cobb2002

J Clin Periodontol 2002; 29 (Suppl. 2): 6–16
Printed in Denmark. All rights reserved
Clinical significance of
non-surgical periodontal
therapy: an evidence-based
perspective of scaling and
root planing
Charles M. Cobb
Department of Periodontics, School of
Dentistry, University of Missouri, Kansas City,
MO, USA
Cobb C M: Clinical significance of non-surgical periodontal therapy: an
evidence-based perspective of scaling and root planing. J Clin Periodontol 2002;
29 (Suppl 2): 6–16. # Blackwell Munksgaard, 2002.
Abstract
Analysis of Egyptian hieroglyphics and medical papyri indicate that non-surgical
periodontal treatment was common 3000–4000 years ago. Even today, scaling
and root planing (SRP) remains an essential part of successful periodontal therapy.
The collective evidence from numerous clinical trials reveals a consistency of
clinical response in the treatment of chronic periodontitis by SRP using manual,
sonic, or ultrasonic instrumentation. Thus, SRP remains the ‘gold standard’ to
which more recently developed therapeutic modalities must be compared. Inherent to
the clinical evaluation of SRP are such concerns as manual versus sonic and
ultrasonic instrumentation, control of sub-gingival bacterial populations, removal
of calculus, root smoothness and changes in various clinical parameters, e.g.
probing depth, attachment levels, bleeding on probing and gingival inflammation.
Lastly, an abbreviated discussion is presented on a relatively new paradigm of
complete mouth ‘disinfection’ in a compressed time-frame that includes SRP as a
significant component of the treatment regimen.
Introduction
Abu I-Qasim in 10th century Cordova,
Spain, appears to have been the first to
give serious thought to the role played by
dental calculus, presence of which led to
‘corruption’ of the gingivae. He recommended a ‘professional’ cleaning of the
teeth, over several days, which was
facilitated by a set of 14 scalers (Weinberger 1948, Held 1989), strongly suggesting that the use of manual scaling
instruments has been ongoing for at
least a thousand years. However, Egyptian hieroglyphics and medical papyri
indicate that, in fact, non-surgical
periodontal therapy may have been
common as far back as 2000 years BC
(Weinberger 1948).
Our ancient predecessors were unaware of the existence of bacteria. Their
primary focus during scaling of the teeth
was undoubtedly the removal of calculus
and extrinsic tooth stain. In spite of the
limitations in scientific knowledge by
modern standards, the clinical observation revealed an improvement in gingival
health and appearance. Hence, in both a
historical and modern context, in the
practice of dentistry, the removal of
sub- and supragingival plaque and
calculus is an important part of any
Key words: scaling and root planing; nonsurgical therapy; ultrasonic instrumentation;
sub-gingival bacterial plaque; root surface
smoothness
systematic treatment of periodontal
disease.
Manual and sonic/ultrasonic
instrumentation
Numerous studies have reported on the
comparative efficiency of sonic and/or
ultrasonic versus manual instrumentation. Collectively, these studies indicate
that manual instrumentation generally
takes longer to achieve the same clinical
end-points than do sonic and/or ultrasonic scaling instruments (Badersten
et al. 1981, 1984a, 1985a, Loos et al.
1987, 1989, Checchi & Pelliccioni 1988,
Perspective on scaling and root planing
Kawanami et al. 1988, Laurell & Pettersson 1988, Laurell 1990, Dragoo
1992, Copulos et al. 1993, Grant et al.
1993, Boretti et al. 1995, Drisko 1995,
Kocher et al. 1997, Yukna et al. 1997). In
fact, several studies have reported that
use of sonic and/or ultrasonic instruments can result in a 20–50% savings
in time compared with manual instrumentation when used for periodontal
debridement procedures (Checchi & Pelliccioni 1988, Dragoo 1992, Copulos
et al. 1993, Drisko 1995).
The time required to achieve clinical
endpoints is only one of several factors
in the equation to determine instrument
efficiency. Obviously, achievement of
desired clinical end-points is severely
impacted by restricted access. Waerhaug
(1978a, 1978b) and later, Stambaugh
et al. (1981) noted that the chances of
removing all sub-gingival plaque from
all tooth surfaces was fairly good if the
probing depth was 3.0 mm. At probing
depths of 3–5 mm, the chance of failure
becomes greater than the chance of success. At probing depths 5.0 mm, the
chance of failure becomes significantly
dominant. In fact, Stambaugh et al.
