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    Lind He 1975

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    Journal of Clinical Periodontology: 1975: 2: 67-79 Key words: dental plaque control marginal periodontitis ~ periodontal therapy. Accepted for publication: October 16, 1974. 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 Jan LinpH Department of Periodontology, University of Géteborg, Gétebor; Abstract. The present clinical study was initiated in 1969 to test the hypothesi: microbial plaque is the cause of periodontal disease and that hence even advanced patients willing to exercise optimal plaque control. can be cured of periodontit material consisted of 75 patients with severe destruction of the periodontal ti tudy because of thei itial examination, a preliminary treatment plan was presented to the cluded detailed instructions in plaque control measures, @ and emergency dental care, including endodontic therapy and extractions, Three the termination of the so-called presurgical treatment, sur was p% patients were selected for the tion. Following an patients. This plan ea to six months afte tion of pathologie ly deepened pockets AND STURE NyMAN Sweden ues, The ability to maintain plaque-free denti- -aling, root ical elimina- formed. The patients were recalled every 3 to 6 months after the end of the treatment. At these reexaminations the following para- meters were assessed: Plaque Index, Gingival Index, Pocket Depths, Marginal alveolar bone topography and height. The results demonstrate that in advanced stages, Studies by Lévdal et al, (1961), Suomi et al. (1971) and Ramfjord et al. (1973) have shown, that it is possible in humans of dif- ferent age groups to retard the rate of pro- gression of marginal periodontitis by regu- larly repeated dental prophylaxis and oral hygiene instruction, Experiments in the dog and the monkey (Saxe et al, 1967, Lindhe et al. 1973, Kennedy & Polson 1973) have demonstrated that gingival inflammation possible to treat periodontal disease su patients willing to maintain plaque-free dentition, fully, even and incipient periodontal breakdown will de- velop if plaque is allowed to accumulate freely and calcify in the gingival third of the tooth surfaces; but also that gingivitis and periodontitis can be prevented (Lindhe et al. 1973) or arrested (Greene & Vermi lion 1971) by frequently repeated metic- ulous tooth cleanings. In 1969 a clinical study was initiated at the University of Gdteborg to test the 68 LINDHE AND NYMAN following hypothesis: (i) the continuous formation of microbial plaque is the main etiological component, not only in gingiv- and early periodontitis, but also in the advanced form of periodontal disease, and (ii) thus even advanced forms of perio- dontal disease can be cured in patients willing to exercise optimal plaque control. The present paper reports observations 5 years after the termination of periodontal treatment from such a group of patients with advanced breakdown of the perio- dontal tissues. Material and Methods Sample The material consisted of 75 patients who were referred to the authors for periodontal treatment. At the start of the treatment period the patients were 26-79 years of age. Age distribution is given in Table 1. Table 1. Age distribution of the patients Tabelle 1, Altersverteilung der Patienten Tableau 1, Distribution des patients selon age Age group Altersgruppe Groupe selon Patientenzahl Nombre de patients Page Years I 26-29 Jahre 6 ans Years 1 30-39 Jahre 5 ans Years mw 40-49 Jahre 21 ans Vv (x: 3) 24 Vv i re | 19 ans The limiting criteria for acceptance of patients ‘for this study were that they had lost on average 50 per cent or more of the periodontal support, and that they should be (i) willing to accept periodontal treat- ment including, when indicated, extra tions, surgery and prosthetic reconstruc- tion, (ii) capable of m: 1 optimal plaque control and (ii) willing to appear for regular (at least once every 6 months) reexaminations. The Sequence of Treatment The patients were treated according to the following basic treatment schedule: 1) Initial Examination > Diagnosis 2) Presurgical Treatment Motivation Oral Hygiene Instruction Elimination of Plaque Retention Factors After 3-6 months of non-supet care: ed home 3) Reexamination 4) Periodontal Surgery 5) Periodic Recall 1) Initial Examination At the initial examination the following parameters were recorded: A. Oral