DOI: 10.1111/prd.
12245
Treatment trends in periodontics
Raúl G. Caffesse1 | Josė J. Echeverría2
1
Postgraduate Periodontics, Faculty of Dentistry, Universidad Complutense de Madrid, Madrid, Spain
2
Periodontics, Faculty of Dentistry, University of Barcelona, Barcelona, Spain
Correspondence: Raúl G. Caffesse, DDS, MS, 2114 Morse Street, Houston, Texas 77019. (rcaffesse@sbcglobal.net).
1 | INTRODUCTION
This volume of Periodontology 2000, entitled “Treatment Trends in
Periodontics”, represents partly a continuum to volume 67, entitled
“A Latin American Perspective of Periodontology”. The former vol-
ume was devoted to the presentation of basic research related to
periodontology in Latin America. It was a compilation of studies cov-
ering areas of epidemiology and microbiology of periodontal dis-
eases, effects of treatment, systemic antibiotics, smoking, lasers, and
basic research on periodontal regeneration. Those chapters provided
a representation of the many centers in Latin America which are
engaged in basic periodontal research. The current volume of Peri-
odontology 2000 is devoted entirely to clinical research in periodon-
tics. This volume, once again, recognizes research from academic
centers in Latin America, which are known for their studies in pre-
clinical periodontal models and randomized controlled clinical trials.
The current volume of Periodontology 2000 also includes clinical
research from Spain. The number of Spanish‐ and Portuguese‐speak-
ing research groups involved in clinical periodontics has skyrocketed
on both sides of the Atlantic during the past decades and these
groups have significantly contributed to the present day knowledge
and practice of periodontics. This volume of Periodontology 2000
also includes the contributions of a highly recognized group of inter-
national clinical researchers covering topics in the control of teeth
and implant diseases. Thus, this volume of Periodontology 2000
aims to bring together a variety of research that has direct clinical
relevance.
2 | CONTENT HIGHLIGHTS
1
Lang et al cover the topic of when and why nonsurgical therapy
needs to be applied to periodontal and implant treatment. After a
historical review on the concept of periodontal therapy and the
influence of development of longitudinal studies in clinical practice,
1
Lang et al stress that almost 50% of the probing pocket depth
reductions achieved after surgery in pockets ≥4 mm were a result of
Periodontology 2000. 2019;1–8. wileyonlinelibrary.com/journal/prd
the scaling and root planing performed before surgery. Also, the con-
cept of “critical probing depth” is reviewed, that is, the initial prob-
ing depth below which a particular treatment will result in loss of
attachment and above which it will result in attachment gain. Surgi-
cal treatment based on modified Widman flap surgery will result in
gain of clinical attachment when probing depths are ≥6 mm. How-
ever, the critical depth for surgery should be assessed after reevalu-
ating the outcome following initial scaling and root planing because
significant clinical reduction in probing depth occurs in response to
such treatment. Thus, only after reevaluation of the outcome
achieved by nonsurgical therapy should surgery be considered, based
on residual probing depths and the presence of inflammation (bleed-
ing on probing). Initial probing depths of ≤5 mm are controlled by
nonsurgical therapy. The authors conclude that every case of peri-
odontal disease needs to be treated nonsurgically and may be sup-
plemented by other antimicrobial means, such as photodynamic
therapy. In peri‐implant diseases, the authors recommend manage-
ment of mucositis by mechanical debridement together with patient‐
performed plaque control. In peri‐implantitis, however, nonsurgical
therapy may not provide sufficient implant decontamination, and
access surgery may be indicated.
In current periodontal treatment, surgical intervention continues
to represent a significant component of the overall treatment plan.
The focus, of course, has evolved over time from a resective
approach to a reparative or regenerative objective approach that is
based on a better understanding of the etiology and pathogenesis of
the disease, wound healing, and the outcome in long‐term prospec-
tive studies. Consequently, two areas that have emerged during the
past decades and dominate the interest of the periodontal commu-
nity are regeneration of lost periodontal support and development of
plastic periodontal procedures.
Sallum et al2 present an exhaustive review of the topic of regen-
erative periodontal therapy based on animal research and random-
ized clinical trials. Regeneration refers to restoration of both the
original architecture and the function of lost tissues (restitutio-ad-
integrum). Histological proof is needed to demonstrate new cemen-
tum, periodontal ligament, and bone coronal to the base of the
© 2019 John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
2 |
periodontal defect in human material, in humans, as well as animal
studies with appropriate controls, and controlled human clinical trials.
