Scaling and root planing

Contents:
 Introduction
 Definition
 Focus of treatment
 Aims and expected outcomes
 Appointment systems
 Periodontal instruments
 Principles of instrumentation
 Preparation of the clinician
 Patient preparation
 Detection skills:
 Supragingival examination
 Subgingival examination
 Principles of scaling and root planing
 Supragingival scaling technique
 Subgingival scaling and root planing technique
 Scaling by manual instruments
 Scaling by power-driven scaling devices
 Indications, contraindications, advantages and
disadvantages of ultrasonic scaling
 Evaluation of tooth surfaces after SRP
 Problems of incomplete scaling
 Risk considerations
 Healing after SRP
 Patient instructions after SRP
 Clinical endpoints
 Conclusion
 Introduction
 Periodontal diseases such as gingivitis,
periodontitis may include supragingival and
subgingival plaque accumulation frequently
associated with calculus formation.
 In order to prevent this and/or to reduce the
disease progression and severity, supragingival
and subgingival scaling & root planing is done.
It is done as a procedure either as full mouth
scaling or quadrant scaling. This can be done
at any form of gingivitis and periodontitis as a
phase I therapy, thereby continuing further
management.t
 Definition

 Scaling:

 It is the process by which plaque and calculus are

removed from both supragingival and subgingival
tooth surfaces

 Root Planing:

 It is the process by which residual embeeded calculus

and portions of cementum are removed from the
roots to produce a smooth, hard, clean surface.
Scaling and root planing_ Initial phase of an orderly
sequence of
treatment.

Phase I therapy _ Non surgical periodontal therapy (or)

cause related therapy (or) etiotropic phase of therapy.

Scaling and root planing are not separate procedures; all

the principles of scaling apply equally to root planing

The difference between scaling and root planing is only

matter of degree

The nature of the tooth surface determines the degree to

which the surface must be scaled or planed .
 Focus of Treatment

 The focus of clinical treatment is on the elimination of the causative

factor.

 1.Bacterial plaque & endotoxins: Plaque – Principal irritant .

Gingival inflammation & periodontal destruction - action of
pathogenic micro organisms & their endotoxins.
 Micro organisms - surfaces of the teeth, to calculus & to gingiva&
may become embedded in the cemental surface & exposed
dentinal tubules.
 LPS- Gm –ve pathogenic micro organisms. They are toxic to
human tissues & cause inflammation & destruction of periodontal
attachment.
 Endotoxins - cemental surface in the superficial bacterial plaque
& can be removed readily.
 2.Cementum: smooth surface is significant,
since the micro organisms collect & colonize
on a rough surface much more rapidly than on
a smooth surface.

 3.Calculus: Contributing factor

It is not directly a cause of Gingival
inflammation, but the irregular surface
provides a nexus for bacterial plaque
collection
It must be removed to provide a healing
environment for the periodontal tissues.
 Aims and Expected outcomes

● Interrupt or stop the progress of disease

● Create an environment that encourages the tissue to heal

and the inflammation to be resolved

 Convert pocket in disease to sulcus in health

 Reduce probing depths
 Eliminate bleeding on probing
 Regenerate the gingival tissues to normal healthy state
 Change the quality of the tissues from spongy to firm
 Gain in clinical attachment
● Induce +ve changes in the quality and quantity of the
subgingival bacterial flora

● Delay repopulation of microorganisms in the pocket;

hence prevent or postpone disease recurrence

● Provide initial preparation (tissue conditioning ) for

complex periondontal therapy required for advanced
disease

● Educate, motivate, follow up the patient

 Appointment Systems

● When a single appointment may be adequate ?

 In case of gingival disease and early periondontitis

 Only a few teeth present, limited areas of anaesthesia may

be needed

 Patient presents with good plaque score

● Planned multiple appointments:

 In case of moderate, advanced and refractory periodontitis
 Patient compliance
 Periodontal Instruments
 Classification:
1. Diagnostic instruments
2. Scaling, root planing and curettage
instruments
3. Surgical instruments
4. Cleansing and polishing instruments
1. Diagnostic Instruments:

Mouth mirror, probe, explorer, periodontal endoscope.

 Periodontal Probes:
 They are used to locate, measure and mark pockets, and to
measure width of attached gingiva

 The periodontal Endoscope:

 It is used to visualize deeply into subgingival pockets and
furcations, allowing the detection of deposits
 Explorers: They are used to locate calculus deposits and
caries
2. Scaling, root-planing and curretage instruments:

-- They are used for removal of plaque and calcified deposits

from the crown and root of a tooth, removal of altered
cementum from the subgingival root surface, and
debridement of the soft tissue lining the pocket
 Sickler Scaler: (Universal scaler,No.65)
 They are heavy instruments used to remove
supragingival calculus
 Triangular shape, double- Cutting edge and
pointed tip.

