17 1 2015 January Supplement

Journal of the International
Academy of Periodontology
The official journal of the International Academy of Periodontology
Volume 17 Number 1 Supplement
January 2015
Presented at the First IAP Conclave, Bangkok, Thailand, 11-13 April, 2014
This supplement has been kindly sponsored by Colgate
Published by The International Academy of Periodontology
Volume 17
Number 1
January 2015
supplement
ISSN 14662094
Journal
of the
International Academy of
Periodontology
EDITORIAL BOARD
Mark R Patters
Editor
Memphis, TN, USA
Andrea B Patters
Associate Editor
Sultan Al Mubarak
Riyadh, Saudi Arabia
P Mark Bartold
Adelaide, SA, Australia
Michael Bral
New York, NY, USA
Cai-Fang Cao
Beijing, Peoples Republic of China
Ahmed Gamal
Cairo, Egypt
Francis Mora
Paris, France
Vincent J Iacono
Stony Brook, NY, USA
Francis Mora
Paris, France
Hamdy Nassar
Cairo, Egypt
Rok Schara
Ljubljana, Slovenia
Uros Skaleric
Ljubljana, Slovenia
Shogo Takashiba
Okayama, Japan
Ahmad Soolari
Tehran, Iran
Thomas E Van Dyke
Boston, MA, USA
Warwick Duncan
Dunedin, New Zealand
Nicola Zitzmann
Basel, Switzerland
Introduction
Group A
Plaque control: Home remedies practiced in developing countries
Initiator Paper
Dagmar E. Slot and Fridus A. Van der Weijden
Reactor Paper
Thomas E. Van Dyke
16
Consensus Paper
Sebastian Ciancio
17
Group B
Non-surgical periodontal therapy: mechanical debridement,
antimicrobial agents and other modalities
Initiator Paper
Magda Feres, Marcelo Faveri, Luciene Cristina Figueiredo, Ricardo
Teles, Thomas Flemmig, Ray Williams, Niklaus P. Lang
21
Reactor Paper
Niklaus P. Lang
31
Consensus Paper
Niklaus P. Lang
34
Group C
Periodontal regeneration - fact or fiction?
Initiator Paper
PM Bartold
37
Reactor Paper
Joerg Meyle
50
Consensus Paper
Shinya Murakami
57
Continued overleaf
Group D
Implants - Peri-implant (hard and soft tissue) interactions in health
and disease: The impact of explosion of implant manufacturers
Initiator Paper
Saso Ivanovski
57
Reactor Paper
Young-Bum Park
69
Consensus Paper
Jamil Shibli
71
Group E
Interprofessional education and multidisciplinary teamwork for
prevention and effective management of periodontal disease
Initiator Paper
Lijian Jin
74
Reactor Paper
Vincent J. Iacono
80
Consensus Paper
A. Kumarswamy
84
The Journal of the International Academy of Periodontology is the official journal of the International Academy of Periodontology
and is published quarterly (January, April, July and October) by The International Academy of Periodontology, Boston, MA, USA and
printed by Dennis Barber Limited, Lowestoft, Suffolk. UK.
Manuscripts, prepared in accordance with the Information for Authors, should be submitted electronically in Microsoft Word to the
Editor at the jiap@uthsc.edu.The Editorial Office can be contacted by addressing the editor, Dr. Mark R.Patters, at jiap@uthsc.edu.
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correspondence, advertisements etc., herein are the responsibility of the contributor or advertiser concerned. Accordingly, the
publishers and Editorial Board and their respective employees, offices and agents accept no liability whatsoever for the consequences of
any such inaccurate or misleading opinion or statement.
2015 International Academy of Periodontology.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any
means, electronic, photocopying, or otherwise, without permission of the Academy.
Produced in Great Britain by Dennis Barber Limited, Lowestoft, Suffolk
Journal of the International Academy of Periodontology 2015 17/1 Supplement 12
The 1st IAP Conclave

11 13 April 2014
Bangkok, Thailand
INTRODUCTION
Ajay Kakar
On 11 13 April 2014, the International Academy of
Periodontology (IAP) held a unique initiative by hosting a conclave meeting of leading periodontists from
developing countries along with established leading
luminaries as the invited faculty. The purpose of the
conclave was to develop and report their conclusive
findings on five different aspects of periodontal diseases
and therapies. The theme for the conclave meeting was
Global strategies to address periodontal health and
diseases, focusing on the emerging nations. The goal
was to address periodontal therapy on a global scale to
achieve periodontal awareness and concomitant periodontal health improvements in developed, developing
and underdeveloped countries. The key areas for discussion and recommendations were:
A. Plaque control - home remedies practiced in developing countries
B. Non-surgical periodontal therapy - mechanical
debridement, antimicrobial agents and other modalities
C. Periodontal regeneration - fact or fiction?
D. Implants - peri-implant (hard and soft tissue) interactions in health and disease
E. Interprofessional education and multidisciplinary
teamwork for prevention and effective management
of periodontal disease
After establishing the five groups, a moderator, an initiator and a reactor was chosen for each of the five workgroups.
The IAP board selected and invited experts in each of the
areas. Subsequently invitations were sent out to periodontal/
implant associations around the world to send representatives
to take part in the deliberations. The Conclave was attended
by representatives of close to 25 countries. The IAP set a
maximum of 100 attendees split among the five groups.
Each workgroup was comprised of an initiator, a reactor
and a moderator. The program was planned with a common
opening session wherein the guidelines of the Conclave were
established and then the moderators of each group led the
discussions of each of the workgroup teams addressing a
number of key questions.
Following the initial discussion, the groups reconvened
and each group presented their initial findings. Comments
and suggestions were taken from all the delegates and the
groups again met for further deliberation to formulate their
final conclusions.
International Academy of Periodontology
This issue of the Journal of the International Academy of

Periodontology contains the initial review papers and the
final outcomes from the three days of discussions and
deliberation by the delegates.
The IAP is extremely thankful to the supporting
companies, without which this Conclave would not have
been possible. We are grateful to Colgate Palmolive as
the Principal Sponsor for the event, Proctor & Gamble
Oral B as the Gold Sponsors, and Giestlich, Johnson
& Johnson and Sunstar as the Supporting Sponsors for
the event.
The final publication of the papers presented herein
was generously supported by additional funding from
Colgate Palmolive.
GROUP LEADERS
Workgroup A Plaque Control
Initiator: Ms. Dagmar Slot
Reactor: Dr. Thomas Van Dyke
Moderator: Dr. Sebastian Ciancio
Workgroup B Non-surgical Therapy
Initiator: Dr. Magda Feres
Reactor and Moderator: Dr. Nicklaus Lang
Workgroup C Periodontal Regeneration
Initiator: Dr. Mark Bartold
Reactor: Dr. Joerg Meyle
Moderator: Dr. Shinya Murakami
Workgroup D - Implants
Initiator: Dr. Saso Ivanovski
Reactor: Dr. Young Bum Park
Moderator: Dr. Jamil Shibli
Workgroup E Interprofessional Education
Initiator: Dr. Lijian Jin
Reactor: Dr. Vincent Iacono
Moderator: Dr. A. Kumarswamy
Journal of the International Academy of Periodontology (2015) 17/1 Supplement
Participants
Agarwal, Ruchi, Private Practice, Melbourne, Australia
Alarcon, Marco, Universidad Peruana Cayetano Heredia,
Peru
Al Bayaty, Foud, Universiti Teknologi MARA, Malaysia
Anagnostou, Fani, Paris Diderot University, France
Aswapati, Nawarat Wara, Khon Kaen University, Thailand
Bakalyan, Vardan, Yerevan State Medical University, Armenia
Bartold, Mark, University of Adelaide, Australia
Bunyaratavej, Pintippa, Mahidol University, Thailand
Byakod, Girish, Rangoonwaala Dental College, India
Cheung, KM, Private Practice, Singapore
Chitguppi, Rajeev, Terna Dental College-Navi Mumbai, India
Chiu, Gordon, Private Practice, Hong Kong
Ciancio, Sebastian, University of Buffalo, USA
Corbet, Esmonde, The University of Hong Kong, Hong
Kong
Darby, Ivan, University of Melbourne, Australia
Ding, Yi, Sichuan University, PR China
Duncan, Warwick, University of Otago, New Zealand
Duygu, Ilhan, Private Practice, Turkey
Emingil, Glnur, Ege University, Turkey
Ettiene, Daniel, Paris Diderot University, France
Faveri, Marcelo, Guarulhos University, Brazil
Feres, Magda, Guarulhos University, Brazil
Fernandes, Benette, Srinivas Institute of Dental Sciences,
India
Gamal, Ahmed, Ain Shams University, Egypt
Giri, Dhirendra, College of Dental Surgery, Nepal
Halhal, Rita, Private Practice, France
Humagain, Manoj, Kathmandu University School of Medical Sciences, Nepal
Iacono, Vincent, Stony Brook Dental School, USA
Ilhan, Duygu, Private Practice, Turkey
Ivanovski, Saso, Griffith University, Australia
Izumi, Yuichi, Tokyo Medical and Dental University, Japan
Jacob, Shaiju, International Medical University, Malaysia
Jin, Lijian, Prince Philip Dental College, Hong Kong
Jin, Yan, Fourth Military Medical University, China
John, Janice, India (Transcriber)
Joshi, Vinayak, MMNGH Institute of Dental Sciences, India
Kakar, Ajay, Private Practice, India
Kakar, Mona, Private Practice, India
Kale, Rahul, M.A. Rangoonwaala College of Dental Sciences,
India (Transcriber)
Kamil, Wisam, International Islamic University Malaysia,
Malaysia
Kemal, Yulianti, Universitas Indonesia, Indonesia
Kendall, Kaye, Private Practice, Australia
Kim, Sung Tae, Seoul National University School of Dentistry, South Korea
Kim, Ti Sun, University Hospital of Heidelberg, Germany
Kumarswamy, A, Yerla Medical Trust Dental College, India
Lang, Niklaus, Universities of Zurich and Berne, Switzerland
Laosrisin, Narongsak, Srinakharinwirot University, Thailand
Leung, Keung, University of Hong Kong, China

Liechter, Jonathan, University of Otago, New Zealand
Loomer, Peter, New York University College of Dentistry,
USA
Mahanonda, Rangsini, Chulalongkorn University, Thailand
Masud, Mahayunah, University Institute Technology Mara,
Malaysia
Matheos, Nikos, Prince Philip Dental College, Hong Kong
Meyle, Joerg, University of Giessen, Germany
Minh, Nguyen Thi Hong, National Hospital of OdontoStomatology, Vietnam
Murakami, Shinya, Osaka University, Japan
Nagata, Toshihiko, University of Tokushima Graduate
School, Japan
Narongsak, Laorisin, Srinakharinwirot University, Thailand
Nazreth, Bianca, India
Nishida, Mieko, Sunstar Inc., Japan
Ouyahoun, Jean Pierre, Paris 7 Denis Diderot University,
France
Pack, Angela, University of Otago (Retired), New Zealand
Panikar, Arjun, Private Practice, India (Transcriber)
Park, Young Bum, Yonsei University, Korea
Patel, Nisha, Rishi Raj Dental College, India (Transcriber)
Patnaik, Samarjeet, India
Pillai, Nihar, Private Practice, India (Transcriber)
Pradhan, Shaili, National Academy of Medical Science, Nepal
Rajpal, Jaisika, Subharti University, India (Transcriber)
Sakellari, Dimitra, Aristotle University of Thessaloniki,
Greece
Senevirante, Cyanthi, Colgate, Singapore
Shibli, Jamil, University of Guarulhos, Brazil
Shibutani, Toshiaki, Asahi University, Japan
Shin, Seung Il, Kyunghee University, South Korea
Shorab, Mohammed, Fiji National University, Fiji
Singh, Preetinder, SDD Hospital & Dental College, India
Slot, Dagmar, Academic Centre for Dentistry Amsterdam,
Netherlands
Soeroso, Yuniarti, Universitas Indonesia, Indonesia
Spahr, Axel, University of Sydney, Australia
Takashiba, Shogo, Okayama University Graduate School of
Medicine, Japan
Tan, Benjamin, National University of Singapore
Tan, Wah Ching, National Dental Centre Singapore, Singapore
Thakur, Roshni, DY Patil Dental College, India (Transcriber)
Van Dyke, Thomas, Forsyth Institute, USA
Vidhale, Priya, Private Practice, India (Transcriber)
Wagh, Aditya, University of Texas, India (Transcriber)
Won, Jung Ui, College of Dentistry, Yonsei University, South
Korea
Xuan, Dong-Ying, Southern Medical University, China
Yamazaki, Kazuhisa, Niigata University, Japan
Yang, Yueh Chao, Taiwan
Yeung, Stephen, University of Sydney, Australia
Zhang, Jin Cai, Southern Medical University, China
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Journal of the International Academy of Periodontology 2015 17/1 Supplement: 415
Group A
Initiator Paper
Plaque control: Home remedies practiced in
developing countries
Dagmar E. Slot and Fridus A. Van der Weijden
Department of Periodontology, Academic Centre for Dentistry
Amsterdam (ACTA), Amsterdam, The Netherlands
Introduction
The importance of plaque control measures to contribute to the oral health status of an individual has
been emphasized in all workshops on periodontology
(Claydon, 2008). Oral cleanliness is important for the
preservation of oral health as it removes microbial
plaque, thereby preventing its accumulation on teeth
and gingivae (Choo et al., 2001). Self-care includes all
self-supporting activities that an individual performs
to prevent and treat personal ill health. Self-care or
home-use activities include toothbrushing combined
with interdental cleaning. People brush their teeth for
a number of reasons: to feel fresh and confident, to
have a nice smile, and to avoid bad breath and disease
(Choo et al., 2001). But despite the widespread use of
both toothbrushes and uoride toothpastes, the majority
of the population do not clean their teeth thoroughly
enough to prevent plaque accumulation (Claydon, 2008).
There is, however, substantial evidence showing that
toothbrushing and other mechanical cleansing procedures
can reliably control plaque. The development of a variety
of powered (electric) toothbrushes has been undertaken
with the aim of enabling the user to achieve higher standards. Although power toothbrushes are sold worldwide
and have been shown to be more effective than manual
toothbrushes (Deacon et al., 2010), their significance in
developing countries is limited because of costs. The
minimum level of income deemed adequate in developing
countries (also called the poverty line) has been estimated
at $1 a day. In 2008, the World Bank came out with a
revised figure of $1.25 as purchasing-power parity (PPP).
Presented at the First IAP Conclave, Bangkok, Thailand,

11-13 April, 2014
Correspondence to: D.E. Slot, Department of Periodontology,
Academic Centre for Dentistry Amsterdam (ACTA), University of
Amsterdam and VU University Amsterdam, Gustav Mahlerlaan
3004, 1081 LA Amsterdam.The Netherlands. E-mail: d.slot@acta.nl
Thus the purchase costs and the need for electricity for
recharging or the cost of batteries restricts the potential
use of power toothbrushes in developing countries.
Additionally, the use of interdental brushes on a daily
basis would be far beyond what the average consumer
in developing countries could afford. Subsequently for
this paper, manual toothbrushing, flossing and the use
of wood sticks were considered to be suitable methods
for mechanical plaque control by oral self-care in developing countries.
With respect to toothbrushing, a PubMed search at
the time of preparation of this manuscript revealed that
over 6500 relevant papers are indexed in this database.
Consequently it was decided to consider the totality of
the evidence as presented in systematic reviews. Such a
synthesis is a comprehensive summary of all the research
evidence related to a focused clinical question that integrates the best available evidence from original single
studies. The present synopses of syntheses (Dicensio et
al., 2009), summarizes the findings of a systematic review on various methods of mechanical plaque removal
which are affordable in developing countries, with the
aim to assess the effect on plaque scores and oral health.
Materials and methods
This synopsis of synthesis was conducted in accordance
with the Cochrane handbook (Higgings and Green,
2011) for systematic reviews of interventions, which
provides guidance for the preparations and the guidelines of Transparent Reporting of Systematic Reviews
and Meta-analyses (PRISMA-statement; Moher et al.,
2009; Dicensio et al., 2009).
Focused question
Based on evidence as presented in systematic reviews,
what is the effect on plaque scores and oral health of
self-care manual plaque control measures appropriate
for developing countries?
Group A Initiator: Developing country home remedies for plaque control
Search strategy
Three internet sources were used to search for appropriate papers that satisfied the study purpose. These sources
included the National Library of Medicine, Washington,
D. C. (MEDLINE-PubMed) and the Cochrane Central
Register of Controlled Trials. For this comprehensive
search, both databases were searched for eligible studies
up to 1 January 2015. The structured search strategy was
designed to include any systematic review published
that evaluated the effect of self-care regarding plaque
control. For details regarding the search terms used,
see Box 1.
The eligibility criteria were as follows:

Systematic reviews
Papers written in the English or Dutch language
Evaluating studies conducted in humans
18 years old
In good general health
Intervention: self care products for controlling the
dental biofilm.
Evaluation with one or more of the following
clinical evaluation parameters: plaque scores (PS);
gingival index (GI); and bleeding scores (BS).
Exclusion criteria: rechargeable or battery powered devices.
Screening and selection

Two reviewers (DES and GAW) independently screened
the titles and abstracts for eligible papers. If eligibility
aspects were present in the title, the paper was selected
for further reading. If none of the eligibility aspects were
mentioned in the title, the abstract was read in detail
to screen for suitability. After selection, the full-text
papers were read in detail by two reviewers (DES and
GAW). Any disagreement between the two reviewers
was resolved after additional discussion. The papers that
fulfilled all of the selection criteria were processed for
data extraction. All of the reference lists of the selected
studies were hand-searched by two reviewers (DES and
GAW) for additional published work that could possibly
meet the eligibility criteria of the study. Unpublished
work was not sought.
Assessment of heterogeneity
The heterogeneity of the outcome parameters across
studies was detailed according to the following factors:
Databases searched
Study and subject characteristics
Manner of analysis of the obtained data
Quality assessment
Two reviewers (DES and GAW) scored the methodological qualities of the systematic reviews. Assessment
of methodological study quality was performed by combining the proposed criteria of the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses: The
PRISMA Statement Checklist, together with items of the
systematic review reviewers checklist (Ades et al., 2013),
Quality Assessment Scale for Systematic Reviews (Barton
et al., 2008, modified by Haladay et al., 2013) and reporting
items suggested by Zorzela et al. (2014). Criteria were designated for evaluating the methods. This comprehensive
combination of quality criteria is presented in Table 2.
Box 1. Search terms used for PubMed-MEDLINE and Cochrane-CENTRAL.

The search strategy was customized according to the database being searched.
The following strategy was used in the search:
{ <Intervention> AND <outcome> }
Filter used: systematic review OR meta-analysis
{ <Intervention: [MeSH terms] Toothbrushing OR (Home Care Dental Devices) OR [text

words] toothbrush OR toothbrushing OR toothbrush* OR toothpick* OR wood stick* OR
(wooden interdental cleaner) OR (wedge stimulator*) OR (wooden stimulator*) OR miswak OR
miswaak OR arak OR siwak OR sewak, (Kayu Sugi) OR (chewing stick) OR Floss OR (Dental
floss) OR Flossing OR Tape OR (Dental tape) OR Superfloss OR Ultrafloss OR (Interdental
cleaning devices) OR (Interproximal cleaning devices) OR (Interspace cleaning devices)>
AND
<(Outcome: <[MeSH terms] (Dental Plaque) OR (Dental Plaque Index) OR (Dental
Deposits) OR [text words] (dental deposit*) OR (dental deposits) OR (dental deposit)
OR plaque OR (plaque removal) OR (plaque index) OR (dental plaque)>}
The asterisk (*) was used as a truncation symbol.
Figure 1
Search and selection results.
Figure 1. Search and selection results.

