Journal of Clinical Periodontology 1981: 8: 57-72

Key words: Periodontal treatment ~ nonsurgical - hand instruments - ultrasonics - clinical measurements.
Accepted for publication March 19, 1980

Effect of nonsurgical periodontal

therapy
I. Moderately advanced periodontitis

ANITA BADERSTTCN, ROLF NiLvius AND JAN EGEL^LRG

School of Dentistry, University ot Lund, Malmo, Sweden and School of Dentistry,
Loma Linda University, Loma Linda, CA, U,S,A,

Abstract. Healing events after notisurgical periodonta! therapy in patients with periodontal
pockets 4-7 mm deep were investigated. Incisors, cuspids and premolars in 15 patients were
treated by plaque control and supra- and subgingival debridement using hand or ultrasonic
instruments in a split mouth approach. The results were evaluated by recordings of plaque
scares, bleeding on probing, probing pocket depths and probing attachment levels. All these
parameters were improved during the initial 4-5 months after start of therapy. Little
change occurred during the rest of the 13-month observation period. No difference of re-
sults could be observed comparing hand and ultrasonic instrumentation or comparing the
results of two different operators. Initially a total of 106 sites demonstrated probity pocket
depths > 6 mm. At 13 months only 13 such sites were observed. The apparently successful
results of cotiservative treatment of patients with 4—7 mm deep pockets in the present study
raise the question to what extent nonsurgical therapy is feasible also in patients with severe-
ly advanced lesions.

A limited number of studies seem to be Hellden et al, (1979) and Listgarten et al,
available on the effect of conservative (non- (1978) reported the effect of treatment of
surgical) therapy of periodontal pockets, periodontal pockets with an average depth
Tagge et al. (1975) evaluated the effect of of 5.5 and 7 mm, respectively. Oral hy-
oral hygiene instruction and root planing in giene instructions alone seemed to have a
buccal and lingual areas with an average of limited effect on the probing depth, where-
3 tnm probing pocket depth. Slight improve- as the average depth 25 weeks after oral hy-
ment of gingival inflammation and pocket giene instructions combined with repeated
depth was obtained by oral hygiene alone, root planing was reduced to 3,6 and 4,8
Additional improvement resulted from oral mm, respectively,
hygiene instnicticai combined with root Torfason et al, (1979) studied the effect
planing, Hughes & Caffese (1978) also stud- of oral hygiene instruction and hand and ul-
ied areas with an average of 3 mm probing trasonic instrumentation in 18 patients with
pocket depth. One month following seal- moderately advanced periodontitis, Signifi-
ing, root planing and oral hygiene, a reduc- cant reductions of the frequency of hleed-
ticMi in pocket depth of 0,6 mm was oh- ing upon probing and of pocket depths were
served, obtained. The study failed to demonstrate
58 BADERSTEN, NILVfiUS AND EGELBERG

any differences of results after the use of pockets was performed by two operators
hand versus ultrasonic instruments. The pe- (authors J. E. and R. N.) treating eight and
riod of observation was limited to 2 months seven patients, respectively. The teeth of
and did not monitor the entire healing pe- the right and left sides of the jaw were ran-
riod. domly assigned for hand or ultrasonic in-
The present study was perfonned in or- strumentation. The hand instruments were
der to acciunulate more complete informa- selected according to the preference of each
tion about the healing events following non- operator. One of the operators used Ash
surgical periodontal therapy in patients TC 13 and 14 curettes (Amalgamated Den-
with moderately advanced periodontitis and tal, London, England) and the other used
to compare tbe effects of hand and ultra- Colombia curettes nos. 13/14 (Star Den-
sonic instrumentation. tal Manufacturing Comp., Conshohoken,
USA). A Dentsply® - Cavitron® Model
600 imit with TFl-10 tips was selected for
ultrasonic instrumentation (Cavitron Ultra-
Material and Methods
sonics Inc., Long Island City, NY, USA).
Fifteen patients, 22-60 years of age, with The setting of the power, tuning and water
moderately advanced periodontal disease irrigation was adjusted to the preference of
were used for the study. Incisors, canines each operator. The debridement was per-
and premolars in either tbe maxilla or the formed under local anesthesia during one
mandible were studied. A minimum of four visit. It was randomly decided if the opera-
and a maximum of 10 teeth were used in tes was to use hand or ultrasonic instru-
each patient. The teeth had periodontal ments first. The instrumentation was car-
bone loss amounting to one-third of the ried out until the operator felt that the
root length or more. Clinical signs of gingi- root surfaces were adequately debrided and
val inflammation and periodontal pockets planed. The average time per tooth re-
> 5 mm deep with calculus and bleeding quired for each of the methods of instru-
upon probing were present on two or more mentation was calculated.
aspK:ts of each tooth. Two and 6 months after the first debride-
The experimental design is shown in Fig. ment repeated instrumentations were con-
I. sidered. Each operator made his own eval-
uation of the need of repeated instrumen-
Oral hygiene instruction tation of the individual tooth surfaces. The
The oral hygiene instruction of the patients same type of instruments were used for the
was provided by a dental hygienist, using a same teeth as before but the order of usage
series of four to five visits during 1 month. was reversed.
Multitufted soft toothbrushes, single tufted
toothbrushes, interdental brushes, triangu-
lar toothpicks, disclosing wafers and illumi- Method of measurements
nated mouth mirrors were used. These aids The results of the treatment were evaluated
were recommended for the patients as by measurements of dental plaque, bleeding
needed. Additional instruction was given to on probing, preying pocket depth, probing
patients according to individual needs dur- attachment level and gingival recession. Re-
ing the first 7 months of the study. cordings were made at the initial examina-
tion and then once a month by one of the
Debridement of periodontal pockets authors (A.B.) who was unaware of which
The instnunentation of the periodontal instrumentation had been used for the dif-
 NONSURGICAL PERIODONTAL THERAPY 59

