Surgical periodontal therapy with and

without initial scaling and root planing in the

management of chronic periodontitis: a
randomized clinical trial
Aljateeli M, Koticha T, Bashutski J, Sugai JV, Braun TM, Giannobile WV, Wang H-
L. J Clin Periodontol 2014; 41: 693700. doi: 10.1111/jcpe.12259

Aim: To compare the outcomes of surgical periodontal therapy with and
without initial scaling and root planing.
Methods: Twenty-four patients with severe chronic periodontitis were
enrolled in this pilot, randomized controlled clinical trial. Patients were
equally allocated into two treatment groups: Control group was treated
with scaling and root planing, re-evaluation, followed by Modified Widman
Flap surgery and test group received similar surgery without scaling and
root planing. Clinical attachment level, probing depth and bleeding on
probing were recorded. Standardized radiographs were analysed for linear
bone change from baseline to 6 months. Wound fluid inflammatory
biomarkers were also assessed.
21-07-2014
2
Results: Both groups exhibited statistically significant improvement in clinical
attachment level and probing depth at 3 and 6 months compared to
baseline. A statistically significant difference in probing depth reduction
was found between the two groups at 3 and 6 months in favour of the
control group. No statistically significant differences in biomarkers were
detected between the groups.
Conclusions: Combined scaling and root planing and surgery yielded
greater probing depth reduction as compared to periodontal surgery
without initial scaling and root planing.
21-07-2014
3
21-07-2014
4
Clinical Relevance
Scientific rationale for the study: Conventional periodontal therapy uses an
initial non-surgical phasevprior to surgical intervention.However, limited
information exists regarding outcomes of surgical intervention performed
without initial therapy.
Principal findings: Although no difference was found in clinical attachment
level (CAL) gain between the two groups, the SRP plus surgery group
showed a statistically significant improvement in probing depth (PD)
reduction when compared to the surgery without SRP group.
Practical implications: SRP is an important component of the periodontal
therapy and its goal is resolution of inflammation evident by reduction of
probing pocket depth and gain of clinical attachment level.
21-07-2014
5
Cross References
21-07-2014
6
Int Dent J. 1983 Jun;33(2):127-36.Indications and rationale
for non-surgical periodontal therapy.
Lang NP.

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

21-07-2014
7
J Clin Periodontol. 1984 Aug;11(7):448-58.Long-term effect
of surgical/non-surgical treatment of periodontal disease.
Lindhe J, Westfelt E, Nyman S, Socransky SS, Haffajee AD.

The present investigation describes the effect of periodontal therapy in a group of patients
who, following active treatment, were monitored over a 5-year period. One aim of the
study was to analyze the rle played by the patients' self-performed plaque control in
preventing recurrent periodontitis. In addition, probing depth and attachment level
alterations were studied separately for sites with initial probing depths of greater than or
equal to 4 mm which were treated initially by either surgical or non-surgical procedures.
Following active treatment (surgical/non-surgical), the patients were maintained on a
plaque control regimen for 6 months, which included professional tooth cleaning once
every 2 weeks. During the subsequent 18 months, the interval between the recall
appointments was extended to 12 weeks and included prophylaxis as well as oral hygiene
instruction. Following the 24-month examination, the interval between the recall
appointments was further extended, now to 4-6 months. In addition, the maintenance
program was restricted to oral hygiene instruction and professional, supragingival tooth
cleaning, but further subgingival instrumentation was avoided. Clinical examinations
including assessments of the oral hygiene, the gingival conditions, the probing depths and
the attachment levels were performed at Baseline and after 24 and 60 months after
completion of active therapy.
21-07-2014
8
Assessments of plaque and gingivitis were repeated annually. The results of the
examinations showed that the patients' standard of self-maintained oral
hygiene had a decisive influence on the long-term effect of treatment. Patients
who during the 5 years of monitoring consistently had a high frequency of
plaque-free tooth surfaces showed little evidence of recurrent periodontal
disease, while patients who had a low frequency of plaque-free tooth surfaces
had a high frequency of sites showing additional loss of attachment. The
present findings demonstrated that sites with an initial pocket depth exceeding
3 mm responded equally well to non-surgical and surgical treatments. This
statement is based on probing depth and attachment level data from sites
which were free of plaque at the 6-, 12-, 24-, 36-, 48-, and 60-month
reexaminations. It is suggested that the critical determinant in periodontal
therapy is not the technique (surgical or non-surgical) that is used for the
elimination of the subgingival infection, but the quality of the debridement of
the root surface.
21-07-2014
9
J Clin Periodontol. 1980 Jun;7(3):199-211.Short-term effects
of initial, nonsurgical periodontal treatment (hygienic
phase).Morrison EC, Ramfjord SP, Hill RW.

