Scaling and root planing

Scaling and Root
Planing
Presented by: Presented to:
Apekshya Dhakal Dr. Nawaraj Lamdari
BDS 2nd Batch Dr. Lalbabu Kumait
Roll no. 10 Dept. of Periodontics

Contents
• Introduction
• Periodontal instruments
• Principles of instrumentation
• Principles of scaling and root planing
• Supragingival scaling technique
• Subgingival scaling technique
• Various approaches to instrumentation
• Conclusion

Introduction:
• Scaling is the process by which biofilm and calculus are removed
from both supragingival and subgingival tooth surfaces.
• Root planing is the process by which residual embedded calculus
and portions of cementum are removed from the roots to produce
a smooth, hard, clean surface.

Classification of PeriodontalInstruments
Periodontal instruments are classified according to the purposes they
serve, as follows:
1. Periodontal probes
2. Explorers
3. Scaling, root-planing, and curettage instruments :
 Sickle scaler
 Hoe, chisel, and file scalers
 Ultrasonic and sonic instruments
4. Periodontal endoscopes
5. Cleansing and polishing instruments

Periodontalprobes:
• Used to locate, measure, and mark pockets,
as well as determine their course on
individual tooth surfaces.
• Tapered, rod like instrument calibrated in
millimeters, with a blunt, rounded tip .
• The World Health Organization (WHO) probe
has millimeter markings and a small, round
ball at the tip.

• Furcation areas can best be
evaluated with the curved, blunt
Nabers probe .
• The shank should be aligned with
the long axis of the tooth surface to
be probed.

Explorers:
• They are used to locate subgingival calculus deposits and caries.
• Also used to check the smoothness of the root surfaces after root
planing.

Scalingand CurettageInstruments:
Sickle Scalers:
• Used primarily to remove supragingival
calculus.
• Have a flat surface and two cutting edges
that converge in a sharply pointed tip.
• Sickle scalers are used with a pull stroke.
• Sickle scalers with straight shanks are
designed for use on anterior teeth and
premolars and those with contra-angled
shanks adapt to posterior teeth.

Curettes:
• Used for removing deep subgingival calculus, root planing altered
cementum, and removing the soft tissue lining the periodontal
pocket.
• The curette is finer than the sickle scalers and does not have any
sharp points or corners other than the cutting edges of the blade.
Therefore curettes can be adapted and provide good access to deep
pockets, with minimal soft tissue trauma.

There are two basic types of curettes:
1. Universal curettes
2. Area specific curettes
Universal curettes:
• Universal curettes have cutting edges that may be inserted in most
areas of the dentition by altering and adapting the finger rest,
fulcrum, and hand position of the operator.
• The face of the blade of every universal curette is at a 90-degree
angle (perpendicular) to the lower shank when seen in cross-
section from the tip.

Area-Specific Curettes:
Gracey Curettes:
• A set of several instruments designed and angled to adapt to
specific anatomic areas of the dentition.
• They provide the best adaptation to complex root anatomy.
• Double-ended Gracey curettes are paired in the following manner:
Gracey #1-2 and 3-4: Anterior teeth
Gracey #5-6: Anterior teeth and premolars
Gracey #7-8 and 9-10: Posterior teeth: facial and lingual
Gracey #11-12: Posterior teeth: mesial
Gracey #13-14: Posterior teeth: distal

• Recent additions to the Gracey curette set:
Gracey #15-16 and 17-18.
The Gracey #15-16:
 modification of the standard #11-12 and is designed for the
mesial surfaces of posterior teeth.
 Gracey #11-12 blade combined with the more acutely angled #13-
14 shank
Gracey #17-18 :
 modification of the #13-14.
 It has a terminal shank elongated by 3 mm and a more accentuated
angulation of the shank to provide complete occlusal clearance and
better access to all posterior distal surfaces.

Extended-Shank Curettes:
• Are modifications of the standard Gracey curette design.
• The terminal shank is 3 mm longer, allowing extension into deeper
periodontal pockets of 5 mm or more.
• Has a thinned blade for smoother subgingival insertion and reduced
tissue distention.

Mini-Bladed Curettes.
• Mini-bladed curettes, such as the Hu-Friedy Mini Five curettes, are
modifications of the After Five curettes.
• The Mini Five curettes feature blades that are half the length of the
After Five or standard Gracey curettes
• The shorter blade allows easier insertion and adaptation in deep,
narrow pockets; furcations; developmental grooves; line angles; and
deep, tight, facial, lingual, or palatal pockets.

