Edith M.

Rateitschak-Pluss, Jean-
Non-surgical periodontal Pierre Schwarz, Richard
Guggenheim^ Marcel Duggelin^
and Klaus H. Rafeitschak
treatment: where are the limits? Department of Cariology and Periodontology,
Dental Institute; 'SEM Laboratory, University
of Basle, Switzerland
An SEM study

Rateitschak-Plii.'is EM, Schwarz J-P, Guggenheim R, DUggelin M and Rateitschak

Abstract. In the present scanning electron microscopic study, the possibilities and
timitations of non-surgical root planing were investigated. iO singie-rooted teeth
from 4 patients with advanced periodontitis were studied. The root surfaces were
cleaned and planed without flap reflection, using fine curettes. The teeth were
then extracted and the root surfaces were systematically exatnined by scanning
electron tnicroscopy (SEM) for the presetice of residual bacteria and caicuius, 29
of 40 curetted root surfaces were free of residues, if they were reached by the
curette. On the remaining 11 surfaces, only small amounts of plaque and minute
islands of calculus were detected, primarily at the line angles and aiso in grooves
and depressions in the root surfaces. Instrumentation to the base of the pocket
was not achieved compieteiy on 75% of the treated root surfaces, however. The
primary reason for this was the extremely tortous pocket morphology on the teeth
selected for study. In conclusion, it may be stated that during non-surgical root
planing in cases of advanced periodontitis, surfaces that can be reached by curettes
are usually free of plaque and calculus. However, in many cases the base of the Key words: root planing; non-surgical treat-
ment.
pocket will not be reached. It is for this reason that deep periodontal pockets
should be treated with direct vision, i.e., after the refieetion of conservative flaps. Accepted for publication 6 February 1991

