Scaling and Root Planning(SRP)

WHY ARE WE REMOVING

PLAQUE?

BECAUSE PLAQUE IS

Biofilm( that is sticky and cant easy to remove bynormal motions of oral tissues)

Including many of microorganisms( bacteria, fungus,viruses etc.)

That a place easily growing all of microorganisms( water, food, O2)

Facilitate the growing and adhering other bacteria etc.

Transforming and producing calculus

Why Antibiotic is useless for

plaque?

Antibiotics are ineffective because the dormant bacteria at the heart of the film are unaffected by the antibiotics targeting rapidly multiplying DNA.

When the danger has passed, they reanimate and build another biofilm, or join one already in progress.

They grow quietly and then symptoms start to accumulate once more.

In addition to this antibiotics cant enter into the biofilm. The biofilm is never really destroyed. The survivors are altered, and a new antibiotic must be used.

Scaling: is the process by which plaque and calculus are removed from both supra- and sub-

gingival tooth surfaces.

Root planning: is the process by which residual calculus and portion of cementum are removed

from the roots to produce a smooth, hard, clean

surface.

Scaling and root planning known as conventional

periodontal therapy, non-surgical periodontal therapy,

deep cleaning, or dental prophylaxis

Scaling and root planning are not separable procedures

All the principles of scaling apply equally to root

planning ,the only difference between them is matter of

degree ,since the nature of tooth surface determines the

degree to which the surface must be scaled.

When plaque and calculus form on enamel ,thedeposite are usually superficially attached to the

surface and are not locked into irregularities. In

such situations scaling alone is sufficient to

remove plaque and calculus completely from

enamel ,leaving a smooth ,clean surface .

While when dentine is exposed ,plaque bacteriamay invade dentinal tubules, therefore scalingalone is insufficient to remove them ,and a portionof root surface must be removed to eliminate thesedeposite.

Scaling and Root Planning are a prerequisite for the arrest and cure of

periodontal disease; together with plaque control,

they constitute the major means by which the

disease is prevented.

Careful subgingival scaling and root planning isan effective mean to eliminate gingivitis and reduce

the probing depth even at sites with initially deep

periodontal pockets.

Changes in root surfaces in

periodontitis

A.Plaque And Calculus Deposition.

Supra and subgingival

calculus have a rough surface capable of

harboring plaque that

cannot be removed by conventional oral

hygiene techniques.

Changes in root surfaces in

periodontitis

B. Alterations in exposed cementum

1. Hypermineralized surface zone

2. Changes in organic matrix

3. Endotoxins cytotoxic in tissue culture

Primary objectiveRestoration of gingival health

Subgingival scaling and root planning

are measures which can be effective in:

Eliminating inflammation

Reducing probing depths

Improving clinical attachment

Objectives of Root Planning

1. Securing biologically acceptable root surfaces

2. Resolving inflammation

3. Decreasing pocket depth

4. Facilitating oral hygiene procedures

5. Improving or maintaining attachment level

6. Preparing the tissues for surgical procedures

Rationale for root planning

Root Smoothness

Removal of Diseased Cementum

Preparation for New Attachment

Scaling and root planning has both local and

systemic effects.

Locally, the results of scaling and root planning are:

1) Debridement of bacteria and calculus

2) Removal of infected cementum and dentin

3) A shift in the microbial population

Scaling and rootplanning are not always

the only measures that

are required in order to

properly eliminate

subgingival infection in

deep pockets.

If, following scaling androot planning, signs of

bleeding on probing to

the bottom of the

pocket persist, and if

the clinical attachment

level fails to improve,

surgical therapy should

be considered since this

treatment may facilitate

more adequate root

debridment .

After thorough scaling and root planning , a

dramatic reduction in the number of subgingival

microorganisms with a shift in the composition of

subgingival plaque from high numbers of gram()

negative anaerobes to gram (+) positive facultative

bacteria compatible with health.

Gram () anaerobes Gram(+) facultative

The microbial shift is effected by two mechanisms

1.The removal of bacteria by scaling and root planning

2.The clinical outcome of scaling and rootplanning which alters the environment favoringpopulation by certain bacteria over others

A. Decreased pocket depth

B. Smooth root surfaces

C. Reduction of inflammation

Scaling and root planning also

has systemic effects. These are a

bacteremia and a host immune

response

Incidence of Bacteremia During Different Dental

Procedures Heimdahl, et al., 1990

Surgical

Procedure

% of Patients

with

Bacteremia

%Viridans

group

streptococci

%

Anaerobes

Dental

Extraction100 85 75

Scaling and

Root Planing70 55 65

Third Molar

Surgery 55 40 45

Endodontic

Treatment 20 15 5

Bilateral

Tonsillectomy 55 40 40

Based on this study it can

be seen that immediately

after undergoing scaling

and root planning the

majority of patients (70%)

will have a bacteremia.

The same study also

showed that ten minutes

after the procedure, the

incidence of bacteremia is

down to 30%.

This indicates that the host

immune response is

effective in eliminating the

bacteria from the

bloodstream, resulting in

the rapid decline in the

recovery of bacteria. For

this reason, it is referred to

as a transient bacteremia.

The endpoint of clinical therapy is the elimination of

inflammation. To achieve this, open debridement may be

required in addition to scaling and root planning, and

treatment may be aided by chemotherapeutic agents.

