CHAPTER 7. Root Treatment, Reattachment, and Repair

112 CHAPTER 7. ROOT TREATMENT, REATTACHMENT, AND REPAIR Section 1.
Root Healing
CHAPTER 7. ROOT TREATMENT,

REATTACHMENT, AND REPAIR
Section 1. Root Healing followed by plaque removal every other day for 1 year.
Radiographs taken after 1 year showed increased radio-
density of the crestal bone. The histological sections
DEFINITIONS showed a long junctional epithelium extending to the most
Repair: Healing of a wound by tissue that does not fully apical point of root instrumentation. The connective tissue
restore the architecture or the function of the part. fibers between the junctional epithelium and the bone were
Reattachment: To attach again. The reunion of epithe- oriented parallel to the long axis of the tooth. They con-
lial and connective tissues with root surfaces and bone such cluded that repair of an osseous defect can occur opposite
as occurs after an incision or injury. Not to be confused junctional epithelium on the root surface without new at-
with new attachment. tachment of connective tissue.
New Attachment: The union of connective tissue or ep- Caton and Zander (1979) created 22 pairs of periodontal
ithelium with a root surface that has been deprived of its pocket in 2 monkeys. All teeth were scaled, then a plaque
original attachment apparatus. This new attachment may be control program consisting of toothbrushing, flossing, and
epithelial adhesion and/or connective tissue adaptation or topical application of 2% chlorhexidine 3 times a week was
attachment and may include new cementum. initiated. On one side of the jaw, root planing and soft
Regeneration: Reproduction or reconstitution of a lost tissue curettage were performed and were repeated at 3, 6,
or injured part. and 9 months after initial therapy. The treatment resulted
in the formation of a long junctional epithelium with no
HEALING BY A LONG JUNCTIONAL EPITHELIUM new connective tissue attachment. In 8 of the 22 pockets,
Following surgery, the curetted root surface may be repo- the procedure produced discontinuities or "windows" of
pulated by 4 different types of cells: epithelial; gingival con- connective tissue attachment in the junctional epithelium.
nective tissue; bone; and periodontal ligament cells. The cells The resistance to probing following root planing and soft
which repopulate the root surface determine the nature of the tissue curettage appears to result from the formation of a
attachment that will form. Periodontal wound healing follow- long junctional epithelium rather than new connective tis-
ing traditional surgical procedures results in the formation of sue attachment.
a long junctional epithelium along the root surfaces, with no Caton et al. (1980) compared the healing after 4 different
new connective tissue attachment. The epithelial downgrowth surgical procedures. Periodontal pockets were induced in 8
prevents the formation of a new connective tissue attachment monkeys then treated by 1) modified Widman flap (MWF)
by preventing repopulation of the root surface by cells derived without osseous surgery; 2) MWF without osseous surgery
from the periodontal ligament. However, the coverage of the but with autogenous red marrow and cancellous bone; 3)
root surface by an epithelial layer has a beneficial effect; MWF without osseous surgery but with beta tricalcium
i.e., the prevention of root resorption and ankylosis, which phosphate; and 4) periodic root planing and soft tissue cu-
otherwise could be induced by gingival connective tissue rettage. Histometric measurements after 12 months of
and bone. healing demonstrated that all treatment procedures resulted
Waerhaug (1955) studied the healing following scaling in the reformation of an epithelial lining (long junctional
and root planing in one dog with subgingival calculus on epithelium) with no difference between treatments. The
4 cuspids. Two of the teeth were scaled and polished and most apical cells of the junctional epithelium were consis-
2 served as untreated controls. After the removal of cal- tently located at or close to the level of the root surface
culus, the bleeding subsided and normal conditions were which had been planed. Adjacent to the epithelial lining
observed. It was concluded that a complete removal of sub- were fibers oriented parallel to the root surface. In a few
gingival calculus will, under favorable conditions, lead to specimens, principal fibers were inserted into new cemen-
a re-formation of a normal epithelial cuff in areas earlier tum and adjacent alveolar bone. This area could represent
covered with calculus, and it may result in a more or less healing of the root surface injured during instrumentation.
complete disappearance of the inflammation caused by the Proye and Poison (1982) studied the effect of root surface
calculus. alterations on periodontal healing. Three teeth in each of 4
Caton and Zander (1976) studied the healing after sur- monkeys were extracted and the coronal third of the root
gical treatment. They created a periodontal pocket on 1 mo- surfaces was planed to remove the attached periodontal fibers
lar in a monkey. The pocket was treated by flap curettage, and cementum. The teeth were reimplanted into their sockets
Section 1. Root Healing CHAPTER 7. ROOT TREATMENT, REATTACHMENT, AND REPAIR 113
within 15 minutes. Histological examination showed a zone concluded that the barrier function of a long junctional ep-
of fibrin containing erythrocytes and PMNs adjacent to the ithelium against plaque infection is not inferior to that pro-
denuded root surface 1 day after reimplantation. Epithelium vided by a dentogingival epithelium of normal height.
migrated rapidly along the denuded root, reached the al- The resistance of the long junctional epithelium was also
veolar crest at 3 days, and was within the ligament space studied by Beaumont et al. (1984). Inflammation by liga-
at 7 days. At 21 days, the epithelium was at the apical limit tures was induced in 6 dogs. Three of the dogs had induced
of root instrumentation. There was no evidence of connec- periodontitis and were treated surgically which resulted in
tive tissue attachment to any portion of a denuded root sur- long junctional epithelium; the remaining 3 dogs had
face. It was concluded that the absence of fibers on the root healthy periodontium. Healing was evaluated over periods
surface results in apical migration of the epithelium, and ranging from 4 to 20 days. There were no instances of
precludes formation of new connective tissue attachment. sulcular ulceration in the group with established long junc-
In a followup study, Poison and Caton (1983) evaluated tional epithelial attachment, but ulcerated sulcular epithe-
the factors influencing periodontal repair and regeneration. lium was seen often in the earlier time periods of the
In 2 monkeys, central incisors with reduced periodontium previously healthy group. It was concluded that there was
were transplanted into sockets of normal height, and central no appreciable difference in resistance to disease between
incisors with normal periodontium were transplanted into a long junctional epithelium and a true connective tissue
sockets of reduced height. After 40 days of healing, the attachment.
normal roots transplanted into the reduced periodontium The coverage of the root surface by an epithelial layer
had connective tissue reattachment in the periodontal liga- has a beneficial effect; i.e., the prevention of root resorption
ment and supracrestal regions. The exposed roots placed and ankylosis, which otherwise could be induced by gin-
into the normal periodontium were lined with epithelium gival connective tissue and bone. Karring et al. (1984) stud-
interposed between the root surface and the alveolar bone. ied the potential for root resorption during periodontal
The results indicated that root surface alterations, rather wound healing. In 2 monkeys, teeth with induced perio-
than the presence of a reduced periodontium, inhibit new dontitis were extracted, and the roots were planed. After
connective tissue attachment. crown resection, the roots were partially embedded into
Lindhe et al. (1984) studied the contribution of alveolar sockets prepared in the buccal surfaces of the jawbone. The
bone to connective tissue re-attachment following treat- coronal periodontitis affected the roots located in contact
ment. The maxillary and mandibular incisors in 3 monkeys with the connective tissue of the mucosal flap after suturing.
were extracted and the buccal root surfaces of the incisors Healing was evaluated between 1 and 24 weeks. The parts
from the left side of the jaws were planed. In 2 of the of the coronal root surfaces which were covered with epi-
monkeys, the buccal alveolar bone plate was removed. All thelium as a result of exposure exhibited no resorption or
teeth were reimplanted into their original sockets within 4 ankylosis. The root portions in contact with bone or gin-
minutes. Histologic examination after 6 months showed that gival connective tissue regularly displayed root resorption.
irrespective of the presence or absence of alveolar bone, The results indicate that root resorption is a progressive
connective tissue reattachment failed to form on that part process in roots exposed to bone and/or gingival connective
of the tooth that had been root planed; instead a long junc- tissue and that epithelial downgrowth exhibits a protective
tional epithelium had formed. However, in non-root planed function to this process.
teeth a connective tissue reattachment had occurred. Alve-
olar bone located adjacent to a root surface may have lim- HEALING BY REATTACHMENT
ited influence on the biological conditions which determine During surgery, if healthy root surfaces are left undis-
whether periodontal healing results in connective tissue re- turbed, healing will result in the reunion of the gingival
attachment or new attachment. connective tissues with the root surfaces and bone. This
Magnusson et al. (1983) evaluated the resistance of the healing will be characterized by the reformation of the
long junctional epithelium to plaque infection in 4 mon- functionally oriented attachment apparatus that was present
keys. Eight test teeth with induced periodontitis were before surgery.
treated surgically. After 4 months of plaque control, plaque Karring et al. (1980) studied the healing following im-
was allowed to accumulate for 6 months on 4 of the treated plantation of periodontitis-affected roots into bone tissue in
teeth and 3 control teeth. Ligatures were placed on the re- 3 beagle dogs. Following crown resection of 12 teeth, the
maining 4 test teeth and on 3 control teeth to enhance sub- periodontitis-affected portion of the roots was scaled and
gingival plaque formation. The infiltrated connective tissue root planed. The roots were extracted and implanted into
of the test teeth covered about 60% of the junctional epi- bone cavities prepared in edentulous areas of the jaws so
thelium while for the controls it was 90%. The inflamma- that epithelial migration into the wound and bacterial in-
tory lesion in the connective tissue did not extend deeper fection were prevented during healing. The results after 1,
into the periodontal tissues in sites with a long junctional 2, and 3 months of healing demonstrated that new connec-
epithelium than in gingival units of normal height. It was tive tissue attachment did not occur to periodontitis-affected
114 CHAPTER 7. ROOT TREATMENT, REATTACHMENT, AND REPAIR Section 1. Root Healing
root surfaces placed adjacent to bone tissue, but healing was Twenty-four (24) teeth in 4 monkeys were extracted, then
characterized by repair phenomena; i.e., root resorption and reimplanted after either root planing the coronal one third
ankylosis. In areas where periodontal ligament tissue was or root planing the coronal one third followed by topical
preserved, a functionally oriented attachment apparatus was application of citric acid. Histological examinations were
reformed. performed at 1, 3, 7, and 21 days after implantation. Epi-
Nyman et al. (1980) in a similar experiment studied the thelium migrated rapidly along the denuded, non-acid
healing following implantation of periodontitis-affected treated root surfaces reaching the level of root denudation
roots into gingival connective tissue. The study was per- at 21 days. Epithelium did not migrate apically along de-
formed on 28 teeth in 1 dog and 2 monkeys. Following root nuded root surfaces treated with citric acid. At 1 and 3 days,
resection and scaling and root planing of the periodontitis- inflammatory cells were enmeshed in a fibrin network
affected portion of the teeth, the extracted roots were im- which appeared to be attached to the root surface by arcade-
planted into grooves prepared in edentulous areas of the jaws like structures. At 7 and 21 days, the region had repopu-
so that the roots were embedded to half their circumference lated with connective tissue cells, and collagen fibers had
in bone, leaving the remaining part to be covered by the replaced the fibrin. It was concluded that collagen fiber at-
gingival connective tissue of the repositioned flap of the re- tachment to the root surface was preceded by fibrin linkage,
cipient site. Histologic examination after 2 and 3 months of and that the linkage process occurred as an initial event in
healing disclosed that a new connective tissue attachment the wound healing response.
failed to form on the previously exposed root surface located Karring et al. (1985) studied the formation of new con-
in contact with gingival connective tissue. In addition, root nective tissue attachment in a submerged environment. Per-
resorption was seen on this portion of the roots, which in- iodontitis was induced in 4 monkeys. Three months later,
dicated that gingival connective tissue does not possess the the teeth were root planed, the crowns resected, and the
ability to form new connective attachment, and may induce roots covered by a laterally displaced flap. The roots that
resorption of the root. In areas where the periodontal liga- remained covered had newly formed cementum with in-
ment was preserved prior to transplantation, a fibrous reat- serting collagen fibers on the instrumented root portions.
tachment occurred between the root and the adjacent New fibrous attachment was 1.0 ± 0.7 mm. The part of
gingival tissue. Resorption and ankylosis were seen in areas the roots coronal to the newly formed cementum exhibited
adjacent to bone. resorption as the predominant feature. In sites with angular
bony defects, regrowth of supporting bone had occurred in
HEALING BY NEW ATTACHMENT the bottom of the defect. The authors concluded that new
Healing after treatment can be in the form of new at- connective tissue attachment forms on previously periodon-
tachment. This new attachment is characterized by the un- titis-involved roots by coronal migration of cells originating
ion of connective tissue or epithelium with the root surface from the periodontal ligament.
that has been deprived of its original attachment apparatus. Blomlof et al. (1987) compared 5 different methods for
Several clinical and histological studies have confirmed that new attachment formation. Four monkeys with induced per-
healing by new attachment is possible, and several tech- iodontitis were treated by 1 of 5 methods: plaque control
niques have been employed to achieve this type of healing. only; surgery with ultrasonics or hand instrumentation; or
chemical treatment by cetylpyridinium chloride and so-
Animal Studies dium-n-lauroyl sarcosine with or without citric acid. Results
The healing of surgical wounds by new connective tissue of surgery with ultrasonic or hand instrumentation were
attachment was studied by Listgarten et al. (1982). A sur- very similar. Epithelium covered the denuded dentin sur-
gical wound was created on the mesial surface of the left face and bone formation was minimal. Both chemically-
maxillary first molar of rats and the root surface curetted treated groups resulted in a significant new attachment
free of soft tissue and cementum. The rats were sacrificed formation, with the citric acid group showing a slight ten-
between 10 days and 12 months after surgery. The junc- dency for more new attachment. The supracrestal fiber bun-
tional epithelium became re-established by migration of ep- dle was 2 to 3 times thicker in the chemically-treated
ithelium from the wound edge along the cut gingival groups than the mechanically-scaled roots.
surface facing the tooth, until contact was established near Selvig et al. (1988) studied new connective tissue for-
the apical border of the instrumented root surface. The en- mation in fenestration wounds. Full thickness flaps were
tire epithelial attachment was displaced coronally, primarily reflected over the maxillary incisors in 8 dogs. A fenestra-
at the expense of sulcus depth which decreased with time, tion Was made labially over each root 3 to 5 mm from the
and by replacement of the apical portion of the junctional alveolar crest. The flap was repositioned and sutured. After
epithelium by a connective tissue junction of increasing di- 7 days of healing, fibroblasts, macrophages, and a few leu-
mension. kocytes were present near the treated root surface. At 14
New connective tissue attachment was also reported by days, interdigitation of the newly-synthesized fibers and the
Poison and Proye (1983) after citric acid root conditioning. fibrils of the demineralized dental matrix was pronounced.
