Examination of Methods of Periodontal Treatment: Scaling and Root Planing in Conjunction

with Local Delivery of Medications for Periodontal Therapy

Kylie Werderman
Periodontology
Fall 2015

Periodontal disease is classified as a group of inflammatory and infectious diseases that

affect the gums and supporting tissues of the teeth (Perry, 2014). Clinical attachment loss,
alveolar bone loss, increased probing depth, furcation involvement, and gingival inflammation
are all factors that contribute to periodontal disease (Clark, 2015). The inflammation begins as a
result of untreated gingivitis because of a shift in bacterial plaque. The bodys immune response
causes the gingiva to inflame and because of the severity of the inflammation, the periodontium
surrounding the teeth are destroyed. The gingiva separates from the teeth, therefore making the
gingival sulcus deeper and allowing bacteria to thrive and create infection. The more the disease
progresses, the pockets get deeper and bone loss becomes more evident. Bringing back lost bone
is impossible without expensive and painful bone grafting procedures. Periodontal disease is
irreversible yet preventable with proper homecare, diet, and lifestyle choices.
Predisposing factors such as hypertension, Coronary Artery Disease, heart valve diseases,
Congestive Heart Failure, Arthritis, artificial joint replacements, COPD, Diabetes, tobacco use,
and alcohol abuse are all risk factors to developing periodontal disease (Perry, 2014).
Hypertension is known as the silent killer because it goes so easily undetected in patients.
Increased blood pressure can also be due to increased stress of dental treatment some people may
share. This in turn makes the heart have to work harder because of the increased blood flow
running through the body (Perry, 2014). Cardiovascular disease can be related to chronic
infections in the same way that the inflammatory response happens in coronary arteries by
developing atherosclerosis (Clark, 2015). In patients with poorly controlled or uncontrolled
diabetes (type I or type II), are more susceptible to infections because of abnormal neutrophil
functions. Other periodontal issues stemming from diabetes include enlarged parotid gland(s)
and xerostomia from reduced saliva flow (Perry, 2014). Diabetic patients also have delayed

wound healing. If there is infection present, it takes longer for treatments to work and tissues to
heal. Predominant bacteria present in patients with periodontal disease include P. gingivalis,
Bacterioides forsythus, F. nucleatum, and A. acinomcetemcomitians (Clark, 2015).
When treating periodontal disease, the first line of defense is mechanical removal of the
bacteria. This would be considered scaling and root planing and will take multiple appointments
instead of just a regular prophylaxis appointment or cleaning. Scaling and root planing would
be considered Phase I of treatment (Wilkins, 2013). A patients initial appointment will consist of
gathering medical and dental history, probing, radiographs, oral cancer exam and a
comprehensive exam done by the dentist. The information is gathered and then a prognosis is
determined if the patient agrees to all treatment necessary. Some ways to determine prognosis is
by assessing all information such as: age, systemic diseases, oral conditions, pocket depths,
mobility, attachment levels, and patient attitude and perception are all elements that will define a
prognosis (Clark, 2015). The treatment plan is put into place that the patient signs and consents
to the treatment planned- also known as informed consent (Perry, 2014). Going beyond scaling
and root planing may be necessary if the patient does not respond to this treatment at their 4-6
week evaluation appointment after SRP is complete. When inflammation is resolved, deep
probing depths are improved by 2+ mm, less plaque (decreased plaque score), and gingival
margins shrink, this is the time to determine the periodontal maintenance interval (Clark, 2015).
Scaling and root planing may be different from a regular prophy in that a power driven
scaler is usually used for calculus removal and flushing bacteria out of periodontal pockets.
Local anesthesia may be needed for patient comfort as calculus deposit is difficult to remove
when periodontal pocketing is involved. If a vasoconstrictor is able to be used in conjunction
with anesthetic, it will help to reduce hemorrhaging and improve visibility (Wilkins, 2013).

Proper homecare and oral hygiene instruction presented to the periodontal patient is
extremely important in educating them about the disease process. The BASS tooth brushing
method has the greatest cleaning potential near the gingival margin, where bacteria gathers most
(Perry, 2014). Using a powered toothbrush may appeal to patients because of the ease of use and
helps clean hard to reach areas in patients with dexterity issues. Different brush heads are
available to patients who may need to concentrate on interproximal plaque control etc. (Perry,
2014). Flossing is extremely important as it cleans more than just interproximal but subgingival
as well. Wrapping floss around both sides of the tooth will help to remove subgingival plaque
that a toothbrush cant reach (Wilkins, 2013). It is important to have patients demonstrate their
homecare habits in front of you so you as the provider can see if they are understanding what you
are educating them about. In order for them to learn, they need to be able to complete the task
without errors (Clark, 2015).
Scaling and root planing should be the first treatment method in a periodontally-involved
patient. The mechanical action of scaling and root planing is the most valuable treatment for the
healing and improvement of oral health in patients with periodontal disease (Pandaya, 2012). If
improvement of probing depths, overall gingival inflammation and plaque score arent improved
at the 4-6 week evaluation, antimicrobial and/or antibiotic therapy may need to be used. Local
delivery of antibiotics is more effective than systemic antibiotics in treating periodontal disease.
Systemic antibiotics do not give high enough concentrations of the antibiotic in the sulcus which
is where it needs to stay concentrated (Clark, 2015).
All periodontal cases are different, so it should be stated that all antibiotics arent broad
spectrum and only treat certain bacteria. Systemic antibiotics include Tetracycline (or a
derivative), Metronidazole, and Penicillin. These may work on certain bacteria present that is the

