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Critical Probing Depths in Periodontal Therapy: Surgical vs Non-Surgical Outcomes

Analysis of critical probing depths in periodontal treatment comparing modified Widman flap surgery and scaling/root planing, highlighting effects on attachment levels and importance of plaque control during maintenance.

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J O U R N A L C L U B P R E S E N TAT I O N Department of Periodontology “Critical Probing Depths” in Periodontal Therapy Lindhe J, Socransky SS, Nyman S, Haffajee A, Westfelt E — J Clin Periodontol 1982; 9: 323–336 GUIDED BY Dr. [Guide Name] Professor and Guide PRESENTED BY Dr. [Presenter Name] MDS
ARTICLE OVERVIEW “Critical probing depths” in periodontal therapy J. Lindhe, S. S. Socransky, S. Nyman, A. Haffajee, E. Westfelt Department of Periodontology, Faculty of Odontology, University of Gothenburg, Sweden — and Forsyth Dental Center, Boston, MA, USA JOURNAL Journal of Clinical Periodontology YEAR 1982 VOLUME / PAGES Vol 9, pp. 323–336 STUDY TYPE Split-mouth clinical trial Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 2
ABSTRACT ▪ 15 patients with moderately advanced periodontal disease; split-mouth design. ▪ One side: scaling and root planing + modified Widman flap (MWF). Other side: scaling and root planing alone (RPL). ▪ 0–6 months = healing phase (recall every 2 weeks); 6–24 months = maintenance phase (recall every 3 months). ▪ Regression analysis used to calculate “critical probing depths” (CPD) for each treatment. ▪ CPD: RPL = 2.9 mm vs MWF = 4.2 mm (P < 0.01) ▪ Surgery caused more attachment loss than non-surgical therapy in initially shallow pockets, but more gain in initially deep pockets. ▪ During maintenance (12 & 24 months), probing depths and attachment levels stayed stable — but oral hygiene mattered more than the original treatment method: plaque-free sites stayed shallow; plaque-harbouring sites lost further attachment. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 3
INTRODUCTION ▪ Long-term studies (Knowles 1973; Ramfjord et al.; Lindhe & Nyman 1975; Badersten et al. 1981) show both surgical and non-surgical therapy can succeed when maintenance care is well designed. ▪ Recent work suggested probing-depth reduction and attachment gain can be achieved by hygiene instruction + scaling/root planing alone — implying surgery's added benefit must be tested against a non-surgical control. ▪ Loss of attachment after therapy has been linked to initial probing depth: shallow pockets tend to lose attachment; deep pockets tend to gain it — and this “critical” threshold may depend on the treatment modality. ▪ Waerhaug (1978) and others: subgingival plaque is difficult to eliminate by instrumentation in pockets deeper than 4–5 mm — raising questions about long-term maintenance of deep sites. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 4
AIMS OF THE STUDY 1 Calculate the critical probing depth (CPD) values for one surgical (MWF) and one non-surgical (RPL) method of periodontal therapy. 2 Monitor, during an 18-month maintenance period, sites with probing depths >4 mm with respect to gingival inflammation and attachment level changes. 3 Evaluate the effect of oral hygiene status on probing depths and attachment levels during maintenance, in patients recalled for prophylaxis every 3 months. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 5
MATERIALS & METHODS Subjects and study design SUBJECTS ▪ 15 individuals, 32–57 years ▪ Referred for treatment of moderately advanced periodontal disease ▪ Department of Periodontology, University of Gothenburg BASELINE EXAMINATION ▪ Oral hygiene status (Plaque Index; Silness & Löe 1964) ▪ Gingival conditions (Gingival Index; Löe & Silness 1963) ▪ Probing depths and attachment levels — all teeth present SPLIT-MOUTH DESIGN ▪ Right / left jaw side, randomly selected ▪ MWF group: scaling & root planing + modified Widman flap (Ramfjord & Nissle 1974) ▪ RPL group (contralateral quadrants): scaling & root planing only ▪ Healing phase: 0–6 months, recall every 2 weeks ▪ Maintenance phase: 6–24 months, recall every 3 months ▪ Reexaminations at 6, 12 and 24 months; same surfaces/points as baseline Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 6
