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Scaling and root planing
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Scaling and root planing
Close-up image of a hand scaler
ICD-9-CM96.54
MeSHD012534

Scaling and root planing, also known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is a procedure involving removal of dental plaque and calculus (scaling or debridement) and then smoothing, or planing, of the (exposed) surfaces of the roots, removing cementum or dentine that is impregnated with calculus, toxins, or microorganisms,[1] the agents that cause inflammation.[2] It is a part of non-surgical periodontal therapy. This helps to establish a periodontium that is in remission of periodontal disease. Periodontal scalers and periodontal curettes are some of the tools involved.

A regular, non-deep teeth cleaning includes tooth scaling, tooth polishing, and debridement if too much tartar has accumulated, but does not include root planing.

Plaque

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Main article: Dental plaque

Plaque is a soft yellow-grayish substance that adheres to the tooth surfaces including removable and fixed restorations. It is an organised biofilm that is primarily composed of bacteria in a matrix of glycoproteins and extracellular polysaccharides. This matrix makes it impossible to remove the plaque by rinsing or using sprays. Materia alba is similar to plaque but it lacks the organized structure of plaque and hence easily displaced with rinses and sprays.

Although everyone has a tendency to develop plaque and materia alba, through regular brushing and flossing these organized colonies of bacteria are disturbed and eliminated from the oral cavity. In general, the more effective one's brushing, flossing, and other oral homecare practices, the less plaque will accumulate on the teeth.

However, if, after 24 hours in the oral environment, biofilm remains undisturbed by brushing or flossing, it begins to absorb the mineral content of saliva. Through this absorption of calcium and phosphorus from the saliva, oral biofilm is transformed from the soft, easily removable form into a hard substance known as calculus. Commonly known as 'tartar', calculus provides a base for new layers of plaque biofilm to settle on and builds up over time. Calculus cannot be removed by brushing or flossing.[3]

Plaque build up and bone loss

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Plaque accumulation tends to be thickest along the gumline. Because of the proximity of this area to the gum tissue, the bacterial plaque begins to irritate and infect the gums. This infection of the gum causes the gum disease known as gingivitis, which literally means inflammation of the gingiva, or gums. Gingivitis is characterized by swelling, redness and bleeding gums. It is the first step in the decline of periodontal health, and the only step which can be fully reversed to restore one's oral health.[4]

As the gingival tissue swells, it no longer provides an effective seal between the tooth and the outside environment. Vertical space is created between the tooth and the gum, allowing new bacterial plaque biofilm to begin to migrate into the sulcus, or space between the gum and the tooth. In healthy individuals, the sulcus is no more than 3 mm deep when measured with a periodontal probe. As the gingivitis stage continues, the capillaries within the sulcus begin to dilate, resulting in more bleeding when brushing, flossing, or at dental appointments. This is the body's attempt to clear the infection from the tissues. Thus, bleeding is generally accepted as a sign of active oral infection. The swelling of the tissue may also result in deeper reading on periodontal probing, up to 4 mm. At a depth of 4 mm or greater, the vertical space between the tooth and surrounding gum becomes known as a periodontal pocket. Because tooth brush and floss cannot reach the bottom of a gum pocket 4–5 mm deep, bacteria stagnate in these sites and have the opportunity to proliferate into periodontal disease-causing colonies.

Once bacterial plaque has infiltrated the pocket, the transformation from biofilm into calculus continues. This results in an ulceration in the lining of the tissue, which begins to break down the attachment of the gum to the tooth. Gingival attachment begins to loosen further as the bacterial plaque continues to invade the space created by the swelling it causes. This plaque eventually transforms into calculus, and the process continues, resulting in deposits under the gum, and an increase in pocket depth. As the depth of the vertical space between the tooth and the gum reaches 5mm, a change occurs. The bacterial morphology, or make up, of the biofilm changes from the gram positive aerobic bacteria found in biofilm located supragingivally, or above the gumline. Replacing these gram positive bacteria of the general oral flora are obligate anaerobic gram negative bacteria. These bacteria are more destructive in nature than their aerobic cousins. The cell walls of gram negative bacteria contain endotoxins, which allow these organisms to destroy gingival tissue and bone more quickly. Periodontitis officially begins when these bacteria begin to act, resulting in bone loss. This bone loss marks the transition of gingivitis to true periodontal disease. In other words, the term periodontal disease may be synonymous with bone loss.

The first evidence of periodontal disease damage becomes apparent in radiographs as the crestal bone of the jaw begins to become blunted, slanted, or scooped out in appearance. This destruction occurs as a result of the effect of bacterial endotoxins on bone tissue. Because the bone is alive, it contains cells in it that build bone, known as osteoblasts, and cells that break down bone, called osteoclasts. Usually these work at the same speed and keep each other in balance. In periodontitis, however, the chemical mediators, or by-products, of chronic inflammation stimulate the osteoclasts, causing them to work more rapidly than the cells that build bone. The net result is that bone is lost, and the loss of bone and attachment tissues is called periodontal disease.

These processes will persist, causing greater damage, until the infectious bacterial agents (plaque) and local irritating factors (calculus) are removed. In order to effectively remove these at this stage in the disease process, brushing and flossing are no longer sufficient. This is due to several factors, the most important being the depth of the periodontal pocket. Brushing and flossing are effective only at removing the soft materia alba and biofilm in supragingival areas, and in pockets up to 3 mm deep. Even the best brushing and flossing is ineffective at cleaning pockets of greater depths, and are never effective in removing calculus. Therefore, in order to remove the causative factors that lead to periodontal disease, pocket depth scaling and root planing procedures are often recommended.