(1981) noted that removal of all subgingival plaque and calculus was unlikely to occur when mean probing
depths were 3.73 mm. In this regard,
it is interesting to note that both Dragoo
(1992) and Clifford et al. (1999)
have evaluated traditional and ‘microultrasonic’ scaling tips for their ability to
reach the most apical extension of periodontal pockets and reported conflicting
results. Dragoo (1992) reported that only
rarely did any of the instruments
approach the most apical depth of the
pocket. On the other hand, Clifford et al.
(1999) reported that both types of scaling tips were able to reach and debride
the apical plaque border in pockets in
4–6 mm and 7 mm pockets.
Notwithstanding apparent limitations
in sub-gingival mechanical therapy,
regardless of instrument type, the periodontal literature contains numerous
reports supporting successful long-term
maintenance following either surgical or
non-surgical therapy (Hill et al. 1981,
Pihlstrom et al. 1983, 1984, Lindhe &
Nyman 1984, Lindhe et al. 1984, Ramfjord et al. 1987, Kaldahl et al. 1996a).
This paradox can be explained, in part,
by the concept of ‘critical mass’ (WWP
1989). As applied to non-surgical periodontal therapy, the concept of critical
mass is best understood by assuming
that a major goal of periodontal therapy
is to reduce the quantity (mass) of bacterial plaque to a level (critical) that
results in an equilibrium between the
residual microbes and the host response,
i.e. no clinical disease. Given the physical limitations, both anatomical and
instrumentational, of sub-gingival scaling and/or root planing, one may argue
that it is whimsical to assume that clinicians can remove all sub-gingival
plaque and calculus.
Control of sub-gingival bacterial
plaque
The efficacy of periodontal therapy is
directly related to the ability of treatment
to lower levels and/or prevalence of one
or more pathogenic bacterial species.
Treatment of chronic periodontitis using
manual instrumentation for sub-gingival
scaling is likely to result in a modest,
albeit transient, shift in the composition
of the microbial flora (Listgarten et al.
1978, Slots et al. 1979, Mousques et al.
1980, Singletary et al. 1982, Greenwell
& Bissada 1984, Magnusson et al. 1984,
Hinrichs et al. 1985, Lavanchy et al.
1987, van Winkelhoff et al. 1988, Southard et al. 1989, Chaves et al. 2000,
Stelzel & Florès-de-Jacoby 2000). In
general, sub-gingival scaling effectively
decreases the population of Gramnegative microbes while concomitantly
allowing for an increase in the populations of Gram-positive rods and cocci.
This shift towards a more dominate
population of Gram-positive microbes
is usually associated with gingival health
(Listgarten et al. 1978, Slots et al. 1979,
Mousques et al. 1980, Singletary et al.
1982, Greenwell & Bissada 1984, Magnusson et al. 1984, Hinrichs et al. 1985,
Harper & Robinson 1987, Lavanchy
et al. 1987, van Winkelhoff et al.
1988, Southard et al. 1989, Sbordone
et al. 1990, Haffajee et al. 1997a, Stelzel
& Florès-de-Jacoby 2000).
Recently, Haffajee et al. (1997a, b)
and Cugini et al. (2000) reported that
scaling and root planing resulted in significant decreases in DNA probe counts
of a specific subset of sub-gingival microbes consisting of Porphyromonas gingivalis, Bacteroides forsythus and
Treponema denticola. Concomitant with
decreases in this subset of bacteria were
significant increases in Actinomyces sp.,
Capnocytophaga sp., Fusobacterium
nucleatum subsp. polymorphum, Streptococcus mitis, and Veillonella parvula.
Similar results showing decreased levels
of P. gingivalis and T. denticola have
7
been reported by Ali et al. (1992),
Simonson et al. (1992), Shiloah & Patters (1994), and Lowenguth et al. (1995).
Although spirochetes, motile microbes, and Bacteroides sp. are routinely
reduced in numbers after scaling and
root planing, other species appear more
resistant, such as Actinobacillus actinomycetemcomitans and P. gingivalis
(Slots & Rosling 1983, Pihlstrom et al.
1984, Christersson et al. 1985, Harper &
Robinson 1987, van Winkelhoff et al.
1988, Southard et al. 1989, Renvert et al.
