4 modalities of periodontal
treatment compared over 5 years*
S.
E.
G.
R.
P. Ramfiord, R. G. Caffesse,
C. Morrison, R. W. Hill,
J. Kerry, E. A. Appleberry,
R. Nissle and D. L. Stults
The University of Michigan School ot
Denlislry, Department of Periodontics, Am
Arbor, Michigan 48109, USA
RamfjordSP. Caffesse RG. Morrison EC, Hill RW, Kerry GJ, Appleherrv EA.
Msslc RR and Slulls DL: 4 modalilics of periodonial ireaimenl compared over
5 years. J Cliti Pcnodomal 1987; 14: 445-4S2.
Ahsiracl. 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
t-'urettage, 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 tooih cleaning and oral hygiene
instructions every 3 nionths. 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 > 2 mm and >j> mm were compared.
For 1-3 mm probing depth, scaling and root planing, as well as subgingiva!
curettage led to significantly less attachment loss than pocket elimination and
modified Widman flap surgery. For 4 6 mm pockets, scaling and rool planing
and curettage had better attachment results than pocket elimination surgery.
For the 7 12 mm pockels. there was no statistically significant difference among
the results following the various procedures.
In a previous paper (Hill et al. 1981). 2year results from a clinical trial comparing surgical and non-surgical techtiiques for treatment of moderate lo advanced periodontitis were published.
The clinical results following the 4 different procedures were fairly similar.
Several other investigators (Pihistrom ct
al. I98K LIndhe et al. 1982. Lmdhe et
al. 1984, Isidor et al. 1984) have also
compared results following surgical and
non-surgical periodontal therapy over
as much as bV^ years (Pihistrom et al.
19H4| and reported ihal only minor differences ocurred between methods with
respect to probing depth and attachment level alterations. With the notoriously slow process of adult-type periodontitis even in the absence of periodontal therapy (LJndhe et al. 1983).
and the limitations of probing in discerning small differences, the focus of
interest in clinical trials involving various modalities of periodontal treatment
should be more and more directed
toward long-temi observations involving as many patients as possible. If the
• This study
'=DE 02731.
supported by Ot
average annual loss of attachment for
untreated cases of periodontilis is 0.2
mm (Lindhe et al. 1983). a crude mstrumcni such as a probe with a unit scale of
1 mm obviously can only record trends
based on numerous measurements over
a long period o\' \\x\\Cit appears from previous observations that results o'i periodontal therapy become fairly stable over 5 years of
observation (Knowles et a!. 1979, Lindhe & Nyman 1984) with measurable
changes only for very few teeth. It also
becomes vcrv difficuU to keep an experimental group together for more than
that length o\' time for well-controlled,
standardized care. 5 years of observation should enable us to spot trends
in behaviour of regularly repeated
measurements including absorption of
unavoidable errors.
Materiai and Methods
The types of patients and methods of
treatment were reported in a previous
paper (Hill et aL 1981), and will only
be summarized here. 90 subjects with
moderate to advanced periodontitis
were treated. Following initial examin-
Key words. Scaling - tool planing — product Gfimination — modified idman
Wi
flap
- probing depth - attachment level - tooth
s - fui
Accepted for public
n 25 August
ation, they were treated with scaling,
root planing and instruction in oral hygiene (hygiene phase o{ therapy) by a
dental hygienist. Occlusal adjustment
was subsequently performed by a periodontist. 4 modalities of periodontal
treatment were randomized and performed by a periodontist. Thus, eaeh of
the 4 quadrants had an equal chance of
receiving any one of the experimental
procedures. The treatments were: (I)
surgical pocket elimination (Prichard
1972) ineluding bone surgery, or pocket
reduction for the vevy deep pockets:
(2) modified Widman flap surgery
(Ramljord & Nissle 1974); (3) subgingival curettage (Ramfjord & Ash 1979):
(4) scaling and root planing only
(Ramfjord & Ash 1979). All treatment
procedures were performed under local
anesthesia. The patients were recalled
for prophylaxis once a week for 4 weeks
post-surgically, and later once every 3
months for the 5 years of the study. The
patients were rcexamined 1 month after
completion of the hygienic phase of
treatment, and then yearly after the experimental surgical treatments. These
re-examinations were performed 3
months after the last prophylaxis. Of
446
fiiimjjord cl al.
the 90 initUil palicnts. 72 completed Ihc
5 years of rollow-up.
Some pockets with overt bieeding
and/or pus secreljons when seen by the
periodontisl tor unnual evaluation were
retreated by a periodontist during the
maintenance phase. The modality of rctrealment was left to the judgement of
the periodontist. but in most mstances.
scaling and rool planing with or without
anesthesia was carried ou(.
