Periodontology 2000, Vol. 75, 2017, 152–188 © 2017 John Wiley & Sons A/S.
& Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Nonsurgical and surgical
treatment of periodontitis: how
many options for one disease?
FILIPPO GRAZIANI, DIMITRA KARAPETSA, BETTINA ALONSO & DAVID HERRERA
Periodontal disease is an infectious disease character-
ized by inflammation of the tooth-supportive tissues,
which can lead to destruction of the periodontal liga-
ment and alveolar bone and possibly also to tooth
loss (261). Periodontal health is a component of over-
all health and is therefore a fundamental human right
(17). Treatment of periodontitis aims to prevent fur-
ther disease progression, to minimize symptoms and
perception of the disease, possibly to restore lost tis-
sues and to support patients in maintaining a healthy
periodontium. Periodontal treatment utilizes a
plethora of therapeutic interventions to achieve these
goals, including behavioral-change techniques, such
as: individually tailored oral-hygiene instructions
(138, 140); smoking-cessation support (39, 237); diet-
ary intervention (116); subgingival instrumentation to
remove plaque and calculus (157); local and systemic
pharmacotherapy (42, 133, 275); and various types of
surgery (53, 54, 149, 232, 280, 284, 318). Management
of chronic periodontal disease requires a combina-
tion of therapeutic modalities and a lifelong commit-
ment to periodontal self-care.
Supragingival biofilm control
May periodontitis be treated with
supragingival biofilm control alone?
Supragingival plaque control relies on self-performed
oral-hygiene measures and professional removal of
plaque/calculus/plaque-retaining factors. Owing to a
high rate of dental plaque formation, long-term pla-
que control depends heavily on self-performed oral
hygiene. Accumulation of high levels of plaque is asso-
ciated with lower healing capability, if not worsening
periodontal conditions, and precludes a successful
outcome with nonsurgical periodontal treatment (71),
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PERIODONTOLOGY 2000
conventional surgery (204, 266) and regenerative sur-
gery (82, 119, 246). Thus, self-performed oral hygiene
represents the keystone of the treatment of periodon-
tal diseases, but one might wonder if daily disruption
of the supragingival biofilm, alone, is sufficient to treat
periodontal disease. Studies have assessed the effect
of oral-hygiene regimens alone on both periodontal
clinical parameters (38, 93, 181, 227, 322) and the sub-
gingival microbiota (181). In a systematic review of
patients with chronic periodontitis (311), oral hygiene
alone was less effective than subgingival debridement
combined with supragingival plaque removal, as mea-
sured by bleeding on probing, probing pocket depth
and clinical attachment level (340). In pockets with
initial depths of ≥ 5 mm, supragingival plaque control
alone produced a decrease in pocket depth of
0.59 mm and a clinical attachment gain of 0.37 mm,
whereas scaling and root planing plus oral hygiene
yielded a decrease in pocket depth of 1.18 mm and an
attachment gain of 0.64 mm (93, 227). Moreover, sub-
jects affected by severe periodontitis showed a signifi-
cant reduction in all microbial parameters 1 week
following subgingival instrumentation but not in the
subgingival microbiota after 12 weeks of oral-hygiene
instructions alone (181). A 3-year study of subjects
receiving solely supragingival plaque control showed
further loss of attachment or an unchanged frequency
of pockets deeper than 6 mm (8% at baseline and
5.3% at the 36-months examination), whereas patients
who also received subgingival debridement experi-
enced a significant reduction of deep pockets (11% at
baseline vs. 0.3% at 36 months) (322).
May periodontitis be treated without
supragingival biofilm control?
A question that emerges quite spontaneously in the
treatment of periodontitis concerns the effectiveness
 Treatment options for periodontitis

of subgingival instrumentation in the absence of oral- may limit patient compliance (274). Interdental
hygiene instructions. Studies on the efficacy of root brushes are favored as the primary choice of inter-
debridement without supragingival plaque control dental cleaning in patients with periodontitis (Fig. 2),
suggest that the improvement in periodontal clinical whilst flossing should be suggested for periodontally
and microbiological parameters is substantially less healthy sites, where interdental brushes will not pass
than that observed after subgingival instrumentation through the interproximal area without causing
plus oral-hygiene instruction (183, 201, 262). trauma (Fig. 3) (45). In sum, the literature has clearly
Worsening clinical parameters occurred at week 24 indicated that oral hygiene, when properly per-
post-treatment in patients who received root instru- formed, can control plaque and gingival inflamma-
mentation but no oral-hygiene instructions (201). Con- tion, but oral hygiene alone is not sufficient to arrest
sidering that recolonization with supragingival bacteria progressive periodontal disease.
begins shortly after root debridement (71), daily
meticulous supragingival plaque control seems to be
What is the role of chemical adjunctive
essential to avoid deterioration of periodontal clinical
anti-plaque agents such as dentifrices
and microbiological disease variables (266, 296).
and mouthrinses?
Mechanical plaque control alone may not prevent the
How should mechanical control of
onset or recurrence of destructive periodontal disease
supragingival biofilm be performed?
(310), for reasons including insufficient time spent
Meticulous and daily application of the correct oral- performing plaque removal, poor skill or failing to
hygiene techniques may reduce the level of plaque carry out interdental cleaning. In this context, chemi-
and prevent the onset of gingivitis and interdental cal products for control of oral biofilm were
caries (49, 161, 162). Development of the correct oral-
hygiene habits is a complex process that needs to be
professionally supported (309). Self-performed pla-
que control is based on both mechanical and chemi-
cal plaque control. Buccal/lingual and occlusal
mechanical plaque removal is performed with tooth-
brushes (309) and is maximally effective with the use
of powered toothbrushes (244, 273). Maintaining lim-
ited or no plaque in the interdental area helps to
ensure the preservation of oro–dental health (12).
Interdental plaque control is usually achieved with
either flossing or interdental brushing (Fig. 1).
According to the evidence available at present, floss-
ing, despite being widely recommended, does not
appear to be particularly efficacious in removing
interdental plaque (22, 255). A possible explanation
for this may be difficulty of the technique itself, which Fig. 2. Brushing of interdental site.

Fig. 3. Papillary trauma caused by incorrect interdental

Fig. 1. Flossing of interdental site. brushing.

153
Graziani et al.
introduced as an adjunctive measure to mechanical
plaque control. The standard to evaluate the control
of plaque and gingivitis of a specific product is a 6-
months randomized clinical trial, which includes a
negative control and perhaps a positive control (59).
A recent systematic review summarizing 6-months
randomized controlled trials assessed the efficacy of
dentifrice and mouthrinses vs. a negative control
(267). The plaque level (measured using the Turesky
modification of the Quigley & Hein Index) was
reduced by 0.475 (66 comparisons) and the gingivitis
level (measured using the Lo € e & Silness Index) was
reduced by 0.217 (46 comparisons), demonstrating a
significant benefit for the use of toothpastes or mou-
thrinses (289). Nonetheless, a significant heterogene-
ity in study outcome was also demonstrated. When
evaluated separately, anti-plaque effectiveness was
shown for dentifrices containing stannous fluoride,
triclosan with copolymer or chlorhexidine and for
mouthrinses containing chlorhexidine, essential oils
or cetylpyridinium chloride (267). No direct compar-
isons have been carried out between different agents
as little relevant data are available; accordingly, a net-
work meta-analysis was designed for such agents
using the Turesky modification of the Quigley & Hein
Plaque Index (78). Dentifrices containing chlorhexi-
dine or triclosan with copolymer and mouthrinses
containing chlorhexidine or essential oils tended to
show highest plaque reduction (81). In patients with
periodontitis, the effectiveness of chemical plaque
control needs to be evaluated in long-term studies in
which supragingival plaque is the secondary outcome
variable and clinical attachment level changes are the
primary outcome variable. Less disease progression
compared with negative controls was found for denti-
frices containing triclosan with copolymer (249) and
stannous fluoride with sodium hexametaphosphate
(213).
Professional mechanical plaque
removal
May periodontitis be treated with
professional mechanical plaque removal
alone?
Oral hygiene cannot be performed properly without
removing pre-existing plaque and calculus. In this
regard, ‘oral prophylaxis’ and recall appointments for
professional tooth cleaning are diffuse terms of peri-
odontal treatment used mostly by nonspecialist prac-
titioners (29, 89). Also, the term ‘professional
154
mechanical plaque removal’ is generally used for all
procedures aiming to remove plaque and supragingi-
val and subgingival calculus without any deliberate
attempt to perform careful root planing (195). The
supragingival component of ‘professional mechanical
plaque removal’ may consist of meticulous supragin-
gival plaque/calculus removal using hand or powered
instruments, or both, whereas the subgingival part of
the procedure is limited to minimal debridement of
the gingival pocket. Such procedures per se may be
considered as effective for reducing plaque and gingi-
val bleeding (172, 285, 328) but information on
improvements in pocket depth or clinical attachment
level is lacking (127). As professional mechanical pla-
que removal constitutes merely an extension of sim-
ple oral-hygiene instructions, the reader may wonder
if the procedure would enhance the results achieved
simply by making improvements to self-performed
oral-hygiene. The results available do not offer a clear
answer but it appears that tooth cleaning plus oral-
hygiene instruction vs. oral-hygiene instruction alone
provide similar benefits in terms of reduction of pla-
que and gingival bleeding. This is particularly true if
oral-hygiene instruction is given repeatedly (195).
However, improvements to self-performed oral-
hygiene may be difficult to achieve in the presence of
calculus, which may act as a plaque retainer and con-
stitutes a physical obstacle for proper hygiene
maneuvers. Moreover, the positive sensation of
‘cleanliness’ obtained by professional plaque and cal-
culus removal may provide patients with yet another
motivation for oral-hygiene improvement and possi-
bly results in better adherence to recall programs
(136, 137). Nonetheless, it should be emphasized that
without proper oral-hygiene instruction and execu-
tion, the professional reduction of plaque and calcu-
lus will be of little, if any, value (301).
Subgingival instrumentation
What are the outcomes of subgingival
debridement?
Both short- and long-term success of periodontal
therapy depend on mechanical disruption of the sub-
gingival biofilm (14, 15, 123, 175). Indeed, subgingival
instrumentation is the cornerstone of cause-related
periodontal therapy. Subgingival instrumentation is
usually divided into three distinct procedures:
debridement; scaling; and root planing (147).
Debridement is defined as the removal or disruption
of the structure of subgingival plaque and is

