131. Non-surgery vs. Surgery

        b. Statistical methods                                    

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What treatments does Non-Surgical Therapy include? What is scaling? What is root planing? What are the endpoints to successful root planing therapy? What studies show the effectiveness of SRP? What are some factors that can limit the effectiveness of SRP? Is SRP equally effective in molars and non-molars? Are more experienced practitioners more effective at SRP?

  1. CobbC. Non surgical pocket therapy: Mechanical. Ann Periodontol 1996;1;443-490

  2. BuchananA., Robertson P. Calculus removal by scaling/root planing with and without surgical access. J Periodontol 1987;58:159-163

  3. LoosB et al. Clinical effects of root debridement in molar and non-molar teeth. A 2 year follow up. J Clin Periodontol 1989;16:498-504

  4. Brayer,W et al. Scaling and root planing effectiveness: The effect of root surface access and operator experience. J Periodontol 1989;60:67-72

  5. BaderstenA, et al. Effect of nonsurgical periodontal therapy. I. Moderately advanced periodontitis. J. Clin. Periodontol. 8:57-72, 1981.

  6. BaderstenA, Nilveus R, Egelberg J: Effect of nonsurgical periodontal therapy. II. Severely advanced periodontitis. J. Clin. Periodontol. 11:63-76, 1984.

  7. BaderstenA, Nilveus R, Egelberg J: Effect of non-surgical periodontal therapy. III. Single versus repeated instrumentation.J.Clin.Periodontol.11:114-124, 1984.

  8. BaderstenA, et al: Effects of nonsurgical periodontal therapy. IV. Operator variability. J. Clin. Periodontol. 12:190 -200, 1985.

  9. BaderstenA, et al: Effect of nonsurgical periodontal therapy. VIII. Probing attachment changesrelated to clinical characteristics. J. Clin. Periodontol. 14:425-432, 1987

  10. GreenwellH, Bissada NF, Dodge JR. Disease masking: A hazard of nonsurgical periodontal therapy. Perio Insights December 1998:14-19.

  11. MatthewsD. Conclusive support for mechanical nonsurgical pocket therapy in the treatment of periodontal disease. How effective is mechanical nonsurgical pocket therapy? Evid Based Dent. 6(3):68-9. 2005

  12. RamfjordS, et al. Results of periodontal therapy related to tooth type. J. Periodontol. 51:270-273, 1980.

  13. PihlstromBL, Oliphant TH, McHugh RB: Molar and nonmolar teeth compared over 6.5 years following two methods of periodontal therapy. J. Periodontol. 55:499-504, 1984

  14. ClaffeyN, Shanley D: Relationship of gingival thickness and bleeding to loss of probing attachment in shallow sites following nonsurgical periodontal therapy. J Clin Perio 13:654, 1986.

  15. LoescheW, Soehren S, et al. Nonsurgical treatment of patients with periodontal disease. Oral Surg, Oral Med, Oral Pathol 1996; 81: 533-543.

  16. LoescheWJ, Giordano JR, Soehren S, Kaciroti N. The nonsurgical treatment of patients with periodontal disease: results after 6.4 years. Gen Dent. Jul-Aug;53(4):298-306; 2005

  17. DriskoCH. Nonsurgical periodontal therapy. Perio 2000 25:77-88,2001. (Review)

Is Surgical Treatment more effective than non surgical treatment?

  1. Lindheet al. Long term effect of surgical/non surgical treatment of periodontal disease. J Clin Periodontol 1984;11:448-458

  2. Caffesse,R et al. Scaling and root planing with and without periodontal flap surgery. J Clin Periodontol 1986;13:205-210

  3. PhilstromB, et al: Comparison of surgical and nonsurgical treatment of periodontal disease. A review of current studies and additional results after six years. J Clin Perio 10:524-541, 1983.

  4. Serino,G et al. Initial outcome and long term effect of surgical and non surgical treatment of advanced periodontal disease. J Clin Periodontol 2001;28:910-916

What is the critical probing depth?

  1. LindheJ, Socransky SS, et al. “Critical probing depths” in periodontal therapy. J Clin Periodontol 9:323-336, 1982.

Statistical Methods

What is sensitivity and specificity? What is positive predictive value and accuracy? What is Prevalence? What is negative predictive value? What is equivalence and superiority? What is regression towards the mean?

  1. D. Brunette: Critical Thinking: Understanding and Evaluating Dental Research 2nd Edition Quintessence Publishing Co, Inc ISBN 978-0-86715-426-9; 2007; pp 163-184, pp192-193

  2. HujoelPP, Moulton LH, Loesche WJ : Estimation of sensitivity and specificity of site-specific diagnostic tests. J. Periodontal Res. 25:193-196, 1990.

  3. GunsolleyJC, Elswick RK, Devenport JM. Equivalence and superiority testing in regeneration clinical trials. J Periodontol 69:521-527, 1998.

  4. GunsolleyJ. Equivalence, superiority, and negative clinical trials. J Periodontol 69:608,1998

  5. DukeSP, Garrett S. Equivalence in periodontal trials: A description for the clinician. J Periodontol 69:650-654, 1998.

