J Clin Periodontol 2005; 32: 851–859 doi: 10.1111/j.1600-051X.2005.00776.x Copyright r Blackwell Munksgaard 2005 Jan L. Wennstro¨ m1, Cristiano Tomasi1, Alberto Bertelle2 Full-mouth ultrasonic 2 and Ester Dellasega 1Department of Periodontology, Faculty of debridement versus quadrant Odontology, The Sahlgrenska Academy at Go¨teborg University, Go¨teborg Sweden; scaling and root planing as an 2Private practice, Trento, Italy initial approach in the treatment of chronic periodontitis Wennstro¨m JL, Tomasi C, Bertelle A, Dellasega E. Full-mouth ultrasonic debridement versus quadrant scaling and root planing as an initial approach in the treatment of chronic periodontitis. J Clin Periodontol 2005; 32: 851–859. doi: 10.1111/j.1600- 051X.2005.00776.x. r Blackwell Munksgaard 2005. Abstract Aim: To evaluate the clinical efficacy of (i) a single session of ‘‘full-mouth ultrasonic debridement’’ (Fm-UD) as an initial periodontal treatment approach and (ii) re-instrumentation of periodontal pockets not properly responding to initial subgingival instrumentation. Methods: Forty-one patients, having on the average 35 periodontal sites with probing pocket depth (PPD) X5 mm, were randomly assigned to two different treatment protocols following stratification for smoking : a single session of full-mouth subgingival instrumentation using a piezoceramic ultrasonic device (EMS PiezonMaster 400, A1PerioSlim tips) with water coolant (Fm-UD) or quadrant scaling/root planing (Q-SRP) with hand instruments . At 3 months, all sites with remaining PPDX5 mm were subjected to repeated debridement with either the ultrasonic device or hand instruments. Plaque, PPD, relative attachment level (RAL) and bleeding following pocket probing (BoP) were assessed at baseline, 3 and 6 months. Primary efficacy variables were percentage of ‘‘closed pockets’’ (PPD44 mm), and changes in BoP, PPD and RAL. Results: The percentage of ‘‘closed pockets’’ was 58% at 3 months for the Fm-UD approach and 66% for the Q-SRP approach (p40.05). Both treatment groups showed a mean reduction in PPD of 1.8 mm, while the mean RAL gain amounted to 1.3 mm for Fm-UD and 1.2 mm for Q-SRP (p40.05). The re-treatment at 3 months resulted in a further mean PPD reduction of 0.4 mm and RAL gain of 0.3 mm at 6 months, independent of the use of ultrasonic or hand instruments. The efficiency of the initial treatment phase (time used for instrumentation/number of pockets closed) was significantly higher for the Fm-UD than the Q-SRP approach: 3.3 versus 8.8 min. per closed pocket (po0.01). The efficiency of the re-treatment session at 3 months was 11.5 min. for ultrasonic and 12.6 min. for hand instrumentation (p40.05). Key words: clinical; debridement; multicentre; periodontitis; randomized-controlled trial; root Conclusion: The results demonstrated that a single session of Fm-UD is a justified planing; scaling; ultrasonic initial treatment approach that offers tangible benefits for the chronic periodontitis patient. Accepted for publication 17 January 2005 The main goal in the treatment of in the dentogingival area. Root/pocket formed supragingival plaque control patients with periodontitis is to establish instrumentation (scaling and root plan- measures, serves this purpose by altering and maintain adequate infection control ing), combined with effective self-per- the subgingival ecological environment 851 852 Wennstro¨m et al. through disruption of the microbial bio- that bacterial endotoxins penetrate into (Fm-UD) as an initial periodontal film and suppression of the inflamma- the cementum (Hatfield & Baumham- treatment approach in comparison with tion. According to recent systematic mers 1971, Aleo et al. 1974), a concept the traditional treatment modality of reviews (Tunkel et al. 2002, van der that was later disproved by data from consecutive sessions of Q-SRP. An Weijden & Timmerman 2002, Hallmon experimental studies showing that the additional aim was to analyse the effect & Rees 2003), there is no major differ- endotoxins were loosely adhering to the of re-instrumentation of periodontal ence in the efficacy of debridement surface of the root cementum and not pockets that were not responding properly techniques using hand- or power-driven penetrating into it (e.g. Hughes & to initial subgingival instrumentation. instruments in terms of pocket reduction Smales 1986, Moore et al. 1986, Hughes and gain in clinical attachment. While et al. 1988, Cadosch et al. 2003). Hence, Tunkel et al. (2002) concluded, based on intentional removal of tooth structures Materials and Methods their systematic review, that the use of by root planing during pocket/root The trial was designed as a randomized, ultrasonic/sonic devices requires less instrumentation may not be considered controlled, single-masked and parallel treatment time than manual instrumen- as a prerequisite for periodontal healing group study of 6 months duration (Fig. tation, Hallmon & Rees (2003), in a (Nyman et al. 1986, 1988). Conse- 1), and was conducted at two centres comparable review, considered