Phase I therapy or cause-related therapy10 is the first in the chronologic

sequence of procedures that constitute periodontal treatment.

The objective of phase I therapy is to alter or eliminate the microbial
etiology and factors that contribute to gingival and periodontal
diseases to the greatest extent possible, therefore halting the progression
of disease and returning the dentition to a state of health
and comfort.5 Phase I therapy is referred to by a number of names,
including initial therapy,5,10 nonsurgical periodontal therapy,18
cause-related therapy.10 All terms refer to the procedures performed
to treat gingival and periodontal infections, up to and
including tissue reevaluation, which is the point at which the course
of ongoing care is determined.
Phase I therapy is defined by the evidence-based American Association
of Periodontology practice guidelines5 as the initiation
of a comprehensive daily plaque control regimen, management
of periodontal-systemic interrelationships as needed, thorough
removal of supra and subgingival bacterial plaque biofilm and
calculus, chemotherapeutic agents as necessary, and elimination
of local factors1,2,3,4,6 such as defective restorations and treatment
of carious lesions.7,9,15,16,20 These procedures are a required part of
periodontal therapy, regardless of the extent of disease present. In
many cases, only phase I therapy will required to restore periodontal
health, or it will constitute the preparatory phase for surgical
therapy. Figures 44-1 and 44-2 show the results of phase I therapy
in two patients with chronic periodontitis. The goal of cause-related
phase I periodontal therapy has been succinctly stated as the
approach aimed at removal of pathogenic biofilms, toxins and calculus,
and the reestablishment of a biologically acceptable root
surface.10
Phase I therapy is a critical aspect of periodontal treatment.
Data from clinical research indicate that the long-term success of
periodontal surgical treatment is dependent upon maintaining the
plaque biofilm control results achieved with phase I therapy. In
fact, patients who do not have adequate plaque biofilm control will
continue to lose attachment regardless of what surgical procedures
are performed.12 In addition, phase I therapy provides an opportunity
for the dentist to evaluate tissue response and provide reinforcement
about home care, both of which are crucial elements to
the overall success of treatment.
Based on the knowledge that microbial plaque biofilm is the
major etiologic agent in gingival inflammation, one specific aim of
phase I therapy for every patient is effective daily plaque biofilm
removal at home. These home care procedures can be complex,
time consuming, and often require changing long-standing habits.
Good oral hygiene is more easily accomplished if the tooth surfaces
are free of calculus deposits and other irregularities so that surfaces
are easily accessible. Management of contributing all local factors
is required in phase I therapy. The following list of elements makes
up phase I therapy:
1. Complete removal of calculus (see Chapters 46 and 47)
2. Correction or replacement of poorly fitting restorations and
prosthetic devices (see Chapter 67)
3. Restoration or temporization of carious lesions
4. Orthodontic tooth movement (see Chapter 51)
5. Treatment of food impaction areas
6. Treatment of occlusal trauma (see Chapter 50)
7. Extraction of hopeless teeth
8. Possible use of antimicrobial agents including necessary
plaque sampling and sensitivity testing (see Chapters 8 and 48)

Treatment Sessions

After careful analysis and diagnosis of the specific periodontal

condition present, the dentist must develop a treatment plan that
includes all required procedures and estimates the number of
appointments necessary to complete phase I therapy. In most cases,

patients require several treatment sessions for the complete debridement

of tooth surfaces. All of the following conditions must be
considered when determining the phase I treatment plan18:
General health and tolerance of treatment
Number of teeth present
Amount of subgingival calculus
Probing pocket depths
Attachment loss
Furcation involvements
Alignment of teeth
Margins of restorations
Developmental anomalies
Physical barriers to access (i.e., limited opening or tendency
to gag)
Patient cooperation and sensitivity (requiring use of anesthesia
or analgesia)

Sequence of Procedures
Step 1: Plaque Biofilm Control Instruction. Plaque

biofilm control is the essential component to successful periodontal

therapy, and instruction should begin at the first treatment appointment.
The patient must learn to correctly brush the teeth, focusing
on applying the bristles at the gingival third of the clinical crowns
of the teeth, and begin using floss or other aids for interdental
cleaning. This is sometimes referred to as targeted oral hygiene22
and emphasizes thorough biofilm removal around the periodontal
tissues. The multiple appointment approach to phase I therapy
permits the dentist to evaluate, reinforce, and improve the patients
oral hygiene skills. (Chapter 45 details plaque control options.)

Step 2. Removal of Supragingival and Subgingival

Plaque Biofilm and Calculus. Removal of calculus is

accomplished using scalers, curettes, ultrasonic instrumentation, or

combinations of these devices during one or more appointments.
Evidence suggests that the treatment results for chronic periodontitis
are similar for all instruments.12,13 In addition to calculus
removal, bacterial plaque biofilm and some cementum are removed
by instrumentation procedures as a matter of course. At one time
it was thought that all cementum had to be systematically planed
off of root surfaces in order to leave a glassy hard surface free of
accumulated bacterial toxins. The rationale was that cementum
became necrotic from penetration of lipopolysaccharide endotoxins
from the microbial biofilm and would interfere with healing.
Lipopolysaccharides are loosely attached and easily removed from
cementum so that instrumentation beyond the thorough removal of
calculus and plaque biofilm will not improve treatment outcomes.
As a consequence the term debridement is now used as commonly
than root planing.12
Laser treatment has also been advocated for periodontal therapy
by and some dentists.8 However, recent reviews suggest that further
well-designed studies are needed to confirm improved outcomes.
In addition, gingival curettage, the systematic removal of the soft
tissue lining of the pockets has not been shown to improve results
of treatment, and there is little if any change in outcomes from
performing irrigation or lavage of periodontal pockets during phase
I treatment appointments
Photodynamic therapy has also been posited as an adjunct to
scaling and root planing. This therapy uses lasers at specific wavelengths
to target microorganisms treated with a photosensitizer.
Studies have not found this intervention to be useful as an alternative
to scaling and root planing, or to improve treatment outcomes,
and further research needs to be conducted to ascertain the efficacy
of this treatment.12
One other interesting approach to calculus removal and debridement

is full mouth disinfection. The technique is to perform the

full mouth treatment at one session, or multiple sessions within a
day or so, and using disinfectants with the intention preventing
reinfection of treated sites from untreated sites.14,17,19 This treatment
approach may also be used for phase I therapy, but it has not been
shown to be superior to any other phase I therapy treatment
plan.11,12,21
There are multiple approaches to planning and performing nonsurgical
phase I therapy. Decisions as to how to proceed should be
discussed and agreed upon by the patient and the dentist based on
amount of disease present and patient comfort.11 Staged therapy
permits the advantage of evaluating and reinforcing oral hygiene
care, and the one or two appointment therapies can be more efficient
in reducing the number of office visits the patient is required
to attend.

Step 3. Recontouring Defective Restorations and

Crowns. Corrections for restorative defects, which are plaque

traps, may be made by smoothing surfaces and overhangs with burs

or hand instruments or by replacing restorations. These procedures
can be completed concurrently with other phase I procedures.
Step 4. Management of Carious Lesions. Removal of
the carious tissue and placement with either temporary or permanent
restorations is indicated in phase I therapy because of the
infectious nature of the caries process. Healing of the periodontal
tissues will be maximized by removing the reservoir of bacteria in
these lesions so that they cannot repopulate the microbial plaque.
Step 5. Tissue Reevaluation. After scaling, root planing,
and other phase I procedures, the periodontal tissues require
approximately 4 weeks to heal so that the connective tissues have
time to heal and accurate probe depths can be measured. Patients
also need the opportunity to improve their home care skills required
to reduce inflammation and adopt new habits that ensure the
success of treatment. At the reevaluation appointment, periodontal
tissues are probed, and all related anatomic conditions are carefully
evaluated to determine if further treatment, including periodontal
surgery, is indicated. Additional improvement from periodontal
surgical procedures can be expected only if phase I therapy resulted
in the gingiva being free of overt inflammation and the patient has
adopted effective daily plaque biofilm control procedures.