PubMed-MEDLINE
29
78
Eligibility
Screening
Identification
Cochrane-CENTRAL
Excluded by title and abstract
Unique title
and abstracts
72
78
Excluded after
full reading
Selected for fulltext reading
Included from the reference

list
Included
0
Final selection
Analyzed
Toothbrushes
Interdental devices
Floss
WS
Ovid-Medline
OVID-EMBASE
Cochrane CENTRAL
Cochrane OHG trials
LILAC-BIREME
CINAHL-EBSCO
ZETOC
Web of science
mRCT
clinicaltrials.gov
PubMed-Medline
Cochrane CENTRAL
Sambunjak et al.
2011
Hoenderdos et al.
2008
= Calculated by the review authors
PubMed-Medline
Cochrane CENTRAL
PubMed-Medline
Cochrane CENTRAL
Databases searched
Data
Berchier et al.,
2008
Interdental cleaning
Slot et al., 2012
Brushing
ID
Author
(year)
Weighted mean
difference
559
participants
438
participants
Vote counting
Standardized
Mean Difference
1083
participants
8
experiments
Meta analysis
12 trials
Vote counting
Meta-analysis
Weighted mean
and 95%
confidence
interval
Meta-analysis
Mode of analysis (methodology, metaanalysis, vote

counting)
11 studies
10,806
participants
212
experiments
# participants
Number of
included
studies/trials
Evidence from controlled trials, most of which were also randomized, shows that wood sticks do not have an additional
effect on visible interdental plaque or gingival index, but do,
however, provide an improvement in interdental gingival
inflammation by reducing the bleeding tendency.
There is some evidence from 12 studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from
10 studies that flossing plus toothbrushing may be associated
with a small reduction in plaque at 1 and 3 months. No studies reported the effectiveness of flossing plus toothbrushing
for preventing dental caries.
The dental professional should determine, on an individual

patient basis, whether high-quality flossing is an achievable
goal. In light of the results of this comprehensive literature
search and critical analysis, it is concluded that a routine instruction to use floss is not supported by scientific evidence.
The efficacy in plaque removal following a brushing exercise

is a reduction from baseline plaque scores of 42% on average,
with a variation of 30 53% dependent on the plaque index
used. The available evidence indicates that bristle tuft arrangement (flat trim, multilevel, angled) and brushing duration are
factors that contribute to the variation in observed efficacy.
Original review authors conclusions
Table 1. Overview of the characteristics of the included systematic reviews processed for data extraction.
No statistical analysis
could be performed.
Only triangular wood
sticks were evaluated.
Two studies included

a control group using
a 5% hydro alcohol.
One study included
an intervention group
using a hummingbird
power flosser which
is not dental floss but
a rubber stimulator.
Two included studies reported the same

experiment; however,
they were of different
durations.
Lacks a comparison
intervention
COMMENTS of the
synopsis authors

7
Study:
substantial
71%
Brush
+
+
+
NA
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Slot
et al., 2012
substantial
63%
Floss
+
+
+
NA
+
+
+
+
+
+
+
+
+
+
+
+
+
?
Berchier
et al., 2008
high
88%
Floss
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Sambunjak
et al., 2011
substantial
71%
Wood sticks
+
+
+
NA
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Hoenderdos
et al., 2008
Each aspect of the score list was given a rating of + for an informative description of the item at issue and a study design meeting the quality standard, - for an informative description without a study design that met the quality standard, and ? for insufficient information. NA, not applicable.
Authors estimated quality
Authors estimated quality score
Oral hygiene device evaluated

Defined outcome criteria of interest
Target population in developing countries
Describes the rationale
Describes the focused (PICO)[S] question/hypothesis
Describes if a protocol was developed a priori.
Protocol registration/publication
Presented eligibility criteria (inclusion/exclusion criteria)
Presents the full search strategy
Various databases searched
Performed (manual) search in additional sources (e.g. grey literature or trial registers)
Stated if selected studies were screened by more than one reviewer
Non-English language papers included
Provided details on the performed study selection process/flow chart
Reports study characteristics, such as patient demographics or length of follow-up
Provide data of the selected studies on the outcome measures of interest
Data were extracted by more than one reviewer
Report heterogeneity of the included studies
Estimated risk of bias in individual studies
Performed a meta-analysis
Performed a descriptive analysis
Performed an analysis based on vote counting
Describes additional/sub-analyses
Grading of the obtained evidence
Present limitations of the systematic review
Provide a conclusion that responds to the objective
Funding source
Quality criteria:
Table 2. Methodological quality scores and estimated risk of bias of the included systematic reviews.
8
Disagreements in scoring for the final quality assessment scores were resolved by consensus. The consensus
quality assessment scores and percent agreement were
calculated. Each aspect of the item score list was given
a rating of + for informative description of the item
at issue and a study design meeting the quality standard,
- for an informative description without a study design
that met the quality standard and ? for insufficient
information. If all quality items were given a positive
rating a 100% quality score was obtained. The percentage estimated quality was interpreted as follows: 0% to
40% - low quality, 40% to 60% - moderate quality, 60%
to 80% - substantial quality, 80% to 100% - high quality.
Data analyses
Plaque scores were considered to be the primary parameter of interest and formed the basis for selection
of publications for this review. The data from those
papers that met the selection criteria were extracted and
processed for further analysis by two reviewers (DES
and GAW). As a measure of oral health also bleeding
scores (BS) and the gingival index (GI) scores were
considered from those studies in which these outcomes
were presented in conjunction with plaque score data.
Data and conclusions as presented in the selected papers
were extracted. Statistical heterogeneity and potential
publication bias were evaluated. Disagreements between
the reviewers were resolved by discussion.
Grading the body of evidence
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, as proposed
by the GRADE working group, was used to grade the
evidence emerging from this synopsis of synthesis
(GRADE, Guyatt et al., 2008). Two reviewers (DES
and GAW) rated the quality of the evidence as well as
the strength of the recommendations according to the
following aspects: risk of bias, consistency and precision
among outcomes, directness of results, and detection
of publication bias.
Results
Search and selection results
The searches resulted in 78 unique papers (Figure 1).
The screening of titles and abstracts initially resulted in
six papers. Based on detailed reading of full texts two
papers were excluded. Hand searching of the reference
lists did not reveal any additional suitable systematic reviews. As a result, four studies were identified as eligible
for inclusion in this synopsis according to intervention
and outcome parameters.
Assessment of heterogeneity
Considerable heterogeneity was observed in the four sys-
tematic reviews with respect to the databases searched,

study and subject characteristics of the original individual papers, description of inclusion and exclusion
criteria, quality assessment scale used, report of effect
scores, presence of meta-analysis, and conclusions made.
Information regarding the included papers is displayed
in detail in Table 1. Various clinical indices and their
modifications have been evaluated.
Quality assessment
Quality assessment values, including details, are presented in Table 2. Based on a summary of these criteria, the
estimated quality is substantial in three studies (Slot et al.
2012; Berchier et al., 2008; Hoenderdos et al., 2008) based
on quality scores of 71%, 63% and 71% respectively.
A high estimated quality based on a score of 88% was
given to the Cochrane paper of Sambunjak et al., 2011.
Study outcomes results
Table 1 shows the results from the data extraction. The
conclusion of the original review authors and the comments of the authors of this synopsis and a descriptive
summary are presented per oral hygiene device.
Manual toothbrushes
The effect of a single brushing exercise using a manual
toothbrush was assessed by Slot and coworkers (2012).
In total, 212 individual brushing exercises as separate
legs of experiments, including 10,806 participants, were
used to calculate a weighted mean overall plaque score
reduction in percentage. Based on the baseline and end
scores, a plaque reduction percentage was calculated
for each of the eligible brushing exercises taken from
the selected studies. Using these data, a weighted mean
difference (WMD) in plaque index scores reduction
from baseline was calculated to be 42% including all
methods of scoring plaque. Taking plaque index scores
used into account, plaque scores dropped from 30% to
53% on average. Sub-analysis of the efficacy in relation
to brush head configurations and brushing duration
shows a numerical advantage of multilevel and angled
designs relative to flat trim. In addition, the effect of a
single brushing exercise with regard to toothbrushing
time was evaluated. From this sub-analysis, based on
Quigley and Hein plaque index scores, the estimated
weighted mean efficacy was 27% after 1 minute and
41% after 2 minutes.
Floss
Berchier and coworkers (2008) evaluated the effect
of flossing as adjunct to toothbrushing. Independent
screening of titles and abstracts resulted in 11 publications that met the eligibility criteria. The majority of
these studies showed that there was no benefit from
flossing on plaque or clinical parameters of gingivitis.
10
From the collective data of the studies, it appeared possible to perform a meta-analysis of plaque and gingival
index scores. In both instances, baseline scores were not
statistically different. Comparing brushing and flossing
against brushing only, the Quigley and Hein plaque index
WMD was - 0.04 (95% CI: -0.12; 0.04, p = 0.39) and the
Lo and Sillness gingival index WMD was -0.08 (95%
CI: - 0.16; 0.00, p = 0.06). End scores also showed no
significant differences between those groups that flossed
in comparison to those that did not floss for the Quigley
and Hein plaque (WMD: -0.24, 95% CI: -0.53; 0.04, p
= 0.09) or Le and Silness gingival index (WMD: -0.04,
95% CI: - 0.08; 0.00, p = 0.06).
In a Cochrane review, the effects of flossing in
combination with toothbrushing were compared with
toothbrushing alone in the management of periodontal
diseases and dental caries in adults (Sambunjak et al.,
2011). Twelve trials were included in this review, with a
total of 582 participants in flossing plus toothbrushing
(intervention) groups and 501 participants in toothbrushing (control) groups. All included trials reported
the outcomes of plaque and gingivitis. Seven of the
included trials were assessed as at unclear risk of bias and
five were at high risk of bias. Flossing plus toothbrushing showed a statistically significant benefit compared
to toothbrushing in reducing gingivitis at the three time
points studied, the standardized mean difference (SMD)
being -0.36 (95% CI -0.66 to -0.05) at 1 month, SMD
-0.41 (95% CI -0.68 to -0.14) at 3 months and SMD
-0.72 (95% CI -1.09 to -0.35) at 6 months.
Wood sticks
Hoenderdos and coworkers (2008) presented a qualitative summary of the effect of wood sticks in combination with toothbrushing. Seven publications describing
eight clinical experiments met the inclusion criteria.
None of the studies that scored plaque demonstrated
any significant advantage of the use of wood sticks. The
improvement in gingival health observed in the studies
represented a significant reduction of bleeding realized
by the use of triangular wood sticks.
Evidence profile
Table 3 shows a summary of the various factors used to rate
the quality of evidence and strength of recommendations
according to GRADE (Guyatt et al., 2008). Because the
data are fairly consistent, indirect and moderately precise,
the strength of the recommendation is considered to be
moderate to strong for the self-care mechanical plaque
removal devices.
Discussion
The model to guide clinical decision begins with original
single studies as the foundation, and builds up from these to
syntheses (systematic reviews), followed by synopses of the
syntheses. Such synopses intend to describe the current best
evidence that matches the patients specific circumstances.
The advantages of a relevant synopsis of a synthesis are
2-fold: first, the synopsis provides a convenient summary
of the corresponding synthesis (systematic reviews), and
second, it is often accompanied by a commentary that addresses the methodological quality of the synthesis and the
clinical applicability of its findings (Dicenso et al., 2009). The
current synopsis intended to evaluate oral hygiene measures
suitable for developing countries. For these specific patients
with limited financial resources no evidence could be retrieved. The papers selected summarized research performed
in Western societies.
Based on the observations by Slot et al. (2012) the efficacy
of plaque removal following a toothbrushing exercise is a
reduction from baseline in plaque scores of 42% on average, with a range of 3053% dependent on the plaque index
used. It appears that there is room for improvement in the
efficacy of manual toothbrushes in their capability for reducing plaque score during a brushing exercise. The duration
of toothbrushing is likely to be an important determinant
of plaque removal in the general population; therefore, it
should be stressed during toothbrushing instruction sessions.
As plaque removal is strongly correlated with brushing time
for any given toothbrush, brushing for 2 minutes or longer
should be encouraged, regardless of the brush used. Brushing time is also likely the most easily controlled parameter of
effective everyday brushing (Slot et al., 2012).
Table 3. GRADE evidence profile for the effect of various methods of mechanical plaque
removal suitable for developing countries based on the selected systematic reviews.
GRADE
Toothbrush
Floss
Wood stick
Estimated quality
Consistency
Directness
Precision
Publication bias
Body of evidence
Substantial
Fairly consistent
Indirect
Moderate
Possible
Moderate
Substantial to high
Fairly consistent
Indirect
Moderate
Possible
Strong
Substantial
Inconsistent
Indirect
Moderate
Possible
Moderate
Based on the individual papers in the review by

Berchier et al. (2008), a trend was observed that indicated a beneficial adjunctive effect of floss on plaque
levels. However, this could only be substantiated as
a non-significant trend in the meta-analyses. Routine
recommendation to use floss is thus not supported
by scientific evidence. The dental professional should
therefore determine, on an individual patient basis,
whether high-quality flossing is an achievable goal. One
may critically ask why the review by Berchier et al. (2008)
does not substantially show dental floss as a co-operative
adjunct to toothbrushing? The advocacy of floss as
an interdental cleaning device hinges, in large part, on
common sense. However, common sense arguments
are the lowest level of scientific evidence (Sackett et al.,
2000). A possible explanation is that the previous narrative reviews have not been conducted systematically.
The fact that dental floss has no additional effect on
toothbrushing is apparent from more than one review.
Sambunjak et al. (2011) in their Cochrane review concluded that overall there is weak, very unreliable evidence
that suggests that flossing plus toothbrushing may be
associated with a small reduction in plaque. Hujoel et al.
(2006) found that flossing was only effective in reducing
the risk of interproximal caries when applied professionally. High-quality professional flossing performed
in first-grade children on school days reduced the risk
of caries by 40%. In contrast, self-performed flossing
failed to show a beneficial effect. The lack of an effect
on caries is most likely the consequence of plaque not
being removed efficiently, as established by Berchier et
al. (2008). Flossing also does not effectively clean wide
interdental spaces, root surfaces or concavities. Such
periodontally involved dentitions are more common in
advancing age, when reduced dexterity and visual acuity
further impede flossing.
Wood sticks can be used effectively where sufficient
interdental space is available. Wood sticks fabricated
from soft wood are designed to allow the mechanical
removal of plaque from these interdental surfaces.
When used on healthy dentition, wood sticks depress
the gingivae by up to 2 mm and therefore clean part of
the subgingival area. Thus, wood sticks may specifically
remove subgingivally located interdental plaque that is
not visible and therefore not evaluated by the plaque
index. This physical action of wood sticks in the interdental area may produce a clear beneficial effect on interdental gingival inflammation (Finkelstein et al., 1990).
Evidence from controlled trials (Hoenderdos et al.,
2008), shows that hand-held triangular wood sticks do
provide an improvement in interdental gingival inflammation by reducing the bleeding tendency. However, no
concomitant effect on visible interdental plaque could
be established. As explanation for this inconsistency
one may consider a series of histological investigations
11
in patients with periodontitis (Walsh and Heckman,

