Periodontal Treatment Methods: Scaling and Root Planing

Larissa Henecke
October 5th, 2017
 Periodontal disease is an inflammatory disease that affects the surrounding soft

and hard tissues that support the teeth. It begins as gingivitis. In this stage, the gingiva

becomes inflamed and is prone to bleeding. This is due to the plaque and bacteria in the

sulcus around the tooth. Common bacteria found in the presence of gingivitis are

Actinomyces, Fusobacterium nucleatum, and Prevotella intermedia (Clark, 2017).

Gingivitis can be reversed with the introduction of proper oral hygiene habits such as

brushing and flossing. If oral hygiene practices are not implemented in daily homecare

the disease may progress to periodontitis. The diseased sulcus becomes inflamed and

infected by the bacteria. Bacteria present in chronic periodontitis include Porphyromonas

gingivalis, P. Inermedia, and Bacteroides forsythus (Clark, 2017). Tissue destruction of

the bone and connective tissue that hold the teeth in place happens both directly and

indirectly. Some of the bacteria create enzymes and toxins that directly destroy the tissue

(Perry, 2014, p. 50). When the body’s immune system initiates the inflammatory

response to try and fight off the chronic infection it creates indirect tissue destruction in

the process (Perry, 2014, p. 50). When not treated the disease will result in continued

bone loss and eventually tooth loss. Causes of the disease include tooth surface

irregularities such as pits, grooves, or calculus, tooth position, dental prostheses, dry

mouth, eating habits, and personal oral care (Wilkins, 1999, p. 251). Risk factors for

periodontal disease are medications that lead to gingival enlargement, tobacco use,

diabetes and immunosuppression, or other systemic diseases such as osteoporosis

(Wilkins, 1999, p. 253). Signs of the disease may be noted by bleeding gums, red

inflamed or swollen gums, a receding gum line, loose or gaped teeth, change in occlusion

or bite, or change in the way a dental appliance (denture or partial) fit. This disease can
cause major discomfort for patients and can result in decreased quality of life by limiting

function of teeth, physical pain when chewing, bad breath, decreased self confidence and

self image, social isolation, and embarrassment. The disease progression is irreversible,

but can be prevented or halted with proper oral hygiene homecare, eating a balanced diet,

regular dental check-ups, and periodontal treatment.

The goal of periodontal treatment is to eradicate the predisposing factors of the

disease, sustain a healthy oral cavity, and prevent recurrence of the disease (Perry, 2014,

p. 165). Common treatment methods for periodontal disease are categorized into phases.

Phase I consists of nonsurgical therapies. Many therapies fall into this category including

plaque and biofilm control, diet control, scaling and root planning, antimicrobial therapy,

restorations, and minor orthodontic treatments (Perry, 2014, p. 166). Phase I is followed

by an evaluation of the gingival condition and pocket depths. If Phase I does not resolve

the periodontal issues it may be followed by Phase II, resulting in the need for

periodontal surgery. Phase III focuses on restorative procedures and Phase IV is the

maintenance phase (Perry, 2014, p. 166). The dental hygienist is likely responsible for the

treatment in Phases I and IV (Perry, 2014, p. 166). It is important for the hygienist to

assess the patient before determining proper treatment. Patients are typed by their disease

progression; gingivitis, slight periodontitis, moderate periodontitis, advanced

periodontitis, or refractory periodontitis. Two essential procedures to successful therapy

of any case type are scaling and root planning by the dental hygienist and daily oral

hygiene practices and plaque control by the patient (Wilkins, 1999, p. 639). Many past

studies as well as a recent study by the Journal of the American Dental Association have

concluded that scaling and root planning alone has been shown to improve clinical
attachment level in patients with chronic periodontitis (Smiley, 2015). Scaling and root

planing helps to eliminate pathological microorganisms and promote healing of the

tissue. For treatment to be successful the patient must take responsibility to manage the

disease; this means attending periodontal therapy and maintance appointments and

performing routine homecare (Wilkins, 1999, p. 639).

Initial treatment of periodontal disease is the debridement of plaque and calculus

with nonsurgical techniques, such as scaling and root planing (Perry, 2014, p. 207).

Scaling is defined as “instrumentation of the crown and root surfaces of the teeth to

remove plaque, calculus, and stains from these surfaces” (Perry, 2014, p. 208). Scaling

can be performed with either sharp hand instruments or ultrasonic instruments (Perry,

2014, p. 208). Root planing is “a treatment procedure designed to remove cementum or

surface dentin that is rough, impregnated with calculus, or contaminated with toxins or

microorganisms” (Perry, 2014, p. 208). Root planing may also be accomplished with

hand instruments or ultrasonic instruments. The goal of root planing is to leave a “glassy

smooth surface” so the pockets are free of any deposits or bacterial plaque (Perry, 2014,

p. 208). The theory behind root planing is the smooth surface makes it harder for biofilm

to reattach to the root surface, therefore the surface is easier to clean, and it promotes

gingival healing (Perry, 2014, p. 212). Local anesthesia may be used to numb the gum

tissue and roots of the teeth to aid in patient comfort during the procedure. Scaling and

root planing is recommended for patients who have symptoms of periodontal disease

such as heavy calculus build up and probing depths of 4mm or more (Pleis, 2015).