Results
Probing pocket depth and clinical
anachment level
In order to keep the findings in perspective with the reported 2-year observmums tm\ e! ;ii. 1981), some iA' the
previously published data (Hill et al.
19!<i) arc ineludej in the present report.
The pockets were grouped into 3
i;liJ.s.se,s :)\ lJic inilial examinution: (1) I
to 3 mm deep (normal depth): (2) 4 to
6 inm (moderate periodontitis): (3) >7
mm deep (advanced periodontitis).
Initial probing depth umi iLttaehment
levels were used as baseline in order
io assess tiie eh;inges which occiu'red
following the various treatments over
the 5 years. Patient means for probing
pocket depths and clinical attachmenl
levels within each category were used
tor the statistical tabulations. All of the
teeth were included, and if a tooth was
tos-i during the treatment, ihe measurements for that tooth were included until
the tooth was lost. For parametric statistic evaluations, it was felt thai the basic unh was ihc puticnl nither thiin lhe
single tooth, or the single pockeL However, for a numerical evaluation o\'
poekets with a certain amount of loss
or gcun. %.s o)' changes were calculated.
These changes will also be considered
in this paper in an attempt lo gain as
much clinically applicable mfnrmiition
as possible. This information is important to the clinician, since it relates to
changes in attachment le\els tor special
teeth and modalities oT treatment.
The variations in depth lor 1-.^ mm
(Class I) pockets were small (Table 1).
AlthiHigh some of the dilfereiices were
significant statistically because o\' a
large number of subjects and small standard deviations, they seemed insignificant from a clinical point of view. They
appeared mainly at the 1st year followup e.xamination. After the second year,
tbllovving the various moda)it!e.s of
treatment, there were no significant differences in this category of pocket.
However, a slight deepening of the shallow products gradually occurred for all
modalities of treatment when compared
to the baseline data.
Of greater interest was the gradual
loss of attachment that continued during the 5 years oi' treatment and maintenance for the Class I (normal) pockets
(Table 2), Part of this loss was apparently the result of the initial treatment
(1st year follow-up), where lhe loss Ibllowmg scaling and curettage was less
than tbiiowing the other surgical treatments. AUo. there was a fairly similar
loss ol attachment during the maintenance phase for all of the treatment
groups, but even at the 5th year, the
curertage and scaling groups showed a
more tavorable attachment I'esponse
tiian the tlap surgery groups, although
the differences were too small to be of
clinical signiUcance.
Pocket reduction for Class II (moderate periodontitis) (Table 3) was greater
•
li
d year
,\
:\ MYaxICC
tc S.D
''()
l.i:
0,2,!
p,..kc( ol,,,,.
S,D,
^* ll,,10
89
if
SO
,,,,,d lV,d,,,a,,
lo, 7*
;
I ^
0,33
h-oiii
h a s c l i n o
90
T
- 0 . 0 4 0.2S
I.4f>y^^-.0.]47S
pocket dim.
CLirelUiiie
IIIOLI. Wniniiin
S9
ron"^hninn
S')
S9
0 37
75
S3
0.40
.''th year
rncan
dilll
S,D,
;V
1
(,,(J2 0,35
72
0.07 0,35
;;
0.1 3*
S
D
-0.003
0 31
-/). )5*
0.30
-0.14*
0.36
1--2.0447
/'<0.10)
i>AK->9
/ • • . l l O 5
x'kels
V
0.05
/'•-
dil
I.MT11CC S . D
0.5.S
1-0.64*
- 0 . 3 5 * 0.40
XS'
[1r
\
SO
-0 SK* 0 4"^
so
m
0.27* 0.42
so
- 14.090
p •^0.0001
icnl from bascliiio /'<0.05.
3 ,1 1, bv
d year
M vcLir
lilt-';);!
TrciiUiKDl
83
\
1- 4,2209
cli;ui!:c(paiic]i
M>^icnic phasL'
HTUilf
.V ditlcroncc S.D.
ditTcrenct S.D
(i.46
(, 0 4
1' !l
/'• it
f
l
0,23* 0,33
f(,(iy
4tl yea.
