non-surgical periodontal therapy (2): scaling and root planing

lecture given 3/24/2026

non-surgical periodontal therapy

not invasive (in a closed environment), local anesthesia may be required (comfort and hemostasis)

modalities: OHI, scaling, root planing, local antibiotics, systemic antibiotics, removal of iatrogenic factors, occlusal therapy

what are the 2 major forms of the inflammatory disease affecting the periodontium?

gingivitis and periodontitis

which is the primary etiological factor of periodontal disease?

bacterial plaque

what is the main outcome of periodontal disease?

inflammation/destruction of gingival tissues, destruction of periodontal attachment apparatus

dental biofilm induced gingivitis

reversible disease

clinical signs: gingival inflammation, plaque, calculus

primary goal: emphasis on plaque/calculus removal

other goals: eliminate/reduce etiologic factors to eliminate/reduce inflammation

appropriate supportive periodontal maintenance to prevent disease

therapeutic goal: establish gingival health

is oral hygiene only sufficient to treat gingivitis?

yes- experimental gingivitis study, depends on compliance, professional plaque control helps in disease prevention, local plaque retentive factors that pre-dispose to gingival inflammation

t/f the treatment plan for dental biofilm induced gingivitis on a reduced periodontium is the same as dental biofilm induced gingivitis

true- possibly additional root planing on exposed root surfaces if needed but rest is the same

what are the local contributing factors that may interfere with oral hygiene and the ability to control inflammation?

calculus, overhanging restorations, restoration margins, poorly designed contacts, overcontoured restorations, caries, poor temporization

scaling

removal of calculus from crown of teeth, supragingival/subgingival/intra-sulcular instrumentation to remove calculus/plaque/deposits/stains, short powerful pull stroke, use of hand/sonic/ultrasonic instruments

gingivitis- limited to tooth crown

periodontitis- performed on either coronal or radicular surfaces

what factors may affect treatment and therapeutic outcome of gingivitis?

systemic risk factors like smoking, diabetes, systemic diseases, stress, ect

what happens if gingivitis is not successfully treated?

continuation of inflammation, risk of progressing to periodontitis

what does it mean if gingivitis is successfully treated but gingival signs still persist?

look for underlying systemic conditions and non-dental biofilm induced gingival diseases

what are the 2 major therapeutic approaches for treating periodontitis?

anti-infective treatment- designed to halt the progression of periodontal attachment loss by removing etiologic factors and resolve inflammation

regenerative therapy- induced anti-infective treatment and is intended to restore structures destroyed by the disease

essential to both treatment approaches is the inclusion of periodontal maintenance procedures

can periodontitis be treated only with controlling supra gingival plaque/calculus and removal of iatrogenic factors?

it is less effective compared to supragingival plaque control and scaling/root planing when assessing all clinical parameters (BOP, pockets, attachment loss)

can periodontitis be treated without proper supra gingival plaque control?

meticulous oral hygiene on a daily basis is crutial to avoid bacterial colonization and progression of periodontal disease

what can be done to address gingivitis?

dental plaque index, oral hygiene instructions, scaling, polishing, eliminate local etiologic factors

what can be done to address periodontitis?

scaling and root planing, polishing, eliminate local etiologic factors, local or systemic antibiotics

what are the local contributing factors that may interfere with oral hygiene and predispose to periodontitis?

calculus, overhanging restorations, restoration margins, open contacts, overcontoured restorations, caries/resorption, ill fitting prosthetic appliance, root proximity, occlusal trauma, tooth mobility

root planing

subgingival instrumentation to remove calculus/plaque on root surface and contaminated cementum (bacterial plaque/toxins)

aiming to smooth root surface (diseased cementum removal), less plaque retentive

reconstruction of periodontal tissues’ morphology in a level compatible with gingival health

moderate pull stroke for final smoothing and root planing, long and overlapping

use of hand, sonic, ultrasonic instruments

gold standard of periodontal treatment and its clinical importance has been proven in many studies

only performed on root surfaces that have been denuded of periodontal attachment by periodontitis

may be a definitive treatment in some stages of periodontal disease, may be part of pre-surgical procedures in others, and an essential part of maintenance care

arduous and time consuming, among the most technically demanding procedures performed in dentistry

may be done by quadrants or full mouth

may need to be repeated during treatment phases and may require local anesthetic

what is the therapeutic goal when treating periodontitis?

to resolve inflammation and establish gingiva health, to eliminate/later microbial etiology and contributing risk factors, to arrest progression of disease, to maintain attachment levels/gain clinical attachment, to reduce/eliminate pockets, to maintain/improve bone levels, to stabilize occlusion, to prevent the recurrence of disease, to regenerate the periodontal attachment apparatus where indicated

to preseve the natural dentition in a state of health, comfort, and function with appropriate esthetics

what happens if periodontitis is not successfully treated in phase I?