  6. Gunsolley, J et al: Is loss of attachment due to root planing and scaling in sites with minimal probing depths a statistical or real occurrence? J Periodontol 2001;72:349-353

What is the difference between statistical significance and clinical significance?

  1. RethmanMP, Nunn ME. Clinical versus statistical significance. J Periodontol 70:700-702,1999.

  2. GreensteinG, Lamster I. Efficacy of periodontal therapy: Statistical versus clinical significance. J Periodontol 71:657-662, 2000.

  3. HujoelPP, Armitage GC, Garcia RI. A perspective on clinical significance. J Periodontol 71:1515-1518, 2000.

How can we evaluate the quality of a RCT? What is a meta-analysis and how accurate are their results? What are the major pitfalls in clinical trials design?

  1. JeffcoatMK. Principles and pitfalls of clinical trials design. J Periodontol 1992;63:1045-1051

  2. CohenME, Ralls SA : False positive rates in the determination of changes in probing depth related to periodontal measurements. J. Periodontal Res. 23:161-165,1988.

  3. HujoelPP, Moulton LH : Evaluation of test statistics in split-mouth clinical trials. J. Periodontal Res. 23:378-380, 1988.

  4. LesaffreE, Garcia Zattera MJ, Redmond C, Huber H, Needleman I; ISCB Subcommittee on Dentistry. Reported methodological quality of split-mouth studies. J Clin Periodontol. Sep;34(9):756-61; 2007. Review.

  5. NeedlemanI, Worthington H, Moher D, Schulz K, Altman DG. Improving the completeness and transparency of reports of randomized trials in oral health: the CONSORT statement. Am J Dent. Feb;21(1):7-12; 2008

  6. MontenegroR, Needleman I, Moles D, Tonetti M. Quality of RCTs in periodontology–a systematic review. J Dent Res. Dec;81(12):866-70; 2002. Review.

  7. EspositoM, Coulthard P, Worthington HV, Jokstad A. Quality assessment of randomized controlled trials of oral implants. Int J Oral Maxillofac Implants. Nov-Dec;16(6):783-92; 2001. Review.

Root Caries

What factors may influence the incidence of root caries? Does periodontal treatment increase root caries?

  1. Ravald N, Birkhed D, Hamp SE. Root caries susceptibility in periodontally treated patients. Results after 12 years. J Clin Periodontol. Feb;20(2):124-9; 1993

  2. Paraskevas S, Danser MM, Timmerman MF, van der Velden U, van der Weijden GA. Amine fluoride/stannous fluoride and incidence of root caries in periodontal maintenance patients. A 2 year evaluation. J Clin Periodontol. Nov;31(11):965-71; 2004

  3. De Soete M, Dekeyser C, Pauwels M, Teughels W, van Steenberghe D, Quirynen M. Increase in cariogenic bacteria after initial periodontal therapy. J Dent Res. Jan;84(1):48-53; 2005

What treatments does Non-Surgical Therapy include? What is scaling? What is root planing? What are the endpoints to successful root planing therapy? What studies show the effectiveness of SRP? What are some factors that can limit the effectiveness of SRP? Is SRP equally effective in molars and non-molars? Are more experienced practitioners more effective at SRP?

Cobb 1996  ARTICLE

P:A literature review regarding: 1) progression of untreated periodontal disease which offers a basis for comparing the effects of mechanical non-surgical treatment 2) the effect of scaling and root planing on specific clinical parameters and selected biologic factors (sub-g microbial flora, cementum and root surface roughness), 3) root preparation using power driven instruments.

Disc:

  • 3- to 4- fold increase in mean annual tooth loss in untreated population

  • Molar teeth most frequently lost

  • Annual progression rate of untreated perio dz ranges from 0.1mm to 0.2mm

  • Positive association between increasing age and increasing loss of perio support

  • Critical for periodontal therapy: thoroughness of root surface debridement and pt’s OH

  • Multi-rooted teeth (anatomic factors, furcation) require more skill and time to effectively treat and generally respond less favorable to sc/rp than single rooted teeth.

  • Clinical predictors for future CAL loss:

    • Tooth type

    • Initial CAL loss or bone height at baseline

    • Moderate and severe gingival inflammation

    • Sub-g calculus

    • Smoking

  • CAL loss after sc/rp of shallow PDs

  • Greater CAL gain with deeper PDs

    • 1-3mm PD- 0.34mm CAL loss

    • 4-6mm PD- 0.55mm CAL gain

    • >7mm PD- 1.29mm CAL gain

  • Amount of reduction directly related to initial PD

  • Single rooted teeth respond better to sc/rp. Molars with furcation involvement respond less favorably than molars without furcation involvement or single rooted teeth.

  • Weak correlation between BOP and dz progression. Absence of BOP correlated with periodontal stability

  • Mechanical non-sx tx- mean reduction in BOP-57%

  • SC/RP

Reduction in % of motile microbes and spirochetes

Increase in cocci and non-motile microbes

  • Presence of supra-g microbial plaque facilitates repopulation of sub-g pockets within 4-8 weeks (spirochetes and motile rods)

  • % of surfaces with residual calculus without flap 17-69%, with flap 14-24%

    • deeper sites-more residual calculus

    • no SSD between anterior and posterior teeth

    • no SDD between closed vs open approach in furcations

    • no SDD between US and manual instrumentation (faster with US)

  • Recent studies support that there is no need for extensive cementum removal. Endotoxins bound superficially to root surface.