Section 1. Root Healing CHAPTER?. ROOT TREATMENT, REATTACHMENT, AND REPAIR 115
At 21 days, collagen fibers attached to the cementum or cementum or bone-like tissue, and in the twenty-sixth week
dentin surface now contained fibrils of mature width. Initial they still showed resorption. Ten of the implants with per-
reattachment to an instrumented, demineralized root surface iodontal ligament showed deposition of cementum with col-
included deposition of newly formed collagen fibrils in lagen fibers attached to it after the twelfth week. The
close approximation to, but not in direct continuity with formation of new attachment could be ascribed to the in-
exposed matrix fibrils. In areas of resorption, new fibrils fluence of cells of the remaining periodontal ligament on
may adhere to the surface of hard tissue without any fi- the implanted root fragments.
brillar interdigitation. Bowers et al. (1989 A, B, and C) in a 3-part study eval-
uated the regeneration of periodontal tissues in a submerged
Human Clinical Studies and non-submerged environment with and without grafting
Proye et al. (1982) monitored 128 pockets in 10 patients material. In Part I, the formation of new attachment (new
immediately before and 1, 2, 3, and 4 weeks after a single bone, new cementum, and an intervening periodontal liga-
episode of subgingival root planing. Significant probing ment) was studied in 9 patients with 25 submerged and 22
depth reduction (initial) occurred at 1 week and was asso- non-submerged defects. Histologic evaluation after 6 months
ciated with gingival recession, was reduced further (sec- showed that a new attachment did form on pathologically ex-
ondary) at 3 weeks, and was associated with gain in clinical posed root surfaces in a submerged environment (0.75 mm).
attachment. It was concluded that substantial reduction in Complete regeneration was limited by the amount of bone and
probing depth occurs within 3 weeks after a single episode cementum formation. Periodontal ligament fibers were em-
of root planing owing to initial gingival recession and sec- bedded in cementum and bone and were most frequently
ondary gain in clinical attachment. oriented parallel to the root. In Part II, new attachment was
Nyman et al. (1988) evaluated the role of diseased ce- evaluated in grafted and non-grafted submerged defects in
mentum on new attachment formation. Eleven (11) patients 10 patients. The results showed that after 6 months of heal-
were treated surgically using a split mouth design. In 2 ing, grafting with demineralized freeze-dried bone allograft
quadrants (control), the teeth were scaled and root planed (DFDBA) enhanced the amount and frequency of new at-
to remove all cementum. In the remaining quadrants (test), tachment apparatus (1.76 mm versus 0.76 mm for non-
calculus was removed without removal of cementum and grafted sites), new cementum (1.88 mm versus 1.48 mm
the teeth were polished. The patients were followed for 24 for non-grafted sites), and new bone (1.96 mm versus 0.80
months. The results showed that the same degree of im- mm for non-grafted sites) in a submerged environment. In
provement was achieved following both types of treatment: Part III, new attachment was evaluated in a non-submerged
there was some gain of probing attachment for both environment with and without bone grafts. Twelve patients
treatment modalities. had 32 defects treated with DFDBA and 25 defects treated
with open debridement. Histometric evaluation after 6
Human Histologic Studies
months of healing demonstrated that grafted defects had a
Nyman et al. (1982) reported on a case of a mandibular
mean new attachment apparatus of 1.21 mm. There was a
lateral incisor with attachment loss of 11 mm that was
mean of 1.24 mm of new cementum formation, 0.13 mm
treated with a barrier membrane. A Millipore filter was
of connective tissue attachment, and 1.75 mm of new bone
placed between the flap and the tooth to prevent the epi-
formation. The junctional epithelium was located 1.36 mm
thelium and the gingival connective tissue from reaching
coronal to the calculus reference notch. In non-grafted sites,
contact with the curetted root surface. The tooth was re-
a long junctional epithelium formed along the entire length
moved en bloc after 3 months of healing. New cementum
of exposed root surfaces.
with inserting fibers was observed extending to a level 5
mm coronal to the alveolar bone crest. New bone had been
formed within the angular bony defect. It was concluded
THE EFFECTS OF TREATMENT ON GINGIVAL
that regeneration of cementum including fibrous attachment
FIBROBLASTS
may be achieved by cells originating from the periodontal
ligament, provided that epithelial cells and gingival con- In Vitro Studies
nective tissue cells are prevented from occupying the The cells in the healing site can only attach to a biolog-
wound area adjacent to the root during the initial phase of ically acceptable root surface. Periodontal treatment should
healing. produce a root surface that will promote cell growth and
Lopez and Belvederessi (1983) implanted 26 root frag- attachment.
ments without periodontal ligament and 18 root fragments Aleo et al. (1975) studied in vitro the attachment of hu-
with periodontal ligament in pouches created in the con- man fibroblasts to root surfaces. Untreated periodontally in-
nective tissue under the mucosa of 44 patients. The im- volved teeth were extracted and cut longitudinally. Three
plants together with the adjacent tissues were removed groups of 20 or more teeth were employed: 1) received no
between the third and twenty-sixth week after implantation. treatment; 2) endotoxin extracted with 45% phenol in wa-
The implants without periodontal ligament failed to form ter; 3) cementum was mechanically removed. Teeth were
116 CHAPTER 7. ROOT TREATMENT, REATTACHMENT, AND REPAIR Section 1. Root Healing
incubated with human gingival fibroblasts for 24 to 48 2.5 mm (77%) and the average amount of crestal resorption
hours. Microscopic examination demonstrated uniform at- was 0.7 mm (18%). Assessment of tooth mobility showed
tachment to the uninvolved portion of the root surface a tendency of a given tooth to decrease by 1 degree of
whereas the involved portion of the root surface allowed mobility. It was concluded that intrabony defects may pre-
only a few cells to attach. When the endotoxin was re- dictably remodel after surgical debridement and establish-
moved from the root surface by phenol extraction or by ment of optimal plaque control.
mechanical removal of the diseased cementum, the fibro-
blasts attached normally to the root surface. Human Histologic Studies
Gilman and Maxey (1986) compared ultrasonics to ul- Waerhaug (1978A) treated 21 patients with a total of 39
trasonics plus air powder abrasive for their ability to re- teeth scheduled for extraction with root planing, some with
move endotoxin. Six teeth were extracted and sectioned flap access. Patients were instructed to carry out supragin-
into 12 specimens. Test specimens were instrumented with gival plaque control, and were observed for periods ranging
the ultrasonics or ultrasonics plus air powder abrasive. Four from 15 days to 7 months. Teeth were then extracted and
calculus-covered control specimens were not instrumented. microscopic observations reported. It was found that re-
Eight root specimens were placed in fibroblast tissue culture formation of a normal dento-epithelial junction invariably
and were stained for determination of fibroblast viability occurs when calculus, including plaque, is completely re-
after 48 hours. No fibroblast growth took place on calculus moved. If good supragingival plaque control is maintained,
control specimens. Ultrasonics specimens showed light fi- no further subgingival plaque will form and health can be
broblast growth and viability. Ultrasonics plus air powder maintained. Residual plaque may give rise to reformation
abrasive specimens showed superior growth and vitality of of plaque within the pocket; however with excellent plaque
fibroblasts. control, the tissues may appear clinically healthy. Residual
plaque progresses apically, with a loss of attachment oc-
curring at the same speed (2 um/day).
THE EFFECT OF PLAQUE CONTROL ON
HEALING FOLLOWING TREATMENT Waerhaug (1978B) treated 84 condemned teeth with
probing depths of > 3 mm by scaling and root planing,
Bacterial plaque is the main etiologic factor in perio-
some with flap access. Thirty-one (31) teeth were extracted
dontal disease. Studies have established that periodontal
immediately, and 53 had healing times of up to 1 year be-
disease will not initiate or progress in the absence of
fore extraction. The results of this light microscopic study
plaque. Also, when healing is considered, numerous reports
have demonstrated that the results of treatment will be com- demonstrated that the distance from the plaque front to in-
tact periodontal fibers is 0.5 mm to > 1.0 mm. It was con-
promised if bacterial plaque is not removed during the heal-
cluded that the chances of removing all subgingival plaque
ing period, and that optimal healing can only be achieved
are fairly good if probing depth is < 3 mm; in the 3 to 5
in a plaque-free environment.
mm range, chances of failure are greater than the chances
Human Clinical Studies of success, and if probing depth exceeds 5 mm the chance
Rosling et al. (1976) treated 24 patients with modified of failure dominates. If all subgingival plaque is removed,
Widman flap surgery. The test group was recalled once the junctional epithelium will be readapted to the plaque-
every 2 weeks and given professional tooth cleaning. Con- free tooth surface. If new supragingival plaque is allowed
trol patients were recalled once every 12 months for pro- to form or subgingival plaque is not removed, they will
phylaxis. All patients were re-examined 6, 12, and 24 give rise to the reformation of subgingival plaque within
months after surgery. There was a gain of attachment in the pocket. Surgical elimination of pathological pockets >
the test group (3.0, 3.2, and 3.5 mm, at 6, 12, and 24 3 mm is the most predictable method for attaining good
months, respectively), whereas in the control group there subgingival plaque control.
was a continuous loss of attachment following surgery. In
the control patients, 58 of 62 2-walled and all 3-walled REFERENCES
defects were present after 2 years. In the test group, both Aleo J, De Renzis F, Farber P. In vitro attachments of human gingival
2-walled and 3-walled defects had a "bone fill" of ap- fibroblasts to root surfaces. J Periodontal 1975;46:639-645.
proximately 80%. Beaumont R, O'Leary T, Kafrawy A. Relative resistance of long junc-
tional epithelial adhesions and connective tissue attachments to plaque-
Poison and Heijl (1978) treated 15 defects in 9 patients induced inflammation. J Periodontal 1984;55:213-223.
by reverse bevel flaps. Patients were recalled once a week Blomlof L, Lindskog S, Appelgren R, Jonsson B, Weintraub A, Ham-
for 3 to 6 weeks. Re-entry procedure performed 6 to 8 marstrom L. New attachment in monkeys with experimental periodon-
months after initial surgery showed a bony morphology titis with and without removal of the cementum. J Clin Periodontal
with the surface texture of alveolar bone adjacent to the 1987;14:136-143.
Bowers G, Chadroff B, Carnevale R, et al. Histologic evaluation of new
tooth in the area of the defect. The results showed that after attachment apparatus formation in humans. Part I. J Periodontal
surgical debridement and establishment of optimal plaque 1989A;60:664-674.
control, the amount of coronal bone regeneration averaged Bowers G, Chadroff B, Carnevale R, et al. Histologic evaluation of new
Section 2. Scaling and Root Planing CHAPTER 7. ROOT TREATMENT, REATTACHMENT, AND REPAIR 117
attachment apparatus formation in humans. Part IL J Periodontol val plaque control. II. As observed on extracted teeth. J Periodontol
1989B;60:675-682. 1978B;49:119-134.
Bowers G, Chadroff B, Carnevale R, et al. Histologic evaluation of new
attachment apparatus formation in humans. Part III. J Periodontol
1989C;60:683-693.
Caton J, Nyman S, Zander H. Histometric evaluation of periodontal sur-
gery. IL Connective tissue attachment levels after four regenerative Section 2. Scaling and Root Planing
procedures. J Clin Periodontol 1980;7:224-231.
Caton J, Zander H. Osseous repair of an infrabony pocket without new
attachment of connective tissue. J Clin Periodontol 1976;3:54-58. ROOT SMOOTHNESS (HAND VERSUS
Caton J, Zander H. The attachment between tooth and gingival tissues ULTRASONICS)
after periodic root planing and soft tissue curettage. J Periodontol
Controversy still exists over the superiority of ultrason-
1979;50:462^66.
Gilman R, Maxey B. The effect of root detoxification on human gingival
ics versus hand instruments in calculus removal, cementum
fibroblasts. J Periodontol 1986;57:436-440. removal, endotoxin removal, and root surface smoothness.
Karring T, Isidor F, Nyman S, Lindhe J. New attachment formation on The smoothness of the root surface after instrumentation
teeth with a reduced but healthy periodontal ligament. J Clin Perio- was studied by Kerry (1967). One hundred and eighty (180)
dontol 1985;12:51-60. anterior teeth from 43 patients were scaled and root planed
Karring T, Nyman S, Lindhe J. Healing following implantation of perio-
dontitis affected roots into bone tissue. J Clin Periodontol 1980;7:96-
using 5 different methods: curets; one of two ultrasonic
105. units; curets followed by ultrasonics; and ultrasonics fol-
Karring T, Nyman S, Lindhe J, Sirirat M. Potentials for root resorption lowed by curets. The teeth were extracted and the relative
during periodontal wound healing. J Clin Periodontol 1984; 11:41-52. roughness was determined with a Profilometer. The
Lindhe J, Nyman S, Karring T. Connective tissue reattachment as related smoothest roots were obtained by first using the ultrasonics
to presence or absence of alveolar bone. / Clin Periodontol 1984;! 1:
33-40.
and finishing with curets. Almost equally as smooth were
Listgarten M, Rosenberg S, Lerner S. Progressive replacement of epithe- the curetted only roots. In the middle range was the group
lial attachment by a connective tissue junction after experimental per- of curets followed by ultrasonics. The roughest roots were
iodontal surgery in rats. J Periodontol 1982;53:659-670. produced by the ultrasonic tips. Hand curets produced
Lopez N, Belvederessi M. Healing following implantation of healthy smoother root surfaces than the ultrasonic instruments.
roots, with and without periodontal ligament tissue, in the oral mucosa.
In a scanning electron microscopic (SEM) study Wilkin-
J Periodontol 1983;54:283-290.
Magnusson I, Runstad L, Nyman S, Lindhe J. A long junctional epithe- son and Maybury (1973) found that teeth root planed by
lium — A locus minoris resistentiae in plaque infection? J Clin Per- curets were smooth and flat and no longer harbored small
iodontol 1983;10:333-340. particles of calculus. The root surfaces treated by ultrason-
Nyman S, Karring T, Lindhe J, Planten S. Healing following implantation ics looked chipped and fractured with the appearance of
of periodontitis-affected roots into gingival connective tissue. / Clin
irregular ridges. They concluded that both methods of in-
Periodontol 1980;7:394-401.
Nyman S, Lindhe J, Karring T, Rylander H. New attachment following strumentation were equally effective in removing foreign
surgical treatment of human periodontal disease. J Clin Periodontol matter from the tooth, but curets produced smoother sur-
1982;9:290-296. faces than ultrasonics.
Nyman S, Westfelt E, Sarhed G, Karring T. Role of "diseased" root Jones et al. (1972) treated 54 teeth using tungsten carbide
cementum in healing following treatment of periodontal disease. A
curets, sealers, or ultrasonics before extraction and exami-
clinical study. J Clin Periodontol 1988;15:464^68.
Poison A, Caton J. Factors influencing periodontal repair and regeneration.
nation under SEM. Twenty-six (26) teeth were completely
J Periodontol 1983;53:617-625. free of calculus after treatment. No difference in the effi-
Poison A, Heijl L. Osseous repair in infrabony periodontal defects. J Clin ciency of calculus removal was found between the various
Periodontol 1978;5:13-23. instruments used; the ultrasonics caused least damage to the
Poison A, Proye M. Fibrin linkage: A precursor for new attachment. J root surface, while sealers and curets caused slight damage.
Periodontol 1983;54:141-147.
Pameijer et al. (1972) using SEM found no difference in
Proye M, Caton J, Poison A. Initial healing of periodontal pockets after
a single episode of root planing monitored by controlled probing root topography when teeth were instrumented by ultrasonics
forces. J Periodontol 1982;53:296-301. or hand instruments. Hand instruments removed substantially
Proye M, Poison A. Effect of root surface alterations on periodontal heal- more tooth structure than ultrasonics. Instrumentation of a
ing. I. Surface denudation. J Clin Periodontol 1982;9:428^40. polished dentinal surface by hand instruments, however, re-
Rosling B, Nyman S, Lindhe J. The effect of systematic plaque control
moved tooth structure and left a rough surface when com-
on bone regeneration in infrabony pockets. J Clin Periodontol 1976;
3:38-53. pared to ultrasonic instruments.