1985) which has shown that the papillary area with the
greatest inflammation corresponds to the middle of
the interdental tissue. It is difficult to clinically assess
the mid-interdental area for plaque, as it is usually not
available for direct visualization.
Toothbrushes
In normal use it must be concluded that the benefits of
toothbrushing far outweigh the potential harm (Addy
and Hunter, 2003). Although toothbrushing is known
to cause gingival abrasions, data regarding the effect
of toothbrushing on the initiation and progression of
non-inflammatory gingival recession are inconclusive
(Rajapakse et al., 2007).
The exact moment at which a toothbrush should
be replaced is difficult to determine. The American
Dental Association advocates toothbrush replacement
every 3 to 4 months or sooner if the bristles become
frayed (American Dental Association, Statement on
Toothbrush Care: Cleaning, Storage and Replacement, available at http://www.ada.org/1887.aspx).
Common sense dictates that toothbrushes should be
replaced because the filaments and tufts do not retain
their shape forever. Completely worn brushes lose
the capacity to remove plaque effectively. This most
likely occurs because of a loss of shear force, as the
tips of the filaments can no longer disrupt the plaque
adequately. Rosema et al. (2013) evaluated 3-monthold used and new manual toothbrushes and did not
observe a clinically relevant difference in plaque score
reductions following a 2-minute brushing exercise.
However, the wear rate of the brushes seems to be
the determining factor in loss of efficacy, rather than
the age of the toothbrush.
When old brushes showed more wear new brushes
had greater benefits over old brushes. Therefore, it
seems appropriate to replace a brush when it shows
wear up to a point where the outer tufts are splayed
and have lost tuft definition, the inner tufts are splayed
and become less distinct and the definition between
inner and outer tufts is lost. Individuals show great
variation in the progression of toothbrush wear so the
age of a toothbrush should not be the guiding factor
for replacement (Rosema et al., 2013). The finding
that heavily worn 14-month-old toothbrushes with
severe bristle matting in the hands of 7- and 8-yearolds are not less effective than new toothbrushes
with regard to plaque-removal capacity has important
consequences for school brushing programs. If the old
toothbrush can be maintained far beyond the generally recommended three-month period, school-based
toothbrushing programs in underserved communities
have a better chance to be sustained (Van Palenstein
Helderman et al., 2006).
12
Toothpaste
The use of fluoride toothpaste is the primary intervention for the prevention of caries. A Cochrane
systematic review (Walsh et al., 2010) confirmed the
benefits of using fluoride toothpaste in preventing
caries in children and adolescents when compared
to placebo, but was significant only for fluoride
concentrations of 1000 ppm and above. The relative
caries preventive effects of fluoride toothpastes of
different concentrations increase with higher fluoride
concentration. The decision of what fluoride levels
to use for children under 6 years should be balanced
with the risk of fluorosis (Walsh et al., 2010). There is
no evidence to support the use of low fluoride toothpastes by preschoolers regarding caries and fluorosis
prevention. A more recent systematic review (Santos
et al., 2013) showed that low fluoride toothpastes significantly increased the risk of caries in primary teeth
[RR = 1.13 (1.07 - 1.20); 4,634 participants in three
studies] and did not significantly decrease the risk
of aesthetically objectionable fluorosis in the upper
anterior permanent teeth [RR = 0.32 (0.03 - 2.97);
1,968 participants in two studies].
The intra-oral retention or substantivity of active ingredients in toothpastes is important for their
effectiveness, and this is influenced by user-related
factors, among others. User-related factors include
biological aspects such as salivary flow and salivary
clearance, and behavioral aspects, such as frequency
and duration of brushing, amount of toothpaste used
and post-brushing rinsing behavior (Parnell and Mullane, 2013). An earlier study by Sjgren and Birkhed
(1994) also showed that eating or drinking immediately
after brushing reduced the salivary fluoride level by
12 to15 times.
There is a lack of high-quality evidence to support definitive guidance in this area. However, the
currently available international guidelines provide
consistent recommendations despite the limited
evidence (Pitts et al., 2012). A modified toothpaste
technique has been suggested as a way to increase
intra-oral fluoride and to prolong fluoride retention in
order to maximize the anti-caries effect of toothpaste
(Sjgren et al., 1995). The technique involves four
steps as follows: 1) apply 1 g (1 cm) of toothpaste
to a wet toothbrush, spread evenly on the teeth and
brush for approximately 2 minutes using the Bass
technique, 2) spit out no more than necessary during
brushing, 3) take a sip of water (approximately 10
ml) and with the remaining toothpaste foam in the
mouth, use the toothpaste slurry as a mouthrinse and
filter it between the teeth by active cheek movements
for 1 minute before carefully spitting out, and 4) no
further rinsing afterwards, and no eating or drinking
for 2 hours after brushing.
Miswak
Methods for oral hygiene vary from country to country
and from culture to culture (Khan et al., 2009). Today,
chewing sticks are being widely used in Asia, Africa,
South America, and throughout the Islamic countries.
They are known by different names in different cultures, such as miswak, siwak or arak. They were initially
used by Babylonians around 7000 years ago, followed
by the Greek and Roman empires. There are several
shrubs and local trees being used as chewing sticks in
different parts of the world, which are selected due to
good taste and a texture like long bristles. The stick is
chewed or tapered at one end until it becomes frayed
into a brush. When the brushy edge is shredded after
being frequently used, the stick becomes ineffective
and it is then cut and further chewed to form a fresh
edge. In this way, it can be used for a few more weeks
(Sukkarwalla et al., 2013). Miswak has been documented
as a potent antibacterial aid and its use is encouraged in
different countries because of its good taste, texture,
availability, cost and beneficial effect on teeth and
supporting tissues.
No systematic review could be retrieved with respect to miswak but a single, blind, randomized crossover study compared it against regular toothbrushing,
Image analysis of the plaque distribution showed a
significant difference in reduction of plaque between
the miswak and toothbrush periods (p < 0.05) and it
was concluded that the miswak is more effective than
toothbrushing for reducing plaque and gingivitis.
Miswak also appeared to be more effective than toothbrushing for removing plaque from the embrasures,
thus enhancing interproximal health (Al Otaibi et al.,
2003). The World Health Organization has, based on
consensus, also recommended and encouraged the
use of these chewing sticks as an affordable and effective alternative tool for oral hygiene (Sukkarwalla
et al., 2013).
Interdental cleaning
Alternatives for commercially available products are
scarce. During the International Symposium on Dental
Hygiene in 2013, a presentation was given regarding
the evaluation of substitutes for dental floss for lower
socioeconomic groups. The fibers of fruit or vegetable
bags were considered as a potential alternative to dental
floss. Based on the results of a randomized controlled
clinical trial there appears to be no difference on the
plaque index scores when the teeth are cleaned with
conventional floss or with the fibers of fruit or vegetable bags (Swart, International Journal of Dental Hygiene
abstracts, p 167).
Behavior
Good oral health is dependent on the establishment
of the key behaviors of toothbrushing with fluoride
toothpaste. Primary schools provide a potential setting
in which these behavioral interventions can support
children to develop independent and habitual healthy
behaviors. Currently, there is insufficient evidence for
the efficacy of primary school-based behavioral interventions for reducing caries (Cooper et al., 2013). For
example, 8- to 11-year-old school children who participated in a school-based toothbrushing program over 2
years did not reveal a statistically significant effect of
this with respect to gingivitis and plaque scores (Rosema
et al., 2012). There is a need for further high quality research to utilize theory in the design and evaluation of
interventions for changing oral health-related behaviors
in children and their parents (Cooper et al., 2013). Van
der Weijden and Hioe (2005) systematically evaluated the
quality of self-performed mechanical plaque removal in
adults with gingivitis. Based on studies 6 months of
duration, it appears that a single oral hygiene instruction, describing the use of a mechanical toothbrush, in
addition to a single professional oral prophylaxis had a
significant, albeit small, positive effect on the reduction
of gingivitis.
In developing countries most patients receive in their
lifetime only a single scaling, or if repeated scaling occurs
they have large time intervals, at best accompanied with
a single oral hygiene instruction. Because of a lack of
dental manpower and resources, Lembariti et al. (1998)
questioned whether an occasional scaling practice
accompanied with limited professional attention for
plaque control is effective in improving the periodontal
condition. Scaling resulted in an approximately 20%
reduction of the gingival bleeding score that remained
during the 22-month follow-up period. Oral hygiene
instruction had no significant effect on the calculus and
bleeding scores. Formation of calculus still continued.
The authors concluded that the effect of scaling alone
on the gingival condition was small and the effect of a
single oral hygiene instruction was negligible. Therefore,
the practice of occasional scaling without repeated oral
hygiene instruction, which is commonly employed in
developing countries, should be considered as clinically
irrelevant and of little use in improving the standard of
periodontal health (Lembariti et al., 1998).
Integrated approach
The high prevalence of poverty-associated diseases such
as diarrhea, respiratory tract infection, parasitic infections and dental caries among children in the developing
world calls for a return to primary health care principles with a focus on prevention. The Fit for School
program in the Philippines is based on international
recommendations and offers a feasible, low-cost and
13
realistic strategy using the principles of health promotion outlined in the Ottawa Charter. The cornerstone
of the program is the use of school structures for the
implementation of preventive health strategies. Fit for
School consists of simple, evidence-based interventions
such as hand washing with soap, toothbrushing with
fluoride toothpaste and other high-impact interventions
such as bi-annual de-worming as a routine school activity
for all children visiting public elementary schools. The
program has been successfully rolled-out in the Philippines, covering 630,000 children in 22 provinces, and it
is planned to reach six million children in the next three
years (Monse et al., 2010). Child health in many low- and
middle-income countries lags behind international goals
and affects childrens education, well-being, and general
development. Large-scale school health programs can
be effective in reducing preventable diseases through
cost-effective interventions. The paper outlining the
baseline and 1-year results of a longitudinal health study
assessing the impact of the Fit for School program
found a reduction in the prevalence of moderate to
heavy soil-transmitted helminth infections, a rise in
mean body mass index, and a trend towards reduction
in dental caries and infections. The study design proved
functional in actual field conditions (Monse et al., 2013)
Limitations of this study
The available evidence as collected in the systematic
review by Hoenerdos et al. (2008) with regard to wood
sticks only refers to triangular shaped wood sticks. No
data were gathered with respect to round or square
toothpicks. None of the included systematic reviews
included original studies that were carried out in developing countries. In particular, financial limitations
should be considered in the evaluation of potential oral
hygiene products.
Conclusion
No systematic reviews could be retrieved regarding
the efficacy of mechanical plaque control as a measure
of self-care in developing countries. Based on data of
mechanical plaque control established in Western societies an affordable method should be to brush twice
daily by means of a manual toothbrush and to use a
fluoride-containing toothpaste. For interdental cleaning, wood sticks seem the most appropriate regarding
costs effectiveness.
14
Acknowledgements
The authors acknowledge the International Academy
of Periodontology Conclave 2014 Working Group A
and Dr. Thomas Van Dyke and Dr. Sebastian Ciancio
for their time and effort in improving this manuscript.
Lastly, we are grateful for the efforts of Dr. Ajay Kakar
in organizing the IAP conclave 2014 in Bangkok.
As this is a synopsis of earlier work, parts of this paper
have been published before and therefore some duplication are inevitable. This paper contains summaries of:
Van Der Weijden F and Slot DE. Oral hygiene in
the prevention of periodontal diseases: The Evidence.
Periodontology 2000 2011; 55:104-123.
Interdental Oral Hygiene: The Evidence. GA Van
der Weijden, DE Slot, Chapter 3 in: Proceedings of
the 9th Asian Pacific Society of Periodontology; Hong
Kong, 2011 - Multi-Disciplinary Management of Periodontal
Disease, PM Bartold, and L Jin, eds. published by The
Asian Pacific Society of Periodontology.
Mechanical Supragingival Plaque Control, F Van der
Weijden, DE Slot, JJ Echeverra, and J Lindhe, Chapter
35, in Clinical Periodontology and Implant Dentistry 6th edition,
J Lindhe, NP Lang and T Karring, eds. John Wiley and
Sons Ltd, to be published in 2015.
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cleaning by dental floss and the toothpick. Dental
Hygiene (Chic) 1985; 59:464-467.
Walsh T, Worthington HV, Glenny AM, Appelbe P,
Marinho VC and Shi X. Fluoride toothpastes of
different concentrations for preventing dental caries in children and adolescents. Cochrane Database of
Systematic Reviews 2010; 1:CD007868.
Zorzela L, Golder S, Liu Y, et al. Quality of reporting
in systematic reviews of adverse events: systematic
review. British Medical Journal 2014; 348:f7668.
Group A
Reactor Paper
Plaque control: Home remedies practiced in
Thomas E. Van Dyke, DDS, PhD
The Forsyth Institute, Boston, MA, USA
Introduction
Medicinal or herbal anti-plaque preparations
The scholarly review by Slot and Van der Weijden (Journal

of the International Academy of Periodontology 2015; 17/1
Supplement) of mechanical oral hygiene practices is
well written and well organized. This is a difficult topic
to address because of the lack of systematic reviews that
have been performed in developing countries. Nonetheless, there are two major areas of interest that should be
addressed at the conclave:
In consideration of the fact that the goal of removal
of biofilm is the prevention of disease, it is also recommended that both anti-plaque and anti-gingivitis effects
be considered as endpoints in the review of the literature.
A number of herbal or traditional medicine preparations are marketed as anti-plaque or anti-gingivitis

agents throughout the world. There are no systematic
reviews of studies relating to any of these compounds.
Nonetheless, these products and the compounds that
they contain represent an important and growing segment of the products available to patients. A literature
search is currently being performed to identify clinical
reports pertaining to the safety and efficacy of an herbal
or traditional medicine preparation currently available
to the public.
While these reports are scarce and there is no systematic review, it is recommended that the reports be
reviewed by the group and recommendations for use be
made based on the current state of the art.
Chemical plaque control

There is a single published systematic review of antiplaque and anti-gingivitis agents that are incorporated
into dentifrices and mouthrinses (Gunsolley, 2006). As
this was performed in 2006, an update of the current
literature should be undertaken at the conclave. In addition, a review of the current literature for papers not
included in a systematic review should be undertaken
to capture data related to new chemical agents that have
been marketed since 2006. The chemical agents that
should be considered include, but are not limited to:

Triclosan
Gantrez
Stannous fluoride
Other fluoride preparations
Chlorhexidine
Cetylpyridinium chloride
Essential oils

11-13 April, 2014
Correspondence to: TE Van Dyke, The Forsyth Institute, 245 First
Street, Cambridge, MA, USA 02142. E-Mail: tvandyke@forsyth.org
References
Gunsolley JC. A meta-analysis of six-month studies
of antiplaque and antigingivitis agents. Journal of
the American Dental Association 2006; 137:1649-1657
Slot D and Van der Weijden FA. Plaque control. Home
remedies, practiced in developing countries -a synopsis of synthesis. Journal of the International Academy
of Periodontology 2015; 17/1 (Supplement): 4-15
Group A
Consensus Paper
Plaque Control - Home remedies practiced in
Moderator: Ciancio, Sebastian, University of Buffalo, USA
Initiator: Slot, Dagmar Else, Academic Centre for Dentistry Amsterdam, Netherlands
Reactor: Van Dyke, Thomas, Forsyth Institute, USA
Working Group A:
Al Bayaty, Foud, Universiti Teknologi MARA, Malaysia
Aswapati, Nawarat Wara, Khon Kaen University, Thailand
Joshi, Vinayak, MMNGH Institute of Dental Sciences, India
Kendall, Kaye, Private Practice, Australia
Leung, Keung, University of Hong Kong, China
Patel, Nisha, Rishi Raj Dental College, India (Transcriber)
Pradhan, Shaili, National Academy of Medical Science, Nepal
Senevirante, Cyanthi, Colgate, Singapore
Takashiba, Shogo, Okayama University Graduate School of
Medicine, Japan
Vidhale, Priya, Private Practice, India (Transcriber)
Introduction
Maintenance of effective plaque control is the cornerstone of any attempt to prevent and control periodontal
disease. Complete natural cleaning of the dentition is
virtually non-existent. To be controlled, plaque must be
removed frequently by active self-care methods. Hence,
the dental community continues to encourage proper
oral hygiene and more effective use of mechanical cleaning. This group addressed the aspect of oral hygiene
practices carried out at home by patients as well as the
general population and a primary objective was to find
out the scientific rationale and efficacy of the vast variety of alternatives available for home remedies for
plaque control. Even though in the past few years more
and more systematic reviews on this subject have been
published, there is a definite lack of such studies and
subsequent publications coming from the developing
countries.

11-13 April, 2014
Correspondence to: Ciancio, Sebastian, University of Buffalo,
USA, E-Mail: ciancio@buffalo.edu
There were three key questions that were ultimately

addressed by the Working Group.
1. What is the current status of mechanical methods
for the removal of bacterial biofilms in developing
countries?
2. What is the current status of anti-plaque and antimicrobial mouthwashes and toothpastes?
3. What is the current status of mouthwashes and
dentifrices containing herbal ingredients
The background for discussion was presented in the
Initiators document prepared by Slot and Van der Weijden
(Journal of the International Academy of Periodontology 2015; 17/1
Supplement). The fundamental question raised in the Initiators document, based on the data available in the systematic
reviews was What is the effect on plaque scores and oral
health of self-care manual plaque control measures appropriate for developing countries? As no systematic reviews for
the same could be retrieved, a conclusion was drawn based
on data on mechanical plaque control established in Western
societies. The conclusion of the Initiators document, keeping in mind the lower economic status of the population,
was that teeth should be brushed twice daily by means of a
manual toothbrush in conjunction with a fluoride toothpaste.
For interdental cleaning wood sticks seem the most appropriate regarding cost and effectiveness in this population.
18
Methods used during the deliberation

Objective 1- The current status of mechanical methods for

the removal of bacterial biofilms in developing countries. A
synopsis of synthesis approach was used to quantify
and assess all possible available published articles
from the developing countries.
Objective 2- The current status of anti-plaque and antimicrobial mouthwashes and toothpastes. A synopsis of
synthesis.
Objective 3- The current status of mouthwashes and
toothpastes containing herbal ingredients. The Studies
approach was the only possible approach and hence a
narrative review of available literature was carried out.
Objective 1. What is the current status of

mechanical methods for the removal of bacterial
biofilms in developing countries?
The objective was to carry out a synopsis of synthesis
for arriving at the findings for this question. This synopsis was to be done from the literature available from the
developing countries. However, a thorough search of
the literature carried out by the Working Group could
not find a single systematic review on mechanical plaque
control from developing countries.
After extensive deliberation the group decided to use
publications from Western countries and to extrapolate
these findings to the developing nations. A total of four
systematic reviews were identified as being eligible for this
synopsis of synthesis. Of the four, one was on manual
toothbrushes, one was on the usage of wood sticks and
two were on dental floss.
These systematic reviews were evaluated for multiple
parameters for each of the three groups. The aspects
examined were the estimated quality, the consistency of
the articles, the directness of the articles, the precision
of reporting, publication bias, if any, and the entire body
of evidence provided by the articles.
A summary of the findings is presented in Table 1.
The studies selected for inclusion in the review were of a
substantial quality, and for the review on floss the quality
of papers selected was very high (a more than average
standard and the data could be completely relied upon).
The data on the toothbrush and floss groups were very

consistent and comparable, but the papers included in the
wood sticks review were of poorer quality. This point was
taken into very strong consideration when arriving at the
conclusions of the efficacy and merits/demerits of wood
sticks in plaque control.
Because brushes, floss and wood sticks are all commercial
products it was essential to confirm if there was any commercial bias involved in the process. It was not possible to
ascertain from any of the papers if there was a bias involved
or not. Hence, it was concluded that the possibility of a
commercial basis was possible in all of the three groups.
After a careful scrutiny of the papers included in the
systematic review the Working Group concluded that the
body of evidence available for the systematic review on
floss was extremely strong. On the other hand the body of
evidence available for wood sticks and tooth brushes could
only be considered to be moderate, with the toothbrush
reviews being marginally stronger than the wood stick review.
Objective 2. What is the current status of antiplaque and antimicrobial mouthwashes and
toothpastes in developing countries?
This question was also approached using the synopsis
of synthesis model. The objective was again to obtain
all the data from publications arising out of developing
countries. The task was not to limit the papers to any
specific countries and the major objective was to analyze data that provided information on plaque/biofilm
inhibition as well as improvement of the gingival health.
All papers based on products that had herbal and/or
traditional chemicals were excluded in the literature
search relevant to this question.
Twelve systematic reviews were identified and
found to be eligible for the synopsis of synthesis for
this question. These reviews were then subjected to a
detailed analysis and discussion by the Working Group.
A paradigm accepted while doing the analysis was that
mouthwashes and dentrifices serve as carriers for chemical agents that would be plaque-inhibiting and could
potentially control gingival inflammation and thereby
improve and enhance gingival health.
Table 1. Summary of findings from systematic reviews
Estimated quality
Consistency
Directness
Precision
Publication bias
Body of evidence
Toothbrush
Floss
Wood stick
Substantial
Fairly consistent
Indirect
Moderate
Possible
Moderate
Substantial to high
Fairy consistent
Indirect
Moderate
Possible
Strong
Substantial
Inconsistent
Indirect
Moderate
Possible
Moderate
Group A Consensus: Developing country home remedies for plaque control
The different chemical agents that were researched

and analysed as potentially effective agents were as
follows:
Mouthwash ingredients
Chlorhexidine digluconate (CHX)
Cetylperidium chloride (CPC)
Essential oils (EO)
Stannous fluoride (SnF2)
Hydrogen peroxide (H2O2)
Hexitidine
Delmopinol
Dentrifice Ingredients
Chlorhexidine digluconate
Stannous fluoride
Triclosan
There was a total of 9 systematic reviews that were
available for mouthwashes and four systematic reviews
available for the dentrifice group. A further four reviews
were identified and retrieved that could be subjected to a
head-to-head comparison on combined use of mouthwash and dentrifice or as a comparison to a vehicle.
It was concluded that there is a benefit of adding
chemical agents to a mouthwash or a dentifrice for
plaque/biofilm control and thereby improving the
health of the gingiva. The magnitude of the benefit
was dependent on the specific active chemical ingredient available.
For dentifrices, chlorhexidine and stannous fluoride
as well as triclosan all have a positive effect towards
improved plaque/biofilm control. Of these three the
triclosan- and stannous fluoride-based toothpastes seem
to have the most potential for reducing plaque scores
and improving gingival health.
A summary of the findings is presented in Table 2.

