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J Am Dent Assoc, Vol 131, No 4, 483-491.
© 2000 American Dental Association
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CLINICAL PRACTICE

JADA Continuing Education

A PRACTICAL APPROACH TO THE DIAGNOSIS AND TREATMENT OF PERIODONTAL DISEASE



DWIGHT E. MCLEOD, D.D.S., M.S.


   ABSTRACT
TOP
 ABSTRACT
DIAGNOSTIC APPROACH
 TREATMENT PLAN PHASES
 EVALUATING THE RESULTS OF...
 TREATMENT CONSIDERATIONS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. Both nonsurgical and surgical periodontal therapies are important in the control of most forms of periodontal disease. Sometimes, nonsurgical therapy is adequate to control the disease in mild cases and to slow progression and maintain periodontal stability in more advanced cases. Other times, both therapies may be indicated to obtain satisfactory results. The author presents treatment guidelines and recommendations for periodontal therapy.

Methods. The author searched the dental literature for information pertaining to periodontal therapy.

Results. The author found evidence-based data to support the effectiveness of nonsurgical and surgical periodontal therapy in controlling periodontal disease. Nonsurgical periodontal therapy requires time, effort, and good diagnostic and clinical skills to obtain satisfactory results. The results are determined by evaluating the patient’s periodontal disease after active therapy, at which time additional surgical or nonsurgical treatment may be recommended. Evaluation should continue throughout the lifelong supportive phase of periodontal therapy.

Conclusion. Clinicians should continue to develop and enhance their diagnostic skills, assess factors that affect diagnosis and prognosis, formulate a comprehensive treatment plan, render appropriate treatment, evaluate the outcome and determine when periodontal care is indicated.

Clinical Implication. Failure to comply with monitoring the patient’s periodontal status may lead to uncontrolled disease and eventually premature tooth loss. Premature tooth loss can be prevented through patient education and application of evidence-based nonsurgical and surgical therapy.

Reports from the American Academy of Periodontology’s, or AAP’s, 1996 World Workshop in Periodontics reaffirmed that nonsurgical and surgical periodontal therapies are effective in controlling periodontal disease.1 After a comprehensive review of the literature on periodontal care, reviewers established an evidence-based approach for the clinical application of nonsurgical and surgical treatments used to control periodontal disease. A summary of their report on evidence-based periodontal therapy was published recently.2

In addition to these reports, the AAP always has made available its position papers on clinical parameters of care.3 These published reports reflect the stance of the organization on various topics and are frequently updated to reflect trends in research.

A plethora of information is available from the AAP, American Dental Association and other organizations to help the clinician diagnose, treat and manage periodontal disease. In this article, I present some important criteria for the diagnosis of periodontal disease and treatment of periodontitis.

In the presence of a microbial challenge, numerous acquired and innate risk factors may influence the initiation and progression of periodontal disease. Skills for understanding, diagnosing and treating periodontitis are taught daily in dental schools throughout the United States. Students are required to learn the different classifications of periodontal disease and develop an appreciation for the various forms of periodontal disease, which may differ in etiology, progression and response to therapy.4,5 In the educational setting, pathogenesis, etiology and risk factors often are emphasized to broaden the students’ scope and understanding of the disease process (the FigureGo shows an illustration of the current paradigm for periodontitis6).



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  		Figure. Schematic illustration of a current paradigm for periodontitis modified from Williams6 with permission from Dental Learning Systems Co. Inc.

 
In addition, students are taught that a general practitioner should be able to treat mild-to-moderate periodontal disease and determine when to refer moderate-to-advanced cases to a specialist for treatment. The diagnostic skills and judgment necessary for critical discernment, diagnosis and knowing how a patient’s periodontal condition is best treated cannot be overemphasized. Therefore, as new information on periodontal disease risk factors, diagnosis, treatments and related topics becomes available, it is of utmost importance that dental practitioners are informed of them.


