SCALING AND ROOT PLANING

Overview: Scaling and Root Planing (NSRP)

  • NSRP is presented as an effective treatment modality for periodontal disease with a focus on reducing clinical signs and symptoms through removal of microbial deposits and calculus from root surfaces.
  • Periodontitis is strongly associated with bacterial biofilms and dental calculus on root surfaces; the ultimate goal of non-surgical pocket/root instrumentation is to render the root free from microbial deposits and calculus.
  • From a practical standpoint, if calculus is detected clinically, it should be removed to reduce the bacterial load on the root surface.
  • The process aims to reach below the individual threshold level of remaining bacterial load on root surfaces.
  • Enamel surfaces can still harbor biofilm, but enamel deposits are usually superficially attached and not locked into irregularities; scaling can completely remove biofilm and calculus from enamel, leaving a smooth, clean surface.
  • Root surface considerations acknowledge that subgingival calculus is porous, harbors bacteria and endotoxin, and is frequently embedded in cementum irregularities; complete removal is necessary because scaling alone is insufficient.
  • The rationale behind removing calculus/cementum has evolved: endotoxins were once thought to penetrate cementum and necessitate removal of cementum; later evidence showed endotoxins are loosely adherent and do not penetrate cementum, reducing the emphasis on aggressive tooth-substance removal.

Stages of NSRP

  • NSRP involves three separate stages of treatment: debridement, scaling, and root planing. (Kieser, 1994)
  • Debridement: instrumentation for disruption and removal of microbial biofilms.
  • Scaling: instrumentation for removal of mineralized deposits (calculus).
  • Root planing: instrumentation to remove contaminated cementum and portions of dentin to restore biologic compatibility of the root surface.

Goals and Principles of Scaling and Root Planing

  • Scaling and root planing: goal is to remove biofilm and calculus from tooth surfaces; never remove tooth substance intentionally with calculus removal (though cementum exposure may occur in the process).
  • The root surface should be prepared to be biocompatible for healthy reattachment and tissue healing.

Root Surface and Cementum Considerations

  • ROOT SURFACE: Subgingival calculus is porous and harbors bacteria and endotoxin; it should be removed completely; it is frequently embedded in cemental irregularities; scaling alone is insufficient.
  • A portion of the root surface may need to be removed to eliminate residual deposits; areas with thin cementum may expose dentin; such exposure may be unavoidable in some cases.
  • Originally, the concept was that bacterial endotoxins penetrate cementum, leading to the belief that removing cementum was necessary; however, evidence showed endotoxins are loosely adherent and do not penetrate cementum, reducing the need for excessive tooth-substance removal.

Instruments for NSRP

  • NSRP can be carried out using various instruments: hand instruments, sonic and ultrasonic instruments, air polishing, and ablative laser devices.

Hand Instruments

  • Hand instruments provide good tactile sensation but are more time consuming and require correct and frequent sharpening.
  • Hand instruments are composed of three main parts: blade, shank, and handle.
  • BLADE/WORKING PART: cutting edges are centered over the long axis of the handle for proper balance; materials include carbon steel, stainless steel; some blades for implants use titanium, plastic, or carbon-fiber.

Periodontal Instruments: Classification and Probes

  • Periodontal instruments are classified by purpose into:
    1) Periodontal probes
    2) Explorers
    3) Scaling, root-planing, and curettage instruments

  • Periodontal Probes:

    • Typically tapered, rodlike, calibrated in millimeters, with a blunt, rounded tip.
    • When measuring a pocket, the probe is inserted with firm, gentle pressure to the bottom of the pocket; shank should be aligned with the long axis of the tooth surface.
    • Calibration and technique are critical for accurate pocket measurement.

  • Explorers:

    • Used to locate subgingival deposits and carious areas; to check the smoothness of the root surfaces after root planing; designed with different shapes and angles.

Basic Scalers, Curettes, and Related Instruments

  • Five basic scaling instruments (illustrated as A–E in Fig. 50.7):

    • A: Curette
    • B: Sickle
    • C: File
    • D: Chisel
    • E: Hoe

  • Sickle Scalers:

    • Flat surface with two cutting edges converging to a sharply pointed tip.
    • Used primarily to remove supragingival calculus.
    • Employed with a pull stroke.
    • Selection depends on area to be scaled: straight shanks for anterior/premolars; contra-angled shanks adapt to posterior teeth.

  • Curettes:

    • Instrument of choice for removing deep subgingival calculus, root-planing altered cementum, and removing the soft tissue lining of the periodontal pocket.
    • Working end has cutting edges on both sides of the blade and a rounded toe; finer than sickle scalers and free of sharp points or corners other than the cutting edges.
    • Two basic types:
    • Universal curettes
    • Area-specific curettes (Gracey curettes)

  • Universal Curettes:

    • Cutting edges may be inserted in most areas by altering finger rest, fulcrum, and hand position; face is at a 90° angle to the lower shank when seen in cross section.

