Board Certified Periodontist

12 – Thoughts about Scaling and Root Planing

Let’s talk about scaling and root planing but do it a little differently.

You already know what it is and you know how you do it – what works and doesn’t work for you. All I really can do to help you is to give you a few, possibly, new thoughts on the subject.

This is the Perio Hygienist Podcast – a podcast centered on the intersection between the specialty of periodontics and the profession of dental hygiene. My name is Dr. Ben Young. I’m a practicing periodontist in San Antonio, Texas.

First, why such a long term for something? Scaling and Root Planing? It has always seemed a bit clumsy to me, but it is supposed to mean something useful when talking to patients. That’s the reason and so I will accept this. Deep cleaning is another term, but this one is less specific. Not sure I care for it. Non-surgical therapy? Perhaps, but this is actually just telling patients that at least it’s not surgery. This builds problems for patients who may need both. If you have good ideas in this area, let me know.

Basically, scaling is the removal of calculus or tartar – hard deposits that have attached to the surface of the root.

Scaling is a part of the prophylaxis for anatomically intact teeth. Pocket depths are less than three millimeters and the calculus is attaching at the CEJ and coronally.

Root planing implies periodontal disease, not just exposed root surface. It is intentional and involves altering the root surface – smoothing it. This means it is a clinical error to root plane in the absence of a diagnosis of periodontal disease.

So, what is periodontal disease? Is it pocket depth beyond three millimeters? Is it even bleeding upon probing?

Obviously, a patient who has not been in a dental office who has pockets and bleeding can correctly be diagnosed as having periodontal disease. This isn’t the case with maintenance patients, otherwise we can never establish a level of health following a round of periodontitis ever.

So what would be the problem with repeat scaling and root planing at every appointment? I think we know the answer to this. Over time roots can be reshaped dramatically. Also there is the problem with sensitivity. Also, intense root instrumentation doesn’t cure the disease. In other words, there is a cross-over point where further root instrumentation simply adds to the patient’s problems rather than correcting them.

So let’s back up a bit and think about initial scaling and root planing compared with repeat scaling and root planing. The initial round with the accumulation of deposits that have formed sometimes over years of time should be qualitatively different compared with a procedure where a patient is consistently returning for care. What they mostly have in common are the insurance code and instruments used for both situations.

Let’s talk about the second situation first because it fits with our general topic here, supportive periodontal therapy.

But before we go there – as an aside, let me say that if I were King of Perio and could establish how students are clinically taught about periodontal disease and patient care, I would begin with students seeing supportive care patients before ever introducing them to patient with active disease. This would be to help them understand what health looks like following a destructive disease. I would want students to be able to learn and understand what a periodontally stable periodontal patient looks like and what recurrent problems look like as well. OK, now back to talking about scaling and root planing in supportive periodontal patients.

In an earlier podcast we talked about how brief the treatment phase of a supportive periodontal appointment should normally or routinely be. It is the use, in my opinion, of a slim-line ultrasonic tip being inserted into pockets in order to gently, at low power setting, flush out the pocket and disrupt the plaque the patient is unable to reach on a daily basis regardless the procedures they have been instructed to perform. This light instrumentation procedure follows the periodontal charting where we can see that pockets are stable in depth and bleeding is low and random.

Over time, however, we can expect that the bleeding index will begin to rise. Why might this be? My simple answer is that eventually plaque disruption alone is not enough because plaque re-attaches to the root and mineralizes into a granular surface. If untreated long enough, this would grow and eventually the patient would be back to where they started.

But let’s not go there. Instead, what might be the first steps to lower the bleeding index back down (which is our way of describing soft tissue inflammation) in our SPT patients?

My first step is to look at the interval of care.

Is it three months?

