Surgical periodontal therapy with and without initial scaling and root planing in the management of chronic periodontitis: a randomized clinical trial

Surgical periodontal therapy with and without initial scaling and root planing in the management of chronic periodontitis: arandomized clinical trialAljateeli M, Koticha T, Bashutski J, Sugai JV, Braun TM, Giannobile WV, Wang H-L. J Clin Periodontol 2014; 41: 693700. doi: 10.1111/jcpe.12259

Journal Club ReviewBy: Dr Rohit RaiAim: To compare the outcomes of surgical periodontal therapy with and without initial scaling and root planing.Methods: Twenty-four patients with severe chronic periodontitis were enrolled in this pilot, randomized controlled clinical trial. Patients were equally allocated into two treatment groups: Control group was treated with scaling and root planing, re-evaluation, followed by Modified Widman Flap surgery and test group received similar surgery without scaling and root planing. Clinical attachment level, probing depth and bleeding on probing were recorded. Standardized radiographs were analysed for linear bone change from baseline to 6 months. Wound fluid inflammatory biomarkers were also assessed.21-07-20142Results: Both groups exhibited statistically significant improvement in clinical attachment level and probing depth at 3 and 6 months compared to baseline. A statistically significant difference in probing depth reduction was found between the two groups at 3 and 6 months in favour of the control group. No statistically significant differences in biomarkers were detected between the groups.Conclusions: Combined scaling and root planing and surgery yielded greater probing depth reduction as compared to periodontal surgery without initial scaling and root planing.21-07-20143

21-07-20144Clinical RelevanceScientific rationale for the study: Conventional periodontal therapy uses an initial non-surgical phasevprior to surgical intervention.However, limited information exists regarding outcomes of surgical intervention performed without initial therapy.Principal findings: Although no difference was found in clinical attachment level (CAL) gain between the two groups, the SRP plus surgery group showed a statistically significant improvement in probing depth (PD) reduction when compared to the surgery without SRP group.Practical implications: SRP is an important component of the periodontal therapy and its goal is resolution of inflammation evident by reduction of probing pocket depth and gain of clinical attachment level.21-07-20145Cross References21-07-20146Int Dent J. 1983 Jun;33(2):127-36.Indications and rationale for non-surgical periodontal therapy.Lang NP.

Non-surgical periodontal therapy, including patient motivation, instruction in oral hygiene and thorough scaling and root planing has been shown to be an acceptable and effective treatment for chronic destructive periodontitis. Even in deep periodontal pockets clinical attachment levels may be maintained by scaling and root planing alone provided that effective plaque control is assured by recall appointments at regular intervals. Even if personal oral hygiene procedures do not reach the required standard of perfection, non-surgical periodontal therapy may significantly delay the loss of periodontal attachment. Scaling and root planing are best performed with hand instruments. Ultrasonic devices save some time but leave rough root surfaces which are highly susceptible to the accumulation of further subgingival plaque. The intervals at which scaling and root planing have to be performed in order to alter successfully the pathogenic subgingival flora and to maintain a flora consistent with periodontal health have not been conclusively established. The limitations of non-surgical periodontal therapy lie within the operator's skill at gaining access to all root surfaces in furcations and deep periodontal pockets. Non-surgical periodontal therapy may have to extend over long time periods. For this reason, limited flap surgery in order to gain access to root surfaces, which would otherwise be too time-consuming to treat with scaling and root planing alone, might still be valuable.

21-07-20147J Clin Periodontol. 1984 Aug;11(7):448-58.Long-term effect of surgical/non-surgical treatment of periodontal disease.Lindhe J, Westfelt E, Nyman S, Socransky SS, Haffajee AD.