The studies selected for inclusion in the review were of a
mixed quality. For the dentrifice and mouthwash reviews
the quality of papers selected was generally very good. For
mouthwashes all of the additives (CHX, CPC, EO, H2O2,
hexetidine, SnF2, delmopinol) demonstrated efficacy towards improved plaque control. The most effective products
regarding reducing plaque scores and improving gingival
health contained CHX, EO or CPC as an active ingredient.
Objective 3. Herbals herbal dentrifices and
mouthwashes
The literature supporting the use of herbal-based antiplaque and anti-gingivitis preparations is generally weak.
No systematic reviews on this topic were identified. Only
five products were directly assessed: green tea, neem, aloe
vera, miswack and Paradontax, because of their presence in the marketplace and available literature. Numerous
other products, including cranberry extract preparations,
triphala, juniper, salvia, chitosan and various other herbal
combinations were not considered because of the lack of
sufficient studies.
From the general scientific publications in this field,
most of the products studied, with the notable exception
of aloe vera, have some evidence of efficacy. However,
most reports suffered from poor experimental design
and lack of relevant controls and comparisons. It is
important to note that head-to-head comparisons with
existing products with known efficacy is not an adequate
experimental design in the absence of a negative control.
Most of the studies also suffered from poor statistical analyses. For example, good statistical theory dictates
that trials be designed to test the null hypothesis, i.e.,
equivalence of the test and control. Failure to reject the
null hypothesis does NOT mean that the tested products
are equivalent. Studies to test equivalence requires substantially more subjects than is practical in a clinical trial.
Table 2: Summary of findings of systematic reviews on dentrifices

and mouthwashes
Estimated quality
Consistency
Directness
Precision
Publication Bias
Body of Evidence
19
Dentrifices
Mouthrinses
Substantial
Fairly consistent
Indirect
Moderate
Possible
Moderate
Substantial
Fairy consistent
Indirect
Moderate
Possible
Moderate
20
Conclusions
Overall, for all three objectives more studies are required
with better study designs. Nonetheless, the final conclusions were derived as the major outcomes from the
deliberations of Working Group A:
Objective 1
Based upon the available evidence, mechanical control of plaque (biofilm) is best achieved with (twice)
daily toothbrushing using a manual toothbrush with
a fluoride-based dentifrice.
The body of evidence for this advice seems moderate.
The World Health Organization (WHO) recommendation is based on consensus that chewing
sticks such as miswaks are an affordable alternative.
For interdental cleaning the wood sticks seem the
most appropriate regarding cost effectiveness.
Dental floss is a less effective tool that requires instructed skills for the user in order to be effective.
There are weak scientific data to advocate flossing.
It has to be a clinicians decision based on patient
needs and dexterity
The body of evidence is moderate to strong
Objective 2
While mechanical plaque removal should be considered the first priority, there is moderate evidence
that dentifrices and mouthwashes are efficacious for
prevention/reduction of plaque-related gingivitis. In
addition, chemical agents added to dentifrices (triclosan
or SnF2) and mouthwashes (CHX, EO, CPC) can be of
value and are recommended. It is recommended that
mouthwashes and dentrifices be used as an adjunct to
mechanical plaque removal.
Objective 3
Recommendations regarding the use of herbal medicaments in plaque and gingivitis are currently not possible
due to a lack of sufficient evidence supporting their
use. Further studies are required to determine the antiplaque and anti-gingivitis properties of herbal additives
to dentifrices and mouth washes.
Reference
Slot DE and Van der Weijden FA. Plaque control. Home
remedies practiced in developing countries - a synopsis of synthesis. Journal of the International Academy of
Periodontology 2015; 17/1 (Supplement): 4-15
Group B
Initiator Paper
Non-surgical periodontal therapy: mechanical
debridement, antimicrobial agents and other
modalities
Magda Feres1, Marcelo Faveri1, Luciene Cristina Figueiredo1, Ricardo
Teles2, Thomas Flemmig3,4 , Ray Williams5, Niklaus P. Lang4,6,7
Department of Periodontology, Dental Research Division, Guarulhos University, Guarulhos, SP, Brazil; 2University of North Carolina
School of Dentistry, Chapel Hill, NC, USA; 3Department of Periodontics, University of Washington, Seattle, WA, USA; 4The University of Hong Kong, Prince Philip Dental Hospital, Hong Kong SAR PR
China; 5State University of New York, Stony Brook, NY, USA, 6University of Zurich, Center for Dental Medicine, Zurich, Switzerland,
7
University of Berne, School of Dental Medicine, Berne, Switzerland
1
Introduction
The main goals of periodontal therapy are to achieve
reductions in probing depth (PD), bleeding on probing
and suppuration, to maintain or gain clinical attachment
(CA) and to prevent future attachment loss (i.e., maintenance of the long-term stability of the periodontal
tissues). These clinical improvements are accompanied
by an ecological shift in the subgingival microbial composition, from a microbial profile related to disease to a
profile compatible with health (Socransky and Haffajee,
2002; Teles et al., 2006; Feres, 2008). To achieve this
microbiological goal, anti-infective treatments should
reach not only deep periodontal pockets, but also shallow sites and other oral surfaces, which may harbor
periodontal pathogens (Mager et al., 2003; Faveri et al.,
2006a). However, to date periodontal treatment remains
largely focused on deep pockets (Heitz-Mayfield and
Lang, 2013). There is overall consensus that scaling
and root planing (SRP), the gold-standard periodontal
therapy, should be restricted to intermediate and deep
pockets, and that instrumentation of shallow sites
should be avoided in order to prevent trauma to both

11-13 April, 2014
Correspondence to: M Feres, Department of Periodontology,
Dental Research Division, Guarulhos University, Guarulhos, SP
Brazil. Email: mferes@ung.br
hard and soft tissues and possible consequent attachment loss (Ramfjord et al., 1987; Heitz-Mayfield et al.,
2002). This mechanical therapy targets only the tooth
surfaces and does not affect other areas of the mouth,
such as the tongue and oral mucosae. In addition, SRP
might not reach microbial reservoirs at the base of deep
pockets, tooth furcations and within epithelial cells and
the connective tissue. Consequently, SRP may fall short
of inducing the changes in the subgingival microbial
composition necessary to achieve and maintain the
desired clinical improvements in all subjects, especially
in cases of advanced disease where deep periodontal
pockets are present (Loesche and Grossman, 2001;
Sampaio et al., 2011). Therefore, other forms of therapy,
such as different scaling modalities or the adjunctive
use of local and systemic antimicrobials, lasers and
photodynamic therapies have been proposed in order
to potentiate the effects of non-surgical mechanical
therapy. In all instances, however, SRP is accepted to be
the basis for all periodontal therapy and the additional
therapies proposed and scrutinized in this paper are
always considered adjunctive and supplemental.
Lasers and photodynamic therapies (PDT)
Laser and photodynamic therapies emerged in the
1990s as promising treatments for periodontitis. The
main appeal of the laser therapy was its selective calculus ablation, bactericidal effect and its potential to
control bleeding (Ando et al., 1996; Folwaczny et al.,
2002; Aoki et al., 2004). Several types of lasers have
22
been proposed, either alone or adjunctive to SRP in

the treatment of periodontitis, such as the erbiumdoped:yttrium-aluminium-garnet (Er:YAG), diode laser
(DL) and neodymium-doped:yttrium-aluminum-garnet
(Nd:YAG). Three recent systematic reviews have evaluated the overall efficacy of laser therapy in the treatment
of chronic periodontitis (Sgolastra et al., 2012c; Sgolastra et al., 2013b; Sgolastra et al., 2014). Sgolastra et al.
(2012c; 2013b) concluded that there were no statistically
significant beneficial effects in the use of Er:YAG-only
or DL as adjuncts to SRP, compared to results obtained
with SRP only. On the other hand, a subsequent review
(Sgolastra et al., 2014) suggested that the adjunctive use of
Nd:YAG could potentially provide additional benefits to
conventional nonsurgical periodontal therapy, especially
in mean PD reduction (0.55 mm, 95 % CI range: 0.34 to
0.76, p < 0.00001). However, only three studies, with 6
to 20 months of follow-up, were included in this metaanalysis (Qadri et al., 2010; Eltas and Orbak, 2012a; Eltas
and Orgak, 2012b).
Photodynamic therapy (PDT) has been proposed as
an adjunct to SRP in the treatment of periodontitis. The
antimicrobial property of PDT involves a photoactivated
dye (photosensitizer) that is absorbed preferentially by
bacterial cells. When the photosensitizer is exposed to
the light of a low power laser in the presence of oxygen
it generates singlet oxygen and free radicals, which are
extremely toxic to some microorganisms (Konopka and
Goslinski, 2007; Maisch, 2007). Some of the clinical
studies that have investigated the effect of adjunctive
PDT associated with SRP in the treatment of chronic
periodontitis have shown promising results (Andersen et
al., 2007; Braun et al., 2008; Lulic et al., 2009; Giannelli et
al., 2012), while other authors failed to show an additional
benefit (Christodoulides et al., 2008; Chondros et al., 2009;
Polansky et al., 2009; Ruhling et al., 2010; Theodoro et al.,
2012). A recent systematic review indicated that SRP in
combination with PDT provided better PD reduction
(0.19 mm, 95% CI range: 0.07 to 0.31, p = 0.002) and
CAL gain (0.37 mm, 95% CI range: 0.26 to 0.47, p <
0.0001) in comparison with SRP alone at 3 months after
treatment. However, this benefit was no longer observed
at 6 months (Sgolastra et al., 2013a).
Applying repeated (five times in two weeks) PDT
in maintenance patients with residual PD 5 mm but
previously treated for periodontitis, and comparing clinical outcomes to maintenance debridement in combination with a non-activated laser control in a randomized
controlled trial (RCT; Lulic et al., 2009), clearly yielded
improved clinical outcomes in residual pockets, while
regular maintenance debridement failed to demonstrate
improvements in both PD and CAL in the residual
pockets. Hence, further RCTs are indicated to elucidate
positive outcomes of PDT in combination with SRP in
maintenance patients.
Four studies to date have assessed the microbiological effects of PDT (Sgolastra et al., 2013a), and only a
modest benefit was observed in the composition of the
subgingvial microbiota. Two studies showed statistically significantly greater reductions in the prevalence
of Treponema denticola, Eikenella corrodens, Capnocytophaga
spp. (Chondros et al., 2009) and Porphyromonas gingivalis
(Polansky et al., 2009) in subjects treated with SRP plus
PDT than in those treated with SRP alone. However, no
studies to date have thoroughly examined the effects of
the PDT in changing the subgingival microbial profile.
In summary, evidence supporting the added benefits
of lasers and PDT in periodontal therapy is still scarce.
The most promising results were obtained with the adjunctive use of Nd:YAG to SRP. Therefore, additional
RCTs examining the long-term microbiological and
clinical effects of Nd:YAG, other laser therapies and
PDT are needed before these treatments are incorporated into routine clinical practice.
Full mouth scaling and root planing (FMSRP)
and full mouth disinfection (FMD)
In 1995, researchers from the University of Leuven suggested that quadrant-SRP would allow reinfection of already
treated sites by a translocation of periodontal pathogens
from untreated periodontal sites or other oral niches (e.g.,
tongue, mucosa and saliva) to recently instrumented pockets.
Based on this hypothesis, the authors advocated a treatment
protocol that consisted of SRP of all pockets within 24 hours
combined with various forms of applications of chlorhexidine (CHX), such as subgingival irrigation, mouthrinsing
and tonsil spraying (Quirynen et al., 1995). This protocol was
named full mouth disinfection (FMD). As a consequence
of studies demonstrating that CHX did not necessarily
contribute to improved clinical outcomes after FMD (Quirynen et al., 2000), clinicians proposed to treat periodontitis
by means of full-mouth SRP in 24 hours, but without the
adjunctive use of CHX, a protocol that became known as
full-mouth scaling and root planing (FMSRP) (Apatzidou
and Kinane, 2004). Three systematic reviews comparing the
clinical (Eberhard et al., 2008; Lang et al., 2008; Farman and
Joshi, 2008) and microbiological (Lang et al., 2008) effects
of FMD and/or FMSRP and conventional quadrant SRP
for the treatment of chronic periodontitis were published
in 2008. The reviews by Eberhard et al. (2008) and Farman
and Joshi (2008) failed to show statistically significant differences between the FMSRP and conventional SRP. A discrete
benefit for the FMD protocol in reducing PD (0.53 mm,
95% CI range: 0.28 to 0.77, p = 0.0001) and gaining CAL
(0.33 mm, 95% CI range: 0.04 to 0.63, p = 0.03) in sites with
PD 5 mm was reported by Eberhard et al. (2008). Lang
et al. (2008) showed that FMD and FMSRP led to a slightly
greater PD reduction in deep sites with PD 7 mm (0.50
mm, 95% CI range: -0.81 to 0.19, p = 0.001 and 0.43 mm,
95% CI range: -0.66 to 0.19, p < 0.0001, respectively) than
Group B Initiator: Non-surgical periodontal therapy
quadrant-wise SRP. No additional reduction in levels and

prevalence of specific periodontal pathogens was identified
for any of the three treatment modalities (Lang et al., 2008).
Taken together, these systematic reviews have suggested
that FMSRP or FMD protocols do not provide clinically
relevant advantages over conventional quadrant-wise scaling.
Nonetheless, the notion that SRP completed in 24 hours
yields clinical improvements similar to those obtained with
quadrant-wise SRP is relevant information and represents
an important contribution to the periodontal field. Today,
it is largely recognized that the FMD and FMSRP protocols are effective alternatives to the quadrant SRP and the
choice between treatment modalities is generally based on
patient preferences, professional skills, logistic settings and
cost-effectiveness (Eberhard et al., 2008; Lang et al., 2008;
Farman and Joshi, 2008).
Antiseptics: pocket irrigation and rinsing
Antiseptics have been used as adjuncts to non-surgical
periodontal treatment for pocket irrigation (Rosling et al.,
1983; Rosling et al., 1986; Rams and Slots, 1996; Guarnelli
et al., 2008; Feng et al., 2011), as part of the FMD protocol
(Quirynen et al., 1995) or to control supragingival plaque
formation during the active phase of periodontal therapy
and the healing phase (Faveri et al., 2006b; Feres et al., 2009).
The agents that have been most commonly used for
pocket irrigation are Povidine-iodine (PVP-I), essential oils
and chlorhexidine digluconate CHX (Rams and Slots, 1996).
Overall, studies evaluating the effects of these antimicrobials in periodontal treatment have shown only short-term
discrete clinical and microbiological benefits (Rosling et al.,
1983; Rosling et al., 1986; Guarnelli et al., 2008; Feng et al.,
2011), but these benefits do not seem to be maintained up
to 6 months (Leonhardt et al., 2007) or one year post-therapy
(Krck et al., 2012). Nonetheless, some studies have also suggested benefits in the use of CHX rinsing as an adjunctive to
SRP and during the healing phase of mechanical treatment
(Quirynen et al., 2006; Faveri et al., 2006b; Feres et al., 2009).
Feres et al. (2009) compared the clinical and microbiological
effects of SRP alone or combined with professional plaque
control or CHX rinsing twice a day for two months in the
treatment of patients with chronic periodontitis. The two test
treatments were more effective in improving PD and CAL
than SRP alone, and the group rinsing with CHX exhibited
the greatest reduction in PD in initially intermediate sites 6
months post-therapy. In addition, the most beneficial microbiological changes were observed in CHX-treated subjects,
who showed a significant reduction in the proportions of
red (P. gingivalis, T. denticola and Tannerella forsythia) and orange
(mainly Fusobaterium spp.) microbial complexes, as well as an
increase in the proportions of the host-compatible bacterial
species. The authors concluded that strict plaque control
performed during and after SRP, particularly by means of
CHX rinsing, improved periodontal treatment outcomes.
Subsequently, CHX rinsing was also shown to improve
23
the clinical (Feres et al., 2012) and microbiological benefits

of systemic antibiotics, especially in initially shallow sites
(Soares et al., 2014).
Local antimicrobial delivery
Local application of antiseptics and antibiotics has been
advocated for the treatment of localized periodontitis lesions,
either as an adjunct to SRP in the active phase of treatment
or to treat re-infected periodontal lesions in patients under
maintenance therapy (Bonito et al., 2005). Local release of
antimicrobial agents or antibiotics is normally performed
by means of fibers, gels, chips or microspheres (Rams and
Slots, 1996). Some examples are doxycycline hyclate gel
(ATRIDOX), minocycline hydrochloride microspheres
(ARESTIN), tetracycline hydrochloride fibers (PERIODONTAL PLUS AB, ACTISITE), metronidazole (MTZ)
gel (ELYZOL) and chlorhexidine gluconate chip (PERIOCHIP). The greatest advantage of this type of local therapy
is in avoiding the side effects of drugs used systemically and
reducing the chances of developing bacterial tolerance to
medications (Rams and Slots, 1996).
Previous systematic reviews have demonstrated a significant beneficial effect in the adjunctive use of local antimicrobials when compared with SRP alone; however, the clinical
magnitude of this effect seems to be rather limited (Hanes and
Purvis, 2003; Bonito et al., 2005; Matesanz-Perez et al., 2013).
A recent systematic review and meta-analysis (Matesanz-Perez
et al., 2013) indicated a statistically significant beneficial effect
of the subgingival application of different antimicrobials
with a weighted mean difference (WMD) of 0.40 mm in PD
reduction and 0.31 mm in CAL gain. The main benefits were
observed with the use of tetracycline fibers, sustained released
doxycycline and minocycline microspheres. The adjunctive
use of tetracycline fibers demonstrated a statistically significant benefit in PD reduction, with a WMD between 0.5 mm
and 0.7 mm. Conversely, the benefit in CAL gain was smaller
and did not provide a significant advantage over SRP alone.
The local application of CHX and MTZ showed a minimal
effect when compared to a placebo (WMD between 0.1 mm
and 0.4 mm). Although this systematic review described some
additional beneficial effect for most of the local antimicrobials
evaluated, the clinical relevance of the data reported needs to
be interpreted with caution. Most of these studies reported
data for deep periodontal pockets, as these are the main targets
for locally delivered antiseptics and antibiotics. This may skew
the overall benefits of these adjunctive treatments, because
these are the sites that respond less favorably to SRP and
therefore any adjunctive treatment would lead to additional
clinical benefits over those obtained with scaling alone. In
addition, only two studies (Eickholz et al., 2002; Sakellari et al.,
2010), out of the 52 included in this review showed low risk
of bias. Thus, it seems necessary to conduct further clinical
studies with strict methodological criteria and longer followup periods in order to justify the regular use of locally delivered
antimicrobials during periodontal treatment.
24
Systemic antibiotics
The first clinical studies on the effects of systemic antibiotics on periodontal treatment were conducted at the end of
the 1970s and during the 1980s, with the use of tetracycline
in the treatment of localized aggressive periodontitis (Slots
et al., 1979; Lindhe, 1981; Lindhe and Liljenberg, 1984). The
treatment seemed promising, and hence, during the 1980s
and 1990s almost all available antibiotics were tested for use
in the treatment of chronic or aggressive periodontitis. At
the beginning of the 2000s, the two first systematic reviews
on the use of systemic antibiotics to treat periodontitis were
published (Herrera et al., 2002; Haffajee et al., 2003). Over 10
different antibiotics or combination of drugs were included
in these meta-analyses, and both studies suggested that the
use of systemically administered adjunctive antibiotics to
SRP provided some additional benefit over SRP alone in
terms of CAL gain and PD reduction. Herrera et al. (2002)
reported that the treatments including systemic antibiotics
yielded a statistically significantly greater reduction in PD
(range 0.2-0.8 mm) and gain in CAL (range 0.2-0.6 mm) in
sites with PD 7 mm in comparison with SRP only. The
meta-analysis reported by Haffajee et al. (2003) indicated
that antibiotics provided statistically significantly better
full-mouth CAL gain of 0.3-0.4 mm. Neither study could
assign superiority to any antibiotic due to insufficient numbers of studies, different treatment protocols (e.g., drugs,
combination of drugs, doses, duration of therapies), small
sample sizes and lack of longitudinal data beyond 6 months
for the majority of the studies evaluated.
Although several different antibiotics were tested for
their use in periodontal treatment up to 2002, certain protocols have been favored, and between 2002 and 2013 the
literature converged on the use of three particular drugs:
MTZ (Sigusch et al., 2001; Rooney et al., 2002; Carvalho et
al., 2004; Xajigeorgiou et al., 2006; Matarazzo et al., 2008;
Silva et al., 2011; Feres et al., 2012; Preus et al., 2013), MTZ
+ amoxicillin (AMX) (Cionca et al., 2009; Silva et al., 2011;
Feres et al., 2012; Goodson et al., 2012) and azithromycin
(AZT; Smith et al., 2002; Mascarenhas et al., 2005; Dastoor
et al., 2007; Haffajee et al., 2007; Haas et al., 2008; Oteo et
al., 2010; Sampaio et al., 2011; Emingil et al., 2012; Han et
al., 2012).
MTZ arose in the 1980s as a particularly effective drug
for the treatment of chronic periodontitis patients mainly
due to its efficacy against obligate anaerobes, including
some important periodontal pathogens, such as the members of the red complex, P. gingivalis, T. forsythia and T. denticola (Proctor and Baker, 1971; Loesche et al., 1982; Feres
et al., 2001). At that time, important clinical benefits with
the adjunctive use of MTZ in periodontal treatment were
demonstrated (Loesche et al., 1987; Loesche et al., 1992).
These findings were corroborated by several additional
studies (Sigusch et al., 2001; Rooney et al., 2002; Loesche
et al., 2002; Carvalho et al., 2004; Xajigeorgiou et al., 2006;
Feres et al., 2012; Preus et al., 2013).
AZT is a relatively new macrolide that emerged in