If it is longer than this, we might inform the patient that problems are beginning to develop, and it would be a good idea to see them again in three months. The same ultrasonic procedure is performed and three months later another periodontal charting is accomplished. If the bleeding index has not adequately lowered hopefully to the patient’s normal baseline, then root planing is a good next step. If it has, perhaps their interval can be stretched once again. Let’s try not to over-analyze apart from real patients and real findings.

What about antibiotics?

This, in my opinion, is a big gun. Also, if the roots are rough, plaque will quickly reattach once again – which means the antibiotic effect will be short-lived.

So what might root planing look like?

First of all, unlike initial scaling and root planing where I always anesthetize with a local anesthetic, this procedure can possibly be accomplished with a little topical anesthetic or no anesthetic at all. It is the light removal of the roughened surface with a sharp curette. The specific instrument type and shape is beyond the scope of this podcast because it depends upon the area being treated. However, this is what I can say here. Too much pressure and a sharp edge will gouge the root. Try not to do this. Also, a great exercise is to take a plastic pen or any other small round object that can represent the root as being a convex surface. Next, with a sharpie marker, color over an area of about a half-inch all the way around. Once it has quickly dried, put the edge of whatever curette or scaler you choose and pull up once.

What surprised me when I did this was how small the line is in thickness. Before doing this, I thought the width would have been wider than it actually is. But it makes sense that it would be thin because the being planed is not flat.

So what can be learn from this?

First, it will take a lot of instrumenting up and down and moving the instrument to cover the surface of the root.

Second, we will likely leave some of the surface untouched. This is consistent with studies on this subject – that calculus is rarely completely removed – and to attempt to do so may be at a price of removal of a lot of root surface not to mention a lot of unnecessary soft tissue injury.

Third, because we know that some calculus will be left behind, and yet the area will most likely improve, we can accept that it is not completely necessary to remove everything in order to obtain a reasonable clinical response. This is not to say we can be sloppy with this procedure. Root planing poorly done will show minimal if any positive response.

Forth, this helps us understand the benefit of using more than one instrument in the area being root planed in order to change the rake angle. Sometimes we can change the rake angle of the same instrument. The point is, that different instruments moving in different directions on a surface aide in best planing results.

And, again, if I were Perio King, this is the first type of instrumentation I would teach students. Light surface planing.

Once this technique is mastered, then the next step would be to introduce scaling methods – the removal of heavy calculus first in health and finally in periodontal patients.

Finally, for this discussion today, let’s address how we know when we have root planed enough.

If we can achieve a smooth surface, then that’s a good time to stop. But what if, after spending a reasonable amount of time and different instruments we are not completely happy with how the root feels? Then I recommend stopping and annotating the record that this area still feels rough or odd or that smoothness was not completely achieved.

The ultimate determination as to whether or not scaling and root planing has achieved its intended results will not come on the day the procedure was performed. This is because we need to see the soft tissue response to the procedure. We need a healing phase. Four to six weeks is a good interval to see this. This is when a new periodontal charting will be accomplished. Also it is important to record bleeding sites. This is more than just calculating the bleeding index. We need to know what is happening specifically site by site.

If a smooth surface is still bleeding and the pockets are unchanged or deeper (and we are talking about abnormally deep pockets, not three millimeters and less) then the problem persists in spite of the root planing procedure.

On the other hand, if the surface documented to have been rough in spite of our best attempt to smooth last time, shows reduction in probing depth and no longer bleeds, then the body liked what we did and this then means our procedure was successful.

If we understand this, then it means that the scaling and root planing procedure can be accomplished in a schedulable amount of time based on our experience level and that spending more time to further instrument difficult areas may be unwise. On the other hand, if at the reevaluation visit, there are sites that we now see we can improve or because soft tissues have tightened we now begin to see exposed dark flecks of subgingival calculus, it is appropriate to repeat instrumentation at this point. I would not charge again for this personally. Rather I would consider this a normal part of the scaling and root planing procedure the patient has already paid for.

That’s it for today. Please let me know if you have questions or comments. Thanks for listening.