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

21-07-2014
10
J Clin Periodontol. 1987 Apr;14(4):231-6.The effect of plaque
control and root debridement in molar teeth.Nordland P,
Garrett S, Kiger R, Vanooteghem R, Hutchens LH, Egelberg J.

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

21-07-2014
11
J Clin Periodontol. 1983 Sep;10(5):524-41.Comparison of surgical and
nonsurgical treatment of periodontal disease. A review of current
studies and additional results after 61/2 years.
Pihlstrom BL, McHugh RB, Oliphant TH, Ortiz-Campos C.

Many well designed clinical studies have established the effectiveness of periodontal
therapy. Surgical procedures have been shown to be effective in treating periodontitis
when followed by appropriate maintenance care. Scaling and root planing alone have
recently been compared to scaling and root planing plus soft tissue surgery in several
longitudinal trials. A review of the literature indicates several important findings including a
loss of clinical attachment following flap procedures for shallow (1-3 mm) pockets and no
clinically significant loss after scaling and root planing. These studies also generally report
either a gain or maintenance of attachment level for both procedures in deeper pockets
(greater than or equal to 4 mm). For these pockets, neither procedure has been shown to
be uniformly superior with respect to attachment gain. All reports indicate that both
treatment methods result in pocket reduction. However, the literature also indicates that
scaling and root planing combined with a flap procedure results in greater initial pocket
reduction than does scaling and root planing alone. This difference in degree of pocket
reduction between procedures tends to decrease beyond 1-2 years. It has been shown
that both treatment methods result in sustained decreases in gingivitis, plaque and
calculus and neither procedure appears to be superior with respect to these parameters.
Additional data from the study at the University of Minnesota indicate that similar results
are maintained up to 61/2 years following active therapy. Pocket depth did not change
for shallow (1-3 mm) pockets treated by either scaling and root planing alone or scaling
and root planing followed by a modified Widman flap.
21-07-2014
12
For pockets 4-6 mm, both treatment procedures resulted in equally
effective sustained pocket reduction. Deep pockets (greater than or equal
to 7 mm) were initially reduced more by the flap procedure. After 2 years,
no consistent difference between treatment methods was found in degree
of pocket reduction. However, as compared to baseline, pocket reduction
was sustained to 61/2 years with the flap and only 3 years with scaling and
root planing alone. After 61/2 years, sustained attachment loss in shallow (1-
3 mm) pockets was found after the modified Widman flap. Scaling and root
planing alone in these shallow pockets did not result in sustained
attachment loss. For pockets initially 4-6 mm in depth, attachment level was
maintained by both procedures but scaling and root planing resulted in
greater gain in attachment as compared to the flap at all time intervals
21-07-2014
13
J Periodontol. 1981 May;52(5):227-42.A randomized four-
years study of periodontal therapy.
Pihlstrom BL, Ortiz-Campos C, McHugh RB.

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

21-07-2014
14
J Clin Periodontol. 1987 Sep;14(8):445-52.4 modalities of periodontal
treatment compared over 5 years.
Ramfjord SP
1
, Caffesse RG, Morrison EC, Hill RW, Kerry GJ, Appleberry
EA, Nissle RR, Stults DL.