ferent teeth. At each examination, the the gingival margin and if this material
bleeding scores were first taken, then the couid be removed with the side of the
plaque scores followed by the measurements probe. The percentage of surfaces with
of probing pocket depth and attachment plaque out of the total number of exam-
level. Recordings were made at four as- ined tooth surfaces was calculated.
pects of each tooth: mid-buccal, disto-buc-
cal, mesio-lingual and mid-lingual. Two ini- Bleeding on probing
tial measurements of pocket depth and at- Bleeding upon probing was determined with
tachment level were taken 1 week apart to a Hilming periodontal probe no. 1 (C-G
evaluate the reproducibility of the record- Brinkers Dentalindustrifabrik, Hvidovre,
ings. Denmark). If hemorrage was noted subse-
quent to the probing, a positive score was
Dental plaque recorded. The proportion of bleeding sur-
Presence or absence of plaque was recorded faces out of the total number of examined
after staining with an erythrosin disclosing surfaces was calculated.
dye (Diaplac Rondell®, Astra, Sweden). During probing of each of the four as-
Presence of plaque was scored if an area of pects of the teeth, the probe was moved
clearly stained material was present along twice in the apical direction to secure find-

EXPEHIMENTAL DESIGN

NITIAL SCORES I

1 WEEK

4IT1AL SCORES 2
RAL HYGIENE INSTRUCTION. VISITS 1
2
3
I MONTH 4
S
MONTH SCORES
NSTRUMENTATION M

1 MONTH

MONTH SCORES initrudian sitar

indiviiiual naads
1 MONTH

MONTH SCORES
(STRUMENTATION ttZ

I MONTH

iONTHLY SCORES UNTIL 7-MONTH SCORES

STRUMENTATION 1*3

3 MONTHS Fig. 1. Flow chart of the ec-

oral hygiana avaluatiftn perimental de&iga.
-MONTH SCORES .a— and yraiaaaianal laatk
ciaaning Das Ablaufschema der Ver-
3 MONTHS suchsplanmng
Organigramme du plan de
-MONTH SCORES I'expirience.
60 BADERSTEN, NILVfiUS AND EGELBERG

ing the base of the pocket. The probing Table 1. Distribution of surface by initial
force was not standardized. However, at probing pocket depth and method of instru-
the end of the study an electronic pres- mentation. Msins of the two initial recordings
Die Verteilung der Oberflachen auf die initial
sure-sensitive probe (Electronic Periodontal gemessenen Taschentiefen und auf die Behand-
Probe, model 200, Vine Valley Research, lung mit Hand- und Vhraschallinstrumenten
Middlesex, NY, U.S.A.) was used to eval- Distribution des surfaces suivant la profondeur
uate the probing force of the examiner. The initiate de sondage des poches et le type d'in-
force was found to be around 0.50-0.60N. struments employe. Moyenne des deux enregi-
strements initiaux.
Probing pocket depth and probing
No. of surfaces
attachment level Initial probing
Probing pocket depth and probing attach- pocket depth Hand Ultra-
ment level were measured to the nearest of instruments sonics
1 mm with a specially machined and cali- 1.0- 1.5 3 4
brated probe (0.5 mm in diameter, 1 mm in- 2.0- 2.5 61 62
crements). A metal onlay was used to pro- 3.0- 3.5 49 49
vide reference points for the measurements. 4.0- 4.5 58 58
The placement of the probe at the individ- 5.0- 5.5 32 46
6.0- 6.5 33 29
ual tooth surface was guided by steering 7.0- 7.5 15 10
grooves placed in the onlays. During prob- 8.0- 8.5 8 3
ing the probe was directed at a slight angle 9.0- 9.5 3 0
to the long axis of the tooth. Again, the 10.0-10.5 2 2
probe was moved twice towards the base of 11.0-11.5 0 0
12.0-12.5 0 1
the pocket to secure finding the pocket
base before the distances to the gingival Total 264 264
margin (probing pocket depth) and to the
edge of the onlay (probing attachment lev- Initial probing pocket depth (initiate Sondie-
rungstiefe, profondeur de sondage initiate des
el) were recorded. poches), no. of surfaces (Anzahl Oberflachen,
The means of the two initial recordings nombre de surfaces), hand instruments (Hand-
for pocket depth and attachment level were instrumente, instruments a main), ultrasonics
used for the comparisons with the subse- (Ultraschailinstrumente, ultra-sons).
quent monthly scores.

Gingival recession Similar distribution of surfaces with differ-

The location of the gingival margin was as- ent pocket depths was prraent for hand and
sessed by subtraction of the figure for pock- ultrasonic instruments. The average pocket
et depth from the figure for attachment depth was 4.3 mm for surfaces to be instru-
level. mented with hand instruments and 4.2 mm
for surfaces to be treated with ultrasonics.