equivalent to supragingival polishing. Scaling is per-
formed to remove calcified accretions. Root planing
aims to remove diseased root cementum through
reshaping of the root surface. More specifically, scal-
ing implies the removal of plaque, calculus and stains
from a clinical crown and root surface, while root
planing consists of the removal of cementum or sur-
face dentin containing calculus or contaminating tox-
ins or microorganisms (6).
Subgingival instrumentation is considered the gold
standard of periodontal therapy and its clinical effi-
cacy is well documented in systematic reviews (111,
276, 311). The removal of plaque and subgingival deb-
ris may reduce gingival bleeding on probing in
approximately 45% of sites (50). After nonsurgical
periodontal therapy, pocket probing depth reduc-
tions vary from 1.29 mm for pockets with initial prob-
ing depth of 5-6 mm to 2.2 mm for deeper pockets;
clinical attachment level may improve by 0.5-2 mm
(50, 276, 311) (Fig. 4). Scaling of pockets less than
4 mm in depth would result in a net attachment loss
(18, 54, 184), and the term ‘critical probing depth’
connotes the minimal pocket depth suitable for
instrumentation (182).
What are the effects of subgingival
debridement on systemic and
psychosocial outcomes?
Studies indicate that periodontitis: (i) represents a rel-
ative risk for aggravating existing diabetes (26)
because of a deterioration of glucose metabolism
(67); (ii) increases the risk for cardiovascular disease
(128, 132) because it augments probability for devel-
oping atherosclerosis (179), probably mediated by
A B
D E
Fig. 4. Baseline buccal conditions of a patient with chronic periodontitis and gingival hyperplasia (A–C), and soft-tissue
changes 3 months after nonsurgical periodontal treatment (D–F).
Treatment options for periodontitis
systemic inflammatory mediators (182, 214); and (iii)
is a potential risk for adverse pregnancy outcome
(41). Subgingival instrumentation during the first
hours/days post-treatment results in a sharp increase
in systemic inflammatory markers, such as C-reactive
protein, fibrinogen and serum-amyloid A (61, 99);
enhancement of coagulative tendency (62); and
reduction of endothelial function (300). This outcome
is probably the result of trauma from the instrumen-
tation and postoperative bacteremia. Nevertheless,
3 months post-treatment, patients with periodontitis
show improvement in the atherosclerotic profile, as
assessed by lower levels of C-reactive protein, fibrino-
gen and total and low-density cholesterol (60, 286).
Periodontal treatment also improves the endothelial
function (209) and provides a significant reduction of
glycated hemoglobin, thus lowering the effect of
diabetes (77).
Periodontitis can also have a significant effect on
the psychosocial well-being of patients, as the disease
has been related to eating difficulty, pain, tooth loss
and changes in facial appearance. Oral health-related
quality of life is recognized to constitute an integral
part of general health, and the extent and severity of
periodontitis have been related to poor oral health-
related quality of life (4, 135, 141, 200, 214, 305). Peri-
odontitis signs and symptoms, such as swollen gin-
giva, sore and receding gingiva, drifting teeth and bad
breath, can deeply affect patients’ physical, social and
psychological aspects of life (20). Tooth loss, often a
result of untreated periodontitis (19, 30), is directly
linked to chewing function (210), esthetic appear-
ance, pronunciation of words and loss of
self-confidence and social well-being. Missing teeth
may limit laughing in public, formation of
C
F
155
Graziani et al.
relationships and enjoyment of food (254). Periodon-
titis may also affect subjects’ overall psychological
profile as it is considered to be a shameful disease,
which patients feel uncomfortable talking about with
friends and family (1). Fortunately, treatment of peri-
odontitis has been shown to enhance the psychoso-
cial and quality of life aspects of patients (139, 272),
and the improvements seem to be independent of
the type of periodontal therapy rendered (142, 277,
294).
What are the limitations of subgingival
debridement?
Not all sites/teeth respond equally well to periodontal
nonsurgical treatment. Not only do smokers have a
higher risk of periodontitis (94), they also show com-
promised healing following surgical and nonsurgical
therapy compared with nonsmokers and former
smokers (4, 298). Smokers average 0.23–1 mm less
pocket depth reduction than do nonsmokers (63, 117)
and exhibit 30% less probability of experiencing
‘pocket closure’ after nonsurgical therapy (293).
Moreover, following nonsurgical therapy, significantly
more smokers (42.8%) than nonsmokers (11.5%)
require further treatment for the residual presence of
pockets exceeding 6 mm in probing depth (211). The
probability of reducing furcation involvement after
nonsurgical periodontal treatment was three times
greater for nonsmokers than for smokers (292). Thus,
smoking-education and smoking-cessation programs
should be considered an integral part of comprehen-
sive periodontal treatment (158, 237).
Medical conditions can affect healing after nonsur-
gical treatment. Patients with poor glycemic control
may tend to have a faster recurrence of deep pockets
and a less favorable long-term outcome (288). Dia-
betic patients with proper glycemic control show
improvements in periodontal clinical parameters that
are similar to those of nondiabetic individuals (47).
Obese subjects may also experience a worse healing
response after nonsurgical treatment in moderate to
deep pockets (95).
Other factors influencing nonsurgical treatment
outcomes are tooth/site dependent and include the
presence of plaque or anatomic features, such as
deep pockets, furcation involvement and intrabony
defects. A multilevel regression analysis revealed that
the presence of plaque, even on a single tooth, had a
negative impact on the clinical outcome of overall
nonsurgical periodontal treatment (292). Anatomic
features also affect the treatment response as they
can inhibit removal of debris in periodontal sites of
156
increased depth (319). Treatment of deep pockets is
typically associated with reduction in pocket depth,
recession of the gingival margin and some clinical
attachment gain (126, 152). Pocket closure can regu-
larly be achieved in pockets of < 5 mm but is less pre-
dictable with greater initial pocket depth (15, 16, 266,
293). Intrabony defects are believed to have an ele-
vated risk of further periodontal breakdown (151) and
may require meticulous periodontal treatment. Fur-
cation involvement has a significant impact on heal-
ing after subgingival instrumentation. Single-rooted
teeth and posterior teeth with intact furcations usu-
ally respond better than multirooted teeth with com-
promised furcations to nonsurgical treatment and are
more easily maintained than teeth with furcation
involvement (12, 96, 124, 188, 202, 224). Molars with
furcation involvement (degree 2 or 3), or any tooth
associated with an intrabony defect, may show a rela-
tively poor long-term outcome (292, 294).
Improvement of treatment
outcomes of subgingival
debridement
Would different delivery strategies have
an impact on the outcomes?
Periodontal treatment has traditionally been sched-
uled with intervals of 1 week between appointments
in order to perform treatment of one part of the denti-
tion at each visit. This staged approach to treatment
can require four to six appointments over a period of
3–6 weeks (14, 15). The staged treatment approach
permits meticulous treatment of a limited segment of
the dentition and repeated reinforcements of patient
plaque control. On the other hand, it has been sug-
gested that translocation of bacteria from nondental
sites (tongue, mucosa, saliva) or untreated periodontal
lesions may cause reinfection of newly treated peri-
odontal sites (14, 314). The therapeutic concept of full-
mouth disinfection within 24 h aims to avoid trans-
mission of bacteria to periodontal sites already treated
(230). Full-mouth disinfection involves scaling and
root planing and chlorhexidine application of the
entire dentition performed in one or two appoint-
ments within a 24-h period. Patients rinse with 0.2%
chlorhexidine and perform subgingival irrigation and
tongue brushing with 1% chlorhexidine. Amendments
to the full-mouth disinfection protocol propose
removal of the application of chlorhexidine (231) and
introduction of same-day nonsurgical periodontal
treatment of the entire dentition in two sessions

