Protected: 101. Principles of Periodontal Surgery

Tonetti MS, Steffen P, et al. Initial extractions and tooth loss during supportive care in a periodontal population seeking comprehensive care. J Clin Periodontol 27:824-831, 2000.

Ramfjord SP, et al. Oral hygiene and maintenance of periodontal support. J Periodontol 53:26-30, 1982.

Becker W, Berg L, Becker B. The long-term evaluation of periodontal treatment and maintenance in 95 patients. Int J Perio Rest Dent 4(2):54-71, 1984.

Lindhe J, Nyman S : Long-term maintenance of patients treated for advanced periodontal disease. J. Clin. Periodontol. 11:504-514, 1984.

Rosling B, Serino G, et al. Longitudinal periodontal tissue alterations during supportive therapy. J Clin Periodontol 2001; 28:241-249.

Teles RP, Patel M, Socransky SS, Haffajee AD. Disease progression in periodontally healthy and maintenance subjects. J Periodontol. 2008 May;79(5):784-94.

Muzzi L, Nieri M, Cattabriga M, Rotundo R, Cairo F, Pini Prato GP. The potential prognostic value of some periodontal factors for tooth loss: a retrospective multilevel analysis on periodontal patients treated and maintained over 10 years. J Periodontol. 2006 Dec;77(12):2084-9.

Listgarten MA, et al: Clinical and microbiological characteristics of treated periodontitis patients on maintenance care. J. Periodontol. 60:452-459, 1989.

Pontoriero R, et al : The angular bony defect in the maintenance of the periodontal patient. J. Clin. Periodontol. 15:200-204, 1988.

Lindhe J, et al: Long-term effect of surgical/non-surgical treatment of periodontal disease. J. Clin. Periodontol. 11:448-458, 1984.

Slots J, Jorgensen MG. Efficient antimicrobial treatment in periodontal maintenance care. JADA 131:1293-1304, 2000.

Matuliene G, Pjetursson BE, Salvi GE, Schmidlin K, Brägger U, Zwahlen M, Lang NP.Influence of residual pockets on progression of periodontitis and tooth loss: results after 11 years of maintenance. J Clin Periodontol. 2008 Aug;35(8):685-95

Position Paper: Supportive Periodontal Therapy (SPT). J Periodontol 69:502-506, 1998. (Review)

Discuss the reported level of patient compliance with maintenance recommendations and its implications for periodontal practice? How important is compliance for prognosis of teeth?

Wilson TG, Glover ME, Schoen J, Baus C, Jacobs. Compliance with maintenance therapy in a private periodontal practice. J. Periodontol. 55:468-473, 1984.

Wilson Jr. T, Hale S, Temple R. The results of efforts to improve compliance with supportive periodontal treatment in a private practice. J Periodontol 1993; 64: 311-314.

Novaes A, Novaes A Jr, Moraes N, Campos G, Grisi M. Compliance with supportive periodontal therapy. J Periodontol 1996; 67: 478-485.

Miyamoto T, Kumagai T, Jones JA, Van Dyke TE, Nunn ME. Compliance as a prognostic indicator: retrospective study of 505 patients treated and maintained for 15 years. J Periodontol. Feb;77(2):223-32. 2006.

Miyamoto T, Kumagai T, Lang MS, Nunn ME. Compliance as a prognostic indicator. II. Impact of patient’s compliance to the individual tooth survival.J Periodontol. 2010 Sep;81(9):1280-8

König J, Plagmann HC, Rühling A, Kocher T.Tooth loss and pocket probing depths in compliant periodontally treated patients: a retrospective analysis.J Clin Periodontol. 2002 Dec;29(12):1092-100.

What are the effects of maintenance therapy on wound healing?

Yumet JA, Polson AM. Gingival wound healing in the presence of plaque induced inflammation. J. Periodontol. 56:107-119, 1985.

Westfelt E, Nyman S, Socransky S, Lindhe J. Significance of frequency of professional tooth cleaning for healing following periodontal surgery. J. Clin. Periodontol. 10:148-156, 1983.

What happens if treated patients are not maintained?

Becker W, Becker B, Berg L. Periodontal treatment without maintenance – A retrospective study in 44 patients. J Periodontol 55:505-509, 1984.

Becker BC, Karp CL, Becker W, Berg L. Personality differences and stressful life events. Differences between treated periodontal patients with and without maintenance. J. Clin. Periodontol. 15:49-52, 1988.

Is there a difference in treatment results if maintenance is done in general dentists offices?

Axelsson P, Lindhe J. The significance of maintenance care in the treatment of periodontal disease. J. Clin. Periodontol. 8:281-294, 1981.

Johansson LA, Oster R, Hamp SE. Evaluation of cause-related periodontal therapy and compliance with maintenance care recommendations. J Clin Periodontol 11:689-699, 1984.

Kerr NW. Treatment of chronic periodontitis- 45% failure rate after 5 years. Brit Dent J 150:222-224, 1981.

McFall WT, Bader JD, Rozier RG, et al. Clinical periodontal status of regularly attending patients in general dental practices. J. Periodontol. 60:145-150, 1989.

Fardal Ø. Interviews and assessments of returning non-compliant periodontal maintenance patients. J Clin Periodontol. 2006 Mar;33(3):216-20.

What is the ideal MT frequency after periodontal treatment ?

Mousques T, Listgarten MA, Phillips R. Effect of scaling and root planing on the composition of the human subgingival microbial flora. J Perio Res 15:144-151,1980.

Sbordone L, Ramaglia L, Gulletta E, Iacono V. Recolonization of the subgingival microflora after scaling and root planing in human periodontitis. J Periodontol. 1990 Sep;61(9):579-84.

Listgarten MA, et al: Comparative longitudinal study of two methods of scheduling maintenance visits; 4-year data. J. Clin. Periodontol. 16:105-115, 1989.

Rosen B, Olavi G, et al. Effect of different frequencies of preventive maintenance treatment on periodontal conditions. J Clin Periodontol 26:225-233, 1999.

Shiloah J, Patters MR. Repopulation of periodontal pockets by microbial pathogens in the absence of supportive therapy. J Periodontol 1995; 67: 130-139

What causes failure of treatment? When would you consider retreatment for a patient? How often do we need to retreat patients for periodontitis?

Chace R. Retreatment in periodontal practice. J Periodontol 48:410, 1977. (Review)

Rateitschak KH.Failure of periodontal treatment. Quintessence Int. 1994 Jul;25(7):449-57.

Fardal and Linden. Re-treatment profiles during long-term maintenance therapy in a periodontal practice in Norway.J Clin Perio 2005; 32:744-749

Morrison EC, Ramfjord SP, et al: The significance of gingivitis during the maintenance phase of periodontal therapy. J Periodontol 53:31-34, 1982.

What is “Refractory Periodontitis” and how can it be managed?

Jenkins WM, Said SH, Radvar M, Kinane DF. Effect of subgingival scaling during supportive therapy. J Clin Periodontol 27:590-596, 2000.

Haffajee AD, Uzel NG, Arguello EI, Torresyap G, Guerrero DM, Socransky SS. Clinical and microbiological changes associated with the use of combined antimicrobial therapies to treat “refractory” periodontitis.J Clin Periodontol. 2004 Oct;31(10):869-77.

Why is maintenance therapy necessary? What is performed at these visits?

Schallhorn 1981 NO ARTICLE

P: To discuss the different aspects of prevention programs and to give the time frame of a typical maintenance visit.

D:PREVENTATIVE PERIODONTAL MAINTENANCE prevents inception of periodontal disease in individuals without periodontal disease.

TRIAL PERIODONTAL MAINTENANCE maintains borderline cases.

COMPROMISE PERIODONTAL MAINTENANCE is designed to slow the progression of periodontal disease in individuals who for what ever reason do not undergo surgical or nonsurgical therapy.

POSTTREATMENT PERIODONTAL MAINTENANCE to prevent re occurrence of periodontal disease in patients that have undergone active therapy.

Maintenance intervals should be individualized.

Factors: nature and extent of periodontal problem, type of therapy performed, effectiveness and frequency of plaque control, rate of calculus formation, systemic health, BOP.

The article outlines the components of an average maintenance appointment as performed by the dental hygienist (total under 1 hour). Greeting and health/dental history 8.5 minutes, Dental screening (extraoral and intraoral exam) 1.12 min., Periodontal assessment (BOP, PD, REC, fremitus, color/ architecture of gingiva),3.25 min., Plaque index 3.0 min., Oral hygiene inst. 4.20 min., Polish/Floss 10.9 min., SC/RP 10.9 min., Ultrasonics 6.83 min., Caries assessment 1.0 min., Chemical therapy (irrigation with antimicrobial agents) 1.50 min., Fluoride 1.0 min, Dismissal 1.0 min.

Patients vary with respect to number of teeth present, PDs, amount of calculus and staining and other considerations influencing the time required for therapy. Appointments should be individualized for the patient with either shorter or longer time allocations as appropriate for adequate therapy.

If the patient’s condition is stable with lack of inflammation, minimal calculus deposits and optimal plaque control, the interval can be extended between maintenance visits. If there are adverse findings the interval should be shortened until the optimal recall time for the patient is determined.