Results

Distribution of material Reproducibility of initial measurements

A total of 528 surfaces were treated. Tlie The reproducibility of the initial recordings
distribution of these surfaces with respect to ctf probing pocket depth and probing attach-
initial probing pocket depths and method of ment level as evaluated from the duplicate,
instrumentation are presented in Table 1. 1 week apart measurements is presented in
 NONSURGICAL PERIODONTAL THERAPY 61

Table 2. Reproducibility of duplicate recordings of probing pocket depth and probing attachment
level. Number of surfaces and percent of surfaces with differences of 0, ± 1, and ± 2 mm, re-
spectively
Wiederholbarkeit von Doppelregistrierungen beim Sondieren der Taschentiefe und des Attach-
mentniveaus. Anzahi der Oberjlachen und Messunterschiede in Prozent bei Messungen von 0 mm
± } mm und + 2 mm
Reproductibilite des enregistrements repetes de la profondeur de sondage des poches et du niveau
de tattachement lors du sondage. Nombre de surfaces et pourcentages des surfaces presentam
des differences de 0 mm, de ± 1 mm et de + 2 mm.

Probing pocket depth Probing attachment level

Difference between
duplicate recordings No. of Percent No. of Percent
surfaces surfaces surfaces surfaces
0 mm 355 67 366 69
± 1 mm 170 32 158 30
± 2 mm 3 1 4 1

Total 528 100 528 100

Difference between duplicate recordings (Unterschied iwischen verdoppelten Registrierungen, dif-
ference entre les enregistrements repetes), probing pocket depth (sondierte Taschentiefe, profon-
deur de sondage des poches}, percent surfaces (Oberflachen in Prozent, pourcentage des sur-
faces), probing attachment level (sondiertes Attachmentniveau, niveau de Vattachement lors du
sondage).

Table 2. The majority of the measurements Bleeding on probing

were duplicated within 1 mm deviation. At the initial examination 77-90 % of the
Only 1 % of the measurements deviated 2 surfaces showed bleeding upon probing. At
mm. the 1-month examination, 1 month after
start of oral hygiene instruction and pri-
Dental plaque or to instrumentation, the bleeding scores
Initially 65.-73 % of the tooth surfaces were not altered. At the 2-month examina-
showed presence of plaque. After 1 month tion, 1 month after the first instrumenta-
the plaque scores were reduced to less than tion, the bleeding scores were reduced to
12 % where they remained throughout the 36-41 %. A further reduction took place
study. Differences between patients treated during the subsequent months until an
by one or the other operator or between ar- 8-16 % level was reached. Both opera-
eas subjected to one or the other method of tors achieved similar reductions of bleeding
instrumentation were negligible (Fig. 2). scores using either method of instrumenta-
Figs. 3 and 4 demonstrate the results for tion (Fig. 2).
the different surfaces of the teeth treated Similar patterns of improvement of bleed-
by hand or ultrasonic instruments. It can be ing scores occurred for all surfaces of the
seen that reductions of plaque scores occur- teeth and for both methods of instrumenta-
red for all surfaces. The scores for the prox- tion. The scores for the proximal surfaces
imal surfaces, however, remained higher remained higher than the scores for the
than the scores for the buccal and lingual buccal and lingual surfaces (Figs. 3, 4).
surfaces.
62 BADERSTEN, NILVfiUS AND EGELBERG

PLAOtX SCORE. \

HAND INSTHUMENIS

ULTRASONICS

m
100]

11
BLEEDING SCORES

POC«FT DEPTH mrr

\

13

3 4 S 6 13
REDUCTION OF POCKET DEPTH rr

Ir In
10

r¥if¥i
2 3 4 5 6 7 10

CHANGE Of ATTACHMENT L E V E L mrn

1 2 3 4 5 6 7 10 13
MONTHS
Fig. 2. Means of the recorded parameters by operator and method of instrumentation at the var-
ious r^istration intervals during the study.
Die Mittelwerte der registrierten Parameter wdhrend der Versuchsabschnitte - aufgeschliisselt
nach dem Behandler und der instrumentellert Methode.
Moyennes des parametres enregistres awe differents intervalles au cours de cette etude, suivant
I'operateur et suivant le type d'irtstruments employe.

Probing pocket depth for all four surfaces of the teeth were 4,1-
Initially, the mean probing pocket depths 4.5 mm. One mcmth after the start of oral
 NONSURGICAL PERIODONTAL THERAPY 63

lUMD MSTIWIMENTS
100

so
so PIJUUE scows «

40

20

100
i -ffh—n-i -i-m
=n_ 10 13

so
ao BifEOMG s c o n e s

40

20 i

rrftl
0 1 2 3 4 5 S 7 10 13

a
5

1 -I

3 4 5 6 10 13
REDUCTJON OF POCKET DEPTH, mm

4 5 S 10 13
GMOWIU. H E C E S S K H mm

3 4 5 6 10 13
OMNGE OF ATTACHMBn LEVEL, mm

4 5
TT 10
MOWTMS

Fig- 3. Means of the recorded parameters for mid-buccal (B), mid-lingUEtl (L), mesio-lingual (M)
and disto-buccal (D) surfaces treated by hand instruments by both cq)erators at the various r ^ -
istration intervals during the study.
Die Mittelwerte der registrierten Parameter fUr "mittenbukkale" (B), "mittenlinguale" (L), me-
sio-Unguale (M) und disto-bukkale (D) Oberflachen wahrend der verschiedenen Versuchsabschmt-
te, nack Behandlung mit Handinstrumenten durck beide Behandler.
Moyennes des paramitres enregistris aux differents intervalles au cours de tetiide, au niveau
du milieu des faces vestibulaires (B) et tinguales (L), et au niveau des faces mesiales du cote lin-
gual (M) et des faces distales du cote vestibulaire (D), dans les cas traitis par les deux opera-
teurs au moyen des instruments & main.
64 BADERSTEN, NILVfiUS AND EGELBERG

