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Dental Scaling and Root Planing for Periodontal Health: A Review of the Clinical Effectiveness, Cost-effectiveness, and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2016 Oct 17.

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Dental Scaling and Root Planing for Periodontal Health: A Review of the Clinical Effectiveness, Cost-effectiveness, and Guidelines [Internet].

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Quantity of Research Available

A total of 670 citations were identified in the literature search. Following screening of titles and abstracts, 615 citations were excluded and 55 potentially relevant reports from the electronic search were retrieved for full-text review. Four potentially relevant publications were retrieved from the grey literature search. Of these 59 potentially relevant articles, 40 publications were excluded for various reasons, while 19 publications met the inclusion criteria and were included in this report. APPENDIX 1 describes the PRISMA flowchart of the study selection.

Additional references of potential interest are provided in APPENDIX 5. One systematic review (SR) from 2013 was excluded as all three of its selected studies were also evaluated in a more recent SR that was identified for this report; the citation for the excluded SR is provided in the appendix.

Summary of Study Characteristics

Detailed study characteristics are provided in APPENDIX 2; characteristics of included SRs are presented in Table A1, study and patient characteristics of randomized controlled trials (RCTs) and non-randomized controlled trials are summarized in Table A2, and evidence-based guideline characteristics are described in Table A3.

Study Design

Two SRs8,9 were identified for the research question on the clinical effectiveness of scaling and root planing (SRP) for periodontal health. Details regarding the methodology of the SR by Smiley et al.9 were provided separately from the journal publication in the unabridged report.10 Both SRs searched multiple electronic databases from 2004 to April 20148 or 1960 to July 20149 for RCTs and supplemented this search by reviewing the bibliographies of identified reviews. The SR by Needleman et al.8 was an update of a previous review from 2005;11 unlike the initial review, the 2014 update did not evaluate study designs other than RCTs. Ten RCTs were included in one SR, eight of which included relevant comparisons for this review8 and a total of 72 RCTs were included in the other SR;9 however, 11 RCTs were identified that included comparisons that are relevant to this report.

Twelve parallel group RCTs1223 regarding the clinical effectiveness of SRP for periodontal health that were not included in the SRs were identified for this report. In addition, one non-randomized, controlled clinical trial met the inclusion criteria.24 In this trial, patients chose the study group to which they would like to be allocated.

Four evidence-based guidelines2528 regarding SRP were identified. Two guidelines were based on the SRs included in this report; the guideline by Smiley et al.25 was based on the SR by Smiley et al.9 and the guideline by Tonetti et al.26 accompanied the SR by Needleman et al.8 The guideline group from the Ministry of Health Malaysia27 searched multiple electronic databases from January 2004 to January 201127 and reviewed the reference lists of selected articles. The HealthPartners Dental Group and Clinics28 performed an electronic database search to identify supporting evidence for their guideline but details regarding the search strategy were not provided. The quality of the body of evidence was given a rating of high, moderate, or low in two guidelines,25,26 and given one of five evidence levels based on study design in one guideline.27 The recommendations in all four guidelines were developed based on expert opinion or through consensus-building after a review of the available supporting evidence, and the strength of the recommendations was formulated according to a combination of the certainty in the effect estimate and net benefit rating,25 or by modifying existing recommendation rating schemes.26,27 One guideline did not specify methods for determining the strength of either the recommendations or the supporting evidence.28

Country of Origin

One SR8 was conducted by authors in the United Kingdom, and its corresponding guideline was produced by participants from several European countries in the European Workshop on Periodontology.26 The other SR9 was performed by a group from the United States, and its accompanying guideline25 was developed by the Council on Scientific Affairs of the American Dental Association. The remaining two guidelines were produced by the Malaysian Ministry of Health, Oral Health Division27 and the HealthPartners Dental Group and Clinics in the United States.28

The clinical trials were conducted in India12,13,20 the United States,15,23 Brazil,16,24 Saudi Arabia,14 Pakistan,17 Turkey,18 Australia,19 Iran,21 and Jordan.22

Patient Population

The SR by Needleman et al.8 and the accompanying guideline from the European Workshop on Periodontology26 focused on prevention of periodontitis in healthy adults, with or without gingivitis. The scope of this review and recommendations excluded adults with specific conditions such as diabetes. The intended users of the guideline were oral health professionals, the public, and policy-makers.26

The SR by Smiley et al.9 and its corresponding guideline from the American Dental Association25 included and were applicable to adults with chronic periodontitis, excluding aggressive periodontitis. Likewise, the 13 identified clinical trials1222,24,29 and the two remaining guidelines27,28 evaluated adults with chronic periodontitis.