   DIAGNOSTIC APPROACH
TOP
 ABSTRACT
 DIAGNOSTIC APPROACH
TREATMENT PLAN PHASES
 EVALUATING THE RESULTS OF...
 TREATMENT CONSIDERATIONS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
The diagnosis of periodontal disease requires a systematic approach. The initial comprehensive periodontal examination typically takes about 30 to 60 minutes and requires several steps to arrive at an accurate diagnosis. The comprehensive examination should include an evaluation of soft tissue, bleeding and exudate on probing, probing depths, gingival recession, mobility, furcation involvement, and an occlusal analysis and temporomandibular disorder assessment. In addition, all secondary etiologic factors that may harbor plaque—such as faulty margins and improperly contoured crowns—should be identified and scheduled for restoration in the form of a treatment plan. Evaluation of a complete series of diagnostic periapical and bitewing radiographs is necessary for diagnosis and treatment planning. A panoramic radiograph may be necessary, especially when creating a treatment plan for dental implants or when impacted third molars are present.

Newer diagnostic tools such as microbial testing and antibiotic sensitivity assays may be done on a case-selection basis in addition to the comprehensive periodontal examination.

Medical and dental histories and factors affecting treatment prognosis also should be closely examined, along with the clinical and radiographic findings, to determine the appropriate diagnosis and treatment plan (BoxGo, Factors to Consider Evaluating at the Initial Periodontal Examination").


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  		FACTORS TO CONSIDER EVALUATING AT THE INITIAL PERIODONTAL EXAMINATION.

 
The treatment plan should be tailored to the specific periodontal diagnosis, which should be clearly stated and should include diagnostic terminology used by the AAP. For example, the case type describes the progression and severity of the periodontal disease and should be written next to the diagnosis. The case type is mainly used for insurance purposes and is not always interchangeable with the periodontal diagnosis as in the case of localized juvenile periodontitis and rapidly progressive periodontitis (Table 1Go), which represent specific forms of the disease and may be associated with different case types, depending on the stage.


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  		TABLE 1 PERIODONTAL DISEASE CLASSIFICATION.*5

 

   TREATMENT PLAN PHASES
TOP
 ABSTRACT
 DIAGNOSTIC APPROACH
 TREATMENT PLAN PHASES
EVALUATING THE RESULTS OF...
 TREATMENT CONSIDERATIONS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
The boxGo "Factors to Consider During the Treatment Phases of Periodontal Therapy" lists items to consider when creating and following a treatment plan for a patient with periodontal disease. As with other forms of disease, the treatment usually is prescribed or tailored according to the diagnosis and severity of the disease. Generally, an early form of a disease requires a less-invasive treatment approach. The treatment usually is performed in phases. This enables the provider to evaluate the results before initiating additional treatment, as well as make the treatment protocol easier for the patient to comprehend.


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  		FACTORS TO CONSIDER DURING THE TREATMENT PHASES OF PERIODONTAL THERAPY.

 
Factors for consideration are included in three phases: phase I (initial, nonsurgical, inflammation control), phase II (surgical), and phase III (supportive periodontal care). As shown in Table 1Go, a person who is diagnosed with gingivitis would be categorized as having Type I periodontal disease, indicating a much lower disease severity when compared with a person who has refractory periodontitis and is classified as having Type V periodontitis (Table 1Go). A person who is diagnosed with refractory periodontitis would require more aggressive treatment.

Gingivitis. A patient with gingivitis has no destruction of the periodontal fibers or bone that support the teeth. Rather, the gingiva is inflamed as a result of bacteria and their pathogenic factors. Treatment should be directed at reducing the bacteria and their effects. Phase I treatment usually is the first approach to controlling the disease. Per the boxGo "Factors to Consider During the Treatment Phases ... ," the periodontal treatment plan for a person with gingivitis would include phase I considerations, which would most likely consist of patient education on the etiology of gingivitis and risk factors for the development of periodontal disease, oral hygiene instructions and a prophylaxis vs. periodontal scaling and root planing. Phase I treatment also includes replacement of missing restorations or treatment of any immediately needed restorations, overhang removal, endodontic therapy and extraction of "hopeless teeth," as well as an attempt to address and eliminate as many etiologic factors as possible. During this phase, effective communication between the general practitioner and other specialists is important to control the local etiologic factors and promote periodontal and dental health. During phase I, any accretions that have extended into the sulcus of patients with gingivitis undergoing a prophylaxis should be removed by gentle subgingival scaling. Depending on the nature and severity of the gingivitis, the patient should be seen for a reevaluation examination of the initial treatment.

Phase II, or surgical, treatment usually is not indicated in patients with gingivitis unless there are gingival pockets that are interfering with plaque control, function or esthetics.