Once the bacteria and calculus are removed from the periodontal pocket, the tissue can begin to heal. The inflammation dissipates as the infection declines, allowing the swelling to decrease which results in the gums once again forming an effective seal between the root of the tooth and the outside environment. However, the damage caused by periodontal disease never heals completely. Bone loss due to the disease process is irreversible. The gingival tissue of the gums also tends to suffer permanent effects once the disease reaches a certain point. Because gum tissue requires bone to support it, if bone loss has been extensive, a patient will have permanent recession of the gums, and therefore exposure of the roots of the teeth in involved areas. If the bone loss is extensive enough, the teeth may begin to become mobile, or loose, and without intervention to arrest the disease process, will be lost.

Contrary to old beliefs, it is not a normal part of aging to lose teeth. Rather, it is periodontal disease that is the main cause of tooth loss in the adult population.[citation needed]

Periodontal intervention

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Treatment of periodontitis may include several steps, the first of which often requires the removal of the local causative factors in order to create a biologically compatible environment between the tooth and the surrounding periodontal tissues, the gums and underlying bone. Left untreated, chronic inflammation of the gums and supporting tissue can raise a person's risk of heart disease.[5]

Prior to beginning these procedures, the patient is generally numbed in the area intended for instrumentation. Because of the deeper nature of periodontal scaling and root planing, either one half or one quarter of the mouth is generally cleaned during one appointment. This allows the patient to be entirely numbed in the necessary area during treatment. It is usually not recommended to have the entire mouth scaled at one appointment because of the potential inconveniences and complications of numbing the entire mouth – i.e., inability to eat or drink, likelihood of self injury by biting, etc.

Generally, the first step is the removal of dental plaque, the microbial biofilm, from the tooth, a procedure called scaling. Root planing involves smoothing the tooth's root. These procedures may be referred to as scaling and root planing, periodontal cleaning, or deep cleaning. These names all refer to the same procedure. The term "deep cleaning" originates from the fact that pockets in patients with periodontal disease are literally deeper than those found in individuals with healthy periodontia. Such scaling and root planing may be performed using a number of dental tools, including ultrasonic instruments and hand instruments, such as periodontal scalers and curettes.

A dental hygienist demonstrates scaling

The objective for periodontal scaling and root planing is to remove dental plaque and calculus (tartar), which house bacteria that release toxins which cause inflammation to the gum tissue and surrounding bone. Planing often removes some of the cementum or dentine from the tooth.[1]

Removal of adherent plaque and calculus with hand instruments can also be performed prophylactically on patients without periodontal disease. A prophylaxis refers to scaling and polishing of the teeth in order to prevent oral diseases. Polishing does not remove calculus, but only some plaque and stains, and should therefore be done only in conjunction with scaling.

Often, an electric device, known as an ultrasonic scaler, sonic scaler, or power scaler may be used during scaling and root planing. Ultrasonic scalers vibrate at a high frequency to help with removing stain, plaque and calculus. In addition, ultrasonic scalers create tiny air bubbles through a process known as cavitation. These bubbles serve an important function for periodontal cleanings. Since the bacteria living in periodontically involved pockets are mainly obligate anaerobes, meaning unable to survive in the presence of oxygen, these bubbles help to destroy them. The oxygen helps to break down bacterial cell membranes and causes them to lyse, or burst.

Since it is of the utmost importance to remove the entirety of the deposit in each periodontal pocket, attention to detail during this procedure is crucial. Therefore, depending on the depth of the pocket and amount of calculus deposit versus soft biofilm deposit, hand instruments may be used to complete the fine hand scaling that removes anything the ultrasonic scaler left behind. Alternatively, power scalers may be used following hand scaling in order to dispel deposits that have been removed from the tooth or root structure, but remain within the periodontal pocket.

Two ultrasonic instruments

Sonic and ultrasonic scalers are powered by a system that causes the tip to vibrate. Sonic scalers are powered by an air-driven turbine. Ultrasonic scalers use either magnetostrictive or piezoelectric systems to create vibration. Magnetostrictive scalers use a stack of metal plates bonded to the tool tip. The stack is induced to vibrate by an external coil connected to an alternating current source. Ultrasonic scalers also include a liquid output or lavage, which aids in cooling the tool during use, as well as rinsing all the unwanted materials from the teeth and gum line. The lavage can also be used to deliver antimicrobial agents.

Although the final result of ultrasonic scalers can be produced by using hand scalers, ultrasonic scalers are sometimes faster and less irritating to the patient. Ultrasonic scalers create aerosols which can spread pathogens when a client carries an infectious disease. Research differs on whether there is a difference in effectiveness between ultrasonic scalers and hand instruments.[6][7] Of particular importance to hygienists themselves is that the use of an ultrasonic scaler may reduce the risk of repetitive stress injury, because ultrasonic scalers require less pressure and repetition compared to hand scalers.[8]

A new addition to the tools used to treat periodontal disease is the dental laser. Lasers of differing strengths are used for many procedures in modern dentistry, including fillings. In a periodontal setting, a laser may be used following scaling and root planing in order to promote healing of the tissues.[9]

After scaling

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Following scaling, additional steps may be taken to disinfect the periodontal tissues. Oral irrigation of the periodontal tissues may be done using chlorhexidine gluconate solution, which has high substantivity in the oral tissues. This means that unlike other mouthwashes, whose benefits end upon expectorating, the active antibacterial ingredients in chlorhexidine gluconate infiltrate the tissue and remain active for a period of time. However effective, chlorhexidine gluconate is not meant for long-term use. A recent European study suggests a link between the long-term use of the mouthrinse and high blood pressure, which may lead to a higher incidence of cardiovascular events. In the United States, it is available only through a doctor's prescription, and in small, infrequent doses it has been shown to aid in tissue healing after surgery. Current research indicates the irrigation of CHX after SC/RP may inhibit the re-attachment of periodontal tissues. Specifically preventing the formation of fibroblasts. An alternate irrigation with povidone-iodine may be used – if no contra-indications exist.