  • Area-Specific Curettes (Gracey Curettes):

    • Designed for specific anatomic areas of the dentition; provide the best adaptation to complex root anatomy.
    • Reduced set includes: #5-6, #7-8, #11-12, #13-14.
    • Double-ended Gracey curettes: #1-2 and #3-4 (anterior); #5-6 (anterior and premolars); #7-8 and #9-10 (posterior, facial and lingual).
    • Gracey #11-12 (posterior teeth, mesial surfaces); Gracey #13-14 (posterior teeth, distal surfaces).
    • Single-ended Gracey curettes: set comprises 14 instruments; experienced operators can adapt each instrument for multiple areas by adjusting hand position and patient position.
    • Differences from universal curettes:
    • Offset blade; blade not at 90° to the lower shank; angled about 70^ ext{o} from the lower shank.
    • Area-specific curettes have curved blades, while universal curettes have a blade curved in one direction.
    • Rigid Gracey: larger, stronger, less flexible shank and blade; rigid shank allows removal of moderate to heavy calculus without a separate set of heavy scalers.
    • Recent additions: Gracey ext{#15-16} (modification of standard #11-12); designed for mesial surfaces of posterior teeth.
    • Extended-Shank Curettes (e.g., After Five): modifications of Gracey designs to reach deeper pockets (5 mm or more).
    • Mini-Bladed Curettes (e.g., Hu-Friedy Mini Five): blades half the length of After Five or standard Gracey curettes; shorter blade allows easier insertion/adaptation in deep, narrow pockets, furcations, developmental grooves, line angles; used with vertical strokes, reducing tissue distention and avoiding tissue trauma.

  • Hoe, Chisel, and File Scalers:

    • Hoe Scalers: used for scaling ledges or rings of calculus; blade bent at 99^ ext{o}; cutting edge formed by junction of flattened terminal surface with inner aspect of blade.
    • Hoe Scalers (alternate descriptions): blade slightly bowed to maintain contact at two points on a convex surface; back of blade rounded; blade thinned to permit access to roots without interference from adjacent tissues.
    • Files: primary function is to fracture or crush large deposits of tenacious calculus or burnished sheets; can gouge and roughen root surfaces if used improperly; not suitable for fine scaling and root planing; sometimes used for removing overhanging margins of dental restorations.
    • Chisel Scalers: designed for proximal surfaces of teeth too closely spaced to permit other scalers; usually used in the anterior part of the mouth; activated with a push motion.
    • Quétin Furcation Curettes: hoes with a shallow, half-moon radius that fits into the roof or floor of the furcation; curvature of the tip fits developmental depressions on the inner aspect of roots.
    • Diamond-Coated Files: used for final finishing of root surfaces; do not have cutting edges; coated with very fine grit diamond; new diamond files are very abrasive and should be used with light, even pressure to avoid gouging; produce a smooth, polished root surface.

  • Implant Instruments:

    • Plastic or titanium scalers and curettes designed for use on implants and implant restorations.

  • Ultrasonic and Sonic Instruments:

    • Used for scaling, cleansing tooth surfaces, and curetting the soft tissue wall of the periodontal pocket.

  • Power-Driven Instruments:

    • Have the potential to make scaling less demanding and more time efficient; can be used alone or in combination with hand instruments.
    • Potential hazards include rough root surfaces, production of bioaerosols, and interference with cardiac pacemakers.

  • Mechanism of Action of Power Scalers:

    • Key factors: frequency, stroke, and water flow.
    • Water contributes to three physiologic effects that disrupt biofilm: acoustic streaming, acoustic turbulence, and cavitation; the combination disrupts biofilm.

  • Type and Benefit of Power Instruments:

    • Sonic units: frequency 2000 to 6500 cycles per second; sonic scaler tips travel in an elliptical or orbital stroke pattern, allowing adaptation to all tooth surfaces.
    • Magnetostrictive ultrasonic: frequency 18{,}000 to 50{,}000 cycles per second; vibrations travel from a metal stack to a connecting body, causing vibration of the tip; tips move in an elliptical/orbital stroke, giving four active surfaces.
    • Piezoelectric ultrasonic: frequency 18{,}000 to 50{,}000 cycles per second; powered by a ceramic disc; tips move primarily in a linear pattern, giving two active surfaces.
    • Power-driven instruments are not only for heavy calculus removal; depending on tip design/size, they are beneficial for supragingival calculus removal, subgingival debridement, and general deplaquing.

  • Bioaerosols and Safety:

    • Bioaerosols from power-driven devices can remain in the air for up to 30 ext{ minutes}; if the operator's face mask becomes damp during the procedure, it should be changed.
    • A face shield may be required; preprocedural rinsing and high-speed evacuation help minimize bioaerosols.

Indications and Precautions

  • Indications:

    • Supragingival debridement of dental calculus and extrinsic stains.
    • Subgingival debridement of calculus, oral biofilm, root surface constituents, and periodontal pathogens.
    • Removal of orthodontic cement; treatment of gingival and periodontal conditions and diseases; surgical interventions; margination (reduces amalgam overhangs).

