131. Non-surgery vs. Surgery

Classical Periodontal Literature Review

Rapid Search Topics

Study Questions:

  • 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?
  • Is Surgical Treatment more effective than non surgical treatment? In what way? What studies support that view?
  • How do patient perception differ according to treatment modalities?
  • What changes occur in the maxillary sinus following periodontal treatment?


(References without links have not been added yet)

Non-Surgical Periodontal Treatment – Scaling and Root planing – Expectations/Limitations

  1. Waerhaug J. Healing of the dento-epithelial junction following subgingival plaque control. I. As observed in human biopsy material. J Periodontol. 1978 Jan;49(1):1-8.
  2. Waerhaug J. Healing of the dento-epithelial junction following subgingival plaque control. II: As observed on extracted teeth. J Periodontol. 1978 Mar;49(3):119-34
  3. Rabbani GM, Ash MM Jr, Caffesse RG. The effectiveness of subgingival scaling and root planing in calculus removal. J Periodontol. 1981 Mar; 52(3):119-23.
  4. Morrison EC, Ramfjord SP, Hill RW. Short-term effects of initial, nonsurgical periodontal treatment (hygienic phase). J Clin Periodontol. 1980 Jun;7(3):199-211
  5. Proye M, Caton J, Polson A. Initial healing of periodontal pockets after a single episode of root planing monitored by controlled probing forces. J Periodontol. 1982 May; 53(5):296-301.
  6. Caton J, Proye M, Polson A. Maintenance of healed periodontal pockets after a single episode of root planing. J Periodontol. 1982 Jul;53(7):420-4.
  7. CobbC. Non surgical pocket therapy: Mechanical. Ann Periodontol 1996;1;443-490
  8. Buchanan A., Robertson P. Calculus removal by scaling/root planing with and without surgical access. J Periodontol 1987;58:159-163
  9. 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
  10. Brayer,W et al. Scaling and root planing effectiveness: The effect of root surface access and operator experience. J Periodontol 1989;60:67-72
  11. Badersten A, et al. Effect of nonsurgical periodontal therapy. I. Moderately advanced periodontitis. J. Clin. Periodontol. 8:57-72, 1981.
  12. Badersten A, Nilveus R, Egelberg J: Effect of nonsurgical periodontal therapy. II. Severely advanced periodontitis. J. Clin. Periodontol. 11:63-76, 1984.
  13. Badersten A, Nilveus R, Egelberg J: Effect of non-surgical periodontal therapy. III. Single versus repeated instrumentation.J.Clin.Periodontol.11:114-124, 1984.
  14. Badersten A, et al: Effects of nonsurgical periodontal therapy. IV. Operator variability. J. Clin. Periodontol. 12:190 -200, 1985.
  15. Badersten A, et al: Effect of nonsurgical periodontal therapy. VIII. Probing attachment changesrelated to clinical characteristics. J. Clin. Periodontol. 14:425-432, 1987
  16. Nordland P, Garrett S, Kiger R, Vanooteghem R, Hutchens LH, Egelberg J. The effect of plaque control and root debridement in molar teeth. J Clin Periodontol. 1987 Apr;14(4):231-6
  17. Fleischer, H, Mellonic J et al: Scaling and root planning efficacy in multirooted teeth. J Periodontol 60: 402-409, 1989
  18. Claffey N, Loos B, Gantes B, Martin M, Heins P, Egelberg J. The relative effects of therapy and periodontal disease on loss of probing attachment after root debridement. J Clin Periodontol. 1988 Mar;15(3):163-9.
  19. Greenstein G. Periodontal response to mechanical non-surgical therapy: a review. J Periodontol. 1992 Feb; 63(2):118-30. Review.
  20. Shanbhag S, Dahiya M, Croucher R. The impact of periodontal therapy on oral health-related quality of life in adults: a systematic review. J Clin Periodontol. 2012 Aug; 39(8):725-35.
  21. Greenwell H, Bissada NF, Dodge JR. Disease masking: A hazard of nonsurgical periodontal therapy. Perio Insights December 1998:14-19.
  22. Matthews D. 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
  23. Ramfjord S, et al. Results of periodontal therapy related to tooth type. J. Periodontol. 51:270-273, 1980.
  24. Claffey N, 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.
  25. Loesche W, Soehren S, et al. Nonsurgical treatment of patients with periodontal disease. Oral Surg, Oral Med, Oral Pathol 1996; 81: 533-543.
  26. Loesche WJ, 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
  27. Haffajee AD, Teles RP, Socransky SS. The effect of periodontal therapy on the composition of the subgingival microbiota. Periodontol 2000. 2006;42: 219-58.
  28. Drisko CH. Nonsurgical periodontal therapy. Perio 2000 25:77-88,2001. (Review)
  29. Van der Weijden GAF, Dekkers GJ, Slot DE. Success of non-surgical periodontal therapy in adult periodontitis patients: A retrospective analysis. Int J Dent Hyg. 2019 Nov;17(4

Is Surgical Treatment more effective than non surgical treatment?

  1. Lindhe, et 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. Pihlstrom BL, 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 (moved from above)
  4. Philstrom B, 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.
  5. 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
  6. Ramfjord SP, et al. 4 modalities of periodontal treatment compared over 5 years. J. Clinic Periodontol.14:445-452, 1987.
  7. Kaldahl WB, Kalkwarf KL, Patil KD, Dyer JK, Bates RE: Evaluation of four modalities of periodontal therapy. J Periodontol. 59: 783 -793, 1988
  8. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK. Long-term evaluation of periodontal therapy: I. Response to 4 therapeutic modalities. J Periodontol. 1996 Feb; 67(2):93-102.
  9. Renvert S, et al: 5-year follow-up of periodontal intraosseous defects treated by root planing or flap surgery. J Clin Periodontol 17: 356 – 363, 1990
  10. Mombelli A, 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.
  11. Becker W, 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
  12. Harrel SK, 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.
  13. Heitz-Mayfield LJ. How effective is surgical therapy compared with nonsurgical debridement? Periodontol 2000. 2005;37:72-87.
  14. Mailoa J, Lin GH, Khoshkam V, MacEachern M, Chan HL1, Wang HL. Long-Term Effect of Four Surgical Periodontal Therapies and One Non-Surgical Therapy: A Systematic Review and Meta-Analysis. J Periodontol. 2015 Oct;86(10):1150-8.

Patient perception to different treatment modalities

  1. Kalkwarf K, 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.
  2. Botelho J, Machado V, Proença L, Bellini DH, Chambrone L, Alcoforado G, Mendes JJ.Botelho J, et al.The impact of nonsurgical periodontal treatment on oral health-related quality of life: a systematic review and meta-analysis. Clin Oral Investig. 2020 Feb;24(2):585-596.

Changes in maxillary sinus after periodontal therapy

  1. Falk H, Ericson S, Hugoson A: The effects of periodontal treatment on mucous membrane thickening in the maxillary sinus. J. Clin. Periodontol.13:217-222, 1986.
  2. N Lathiya V, P Kolte A, A Kolte R, R Mody D.N Lathiya V, et al. Effect of periodontal therapy on maxillary sinus mucous membrane thickening in chronic periodontitis: A split-mouth study. J Dent Res Dent Clin Dent Prospects. 2018 Summer;12(3):166-173.

What is the critical probing depth?

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



Non-Surgical Periodontal Treatment – Scaling and Root planing – Expectations/Limitations

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?


Topic: Non-surgical

Authors: Waerhaug J.

Title: Healing of the dento-epithelial junction following subgingival plaque control. I.

As observed in human biopsy material.

Source: J Periodontol. 1978 Jan;49(1):1-8

Type: Clinical

Rating: Good

Keywords: dento-epithelial junction, plaque, scaling and root planing

Purpose: The purpose of the present study was to shed light on the tissue reaction incident to subgingival plaque control in man.

Method: 21 persons, 39 teeth to be extracted. Only teeth on which calculus could be probed at least 2 mm below the gingival margin were included. Meticulous removal of subgingival calculus using small currettes and hoes. In some cases, the scaling was done in combination with a Widman flap operation to attain visibility. All patients were instructed to carry out supragingival plaque control, but not all of them cooperated. The observation period varied between 15 days and 7 months. Most of the biopsies were taken from the vestibular side.

Results: The junctional epithelium invariably became readapted to the tooth surface in areas which previously had been covered with subgingival calculus and plaque. In those cases in which adequate supragingival plaque control had been maintained by the patient, there was virtually no cellular infiltration in the soft tissue wall of the pocket. Subgingival restorations are likely to provide retention areas for plaque which are inaccessible for scalers. In those cases in which plaque control by the patient had been inadequate, supragingival plaque accumulated and caused inflammation in the adjacent gingiva. On 8 out of the 39 experimental teeth, some subgingival plaque had been left behind on the tooth surface during scaling.


