Surgical Periodontal Therapy with and Without Initial Scaling and Root Planing in the Management of Chronic Periodontitis: a Randomized Clinical Trial

J Clin Periodontol 2014; 41: 693–700 doi: 10.1111/jcpe.12259

Manar Aljateeli1,2, Tapan Koticha1, Surgical periodontal therapy with Jill Bashutski1, James V. Sugai1, Thomas M. Braun3, William V. Giannobile1 and Hom-Lay Wang1 and without initial scaling and 1Department of Periodontics and Oral Medicine, University of Michigan, Ann Arbor, MI, USA; 2Department of Surgical Sciences, root planing in the management Faculty of Dentistry, Kuwait University, Kuwait City, Kuwait; 3Biostatistics Department, School of Public Health, of chronic periodontitis: a University of Michigan, Ann Arbor, MI, USA randomized clinical trial

Aljateeli M, Koticha T, Bashutski J, Sugai JV, Braun TM, Giannobile WV, Wang H-L. Surgical periodontal therapy with and without initial scaling and root planing in the management of chronic periodontitis: a randomized clinical trial. J Clin Periodontol 2014; 41: 693–700. doi: 10.1111/jcpe.12259

Abstract Aim: To compare the outcomes of surgical periodontal therapy with and without initial scaling and root planing. Methods: Twenty-four patients with severe chronic periodontitis were enrolled in this pilot, randomized controlled clinical trial. Patients were equally allocated into two treatment groups: Control group was treated with scaling and root planing, re-evaluation, followed by Modified Widman Flap surgery and test group received similar surgery without scaling and root planing. Clinical attachment level, probing depth and bleeding on probing were recorded. Standardized radiographs were analysed for linear bone change from baseline to 6 months. Wound fluid inflammatory biomarkers were also assessed. View the pubcast on this paper at Results: Both groups exhibited statistically significant improvement in clinical http://www.scivee.tv/journalnode/62444 attachment level and probing depth at 3 and 6 months compared to baseline. A statistically significant difference in probing depth reduction was found between the two groups at 3 and 6 months in favour of the control group. No statistically Key words: initial therapy; modified Widman Flap; periodontal surgery; periodontal significant differences in biomarkers were detected between the groups. Conclusions: therapy; periodontitis; scaling and root Combined scaling and root planing and surgery yielded greater planing; wound healing probing depth reduction as compared to periodontal surgery without initial scaling and root planing. Accepted for publication 6 April 2014

The rationale for periodontal ther- (Yusof 1987, Caffesse et al. 1995). surgical therapy phase followed by a apy is to re-establish and maintain The traditional approach to treating surgical phase as necessary. Several periodontal health and function periodontitis includes an initial non- longitudinal studies showed that non-surgical and surgical periodontal therapy is effective in arresting peri- Conﬂict of interest and source of funding statement odontitis (Knowles et al. 1979, 1980, The authors do not have any ﬁnancial interests, either directly or indirectly, in the Isidor & Karring 1986, Kaldahl products or information listed in the paper. et al. 1996). This study was supported by the graduate student research fund, University of Michi- In conventional periodontal gan, Department of Periodontics, the Rackham Graduate Funding, Bunting Scholar- therapy the “non-surgical phase” or ship & Endowment, and Delta Dental Foundation (dental master’s thesis award). the “initial phase” precedes the sur-