The present investigation describes the effect of periodontal therapy in a group of patients who, following active treatment, were monitored over a 5-year period. One aim of the study was to analyze the rle played by the patients' self-performed plaque control in preventing recurrent periodontitis. In addition, probing depth and attachment level alterations were studied separately for sites with initial probing depths of greater than or equal to 4 mm which were treated initially by either surgical or non-surgical procedures. Following active treatment (surgical/non-surgical), the patients were maintained on a plaque control regimen for 6 months, which included professional tooth cleaning once every 2 weeks. During the subsequent 18 months, the interval between the recall appointments was extended to 12 weeks and included prophylaxis as well as oral hygiene instruction. Following the 24-month examination, the interval between the recall appointments was further extended, now to 4-6 months. In addition, the maintenance program was restricted to oral hygiene instruction and professional, supragingival tooth cleaning, but further subgingival instrumentation was avoided. Clinical examinations including assessments of the oral hygiene, the gingival conditions, the probing depths and the attachment levels were performed at Baseline and after 24 and 60 months after completion of active therapy. 21-07-20148Assessments of plaque and gingivitis were repeated annually. The results of the examinations showed that the patients' standard of self-maintained oral hygiene had a decisive influence on the long-term effect of treatment. Patients who during the 5 years of monitoring consistently had a high frequency of plaque-free tooth surfaces showed little evidence of recurrent periodontal disease, while patients who had a low frequency of plaque-free tooth surfaces had a high frequency of sites showing additional loss of attachment. The present findings demonstrated that sites with an initial pocket depth exceeding 3 mm responded equally well to non-surgical and surgical treatments. This statement is based on probing depth and attachment level data from sites which were free of plaque at the 6-, 12-, 24-, 36-, 48-, and 60-month reexaminations. It is suggested that the critical determinant in periodontal therapy is not the technique (surgical or non-surgical) that is used for the elimination of the subgingival infection, but the quality of the debridement of the root surface.21-07-20149J Clin Periodontol. 1980 Jun;7(3):199-211.Short-term effects of initial, nonsurgical periodontal treatment (hygienic phase).Morrison EC, Ramfjord SP, Hill RW.

Longitudinal studies have reported the effect of various modalities of periodontal surgery on pocket depth and attachment levels related to pretreatment measurements. However, possible changes in these measurements as a result of scaling, oral hygiene improvements and occlusal adjustment during the hygienic phase were not considered. The purpose of the present study was to examine the short-term effect of treatment of the hygienic phase in 90 patients with some pockets extending 4 mm or more apically to the CEJ. Pretreatment pocket depths and attachment levels related to the CEJ were measured by a thin probe in five sites at all 2,355 teeth in the sample. Scaling, root planing, instruction in oral hygiene and occlusal adjustment were completed during four to six sessions for each patient. Four weeks after completion of the hygienic phase, all variables were recorded. Mean measurements for pocket depths 1-3 mm, 4-6 mm, and greater than or equal to 7 mm prior to treatment were compared to their posttreatment scores. Pocket depth decreased significantly for pockets extending 4 mm or more apically to the FGM. For pockets 4-6 mm there was a mean difference in pocket depth of 0.96 +/- 0.47 mm (P < .0001) between pretreatment and posttreatment observations. For pockets 7 mm or greater the mean difference was 2.22 +/- 1.35 mm (P < .0001). Reduction in depth of pocket and improvement in attachment levels were related to the initial level of severity. Pocket reduction was in part due to the improvement in attachment levels. This study has demonstrated that the clinical severity of periodontitis is reduced significantly 1 month following the hygienic phase of periodontal therapy, and that need for surgical pocket treatment cannot be assessed properly until completion of the hygienic phase of treatment.

21-07-201410J Clin Periodontol. 1987 Apr;14(4):231-6.The effect of plaque control and root debridement in molar teeth.Nordland P, Garrett S, Kiger R, Vanooteghem R, Hutchens LH, Egelberg J.

The healing response of non-molar sites, molar flat surface sites, and molar furcation sites was investigated in 19 adult periodontitis patients following a periodontal therapy of plaque control and root debridement. A total of 2472 sites were monitored by recordings of dental plaque, bleeding on probing, probing depth, and probing attachment levels every 3rd month for 24 months. The results demonstrated that in sites with initial probing depth of 4.0 mm or greater, molar furcation sites responded less favorably to the therapy as compared to molar flat surface sites or non-molar sites. This was demonstrated by higher mean scores for bleeding on probing, less reduction in probing depth, and a mean loss of probing attachment of 0.5 mm over 24 months. Site analyses using linear regression showed a higher % of deeper sites with probing attachment loss for the molar furcations than either molar flat surface or non-molar sites. Among sites initially 7.0 mm or deeper, 21% of molar furcations were identified as showing probing attachment loss as compared to 7% of the molar flat surface sites and 11% of the non-molar sites.