A B
D E
Fig. 5. Aggressive periodontitis (A–C) was treated with full-mouth scaling and root planing, and results at the 3-month fol-
low-up are shown (D–F).
within a 1.5-h period (9) (Fig. 5). A one-stage full-
mouth debridement performed in a 1-h session that
uses exclusively an ultrasonic device with fine tips has
also been proposed (291). In terms of effectiveness,
there is no clear evidence that full-mouth disinfection
provides additional benefit compared with staged
periodontal therapy (73, 74). Statistically significant
differences in favor of full-mouth treatment are small
and perhaps not clinically relevant (83, 84, 165). Both
therapeutic approaches may be successful and thus
the choice of treatment should be based on patient
preference, professional skills, logistic setting and
cost-effectiveness. Full-mouth approaches may repre-
sent the choice of treatment in patients requiring sys-
temic antibiotics (143), which is most effective if given
in conjunction with a reduced subgingival bacterial
load (126, 149).
The time needed for subgingival instrumentation is
shorter per pocket site with full-mouth disinfection
(3.3 min) than with the staged treatment approach
(8.8 min) (321). However, the time benefit gained for
full-mouth disinfection is lost by the requirement for
a larger number of sessions for oral hygiene instruc-
tion. Moreover, the full-mouth approach may create
a greater acute-phase response after 24 h than the
staged approach to treatment (100), suggesting a pos-
sible preference for shorter clinical sessions in sub-
jects with medical comorbidity.
Would different instruments have an
impact on the outcomes?
The success of periodontal therapy depends on the
removal of hard and soft deposits from the root
Treatment options for periodontitis
C
F
surfaces (14, 15, 123, 175). The different modes of
subgingival instrumentation vary in their ability to
remove subgingival deposits (167, 169, 207, 208, 282).
In comparison with hand instruments, ultrasonic
devices remove less root structure and cause less soft-
tissue trauma (303, 307), are less operator dependent
and technique sensitive (50) and require a signifi-
cantly shorter treatment time (46, 50), but they do
leave behind a rougher root surface (21). Ultrasonic
devices with irrigation systems containing chlorhexi-
dine gluconate (43) or povidone-iodine (66, 170) gen-
erally provide no significant additional clinical
benefits.
Curettes, when compared with sonic and ultrasonic
scalers, leave a smoother root surface (28, 153) and
remove significantly more calculus (28, 153). The safe
number of curette strokes is quite limited, as 15 or
more remove mainly cementum (157). A substantial
drawback of hand curettes, besides being technique
and operator sensitive, is the fact that they require
sharpening on a regular basis in order to achieve clin-
ical effectiveness without damaging the root surface
(21, 205, 250). Current nonsurgical treatment consists
of root debridement with sonic/ultrasonic devices
and finishing instrumentation with curettes (252)
(Fig. 6).
Would new technologies have an impact
on the outcomes?
As sonic and ultrasonic scaling can cause high sensi-
tivity/pain during instrumentation (89) and as instru-
mentation with curettes, albeit modestly, may reduce
dentin and induce hypersensitivity (317), new
157
Graziani et al.

A B C

D E F

Fig. 6. Periodontal pocket of 10 mm (A, B) and exudate after tissue compression (C). Instrumentation with ultrasonic fine
tips (D) and mini-curette (E). Three months after instrumentation (F, G).

technologies for subgingival debridement have been Powdered air abrasive systems are based on air-
developed. Unfortunately, some of these new tech- spray of powders onto the tooth/root surface to
nologies carry high acquisition costs. remove plaque and debris without removing hard

158

A The VectorTM system, a device based on ultrasonic
B During the past 20 years, different types of lasers
C therapy
Fig. 7. Baseline view of an inflamed pocket (A), during
subgingival instrumentation with air polishing (B) and
3 months postoperatively (C).
deposits. Traditional air abrasive systems were used
for tooth polishing and stain removal but their high
abrasiveness was found to cause root damage (155).
A more recently developed powered air abrasive sys-
tem based on a low-abrasive amino-acid glycine
powder has demonstrated effectiveness in removing
biofilm from the root surface without damaging the
hard and soft tissues (222) (Fig. 7). The amino-acid
glycine powder system has been compared with
standard instrumentation and no significant
differences were detected in either clinical or micro-
biological outcome variables (203). The use of inap-
propriate nozzles, or directing the air spray toward
the bottom or the soft-tissue component of the
pocket, can cause emphysema, suggesting caution in
usage (87, 171, 221).
Treatment options for periodontitis
vibrations with vertical oscillations, has shown clini-
cal and microbiological outcomes comparable with
those of manual and conventional ultrasonic instru-
mentation (105). The VectorTM system is less efficient
than manual and conventional ultrasonic instrumen-
tation in removing large masses of calculus (150) but
may be useful in supportive periodontal treatment as
it is well tolerated by patients and results in less
removal of cementum than other methods of instru-
mentation (144).
have been used in the treatment of periodontitis. Sys-
tematic reviews have compared laser treatment with
conventional subgingival instrumentation and found
no marked additional clinical or microbiological ben-
efits with laser therapy, when used either as
monotherapy or as an adjunct to scaling and root
planing (50, 286, 291, 298).
Adjunctive pharmacological
Among the more than 700 different bacterial spe-
cies in the oral microbiota, only 10–15 have been
associated with the initiation and progression of
periodontitis (199, 278). Despite this high level of
microbial specificity, standard periodontal therapy
is highly nonspecific, consisting essentially of
mechanical debridement of supraingival and sub-
gingival biofilms. Mechanical therapy alone can
result in long-term success for most patients (71);
however, a relatively small, albeit relevant, propor-
tion of sites and patients may not respond ade-
quately. This may partly be the result of limitations
of mechanical debridement, including difficulty in
accessing deep and tortuous pockets, furcations
and vertical defects. In addition, mechanical ther-
apy may have limited effects on some key patho-
gens (240, 241) and fail to eliminate periodontal
pathogens in nondental biofilms (e.g. tongue, oral
mucosa) (65). Moreover, mechanical debridement
may cause unpleasant side effects, including gingi-
val recession, loss of tooth substance and dentin
hypersensitivity (14, 108). These limitations may
partly be overcome by employing microbiologic
diagnostic testing to identify specific periodontal
pathogens (178) or by a number of alternative tech-
nologies (257). Pharmacologic therapies based on
antimicrobials (including antiseptics and local or
systemic antibiotics), probiotics and host modula-
tion have attracted considerable research interest.
159
Graziani et al.
What are the additional effects of using
adjunctive antiseptics?
Antiseptics are used in periodontal treatment for sub-
gingival irrigation and biofilm control (Table 1). A
systematic review compared chlorhexidine irrigation
plus scaling and root planing with scaling and root
planing alone and found a similar outcome (114).
Another study also found that chlorhexidine, saline or
hydrogen peroxide offered no added benefit to scal-
ing and root planing alone (111). On the other hand,
a recent systematic review with meta-analysis of six
studies found 0.28 mm of additional reduction in
pocket depth after subgingival irrigation with povi-
done-iodine (253). Sodium hypochlorite, which is
readily available as chlorine bleach, offers distinctive
advantages and constitutes a new and promising
antiseptic in the prevention and treatment of peri-
odontal disease (299).
Chlorhexidine can determine reduction of plaque
and gingivitis. When used as adjunct to nonsurgical
treatment, chlorhexidine rinse resulted in additional
reduction of supragingival plaque compared with
nonsurgical treatment only (7), and the plaque-inhi-
bitory effects of chlorhexidine may delay subgingival
bacterial recolonization (3, 97). Chlorhexidine rinse
may kill bacteria also in other oral reservoirs (tongue,
mucosal biofilms), which are not directly affected by
periodontal instrumentation. Full-mouth disinfection
uses chlorhexidine in the form of mouthrinse, spray,
irrigation and gel for the tongue dorsum (231).
Chlorhexidine oral rinse has yielded better clinical
and microbiological outcomes than scaling and root
planing alone, scaling and root planing plus strict
professional plaque control (86) or scaling and root
planing plus placebo (85). However, the adverse
effects of chlorhexidine, including brown staining of
teeth, tongue and restorations, alterations in taste
perception and increased calculus deposition, may
limit patient acceptance (180).
What are the additional effects of using
adjunctive local antibiotics?
Local application of antibiotics has been advocated
for patients with localized lesions or nonresponding
and recurrent sites (24, 148). Local antimicrobials
cause fewer adverse effects, result in less risk of devel-
oping bacterial resistance and have better patient
compliance than systemic antimicrobials (80). Appli-
cation of local antibiotic has been promoted as a sub-
stitute for surgical therapy (11, 148, 168, 175, 187, 196)
(Fig. 8), but the value of locally applied antibiotics
160
has been questioned, and some commercial products
have been withdrawn (191).
Local antimicrobials have been evaluated, for the
treatment of periodontitis, in systematic reviews and
randomized controlled trials (Table 2) (24, 42, 114,
185, 229, 251, 276). Periodontal pocket depth reduc-
tion beyond that obtained by scaling alone may vary
from 0.4 mm (185) to 0.6 mm (27, 120), and addi-
tional clinical attachment gain of up to 0.3 mm may
be achieved (24, 114). The most effective agents (with
weighted mean probing depth reduction ranging
from 0.5 to 0.7 mm) were tetracycline fibers, sus-
tained-release doxycycline and minocycline; less
effective agents were chlorhexidine and metronida-
zole (weighted mean probing depth reduction of 0.1–
0.4 mm) (185). Randomized controlled trials with a
minimum duration of 6 months showed additional
clinical attachment gain of 0.40 mm for chlorhexidine
chips, (moderate evidence, six studies), 0.64 mm for
doxycycline gel (low evidence, three studies) and
0.24 mm for minocycline microspheres (low evi-
dence, five studies) (277). Two systematic reviews
suggested that local antimicrobials provided addi-
tional benefits to smokers (45) and to patients with
periodontitis and diabetes (251). However, significant
limitations prevent a clear assessment of the useful-
ness of topical antimicrobials (80, 114, 121, 185). The
studies available show a wide range of outcomes that
are dependent on the active agent tested, the
research protocols, the target population and sample
selection and the duration of the studies – and most
antimicrobial drugs have yet to be evaluated in com-
parative investigations. Some products are technically
difficult to handle, are rapidly cleared from periodon-
tal pockets and carry a high acquisition cost.
What are the additional effects of using
adjunctive systemic antibiotics?
The adjunctive effect of systemic antimicrobials in the
treatment of periodontitis has been analyzed in a
number of systematic reviews (Table 3) (8, 25, 42, 81,
91, 110, 120, 145, 154, 268–270, 276, 327). One might
wonder if, owing to the infectious nature of periodon-
tal disease, systemic antibiotics would be a feasible
sole treatment of periodontitis. This seems not to be
the case (110, 120), as organized biofilm is highly resis-
tant to antimicrobials (109), and meta-analyses of
antimicrobials used as monotherapy show no signifi-
cant improvements (110, 122). Systemic antimicro-
bials should be used adjunctively to mechanical
debridement, preferably as part of nonsurgical peri-
odontal therapy (260). Systemic antimicrobials plus
 Table 1. Selected systematic reviews assessing adjunctive antiseptics, probiotics and host-modulating agents, as adjuncts to scaling and root planing