Scahng and thorough planing of root Several investigators have utilized the periodontitis were selected. All patients
surfaces are the critical components of stereomicro scope to evaluate residua! required comprehensive periodonta!
periodontitis therapy (Garrett 1977, caicuJus after extraction of root planed and prosthetic treatment. None of the
Ramljord et al. 1980. Garrett 1983). The teeth (Rabbani et al. 1981, Caffesse et al. patients had received periodontal ther-
creation of a plaque- and calculus-free 1986). In other investigations, treated apy in the previous five years, A total
surface may be aehieved by routine non- root surfaces were stained with dis- of 10 single-rooted teeth was studied: 5
surgical scaling, or with direct vision closing agents in order to reveai residual maxillary incisors, 3 maxiliary cuspids
after refleetion of gingival flaps (Bader- bacteria (Eaton et al. 1985). However, and 2 mandibular bicuspids. Informed
sten et al. 1984, Lindhe et ai, i 984, Flem- Breininger et al. (1987) as well as consent was obtained from all subjects.
ming & Karring 1986, Loos et al. 1989), Schwarz et al. (1989) demonstrated that All aspects of the root surfaces of the
Both methods can lead to successful in addition to residual bacteria, other test teeth were instrumented using fine
therapy (Pihlstrom et al. 1983, Ramfjord protein-containing substances were also double-ended curettes (GX 4* and M
et al. 1987). Studies in the literature re- stained. It is for this reason that the use 23 A*).
veal that single-rooted teeth with shallow of diseiosing agents after root planing is
pockets (to 5 mm) can be successfully not a reliable method for demonstrating
Clinical procedures
root planed non-surgicaily. On the other residual bacteria. Precise study of the
hand, in the case of deep pockets, es- root surface can be performed only by Following ciinicai data collection and
pecially around multirooted teeth, root means of scanning electron microscopy completion of the treatment plan, a
planing with direct vision is more suc- (SEM). gross debridement was performed ini-
cessful (Buchanan & Robertson 1987, The goal of the present study was to tially to remove supragingivai plaque
Brayeretal. 1989, Fleischer etal. 1989). employ SEM to investigate the efficacy and calculus. Before initiating therapy,
The efficacy of root planing pro- of non-surgical root planing. Results of a spherical diamond was used to create
cedures can be studied in 2 different such study could also be used to delineate a circular groove along the course of
ways. The tissue healing around the the limitations of this mode of treatment. the gingival margin on each of the teeth
treated teeth can be evaluated, or the under study. Non-surgicai root planing
teeth may be extracted immediateiy after
treatment in order to observe directly the Material and Methods
cleanliness and surface characteristics of Four patients (age 38-50 years; 3 fe- * A, Deppeler Co,, Inc, CH-1180 Rolle/
the root planed surfaces. males, 1 male) diagnosed with advanced Switzerland.
 Non-surgical periodontal treatment 241
(without flap reflection) was then per- tected. 9 of these 22 were larger than
formed under block anesthesia. Cu- 0.4x0.4 mm and 13 of them were equal
rettes were re-sharpened for each tooth to or less than this measure. Virtually
using a medium India stone. Pockets al! of the plaque and calculus residues
were repeatedly rinsed with Ringer sa- were detected in 2 specific sites:
hne solution during the root planing (1) Grooves and depressions in the
procedure. The total time for root plan- root surface. For example, on a man-
ing each tooth was measured. The dibular bicuspid with fused roots,
cleanliness and smoothness of the root plaque residues were observed in the
surfaces were checked using a fine groove that delineated ofthe root fusion
pointed explorer. (Fig. 2a).
The goal of the therapy was a root (2) The so-called "line angles", i.e.,
surface free of plaque and concrements. the area where a change would be made
After completion of root planing, the from one curette blade to another dur-
teeth were carefully extracted, without ing the root planing process (Fig. 2b).
touching the root planed surfaces.
Blood was rinsed from the teeth under
Root surfaces not reached by the curette
running water for 20 s.
In 31 ofthe 40 treated root surfaces, the
base of the pocket was not completely
Staining of teeth and photographs
reached by the curettes. The reasons for
Immediately after extraction the teeth the difficulties encountered in instru-
were immersed in Karnovsky solution menting the root all the way to the base
(Kamovsky 1965) for fixation. Teeth of the pocket included the following.
were then rinsed in Ringer sahne solu-
tion in preparation for macroscopic (1) Pocket depth
photography, and subsequently were The deeper the pocket, the more often
placed for 30 s in !% malachite green the base of the pocket was not reached
staining solution. A distilled water rinse by the curette (Fig. 3).
followed the staining procedure.
Color photographs were made of all Fig. J. SEM photomicrograph of the facia!
(2) Pocket width
facial, oral and proximal root surfaces root surface of tooth 35 after treatment. The Very narrow pockets often defied access
using standardized methods. Stained borderline between treated and untreated to the curette with root surfaces exhibit-
areas on the root planed surfaces as de- areas is labelled. The arrows mark a line ing plaque and sometimes calculus (Fie.
tected on the photographs assisted in angle area (magnification x 12). 3).
the orientation for the subsequent SEM
study. Teeth were stored in Karnovsky's (3) Course ofthe base of the pocket
solution at 4"C until preparation for the with regard to residual plaque and cal- An additional factor that rendered
SBM studies. culus. The expanse of such residual de- "closed" root planing difficult was the
posits was categorized as "islands" less course of the base of the pocket. It is
than, equal to or greater than 0.4 x 0.4 known that the attachment loss associ-
Scanning electron microscope
mm. ated with periodontitis seldom progress-
examination
es in an even manner, and that it is often
After fixation, the specimens were very irregularly advanced on individual
Results
washed for 90 min in buffer solution teeth. This accounts for the fact that the
(0.02 M sodium cacodylate. pH 7.2, 660 40 aspects of 10 teeth were evaluated. base of the pocket is extraordinarily ir-
mOsm). Subsequently, specimens were The treatment time per tooth ranged regular. The periodontal pocket may
post-fixed for 90 min in 1.3% OSO4 (buf- from 8-12 min. during which root plan- even interconnect with attachment loss
fered with 0.067 Ms-coilidine, pH 8.34), ing with curettes, rinsing of the field apical to persistent attachment. Areas
then dehydrated in an ascending ace- operation and checking the root surface such as this cannot be reached with cu-
tone series (beginning with 50%, and smoothness with a fine explorer were rette. Plaque and calcuius residues will be
increasing by 10 x stages), then dried accomplished. routinely detected in such areas (Fig. 3).
according to the CPD method (Bomar,
SPC-900 EX, Balzers Union). The teeth
Planed root surfaces Discussion
were sputter coated with a 20 nm gold
layer (SCD 030, Balzers Union). 29 of the 40 planed root surfaces were The results of this study provide insight
All 4 aspects of each root surface free of ail plaque and calculus, if they concerning non-surgical ("closed") scal-
were observed in the SEM (Philips 515) were reached by the curette. The re- ing and root planing. If the root surface
including surfaces that had been suc- maining 11 surfaces, distributed among can be reached by the curette, that sur-
cessfully planed with curettes as well 6 teeth, exhibited minimal residual face will be virtually free of plaque and
as those areas that remained untreated plaque and small islands of calculus. calculus after scaling and root planing.
(Fig. 1). Successfully treated surfaces A total of 22 discrete areas harboring In some cases small islands of bacteria
were then systematically investigated plaque and calculus residues were de- may persist, but these will be found pri-
242 Rateitschak-Pliiss et al.