21-07-201411J Clin Periodontol. 1983 Sep;10(5):524-41.Comparison of surgical and nonsurgical treatment of periodontal disease. A review of current studies and additional results after 61/2 years.Pihlstrom BL, McHugh RB, Oliphant TH, Ortiz-Campos C.

Many well designed clinical studies have established the effectiveness of periodontal therapy. Surgical procedures have been shown to be effective in treating periodontitis when followed by appropriate maintenance care. Scaling and root planing alone have recently been compared to scaling and root planing plus soft tissue surgery in several longitudinal trials. A review of the literature indicates several important findings including a loss of clinical attachment following flap procedures for shallow (1-3 mm) pockets and no clinically significant loss after scaling and root planing. These studies also generally report either a gain or maintenance of attachment level for both procedures in deeper pockets (greater than or equal to 4 mm). For these pockets, neither procedure has been shown to be uniformly superior with respect to attachment gain. All reports indicate that both treatment methods result in pocket reduction. However, the literature also indicates that scaling and root planing combined with a flap procedure results in greater initial pocket reduction than does scaling and root planing alone. This difference in degree of pocket reduction between procedures tends to decrease beyond 1-2 years. It has been shown that both treatment methods result in sustained decreases in gingivitis, plaque and calculus and neither procedure appears to be superior with respect to these parameters. Additional data from the study at the University of Minnesota indicate that similar results are maintained up to 61/2 years following active therapy. Pocket depth did not change for shallow (1-3 mm) pockets treated by either scaling and root planing alone or scaling and root planing followed by a modified Widman flap. 21-07-201412For pockets 4-6 mm, both treatment procedures resulted in equally effective sustained pocket reduction. Deep pockets (greater than or equal to 7 mm) were initially reduced more by the flap procedure. After 2 years, no consistent difference between treatment methods was found in degree of pocket reduction. However, as compared to baseline, pocket reduction was sustained to 61/2 years with the flap and only 3 years with scaling and root planing alone. After 61/2 years, sustained attachment loss in shallow (1-3 mm) pockets was found after the modified Widman flap. Scaling and root planing alone in these shallow pockets did not result in sustained attachment loss. For pockets initially 4-6 mm in depth, attachment level was maintained by both procedures but scaling and root planing resulted in greater gain in attachment as compared to the flap at all time intervals21-07-201413J Periodontol. 1981 May;52(5):227-42.A randomized four-years study of periodontal therapy.Pihlstrom BL, Ortiz-Campos C, McHugh RB.

The purpose of this study was to compare the long term effectiveness of scaling and root planing alone to scaling and root planing followed by periodontal surgery. Seventeen subjects with moderate to advanced periodontitis received through scaling and root planing as well as oral hygiene instruction. A modified Widman flap was then randomly performed for one-half of each subject's dentition. Recall prophylaxis and oral hygiene reinforcement were administered for 4 years after completion of therapy. Shallow crevices (1--3 mm)subjected to either procedure tended to increase slightly in depth and exhibit a slight loss of attachment when compared to pretreatment measurements. Moderately deep pockets (4--6 mm) treated by either procedure were reduced and demonstrated a sustained gain or maintenance of attachment level. Pockets initially greater than or equal to 7 mm exhibited the greatest reduction in depth and attachment gain. Gingivitis was reduced following either procedure for moderate and deep pockets. No difference in supragingival plaque retention was noted and both procedures reduced calculus. The results indicate that both procedures were effective in treating moderate to advanced periodontitis. However, the additional flap procedure tended to result in greater pocket reduction and attachment gain for deeper pockets.

21-07-20141414J Clin Periodontol. 1987 Sep;14(8):445-52.4 modalities of periodontal treatment compared over 5 years.Ramfjord SP1, Caffesse RG, Morrison EC, Hill RW, Kerry GJ, Appleberry EA, Nissle RR, Stults DL.

The purpose of the present study was 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 rool planing). 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. 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.

21-07-201415J Clin Periodontol. 1992 Apr;19(4):240-4.Non-surgical periodontal treatment: where are the limits? An SEM study.Rateitschak-Plss EM1, Schwarz JP, Guggenheim R, Dggelin M, Rateitschak KH.