Selvig G, Bogle G, Claffey N. Collagen linkage in periodontal connective Lie and Meyer (1977) using SEM showed that calculus
tissue reattachment. J Periodontol 1988;59:758-768. removal was considerably more complete with the diamond
Waerhaug J. Microscopic demonstration of tissue reaction incident to re- point than with curets, ultrasonics, or Roto-Pro instrument.
moval of subgingival calculus. J Periodontol 1955;26:26-29. The ultrasonic instrument gave the least satisfactory clean-
Waerhaug J. Healing of the dento-epithelial junction following subgingi-
val plaque control. 1. As observed in human biopsy material. J Per-
ing of the tooth surface. When the loss of tooth substance
iodontol 1978A;49:l-8. was scored, only minor differences were found between the
Waerhaug J. Healing of the dento-epithelial junction following subgingi- Roto-Pro, curets, and the ultrasonic instrument, while the
118 CHAPTER 7. ROOT TREATMENT, REATTACHMENT, AND REPAIR Section 2. Scaling and Root Planing
diamond scored considerably higher than any of the other after scaling. Sites with probing depths less than 3 mm were
instruments. the easiest to scale and those deeper than 5 mm were the
Breininger et al. (1987) instrumented 30 molar and 30 most difficult. Tooth type did not influence the results.
non-molar teeth with either hand curets or ultrasonics. These Stambaugh et al. (1981) scaled 42 sites on 7 teeth with
treated teeth plus 20 untreated controls were extracted, an ultrasonic instrument followed one week later by hand
stained with 0.5% toluidine blue, and examined under SEM curets. Teeth were extracted immediately after hand instru-
for residual stainable material and calculus. The results mentation. Measurements were taken before treatment, 1
showed that a large percentage of treated proximal root sur- week after ultrasonic instrumentation, and after extraction
faces had stainable deposits, but these surfaces were often of the teeth. The average depth of pocket instrumented to
"unexpectedly" free of microbes. The majority of stained a plaque and calculus free surface "curet efficiency" was
deposits was composed of adherent fibrin and instrumenta- 3.73 mm, and was not deeper than 4 mm (range 2.7 to 4.1
tion debris. When plaque was found, it was in small "mini- mm). The maximum mean probing depth at which evidence
colonies" (< 0.55 mm diameter). Both instrumentation could be seen of instrumentation on the root surface was
methods appeared to be effective in bacterial debridement termed "instrument limit" and 6.21 mm, (range 2 to 10
but only partially effective in removing subgingival calculus. mm). Instrumentation was more efficient on the distal and
The effect of root roughness on plaque accumulation and mesial than on the buccal and lingual surfaces. The results
inflammation of the adjacent gingival tissues was studied of the study support the surgical debridement and the re-
by Rosenberg and Ash (1974). Fifty-eight (58) teeth were duction of pockets in areas of deep probing depth.
extracted 28 to 232 days after instrumentation. Using a Pro- Gellin et al. (1986) compared the effectiveness of cal-
filometer to measure root roughness, they found a statisti- culus removal using either a sonic sealer, hand curets, or a
cally significant difference in mean roughness between sonic sealer plus hand curets. Six-hundred-ninety (690) root
curetted teeth (mean 9.51) and either teeth treated with ul- surfaces in 11 patients with moderate to advanced perio-
trasonics (mean 17.21) or control teeth (18.30). No signifi- dontitis were studied. The results showed that the percent-
cant differences in mean plaque scores or mean inflammatory age of surfaces with residual calculus was: sonic sealer only
indices were observed between the 3 groups. It was con- (31.9%); curets only (26.8%); and sonic sealer plus curets
cluded that root roughness was not significantly related to (16.9%). The combination of sonic sealer and curets was
the mean inflammatory index of the adjacent gingival tis- more effective in the removal of subgingival calculus than
sues or to supragingival plaque accumulation. either method used alone. As probing depth increased, the
Khatiblou and Ghodssi (1983) studied the effects of root percentage of surfaces with residual calculus increased for
roughness on healing following surgical treatment. Eight- all 3 methods.
een (18) single rooted teeth in 12 patients with advanced Kepic et al. (1990) treated 31 teeth by closed scaling
periodontitis were divided into 2 groups. Modified Widman and root planing with either ultrasonic (14) or hand instru-
flaps were performed for both groups. In one group, shal- ments (17). After a healing period of 4 to 8 weeks, the
low horizontal grooves were made on root surfaces to teeth were root planed again using the same instruments
roughen them after root planing. Healing was evaluated 4 after flap reflection. The teeth were then extracted and pre-
months after surgery. Results indicated that there were no pared for light microscopic evaluation. Twelve of the 14
significant differences between the two groups in terms of teeth treated by ultrasonics and 12 of the 17 teeth treated
probing depth reduction and gain of attachment. Both by hand instruments retained calculus. Hand instrumenta-
groups showed a gain of attachment and reduced probing tion appeared to be more effective than ultrasonics in re-
depth as a result of the surgical treatment. It was concluded moving cementum from proximal surfaces. Five blocks
that clinical healing is not affected by varying degrees of were studied under a scanning electron microscope. All 5
root surface roughness. specimens displayed residual calculus at either the light mi-
croscope, the SEM level, or both. The results indicate that
CALCULUS REMOVAL complete removal of calculus from a periodontally diseased
Several studies evaluated the effectiveness of calculus root surface is rare.
removal using ultrasonics, hand curets, or a combination of Sherman et al. (1990) instrumented 476 surfaces on 101
ultrasonics and hand instruments. extracted teeth using ultrasonics and hand instruments. The
Rabbani et al. (1981) studied the influence of probing teeth were then evaluated stereomicroscopically for the
depth on the efficiency of calculus removal. Sixty-two (62) presence of calculus. The percent surface area with calculus
teeth were scaled and root planed with hand instruments, was determined by computerized imaging analysis. Fifty-
and 57 were left untreated and served as controls. The gin- seven percent (57%) of all surfaces had residual micro-
gival margin was marked on the teeth. The teeth were then scopic calculus and the mean percent calculus per surface
extracted, stained with 1% methylene blue, and viewed un- area was 3.1% (0 to 31.9%). The inter-examiner and intra-
der a stereomicroscope. The results indicated a high cor- examiner clinical agreement in detecting calculus was low.
relation between probing depth and the remaining calculus There was a high false-negative response (77.4% of the
surfaces with microscopic calculus were clinically scored rience level or type of procedure in shallow (1 to 3 mm)
as being free of calculus) and a low false-positive response pockets. However, in moderate (4 to 6 mm) and deep (> 6
(11.8% of the surfaces microscopically free of calculus mm) periodontal pockets, scaling and root planing com-
were clinically determined to have calculus). This study bined with an open flap procedure was more effective than
indicates the difficulties in clinically determining the thor- S/RP alone for both experience levels. Also, the more ex-
oughness of subgingival instrumentation. perienced operators produced a significantly greater number
Rateitschak et al. (1992) non-surgically scaled and root of calculus-free root surfaces than the less experienced op-
planed 10 single-rooted teeth in 4 patients with advanced erators in periodontal pockets with moderate and deep
periodontitis. The teeth were then extracted and examined probing depths. Best calculus removal was accomplished
under SEM. Twenty-nine (29) of the 40 curetted root sur- by experienced operators employing an open procedure.
faces were free of residues, if they were reached by the Parashis et al. (1993) treated 30 mandibular molars with
curet. On the remaining 11 surfaces, only small amounts of furcation involvement using either a closed or an open ap-
plaque and minute islands of calculus were detected, pri- proach, or with an open approach using rotary diamond.
marily at the line angles and also in grooves and depres- After extraction, the teeth were assessed under a stereo-
sions in the root surfaces. Instrumentation to the base of microscope and the percentage of residual calculus was cal-
the pocket was not achieved completely on 75% of the culated on external and furcation surfaces. The percentage
treated root surfaces. Surfaces that can be reached by curets of residual calculus on the external surfaces was signifi-
are usually free of plaque and calculus; however, in many cantly higher after closed than open root planing. Probing
cases the base of the pocket will not be reached. It is for depth influenced the effectiveness of scaling and root plan-
this reason that deep periodontal pockets should be treated ing, with more residual calculus observed for depths equal
surgically. to or greater than 7 mm for both groups. The most effective
method was the combination of open root planing and ro-
tary diamond.
OPEN VERSUS CLOSED APPROACH
Closed and open scaling and root planing were also
Root instrumentation could be performed using either a
compared by Wylam et al. (1993). Sixty (60) multi-rooted
closed (non-surgical) or an open (surgical) approach. It is
teeth were assigned to one of 3 groups: untreated controls,
generally agreed that open scaling and root planing gives a
closed scaling and root planing, and open flap scaling and
better access to the root surfaces and improves calculus
root planing. Following extraction, the mean percent
removal using either ultrasonics or hand instruments. This
stained surface area was 54.3% in the closed group com-
is especially true in sites with greater probing depth.
pared to 33.0% in the open flap group. No difference was
The effectiveness of instrumentation with or without flap
found between shallow sites (< 3 mm) and deeper sites (>
reflection was compared by Eaton et al. (1985). Periodon-
3 mm). Examination of furcation regions demonstrated
tally-involved buccal root surfaces on the anterior teeth of
heavy residual stainable deposits for both treatment meth-
33 patients were instrumented either before or after the re-
ods, with no significant differences between techniques.
flection of the flaps. The remaining deposits were stained,
then photographed. The findings revealed that root planing
under direct vision at the time of surgery was more effec- FURCATION AND ROOT MORPHOLOGY
tive than blind instrumentation. However, in no instance Root morphology plays a major role when root instru-
was any root surface found to be completely free of stain- mentation is considered. Multi-rooted teeth with furcation
able deposits. invasion are harder to instrument than single-root teeth.
Caffesse et al. (1986) found that for 1 to 3 mm pockets Other anatomical variations such as root grooves, narrow
S/RP alone and flap plus S/RP were equally effective in furcation openings, or furcation ridges make complete cal-
obtaining calculus-free surfaces (86%). For 4 to 6 mm culus removal harder if not impossible, even when an open
pockets 43% of the surfaces were calculus-free when S/RP approach is used.
alone and 76% when flap plus S/RP was performed. In sites The effectiveness of instrumenting furcation areas was
greater than 6 mm, S/RP alone obtained only 32% calculus- studied by Matia et al. (1986). Forty-eight (48) patients
free surfaces while flap plus S/RP obtained 50% calculus- with 50 mandibular molars with severe periodontitis sched-
free surfaces. The extent of residual calculus was directly uled for extraction were selected. Twenty (20) teeth were
related to probing depth, was greater following S/RP alone, instrumented with curets, 10 after surgical exposure (open)
and was greatest at the CEJ or in association with grooves, of the furcation, and 10 without surgical exposure (closed).
fossae, or furcations. Twenty (20) teeth were instrumented with an ultrasonic
Brayer et al. (1989) distributed 114 periodontally in- sealer, 10 teeth open and 10 teeth closed. The remaining
volved, single-rooted teeth among 4 operators of 2 expe- 10 teeth were not instrumented and served as untreated con-
rience levels for either an open or closed session of scaling trols. The teeth were extracted after instrumentation and the
and root planing. The results showed that there was no dif- furcations were assessed under a stereomicroscope for re-
ference in scaling and root planing effectiveness for expe- sidual calculus. The results indicated that calculus removal
in the furcation area is more effective when a surgical flap sealer (93.5 \im), the curet (108.9 |o,m) and the diamond bur
is utilized, and that the ultrasonic sealer is more effective (118.7 |4,m). The ultrasonic sealer caused the least amount
than the curet in removing calculus in the furcation area of substance loss while the diamond bur caused the most
utilizing a surgical flap. amount of loss.
Fleischer et al. (1989) compared open and closed scaling Zappa et al. (1991) scaled and root planed 40 extracted
and root planing on 50 molars designated for extraction. teeth. Low forces (mean 3.04 N) were used in 30 teeth and
They found that calculus-free root surfaces were obtained high forces (mean 8.84 N) in 10 teeth. Root substance loss
significantly more often with flap access than with a non- was measured after 5, 10, 20, and 40 working strokes. The
surgical approach. Their results suggest that, although both results showed that the mean cumulative loss of root sub-
surgical access and a more experienced operator signifi- stance across 40 strokes was 148.7 (im at low forces, and
cantly enhance calculus removal in molars with furcation 343.3 (Am at high forces. The results suggest that high
invasion, total calculus removal in furcations utilizing con- forces remove more root substance, and loss per stroke be-
ventional instrumentation may be limited. comes less with increasing numbers of strokes.
The influence of root morphology on the effectiveness
of calculus removal was studied by Fox and Bosworth
ENDOTOXIN REMOVAL
(1987). The mesial and distal surfaces of 168 extracted
One of the aims of root instrumentation is the removal
teeth, representing all tooth types except third molars, were
of endotoxin from the periodontally involved root surface
examined to document the presence or absence of proximal
to make it biologically acceptable. Jones and O'Leary
concavities. Results showed that teeth from nearly every
(1978) compared 296 root surfaces from 5 treatment groups
tooth position, both maxillary and mandibular had concav-
for the presence of endotoxin. The groups were: subgingi-
ities at or within 5 mm apical to their cemento-enamel junc-
val root planing, supragingival root planing, untreated roots
tion (CEJ). It was concluded that proximal concavities are
with disease, gross scaled roots in vitro, and healthy non-
extremely common, the existence of which may complicate
diseased root surfaces. Pooled samples had endotoxin ex-
restorative and periodontal therapy as well as the patient's
tracted by water/phenol method and assayed for quantity of
ability to maintain effective plaque control.
endotoxin by the limulus lysate test. It was found that the
root planed groups (both supra- and subgingival) had far
REMOVAL OF TOOTH STRUCTURE less endotoxin recovered than the gross scaled or untreated
An excessive amount of tooth structure can be removed groups; the amounts were close to non-diseased tooth lev-
during root planing. Special attention should be paid not to els. It was concluded that root planing was able to render
overinstrument the roots. Riffle (1953) found that it was previously diseased root surfaces nearly free of endotoxin,
impossible to distinguish between curetting cementum and to levels comparable to healthy root surfaces of unerupted
curetting dentin. When dentin was removed a V-shaped teeth.
ditch was created near the CEJ. Nishimine and O'Leary (1979) compared endotoxin re-
Borghetti et al. (1987) root planed 4 periodontally in- moval by hand curets and ultrasonics. Two groups of 46
volved teeth with a curet from 1 to 4 repeated "firm" teeth each were treated, one by curets and the other by
strokes per surface. Teeth were subsequently extracted, sec- ultrasonics, and were compared to 2 control groups, one of
tioned, and measured for cementum thickness. The results 46 untreated periodontally diseased teeth and the other of
showed that the amount of cementum removed increases 31 unerupted healthy teeth. The results showed that thor-
with the number of strokes with the curet. Except for cor- ough root planing with curets produces root surfaces nearly
onal areas, cementum was never completely removed; at as endotoxin free (2.09 ng/ml) as the surfaces of unerupted
best was reduced by two-thirds. Root planing seems to be healthy teeth (1.46 ng/ml), and that curets are more effec-
more effective in the coronal areas where the cementum is tive than ultrasonics in removing endotoxin from the peri-
thinner than in the apical areas. It was concluded that total odontally involved root surfaces. Ultrasonics treated root
removal of cementum cannot be accomplished under rou- surfaces had 16.8 ng/ml and untreated periodontally dis-
tine clinical conditions with a curet. eased surfaces had 169.5 ng/ml.
The removal of tooth structure was also studied by Ritz Gilman and Maxey (1986) compared ultrasonics to ul-
et al. (1991). Three-hundred-sixty (360) sites on 90 ex- trasonics plus air powder abrasive for their ability to re-
tracted mandibular incisors were instrumented with 4 dif- move endotoxin. Six teeth were extracted and sectioned
ferent instruments: hand curet, ultrasonic sealer, air-sealer, into 12 specimens. Test specimens were instrumented with
and fine grit diamond. Twelve strokes were used with clin- the ultrasonics or ultrasonics plus air powder abrasive. Four
ically appropriate forces of application. The loss of tooth calculus-covered control specimens were not instrumented.
substance was measured with a device especially con- Eight root specimens were placed in fibroblast tissue culture
structed for this investigation. Only a thin layer of root and were stained for determination of fibroblast viability
substance (11.6 (0,m) was removed by the ultrasonic sealer, after 48 hours. No fibroblast growth took place on calculus
compared to the much greater losses sustained with the air- control specimens. Ultrasonic specimens showed light fi-
broblast growth and viability. Ultrasonics plus air powder of the keratinized tissue. No change in the location of the
abrasive specimens showed superior growth and vitality of mucogingival junction occurred after treatment.
fibroblasts. Torfason et al. (1979) treated 51 pairs of single rooted
Assad et al. (1987) studied the chemical removal of en- teeth with 4 to 6 mm probing depth in 18 patients with
dotoxin from the root surface. Twenty (20) extracted perio- either hand or ultrasonic instruments using a split-mouth
dontally involved teeth were cut into halves bucco-lingually design. Instrumentation was repeated after 4 weeks. Meas-
and sterilized. The control half of each tooth was rubbed urements taken after 8 weeks showed a gradual reduction
with saline and the experimental half was rubbed with 2% of probing depth and the number of bleeding sites. There
sodium desoxycholate followed by human plasma. Both were no significant differences between the two groups ex-
groups were then placed in separate petri dishes, with fi- cept ultrasonic treatment required less time to treat. They
broblast cell suspension. The control tooth surfaces showed concluded that for treatment of 4 to 6 mm probing depth,
a mean of 307 ± 63 attached cells. The experimental sur- there is no significant difference between hand instrumen-
faces exhibited a mean of 650 ± 1 30 attached cells. The tation and ultrasonic in terms of clinical improvement.
findings suggest that the desoxycholate/plasma combination Badersten et al. (1981) also found no difference in the
enhanced in vitro fibroblast attachment to diseased root sur- healing response following treatment using hand or ultra-
faces. sonic instruments; 528 tooth surfaces of single-rooted teeth
Nyman et al. (1988) evaluated the effect of removing in 15 patients with moderate periodontitis were treated by
diseased cementum on healing following surgery. Eleven hand and ultrasonic non-surgical therapy. Improvements in
patients were treated surgically using a split mouth design. plaque scores, bleeding on probing, decreased probing and
In 2 quadrants (control), the teeth were scaled and root attachment levels were similar for both treatment methods.
planed to remove all cementum. In the remaining quadrants It was shown that shallower sites had a slight loss of at-
(test), calculus was removed without removal of cementum tachment while deeper sites showed some improvement.
and the teeth were polished. The patients were followed for Badersten et al. (1984A) evaluated the response of deep
24 months. The results showed that the same degree of sites in 16 patients with advanced periodontal disease using
improvement was achieved following both types of treat- hand or ultrasonic non-surgical therapy. Comparable results
ment. There was some gain of probing attachment for both were obtained by both methods. It was shown that the deep
treatment modalities. probing depths could be successfully treated non-surgically.