Ramfjord 1987 ARTICLE

P:Review of current literature with clinical observations to evaluate maintenance care

Caton 1982 showed that initial gross clinical results of therapeutic procedures are established 4-6 wks after completion of therapy, although changes can be observed 6-9 months after completion of treatment.
Maintenance appointments should include prophylaxis of all teeth, OHI and fluoride. Maintenance should be scheduled every 3-4 months(although post surgical, recommend professional plaque removal once/wk for first month then 3 month maintenance).
Pts with better plaque control will have better surgical results, but once they have healed, maintenance results are similar regardless of OH (Ramfjord 1982) as long as pts have professional tooth cleaning every 3 months.
Pocket depth after treatment may not be the most critical determinant for prognosis.
Retreatment is often necessary to remove residual accretion of calculus and the treatment of new active lesions (bleeding or suppuration). These areas should be re-evaluated after 2-3 weeks to retest and decide if more SRP or surgery is needed.
Maintenance visits should also be used to monitor sensitivity, caries, pulpal status, evaluate old restorations and check occlusion.

BL: Maintenance should be completed every 3 months.

Echeverria1996 ARTICLE

P: This review addresses the most significant questions regarding supportive (maintenance) care after active periodontal treatment: the effectiveness and ideal frequency of maintenance appointments, the adequacy of the supportive therapy according to pt needs, the possible alternatives to currently accepted protocols, and the relative value of personal in the overall context of supportive care.

Disc: Periodontal diseases are infections with a high potential for recurrence, progressive loss and eventually, tooth loss. Current treatmentsfor periodontal diseases are highly predictable in arresting disease activity. Supportive periodontal care has been shown to be very effective in maintaining support when adapted to each particular case. Nevertheless, current maintenance therapies may be unsuccessful in preventing further ALoss in a smallnumber of sites for some patients. Tests aiming at bacterial identification and the subgingival application of antimicrobials may be helpful in the management of such cases, however the practical value in a specific setting is not known. There is growing evidence of the fundamental role of personal in supportive periodontal care. Careful consideration of the pt’s personal risk factors relating to the development of further disease is essential in the long-term management of the periodontal pt after the completion of active tx.

BL: In cases with rapid and severe periodontal destruction and where local and/or systemic risk factors are present, personal becomes a key factor in the long-term preservation of periodontal support.

Tonneti 2000 ARTICLE

Purpose: To describe 1) the prevalence of tooth loss and 2) the dental pathologies associated with extraction during active periodontal therapy and in the subsequent supportive periodontal care (SPC) period in a periodontal population who received comprehensive care at a University clinic and was maintained in an individualized recall program.

Materials and methods:Retrospective longitudinal survey of tooth extraction during active periodontal therapy tooth loss during the following SPC interval at University of Bern. Number of teeth present was determined at three time points: the initial consultation, the first SPC apt following active treatment and the latest clinical session of SPC. Clinical diagnosis according to ADA case type was retrospectively performed. Consecutive patients presenting for SPC between January and April 1995 were invited to participate in the study. 270 patients, 58% females between 16-1 years of age were included. The had completed active periodontal therapy 6 months previously, the did not have a contributory medical history and the clinical records were available. Whenever surgery was performed it did not include osseous recontouring. Each tooth that was extracted was classified as having one of the following pathologies: periodontal disease, caries, endodontic problems, technical failures (e.g. root fractures) or unknown. If teeth were used as abutments or had furc involvement was also recorded. Smoking status and radiographic bone loss were also assessed.

Results: Patients remained in an SPC program for 67+/- 46 months. 39.6% were current smokers and 27.8% previous smokers. 6.2% had gingivitis, 20.5% mild, 48.4% moderate and 24.9% severe periodontitis. Average frequency of the recall visits was 4.4+/- 1.5 apts/year.

Pts presented with 6503 teeth at their initial examination and 5929 at the recall. 574 were extracted totally, 311 (4.8% of total teeth, 1.1 extractions/patient but performed in 46% of patients) during the initial phase of treatment and 263 (4.2% of teeth present after completion of active treatment) during the recall period. 15.7% were 3^rd molars and 1.9% retained primary teeth.

299 were maxillary teeth (106 molars, 47 multi-rooted upper premolars) and 175 mandibular (79 molars).

Pathologies associated with tooth extraction:

In the initial phase extractions that were associated with periodontal disease only were 63% and during recall 50%.

The teeth extracted with periodontal disease as the only pathology had an average radiographic bone loss of 56%. 62% in single rooted teeth and 49% in multi rooted teeth.

Caries, endodontic, and technical problems represented the leading pathology associated with gingivitis and mild periodontitis patients. Severe periodontal disease alone or in combination with other problems was present in 76-94% of initial extractions in moderate and severe periodontitis cases respectively.

During recall the incidence tooth loss/year was 0.17+/-0.31 teeth. During this period 41% of subjects had extractions, number of teeth that was extracted amounted to 2.35+/- 1.9 teeth/patient in this population and 0.4+/-0.37 teeth/year. The % of teeth that were extracted because of technical problems increased from 14% during initial phase to 27% during recall visits. During maintenance visits, 45% of patients presenting with moderate periodontitis at baseline had extractions and 48% of patients that had severe periodontitis had extractions. 86% of extraction in severe periodontitis patients were extracted because of periodontal reasons alone or in combination with other etiologies. In moderate periodontitis teeth extracted for this reason were 60%.

Conclusion: 8.8% of teeth present at baseline were extracted either during active therapy or in the subsequent SPC period. 4.2% of teeth were extracted during SPC and this suggests that initial extractions should be taken into account to compare the overall impact of comprehensive therapy on tooth loss.

Advanced periodontitis was associated with the majority of teeth that were extracted and was the only obvious pathology in 57% of the cases.

Tooth extractions were experienced by specific sub-populations and a minority of cases accounted for the majority of extractions.

Ramjford 1982 ARTICLE

Purpose: To evaluate if PD and AL gained by therapy can be maintained despite variations in levels of OH while on 3 months maintenance.

Materials and methods:

78 patients previously treated and on 3 month recall over 8 years.
PD and AL related to plaque scores above and below the median were assessed. 25% of sample having lowest plaque score was compared with 25% of sample with the highest plaque score over 6-8 years of maintenance.
All pts were given repeated instruction and motivation to improve their OH.

Results:

Plaque score was not critical for maintenance of posttreatment PD and AL in patients with professional prophylaxis every 3 months.
Initially OH had an effect (the better the OH, the better the results for 4-5 years) on PD and AL, but their effect did not hold long term.
Although initial post-tx gain of AL appears highly related to the degree of OH, the long-term results were not dependent on plaque scores.

BL: AL and PD 1 year after therapy can be maintained over 6-8 years with maintenance every 3 months, regardless of unavoidable variations in the effectiveness of the patient’s plaque control.

Becker 1984 ARTICLE

P: A retrospective study to evaluate the clinical results of periodontal therapy and maintenance.

M&M: 95 diagnosed, treated and maintained perio patients (ages 25-74) in a private practice (average length of tx was 6.5 yrs). Each patient had minimum of 2 exams, excluding 3^rd molars. Clinical exam included PD, GM, furcations, and FMX. On the basis of clinical and radiographic findings, teeth were given a questionable prognosis (bone loss 50% of root length, PD 6-8mm, Class II Furcation) or hopeless prognosis (bone loss over 75%, PD 8-10mm or more, Class III furcation). All teeth not questionable or hopeless were given a good prognosis. Bone scores were determined using the Bjorn bone score. Tx included OHI, 1-3 sessions of SRP, occlusal adjustment, and pocket reduction surgery. All pts were placed on 3-4month recall.

6.21% of the total teeth were lost (150/2414) or 0.24 teeth per pt. per year(w/o hopeless teeth corrected to 0.11).
The maxillary second molars lost most often. Canines and mandibular incisors were lost least often.
Mortality based on prognosis, 87 of 102 (85%) given a hopeless prognosis were lost, thus 87/150 (58%) of the lost teeth were hopeless teeth.
Only 1.7% of teeth w/ good prognosis were lost.
22% of molars with no furcations had furcations by the last exam.
55% of the pockets 4-6mm at the first exam were in the 1-3mm range at the second exam
Over 50% had no changes in bone score.
Maintenance interval average was 5.2 mos. They had a 22% drop out rate.

BL:Perio Tx and maintenance are successful in reducing mod to deep pockets with minimal long term bone loss.

Lindhe 1984 ARTICLE

PURPOSE: To evaluate the perio condition of pts who had undergone treatment for advanced periodontitis and were well maintained for 14 years.

M&M: 61 of the 75 original patients treated in 1969 for advanced perio dz. All patients had received treatment consisting of OHI, SRP, Sx (pocket elimination) and then 3-6 month recall interval. Once a year plaque, GI, PD, AL and alveolar bone height were examined. This was evaluated at 1, 3, 5, 8, 10, 12, and 14 years after the completion of active therapy.

RESULTS: Prior to txt, 76% of sites examined had PD>4 mm, with 47% having PD >6 mm. Initial therapy reduced GI and improved plaque control, which was maintained over the life of this study. 92-99% of sites remained <4mm over 14 yrs. <1% developed PD >6 mm over 14 yr period. Individual mean values describing PD, AL and bone heights did not significantly vary over the 14 years; however, a small number of sites in a few pts lost substantial attachment. 0.8% of sites lost >2 mm of attachment over 14 yrs. During the entire treatment course, 30 teeth were lost out of 1330 (2.3%) from all 61 pts. Looking at individual data, 16 teeth were lost from 7 pts.

BL:Tx of advanced forms of periodontal disease can be maintained over a period of 14 years. Recurrent disease in well-maintained pts is a site-specific disorder which evidently develops and progresses in a few unpredictable sites and is not a generalized phenomenon

Rosling 2001 ARTICLE attachment loss

P:To evaluate disease progression in “normal” susceptibility patients (NSG) and “high” susceptibility patients (HSG) to periodontitis during SPT.

