A Randomized Four-Year Study of Periodontal Therapy

Bruce L. Pihlstrom,* Cesar Ortiz-Campos,* and Richard B.

McHughf

The purpose of this study was to compare the long term effectiveness of scaling and root
planing alone to scaling and root planing followed by periodontal surgery. Seventeen subjects
with moderate to advanced Periodontitis received thorough scaling and root planing as well as
oral hygiene instruction. A modified Widman flap was then randomly performed for one-half
of each subject's dentition. Recall prophylaxis and oral hygiene reinforcement were adminis-
tered for 4 years after completion of therapy. Shallow crevices (1-3 mm) subjected to either
procedure tended to increase slightly in depth and exhibit a slight loss of attachment when
compared to pretreatment measurements. Moderately deep pockets (4-6 mm) treated by either
procedure were reduced and demonstrated a sustained gain or maintenance of attachment
level. Pockets initially >7 mm exhibited the greatest reduction in depth and attachment gain.
Gingivitis was reduced following either procedure for moderate and deep pockets. No
difference in supragingival plaque retention was noted and both procedures reduced calculus.
The results indicate that both procedures were effective in treating moderate to advanced
Periodontitis. However, the additional flap procedure tended to result in greater pocket
reduction and attachment gain for deeper pockets.

Conventional periodontal therapy routinely involves when thorough scaling and root planing is initially ac-
a presurgical phase which utilizes scaling and root plan- complished. Of these, Waite31 compared the effect of
ing combined with oral hygiene instruction. This is gen- scaling and gingivectomy in a split mouth design of 28
erally followed by surgical intervention for the purpose patients over a 48 week period. It was concluded that
of obtaining more definitive resolution of the disease surgical therapy was more effective in reducing pockets
process. In recent years, many well designed prospective and inflammation than scaling alone. Morrison et al.32
clinical trials have established the longitudinal effective- reported a 3 year study of beagles in which scaling and
ness of such therapy in
arresting the progressive destruc- root planing was compared to various forms of surgical
tion of Periodontitis.1"11 Similarly, retrospective studies therapy. It was noted in general that attachment levels
have documented the effectiveness of periodontal ther- were maintained for all treatment groups but, for deeper
apy over a period of many years.12"15 These studies are pockets, attachment was lost following scaling alone. A
particularly enlightening in view of the continuing peri- recent report33 from the same institution has documented
odontal destruction which occurs when Periodontitis is the beneficial effects of scaling and root planing in
untreated.16"17 However, limited information is available humans over a 2 year time period. In spite of these
concerning the relative longitudinal effectiveness of scal- studies, there is little information available concerning
ing and root planing alone compared to scaling and root the relative beneficial effects of scaling and root planing
planing following by periodontal surgery. Research alone as compared to scaling and root planing followed
which is available has been directed at defining the by a periodontal flap procedure.
beneficial effects of periodic dental prophylaxis and oral The purpose of the present study therefore, was, to
hygiene instruction in limiting or arresting the destruc- compare the relative longitudinal effectiveness of thor-
tive effects of Periodontitis.18"23 Others have documented ough scaling and root planing alone (R.P.) with scaling
the beneficial effect of subgingival scaling and root plan- and root planing followed by a modified Widman flap
ing on gingivitis,22"30 pocket depth23"26,30 and attachment procedure (R.P. + Sx).
levels.23"25, 30 A few studies have attempted to define the
additional benefit obtained by surgical intervention METHOD

Description of Sample
Department of Periodontology. School of Dentistry. University of
*

Seventeen volunteers, age 22 to 59 were initially in-

Minnesota. Minneapolis, MN 55455.
t Department of Biometry, School of Public Health, University of cluded in this study. Their mean age was 43. Each of the
Minnesota. four males and 13 females had moderate to advanced
227
 J. Periodontol.
228 Pihlstrom,Ortiz-Campos, Me Hugh May, 1981
Periodontitis. Crevices or pockets varied from 1 to 14 by Ramfjord and Nissle.34 No further periodontal ther-
mm in depth among all teeth. A total of 453 teeth were apy was accomplished for the remaining one-half of the
present in the 17 subjects, the mean number of teeth per dentition. Therefore, one-half of each subject's dentition
subject being 26.6. All teeth were included in the study received scaling and root planing alone and the other
and none were extracted before the study began regard- half received this therapy plus modified Widman flap
less of the severity of Periodontitis. This was to insure surgery.
that no bias against treating advanced disease was intro- All patients were recalled for routine dental prophy-
duced. laxis by a dental hygienist. The frequency of these recalls
varied. However, most had recalls three to four times per
Experimental Design year. At these appointments, oral hygiene was reinforced
The experimental protocol is illustrated in Figure 1. and all teeth were scaled both supra and subgingivally
Initially, clinical measurements were recorded by a single to the best of a hygienist's ability during a 1 hour
calibrated examiner. All subjects then received thorough appointment. Three hygienists were used for these re-
scaling and root planing for all teeth and oral hygiene calls. Each was judged to be well trained and all subjects
instruction. A sulcular technique of brushing and the use were also examined by the same periodontist at the

of dental floss and other oral hygiene aids as necessary recalls. If overt signs of periodontal inflammation were
were introduced. Local infiltration or block anesthesia apparent such as purulence or bleeding on gentle prob-
was used as necessary for patient comfort during the ing, the periodontist thoroughly root planed the areas.
scaling and root planing. All therapy was performed by The patient was then recalled within the next few weeks.
a
periodontist in training and three to four 2 hour If the inflammation persisted, the patient was advised of
appointments were generally necessary to complete this it and the need for further corrective therapy. The form
phase of treatment. The objective of this therapy was to of this therapy was left to the discretion of the periodon-
remove all local irritants including calculus and plaque tist based on his clinical judgement irrespective of the
which are associated with periodontal inflammation. design of the study. Therefore, it was possible for a
Furthermore, all overhangs and defective restorations patient to have subsequent periodontal surgery in local-
were corrected by reshaping or replacement as necessary. ized areas of his dentition. Since the experimental pro-
The root surfaces were smoothed with periodontal cu- tocol had been violated for these teeth, data for retreated
rettes until a clinically "hard smooth surface" was teeth were omitted after corrective therapy was com-
achieved. Occlusal adjustment was also accomplished as pleted. It should be noted, however, that data were not
indicated by trauma based upon tooth mobility during omitted for these teeth up to the time of the corrective
function and radiographie signs. therapy. In this way, the data were not biased against an
Upon completion of the scaling and root planing, one unfavorable response. Of the 17 subjects originally in the
half of each subject's dentition, including a maxillary study, four required corrective therapy in the form of
and mandibular quadrant on one side, was randomly subsequent localized surgery. A total of 31 such teeth
selected to receive a modified Widman flap as described were included in these four patients. None of these teeth
had received the flap procedure previously. The duration
of time for this corrective therapy varied from 14 to 36
CLINICAL PARAMETERS SCORED
months after completion of initial active therapy.
J
Thorough scalini and root planing
Since no teeth were extracted prior to beginning the
study, it was expected that some might be lost. The
Oral hygiene instructions criteria for extraction was based upon persistent overt
inflammation in the form of purulence on probing and/
1
Random selection or persistent discomfort and what was felt to be a result
of untreatable periodontal or endodontic involvement.

