Healing following surgical non-surgical treatment of periodontal disease

Abstract A clinical trial was undertaken to study the effect of one surgical and one non-surgical treatment modality in patients with advanced periodontal disease. Fifteen patients were selected for the study. Following a Baseline examination comprising assessments of oral hygiene status, gingival conditions, probing depths and attachment levels, all participants were subjected to treatment. In each patient, scaling and root planing were carried out in conjunction with the modified Widman flap procedure in two jaw quadrants while in the contralateral quadrants the treatment was restricted to scaling and root planing. During the phase of active treatment, i.e. the period between the first and last operation, and for the subsequent 6 months of healing, the patients were subjected to “professional toothcleaning” once every 2 weeks. From this time until the end of the trial which was 24 months after active treatment, the patients were recalled for prophylaxis once every 3 months. Reexaminations were performed 6, 12 and 24 months after the completion of active treatment. The results demonstrated that scaling and root planing used alone were almost equally effective as their use in combination with the modified Widman flap procedure in establishing clinically healthy gingiva and in preventing further loss of attachment. Both treatment modalities prevented recurrence of periodontal disease for the 24 months of observation. The analysis of the probing depth data revealed that both methods of treatment resulted in a high frequency of probing depths of <4 mm. The probing depth reduction was more pronounced in initially deep than in initially shallow pockets and, for initially deep pockets, more marked in sites subjected to surgery than in sites exposed to scaling and root planing alone. The measurements also showed that sites with initially deep pockets exhibited more pronounced gain of clinical attachment than sites with initially shallow pockets. Significant loss of attachment did not occur in sites treated with scaling and root planing alone while attachment loss was found following Widman flap surgery in sites with initial probing depth of <4 mm.     

"Critical probing depths" in periodontal therapy

Abstract The present investigation was carried out on 15 individuals who were referred for treatment of moderately advanced periodontal disease. All patients were first subjected to a Baseline examination comprising assessment of oral hygiene and gingival conditions, probing depths and attachment levels. Following case presentation and instructions in oral hygiene measures, the patients were given periodontal treatment utilizing a split mouth design. In one side of the jaw scaling and root planing were performed in conjunction with a modified Widman flap procedure while in the contralateral jaw quadrants the treatment was restricted to scaling and root planing only. The period from initial treatment to 6 months after treatment was considered to be the Healing phase and from 6–24 months after treatment the maintenance phase. During the healing phase the patients were recalled for professional tooth cleaning once every 2 weeks. During the maintenance phase the interval between the recall appointments was extended to 3 months. Reexaminations were carried out 6, 12 and 24 months after the completion of active treatment. The results revealed that treatment resulted in loss of clinical attachment in sites with initially shallow pockets, while sites with initially deep pockets gained clinical attachment. With the use of regression analysis “critical probing depths” were calculated for the two methods of treatment used. It was found that the critical probing depth value for scaling and root planing was significantly smaller than the corresponding value for scaling and root planing used in combination with modified Widman flap surgery (2.9 vs 4.2 mm). In addition, the surgical modality of therapy resulted in more attachment loss than the non-surgical approach when used in sites with initially shallow pockets. On the other hand, in sites with initial probing depths above the critical probing depth value more gain of clinical attachment occurred following Widman flap surgery than following scaling and root planing. The data obtained from the reexaminations 12 and 24 months after active treatment demonstrated that the probing depths and the attachment levels obtained following active therapy and healing were maintained more or less unchanged during a maintenance care period which involved careful prophylaxis once every 3 months. However, the data also disclosed that the level of oral hygiene maintained by the patients during healing and maintenance was more critical for the resulting probing depths and attachment levels than the mode of initial therapy used. Thus, sites which during the maintenance period were found to be free from supragingival plaque were associated with shallow pockets and maintained attachment levels. In contrast, sites which harboured plaque exhibited increasing probing depths and further attachment loss.     

