Periodontology 2000, Vol.
28, 2002, 56–71
Printed in Denmark ¡ All rights reserved
Antimicrobial effects of
mechanical debridement
G REGOR J . P ETERSILKA, B ENJAMIN E HMKE & T HOMAS F. F LEMMIG
Because the role of microorganisms in the causa-
tion and pathogenesis of periodontal disease is
well documented, therapy is directed primarily to-
wards reducing the number of pathogenic micro-
organisms in contact with periodontal tissues.
Therefore, mechanical plaque removal is the basis
of most periodontal treatment regimens. This
chapter aims at describing the effects of tooth-
brushing, interdental hygiene and supragingival as
well as subgingival debridement on plaque bac-
teria. It is beyond the scope of this chapter, how-
ever, to discuss the effects of various treatment
regimens on clinical parameters.
Patient-performed plaque control
Manual and powered toothbrushing
The toothbrush is the most frequently used oral hy-
giene device (121). Irrespective of design, the func-
tion of the toothbrush is simple: plaque is disrupted
by the mechanical action of the bristles and swept
away from the surface. The cleaning efficacy of a
toothbrush correlates with brushing time (84) and is
significantly enhanced by the use of toothpaste (52,
68). There is, however, only a low correlation be-
tween applied pressure and brushing effectiveness
(187, 188). Several studies evaluated the influence of
specific features, such as bristle design (8, 20, 23, 26,
39, 63, 148, 191), toothbrush head (165, 181, 202,
212) and handle (51, 96, 97, 104) on the efficacy of a
toothbrush. Although minor differences in the effec-
tiveness of various toothbrushes were found, the
clinical relevance of these findings is unclear. The
need to simplify the often tedious and time-consum-
ing brushing procedures led to the development of
automated toothbrushes as early as 1885 (166). Since
then, steady developments have been made, and
while the benefit of powered toothbrushes was con-
sidered negligible during the 1960s (9, 75), modern
powered toothbrush models have been shown to be
56
Copyright C Munksgaard 2002
PERIODONTOLOGY 2000
ISSN 0906-6713
slightly more effective in plaque removal than man-
ual toothbrushes (78).
If oral hygiene is neglected or discontinued,
plaque growth reaches its maximum extent within
3–4 days, and plaque accumulation is detected on
almost all tooth surfaces (69, 113). Therefore, in
populations without access to customary oral hy-
giene devices such as toothbrushes, up to approxi-
mately 95% of assessed surfaces exhibit visible
plaque (16). In contrast, patients living in industrial-
ized countries and practicing regular oral hygiene
have on average only 40% to 60% of tooth surfaces
covered with plaque (95). Under study conditions,
instruction on how to use manual toothbrushes has
been shown to achieve a reduction of approximately
30% in plaque levels compared with normal oral hy-
giene (Fig. 1). After manual toothbrushing, most
plaque remnants are found in the buccal upper mo-
lar and premolar region as well as on the lingual as-
pects of the mandibular molars. The instructed use
of newly designed power-driven toothbrushes has
been shown to enhance cleaning effectiveness, espe-
cially in these regions (2, 183, 185, 186). This may
explain why the use of powered brushes is slightly
more effective than manual brushing and may lead
overall to a mean plaque reduction of about 45%
compared with normal oral hygiene using manual
toothbrushes (Fig. 1). The higher efficacy of these
devices may in part also be ascribed to advances in
brush design, such as more compact brush heads
with concentrically oriented bristles (81). In vitro,
the high oscillation velocity of the toothbrushes has
been shown to enhance the cleaning efficacy
through flow phenomena and microstreaming ef-
fects, resulting in damage to bacterial cell wall com-
ponents (61, 90, 130). Additionally, though designed
primarily for the removal of supragingival plaque,
the use of both powered and manual toothbrushes
may allow penetration of the subgingival area to a
maximum depth of about 0.9 to 1.5 mm (Fig. 2) (153,
179, 195).

