Is loss of attachment due to root planning and scaling in sites with minimal probing depths a statistical or real occurrence?

Impact of Nonsurgical Periodontal Treatment of Periodontitis Stages 2 and 3 on Oral Health-Related Quality of Life

This study investigates the impact of nonsurgical periodontal treatment (NSPT) on oral health-related quality of life (OHRQoL) in patients with periodontitis stages (S)2 and S3, and the factors associated with the prediction of patient-reported outcomes. Periodontitis patients (n = 68) with moderately deep periodontal pockets were recruited. Responses to the Oral Health Impact Profile (OHIP)-14 questionnaire and clinical parameters including plaque index, bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment loss (CAL) were recorded. All patients received supra- and subgingival professional mechanical plaque removal. All clinical parameters and questionnaire responses were recorded again 3 months after NSPT. Clinical parameters and OHIP-14 scores for both stages of periodontitis were significantly improved 3 months after treatment. However, participants with periodontitis S3 had significantly higher total OHIP-14, physical pain, and functional limitation domains scores than periodontitis S2 cases. Baseline CAL, BOP, and the presence of PPD in anterior teeth were positively associated with increased OHIP-14 scores after NSPT. NSPT improved OHRQoL in participants with periodontitis S2 and S3. This was more pronounced in participants having periodontitis S3 than S2. Poorer OHRQoL could be anticipated in people having severe CAL, high BOP, and presence of pockets in the anterior teeth.

Effectiveness of a 30-year periodontist's primary care for 1946 patients during five-year follow-up

OBJECTIVE

To evaluate the effect of the periodontal primary care (PPC) on the improvement of periodontal probing depth based on a periodontist's 30-year practice.

MATERIALS AND METHODS

We enrolled a total of 2,894 patients who underwent periodontal basic treatment between 1987 and 2017 with 84.5% retention rate. The study population was composed of 80% (n = 1,946) of retained patients with complete re-evaluation up to five-year follow-up. The outcome was measured by the improvement of probing depths (graded as 1:1-3 mm; 2:4-6 mm; 3: ≥7 mm) before and after PPC on both sextant and patient levels. Whether a better improvement was seen in the surgical group and the non-smoker group opposed to their comparators was assessed with various multi-variable regression models.

RESULTS

On patient (sextant) level, 82% (38%) improved, 13% (59%) unchanged, and 5% (3%) deteriorated. Adjusted better improvement of probing depth was noted for the surgical group by 63% and non-smoker by 31% compared with their counterparts. The similar findings were found for the outcomes based on continuous probing depth scores.

CONCLUSIONS

We demonstrate the improvement of probing depth scores with a periodontal primary care offered for the retained patients and larger effect for the surgical group and non-smoker patients.

Scaling and root planing vs. conservative surgery in the treatment of chronic periodontitis

A renewed interest in conservative surgical techniques has been fueled by new technology, changes in referral patterns to periodontists and a desire to achieve periodontal health in the least invasive, most cost-efficient manner possible. Trends suggest that an increasing amount of periodontal care is being provided in the offices of general dentists. If true, it is likely that patients receiving care in these offices will be offered simpler surgical treatment modalities that do not require an extensive armamentarium. The purpose of this article was to review the effectiveness of six relatively simple surgical techniques - gingivectomy, flap debridement, modified Widman flap, excisional new attachment procedure, modified excisional new attachment procedure and laser-assisted new attachment procedure - and to compare the results obtained using these procedures with the well-known clinical benefits of scaling and root planing. The intent was to determine whether the benefits of surgical procedures in the hands of most general dentists extend beyond those of conventional nonsurgical therapy.

