
There are both surgical and non-surgical options for treating periodontal disease. The
non-surgical option of scaling and root planing is the most common treatment to assess the

severity and aggressiveness of an individual patients condition. Generally, scaling and root
planing is done prior to any other treatment option, surgical or non-surgical, because it is the
most basic starting point. If the patients tissues dont respond to scaling and root planing,
another option should be looked into. According to an article in the International Journal of
Dental Hygiene, thorough scaling and root planing (SRP) is still considered the gold
standard in periodontal therapy. Beyond SRP, no one treatment modality is the answer in
every case (Agrawal, et al, 2011).
Localized antibiotics, such as Periochip or Arestin are other non-surgical methods that
aid in cutting down on the amount of bacteria in the periodontal pockets, allowing healing to
occur. Both of these antibiotic options deliver medication slowly over a period of a couple
weeks to the areas of infection and should be used if there has been no response to the tissue
from scaling and root planing. Periochip is a biodegradable chlorhexidine chip that is placed
directly in the periodontal pocket and is a great option for patients that are allergic to
tetracycline based medicines. Periochip requires the pocket depth be greater than 5mm or the
chip will not be completely covered by the tissue and could therefore become dislodged.
Arestin is a tetracycline based gel that is injected into the periodontal pocket that has been
proven to decrease 7mm pocket depths by 2mm. Following either of these treatments,
patients should refrain from brushing the treated area for 12 hours and interdental cleaning for
12 days to give the medicine maximum time to serve its purpose (Hebl, 2015).
If neither of the non-surgical options generates benefits for the patient, a more
elaborate surgical procedure may be necessary. One of these options is pocket reduction
surgery, which can be accomplished by either excisional periodontal surgery (gingivectomy)
or an incisional periodontal surgery (flap). A gingivectomy involves removal of excess tissue

surrounding the tooth, leading to shallower pockets and easier access for cleaning. Flap
surgery involves cutting the gingiva creating a flap allowing access to the root surfaces of the
teeth. The teeth and roots are fully cleaned and the tissue is reattached apically to the initial
location, leaving a shallower pocket depth (Perry & Beemsterboer. 2014).
Scaling and root planing is the most popular and conservative treatment option for
treating periodontal disease. The most important step in combating this disease is regulating
the infection, which is done by removing all plaque and calculus from the tooth and root
structure. Scaling and root planing is generally done over several appointments, depending on
the severity of the disease. Typically one quadrant is done at a time with a week in between to
allow the tissue to begin to heal (Wilkins, 2014). With the amount of bleeding and risk of
bacteremia, a systemic antibiotic could be administered prior to scaling. Anesthesia is most
often required for both the patients and the clinicians comfort. Since the periodontal pockets
are often deeper than normal and inflamed, the anesthesia makes it easier to access the bottom
of the sulcus to ensure a complete removal of bacteria. An ultrasonic scaler is very helpful in
breaking up calculus and flushing the bacteria out of the pockets, but it is not required. Hand
scaling can be just as effective as ultrasonic scaling in removing calculus if done correctly, but
it does not have the advantage of rinsing debris out of the pockets. This treatment can be used
on any patient that presents with periodontal disease but the procedure can cost about 4 times
as much as a regular dental cleaning (Consumer Guide to Dentistry, n.d.). Scaling and root
planing can be performed by a dental hygienist, a general dentist, or a periodontist and there is
not any special training required.
Scaling and root planing can be very beneficial for patients suffering from painful
periodontal disease. A major benefit is that since oral health is related to overall health,

removing bacteria and disease from the mouth prevents it from travelling through the
respiratory and digestive systems into the rest of the body. Since the first and most important
step in healing is removing the irritant, scaling and root planing is ideal for treating this
disease. It can be used alone or in conjunction with other therapies such as antibiotics.
Scaling and root planing smooths the root structure, preventing bacteria from accumulating in
the small crevices that are present on rough surfaces. Ultrasonic scaling is the best
recommendation for removal of plaque and calculus because they flush the periodontal pocket
and remove buildup quicker.
While there are some undesirable factors associated with scaling and root planing, the
benefits greatly outweigh them. One downfall of scaling and root planing as a treatment for
periodontal disease is that there is a significant chance that there will be residual calculus left
behind in some of the deeper pockets. Since there is no direct vision, the calculus is harder to
detect. In a study done by Kepic and colleagues, after 45-60 minutes of scaling, most teeth
with deeper pockets had residual calculus. Only teeth with 3-4mm probing depths were
completely free of calculus (Perry & Beemsterboer, 2014). Another issue associated with
scaling and root planing is the destruction of the cementum that comes along with repeated
scaling. Since the cementum is so much softer than enamel, it is more easily eroded which
could lead to sensitive root surfaces and possibly premature tooth loss.
A patient being treated for periodontal disease first and foremost needs to understand
that their condition is not going to disappear, but if they are willing to work with the dental
team to keep their mouth healthy, they can slow or even stop the progression of the disease.
The hygienist needs to give the patient all of the proper knowledge and tools needed to
maintain the cleanliness of their mouth and prevent reinfection. The patients homecare will

need to be altered to brushing twice a day and flossing at least once daily. Other auxillary
aids, such as an interdental brush, stim-u-dents, or a rubber tip gum stimulator are
recommended to be used to ensure complete cleaning of the deeper periodontal pockets. A
chlorhexidine rinse could also be used, either as a mouth rinse or in an oral irrigator. The
patient must be committed to putting in the time and effort it takes to preserve their health by
also attending their 3-4 month interval maintenance appointments. Since the initial scaling
and root planing is a much more time consuming job, the patient needs to be understanding of
the time the dental office is putting in. If it were possible to have the appointments progress
faster, they would. If the dental hygienist or the general dentist are not confident that they can
provide the care that the patient needs, the patient should be prepared to be referred to a
periodontist. If the patient does not comply with these requests made by the dental team, their
treatment will not be successful. The bacteria will not be removed and the tissues will not
heal if the cleaning is only done at maintenance appointments and poor personal habits are not
eliminated.
With the amount of knowledge and research done regarding periodontal disease, there
are still an alarming number of individuals suffering from it. It can be treated and the effects
can be lessened, but the disease will never fully go away. Dental hygienists and the dental
care team have the responsibility and the opportunity to educate their patients on how to
prevent periodontal disease and also provide them with the tools needed to achieve the goal of
oral health.

REFERENCES

Agrawal, N., Agrawal, K., & Mhaske, S. (2011). An uncommon presentation of an


inflammatory gingival enlargement - responding to non-surgical periodontal therapy.
International Journal of Dental Hygiene, 303-307. Retrieved October 7, 2015, from
http://web.b.ebscohost.com.resources.kirkwood.edu/ehost/pdfviewer/pdfviewer?
sid=3ffbd3dc-eeed-48e2-bd6d-29a7009f7e1f@sessionmgr110&vid=15&hid=115
Clark, S. (2015). Periodontology, Kirkwood Community College.
Consumer Guide to Dentistry. (n.d.). Scaling and root planing: dental deep cleaning.
Retrieved from www.yourdentistryguide.com/premiums/ on October 4, 2015.
Hebl, L. (2015). Dental Hygiene IV, Kirkwood Community College.
Perry, D., & Beemsterboer, P. (2014). Periodontology for the dental hygienist (4th ed.). St.
Louis, MO: Elsevier/Saunders.
Wilkins, E. (2013). Clinical practice of the dental hygienist (11th ed.). Philadelphia, PA:
Wolters Kluwer Health/Lippincott Williams & Wilkins.