Periodontology 2000, Vol. 62, 2013, 218231 Printed in Singapore.

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2013 John Wiley & Sons A/S

PERIODONTOLOGY 2000

Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts

L I S A J. A. H E I T Z -M A Y F I E L D & N I K L A U S P. L A N G

Nonsurgical and surgical periodontal therapies have, for several decades, been and remain the basis of periodontal treatment concepts. However, one must be aware that the way we treat patients in 2013 is indeed different from how we treated them 30 years ago. We now have a greater understanding of the etiologic factors associated with periodontitis, the mechanisms involved in periodontal wound healing and the inter-relationship between patient factors (such as smoking and diabetes) and treatment outcomes. Technological advances have provided clinicians with a range of options for instrumentation. Furthermore, greater emphasis has been placed on the importance of patient-centered outcomes in clinical research. We have learned a lot during these past years, having been fortunate enough to learn from the experience of some very famous periodontists from all over the world. Research in periodontology has, for much of the last 50 years, exceeded that of any other dental specialty. In addition to the sheer volume of investigative work, education and teaching in periodontology have been underpinned by the critical evaluation of both old and new concepts. So what have we learned in relation to nonsurgical and surgical periodontal therapy, and what has changed over the past few decades?

tissue shrinkage, leading to pocket-depth reduction. In the early 1980s, the value of gingival curettage was challenged in a split-mouth clinical study where scaling and root planing was performed in all quadrants and was followed, 4 weeks later, by gingival curettage in two quadrants. Five weeks following treatment, similar improvements in periodontal tissue health were observed, regardless of treatment, with a reduction in probing depth and gingival inammation, and an increase in clinical attachment level (26). It was concluded that gingival curettage did not result in any additional improvement in periodontal tissue health and, as a result, intentional softtissue curettage was phased out.

Removal of contaminated root cementum

In the 1970s and 1980s nonsurgical periodontal therapy was performed using predominately hand instrumentation, with the aim being to remove supragingival and subgingival calculus and plaque, and contaminated root cementum. Historically it was thought that aggressive scaling and root planing was required to remove bacterial products (lipopolysaccharide endotoxin) bound to the contaminated root surface (22). We have since learned from in-vitro studies that bacterial endotoxins are weakly adherent to root surfaces and therefore excessive removal of cementum is not required to remove bacterial products (14, 45, 75, 79). The concept of removal of contaminated cementum and hard-tissue deposits as the key to successful periodontal treatment was challenged in a clinical study published in 1995 (73). In this study mucoperiosteal aps were raised following supragingival debridement and oral-hygiene instruction, and

Gingival curettage
In the 1970s, scaling and root planing combined with gingival curettage was a common procedure for periodontal therapy. Gingival curettage, dened as the removal, by means of a curette, of the inner surface of the soft-tissue wall of the pocket, was performed in order to promote new attachment and

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bone was recontoured to eliminate angular bony defects. While the control teeth were thoroughly root planed, the test teeth were not instrumented other than to chip off large calculus deposits using the tip of a scaler, followed by irrigation with sterile saline. Flaps were apically repositioned at the level of the bone crest. One year after therapy, clinical and microbiological parameters showed similar improvements at test and control teeth with reductions in probing depths and in the proportions of periodontal pathogens (Porphyromonas gingivalis, Fusobacterium sp. and Campylobacter rectus). It was concluded that the reduction of selected gram-negative anaerobic organisms in the subgingival plaque is a more important element for the success of periodontal therapy than is the removal of contaminated root cementum and mineralized deposits by root planing (73). Furthermore, in an experimental study it was observed, using electron microscopy, that the epithelial attachment on calculus that had been treated with chlorhexidine gluconate had the same ultrastructure as normal epithelial attachment on various tooth surfaces (60). Periodontal healing occurred, even in the presence of calculus, provided that the subgingival bacterial plaque had been removed. From this we learned that while the removal of calculus is important because it is a major plaque-retentive factor, the intentional removal of root substance and contaminated cementum is not required for successful treatment. Thus, the term root planing is now frequently referred to as debridement.

ing adjunctive antimicrobials via a systemic, local or topical route.