  • Root surface roughness after scaling may be associated with increased initial adhesion and retention of microbes. More true for supra-g root surfaces, less dramatic for sub-g root surfaces.

  • Healing with long junctional epithelium. Re-establishment of the attachment epithelium occurs within one or two weeks. There is reduction in inflammation that appears correlated to reduction of inflammatory cells and GCF flow and repair of connective tissue matrix.

Progression of untreated periodontal disease

Distribution of periodontal disease and factors affecting progression

Annual tooth loss rates in patients with and without periodontal therapy

Mechanical non-surgical therapy

The 1989 Proceedings of the World Workshop in Clinical Periodontics defined scaling as “Instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus and stains from these surfaces. Root planing was defined as “A definitive treatment procedure designed to remove cementum or surface dentit that is rough, impregnated with calculus or contaminated with toxins or microorganisms.

  • Shallow PDs 1-3mm lost attachment 0.34mm.

  • PDs 4-6mm had a mean gain of 0.55mm, PDs 7mm exhibited the greatest CAL gain- 1.29mm.

  • Lindhe- critical probing depth: 2.9mm for sc/rp and 4.2mm for surgical treatment.

  • Ramfjord and Kiester were the first to report on CAL loss subsequent to scaling on initial shallow PDs.

Effectiveness of scaling and root planing

Effectiveness of calculus removal with or without flap

Amount of cementum removal during scaling and root planing

Comparison of manual instrumentation to sonic/ultrasonic instrumentation

Buchanan 1987     (efficacy)                ARTICLE

P:To evaluate the presence and extent of calculus on subgingival root surfaces of teeth that received SRP alone, SRP with modified Widman flap, or no treatment.

M+M:10 pts (28-62 years old) that had at least 3 teeth that needed extractions due to severe periodontitis. Teeth in each pt randomly assigned to one of three groups: SRP alone (29 teeth), SRP w/ MWF (35 teeth), or not tx before extraction (22 teeth). SRP completed with ultrasonic scalers and hand instruments. Teeth were extracted and stained with methylene blue to disclose and looked under 10x stereomicroscope. Each surface was examined to determine the pocket depth, area of root surface exposed to the pocket , and amount of pocket area showing retained calculus. Calculus-positive teeth (CPT) and surfaces (CPS), and percentage of pocket area occupied by calculus (C/A) were derived for each group.

R:The mean treatment time per tooth for SRP alone was 12.9 ± 2.1 minutes, for the SRP w/flap it was 11.5 ± 2.0 minutes per tooth plus an additional 6.6 ±1.9 minutes per tooth for incision, reflection, and removal of granulation tissue, to a total treatment time per tooth of 18.1 ±2.0 minutes.

Pocket depth and area: were similar for all three groups averaged 5.9 mm and 26.0 mm2 respectively.

Calculus:

  • In the no-treatment group was present on most surfaces of all 22 teeth and occupied an average of about 1/3 of the mean pocket area.

  • Bothtreatment groups showed SS lower values than the no-treatment group for calculus-positive teeth and surfaces and percentage of pocket area with retained calculus.

  • 13/ 35 teeth (37%) had residual calculus after SRP w/flap, whereas 18/29 teeth (62%) had residual calculus after SRP aloneSSD

  • Increased efficiency in calculus removal by SRP w/ flap as compared with SRP alone was limited primarily to anterior and premolar teeth, and NSSD in calculus positive molar teeth or surfaces were found between the two groups.

  • All measures of calculus retention were SS greater in the no treatment group than in either treatment group.

  • The percentage of calculus positive surfaces was lower after SRP w/ flap than after SRP alone for all surfaces, and the difference was SS on facial and lingual surfaces.

  • Theeffects of SRP w/ and w/o flap access were NSSD in pocket depth ranges of 0 to 6.0 mm. For pocket depths greater than 6 mm, calculus positive surfaces after SRP w/flap remained constant at approximately 17% , but after SRP alone they continued to increase and averaged 45% for-pocket depths greater than 8.0 mmSSD

BL: SRP w/ flap proved to be more effective than SRP alone in reducing the percentage of calculus positive teeth and surfaces. The advantage of SRP w/flap was most dramatic on anterior and premolar teeth, and on facial and lingual surfaces. In pocket depths >6 mm, calculus positive surfaces after SRP alone increased linearly and SS and in pockets deeper than 8 mm, calculus-positive surfaces averaged about 45% after SRP alone whereas after SRP w/ flap they remained constant at about 17%.

Loos 1989   ARTICLE

P:To report on the longitudinal observations over 2 years of the clinical effects of root debridement in molar furcation sites, molar flat-surface sites and non-molar sites.