ULTRASONICS
too
PLAOUE SCORES S
so
60
40
20
r-rm—iTh r-u- n r-r-rf]
_•_ 10
-N—-^

too
80 BL£EnsiC SCORES

60
40
TO
J] Ah. -r-m 10

PnoeiNG POCKET DEPTH mm

4 5 « T 10
REDuCTKW OF POCKET DEPTH, mm

r-rrn , rfffl
4 S 6 10 13
GwavAL RECESSION mm

rrrfl
3 4 5 6 7 10 13
CMANQE O f ATTACMMeNT LEVEL mm

_ij-__r'~t , . f"*"^ |—I I I I , --^—I—I—I—^

MONTHS

f I?. 4. Means of the recorded parameters fcs- mid-buccal (B), mid-lingual (L), mesio-lingusi! (M)
and disto-buccal (D) surfaces treated by ultrasonic itistruments by both operators at the various
registration intervals during the study.
Die Mittelwerte der registrierten Parameter fur "mittenbukkale" (B), "mittenlinguale" (L), me-
sio-linguale (M) und disto-bukkale (D) Oberfldchen wahrend der verschiedenen Versuchsabschnit-
te, nach Behandlung mit VUraschaUinstrumenten durck beide Behandler.
Moyennes des parantetres enregistres aux differents intervalles au cours de I'itude, au niveau du
milieu des faces vestibulaires (B) et linguales (L), et au niveau des faces misiales du coti lingual
(M) et des faces distales du cote vestibulaire (D), dans les cas trcutis par les deux operateurs au
moyen des uhra-sora.
 NONSURGICAL PERIODONTAL THERAPY 65

Table 3. Distribution of surfaces according to place for all surfaces of the teeth and in a
residua] probing depth at 13 months and meth- corresponding pattern for both methods of
od of instrumentation
instnimentation. The reductions were most
Die VerteiluKg der Oberflachen auf die Resui-
tate der noch verbleibenden Taschentiefen nach
notable for those surfaces of the teeth
13 Moriaten sowie auf die instrumentelie Me- which showed the greatest initial pocket
thode depth, Le, the proximal surfaces (Figs.
Distribution des surfaces suivant la profondeur 3,4),
de sondage persistante au bout de 13 mois et The distribution of the 528 experimental
suivatit le type d'instruments. surfaces according to residual probing depth
No, of surfaces
at 13 months and method of instrumenta-
Residual tion is presented in Table 3, The distribu-
probing Hand Ultra- tion of surfaces with different residua! prob-
deptn instruments sonics ing depth was similar for hand and ultra-
1,0 30 23 sonic instruments. Only 31 surfaces had re-
2,0 106 109 sidual probing depths > 5 mm, A compari-
3,0 68 69 son with Table 1 shows that 184 surfaces
4,0 45 47 had pocket depths > 5 mm at the initial ex-
5,0 8 10 amination.
6,0 7 0
7,0 0 4 Reduction of pocket depth took place
8,0 0 0 also for deeper pockets, irrespective of oper-
9,0 0 0 ator and method of instrumentation (Ta-
10,0 0 1*) ble 4),
11,0 0 0
12,0 0 1»)
The number of surfaces with probing
pocket depth > 6 mm at the initial exami-
Total 264 264 nation and at 7 and 13 months is presented
in Table 5. Initially, there were 106 surfaces
*) These pockets were located on a tooth that
had an initial periodontal lesion with sus- with pockets > 6 mm. At the 7- and 13-
pected periapical involvement. The periapi- month examinations only 11 and 13 sur-
cal involvement was confirmed at the 13- faces, respectively, could be probed to such
month interval and the tooth had to be ex- depth. Again, similar results were obtained
tracted.
Residual probing depth (verbliebene Sondie-
by the two operators and by the two meth-
rungstiefe, profondeur de sondage persistante). ods of instrumentation.

Gingival recession
hygiene instruction the mean depths were The mean gingival recessions for all sur-
reduced hy 0.3-0,7 mm. At the 2-month ex- faces at the 13-month examination were 1,4
amination, 1 month after the first instru- -1,6 mm. Most of the recession took place
mentation, the mean depths were reduced during the first 2-3 months (Fig, 2), The
by an additional 0,5-0,7 mm, A further re- proximal surfaces showed the greatest
duction took place during the suteequent amount of recession (Figs, 3, 4).
months until the 4- and 5-month examitia-
tions, when mean total reductions of 1,3- Probing attachment level
1.7 mm had taketi place. The results were Only minor changes of prohing attachment
similar for both operators and both methods level occurred during the course of the
of instrumentation (Fig. 2). study (Figs, 2, 3, 4), Buccal surfaces showed
ReducticHi of probing pocket depths took a tendency towards loss of attachment.
66 BADERSTEN, NILVfiUS AND EGELBERG

Table 4. Residual probing depth (mean ± standard deviation) at the 7- and 13- month examina-
tions by initial probing pocket dq)th and method of instrumentation. Pooled surfaces from all
patients
Verbleibende sondierte Taschentiefen (Mittelwerte ± Standarddeviationj anlasslich der Unter-
suchungen nach 7 und 13 Monaten in Bezug auf die initial sondierten Taschentiefen und auf die
Instrumentationsmethode. Die Oberflacken aller Patienten sind hier zusamntengefasst warden
Profondeur de sondage persistante (moyenne + ecart-type) aux examens du 7^"" et du I3^<^'
mois, suivant la profondeur de sondage initiale et le type d'instruments employe. Ensemble des
surfaces chez tous les patients.