It was shown that shallower sites were at risk of losing
attachment, while the deep sites were more likely to gain
HEALING RESPONSE AND THE EFFECT OF attachment. Deeper residual probing sites were more likely
THERAPY to bleed on probing.
The primary goal of periodontal treatment is to arrest Cercek et al. (1983) monitored 7 periodontitis patients
the progression of disease, which could be done using hand during 3 phases of treatment: 1) toothbrushing and flossing;
or ultrasonic instruments and employing a closed or an 2) Perio-Aid used sub-gingivally; and 3) sub-gingival de-
open approach. The best way to determine which technique bridement. The mean probing depth of 4.4 mm was reduced
is superior in achieving that goal is by evaluating the heal- to 4.0 mm in phase I; no improvement in phase II; and
ing response following treatment. reduced to 3.2 mm after instrumentation. Clinical attach-
Tagge et al. (1975) evaluated 3 matched sites in each of ment level showed a slight loss through phase II, but im-
22 patients for the effects of scaling and oral hygiene versus proved attachment levels were found after instrumentation.
oral hygiene alone. One site served as control, the second Minimal effect was derived from patient performed plaque
received oral hygiene alone, and the third was treated by control, whether supra- or subgingival. The bulk of the ef-
root planing and oral hygiene. Eight to 9 weeks after treat- fect was derived from professional subgingival instrumen-
ment, measurements were taken and biopsies were ob- tation (scaling and root planing). This is one of the few
tained. Microscopically and clinically, scaling and root studies that examines the separate effects of plaque control
planing with oral hygiene was shown to be more effective and that of scaling and root planing on periodontal healing.
in reducing gingivitis scores, probing depths, and gain in Badersten et al. (1985B) studied the incisors, canines,
attachment levels than oral hygiene alone. and premolars in 33 patients with generalized periodontal
Hughes and Caffesse (1978) treated 61 teeth in 15 pa- destruction for patterns of clinical attachment loss. Patients
tients by scaling and root planing. Clinical measurements received supra- and subgingival debridement after oral hy-
and scores were taken at initial exam, 1 week, and 1 month giene instructions, and were followed for 24 months. Meas-
after treatment. The findings indicated that thorough scaling urements were made every third month and 7 patterns of
and root planing of teeth with severe inflammation of the probing attachment were identified. Seventy-three percent
gingiva is commonly followed within 1 week to 1 month (73%) of the sites showed a gradual loss of probing attach-
after scaling by a decrease in probing depth, gain in at- ment. Seventeen percent (17%) showed an early loss fol-
tachment, gingival recession, and a decrease in the width lowed by a stabilization in attachment level. Shallower sites
showed a pattern of early loss followed by stabilization THE EFFECT OF SCALING AND ROOT PLANING
while deeper sites showed a gradual loss. ON THE DENTIN AND THE PULP
Claffey et al. (1988) treated 1,248 sites in 9 patients by Fischer et al. (1991) evaluated the effect of instrumen-
a single episode of root debridement with ultrasonics. Prob- tation on the pulp in 11 patients with periodontally diseased
ing depth and attachment level were measured by 3 differ- mandibular incisors. The subjects were divided into 2
ent examiners before instrumentation and at 3, 6, and 12 groups according to marginal bone loss. The pulp sensitiv-
months after treatment. Results showed an initial mean loss ity was evaluated by an electric pulp test. Dentin sensitivity
of probing attachment of 0.5 to 0.6 mm as a result of in- was evaluated with 2 forms of controlled stimulations
strumentation. Only 5% of all sites lost > 1 mm of attach- (probe and air-jet) and with a questionnaire. No changes in
ment from pre-instrumentation to 12 months. Only 2% of pulp sensitivity were found after scaling, but a clinically
all sites lost attachment from post-instrumentation to 12 significant increase in dentin sensitivity to probe and/or air
months. The results suggest that the observed attachment stimuli was observed in 6 patients. A natural mechanism of
loss was either directly attributable to instrumentation or to desensitization seemed to have occurred 2 weeks after sub-
a remodeling process as a result of therapy rather than to gingival debridement.
progressive disease. Fogel and Pashley (1993) used unerupted third molars
in their in vitro study. The crowns were removed and lon-
gitudinal slices cut. The hydraulic conductance of the root
OPERATOR VARIABILITY dentin was measured before and after root planing, acid
The effect of operator variability on healing following etching, and potassium oxalate application using a fluid fil-
non-surgical therapy was evaluated by Badersten et al. tration method. The results showed that root planing creates
(1985A). The incisors, canines, and premolars were studied a smear layer that reduces the permeability of the under-
in 20 patients with generalized severe periodontitis. The lying dentin. However, this smear layer is acid labile. Thus,
periodontal pockets were debrided using either hand and/or root planing may ultimately cause increased dentin per-
ultrasonic instruments under local anesthesia by a perio- meability and the associated sequelae of sensitive dentin,
dontist or by 1 of a group of 5 dental hygienists. A split- bacterial invasion of tubules, reduced periodontal reattach-
mouth design was used with measurements recorded at the ment, and pulpal irritation.
initial examination and every third month. The results in-
dicated that deep periodontal pockets in single-rooted teeth
may be successfully treated by plaque control and 1 episode REFERENCES
of instrumentation and that operator variability may be lim- Assad D, Dunlap R, Weinberg S, Ahl D. Biologic preparation of diseased
root surfaces. An in vitro study. J Periodontol 1987;58:30-33.
ited. Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal
Brayer et al. (1989) found no difference in scaling and therapy. I. Moderately advanced periodontitis. J Clin Periodontol
root planing effectiveness for experience level in shallow 1981;8:57-72.
(1 to 3 mm) pockets. However, the more experienced op- Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal
erators produced a significantly greater number of calculus- therapy. II. Severely advanced periodontitis. J Clin Periodontol
1984A;11:63-76.
free root surfaces than the less experienced operators in Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical therapy. III.
periodontal sites with moderate and deep probing depths. Single versus repeated instrumentation. J Clin Periodontol 1984B;11:
Fleischer et al. (1989) also found that operators with more 114-124.
experience achieved calculus-free root surfaces significantly Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal
more often than operators of lesser experience with both an therapy. IV. Operator variability. J Clin Periodontol 1985 A; 12:190-
200.
open and closed procedure. Badersten A, Nilveus R, Egelberg J. Effects of nonsurgical periodontal
therapy. V. Patterns of probing attachment loss in non-responding
sites. J Clin Periodontol 1985B;12:270-282.
SINGLE VERSUS REPEATED INSTRUMENTATION Borghetti A, Mattout P, Mattout C. How much root planing is necessary
Badersten et al. (1984B) evaluated the effect of single to remove the cementum from the root surface? Int J Periodontics
versus repeated instrumentation on healing following non- Restorative Dent 1987;7(4):23-29.
surgical treatment. Incisors, canines, and premolars were Brayer W, Mellonig J, Dunlap R, Marinak K, Carson R. Scaling and root
planing effectiveness: The effect of root surface access and operator
studied in 13 patients with severe periodontitis. Teeth were experience. J Periodontol 1989;60:67-72.
instrumented using ultrasonic instruments. Instrumentation Breininger D, O'Leary T, Blumenshine R. Comparative effectiveness of
was repeated in one side of the jaw after 3 and 6 months. ultrasonic and hand scaling for the removal of subgingival plaque and
A gradual and marked improvement took place during the calculus. J Periodontol 1987;58:9-18.
first 9 months. No differences in results could be observed Caffesse R, Sweeny P, Smith B. Scaling and root planing with and without
periodontal flap surgery. J Clin Periodontol 1986; 13:205-210.
when comparing the effects of a single versus repeated in-
Cercek J, Kiger J, Garrett S, Egelberg J. Relative effects of plaque control
strumentation. It was concluded that deep periodontal pock- and instrumentation on the clinical parameters of human periodontal
ets in incisors, canines, and premolars may be treated by disease. J Clin Periodontol 1983; 10:46-56.
plaque control and one episode of instrumentation. Claffey N, Loos B, Gantes B, Martin M, Heins P, Egelberg J. The relative
Section 3. Ultrasonics and Air Abrasives CHAPTER 7. ROOT TREATMENT, REATTACHMENT, AND REPAIR 123
effects of therapy and periodontal disease on loss of probing attach- Sherman P, Hutchens L, Jewson L, Moriarty J, Greco G, McFall W. The
ment after root debridement. J Clin Periodontal 1988;15:163-169. effectiveness of subgingival scaling and root planing. I. Clinical de-
Eaton K, Kieser J, Davies R. The removal of root surface deposits. J Clin tection of residual calculus. J Periodontol 1990;61:3-8.
Periodontal 1985;12:141-152. Stambaugh R, Dragoo M, Smith D, Carasali L. The limits of subgingival
Fischer C, Wennberg A, Fischer R, Attstrom R. Clinical evaluation of scaling. Int J Periodontics Restorative Dent 1981;1(5):30-41.
pulp and dentine sensitivity after supragingival and subgingival scal- Tagge D, O'Leary T, El-Kafrawy A. The clinical and histologic response
ing. Endod Dent Traumatol 1991;7:259-265. of periodontal pockets to root planing and oral hygiene. J Periodontol
Fleischer H, Mellonig J, Brayer W, Gray J, Barnett J. Scaling and root 1975;46:527-533.
planing efficacy in multirooted teeth. JPeriodontol 1989;60:402^K)9. Torfason T, Kiger R, Selvig N, Egelberg J. Clinical improvement of gin-
Fogel H, Pashley D. Effect of periodontal root planing on dentin perme- gival conditions following ultrasonic versus hand instrumentation of
ability. J Clin Periodontol 1993;20:673-677. periodontal pockets. J Clin Periodontol 1979;6:165-176.
Fox S, Bosworth B. A morphological survey of proximal root concavities: Wilkinson R, Maybury J. Scanning electron microscopy of the root surface
A consideration in periodontal therapy. J Am Dent Assoc 1987; 114: following instrumentation. J Periodontol 1973;44:559-563.
811-814. Wylam J, Mealey B, Mills M, Waldrop T, Moskowicz D. The clinical
Gellin R, Miller M, Javed T, Engler W, Mishkin D. The effectiveness of effectiveness of open versus closed scaling and root planing on multi-
the titan-s-sonic sealer versus curets in the removal of subgingival rooted teeth. J Periodontol 1993;64:1023-1028.
calculus: A human surgical evaluation. J Periodontol 1986;57:672— Zappa U, Smith B, Simona C, Graf H, Case D, Kim W. Root substance
680. removal by scaling and root planing. J Periodontol 1991;62:750-754.
Gilman R, Maxey B. The effect of root detoxification on human gingival
fibroblasts. J Periodontol 1986;57:436-440.
Hughes T, Caffesse R. Gingival changes following scaling, root planing
and oral hygiene. A biometric evaluation. J Periodontol 1978;49:245- Section 3. Ultrasonics and Air
252.
Jones S, Lozdan J, Boyde A. Tooth surfaces treated in situ with perio- Abrasives
dontal instruments: Scanning electron microscopic studies. Br Dent J
1972;132:57-64.
DEFINITION
Jones W, O'Leary T. The effectiveness of in vivo root planing in removing
bacterial endotoxin from the roots of periodontally involved teeth. J Ultrasonic Sealer: An instrument vibrating in the ultra-
Periodontol 1978;49:337-342. sonic range (approximately 30,000 cps) which, accompa-
Kepic T, O'Leary T, Kafrawy A. Total calculus removal: An attainable nied by a stream of water, can be used to remove adherent
objective? J Periodontol 1990;61:16-20. deposits from teeth.
Kerry G. Roughness of root surfaces after use of ultrasonic instruments
and hand carets. J Periodontol 1967;38:340-346.
Khatiblou F, Ghodssi A. Root surface smoothness or roughness in peri- PRINCIPLES OF ULTRASONICS
odontal treatment. A clinical study. J Periodontol 1983;54:365-367. Magnetostrictive units contain a generator that converts
Lie T, Meyer K. Calculus removal and loss of tooth substance in response 60 HZ, 120-volt current into high-frequency current that
to different periodontal instruments. A scanning electron microscope
continually alters the shape of the magnetostrictive bime-
study. J Clin Periodontol 1977;4:250-262.
Matia J, Bissada N, Maybury J, Ricchetti P. Efficiency of scaling the tallic stack. As the stack vibrates, the sealer tip vibrates.
molar furcation area with and without surgical access. Int J Periodon- Ferromagnetic metals (nickel-cobalt alloys) in the stack
tics Restorative Dent 1986;6(6):24-35. change length in accordance with alterations in polarity.
Nishimine D, O'Leary T. Hand instrumentation versus ultrasonics in the The resulting 25,000 contractions and expansions per sec-
removal of endotoxin from root surfaces. J Periodontol 1979;50:345-
ond produce the ultrasonic wave, moving the ultrasonic tip
349.
Nyman S, Westfelt E, Sarhed G, Karring T. Role of "diseased" root
an amplitude of approximately 0.0015 cm. The greater the
cementum in healing following treatment of periodontal disease. A power setting on the unit, the greater the distance traveled
clinical study. J Clin Periodontol 1988; 15:464^168. by the tip. Water flow through the tip dissipates heat and
Pameijer C, Stallard R, Hiep N. Surface characteristics of teeth following produces a cavitational effect. Cavitation is almost an in-
periodontal instrumentation: A scanning electron microscope study. J stantaneous release of energy resulting from alternating
Periodontol 1972;43:628-633.
Parashis A, Anagnou V, Demetriou N. Calculus removal from multirooted
pressures of the water which is accompanied by rapidly
teeth with and without surgical access. (I). Efficacy on external and expanding and contracting the air bubbles that collapse in
furcation surfaces in relation to probing depth. J Clin Periodontol the water. As the bubbles change size at the root surface,
1993;20:63-68. they dislodge and wash away debris.
Rabbani G, Ash M, Caffesse R. The effectiveness of subgingival scaling Piezoelectric units produce ultrasonic energy with a
and root planing in calculus removal. J Periodontol 1981;52:119-123.
crystal system which expands and contracts when an elec-
Rateitschak P, Schwarz J, Guggenheim R, Duggelin M, Rateitschak K.
Non-surgical periodontal treatment: Where are the limits? An SEM tric current is applied, creating a reciprocal rather than an
study. J Clin Periodontol 1992;19:240-244. elliptical motion. The low electromagnetic interference
Riffle A. The dentin: Its physical characteristics during curettage. J Per- (EMI) level emitted by piezoelectric sealers is not hazard-
iodontol 1953;24:232-241. ous to cardiac pacemakers; therefore, it is a safe alternative
Ritz L, Hefti A, Rateitschak K. An in vitro investigation on the loss of to magnetostrictive sealers (Brown et al., 1987).
root substance in scaling with various instruments. J Clin Periodontol
1991;18:643-647.
Checchi et al. (1991) studied the effect of sharpening on
Rosenburg R, Ash M. The effect of root roughness on plaque accumula- the ultrasonic sealer tip movement. Physical behavior of the
tion and gingival inflammation. J Periodontol 1974;45:146-150. sealer was not significantly modified by changes in tip di-
124 CHAPTER 7. ROOT TREATMENT, REATTACHMENT, AND REPAIR Section 3. Ultrasonics and Air Abrasives
ameter, although the resonant frequency of the tip was calculus increased; and 4) subgingival calculus removal was
changed. more difficult in multi-rooted teeth and for proximal sur-
faces.