Fig. 2. (a) SEM photomicrograph of the distal root surface of tooth 34 after treatment. Labelled (O) bacterial residue was found in a
depression (-•) caused by the fusion of two roots (magnification x 12). Inset: SEM photomicrograph of bacteria observed in the labelled area
(magnification x 1500). (b) SEM photomicrograph of the mesial root surface of tooth 11 after treatment. Bacterial residues are visible in the
line angle area, which is labelled (magnification x 10).

marily at the line angles and in grooves one considers that this was a study of search. In the long-term clinical studies
and root irregularities. Residual bac- single-rooted teeth exclusively. On the the emphasis was on therapeutic suc-
teria at the line angles is an indication other hand, only teeth with expansive cess, with data presented as averages for
of inadequate skill, persistence or ex- attachment loss and deep pockets were attachment gain and pocket reduction.
perience of the treatment provider. studied. These results agree with those Subjects were for the most part patients
Fine grooves, ridges and even lacunae of Stambaugh et al. (1981), whose re- who had undergone extensive initial
(Schroeder & Rateitschak-Pluss 1983) sults also showed a direct correlation therapy, and most also complied with
are extremely difficult to detect during between pocket depth and residual an intensive follow-up phase. In ad-
non-surgical root planing and for this plaque or calculus. dition to the repeated professional de-
reason are predestined as plaque-reten- On the other hand, the results of the bridement procedures, patients also es-
tive areas. present study appear to contradict sev- tablished optimum plaque control. The
It was not possible in this study to eral previous long-term clinical studies, latter appears to be of extreme import-
determine whether the detected residual which demonstrated that "closed" root ance; for example, Lindhe (1984) wrote:
bacteria maintained their vitality; there- planing can be a successful therapeutic "The results of the examinations
fore, whether they play any role what- modality even in the presence of deep showed that the patients' standard of
ever in terms of therapeutic success or self-maintained oral hygiene had a deci-
pockets (Lindhe et al. 1982, 1984, Pihl-
failure remains an open question. sive influence on the long-term effect of
strom et ai. 1983, Badersten et al. 1984, treatment."
It is worthy of note that in fully 75% Isidor & Karring 1986, Ramfjord et al.
of root surfaces examined the base of 1987, Renvert et ai. 1990). However, In contrast to the long-term clinical
the pocket was not completely reached. these previous studies cannot be com- studies, the goal ofthe present work was
This is particularly remarkable when pard directly to the present SEM re- to determine by means of scanning elec-
 Non-surgical periodontal treatment 243

Fig, 3, (a) The oral root surface of loolh I 1 was successfully instrumented to the line drawn at the apical extent. The pocket was deep and
became exceedingly narrow at its apical termination. The pocket floor courses irregularly. Although some stained areas are visible, paralleling
the long axis of the root, these areas were not composed of bacteria, (b) SEM photomicrograph of the root surface corresponding to (a). The
arrows depict the borderline between treated and untreated (i,e., not reached by the curette) areas (magnification x 12),

tron microscopy the cleanliness of root However, such results do not force one
Acknowledgements
surfaces and the success of therapists in to the conclusioti that open treatment of
actually achievitig the base of perio- deeper pockets is clitiically tnore effective Siticere thatiks are due to Dr, Thomas
dontal pockets when working without than non-surgical treatment. These re- Hassell, Departtnent of Periodontology,
flap reflection. The treatment was given sults are limited by the fact that after University of Florida College of Den-
at a single appointment and without the closed therapy, more residual bacteria tistry, Gainesville, for translation of the
benefit of any previous subgingival de- remain in the depth of the pocket thati Gerrnan language manuscript. The au-
bridetnent procedures having been per- following open debridement. thors also thank Mr, W, Kirchhofer for
formed. The teeth examined in the pres- The question remains whether the preparation of specimens, and Mr, D,
ent study were, in fact, condemned to ex- good long-tertn clinical results, eveti Isch for production of the photographs,
traction and most exhibited extremely after non-surgical therapy, could be due Ms, B, Kaiser is gratefully acknowl-
deep probing depths, to an effective host response to residual edged for secretarial assistatice,
A previous study by our group micro-organisms. Furthermore the
(Schwarz et al, 1989) showed that root favorable results from other clinical
surfaces examined by SEM were cleaner studies could be attributed, at least in Zusammenfassung
after "open" debridetnent than teeth de- part, to the intensive professional follow- Nichtchirurgische Parodontalbeliandlung -
brided in a "non-surgical" mantier. up. Wo liegen die Greiizen? Eine REM-Studie
244 Rateitschak-Pluss ct at.