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 693 694 Aljateeli et al. gical phase. Non-surgical therapy cal treatment resulted in more PD an informed consent and to comply involves, and not limited to, scaling reductions than the non-surgical with all study-related procedures and root planing (SRP) combined treatment for all initial pocket including good plaque control with oral hygiene instructions (OHI) depths. In addition, in the long term, (O’Leary plaque score of ≤30%) and and patient motivation (Lang 1983), surgical treatment showed greater follow-up appointments; patients which aims at eliminating or reduc- PD reductions with deepest initial with localized or generalized chronic ing putative pathogens and shifting pockets (>7 mm) when compared to periodontitis. Exclusion criteria were the microbial flora to a more favour- non-surgical treatment (Antczak- as follows: pregnant women; antibi- able environment to achieve stable Bouckoms et al. 1993). otic therapy for more than 10 days periodontal conditions (Rawlinson & Previous investigations have not within the last 3 months of enrol- Walsh 1993). compared SRP to surgical proce- ment or necessity of antibiotic pro- Although non-surgical therapy dures performed without initial ther- phylaxis; medications affecting bone alone can successfully arrest peri- apy. This study was designed to metabolism or gingiva; history of a odontitis progression in shallow to compare the outcomes of surgical previous periodontal surgery within moderate pockets (Badersten et al. periodontal therapy completed with the last 2 years; history of SRP 1981), its effectiveness in successfully and without an initial SRP. The pri- within the last year; Miller Class 2 treating deeper pockets is debatable mary endpoint variable was the dif- or greater mobility on any teeth in and has its limitations (Waerhaug ference in CAL change over the treatment quadrant. The selected 1978, Stambaugh et al. 1981). Using 6 months. Secondary outcome vari- patients were then randomly scanning electron microscopy, Rate- ables included: PD, bleeding on assigned to one of two treatment itschak-Pluss et al. (1992) demon- probing (BOP), linear bone gain and groups with 12 patients in each strated that non-surgical therapy changes in gingival crevicular fluid group. Each patient picked a num- failed to completely reach the base (GCF) inflammatory biomarkers. ber from an enclosed envelope dur- of the pocket on 75% of the root ing the screening appointment. surfaces. In addition, molar furca- Twenty-four labelled papers were Materials and Methods tion sites with initial pocket depths placed into two envelopes which (PD) of ≥4 mm were shown to have were labelled either with number 1 a poor response following a non-sur- Study population or number 2 evenly. If the patient gical approach alone (Nordland Human subjects approval was picked 1 he or she was assigned to et al. 1987). A more recent obtained from the University of control group, while picking 2 meant study showed that a successful treat- Michigan Human Subject Institution assignment into test group. The first ment outcome of pocket closure Review Board prior to study initia- 12 screened patients that met the (PD ≤4 mm) following non-surgical tion, which was conducted in accor- inclusion criteria picked from the 1st debridement was achieved only at dance with the Declaration of envelope, and the last 12 patients 50% of the tooth sites with an initial Helsinki (version 2008). A power picked from the 2nd envelope to PD ≥5 mm (Tomasi et al. 2008). The analysis was completed to determine ensure that the first screened 12 same study showed that even with an appropriate number of partici- patients are assigned to the two retreatment, the probability of pants for enrolment. Assuming a groups evenly. Control group achieving pocket closure was 45% 1 mm difference in CAL and using (SRP + S) received SRP followed by while the probability was only 12% 0.8 mm as standard deviation, which surgery 6–8 weeks later, if necessary, at sites with PD <6 mm. To over- seemed to be a reasonable estimate while the test group (S only) received come these shortcomings, a direct for both groups based on Serino direct surgery with no SRP. Patients surgery approach without an initial et al. (Serino et al. 2001), power were treated at the Department of phase is proposed as an alternative analysis revealed that 12 patients Periodontics and Oral Medicine, to the conventional approach. were required in each group for a University of Michigan, School of Over the years, a great number of t-test power level of 80%. Hence, 24 Dentistry. studies compared the effectiveness of participants were recruited for the SRP alone and SRP with surgery study. Research procedures were Procedures (Hill et al. 1981, Pihlstrom et al. explained to all patients after they 1981, Lindhe et al. 1982, Ramfjord read and signed an informed consent Detailed and comprehensive OHI et al. 1987). Their results are in document prior to any treatment. were given to all patients, including agreement with a systematic review The primary investigator (MA) the Bass toothbrushing (Bass 1954) (Heitz-Mayfield et al. 2002) and a screened the patients according to technique and interproximal cleaning literature review (Pihlstrom et al. the inclusion and exclusion criteria with dental floss and inter-dental 1983) that showed that although and selected those who fulfilled the brushes. Clinical baseline measure- SRP alone and SRP with a surgical criteria for the study. Inclusion crite- ments were taken at screening flap were effective treatment modali- ria were as follows: adults ≥ 18 years appointment along with standardized ties for managing periodontitis, open of age; patients with no systemic dis- periapical radiographs. For both flap debridement resulted in greater eases which could influence the out- treatment groups, baseline measure- PD reductions and clinical attach- come of the therapy; presence of two ments were the measurements col- ment level (CAL) gains in deeper or more periodontal pockets with lected at this screening appointment pockets. A meta-analysis also con- PD ≥6 mm and CAL ≥5 mm; before any treatment was initiated. firmed that in the short term, surgi- patients willing and able to provide Data collected included: O’Leary © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Surgical periodontal therapy without SRP 695

