_367

Effectiveness of Subgingival Scaling

and Root Planing: Single Versus
Multiple Episodes of Instrumentation
Gissela B. Anderson* John A. Palmer* Fred L. Bye* Billy A. Smith,** and Raul G.
Caffé sse*

This study evaluates the effectiveness of subgingival scaling and root planing
comparing the effect of a single instrumentation to the effect of three instrumentations.
A total of 35 teeth in 15 patients were selected; 15 were scaled once (Group A), 15
were scaled three times (Group B), and 5 were used as controls (Group C), repre-
senting teeth that were not instrumented. The Group A and teeth were chosen in
the same patient based on random selection. All the teeth were scored by the calculus
index of the periodontal disease index. Six surface locations were probed to determine
probing depth. Thè level of the gingival margin was marked on the teeth to locate
supra- and subgingival calculus after extraction. The Group A and teeth received
the initial episode of scaling and root planing for not more than 10 minutes, then only
the Group teeth received two additional instrumentations of not more than 5 minutes
each. The additional instrumentations were performed 24 hours after the initial scaling.
The scaled and control teeth were extracted immediately after the third instrumentation
period. The teeth were washed with water and stained with méthylène blue. They were
viewed under a stereomicroscope which had a tenth grid on its eyepiece. Assessments
were made involving the total counts and percents of the surfaces covered with cal-
culus on the scaled and unsealed teeth. The results demonstrated no significant dif-
ference in the effectiveness of calculus removal between single and multiple episodes
of scaling and root planing. Similar results were found for the total amount of calculus
removed, the calculus removed from individual surfaces, and the calculus removed
from various probing depth levels. J Periodontol 1996;67:367-373.

Key Words: Dental calculus/prevention and control; planing/instrumentation; planing/

methods; scaling/instrumentation; scaling/methods.

Bacterial deposits that include calculus have been firmly would indicate that other more invasive procedures would
established as the most important factors in the develop- be required to allow for a calculus free surface. Indeed,
ment of periodontal disease.1-4 Clinical investigations surgical procedures have been shown to be more effective
have shown that the removal of subgingival calculus from in removing calculus, but by no means provide complete
the root surface significantly reduces gingivitis,5 tooth removal of all accretions.20-23-28
loss,5"6 attachment loss,7-10 severity of disease,10-11 and While periodontal surgery is an effective mode of treat-
probing depth10-15 along with improvement in many other ment, non-surgical periodontal therapy is the first line of
clinical parameters. treatment in the majority of cases of Periodontitis.29 It is
The effectiveness of a single episode of closed gingival
possible that repeated instrumentation could lead to more
scaling and root planing in removing calculus is limited, successful results than single root planing episodes with-
as has been demonstrated by many researchers.16-22 This out invasive efforts. Repeated instrumentation may be re-
quired to insure complete debridement of plaque, calcu-
*The University of Texas, Health Science Center, Dental Branch, De- lus, and root surface contaminants and, therefore, achieve
partment of Stomatology, Division of Periodontics, Houston, TX. more optimal results. Badersten et al.30 showed that there
'Private practice, Wheeling, WV. was no difference between single and multiple instru-
'Private practice, Hagerstown, MD. mentation when assessed by clinical parameters.
department of Periodontics/Prevention and Geriatrics, School of Den-
tistry, The University of Michigan, Ann Arbor, MI. When determining the effectiveness of single and mul-
 J Periodontol
368 SINGLE VERSUS MULTIPLE SCALING AND ROOT PLANING April 1996