The authors stress the challenge to achieve predictable periodontal
regeneration in clinical practice and the somehow inconsistent
results reported in the treatment of angular bony defects, furcations,
and gingival recessions. Guided tissue regeneration is evaluated in
detail, including the use of resorbable and nonresorbable mem-
branes. Both types of membrane yield similar results, favoring tissue
integration achieved with resorbable membranes in order to avoid a
second surgery. Significant results can be obtained with Class II fur-
cations and angular bony defects, while the outcome is less consis-
tent with Class III furcations and recession defects. The possibility of
using acellular dermal matrix as a membrane in treating Class II fur-
cations, and the anatomical factors that may affect guided tissue
regeneration results are also discussed, as are the results obtained
with modified membranes counteracting cervical concavities on the
root. The role of the “old cementum” in promoting new cementum
formation is discussed in detail, and a conservative approach with
less aggressive root instrumentation than that applied in the past in
periodontal defects is recommended in order to achieve better histo-
logical regenerative results. Based on gene expression data, it seems
that the maintenance of root cementum may modulate the expres-
sion of growth and mineral‐associated factors during periodontal
regeneration. Bone grafts and graft substitutes are discussed when
applied either alone or in combination with regenerative strategies.
Autogenous grafts are considered the “gold standard” because of
their osteoinductive possibilities; however, even with the use of such
grafts, the results can be variable and inconclusive. Histological
assessment has revealed that periodontal regeneration, especially
after the use of alloplastic materials, may not produce predictable
gain in clinical attachment and radiographic evidence of bone fill. In
addition, alloplastic materials seem to have little or no osteoinductive
capacity. The alloplastic graft acts mainly as a scaffold or biological
filler. In combined therapy, addition of grafting material does not
seem to significantly improve the clinical outcome. Despite reports
on positive outcomes with intrabony and Class II furcation defects,
the advantages and possible additive benefits of the concomitant
use of allografts, autografts, and/or other filling materials with guided
tissue regeneration remain controversial. The treatment of Class III
furcations is unpredictable, although partial closure of Class III furca-
tion lesions might be achievable with guided tissue regeneration plus
bovine inorganic bone matrix. Enamel matrix derivative, a heteroge-
neous mixture of proteins containing amelogenins, can enhance gene
expression, protein production, proliferation, and differentiation of
various cell types. Enamel matrix derivative is considered to be able
to induce acellular cementum, collagen fibers, and bone in intrabony
defects, Class II furcations, gingival recessions, and even in horizontal
bone loss, and to improve clinical attachment, reduce probing depth,
and minimize gingival recession.3 When comparing enamel matrix
derivative with guided tissue regeneration, the results are similar but
guided tissue regeneration is associated with a larger number of
postoperative complications, such as membrane exposure, than
enamel matrix derivative. In combination therapies, the additional
CAFFESSE AND ECHEVERRÍA
benefit achieved is nonsignificant compared with single therapy with
either enamel matrix derivative or guided tissue regeneration. Finally,
Sallum et al2 review the role of growth differentiation factors and
tissue engineering procedures. These methodologies are still at an
experimental stage, and the results obtained using these methodolo-
gies, when applied alone or in combination therapies, are conflicting.
Improvement in tissue‐engineering outcomes may depend on con-
trolling or modifying specific factors associated with the wound heal-
ing process, and numerous biological, technical, and clinical
difficulties need to be overcome before periodontal tissue engineer-
ing can be incorporated into clinical practice. In summary, this chap-
ter nonetheless presents unequivocal evidence that regenerative
periodontal therapy can be effective, as long as patient cases are
properly selected and risks and modifying factors are addressed.
Novaes and Palioto4 present an extensive review on periodontal
plastic surgery to cover denuded roots. A description of different fac-
tors, anatomical in nature, that contribute to the development of
localized gingival recessions is presented; however, dental biofilm‐
associated inflammation and traumatic toothbrushing are reported to
be responsible for most gingival recessions. Localized gingival reces-
sions may receive treatment because of functional requirements;
however, treatment is most commonly a result of esthetic demands.