medicine in the late 1980s (Girard et al., 1987) as a promising drug due to excellent pharmacological properties,
which allow its administration only once a day (500 mg)
for short periods of time (from 3 to 5 days; Henry et al.,
2003). This simple dosage protocol and low incidence of
side-effects associated with the use of AZT facilitated
patient compliance, which represented a major advantage
over other commonly used antibiotics in periodontics,
including MTZ and AMX. Unfortunately, the results
of the clinical studies evaluating the effects of AZT in
association with SRP to treat subjects with advanced
periodontitis demonstrated minimal or no additional
effects of this antibiotic beyond that attained with mechanical debridement alone (Sampaio et al., 2011; Emingil
et al., 2012; Han et al., 2012). In addition, the only clinical trial that directly compared the effect of AZT with
another systemic antibiotic, MTZ, detected a statistically
significant clinical advantage for MTZ+SRP in comparison with SRP-only, but not for AZT+SRP (Haffajee et
al., The association of MTZ + AMX was suggested by
van Winkelhoff and co-workers (1989) to treat Aggregatibacter actinomycetemcomitans-associated periodontitis, and
in 2005, the first placebo-controlled RCT demonstrating
the additional benefit of this combination of antibiotics
in treating subjects with aggressive periodontitis, which
were maintained up to 6 months post-treatment, was
published (Guerrero et al., 2005). A few years later, the
same benefits were suggested in subjects with chronic
periodontitis (Cionca et al., 2009; Cionca et al., 2010).
Thus, although various antibiotics have been used as
adjuncts to periodontal therapy from the 1970s to 1990s,
current literature appears to converge on the use of the
combination of MTZ+AMX. This trend may clearly be
observed in the literature. From 2002 to 2013, 70% of the
published RCTs on the effect of systemic antibiotics in
the treatment of periodontal diseases used MTZ+AMX.
Moreover, three systematic reviews examining this antibiotic regimen were published (Sgolastra et al., 2012a;
Sgolastra et al., 2012b; Zandbergen et al., 2012). Sgolastra
et al., (2012a, 2012b) reported a significant reduction in
mean PD (0.43 mm, 95% CI range: 0.24 to 0.63, p < 0.05
and 0.58 mm, 95% CI range: 0.39 to 0.77, p < 0.05) and
mean CAL gain (0.21 mm, 95% CI range: 0.02 to 0.4,
p < 0.05 and 0.42 mm, 95% CI range: 0.23 to 0.61, p <
0.05) in favor of SRP in association with MTZ+AMX
in subjects with chronic and aggressive periodontitis, respectively. Although the data in these systematic reviews
indicated an important benefit of the use of this antibiotic
protocol, long-term data beyond 6 months of follow-up
were sparse (Pavicic et al., 1994).
Three recently published RCTs presented the longterm effects (1 and 2 years of follow-up) of MTZ+AMX
in the treatment of patients with chronic (Feres et al.,
2012; Goodson et al., 2012) and aggressive (Mestnik et al.,
2012) periodontitis and suggested a sustained benefit of

this therapy. Feres et al. (2012) evaluated the effects of the
adjunctive use of MTZ or MTZ+AMX in the treatment
of generalized chronic periodontitis. The mean number of
deep sites with PD 5 mm did not differ among the three
groups at baseline (38), but there were clear differences at
1 year post-treatment. Subjects receiving only SRP still had
a mean of 16.1 residual pockets, compared to 6.3 and 4.7 in
the MTZ and MTZ+AMX groups, respectively. SRP was
able to bring only 22% of the subjects to a low risk profile
( 4 sites with PD 5 mm) for further disease progression
(Lang and Tonetti, 2003; Matuliene et al., 2008; Matuliene
et al., 2010) at 1 year, as opposed to 61% and 66% reached
by SRP+MTZ and SRP+MTZ+AMX, respectively. These
findings have clinical implications because they suggest a
reduced need for periodontal surgery in subjects receiving
one of these antibiotic protocols. Although no statistically significant differences were detected between the
two antibiotic groups for this parameter and for the other
parameters evaluated by the authors, there was a constant
trend towards better clinical outcomes when MTZ and
AMX were combined, in agreement with two other studies
(Matarazzo et al., 2008; Silva et al., 2011). These sustained
long-term clinical benefits obtained with the combination
of SRP and MTZ+AMX were corroborated by two other
RCTs that evaluated the treatment of chronic (Goodson et
al., 2012; Socransky et al., 2013) and aggressive periodontitis
(Mestnik et al., 2012).
One question that could be raised is whether the combination of antibiotics and surgeries would provide any
additional benefit. An answer to this question was given
by the study of Goodson et al. (2012), which assessed
eight different periodontal therapies and demonstrated
that SRP+MTZ+AMX was the best of all treatments in
terms of improving attachment levels. When the antibiotic
and surgical groups were directly compared, a statistically
significant higher mean CAL gain was observed in subjects
receiving SRP+MTZ+AMX (1.53 0.16 mm) compared
to subjects treated by means of SRP and modified Widman
flap (0.96 0.21 mm). Interestingly, when all the eight treatments were compared, it was revealed that the inclusion
of periodontal surgery did not significantly improve the
clinical response in subjects with advanced chronic periodontitis (Goodson et al., 2012).
Economic evaluation of adjunctive antimicrobials
in the treatment of periodontitis
When comparing alternative treatments for a given clinical
condition, it is not only important to evaluate their effectiveness, but also their economic costs. If an alternative
treatment is more effective and less costly, or less effective
and more costly compared to the standard of care, it is
quite obvious which treatment may be considered superior.
However, for an alternative treatment that is more effective and more costly than the standard of care, it is less
25
clear which treatment may be preferred. What treatment

is considered superior will depend on the marginal costs in
relation to the additional benefits and on how much payers
are willing to pay for the incremental benefits (Higgins et
al., 2012).
The costs that may be considered in analysis of costeffectiveness include out-of-pocket payments by patients,
reimbursements by third-party payers, travel costs, opportunity costs, and treatment costs averted (Vernazza et al.,
2012). The societal perspective, which combines all relevant
costs irrespective of who pays for them, provides the most
comprehensive view on costs (Russel et al., 1996). As costs
for dental services may vary considerably among countries
(Pennington et al., 2011), and even among providers within
the same country (Flemmig and Beikler, 2013), they need to
be assessed for each healthcare delivery system separately
and outcomes cannot be generalized.
Using the perspective of a third-party payer in the
United States, average per patient costs for the treatment
of moderate to severe periodontitis have been evaluated
over a 12-month period. Costs for SPR plus adjunctive
local delivery of CHX using a disk device were US$1,568
and for SRP alone, US$1,393. The additional costs for the
application of CHX disks were partly offset by a significant
reduction in the frequency of periodontal surgery (9.2%)
when compared to SRP alone (15.5%; Henke et al., 2001).
If a third-party payer were willing to pay the additional cost
of US$175 per patient in order to reduce the frequency of
periodontal surgery by almost half, adjunctive local delivery
of CHX with a disk device was cost-effective.
From the perspective of a self-paying patient, local
delivery of MTZ gel as an adjunct to SRP was found to
be less effective in providing average attachment gain at
affected sites compared to adjunctive local delivery of
CHX using a disk device. Adjunctive local delivery of
CHX was extensively dominated by the adjunctive local
delivery of minocycline gel. Adjunctive minocycline gel
was cost-effective if patients were willing to pay 1,761 (in
pound sterling) for an average of 1 mm attachment gain
compared to no treatment. SRP alone was cost effective
if the patients were willing to pay between 1,467 and
1,761 for an average of 1 mm attachment gain (Heasman
et al., 2011). Comparing the use of systemic versus local
antibiotics, Heasman et al. (2011) reported that the costs
for an average of 1 mm attachment gain for SRP with
adjunctive systemic administration of MTZ and AMX
was only 837, suggesting that adjunctive systemic administration of antibiotics was more cost-effective compared
to local delivery of antibiotics. Systemic antibiotics might
also offer economic benefits if one considers treatment
costs averted. Recent publications have indicated that
the adjunctive use of systemic MTZ and AMX results in
fewer residual deep pockets and, consequently, the need
for surgical procedures (Cionca et al., 2009; Mestnik et al.,
2012; Feres et al., 2012).
26
In conclusion, as patients willingness to pay depends

on a number of factors including perceived health state,
income, gender, and insurance coverage, cost-effectiveness of alternative treatments may vary considerably
among patients (Grytten, 2002; van Steenberghe et al.,
2004; Tianviwat et al., 2008; Leung et al., 2010).
Concluding remarks
This review aimed to provide readers with an overview
of the current literature on the effectiveness of adjunctive
periodontal therapies. The data suggested that the use of
adjunctive treatments to SRP might lead to additional
clinical benefits to patients with chronic and aggressive
periodontitis. Nonetheless, the practical question to be
answered is: Which of these therapies would lead to
clinically relevant and long-lasting benefits that would
justify its use in the daily clinic? Apparently, the only
adjunctive therapy with compelling data supported by
RCTs with long-term evaluation and systematic reviews
is the use of systemic MTZ alone or in combination with
AMX. There is also some evidence of a clinical benefit
for up to 6 months for the use of laser Nd:YAG, and a
microbiological benefit up to 1 year for the use of CHX
as a mouthwash in combination with SRP+MTZ+AMX
during the active phase of therapy.
The data supporting the adjunctive use of MTZ+AMX
for the treatment of generalized chronic and aggressive
periodontitis are based on the results of numerous RCTs,
including two trials with 1 or 2 years of follow-up (Feres
et al., 2012; Goodson et al., 2012) and three systematic
reviews (Sgolastra et al., 2012a, Sgolastra et al., 2012b,
Zandbergen et al., 2012). It is important to mention that
this treatment should be considered safe, as there seem
to be no major side-effects associated with the intake of
MTZ+AMX (Guerrero et al., 2005; Cionca et al., 2009;
Mestnik et al., 2010; Silva et al., 2011; Feres et al., 2012).
The reduced need for additional treatment associated with
the use of adjunctive systemic MTZ+AMX seems to be
one of the greatest advantages for patients.
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Group B
Reactor Report
modalities
Niklaus P. Lang
University of Hong Kong, Hong Kong SAR PR China,
and Universities of Zurich and Berne, Switzerland
Introduction
The Initiator Paper for this discussion group by Feres et
al. (2015), is a well balanced and objective review of most
of the non-surgical treatment modalities suggested in the
recent decade either as adjunct or supplemental measures
to mechanical debridement.
Periodontal diseases are opportunistic infections
caused by a proliferation of putative periodontal pathogens in a susceptible host and in an ecologic environment
conducive to the colonization of periodontal niches with
strict anaerobic bacteria. Consequently, the treatment of
periodontitis must be anti-infective in nature and address
both the composition of the bacterial colonization as well
as the environmental factors that made it possible for
pathogenic microorganisms to establish and proliferate.
Hence, treatment of periodontitis is not only aimed at
the eradication of the pathogenic microbiota, or at least
the significant reduction of it, but also at influencing the
environment to the extent that a health-associated instead
of a strictly anaerobic microbiota may be established in
periodontally diseased sites. This, in turn, means that
physico-chemical conditions with a high partial pressure of oxygen (pO2), a high redox potential (Rh) and a
neutral or low pH are promoted through the therapeutic
measures.
Probably the most effective therapy to achieve these
goals is the mechanical debridement of the diseased
sites by scaling and root planing. While the always improved clinical outcomes are undisputed, residual pocket
environments may occasionally lead to conditions for
re-infection or recolonization of the sites with residual

11-13 April, 2014
Correspondence to: NP Lang, Scheuermattweg 33, Uettligen/Bern
CH-3043, Switzerland. E-mail: nplang@switzerland.net
pockets. Hence, it is imperative to treat the oral cavity as

one ecological system rather than addressing only single
sites for therapy.
The necessity of mechanical debridement as the gold
standard of care has been clearly demonstrated (Feres
et al., 2012). Moreover, it becomes clear that mechanical
debridement is not only a treatment modality, but an essential treatment for all periodontitis sites, and, hence, the
outcomes of additional or supplemental measures will have
to be compared to this gold standard. Because mechanical
debridement is associated with some loss of tooth substance and repeated instrumentations may, therefore, result
in considerable damage to the hard structures, additional
measures of non-surgically eliminating biofilm may help to
minimize such undesired side-effects of the very effective
mechanical debridement, especially in patients in periodontal supportive therapy.
Photodynamic therapy (PDT) and lasers
The use of photodynamic therapy (PDT) may provide
welcome supplemental measures in order to reduce the
loss of tooth substance usually encountered with conventional repeated mechanical debridement. Moreover, clearly
improved clinical outcomes in residual pockets were demonstrated in a study of patients in supportive periodontal
therapy (SPT) and multiple applications of PDT, while the
regular maintenance debridement failed to demonstrate improvements in both pocket depth (PD) and clinical attachment level (CAL) in the residual pockets (Lulic et al. 2009).
Therefore, further randomized clinical trials (RCTs) ought
to elucidate positive outcomes of PDT in combination with
scaling and root planing (SRP) in maintenance patients.
Regarding the use of other lasers, it may be stated that
the investment in expensive machines neither facilitates the
debridement procedure nor improves the clinical outcomes
of debridement. Many more well-controlled studies have
to be performed before lasers can be recommended to the
clinician for routine periodontal therapy.
32
Full mouth disinfection and full mouth scaling