tiple instrumentations, measurement of residual calculus sured from the freegingival margin to the bottom of the
deposits is a more direct and objective measure than periodontal pocket of the
experimental and control teeth.
changes in clinical parameters. Probing measurements were made at six locations on each
If repeated instrumentation can be obviated, a signifi- tooth and rounded to the nearest millimeter; however,
cant reduction in time of active therapy will be accom- measurements close to 0.5 mm were rounded to the lower
plished. On the other hand, if repeated instrumentation whole number. The distobuccal, buccal, mesiobuccal, dis-
appears significantly more beneficial, the need for more tolingual, lingual, and mesiolingual aspects of each indi-
invasive techniques could be reduced in some cases. vidual tooth were scored separately. The buccal and lin-
Thus, it was necessary to determine that three episodes gual measurements were made on the midline of each
of root planing are as effective as one. tooth. The rest of the measurements were made as close
The purpose of this study was to quantitatively evaluate as possible to the interproximal contact areas of the teeth
the effectiveness of calculus removal in single and mul- with the probe pointed in an axial direction.
tiple instrumentations.
Experimental Procedure
METHODS AND MATERIALS The experimental procedures were performed in the fol-
lowing order:
Selection of Patients 1. Review of the patient's medical history.
Fifteen patients (10 male, 5 female), with ages ranging 2. PDI calculus scoring.
from 27 to 73 years old and who were scheduled for 3. Probing depth measurements.
immediate complete denture treatment or whose teeth 4. Following local anesthesia, the teeth were marked
were to be extracted due to periodontal disease, were se- circumferentially at the level of the free gingival margin
lected for this study. The patients had to have at least two with a high speed handpiece and an inverted cone bur.
teeth of any type scheduled for extraction in order to par- 5. Two experimental teeth on each patient (Group A
ticipate. None of these patients had previously received and B) were scaled and root planed thoroughly. Each
any periodontal treatment besides routine prophylaxis at tooth was instrumented for not more than 10 minutes or
a dentist office. After explaining the purpose, benefits, until a smooth root surface was detected along the entire
and risks of the study to the patient, they were asked to root coronal to the depth of the pocket using the probe
sign a consent form. The protocol was approved by the or the explorer. The control tooth (Group C) was not in-
institutional review committee for human subjects of The strumented.
University of Michigan. 6. The patient returned in not less than 24 hours for
the second episode of scaling and root planing on one of
Selection of Teeth the experimental teeth determined randomly at that time
All tooth types except third molars were included in the and thereafter designated as Group B. The Group tooth
investigation. Calculus was measured on the four external was instrumented in the same manner not exceeding 5
surfaces of the teeth (buccal, lingual, mesial, and distal). minutes in duration. Neither the other experimental tooth
However, in order to participate in the study, the patient (Group A) or the control tooth received further instru-
had to have at least two teeth with a periodontal disease mentation.
index calculus score3' of 2 or more. This ensured the same 7. After a period not less than 24 hours after the sec-
relative magnitude of initial subgingival calculus. If a ond instrumentation the patient received a third episode
third tooth satisfying the same criterion was available, it of scaling and root planing on the Group tooth, also
served as a control. Taking into consideration that a pre- not exceeding 5 minutes in duration; all the teeth (Groups
vious study employing the same technique already com- A, B, and C) were then immediately extracted.
pared a single episode of scaling and root planing to con-
trols receiving no instrumentation,21 controls were used in Preparation of Teeth
the present study only to illustrate the state of noninstru- Teeth were immediately rinsed with running water to re-
mented teeth. The total number of teeth was 35 (15 scaled move surgical hemorrhage. Soft tissue tags were re-
once, 15 scaled three times, and 5 controls). moved, and the teeth transferred to 1% méthylène blue
for 2 minutes. This solution stained the connective tissue
Measurements and remaining calculus. Finally the teeth were rinsed with
Dental calculus was assessed according to the periodontal running water for 2 to 3 minutes.
disease index (PDI).3'
A CP-11 probe11 or a #3 explorer11 was used for the de- Assessment of Residual Calculus Under the
tection of subgingival calculus. Probing depth was mea-
Stereomicroscope
The same methodology previously described21 was fol-
"Hu-Friedy Manufacturing, Inc., Chicago, IL. lowed for the assessment of residual calculus. The teeth
Volume 67
Number 4 ANDERSON, PALMER, BYE, SMITH, CAFFESSE 369