M&M:12 pts with generalized perio included. Sites grouped as either molar furcation, molar flat-surface or non-molar as well as being shallow (<3.5mm), moderate (4.0-6.5) or severe (>7mm). Pts received OHI 3wks prior to the initial therapy, which consisted of only 2 sessions of SRP (1 each jaw). Every 3 months, pts received supra-g prophy and OHI and had their clinical parameters recorded with an electronic, pressure-sensitive probe set at 0.5N for a 2-year period.

R:Initially moderately deep and deep molar furcation sites responded less favorably to therapy compared to non-molar sites and molar flat-surface sites of similar PD. Initial improvements in PDs for moderately deep and deep molar furcation sites were limited and also tended to revert during the observation interval. For moderately deep surfaces at molar flat-surfaces and non-molar sites, the 3-month gain in PAL from 0.2-0.4mm, followed by a return to baseline. There was no change in PAL in furcation sites at 3 months, followed by a gradual mean loss amounting to 0.8mm at 24 months. 25% of molar furcation sites had PALoss, versus 7% of non-molar sites and 10% for molar flat-surface sites. Reduction in BOP was primarily noted in shallow sites. BOP in moderately deep and deep sites remained high.

BL:Furcations require additional treatment after SRP.

Cr: Only 12 pts. 2 years without addressing sub-g sites is not a realistic clinical situation (hopefully). Initial therapy only consisted of SRP (no elimination of overhangs, occlusal adjustment, etc). No sx pocket elimination performed. Therefore, this study cannot be compared to many traditional perio lit maintenance studys.

Brayer 1982  ARTICLE

Purpose:To investigate 1) if access to the root surface affects an operator’s ability to effectively scale and root plane teeth and 2) if operator skills as measured by experience level affect the ability to effectively perform SRP.

Materials and methods: 29 patients with 114 hopeless teeth were included in the study. Total of four operators performed SRP. Two fully trained Board certified periodontists (EL-1) and two 2ndyear perio residents (EL-2). SRP was performed either as a closed procedure or after flap access. Unscaled teeth were retained as controls. PDs and calculus index were recorded. No time limits were placed but time was also recorded. Teeth were then extracted and root surfaces were then microscopically evaluated for residual calculus by a periodontists that did not participate in the operating procedures.

Results:Time to elevate the flap: 6.5 min/tooth (EL-1) vs 7.8 min/tooth (EL-2)

Open SRP time: 5.3 min/tooth (EL-1) vs 6.7 min/tooth (EL-2)

Closed SRP time: 8.1 min/tooth (EL-1) vs 9.5 min/tooth (EL-2)

Calculus free areas in open SRP: 96.4% EL-1 vs 91.2% EL-2

Calculus free areas in closed SRP: 86.2% EL-1 vs 65.7% EL-2

In shallow periodontal pockets no significant difference between groups in % of residual calculus, in pockets 4-6mm open SRP resulted in 92% of calculus free areas comparing to 71% with closed SRP.

The more experienced operators produced significantly greater number of calculus-free root surfaces (89% vs 74%) in 4-6mm pockets and >6mm pockets (91% v 69%). No difference in 1-3mm pockets.

Conclusion:In single rooted teeth with PDs more than 4mm SRP with flap access was more effective and the more experienced operators produced fewer root surfaces containing residual calculus.

Badersten 1981(I)  ARTICLE

Purpose:To compare the effect of hand versus US instrumentation in patients with moderately advanced periodontitis.

Materials and methods:

  • 15 patients had initial prep only using US or hand instruments in a split mouth design (no molars studied).

  • A total of 528 sites were treated with average PD of 4.2 mm (most pockets ranged from 2-7 mm, highest PD was 12.5 mm).

  • Evaluated plaque scores, BOP, PD &CAL up to 13 months.

Results:

  • All parameters improved during the first 4-5 months after start of treatment, but little change occurred during the rest of the 13 months observation period.

  • Mean total reduction in PD was 1.3-1.7 mm.

  • Only 13/106 (12%) of the initial sites exhibited PD of >6 mm after 6 months.

  • Deeper pockets reduced about 1.1-1.5 mm with a decrease in bleeding

  • No difference between HI & US.

  • Shallower sites had some loss of attachment (2-3 months) while deeper sites showed some improvement.

BL:Non-surgical treatment of non-molar teeth with moderate PD is effective, with no difference between HI and US.

Badersten 1984(II)  ARTICLE

P:To study the healing events in patients with pockets up to 12 mm deep, to compare hand to ultrasonic instruments

M&M:16 patients, with severe periodontitis, 4-10 teeth in each patient (incisors, canines, premolars), probing depths > 5 mm with calculus & bleeding on probing on > 2 aspects each tooth. OHI over 2-3 visits, extra instructions were given as needed. 3 months after OHI, measurements were taken, then preparation with either ultrasonic or hand instruments in a split mouth design was performed, measuring plaque index, bleeding on probing, attachment level and recession were recorded and repeated every 3 months up to 24 months, instrumentation was performed again at 6 & 9 months. (3 sessions overall)

R:Total of 852 surfaces were treated

– Plaque index: NSD between 2 instruments, higher with reduction with one of the two investigators

– Bleeding On Probing: No change between initial exam & 3 month after OHI. It did, however, decrease after instrumentation (84-90% decreased to 14-18%). Similar decrease in bleeding on probing for both investigators and instruments.