Various types of sickle scalers

 Curettes:
 They are fine instruments used
for subgingival scaling, root
planing, and removal of soft
tissue lining the pocket
 Spoon shaped blade and rounded
tip

Gracey Universal
 Hoe, chisel and file
scalers:

 They are used to remove

tenacious subgingival
calculus and altered
cementum. Their use is
limited compare with that
of curettes.
 Ultrasonic and sonic instruments:

 They are used for scaling tooth surfaces and curetting the
soft tissue wall of the periodontal pocket

MAGNETOSTRICTIVE PIEZOELECTRIC
Various sonic & ultrasonic tips
3. Cleansing and Polishing instruments:

 Rubber cups, brushes and dental tape are used to clean and
polish tooth surfaces. Air-Powder abrasive systems are also
available for tooth polishing.
 Instrument parts:

1. Working end
2. Shank
3. Handle or Shaft

 Working end:

 Used to carry out purpose and function of the instrument

 Sharp instruments – Sharp blade
1.Cutting Edge
2. Lateral Surfaces
 Non sharp instruments – Nib
 Shank:
 Connects working end with handle.

 Classification
1. Based on shape
 Straight
 Angled
2.Lower or terminal shank

3. Based on flexibility
 Rigid, thick shank
 Less rigid, more flexible shank
 Handle

 Part of the instrument that is held or grasped during

activation of the working end.

 Classification

1. Single-endinstrument
2. Double-ended instrument
3. Cone socket handles
 Principles of instrumentation

1. Accessibility:
Positioning of patient and operator:

•Clinician should be able to

observe the field of operation
while keeping the back straight
and head erect.
 Patient should be in a supine position and
placed so that the mouth is close to the
resting elbow of the clinician
 For instrumentation of maxillary arch –
raise the chin.
 Clinician’s feet of flat on the floor with
the thighs parallel to the floor
 For instrumentation on the mandibular
arch – raise the back of the chair slightly
and request the patient to lower the chin
until the mandible is parallel to the floor.
 Accessibility facilitates thoroughness of
instrumentation
2. Visibility, illumination and retraction:
3. Condition and Sharpness of instruments:

 Sharp instruments- enhance tactile sensitivity.

 Dull instruments - incomplete calculus removal
-unnecessary trauma due to
excess force

4. Maintaining a clean field:s

 Suction is essential
5. Instrument stabilization:
 Stability and control are essential for effective
instrumentation and avoidance of injury
 Modified pen grasp – Commonly used for SRP
 Standard pen grasp
 Palm and Thump grasp – For sharpening of instruments
 Finger Rest:
 To stabilize the hand and the instrument by providing a
firm fulcrum as movements are made to activate the
instrument.
 Instrument activation
 Adaptation:

 Objective is to make
the working end of
the instrument
conform to the
contour of the tooth
surface
 Angulation: (Tooth – Blade relationship)

 It refers to the angle b/w the face of a bladed

instrument & the tooth surface
 Lateral Pressure:
 Refers to the pressure created
when force is applies against the
surface of a tooth with the cutting
edge of a bladed instrument
 It may be firm, moderate or light.

 Strokes:

1. Exploratory (Light feeling stroke)

2. Scaling (Short powerful pull
stroke)
3. Root – Planing (Shaving stroke)
 Activated by pull or push motion
in a vertical, oblique or horizontal
direction
 Instrument Sharpening:

 Evaluation of sharpness:

 Visual or glare test

 Plastic testing stick
 Sharpening Stones:

 Natural abrasive stones – Arkansas

 Artificial materials – ruby stone, carborundem stone, diamond hone,
ceramic aluminum oxide, Nievert whittler
 Unmounted
 Stationary flat stones
 Hand stones
 Nievert whittler
 Mandrel mounted:
 Cylindrical, conical or disc shaped
 Patient preparation:
 Premedication requirements for medically compromised patients:
 High risk category:
 Prosthetic cardiac valves, previous infective endocarditis ,complex
cyanotic congenital heart disease, individuals with total joint
replacement.

 Moderate risk category:

 Acquired valvular dysfunction (eg: RHD), hypertrophic
cardiomtopathy, MVP with regurgitation.
 No risk category:
 MVP without valvular regurgitation/ previous RHF without
valvular dysfunction, previous coronary artery bypass graft surgery.
 Transient bacteremia can occur during and immeditely
after scaling proccedures.
 Check that the patient has taken the medication as
prescribed.