According to the Journal of Evidence -Based Dental Practice, it is considered the “gold

standard” of treatment for patients with chronic periodontitis (Sanz, 2012). In earlier
stages of periodontal disease, scaling and root planing may be done with a general dentist

or dental hygienist (Rondon, n.d.). In more advanced or complex stages the patient will

likely be referred to a periodontist. Periodontists receive an additional three years of post-

dental school education to specialize in periodontal care, the care of structures

surrounding the teeth that are affected by periodontal disease. The cost of scaling and

root planing can range from $140 to $300 per quadrant (Rondon, n.d.). In addition, there

may be charges for antimicrobial agents or periodontal maintenance therapy as needed.

Cost is dependent on each patient’s individual status.

As stated previously, the Journal of Evidence-Based Dental Practice has named

scaling and root planing the treatment of choice for those with chronic periodontitis. In

2012 a study was conducted to compare scaling and root planing to other non-surgical

therapies. The study concluded that the technological advances and new protocols did not

show significant differences in efficacy when compared to the conventional scaling and

root planing (Sanz, 2012). There are many benefits of scaling and root planing, these

include halting the progression of periodontal disease, preventing tooth loss, preventing

decay, returning gingival tissues to health, and eliminating the need for periodontal

surgeries in the future. Much of the research on the success of scaling and root planing is

dated, but a study conducted in 2002 on the efficacy of scaling and root planing in the

treatment of periodontal pockets showed and increase in gingival status and decrease in

pocket depths on 84.61% of treated sites with scaling and root planing alone (Coulibaly,

2002). They concluded that scaling and root planing is an efficient and useful method in

periodontal treatment. Newer research focuses on scaling and root planing in combination

with adjunctive therapies. A 2014 study compared scaling and root planing to different
adjunctive therapies and concluded that debridement is still the number one choice for

treatment, validated by decades of sound scientific evidence (Drisko, 2014).

Though the success rate for scaling and root planing is high, it is not a cure all.

For the treatment to work the patient must take responsibility and continue to attend

regular maintenance appointments and practice oral homecare. Drawbacks of scaling and

root planing include high cost and potential discomfort for the patient. When compared to

the even higher costs of surgical treatment or future discomfort the disease may cause,

these inconveniences seem very minimal.

During the process of periodontal treatment the dental hygienist has many

responsibilities. They are expected to do an initial assessment of the patient which

includes; assessment of the medical history, dental history, periodontal risk factors (eg.

age, medications, smoking, ethnicity), extraoral and intraoral exam, examination of teeth

(eg. mobility, furcations, occlusual relationship), soft tissue assessment (eg. color,

contour, consistency, probing depths, BOP, CAL), and radiograph evaluation (Sweeting,

2008). After the assessment is complete they will aid in the diagnosis of the patient,

classifying them into one of the periodontal case types. After the patient has a case type

treatment planning will begin followed by implementation of the therapy. Scaling and

root planing will be done in adjunct with patient education and counseling on plaque

control and management of periodontal risk factors (Sweeting, 2008). The hygienist will

be responsible for providing both portions of treatment. Education of the patient is

essential for effective treatment. They hygienist needs to explain the progression of the

disease and the data collected in the assessment to the patient; probing depths,

radiographs, areas of bone loss, mobility, furcations, and tissue condition (Sweeting,
2008). The hygienist should emphasize the importance of plaque control and the patient

must be taught proper oral hygiene homecare. This includes brushing 2x daily using

proper technique and cleaning interproximally with floss or other aids. If the patient does

not comply with the oral homecare routine progression of the disease may continue,

regardless of other treatments. After scaling and root planing is complete the patient

should return for reevaluation in 4-6 weeks. If the disease shows progression, a referral to

a periodontist may be required. If the patient is stable they may be placed on a 3-month

periodontal maintenance recall (Sweeting, 2008). This is standard procedure and has been

shown to be effective in reducing disease progression and preserving teeth (Sweeting,

2008).

Of all the periodontal treatment options, scaling and root planing has been

continually shown to be the gold standard treatment. Scaling and root planing can be used

in adjunct with many other treatments including local antibiotic therapy, systemic

antibiotic therapy, antimicrobial rinses, and local antimicrobial agents, which have also

been shown to be effective in the treatment of the disease. Treatment plans for patients

differ depending on the patient’s progression of the disease and initial response to the

treatments. With this being said, there is no “perfect” plan, but from years of research we

can conclude that scaling and root planing is an ideal place to start for most periodontitis

patients.
 References

Clark, Shaunda. (2017). Periodontal epidemiology and microbiology. [Powerpoint

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Coulibaly, N., Kone, D., Kamagate, A., Yao, A., & Brou, E. (2002). Efficacy of scaling

and root planing in the treatment of periodontal pockets. Odontostomatologie

Tropicale, 25(19), 17-21.

Drisko, C. L. (2014). Periodontal debridement: Still the treatment of choice. Journal

of Evidence Based Dental Practice, 14.

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

hygienist (4th ed.). St. Louis, MO: Elsevier.

Pleis, D. (2015). What dentists do when root planing and scaling teeth. Retrieved

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Sanz, I., Alonso, B., Carasol, M., Herrera, D., & Sanz, M. (2012). Nonsurgical

treatment of periodontitis. Journal of Evidence Based Dental Practice, 12(3),

76-86. doi:10.1016/s1532-3382(12)70019-2

Smiley, C., et. al. (2015). Systematic review and meta-analysis on the

nonsurgical treatment of chronic periodontitis by means of scaling and root

planing with or without adjuncts. The Journal of the American Dental

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Sweeting LA, Davis K, Cobb CM. (2008). Periodontal treatment protocol (PTP) for

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Wilkins, Esther M. (1999). Clinical practice of the dental hygienist (11th ed.).

Philadelphia: Lippincott Williams & Wilkins.