M&M: HSG : 109 patients, NSG: 232 patients. All received 4-6 one hr sessions of S/RP, followed by 3-4x/year recalls. If BOP or PD>5mm noted at recall, site was re-treated. Teeth that presented with abscess or unresolved mob were extracted. The following clinical parameters measured at baseline (1 year after S/RP) and 12 years: # of teeth, PPD, PAL, RA bone level (standardized).

R:NSG: most subjects maintained their perio condition unchangedduring the MT period; only a few subjects experienced small amount of bone and ALoss (0.5 mm and 0.3 mm respectively). HSG: patients lost significant amounts of bone and attachment during the 12 years of SPT. Thus, in this group of subjects, the mean overall PAL loss amounted to 0.8 mm (0.06 mm/tooth surface/year). In the NSG, the overall ALoss was significantly smaller: 0.5 mm (0.04 mm/tooth surface/year). The subjects in the NG lost 0.3 teeth during the 12 years interval while the corresponding loss in the HSG was 1.9 (0.8 non-molar and 1.1 molar teeth). 20% of the HSG patients and 3% in the NG were exited of the study after 3-5y of SPT due disease progression.

BL:In patients with a high susceptibility for perio disease it is possible to maintain bone and Attach Levels at a reasonably stable level over a 12-year period after no-sx therapy. SPT in pts with normal susceptibility to perio disease, prevented almost entirely major tooth, bone and attach loss. Some patients and sites could be identified that responded poorly to therapy despite good plaque control and regular recall appointments.

Teles 2008 ARTICLE

P:To determine whether the rate of attachment loss in periodontally healthy subjects in a prevention regimen would differ from the rate of disease progression in periodontitis subjects in a maintenance program.

M&M:55 periodontally healthy patients and 57 periodontitis patients were clinically and microbiologically monitored at baseline and at 1, 2, and 3 years. Parameters measured included BOP, plaque, PD, and AL. Periodontally healthy and maintenance groups received SPT every 6 and 3-6 months respectively. Subgingival plaque samples were taken from the MB aspect of every tooth and were measured by checkerboard DNA/DNA hybridization. No subgingival treatment was carried out within 3 months prior to the annual examinations.

R:Clinical parameters for both groups improved over time. 4% of the sites in the periodontitis patients lost ≥2 mm of attachment. Only 1% of the healthy periodontal patients lost ≥2 mm of attachment. Maintenance group lost 0.12 teeth/subject/year, whereas the prophylaxis group lost 0.02 teeth/subject/year over 3 years of study. At baseline, the maintenance subjects showed SS higher levels of red complex species compared to prophylaxis subjects. By year 2, both groups demonstrated reductions in the mean levels of most species.

BL:Treated periodontitis patients under maintenance displayed more rapid attachment loss than periodontally healthy subjects in a preventive regimen. This may be related to an elevated exposure to periodontal pathogens in the red complex.

Muzzi 2006 ARTICLE

P:To evaluate the value of some clinical, genetic, and radiographic variables in predicting tooth loss in periodontal patients treated and maintained for 10 years.

M&M:retrospective analysis, 60 (29M/31F) healthy, mean age 46.77 years, non-smoking patients, all 40-60 years of age and of white heritage (study from Italy) with moderate to severe periodontitis, treated in private practice with SRP and surgery per need (MWF or Osseous), and all received maintenance for 10 years. Probing depths, number of teeth, prosthetic restorations recorded. CEJ- to root apex, CEJ- to bottom of defect, CEJ- to bone crest, bone crest to bottom of defect, and bottom of defect to root apex (residual supporting bone) all were measured from radiographs. IL-1 genotypes were recorded.

R:two-level variance analysis for both patient level prognostic variables and tooth level prognostic variables.

SS prognostic relationship was found for molar teeth (positive correlation). Molar teeth were found more prone to loss. Bottom of defect to root apex distance was associated with tooth loss. The lower the amount of residual supporting bone, the greater the probability of losing the tooth. Bone crest to bottom of the defect distance was associated with tooth loss (negative correlation). The greater the distance the lower the probability of losing the tooth. Deep infrabony defects tend to respond better to regenerative procedures. Tooth mobility, PDs, presence or restorations and CEJ-bottom of defect were not found predictive for tooth loss.

C:Molar teeth, infrabony component of the defect and residual supporting bone may be considered prognostic factors for tooth loss.

Listgarten 1989 ARTICLE

P:To determine whether the presence of Aa, Pg, Pi in selected periodontal sites can predict future disease recurrence.

M+M:98 adults (>25 years old) with moderate to advanced periodontal disease that had been treated surgically and in maintenance programs for at least 1 year (75% over 5 yrs) were evaluated for PI, GI, PD, AL and microbiological analysis with paper points from sites with greatest PD in each sextant. A site was considered infected and positive for Aa, Pg, or Pi, if the above mentioned microbes were found at levels of > 0.01% for Aa, 0.1% for Pg, and 2.5% for Pi.

PI scores were higher for molars than the rest of the teeth.
GI was uniform throughout the dentition.
PD tended to be greater for the M/D than the B/L surfaces with a bilateral symmetrical pattern, PD increased from midline to posterior.
Sites positive for Aa, Pg, and Pi tended to have greater PD (mean: 4.14mm) than non-infected sites in the same pts (mean: 3.76).

BL:There was a positive correlation between Aa, Pg, Pi, Capnocytophaga and increased AL loss, as well as greater GI and PD.

CR:While it does somewhat correlate to disease activity, it is not enough to rationalize its routine use, especially in maintenance pts.

Pontoriero 1988 ARTICLE

P:To evaluate some long-term alterations of the alveolar bone level at sites with angular & horizontal bone loss.

M&M:48 patients were treated for advanced perio disease and then placed on SPT with recalls q 3-6 months for 5-16 years. 100 teeth with angular defects that could be detected after active treatment phase were included. A comparison was made between post-tx radiographs to current radiographs. Contralateral or neighboring teeth with horizontal bone loss used as controls. The following measurements were taken and measured with the Bjorn technique at 2x:

1.distance between base of defects & apex (B-A)

2.distance between alveolar crest & base of defect (C-B)

3.Distance between crest & apex on control teeth.

R: Current measurements (5-16 years post-active tx):

1.B-A distant remained unchanged.

2.The average C-B distance decrease from 1.41 bone scoring units (BSU) to 1.07 BSU. 12% of the sites showed ~ 0.7 to 2.0 mm apical shift in this distance (possibly downhill patients).

3.Distance from crest to apex remained almost unchanged in controls.

BL:The presence of angular bony defect after active treatment does not make a site more prone to additional bone loss in well-maintained patients. After perio treatment, most sites with angular or horizontal patterns of AB loss underwent none, or very little additional bone loss after 5-16 years of SPT.

Crit:Non-standardized radiographs. Authors do not describe what active perio tx included. Where there attempts to eliminate the defects that were unsuccessful (osseous, GTR)? The distance between bone crest-base of defect initially was 1.4, which is not a very deep bony defect…

This study does not apply to pts that present with deep verticals defects.

Lindhe(2) 1984 ARTICLE plaque control

Purpose: 1) To further analyze the role played by the patients’ self performed plaque control in preventing recurrent periodontal disease and 2) TO assess the periodontal conditions of patients 5 years after completion of active treatment (SRP or SRP + MWF) with special emphasis on sites with initial PD>3mm.

Materials and methods:15 subjects 32-57 years old were selected. After baseline examination patients received SRP or SRP + MWF in a split mouth design and had follow-up for 24 months. After the 24-month examination, the recall appointments were extended to 4-6 months. Maintenance program was restricted to OHI and supra-g tooth cleaning (sub-g instrumentation was avoided) and at 26, 48 and 60 months after Tx the quality of patients’ plaque control was assessed. At 60 months a final examination was performed and included the same parameters as assessed at baseline. Data include 11/15 patients that took part in the entire 5-years study and represent baseline – 60-month changes as well as 24-60 months changes.

Results: Group I: patients that maintained an excellent standard of OH during the 5 -year period at each re-examination. Group II: patients who failed to maintain a proper standard of OH at each re-examination.

24-60 months: AL remained unchanged in 86-88% of the sites. 2% gained 2mm or more of attachment and 10-12% exhibited attachment loss of 2mm or more. Attachment loss was more prevalent in interproximal surfaces. In Group I 2-3% of sites had attachment loss and 95% of istes remained unchanged or gained attachment, in Group II no sites had attachment gain and 20% had attachment loss.

Baseline-60-months in sites with PD>3mm at baseline: 55-65% showed PD reduction. 1-2% showed increase in PD. 85% in of sites with 4mm or more PD in Group I were reduced in depth, in the majority more than 2mm. Such a reduction of the PD was less prevalent in Group II. In Group II 60% of sites remained unaltered.

For sites with PD of 4mm or more, more sites lost attachment in the patients in Group II (20% and 6% vs 7% and 2%). Gain of attachment occurred more frequently in the patients of subgroup I.

24-60 months for PD>3mm at 24 month re-eval: 75-85% of PDs and 85% of AL remained unchanged. Reduction in PD and AL gain occurred mainly in patients in Group I while further increase in PD was found mainly in patients in Group II.

It is likely that attachment level gain is the result of reduction of inflammatory infiltrate after treatment and increase in collagen.

