Clinical and radiographic long-term study of teeth with periodontal destruction treated by a modified flap operation

Supportive periodontal care: the effect of periodic subgingival debridement compared with supragingival prophylaxis with respect to clinical outcomes

BACKGROUND

The programme of supportive periodontal care (SPC) is essential to the long-term stability of patients with chronic periodontitis. The clinical strategy for SPC is often determined according to 'clinical needs' of the patient and is thus determined by clinical observation and individual decision-making rather than being based on the best available clinical evidence.

OBJECTIVE

To evaluate the effectiveness of supragingival prophylaxis vs. sub-gingival debridement for SPC following the treatment of chronic periodontitis.

SEARCH STRATEGY

Computerized for Medline and the Cochrane Oral Health Group Specialty Trials Register. Hand searching of the Journals of Clinical Periodontology, Periodontal Research and Periodontology. Reference lists from relevant articles were scanned and the authors of eligible studies were contacted to obtain additional information.

SELECTION CRITERIA

Studies were selected if they were designed as a prospective clinical trial in which patients with chronic periodontitis had followed a programme of SPC, which included at least one of the regimens of interest in part of the mouth, for a minimum of 12 months.

DATA COLLECTION AND ANALYSIS

Information regarding methods, patients, interventions (SPC), outcome measures and results were extracted independently, in duplicate, by two reviewers (P.A.H., G.McC.). Absent data were recorded as such and incomplete data were sought from the researchers wherever possible.

RESULTS

In all, 28 papers were identified by the manual and electronic searches; 11 papers were eligible for inclusion. Only one study reported a direct comparison of the two SPCs of interest. The data were reported as mean changes in probing depth and attachment level between baseline and the 12-month follow-up point. For coronal scaling DeltaPD = 0.59 mm [0.13], DeltaAL = -0.13 mm [0.19]. For subgingival debridement DeltaPD = 0.37 mm [0.15], DeltaAL = -0.14 mm [0.18]. There were no significant differences between the SPC regimens. The weighted mean DeltaPD [95% confidence intervals] for the five additional studies that reported supragingival prophylaxis as the SPC regimen was 1.15 mm [-0.17, 2.38]. The weighted mean DeltaPD [95% confidence intervals] for the four studies that reported subgingival debridement as the SPC regimen was 0.56 mm [0.37, 1.47]. The difference between the SPC treatments for the mean DeltaPD is therefore 0.23 mm. The confidence interval for the combined studies was very wide [0.37, 1.47] and very little additional information is gained unless some strong assumptions are made about the comparability of the populations from which the samples are drawn. Such an assumption was not considered appropriate. The weighted mean DeltaAL [95% confidence intervals] for the six additional studies that reported supragingival prophylaxis as the SPC regimen was 0.18 mm [-0.38, 0.74]. The weighted mean DeltaAL [95% confidence intervals] for the six additional studies that reported supragingival prophylaxis as the SPC regimen was 0.50 mm [0.11, 0.89]. The difference between the SPC treatments for mean DeltaAL is 0.32 mm. The confidence interval [-0.36, 1.00] is very wide and the data from the additional studies provide little extra information than that reported in the one study that compared the treatments directly.

CONCLUSION

It is not possible to make any firm recommendations regarding clinical practice based on the crude meta-analysis and the review of these 11 studies. The best available evidence indicates that SPC regimens of supragingival prophylaxis and subgingival debridement are comparable with respect to the clinical outcomes of probing depth and attachment levels at 12 months post non-surgical treatment.

Rationale of mechanical plaque control

Patients who have received extensive periodontal treatment also demonstrate a high susceptibility to periodontal disease. Maintenance of periodontal health following therapy includes a lifelong supportive care consisting of daily removal of the microbial plaque by the patient, supplemented by professional care in an individually designed programme. Mechanical supragingival plaque control by self care is of utmost importance. The goal is to create a positive attitude by information and motivation to give the patient knowledge and confidence. The patient should be advised to use appropriate aids and technique. A soft brush, an interspace brush, interdental tooth brushes or tooth picks are recommended in periodontal patients. Professional tooth cleaning involves removal of supragingival plaque from all tooth surfaces using mechanically driven instruments and fluoride prophy paste and, when indicated, removal of calculus and subgingival plaque. Disclosing solution is used to visualize the plaque to the patient and to the clinician in order to reinforce instruction in oral hygiene. Oral hygiene measures alone seem to have limited effect on subgingival microflora in cases of severe disease. In shallow and moderately deep pockets a good plaque control can change the subgingival flora towards a more "healthy" composition. Subgingival plaque removal is performed with hand- and/or ultrasonic instruments. Cracks within the cementum, grooves, fissures, resorption lacunae, furcations may create difficulties in cleaning the root surface. Ultrasonic instrumentation has a beneficial effect in creating a smooth surface without extensive removal of cementum. Besides, the cavitational activity contributes to plaque removal which makes the instrument further suitable during maintenance therapy. The result of the debridement is assessed on the healing response in the tissues. The frequency of maintenance visits must be given on an individual basis according to the needs of every special patient. The visit includes plaque evaluation (disclosion), oral hygiene instruction, probing depth measurements, registration of bleeding on probing, scaling (plaque removal) if indicated, tooth polishing, fluoride application and radiographs if indicated. The goal is to identify and treat signs of recurrence of periodontal disease in order to prevent further loss of attachment.

