Efficacy of Root Planning

Definitions and Descriptions

Scaling: instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus and stains from these surfaces.
  
           Root Planing:
a) A treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus, or contaminated with toxins or microorganisms. (Amer. Acad. of Perio.)

b) A technique of instrumentation by which the “softened” cementum is removed and the root surface is made “hard” and “smooth” (Lindhe’s textbook)

c) American Academy of Periodontology Description:
    " Periodontal scaling is a treatment procedure necessary to remove hard and soft deposits from the tooth surface.  It is performed on patients with periodontal disease and is therapeutic, not prophylactic in nature.  Periodontal scaling may precede root planing.  Root planing is a meticulous treatment procedure designed to remove bacterial plaque and its toxins, calculus, and diseased cementum and dentin from the root surface.  The procedure may be a definitive treatment in some stages of periodontal disease, may be a part of pre-surgical procedures in others and an essential part of maintenance care.  Root planing is arduous and time consuming.  It may be done by quadrant(s) or full mouth (note: not allowed by insurance), may need to be repeated, and may require local anesthetic."

d) Root Preparation: Use of instruments or chemicals on root to eliminate irritants, prevent bacterial accumulation, and encourage wound healing.  (Amer. Acad. of Perio.)

e) Root Debridement:  The mechanical removal or disruption of
irritants to the periodontium: bacterial plaque, LPS (lipopolysacchirides), deposits and other plaque retentive factors to establish an environment favorable to the health of the periodontal tissues that will facilitate plaque control by the patient. The endpoint of debridement is recognizable by the color of the lavage and the feel of the tooth. Clinical endpoints are evaluated at various times post treatment. (Various sources)


Initial Therapy Procedures That Reduce Inflammation and Tooth Mobility  
            A). Periodontal
                        a) oral hygiene instructions
b) scaling and root planing
c) adult prophylaxis (scaling and tooth polish)
d) occlusal therapy
                                    1) occlusal adjustment
                                    2)  occlusal splints and bite planes.

            B)  Non-periodontal
                        a) removal of overhangs
b) caries control
c) extraction of hopeless teeth
d) provisional restorations

Biological Basis for Root Planing
A) The role of calculus and altered cementum

B)  Terms for periodontal healing:
a) Repair: Healing of a wound by tissue that does not fully restore the architecture or the function of the part.

b) Reattachment: To attach again. The reunion of connective tissue with a root surface on which viable periodontal tissue is present. Not to be confused with new attachment.

c) New attachment:
1) True new attachment: The reunion of connective tissue with a root surface that has been deprived of its periodontal ligament.  This reunion occurs by the formation of new cementum with inserting collagen fibers.
2) Long junctional epithelium (epithelial attachment): Adhesion of the junctional epithelium to a root surface that has been deprived of its periodontal ligament or connective tissue attachment.
d) Regeneration: Reproduction or reconstitution of a lost or injured part.



C) Objectives in root planing:
a)    restore gingival health by completely removing tooth surface factors that promote gingival inflammation

b)    make the root surface biologically acceptable to the soft tissues.


Limitations in root planing as part of non-surgical periodontal therapy.



Decision-Making Regarding Response to Initial Therapy
            A)  periodontal surgery
B) periodontal maintenance         
A)   initial therapy end point not reached

Summary of Recent Literature


PERIODONTAL SCALING AND ROOT PLANING
SUMMARY OF ISSUES CONTROVERSIES IN THE LITERATURE


In the past 30 years there have been numerous studies designed to test the effectiveness of scaling and root planing as a method of controlling periodontal diseases.  If there is one area in dentistry that is evidence based, it is periodontal instrumentation, because of the extensive studies and literature.  However, because many issues are controversial with support on each sides, conclusive evidence is lacking. Therefore, periodontal scaling and root planing remains as much an art as a science despite the literature.  Some of the important issues are listed below.  In the 1989 World Workshop in Clinical Periodontics, it was emphasized that in many of the studies, instrumentation was performed by experienced periodontists with unlimited time.  Extrapolation from carefully controlled experimental studies to real-life clinical situations should be done cautiously. 

Surgical Vs. Non-surgical Therapy
There is support that in non-surgical scaling and root planing the deeper the pocket is, the more difficult it becomes to instrument non-surgically.  Rabbini (1981) had results that “demonstrated a high correlation between percent of residual calculus and pocket depth”.  It was shown that pockets less than 3 mm were the easiest sites for scaling and root planing.  Pocket depths between 3 to 5 mm were more difficult to scale and pockets deeper than 5 mm were the most difficult.  Sherman  (1990) evaluated the ability of experienced clinicians to detect residual calculus following subgingival scaling and root planing.  She compared the clinical detection with the microscopic presence of calculus.  The results showed that "there was a high false negative response (77.4% of the surfaces with microscopic calculus were clinical scores as being free of calculus) and a low false positive response (11.8% of the surfaces microscopically free of calculus were clinically determined to have calculus)."  Her study indicates the difficulties in clinically determining the thoroughness of subgingival instrumentation.  Kepic (1990) found that complete removal of calculus from a periodontally diseased root, even with an open (surgical) approach is rare.  Rateitschak (1992) found that in non-surgical therapy, curettes could not reach the bottom of deep pockets.   It may be concluded from the above studies that in deeper sites, periodontal surgery may be required to gain direct access to the root surface for debridement. 