  1. A normal dento-epithelial junction is routinely reformed in areas from which subgingival calculus and plaque has been removed.
  2. If adequate supragingival plaque control is instituted, no further subgingival plaque will be formed, and periodontal health can be maintained.
  3. Subgingival plaque left behind during scaling gave rise to a rapid reformation of plaque within the pocket.
  4. Small or large remnants of subgingival plaque do not cause inflammatory reactions which give visible clinical symptoms if a high standard of supragingival plaque control is maintained. Therefore, the clinician may be led to believe that the treatment has been successful.
  5. The front of the remnants of plaque left behind will continue to grow in an apical direction with the same speed as before the scaling, and the loss of attachment will keep speed with the plaque front.
  6. Subgingival restorations are likely to provide retention areas for plaque which are inaccessible for scalers. Such plaque remnant will quickly give rise to new subgingival plaque formation even if adequate supragingival plaque control is maintained.
  7. Biopsies from the dento-gingival junction cannot be removed without the junctional epithelium being moved in relation to the tooth. If the soft tissue is fixed in its proper place, the location of the rupture cannot be seen in the section. Thus, conclusions on the nature and strength of the epithelial attachment based on light microscope studies should be drawn with care. The same caution should be observed in electron microscope studies.


Topic: Plaque front

Authors: Waerhaug J.

Title: Healing of the dento-epithelial junction following subgingival plaque control. II:

As observed on extracted teeth.

Source: J Periodontol. 1978 Mar;49(3):119-34

Type: In vitro

Keywords: oral hygiene, orthodontics, tissue healing, dento-epithelial junction

Purpose: Determine what happens on the tooth surface in the hidden ara of the gingival pocket following of the sub gingivial plaque control

Methods and Materials: 84 teeth planned for extraction were included. Sub g plaque was removed with hand instruments and sometimes a small rotating diamond bur. In 53 cases the SRP were carried out at varying observation periods before extraction as to establish how quickly a normal DEJ will reestablish and conversely how quickly and in which was sub g plaque reformed.

Results: It was observed that complete plaque removal was more likely seen in shallower PDs whereas plaque was commonly left behind in the deeper areas. It was seen that narrower spaces such as furcations, and certain root anatomy make plaque removal difficult. Restoration of the DEJ around teeth was seen around completely plaque free surfaces. The distance from the plaque front to the periodontal fibers was seen to range from 0.5mm to 1mm.

Conclusions: Chances of plaque removing all of sub g plaque from all 4 surfaces are fairly good if the PD is less than 3mm, if the PD ranges from 3-5mm the chances of failure are greater than the chances of success and if the PD is >5mm the chances of failure dominate. If all sub g plaque is removed, the JE will readapt to plaque free surface from the borderline of the attachment fibers to the gingival margin.


Topic: Non Surgical Treatment

Authors: Rabbani GM, Ash MM Jr, Caffesse RG.

Title: The effectiveness of subgingival scaling and root planing in calculus removal.

Source: J Periodontol. 1981 Mar; 52(3):119-23.

Type: Clinical study

Keywords: subgingival scaling, root planning, pocket depth, calculus

Purpose: To evaluate the effectiveness of subgingival scaling and root planing related to depth of pocket and type of teeth.

Methods: A total of 119 teeth in 25 patients were selected; 62 were scaled and 57 were used as controls. All teeth were initially scored using the calculus index of the P.D.I. (Ramfjord). Six surface locations were probed to determine pocket depth. The levels of the gingival margin were marked on the teeth to locate supra and subgingival calculus after extraction. The experimental teeth then were scaled. Both scaled and unsealed teeth were extracted immediately after the experimental procedures. The teeth were washed with water and stained with methylene blue. They were viewed under a stereomicroscope which had a tenth grid on its eyepiece. Percent of surface covered by calculus was assessed on both scaled and unsealed teeth.

Results: The results demonstrated a high correlation between percent of residual calculus and pocket depth. It was shown that pockets less than 3 mm were the easiest sites for scaling and root planing. Pocket depths between 3 to 5 mm were more difficult to scale and pockets deeper than 5 mm were the most difficult. Tooth type did not influence the results.


Topic: non-surgical

Authors: Morrison EC, Ramfjord SP, Hill RW.

Title: Short-term effects of initial, nonsurgical periodontal treatment (hygienic phase).

Source: J Clin Periodontol. 1980 Jun;7(3):199-211

Type: longitudinal

Keywords: longitudinal, periodontal treatment, hygienic phase, attachment level

Purpose: To examine the short-term effect of treatment of the hygienic phase.

Methods: 90 patients (2335 teeth) with some pockets extending 4mm or more apically to the CEJ were entered. Pre-treatment pocket depths and attachment levels were measured in 5 sites. Plaque, gingival, calculus and plaque indices were recorded. Scaling, root planing (by a hygienist under supervision of a periodontist), instruction in oral hygiene and occlusal adjustment were completed during four to six sessions for each patient. 4 weeks after completion of the hygienic phase, all variables were recorded.

Results: A significant decrease in plaque and gingival indices was seen. Mean measurements for pocket depths 1-3, 4-6, and > 7mm were compared to their post-treatment scores;

  • Pocket depths decreased significantly for pockets 4mm or more.
  • For pockets 4-6 mm, there was a mean difference in pocket depth of 0.96 mm between pre-and post-treatment observations.
  • For pockets 7 or more, the mean difference was 2.22mm.
  • Pocket reduction was in part due to the improvement in attachment levels.

Conclusion: Severity of periodontitis is significantly reduced 1 month following the hygienic phase of periodontal therapy, and that need for surgical treatment cannot be assessed properly until completion of the hygienic phase of treatment.



Topic: Initial therapy

Author: Proye M, Caton J, Polson A

Title: Initial healing of periodontal pockets after a single episode of root planing monitored by controlled probing forces

Source: J Periodontol. 1982 May; 53(5):296-301

Type: Prospective study

Keywords: Healing; scaling and root planing

Purpose: To characterize periodontal pocket response within 1 month after a single episode of root planing and to evaluate the probing characteristics of such pockets using both controlled and manual probing forces.


  • 10 patients (5m, 5f) requiring treatment for chronic periodontitis.
  • Each patient had 6 or more interproximal pockets greater than 3mm. A total of 128 interproximal pockets were subjected to a single episode of root planing and monitored for changes.
  • Clinical measurements were taken at baseline, and 1, 2, 3, and 4 weeks after the single episode of SRP (Visual inflammation, bacterial plaque, PD, BOP, gingival margin location, CAL)
  • To evaluate BOP, a controlled probing of 15gm, 25gm, 50gm and a manual probe were used.


  • The PI was SS reduced compared between baseline and 1 week, but NSSD between any of the weeks following SRP.
  • Irrespective of probing force used, there was a SS reduction in the number of bleeding pockets at 1 week.
  • When 15 and 25gm were used, there was a virtual elimination of the bleeding tendency 3 weeks after SRP.
  • At 4 weeks, only PD recorded with controlled probing forces, and not with the manual probing, was SS less than that recorded at the 1-week time point.
  • At 1 week there was a SS greater amount of recession, but NSSD were noted at any other time
  • The loss of attachment was SS less than the baseline values at the 3-week post-root planing.

Discussion: The reduction in pocket depth consisted of two phases: a component due to gingival recession, and a component due to gain in clinical attachment. The reduction in pocket depth at 1 week was due primarily gingival recession, whereas the reduction at 3 weeks was due to gain in clinical attachment.


Topic: Scaling and root planing

Author: Caton J, Proye M, Polson A

Title: Maintenance of healed periodontal pockets after a single episode of root planing

Source: J Periodontol. 1982 Jul;53(7):420-4.

Type: Clinical study

Keywords: Scaling and root planing, recall interval, maintenance, clinical study

Purpose: To evaluate the behavior of healed periodontal pockets over an additional 3 month time period to determine whether detrimental clinical signs recur during this commonly recommended interval between periodontal recall maintenance appointments.

Methods: 128 pockets 3-7 mm in depth distributed in 10 patients were monitored immediately before and 1, 2, 3, 4, 8 and 16 weeks after a single episode of subgingival root planing. Oral hygiene instruction and supragingival cleaning were given at each time point. Maintenance of the healed pockets was followed from 4-16 weeks after root planing. Plaque index, inflammation, bleeding on probing, pocket depth, gingival margin location, and clinical attachment level were assessed. Data analysis was performed.

Results: The initial improvement in gingival health noted during the first 4 weeks after root planing was maintained from 4 to 16 weeks. Plaque and inflammation reduction were also maintained up to 16 weeks. A reduction in BOP was noted at 4 weeks and maintained up to 16 weeks. Pocket depth, recession, and clinical attachment levels were also not significantly different from 4 to 16 weeks.

Discussion: Beneficial changes seen at 4 weeks after initial therapy can be maintained as long as 16 weeks with proper main oral hygiene, suggesting that the 3-4 month maintenance regiment is appropriate and effective in patients with good plaque control.

Cobb 1996

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.


  • 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

    • Age

    • 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

  • Mean PD reduction 4-6mm PD- 1.29mm, 7mm PD-2.16mm

  • 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)

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.


  • 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.

  • Both treatment 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.

  • The effects 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

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

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 2nd year 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)

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.


  • 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)

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)

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.

PI was 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)

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

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

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

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.

  • The effect of mechanical nonsurgical pocket therapy on PD reduction and 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

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

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.

Topic: Scaling and root planing

Author: Nordland P, Garrett S, Kiger R, Vanooteghem R, Hutchens LH, Egelberg J

Title: The effect of plaque control and root debridement in molar teeth

Source: J Clin Periodontol. 1987 Apr;14(4):231-6

Type: Clinical study

Keywords: Plaque control, root debridement, molar teeth

Purpose: To compare the effects of plaque control and root debridement in non-molar sites, molar flat surface sites, and molar furcation sites.