In the present scanning electron microscopic study, the possibilities and limitations of non-surgical root planing were investigated. 10 single-rooted teeth from 4 patients with advanced periodontitis were studied. The root surfaces were cleaned and planed without flap reflection, using fine curettes. The teeth were then extracted and the root surfaces were systematically examined by scanning electron microscopy (SEM) for the presence of residual bacteria and calculus. 29 of 40 curetted root surfaces were free of residues, if they were reached by the curette. On the remaining 11 surfaces, only small amounts of plaque and minute islands of calculus were detected, primarily at the line angles and also in grooves and depressions in the root surfaces. Instrumentation to the base of the pocket was not achieved completely on 75% of the treated root surfaces, however. The primary reason for this was the extremely tortous pocket morphology on the teeth selected for study. In conclusion, it may be stated that during non-surgical root planing in cases of advanced periodontitis, surfaces that can be reached by curettes are usually free of plaque and calculus. However, in many cases the base of the pocket will not be reached. It is for this reason that deep periodontal pockets should be treated with direct vision, i.e., after the reflection of conservative flaps.

21-07-201416Br Dent J. 1993 Mar 6;174(5):161-6.Rationale and techniques of non-surgical pocket management in periodontal therapy.Rawlinson A1, Walsh TF.

Traditional views on pocket instrumentation in periodontal therapy have centred upon the thorough scaling and planing of root surfaces, which aim to remove all calculus and substantial amounts of 'necrotic' and 'contaminated' cementum. The lack of scientific evidence for removing calculus in periodontal therapy, was highlighted by Frandsen and recent studies have also questioned the need for extensive root planing to remove 'substantial' amounts of cementum. The need for some degree of pocket instrumentation during periodontal therapy however, is beyond doubt, as clinical studies on the efficacy of nonsurgical periodontal treatment published during the last decade have clearly shown. A review of this important topic is therefore timely and this paper aims to elucidate some of the concepts which are currently the subject of debate. A resume of the formation and characteristics of the subgingival environment is a necessary starting point.

21-07-201417J Clin Periodontol. 2001 Oct;28(10):910-6.Initial outcome and long-term effect of surgical and non-surgical treatment of advanced periodontal disease.Serino G1, Rosling B, Ramberg P, Socransky SS, Lindhe J.

AIM: A clinical trial was performed to determine (i) the initial outcome of non-surgical and surgical access treatment in subjects with advanced periodontal disease and (ii) the incidence of recurrent disease during 12 years of maintenance following active therapy.MATERIAL AND METHODS: Each of the 64 subjects included in the trial showed signs of (i) generalized gingival inflammation, (ii) had a minimum of 12 non-molar teeth with deep pockets (> or =6 mm) and with > or =6 mm alveolar bone loss. They were randomly assigned to 2 treatment groups; one surgical (SU) and one non-surgical (SRP). Following a baseline examination, all patients were given a detailed case presentation which included oral hygiene instruction. The subjects in SU received surgical access therapy, while in SRP non-surgical treatment was provided. After this basic therapy, all subjects were enrolled in a maintenance care program and were provided with meticulous supportive periodontal therapy (SPT) 3-4 times per year. Sites that at a recall appointment bled on gentle probing and had a PPD value of > or =5 mm were exposed to renewed subgingival instrumentation. Comprehensive re-examinations were performed after 1, 3, 5 and 13 years of SPT. If a subject between annual examinations exhibited marked disease progression (i.e., additional PAL loss of > or =2 mm at > or =4 teeth), he/she was exited from the study and given additional treatment.

21-07-201418RESULTS: It was observed that (i) surgical therapy (SU) was more effective than non-surgical scaling and root planing (SRP) in reducing the overall mean probing pocket depth and in eliminating deep pockets, (ii) more SRP-treated subjects exhibited signs of advanced disease progression in the 1-3 year period following active therapy than SU-treated subjects.CONCLUSION: In subjects with advanced periodontal disease, surgical therapy provides better short and long-term periodontal pocket reduction and may lead to fewer subjects requiring additional adjunctive therapy.