3rd Yea
S 0
I'l Tciee
S,D
,t,Lnh i d
3rd yea.
meiiu
.V < itTere,iee S,D,
1;
411i y e a .
i))e;),i
V lifiere,ice S,D,
(1,82* 0,51 83
0,59* 0,47 83
0 81* 0 51 8 '
r (I 99* 0,55
1-0,8(1* 0,49
0 95* 0 51
7S
0,50* 0,41
I 0,69* 0,53
F-5,792"
P< 0,0007
75
F 8,8426
P- 0,0(10
83
75
75
T-1,10* 0,57
1-0,90* 0,54
5,1, year
,,,ean
;V t rfe,ence S,D,
72
y 1,17* 1 5 7
L- 0,99* 0,57
1,12* 0 54
72
•- 0,89* 0,58
7-'
^ - 0,9S* 0,61
il-0,78*
F 4,1904
P< 0,0063
0,56
F-3,58M
/'<0,0142
PcriatiofUal llwrapy after 5 years
447
•iihk' J. Pocket reduction (patienl means) from baseline for pockets 4-6 mm by treatment method
Hygienic phase
mean
,V diflercnce S.D.
90
O.'»6
0.47
2nd ye;
1st year
mean
,V difference S.D.
Trealmeni
pockel elim.
curettage
mod. Widman
scaling and
rool piatiing
• S.D.
0.54
0.63
0.73
A- difierence S.D.
0.70
0.76
1.27*
1.00*
1.20*
F-13.527
P<O.O()OI
T-19.28 P < 0.000
.V difierence S.D.
0.76
0.80
0.44
0.67
0.54
0.87
[-"•2.3258
P < 0.0747
F- 13.848
P< 0.0001
F-9.6960
p<.omo\
' Specific irealmcnl diffcrcnl from has.
1 year following both types of tlap surgeries ihan following eurettage or scaling. 5 years later, the same trend prevailed, with significantly more reduelion
following pocket elimination surgery
than lbliowing curettage. The pocket reduetion following sealing was similar to
the reduction following open surgical
treatments and significantly greater
than following curettage. From a clinical statidpoint, (he differences were
small for all of the methods. However,
the pockets were reduced significantly
from the baseline.
The attachment level response lor
Class II pockets (pocket depth 4-6 mm)
1 year after treatment was significantly
better for scaling and for cureltage than
for both pocket elimination and modified Widman Hap surgeries (Table 4).
This trend was sustained over the 5
years, although there wus a alight los^
ol ;ittachrnenl following ;ill modalities
of treatment. The greatest loss was following pocket elimination stirgery. The
loss seemed lo occur niainlv during the
.;. .^t
ehaiige (pattc
1 niL
ce S D
(,
O'!8
90
T-5 68 p< 0.0001
Ticatmcnt
pocket elim.
curettage
mod. Widma
scaling and
root phinmg
1
There was a gain of elinieal atiaehment following all 4 methods of treatment tor the Class III poekels (>7 mm)
(Table 6). There was. however, no statistically significant difference among the
methods during the 5 years of observation. At 5 years of maintenance, only
curettage and scaling showed a statislically significant gain of atlaehment
compared lo the baseline dala. The gain
nis) iioni basel
IK-
observed in the other 2 groups
similar.
Frequency distribution of sites with gain or
loss of clinical attachment
The lVequeney distribution of sites gaining or losing 2 mm or more and 3
mm or more of elinieal attachment from
baseline to year 5 was related to m o dality of treatment (Tables 7. 8). T h e
sites with pockel depth of 1 3 mm
(Class I) had the highest lrequency of
attachment loss both > 2 mm and > 3
mm, and a higher frequency of attachment loss for surgical procedures than
for either eurettage or scaling and root
planing. G a i n s in this category were
practically non-existent, and aimosl
9 0 % of the treated sites were recorded
as unaltered when changes oi' > 3 mm
were used as the basis for the counts.
When pockets o f 4 - 6 mm (Class II) were
considered (Tables 7, 8), a higher %
oi' attaehmenl losers than gainers still
or piickets 4-6 m n b Irealmen meth )d
isl vear
2nd yea,
3rd year
4ili year
,.V difference S.D
,V dirferencc S.D
.V difference S.D.
,V d Terenee S.D.
H) g,e ,.c phase
V d (Te
maintenanee phase, although il apparently become sutbitized after the 3rd
yea r.
For the deep pockets, >7 mm (Class
IK), there was a considerable reduction
in pocket depth following the hygienic
phase, and even greater 1 year following
the various treatment modalities. The
greatest reduetion oeeurred following
pocket elimination or reduetion surgery
and the least following scaling {Table
5). For all methods, the pocket reduction stili remained significant after 5
years. However, the differences among
the methods of treatment were small
and not statistically significant.
8^1 r -(I TT* 0 K 80
K7 I 0 15* 0 58 78
80 L-o 11 0.67 80
89
1L 0.3-5* 0.61
F-10.879
/=< 0.000
r Sigmrieanl difference
L between means
' Specific treatment different from baseline /'<0.05.