Evidence-based periodontology
Evidence-based periodontology has been described as a tool to support decision-making and integrate the best available evidence into clinical practice (80). The systematic review, as opposed to the traditional narrative review, provides a comprehensive appraisal of research using transparent methods whilst aiming to minimize bias (81). In 2002, the 4th European Workshop on Periodontology was held in Ittingen, Switzerland, and for the rst time for a major workshop, all reviews were carried out as systematic reviews. These were discussed by a select group of 60 periodontists, most of whom were unfamiliar with the new system, so the learning curves were steep. After much discussion and debate, the systematic reviews were accepted and published in the Journal of Clinical Periodontology; from this, some old concepts were unlearned, some were conrmed and some new ones were introduced. The introduction of the systematic review process to periodontology has also inuenced the way in which research has been designed and reported over the past decade. The randomized controlled trial, considered to be the highest level of evidence, has been strongly promoted to be used when appropriate. The Consolidated Standards of Reporting Trials guidelines have also been more widely promoted. Furthermore patient-based analyses, as opposed to periodontal site-based analyses, are now considered as the standard. Systematic reviews published in the last decade have addressed a number of focused questions related to nonsurgical and surgical periodontal therapy. This has led to a greater understanding of the combined results of research published over previous decades, and to identication of areas where further research is required.

Periodontal biolms
The end of the 20th century saw some great advances in techniques for microbial analysis. With the use of molecular identication techniques, checkerboard DNADNA hybridization, biolm models, uorescence in-situ hybridization and confocal scanning laser microscopy, our understanding of the complex nature, composition and role of periodontal biolms in health and disease expanded signicantly (65, 66, 115, 118, 119). Recent elucidation of the human oral microbiome and the identication of new species associated with periodontitis have established that the periodontal microora is extremely diverse (24, 128). These advances have had a signicant impact on microbial diagnostics and on our understanding of bacterial cell interactions and antimicrobial-resistance mechanisms. In particular, they underpinned the necessity for the thorough mechanical removal or disruption of the periodontal biolm when prescrib-

Nonsurgical periodontal therapy

Manual debridement vs. machine-driven debridement
Most studies in the 1970s and 1980s were conducted using hand instruments, including curettes, scalers and hoes, and this was considered the gold standard. Since the 1990s, the use of powered instruments, including the magnetostrictive and piezoelectric

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ultrasonics, the linear oscillating device (Vectorsystem) and sonic instruments, have become increasingly popular, with claims of increased efcacy and efciency (123, 130). Some studies have reported a reduced time for scaling and root planing, improved access, less damage to the root surface and less discomfort for the patient using slimline tip designs (12). However, overall, similar positive clinical and microbiological outcomes were achieved with the use of machine-driven and hand instrumentation, and even newer designs of powered instruments have so far not shown any further benet when compared with other ultrasonic devices in nonsurgical periodontal therapy (48, 123, 130). Studies by Badersten and co-workers in the 1980s, using hand instruments, found that the effectiveness of calculus removal is inuenced by initial pocket depth, tooth type and surface, as well as operator experience (57). As probing depths increase, elimination of calculus and associated biolm becomes more challenging, with studies reporting a higher percentage of residual calculus on root surfaces in pockets with probing depths of >6 mm (up to 44%) compared with pockets with probing depths of 4 5 mm (up to 29%; 30, 92). These ndings have been conrmed in studies evaluating machine-driven instrumentation (130). Adverse outcomes following nonsurgical debridement may include patient discomfort, root-surface damage and root-surface sensitivity (48). Overzealous debridement should be avoided in sites with shallow probing depths (<3 mm) to avoid trauma and subsequent attachment loss and root-surface sensitivity (57).

included studies and concluded that further welldesigned studies are required to determine the effectiveness of the Er:YAG laser for nonsurgical treatment of chronic periodontitis (107).

