Value of Coronal Scaling and Subgingival Debridement

TERMINOLOGY

Prophylaxis, Oral: The removal of plaque, calculus and stains from the exposed and unexposed surfaces of the teeth by scaling and polishing as a preventive measure for control of local irritational factors. In the clinic this procedure is selected in the treatment of gingivitis in the hope that the gingival will be returned to a state of health or at least will not develop into periodontitis.
Future preventive / recall cleaning will be termed prophylaxes as opposed to maintenance therapy.

Scaling: Instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus and stains from the teeth.

Root Planing: A treatment procedure designed to remove cementum or surface dentin that is rough impregnated with calculus, or contaminated with toxins or microorganisms. The term is in common usage but is not favored at the UW because it is restrictive, referring only to the root surface and not the adjacent soft tissues.

Root Curettage: Scraping or cleaning the walls of a cavity or surface by mean if a curet.
The procedure not only addresses the root surfaces but also focuses on the soft tissue of the periodontal pocket, especially when sharp, double-edged curets are used. In the patient with periodontitis (as opposed to gingivitis), the student and supervising Periodontics instructor will design a treatment plan consisting of from between 1 to 4 quadrant- equivalents of root curettage depending on the severity of the case. Once this treatment of periodentitis has been selected, then future recall treatment will be termed maintenance as attempts are made to maintain the status quo and prevent further breakdown of the periodontal support. Unfortunately this term is not widely used because many people consider it a surgical procedure.

Subgingival Debridement (SD): The removal of inflamed, devitalized, or contaminated tissue or foreign material from or adjacent to a lesion. This descriptive term for  “ subgingival cleaning” is favored by the UW Department of Periodontics.

Note:  A prophylaxis and quadrants root curettage cannot both be treatment planned on the same patient at the same time.

Benefits and Limitations

During the 1960s, it was shown that supragingival plaque accumulation led to gingival inflammation. It also is generally accepted that pathogenic subgingival plaque cannot develop in the absence of supragingival plaque. Furthermore, changes in supragingival plaque can induce changes in subgingival plaque. Successful periodontal therefore depends on meticulous daily removal of supragingival plaque by the patient and removal of plaque (and probably calculus) by debridement og the crown and root surfaces of the tooth by dental personnel. Both are fraught with problems. Patient compliance usually is not ideal and access to deep periodontal pockets and furcation invasions is difficult, if not impossible. Waerhaug (J Periodontol 49:119,1978) and Rabbani et al (J Periodontol 52:119,1981) demonstrated that SD was fairly effective in removing subgingival deposits in shallow pockets. In pocket depths between 3-5 mm the chances of failure exceeded the chances for success. When pocket depth surpass 5 mm or if significant furcation invasion existed, the chances for failure dominated.

All is not lost! In spite of these limitations there is ample evidence of benefit – at least short-term benefit.

Clinical Studies:
In a 4-week study Morrison et al (J Clin Periodontol 7:199,1980) looked at the effects of OHI, S/SD and occlusal adjustment performed on 90 patients each of whom had at least 20 teeth. The treatment took 4-6 visits. Importat results are illustrated in the following figures.


Results do depend on the degree of inflammation in soft tissue. After 4 week there was a decrease in probing depth and a decrease in periodontal attachment loss in moderate to deep periodontal pockets.  Of equal importance was the slight loss of attachment after instrumentation in shallow pockets. Let the tissues do the talking. In the absence of gingival inflammation, increased probing depths, and calculus, the clinician should be cautious and avoid subgingival instrumentation. “If it ain’t broke, don’t fix it!”

Histologic Studies:
In a clinical / microscopic study in 22 patients, Tagge et al (J Periodontol 46:527,1975) gave OHI and per formed SD and in a site that displayed the same amount of gingival inflammation clinically as another area in the same mouth which was not treated – i.e., the control site. A third similar site was treated by OHI alone. Eight weeks later all 3 sites were assessed clinically for inflammation and 66 biopsy specimens were taken. Clinically and microscopically there was less evidence of inflammation in the SD + OHI sites than in the other two. The data are presented graphically below.


Stahl et al (J Periodontal 42:678,1971) conducted a study to ascertain how long it would take the histologic improvement seen in gingival inflammation as a result of SD to return pre-treatment levels. Eighty suprabony pockets averaging 4.6 mm depth were curetted and then biopsied at appearing specimens from the same patient. By 8 weeks the inflammatory infiltrate was similar in distribution and degree to the control specimens.

Microbiological Studies:
Subgingival debridement has been shown to alter the subgingival microflora purportedly associated with the development of periodontal disease. But for how long? Magnusson et al (J Clin Periodontal 11:193,1993) studied the recolonization of spirochetes and motile rods following SD. The total counts and percentage of these organisms dropped immediately after treatment. By 4 weeks a gradual increase was noted and by the examinations conducted at 8,12, and 16 weeks post- treatment the motile segment of the subgingival microbiota had approached baseline. In a similar study by Handleman and Hess (J Dent Res 49:340,1970) repeated bacterial samples were evaluated after SD at day 3, 10, 30 and 60. There was an immediate increase in Gm + cocci and a decrease in the more complex organisms. The various bacteria studied returned to baseline levels by day 60. Interestingly probing depth was not correlated to the degree of inflammation.

Extended Studies:
()  Badersten et al (J Clin periodontal 8:57,1981 and 11:63,1984) investigated the effect of SD on moderately advanced (4-7mm) and severely advanced (>7mm) periodontitis. In both studies only single-rooted teeth were treated and assessed. The common format included repeated OHI for at least 3 months followed by aggressive SD (with either hand instruments or ultrasonics) every three months until 1 year. The advanced study continued for a second year during which time OHI was given and the teeth received a coronal polish every 3 months. Plaque index, bleeding on probing, pocket depth all improved during the first few months and then remained stable. The results for periodontal attachment level were mixed. In the moderate study there were 106 sites that initially measured at least 6 mm. At 7 months there were 11 such sites and at 13 months there were 13. The advanced study had 305 sites initially measuring at least 7 mm; there were 43 such sites by 24 months. Thus the investigators were able to improve and maintain the periodontal status for 13 to 24 months. It took careful and repeated OHI in a motivated group of people. It took several rounds of thorough SD during the first year and in the second study periodic OHI and coronal polishing for the next 12 mouths. Not to be overlooked is the fact that all teeth were single-rooted. Molars, especially those with furcation invasions, really complicate treatment. May require surgical access to cope with problems.

()  In an excellent long-term clinical study by Kalkwarf et al (J Periodontol 59:794,1988) a variety of surgical and non-surgical modalities were compared in teeth with furcation invasions. Regardless of the method used all sites tended to breakdown in the second year of maintenance.

()  Fleischer et al (J Periodontol 60:402,1989) demonstrated that in molars with furcation invasions and probing depths of at least 7 mm, the percent  of attachment loss in the furcations was over 3 times the percent of loss on external root surfaces. That’s ugly!

Summary:
In spite of the limitations of access, especially in the posterior of the mouth and in the presence of furcation invasions, careful SD will lead to clinical, histologic and microbiologic improvement in moderate to severe periodontal disease – at least over a 2-3 month period. The better the patient’s plaque control efforts, the better the results, and the longer they will last.
Subgingival debridement is not advised in healthy sulci.


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