Subgingival calculus. Dental scaling. Workmanship and price

Scaling is the removal of tartar from the surface of teeth, dentures or braces.

Tartar is a mineral-organic deposit that adheres to the tooth surface, dentures or orthodontic appliances and is produced by mineralization of bacterial plaque.

Tartar consists of both mineral substances and organic components similar to those in dental plaque.

Tartar is covered by a layer of bacterial plaque, not yet mineralized.

Scaling and root planing

Scaling and root planing, also known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is a procedure that involves removing dental plaque and calculus and then smoothing or planing the root surfaces, removing cementum or dentin that are impregnated with calculus, toxins or micro-organisms, the etiological agents that cause inflammation.

These procedures help to treat periodontium damaged by periodontal disease. Periodontal splints and apical surgery tips are some of the instruments used.

Bacterial plaque

Plaque is a soft, yellow-grey film that adheres to tooth surfaces, including fixed or mobile restorations. It is a clustered biofilm that is mainly composed of bacteria in a matrix of extracellular glycoproteins or polysaccharides. This matrix makes it impossible to remove plaque by rinsing or sprays alone. The white matter is similar to bacterial plaque, but lacks the organized plaque structure and can be easily removed by rinsing with water.

Although everyone has a tendency to develop plaque and white matter, by regular brushing and flossing, organized bacteria colonies are destroyed and removed from the oral cavity. In general, the more effective brushing and flossing is, the less plaque will build up on the teeth.

However, if after 24 hours in the oral environment, biofilm that remains unremoved by brushing or flossing begins to absorb the mineral content of saliva. Through this absorption of calcium and phosphate from saliva, oral biofilm is transformed from the soft, easily removed form into the hard form known as tartar. Tartar acts as a foundation for new layers of biofilm to form and develop over time. Tartar can no longer be removed by brushing or flossing.

Bacterial plaque buildup and bone loss

Bacterial plaque buildup tends to be in a thicker layer along the gum line. Due to the proximity of this area to the gum tissue, plaque can begin to cause irritation and infection of the gums.

This gum tissue infection causes gingivitis, which is what gingivitis is really all about, inflammation of the gums. Gingivitis is characterized by enlargement, bright red discoloration and bleeding gums. It is the first step in the gap in periodontal health, and the only step from which to fully restore oral health.

As the gums enlarge, they can no longer provide an effective seal between the tooth and the external environment. A vertical space is created between the tooth and gum, allowing new bacterial biofilm to migrate into the sulcus.

In healthy people, the sulcus is no more than 3 mm deep when measured with a periodontal probe. As the stages of gingivitis continue, the capillaries in the sulcus begin to dilate, resulting in more bleeding when brushing, flossing or during dental treatments. This is the body’s attempt to clear the infection from the tissues.

However, bleeding is generally accepted as a sign of active oral infection. The increased volume of gum tissue may also result in a greater depth of sulcus, up to 4 mm. At a depth of 4 mm or greater, the vertical space between the tooth and the surrounding gingiva becomes known as a periodontal pocket. Since toothbrush or floss cannot penetrate to such a depth of 4-5 mm, bacteria stagnate in these areas and have the ability to proliferate, causing colonies to form.

Once plaque has infiltrated the periodontal pocket, the transformation from biofilm to tartar continues. This will result in an ulceration at the gum tissue boundary, which begins by damaging the attachment of the tooth to the gum.

This attachment begins to weaken as plaque continues to invade the space created by the inflammation. The plaque eventually turns into tartar and the process continues, resulting in deposits under the gum and an increase in the depth of the periodontal pocket. As the vertical space between tooth and gum reaches 5 mm, a change occurs.

The bacterial morphology of the biofilm changes from aerobic gram-positive bacteria found in biofilm located supragingivally or above the gingival margin. Replacement of these gram-positive bacteria of the general oral flora is done by anaerobic gram-negative bacteria. These bacteria are more destructive in nature than aerobic bacteria.

The walls of gram-negative bacteria contain endotoxins, which allows these organisms to destroy gum tissue and bone much faster. Periodontitis officially begins when these bacteria start to act, resulting in bone loss. This bone resorption marks the transition from gingivitis to periodontal disease. In other words, the term periodontal disease can be synonymous with bone loss.

The first evidence of damage from periodontal disease becomes visible in radiographs of the bony crest of the jaws, which becomes tilted, with low radiopacity and loss of substance.