Langer and Mini-Langer Curettes.
• The Langer and Mini Langer curettes are a 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 degrees rather
than the offset blade of the Gracey curette.
• The Langer #5-6 curette adapts to the mesial and distal surfaces of
anterior teeth;
mandibular posterior teeth;
maxillary posterior teeth.

Hoe Scalers:
Used for scaling of ledges or rings of calculus.
The blade is inserted to the base of the periodontal pocket so that it
makes two-point contact with the tooth.
This stabilizes the instrument and prevents nicking of the root.
The instrument is activated with a firm pull stroke toward the crown.

Chisel Scalers:
Designed for the proximal surfaces of teeth too
closely spaced to permit the use of other scalers.
It is a double-ended instrument with a curved
shank at one end and a straight shank at the
other.
The blades are slightly curved and have a straight
cutting edge beveled at 45 degrees.

GeneralPrinciplesof Instrumentation

Accessibility: Positioningof Patientand Operator
• The position of the patient and operator should provide maximal
accessibility to the area of operation.
The clinician’s position:
• His/her feet should be flat on the floor.
• The thighs parallel to the floor.
• Back straight and the head erect.

Patient’s position:
• Supine position and placed so that the mouth is close to the resting
elbow of the clinician.
• For instrumentation of the maxillary arch, the patient should be
asked to raise the chin.
• For instrumentation on the mandibular arch, the patient should be
asked to lower the chin until the mandible is parallel to the floor.

Visibility, Illumination,and Retraction
• Whenever possible, direct vision with direct illumination from the
dental light is most desirable.
• If this is not possible, indirect vision may be obtained by using the
mouth mirror and indirect illumination may be obtained by using the
mirror to reflect light to where it is needed.

• Retraction provides visibility, accessibility, and illumination.
• The mirror may be used for retraction of the cheeks or the tongue.
• The index finger is used for retraction of the lips or cheeks.

Conditionand Sharpness of Instruments
• Before any instrumentation, all instruments should be inspected to
make sure that they are clean, sterile, and in good condition.
• Sharp instruments:
 Enhance tactile sensitivity and allow the clinician to work more
precisely and efficiently .
• Dull instruments :
 Incomplete calculus removal
 Unnecessary trauma because of the excess force usually applied to
compensate for their ineffectiveness.

Maintaininga Clean Field
• Despite good visibility, illumination, and retraction, instrumentation
can be hampered if the operative field is obscured by saliva, blood,
and debris.
• Adequate suction is essential.
• Blood and debris can be removed from the operative field with
suction and by wiping or blotting with gauze squares.

InstrumentStabilization
The two factors of major importance in providing stability are the
instrument grasp and the finger rest.
Instrument Grasp: A proper grasp is essential for precise control of
movements made during periodontal instrumentation.
Modified pen grasp : The thumb, index finger, and middle finger are
used to hold the instrument as a pen is held, but the pad of the
middle finger rests on the shank.

Standard pen grasp:
The side of the middle finger rests on the shank.
The palm and thumb grasp:
Is useful for stabilizing instruments during sharpening and for
manipulating air and water syringes

Finger Rest:
• The finger rest serves to stabilize the hand and the instrument by
providing a firm fulcrum as movements are made to activate the
instrument.
• The fourth (ring) finger is preferred by most clinicians for the finger
rest.

Intraoral finger rest:
• Conventional: The finger rest is established on tooth surfaces
immediately adjacent to the working area.
• Cross-arch: The finger rest is established on tooth surfaces on the
other side of the same arch.
• Opposite arch: The finger rest is established on tooth surfaces on
the opposite arch.
• Finger on finger: The finger rest is established on the index finger or
thumb of the non-operating hand .

Extraoral fulcrums:
• Palm up: By resting the backs of the middle and fourth fingers on
the skin overlying the lateral aspect of the mandible on the right
side of the face.
• Palm down: By resting the front surfaces of the middle and fourth
fingers on the skin overlying the lateral aspect of the mandible on
the left side of the face.

InstrumentActivation
Adaptation:
• Adaptation refers to the manner in which the working end of a
periodontal instrument is placed against the surface of a tooth.
• Precise adaptation :
 To avoid trauma to the soft tissues and root surfaces
 To ensure maximum effectiveness of instrumentation.
• Precise adaptation is maintained by carefully rolling the handle of
the instrument against the index and middle fingers with the thumb.
This rotates the instrument in slight degrees so that the toe or tip
leads into concavities and around convexities.