Patient motivation and oral hygiene instruction
are claimed to be a major factor influencing the de-
gree of plaque control (158, 204). It should be noted,
however, that effective instruction and long-lasting
patient motivation are time-consuming and require
frequent remotivation. For example, long-term
studies on the efficacy of patient instruction and
motivation programs have demonstrated that even
an oral hygiene training program lasting 1.5 hours
overall led to only indiscernible improvements in
plaque status and gingival inflammation in adoles-
cents. To achieve clinically relevant reductions in
plaque levels, as much as 3.5 hours of instruction
and motivation are needed (3, 4).
Along with the quantitative reduction in supragin-
gival plaque expressed by lower plaque indices and
seen with both manual and powered toothbrushes,
there is a marked reduction in total viable bacteria
counts (197). There is a concomitant decrease in the
percentage of spirochetes and anaerobic bacteria,
while percentages of aerobe flora are elevated (62).
While toothbrushing may reduce the levels of peri-
odontopathogenic bacteria such as Actinobacillus
actinomycetemcomitans, Bacteroides forsythus, Por-
phyromonas gingivalis, Eikenella corrodens and Tre-
ponema denticola in supragingival plaque, it does
not significantly reduce the percentage of subgingi-
val sites infected with these pathogens even when
toothbrushing is combined with supragingival scal-
ing (208).
Interdental hygiene
Oral hygiene measures in the interdental (directly
under the contact area) or interproximal areas (vis-
Antimicrobial effects of mechanical debridement
Fig. 1. Effectiveness of supra-
gingival plaque removal
using manual or powered
toothbrushes
ible spaces between the teeth, which are not under
the contact area) have been of major interest since
the publication of reports that these surfaces cannot
be cleaned by toothbrushing alone (24, 43, 105). It is
therefore necessary to carry out interdental cleaning
on a regular basis, such as by using dental floss,
interdental brushes, wooden sticks or powered inter-
dental cleaning devices. Since interdental hygiene is
technically demanding, it is performed on a daily
basis by only about 10% of the population (17, 95,
158). Among the many factors with a potential in-
fluence on the effectiveness of interdental hygiene
are the type of cleaning device used and the inter-
dental anatomy (47, 106). Both waxed and unwaxed
dental floss may be effective in narrow interdental
spaces or the interproximal area, while dental tape,
wooden sticks or interdental brushes have been
shown to be more effective in wider interdental
spaces (25, 42, 73). Interdental cleaning with inter-
dental brushes was shown to extend to 2.5 mm be-
Fig. 2. Mean range of penetration depths of toothbrushes
and interdental hygiene devices (153, 179, 193, 195, 196)
57
Petersilka et al.
low the gingival margin, while interdental floss may
penetrate to a depth of up to 3.5 mm (193, 196) (Fig.
2).
To overcome problems of patient dexterity, floss-
holding devices (36, 149, 174) and powered interden-
tal cleaning devices operating with a rotating fila-
ment have been invented in recent years. Although
they have been reported to find a higher degree of
patient acceptance, they have so far failed to show
superiority over the use of floss or interdental brush-
es (74, 164, 179).
Overall, the results of the studies indicate that
waxed or unwaxed dental floss, Superflossc, dental
tape or powered interdental hygiene devices are
more or less equally effective in removing plaque if
used with appropriate indication and thorough pa-
tient information, although comparison between
studies is difficult due to variations in study design.
Approximately 85% of interdental surfaces exhibit
plaque when oral hygiene is performed without
interdental cleaning (142, 209). The absolute plaque
levels in this area may be reduced by 30% to 40%
after interdental cleaning, irrespective of the type of
product used, in comparison to oral hygiene without
interdental cleaning (36, 42, 47, 89, 110, 142, 207,
209) (Fig. 3). Interestingly, plaque reduction effec-
tiveness is slightly lower in studies with longer obser-
vation periods, (6 months or more) (110), which may
reflect reduced patient compliance with ongoing
study duration.
Supragingival irrigation
Irrigation devices are aimed at flushing away bac-
teria from the periodontal tissues. If applied supra-
58
gingivally, the irrigant may penetrate up to 71% in
shallow and up to 68% in moderately deep pockets
(31). However, with water or saline used as an irrig-
ant, supragingival irrigation as a monotherapy was
shown to be inferior to mechanical plaque control
by conventional oral hygiene techniques (86), and its
effect on supragingival plaque to be limited (66, 91,
139). Also, the effect of supragingival irrigation on
the subgingival microflora was reported to be negli-
gible (45, 56, 65, 66, 91, 139). Thus, the overall anti-
microbial effect of irrigation using tap water or sa-
line on the oral microflora is limited. Despite its poor
efficacy in supragingival plaque control, irrigation
was reported to lead to a marked reduction of gingi-
val inflammation, such as bleeding on probing,
possibly by diluting or washing away bacterial toxins
(13, 66).
