root planing/ root debridement, instrumentation,

1. ROOT
PLANING

2. • Marginal periodontitis is induced by bacterial
plaque deposits and maintained by
subgingival plaque and calculus present on
root surfaces.
• Therefore therapy of periodontally involved
teeth is primarily directed towards removal of
these accretions from root surfaces in order to
allow for healing.

3. Non surgical therapy
Non surgical therapy is defined as “plaque removal,
plaque control, supra and sub gingival scaling, root
planing and the adjunctive use of antibiotics.”
(Ciancio 1989,1992)

4. Scaling is the process by which plaque
and calculus are removed from both
supragingval and subgingival tooth
surfaces .

5. Root planing: instrumentation to remove the
microbial flora on the root surface or lying free in
the pocket, all flecks of calculus and all
contaminated cementum and dentin.( O Leary,
1977)

8. • DCNA
Meticulous instrumentation of the cemental surface
of the root during periodontal treatment for the
purpose of removing all the dental
accretions(calcified and noncalcified) to render the
surface biologically clean and clinically smooth

9. CLOSED DEEP SCALING
ROOT SURFACE
DEBRIDEMENT
ROOT SURFACE
INSTRUMENTATION
ROOT
DETOXIFICATION

10. ROOT SURFACE DEBRIDEMENT OR
ROOT SURFACE INSTRUMENTATION
Debridement of the root surface with only few
strokes, and not to undertake aggressive
instrumentation to remove the endotoxin and
other root surface irregularities

11. • This term has appeared recently in the literature to
better describe periodontal instrumentation
associated with periodontal therapy.
• “the treatment of gingival and periodontal
inflammation through mechanical removal of tooth
and root surface irritants to the extent the adjacent
soft tissues maintain or return to a healthy , non
inflamed state”

12. SCALING ROOT PLANING PERIODONTAL DEBRIDEMENT
Removal of calculus from all tooth
surfaces and removal of cementum from
root surfaces
Removal of plaque biofilms and
calculus from tooth surface and within
the pocket space
Aggressive instrumentation removes
significant amounts of cementum
Conservation of cementum is a goal;
bacterial products are removed with
ultrasonic instruments or light
instrumentation strokes
Hand activated instrumentation A combination of hand activated and
ultrasonic instrumentation preferred

13. CLARITY OR CONFUSION- BEST WAY TO DEBRIDE ROOT
SURFACES
• “Root planing implies removal of cementum
(and possibly dentine) exposed within the
pocket to maximise the chance of removing all
components of the subgingival plaque....
• Subgingival scaling is the removal of deposits of
subgingival calculus
• “....in reality the procedures are similar and the
term ‘root surface debridement’ is often used
as a more generic term.”
• Subgingival Plaque Control - The Clinician( BDJ)

14. RATIONALE OF ROOT
PLANING
REMOVAL OF DISEASED
CEMENTUM
GLASSY SMOOTH
TOOTH SURFACE
NEW ATTACHMENT

15. Stripped of periodontal
attachment
Contains remnants of embedded
calculus, whole bacteria, and the
products of microbial life.
Exposed to septic contents of
periodontal pocket
DISEASED/ALTERED/NECROSED
CEMENTUM

16. CHANGES IN DISEASED
CEMENTUM
STRUCTURAL
CHANGES
• Hypermineralization/
Demineralization
• Presence of
pathological granules
CHEMICAL
CHANGES
• Changes in conc of Ca,
Mg, Phosphate
• Adsorption from
saliva
CYTOTOXIC
CHANGES
• Adsorption of
endotoxins
• Invasion of bacteria
• Cell mediated
resoption lacunae

17. • Polson and Caton( 1982)
Role of reduced Periodontium and altered root surface
Role of altered root surface on wound healing
Experimental Periodontitis
Rhesus monkey
Block sections of periodontium evaluated after 40 days

18. • RESULTS
No new CT attachment . pathologically
altered root surface although placed in
healthy periodontium
• CONCLUSION
pathologically altered root surface rather
than reduced periodontium – prevented
regeneration

19. ENDOTOXINS
• THE MOST COMMONLY STUDIED SEPTIC
COMPONENT IN DISEASED CEMENTUM IS
ENDOTOXIN.
• THEY ARE LIPOPOLYSACCHARIDE OF GRAM
NEGATIVE BACTERIA.