hygiene status (Plaque Index; Silness & Lée 1964), B, Severity and extent of mation (Gingival Index; 1963), ©. Location and depth of periodontal pockets (measured by a periodontal probe and noted on a Pocket Depth Chart; Fig. 1). D. Furcation involvements. The degree of furcation involvement, when present, was recorded in Roman numerals on the Pocket Chart. ingival inflam- Lée & Silness PLAQUE denotes a horizontal loss of perio- dontal tissue support less than 3 mm within the fureation area. II, denotes a horizontal loss of support exceeding 3 mm but not enc: passing the total width of the furea- tion area, III, denotes a horizontal “through-and- through” destruction of the perio- dontal tissues in the furcation. E. Tooth mobility, The degree of tooth mobility was noted in Arabic numerals on) the Pocket Chart. Degree 1 means a mobility in the labio-oral (or mesio-distal) direction of 0.2-1 mm. Degree 2 means a mobility of 1-2 mm, and degree 3 a mobility ex- ceeding 2 mm in the labio-oral (or mesio- distal) direction and/or mobility in the vertical direction. F, The level of the alveolar bone and the configuration of the alveolar crest were as- sessed in the roentgenographs and with the aid of the data in the Pocket Depth Chart. In order to determine alterations in alveolar bone height all roentgenographie procedures were carried out with a long cone technique and with the use of a device (Eggen 1969) which provides a periodic-reproducible geo- metrical relationship between the central beam, the tooth and the f The actual interproximal bone level was determined in the manner originally de- scribed by Marshall-Day & Shourie (1949), and further developed by Bjérn & Holm- berg (1966) and Bjérn et al. (1969), The bone heights on the mesial and distal sides of each tooth were measured individually, and the mean value calculated for each tooth, or in cases with multirooted teeth each root [Bone Score]. A PERIODONTAL DIAGNOSIS, based on the evaluation of parameters B-F, was then given to every single tooth, im. Gingivitis means that a clinical inflamma- tion exists in one or more gingival units NTROL AND PERIODONTAL HEALTH 69 around a particular tooth, The pocket depth measurements and the roentgeno- graphic analysis should not indicate loss of periodontal support around the tooth. Periodontitis levis means that the pocket depth values and/or the roentgenographic analysis provide evidence of “horizontal” marginal bone loss of not more then 4 of the normal bone height. Periodontitis gravis means evidence of “horizontal” bone loss of more than % of the normal bone height. Periodontitis complicata means that there roentgenographic evidence of angular bone loss and/or a discernible furcation involvement of degree I or III. This diag- nosis is also made when there is a tooth mobility of degree 3. In addition to the periodontal examina- tion and diagnosis, the following conditions were checked: caries and pulpal disease, periapical pathology, defective restorations and prostheses, and symptoms of temporo- mandibular disorders and pain-dysfunction syndromes. A typical Pocket Depth Chart with ac- companying Chart of Diagnosis is presented in Fig. 1, 2) Presurgical Treatment The preliminary treatment plan was based ‘on the preceding diagnosis made for each individual tooth, Detailed information on the role of dental plaque in the etiology of the oral diseases was presented to the pa- tients together with the proposed treatment plan, Every effort was made to motivate the patients to practice a meticulous plaque control program, Following motivation, de- tailed instructions on plaque control meth- ods were given. This was accompanied by calculus and plaque removal and the cor- rection of ill-fitted margins of restorations. 70 LINDHE AND NYMAN Frequent appointments were made for re- motivation and reinstruction, Furthermore, necessary cariologic and endodontic condi- tions were treated. Teeth which from end- odontic and cariologic view points could not be successfully treated, teeth with peri- odontal pockets extending down to the apex, and teeth which on prosthodontic indications should not be maintained, were extracted. All patients who needed it were given emergency dental care, including endodontic therapy and extractions. Most patients were given caries treatment, in- cluding excavation, endodontic therapy and restorati si , and, in some instances, provi- nal prosthetic reconstructions. The presurgical treatment was followed by an observation period of 3-6 months in order to evaluate the degree of coopera tion and willingness of the patient to prac- tice the strict plaque control program. 