Results

Scaling and root planing therapy has been studied extensively to

evaluate its effects on periodontal disease. Many studies indicated
that this treatment is both effective and reliable. Studies ranging
from 1 month to 2 years in length demonstrated up to 80% reduction
in bleeding on probing and mean probing depth reductions of
2 to 3 mm. Others demonstrated that the percentage of periodontal
pockets of 4-mm or greater depth was reduced more than 50% and
up to 80%.9 Figures 44-1 and 44-2 show examples of the effectiveness
of phase I therapy.
It is also important to recognize that deeper probing depths
present the dentist with greatly increased instrumentation
challenges due to the complexity of root anatomy and difficulty of
access. Badersten and colleagues7 showed in the 1980s that more
residual calculus remained in deeper pockets on up to 44% of the
surfaces. Other studies have confirmed these findings, including
those comparing the use of hand instruments to powered scaling
instruments.12
Additional individual treatments, such as caries control and
correction of poorly fitting restorations, clearly augment the healing
gained through good plaque biofilm control and debridement by
making tooth surfaces accessible to cleaning procedures. Figure
44-3 demonstrates the effects of an overhanging amalgam restoration
on gingival inflammation in an otherwise healthy periodontium.
Maximal healing from phase I treatment is not possible when

local conditions retain biofilm and provide reservoirs for repopulation

of periodontal pathogens.

Healing

Healing of the gingival epithelium consists of the formation of a

long junctional epithelium rather than new connective tissue
attachment to the root surfaces. The attachment epithelium reappears
about 1 week after therapy. Gradual reductions in inflammatory
cell population, crevicular fluid flow, and repair of connective
tissue result in decreased clinical signs of inflammation, including
less redness and swelling. One or two millimeters of recession is
often apparent as the result of tissue shrinkage.9 Connective tissue
fibers are disrupted and lysed by the disease process and also by
the inflammatory reaction to treatment. These tissues requires 4 or
more weeks to reorganize and heal, and complete healing can take
months.
Transient root sensitivity frequently accompanies the healing
process. Although evidence suggests that relatively few teeth in a
few patients become highly sensitive, this development is common
and can be disconcerting to patients. The extent of the sensitivity
can be diminished through good plaque biofilm removal. 23 Warning
patients about the potential outcomes of the teeth appearing longer
because of shrinkage of periodontal tissues and tooth root sensitivity
at the beginning of the treatment sequence will avoid surprise
if these changes occur. Unexpected and possibly uncomfortable
consequences to treatment may result in distrust and loss of motivation
to continue therapy.

Decision to Refer for Specialist Treatment

Often, periodontal conditions heal sufficiently well after phase I

therapy that no further treatment is required beyond routine maintenance,
making treatment of most periodontal patients the responsibility
of the general dentist. However, advanced or complicated
cases benefit from specialist care. It has been demonstrated by
Heitz-Mayfield and coworkers12 that surgical treatment in deep
pockets, those >6 mm, gained 0.6 mm more probing depth reduction
and 0.2 mm more clinical attachment gain than did deep
pockets treated with scaling and root planing alone. That group also
confirmed that in pockets of 4 to 6 mm probing depth, scaling and
root planing resulted in 0.4 mm more attachment gain than surgical
procedures, and shallow pockets of 1 to 3 mm had 0.5 mm less
attachment loss compared to surgical results.12 It is critical to be
skilled in determining which patients would benefit from specialist
care and should be referred.
The concept of the critical probing depth of 5.4 mm has been
advanced to assist in making the determination to proceed to surgical
intervention. This is the measurement above which therapy will
result in clinical attachment gain, and below it will result in clinical
attachment loss. This determination was made based on statistical
analysis of surgical outcomes data.12 A similar 5-mm standard has
been commonly used as a guideline for identifying candidates for
surgical referral based on the understanding that the typical root
length is about 13 mm and the crest of the alveolar bone is at a
level approximately 2 mm apical to the bottom of the pocket. When
there is 5 mm of clinical attachment loss, the crest of bone is about
7 mm apical to the cementoenamel junction, therefore only about
half the bony support for the tooth remains. Periodontal surgery
can help improve support for teeth in these cases through pocket
reduction, bone augmentation, and regeneration procedures .
Figure 44-4 depicts the relationship of clinical attachment loss to
tooth support.
In addition to consideration of 5-mm probing depths, other
factors must also be factored into the decision to refer:
1. Extent of disease and generalized or localized deep involvement.
Extensive bone loss, even in localized areas, suggest
the need for specialized surgical techniques.

2. Root length. Short roots are more seriously jeopardized by

5 mm of clinical attachment loss than long roots.
3. Hypermobility. Excessive tooth mobility suggests contributing
factors and a more guarded prognosis.
4. Difficulty of scaling and root planing. The presence of deep
pockets and furcations makes instrumentation much more
difficult and results can often be improved with surgical
access.
5. Restorability and importance of particular teeth for reconstruction.
Long-term prognosis of each tooth is important
when considering extensive restorative work.
6. Age of the patient. Younger patients with extensive attachment
loss are more likely to have aggressive forms of disease
that require extensive therapy.
7. Lack of resolution of inflammation after scaling and planing.
If inflammation persists, further therapy is often necessary
to gain the most positive results.
Every patient is unique, and the decision process for each
patient is complex. The considerations presented in this chapter
should provide guidance understanding the significance of phase I
therapy and in making referral decisions.

Conclusion

The major goal of phase I therapy is to control the factors responsible

for the periodontal inflammation; the removal of subgingival
bacterial biofilms and the subsequent control of plaque biofilm
levels by patients are particularly significant. Phase I therapy
should be comprehensive and include scaling, root planing, and
oral hygiene instructions, as well as other therapies such as caries
control, replacement of defective restorations, occlusal therapy,
orthodontic tooth movement, and cessation of confounding habits
such as tobacco use. Comprehensive reevaluation after phase I
therapy is essential to determine treatment options and to estimate
prognosis. Many patients can have their periodontal disease controlled
with phase I therapy alone and not require further surgical
intervention. For patients who do need surgical intervention, phase
I therapy is an advantageous element of treatment in that it permits
tissue healing, thus improving the surgical management and healing
response of the tissues.
Periodontal surgical intervention should be considered for
patients with critically deep pocket depths and those with 5 mm or
more of attachment loss still present after phase I therapy. Periodontal
specialists can best provide treatment to preserve the teeth
for these patients with advanced disease. It is also important to note
that patients who do not demonstrate the ability to successfully
control plaque biofilm at home, on a daily basis, are poor candidates
for successful surgical outcomes and should be closely monitored
on a recall maintenance program unless conditions change.