Author Study design Follow-up Disease Test group Comments

Hallmon & Human 3 months Chronic Scaling and root planing Systematic review presented
Rees (111) studies periodontitis, plus other physical/ at the 2003 World Workshop.
aggressive chemical approaches Three papers compared
periodontitis adjunctive subgingival
irrigation, reporting similar
clinical outcomes when
compared with scaling and
root planing alone
Hanes & Randomized 3 months Chronic Local antimicrobial Systematic review presented
Purvis (114) clinical trial, periodontitis with/without scaling at the 2003 World Workshop.
cohort study, and root planing Six papers compared
case–control adjunctive subgingival
irrigation with chlorhexidine,
reporting similar clinical
outcomes when compared
with scaling and root
planing alone
Sahrmann Randomized Not stated Chronic Scaling and root planing Systematic review including
et al. (253) clinical trial periodontitis with povidone-iodine seven studies. A small, but
statistically significant
(P = 0.007), benefit of
0.28 mm was reported in
probing pocket depth changes
(95% confidence interval:
0.08–0.48)
Martın-Cabezas Randomized Not stated Chronic Scaling and root planing Systematic review including four
et al. (184) clinical trial periodontitis plus probiotic studies, demonstrating
short-term significant benefits
in clinical attachment level
(0.42 mm, P = 0.002) and
bleeding on probing (14.66%,
P = 0.003) changes. For probing
pocket depth changes,
differences were statistically
significant when probing
pocket depths were stratified:
moderate (0.18 mm), P = 0.001;
and deep (0.67 mm), P < 0.001.
Treatment options for periodontitis

161
 Table 1. (Continued)

162
Author Study design Follow-up Disease Test group Comments

Matsubara Randomized Not stated Chronic Scaling and root planing Systematic review including 12
Graziani et al.

et al. (186) clinical trial periodontitis, plus probiotic/probiotic studies, but no meta-analysis.
aggressive alone The review concludes that oral
periodontitis administration of probiotics is
a safe and effective adjunct to
scaling and root planing in the
management of periodontitis
Reddy Human Not stated Periodontal Antiproteinase/ Systematic review presented at
et al. (238) studies diseases, anti-inflammatory/ the 2003 World Workshop,
implants bone-sparing agents including 16 papers on
antiproteinase agents, 23 on
anti-inflammatory agents and
three on bone-sparing agents.
Meta-analysis was only available
for sub-antimicrobial dose
doxycycline, demonstrating
that the adjunctive use with
scaling and root planing was
statistically more effective
than scaling and root planing
alone in terms of probing pocket
depth and clinical attachment
level changes
Smiley Randomized 6 months Chronic Scaling and root planing Systematic review developed for
et al. (276) clinical trial periodontitis plus adjuncts the preparation of American
(sub-antimicrobial dose Dental Association guidelines,
doxycycline) including 11 papers assessing
sub-antimicrobial dose
doxycycline. Systemic
subantimicrobial-dose doxycycline
was considered beneficial with a
moderate level of certainty
Muniz Randomized Not stated Periodontal Lycopene, vitamin C, Systematic review including
et al. (194) clinical trial diseases vitamin E, capsules with seven papers. Only the studies
fruits/vegetables/berry, that used lycopene and
dietary interventions vitamin E demonstrated
statistically significant
improvements

A be carried out immediately before or during the period
B but different clinical scenarios exist for the use of sys-
C were confirmed in a meta-analysis that found an addi-
Fig. 8. Residual periodontal pockets with pus discharge
(A) treated with scaling and root planing and subgingival
application of antimicrobials (B) and 3 months post-treat-
ment (C).
scaling and root planing may provide additional bene-
fit over scaling and root planing alone, with additional
clinical attachment gains of 0.2–0.6 mm and extra
probing pocket depth reductions of 0.2–0.8 mm, and
the changes are even more pronounced with very deep
pocket and in subjects with aggressive periodontitis or
specific microbial infections (110, 122, 174). Systemic
antimicrobial therapy will be most effective with a
concomitant mechanical disruption of the subgingival
biofilm, suggesting periodontal debridement should
Treatment options for periodontitis
of antibiotic therapy (120, 260). Most research data
pertain to treatment with amoxicillin plus metronida-
zole, ciprofloxacin plus metronidazole, metronidazole
alone or azithromycin (299, 300), with azithromycin
being generally less effective but more convenient in
terms of compliance and adverse effects.
Adjunctive systemic antimicrobial therapy is indi-
cated primarily in patients with severe types of peri-
odontitis, including aggressive, severe and ‘refractory’
periodontitis, and periodontitis associated with speci-
fic microbiological profiles (110, 120, 122). Of these,
aggressive periodontitis has attracted most attention,
temic antimicrobials. The use of antimicrobials may
be postponed until re-evaluation of conventional
nonsurgical treatment as the latter can provide signifi-
cant clinical improvements (71). Antibiotic treatments
should be discouraged when unnecessary in order to
prevent the emergence of antimicrobial resistance
(323). Systemic antimicrobials might be incorporated
in the basic periodontal treatment of aggressive peri-
odontitis following the approach used in the 1980s for
localized juvenile periodontitis. Indeed, the empirical
use of the combination of amoxicillin and metronida-
zole is supported by excellent outcomes (106), which
tional probing depth reduction of 0.58 mm and an
additional clinical attachment gain of 0.42 mm (268).
The combination of amoxicillin and metronidazole
was initially developed to treat periodontitis caused
by Aggregatibacter actinomycetemcomitans (216–218)
but was later extended to treat periodontitis caused by
other microorganisms, as data suggested that in addi-
tion to patients harboring A. actinomycetemcomitans
(88, 107, 189), patients with other microbiological pro-
files (48, 192) could also benefit. However, the preva-
lence of A. actinomycetemcomitans is relatively low in
some populations (201, 204, 284) and amoxicillin and
metronidazole can be associated with adverse effects
(145) and may not cover the entire spectrum of peri-
odontal pathogens (299). The empirical use of
metronidazole alone may also be justified (92, 193,
264, 296, 302), but combination therapies tend to
show greater clinical effectiveness than monotherapy.
The microbial diversity may warrant a microbiological
evaluation before prescribing antibiotics (185).
What are the additional effects of using
adjunctive probiotics?
Probiotics is an estabished treatment concept for cer-
tain respiratory and enteric infections. Basically,
163
Graziani et al.