Site specific antibiotics may also be placed in the periodontal pocket following scaling and root planing in order to provide additional healing of infected tissues. Unlike antibiotics which are taken orally to achieve a systemic effect, site specific antibiotics are placed specifically in the area of infection. These antibiotics are placed directly into the periodontal pockets and release slowly over a period of time. This allows the medication to seep into the tissues and destroy bacteria that may be living within the gingiva, providing even further disinfection and facilitation of healing. Certain site specific antibiotics provide not only this benefit, but also reduce pocket depth. Arestin, a site specific brand of the antibiotic minocycline, is claimed to enable regaining of at least 1 mm of gingival reattachment height.

In cases of severe periodontitis, scaling and root planing may be considered the initial therapy prior to future surgical needs. Additional procedures such as bone grafting, tissue grafting, and/or gingival flap surgery done by a periodontist (a dentist who specializes in periodontal treatment) may be necessary for severe cases or for patients with refractory (recurrent) periodontitis.[10]

Patients who present with severe or necrotizing periodontal disease may have further steps involved in their treatment. These patients often have genetic or systemic factors that contribute to the development and severity of their periodontitis. Common examples include diabetes type I and type II, a family history of periodontal disease, and immunocompromised individuals. For such patients, the practitioner may take a sample from the pockets to allow for culture and more specific identification and treatment of the causative organism. Intervention may also include discontinuation of medication that contributes to the patient's vulnerability or referral to a physician to address an existing but previously untreated condition if it plays a role in the periodontal disease process.

Full mouth treatment

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The "traditional" debridement procedure involves four sessions spaced two weeks apart, doing one quadrant (one quarter of the mouth) each session. In 1995 a group in Leuven proposed doing the whole mouth in about 24 hours (two sessions).[11] When done using ultrasonic instruments this is called full mouth ultrasonic debridement (FMUD). The rationale for full mouth debridement is that quadrants that have been cleaned will not be reinfected with bacteria from quadrants that have not yet been cleaned. Other advantages of full mouth ultrasonic debridement include speed/reduced treatment time, and reduced need for anaesthesia, with equivalent results to scaling and planing. One study found that the average time to treat each pocket with full-mouth ultrasonic debridement was 3.3 minutes, whereas it took 8.8 minutes per pocket for quadrant scaling and root planing (SRP). Differences in improvement were not statistically significant.[12] Studies by the Leuven group, using somewhat different protocols, found that the one-stage treatment (i.e. in 24 hours) gave better results than the quadrant-by-quadrant approach (taking six weeks). They also had the patients use chlorhexidine for two months after the treatment.[13]

Depth of planing

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Another question in dental cleaning is how much cementum or dentine should be removed from the roots. Bacterial contamination of root surfaces is limited in depth, so extensive planing away of cementum – as advocated by traditional scaling and root planing – is not necessary to allow periodontal healing and the formation of new attachment.[14][7] In contrast to traditional scaling and root planing, the aim of some FMUD procedures is to disturb the bacterial biofilm within the periodontal pocket, without removing cementum.[12] Typically, root planing will require the use of hand instruments such as specialized dental curettes instead of the scaler tips used in FMUD to debride the root surface and periodontal pocket.

Evidence-based dentistry

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Several systematic reviews have been made of the effectiveness of scaling and root planing as evidence-based dentistry. A Cochrane review updated in 2018, considered only scaling and polishing of the teeth, but not root planing.[1] After examining two studies with 1711 participants, they concluded that routine scale and polish treatment for adults without severe periodontitis makes little to no difference for gingivitis, probing depths or oral health quality of life when compared to no scheduled care.[1] Oral hygiene instruction was found to help as well. Another inconclusive review of scaling and polishing (without planing) was published by the British Dental Association in 2015.[15]

An extensive review that did involve root planing was published by the Canadian Agency for Drugs and Technologies in Health in 2016.[16] It made a number of findings, including (1) In five randomized controlled trials, scaling and root planing "was associated with a decrease in plaque from baseline at one month, three months, or six months;" and (2) Four studies analyzed changes in the gingival index (GI) from the baseline and "found a significant improvement from baseline in the scaling and root planing group at three months and six months." This study also discussed evidence-based guidelines for frequency of scaling with and without root planing for patients both with and without chronic periodontitis. The group that produced one of the main systematic reviews used in the 2016 Canadian review has published guidelines based on its findings.[17] They recommend that scaling and root planing (SRP) should be considered as the initial treatment for patients with chronic periodontitis. They note that "the strength of the recommendation is limited because SRP is considered the reference standard and thus used as an active control for periodontal trials and there are few studies in which investigators compare SRP with no treatment." They add however that "root planing ... carries the risk of damaging the root surface and potentially causing tooth or root sensitivity. Generally expected post-SRP procedural adverse effects include discomfort."