This destruction occurs as a result of bacterial endotoxins on bone tissue. Because bone is alive, it contains bone-laying cells known as osteoblasts and bone-destroying cells called osteoclasts. They usually move at the same speed and keep each other in balance.

In periodontitis, however, chemical mediators, or by-products of chronic inflammation, stimulate the osteoclasts, allowing them to act faster than the bone-depositing cells. Bone loss results, and this, together with loss of tissue attachment, is called periodontal disease.

This process will persist, causing extensive damage, until infectious bacterial agents (plaque) and local irritants (tartar) are removed. To remove them effectively at this stage of the disease process, brushing and flossing are no longer sufficient. This is due to several factors, the most important one to note being the depth of the periodontal pocket.

Brushing and flossing are only effective for removing soft white matter and biofilm in supragingival areas and in pockets up to 3 mm deep.

Even the best brushing and flossing is ineffective for cleaning deeper pockets and is never effective in removing tartar. Therefore, to remove the causative factors leading to periodontal disease, root planing and deep scaling procedures in periodontal pockets are often recommended.

Once bacteria and calculus are removed from the periodontal pocket, the tissue can begin to heal.

Inflammation dissipates as the infection subsides, allowing a decrease in volume, which results in the gums forming a new effective seal between the tooth root and the external environment.

However, the damage caused by periodontal disease is never completely healed. Bone loss due to the disease process is irreversible. Also, gum tissue 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, the patient will experience permanent recession of the gums and therefore exposure of the roots of the teeth in the affected areas.

If bone loss is extensive enough, teeth can start to become loose and without any intervention to stop the disease process, they will be lost.

Contrary to old beliefs, tooth loss is not a normal part of ageing. Rather, it is periodontal disease that is the leading cause of tooth loss in the adult population.

Periodontal intervention

The treatment of periodontitis may include several steps, the first of which relates to the need to remove local causative factors so as to create a compatible biological environment between the tooth and the surrounding periodontal tissue, gingiva and adjacent bone.

Left untreated, chronic inflammation of the gums and supporting tissue can increase the risk of cardiovascular disease in affected individuals.

When these procedures are initiated, the patient is anaesthetized in the area where the treatment is to be performed. Due to the deeper nature of periodontal scaling and root planing, either one half or one quarter of the oral cavity is generally cleaned during an appointment.

This allows the patient to be fully anesthetized in the required area during treatment.

It is usually not recommended that the entire mouth be treated in one appointment because of the potential inconvenience and complications following anesthesia of the entire oral cavity – i.e. inability to eat or drink, likelihood of self-injury through biting, etc.

In general, the first step is to remove plaque and microbial biofilm from the tooth, a procedure called scaling. Root planing involves smoothing the root of the tooth.

These procedures may be called periodontal cleaning or deep cleaning. All these names refer to the same procedure. The term “deep cleaning” comes from the fact that periodontal pockets in patients with this disease are deeper than those found in people with healthy periodontium.

Such scaling and root planing can be performed using a variety of dental instruments, including ultrasonic instruments and hand instruments such as periodontal apical tips and sponges.

The objective of periodontal scaling and root planing is to remove dental plaque and tartar, which harbors bacteria that excrete toxins, causing inflammation of the gum tissue and surrounding bone. Planing also often removes some cementum or dentin.

Removal of adherent plaque and calculus with hand instrumentation can also be performed prophylactically in patients with periodontal disease. Prophylaxis involves scaling and brushing the teeth so as to prevent oral pathologies. This in-office brushing does not remove tartar, but only plaque and some stains, and should therefore only be done in conjunction with scaling.

Often an electric device, known as an ultrasonic scaling handpiece, can be used during scaling and root planing.

Ultrasonic handpieces vibrate at a high frequency to help remove stains, plaque and tartar. In addition, ultrasonic scaling creates tiny air bubbles through a process known as cavitation. These bubbles serve an important function for periodontal cleanings.

Because the bacteria living in periodontally affected pockets are mainly anaerobic, meaning they are unable to survive in the presence of oxygen, these bubbles help to destroy them. Oxygen helps break down bacterial cell membranes leading to their lysis.

Since it is extremely important to remove the entire deposit from each periodontal pocket, attention to detail during this procedure is crucial. Therefore, depending on the depth of the pocket and the amount of tartar deposit versus soft biofilm deposit, hand instruments can be used to complete the scaling, which removes everything that ultrasonic scaling has left behind.

Alternatively, electric handpieces can be used after manual scaling to disperse deposits that have been removed from the tooth or root structure but remain in the periodontal pocket.