additional therapy may be required- phase II

what are treatment considerations/limitations?

patient related: systemic health, age, compliance, therapeutic preferences, patient’s ability to control plaque

other factors: clinician’s ability to remove subgingival deposits, depth of pockets, local factors, restorative and prosthetic needs, severity of periodontitis

when performed with optimal access and skill, SRP will produce a…

decrease in gingival inflammation, reduction in periodontal probing depths, and a gain in periodontal attachment

what is the rational for root planing?

root smoothness, removal of diseased cementum, preparation for new attachment (long junctional epithelium)

what are the objectives for root planing?

securing biologically acceptable root surfaces, eliminating periodontal pathogens, resolving inflammation, decreasing probing depth, facilitating oral hygiene procedures, improving or maintaining attachment levels, preparing tissues for surgical procedures

repair

healing of a wound by tissue that does not fully restore the architecture or the function of the part

reattachment

to attach again, the reunion of connective tissue with a root surface on which viable periodontal tissue is present

true new attachment

the reunion of connective tissue with a root surface that has been deprived of its periodontal ligament

this reunion occurs by the formation of new cementum with inserting collagen fibers

long junctional epithelium new attachment

adhesion of the junctional epithelium to a root surface that has been deprived of its periodontal ligament or connective tissue attachment

regeneration

reproduction or reconstruction of a lost or injured part

ODU 11/12 explorer

double ended with mirror image working ends

small fine tip and rounded back (easier insertion into deep and narrow pockets)

universal application

used for detecting calculus

mechanical debridement of natural teeth

hand instruments (scalers, universal and area specific curettes)

power driven instruments- sonic air scalers, ultrasonics- magnetostrictive scalers, piezoelectric scalers

scalers

used for supragingival scaling and are designed to remove plaque and calculus from the tooth surface

curettes

instruments of choice for subgingival instrumentation where scalers cannot be used due to their large, rigid design and their dual-edge blades

can be broadly subdivided into universal and area specific

all share the same elements: rounded back, rounded toe, semi-circular cross section

universal curettes

designed for easy adaptation on all tooth surfaces

2 cutting edges, round toe

2R/RL- anterior

4R/4L- posterior

17/18 or 13/14 McCall

barnhart

area specific curettes/gracey curettes

are designed to work in specific areas of the dentition

a series of isntruments with offset blades were designed to reach the deepest and least accessible periodontal pockets easily without traumatic injury to the gingiva

one cutting edge, round toe

after five gracey curette

designed for instrumentation in deeper periodontal pockets

the terminal shank is elongated 3mm to provide better clearance around crowns and superior access to root contours and pockets 5mm or more in depth

blade thinned by 10% to ease gingival insertion and reduce tissue distention

mini five curettes

designed with the same elongated terminal shank and thinned blades as the after five gracey curettes

50% shorter blade for access to smaller roots, narrow pockets, furcations, and developmental grooves

vision curettes

modification of the gracey curettes

50% shorter blade, increased blade curvature, straighter terminal shank, longer terminal shank

includes visual features like blade ID mark, shank demarcation, and bands on handles (marks 5mm and 10mm)

the shorter blade provides better adaptation on narrow root surfaces and tight periodontal pockets and minimizes tissue displacement

what are the limitations of hand instruments?

technique sensitive- success of SRP procedures depends on the ability of the therapist and the patient to keep the oral cavity below the threshold for disease

anatomic limitations- prevent proper adaptation of the instrument to effectively remove root deposits, like deep narrow pockets, furcations, and concavitites

instrument limitations- size of the instrument does not allow adequate access at a particular site, like root grooves that are smaller than the working portion of the instrument or in areas of root proximity

power driven instrumentation

are usually used to provide a rapid calculus and stain removal with minimum discomfort to the patient or trauma to hard and soft tissues

may be used in both supra and subgingival areas

includes sonic scalers and ultrasonic scalers (magnetostrictive and piezoelectric)

sonic air scalers

functions in the audible range, 2,500 - 700 cps or Hz

attaches to a conventional handpiece

driven by compressed air

orbital or elliptical tip movement

all surfaces active

magnetostrictive ultrasonic scaler

20,000 - 42,000 cps or Hz

metal rod or stack of metal sheets

elliptical tip movement

all surfaces active

peizoelectric ultrasonic

functions above the audible range, 29,000 - 50,000 cps or Hz

ceramic transducer

linear tip movement

lateral surfaces are more active

what are the advantages of ultrasonics?

reduced clinician fatigue, less repetitive stress, increased access, less tissue distension, potential for antimicrobial delivery, benefits of lavage

what are the limitations of ultrasonics?

altered tactile sensitivity, fluid control/evacuation, effects of noise and vibration, contaminated aerosol production

what are contraindications for ultrasonics?