Effect of surgical and non-surgical periodontal treatment on periodontal status and subgingival microbiota

The purpose of this study was to evaluate, on a short-term basis, the clinical and microbiological effects of a single course of scaling and root planing as compared with those obtained by flap surgery in patients with moderate to advanced periodontitis. 11 patients participated in the study. Using a split-mouth design, one quadrant of the mouth was treated with reverse bevel flap surgery, whereas the contralateral one was subjected to a single course of scaling and root planing. 2 approximal sites on single-rooted teeth with a pocket depth greater than or equal to 5 mm were monitored clinically and microbiologically for 16 weeks after active treatment. Both techniques resulted in a gain of probable attachment levels, a reduction in bleeding on probing and a reduced mean pocket depth, although 31.2% of the sites in the scaling and root planing group still had 6-7 mm deep pockets at 8 and 16 weeks after treatment. Both techniques reduced median relative proportions and frequencies of detection of black-pigmented Bacteroides species. A highly statistically significant increase (p less than 0.01) in median proportions of oral streptococci was recorded only for surgery within the 1st month post-operatively. No correlation was found between residual pocket depth and any of the microbiological parameters considered in the study, suggesting that residual pocket depth does not exert a significant influence on bacterial subgingival recolonization after therapy. The results from this study suggest that surgery can be as effective as scaling and root planing in favoring the establishment of micro-organisms compatible with periodontal health, although this effect is limited to the 1st month after therapy.     

Regeneration of alveolar bone following surgical and non-surgical periodontal treatment

The purpose of this investigation was to examine the regeneration of alveolar bone following surgical and non-surgical periodontal treatment. A total of 16 patients who had advanced periodontitis and demonstrated angular bony defects on radiographs participated in the study. After the initial examination, they received instruction in oral hygiene and had their teeth thoroughly scaled. When the individual patient at 2 succeeding appointments had plaque on less than 20% of the tooth surfaces, one maxillary and one mandibular quadrant was treated with the modified Widman flap procedure while one of the remaining quadrants was treated with the reverse bevel flap procedure. The last quadrant was treated with root planing under local anesthesia. None of these procedures included bone contouring. Following treatment, the patients were recalled every 2 weeks for professional tooth cleaning. Radiographs taken 12 months following treatment revealed that only minor changes in the bone level had occurred in areas with horizontal bone loss following the various treatment modalities. Following the modified Widman flap procedure, however, a statistically significant coronal regrowth of bone (0.5 mm) had occurred in angular bony defects. The majority of the angular bony defects persisted following all 3 treatment modalities.     

Locally delivered doxycycline improves the healing following non-surgical periodontal therapy in smokers

OBJECTIVE: The outcome of non-surgical periodontal therapy is known to be inferior in smokers compared to non-smokers. In the present study, the question was asked whether such a difference in healing response may be less evident following adjunctive use of locally delivered controlled-release doxycycline. METHODS: One hundred and three patients (42 smokers, 61 non-smokers), each having at least eight periodontal sites with PPD (probing pocket depth) > or =5 mm, were following stratification for smoking randomly assigned to two different treatment protocols; non-surgical scaling/root planing (Control) or ultrasonic instrumentation+application of a 8.5% w/w doxycycline gel (Atridox trade mark ) (Test). Instructions in oral hygiene were given to all patients. Clinical examinations of plaque, PPD, clinical attachment level (CAL) and bleeding following pocket probing were performed at baseline and after 3 months. Primary efficacy endpoints were changes in PPD and CAL. Patient mean values were calculated as basis for statistical analysis (multiple regression analyses). RESULTS: The baseline examination revealed no significant difference in mean PPD between treatment groups or between smokers and non-smokers (mean PPD 5.7-5.9 mm). The mean PPD reduction in the control group at 3-month was 1.1 mm (SD=0.45) for smokers and 1.5 mm (0.67) for non-smokers. In the test group the PPD reduction was 1.4 mm (0.60) and 1.6 mm (0.45) for smokers and non-smokers, respectively. The mean CAL gain for smokers and non-smokers amounted to 0.5 mm (0.56) and 0.8 mm (0.71), respectively, in the control group, and to 0.8 mm (0.72) and 0.9 mm (0.82), respectively, in the test group. Multiple regression analysis revealed that smoking and initial PPD negatively influenced the treatment outcome in terms of PPD reduction and CAL gain, while the use of doxycycline had a significant positive effect. CONCLUSION: Locally applied controlled-release doxycycline gel may partly counteract the negative effect of smoking on periodontal healing following non-surgical therapy.     

