scaling and root planing scaling and root planing scaling and root planing, also known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is a procedure involving removal of dental plaque and calculus (scaling or debridement) and then smoothing, or planing, of the (exposed) surfaces of the roots, removing cementum or dentine that is impregnated with calculus, toxins, or microorganisms, the agents that cause inflammation. it is a part of non-surgical periodontal therapy. this helps to establish a periodontium that is in remission of periodontal disease. periodontal scalers and periodontal curettes are some of the tools involved. scaling and root planingclose-up image of a hand scalericd-9-cm96.54meshd012534 a regular, non-deep teeth cleaning includes tooth scaling, tooth polishing, and debridement if too much tartar has accumulated, but does not include root planing. plaque main article: dental plaque plaque is a soft yellow-grayish substance that adheres to the tooth surfaces including removable and fixed restorations. it is an organised biofilm that is primarily composed of bacteria in a matrix of glycoproteins and extracellular polysaccharides. this matrix makes it impossible to remove the plaque by rinsing or using sprays. materia alba is similar to plaque but it lacks the organized structure of plaque and hence easily displaced with rinses and sprays. although everyone has a tendency to develop plaque and materia alba, through regular brushing and flossing these organized colonies of bacteria are disturbed and eliminated from the oral cavity. in general, the more effective one's brushing, flossing, and other oral homecare practices, the less plaque will accumulate on the teeth. however, if, after 24 hours in the oral environment, biofilm remains undisturbed by brushing or flossing, it begins to absorb the mineral content of saliva. through this absorption of calcium and phosphorus from the saliva, oral biofilm is transformed from the soft, easily removable form into a hard substance known as calculus. commonly known as 'tartar', calculus provides a base for new layers of plaque biofilm to settle on and builds up over time. calculus cannot be removed by brushing or flossing. plaque build up and bone loss plaque accumulation tends to be thickest along the gumline. because of the proximity of this area to the gum tissue, the bacterial plaque begins to irritate and infect the gums. this infection of the gum causes the gum disease known as gingivitis, which literally means inflammation of the gingiva, or gums. gingivitis is characterized by swelling, redness and bleeding gums. it is the first step in the decline of periodontal health, and the only step which can be fully reversed to restore one's oral health. as the gingival tissue swells, it no longer provides an effective seal between the tooth and the outside environment. vertical space is created between the tooth and the gum, allowing new bacterial plaque biofilm to begin to migrate into the sulcus, or space between the gum and the tooth. in healthy individuals, the sulcus is no more than 3 mm deep when measured with a periodontal probe. as the gingivitis stage continues, the capillaries within the sulcus begin to dilate, resulting in more bleeding when brushing, flossing, or at dental appointments. this is the body's attempt to clear the infection from the tissues. thus, bleeding is generally accepted as a sign of active oral infection. the swelling of the tissue may also result in deeper reading on periodontal probing, up to 4 mm. at a depth of 4 mm or greater, the vertical space between the tooth and surrounding gum becomes known as a periodontal pocket. because tooth brush and floss cannot reach the bottom of a gum pocket 4–5 mm deep, bacteria stagnate in these sites and have the opportunity to proliferate into periodontal disease-causing colonies. once bacterial plaque has infiltrated the pocket, the transformation from biofilm into calculus continues. this results in an ulceration in the lining of the tissue, which begins to break down the attachment of the gum to the tooth. gingival attachment begins to loosen further as the bacterial plaque continues to invade the space created by the swelling it causes. this plaque eventually transforms into calculus, and the process continues, resulting in deposits under the gum, and an increase in pocket depth. as the depth of the vertical space between the tooth and the gum reaches 5mm, a change occurs. the bacterial morphology, or make up, of the biofilm changes from the gram positive aerobic bacteria found in biofilm located supragingivally, or above the gumline. replacing these gram positive bacteria of the general oral flora are obligate anaerobic gram negative bacteria. these bacteria are far more destructive in nature than their aerobic cousins. the cell walls of gram negative bacteria contain endotoxins, which allow these organisms to destroy gingival tissue and bone much more quickly. periodontitis officially begins when these bacteria begin to act, resulting in bone loss. this bone loss marks the transition of gingivitis to true periodontal disease. in other words, the term periodontal disease may be synonymous with bone loss. the first evidence of periodontal disease damage becomes apparent in radiographs as the crestal bone of the jaw begins to become blunted, slanted, or scooped out in appearance. this destruction occurs as a result of the effect of bacterial endotoxins on bone tissue. because the bone is alive, it contains cells in it that build bone, known as osteoblasts, and cells that break down bone, called osteoclasts. usually these work at the same speed and keep each other in balance. in periodontitis, however, the chemical mediators, or by-products, of chronic inflammation stimulate the osteoclasts, causing them to work more rapidly than the cells that build bone. the net result is that bone is lost, and the loss of bone and attachment tissues is called periodontal disease. these processes will persist, causing greater damage, until the infectious bacterial agents (plaque) and local irritating factors (calculus) are removed. in order to effectively remove these at this stage in the disease process, brushing and flossing are no longer sufficient. this is due to several factors, the most important to note being the depth of the periodontal pocket. brushing and flossing are effective only at removing the soft materia alba and biofilm in