Professionally performed plaque
removal
Rubber cup and air powder polishing
devices
For professional supragingival plaque removal in ini-
tial or supportive periodontal therapy, polishing de-
vices such as rotating rubber cups with polishing
paste or air powder polishing devices are frequently
used. The effectiveness of rubber cup and paste sys-
tems depends on paste abrasiveness, rotation speed,
pressure applied with the handpiece and the dur-
ation of the polishing procedure (18, 40, 125).
For air powder polishing devices the determi-
nation of instrument effectiveness is more complex.
Fig. 3. Effectiveness of supragingival
plaque removal using interdental hygiene
devices

The abrasive slurry of water, powder and air is
created by stirring up sodium bicarbonate powder
inside the powder chamber with pressurized air. A
flow of air and powder is transported to the tip of
the nozzle, where a jet of water is added. Plaque and
stain removal, and to some degree also a polishing
effect, are achieved by the mechanical action of the
accelerated particles within a jet of water. The effi-
cacy of the instrument may be influenced by the
powder and water setting, the distance of the jet
from the treated surface and the shape and size of
the particles used (10, 27, 28, 53, 83, 93). Supragin-
gival plaque removal is considered to be more ef-
ficient with air powder polishing devices than with
conventional rubber cup and polishing paste sys-
tems (19, 27, 40, 83, 111, 203). However, professional
tooth polishing using air powder polishing devices
with conventional sodium bicarbonate powder may
result in some clinically relevant loss of tooth sub-
stance, especially if applied to denuded root surfaces
or dentin (19, 111, 125).
Hand instruments, sonic and ultrasonic
scalers
Traditionally, root surface debridement has been car-
ried out with hand instruments: curettes, scalers, files
or hoes. As a common feature, all these instruments
operate by pulling or pushing a sharp or cutting edge
across the surface to be cleaned, thereby disrupting
and dislodging the bacterial biofilm and calculus and
removing stains. Power-driven instruments such as
sonic scalers, magnetostrictive and piezoelectric
ultrasonic scalers, may be applied supragingivally and
subgingivally (55, 99). Irrespective of instrument type,
bacterial deposits are removed by a scraping or ham-
mering motion of the working tip towards the root
surface and are then washed away by the cooling irrig-
ant used (29, 70). Thus, the main plaque-removing ef-
fect of power-driven scalers is, as in hand instrumen-
tation, solely the mechanical action of the scaler tip.
This is corroborated by clinical studies showing iden-
tical treatment results with both hand and powered
instruments (15, 114, 122, 182). To date, potential
acoustic microstreaming or cavitational effects that
may enhance the cleaning efficacy of oscillating
scalers have been demonstrated only in vitro (102,
198–201) but not in vivo. Antimicrobial effects are un-
likely to result from disruption of bacterial cell walls,
as in vitro studies have shown a clear lack of bacteri-
cidal effect on periodontopathogenic bacteria by
ultrasonic and sonic scalers even after 150 seconds of
exposure (162).
Antimicrobial effects of mechanical debridement
Besides sonic and ultrasonic scalers, several other
powered devices have been invented during the past
decades. These may remove plaque and calculus
with a reciprocating (Peri-O-TorC, Perioplaner and
PeriopolisherC system, EVA system) or a rotating
motion (IntensivC, DesmocleanC). Although their ef-
fectiveness in removing subgingival plaque and cal-
culus is well documented (79, 85, 107, 163), these
instruments have not been widely used, possibly due
to handling difficulties and limited access to the sub-
gingival root surface.