Table 2. Selected systematic reviews assessing local antimicrobials as adjuncts to scaling and root planing

Author Study design Follow-up Disease Test group Comments

Hanes & Purvis Randomized 3 months Chronic Local antimicrobial Systematic review presented
(114) clinical trial, periodontitis with/without at the 2003 World Workshop;
cohort study, scaling and root 19 studies were included,
case–control planing and meta-analysis
demonstrated significant
benefits in terms of probing
pocket depth and clinical
attachment level changes for
adjunctive local
sustained-release agents
compared with scaling and
root planing alone. The most
effective agents were:
minocycline gel,
microencapsulated
minocycline,
chlorhexidine
chip and doxycycline gel.
Bonito Randomized Not stated Chronic Scaling and root Systematic review including
et al. (24) clinical trial periodontitis planing plus 50 papers, demonstrating
local antimicrobial some benefits in terms of
probing pocket depth
changes, while clinical
attachment level benefits
were smaller and with a lower
common statistical
significance. The best results
were identified for agents
with tetracycline, minocycline,
metronidazole and
chlorhexidine
Preus et al. (229) Randomized 3 months Chronic Scaling and root Systematic review including
clinical trial periodontitis planing plus 11 studies and summarizing
local antimicrobial clinical attachment level
results. A possible benefit was
shown of applying topical
antibiotics in conjunction with
scaling and root planing, but
this benefit was small and of
doubtful clinical
significance
Matesanz-Pe rez Randomized Not stated Chronic Scaling and root Systematic review with 56
et al. (185) clinical trial periodontitis planing plus studies. Meta-analyses showed
local antimicrobial significant effects in probing
pocket depth and clinical
attachment level changes
(P < 0.001) of 0.407 and
0.310 mm, respectively.
Improvements ranging
from 0-5-0.7 mm were obtained
with tetracycline fibers,
sustained-released
doxycycline and
minocycline

164
 Treatment options for periodontitis

Table 2. (Continued)

Author Study design Follow-up Disease Test group Comments

Smiley et al. (276) Randomized 6 months Chronic Scaling and root Systematic review developed
clinical trial periodontitis planing plus for the preparation of
adjuncts (chlorhexidine American Dental Association
chips/doxycycline/ guidelines, including six
minocycline) papers on chlorhexidine chips,
three on doxycycline and five
on minocycline. Chlorhexidine
chips were considered as a
beneficial adjunctive therapy with
a moderate level of certainty
Chambrone Randomized 6 months Chronic Scaling and root Systematic review including four
et al. (42) clinical trial periodontitis planing plus studies assessing local
local/systemic antimicrobials in smokers.
antimicrobial Meta-analysis reported an
additional probing pocket depth
reduction of 0.81 mm (P = 0.01)
and clinical attachment level gain
of 0.91 mm (P = 0.01) at sites with
baseline probing pocket depth
of ≥ 5 mm
Rovai et al. (251) Randomized 6 months Chronic Scaling and root Systematic review including six
clinical trial periodontitis planing plus studies assessing local
local antimicrobial antimicrobials in people with
diabetes. Only studies that
included well-controlled patients
and applied antimicrobials at the
deepest sites or at sites with
baseline probing pocket depth
of ≥ 5 mm presented significant
probing pocket depth reduction
and clinical attachment level gain

benign bacteria are introduced to compete with What are the additional effects of using
pathogens for binding sites and nutrients or to pro- adjunctive host-modulating agents?
duce substances against pathogenic bacteria (290). In
As the pathogenesis of periodontitis involves subject
periodontics, probiotic strains may interfere with
bacterial recolonization (131), and at least nine ran- susceptibility, host modulation therapy may serve to
limit periodontal breakdown (255, 301, 323). Low-
domized trials have been published since 2010, in
dose doxycycline (20 mg twice daily) can potentially
which different probiotics were evaluated as adjunct
inhibit matrix metalloproteinases and limit destruc-
to scaling and root planing (Table 4) (130, 159, 193,
tion of the periodontal ligament, but only a modest
219, 271, 287, 289, 315, 316). Most probiotic studies
0.35–0.49 mm of clinical attachment gain has been
have used Lactobacillus species, and five studies eval-
reported (238, 276). The inflammatory nature of
uated a commercial product containing Lactobacillus
periodontitis has prompted the use of nonsteroidal
reuteri. A meta-analysis of randomized trials found
anti-inflammatory drugs, most notably flurbiprofen.
that probiotic treatment added 0.42 mm in clinical
Most studies found a lack of significant effects when
attachment gain, and added 0.18 mm in probing
nonsteroidal anti-inflammatory drugs were used
pocket depth reduction in moderate pockets and
0.67 mm in deep pockets (184). A continous intake of adjunctively to scaling and root planing (238), and a
rebound of disease after long-term use may also be
probiotic bacteria may produce most improvements
expected (323). Moreover, nonsteroidal anti-inflam-
(186). Although the results available tend to favor pro-
matory drugs can produce adverse effects, including
biotics, heterogeneity in study design and great vari-
increased bleeding time and gastric ulcers. Prore-
ability in results suggest a cautious approach to
solving lipid mediators (313) are nonsteroidal anti-
interpretation of their clinical usefulness.

165
Graziani et al.

Table 3. Selected systematic reviews assessing systemic antimicrobials as adjunct to scaling and root planing

Author Study design Follow-up Disease Test group Comments

Herrera Randomized 6 months Chronic Scaling and root Systematic review presented at
et al. (122) clinical trial, periodontitis, planing the 2002 European Workshop.
controlled aggressive plus systemic Twenty-five studies were
clinical trial periodontitis antimicrobial included. Meta-analysis
demonstrated significant
benefits in terms of changes in
probing pocket depth/clinical
attachment level following
treatment with metronidazole/
spiramycin, metronidazole/
amoxicillin and metronidazole
alone, in deep pockets
Haffajee Randomized 1 month Chronic Systemic antimicrobial, Systematic review presented at
et al. (110) clinical trial, periodontitis, with or without the 2002 European Workshop.
controlled aggressive scaling and root Twenty-nine studies were
clinical trial, periodontitis, planing included. Meta-analysis
case series other demonstrated significant
benefits in terms of clinical
attachment level changes for
the use of systemically
administered adjunctive
antibiotics with and without
scaling and root planing
and/or surgery
Herrera Randomized 6 months Chronic Scaling and root planing Systematic review/narrative
et al. (120) clinical trial, periodontitis, plus systemic review presented at the 2008
controlled aggressive antimicrobial European Workshop.
clinical trial periodontitis Thirty-two studies were
included. It is suggested that
systemic antimicrobials should
be used adjunctively, to
scaling and root planing,
debridement should be completed
within a short time (preferably <1
week) while the systemic
antimicrobial intake should start
on the day of debridement
completion
Angaji Randomized 6 months Chronic Scaling and root planing/ Systematic review including
et al. (8) clinical trial periodontitis surgery plus local/ five studies in smokers. It is
systemic antimicrobial concluded that the evidence
for an additional benefit of
adjunctive antibiotic therapy
in smokers with chronic
periodontitis is insufficient
and inconclusive
Bono Randomized Not stated Chronic Amoxicillin and/or Systematic review including
et al. (25) clinical trial periodontitis metronidazole 10 studies. There were no
statistically significant benefits
Sgolastra Parallel 3 months Chronic Scaling and root planing Systematic review including four
et al. (268) randomized periodontitis plus amoxicillin/ studies. Meta-analyses showed
clinical trial metronidazole significant clinical attachment
level gain (0.21 mm; 95%
confidence interval: 0.02–0.4mm)
and probing pocket depth
reduction (0.43 mm; 95%
confidence interval:
0.24–0.63 mm)

166
 Treatment options for periodontitis

Table 3. (Continued)