Microbial plaque biofilm control is an effective way of treating and

preventing gingivitis and is an essential part of all the procedures
involved in the treatment and prevention of periodontal diseases, 47
It is critical to the long-term success of all periodontal and dental
treatment.3 In 1965, Le et al86 conducted the classic study demonstrating
the relationship between microbial plaque biofilm accumulation
and the development of experimental gingivitis in
humans. Subjects in the study stopped brushing and other plaque
biofilm control procedures, resulting in the development of gingivitis
in every person within 7 to 21 days. The composition of the
biofilm bacteria also shifted so that more virulent gram-negative

organisms predominated, and these changes were shown to be

reversible within 7 days. Good supragingival biofilm control has
also been shown to affect the growth and composition of subgingival
plaque, so that it favors a healthier microflora and reduces
calculus formation.117 Carefully performed daily home plaque
biofilm control, combined with frequent professionally delivered
plaque biofilm and calculus removal, reduces the amount of supragingival
biofilm; decreases the total number of microorganisms in
moderately deep pockets, including furcation areas; and greatly
reduces the quantity of periodontal pathogens.27,58 Reviews of
home care procedures in 2011 and 2013 confirm the positive effects
of daily plaque biofilm removal but cautions that these gains appear
to be small and best results also require professional maintenance
care.30,103
Microbial biofilm growth occurs within hours, and it must be
completely removed at least once every 48 hours in the experimental
setting with periodontally healthy subjects to prevent inflammation.
116 The American Dental Association (ADA) recommends that
individuals brush twice per day and use floss or other interdental
cleaners once per day to effectively remove microbial plaque biofilms
and prevent gingivitis.3 They recommend twice daily brushing
because most individuals do not adequately remove microbial
biofilms at one brushing and doing it a second time improves the
results.
Periodontal lesions are predominantly found in interdental locations,
so toothbrushing alone is not sufficient to control gingival
and periodontal diseases.72 It has been demonstrated in healthy
subjects that plaque biofilm formation begins on the interproximal
surfaces where the toothbrush does not reach. Masses of biofilm
first develop in the molar and premolar areas, followed by the
proximal surfaces of the anterior teeth and the facial surfaces of
the molars and premolars. Lingual surfaces accumulate the least
amount of biofilm. Patients consistently leave more plaque biofilm
on the posterior teeth than the anterior teeth, with interproximal
surfaces retaining the highest amounts of biofilm, exactly the
places in which periodontal infections begin.116 In addition, periodontal
patients have increased susceptibility to disease, 120 complex
defects in gingival architecture, and long exposed root surfaces to
clean, compounding the difficulty of doing a thorough job of
cleaning.
Chemical inhibitors of plaque biofilm and calculus that are
incorporated in mouthwashes or dentifrices also play important
roles in controlling microbial biofilms.30 Fluorides delivered
through toothpastes and mouthrinses are essential for caries
control.36 Many products are available as adjunctive agents to
mechanical techniques. These medicaments, as with any drug,
should be recommended and prescribed according to the needs of
individual patients.
Daily plaque biofilm control permits each patient to assume
responsibility for oral health every day. Without it, optimal oral
health through periodontal treatment cannot be attained or preserved.
Elements of biofilm control include mechanical cleaning
and chemical adjuncts.

The Toothbrush

Toothbrushes vary in size and design as well as in length, hardness,

and arrangement of the bristles111 (Figure 45-1). Some toothbrush
manufacturers claim superiority of design for such factors as minor
modifications of bristle placement, length, and stiffness. These
surfaces.104
claims are primarily based on plaque biofilm removal shown to be
significantly superior to other toothbrushes in short-term clinical
studies. However, the research does not show significant differences
in gingivitis scores or bleeding indices, which are the more
important measures of improved gingival health. In fact, at least
one study compared four commercially available toothbrushes for

total plaque biofilm removal at a single brushing; all four toothbrushes

removed biofilms equally, and the authors concluded that
no one design was superior to others.23 In addition, systematic
review of multiple studies did not identify any one superior
design.30
When recommending a particular toothbrush, ease of use by
the patient and the perception that the brush works well are the
important considerations. The effectiveness of and potential injury
from different types of brushes depend to a great degree on
how the brushes are used. Data from in vitro studies of abrasion
by different manual toothbrushes suggest that brush designs permitting
the bristles to carry more toothpaste while brushing
contribute to abrasion more than brush bristles themselves. 31
However, it has been shown that use of hard toothbrushes, vigorous
horizontal brushing, and use of extremely abrasive dentifrices
may lead to cervical abrasions of teeth and recession of
gingiva

Toothbrush Design

Toothbrush bristles are grouped in tufts that are usually arranged

in three or four rows. Rounded bristle ends cause fewer scratches
on the gingiva than flat-cut bristles with sharp ends26,111 (see Figure
45-1). Two types of bristle material are used in toothbrushes:
natural bristles from hogs and artificial filaments made of nylon.
Both remove microbial plaque biofilms, but nylon bristle brushes
vastly predominate in the market. Bristle hardness is proportional
to the square of the diameter and inversely proportional to the
square of bristle length.53 Diameters of common bristles range from
0.007 inch (0.2 mm) for soft brushes to 0.012 inch (0.3 mm) for
medium brushes and 0.014 inch (0.4 mm) for hard brushes. 60 Soft
bristle brushes of the type described by Bass11 have gained wide
acceptance. Handle design characteristics are entirely a matter of
personal preference.
Softer bristles are more flexible, clean slightly below the gingival
margin when used with a sulcular brushing technique, 12 and
reach farther onto the proximal surfaces.42 Use of hard-bristled
toothbrushes is associated with more gingival recession. 71 However,
the manner in which a brush is used and the abrasiveness of the
dentifrice affect the abrasion to a greater degree than the bristle
hardness itself.90 Bristle hardness does not significantly affect wear
on enamel surfaces.104
The amount of force used to brush is not critical for effective
plaque biofilm removal.122 Vigorous brushing is not necessary and
can lead to gingival recession, wedge-shaped defects in the cervical
area of root surfaces,105 and painful ulceration of the gingiva.98
Toothbrushes must also be replaced periodically, although the
amount of visible bristle wear does not appear to affect plaque
biofilm removal for up to 9 weeks.25 Most clinicians recommend
that toothbrushes be replaced every 3 to 4 months.

Recommendations

Soft, nylon bristle toothbrushes clean effectively when used

properly, remain effective for a reasonable time, and tend
not to traumatize the gingiva or root surfaces.
Toothbrushes should be replaced about every 3 to 4 months.
If patients perceive a benefit from a particular brush design,
they should use it.

Powered Toothbrushes

Electrically powered toothbrushes designed to mimic back-andforth

brushing techniques were invented in 1939. Subsequent
models featured circular or elliptical motions, and some had combinations
of motions. Currently, powered toothbrushes have oscillating
and rotating motions (Figure 45-2), and some brushes use
low-frequency acoustic energy to enhance cleaning ability. Powered
toothbrushes rely primarily on mechanical contact between the

bristles and the tooth to remove plaque biofilm. The addition of

low-frequency acoustic energy generates dynamic fluid movement
and provides cleaning slightly away from the bristle tips. 41 The
vibrations have also been shown to interfere with bacterial adherence
to oral surfaces. Neither the sonic vibration nor the mechanical
motion of powered toothbrushes has been shown to affect
bacterial cell viability.88 Hydrodynamic shear forces created by
these brushes disrupt biofilms a short distance from the bristle tips,
explaining the additional interproximal biofilm removal. 64
Typically, comparison studies of powered toothbrushes, manual
toothbrushes, or other powered devices demonstrate slightly
improved plaque biofilm removal for the device of interest in shortterm
clinical trials.92,102 A recent Cochrane review reported that
mechanical brushes with oscillating and rotating motions reduced
microbial plaque biofilm 11% and demonstrated 6% greater reduction
in gingival bleeding than manual brushing. These improveFigure 45-2 Powered toothbrush designs offer options in head
shape and size.
ments were maintained over 3 months. Although long-term benefits
have not been established, this particular style of mechanical brush
resulted in better microbial plaque biofilm and gingivitis reduction
in a number of well-controlled studies.30,55
Patient acceptance of powered toothbrushes is good. One study
reported that 88.9% of patients introduced to a powered toothbrush
would continue to use it.124 However, patients have also been
reported to quit using powered toothbrushes after 5 or 6 months,
presumably when the novelty is gone. Powered toothbrushes have
been shown to improve oral health for (1) children and adolescents,
(2) children with physical or mental disabilities, (3) hospitalized
patients, including older adults who need to have their teeth cleaned
by caregivers, and (4) patients with fixed orthodontic appliances.
Powered brushes have not been shown to provide benefits routinely
for patients with rheumatoid arthritis, children who are wellmotivated
brushers, or patients with chronic periodontitis.56