Angulation:
• Angulation refers to the angle between the face of a bladed
instrument and the tooth surface.
• It may also be called the tooth-blade relationship.
• For subgingival insertion of a bladed instrument such as a curette,
angulation should be as close to 0 degree as possible.
• During scaling and root planing, optimal angulation is between 45
and 90 degrees .

• During scaling, angulation should be just less than 90 degrees so
that the cutting edge “bites” into the calculus.
• With angulation of less than 45 degrees, the cutting edge will not
bite into or engage the calculus properly. Instead, it will slide over
the calculus, smoothing or “burnishing” it.

Lateral Pressure:
• Lateral pressure refers to the pressure created when force is
applied against the surface of a tooth with the cutting edge of a
bladed instrument.
• Lateral pressure may be firm, moderate, or light.

Strokes:
Three basic types of strokes are used during instrumentation:
I. The exploratory stroke,
II. The scaling stroke, and
III. The root planing stroke.
The exploratory stroke is a light, “feeling” stroke that is used with
probes and explorers to evaluate the dimensions of the pocket and
to detect calculus and irregularities of the tooth surface.
The scaling stroke is a short, powerful pull stroke that is used with
bladed instruments for the removal of both supragingival and
subgingival calculus.
The root-planing stroke is a moderate to light pull stroke that is used
for final smoothing and planing of the root surface.

Principles ofScaling and Root Planing
• The primary objective of scaling and root planing is to restore
gingival health by completely removing elements that provoke
gingival inflammation (i.e., biofilm, calculus, and endotoxin) from
the tooth surface.
• Scaling and root planing should not be viewed as separate
procedures unrelated to the rest of the treatment plan.
• After careful analysis of a case, the number of appointments
needed to complete this phase of treatment is estimated.
• Patients with small amounts of calculus and relatively healthy
tissues can be treated in one appointment.

• The dentist should estimate the number of appointments needed
on the basis of the number of teeth in the mouth, severity of
inflammation, amount and location of calculus, depth and activity
of pockets, presence of furcation invasions, patient’s
comprehension of and compliance with oral hygiene instructions,
and need for local anesthesia.

DetectionSkills
• Good visual and tactile detection skills are required for the accurate
initial assessment of the extent and nature of deposits and root
irregularities before scaling and root planing.
• Light deposits of supragingival calculus are often difficult to see
when they are wet with saliva.
• Compressed air may be used to dry supragingival calculus until it is
chalky white and readily visible.
• Air also may be directed into the pocket in a steady stream to
deflect the marginal gingiva away from the tooth so that
subgingival deposits near the surface can be seen.

• Tactile exploration of the tooth surfaces in subgingival areas of
pocket depth, furcations, and developmental depressions is much
more difficult than visual examination of supragingival areas and
requires the skilled use of a fine-pointed explorer or probe.
• The explorer or probe is held with a light but stable modified pen
grasp.
• After a stable finger rest is established, the tip of the instrument is
carefully inserted subgingivally to the base of the pocket.
• Light exploratory strokes are activated vertically on the root
surface.

• When calculus is encountered, the tip of the instrument should be
advanced apically over the deposit until the termination of the
calculus on the root is felt.
• The distance between the apical edge of the calculus and the bottom
of the pocket usually ranges from 0.2 to 1.0 mm.
• The tip is adapted closely to the tooth to ensure the greatest degree
of tactile sensitivity and avoid tissue trauma.

SupragingivalScalingTechnique
• Supragingival calculus is generally less tenacious and less calcified
than subgingival calculus.
• Sickles, curettes, and ultrasonic and sonic instruments are most
often used for the removal of supragingival calculus.
• The sickle or curette is held with a modified pen grasp, and a firm
finger rest is established on the teeth adjacent to the working area.
• The blade is adapted with an angulation of slightly less than 90
degrees to the surface being scaled.
• The cutting edge should engage the apical margin of the
supragingival calculus while short, powerful, overlapping scaling
strokes are activated coronally in a vertical or an oblique direction.