Photodynamic therapy
Antimicrobial photodynamic therapy, used alone or as an adjunct to scaling and root planing, was introduced in the late 1990s and involves the use of low-power lasers with appropriate wavelength to target microorganisms treated with a photosensitizer. A systematic review published in 2011, which included seven randomized controlled trials with a parallel design, concluded that the use of photodynamic therapy adjunctive to scaling and root planing provides short-term benets, but microbiological outcomes are contradictory (110). Six of seven studies included in the review evaluated photodynamic therapy plus scaling and root planing vs. scaling and root planing alone, whilst two studies compared photodynamic therapy with scaling and root planing. No evidence of the effectiveness for the use of antimicrobial photodynamic therapy as an alternative to scaling and root planing was found. The authors concluded that long-term randomized controlled trials reporting data on microbiological changes and costs are needed to support the long-term efcacy of adjunctive antimicrobial photodynamic therapy (110).

Pocket irrigation with antiseptics

The use of antiseptics in nonsurgical periodontal therapy may include pocket irrigation. Antiseptics, including povidone-iodine, dilute sodium hypochlorite and chlorhexidine gluconate, have been used for periodontal pocket irrigation following debridement with the aim of suppressing the biolm. Some studies have shown further reduction in periodontal pathogens and probing depths compared with scaling and root planing alone (95, 97, 102, 103). As gingival crevicular uid within a periodontal pocket is replaced every 90 s, the effects of antiseptic pocket irrigation are only transient and the risks of antiseptics penetrating the gingival tissue and causing systemic effects are minimized. Nevertheless, care should be taken to check the patients medical history as povidone-iodine can cause allergic reactions and should not be used in patients with thyroid dysfunction or during pregnancy or breastfeeding (116). While a recent systematic review shows that adjunctive use of povidone-iodine irrigation of

Lasers
In the 1990s the erbium-doped:yttrium-aluminiumgarnet (Er:YAG) laser was introduced for periodontal therapy; however, the clinical effectiveness of the Er:YAG laser remains controversial. A systematic review, including ve randomized controlled trials of split-mouth design, evaluated the effectiveness of the Er:YAG laser in the treatment of chronic periodontitis as an alternative therapeutic strategy to scaling and root planing (112). Meta-analyses showed no statistically signicant difference in clinical attachment gain, probing-depth reduction or change in gingival recession, indicating no evidence of a superior effectiveness of the Er:YAG laser compared with scaling and root planing (112). The results were in agreement with an earlier systematic review, published in 2008, which observed heterogeneity of

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pockets during nonsurgical periodontal therapy may offer a small increase in probing-depth reduction (104), overall the use of antiseptic irrigants delivered in conjunction with powered instruments has not shown any advantage (106).

Full-mouth disinfection
In the 1990s the convention of staged debridement with quadrant or sextant instrumentation at 1- to 2week intervals was challenged with the introduction of the full-mouth disinfection approach aimed at preventing re-infection from untreated pockets (90). The full-mouth disinfection protocol includes fullmouth scaling and root planing within 24 h, in addition to twice-daily chlorhexidine mouthrinsing, tongue scraping, chlorhexidine tonsil spraying and subgingival irrigation with chlorhexidine three times within 10 min and repeated after 8 days. The fullmouth scaling and root planing protocol includes full-mouth scaling and root planing without antiseptics. Two systematic reviews, combining the results of a number of randomized controlled trials, concluded that all three treatment approaches may be recommended for nonsurgical periodontal therapy (25, 53). Thus, while technological advances have introduced a range of different instruments and novel techniques over the past decades, the critical factor for successful nonsurgical periodontal therapy remains the thoroughness of root debridement and the patients standard of oral hygiene, rather than the treatment modality. Therefore, operator and patient preference may play a large part in determining the choice of instrumentation for nonsurgical therapy, including the choice between staged debridement, full-mouth disinfection and full-mouth scaling and root planing.

time. Although some of these locally applied antimicrobial systems have been shown to offer some benet over scaling and root planing alone, the effects were modest and mostly short term. In a systematic review published in 2003, a meta-analysis of 19 studies that included scaling and root planing and local sustained-release agents compared with scaling and root planing alone, indicated signicant adjunctive probing-depth reduction or clinical attachment gain for minocycline gel, microencapsulated minocycline, chlorhexidine chip and doxycycline gel (39). In a subsequent systematic review, published in 2005, the most positive results occurred for adjunctive tetracycline, minocycline, metronidazole and chlorhexidine, with modest improvements in probing-depth reductions compared with scaling and root planing alone (11). The authors questioned the clinical signicance of these small improvements. Furthermore, some of the subgingival antimicrobialdelivery systems developed for clinical use are no longer available.