Recommendations

Powered toothbrushes with oscillating and rotating motions

remove plaque biofilm and reduce gingival bleeding slightly
better than manual toothbrushes.
Patients who want to use powered toothbrushes should be
encouraged to do so.
Patients need to be instructed in the proper use of powered
devices.
Patients who are poor brushers, children, and caregivers may
particularly benefit from using powered toothbrushes.

Dentifrices

Dentifrices aid in cleaning and polishing tooth surfaces. They are

used mostly in the form of pastes, although tooth powders and gels
are also available. Dentifrices are made up of abrasives (e.g.,
silicon oxides, aluminum oxides, and granular polyvinyl chlorides),
water, humectants, soap or detergent, flavoring and sweetening
agents, therapeutic agents (e.g., fluorides, pyrophosphates),
coloring agents, and preservatives.54,115 Abrasives are insoluble
inorganic salts that enhance the abrasive action of toothbrushing as
much as 40 times and make up 20% to 40% of dentifrices. 90 Tooth
powders are much more abrasive than pastes and contain about
95% abrasive materials. The abrasive quality of dentifrices affects
enamel only slightly and is a much greater concern for patients
with exposed roots. Dentin is abraded 25 times faster and cementum
35 times faster than enamel, so root surfaces are easily worn
away, leading to notching and tooth sensitivity.115 Oral hygiene
procedures mainly cause hard tissue damage from abrasive dentifrices,
although gingival lesions can also be produced 98,104 (Figure
45-3). Dentifrices are very useful for delivering therapeutic agents
to the teeth and gingiva. The pronounced caries-preventive effect
of fluorides incorporated in dentifrices has been proved beyond

question.114 Fluoride ion must be available in the amount of 1000

to 1100 parts per million (ppm) to achieve caries reduction effects.
Toothpaste products that have been tested by the ADA and have
fluoride ion available in the appropriate amount carry the ADA seal
of approval for caries control and can be relied on to provide caries
protection.5
Calculus control toothpastes, also referred to as tartar control
toothpastes, contain pyrophosphates and have been shown to
reduce the deposition of new calculus on teeth. These ingredients
interfere with crystal formation in calculus but do not affect the
fluoride ion in the paste or increase tooth sensitivity. Dentifrice
with pyrophosphates has been shown to reduce the formation of
new supragingival calculus by 30% or more.67,89,129 Pyrophosphatecontaining
toothpastes do not affect subgingival calculus formation
or gingival inflammation. The inhibitory effects reduce the deposition
of new supragingival calculus but do not affect existing calculus
deposits. To achieve the greatest effect from calculus control
toothpaste, the patients teeth must be cleaned and completely free
of supragingival calculus when adding these products to the daily
home care regimen.

Recommendations

Dentifrices increase the effectiveness of brushing but should

cause a minimum of abrasion to root surfaces.
Products containing fluorides and antimicrobial agents
provide additional benefits for controlling caries and
gingivitis.
Patients who form significant amounts of supragingival calculus
benefit from the use of a calculus control dentifrice.

Toothbrushing Methods

Many methods for brushing the teeth have been described and
promoted as being efficient and effective. These methods can be
categorized primarily according to the pattern of motion when
brushing and are primarily of historic interest, as follows 65:
Roll: Roll2 or modified Stillman technique61
Vibratory: Stillman,113 Charters,20 and Bass12 techniques
Circular: Fones technique40
Vertical: Leonard technique79
Horizontal: Scrub technique126
Patients with periodontal disease are most frequently taught a
sulcular brushing technique using a vibratory motion to improve
access to the gingival margin areas. It is important for patients to
understand that the plaque biofilm removal at the dento-gingival
junction is necessary to prevent caries as well as periodontal
disease. This is referred to as target hygiene. 118 The method most
often recommended is the Bass technique because it emphasizes
the placement of the bristles at this most important area. This
sulcular placement of the bristle and adapting the bristle tips to the
gingival margin to reach the supragingival plaque biofilm and
accessing some of the subgingival biofilm may be the most important
aspect of target hygiene. A controlled vibrating motion is
used to dislodge microbial plaque biofilm and avoid trauma. The
brush is systematically placed on all the teeth in both arches.
Figures 45-4 and 45-5 illustrate this brushing technique.

Bass Technique11

1. Place the head of a soft brush parallel with the occlusal plane,
with the brush head covering three to four teeth, beginning
at the most distal tooth in the arch.
2. Place the bristles at the gingival margin, pointing at a
45-degree angle to the long axis of the teeth.
3. Exert gentle vibratory pressure, using short, back-and-forth
motions without dislodging the tips of the bristles. This
motion forces the bristle ends into the gingival sulcus area
(see Figure 45-4), as well as partly into the interproximal

embrasures. The pressure should be firm enough to blanch

the gingiva

Brushing with Powered Toothbrushes

The various mechanical motions built into powered toothbrushes

do not require special techniques. The patient needs only place the
brush head next to the teeth at the gingival margin, using a targeted
hygiene approach, and proceed systematically around the dentition.
121 A routine method of brushing all the teeth, similar to the
method described for manual brushing, should also be used with
powered toothbrushes (Figure 45-6).

Recommendations

Targeted hygiene118 focuses brushing efforts on the cervical

and interproximal portions of the teeth, where microbial
plaque biofilm accumulates first.
Brushing with either a manual or a powered toothbrush
requires a systematic routine to clean all the accessible
areas.92
Patients will modify any technique to their needs but must
achieve the goal of brushing effectively until the teeth are
free of plaque biofilm on all accessible surfaces.

Interdental Cleaning Aids

Any toothbrush, regardless of the brushing method used, does not

completely remove interdental plaque biofilms. This is true for all
brushers, even periodontal patients with wide-open embrasures. 44,107
Daily interdental plaque biofilm removal is crucial to augment the
effects of toothbrushing because most dental and periodontal diseases
originate in interproximal areas.1
Tissue destruction associated with periodontal disease often
leaves large, open spaces between teeth and long, exposed root
surfaces with anatomic concavities and furcations. These areas
shelter plaque biofilms and are both difficult for patients to clean
and poorly accessible to the toothbrush.72 Patients need to understand
that the purpose of interdental cleaning is to remove microbial
plaque biofilms, not just dislodge food wedged between teeth.
Many tools are available for interproximal cleaning and they
should be recommended based on the size of interdental spaces,
presence of furcations, tooth alignment, and presence of orthodontic
appliances or fixed prostheses. Also, ease of use and patient
cooperation are important considerations. Common aids are dental
floss and interdental cleaners such as wooden or plastic tips, and
interdental brushes.