1/2 dentition received 1/2 of dentition received Clinical Measurements

modified Widman flap surgery no further therapy Clinical measurements were obtained prior to any
therapy, again at six months after completion of the
Recall prophylaxis * surgical phase and annually thereafter. All measure-
Oral hygiene reinforcement ments were recorded by a individual different than the
(3-6 month Intervals) one providing therapy. These included the plaque and

gingivitis index described by Ramfjord,1' the calculus

i
Clinical parameters rescored
index of Greene and Vermillion,3b as well as pocket

6 months post-surgically and

depth and attachment levels for all teeth. Plaque and
calculus was scored for the buccal and lingual surface of
annually thereafter each tooth separately but gingivitis was combined for
Figure 1. Flow chart of experimental protocol. both buccal and lingual surfaces of each tooth. Pocket
Volume 52
Number 5 Four- Year Study 229

and attachment levels recorded at six loca- adjacent to pockets initially 1 to 3 mm, 4 to 6 mm, and
depth were
tions for each tooth. These included four proximal (me- >7 mm were segregated within each patient. This was
sio-buccal, mesio-lingual, disto-buccal and disto-lingual) necessary since it would be important to determine
as well as midfacial and midlingual measurements. All whether changes in these indices occurred with respect
measurements were recorded to the nearest millimeter to the therapy used for different pocket depths. Patient
means for each index based upon the method of therapy
using a University of Michigan "O" probe with Williams
were then computed for each time interval from the data
depth markings. The probes were chosen out of stock on
the basis of uniformity and accuracy of millimeter mark- in the three pocket depth categories. These means were
ings and diameter. The same calibrated probes were used the basis of a paired t test to determine statistical signif-
throughout the duration of the study. Pocket depth was icance between the two therapeutic methods. As a check
recorded at each location as the distance from the free on the robustness of the analysis, both nonparametric

gingival margin to the most apical extent of probe pen- and parametric tests were conducted for plaque, calculus
etration. Attachment level was also documented at the and gingivitis indices. The results of the nonparametric
same locations. This was accomplished by recording the test did not vary from those obtained using a paired t
distance from the cemento-enamel junction to the free test. Therefore, theanalysis reported in this study is
gingival margin. If gingival recession apical to the ce- confined parametric methods.
to
mento-enamel junction was evident, this value was re- Patient means of pocket depth and attachment level
corded as a negative value. Attachment level was later were also calculated for all teeth receiving either treat-
ment in each patient at the different time intervals. These
computed by subtracting this distance from the pocket
were subdivided into three categories based upon initial
depth.
pocket depths of 1 to 3 mm, 4 to 6 mm and >7 mm.
Examiner Calibration Initially, the group of four proximal measurements and
Calibration of the examiner recording all measure- the buccal as well as lingual measurements for each tooth
ments was accomplished before beginning the study and were analyzed separately to determine whether any dif-
ferences among surfaces occurred with respect to the
throughout its duration by randomly selecting eight teeth
for remeasurement after data for the subjects were re- types of therapy. Since none was found, the means were
corded. As an example, a subject had each parameter subsequently grouped without respect to surface to ob-A
recorded for all teeth. A dental assistant then directed tain patient means for the two treatment methods.
the examiner to rescore each measurement on eight teeth paired / test was then used to compare the results of
selected by means of a table of random numbers. Al- therapy at each time interval.
though this system of calibration was consecutive in that RESULTS
it followed the data measurements, there was little chance
of recalling the original measurements because the ex- Calibration Trials
aminer had no knowledge of the teeth which would be The results of calibration trials for the single examiner
selected for remeasurement. In addition, the large vol-
who recorded all clinical measurements are presented in
ume of data precluded recall of individual measure-
Table 1. The statistic (d) presented is the average of the
ments. For each clinical parameter, a total of 16 such differences obtained between each of the 16 cali-
mean
trials was conducted.
bration trials. The standard error (SEs) jind statistical
Statistical Method significance (P) based on a paired / test ofd is also given.
It should be noted that these results are based upon
There is good evidence that pockets of varying initial patient means for the teeth remeasured during calibra-
depth respond differently to therapy.1 This is especially tion trials. Therefore, each of the 16 trials (N) is a
critical for data analysis when shallow crevices are much individual For the
more numerous than deep pockets. Data which is pooled
composite of many measurements.

from all pockets may lead to erroneous conclusions. gingivitis, plaquewere scored twice for each of the and
and calculus indices, the buccal
lingual surfaces eight
Furthermore, to allow comparison of the present results randomly selected teeth. A total of 256 paired observa-
with earlier work, it was necessary to categorize the data tions were therefore made for each index (2 surfaces X
on the basis of the covariate of original pocket depth as

suggested by Knowles et al.1 Therefore, the data was Table 1

separated for all parameters into three categories on the Analysis of Calibration Trials for Clinical Indices, Pocket Depth and
basis of initial pocket depth. These consisted of pockets Attachment Level
1 to 3 mm, 4 to 6 mm, and those greater than or equal SEj N
to 7 mm. Gingival Index 0.146 0.033 16 <0.01
All data were transferred to punch cards for computer Plaque Index 0.003 0.016 16 0.83
Calculus Index 0.008 0.025 16 0.76
analysis. Indices for gingivitis, plaque, and calculus were Pocket depth 0.08 mm 0.02 16 <0.01
separated according to the deepest pocket on each sur- Attachment level 0.02 mm 0.04 16 0.63
face used for scoring the index. Thus, indices obtained
 J. Periodontol.
230 Pihlstrom, Ortiz-Campos, Me Hugh May. 1981
8 teeth X 16 trials). For pocket depth and attachment G I (Bu + Li)
level calibration, each of the 16 trials is representative of 3n
two measurements for each of the six locations on eight 1 3 mm CREVICES
-

randomly selected teeth. Therefore, 768 paired measure-

ments for pocket depth as well as attachment level were
made during this calibration test. Patient means were 2H
used for data analysis to insure consistency with the
overall statistical method used in the study.
As may be seen from Table 1, the values ford in the
plaque and calculus indices were not statistically signifi-
cant. Furthermore, the value for the SE of d was quite
--
ROOT PLANING + FLAP
low when the magnitude of the scoring system is consid- —
ROOT PLANING
ered (0, 1, 2, 3). Similarly, d in attachment level mea- _L
surement was not statistically significant and the SE was 0 J_L _L J

quite low. There was a statistically significant difference 1/2

between the remeasurement values of the gingivitis index
YEARS
and pocket depth measurements. Although these differ-
Figure 2. Changes with time for gingivitis (GI) adjacent to initial 1-3
ences were quite low (0.146 units for the GI and 0.08
mm crevices. X denotes < 0.05
from time zero.
mm for pocket depth), they were highly significant.
However, the SE of these values was quite low when it G I (Bu+Li)
is considered that measurements were made clinically to
the nearest index unit or depth in whole millimeters. 4 6 mm POCKETS
-

Further data analysis revealed that 97% of pocket depth

and 92% of attachment level measurements were repro- -
ROOT PLANING + FLAP
ducible by the examiner within ± 1 mm. This was based —
ROOT PLANING
upon 768 paired measurements and is also comparable 24,
to data reported by others.37,38
The results of the calibration trial confirmed the re-
producibility of the examiner for plaque, calculus, and
attachment level. However, the calibration trials also
established that any changes which are noted as a result X P<.05 BETWEEN
of therapy for pocket depth and gingivitis must exceed THERAPY METHODS
the variability of the examiner. For gingivitis this was
0.15 index units and for pocket depth this was 0.08 mm. 0 J_L _l_I_
It should also be noted that the results for these calibra- '/2 I
tion trials are well within the limits established by other
investigators.37 YEARS
Figure 3. Changes with time for gingivitis (GI) adjacent to initial 4-6
Gingival Inflammation mm pockets. X denotes < 0.05 from time zero.