Some of the RCTs recruited adults with periodontitis and other specific health conditions, including rheumatoid arthritis,12 type 2 diabetes mellitus (T2DM),13,15,21 coronary heart disease,17 hyperlipidemia,14 cardiovascular disease,20 and erectile dysfunction.18 The objective of these studies was to determine the effect of SRP on condition-specific outcomes as well as periodontal outcomes. The non-randomized controlled clinical trial24 exclusively recruited pregnant women with periodontitis to evaluate the birth and periodontal outcomes associated with non-surgical periodontal treatment.

Interventions and Comparators

The SR by Needleman et al.8 evaluated the clinical effectiveness of professional mechanical plaque removal (PMPR) for the prevention of periodontitis, which was defined as supragingival and subgingival scaling but excluding root planing, performed with or without oral hygiene instruction (OHI). PMPR was compared with no treatment, different modes or timing of supragingival plaque removal, or OHI alone. The related guideline by Tonetti et al.26 from the European Workshop on Periodontology produced recommendations regarding several approaches to the prevention of periodontitis, including PMPR.

All other publications identified for this report evaluated non-surgical interventions for the treatment of chronic periodontitis. The 11 relevant RCTs included in the SR by Smiley et al.9 compared SRP alone with no treatment; the remaining 61 RCTs in the SR that are not addressed in this report evaluated combined interventions (SRP and antimicrobials or laser treatment).The guidelines by the Ministry of Health Malaysia27 and the HealthPartners Dental Group28 considered several interventions for diagnosis and treatment of periodontitis; only the recommendations related to SRP are reviewed in this report. The treatment comparisons in the clinical trials included SRP versus no treatment,13,17,18,20 SRP with OHI versus OHI alone,14,15,19,2123 SRP with OHI versus no treatment,12 or a combination of SRP, OHI, and “professional prophylaxis” (not otherwise described) versus OHI and “professional prophylaxis.”24

The RCTs included in the two SRs inconsistently reported the number of sessions of SRP; when reported, SRP was conducted over either one or two sessions, or once per quadrant.8,9 Eight clinical trials specified that SRP was conducted at the start of the trial, completed either in a single session16,18,19 or over two to four sessions.13,15,17,20,22 Two of these studies indicated that additional supportive periodontal therapy was provided to the SRP treatment group at follow-up visits.13,22 One study provided SRP within 30 days of baseline and again at 16 weeks; periodontal outcomes were measured at 16 weeks (before the second round of SRP) and at 28 weeks.23 Four studies did not provide details about the number of SRP sessions provided.12,14,21,24

The length of time spent to perform SRP (per session or overall) was not frequently reported in these studies. Two of the eight relevant RCTs in one SR reported that SRP sessions lasted 30 minutes, or 15 to 20 minutes (“plus additional time permitted at the visit”, not otherwise described).8 In the other SR, one of the 11 relevant included RCTs reported a 45 minute time limit for SRP.9 Of the individual clinical trials included in this report, two RCTs discussed time limits for SRP; one specified that full-mouth SRP was completed in one session, lasting from 45 minutes to three hours,19 and the other stated that there was no time limit to complete full-mouth SRP, and did not describe what the average session length was.21

One RCT evaluated different intervals of periodontal therapy.16 All patients initially received one SRP session lasting up to 45 minutes and OHI, and then were randomized to receive supportive supragingival scaling and polishing at one month or three month intervals over the six month duration of the study.


Several periodontal outcomes were assessed in the SRs and clinical trials, including:

  • Periodontal status as measured by the Simplified Oral Hygiene Index (OHI-S),12,20 where a higher score indicates a poorer periodontal status
  • Probing depth (PD);8,1224 measured from the gingival margin to the base of the sulcus
  • Clinical attachment level (CAL);8,9,1219,21,23,24 defined as the distance between the cemento-enamel junction and the base of the gingival sulcus
  • Plaque Index (PI) or number of teeth with plaque;8,13,14,16,18,19,21,22,24 measured using the Silness and Loe method in four studies13,14,19,22 and the O’Leary method in two studies18,21
  • Gingival Index (GI), measured using the Loe and Silness method1214,19,21,22
  • Bleeding on probing (BOP);12,13,1518,23,24 specified in four studies as the proportion of sites that bled within 10 seconds,12 15 seconds24 or 30 seconds of probing13,17
  • Gingival recession15,16
  • Periodontal epithelia surface area (PESA)13
  • Periodontal inflammatory surface area (PISA)13

Though addressed by some studies that included study populations with specific clinical conditions, non-periodontal clinical outcomes are not reported in this review.

