I AM sure that most of my fellow dentists when they meet a friend often hear, “By the way Doc, I have to come in and see you for a cleaning.” Those who are lucky to still be in the possession of their natural teeth should be intelligent enough to maintain their good fortune by having prophylaxis (cleaning) done at least once every three months. The word prophylaxis means prevention.

Mind you, cleaning does not whiten teeth; all it does is to remove plaque, calculus and extraneous stains such as nicotine deposits. If cleaning is not done, persons may suffer from periodontal (gum) disease despite regular and thorough brushing with flossing. These preventative measures cannot guarantee the absolute freedom from any dental affliction because direct vision and objective procedures are essential.

What patients refer to as “clean and polish” clinically means to clean the teeth and polish the fillings. Scaling, root planing and curettage (scraping diseased gums) have been the basic procedures in the periodontal therapy long before periodontics was recognised as a speciality of dentists. Exactly, what are the indications, contradictions and expectations of these modalities of treatment?

The periodontal lesion consists of a pocket. The tooth aspect of this pocket is the dentin and cementum of the root. The soft tissue aspect is comprised of an epithelial lining and connective tissue.When observed under a microscope, the soft tissue displays a chronic inflammatory lesion. In other words, certain types of cells invade the gum manifesting breakdown products as well as a sign of repair. The pocket deepens in response to this chronic inflammatory process. The atypical migration (penetration along the roots) of the attachment results in a deep sulcus (grove).

Prophylaxis includes the removal of dental plaque, calculus and stains, thereby eliminating all the factors causing the inflammation. The supragingival (which is visible above the gum line) deposits are easily removed. Subgingival calculus requires the placing of the instruments below the gingival margin. Scalers are used on the crown of a root to scrape off the hard calculus (tartar) while curettes of an ultrasonic machine fit below the crest.
Root planing is the removal of calculus and “root roughness” from the surface of the tooth. The goal is to leave a smooth glasslike surface. This accomplishes the removal of necrotic cementum and dentin, bacterial products and endotoxins (poisons) in the decayed cementum. Curettage has a minimal effect on the fibrous or firm gingival pockets.

However, in the case of spongy gums, the inner pocket lining is scraped away. The more bleeding that occurs in the process, the better the results. Deep, narrow pockets will not shrink and are difficult to scale due to the adjacent soft tissue walls which are firmly attached. Such areas are often seen in the upper anterior region.

The most desirable outcomes to curettage, therefore, are regeneration and reattachment. Unfortunately, epithelial adaption does not create a stable result.

Healing of the pocket may occur in three different ways: regeneration, reattachment and epithelial adaption. Regeneration is the growth of new tissues. Young cells develop into specialised tissues. Regeneration is the formation of new periodontal ligament and new cementum with the attachment of gingival epithelium to tooth surface denuded of disease. Epithelial adaption is close apposition of gingival epithelium to the tooth surface. This is not firmly attached to the root surface. A probe (dental instrument) will not pass into the pocket, but breakdown can occur with the first insult from plaque and calculus.

Generally, there can never be a complete recovery from moderate to severe periodontal disease. Once the alveolar bone is destroyed in the process of the ailment, naturally, there is inadequate support for the tooth and it now becomes shaky. Depending on the degree of looseness extraction may be the only solution.

In some severe cases, more than one cleaning sessions is required to achieve the desired result. It is obvious that on a clinical level, scaling, root planing and curettage are interrelated and necessary for the healing of specific types of periodontal lesions.