1 to 3 mm. The results for gingivitis adjacent to 1 to 3

mm crevices are illustrated in Figure 2. As may be seen, methods was observed only at 3 years. This difference
there was a trend for overall reduction in gingivitis for was only 0.17 index units and is just slightly more than
both treatment methods. However, after an initial sharp the examiner error of 0.15 index units. Furthermore, this
decrease at 6 months, the degree of gingival inflamma- difference was not maintained at 4 years. Overall, there
tion tended to return although it did not reach pretreat- was a statistically significant reduction in inflammation
ment levels at time 0. Only the values obtained adjacent by both treatment methods, with neither being superior.
to teeth subjected to root planing alone were significantly 7 mm or more. The results for gingivitis adjacent to
different at 6 months as compared to time 0. Further- pockets >7 mm are presented in Figure 4. Both methods
more, there was no significant difference in the degree of of treatment resulted in a significant reduction for all
gingivitis between the two treatment modalities at any time intervals when compared with values prior to ther-
time interval over the 4 year period. apy. However, there were no significant differences be-
4 to 6 mm. The results for gingivitis adjacent to initial tween treatment methods with respect to reduction in
pockets 4 to 6 mm in depth are presented in Figure 3. A gingivitis at any time interval up to 4 years.
significant reduction in gingivitis occurred after both Plaque
treatment methods and was maintained at all time inter-
vals up to 4 years. A difference in the degree
significant I to 3 mm. The results of the plaque index for buccal
of gingival inflammation between the two treatment and lingual surfaces adjacent to 1 to 3 mm crevices are
Volume 52
Number 5 Four- Year Study 231

G I (Bu + Li) 4 to 6 mm. Results from the calculus index adjacent to

3-, initial pockets of 4 to 6 mm are presented in Figure 9.
P0CKETS>7 mm
Both treatment methods significantly reduced calculus at

BUCCAL I
24 1 3mm CREVICES
-

ROOT PLANING + FLAP

ROOT PLANING
J_L _L _L
0
I/2 I 2 3 4 '/2 12 3 4
—
ROOT PLANING-t-FLAP
YEARS ROOT PLANING
Figure 4. Changes with timefor gingivitis (GI ) adjacent to initial pockets 3-
-

> 7 mm. X denotes £ 0.05 from time zero. LINGUAL I

1-3 mm CREVICES
shown in Figure 5. As may be observed, no significant 2-
difference in plaque was found either between treatment
methods or over time when compared to pretreatment
values for either procedure separately.
4 to 6 mm. The results for the plaque index on buccal
and lingual surfaces adjacent to initial pockets of 4 to 6
mm is presented in Figure 6. No significant differences J_L J
0
occurred with either treatment in respect to time except l/2 I 2 3 4
a reduction of buccal plaque at 6 months on teeth YEARS
receiving root planing alone. Furthermore, no significant Figure 5. Changes with lime for plaque (PIj adjacent to initial 1-3 mm
differences between treatment methods at any time inter-
val were found except at 2 years on the lingual surface. 3-, BUCCAL PI
At this isolated time interval, scaled and root planed 4 6 mm POCKETS
-

teeth had lower plaque values than those receiving scal-

ing and root planing plus modified Widman flap. 2^
7 mm or more. The results for the plaque index are
illustrated in Figure 7. As may be seen, no lasting
differences are observed between the two treatment meth-
ods. However, at 6 months, teeth receiving only scaling
and root planing had significantly less plaque on lingual
surfaces than teeth which received the additional flap 0 _L J
procedure. This was also the only time interval at which V2 I 2 3 4
plaque was significantly reduced as compared to pre- —
ROOT PLANING + FLAP
treatment values at time 0. In general, there were no -
ROOT PLANING
superior effects of either procedure with regard to supra- 3"
gingival plaque adjacent to pockets 7 mm or greater. LINGUAL I
4 6 mm POCKETS
-

Calculus
2-
1 to 3 mm. The results of the statistical analysis for the
calculus index on buccal and lingual surfaces is illus-
trated in Figure 8. Both treatment methods resulted in I -
P5.05 BETWEEN
significantly decreased calculus at all intervals compared THERAPY METHODS
to pretreatment levels at time 0. It may also be seen that
the calculus index tended to be somewhat higher on 0
lingual than buccal surfaces. However, no difference 1/2 I 2 3 4
between treatment methods was found at any time inter- YEARS
val. Both methods were equally effective in reducing Figure 6. Changes with time for plaque (PI) adjacent to initial 4-6 mm
calculus. pockets. X denotes £ 0.05 from lime zero.
 J. Periodontol.
232 Pihlstrom, Ortiz-Campos, McHugh May, 1981
3 BUCCAL I BUCCAL C I
P0CKETS27 mm 4 6 mm POCKETS
-

t P< .05 BETWEEN

2 THERAPY METHODS

0 J_L
1/2 I 1/2 1 2 3 4
ROOT PLANING+FLAP
---
ROOT PLANING + FLAP
•ROOT PLANING -
ROOT PLANING
3
LINGUAL I LINGUAL C I
P0CKETS> 7 mm 4 6 mm POCKETS
-

X P< .05 BETWEEN

THERAPY METHODS

0
V2 2 3 4
YEARS YEARS
Figure 7. Changes with time for plaque (PI) adjacent to initial pockets Figure 9. Changes with time for calculus (CI) adjacent to initial 4-6 mm
> 7 mm. X denotes < 0.05 from time zero. pockets. X denotes < 0.05 from time zero.

3 BUCCAL C I
1 3 mm CREVICES ods. In general, both methods were effective in reducing
-

calculus and neither was superior.

2H 7 mm or more. Results for the calculus index adjacent
to pockets 7 mm or greater are presented in Figure 10.
Statistically significant reductions in calculus were found
at all time intervals compared to pretreatment levels for
both methods of therapy. No difference between treat-
ment methods was found with respect to this index at
any time interval up to 4 years.
1/2
Pocket Depth
ROOT PLANING +FLAP
ROOT PLANING 1 to 3 mm. The results of mean changes in depth of
crevices initially 1 to 3 mm are presented in Figure 11.
LINGUAL C I At 6 months and 1 year, there was an initial nonsignifi-
l-3mm CREVICES cant reduction in crevice depth following both proce-
dures. After 1 year, the depth tended to increase slightly
with time. By 3 years, there was a small (0.1 mm) but
statistically significant increase in mean crevice depth
treated by root planing plus the flap procedure. This
slightly increased depth was also apparent at 4 years
when these crevices had a mean depth 0.17 mm greater
(P < 0.05) than that prior to therapy. Crevices which
1/2 1 2 3 received only root planing also increased in depth and
YEARS their mean was slightly greater (0.17 mm) at 4 years than
Figure 8. Changes with time for calculus (CI ) adjacent to initial crevices the mean depth prior to therapy. This difference ap-
1-3 mm. X denotes S 0.05 from time zero.
proached statistical significance (P < 0.06) at 4 years.
all time intervals compared to pretreatment levels. Only The results of differences between treatment methods
the 1 year data for buccal surfaces showed a significant at each time interval is presented in Table 2 as well as in
difference in the calculus index between treatment meth- Figure 11. At 3 and 4 years, a small difference in crevice
Volume 52
Number 5 Study 233Four-Year

depth between treatment methods was apparent. The and sustained reduction in mean pocket depth. This
mean depth of crevices treated by root planing plus the reduction was apparent at the 6 month postoperative
flap procedure was somewhat greater (0.1 mm, < 0.05) time period. Root planing alone resulted in an initial
than those treated by root planing alone. mean pocket reduction of 0.94 mm at 6 months (P <
In general, neither procedure had any significant clin- 0.01) compared to pretreatment depth at time 0. On these
ical effect on crevice depth over 4 years although some teeth, there was a trend between 6 months and 1 year for
statistically significant differences were observed. pocket depth to increase slightly. However, the mean
4 to 6 mm. The results of mean changes in initial reduction from baseline remained statis-
measurements
pockets 4 to 6 mm are presented in Figure 12. Both tically significant (P < 0.01) intervals up to 4
at all time
treatment procedures resulted in a statistically significant years. These mean reductions were computed to be 0.79
mm at 1 year, 0.78 mm at 2 years, 0.62 mm at 3 years
BUCCAL C I
and 0.66 mm at 4 years. When means of 4 to 6 mm
POCKETS>7 mm
pockets treated by root planing plus the flap procedure
are compared to pretreatment levels at each time interval,
similar results were found. The initial mean pocket depth
at 6 months was less (1.44 mm, <5c0.01) than the =

o mean depth of the same pockets at time 0 prior to

therapy. Subsequently, pocket depth tended to increase

somewhat up to 3 and 4 years when pocket reduction
was 0.80 mm (P < 0.01) and 0.84 mm (P < 0.01)

fel 2 3 4 respectively as compared to pretreatment means.