The purpose of the present study was to assess in a clinical trial over 5 years the
results following 4 different modalities of periodontal therapy (pocket elimination
or reduction surgery, modified Widman flap surgery, subgingival curettage, and
scaling and rool planing). 90 patients were treated. The treatment methods
were applied on a random basis to each of the 4 quadrants of the dentition.
The patients were given professional tooth cleaning and oral hygiene
instructions every 3 months. Pocket depth and attachment levels were scored
once a year. 72 patients completed the 5 years of observation. Both patient
means for pocket depth and attachment level as well as % distribution of sites
with loss of attachment greater than or equal to 2 mm and greater than or
equal to 3 mm were compared. For 1-3 mm probing depth, scaling and root
planing, as well as subgingival curettage led to significantly less attachment loss
than pocket elimination and modified Widman flap surgery. For 4-6 mm
pockets, scaling and root planing and curettage had better attachment results
than pocket elimination surgery. For the 7-12 mm pockets, there was no
statistically significant difference among the results following the various
procedures.

21-07-2014
15
J Clin Periodontol. 1992 Apr;19(4):240-4.Non-surgical periodontal
treatment: where are the limits? An SEM study.
Rateitschak-Plss EM
1
, Schwarz JP, Guggenheim R, Dggelin M,
Rateitschak KH.

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

21-07-2014
16
Br Dent J. 1993 Mar 6;174(5):161-6.Rationale and
techniques of non-surgical pocket management in
periodontal therapy.Rawlinson A
1
, Walsh TF.

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

21-07-2014
17
J Clin Periodontol. 2001 Oct;28(10):910-6.Initial outcome and long-term
effect of surgical and non-surgical treatment of advanced periodontal
disease.
Serino G
1
, Rosling B, Ramberg P, Socransky SS, Lindhe J.

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

21-07-2014
18
RESULTS: It was observed that (i) surgical therapy (SU) was more effective
than non-surgical scaling and root planing (SRP) in reducing the overall
mean probing pocket depth and in eliminating deep pockets, (ii) more
SRP-treated subjects exhibited signs of advanced disease progression in the
1-3 year period following active therapy than SU-treated subjects.
CONCLUSION: In subjects with advanced periodontal disease, surgical
therapy provides better short and long-term periodontal pocket reduction
and may lead to fewer subjects requiring additional adjunctive therapy.

21-07-2014
19
J Periodontol. 2008 Mar;79(3):431-9. doi: 10.1902/jop.2008.070383 .
Locally delivered doxycycline as an adjunct to mechanical
debridement at retreatment of periodontal pockets.
Tomasi C
1
, Koutouzis T, Wennstrm JL.

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

21-07-2014
20
RESULTS: Baseline examination revealed no significant difference in mean
PD between treatment groups. The mean PD reduction at 3 months was 0.9
mm (95% confidence interval [CI]: 0.6 to 1.2) in the control group and 1.0
mm (95% CI: 0.7 to 1.3) in the test group (P >0.05). At 9 months, both
treatment groups showed a mean PD reduction of 1.1 mm. The mean RAL
gain was 0.6 mm at 3 months and approximately 0.8 at 9 months for both
groups. The probability of pocket closure was not improved by the
adjunctive antibiotic therapy. Only factors at the tooth site level (plaque
presence, furcation involvement, and presence of an intrabony defect)
were identified by multilevel analysis as significant for the treatment
outcome.
CONCLUSION: Locally delivered doxycycline failed to improve the healing
outcome of reinstrumentation of periodontal pockets showing a poor initial
response to pocket/root debridement.

21-07-2014
21
J Clin Periodontol. 1984 Jan;11(1):63-76.Effect of
nonsurgical periodontal therapy. II. Severely advanced
periodontitis.Badersten A, Nilveus R, Egelberg J.

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

21-07-2014
22
J Periodontol. 1988 Jun;59(6):351-65.A longitudinal study comparing
scaling, osseous surgery and modified Widman procedures. Results
after one year.Becker W
1
, Becker BE, Ochsenbein C, Kerry G, Caffesse
R, Morrison EC, Prichard J.