A detailed analysis of different surgical strategies in the treatment of
single and multiple gingival recessions are discussed, including the
use of free gingival grafts and pedicle flaps (semilunar, laterally posi-
tioned, and coronally positioned). Pedicle coronally positioned flaps
are considered the “gold standard”, and the subepithelial connective
tissue graft is extensively reviewed. The authors suggest the use of
autologous and allogenic grafts as alternatives for subepithelial con-
nective tissue grafts, and present modifications to the classical coro-
nally advanced flap design. The treatment of multiple gingival
recessions is also addressed, as is the rationale for using guided tissue
regeneration and/or enamel matrix derivative for their treatment. The
authors questioned the use of guided tissue regeneration in the treat-
ment of gingival recessions because of the technical difficulty of the
method and the superiority of plastic periodontal procedures, propos-
ing that guided tissue regeneration has become obsolete for root
coverage procedures, especially in demanding esthetic cases. Addi-
tionally, the negative effect of smoking on the outcome of plastic
procedures is emphasized, and minimally invasive techniques are sug-
gested to have indications in periodontal plastic procedures, although
such techniques need to be further evaluated in clinical trials.
Chambrone et al5 evaluate the same issue of periodontal plastic
surgery in the treatment of gingival recessions, based on data from
randomized clinical trials, systematic review and meta‐analysis. The
authors corroborate the role of subepithelial connective tissue grafts,
with or without a coronally advanced flap, as the “gold standard” for
complete root coverage, with long‐term stability and gain in kera-
tinized tissue. The authors suggest that a coronally advanced flap in
combination with biomaterials (allogeneic or heterogenic tissue sub-
stitutes and/or enamel derivative proteins) may provide satisfactory
results and serve as an alternative procedure to a subepithelial con-
nective tissue graft. Their conclusions are based on knowledge about
CAFFESSE AND ECHEVERRÍA
the etiology of gingival recession, the ability of plastic surgical proce-
dures to achieve root coverage, and the outcome findings in system-
atic reviews.
Stem cells may form the basis for more successful periodontal tis-
sue engineering. Nuñez et al6 discuss animal studies performed
in vitro and in vivo to investigate the role of cellular therapy in peri-
odontal regeneration. After pointing out the limited capacity of peri-
odontal tissues for self‐regeneration, the authors evaluate the
potential role of enamel matrix proteins in differentiation of cemento-
blasts and in attaining new cementum formation. In studies from the
Nuñez group, human periodontal ligament fibroblasts and cementum‐
derived cells were isolated, incubated, processed, and characterized
by immunocytochemistry, real‐time PCR, and western blotting. The
study cells showed production of enamel‐ and cementum‐associated
proteins, indicating that they may be able to regulate cementoblast
differentiation and cementum deposition. In a dog model, stem cells
from periodontal ligament and cementum were isolated, character-
ized, and implanted in experimentally created intrabony defects, using
a collagen sponge as the carrier. Both cementoblasts and mesenchy-
mal stem cells showed ability to stimulate an increase in the amount
of new cementum and histological periodontal attachment. However,
the need for an appropriate carrier and for developing a proper
wound environment became apparent. As both types of stem cells
produced similar results, use of the more easily accessible periodontal
ligament‐derived stem cells has greater appeal, but either experimen-
tal approach requires additional studies before current findings can
be translated into patient treatment.
After decades of rejecting the focal infection theory and ignoring
the possible connection between the oral cavity and the rest of the
body, interest has resurfaced on the impact of oral diseases systemi-
cally. Systemic diseases may influence periodontal disease, but peri-
odontitis may also contribute to systemic diseases. In the 1960s and
7,8
1970s, individuals such as Cheraskin and Ringsdorf and Clark et
al9 tried to stress the importance of systemic nutrition in periodontal
disease etiology and treatment, but this approach was considered by
the dental profession to be faddish and without scientific support.
There was almost no research linking systemic conditions and peri-
odontal disease. Today, with the resurgence of “periodontal medi-
cine”, new knowledge has been gained on a possible link between
periodontitis and systemic diseases. The mouth and the periodontal
pocket contain a wide variety of infectious agents that can enter the
bloodstream or the respiratory tract. These potential pathogens can
produce or exacerbate a systemic inflammatory response or directly
infect various organ systems of the body. Falcao and Bullon10 dis-
cuss, in this volume of Periodontology 2000, the relatively limited and
somewhat inconclusive evidence of the effect of periodontal therapy
on certain systemic diseases. Evaluations have been difficult because
of heterogeneity of the parameters evaluated, limited sample size,
short time duration of studies, variability in periodontal disease defi-
nition, and different periodontal treatment types and end‐points.