STATISTICAL ANALYSIS ▪ Mean, standard deviation and 95% confidence intervals computed by standard methods. ▪ Significance of difference of means determined using the t-test. ▪ Regression analysis: – Independent (X-axis) variable: initial probing depth – Dependent variable: change in attachment level during healing – Slope and X-intercept computed with 95% confidence intervals – X-intercept = the “critical probing depth” (CPD) ▪ Significance of differences in slope and X-intercept between treatments was also calculated. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 7
RESULTS Critical probing depth: healing phase (0–6 months) Scaling & Root Planing (RPL) Modified Widman Flap (MWF) 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 3 4 CPD by treatment modality Critical Probing Depth (mm) ▪ RPL: CPD = 2.9 mm ± 0.4 – Sites with initial PD < 2.9 mm lose attachment even under optimal plaque control; sites > 2.9 mm gain attachment. ▪ MWF: CPD = 4.2 mm ± 0.2 – Significantly higher than RPL (P < 0.01) — surgery tolerates deeper sites before attachment loss occurs. ▪ Slopes: RPL = 0.2 ± 0.04; MWF = 0.42 ± 0.04 – In deep pockets (≥7 mm) MWF produced more attachment gain; in shallow pockets (<3 mm) MWF caused more attachment loss than RPL. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 8
RESULTS CPD by tooth group and tooth surface (Table 1) Incisors Premolars Molars -0.5 0.5 1.5 2.5 3.5 4.5 5.5 3 3 4 4 5 4 By tooth group RPL MWF CPD (mm) Buccal Interprox. Lingual -0.5 0.5 1.5 2.5 3.5 4.5 5.5 3 3 3 4 4 4 By tooth surface RPL MWF CPD (mm) Non-surgical therapy (RPL) consistently yielded lower CPD values than surgical therapy (MWF), across every tooth group and surface. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 9
RESULTS Effect of plaque on attachment levels during healing PlI = 0 PlI > 0 PlI 2–3 0 1 2 3 4 5 6 7 8 3 4 5 4 5 7 CPD (mm) by 6-month Plaque Index score RPL MWF CPD (mm) ▪ Plaque-free sites (PlI = 0) at 6 months: CPD = 2.7 mm (RPL) / 4.2 mm (MWF). ▪ Sites with any plaque (PlI > 0): CPD rises to 4.3 mm (RPL) / 4.9 mm (MWF). ▪ Sites with heavy plaque (PlI 2–3): CPD rises further to 5.1 mm (RPL) / 7.3 mm (MWF). ▪ For every treatment, the CPD increases with increasing plaque score — healing-phase hygiene, not just the initial probing depth, determines the outcome. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 10
RESULTS Probing depth stability during maintenance (6–24 months) Category (PD @ 6 mo) Baseline 12 mo 24 mo Attachment Δ (6–24 mo) < 4 mm (RPL) 58% <4mm 91% <4mm 91% <4mm –0.29 mm ± 0.15 < 4 mm (MWF) 54% <4mm 93% <4mm 90% <4mm –0.26 mm ± 0.2 4–6 mm (RPL) 63% in 4–6mm 70% still 64% still +0.05 mm ± 0.15 4–6 mm (MWF) 63% in 4–6mm 71% still 69% still –0.08 mm ± 0.2 >6 mm (RPL) 68% in >6mm 73% >6mm 48% >6mm +1.2 mm ± 0.7 >6 mm (MWF) 80% in >6mm 60% >6mm 40% >6mm +1.6 mm ± 0.8 Shallow pockets (<4 mm) remained shallow through maintenance in ~90% of sites for both treatments; deeper pockets tended to gain attachment. Change in attachment level during maintenance was not significantly influenced by the original treatment modality. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 11
RESULTS Effect of plaque during maintenance PLAQUE-FREE SITES (PlI = 0) ▪ 82–94% of plaque-free sites (RPL & MWF) remained <4 mm at 6, 12 and 24 months. ▪ Little or no attachment change during 18-month maintenance (−0.16 to −0.18 mm). ▪ Plaque control after active therapy maintains shallow, stable pockets. PLAQUE-HARBOURING SITES (PlI > 0) ▪ Only 37–55% of plaque-positive sites stayed <4 mm; the rest were in the 4–6 mm or >6 mm categories. ▪ Attachment loss during maintenance: –0.72 mm ± 0.2 (MWF) and –0.55 mm ± 0.15 (RPL). ▪ Difference between plaque-free and plaque-positive sites was statistically significant (P < 0.05). Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 12