21-07-201419J Periodontol. 2008 Mar;79(3):431-9. doi: 10.1902/jop.2008.070383 .Locally delivered doxycycline as an adjunct to mechanical debridement at retreatment of periodontal pockets.Tomasi C1, Koutouzis T, Wennstrm JL.

BACKGROUND: The aim of this study was to evaluate if adjunctive, locally delivered controlled-release doxycycline might improve the outcome of reinstrumentation of pathologic pockets persisting after initial periodontal therapy.METHODS: Subjects with chronic periodontitis underwent initial treatment including full-mouth ultrasonic debridement and oral hygiene instructions. At the 3-month reexamination, 32 subjects with remaining pathologic sites were assigned randomly to one of two retreatment protocols: ultrasonic instrumentation alone (control) or ultrasonic instrumentation plus application of an 8.8% doxycycline gel (test). Clinical examinations of plaque, probing depth (PD), relative attachment level (RAL), and bleeding on probing were performed before retreatment (baseline) and after 3 and 9 months. Primary efficacy variables were the percentage of closed pockets, i.e., PD < or =4 mm, and changes in PD and RAL.

21-07-201420RESULTS: Baseline examination revealed no significant difference in mean PD between treatment groups. The mean PD reduction at 3 months was 0.9 mm (95% confidence interval [CI]: 0.6 to 1.2) in the control group and 1.0 mm (95% CI: 0.7 to 1.3) in the test group (P >0.05). At 9 months, both treatment groups showed a mean PD reduction of 1.1 mm. The mean RAL gain was 0.6 mm at 3 months and approximately 0.8 at 9 months for both groups. The probability of pocket closure was not improved by the adjunctive antibiotic therapy. Only factors at the tooth site level (plaque presence, furcation involvement, and presence of an intrabony defect) were identified by multilevel analysis as significant for the treatment outcome.CONCLUSION: Locally delivered doxycycline failed to improve the healing outcome of reinstrumentation of periodontal pockets showing a poor initial response to pocket/root debridement.

21-07-201421J Clin Periodontol. 1984 Jan;11(1):63-76.Effect of nonsurgical periodontal therapy. II. Severely advanced periodontitis.Badersten A, Nilveus R, Egelberg J.

Healing events following nonsurgical periodontal therapy in patients with periodontal pockets up to 12 mm deep were investigated. Incisors, cuspids and premolars in 16 patients were treated by plaque control and supra- and subgingival debridement using hand or ultrasonic instruments in a split mouth approach. The results were evaluated by recording of plaque scores, bleeding on probing, probing pocket depths and probing attachment levels. Minimal change in gingival conditions occurred during the initial 3 months of experimentation, which were utilized for plaque control measures alone. Subsequent to instrumentation and during the following 9-month period, a gradual and marked improvement of periodontal conditions took place. During the remaining 12 months of the 24-month experimental period no further changes of the recorded parameters were noted. No differences in results could be observed when comparing hand versus ultrasonic instrumentation, or when comparing the results of 2 different operators. Initially, a total of 305 sites demonstrated probing pocket depths greater than or equal to 7 mm. At the 24-month examination 43 such sites remained. The results indicate that there is no certain magnitude of initial probing pocket depth where nonsurgical periodontal therapy is no longer effective.

21-07-201422J Periodontol. 1988 Jun;59(6):351-65.A longitudinal study comparing scaling, osseous surgery and modified Widman procedures. Results after one year.Becker W1, Becker BE, Ochsenbein C, Kerry G, Caffesse R, Morrison EC, Prichard J.