Dental Floss

Dental floss is the most widely recommended tool for removing

biofilm from proximal tooth surfaces.43 Floss is made from nylon
filaments or plastic monofilaments, and comes in waxed, unwaxed,
thick, thin, and flavored varieties. Some prefer monofilament
flosses made of a nonstick material because they are slick and do
not fray. Clinical research has demonstrated no significant differences
in the ability of the various types of floss to remove dental
plaque biofilm; they all work equally well.38,59,69,70 Waxed dental
floss was thought to leave a waxy film on proximal surfaces, thus
contributing to biofilm accumulation and gingivitis. It has been
shown, however, that wax is not deposited on tooth surfaces 99 and
that improvement in gingival health is unrelated to the type of floss
used.38 Factors influencing the choice of dental floss include the
tightness of tooth contacts, roughness of proximal surfaces, and the
patients manual dexterity, not the superiority of any one product.
Therefore recommendations about type of floss should be based on
ease of use and personal preference.
Technique. The floss must contact the proximal surface from
line angle to line angle to clean effectively. It must also clean the
entire proximal surface, including accessible subgingival areas, not

just be slipped apical into the contact area. Flossing technique

requires the following:
1. Start with a piece of floss long enough to grasp securely; 12
to 18 inches is usually sufficient. It may be wrapped around
the fingers, or the ends may be tied together in a loop.
2. Stretch the floss tightly between the thumb and forefinger
(Figure 45-7), or between both forefingers, and pass it gently
through each contact area with a firm back-and-forth motion.
Do not snap the floss past the contact area because this may
injure the interdental gingiva. In fact, zealous snapping of
floss through contact areas creates proximal grooves in the
gingiva.
3. Once the floss is apical to the contact area between the teeth,
wrap the floss around the proximal surface of one tooth, and
slip it under the marginal gingiva. Move the floss firmly
along the tooth up to the contact area and gently down into
the sulcus again, repeating this up-and-down stroke two or
three times (Figure 45-8). Then, move the floss across the
interdental gingiva, and repeat the procedure on the proximal
surface of the adjacent tooth.
4. Continue through the whole dentition, including the distal
surface of the last tooth in each quadrant. When the working
portion of the floss shreds or becomes dirty, move to a fresh
portion of floss.
Flossing can be facilitated by using a floss holder (Figure 45-9,
A). Floss holders are helpful for patients lacking manual dexterity
and for caregivers assisting patients in cleaning their teeth. A floss
holder should be rigid enough to keep the floss taut when penetrating
into tight contact areas, and it should be simple to string with
floss. The disadvantage is that floss tools are time-consuming
because they must be rethreaded frequently when the floss shreds.
Disposable, single-use floss holders with prethreaded floss are
also available. Short-term clinical studies suggest that plaque
biofilm reduction and improvement in gingivitis scores are similar
malessss

Gingival Massage

Massaging the gingiva with a toothbrush or an interdental cleaning

devices produces epithelial thickening, increased keratinization,
and increased mitotic activity in the epithelium and connective
tissue.16,19,46 The increased keratinization occurs only on the gingiva
facing the oral cavity and not on the areas more vulnerable to
microbial attack, which are the sulcular epithelium and the interdental
areas where the gingival col is present. Epithelial thickening,
increased keratinization, and increased blood circulation have
not been shown to be beneficial for restoring gingival health. 45
Improved gingival health associated with interdental stimulation is
much more likely the result of microbial plaque biofilm removal
than gingival massage.

Oral Irrigation
Supragingival Irrigation

Oral irrigators for daily home use by patients work by directing a

pulsating stream of water through a nozzle to the tooth surfaces.
Most often, a device with a built-in pump generates the pressure
(Figure 45-16, A). Oral irrigators clean nonadherent bacteria and
debris from the oral cavity more effectively than toothbrushes and
mouth rinses. They are particularly helpful for removing debris
from inaccessible areas around orthodontic appliances and fixed
prostheses. When used as adjuncts to toothbrushing, these devices
can have a beneficial effect on periodontal health by reducing the
accumulation of microbial plaque biofilm and calculus63,84,101and
decreasing inflammation and pocket depth.17,101

Oral irrigation has been shown to disrupt and detoxify subgingival

plaque biofilm and can be useful in delivering antimicrobial
agents into periodontal pockets.4 Daily supragingival irrigation
with dilute chlorhexidine for 6 months resulted in significant reductions
in bleeding and gingivitis compared with water irrigation
and chlorhexidine rinse controls. Irrigation with water alone
also reduced gingivitis significantly but not as much as the dilute
chlorhexidine.39

Technique.

1. The common home-use irrigator tip is a plastic nozzle with

a 90-degree bend at the tip (see Figure 45-16, B), attached
to a pump providing pulsating beads of water at speeds regulated
by a dial. Patients should be instructed to aim the
pulsating jet across the proximal papilla, hold it there for 10
to 15 seconds, then trace along the gingival margin to the
next proximal space, and repeat the procedure.
2. The irrigator should be used from both the buccal and the
lingual surface.
3. Patients with gingival inflammation should start at low pressure
and they can increase the pressure comfortably to about
medium as tissue health improves. Some individuals like to
use the device on the highest pressure setting, with no
reported harm. Patient comfort should be the guide for pressure
setting.

Subgingival Irrigation

Subgingival irrigation can be performed both in the dental office

and at home by the patient, to apply antimicrobial agents. Home
irrigation is performed by aiming or placing the irrigation tip or a
blunt syringe tip into the periodontal pocket, attempting to insert
the tip at least 3 mm.29 A soft rubber irrigator tip is shown in Figure
45-16, C. Irrigation performed in the dental office, also called
lavage or flushing of the periodontal pocket, as a one-time treatment
after scaling and root planing, has not been shown to improve
clinical healing, and data do not support its use in improving therapeutic
results.4,51,108
Subgingival irrigation performed with an oral irrigator using
chlorhexidine diluted to one-third strength and performed regularly
at home and after scaling, root planing, and in-office irrigation
therapy has produced significant gingival improvement compared
with controls.51,66,108 Subgingival irrigation has been shown to
disrupt more than half the subgingival plaque biofilm 62 and reach
about half the depth of pockets, up to 7 mm, much further apically
than a toothbrush or floss can reach.32 These data suggest that
patients can benefit from daily subgingival irrigation, particularly
in difficult sites such as furcations and residual pockets. A more
detailed discussion of irrigation is presented in Chapter 47.
Technique. The soft rubber irrigator tip reduces the pressure
and flow of the pulsating jet of water (see Figure 45-16, C) when
inserted subgingivally and permits penetration of irrigant of up to
70% of pocket depth in laboratory simulation.22,62 The subgingival
irrigation tip should be gently inserted into pockets or furcation
areas, 3 mm if possible, and each pocket should be flushed for a
few seconds.
One caution must be considered. Transient bacteremia has
been reported after water irrigation in patients with periodontitis 37
and patients receiving periodontal maintenance therapy.123 However,
bacteremia has also been found after toothbrushing 96 and is
known to occur in a significant number of patients after scaling
alone.123 Subgingival irrigation at home is not the oral hygiene
procedure of choice for patients requiring antibiotic prophylaxis
before dental treatment, particularly if extensive inflammation is
present.29 For these patients, supragingival irrigation used in combination
with toothbrushing and other interdental cleaning aids is
recommended.