In vodiegender REM-Studie wurden die fond de la poche. C'est pourquoi les poches Lindhe, J., Westfelt, E., Nyman, S., Socran-
Moglichkeiten und Grenzen der geschlosse- parodontales profondes doivent etre traitees sky, S. S. & Haffajee, A, D. (1984) Long-
nen Wurzelreinigung untersucht. 10 einwurz- a ciel ouvert, en vision directe, c-a-d, apres term effect of surgical/non-surgical treat-
lige Zahne von 4 Patienten mit profunder reclinaison de lambeaux conservateurs. ment of periodontal disease. Journal of
Parodontitis wurden in die Studie einbezo- Clinical Periodontology 11, 448-458.
gen. Die Wurzeioberflachen wurden geschlos- References Loos, B., Nyiund, K., Claffey, N, & Egelberg,
sen mit Feinkuretten gereinigt. Nach Extrak- J, (1989) Clinical effects of root debride-
tion der Zahne wurden die Wurzeiober- Badersten, A,, Nilveus, R. & Egelberg, J. ment in molar and nonmolar teeth. Journal
flachen im REM systematisch auf zuruckge- (1984) Effect of nonsurgica! periodontal of Clinical Periodontology 16, 498-504,
lassene Bakterien- und Zahnsteininseln un- therapy. IL Severely advanced peridontitis. Pihlstrom, B. L., McHugh, R.B., Oliphant,
tersucht. 29 von 40 mit Kiiretten bearbeiteten Journal of Clinical Periodontology 11, T. H. & Ortiz-Campos, C. (1983) Compari-
Wurzeioberflachen waren sauber. Auf den 63-76, son of surgical and non-surgical treatment
ubrigen 11 Seiten fanden sich nur wenige und Brayer, W. K., Mellonig, J, T., DunJap, R. of periodontal disease. A review of current
sehr kleine Plaque- und Zahnsteininsein, Die- M,, Marinak, K, W. & Carson, R, E. studies and additional results after 6 1/2
se befanden sich an Einziehungen und RiJlen (1989) Scaling and root planing effective- years. Journal of Clinical Periodontology
der Wurzeioberflachen sowie an "line an- ness: the effect of root surface access and 10, 524-541.
gles". An 3/4 (75yo) der behandelten Zahnsei- operator experience. Journal of Perio- Rabbani, G. M., Ash, M, M, & Caffesse, R.
ten wurde der Taschenboden nicht ganz er- dontology 60, 67-72, G. (1981) The effectiveness of subgingival
reicht, Der Grund daftir war die ausserst Breininger, D, R., O'Leary, T, J, & Biumen- scaling and root planing in calculus re-
kompiizierte Taschenmorphologie bei den shine, R, V. H, (1987) Comparative effec- moval. Journal of Periodontology 52,
untersuchteii Zahnen. Zusammenfassend tiveness of ultrasonic and hand scaling for 119-123.
kann gesagt werden, daB Wurzeioberflachen. the removal of subgingival plaque and cal- Ramljord, S. P., Knowles, J. W, Morris, E.
die erreicht und bearbeitet werden, weitge- culus. Journal of Periodontology 58, 9-18. C , Burgett, F. G. & Nissle, R, R. (1980)
hend plaque- und zahnsteinfrei sind. Bei fort- Buchanan, S. A. & Robertson, P, B. (1987) Results of periodonta! therapy related to
geschrittenen Parodontitiden kann der Ta- Calculus removal by scaling/root planing tooth type. Journal of Periodontology 51,
schenboden jedoch oft nicht erreicht werden. with and without surgical access. Journal 270-273.
In diesen Fallen sollte offen, d.h. unter Sicht of Periodontology 58, 159-163. Ramtjord, S. P., Caffesse. R. G., Morrison,
gearbeitet werden. Caffesse, R. G., Sweeney, R L, & Smith, B. E, C , Hill, R. W., Kerry, G. J. Appleberry,
A. (1986) Scaling and root planing with E, A.. Nissle, R. R. & Stults, D. L, (1987)
and without periodonta3 flap surgery. 4 Modalities of periodontal treatment
Resume Journal of Clinical Periodontology 13, compared over 5 years. Journal of Clinical
205-210. Periodontology 14, 445-452,
Traitement parodontal non-chirurgical - Oii Eaton, K, A,, Kieser, J, B, & Davies, R. M, Renvert, S., Nilveus, R., Dahlen, G., Slots,
sont les limites? Etude au MEB (1985) The removai of root surface de- J, & Egelberg, J, (1990) 5-year follow up