Differences between treatment methods are given in
---
ROOT PLANING + FLAP Table 3 as well as Figure 12. Scaling and root planing
-ROOT PLANING followed by the flap procedure resulted in statistically
3i
significant greater pocket reduction than did root planing
alone up to the 1st year after completion of therapy. It
LINGUAL C I
should be noted that at time 0, there was a statistically
POCKETS.* 7 mm
significant difference (0.12 mm, 0.03) in mean pocket =

depth between sides of the dentition treated by either

procedure. The mean pretreatment pocket depth for root
planed teeth was 4.76 mm while it was 4.88 mm for teeth
which received root planing plus the flap (Table 3). In
0 spite of this initial mean difference before therapy, the
1/2 2 3 4 additional flap procedure reduced mean pocket depth
YEARS significantly more (0.38 mm, 0.02) when the proce-
=

Figure 10. Changes with timefor calculus (CI ) adjacent to initial pockets dures were compared at 6 months. A significantly greater
> 7 mm. X denotes < 0.05 from time zero. reduction in pocket depth for the flap procedure was

+ 3i _ROOT PLANING + FLAP

-ROOT PLANING 1 3 mm CREVICES
X PS.05 FROM BASELINE -

t P<.05 BETWEEN PROCEDURES

+ 2

( + I POCKET DEPTH INCREASE

or

-1--i
I 0

ATTACHMENT LOSS
-2

° J_I-1-1-1-1
_-3
·
Y2 I 2 3 4
YEARS
Figure 11. Changes in depth and attachment level with time for initial crevices 1-3 mm. X denotes < 0.05 from time zero.
 J. Periodontol.
234 Pihlstrom, Ortiz-Campos, Me Hugh May, 1981
Table 2
Analysis of Mean Differences in Depth of Crevices Initially 1 to 3 mm

Time
Number of Meanpocket Differences in
Procedures SE
patients depth mean depth
mm mm

17 R.P. 2.43 -0.05 0.04 0.16

R.P. + Sx 2.48

6 mo 15 R.P. 2.36 0.02 0.05 0.74

R.P. Sx 2.34

lyr 14 R.P. 2.38 -0.03 0.04 0.41

R.P. + Sx 2.41

2yr 15 R.P. 2.42 -0.10 0.05 0.07

R.P. + Sx 2.52

3yr 12 R.P. 2.53 -0.12 0.05 0.04

R.P. + Sx 2.65

4 yr 10 R.P. 2.58 -0.11 0.04 0.02

R.P. + Sx 2.69

+ 3 ---
ROOT PLANING + FLAP 4-6 mm POCKETS
-
ROOT PLANING
COS FROM BASELINE
+ 2 J P<,05 BETWEEN PROCEDURES

ATTACHMENT GAIN

POCKET REDUCTION
-24
-3-
1/2
YEARS
Figure 12. Changes in depth and attachment level with time for initial pockets 4-6 mm. X denotes P S 0.05 from time zero.

maintained up to 1 year (0.48 mm, < 0.01). However, dure was used in addition to root planing, pocket depth
after this time, a gradual increase of pocket depth re- was also reduced significantly over the pretreatment
sulted in no statistically significant difference between mean. This reduction was 2.9 mm (P< 0.01) at 6 months.
the two procedures at 2, 3, and 4 years (Table 3 and Fig. There was a slight tendency for some return of pocket
12). In general, both procedures reduced 4 to 6 mm depth over the subsequent time interval, but all reduc-
pockets to a significant degree over the entire 4 year time tions remained statistically significant (P < 0.01). The
interval. mean pocket reduction was computed to be 2.6 mm at 1
7 mm or more. The results of mean changes in pockets year, 2 mm at 3 years, and 1.9 mm at 3 and 4 years.
initially >7 mm are illustrated in Figure 13. Both meth- The results of differences between treatment proce-
ods of therapy reduced pocket depth. Root planing alone dures with respect to pocket reduction are given in Table
reduced pockets by 1.6 mm (P < 0.01) at 6 months as 4 as well as Figure 13. The additional flap procedure
compared to pretreatment depth. This degree of pocket resulted in statistically significant (P < 0.05) increased
reduction was generally maintained throughout the 4 pocket reduction when compared to root planing alone
year time interval, although at 4 years, mean pocket at 6 months, 1 and 2 years. These mean differences were
reduction was 1.3 mm and not significantly (P 0.14) =
1.35 mm, 0.91 mm, and 0.97 mm, respectively. At 3
less than the pretreatment mean. When the flap proce- years, the flap resulted in 0.43 mm more pocket reduc-
 Volume 52
Number 5 Four-Year Study 235
Table 3
Analysis of Mean Differences in Depth of Pockets Initially 4 to 6 mm
Mean
Number Differences in
lime Procedures pocket SE
or patients mean depth
.

depth
mm mm

17 R.P. 4.76 -0.12 0.05 0.03

R.P. + Sx 4.88

6 mo 15 R.P. 3.80 0.38 0.15 0.02

R.P. + Sx 3.42

lyr 14 R.P. 4.00 0.48 0.10 <0.01

R.P. + Sx 3.52

15 R.P. 3.99 0.21 0.16 0.23

2yr
R.P. + Sx 3.78

12 R.P. 4.06 0.01 0.19 0.96

3yr
R.P. + Sx 4.05

4 yr 10 R.P. 4.05 0.03 0.23 0.92

R.P. + Sx 4.02

+ 3 ---
ROOT PLANING+FLAP POCKETS>7 mm
-
ROOT PLANING
X P<.05 FROM BASELINE
X P<.05 BETWEEN PROCEDURES
ATTACHMENT GAIN

<r> +1
or
ÜJ

I
-I
O

-I -

-2 -

-3

YEARS
Figure 13. Changes with time in depth and attachment level for initial pockets
> 7 mm. X denotes < 0.05 from time zero.

tion, but this difference was not significant (P 0.28). =

apparent the first 6 month postoperative time period
at

Although this mean difference in pocket reduction in- especially for teeth which received root planing plus the
creased to 0.93 mm by 4 years, it did not reach signifi- flap procedure. By 6 months, teeth treated in this manner
cance (P =
0.16). had lost a mean attachment of 0.73 mm. Moreover, this
In summary, pockets were reduced by both treatment loss was not regained over the 4 years. It remained at
methods. However, the additional flap procedure re- mean levels of 0.74 mm less at 1 year to 0.86 mm less at
sulted in statistically significant greater reduction for the 4 years as compared to pretreatment means. All of these
first 2 years as compared to root planing alone. mean losses had a high degree of statistical significance
(P< 0.01).
Attachment Level Although root planing alone also resulted in a loss of
1 to 3 mm. The results of changes in mean attachment attachment for 1 to 3 mm crevices, it was not of the same
levels at each time interval for initial 1 to 3 mm crevices magnitude as that following the flap procedure. By 1
are presented in Figure 11. Both procedures tended to year, the mean attachment level was 0.27 mm less than
result in loss of attachment over 4 years. This loss was that obtained prior to therapy {P 0.01). At 3 years.
=
 J. Periodontol.
236 Pihlstrom, Ortiz-Campos, McHugh May, 1981
Table 4
Analysis of Mean Différences in Depth of Pockets Initially 7 mm or more

Mean
_. Number , Differences in
Procedures pocket .SE
„
Time ,
ot patients
depth
mean depth
mm mm

0 15 R.P. 7.44 0.06 0.16 0.68

R.P. + Sx 7.38

6 mo 13 R.P. 5.72 1.35 0.37 <0.01

R.P. + Sx 4.37

1 yr 12 R.P. 5.74 0.91 0.39 0.04

R.P. + Sx 4.83

2yr 14 R.P. 6.03 0.97 0.34 0.01

R.P. + Sx 5.06

3yr II R.P. 5.89 0.43 0.38 0.28

R.P. + Sx 5.46

4yr 9 R.P. 6.23 0.93 0.59 0.16

R.P. + Sx 5.30

the mean loss was 0.41 mm (P < 0.01) greater than as compared to baseline means at time 0 (0.18 mm, =

that before therapy. There was a slight gain between 3 0.32). This initial slight gain decreased by 1 year and
and 4 years so that the attachment loss at 4 years (0.30 approached the pretreatment mean by 2 years. At 3
mm, =
0.06) only approached statistical significance. years, the mean dropped slightly below the pretreatment
Differences in attachment level between treatment pro- level (0.16 mm) but was not statistically significant
cedures are given in Table 5 and also are illustrated in (P 0.24). By 4 years, there was no net gain or loss in
=