20. ROLE OF ENDOTOXINS
PYROGENICITY
ATTRACTION OF
INFLAMMATORY CELLS
ACTIVATION OF
COMPLEMEMT
SYSTEM
STIMULATION
OF
OSTEOCLASTIC
ACTIVITY
MITOGENIC
ACTIVITY
FIBROBLAST
CYTOTOXICITY

21. • Aleo et al. (1974)
LIMULUS LYSATE ASSAY
Periodontally involved root surfaces contained an
endotoxin-like material capable of depressing cell
growth of tissue culture fibroblasts.
Conclusion led to the long accepted concept that
endotoxin lies within cementum, and that cementum
removal during periodontal therapy might be
appropriate.

22. HATFIELD AND BAUMHAMMERS( 1971)
Periodontally involved roots which had been washed and
scaled (not root planed) and placed these roots in sterile
tissue cultures.
Controls - uninvolved third molar roots.
Results: After 24 to 96 hours, cell cultures over control roots
showed irreversible morphologic changes.
Conclusion: presence of some toxic factor, possibly
endotoxin, which had penetrated the diseased root and
was capable of upsetting cell attachment.

23. Jones and O’leary (1978)
• Effect of vigorous root planing on quantity of
endotoxin.
• 50 root surfaces each of
Diseased 146.8ng
Healthy roots(0.05-0.45ng)
• Meticulous instrumentation was performed.

24. • RESULT: Root planed roots contained only
about 1 ng more endotoxin than healthy root
surfaces. This small difference can be
accounted for small flecks of calculus
remaining after planing.
• Conclusion: Root planing performed in the
study was able to render diseased root as free
of endotoxin as healthy root.

25. ENDOTOXIN
PENETRATION
• Endotoxin and whole bacteria may be found as deep as 12
microns beneath the cemental surface.
• Zander (1953)
Penetration of calculus bacteria
Calculo-cementum
Must be removed
• Selvig (1969)
Normal appearing areas
Areas of decreased radio- opacity & cavitation
Areas of partial decalcification (300µ)
Highly mineralized areas

26. ENDOTOXIN DOES NOT PENETRATE BUT LOOSELY ATTACHED
SUPERFICIAL LAYER
Nakib et al (1982)
• Weakly adherent
• No penetration into cementum
• Brushed away
Nyman et al (1986)
• Study on dogs
• Endotoxins did not interfere with healing following
flap surgery once soft deposits were removed
• Endotoxin removed with bacteria during polishing
within cementum. Neutralized by inflammatory response
OPPOSING STUDIES

27. • Moore & coworkers (1986)
Toxins(LPS) weakly bound to root surface
Washing for 1 minute removes 40%
Brushing for 1 minute removes 60%
Remainder 1%

28. REMOVAL OF
DISEASED CEMENTUM
• The portion of root exposed to the disease process has
little or no fibroblast cells attachment to the remainder of
root surface. Following the mechanical removal of
diseased cementum and the bacterial endotoxin, the cells
attached normally on the planed root surfaces. The
cementum bound endotoxin is capable of both cell death
and decreased cell proliferation ( Simon, Goldman 1971)

29. LOPEZ et al,1980
• Inflammatory potential of diseased cementum
• Histologic results showed –
Implanted fragments from roots that had been scaled
caused the most response with acute inflammation up to
14 days and chronic inflammation to 21 days.
Autoclaved Fragments- the acute inflammation was not
as severe.

30. • Autoclaved and planed roots- even less acute
inflammation was seen in the 7-day specimens
while some chronic inflammation persisted in the 21-
day specimens.
• Implants from healthy roots evoked no response.
• The inflammation caused by the autoclaved
diseased cementum: attributed to thermo-stable
endotoxin.
• Conclusion- Necessary to remove all of the
cementum exposed to the pocket to eliminate its
potential for inducing inflammation

31. CONTRADICTORY
STUDIES
• Nyman et al. (1986) demonstrated in beagle dogs that the
removal of diseased cementum was not necessary for
successful periodontal therapy.
• In a later study in humans, Nyman et al. (1988) showed that
the same degree of improvement of periodontal status was
achieved regardless of whether cementum was removed or
not.
• Results : Intentional root cementum removal is not necessary
for optimal postoperative healing.

32. ROOT SMOOTHNESS
• EMPHASIS IN ROOT PLANING HAS ALWAYS BEEN ON THE
ELIMINATION OF PLAQUE AND CALCULUS ALONG WITH
SMOOTHENING THE ROOT SURFACE.
• HOWEVER THE IMPORTANCE OF ROOT SMOOTHNESS
NOT ESTABLISHED.