Twelve studies specified that outcomes were measured at four13,1922,24 and/or six sites per tooth.1218,22 Nine studies specified that outcomes were measured on six teeth14,19 or all teeth except third molars.13,1619,22,24 One RCT23 and the two SRs8,9 did not specify where measurements were taken.

The SRs included studies that had follow-up periods ranging from less than one month to 48 months,8 or least 6 months in length.9 For the 13 primary studies, outcomes were measured at baseline and one month,15,17,18 two months,17,20 three months,1214,16,18,19,21,22 and/or 6 months.13,16 One RCT provided SRP at baseline and 16 weeks and measured outcomes at 16 weeks (prior to the second round of SRP) and at 28 weeks.23 The non-randomized controlled clinical trial that provided SRP to pregnant women evaluated periodontal outcomes at the second study visit, which was performed post-partum but specific intervals between treatment and follow-up were not provided.24

The major outcomes considered by the guidelines included CAL and adverse effects of treatment,25 prevention of periodontitis,26,27 diagnosis of periodontitis,27,28 and effectiveness of treatment for periodontitis.27,28

Summary of Critical Appraisal

A detailed list of study strengths and limitations are provided in APPENDIX 3.

Systematic Reviews

The two SRs8,9 had several methodological strengths related to the comprehensive literature search of multiple databases and duplicate study selection and data extraction. Both reviews stated that the electronic database search was supplemented by reviewing bibliographies of key articles; however, one SR did not search for grey literature.8 Both SRs clearly reported the risks of bias for each included study, and used these assessments of evidence quality to inform the conclusions. Each review used appropriate methods to synthesize the evidence; Needleman et al.8 chose a narrative summary format due to the observed heterogeneity of the included studies, while Smiley et al.9 performed a random-effects meta-analysis and statistical tests to address heterogeneity. The SR by Smiley et al.9 also clearly reported a full list of included studies and their characteristics and excluded studies with reasons for exclusion. The possibility of publication bias was assessed in this SR both graphically and using statistical tests.9 Publication bias was not assessed in the SR by Needleman et al.,8 though the authors acknowledged that it may have been possible due to the focus on electronic database searches and exclusion of grey literature. Most other limitations of the SRs were related to unclear or insufficient reporting. For example, neither SR referred to a registered protocol or methods published prior to the start of the review or described conflicts of interest for the primary studies,8,9 and one SR did not provide an excluded studies list or study characteristics for some of the included RCTs.8

The strengths and limitations noted for each SR are provided in Table A4.

Clinical Trials


The main strengths of the identified RCTs and non-randomized controlled clinical trial were noted to be due to clear reporting. All 13 trials described the study objectives, provided clear patient inclusion and exclusion criteria, and all but one12 summarized baseline characteristics and distribution of potential confounders between study groups. Eleven studies listed the main outcomes in the Methods section, with descriptions or references to how the outcomes would be measured;1215,1723 however, two studies did not describe the methods for measuring the outcomes.16,24 Most studies provided some detail about how SRP was performed, including the tools used during the procedure and number of sessions to complete treatment. However, one study stated that SRP was completed within 30 days of the baseline visit but did not provide further detail,23 and three studies did not describe any methods for SRP.12,14,24 The study by Sant’Ana et al.24 also did not describe the “professional prophylactic” intervention provided to both treatment and control groups, so it is unclear how this may have contributed to response to therapy. The results were generally reported well; all studies summarized the results for the main outcomes by presenting mean values for each group. Estimates of the random variability in the data (standard deviation or standard error) were presented in all but one of the studies23 and actual probability values were provided in all but four studies.13,16,18,24 Likewise, patient loss to follow-up and the number in each study group when it occurred were reported in the majority of studies.1217,1922,24 Some aspects were infrequently reported in the included clinical trials; none provided the simple outcome data that contributed to those mean values, and adverse events potentially associated with the study interventions were not addressed by 10 studies.1215,17,18,20,2224