ULTRASONICS VERSUS HAND INSTRUMENTS Kepic et al. (1990) treated 31 teeth by closed scaling and
root planing with either an ultrasonic or hand instruments
Plaque repeated the instrumentation 4 to 8 weeks later following flap
Thornton and Garnick (1982) compared removal of sub- reflection, and extracted the teeth. Light microscope (LM)
gingival plaque by ultrasonic and hand instrumentation. evaluation indicated that 12 of the 14 teeth treated by ultra-
Twenty-four (24) periodontally hopeless teeth were treated sound and 12 of the 17 treated by hand instruments retained
by: 1) scaling with hand instruments; 2) scaling with an calculus. In addition to LM, 5 blocks were evaluated by
ultrasonic unit; or as 3) uninstrumented controls. Following scanning electron microscope (SEM). All 5 specimens dis-
extraction and staining, plaque removal was assessed with played residual calculus at either the light microscope, the
a compensating polar planimeter. Residual plaque was pres- SEM level, or both. The results indicate that complete re-
ent on 33% of the surfaces of hand scaled teeth and 34% moval of calculus from a periodontally diseased root sur-
of ultrasonically scaled teeth. Uninstrumented teeth exhib- face is rare.
ited 87% total root surface coverage with plaque. Walmsley
(1990) showed increased plaque removal due to the cavi- Microflora
tation during ultrasonic scaling as compared to ultrasonic Leon and Vogel (1987) compared the effectiveness of
scaling without water spray and water spray alone. Baehini hand scaling and ultrasonic debridement in furcations. Be-
et al. (1992) reported no difference in microscopic or cul- fore treatment, Class I furcations had more coccoid cells
tural data between ultrasonic and sonic instrumentation. and fewer motile bacteria than Class III furcations. Class II
furcations had percentages of bacteria between those of
Calculus Class I and Class III furcations. In Class I furcations, hand
Jones et al. (1972) treated 54 teeth scheduled for extrac- scaling and ultrasonic debridement had equivalent effects
tion using curets, sealers, or ultrasonics and then exmined on the flora with no significant differences between the 2
them under a scanning electron microscope (SEM). treatment modalities. When compared to baseline at 2
Twenty-six (26) of the teeth were completely free of cal- weeks, both treatments altered the microbiota and gingival
culus after treatment and no difference in the efficiency of crevicular fluid levels to one more consistent with health.
calculus removal was observed between the various instru- In Class II and III furcations, both hand instrumentation
ments. The ultrasonic unit caused least damage to the root and ultrasonics resulted in a bacterial form consistent with
surface, although sealers and curets caused little damage. health at 2 weeks post-debridement. By 4 weeks, the mi-
Nishimine and O'Leary (1979) compared the effective- crobial profile was returning to one consistent with disease.
ness of hand instruments and ultrasonic sealers in removing At all times, ultrasonic instrumentation provided greater im-
calculus and endotoxin from proximal root surfaces treated provement in microbial parameters than hand instrumenta-
before extraction. Visual inspection revealed that 30.4% of tion in both Class II and Class III furcations. The authors
ultrasonically scaled teeth had residual calculus compared suggested that this may be due to better access. Oosterwaal
to 21.7% of teeth root planed with hand instruments. Hunter et al. (1987) treated single-rooted teeth and showed that
et al. (1984) compared hand and ultrasonic instrumentation hand scaling and ultrasonic treatment were equally effective
during open flap root planing. Overall, hand-scaled root in reducing probing depths; bleeding scores; and micro-
surfaces demonstrated less residual calculus (5.78%) than scopic counts of rods, spirochetes, and motile forms. In
ultrasonically-treated surfaces (6.17%). Hand-scaled ante- addition, there was a reduction in total colony-forming units
rior teeth had less residual calculus (3.55%) on the avail- and numbers of Bacteroides and Capnocytophaga, resulting
able surface area than ultrasonically-scaled anterior teeth in a subgingival microbiota consistent with periodontal
(5.49%). Conversely, posterior teeth had less residual cal- health.
culus with ultrasonic scaling (6.87%) than hand-scaling Breininger et al. (1987) compared the effectiveness of
(7.42%). Gellin (1986) evaluated the effect of hand versus ultrasonic and hand scaling in the removal of subgingival
sonic instrumentation on the removal of calculus by visu- plaque and calculus. Both methods were only partially ef-
ally examining the root surfaces during periodontal flap sur- fective in removing subgingival calculus; however, both
gery. The percentage of surfaces with residual calculus for methods were "remarkably effective" at supragingival
each method of instrumentation was: 1) sonic sealer only plaque removal. When plaque was present after instrumen-
(31.9%); 2) curets only (26.8%); and 3) sonic sealer and tation, it was usually found in "mini colonies" less than 0.5
curets (16.9%). The authors concluded that: 1) there was no mm in diameter. Cuticle-like substances were frequently
consistent difference between curets and the sonic sealer; 2) found on ultrasonic but not hand-instrumented surfaces.
the combination of the sonic sealer and curet instrumentation Thilo and Baehni (1987) reported vibrations generated by an
was more effective than either method alone; 3) as the prob- ultrasonic sealer have the potential to alter the composition
ing depth increased, the percentage of surfaces with residual of dental plaque and to kill spirochetes in vitro.
Wound Healing Incisors, canines, and premolars in 33 patients with gen-

Rosenberg and Ash (1974) studied 58 teeth from 20 pro- eralized periodontal destruction were studied by Badersten
spective denture patients which were assigned to curets, et al. (1985) for patterns of probing attachment loss. Pa-
ultrasound, or control groups. Twenty-eight (28) to 232 tients received supra- and subgingival debridement after
days after instrumentation and before extraction, plaque oral hygiene instruction and were followed for 24 months.
scores and labial biopsies were performed. After extraction, Measurements were made after every third month and 7
root surface roughness was determined with a Profilometer. patterns of probing attachment identified. Seventy-three
A statistically significant difference in mean roughness was percent (73%) of sites showed a gradual loss of probing
present between curetted teeth (mean 9.51) and either Cav- attachment; 17% showed an early loss followed by a sta-
itron (mean 17.21) and control teeth (18.30). No significant bilization in attachment level. Shallower sites showed a
differences in mean plaque scores or mean inflammatory pattern of early attachment loss followed by stabilization
indices were observed between the 3 groups. Root rough- while deeper sites showed gradual loss.
ness was not significantly related to the mean inflammatory
index of the adjacent gingival tissues or to supragingival Root Surface
plaque accumulation. Roughness. In a study by Kerry (1967), 180 anterior
In a study by Khatiblou and Ghodssi (1983), 18 single- teeth from 43 patients were divided into 5 groups and the
rooted teeth in 12 patients with advanced periodontitis were roots were scaled and root planed by curets; Cavitron
divided into two groups and modified Widman flaps per- EW.PP; Cavitron EW.P10; curets followed by ultrasonics;
formed on both groups. In 1 group, shallow horizontal and ultrasonics followed by curets. Following extraction,
grooves created roughened root surfaces after root planing. the relative root roughness was determined with a Profil-
The other group served as an unroughened control. Healing ometer. The smoothest roots were obtained by ultrasonics
was evaluated 4 months after surgery, indicating no signif- followed by curets. The roughest roots were produced by
icant differences between the groups. Both groups showed the ultrasonic tips. Hand curets produced smoother root sur-
attachment gain and reduced probing depth as a result of faces than the ultrasonic instruments.
the surgical treatment. The authors concluded that clinical Pameijer et al. (1972) studied 25 teeth scheduled for
healing is not affected by varying degrees of root surface extraction and 10 freshly extracted teeth which were treated
roughness. with either hand or ultrasonic instruments or were left un-
Torfason et al. (1979) studied 51 pairs of single-rooted treated. The 10 extracted teeth were ground flat; polished
teeth with 4 to 6 mm pockets in 18 patients who were and then treated with both previous methods. Replicas were
treated with either hand or ultrasonic instruments using a made to duplicate the original morphology and topography
split-mouth design. Instrumentation was repeated after 4 of the specimens which were then studied utilizing scanning
weeks. Measurements taken after 8 weeks showed a gradual electron microscopy (SEM). No differences were observed
reduction of probing depth and the number of bleeding in root topography, whether instrumented by ultrasonics or
sites. For treatment of 4 to 6 mm pockets, there was no hand instruments. Hand instruments removed substantially
significant difference between hand instrumentation and ul- more tooth structure than ultrasonics. Instrumentation of a
trasonics in terms of clinical improvement, although ultra- polished dentinal surface by hand instruments, however, re-
sonic instrumentation required less time. moved tooth structure and left a rough surface when com-
Badersten et al. (1981) treated 528 tooth surfaces of in- pared to ultrasonic instruments.
cisors, canines, and premolars in 15 patients with severely Hunter et al. (1984) found that 81.2% of ultrasonically-
advanced periodontal disease by hand and ultrasonic non- treated teeth were rough (gouges or ripples 50 urn in depth),
surgical therapy. Improvements in plaque scores, bleeding while only 43.4% of hand-scaled surfaces were graded as
on probing, decreased probing depths, and attachment lev- rough. Dragoo (1992) compared hand instruments to mod-
els were similar for both treatment methods. Shallower sites ified and unmodified Cavitron tips. He reported that the
had a slight loss of attachment while deeper sites showed modified tips (reduced in size) produced smoother roots
some improvement. with less damage, better access to the bottom of the pocket,
Badersten et al. (1984A) treated 16 patients with se- and better plaque and calculus removal than either hand
verely advanced periodontal disease by hand or ultrasonic sealers or ultrasonic sealers with unmodified inserts. Less
non-surgical therapy. Comparable results were obtained by operator time was required and less operator fatigue oc-
both methods, indicating that the deep probing depths could curred with modified tips.
be successfully treated non-surgically, based on probing Endotoxin. Garrett (1977) suggested ultrasonics fol-
depth, probing attachment levels, bleeding on probing, lowed by hand instrumentation for superior endotoxin re-
plaque, and gingival recession. Shallower sites were at a moval and production of a smoother root surface.
risk of losing attachment, while the deep sites were more Nishimine et al. (1979) compared effectiveness of hand in-
likely to gain attachment. Deeper residual probing sites struments and ultrasonic sealers in removing endotoxin
were more likely to bleed on probing. from root surfaces in vivo using Westphal (phenol-water)
extraction and the limulus amebocyte lysate test. Endotoxin Single Versus Repeated Instrumentation. Badersten et
levels reported were: 1) healthy controls (unerupted third al. (1984B) studied incisors, canines, and premolars in 13
molars), 1.46 ng/ml; 2) teeth roots planed with hand instru- patients with severe periodontitis. Teeth were instrumented
ments, 2.09 ng/ml; 3) ultrasonic-treated teeth, 16.8 ng/ml; using ultrasonic instruments, and repeated instrumentation
and 4) untreated perio-diseased controls, 169.5 ng/ml. in one side of the jaw was performed after 3 and 6 months.
Checchi et al. (1988) showed no significant difference in A gradual and marked improvement took place during the
in vitro fibroblast growth between periodontally involved first 9 months. No differences in results could be observed
root surfaces treated with curets or ultrasonic sealers. The when comparing the effects of a single versus repeated in-
authors concluded that both treatments resulted in the re- strumentation, suggesting that deep periodontal pockets in
moval of endotoxin from diseased root surfaces. Chiew et incisors, canines, and premolars may be treated by plaque
al. (1991) confirmed the superficial location of bacterial control and 1 episode of instrumentation.
toxic products associated with periodontally involved root Antimicrobial Lavage. The penetration depth of the
surfaces. Smart et al. (1990) achieved root surface cleanli- water from an ultrasonic instrument into the periodontal
ness (removal of endotoxin) with a Cavitron and light pres- pocket was evaluated histologically by Nosal et al. (1991).
sure (50 grams/force for 0.8 seconds/mm2) on extracted Patients having teeth planned for extraction and exhibiting
roots with no clinically detectable calculus. probing depths at least 3 mm in depth were used for study.
Cementum Removal. Hunter et al. (1984) reported ap- Erythrosin dye was added to the coolant which was deliv-
proximately equal amounts of cementum removal by ultra- ered to the apical extent of the pocket by vertical movement
sonics and hand instruments with neither method removing of the ultrasonic probe tip. After extraction of the tooth, the
all cementum. Pameijer (1972) stated that ultrasonic instru- dye-stained root surface was observed along the full extent
ments will not plane root surfaces while Wilkinson and of the probe tip's penetration path. The findings indicate
Maybury (1988) indicated that ultrasonics could remove ce- that the ultrasonic instrument may be an effective system
mentum, but only by producing root damage. for both removal of plaque and calculus while simultane-
Nyman et al. (1988) treated 11 patients surgically using ously delivering a chemotherapeutic agent. Limited disper-
a split-mouth design. In 2 quadrants (control), the teeth sion of the erythrosin dye in a lateral direction indicates
were scaled and root planed to remove all cementum. In that thorough debridement of the root surface is necessary
the remaining quadrants (test), calculus was removed with- to adequately deliver chemical agents.
out removal of cementum and the teeth polished. The pa- Single-rooted Versus Multi-rooted Teeth. Hunter et al.
tients were followed for 24 months. Results indicated that (1984) compared open flap root planing techniques and re-
the same degree of improvement was achieved regardless ported that hand instruments removed calculus better in an-
of treatment and that some gain of probing attachment ac- terior teeth, while the Cavitron was more effective in
companied both treatment modalities. posterior teeth. Leon and Vogel (1987) showed that hand
Bone. Horton et al. (1975A) studied the effect of ultra- instruments and ultrasonics were equally effective in Grade
sonic instrumentation on bone removal during periodontal I furcation; however, ultrasonics were more effective in
surgery. Healing was uneventful with no post-operative Grade II and III furcations, based on differential darkfield
complications and minimal patient discomfort. Histologi- microscopy and gingival crevicular fluid evaluation pa-
cally, no alterations in osteocytes, vascular channels, or un- rameters. Loos et al. (1987) compared the clinical effect-
derlying periodontal tissues were noted. In another report iveness of a single treatment with ultrasonic and sonic
(Horton et al., 1975B), the authors showed faster healing sealers using a split-mouth design in 10 patients. Similar
of surgical defects in alveolar bone with ultrasonics than changes in clinical parameters were observed for ultrasonic
with rotary burs. Glick and Freeman (1980) found no sig- (3.3 minutes/tooth) and sonic sealers (4.0 minutes/tooth).
nificant difference in post-surgical bone loss in cats after
full mucoperiosteal flap reflection and debridement with ei-
ther hand instruments or ultrasonics. Three month re-entry PREPROCEDURAL RINSING
surgery revealed 0.333 ± 0.077 mm mean bone loss with Fine et al. (1992) reported that preprocedural rinsing
ultrasonic debridement versus 0.329 ± 0.075 mm mean with an antiseptic mouthwash (Listerine) can significantly
bone loss with hand instrumentation. reduce the microbial content of aerosols generated during
Walmsley et al. (1990) evaluated the effect of cavita- ultrasonic scaling. Gross et al. (1992) showed no significant
tional action of the ultrasonic sealer on root surfaces . Using difference in mean combined total colony-forming units
a gold ingot and extracted teeth, the ultrasonic tip was held (CPU) per cubic foot (CF) for magnetostrictive, piezoelec-
against the surface and also away from the surface. Pho- tric or air turbine sonic sealers. The magnetostrictive sealer
tomicrographs and scanning electron microscopy studies re- generated the lowest CFU/CF at the deepest level of pen-
vealed that cavitational activity within the cooling water etration, but there was no significant difference in level of
supply of the ultrasonic sealer results in superficial removal a simulated lung penetration of the aerosol produced by any
of root surface constituents. of the 3 instruments.
AIR ABRASIVES 3 dogs were intentionally sprayed for 5 seconds at a dis-

Mechanism of Action. Abrasive particles propelled by tance of 6 mm. After 2 and 4 days, a fibrinopurulent exu-
high-speed air emerge from a point source at the tip of the date was associated with the sulcus and bone. Moderate
handpiece. The abrasive powder is composed of sodium inflammation of bone resolved by 7 and 14 days postop-
bicarbonate treated with 0.5 to 0.8% tricalcium phosphate eratively. The effect of the abrasive spray on the root sur-
to improve flow characteristics. The powder is converted faces was evaluated following a 20-second sweeping spray
into a slurry aerosol at the point source by turbulent mixing of the buccal surfaces with the handpiece tip held 4 to 6
with 95 F water spray. mm from the root surface. The AAU treated and control
Advantages. Weaks (1984) evaluated an air abrasive unit sides healed equally well, and no significant difference was
(AAU) for effectiveness in removal of stain and plaque and observed in inflammatory response. Inflammation was
its effect on the marginal gingiva, reporting complete re- greatest at days 2 and 4, lessened by day 7, with little in-
moval of extensive stain and plaque in significantly less flammation present at 14 days post-operatively. To study
time (5.5 ± 3.6 minutes) than a rubber cup and pumice the effect of AAU powder on bone, each dog also had a
(13.4 ± 6.0 minutes). separate flap reflected and a 40 mg bolus of dry powder
Disadvantages. Weaks (1984) reported increased soft placed directly on the bone. The flap was replaced and su-
tissue trauma immediately following use of an air abrasive tured. At 2 and 4 days, there was clinical ulceration and
unit; however, this effect was not detected after 6 days. partial necrosis of the flap immediately overlying the pow-
Finlayson and Stevens (1988) reported oral emphysema fol- der. Histologically, there was acute inflammation and active
lowing use of an AAU during maintenance of deep perio- bone resorption. At 7 and 14 days in general, the inflam-
dontal pockets associated with teeth numbers 13 to 15. The matory response to the powder had subsided and few os-
complication resolved after 7 days (pen VK 500 mg QID). teoclastic lacunae were present.