33. Jens Waerhaug(1956)
Effect of rough surfaces upon gingival tissue,
EXPERIMENT IN DOGS
Described the irritating effect of calculus that is caused by
bacteria or toxin.

34. • Emphasized - rough surface facilitates the retention of
bacterial plaque and stressed the needs of well
polished restoration below the gingival margin.
• Supported by :
Lindhe et al1984
Lekens KN 1996
Quiryen N 1995

35. Rosenberg & Ash(1974)
Profilometer
Sig diff b/w curretted & control
teeth
No significant diff in mean
plaque scores/inflammatory
indices
Root roughness not
significantly related to mean
inflammatory index
Khatiblou &
Ghodssi
(1983)
Healing
following
surgical Rx
Healing not
affected by
root roughness
Hunter et al (1984)
Gouges/ ripples ≤ 50µ
smooth
Biologically lack of
evidence relating smooth
surfaces to plaque
formation
Rough area favor plaque
& calculus
Smoothness only
indicator of calculus
removal
OPPOSING
STUDIES

36. PREPARATION FOR NEW ATTACHMENT
• Removal of contaminated root surface
Root surface demineralization with citric acid
Pre requisite for new connective tissue attachment
Accelerates new attachment in healing
periodontal wounds

37. • Removal of hypermineralized surface- Prerequisite for
effective demineralization.
• ROOT PLANING –

38. • Garrett et al (1978)
SEM & TEM
Citric acid- no effect on unplaned roots
Planed root surfaces- 4nm wide areas of demineralization
Failure- hypermineralized areas on diseased roots
• Polson et al (1984)
Root planing (smear layer)2-15µm thick
Citric acid (ph1 for 3 min)
Removal of smear layer
Fibrous mat like structure
Not evident on unplaned roots

39. OBJECTIVES OF ROOT
PLANING
Restore health
•Remove elements that provoke
gingival inflammation
Remove pathogenic microflora

40. • O’ LEARY
Biologically acceptable root surface
Probing depth
Resolving
inflammation
Facilitating oral
hygiene
Improving &
maintenance of
attachment levels
Preparing tissues
for surgical
procedures

41. INSTRUMENTATION

42. Hand instruments
• HOE
Blade, bowed -2 point contact instrument
Single blade 99-100, bevelled at 45o
Macalls type and Holst type

43. FILES
Series of cutting edge lined up on a single base
Series of hoes mounted on the base
Mode of use- held parallel to calculus and crushed,
Use of curette

44. • CHISEL
Only instrument used with the push motion
No more used for root planing

45. • CURETTES
Instrument of choice for root planing
Curved blade and rounded toe better adapted to the
root surface

46. 2 TYPES –AREA SPECIFIC AND UNIVERSAL
• Universal curettes have limited adaptability:
Deep pockets
Root convexities, and
Developmental depressions
Gracey curettes are the new
modifications
which are area specific and specially
designed for subgingival scaling and
root planing in periodontal patients.

47. • Gracey curettes are a set of area-specific
instruments .
• Designed by Dr. Clayton H. Gracey of
Michigan in the mid-1930s

48. Four design features make the
Gracey curettes unique:
(1) They are area specific,
(2) Only one cutting edge on each
blade is used,
(3) The blade is curved in two
planes, and
(4) The blade is “offset

49. Extended-Shank Gracey Curettes
• 3 mm longer in the terminal shank
• Deep pockets on maxillary
and mandibular posterior teeth,

50. Mini-Bladed Gracey Curettes
Mini-bladed Gracey curettes, such as the Mini Five
curettes and the Gracey Curvettes,
Terminal shank that is 3 mm longer than the standard
Gracey curettes
Blade that is 50% shorter.
Micro Mini Five curette blades are 20% smaller than Mini
Five curette blades

51. Standard Gracey curet vs
a “Mini- Gracey curet”.
GRACEY CURETTE
MINI GRACEY CURETTE

52. • Micro Mini Five Gracey curettes (Hu-Friedy)
• Blades that are 20% thinner and smaller than the Mini
Five curettes
• These are the smallest of all curettes,

53. • Provide exceptional access and
adaptation
• Deep, or narrow pockets; narrow furcations;
Developmental depressions; line angles;
and deep pockets on facial, lingual, or
palatal surfaces.