External Validity

The external validity of the studies was influenced by the choice of patients to include in the studies, the methods for patient selection, and the environments in which the studies were conducted. Six studies described the source population or methods for selecting patients.13,14,1719,24 However, seven studies did not clearly describe methods regarding patient recruitment or selection,12,15,16,2023 and six studies did not provide reasons for refusal in patients who declined to participate in the study.13,1618,21,24 The study by Sant’Ana et al.24 identified eligible pregnant women with periodontitis from an antenatal care program, and the study by Kapellas et al.19 included a convenience sample of Indigenous Australians; however, it is possible that individuals who are already participating in a health care program, or who are easily accessible to or cooperative with health care providers, would exhibit different health-related behaviours than people who do not do these things. In general, people who agree to participate in clinical trials may be more likely to be health conscious, for example brushing and flossing regularly, so this consideration applies to most studies, particularly those that did not specify how patients were recruited or selected. One study that recruited patients with rheumatoid arthritis was conducted in an orthopedics department,12 and another that included patients with hyperlipidemia was conducted in a cardiac and renal transplant centre;14 it is unclear whether the majority of patients with these specific health conditions would normally attend or receive the level of care provided at these types of facilities. All of these factors contribute to uncertainty around whether the patients who were approached or those who agreed to participate in these studies would be representative of the larger patient population.

Internal Validity

The internal validity of the studies was influenced by the study designs and methods for analyzing the results. Blinding patients to the intervention they were receiving was not done in any study, though this was likely impossible due to the nature of the interventions. Potential performance bias can still be minimized by blinding outcome assessors to the patient’s study group; this practice was described in six studies13,17,18,21,23,24 and not mentioned in seven.12,1416,19,20,22 A common strength for all studies was that they recruited all patients from the same source over the same period of time, and 12 of the 13 studies measured the outcomes at consistent time points that were the same for both the treatment and control groups.1221,23 One study referred to follow-up at the “2nd visit”, the timing of which may have varied within and between groups.24 Twelve of the included clinical trials were RCTs, but two did not describe methods for randomization.16,20 Likewise, allocation concealment was not described in nine studies.1214,16,2024 The study by Sant’Ana et al.24 did not randomize patients to study groups; rather, allocation was based on patient choice. Despite a lack of randomization in this study, there were no significant differences between the treatment and control groups at baseline in any of the measured periodontal parameters and other baseline characteristics. Likewise, most of the RCTs demonstrated that baseline characteristics were well balanced between study groups. However, In the RCT by Khare et al.12 the baseline OHI-S and BOP scores of the SRP group were significantly higher than those of the control group, indicating that the SRP group started the study with a poorer periodontal status. In the study by Sexton et al.23 the SRP group was significantly younger than the control group. In both cases, these intergroup differences could have impacted response to therapy. Regarding the data analyses, all studies used appropriate statistical tests to assess the main outcomes, none appeared to perform any unplanned, retrospective analyses, and six clearly reported either analyzing all patients (none lost to follow-up)12,14,16,21,22 or analyzing an intention-to-treat population using the last observation carried forward.13 Compliance with treatment was not a concern given that most studies performed SRP once at baseline; however, four studies only analyzed post-treatment data from patients who were available at a follow up visit,15,19,20,24 and the population analyzed was unclear in three studies.17,18,23 This may not accurately account for confounding variables (such as the age difference between groups in one RCT23) or reflect the true difference between treatment and control groups. Losing patients throughout the study can be especially impactful for studies with small sample sizes, but five studies reported an a priori power calculation to determine the necessary sample size required to detect a difference between groups in the non-periodontal primary outcomes.13,15,1719 Four of these studies maintained the necessary sample size was after attrition13,15,17,19 while one study reported the power of the study at randomization but did not discuss accounting for attrition in this calculation, and the number of patients lost to follow-up was not reported.18

The strengths and limitations of individual clinical trials are provided in Table A5.

Evidence-based guidelines

Scope and Purpose

All four included evidence-based guidelines2528 had clearly described objectives, scope, and intended users and target populations.