Nonsurgical therapy and adjunctive systemic antimicrobials

The adjunctive use of systemic antimicrobials for periodontal therapy has been discussed for many decades. Owing to the heterogeneity of the study designs employed to assess the efcacy of systemically administered antimicrobial agents, it is difcult to reach a conclusion regarding whether or not there are clinical benets, the type of drug that should be prescribed and the dose, and the most effective timing of drug administration in relation to mechanical therapy. Most studies have evaluated systemic antimicrobials in conjunction with nonsurgical debridement, the rationale for their use being the suppression of periodontal pathogens persisting in biolms in deep pockets, root furcations and concavities or residing within the periodontal tissues. In particular the periodontal pathogen Actinobacillus actinomycetemcomitans has been reported to be difcult to eradicate with nonsurgical therapy alone (72, 74, 87). The persistence of A. actinomycetemcomitans and other periodontal pathogens has been associated with continued progression of disease compared with improved clinical outcomes when these organisms are not detected following therapy (21). Despite the obvious possible benets of targeting periodontal biolms with antimicrobials there has been a consensus that, owing to the risk of adverse effects, including the development of bacterial antimicrobial

Nonsurgical therapy and adjunctive local antimicrobial delivery

Local delivery of antibacterial agents into periodontal pockets has been investigated since the late 1970s, and various antimicrobials and delivery systems have been developed with the aim of maintaining high levels of antimicrobial agents in the crevicular uid with minimal systemic uptake. All are intended for use as adjunctive therapies, with scaling and root planing providing substantivity of an antimicrobial system at an effective concentration of drug over

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resistance, interactions with other drugs and possible allergic reactions (91, 108, 125), systemic antimicrobials should be used in select cases where microbial diagnostics indicate the presence of high levels of periodontal pathogens (A. actinomycetemcomitans and P. gingivalis) or in patients diagnosed with aggressive periodontitis. The use of adjunctive systemic antimicrobials for nonsurgical treatment of chronic or aggressive periodontitis was evaluated in two systematic reviews: one in 2002 (43) and the other in 2003 (38). From the limited meta-analyses that could be performed, a statistically signicant additional benet for spiramycin (probing-depth change = 0.41 mm) and amoxicillin plus metronidazole (clinical attachment change = 0.45 mm) in deep pockets (probing depth >6 mm) was observed (43; Table 1). We learned that systemic antimicrobials, in conjunction with scaling and root planing, can offer an additional benet over scaling and root planing alone in terms of probingdepth reduction, clinical attachment gain and reduced risk of additional clinical attachment loss. Herrera et al. (43) concluded, in their systematic review, that patients with deep pockets, active or progressive periodontitis or a specic microbiological prole might benet from adjunctive systemic antimicrobials. The authors, however, cautioned that the evidence was limited and that the decision to prescribe systemic antibiotics should be made on an individual patient basis, taking into account the possibility of adverse events. Haffajee et al. (38) concluded that systemically administered antimicrobials were uniformly benecial in providing an improvement in clinical attachment gain when used as adjuncts to scaling and root planing. Overall, adjunctive systemic antimicrobials provided a mean benet, at 6 months, of clinical attachment change of 0.29 mm in shallow pockets (probing depth <4 mm) in seven (87%) of eight comparisons, of 0.29 mm in moderate pockets (probing depth 45 mm or 4 6 mm) in eight (80%) of 10 comparisons and of