Conclusion: Patients’ standard of OH had a decisive influence on the long – term result of treatment of periodontal disease.

Sites with an initial PD exceeding 3mm responded equally well to the non-surgical as to the surgical mode of treatment.

Slots 2000 ARTICLE

Purpose:To outline the current approaches to follow-up care after initial (“definitive”) perio tx and advance a suitable protocol for perio maintenance care.

Discussion:

Preventive periodontal therapy can be categorized as primary, secondary or tertiary. Primary prevention aims to reduce risk factors before clinical presentation of disease and can be accomplished by intervention strategies aimed at both the general public and special, high-risk populations.
The aim of secondary prevention is to intervene at early disease or precursor
Tertiary prevention seeks to limit the impact of established disease.
Perio exam should include full-mouth probing, with PD, BOP, AL, PI, plaque score. Calculus removal using hand instruments or ultrasonic. Recommend using 10% povidone-iodine diluted 1:9 with water for irrigant in the ultrasonic. After ultrasonic use air-polishing device on each tooth for 5 sec. OHI is given to the pt along with any necessary prescription or rinses like CHX.
Mechanical and chemical antimicrobial intervention is the mainstay of preventive periodontal therapy. Chemotherapeutics alone are unlikely to be effective in the presence of subgingival calculus, subgingival mechanical debridement is very important.
Toothbrushing and rinsing alone do not reach pathogens residing in periodontal pockets of increased depths, oral hygiene procedures should include subgingival treatment with home irrigators or other appropriate self-care remedies.
Recall every 3 months in pts with ongoing perio destruction and microbial sampling may be needed. Pts with stable perio diagnosis can be scheduled for maintenance every 4 months.

Matuliene 2008 ARTICLE

P:To investigate the influence of residual PPD 5mm and BOP after active periodontal therapy (APT) on the progression of periodontitis and tooth loss.

M&M:Retrospective longitudinal study, 172 patients (95F/77M), 14-69 years of age were included in the study. Complete clinical periodontal (PD, REC, CAL, BOP, MOB, FURC) and radiographic examinations were performed (full mouth x-rays) at baseline, at the end of the active therapy and at re-evaluation. At re-eval the full mouth x-rays were replaced by panoramic x-rays. Periodontal therapy consisted of OHI, SRP and periodontal surgery if indicated. Prosthetic therapy using dental implants or fixed prosthesis was performed. Following completion of comprehensive periodontal treatment, patients were enrolled in SPT program. Re-eval was performed after a mean of 11.34.9 years of age. Smoking habits, health status and frequency of recalls during SPT were assessed. A case was defined as being progressive if there were at least 2 teeth with 3mm attachment loss at the end of APT and re-eval.

Number of residual PPD increased during SPT.
Increased PPD was associated with tooth loss. The increase by 1mm PPD increased the odds and therefore the probability of tooth loss in a statistically significant way.
Heavy smoking (, initial diagnosis (severe periodontitis), duration of SPT (>10years) and PD6mm were risk factors for disease progression.
PPD6mm and BOP 30% represented a risk for tooth loss.

C:Residual PPD 6mm after APT represented a risk factor for both progression of periodontitis and tooth loss during SPT.

Position Paper: Supportive Perio Therapy 1998 NO ARTICLE

P:To provide an overview of the role of SPT in the tx of perio dz

D:SPT includes an update of medical and dental hx, extraoral and intraoral soft tissue exam, dental exam, perio evaluation, rx review, removal of plaque and calculus from supra-g and sub-g regions, selective root planing if indicated, polishing of teeth, and a review of the pt’s plaque removal efficacy.

Tooth loss in some pts has been shown to be inversely proportional to the frequency of SPT. Ten years after perio therapy, pts who had received at least periodic SPT had SS decreased PD and tooth loss. Less CALoss has also been linked to frequency of SPT. Some individuals still may suffer CALoss despite maintaining a regular SPT schedule. Additional microbial analysis as well as anti-microbial therapy may be necessary for those individuals.

For pts without a history of periodontitis (simply gingivitis), SPT performed every 6 months is sufficient. Although there are several different opinions on how often perio pts should receive SPT, the data suggests that it should be performed at least every 3 months. Nevertheless, the frequency of SPT should be individualized. SPT may be performed by the dentist and/or periodontist depending on severity of the perio dz.

Discuss the reported level of patient compliance with maintenance recommendations and its implications for periodontal practice? How important is compliance for prognosis of teeth?

Wilson 1984 ARTICLE

P:To determine compliance of maintenance schedules recommended in a private periodontal practice.

M&M:961 patients with chronic periodontitis were divided based on the severity of disease. Procedure performed was either SC/RP, flap with osseous, or flap alone. During active therapy, the importance of recall was stressed to patients. After active therapy, all patients were placed on 3-month recall schedule and later modified as needed. 92% of the patients were on a 3- or 4-month recall interval. Compliance was classified as complete, erratic, or none based on the longest recall interval possible for each classification. Study period was 8 years.

R:Only 16% completely complied with recommended maintenance recall. Erratic compliance was found in 49% of patients, and 34% never reported for any maintenance therapy. Compliance decreased over time after active therapy. Patients who had periodontal surgery were in compliance slightly more often, and patients with mild disease kept their maintenance schedules the best. Patients with a poor prognosis had the worst record of all categories (higher proportion of non-compliant, and least completely compliant). The less often patients were required to return for maintenance, the better they complied.

BL:The vast majority of patients (84%) did not completely comply with maintenance recall. One third didn’t return after active therapy.

Wilson 1993 ARTICLE

Purpose:Comparison of a literature review on compliance improvement techniques and the results shown by implementing these techniques in a practice.

Methods: 604 patients were studied during the 5 yrs from which data were collected. Some patients were alternating maintenance with their general dentist office. Efforts to improve compliance included simplifying compliance, maintaining records of compliance, informing patients of the consequences of noncompliance, and attempting to identify non-compliers before active therapy was initiated. Also patients’ scheduling included accommodating patients’ schedules and post card reminders.

Results: Mean age 46 yrs (range 18-78). 32% were complete compliers. 48% were erratic. 20% were non-compliers. 44% were men. Noncompliance was highest in the 0-2 month group.

Conclusion: Non-compliance can be reduced if the problem is recognized and efforts are made to increase compliance.

Novaes 1996 ARTICLE

P:To present data from private periodontal practice records to analyze compliance according to age, sex, and type of therapy and to discuss about the need for an aggressive office routine to keep patients committed to supportive therapy.

M&M:Data was obtained from 1280 records of patients seen over a 20- year period in a private periodontal practice in Brazil. All patients had completed the proposed treatment including the procedures indicated. Cases were considered surgical if they received basic periodontal therapy followed by surgical intervention in at least 3 areas. Recall visits were scheduled with intervals 2-6 months. Those who fulfilled 2/3 of the appointments were considered regular (R) less than 2/3, irregular (I); and those who did not return for any appointments, noncompliant (N). Patients were classified according to age, sex, and type of therapy. The compliance and noncompliance groups were further subdivided according to age: <20, 21-40, 41-60, & > 60 years. The 854 patients who initially co-operated and then abandoned supportive periodontal therapy were analyzed according to sex and type of surgery.

25.2% were non-compliant and 74.8% returned for at least some appointments
Among those who returned, 40.1% returned regularly, 34.7% returned irregularly
Number of women who returned was greater than the number of men (76.5% vs 72.2%)
Patient ages 21-40 and 41-60 showed the greatest interest in supportive therapy
Proportion of surgical patients who returned for supportive therapy was significantly greater than non-surgical patients, however there was not SSD between surgical therapy and non-surgical therapy for regular compliance (40.5% vs 38.9%)
854 patients begun but did not continue with SPT (66.7%), more females than males (59.5% vs 40.5%), greater among surgical cases than non-surgical

C:The vast majority of patients did not comply w/ the recommended recall periods. The authors recommended an intense program of education and motivation for the 1^st year of therapy.

Miyamoto 2006 ARTICLE

P: To evaluate the impact of compliance (complete vs erratic) on common clinical parameters in a long term observation period (15-23 years).

M+M: A retrospective study of 505 patients over an observation period of 15-23 years. Patients were classified by two methods of classification:

Compliance 1 classification– pts attended at least 70% of all expected maintenance visits were considered complete compliers while those who failed >30% of maintenance visits were considered erratic

Compliance 2 classification– pts who attended most of their scheduled maintenance visits were considered complete compliers while those who failed to attend a maintenance visit for a minimum of 2 years were considered erratic

In both classification schemes, patients who did not respond to recommendations for maintenance therapy or disappeared completely during the active phase of treatment were designated as total non-compliers. Total non-compliers were excluded from this study.

The groups were evaluated for: Plaque index reduction vs. no reduction; bleeding index reduction vs no reduction; reduction in pockets >3 mm vs no reduction; no increase in DMFT vs increase; and no tooth loss vs tooth loss

R: Complete compliers tended to show a reduction in BOP and a reduction in plaque index compared to the other groups.

Complete compliers under compliance 2 were less likely to see a reduction in pockets

Protected: 51. Alveolar Bone: Normal Anatomy, Extraction socket healing, bone loss, osseous defects

There is no excerpt because this is a protected post.

132. Effects of Therapy:

a. Results of Non-Treatment

b. Evaluation of Therapy

HOME PERIO TOPICS

1. What are the consequences of non-treatment of periodontal disease? How fast does untreated periodontal disease progress?

BeckerW, Berg L, Becker BE: Untreated periodontal disease: a longitudinal study. J. Periodontol.50:234 -244, 1979.