Plaque index (PlI) (O’Leary et al. Clinical measurements 1972), BOP, PD (distance from the Screening (62 patients) WF samples free gingival margin “FGM” to the Standardized radiographs base of the pocket in millimetres), Excluded (38 patients) CAL and gingival recession. Clinical 24 patients measurements were registered by one masked and calibrated investigator (TK) to the nearest millimetre using a University of North Carolina Control Test (UNC) periodontal probe with N N 1 mm markings (Hu-Friedy, Chi- = 12 = 12 cago, IL. USA). Calibration was completed at two time points: pre- study and –intra-study evaluation. Each calibration was carried out by SRP Surgery performing double measurements of a randomly selected patient not involved in the study with a 1-week WF samples gap. Measurements were taken at six 1, 2, & 4 week SRP of other 1, 2, & 4 week sites around the teeth (mesiobuccal, quads at 2 midbuccal, distobuccal, distolingual, week post-op midlingual and mesiolingual). To decrease a possible bias, the experimental quadrant was selected at the 6–8 weeks screening appointment that included Clinical Re-evaluation the experimental tooth that fulfilled measurements the selection criteria. This tooth with the deepest PD, along with the two Surgery neighbouring teeth was included in the analysis. GCF and oral wound fluid (WF) were collected from sites within the treatment quadrant, one 2 week post-op of which was the study tooth site, using a sterile methylcellulose sampling strip (Periopaper, Oraflow, Maintenance Inc., Smithtown, NY. USA), to 3 months WF samples assess the biomarkers interleukin-1ß Clinical measurements (IL-1b), interleukin-6 (IL-6), matrix metalloproteinases-8 and -9 (MMP- Maintenance 8, -9) and vascular endothelial Standardized radiographs growth factor (VEGF). Additional 6 months Clinical measurements GCF samples were collected from sites of the contra-lateral quadrant Fig. 1. Experimental flow chart for study design. that served as control samples (Fig. 1). + study tooth demonstrating a PD of location and sutured using Vicryl Control group (SRP S) ≥5 mm were scheduled to receive a sutures (Ethicon, Inc., Menlo Part, A conventional SRP procedure was surgery in that study quadrant, CA. USA) and a single interrupted performed on the study quadrant whereas patients who presented with suture technique. General postopera- under local anaesthesia. SRP was PD <5 mm received no surgery and tive instructions for periodontal sur- performed using both ultrasonic were placed on periodontal mainte- gical procedures were provided both scalers and hand instruments. GCF nance. Modified Widman Flap verbally and with a standard written samples were collected at 1, 2 and (MWF) surgery was completed under form. Patients were instructed to 4 weeks following SRP. If the local anaesthesia by one surgeon rinse with 0.12% of chlorhexidine â â patient needed SRP in other non- (MA) in the study quadrant within solution (Colgate PerioGard Oral study-related quadrants, SRP of 2 weeks after the re-evaluation. Rinse, Colgate Oral Phamaceuticals, these remaining quadrants was also Degranulation and debridement were New York, NY) twice/day for completed at 2 weeks, as necessary. completed using ultrasonic and hand 2 weeks and to refrain from oral Re-evaluation was completed instruments. When found, local con- hygiene measures in the study quad- 6–8 weeks following the SRP com- tributing factors (e.g. enamel pearls, rant. Oral analgesics (Ibuprofen, pletion. cervical enamel projections (CEP), 600 mg, every 8 h as necessary) were Patients who presented at the overhangs) were eliminated. Flaps also prescribed. Patients were seen re-evaluation appointment with a were repositioned to their original 2 weeks after surgery for follow-up © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 696 Aljateeli et al. and suture removal. At this time, dardized radiographs were Statistical analysis oral hygiene measures were re-insti- digitalized then analysed using Ema- Data collected were uploaded to a tuted in the study quadrant. go software (Oral Diagnostic Sys- database in which patient privacy tems, Amsterdam, the Netherlands). Test group (S only) was protected according to current Anatomical landmarks were marked regulations. A two-sample t-test Patients in this group received peri- and linear distance was measured (continuous measures) or a chi- odontal surgery without an initial from the CEJ or from any other squared test of association (categori- SRP phase. Surgery and subsequent exact margin of a restoration to the cal measures) was used to evaluate postoperative follow-up care were most apical part of the alveolar statistically significant differences performed in the study quadrant as bone crest, where the periodontal between the two groups and a paired described above. GCF samples were ligament space was judged to retain t-test was used to evaluate statisti- collected at 1, 