1990a, Sbordone et al. 1990, Gunsolley
et al. 1994, Mombelli et al. 1994b, Shiloah & Patters 1994, von Troil-Lindén
et al. 1996, Haffajee et al. 1997a). The
persistence of specific sub-gingival species including A. actinomycetemcomitans, P. gingivalis and T. denticola has
been associated with poor response to
treatment by scaling and root planing
(Haffajee & Socransky 1994, Haffajee
et al. 1994, 1997a, Chaves et al. 2000).
Indeed, Haffajee et al. (1997a) reported
that scaling and root planing was a useful
treatment for 68% of the subjects in their
study, resulting in no loss or a modest
gain in mean attachment levels. Thus,
32% of the subjects exhibited little
benefit from non-surgical therapy and
continued to have elevated levels of putative pathogens and progressive loss of attachment.
The persistence of P. gingivalis,
Prevotella intermedia/nigrescens (Sato
et al. 1993, Mombelli et al. 2000), A.
actinomycetemcomitans (Mombelli et
al. 2000), Campylobacter recta and
F. nucleatum (Sato et al. 1993) is
reported to have a highly significant
relationship with bleeding on probing.
In addition, Mombelli et al. (2000) found
a direct correlation between the increasing number of post-treatment residual
pockets of >4 mm and the number of
P. gingivalis-positive sites.
The inability of sub-gingival instrumentation to eradicate A. actinomycetemcomitans and P. gingivalis has been
attributed to their ability to invade the
subjacent periodontal tissues (Slots &
Rosling 1983, Christersson et al. 1985,
Shiloah & Patters 1994), existing high
pretreatment levels and deep initial probing depths (Mombelli et al. 1994a,
1994b). In addition, several studies have
demonstrated the presence of bacteria in
root cementum and radicular dentin of
periodontally diseased teeth. Such bacterial invasion of root structure may
represent a reservoir of periodontopathic bacteria for recolonization and
8
Cobb
re-infection (Daly et al. 1982, Adriaens
et al. 1988, Giuliana et al. 1997).
Furthermore, sub-gingival therapy does
little to address other oral sites that may
act as a source for re-emerging periodontal pathogens, e.g. posterior tongue
and peritonsillar areas (von Troil-Lindén
et al. 1996). It is recognized that shifts to
a sub-gingival microbial flora representative of health appear to be transient.
Thus, to sustain the positive effects of
periodontal treatment, scaling and root
planing must be performed periodically
during the maintenance phase of therapy
(Westfelt et al. 1983, Lindhe & Nyman
1984, Harper & Robinson 1987, van
Winkelhoff et al. 1988, Renvert et al.
1990a, Shiloah & Patters 1996).
Studies regarding the effect of ultrasonic instrumentation on the sub-gingival
microbial flora and microbial toxins are
relatively few but consistent in their
findings. When this small number of
investigations is evaluated as a collected
body of literature, one common agreement appears to exist, that is manual,
sonic and ultrasonic scalers cannot effect
the complete removal of sub-gingival
bacterial plaque and calculus, and they
all achieve similar clinical and microbiological results (Lie & Meyer 1977,
Thornton & Garnick 1982, Hunter et al.
1984, Eaton et al. 1985, Lie & Leknes
1985, Gellin et al. 1986, Breininger et al.
1987, Kawanami et al. 1988, Coldiron
et al. 1990, Baehni et al. 1992, Dragoo
1992, Jotikasthira et al. 1992, Bollen &
Quirynen 1996, Checchi et al. 1997).
Removal of sub-gingival calculus
The concept of removing all sub-gingival
calculus and contaminated cementum
has been shown to be unrealistic and
quite likely unnecessary (Borghetti
et al. 1987, Breininger et al. 1987, Kepic
et al. 1990, Robertson 1990, Sherman
et al. 1990a, 1990b, Eschler & Rapley
1991, Fukazawa & Nishimura 1994).
Further, it appears that a clinically
acceptable level of gingival wound healing occurs, despite the presence of
microscopic aggregates of residual root
calculus (Nyman et al. 1986, Blomlöf
et al. 1987, Buchanan & Robertson
1987). Even though complete removal
of sub-gingival calculus is not likely to
occur, and removal of cementum is
unnecessary, it appears that a considerable root detoxification and gingival
healing is accomplished using multiple
light strokes with a sonic or ultrasonic
scaler (Badersten et al. 1981, 1984a,
1984b, Nyman et al. 1986, Checchi &
Pelliccioni 1988, Cheetham et al. 1988,
Smart et al. 1990, Chiew et al. 1991).