3) Reexamination In order to determine the degree of the pa- tient’s cooperation and to plan the surgical approach in detail, Plaque and Gingival Indices were recorded and pocket depths were measured again 3-6 months after the termination of the presurgical treatment. 4) Periodontal Surgery Surgical elimination was always carried out for periodontal pockets deeper than 4 mm. The gingivectomy procedure was advocated for pockets which could be eradicated within the attached gingiva, and when the configuration of the alveolar crest gave evidence of horizontal bone loss. Modified reverse bevel flaps (Widman 1920, Wright 1965) were used: when the pockets extended beyond the attached gingiva; when bone contouring was indicated due to the presence of vertical osseous defects and crater formations around single or multiple teeth; and when furcation involve- ments If and II had been recorded. Teeth with furcation involvements re- ceived some of the following alternative treatments: (Seating and root planing in incipient stages of degree I-involvements. ( Furcation plasty in more advanced stages of degree I-involvements. This procedure included: 1) elimination of granulation tissue and soft and hard bacterial deposits with- in the furcation, 2) elimination of soft tissue pockets and adjacent bony defects present, and 3) removal of tooth substance (odont- oplasty) in order to eliminate or re- duce the extension of the enamel and dentine wall of the horizontal defect in the furcation, (5) Root separation with extraction of one or two roots. (Furcation involvements, degrees II and It). (J Tunnel preparation = complete opening of the furcation, always involving bone remoyal to give access into the furca- tion with an interdental toothbrush post- surgically. (Furcation involvements de- grees I and II), ( Extraction In cases of multirooted teeth, a combination of the different types of procedure was sometimes used. 5) Periodic Recall After the termination of the periodontal surgery phase, the patients were supplied with permanent restorations of amalgam, silicate, and gold or prosthetic reconstruc- tions where these were needed. The patients were then placed on maintenance care, including recall every 3 to 6 months. At these periodic recalls, prophylaxis was per- formed by a dental hygienist and repeated instruction in oral hygiene was given. Once: a year, oral hygiene was evaluated (Plaque Index), and the conditions of the perio- PLAQUE CONTROL AND PERIODONTAL HEALTH n | ure 1 ae r ‘Tooth alahgene pred Pocket depth Fureation “mobility Score ' 1 footh No. — Taschentiefe ed Zahnbe- Knochen- a Del Brofondesr des, <2 tion) WEBI 5 index pees asi Portis IPircalibne entapting eset _ M BD L __impliquée dentaire MD 48 Impacted 7 810 8 6 bi;ai 8) a 16 7 7 4 Gna) 15 646 4 6 6 | 14 1 Seas) 1 Pa 13 6 4 6 4 6 6 12 icnesergi a4 nea i Badr sy) 4 1 TS 21 4 7 1 Chet 22 GumouoynnS) 6 7 23 6 6 4 1 6 6 Lon 8 4 1 6 4 25 4.8 a7 | 26 Ge Gog ail Ta, 27 8 6 6 6 bi; all ims 28 Sem. imp. 38 CS RnNTaN 4) Dep b 37, Biead ya al sen7 | 36 6 4 11 6 6 35 6 7 5 6 | 34 5 6 6 6 33 6 6 6 5 6 32 5 5 6 6 31 44 6 6 6 a 4 6 5 42 SiS 43 Se 44 4 ee 45 4 4 45 46 6 arc es IFT 6 6 | 47 6 one 6 6 48, SN WO) LS) 6 6 Plaque Index Gingival Index 2.2 24 DIAGNOSIS 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Ss friodontitis levis triodontitis gravis a XN Xe XX. fiodontitis comp. — -X xx 38 37 36 35 34 33 32 31 41 42 43 44 45 46 47 48 friodontitis levis. -X XXXXX aK: triodontitis gravis = X X X X X XX Bd jriodontitis comp. x jg, Z. Pocket depth chart, chart of periodontal diagnosis and roentgenogram of a 26-year-old patient. fe. 1. Taschentiefe, Parodontal-Diagnoseblatt und Rénigenstatus eines 26-jihrigen Patienten. ig. 1. Profondeur des poches, schéma diagnostique et status radiographique parodontal d'un patient de 26 ans. 2 LINDHE AND NYMAN dontal tissues were assessed by the Ging ival Index and pocket depth measurements. A thorough caries examination with an explorer (Maillefer® No. 6) was also per- formed. In addition, roentgenographs were obtained. Results Examination before Treatment The 75 patients included in this study had 1898 teeth in all (X=25.3). During the pre- surgical treatment period, 278 teeth (8=3.3 per patient) were extracted for