  • Precautions:

    • Unshielded pacemakers; infectious diseases (HIV, hepatitis, active TB);
    • Demineralized tooth surfaces; exposed dentin (sensitivity concerns).

  • Contraindications:

    • Chronic pulmonary disease (asthma, emphysema, cystic fibrosis, pneumonia);
    • Cardiovascular disease with secondary pulmonary disease;
    • Dysphagia (swallowing difficulties).

  • Periodontal Endoscopes:

    • Used for deep visualization into subgingival pockets and furcations to detect deposits.

Cleansing and Polishing Instruments

  • 5. Cleansing and Polishing Instruments (Fig. 50.45–50.46):
    • Metal prophylaxis angle with rubber cup and brush; disposable plastic prophylaxis angle with rubber cup and brush.
  • Bristle Brushes: used for polishing; bristle brush should be confined to the crown to avoid injuring cementum and gingiva.
  • Dental Tape: used for polishing proximal surfaces inaccessible to other polishing instruments.
  • Air-Powder Polishing: delivers an air-powered slurry of warm water and sodium bicarbonate for polishing; slurry removes stains rapidly via mechanical abrasion and provides warm rinse.

General Principles of Instrumentation

  • Fundamental prerequisites for effective instrumentation:

    • Proper positioning of patient and operator; adequate illumination and retraction for visibility; sharp instruments.
    • Awareness of tooth and root morphologic features and the condition of periodontal tissues; knowledge of instrument design.
    • Clinician should be seated with feet flat, thighs parallel to the floor.

  • Visibility, Illumination, and Retraction:

    • Direct vision with direct illumination from dental light is most desirable.

  • Methods for Retraction:

    • Use of the mirror to deflect the cheek with nonoperating hand retracting lips; protection of the angle of the mouth from mirror handle irritation.
    • The mirror alone can retract lips and cheek.
    • The nonoperating hand fingers can retract lips; the mirror can retract the tongue; combinations of methods.

  • Condition and Sharpness of Instruments:

    • Before instrumentation, instruments should be clean, sterile, and in good condition.
    • Sharp instruments enhance tactile sensitivity and precision; dull instruments may lead to incomplete calculus removal and unnecessary trauma due to extra force.

  • Maintaining a Clean Field:

    • Saliva, blood, or debris can obscure the operator's field; adequate suction is essential (saliva ejector).

  • Instrument Stabilization:

    • Stability of the instrument and hand is essential for controlled instrumentation and to avoid patient or practitioner injury.

  • Key Stabilization Factors:

    • Instrument grasp; finger rest.

  • Instrument Grasp:

    • The most effective and stable grasp for periodontal instruments is the modified pen grasp.

  • Finger Rest (Fulcrum):

    • Stabilizes the hand and instrument by providing a firm fulcrum; prevents injury and tissue trauma.

  • Intraoral Finger Rest Variations:

    • Conventional: established on tooth surfaces adjacent to the working area.
    • Cross-arch: established on tooth surfaces on the opposite side of the same arch.
    • Opposite arch: established on tooth surfaces on the opposite arch.
    • Finger on finger: rest established on the index finger or thumb of the nonoperating hand.

  • Extraoral Fulcrums:

    • Essential for access to some maxillary posterior teeth; provide stabilization and proper angulation.

  • Common Extraoral Fulcrums:

    • Palm up: resting the backs of the middle and fourth fingers on the skin over the lateral aspect of the mandible on the right side.
    • Palm down: resting the front surfaces of the middle and fourth fingers on the skin over the lateral aspect of the mandible on the left side.

  • Reinforcement of Rest:

    • Intraoral rests may be reinforced by the index finger or thumb of the nonoperating hand on the handle or shank for added control and pressure.

  • Index Finger-Reinforced Rest:

    • The index finger is placed on the shank for pressure and control in specific regions (e.g., maxillary left mesial and lingual region).

  • Thumb-Reinforced Rest:

    • The thumb is placed on the handle for control in specific regions (e.g., maxillary right posterior lingual region).

  • Activation and Adaptation:

    • Adaptation: placement of the working end against the tooth surface with a goal of conforming to the contour of the surface; prevents tissue trauma and enhances effectiveness.
    • Angulation: the angle between the blade face and the tooth surface (tooth–blade relationship); correct angulation is essential for effective calculus removal.
    • Lateral Pressure: force applied with the blade edge on the tooth surface; can be firm, moderate, or light.

  • Basic Stroke Types:

    • Exploratory stroke: a light “feeling” stroke used with probes/explorers to evaluate pockets and detect calculus/irregularities.
    • Scaling stroke: a short, powerful pull stroke used with bladed instruments for removal of both supragingival and subgingival calculus.
    • Root-planing stroke: a moderate to light pull stroke used for final smoothing and planing of the root surface; curettes are highly effective for this procedure.

  • Activation Modes:

    • Any of these basic strokes may be activated by a pull or push motion in a vertical, oblique, or horizontal direction.