supragingival areas, and in pockets up to 3 mm deep. even the best brushing and flossing is ineffective at cleaning pockets of greater depths, and are never effective in removing calculus. therefore, in order to remove the causative factors that lead to periodontal disease, pocket depth scaling and root planing procedures are often recommended. once the bacteria and calculus are removed from the periodontal pocket, the tissue can begin to heal. the inflammation dissipates as the infection declines, allowing the swelling to decrease which results in the gums once again forming an effective seal between the root of the tooth and the outside environment. however, the damage caused by periodontal disease never heals completely. bone loss due to the disease process is irreversible. the gingival tissue of the gums also tends to suffer permanent effects once the disease reaches a certain point. because gum tissue requires bone to support it, if bone loss has been extensive, a patient will have permanent recession of the gums, and therefore exposure of the roots of the teeth in involved areas. if the bone loss is extensive enough, the teeth may begin to become mobile, or loose, and without intervention to arrest the disease process, will be lost. contrary to old beliefs, it is not a normal part of aging to lose one's teeth. rather, it is periodontal disease that is the main cause of tooth loss in the adult population. periodontal intervention treatment of periodontitis may include several steps, the first of which often requires the removal of the local causative factors in order to create a biologically compatible environment between the tooth and the surrounding periodontal tissues, the gums and underlying bone. left untreated, chronic inflammation of the gums and supporting tissue can raise a person's risk of heart disease. prior to beginning these procedures, the patient is generally numbed in the area intended for instrumentation. because of the deeper nature of periodontal scaling and root planing, either one half or one quarter of the mouth is generally cleaned during one appointment. this allows the patient to be entirely numbed in the necessary area during treatment. it is usually not recommended to have the entire mouth scaled at one appointment because of the potential inconveniences and complications of numbing the entire mouth- i.e., inability to eat or drink, likelihood of self injury by biting, etc. generally, the first step is the removal of dental plaque, the microbial biofilm, from the tooth, a procedure called scaling. root planing involves smoothing the tooth's root. these procedures may be referred to as scaling and root planing, periodontal cleaning, or deep cleaning. these names all refer to the same procedure. the term "deep cleaning" originates from the fact that pockets in patients with periodontal disease are literally deeper than those found in individuals with healthy periodontia. such scaling and root planing may be performed using a number of dental tools, including ultrasonic instruments and hand instruments, such as periodontal scalers and curettes. a dental hygienist demonstrates scaling the objective for periodontal scaling and root planing is to remove dental plaque and calculus (tartar), which house bacteria that release toxins which cause inflammation to the gum tissue and surrounding bone. planing often removes some of the cementum or dentine from the tooth. removal of adherent plaque and calculus with hand instruments can also be performed prophylactically on patients without periodontal disease. a prophylaxis refers to scaling and polishing of the teeth in order to prevent oral diseases. polishing does not remove calculus, but only some plaque and stains, and should therefore be done only in conjunction with scaling. often, an electric device, known as an ultrasonic scaler, sonic scaler, or power scaler may be used during scaling and root planing. ultrasonic scalers vibrate at a high frequency to help with removing stain, plaque and calculus. in addition, ultrasonic scalers create tiny air bubbles through a process known as cavitation. these bubbles serve an important function for periodontal cleanings. since the bacteria living in periodontically involved pockets are mainly obligate anaerobes, meaning unable to survive in the presence of oxygen, these bubbles help to destroy them. the oxygen helps to break down bacterial cell membranes and causes them to lyse, or burst. since it is of the utmost importance to remove the entirety of the deposit in each periodontal pocket, attention to detail during this procedure is crucial. therefore, depending on the depth of the pocket and amount of calculus deposit versus soft biofilm deposit, hand instruments may be used to complete the fine hand scaling that removes anything the ultrasonic scaler left behind. alternatively, power scalers may be used following hand scaling in order to dispel deposits that have been removed from the tooth or root structure, but remain within the periodontal pocket. two ultrasonic instruments sonic and ultrasonic scalers are powered by a system that causes the tip to vibrate. sonic scalers are powered by an air-driven turbine. ultrasonic scalers use either magnetostrictive or piezoelectric systems to create vibration. magnetostrictive scalers use a stack of metal plates bonded to the tool tip. the stack is induced to vibrate by an external coil connected to an ac source. ultrasonic scalers also include a liquid output or lavage, which aids in cooling the tool during use, as well as rinsing all the unwanted materials from the teeth and gum line. the lavage can also be used to deliver antimicrobial agents. although the final result of ultrasonic scalers can be produced by using hand scalers, ultrasonic scalers are sometimes faster and less irritating to the client. ultrasonic scalers do create aerosols which can spread pathogens when a client carries an infectious disease. research differs on whether there is a difference in effectiveness between ultrasonic scalers and hand instruments. of particular importance to dentists themselves is that the use of an ultrasonic scaler may reduce the risk of repetitive stress injury, because ultrasonic scalers require less pressure and repetition compared to hand scalers. a new addition to the tools used to treat periodontal disease is the dental laser. lasers of differing strengths are used for many procedures in modern