DISCUSSION ▪ Confirms earlier findings: sites with initially deep pockets gain attachment, while initially shallow pockets tend to lose attachment following therapy (Ramfjord et al.; Knowles et al. 1979, 1980; Pihlstrom et al. 1981). ▪ Regression analysis quantified this as a critical probing depth (CPD) — below it, loss is likely; above it, gain is likely — and showed the CPD is significantly higher for surgical (MWF, 4.2 mm) than non-surgical (RPL, 2.9 mm) therapy. ▪ Clinical implication: patients with mostly shallow pockets may be better served by a non-surgical approach; patients with mostly deep pockets may gain more attachment from surgical treatment. ▪ Findings by Knowles et al. (1979) and Pihlstrom et al. (1981) using the same modified Widman technique support this pattern of loss <4 mm and gain in deeper sites. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 13
DISCUSSION Using CPD to predict outcomes — worked example A single premolar with initial probing depths: buccal 1 mm, mesial 6 mm, lingual 2 mm, distal 5 mm. Buccal Initial PD: 1 mm MWF: −1.4 mm loses (< CPD) Mesial Initial PD: 6 mm MWF: +0.7 mm gains (> CPD) Lingual Initial PD: 2 mm MWF: −1.2 mm loses (< CPD) Distal Initial PD: 5 mm MWF: +0.2 mm gains (> CPD) If treated with MWF surgery: net total change ≈ –1.7 mm attachment (loss) If treated with RPL alone: net total change ≈ +0.1 mm attachment (gain) Regression-derived CPDs can act as a chairside guide to the expected net effect of a treatment modality on a given tooth — not a guarantee for any single patient. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 14
DISCUSSION Maintenance care and root-surface plaque ▪ Probing depths and attachment levels obtained after active therapy were maintained — or further improved — during 18 months of 3-monthly prophylaxis, regardless of whether therapy had been surgical or non-surgical. ▪ Waerhaug (1978), Rabbani et al. (1981) and Tabita et al. (1981): root surfaces in pockets >3–5 mm may retain microscopic plaque/calculus even after thorough instrumentation. ▪ Listgarten et al. (1978): subgingival scaling and root planing in sites >5 mm effectively reduced inflammation and probing depth, with a resulting microbiota (coccoid cells, non-motile rods) compatible with gingival health. ▪ Key message: the level of oral hygiene during healing and maintenance is more critical to the outcome than which initial therapy (surgical vs non-surgical) was used. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 15
CONCLUSION ▪ The critical probing depth (CPD) for non-surgical scaling and root planing (2.9 mm) is significantly smaller than for scaling and root planing combined with modified Widman flap surgery (4.2 mm). ▪ In patients with mostly shallow pockets, non-surgical therapy limits unnecessary attachment loss; in patients with mostly deep pockets, surgical therapy yields more attachment gain. ▪ Once healing is complete, the quality of long-term maintenance — specifically plaque control — outweighs the initial choice of surgical vs non-surgical therapy in determining probing depth and attachment stability. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 16
REFERENCES ▪ Lindhe, J., Socransky, S. S., Nyman, S., Haffajee, A. & Westfelt, E. (1982) “Critical probing depths” in periodontal therapy. Journal of Clinical Periodontology 9, 323– 336. ▪ Ramfjord, S. P. & Nissle, R. R. (1974) The modified Widman flap. Journal of Periodontology 45, 601–607. ▪ Knowles, J. W., Burgett, F. G., Nissle, R. R., Shick, R. A., Morrison, E. C. & Ramfjord, S. P. (1979) Results of periodontal treatment related to pocket depth and attachment level. Journal of Periodontology 50, 225–233. ▪ Waerhaug, J. (1978) Healing of the dento-epithelial junction following subgingival plaque control. II. Journal of Periodontology 49, 119–134. ▪ Listgarten, M. A., Lindhe, J. & Helldén, L. (1978) Effect of tetracycline and/or scaling on human periodontal disease. Journal of Clinical Periodontology 5, 246–271. ▪ Badersten, A., Nilvéus, R. & Egelberg, J. (1981) Effect of nonsurgical periodontal therapy. I. Journal of Clinical Periodontology 8, 57–72. ▪ Pihlstrom, B. L., Ortiz-Campos, C. & McHugh, R. B. (1981) A randomized four-year study of periodontal therapy. Journal of Periodontology 52, 227–242. Lindhe et al. 1982 | J Clin Periodontol 9: 323–336 17
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