Table 1. Percent Residual Calculus Scores for Each Treatment

Group for All Surfaces
Range/Surface Mean/Surface SD
Level of
Gingival C.E.J.
Scaled IX 15 11.6-32.8% 25%
Margin (Group A)
Scaled 3X 15 11.5-44.8% 23.7%
(Group B)
Control 5 55.6-76.9% 70%
(Group C)
Level of
Connective Tissue *P < .0004.
< .0015.
Attachment

Statistical Analysis
MIDAS (Michigan Interactive Data Analysis System) was
used to test the hypothesis that there was no difference
Squares counted
in. the effectiveness of one and three episodes of subgin-
j ~j Squares not counted gival scaling and root planing. The study was designed
to compare teeth scaled once, teeth scaled three times,
a One square with calculus and non-scaled control teeth in terms of the percent of
ß One square with calculus
c Four squares with calculus calculus and total counts of calculus left on the surfaces
of each experimental group.
Total squares with calculus =
6 The statistical tests utilized to evaluate the data were
Total squares covering surface =
32 the paired r-test and the Student i-test.
Percent calculus X 100
32 When attempting to relate calculus scores and probing
Figure 1. Assessment of calculus under microscope (from Rabbani et depth the following modification was performed: the
al.21). probing depth was measured at six locations on each tooth
(buccal, lingual, mesiobuccal, mesiolingual, distobuccal,
distolingual). However, the percentage and total counts of
were viewed under a stereomicroscope1 with a magnifi- calculus remaining were computed for four surfaces of
cation of 6.3/12.5. The calculus was measured on four each tooth (buccal, lingual, mesial, distal) under the ste-
surfaces (buccal, lingual, mesial, and distal) using a mi- reomicroscope. In order to make the probing depth mea-
crometer disc,* 10 mm X 10 mm square subdivided into surements and the calculus scores comparable for a given
100 squares, which was placed on the eyepiece** of the surface, the average of mesiobuccal and mesiolingual and
also the average of distobuccal and distolingual probing
stereomicroscope. The four surfaces were separated by
placing a small scratch with a curet on each line angle of depth measurements were calculated and the means used
the tooth, from the areas of the gingival landmark (bur for the comparison with calculus scores for these surfaces.
mark) to the line of the connective tissue attachment.
Based on the view in the stereomicroscope, the total num- RESULTS
ber of squares which covered each surface of the tooth The results of one and three episodes of scaling and root
from the connective tissue attachment to the free gingival planing and control teeth were analyzed according to per-
margin scratch were added. The number of squares with cents and total counts of residual calculus. Assessments
calculus for each of the surfaces were then counted and of calculus scores were also made in various probing
added. This represented the total number of squares with depth categories.
calculus. From these numbers, percents and total counts There were no differences between Groups A, B, and
of calculus remaining could be obtained. In the assess- C in terms of calculus scores at baseline. This was a cri-
ment of calculus, the presence of calculus in each square terion of tooth selection. The two or three teeth (when a
of the tenth grid was counted as one, even if it was a control was available) used from each patient all pos-
very small fragment (Fig. 1). All measurements were per- sessed the same calculus score. A description of percent
formed by the same examiner at different times and were residual calculus scores for the three groups is presented
highly reproducible. in Table 1. It can be observed that the range and mean
values per surface for scaled teeth (Group A and B) are
very similar, while the same values for the control group
are much higher. This can be observed in Figure 2. Com-
'"J.M.
Stereomicroscope, Olympus Optical Co., Ltd, Tokyo, Japan.
"Whipple Net Micrometer Disc, Olympus, WA. parisons of percent residual calculus scores between the
**WFX Micro-Optics Co., Southfield, MI. Group A teeth and the controls (Group C) show that
 J Periodontol
370 SINGLE VERSUS MULTIPLE SCALING AND ROOT PLANING April 1996

Figure 2. A. Photograph of a typical root surface evaluated from Figure 2. B. Photograph of a typical root surface evaluated from Group
Group A (instrumented once). (scaled three times). Although surface appears smoother, remaining
calculus is also seen.