and root planing
Commonly, non-surgical periodontal therapy is performed in stages in weekly to biweekly intervals. In
order to avoid the hypothetical spread of bacteria
from not yet treated sites to the freshly treated sites,
the concept of full mouth disinfection or full mouth
scaling and root planing within 24 to 36 hours has
been advocated and promoted as being a superior
way of delivering care than by the staged approach.
Numerous studies and two systematic reviews have,
indeed, revealed that differences in clinical outcomes,
if admittedly present in certain locations and root
configurations, are minimal and clinically of limited
relevance. Consequently, it may be stated that all debridement protocols may be effective irrespective of
their modality of delivery, and, hence, the clinician may
choose the protocol most suitable for the practice and
the patients needs.
Use of antiseptics adjunctive to mechanical
debridement
Ever since the introduction of antiseptics as adjuncts
for the prevention of biofilm formation and the development of gingivitis (Le and Schitt, 1970), the
use of antiseptics has been advocated as an adjunct to
mechanical biofilm control in various situations and
indications. Antiseptics have to be recognized according to their substantivity as first and second generation
antiseptics. While first generation antiseptics yield high
substantivity, and, consequently, are released from the
reservoirs within the oral cavity over longer periods
of time (8-24 hours), second generation antiseptics
may only be active for short periods owing to limited
substantivity. Only the bis-biguanides (chlorhexidine)
have been recognized as first generation antiseptics
and result in optimal clinical outcomes, while all other
antiseptics may have limited preventive effects even
if they yield antibacterial activity in vitro. The biofilm
preventive effect of antiseptics is most reliably tested
by applying the experimental gingivitis model, in which
during a three-week period of abolished oral hygiene
procedures, a placebo control would result in a generalized gingivitis owing to biofilm accumulation. Test solutions of antiseptics may prevent biofilm formation to
various degrees (usually 20-30%), while chlorhexidine
has proven to reduce biofilm formation by 80-100%
owing to its high substantivity. Consequently, gingivitis
is prevented by applying this antiseptic drug. It has to
be realized that the significant preventive effect of the
antiseptics is aimed at the control of the supragingival
plaque reservoir, and, hence, may affect the development of gingivitis. However, in periodontitis patients,
the microbiota in the deep pockets is not effectively
attacked. Rinsing or irrigating pockets is, therefore, a
non-substantiated regime of limited clinical value. Nevertheless, when the supragingival plaque reservoir is to
be depleted, first generation antiseptics are welcome
adjuncts to mechanical debridement.
Unfortunately, effective antiseptics have side effects
that affect their selection for long-term routine use.
These are the development of discolorations, especially
on teeth and prostheses, and a short lasting taste impairment for the salty taste modality. Recently, industry
has promoted chlorhexidine rinsing with the addition
of an anti-discoloration system (ADS). However, in
testing the microbiological effects of these products
using the Zurich biofilm in vitro model (Hofer et al.,
2011), the test solution was able to reduce biofilm formation by 3 log steps compared with a negative (water)
control. However, this was significantly less effective
than the positive control (standard chlorhexidine solutions) which reduced viable counts by 6 log steps.
Both the test and control solutions exhibited staining
on all surfaces. A subsequent in vivo study applying the
experimental gingivitis model (Li et al., 2014) clearly
demonstrated that the combination of a chlorhexidine
solution with an ADS was ineffective in preventing
biofilm formation and was unable to prevent gingivitis
from developing over the three weeks.
Local antimicrobial delivery
When using local antimicrobial agents for the treatment
of residual pockets, it has to be realized that the release
kinetics of the carrier system of the drug are extremely
important. In order to be effective in attacking the
microbiota in the pocket, the antimicrobial agent must
be released over a long enough time (at least 7-10 days)
in a high enough concentration that corresponds to at
least 100x the minimal inhibitory concentration (MIC)
of in vitro activity against the biofilm bacteria. Very few
release systems present with such kinetics, and, hence,
very few products can be recommended for controlled
release of local antibiotics. However, with appropriate kinetics the application of controlled release local
antibiotics has been demonstrated to be very effective,
yielding good clinical outcomes. They are best used
as adjuncts to a systematic mechanical debridement
at single residual pockets or for the treatment of reinfected sites during supportive periodontal therapy.
Moreover, they are welcome adjuncts in the treatment
of peri-implant diseases.
Systemic antibiotics as part of periodontal therapy
The key question to be answered regarding the adjunctive use of systemic antibiotics is, indeed, what is the
role and what are the priorities of the administration of
antibiotics in the treatment concepts of chronic periodontitis. While there is clear evidence to incorporate
an antibiotic regime in the treatment of aggressive
Group B Reactor: Non-surgical periodontal therapy
periodontitis, chronic periodontitis is generally successfully treated without the use of antibiotics. For
aggressive periodontitis, the eradication of pathogens
such as Aggregatibacter actinomycetemcomitans requires the
use of a combination of amoxicillin and metronidazole, owing to the fact that A. actinomycetemcomitans is
not strictly anaerobic, but rather a facultative anaerobic
bacteria. This organism seems to penetrate into the
tissues and should be eradicated to avoid re-infection.
Obviously, mechanical debridement does not eradicate
A. actinomycetemcomitans, while other major presumptive
pathogens are usually present below detection levels
following mechanical debridement.
For chronic periodontitis, however, there is no need
for the use of antibiotics owing to the effectiveness
of the mechanical debridement process. However, in
recent years well conducted studies demonstrated that
the administration of the amoxicillin/metronidazole
regime for 7 to 14 days in addition to full mouth scaling
and root planing may result in fewer residual pockets
needing additional therapy when compared to a placebo group (Cionca et al., 2009; Silva et al., 2011; Feres
et al., 2012, Goodson et al., 2012). These studies have
opened the debate concerning the priority of the use
of antibiotics in the treatment of chronic periodontitis.
At present, there is not enough evidence to routinely
recommend antibiotics as adjunct to mechanical debridement. Similar to the application of controlled
release devices, systemic antibiotics should be reserved
for specific indications. Never should they be given to
compensate for poor biofilm control or in place of
adequate mechanical debridement.
Concluding remarks
Even though various treatment regimes and protocols
have been suggested in recent years, the undisputed
concept of mechanical debridement has priority over
all other modalities in the treatment of chronic periodontitis. The cost-benefit analysis is an often times
neglected issue when new approaches are evaluated.
Hence, patient-centered outcomes have to be studied
in relation to the clinical benefits and in the light of
environmental factors.
33
References
Cionca N, Giannopoulou C, Ugolotti G and Mombelli A.
Amoxicillin and metronidazole as an adjunct to fullmouth scaling and root planing of chronic periodontitis.
Feres M, Soares GMS, Mendes JAV, et al. Metronidazole
treatment of chronic periodontitis: a 1-year doubleblinded, placebo-controlled, randomized clinical trial.
Feres M, Faveri M, Figueiredo LC, et al. Non-surgical periodontal therapy: mechanical debridement, antimicrobial
agents and other modalities. Journal of the International
Academy of Periodontology 2015; 17/1 (Supplement): 21-30.
Goodson JM, Haffajee AD, Socransky SS, et al. Control of
periodontal infections: a randomized controlled trial
I. The primary outcome attachment gain and pocket
depth reduction at treated sites. Journal of Clinical Periodontology 2012; 39:526-536.
Hofer D, Meier A, Sener B, Guggenheim B, Attin T and
Schmidlin PR. Biofilm reduction and staining potential
of a 0.05% chlorhexidine rinse containing essential
oils. International Journal of Dental Hygiene 2011; 9:60-67.
Li W, Wang RE, Finger M and Lang NP. Evaluation of
the antigingivitis effect of a chlorhexidine mouthwash
with or without an antidiscoloration system compared
to placebo during experimental gingivitis. Journal of
Investigative and Clinical Dentistry 2014; 5:15-22.
Le H and Schitt CR. The effect of mouthrinses and
topical application of chlorhexidine on the development of dental plaque and gingivitis in man. Journal of
Lulic M, Leiggener Grg I, Salvi GE, Ramseier CA, Mattheos N and Lang NP. One-year outcomes of repeated
adjunctive photodynamic therapy during periodontal
maintenance: a proof-of-principle randomized controlled clinical trial. Journal of Clinical Periodontology 2009;
36:661-666.
Silva MP, Feres M, Sirotto TA, et al. Clinical and microbiological benefits of metronidazole alone or with
amoxicillin as adjuncts in the treatment of chronic
periodontitis: a randomized placebo-controlled clinical
Group B
Consensus Paper
modalities
Moderator & Reactor: Lang, Niklaus, University of Hong Kong,
Hong Kong SAR PR China, Universities of Zurich and Berne,
Switzerland
Initiator: Feres, Magda, Guarulhos University, Brazil
Working Group B:
Corbet, Esmonde, University of Hong Kong, Hong Kong
Ding, Yi, Sichuan University, PR China
Emingil, Glnur, Ege University, Turkey
Faveri, Marcelo, Guarulhos University, Brazil
Humagain, Manoj, Kathmandu University School of Medical
Sciences, Nepal
Izumi, Yuichi, Tokyo Medical and Dental University, Japan
Kamil, Wisam, International Islamic University Malaysia, Malaysia
Mahanonda, Rangsini, Chulalongkorn University, Thailand
Rajpal, Jaisika, Subharti University, India (Transcriber)
Sakellari, Dimitra, Aristotle University of Thessaloniki, Greece
Tan, Wah Ching, National Dental Centre Singapore, Singapore
Yamazaki, Kazuhisa, Niigata University, Japan
Introduction
Periodontal diseases are complex opportunistic infections modified by the host inflammatory response.
Therefore, the current recommended treatment of
periodontitis is primarily anti-infective in nature. Antiinfective approaches rely on adequate patient removal
of plaque through good oral hygiene practices and
mechanical debridement by an oral health professional.
Scaling and root planing (SRP) is accepted to be the basis
for all periodontal therapy, and any additional therapies
should be considered adjunctive and supplemental.

11-13 April, 2014
Correspondence to: Ciancio, Sebastian, University of Buffalo,
USA, E-Mail: ciancio@buffalo.edu
What is the current status of laser and

photodynamic therapy as adjunctive measures
to mechanical debridement?
The benefits of laser and photodynamic therapy (PDT)
have been proposed and documented over the past two
decades. While laser therapy (Nd:YAG) used in conjunction with SRP yielded beneficial short-term clinical
outcomes, especially in reducing probing depths (PD),
the long-term clinical benefits of such therapy are questionable. Hence, from the current available evidence, as
well as the associated high cost, laser therapy cannot be
recommended for the treatment of periodontal disease.
Photodynamic therapy as an adjunct to SRP in the
treatment of periodontal disease provides some additional benefits in terms of PD reductions and clinical
attachment level (CAL) gains compared to SRP alone
at 3 months. However, these benefits have not been
observed at 6 months. For patients undergoing supportive periodontal care, the repeated use of adjunctive
Group B Consensus: Non-surgical periodontal therapy 35
PDT with SRP has shown improved clinical outcomes

with regards to reducing the number of residual pockets (PD 5 mm). However, the long-term benefit for
applying this approach to maintenance patients needs
confirmation by well-planned randomized controlled
clinical trials (RCTs).
What is the effect of various protocols for the
delivery of mechanical debridement?
While various protocols for the delivery of mechanical subgingival debridement have been proposed,
two systematic reviews have indicated slightly greater
probing depth reductions in deep sites with PD 7
mm following full mouth disinfection (FMD) or full
mouth scaling and root planing (FMSRP) compared
to quadrant-wise scaling and root planing. These FMD
or FMSRP protocols for the delivery of mechanical
subgingival debridement may be chosen depending
on patient availability and preferences, logistic settings
and cost effectiveness. Irrespective of what protocol is
used for subgingival debridement, it is recognized that
the optimal clincial results can only be obtained if the
patient is able to adequately perform oral hygiene.
What is the role of adjunctive antiseptics in
non-surgical periodontal therapy?
A large number of antiseptics have been proposed for
chemical plaque control. However, there is limited evidence demonstrating a significant, or clinically relevant,
beneficial effect of these compounds used either in
active periodontal therapy or during maintenance. The
use of chlorhexidine digluconate (CHX) in a concentration of 0.12% as a mouth rinse during the healing phase
of periodontal interventions has shown good clinical
outcomes. In two RCTs, CHX mouth rinses have been
tested as an adjunct to quadrant-wise routine SRP in the
management of chronic periodontitis. Improved PD
reductions and CAL gains have been documented with
a two-month application of CHX adjunctive to SRP
compared with SRP alone. Moreover, the CHX-SRP
regime yielded greater reductions in the proportions
of red and orange complex pathogens. It is recognized
that only CHX results in adjunctive beneficial clinical
outcomes due to its high substantivity. Furthermore,
the effect of CHX results from modification of the
supragingival plaque ecosystems. When CHX rinses
are considered, the side-effects of such therapy (e.g.,
tooth staining) should be taken into consideration, and
the additional clinical benefits to be expected have to
be weighed against such side-effects. To date, there is
no evidence of clinical efficacy of non-staining antiseptics used during the healing phase of periodontal
interventions. With regards to FMD, there is no RCT
that has tested the presumptive additional benefits of
CHX administration.
What is the current status of local and systemic

antimicrobials as adjuncts in subgingival biofilm
control?
Local delivery antimicrobial agents may be useful as
an adjunct in the treatment of periodontal disease. The
release kinetics of the devices must allow for delivery
of a sustained high dose of antimicrobials capable of
entering the subgingival biofilm. Generally, at least 7
days of controlled release of the drugs is necessary to
provide the desired clinical effects. Unfortunately, very
few controlled release devices are available in the market
today. Nevertheless, the concept of controlled local antimicrobial delivery deserves attention. Multiple RCTs
and systematic reviews have documented significantly
greater PD reductions and CAL gains in deep pockets
treated with local delivery of antibiotics and SRP both
for active periodontal therapy and for maintenance care
of residual pockets. In the future the use of controlled
release local devices for the treatment of peri-implant
infections is recommended.
The value of systemic antibiotics in the management of periodontitis has been debated for decades.
In two systematic reviews covering six and 27 studies
(12 in aggressive periodontitis) that have investigated the
administration of adjunctive systemic antibiotics for the
treatment of periodontitis, additional clinical beneficial
outcomes have been documented. In patients with
aggressive periodontitis, the control of Aggregatibacter
actinomycetemcomitans preferably requires the use of a
combination of antibiotics such as amoxicillin (AMX)
and metronidazole (MTZ). The efficacy of AMX/
MTZ used as an adjunct to mechanical debridement
for the treatment of aggressive periodontitis has been
studied in eight RCTs lasting from 2 months to 1 year.
All these studies have demonstrated significant and
clinically meaningful benefits when this regime was used,
compared to SRP alone. Consequently, the adjunctive
use of AMX/MTZ is recommended in the treatment
of aggressive periodontitis.
However, in the treatment of chronic periodontitis the
use of systemic antibiotics as an adjunct to mechanical
debridement is still under debate. In recent years, there
have been at least 10 RCTs conducted evaluating the
clinical efficay of the adjunctive use of AMX/MTZ in
the treatment of advanced chronic periodontitis. All
of these studies demonstrated additional reductions
in PD, gains of CAL and fewer residual pockets (PD
5 mm) when AMX/MTZ was used as an adjunct to
therapy compared to mechanical debridement alone. In
advanced periodontitis patients, as defined by a Level 2
periodontitis case (proximal attachment loss of 5 mm
in 30% of the teeth present; Tonetti & Claffey, 2005),
a benefit from additional AMX/MTZ administration has
been demonstrated to various degrees depending on
their risk profile (smoking, diabetes mellitus). The effect
36
has predominantly been documented over 3-6 months

with three studies from 1 to 2 years. In all studies, the
adjunctive systemic antibiotics were administered in
conjunction with the initial mechanical debridement, i.e.,
prior to the healing of the periodontal intervention. It is
unknown whether or not the additional benefits would
be observed if the antibiotic regime is postponed to the
healing phase, following the initial mechanical debridement. Hence, an RCT is needed to determine the proper
timing for adjunctive systemic antibiotic administration. The potential additional clinical benefits obtained
through other systemic antibiotics (e.g., azithromycin)
has also been studied, but the results have not been as
good as for AMX/MTZ. For instance, in eight RCTs
of chronic and two RCTs of aggressive periodontits the adjunctive administration of azithromycin (AZT) to SRP
did not provide similar improved clinical outcomes as
noted for AMX/MTZ.
As AMX/MTZ is a combination of antibiotics
with high morbidity and substantial side-effects the
potential benefits of this regime in the treatment of
advanced periodontitis have to be weighed against such
side-effects. Furthermore, the influence of additional
systemic antibiotic administration on the environment
should not be overlooked.
demonstrate such benefits. Since the evidence available

on the influence of effective periodontal therapy on
glycemic control is contradictory, no specific recommendations can be made at this time. However, effective periodontal therapy is beneficial for all patients by
lowering the infective burden in the tissues. It should
be noted that studies testing the effect of periodontal
therapy on glycemic control should be performed with
a quality assurance, i.e., ensuring that the outcome of
the periodontal treatment has been successful.
What is the current status of the effect of nonsurgical periodontal treatment on glycemic
control in people with diabetes?
When considering the influence of periodontal therapy
on glycemic control in periodontitis patients with type
2 diabetes mellitus, there are contradictory outcomes.
While some studies have demonstrated a positive influence following effective periodontal therapy on glycosylated hemoglobin levels, other studies have failed to
Reference
What are the potential benefits of

immobilization of teeth with moderate to
extensive periodontal damage?
Potential benefits of immobilization of periodontally
involved teeth have been suggested as part of periodontal therapy for decades. However, the evidence for this
approach is completely lacking. Splinting of teeth has,
at best, only a limited place in periodontal therapy that
is aimed at infection control. However, there is some
evidence that during regenerative procedures , immobilization of very mobile teeth may slightly improve the
clinical outcome. Moreover, splinting may be performed
to facilitate mechanical debridement or for improving
the patient comfort.
Tonetti MS and Claffey N. Advances in the progression of periodontitis in proposal of definitions of

a periodontitis case and disease progression for use
in risk factor research. Group C consensus of the
5th European Workshop in Periodontology. Journal
of Clinical Periodontology 2005; 32 Suppl 6:210-213.
Group C
Initiator Paper
PM Bartold
Colgate Australian Clinical Dental Research Centre
Department of Dentistry, University of Adelaide, Australia
Introduction
Periodontal disease is an all-encompassing term relating
to inflammatory disorders of the periodontium, which
range from the relatively benign form known as gingivitis
to the more aggressive forms of early onset periodontitis and rapidly progressive periodontitis. All forms of
inflammatory periodontal diseases are associated with
bacterial deposits on the root surfaces (Offenbacher et
al., 1996; Page et al., 1997). One of the most significant
outcomes of periodontal inflammation is connective
tissue damage. Because the gingival tissues have a remarkable capacity to regenerate to their original form
and function, the tissue damage caused by gingivitis is
reversible, provided the causative agent(s) are removed
(Melcher, 1976). However, with long-term plaque
deposition the disease may become more established
and destructive. Depending upon host, genetic, environmental and other factors, there may be subsequent
loss of connective tissue attachment to the root surface,
bone resorption, and formation of a periodontal pocket.
In contrast to gingivitis, with the establishment of periodontitis, many of the architectural changes to the hard
and soft connective tissues are irreversible - even if the
causative inflammation is controlled.
One of the goals of periodontal therapy is to
restore periodontal tissues affected by disease to
their original architectural form and function. This
requires regeneration of the gingival connective tissues
destroyed by inflammation, formation of cementum,
restoration of lost bone, and re-establishment of
connective tissue fiber attachment into previously
diseased root surfaces. However, predictable and
complete regeneration of the diseased periodontium

11-13 April, 2014
Correspondence to: PM Bartold, Colgate Australian Clinical
Dental Research Centre, Department of Dentistry
University of Adelaide, Adelaide, South Australia 5005, Australia
E-mail: mark.bartold@adelaide.edu.au
has been difficult to achieve. Nonetheless, since the

pioneering guided tissue regeneration experiments of
just over 30 years ago (Nyman et al., 1982), studies have
repeatedly demonstrated that periodontal regeneration
is biologically possible and clinically feasible.
What is regeneration?
To understand the outcomes of periodontal therapy
precisely, the following terms have been defined (The
American Academy of Periodontology, 1992): Periodontal repair is the restoration of new tissue that does not
replicate the structure and function of lost tissue and is
analogous to scar tissue formation. Periodontal regeneration
is defined histologically as regeneration of the tooths
supporting tissues, including alveolar bone, periodontal
ligament and cementum over a diseased root surface.
It should be noted that the full extent and success of
periodontal regeneration must be assessed not only using
clinical parameters (periodontal probing, radiographs),
but also re-entry evaluations and, ideally, histological
confirmation (Bosshardt and Sculean, 2009). Clearly
such assessments are not always possible, and so there
has been great reliance upon animal models and some
rare human histology studies.
There are at least four criteria that must be met in
order for periodontal regeneration to have occurred.
These include all the features of the normal dentogingival complex that would equate to restoration of these
tissues to their original form, function and consistency
(Bartold et al., 2000):
1. A functional epithelial seal must be re-established
at the most coronal portion of the tissues and be
no more than 2 mm in length.
2. New connective tissue fibers (Sharpeys fibers) must
be inserted into the previously exposed root surface
to reproduce both the periodontal ligament and the
dentogingival fiber complex.
3. New acellular, extrinsic fiber cementum must be
reformed on the previously exposed root surface.
4. Alveolar bone height must be restored to within 2
mm of the cemento-enamel junction.
38
Processes involved in periodontal regeneration

The processes involved in periodontal healing are largely
the same as those for other organs and tissues. However,
there are some significant differences. Inflammation is
a major requirement: the formation of a blood clot at
the site to be healed is needed to provide a provisional
matrix, which subsequently becomes organized into
granulation tissue. Formation of granulation tissue
and fibroblast proliferation are features of chronic
periodontitis associated with healing and repair. The
granulation tissue is subsequently remodelled into scar
tissue or regenerated tissue. Periodontal regeneration is
unique because it involves both soft (gingival and periodontal ligament) and mineralized (bone and cementum) connective tissues. The healing of all periodontal
components needs to be coordinated and integrated in
order for regeneration to occur. Many molecules and
cell types presumably participate in this process. The
cellular events required are migration of cells by chemotaxis, their adhesion, proliferation, differentiation and
production of matrix components. One of the crucial
cellular events is recruitment of cells through which the
selected cell type determines whether healing occurs by
repair or regeneration. The mechanisms involved in cell
selection are still largely unknown, although it is likely
to involve selective chemotaxis, adhesion, and specific
cell-molecular interactions.
Historical perspective of regenerative
procedures
Root surface conditioning
Over the years many techniques have been used in an
attempt to increase the amount of connective tissue
reattachment to tooth roots following periodontal
treatment. Most of these have focussed on trying to
improve the biological compatibility of the root surface
to new connective tissue attachment. These concepts
were founded in the belief that the root surface must
serve as a suitable site for cell attachment and fiber
development during regeneration. Furthermore, it was
considered that diseased root surfaces were contaminated
by bacterial products, and were characterized by loss of
collagen, alterations in mineral density, and composition
of the surface. Accordingly it was proposed that these
surfaces did not support the attachment or growth of
fibroblasts but promoted epithelial migration along
the surface. For these reasons, attempts were made
to modify the diseased root surfaces to make them
conducive for the attachment of connective tissue cells.
A list of root surface conditioning agents investigated
over the years is detailed in Table 1. Despite the apparent
sense in trying to improve the biological compatibility
of the root surfaces using such conditioning agents,
clinical results were disappointing (Fuentes et al., 1993;
Mariotti, 2003; Moore et al., 1987). Irrespective of the

type of demineralizing agent used, it cannot be claimed
that demineralization of the root surface per se is a regenerative procedure. It may, however, have a positive
effect on wound healing and be used as a component
of, or a step within, various regenerative procedures.
Table 1. Agents used for root surface conditioning
Acid etching

Citric acid
Tetracycline
Detergents

Cetylpyridinium chloride
Sodium N-lauroyl sarcosine
Chelating agents

Ethylenediaminetetraacetic acid
Egtazic acid
Enzymes
Attachment proteins
Growth factors
Fibronectin
Graft materials used for periodontal regeneration

Regeneration of bone defects associated with periodontal disease and restoration of architectural form
of the alveolar arch due to tooth loss remains a significant problem in dentistry. Ingrowth of soft connective
tissue into such defects often occurs and this prevents
the formation of new bone tissue, causing aberrations
and functional disturbances. In an effort to stimulate
osteogenesis, various grafting procedures and materials
have been developed. However, the search for an ideal
graft material continues to be a challenge. A list of some
graft materials investigated is shown in Table 2.
There have been several philosophies developed regarding the importance of repair of bony defects caused
by chronic periodontal diseases. The rationale behind
the use of bone grafts in angular bony defects is that the
presence of bone tissue close to a scaled and root planed
surface would stimulate the formation of a connective
tissue attachment. However, such concepts have been
disputed because, on biological grounds, the use of bone
transplants for the management of periodontal defects
is highly questionable (Karring et al., 1984).
Table 2. Grafts and biomaterials used for periodontal
regeneration
Grafts

Autogenous bone
Allogeneic bone
Xenogenic bone
Biomaterials

Beta tricalcium phosphate

Hydroxyapatitie
Calcium sulfate
Calcium phosphate
Bioactive glass
Group C Initiator: Periodontal regeneration
Boyne (1973) stated that an ideal graft material

should: (1) exist in an unlimited supply, without the
need for violation of a distant donor site; (2) provide
immediate osteogenesis for rapid consolidation; (3) elicit
no adverse host responses such as immune reaction; (4)
facilitate re-vascularization, which assists early healing
and resistance to infection; (5) stimulate osteoinduction of recipient site cells; (6) be adaptable to a variety
of physical requirements; (7) cause no impediment to
growth or orthodontic tooth movement; (8) provide
support and stability where discontinuity or mobility
exists; (9) provide a framework for osteoconduction; and
(10) be completely replaced by host bone of the same
or superior quality and quantity as quickly as possible.
In light of our current understanding of the contribution of specific components of the periodontium, for
periodontal defects, an ideal graft material should also
induce or enhance cementogenesis and the formation of
a new attachment apparatus (new bone, cementum, and
periodontal ligament). To date there is no such material
that fulfills these requirements.
Many osseous grafting materials have been used to
try to promote periodontal regeneration and have included autografts, allografts, xenografts and alloplastic
materials.
The use of various grafting materials may produce
radiographic evidence of bone fill and clinical evidence
of improvement in probing depths and clinical attachment levels. However, several studies have shown that,
even though there is some bone growth around the
graft particles, there is substantial fibrous encapsulation
of the graft (Becker et al., 1996; Xiao et al., 1996). In
addition, there is an interposed layer of epithelial cells
present on the root of the tooth, and consequently, no
connective tissue reattachment (Yukna, 1976; Listgarten
and Rosenberg, 1979; Caton et al., 1980). Consequently,
the relevance of these materials to the regeneration the
periodontium can be questioned.
Evidence to date regarding grafting materials
for periodontal regeneration
Several systematic reviews have concluded that the use
of grafting materials for the management of class II furcations may result in improved probing depth reduction
and gains in clinical attachment levels compared with
open flap debridement (Trombelli et al., 2002; Reynolds
et al., 2003). However in terms of regeneration it is clear
that bone fillers generally result in bone deposition
adjacent to pre-existing bone. Further away from the
pre-existing bone edge, simple bone fillers without the
presence of any osteoinductive agents are usually engulfed by fibrous connective tissue. Interestingly, this response does vary among various bone filling agents. For
example, BioOss (Geistlich, Wolhusen, Switzerland)
tends to show less fibrous encapsulation compared to
39
bioactive glass and biphasic calcium phosphate (Sculean

et al., 2004; Windisch et al., 2008). Furthermore, it must
be noted that most of the responses noted to date are
limited to bone regeneration with little regard for new
cementum and new periodontal ligament formation.
Indeed, histological evidence for new connective tissue
attachment to root surfaces following the implantation
of these graft materials is very limited. Similar findings
have been noted for autogenous bone grafts (Wang et
al., 2005). The outcomes following the use of allogeneic
bone grafts in periodontal defects have also been extensively reviewed (Wang et al., 2005). There appears to be
little good evidence that the use of allogeneic materials
results in any significant periodontal regeneration (Dragoo and Kaldahl, 1983; Bowers et al., 1989a, Bowers et
al., 1989b; Bowers et al., 1989c).
Guided tissue regeneration
Principles
By the early 1980s a number of important observations
had been made in relation to periodontal regeneration.
These have been summarized by Card et al. (1987) and
are presented here in a slightly modified form:
1. Regeneration is biologically possible but can only
be verified by histological analysis.
2. Epithelial migration and formation of a long junctional epithelium is a fundamental healing process
occurring after either surgical or non-surgical periodontal therapy.
3. Formation of a long junctional epithelium prevents
root resorption by gingival connective tissue but also
impedes new connective tissue attachment onto the
root surface.
4. Periodontal ligament cells colonize root surfaces
quicker than bone-derived cells, thus preventing
ankylosis.
5. New attachment can be obtained onto a root surface
that has been exposed to the oral environment.
6. Gingival connective tissue cells and bone cells do
not appear to have the ability to form new connective tissue attachment onto a root surface.
7. Cells derived from the periodontal ligament appear
to have the potential to form new connective tissue
attachment onto a root surface.
8. In order for regeneration to occur, selective repopulation of the wound site must occur with cells
possessing the potential to form new cementum,
periodontal ligament, and alveolar bone.
From the above observations, a clinical procedure
based on the principles of guided tissue regeneration
was developed (Nyman et al., 1982b). This method relies
on draping a barrier membrane from the root surface over
the periodontal defect and onto adjacent alveolar bone
prior to replacement of a full thickness mucoperiosteal
40
flap. In doing so, a space is provided into which cells from

the periodontal ligament may migrate, and an effective
barrier prevents either gingival connective tissue or epithelium from occupying this space during the healing
(regenerative) phase. Apart from exclusion of gingival
epithelium and connective tissue from the healing site,
wound stability, adhesion of the blood clot to the tooth
surface, and the provision of adequate space by the barrier membrane are also considered to be contributory
to the successful outcome of guided tissue regeneration
therapy (Scantlebury, 1993).
Types of membranes
A wide range of materials, including methylcellulose
acetate, expanded polytetrafluoroethylene (ePTFE;
GORE-TEX, Gore, Flagstaff, AZ, USA), collagen,
polyglycoside synthetic polymers, and calcium sulfate
have been tested for effectiveness and used as a physical
barrier in guided tissue regeneration. These membranes
are derived from a variety of sources, natural and synthetic, and are either bioabsorbable or nonresorbable
(Villar and Cochran, 2010; Bottino et al., 2012).
Non-resorbable membranes
Prior to commercialization of guided tissue regeneration
membranes, the original experiments in this field used
Millipore filters (type GS: Millipore A, 67 Mosheim,
France: pore size 0.22 m; Nyman et al., 1982b). However, these membranes were fragile and tended to tear,
which limited their clinical use. Methylcellulose acetate
barriers were later replaced by non-resorbable ePTFE
membranes specifically designed for periodontal regeneration. A specific design feature of the ePTFE
membranes was an open microstructure collar and a
cell occlusive apron. The collar was designed to impede
epithelial downgrowth and the occlusive apron was
designed to inhibit gingival epithelium and connective
tissue gaining access to the repairing periodontal defect.
This material not only possesses adequate stiffness to
allow creation and maintenance of a secluded space into
which the new attachment will form, but also is supple
enough to allow adequate adaptation over the defect
(Villar and Cochran, 2010). Non-resorbable membranes
are particularly prone to exposure to the oral environment. As a consequence, bacterial contamination and
infection may result in delayed wound healing and poor
regenerative outcomes. These membranes need to be removed after 6 to 8 weeks in a second surgical procedure.
Resorbable membranes
Various bioabsorbable materials, including polyglycoside
synthetic polymers (i.e., polymers of polylactic acid,
polyglycolic acid, polylactate/poly-galactate), collagen,
and calcium sulfate have been developed as membrane
barriers. The clinical efficacy of bioabsorbable mem-
branes depends on their ability to retain their structural

physical integrity during the first 6 to 8 weeks of healing
and to be gradually absorbed thereafter. Based on this
concept, chemicals and structural modifications (i.e.,
polymerization, cross-linking) were incorporated into
bioabsorbable membranes to extend their absorption
time and increase the clinical effectiveness of these
materials.
Biodegradable collagen membranes possess a lower
risk of exposure and do not need a second surgical
procedure for their removal. As collagen membranes
possess fewer favorable mechanical properties than nonresorbable membranes, bone filler is needed to prevent
their collapse into the defect area.
Chitosan, a deacetylated derivative of chitin, is another biomaterial used for guided tissue regeneration
that is biodegradable. Its property of bacteriostasis may
reduce the bacterial contamination and benefit periodontal tissue regeneration (Xu et al., 2012).
In the future there will be further developments in
the rational design of biodegradable products for guided
tissue regeneration. It is likely these developments will
include enhanced mechanical properties with controlled
degradation dynamics together with delivery systems for
bioactive and antibacterial agents (Bottino et al., 2012).
Does guided tissue regeneration work?
The guided tissue regeneration technique is sensitive
and technically demanding. From the studies published
to date it is apparent that gains in both probing and
attachment levels can be expected following guided tissue
regeneration procedures, although there is significant
variability depending on numerous clinical parameters
that affect periodontal regeneration outcomes (Demalon
et al., 1993; Tonetti et al., 1993; Mellonig et al., 1994;
Machtei et al., 1994). Some of the major limiting factors
include: defect size and location, type of furcation
defect, degree of membrane exposure during healing
period, and degree of microbial contamination. A more
recent systematic review confirmed that the clinical
outcomes of guided tissue regeneration on parameters
such as attachment gain, reduced pocket depth and hard
tissue gain at re-entry surgery are all greater than open
flap debridement (Needleman et al., 2005). However,
it was noted that there was marked variability among
studies and the clinical relevance of these improvements
was unclear.
Long-term studies and evaluations of guided tissue
regeneration have indicated that the clinical improvements obtained by this procedure are of small magnitude
and exhibit large variability (Bratthall et al., 1998; Pontoriero and Lindhe, 1995; Wallace et al., 1994; Machtei et al.,
1996). Two meta-analyses have concluded that guided
tissue regeneration yields greater clinical attachment
gain than open flap debridement alone for intrabony
and furcation defects (Jepsen et al., 2002; Murphy and

Gunsolley, 2003). In addition, quantitative analyses of
clinical outcomes following guided tissue regeneration
treatment suggests that this therapy is only a successful
and predictable alternative in well-selected cases such
as narrow intrabony defects and class II mandibular
furcations (Villar and Cochran, 2010). Notwithstanding the generally modest gains in clinical attachment,
10-year follow-up studies demonstrate stable gains in
clinical outcomes and thus support the use of guided
tissue regeneration in treatment of infrabony periodontal defects and class II furcation defects (Eikholz et al.,
2006; Pretzl et al., 2009; Nickles et al., 2009; Sculean et
al., 2008a). However, for more advanced defects such as
class III furcations and 1-wall infrabony defects guided
tissue regeneration does not result in very predictable
outcomes (Gottlow et al., 1992; Becker and Becker 1993).
While the histological outcomes of new attachment, new cementum and new bone formation are
well documented in animals, the outcome is less well
documented for humans. At the time of membrane
removal (for non-resorbable membranes), the regenerating tissues forming underneath the membrane are
of a soft, gelatinous consistency (Becker et al., 1988).
With time, this tissue may mature into bone - although
this appears to be a rather variable response. All of the
human histological studies to date have been either case
reports or case series on very low numbers of subjects
under non-standardized experimental conditions (Nyman et al., 1982; Gottlow et al., 1986; Stahl et al., 1990;
Sculean et al., 1999; Stoller et al., 2001; Windisch et al.,
2002). These studies have indicated that the predominant healing process following guided tissue regeneration procedures is via new connective tissue attachment
to the root surface with minor contributions of new
cementum and bone formation. Therefore, by definition, regeneration has not occurred.
Combinations of guided tissue regeneration and
bone grafts
One challenge of regenerative therapies has been to
achieve alveolar bone replacement in furcation, dehiscence, and horizontal defects coronal to the existing
bony crest level. Guided tissue regenerative techniques
alone have failed to achieve this. More recently, a combination of grafting treatments and barrier membranes
has been attempted to augment the technique of guided
tissue regeneration. Often these were combined with
root demineralization techniques. The combinations
include resorbable or non-resorbable barrier membranes
with bone graft or synthetic grafts placed under them,
and coronally positioned flaps. Several studies have reported some improvement in the healing of furcation
defects when a combination of guided tissue regeneration membranes and demineralized freeze-dried bone
41
allografts or dura mater membrane were used (Anderegg

et al., 1991; Schallhorn and McCain 1988; Zaner et al.,
1989). However, these assessments were based solely on
clinical criteria and no histological data were available.
More recently, the effects of guided tissue regeneration,
with and without demineralized freeze-dried bone allografts, in the treatment of furcation defects in dogs
with naturally occurring periodontal disease, has been
evaluated (Caffesse et al., 1993). In this histological study,
adjunctive bone grafting did not appear to enhance regeneration. In a human study, comparing demineralized
freeze-dried bone allografts with and without ePTFE
membranes in periodontal defects and using allografts
as controls, it was concluded that utilization of ePTFE
membranes, in addition to demineralized freeze-dried
bone allografts, did not lead to additional radiographic
gains in the defect area (Guillemin et al., 1993). However,
a relatively recent systematic review came to the conclusion that most preclinical studies have histologically
demonstrated periodontal regeneration when grafting
materials are combined with barrier membranes (Sculean
et al., 2008b). Thus, the overall conclusion of these
studies is that the results for combined guided tissue
regeneration and grafting materials are variable and
benefits, if any, are only marginal.
Biological agents for periodontal regeneration
With the limitations of the above agents and procedures
in mind, more recent efforts in periodontal regeneration
have been focused on the use of biological agents to assist in stimulating self-repair/regeneration mechanisms
within the periodontium. This approach has been referred to as endogenous regenerative therapy (Chen
et al., 2010), and is an important and exciting emerging
area in periodontal regeneration. This field focuses on
the use biological agents such as growth factors, matrix
extracts, plasma concentrates and biologically active
peptides to stimulate the hosts inherent capacity for
periodontal regeneration.
Enamel matrix proteins
An important advancement in periodontal regeneration
was the discovery of enamel matrix proteins, produced
by Hertwigs epithelial sheath (Lindskog, 1982;
Slavkin et al., 1989). These proteins were shown to
play an important role in cementogenesis, as well as
in the development of the periodontal attachment
apparatus (Ten Cate, 1996; Hammarstrm, 1997). This
observation led to the development and utilization of
the biologically active agent enamel matrix derivative
(EMD, Emdogain; Straumann AG, Basel, Switzerland)
as a local adjunct to periodontal surgery for stimulating
regeneration of periodontal tissues (Hammarstrm et
al., 1997; Wilson, 1999; Rathe et al., 2009; Sculean et
al., 2007a; Sculean et al., 2007b; Venezia et al., 2004).
42
Numerous clinical and histological studies have

demonstrated that treatment of periodontal defects
with EMD results in periodontal regeneration (Esposito
et al., 2005; Venezia et al., 2004; Kalpidis and Ruben,
2002; Esposito et al., 2009; Rathe et al., 2009; Sculean
et al., 2007c). In addition, several systematic reviews
evaluating the results of randomized clinical trials have
confirmed the positive clinical outcomes of using EMD
for periodontal regeneration which appear to be stable
over the long term (Kalpidas and Ruben 2002; Venezia
et al., 2004; Esposito et al., 2005; Tu et al., 2008; Esposito
et al., 2009). Most recently it has been concluded that
EMD is superior to control treatments for intrabony
defects and as effective as resorbable membranes but
superior to non-resorbable membranes for class II
furcation defects (Koop et al., 2012)
Combination treatments of guided tissue
regeneration, EMD and bone grafts
A number of studies have investigated whether there is
any additive effect for the use of EMD when combined
with bone grafts and or guided tissue membranes for
the treatment of infrabony lesions (Zucchelli et al., 2003;
Gurinsky et al., 2004; Sculean et al., 2005; Bokan et al.,
2006; Kuru et al., 2006; Hoidal et al., 2008). Systematic
reviews of the results of such studies have indicated that
there is little evidence to support any significant additive
effect of EMD in combination with other regenerative
materials (Trombelli and Farina, 2008; Tu et al., 2010).
Growth factors in periodontal regeneration
Nearly all of the events associated with tissue repair
and regeneration are regulated by polypeptide growth
factors. Therefore it is logical to consider that these
factors may be able to promote regeneration (Caffesse
and Quinones, 2000; Giannobile et al., 2010; Murakami,
2011; Stavropoulos and Wikesjo, 2012). A number of
growth factors, both alone and in combination, have
been studied for treatment of natural and experimentally induced periodontal defects in animal models
(Table 3). Although there has been little uniformity
among these studies in terms of study design, animal
and periodontal defect model, types of growth factors
and carrier vehicles, the results in general indicate that
the application of various growth factors for periodontal
regeneration produces favorable results (Reynolds and
Aichelmann-Reddy, 2012; Darby and Morris, 2013).
Despite a large body of evidence arising from both
pre-clinical trials and randomized clinical trials, with
the exception of Gem-21S, a -TCP/rhPDGF-BB
combination (Osteohealth-Luitpold Pharmaceuticals,
Shirley, NY), few of these growth factors have been
developed into an everyday clinical practice product.
This is largely due to a number of critical issues that
still impede progress and need to be resolved. These
include: (1) the complexity of the periodontium,

which consists of four different tissues; (2) restricted
understanding of the differentiation repertoire of
the periodontal cells; (3) the exact target cells that are
to be modulated by these factors; (4) the stability of
the tissues that are to be formed under the influence
of these factors; (5) the use of very high doses of
bone morphogenetic proteins; (6) the ideal carrier has
still not been found; and (7) the high costs that are
associated with production of recombinant growth
factors (Ripamonti and Petit, 2009; Bartold et al., 2000).
Thus, further investigation is needed to facilitate the
clinical translation of the polypeptide growth factors
and their delivery systems.
Table 3. Growth factors used for periodontal regeneration
Platelet-derived growth factor
Bone morphogenetic proteins
Transforming growth factor beta
Insulin-like growth factor
Fibroblast growth factor
PepGen-15
The cell binding peptide P-15 (Dentsply Friadent,
Mannheim, Germany) is a short polypeptide of 15
amino acids which mimics the cell binding domain of
type I collagen combined with anorganic bovine bonederived hydroxyapatite matrix. Its principal biological
action is to enhance cell attachment of fibroblasts
and osteoblasts, which may promote osteogenesis
(Bhatnagar et al., 1999). Several clinical studies (case
series and a controlled monitored multicenter trial)
investigating the efficacy of P-15 for periodontal
regeneration have shown it to yield better clinical
outcomes compared to the carrier alone (Yukna et
al., 2000; Yukna et al., 2002). These clinical outcomes
were found to be stable up to 3 years. However, no
studies have made comparisons between P-15 and the
gold standard of guided tissue regeneration or other
regenerative procedures.
Platelet-rich plasma
Platelet-rich plasma (PRP) is an autologous blood
preparation enriched in growth factors such as transforming growth factor beta (TGF-), vascular endothelial growth factor (VEGF), and platelet-derived
growth factor (PDGF). Platelet-rich plasma has been
used in various surgical fields, including maxillofacial and periodontal surgery with the expectation of
enhancing bone and soft-tissue healing (Mehta and
Watson, 2008; Foster et al., 2009). To date the evidence
for enhanced periodontal regenerative outcomes has
been poor (Dori et al., 2008; Kotsovilis et al., 2010; Del
Fabro et al., 2011).
Future technologies for periodontal