2 and 4 weeks follow- its normal width. Linear subtraction cally significant changes from base- ing surgery. SRP of the remaining radiography was used to calculate line within each group. A p-value quadrants was also completed at the linear bone change from base- less than 0.05 was considered statisti- 2 weeks after surgery, if necessary. line to 6 months. cally significant. To minimize variability and bias, both SRP and surgery were com- GCF/WF sampling and analysis pleted by a single clinician (MA). Results Gingival crevicular fluid/Wound The study cohort, who had a mean fluid samples were collected from Follow-up appointments age of 49 and percentage of smokers both test and control teeth at base- at 37.5%, consisted of a test group Periodontal maintenance of all teeth line (GCF), 1-, 2-, 4 weeks and with seven females and five males was performed at 3 and 6 months 3 months post treatment. Sampling and a control group with four during which clinical measurements was performed after assessing females and eight males. Patients were taken. Supra- and subgingival O’Leary plaque score and before were recruited from April 2011 to debridement was provided using completing any clinical parameters January 2012. Twenty-one partici- ultrasonic and hand instruments. to avoid mechanical irritation and pants completed the scheduled OHI was re-enforced at all appoint- bleeding from periodontal probing. 6-month examination appointments ments. GCF samples were collected Before collecting the oral fluids, the and two patients, one from each at 3 months and standardized peri- area around each sample site was group, did not complete the 3- and apical radiographs were taken at isolated using cotton rolls, dried with 6-month examination due to non- 6 months. gauze and a quick blast of air from compliance with the study visit sche- the air/water syringe making sure dule. A third patient from the con- not to direct any air flow into the Radiographic examination trol group was not able to complete gingival sulcus. If present, any su- the study beyond the 4-week evalua- Standardized long cone radiographs pragingival plaque was gently tion due to personal scheduling were taken using a bite registration removed prior to sampling. Each issues. Therefore, 21 patients were material (Blu-Bite HP, Henry â Periopaper strip was inserted into available for the final analysis. One Schein, INC., Melville, NY. USA) the gingival crevice until a slight patient from the control group pre- and a step wedge to maintain a resistance was felt and kept in posi- sented at the re-evaluation visit with reproducible projection. The impres- tion for a total of 30 s before imme- PD <5 mm at the study tooth and sion material was fixed on both diate removal. Since presence of therefore did not qualify for peri- sides of the film-holder and stored blood on the strip can affect the test- odontal surgery. There were no sta- for the duration of the study. Intra- ing results, if bleeding occurred at tistically significant differences in oral films were exposed and devel- the site prior to sampling, it was clinical and radiographic baseline oped under standardized conditions. rinsed and cleared away prior to tak- characteristics observed among the These radiographs were taken at ing another sample with a minimum two treatment groups (including baseline and 6 months post surgery. of 90 s between sampling times. Fol- CAL, PD, BOP and linear bone lev- The consecutive radiographs were lowing oral fluid collection, the strips els). In addition, no statistically sig- paired, coded and evaluated by a were immediately placed onto dry nificant difference was found in masked and calibrated examiner ice for transport to the laboratory biomarkers baseline levels (pg/ml) with no knowledge of the treatment ° and stored in an 80 C freezer until between the two treatment groups. group or whether a radiograph had further analysis. Proteins within the There was also no statistically signif- been taken prior to surgery or harvested crevicular fluid were icant difference in patient population 6 months later. Calibration of the extracted from the GCF strips using in term of age, gender and smoking radiographic measurements was per- an elution method involving a series status (Table 1). The observed post- formed by double measurements of of washes and centrifugations (Palys operative healing was similar for 20 radiographs of 1-week gap. et al. 1998). Analysis of the samples â both groups and uneventful in all Intra-examiner value of Pearson’s using Custom Quantibody Array patients. correlation coefficient was 0.95 and was completed by following the pro- Both treatments resulted in a sta- inter-examiner values were 0.94 and tocol provided by the manufacturer tistically significant difference in 0.99, for the first and second mea- (Ray Biotech, Inc., Norcross, GA. CAL gain at 3 and 6 months com- surements respectively. All the stan- USA).