Figure 11. There was a statistically significant difference attachment level. Therefore, both procedures resulted in
between treatment procedures at each postoperative time a maintenance of attachment levels over the 4 year time
period with regard to attachment level. The additional period.
flap procedure resulted in a sustained mean attachment The difference between treatment procedures with re-
loss which averaged 0.7 mm greater than that after root spect to attachment level are given in Table 6 as well as
planing alone. As may be observed in Figure 11, most of Figure 12. Root planing alone gained significantly more
this loss occurred during the first 6 month posttreatment attachment than root planing plus the flap. This gain
time period. This mean difference between procedures varied from 0.48 mm at 6 months to 0.52 mm at 2 years.
was highly significant at each postoperative time period With the exception at 3 years (0.45 mm, 0.07) all
=

(Table 5). gains were significantly more with root planing than with
For 1-3 mm crevices, the result clearly indicated a root planing plus the flap.
mean loss of attachment for both procedures over a In summary, the results for attachment level indicate
period of 4 years. Furthermore, the mean loss from the both procedures maintained pretreatment levels and no
flap procedure was about twice that which occurred after further loss occurred over the 4 year time period. Fur-
root planing alone. thermore, a slight gain in attachment level was found
4 to 6 mm. The results of mean change in attachment with root planing alone compared to root planing plus
level for pockets initially 4 to 6 mm are illustrated in the flap procedure.
Figure 12. Scaling and root planing alone resulted in an 7 mm or greater. The results for attachment level
initial mean gain of attachment level of 0.56 mm (P =
changes of pockets initially 7 mm or more are illustrated
0.01) at 6 months as compared to the baseline mean in Figure 13. Both root planing alone and root planing
prior to therapy. This gain was somewhat less at 1 year plus the flap procedure resulted in a gain of mean
(0.41 mm, =
0.02) but remained statistically significant. attachment level. This gain was 1.4 mm (P < 0.01) at 6
2
At years, the gain was 0.44 mm and remained signifi- months for root planing alone. For this treatment
cant (P < 0.01). However, at 3 and 4 years, the gain was method, the gain decreased to 1.0 mm (P 0.02) at 1 =

not maintained to a statistically significant degree al- year and 0.87 mm (P 0.01) at 2 years. At both 3 and
=

though the mean attachment level remained somewhat 4 years postoperatively, the mean gain was 1.1 mm and
greater than that obtained prior to therapy. Root planing although approaching significance, these means were not
plus the modified Widman flap resulted in a nonsignifi- statistically significant (P > 0.05). The modified Widman
cant gain of attachment level 6 months following therapy flap resulted in a statistically significant gain in attach-
 Volume 52
Number5 Four-Year Study 237
Table 5
Analysis of Mean Differences in Attachment Level of Crevices Initially I to 3 mm

Number , Differences in
lime Procedures tachment
,
SE
of patients
. .

.
_

mean depth
mm mm

0 17 R.P. 1.78 -0.18 0.09 0.06

R.P. + Sx 1.96

6 mo 15 R.P. 1.80 -0.75 0.13 <0.0I

R.P. + Sx 2.55

1 yr 14 R.P. 2.01 -0.71 0.12 <0.01

R.P. + Sx 2.72

2yr 15 R.P. 2.16 -0.66 0.12 <0.01

R.P. + Sx 2.82

3yr 12 R.P. 2.20 -0.65 0.16 <0.01

R.P. + Sx 2.85

4yr 10 R.P. 2.02 -0.76 0.11 <0.01

R.P. + Sx 2.78

Table 6
Analysis of Mean Differences in Attachment Level of Pockets Initially 4 to 6 mm
Mean at
_.. Number Differences in
Time , Procedures tachment . Sh
depth
.

of patients _

mean
j j
mm mm

0 17 R.P. 3.71 -0.13 0.12 0.28

R.P. + Sx 3.84

6 mo 15 R.P. 3.03 -0.48 0.08 <0.01

R.P. + Sx 3.51

1 yr 14 R.P. 3.34 -0.42 0.14 0.01

R.P. + Sx 3.76

2yr 15 R.P. 3.40 -0.52 0.15 <0.01

R.P. + Sx 3.92

3yr 12 R.P. 3.50 -0.45 0.22 0.07

R.P. + Sx 3.95

4yr 10 R.P. 3.30 -0.46 0.20 0.05

R.P. + Sx 3.76

ment level at all postoperative time periods. This gain procedure, there was no statistical significance in be-
varied from 1.4 mm (P < 0.01) at 6 months to the mean tween the procedures in this respect.
gain recorded at 4 years of 1.1 mm (P 0.02). All means
=

Tooth Loss
at each time interval were significantly greater (P < 0.05)
than pretreatment means of attachment level. Fourteen of the 453 teeth included at the outset of the
The mean differences between treatment methods for study extracted over the 4 year time period. This
were
attachment level are given in Table 7 and are illustrated represents total loss of 3%. Eight of the 14 teeth were
a
in Figure 13. No significant difference was found at any extracted before therapy could be completed. These teeth
postoperative time period between the treatment meth- became symptomatic and were so severely involved that
ods with respect to attachment gain, although the differ- no treatment could be ethically performed. Six teeth
ence approached significance at 2
years (0.57 mm,
= were extracted after therapy was completed. This repre-
0.08). sents about 1% of all the teeth receiving therapy. One
In summary, both root planing alone and planing root tooth was extracted at each of 2, 8, 12 and 19 months
plus a modified Widman flap resulted in gain of attach- while two were extracted at 27 months after completing
ment. Although this gain tended to be more with the flap therapy. Five of the 14 teeth were third molars, five were
 J. Periodontol.
238 Pihlstrom, Ortiz-Campos, Me Hugh May, 1981
Table 7
Analysis of Mean Differences in Attachement Level of Pockets Initially 7 mm or more

Mean at-
Number Differences in
Time Procedures tachment SE
of patients
. .

level
mean depth
mm mm

15 R.P. 6.25 0.29 0.27 0.29

R.P. + Sx 5.96

6 mo 13 R.P. 4.71 0.28 0.34 0.43

R.P. + Sx 4.43

tyr 12 R.P. 5.03 -0.02 0.38 0.97

R.P. + Sx 5.05

2yr 14 R.P. 5.33 0.57 0.30 0.08

R.P. + Sx 4.76

3yr II R.P. 5.05 0.11 0.31 0.73

R.P. + Sx 4.94

4 yr R.P. 5.18 0.68 0.59 0.28

R.P. + Sx 4.50

second molars, two were maxillary first molars, one was regained during the 4 years after completion of active
a retained deciduous cuspid and one was a maxillary therapy. Others have noted a similar loss of attachment
second bicuspid. Of those teeth extracted after comple- following such therapy for shallow crevices.1 It should
tion of therapy, four had received scaling and root also be noted that a loss of attachment may occur with
planing alone and two had received scaling and root scaling and root planing alone. Therefore, if this proce-
planing plus the flap procedure. dure is not indicated for the specific purpose of treatment
of a pathologically deepened sulcus or inflammation, it
DISCUSSION
could result in loss of support.
The results of the present study clearly indicate that
both thorough scaling and root planing alone as well as
Pocket Depth
scaling and root planing followed by a modified Widman
flap are effective in treating Periodontitis. This conclusion Pocket depthwas reduced by both procedures when
is based upon data for attachment level, pocket reduction applied to moderate (4-6 mm) as well as deep (>7 mm)
and reduction in the degree of inflammation. pockets. For moderate pockets, the initial reduction was
Attachment Level
greater with the additional flap procedure but from 2 to
4 years following active therapy, no significant difference
Attachment level was maintained at least at pretreat- in pocket reduction between procedures was found.
ment levels by both procedures for moderate (4-6 mm) When deeper pockets were treated, pocket reduction
and deep (>7 mm) pockets. Furthermore, when applied tended to be greater following the flap procedure. This
to deeper pockets, both procedures resulted in a general difference between procedures was not statistically sig-
gain of attachment over the 4 year time interval, although nificant at 3 and 4 years postoperatively. At 4 years, the
the attachment gain tended to be greater with the use of the flap procedure resulted in a sustained reduc-
additional flap procedure for the deep pockets. There tion of deep pockets compared to pretreatment levels
was no statistically significant difference between the whereas root planing alone did not result in a sustained
procedures with respect to attachment gain for either reduction of pretreatment pocket depth. Shallow crevices
moderate or deep pockets after 4 years. On the basis of (1-3 mm) increased slightly in depth after the flap pro-
attachment level, it may be concluded that there was no cedure over the 4 year time interval. Although clinically
clear advantage of one procedure over the other with very small (0.1 mm) the mean increase at 3 and 4 years
respect to therapy. However, there was a tendency for a was significantly greater following the flap procedure