Enamel cracks, early caries and resin restorations can be damaged during scaling. A study conducted in 2018 recommended that teeth condition and restorations should be identified before undergoing the ultrasonic scaling procedures.[18]

Effectiveness of the procedure

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A scaling and root planing procedure is to be considered effective if the patient is subsequently able to maintain their periodontal health without further bone or attachment loss and if it prevents recurrent infection with periodontal pathogens.[19]

The long term effectiveness of scaling and root planing depends upon a number of factors. These factors include patient compliance, disease progress at the time of intervention, probing depth, and anatomical factors like grooves in the roots of teeth, concavities, and furcation involvement which may limit visibility of underlying deep calculus and debris.

First and foremost, periodontal scaling and root planing is a procedure that must be done thoroughly and with attention to detail in order to ensure complete removal of all calculus and plaque from involved sites. If these causative agents are not removed, the disease will continue to progress and further damage will result. In cases of mild to moderate periodontitis, scaling and root planing can achieve excellent results if the procedure is thorough. As periodontitis increases in severity, a greater amount of supporting bone is destroyed by the infection. This is illustrated clinically by the deepening of the periodontal pockets targeted for cleaning and disinfection during the procedure. Once the periodontal pockets exceed 6 mm in depth, the effectiveness of deposit removal begins to decrease, and the likelihood of complete healing after one procedure begins to decline as well. The more severe the infection prior to intervention, the greater the effort required to arrest its progress and return the patient to health. Diseased pockets over 6 mm can be resolved through periodontal flap surgery, performed by a dental specialist known as a periodontist.[20]

Although healing of the soft tissues will begin immediately following removal of the microbial biofilm and calculus that cause the disease, scaling and root planing is only the first step in arresting the disease process. Following initial cleaning and disinfection of all affected sites, it is necessary to prevent the infection from recurring. Therefore, patient compliance is by far the most important factor having the greatest influence on the success or failure of periodontal intervention. Immediately following treatment, the patient will need to maintain excellent oral care at home. With proper homecare, which includes but is not limited to brushing twice daily for 2–3 minutes, flossing daily and use of mouthrinse, the potential for effective healing following scaling and root planing increases. Commitment to and diligence in the thorough completion of daily oral hygiene practices are essential to this success. If the patient fails to change the factors that allowed the disease to set in – for example, not flossing or brushing only once a day – the infection will likely recur.

The process which allows for the formation of deep periodontal pockets does not occur overnight. Therefore, it is unrealistic to expect the tissue to heal completely in a similarly short time period. Gains in gingival attachment may occur slowly over time, and ongoing periodontal maintenance visits are usually recommended every three to four months to sustain health.[21] The frequency of these later appointments is key to maintaining the results of the initial scaling and root planing, especially in the first year immediately following treatment.

Since the patient may still have pockets that surpass the effective cleaning ability of a brush or floss, for long-term success of their treatment they should return every 90 days in order to ensure that those pockets remain free of deposit. Patients should be counseled that 90 days is not an arbitrary interval; at 90 days, the healing made possible by the scaling and root planing will be complete. This will allow the practitioner to re-measure pocket depths to determine whether the intervention was successful. At this appointment, progress should be discussed, as well as any refractory periodontitis. At 90 days from the original scaling and root planing, the periodontal bacteria, if any remain, will have reached their full strength again. Therefore, if there are remaining areas of disease, the practitioner will clean them again, and may place more site-specific antibiotic. Furthermore, this appointment allows for the review of homecare, or necessary additions or education.

See also

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References

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Revisions and contributorsEdit on WikipediaRead on Wikipedia

Scaling and root planing

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from Grokipedia
Scaling and root planing is a non-surgical periodontal procedure designed to treat gum disease, specifically periodontitis, by removing plaque, tartar (), and bacterial toxins from the surfaces of teeth and below the gumline, while smoothing the root surfaces to promote healing and prevent reattachment of harmful . The procedure consists of two primary components: scaling, which involves scraping away hardened deposits of plaque and tartar from both supragingival (above the gumline) and subgingival (below the gumline) areas using specialized instruments such as curettes or ultrasonic scalers, and root planing, which meticulously smooths irregular or roughened root surfaces to eliminate bacterial harboring sites and facilitate the reattachment of healthy gum tissue. Performed typically by a , periodontist, or , it often requires to minimize discomfort and may span multiple appointments—usually one to four quadrants per visit—depending on the severity and extent of periodontal pockets. In some cases, adjunctive therapies like rinses or lasers may be incorporated to reduce , swelling, and bacterial load. This treatment is a cornerstone of nonsurgical periodontal therapy, targeting the infectious etiology of periodontitis, which affects approximately 42% of dentate U.S. adults aged 30 years or older, with severe forms impacting about 8%. By reducing gingival inflammation, shrinking periodontal pocket depths, and controlling bacterial proliferation, scaling and root planing helps prevent progressive bone loss, , and eventual , though long-term success relies on meticulous , regular professional maintenance, and addressing risk factors such as or . Common post-procedure effects include temporary tooth sensitivity, gum recession, or mild , which typically resolve within a week, but patients may require antibiotics or in more advanced cases.