 Provide preprocedural bacterial rinse.

 Prepare for anaesthesia if necessary.
 Procedures requiring antibiotic prophylaxis:
 Periodontal procedures including surgery, subgingival
placements of antibiotic fibers or strips.
 Scaling and root planing

 Implant placement

 Intraligamentary injections

 Prophylactic cleaning of teeth where bleeding is anticipated.

 Procedures not requiring antibiotic prophylaxis:

 LA injections (Non intraligamentary)
 Post operative suture removal.
 Preparation of the clinician:

 Knowledge of the anatomic, histopathologic and

physiologic characteristics of the teeth and supporting
tissues is necessary.

 Skills in procedures for disease control in a patient

requires more than the development of manual
techniques for applying instruments to the tooth
surfaces.
 Detection skills

 Supragingival examination:

 Visual examination- Use of a compressed air.

 Direct examination.

 Tactile examination:

 Without deposits or anatomical irregularities, the enamel

surface is smooth.
 An explorer passed over the surface slides freely, smoothly
and quietly.
 When rough calculus deposits are present, the explorer does
not slide freely, but meets with resistance and produces a
scratchy sound.
 Subgingival examination:
 Visual examination:
 Gingiva: Soft, spongy, bluish red gingiva with
enlargement of interdental papillae over proximal surface
calculus.
 Dark colored area beneath relatively translucent marginal
gingiva.
 Calculus: A loose, resilient pocket wall can be deflected
from tooth surface with a stream of compressed air. Dark,
subgingival calculus can be seen within the pocket on the
root.
 Tactile examination:
 Periodontal charting.
 Determine distribution and extent of
deposits using explorer.
 Evaluate tooth topography.
 Detect grooves and furcations using a
horizontal stroke.
 Use a furcation probe to examine
furcations.
 Principles of scaling and root planing:

 Based on the technique:

 Supragingival scaling technique.

 Subgingival scaling technique.

 Based on the instrumentation:

 Scaling by manual instruments.

 Scaling by power-driven scaling devices.
 Supragingival scaling technique:

 Less tenacious and less calcified than subgingival

calculus.
 Sickles, curettes and ultrasonic and sonic instruments
are most of often used.
 Hoes and chisels are less frequently used.
 Blade angulation- less than 90 degree.
 Subgingival scaling and root planing technique:

 More complex and difficult to perform.

 Subgingival calculus is usually harder. Vision is obscured by
bleeding that inevitably occurs during instrumentation and by
the tissue itself.
 Cureete is most often used.
 Sickles, hoes, files and ultrasonics are also used.
Scaling by manual instruments:

1. Probe to determine pocket/sulcus characteristics.

2. Explore to determine location and extent of

deposits
and tooth surface irregularities.

3. Select correct instrument for areas being treated.

4. Hold instruments with a modified pen grasp.

5. Establish stable finger rest.

6. Identify correct cutting edge of blade for surface

being scaled.

7. Insert. Use placement or exploratory stroke to

locate apical edge of deposit.
 8. Adjust working angulation
(average at 70 degree).
 9. Activate for working stroke.
a) Apply
moderate to firm lateral
pressure for calculus removal.
b) Apply
light lateral pressure to
smooth the surface.
c) Controlthe length and
direction of stroke.
d) Maintain
continuous adaptation
throughout the stroke.
10. Continue channel scaling with
overlapping strokes.
a) Apply placement stroke to
reposition blade for next
stroke.
b) Activate instrument
circumferentially around line
angles to treat the entire
surfaces that require
instrumentation.
11. Plane the root surface:

● Adaptation- close the angulation slightly after calculus is

believed to be removed.

● Touch and pressure- A lighter grasp must be used to

increase the tactile sensitivity. Light lateral pressure is
applied for maximum sensitivity to minute irregularities
of the surface.

● Strokes

 Smooth strokes with even lateral pressure that

systemically overlap are used.
 As the surface becomes smoother, longer
strokes with reduced pressure help to
remove small lines, scratches, or grooves
without gouging the surface.

 Vertical, then oblique strokes are used.

When applicable away from the
attachment epithelium, horizontal strokes
may be used.

 At the completion, the instrument may

be as quiet as when used on polish
enamel.