80
-0.41*
-0.19*
-0.24*
0.70
0.84
0.85
83 f-0.79* 0.78
81 ri-0.37* 0.88
83 L -0.43* 0.86
75
73
7^
-0.10
0.75
83
•h
F-2.443
P< 0.0642
L -0.26* 0.26
F-6.7331
/ ' < 0.0002
5th year
.••V
-0.70'' )M 72
- 0 . 5 1 * i.i 1 70
-0.44* 0.98 12
L-0.33* 0.67
P-2.3059
/ ' < 0.0769
11
iflerenee S.D,
r--0.7l* ).76
1-0.27* 0.9/
0.54* (1.97
-0-32* 0.12
i--4.0306
/'<().O079
448
Ramfjord cl ai
unsi from baseline lor pockcls
Tahk' 5. Pocket reduction (palicn
Treatment
st ve;
mean
,V differenc e
.eket d i m .
11
ilvgienic ph
,V diffei-ence S.D.
S5
~> 22 I ^S
^,
7Q
in o d . W i d m a n
30
4.17*
?.57'
3.41*
mm by treatment method
2nd year
mean
S.D.
,3rd year
mean
,V difference S.t>
S.D.
,V
1.57
-)()
3 43*
1.69
Ml
29
3.32*
1 68 30
1 S7
i.35 29
2 76*
1.65
difference
1 37"
3.38*
3-36*
3.10*
1.77 27
1.89 26
1.71 2y
2.9!*
2.02
r3.77*
1.2.41*
3.20*
sc almc and
33
1.91
F-3.0,s
P <().()}
10
r Siirmficanl if fere
L between TIIL ins
d Tercnl ironi
* SpL'til'ic Ire;
liie l'<.
).O5.
5^^
0.91
I si ve
mean
ISC
0.95
P K-k. elim.
31
od. Widman 30
alim; and
r( ol planing 33
ir
]•
29
_ 2.52*
mean
/V differenee S.f).
1.75 26
1.77 24
1.61 27
1.97
28
3.53*
2.28'
3.13'
.69
1.87
.56
2.92*
2.17
F < 0.3599
F-4.3524
/'<0.72fi2
F- 3.4665
/'-£O.O188
F-2.t)053
P<O.I180
2nd vear
mean
3rd vear
mean
4th vear
mean
5lh vear
mean
F-1.OS 13
T- 12.IS / ' - . o 0001
iiv'ii.e.iicpl
30
5tb year
4|li year
mean
,V differenee S.D,
0.69'
1.39
29
0.3O
1.40
30
0.36
1.44
27
0,54
1.81
26
0.43
1.83
.16*
1.66
29
O.W*
1.60
32
0.5S*
1.57
29
0.50
2.40
29
0.79
2.51
27
0.63
2.12
0.47
2,49
30
0.68*
1.78
30
0.30
1.73
28
0.59*
1 95
SL
F- 1 OS 0
/'•-().3^ 99
T 7.12 /'- 0. K)OI
* Specific tre; I men <.! Tereni from has li
elimination s h o w e d the most stable results. However, the frequency distribution d a t a should he considered with
I lew sites were included,
it is w o r t h noticing that atHowi
tachnieni loses of > 2 or of > .3 mm
were re tively rare. This indicates that
very few ites with pocket depth of > 7
m m , reg, (.iless of method of treatment,
lost attai mient of 2 mm or m o r e over
5 years.
Of the original 9(t patients with 2401
teeth, 28 teelh were lost. 72 patients with
gaming (^y losinsz
2 m m or m ore ol cl inical;attach me 11t
1- 3 mm
,V
gain
pockel elimln; I lion
1497
curctla ge
1611
modifii sd Widitn;m Map
15.=.4
18
1.2 "o
22
1.4%
18
1,3%
26
1.6%
scaling and l oot planing
1604
F 0.36778
/>< 0.7764
c- !'< ),05.
appeared, btit the iidv;int:ige for cureltagc and scaling with root pliining sile^
was less noticeable thiiti for the I -.'' mm
pockets, ir. however. :i v;iri;ition of > 2
mtn was used for the CLit-o!T poitit. scalitig and root planing had a higher "/<i
o\ attachtnent gaitiers than any of the
other procetlures. ami Ingher than
curettiige. whicii was not the ease when
tnean values were cotisidered (Table 4).
These diiTerenecs however, were small
and the % oi sites was very similar for
iill o r ihc 4 pwccduvcs.
K.r Cla.ss HI
pockets. ( > 7 m m ) , there were more
sites which gained attachtiieiit thati lost.