The purpose of this study was to compare, longitudinally, the effectiveness of scaling and root planing, osseous surgery, and the modified Widman procedures. The study was carried out in a private practice setting. Sixteen adult patients with moderate to advanced adult periodontitis were treated with initial scaling and oral hygiene procedures. Posthygiene data were used for comparison of changes in probing depth, clinical attachment levels and gingival recession. The initial examination data were used to compare changes in plaque and gingival indices. Frequency distributions were used to compare changes that occurred at individual sites. At one year, plaque and gingival indices were significantly reduced when compared with the initial examination. At one year, shallow pockets (1-3 mm) were reduced when compared to posthygiene. Four- to six-millimeter pockets were significantly reduced by the three procedures. Osseous surgery and modified Widman had significantly greater pocket reduction when compared with scaling. For pockets greater than 7 mm, osseous surgery and the modified Widman had significantly greater reduction when compared with scaling. For pockets 1-3 mm at one year osseous surgery had significantly greater clinical attachment loss when compared with scaling. For 4-6 mm pockets at one year, the three procedures had slight gains in clinical attachment levels. The results were similar for pockets with greater than 7 mm. Interproximal soft tissue craters were measured for six postoperative weeks. 21-07-201423Initially, the modified Widman had a higher percentage of soft tissue craters when compared with osseous surgery. At six weeks, however, there were no significant differences when the surgical procedures were compared. Recession was measured at each examination. Recession for 1-3 mm pockets at one year was greater for osseous surgery when compared with scaling and the modified Widman. Recession for 4-6 mm and greater than 7 pockets was greater for the surgical procedures than scaling. The results from this study indicate that with three-month maintenance recalls, both the modified Widman and osseous surgery are effective for pocket reduction, and each will produce a slight gain of clinical attachment over one year. Scaling was effective at maintaining attachment levels but was not as effective in reducing pocket depth.21-07-201424J Clin Periodontol. 2002 Feb;29(2):92-102.Clinical and microbiological studies of periodontal disease in Sjgren syndrome patients.Kuru B1, McCullough MJ, Yilmaz S, Porter SR.

BACKGROUND: Little is known about the periodontal status of patients with Sjgren's Syndrome (SS), a chronic inflammatory autoimmune disease characterized by xerophthalmia and xerostomia. The aim of the present study was to evaluate whether the periodontal status of SS patients, in terms of clinical and microbiological parameters, differs from systemically healthy age- and gender-matched controls.METHODS: 8 primary SS and 10 secondary SS patients were examined in comparison with 11 control subjects. All patients were diagnosed by the European Community Criteria. Control subjects were systemically healthy and not undergoing periodontal treatment. The comparison of clinical status was made in terms of mean periodontal parameters (plaque index, gingival index, gingival recession, probing pocket depth, probing attachment level and bleeding on probing) as well as the frequency distribution of probing pocket depth and probing attachment level measurements. Microbiological assays of the subgingival dental plaque samples were carried out by both a chairside enzyme test (Periocheck) for the detection of peptidase activity (PA) and a polymerase chain reaction (PCR) analysis for 9 selected periodontal micro-organisms (Actinobacillus actinomycetemcomitans, Fusobacterium nucleatum, Prevotella intermedia, Treponema denticola, Porphyromonas gingivalis, Eikenella corrodens, Campylobacter rectus, Bacteroides forsythus, Streptococcus oralis).

21-07-201425RESULTS: The occurrence, severity and extent of periodontal lesions were not significantly different between the 3 patient groups for all periodontal parameters examined. No significant differences in the sub-gingival plaque samples from control, primary or secondary SS patients for the PA test, frequency or type of periodontal micro-organisms observed.CONCLUSION: No significant differences could be detected in either clinical or microbiological parameters of primary or secondary SS patients compared with that of control subjects. The results of the present study thus support the notion that the periodontal status of patients with SS do not differ from systemically healthy age- and gender-matched controls.

21-07-201426J Periodontol. 1981 Nov;52(11):655-62.Four types of periodontal treatment compared over two years.Hill RW, Ramfjord SP, Morrison EC, Appleberry EA, Caffesse RG, Kerry GJ, Nissle RR.