Effects of AAU on Root Surfaces. Atkinson et al.
(1984) noted that an AAU removed an average of 636.6 set REFERENCES
Atkinson DR, Cobb C, Killoy W. The effect of an air-powder abrasive
urn (range, 470 to 856 urn) of root structure in 30 seconds system on in-vitro root surfaces. J Periodontol 1984;55:13—18.
of exposure. They also observed "partially obliterated" Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal
dental tubules, but found it impossible to distinguish oc- therapy. I. Moderately advanced periodontitis. J Clin Periodontol
cluded and open tubules. Horning et al. (1987) reported a 1981;8:57-72.
Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal
mean of 80 um of cementum removed after 40 seconds of
therapy. II. Severely advanced periodontitis. J Clin Periodontol
exposure of extracted teeth to the air powder spray. The 1984A; 11:63-76.
decreased cementum removal in this study may have been Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical therapy. HI.
due to distribution of the spray over a surface area of 30 Single versus repeated instrumentation. J Clin Periodontol 1984B;11:
mm2 versus 3/14 mm2 in Atkinson's study. 114-124.
Badersten A, Nilveus R, Egelberg J. Effects of nonsurgical periodontal
Horning et al. (1987) studied 32 teeth scheduled for ex- therapy. V. Patterns of probing attachment loss in non-responding
traction using flap reflection, ultrasonic scaling, and either sites. J Clin Periodontol 1985;12:270-282.
an AAU or manual root planing. The ultrasonic plus AAU Baehni P, Thilo B, Chapuis B, Fernet D. Effects of ultrasonic and sonic
and ultrasonic plus root planing techniques were similar in sealers on dental plaque microflora in vitro and in vivo. J Clin Per-
plaque, calculus, and cementum removal (both methods left iodontol 1992;19:455^59.
Breininger D, O'Leary T, Blumenshine R. Comparative effectiveness of
some calculus but no plaque). The study showed no time ultrasonic and hand scaling for removal of subgingival plaque and
advantage in using the AAU; however, it was less fatiguing calculus. J Periodontol 1987;58:9-18.
than manual root planing. Clinically, the AAU showed Brown F, Lubow R, Cooley R. Applied ultrasonics in periodontal therapy.
more favorable (clean, white, and smooth) root surfaces in- / West Soo Periodontol Periodont Abstr 1987;35:53-60.
cluding proximal flutings and furcal areas. Compared to Chappie I, Walmsley A, Saxby M, Moscrop H. Effect of subgingival ir-
rigation with chlorhexidine during ultrasonic scaling. J Periodontol
hand instrumentation at 200 X and 3000 X magnification, the 1992;63:812-816.
AAU-treated surfaces were smoother and had less debris. Checchi L, Pelliccioni G, D'Achille C. Sharpening of ultrasonic sealers.
The AAU treated surfaces often exhibited tiny globular, crys- J Clin Periodontol 1991;18:505-507.
talline particles, assumed to be tricalcium phosphate parti- Chiew S, Wilson M, Davies E, Kieser J. Assessment of ultrasonic de-
bridement of calculus-associated periodontally-involved root surfaces
cles.
by the limulus amoebocyte lysate assay. An in vitro study. J Clin
Effects of AAU on Wound Healing After Surgery. Pip- Periodontol 1991;18:240-244.
pin (1988) investigated the effects of an AAU on wound Dragoo M. A clinical evaluation of hand and ultrasonic instruments on
healing after periodontal flap surgery in dogs, including ab- subgingival debridement. Part I. With unmodified and modified ultra-
rasive spray on tissue and roots and abrasive powder on sonic inserts. Int J Periodontics Restorative Dent 1992;12:311-13.
Fine D, Mendieta C, Barnett M, et al. Efficacy of pre-procedural rinsing
bone to study the effect of abrasive spray on tissue. No with an antiseptic in reducing viable bacteria in dental aerosols. J
effort was made to shield the connective tissue side of the Periodontol 1992;63:821-824.
flap from Overspray and no rinsing was performed, leaving Finlayson R, Stevens F. Subcutaneous facial emphysema secondary to use
residual material on tooth and tissue surfaces. The flaps in of the Cavi-Jet. J Periodontol 1983;59:315-317.
Garrett J. Root planing: A perspective. J Periodontol 1977;48:553-557. Weaks LM, Lescher NB, Barnes CM, et al.: Clinical evaluation of the
Gellin R. The effectiveness of the Titan-S sonic sealer versus curettes in Prophy Jet as an instrument for routing removal of tooth stain and
the removal of subgingival calculus. A human evaluation. J Periodon- plaque. J Periodontol 1984;55:486^88.
tol 1986;57:672-680. Wilkinson R, Maybury J. Scanning electron microscopy of the root surface
Click D, Freeman E. Post surgical bone loss following root planing by following instrumentation. J Periodontol 1973;44:559-563.
ultrasonic and hand instruments. J Periodontol 1980;51:510-512.
Gross K, Overman PK, Cobb C, Brockmann S. Aerosol generation by two
ultrasonic sealers and one sonic sealer. A comparative study. J Dent
Hyg 1992;66:314-318. Section 4. Root Conditioning
Horning GM, Cobb CM, Killoy WJ. Effect of an air-powder abrasive A primary goal of periodontal therapy is to treat the
system on root surfaces in periodontal surgery. J Clin Periodontol diseased root surface making it biologically compatible
1987;14:213-220. with a healthy periodontium. This includes removing the
Morton JE, Tarpley TM Jr, Jacoway JR. Clinical applications of ultrasonic
instrumentation in the surgical removal of bone. Oral Surg Oral Med
endotoxins, bacteria, and other antigens found in the ce-
OralPathol 1975A;39:236-242. mentum of the root surface. A prerequisite for this root
Morton J, Tarpley T, Wood L. The healing of surgical defects in alveolar preparation is scaling and root planing which was shown
bone produced with ultrasonic instrumentation and rotary bur. Oral by Jones and O'Leary (1978) to remove nearly all detect-
Surg Oral Med Oral Pathol 1975B;39:536-546. able levels of bacterial endotoxins. Another form of root
Hunter R, O'Leary T, Kafrawy A. The effectiveness of hand versus in-
strumentation in open-flap root planing. J Periodontol 1984;55:697-
conditioning used to help achieve this goal and facilitate
703. new attachment is root surface demineralization. In a re-
Jones S, Lozdan J, Boyde A. Tooth surfaces treated in site with perio- view article, Holden and Smith (1983) state that root con-
dontal instruments: Scanning electron microscope study. Br Dent J ditioning was performed as early as 1883 when Marshall
1972;132:57-64. placed aromatic sulfuric acid on root surfaces, Younger
Kepic T, O'Leary T, Kafrawy A. Total calculus removal: An attainable
objective? J Periodontol 1990;61:16-20.
used lactic acid in 1897, and in 1899 when Stewart decal-
Kerry G. Roughness of root surfaces after use of ultrasonic instruments cified the root surface with pure hydrochloric or sulfuric
and hand curettes. J Periodontol 1967;38:340-346. acid.
Khatiblou F, Ghodssi A. Root surface smoothness or roughness in peri-
odontal treatment. A clinical study. J Periodontol 1983;54:365-367.
CITRIC ACID: HISTOLOGIC RESULTS
Leon L, Vogel R. A Comparison of the effectiveness of hand scaling and
ultrasonic debridement in furcations as evaluated with dark-field mi-
Register and Burdick (1975) studied several demineral-
croscopy. J Periodontol 1987;58:86-94. izing agents for optimum concentration and time of appli-
Loos B, Kiger R, Egelberg J. An evaluation of basic periodontal therapy cation in gaining reattachment with cementogenesis. Dogs
using sonic and ultrasonic sealers. J Clin Periodontol 1987;14:29-33. and cats were used as the experimental model and agents
Nishimine D, O'Leary T. Hand instrumentation versus ultrasonics in the tested included hydrochloric, lactic, citric, phosphoric,
removal of endotoxins from root surfaces. J Periodontol 1979;50:345-
349.
trichloroacetic, and formic acids and a proprietary demi-
Nosal G, Sheidt M, O'Neal R, Van Dyke T. The penetration of lavage neralizer RDO. Citric and lactic acids and RDO produced
solution into the periodontal pocket during ultrasonic instrumentation. slightly wider bands of cementum deposition while trich-
J Periodontol 1991;62:554-557. loroacetic and formic acids stimulated more dentin resorp-
Nyman S, Westfelt E, Sarhed G, Karring T. Role of "diseased" root tion before cementum deposition. It was determined that
cementum in healing following treatment of periodontal disease. A
clinical study. J Clin Periodontol 1988; 15:464-468.
citric acid at pH 1 for 2 to 3 minutes would be the best
Oosterwaal P, et al. The effect of subgingival debridement with hand and agent. They later showed the formation of cementum pins
ultrasonic instruments on the subgingival flora. J Clin Periodontol (perpendicularly extending fiber bundles seen in the tubules
1987;14:528-533. at 3 weeks, which appear continuous with and inseparable
Pameijer C. Surface characteristics of teeth following periodontal instru- from the induced cementum at 6 weeks) extending into den-
mentation. J Periodontol 1972;43:628-633.
tin tubules widened by demineralization when denuded root
Pippin DJ, et al.: Effects of an air-powered device used during periodontal
flap surgery on dogs. J Periodontol 1988;59:584-588. surfaces in dogs were treated by citric acid pH 1 for 2
Rosenburg R, Ash M. The effect of root roughness on plaque accumula- minutes.
tion and gingival inflammation. J Periodontol 1974;45:146-150. Garrett et al. (1978) used scanning and transmission
Smart G, Wilson M, Davies E, Kieser J. The assessment of ultrasonic root electron microscopes to examine the morphological effects
surface debridement by determination of residual endotoxin levels. J of citric acid on periodontally diseased root surfaces. Scan-
Clin Periodontol 1990;17:174-178.
Thilo B, Baehni P. Effect of ultrasonic instrumentation on dental plaque
ning microscopy showed acid decreased the surface char-
microflora in vitro. J Periodontol Res 1987;22:518-521. acteristics of non-root planed teeth. Non-etched root planed
Thornton S, Garnick J. Comparison of ultrasonic to hand instruments in surfaces were smooth and flat. Acid-etched root planed sur-
the removal of subgingival plaque. J Periodontol 1982;53:35-37. faces were flat with frequent depressions and numerous fi-
Torfason T, Kiger R, Selvig N, Egelberg J. Clinical improvement of gin- ber-like structures. Transmission microscopy revealed root
gival conditions following ultrasonic versus hand instrumentation of
periodontal pockets. J Clin Periodontol 1979;6:165-176.
planed and acid-etched surfaces produced a zone of demi-
Walmsley A, Walsh T, Laird W, Williams A. Effects of cavitational ac- neralization of 4 um wide. This zone was dominated by
tivity on the root surface of teeth during ultrasonic scaling. / Clin exposed collagen fibrils. Lasho et al. (1983) also showed
Periodontol 1990;17:306-311. numerous collagen fibers exposed by the application of sat-
urated citric acid, EDTA, or NaOCl followed by rinsing of exposed collagen and a reduced or eliminated smear
with 5% citric acid. layer.
Poison et al. (1984) showed by SEM evaluation that root Wen et al. (1992) compared different application tech-
planing leaves an amorphous layer 2 to 15 urn thick which niques for citric acid demineralization using scanning electron
consists of organic and inorganic material. When these sur- microscopy. Citric acid pH 1 was applied to dentin surfaces
faces were treated by citric acid (pH 1 for 3 minutes) this prepared from extracted teeth by 1) immersion; 2) placement
smear layer was removed. The result was a fibrous mat- of saturated cotton pellets; 3) burnishing with cotton pellets;
like structure with a fibrillar texture having numerous fun- or 4) camel hair brush. Immersion demonstrated tufting of
nel-shaped depressions corresponding to open dentinal intertubular dentin fibrils and wide open dentinal orifices. Pel-
tubules. Similarly, Sterrett and Murphy (1989) used SEM let placement revealed a more matted surface and some debris
photographs to evaluate extracted periodontally diseased- inside the orifices. Burnishing resulted in a variation of char-
root surfaces that had been scaled and root planed, stored acteristics. Two of 8 slabs showed tufting with widened tu-
in formalin, and then treated with a 5-minute cotton pellet bular openings, while 6 of 8 showed surface smearing with
application of either passively placed or burnished citric complete obturation of the tubules. The camel hair brush re-
acid. They examined the dentinal surfaces for root roughness sulted in surface characteristics close to those treated by im-
and maximal exposure of the collagen surface. The smear mersion (tufting with widened tubules). Immersion resulted in
layer was removed by both treatments. The burnished spec- the greatest number of openings followed by cotton pellet
imens were found to have patent dentinal tubules and an placement and camel hair brush.
intertubular area with a very distinct "shag carpet" appear- Sterrett et al. (1993) examined the effects of citric acid
ance of deeply tufted collagen fibrils. The passively placed concentration and application time on dentin demineraliza-
citric acid specimen exhibited open dentinal tubules with a tion. The measurements of calcium parts per million released
matted collagen surface. They proposed that the burnishing for citric acid concentrations of 0, 10, 20, 25, 30, 35, 40,
application removed more inorganic material through a and 65% were determined at 1, 2, and 3 minutes. The peak
combined mechanical/chemical process while fluffing and demineralization for 1 minute was 30% (pH 1.55), for 2
separating the entangled fixed dentin collagen. minutes was 25% (pH 1.62), and for 3 minutes was 25%.
Hanes et al. (1988) evaluated the initial wound healing For all concentrations, demineralization was time dependent.
response to demineralization in the same model as the pre-
vious study. They showed that acid-treated teeth had a fi- WOUND HEALING AND ATTACHMENT EFFECTS
brillar zone 3 to 8 um thick consisting of collagenous fibrils Animal Histology: Positive Effects
of the dentin exposed during acid treatment. There appeared Register and Burdick (1976) examined reattachment with
to be a layer of cells in dynamic activity and distinct at- cementogenesis in dogs. Citric acid pH 1 was applied with
tachment to dentin with cells migrating over the root sur- cotton tip applicators for 2 minutes. Denuded root surfaces
face. In the controls, there were large areas devoid of cells healed with cementogenesis with a secure fiber attachment
and other connective tissue components. This suggests that at 6 weeks. However, circumferential and bifurcation defects
citric acid treatment may result in fibrin clot stabilization only healed with approximately 10% reattachment.
and initiate wound healing that results in new connective Crigger et al. (1978) also studied the effect of citric acid
tissue attachment. in the dog model. Through and through furcation defects
Fardal and Lowenberg (1990) evaluated in vitro citric were created and allowed to accumulate plaque for 42 days.
acid conditioning compared to EDTA conditioning on fi- The denuded roots were treated with citric acid pH 1 for 3
broblasts cultured on sections of human periodontally in- minutes. These were compared histologically to non-acid
volved teeth on migration, attachment and orientation. They treated roots. The controls healed by long junctional epi-
found that: 1) root planing improves diseased roots and that thelium leaving a patent furcation. Thirteen of 23 acid-
root planing followed by citric acid demineralization im- treated furcations demonstrated complete new attachment;
proves diseased roots to a level comparable to non-diseased 8 were incomplete and 2 remained patent.
roots; 2) citric acid demineralization alone improves Poison and Proye (1982) also studied the effects of citric
diseased roots to a level comparable to root planed diseased acid conditioning in the monkey. Twelve teeth in 4 mon-
roots; and 3) acid demineralization results in both collagen keys were extracted and the coronal third was planed to
fiber exposure and a more hospitable environment. remove the fibers and cementum. The root surfaces were
Different methods of citric acid application and time then treated with citric acid for 3 minutes and then re-im-
have been proposed. Codelli et al. (1991) evaluated citric planted into their sockets. They were histologically exam-
acid effects upon extracted previously diseased human teeth ined at 1, 3, 7, and 21 days. At days 1 and 3, a fibrin linkage
relative to the duration and method of application. They was shown between the periodontal ligament and the root
found that passive applications for 5 minutes and burnished surface. A new connective tissue attachment was present at
applications for 3 minutes both produced seemingly optimal 21 days with no cementum formation. Extensive root re-
surface characteristics consisting of a fine, fibrillar network sorption had occurred with some new bone formation.