SubgingivalScaling and Root-PlaningTechnique
• 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 inevitably occurs during
instrumentation and by the tissue itself.
• In addition, the adjacent pocket wall limits the direction and length
of the strokes.
• The curette is preferred by most clinicians for subgingival scaling
and root planing because of the advantages afforded by its design.

• Its curved blade, rounded toe, and curved back allow the curette to
be inserted to the base of the pocket and adapted to variations in
tooth contour with minimal tissue displacement and trauma.
• Sickles, hoes, files, and ultrasonic instruments also are used for
subgingival scaling of heavy calculus.
• Some small files may be inserted to the base of the pocket to crush
or initially fracture tenacious deposits.

• The curette is held with a modified pen grasp, and a stable finger
rest is established.
• The correct cutting edge is slightly adapted to the tooth, with the
lower shank kept parallel to the tooth surface.
• The lower shank is moved toward the tooth so that the face of the
blade is nearly flush with the tooth surface.
• The blade is then inserted under the gingiva and advanced to the
base of the pocket by a light exploratory stroke. When the cutting
edge reaches the base of the pocket, a working angulation of
between 45 and 90 degrees is established, and pressure is applied
laterally against the tooth surface.
• Calculus is removed by a series of controlled, overlapping, short,
powerful strokes primarily using wrist-arm motion.

• As calculus is removed, resistance to the passage of the cutting
edge diminishes until only a slight roughness remains.
• Longer, lighter root-planing strokes are then activated with less
lateral pressure until the root surface is completely smooth and
hard.
• Scaling and root-planing strokes should be confined to the portion
of the tooth where calculus or altered cementum is found; this area
is known as the instrumentation zone.
• Sweeping the instrument over the crown where it is not needed
wastes operating time, dulls the instrument, and causes loss of
control.

• If heavy lateral pressure is continued after the bulk of calculus has
been removed and the blade is repeatedly readapted with short,
choppy strokes, the result will be a roughened root surface,
resembling the rippled surface of a washboard.
• If heavy lateral pressure is continued with long, even strokes, the
result will be excessive removal of root structure, producing a
smooth but “ditched” or “riffled” root surface.
• To avoid these hazards of over instrumentation, a deliberate
transition from short, powerful scaling strokes to longer, lighter root-
planing strokes must be made as soon as the calculus and initial
roughness have been eliminated.

Subgingival scaling procedure. A, Curette inserted with the face of the
blade flush against the tooth. B, Working angulation (45 to 90 degrees)
is established at the base of the pocket. C, Lateral pressure is applied,
and the scaling stroke is activated in the coronal direction.

Various approaches to instrumentation:
Maxillary right posterior sextant: facial aspect
• Operator position: Side position.
• Illumination: Direct.
• Visibility: Direct (indirect for distal surfaces of molars).
• Retraction: Mirror or index finger of the nonoperating hand.
• Finger rest: Extraoral, palm up.

Maxillary right posterior sextant, premolar region only: Facial aspect.
• Operator position: Side or back position.
• Visibility: Direct.
• Retraction: Mirror or index finger of the nonoperating hand.
• Finger rest: Intraoral, palm up. Fourth finger on the occlusal
surfaces of the adjacent maxillary posterior teeth.

Maxillary right posterior sextant: Lingual aspect
• Operator position: Side or front position.
• Illumination: Direct and indirect.
• Visibility: Direct or indirect.
• Retraction: None.
• Finger rest: Extraoral, palm up. Backs of the middle and fourth
fingers on the lateral aspect of the mandible on the right side of the
face.

Maxillary right posterior sextant: Lingual aspect
• Operator position: Front position.
• Finger rest: Intraoral, palm up, finger on finger.

Maxillary anterior sextant: Facial aspect, surfaces away from the
operator
• Operator position: Back position.
• Retraction: Index finger of the nonoperating hand.
• Finger rest: Intraoral, palm up. Fourth finger on the incisal edges or
occlusal surfaces of adjacent maxillary teeth.

Maxillary anterior sextant: Facial aspect, surfaces toward the operator
• Retraction: Index finger of the nonoperating hand.
• Finger rest: Intraoral, palm down. Fourth finger on the incisal edges
or the occlusal or facial surfaces of adjacent maxillary teeth.