Results of various modalities of periodontal therapy were studied in 90 subjects (mean age 45 years) with moderate to severe periodontitis. Initial measurements of pocket depth and clinical attachment levels were compared with measurements obtained after the initial hygienic phase of the treatment and measurements of the same areas 1 and 2 years after four different types of periodontal treatment had been applied on a randomized basis to each of the four quadrants of the dentition. These treatments were: (1) surgical pocket elimination or reduction, (2) modified Widman flap surgery. (3) subgingival curettage, (4) scaling and root planing only. The patients were recalled for prophylaxis every 3 months, and rescored annually. One-way analysis of variance and Scheffe's method were used to test the hypothesis of equal treatment effects. The results were analyzed both with initial pocket depth as the baseline and with pocket depth at the hygienic phase as the baseline using a grouping of pockets 1 to 3 mm, 4 to 6 mm, and greater than or equal to 7 mm. For the 1 to 3 mm pockets there was a slight reduction in depth at the hygienic phase, with only minor changes after the various modalities of treatment over 2 years. However, significant losses of attachment after all modalities of periodontal therapy, including scaling alone, were observed at both the 1-year an 2-year intervals. For pockets 4 to 6 mm deep, the main reduction in pocket depth occurred at the hygienic phase, but the pockets also were reduced by further treatment, most by pocket elimination and modified Widman surgery. However, this reduction in pocket depth after surgery had no beneficial influence on maintenance of the attachment level, which actually was maintained best by scaling alone. For deep pockets greater than or equal to 7 mm, significant reduction in pocket depth occurred both at the hygienic phase and 1 to 2 years after treatment, with the greatest initial reduction after pocket elimination surgery. However, again there was no significant difference in attachment results among the four methods.

21-07-201427J Clin Periodontol. 1995 Feb;22(2):162-7.Crevicular interleukin-1 beta in moderate and severe periodontitis patients and the effect of phase I periodontal treatment.Hou LT1, Liu CM, Rossomando EF.

Interleukin-1 beta (IL-1 beta), a potent stimulator of bone resorption, has been implicated in the pathogenesis of periodontal destruction. However, the relationship between cytokines and periodontal disease has not been studied sufficiently to allow definitive conclusions. The aims of this study are to investigate crevicular IL-1 beta and the clinical status of patients with periodontitis and the effect of phase I periodontal therapy on levels of IL-1 beta. For this study, 130 gingival crevicular fluid (GCF) samples were harvested from non-inflamed (15) and diseased sites (115) in 11 patients with periodontitis. The gingival index (GI) and probing depth (PD) of each site was recorded initially and one month after treatment. The amount of IL-1 beta in the GCF was measured by enzyme-linked immunosorbent assay (ELISA) using an antibody specific for this cytokine. Before treatment, IL-1 beta was found in 12 of 15 non-inflamed gingival crevices and in 112 of 115 diseased pockets. The amount of IL-1 beta varied from 4.03 to 511.12 pg/site. The average amount of IL-1 beta from diseased sites was 3-fold greater than that from non-inflamed sites. Both total amount of IL-1 beta and the GCF volume, but not IL-1 beta concentration, were found to be correlated, positively, with GI score and PD. After therapy, 63 sites from 7 patients were re-examined, and the amount of IL-1 beta in 49 of 63 sites was found to have declined. These data suggest that the amount of crevicular IL-1 beta is closely associated with periodontal status. This relationship may be valuable in monitoring periodontal disease activity.

21-07-201428J Clin Periodontol. 1984 Nov;11(10):669-81.The effect of root planing as compared to that of surgical treatment.Isidor F, Karring T, Attstrm R.

This study was undertaken in order to evaluate the effect of root planing as compared to that of surgical periodontal treatment in patients with advanced periodontal disease. 17 patients with advanced periodontal disease participated in the study. After the initial examination, the teeth were scaled and the patients were given instruction in performing proper oral hygiene. The hygienic phase for the individual patient was continued until less than 20% of the tooth surfaces demonstrated plaque at 2 succeeding appointments. After re-assessment of the periodontal status, 1 side in both the maxilla and mandible was treated with modified Widman flap surgery. In 1 of the remaining quadrants, in the maxilla or mandible, reverse bevel flap surgery was used. Bone contouring was not performed in any of the surgical procedures. The last quadrant was subjected to meticulous root planing under local anesthesia. Subsequently, the patients were recalled every second week for professional tooth cleaning. The periodontal status of each patient was assessed 3 and 6 months following treatment. Root planing resulted in considerable reduction in pocket depth, although more shallow pockets were obtained following modified Widman flap and reverse bevel flap surgery. Clinical gain of attachment was obtained following all 3 modalities, but root planing resulted in slightly more gain of attachment than the 2 surgical procedures.

21-07-201429J Periodontol. 1996 Feb;67(2):93-102. Long-term evaluation of periodontal therapy: I. Response to 4 therapeutic modalities.Kaldahl WB1, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK.