Ultrasonics Vs. Hand Instrumentation
    a. Calculus removal
Most studies have found both ultrasonic/sonic and hand instrumentation to be equally effective in calculus removal.  Gellin (1986) found that the combination of sonic instrumentation and hand instrumentation to be better than either method alone.

    b. Rough vs. smooth roots and cementum removal
There is little question that root surfaces which have become rough due to exposure to the oral environment and calculus promote bacterial adherence, increased surface area.  Several S.E.M. studies have shown that hand instrumentation is more effective than ultrasonics in cementum removal and may result in a smoother root, although a few studies show equal effectiveness.  Improperly used hand instruments, ultrasonics or rotary instruments may induce root surface roughness which may in themselves cause future periodontal problems.  It can be concluded that when root roughness is present, hand instruments are more effective in making a rough root smoother.  When improperly used, hand instruments or ultrasonic instruments may gouge the root surface.  When scaling and root planing is done as a closed procedure, the smoothness of the root is one of the best ways to determine if a suitable end point is being reached.   Quirynen and Bollen (1995) extensively reviewed the literature on rough roots and the relationship to adhesion and retention of oral microbes.  Most of the studies they reviewed show rough roots lead to high-energy surfaces, which collect and bind more bacteria.  

   c. Difficult to reach areas
O'Leary found the most difficult sites to instrument completely are furcations, grooves, CEJ's and line angles.  Ultrasonic instrumentation seems to be superior in accessing difficult to reach areas, especially furcations, although neither technique can completely remove calculus in this area.  The new modified ultrasonic  tip (e.g.: slimline® tips) has made deep pockets more accessible. 

   d. Resolving inflammation
Some studies have shown that ultrasonic and hand instruments are both equally effective in reducing inflammation.  Badersten (1983) when evaluating reduction of inflammation on single rooted found " no differences in results could be observed when comparing hand versus ultrasonic instrumentation".  She also found that there was no advantage to repeated root planing and that improvement occurred over a 9 month period of time.

   e. Overall conclusion on hand vs. ultrasonic instrumentation
There is evidence in the literature that it makes good clinical sense to use both types of instrumentation, whenever possible, because the two methods supplement each other.


Cementum Removal and Endotoxin (LPS)
Endotoxin is the potent inflammatory stimulator that is released by gram negative bacteria on cell death and thought to contribute to the progression of periodontal disease through its absorption into the root.  Jones and O'Leary (1978) showed that scaling diseased roots (without root planing) only partly reduced endotoxin but root planing "was able to render diseased root surfaces approximately as free of detectable endotoxin as were uninvolved, healthy root surfaces of unerupted teeth".  Nishimine and O'Leary 1979 found hand instruments to be more effective than ultrasonics in removing endotoxin in vivo. Several recent studies have shown that ultrasonic instrumentation is effective at removing adsorbed endotoxins, but these studies are in vitro.   There is clinical support for the removal of some of the cementum but not to the extent of removing all of the cementum.  Endotoxin, originally believed to require extensive instrumentation to be removed from the root surface, is now believed to be more weakly adherent than originally believed.  Several more recent studies have shown that ultrasonics is quite effective in removing cementum bound endotoxins.  Nyman (1988) compared scaling and root planing with scaling and polish (without cementum removal) and found the same degree of improvement following periodontal surgery.   It may be concluded that it is clinically sound to remove enough cementum to make the root surface smooth and clean, but removal of all the cementum is not justified.

Root Planing At Shallow Versus Deep Sites
A few studies have shown that root planing healthy sites tends to result in clinical attachment loss, while root planing at sites deeper results in clinical attachment gain. The critical probing is the average probe depth below which there is attachment loss and above which there is attachment gain for a particular procedure.  Lindhe (1982) found the critical probing depth for periodontal scaling and root planing to be 2.9 mm on average (shallower sites show attachment loss; deeper sites show attachment gain).  The important message here is that root planing should be directed at sites with disease and not performed at healthy shallow sites.

The Role of Calculus in Periodontal Disease
In a 1985 Review article on the pathogenesis of periodontal disease entitled "Calculus Revisited", Irwin Mandel states that "since the accepted scenario is that apical growth of supragingival plaque precedes the formation of subgingival calculus, there is no longer an issue of whether subgingival calculus is the cause or the result of periodontal disease.  Subgingival mineralization results from the interaction of subgingival plaque with the influx of mineral salts that is part of the serum transudate and inflammatory exudate.   This however should not be the basis for relegating calculus to the ash heap.  Morphologic and analytical studies point to the porosity of calculus and retention of bacterial antigens and the presence of readily available toxic stimulators of bone resorption.  When coupled with the increased build up of plaque on the surface of the calculus, the combination has the potential for extending the radius of destruction and the rate of displacement of the adjacent junctional epithelium.  The centrality of thorough scaling and root planing in the successful maintenance of periodontal health supports the view the subgingival calculus contributes significantly to the chronically and progression of the disease, even if it can no longer be considered as responsible for initiation".

Gingival Curettage and Root Planing
The American Academy of Periodontology Glossary states "gingival curettage is the process of debriding the soft tissue wall of a periodontal pocket".  It involves removal of ulcerated sulcular epithelium and some of the inflamed connective tissue ("granulation tissue").  Inadvertent curettage is done when the trailing edge of the curet removes some of the pocket wall during root planing.  Intentional curettage is accomplished when the cutting edge of the curet is directed toward the pocket wall.  Since teeth that are curetted are always root planed and inadvertent curettage occurs during root planing the two procedures cannot be separated.  Moreover, curettage is difficult to accomplish effectively in deep pockets.   At the current time gingival curettage, as a separate procedure, apparently has no justifiable application during active therapy for chronic adult periodontitis.


Key Words : gum disease bleeding gums gums receding gums swollen gums sore gums healthy gums

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