Background

Definition and Purpose

Scaling and root planing (SRP) is a non-surgical periodontal procedure that involves the meticulous removal of plaque, (tartar), and bacterial toxins from both the surfaces and the structures beneath the gumline. This deep cleaning targets subgingival areas to address the underlying causes of , distinguishing it from superficial cleanings by extending into periodontal pockets where harmful deposits accumulate. The primary purpose of SRP is to eliminate infectious agents, thereby reducing gingival inflammation and pocket depths, while smoothing the root surfaces to facilitate the reattachment of periodontal tissues and halt progression. By removing these etiologic factors, the procedure promotes healing, decreases , and creates an environment conducive to gingival health, often serving as the cornerstone of non-surgical periodontal therapy for early to moderate cases.00334-7/fulltext) SRP originated in the mid-20th century as a foundational element of , evolving from manual scraping techniques to incorporate ultrasonic starting in the 1950s. This advancement allowed for more efficient removal of subgingival deposits, with widespread adoption by the 1970s enhancing its role in . Unlike routine supragingival prophylaxis, which focuses on above-the-gumline cleaning for preventive maintenance, SRP specifically addresses subgingival in areas with probing depths of 4 mm or greater, where plaque initiates deeper and tissue destruction.

Periodontal Disease Overview

is a chronic inflammatory condition primarily initiated by the accumulation of , a complex composed of , saliva-derived proteins, and food debris that adheres to surfaces. This forms through the adhesion of initial colonizers like streptococci to the acquired pellicle on enamel, followed by maturation involving diverse microbial embedded in an of host and bacterial polymers. If not disrupted by , plaque hardens into , providing a scaffold for further bacterial proliferation. The disease progresses in stages, beginning with , a reversible confined to the gingival tissues caused by supragingival plaque accumulation. This stage affects up to 90% of the and manifests as gingival redness, swelling, and bleeding, but without loss of attachment or bone support, allowing reversal through plaque removal. Untreated, it advances to periodontitis, characterized by irreversible destruction of the periodontal ligament and alveolar bone due to subgingival plaque and . In periodontitis, probing depths increase to form periodontal pockets (typically 4-12 mm), with clinical attachment loss exceeding 2 mm, leading to potential and loss if severe. At the core of this progression is the driven by bacterial invasion from the dysbiotic plaque , which shifts from symbiotic to pathogenic communities dominated by keystone pathogens like . These microbes invade gingival tissues and trigger a dysregulated host inflammatory response, involving neutrophils, cytokines such as interleukin-1 beta and tumor necrosis factor-alpha, and matrix metalloproteinases that degrade . This response promotes pocket formation, persistent gingival bleeding on provocation, and initial alveolar via activation, establishing a cycle of tissue damage and microbial persistence. Several risk factors uniquely contribute to the exacerbation of subgingival plaque buildup and severity in the context of conditions treatable by scaling and root planing. Poor directly enables plaque maturation and calculus formation below the gumline. impairs immune function and increases subgingival levels, elevating periodontitis risk by 5-20 times. , particularly when poorly controlled, heightens susceptibility through impaired activity and elevated inflammatory mediators, accelerating attachment loss. Genetic predispositions, such as polymorphisms in interleukin-1 genes, affect 10-15% of individuals and intensify host responses to subgingival . Scaling and root planing serves as the primary non-surgical intervention for moderate periodontitis to disrupt this pathogenic biofilm and mitigate progression.

Diagnosis and Indications

Clinical Assessment

Clinical assessment for scaling and root planing begins with a comprehensive evaluation of periodontal health to identify the extent of disease and guide treatment decisions. A key component is the measurement of probing depth using a calibrated periodontal probe inserted gently into the gingival sulcus around each tooth, typically at six sites per tooth, to determine the distance from the gingival margin to the base of the pocket. Probing depths of 3 mm or less are generally considered indicative of a healthy periodontium, while depths of 4 mm or greater may suggest early periodontal disease, and depths greater than 5 mm indicate more advanced disease progression. Additional clinical parameters provide further insight into disease activity and severity. , assessed immediately after probe insertion, serves as a marker of gingival , with a prevalence exceeding 10-20% often signaling active periodontitis. Clinical attachment loss is calculated by adding the probing depth to the extent of gingival recession (the distance from the to the gingival margin), quantifying the amount of periodontal support lost and helping to differentiate between gingival and periodontal issues. is evaluated using standardized indices, such as the Miller classification, where grade 0 denotes no detectable movement and higher grades (1-3) indicate increasing instability due to bone loss or . Radiographic evaluation, typically via full-mouth periapical or panoramic radiographs, assesses alveolar bone levels, identifying horizontal or vertical bone loss patterns that correlate with disease chronicity and extent. The 2017 classification system jointly developed by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) integrates these assessments to stage and grade periodontitis, facilitating standardized diagnosis. Staging ranges from Stage I (initial periodontitis, characterized by interdental clinical attachment loss of 1-2 mm and no tooth loss beyond crowding) to Stage IV (advanced, with extensive bone loss, significant tooth loss, and complex restorative needs), determined primarily by the most severe manifestations of probing depth, attachment loss, bone loss, and complexity factors like furcation involvement or vertical defects. Grading (A-C) evaluates progression risk based on indirect evidence such as bone loss relative to age and direct indicators like plaque and bleeding scores, influencing the urgency of interventions like scaling and root planing. A thorough review of patient history is essential to contextualize clinical findings and identify modifying factors. This includes documenting systemic conditions such as , , or , which can exacerbate periodontal or impair healing, as well as medications like antihypertensives or anticoagulants that may affect treatment planning. history and genetic predispositions are also noted, as they represent modifiable risk factors influencing disease susceptibility and response to therapy.