12. Evaluation:

 Use subgingivally explorer to examine for

completion of calculus removal and
smoothness of the treated surfaces.
Before treatment

After treatment
 Scaling by power-Driven devices:

Ultrasonic and sonic scaling:

 The power driven scaling device (PDSD) converted high

frequency electrical energy into mechanical energy in the form
of rapid vibrations.

Mode of action:

1. Mechanical vibration: PDSD convert electrical energy or air

pressure – high frequency sound waves – produce rapid
vibrations in the scaling tips – calculus is shattered from the
tooth surface.
2.. Cavitation: Water is required to dissipate the heat produced at the
vibrating tip.
 Cavitation occur when water meets the vibrating tip, creating minute
bubbles that collapse and release energy.

 Effect of cavitation: Although it has little influence on hard deposit

removal, it can destroy bacteria and remove endotoxin from the root
surface.

3. Irrigation:
 The water spray penetrates to the base of the pocket to provide a
continuous flushing of debris, bacteria and endotoxin.

 Oscillation of the ultrasonic tip causes hydrodynamic waves to surround

the tip. This acoustic turbulence is believed to disrupt bacteria.
 Types of power-Driven scaling devices:

 Ultrasonic scalers.

 Magnetostrictive.
 Piezoelectric.

 Sonic scalers
Indications:
 Removal of supragingival calculus and
tenacious stains.
 Subgingival periodontal debridement, including
removal of calculus, attached plaque and
endotoxins from the root surface and unattached
plaque from the sulcular space.
 Initial debridement for a patient with ANUG or
other condition that can be relieved by removal
of deposits.
 Debridement of furcation areas.
 Debridement of deposits prior to oral surgery.
 Removal of orthodontic cement, debonding.
 Removal of overhanging margins of restorations.
 Contraindications and precautions:
I. General health conditions:
 Communicable disease (eg: T.B.).

 Susceptibility to infection. Eg:

Immunocompromised patients such as
uncontrolled diabetes, debilitating disease,
kidney and other organ transplant.
 Respiratory Risk:

 History of chronic pulmonary disease, including

asthma, emphysema or cystic fibrosis and
history of cardiovascular disease.
 Swallowing difficulty: Eg: Muscular dystrophy,
paralysis, multiple sclerosis.
 Cardiac pacemaker.
II. Oral conditions:

 Demineralized areas.

 Exposed dentinal surfaces.

 Restorative materials.

 Titanium implant abutments.

 Narrow periodontal pockets.

III. Children:

 Young , growing, developing tissues are sensitive to ultrasonic vibrations.

 Primary and newly erupted permanent teeth have large pulp chambers. The
vibrations and heat from ultrasonic scaler may damage pulp tissue.
 Advantages of using U/S scaling:

 Size and shape of the tips are suitable for supra and
subgingival scaling and root planing.
 It is effective on all surfaces of teeth.
 It is used with light touch and hence does not require a
firm finger rest as in hand scaling.
 Causes less soft tissue trauma and post-operative
discomfort.
 Pocket irrigation is achieved. It may possibly have a
bactericidal effect also.
 Increased patient comfort and acceptance.
 Requires less time than hand scaling.
 It is less tiring for the operator.
 Disadvantages of U/S scaling:

 Less tactile sense of the root surface.

 Produces microscopic rippling of root surface.
 Requires high speed evacuation.
 Produces contaminated aerosol.
 Operator has to wear mask and eye shield and
patient should be given CHX preprocedural
rinse.
 Scaling by ultrasonic scalers:
`
 Thoroughly wipe the ultrasonic unit and handpiece with a disinfectant.
Flush the waterlines and handpiece for two minutes to decrease the
number of microorganisms in the lines.

 Direct the patient to rinse for one minute with an antimicrobial oral
rinse such as 2% CHX to reduce contaminated aerosol.

 The clinician and the assistant should wear protective eye wear and
masks and use high speed evacuation to minimize inhalation of the
contaminated aerosol during instrumentation.

 Turn on the unit, select an insert, place it onto the handpiece, and then
adjust water control knob to produce a light mist of water at the
working tip.
 The power setting should begin on low and be adjusted no higher
than necessary to remove calculus.
  The instrument is grasped with a light pen grasp and a finger rest
or extra oral fulcrum should be established to allow a feather like
touch.

 Use short, light, vertical, horizontal or oblique overlapping

strokes.

 The working end should be kept in constant motion, and the tip
should be kept parallel to the tooth surface or at no more than a 15
degree angle to avoid etching or grooving the tooth surface.

 The instrument should be switched off periodically to allow for

aspiration of water, and the tooth surface should be examined
frequently with an explorer.