that quently, pocket/root instrumentation (Department. of Periodontology, the there is insufficient evidence to make should preferably be carried out with Sahlgrenska Academy at Go¨teborg Uni- any conclusion regarding differences in instruments that cause minimal root versity, Sweden and a private dental treatment time. substance removal, but are effective in office in Trento, Italy) during 2002. The traditional modality as an initial disrupting the biofilm and removing Approval of the study protocol by the periodontal treatment phase has been to calculus. In this respect, data reported Ethics Committee at Go¨teborg Univer- perform scaling and root planing by jaw in studies that evaluated root substance sity was obtained, and all participating quadrant (Q-SRP) at a series of appoint- removal following the use of various subjects provided informed consent ments (Badersten et al. 1984a). More manual and power-driven instruments before the start of the study. recently, Quirynen et al. (1995) advo- (Ritz et al. 1991, Busslinger et al. cated the benefit of performing full- 2001, Schmidlin et al. 2001) favour the Patient sample mouth SRP within 24 h in order to use of ultrasonic devices. prevent re-infection of the treated sites The aim of this study was to evaluate Forty-two adult patients, 21 at each from the remaining untreated perio- the clinical efficacy of a single session centre, with moderately advanced dontal pockets. The authors also consid- of full-mouth ultrasonic debridement chronic periodontitis, were recruited ered the risk of re-infection from other intra-oral niches such as the tongue and Screening examination tonsils, and therefore included tongue OH instruction cleaning and an extensive anti-microbial regimen with chlorhexidine (full-mouth disinfection). In a series of studies (Quirynen et al. 1995, Bollen et al. Stratification for smoking Randomization 1996, 1998, Vandekerckhove et al. Test Control 1996, Mongardini et al. 1999), it was documented that this combined Ultrasonic n = 21 n = 21 debridement SRP approach resulted in improved healing, as assessed by clinical and microbiolo- n = 20 n = 21 gical means, compared with Q-SRP with Baseline examination Baseline examination 2-week intervals. It was, however, Full-mouth ultrasonic debridement Quadrant scaling/root planing 1-hour session 4 × 1-hour session shown in a subsequent study by the OH instruction OH instruction-first session only same research group (Quirynen et al. 2000) that the major part of the improved treatment outcome of the 1 month 1 month full-mouth disinfection approach was OH control OH control attributed to the SRP of all four quad- Questionnaire Questionnaire rants within 24 h, rather than to the adjunctive chlorhexidine regimen. n = 20 n = 21 Another consideration in relation to 3-month re-examination 3-months re-examination Re-treatment of sites with PPD ≥ 5 mm S/RP of sites with PPD ≥ 5 mm non-surgically performed SRP is the No time limitation No time limitation extent of root instrumentation required for periodontal healing. The original intention with SRP was not only to remove microbial biofilm and calculus n = 20 n = 21 but also ‘‘contaminated’’ root cementum 6-month re-examination 6-month re-examination or dentin in order to prepare a root Termination of the study Termination of the study surface biocompatible for soft-tissue healing. The rationale for performing Fig. 1. Flowchart of the study outline. One of the 42 initially enrolled patients decided to exit root planing was based on the concept from the study before the baseline examination/treatment session (test group). Full-mouth ultrasonic debridement 853 for the study following a screening scored by running a probe along the Treatment procedures examination including full-mouth prob- tooth surface. ing and radiographic evaluation. The PPD: measured with a manual Hu– In conjunction with the screening exam- following criteria were used in the Friedy PCP15 periodontal probe (Hu– ination (2–3 weeks before the start of selection of study subjects: Friedy Inc., Leimen, Germany) to the the trial), the patients were given careful closest lower millimetre. instructions in self-performed plaque BoP: presence/absence of bleeding control measures: twice-daily tooth- Inclusion criteria within 15 s following pocket probing. brushing using the modified Bass brush- Age 25–75 years; Location of gingival margin (GM): the ing technique with a soft toothbrush and A minimum of 18 teeth; distance between the GM and a fixed a regular toothpaste with fluoride, and At least eight teeth must show prob- reference point on the tooth (cemento once-daily inter-dental cleaning using ing pocket depths (PPD) of X5mm enamel injection (CEJ) or the margin of triangular wooden toothpicks and/or and bleeding on probing (BOP). At a restoration). A negative value was inter-dental brushes. The standard of least two of these teeth must have a given when the gingival margin was oral hygiene was checked at the baseline PPD of X7 mm and at additional located coronal to the CEJ.