The purpose of this study was to compare, longitudinally, the effectiveness of scaling and
root planing, osseous surgery, and the modified Widman procedures. The study was
carried out in a private practice setting. Sixteen adult patients with moderate to
advanced adult periodontitis were treated with initial scaling and oral hygiene
procedures. Posthygiene data were used for comparison of changes in probing depth,
clinical attachment levels and gingival recession. The initial examination data were used
to compare changes in plaque and gingival indices. Frequency distributions were used to
compare changes that occurred at individual sites. At one year, plaque and gingival
indices were significantly reduced when compared with the initial examination. At one
year, shallow pockets (1-3 mm) were reduced when compared to posthygiene. Four- to
six-millimeter pockets were significantly reduced by the three procedures. Osseous surgery
and modified Widman had significantly greater pocket reduction when compared with
scaling. For pockets greater than 7 mm, osseous surgery and the modified Widman had
significantly greater reduction when compared with scaling. For pockets 1-3 mm at one
year osseous surgery had significantly greater clinical attachment loss when compared
with scaling. For 4-6 mm pockets at one year, the three procedures had slight gains in
clinical attachment levels. The results were similar for pockets with greater than 7 mm.
Interproximal soft tissue craters were measured for six postoperative weeks.
21-07-2014
23
Initially, the modified Widman had a higher percentage of soft tissue craters
when compared with osseous surgery. At six weeks, however, there were
no significant differences when the surgical procedures were compared.
Recession was measured at each examination. Recession for 1-3 mm
pockets at one year was greater for osseous surgery when compared with
scaling and the modified Widman. Recession for 4-6 mm and greater than
7 pockets was greater for the surgical procedures than scaling. The results
from this study indicate that with three-month maintenance recalls, both
the modified Widman and osseous surgery are effective for pocket
reduction, and each will produce a slight gain of clinical attachment over
one year. Scaling was effective at maintaining attachment levels but was
not as effective in reducing pocket depth.
21-07-2014
24
J Clin Periodontol. 2002 Feb;29(2):92-102.Clinical and microbiological
studies of periodontal disease in Sjgren syndrome patients.
Kuru B
1
, McCullough MJ, Yilmaz S, Porter SR.

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

21-07-2014
25
RESULTS: The occurrence, severity and extent of periodontal lesions were
not significantly different between the 3 patient groups for all periodontal
parameters examined. No significant differences in the sub-gingival plaque
samples from control, primary or secondary SS patients for the PA test,
frequency or type of periodontal micro-organisms observed.
CONCLUSION: No significant differences could be detected in either
clinical or microbiological parameters of primary or secondary SS patients
compared with that of control subjects. The results of the present study thus
support the notion that the periodontal status of patients with SS do not
differ from systemically healthy age- and gender-matched controls.

21-07-2014
26
J Periodontol. 1981 Nov;52(11):655-62.Four types of periodontal
treatment compared over two years.
Hill RW, Ramfjord SP, Morrison EC, Appleberry EA, Caffesse RG, Kerry
GJ, Nissle RR.

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

21-07-2014
27
J Clin Periodontol. 1995 Feb;22(2):162-7.Crevicular interleukin-1 beta in
moderate and severe periodontitis patients and the effect of phase I
periodontal treatment.
Hou LT
1
, Liu CM, Rossomando EF.

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

21-07-2014
28
J Clin Periodontol. 1984 Nov;11(10):669-81.The effect of root planing as
compared to that of surgical treatment.
Isidor F, Karring T, Attstrm R.

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

21-07-2014
29
J Periodontol. 1996 Feb;67(2):93-102. Long-term evaluation of
periodontal therapy: I. Response to 4 therapeutic modalities.
Kaldahl WB
1
, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK.

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

21-07-2014
30
J Clin Periodontol. 1980 Feb;7(1):32-47.Comparison of results following
three modalities of periodontal therapy related to tooth type and initial
pocket depth.
Knowles J, Burgett F, Morrison E, Nissle R, Ramfjord S.

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

21-07-2014
31
J Periodontol. 2001 Aug;72(8):1045-51.Effect of non-surgical periodontal
therapy on C-telopeptide pyridinoline cross-links (ICTP) and
interleukin-1 levels. Al-Shammari KF
1
, Giannobile WV, Aldredge WA,
Iacono VJ, Eber RM, Wang HL, Oringer RJ.