Numerous studies have demonstrated
that sonic or ultrasonic instrumentation,
when compared with manual instrumentation, achieves equal or superior treatment outcomes (Lie & Meyer 1977,
Torfason et al. 1979, Thornton & Garnick 1982, Badersten et al. 1984a,
1984b, Lie & Leknes 1985, Loos et al.
1987, Laurell & Pettersson 1988, Laurell
1990, Copulos et al. 1993).
Root surface smoothness
It has long been assumed by clinicians
that a smooth root surface is also a clean
surface. Yet it remains to be determined
that a smooth root surface is a desirable
end-point of non-surgical periodontal
therapy. There are relatively few reports
dealing with the impact of root surface
roughness on wound healing or, in the
reverse, the biocompatibility of a smooth
root surface (Rosenberg & Ash 1974,
Khatiblou & Ghodssi 1983, Lindhe
et al. 1984, Leknes et al. 1996, Oberholzer & Rateitschak 1996). Early on,
Rosenberg & Ash (1974) concluded that
root surface roughness resulting from
instrumentation by manual curettes and
ultrasonic scalers had no significant
effect on plaque retention or gingival
inflammation. These observations were
later supported by Khatiblou & Ghodssi
(1983) and Oberholzer & Rateitschak
(1996), who reported that periodontal
healing, reductions in probing depth,
and attachment gains, were independent
of root surface texture. However, such
observations are in contrast to those of
Waerhaug (1956), who noted that intentional roughening of sub-gingival
enamel in dogs resulted in an increased
deposition of bacterial plaque and calculus. Several other studies have noted
the direct relationship between surface
roughness and the rate of supragingival
bacterial colonization (Keenan et al.
1980, Budtz-Jorgensen & Kaaber 1986,
Quirynen & Listgarten 1990, Leknes
et al. 1996). Further, both Quirynen &
Bollen (1995) and Leknes et al. (1996)
have noted that rough supragingival surfaces accumulate and retain more bacterial plaque. In addition, Quirynen &
Bollen (1995) report that gingivitis and
periodontitis is more frequently associated with teeth exhibiting a rough surface. Not so surprising, then, are the
observations by Lindhe et al. (1984),
who noted that smooth root surfaces
were compatible with normal healing
of the dentogingival complex.
Schlageter et al. (1996), using an in vitro study design, reported an instrument
hierarchy of smooth to rough root surfaces using an average roughness value
(Ra) to be 15 mm rotating diamond
(1.64 0.81), Gracey curette (1.90 0.84), Perioplaner curette (2.10 1.03),
piezo-electric scaler (2.48 0.90), 75 mm
rotating diamond (2.60 1.06) and the
sonic scaler (2.71 1.12).
The significance of the study by
Schlageter et al. (1996) lies in the Ra
values, none of which appear to achieve
a surface smoothness threshold of
Ra ¼ 0.2 mm, below which no impact
on bacterial adhesion and/or colonization should be expected. However, surfaces with a roughness exceeding the
0.2 mm threshold should be expected to
facilitate greater amounts of bacterial
plaque accumulation (Quirynen et al.
1993, Bollen et al. 1996a). In fact, a
study using titanium implant abutments
indicated that an Ra value of 0.8 mm
resulted in a dramatic increase in subgingival plaque (25) when compared
with surfaces with an Ra value of 0.2 mm
(Quirynen et al. 1996). Thus, a comparison of the Ra values reported by Schlageter et al. (1996) with the threshold
value of 0.2 mm would lead one to
assume that achieving root surface
smoothness with the instrumentation
available at present is simply not possible. Given that the smoothest root surface in the study by Schlageter et al.
(1996) had an Ra value roughly 8 greater than the threshold value of
0.2 mm, it would appear that for the foreseeable future, sub-gingival microbes
will continue to have a friendly surface
for colonization.