BeckerW, Becker BE: Bone loss in untreated periodontal disease: a longitudinal study. Int J Perio Restor Dent1:25-33, 1981.

GoodsonJM, et al: Patterns of progression and regression of advanced destructive periodontal disease. J. Clin. Periodontol.9:472-481, 1982.

LindheJ, Haffajee AD, Socransky SS. Progression of periodontal disease in adult subjects in the absence of periodontal therapy. J. Clin. Periodontol. 10: 433-442, 1983.

LindheJ, Okamoto H, Yoneyama T, Haffajee A, Socransky SS: Longitudinal changes in periodontal disease in untreated subjects. J. Clin. Periodontol. 16:662-670, 1989.

JeffcoatMK, Reddy MS: Progression of probing attachment loss in adult periodontitis. J. Periodontol. 62:185-189, 1991.

MachteiEE, Norderyd J, Koch G, Dunford R, Grossi S, Genco RJ. The rate of periodontal attachment loss in subjects with established periodontitis. J Periodontol1993; 64:713-718.

PapapanouPN, Wennstrom JL. A 10-year retrospective study of periodontal disease progression. Clinical characteristics of subjects with pronounced and minimal disease development. J. Clin. Periodontol. 17:74-84, 1990.

2. Are patients doomed to lose all their teeth if they do not receive periodontal treatment? What is the rate of tooth loss with and without periodontal treatment?

HirschfeldL, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J. Periodontol. 49:225, 1978.

McFallWT: Tooth loss in 100 treated patients with periodontal disease. A long term study. J. Periodontol. 53:539-549, 1982.
GoldmanMJ,Ross IF,Goteiner D. Effect of periodontal therapy on patients maintained for 15 years or longer. A retrospective study. J Periodontol.1986 Jun;57(6):347-53.

McLeodD, Lainson P, Spivey J. The effectiveness of periodontal treatment as measured by tooth loss. JADA 1997; 128: 316-324.

HujoelPP, Leroux BG, Selipsky H, White BA. Non-surgical periodontal therapy and tooth loss. A cohort study. J Periodontol 71:736-742, 2000.

3. Do patients benefit from periodontal therapy? How effective are different treatment modalities in the short/long term? What are the most significant factors in the success of periodontal treatment?

LindheJ, Nyman S: The effect of plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health. A longitudinal study of periodontal therapy in cases of advanced disease. J. Clin. Periodontol. 2:67-79, 1975.

BaderstenA, Nilveus R, Egelberg J : 4-year observations of basic periodontal therapy. J. Clin. Periodontol.14:438-444, 1987.

RenvertS, et al: 5-year follow-up of periodontal intraosseous defects treated by root planing or flap surgery. J Clin Periodontol 17: 356 – 363, 1990.

RamfjordSP, et al. 4 modalities of periodontal treatment compared over 5 years. J. Clin. Periodontol.14:445-452, 1987.

BeckerW, Becker BE, Caffesse R, Kerry G, Ochsenbein C, Morrison E, Prichard J. A longitudinal study comparing scaling, osseous surgery, and modified Widman procedures: results after 5 years. J Periodontol. Dec;72(12):1675-84. 2001

KaldahlWB, Kalkwarf KL, Patil KD, Dyer JK, Bates RE: Evaluation of four modalities of periodontal therapy. J Periodontol. 59: 783 -793, 1988

HarrelSK, Nunn ME. Longitudinal comparison of the periodontal status of patients with moderate to severe periodontal disease receiving no treatment, non-surgical treatment, and surgical treatment utilizing individual sites for analysis. J Periodontol. 2001 Nov;72(11):1509-19.

Kaldahl WB, Kalkwarf KL, Patil KD. A review of longitudinal studies that compared periodontal therapies. J. Periodontol. 1993; 64: 243-253. (Review) – No need to abstract, Keep for Reference

WassermanB, Hirschfeld L. The relationship of initial clinical parameters to the long-term response in 112 cases of periodontal disease. J Clin Periodontol 15:38-42,1988.

HaffajeeAD, Dibart S, Kent Jr. RL, Socransky SS. Factors associated with different responses to periodontal therapy. J Clin Periodontol 22:628-636, 1995.

Van der Velden U, Abbas F, Armand S, Loos BG, Timmerman MF, Van der Weijden GA, Van Winkelhoff AJ, Winkel EG. Java project on periodontal diseases. The natural development of periodontitis: risk factors, risk predictors and risk determinants. J Clin Periodontol. 2006 Aug;33(8):540-8.

FisherS, Kells L, Picard JP, Gelskey SC, Singer DL, Lix L, Scott DA. Progression of periodontal disease in a maintenance population of smokers and non-smokers: a 3-year longitudinal study. J Periodontol. Mar;79(3):461-8. 2008

TelesRP, Patel M, Socransky SS, Haffajee AD. Disease progression in periodontally healthy and maintenance subjects. J Periodontol. May;79(5):784-94. 2008

4. What changes can we expect in the subgingival microbiota over time in untreated and treated periodontitis?

MacFarlaneTW, Jenkins WMM, et al. Longitudinal study of untreated periodontitis. II. Microbiological findings. J. Clin. Periodontol. 15:331-337, 1988.

RosenbergES, Evian CI, Listgarten MA : The composition of the subgingival microbiota after periodontal therapy. J. Periodontol. 52:435, 1981.

MombelliA, Nyman S, et al. Clinical and microbiological changes associated with an altered subgingival environment induced by periodontal pocket reduction. J Clin Periodontol 22:780-787,1995.

5. What changes can we expect in the maxillary sinus after periodontal therapy?

FalkH, Ericson S, Hugoson A: The effects of periodontal treatment on mucous membrane thickening in the maxillary sinus. J. Clin. Periodontol.13:217-222, 1986.

6. Are there differences in patient perception to different tx modalities?

KalkwarfK, Kaldahl W, Patit K. Patient preference regarding 4 types of periodontal therapy following 3 years of maintenance follow-up. J Clin Periodontal 1992; 19:788-793.

Abstracts

What are the consequences of non-treatment of periodontal disease? How fast does untreated periodontal disease progress?

Becker 1979 ARTICLE

P: To determine the rate teeth are lost in untreated periodontal patients.

M&M: 30 patients, 20-71 years old (16M/14F) who were referred to a private periodontal practice and decided not to undergo treatment were given at least two exams over a period of 18- 115 months. Mean time period was 3.72 years. Clinical parameters records: PD, REC, MOB. No reference points were used. Medical history forms were filled and missing teeth were recorded. FMX taken at each appointment, no standardized radiographs.

R: 10.6% of teeth lost between exams. One patient lost 25 teeth and was eliminated from the study. This brought the % of teeth lost down to 7.7. The adjusted mean annual tooth loss per patient was 0.61. Teeth with hopeless prognosis were excluded and this gave 0.36 teeth per pt/per yr. lost. Aside from the 3rds, mandibular 1^st and 2^ndmolars were the most frequently lost teeth and the max molars were slightly less frequently lost. Mandibular central incisors, laterals and canines appeared the most resistant to loss. Teeth which were lost between examinations had initial PDs significantly higher that the PDs of teeth present in the 2^nd examination. The greatest increase in PDs was on disto-lingual and mesio- lingual surfaces closely followed by the lingual surface. The buccal or facial surface had the smallest increase. Maxillary and mandibular molars had the highest mean annual PD increase followed by maxillary bicuspids and canines. A significant correlation existed between patient age and PD increase. No correlation between PD and MOB. Teeth that were lost between examinations had significantly greater mobility than teeth that were present at 2^nd examination. MOB remained the same in 50% of teeth and increased in 38 % of teeth. Mandibular 1^st molars and incisors had the greatest MOB. All patients showed radiographic bone loss, horizontal and vertical, this was greatest in the posterior segments. Diabetes and HTN showed no correlation to increase in PD or AL loss but smoking did.

BL: Untreated periodontal disease results in loss of .61 teeth per pt/per yr. If hopeless teeth are not included then the number decreased to .36 teeth per year. Mandibular anterior teeth were the most resistant to loss and maxillary and mandibular molars were the most commonly lost.

Becker 1981 ARTICLE

P: To evaluate bone score changes in untreated periodontitis.

M+M: 27 untreated patients (25-71 years old, 15 M, 12 F) with minimum of 2 exams, baseline and followup of 18-115 months. 54 sets of FMX, patient evaluated, long cone technique (with an attempt to duplicate angulation of initial exam); bone scores determined (similar to the Bjorn technique: scale constructed, 15 inches long, divided into 20 horizontal and vertical lines, photographed, reduced 8 times, then placed over the films to evaluate them, mesial and distal of all teeth evaluated, except 3^rd molars, bone scores read as % of bone present). The optimal bone score was considered to be 65 +/- 5 % of the total root length.

Mean bone scores on first exam was 49.5% (range 39 to 60%). Mean bone scores for second exam was 43.2% (range 35.4 to 53.4%).
A decrease in mean bone scores was seen for all 27 patients.
The distal surface had lower bone scores than the mesial surfaces.
The molars with the lowest initial bone scores (max molars lowest overall) and showed the greatest decrease between 1^st and 2^ndexams -19.8%, bicuspids- 10.6%, anteriors – 7.9%.
PDs seemed to parallel bone scores, however, the correlation was SS.
Progression varied from patient to patient and tended to be age related. Pts < 44 year had greater decrease in bone score than older group.