Stakeholder Involvement

The American Dental Association guideline development group had broad representation from relevant groups, including research and methodology experts.25 The guideline by Tonetti et al.26 described member affiliations but not specific job titles. The group responsible for the Ministry of Health Malaysia’s guideline27 included representatives from clinical practice and the government; however, it was unclear whether a methodologist was included to provide guidance on best practices for evidence searches and synthesis. One guideline did not provide any details about those involved in development.28 All publications described the target users of the guideline. None of the guidelines considered patient input; one group acknowledged that this process was ideal but not feasible for the development of their guideline, for unspecified reasons.27

Rigour of Development

Two guidelines25,26 were based on separate SR publications8,9 (see Table A4 for details of their strengths and limitations). The other two guidelines27,28 used systematic methods to identify evidence from multiple databases and listed search terms and dates. The Ministry of Health Malaysia guideline also reviewed reference lists of key articles to search for publications not identified from the electronic database search;27 however, neither guideline specified whether grey literature was included in the search.27,28 These two guidelines also lacked clear descriptions of how evidence was selected, as inclusion and exclusion criteria were not provided.27,28 In three guidelines, the body of evidence was evaluated, evidence statements were assigned a quality or certainty level, and these evidence statements were clearly linked to recommendations.2527 However, the guidelines referred to relying on expert consensus to develop recommendations, but none described methods used during this process. One of the four guidelines explicitly considered evidence related to adverse events;25 another guideline reported that adverse events were addressed in another guideline from the same European Workshop on Periodontology.26 An external review process was described in three guidelines,25,27,28 and a plan for updating the guideline was presented in two cases.25,27

Of note, the full text of the original HealthPartners Dental Group guideline could not be obtained for review, and a guideline summary28 from the National Guidelines Clearinghouse (NGC) was used for this report. Several details regarding the methodology of guideline development were not provided in the summary. Guidelines summarized by NGC are considered evidence-based, and it is possible that more detailed methodology would be presented in another source that would change a critical appraisal of this guideline.

Clarity of Presentation

The recommendations from three of the guidelines were somewhat ambiguous, as they did not describe the elements that would influence treatment choices when considering SRP as initial treatment,25 what combination of treatments should be provided given that SRP should not be the sole modality for patients with periodontitis,26 or how to tailor periodontal treatment to patients’ risk factors for disease progression.27 However, these three guidelines addressed a range of periodontitis management options across the guidelines as a whole and clearly presented key recommendations in a visually identifiable way.2527 The majority of the content in the HealthPartners Dental Group guideline summary was presented in the Major Recommendations section, making it unclear which portions of the text reflected evidence summaries, expert opinion or commentary, or recommendations.28


Applicability considerations were infrequently described; potential barriers and facilitators to implementation of the recommendations were not described in two guidelines,25,28 one of the four guidelines specifically addressed cost considerations,27 and none provided additional resources to assist guideline implementation. Two of the four guidelines presented or referred to auditing criteria.27,28

Editorial Independence

Each guideline addressed potential conflicts of interest of guideline development group members, but none provided an explicit statement that the recommendations were developed without undue influence from the funder.

The strengths and limitations of individual guidelines are provided in Table A6.

Summary of Findings

Two SRs,8,9 12 RCTs,1223 and one non-randomized controlled clinical trial24 were identified regarding the clinical effectiveness of scaling with or without root planing for the prevention or treatment of periodontal disease in adults. In addition, four evidence-based guidelines regarding scaling and root planing were identified.2528 No relevant literature was identified to address the cost-effectiveness question.

Detailed study findings are provided in Table A7.

What is the clinical effectiveness of scaling with or without root planing for periodontal health?

Simplified Oral Hygiene Index (OHI-S)

Two RCTs evaluated OHI-S scores after treatment with SRP alone20 or in combination with OHI12 compared with no treatment. In the RCT by Khare et al.12 the baseline OHI-S score of the SRP group was significantly higher than that of the control group, indicating that the SRP group started the study with a poorer periodontal status overall which may have impacted this group’s response to therapy. Despite this baseline discrepancy, this study also showed that OHI-S scores were significantly lower in the SRP group than in the control group at three months.12 The RCT by Koppolu et al.20 reported a statistically significant reduction in OHI-S scores from baseline in the SRP group, while scores increased in the control group over the same period. This study did not report a statistical comparison between groups.20 Neither study that evaluated this outcome commented on what constitutes a minimal clinically important difference in OHI-S score, yet Koppolu et al.20 described plaque reduction in the treatment group as “satisfactory”.

Probing Depth (PD)

PD was evaluated in 11 RCTs1215,1723 and one non-randomized controlled trial.24 General trends for the PD results from the clinical trials are presented in Table 2.

Table 2. Clinical Trial Results for Probing Depth.

Table 2

Clinical Trial Results for Probing Depth.