0.45 mm in deep pockets (probing depth 6 mm) in 19 (83%) of 23 comparisons (38). In the past decade there has been further evidence to support the use of systemic antimicrobials, in combination with nonsurgical debridement, for treatment of patients with advanced disease and deep pockets (probing depth >6 mm) with the aim of reducing the need for additional therapy. While a range of systemic antimicrobials, including azithromycin (23, 36, 67, 105, 117), spiramycin (3, 8), tetracycline (3, 37, 41, 55, 87, 93), clindamycin (64, 113), doxycycline (28, 82, 113), metronidazole (17, 54, 61, 62, 83, 85, 86, 100, 113, 120, 131, 137), amoxicillin and clavulanic acid (37, 64, 89, 132) and amoxicillin (100), has been included in clinical studies, the combination of metronidazole and amoxicillin has recently been the most widely documented (9, 10, 15, 27, 35, 68, 69, 100, 114, 121, 127, 133, 135, 136) for adjunctive treatment of chronic and aggressive periodontitis. Cionca et al. (15) found that systemic metronidazole, combined with amoxicillin, signicantly improved the 6-month clinical outcomes of full-mouth nonsurgical periodontal debridement, thus signicantly reducing the need for additional therapy. Ten years after the rst systematic reviews were published, a large multicenter randomized controlled trial conrmed the adjunctive benet of the combination of amoxicillin and metronidazole with scaling and root planing on clinical attachment gain and probing-depth reduction for the treatment of moderate chronic periodontitis (32). At 3 months, scaling and root planing alone resulted in pronounced probing-depth reduction at sites with initially deep pockets (probing depth 5 mm) and some clinical attachment gain. While adjunctive antimicrobials did not improve the clinical outcomes at 3 months, at 24 months there was signicantly more clinical attachment gain (0.5 mm) and probing-depth reduction (0.5 mm) in the group who received adjunctive systemic amoxicillin and metronidazole.

Table 1. Adjunctive systemic antimicrobials for nonsurgical treatment of chronic or aggressive periodontitis in deep pockets. Initial probing depth >6 mm.
Drug Spiramycin Amoxicillin metronidazole Variable Probing-depth reduction Clinical attachment gain Pooled estimate 0.41 mm 0.45 mm 95% condence interval 0.080.73 0.190.71 P-value for estimate 0.014 0.001 References (3, 8) (10, 29)

Meta-analyses of the differences in treatment effect between scaling and root planing and scaling and root planing plus systemic antimicrobials. From Herrera et al. (43). Studies include patients diagnosed with either chronic or aggressive periodontitis. Pooled estimate represents the difference (in mm) in favor of scaling and root planing plus the systemic antimicrobial therapy.

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Smoking reduced clinical attachment gain and probing pocket-depth reduction in both treatment groups (32). A recent systematic review included studies (randomized controlled trials and case series) in patients diagnosed with aggressive (1, 2, 9, 13, 34, 35, 42, 49, 51, 63, 69, 76, 99, 124, 127, 135, 136) or chronic (10, 15, 16, 27, 31, 32, 70, 71, 78, 114, 126, 133, 134) periodontitis, and aimed to estimate the size of the effect when systemic amoxicillin and metronidazole were combined with scaling and root planing (138; Table 2). An indirect comparison was made with data from another review that analyzed the overall effect of nonsurgical therapy alone (18). The authors concluded that the adjunctive use of amoxicillin and metronidazole resulted in additional clinical benets compared with scaling and root planing alone (18, 138). Another systematic review, published in 2012, included six randomized controlled trials (9, 35, 69, 127, 135, 136) in patients with aggressive periodontitis who had been treated with scaling and root planing, alone, or in combination with amoxicillin and metronidazole (111). The results of the meta-analysis analyzing full-mouth data showed signicantly more clinical attachment gain (0.4 mm) and probing-depth reduction (0.6 mm) in favour of full-mouth scaling and root planing and systemic amoxicillin and metronidazole with no signicant risk of adverse events (Table 3).