Curettage had the highest % O'L both of
attachment gain and loss, while pocket
7 «/)/«•:". Freqiileiicv di.stribntio
piohin {! dt^p!h
F-0.7834^
/'<0.505
F 0 3331':
P-- O.SOK
F--0.4907
/'••' O.(>89
after ,S vears acco rding to trtlatment and initial
7 1 2 mm
4-6 mm
same
loss
,V
gain
9{)M
571
772
51
60.7"',,
38.1%
1048
541
65.1%
33.6%
986
1881 teeth initially, completed the 5year study. They lost a total of 22 teeth
(3 during surgery, 1 d u r i n g the Isl year
of maintenance, 0 during the 2nd year,
10 during the 3rd year., 3 during the 4th
year, and 5 during the 5th year). 17
of these tceih were lost for periodontal
reasons, a n d 16 of the 17 teeth had furcation involvement ai baseline. Thus.
less than ) % o'i (he treated leeth were
lost for periodontal reasons during the
5 years. Of these 17 teeth, 5 had been
treated originaDy with pocket elimination, 4 with eurettage, 6 with modiiied
W i d m a n tlap, a n d 2 with scaling and
root planing. 5 teeth were extracted for
non-periodontal reasons.
550
63.4%
.15.4%
1O'J2
68,1 "/„
486
30.3%
6.6'!-'i,
659
60
9.1"/; ,
649
46
7,1 •>/.
'j
705
Si
Il.5"/i.,
same
loss
495
2''6
64.1 %> ^9.3%
450
149
68.3 "/I1 22 6%
422
181
65.0^'^; 27.9%
475
149
67.4"'i. 21.1%
A'
gain
same
loss
65
12
18.5%
18
32.7%
14
22.6%
18
29,5%
46
70.8%
31
56,4%
43
69.4%
34
55.7%
7
10.8%
6
10.9%
55
62
61
s
fi,]%
9
14.8%
Pcriodonuil therapy afier 5 years
449
Table 8. Frequency distribution olsite^ gaining oi losing 3 mm or more of clinical aiiacimicnl iit'icr 5 years jccordmg lo Irealmcut and inilial
probing depth
pocket eliminalion
-V
gam
same
loss
A'
gain
same
loss
A'
gain
same
loss
1497
4
0.3%
4
0.2%.
3
0.2"/,,
3
0.2%
1288
86.0"--',,
1441
89 4%
1359
87.5"-',,
1453
90.6%
205
n.7%,
166
IO..i"/l,
192
12.4%,
148
y.2"';,
772
14
1.8"-'(,
18
2.7"/u
12
1.8"'r,
19
2,7"/,,
684
88.6%
588
,S9.2"--',i
569
S7.7",,
629
89,2"--',,
74
9.6"--,,
53
8.0"/'^
68
\0.?%
57
8.l"--;t
65
5
7,7%,
M
l6.4'!-'ii
^
11.3",,
9
I4.S'\.
59
90.8"'D
42
76 4"-,,
52
83.9"-!.
49
80.3"'',.
I
1.5";
4
7,3"--;
3
4.8"-i
3
4.9"-^,
cureltage
1611
modiHed Widman flap
1554
sealing and root planing
1604
Retreatment
When bleeding and pus secretion following mild provoeation oceurred 2-3
weeks after prophylaxis, the periodontist decided what teeth to retreat and
which modality o( retreatment to nse.
Flap surgery was not performed in
quadrants which had been treated with
curettage or scaling alone. Some teeth
with overt bleeding tendcticy but without pus were aiso retreated. Some teeth
with apparently hopeless fureaiion involvement were not retreated. A lotal
of 10] ieeth in 24 patients were retreated. The originaltreatnient of these teeth
had been;
surgical pocket elimination - 16
teeth;
eurettage - 20 teeth;
ttiodifted Widrttan flap- 21 teeth;
scaling and root planing - 44 teeth.