Group A teeth had a significantly lower percent of cal- determine the amount of residual calculus of the scaled
culus than the control. A similar result was found between treatment groups. Table 3 describes the data using total
Group and the controls. Therefore, scaling had an ob- counts of residual calculus. It shows a large difference in
vious, significant effect in reducing the percent of residual calculus scores between the scaled teeth and the controls.
calculus. Table 2 shows results comparing the group Range and mean values of total counts per surface are
scaled one time (Group A) to the group receiving three much larger in the control group receiving no scaling and
instrumentations (Group B). There was no significant dif- root planing. However, data presented in Table 4 show no
ference between the two groups when surfaces were to- significant difference in total count values when compar-
taled together, or when each surface (mesial, buccal, dis- ing the group that received scaling one time and the group
tal, lingual) was evaluated individually. receiving three episodes of instrumentation. Significant
Assessments were made using total counts to further differences could not be detected when all the surfaces in
Volume 67
Number 4 ANDERSON, PALMER, BYE, SMITH, CAFFESSE 371

Table 3. Total Count Scores of Residual Calculus for Each Treat-

ment Group
Range/
Surface Mean/Surface SD
Scaled IX 15 2.3-9.8 5.2 2.1
(Group A)
Scaled 3X 15 2.3-7.8 4.7 1.9
(Group B)
Control 5 7.8-24.0 13.5 6.5
(Group C)
*P < .001.
< .001.

Table 4. Comparison of Total Counts of Residual Calculus for

Treatment Groups A and for Individual Surfaces and for Total
Surfaces (N =
15)
Total Count Average
Mesial Buccal Distal Lingual Total
Scaled IX 7.1 4.7 5.5 3.4 5.2
(Group A)
Scaled 3X 5.8 4.5 5.1 3.7 4.7
(Group B)
Significance* .3438 .8713 .6753 .9466 .4286

*Significance is based on all scores, not limited to averages; significance

determined via paired t-test.

each group were totaled or when each surface was ana-

lyzed individually.
Comparisons involving probing depths were also made.
Table 5 describes the scores for residual calculus in var-
ious probing depth categories: 1.0 to 3.0 mm, 3.5 to 6.0
mm, and & 6.5 mm for scaled treatment Groups A and
B. Comparisons between percents and total counts of re-
sidual calculus are presented and show that there were no
significant differences between the percent of residual cal-
culus in Groups A and when categorized by the various
probing depths.
Observing the mean scores, Table 5 shows apparently
contradictory results. Mean total count scores of residual
calculus reveal that more calculus is associated with deep-
Figure 2. (continued) C. Photograph of a typical root surface evaluated
er pockets. As the pockets increased in depth, the amount
from Group C (control), showing more calculus present than either Fig-
ure 2A or Figure 2B. of residual calculus became greater. However, when as-
sessing the mean scores for the percent values of residual
calculus, as the depth of the pocket increases, the percent
of residual calculus decreases.

Table 2. Comparison of Percent Residual Calculus Scores for Treatment Groups A and for In-
dividual Surfaces and the Total Surfaces (N = 15)

Total
Percent Residual Calculus
Mean/ Range/
Mesial Buccal Distal Lingual Surface SD Surface
Scaled IX 22.9 29.2 20.9 26.8 25.0 11.6-32.8
(Group A)
Scaled 3X 22.6 29.7 18.8 23.5 23.7 11.5-44.8
(Group B)
Significance" .9461 .9120 .5464 .5031 .4909

Significance is based on all scores, not limited to mean values; significance determined via paired i-test.
 J Periodontol
372 SINGLE VERSUS MULTIPLE SCALING AND ROOT PLANING April 1996