Initial Hand instruments Ultrasonics

, probing
pocket No. of Depth at Depth at No. of Depth at Depth at
depth surfaces 7 months 13 months surfaces 7 months 13 months

Operator 1

4.0-4.5 34 2.6 ± 0.7 2.6 + O7 32 2.7 ± 0.6 2.8 ± 0.7

5.0-5.5 13 3.2 + 1.1 3.0 ± O8 17 3.0 ± 0.8 3.3 ± 0.8
6.0-6.5 13 2.9 ± 1.0 3.4 ± 1.0 14 3.1 ± 0.9 3.6 ± 1.0
7.0-7.5 10 3.9 ± 1.3 3.9 ± 1.0 5 4.0 ± 1.0 4.0 ± 0.7

Operator 2
4.0-4.5 24 3.0 ± 0.8 3.0 ± 0.8 26 2.5 ± 0.7 2.8 ± 0.8
5.0-5.5 19 3.4 ± 1.0 3.8 ± 0.9 29 3.3 ± 0.9 3.5 ± 1.0
6.0-6.5 20 3.8 ± 1.1 3.9 + 1.3 15 3.5 + 1.0 3.8 ± 0.9
7.0-7.5 5 3.0 ± 1.2 3.0 ± 0.7 5 3.4 ± 0.9 4.0 ± 0.0

Table 5. Number of surfaces with probing pocket dq)th > 6 mm at initial examination and at 7
and 13 months by operator and method of instrumentation. Pooled data from all patients
Anzahl der Oberflachen mit initialen Sondierungstiefen von ^ 6 mm im Vergleich zu den Werten
nach 7 und 13 Monaten. Die Resultate sind nach den individuellen Werten der Behandler und
den angewendeten Irtslrumenten aufgeschliisselt
Nombre de surfaces ou la profondeur de sondage est ^ 6 mm a I'examen initial, ainsi qu'au
jime et au 13^^' mois, suivant I'operateur et le type d'instruments employe. Donnees concer-
nant I'ensemble des patients.

Operator 1 Operator 2 Operators 1 & 2

Hand Ul- Hand Ul- Hand Ul-
instru- tra- instru- tra- instru- tra-
ments sonics ments sonics ments sonics
Initial 31 21 30 24 61 45
At 7
months 3 2 2 4 5 6 ,
At 13
months 3 2 3 5 6 7
 NONSURGICAL PERIODONTAL THERAPY 67

m liilML il RESOUAL
DEPTH

Fig. 5. Mean amounts of gingival recession, residual probing depth and gain/loss of probing at-
tachment level at 7 and 13 months. Pooled surfaces for hand (H) and ultrasonic (U) instruments
from all patients.
Mittlere Werte gingivaler Rezession, verbliebener Sondierungstiefen und Gewinn bzw^ Verlust
an sondiertem Attachmentniveau nach 7 und 13 Monaten. Die mit Hand- (H) und Ultraschall-
instrumenten (V) bekandehen Oberfiachen alter Patienten wurden hier summiert.
Moyennes du retrait gingival (gingival recession), de ta profondeur de sondage persistante et de
ta perte ou du gain en ce qui concerne le niveau de I'attachement tors du sondage, au bout de
7 mois et de 13 niois. Ensembte des surfaces pour les instruments d main (H) et a ultra-sons (U)
chez tous les patients.

while recordings for proximal surfaces indi- of different initial depth which showed
cated a slight gain of attachment. changes of probing attachment level at 7

Attachment changes as related to initial

probing pocket depth
In Fig. 5 the data from all surfaces of all
patients have been pooled and grouped ac-
cording to initial probing pocket depth of
the individual surfaces. Sites with initially
deeper probing pocket depth showed more
mi
gingival recession and deeper residual depth
Fig. 6. Proportion (%) of surfaces with gain or
at 7 and 13 months than sites where the ini- loss of probing attachment level > 1.5 mm at
tial depth was shallow. Surfaces with initial 7 and 13 months grouped by initial probing
2.0-3.5 mnj probing pocket depth had a pocket depth. N = number of available sur-
slight average loss of attachment. Surfaces faces.
with 7.0-7.5 mm initial pocket depth dem- Oberftachen (in %} mit Gewinn oder Verlust
onstrated 1.1-1.5 mm average gain of at- an sondierbarem Attachmentniveau von '> I.S
mm, nach 7 und 13 Monaten. Die Werte wur-
tachment. den, den Sondierungsergebnissen der initial
Computation of the data of Fig. 5 was vorhandenen Taschentiefen entsprechend, grup-
also performed using patient means of sur- piert. N = Anzahl verfUgbarer Oberftachen,
faces of different initial probing pocket Proportions (%} des surfaces presentant un
gain ou une perte en ce qui concerne le niveau
depth. These calculations showed the same de I'attachement lors du sondage > 1,5 mm au
average changes of the parameters as the bout de 7 mois et de 13 mois, groupees suivant
pooled data of the individual surfaces. la profondeur initiate de sondage des poches.
Fig. 6. presents the percentage of pockets N ^= nombre des surfaces a considerer.
68 BADERSTEN, NILVfiUS AND EGELBERG