7 teeth in 2 patients were retreated
with modified Widntan llap surgery; all
of the others were retreated with,sealing
and root planing, with or without curetlage and usually- under local anesthesia,
Of the retreated 101 teeth, only 2
were subsequently lost, 1 of these teeth
had orminally had surgical pocket elimination," the other had had eurettage,
and they were both retreated with sealing and cureltage,
atliichmcnl
659
649
705
a p p a n n i i s d u r i n g the
re-
peated rceall se.ssions. However. 1 year
after treatmeril. there was a signiheantly
greater loss for poeket elimination and
modified Widman flap. M(^st of these
differences were maintained over 5
years, indicating some inliuence of lite
modality of Ireattiiem (Table 2). The
loss continued during ilie .5 years, but
the initial differences between Ihe ireatmem groups beeamc smaller over time,
This may indicate that in addition to an
initial loss related to Ireatmeni. ihere
was a gradual I()ss during the maintenance phase. The pocket depth stayed
close lo baseline trom years .3- 5 {Table
1). indicating ihat Ihe allachmcnt loss
observed was acei>mpanied by gingixal
leeession. It was shown by O'Leary et
al. (19711 thai most gmgival recessions
occurred in patients wilh efficient oral
hygiene, and thus a mechanical effect of
oral hygiene procedures may be suspeeled, A preliminary comparison of
plaque indices and loss ol' allachmcnl
for these shallow pockets indieated thai
ihe loss of allachment was not grealer
with plaque index 0 ihan wiih plaque
index of 2, which would tend to rule oul
recession from ovcr/ealous toothbrushing as a cause of the loss, Data related
lo plaque scores will be reported in a
separate paper. This loss of clinical atlachment for shallow pockets during
Discussion
treattTtent and maintenance appears lo
fhe gradual loss of atlachmenl over occur at a faster rale ihan the common
ime for site,s wilh shallow pockets, re- loss associated with aging in well-cared
.ardless of initial treatment is a disturfor populations (Suomi et al, 1971, Loe
ling but common observation (Hill et et al, 1978), Over the years, there ap:1. 1981. Pihistrom et al. 1981. Lindhe, pears lo be an equalization proeess of
•1 al, 1982, Isidor et al 1984. Knowles gineival height taking place after peri-tal, 1979), It has been suggested (Lind- odo^ntal treatment. This equalization
>e et al 1982) that this phenomenon
has also been pointed out by Rosllng
nay be a consequence of the frequent
et al, (1976) (or intrabony lesions. This
nechanical disturbance of the marginal
natural tendency for reeontouring and
55
62
61
r e b o u n d may explain sonte of the re-
eession associated vvHh shallow ereviees,
sinee they initially had the least loss ol
attaeltntenl. However. Ironi this and
long-term studies (l.nulhe et al 1982.
Baderslen et al. I'J84). il appears that
[he minute k^ss of attachment in shallow
pocket does not represent a threal to
the tuuire maintenance {^f the dentilion.
The magnitnde of pocket reduction
for 4 6 mm pockets (Table 3) varied
significantly according to the method
oi' treatment for the lirst 2 years postoperativeiy. However, alter 5 years.
(here was no difference in reduction after scaling compared with the reduction
after pocket elimination surgery, and
some of the differences whieh were statistieally significant appeared to be too
small to be of any elinieal signitleance.
Although the pockets were significantly
reduced compared to baseline, after 5
years, the reduction was mmmial heyond that which occurred as a result of
the initial, presurgical hygienic phase of
treatment. When attaehmem levels were
considered for the 4 6 mm pockets
(Table 4), the long-term effect was a
slight loss of attachment. This loss of
attachment was significantly more pronouneed for pockcl eliminalion surgery
than for the eurettage and the sealing
procedures. These findings differ from
what were reported in a previous study
(Knowles et al, 1979), and a further
examination of the data revealed that in
the present study, the majority of Ihe
pockets in the 4-6 mm class was 4 mm,
while in the other study (Knowles et al,
1979), there was in this probing depth
class a much higher % of 6 mm deep
pockets. This dilTerenee in response to
various treatment modalities related to
poeket depth has been discus,sed in detall in a recent paper by Lindhe et al.
450
Ramfjord e! al.
(1982). A slight additional attachment
loss (Table 4) iippearcd in this pocket
depfh class after 5 years for aW ol' the
treatment modalities. U is important lo
note that the 5-year effects on the attachmeni levels for 4-6 mm pockets
were almost identical for curettage and
for scaling. Attachment level responses
(or scaling and for curettage for these
pockets were significantly better than
(br pocket elimination surgery. Since
scaling and rool planing are basic procedures for all periodontal therapy, and
gave re.stilts that were a.s aood or beilcr
than for suraical techniques (or 4 6 mtn
pockets, scaling and root p(aning appear to be the treatment of choice for
sites with 4 6 mm deep pockets. When
access for effective scaling cannot be
gained without stirgery. as in the presenee ot furcation involvement, flap surgcry for ac'ce.s.s is obviou^vly indicated.
Similar, or even better results. foHowing
scaling in pockets of this depth have
been reported over 6/. years by PihlStrom et al. (1984). They reported signifieant gain ot aliaehment alter scaling
in sites with 4 6 mm deep pockets for
the enttrc period of observation. The
attachment levcis Tor the deep pockels
(C'lass III > 7 mm) were tnaintained
above the baseline level for all ot the
tre;Jlment meiiinds wiih no .sigjuncant
thfterence amotig thetn (Table 6).
