Classical Periodontal Literature Review

a. Results of Non-Treatment

b. Evaluation of Therapy

 

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

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

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

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

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

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

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

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

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

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

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

1. McFallWT: Tooth loss in 100 treated patients with periodontal disease. A long term study. J. Periodontol. 53:539-549, 1982.

2. GoldmanMJ,Ross IF,Goteiner D. Effect of periodontal therapy on patients maintained for 15 years or longer. A retrospective study. J Periodontol.1986 Jun;57(6):347-53.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Abstracts

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

Becker 1979 ARTICLE

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

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

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

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

Becker 1981 ARTICLE

P: To evaluate bone score changes in untreated periodontitis.

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

R:

• Mean bone scores on first exam was 49.5% (range 39 to 60%). Mean bone scores for second exam was 43.2% (range 35.4 to 53.4%).

• A decrease in mean bone scores was seen for all 27 patients.

• The distal surface had lower bone scores than the mesial surfaces.

• The molars with the lowest initial bone scores (max molars lowest overall) and showed the greatest decrease between 1^st and 2^nd exams -19.8%, bicuspids- 10.6%, anteriors – 7.9%.

• PDs seemed to parallel bone scores, however, the correlation was SS.

• Progression varied from patient to patient and tended to be age related. Pts < 44 year had greater decrease in bone score than older group.

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

Goodson 1982 ARTICLE

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

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

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

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

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

Lindhe 1983 ARTICLE

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

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

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

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

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

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

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

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

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

Lindhe 1989 ARTICLE

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

Materials and methods:

• 319 pts (age 20-79) were divided into 6 groups by age. Clinical measurements (BOP, PD, AL, recession, missing teeth, PI, GI) were taken at baseline, 12 mo. and 24 mo, with no OHI or tx rendered.

• Mean values for subjects in each age group were computed. 57 pts dropped out of the study.

• Those who returned for both 1 and 2 yr exams were identified as respondents vs. those who came only to one re-exam (either 1 or 2 yrs) were identified as non-respondents.

Results:

• Mean values describing gingivitis and periodontitis tended to increase with age. 82 teeth were lost in 53 subjects. 26/82 (32%) teeth extracted were due to periodontal dx and 62% were in the oldest age group.

• PI and GI decreased in all groups over the 2 yr even though no OH was discussed with patient; however, within each age group was a subgroup that had failing OH.

• PD increased slightly in all groups over the two years, with most pronounced deepening in the oldest age group (60-79). Mean PAL had no sig variation.

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

Jeffcoat 1991 Florida Probe ARTICLE

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

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

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

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

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

Machtei 1993 ARTICLE

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

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

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

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

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

Papapanou 1990 ARTICLE

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

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

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

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

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

Hirschfeld 1978 ARTICLE

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

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

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

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

McFall 1982 ARTICLE

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

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

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

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

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

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

Goldman 1986 ARTICLE

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

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

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

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

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

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

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

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

D group- lost an avg of 5.8 teeth/patient (2^nd and 3^rd molars comprised 45.6% of the teeth lost)

ED group- lost an avg of 14.2 teeth/patient (2^nd and 3^rd molars comprised 26.% of teeth lost)

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

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

McLeod 1997 ARTICLE

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

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

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

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

Hujoel 2000 ARTICLE

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

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

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

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

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

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

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

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

Lindhe 1975 ARTICLE

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

Materials and methods:

• 75 pts with greater than 50% attachment loss that were capable of maintaining optimal plaque control and were willing to appear regularly at least once every 6 months were enrolled in the study.

• Initial therapy with repeated OH instruction/motivation was given to each pt.

• Teeth from which endodontic and cariologic view points could not be successfully treated, teeth with perio pockets extending down to the apex, and teeth which on prosthodontics indications should not be maintained were extracted.

• The pre-sx observation period was 3-6 months in order to evaluate the degree of cooperation of the pts. Sx pocket elimination was performed for pockets greater than 4mm. Pts came to maintenance visits every 3 to 6 months.

Results:

• The 75 pts had a total of 1898 teeth when they enrolled in the study. During the pre-sx tx period, 278 teeth were extracted.

• A total of 1620 teeth were maintained for 5 years. The mean PD was 5.7mm before tx, and later was reduced to less than 3mm.

• Also, after 5 years PDs exceeding 3mm were only found on 8 teeth. On no occasion did PD exceed 6mm.