Phase III, or supportive, periodontal care involves follow-up care such as a recall program designed to meet the patient’s need at three-, four- or six-month intervals. Typically, a patient with chronic mild gingivitis should remain on a six-month recall program or one deemed otherwise by the treating clinician.

Patient education in areas such as disease etiology, modifying risk factors, significance of treatment, plaque control and lifelong supportive periodontal care is especially important during the initial management of periodontal disease. The practitioner should involve the patient in the treatment by instituting new oral hygiene techniques or modifying present habits, as well as stressing and reinforcing the frequency, duration, method and hygiene aids used until the patient attains a level of home care that is physiologically compatible with target periodontal health.

Periodontitis. Patients classified as having Type II through Type V periodontal disease initially will require periodontal scaling and root planing in addition to patient education and oral hygiene instructions. Periodontal scaling and root planing are the recommended treatments for those diagnosed with untreated periodontal disease or for those with residual periodontal defects who declined surgical intervention. Periodontal scaling is aimed at removing the root accretions, and root planing is aimed at removing diseased cementum and dentin. Patients classified as having Type II through Type V periodontal disease have bacterial-induced destruction of the supporting periodontal fibers and bone that support the teeth. The loss of tissues leads to pocketing.

Periodontal scaling and root planing is a physically demanding clinical procedure for dental practitioners that requires a meticulous approach. It is an uncomfortable procedure for most patients and usually requires local anesthesia to achieve thorough root débridement.

Several studies have shown that the use of sonic scalers, ultrasonic scalers and hand instruments achieve similar results when applied correctly.7–11 Most periodontists feel more comfortable, however, using sonic or ultrasonic devices followed by hand instruments. A fine-tipped periodontal explorer, which is designed for subgingival access to detect accretions, is a useful tool. The ability and skill of detecting and removing all subgingival accretions is only mastered after multiple sessions. A fine-tipped periodontal explorer can be used to spot-check areas of previous instrumentation between visits. It is not surprising to detect residual areas of burnished accretions. It is imperative for clinicians to develop the dexterity and manual sensitivity to detect subgingival accretions or root roughness and render effective therapy. The clinician also must be able to evaluate soft-tissue response such as bleeding on probing and make a judgment of whether additional periodontal scaling and root planing is needed in deeper pockets. It is the clinician’s responsibility to make an earnest attempt to reduce the accretions to a state that is compatible with gingival health. Any patient having difficulty with plaque control should be seen more frequently for oral hygiene reinforcement and prescribed antiplaque/antigingivitis agents when indicated.


   EVALUATING THE RESULTS OF PHASE I THERAPY
TOP
 ABSTRACT
 DIAGNOSTIC APPROACH
 TREATMENT PLAN PHASES
 EVALUATING THE RESULTS OF...
TREATMENT CONSIDERATIONS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
The reevaluation of phase I periodontal therapy is best accomplished six to eight weeks after periodontal scaling and root planing; this period is necessary for the tissues to heal. The patient usually is examined to evaluate the treatment results; the examination is similar to the initial periodontal examination. Clinical findings from the reevaluation examination are compared with those of the initial periodontal examination. Depending on the findings at the reevaluation appointment, treatment may proceed in several directions: to additional nonsurgical treatment (phase I), to surgical treatment (phase II) or to supportive periodontal care (phase III).

The reevaluation visit of nonsurgical therapy marks the end of phase I (inflammation control, nonsurgical or initial therapy) of periodontal therapy. This stage is perhaps the most important aspect of therapy because it involves determining whether nonsurgical treatment was effective. Is the patient compliant? Is additional reinforcement necessary? Is additional periodontal therapy indicated such as surgeries? How will the prognosis affect the overall restorative plan? Depending on the case, there will be many questions to answer; therefore, communication between the periodontist and the referring general dentist is critical.

Phase II therapy. Phase II is an important aspect of comprehensive periodontal care. Studies have demonstrated that it is difficult to achieve adequate root instrumentation in a periodontal pocket of 5 millimeters or greater and that periodontal scaling and root planing is more difficult to accomplish on posterior vs. anterior teeth.12–17 Periodontal scaling and open débridement have been compared, and the studies have shown that open débridement is more effective in the removal of subgingival accretions from root surfaces in areas with pockets of 6 mm or greater.13,18 In addition, advances in periodontal surgical treatment have made it possible to regenerate lost structures of the periodontium through guided tissue regeneration and osseous grafts.