Methods: 19 patients participated in the study. After baseline examination and 6 months of oral hygiene instruction/reinforcement, patients received a single episode of crown and root debridement. Patients received maintenance at 15, 18, and 21 months. Clinical parameters were recorded at baseline and every 3 months for the 24 month study. Parameters incuded plaque, bleeding on probing, probing depth and attachment level. Statistical analysis was performed based on anatomical group (non-molar, flat molar surface, furcation areas) and compared.

Results: Plaque scores were reduced significantly at 3 and 6 months for all groups, then deteriorated thereafter. BOP was also significantly reduced for all groups at 3 and 6 months, followed by deterioration. Furcation areas had the highest amount of bleeding, especially when deeper probing depth were present. Probing depth reduction was seen in pockets initially 4-6.5 mm and were maintained for the 24-month study. Furcation areas had the highest tendency for PD relapse. Furcation areas showed a gradual loss of attachment, whereas non-molar and flat molar areas showed a slight gain with a return to baseline at 24 months. Furcation sites showed a higher percentage of deterioration in probing attachment loss compared to sites on non-molar and flat-molar surfaces.

Discussion: Flat molar sites respond in a similar manner to non-molar sites when treated by plaque control and root debridement. A poorer response was seen in furcation sites when compared to flat and non-molar sites with the same initial probing depths.


Topic: SRP Molars

Author: Fleischer H, Mellonig J

Title: Scaling and root planning efficacy in multi-rooted teeth.

Source: J Periodontol 1989; 60: 402-409

Type: Clinical

Keywords: Scaling and root planning, periodontal disease, operator experience, molar teeth

Purpose: The goal of the study was to address two questions:

  1. Is the effectiveness of scaling and root planning (SRP) of multi-rooted teeth enhanced by surgical access?
  2. Are the results of this treatment different between operators of two different experience levels?

Methods: 61 Molars designated for extraction with at least one probing depth of 6mm and no recent periodontal treatment were included in the study. Teeth were randomly assigned to 1 of 5 groups. Group 1 and 2 received closed SRP, group 3 and 4 received open SRP, and group 5 received nothing. Groups 1 and 3 were treated by an experienced periodontist, while groups 2 and 4 were treated by a periodontal resident. During treatment, grooves were made at the free gingival margin as a reference point. Teeth were scaled with or without flap with and the time was recorded. Teeth were extracted and each root surface was analyzed for remaining calculus. Teeth were sectioned to analyze the presence of remaining calculus in the furcation.


  • There was no difference in the effectiveness of SRP in pockets less than 4mm for either open or closed debridement.
  • There was a significant difference between groups for open and closed SRP for pockets of 4-6mm and >6mm.
  • Evidence shows that the ability to achieve a calculus-free surface decreases with increasing probing depth.
  • With either open or closed SRP, the more experienced operator was more effective at calculus removal. Both operators were significantly more effective at calculus removal with open SRP.
  • Calculus removal in the furcation area was significantly improved with open SRP.
  • Residual calculus on the root was found most often at the entrance of the furcation, external and furcation line angles, just below the CEJ, and in root concavities.

Conclusion: The results suggest that surgical access for SRP and a more experienced operator significantly enhance calculus removal in molars with furcation involvement. Total calculus removal in furcations with conventional instrumentation is limited.

Topic: Non-surgical

Authors: Claffey N, Loos B, Gantes B, Martin M, Heins P, Egelberg J

Title: The relative effects of therapy and periodontal disease on loss of probing attachment after root debridement

Source: J Clin Periodontol. 1988 Mar;15(3):163-9.

Type: Clinical

Keywords: Probing attachment, root debridement, loss of periodontal attachment

Purpose: To investigate the immediate effects, and the effects during 12 months, of a single episode of root debridement.

Method: 9 perio patients with 1248 sites were included in the study. A single session of SRP was done. Single recordings for probing depths and probing attachment levels were made at baseline, 3, 6, 9 and 12 months. In addition, triplicate recordings of attachment levels were made for all sites by 3 independent examiners immediately prior to debridement, immediately post debridement, and at 3 and 12 months.

Results: Mean CAL of 0.5 to 0.6 mm occurred because of instrumentation, irrespective of initial probing depth. Individual sites were identified as having lost probing attachment using a sites specific standard deviation for measurement variability and a > 1.0 mm change. 5% of all sites lost probing attachment from pre-instrumentation to 12 months. Approximately half of these had probing attachment loss inflicted during instrumentation. 23 sites (2% of all sites) were identified as having lost probing attachment from the post-instrumentation time point to 12 months. Most these sites seemed to undergo this probing attachment loss because of a remodeling process during the healing phase

Conclusion: Most the attachment loss identified seems to be either directly attributable to instrumentation or to a remodeling process because of the therapy rather than to progressive periodontitis.


Topic: Pathogenesis

Authors: Greenstein G.

Title: Periodontal response to mechanical non-surgical therapy: a review.

Source: J Periodontol. 1992 Feb; 63(2):118-30.

Type: Review

Keywords: oral hygiene, personal oral hygiene, mechanical instrumentation, plaque retention

Discussion: This review is concerned with the ability of personal oral hygiene and mechanical instrumentation to establish and maintain periodontal health. Clinical, microbiologic, and histologic responses to non-surgical therapy are evaluated to provide guidelines for expected treatment results. Factors that may limit the effectiveness of non-surgical therapy as a closed procedure are also addressed. These include length of therapy, skill of therapists, patient compliance, responsibility of clinician for maintenance, and disease activity status of the patient.Effects of Personal Oral Hygiene on Perio status: Cercek reported that oral hygiene performed by patients caused an approximate 25% decrease in bleeding tendency, about 0.5mm reduction in PD, no gain of CAL, and 0.7mm of recession. Conflicting data exists regarding the effect of personal oral hygiene on sub g microflora. Smulow found decreased gram neg bacteria after 3 weeks of daily supra g plaque control.

  • Ability of SRP w/o surgical access for perio health: complete removal of sub g plaque is difficult, Caffesse reportd that roots were completely cleaned 83% of the time when PDs were 1 to 3mm, 43% in PDs 3-5mm, 32% >6mm.
  • Factors that may limit effectiveness of non-sx therapy: skill level of therapist, varying level of compliance of patients with professional maintenance and personal plaque control (Wilson study, 16% good compliers, 49% erratic, 34% poor compliers), disease activity (BOP and increased but static deeper PDs are not a reliable measurement of disease activity or breakdown).

Conclusion: If factors associated with successful treatment are accommodated (root debridement, compliance of supportive therapy, oral hygiene), then the potential for successful non-surgical care is greater than previously thought and should be given increased consideration as a definitive mode of therapy for patients and clinicians.


Topic: Non Surgical Treatment

Authors: Shanbhag S, Dahiya M, Croucher R.

Title: The impact of periodontal therapy on oral health-related quality of life in adults: a systematic review.

Source: J Clin Periodontol. 2012 Aug; 39(8):725-35.

Type: Systematic review

Keywords: periodontal disease, periodontal therapy, oral health, quality of life

BACKGROUND: Periodontal disease negatively affects oral health-related quality of life (OHRQoL). While there is sufficient evidence for the clinical efficacy of periodontal therapy, data on patient-based outcomes are limited.

OBJECTIVES: To systematically review the available evidence on the impact of periodontal therapy on OHRQoL in adults.

MATERIAL & METHODS: MEDLINE, EMBASE, CENTRAL and LILACS were searched without language restrictions. Longitudinal observational and intervention studies assessing changes in OHRQoL using validated measures, in adults with periodontal disease undergoing non-surgical (NST) or surgical therapy (ST), were eligible for inclusion. Study quality was assessed using the Newcastle-Ottawa scale and CONSORT-checklist. No meta-analysis was performed.

RESULTS: Eleven studies (seven prospective case-series’, one controlled before-after study and three randomized controlled trials) of “medium” methodological quality were included in the review. All studies reported impaired OHRQoL before therapy. Nine studies reported a statistically significant improvement in OHRQoL after NST (follow-up = 1 week to 12 months, p < 0.05). The effect size for this improvement ranged from small (0.27) to large (0.8). No significant differences were reported between different forms of NST. Surgical therapy had a relatively lower impact on OHRQoL. A correlation between poor clinical response to therapy and poor OHRQoL outcomes was observed.

CONCLUSION: Routine non-surgical therapy can moderately improve the OHRQoL in adults with periodontal disease.

Claffey, Shanley, 1986

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.


  • 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 bleeding sites 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)

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

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)

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


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 debridement. Sys disease. Genetics. Smoking. Furcation involvement. Pockets >5mm may have better result with sx.

Principles to control disease: Plaque control care alone won’t provide a good long term result. Debridement should perform every 3 months. Mechanical therapy: Modified ultrasonic tips reach furcations and pockets >5mm better. Manual and power driven instruments are equally effective. Power driven instruments or it combination with manual may produce the best overall result.

Antimicrobial agents: Due to pt inability of plaque control chemotherapy is often needed. Indicated when mechanical debridement alone may not be effective, especially deep pockets. Poor plaque control, bacteria can’t be eradicated with out antibiotic therapy (A.a). Mouth rinses and dentifrices can reduce plaque accumulation. Sub-gingival re-population occurs within 40-60d with poor supragingival plaque control and 120-240d with a good control.