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

21-07-2014
32
RESULTS: Deep sites exhibited significantly (P<0.001) higher ICTP and IL-1 levels
compared to shallow sites at all time intervals. ICTP demonstrated a stronger
association to clinical parameters than IL-1 including a modest correlation (r =
0.40, P<0.001) between ICTP and attachment loss. Significant improvements in
PD, CAL, and BOP were observed at 1, 3, and 6 months in all sites (P<0.01).
However, non-surgical mechanical therapy did not significantly reduce ICTP
and IL-1 levels over the 6-month period. Further examination of subjects based
on smoking status revealed that ICTP levels were significantly reduced at 3 and
6 months and IL-1 levels reduced at 3 months among non-smokers only.
CONCLUSIONS: A single episode of non-surgical mechanical therapy did not
significantly reduce biochemical markers associated with bone resorption in
patients exhibiting chronic periodontitis. Future longitudinal studies are
warranted to specifically evaluate the relationship between C-telopeptide
pyridinoline cross-links and periodontal disease progression.

21-07-2014
33
J Clin Periodontol. 1993 Apr;20(4):259-68.Meta-analysis of surgical
versus non-surgical methods of treatment for periodontal disease.
Antczak-Bouckoms A
1
, Joshipura K, Burdick E, Tulloch JF.

A meta-analysis was performed on 5 randomized controlled trials comparing
surgical with non-surgical treatment for periodontal disease. The specific
procedures considered were the modified Widman flap compared with scaling
and root planning or curettage with anesthesia. We chose the most consistently
reported outcomes, pocket depth and attachment level, for analysis. At 1 year
of follow-up, surgical treatment reduced pocket depth more than non-surgical
for all initial levels of disease, but by 5 years, only the deepest initial pockets (> 7
mm) showed significant improvement over non-surgically treated teeth (0.51
mm reduction, p < 0.01). Attachment level showed significantly better early
results for non-surgical treatment for less diseased teeth, but by 5 years, all
significant differences had disappeared. We computed quality scores following
a method described by Chalmers. The mean quality score for study data
analysis and presentation was 0.37 +/- 0.009 and for the study protocol, the
mean quality score was 0.19 +/- 0.002. We find that this meta-analysis supports
findings relating response to therapy with initial level of disease severity. We also
find that the choice of outcome measure influences the choice of therapy, with
surgical therapy providing greater benefit for probing depth and non-surgical
therapy providing greater benefit for attachment level. These results must be
viewed, however, in light of the low quality scores of the evaluated studies and
the potential for bias due to lack of binding, the small mean treatment
differences, and the observer measurement variability.

21-07-2014
34
J Clin Periodontol. 1981 Feb;8(1):57-72.Effect of nonsurgical periodontal
therapy. I. Moderately advanced periodontitis.
Badersten A, Nilvus R, Egelberg J.

Healing events after nonsurgical periodontal therapy in patients with
periodontal pockets 4--7 mm deep were investigated. Incisors, cuspids and
premolars in 15 patients were treated by plaque control and supra- and
subgingival debridement using hand or ultrasonic instruments in a split
mouth approach. The results were evaluated by recordings of plaque
scores, bleeding on probing, probing pocket depths and probing
attachment levels. All these parameters were improved during the initial 4--
5 months after start of therapy. Little change occurred during the rest of the
13-month observation period. No difference of results could be observed
comparing hand and ultrasonic instrumentation or comparing the results of
two different operators. Initially a total of 106 sites demonstrated probing
pocket depths greater than or equal to 6 mm. At 13 months only 13 such
sites were observed. The apparently successful results of conservative
treatment of patients with 4--7 mm deep pockets in the present study raise
the question to what extent nonsurgical therapy is feasible also in patients
with severely advanced lesions.