Eight RCTs found that PD improved after SRP treatment at follow-up time points ranging from four to 28 weeks after baseline.1315,18,2023 This was signified by either a statistically significant reduction in mean PD in mm,1315,18,20,21 or a significant decrease in the proportion of sites with PD greater than 4 mm or 5 mm.22,23 One study also showed a significant increase in the proportion of sites with PD ≤ 3 mm, demonstrating an overall decrease in PD severity as the PD distribution shifted to the less severe category at follow-up.22 In some cases, PD improvement was only observed when PD was more severe (≥ 4 mm) at baseline.15

In these same eight RCTs, PD did not change14,18,22 significantly increased,13,20,21 or significantly decreased over time in the control group.15,23 These latter two studies offered SRP and OHI to the treatment group and OHI alone to the control group, suggesting that OHI provides some benefit for patients with periodontal disease. However, SRP and OHI were significantly more effective at improving PD than OHI alone in these two studies.15,23 Likewise, five of these studies statistically analyzed intergroup differences at follow-up and found that PD was significantly smaller in the SRP group than the control group,13,15,18,21,23 and in one study this finding depended on the initial severity of periodontal disease.15 Intergroup differences were not analyzed statistically in three of these eight RCTs.14,20,22

Two RCTs12,19 did not statistically analyze changes from baseline in either study group but showed that the SRP group had significantly smaller PD12 or significantly fewer sites with PD of at least 4 mm19 than the control group at three months.

One RCT showed that there was no change from baseline in PD at two months in either the SRP or control group, and no difference between these groups at two months.17 However, the mean PD in both groups at baseline was less than 4 mm, and the authors discussed an observed reduction in the prevalence of patients with PD greater than 4 mm, suggesting that perhaps the benefit of SRP was greater in a subset of patients with more severe periodontal disease. Finally, one non-randomized study showed that PD worsened in both the SRP and control groups; the authors attributed this to the fact that the study patients were pregnant women, suggesting that periodontal deterioration may be expected during pregnancy.24 However, there was a significant difference between the SRP and control groups at follow-up, leading the authors to conclude that SRP may mitigate periodontal disease progression during pregnancy.24

Clinical Attachment Level (CAL)

CAL was evaluated in one SR,9 nine RCTs,1215,1719,21,23 and one non-randomized controlled clinical trial.24 General trends for the CAL results from the clinical trials are presented in Table 3.

Table 3. Clinical Trial Results for Clinical Attachment Level.

Table 3

Clinical Trial Results for Clinical Attachment Level.

The SR by Smiley et al.9 meta-analyzed the results from 11 RCTs and found that SRP was associated with a statistically significant improvement in CAL of 0.49 mm as compared with no treatment when measured at least six months after baseline. No details were provided in this review regarding the duration or frequency of SRP treatment.

Of the 10 individual clinical trials that evaluated this outcome, six found that the SRP group demonstrated significant improvements from baseline in CAL.1315,18,21,23 CAL improvement was reflected in statistically significant reductions in the mean CAL in mm1315,18,21 or the proportion of sites with a CAL greater than 2 mm.23 One of these studies showed that a significant change from baseline in the SRP group was limited to patients with an initial PD of at least 4 mm.15 This study also found that, in the SRP group, a greater proportion of measured sites had a less severe CAL (1 to 2 mm) and fewer sites had more a severe CAL (at least 5 mm) compared with baseline; no such CAL severity shift was observed in the control group.15

In these six RCTs, CAL did not change,14,15,18 significantly increased,13,21 or significantly decreased from baseline in the control group.23 This last result was from the same study that noted significant decreases in PD from baseline in the control group, who received OHI alone.23 Four of the six RCTs found a significant difference in CAL between the SRP and control groups,13,15,18,21 and in one study this finding was limited to the subgroup of patients with more severe periodontal disease at baseline.15

Of the remaining four clinical trials, two RCTs12,19 did not statistically analyze changes from baseline but showed that the SRP group had significantly smaller CAL12 or significantly fewer sites with CAL of at least 3 mm and PD of at least 4 mm19 as compared with the control group at three months.

As with the findings for PD, one RCT showed that there was no change from baseline in CAL at two months in either the SRP or control group, and no difference between these groups at two months.17 Likewise, the non-randomized controlled trial that recruited pregnant women with periodontitis showed that CAL did not change in the SRP group and worsened in the control groups, and this difference between groups was statistically significant.24


One SR8 and seven clinical trials13,14,18,19,21,22,24 evaluated plaque-related outcomes (plaque index (PI),13,14,22,24 number of teeth with plaque,19 or proportion of sites with plaque18,21). The SR8 found that PMPR (scaling but not root planing) was associated with reduction in plaque levels, but that this improvement was not always significantly different from results for the control groups.