• However, 422 teeth did show signs of increased mobility at the end of the study. Only 14 new carious lesions were detected at the recall appointments.

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

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

Badersten 1987 ARTICLE

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

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

R:

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

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

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

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

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

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

.

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

Renvert 1990 ARTICLE comparison of various forms of treatment

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

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

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

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

Cr: small number of patients

Ramfjord 1987 ARTICLE

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

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

R:

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

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

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

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

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

Becker 2001 ARTICLE

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

M&M: 16 pts w/ moderate to advanced adult periodontitis (at least 2 posterior sites w/ at least 6mm AL) were given an initial exam, and then Tx’d with initial scaling and OHI, followed in 4-6 w by either SRP, osseous Sx, or MWF. Teeth were polished weekly for 6 w, then MT, including subgingival scaling, was performed every 3 mos until 1 yr post-op. PD, AL, GI, PI, mobility, furcations and recession were measured at initial examination, after initial therapy, at 8 wk and at 6 mo. and 1,3,4 and 5 years post op

R: 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 MW (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.

BL: 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.

Kaldahl 1988 ARTICLE

P: To evaluate four modalities of periodontal therapy {Coronal scaling “CS”, Root planing “RP”, MWF, and Flap Osseous “FO”}.

M&M: 82 patients with 2090 teeth (PD 2-14 mm) were enlisted for a quad mouth design to evaluate the perio txt modalities with respect to mean PD, PAL, and recession. 75 pts continued with maintenance and were followed for 2 years. Random allocation: 1 quad had CS (did NOT scale sub G), 3 quads SRP. All had occlusal adjustment and other phase I if needed. All patients had modified O’leary >80% to proceed in study. 4 week re-eval, then one of 4 quads had either repeat CS, repeat SRP, MWF or osseous. Sx was done ONLY if 5 mm PD still remained in designated quadrant. Adjacent teeth included in flap design. Any teeth in quad that did not qualify for surgical intervention were NOT included in results. Data collection: initial exam, 4 week re-eval, 10 weeks post-sx, 1-2 years of maintenance. Pts placed on 3 month recall and had yearly exam.

R: Data grouped by severity of PD: 1-4 mm, 5-6, 7+mm. Mean reductions in PD were seen for all treatments. FO produced the greatest followed by MW, RP, and CS. Large initial PD resulted in the larger reductions in PD. Gains in CS and RP were short lived and later reverted with losses in probing attachments whereas FO produced these losses initially in the 1-4 mm groups. Moderate depths 5-6mm responded favorably to RP and MW. Deep PDs > 7mm responded to FO with the greatest PD reduction followed by MW, RP, and CS. RP and MW produced greatest CAL gain in 4-6mm category. RP, MW, FO produced similar CAL gain in the ≥ 7mm category. Gingival recession was greatest in the FO followed by MW, RP, and CS. Probing depths increased during maintenance of the sx groups due to coronal growth of the marginal tissues. Gains in probing attachments were not maintained to the two year mark.

C: 1) PD reduction occurred following all txt: osseous had the best. The deeper the initial PD, the greater the reduction.

CS and RP showed initial gain of PAL which was then lost in the 1-4mm category; FO only had loss of attachment in this category.

In 5-6mm PD category, RP and MWF gave largest gain of PAL, while CS and FO gave a lesser amount.

>7mm category, RP, MWF, and FO produced greatest gain of PAL while CS gave least.

Recession occurred for all tx: FO>MW>RP>CS.

Increase in mean PD during two years of SPT in MW and FO due to coronal movement of FGM

Harrel and Nunn 2001 ARTICLE

P: To retrospectively evaluate the effect of no treatment, non-surgical treatment, and non-surgical with surgical treatment on the progression of periodontal disease.

M+M: Data were 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.

R:

• 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.

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

Wasserman 1988 ARTICLE

Purpose: To test for correlations between the clinical signs of the untreated cases and periodontal attachment and tooth loss during long-term maintenance.

Materials and methods: 112 patients, mean age of 43.5 year at initial examination were studied. Patients with at least 15 years maintenance care were selected. Gingival tissue reaction to local etiologic factors, amount of subgingival calculus (assessed radiographically), form of subgingival calculus (flat, spurred and rounded) and severity of disease (PDs, recession and radiographic evaluation) were determined. Initial severity was determined as early, intermediate or advanced. The long-term case response was graded on the basis of radiographically evident bone loss as well as the number of teeth lost for periodontal reasons as good, intermediate or poor.