Recommendations

Supragingival irrigation reduces gingival inflammation and

is easier for some patients than using mechanical interdental
aids.
Subgingival irrigation with specialized tips for deep pockets
and furcation areas is effective when used daily as part of
the home care routine.
Patients requiring antibiotic premedication for dental procedures
should use supragingival techniques.
Figure 45-16 Oral irrigation. A, The most common oral irrigators
have a built-in pump and reservoir. B, Conventional plastic tips are
used for daily supragingival irrigation at home by the patient. Left,
Tip for gingival irrigation. Right, Tip for cleaning dorsal surface
of the tongue. C, Soft rubber tip is used for daily subgingival irrigation
by the patient at home.

ABC

Caries Control
Dental caries, particularly root caries, is a problem for periodontal
patients because of attachment loss and exposed root surfaces
associated with the disease process and periodontal therapeutic
procedures. Root caries develops through a process similar to
coronal caries, involving the alternating cycle of demineralization
and remineralization of the surfaces and other risk factors associated
with diet and salivary flow. The demineralization process
requires the fermentation of carbohydrates in the plaque biofilm by
oral bacteria, resulting in loss of mineral from the root surface.
Lactobacillus and Streptococcus species are involved in the root
caries process, as with coronal caries. The major difference is that
the amount of organic material in the root surfaces is greater than
in enamel, so once the demineralization has occurred, the organic
matrixmostly collagenis exposed. Organic material is then
further broken down by bacterial enzymes, resulting in rapid
destruction of the root surface.34,125
Fluoride works primarily by topical effects to prevent and
reverse the caries process, whether in enamel, cementum, or dentin.
Low concentrations of topical fluoride inhibit demineralization,
enhance remineralization, and inhibit the enzyme activity in bacteria
by acidifying the cells.35,36 Adult patients benefit from the
prevention and reversal of root caries provided by low-concentration
topical fluoride delivered by toothpastes or other topical applications.
35 It also has been demonstrated that the use of fluoride dentifrice
containing 5000 ppm of fluoride was more effective in
reversing active root caries lesions than the fluoride level of
1100 ppm found in conventional toothpastes.13

Recommendations

All periodontal patients should be encouraged to use a

fluoride-containing toothpaste daily, 1000 to 1100 ppm, to
reduce demineralization and enhance remineralization of
tooth surfaces.
Patients at high risk for caries, including those with a history
of root lesions or who have active lesions, should use higherconcentration
fluoride toothpaste or gels, 5000 ppm, daily
until the risk for caries is controlled, then maintain with the
lower concentration toothpastes and mouthrinses.
Periodic chlorhexidine rinsing to control cariogenic bacteria
in the oral cavity should also be used as part of a caries risk
management program.36
Other considerations in caries control, such as diet and
reduced salivary flow, should be evaluated as with all dental
patients.
in the human model for experimental gingivitis.52 Clinical studies
of several months duration have reported plaque biofilm reductions
of 45% to 61% and more importantly, gingivitis reductions

of 27% to 67%.52,76 The 0.12% chlorhexidine digluconate preparation

available in the United States for reducing plaque biofilm and
gingivitis has been shown to be equally effective as the higherconcentration
product.68,74
Localized, reversible side effects to chlorhexidine use occur,
primarily brown staining of the teeth, tongue, and silicate and resin
restorations76 and transient impairment of taste perception.85
Chlorhexidine has very low systemic toxic activity in humans, has
not produced any appreciable resistance of oral microorganisms,
and has not been associated with teratogenic alterations. 74 The
preparation contains 12% alcohol, which may be of interest to
clinicians and patients over concerns that alcohol increases the risk
of oropharyngeal cancer.33 However, an extensive review of the
available epidemiologic evidence associating alcohol-containing
oral rinse preparations with cancer concluded that existing data do
not support this association.110 A nonalcoholic form of chlorhexidine
mouthrinse is also available. It has been shown to be equally
effective for microbial plaque biofilm control10,82 and may be preferred
by patients.

Nonprescription Essential Oil Rinse

Essential oil mouthrinses contain thymol, eucalyptol, menthol, and

methyl salicylate. These preparations have been evaluated in longterm
clinical studies and demonstrated plaque biofilm reductions
of 20% to 35% and gingivitis reductions of 25% to 35%.28,48,73 This
type of oral rinse has a long history of daily use and safety since
the nineteenth century, and many patients have used the products
for decades. These products also contain alcohol (up to 24%
depending on the preparation), so some patients prefer not to
use them.

Other Products

A preparation containing triclosan has shown some effectiveness

in reducing plaque biofilm and gingivitis. It is available in toothpaste
form, and the active ingredient is more effective in combination
with zinc citrate or a copolymer of methoxyethylene.8 Other
oral rinse products on the market have shown some evidence of
plaque biofilm reduction, although long-term improvement in gingival
health has not been substantiated. These include stannous
fluoride, cetylpyridinium chloride (quaternary ammonia compounds),
and sanguinarine. Evidence suggests that these and other
available mouth rinse products do not possess the antimicrobial
potential of either chlorhexidine products or essential oil
preparations.91,97
One type of agent has been marketed as a prebrushing oral rinse
to improve the effectiveness of toothbrushing. The active ingredient
is sodium benzoate. Research to support its effectiveness is
contradictory, but the preponderance of evidence suggests that
using a prebrushing rinse is no more effective than brushing
alone.14,15
Chemical plaque biofilm control has been shown to be effective
for both plaque biofilm reduction and improved wound healing
after periodontal surgery.106 Both chlorhexidine6 and essential oil128
mouthrinses have significant positive effects when prescribed for
use after periodontal surgery for 1 to 4 weeks.

Recommendations

Chemical plaque biofilm control can augment mechanical

plaque biofilm control procedures and reduce gingivitis and
caries.

Chemical Plaque Biofilm Control with Oral

Rinses

Improved understanding of the infectious nature of dental diseases

has dramatically increased interest in chemical methods of plaque
biofilm control and holds great promise for advances in disease
control and prevention. The ADA Council on Scientific Affairs has
adopted a program for acceptance of chemical plaque biofilm
control agents. The agents must be evaluated in placebo-controlled

clinical trials of 6 months or longer that demonstrate significantly

improved gingival health compared with controls. To date, the
ADA has accepted two agents for treatment of gingivitis: prescription
solutions of chlorhexidine digluconate oral rinse and nonprescription
essential oil mouthrinse.

Prescription Chlorhexidine Rinse

The agent that has shown the most positive antibacterial results to
date is chlorhexidine, a diguanidohexane with pronounced antiseptic
properties. Several clinical investigations confirmed the initial
finding that two daily rinses with 10 mL of a 0.2% aqueous solution
of chlorhexidine digluconate almost completely inhibited the
development of microbial plaque biofilm, calculus, and gingivitis
in the human model for experimental gingivitis.52 Clinical studies
of several months duration have reported plaque biofilm reductions
of 45% to 61% and more importantly, gingivitis reductions
of 27% to 67%.52,76 The 0.12% chlorhexidine digluconate preparation
available in the United States for reducing plaque biofilm and
gingivitis has been shown to be equally effective as the higherconcentration
product.68,74
Localized, reversible side effects to chlorhexidine use occur,
primarily brown staining of the teeth, tongue, and silicate and resin
restorations76 and transient impairment of taste perception.85
Chlorhexidine has very low systemic toxic activity in humans, has
not produced any appreciable resistance of oral microorganisms,
and has not been associated with teratogenic alterations. 74 The
preparation contains 12% alcohol, which may be of interest to
clinicians and patients over concerns that alcohol increases the risk
of oropharyngeal cancer.33 However, an extensive review of the
available epidemiologic evidence associating alcohol-containing
oral rinse preparations with cancer concluded that existing data do
not support this association.110 A nonalcoholic form of chlorhexidine
mouthrinse is also available. It has been shown to be equally
effective for microbial plaque biofilm control10,82 and may be preferred
by patients.