The sonic and ultrasonic scaling parts are powered by a system that determines their vibration. The sonic ones are connected to an air-driven turbine, while the ultrasonic ones use either magneto strictive or piezoelectric systems to create vibrations. Magneto strictive systems use a stack of metal plates attached to the tip of the instrument.

The metal plates are induced to vibrate by an external coil connected to an alternating current source. Ultrasonic systems also include a water-removing orifice and a rinsing function, helping to cool the instrument during use, as well as rinsing away any unwanted material from the teeth and gum line. The rinse can also be used to deliver antimicrobial agents.

Although the end result of ultrasonic scaling devices can also be produced using manual scaling instruments, ultrasound is sometimes faster and less irritating to the patient. In addition, ultrasonic scaling creates aerosols that can spread pathogens when a patient has an infectious disease.

Research differs as to whether there is a difference in effectiveness between ultrasonic scaling devices and manual instruments. Of particular importance to dentists is that the use of ultrasound can reduce the risk of repetitive stress injury, as it requires less pressure and persistence compared to manual scaling instruments.

A new addition to the tools used to treat periodontal disease is the dental laser. Lasers with different powers are used for many procedures in modern dentistry, including fillings. In a periodontal treatment, a laser can be used after scaling and root planing to facilitate tissue healing.

Post-scaling

After scaling, several additional steps are required to disinfect the periodontal tissue. Oral irrigations can be performed using chlorhexidine gluconate solution, which has a high substantivity in oral tissues.

This means that unlike other mouthwashes, whose benefits end once rinsed, the active antibacterial ingredients in chlorhexidine gluconate seep into the tissues and remain active for a period of time. Despite the effectiveness of this solution, it is not produced for long term use.

A recent European study suggests a connection between long-term use of mouthwash and high blood pressure, which can lead to a high incidence of cardiovascular events.

In the United States, they are available by prescription only and in small, occasional doses, having the desired tissue-healing effect after surgery. Recent research indicates that chlorhexidine irrigation after scaling and root planing may inhibit reattachment of periodontal tissue. Specifically, it prevents fibroblast formation. An alternative would be iodine-povidone irrigation, if there are no contraindications.

Specific antibiotics can also be applied to periodontal pockets after scaling and root planing to ensure further healing of infected tissues. Unlike antibiotics that are administered orally to achieve a systemic effect, local antibiotics are placed specifically in the area of infection.

These antibiotics are placed directly into the periodontal pockets and are released slowly over a period of time. This allows the drug to seep into the tissues and destroy bacteria that may exist within the gums, providing increased disinfection and facilitating healing. Some locally specific antibiotics not only provide this benefit, but also have the added advantage of reducing the depth of the pit.

In cases of severe periodontitis, scaling and root planing can be considered as part of initial therapy prior to future surgical needs. Additional procedures, such as bone grafting, tissue grafting and/or gingival flap surgery, performed by a periodontist may be necessary for severe cases or for patients with refractory (recurrent) periodontitis.

Patients with severe or necrotizing periodontal disease may require additional steps in their treatment. These patients often have genetic or systemic factors that contribute to the development and severity of their periodontitis.

Common examples include type I and type II diabetes, family history of periodontal disease and immunocompromised individuals. For such patients, the doctor may take a sample from the periodontal pockets to identify the culture and more specific treatment of the causative organism.

Intervention may also include discontinuing medications that contribute 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 oral treatment

The “traditional” gum debridement procedure involves 4 sessions 2 weeks apart, with a quadrant performed at each session. In 1995, a group in Leuven proposed to perform a complete debridement in 24 hours (2 sessions). The reason for complete debridement of the entire oral cavity is that the quadrants that have been cleaned will not be reinfected with bacteria from quadrants that have not yet been sanitized. Other advantages of ultrasonic debridement include reduced treatment speed/time and reduced need for anesthesia, with results equivalent to scaling and root planing.

One study found that the average time to treat each periodontal pocket with this procedure was 3.3 minutes, while it took 8.8 minutes per pocket for quadrant scaling and root planing. The differences in improvement were not statistically significant. Studies by the Leuven group, using somewhat different protocols, found that single-stage treatment (i.e., within 24 hours) gave better results than the quadrant-by-quadrant approach (which takes six weeks). They also advised patients to use chlorhexidine for two months after treatment.

