Gross Scaling Vs. Scaling to Completion

According to insurance billing, an indication for gross debridement would be if a patient presents with so much supragingival calculus that it is necessary to remove the calculus for the doctor to do an exam. According to the literature, another indication for gross scaling would be if a patient has ANUG. Main concerns of gross debridement include abscess formation and healing and tightening of the tissue, making it difficult to remove subgingival calculus when the patient returns for a recare appointment. Another main concern with gross debridement is patient compliance. A patient may have gross debridement performed and may not want to return for complete scaling. However, a question arises; if a patient were to have gross debridement, how soon after the procedure should the patient return for complete scaling to prevent formation of an abscess? Unfortunately, the answer is not found in the literature, but the patient should return within 4-7 days. Formation of an abscess as a result of gross scaling greatly depends on the topography of the bone and the systemic health of the patient.

Incomplete or gross scaling is seen in private practice, however many feel it shouldn’t be done. When a dental hygienist does not scale to completion it leaves various pieces of calculus or debris within the patient’s oral cavity. These pieces act as an irritant and do not permit the tissue and periodontium to fully heal. The etiological factor and bacterial toxins are left in the pocket, which leads to progression of the disease. Also, this can lead to a periodontal abscess. Many feel scaling to completion is more beneficial for the patient, even if you have to spilt the scaling into 2-4 appointments, to maximize their oral health.

American Dental Hygiene Association (2009). American Dental Hygienist’s Associations on polishing procedures. Retrieved on May 22, 2009, from

Chapper, A., Catao, V. V., Oppermann, R. V. (2005). Hand and ultrasonic instrumentation in the treatment of chronic periodontitis after supragingival plaque control. Brazil Oral Resource, 19(1), 41-46.

When billing out for gross debridement it may not be done the day of the dental examination even though gross debridement is intended to help the dentist in better evaluate of the tissue and teeth. It however can be billed a different day before completely scaling the patient. When the patience notices that the stains and build up is removed they might think that they have already had their cleaning and not return to the office. Considering this can be an issue it is important in educating the patients of the importance of following up with treatment.

Tekavec, C. (2005). What is debridement? Dental Assisting digest. Retrieved on May 29, 2009 from

Incomplete scaling is preliminary partial, full-mouth, or gross scaling. Incomplete scaling is usually used before scaling and root planning. It is used to remove plaque and calculus that prevent the ability to perform an oral evaluation. Then many appointments are schedule for scaling and root planning to complete periodontal treatment. This approach has abandoned many years ago due to potential for problems that can affect patients’ systemic health. Removing mostly supra calculus and some subgival calculus can interfere with the implementation process and the outcomes of the treatment.
Incomplete scaling can cause limited access to the subgingival calculus. After removing supra calculus, the tissue may heal tightly around the tooth; this makes harder to insert instrument to do a thorough job. In addition, the patient may think that his gingival look “health,” so they may not come back for the SRP. Patient education is also hard to achieve because there are no supra calculus to compare the complete scaled quadrant to the untreated quadrant. Patients may misunderstand about periodontal treatment because their teeth feel clean after the gross scaling, so why they need to have SRP? Later, if they develop abscess, they stated that because dental hygienists did not do their job appropriately. Incomplete scaling can cause potential for abscess formation in deep suppurating pockets and deep defect areas and on medical compromised patients.
Scaling to completion includes scaling and root planning and requires multiple appointments. SRP is removal of etiological factors that cause periodontal disease, such as plaque and calculus. Deep cleaning is usually done by quadrant or sextant depending on the severity of each case. Care treatment plan consideration includes patients’ health status, anesthesia, tooth anatomy, and the amount of deposition.
Overall, it is extremely important to scale to completion to prevent any future periodontal diseases and scaling limitation.

Matsuda, S. (2005). Nonsurgical periodontal instrumentation. In J. Goucher (Eds.), Clinical Practice of the Dental Hygienist (645-651). Massachusetts: Lippincott Williams & Wilkins.

Takei, N. & Carranza, K. (2006). Scaling and root planing. In J. Dolan, J. Pendill & J. Dedeke (Eds.), Carranza's Clinical Periodontalogy (pp.774-788). Elsevier Inc.

Our goal as dental health care professionals is to remove etiological factors of periodontal or gingival disease, restore health, and promote oral well being. The purpose of gross scaling is to remove supragingival calculus or plaque that interferes with the diagnostic ability of the dentist to perform an exam and determine what dental work the patient may need. Gross scaling is controversial among dental hygienists because it provides no therapeutic value and the primary purpose for performing a gross scale is to be able to bill the insurance or pts. Periodontal abscess which can result in tooth loss are a common result of gross scaling or not scaling to completion. On the other hand, pts that have ANUG may require a gross scaling accompanied by antibiotics to help reduce irritation of the gingival prior to SRP. To obtain the best outcome for the pt, we should attempt to scale to completion at every appt. It is our ethical duty and the pts right to receive the best treatment possible and that we try our best to remove all plaque and calculus.

In a standard periodontal treatment strategy with consecutive root planings per quadrant at a one- to two-week interval, re-infection of a disinfected area might occur before completion of the treatment. This study clinically and microbiologically examines whether a full-mouth disinfection within 24 hours significantly improves the outcome of periodontal treatment. While the one-stage full-mouth disinfection resulted in a mean pocket reduction from 7.3 to 4.0 mm, the control group had a reduction of only from 7.4 to 4.9 mm. It takes several months before microbiological differences result in clinically detectable changes. The one-stage full-mouth disinfection showed significant clinical (pocket reduction) and microbiological (shift toward a more beneficial flora) advantages on a short-term basis.