Lasers
Lasers transfer energy from the emitted laser light
beam to the irradiated substance. Their effectiveness
and safety depend on the laser wavelength and the
absorbing characteristics of the tissue to be treated
(14, 112, 143, 147, 155, 178). The use of lasers pro-
vides a variety of potentially promising features, and
intense research has been carried out in that field in
recent years. However, the effectiveness of lasers in
calculus removal is lower than that of ultrasonic
scalers; also, higher surface roughness may occur
after laser application (7). Antimicrobial effects of
lasers have been shown in vivo for diode (134) and
Nd:YAG lasers (46, 119) without any clinically rel-
evant superiority of lasers over traditional debride-
ment procedures being demonstrated. To date, no
data suggest that the use of lasers in periodontal
treatment may be as good as or even better than de-
bridement using hand instruments or power-driven
scalers.
Supragingival debridement
Professional supragingival debridement is aimed at
plaque elimination; especially under study con-
ditions, every effort is made to reach this goal.
Nevertheless, some plaque remains even immedi-
ately after professional supragingival debridement
(54, 111). However, long-term effects of professional
supragingival scaling on plaque accumulation
should be regarded as more clinically relevant. A re-
view of studies with durations of up to 1 year shows
that professional supragingival debridement in con-
junction with personal oral hygiene may result in
plaque levels being reduced by about half compared
with baseline values (21, 98, 115, 129) (Fig. 4). Solely
patient performed oral hygiene, however, has been
shown to result in a reduction of only approximately
30% from baseline plaque scores (150, 180, 186, 210).
Lower plaque accumulations recorded in patients re-
59
Petersilka et al.
ceiving frequent professional supragingival debride-
ment (6, 12, 48, 77, 80, 82, 103, 136, 208) may reflect
a positive influence on oral hygiene compliance.
The influence of supragingival plaque removal on
the subgingival microbiota is the subject of contro-
versy. Unfortunately, comparisons between studies
on that topic are difficult due to major differences
in study design. Variations in periodontal conditions
such as degree of inflammation and pocket depth,
kind of pretreatment, patient performed oral hy-
giene, and supragingival instrumentation technique
may influence the results. In addition, microbiologi-
cal sampling and processing techniques vary greatly.
Most studies examining the effects of supragingival
plaque removal on the plaque in pockets deeper
than approximately 3 mm find no significant alter-
ations in the subgingival microbiota (6, 22, 49, 173,
205). In contrast, some authors claim that pro-
fessional supragingival debridement has relevant ef-
fects on subgingival microbiota such as a lowering of
total viable counts, increased proportions of gram-
positive cocci and rods, and a decrease in peri-
odontal pathogens such as A. actinomycetemcomit-
ans, B. forsythus, P. gingivalis and T. denticola (82,
129, 208).
Factors accounting for an ascertained influence of
supragingival debridement on the subgingival eco-
system may be seen in unintended and unperceived
instrumentation of pockets during supragingival
cleaning and in the fact that patient-performed oral
hygiene may reach beyond the gingival margin,
especially in more shallow pockets. Healing of the
marginal gingiva with a concomitant reduction in
probing depth may result from supragingival scaling,
thus inducing changes in subgingival ecology (94).
In addition, even plaque sampling itself, especially if
performed repeatedly, may cause alterations in the
60
Fig. 4. Effectiveness of patient
performed oral hygiene (OH) in
comparison to adjunctive pro-
fessional supragingival debride-
ment (OHπDeb.)
subgingival ecological niche. Despite the fact that
supragingival plaque has been shown to serve as a
reservoir for gram-negative organisms (171, 208), the
factors outlined above may be confounding and dis-
torting and may lead to the effects of supragingival
debridement on the subgingival flora being over-
estimated. It is supported by clinical studies that
supragingival scaling alone is insufficient for the
treatment of periodontitis (94).
Subgingival debridement
Instrumentation of the subgingival area is aimed at
removing as much as possible of the bacterial bio-
film and subgingival calculus. However, thorough
subgingival scaling is technically demanding as ac-
cess to and visibility of the area are limited, so that
complete subgingival plaque and calculus removal
is rarely achieved (154). Although calculus has been
shown not to be a factor in the causation of in-
flammatory periodontal disease (118, 132), most
studies evaluated instrument efficiency by estimat-
ing residual calculus, whereas the estimation of re-
sidual subgingival plaque would actually be more
meaningful. However, as cementum and dentin also
take up plaque-revealing agents, the reliability of
staining methods has been questioned (37, 71, 83).