Changes in probing depth and
attachment level
Reduction in probing depth following
mechanical instrumentation results from
a combination of gain in clinical attachment and gingival recession (Hughes &
Caffesse 1978, Proye et al. 1982). The
magnitude of probing depth reduction
and gains in attachment levels are related
to the initial measurement, a phenomena
supported by the collective data reported
in various clinical studies over several
decades (Cobb 1996) (Table 1). For
example, the mean reduction in probing
depths with an initial depth of 1–3 mm
has been calculated to be 0.03 mm with a
mean net loss in attachment level of
9
Perspective on scaling and root planing
Table 1. Summary from selected studies reporting the mean decrease in probing depth and changes in clinical attachment levels following nonsurgical treatment of moderate to severe periodontitis using manual scalers/curettes
Mean decrease in probing depth (mm),
month:
Reference
Torfason et al. (1979)
Badersten et al. (1981)
Pihlstrom et al. (1981)
Caton et al. (1982)
Cercek et al. (1983)
Badersten et al. (1984a)
Becker et al. (1988)
Claffey et al. (1988)
Kaldahl et al. (1988)
Laurell & Pettersson (1988)
Copulos et al. (1993)
Drisko et al. (1995)
Haffajee et al. (1997a)
Noyan et al. (1997)
Soskolne et al. (1997)
Jeffcoat et al. (1998)
Garrett et al. (1999)
Kinane & Radvar (1999)
Preshaw et al. (1999)
Cugini et al. (2000)ô
Machtei et al. (2000)
Stelzel et al. (2000)
IPD (mm)
1
5.00
4.30
4–6.0
6.0
4–7.0
3.5–5
5.70
4–6.0
7.0
4–6.5
5–6.0
7.0
4.0
5.07
5.34
4–6.0
5.0
6.01
5–8.0
5.30
7.55
5.0
5.73
> 6.0
1.10y
0.0z
6.02
3
1.30
0.56
0.73
9
1.25
0.94
1.66
1.39
1.00
0.0z
26%§
6
1.20
1.23
2.18
66%
0.70
0.75
0.4z
0.45
1.40
Change in attachment level (mm), month:
12
1
1.10
0.10z
1.60
0.86
1.54
1.30
3
6
9
0.25
0.56
1.40
0.70
0.10
0.10z 0.10
0.20
12
0.10
0.20
0.49
1.54
0.40
0.96
1.66
0.50
2.01
0.50
0.2z
0.25
0.25
0.63
0.70
0.45
0.95
0.58
0.50
1.05
0.5z
0.50
0.50
0.50
1.20
0.20
0.59
0.73
0.72
1.00
1.70
0.71
0.65
0.90
1.65
1.0z
1.20
1.70
0.63
1.56
1.56
0.19
0.90
0.44
1.20
IPD, initial probing depth (indicates mean IPD).
yMean for all pockets regardless of location.
zCalculated from published data tables and does not include decreases in probing depth or increases in attachment level due to oral hygiene.
§Percentage reduction in the mean number of pockets of 4.0 at 1 and 4 months post-treatment.
ôTwelve-month results calculated from published data tables and represents data from subset of patients in the study by Haffajee et al. (1997a).
0.34 mm. For those pockets initially
measuring 4–6 mm, the mean reduction
in probing depth is 1.29 mm with a
net gain in clinical attachment levels
of 0.55 mm. Periodontal pockets of
7.0 mm show a mean reduction in
probing depth of 2.16 mm and a gain
in attachment level of 1.19 mm (Cobb
1996). The greatest change in probing
depth reduction and gain in clinical
attachment occurs within 1–3 months
post-scaling and root planing, although
healing and maturation of the periodontium may occur over the following
9–12 months (Morrison et al. 1980,
Badersten et al. 1981, 1984a, Proye
et al. 1982, Cercek et al. 1983, Kaldahl
et al. 1988, Preshaw et al. 1999, Cugini
et al. 2000). Thus, evaluation of the
response of the periodontium to scaling
and root planing should be performed no
earlier than 4 weeks following treatment
(Caton et al. 1982, Kaldahl et al. 1988,
Dahlén et al. 1992). Measurements taken
prematurely will not be representative of
completed healing and could therefore
be misinterpreted as a poor clinical
response.
Bleeding on probing and gingival
inflammation
In spite of a weak correlation, clinicians
continue to use bleeding on probing as a
primary indicator of disease activity.
This persistence on behalf of the clinician is likely based on several studies
conducted in the 1980s and early 1990s,
which indicated that frequent bleeding
on probing was a predictor of future
clinical attachment loss (Badersten
et al. 1985b, 1990, Lang et al. 1986,
Claffey & Egelberg 1995). For example,
Badersten et al. (1990) reported that 13%
of sites that exhibited bleeding on probing at least 75% of the time during a 12month period experienced subsequent
loss of attachment. However, over a
60-month period, 29% of sites with a
75% frequency rate of bleeding on probing exhibited loss of clinical attachment
compared with 14% of all sites examined during the same time interval.
