Table of Contents
The difference between scaling and root planing
Treatment for all stages of periodontal disease involves the thorough removal of all plaque and calculus that has adhered to the teeth. Even for patients who fit into the “prophylaxis patient” category above, calculus may build up very slightly below the gum line. This can be removed during a normal prophylaxis without too much discomfort on the part of the patient. When the damage from gum disease is slight, this can be done without local anesthesia. The process is called “scaling” and is on the right image below.
When the damage from periodontal disease is more pronounced, exposing more root structure above bone, the process is called “root planing“. Think of a carpenter’s wood plane. It is like smoothing the surface of a piece of wood, except it is done on the root of a tooth. Root planing always requires local anesthesia. The figure on the left above shows the full extent of the area scaled. The root of a tooth is naturally sensitive, and that is why local anesthesia may be needed when working in this area. It is apparent that there is also a great deal more root available to scale, which means more work for the hygienist or dentist to do. This accounts for the greater cost of a periodontal cleaning.
The images on the left are what the teeth looked like before scaling. The image on the right are the same teeth after scaling.
Whenever the condition of the gums requires root planing or surgical procedures, the treatment is usually accompanied by a course of antibiotics, such as special forms of tetracycline, which have an affinity for teeth and gums. The hygienist may also apply localized antibiotics or other medicaments beneath the gum line in deep pockets after finishing the root planing procedure. Because periodontal disease is the body’s response to what is essentially a bacterial attack on the gums, the use of antibiotics, along with the drastically altered conditions around the teeth brought about by the root planing procedure can give the body a great boost in its fight against the disease.
Three categories of gum surgery (plus one)
The periodontist will generally assess the patient for surgical procedures to reduce the pockets to make it possible to maintain the hygiene himself. There are three general categories of pocket elimination surgeries performed by periodontists, over and above scaling and root planingwhich also is always done during these surgeries.
Gingivectomy is used mostly in the treatment of Type II periodontal disease. In this case, the level of the bone is ascertained, and the gingiva are simply cut off at that level. By eliminating the top of the gingiva, the sulcus is reduced to manageable depth, and oral hygiene can resume at normal levels. This type of surgery used to be the gold standard in the treatment of periodontal disease, but patients were left with long teeth and irregular gum lines. Also, simple gingivectomies did nothing to correct the bony defects seen in more severe type III disease. This type of surgery still has its place, but it has been eclipsed by other more modern forms.
Dilantin (phenytoin)–A drug used to treat seizures in epileptics–can cause overgrowth of the gums (gingival hyperplasia), especially in persons who do not brush their teeth regularly. The image above shows what the combination of poor oral hygiene and Dilantin can do to a patient’s gums. Certain other commonly used medications can also cause this condition, although to a lesser extent. They include blood pressure medications in the calcium channel blocker category (Cardizem), birth control and hormone replacement drugs (Progestogen) and immunosupressive agents such as cyclosporine. Better oral hygiene generally reduces likelihood of this complication. This type of gingival enlargement can be prevented by good hygiene, but once it occurs, the only way to eliminate it is through surgical removal of the excess tissue–in other words, a gingivectomy.
2. Apically Repositioned Flap
In an Apically repositioned flap procedure, a pair of vertical incisions are made at either end of a scalloped incision around the necks of the teeth. The gingiva are then retracted exposing the bone and roots underneath. Once exposed, the bone is reshaped. and sometimes augmented with bone-graft material to eliminate bony pockets and to even out the gum line. After the bone has been resculpted, the gingiva are replaced back into a position which is closer to the bone line. This results in an even, and well scalloped gum line. Because of the care taken in reshaping the underlying bone, this surgery technique produces much more esthetic results than gingivectomy and allows for the treatment of the bony defects seen in type III disease.
3. Functional and esthetic grafting techniques
The ability to replace bone and gum tissues lost to periodontal disease has made slow but steady progress over the last twenty years. Where once the non supporting bone surrounding the “wells” of the infrabony pockets could only be shaved down to allow for better healed contours of soft tissue around the roots of teeth, now it has become possible to replace some of the missing bone with bone graft material. The use of bone graft material generally requires the use of a collagen membrane to help hold it place. The use of bone graft material and a collagen membrane is called guided tissue regeneration (GTR).
Sometimes, it is advantageous to use grafting procedures to improve the appearance of the teeth and gums. This is frequently done by moving gum tissue from places where it can rebuild itself, such as from the roof of the mouth, to areas where it is needed for esthetic repair. In fact, these repairs have functional value as well, and may make quite an improvement in the overall health of the teeth and gums.
4. Laser-assisted new attachment procedure (LANAP)
LANAP is a therapy designed for the “effective treatment of periodontitis” through regeneration rather than resection. In other words, it is claimed to be a relatively simple way to root plane the teeth, as well as to perform curettage, which means removing diseased soft tissue from the lining of the periodontal pocket. In this procedure, a special laser (variable pulsed neodymium:yttrium-aluminum-garnet) is used to debride the periodontal pocket, removing the diseased epithelial tissue from the lining of the pocket, as well as calculus and diseased cementum from the tooth root. This allows regeneration of both soft tissue epithelium and the cementum. It is claimed that this procedure creates a new periodontal attachment which is supposed to be more resistant to further disease.
The studies and claims for this procedure come nearly exclusively from Millennium Dental Technologies, Inc., the manufacturer of the laser, or from academics closely associated with the company. I can make no claims about LANAP except to say that the American Academy of Periodontology (the premier mainstream organization representing periodontists in the United States) has issued this statement: “The Academy [has] urged Millennium to withdraw its marketing claims due to insufficient evidence.”