Treatment Indications

Scaling and root planing (SRP) is primarily indicated for patients with stage II periodontitis, characterized by probing pocket depths of 4 to 6 mm, the presence of subgingival deposits, and affecting more than 20% of sites. This non-surgical intervention targets disruption and root surface to halt disease progression in such cases, where diagnostic probing reveals attachment loss without extensive bone involvement. Relative contraindications or cautions for SRP include acute periodontal infections, such as abscesses, which require initial antibiotic therapy or drainage before ; and poorly controlled systemic conditions like , which may impair healing and necessitate medical consultation or stabilization prior to treatment. In these scenarios, adjunctive systemic antibiotics or referral for medical stabilization may be necessary to mitigate risks. Patient selection for SRP typically involves adults with periodontitis across stages I-IV, particularly those with probing pocket depths of 4 mm or greater, though advanced cases (e.g., Stage III or IV with pockets >6 mm) may require adjunctive therapies or subsequent surgical intervention if non-responsive. These criteria ensure SRP serves as an effective first-line therapy for disease stabilization without immediate need for more invasive procedures. Prognostic success of SRP is enhanced in non-smokers, who exhibit greater reductions in pocket depths and bleeding compared to smokers, and in patients demonstrating strong compliance with oral hygiene practices and follow-up maintenance. Factors such as smoking and non-compliance can reduce treatment efficacy by up to 50% in clinical attachment gain over 6 months.

Procedure Execution

Preparation and Anesthesia

Patient preparation for scaling and root planing (SRP) begins with a thorough review of the 's medical history to identify any contraindications or special considerations, such as cardiovascular conditions that may necessitate prophylaxis. For at high risk of , such as those with prosthetic heart valves or previous endocarditis, prophylaxis is recommended prior to SRP, as the procedure involves manipulation of gingival tissue that can induce bacteremia; the guidelines specify regimens like 2 grams of oral amoxicillin 30-60 minutes before the procedure for such cases. Additionally, receive instructions on optimal practices, including gentle brushing and flossing to minimize plaque accumulation and reduce before treatment, which helps improve outcomes in moderate periodontitis where deeper cleaning is indicated. Anesthesia is tailored to the depth of periodontal pockets and patient sensitivity to ensure comfort during SRP. For shallow scaling in mild cases, no anesthesia may be required, as the procedure causes minimal discomfort. Topical anesthetics, such as lidocaine-prilocaine gels applied intrapocket, are suitable for mild to moderate cases to reduce pain without injection, though they may not fully eliminate discomfort in deeper areas. For deeper pockets in moderate to severe periodontitis, local infiltration or block —typically using injectable agents like lidocaine with epinephrine—is preferred to provide profound numbness, significantly decreasing pain intensity and the need for supplemental anesthesia during root planing. SRP appointments are commonly scheduled in sessions lasting 1 to 2 hours per quadrant to manage patient fatigue, minimize discomfort, and allow for effective healing between treatments, as full-mouth procedures in one visit can lead to prolonged soreness. This quadrant-based approach divides the mouth into upper right, upper left, lower right, and lower left sections, often spacing sessions 1-2 weeks apart to optimize recovery. Informed consent is obtained prior to SRP, involving a detailed discussion of potential side effects to set realistic expectations. Patients are informed about expected sensitivity to temperature or sweets due to root exposure, gingival bleeding that may persist for a few days, and temporary aesthetic changes such as gum recession or increased length appearance, all of which typically resolve with time and maintenance. This process ensures patients understand the benefits of disease control against these transient risks.

Scaling Process

The scaling process in non-surgical periodontal begins with supragingival , where plaque, , and stains are removed from the visible surfaces above the gumline using manual or ultrasonic instruments to improve access and for subsequent subgingival work. This initial step helps expose the gingival margins and reduces surface debris that could interfere with deeper cleaning. Following supragingival scaling, the clinician proceeds to subgingival instrumentation by inserting specialized probes or scalers into the periodontal pockets, typically to depths of 4-6 mm or more, to dislodge and remove adherent , plaque biofilms, and bacterial endotoxins from the root surfaces. The primary goals of scaling are to eliminate supragingival and subgingival deposits that harbor , thereby disrupting the infectious environment and facilitating gingival , while also removing bacterial endotoxins embedded in rough root surfaces to minimize . with solutions, such as 0.12-0.2% , is often incorporated during or immediately after to flush out debris, reduce residual bacterial load in the pockets, and enhance the effect. may be administered to facilitate comfort and access during subgingival scaling, particularly in areas with deeper pockets or sensitivity. Scaling is typically performed quadrant by quadrant, with each session lasting 45-60 minutes to ensure thorough debridement without rushing, and sequencing often starts from posterior teeth (molars and premolars) and progresses anteriorly (canines and incisors) to optimize operator and patient tolerance. Clinicians rely on tactile feedback from instrument tips to detect through characteristic "stickiness" or ledges on root surfaces, guiding precise removal while avoiding over-instrumentation that could damage healthy or exacerbate pocket depths.

Root Planing Process

Following the scaling phase, which removes the bulk of supragingival and subgingival plaque and deposits, root planing targets the root surfaces to eliminate irregular layers embedded with bacterial toxins and pathogens. This step involves systematically planing the root to create a smooth, hard surface that resists future plaque adhesion and supports periodontal healing. The procedure is typically performed under in affected areas, with the working systematically around the to address all sites. Planing extends to a depth of 1-2 mm below the level of the epithelial attachment to ensure removal of diseased tissue while minimizing excessive or removal, which can increase the risk of root sensitivity and . Clinicians monitor the extent of planing to preserve viable structure, focusing on areas with probing depths greater than 4 mm where irregular surfaces are most prevalent. To verify the effectiveness of root planing, periodontal explorers are employed to tactilely assess root smoothness, detecting any residual calculus or roughness that requires additional . Follow-up probing measurements are then conducted to evaluate clinical improvements, such as depth reduction, often at a re-evaluation appointment 4-6 weeks post-procedure. The biological rationale for root planing lies in transforming the root surface into one that is biocompatible, enabling gingival fibroblasts to migrate and attach more effectively, which promotes healing and new attachment formation. This smoothing reduces the surface area for bacterial recolonization and typically achieves an average depth reduction of 1-2 mm, contributing to overall periodontal stability.