Depth of root planing

Another common question in root planing is how much cement or dentin should be removed from the roots. Bacterial contamination of root surfaces is limited in depth, so excessive cement planing, as indicated in traditional scaling and root planing, is not necessary to allow periodontal healing and new attachment formation. In contrast to traditional scaling and planing procedures, the need for ultrasonic debridement procedures is to disrupt the bacterial biofilm in the periodontal pocket without removing the cementum. Typically, root planing will require the use of hand instruments, such as special curettes.

Evidence-based dentistry

There have been several systematic reviews of the effectiveness of scaling and root planing in evidence-based dentistry.

A Cochrane review by Worthington in 2013 considered only scaling and tooth polishing, but not root planing. After reviewing 88 papers, they found only three studies that met all their requirements, noting that “the quality of evidence was generally low.”

They reported mixed results: one study “showed no benefit but no disadvantage for regular scaling and brushing treatments at six or 12 months compared to those without these procedures”, but an earlier study found that treatments every three months had better results for gingivitis, plaque and tartar than annual treatments (with evaluation after two years in each case). Oral hygiene instructions have also been found to help.

Another inconclusive review of scaling and polishing (without planing) was published by the British Dental Association in 2015.

In 2016, the Canadian Agency for Drugs and Technologies in Health published an extensive review involving root planing. It made a number of findings, including in five randomized controlled trials, scaling and root planing were “associated with a decrease in plaque from baseline at one month, three months or six months; and four other studies looked at changes in the gingival index from baseline and “identified a significant improvement from baseline in the scaling and root planing group at three months and six months”.

This study also considered articles referring to the frequency of scaling with and without root planing for patients with and without chronic periodontitis.

The group that produced one of the main systematic reviews in 2016 published studies based on its findings. They recommend that scaling and root planing should be considered as initial treatment for patients with chronic periodontitis.

They note that “the strength of the recommendation is limited because scaling and root planing are considered the gold standard and are therefore used as an active control for periodontal studies, and there are few studies in which researchers compare these procedures with the application of any treatment.” However, they add that “root planing… runs the risk of damaging the root surface and causing tooth or root sensitivity”.

Enamel cracks, early decay and resin restorations can be damaged during scaling. A 2018 study recommended that the condition of teeth and restorations be identified before undergoing the ultrasonic scaling procedure.

Effectiveness of the procedure

The scaling and root planing procedure is considered effective if the patient is able to maintain periodontal health without future bone or attachment loss and if it prevents recurrent infection with periodontal pathogens.

The duration of the effectiveness of scaling and root planing depends on a number of factors. These include: patient compliance, disease progression and timing of the procedure, depth of the periodontal pocket, anatomical factors such as tooth root grooves, concavities and furcations, which may limit the visibility of deep calculus.

First and foremost, periodontal scaling and root planing are procedures that must be performed thoroughly and with attention to detail to ensure complete tartar and plaque removal from the targeted areas. If these causative agents are not removed, the disease will continue to progress, resulting in further damage.

In mild to moderate periodontitis, scaling and root planing can achieve excellent results if the procedures are complete. As periodontitis increases in severity, a greater amount of bone support is destroyed by infection. This is clinically illustrated by the depth of periodontal pockets targeted for cleaning and disinfection.

Once periodontal pockets have exceeded 6 mm in depth, the effectiveness of removing tartar deposits begins to decrease, and the likelihood of complete healing after a single procedure will be decreasing as well.

The more severe the infection prior to surgery, the greater the effort required to stop the progression and restore the patient to health. Periodontal pockets over 6 mm can be treated by a periodontal flap performed by a periodontic specialist.

Although soft tissue healing will begin immediately after removal of the microbial biofilm and calculus that caused the disease, scaling and root planing are only the first step in stopping the disease process.

After initial cleaning and disinfection of all affected sites, it is necessary to prevent recurrence of the infection. Patient compliance is therefore by far the most important factor, having the greatest influence on the success or failure of periodontal intervention. Immediately after treatment, the patient will need to maintain excellent oral care at home.

With proper home care, which includes but is not limited to brushing twice a day for 2-3 minutes, flossing daily and using mouthwash, the potential for effective healing after scaling and root planing increases. Commitment and diligence in thoroughly performing daily oral hygiene practices are essential for success.

The process that allows deep periodontal pockets to form does not happen overnight. It is therefore unrealistic to expect the tissue to heal completely in an equally short period of time.

Fixing of the gum attachment can occur slowly over time, and periodontal evaluation visits are usually recommended every three to four months to maintain the result achieved. The frequency of these appointments with the periodontist is important for maintaining the initial scaling and root planing results, especially in the first year immediately following treatment.