Even though surgical periodontal therapy offers better access for eliminating root accretions and recontouring alveolar bone destroyed by periodontal disease, there are limitations. Surgical periodontal therapy is not meant for every patient with moderate-to-advanced periodontal disease who did not respond favorably to nonsurgical periodontal therapy. Factors such as poor plaque control, smoking and uncontrolled diabetes may adversely affect the outcome of surgical treatment. In such cases, the patient should be put on a three-month supportive periodontal recall program and managed nonsurgically. The patient should be continually evaluated at each supportive periodontal therapy appointment to determine the outcome of nonsurgical treatment and the stability of his or her periodontal status. Additional assessments can be performed at a later date to determine if the patient is a candidate for surgical treatment.

Phase III therapy. Evaluation of the patient’s periodontal status should be an ongoing process during periodontal maintenance. Close monitoring is important to control the disease progression, prevent further attachment loss, sustain a satisfactory level of plaque control and maintain a high level of patient motivation. Monitoring disease activity is achieved by evaluating the clinical parameters that were assessed during the initial examination, along with the use of appropriate radiographs taken at different recall intervals.

At times, retreatment may be necessary during the maintenance phase, which may include additional root instrumentation, surgery or local delivery of antimicrobial therapy in sites that are breaking down or are refractory to previous treatment. General dentists should refer patients who are on a two-, three- or four-month supportive periodontal recall who continue to show signs of periodontitis with deep pockets, bleeding on probing, purulence or any signs of disease progression for specialty periodontal therapy.19 The decision to refer patients to a periodontist primarily depends on the clinician’s experience and skills in treating periodontal disease and the need for multidisciplinary management of the case. Patients who are referred may range from those with various forms of gingivitis to those with more complex forms of periodontal disease such as localized juvenile periodontitis, rapidly progressive periodontitis or refractory periodontitis. Referrals may not only involve periodontal disease treatment, but surgeries such as crown lengthening or other cosmetic surgical procedures. The knowledge and the decision behind knowing when to refer a patient constitute patient management (Table 2Go).


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  		TABLE 2 GUIDELINES FOR REFERRING PATIENTS WITH PERIODONTAL DISEASES FOR SPECIALTY TREATMENT.

 

   TREATMENT CONSIDERATIONS
TOP
 ABSTRACT
 DIAGNOSTIC APPROACH
 TREATMENT PLAN PHASES
 EVALUATING THE RESULTS OF...
 TREATMENT CONSIDERATIONS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Epidemiologic studies have shown that severe periodontal disease affects about 10 to 20 percent of the general population.20,21 Those with severe forms of periodontal disease may include younger people with immunological deficiencies, as well as those with longstanding, untreated adult periodontitis and those who no longer respond to conventional periodontal therapy. A recent study22 indicated that among the younger people with severe forms of periodontal disease, there is evidence of differences in disease progression and response to therapy within each diagnostic category such as rapidly progressive periodontitis and juvenile periodontitis. Cases of early-onset and refractory periodontitis often present a challenge for the periodontist,23–26 as these patients require a different treatment approach from patients with chronic adult periodontitis. In this situation, incorporation of bacteriologic testing and systemic treatment or local antimicrobial therapy often are introduced along with conventional nonsurgical therapy. Surgical therapy often is delayed until the periodontal condition is stabilized. By the time these patients are diagnosed and referred for treatment they usually exhibit moderate-to-severe periodontal disease and loss of clinical attachment. Therefore, early diagnosis and treatment are critical.
The decision to refer patients to a periodontist primarily depends on the clinician’s experience and skills in treating periodontal disease and the need for multidisciplinary management of the case.

Several retrospective studies27–30 have evaluated the effectiveness of periodontal therapy by assessing tooth loss. These studies have classified patients into groups based on the number of teeth lost after initial periodontal treatment and supportive periodontal care. Patients in the "downhill" and "extreme downhill" categories suffered significantly greater tooth mortality regardless of treatment when compared with patients in the well-maintained group. However, patients in the "downhill" and "extreme downhill" groups could have had the more aggressive forms of periodontitis such as rapidly progressive periodontitis, refractory periodontitis or systemics associated periodontitis.27 These patients would have required a different treatment protocol from patients with chronic adult periodontitis.


