dentistry, including fillings. in a periodontal setting, a laser may be used following scaling and root planing in order to promote healing of the tissues. after scaling following scaling, additional steps may be taken to disinfect the periodontal tissues. oral irrigation of the periodontal tissues may be done using chlorhexidine gluconate solution, which has high substantivity in the oral tissues. this means that unlike other mouthwashes, whose benefits end upon expectorating, the active antibacterial ingredients in chlorhexidine gluconate infiltrate the tissue and remain active for a period of time. however effective, chlorhexidine gluconate is not meant for long-term use. a recent european study suggests a link between the long-term use of the mouthrinse and high blood pressure, which may lead to a higher incidence of cardiovascular events. in the united states, it is available only through a doctor's prescription, and in small, infrequent doses it has been shown to aid in tissue healing after surgery. current research indicates the irrigation of chx after sc/rp may inhibit the re-attachment of periodontal tissues. specifically preventing the formation of fibroblasts. an alternate irrigation with povidone-iodine may be used - if no contra-indications exist. site specific antibiotics may also be placed in the periodontal pocket following scaling and root planing in order to provide additional healing of infected tissues. unlike antibiotics which are taken orally to achieve a systemic effect, site specific antibiotics are placed specifically in the area of infection. these antibiotics are placed directly into the periodontal pockets and release slowly over a period of time. this allows the medication to seep into the tissues and destroy bacteria that may be living within the gingiva, providing even further disinfection and facilitation of healing. certain site specific antibiotics provide not only this benefit, but also boast an added benefit of reduction in pocket depth. arestin, a popular site specific brand of the antibiotic minocycline, is claimed to enable regaining of at least 1 mm of gingival reattachment height. in cases of severe periodontitis, scaling and root planing may be considered the initial therapy prior to future surgical needs. additional procedures such as bone grafting, tissue grafting, and/or gingival flap surgery done by a periodontist (a dentist who specializes in periodontal treatment) may be necessary for severe cases or for patients with refractory (recurrent) periodontitis. patients who present with severe or necrotizing periodontal disease may have further steps involved in their treatment. these patients often have genetic or systemic factors that contribute to the development and severity of their periodontitis. common examples include diabetes type i and type ii, a family history of periodontal disease, and immunocompromised individuals. for such patients, the practitioner may take a sample from the pockets to allow for culture and more specific identification and treatment of the causative organism. intervention may also include discontinuation of medication that contributes to the patient's vulnerability or referral to a physician to address an existing but previously untreated condition if it plays a role in the periodontal disease process. full mouth treatment the "traditional" debridement procedure involves four sessions spaced two weeks apart, doing one quadrant (one quarter of the mouth) each session. in 1995 a group in leuven proposed doing the whole mouth in about 24 hours (two sessions). when done using ultrasonic instruments this is called full mouth ultrasonic debridement (fmud). the rationale for full mouth debridement is that quadrants that have been cleaned will not be reinfected with bacteria from quadrants that have not yet been cleaned. other advantages of full mouth ultrasonic debridement include speed/reduced treatment time, and reduced need for anaesthesia, with equivalent results to scaling and planing. one study found that the average time to treat each pocket with full-mouth ultrasonic debridement was 3.3 minutes, whereas it took 8.8 minutes per pocket for quadrant scaling and root planing (srp). differences in improvement were not statistically significant. studies by the leuven group, using somewhat different protocols, found that the one-stage treatment (i.e. in 24 hours) gave better results than the quadrant-by-quadrant approach (taking six weeks). they also had the patients use chlorhexidine for two months after the treatment. depth of planing another question in dental cleaning is how much cementum or dentine should be removed from the roots. bacterial contamination of root surfaces is limited in depth, so extensive planing away of cementum – as advocated by traditional scaling and root planing – is not necessary to allow periodontal healing and the formation of new attachment. in contrast to traditional scaling and root planing, the aim of some fmud procedures is to disturb the bacterial biofilm within the periodontal pocket, without removing cementum. typically, root planing will require the use of hand instruments such as specialized dental curettes instead of the scaler tips used in fmud to debride the root surface and periodontal pocket. evidence-based dentistry several systematic reviews have been made of the effectiveness of scaling and root planing as evidence-based dentistry. a cochrane review by worthington et al. in 2013 considered only scaling and polishing of the teeth, but not root planing. after examining 88 papers they found only three studies that met all their requirements, remarking that "the quality of the evidence was generally low." they reported mixed results: one study "did not show either a benefit or harm for regular six or 12-month scale and polish treatments when compared to no scale and polish", but an earlier study found that treatments every three months produced better results in terms of gingivitis, plaque and calculus than annual treatments (with evaluation after two years in each case). oral hygiene instruction was found to help as well. another inconclusive review of scaling and polishing (without planing) was published by the british dental association in 2015. an extensive review that did involve root planing was published by the canadian agency for drugs and technologies in health in 2016. it made a number of findings, including (1) in five randomized controlled trials, scaling and root planing "was associated with a decrease in plaque from baseline at one month, three months, or six months;" and (2) four studies analyzed changes in the gingival index (gi) from the baseline and "found a significant improvement from baseline in the scaling and root planing group at three months and six months." this study also discussed evidence-based guidelines for frequency of scaling with and without root planing for patients both with and without chronic periodontitis. the group that produced one of the main systematic reviews used in the 2016 canadian review has published guidelines based on its findings. they recommend that scaling and root planing (srp) should be considered as the initial treatment for patients with chronic periodontitis. they note that "the strength of the recommendation is limited because srp is considered the reference standard and thus used as an active control for periodontal trials and there are few studies in which investigators compare srp with no treatment." they add however that "root planing ... carries the risk of damaging the root surface and potentially causing tooth or root sensitivity. generally expected post-srp procedural adverse effects include discomfort." enamel cracks, early caries and resin restorations can be damaged during scaling. a study conducted in 2018 recommended that teeth condition and restorations should be identified before undergoing the ultrasonic scaling procedures. effectiveness of the procedure a scaling and root planing procedure is to be considered effective if the patient is subsequently able to maintain their periodontal health without further bone or attachment loss and if it prevents recurrent infection with periodontal pathogens. the long term effectiveness of scaling and root planing depends upon a number of factors. these factors include patient compliance, disease progress at the time of intervention, probing depth, and anatomical factors like grooves in the roots of teeth, concavities, and furcation involvement which may limit visibility of underlying deep calculus and debris. first and foremost, periodontal scaling and root planing is a procedure that must be done thoroughly and with attention to detail in order to ensure complete removal of all calculus and plaque from involved sites. if these causative agents are not removed, the disease will continue to progress and further damage will result. in cases of mild to moderate periodontitis, scaling and root planing can achieve excellent results if the procedure is thorough. as periodontitis increases in severity, a greater amount of supporting bone is destroyed by the infection. this is illustrated clinically by the deepening of the periodontal pockets targeted for cleaning and disinfection during the procedure. once the periodontal pockets exceed 6 mm in depth, the effectiveness of deposit removal begins to decrease, and the likelihood of complete healing after one procedure begins to decline as well. the more severe the infection prior to intervention, the greater the effort required to arrest its progress and return the patient to health. diseased pockets over 6 mm can be resolved through periodontal flap surgery, performed by a dental specialist known as a periodontist. although healing of the soft tissues will begin immediately following removal of the microbial biofilm and calculus that cause the disease, scaling and root planing is only the first step in arresting the disease process. following initial cleaning and disinfection of all affected sites, it is necessary to prevent the infection from recurring. therefore, patient compliance is by far the most important factor having the greatest influence on the success or failure of periodontal intervention. immediately following treatment, the patient will need to maintain excellent oral care at home. with proper homecare, which includes but is by no means limited to brushing twice daily for 2–3 minutes, flossing daily and use of mouthrinse, the potential for effective healing following scaling and root planing increases. commitment to and diligence in the thorough completion of daily oral hygiene practices are essential to this success. if the patient fails to change the factors that allowed the disease to set in – for example, not flossing or brushing only once a day – the infection will likely recur. the process which allows for the formation of deep periodontal pockets does not occur overnight. therefore, it is unrealistic to expect the tissue to heal completely in a similarly short time period. gains in gingival attachment may occur slowly over time, and ongoing periodontal maintenance visits are usually recommended every three to four months to sustain health. the frequency of these later appointments is key to maintaining the results of the initial scaling and root planing, especially in the first year immediately following treatment. since the patient may still have pockets that surpass the effective cleaning ability of a brush or floss, for long-term success of their treatment they should return every 90 days in order to ensure that those pockets remain free of deposit. patients should be counseled that 90 days is not an arbitrary interval; at 90 days, the healing made possible by the scaling and root planing will be complete. this will allow the practitioner to re-measure pocket depths to determine whether the intervention was successful. at this appointment, progress will be discussed, as well as any refractory periodontitis. at 90 days from the original scaling and root planing, the periodontal bacteria, if any remain, will have reached their full strength again. therefore, if there are remaining areas of disease, the practitioner will clean them again, and may place more site-specific antibiotic. furthermore, this appointment allows for the review of homecare, or necessary additions or education.