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 radio- graphs 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 scal- ing 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