Changes in attachment levels from yearU>-year were very small as reported by
others (Pihistrom ct al. 1984. Knowles
el al. 1979) Thi--trend of sunilar results
trom the v.iruuis procedures lend to be
;it variance wuh ;.i comm^.mK' expiessed
beht'i thai .sc;,|n)y aiu! rool p);)!iiiig are
itnpiopei procedure^ to u>c lu Uie treatmeni ot deep pickets. lUiwcver. Uic
present results seem to conlirm tmduigs
by BaUersten et al. (l*-»84) tor singlerooted teeth.
cation that removal of accretions was
less successful foUowing scaling than
following the other methods. However,
the longitudinal results of scahng, were
as good as for the other procedures with
regard io maintenanee of attaehment
level and prevention of loss of teeth.
Furthermore, the retreatment by scaling
was highly successful in arresting the
progress of the attachtnent loss for practically yll o/the retreated teeth, The los.s
of teeth was lower in this study than in
previous ^.tudies where no retreatment
by iJie periotlontis! was performed eseept for treatment of abscesses (Know(es et al. 1979), It was also inleresting
to note that \h of the 17 teeth lost from
periodontal disease had furcation involvement, Thts confirms the assumption that the prognosis for single-rooted
teeth is better than lor tce\h with furcation itivolvemenl.
The well-known probtems associated
with less than perfeet reproducibility of
probing pocket measurements tiiakes a
% comparison of loss or gain or attachment tinted wiih unavoidable errors, especially for the deep pockets, fhe
chances for tnaking errors decrease as
the level ol'tolerance increases, but such
errors may oecur even at 3 mm levels.
This makes standardization of the error
difficult, and one can never property
determine how many apparent "gains"
or "losses" were in tact measurement
errors.
It should be understood that the resuits listed in Tables 7 and 8 do not
indicate that the sites presented under
""simic" had the same measurements
each time, on}) that the variations were
\css than Z mm. Even if \he measurements were the same, the allachtnent
levels may have shown variations due
to the inhereni errors in the use of the
probe. It should therelbre be aekaowl-
it is becoming increasuigly evident
thai ccMnplete removal ot all calculus
knid residual pktquc trom roo\ surfaces
exposed in deep periodontal pockets ts
not eommonly attained (Caffesse et al.
1985. Eaton et al, 198.^. Rabbani ei nl,
1*^S*)'
Data from res(;arch and clinical experience indicate that less deposits jre
left behind when root planing is done
after llap elevation than after"non-surgical"' subgingival sealing. The fact that
in this study, 44 teeth had lobe retreated
in the quadrants that inilialiy had been
scaled and root planed compared with
about 20 for the other treatment
methods, may also be taken as an indi-
edged that at the present time we can
only measure trends of attachment level
changes.
Speculations regarding time requirements for the various procedures cannot
be answered by data fwm this study.
All of the patients received initial sealing and instruction in oral hygiene by
a dental hygienist who spent from 5 to
8 h with each patient. Then, the periodontist was allotted an average of Wz
h to each quadrant for the treatment,
regardless oV which procedure he was
scheduled to per/brm.
Thus, in this study, there was no differenee in time spent for each proeedure, Tf one were to save tiine doing
surgery, compared with scaling and root
planing alone, the surgery would have
to be done without prescaiing in the
numerous shallow pockets where the resuits o\' scaling alone are often better
than after surgery (Pihlstrom et al.
1984). As a consequence, the most sensible clinical approach seems to be scaling
and instruction by a hygienist, with reexamination 4-6 weeks later by the dentist. If there is no bleeding from the
bottom of the pocket with gentle probing and no pus can be provoked, it can
be assumed that the progres.s of the disease is arrested and the area is ready for
maintenanee eare. It the site does not
heal, and bleeding and/or pus ean be
provoked, the dentist must decide what
procedure to use to clean that particular
rool surface. This will depend on access,
especially for furcations which are
u.sually more easy to reach during flap
surgery than during "non-surgical"
subgingival sealing. Deliberate soft-tissue curetlage does not seem to enhance
the results of sealing or root planing,
Unquestionably, tlap elevation will
facilitate access to the root surfaces with
furcation involvement or tortuous deep
pockets and shotild be used al (he discression of the operator. However, emphasis should be placed on thorough
.scaling and root planing inilialJy and at
the time of surgery. It also appears that
retreatment (with or without surgery)
should be a routine consideration beyond the "recall prophylaxis" or professionai tooth cleaning during the
maintenance phase of therapy. Mechanical periodontal therapy cannot be standardized a.s drug prescriptions, and the
results oVclinical trials will only indicate
probable outeome of various treatments
when performed under the standardised
conditions of the trial, and with personnel with simitar training.
_
. .