Sufficient level of evidence exists to support an association between
atherosclerotic vascular disease and periodontal disease, but the
relationship cannot be considered causal. Current studies indicate
| 3
that periodontal treatment (scaling and root planing) might result in
a reduction of cardiovascular disease risk because treatment
improves most values of the biomarkers associated with cardiovascu-
lar diseases. However, there is a need for larger numbers of long‐
term interventional studies to provide conclusive evidence. For
years, diabetes mellitus and periodontal disease have been consid-
ered to bear a bidirectional relationship. Evidence indicates higher
prevalence and greater severity of periodontal disease in diabetic
patients than in individuals without diabetes, and also that periodon-
tal disease may jeopardize metabolic control of diabetes. However,
whether periodontal treatment can improve glycemic control in
patients with type 2 diabetes is controversial. Systematic reviews
evaluating nonsurgical periodontal treatment have shown inconsis-
tent results, with little or no improvement in glycated hemoglobin
levels in patients with moderate to severe periodontal disease. Co‐
founding factors, such as degree of diabetes, diabetic medications,
lifestyle, etc may contribute to the lack of clear benefit from peri-
odontal treatment. Pregnancy and the possible effect of periodontal
treatment in reducing risks of adverse outcomes are also discussed.
Studies continue to indicate that periodontal therapy in pregnant
women improves the levels of biomarkers, such as C‐reactive protein
and other inflammatory cytokines, but there is no definitive evidence
that periodontal treatment can improve pregnancy outcomes. How-
ever, the authors stress that this lack of evidence is not an excuse
to avoid proper periodontal treatment during pregnancy to control
infection and inflammation. Psoriasis has also been linked to peri-
odontal disease, with increased bone and tooth loss in affected
patients. An increase in psoriasis severity has been reported in
patients with periodontal disease. Surgical periodontal treatment
reduced, but did not eliminate, the risk for subsequent episodes of
psoriasis. A few case reports indicate improvement of symptoms and
clinical manifestations. Rheumatoid arthritis and periodontal disease
show a positive association, and several similarities seem to exist
between the inflammatory mechanisms of rheumatoid arthritis and
alveolar bone resorption. Periodontal treatment has been found to
be beneficial in reducing rheumatoid arthritis activity and severity.
Oral and (specifically) periodontal bacteria have the possibility of
being inhaled into the respiratory system. Hence, periodontal disease
has also been associated with respiratory diseases, such as chronic
obstructive pulmonary disease and pneumonia. Greater attachment
loss increases the risk for chronic obstructive pulmonary disease, as
well as diminishing lung function and quality of life. Systematic
reviews have signaled the positive effects of periodontal treatment
in reducing the occurrence of pneumonia. Relationships are also con-
sidered to exist between periodontal disease and chronic kidney dis-
ease and between periodontal disease and head and neck carcinoma,
among others. In essence, it is evident from the many systematic
reviews and meta‐analyses that the final word on the effects of peri-
odontal treatment on systemic conditions has yet to be clearly
established. However, as the authors state, no study has reported
any detrimental effects of periodontal treatment on the systemic
condition, meaning that if performed, at least its beneficial effect will
be improved periodontal health. A medico‐dental multidisciplinary
4 |
approach to the evaluation and treatment of patients affected by
possibly combined conditions, needs to be promoted.
An area of constant disagreement in periodontics is the role that
occlusion plays in the initiation and progression of the periodontal
lesion. Throughout the history of periodontics, occlusal factors have
been considered as a fundamental etiologic agent, a feature that
contributes (together with microbial biofilm) to periodontal break-
down, or a clinical entity that affects the periodontal tissues but is
independent of infectious periodontitis. Passanezzi and Passanezzi
Sant'Ana11 deal with the role of occlusion in periodontal disease.
They present a comprehensive historical review from the late 1930s
(when the first reports considering occlusion as an etiologic factor in
periodontitis were published) until present. Furthermore, they dis-
cuss the physiologic and pathologic effects of occlusion on the sup-
porting periodontal tissues, the role of traumatogenic occlusion and
occlusal trauma, the capacity of tissue adaptation and remodeling
based on current research findings, and current understanding of the
mechanisms of molecular modulation in the presence of physiological
and altered occlusal functions. The authors consider that occlusion
influences the homeostatic behavior of the periodontal supporting
tissues and state that periodontitis and trauma from occlusion may
coexist independently or may co‐act to produce a combined lesion.
These authors conclude that implicating trauma from occlusion as an
exacerbation of the biofilm‐initiated periodontal lesion has been, and
is still, an open question, which deserves further research.