100-, initial

90- 7 months

eo- 13 "

70-
60-
RESIXML PROBMG DEPTH
50-
Fig. 7. Mean change of probing attachment lev- 4D-.
el for surfaces with different residual probing
depth at 13 months. Pooled surfaces from all 30-
patients. 20-
Veranderungen des sondierten Attachmentni-
veaus (Mittelwerte} an Oberflachen mit unter-
schiedlicher Tiefe verbliebener Taschen nach
13 Monaten. Die behandelten Oberfldchen al-
ler Patienten sind hier summiert angegeben. Fig. 9. Proportion (%) of surfaces showing
Changement moyen du niveau de Vattachement bleeding upon probing at initial examination
lors du sondage, suivant la profondeur de son- and at 7 and 13 months grouped by initial pro-
dage persistante au bout de 13 mois. Ensemble bing pocket depth. Pooled data from all pa-
des surfaces chez tous les patients. tients. N = number of available surfaces.
Oberfldchen (in %) an denen bei der initialen
Untersuchung sowie nach 7 und 13 Monaten
Blutungsbereitschaft nach Sondierung konsta-
tiert wurde. Die Werte sind, den initial son-
dierten Taschentiefen entsprechend, gruppiert.
Die Daten aller Patienten sind summiert.
N — Anzahl verfUgbarer Oberflachen.
•I.
60-, Proportions (%) des surfaces presentant un
Dlos^iS ^Ks mm
saignement lors du sondage a I'examen initial
50-
et au bout de 7 et de 13 mois, suivant la pro-
40- fondeur initiate de sondage des poches. Don<-
30- nees pour I'ensemble des patients. N = nombre
20- des surfaces a considerer.
10- N=S3

1 2 3 i S 6 7
mm
Fig. 8. Proportion (%) of surfaces with gain or
ioss of probing attachment level > 1.5 mm at
13 months grouped by residual probing depth and 13 months. OtUy surfaces demonstra-
at 13 months. N = number of available sur- ting loss or gain of attachment level > 1.5
faces. tntn have been included. Loss of attachment
Verhaltnis (in %) zwischen den Oberflachen an of this magnitude was encountered for some
denen nach 13 Monaten Gewinn oder Verlust surfaces with initially shallow pockets while
des sondierbaren Attachmentniveaus von ^ 7.5 gain of probing attachment level occurred
mm konstatiert wurde. Die Werte wurden so
gruppiert, dass sie den Residualtiefen nach 13 for deep pockets.
Monaten entsprachen.
N — Anzahl verfUgbarer Oberfldchen Changes of probing attachment level as
Proportions (%) des surfaces presentant un related to residual probing pocket depth
gain ou une perte en ce qui concerne le niveau Fig. 7. presents the mean changes of prob-
de Vattachement lors du sondage > 1,5 mm au
bout de 13 mois, groupies suivant la profon- ing attachment level for pooled surfaces of
deur de sondage persistante au bout de 13 different residual probing depths at 13
mois. N — nombre des surfaces & considerer. months. Surfaces with a residual probing
 NONSURGICAL PERIODONTAL THERAPY 69

with \-A and 7 mm residual probing depth.

100- I 7 months Gain of > 1.5 mm attachment had taken
90- 113 •• place for 10-14 % of surfaces with 4-6 mm
80- residual probing depth.
70- zz
Relationship of bleeding on probing and
60-
probing pocket depth
50- The percentage of bleeding surfaces at the
iO- initial examination was higher for surfaces
30- with probing pocket depth of 4-7 mm than
20- for surfaces with 2-3 mm depths (Fig. 9).
At the 7- and 13-maath examinations, the
10-
bleeding frequencies were markedly re-
duced not only for the shallow pockets, but
2 3 4 5 »6
also for pockets of greater initial probing
mm
Fig. 10. Proportion (%) of surfaces showing depth. Bleeding upon prcAing was encoun-
bleeding upon probing at 7 and 13 month ex- tered more often in deeper residual probing
aminations grouped by residual probing depths depths than in shallow depths (Fig. 10).
at 7 and 13 months. Pooled data from all pa-
tients. N = number of available surfaces.
Oberflachen (in %) an denen bei den Unter- Time of instrumentation
suchungen nach 7 und 13 Monaten Blutungsbe- The total time required for instrumentation
reitschaft nach dem Sondieren bestand. Die varied between the two operators (Table 6).
Werte sind nach den verbteibenden, nach 7 und They both used somewhat less time with ul-
13 Monaten sondierten, Taschentiefen grup- trasonics than with hand instruments.
piert. Die Daten alter Patienten sind summiert.
N — Anzahl verfUgbarer Oberftachen,
Proportions (%) des surfaces presentant un
saignement lors du sondage au bout de 7 mois
et de 13 mois, groupees suivant la profondeur Discussion
de sondage persistante au bout de 7 mois et de The results of the present study demon-
13 mois. Donnees pour Vensemble de tous les strated that marked improvement of gingi-
patients. N = nombre des surfaces a conside-
rer. val conditions can be obtained after oral hy-
giene instruction, scaling and root planing
in patients with moderately advanced perio-
dontitis.
The design of this study does not allow
separate interpretations of the effect of the
depth of 1-2 mm seem to have lost a slight improved oral hygiene and the effect of in-
amount of attachment while surfaces with a strumentation. Only 1 month of observation
residual depth of 3-6 mm seem to have un- was scheduled between the start of the oral
dergone a minor improvement of probing hygiene instruction and the first instrumen-
attachment level. Four surfaces that had 7 tation. During this month, the bleeding
mm residual probing depth showed ati aver- scores were unaffected but some gingival re-
age attachment loss of 0.8 mm. cession was observed. During the subse-
If only surfaces showing loss or gain of quent months gradual reductions of bleed-
attachment > 1.5 mm are considered (Fig. ing scores and pocket depths occurred. Af-
8), it appears that loss of attachment of this ter 4-5 monAs little further improvement
magnitude had occurred for some surfaces seemed to take place.
70 BADERSTEN, NILVfiUS AND EGELBERG