Nonprescription Essential Oil Rinse

Essential oil mouthrinses contain thymol, eucalyptol, menthol, and

methyl salicylate. These preparations have been evaluated in longterm
clinical studies and demonstrated plaque biofilm reductions
of 20% to 35% and gingivitis reductions of 25% to 35%.28,48,73 This
type of oral rinse has a long history of daily use and safety since
the nineteenth century, and many patients have used the products
for decades. These products also contain alcohol (up to 24%
depending on the preparation), so some patients prefer not to
use them.

Other Products

A preparation containing triclosan has shown some effectiveness

in reducing plaque biofilm and gingivitis. It is available in toothpaste
form, and the active ingredient is more effective in combination
with zinc citrate or a copolymer of methoxyethylene.8 Other
oral rinse products on the market have shown some evidence of
plaque biofilm reduction, although long-term improvement in gingival
health has not been substantiated. These include stannous
fluoride, cetylpyridinium chloride (quaternary ammonia compounds),
and sanguinarine. Evidence suggests that these and other
available mouth rinse products do not possess the antimicrobial
potential of either chlorhexidine products or essential oil
preparations.91,97
One type of agent has been marketed as a prebrushing oral rinse
to improve the effectiveness of toothbrushing. The active ingredient
is sodium benzoate. Research to support its effectiveness is
contradictory, but the preponderance of evidence suggests that
using a prebrushing rinse is no more effective than brushing
alone.14,15
Chemical plaque biofilm control has been shown to be effective
for both plaque biofilm reduction and improved wound healing

after periodontal surgery.106 Both chlorhexidine6 and essential oil128

mouthrinses have significant positive effects when prescribed for
use after periodontal surgery for 1 to 4 weeks.

Recommendations

Chemical plaque biofilm control can augment mechanical

plaque biofilm control procedures and reduce gingivitis and
caries.
Chlorhexidine rinses can be used to augment plaque biofilm
control during phase I therapy, for patients with recurrent
disease, for use after periodontal or oral surgery, and for
caries management.
Essential oil rinses are effective as irrigants, have fewer side
effects, and are available without prescriptions.
Oral irrigators used with dilute solutions of effective antimicrobial
agents reduce gingivitis.
Oral rinse preparations are also available with no alcohol
content, which may be preferable to some clinicians and
patients.
The use of cosmetic oral rinses and prebrushing rinses
should not be used to replace proven mechanical and chemical
means of plaque biofilm removal, but can be useful if
patients perceive benefits from them.

Disclosing Agents

Disclosing agents are solutions or wafers capable of staining bacterial

biofilms on the surfaces of teeth, tongue, and gingiva. These
can be used as educational and motivational tools to improve the
efficiency of plaque biofilm control procedures7 (Figure 45-17).
Solutions are applied to the teeth as concentrates on cotton swabs
or diluted as rinses. They usually produce heavy staining of bacterial
plaque biofilm, gingiva, tongue, lips, and fingers, as well as the
sink. Wafers are crushed between the teeth and swished around the
mouth for a few seconds and then spit out. Either form can be used
for plaque biofilm control instruction in the office and dispensed
for home use to aid periodontal patients in evaluating the effectiveness
of their oral hygiene routines.
Figure 45-17 Effect of a disclosing agent. A, Unstained, the teeth look clean, but close inspection
shows subtle signs of gingivitis. B, Plaque
shows as dark-red particulate matter when stained with a disclosing dye. It is useful to
demonstrate toothbrushing in the patients mouth
with the teeth disclosed and plaque visible.

AB

Frequency of Plaque Biofilm Removal

In the controlled and supervised environment of clinical research,

where well-trained individuals remove all visible plaque biofilm,
gingival health can be maintained by one thorough cleaning with
brush, floss, and toothpicks every 24 to 48 hours.27,65,72,75 However,
most patients fall far short of this goal. The average daily home
care routine lasts less than 2 minutes and removes only 40% of
plaque biofilm.29 It has been reported that improved plaque biofilm
removal and therefore improved periodontal health is associated
with increasing the frequency of brushing to twice per day. 65,93
Cleaning three or more times per day does not appear to further
improve periodontal conditions.

Recommendations

Emphasis should be placed on cleaning the teeth meticulously

once daily with all necessary tools.
If plaque control is not adequate, a second daily brushing
will help.

Patient Motivation and Education

In periodontal therapy, plaque biofilm control has two important

purposes: to minimize gingival inflammation and to prevent the
recurrence or progression of periodontal diseases and caries. Daily
mechanical removal of plaque biofilm by the patient, including the

use of appropriate antimicrobial agents, is the only practical means

for improving oral health on a long-term basis. The process requires
interest on the part of the patient and education and instruction
from the dentist, followed by encouragement and reinforcement.
Keeping records of patient performance facilitates this process.
Figure 45-18 provides an example of a plaque biofilm control
record that permits repeated measures and comparison over time.

Motivation for Effective Plaque Biofilm Control

Motivating patients to perform effective plaque biofilm control is

one of the most critical and difficult elements of long-term success
in periodontal therapy. It requires both commitment by the patient
to change daily habits and regular return visits for maintenance and
reinforcement. The scope of this compliance problem is immense.
It has been shown that patients stop using interproximal cleaning
aids after a very short time. Heasman et al57 followed 100 patients
treated for moderate to severe periodontal disease and taught to use
one or more interdental cleaning aids. It was found that only 20%
used the aids after 6 months. Of those who had started using three
devices, one-third had stopped all interdental cleaning at 6 months;
the others used one or two of the aids.63 The situation is no better
when looking at patient willingness to return for office visits. In
one study of 1280 patients, most of whom had periodontal surgery
in multiple sites after intensive scaling, root planing, and home care
instruction, 25% never returned for a follow-up visit; only 40%
returned regularly.94 Wilson et al127 reported that 67% of periodontal
patients were noncompliant with return visits in a 20-year retrospective
of a private periodontal practice.
Adopting new habits and returning for office visits is not an
impossible task. To be successful, the patient (1) must be receptive
and understand the concepts of pathogenesis, treatment, and prevention
of periodontal disease; (2) must be willing to change the
habits of a lifetime; and (3) must be able to adjust personal beliefs,
practices, and values to accommodate new regimens. Manual skills
must be developed to establish an effective plaque biofilm control
regimen. In addition, the patient must understand the dentists critical
role in treating and maintaining periodontal health.100 If not,
long-term success of treatment is much less likely.

Classification of Periodontal Instruments

Periodontal instruments are classified according to the purposes
they serve, as follows:
1. Periodontal probes are used to locate, measure, and mark
pockets, as well as determine their course on individual tooth
surfaces.
2. Explorers are used to locate calculus deposits and caries.
3. Scaling, root-planing, and curettage instruments are used for
removal of biofilm and calcified deposits from the crown and
root of a tooth, removal of altered cementum from the subgingival
root surface, and debridement of the soft tissue lining
the pocket. Scaling and curettage instruments are classified as
follows:
Sickle scalers are heavy instruments used to remove supragingival
calculus.
Curettes are fine instruments used for subgingival scaling,
root planing, and removal of the soft tissue lining the pocket.
Hoe, chisel, and file scalers are used to remove tenacious
subgingival calculus and altered cementum. Their use is
limited compared with that of curettes.
Ultrasonic and sonic instruments are used for scaling and
cleansing tooth surfaces and curetting the soft tissue wall of
the periodontal pocket.41,42,61

4. Periodontal endoscopes are used to visualize deeply into subgingival

pockets and furcations, allowing the detection of
deposits.
5. Cleansing and polishing instruments, such as rubber cups,
brushes, and dental tape, are used to clean and polish tooth
surfaces. Also available are air-powder abrasive systems for
tooth polishing.
The wearing and cutting qualities of some types of steel used
in periodontal instruments have been tested,83,84,146 but specifications
vary among manufacturers.146 Stainless steel is used most
often in instrument manufacture. High-carbon-content steel instruments
are also available and are considered by some clinicians to
be superior.
Each group of instruments has characteristic features; individual
therapists often develop variations with which they operate
most effectively. Small instruments are recommended to fit into
periodontal pockets without injuring the soft tissues. 109,111,112,163
The parts of each instrument are referred to as the working end,
shank, and handle (Figure 46-1).