54. Langer and Mini-Langer Curettes
• Set of three curettes
• Combining the shank design of the standard Gracey
#5-6, 11-12, and 13-14 curettes
with a universal blade honed at 90
Marriage of the Gracey and universal curette

55. QUENTIN FURCATION CURETTE
• Shallow half moon radius that fits in to the roof or floor
of the furcation
• Shanks are slightly curved
• Available in two width, BL1 & MD1 – small and fine 0.9
mm width
• BL2 & MD2- larger 1.3 mm

56. Diamond coated files
• Coated with fine grit diamond . Do not have cutting
edge
• Sharply abrasive – produce smooth, even clean
surface
• Particularly used along with the endoscope
• Disadv : can cause over instrumentation

57. • Diamond-coated ultrasonic instruments will effectively
plane roots, and that caution should be used during
periodontal root planing procedures. Additionally, the
diamond-coated instruments will produce a rougher
surface than the plain inserts or the hand curettes.
( Vastardis 2005)

58. ULTRASONIC AND
SONIC INSTRUMENTS
• Magnetostricitve & Piezoelectric
• Air or sonic
• Operated by the air line usually connected to air
turbine

59. COBB et al 2002
• “When one considers the demands of clinical skill,
time and stamina, the instrument of choice for
universal application would appear to be either a
sonic or ultrasonic scaler.”

60. PERIOSCOPY SYSTEM
• The Perioscopy system consists of a 0.99-mm-diameter,
reusable fiberoptic endoscope over which is fitted a
disposable, sterile sheath.

61. Allows clear visualization deeply into subgingival
pockets and furcations
Permits operators to detect the presence and location
of subgingival deposits and guides them in the thorough
removal of these deposits.
Magnification ranges from 24X to 48X, enabling
visualization of even minute deposits of plaque and
calculus

62. PERIO TOR
• Specially designed to optimize cleaning and planing of
the rough root cementum and
• Prevent further removal of root cementum once the
surface is clean and smooth.

64. PERIOTOR
CURETTE ULTRASONIC/HANS SCALER

65. Vector™ system
• Specially devised to reduce the amount of tooth
surface loss and treat the periodontal tissues less
aggressively.
• Uniqueness of this system lies in the oscillations
produced by the ultrasonic tip.

66. • Ultrasonic tip of this system vibrates parallel to
the tooth surface, which leads to less
removal of the tooth structure.
• Reduction in pain perception of the patient.
This may be attributed to vertical vibrations of
the ultrasonic tip.

67. AUTHOR STUDIES RESULTS
SCULEAN et al 2004 (Vector-ultrasonic system)
or scaling and root planing
(SRP) using hand
instruments.
Non-surgical periodontal
therapy with the tested
ultrasonic device may lead
to clinical improvements
comparable to those
obtained with
conventional hand
instruments.
DAHIYA et al 2011,2012 Gracey curette, ultrasonic
tip and rotary bur,
compared for root
debridement
Favored the use of rotary
instruments for root
planing to achieve a
smooth, clean root surface;
however, the use of rotary
instrument was more time
consuming,

68. MARDA et al ,2012 Compare the remaining
calculus, loss of tooth
substance, and roughness
of root surface after root
planing with Gracey
curette, ultrasonic
instrument (Slimline®
insert FSI-SLI-10S), and
DesmoClean® rotary bur.
Slimline™ insert was
shown to be better than
the other methods as
assessed by the indices
scores and the
instrumentation time.
Ana Chapper,2005 Compared the clinical
effects of hand or
ultrasonic scaling and root
planing on the treatment
of chronic periodontitis. (
BOP, PD,CAL)
Methods of subgingival
instrumentation were
equally efficacious in the
improvement of the
studied clinical
parameters.

69. LASERS
• ABLATIVE LASER THERAPY
Removes plaque and calculus with low mechanical stress
No smear layer
Can be reached to all the areas
Photoablative and Photodynamic diode laser in adjunct to
scaling -root planing (SRP) Diode laser treatment
(photoablation followed by multiple photodynamic cycles)
adjunctive to conventional SRP improves healing in chronic
periodontitis patients.

70. AUTHOR STUDIES RESULTS
Liu CM,1999 Nd:YAG laser treatment
versus scaling/root
planing (SRP) treatment
on crevicular IL-1beta
levels
SRP was found to have a
superior IL- 1beta
response,
Matthias Kreisler,2005 Clinical efficacy of
semiconductor
laser periodontal pocket
irradiation as an adjunct
to
conventional scaling and
root planing.
Lasers can be
recommended as an
adjunct to conventional
scaling and root planing.
Schwarz F,2001 Effectiveness of an
Er:YAG laser to that of
scaling and root planing
for non-surgical
periodontal treatment.
Er:YAG laser may
represent a suitable
alternative for non-
surgical periodontal
treatment

71. AIR POLISHING
• The air-abrasive technology uses an abrasive powder
introduced into a stream of compressed air to clean or
polish a surface by removing deposits attached to it or
smoothing its texture.