Table 1. Demographic data and baseline characteristics for control (SRP + S) and test (S in the control (SRP + S) group. This only) groups suggests that the initial phase of SRP + S group S only group p-value Range SRP contributed in greater reduction of inflammation of the gingival tis- Age (Mean) 51.5 46.6 0.23 [31–65] sues. One might also argue that the Female/male 4/8 7/5 0.41 greater reduction in PD in the con- Smokers/non-smokers 4/8 5/7 >0.99 trol group besides the treatment CAL (Mean) (mm) 7.25 6.42 0.24 [5–9] – effect might also be in part due to PD (Mean) (mm) 7.42 6.42 0.06 [6 9] the initially deeper probing depths BOP (percentages of sites) (%) 55 67 0.55 Radiographic mean linear found in this group. While the initial bone level (mm) 2.95 2.31 0.10 [1.7–3.7] mean PD in the control group was Tooth type 7.42 mm, the corresponding value in Bicuspids 4 1 0.31 test group was 6.42 mm. This could Molars 8 11 have contributed to the greater Biomarker Levels (pg/ml) reduction in PD observed as studies VEGF 192 119 0.27 have shown that reduction in PD IL-1ß 152 96.4 0.18 was related to the initial IL-6 11.2 27.4 0.17 disease severity (Morrison et al. MMP-8 3366 3327 0.87 MMP-9 9264 8919 0.71 1980, Badersten et al. 1984). Morri- son et al. found that in cases of a 4–6 mm PD there was a reduction of 0.95 mm, while an initial PD of pared to baseline (p < 0.05), with no expression was not significantly dif- ≥7 mm yielded 2.22 mm of PD difference between the two groups. ferent from baseline levels except in reduction (Morrison et al. 1980). By Both groups also showed statistically the test group, which showed higher eliminating the initial SRP procedure significant PD reduction at 3 and 6 mean levels of VEGF at weeks 1 one might think that it would offer months compared to baseline and 2 following treatment (p < 0.001 additional benefits such as saving (p < 0.001). A statistically significant and p < 0.05) respectively. However, treatment time and minimizing difference in PD reduction was when comparing the changes in potential treatment recession. None- found between the two groups at 3 mean VEGF levels from baseline in theless, the following concerns have months (3.53 mm versus 2.05 mm) both groups, no statistically signifi- to be considered when selecting a and at 6 months (3.42 mm versus cant change was observed. The mean direct surgical approach without an 2.02 mm) respectively, in favour of levels of IL-1b, IL-6, MMP-8 and initial SRP: providing an over-treat- the control group (p < 0.05) (Fig. 2 MMP-9 showed no statistically sig- ment since surgery may not be and Table 2). nificant difference, except in the test required after the initial treatment. At 6-month examination, results group at week 1 for IL-6, which was In addition, one should expect more revealed that pocket closure (PD significantly higher when compared demanding surgical procedure due to ≤4 mm) was achieved at 60% of to baseline (p < 0.001). However, no active inflammation and potential tooth sites in the control group, statistically significant difference was increased bleeding. whereas only 40% in the test group. found between the two groups Although multiple studies have The mean overall linear bone (Fig. 3). been conducted that compared the gain was 0.39 mm for the control effectiveness of SRP alone to peri- group and 0.22 mm for the test odontal surgery (Hill et al. 1981, Isi- Discussion group, compared to baseline, with a dor et al. 1984, Becker et al. 1988), range of (À0.1 to 1.0 mm) and (À0.1 This study compared surgery alone this is the first study to investigate the to 1.2 mm) respectively. This was or surgery combined with an initial surgical treatment outcome without determined to be statistically signifi- phase of SRP. The findings from this performing the initial phase therapy. cant in the control group study demonstrated that both treat- Even though a similar study design (p < 0.001), while the bone gain in ments resulted in statistically signifi- was conducted (Serino et al. 2001), the test group had a tendency to cant CAL gain and PD reduction patients in the non-surgical group did reach a statistical significance. How- compared to baseline. However, the not receive a surgical therapy after ever, no statistical significance differ- PD reduction observed in the control the completion of the initial non-sur- ence was found between the two (SRP + S) group showed a statisti- gical phase. Instead of comparing groups. cally significant difference when these two therapies, we aimed to eval- compared to the test (S only) group uate the advantages of performing at both 3- and 6-month follow-up SRP by eliminating this initial ther- Gingival crevicular fluid/Wound fluid examinations. The greater decrease apy in our test group and assess the For both the control and test in PD in the control group might be feasibility of performing surgery as an groups, the mean levels (pg/ml) of due to the two phases of instrumen- initial therapy. In this study, SRP not VEGF within WF increased after tation. As there was no difference in only led to significantly greater reduc- respective treatment when compared CAL gain observed between the two tion in PD but also eliminated the to baseline, then decreased by 3 groups, this might be explained by need for surgery in one patient in the months. This overall difference in the greater gingival recession noted control group. In addition, SRP © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 698 Aljateeli et al.