A critical review of studies evaluating the effective-
ness of subgingival debridement procedures by a
variety of assessment methods shows that a wide
range of approximately 5% to 80% of treated roots
have residual plaque or calculus deposits. Up to 30%
of the total surface area of these roots may be cov-
ered with residual calculus following subgingival
scaling (Table 1). Scaling efficacy is reduced with in-
creasing pocket depth and furcation involvement
(35, 37, 44, 109, 127, 175). Maximum instrumen-
 Table 1. Effectiveness of nonsurgical in vivo root debridement; assessments made on extracted teeth
Author Study design Assessment criteria Instruments used Results
Chan et al. (37) 30 teeth % apical plaque border Ultrasonic Apical plaque border: 36%,
120 surfaces Instrument efficacy instrument efficacy: 0.9 mm, root surface
PPDΩ5 mm Root surface with calculus with calculus: 5%
3 to 5 min instrumentation Ultrasonic with slim tip Apical plaque border: 36%,
instrument efficacy: 1.0 mm,
root surface with calculus: 6%
% Surface
Plaque free Calculus free
Kocher et al. (109) 84 teeth % surface debrided Hand curettes 87% 100%
PPDØ5 mm Sonic scaler 92% 98%
Ultrasonic 84% 98%
Sonic scaler with plastic coated tip 84% 90%
Perio-o-tor 80% 90%
Treated teeth Untreated teeth
Yukna et al. (210) 15 patients % teeth with residual calculus Hand curettes 4.6% 57.5%
80 teeth Ultrasonic 4.7% 54.5%
PPD 5–12 mm Ultrasonic diamond-coated fine 4.3% 37.5%
Ultrasonic diamond-coated rough 3.4% 50.7%
Kepic et al. (101) 16 patients % teeth with residual calculus Hand curettes 70%
31 teeth Ultrasonic 85%
Sherman et al. (167) 7 patients Residual calculus Hand curettes and ultrasonic scalers 57% of assessed surfaces exhibit calculus
101 teeth Mean % area of root covered with calculus:
No information on PPD 3.3% (range: 0–31%)
Treated teeth Untreated teeth
Kawanami et al. (99) 12 patients % surfaces with residual staining Experimental ultrasonic scaler with 4.6∫7.4% 95.8∫8.3%
30 teeth slim tip
PPD 7∫1 mm
Teeth Surfaces
Buchanan et al. (34) 10 patients % teeth and surfaces with Hand curettes 62% 11%
344 surfaces residual calculus Hand curettes during flap surgery 37% 11%
PPD 6 mm No treatment 100% 37%
Hunter et al. (87) 18 patients % surfaces area with residual Ultrasonic 6.37%
5 teeth calculus Hand curettes 5.87%
PPD±5 mm
Stambaugh (175) 7 teeth Maximum instrumentation depth Hand curettes 10 mm
42 sites Instrumentation limit 5.50 mm
mean PPD 6.9 mm Instrument efficacy 3.73 mm
Rabbani et al. (152) 25 patients % surfaces with residual calculus Hand curettes 17%
119 teeth Untreated control 53%
PPD±6 mm
Dummy head trial, scaling on acrylic teeth Experienced Unexperienced
Kocher et al. (107) 140 teeth % surfaces with residual staining Hand curettes 13% 24%
Sonic scaler 21% 28%
Perioplaner 19% 27%
Ultrasonic 20% 28%
Mean total 18% 27%
PPD: pocket probing depth.

61
Antimicrobial effects of mechanical debridement
Petersilka et al.
tation accessibility has been shown to be limited to
approximately 10 mm of probing depth (55, 140,
175). Instrument effectiveness in terms of the mean
depth of a pocket completely debrided after therapy
has been found to vary greatly.
Neither hand nor powered instrumentation has
been proven to be actually more effective in subgin-
gival scaling procedures on flat surfaces (101, 210).
In the molar region, however, the use of oscillating
or rotating instruments with slim tips allowing good
access to furcations was shown to be superior to the
use of hand instruments in terms of plaque and cal-
culus removal (109, 123, 127). The most important
factors underlying improved scaling efficacy appear
to be operator experience, skill and training (32, 64,
107).
