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The importance of effective scaling and root planing

Monday, November 8, 2021 | Posted in GEHA Connection Dental Network News

Periodontal diseases are a worldwide public health issue. Undiagnosed, untreated, or inappropriately treated, periodontitis can have devastating effects on oral health, quality of life and overall health. The destructive effects and systemic impacts of periodontitis are the result of inflammation. Oral inflammation can cause tooth loss and has been linked to numerous health problems. Inflammation results from the interaction of a host’s immune system and dysbiotic subgingival biofilms.

The traditional first step in periodontal therapy involves eliminating subgingival biofilm and calculus to resolve periodontal inflammation. Success requires effective self-care and thorough subgingival debridement, including scaling and root planing (SRP), that may need to be repeated over time. 

How does scaling and root planing impact oral health?

The goal of SRP is to remove subgingival calculus and biofilm. Numerous studies have confirmed the significant reduction of subgingival bacteria following SRP. Smooth or burnished calculus, circuitous periodontal pockets, irregular roots, and a lack of visibility make SRP a demanding procedure for even accomplished clinicians.

When performed effectively, SRP can reduce subgingival biofilm, clinical inflammation, and probing depths. However, studies evaluating SRP effectiveness indicate that many teeth exhibit residual subgingival biofilm and calculus. Deeper probing depths, root concavities, grooves, restorative contours, and furcation involvements reduce efficacy. No specific type of instrumentation has demonstrated consistent superiority, be it manual, ultrasonic/sonic, or lasers. The most important factors affecting SRP efficacy are operator experience, skill, and training.

No treatments can completely eradicate all bacteria. Limited visibility, restricted access, tissue invasion of certain microbes, and inaccessible biofilm retained in surface irregularities all impact the effectiveness of treatment. Previously treated sites may also be re-infected by bacteria from untreated sites, saliva, epithelium of the periodontal pocket wall and/or oral and pharyngeal mucosa, and even from other individuals.

How can you spot periodontal diseases?

  • A root no longer protected by the periodontal ligament or junctional epithelium is readily colonized by bacteria that may, over time, result in mature biofilm and subgingival calculus. Exposed root surfaces are uneven and hypermineralized. Lacunae, resorptive defects, and mounds are common.
  • Endotoxin penetrates and adsorbs to the roots of periodontally diseased teeth. Attachment loss also exposes cementum into which biologically active products can diffuse. Although weakly bound, endotoxin can wreak havoc on healing following inadequate periodontal therapy. 

What methods are effective when treating periodontal diseases?

Lasers are among the most recent additions to be used to mitigate SRP’s traditional inadequacies in the hope of increasing desired clinical outcomes. There is an absence of strong evidence supporting the effectiveness of lasers as adjuncts to SRP. 

Periodontal maintenance must meet or exceed the norm. Repeated re-assessment is necessary to determine if different approaches are warranted. Absent good self-care, it’s difficult to determine how persistent signs of inflammation are caused.

The interval between completion of nonsurgical periodontal therapy (i.e. SRP) and the first re-evaluation appointment should be long enough to allow near-complete healing of treated sites. The connective tissues of an inflamed gingival lamina propria may require as many as 12 weeks of healing following SRP. Re-evaluation is not an endpoint but a waypoint. Re-evaluation of any periodontal treatment, including SRP, requires a reassessment of the same clinical parameters used to diagnose disease and to construct the original treatment plan. 

Results of reassessment determine the next steps in treatment. This is likely to be periodontal maintenance or a second SRP at nonresponding, still-diseased sites. A second SRP is often more successful if performed using advanced instrumentation designed to improve operator visibility. If diseased sites persist (generally assessed by the presence of bleeding on probing), the next step may be surgical intervention. 

Surgical treatment typically seeks improved access for removal of subgingival calculus and biofilm. Some surgeries may also employ regenerative technologies or tissue sculpting aimed at providing better support or tissue anatomy that is more easily maintained. Other surgical procedures may improve appearance and mitigate chronic pain. In recent years, minimally invasive surgeries have facilitated improved SRP and regenerative opportunities at some sites, but they necessitate use of advanced instrumentation that improves visualization and instrumentation. 

Like other chronic diseases, the ongoing nature of periodontitis requires meticulous re-evaluations and modulations of subsequent care, including maintenance. The initial interval between maintenance appointments should be based on a patient’s risk for disease recurrence. Factors such as residual probing depths, persistent bleeding on probing, erratic or inadequate self-care, and failure to appear at periodontal maintenance appointments are signals of greater risk.

Unfortunately, periodontal diseases are often not managed properly or in a timely manner. If clinical procedures, such as SRP, do not produce desired results, other therapies should be considered along with referral to a specialist. On average, SRP is an effective treatment if executed with precision by skilled clinicians. 


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