reasons described above. The individual mean PII was 1.6 and the individual mean GI was 1.3. The average Pocket Depth of all teeth was 6.3 + 0.37 and the mean Bone Score 7.1 + 0.19. Table 2 gives the number of teeth with furcation involvement and the kind of treatment given to these tecth, During the presurgical treatment period 113 (46 %) out of 247 teeth were extracted. Only 9 teeth (6 lower and 3 upper molars) were subjected to tunnel preparation, whereas 69 teeth (28 %) were root-separated and converted into single-rooted teeth. Fifty- six teeth (23 %) with incipient signs of furcation involvement were handled with sealing and root planing only, or with furcation plasty. Increased mobility was exhibited in 931 teeth (Table 3). Only 207 (22 %) showed pronounced horizontal or vertical mobility (Degree 3). Examination Immediately after the Comple- tion of the Treatment and after 1 and 5 Years During the treatment it was possible to maintain 1620 teeth. All these teeth were maintained during the entire 5-year observa- tion period, All the data given in Table 4 refer to the condition of the periodontal tissues around the remaining teeth, Table 2. Distribution of the various therapeu- tic procedures in the treatment of furcation involvements Tabelle 2. Verteilung der verschiedenen thera- peutischen Massnahmen zur Behandlung pa- rodontaler Liisionen im Furkationsbereich Tableau 2. Distribution des différents procédés thérapeutiques dans le traitement des bi- ou trifurcations Number of EIbersLy teeth Art der Behandlung Oana Thérapie Nombre de dents Scaling/Root planing or Furcation Plasty Zahnsteinentfernung, Curettage und 56 Furkationsplastik Détartrage, polissage radi- culaire ou radiculoplastie Root separation Wurzeltrennung 69 Séparation radiculaire ‘Tunnel preparation Tunnelbildung 9 Tunnelisation Sum. 134 Extraction 113 TOTAL 247 The individual mean PII score immedi- ately after treatment and at the recalls after 1 and 5 years were 0.41, 0.35 and 0.34, respectively. In most patients plaque at the different examinations did not show a con- sistent pattern of location within the denti- tion. The GI score, which at the initial ex- amination was 1.5, showed consistently low values after the treatment phase. ‘The mean pocket depth value was 5.7 mm before treatment. At all reexaminations this value was less than 3 mm. Pocket depths exceeding 3 mm were found on 14 surfaces of 8 teeth, most of which had been PLAQUE CONTROL AND Table 3. Number of teeth with increased mo- bility at the initial examination and at the final control Tabelle 3. Anzahl Zihne mit erhdhter Beweg- lichkeit bei der initialen Untersuchung und Schlusskontrolle Tableau 3. Nombre de dents avec mobilité augmentée a Vexamen initial et lors du con- tréle final Number of teeth after 5 years Mo Beweglichkeitsgrad ity score : “Initial nach 5 Jahren Degré de mobilité pas es 1 255 309 2 469 97 3 207 16 sum 931 422 PERIODONTAL HEALTH B subjected to root separation or tunnel pre- paration, On no occasion, however, did the pocket depth exceed 6 mm. The Bone Scores revealed that no further loss of alveolar bone had occurred during the observation period. It should be noted that 5 years after peri- odontal treatment 422 teeth (26 %) out of 1620 still exhibited clinical signs of in- creased mobility. The majority of these teeth (309) had a mobility of score 1, ie, a horizontal mobility amplitude of less than 1 mm (Table 3). In all, only 14 new smooth surface carious lesions were detected at the recall examina- tions. Table 4, Plaque Index (PID, Gingival Index (GI), Pocket depth and Bone Scores of maintained and recall-examinations teeth from the initial- Tabelle 4. Plaque Index (Pll), Gingival Index (GI), Taschentiefen und Knochenindices der er- haltenen Ziihne Tableau 4. Index de Plaque (Pil), Index gingival (G1), profondeur des poches et index osseux des dents gardées Parameters Pocket Depth Bone Score mm PIL GI Taschentiefe Knochenindex Profondeur des Index osseux Examination poches period x x ull sis RSE) Initial 14 15 5.7034 6.65 £0.17 Recall after treatment Nachuntersuchung nach controle aprés year Jahr 0. 