Since the patient may still have periodontal pockets that exceed the effective cleaning capacity of a toothbrush or floss, for long-term treatment success, they should return every 90 days to the doctor to ensure that those periodontal pockets are free of any dental deposits.

Patients should be advised that 90 days is not an arbitrary interval; at 90 days, healing through scaling and root planing will be complete. This will allow the specialist to remeasure the depth of the pocket to determine if the intervention was successful. At this appointment progress will be discussed, as well as any refractory periodontitis.

Ninety days after the initial scaling and root planing, periodontal bacteria, if left, will again reach full strength. Therefore, if areas of disease remain, the dentist will clean them again and may apply more locally specific antibiotics. In addition, these consultations allow for a review of home care or the addition of necessary information.

Frequently asked questions and answers: What is scaling?

The removal of mineralized bacterial plaque, located either at the dental or subgingival level, using an ultrasonic and water loop.

Is it painful?

Modern techniques help make this procedure painless. Rarely the patient may experience tooth sensitivity when subgingival tartar is removed. Sensitivity, if it occurs, passes very quickly.

Does scaling attack enamel?

Well, just the opposite. Decalcification protects the teeth and gums from damage that can occur to them.

Does scaling whiten the teeth?

It’s true that after scaling and brushing, teeth look neater and cleaner, but they don’t get whiter, possibly unpigmented, as a result of the process called air flow (mechanical blasting with baking soda).

Do gaps appear between teeth after scaling?

These spaces were covered by mineralized plaque, which is why they were not visible. The longer the tartar stagnates on the gums, the more that spacing will increase.

Why does tartar build up if I brush my teeth regularly?

It’s because of the factors that make it happen:

– smoking

– frequent coffee drinking

– salivary pH

– dental crowding

– incorrect brushing technique

How many types of tartar are there?

There are two types of tartar: supragingival (salivary) and subgingival (serous).

Supragingival tartar forms on the following surfaces:

• lingual surface of the lower frontals

• the buccal surface, at the level of the upper molars, corresponding to the orifice of the Stenon’s canal

• on the occlusal (chewing) surface of the lateral teeth, without antagonists (without a pair to meet in the bite)

Is diet important in relation to tartar?

Consistency, hardness of food and its acidity influence tartar deposition.

Chewing hard food, by its accentuated mechanical action, delays the formation of tartar.

Citrus fruits, fruits and vegetables slow down the deposition of dental calculus.

How does tartar form?

Tartar begins to deposit at an early age, the first to deposit being supragingival tartar. Subgingival tartar occurs in children over the age of 9 and can occur in 47-100% of cases after the age of 40. The duration of tartar formation depends on:

• tooth positioning

• salivary flow

• the nature of the diet

• chewing characteristics

4-6 months after the start of build-up, a maximum level of deposition is achieved, after which it begins to stabilize.

What is the treatment?

The prophylaxis of periodontal disease consists of removing tartar deposits by scaling, avoiding their appearance.

We recommend scaling before any dental work, as tartar deposits retain plaque, creating an environment that is not conducive to surgery, tooth extractions or prosthetic and orthodontic treatment.

Some patients do not agree to have this scaling performed on their mobile teeth, as they believe that tartar keeps them stable, helping to keep them in the arch for longer. But the reality is different: plaque on tartar-covered surfaces only worsens the periodontal disease that led to tooth mobility in the first place.

Scaling is carried out with manual instruments as well as ultrasonic or compressed air devices.

Mechanical scaling helps to remove tartar deposits more easily, does not damage the gums and allows dental stains to be removed.

After scaling, professional brushing is recommended for proper hygiene of the tooth surfaces. It is recommended that cleaning be done at least every six months.

What precautions can we take?

It is the patient’s duty to inform the doctor about certain general health problems, such as respiratory problems, aerosol-borne diseases, severe coughing or vomiting.

For patients who wear electronic devices (e.g., heart pacemakers), magneto strictive scaling devices may affect their functionality. Vibrations produced by the handle of the scaler can decimate veneers or crack porcelain dentures.

How much does scaling cost?

Depending on the difficulty of the treatment, prices start from 150 lei scaling/arch.

If anesthesia is required, this is charged separately at 50 lei.

Conclusion

The 6-month check-up and scaling are very important for your oral health! Tartar is the main culprit in periodontal disease and bad breath (foul breath).