Table 6. Mean time of instrumentation (minutes per tooth) by opetator and method of instru-
meatation
Mittelwerte der instrumentellen Bekandiungszeit (Minuten pro Zahn) in Bezug auf den Bekand-
ler und die instrumentelle Methode
Duree moyenne du traitement instrumental (minutes par dent) suivant I'operateur et le type
d'instrumerus employe.

Operator 1 Operator 2
Hand Hand
instru- Ultra- instru- Ultra-
ments sonics ments sonics
Instrumentation # 1
(at 1 mcnth) 4.7 3.6 7.6 7.1
Instrumentation # 2
(at 3 months) 1.3 1.0 1.2 1.0
Instrumentation #3
(at 7 months) 0.6 0.3 0.2 0.4

Total 6.6 4.9 9.0 8.5

The similarity of results foUowing hand tially. Some surfaces still showed bleeding
and ultrasonic instrumentation agrees with after treatment. The proportion of surfaces
the findings by Torfason et al. (1979). Pre- where bleeding could be provoked after
vious laboratory studies have shown that ul- therapy was somewhat higher for surfaces
trasonic instruments remove less root struc- with deeper residual probing depth than for
ture and leave a rougher surface behind surfaces with shallow residual depth. These
than hand instruments (see Suppipat 1974, circumstances seem to indicate that bleed-
Torfason et al. 1979 for review). Apparent- ing on probing is a valuable clinical para-
ly, these differences in mechanical perfor- meter. On the other hand, 7 % of surfaces
mance of the two types of instruments do with 2 mm residual probing depth and 16-
not seem to influence the gingival healing 17 % of the surfaces with 3 mm residual
as observed from clinical methods of eval- probing depth showed bleeding after thera-
uation. Adequate debridement of the con- py. This raises the question as to what
taminated root surfaces aj^jarently can be extent bleeding may be encountered in
accomplished by ultrascmic instrumentation sites which seem to have bren successfully
as well. Results from a recent in vitro study treated.
by Nishimine & O'Leary (1979) support this The probing pocket depths of sites ini-
view. These authors found that ultrasonic tially 4.0L-7.5 mm deep were markedly re-
instrumentation can remove most of the eo- duced in the present study using nonsurgical
dotoxin found in contaminated root sur- therapy. The probing attachment levels wrae
faces. also improved. More pocket reduction and
Most of the examined surfaces showed more gain of attachment were obtained for
bleeding on probing at initial examinaticoi. surfaces with 6.0-7.5 mm initial depth than
The therapy resulted in marked reduction fcff surfaces with 4.0i-5.5 mm initial depth.
of the bleeding frequency including sites In fact, the improvements of pocket depth
with 6.0-7.5 mm probing pocket icpth ini- and attachment level were ^milar to thc»c
 NONSURGICAL PERIODONTAL THERAPY 71