This led Poison and Proye (1983) to determine the heal- migrating over the root surface. In the controls there were
ing sequence related to the fibrin clot and its interaction large areas devoid of cells and other connective tissue com-
with collagen. Twenty-four (24) teeth in 4 monkeys were ponents. They suggest that citric acid treatment may result
extracted and root planed and 12 teeth treated with citric in fibrin clot stabilization and initiate wound healing that
acid pH 1. They were reimplanted and then biopsied at 1, results in new connective tissue attachment.
3, 7, and 21 days. At 1 and 3 days there was a fibrin net- Steinberg et al. (1986) studied the effect of various root
work which appeared to be attached to the root surface. surface alterations on thrombogenicity and the morpholog-
Teeth not treated with citric acid had epithelium migrating ical appearance of initial clot formation. Periodontally-in-
apically, reaching the crest by day 3, and by day 21 had volved human teeth were extracted, sectioned, and
reached the apical extent of root planing. Those teeth reimplanted. One section was immediately removed while
treated with citric acid had collagen fibers replacing the the other was removed 1 minute later and examined by
fibrin network by days 7 and 21. The epithelium was lo- scanning electron microscopy. Platelet attachment condi-
cated at the CEJ. They concluded that the fibrin network tions were examined: 1) intact fibers; 2) periodontitis, no
was the initial stage in healing and precedes the collagen treatment; 3) root planed; 4) root planed plus citric acid;
attachment. and 5) root planed, citric acid, and collagenase incubation.
The importance of the fibrin linkage was also shown by Platelet attachment was greatest when the intact fiber was
Woodyard et al. (1984). They studied the effects of citric present. Citric acid enhanced platelet attachment in the dis-
acid on root coverage with pedicle flap procedures in the eased surfaces.
monkey model. Healing was studied histologically at 0, 3, Selvig et al. (1988) also studied the development of at-
7, 14, 21, 28, and 42 days after treatment. Test teeth were tachment on citric acid treated teeth. Eight beagle dogs had
treated by citric acid application. They showed the citric fenestration defects created which were treated with citric
acid-treated teeth had a fibrin network while the controls acid pH 1 for 3 minutes. Biopsies were obtained at 7, 14,
did not. Controls displayed proliferation of the epithelium and 21 days. They concluded that initial reattachment to an
apical to the notch. Although citric acid treatment did not instrumented, demineralized root surface generally takes
show enhanced root coverage, it did result in greater place by interdigitation between newly synthesized collagen
amounts of new connective tissue attachment. fibrils of the cementum or dentin matrix. In areas of re-
Poison et al. (1986) evaluated the cellular, connective sorption, new fibrils may adhere to the surface of hard tis-
tissue, and epithelial response of demineralization on per- sue without any fibrillar interdigitation.
iodontitis affected dentin surfaces. Dentin specimens were Wikesjo et al. (1991) studied the effect of citric acid
obtained from root surfaces covered by calculus. Experi- treatment on root resorption. Surgically-created defects
mental specimens were immersed in citric acid pH 1 for 3 were treated in 6 beagle dogs with citric acid or stannous
minutes. All specimens were then implanted into the necks fluoride and the flaps replaced to cover the tooth to the level
of rats with 1 mm protruding through the skin. Biopsies of the cusp tips. After 12 weeks, histology showed 45% of
were prepared at 1, 3, 5, and 10 days for histological ex- the defect in the saline treated controls healed by long junc-
amination. Healing of those specimens treated with citric tional epithelium; 78% of the defects in stannous fluoride
acid occurred by inflammatory cells and fibroblasts in a healed by long junctional epithelium, while only 17% of
fibrin network and attached fibers oriented obliquely and the defects healed by long junctional epithelium in citric
perpendicular to the root surface. The non-acid treated acid treated specimens. Control and acid-treated teeth
specimens showed fewer attached cells with epithelial mi- showed similar amounts of root resorption, suggesting citric
gration to the apical portion resulting in extrusion. In a acid does not enhance or prevent resorption.
similar follow-up study, Poison and Hanes (1987) com-
pared non-periodontitis affected specimens to periodontitis-
affected root. Specimens were treated with citric acid pH 1 Animal Histology: No Effect
for 3 minutes and then implanted transcutaneously in the Nyman et al. (1981) studied the potential for new at-
neck of rats. Healing was initiated by a fibrin network tachment in the monkey model using citric acid. Experi-
which prevented the apical migration of epithelium, allow- mental periodontitis was treated by flap and citric acid pH
ing fiber attachment in the periodontitis affected specimens. 1 for 3 minutes. The monkeys were sacrificed 6 months
In non-periodontitis specimens healing resulted in a similar after surgery. Root planed alone (controls) and acid-treated
attachment. In a follow-up study Hanes et al. (1988) eval- teeth resulted in healing by long junctional epithelium. It
uated the initial wound healing response to demineraliza- was determined that citric acid application did not promote
tion in the same model as the previous study. They showed formation of new cementum and connective tissue.
acid treated teeth had a fibrillar zone 3 to 8 um thick con- Bogle et al. (1981) also provided evidence that citric
sisting of collagenous fibrils of the dentin exposed during acid conditioning might not be significant. Citric acid-root
acid treatment. There appeared to be a layer of cells in conditioning was used in naturally occurring furcation de-
dynamic activity and distinct attachment to dentin with cells fects in dogs. They found epithelialization of the furcation
fornix in 17/26 defects. Complete new attachment occurred examined by scanning and light microscopy. Six of 9 acid-
in 2 and incomplete new attachment in 7 defects. treated teeth displayed connective tissue coronal to the
Isidor et al. (1985) failed to demonstrate a difference for notch with fibers generally exhibiting a functional orienta-
citric acid conditioning in the monkey model with ortho- tion. The control displayed a junctional epithelium.
dontic elastic-induced periodontitis. Histologic sections Common and McFall (1983) compared treatment of ex-
showed 1.0 mm of newly formed connective tissue for the perimentally-induced human recession using laterally po-
non-acid treated controls and 1.1 mm for the acid-treated sitioned pedicle flap surgery with and without citric acid
test teeth. conditioning. Block sections were obtained at 1, 2, 4, 12,
Nyman et al. (1985) also studied the effects of citric acid and 20 weeks to observe healing. Citric acid (pH 1) was
on root planed teeth that were re-implanted. Five adult rubbed onto the prepared root surface for 2 minutes. Con-
monkeys were used, forming 3 groups. Group 1 had teeth trol teeth exhibited a long junctional epithelium with no
extracted and immediately re-implanted; group 2 was root cementogenesis. The citric acid-treated pedicles had a con-
planed and then re-implanted; and group 3 was root planed, nective tissue attachment to new cementum and, at 1 month
treated with citric acid pH 1, and re-implanted. Six months postsurgery, did not separate from the teeth as easily as the
later animals were examined histologically. Immediately re- controls.
implanted teeth showed connective tissue reattachment to a Frank et al. (1983) made observations with electron mi-
level 1 mm apical to the CEJ. Root planed teeth demon- croscopy on teeth treated with citric acid. After treatment
strated apical migration of the epithelium to areas of re- by flap procedures, roots were conditioned with citric acid
sorption were ankylosis was present. Teeth root planed and pH 1 for 3 minutes. Sixty-seven (67) days after the surgery
treated with citric acid were similar to the root planed only the teeth were removed. They determined that two types of
group. They concluded citric acid had no effect on the heal- connective tissue reattachment occurred. One was splicing
ing of reimplanted teeth. of the newly secreted collagen fibrils by mineralization of
Aukhil and Pettersson (1987) studied the effect of citric the decalcified dentin band, while the second involved ce-
acid on cell density. Maxillary canines in 6 dogs were used. mentum formation on top of the dentin surface.
Experimental roots were conditioned with citric acid pH 1 Lopez (1984) studied connective tissue healing of peri-
for 3 minutes and the dogs were sacrificed after 10 days. odontally-involved teeth treated by citric acid pH 1 for 5
They found fibroblast cell density to be less on the acid minutes. Experimental teeth were extracted, cementum re-
treated surfaces when compared to controls. It was sug- moved, treated by citric acid, and then placed in a pouch
gested that citric acid conditioning may result in low cell under the mucosa. They were recovered at 2, 6, 12, 18, 20,
density during the early stages of healing. and 24 weeks for histological evaluation. At various time
Dyer et al. (1993) used the beagle dog to study the ef- intervals they showed resorption, connective tissue attach-
fects of demineralization during guided tissue regeneration. ment to old cementum, and dentin and fibers attached per-
Teeth in 12 quadrants were treated, 4 by citric acid, 4 by pendicular to the root surface. They concluded that a new
tetracycline, and 4 by membrane alone. Histometric anal- connective tissue attachment could form, even in the ab-
ysis demonstrated that root conditioning by either agent did sence of periodontal ligament cells.
not enhance the amount of connective tissue and bone
gained by membrane alone. These results are substantiated Human Histology: No Effect
by Parashis and Mitsis (1993). Stahl and Froum (1977) evaluated the effects of citric
acid on pocket closure both clinically and histologically.
Human Histology: Positive Effects Seven extracted teeth from 2 patients were examined. Root
Cole et al. (1980) examined specimens histologically to surfaces were treated with citric acid and measurements
determine if new attachment to periodontally-diseased root were repeated at 4, 8, 12, and 16 weeks. Block sections
surfaces could be achieved by topical application of citric were performed at the 16-week visit. In 5 of 6 citric acid-
acid. Teeth treated by flap procedures had citric acid ap- treated teeth, no evidence was observed of accelerated ce-
plied for 5 minutes. Four months later block sections were mentogenesis or functional connective tissue attachment.
recovered. In all 10 specimens, connective tissue forming Kashani et al. (1984) obtained human histology on citric
a periodontal ligament extended 1.2 to 2.6 mm coronal acid-treated teeth extracted 3 months after surgery. Maxil-
from the reference notch. lary anterior teeth planned for extraction were treated with
Albair et al. (1982) also histologically examined the ef- citric acid pH for 1 to 5 minutes. There was no difference
fects of citric acid on formation of new connective tissue on pocket closure between citric acid treated and non-acid
attachment. Eight patients requiring extractions for pros- treated teeth, which was by long junctional epithelium.
thetic reasons were treated by flaps with vigorous root plan- Cogen et al. (1984) compared root planing alone, citric
ing. Experimental teeth were treated with citric acid for 5 acid alone, and a combination of root planing plus citric
minutes while contralateral teeth served as non-acid treated acid on fibroblast attachment to diseased roots. Human gin-
controls. Six to 15 weeks later the teeth were extracted and gival fibroblasts adhered and grew on root planed surfaces
but not on surfaces treated by citric acid alone. Addition of Marks and Mehta (1986) evaluated citric acid condition-
citric acid treatment after root planing offered no additional ing (pH 1 for 3 minutes) on 3 patients involving 72 teeth
fibroblastic attachment compared to root planing alone. with moderate periodontitis. Results at 12 months showed
citric acid did not enhance new connective tissue attach-
CITRIC ACID: CLINICAL RESULTS ment as measured clinically.
Smith et al. (1986) used a split mouth design to study
Human Studies: Positive Effects the effects of citric acid on new attachment during surgery.
Cole et al. (1981) examined the effects of citric acid in Experimental sites were treated with citric acid pH 1 for 3
a pilot study after replaced flap surgery. A split mouth de- minutes. Clinical attachment levels were evaluated at 3 and
sign was used in 12 patients with advanced periodontitis 6 months after surgery. There was no difference between
who were treated with citric acid pH 1 for 3 to 5 minutes acid treated and non-acid treated teeth.
on the experimental side. A probing attachment level gain Moore et al. (1987) clinically evaluated the results of
of 2.1 mm for the acid-treated teeth resulted, compared to citric acid treatment during replaced flap surgery. In a split
1.5 mm for controls (60% of the acid-treated areas gained mouth design, 12 patients had the experimental teeth treated
2 mm of attachment while about 40% of the controls gained with citric acid pH 0.6 for 3 minutes. Measurements were
2 mm). The clinical results cannot reveal if improvement made from a fixed stent at 3 and 9 months after surgery.
is from gain in connective tissue attachment or improved They showed that both controls and acid-treated teeth dem-
adaptation of the junctional epithelium. onstrated gain in attachment levels, but there was no dif-
This was followed by a similar study by Renvert and ference between them.
Egelberg (1981) where 13 periodontally involved patients
had intraosseous defects treated with citric acid pH 1 for 3
minutes. Six months after surgery, final measurements of CITRIC ACID EFFECTS ON OTHER TISSUES
probing depth, attachment level, and bone level were car- Nilveus and Selvig (1983) studied the effects of citric
ried out. For acid treated teeth there was a gain in probing acid on the dental pulp after topical application using 6
attachment level of 2.0 mm while the non-acid treated con- beagle dogs. After removal of the alveolar plate, the sur-
trols showed a gain of 1.2 to 1.3 mm. In 19 of 26 acid- faces were root planed and treated with citric acid or with-
treated teeth gain in probing attachment was 2 mm or more. out. Biopsies were obtained after 1 and 15 weeks. It was
Caffesse et al. (1988) treated two sextants in each of 29 determined that reparative dentin formed but did not cause
subjects with modified Widman flap surgery while another inflammatory reactions in the pulp.
two sextants received the same treatment supplemented Crigger et al. (1983) evaluated the effects of citric acid
with citric acid and fibronectin application. While citric on exposed connective tissue after flap procedures. Buccal
acid/fibronectin application improved probing depth and and lingual flaps were raised in 4 dogs. On the test side,
probing attachment levels to a statistically significant de- citric acid was applied to the inner flap for 3 minutes while
gree, the difference was clinically insignificant (a matter of the control side was treated with saline. Histology was per-
0.2 to 0.3 mm). formed at 3, 7, 14, and 21 days. They demonstrated no
irreversible effects resulted on the exposed soft tissues or
Human Studies: No Effect underlying alveolar bone at any time point.
Parodi and Esper (1984) tested the ability of citric acid Ryan et al. (1984) showed a different pulpal response to
to promote new attachment and induce bone formation in citric acid treatment while studying cats. Nine cats each
alveolar defects in humans. Twenty (20) lower molars with provided 1 negative and 1 positive control and 2 experi-
Class II and III furcation defects were used. The experimental canine teeth. Positive controls were treated by sur-
mental group was treated with citric acid pH 1 for 3 gery only while the experimental teeth received surgery
minutes. At 6 months a re-entry was done to repeat meas- with citric acid conditioning. Positive controls showed mild
urements. Results showed a reduction in probing depth (2 to moderate short-term and mild to no pulpal reactions
to 3 mm) gain in attachment (1 to 1.5 mm), and a gain in long-term. Five experimental teeth became abscessed or ne-
bone level (1 mm) for both groups. The results show no crotic, although 4 teeth were relatively non-inflamed.
difference between acid and non-acid treated teeth. Valenza et al. (1987) examined histologically the effects
Renvert et al. (1985) also evaluated the relationship be- of citric acid on the gingival epithelium. Nine patients had
tween citric acid conditioning and osseous grafts. They citric acid pH 1 applied locally to the gingiva for 5 to 10
treated 19 patients by mucoperiosteal flaps, debridement, minutes. Gingival biopsies were taken before and after ap-
root planing, and citric acid with or without autogenous plication. Citric acid resulted in edema of the prickle cell
osseous grafts. They found that osseous grafting did not layer with disarrangement of the tonofilaments and kary-
enhance the results achieved by citric acid conditioning olysis of the nucleus. It was suggested that the alterations
alone and provided results similar to that expected with may contribute to the prevention of the formation of a long
surgical debridement alone. junctional epithelium.