Impact of scaling and root planing on the
subgingival microflora
Many authors have attempted to evaluate the
changes in the subgingival flora and the subsequent
recolonization of this ecological niche (5, 41, 48, 77,
123, 146, 151, 156, 157, 160, 161, 168, 172, 177, 189,
190). Although study designs vary greatly, it may be
concluded that total viable counts are reduced by
approximately 99% immediately after thorough de-
bridement. For example, the effect of manual de-
bridement in 6- to 10-mm-deep untreated pockets
immediately upon completion of scaling and root
planing is a significant reduction in viable counts
from mean log 7.2∫0.2 to 5.3∫0.2 as assessed by cul-
ture (126). Thus, despite the large reduction, it is be-
yond the power of current mechanical therapeutic
modalities to achieve an eradication of all bacteria,
due to limited instrumentation efficacy and the fact
that bacteria may reside in soft tissues (48, 67, 77,
177) or in root surface irregularities and dentinal tu-
bules (1). Instrumentation of the periodontal pocket
reduces the entire plaque unspecifically, resulting in
a partly depleted ecological niche that is subse-
quently recolonized.
Bacterial regrowth and recolonization of the
pocket occur, with subgingival bacterial counts
being restored almost to pretreatment values 3 to 7
days after treatment (80). However, the change in-
duced in the composition of the microflora lasts
longer. A significant decrease in mean counts, site
specific prevalence and proportions following ther-
apy was found for B. forsythus, P. gingivalis and T.
denticola (48, 77, 146). In contrast, a significant in-
crease occurs in the mean proportion of Actinomyces
spp., Veillonella parvula, Capnocytophaga spp. and
62
non-periodontopathogenic streptococci, with the
dynamics of subgingival recolonization appearing to
play a major role in this context. Following the re-
moval of the bacterial biofilm, parts of the early col-
onizers, which are predominantly nonpathogenic,
may be faster in occupying the ‘‘vacant’’ habitat, and
thus inhibit the establishment of pathogens. This
means that, in clinically successful treatment, sub-
gingival scaling and root planing will lead to reduced
counts of periodontal pathogens (Fig. 5).
The time needed for recolonization to reach full
pretreatment levels of mean counts and proportions
of the subgingival microflora depends on disease se-
verity and thoroughness of debridement with sub-
sequent supportive therapy. Also, sampling as well as
identification procedures may be important factors
influencing study outcomes (135, 161). Ecological
niches for bacteria, other than periodontal pockets,
within the oral cavity are unlikely to be affected by
scaling, as oral mucous membranes, tongue dorsum
and saliva may constitute a source for recolonization
(50, 184). Also, recolonization with specific micro-
organisms such as A. actinomycetemcomitans ap-
pears to involve the same genotype infecting the site
before therapy (60). To prevent rebound to pretreat-
ment levels of periodontal pathogens in subgingival
plaque, repeated reinstrumentation and mechanical
removal of subgingival plaque is essential. This
underlines the importance of regularly performed
supportive periodontal therapy including subgingi-
val debridement of pockets deeper than 3 to 4 mm.
Immune response induced by
subgingival debridement
The inoculation of periodontal pathogens during de-
bridement and the resulting bacteremia may also
cause systemic effects. As a result of the increased
exposure of the immune system to periodontal
pathogens following scaling, seroconversion in pa-
tients previously seronegative to periodontal patho-
gens or a significant increase in antibody titers in
patients seropostive before therapy has been shown
to occur (38, 206). For example, an increase in serum
antibody titers against A. actinomycetemcomitans
and P. gingivalis was found after scaling (59).
Thus, mechanical therapy may induce a humoral
immune response, and this may be one of the rea-
sons for clinical improvement after therapy (170).
However, the influence of subgingival debridement
on patients diagnosed as seropositive for different

Fig. 5. Diagram showing the reduction and recolonization pattern in subgingival debridement
periodontal pathogens before treatment is not yet
fully understood and data are equivocal. Besides an
increase in antibody titers, slightly decreased or un-
changed serum antibody titers against specific peri-
odontal pathogens following treatment have also
been reported (11, 138). Aside from the mere quan-
tity of antibodies in the serum, aspects of antibody
quality and function, that is, avidity, may also be an
important factor, as studies have shown enhanced
antibody avidity following mechanical therapy (133).