– PD: Initial : 5.5-5.8 mm. 3 months: 5.1-5.3 mm. 12 months: 3.6-3.9 mm. 24 months: residual probing depths decreased irrespective of operator or instrument for all probing depths; 43 surfaces had PD > 7 mm (86% reduction)

– Recession: limited gingival recession during the 3 months but at 12 months 1.6-1.8 mm recession

– PAL:

Residual PD: Loss of attach of ≥1.5 mm in surfaces with residual PD ≤2.5 mm and ≥6 mm. Gain of attachment of ≥1.5 mm for 24-31% of surfaces with residual probing depths of 3-4.5 mm.

Initial PD: Gain/Loss of PAL 1.5 mm or more/less. Found Majority of initial PD < 4-4.5 mm loss of PAL, while PD >6-6.5 mm gain of PAL.

– NSSD between ultrasonic & hand instruments, but 1 operator used less time with ultrasonic.

BL:Deeper sites had more: recession, residual probing depths, gain in attachment. Sites < 3.5 mm lost attachment, sites >8 mm gained attachment. Authors mentioned that decision to proceed with Surgery Treatment should be postponed until 6-9 months after initial instrumentation.

Badersten 1984 (III)  ARTICLE

P: To compare the effect of a single session of subgingival instrumentation using ultrasonic scaler with 3 sessions separated by 3 months.

M&M:13 patients (30-55yrs) with PD up to 5-11mm were included in the study. Incisors, canines, premolars only, 6-10 teeth in each patient were used in split mouth design. OHI, US debridement with one side received 1 session and the other received 3 sessions at 0, 3, 6 months. PI, BOP, PD, CAL, and recession were recorded at baseline and every 3 months for 24 months (blinded examiner).

R: Avg PD prior to txt 5.8 mm for surfaces to be instrumented once and 5.9 mm for surfaces to be treated 3 times.

PIwas sig reduced with both forms of txt.

Initial BOP 78%-80% reduced to 15-20% for both treatments, maintained throughout observation.

PD, similar decrease for both groups: initial PD score 5.5-5.9mm. PD reduced to 4.1-4.2 mm after 3 months, and a further reduction to 3.5-3.7 mm was seen at 9-month exam.

Recession:occurred during 1st 9 months of study and stabilized at an average of 1.8mm.

CAL gain: A mean of 0.4mm if seen after 3 months and remained constant throughout the study.

Sites with <3mm PD showed 0.4-1mm of CAL loss, sites >8mm gained 0.9-2.8mm. Only 25% of PD between 3-4.5 mm gained; >1.5mm of attachment.

Initial healing was the same for both groups. Full effect of healing was not obtained until 6-9 months after instrumentation.

BL:Similar results were recorded with 1 or 3 sessions of SCRP. Repeated instrumentation is of limited value. Clinical parameters remained unchanged during 24 months and did not show recurrence of disease. Full effect of healing not obtained for 6-9 months after instrumentation.

Limitation:molar were excluded from the study

Badersten 1985 (IV)                     ARTICLE

P: To compare the results achieved by other operators in treating severe periodontitis with a single instrumentation.

M&M:20 patients (28-64 years old) with severe periodontal disease were included. Incisors, cuspids, and premolars in maxilla or mandible were used (each patient had between 6-10 of these teeth). Pockets of at least 5mm with calculus and BOP on at least 2 aspects of each tooth. OHI 2 or 3 times were given during the first month. Additional OHI provided as needed. Periodontal pockets were debrided immediately following the initial examination. Split mouth design was used, one half was assigned to a periodontist, and the other half to a hygienist (5 different hygienist participated); both using US and/or HI for instrumentation. Time of instrumentation was recorded. Pl, BOP, PD, PAL were recorded every 3 months for 24 months.

R: 1056 sites were treated. Significant positive trend was seen in all patients after treatment (improvement at 3 months and essentially the same or slightly better thereafter). Reduction in PI, PD, BOPS with no difference b/w the 2 operator types. The periodontist sites showed slightly greater gains in PAL and less recession than hygienist sites. The average time spent in instrumentation per tooth was 9-12 minutes.

CL: The results of non-sx periodontal therapy b/w different operators were minimal. Overall, it was observed that incisors, cuspids and premolars might be maintained by plaque control and single instrumentation.

Badersten 1987  ARTICLE

P:To observe the effect of non-sx perio tx on probing attachment changes related to clinical characteristics.

M&M:1688 proximal sites in non-molar teeth from 49 pts were monitored for 24 mo. following OHI and root debridement. Gain and loss of CAL was recorded, for incisors, canines, and PM, max or mandibular, presence/absence of endo, and for surfaces w/ and w/o the presence of root concavity/furcation involvement. Changes were compared to: initial PD, radiographic bone score, depth of osseous defect (radiographically), and widened PDL.

R:12% had probing attachment gain, 4% had probing attachment loss (PAL).