A systematic review including four randomized controlled trials (27, 68, 114, 125, 133), which evaluated the effect of systemic amoxicillin and metronidazole in combination with scaling and root planing in patients with chronic periodontitis, also reported a clinical benet of this antibiotic combination compared with scaling and root planing alone (109). The results of the meta-analyses showed signicantly more clinical attachment gain (0.2 mm) and probingdepth reduction (0.4 mm) in favor of scaling and root planing in conjunction with amoxicillin metronidazole. No signicant differences were found for bleeding on probing or suppuration [Sgolastra et al. (109); Table 3]. Thus, in 2012 we have a greater body of research to support the adjunctive use of some systemic antimicrobials in nonsurgical periodontal therapy. The main effect of this adjunctive benet is observed in patients with deep pockets (initial probing depth >6 mm) or in patients diagnosed with aggressive periodontitis. The most well-documented systemic antimicrobial drug regimen is the combination of amoxicillin and metronidazole, which is most commonly administered for 714 days at the completion of scaling and root planing. The prescribed dosage varies from to 250500 mg of amoxicillin three times a day and 250400 mg of metronidazole three times a day. This, however, does not mean that indiscriminate use of systemic antimicrobials should be advocated. The decision to use adjunctive systemic antimicro-

Table 2. Probing-depth reduction (A) and clinical attachment gain (B) (pre- and post-treatment) following scaling and root planing in conjunction with the combination of amoxicillin and metronidazole
Baseline probing depth Weighted mean difference standard deviation (mm) 95% condence interval References For comparison (scaling and root planing alone) Cobb (18)

(A) Probing-depth reduction 46 mm >4 mm 6 mm 7 mm 1.47 0.22 2.17 0.62 2.59 033 3.72 0.66 1.521.42 2.32.04 2.652.53 3.833.61 95% condence interval 1.242.73 1.401.58 1.541.78 2.512.81 (34, 35, 76, 133) (15, 16, 32, 70, 98) (1, 124, 126, 134) (13, 34, 35, 51, 76, 98, 133) 2.16 References For comparison, Cobb (18) 1.29

Baseline Weighted mean probing difference standard depth deviation (mm) (B) Clinical attachment gain 46 mm 1.31 0.33 >4 mm 1.49 0.42 6 mm 1.66 0.66 7 mm 2.66 0.88

(51, 70, 71, 124) 0.55 (15, 16, 32, 70) (1, 126, 134) (13, 34, 35, 51, 76, 98, 133) 1.19

From Zandbergen et al. (138). Results presented according to initial probing-depth categories. For comparison, data from Cobb (18), describing the pre- and post-treatment effect of scaling and root planing alone, are presented. Studies include patients diagnosed with either chronic or aggressive periodontitis.

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Table 3. Clinical therapeutic efciency of scaling and root planing vs. scaling and root planing plus systemic amoxicillin + metronidazole in patients with chronic periodontitis* (A) (109) and aggressive periodontitis (B) (111)
Full-mouth analysis (A) Chronic periodontitis Clinical attachment gain Probing-depth reduction Full-mouth analysis 0.21 0.43 Mean difference (mm) 0.42 0.58 0.020.4 0.240.63 95% condence interval 0.230.61 0.390.77 <0.05 <0.05 Mean difference 95% condence P-value for estimate in favor of scaling (mm) interval and root planing + amoxicillin metronidazole

P-value for estimate in favor of scaling and root planing + amoxicillin metronidazole

(B) Aggressive periodontitis Clinical attachment gain Probing-depth reduction <0.00001 <0.0004

*From Sgolastra et al. (109): randomized controlled trials included refs (27, 68, 114 and 133). Follow-up varied from 3 to 24 months. From Sgolastra et al. (111): randomized controlled trials included refs (9, 35, 69, 127, 135 and 136).

bials should be made on an individual basis, and adequate debridement, good oral hygiene and maintenance care are still the most important criteria for successful treatment outcomes. The reliance on patient compliance must be taken into account when considering the use of adjunctive systemic antimicrobials.