Table 5. Comparison and Percentage Calculus and Total Counts

of Residual Calculus in Various Pocket Depth Categories in Treat-
Therefore, results of this study suggest that residual
ment Groups A and (N = IS) calculus not removed after one thorough episode of scal-
ing and root planing is not likely to be removed by re-
Probing Depth peated'instrumentation. Many authors have suggested var-
1.0-3.0 3.5-6.0 ious reasons for the inability of scaling and root planing
mm mm 6.5 mm
procedures to routinely provide a calculus-free root sur-
Scaled IX Number of surfaces 19 33 face. Some researchers attribute limited success of non-
(Group A) at risk
Average % calculus 28.0 24.1 22.7 surgical instrumentation to poor accessibility due to prob-
per root surface ing depth,20-2132 defects in the root surface,1618 root surface
Average total count 4.5 5.1 7.0
topography,16-18-19-33-34 and operator variability.26-27-35 Other
per root surface
authors do not feel that smoothness is the proper indicator
Scaled 3X Number of surfaces 25 26 9
(Group B) at risk of a "clean" root surface due to operator inability to dis-
Average % calculus 26.1 22.7 19.7 tinguish between burnished calculus, cementum or den-
per root surface tin.1718-21 In addition, Sherman et al.36 reported the diffi-
Average total count 4.4 -4.5 6.0
culties encountered in determining the thoroughness of
per root surface
*Significance % .7144 .6387 .6195 subgingival instrumentation, especially when the inter-
*Significance total count .9219 .4805 .5939 examiner and intraexaminer clinical agreement in detect-

*Significance determined via Student r-test. ing calculus was low. This study showed that problems
associated with the effectiveness of single episodes of
scaling and root planing will not be overcome by repeated
discussion instrumentation.
The effectiveness of scaling and root planing procedures Badersten et al.30 also evaluated the effects of single
in removing accretions from root surfaces has been clear- and multiple instrumentation in patients with severely ad-
ly demonstrated by this study. Percent residual/calculus vanced periodontal disease using clinical parameters.
scores revealed that teeth receiving both single and mul- Probing depth, bleeding scores, and clinical attachment
tiple instrumentations had significantly less calculus than levels were used to measure the healing response. While
did the control teeth. Analyses were made in terms of the the parameters used in that study were different from
total surfaces in each group and when surfaces were those of the present study, the results were similar. Both
grouped individually (mesial, buccal, distal, lingual). reports showed that no significant, measurable benefit was
However, by no means were these surfaces calculus free. accomplished by repeated episodes of non-surgical scal-
This is in keeping with previous reports demonstrating ing and root planing.
that complete calculus removal is technically very diffi- As mentioned previously, there was a discrepancy be-
cult. Using a scanning electron microscope, Jones et al.16 tween mean percent and total counts of residual calculus
found numerous residual calculus deposits after in vivo as probing depth increased (Table 5). The mean total

scaling and root planing. Walker and Ash17 reported sim- counts of remaining calculus showed a moderate increas-
ilar results after one instrumentation. They noted the pres- ing trend as the probing depth increased. This result is
ence of burnished calculus that was not detected clinical- similar to those achieved by Waerhaug,20 Rabbani et al.,21
ly. Schaffer18 reported the presence of residual calculus in Stambaugh et al.,32 and Fleischer et al.,27 who showed that
cementai defects post-instrumentation, while Frumker and larger amounts of residual calculus remained in deeper
Gardner'9 felt that root surface topography made calculus pockets. Those authors indicated that probing depth was
removal difficult. a main determining factor in the effectiveness of root
While this study clearly demonstrated the ability of preparation. However, in this study, mean percent calculus
non-surgical scaling and root planing procedures to re- scores showed a mild decrease with increasing probing
move calculus from root surfaces, it also showed that depth. It is felt that the difference between these two
short-term frequency of such procedures (24 hours) is in- trends is due to the time limitation placed on the instru-
significant in relation to the effectiveness of calculus re- mentation period for each tooth. Teeth that were scaled
moval. Surfaces that had undergone three episodes of one time were not instrumented more than 10 minutes