Eighty-two periodontal patients were treated in a split mouth design with coronal scaling (CS), root planing (RP), modified Widman surgery (MW), and flap with osseous resection surgery (FO) which were randomly assigned to various quadrants in the dentition. Therapy was performed in 3 phases: non-surgical, surgical, and supportive periodontal treatment (SPT) < or = 7 years. Clinical data consisted of probing depth (PD), clinical attachment level (CAL), gingival recession (REC), bleeding on probing (BOP), suppuration (SUP), and supragingival plaque (PL). Because of the necessity to exit many CS treated sites due to breakdown, data for CS were reported only up to 2 years. All therapies produced mean PD reduction with FO > MW > 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 4 mm sites. There were no differences in PD reduction between MW and RP treated sites by the end of year 3 in the 5 to 6 mm sites and by the end of year 5 in the > or = 7 mm sites. FO produced greater PD reduction in > or = 5 mm 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 1-4 mm sites. RP and MW produced a greater gain of CAL than CS and FO following the surgical phase in 5 to 6 mm sites, but the magnitude of difference decreased during SPT. Similar CAL gains were produced by RP, MW, and FO in sites > or = 7 mm. These gains were greater than that produced by CS and were sustained during SPT. Recession was produced with FO > MW > RP > CS. This relationship was maintained throughout SPT. The prevalences 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 BOP and SUP.

21-07-201430J Clin Periodontol. 1980 Feb;7(1):32-47.Comparison of results following three modalities of periodontal therapy related to tooth type and initial pocket depth.Knowles J, Burgett F, Morrison E, Nissle R, Ramfjord S.

Results following three modalities of periodontal therapy (subgingival curettage, modified Widman flap surgery, and pocket elimination or reduction surgery) in 78 patients over 8 years were compared for variations in pocket depth and clinical attachment level related to tooth types (maxillary molars, mandibular molars, maxillary biscupids, mandibular biscupids, maxillary anterior teeth, mandibular anterior teeth). The analysis was based on a classification of three severity groups according to initial crevice or pocket depth (Class I, 1-3 mm; Class II, 4-6 mm; and Class III, 7-12 mm) and with patient's means of measurements being the experimental units for the statistical analysis. Reduction in pocket depth and gain of clinical attachment for pockets 4 mm or deeper occurred following all three methods of treatment, and was well sustained over 8 years. No one modality of treatment was consistently superior to any of the other two with regards to sustained reduction of pocket depth and gain of clinical attachment. Surgical pocket elimination or reduction did not enhance the prognosis for maintenance of periodontal support in either moderate or advanced periodontal lesions anywhere in the mouth compared with more conservative modalities of treatment. In spite of prophylaxis and instruction in home care every 3 months, there was a slight progressive loss of attachment over time in areas of shallow crevices (1-3 mm).

21-07-201431J Periodontol. 2001 Aug;72(8):1045-51.Effect of non-surgical periodontal therapy on C-telopeptide pyridinoline cross-links (ICTP) and interleukin-1 levels. Al-Shammari KF1, Giannobile WV, Aldredge WA, Iacono VJ, Eber RM, Wang HL, Oringer RJ.

BACKGROUND: Biochemical markers harvested from gingival crevicular fluid (GCF) may be useful to identify and predict periodontal disease progression and to monitor the response to treatment. C-telopeptide pyridinoline cross-links (ICTP), a host-derived breakdown product specific for bone, and interleukin-1beta (IL-1), a potent bone-resorptive cytokine, have been associated with periodontal tissue destruction. The aim of this study was to examine the effect of non-surgical periodontal therapy on GCF levels of ICTP and IL-1.METHODS: Twenty-five chronic periodontitis subjects were monitored at 8 sites per subject at baseline prior to scaling and root planing and 1, 3, and 6 months after therapy. Four shallow (probing depths < 4 mm) and 4 deep (probing depths > or = 5 mm) sites were monitored for both marker levels and clinical parameters. GCF was collected for 30 seconds on paper strips, and levels of ICTP and IL-1 were determined using radioimmunoassay (RIA) and enzyme-linked immunosorbent assay (ELISA) techniques, respectively. Clinical measurements included probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP).

21-07-201432RESULTS: Deep sites exhibited significantly (P