Examination of Methods of Periodontal Treatment:

Scaling and Root Planing

Rachel Oakes

Periodontology
 Rachel Oakes
Periodontology

Periodontal disease, commonly known as gum disease, is a set of infectious transmittable

diseases that are initiated by inflammation caused from microorganisms in the oral cavity. The

different microorganisms can cause gingival inflammation and increased periodontal probing

depths leading to clinical attachment loss and absorption of alveolar bone. Gingivitis is the

mildest form of periodontal disease and left untreated can progress into periodontitis, which has

multiple levels of severity ranging from slight periodontitis to chronic or advanced periodontitis.

The cause of periodontal disease are the bacterial microorganisms in the oral cavity.

Dental plaque is mostly made up of bacteria; these bacteria should be disrupted often, so they are

unable to colonize and form more complex arrangements in the oral cavity, by the friction of

flossing and brushing. When dental plaque accumulates and isn’t disrupted, plaque can cause

inflammation of the gum tissues known as gingivitis. Gingivitis is reversible if proper bacterial

disruption occurs, but if left untreated, the inflammation can lead to an autoimmune response to

begin breaking down the supporting structures in the oral cavity. Once these alveolar structures

have begun reabsorption, the disease state has progressed into periodontitis and is irreversible.

There are predisposing factors that make a person more susceptible to periodontal

disease. Determinant risk factors make a person more prone to periodontal disease and are

factors that cannot be changed such as gender, age, or race. Males are statistically more likely to

develop periodontal disease in comparison to females; as a person ages they become more likely

to develop periodontal involvement. There are also activities or conditions that put a person at a

higher risk to develop periodontal disease such as smoking tobacco, alcohol use, or childhood

obesity. These risk factors are different from determinant risk factors because they can be

changed, altered or modified. Diabetes, cardiovascular disease, and low socioeconomic status are

also potential risk factors in the development of periodontal disease.

 Rachel Oakes
Periodontology

Even though each person’s oral microbiota differs from the person standing next to them,

there are specific bacteria that have been identified and tend to be present in the oral cavity

during different stages of periodontal disease. Bacteria can be gram positive or gram negative;

Bacteria can also be aerobic (needs oxygen to survive) or anaerobic (does not need oxygen to

survive). A healthy oral cavity contains thousands of bacteria, many of which will be gram-

positive cocci and rod species. Those bacteria found in a healthy oral cavity will change as

periodontal disease begins and progresses. As periodontal disease progresses, the bacteria

continue microbial succession; the aging bacteria changes its composition to become more

resistant and begin the thrive in the oral environment.

In the first few weeks of plaque accumulation that leads to gingivitis and periodontal

disease, the bacteria strain Actinomyces will grow in increasing numbers, followed by Veillonella

(which is gram negative and anaerobic) species. As gingivitis progresses, there will be an

increase of gram negative, anaerobic rods present in the oral cavity. The bacteria begin to

coaggregate with each other and periodontal disease will progress as these species move

subgingivally. This progression is because much of the bacteria present is gram negative,

anaerobic and motile; the motile bacteria can move around freely and group with other bacteria

that will benefit their survival. P. gingivalis is found to be present in all of the different stages of

periodontitis and is the most important bacteria found in periodontal disease because it is found

in such high numbers. Other bacteria that are commonly present in periodontitis patient’s oral

microbiota are P. intermedia and B. forsythus.

There are multiple ways to treat periodontal disease in its different stages. Some are non-

surgical procedures such as scaling and root planing (SRP) and gingival curettage. Other

procedures require surgical measures to treat periodontal disease. Periodontal pocket reduction
 Rachel Oakes
Periodontology

with regenerative procedures like bone grafts and soft tissue grafts are examples of surgical

treatments for periodontal disease. These procedures can be done alone or in a combination.

While each of these procedures will help treat periodontal disease, they need to be done with

patients who are willing to comply with and maintain necessary homecare for the best potential

outcome.