The advent of osseointegration certainly revolutionized den-
tistry, and implants have been embraced by periodontics, especially
after alveolar ridge correction procedures allowed for their univer-
sal placement. Traditionally, implants were placed on healed ridges
after the extractions, which required postponing their placement
for several months. However, this waiting period permitted, in cer-
tain circumstances, the development of bone resorption and ridge
deformities at the extraction site, yielding compromised esthetic
results. As a consequence, in the anterior esthetic zone, implants
began to be placed immediately after extraction in the fresh socket,
under the assumption that the immediate placement was sufficient
to negate the detrimental bone and ridge effects of the extraction.
Araujo et al12 report, based on studies obtained from MEDLINE
and other database searches, on the effect of socket healing with
or without immediate implant placement. Studies in animal models
have described the evolution of socket healing, including loss of
buccal bone height being dependent on the thickness of the labial
plate. However, placement of implants in fresh extraction sockets
failed to prevent buccal bone loss and height reduction. The thin-
ner the socket wall, the higher the chances for bone resorption
and dehiscence formation. Furthermore, the closer the implant was
placed to the buccal wall, the greater the resorption. In essence,
they conclude that immediate implant placement in fresh extraction
socket allows for osseointegration but fails to prevent ridge reduc-
tion. The application of regenerative strategies, including hard and
soft tissue grafting, at the time of implant placement, may reduce
the dimensional changes of the alveolar ridge but will not eliminate
them completely.
CAFFESSE AND ECHEVERRÍA
The same topic of implant placement in fresh extraction sockets
is covered by Blanco et al13 who focuses on the clinical evidence
and practical considerations. Although recent systematic reviews
indicate that immediate implants survive at a rate similar to those
installed with a delayed approach, it is proven that placement of the
implant does not preclude the loss of buccal bone, which may create
dehiscences and thus affect the esthetic results. They consider the
success and survival rates of immediate implants and compare those
with the success and survival rates for delayed implants, based on
published evaluations, and discuss the biological, technical, and
esthetic complications reported in the literature. Furthermore, the
authors review, in detail, clinical studies in which a variety of factors
have been identified that may help prevent bone resorption associ-
ated with immediate implant placement. Size of the alveolus, thick-
ness of the buccal bony plate, gingival biotype, dimension of the
void between implant and buccal bone, whether a flap or flapless
procedure is performed, implant diameter and positioning, the simul-
taneous use of bone and/or connective tissue grafts, and the use of
provisional restorations and antibiotic coverage, are all discussed in
detail. The authors conclude that after thorough evaluation and
detailed planning, immediate implants placed in fresh extraction
sockets could be carried out according to a series of guidelines they
describe as clinical implications of the research reviewed. Consider-
ing all those factors in the hands of an expert professional, the
immediate treatment approach seems to be possible and beneficial
for the patient.
Guglielmotti et al14 give a detailed account of the many lines of
research related to dental implants and osseointegration performed
using experimental models in rats. Osseointegration has been studied
using titanium, zirconium, and other bioceramic implant materials.
Data are available on bone repair at the bone‐implant interface, in
which the properties and biological effects of biomaterials for dental
implants and of bone substitutes are assessed. The results of local
and systemic factors affecting the process of peri‐implant bone heal-
ing, such as implant surface treatments and bisphosphonates, and
the effect of implant corrosion in surrounding tissues and its integra-
tion, are also discussed. In addition, the authors evaluated failed den-
tal implants and assessed bone biopsies from maxillary sinus floor
augmentation procedures using bone substitutes. The authors con-
clude that research on biomaterials and their interaction with the
biological environment remain important issues for improving bio-
compatibility and patient health.
Mombelli15 presents an extensive review of the current approach
to the maintenance of teeth and implants, stressing that long‐term
stability has been documented provided that proper patient care is
followed after therapy. Three different components are considered
in maintenance: those performed by the patient on a daily basis; pre-
ventive steps provided by the dental team (ie, prophylaxis); and pro-
cedures usually performed by the dentist as part of supportive
therapy to control recurrent or residual disease. Stressing that differ-
ent avenues of research have documented a predominant role for
build‐up of the bacterial biofilm in the initiation and progression of
periodontal and peri‐implant diseases, the author emphasizes that to
CAFFESSE AND ECHEVERRÍA
secure long‐term success, accumulation of large amounts of bacte-
ria should be avoided, local factors favoring that accumulation
should be eliminated or controlled, and removal of the bacterial
deposits is a critical step during maintenance. The importance of
risk factors is mentioned and, from the evidence, it is emphasized
that smoking cessation therapy should be advised, when indicated,
as part of tooth and implant maintenance. Mombelli recommends
to start maintenance care after treatment at 3‐month intervals.