Techniques and Variations

Instruments and Tools

Manual instruments for scaling and root planing primarily include scalers and curettes, designed to mechanically remove and plaque from surfaces. scalers, characterized by a hooked with double-cutting edges, are typically used for supragingival removal due to their ability to access interproximal areas efficiently. Curettes, finer instruments with a rounded toe and single- or double-cutting edges, are employed for subgingival and root planing; Gracey curettes, for instance, feature angled blades offset at 70 degrees for adaptation to specific surfaces, such as mesial or distal aspects, enhancing precision in deep pockets. Powered tools, particularly ultrasonic scalers, facilitate efficient disruption of through high-frequency vibrations. These devices operate via magnetostrictive or piezoelectric mechanisms: magnetostrictive scalers produce elliptical tip movements at frequencies of 18 to 45 kHz, while piezoelectric models generate linear vibrations at 25 to 50 kHz, allowing for varied power settings to minimize surface damage. Tips for these scalers vary in —such as universal or area-specific—for both supra- and subgingival applications, with slim designs preferred for deep periodontal pockets to reduce tissue trauma. Adjunct instruments support the procedure by aiding assessment and finishing. Periodontal probes, thin and calibrated, measure pocket depths to guide during scaling and root planing. Air polishing units, using a of air, water, and abrasive powder like or , provide a final supragingival polish to remove stains and remnants without excessive abrasion. Maintenance of these instruments is essential to ensure efficacy and prevent cross-contamination. Manual tools like curettes and scalers require cleaning, sharpening, and sterilization via autoclaving at 121–134°C for 15–30 minutes, following CDC guidelines for heat-stable . Ultrasonic scaler tips, prone to wear, necessitate regular inspection and replacement after 20–50 uses or when dullness affects performance, with disposable options available to minimize infection risk.

Treatment Approaches

Scaling and root planing (SRP) can be delivered through various approaches tailored to needs and presentation, with the traditional quadrant approach serving as the standard method. In this protocol, treatment is performed on one oral quadrant per visit, typically spanning four sessions over 4 to 6 weeks, which permits gingival and reduces discomfort between appointments. This staged method minimizes systemic bacteremia risk and allows for progressive assessment of treatment response. An alternative is full-mouth disinfection (FMD), a more intensive protocol introduced in the , where all surfaces are scaled and planed within 24 hours or over one week, often combined with adjunctive antimicrobials such as rinses or local applications to eradicate bacterial reservoirs throughout the oral cavity. The aim is to disrupt the periodontal comprehensively in a single phase, potentially enhancing short-term microbiological outcomes by preventing cross-contamination between treated and untreated sites. Clinical studies indicate FMD yields comparable or slightly superior initial reductions in probing depths and bleeding compared to quadrant therapy, though long-term benefits are similar. Laser-assisted SRP represents an emerging adjunctive technique, employing or Er:YAG lasers to target subgingival and while minimizing mechanical trauma. lasers (typically 810-980 nm) provide photodynamic antimicrobial effects, whereas Er:YAG lasers (2940 nm) enable precise of root surfaces due to their ablative properties on hard tissues. Systematic reviews show mixed for superiority over conventional SRP alone, with some short-term gains in pocket reduction and bacterial load but no consistent long-term advantages, and potential risks like thermal damage if not properly calibrated. Selection of the approach depends on factors such as disease severity, patient , and systemic . The quadrant method is preferred for patients with low pain thresholds or localized disease, allowing incremental treatment and monitoring. In contrast, full-mouth protocols suit cases of aggressive or generalized periodontitis, aiming to rapidly reduce overall bacterial burden and prevent reinfection across sites. Laser assistance may be considered for adjunctive use in patients seeking minimally invasive options, though it requires specialized equipment.

Post-Procedure Management

Immediate Aftercare

Following scaling and root planing (SRP), patients commonly experience tooth sensitivity to temperature and touch, gingival bleeding, swelling, and temporary changes in periodontal pocket depths due to resolution. These effects typically peak within 24 to 48 hours post-procedure and subside over the following days to weeks, with pain often most intense between 2 and 8 hours after treatment and tenderness lasting a few days. A full-mouth treatment approach may result in less perceived discomfort compared to quadrant-wise methods, according to a 2025 . To manage these effects, patients should follow a soft diet for the first 24 to 48 hours, opting for items like , soups, or smoothies while avoiding hot, spicy, acidic, crunchy, or hard foods that could exacerbate or sensitivity. Patients should also avoid staining beverages, such as coffee, tea, red wine, fruit juices, and fruit teas, for the first 24 hours to prevent temporary tooth discoloration. However, fruit teas can still serve as an effective hydrating beverage, as they consist primarily of water and contain little or no caffeine, providing hydration similar to plain water. Over-the-counter analgesics such as ibuprofen can help control and swelling, and dentists may prescribe desensitizing agents like gels or potassium nitrate-based products to alleviate tooth sensitivity. Additionally, prescribed medications, including antimicrobial mouth rinses or subantimicrobial-dose inserted into pockets, may be recommended to prevent and promote healing. Oral hygiene should be modified during the initial recovery period to minimize trauma to treated tissues: use a soft-bristled for gentle brushing twice daily, avoiding vigorous pressure in sensitive areas, and incorporate daily interdental cleaning with floss or interdental aids once subsides. For 1 to 2 weeks, antimicrobial rinses such as gluconate (0.12%) should be used as directed, typically twice daily for 30 seconds, to reduce bacterial load and support gingival healing without disrupting the oral excessively. Warm saltwater rinses (½ teaspoon salt in 8 ounces of ) can also provide soothing relief and aid in plaque control, performed 2 to 3 times daily. A follow-up is essential, typically scheduled at 4 to 6 weeks post-SRP, to assess gingival , measure reductions in depths, monitor for persistent sensitivity or , and adjust ongoing care as needed.