Author Study design Follow-up Disease Test group Comments

Sgolastra Randomized 2 months Aggressive Scaling and root planing Systematic review with six studies.
et al. (269) clinical trial periodontitis plus amoxicillin/ Meta-analyses showed significant
metronidazole clinical attachment level gain
(0.42 mm; 95% confidence
interval: 0.23–0.61 mm) and
probing pocket depth reduction
(0.58 mm; 95% confidence
interval: 0.39–0.77 mm).
Zandbergen Randomized 1 month Periodontitis Scaling and root planing Systematic review with 28 studies.
et al. (327) clinical trial, plus amoxicillin/ Scaling and root planing plus
controlled metronidazole amoxicillin/metronidazole
clinical trial, achieved significantly better
Pilot study, results (e.g. 0.86 mm of probing
case series pocket depth reduction in initial
pockets of ≥ 6 mm).
Kolakovic Randomized 3 months Periodontitis Scaling and root planing Systematic review with 12 studies.
et al. (154) clinical trial plus amoxicillin/ Administration of antibiotics
metronidazole resulted in a 3.55- to 4.43-fold
higher probability of pocket
closure after 3–6 months
compared with scaling and root
planing alone
Faggion Systematic Not stated Periodontitis Scaling and root planing Overview of nine systematic
et al. (81) review plus systemic reviews. Three systematic reviews
antimicrobial showed statistically significant
improvements. No studies
reported tooth survival
Keestra Randomized 1 month Chronic Scaling and root planing Systematic review with 43 studies.
et al. (145) clinical trial periodontitis plus systemic Significant additional probing
antimicrobial pocket depth reduction was
observed after 1 year for
moderate (0.25  0.27 mm)
and deep (0.74  0.30 mm)
pockets
Fritoli Randomized Not stated Chronic Scaling and root planing Systematic review including only
et al. (91) clinical trial periodontitis, plus systemic one study. Better results were
aggressive antimicrobial achieved when the antimicrobial
periodontitis was prescribed at the initial
phase of treatment compared
with after healing
Smiley Randomized 6 months Chronic Scaling and root planing Systematic review developed for
et al. (276) clinical trial periodontitis plus adjuncts the preparation of American
(systemic Dental Association guidelines.
antimicrobials) Twenty-four papers assessing
systemic antimicrobials were
included; adjunctive use of
antimicrobials was considered
as beneficial with a moderate
level of certainty
Chambrone Randomized 6 months Chronic Scaling and root Systematic review including
et al. (42) clinical trial periodontitis planing plus local/ three studies that assessed the
systemic antimicrobials use of systemic antimicrobials
in smokers. No additional
benefits were demonstrated

167
Graziani et al.

Table 4. Selected randomized clinical trials assessing probiotics as adjuncts to scaling and root planing

Author Duration Patients Test Probiotics Comments

Vivekananda 42 days 30 chronic Probiotic/placebo Lactobacillus reuteri Test group achieved better
et al. (316) periodontitis (Prodentis) results in probing pocket depth
21–42 days, 29 (1.31 mm vs. 0.49 mm) and
clinical attachment level
(1.09 mm vs. 0.29 mm)
changes. Additional
microbiological benefits were
assessed by culture
Shah 2 months 30 aggressive Scaling and root planing Lactobacillus brevis Significant benefits were
et al. (271) periodontitis plus probiotic/ (Inersan), 14 days, observed, although no scaling
doxycycline/both 2–4 weeks, 29 and root planing alone was
included. Microbiological data
were available from saliva
(culture)
Teughels 12 weeks 30 chronic Scaling and root planing Lactobacillus reuteri No differences were detected in
et al. (289) periodontitis plus probiotic (Prodentis) terms of clinical outcomes.
12 weeks, 29 Greater reduction in numbers
of Porphyromonas gingivalis
was observed in the test group
(quantitative PCR)
Vicario 1 month 20 chronic Scaling and root planing Lactobacillus reuteri Significant benefits in probing
et al. (315) periodontitis plus probiotic (Prodentis) 4 weeks, pocket depth changes were
19 observed in the test group.
Clinical attachment level and
microbiological variables were
not assessed
_
Ince 1 year 30 chronic Scaling and root planing Lactobacillus reuteri, Test group achieved better
et al. (130) periodontitis plus probiotic 3 weeks, 29 results in probing pocket depth
(1.62 mm vs. 1.52 mm) and
clinical attachment level
changes (1.39 mm vs.
0.43 mm). Additional benefits
in biomarkers were assessed
by ELISA
Laleman 12 weeks 48 chronic Scaling and root planing Streptococcus oralis KJ3, No differences were detected in
et al. (159) periodontitis plus probiotic Streptococcus uberis KJ2, terms of clinical outcomes:
Streptococcus rattus probing pocket depth
JH145; 12 weeks, 29 (1.70 mm vs. 0.55 mm) and
clinical attachment level
changes (0.75 mm vs.
0.71 mm). Some
microbiological benefits were
assessed by quantitative PCR
Tekce 1 year 40 chronic Scaling and root planing Lactobacillus reuteri, Test group achieved better
et al. (287) periodontitis plus probiotic 3 weeks, 29 results in probing pocket depth
(1.75 mm vs. 1.07 mm).
Clinical attachment level was
not reported. Microbiological
findings were assessed by
culture
Morales 1 year 28 chronic Scaling and root planing Lactobacillus rhamnosus Similar results were observed in
et al. (193) periodontitis plus probiotic SP1, 3 months, 19 test and control groups

168

Table 4. (Continued)
Author Duration Patients Test
Penala 3 months 32 chronic Scaling and root planing Lactobacillus salivarius Some minor differences in
et al. (219) periodontitis plus probiotic
and halitosis (subgingival and rinse) reuteri (Unique Biotech) detected, favoring the test
inflammatory drugs that exhibit fewer adverse effects
(312), and their potential usefulness in periodontal
treatment has been evaluated in animal models (74).
The concept of ‘nutritional modulation’ (299) may
also constitute a part of periodontal treatment, as
increased caloric intake may induce inflammation
and some nutrients may help reduce inflammation
(e.g. antioxidants) or avoid nutritional deficiencies
associated with periodontitis (e.g. vitamins C and D,
magnesium) (308). A randomized trial found that use
of antioxidant dietary supplements (e.g. fruit and veg-
etables) in conjunction with scaling and root planing
produced short-term clinical benefits (44). A system-
atic review, which examined the effect of antioxidants
(lycopene, vitamin C, capsules with fruits, vegetables
or berry, and dietary interventions) together with
with scaling, found that lycopene and vitamin E
improved periodontal disease variables (194).
Surgical treatment of periodontitis
Why perform periodontal surgery? Could
nonsurgical retreatment of residual
pockets be effective?
The primary aim of periodontal surgery is to create
accessibility for professional scaling and root plan-
ing and to establish a gingival morphology con-
ducible to efficient plaque control (320). Compared
with nonsurgical intervention of deep untreated
pockets (14, 16), surgical treatment has demon-
strated a better performance in terms of pocket clo-
sure and preservation of teeth (266) and is
particularly useful in sites associated with furcation
involvement or intrabony defects (197, 316, 318).
However, surgery should be limited to pockets dee-
per than 5 mm to avoid mechanical damage to the
periodontium. Differences in outcome of the various
types of surgical and nonsurgical treatments tend to
disappear over time with meticulous oral hygiene
(158, 239, 252).
Treatment options for periodontitis
Probiotics Comments
and Lactobacillus probing pocket depth were
group. In addition, N-benzoyl-
DL-arginine-naphthylamide
(BANA) and organoleptic tests
were conducted
What are the effects of periodontal
surgery without previous nonsurgical
debridement?
Traditional periodontal treatment consists of surgical
resection of diseased soft tissues to gain access to the
root area (90, 197, 206, 232, 264, 281, 324). A direct
surgical approach with no previous nonsurgical treat-
ment has been investigated in several studies (141,
152, 176, 177, 223, 235). Higher numbers of residual
deep pockets remain after nonsurgical treatment
than after surgical treatment immediately after ther-
apy, but differences in pocket depth are not detect-
able at 6 months post-treatment (190). The cost of
surgical treatment, because of longer chair-time,
exceeds that of nonsurgical treatment. A comparison
between direct surgery and nonsurgical treament fol-
lowed by surgery found greater pocket depth reduc-
tion and a larger number of closed pockets among
patients that had undergone nonsurgical treatment
followed by surgery (3). Initial nonsurgical treatment
will also reduce gingival inflammation and thereby
facilitate visibility and tissue handling during surgery,
and sometimes may even suffice as the sole treat-
ment. Thus, periodontal treatment should routinely
start with nonsurgical treatment.
What are the outcomes of periodontal
surgery in a dentition previously treated
with nonsurgical treatment?
The outcome of periodontal surgery depends on the
anatomy of bony defects. Periodontal bony defects
are classified as intrabony, suprabony and interradic-
ular (97, 212).
Surgical treatment of residual pockets associated
with intrabony defects
Intrabony defects, despite occurring less frequently
than other forms of osseous defects (220), have been
studied extensively (58, 160). Intrabony defects may
be treated with conservative, resective or regenerative
surgery. Conservative surgical treatment (i.e. surgical
169
Graziani et al.
A B
D E
Fig. 9. Open-flap debridement of the intrabony defect: preoperative view (A, B); flap elevation (C); suture (D); suture
removal (E); and soft-tissue healing after 12 months (F, G).
procedures aimed at gaining access to the root sur-
face in order to remove residual plaque/calculus with
no active removal of alveolar bone and with minimal
resection of soft tissues) (104) can produce significant
improvements. Meta-analysis of studies found, at
12 months, a probing pocket depth reduction of
2.85 mm, clinical attachment gain of 1.65 mm and
gingival recession increase of 1.15 mm (Fig. 9) (101).
Follow-ups of at least 24 months confirm those find-
ings, but the surgical flap design can determine the
magnitude of improvements. Open flap debridement
(149) or modified Widman flap (232) yielded attach-
ment gain of 1.57 mm and pocket depth reduction of
2.77 mm (Fig. 10); a papilla preservation approach
(52, 53) showed attachment gain of 2.48 mm and
pocket depth reduction of 3.59 mm; and a minimally
170
C
F
invasive flap design (55) revealed attachment gain of
4.1 mm and pocket depth reduction of 4.4 mm
(Fig. 11). A similar effect of flap design on postopera-
tive healing has been found in trials assessing access
flap surgery vs. regenerative surgery (306). Access
flaps are characterized by ischaemia and subsequent
reperfusion during the primary healing phases (242),
whereas papilla preservation flaps show faster post-
operative recovery (243), probably because of preser-
vation of the microvasculature of soft tissues and a
higher revascularization rate (71).
Small (< 4 mm) intrabony defects located palatally
or in the posterior area of the dentition may receive
resective surgery (90, 206, 264) (i.e. surgical procedures
aimed at reducing a residual pocket through active
removal of the alveolar bone and extensive resection