Local drug delivery: Rationale is to locally kill or reduce the microbes in the pocket. Radvar compared Tetracycline fiber, metronidazole gel and minocycline gel and all improved CAL without difference b/w them. Atridox has showed CAL gain of 0.8mm and PD reduction 1.3mm.

Antibiotics: For cases that not respond as well as expected. Radiographic bone fill and periodontal regeneration has been reported with SRP + Sys Ab in patients with LAP.

Host Modulation: Periostat: Block enzymes associated with alveolar bone and connective tissue loss. Clinical differences are small, but have shown more PD reduction and more CAL.

Total health: Periodontal disease is associated with diabetes, cardiovascular disease, pre-term low birth weight babies.

BL: Nonsurgical therapy remains the cornerstone of periodontal treatment. Attention to detail, patient compliance and proper selection of adjunctive antimicrobial agents for sustained plaque control are important elements in achieving successful long-term results. Frequent re-evaluation and careful monitoring allows the practitioner the opportunity to intervene early in the disease state, to reverse or arrest the progression of periodontal disease with meticulous nonsurgical anti-infective therapy.

Topic: Subgingival microbiota

Author: Haffajee AD, Teles RP, Socransky SS

Title: The effect of periodontal therapy on the composition of the subgingival microbiota

Source: Periodontol 2000 2006;42: 219-58

Type: Review

Purpose: This article synthesizes data from various longitudinal studies of periodontal therapy conducted at The Forsyth Institute in order to show the changes that occur in the subgingival microbiota and the relationship to changes in periodontal status.

Methods: Data from multiple studies conducted over a 10-year span were collected. In each group, clinical measurements and microbial sampling was conducted at baseline and different time points up to 2 years after treatment. Treatment modalities included combinations of: scaling and root planning, systemic antibiotics, local antibiotics, modified Widman flap surgery, apically repositioned flap surgery, and maintenance. A total of 493 subjects from the different studies were included, making a total of 17 different treatment groups. Similarities between the studies include: randomized clinical trials, similar clinical monitoring, and standardized clinical measurements. Examiners were calibrated for each study. All patients were systemically healthy with chronic periodontitis (at least 8 teeth with PD’s >4mm). All microbiological monitoring was performed in the same manner for all studies, samples were taken with sterile Gracey curettes from the mesial aspect of all teeth. Samples were monitored for 40-bacterial species.


  1. Effect of the employed periodontal therapies on clinical parameters:
    1. Improvement was seen for all modalities from baseline to 3 months and there was a continued modest improvement to 12-months post therapy.
    2. Mean full mouth pocket depth reduction at 12 months was 0.59mm
      1. Initial PDs >7mm showed a mean reduction of >3mm while sites with an initial PD of 1mm increased PD by 0.3mm.
      2. >80% of sites with an initial PD of >4mm had a reduction in PD at 12 months.
  • Deeper sites received the most benefit from therapy.
  1. Individual responses varied: 88.6% of subjects had a mean reduction in PD and 11.4% of subjects showed a mean increase in PD.
  1. Effect of the employed periodontal therapies on microbiological parameters
    1. All therapies reduced the total subgingival bacterial count significantly at 3 months and was maintained to 12 months.
    2. The majority of species decreased in highly colonized sites were members of the red and orange complexes.
    3. The pattern of reduction and recolonization over time differed among species
      1. P. intermedia: decreased and remained reduced
      2. T. forsythia: greatly decreased and slowly increased from 6-12 months
  • F. nucleatum: decreased and returned to baseline at 12 months
  1. Sites were divided into subsets of <4, 4-6 and >6mm PD.
    1. Lowest counts of species were seen in <4mm pockets
    2. Highest counts of species were seen in >6mm pockets
  • While deeper sites (>6mm) had the greatest reduction in species and counts of microbes, the residual counts were still higher than baseline counts for shallow pockets (<4mm).
  1. Sites that had BOP had significant higher counts of 13/40 species including all red complex and many orange complex species.
    1. Sites with initial BOP often had faster recolonization of T. forsythia, P. gingivalis, P. intermedia, and P. nigrescens.
  2. Relationship between change in clinical parameters and change in microbial parameters
    1. The decrease in mean pocket depth was significantly related to:
      1. Decrease in counts of T. forsythia, P. gingivalis and C. gingivalis
      2. Decrease in proportions of T. forsythia, C. gingivalis and red complex
  • Decrease in % of sites colonized by 11/40 species
  1. Gain in attachment level at 12 months was significantly associated with:
    1. Decrease in counts of T. forsythia and P. gingivalis
    2. Decrease in % of T. forsythia and red complex
  • Decrease in % of sites with T. forsythia and P. gingivalis
  1. Relationship between change in clinical parameter and change in microbiological parameters at individual sites
    1. The greatest reductions in mean bacterial counts at 12 months were seen at sites that gained attachment level. Especially considering red complex species.
    2. Sites that exhibited little change in attachment showed the least mean change in species counts.
  2. Changes in mean microbial counts at periodontal sites exhibiting attachment level gain or loss during periodontal maintenance therapy
    1. Sites that gained attachment showed a mean reduction for many species or continued low levels from 3-12 months.
    2. Sites that showed new attachment loss exhibited mean increases in subgingival taxa.
  3. Effect of different periodontal therapies on clinical parameters
    1. All treatments (with the exception of Modified Widman flap and APF) showed a mean gain in attachment level at 12 months.
    2. Loss of attachment was seen and was expected in the surgery groups.
    3. There was a better mean attachment gain in subjects that received adjunctive systemic antibiotics than patients who only received mechanical debridement.
    4. All groups showed reductions in mean pocket depth at 12 months.
  4. Comparison of responses to periodontal therapies that included or did not include systemically administered antibiotics
    1. Subjects receiving systemic antibiotics responded better than those not receiving such agents at 12 months.
    2. However, there was a significant amount of variability in both groups.
  5. Risk-burden for disease progression of sites in subjects who did or did not receive adjunctive systemically administered antibiotics
    1. Systemic antibiotics reduced the risk of a site showing disease progression and reduced the number of sites that showed disease progression –this represents an overall decreased burden on the clinician
    2. The progression of sites was cut in half by adding the systemic antibiotics.
  6. Effect of baseline pathogen levels on clinical outcomes after different therapies
    1. Sites with greater baseline levels of P. gingivalis exhibited greater pocket depth reduction for any treatment group.
    2. Treatment that included periodontal surgery reduced PD at sites with different levels of P. gingivalis more than treatment including systemic antibiotics.
    3. Greater attachment level reduction occurred at sites with higher P. gingivalis.
  7. Effect of different periodontal therapies on microbiological parameters
    1. In general subjects receiving therapy that included systemic antibiotics had a better response.
    2. Systemic antibiotics reduced all species of the red complex and 9/12 orange complex species at 12 months.
  8. Overall effects of periodontal therapy on clinical parameters and the subgingival microbiota to 2 years
    1. There was a decrease in mean clinical parameters over time for the entire group of subjects, the major reductions occurred at 3-months but remained at lowered levels to 24 months.
    2. The pattern of red and orange complex species showed the greatest reduction post-therapy and was maintained until the 2-year time point.
    3. Reduction in specific bacterial species was associated with gain in attachment level including: E. nodatum, T. forsythia, P. gingivalis, T. denticola
    4. Failure to reduce periodontal pathogens after therapy leads to a diminished therapeutic benefit
  9. Effects of individual therapies on clinical parameters and the subgingival microbiota to 2 years
    1. The greatest pocket depth reduction occurred in subjects receiving surgery together with systemic antibiotics
    2. Attachment level change over 24-months was less consistent
    3. The least pocket depth reduction occurred in subjects who received neither adjunctive surgery or systemic antibiotics
    4. Systemic amoxicillin and metronidazole provided significantly better attachment level gain and PD reduction from 6 to 24 months
    5. This 24-month data suggests that benefits of therapy can be seen past the initial 3-6months.
  10. Polymicrobial complexes and different periodontal therapies
    1. Subgingival microbial species occur in specific associations in subgingival biolfilms
    2. Initiation and progression of periodontitis may be polymicrobial in nature
    3. Cluster analysis shows different subjects with similar clusters of microbes
    4. Clusters with high levels of red complex respond to a variety of therapies
    5. Clusters with low red complex but high E. nodatum or Actinomyces species did not respond as well.

Conclusion: 2 important phenomena occur as a result of mechanical removal of organisms: 1) a shift in proportions on species during the recolonization period 2) habit modification. Streptococcus species recolonize quickly, but periodontal pathogens return more slowly. If a species depends on the presence of a deep pocket, then modification of the habitat can alter recolonization. The addition of systemic antibiotics may enhance clinical responses. However, subjects differ in the composition of their subgingival microbiota and may respond differently. The goal of future studies should match treatment to the specific microbial profiles. The major outcome of most forms of periodontal therapy is establishment of an uneasy equilibrium with lower numbers of pathogens which must be maintained.


Topic: Non-surgical therapy

Author: Van der Weijden GAF, Dekkers GJ, Slot DE.