Long-Term Maintenance

Following scaling and root planing (SRP), long-term maintenance through supportive periodontal therapy (SPT) is essential to preserve the initial benefits, such as depth reduction, and prevent progression. This involves regular professional interventions tailored to individual risk factors, typically consisting of cleanings every 3 to 6 months to remove plaque and accumulation that could lead to reinfection. These recall visits may include selective re-planing of residual deposits in deeper pockets, as determined by clinical assessment, to maintain periodontal stability over years. Patient education plays a central role in sustaining shallow pocket depths achieved post-SRP, emphasizing consistent home care practices. Daily flossing is recommended to remove interdental plaque, complemented by twice-daily brushing using an for more effective plaque control compared to manual methods. Smoking cessation is particularly critical, as tobacco use impairs gingival healing and increases recurrence risk, with patients advised to quit to enhance long-term outcomes. Ongoing monitoring during appointments ensures early detection of recurrence, typically involving annual full-mouth probing to measure depths and attachment levels for signs of progression. Radiographs, such as full-mouth series or bitewings, are also performed annually in moderate- to high-risk cases to evaluate bone levels and support clinical findings. The American Academy of Periodontology recommends an annual comprehensive periodontal evaluation incorporating these elements to assess overall health and adjust the maintenance plan accordingly. For high-risk patients, such as those with aggressive disease or systemic factors like , adjunct therapies may be incorporated into to further inhibit progression. Systemic antibiotics can be prescribed selectively for acute exacerbations or persistent sites, while host modulation agents like low-dose (20 mg subantimicrobial dose) target inflammatory pathways by inhibiting matrix metalloproteinases, reducing tissue breakdown without promoting resistance. These approaches are used judiciously alongside mechanical therapy to optimize outcomes in susceptible individuals.

Effectiveness and Evidence

Clinical Outcomes

Scaling and root planing (SRP) typically results in an average reduction of probing pocket depths by 1-2 mm, particularly in moderate pockets of 4-6 mm, with deeper pockets showing somewhat greater absolute reductions but often leaving residual depths. is commonly decreased following treatment, reflecting reduced gingival . SRP often halts further attachment loss in treated sites, contributing to periodontal stability. Success rates are higher in shallow to moderate pockets (≤6 mm), where clinical improvements such as pocket reduction and attachment gain are more predictable. However, efficacy diminishes in deep pockets greater than 7 mm, where residual disease often persists and adjunctive therapies like antibiotics or may be required for optimal results. Smokers experience poorer outcomes, with reduced pocket depth reductions and higher rates of disease progression compared to non-smokers, necessitating additional interventions. Patient-reported outcomes include reduced halitosis due to decreased bacterial load and improved from healthier . Temporary sensitivity to or stimuli may occur post-treatment, affecting comfort in some cases. These benefits are best preserved through regular maintenance to prevent recurrence.

Research Findings

A landmark review by Cobb synthesized evidence from multiple clinical trials, demonstrating that scaling and root planing (SRP) is superior to no treatment in reducing probing pocket depths and gaining clinical attachment levels in patients with . This analysis highlighted SRP's role in achieving biologically compatible root surfaces and reducing bacterial biofilms, with mean pocket depth reductions ranging from 1.0 to 2.0 mm across studies. Updates from the American Academy of Periodontology (AAP) in recent years have reaffirmed SRP's efficacy, particularly when combined with adjunctive antimicrobials, showing enhanced reductions in and depths compared to SRP alone. For instance, local antimicrobials as adjuncts to SRP have been associated with additional depth reductions of approximately 0.4 mm and improved clinical attachment gains in moderate to deep sites. Systematic reviews, including a key meta-analysis, have confirmed that SRP results in approximately 0.5 mm greater clinical attachment level gain compared to control treatments. This evidence underscores SRP's consistent benefits in non-surgical periodontal therapy for stage II and III periodontitis, with sustained outcomes observed up to 12 months post-treatment. Long-term studies indicate that SRP, combined with regular maintenance, can reduce the risk of by 50-60% over 5-10 years. Emerging research from 2025 has explored laser-assisted SRP, reporting marginal improvements in reducing bacterial load in subgingival pockets but no significant additional gains in clinical attachment levels over conventional SRP. For example, studies on and Nd:YAG lasers as adjuncts showed enhanced microbiological outcomes, such as decreased levels of periodontal pathogens, yet attachment gains remained comparable to traditional methods. Professional guidelines from the (ADA) and the European Federation of (EFP) endorse SRP as the standard non-surgical therapy for stage II periodontitis, supported by Level A evidence indicating high predictability in pocket reduction and disease stabilization. These recommendations emphasize SRP's stepwise integration in initial periodontal management, with strong consensus on its efficacy for moderate disease severity.

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