No consideration was given to the type of periodontal treatment since all cases were essentially brought to a level of health during active therapy. Maintenance visits were performed at 4-6 month intervals.

Results: No statistically significant relation was found between case severity and initial gingival tissue reaction.

There was direct relation between the amount of calculus and the severity of initially evident inflammation. There were more cases with non-visible calculus in the non-inflamed group and more cases of heavy calculus in the severely inflamed group.

Initially advanced cases were not doomed to continue downhill but had an equal possibility of remaining stable or undergoing further attachment loss.

72.6% of cases with good long-term prognosis initially had heavy subgingival calculus. Overall relationship however (sub-g calculus-long term prognosis) was NSSD. Form of calculus was2 not related to long-term response.

63% of initially non-inflamed cases fell into the poor response group. 82% of the initially severely inflamed cases were associated with good long-term prognosis. These relationships were SSD.

There was a trend toward light calculus, little initial inflammation and poor long term response, and in cases with heavy calculus there was a trend toward intermediate and severe initial tissue reaction and good long-term prognosis.

Conclusion: Results of this study indicate strong relationships between initial case characteristics and long-term results of treatment.

Haffajee 1995 ARTICLE

Purpose: To identify some of the clinical and microbiological factors which were associated w/ differences in treatment response in a group of subjects who showed different levels of attachment change post-therapy.

Materials and methods:

• 98 subjects w/prior evidence of periodontitis were selected (at least 4 PD >4 with at least 4 sites showing CALoss >3 mm), monitored q 2 mos for 6 mos total. Changes in CAL were the definition of dz activity pts who had >2.5mm in CALoss were considered to have active dz. 41% of subjects were considered to have active dz and were treated w/ MWF at all sites >4 mm or showing active dz and SRP at all sites <4 mm.

• In addition, these 40 pts were treated w/ 1 of 4 adjunctive agents for 30 days: Augmentin 250mg tid, TTC 250mg tid, ibuprofen 400mg tid or placebo. After surgery, CHX bid for 2wks then 3 mo SPT. Subjects re-evaluated 10±4 mos.

• Clinical parameters were measured at 6 sites/tooth both pre- and post-txt.

• Microbiological samples were taken from the M aspect of each tooth and evaluated individually for their content of 14 sub-g taxa using a colony lift method and DNA probes. % of sites colonized by each species was computed for each subject both pre- and post-thx.

Results:

• 40 pts subset into 3 groups based on mean CAL change post-thx:

  • 10 poor response subjects showing mean CALoss

  • 19 mod response subjects w/ mean CAL gain b/w 0.02-0.5 mm

  • 11 good response subjects w/ a mean CAL gain > 0.5 mm.

• Regardless of txt, the group on antbiotics tended to have less CALoss than those on ibuprofen or placebo.

• The poor response subjects had the lowest mean PD and Attachment level, but the highest plaque levels.

• Post-treatment, the poor response group exhibited the greatest degree of inflammation.

• P.i., A.a., B.f. increased at sites which lost attachment and decreased at sites that showed a CAL gain post-treatment. Tf had the strongest link to CALoss. In good response patients, perio pathogens were reduced by 50% post-thx.

BL: Good response subjects showed decreased ging inflammation, decreased plaque and lower % perio pathogens. Poor responders had similar or greater levels of gingival inflammation and were colonized by more perio pathogens. Good responders tended to have higher PD at baseline than poor responders, but less sites harboring plaque.

Van Der Velden 2006 ARTICLE risk predictors

P: Longitudinal changes in the clinical condition of periodontal disease over a 15-year period and to study the value of baseline clinical, microbiological, and background variables as possible risk factors, risk predictors and risk determinants for future periodontal breakdown.

M&M: Longitudinal, prospective study that selected subjects’ ages 15–25 years living in a village of approximately 2000 inhabitants at a tea estate on Western Java, Indonesia. This group of people had not received dental care and had not been exposed to preventative dental programs. Baseline examination was carried out in 1987 and follow-up examinations in 1994 and 2002. In 2002, 128 subjects could be retrieved from the original group of 255. Baseline examination included evaluation of plaque, bleeding on probing, calculus, pocket depth, attachment loss and presence of A.a, P.g, P.i, spirochetes and motile microorganisms. >80% have been smoking for >10 years and mean # of cig was 12.8/day.