scaling and root planing were not significantly different while teeth scaled three times were not root planed more
from those that had a single instrumentation. This was than a total of 20 minutes. Because of these limitations,
evident in terms of both percents and total counts of re- more instrumentation was performed in the deepest por-
sidual calculus. Further evaluation of percent and total tion of pockets with more surface area harboring calculus.
count scores showed that there was also no difference Since more surface area was instrumented, the percent
observed when assessing individual tooth surfaces (me- scores for these deeper pockets were lower, even though
sial, buccal, distal, lingual) nor when surfaces were they actually had more calculus as evidenced by the total
grouped into various probing depth categories (Table 5). count scores. It is, therefore, felt that the mean total count
Volume 67
Number 4 ANDERSON, PALMER, BYE, SMITH, CAFFESSE' 373

16. Jones SJ, Lozdan J, Boyde A. Tooth surfaces treated in situ with
scores are a truer representation of the calculus associated
with increasing probing depth. Another observation was periodontal instruments. Scanning electron microscopic studies. Br
DentJ 1972;132:57-64.
the clinical healing and decrease in inflammation seen in 17. Walker SL, Ash MM. A study of root planing by scanning electron
some patients even a short time after initial instrumenta-
microscopy. Dent Hyg 1976;50:109-114.
tion. 18. Schaffer EM. Histological results of root curettage of human teeth.
J Periodontol 1956;27:296-300.
19. Frumker SC, Gardner WM. The relation of the topography of the
Conclusions root surface to the removal of calculus. J Periodontol 1956;27:292-
Based on this study, we conclude that: 1 ) single and mul- 295.
tiple episodes of scaling and root planing significantly 20. Waerhaug J. Healing of the dentoepithelial junction following sub-
reduced the amount of calculus on root surfaces; and 2) gingival plaque control. I. As observed in human biopsy material.
there is no significant difference in the effectiveness of J Periodontol 1978;49:1-8.
21. Rabbani GM, Ash MM, Caffesse RG. The effectiveness of subgin-
calculus removal between single and multiple episodes of
gival scaling and root planing in calculus removal. / Periodontol
scaling and root planing within 24 hours, without allow- 1981;52:119-123.
ing for possible probing depth reduction. 22. Waerhaug J. Healing of the dentoepithelial junction following sub-
gingival plaque control. II. As observed on extracted teeth. J Per-
iodontol 1978;49:119-134.
REFERENCES 23. Caffesse RG, Sweeney PL, Smith BA. Scaling and root planing with
.