A B
D E
G H
Fig. 10. Open flap debridement in the maxillary anterior area (A); details of the incision (B, C); flap elevation (D); root plan-
ing (E); suture (F); suture removal (G); and soft-tissue healing after 12 months (H).
of soft tissues) (31, 33). The indication for this type of
surgery is based on need for anatomic changes and is
an ideal surgical technique for root lengthening and
pre-prosthetic management of soft tissues (32, 34).
Regenerative surgery is mainly used for deep intra-
bony defects, as the advantage of regeneration is min-
imal in shallow intrabony defects (82, 297). Guided
tissue regeneration has yielded additional clinical
attachment gain of 1.22 mm and additional pocket
reduction of 1.21 mm (Fig. 12) (196). Treatment with
enamel matrix derivatives shows additional clinical
improvements of similar magnitude, namely 1.1 mm
of attachment gain and 0.9 mm of pocket depth
reduction (Fig. 13) (79). A combination of guided tis-
sue regeneration and enamel matrix derivatives may
provide further improvements, although of quite lim-
ited magnitude and of uncertain clinical significance
(306). No clear indication exists for using one or the
other of the intrabony treatments (56).
Healing of surgically treated intrabony defects is
influenced by local and systemic factors. Smoking is
associated with lower pocket depth reduction after
conservative surgery (228) particularly in deep pockets
Treatment options for periodontitis
C
F
(263), and with lower attachment gain (57, 302) and
lower bone regeneration (215) after regenerative sur-
gery. Plaque control is a critical determinant of suc-
cessful postsurgical outcome (204, 246). Patients who
have undergone intrabony defect surgery may receive
either supportive periodontal care every 2 weeks for
2 years, or prophylaxis once every 12 months (246).
Patients in the test group showed a clinical attach-
ment gain of 3.5 mm and a radiographic bone fill of
2.5 mm, whereas patients in the control group experi-
enced loss of attachment of 2.1 mm and bone loss of
0.9 mm. Another study found that patients receiving
different modes of periodontal surgery may experi-
ence short-term benefits, but a lack of adequate pla-
que control will frequently result in reoccurrence of
periodontal pocketing and loss of clinical attachment
long term (204). The presence of red-complex bacteria
will adversely affect clinical outcome (119).
Surgical treatment of residual pockets associated
with suprabony defects
A suprabony defect has the base of the pocket located
coronally to the alveolar crest with equal bone
171
Graziani et al.

A B C

D E F

G H I

Fig. 11. Minimally invasive surgical approach: preoperative view (A–C); defect exposure (D, E); suture (F); suture removal
(G); and healing after 12 months (H–J).

172

A B
D E
G H
Fig. 12. Guided tissue regeneration with xenograft and collagen membrane: preoperative view (A, B); defect exposure (C);
graft and membrane application (D–F); and healing after 12 months (G, H).
resorption on the interproximal mesial and distal sur-
faces (227), and appears clinically as horizontal bone
destruction (8). Although suprabony defects are com-
mon in patients with periodontitis, literature on their
surgical treatment is scarce. Conservative surgery
obtained a pocket depth reduction of 1.41 
1.35 mm, a clinical attachment gain of 0.55 
1.22 mm and a recession increase of 1.15  1.23 mm
(102). Papilla preservation flaps may further enhance
the outcome of suprabony defects (Fig. 14) (70).
Regenerative surgery may yield better results than
open debridement, but an absence of cellular sources
for wound healing may yield a highly unpredictable
outcome (102), and anatomic variations of suprabony
defects can complicate regenerative treatment and
make the operative handling of regenerative materials
long and tiresome (226). Enamel matrix derivative has
been suggested for treatment of suprabony defects
Treatment options for periodontitis
C
F
(265); it may provide an additional 1.19 mm of clini-
cal attachment gain and 1.18 mm of probing depth
reduction vs. open access treatment but showed no
clinical evidence of bone fill (102).
Surgical treatment of residual pockets associated
with furcation defects
Interradicular or furcation defects represent a clini-
cal challenge because of their unique anatomic fea-
tures and their posterior location in the dentition
(227). Different therapeutic strategies have, over the
years, ranged from surgical debridement, resective
surgery and regenerative procedures (35, 36, 68,
134, 156). Open flap debridement produces less
clinical improvement with furcation lesions, com-
prising less than 1 mm of horizontal attachment
gain, than with other types of periodontal defects
(Fig. 15) (103). Tunnel treatment of furcation
173
Graziani et al.
A B
D E
G H
Fig. 13. Regenerative surgery with enamel matrix derivative: preoperative view (A, B); defect exposure (C, D); enamel
matrix derivative application (E); suture (F); and healing after 12 months (G, H).
defects is best performed at teeth with short root
trunks, severe intrafurcal bone loss and wide root
divergence, but may give rise to soft tissue resec-
tion (37). The 5-year tooth-survival rate after tunnel
treatment ranges from 57.1% to 92.9% (129), but
the increased root surface area is associated with
elevated caries risk (329). Guided regeneration
treatment may benefit from use of regenerative
material, such as enamel matrix derivative (156),
bioactive glasses (279) or platelet concentrates (36),
but even combined procedures can rarely produce
complete furcation closure (129, 134). Surgical
treatment of furcation defects is least predictable
with intrabony and suprabony lesions, inconsistent
plaque control, smoking and infrequent supportive
periodontal therapy (75, 76). Other outcome deter-
minants are related to defect characteristics, such
as the degree and location of the furcation (75),
the length of the root trunk, the width of the furca-
tion entrance and the initial pocket depth (125).
Finally, root resection/amputation has been fre-
quently advocated for furcation involved teeth (23,
35, 64, 112, 283). Root resection/amputation may
174
C
F
eliminate furcation defects but these procedures are
counterbalanced by the need for endodontic treat-
ment and prosthodontic restoration of the anatomi-
cally changed tooth (23, 35, 69, 72, 115). This may
significantly increase costs and risk for further com-
plication (121, 161).
Supportive periodontal therapy
Supportive periodontal therapy entails regularly
scheduled recall sessions, starting after the active
treatment phase, to monitor periodontal health and
control risk factors with the aim of preventing recur-
rence and progression of periodontitis (256). Periodic
examination for active periodontal disease is a neces-
sary component of periodontal treatment because of
the chronic nature and multifactorial etiology of peri-
odontal diseases and the inability of existing diagnos-
tic tests to predict disease progression. Supportive
periodontal therapy and early disease intervention is
able to avoid major damage to the dentition (118,
212).
 Treatment options for periodontitis

A B C

D E F

Fig. 14. Papilla preservation flap in suprabony defect: preoperative view (A, B); defect exposure (C–E); suture (F); and heal-
ing after 12 months (G).

Different terms have been used to capture the How relevant is supportive periodontal
concept of ‘periodontal maintenance’ (51), includ- treatment?
ing preventive maintenance, recall maintenance (6),
Patients who attend regular supportive periodontal
periodontal recall, maintenance care (234, 235) and
visits experience relatively few changes in clinical
supportive periodontal care (18). In 1989, the
parameters (51, 233, 239, 260). Patients who do not
American Academy of Periodontology suggested the
attend regular periodontal visits tend to show
term ‘supportive periodontal therapy’ to highlight
increases in plaque level to pretreatment values (118,
the need for therapeutic measures in support of
256). Tooth loss is the primary variable of interest in
patient self-care (198). Supportive periodontal ther-
supportive periodontal therapy. The prevalence of
apy (5, 51) aims: (i) to prevent the recurrence and
tooth loss over ≥ 10 years varies from 1.3% to 20%
progression of periodontal diseases in patients who
(295) but is only 9.5% in well-maintained periodontal
have previously been treated for gingivitis, peri-
patients, with more than half of the patients experi-
odontitis or peri-implant diseases; (ii) to prevent or
reduce the incidence of tooth loss by monitoring encing no tooth loss and a small minority of patients
showing most of the tooth loss (40). Compliance with
the dentition and any prosthetic replacements of
a supportive program will diminish the risk of tooth
the natural teeth; and (iii) to increase the probabil-
loss compared with erratic compliance (174, 319).
ity of locating and treating, in a timely manner,
Nonetheless, analysis of tooth loss is hampered by a
other diseases and conditions occurring in the oral
multiplicity of risk factors and a wide heterogeneity
cavity.