Surgical periodontal therapy

In the 1970s and 1980s we learned, from some important clinical trials, that nonsurgical periodontal therapy is effective in eliminating inammation in deep pockets and in improving clinical attachment levels (4, 44, 77). However, we also learned that, despite our best efforts at meticulous nonsurgical instrumentation, residual plaque and calculus may still be found (129). It was accepted that in situations where signs of inammation persist, surgical therapy may be indicated. Periodontal surgery was historically advocated for the removal of diseased tissue, with the predominant technique being excision of the diseased gingival tissue by gingivectomy and removal of what was thought to be necrotic bone. Upon the discovery that periodontal disease did not result in necrosis of bone, and that gingival inammation and bone loss represented a defense reaction, this concept was abandoned. Pocket elimination then became the main objective of periodontal therapy, and the gingivectomy or apically positioned ap procedures were commonly performed to eliminate the periodontal pocket and allow access to the root surface for scaling and oral-hygiene procedures. In the 1980s, with a greater understanding of the biology of the peri-

odontal tissues, the pathogenesis of periodontal disease and the mechanisms of periodontal wound healing, the necessity for pocket elimination was also challenged. We learned that the main goal of periodontal surgery was to gain access to the root surface for adequate debridement and to establish gingival contours that are optimal for the patients self-performed plaque control. The access ap (including the numerous techniques described over nearly 100 years: the original Widman ap described in 1918, the Neumann ap described in 1920, the modied ap operation described by Kirkland in 1931, the apically repositioned ap described by Friedman in 1962 and the modied Widman ap described by Ramfjord & Nissle in 1974) enabled access to the root surfaces, root concavities and furcations for adequate debridement. The type of surgery performed in the 1970s and 1980s was largely dependent on the philosophy of each dental school. A number of clinical trials in the 1970s and early 1980s, evaluating the potential of periodontal surgery, revealed that in patients meeting high standards of oral hygiene the surgical technique used to gain access for thorough debridement of the root surfaces was of minor importance for the overall long-term result (52, 94, 101). We also learned the importance of postoperative plaque control in determining the outcome of periodontal surgery. In a study evaluating periodontal surgery, patients who did not have adequate plaque control continued to lose attachment, irrespective of the type of surgery they received (84). Patients who had adequate plaque control had longterm maintenance of clinical attachment levels, demonstrating that the success of surgical periodontal therapy is aligned to the quality of the maintenance care and plaque control (84). Provided

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that proper postoperative plaque-control levels are established and maintained, most surgical-treatment techniques will result in conditions that favor the long-term maintenance of the periodontium. We also learned the importance of subject-related factors, including compliance and smoking, as they relate to periodontal wound healing and treatment outcomes following surgical therapy (47). In recent years, renement of periodontal surgical techniques has been possible with development of new instrumentation and the use of illumination and magnication. Minimally invasive periodontal surgical approaches and microsurgical techniques are currently being evaluated and may show advantages in wound-healing outcomes and less recession and patient morbidity (19, 20, 33, 96, 122). A recent systematic review showed that periodontal surgery for the treatment of intrabony defects was associated with high tooth retention and improvement of periodontal clinical parameters, and that clinical attachment gain may be greater when a papilla preservation ap is used in comparison with an access ap (33). The papilla preservation technique is one of a number of techniques developed as part of the surgical approach to regenerative therapy, which is discussed in another article in this volume of Periodontology 2000.

Surgical debridement vs. nonsurgical debridement

In 2002, Heitz-Mayeld et al. (40) evaluated the effectiveness of surgical vs. nonsurgical therapy for the treatment of chronic periodontitis in a systematic review. Six randomized controlled studies of splitmouth design, published from 1982 to 1996 (46, 50, 56, 59, 88, 94) and comparing surgical with nonsur-

gical treatment of chronic periodontal disease, were included. Meta-analyses indicated that 12 months following treatment, surgical therapy resulted in 0.6 mm more probing-depth reduction and in 0.2 mm more clinical attachment gain than did nonsurgical therapy in deep pockets (>6 mm). In pockets of 46 mm, scaling and root planing resulted in 0.4 mm more clinical attachment gain and 0.4 mm less probing-depth reduction than did surgical therapy. Therefore, when considering surgery in pockets of 46 mm, the advantage in probing-depth reduction should be balanced against the disadvantage in clinical attachment gain. In shallow pockets (1 3 mm), nonsurgical therapy resulted in 0.5 mm less clinical attachment loss compared with surgical therapy (Table 4). From this systematic review it was concluded that both scaling and root planing alone and scaling and root planing combined with a ap procedure are effective methods for the treatment of chronic periodontitis, in terms of attachment gain and reduction in gingival inammation. Furthermore, in the treatment of deep pockets (probing depth >6 mm), open-ap debridement results in greater probing-depth reduction and clinical attachment gain (40). Longterm treatment outcomes available from studies comparing nonsurgical with surgical treatment suggest that both treatment modalities are equally effective in establishing gingival health and preventing further loss of attachment (40).