BL: Bone scores in pts with untreated periodontal disease decreased from the initial to the final exam. Distal surfaces had lower bone scores than mesial surfaces, and molars had the lowest initial and greatest change in bone scores between exams. Bone scores may be used to evaluate periodontal disease progression.

Goodson 1982 ARTICLE

P: To determine if a more reliable estimate of disease progression could be obtained by regression analysis of a series of measurements and if sites which were “breaking down” could be identified.

M&M: 22 patients (13-63 yo, 8 m, 14 f) with untreated perio disease with at least 20% of their PD >4 mm, were monitored by repeated monthly measurements of PD & AL at 2 sites per tooth, for 9.3-23 months.

R: 82.8% of sites remained unaltered. 5.7% became significantly deeper & 11.5% became significantly shallower (>2 mm). Among those sites in which the PD increased, approximately half exhibited a cyclic deepening followed by spontaneous recovery to their original depth. In 15 pts, sites were found which became significantly deeper while other sites within the same subject became significantly shallower. In 6 pts, 11-36% of their sites became significantly shallower and virtually no sites became significantly deeper. In general, deeper initial sites became deeper/shallower at a more rapid rate. No evidence of synchronization between sites within any individual oral cavity could be seen.

Disc: Diseased sites may undergo cycles of exacerbation & spontaneous remission. This suggests that at least some forms of disease may be characterized by cycles of bacterial attack followed by host response. Existence of pockets alone cannot substantiate the existence of active disease. Disease activity may be a transient phenomenon, which would be altogether missed by an inadequate frequency of monitoring.

BL: Periodontal disease is characterized by periods of exacerbation and remission as well as periods of inactivity. Disease activity may be missed by inadequate frequency of monitoring.

Lindhe 1983 ARTICLE

Purpose: To monitor the attachment level changes in a group of 64 adults over a 6-year period during which they were not subjected to periodontal therapy and to compare disease progression to that which occurred in a second group with initially more advanced destructive periodontal disease.

Materials and methods: 64 Swedish subjects between 16 and 64 years of age at initial examination. Subjects had at least 20 teeth and treated for caries and associated lesions once a year. Subjects were informed and accepted that periodontal disease would not be treated over a 6-year period. They had mild moderate bone and attachment loss.

20 male and 16 females Americans between 13-62 years of age with advanced periodontal disease were selected for comparison. This group did not receive periodontal treatment for a period of 1 year. Swedish group was examined at baseline and at 3 and 6 years. The American subjects were monitored more often but data from baseline and 1 year visits were used. Probing attachment level measurements were recorded.

Results: In the Swedish group in the first 3 years 3.9% of sites showed attachment loss of more than 2mm. No change was found in 35.1%. The overall mean attachment level change was -0.82 +/- 0.87mm. The proportions of sites which changed and the extent of change did not appear to be related to the initial attachment level.

Between 3 and 6 years 57.4% of sites showed no measurable change. The overall mean change was -0.45+/-0.84mm. The average loss was approximately half of loss observed in the first period.

During the 6 years, 11.6% showed additional AL of more than 2mm. 20% of sites showed no measurable attachment loss. The overall AL was -1.29+/-1.12mm.

2/3 of the sites that showed some attachment loss in the first 3 years, showed no AL in the next 3 years.

In the American group, 26% showed no measurable change, and the overall mean attachment change was 0.08+/-1.4mm. There appeared to be a relationship between the extent of attachment level change and initial attachment level (more pronounce decrease in sites with initially advance loss of attachment) but regression analysis did not support that.

Conclusion: Data do not support the hypothesis that periodontal disease in a given individual is a slowly progressive disorder, but rather imply that certain sites in some individuals are affected by progressive disease. Maximum loss in Swedish population was 7mm in 3 years and in American population 7mm in 1 year. Haffajee (1983) indicated that attachment loss of up to 5mm can occur with a 2-month period. The attachment loss in the Swedish population may have occurred within a short span of time during monitoring period.

Lindhe 1989 ARTICLE

Purpose: To report effect on periodontal tissue alterations occurring 1 and 2 yrs following baseline data collection without any type of treatment.

Materials and methods:

319 pts (age 20-79) were divided into 6 groups by age. Clinical measurements (BOP, PD, AL, recession, missing teeth, PI, GI) were taken at baseline, 12 mo. and 24 mo, with no OHI or tx rendered.
Mean values for subjects in each age group were computed. 57 pts dropped out of the study.
Those who returned for both 1 and 2 yr exams were identified as respondents vs. those who came only to one re-exam (either 1 or 2 yrs) were identified as non-respondents.

Results:

Mean values describing gingivitis and periodontitis tended to increase with age. 82 teeth were lost in 53 subjects. 26/82 (32%) teeth extracted were due to periodontal dx and 62% were in the oldest age group.
PI and GI decreased in all groups over the 2 yr even though no OH was discussed with patient; however, within each age group was a subgroup that had failing OH.
PD increased slightly in all groups over the two years, with most pronounced deepening in the oldest age group (60-79). Mean PAL had no sig variation.

Conclusion: Pts with untxted perio dx fail to show a marked deterioration with 2 yrs of monitoring. Rather, the majority undergo little change and a small subset show marked disease progression.

Jeffcoat 1991Florida Probe ARTICLE

P: To describe the results of a 6-month study of probing attachment loss in adult periodontitis using an automated probe (w/ a resolution of 0.1mm).

M&M: 30 patients age 20-73. Inclusion criteria: presence of 3-8mm PDs, at least 4mm of AL, and bone loss evident on vertical bite-wing radiographs. Effort was made to include patients who had sites demonstrating progressive perio by comparison of their vertical bite-wings taken from the start of the waiting list (1 year prior). All patients had suprag prophy to remove calculus. Automated probing attachment levels were taken at 0,2,4 and 6 months in 5 posterior tooth sites. Instrument repeatability was confirmed by taking 5 measurements for each indv tooth site and calculated by averging the st. dev. from all sites.

R: This study confirmed the repeatability of the automated probe. Overall repeatability was 0.17mm + 0.2mm. There was no SD in the repeatability of the measurement in shallow (<4mm AL) or deep sites (>4.5mm AL). This data verified that the repeatability of measurement was better than 0.2mm. The prevalence of activedisease in the 6-month period was 29% when a cut off of 0.4mm was used. 77% of the pts exhibited one or more active sites during the study period. Mean probing at baseline was 4.4 +/- 0.8mm. Increasing the cutoff to 2.4mm resulted in 2% of active sites. 76% of sites with attachment loss followed a linear pattern. 12% showed a burst pattern, with the burst tapering off at 2 months and 12% showed exacerbations and remissions.

D: Ability to detect disease is dependent on the sensitivity and specificity of the system used to measure. Changes in probing attachment level can be due to true changes in CAL or change in tissue tone or both. With a high-resolution probe, it is possible to increase the sensitivity at the expense of specificity. This probe has been designed to limit this by applying a constant force (35gm) and has a 0.5mm ball at the tip, decreasing the probability of penetration into the CT (previous studies in beagles show this probe is accurate to within 0.9mm in detecting the attachment level). The prevalence of active sites was dependent on the threshold or cut-off for disease activity selected.

BL: High precision probing attachment measurements improves the detection of active disease and patterns of CAL over time.

Machtei 1993 ARTICLE

P: To assess the nature of progression of periodontal disease among subjects with established periodontitis using a stepwise approach to determineactive sites and attachment level changes.

M+M: 51 patients (21F, 30M; 28-62 years old) out of 1427 examined selected for longitudinal study. Inclusion criteria: established perio disease (CAL greater or equal than 6mm in 2 or more teeth); presence of 14 or more teeth; bw 25-65 years old; written consent. Patients had not received periodontal treatment in 12 months prior to study. PD using a constant-force electronic probe (20 g), CAL, relative attachment level (RAL) were taken at baseline, which was 3 months after the screening exam, and every 3 months for another 9 months (total 12 months after initial exam). Sites were sorted by PDs (Shallow = 0-3.9 mm; moderate 4-6.9 mm; deep >7 mm); molars vs non-molars and buccal vs lingual sites. Losing sites were determined by plotting individual sites over time. Linear, exponential, and logarithmic regression models were tested for each site. The slope of the regression model was used to generate AL changes and were compared to individual site measurements. Sites with AL exceeding these thresholds were determined to exhibit true AL.

R: 581 sites, 8.3% of all sites measured had AL, 2.5% when corrected type I error. Net losing sites 5.8%. Linear progression occurred in 33.6% of losing sites. Logarithmic progression (early burst with smaller changes thereafter), occurred in 38.5% of losing sites. 20 pts had small percentiles of losing sites (<5%), 16pts had moderate(5-11%), and 13pts massive (>11%). Deeper pockets (>7mm) lost attachment faster. Mean loss for all patients was 0.2 mm but deep sites lost 1.03 mm, moderate lost 0.34 and shallow lost 0.1mm. Lingual sites lost attachment faster than buccal (0.24 vs 0.16). NSS between molars and non-molars.

BL: Deeper pockets (>7mm) lost attachment faster.

Critique: Have to assume over a long period of time, any sites can exhibit different patterns of progression, ie linear, non-linear, or non-progression. Good that true changes were documented only if they exceeded the regression model.

Papapanou 1990 ARTICLE

P: To describe clinical characteristics based on a 10-year retrospective study of periodontal disease progression and to analyze the correlation between radiographic and clinical assessments of proximal loss of periodontal tissue support.