Mean clinical attachment level (CAL) Control Test In addition to evaluating clinical parameters, this study also aimed at 3.50 assessing changes in WF biomarkers * within each group after treatment and compared the changes between 3.00 ** ** the two groups. The use of GCF/ WF components as a diagnostic aid * has been extensively studied. Evi- 2.50 dence suggests that the GCF/WF constituents can qualitatively and 2.00 quantitatively reﬂect the severity of periodontal disease (Hou et al. 1995, Rescala et al. 2010, Teles et al. 1.50 2010). Hence, GCF/WF inﬂamma- tory cytokine levels can be used to study the course of the disease or 1.58 1.75 1.62 1.00 the periodontal treatment outcomes. 1.33 Our results showed that the mean

Difference from baseline (mm) levels of VEGF increased after treat- 0.50 ment when compared to baseline in both groups then decreased at 3 months. However, only in the test 0.00 group was this difference statistically 3 months 6 months significant as it showed higher mean (a) Time (months) levels of VEGF at weeks 1 and 2 following treatment. This is in agreement with the results obtained by Mean probing pocket depth (PD) Control Test Cooke et al. (2006) who demon- 5.00 strated that non-surgical sites had ** little change in the amount of VEGF 4.50 released in the GCF. For the surgi- ** cal sites, however, Cooke observed 4.00 an immediate increase in the amount of VEGF released over the first 3.50 2 weeks following surgery. ** In our study, the mean levels of 3.00 ** IL-1ß, IL-6, MMP-8 and MMP-9 showed no statistically significant difference, except in the test group 2.50 at week 1 for IL-1ß and IL-6, which was significantly higher when com- 2.00 pared to baseline. This is in agree- 3.53 3.42 ment with other studies that showed 1.50 while SRP did not significantly reduce IL-1 levels (Al-Shammari Difference from baseline (mm) 1.00 2.05 2.02 et al. 2001), a surgical therapy resulted in significantly increased IL- 0.50 1ß levels (Reinhardt et al. 1993). These results may suggest a pro- 0.00 longed production of certain pro- 3 months 6 months inflammatory cytokines after a surgi- (b) Time (months) cal procedure. This in turn may suggest a prolonged wound healing Fig. 2. (a) Changes in mean clinical attachment level (CAL) from baseline at different after a surgical procedure when com- time intervals. (b) Changes in mean probing pocket depth (PD) from baseline at differ- pared to SRP only. ent time intervals. Longitudinal plots “error bars” = 95% confidence interval. *Statisti- < ** One of the limitations of this cally significant difference between baseline and 3 months (p 0.05); Statistically study was the small sample size that significant difference between baseline and 3 months and between baseline and 6 months (p < 0.001). may have affected our ability to detect a difference for an effect of initial SRP on CAL gain. Another resulted in achieving greater percent- SRP. Therefore, SRP as an initial consideration is the relatively short ages of closed pockets 60% compared phase may be a very important ele- 6-month follow-up period. The to 40% in the group without an initial ment of the periodontal therapy. threshold of a 1-mm difference © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Surgical periodontal therapy without SRP 699