  • Sites w/ clinical attachment gain were more frequent in mand cuspids and premolars

  • Intially deeper sites had higher occurrence of clinical attachment gain.

  • More clinical attachment gain occurred in sites w/ more initial bone loss and deeper osseous defects.

  • Sites w/ a widened PDL at baseline, showed more clinical attachment gain than non-widened

  • Presence of IP root concavity or furcation involvement was assoc’d w/ lower frequency of attachment gain

CL:outcome of debridement and maintenance in proximal surfaces of non-molar teeth is not compromised by the severity of the initial soft tissue or bony lesion.

More attachment gain is assoc w/ mand cuspids and premolars, deeper initial PD, deeper osseous defects, widened PDL, and w/ no-root concavities/furcas.

Greenwell 1998 ARTICLE

P:To describe situations in which non-surgical therapy can obscure the disease.

D:Periodontal disease masking results when marginal tissue at 3-4 mm within the gingival margin appears healthy, while apical tissue is unhealthy. This can lead to attachment and bone loss, hidden by the relatively non-inflamed appearance of the gingiva. This is most common after SRP where calculus in the apical part of pocket is missed. Primary goal of post-S/RP is to evaluate for inadequate calculus removal, manifested by residual inflammation, BOP or suppuration. The additional SRP should be directed at calculus removal. Prescribing antibiotics or antimicrobials after SRP would further mask unresolved disease. The most appropriate time for antibiotic therapy is after removal of all calculus & plaque-retentive factors, which is post-surgical, not post-SRP. Reports of abscesses post-prophy demonstrate disease masking. The concept of “soft tissue management” is questionable, since it’s the root, not the soft tissue that needs treatment. Proper non-surgical therapy should include meticulous SRP.

Recognizing disease masking: Absence of BOP & improvement/return of radiographic crestal lamina dura may be the best clinical signs of improved health. Although absence of lamina dura does not mean disease activity present, its reestablishment indicates that disease progression has been halted. Be suspicious of an absent lamina dura. Delayed BOP could be a sign of disease masking and its importance should not be minimized.

Case Report: A 43 year-old healthy patient who underwent surgical therapy for posterior quadrants and was put on 9 SPT/year x 3 years. Despite clinical healthy-looking gingival tissue on anterior areas, BOP was erratic & present about 50 % of time on the area; also, no return in crestal lamina dura & no increase in radiographic density. 2 mm increase in PD was found after 3 years & 1 mm AL around teeth 7 & 8. Sx recommended & burnished calculus found. At 3 years after surgery, increase in bone density was seen, no BOP & Attachment level was stable.

BL:Inadequate SRP or inappropriate antibiotic therapy can potentially mask an area with perio disease. Comparing subsequent exams for BOP & CAL is essential to detect unresolved or recurrent disease.

Matthews 2005 ARTICLE

P:Systematic review to answer the question, “How effective is mechanical nonsurgical pocket therapy?”

M+M: The authors used the Cochrane Oral health Group List of Systematic Reviews in Dentistry, Database of Abstracts of Reviews of Effectiveness, Medline, Embase, and Scisearch. No date or language restriction was imposed. Reference lists of located reviews were checked for additional references. 12 reviews were selected for inclusion, and a narrative appraisal of the reviews was conducted.

R: Implications for clinical practice were identified.

Initial Therapy:

  • Mechanical nonsurgical pocket therapy reduces inflammation and pocket depth and increases clinical attachment level in patients with periodontitis

  • The amount of PD reduction correlates with greater pocket depth before treatment

  • Nonsurgical mechanical debridement may cause loss of attachment in shallow pockets (<3mm)

  • There is no evidence of any difference in efficacy between machine-driven (ultrasonic and sonic) and hand instruments in single-rooted teeth. Machine driven instruments may be faster than hand instruments

  • Adjunctive therapies have been developed and investigated but, to date, no therapy exists as a stand alone replacement for mechanical nonsurgical pocket therapy.

Maintenance Therapy:

  • In periodontal maintenance patients, mechanical debridement reduces inflammation and disturbs the bacterial biofilm, which is though critical to disease control including prevention of progression.

  • Theeffect of mechanical nonsurgical pocket therapy on PD reductionand clinical attachment gain in maintenance patients is unclear; maintenance or stability of pocket PD and clinical attachment level, however , has been demonstrated and meets the goal of maintenance therapy.

  • There is not clear evidence to form recommendations over time taken, thoroughness and frequency of mechanical debridement for periodontal maintenance care

BL: Existing evidence in the form of systematic reviews provides conclusive support for the beneficial effect and efficacy of mechanical nonsurgical pocket therapy in the treatment of periodontal diseases.

Ramfjord 1980  ARTICLE

P:To determine the influence of tooth type on the results of periodontal treatment over 8 years of a longitudinal study.

M&M: Data from a previous periodontal therapy involving 78 patients over 8 years (Knowles et al., 1979) was analyzed with regard to effect of tooth type on treatment results. Initial probing depths (1-3mm, 4-6mm, and 7-12mm) were used as an expression of the severity of the disease. The dentition was divided into six tooth types: Maxillary molars, mandibular molars, maxillary premolars, mandibular premolars, maxillary anteriors, and mandibular anteriors. Probing depths and attachment levels were measured annually.