175
Graziani et al.
A B
C D
Fig. 15. Open-flap debridement of a furcation defect: preoperative view (A, B); defect exposure (C); and healing after
6 months (D).
among studies on tooth loss (98, 124, 173, 188, 326).
Risk indicators for tooth loss include baseline bone
loss, the number of remaining molars, degree III fur-
cation involvement, initial tooth prognosis (64), age
and smoking (40).
What is the optimal interval between
supportive periodontal visits and how
should it be defined?
The interval between supportive periodontal visits is
a matter of controversy (164, 166, 239). The literature
suggests 2 weeks (247), 2–3 months (13), 3 months (2,
51, 152), 3–4 months (163, 225), 3–6 months (27) or
even 18 months (245). However, no direct compar-
isons of different intervals between supportive peri-
odontal visits are available, and systematic reviews
have not helped to identify optimal intervals (88,
261). Difficulty in determining proper recall intervals
is related to the episodic nature of progressive peri-
odontal disease and the failure to identify patients at
risk of disease recurrence. Therefore, frequency of
supportive periodontal therapy has to be individually
tailored by assessing risk factors (systemic, genetic,
environmental, behavioral), initial disease severity,
treatment outcomes, age in relation to disease sever-
ity, caries susceptibility, plaque control or presence of
restorations (51, 113, 203, 224, 239, 248). Models are
available to assess individual disease risk and suscep-
tibility (164, 166, 239), and patients with higher
176
disease risk may receive supportive periodontal treat-
ment every 3–4 months and patients with lower dis-
ease risk may receive such treatment every 6 months
(51, 234).
The supportive periodontal treatment
appointment: a step-by-step process
Supportive periodontal therapy is an articulated clini-
cal process compromising more than one phase and
is not synonymous to professional prophylaxis or pro-
fessional mechanical plaque removal (7, 55, 119, 350).
A typical session of supportive periodontal therapy
includes: (i) overall evaluation of the oral health sta-
tus, including an update of the patient’s medical and
dental histories, a review of the patient’s plaque con-
trol efficacy, radiographic evaluation (if needed),
extraoral and intraoral examination of soft tissues,
dental examination and periodontal assessment; (ii)
supportive therapy with reinforcement, motivation
and instructions in oral hygiene, promotion of a
healthy lifestyle (e.g. smoking cessation) and profes-
sional mechanical plaque removal (always including
supragingival areas and subgingival debridement of
residual pockets) (10, 113, 224); and (iii) in the case of
disease recurrence, determination of the reason(s)
and a plan for adequate treatment (146, 198, 224,
325).
The relevance of plaque control is well established
(113, 259), but studies debate whether an exhaustive

program of plaque control is critical for preventing
disease progression, especially in advanced cases
(173), or whether professional supportive care pro-
vides more benefit than variations in oral hygiene
performance (236). Controversies exist on the need to
perform subgingival debridement with each support-
ive periodontal session. Highly variable outcomes in
probing pocket depth and clinical attachment level
complicate definitive conclusions (118, 258), but fre-
quent professional plaque removal with subgingival
debridement seems to control periodontitis more
effectively in the long term (259, 304).
Conclusions
Various nonsurgical and surgical options are available
to treat periodontal disease. No periodontal treat-
ment has shown clear superiority over any other peri-
odontal treatment. Treatment of periodontitis
involves a fine balance of highly developed and
skilled techniques, which together decrease the risk
of disease progression. In particular:
 Supragingival plaque control performed by
patient self-care is crucial in the treatment of peri-
odontal disease. Nevertheless, despite significant
plaque and gingivitis reduction, oral hygiene by
itself may result in clinically insignificant improve-
ment of periodontitis disease status.
 Oral hygiene instructions in the periodontal
patient should focus on interdental cleaning per-
formed with interdental brushes when no risk
exists for papillary gingival trauma. Powered
toothbrushes show superiority in terms of plaque
and gingivitis reduction.
 Chemical plaque control may enhance the out-
come of toothbrushing and interdental cleaning.
Dentifrices containing stannous fluoride, triclosan
with copolymer or chlorhexidine, and mou-
thrinses containing chlorhexidine, sodium
hypochlorite, essential oils or cetylpyridinium
chloride can enhance the efficacy of patient self-
care.
 Professional plaque and calculus removal as a sole
treatment is not effective in treating periodontal
disease and shows no benefit additional to oral
hygiene instruction only. Nevertheless, as calculus
and restoration overhang may constitute a physi-
cal barrier to correct oral hygiene techniques, pla-
que and calculus removal is needed as part of the
overall treatment to facilitate patient self-care.
 Subgingival instrumentation, with an open or
closed approach, would provide no benefit, if not
Treatment options for periodontitis
and may be detrimental, in the absence of proper
supragingival plaque control by the patient.
 Subgingival instrumentation, performed together
with patient self-performed supragingival plaque
control, provides significant benefits in terms of
pocket depth reduction and clinical attachment
gain in sites with probing pocket depth above
4 mm.
 Subgingival instrumentation can give rise to sig-
nificant improvement in systemic inflammatory
markers and glucose/lipid metabolism, suggesting
a possible beneficial systemic role of periodontal
treatment, especially in subjects with medical
comorbidities.
 Oral health-related quality of life may be signifi-
cantly enhanced after nonsurgical instrumenta-
tion, irrespective of the instruments and type of
treatment chosen, with no additional effects of
surgical treatment.
 Healing after nonsurgical debridement may be
affected by patient characteristics, such as
smoking habits and overall health. Local factors,
including presence of plaque, furcation involve-
ment or intrabony defects, may complicate
healing.
 Instrumentation is typically performed using root
debridement with sonic/ultrasonic instruments
and the finishing phases of root planing with man-
ual curettes. New, more expensive technologies
have not yet shown, in the best possible scenario,
additional improvements when compared with
traditional instrumentation.
 Treatment may be delivered by conventional
staged or full-mouth approaches. No clear differ-
ences exist between the two types of treatment,
and one or the other may be chosen according to
the specific situation.
 Commercially available local antimicrobials may
be useful in some clinical situations (i.e. localized
deep pockets, at supportive periodontal therapy),
but their usefulness is limited because of an
uncertain cost–benefit ratio.
 Systemic antimicrobials are not capable of treat-
ing periodontitis as monotherapy. However,
amoxicillin plus metronidazole, ciprofloxacin plus
metronidazole, metronidazole alone or azithro-
mycin, may improve the clinical outcomes of non-
surgical periodontal therapy especially in subjects
affected by aggressive, severe or ‘recurrent’ peri-
odontitis. However, systemic antimicrobials may
be associated with significant adverse effects and
increased bacterial resistance, suggesting careful
considerations.
177
Graziani et al.
 Probiotic and host-modulating therapy may be
considered in future treatment of periodontal dis-
ease.
 Nonsurgical retreatment of deep pockets is often
ineffective. Nonetheless, nonsurgical retreatment
may improve healing of anterior mono-radicular
teeth and of teeth with no intrabony component.
The degree of pocket reduction is limited and
improvement can only be expected in moderately
deep pockets.
 Periodontal surgery, without previous nonsurgical
treatment, produces benefits that appear to be
inferior to a more ‘conventional’ approach (i.e.
nonsurgical treatment followed by surgical treat-
ment). Also, excessive inflammation with direct
surgery may complicate tissue handling and intra-
operative visibility.
 Residual pockets associated with intrabony
defects can be successfully treated surgically. Con-
servative surgery may provide important benefits,
especially if using newer, minimally invasive flap
techniques. Treatment of deep intrabony defects
may benefit from the addition of regenerative
material. Small defects located in nonesthetic
areas may still be treated by resective surgery.
 Residual pockets associated with suprabony
defects may be reduced surgically. Whether the
application of enamel matrix derivative provides
additional benefits awaits further studies.
 1981: 8: 281–294.
Furcation defects constitute a challenging clinical
reality for which several therapeutic alternatives
have been suggested. A careful and detailed analy-
sis of a defect is needed in order to select the opti-
mal treatment.
 Supportive periodontal therapy is essential to limit
or avoid disease recurrence and tooth loss. An
individually tailored program involves analysis of
risk factors for disease progression to guide opti-
mal recall scheduling.
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