   DISCUSSION
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 ABSTRACT
 DIAGNOSTIC APPROACH
 TREATMENT PLAN PHASES
 EVALUATING THE RESULTS OF...
 TREATMENT CONSIDERATIONS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Nonsurgical and surgical periodontal therapy12–18,31–35 have played significant roles in the treatment of periodontitis with great success over long periods. Information obtained by research continues to pose new questions. Loesche and colleagues,36 for example, questioned whether surgical treatment is necessary in the treatment of inflammatory periodontal disease. They reported eliminating a need for surgery among the majority of the patients by relying on non-surgical treatment and multiple applications of antimicrobial agents in the treatment of moderate-to-advanced periodontitis. Their study has been perceived by most periodontists as controversial because it placed little emphasis on the benefits of surgery, while encouraging the use of antibiotics during non-surgical therapy. For some time now, the indiscriminate use of antibiotics has been judged unwise due to the development of resistant strains of pathogenic bacteria, not to mention the untoward systemic effects and development of drug hypersensitivity. Yet, prescribing antibiotics discriminately is an important adjunctive approach in the treatment of severe forms of periodontal disease and has been based on empirical judgments; it does, however, warrant an assessment of the medical history, the clinical findings of each patient, and microbial testing and antibiotic sensitivity assays obtained before initiating antibiotic therapy.37

Surgical periodontal therapy remains a viable treatment rationale in the management of some types of moderate-to-advanced periodontitis. Surgical therapy allows the clinician to gain access to root surfaces, restore a more favorable bony and gingival architecture, and regenerate lost structures of the periodontium. It also is indicated in the correction of mucogingival defects, gingival overgrowth and cosmetic conditions.

Recently, the introduction of antimicrobial products such as a chlorhexidine-containing resorbable polymer (PerioChip, Astra Pharmaceuticals) and a biodegradable polymer with 8.5 percent doxycycline (Atridox, Atrix Laboratories) for local treatment of periodontitis have been given a lot of focus as an adjunctive approach to nonsurgical periodontal therapy. These products are aimed at locally delivering a high concentration of antibiotics in the periodontal pocket to kill the putative pathogens.

A low-dose (20-milligram) doxycycline tablet (Periostat, CollaGenex Pharmaceuticals) also has been introduced for systemic use. CollaGenex Pharmaceuticals has assured clinicians that development of resistant strains of microbes is not an associated adverse effect and that Periostat does not have any antimicrobial effects at such a low dosage. Its efficacy is attributed to its potential to block the release of matrix metalloproteinases or destructive host enzymes. One example of such enzymes is host-derived collagenase, which can lead to destruction of the host’s connective tissue.

This use may sound promising but clinical trials38–40 have failed to provide overwhelmingly meaningful clinical data when compared with traditional nonsurgical treatment involving periodontal scaling and root planing and compliance with home care. Long-term studies are not yet available on most of these products, since they were introduced only recently. These products are not a cure for periodontitis, but are marketed for treatment of patients with adult periodontitis and should be used cautiously. Clinicians should always become familiar with the manufacturer’s recommendations on product information inserts before using them. In addition, clinicians should consult peer-reviewed journals for recent studies involving the use of these products to make a sound professional judgment on whether adequate information is available to support an evidence-based therapeutic approach.

When performed appropriately, nonsurgical treatment is effective in controlling many forms of periodontal disease.

Case selection is important when using these products, as well as in selecting forms of treatment. The application of these products to treat patients with the more aggressive forms of periodontitis has not yet been substantiated and is not recommended by the manufacturers. Clinicians should refrain from using these products in the treatment of patients with the more aggressive forms of periodontitis until research has indicated clinical success. Until more research data on these products become available, only patients who fall into the recommended periodontal diagnostic category and only those who may benefit from the aforementioned therapies should receive treatment.


   CONCLUSION
TOP
 ABSTRACT
 DIAGNOSTIC APPROACH
 TREATMENT PLAN PHASES
 EVALUATING THE RESULTS OF...
 TREATMENT CONSIDERATIONS
 DISCUSSION
 CONCLUSION
REFERENCES
 
The efforts of pharmaceutical companies and dental researchers should be applauded as they strive to revolutionize the approach to nonsurgical periodontal therapy; however, until more evidence-based data become available, other conventional periodontal treatment options including surgical periodontics should remain viable considerations.