Periodontal flap surgery
As thoroughness of debridement has been shown to
decrease with increasing pocket depth and inac-
cessibility, periodontal flap surgery is often con-
sidered a valuable adjunct to subgingival debride-
ment in deep pockets (92, 124, 152, 192, 194). The
need for surgery is reduced with increasing levels of
operator experience and skill. In single-rooted teeth
with pockets exceeding 4 mm of probing depth, it
has been documented that well-trained operators
achieve a greater percentage of calculus-free root
surfaces with both nonsurgical or surgical tech-
niques compared with untrained operators. In
pockets exceeding 6 mm, the amounts of undebrid-
ed root surfaces left behind after closed scaling by
experienced operators were even similar to those left
by less experienced operators using the open de-
bridement technique (32) (Table 2, Fig. 6).
The influence of operator skill is, however, limited
in multirooted teeth, as furcation anatomy has been
Antimicrobial effects of mechanical debridement
found to have a substantial impact on debridement
ability (30). Overall, the attainable percentages of
calculus-free surfaces after both nonsurgical and
surgical techniques appear to be much lower in mo-
lars compared with single-rooted teeth, especially
for pockets exceeding 6 mm probing depth (64, 144,
145). To enhance cleaning efficacy of the furcation
area during periodontal flap surgery, diamond-
coated sonic scaler tips have recently been invented.
These bud-shaped instruments have been shown to
be superior to hand instruments or conventional
sonic scaler inserts in removing plaque and calculus
from the furcation area (108).
Periodontal surgery and subgingival
microflora
The results of studies on the influence of surgery on
the subgingival microflora are conflicting. Whereas
some authors described predictable eradication of
periodontal pathogens such as A. actinomycetem-
comitans (5, 41) after modified Widman surgery,
others found that access surgery fails to eliminate
the pathogens (156). In addition, no significant dif-
ferences in mean counts and site-specific prevalence
rates of various periodontal pathogens were ob-
served between subgingival scaling and access flap
surgery (146, 157). These findings are corroborated
by other studies evaluating the effects of open access
surgery on larger numbers of pathogens. Compared
with pretreatment levels, modified Widman surgery
failed to induce profound microbiological changes
and to eradicate A. actinomycetemcomitans, P. gingi-
63
Petersilka et al.
Fig. 6. Palatal aspect of upper left quadrant before (left)
and after (right) resective flap procedure with osseous re-
valis, Prevotella intermedia and B. forsythus (76), and
recolonization of the subgingival environment oc-
curred after a 2- to 4-week period (128). Overall, the
shift in the composition of the subgingival micro-
flora following access surgery is similar to what is
found following subgingival debridement (76, 77).
The residual pocket depth may play an important
role in the subgingival ecology, as it has been dem-
onstrated that the physicochemical characteristics of
the physiological sulcus differ substantially from
those found in deep pockets. The oxygen partial
pressure and the redox potential in shallow and deep
periodontal sites differ significantly (100, 131).
Therefore, anaerobic conditions are more likely to
occur in deep pockets, which in turn may favor
colonization with suspected periodontal pathogens.
As a consequence, one aim of surgical interventions
may be to alter the subgingival environment by re-
ducing pocket depths. For example, after converting
deep pockets into shallow sites by means of apically
positioned flap surgery and osseous recontouring
without deliberate root debridement, significant de-
creases in the proportion of gram-negative anaer-
obic rods were observed (132). The clinical and
microbiological outcomes were similar to those
achieved by concomitant scaling and root planing
during surgery, so that these microbial changes may
be attributed primarily to morphological alterations
of the subgingival ecological niche. Other studies de-
tecting reduced counts and decreased proportions of
pathogens in the subgingival microflora after re-
sective periodontal surgery confirm the relevant role
of pocket elimination techniques in periodontal
therapy (116, 141).
64
contouring. Arrows indicate previous subgingival root sur-
faces.