culprit of the periodontal disease. Bacterial cultures and a DNA test can be useful to determine
the best antibiotic route to use to heal deep pocket depths (Clark, 2015). The use of locally
delivered antibiotics in a periodontal patient can only happen after scaling and root planing is
completed and proper plaque control is reached (Perry, 2014).
Some commonly used antimicrobial agents include Minocycline (Arestin), Doxycycline
(Atridox), and Chlorhexidine (PerioChip). These three are placed subgingival with either a
syringe or an instrument (Perry, 2014). The substantivity of the locally delivered antibiotics are
much higher than an antimicrobial rinse like Peridex (Chlorhexidine) (Perry, 2014). The cost of
these controlled-release antibiotics are usually billed to insurance by site and not a flat fee. The
cost is also usually excluded from the cost of scaling and root planing. Dentists and Hygienists
are able to administer the drugs and hygienists must have a prescription written from the dentist
to administer (Periodontal, 2013).
By first scaling and root planing and mechanically removing plaque and calculus, the
tissues have a chance to heal on their own without the help of other measures. When after a 4-6
week evaluation the tissues still arent healing and plaque isnt a problem, this is why it is a good
time to look into local delivery of antibiotics. Using antibiotics is non-invasive unlike other
treatments such as laser therapy.
A study has been done with another antimicrobial, povidone iodine. Four quadrants were
treated with either scaling and root planing only, both scaling and root planing with povidone
iodine, povidone iodine only, and no treatment for the last quadrant. This study showed that with
the help of both scaling and root planing and povidone iodine that probing depths decreased by
almost 1.5mm (Pandaya, 2012).

The only drawbacks that I can imagine from locally delivered antibiotics are once the
antibiotic is placed, there can be no brushing or flossing for up to 9 days (Perry, 2014). This is a
downfall to newly placed good oral hygiene patterns that the patient has recently learned. There
is also a chance of the PerioChip expelling from the sulcus and may need to be re-placed in
office. (Perry, 2014). Drug allergies can alter which drugs can be used.
The expectations of the scaling and root planing patient include soreness and bleeding
until pockets and gingiva begin to heal. An NSAID or something the patient takes for a headache
can help with any discomfort. Warm salt water rinses can also help to ease gingival distress from
the physical trauma of calculus removal. The oral hygiene habits that they have been recently
educated on should be instilled in their daily homecare.
Hygienist expectations include complete calculus removal at quadrant or half mouth
scaling appointments, proper oral hygiene instructions given to patients on an individual basis,
information on the periodontal disease process, and expected improvement of the patients
overall oral health. The hygienist is also responsible for proper documentation of how the
patients baseline data compares to the improvement after their appointments. Showin the patient
areas of improvement and including them in their treatment and showing them that their hard
work is either paying off or areas where they could improve on to get them to the maintenance
phase. Educating, motivating and customizing care to each patient helps set them up for success
in the end (Clark, 2015).
Periodontal maintenance is for life after periodontal scaling and root planing therapy. The
maintenance intervals are decided at the 4-6 week evaluation appointment when the hygienist
can see a visible improvement in their oral health. The main reason for periodontal maintenance

is to make sure the patient doesnt get worse (Clark, 2015). Staying on top of calculus removal
and proper plaque control with reinforcing homecare at each appointment will help the patient
stay in maintenance mode. There are five objectives of perio maintenance appointments. 1.
Preserving clinical attachment level. 2. Maintaining bone levels. 3. Inflammation control. 4.
Assess and reinforce homecare. 5. Maintain at the best oral health possible (Clark, 2015).
Helping patients comply with more frequent appointments will help them long term. Making
sure that they have the necessary information to help themselves with answering any questions,
simplifying the process, appointment reminders via text or voicemail, giving them positive
reinforcement to either begin compliance from the start or keep compliant and let them know
what could happen if they dont comply (Clark, 2015). If patients feel like they are just being
treated by the dental office and not as a personalized appointment, they may have a lower
compliance rate than those who do provide an appointment that includes patients in their success.

References
Clark, S. (2015). Periodontology, Kirkwood Community College.

Pandaya, D. (2012). Povidone iodine- An adjunct to periodontal therapy. National Journal of

Integrated Research in Medicine 3(3), 148-151.

Periodontal Maintenance. (2013, December 28). Retrieved from http://www.toothiq.com/dentalprocedure/periodontal-maintenance/

Perry, D. A., Beemsterboer, P. L., Essex, G. (2014). Periodontaology for the Dental Hygienist
(4th ed.). Elsevier Saunders.

Wilkins, E. M., Wyche, C. J. (2013). Clinical Practice of the Dental Hygienist (11th ed.).
Philadelphia, PA: Lippincott, Williams & Wilkins.