Because of the weak correlation, Lang
et al. (1986) have suggested that an
absence of bleeding on probing be used
as a criterion for stability rather than
using the presence of bleeding as a predictor of disease activity.
Regardless of the lack of correlation
between bleeding on probing and risk for
future loss of clinical attachment, a
review of the collective literature indicates that mechanical non-surgical
periodontal therapy will predictably
reduce the levels of inflammation
(Table 2). For probing depths of 4.0–
6.5 mm, the mean reduction in bleeding
on probing from baseline levels is 45%
for all studies considered collectively
(Listgarten et al. 1978, Torfason et al.
1979, Badersten et al. 1981, 1984a,
Pihlstrom et al. 1981, 1983, Caton et al.
1982, Lindhe et al. 1982, 1987, Proye et al.
1982, Singletary et al. 1982, Cercek et al.
1983, Greenwell & Bissada 1984, Isidor
et al. 1984, Lindhe & Nyman 1985,
Renvert et al. 1985, 1990b, Westfelt
et al. 1985, Isidor & Karring 1986,
Lavanchy et al. 1987, Loos et al. 1987,
Becker et al. 1988, Kawanami et al. 1988,
Laurell & Pettersson 1988, Al-Joburi et al.
1989, Kalkwarf et al. 1989, Hämmerle
et al. 1991, Klinge et al. 1992, Pedrazzoli
et al. 1992, Copulos et al. 1993, Sato et al.
10
Cobb
Table 2. Summary of selected studies reporting the percentage decrease in bleeding on
probing following non-surgical mechanical treatment of moderate to severe periodontitis
% decrease in bleeding on probing, month:
Reference
Torfason et al. (1979)
Badersten et al. (1981)
Caton et al. (1982)
Proye et al. (1982)
Badersten et al. (1984a)
Loos et al. (1987)
Kawanami et al. (1988)
Laurell & Pettersson (1988)
Al-Joburi et al. (1989)
Kalkwarf et al. (1989)
Hämmerle et al. (1991)
Klinge et al. (1992)
Pedrazzoli et al. (1992)
Copulos et al. (1993)
Sato et al. (1993)
Newman et al. (1994)
Drisko et al. (1995)
Boretti et al. (1995)
Forabosco et al. (1996)
Haffajee et al. (1997a)
Soskolne et al. (1997)
Preshaw et al. (1999)
Stelzel et al. (2000)
IPD (mm)
5.00
4.30
4–7.0
3–7.0
5.70z
4–6.5
5.50
4.0
4.0
5–6.0
4.0
5.0
5.0
5.07
5.0
6.31
5.34
5.60
4–6.0
> 4.0
6.01
5.73
6.02
1
3
42y
6z
6
9
87z
12
87z
48
38
12z
17z
75
34
63z
35z
67z
39z
81z
37
80
55
29z
42
74
24z
40z
20
30z
47
43
64§
53
42
40
60§
76§
25z
10z
25z
12z
35z
21z
41
28
IPD, initial probing depth (indicates mean IPD).
yMean percentages for all pockets regardless of location.
zCalculated from data tables presented in paper.
§Percentage decrease in bleeding sites for all pocket depths.
1993, Newman et al. 1994, Boretti et al.
1995, Drisko et al. 1995, Forabosco et al.
1996, Haffajee et al. 1997a, Soskolne et al.
1997, Preshaw et al. 1999, Stelzel et al.
2000).
An examination of the data presented in
Table 2 shows a wide range of results with
respecttopercentagereductioninbleeding
on probing, i.e. 6–64% at 1 month posttherapy, 10–80% at 3 months, and 12–
87% at 6 months. In addition, it appears
that the initial reductions in bleeding on
probing either remained relatively stable
or improved with increasing time posttherapy.
It is interesting to note that several
studies have compared the effects of
non-surgical and surgical therapy on gingival inflammation, using as a basis of
comparison such parameters as bleeding
on probing or gingival index scores. With
rare exception, the studies areconsistent in
that neither treatment regimen shows an
advantage in reducing gingival inflammation, either short-term or long-term (Pihlstrom et al. 1981, 1983, Lindhe et al.