 Any remaining. irregularities of the root surface may be removed

with sharp standard or mini bladed curettes if necessary.
 Evaluation
 Immediately after instrumentation, the tooth surfaces should be
carefully inspected visually with optimal lighting and the aid of a
mouth mirror and compressed air.

 Surfaces also should be examined with a fine explore or probe.

 Clinical evaluation of the soft tissue response to scaling and root

planing including probing, should not be conducted earlier than
two weeks postoperatively

 Therefore a longer period of evaluation may be indicated before

deciding whether to intervene with further instrumentation or
surgery.
 Healing after scaling and root planing:

 Resolution of inflammation:

 Edema recedes, necrotic cells are cleared away, and tissue

regenerates.

 Sequence:

 Within two days after epithelial regeneration starts. New

attachment to tooth surface can appear as early as 5 days and
regeneration of epithelium by approximately 2 weeks.

 Clinical attachment:

 A long epithelial attachment can be expected.

Problems of incomplete scaling: ( Gross scaling or prescaling )
 Healing at the gingival margin:

 When the irritants are removed around the opening of the

pocket, the tissue heals and the gingival margin can close
around the tooth.
 The marginal tissue may take on a color and shape that appears
normal to the patient, but underneath the probing depth and
bleeding on probing have not changed.

 Potential for abscess formation:

 With partial scaling, healing can begin, the tissue at the gingival
margin tightens, the pocket closes, microorganisms multiply
within, an abscess develops.
• Roughened calculus:

– Calculus roughened by partial removal may be a source of increased

subgingival plaque collection.
– Bacteria readily collect and colonize on a rough surface thus provides
more sources for infection in the surrounding gingival tissues.

• Patient misunderstanding:

– For the patient with limited understanding of the seriousness and

extent of periodontal infection, the mouth may feel good and look
good after a gross cleaning.
– As a result, the patient may not realize the need to return for the
continuing appointments to complete the deep scaling.ions
– Later severe periodontitis may develop.
 Risk considerations
 Clinician:
 Cumulative trauma from scaling by manual instruments.
 Patient:
 Heat production:
 Potential damage to the pulp tissue may occur.

 Constant motion of the instrument, correct angulation

and ample water for cooling are essential to operation.
 Temporary hearing shifts
 Damage to the integrity of restorations:

 Porcelain –Fracturing, loss of marginal integrity.

 Amalgam –surface defects, loss of marginal integrity.

 Composites: Surface alterations.

 Titanium implant abutments: Metal scratches titanium.

Patient instructions after scaling and root planing:
 Printed instructions.
 Information to include:
 Possible discomfort to expect.
 Rinsing.
 Tooth brushing.
 Eating.
 Rinsing:
 A warm solution is soothing to the tissues and improves the
circulation, thereby helping healing.
 Solutions suggested for use:
 Hypertonic salt solution.
 Sodium bicarbonate solution.
 CHX 0.12%.
  Directions for rinsing:
 Every 2 hrs after eating, after tooth brushing,
before retiring.
 Use the rinse mouthful by mouthful, forcing the
solution b/w the teeth.

 Tooth brushing:
 The use of a soft brush is recommended after
scaling and root planing.

 Eating:
 The temporary use of bland foods lacking in
strong spicy seasonings, as well as continuing use
of nutritional foods to promote healing are basic.
 Clinic End points:
 Bleeding on probing – Eliminated.
 Probing depth – reduced.
 Attachment Levels: Same or improved.
 Gingival Appearance: Size reduced, color normal.
 Subgingival micro flora: Lowered in numbers, delay in
repopulation.
 Bacterial plaque control record: Improvement in plaque
scores approaching 100%.

 Tooth surface: Smooth, free from plaque-retentive

irregularities.
 Effect on microorganisms

 PDL infection before  PDL infection after

treatment: treatment:
 Predominant flora is  Predominant flora is

 Anaerobic  Aerobic

 Gm-ve  Gm+ve

 Motile  Nonmotile

 Spirochetes, motile  Coccoid forms, non

rods, pathogenic pathogenic

 Very high total count  Much lower counts of

of all types of all types of

microorganisms microorganisms
 Many leucocytes.  Lower leukocyte count
 Hand scaling Vs Ultrasonic scaling:

 Produce equivalent results in calculus and bacterial

plaque removal.

Conclusion

 To conclude as we already know SRP is the initial non-

surgical periodontal treatment. It should be done with
proper instruments and clinician should follow the
correct method of SRP for the reduction of pocket
depth and elimination of local factors in order to avoid
further progression of the disease.