Summary and conclusion
Self-performed plaque removal using manual or
powered toothbrushes and interdental cleaning de-
vices is improved in subjects that have received
oral hygiene instructions. Personal oral hygiene
coupled with regular professional supragingival de-
bridement may further improve the level of plaque
control but still fails to achieve a completely
plaque-free dentition. Both patient-performed and
professional supragingival plaque removal has an
effect on subgingival microbiota that is limited to
the marginal 3 mm of the periodontal pocket. At
sites with 4 mm or more of probing depth, only
subgingival scaling leads to a significant reduction
of the bacterial load. The subgingival microflora
can be further reduced by pocket elimination
surgery. Due to the sequence of bacterial recolon-
ization that occurs following mechanical debride-
ment, the level of periodontal pathogens such as
B. forsythus, P. gingivalis and T. denticola may be
reduced for several months. Mechanical debride-
ment also influences the patient’s immune system
response, resulting in antibody titers and avidity
against periodontal pathogens. As a basis for the
restoration and maintenance of periodontal health,
repeated subgingival debridement, as performed in
supportive periodontal therapy, can reduce the
number and proportions of periodontopathogenic
bacteria in subgingival plaque. However, intensive
subgingival scaling and root planing should be
avoided in sites that probe less than 3 mm, as this
is likely to traumatize the periodontium and cause
attachment loss.
 Table 2. Effectiveness of surgical root debridement
Number and condition
Author Study design of teeth used Assessment criteria Instruments and techniques Results
Hürzeler In vivo scaling 11 patients % surface with No treatment 53.5∫26.4%
et al. (88) Open debridement 44 mandibular incisors residual staining Gracey curette 4.2∫2.1%
Assessment on Curette and bur 2.0∫0.9%
extracted teeth Curette and bur and air polisher 0.6∫0.6%
Parashis In vivo scaling 30 upper molars % surfaces with Closed treatment 70%
et al. (144) Open and closed 30 lower molars residual calculus in Open treatment 35–50%
debridement 180 surfaces roof and flute Open treatment in combination 5%
Assessment on PPDØ5 mm of furcation with rotating diamond bur
extracted teeth Furcation degree II or III
PPD 5-6 mm PPDØ7 mm
Parashis In vivo saling 30 upper molars % surfaces with Closed 5–11% 14–20%
et al. (145) Open and closed 30 lower molars residual calculus by Open 3–7% 7–9%
debridement 180 surfaces pocket probing depth Open and diamond 3% 2–7%
Assessment on PPDØ5 mm (PPD)
extracted teeth Furcation degree II or III
Brayer In vivo scaling 114 teeth, 396 sites % surfaces with Hand instruments Open experienced 95–100%
et al. (32) Open and closed PPD up to 6 mm and residual calculus experienced versus Closed experienced 81–96%
debridement deeper (single-rooted teeth) inexperienced operators Open inexperienced 83–100%
Assessment on Closed inexperienced 34–86%
extracted teeth
Fleischer In vivo scaling 61 molars, 36 patients % surfaces with Open versus closed Open experienced 22%
et al. (64) Open and closed PPD 1–3 mm residual calculus approach and Closed experienced 64%
debridement 4–6 mm (molars) experienced versus Open inexperienced 55%
Assessment on ±6 mm inexperienced Closed inexperienced 82%
extracted teeth
Gellin In vivo during 11 patients % surfaces with Titan S air scaler 75%
et al. (72) flap surgery 690 surfaces residual calculus Curettes 68%
PPD up to 12 mm Curettes and Titan S 34%
1–3 mm 4–6 mm ±6 mm
Caffesse In vivo scaling 21 patients % surfaces without Scaling 86% 43% 32%
et al. (35) Open and closed 127 teeth residual calculus Flap 86% 76% 50%
debridement Control 80% 43% 77%
Assessment on
extrated teeth
Matia In vivo on 48 patients % surfaces with Ultrasonic closed 31%
et al. (127) extracted teeth 50 teeth residual staining Ultrasonic open 2.5%
No information on PPD Hand closed 28%
Hand open 4.3%
Eaton 2 parts: PPD mean 3.9 mm % stainable surface Instrument of choice In vitro: 100% plaque-free surface in
et al. (58) A: in vitro scaling Mostly ultrasonics non-periodontally
B: in vivo scaling diseased teeth only
Open and closed
debridement In vivo: Open Closed
Assessment on
extracted teeth 18–95% 14–92%

PPD: pocket probing depth.

65
Antimicrobial effects of mechanical debridement
Petersilka et al.
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