R: The mean attachment loss increased from 0.33mm in 1987 to 0.72mm in 1994 and 1.97mm in 2002. No diff in amount of disease progression b/w smokers and non-smokers. Gingival recession showed no increase during the first 7 years, following that a 6-fold increase had occurred. Analysis identified amount of sub-gingival calculus and sub-gingival presence of A.a as risk factors, and age as a risk determinant, for the onset of disease. Regarding disease progression, the number of sites with a probing depth ≥5mm and the number of sites with recession were identified as risk predictors and male gender as a risk determinant. No effect of age on the rate of progression of AL.

D: The results show a mean annual attachment loss of 0.05mm during the first 7 years and increased during the following 8 years. The initial progression rate of 0.05 is comparable with values reported in other longitudinal studies (Papapanou 1989, Norderyd 1999, Ismail 1990, Loe 1986).

BL: Screening of these parameters early in life could be helpful in the prevention of onset and progression of periodontal diseases. In addition, prevention of colonization by A.a might contribute to reduction of the odds to develop periodontitis.

Fisher 2008 ARTICLE

P: to monitor disease progression over 3 yr period of chronic perio in smokers compared to non-smokers.

M&M: 108 pts who have completed active therapy and were on a 3-4 mo maintenance schedule for 3 consecutive years. Smoking status and history was determined by self history and by expired air CO concentrations. This has been established as an adequate means of identifying and quantifying smoking status. pts would take a deep breath, hold for 15sec and expire into the CO monitor. Clinical parameters measured: PI, BOP, PD, CAL. Measurements were taken 4-6wks after each maintenance visit.

R:

• 23 patients were classified as smokers and 85 as non smokers by expired CO levels.

• There was NSSD in avg number of missing teeth at baseline (8tth) or at 3 yrs (10tth).

• NSSD in PI ( 38% at baseline for smokers, 32% for non, at 3 yrs: smokers- 36%, non-smokers 30%) or BOP( 20% for both at baseline, 15% for non smokers and 14 for smoker at 3 yrs).

• Smokers showed deeper PD ( 2.8mm vs 2.6 at baseline, 2.4mm vs 2.3mm at 3yrs) and greater CAL loss (3.3mm vs 2.9mm at baseline, 3.2 vs 2.9mm at 3yrs) but was not significant, and the rate of loss was similar.

C: well maintained, highly motivated pts showed comparable PD increase and CAL loss regardless of being classified as a smoker or not.

Cr: sample sizes don’t seem comparable, no stratification of how much CO expired vs CAL

Teles 2008 ARTICLE

P: To determine whether the rate of attachment loss in periodontally healthy subjects in a prevention program is lower than the rate of attachment loss in treated periodontitis patients on a maintenance program. Also microbial changes over time were examined.

M+M: 55 periodontally healthy and 57 periodontitis subjects were monitored at baseline, 1, 2, and 3 years (longitudinal). Clinical parameters were measured at six sites per tooth; BOP, Plaque, PD, AL. Subgingival plaque samples were taken from MB aspect of every tooth and analyzed for the levels of 40 bacterial species using DNA hybridization.

R: Mean clinical parameters improved for both groups over time. 2 mm or greater AL found in 4% of sites in maintenance subjects, but only 1% in prophylaxis subjects. The maintenance

group lost 0.12 teeth/subject/year, whereas the prophylaxis group lost 0.02 teeth/subject/year. At baseline and at end of study, the maintenance subjects showed SS higher levels of the three red complex species Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola compared to the prophylaxis subjects.

BL: Treated periodontitis subjects under maintenance displayed more rapid attachment loss than periodontally healthy subjects in a preventive program. This elevated susceptibility to periodontal disease progression in the maintenance subjects was associated with a higher exposure to subgingival biofilm species, particularly members of the red complex.

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

MacFarlene 1988 ARTICLE

Purpose: To relate changes in probing attachment levels to % of spirochetes and black pigmented bacteriodes species collected over a 1 year period from patients with untreated chronic periodontitis and to establish if collecting subgingival plaque periodically has an effect on the microbiological findings.

M&M: 11 pts w/ advanced chronic periodontitis had subgingival plaque collected at 7 visits from 148 pre-selected sites in left jaw (test), and on first and last visits from 117 sites in right jaw (control). Plaque was removed using a curette and wad discarded. Samples were examined under LM, and also looked at clinical parameters.