M&M: 2 groups of 14 patients were chosen from a sample of 191 individuals who had FMX exams in 1975 and 1985. The 1^st group experienced pronounced bone loss during a 10-year period (mean 4.13 mm). The 2^ndgroup had suffered no or minimal periodontal disease progression (mean bone level change +0.35mm). Clinical examination included: PI, GI, BOP, PD, CAL. A questionnaire was completed from all subjects regarding OH habits, frequency of treatment, and type of periodontal therapy received over the 10 preceding years.

R: The 1^stgroup had more plaque and gingivitis, deeper PD and greater attachment loss than the 2^nd group. The longitudinal tooth loss was more pronounced in 1^st group. Subjects in 1^stgroup lost on average approximately 7 teeth over the 10 year period, as compared to 4 teeth in 2^nd group. The radiographic assessments of alveolar bone loss were strongly correlated with the assessments of probing attachment loss. In 92% of the sites, the difference between the radiographic and the clinical assessment of periodontal tissue loss was within 2mm. Self- reported data on questionnaires showed that both groups practiced similar OH, all subjects reported brushing their teeth at least once daily, while 50-65% of the subjects regularly used some means of interdental cleaning. Subjects from both groups were subjected to dental treatment equally often. However, subjects in 1^st group claimed to have received a greater amount of periodontal treatment over the 10-year period compared to subjects in 2^nd group.

BL: Both groups had similar oral hygiene habits and frequencies of dental care visits. Patients with more loss of periodontal support had a worse periodontal status and more extensive periodontal treatment done. Radiographic assessments of alveolar bone loss were strongly correlated with the assessments of probing attachment loss. Both groups had similar bone loss at baseline but behaved differently with respect perio disease progression. The subjects in the 1^stgroup were ineffectively treated, with respect perio disease.

Are patients doomed to lose all their teeth if they do not receive periodontal treatment? What is the rate of tooth loss with and without periodontal treatment?

Hirschfeld 1978 ARTICLE

P: To report on the tooth loss over an average of 22 years of maintenance therapy.

M&M: 600 pts. from private practice under 4 to 6 month recall. 2X as many females as males, predominantly Caucasian, middle class, and highly motivated in dental health. Average age at the start of treatment was 42. 76.5% were classified as having advanced periodontal disease, 16.5% intermediate severity, and 7.0% had early disease. Patients were divided into well maintained (WM, lost 0-3 teeth), downhill (D, lost 4-9 teeth), and extreme downhill (ED, lost 10-23 teeth). The prognosis was also evaluated for those that remained in maintenance. Most received sc/rp (few surgeries). Recall visits w/ deep scaling every 4-6 months.

R: Distribution: Over 22yrs 7% of tooth loss was due to periodontal reasons. Half of the total sample lost no teeth during the 22 year period. WM – 83%, D – 13%, ED – 4%. WM had an average tooth loss of .68 th/yr. Of the teeth lost in the WM group, 79.5% were initially marked questionable. The D group lost 22.7% and ED lost 55.4% of teeth (with higher percentages of non-questionable teeth lost). The most likely teeth to be lost were upper molars and many of these had furcation involvement. The least likely to be lost even with a poor initial prognosis were the canines. When surgery was performed, the mandibular teeth would have repeated surgery 4x more often than the maxillary.

B/L: There appears to be a pattern of cyclic and sporadic outbursts of disease. The degree of plaque control does not always parallel disease progression. Tooth retention is more closely related to the case type than the surgery performed. Periodontitis is bilaterally symmetrical and there is a predictable order of likelihood of tooth loss according to position in the arch.

McFall 1982 ARTICLE

P: To follow the format established by Hirschfield and Wasserman to evaluate 100 treated periodontal patients maintained for longer than 15 years.

M&M: 100 patients (59M, 41F), treated & maintained for >15 yrs. All patients were on periodic maintenance (3-, 4- or 6- months intervals). Average duration of maintenance was 19 years. Periodontal parameters were recorded at initial exam and at maintenance (PD, REC, FURC, MOB, mucogingival considerations). 36/100 patients had advanced periodontal disease, 53/100 intermediate severity and 11/100 were in the early stages. The patients were classified as: WM-well maintained, lost 0-3 teeth (77 patients), D-downhill, lost 4-9 teeth (15 patients) and ED-extreme downhill, lost 10-23 teeth (8 patients). Teeth were given a prognosis based on PD, mobility, furcation and gingival issues. The degree of tooth loss in each group was evaluated (did NOT include teeth extracted as part of initial therapy). All patients had SRP, OHI and occlusal adjustment. Patients that were treated surgically in 50s and 60s received mostly gingivectomy and in 80s with OFD or osseous.

R: Over an average of 19 years: 2,627 teeth were initially present and 259 (9.8%) were lost due to periodontal disease and 40 (1.5%) lost to other causes. 45% of patients lost NO teeth. Of the total number of teeth lost due to all causes 30.7% occurred in the WM group, 30.7% in the D group and 38.6% in the ED group. For disease severity, 100% of ED and 87% of D were initially classified as having advanced periodontal disease.

WM: 0.68 teeth/pt were lost (similar to Hirschfeld and Wasserman), 45/77 of the WM group lost no teeth. D: 6.7 teeth/pt were lost, ED: 14.4 teeth/pt were lost.

62% of teeth lost were originally labeled as questionable. Highest loss of max molars and lowest loss of mandibular cuspids. Compared to the Hirschfeld and Wasserman studies, fewer patients were diagnosed with having advanced disease (3.6% vs. 76%). As seen in previous studies, the majority of tooth loss occurs in a small % of patients, often after years of no progression. This study reaffirms bilateral symmetry and cyclical nature of the disease. Teeth with furcation involvement appear no more likely to be lost than other questionable single rooted teeth. Further supports the benefits of treatment and maintenance.

BL: Periodontal disease often presents with bilateral symmetry. There seems to be an irregular cyclical nature of tooth loss. Treatment appears to be effective in most of the patients who are well maintained. A higher percentage of teeth lost were in a patient population that had more advanced disease, less molars at initial exam, and more teeth w/questionable prognosis. A minority of the patients got worse no matter what.

Goldman 1986 ARTICLE

P:Retrospective study to provide additional information on the effects of periodontal treatment and maintenance therapy on a group of patients who were seen in a private practice setting for at least 15 years.

M+M:211 patients (122 F, 89 M, mean age=42 years, predominantly Caucasian). Initial exam included FMX, and FMX would be taken every two years to assess bone level changes, all teeth present were counted.

Initial therapy: OHI and SRP, occlusal adjustment (on all patients) , bite guards fabricated.

Surgical therapy: gingivectomy-gingivoplasty, OFD, at no time was osseous tissue removed, frenectomies, root amputations.

Maintenance: Extra and intraoral exams, occlusion checked for trauma and mobility- where extensive mobility, pt was rescheduled for either occlusal correction or intracoronal splinting. Teeth with extensive bone loss were maintained for many years by periodic recalls. Residual pocket depth was also kept stable in many instances by frequent maintenance.

Response to therapy was classified based on Hirschfield and Wasserman classification of well maintained (WM)- 0 to 3 teeth lost, down hill (D)- 4 to 9 teeth lost, and extreme downhill (ED)- 10 or more teeth lost.

R:On the basis of response to therapy, 131 patients were classified as WM (62%), 59 D (28%) and 21 ED (10%). During maintenance period a total of 771 teeth were lost (13.4%). Molar teeth (max> mand) are the most prone to loss and the mandibular cuspid is the most resistant.

WM group- 59 pts lost no teeth, remaining 72 pts lost 1 tooth/patient

D group- lost an avg of 5.8 teeth/patient (2^ndand 3^rdmolars comprised 45.6% of the teeth lost)

ED group- lost an avg of 14.2 teeth/patient (2^ndand 3^rdmolars comprised 26.% of teeth lost)

BL:The teeth at highest risk of being lost are molar teeth, especially the maxillary first and second

molars. Only one mandibular cuspid was lost. This study emphasizes the importance of maintenance therapy.

McLeod 1997 ARTICLE

P: To evaluate the effectiveness of perio treatment as measured by tooth loss.

M&M: 114 patients (26-79 years old at the start of treatment), seen by periodontist for maintenance for an average of 12.5 years, (99% on 3-month recalls). All had moderate (ALoss 4-7mm)-advanced (ALoss >7mm) perio. Records were reviewed for medical and dental history. Patients were divided into well-maintained (0-3 teeth lost), downhill (4-9 teeth lost), and extreme-downhill (10-23 teeth lost).

R: 2987 teeth present at initial exam; 88 (3%) extracted during periodontal treatment; 220 (7.6%) lost during maintenance. Tooth loss: 5% due to perio, 1.6% because of pros or restorative reasons. More molars lost than non-molars and bilateral pattern of tooth loss was observed. Greatest tooth loss max 2^nd M > 1^stM> 1^st PM> mand 2^ndM. Least tooth loss max C> mand C> 1^st PM> 2^nd PM. More patients were initially included in the well-maintained group after perio treatment, than in the down-hill, than extreme down hill group (96, 15, 3 respectively). Average tooth loss for all patients was 1.9. Tooth loss in well maintained= 0.9 per patient, downhill=6, extreme downhill=12. 17% of the teeth with furcations initially, were lost after active treatment. Only 2 patients had systemic diseases that predisposed them to periodontitis (Juvenile diabetes, and systemic lupus erythematosus).

C: Perio treatment followed by periodontal maintenance was effective in decreasing tooth loss; however, surgical treatment did not significantly improve tooth retention in the high-risk groups.