Periodontal Probes

Periodontal probes are used to measure the depth of pockets and

to determine their configuration. The typical probe is a tapered,
rodlike instrument calibrated in millimeters, with a blunt, rounded
tip (Figure 46-2). There are several other designs with various millimeter
calibrations (Figure 46-3). The World Health Organization
(WHO) probe has millimeter markings and a small, round ball at the
tip (Figure 46-3, E). Ideally, these probes are thin, and the shank is
angled to allow easy insertion into the pocket. Furcation areas can
best be evaluated with the curved, blunt Nabers probe (Figure 46-4).
When measuring a pocket, the probe is inserted with a firm,
gentle pressure to the bottom of the pocket. The shank should be
aligned with the long axis of the tooth surface to be probed. Several
measurements are made to determine the level of attachment along
the surface of the tooth.

Explorers

Explorers are used to locate subgingival deposits and carious areas

and to check the smoothness of the root surfaces after root planing.
Explorers are designed with different shapes and angles, with
various uses (Figure 46-5), as well as limitations (Figure 46-6).
The periodontal probe can also be useful in the detection of subgingival
deposits (Figure 46-6, D).

Scaling and Curettage Instruments

Scaling and curettage instruments are illustrated in Figure 46-7.

Sickle Scalers. Sickle scalers have a flat surface and two
cutting edges that converge in a sharply pointed tip. The shape of
the instrument makes the tip strong so that it will not break off
during use (Figure 46-8). The sickle scaler is used primarily to
remove supragingival calculus (Figure 46-9). Because of the design
of this instrument, it is difficult to insert a large sickle blade under
the gingiva without damaging the surrounding gingival tissues
(Figure 46-10). Small, curved sickle scaler blades such as the
204SD can be inserted under ledges of calculus several millimeters
below the gingiva. Sickle scalers are used with a pull stroke.
It is important to note that sickle scalers with the same basic
design can be obtained with different blade sizes and shank types
to adapt to specific uses. The U15/30 (Figure 46-11), Ball, and
Indiana University sickle scalers are large. The Jaquette sickle
scalers #1, 2, and 3 have medium-size blades. The curved 204
posterior sickle scalers are available with large, medium, or small
blades (Figure 46-12). The Montana Jack sickle scaler and the Nevi
2, Nevi 3, and Nevi 4 curved posterior sickle scalers are all thin
enough to be inserted several millimeters subgingivally for removal
of light to moderate ledges of calculus. The selection of these

instruments should be based on the area to be scaled. Sickle scalers

Curettes. The curette is the instrument of choice for removing

deep subgingival calculus, root planing altered cementum, and

removing the soft tissue lining the periodontal pocket (Figure
46-13). Each working end has a cutting edge on both sides of the
blade and a rounded toe. The curette is finer than the sickle scalers
and does not have any sharp points or corners other than the cutting
edges of the blade (Figure 46-14). Therefore curettes can be
adapted and provide good access to deep pockets, with minimal
soft tissue trauma (see Figure 46-10). In cross-section, the blade
appears semicircular with a convex base. The lateral border of the
convex base forms a cutting edge with the face of the semicircular
blade. There are cutting edges on both sides of the blade. Both
single- and double-end curettes may be obtained, depending on the
preference of the operator.
As shown in Figure 46-10, the curved blade and rounded toe of
the curette allow the blade to adapt better to the root surface, unlike
the straight design and pointed end of a sickle scaler, which can
cause tissue laceration and trauma. There are two basic types of
curettes: universal and area specific.
Universal Curettes. Universal curettes have cutting edges that
may be inserted in most areas of the dentition by altering and
adapting the finger rest, fulcrum, and hand position of the operator.
The blade size and the angle and length of the shank may vary, but
the face of the blade of every universal curette is at a 90-degree
angle (perpendicular) to the lower shank when seen in cross-section
from the tip (Figure 46-15, A). The blade of the universal curette
is curved in one direction from the head of the blade to the toe.
The Barnhart curettes #1-2 and 5-6 and the Columbia curettes
#13-14, 2R-2L, and 4R-4L (Figures 46-16 and 46-17, A) are examples
of universal curettes. Other popular universal curettes are the
Younger-Good #7-8, McCalls #17-18, and the Indiana University
#17-18 (Figure 46-17, B).
Area-Specific Curettes
Gracey Curettes. Gracey curettes are representative of the areaspecific
curettes, a set of several instruments designed and angled Evaluation
The adequacy of scaling and root planing is evaluated when the
procedure is performed and again later, after a period of soft tissue
healing.
Immediately after instrumentation, the tooth surfaces should be
carefully inspected visually with optimal lighting and the aid of a
mouth mirror and compressed air; surfaces also should be examined
with a fine explorer or probe. Subgingival surfaces should be
hard and smooth. Although complete removal of calculus is definitely
necessary for the health of the adjacent soft tissue, 164 little
documented evidence of the necessity for root smoothness is available.
47,50,155 Nevertheless, relative smoothness is still the best immediate
clinical indication that calculus has been completely
removed.47
Although smoothness is the criterion by which scaling and root
planing are immediately evaluated, the ultimate evaluation is based
on tissue response.162 Clinical evaluation of the soft tissue response
to scaling and root planing, including probing, should not be conducted
earlier than 2 weeks postoperatively. Reepithelialization
of the wounds created during instrumentation takes 1 to 2
weeks.121,147,148 Until then, gingival bleeding on probing can be
expected even when calculus has been completely removed because
the soft tissue wound is not epithelialized. Any gingival bleeding
on probing noted after this interval is more likely the result of
persistent inflammation produced by residual deposits not removed
during the initial procedure or inadequate plaque control. Positive
clinical changes after instrumentation often continue for weeks or
months. Therefore a longer period of evaluation may be indicated
before deciding whether to intervene with further instrumentation

or surgery.30
Occasionally, the clinician may find that some slight root roughness
remains after scaling and root planing.39,92,104 If sound principles
of instrumentation have been followed, the roughness may
not be calculus. Because calculus removal, not root smoothness,
has been shown to be necessary for tissue health, it might be more
prudent in such a case to stop short of perfect smoothness and
reevaluate the patients tissue response after 2 to 4 weeks or longer.
This avoids overinstrumentation and removal of excessive root
structure in the pursuit of smoothness for its own sake. If the tissue
is healthy after an interval of 2 to 4 weeks or longer, no further
root planing is necessary. If the tissue is inflamed, the clinician
must determine to what extent this is caused by biofilm accumulation
or the presence of residual calculus and to what degree further
root planing is necessary.

Instrument Sharpening

It is impossible to carry out periodontal procedures efficiently

with dull instruments. A sharp instrument cuts more precisely
and quickly than a dull instrument. To do its job at all, a dull instrument
must be held more firmly and pressed harder than a sharp