1982, 1987, Isidor et al. 1984, Lindhe &
Nyman 1985, Renvert et al. 1985, 1990b,
Westfelt et al. 1985, Isidor & Karring
1986, Becker et al. 1988, Kalkwarf et al.
1989).
When plaque control alone was compared with plaque control plus root
planing, all studies reported that plaque
control alone produced either no change
or a minimal reduction in clinical inflammation. However, root planing plus
plaque control consistently produced a
greater reduction in the inflammatory
indices in all studies (Tagge et al.
1975, Listgarten et al. 1978, Helldén
et al. 1979, Badersten et al. 1981,
1984a, Cercek et al. 1983, Kalkwarf
et al. 1989). Using the gingival index
of Löe and Silness (Löe 1967), it appears
that a reduction of one scoring level was
routine for the collected studies; e.g. a
baseline score of 2.0 reduced to a score
of 1.0.
Variations on a theme
Recently, Anderson et al. (1996) evaluated the effectiveness of calculus removal of a single episode of subgingival scaling and root planing versus
that removed by three episodes of instrumentation. In the final analysis, the
authors concluded that there was no
significant difference in the effectiveness
of calculus removal between single and
multiple episodes of scaling and root
planing. Their findings confirm those
of an earlier study by Badersten et al.
(1984b), which used changes in clinical
parameters as the assessment end-point
and also showed no difference between
single and multiple episodes of instrumentation. However, recent studies comparing traditional consecutive sessions
of quadrant scaling and root planing over
time to a one-stage, full-mouth ‘disinfection’ report that significant clinical
and microbiological improvements are
associated with the latter approach
(Quirynen et al. 1995, Bollen et al.
1996b, Vandekerckhove et al. 1996, Bollen et al. 1998, Mongardini et al. 1999).
In this series of studies, a full-mouth
disinfection consisted of a definitive
scaling and root planing in less than
24 h, pocket irrigation with a 1% chlorhexidine gel (three times in 10 min.),
oral rinsing with 0.2% chlorhexidine
twice a day for 1 min. for 14 days, and
daily tongue brushing. At 2 months posttreatment, the full-mouth disinfection
treatment group exhibited a significant
additional reduction in probing depth of
1.4 mm for multirooted teeth and 2.3 mm
for single-rooted teeth in pockets initially 7 mm. Differential phase contrast
microscopy revealed significantly lower
proportions of spirochetes and motile
rods in the test group at 1 month posttreatment. Evaluation at 8 months posttherapy confirmed the 2-month findings,
i.e. reductions in probing depth and proportions of spirochetes and motile rods,
although statistical significance of the
differences between test and control
groups disappeared after 2 months.
Thus, based on this limited series of
studies, one might conclude that, indeed,
full-mouth ‘disinfection’ suppresses the
possibility of cross-contamination between treated and untreated sites that
may occur during the more traditional
treatment protocol.
Summary
Sub-gingival debridement and scaling
and root planing are the traditional methods of controlling sub-gingival microflora. The objectives of sub-gingival
debridement are to remove not only
adherent and unattached bacterial plaque
but also, to a lesser extent, deposits of
calculus. The primary objective of scaling and root planing is the removal of
both calculus and contaminated cementum. The effectiveness of either procedure decreases with increasing probing
depth, especially when probing depths
exceed 5 mm (Cobb 1996). Except for
the decreased time required to achieve
clinical end-points, there is no specific or
significant difference between manual
Perspective on scaling and root planing
and sonic/ultrasonic instrumentation.
Each method of instrumentation appears
to yield the same degree of sub-gingival
calculus removal and control of subgingival plaque, and both provoke a
similar healing response (Walsh & Waite
1978, Torfason et al. 1979, Badersten
et al. 1984a, 1984b, Leon & Vogel
1987, Oosterwaal et al. 1987, Eschler &
Rapley 1991, Cobb 1996). Equivalent
results when evaluating manual and
sonic/ultrasonic instrumentation appear
to be generalizable, even when comparing closed (no surgery) to open (surgical
exposure of the root surface)
approaches. Thus, 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.
Regardless of instrument choice,
inter-proximal areas, furcas, the
cemento-enamel junction and multirooted teeth are most likely to exhibit
residual plaque and calculus following
treatment (Hunter et al. 1984, Gellin
et al. 1986, Breininger et al. 1987,
Fleischer et al. 1989, Patterson et al.