The stability of the results must be evaluated constantly, and the
recall interval adjusted accordingly. Not only should the biofilm be
taken into consideration, available risk factors should also be con-
sidered. Regularly repeated scaling and root planing with stainless
steel curettes may be overtreatment – and detrimental to the
tooth, resulting in loss of cementum and dentin – therefore, less
aggressive mechanical and nonmechanical approaches are being
evaluated. As there are no microbiological or biochemical tests
that provide better assessment of disease than the clinical param-
eters, Mombelli15 recommends to document the percentage of
bleeding points, number of residual pockets >4 mm, number of
lost teeth, loss of periodontal support relative to patient's age,
systemic conditions, and environmental factors (smoking). From
the interplay of these 6 factors a risk of disease recurrence can
be attained and an individual supportive regimen tailored,
although, so far, this concept has not yet been validated in scien-
tific studies. It is also recommended to use approaches less trau-
matic than steel curettes to control subgingival biofilm, namely
methods which will remove calculus but not necessarily the bio-
film. Antimicrobial rinses, gels, ointments, varnishes or drug release
devices, photodynamic therapy, and subgingival air‐polishing are
being evaluated as possible options. Finally, referring specifically to
15
implant maintenance, Mombelli indicates that the progression
from mucositis to peri‐implantitis is usually slow, which should
provide a reasonable period of time to prevent the latter. How-
ever, the evaluation ought to include “sensitive clinical assess-
ments” to detect inflammation and infection before a significant
amount of bone support has been lost. The regimen of the cumu-
lative interceptive supported therapy is recommended.
In a similar vein, Echeverria et al16 discuss the topic of motiva-
tion and adherence during supportive periodontal therapy, which is
crucial for the long‐term success of treatment, as already emphasized
by Mombelli.15 While compliance refers to a person's response to
medical advice, adherence implies that the patient follows the
instructions given. Furthermore, adherence requires that the patient
partakes an active role in the management of his disease, and, of
course, in the long‐term consideration of any chronic disease, such
as periodontitis, it will also mean a persistence of efforts to guaran-
tee success. In periodontitis, adherence and persistence involves the
patient's routine responsibility with self‐care at home, and, very par-
ticularly, willingness to routinely attend periodic follow‐up visits in
the dental office. It is agreed that oral hygiene alone is not effective
maintenance in the absence of professional intervention. Although it
is considered that a 3‐ to 4‐month recall is ideal for long‐term suc-
cess, the minimum recall compatible with long‐term stable results
| 5
has not been yet determined and should be implemented according
to patient need. Clinical reports and a few randomized clinical trials
indicate that compliance with supportive periodontal treatment pro-
motes reductions in plaque and bleeding, minimizes progression and
recurrence of disease, and reduces tooth loss. However, after the
first 2 years of maintenance, only around 30% of the patients show
satisfactory adherence and persistence. The professional team needs
to reinforce the importance of patient self‐care and follow‐up dental
visits and apply motivational intervention resources to promote
patient compliance. Compliance could be considered a disease‐modi-
fying factor affecting tooth survival.
Bringing a different approach to the treatment and control of the
periodontal infection, Slots and Slots17 present a thorough review on
the role of herpesviruses. After discussing herpesvirus classification
and characteristics, their role in oral and medical diseases are consid-
ered with particular emphasis on severe periodontitis. Stating that
herpesviruses, together with specific bacterial pathogens, are primar-
ily responsible for the initiation and progression of periodontal
breakdown, the authors outline a treatment and maintenance regi-
men with the overall objective of controlling both herpesviruses and
bacteria. The authors recommend the combined use of povidone‐
iodine for subgingival irrigation, systemic antiviral and bacterial
antibiotic medications, and mechanical treatment. Furthermore,
patient home care, including twice‐weekly oral rinses with 0.1%‐
0.25% sodium hypochlorite, is strongly emphasized. The authors
stress that the therapeutic approach comprises an efficient and reli-
able antiinfective treatment of advanced periodontitis, reducing time
of application with minimal cost and risk, making it ideal for world-
wide use in all economic settings.
Valkenburg et al18 evaluate the usefulness of dentifrices on the
control of plaque and gingivitis. Based on a meta‐review and analysis
of systematic reviews, they conclude that a regular dentifrice con-
taining a standard concentration of sodium fluoride for caries control
does not provide any added effect to the mechanical action of
toothbrushing alone on plaque removal. Of all the products added to
a dentifrice and evaluated by systematic reviews, only triclosan and
stannous fluoride seem to provide (moderate) improvements in con-
trolling dental plaque and gingivitis. A comparison between these
two products in reducing dental plaque has yielded inconclusive
results.
3 | PRINCIPLES IN PERIODONTAL
THERAPY
3.1 | Treating the periodontal pocket
Since Sigurd Ramfjord, our mentor, published his “Rational for peri-
odontal therapy”19 in 1953, in which four phases – systemic, hygienic,
corrective, and maintenance – were outlined in the treatment of peri-
odontitis, this framework has become the blueprint of therapy. The
designations might change but the rationale and objectives of each
therapeutic phase remain the same. Every patient treated for adult
periodontitis should go through those four phases of therapy.
6 |
Patients should receive a thorough, nonsurgical debridement,
including scaling and root planing with hand and/or mechanical
instruments, to remove subgingival biofilm and calculus deposits.
This instrumentation, coupled with instruction to the patient on an
adequate means of oral hygiene, constitute a most important foun-
dation for successful treatment.20 In specific instances, the above
treatment may be complemented by antibiotic therapy. However,
adult periodontitis, the garden‐variety of periodontitis, may not ben-
efit from adjunctive antibiotic therapy. The use of different mou-
thrinses with antimicrobial effect may help to control chronic
periodontal infections. Severe periodontitis, however, may benefit
from the adjunctive application of systemic antimicrobials.
The key issue in periodontal therapy is how the soft tissues
respond to the treatment rendered. This response of the soft tissues
to scaling and root planing needs to be assessed at reevaluation,
which should be performed 4‐6 weeks after root surface instrumen-
tation. If the debridement has been thorough, and the objectives
have been reached, pockets will be reduced, clinical attachment will
be gained, and tissue inflammation will be controlled as indicated by
the elimination of bleeding on probing.21,22 In essence, pocket clo-
sure will be achieved by a combination of gingival margin recession
and clinical attachment gain.23,24 Only after reevaluation should the
need for further treatment be considered. Thus, surgical indication
for the treatment of periodontal pockets in chronic adult periodonti-
tis should be postponed until reevaluation after the hygienic
phase.25
3.2 | Surgery or no surgery in routine periodontal
therapy
Since the original Michigan longitudinal studies in the 1960s and
1970s, it has been shown that shallow periodontal pockets (<4mm)
cannot be reduced and that clinical attachment is lost after sur-
gery.26 Other longitudinal studies that followed showed similar
results.20,21 However, in their assessment, most of these studies
included the combined effect of nonsurgical and surgical treatments.
The Minnesota study was the first attempt to compare the effect of
nonsurgical treatment alone with nonsurgical treatment plus modi-
fied Widman flap surgery. With proper maintenance, it was shown
that, after 4 and 6.5 years, there was no difference in probing reduc-
tion when treating pockets ≤6 mm deep. In pockets ≥7 mm, how-
ever, probing depth reduction was greater when the modified
Widman flap surgery was performed. In both instances, clinical
attachment levels were maintained.27
It is worth remembering that it has also been demonstrated that
scaling and root planing in pockets ≤4 mm was equally effective in
removing subgingival calculus, regardless of whether it was performed
in conjunction with raising a flap. However, in pockets ≥5 mm, an
access flap, providing visibility and accessibility, allowed for better cal-
28
culus removal. In essence, shallow periodontal pockets should not
be treated using a surgical approach. The root surfaces can be instru-
mented properly without raising a flap, so the infection and tissue
inflammation can be controlled. Furthermore, probing depths will be
CAFFESSE AND ECHEVERRÍA
reduced only minimally or not at all, whereas clinical attachment can
be lost as a consequence of a surgical procedure.
Subsequent Michigan long‐term studies, in which the effect of the
hygienic phase performed by a dental hygienist and surgical and non-
surgical procedures performed by a periodontist were individually con-
sidered, demonstrated that approximately 50% of the overall
improvement obtained in pockets ≥4 mm was achieved during the
hygienic phase of therapy.22 Later on, the long‐term Tucson study, in
which surgical procedures and scaling and root planing were carried out
by seasoned periodontists after the hygienic phase, demonstrated no
difference in probing pocket depth reductions and clinical attachment
gains after 5 years when considering pockets ≥4 mm.29 Hence, classi-
cal pocket elimination is not mandatory for the success of therapy.