72. PERIOPLANER/
PERIOPOLISHER
• The system involves two motor driven handpieces. One
handpiece works with curettes and hoes (Perioplaner)
and the other works with diamond-layered instruments
(Periopolisher)
• Study has shown that the use of the Perioplaner and
Periopolisher results in about the same loss of root
substance as the use of hand instruments.
• Schweiz MZ, 1991

73. ROOT PLANING
PROCEDURE
SUBGINGIVAL
CALCULUS TENACIOUS
VISION OBSCUED BY
BLEEDING
MUST RELY ON
TACTILE SENSITIVITY
SRP COMPLEX THAN
SUBGINGIVAL
SCALING

74. INSTRUMENT
SELECTION
BEGIN WITH SMALL FILES/ HOES
LOWER POWER SET ULTRASONIC/SONIC
SCALER OR RIGID CURET
FINISH WITH FINISHING CURET

75. STRATEGIES FOR
INSTRUMENTATION
• SELECTION OF CURET
FINE SET: NON RETRACTABLE TISSUE
HEAVY SET: RETRACTABLE TISSUE
MEDIUM SET: RETRACTABLE TISSUE
• FINGER REST/GRASP
Grasp- modified pen and stable finger rest
Identify the cutting edge of curette

76. • ACTIVATION OF INSTRUMENT
Adaptation- lower shank parallel
Angulation- 45- 90 degree established
• STROKES
Stroke length
Stroke direction
Stroke activation

77. Terminal shank parallel to
tooth long axis.

78. • STROKE DIRECTION
Vertical and oblique strokes are most effective
strokes for root planing and exploring.
VERTICAL OBLIQUE HORIZONTAL

79. • STROKE LENGTH
Root planing strokes extend from the base of the
pocket to the cemento enamel junction.
• STROKE ACTIVATION
Wrist forearm motion is the fundamental means
of activation.

80. CHANNELS OF
INSTRUMENTATION

81. • FORCE MAXIMIZED BY SCALING IN CHANNELS AND BY
CONCENTRATING PRESSURE ONTO LOWER ONE THIRD
OF THE BLADE.
• Overlapping , short powerful stroke- Large calculus
removal( Carranza,10th ed)
• Root planing stroke- Long lighter overlapping with less
lateral pressure( Carranza,10th ed)

82. TERMINAL FEW MILLIMETERS OF THE BLADE
ENGAGES THE LATERAL EDGE OF THE
DEPOSIT
WITHOUT WITHDRAWING THE INSTRUMENT,
LOWER THIRD OF THE BLADE ADVANCED
LATERALLY AND REPOSITIONED TO ENGAGE
THE NEXT PORTION
CHANNELS ON
TOOTH SURFACE

83. • HEAVY LATERAL PRESSURE WITH SHORT
CHOPPY STROKES AFTER CALCULUS
REMOVAL- ROOT SURFACE WITH NICKS AND
GOUGES
• HEAVY LATERAL PRESSURE WITH LONG
STROKES- SMOOTH BUT DITCHED OR
GOUGED ROOT SURFACE

84. NUMBER OF STROKES
• Root modification using periodontal curette- 10 to
70 strokes
• 20 strokes are sufficient for removing cementum
• Aggressive root planing involves -10 or 20 strokes
more

85. • Study used a piezo-electric receiver
mounted into the upper shank of a curet in
Gracey 1/2 design.
• Results - 40 strokes at low force removed
148.7 μ and at high forces 343.3 μ .
With an increasing number of strokes the
amount of substance removed per stroke
became less. (Zappa et al,1991)

86. • Oda (1992)
Series of in vitro studies
2 scaling strokes with a sharp manual scaler – enough to
remove endotoxin
• Moore (1986)
Gentle washing in water for 1 min or brushing with slowly
rotating brush is enough to remove endotoxin
Ultrasonic scalers with its cavitational effect considered
effective for removal of Endotoxin

87. Manual scalers
• Horning(1987) -57.8μ/40 strokes
• Coldiron et al(1990) - 60μ/20 strokes
• Ishizuker and co workers(1980)
3.9μ with 750g lateral pressure with 50 strokes
Fine curettes- 9.1μ with clinically applied force/working
stroke