Quirynen, M., Bollen, C. M., Vandekerckhove, B. N., Dekeyser, C., Papaioannou, W., & Eyssen, H. (1995, August). Full- vs. partial-mouth disinfection in the treatment of periodontal infections: Short-term clinical and microbiological observations. Journal of Dental Research, 74(8), 1459-1467.

Periodontitis occurs when inflammation or infection of the gums is untreated or treatment is delayed. Infection and inflammation spreads from the gums to the ligaments and bone that support the teeth. Loss of support causes the teeth to become loose and eventually fall out. Periodontitis is the primary cause of tooth loss in adults. This disorder is uncommon in childhood but increases during adolescence. Plaque and tartar accumulate at the base of the teeth. Inflammation causes a pocket to develop between the gums and the teeth, which fills with plaque and tartar. Soft tissue swelling traps the plaque in the pocket. Continued inflammation eventually causes destruction of the tissues and bone surrounding the tooth. Because plaque contains bacteria, infection is likely and an infection may also develop, which increases the rate of bone destruction. The goal of treatment is to reduce inflammation, eliminate pockets if present, and address any underlying causes. Dental irritants, such as rough surfaces of teeth or dental appliances, should be repaired. General illness or other conditions should be treated.
It is important to have the teeth cleaned thoroughly. This may involve use of various instruments or devices to loosen and remove deposits from the teeth. Incomplete scaling causes more problems later.
Canakci,C., and Cankci, V. (2007). Pain experienced by patients undergoing different periodontal therapies. The Journal of the American Dental Association. 138 (12) 1563-1573.
The American Academy of Periodontology. (2001) Treatment of Plaque-Induced Gingivitis, Chronic Periodontitis, and Other Clinical Conditions. Journal of Periodontology. 72:1790-1800

The only time when gross scaling is recommended is when treating ANUG/ANUP. The use of antibiotics is also part of these gross scaling treatment when treating ANUG/ANUP. The down side of gross scaling when ANUG/ANUP is not present may lead to a periodontal infection, so the practice of gross scaling is not recommended.
How often a furcation gets infected when incomplete scaling is performed?
The American Academy of Periodontology (2003). Periodontal maintenance. Journal of Periodontology, 74, 1395-1401.
Chapper, A., Catao, V., Oppermann, R., (2009). American dental hygienist’s association on polishing procedures. American Dental Hygiene Association. Retrieved on May 28th, from

Gross scaling was once used because calculus was thought to be a mechanical irritant rather than a bacterial infection. Before quadrant scaling hygienist would do a full mouth scale but not go to the base of the pocket, the next appointment they would continue even deeper, and continue to move down wards until the full mouth was complete. Now we know that calculus cause a bacterial infection and needs to be completely removed. If the calculus is not completely removed the tissue around the piece will heal enclosing the calculus and cause an abscess, also the tissue will tighten making it harder to access the calculus in the pocket. A periodontal abscess can occur within three to six day. After scientific evidence reveled that quadrant scaling to completion has a better result we now use the term gross debridment for the removal of supra and supra only calculus to allow for assessments of the patients oral health. Gross debriment can also be used for a patient with NUG or NUP.

Perry, D., Beemsterboer,P. 2007. Periodontology for the dental hygienist. Saunders (2) Drina:
It seems as though incomplete scaling can have a negative effect on the gingival tissue because the calculus that is left behind can cause gingival inflammation and attachment loss. There is research that shows that no matter how skilled the clinician there is always burnished calculus that is left behind so scaling to completion is not really met. The only true way to remove calculus especially in furcation areas is by periodontal surgery.
Pattison, A.M., & Pattison, G.L. (2003, April/May). Periodontal instrumentation transformed. Dimensions of Dental Hygiene; 1(2): 18-20,22.
Quirynen, M., Bollen, C. M., Vandekerckhove, B. N., Dekeyser, C., Papaioannou, W., & Eyssen, H. (1995, August). Full- vs. partial-mouth disinfection in the treatment of periodontal infections: Short-term clinical and microbiological observations. Journal of Dental Research, 74(8), 1459-1467.
Outcomes of Incomplete Scaling & Gross scaling versus Scaling to Completion - Stacy
Incomplete scaling and gross scaling are the same thing. It is a supragingival removal of hard deposits. This gross scaling is not considered to be appropriate treatment for patients. Because deposits have been removed, some healing does occur. Unfortunately, healing occurs over unremoved subgingival deposits which will eventually lead to bony defects. Gross scaling is only beneficial when the calculus build up is so intense that it makes diagnosing difficult. Therefore, a gross scale would remove enough calculus to allow for diagnosis and a treatment plan to remove remaining calculus would be implemented. It has been discussed that gross scaling is not appropriate and rather than a full mouth gross scale, a half mouth complete scale would be far more beneficial for the patient. This would prevent healing over unremoved subgingival calculus deposits.
Takei, N. & Carranza, K. (2006). Scaling and root planing. In J. Dolan, J. Pendill & J. Dedeke (Eds.), Carranza's Clinical Periodontalogy (pp.774-788). Elsevier Inc.
Tekaves, C. (2005). What is debridement. Dental Economics. Retreived May 15, 2009 from: