J Clin Periodontol 2002; 29(Suppl.

3): 92–102 Copyright # Blackwell Munksgaard 2002

Printed in Denmark. All rights reserved

ISSN 1600-2865

Review article

A systematic review of the L. J. A. Heitz-Mayfield1, L. Trombelli2,

F. Heitz1, I. Needleman3 and D. Moles4
1
Department of Periodontology and Fixed
Prosthodontics, University of Berne, Berne,

effect of surgical debridement vs. Switzerland, 2Research Center for the Study of
Periodontal Diseases, University of Ferrera,
Italy, 3Department of Periodontology and
4
Department of Oral Pathology, Eastman

non-surgical debridement for the Dental Institute, University College London, UK

treatment of chronic periodontitis

Heitz-Mayfield L. J. A, Trombelli L, Heitz F, Needleman I, Moles D: A systematic review of the
effect of surgical debridement vs. non-surgical debridement for the treatment of chronic period-
ontitis. J Clin Periodontol 2002; 29(Suppl. 3): 92–102. # Blackwell Munksgaard, 2002.

Abstract
Objective: To systematically review the evidence of effectiveness of surgical vs.
non-surgical therapy for the treatment of chronic periodontal disease.
Methods: A search was conducted for randomized controlled trials of at least
12 months duration comparing surgical with non-surgical treatment of chronic
periodontal disease. Data sources included the National Library of Medicine
computerised bibliographic database MEDLINE, and the Cochrane Oral
Health Group (COHG) Specialist Trials Register. Screening, data abstraction
and quality assessment were conducted independently by multiple reviewers
(L.H., F.H., L.T.). The primary outcome measures evaluated were gain in
clinical attachment level (CAL) and reduction in probing pocket depth (PPD).
Results: The search provided 589 abstracts of which six randomized controlled
trials were included. Meta-analysis evaluation of these studies indicated that
12 months following treatment, surgical therapy resulted in 0.6 mm more PPD
reduction (WMD 0.58 mm; 95% CI 0.38, 0.79) and 0.2 mm more CAL gain
(WMD 0.19 mm; 95% CI 0.04, 0.35) than non-surgical therapy in deep pockets
(>6 mm). In 4–6 mm pockets scaling and root planing resulted in 0.4 mm more
attachment gain (WMD
0.37 mm; 95% CI
0.49,
0.26) and 0.4 mm less
probing depth reduction (WMD 0.35 mm; 95% CI 0.23, 0.47) than surgical
therapy. In shallow pockets (1–3 mm) non-surgical therapy resulted in 0.5 mm less
attachment loss (WMD
0.51 mm; 95% CI
0.74,
0.29) than surgical therapy.
Conclusions: Both scaling and root planing alone and scaling and root planing
combined with flap procedure are effective methods for the treatment of
chronic periodontitis in terms of attachment level gain and reduction in Key words: non-surgical therapy; periodontal
gingival inflammation. In the treatment of deep pockets open flap debridement diseases/ therapy; surgical therapy; system-
results in greater PPD reduction and clinical attachment gain. atic review

Chronic periodontitis is defined as an (1999 International Workshop for a fying factors such as systemic diseases,
inflammatory disease of the supporting Classification of Periodontal Diseases). cigarette smoking, and local factors.
tissues of the teeth caused by groups of Chronic perio dontitis affects most of Cross-sectionalepidemiologicalstud-
specific microorganisms, resulting in the adult population and may be ies indicate that about 10–15% of the
progressive destruction of the periodon- further classified on the basis of extent adult population have ‘advanced peri-
tal ligament and alveolar bone with and severity. Furthermore, chronic peri- odontitis’, while about 80% have
pocket formation, recession or both odontitis may be associated with modi- ‘moderateperiodontitis’, and 10% of the
 Surgical vs. non-surgical periodontal therapy 93

population are periodontally healthy incidence of bleeding on probing Validity assessment

(Löe et al. 1978, Baelum et al. 1986, (DBOP). Other outcome variables of Two reviewers (L.H. & F.H.) inde-
Okamoto et al. 1988, Papapanou et al. interest were adverse reactions to treat- pendently screened titles and abstracts
1988, Hugoson et al. 1998). ment, and long-term outcome measures of the search results for possible
The primary goal of periodontal of disease recurrence and tooth loss. inclusion. The full text of all studies
therapy is to arrest the inflammatory of possible relevance was obtained
disease process. Treatment involves for independent assessment against
mechanical removal of the subgin- Literature search
the stated inclusion criteria. Any dis-
gival biofilm, and the establishment A search of MEDLINE (1965 to agreement was resolved by discussion
of a local environment and microflora April 2001) and the Cochrane Oral amongst the reviewers. Authors were
compatible with periodontal health. Health Group specialist trials (1965 contacted to provide additional infor-
Parameters including clinical attach- to April 2001) was made. Only papers mation where possible.
ment level (CAL) and probing pocket written in the English language were The methodological quality assess-
depth (PPD) measurements, and the considered. In addition, reference lists ment, and data abstraction for included
presence of bleeding on probing (BOP) from review articles and books were studies was independently conducted by
are commonly used to assess and moni- searched. two reviewers (L.H. & L.T.). Methodo-
tor the periodontal status. To improve The search strategy applied for the logical quality was assessed focusing on
periodontal health, treatment aims to MEDLINE search was a combination individual components shown to affect
reduce probing pocket depths (PPD), of non-surgical therapy AND surgical study outcomes including the randomi-
maintain or improve clinical attachment therapy AND types of studies. zation method, allocation concealment
levels (CAL) and reduce the incidence (concealment of the randomization code
of BOP. Non-surgical therapy from those recruiting patients to avoid
Chronic periodontal disease can be selection bias), and completeness of fol-
successfully treated by non-surgical or * MeSH terms: periodontics OR peri- low-up. Agreement concerning study
surgical mechanical therapy provided odontal diseases OR dental scaling inclusion, and quality assessment was
adequate plaque control is maintained OR root planing OR dental prophy- determined by Kappa statistics.
during the supportive phase of treat- laxis OR;
ment (Lindhe & Nyman 1975, Nyman * Text words: initial therapy OR Quantitative data analysis
et al. 1977, Axelsson & Lindhe 1981).
The objective of this review is to debridement OR non-surgical.
Studies were combined in meta-ana-
evaluate the effect of surgical debride- Surgical therapy lyses to evaluate the treatment effect
ment versus non-surgical debridement of surgical (open flap debridement,
in terms of changes in clinical attach- * MeSH terms: surgical flaps OR OFD) and non-surgical (scaling and
ment level, probing pocket depth and root planing, SRP) procedures. The
gingivectomy OR periodontal-
bleeding on probing for patients with meta-analyses were performed using
chronic periodontitis. pocket-surgery OR;
the statistical software package Stata
* Text words: modified widman flap version 6 (STATA version 6. Texas:
Material and Methods OR access OR kirkland OR osseous Stata Corporation 1999). Results
Study selection surgery OR apically repositioned were expressed as weighted mean dif-
OR coronally. ferences (WMD and 95% CI). A fixed
To be eligible for inclusion in this
effects model was used where appro-
review, studies had to be randomized
Types of studies priate and a random effects model
controlled trials of at least 12 months
was used when studies showed stat-
duration. Studies were considered for
MeSH terms: longitudinal study OR istically significant heterogeneity.
inclusion if they included patients with *

randomised controlled study OR Variance imputation methods were

a clinical diagnosis of chronic peri-
comparative study OR clinical trial. used to estimate appropriate variance
odontitis who were at least 20 years
estimates in some studies, where the
of age. The lower age limit was The search strategy applied for the appropriate standard deviation of the
selected in order to be as inclusive of Cochrane search was ((Periodontics differences was not included in study
studies as possible. However, studies OR periodontal-disease OR ‘peri- reports (Follmann et al. 1992).
specifically treating aggressive forms odontal disease* OR dental-scaling OR Analyses were planned to investi-
of periodontitis were excluded. ‘‘dental scaling’’ OR root-planing OR gate the treatment effects of non-
A patient-based analysis was ‘root planing’ OR dental-prophylaxis surgical therapy and open flap
required for inclusion. Studies were OR ‘dental prophylaxis’ OR ‘oral debridement. Subgroup analyses were
excluded if site-based data was presented prophylaxis’ OR ‘initial therap’ OR planned to investigate the treatment
without a patient-based analysis. debridement OR ((non-surgical OR effects for non-molar and molar teeth.
‘non surgical’) AND perio*)) AND
(‘surgical flap*’ OR gingivectom*
Outcome variables Results
OR ‘periodontal pocket surgery’
Study characteristics
The primary outcome variables OR ‘modified Widman flap’ OR
assessed were clinical attachment access OR Kirkland OR ‘osseous The search resulted in the identifica-
level change (DCAL), probing pocket surgery’ OR apical* OR reposition* tion of 589 studies. Independent initial
depth change (DPPD) and change in OR coronally)). screening of the titles and abstracts by
94 Heitz-Mayfield et al.

two reviewers (L.H. & F.H.) resulted in

Potentially relevant publications
further consideration of 14 randomized
identified from search (n = 589)
controlled trials for possible inclusion.
Of these studies, seven met the defined
Publications excluded on the basis
inclusion criteria (Fig. 1). The Kappa of title and abstract (n = 575)
value for interreviewer agreement for
study inclusion was 0.93, 95% CI: 0.80, Potentially relevant RCTs retrieved
for detailed evaluation (n = 14)
1.06, indicating strong agreement. Dis-
agreement concerning one paper was
Excluded publications, not fulfilling
resolved by discussion. A further study,
inclusion criteria (n = 8) (Table 2)
Sigurdsson et al. (1994), was excluded
Potentially appropriate RCTs for
from the review following discussions
meta-analyses (n = 6) (Table 1)
during the workshop group session.
This study included patients who were RCTs excluded from meta-analyses,
described as having recurrent disease and inappropriate data presentation (n = 1)
the consensus of the group was that this
RCTs included in the
study was at variance with other studies
meta-analyses (n = 5)
and should be excluded from the review.
The remaining six randomized con-
trolled trials were all of split mouth Fig. 1. Flow chart for inclusion in review and meta-analyses.
design with a non-surgical and surgi-
cal procedure performed within each in the SRP and OFD groups (Ramfjord In pockets of initial probing depth
patient. There was, however, consider- et al. 1987, Isidor et al. 1984, Kaldahl 4–6 mm there was 0.4 mm more
able variation in study design and data et al. 1996). attachment gain following non-surgical
presentation among the studies. Table 1 Studies of all three designs cate- therapy. The difference between the treat-
describes the characteristics of the gories were included in the meta- ment modalities was highly statistically
included studies. The eight excluded analyses for treatment effect for sites significant (Table 3, Fig. 3). The weighted
publications and reasons for exclusion with initial PPD of 4–6 mm, and mean difference between surgical and
are presented in Table 2. greater then 6 mm. The analyses, how- non-surgical therapy was
0.37 mm
ever, showed no statistically significant (95% CI: [
0.49,
0.26], P ¼ 0.000).
Methodological quality of included studies
heterogeneity between the studies. In deep pockets (PPD > 6 mm),
there was 0.2 mm more attachment
Two studies described the randomiza- gain following access flap surgery
Change in clinical attachment level (CAL)
tion method (Isidor et al. 1984, (Table 3, Fig. 4). The weighted mean
Kaldahl et al. 1996), while allocation One study presented data for the difference between surgical and non-
concealment was not reported in any clinical attachment level change and surgical therapy was 0.19 mm (95%
of the studies. probing depth change (mm) for all CI [0.04, 0.35], P ¼ 0.017).
Completeness of follow-up: A num- initial probing depths combined
ber of studies were based on a (Lindhe et al. 1982). All other studies Probing pocket depth reduction
decreasing number of subjects. Data presented data in relation to initial
from these patients were included probing depth severity. Four studies When initial probing depth severity
until the time of exit from the study. presented data using the initial probing was considered, differences in treatment
There was 100% agreement between depth categories 1–3 mm, 4–6 mm and effect could be observed between sur-
reviewers concerning study quality issues. >6 mm (Lindhe et al. 1982, Lindhe & gical and non-surgical therapy. In shal-
Nyman 1985, Pihlstrom et al. 1983, low pockets (1–3 mm), no statistically
Ramfjord et al. 1987). Kaldahl et al. significant difference in pocket depth
Study design – Initial therapy
(1996) presented data using an alterna- reduction between treatment proce-
Initial therapy varied among studies tive initial probing depth classification dures was observed (Table 3, Fig. 5).
with three different study designs of 1–4 mm, 5–6 mm, and >6 mm. When the initial probing depth was
identified within the papers. The first Thus for the initial probing depth 4–6 mm, there was 0.4 mm more pocket
involved no presurgical scaling (Lindhe categories 1–3 mm and 4–6 mm there reduction following open flap debride-
et al. 1982, Lindhe & Nyman 1985). The were four studies available for meta- ment (Table 3, Fig. 6). The weighted
second reported by Pihlstrom et al. analysis evaluation and for deep pockets mean difference between surgical and
(1983) incorporated initial scaling and (>6 mm), five studies were available. In non-surgical therapy was 0.35 mm
root planing with no further treatment the Lindhe et al. (1982) paper, the stan- (95% CI: [0.23, 0.47], P < 0.001).
in the control group. Thus the control dard error was estimated from a figure. In deep pockets (>6 mm) the open
group received scaling and root planing In shallow pockets (1–3 mm) there flap debridement resulted in 0.6 mm
once, while the test group received scal- was 0.5 mm less attachment loss more pocket reduction than scaling
ing and root planing at initial therapy following scaling and root planing and root planing (Table 3, Fig. 7).
and again during surgery. The third (Table 3, Fig. 2). The weighted mean The weighted mean difference between
group of studies incorporated scaling difference between surgical and non- surgical and non-surgical therapy
and root planing during initial therapy surgical therapy was
0.51 mm (95% was 0.58 mm (95% CI [0.38, 0.79],
with repeated scaling and root planing CI: [
0.74,
0.29], P < 0.001). P < 0.001).
Table 1. Characteristics of included studies
Study Methods Participants Interventions Outcomes Location and funding Comments
Lindhe et al. RCT 15 individuals, Initial therapy: OHI D CAL University Tooth loss not reported
(1982, 1984) Split-mouth 11 completed Control: SRP. Test: MWF D PPD Data:
(5-year follow-up) 2 treatment the study Maintenance intervals: GI Overall data
groups 6 females every 2 weeks for first 6 months, PLI Initial PPD 1–3 mm
2–5 years’ Age 32–57 3-monthly from 6 to 24 months, Initial PPD 4–6 mm
duration years 4–6-monthly supragingival Initial PPD >6 mm
cleaning from 24 to 60 months non-molars
molars
5-year data: frequency
distribution of DCAL in patients with
Plaque score 410% and 50%
Lindhe & RCT 15 individuals Initial therapy: OHI DCAL University Data:
Nyman (1985) Split-mouth Age 42–59 years Control: SRP DPPD Initial PPD 1–3 mm
3 treatment groups Test 1: MWF PLI Initial PPD 4–6 mm
12 months’ duration Test 2: modified Kirkland flap GI Initial PPD >6 mm
Maintenance intervals: every BOP
2 weeks for first 3 months
supragingival cleaning,
3-monthly from 3 to 12 months
(supra- and subgingival debridement)
Pihlstrom RCT 17 individuals, Initial therapy: OHI + SRP (+LA) DCAL University Results based on a decreasing number of subjects
et al. (1981, 1983, Split-mouth 10 completed Control: no further treatment DPPD Data:
1984) 2 treatment the study, Test: MWF GI Initial PPD 1–3 mm
groups 13 females Maintenance intervals: PLI Initial PPD 4–6 mm
6.5 years’ Age 22–59 3–4-monthly Initial PPD > 6 mm
duration years supra- and subgingival non-molars
debridement molars
Isidor & RCT 16 individuals Initial therapy: OHI + SRP(-LA) DCAL University Non-molar teeth only
Karring (1986) Split-mouth Age 28–52 Control: SRP DPPD angular defects evaluated
Isidor et al. 3 treatment years Test 1: MWF (OFD) PLI
(1984) groups Test 2: Reverse Bevel Flap GI
5 years’ Maintenance intervals: BOP
duration every 2 weeks year 1,
professional prophylaxis
3-monthly year 2,
6-monthly years
3, 4 & 5 – subgingival
debridement
Ramfjord et al. RCT 90 Individuals, Initial therapy: OHI + SRP DCAL University Recordings obtained both prior to and 1 month following
(1987) Split-mouth 72 completed Control: SRP DPPD completion of initial therapy
4 treatment the study; Test 1: MWF Results based on a decreasing number of subjects
groups 37 females Test 2: Pocket elimination surgery. Detailed data for plaque and bleeding scores not presented
5 years’ Age 24–68 Test 3: subgingival curettage Data:
duration years Maintenance intervals: weekly for Initial PPD 1–3 mm
1 month, 3-monthly for 5 years Initial PPD 4–6 mm
(supra- and subgingival debridement) Initial PPD >6 mm
Kaldahl et al. RCT 82 individuals, Initial therapy: OHI + SRP DCAL University Analysis of coronal scaling group discontinued
(1988, 1996) Split-mouth 51 completed Control: additional SRP DPPD Results based on a decreasing number of subjects
Kalkwarf et al. 4 treatment the study Test 1: MWF Detailed data for plaque and bleeding scores not presented
(1988) groups 52 females Test 2: Osseous surgery Data:
(Molar 7 years’ Mean age 43.5 Test 3: Coronal scaling Initial PPD 1–4 mm
furcations) duration years Maintenance intervals: Initial PPD 5–6 mm
Surgical vs. non-surgical periodontal therapy

Kalkwarf et al. (1989) subgingival debridement) Initial PPD >6 mm

RCT: randomized control trial; LA: local anaesthesia; OHI: oral hygiene instruction; BOP: bleeding on probing; CAL: clinical attachment level; OFD: open flap debridement; PPD: probing pocket
depth; PLI: plaque index; GI: gingival index; MWF: modified Widman flap (OFD); SRP: scaling and root planing.
95
 96

Table 2. Characteristics of excluded studies

Reason for
Study exclusion Methods Participants Interventions Outcomes Location and funding
Westfelt et al. 6 months’ RCT 16 individuals Initial therapy: OHI DCAL University
(1985) duration Split-mouth Age 35–65 years Control: SRP DPPD
5 treatment groups Test 1: MWF
6 months’ duration Test 2: Gingivectomy
Heitz-Mayfield et al.

Test 3: Apically repositioned flap

Test 4: Apically repositioned flap + bone recontouring
Maintenance intervals: 2-weekly for 6 months
Becker et al. Antibiotics RCT 16 individuals Initial therapy: OHI DCAL University
(1988) prescribed for Split-mouth Age 30–57 years Control: SRP DPPD
4 days after 3 treatment groups Test 1: MWF
treatment 12 months’ duration Test 2: Apically repositioned flap + osseous surgery
Anterior teeth not included Maintenance intervals: 3-monthly
Renvert et al. Citric acid root RCT 14 individuals, 12 Initial therapy: OHI + SRP DCAL University
(1985) surface Split-mouth completed the study Control: SRP DPPD
conditioning 2 treatment groups Age 32–67 years Test: Access flap + citric acid
as an adjunct to 5 years’ duration Maintenance intervals: every 6 weeks for first year,
OFD then every 6 months
Knowles et al. No SRP group RCT 78 individuals, Initial therapy: OHI + SRP(-LA) DCAL University
(1979) Subgingival Split-mouth 43 completed the Control: subgingival curettage DPPD
curettage study Test 1: MWF
(Root planing and 3 treatment groups Age 19–61 years Test 2: pocket elimination
soft tissue curettage) 8 years’ duration Maintenance intervals: 3-monthly
Waite et al. No SRP RCT 28 individuals Initial therapy: OHI + SRP DCAL University
(1976) group, Split-mouth Age 21–49 years Control: supragingival scaling and polishing DPPD
supragingival 2 treatment groups Test: gingivectomy
scaling and 2 years’ duration Maintenance intervals: 3-monthly
polishing only
Schroer et al. Not randomized, teeth CCT 11 individuals, Initial therapy: OHI +SRP DCAL University
(1991) selectively assigned to Split-mouth 10 completed the Control: SRP DPPD
treatment groups 2 treatment groups study Test: OFD
Age 32–69 years
Grade II molar furcations 12 months’ duration Maintenance intervals: 3-monthly
Forabosco et al. SRP with betadine RCT 8 individuals Initial therapy: OHI +supragingival scaling DCAL University
(1996) 0.5% irrigation Split-mouth Age 35–50 years Control: SRP + Betadine 0.5% DPPD
Site-based analysis 2 treatment groups Test: MWF
12 months’ duration Maintenance intervals:every 2 weeks
Sigurdsson Patients described as RCT 11 individuals Initial therapy: OHI DCAL Private practice
et al. (1994) having recurrent Split-mouth 7 females Control: SRP DPPD
periodontitis excluded 2 treatment Age 34–57 years Test: MWF
during group groups Maintenance intervals:
discussion 12 months’ duration 3-monthly, subgingival
debridement avoided

CCT: controlled clinical trial.

 Surgical vs. non-surgical periodontal therapy 97

showed more probing pocket depth

reduction following open flap debride-
Lindhe 1982 ment for non-molar teeth. Mean attach-
ment level changes, however, showed
little variation between tooth types and
Pihlstrom 1983
treatment modalities.
Isidor & Karring (1986) evaluated
Lindhe & Nyman
1985 non-molar teeth over a period of
5 years. Similar results in probing
Ramfjord 1987 depth reduction and attachment gain
were achieved following non-surgical
and surgical procedures. An analysis
of angular defects was also included,
Combined and indicated no difference in out-
come between treatment modalities.
–2 –1 0 1 2
Data were not presented in relation
diff
to the initial probing depth severity
Weighted mean difference (mm) in this paper, and therefore could not
Favours SRP Favours OFD be combined in a meta-analysis with
data from Lindhe et al. (1982).
Fig. 2. Difference in the CAL change between OFD and SRP at sites with initial PPD 1–3 mm.
Random effects Forest plot.
Molar furcations

Kalkwarf et al. (1988) evaluated

furcation areas of molar teeth 2 years
Lindhe 1982 after non-surgical and surgical
therapy. Similar treatment effects were
Pihlstrom 1983 observed following both procedures
(Table 5).
Ramfjord 1987
Incidence of bleeding on probing (BOP)
Lindhe & Nyman
1985 The incidence of bleeding on probing
was inconsistently reported and
a meta-analysis was therefore not
possible for this outcome variable.
Combined Table 6 shows a similar reduction in
–2 –1 1 2
the percentage of sites with presence
0
diff of BOP following non-surgical and
Weighted mean difference (mm)
surgical treatment modalities.
Favours SRP Favours OFD
Long-term treatment outcomes
Fig. 3. Difference in the CAL change between OFD and SRP at sites with initial PPD 4–6 mm. A number of studies presented long-
Fixed effects Forest plot. term treatment outcomes after 5 years
(Isidor & Karring 1986, Ramfjord
Molar and non-molar teeth
(Tables 4a, b, c, d)
et al. 1984). A meta-analysis was not et al. 1987, Lindhe et al. 1984),
performed, as it was not possible to 6.5 years (Pihlstrom et al. 1983) and
Two studies evaluated the treatment derive the standard error in the paper 7 years (Kaldahl et al. 1996). The
outcome in both molar and non-molar by Pihlstrom et al. (1984). Both studies long-term results of these studies
teeth (Lindhe et al. 1982, Pihlstrom reported that deep sites (PPD > 6 mm) were based on a decreasing number

Table 3. Summary of meta-analyses for clinical outcomes

Initial PPD WMD Heterogenity
category No. of weighted mean P-value
Outcome (mm) studies difference (mm) 95% 95% CI for WMD P-value Method
CAL gain 1–3 mm 4
0.513
0.737,
0.290 0.000 0.005 random
PPD reduction 1–3 mm 2 0.101
0.036, 0.239 0.147 0.008 random
CAL gain 4–6 mm 4
0.373
0.485,
0.261 0.000 0.331 fixed
PPD reduction 4–6 mm 2 0.351 0.234, 0.467 0.000 0.108 fixed
CAL gain >6 mm 5 0.191 0.035, 0.347 0.017 0.897 fixed
PPD reduction >6 mm 3 0.584 0.383, 0.785 0.000 0.687 fixed
98 Heitz-Mayfield et al.

frequently found in deep sites treated

by scaling and root planing. They
Pihlstrom 1983 also observed that similar numbers of
teeth were extracted due to progressive
Ramfjord 1987 periodontal disease following non-
surgical treatment (21 teeth) and
modified Widman flap (21 teeth).
Kaldahl 1996
Pihlstrom et al. (1983) also reported
Lindhe & Nyman a similar incidence of tooth loss follow-
1985 ing surgical (five teeth) and non-surgical
Lindhe 1982 (six teeth) therapy over a 5-year
observation period.
Overall, the long-term data sug-
gests that non-surgical and surgical
Combined therapy were equally effective in
establishing gingival health, and pre-
–2 –1 0 1 2 venting further loss of attachment.
diff
Weighted mean difference Discussion
Favours SRP Favours OFD This systematic review illustrates the
heterogeneity of study design within
Fig. 4. Difference in the CAL change between OFD and SRP at sites with initial PPD >6 mm. the literature. While individual stud-
Fixed effects Forest plot. ies may offer valuable information,
only six randomized, controlled trials
met the inclusion criteria for this
systematic review. Due to the limited
number of studies in the analyses,
formal testing for publication bias
Pihlstrom 1983 was not possible.
Regarding the quality of the
included studies, some reports were
incomplete in their presentation of
Ramfjord 1987 methods or results. Allocation con-
cealment was not reported, and ran-
domization method was described in
only two studies. Furthermore, some
studies did not report standard devi-
ation or standard error. Data for the
meta-analyses were frequently obtained
by estimation from figures in the papers.
Combined
It is recommended that authors of
–2 –1 0 1 2 randomized controlled trials (RCTs)
diff should follow the CONSORT statement
Weighted mean difference (mm) (http://www.consort-statement.org/)
for reporting of trials (Needleman
Favours SRP Favours OFD 1999). This report provides concise
guidelines on presentation of trial
Fig. 5. Difference in the PPD change between OFD and SRP at sites with initial PPD 1–3 mm. reports and may facilitate future
Random effects Forest plot. systematic reviewing of the literature.
While all included studies were of
of subjects compared with baseline re-treatment in the non-surgical split mouth design there were differ-
(Lindhe et al. 1982, Pihlstrom et al. treatment group, while about 20 ences in a number of aspects between
1983, Ramfjord et al. 1987, Kaldahl teeth for the surgical groups were studies. Firstly, there was a range of
et al. 1996). In these studies, data re-treated. However, the long-term terminology used to describe the
were included in the analyses up results of scaling and root planing study population and disease severity
until the time of dropout. were equivalent to those of the sur- among studies. The age range also
Re-treatment of sites and tooth loss gical procedures with regard to main- varied from 22 to 68 years and this
was reported in several studies. tenance of attachment and prevention suggests that participants may have var-
Ramfjord et al. (1987) reported a of loss of teeth. ied in their susceptibility to periodontitis.
total of 101 teeth in 24 patients Similarly, Kaldahl et al. (1996) Secondly, the initial therapy pro-
requiring re-treatment due to persis- reported that breakdown sites (attach- vided varied among studies. In two
tent inflammation; 44 teeth required ment loss 3 mm/year) were more studies initial therapy consisted of
 Surgical vs. non-surgical periodontal therapy 99

oral hygiene instruction alone (Lindhe

et al. 1984, Lindhe & Nyman 1985).
In contrast, Ramfjord et al. (1987),
Isidor et al. (1984) and Kaldahl
Ramfjord 1987
et al. (1996) performed scaling and
root planing as part of initial therapy
and this was repeated during the
Pihlstrom 1983 definitive phase of treatment. In one
study the control group received a
single session of scaling and root planing
while the test group received scaling
and root planing at initial therapy,
and again during the flap procedure
(Pihlstrom et al. 1983).
Combined Furthermore, supportive periodon-
–2 –1 0 1 2
tal therapy (SPT), or professionally
diff
supervised maintenance care, also var-
ied considerably among studies. In
Weighted mean difference (mm)
a number of studies, patients followed
Favours SRP Favours OFD a programme of professional prophy-
laxis at 2-weekly intervals, as described
Fig. 6. Difference in the PPD change between OFD and SRP at sites with Initial PPD 4–6 mm. by Axelsson & Lindhe (1974), for
Fixed effects Forest plot. a period of up to 1 year following treat-
ment (Lindhe et al. 1984, Lindhe &
Nyman 1985, Isidor & Karring 1986).
In other studies, supra- and sub-
gingival debridement at 3–4-monthly
Kadahl 1996
intervals was the standard of care
(Pihlstrom et al. 1983, Ramfjord et al.
Ramfjord 1987 1987, Kaldahl et al. 1996).
While SPT intervals differed among
studies, all studies incorporated regu-
Pihlstrom 1983 lar supervised maintenance care in
their protocols and interpretation of
the results should be made with this
in mind.
The importance of supportive peri-
odontal therapy (SPT) was empha-
Combined sized in the 5-year report by Lindhe
–2 –1 0 1 2 et al. (1984). In this study a strict
diff programme of professional supragin-
Weighted mean difference (mm) gival plaque removal at 2-weekly
Favours SRP Favours OFD intervals was provided for 6 months
following treatment. The mainten-
ance care programme was then
Fig. 7. Difference in the PPD change between OFD and SRP at sites with Initial PPD >6 mm.
Fixed effects Forest plot
extended to 3-monthly visits including
subgingival scaling as required. Fre-
Table 4a. Non-molar teeth DCAL quency distribution of attachment
level changes for patients with excel-
DCAL mm (12 months) lent plaque control (PLI  10%), and
SRP OFD poor oral hygiene (PLI  50%) at
n mean  SD/SE* mean  SD/SE* each re-examination were described.
Lindhe et al. (1982)
Reduction of probing depth, and
PPD 1–3 mm 15
0.9  0.4*
0.2  0.2* gain of clinical attachment occurred
PPD 4–6 mm 15 0.7  0.4* 0.3  0.2* predominantly in the group of patients
PPD >6 mm 15 0.9  0.9* 1.5  0.6* with a high standard of oral hygiene.
Pihlstrom et al. (1984) Overall, studies showed a substan-
PPD 4–6 mm 14 0.34 0.06 tial reduction in the percentage of
PPD >6 mm 10 0.41 1.19 BOP positive sites following both
Isidor & Karring (1986) treatment modalities, reflecting the
All initial PPD 16 0.6  0.2* 0.2  0.3* systematic approach to plaque
Angular defects 16 1.6  0.3* 0.9  0.5*
control incorporated in the included
OFD: open flap debridement. SRP: scaling and root planing. studies.
100 Heitz-Mayfield et al.

Table 4b. Non-molar teeth DPPD Subject dropout, re-treatment of

teeth and tooth loss were reported in
DPPD mm (12 months)
several studies. In these studies the
SRP OFD data were included in the analysis
n mean  SD/SE* mean  SD/SE* until the time of exit. It is not clear,
Lindhe et al. (1982) however, how this subject dropout
PPD 1–3 mm 15 0.4  0.2* 0.6  0.2* and tooth loss affects the results and
PPD 4–6 mm 15 2.0  0.4* 2.3  0.4* conclusions within these studies.
PPD >6 mm 15 2.6  1.0* 3.4  0.8* All studies were university-based,
Pihlstrom et al. (1984) which may have influenced the results
PPD 4–6 mm 14 0.80 1.45 of comparison of treatment modal-
PPD >6 mm 10 1.71 3.14
ities in that conditions were ‘ideal’
Isidor & Karring (1986) for research with no time constraints
All initial PD 16 2.3  0.3* 2.5  0.4*
Angular defects 16 3.7  0.3* 3.5  0.3* during treatment and maintenance.
Operator experience was inconsist-
OFD: open flap debridement. SRP: scaling and root planing. ently reported and this may also
have influenced the outcome of treat-
ment modalities.
Despite these differences, the out-
comes of the seven studies included in
Table 4c. Molar teeth DCAL this review show similar results 1 year
DCAL mm (12 months) after surgical and non-surgical peri-
odontal therapy. In deep pockets
SRP OFD
n mean  SD/SE* mean  SD/SE* (>6 mm), surgical therapy resulted in
more probing pocket depth reduction
Lindhe et al. (1982) and more attachment gain than the
PPD 1–3 mm 15
0.3  0.2*
1.0  0.6* non-surgical therapy, whereas in shal-
PPD 4–6 mm 15 0.3  0.4*
0.1  0.2*
PPD > 6 mm 15 0.9  0.6* 0.7  0.6* low pockets (1–3 mm) there was more
Pihlstrom et al. (1984)
attachment loss following surgery
PPD 4–6 mm 14 0.50 0.07 than scaling and root planing. Long-
PPD > 6 mm 10 0.64 1.21 term results suggest that the two
treatment modalities are equally effec-
OFD: open flap debridement. SRP: scaling and root planing.
tive in PPD reduction, CAL gain and
reduction in incidence of BOP.
Insufficient studies are available to
evaluate the various treatment proced-
ures in furcation regions and angular
Table 4d. Molar teeth DPPD
defects.
DPPD mm (12 months) At the time when most of the stud-
SRP OFD
ies were conducted, subject character-
n mean  SD/SE* mean  SD/SE* istics and their possible effect on
treatment outcome were not addressed.
Lindhe et al. (1982) Patient preference and patient-
PPD 1–3 mm 15 0.2  0.2* 0.5  0.4*
PPD 4–6 mm 15 1.2  0.4* 1.4  0.4*
based outcomes were not reported in
PPD > 6 mm 15 2.0  1.0* 2.0  1.2* any of the studies and this area should
Pihlstrom et al. (1984) be addressed in future research.
PPD 4–6 mm 14 0.67 1.26
PPD > 6 mm 10 0.94 2.28
Conclusions
OFD: open flap debridement. SRP: scaling and root planing.
* When sites with initial PPD 1–3 mm
were involved in treatment by open
flap debridement, there was signifi-
Table 5. Molar furcation sites: data from Kalkwarf et al. (1988) (all values estimated from
cantly more CAL loss than with
Figures: no SD/SE given). 12-month results treatment by scaling and root
planing (WMD –0.51 mm; 95%
SRP OFD
CI –0.74, –0.29).
n mean n mean * When sites with initial PPD 4–6 mm
DCAL vertical (mm) 78 0.8 74 0.6 were treated by open flap debride-
DCAL horizontal (mm) 78 0.2 74
0.4 ment, there was significantly less
DPPD (mm) 78 1.2 74 1.5
CAL gain than with the scaling
OFD: open flap debridement. SRP: scaling and root planing. and root planing procedure (WMD
 Surgical vs. non-surgical periodontal therapy 101

Table 6. Bleeding on Probing BOP% Lindhe, J. & Nyman, S. (1975) The effect of
plaque control and surgical pocket elimina-
SRP OFD tion on the establishment and maintenance
baseline 12 months baseline 12 months of periodontal health. A longitudinal study
Lindhe & Nyman (1985) n M  SD/SE* M  SD/SE* M  SD/SE* M  SD/SE* of periodontal therapy in cases of advanced
disease. Journal of Clinical Periodontology 2,
15 79  9* 8  5* 78  10* 5  4* 67–79.
SRP OFD Lindhe, J. & Nyman, S. (1985) Scaling and
granulation tissue removal in periodontal
Kalkwarf et al. (1989) n baseline 12 months baseline 12 months therapy. Journal of Clinical Periodontology
1–4 mm initial PPD 78 70 32 70 38 12, 374–388.
5–6 mm initial PPD 78 90 45 90 55 Lindhe, J., Westfelt, E., Nyman, S., Socransky, S. S.,
> 6 mm initial PPD 78 90 58 90 55 Heijl, L. & Bratthall, G. (1982) Healing fol-
lowing surgical/non-surgical treatment of
OFD: open flap debridement. SRP: scaling and root planing. periodontal disease. A clinical study. Journal
of Clinical Periodontology 9, 115–128.
Lindhe, J., Westfelt, E., Nyman, S., Socransky, S. S. &
Widman procedures. Results after one year. Haffajee, A. D. (1984) Long-term effect of
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The PPD reduction was significantly Follmann, D., Elliott, P., Suh, I. & Cutler, J. tal disease. Journal of Clinical Periodontology
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0.35 mm; 95% CI 0.23, 0.47). Journal of Clinical Epidemiology 45, 768–773. (1978) The natural history of periodontal
Forabosco, A., Galetti, R., Spinato, S., disease in man. The rate of periodontal
* When sites with initial PPD >6 mm
Colao, P. & Casolari, C. (1996) A compara- destruction before 40 years of age. Journal
were treated with open flap debride- of Periodontology 49, 607–620.
tive study of a surgical method and scaling
ment, there was significantly more and root planing using the Odontoson. Jour- Needleman, I. G. (1999) CONSORT. British
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0.35). Open flap debridement resulted Thorstensson, H. (1998) Distribution of peri- Periodontal surgery in plaque-infected denti-
odontal disease in a Swedish adult population tions. Journal of Clinical Periodontology 4,
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Isidor, F., Karring, T. & Attstrom, R. (1984) Papapanou, P. N., Wennstrom, J. L. &
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The effect of root planing as compared to Grondahl, K. (1988) Periodontal status in
effects. relation to age and tooth type. A cross-
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Acknowledgements Kaldahl, W. B., Kalkwarf, K. L., Patil, K. D., Periodontology 15, 469–478.
Dyer, J. K. & Bates, R. E. Jr (1988) Evalu- Pihlstrom, B. L., McHugh, R. B., Oliphant,
Sincere thanks to Mrs Sylvia Bickley T. H. & Ortiz-Campos, C. (1983) Com-
ation of four modalities of periodontal
at the Cochrane Oral Health Group therapy. Mean probing depth, probing attach- parison of surgical and nonsurgical treat-
in Manchester UK, for help in search- ment level and recession changes. Journal ment of periodontal disease. A review of
ing the literature. of Periodontology 59, 783–793. current studies and additional results after
Kaldahl, W. B., Kalkwarf, K. L., Patil, K. D., 6½ years. Journal of Clinical Periodontology
Molvar, M. P. & Dyer, J. K. (1996) Long- 10, 524–541.
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