Title: Success of non-surgical periodontal therapy in adult periodontitis patients: A retrospective analysis.

Source: Int J Dent Hyg. 2019 Nov;17(4):309-317.

DOI: 10.1111/idh.12399

Type: Retrospective analysis

Keywords: Non-surgical periodontal therapy, adults, peridontitis 

Purpose: What are the results of active non-surgical treatment in patients diagnosed with adult periodontitis treated in a specialized clinic for periodontology? 

Methods: A total of 1182 patients with moderate to severe adult periodontitis were involved in the study. At the first appointment, baseline measurements were made including PD, BOP, and furcation involvement. Patients then received SRP of all teeth with piezoelectric and hand instrumentation. Patients were prescribed amoxicillin 375 mg with metronidazole 250 mg 3 times daily for 7 days. Patients returned 6 weeks later for recall, where OHI was reinforced, and a prophy was performed with subgingival debridement as needed. About 2.5 months later, a final evaluation was performed with PD, BOP, and FI measured again. Smoking status and age were also recorded. 

Results: Overall, 39% of patients achieved the success of pockets <= 5mm. Single rooted teeth had a greater success rate (85%) compared to molars (47%). Teeth with furcation involvement had a lower rate of success than teeth without (55% for molars with furcations had residual pockets >5 mm). Mean BOP was 13.9 +/- 11.1%. If BOP was the main clinical determinant for health, 44% of patients were considered successful. Only 19% of patients had pocket depths <= 5 mm with < 10% BOP. The mean starting age was 52.6+/- 9.8 years and 28.6% of patients were smokers, though total cigarettes per day was not recorded. There was no significant difference between smokers and non-smokers for the presence of initially deep pockets, but smokers overall had a slightly poorer response to therapy (15% BOP for smokers vs 13% for non-smokers). 

Conclusion: About one third of the patients achieved the success endpoint of PD <= 5 mm, which was most often obtained in the anterior teeth and premolars. Factors affecting outcome included tooth type, furcation involvement, severity of periodontal disease at intake, and smoking status. Single-rooted teeth had better outcomes than molar teeth, especially molars with furcation involvement.


Is Surgical Treatment more effective than non surgical treatment?

Lindhe 1984

P: To further analyze the role played by the patients’ self-performed plaque control in preventing recurrent periodontal disease and to assess the periodontal conditions of this group of patients 5 years after completion of active treatment with special emphasis on sites with initial pocket depth >3mm.

M&M: 15 subjects w/ mean age of 47.9 selected at random. Following baseline exam, all patients were subjected to treatment utilizing a split mouth design. One side of mouth had SRP w/ a modified Widman flap while the contralateral quadrants were treated by subgingival SRP. Following tx the pts were maintained every 2 weeks with professional cleaning for 6 months. For the following 18 months the recall was extended to 3 months. Pts were evaluated for PI, GI, PD, and CAL at baseline, 6, 12, 24 months. Following 24 months the recall appointments were extended to 4-6 months and maintenance was restricted to OHI and professional supragingival cleaning. Further subgingival instrumentation was avoided. 36, 48, and 60 months after active treatment the quality of the patient’s self-performed plaque control was assessed. At 60 months PI, GI, PD, and CAL were measured.

R: Patients were divided into total sample, subgroup 1 (patients who had excellent standard of OH during the 5 year period), and subgroup 2 (patients who failed to maintain proper standard of oral hygiene). No obvious difference in attachment level alteration between the two groups but loss of attachment was more prevalent at interproximal than buccal surfaces. Subgroup 1 only had loss of attachment in 2-3% of sites where as 95% of the sites remained unchanged or gained attachment. There were no differences between the 2 treatment groups or between interproximal and buccal sites. Subgroup 2 had no sites with a gain in attachment but loss of attachment was found in 20% of the sites. Subgroup 1 had 85% of initial deep pockets ≥4mm reduced (majority more than 2mm) which was less evident in subgroup 2. Gain of attachment occurred more frequently in subgroup 1 than subgroup 2. Subgroup 2 had more sites with clinical attachment loss in the quadrants treated surgically than the ones treated with SRP alone (36% vs 18%).

BL: Oral hygiene has a decisive influence on long-term result of treatment of periodontal disease. Pts who consistently had a high frequency of plaque-free tooth surfaces showed few signs of recurrent gingivitis, increased PD, or additional CAL. The opposite is true for pts with poor oral hygiene. Initial pocket depth ≥3 mm responded equally well to the non-surgical as the surgical mode of treatment. The critical determinant in periodontal therapy is the removal of inxn and debridement of the root surface is properly performed.

Caffesse 1986

P: To evaluate the effectiveness of SRP on calculus removal with or without the use of periodontal flap for access.

M&M: 21 patients, 29-88 years old, with at least 6 teeth, no history of periodontal treatment who were planned for extractions and immediate denture placement were included. Pre-operatively: calculus was scored and PDs were measured. A mark was placed at the level of the free gingival margin to allow differentiation between supra-g and sub-g calculus. Prior to extraction, 2/6 teeth received sc/rp, 2 of the remaining 4 teeth received sr/rp +gingival flap, the rest 2 were left unscaled and served as control. Maxillary and mandibular incisors, cuspids, bicuspids and first and second molars were included. The teeth were extracted and residual calculus was examined by a stereomicroscope. Total number of teeth was 127 (43 scaled, 42 flapped and 42 control teeth).

R: % of calculus free surfaces after treatment

Pocket depth

SC/RP alone











NSSD between anterior and posterior teeth. SSD for % of remaining calculus and PD (probability of leaving calculus increases as PD increases). Areas where residual calculus was found was apical to restorations, furcations, developmental grooves, as well as the CEJ area.

CON: Periodontal flaps for access provide a means for greater reduction of residual calculus in PDs>3mm. The % of residual calculus is related to PD, despite treatment approach. Anterior and posterior teeth respond similarly. Despite open flap approach residual calculus was still found to be significant.

Pihlstrom 1983 ( Comparisons)

P: A review comparing surgical versus non-surgical treatment, with additional data from a study comparing these 2 methods of therapy over 6.5 years

Review of literature:

Wasserman 1978: 7.1% loss rate for treated teeth in 600 pts over 22 yrs. 40% of patients had surgical intervention (pts who appeared to be more susceptible to disease had more surgery). Tooth retention was more related to susceptibility to recurrent disease or case type than method of therapy.

McFall 1982: 100 surgically treated and maintained pts, 832 teeth, maintenance for 15-29 years. 16% of teeth were lost. 2,627 teeth treated non-surgically, 9.9% were lost (does not mean less teeth are lost w/ non-surgical but that more advanced disease is treated more aggressively). However, 23 of the 100pts accounted for 80% of the tooth loss, so 77% of the pts lost an avg of 0.68teeth.

Ross and Thompson 1971: 180 pts followed for 2-20 years, 15 pts accounted for 60% of tooth loss. These findings suggest that disease activity is more important in retention/prognosis than therapy delivered.

Nyman 1975: Perio surgery w/o a regular maintenance program and OHI will fail. Recall of every 3months is sufficient to maintain effects of therapy (Ramjford 1982).

Listgartenand and Levin 1981: Large subgingival population of spirochetes and motile rods precede detectable CAL loss.

M+M: Longitudonal study analyzing the 6.5 year results. 17 pts (25-59 years old) diagnosed w/ moderate-advanced periodontitis (PDs 1-14mm, 453 teeth) were utilized in a split-mouth design study to compare the effects of SRP alone and combined with MWF surgery. Study started w/ 17 subjects but only 10 pts were available at 6 ½ years. Time for SRP was 2 hours 3-4 appointments Data were collected at baseline, 6 months after treatment, every year up to 4 years, and then at 5.5 and 6.5 years. Recalls for all pts were 3-4 times/year, OHI reinforced.


  • Sites w/ PD < 3 mm lost some attachment after SRP+ MWF, but not after SRP aloneSSD of 0.75 mm of AL for first 6 months and maintained AL loss of 0.7 mm over the entire 6.5 years

  • Sites w/ PD of 4-6 mm showed similar amount of PD reduction after both treatments after 2 – 6.5 years. SRP w/ flap was more effective at 6 month and 1 year. Some gain of attachment was noticed with SRP alone (about 0.5 mm from 6 month up to 6.5 years).

  • Sites w/PD > 7 mm showed slightly more reduction of PD following SRP+MWF. Compared to baseline, PD decrease was sustained for 6.5 years afer SRP w/flap, and only for 3.5 years after SRP alone.

BL: SRP alone or in combination with MWF surgery resulted in sustained decreases in gingivitis, plaque and calculus but neither procedure appears to be superior with respect to these parameters. Surgery had slightly better 2 year results but showed no advantage by 6.5 years over SRP alone, except for more sustained PD reduction in deep pockets. Decision for or against surgery must be made on individual basis.

Topic: Non Surgical Treatment

Authors: Ramfjord SP, et al

Title: 4 modalities of periodontal treatment compared over 5 years.

Source: J. Clinic Periodontol.14:445-452, 1987.

Type: Clinical Study

Keywords: Scaling – rool planing – curettage – product elimination — modified Widman flap – probing depth – attachment level – tooth loss – furcations

Purpose: To assess in a clinical trial over 5 years the results following 4 different modalities of periodontal therapy (pocket elimination or reduction surgery, modified Widman flap surgery, subgingival curettage, and scaling and root planing).