greater sustained gain in attachment level when the than root planing alone.
additional flap procedure was used. From the data concerning pocket depth, it may be
The results also indicate that either procedure applied concluded that either scaling and root planing alone or
to crevices of minimal depth (1-3 mm) resulted in at- scaling and root planing followed by the flap procedure
tachment loss. The additional flap procedure resulted in were successful in reducing the depth of 4 to 6 mm

significantly more attachment loss than root planing pockets. Furthermore, no advantage of one procedure
alone for these crevices. Furthermore, this loss was not over another was noted for such pockets over a 4 year
 Volume 52
Number 5 Four- Year Study 239
time interval. Regarding deeper pockets, there was a importance of regular recall prophylaxis is further em-
tendency for greater pocket reduction with the additional phasized. The optimal time for recall prophylaxis has
flap procedure. It should be noted that scaling and root not been established. In the present study, three to four
planing alone for these pockets also resulted in reduction times per year appeared to be effective.
which was sustained up to 3 years after therapy. At 4
Measurement Technique
years, however, this reduction was not statistically sig-
nificant as compared to pretreatment means. Attachment level and pocket depth measurements
were obtained by clinical probing. There is good evi-
Gingival Inflammation dence that such measurements terminate at the junction
of connective tissue and junctional epithelium.43"4 How-
'
Both procedures resultedin a significant reduction in
gingival inflammation as measured by the index used in ever, several reports indicate that the depth of probe tip
this study. This reduction in inflammation was statisti- penetration depends upon the degree of gingival inflam-
cally significant for all time intervals and both treatment mation and probing force. Experiments in beagles46 and
methods for 4 to 6 mm pockets as well as those >7 mm. humans47 have reported increasing penetration of peri-
However, neither procedure was superior in reducing odontal probes with increased inflammation. Others
inflammation. With regard to crevices 1 to 3 mm in have reported that the health of the connective tissue is
depth, an initial reduction at 6 months was noted with more important than the junctional epithelium in limit-
root planing alone. However, after 6 months, no differ- ing apical penetration of probes.48 In the present study,
ence in inflammation from pretreatment levels was the degree of clinical inflammation decreased following
noted. both treatment modalities. It is, therefore, quite possible
Therefore, it may be concluded that both procedures that the decreased probing depth which reflects increased
reduced inflammation and neither was superior in this gain in attachment as well as decreased pocket depth
respect when utilized to treat Periodontitis. was a function of this decrease in gingival inflammation
rather than a true gain in connective tissue attachment.
Plaque and Calculus In any event, an increase in attachment loss was not
The results of periodontal therapy in this study with recorded. At the very least this would imply that the
respect toplaque control were disappointing. In spite of ongoing destructive effects of Periodontitis had been
initial intensive oral hygiene instruction and reinforce- arrested. This is especially important in view of the
ment at regular intervals, the supragingival plaque index continued destruction which occurs in untreated Peri-
did not vary from pretreatment levels with a few excep- odontitis.16, 17
tions as noted. In spite of this rather poor performance Controlled forces were not usedduring clinical prob-
of plaque control, pocket depth was reduced, attachment ing. It has been shown that probing depth is related to
level maintained or increased and inflammation was degree of force which is used.4'' Therefore, this factor is
reduced over the 4 year time interval. One explanation an unknown variable in the data for this study. However,
for this may be the significant reduction in calculus at it is likely that with the large number of measurements
all postoperative time periods. The calculus reduction obtained, variations in force used on any occasion would
was expected since this was under the control of the tend to balance each other. There is no reason to expect
therapist. It was reduced because calculus was removed that the examiner used any greater or less force when
during the active phase of therapy and any subsequent probing at any of the intervals when data were recorded.
formation was removed at recalls. This reduction in
calculus may be one factor in the success of therapy in Comparison With Other Studies
the presence of poor supragingival plaque control. When changes in pocket depth and attachment level
It was recently reported that the character of the obtained in the present study are compared with the
subgingival flora is altered by scaling and root planing results of similar studies, some minor differences are
and that the re-establishment of the flora may vary from noted. Knowles et al. reported a gain in attachment for
42 days39 to 3 to 6 months.4" Furthermore, treated pockets 4 to 6 mm pockets of about 0.5 mm for the first 4 years
in patients receiving a prophylaxis every 3 months have following therapy using a modified Widman flap.1 In the
been reported as having markedly reduced numbers of present study, no statistically significant gain in attach-
Bacteroides asaccharolyticus and spirochetes compared ment level was found using the same procedure on 4 to
to untreated pockets.41 It is quite possible, therefore, that 6 mm pockets. This level of attachment, however, was
periodic recall prophylaxis prevented the redevelopment maintained and no further loss occurred. Furthermore,
of a pathogenic flora. Most patients in the present study pocket reduction was somewhat greater as reported by
returned for recalls three to four times per year. This was Knowles et al.1 than in the present study. While the
probably a significant factor in the success of therapy in group at Michigan found sustained mean pocket reduc-
view of the poor plaque control. It has been established tion of about 2.0 mm over 4 years following the modified
by others that periodontal therapy without a system of Widman flap, our data indicated a mean pocket reduc-
recall maintenance results in failure.4" Therefore, the tion of about 1.5 to 1.0 mm. When the results obtained
 J. Periodontol.
240 Pihlstrom, Ortiz-Campos, McHugh May, 1981
using a modified Widman flap for deep pockets (>7 the presence of relatively poor plaque control by the
mm) are compared, the results of the present study patient. This does not mean that plaque control should
indicate a mean pocket reduction varying from 2 to 3 be of little concern to the patient or the therapist. It does
mm over 4 years. Knowles et al.1 reported a sustained mean that appropriate periodontal therapy coupled with

pocket reduction of about 4 mm. With respect to attach- frequent recall prophylaxis is a necessity for successful
ment level, the Michigan group found a sustained mean therapy. Indeed, the quality of the bacterial flora may be
gain of just over 2 mm while our data indicates a mean more important than the quantity of supragingival