SRP is a non-surgical treatment procedure in which calculus, plaque and staining are

removed during instrumentation and the root surface is smoothed and removed of rough, toxin

contaminated structure. Local anesthesia can be given to the patient to reduce discomfort during

an SRP treatment. Gingival curettage is a procedure in which a layer of inflamed tissue in a

periodontal pocket is removed by mechanical means; the tissue post-gingival curettage will

shrink and there’s a potential for the pocket to reduce in size. Curettage is not practiced as widely

as it once was due to recent studies that show SRP is just as effective, if not more so.

Soft tissue grafts are the most common procedure currently used to increase the amount

of attached gingiva on a periodontally involved tooth; it has the most predictable outcomes as

opposed to other mucogingival surgeries and can treat multiple teeth at the same time. While it is

a predictable surgery, it can produce negative outcomes and has a greater amount of discomfort

than non-surgical procedures. Thinning, splitting or necrosis of the transplanted graft tissue does

happen and can cause the surgery to fail. Bone grafts are also used as a treatment for advanced

periodontal disease. Bone grafts can only be done after the root surface has been scaled and root

planed. There must be enough of the correct bone type to do a graft successfully and failure is

common due to a low potential for osseous induction.

Scaling and root planing (SRP) is the first treatment of choice for many dental hygienists

with patients combating periodontal disease in order to restore gingival health; clinical trials
 Rachel Oakes
Periodontology

have shown repeatedly overtime that SRP helps reduce probing depths, gingival inflammation

therefore increasing clinical attachment on patients. Scaling is the process of removing the

plaque biofilm, supragingival and subgingival calculus deposits that sit on the crown and root of

the tooth structure; these deposits are the instigators in the inflammatory process that causes

periodontitis. Scaling can be done both with ultrasonic scaling devices such as the Cavitron and

with hand scaling instruments. Checking the smoothness of the tooth post-scaling by using an

explorer will determine if the scaling was successful.

After scaling, root planing helps remove toxins and microorganisms present on the

cementum, as well as rough root surface and any calculus that may have been burnished flat

while scaling. A rough root surface is thought to facilitate the formation of plaque biofilm and

calculus. As is the case with scaling, both hand scaling instruments and ultrasonic scaling

devices can be used for proper root planing. Root planing differs from scaling because the

clinician uses a working stroke on the entirety on the root surface, whereas during scaling when a

working stroke is only used once deposit has been identified through the tactile sense of the

clinician. Root scaling provides a uniformly-smooth texture to the roots of periodontally

involved teeth, which is believed to make the tooth less susceptible to plaque biofilm post-

treatment.

Nonsurgical therapy, such as SRP, is always indicated for all stages periodontal disease;

SRP may be used in combination with surgical therapies in more severe stages of periodontitis.

Due to these facts, ideal candidates for SRP are patients who have any stage of periodontal

disease and are willing to comply with home care after the procedure and for the future to

maintain their gingival health. SRP treatment can range in cost depending on a variety of factors

such as the location of the treatment, how many teeth require SRP, how many appointments will
 Rachel Oakes
Periodontology

be needed and many other aspects. The procedure can range from anywhere from $400 to $4000.

A dental hygienist can perform many SRP procedures as well as a general dentist and a

periodontist. Periodontists tend to charge more for an SRP than a general dentist due to their

specialty in periodontology and they usually see the more severe cases.

I feel that SRP is my first treatment of choice in the treatment of periodontal disease

because it has been shown to reduce bleeding, probing depths, increase attachment, show

changes in recession and decrease the amount of red, inflamed tissue with good success rates. It

can be the first step in treating periodontal disease without surgery and many surgical methods

need to be paired with SRP treatments to be successful. It has been shown in studies that after

SRP treatment, pockets of 7 mm or more showed the highest incidence in pocket reduction with

pockets shrinking from 1.5 to 3 mm. Bleeding sites can be reduced by 50% and gingival redness

can be completely removed. After SRP, healing can take as short as 3 to 6 weeks versus other

treatments.