It is important for clinicians to become knowledgeable in diagnosing periodontal diseases, assessing factors that affect diagnosis and prognosis, and formulating individualized treatment plans. Clinicians must continue to develop and enhance their skills and dexterity to perform nonsurgical periodontal therapy and recognize changes between pre- and posttreatment clinical parameters by continuously evaluating their patients’ periodontal statuses. Nonsurgical therapy primarily is used in the initial and supportive phases of periodontal therapy. Only by diligence in continuous evaluation of each case can the disease be arrested in most patients. When performed appropriately, non-surgical treatment is effective in controlling many forms of periodontal disease. When non-surgical therapy is not adequate or effective in controlling the disease, however, periodontal surgery should remain an option. Many moderate-to-advanced cases may benefit from surgical intervention to access root surfaces in deep pockets and to correct bony topography or regenerate missing structures.

As always, the best interest of the patient should be the primary consideration when administering treatment. Consequently, clinicians should know when to treat and when to refer new and existing patients with periodontal disease for specialty care.


   FOOTNOTES
 

Dr. McLeod is an assistant professor and the section head, Section of Periodontology, Department of Applied Dental Medicine, Southern Illinois University, School of Dental Medicine, 2800 College Ave., Alton, Ill. 62002-4798. Address reprint requests to Dr. McLeod.


The author thanks Dr. Phillip A. Lainson, professor and director of Graduate Periodontics, the University of Iowa College of Dentistry, Iowa City, Iowa, and Dr. William F. Killian, clinical professor, Section of Periodontics, Southern Illinois University School of Dental Medicine, Alton, Ill., for their editorial comments.


   REFERENCES
TOP
 ABSTRACT
 DIAGNOSTIC APPROACH
 TREATMENT PLAN PHASES
 EVALUATING THE RESULTS OF...
 TREATMENT CONSIDERATIONS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Proceedings of the 1996 World Workshop in Periodontics. Lansdowne, Va., July 13–17, 1996. Ann Periodontol 1996;1(1):443–706.[Medline]

  2. Jeffcoat MJ, McGuire M, Newman MG. Evidence-based periodontal treatment: highlights from the 1996 World Workshop in Periodontics. JADA 1997;128:713–24.

  3. The American Academy of Periodontology ad hoc committee on parameters of care: Parameters of care. Chicago: The American Academy of Periodontology; 1996.

  4. Early-onset periodontitis: genetic, host response and microbiological factors in the understanding of the pathogenesis, diagnosis and treatment of disease. J Periodontol 1996;67(suppl):279–366.

  5. Current procedural terminology for periodontics and insurance reporting manual. 7th ed. Chicago: The American Academy of Periodontology; 1997:1–2.

  6. Williams RC. Periodontal disease: the emergence of a new paradigm. Comp Cont Educ Dent 1998;190(special issue):4–10.

  7. Pattison AM. The use of hand instruments in supportive periodontal treatment. Periodontol 2000 1996;12:71–89.

  8. Stendhe FW, Schaffer EM. A comparison of ultrasonic and hand instrument. J Periodontol 1961;32:312–4.

  9. Laurell L. Periodontal healing after scaling and root planing with the Kavo Sonicflex and the Titan-S sonic scalers. Swed Dent J 1990;14(4):171–7.[Medline]

  10. Breininger DR, O’Leary TJ, Blumenshine RV. Comparative effectiveness of ultrasonic and hand scaling for the removal of sub-gingival plaque and calculus. J Periodontol 1987;58(1):9–18.[Medline]

  11. Dragoo MR. A clinical evaluation of hand and ultrasonic instruments on subgingival débridement: Part 1, with unmodified and modified ultrasonic inserts. Int J Periodontics Restorative Dent 1992;12(4):310–23.[Medline]

  12. Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal therapy: Part 1, moderately advanced periodontitis. J Clin Periodontol 1981;8(1):57–72.[Medline]

  13. Caffesse RG, Sweeney PL, Smith BA. Scaling and root planing with and without periodontal flap surgery. J Clin Periodontol 1986;13(3):205–10.[Medline]