Maxillary anterior sextant: Lingual
aspect, surfaces away from the
operator
• Illumination: Indirect.
• Visibility: Indirect.
• Finger rest: Intraoral, palm up.
Fourth finger on the incisal edges
or the occlusal surfaces of adjacent
maxillary teeth

Maxillary left posterior sextant: Facial aspect.
• Operator position: Side or back position.
• Illumination: Direct or indirect.
• Retraction: Mirror.
• Fingear rest: Extraoral, palm down. Front surfaces of the middle and
fourth fingers on the lateral aspect of the mandible on the left side
of the face.

Maxillary left posterior sextant: Facial aspect
• Operator position: Back or side position.
• Illumination: Direct or indirect.
• Retraction: Mirror.
• Finger rest: Intraoral, palm up. Fourth finger on the incisal edges or
the occlusal surfaces of adjacent maxillary teeth

Maxillary left posterior sextant: Lingual
aspect
• Finger rest: Intraoral, palm down,
opposite arch, reinforced. Fourth finger
on the incisal edges of the mandibular
anterior teeth or the facial surfaces of
the mandibular premolars, reinforced
with the index finger of the
nonoperating hand.

Maxillary left posterior sextant: Lingual
aspect
• Visibility: Direct and indirect.
• Finger rest: Extraoral, palm down.
Front surfaces of the middle and
fourth fingers on the lateral aspect
of the mandible on the left side of
the face. The nonoperating hand
holds the mirror for indirect
illumination.

Maxillary left posterior sextant: Lingual aspect
• Operator position: Side or front position.
• Finger rest: Intraoral, palm up. Fourth finger on the occlusal surfaces
of adjacent maxillary teeth.

Mandibular left posterior sextant:
Facial aspect
• Operator position: Side or back
position.
• Retraction: Index finger or
mirror of the non-operating
hand.
• Finger rest: Intraoral, palm
down. Fourth finger on the
incisal edges or the occlusal or
facial surfaces of adjacent
mandibular teeth.

Mandibular left posterior sextant: Lingual
aspect
• Operator position: Front or side
position.
• Retraction: Mirror retracts tongue.
• Finger rest: Intraoral, palm down.
Fourth finger on the incisal edges or
the occlusal surfaces of adjacent
mandibular teeth.

Mandibular anterior sextant: Facial
aspect, surfaces toward the
operator.
• Retraction: Index finger of the
non-operating hand.
or the occlusal surfaces of
adjacent mandibular teeth.

Mandibular anterior sextant: Facial
aspect, surfaces away from the
operator.
• Retraction: Index finger or thumb
of the nonoperating hand.

Mandibular anterior sextant: Lingual aspect, surfaces away from the
operator
• Retraction: Mirror retracts tongue.
• Finger rest: Intraoral, palm down. Fourth finger on the incisal edges
or the occlusal surfaces of adjacent mandibular teeth.

Mandibular anterior sextant:
Lingual aspect, surfaces toward
the operator.
• Operator position: Front
position.
• Illumination: Direct and
indirect.
• Retraction: Mirror retracts
tongue.
down. Fourth finger on the
incisal edges or the occlusal
surfaces of adjacent
mandibular teeth.

Mandibular right posterior sextant:
Facial aspect.
• Operator position: Side or front
position.
• Retraction: Mirror or index finger
of the nonoperating hand.

Mandibular right posterior
sextant: Lingual aspect.
• Operator position: Front
position.
• Illumination: Direct and
indirect.
• Visibility: Direct and
indirect.
• Retraction: Mirror retracts
tongue.
down. Fourth finger on
the incisal edges or the
occlusal surfaces of
adjacent mandibular
teeth.

conclusion
• Scaling and root planing is one of the most effective ways to treat
gum disease before it becomes severe.
• Proper instrumentation technique and chair positions helps the
operator to complete the procedure without delaying and also
reduces the chances of future musculoskeletal problems.

“You don’t have to lose teethto periodontal diseases. They
oftencan be treated successfully.”

References:
• Carranza, F. A., Takei, H. H., Klokkevold, P. R., & Newman, M. G.
(2012). Carranzas clinical periodontology (12th ed.). St. Louis (Mo):
Saunders Elsevier.
• Treating periodontal diseases. (2005). The Journal of the American
Dental Association, 136(1), 127.
doi:10.14219/jada.archive.2005.0036
• Caffesse, R. G., Sweeney, P. L., & Smith, B. A. (1986). Scaling and
root planing with and without periodontal flap surgery. Journal of
Clinical Periodontology J Clin Periodontol, 13(3), 205-210.
doi:10.1111/j.1600-051x.1986.tb01461.x

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