Jessica Fox

Periodontology Research Paper

Examination of Methods of Periodontal Treatment – SRP

The definition of periodontal disease is any group of inflammatory and infectious

diseases affecting the gums and supporting tissues of the teeth. Essentially, periodontal disease

begins with the body’s inflammatory response due to the presence of bacteria biofilm. The

initial response by the body is gingival inflammation. When this biofilm is not disrupted, the

types of bacteria present, begin to change. The bacterial community becomes an organized

matrix and disease progresses. Microorganisms in the biofilm produce irritants. The immune

system does not like this and begins a cascade of destruction. The alveolar bone is vulnerable,

the body activates osteoclasts to break it down in an effort to keep it ‘safe’ and away from the

potentially damaging bacteria. Connective tissue in the gingiva has already taken a hit, but the

devastation continues as the gingival margin becomes detached and moves toward the root of

the tooth. The body is again making an attempt to keep these tissues safe by moving them

away. Cementum is exposed, pockets are forming, bone loss has occurred, and the tooth may

be mobile. Periodontitis and periodontal disease is occurring.

As you have just read, present, undisrupted, dental biofilm and its bacterial contents are

the causative agents that initiate gingivitis and periodontal disease and cause them to progress.

Proper oral hygiene and removal of this biofilm decreases the prevalence and severity of

periodontal disease. Predisposing factors associated with periodontal disease may include; risk

factors and determinants. Risk factors include characteristics that can be modified; the use of

tobacco, alcohol, poor nutrition, and poor oral home care are a few. Determinants to

periodontal disease include factors that cannot be changed; gender, age, socioeconomic status,
hormone levels, and systemic diseases such as diabetes, obesity, osteoporosis and

cardiovascular disease contribute to the severity of periodontal disease.

The oral cavity is naturally filled with bacteria. Different bacteria are found in different

areas of the mouth. Bacteria found on the teeth above the gum line are initially Streptococcus

mutans and Streptococcus sanguis. These bacteria are mainly gram-positive and round, or

cocci. They are facultative anaerobes meaning they can grow in the presence or absence of

oxygen. As the bacteria proliferate, colonize, and mature, the environment is altered. The

bacteria organize, forming a matrix and allow new bacteria to inhabit. Veillonella, an anaerobic

cocci, and strands of filamentous bacteria adhere to this initial colonizatio. The early

filamentous bacteria are facultative gram-positive rods Actinomyces and Corynebacterium

matruchotii. Some filamentous bacteria join later if the plaque remains undisturbed, these are

typically anaerobic, gram-negative rod bacteria named Fusobacterium nucleatum and

Prevotella intermedia. Motile rods and spirochetes begin to appear in these first few weeks as

well. As these bacteria increase, the numbers of Streptococci decrease throughout the biofilm.

At this stage, the potential for the bacteria to travel into the subgingival space is also on the

rise. The bacterial components in these early stages are similar to that of gingivitis. But, as the

bacterial biofilm matures, it’s inhabitants become more complex and symptoms worsen.

Chronic periodontitis is caused by accumulation of plaque and bacterial biofilm. It is

characterized by bleeding on probing, increased probing depths, clinical attachment loss and

possible tooth mobility. This stage of periodontal disease is categorized into slight, moderate or

severe and can include deterioration of the gingiva and destruction of bone if allowed to

progress. Based on quantity and ability to contribute to disease, Porphyromonas gingivalis is

the most important bacteria in this stage of periodontal disease. P. gingivalis is an anaerobic,

gram-negative, rod bacteria. Some other prominent periodontal pathogens important during

this stage include Prevotella intermedia and Bacteroides forsythus, both also anaerobic, gram-

negative bacteria.

Localized aggressive (juvenile) periodontitis involves early onset destruction of the

alveolar bone around the permanent incisors and first molars of otherwise healthy patients

who may present with little plaque and inflammation. These patients may have an increased

susceptibility to the disease from a genetic standpoint, lacking adequate white blood cells

whose job is to move to an area and eat or destroy the bacteria present. The bacteria in

patients with this disease also predominates as gram-negative rods such as Actinobacillus

actinomycetemcomitans.