gain of about 1.5 mm. For shallow crevices 1 to 3 mm in plaque. There are indications that the quality of plaque
depth, both reports indicate an attachment loss of about is affected by therapy and recall prophylaxis.39"41 This
0.5 mm over a 4 year postoperative time period. may be especially critical for patients who have difficulty
While differences in magnitude between these studies with oral hygiene procedures. Furthermore, it is very
are apparent, the trends are remarkably similar. The likely that if improved plaque control had been achieved
deepest pockets were reduced more and gained most by patients in this study, the results would have been
attachment in both reports. Moderately deep pockets even better.
were reduced less and changes in attachment level were This study also indicates that thorough scaling and
not as great in the present study. Shallow crevices lost root planing alone may arrest the progression of destruc-
attachment in both studies. The difference in magnitude tive periodontal disease. This does not imply that routine
between the studies may be a result of the difference in prophylaxis is adequate periodontal therapy. All perio-
experience of the operators. All therapy in the present dontists are well aware of the difficulty in performing
study was performed by a periodontist in training while this task well. The scaling and root planing used in this
the Michigan study utilized periodontists with many study was extensive and time consuming. Approximately
years of experience. This may account for the differences three to four 2 hour appointments were necessary to
in magnitude of results between the studies. complete this procedure. Local anesthesia was used as
A brief report concerning scaling and root planing necessary for patient comfort and the procedure was
alone as compared to other forms of therapy has been accomplished with no time constraints by an individual
reported recently by Ramfjord et al." This report noted who was being trained in the practice of periodontics.
similar results over a 2 year period of time to those Many clinicians would question the practicality of such
obtained in the present study. Subsequent data collected therapy since it could be accomplished with less difficulty
over a longer period of time from this study will be and perhaps more effectively by raising a flap. Further-
necessary to compare results between the two reports. more, it should be noted that all areas did not respond
Several other studies have noted favorable results follow- to such therapy alone. Thirty-one teeth in four patients
ing thorough scaling and root planing alone. Hughes et received additional surgical therapy since the disease
al.25 noted decreased pocket depth and gain in attach- process was not arrested in the subjective opinion of a
ment level in a 1 month study and Torfason et aLM noted periodontist. This emphasizes the need for close obser-
decreased pocket depth, bleeding and crevicular fluid vation of patients for signs of ongoing active disease.
flow in a 8 week study using both hand and ultrasonic If the results of this study are viewed from the per-
scaling. A reduction in inflammation has been noted by spective of making a decision whether or not to perform
several authors following scaling and root planing.27"29 a modified Widman flap in addition to thorough scaling
In addition, there is good documentation that regular and root planing, the severity of the disease must be
dental prophylaxis slows the rate of attachment loss and considered. If pocket depth is 4 to 6 mm, the results
reduces gingivitis especially in the presence of good oral indicate that scaling and root planing alone is as effective
hygiene.20"23 as the modified Widman flap over a 4 year postoperative
The results of the present study, therefore, are in time period. This, of course, is based upon frequent recall
general agreement with the results of other reports of prophylaxis, reinforcement of plaque control and close
scaling and root planing. Decreased inflammation, postoperative observation. For deeper pockets (>7 mm),
pocket depth, and gain in attachment levels have been while scaling and root planing alone was effective in
reported previously with such therapy. maintaining attachment levels, the additional flap pro-
cedure resulted in significant increased gain of attach-
Implications for Therapy ment level and pocket depth reduction as compared to
The most important finding in the present study is pretreatment values. Root planing alone did not accom-
that additional evidence is offered regarding the effec- plish this when 4 year data is compared to that obtained
tiveness of conventional periodontal therapy in arresting prior to therapy. Furthermore, scaling and root planing
the ongoing destruction of the supporting tissues. As has for deep pockets is extremely difficult to accomplish
been noted, many others have also documented the without flap reflection. Therefore, the clinician would
effectiveness of periodontal therapy. Furthermore, the certainly be justified in performing a modified Widman
present study indicates that it may be possible to arrest flap to obtain access for instrumentation of root surfaces.
the progress of destructive periodontal disease even in If flap reflection is not accomplished for these deeper
 Volume 52
Number 5 Four- Year Study 241

pockets, the clinician must be careful to closely document 17. Becker, W., Berg, L., and Becker, B. E.: Untreated periodontal
disease: A longitudinal study. J Periodontol 50: 234. 1979.
any ongoing disease and be prepared to intervene sur- 18. Lightner, L. M., O'Leary, T. J., Drake, R. B.. Crump, P. P., and
gically to obtain access for thorough calculus removal Allen, M. F.: Preventive periodontic treatment procedures. J Periodon-
and root planing. tol 42: 555, 1971.
Finally, the present study offers additional evidence 19. Suomi, J. D., Greene, J. C, Vermillion, J. R.. Doyle, J.. Chang.
J. J., and Leatherwood, E. C: The effect of controlled oral hygiene
that crevices of minimal depth (1-3 mm) tend to have a
small but statistically significant amount of attachment procedures on the progression of periodontal disease in adults: Results
after third and final year. J Periodont 42: 152. 1971.
loss when treated by a flap procedure. This may indicate 20. Suomi, J. D., Leatherwood. E. C, and Chang, J. J.: A follow-up
that caution should be exercised by the clinician in study of former participants in a controlled oral hygiene study. J
extending such treatment procedures to areas of minimal Periodontol A4: 662, 1973.
21. Axelson, P., and Lindhe, J.: Effects of controlled oral hygiene
crevice depth.
procedures on caries and periodontal disease in adults. J Clin Periodont
ACKNOWLEDGMENTS 5: 133, 1978.
We wish to thank Dr. Lars Folke and Dr. Carl Bandt for their 22. Lövdal, ., Arno, ., Schei, ., and Waerhaug. J.: Combined
valuable suggestions during the early phase of this study and Mr. effect of subgingival scaling and controlled oral hygiene in man. Acta
Thomas Oliphant for his assistance in data management. Ódontól Scand 19: 537, 1961.
23. Chawla, T. N., Nanea, R„ and Kappoor, K. K.: Dental prophy-
REFERENCES laxis procedures in control of periodontal diseases in Lucknow (rural)
1. Knowles, J. W„ Burgett, F. G., Nissle, R. R., Shick, R. ., India. J Periodontol 46: 498, 1975.
Morrison, E. C, and Ramfjord, S. P.: Results of periodontal treatment 24. Tagge, D. L., O'Leary, T. J., and El-Kafrawy. A. H.: The
related to pocket depth and attachment level: Eight years. J Periodontol clinical and histological response of periodontal pockets to root planing
50: 225, 1979. and oral hygiene. J Periodontol 46: 527. 1975.
2. Knowles, J., Burgett, F., Morrison, E., Nissle, R., and Ramfjord, 25. Hughs, T. P., and Caffesse. R. G.: Gingival changes following
S.: Comparison of results following three modalities of periodontal scaling, root planing and oral hygiene: A biometrie evaluation. J
therapy related to tooth type and initial pocket depth. J Clin Periodont Periodontol 49: 245, 1978.
7: 32, 1980. 26. Torfason, T., Kiger, R., Selvig, . .. and Egelberg. J.: Clinical
3. Ramfjord, S. P., Knowles, J. W., Nissle, R. R., Burgett, F. G., improvement of gingival conditions following ultrasonic versus hand
and Shick, R. .: Results following three modalities of periodontal instrumentation of periodontal pockets. J Clin Periodont 6: 165, 1979.
therapy. J Periodontol 46: 522, 1975. 27. O'Bannon, J. Y., Jr.: Gingival tissues before and after scaling
4. Ramfjord, S. P., Knowles, J. W., Nissle, R. R., Shick, R. ., the teeth. J Periodontol 35: 69, 1964.
and Burgett, F. G.: Longitudinal study of periodontal therapy. J 28. Ambrose, J. ., and Detamore, R. J.: Correlation of histologie
Periodontol 44: 66, 1973. and clinical findings in periodontal treatment: Effect of scaling on
5. Ramfjord, S. P., Nissle, R. R., Shick, R. ., and Cooper, H. Jr.: reduction in gingival inflammation prior to surgery. J Periodontol 31:
Subgingival curettage versus surgical elimination of periodontal pock- 238, 1960.
ets. J Periodontol 39: 167, 1968. 29. Alexander, A. G.: The effect of subgingival scaling on gingival
6. Yukna, R. .: Longitudinal evaluation of the excisional new inflammation. J Periodontol 40: 717, 1969.
attachment procedure in humans. J Periodontol 49: 142, 1979. 30. Helldén, L. B., Listgarten, . ., and Lindhe. J.: The effect of
7. Rosling, B„ Nyman, S., Lindhe, J., and Jern. B.: The healing tetracycline and/or scaling on human periodontal disease. J Clin
potential of the periodontal tissues following different techniques of Periodont 6: 222, 1979.
periodontal surgery in plaque free dentitions. A 2 year clinical study. 31. Waite, I. M.: A comparison between conventional gingivectomy
J Clin Periodont 3: 233, 1976. and a non-surgical regime in the treatment of Periodontitis. J Clin
8. Nyman, S., and Lindhe, J.: A longitudinal study of combined Periodont 3: 173, 1976.
periodontal and prosthetic treatment of patients with advanced peri- 32. Morrison, E. C, Lang, . P., Loe, H., and Ramfjord. S. P.:
odontal disease. J Periodontol 50: 163, 1979. Effects of repeated scaling and root planing and/or controlled oral
9. Nyman, S., Rosling, BH., and Lindhe, J.: Effect of professional hygiene on the periodontal attachment level and pocket depth in beagle
tooth cleaning on healing after periodontal surgery. J Clin Periodont 2: dogs. I. Clinical findings. J Periodont Res 14: 428, 1979.
80, 1975. 33. Ramfjord. S., Morrison, E. C. Hill, R., Appleberry. E.. Caffesse.
10. Lindhe, J., and Nyman, S.: The effect of plaque control and R„ Kerry, G., and Nissle. R.: Four types of periodontal treatment. Tw o
surgical pocket elimination in the establishment and maintenance of year follow-up (Abstr. 374). J Dent Res 59: Special Issue B. 1980.
periodontal health. A longitudinal study of periodontal therapy in 34. Ramfjord, S. P.. and Nissle. R. R.: The modified Widman flap.
cases of advanced disease. J Clin Periodont 2: 67, 1975. J Periodontol 45: 601, 1974.
11. Rosling, ., Nyman, S., and Lindhe, J.: The effect of systematic 35. Ramfjord, S. P.: The periodontal disease index. J Periodontol
plaque control on bone regeneration in infra-bony pockets. J Clin 38: 602. 1967.
Periodont 3: 38, 1976. 36. Greene, J. C: The oral hygiene index-development and uses. J
12. Ross, I. F., Thompson, R. H., and Galdi, M.: The results of Periodontol 38: 625, 1967.
treatment. A long term study of one hundred and eighty patients. 37. Glavind. L., and Löe. H.: Errors in the clinical assessment of
Parodontologie IS: 125, 1971. periodontal destruction. J Periodontol Res 2: 180. 1967.
13. Hirschfeld, L., and Wasserman, B.: A long-term survey of tooth 38. Smith, L. W., Suomi, J. D.. Greene, J. C, and Barbano, J. P.:
loss in 600 treated periodontal patients. J Periodontol 49: 225. 1978. A study of intra-examiner variations in scoring oral hygiene status,
14. Oliver, R. C: Tooth loss with and without periodontal therapy. gingival inflammation and epithelial attachment level. J Periodontol
Periodont Abstr. 17:8, 1969. 41: 671, 1970.
15. Ross, I. F., and Thompson, R. H., Jr.: A long term study of root 39. Mousquès, T., Listgarten, . ., and Phillips. R. W.: Effect of
retention in the treatment of maxillary molars with furcation involve- scaling and root planing on the composition of human subgingival
ment. J Periodontol 49: 238, 1978. microbial flora. J Periodont Res 15: 144, 1980.
16. Löe, H., Age, R„ Boysen, H., and Smith. M.: The natural history 40. Slots, J., Mashimo, P.. Levine. M. J., and Genco. R. J.: Peri-
of periodontal disease in man. J Periodontol 49: 607. 1978. odontal therapy in humans. I. Microbiological and clinical effects of a
 J. Periodontol.
242 Pihlstrom, Ortiz-Campos, Me Hugh May, 1981
single course of periodontal scaling and root planing, and of adjunctive 46. Armitage, G. C, Svanberg, G. F., and Löe, H.: Microscopic
tetracycline therapy. J Periodontol 50: 495, 1979. evaluation of clinical measurements of connective tissue attachment
41. Syed, S. ., Morrison, E. C, Loesche, W. J., and Ramfjord, S. levels. J Clin Periodont 4: 173, 1977.
P.: The bacterial flora of treated periodontal pockets Abstr. No. 76. J 47. Robinson, P. J., and Vitek, R. M.: The relationship between
Dent Res 59: Special Issue B, 1980. gingival inflammation and resistance to probe penetration. J Periodont
42. Nyman, S., Lindhe, J., and Rosling, B.: Periodontal surgery in Res 14: 239, 1979.
plaque infected dentitions. J Clin Periodont 4: 240, 1977. 48. Spray, J. R., Garnick, J. J., Doles, L. R„ and Klawitter, J. J.:
43. Listgarten, . ., Mao, R., and Robinson, P. J.: Periodontal Microscopic demonstration of the position of periodontal probes. J
Periodontol 49: 148, 1978.
probing and the relationship of the probe tip to periodontal tissues. J
Periodontol 47: 511, 1976.
44. Sivertson, J. F., and Burgett, F. G.: Probing of pockets related
to attachment level. J Periodontol 47: 281, 1976.
45. Van Der Veiden, U.: Probing force and the relationship of the Send reprint requests to: Dr. Bruce L. Pihlstrom, School of Den-
probe tip to the periodontal tissues. J Clin Periodont 6: 106, 1979. tistry, University of Minnesota, Minneapolis, MN 55455.