communicable disease that can be transmitted by aerosol, susceptibility to infection, respiratory risk, dysphagia, cardiac pacemaker (consult with cardiologist is needed to determine type of pacemaker)

what do you need to have caution with when using an ultrasonic?

titanium surfaces of implants- use proper tips

demineralized areas, exposed dentinal surfaces (where dentinal tubules can be uncovered and sentivity can be created)

margins of porcelain/amalgam restorations as they may be damaged or removed

hand versus power driven instruments

plaque removal can be equivalently accomplished by power-driven scalers or hand instrumets

when compared to sonic or ultrasonic instruments, manual instrumentation requires more time to achieve the same clinical result

equally effective in decreasing PD, BOP, and periodontal pathogens

root surface hand v power driven

roughness/smoothness- smoothest roots were produced by ultrasonics followed by curettes

alterations- ultrasonics used on medium power may do less damage to the root surface than hand or sonic scalers, as instrument contact time/tip to tooth angle/instrumentation pressure is increased the likelihood of root surface damage is also increased

endotoxin and cementum removal hand v power driven

endotoxin (lipopolysaccharide) is a surface substance which is superficially associated with the cementum and calculus

endotoxin can be removed by washing, brushing, lightly scaling, or polishing the contaminated root surface

extensive cementum removal is not necessary for periodontal healing

side effects of scaling and root planing

bleeding, gingiva tears/lacerations, necrosis of pocket gingival lining, pain, periodontal asbcess (residual calculus), dental hypersensitivity

mechanical debridement for implants

plastic/titanium/gold hand instruments

power driven instruments- ultrasonics with plastic tips, titanium brush

how effective is scaling and root planing when considering probing depths?

100 teeth extracted after SRP, 57% of teeth surfaces had remaining calculus

if PD was </= 4mm there was 90% calculus removal, 5-6mm there was 75% calculus removal, >6mm there was 65% calculus removal

how effective is scaling and root planing when considering root surfaces?

if the probing depth was 0-3mm, 85% of calculus was removed from interproximal surfaces and 80% was removed from buccal surfaces

if the probing depth was >4mm, 60% of calculus was removed from interproximal surfaces and 80% was removed from buccal surfaces

how effective is scaling and root planing when considering furcation involvement?

68% of molars had remaing calculus after SRP

prevalence of the width of furcation entrance smaler than hand instrument size: 58%

in single rooted teeth: 90% calculus removal / in multi rooted teeth: 70% calculus removal

furcation involvement in max molars: 40% calculus removal / fucation involvement in mand molars: 70% calculus removal

what are the microbiological effects of scaling and root planing?

anaerobes with no treatment, baseline 70.8% to 65.7% at 3 months

anaerobes with SRP, at basline 71.8% to 24.5% at 3 months

what is the full mouth disinfection protocol?

1: SRP full mouth- all teeth in 2 visits within 24 hrs, under local anesthesia

2: brushing the back of the tongue- for 1 minute, with 1% CHX gel

3: mouthwash- 2x for 1min, with 10mL of CHX at 0.2% and gargling the last 10 sec to reach the tonsils

4: subgingival irrigation of all pockets- 3x for 10 min, with 1% CHX gel, after each of the 2 sessions, and repeated at D8 using a 6 and 8mmg syringed labeled

5: mouthwash (at home)- with 10mL of CHX at 0.2%, 2x a day for 1 min, over 2 weeks

6: oral hygiene instructions- tooth brushing, interdental cleaning with brushes or other hygiene aid, brushing of the tongue

what does the research on full mouth disinfection say?

clinically, not superior to SRP per quadrant in terms of efficacy

differences are not significant after 4 mo

differences are similar independently of probing depth and furcation involvement

lasers in perio

gingivectomy, frenectomy, melanin pigmentation removal, removal of metal tattoos of gingiva, osseous recontouring`

subgingival debridement and curettage, removal of granulation tissue (flap surgery), maintence of implants, treatment of peri-implantitis

perioscope

periodontal endoscope

specifically designed to explore and visualize the periodontal pocket in patients with periodontitis

allows for subgingival visualization of the root surface at magnifications of 24x to 48x

a 0.99mm fiber optic bundle is delivered to the gingival margin coupled into an instrument called an explorer

minimally invasive non-surgical treatment

minimize need for surgery

clinical health

no clinical signs of inflammation

physiologic or reduced periodontium

gingivitis classification

clinical signs of inflammation

no CAL or reduced periodontium

periodontitis classification

clinical signs of inflammation

CAL

what are the realistic, ideal, and long term goals of periodontal treatment

realistic- resolution of inflammation, PD reduction, CAL gain/maintenance, mobility reduction

ideal- periodontal tissue regeneration

long term- treatment outcome maintenace, no disease progression