Methods: 90 patients were treated. The treatment methods were applied on a random basis to each of the 4 quadrants of the dentition. The patients were given professional tooth cleaning and oral hygiene instructions every 3 months. Pocket depth and attachment levels were scored once a year. 72 patients completed the 5 years of observation. Both patient means for pocket depth and attachment level as well as % distribution of sites with loss of attachment greater than or equal to 2 mm and greater than or equal to 3 mm were compared.

Results: For 1-3 mm probing depth, scaling and root planing, as well as subgingival curettage led to significantly less attachment loss than pocket elimination and modified Widman flap surgery. For 4-6 mm pockets, scaling and root planing and curettage had better attachment results than pocket elimination surgery. For the 7-12 mm pockets, there was no statistically significant difference among the results following the various procedures.


Topic: comparing treatment modalities

Authors: Kaldahl WB, Kalkwarf KL, Patil KD, Dyer JK, Bates RE

Title: Evaluation of four modalities of periodontal therapy.

Source: J Periodontol. 59: 783 -793, 1988

Type: longitudinal

Keywords: periodontal treatment, longitudinal, treatment modality

Purpose: To longitudinally compare the clinical effects on the periodontium of four treatment modalities: 1) coronal scaling (CS), 2) root planing (RP) 3) modified Widman surgery (MW) and 4) flap with osseous resection surgery (FO).

Methods: Experimental design: 82 individuals with 2,090 teeth and moderate to advanced periodontal disease were treated in this study and 75/82 completed two years of maintenance therapy. Each of the patient’s dental quadrants were randomly assigned to receive one of the four therapy modalities. After initial treatment and re-evaluation, the surgical therapy was performed and patients were placed in 3-month recall with annual re-examinations. PD, CAL and recession data were collected by one calibrated examiner at baseline, 4 weeks after phase I, ten weeks post-surgical and after 1 and 2 years of maintenance therapy.

Results/conclusion: At the initial examination: 1-4mm PD severity category: There was a significant decrease in PD after all treatment groups after phase II. After two years of maintenance sites treated with FO showed the greatest loss of probing attachment (more gingival recession) followed by the sites treated with MW and then CS and RP.

5-6mm PD severity category: Sites treated with FO showed the greatest decrease in PD and recession after Phase II, followed by MW, RP and CS treated sites. This difference was sustained during two years of maintenance care, although there was some decrease in the amount of probing depth reduction.

Sites treated with RP and MW showed the greatest attachment level gain.

7mm PD or more category: RP, MW and FO treated sites demonstrated greater attachment level gain than the CS treated sites. Recession was greatest in the FO sites at 3 months, which decreased during the maintenance therapy.

After Phase I therapy: 1-4mm sites: FO produced loss of attachment, 5-6mm sites: FO sites showed the greatest reduction in PD followed by MW, RP and CS. FO sites showed the greatest amount of recession. 7mm or higher: FO sites showed the highest AL gain which was sustained during the maintenance period.


Topic: Initial therapy

Author: Kaldahl WB1, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK.

Title: Long-term evaluation of periodontal therapy: I. Response to 4 therapeutic modalities

Source: J Periodontol. 1996 Feb; 67(2):93-102.

Type: Split mouth study

Rating: Good

Keywords: Periodontal disease/surgery; periodontal diseases/surgical flaps; therapy; planing; scaling

Purpose: The purpose of this study was to longitudinally compare clinical effects following completion of four modalities of periodontal treatment and seven year of supportive periodontal treatment.


  • 82 patients treated in a split mouth design with coronal scaling (CS), root planing (RP), modified Widman surgery (MW), a flap with osseous resection surgery (FO), which were randomly assigned to various quadrants of the dentition.
  • Therapy was completed in three phases: non-surgical, surgical and supportive periodontal treatment (SPT) <7 years.
  • Clinical data consisted of PD, CAL, gingival recession (REC), BOP, suppuration (SUP) and supragingival plaque (PL).
  • Data was collected initially, 4 weeks following completion of phase I therapy, 10 weeks following completion of phase II therapy and yearly prior to each SPT appointment.
  • Supragingival plaque, gingival suppuration, BOP, PD, REC and CAL were all collected values


  • All therapies produced PD reduction with FO>MO>RP>CS following the surgical phase for all probing depth severities.
  • By the end of year 2 there were no differences between the therapies in the 1 to 4mm sites.
  • NSSD in PD reduction between MW and RP treated sites by the end of year 3 in the 5 to 6mm sites and by the end of year 5 in the >7mm sites.
  • FO produced greater PD reduction in >5mm sites through year 7 of SPT.
  • Following the surgical phase, FO produced a mean CAL loss and CS and RP produced a slight gain in 1-4mm sites.
  • RP and MW produced a greater gain of CAL than CS and FO following the surgical phase in 5 to 6mm sites, but the magnitude of difference decreased during SPT.
  • Similar CAL gains were produced by CS and were sustained during SPT.
  • Recession was produced with FO>MW>RP>CS.
  • The prevalence of BOP, SUP and PL were greatly reduced throughout the study and were comparable between sites treated by RP, MW, and FO while the CS sites had more COP and SUP.

Bottom Line: This clinical trial demonstrated that non-surgical and surgical periodontal therapy greatly improves the clinical parameters and sustains them long-term.


Topic: Surgical vs. non-surgical periodontal treatment

Author: Renvert S, et al

Title: 5-year follow-up of periodontal intraosseous defects treated by root planing or flap surgery

Source: J Clin Periodontol 17: 356 – 363, 1990

Type: Longitudinal study

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

Methods: 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 received FTF, defects degranulation, root planing and citric acid treatment. No osseous recontouring was performed, flaps were replaced and sutured to obtain complete closure of the wounds. Defects treated with root planing had their roots were instrumented with curettes, and 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. Patients 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 subgingival 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.

Results: 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.

Discssion: 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.


Topic: Subgingival microbiota

Author: Mombelli A, Nyman S, Brugger U, Wennstrom J, Lang NP

Title: Clinical and microbiological changes associated with an altered subgingival environment induced by periodontal pocket reduction

Source: J Clin Periodontol 1995; 22:780-787

Type: Clinical

Keywords: subgingival environment, periodontal tissue morphology, periodontal surgery

Purpose: To study the effect of an altered subgingival environment, induced by pocket depth reduction on the subgingival microbiota and the clinical conditions.

Methods: 7 patients (30-60yo) with generalized marginal periodontitis. Inclusion criteria: systemically healthy, no medications, at least 20 teeth, no SRP within last 6 months. On each of 6-8 single rooted teeth per patient, 1 deep lesion was selected for the experiment. Clinical data (PI, GI) was obtained at baseline and 1, 3, 6, 12 months. PD taken at baseline and 6 and 12 months after the treatment. Subgingival microbiota sample was obtained prior to treatment and 1,3,6 and 12 months post-treatment. Patients were given OHI and all teeth had supragingival scaling. All sites: mucoperiosteal flaps were raised and the bone re-contoured to eliminate angular bony defects. In the control teeth: extensive root planning was performed. In the experimental teeth: no subgingival instrumentation performed, and only large calculus deposits were removed. The flaps were apically repositioned and sutured at the level of the bone crest.

Results: Clinical parameters showed a similar pattern of response in the test and control sites over 1 year observation period post therapy. PDs and probing attachment levels were significantly reduced one month after surgery and remained at a lower level. A SS decrease was also noted for total anaerobic viable bacterial counts. The proportion of the Gram-negative anaerobic rods decreased significantly in both groups. P. gingivalis, Fusobacterium sp., C rectus were detected significantly less often after treatment in both groups except A. Aactinomycetemcomitans.

Conclusion: These findings suggest that the reduction of selected subgingival bacteria is essential for the success of periodontal treatment. Root planning and debridement of teeth at the time of surgery had not added benefit in the treatment outcome. This should not be interpreted to mean that root debridement is redundant or may be omitted, but rather that the altered ecologic environment has a greater effect on subgingival microbiota.


Topic: Comparisson of SRP, Osseous Surgery, and Modified Widman

Author: Becker W., Becker B.E., Caffesse R., Kerry G., Ochsenbein C., Morrison E., Prichard J.

Title: A longitudinal study comparing scaling, osseous surgery, and modified Widman procedures: results after 5 years.

Source: J Periodontol. Dec;72(12):1675-84. 2001

Type: Longitudinal Study

Purpose: to present 5-year results from a longitudinal study comparing the effectiveness of SRP, osseous Surgery (OS), and Modified Widman Flap (MWF) procedures as performed by periodontists who are proponents of the specific technique.