Results: 64% of all sites remained stable, 12% improved and 24% deteriorated. Distribution of these changes was similar between test and control sites. AL changes were not dependent on the initial % of spirochetes or black-pigmented bacteroides counts. There was no evidence of a relationship between mean amount of deterioration over 1 year and the baseline mean microbiological values (i.e. as a predictor of future loss). Significant differences were noted only when % of spirochetes was related to those sites showing the greatest improvement in attachment levels over the 1 year period (% was decreased at 12 months).

BL: Cannot use spirochetes or bacteroides species to identify or predict disease in active sites.

Rosenberg 1981 ARTICLE

P: To investigate the effect of SRP on periodontal pockets using dark field microscopy.

M&M: 18 patients, inclusion criteria were: untreated chronic periodontal disease, >5 mm PD around one or more teeth in at least 3 quadrants. Baseline PI, GI, PD were recorded. Sub-g microbial debris samples from deepest PD were taken with a currette and sampled with darkfield microscopy. Bacterial forms classified in 4 groups: coccoid cells, motile rods, spirochetes, and others. Perio therapy was then performed including: OHI, several sessions of S/RP and occlusal adjustment if needed. Microbial samples were taken again at re-eval. Osseous was completed where necessary and microbial sampling taken a third time between 1.5-10 months post surgery.

R:

Type	Baseline	Post SRP	Post Sx
coccoid	25.1%	33.3%	49.2%
Spiros	18.6%	12.4%	9%
Motile Rods	36.3%	20.7%	11.8%
Spiros+Motile rods	54.9%	33.1%	20.8%

Percentage of coccoid cells increased significantly from one visit to next, whereas percentage of motile rods/spirochetes decreased. There was a significant change in all bacterial levels between each time frame. Sig changes occurred between baseline and 1^st re-eval for all clinical parameters (PI, GI,PD), but little improvement was noted after surgical therapy. 2 patients that did not have a decrease in motile rods/spirochetes, showed evidence of clinical deterioration.

BL: A higher % of cocci in the microbial flora is associated with healthy peridontium, whereas spirochetes and motile rods are associated with a diseased. Periodontal therapy can have significant effect on the microflora, shifting toward a more healthy state.

Mombelli 1995 ARTICLE

P: To study the effect of an altered subgingival environment, induced by changing the local soft tissue morphology (pocket depth reduction) on the subgingival microbiota and the clinical conditions.

M+M: 7 patients (30-60 years old) with generalized marginal periodontitis. Systemically healthy, no meds, 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 tx. Subgingival microbiota sample was obtained prior to tx and 1,3,6 and 12 months post tx. Patients were given OHI and all teeth had supragingival scaling. Mucoperiosteal flaps were raised and the bone re-contoured to eliminate angular bony defects. Control teeth: root planed. Experimental teeth : no subgingival instrumentation performed. Calculus deposits visible to the naked eye were only chipped-off with the tip of a scaler. The flaps were apically repositioned and sutured at the level of the bone crest.

R: 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 AA .

BL: These findings suggest that the reduction of selected subgingival bacteria is essential for the success of perio treatment. Root planning and debridement of teeth at the time of surgery had not added benefit in the treatment outcome.

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

Falk 1986 ARTICLE

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

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

M&M: 21 pts with marginal periodontal lesions associated with thickening of the sinus (excluding cysts, polyps or tumors) and did not have periapical lesions were included. 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 xrays (PA’s, panoramic, sinus xray; not 3D imaging). None of the participants received antibiotics or decongestants during therapy. The teeth received either extraction, SRP, perio sx, and then were placed on a maintenance during 15-20 months after completion of the perio tx.

R: Most of the teeth had lost more than 30% of bone height before tx. All insensible teeth received endo therapy (no PA lesions though, or they would have been excluded from the study). Perio tx was successful in 29 quadrants, 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 tx 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 tx failed, one had no change in the sinus mucosa and the other case had a thickening of the membrane.

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

BL: Successful tx of teeth with marginal periodontitis will most likely result in normalization of the sinus mucosa. -No control group, but it would be unethical to not treat pts with perio dz (however, could have tried to find pts that refuse tx)

Are there differences in patient perception to different tx modalities?

Kalkwarf 1992 ARTICLE

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

Materials and methods: 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 resectional surgery (FO). Maintenance therapy was performed at 3 month intervals by hygienists. At 3- years a 7 question s interview using a standardized format was conducted with each patient.

Results: 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. Tx decisions should be made based upon the ability to obtain clinical goals.