21-07-2014
35
Tissue Eng. 2006 June ; 12(6): 14411450. doi:10.1089/ten.2006.12.1441
Effect of rhPDGF-BB Delivery on Mediators of Periodontal Wound
Repair
COOKE et al.
Growth factors such as platelet-derived growth factor (PDGF) exert potent effects
on wound healing including the regeneration of tooth-supporting structures. This
investigation examined the effect of the local delivery of PDGF-BB when combined
with reconstructive periodontal surgery on local wound fluid (WF) levels of PDGF-
AB, vascular endothelial growth factor (VEGF), and bone collagen telopeptide
(ICTP) in humans with advanced periodontitis. Sixteen patients exhibiting localized
periodontal osseous defects were randomized to one of three groups (-TCP carrier
alone, -TCP + 0.3 mg/mL of recombinant human PDGF-BB [rhPDGF-BB], or -TCP +
1.0 mg/mL of rhPDGF-BB) and monitored for 6 months. WF was harvested and
analyzed for PDGF-AB, VEGF, and ICTP WF levels. Teeth contralateral to the target
lesions served as controls. Increased levels of VEGF in the WF was observed for all
surgical treatment groups with the 1.0 mg/mL rhPDGF-BB group showing the most
pronounced difference at 3 weeks in the AUC analysis versus control (p < 0.0001).
PDGF-AB WF levels were increased for the carrier alone group compared to both
rhPDGFBB groups. Low-dose rhPDGF-BB application elicited increases in ICTP at
days 35 in the wound healing process, suggesting a promotion of bone turnover
at early stages of the repair process (p < 0.02). These results demonstrate
contrasting inducible expression patterns of PDGF-AB, VEGF, and ICTP during
periodontal wound healing in humans.
21-07-2014
36
J Clin Periodontol. 1998 November ; 25(11 Pt 1): 865871Relationship between
C-telopeptide pyridinoline cross-links (ICTP) and putative periodontal
pathogens in periodontitis Michael D. Palys, Anne D. Haffajee, Sigmund S.
Socransky, William V.Giannobile
Crevicular fluid pyridinoline cross-linked carboxyterminal telopeptide of type 1
collagen (ICTP) is predictive for future alveolar bone loss in experimental
periodontitis in dogs. The present study sought to relate ICTP to a panel of
subgingival species in subjects exhibiting various clinical presentations such as
health (n=7), gingivitis (n=8) and periodontitis (n=21). 28 subgingival plaque and
GCF samples were taken from mesiobuccal sites in each of 36 subjects. The
presence and levels of 40 subgingival taxa were determined in plaque samples
using whole genomic DNA probes and checkerboard DNA-DNA hybridization. GCF
ICTP levels were quantified using radioimmunoassay (RIA). Clinical assessments
made at the same sites included: BOP, gingival redness, plaque, pocket depth,
and attachment level. Differences among ICTP levels in the 3 subject groups were
sought using the Kruskal-Wallis test. Relationships between ICTP levels and clinical
parameters as well as subgingival species were determined by regression analysis.
The results demonstrated significant differences among disease categories for GCF
ICTP levels for healthy (1.1+0.6 pg/site (meanSEM)) gingivitis (14.86.6 pg/site) and
peridontitis subjects (30.3+5.7 pg/site) (p=0.0017). ICTP levels related modestly to
several clinical parameters. Regression analysis indicated that ICTP levels
correlated strongly with mean subject levels of several periodontal pathogens
including B. forsythus, P. gingivalis, P. intermedia, P. nigrescens and T. denticola
(p<0.01). The data indicate that there is a positive relationship between the
putative bone resorptive marker ICTP and periodontal pathogens.
21-07-2014
37
Journal of PeriodontologyJanuary 2010, Vol. 81, No. 1, Pages 89-98 , DOI
10.1902/jop.2009.090397 (doi:10.1902/jop.2009.090397) Relationships Among Gingival
Crevicular Fluid Biomarkers, Clinical Parameters of Periodontal Disease, and the
Subgingival Microbiota
Ricardo Teles,
*
Dimitra Sakellari,