Methods: 16 patients with moderate to advanced adult periodontitis (at least 2 posterior sites w/ at least 6mm AL) were given an initial exam, and then treated with initial scaling and OHI, followed in 4-6 weeks by either SRP, OS or MWF. Teeth were polished weekly for 6 weeks, then maintenance, including subgingival scaling, was performed every 3 months until 1 yr post-op. (PD) probing depth , attachment loss (AL), gingival index (GI),plaque index (PI), mobility, furcations and recession were measured at initial examination, after initial therapy, at 8 weeks and at 6 months and 1,3,4 and 5 years post op

Results: At 5 years, there were significant decreases in gingival and plaque scores. For the 3 procedures, there were significant decreases in baseline 4 to 6 mm PD (P<0.0001); however, there were no differences between the methods. Similar findings were noted for PD initially greater than 7 mm. At 5 years, OS had the greatest number of 1 to 3 mm sites (332 sites, 73.2%), while MW had the fewest number of 4 to 6 mm PD (98 sites, 21.8%). SRP had the fewest 7 mm and greater sites (15 sites, 3.4%). At 5 years, CAL loss for 1 to 3 mm PD was statistically significant for the 3 procedures. There were slight gains in CAL for 4 to 6 mm probing depths. These gains were not significant. Similar findings were seen for CAL for probing depths greater than 7 mm. OS had the greatest number of sites losing more than 2 mm of CAL (64 sites), followed by SRP (21 sites) and MWF (34 sites), respectively. There was SS amounts of recession for all treatment types and probing depths. There was more tissue rebound after surgical procedures when compared to SRP.

Conclusion: This 5-year clinical trial demonstrates that with good patient maintenance excellent clinical results can be achieved with various methods of treatment. Within the limits of this study, SRP, OS, and MW were effective at reducing probing depths with slight changes in clinical attachment levels.


Topic: surgical vs. non-surgical periodontal treatment

Authors: Harrel SK, Nunn ME.

Title: 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.

Source: J. Periodontol. 2001; Nov:72(11):1509-19.

Type: longitudinal

Keywords: Disease progression; follow-up studies; periodontal disease/ surgery; periodontal therapy

Purpose: To evaluate the response of individual teeth to treatment or non-treatment
Methods: Data collected on the records of 91 patients, through a period of 24 years who had a complete periodontal chart at base line and at one year reevaluation. 41 patients completed all the recommended treatment (nonsurgical + surgical), 20 received only non-surgical treatment (4 fully compliant) and 30 patients who did not wish to receive any treatment and voluntarily returned for re-evaluation. The treatment performed for each tooth was recorded as yes or no for: root planing, occlusal adjustment, osseous, GTR, and soft tissue grafts. Prognosis was assigned based on projected outcome. Statistical analysis was done.


  • SSD in changes in PDs per year were found for all groups.
  • SS increase in PD was found for the untreated and non-surgically treated teeth for PDs 2-4mm and 5-6mm. PDs >7mm SS increase per year only for the untreated group.
  • Deeper PDs showed greater progression rate.
  • Surgically treated teeth showed greater reductions in PD/year for all groups, with a trend for greater reductions in PD/year in deeper pockets.
  • Teeth with untreated periodontal disease and those that had been treated non-surgically showed progression of periodontal disease and SS increase in PD over time.
  • Teeth that had periodontal surgery SS improvements in periodontal status with SS improvements in PD over time.
  • No SSD was noted between teeth that had no tx and teeth that had non-surgical tx.

BL: Teeth that had sx treatment showed SS improvements in reduced PDs over time as compared to the untreated and non-surgically treated group.


Topic: Nonsurgical

Authors: Serino 2001

Title: Initial outcome and long term effect of surgical and non-surgical treatment of advanced periodontal disease

Source: J Clin Periodontol 2001;28:910-916

Type: Clinical

Rating: Good

Keywords: nonsurgical, periodontal disease

Purpose: To determine the initial outcome of non-surgical and surgical access treatment in pts with advanced perio and the incidence of recurrent disease during 12 years of maintenance following active therapy.

Method: 64 pts with minimum of 12 non-molar teeth with deep pockets > 6mm) and with > 6mm of bone loss. Only non-molar teeth were evaluated. Pts were randomly assigned to 2 groups: surgery (SU) and non-surgery (SRP). After baseline exam (PI, BOP, PD, PAL, BL), all patients were given OHI. After Surgery (MWF, 4-6 sessions) or SRP (4-6 sessions, 60-90min) and rinsed with 0.2% CHX bid for 2 months. All pts were enrolled in a maintenance program (3-4 visits/year). Sites that at a recall appointment that had BOP and a PD of > 5mm had new sub-g instrumentation. OHI was repeated as needed. Comprehensive re-exams were performed after 1, 3, 5, and 13 years of SPT. If a patient between annual exams displayed marked disease progression (eg CALoss > 2mm at > 4 teeth), they were exited from the study and given additional treatment.

Results: 4pts (14%) in the SU group and 8 pts (29%) in the SRP group were excluded between years 1 and 3 due to additional disease progression. At different intervals after that time frame, 3 pts in the SU group and 4 in the SRP group were excluded for the same reason as well. NSSD between groups with respect to the various perio parameters examined at baseline. Both groups maintained high standard of OH at 13 years (PI < 15%). In both groups, BOP increased significantly from 18% at year 1, to 20-25% at year 3 and finally to about 30% during the later periods. Mean PD underwent minor changes over time, being 0.6mm in both groups over the 13 years. The SU group had a SS larger proportion of sites with shallow pockets (<4mm) than SRP (70-60% vs 55-40%), and a SS smaller proportion of medium deep (25-35% vs 35-50%) and deep (5-10% vs 10-15%) PD sites. Mean CALoss between SRP and SU was not SS. Shallow sites tended to lose 0.1mm PAL/yr regardless of location (buccal, lingual, interproximal).

-SU was more effective that SRP in reducing mean PD and elimination deep pockets

-The number of sites that displayed advanced disease progression after treatment was SS smaller in the SU group (14% vs 29%)

-The majority of subjects could be maintained on SPT over a 12-yr period with only minor episodes of recurrent dz.

Discussion: The reason for higher incidence of disease progression in SRP group may be due to more residual sites with deep pockets.

Conclusion: Surgical therapy is more effective in preventing disease progression than non-surgical therapy in pts with advanced perio that are placed on 3-4 month SPT over a 12-yr period. In pts that did not display advanced disease progression and were therefore not excluded from the study, there was NSSD in the periodontal parameters between Surgical therapy and SRP.


Topic: Pathogenesis

Authors: Heitz-Mayfield LJ

Title: How effective is surgical therapy compared with nonsurgical debridement?

Source: Periodontol 2000. 2005;37:72-87.

Type: Systematic Review

Keywords: oral hygiene, orthodontics, crowding, plaque-retetion, periodontal pathogens

Purpose: To evaluate the methods and quality of the systematic reviews in order to facilitate clinical decision-making in the choice of surgical vs. nonsurgical therapy for the treatment of chronic periodontitis.

Methods and Materials: A literature search was conducted of two databases (MEDLINE and the Cochrane Oral Health Group). The search provided 589 potentially relevant publications, 14 of which were retrieved for detailed evaluation. Of these, eight studies did not meet the inclusion criteria, leaving six randomized controlled trials for evaluation. The six randomized controlled trials were all of split mouth design with a nonsurgical and a surgical procedure performed within surgical and nonsurgical therapies were combined where appropriate in meta-analyses and presented for respective initial probing depth categories.


  • Surgical treatment is better for reduction of periodontal probing depth and these benefits become greater with the increase of initial probing depth.
  • The gain of attachment level differences indicates an advantage for nonsurgical treatment in shallow and medium initial periodontal probing depths.
  • For deep initial periodontal probing depths, surgical therapy showed similar attachment gains when compared with scaling and root planing.

Topic: Non Surgical Treatment

Authors: Mailoa J et al

Title: Long-Term Effect of Four Surgical Periodontal Therapies and One Non-Surgical Therapy: A Systematic Review and Meta-Analysis.

Source: J Periodontol. 2015 Oct;86(10):1150-8.

Type: Systematic Review and Meta-Analysis

Keywords: Longitudinal studies; periodontal debridement; periodontitis; review; surgical flaps; systematic root planning.

Purpose: To evaluate the long term (≥ 2 years) effect of four surgical and non-surgical therapies in treating periodontal disease.

Methods: An electronic search of four databases and a hand search of peer-reviewed journals for relevant articles were conducted. Prospective human controlled clinical trials were included that compared surgical therapy to non-surgical therapy in ≥ 10 patients diagnosed with chronic periodontitis with a follow-up period of ≥ 2 years and that reported change in probing depth (PD) and clinical attachment level (CAL) after the therapy. Random effect meta-analysis was performed to compare the outcome of surgical and non-surgical therapy in shallow, moderate, and deep PD.

Results: Eight human prospective clinical trials were included.

In 1- to 3-mm PD, scaling and root planing (SRP), modified Widman flap (MWF), and osseous surgery (OS) resulted in 23.2%, 39.4%, and 61.39% CAL loss, respectively;

SRP, MWF, and OS resulted in increased mean PD of 2.5%, 3.3%, and 6.3%, respectively.

In 4- to 6-mm PD, SRP, MWF, and OS resulted in 8.4%, 6.5%, and 5.22% CAL gain, respectively;

SRP, MWF, and OS resulted in 18.7%, 25.4%, and 30.8% PD reduction respectively.

In PD ≥ 7 mm, SRP, MWF, and OS resulted in 9.8%, 14.2%, and 9.38% CAL gain, respectively;

SRP, MWF, and OS resulted in mean PD reduction of 21.6%, 33.1%, and 42.8%, respectively.