The dentist should estimate the number

of appointments needed on the basis of

:

1.The number of teeth in the mouth

2.Severity of inflammation

3.Amount and location of calculus

4.Depth and activity of pocket

5.Presence of furcation invasions

6.Patients understanding of compliance with oral hygiene instructions

7.Need for local anesthesia

Supragingival Scaling Technique:

Supragingival calculus is generally less tenacious and

less calcified than subgingival calculus ,Instrumentation is

performed coronal to the gingival margin ,so scaling stroke

are not confined by surrounding tissue.

this :

Makes adaptation and angulation easier,

Allows direct visibility and Allow freedom of movement

Subgingival Scaling And Root Planning Technique:

Subgingival calculus is usually harder than supragingival calculus and

is often locked into root irregularities ,making it more tenacious and

therefore more difficult to remove .

Vision is obscured by the bleeding that occurs during instrumentationand by the tissue itself ,so the clinician must rely heavily on tactile

sensitivity to detect calculus and irregularities ,also must form a

mental image of the tooth surface.

The curette is preferred by most clinicians for subgingival scaling and

root planning because of the advantages afforded by its design and

ultrasonic instruments also are used for subgingival scaling of heavy

calculus

Methods of Scaling:

1. Manual scaling - used hand scalers for removing

supragingival calculus (sickle, chisel, hoes, curettes).

2. Sonic scalers - are air-turbine units that operate at lowfrequencies ranging between 2000-6000 cycles per

second, with a vibratory-type tip movement.

3. Ultrasonic scaling are currently available in 2 basic

types- magnetostrictive and piezoelectric, which differ

in their mechanism of action.

Sickle scalers

Is primarily used for supra-gingival calculus

removal.

There are two types:

Anterior, with blade designed in mon-angle form. It

used for scaling dental calculus of anterior teeth.

Posterior, with blade designed in bin-angle (two)

form that permit access between premolars and

molars.

Sickle scalers

Technique:

Both types of the sickle scalers used the movement

of pushing and traction the blocks of supra-gingival

calculus

Chisel scalers

Used in the anterior part of the mouth.

Designed for proximal surface of theteeth.

Position of the instrument is at the longaxis of the tooth.

Removing the calculus is made bypulling, traction movements to occlusalsurface or marginal edge

Chisel scalers

Hoe scalers

The blade is bent in 99-100 degree,the cutting edge is

beveled at 45 degree,

They are used in anterior teeth.

They are indicated for removing the supra- and sub-

gingival calculus

Position of the instrument is at the long axis of the

tooth by pushing and traction movements to dislodge

the calculus.

Classification of Curettes

1. Universal curettes:

1. One curettes is designed for all areas and

surfaces.

2. The face of the universal curettes blade

beveled to 90 degrees to the lower shank.

3. Curved in one plane.

Classification of Curettes2. Specials (Curettes Gracey)

are a set of area-specific instruments that were designed by Dr.

Clayton H. Gracey of Michigan

They are area specific: there are 7 pairs of curettes in the set:

#1-2 and 3-4 are used on anterior teeth.

#5-6 are used on both anterior teeth and premolar teeth.

#7-8 and 9-10 the facial and lingual surfaces of posterior teeth.

#11-12 for mesial surfaces of posterior teeth.

#13-14 for distal surfaces of posterior teeth.

Only one cutting edge on each blade is used, work with outer edge only.

Ultrasonic Scaler

1. Magnetostrictive (e.g. Dentsply, Cavitron, Odontosson).

Inside the hand-piece a live coil generates analternating electromagnetic field that leads to

expansion or contraction of the ferromagnetic

material.

The resulting vibrations are conducted to thescaler tip, causing oscillation at frequencies of

20,000 Hz to 45,000 Hz.

Ultrasonic Scaler

2. Piezoelectric scalers (e.g. Amdent, EMS Piezon master, Satellec Suprasson.)

Oscillate with frequencies of 20,000 to 45,000 Hz.

The vibration is generated by changes in dimension of a quartz crystal caused by the application of an alternating current.

The resulting oscillation mode of the piezoelectric scaler tip is linear.

Indications of Ultrasonic

Scaler:

1. Supra-gingival and sub-gingival calculus and periodontal

pockets.

2. In initial phases of chronical gingivitis and superficial

periodontitis.

3. Necrotizing ulcerative gingivitis and gingivostomatitis.

4. In haemolitic patients and in acute periodontitis with

increased bleeding, because of less traumatic lesion when

we use ultrasonic scaler than manual instrumentation.

5. Colored spots on the enamel surface.

Contraindications of Ultrasonic

Scaler1. Should not used when treating patient with

transmissible diseases.

2. Patients with excessive vomiting reflex.

3. Pronounced dentin hyperesthesia.

4. In small children

5. Patients with a cardiac pacemaker.

6. Patients at risk for respiratory disease.

Advantages of Ultrasonic

Scaling:

1. Modern, ergonomically, efficient scaling.

2. Atraumatic action on tooth surfaces and gingiva.

3. Removal of pigmented deposits from the tooth

surfaces.

4. Well supported, painless to patients.

5. Ultrasonic instrumentation is accomplished with a

light touch and light pressure.

Disadvantages of Ultrasonic

Scaling:

1. Strong vibrations applied for too long can cause

dislocation of the enamel.

2. Strong vibration can disrupt the junction epithelium.

3. Under the action of vibrations the scaler can dislocate

the metal filliings and composite materials from the

tooth.

4. The hyperesthesia pains sometimes can be intolerable

(unpleasant for patietns).