Abstracts
Gingival Tissue Reactions to Orthodontic Closure of Human Gingival Collagenase in Periodontal Disease: The
Extraction Sites Release of Collagenase and the Breakdown of Endogenous
Rönnerman, ., Thilander, B„ and Heyden. G. Collagen in Gingival Explants
Am J Orthodont 77:620, June, 1980. Geiger, S. and Harper, E.
J Dent Res 59: 11, January, 1980.
After the extraction of the maxillary first premolars of seven patients
(12-17 years of age), interproximal gingiva was biopsied after ortho- To examine collagen degradation in different stages of gingival
dontic treatment with an edgewise device. Control specimens were inflammation, gingival tissues from patients having periodontal surgery
obtained from corresponding locations in four patients before teeth were obtained and prepared for culture. The supernatant from the
were extracted. Histomorphologic and histochemical determinations culture medium was collected
every 24 hours and processed for colla-
showed epithelial hyperplasia and a decrease in collagen. An increase genase activity. Measurements were made by radioactive techniques.
in glucose aminoglycan was noted which was claimed to be a possible Reaction products of collagen breakdown were examined by electro-
cause of relapse of the orthodontically closed extraction site.
Depart- phoresis. It was concluded that higher collagenolytic activity and
ment of Orthodontics. Institute for Postgraduate Dental Education, S- nonspecific protease activity were apparent in the severely inflamed
552 55 Jönköping, Sweden. Dr. Richard S. Harold gingiva as compared to mildly inflamed or healthy gingiva. Department
of Chemistry, D-006, University of California, San Diego, La Jolla,
CA 92093. Dr. John A. Vrotsos
Systemic Complications With Intravenous Diazepam
Donaldson, D., and Gibson, G. Squamous Odontogenic Tumor: Report of Case With Long-
Oral Surgen-. 127, February, 1980. Term History

For the last 20 years, diazepam has been employed for intravenous McNeill, J., Price, H. M., and Stoker, N. G.
sedation during major and minor surgery. Diazepam is a
relatively safe Surg 38: 466, June, 1980
J Oral
drug with few adverse reactions reponed in the literature. A summary A 26-year-old black female patient who came to the clinic because
was made of 220 cases in which there were complications and which of pain around the mandibular right first molar during mastication was
were reponed to the United States Department of Health. Education, evaluated clinically and a generalized chronic gingivitis with local areas
and Welfare over a 7-year period. Respiratory depression was reported of acute inflammation was found. Radiographic examination showed
as the most common systemic
complication. Cardiovascular compli- severe generalized bone loss and an initial diagnosis of periodontosis
cations were reported including cardiac arrest and alterations in blood was made. After the extraction of the first molar, tissue from that area
pressure. Urticarial rash when observed, nearly always involved the was submitted for histologie examination which showed proliferation
head and neck. In addition, coma, hysteria, jaundice, muscular flaccid- of mature stratified squamous epithelial tissues in a mature fibrous
ity, headaches, and visual disturbances were reported. Diazepam is a connective tissue stroma. The diagnosis was squamous epithelial odon-
relatively safe drug and when adverse reactions do occur, they are most togenic tumor. Advanced involvement of all quadrants was found
likely found in the very young or the geriatric patient. Department of which had been present for at least 8 years as shown by radiographs
Restorative Dentistry. School of Dentistry, University of British Co- obtained from a previous dentist. This is the tenth documented case.
lumbia. Vancouver. British Columbia. Canada. Department of Oral and Maxillofacial Surgery, Valley Medical Center,
Dr. Richard S. Harold 445 S. Cedar Ave, Fresno, CA 93702. Dr. John Vrotsos