Conclusion: Surgical therapy had significantly more CAL loss than non-surgical therapy in shallow PD. In moderate PD, MWF had significantly more PD reduction than SRP, and there was significantly less CAL gain with surgical therapy. In deep PD, OS had significantly higher PD reduction than SRP.


Patient perception to different treatment modalities


Topic: patient perception

Authors: Kalkwarf K, Kaldahl W, Patit K.

Title: Patient preference regarding 4 types of periodontal therapy following 3 years of maintenance follow-up.

Source: J Clin Periodontal 1992; 19:788-793.

Type: clinical

Keywords: periodontal therapy; clinical studies; split-mouth study design; patient preference.

Purpose: To evaluate patient perceptions regarding 4 types of periodontal therapy following 3 years of maintenance care.


  • 82 subjects initiated and completed the active therapy stage and at the 3 years of maintenance 74 subjects remained in the study. Each quad of each patient received coronal scaling (CS), CS + SRP , CS/SRP followed by modified Widman surgery (MW) and SC/SRP followed by flap with osseous resection surgery (FO).
  • Maintenance therapy was performed at 3 month intervals by hygienists. At 3- years a 7 questions interview using a standardized format was conducted with each patient.


  • Regions treated with FO were more difficult for the patient to clean than sites treated with CS and SRP.
  • Slightly higher % of subjects reported sensitivity in areas with MW.
  • No SSD between subjects in assessing the general feel of the different areas in the mouth (80-85% said they felt absolutely normal).
  • Regions treated with FO were generally perceived as having less food retention, but NSSD.
  • 80-90% of subjects would agree to repeat and of 4 Tx modalities.
  • NSSD between treatments for the rest of the questions.

Conclusion: The ability of the patient to cope with post-therapy effects following CS, SRP, MW, FO is not significantly different. Treatment decisions should be made based upon the ability to obtain clinical goals.

Topic: Oral health related quality of life

Author: Botelho J, Machado V, Proença L, Bellini DH, Chambrone L, Alcoforado G, Mendes JJ.Botelho J, et al.

Title: The impact of nonsurgical periodontal treatment on oral health-related quality of life: a systematic review and meta-analysis.

Source: Clin Oral Investig. 2020 Feb;24(2):585-596.

DOI: 10.1007/s00784-019-03188-1

Type: Systematic review

Keywords: oral health related quality of life, nonsurgical periodontal treatment, periodontitis, survey 

Purpose: To estimate the impact of nonsurgical periodontal treatment (NSPT) on patients oral health-related quality of life (OHRQoL). Focused question: in adult patients with periodontitis, does NSPT improve oral health-related quality of life? 

Methods: PubMed, CIHNL, EMBASE, LILACS, and CENTRAL were searched up to April 2019.

  • P: systemically healthy adults >18 years old with periodontitis
  • I: NSPT
  • C: a group that did (not) receive NSPT or a group that had no need for NSPT; A single group pretest and posttest following NSPT
  • O: responsiveness of validated OHRQoL ques-tionnaires to intervention related to NSPT

Review studies were included that measured OHRQoL levels before and after NSPT with or without control groups.There was no restriction for the follow-up period. Primary outcomes included patient centered outcomes and oral health related quality of life questionnaires. Secondary outcomes included baseline and foll-wup PI, BOP, PD, CAL, number of teeth, and percentage of sites with PD >= 4 mm. 

Results: Of an initial 491 studies, 19 met the inclusion criteria for the review. Twelve studies had NSPT data, and of these 5 used heterogenous questionnaires. Meta-analysis was only possible for 7 cohort studies. The studies covered a total of 519 patients, showing that NSPT increases OHRQoL homogenously with an average of 2.49 which remained for 6-12 weeks post-treatment. There was not enough information to show comparison between treatments (NSPT and control groups). 

Conclusion: NSPT procedures greatly improve the oral health-related quality of life within a short time, remaining stable after 3 months of treatment.

Changes in maxillary sinus after periodontal therapy

Topic: Maxillary sinus

Author: Falk H, Ericson S, Hugoson A

Title: The effects of periodontal treatment on mucous membrane thickening in the maxillary sinus

Source: J. Clin. Periodontol.13:217-222, 1986

Type: Clinical study

Keywords: Periodontitis; maxillary sinus; maxillary molars
Background: Mucous membrane thickening in the maxillary sinus is more common in people with apical and marginal infections at the upper molars and/or premolars.

Purpose: To determine the effect perio treatment has on an already thickened sinus membrane.


  • 21 pts with periodontal lesions of the upper molars and/or premolars and chronic mucous membrane thickening in the maxillary sinus participated in the study.
  • No teeth in the regions studied showed pulpal or periapical changes
  • These pts had a total of 36 sinuses that could be used in the study (15 pts had bilateral thickening).
  • Thickening of the membrane was determined by different dental x-rays (PA’s, panoramic, sinus x-ray; not 3D imaging).
  • None of the participants received antibiotics or decongestants during therapy.
  • The teeth received either extraction, SRP, perio surgery, and then were placed on maintenance during 15-20 months after completion of the perio treatment.


  • Most of the teeth had lost more than 30% of bone height before treatment.
  • All insensible teeth received endo therapy (no PA lesions though, or they would have been excluded from the study).
  • Perio treatment was successful in 29 quadrants and led to improved perio conditions in 5 quads, and was unsuccessful in 2 quads.
  • The sinus mucosa was normalized or markedly improved in all 29 quads in which the perio treatment was successful.
  • Of the 5 quads that led to improved perio conditions, 4 of those lead to normalization of the sinus and 1 led to a marked improvement of the membrane thickness.
  • In the cases that perio treatment failed, one had no change in the sinus mucosa and the other case had a thickening of the membrane.

Discussion: The authors infer, due to this study, that marginal periodontitis can cause thickening of the sinus membrane.

Bottom Line: Successful treatment of teeth with marginal periodontitis will most likely result in normalization of the sinus mucosa.

Topic: membrane thickening

Author: Lathiya N, et al

Title: Effect of periodontal therapy on maxillary sinus mucous membrane thickening in chronic periodontitis: A split-mouth study

Source: J Dent Res Dent Clin Dent Prospect 2018; 12(3):166-173|

DOI: 10.15171/joddd.2018.026.

Type: clinical

Keywords: Maxillary sinus, mucosal thickening, periodontitis, periodontal surgery.

Purpose: to evaluate the effect of periodontal therapy on mucous membrane thickening in maxillary sinus in chronic periodontitis patients by radiovisiography (RVG) and CBCT


  • 33 patients with chronic periodontitis with bilateral mucosal thickening of the maxillary sinus
  • oral hygiene and gingival health, plaque index and gingival index were obtained at baseline and at 9 months.
  • Group I: not subjected to any presurgical hygiene therapy (control)
  • Group II: SRP
  • If the pockets were unresolved (PP ≥5 mm) at the end of 3 months, the patients underwent OFD.
  • the mucosal thickening was measured by both RVG and CBCT at baseline and at 6 months after the surgical procedure.


  • PI & GI SS decrease from baseline to followup for both groups
  • SS greater PD decrease in Group II versus Group I (3mm vs 5mm)
  • Group I showed a mean increase in the mucosal thickening at the end of 9 months.
  • Group II showed a decrease in the mean mucosal thickening at the end of 9 months, which was SS at all time points

Conclusion: the surgical periodontal therapy led to a reduction in microbial load which ultimately affected the mucosal thickening (resolution).

What is the critical probning depth?

Lindhe 1982

Purpose: 1) to calculate the critical PDs (CPD) for one surgical and one non-surgical method of periodontal therapy, 2) To monitor during an 18-month maintenance period sites which following active therapy were associated with PD>4mm with respect to gingival inflammation and attachment level alterations and 3)TO evaluate the effect of the oral hygiene status on PDs and attachment levels during the maintenance care period in patients who following active therapy were recalled for prophy every 3 months.

Materials and methods: 15 subjects 32-57 years old. After baseline examination (PI, GI, PD, AL) and OHI patients were subjected to perio Tx in a split mouth design. In one side debridement was performed in conjunction with modified Widman flap (MWF) and on the other side SRP was performed. In the first 6 months patients were recalled for maintenance visits every 2 weeks and after that every 3 months. Re-eval was performed at 6, 12 and 24 months.

Results/BL: Critical PDs for sites subjected to SRP was 2.9 mm and for the MWF group 4.2 mm. This means that sites with initial PD of less than 2.9mm are likely to show attachment loss if SRP is performed. In sites with initially deeper pockets (7 mm or more) the resulting attachment gain was more pronounced following surgical than non-surgical treatment.

If the plaque score assessed at the 6-month examination is representative of the oral hygiene conditions during the phase of healing, the CPD – value obtained for a given site increase as PI increases.

90% of sites with PD<4mm at 6 months remained in this category during the maintenance phase, 10% became deeper.

60% of sites with PD 4-6mm at 6 months remained in this category, 30% entered in the <4mm category and 1-4% became deeper.

For sites with PD>6mm , 27-60% entered in the 4-6mm or<4mm during maintenance phase and and 40-50% remained unchanged. There was a significant attachment gain during maintenance (1.6mm for MWF and 1.2mm for SRP.

Shallow pockets tend to lose and deeper sites to gain attachment during maintenance phase. Sites with plaque score more than 0 lost attachment during maintenance (0.72mm MWF and 0.55mm SRP).