Refractory periodontitis is an aggressive form. These patients are receiving or have

received preventative periodontal therapy, but their condition is still worsening. Typically, these

patients will also have a systemic condition like diabetes in addition to their periodontitis

contributing to their delay in healing. There are many bacteria involved with these patients

including Fusobacterium nucleatum and Prevotella intermedia, both anaerobic gram-negative

rods, as well as Actinobacillus actinomycetemcomitans.

Necrotizing ulcerative periodontitis or NUP is what the previous periodontal conditions,

such as NUG, can become if they are left to continue on, undisrupted. The bacteria here are

gram negative Prevotella intermedia and intermediate sized spirochetes. Spirochetes are a

spiral-shaped bacteria that do have the ability to move, some even have flagella that enhance
their movement. These motile bacteria are responsible for triggering the bodies responses and

causing the most destruction.

Common treatment methods for periodontal disease include nonsurgical methods, such

as scaling and root planing, and surgical methods including procedures for pocket reduction, to

access root surfaces, for bone defects, correcting gingival defects and to provide new

attachment. The surgical approach to periodontal disease has a goal of controlling the

progression and destruction of the disease. Surgical options are considered when nonsurgical

options have failed. A surgical approach may be necessary to provide access to a surface or

furcation to provide scaling and root planing. However, these procedures are costly, time

consuming, and can be painful.

The nonsurgical approach to periodontal disease include scaling, root planing, gingival

curettage, polishing or a combination commonly assisted by anesthesia. A nonsurgical approach

is used to remove the bacteria biofilm and improve the overall condition of the mouth.

When researching, I found 2 interesting studies. One study compared a surgical pocket

elimination or reduction procedure, modified Widman flap surgery, subgingival curettage and

scaling and root planing in patients with moderate to severe periodontitis over two years.

These patients were seen every 3 months. At these visits, the pocket depth and attachment

levels were recorded. This study found that initial pocket depths were reduced the most by the

pocket elimination procedure and the modified Widman flap surgery. However, the study also

found that these procedures had no benefit on maintenance of the attachment levels. The

study found that attachment levels were maintained best by scaling and root planing alone. The

conclusion of the study found that there was no significant difference found in attachment
levels across the methods. Another study looked at long term effectiveness of scaling and root

planing alone versus scaling and root planing followed by a Widman flap procedure. This study

compared molar and non-molar teeth over 6 ½ years. These patients were also recalled every

3-4 months for reevaluation and to record pocket depths and clinical attachment levels. They

found that the flap procedure worked better on non-molar teeth than molars resulting in better

pocket reduction. However, with either treatment, there was no difference in clinical

attachment levels.

With both of these studies and with any treatment performed, the end result is heavily

influenced by at home oral hygiene care. Proper oral home care needs to be discussed,

demonstrated and recorded at each visit to ensure the patient is going to get the best results

and maintain or improve their level of health. Without proper oral home care, any treatment

will have poor results as the bacteria biofilm will be allowed to invade the areas being treated.

Another study looked at the effectiveness of scaling and root planing across patients

with different levels of health. This study looked mainly at a change in the bacteria load. But,

also took into account gingival bleeding, pocket depths and attachment levels. This study

concluded that scaling and root planing is a sufficient therapy for those with initial periodontal

disease and those maintaining their level of health. When deep pockets or bone defects are

present, scaling and root planing alone.

My chosen method of treatment for initial periodontal disease and to evaluate a

patients level of health is scaling and root planing assisted by anesthesia. Studies have shown

either no difference or improved maintenance of attachment levels with scaling and root

planing. Scaling and root planing is involved no matter what treatment method is chosen. It
makes the most sense to begin with scaling and root planing and advance to a surgical

procedure or add in antibiotic therapy in the event the desired result is not being achieved.

Even in advanced periodontal disease, scaling and root planing has shown pocket reduction,

reduction in bleeding, and reduction in gingival redness. Another benefit to scaling and root

planing over surgical options is that this treatment can be performed on almost any individual

where some individuals may not be healthy enough to endure a surgical procedure. Utilizing

anesthesia can help control or reduce bleeding and make the patient comfortable to ensure the

base of the pocket is reached and all surfaces of the tooth are adequately cleaned.