  14. Lindhe J, Nyman S. The effect of plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health: a longitudinal study of periodontal therapy in cases of advanced disease. J Clin Periodontol 1975;2(2):67–79.[Medline]

  15. Ramfjord SP, Knowles JW, Nissle RR, Shick RA, Burgett FG. Longitudinal study of periodontal therapy. J Periodontol 1973;44(2): 66–77.[Medline]

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  17. Lindhe J, Westfelt E, Nyman S, Socransky SS, Haffajee AD. Long-term effect of surgical/non-surgical treatment of periodontal disease. J Clin Periodontol 1984;11(7): 448–58.[Medline]

  18. Brayer WK, Mellonig JT, Dunlap RM, Marinak KW, Carson RE. Scaling and root planing effectiveness: the effect of root surface access and operator experience. J Periodontol 1989;60(1):67–72.[Medline]

  19. Townsend CH. Guidelines for supportive periodontal therapy intervals and for referral to a periodontist. Periodontal Insights 1994;1(4):9–10.

  20. National Institute of Dental Research. Oral health of the United States adults: National findings. Bethesda, Md.: National Institute of Dental Research; 1987. U.S. Public Health Service publication National Institutes of Health 87–2868.

  21. Johnson NW. Detection of high-risk groups and individuals for periodontal diseases. Int Dent J 1989;39(1):33–47.[Medline]

  22. Albandar JM, Brown LJ, Genco RJ, Löe H. Clinical classification of periodontitis in adolescents and young adults. J Periodontol 1997;68(6):545–55.[Medline]

  23. Gunsolley JC, Zambon JJ, Mellot CA, Brooks CN, Kaugars CC. Maintenance therapy in young adults with severe generalized periodontitis. J Periodontol 1994;65(3): 274–9.[Medline]

  24. Brown LJ, Albandar JM, Brunelle JA, Löe H. Early-onset periodontitis: progression of attachment loss during 6 years. J Periodontol 1996;67(10):968–75.[Medline]

  25. Magnusson I, Walker CB. Refractory periodontitis or recurrence of disease. J Clin Periodontol 1996;23(3 pt 2):289–92.[Medline]

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  27. McLeod DE, Lainson PA, Spivey JD. The effectiveness of periodontal treatment as measured by tooth loss. JADA 1997:128: 316–24.

  28. Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978;49(5): 225–37.[Medline]

  29. McFall WT Jr. Tooth loss in 100 treated patients with periodontal disease: a long-term study. J Periodontol 1982;53(9):539–49.[Medline]

  30. Becker W, Berg L, Becker BE. The long term evaluation of periodontal treatment and maintenance in 95 patients. Int J Periodontics Restorative Dent 1984;4(2):54–71.[Medline]

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  32. Cercek JF, Kiger RD, Garrett S, Egelberg J. Relative effects of plaque control and instrumentation on the clinical parameters of human periodontal disease. J Clin Periodontol 1983;10(1):46–56.[Medline]

  33. Lindhe J, Socransky SS, Nyman S, Westfelt E. Dimensional alteration of the periodontal tissues following therapy. Int J Periodontics Restorative Dent 1987;7(2):9–21.

  34. Lindhe J, Nyman S. Long-term maintenance of patients treated for advanced periodontal disease. J Clin Periodontol 1984;11(8): 504–14.[Medline]

  35. Lang NP. Indications and rationale for non-surgical periodontal therapy. Int Dent J 1983;33(2):127–36.[Medline]

  36. Loesche WJ, Giordano J, Soehren S, et al. Nonsurgical treatment of patients with periodontal disease. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81(5):533–43.[Medline]

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  38. Jeffcoat MK, Bray KS, Ciancio SG, et al. Adjunctive use of a subgingival controlled-release chlorhexidine chip reduces probing pocket depth and improves attachment level compared with scaling and root planing alone. J Periodontol 1998;69(9):989–97.[Medline]

  39. Garrett S, Johnson L, Drisko CH, et al. Two multi-center studies evaluating locally delivered doxycycline hyclate, placebo control, oral hygiene, and scaling and root planing in the treatment of periodontitis. J Periodontol 1999;70(5):490–503.[Medline]

  40. Caton JG, Ciancio SG, Crout RJ, Hefto AF, Polson AM. Adjunctive use of doxycycline therapy for periodontitis (abstract 2957). J Dent Res 1998;77:1001.




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