There are a few drawbacks for SRP treatment. Due to the deep pockets caused by

periodontal disease and recession, this procedure may be uncomfortable for the patient, so local

anesthesia is commonly administered for the appointment. This helps manage the patient’s pain

and make the SRP process easier for the clinician. Root scaling may cause thinning dentin and

root sensitivity in some patients post procedure, but there is no available data on how often this

occurs; toothpaste with desensitizing agents and fluoride treatments should be considered for

patients experiencing sensitivity. Patients will also need to be complaint with multiple SRP

appointments as well as recall checkups to maintain their oral and gingival health post SRP.

While I was unable to find SRP failure rates, I was able to find some information

regarding nonresponsive disease sites and some readings questioning the need for root planing.
 Rachel Oakes
Periodontology

After an SRP procedure, if there are still nonresponsive sites present, there may have been

deposit left behind during the initial SRP or there may be other factors such as smoking or an

undiagnosed systemic disease that is contributing to the problem. There are also no clinical

studies that prove that root planing makes teeth easier to maintain than those teeth that just had a

scaling procedure. The process of root planing used to have the end goal that the tooth would feel

glassy-smooth, but this has changed overtime to simply having uniform-smoothness of the tooth

root. Selective root planing is also something that I was able to find some information on and it

reduces the amount of root surface that needs to be removed in order to free the tooth of

imbedded bacteria and toxins.

Any periodontal treatment, whether nonsurgical or surgical, will require the patient to

follow post-operation instructions for ideal results. All SRP patients are put on a 4-6-week recall

checking their progress and healing. They are also put on a maintenance recall schedule in which

they will need to be responsible to attend all appointments scheduled with their dental provider.

They also must keep up with homecare routine including brushing and flossing, in addition to

their regular dental visits. Incorporating homecare aids such as an electric tooth brush, a

Waterpik or interdental brushes to keep periodontal pockets as clean as possible is also

suggested.

Dental hygienists are expected to provide a thorough SPR cleaning and debridement to

the best of their ability while helping maintain patient comfort with the administration of local

anesthesia. They also need to help the patient understand their condition, how best to keep their

condition of further deterioration with homecare and oral hygiene instruction and understandable

post-operative instructions. Most SRP procedures are successful unless there are compliance

issues with homecare and keeping up with necessary appointments, an underlying systemic
 Rachel Oakes
Periodontology

condition or the patient is still smoking. Overall, SRP is a good nonsurgical procedure that can

help the overall oral health of patients who have periodontal disease.
 Rachel Oakes
Periodontology

Bibliography

Allen, D. L., McFall, W. T., & Jenzano, J. W. (1987). Periodontics for the dental hygienist.

Philadelphia: Lea & Febiger.

Clark, S. (n.d.). Periodontology Lecture Notes. Reading presented in Kirkwood Community

College, Cedar Rapids.

Cohen, E. S. (1988). Atlas of periodontal surgery. Philadelphia: Lea & Febiger.

Fedi, P. F., Vernino, A. R., Amme, J., & Burns, S. (1995). The periodontic syllabus. Baltimore:

Williams & Wilkins.

Nield-Gehrig, J. S., & Willmann, D. E. (2016). Foundations of periodontics for the dental hygienist.

Philadelphia: Wolters Kluwer.

Nowak, S. (2018, September 26). Dental deep cleaning cost (scaling and root planing). Retrieved

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

Perry, D. A., Beemsterboer, P. L., & Essex, G. (2014). Periodontology for the dental hygienist. St.

Louis, MO: Elsevier.

Wilkins, E. M., Wyche, C. J., & Boyd, L. D. (2017). Clinical practice of the dental hygienist.

Philadelphia: Wolters kluwer.