As already discussed early in this volume of Periodontology 2000,
these findings are closely related to the concept of “critical probing
depth”, as stated by Lindhe et al.30 This represents the initial probing
depth that, when treated, will show loss of clinical attachment when
shallower and gain of clinical attachment when deeper. In other words,
pockets shallower than the critical probing depth will lose attachment,
and pockets deeper than the critical probing depth will gain attachment.
Those critical probing depth values have been set at approximately
3 mm for nonsurgical therapy and 6 mm for surgical procedures.30
It is evident from the above that surgical procedures should not
be applied to treat shallow pockets, and that moderate‐to‐severe dis-
ease should be treated surgically only after nonsurgical debridement
has been thoroughly performed and reevaluated. At that time, tissue
response and the critical probing depth must be considered. If
needed, an access flap procedure may be implemented to gain
accessibility and visibility for instrumentation in order to achieve a
biologically acceptable root surface and to obtain pocket closure.
Probing depths deeper than 6 mm, in which inflammation is still pre-
sent and cannot be controlled by other means, fit into this category.
3.3 | Other conditions
Aside from chronic adult periodontitis in which the above‐mentioned
scheme applies, there are other clinical situations for which the over-
all approach to treatment requires adjustments. Aggressive periodon-
titis must be treated with adjunctive use of antibiotics during the
hygienic phase of therapy.31 Biofilm culturing is ideal for determining
the correct choice of antibiotic. If surgery is performed, it should be
undertaken after thorough reevaluation and bearing in mind that the
more severe the periodontitis the more conservative the surgical
approach should be with the aim of reconstructing some of the lost
periodontal support. Besides, there are also specific, localized peri-
odontal bony defects which develop in isolation or are associated
with milder generalized periodontitis. In such cases, lost localized
periodontal support might be restored according to current knowl-
edge on regeneration.32 Guided tissue regeneration and enamel
matrix derivative proteins, used with minimally invasive surgical
approaches and with or without the adjunct application of bone
grafts or substitutes, promote restitution of the attachment appara-
tus lost from periodontal disease. Regeneration can be a clinical
CAFFESSE AND ECHEVERRÍA
reality, and advances in cellular therapy and stem cell research will
make achieving regeneration even more predictable in the future.
Furthermore, new surgical approaches are being developed to mini-
mize the negative esthetic effects of traditional surgery. Esthetics is
another aspect of periodontal therapy in which periodontal surgery
will play an important part. Plastic periodontal procedures and
esthetic periodontics will continue to develop with the design of
new approaches and new tissue substitutes. Classical resective pro-
cedures are presently limited to osteoplasty recontouring, crown
lengthening, and pre‐prosthetic surgery.
Finally, it is worth reiterating that periodontitis is a chronic dis-
ease with a multifactorial etiology and, as such, it may not be cured
– only controlled. The more that risk factors are recognized and
(whenever possible) controlled, the better the long‐term results will
be. For this reason, maintenance care is the phase of the treatment
plan which becomes fundamental for the long‐term success of ther-
apy. Whether or not surgery is performed, the necessity of proper
maintenance remains the same. Constant reassessment and reevalua-
tion and, if necessary, retreatment, are required for the successful
long‐term maintenance of the dentition in health, function, esthetics,
and efficiency, promoting patient's satisfaction and self‐esteem.33
Long‐term survival of the dentition is becoming more the rule than
the exception after treatment.
Conventional periodontal therapy, both surgical and non‐surgical,
has proven to be very effective, and with close and thorough super-
vision, even active bleeding sites can be maintained over time with-
out further loss of attachment. The dentition affected by
periodontitis most of the times can be kept healthy and functional
for many years if properly treated and maintained. Long-term survi-
val of the dentition is more the rule than the exception after treat-
ment. Osseointegrated implants represent the best choice to replace
missing teeth, but it is not ideal to extract and replace. The tooth
wants to live, and this goal is achievable with the dedication of the
profession, and the application of proven and accepted approaches
to therapy. The responsibility is in the hands of the profession.
4 | CONCLUDING REMARKS
This chapter provides a summary of a few general points that
research evidence obtained over the past 25 years has concluded to
be of utmost importance in the overall periodontal treatment plan.
With minor variations, the therapeutic principles described in this
volume of Periodontology 2000 have been widely accepted by most
of the periodontal specialty and caused a shift in the overall goal of
therapy, from focusing on a physical reduction of the periodontal
pocket to suppression of the periodontal infection and consequently
of the inflammatory tissue response.
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How to cite this article: Caffesse RG, Echeverría JJ.
Treatment trends in periodontics. Periodontol 2000.
2019;00:1–8. https://doi.org/10.1111/prd.12245