R:Tooth type has little influence on the response on the periodontal treatment outcome. Reduction in probing depths and potential for attachment level gain were slightly better in anteriors than molars teeth. Poorest results were seen in maxillary premolars and molars, and one of the reasons could be possibly due to furcation complications. The trend was for probing depths to return more rapidly in deep molar pockets than deep anterior pockets. Anterior teeth sustained gain in attachment better than the rest of the teeth in the arch.

BL:Prognosis for treatment of periodontal pockets is good for all tooth types, and this applies to moderate as well as to deep pockets.

Previous Critique: Measurements taken did not really account for furcation involvement, since the straight buccal probing depths were taken from root prominences rather than furcation areas.

Pihlstrom 1984  ARTICLE

Purpose:To investigate the periodontal response of molar and nonmolar teeth to either SRP alone or SRP followed by modified Widman flap (MWF).

Materials and methods: 17 subjects 22-59 years old. After initial scoring of the clinical measurements thorough SRP and OHI were performed by a periodontist in training. Overhangs and defective restorations were corrected and occlusal adjustment was performed when needed. Two quads (one maxillary and one mandibular) per patient were selected to receive MWF. Periodontal prophylaxis was then performed 3-4 times/year. Hopeless teeth were not extracted in the initial treatment, but during the maintenance phase if needed. Clinical measurements were obtained prior to any therapy, 6 months after completion of the therapy and then annually for 4 years. PDs and AL were recorded at 6 sites/tooth.

Results:Of the 17 initial subjects 10 remained as participants after 6,5 years.

PDs 4-6mm: There was 0.4mm less pocket depth at baseline for nonmolar teeth treated with SRP and 0.27mm for nonmolar teeth treated with MWF comparing to molars treated with these procedures. This difference increased throughout the study and 6,5 years nonmolar teeth had an average of 1mm less PD irrespective of typed of procedure performed.

Attachment loss was greater at pretreatment baseline was greater for molar teeth (0.74mm more) and tended to remain the same over the 6,5 year period.

PDs of 7mm or more: For teeth treated with SRP there was a difference of 1.86mm and 2.32mm in PD only at 2 and 3 years post-treatment respectively (deeper in molars). No SSD between the teeth group in other time intervals but there was a tendency for more shallow PDs in nonmolar teeth. Teeth treated with MWF nonmolar teeth had 0.41mm less PD at baseline and the magnitude of this difference increased dramatically over the 6,5 years (2.36mm at 6,5 years with 1.22mm standard error). Differences in AL were only SSD at 2 years after flap procedure with nonmolar teeth having 0.93mm less attachment loss than molars.

Tooth loss: Total tooth loss was 4%. 8/19 teeth before therapy was completed. 11/19 after therapy was completed (2.5% of teeth receiving therapy). 7/11 max molars, 2/11 mand molars, 1/11 deciduous cuspid and 1/11 mand lateral incisor. 5/11 were lost after SRP and 6/11 after SRP + MWF.

Conclusion:1) Both procedures were effective in treating periodontitis in terms of maintenance of CAL on molar and nonpolar teeth

2) For initial PDs of 4-6mm, there was greater PD and a more apical CAL on molar than nonmolar teeth treated by either method

3) For pockets initially 7mm or more, the flap resulted in less PD on nonmolars than molars but there was no difference in CAL between tooth types for either method of therapy.

Claffey, Shanley, 1986  ARTICLE

Purpose:To examine the relationship of gingival thickness, bleeding, and the tendency for attachment loss in shallow buccal sites (< 3.5mm PD) following non-surgical periodontal therapy.

Materials & Methods:

  • 15 pts with moderate-severe perio dz were selected for the study.

  • Pt’s were given 2 sessions of OHI, and on the 2nd session received SRP (Incisors, Canines, PM).

  • Pts received an additional session of OHI 1 week post-SRP. No further OHI or therapy was performed for 3 months.

  • Clinical measurements (CAL, PD, BOP, PI, & gingival thickness) were performed at baseline and at 3 months following debridement for 6 surfaces of experimental teeth.

Results:

  • Slight attachment loss ( 0.1 ± 1.0 mm) was observed for sites initially < 3.5 mm PD.

  • A slight gain (0.5 ± ­1.2 mm) noted for pockets initially 4.0 6.5 mm, and a > gain (1.4 ±1.5 mm) for those initially 7.0 mm.

  • Thin gingiva (<1.5 mm thickness), initially non bleeding sites displayed a mean loss of probing attachment of 0.3mm.

  • Thick gingiva (2.0 mm), non-bleeding sites displayed a less noticeable mean loss of probing attachment, whereas bleedingsites of both categories of gingival thickness showed a tendency towards gains in probing attachment levels.

  • A mean loss of probing attachment was seen with thin, nonbleeding sites.

BL:Sites with bleeding prior to instrumentation did not seem to lose attachment. Thin, non-bleeding sites seem to be ones primarily associated with this probing attachment loss.