The role of supragingival plaque in the control of progressive periodontal disease. A review

Levels of supragingival plaque and calculus have been related to progressive periodontal disease, and control of supragingival plaque in conjunction with professional tooth cleaning subgingivally forms the basis for the management of progressive periodontal disease. However, the contribution towards the management of progressive periodontal disease brought about by supragingival plaque control alone is not clear. There are studies which address, directly or indirectly, the contribution of supragingival plaque control alone towards the management of progressive periodontal disease. The effects of supragingival plaque control alone have been evaluated clinically, histologically and microbiologically, and taken together, the evaluations suggest that these effects may not be as marked as when professional subgingival tooth cleaning is also performed. These studies, however, given the patterns of periodontal disease found in adults in many communities, can form the basis for advocating high individual levels of supragingival plaque control as a community measure in the management of periodontal disease. Further long-term investigations into this approach may be warranted.

5-year evaluation of durapatite ceramic alloplastic implants in periodontal osseous defects

Six patients who participated in a clinical study comparing the response of periodontal osseous defects to either grafting with Periograf (durapatite) hydroxylapatite (HA) ceramic or debridement alone (DEBR) were followed under an active maintenance program for 5 years. Mean values for gingival recession and attachment levels remained essentially stable following either treatment over the 5 year period. However, mean probeable pocket depths shifted from being significantly (P less than 0.05) shallower for DEBR sites at 6 months and 1 year to being significantly shallower for HA sites at 5 years. The probing pocket depth change for grafted sites was steady and the change from presurgical values was significantly greater than the change for DEBR areas, which became about 1.5 mm deeper over the 5 year postsurgical period. Intrapatient comparisons showed that recession, attachment gain, and pocket depth decrease were most frequently greater for the Periograf-treated sites. Assessment of the pattern of clinical changes during the 5 year postsurgical period demonstrated that the attachment level of grafted sites improved or stayed the same 86% of the time compared to only 62% stability or improvement in the DEBR only sites. In fact, 38% of the DEBR sites were worse at 5 years than at the time of surgery, a 3 times greater failure rate than that found in the HA-grafted sites. Pocket depth measurements showed that 98% of the Periograf-treated sites were better or the same as presurgically (2% worse), while only 80% of DEBR sites showed positive results and 20% had deeper pockets than at the time of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical responses following periodontal treatment by local drug delivery

A 4-quadrant, single-blind study was designed to test the efficacy of periodontal disease therapy by local drug delivery. A delivery system made of extruded ethylene vinyl acetate fibers loaded with 25% USP tetracycline hydrochloride was placed and maintained in periodontal pockets for 10 days. The clinical effects of this form of therapy were compared with treatment by periodontal scaling. In addition, the effect of treatment by combined local delivery and scaling was investigated. Untreated quadrants were included as control. Placement of tetracycline-loaded ethylene vinyl acetate fibers into periodontal pockets established a drug concentration of approximately 0.06%. By covering the delivery system with a periodontal dressing, this concentration level was maintained throughout the 10-day therapeutic period. The average tetracycline dose used was 2.4 mg/tooth treated. Following fiber therapy, treated sites improved clinically, as evidenced by a gain in periodontal attachment and a decrease in periodontal pocket depth. The rate of new lesion formation at fiber-treated sites decreased from a pretreatment rate of 26.5% of sites/year to a posttreatment rate of 4.8% of sites/year. Periodontal scaling also produced clinical improvement, as indicated by significant attachment gain, pocket depth reduction and a decreased rate of new lesion formation. However, in no case were clinical results by scaling superior to results by local drug delivery, and by several measures local drug delivery was found to provide a better clinical response. Principal measures by which the clinical response using local drug delivery exceeded that by scaling were in early (3-6 months) attachment gain and in the degree of reduction of new lesion formation.(ABSTRACT TRUNCATED AT 250 WORDS)