0.41 0.34 <3 6.61+0.18 an year Jahr 1 0.35 0.36 <3 6.59 40.20 an year Jahr 5 0.34 0.29 <3 6390.17 an 74 LINDHE AND NYMAN Discussion The present study has clearly demonstrated, that it is possible to treat periodontal dis- ease successfully, even in advanced stages, in patients willing to carry out optimal plaque control programs. Healing of the periodontal tissues was achieved by scaling and root planing, combined with the com- plete eradication of periodontal pockets, irrespective of their location along the root surfaces (soft tissue pockets, infrabony pockets, and combinations of soft tissue and jinfrabony pockets in the furcation areas). It should be pointed out that the patients of this 5-year study were selected because of their capacity to meet high requirements of plaque control, following repeated instruction in oral hygiene tecl niques. This fact does not, in our opinion, detract from the validity of the present study, because it shows beyond doubt that microbial plaque is the major, maybe the only, factor of importance not only in the etiology of gingival inflammation and incipient periodontal disease, but also in the state of the disease when the continuous breakdown of the periodontal tissues has reached an advanced apical level. This, in turn, does not mean that the significance of host resistance factors in gin| and periodontal breakdown can be oy. looked. Table 5 presents the mean PII, GI, Pocket Depth and Bone Score of age-groups I (26-29 years) and V (> 60 years) from the initial examination, Fig. 1 gives the periodontal status (PI, GI, Pocket Depths, Furcation involvements, Tooth mo- bility, Bone Scores and roentgenogram) of one 26-year-old patient belonging to the group of 6 patients forming age group I. Fig. 3 gives the comparable data of a 64- year-old man, who belongs to the 19 pa- tients in age-group V. As can be seen from the table and the figures, these two groups of patients exhibited not only practically Table 5. Mean values of Plaque Index, Gin- gival Index, Pocket Depth and Bone Score of age-group I (26-29 years) and age-group V (> 60 years) Tabelle 5. Mittelwerte der Plaque- und Gin- giva-Indices, der Taschentiefen und Knochen- indices der Altersgruppe I (26-29 Jahre) und Gruppe V (> 60 Jahre) Tableau 5. Valeurs moyennes d’index de plaque et gingival, de la profondeur des poches et de Vindex osseux des patients du groupe 1 (26-29 ans) et du groupe V (> 60 ans) Age group ee Altersgruppe Vv pee Groupe Plaque Index 18 14 Gingival Index 1.6 15 Pocket Depth Taschenticfe 67 53 Profondeur des poches Bone Score Knochenindex 716 6.94 Index osseux identical PI scores, but also very similar Pocket Depth and Bone Score values, re- flecting a similar degree of periodontal breakdown, Considering the fact that the average age difference between these two groups is 30 years or more, the data indi- cate either differences in the pathogenity of the microbial plaque (Newman et al. 1974) or differences in degree or nature of host resistance (for review see Horton et al. 1974, Nisengard 1974) between the two samples. However, irrespective of the host resistance factors (which at present have been explored to only a minor extent and are therefore difficult to influence), the elimination of plaque, calculus and diseased periodontal tissues will result in the disappearance of the clinical symptoms of periodontitis. This is illustrated by Figs. 2 and 4, which show ~ the same two patients as in Figs. 1 and 3, 5 years after the termination of periodontal treatment, PLAQUE CONTROL AND PERIODONTAL HEALTH 15 Figure 2 Bone Score Knochen- index Index osseux Pocket depth Furcation roth, involvement mobility Furkations- Zahnbe- befall weglichkeit Furcation Mobilité impliquée dentaire M D Tooth no. Taschentiefe Zahntyp Profondeur des Type de poches dent 16 15 14 13 12 u 21 22 23 24 25 38 37 36 35 34 33 32 31 41 42 43 44 45 46 47 48 AAARUUMADQAUUNAUALAAAABAUIAD AADARERUAAAAAAIAYERIAIVANAN Plaque Index Gingival Index 03, 02 Fig. 2. Pocket depth chart and roentgenogram of the same 26-year-old patient as presented in Fig. 1, 5 years after treatment. Fig. 2. Taschentiefe und Réntgenstatus des gleichen 26-jéhrigen Patienten wie in Fig. 1, 5 Jahre nach Behandlung. Fig. 2. Profondeur des poches et status radiographique parodontal du méme patient que dans la Fig. 1, 5 ans aprés traitement. 16 LINDHE AND NYMAN Figure 3 : Tooth Pocket depth. Fureation paohitity Gone 5 involvement Score Tooth No, _Taschentiefe —‘M¥ONEMEM Faye, hg, Zahntyp Profondeur des Se NERS ena Type de dent poches Rurdation Kell. Under osseux Wer BUN auiiipiidues senate ee dentaire MD 7 6 6 8 8 bi; mi adI ia 16 6 6 8 8 midi 2 ries 45 Beton 2 RG 14 ined ea ae OT 2 suis 3 848 4 2 OG 2 848 4 2 8.8 rr 6

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