Non-surgical management of periodontal disease

Non-surgical removal of plaque and calculus has been part of the initial phase of the management of patients with gingivitis and periodontitis for decades. It consists of patient motivation and oral hygiene instruction as well as mechanical removal of supra and subgingival plaque deposits. The purpose of this review was to assess recent changes. The article reports on changes in our understanding of plaque as a biofilm, developments in patient plaque control, chemical plaque control and scaling instruments. It also comments on full-mouth disinfection, the use of lasers and host modulation. Modern technology has made removal of microbial deposits by the patient and dental professionals more efficient. However, other advancements need to be used in conjunction with mechanical debridement at this time.     

Changes in subgingival microflora and humoral immune response following periodontal therapy

OBJECTIVES: To investigate the effect of scaling and root planing (SRP) on the microflora and humoral immune response in adult periodontitis. MATERIALS & METHODS: Clinical measurements, subgingival plaque samples, gingival crevicular fluid and sera were taken from 4 sites in 28 adult periodontitis patients before and after SRP. Polymerase chain reaction was used to determine the presence of A. actinomycetemcomitans, P. gingivalis, B. forsythus, P. intermedia, and T. denticola. ELISA was used to investigate the systemic and local antibody titres to these organisms, and thiocyanate dissociation for the determination of serum antibody avidity. RESULTS: SRP produced a good clinical improvement. On a subject basis there was little significant change in the microflora. However, on a site basis, there were significant reductions in P. intermedia, B. forsythus and T. denticola. There was little change in systemic and local antibody titres following SRP, although there was a significant reduction in antibody avidity to P. gingivalis and P. intermedia CONCLUSION: Post-therapy clinical improvement was associated with a reduction in bacterial prevalence, but statistical significance was only reached at a site level and this microbial reduction was not significant for all organisms. No significant post-therapy effects on the humoral immune response were noted other than a reduced antibody avidity to P. gingivalis and P. intermedia. The lack of a clear pattern in the humoral immune response may reflect a failure of the host response to produce adequate levels of biologically functional antibodies, and complex interactions between the subgingival flora and the host response.     

Evaluation of enamel matrix derivative as an adjunct to non-surgical periodontal therapy

OBJECTIVES: The aim of this study was to evaluate the adjunctive use of enamel matrix derivative (EMD) on periodontal healing following nonsurgical periodontal therapy (scaling and root planing - SRP). MATERIAL AND METHODS: The study was performed as an intraindividual, longitudinal trial of 3 months duration with a double-blinded, split-mouth, controlled, and randomized design. Twenty-two patients with moderate to severe chronic periodontitis were enrolled in the study. In each patient, two sites with pocket depths >/=5 mm and with radiographic angular bone defects >3 mm were selected. Baseline examination included measurement of probing pocket depth (PPD) and clinical attachment levels (CAL). The presence or absence of plaque and bleeding on probing at selected sites was also recorded. Following initial examination, full-mouth SRP was performed. Study sites were then treated with 24% EDTA for 2 min, followed by thorough irrigation with sterile saline. The sites were then randomized. The experimental site received subgingival application of enamel matrix derivative (Emdogain, BIORA AB, Malmo, Sweden). The control site received no additional treatment. At 3 months, all sites were re-examined. The response to therapy in experimental and control sites was evaluated, using change in probing depth and CAL as the primary outcome variables. Statistical analysis (paired t-tests) was used to compare response to treatment in control versus experimental sites. RESULTS: Statistically significant changes in PPD and CAL were seen in both treatment groups from baseline to 3 months. The mean PPD reduction was 2.3+/-0.5 mm for control sites and 2.0+/-0.3 mm for experimental sites. The mean CAL gain was 1.8+/-0.4 mm for control sites, and 1.4+/-0.3 mm for experimental sites. Statistical analysis, however, revealed no significant difference in PPD reduction or CAL gain between experimental and control groups (p>0.4). In addition, no difference was found between treatment groups in bleeding or plaque indices at 3 months. CONCLUSION: The findings from the present study do not support the use of EMD during routine, nonsurgical debridement of periodontal pockets as measured 3 months post SRP.     