88. CEMENTUM REMOVAL
• U.S scaler-1 to 7.2 μ
• Sonic-4.3 to 7.8 μ
• Diamond file- 7.9 to 15.5μ
• Fine curette- 5 –22μ/stroke
ULTRASONIC SCALERS REMOVE LESS CEMENTUM BUT
LEAVE A ROUGHER SURFACE.( KOCHER ET AL 2001)

89. Pain and discomfort
during SRP
• Tissue trauma due to inadvertent curettage
Philstrom( 1999)
• Pain of significant duration, peak in intensity between
2 and 8 hrs post SRP- almost 25 % self medicated
• Small portions of patients noted root sensitivity ,
reduction occurred over 4 weeks . Tammaro et al (
2006)

90. • Steenburgh et al ( 2004)
1/3 of patients taking analgesia
1/2 of the total patients revealed gingival soreness
2/3 complained problem while eating.
• Ettin et al ( 2006)
Pre-emptive analgesics (ibuprofen arginine)may have
some beneficial effect.

91. LA DURING ROOT
PLANING
• Usually do not require.
• Patients vary in their ability to tolerate pain.
• LIDOCAINE 25mg/g can be an useful
alternative to injections anesthesia in pain
sensitive patients. (Magnusson 2003)

92. • Perry DA et al,2008
Transmucosal lidocaine patches provided sufficient
anaesthesia for therapeutic quadrant scaling and root
planing procedures.Lidocaine patch (46.1mg/2m)
compared to placebo patch VA scale for pain
Results greater pain relief with treatment patches after 15
min and at the end of treatment.

93. • Scotelberg JL(2007)
Compared 20% topical benzocaine gel to 2% injected
lidocaine
21 patients – divided 2 groups
Results
• The injected anaesthesia had less pain
• 11 participants preferred topical – fear of injection

94. • Lidocaine plus prilocaine in a thermosetting agent
also has been shown to be effective in controlling
intra-operative pain during scaling and root planing
(Jeffcoat et al. 2001, Donaldson et al. 2003,
Magnusson et al. 2003).
• Topical anaesthetics may be preferred over
injected anaesthetics .

95. EVALUATION OF SRP
• ROOT SMOOTHNESS
• HEALING OF SOFT TISSUE FOLLOWING SRP

96. ROOT SMOOTHNESS
• RELATIVE SMOOTHNESS OF THE ROOT SURFACE IS THE BEST
IMMEDIATE CLINICAL INDICATION OF ADEQUATE
INSTRUMENTATION.
• Hu friedy 3-A
• No 17 or orban
• Pig tail (no 3ML)
• generally thin and good tactile sensitivity, working end is
curved, permits easy adaptation, enough to extend to deep
pocket

97. ODU- 11-12,
• Adapted from the gracey curette 11-12 by faculty of
old Dominion university
• Combines pigtail design with a long shank – deep
pockets
• Smoothness- does not guarantee the complete
removal of calculus

98. HEALING SEQUENCE
Histologic studies –humans and primates
Long junctional epithelium – repair
New dentogingival junction firms within 2 weeks
• Sequence
• 1-3 days
• Hyperaemia, change in color& edema

99. PERIODONTAL
DEBRIDEMENT

100. 1 -2 weeks
• Resolution of edema
• Shrinkage of the gingival margin
• Color is about to normal
• Little or no bleeding/suppuration

101. 2-3 weeks
• Color is normal
• Consistency firm ,no bleeding
• Reduced tooth mobility
• Histologically- connective tissue maturation-21 to 28
days, establishment of GM- 3-6 months

102. HEALING- CLINICAL
END POINTS
• CLINICAL EVALUATION OF SOFT TISSUE RESPONSE
INCLUDING PROBING NOT CONDUCTED PRIOR TO 2
WEEKS FOLLOWING SRP.ASSESSMENT 4-6 WEEKS
AFTER THERAPY.REPAIR CAN CONTINUE FOR
ADDITIONAL 9 MONTHS.
• RE EPITHELIAZATION OF THE WOUND CREATED
DURING INSTRUMENTATION TAKES FROM 1 TO 2
WEEKS.

103. MOST COMMON END POINTS EVALUATED:
• PROBING POCKET DEPTH
• CLINICAL ATTACHMENT LEVEL
• REDUCTION IN BLEEDING SITES AND EDEMA IS A
SURROGATE INDIACTOR FOR THE RESOLUTION OF
GINGIVAL INFLAMMATION.