Defining and predicting outcomes of non-surgical periodontal treatment: a 1-yr follow-up study

This study reports on 1-yr outcomes of non-surgical periodontal therapy and compares predictive models resulting from different definitions of treatment success. A total of 149 participants, 30-70 yr of age, provided clinical periodontal data and data on sociodemographic status, health status, symptoms, and oral health-care behaviors at baseline. One week later, clinical attachment level and probing pocket depth were recorded again in 148 patients. Participants underwent non-surgical periodontal therapy, including scaling and root planing, during three to four clinical sessions. Three and 12 months later, clinical attachment level, probing pocket depth, and bleeding on probing (BOP) were recorded in 141 and 137 participants, respectively. Using test-retest data, patients were classified as having 'downhill', 'stable', or 'improved' results on three clinical attachment level and three probing pocket depth outcomes, and their classification was found to vary considerably according to outcome. Although the predictors of treatment outcome varied depending on the variable chosen to represent the treatment outcome, some predictors were more commonly noted as predicting improvement, namely a high baseline percentage of sites with subgingival calculus and the presence of suppuration at baseline. The latter was, however, also predictive for tooth loss during the study. Our findings underline the need for uniformity in defining the outcomes in trials of periodontal therapy.

Clinical effects of scaling and root planing in adults infected with Actinobacillus actinomycetemcomitans

The periodontal pathogen Actinobacillus actinomycetemcomitans can frequently be isolated from subgingival plaque of adults with chronic inflammatory periodontal disease and individuals with plaque-induced gingivitis. Problems with the persistence of the organism after thorough debridement of root surfaces have been reported. In the present study clinical effects of the hygienic phase of periodontal therapy in ten adult patients with moderate or advanced periodontitis harbouring A. actinomycetemcomitans were analysed. Since proper analysis of highly correlated data within a given patient is crucial for appropriate interpretation, a major objective of this study was to compare the results of different models derived from logistic regression of clinical and microbiological factors on gain or loss of clinical attachment under different assumptions. Subgingival samples from every tooth present were obtained before and 6 weeks after thorough subgingival scaling, and selectively cultivated for the organism. A relevant gain of clinical attachment of 2 mm or more was observed at a total of 36% of periodontitis sites after scaling. Overall, loss of attachment of 2 mm or more was observed at 8% sites. Most loss occurred at sites with gingival enlargement (15%), whereas 3% periodontitis sites lost 2 mm or more. In multivariate analyses erroneously assuming either independence of data or correctly considering the correlated structure of observations attachment gain was mainly associated with deep probing depths at the outset. Presence or absence of A. actinomycetemcomitans before or after therapy was not included into the periodontitis models. Also, loss of attachment of 2 mm or more after subgingival scaling was not influenced by the organism. A direct comparison of the results obtained with both approaches of logistic regression may be helpful in the assessment of the influence of the magnitude of correlation of the data on the regression coefficients.

The Application of Multilevel Modeling in the Analysis of Longitudinal Periodontal Data – Part I: Absolute Levels of Disease

BACKGROUND

Statistical analyses of periodontal data that average site measurements to subject mean values are unable to explore the site-specific nature of periodontal diseases. Multilevel modeling (MLM) overcomes this, taking hierarchical structure into account. MLM was used to investigate longitudinal relationships between the outcomes of lifetime cumulative attachment loss (LCAL) and probing depth (PD) in relation to potential risk factors for periodontal disease progression.

METHODS

One hundred males (mean age 17 years) received a comprehensive periodontal examination at baseline and at 12 and 30 months. The resulting data were analyzed in two stages. In stage one (reported here), the absolute levels of disease were analyzed in relation to potential risk factors; in stage two (reported in a second paper), changes in disease patterns over time were analyzed in relation to the same risk factors. Each approach yielded substantially different insights.

RESULTS

For absolute levels of disease, subject-level risk factors (covariates) had limited prediction for LCAL/PD throughout the 30-month observation period. Tooth position demonstrated a near linear relationship for both outcomes, with disease increasing from anterior to posterior teeth. Sites with subgingival calculus and bleeding on probing demonstrated more LCAL and PD, and supragingival calculus had an apparently protective effect. Covariates had more "explanatory power" for the variation in PD than for the variation in LCAL, suggesting that LCAL and PD might be generally associated with a different profile of covariates.

CONCLUSION

This study provides, for a relatively young cohort, considerable insights into the factors associated with early-life periodontal disease and its progression at all levels of the natural hierarchy of sites within teeth within subjects.