In five RCTs,13,14,18,21,22 SRP was associated with a decrease in plaque from baseline at one month,18 three months,13,14,18,21,22 or six months.13 There was a significant decrease14 or no change13,18,21,22 from baseline in the plaque levels of the control groups. Furthermore, in three of these five RCTs that analyzed intergroup differences, plaque levels were significantly lower in the SRP group than in the control group.13,18,21

The study of pregnant women with periodontitis found that professional prophylaxis and OHI, with or without SRP, did not affect PI scores at the second visit.24 One RCT that found significant differences between SRP and control groups in other periodontal outcomes (PD, CAL, GI) did not observe the same results for the number of teeth with plaque at three months.19

Gingival Index (GI)

Six RCTs evaluated changes in GI after SRP treatment.1214,19,21,22 Four studies analyzed changes from baseline and found a significant improvement from baseline in the SRP group at three months13,14,21,22 and six months.13 In the control groups, GI worsened,13,21 did not change,22 or improved from baseline (when the control group received OHI).14 All four studies that analyzed intergroup differences at follow-up found that GI scores were significantly different between the SRP and control groups at three months12,13,19,21 and six months.13

Bleeding on Probing (BOP)

One SR8 and seven clinical trials12,13,15,17,18,23,24 evaluated the impact of periodontal treatment on gingival bleeding.

The SR8 identified some evidence that showed a greater reduction in gingival bleeding or inflammation after PMPR as compared with no treatment, but this finding was not consistent across all studies and the authors suggested that the magnitude of effect did not appear to be as great as for plaque-related outcomes; however, no statistical comparisons were presented to support this conclusion.

Five RCTs with follow-up time points ranging from four weeks to 28 weeks found that the percentage of sites with BOP significantly decreased from baseline after SRP treatment.13,15,17,18,23 There was no change17,18 or an increase in BOP13 from baseline for the control group in studies where no treatment was provided,17,18 but there was also a significant decrease in BOP in control groups that received OHI alone.15,23

As with PD, BOP significantly increased from baseline in both study groups in the trial that recruited pregnant women with periodontitis.24

All seven clinical trials analyzed intergroup differences at follow-up; BOP was significantly lower in the SRP group than the control group in six studies12,13,17,18,23,24 and there was no significant difference between groups in the RCT that found improvements in BOP in both groups.15

Gingival Recession

One RCT15 evaluated gingival recession, which significantly decreased from baseline with SRP when the initial PD was at least 4 mm. There was no significant change at four weeks in the SRP group when initial PD was 1 to 3 mm, or in any patient from the control group. In addition, there was no significant difference between treatment groups overall at four weeks.15

Periodontal epithelia surface area (PESA) and Periodontal inflammatory surface area (PISA)

One RCT13 evaluated PESA and PISA, which significantly decreased from baseline in the SRP group at the three month and six month follow-up visits.13 The control group, which did not receive any treatment, demonstrated significantly higher PISA scores at 3 months and higher PISA and PESA values at six months. Scores for both outcomes were significantly lower in the SRP group than the control group at both time points.13

What is the clinical effectiveness of different frequencies or number of units of scaling with or without root planing?

One SR8 and one RCT16 were identified that evaluated the clinical effectiveness of different frequencies of dental scaling (not including root planing). No studies were identified that evaluated different frequencies of SRP.

The SR8 included three RCTs that addressed different scaling frequency comparisons, ranging from once every three months to once every 24 months, and provided a narrative summary of the evidence by periodontal outcome. Two of the studies evaluated different fixed frequencies compared with each other (though the studies did not evaluate the same intervals) and one study compared scaling at fixed versus variable (as needed) intervals. Two of the three studies in the SR reported that there were no statistically significant differences in plaque levels, gingival bleeding, PD, or periodontal index between any of the scaling frequency groups. They also noted that plaque levels or gingival bleeding worsened in all groups, despite treatment. One study observed a trend toward improvement in attachment loss, plaque, and gingival bleeding or inflammation with increased scaling frequency; however, no statistical analysis of these comparisons was performed. This study also showed that, if combined with OHI, less frequent scaling was associated with greater plaque reduction than more frequent scaling alone. The overall conclusions provided in the SR were that, based on low quality evidence, there was some evidence to suggest that increased frequency of scaling was associated with improved plaque levels, gingival bleeding, and attachment loss, and that OHI is an important contributor to periodontal treatment outcomes.8

The RCT by Ueda et al.16 compared the impact of supportive periodontal therapy (scaling and polishing) offered once every month versus once every three months after initial full-mouth debridement in patients with chronic periodontitis. At the six month follow-up appointment, both groups demonstrated significant improvements from baseline in PD, CAL, gingival recession, and the proportion of sites with plaque and BOP. However, the only statistically significant difference between the one month and three month groups was observed for the proportion of sites with plaque at the six month follow-up visit (19.2% versus 28.1%, respectively).16

What is the cost-effectiveness of scaling with or without root planing for periodontal health?