obtained by Knowles et al. (1979) using dif- and Bodil Gustavsson for devoted dental
ferent surgical treatment modalities. These hygiene and technical assistance.
findings give rise to the question whether
surgical therapy is needed for pockets up
to 7 mm deep in the "average" periodon- Zusammenfassung
titis case. Also, they emphasize that clini- Der Erfolg nicht-chirurgischer Parodontat-
cal studies evaluating periodontal surgery therapie I
should be performed only after adequate I. Miissig forigeschrittene Parodontitis
In dieser Studie werden die Heilungserfolge
periods of nonsurgical therapy. Only sites nicht-chJnirgischer Parodontaltherapie bei Pa-
which were not successfully treated with tienten mit Taschentiefen von 4—7 mm unter-
root planing should be included in such sucht. Schneidezahne, Eckzahne und Pramola-
studies. ren von 15 Patienten wurden bei Anwendung
der "spllt-mouth"-Versuchsstrategie (die eine
Some loss of probing attachment level Halfte des Mundes wird beiiaadelt, die andere
was observed for sites with initially shallow wird als KontroUgnipire nicht oder anders be-
probing pocket depth. The majority of these handelt), mit PlaquekontroUe und der Entfer-
sites were located on buccal surfaces of the nung von sub- und supragingivalem 21ahnstein
behandelt. Es kamen Hand- oder Ultraschall-
teeth. The attachment loss seemed to occur instrumcDte zur Anwendung.
soon after start of therapy. For buccal sur- Plaque-Bewertungseinheiten, die Beurteilimg
faces this initial attachment loss was not der Blutungsbereitschaft beim Sondieren sowie
followed by a subsequent improvement of die Sondiemng der Taschen und der Attach-
attachment levels in the way which could be mentniveaus wurden als Parameter zur Erfcdgs-
observed for proximal surfaces. Similar bewertung herangezogen. AUe diese Parameter
verbesserten sich wahrend der ersten 4-5 Mo-
findings with some loss of attachment for nate nach dem Therapiebeginn. Wahrend des
sites with initially shallow probing depth dann verbleibenden Zedtabschnittes der 13 Mo-
and for buccal surfaces have been reported nate dauemden Beobachtui^speriode, wurden
by Ramfjord et al. (1975) and Knowles et nur wenige Veranderungen ge&ehen. Bra der
Anwendung von Hand- Oder Ultraschailgera-
al. (1979) following various forms of surgi- ten wurden keine unterschiedlichen Behand-
cal therapy. lungsergebnisse gesehen. Dasseibe gilt fur den
The results of the present study must be Vergleich zwischen den Behandlungsei^ebnis-
sen zweier verschiedener Behandler. Urspriing-
interpreted within the limitations of the ma- lich wurde bei der Taschensondienmg an 106
terials and methods utilized. A limited Stellen Taschentiefen von ^ 6 mm konstatiert.
number of patients, treated by two opera- Nach 13 Monaten wurden solche Taschentiefen
tors only, was used for the study- Molars nur an 13 Stdlen regi&triert. Das augenschein-
lich erfolgreiche Resultat einer kcmservativen
were excluded from observations because of Behandlung von Patienten mit Taschentiefen
frequent interference from furcation in- von 4-7 mm lasst die Frage entstehen, inwie-
volvements in these teeth. A limited num- weit nicht-chirurgische Therapie auch bei Pa-
ber of surfaces with initial pocket depth > tienten mit fortgeschrittenen parodontalen La-
7 mm was available. However, the satisfac- sionen moglich ist.
tory results of ncmstirgical therapy which
were obtained in the present investigation
motivate extension of these studies to pa-
tients with advanced periodontitis. Action du traitement parodontal non
chirurgical.
I. Parodontite moderement avancee
Cette etude porte sur la fagcai dont evolue
Acknowledgmani* la guerison apres traitement parodontal nan
chirurgical chez des patients pr^soitant des
Sincere thanks are due to Solveig Eriksson poches parodontales de 4-7 mm de profondeur.
72 BADERSTEN, NILVfiUS AND EGELBERG

Chez 15 patients, les incisives, canines et pr^- Shick, R. A., Morrison, E. C. & Ramfjord,
molaires ont ete traitees par Elimination de la S. P. (1979) Results of periodontal treatment
plaque et par curetages supra- et subgingivaiK related to pocket d ^ t h and attachment level.
a l'aide d'instruments k main mi a l'aide des Eight years. Journal of Periodontology SO,
ultra-sons, en utilisant une methode dite "de 225-233.
bouche divisee" (split mouth). Les resultats ont Listgarten, M. A., Lindhe, J. & Hellden, L.
ete evalues par l'enregistrement des scores de la (1978) Effect of tetracycline and/or scaling
plaque, des scores du saignement lois du son- on human periodontal disease. Journal of
dage (bleeding scores), de la profondeur des Clinical Periodontology 5, 246-271.
poches et du niveau de I'attachement lors da Nishimine, D. & O'Leary, T. i. (1979) Hand in-
sondage. Tons ces parametres se sont ameliores strumentation versus ultrasonics in the remo-
pendant les 4-5 premiers mois apres le debut val of endotoxins from root surfaces. Jour-
du traitement. II ne s'est produit que peu de nal of Periodontology 50, 345-349.
cfaangement pendant le reste des 13 mois de la Ramfjord, S. P., Knowles, J. W., Nissle, R. R.,
periode d'observation. II n'a pas ete possible Burgett, F. G. & Shick, R. A. (1975) Results
d'observer de difference entre les resultats ob- following three modalities of periodontal
tenus avec les deux types d'instruments, ni en- therapy. Journal of Periodontology 46, 522-
tre les resultats obtenus par !es deux opera- 526.
teurs. Au depart, un total de 106 localisations Suppipat, N. (1974) Ultrasonics in periodontics.
presentaient des profondeurs de sondage ^ 6 Journal of Clinical Periodontology 1, 206-
mm. Au bout de 13 mois, on n'a pu observer 213.
que 13 localisations ayant une telle profondeur.
Tagge, D. L., O'Leary, R. J. & El-Kafrawy, A.
Le succes apparent obtenu dans cette etude lors
H. (1975) The clinical and histological re-
du traitement conservateur de patients presen-
sponse of periodontal pockets to root planing
tant des poches de 4—7 mm de profondeur
and oral hygiene. Journal of Periodontology
mene a se demander dans quelle mesure un
46, 527-534.
traitement non chirurgical serait praticable
Chez des patients presentant des lesions forte- Torfason, T , Kiger, R., Selvig, K. A. & Egel-
meQt avancees. berg, J. (1979) Clinical improvement of gin-
gival conditions following ultrasoaic versus
hand instrumentation of periodontal pockets.
References Journal of Clinical Periodontology 6, 165-
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H e l l d ^ L. B., Listgarten, M. A. & Lindhe, I.
(1979) The effect of tetracycline and/or scal-
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Clinical Periodontology «, 222-230. Address:
Hughes, T. P. & Caffesse, R. G. (1978) Gingi- Dr. Anita Badersten
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Knowles, J. W., Burgett, F. G., Nissle, R. R., Sweden