1. Lovdal A, Arno A, Waerhaug J. Incidence of clinical manifestations

or without periodontal flap surgery. J Clin Periodontol 1986; 13:
of periodontal disease in light of oral hygiene and calculus forma-
205-210.
tion. J Am Dent Assoc 1958;56:21-33.
24. Eaton KA, Kieser JB, Davies RM. The removal of root surface
2. Green JC. Periodontal disease in India: Report of an epidemiological
deposits. J Clin Periodontol 1985;12:141-152.
study. J Dent Res 1960;39:302-312. 25. Waerhaug J. A method of evaluation of periodontal problems on
3. Greene JC. Oral hygiene and periodontal disease. Am J Public
extracted teeth. J Clin Periodontol 1975;2:160-168.
Health 1963;53:913-922.
26. Brayer WK, Mellonig JT, Dunlap RM, Marinak KW, Carson RE.
4. Löe H. Epidemiology of periodontal disease. An evaluation of the
relative significance of the aetiological factors in the light of recent Scaling and root planing effectiveness: The effect of root surface
access and operator experience. J Periodontol 1989;60:67-72.
epidemiological research. Odont 1963;71:479-503. 27. Fleischer HC, Mellonig JT, Brayer WK, Gray JL, Barnett JD. Scal-
5. Lovdal A, Arno A, Schei O, Waerhaug J. Combined effect of sub-
ing and root planing efficacy in multi-rooted teeth. J Periodontol
gingival scaling and controlled oral hygiene on the incidence of 1989;60:402-409.
gingivitis. Acta Odontol Scand 1961;19:537-555. 28. Kepic TJ, O'Leary TJ, Kafrawy AH. Total calculus removal: An
6. Hirschfeld L, Wasserman B. A long-term survey of tooth loss in
attainable objective? J Periodontol 1990;61:16-20.
600 treated periodontal patients. J Periodontol 1978;49:225-237.
29. Ciancio SG. Non-surgical periodontal treatment. In: Proceedings of
7. Suomi JD, Green JC, Vermillion JR, Doyle J, Chang JJ, Leather-
the World Workshop in Clinical Periodontics. Chicago. The Amer-
wood EC. The effect of controlled oral hygiene procedures on the
ican Academy of Periodontology; 1989:11-1.
progression of periodontal disease in adults: Results after third and 30. Badersten A, Nilvéus R, Egelberg J. Effect of nonsurgical peri-
final year. J Periodontol 1971;42:152-160.
odontal therapy III. Single versus repeated instrumentation. J Clin
8. Axelsson R Lindhe J. Effect of oral hygiene procedures on caries
Periodontol 1984;11:114-124.
and periodontal disease in adults. J Clin Periodontol 1978;5:133—
31. Ramfjord SP. Periodontal disease index (PDI). J Periodontol
151.
9. Axelsson R Lindhe J. The significance of maintenance care in the
1967;38:602-610.
treatment of periodontal disease. J Clin Periodontol 1981 ;8:281
32. Stambaugh RV, Dragoo M, Smith DM, Carasali L. The limits of
294. — subgingival scaling, lnt J Periodontics Restorative Dent 1981 ; 1 (5):
30-41.
10. Badersten A, Nilveus R, Egelberg J. Effect of non-surgical peri-
33. Jones WA, O'Leary TJ. The effectiveness of in vivo root planing in
odontal therapy. II. Severely advanced Periodontitis. J Clin Perio-
dontol 1984;11:63-76. removing bacterial endotoxin from the roots of periodontally in-
volved teeth. J Periodontol 1978;49:337-342.
11. Badersten A, Nilveus R, Egelberg J. Effect of non-surgical peri-
34. Zander HA. The role of calculus in the etiology and treatment of
odontal therapy: I. Moderately advanced Periodontitis. J Clin Per-
iodontol 1981;8:57-72. periodontal disease. Acad Rev 1955;3(2):14-17.
35. Badersten A, Nilvéus R, Egelberg J. Effect of non-surgical peri-
12. Tagge DK, O'Leary TJ, El-Kafrawy AH. The clinical and histolog-
odontal therapy (IV). Operator variability. J Clin Periodontol
ical response of periodontal pockets to root planing and oral hy-
1985;12:190-200.
giene. J Periodontol 1975;46:527-533. 36. Sherman PR, Hutchens Jr, LH, Jewson JG, Moriarty JM, Greco GW,
13. Hughs TR Caffesse RG. Gingival changes following scaling, root
McFall Jr, WT. The effectiveness of subgingival scaling and root
planing and oral hygiene. A biometrie evaluation. J Periodontol planing. I. Clinical detection of residual calculus. J Periodontol
1978;49:245-252.
14. Hellden LB,
1990;61:3-8.
Listgarten MA, Lindhe J. The effect of tetracycline and/
or scaling on human periodontal disease. J Clin Periodontol 1979;6: Send reprint requests to: Dr. Gissela B. Anderson, The University of
222-230. Texas, Health Science Center, Dental Branch, Department of Stomatol-
15. Proye M, Canton J, Poison A. Initial healing of periodontal pockets ogy, Division of Periodontics, 6516 John Freeman Avenue, Room 309,
after a single episode of root planing monitored by controlled prob- Houston, TX 77030-3402.
ing forces. J Periodontol 1982;53:296-301. Accepted for publication October 6, 1995.