Loesche 1996      (sx prevention)              ARTICLE

P:To determine whether the short-term use of systemic antimicrobials (metronidazole or doxycycline) and locally delivered antimicrobials (metronidazole, chlorhexidine) in patients with advanced forms of periodontal disease could prevent access surgery.

M+M: Inclusion criteria: presence of an anaerobic infection, spirochetes greater than 20% of the microscopic count and the hydrolysis of benzoyl- DL-arginine napththylamide (BANA-positive reactions) in at least 3 of 4 subgingival plaque samples taken from the site in each quadrant that had the greatest PD. Subjects examined for number of teeth in need of surgery, those that had >4 teeth needing to be extracted were kept in the study. Study was conducted in a double-blind fashion in which patients were randomly assigned to antimicrobial treatment groups. No patient would receive more than two rounds of systemic antimicrobial treatments or more than three rounds of local antimicrobial treatments about individual teeth. A placebo treatment would be used only in the first round of systemic treatment or in the first round of local treatment. Any patient or tooth still in need of treatment after the first round of the systemic or local treatment would be retreated with the opposite medication from what they had received in the first round. All patients progressed through the first round of treatment. After SRP the patients were randomly assigned to receive either placebo, metronidazole, or doxycycline, for 2 weeks unsupervised at home. If anyone had > 6 teeth in need of surgery or extraction after first round of systemic medication, they were retreated with systemic medication. If they had 6 or less teeth, they were treated with ethyl cellulose (EC) films containing either no addition (placebo), 20% metronidazole, or 20% chlorhexidine. If they had no teeth in need of surgery, SPT every 3 months. 90 of 125 patients initially recruited completed all phases of the study and entered into the recall maintenance program.

Loesche 2005  NO ARTICLE

B:In a previous study involving patients at the dental clinic of a hospital in Detroit, 87% of teeth that initially had been recommended for surgery or extraction were spared either treatment through a combination of debridement and short-term usage of antimicrobial agents.

P:The purpose of the current study was to determine the changes that occurred to these teeth after a median of 6.4 years in the maintenance phase of treatment.

M&M:90 Patients were scheduled for maintenance therapy at 3-month intervals over a period of 6.4 years. Subjects were diagnosed as having an anaerobic periodontal infection if 3 or more of their plaque samples contained spirochetes exceeding 20% of the microscopic count and were capable of hydrolyzing the synthetic peptide benzoyl-DL-arginine naphthylamide (BANA*-positive).

Treatment phase: Pts with 4 or more teeth requiring sx were entered in the protocol.

After debridement, the patients were randomly assigned in a double-blind design to receive metronidazole (500 mg twice daily), doxycycline (100 mg daily), or placebo tablets/capsules for two weeks. Re-eval after 4-6 weeks. Pts that required surgery on 1-6 teeth were treated with locally delivered antimicrobial agents and > 6 teeth requiring surgery were retreated with systemic agents. No patient received more than two systemic treatments and 3 local treatments. Pts were scheduled for debridement every 3 months.

Maintenance phase: q3 months. OHI given, PD and AL, BOP, root topography and nature of bony defect via x-rays, mobility were assessed. Double-blind design prophylactic antimicrobial with metronidazole 500 BID x1wk or placebo was given.

R: 10-15% of the 90pt who entered the maintenance phase were lost.

The results during the maintenance phase were as follows:

55% – no new surgical needs or reduced surgical needs

24% – new surgery or extraction recommended for either 1 or 2 teeth

15% – new surgery or extraction recommended for 3 or 4 teeth

6% – Extraction recommended of at least 8 teeth

  • Initial antimicrobial treatments reduced the surgical needs to an average of 0.5-1.7 in these outcome groups

  • Most of the relapse occurred in multi-rooted teeth, esp. among pts with aggressive periodontitis.

  • The initial antimicrobial treatments reduced the surgical needs of both groups by approximately 85%. There was no difference between the 2 groups during the maintenance phase until the 6.4 year examination, an average of 0.5-1.7 in these outcome groups.

  • Current smoking remained a predicator of surgical needs.

  • An increase maintenance visits were a powerful predictor of increased surgical needs, while prophylactic metronidazole was strongly associated with reduced surgical needs.

C: These findings indicate that an antimicrobial regimen reduced the initial surgical needs of patients by approximately 85%, and this result can be sustained in the maintenance phase by home care, periodic sessions of SRP and annual prescriptions of 1 week of metronidazole.

BANA test*= examines dental plaque, measuring the presence of an arginine hydrolase possessed by 3 anaerobic species associated with periodontal infections (P. Gingivalis, T. denticola, T. forsuthensis).

Drisko 2001(Review)  ARTICLE

P:To review literature that addresses the non-surgical approach to treat periodontal disease.

Discussion:

Anti-infective therapy: Successful periodontal therapy depends of the elimination of pathogens. Since perio disease primary etiology is plaque, and most of the pt are not skilled in removing plaque, periodically professional cleaning is indicated. Includes Mechanical and chemotherapeutic approaches. Debridement is performed to produce a root that is biologically acceptable for a healthy attachment.

Risk Factor: Non-compliance or no regular maintenance care. Insufficient debridemen

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