Hujoel 2000 ARTICLE

Purpose: To assess the relationship between non-surgical periodontal therapy and tooth loss in patients with chronic periodontitis.

Materials and methods: Study was conducted in the Kaiser Permanente Dental Care Program a dental care system that includes 14 offices in the US and provides comprehensive dental services. Subjects were patients with chronic periodontitis with initial exam between 1988 and 1992, age 40-65 at the initial exam and FMX were taken between 1 year prior to and 6 months after the periodontal exam. The non surgical periodontal treatment was divided in 1) continuous prior therapy (one or more non-surgical procedures performed during each of the prior 3 years) 2) no prior therapy performed during each of the prior 3 years and 3) intermittent prior therapy (one or more non-surgical procedures performed during some but not all of the prior 3 years). Number of teeth lost in each year subsequent to the initial exam was determined based on a review of the electronic database records. Results were adjusted for periodontal disease severity (more or less than 5mm PD), age, gender, prior periodontal therapy, caries activity and dental attitude (diagnostic, preventive and non-periodontal interventions).

Results: Mean age of the patients was 50.2 years and 48.7% were males. On average they were followed for 7.1 years and the mean number of teeth at the initial exam was 25.3. Mean number of sites with PD 5mm or more was 35.4 and mean PD of all sites (excl. 3^rd molars) was 3.6mm, and mean clinical PD of site with 5mm or more was 5.6mm. 1021 individuals participated in the study, 319 became ineligible during follow-up and data were used until that point. No association was found between tooth loss during study and dropout.

The mean tooth loss rate during the entire follow up was 7.5/1,000 teeth per year. 57% lost no teeth, 19% lost one tooth, 8% lost 2 teeth, 6% lost 3 teeth and 10% lost 4 or more teeth. Subsequent to the first 3 years after initial exam, tooth loss rate was 6.9/1,000 teeth per year.

Disease severity at baseline (mean PD, number of sites with 5mm or more PD, average depth of these site and having fewer teeth present) was associated with an increased tooth morality rate. For every additional site deeper than 5mm, tooth mortality rate increase by 2%. For every additional 1mm increase in the average PD of sites deeper than 5mm, tooth mortality rate increased by 56%. For every additional tooth present at baseline, tooth mortality rate increased by 16%. Gender and age were not significantly related to tooth loss.

Compared to periodontal therapy cessation for ≥3 years, intermittent or continuous non-surgical periodontal therapy was associated with a reduction in the tooth loss rate by approximately half (58% for continuous non-Sx therapy and 48% for intermittent therapy). For each additional periodontal procedure performed in the prior 3 years, tooth mortality decreased by 6%.

Conclusion: Non-surgical periodontal treatment may reduce tooth loss substantially and at a dose-response relationship exists.

Do patients benefit from periodontal therapy? How effective are different treatment modalities in the short/long term? What are the most significant factors in the success of periodontal treatment?

Lindhe 1975 ARTICLE

Purpose: To test whether periodontitis can be cured in advanced cases if pts are willing to exercise excellent plaque control.

Materials and methods:

75 pts with greater than 50% attachment loss that were capable of maintaining optimal plaque control and were willing to appear regularly at least once every 6 months were enrolled in the study.
Initial therapy with repeated OH instruction/motivation was given to each pt.
Teeth from which endodontic and cariologic view points could not be successfully treated, teeth with perio pockets extending down to the apex, and teeth which on prosthodontics indications should not be maintained were extracted.
The pre-sx observation period was 3-6 months in order to evaluate the degree of cooperation of the pts. Sx pocket elimination was performed for pockets greater than 4mm. Pts came to maintenance visits every 3 to 6 months.

Results:

The 75 pts had a total of 1898 teeth when they enrolled in the study. During the pre-sx tx period, 278 teeth were extracted.
A total of 1620 teeth were maintained for 5 years. The mean PD was 5.7mm before tx, and later was reduced to less than 3mm.
Also, after 5 years PDs exceeding 3mm were only found on 8 teeth. On no occasion did PD exceed 6mm.
However, 422 teeth did show signs of increased mobility at the end of the study. Only 14 new carious lesions were detected at the recall appointments.

Discussion: Microbial plaque is the major, maybe only, factor of importance in the etiology of gingival inflammation and incipient perio dz.

BL: It is possible to treat perio dz successfully, even in advanced stages, in pts willing to carry out optimal plaque control.

Badersten 1987 ARTICLE

P: To report a 48-month follow-up of the previous Badersten studies on non-surgical periodontal therapy (1984, 1984, 1985).

M&M: A total of 2214 sites from non-molar teeth in 46 pts (PD ≥5mm, BOP and calculus on at least 2 aspects of each tooth) were analyzed. 24-month status was used as baseline. SPT was performed every 6 months and OH was continuously reinforced. Data pooled by PD ≤3.5mm, 4-6.5mm and ≥7mm.

– 53 teeth (13%) were discontinued: 20 pt preference, 25 progressive attachment loss, 8 fracture/esthetics, etc.

– Mean plaque score increased slightly from 8-20% to 10-30%.

– BOP and PD improved in the > 7mm group and did not change for the other groups.

– 2-3% of sites lost attachment during 24-48 months

– Few sites that showed PAL during the 0-24-month period showed continued loss during the subsequent 24-48-month period.

– Initially shallow/deep sites that showed loss/gain of attachment had some loss/gain attachment during the 0-24-month period

BL: Plaque control and root debridement may be an effective way to treat chronic periodontal disease over several years in non-molar teeth in a patient population with good compliance. Probing attachment loss over 4 yrs: ≤3.5mm PD = 19-24%, 4-6.5mm PD = 5-7%, and ≥7mm PD =1-4% of the sites. This study failed to demonstrate that sites with deeper PD were more difficult to maintain than shallower sites

Renvert 1990 ARTICLE comparison of various forms of treatment

P: To report 5-year clinical observations following treatment of intraosseous periodontal defects with root planing alone compared to treatment with flap surgery. Results of sub-g microbial samples taken after 42, 48 and 60 months are reported.

M&M: 14 patients, 32-62 years of age were included. 21 defects were treated with root planing alone and 21 defects were treated with flap surgery. Defects surgically treated: FTF, defects were degranulated, root surfaces were planed and treated with citric acid, no osseous recontouring, flaps were replaced and sutured to obtain complete closure of the wounds. Defects treated with root planing: roots were instrumented with curettes, intentional soft tissue curettage was not performed. Oral rinses with 0.2% CHX were prescribed adjunctively to OH procedures for the first 2 weeks post-op. Pts were seen at weekly intervals the first 3 weeks post-op and at 6, 12, 18 and 24 weeks for OHI and polishing of the teeth. Maintenance therapy from 6 to 60 months was limited to reinforcement of OH and tooth polishing every 6 months. No sub-g instrumentation was done at the defects sites at these visits. The following parameters were recorded at 6, 12, 24, 36, 42, 48, 54 and 60 months post-op: plaque scores, BOP, PD, AL, probing bone level. Microbial samples were taken from the buccal aspect of the proximal defect sites at 42, 48 and 60 months.

R: Surgically treated lesions responded with a slight more reduction of PD and more gain of probing bone level than root planed lesions. Mean gains of AL were similar for the 2 treatments. Some relapse of clinical conditions could be observed towards the end of the 60-month observation interval. The majority of defects subjected to either treatment showed 60-month recording of probing attachment and probing bone levels equal or slightly improved compared to baseline. The results of the microbial counts at 42, 48 and 60 months revealed similar counts of the various bacterial groups at all 4 time points and for both treatments.

C: Although the results indicate similar long term results following root planing and surgical treatment, this should not be interpreted as documentation that root planing is an adequate therapy in all situations.

Cr: small number of patients

Ramfjord 1987 ARTICLE

P: To clinically assess, over 5 yrs, tx results following 4 diff modalities of perio tx.

M&M: After initial SRP and OHI, 90 mod-adv perio pts had the 4 quads randomly treated with 1) S/RP, 2) MWF, 3) APF + osseous, or 4) subg-curettage. This was followed by OHI and prophy every 3m. PD sites were grouped: shallow (1-3 mm), mod (4-6 mm), or adv (>7 mm). PD and AL were recorded annually and % sites w/ 2+mm and 3+mm AL gain/loss were compared. Pts w/ overt bleeding or suppuration were re-tx’d. 72 of these pts were followed for 5 yrs.

Shallow sites: all had ALoss, but it was less w/ SRP or curettage and most w/APF.

Mod sites: More PD reduction: sx > SRP > curettage. All 4 types of tx had some ALoss, but APF had the most.

Adv sites: all showed PD reduction and most showed att gain but there were NSD b/w the 4 methods of tx.

At 5y, there were few sites w/ ≥2-3 mm gain or ALoss – shallow sites had the most losses and almost no gains. Mod sites had more losses than gains and adv sites had more gains than losses. Adv sites rarely lost att regardless of tx. 1% of the treated tth were lost (22)-17 for perio reasons (16 furc involvement).

BL: SRP alone is as effective as other modalities of tx as long as access to the root surface can be obtained. For pts ≥7 mm, the results are similar for all 4 types of tx. There is no benefit to curettage vs SRP. Regardless of tx, furc involvement is the greatest hazard in the prognosis. Re-tx is needed more often after SRP than after the other procedures, but with additional scaling, the results are as good as for any other procedure.

Becker 2001 ARTICLE

to present 5-year results from a longitudinal study comparing the effectiveness of SRP, osseous Sx, and MWF procedures as performed by periodontists who are proponents of the specific technique.

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