104. Hajol(2004)
• True end point- relief of pain, esthetics, and chewing
comfort
• Surrogate end point- No B.O.P. , pocket closure,
attachment gain, and tooth loss

105. Probing depth and CAL
A)Clinical attachment levels:
• Loss of attachment low initial PD
• Gain Deeper PD
Proye et al (1982):
• Recession after 1 wk (0.84mm)
• Gain after 3 wks (0.52mm)
• Probing depths reduced to1.36mm

106. COBB 1996
• 1-3 MM PD RED OF 0.03MM CAL 0.34MM
• 4-6MM PD RED OF 1.3MM WITH GAIN OF 0.55MM
• >7MM PD RED 2.6MM WITH GAIN OF 1.19MM
• SIMILAR RESULTS REPORTED BY VENDER WEJDEN ET AL,
2002

107. • HALF OF THE DECREAE IN PROBING DEPTH
ATTRIBUTED TO ATTACHMENT GAIN AND THE
REMAINING DECREASE IS THE RESULT OF CHANGE IN
GINGIVAL MARGIN POSITION.

108. Critical probing depth ( LINDHE et al,1982)
BELOW- LOSS OF
ATTACHMENT
LEVEL
ABOVE- GAIN IN
ATTACHMENT
LEVEL
2.92mm- Root planing
4.2mm- Flap debridement surgery

109. Creeping attachment
• Goldman proposed the term mainly following FGG
• Coronal shift in the position of the gingival margin

110. Aimetti et al (2005)
• Coronal shift of 0.40 to 0.89 mm ( several other
studies reported same)
• This achieved complete root coverage 45.83%
in 12 month

111. Reasons for root coverage in root planing
• Initially thick gingiva will have better root coverage
• Reduction in the convexity of the root and m-d
distance between the periodontal space
• Plaque free and flat root surface helps in easy
regrowth of the marginal tissue

112. MICROBIOLOGICAL
CHANGES
• DECREASE IN GRAM NEGATIVE MICROBES
ACCOMPANIED BY AN INCREASE IN GRAM POSITIVE
COCCI AND RODS.
• DOMINANCE BY BENEFICIAL SPECIES RESULTS IN:
DECREASE IN GINGIVAL INFLAMMATION
DECREASE IN PROBING DEPTH
DECREASE IN BLEEDING ON PROBING
COBB ET AL,2002

113. CUGNI ET AL 2000
DNA PROBE COUNT STUDY
• DECREASE IN T.FORSYTHUS, P.GINGIVALIS,
T.DENTICOLA AND INCREASE IN ACTINOMYCES SPS,
STEPTOCOCCI, F.NUCLEATUM,VEILONELLA.
• SIMILAR RESULTS REPORTED BY HAFFAJEE1997,
MOMBELLI 2000.

114. Teles et al ( 2006)
• Bacterial count decreased from 91+ 11x 105 to 23+6
x 105
Darby et al ( 2005)
• Decreased T. forsythia and T.denticola several week
following SRP

115. Bickler et al ( 2004)
• if home care not followed, re-establishment of the
pathogenic flora and rebound in the clinical
parameters occur.
Haffejee( 2006)
• Increase in the Streptococci and Actinomyces
species 3 months past SRP
• Also noted re-emergence in the red complex and
orange complex 3 to 12 months results in the increase
loss of attachment

116. Re-emergence can occur from following
locations;
• Residual subgingival plaque deposit
• Radicular dentin or cementum
• Pocket epithelium or connective tissue
• Supragingival plaque deposits
• Subgingval deposits of adjacent teeth and from
intraoral soft tissue sites

117. EFFECT ON DENTIN AND
PULP
• Minor structural alterations of both root surface and
restoration margins.(Lee SY,1995,Eberhard ,2003)
• Dentinal tubules are exposed, leading to direct
avenues to the pulp for bacteria and bacterial
elements present in the oral environment (Bergenholtz
• & Lindhe 1978).

118. • Root sensitivity occurs in approximately half of the
patients following subgingival scaling and root planing.
The intensity of root sensitivity increases for a few weeks
after therapy, after which it decreases.( Von Troil,2002-
systematic review)
• Unnecessary excessive root substance loss (hour-glass
shaped roots),
• Root fracture or Pulpitis

119. SRP IN COMBINATION WITH
PHOTODYNAMIC THERAPY
• SRP in combination with PDT seems to be effective
and Is therefore suitable as an adjuvant therapy to
the mechanical conditioning of the periodontal
pockets in patients with chronic periodontal
diseases. (Berakdar 2012)

120. SRP WITH AND WITHOUT PERIODONTAL
FLAP
• Mean accessible depth by curettes – 4.6 mm
Supported by:
• RABBANI et al,1981 concluding that curettes can not
reach to a depth of more than 4 mm.
• CLIFFORD,1999: Available depth for curettes has
been re-ported to be 3.45 mm .The maximum
accessible depth was found to be 6 mm in distal and
buccal surfaces

121. • 1.Periodontal flaps for access provide a means for
greater reduction of residual calculus.
• 2. Periodontal flaps for access provide a means to
achieve more tooth surfaces free of calculus in
pockets >3 mm.
• 3. The % of residual calculus is related to probing
depth, despite the treatment approach.
• 4. Anterior and posterior teeth respond similarly.
CAFFESSE 1986

122. WYLAM ET AL 1993
• Sixty multi-rooted teeth were assigned to one of three
groups:
Untreated controls,
Closed scaling/root planing, and
Open flap scaling/root planing.
• No significant difference in the percent stained residual
plaque and calculus in shallow areas of the pocket
• Furcation regions demonstrated heavy residual stainable
deposits for both treatment methods, with no significant
differences between techniques.

123. QUIRYNEN ET AL Full mouth disinfection vs
PDS vs full mouth root
planing
Greater gain in clinical
attachment and less
bleeding upon probing
with FRP and FDIS
Reduced motile forms by
20%
BOLLEN ET AL 1998 FDIS VD PDS Better gain in clinical
attachment levels with fdis
Fdis reduced motile rods
and spirochetes reduced by
10% whereas pdis reduced
by 20%

124. AUTHOR STUDIES RESULTS
Eberhard et al (Cochrane
SR 2008)
Full-mouth disinfection
for the treatment of adult
chronic periodontitis
The treatment effects of
FMD compared with
conventional SRP are
modest and the
implications for
periodontal care are not
profound.”
Sanz & Teughels 6th
(EWP 2008)
FMD and chronic
periodontitis
Need to investigate the
impact of different
mechanical debridement
protocols on patient
centred outcomes and
cost-effectiveness using
appropriate
methodology”

125. NON SURGICAL THERAPY VS
SURGICAL THERAPY
Meta analysis
• Knowles( 1979)
• Split mouth design
• RP, RP+curettage, MWF, APF
• 3 month maintenance, 6 yr follow up
• Surgical technique better pocket depth reduction
• All tech. yielded gain in attachment in deeper
pocket

126. • Kaldahl (1988, 1996)
• Split mouth
• Root Planing Vs Modified widman flap
• 6 yr follow up
• Result favored non surgical treatment

127. Conclusion:
• Shallow pocket- no significant difference of ---0.02
mm after 6 years
• Medium pockets- no significant difference of –0.22
mm after 6 years
• Deep pockets – the difference is 1.03 mm after 6
months to 0.22 mm after 6 years

128. SRP VERSUS CURETTAGE
• Curettage
Closed definitive surgical procedure aimed at pocket
elimination, reattachment or new attachment.
Removes pocket epithelium intentionally
WORLD WORKSHOP IN CLINICAL PERIODONTICS,1989
Gingival curettage as a separate procedure has no
justifiable application during active therapy during chronic
preriodontitis.
Without clean, hard roots results of curettage are
limited.(Cohen,2007)

129. Limitations
Anatomy of roots
Depth of pockets
Position of teeth
Inadequate instruments for diagnosis
Inadequate instruments for treatment
Area of mouth being treated
Size of mouth
Elasticity of cheeks
Range of opening
Dexterity of operator

130. • Total substance removal by instrumentation
includes calculus and root substance removal.
• Calculus removal seems to require less than 20
working strokes to be complete, relative to a
standard area of 1-mm width on the circumference
of the root. The following strokes serve only to
remove root substance, which seems to be
unnecessary.

131. • Endotoxin removal is nearly completed after the
same number of working strokes, reaching levels
similar to periodontally healthy teeth. Clearly these
levels are low enough to enable good clinical
healing.
• Aggressive scaling and root planing might be
counterproductive for the future health of the
periodontally diseased tooth.

132. SUMMARIZE
Deep Endotoxin
penetration
Endotoxin as a
superficial layer
ROOT
DEBRIDEMENT
ROOT
CONDITIONING

133. • Clinicians should choose the modality of
debridement according to the needs and the
preferences of the patient, their personal skills and
experience, the logistic setting of the practice and
the cost-effectiveness of the therapy rendered”

134. Thank you