Interclinician disparity in periodontal decision making: need for consensus statements on surgical treatment

BACKGROUND AND OBJECTIVE: The clinical factors involved in the decision-making process for surgical treatment have been described. However, there is still little standardization of the criteria upon which such a decision should be based. The impact of this lack of practice guidelines on the recommendation of surgery in clinical practice is unclear. The objective of the present study was to investigate the recommendation of surgical therapy during the corrective/reparative treatment phase by trained clinicians with various backgrounds on the basis of clinical data. MATERIAL AND METHODS: Fifteen clinicians (10 periodontal students and/or recent graduates from two dental schools and five experienced practitioners) were asked to make a treatment decision (surgery or no surgery) at a tooth level. Therefore, they were given 23 initially treated patients with details on demographics and smoking habits. Radiographs and clinical information on 573 teeth at baseline (prior to root debridement) and at 9 mo of follow-up were provided. RESULTS: Clinicians interpret clinical data quite differently in their advice of surgery when practice guidelines are not provided, as the results showed high variation in surgical recommendation. Experienced practitioners showed most variation, with a range from 13 to 50% in surgical recommendation. Clinicians linked to a training center shared a common treatment philosophy as to when periodontal surgery should be performed. This philosophy differed markedly among the two dental schools. Most disagreement among the 15 clinicians was found for deep pockets and for multirooted teeth. Disease status, tooth type, age, and full-mouth plaque levels had a significant impact on decision making. CONCLUSION: The substantial variation in recommending surgery calls for consensus statements on surgical treatment.     

Pain levels in patients during periodontal probing and mechanical non-surgical therapy

The purpose of this study was to assess the degree of pain during periodontal probing and mechanical non-surgical therapy according to age, gender, and intersubject variation such as tooth type, tooth surfaces or regions of mouth, probing depth, and bleeding on probing. The study was carried out on 64 patients with chronic periodontitis. Pain/discomfort of patients during both periodontal probing and scaling and root planing (SRP) was measured using a visual analog scale (VAS). During periodontal probing and SRP, VAS scores decreased with increasing age for two procedures (Spearman ρ, −0.301 and −0.348, respectively; P < 0.01). VAS scores were considerably lower for oral sites than for facial sites. VAS scores in probing were significantly higher in sites ≥4 mm deep than sites <4 mm deep. Sites bleeding on probing had a significantly higher VAS scores than sites no bleeding on probing (p < 0.05). The results showed that although there is no difference between genders, the intensity of pain during periodontal probing and SRP was different dramatically between patients as well as vary between different locations in the same mouth. If pain responses for probing in different several regions in the same mouth during initial examination were noted into patient chart used for initial examination, the therapist will recognize patients with elevated pain responses. If need be, they will then apply some pain control medication or anesthetic for patients during probing and SRP.     

Role of "diseased" root cementum in healing following treatment of periodontal disease

This clinical trial was undertaken to examine whether root debridement in the treatment of periodontal disease must include the removal of the exposed cementum in order to achieve periodontal health. The study included 11 adult patients with moderate to advanced periodontal disease. In a split-mouth design, the dentition of each patient was by random selection divided into test- and control quadrants comprising the incisors, canines and premolars. Following a baseline examination, all patients were given a case presentation and a detailed instruction in self-performed oral hygiene measures. The patients were then subjected to periodontal surgery. Following reverse bevel incisions, buccal and lingual mucoperiosteal flaps were elevated and all granulation tissue was removed. In 2 jaw quadrants (control quadrants) in each patient, the denuded root surfaces were carefully scaled and planed in order to remove soft and hard deposits as well as all cementum, using hand instruments and flame-formed diamond stones. In the contralateral quadrants (test quadrants) the roots were not scaled and planed but soft microbial deposits were removed by polishing the root surfaces with the but soft microbial deposits were removed by polishing the root surfaces with the use of rubber cups, interdental rubber tips and a polishing paste. Calculus in the test quadrants was removed by the use of a curette, but precaution was taken to avoid the removal of cementum. The flaps were repositioned to their original level and sutured. The patients were following active treatment enrolled in a supervised maintenance care program including "professional tooth cleaning" once every 2 weeks for a 3-month period.(ABSTRACT TRUNCATED AT 250 WORDS)