No relevant literature regarding the cost-effectiveness of scaling and root planing for periodontal health was identified; therefore, no summary can be provided.

What are the evidence-based guidelines regarding scaling with or without root planing?

Four evidence-based guidelines were identified that provide recommendations regarding scaling for the prevention of periodontitis in healthy adults26 and regarding SRP for the treatment of chronic periodontitis.25,27,28

The guideline by Tonetti et al.26 recommends that PMPR should be performed both supra-gingivally and sub-marginally until all plaque and calculus have been removed; however, scaling alone is insufficient for treating patients with periodontitis. Both statements were classified as good practice points; this classification was not explicitly defined in the guideline but likely reflects recommendations based on clinical expertise rather than evidence as this is the only type of recommendation in the guideline that was not presented along with a level of evidence.

Two guidelines recommend that SRP should be considered as a first-line therapy for patients with chronic periodontitis.25,27 These recommendations were supported by evidence that was described as having either a moderate or high level of certainty,25 or evidence rated as good or directly applicable to the target population.27 Specific considerations affecting clinical decisions around using SRP were not described in the recommendation statements. One guideline suggests that SRP is the most effective treatment for necrotizing ulcerative periodontitis in particular, and that ultrasonic and hand tools can be combined to improve performance of SRP in locations where access is poor; however, this guideline did not provide ratings for the strength of any recommendation.28

One guideline was identified that discussed frequency of scaling. The guideline from the Ministry of Health Malaysia27 recommends that supportive periodontal treatment should be provided every three to six months. Supportive periodontal treatment may include several potential therapy options, including supra- and sub-gingival removal of plaque and calculus, and treatment choices were recommended to be made according to the patient’s specific characteristics. This recommendation was given Grade B based on the strength of the supporting evidence.27


This review was limited by the lack of available evidence to address the cost-effectiveness question and to address the clinical effectiveness of scaling with or without root planing in children. Furthermore, few studies were identified comparing the clinical effectiveness of different frequencies of SRP, and the strength of evidence identified for this comparison in one SR was categorized as low due to the limited amount of data and unclear risk of bias in the evaluated studies.8 In addition, two of 13 included studies19,21 described the length of time spent on SRP procedures; this makes it difficult to draw conclusions about the optimal performance of SRP or preferred methods for clinical practice. Furthermore, one study spent up to three hours on SRP treatments,19 and the other study did not impose a time limit,21 and this may not be reflective of the level of care typically provided or eligible for coverage in clinical practice. All of the studies were conducted over a relatively short-term, with the majority measuring clinical outcomes at three months after SRP. While benefits were observed for most types of patients at this length of follow-up, it is unclear how long these benefits would be maintained. Therefore, the studies included in this report do not address what the maximum effective interval between sessions of scaling with or without root planing would be. All studies performed statistical tests to inform a conclusion regarding statistical significance of outcomes; however, it is unclear how many of these findings would be considered clinically significant. Several studies recruited patients with periodontitis and other health conditions, such as diabetes13,15,21 and cardiovascular or coronary heart disease;17,20 it is possible these comorbidities could affect the patients’ response to periodontal therapy, and therefore it is unclear whether the results obtained in these studies would be sufficiently generalizable to a more general population.

Copyright © 2016 Canadian Agency for Drugs and Technologies in Health.

Copyright: This report contains CADTH copyright material and may contain material in which a third party owns copyright. This report may be used for the purposes of research or private study only. It may not be copied, posted on a web site, redistributed by email or stored on an electronic system without the prior written permission of CADTH or applicable copyright owner.

Links: This report may contain links to other information available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners’ own terms and conditions.

Except where otherwise noted, this work is distributed under the terms of a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International licence (CC BY-NC-ND), a copy of which is available at http://creativecommons.org/licenses/by-nc-nd/4.0/

Bookshelf ID: NBK401542


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