Local Anti-Infective Therapy: Mechanical and Physical Approaches. A Systematic Review

BACKGROUND

Although mechanical non-surgical therapy (scaling and root planing) is the most common means of initial treatment of periodontal diseases, the relative clinical efficacy of various methods, including manual versus machine-driven, with or without adjunctive agents, has not been determined.

RATIONALE

This systematic review analyzes the literature in an effort to identify the most effective therapies, based on both clinical and patient-centered outcomes.

FOCUSED QUESTION

In patients with periodontitis, what is the effect of mechanically-driven instrumentation (e.g., power-driven) and/or subgingival irrigation with and without manual instrumentation compared to manual instrumentation alone?

SEARCH PROTOCOL

Two investigators examined MEDLINE and the Cochrane Oral Health Group specialized registry for clinical trials published in English. Hand searches were performed of the International Journal of Periodontics & Restorative Dentistry, Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Periodontal Research. Searches were performed for articles published through April 2002. Editors of these journals were asked to provide information on articles currently under review. In addition, an electronic discussion group on periodontal diseases and treatment was contacted, as were manufacturers of manual and mechanical instruments and of adjunctive agents.

SELECTION CRITERIA

INCLUSION CRITERIA

Only randomized clinical trials, cohort studies, or case-control studies at least 3 months long were included. All studies had to compare manual instrumentation (MI; scaling and root planing [SRP]) alone with some other form of non-surgical therapy. These included MI versus mechanically-driven instruments (MDI) alone; MI versus MI plus MDI; MI versus MDI plus an agent (e.g., chlorhexidine); and MI versus subgingival irrigation (SGI) delivered in conjunction with MI or MDI.

EXCLUSION CRITERIA

Studies not meeting the inclusion criteria or those treating periodontal diseases as a manifestation or complication of some other disease or disorder were not included.

DATA COLLECTION AND ANALYSIS

Probing depth, clinical attachment level, bleeding on probing, and gingival recession were the primary outcomes. Because of the heterogeneity of the patient populations, treatments, and outcome measures, meta-analysis was not appropriate. Only in-study data were compared. Four of the studies required extrapolating data from figures and graphs, resulting in questionable accuracy.

MAIN RESULTS

1. Nine studies, representing a study population of 129, were included in the review. 2. Five studies compared MI with MDI alone. The other 4 compared MI alone to MI plus SGI or subgingival tissue treatment. 3. There was comparable efficacy between MI and MDI when treating single-rooted teeth. 4. The use of SGI or subgingival tissue treatment as an adjunct to MI provided no additional benefit compared to MI alone. 5. Findings reported in the review must be interpreted with considerable caution, as lack of study heterogeneity made meta-analysis unfeasible and the need to extrapolate outcomes values from graphs and figures may have resulted in some inaccuracy.

REVIEWERS' CONCLUSIONS

1. Manual and mechanically-driven instrumentation appears comparable in affecting improved clinical outcomes. 2. Instrumentation time for MI and MDI were similar, except for 1 study in which MDI was significantly shorter. 3. Adjunctive SGI plus MI and subgingival tissue treatment result in similar clinical outcomes when compared to MI alone. 4. If study data are to be effectively and analytically combined to facilitate meaningful comparisons of treatment outcomes, detailed and standardized study designs must be developed and used consistently in clinical trials.

Is reduction of pocket probing depth correlated with the baseline value or is it "mathematical coupling"?

Previous studies using correlation or regression analysis have showed that treatment effects measured by the change in clinical parameters are often associated with baseline values of the same parameters. These studies, however, have a methodological weakness. Correlation/regression between baseline measures and the derived change variable invalidates the statistical procedures of testing the null hypothesis: that the coefficient of correlation/regression is zero. This is due to the phenomenon of mathematical coupling. To investigate the impact that this has on the observed correlation/regression coefficient when in reality this is zero, we used random simulations of hypothetical data to model the treatment of periodontal pockets. Results showed a strong probability of obtaining statistically significant correlation/regression coefficients. To separate this artificial effect of mathematical coupling from the true underlying biological relationship, one must apply appropriate analytical strategies to re-evaluate previous evidence within the periodontal literature.