Table 2. Clinical attachment level values, PD values (mm; mean Æ SE), percentage of sites with BOP for the two groups at baseline, 3 and 6 months post treatment (N = 21 subjects) Parameter SRP + S group S only group

Baseline 3 months 6 months Difference from Baseline 3 months 6 months Difference from baseline baseline

CAL (mm) 7.3 Æ 0.4 5.7 Æ 0.9* 5.5 Æ 0.6** 1.75** 6.4 Æ 0.6 5.1 Æ 0.49* 4.8 Æ 0.5* 1.62** PD (mm) 7.4 Æ 0.3 3.9 Æ 0.4** 4.0 Æ 0.4** 3.42** 6.4 Æ 0.5 4.4 Æ 0.41** 4.4 Æ 0.4** 2.02** % of sites with 55% 78% (NS) 30% (NS) 67% 45% (NS) 50% (NS) BOP

*p < 0.05 for difference from baseline. **p < 0.001 for difference from baseline. NS, no statistically signiﬁcant difference from baseline.

600 the contrary, patients with poor oral Control hygiene showed additional loss of Test attachment and probing depth 500 increase regardless if the patients were treated with non-surgical or 400 surgical technique (Axelsson & Lind- * he 1981, Lindhe et al. 1984). In this 300 ** study, only patients with good oral hygiene were included to avoid the possible negative effects of perform- VEGF (pg/ml) 200 ing surgery on plaque-infected denti- tion. 100 In conclusion, combined SRP and surgery resulted in greater probing pocket depth reduction as compared 0 012345678910111213to periodontal surgery only without an initial phase of SRP. However, Weeks comparable results for clinical Fig. 3. Mean levels (pg/ml) of VEGF at Baseline, 1, 2, 4 and 12 weeks. Mean levels attachment level gain were achieved (pg/ml) of VEGF increased after treatment when compared to baseline in both groups by the two treatments. These find- then decreased at 3 months. However, this difference was statistically significantly ings should be viewed with caution higher when compared to baseline only in the test group at weeks 1 and 2 following given the limited sample size. treatment (p < 0.001). Longitudinal plots “error bars” = 95% confidence interval. *Statistically significant difference from baseline (p < 0.05); **Statistically significant difference between baseline and 1 week (p < 0.001). References

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Clinical Relevance cal intervention performed without (PD) reduction when compared to Scientific rationale for the study: initial therapy. the surgery without SRP group. Conventional periodontal therapy Principal findings: Although no dif- Practical implications: SRP is an uses an initial non-surgical phase ference was found in clinical attach- important component of the peri- prior to surgical intervention. ment level (CAL) gain between the odontal therapy and its goal is reso- However, limited information two groups, the SRP plus surgery lution of inflammation evident by exists regarding outcomes of surgi- group showed a statistically signifi- reduction of probing pocket depth cant improvement in probing depth and gain of clinical attachment level.