Critical probing depth for decision making

On the basis of clinical outcome data from a longitudinal randomized controlled clinical trial in 15 patients

Table 4. Clinical therapeutic efciency of nonsurgical therapy vs. surgical therapy 12 months after treatment
Initial probing depth 13 mm 46 mm 46 mm >6 mm >6 mm Outcome variable Weighted mean difference (mm)a )0.51 0.35 )0.37 0.58 0.19 95% condence interval )0.73 to )0.29 0.23 to 0.45 )0.49 to )0.26 0.38 to 0.79 0.04 to 0.35 P-value for weighted mean difference 0.000 0.000 0.000 0.000 0.017 Conclusion

Clinical attachment gain Probing-depth reduction Clinical attachment gain Probing-depth reduction Clinical attachment gain

Favors scaling and root planing Favors surgery Favors scaling and root planing Favors surgery Favors surgery

The results are presented according to initial probing-depth categories. *(Weighted mean difference between surgical therapy and nonsurgical therapy (scaling and root planing). From Heitz-Mayeld et al. (40).

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Fig. 1. Regression analysis leading to critical probing depth as a basis for the decision-making process in periodontal therapy (from Lindhe et al. (58)). MWF, modied Widman ap; RPL, scaling and root planing.

with advanced periodontitis (58), a concept of critical probing depth was developed for decision making following the completion of a hygienic phase [initial periodontal therapy (non-surgical therapy + oral hygiene instruction)]. The critical probing depth represents a baseline probing-depth value above which the outcome of a therapy will result in attachment gain and below which the outcome of therapy will result in clinical attachment loss (Fig. 1). In the present illustration the critical probing depth for nonsurgical therapy (scaling and root planing) is 2.9 mm. This, in turn, means that below this probing depth the site would lose clinical attachment as a result of therapy. However, above this value clinical attachment gain will result. On the other hand, for the access ap therapy, the critical probing depth is 4.2 mm. Again, this means that open ap debridement is only benecial above this value, while below this value, attachment loss may result. Looking at the data from both scaling and root planing and access ap surgery, another critical probing depth is 5.4 mm. This, in turn, means that ap surgery is indicated predominantly with a probing depth of 5.4 mm, while between 2.9 mm and 5.4 mm nonsurgical therapy is to be preferred. It has to be borne in mind, however, that these critical probing-depth values represent mean scores with a modest variation. Nevertheless, the principle

may be used as a guideline in the clinical decisionmaking process on periodontal therapy.

Conclusions
While we have learned a great deal over the past decades and have been introduced to new techniques and technologies, this new information has not diminished our recognition of the importance of thorough mechanical debridement and optimal plaque control for successful nonsurgical and surgical periodontal therapy. We have learned that while a thorough disruption and removal of the periodontal biolm is required for successful treatment outcomes, removal of the root surface is not necessary. We have learned that the use of specic systemic antimicrobials, in patients with advanced or aggressive periodontitis and deep probing depths, may be benecial as an adjunct to nonsurgical periodontal therapy, thereby reducing the need for additional therapy. We have learned that full-mouth disinfection and full-mouth scaling and root planing protocols can be an equivalent treatment option to conventional quadrant debridement.

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We have learned that in patients with deep pockets (>6 mm), access ap surgery may be benecial, provided the patient receives regular supportive periodontal therapy and has adequate oral hygiene. We have learned that the value of new technologies and concepts may not be known for some time after their introduction. Proper evaluation requires adequate follow-up in well-conducted studies of sufcient sample size. We have learned that an unbiased and transparent appraisal of the literature, using the systematic review process, may change our paradigms. Sometimes we need to be prepared to unlearn old concepts in order to learn new ones.

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