Scaling and root planing may be performed using hand or power instruments. Scaling is

defined by instrumenting on the crown and root surface of a tooth or teeth to remove plaque,

calculus and stains. The bacteria biofilm would also be removed with scaling. Root planing is

defined as a treatment procedure to remove cementum or surface dentin that is rough,

impregnated with calculus, or contaminated with toxins or microorganisms. The focus is on the

entire root surface with a goal of removing the surface layer creating a glassy hard surface.

Root planing can also be done using hand or powered instruments. Scaling and root planing

takes practice, but it can be done by a dental hygienist with enough experience and confidence

to reach every surface. The smooth surfaces or the crown and root are easier to clean and

better at preventing plaque buildup, thus promoting gingival healing.

Efficient scaling and root planing would require current radiographs, anesthetic and

possibly multiple hygiene appointments. The patient would then ideally be placed on 3 month

recall appointments to continue to debride the surfaces of any buildup and ensure proper

home care is being conducted. At these recall visits, if the patients level of health is still
worsening, advanced procedures could be discussed. Sensitivity is likely to be experienced by

the patients during the initial visits. This sensitivity typically resolves on its own after a few

weeks. Ideal candidates are those with deeper pockets, more than 3 mm, as those patients

have seen the greatest improvement. Scaling and root planing has shown little improvement to

pockets 1-3 mm because these areas are considered healthy.

There are costs to consider with scaling and root planing. This is a procedure that the

patient may have the option of completing with their general dentist. However, some may be

referred to a periodontist for treatment, or the patient may be seen by both and alternate

between the periodontist and their general dentist. This treatment is typically not covered by

insurance and many of the visits can be paid out of pocket by the patient. Scaling and root

planing is a time-consuming treatment, the cost per visit may be twice as much as a regular

teeth cleaning and could be even more if the patient is being seen at a periodontal office. There

are commonly added costs of x-rays and anesthesia. However, these costs would also be

included in a surgical procedure. The time it takes to complete scaling and root planing and the

costs involved could be seen as a drawback to this treatment option. However, there would

also be significant cost to a surgical procedure that would need to be paid at the time of

treatment. Scaling and root planing would need to be done in addition to a surgical option so

when comparing options, scaling and root planing is likely to be more cost effective in the long

run. In the case of scaling and root planing, there may be an option to break up the costs since

there is going to be multiple visits, where a surgical procedure would likely need to be paid at

once.
 These patients may be sent home with additional products and tools to use during their

oral hygiene routine. They may also be asked to brush in a way they never have before or more

frequently than they ever have. It is the responsibility of the patient to keep up with adequate

home care and return visits for treatment. It is the responsibility of the hygienist to observe and

record the patient’s status at each visit and determine if they are meeting their goals or need

further instruction/treatment which may include antibiotic or surgical treatments. It may be

difficult for a patient to change their ways and adapt to a new routine. But, in order for their

current level of health to improve, and their scaling and root planing to be successful, they

must be willing and able to participate and make changes to their current oral home care

routine and possibly their lifestyle. The hygienist must explain, demonstrate and determine if

the patient has an adequate level of understanding of their disease, level of health, nutrition

and oral hygiene instruction. Without the patients understanding and cooperation any

periodontal improvements would likely be a failure.

 References

Clark, S. Periodontology lecture notes. 2018.

Hill, R. (1981). Four types of periodontal treatment compared over two years. Journal of

periodontology. 52(11). Retrieved from https://doi.org/10.1902/jop.1981.52.11.655

Ivic-Kardum, M. (2001). The effect of scaling and root planing on the clinical and microbiological

parameters of periodontal diseases. Acta stomat croat. 39(42).

Nowak, S. (2018). How much does a dental deep cleaning cost? The average price for

periodontal scaling and root planing. Authority dental.

https://www.authoritydental.org/scaling-and-root-planing-costs

Perry, D. (2014). Periodontology for the Dental Hygienist. St. Louis, MO. Elsevier Saunders.

Pihlstrom, B. (1984). Molar and non-molar teeth compared over 6 ½ years following two

methods of periodontal therapy. Journal of periodontology. Retrieved from

https://doi.org/10.1902/jop.1984.55.9.499

Wilkins, E. (2017). Clinical practice of the dental hygienist. Philadelphia, PA. Wolters Kluwer.

https://www.authoritydental.org/scaling-and-root-planing-costs