La presente etude au microscope electronique posits. Journal of Clinical Periodontology of periodontai intraosseous defects treated
a batayage (MEB) coneemait ies possibilites 12, 141-152. by root planing or flap surgery. Journal of
offertes par le surfa^age non-chirurgical des Fleischer, H. C , Mellonig, J, T , Brayer, W. Clinical Periodontology 17, 356-363,
racines et ses limites. 10 monoradiculees pro- K,, Gray, J. L. & Barnett, J. D. (1989) Schroeder, H, E, & Rateitschak-Pliiss, E. M,
venant de 4 patients atteints de parodontite Scaiing and root planing eflicacy in multi- (1983) Focal root resorption lacunae caus-
avancee ont ete etudiees, Les surfaces radicu- rooted teeth. Journal of Periodontology 60, ing retention of subgingival plaque in
laires ont ete nettoyees et surfacees sans recli- 402^09. periodontal pockets. Acta Parodontolog-
naison de lambeaux, a l'aide de fines curettes. Flemming, I, & Karring, T, (1986) Long-term ica. In: Schweizcrische Monat.sschrift jur
Les dents ont ete extraites et les surfaces radi- effect of surgical and non-surgical' perio- Zahnheilkunde 93. 1033/179-1041/187,
cuiaires ont ete soumises a un examen syste- dontal treatment. A 5-year clinical study. Schwarz, J,-P-., Guggenheim, R,, Duggelin,
matique au MEB pour rechercher la presence Journal of Periodontal Research 21, M,, Hefti, A, F , Rateitschak-Pluss, E.
eventuelle de bacteries ou de tartre residuels, 462-472. M. & Rateitschak, K, H. (!989) The effec-
Sur 29 des 40 surfaces radiculaires traitees a Garrett, i. S. (1977) Root planing: a perspec- tiveness of root debridement in open flap
la curette, il n'y avait pas de residus si la tive. Journal of Periodontology 48, procedures by means of a comparison be-
curette avait eu acces a cette surface, Sur 553-557, tween hand instruments and diamond
les 11 autres surfaces, on ne trouvait que Garrett, J. S, (1983) Effects of non-surgical burs. Journal of Clinical Periodontology 16,
de petites quantites de plaque et des ilots periodontaJ therapy of periodontitis in hu- 510-518,
minuscules de tartre, principalement au ni- man, A review. .Journal of Clinical Perio- Stambaugh, R, V., Dragoo, M., Smith, D,
veau des angles formes par les lignes delimi- dontology 10, 515-523, M. & Carasali, L, (1981) The limits of
tant I'endroit ou on changeait de lame de Isidor, F, & Karring, T, (1986) Long-term subgingival scaling. International Journal
curette pendant le surfacage, ainsi que dans effect of surgical and non-surgical perio- of Periodontics and Restorative Dentistry 1,
ies silions et depressions des surfaces radicu- dontal treatment. A 5-year clinical study.
laires, Cependant, sur 75% des surfaces radi- Journal of Periodontal Research 21.
culaires traitees, ]'instrument n'avait pas 462-472.
completemenl pu atteindre la base de ia po- Karnovsky, M. A. (!965) A formaldehyde/
che. Cela etait principaiement du a la mor- glutaraldehyde fixative of high osmolality Address:
pboiogie extremement tortueuse des poches for use in electron microscopy. Journal oj
sur les dents choisies pour cette etude. On Cell Biology 21. 137A, Edith M. Rateitschak-PIUss
peut conclure que, pendant Ie surfaijage non Lindhe, J,, Westfelt, E,, Nyman, S., Socran- University of Basle
chirurgical des poches dans les cas de paro- sky, S. S,, HeijI, L, & Bratthall, G. (1982) Dental Institute
dontite avancee, les surfaces que la curette Healing foiiowing surgical/non-surgical Department of Cariology and Periodontology
peul atteindre sont en generai exemptes de treatment of periodonta! disease, A clinical Petersplatz 14
plaque et de tartre. Cependant, dans de nom- study. Journal of Clinical Periodontology 9, CH-4051 Basle
breux cas, on ne reussit pas a atteindre le 115-128, Switzerland