CITRIC ACID: ANTIBACTERIAL EFFECTS eration. Assays using human gingival epithelial and con-
Daly (1982) reported on the antibacterial effects of citric nective tissue cells were done on dentin blocks prepared
acid. Twenty (20) human teeth affected by periodontal dis- from bovine teeth. Tetracycline (TTC) and non-TTC treated
ease were extracted. Ten (10) teeth were immersed in citric slabs were incubated with fibronectin. Maximal binding of
acid pH 1 for 3 minutes. Samples from the surfaces were fibronectin occurred when slabs were immersed in 100 mg/
plated on a culture dish. Citric acid treated teeth reduced ml and above of TTC, which varied in a dose dependent
both aerobic and anaerobic numbers, while there was no manner. TTC also reversed the greater binding of laminin
difference in numbers before and after saline treatment in in control specimens. When slabs were treated with TTC
the control teeth. and fibronectin there was a 4-fold increase in the attach-
Sarbinoff et al. (1983) also studied the effect chemical ment of fibroblastic cells. TTC bound 3 times more cells
treatments had upon endotoxin levels. They found that an- than citric acid and 7 times more than controls.
tiformin alone or in combination with citric acid neutrali- Alger et al. (1990) used 22 human non-molar teeth with
zation resulted in endotoxin levels of less than 1 ng/gm, moderate to advanced periodontitis to compare root surface
approaching levels found in undiseased roots. Citric acid treatments of root planing versus a 3 minute burnished ap-
alone did not remove endotoxin. Besides the effects upon plication of tetracycline-hydrochloride (TCN). They also
the root, citric acid may also affect the flora. added a 5-minute application of fibronectin (10 mg/ml) to
Forgas and Gound (1987) compared the effects on dark- the TCN treatment in a third group. The teeth were re-
field microscopic parameters of root planing alone versus moved in block sections at 90 days and examined histolog-
root planing plus antiformin-citric acid application. Both ically. New attachment was not found in any of the
treatments resulted in decreased proportions of spirochetes specimens. TCN was found to result in small amounts of
and motile rods, with no differences between treatments. reattachment, which the addition of fibronectin generally
Microscopic parameters returned to baseline at 12 weeks in inhibited.
both groups. Demirel et al. (1991) evaluated the substantivity of
Tanaka et al. (1989) studied the effects of citric acid on doxycycline on disease-affected cementum and dentin by
retained plaque and calculus after instrumentation. Five ex- treating prepared root surfaces with 3-minute applications
tracted teeth were sectioned longitudinally, and 1 segment of aqueous solutions of doxycycline HC1 in concentrations
was treated with citric acid pH 1 for 3 minutes. Controls of 1, 10, 50, and 100 mg/ml. The specimens were then
showed surface debris and large amounts of bacteria on the rinsed and incubated for either 10 minutes, or 7 or 14 days
retained calculus. Acid treated teeth showed little debris in seeded agar containing either A. viscosus, Actinobacillus
with virtually no bacteria. The surface morphology varied actinomycetemcomitans (Aa) or Porphyromonas gingivalis
from layered-like to honeycombed. (Pg), with substantivity determined by agar diffusion inhi-
Corley and Killoy (1982) studied the stability of citric bition assay. Doxycycline substantivity was found to be
acid solutions used for root conditioning. A solution of cit- similar on both dentin and cementum at all concentrations
ric acid pH 1 achieved by 61 grams of citric acid crystals and time intervals. Only the 100 mg/ml concentration of
in 100 ml of distilled water was tested for the effects of doxycycline produced zones of inhibition in all test organ-
light, time, and air exposure. A stable pH was maintained isms at all time intervals, while the 50 mg/ml concentration
for a 5 month period. They showed that the solution was was effective at all times, except on day 14 with Aa. Aa
not affected by time, light, or air exposure. was found to be most resistant to doxycycline, while Pg
was found to be most sensitive. They concluded that ce-
TETRACYCLINE mentum and dentin may be capable of acting as reservoirs
Wikesjo et al. (1986) evaluated the effects of tetracycline for doxycycline with its slow release taking place for sev-
conditioning on dentin surfaces. Dentin slabs were prepared eral days.
from extracted bovine teeth. They were immersed in vari- Stabholz et al. (1993) assessed in vitro the substantivity
ous concentrations of tetracycline solutions for 5 minutes. of tetracycline. Fifty-one extracted teeth were root planed
Morphological effects were compared to slabs treated with and then immersed in 10 or 50 mg/ml solutions for 1, 3,
saline and inhibition of bacterial growth was tested by in- and 5 minutes. The 10 mg/ml concentration of TCN
oculating pretreated slabs. Immersion of the slabs removed showed antimicrobial activity for 4 days while the 50 mg/
the smear layer and exposed a regular pattern of open den- ml concentration demonstrated antimicrobial activity up to
tin tubules. Maximum binding of tetracycline was greatest 14 days. Chlorhexidine was also tested ( 0.12 and 0.2%)
with concentrations greater than 50 mg/ml. Maximal bac- and showed activity for only 24 hours.
terial inhibition was achieved at 11 and 33 u,m/ml tetra- Parashis and Mitsis (1993) studied the effect of tetra-
cycline. cycline (TCN) root conditioning in conjunction with guided
Terranova et al. (1986) studied the effects of tetracycline tissue regeneration. Controls were treated by expanded
root conditioning on cell adhesion, migration, and prolif- polytetrafluoroethylene membranes alone while test teeth
were treated with TCN plus membrane. The change in ver- Forgas L, Gound S. The effects of antiformin-citric acid chemical curet-
tage on the microbial flora of the periodontal pocket. J Periodontol
tical attachment was 1.7 mm for test teeth and 1.6 mm for
1987;58:153-158.
controls. The horizontal changes were 4.7 mm for test teeth Frank R, Fiore-Donno G, Cimasoni G. Cementogenesis and soft tissue
and 4.8 mm for controls, indicating there was no advantage attachment after citric acid treatment in a human. J Periodontol 1983;
to TCN when compared to membrane alone. 54:389-401.
Lafferty et al. (1993) compared the surface effects of Garrett J, Crigger M, Egelberg J. Effects of citric acid on diseased root
tetracycline and citric acid on periodontally diseased teeth surfaces. J Periodont Res 1978;3:155-163.
Hanes P, Poison A, Frederick G. Initial wound healing attachments to
which were extracted and root planed. SEM evaluation demineralized dentin. J Periodontol 1988;59:176-183.
demonstrated both agents to be equally effective in remov- Holden M, Smith B. Citric acid and fibronectin in periodontal therapy. J
ing the smear layer resulting in a similar surface morphol- West Soc Periodontol Periodont Abstr 1983;31:45-56.
ogy. All specimens demonstrated opened dentinal tubules Isidor F, Karring T, Nyman S, Lindhe J. New attachment formation on
and a fibrillar matrix with a matted appearance. citric acid treated roots. J Periodont Res 1985;20:421^30.
Jones W, O'Leary T. The effectiveness of in vivo root planing in removing
bacterial endotoxin from the roots of periodontally involved teeth. J
REFERENCES Periodontol 1978;49:337-342.
Albair W, Cobb C, Killoy W. Connective tissue attachment to periodon- Kashani H, Magner A, Stahl S. The effect of root planing and citric acid
tally diseased roots after citric acid demineralization. J Periodontol applications of flap healing in humans. A histologic evaluation. J Per-
1982;53:515-526. iodontol 1984;55:679-683.
Alger F, Solt C, Vuddhakanok S, Miles K. The histologic evaluation of Lafferty T, Gher M, Gray J. Comparative SEM study on the effect of acid
new attachment in periodontally diseased human roots treated with etching with tetracycline HC1 or citric acid on instrumented periodon-
tetracycline-hydrochloride and fibronectin. J Periodontol 1990;61: tally involved human root surfaces. J Periodontol 1993;64:689-693.
447^55. Lasho D, O'Leary T, Kafrawy A. A scanning electron microscope study
Aukhil I, Pettersson E. Effect of citric acid conditioning on fibroblast cell of the effects of various agents on instrumented periodontally involved
density in periodontal wounds. J Clin Periodontol 1987;14:80-84. root surfaces. J Periodontol 1983;54:210-220.
Bogle G, Adams D, Crigger M, Klinge P, Egelberg J. New attachment of Lopez N. Connective tissue regeneration to periodontally diseased roots,
the surgical treatment and acid conditioning of roots in naturally oc- planed and conditioned with citric acid and implanted into the oral
curring periodontal disease in dogs. JPeriodont Res 1981;16:130-133. mucosa. J Periodontol 1984;55:381-390.
Caffesse R, Kerry G, Chaves E, et al. Clinical evaluation of the use of Marks S, Mehta N. Lack of effect of citric acid treatment of root surfaces
citric acid and autologous fibronectin in periodontal surgery. J Per- on the formation of new connective tissue attachment. J Clin Perio-
iodontol 1988;59:565-569. dontol 1986;13:109-116.
Codelli G, Fry H, Davis J. Burnished versus nonburnished application of Moore J, Ashly F, Waterman C. The effect on healing of the application
citric acid to human diseased root surfaces: the effect of time and of citric acid during replaced flap surgery. J Clin Periodontol 1987;
method of application. Quintessence Int 1991;22:277-283. 14:130-135.
Cogen R, Al-Jaburi W, Gantt D, Denys F. Effect of various root surface Nilveus R, Selvig K. Pulpal reactions of the application of citric acid to
treatments on the attachment of human gingival fibroblasts: histologic root-planed dentin in beagles. J Periodont Res 1983;18:420^J28.
and scanning electron microscopic evaluation. J Clin Periodontol Nyman S, Lindhe J, Karring T. Healing following surgical treatment and
1984;! 1:531-539. root demineralization in monkeys with periodontal disease. J Clin Per-
Cole R, Crigger M, Bogle G, Egelberg J, Selvig K. Connective tissue iodontol 1981:8:249-258.
regeneration to periodontally diseased teeth. A histologic study. J Per- Nyman S, Houston F, Sarhed G, Lindhe J, Karring T. Healing following
iodont Res 1980;15:l-9. reimplantation of teeth subjected to root planing and citric acid treat-
Cole R, Nilveus R, Ainamo J, Bogle G, Crigger M, Egelberg J. Pilot clinic ment. J Clin Periodontol 1985;12:294-305.
studies of the effect of topical citric acid application on healing after Parashis A, Mitsis F. Clinical evaluation of the effect of tetracycline root
replaced periodontal flap surgery. J Periodont Res 1981;16:117-122. preparation on guided tissue regeneration in the treatment of class II
Common J, McFall W. The effects of citric acid on attachment of laterally furcation defects. J Periodontol 1993;64:133-136.
positioned flaps. J Periodontol 1983;54:9-18. Parodi R, Esper M. Effect of topical application of citric acid in the treat-
Corley J, Killoy W. Stability of citric acid solutions during a five-month ment of furcation involvement in human lower molars. J Clin Perio-
period. J Periodontol 1982;53:390-392. dontol 1984:11:644-651.
Crigger M, Bogle G, Nilveus R, Egelberg J, Selvig K. The effect of topical Poison A, Proye M. Effect of root surface alterations on periodontal heal-
citric acid application on the healing of experimental furcation defects ing. II Citric acid treatment of the denuded root surface. J Clin Per-
in dogs. J Periodont Res 1978;13:538-549. iodontol 1982;9:441-^54.
Crigger M, Renvert S, Bogle G. The effect of citric acid application on Poison A, Proye M. Fibrin linkage: A precursor for new attachment. J
surgically exposed periodontal attachment. J Periodont Res 1983; 18: Periodontol 1983;54:141-147.
303-305. Poison A, Frederick G, Ladenheim S, Hanes P. The production of a root
Daly C. Antibacterial effect of citric acid treatment of periodontally dis- surface smear layer by instrumentation and its removal by citric acid.
eased root surfaces in vitro. J Clin Periodontol 1982;9:386-392. J Periodontol 1984;54:443-446.
Demirel K, Baer P, McNamara T. Topical application of doxycycline on Poison A, Ladenheim S, Hanes P. Cell and fiber attachment to deminer-
periodontally involved root surfaces in vitro: Comparative analysis of alized dentin from periodontitis-affected root surfaces. J Periodontol
substantivity on cementum and dentin. J Periodontol 1991;62:312- 1986;57:235-246.
316. Poison A, Hanes P. Cell and fiber attachment to demineralized dentin. A
Dyer B, Caffesse R, Nasjleti C, Morrison E. Guided tissue regeneration comparison between normal and periodontitis-affected root surfaces. J
with dentin biomodification. J Periodontol 1993;64:1052-1060. Clin Periodontol 1987;14:357-365.
Fardal O, Lowenberg B. A quantitative analysis of the migration, attach- Register A, Burdick F. Accelerated reattachment with cementogenesis to
ment, and orientation of human gingival fibroblasts to human dental dentin, demineralized in situ. I. Optimum range. J Periodontol 1975;
root surfaces in vitro. J Periodontol 1990;61:529-535. 46:646-655.
Register A, Burdick F. Accelerated reattachment with cementogenesis to Sterrett J, Sankey T, Murphy H. Dentin demineralization. The effects of
dentin, demineralized in situ. II. Defect repair. J Periodontol 1976;47: citric acid concentration and application time. JClin Periodontol 1993;
497-505. 20:366-370.
Renvert S, Egelberg J. Healing after treatment of periodontal intraosseous Sterrett J, Murphy H. Citric acid burnishing of dentinal root surfaces. A
defects. II. Effect of citric acid conditioning of the root surface. JClin scanning electron microscopy report. J Clin Periodontol 1989;16:98-
Periodontol 1981;8:459-473. 104.
Renvert S, Garrett S, Schallhorn R, Egelberg J. Healing after treatment of Tanaka K, O'Leary T, Kafrawy A. The effect of citric acid on retained
periodontal intraosseous defects. III. Effects of osseous grafting and plaque and calculus. A short communication. J Periodontol 1989;60:
citric acid conditioning. J Clin Periodontol 1985;12:441^J55. 81-83.
Ryan P, Newcomb G, Seymour J, Powell R. The pulpal response to citric Terranova V, Franzetti L, Hie S, et al. A biochemical approach to peri-
acid in cats. J Clin Periodontol 1984;! 1:633-643. odontal regeneration: Tetracycline treatment of dentin promotes fibro-
Sarbinoff T, O'Leary T, Kafrawy A. The comparative effectiveness of blast adhesion and growth. J Periodont Res 1986;21:330-337.
various agents in detoxifying diseased root surfaces. J Periodontol Valenza V, D'Angelo M, Farina-Lipari E, Farina F, Margiotta V. Effects
1983;54:77-80. of citric acid on human gingival epithelium. J Periodontol 1987;58:
Selvig K, Bogle G, Claffey N. Collagen linkage in periodontal connective 794-795.
tissue reattachment. J Periodontol 1988;59:758-768.
Wen C, Caffesse R, Morrison E, Nasjleti C, Parikh U. In vitro effects of
Smith B, Mason W, Morrison E, Caffesse R. The effectiveness of citric
citric acid application techniques on dentin surfaces. J Periodontol
acid as an adjunct to surgical reattachment procedures in humans. J
1992;63:883-889.
Clin Periodontol 1986;13:701-708.
Wikesjo UME, Baker P, Christersson L, et al. A biomedical approach to
Stabholz A, Kettering J, Aprecio R, Zimmerman G, Baker P, Wikesjo U.
periodontal regeneration: Tetracycline treatment conditions dentin sur-
Antimicrobial properties of human dentin impregnated with tetracy-
faces. J Periodont Res 1986;21:322-329.
cline HC1 or chlorhexidine. J Clin Periodontol 1993;20:557-562.
Stahl S, Froum S. Human clinical and histological repair responses fol- Wikesjo UME, Claffey N, Nilveus R, Egelberg J. Periodontal repair in
lowing the use of citric acid in periodontal therapy. J Periodontol dogs: Effect of root surface treatment with stannous fluoride or citric
1977;48:261-266. acid on root resorption. J Periodontol 1991;62:180-184.
Steinberg A, LeBreton G, Willey R, Mukherjee S, Lipwoski J. Extravas- Woodyard S, Snyder A, Henley G, O'Neal R. A histometric evaluation
cular clot formation and platelet activation on variously treated root of the effect of citric acid preparation upon healing of coronally po-
surfaces. J Periodontol 1986;57:516-522. sitioned flaps in non-human primates. J Periodontol 1984;55:203—212.

CHAPTER 7. Root Treatment, Reattachment, and Repair

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CHAPTER 7. Root Treatment, Reattachment, and Repair

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112 CHAPTER 7. ROOT TREATMENT, REATTACHMENT, AND REPAIR Section 1.

CHAPTER 7. ROOT TREATMENT,

Wound Healing Incisors, canines, and premolars in 33 patients with gen-

AIR ABRASIVES 3 dogs were intentionally sprayed for 5 seconds at a dis-

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