Flavia Teles,
*
Antonis Konstantinidis,

Ralph Kent,
*

Sigmund Socransky,
*
and Anne Haffajee
*


Background: The objectives of this study were to measure levels of gingival
crevicular fluid (GCF) biomarkers and subgingival bacterial species in
periodontally healthy subjects and subjects with periodontitis to explore the
relationships among these biomarkers, the subgingival microbiota, and the
clinical parameters of periodontal disease.
Methods: Clinical periodontal parameters were measured at six sites per tooth in
20 subjects with periodontitis and 20 periodontally healthy subjects. GCF and
subgingival plaque samples were obtained from the mesio-buccal aspect of
every tooth. GCF levels of interleukin (IL)-1 and IL-8 and matrix
metalloproteinase 8 were measured using checkerboard immunoblotting, and
the levels of 40 bacterial taxa were quantified using checkerboard DNA-DNA
hybridization. A subset of clinically healthy sites from each group was
analyzed separately. The significance of the differences between groups was
determined using the unpaired t test or the Mann-Whitney test. Correlations
among immunologic, microbiologic, and clinical data were determined using
the Spearman rank correlation coefficient.
21-07-2014
38
Results: There were positive correlations among mean clinical parameters,
mean levels of the three biomarkers, and the proportions of orange and red
complex species (P <0.05). Clinically healthy sites from subjects with periodontitis
had higher levels of IL-1 and IL-8 and higher proportions of orange and red
complex species (P <0.05) than clinically healthy sites from periodontally healthy
subjects. Red complex species were positively associated with the expression of
all biomarkers (P <0.05), whereas purple and yellow complex species had
negative correlations with IL-1 and IL-8 (P <0.05).
Conclusions: Clinically healthy sites from subjects with periodontitis have higher
levels of GCF biomarkers and periodontal pathogens than clinically healthy sites
from periodontally healthy subjects. Different microbial complexes
demonstrated distinct associations with specific GCF biomarkers.
KEYWORDS: Cytokines, gingival crevicular fluid, matrix metalloproteinases,
microbiology, periodontal diseases

21-07-2014
39
Journal of PeriodontologySeptember 2010, Vol. 81, No. 9, Pages 1308-1316 , DOI
10.1902/jop.2010.090643 (doi:10.1902/jop.2010.090643) Immunologic and Microbiologic
Profiles of Chronic and Aggressive Periodontitis Subjects
Bruno Rescala,
*
Wilson Rosalem Jr.,
*
Ricardo P. Teles,

Ricardo G. Fischer,
*
Anne D.
Haffajee,

Sigmund S. Socransky,

Anders Gustafsson,

and Carlos Marcelo Figueredo,

*


Background: This study determines the gingival crevicular fluid (GCF) levels
of interleukin (IL)-1, IL-2, IL-4, IL-8, interferon (IFN)- and elastase activity in
inflamed shallow and deep periodontal sites from patients with generalized
chronic (GCP) and generalized aggressive periodontitis (GAgP), and to
compare them to shallow sites from subjects with gingivitis. A secondary
aim analyzes the microbiologic profile of these subjects.
Methods: Cross-sectional clinical data were obtained from 20 GCP, 17
GAgP, and 10 gingivitis subjects. GCF samples were collected with paper
strips and the levels of IL-1, IL-2, IL-4, IL-8, and IFN- were measured using a
multiplexed bead immunoassay. Elastase activity was assessed by an
enzymatic assay. Subgingival plaque samples were analyzed using
checkerboard DNA-DNA hybridization. Significance of differences among
groups for immunologic and microbiologic data was examined using
Kruskal-Wallis adjusting for multiple comparisons.

21-07-2014
40
Results: Mean clinical parameters and GCF volumes were higher in patients
with GCP and GAgP compared to the gingivitis group. Higher levels of IL-1
and higher elastase activity were found in deep sites compared to shallow
sites in both periodontitis groups (P <0.05). The microbiologic data showed
significantly higher levels of the red complex species in patients with GCP
and GAgP compared to gingivitis (P <0.05). There were no statistically
significant differences in levels of GCF biomarkers and in levels of
subgingival bacterial species between subjects with GCP and GAgP.
Conclusion: There were no statistically significant differences in the
measured immunologic and microbiologic parameters between subjects
with GCP and GAgP.
KEYWORDS: Cytokines, gingival crevicular fluid, microbiology, periodontal
diseases

21-07-2014
41