1989, Takacs et al. 1993, Kocher et al.
1998a, 1998b). Further, as probing depth
increases, scaling and root planing
becomes less effective at removing bacterial plaque and calculus (Waerhaug
1978a, 1978b, Rabbani et al. 1981,
Stambaugh et al. 1981, Caffesse et al.
1986, Fleischer et al. 1989).
A single session of sub-gingival root
planing can yield a significant reduction
in the bacterial population, even without
effective removal of all sub-gingival calculus (Breininger et al. 1987). In fact,
there appears to be no additional benefit
from a single versus multiple episodes of
sub-gingival scaling and root planing
(Badersten et al. 1984b, Anderson et al.
1996). Recent studies indicate that the
traditional quadrant-by-quadrant treatment separated by extended periods of
time is less effective at controlling
selected sub-gingival bacteria and yielding reductions in clinical parameters
than a complete mouth treatment performed in one or two sessions separated
by a few hours (Quirynen et al. 1995,
Bollen et al. 1996b, 1998, Vandekerckhove et al. 1996). Finally, one must not
forget supragingival contributions to the
sub-gingival bacterial population. It
appears that the sub-gingival microbial
flora has supragingival origins (Waerhaug 1978b, Mousques et al. 1980, Magnusson et al. 1984, Braatz et al. 1985,
McAlpine et al. 1985, Sbordone et al.
1990, Pedrazzoli et al. 1992). Westfelt
et al. (1998) have reported that in
patients with advanced periodontal disease, control of supragingival plaque in
the absence of sub-gingival therapy fails
to prevent further destruction of the periodontal tissues. This observation concurs with that of Kaldahl et al. (1996b),
who noted continued attachment loss in
patients with chronic periodontitis who
received only supragingival therapy. The
results of these two studies would appear
to be at odds with numerous previous
studies. For example, it has been shown
that meticulous supragingival plaque
control may interfere with both the quantity and quality of the sub-gingival
microbiota and the clinical symptoms
associated with adult periodontitis. As
the quantity, composition and rate of
sub-gingival plaque recolonization is,
to some degree, dependent upon supragingival plaque accumulation (Dahlén
et al. 1992, Katsanoulas et al. 1992,
McNabb et al. 1992, Hellström et al.
1996), it would seem that effective
supragingival control of microbial plaque would be absolutely critical if the
clinician hopes to achieve long-term
control of inflammatory periodontal disease (Lindhe & Nyman 1975, 1984,
Knowles et al. 1979, Nyman & Lindhe
1979, Axelsson & Lindhe 1981a, 1981b,
Westfelt et al. 1983). The apparent conflict between the Westfelt et al. (1998)
and Kaldahl et al. (1996b) studies and
the other investigations noted may simply be that supragingival plaque control
is effective in early and moderate disease
but not advanced periodontal disease.
This would seem to make sense given
the dramatic changes in microbial ecology that occur as probing depths deepen.
Discussion
Dr Jeffcoat: It is familiar literature, but
still, as we take a look at it with a
different point of view, as we will be
for the rest of the morning, with what is
clinical significance . . . Do you feel that
the literature at this point would bear out
a threshold for what is a good scaling and
root planing, or is it very highly patient
dependent? What would you say in
having done this literature review?
Dr Cobb: Having done this review for
the second or third time now in the last
5 years, it has become apparent to me
that there are very few studies with
which one could do a meta-analysis.
For instance, the experimental designs
11
vary greatly, and, of course, of late the
studies that have been done used scaling
and root planing as the quadrant to which
one compares the site-specific treatments, so it is a positive-control quadrant, so to speak. My feeling, to answer
your question, is that I would have to go
on the average or the mean data of all of
these studies which show that in a 6-mm
pocket, you can expect roughly a 1.5mm reduction, half of that being gain in
clinical attachment. It occurs over and
over, and I have noticed that even in
presentations yesterday morning that
the quadrants used as positive controls,
which were scaling and root planing, had
the same types of measurements that I
have derived from the literature. So it
has not seemed to change over several
decades.
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Address:
Dr Charles M. Cobb
Department of Periodontics
School of Dentistry
University of Missouri-Kansas City
650 East 25th Street
Kansas City
MO 64108
USA
e-mail: [email protected]