0"C usions
Scaling and root planing was the treatment of choice for periodontal pockets
of > 6 mm, provided hereby proper access to the root surface could be obtained. For pockets of > 7 mm, the resuits were similar for all of the 4
methods oV treatment examined. There
was no additional benefit from cnreltage over scaling and root planing,
Maintenance eare should inelude retreatment of pockets with persistant pus
Periodonlal
secretion a n d / o r bleeding. Regardless of
the modality of treatment, furcation involvement was the greatest hazard in
the prognosis, Retreatment was needed
more often after scaling and root planing than after the other proeedures but
with additional scaling, the results were
J
,
,
as good as tor any other procedure.
Zusammenfassung
E,n >Juhresver^leich zwiscln: 4 MndaluaWi
ik-r rarodoniulhc'luuunung
Mitder hier vorliegcnden Sludie wurdc beahsichligi. die ResultalL- der lblgenden 4 Modaliliilen parodonlaler Tht:rapie (Tascheocliminalion^- oder -reduktionschirurgic. die Teehnik dc^ modillzierlen Widnianlappcns, sul>
gingivale Kiircllage iind Zahnsldncnirerniing
mi! W-urzclglallimg) wahrend eiiies 5 .lalire
andauernden klinisehen Versiiclies/u bcstinimen. 90 Palienlen wurdeii behandell. Die Behandlungsmeihodcn wurden /ulailig fiir jeden dcr 4 Gehisscjiiadranien bcstimml. In jeliem 3. Versuehsmonat wurden die Ziihneder
Palienlen prolessioncll gcreimgl Die Tiefe
der Taschen und die .^ttachn!ennliveails warden einmal Jahrlich beurieilL 72 Palienk-11
staiiden wiihrend der gesamtcn Behandlungszeil /ur Verfiigung. ,Sov^nhl die Millelwerle
dor Tasehenliefen. der .Attachmentniveaus ais
aueh die prozentuale Verieilung der "Seilen"
mil AtiaehmenUerluslen vonV^2 mm und
>3 mm wurden milemander verglieheii. Hei
[-3 mm SondLcrungstiefe fiihiien sottohi
Xahnsteinentlernimg iind VVuivelglatumg al^
aueh die subgmgivale Kiircttage /LI signifikant weniger .Allachmentverlust al> die Tasehenelimination und die niodiH/ierle Widnian'sehe Lappenchirurgie. Bei 4-(-> mm tiekn Tasehen hatic Zahnsteinenifernung und
Wiir/elglatiung sovwe Kiiietiage liinsieiulieh
der Position des ,'\ilachments bessere Frgebnisse ah die chirurai^ehc Tasclieiieliminaiion.
Ik-iden7 I2minfaselienvuirdenkeineslat]sliseh abgesicherlen Unierschiede /wischen
den Rcsullaten der verschiedenen HehandiLingsmodahtaten geselieii.
Resume
Traiiemcnl parodoniah comparaison dc 4 modi-'s dc Iraiiemeni .sur ? ans
Le but du present travail etait d'evaluer pendant 5 ans par une etude clinique lcs rcsultats
ubtenus par traitement parodontal suivant 4
modes de traitemcnt differents (elimination
ou reduction ehirurgieale des poches. operation a lambcau de Widman tnodifice, curcta-
ge sous-gingival ct detartrage avec surfavage
radiculaire). Le traitemcnt a porie .sur 90 patients. Pour chaeun des 4 quadrants de la
I'tniche. les methodes dc trailement appliquees ont etc choisies au hasard. Les patients
^'"'•'^"•-"''^^ '^^^ 1"^^ -"* '""'•'^ " " netloyage den" " " ' I^'-^'^-^^'™"'--! '^' f ' mstructions d'hygiene bucco-dentaire. Les observations ont
nu etre m^ ees sur 1 s 5 • ••- -h 7'' •
—
—
iherupy afler 5 ycar.s
451
tienls. Les valcurs moyennes de la proi'ondeur des poches et du niveau de Taitaehe par
patient et la distribution de frequence des
loealisalions prcscntant une perte d'attache
de > 2 mm et > 3 mm onl eU- eomparecs.
Pour les profondeurs de sondage de i 3 mm.
le deiartrage avec surfa^age rad.eulaire, ains,
que le euretage sous-amgivai resultaieiii en
^ - t - I'-if i^ "' T -i' • • i
~—
—
~ —
"^^^^^^^^eS
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452
Ramf/ortJ cl al.
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'
'^'•'^•''"
Dr Sii-wcJ P Ramfjord
y ,if Mklni;a
Tlw U>i
Sriwol ol I
• les dilTcreiites mciAnn Arhor.