Survival analysis of periodontal sites before and after periodontal therapy

Periodontal diseases appear to progress with bursts of destructive activity at individual sites. One effect of treatment might be to diminish the frequency of such bursts. Survival analysis was employed to seek such effects on the periodontal sites of 16 individuals with prior evidence of destructive periodontal disease. The subjects were monitored at bi-monthly intervals and actively breaking down sites were detected using attachment level measurements and the tolerance method of analysis. When active sites were detected, control sites of equal pocket depth and attachment loss were selected and microbiological and immunological samples were taken. The subjects were treated by modified Widman flap surgery and systemically administered tetracycline. On completion of therapy, bi-monthly monitoring was reinstituted. Life tables were constructed for periodontal sites in each of the 16 subjects prior to and after therapy. A site losing more than 3 mm of attachment at any time interval was considered to have relapsed or "died". Survivor functions were calculated for each time period indicating the % of sites which survived at any time. The subjects were divided into 3 categories on the basis of post-therapy survivor functions. The annual hazard rate in 9 good treatment response subjects (group 1) was reduced from 0.10/year to 0.01/year. The hazard rate of 5 intermediate treatment response subjects (group 2A) was reduced from 0.16/year to 0.04/year and that of 2 poor treatment response subjects (group 2B) from 0.15/year to 0.07/year. Group 2A and 2B individuals were combined and differences were sought in clinical, microbiological and immunological parameters between the good and poor treatment response groups. 5 out of 7 of the poor responding individuals showed elevated humoral antibody responses to 3 or more gram-negative subgingival species tested. Many of the elevated responses in this group were to organisms which are widely distributed and return quickly after therapy such as Fusobacterium nucleatum, Eikenella corrodens, Bacteroides intermedius and Capnocytophaga sputigena. The predominant cultivable microbiota in subgingival samples taken prior to therapy from the good responding group had significantly greater proportions of Actinobacillus actinomycetemcomitans, C. ochracea and B. intermedius than the poor responding group. The latter group showed significantly elevated proportions of F. nucleatum, Peptostreptococcus micros and Streptococcus intermedius.

Intraclass correlations of periodontal measurements

Components of variance and intraclass correlation coefficients were computed for changes in attachment level, pocket depth, gingival and plaque index scores for 5 groups of treated periodontal disease patients and 1 group of untreated subjects with periodontal disease. The intraclass correlation coefficients for attachment level change ranged from 0.011 to 0.165 (median 0.067), while intraclass correlation coefficients for pocket depth changes ranged from -0.009 to 0.178 (median 0.071). These intraclass correlation coefficients were much lower than those computed for changes in measurements of plaque which ranged from 0.086 to 0.568 (median 0.268) or gingival inflammation which ranged from 0.119 to 0.522 (median 0.264). Intraclass correlation coefficients at baseline for pocket depths ranged from 0.000 to 0.199 (median 0.053), for plaque accumulation from 0.121 to 0.531 (median 0.222) and for gingival inflammation from 0.229 to 0.596 (median 0.391). The differences in the intraclass correlation coefficients between pocket depth and attachment level on the one hand and plaque accumulation or gingival inflammation on the other could not be explained on the basis of differences in the measurement scale employed, since collapsing measurement scales had little effect on the intraclass correlation coefficients. The observed larger intraclass correlation coefficients for changes in plaque and gingival indices suggest a larger rôle for host contribution to these measurements. In contrast, the data suggest that the major but by no means the sole factor determining the variability of attachment level or pocket depth changes is the nature of the local factors.

Longitudinal evaluation of durapatite ceramic as an alloplastic implant in periodontal osseous defects after 3 years

Seven patients who participated in a clinical study comparing the response of periodontal osseous defects to either grafting with Durapatite ceramic or debridement alone were followed under an active maintenance program for 3 years. Comparison of mean values showed that gingival recession, attachment levels and probeable pocket depths remained essentially stable for Durapatite sites over the 3 years. Attachment levels for debridement sites also remained constant, but these areas showed significant coronal migration of the free gingival margin and increases in probeable pocket depths. These latter changes became apparent and significant only after 3 years. Intrapatient comparisons showed that recession and attachment gain were most frequently greater and pocket depths most frequently less for Durapatite sites. These findings suggest that the Durapatite-treated sites were stable for 3 years following surgery, while areas treated with debridement alone regressed.