regeneration
The emerging fields of personalized medicine and regenerative medicine are evolving quickly. Both are largely
based on the concepts of tissue engineering, which is
the science of reconstructing or mimicking natural processes through the use of synthetic polymer scaffolds
with the expectation of tissue regeneration (Bartold et
al., 2000). The vision is that suitable cells, produced in
large enough quantities through cell culture methods,
together with appropriate bioscaffolds will be implanted
into tissues and organs to produce fresh replacement
cells to take over from lost or damaged cells and result
in tissue regeneration.
Stem cells and tissue engineering
An appealing approach to periodontal regeneration involves the use of cells, bioactive agents and biomaterials for
therapeutics using tissue engineering principles (Bartold et al.,
2000). The concept of tissue engineering, taking into account
the need for regenerative treatment of periodontal defects
with an agent or procedure, requires that each functional
stage of reconstruction be grounded in a biologically directed
process. This biological technology, together with the emerging field of nanotechnology (the science of bioengineering
at the molecular level to produce materials with hitherto
unknown and unthought-of properties) will pave the future
of periodontal regeneration. To this end there is considerable
work being carried out with regards to the rational use of biodegradable scaffolds, informed use of instructive molecular
messengers and the selection of specific cell phenotypes or
even stem cells for periodontal regeneration.
Key factors in attaining successful periodontal
regeneration are the correct recruitment of cells to the
site and the production of a suitable extracellular matrix
consistent with the periodontal tissues. As cell seeding
to enhance regeneration of other tissues (skin, cartilage,
bone, cardiovascular components, pancreas, etc.) has been
used successfully (Persidis, 1999), it is seems logical that
autologous periodontal ligament stem cells cultured within
a suitable delivery scaffold, in conjunction with the growth
and differentiation factors present in an autologous blood
clot, will lead to new periodontal tissue attachment via a tissue
engineering approach (Bartold et al., 2006).
The discovery of periodontal ligament stem cells has
opened a new vista for periodontal regeneration (Seo et al.,
2004). Many studies have now confirmed the presence of
mesenchymal stem cell (MSC)-like cells in the periodontal
ligament (Trubiani et al., 2005; Nagatomo et al., 2006;
Gronthos et al., 2006; Jo et al., 2007; Techawattanawisal et al.,
2007). These cells have the characteristics of multipotency
with an ability to differentiate into osteoblast, cementoblast
or lipidogenic phenotypes. These cells are also able to survive
cryo-freezing, which is of particular significance if these cells
are to be banked for future use (Seo et al., 2005).
43
Successful cell transplantation into periodontal

defects and subsequent regeneration was first described
over 20 years ago (van Dijk, 1991). Since then, a new
field of periodontal cell transplantation opened up
with encouraging results being reported. While the
early investigations met with some success, overall
the treatment outcomes were limited because of the
heterogeneous nature of the cells used for such studies.
More recently, the use of periodontal ligament stem cells
for tissue engineering approaches to facilitate periodontal
regeneration has emerged. To date most of the studies
have been restricted to experimental animals, with only
one report involving transplantation of periodontal
ligament stem cells into human periodontal defects being
published (Feng et al., 2010; Hynes et al., 2012).
Thus periodontal ligament stem cells can be used for
regeneration of the periodontium in surgically created
defects in both small and large animal models, albeit with
limited success and in only a narrow field of application.
A significant issue with these studies is that surgically created periodontal defects are very different from defects
arising from periodontitis and thus any extrapolation of
findings for stem cell regeneration in surgically created
defects and what may happen in periodontitis needs to
be made with caution. Another problem encountered
with this approach is that very few of these stem cells
attach to the surface of the alveolar bone and teeth. This
led to the application of using cell sheet technology in
conjunction with regenerative principles to deliver the
regenerative potential of the periodontal ligament stem
cells to the appropriate location (Iwata et al., 2009; Washio
et al., 2010). This requires the identification and isolation of the cells required for periodontal regeneration
and then growing these cells on a temperature-sensitive
sheet in culture. Cell sheet construction involves the use
of a temperature-sensitive polymer biomaterial, poly
N-isopropylacrylamide (PIPA Am), in the cell culturing
process. Once a mature cell sheet is formed, it is harvested
by decreasing the temperature, which leads to detachment
from the temperature-sensitive substrate. This allows
harvesting of a complete sheet of cellular material with
an intact extracellular matrix and cell-cell junctions, in an
attempt to optimize any regenerative attempts. Recently
a clinical study of periodontal regeneration using cell
sheet technology in humans has commenced in Japan
(Yoshida et al., 2012). Following approval by the appropriate government regulatory bodies, autologous cell sheet
transfers with autologous serum have been prepared using
a standard operating procedure to ensure the quality of
the transplant material. Following in vitro and in vivo testing,
the cell sheets were prepared and approved for human
clinical trials in January 2011. To date we still await the
results of these trials, but on the basis of the preclinical
trials the potential for this technology for periodontal
regeneration is promising.
44
Gene and cell-based therapy

Despite the emerging evidence that local application
of growth factors may encourage periodontal regeneration, a number of issues remain which limit their
efficacy. These include containment of the factor at
the local site, limited controlled release of the bioactive peptides, and inactivation of the growth factor via
locally produced proteinases. As a result, more refined
techniques have been explored to improve growth factor delivery and release for periodontal regeneration.
One such method is gene transfer, whereby genes for
regeneration-promoting growth factors using plasmid
and adenovirus gene delivery methods are used (Giannobile et al., 1998; Zhu et al., 2001)
Specifically, the use of adenoviral vectors encoding for growth factors such as platelet-derived growth
factor and bone morphogenetic protein-7 has been
investigated for use in periodontal regeneration (Anusaksathien et al., 2003; Jin et al., 2003; Jin et al., 2004).
These studies have shown that using such an approach
there is sustained transgene expression for up to 10
days and enhanced bone and cementum regeneration
at treated sites beyond this time period compared to the
sites treated with control vectors (Jin et al., 2003; Jin et al.,
2004). However, there is still a considerable amount of
further work required before such an approach becomes
a clinical reality. In particular, in order to maximize the
duration and extent of gene expression, and ultimately
to determine the success of gene transfer techniques in
periodontal regeneration, the number of cells that are
virally transduced to express specific genes needs to be
optimized. Issues remain regarding the overall control
of the process and how to both turn on and turn
off the genes. In addition, research is required to assess
the potential risks of the immunogenicity of viral recombination, which could significantly alter the success
of gene transfer therapies for periodontal regeneration
(Imperiale and Kochanek, 2004; Rios et al., 2011).
Summary and conclusions
Numerous techniques have been tried and tested to regenerate tissues lost to periodontal disease. While there
has been some success to date, more work is required to
move this to a reliable and clinically predictable procedure. Much of the future success for such treatments will
rely largely on our understanding of the biology of both
developmental and regenerative processes. Nonetheless,
despite the noble goal of periodontal regeneration, the
relevance of re-creation of a connective tissue attachment has been questioned. Since formation of a long
junctional epithelial attachment to the tooth following
a variety of periodontal treatment procedures has been
shown to be no more susceptible to further breakdown
than a non-diseased site, the question arises as to what
purpose do we seek the ultimate outcome of periodontal

regeneration? The answer lies in the fact and fiction
of periodontal regeneration. There is no doubt that the
regenerative procedures that have been developed can
be shown to be biologically successful at the histological
level. Furthermore, the results of periodontal regeneration (particularly guided tissue regeneration) have been
stable over the long term (at least up to 10 years). However, the techniques currently under use which show
the greatest promise (guided tissue regeneration and
growth factors) are still clinically unpredictable because
of their highly technique-sensitive nature. In addition,
whether the slight clinical improvements offered by
these procedures over routine open flap debridement
procedures are of cost or patient benefit with regards
to improved periodontal health and retention of teeth
remains to be established.
The next phase in regenerative technologies will
undoubtedly involve a deeper understanding of the
molecular signaling (both intra- and extra-cellular)
and cellular differentiation processes involved in the
regenerative processes. So in answer to the question
of whether periodontal regeneration is fact or fiction,
the answer clearly is that it is both. However, with
more work it will become established fact with little
fiction and the desired clinical endpoint of predictable
regeneration of the periodontal tissues damaged by
inflammation to their original form and function will
be achieved.
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Group C
Reactor Paper
Joerg Meyle
University of Giessen, Germany
Introduction
In the comprehensive and elegantly written review by
Bartold et al. in Periodontology 2000, the authors have
reviewed all different aspects of periodontal regeneration. At first, the principles of periodontal regeneration
are defined as:
1. A functional epithelial seal that should be no more
than 2 mm in length.
2. Connective tissue fibers that are inserted into the
previously exposed root surface to reproduce both
periodontal ligament and the dentogingival fiber
complex.
3. New acellular, extrinsic fiber cementum must be
reformed on the previously exposed root surface.
4. Alveolar bone height must be restored to within 2
mm of the cemento-enamel junction.
In general, periodontal regeneration is part of the
healing process of the periodontal tissues after surgical
intervention. Thus, the events and interactions that occur
during healing have a substantial impact on the healing
result, which normally is characterized by a long junctional
epithelial attachment (Caffesse et al., 1995; Beaumont et
al., 1984). In order to change the results of healing, which
is one of the major goals of regenerative therapy, our
understanding of the basic events has to be substantially
improved. In several reviews the involvement of growth
factors, their interactions and the different cell types have
driven knowledge about healing events and the organization of the blood clot, but still the precise mechanisms
in periodontal healing and regeneration have not been
elucidated (Aukhil, 2000; Caffesse and Quinones, 1993).
During the initial phase a fibrin meshwork is established
and later organized. Even during these steps variations may

11-13 April, 2014
Correspondence to: J Meyle, Periodontology, University of
Giessen, Schlangenzahl 14, Giessen 35392, Germany.
E-mail: joerg.meyle@dentist.med.uni-giessen.de
occur: recently it has been detected that the properties of

the fibrin meshwork change considerably as a reaction
to mechanical stress (Weisel, 2008; Weisel, 2007; Weisel,
2011; Varju et al., 2011).
Early periodontal regeneration studies investigated
the importance of different components of the periodontal tissues in a series of animal experiments. Based
on the results of these studies the concept of guided
tissue regeneration (GTR) was established (Nyman et al.,
1982a; Nyman et al., 1982b; Nyman et al., 1981; Nyman
et al., 1980; Karring et al., 1980; Ellegaard et al., 1974b;
Ellegaard et al., 1974a; Ellegaard et al., 1973). This concept introduced the use of a physical barrier in order to
guide and change events after periodontal surgery. Even
though this clinical concept was established, the basic
biological events associated with the noted periodontal
regeneration were unknown and not further investigated
for many years.
When the GTR concept was introduced into clinical
practice failures were experienced and, as a result, some
people concluded that the basic biological concept did
not work. This was mostly due to the fact that in many
cases the original concept and protocols were not meticulously followed and the properties of the materials
which were introduced into the periodontal wound
were not known. The first human experimental study
for periodontal regeneration used a filter paper made
of cellulose, which was fixed around the diseased root
surface and then the tissues were closed (Nyman, et al.,
1982). Afterwards a block biopsy sample was taken and
the tooth together with the surrounding tissues was
removed. Later on a different barrier was manufactured
and was introduced in general practice, which was not
made of cellulose but of expanded tetrafluorethylene,
which has completely different properties with regard
to diffusion, adhesion and wettability. From then on
the concept of tissue regeneration was largely based
on mechanical interventions.
The first approach to introduce biological factors was based on systematic investigations and observations of the early events of root and ligament
formation (Slavkin et al., 1989; Gestrelius et al., 1997;
Gestrelius et al., 2000).
Group C Reactor: Periodontal regeneration
From these studies it was noted that secretion and

deposition of enamel matrix proteins on the dentin surface
was based on the activity of cells arising from the Hertwigs
epithelial root sheath. Hammarstrom (1997) was able to
demonstrate a layer of enamel matrix proteins in histological sections in different animals and experimental studies.
Enamel matrix proteins would then initiate the differentiation
of cells from the dental follicle into cementoblasts (Hammarstrom, 1997; Hammarstrom et al., 1997).
In contrast to these results, others were not able to
demonstrate any secretion of enamel matrix proteins by
epithelial root sheath cells and questioned this early concept
of enamel matrix proteins (Bosshardt, 2008; Nanci and
Bosshardt, 2006).
To date, the precise steps of cementoblast differentiation
and the importance of enamel matrix proteins in this process
are still not known; however, there is an ongoing discussion
based on the basic cellular and molecular biological effects
leading to the deposition of enamel matrix proteins on the
root surface (Nanci and Bosshardt, 2006; Bosshardt and
Sculean, 2009).
Despite this fact, there is a very large number of
growth factors that have been identified as being important in wound healing and tissue regeneration. Further
research so far has not resulted in any major breakthrough with regard to using these biological agents
for periodontal tissue regeneration, and the influence
of the orchestration of the different cell types that are
involved in these complex healing events.
The introduction of the enamel matrix proteins into
clinical practice resulted in a large number of clinical studies
where it was demonstrated that indeed regenerative therapy
using these proteins resulted in clinical gain of attachment
and bone healing (Sculean et al., 1999a; Sculean et al., 1999b;
Sculean et al., 1999c; Sculean et al., 2000; Sculean et al., 2001;
Sculean et al., 2002; Ebersole et al., 1982; Jepsen et al., 2004;
Meyle et al., 2004; Jepsen et al., 2008; Meyle et al., 2011;
Needleman et al., 2001; Needleman et al., 2005; Needleman
et al., 2006). But still the postulates that were formulated as
the basis of periodontal regeneration could not be fulfilled,
as already stated in the initiators review (Bartold).
In addition, it is known that during the development
of periodontal ligament and root formation, the first
events are the interactions of the fiber systems between
the periodontal ligament and the dentin (Bosshardt and
Schroeder, 1992). These interactions are the result of
very complex cellular activity originating from cementoblasts sitting on the fiber system of dentin that is not yet
mineralized and connecting the fiber systems in order to
achieve a mechanically resistant connection. After the
fiber systems have been connected with each other, the
whole system mineralizes during the following years, thus
leading to the well known periodontal ligament and anchorage of the root in acellular extrinsic fiber cementum
(Bosshardt and Selvig, 1997).
51
Despite the demineralization of the root surface by

acids or chelating agents during regenerative therapy, the
dentin itself is still mineralized and thus a real interconnection of the different fiber systems does not take place
even though a new cementum layer is deposited on top
of the cleaned, previously diseased root surface. According to some investigators, regenerative cementogenesis
along established but formerly diseased and denatured
root surfaces is not achieved in the true sense of the
term (Schroeder, 1992).
In many histological samples it is obvious that during
sample preparation the covering layer of newly formed
cementum is (artificially) separated from the root surface. This does not occur when a natural periodontal
ligament is handled in the same way and prepared for
histological analysis (Bosshardt and Sculean, 2009). In
some specimens, bacteria have been detected on the
dentin surface, indicating that this contamination could
also be responsible for the gap formation (Bosshardt
et al., 2005).
Thus the question arises of how strong the interconnection is between the newly formed cementum layer
and the root surface. In addition, the type of mineralized
tissue formed is another point of discussion: according to Bosshardt this resembles newly formed bone
and not acellular extrinsic fiber cementum (Bosshardt
et al., 2006).
Assessment of human histological samples from
regenerative procedures have demonstrated periodontal
regeneration in terms of new cementum, bone and periodontal ligament. Furthermore, clinical measurements
and radiographs have also demonstrated the clinical
success of this type of therapy by a combination of
reduced probing depths together with gain of clinical attachment. However, to date, it has not been proven that
regenerative treatment is really improving the anchorage
of the tooth in the surrounding tissues.
As another conceptual problem for this treatment
approach, data are missing that demonstrate that
through regenerative therapy, either using mechanical
barriers or biologically active proteins, the longevity of
the tooth is improved, i.e., that this type of treatment
avoids tooth loss.
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Bartold PM. Periodontal regeneration fact or fiction?
Journal of the International Academy of Periodontology
2015; 17/1 (Supplement):37-49.
Bartold PM, McCulloch CA, Narayanan AS and Pitaru S.
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Periodontology 2000 2000; 24:253-269.
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Beaumont RH, OLeary TJ and Kafrawy AH. Relative

resistance of long junctional epithelial adhesions and
connective tissue attachments to plaque-induced inflammation. Journal of Periodontology 1984; 55:213-223.
Bosshardt DD. Biological mediators and periodontal regeneration: a review of enamel matrix proteins at the
cellular and molecular levels. Journal of Clinical Periodontology 2008; 35:87-105.
Bosshardt DD and Schroeder HE. Initial formation of
cellular intrinsic fiber cementum in developing human
teeth. A light- and electron-microscopic study. Cell and
Tissue Research 1992; 267:321-335.
Bosshardt DD and Sculean A. Does periodontal tissue
regeneration really work? Periodontology 2000 2009;
51:208-219.
Bosshardt DD, Sculean A, Donos N and Lang NP. Pattern
of mineralization after regenerative periodontal therapy
with enamel matrix proteins. European Journal of Oral
Science 2006; 114(Suppl 1):225-231.
Bosshardt DD, Sculean A, Windisch P, Pjetursson BE and
Lang NP. Effects of enamel matrix proteins on tissue
formation along the roots of human teeth. Journal of
Bosshardt DD and Selvig KA. Dental cementum: the
dynamic tissue covering of the root. Periodontology 2000
1997; 13:41-75.
Caffesse RG, Mota LF and Morrison EC. The rationale
for periodontal therapy. Periodontology 2000 1995; 9:7-13.
Caffesse RG and Quinones CR. Polypeptide growth factors and attachment proteins in periodontal wound
healing and regeneration. Periodontology 2000 1993;
1:69-79.
Ebersole JL, Taubman MA, Smith DJ, Genco RJ and Frey
DE. Human immune responses to oral micro-organisms. Clinical and Experimental Immunology 1982; 47:43-52.
Ellegaard B, Karring T, Davies R and Loe H. New attachment after treatment of intrabony defects in monkeys.
Journal of Periodontology 1974a; 45:368-377.
Ellegaard B, Karring T, Listgarten M and Loe H. New
attachment after treatment of interradicular lesions.
Ellegaard B, Karring T and Loe H. New periodontal
attachment procedure based on retardation of epithelial migration. Journal of Clinical Periodontology 1974b;
1:75-88.
Gestrelius S, Andersson C, Lidstrom D, Hammarstrom
L and Somerman M. In vitro studies on periodontal
ligament cells and enamel matrix derivative. Journal
Gestrelius S, Lyngstadaas SP and Hammarstrom L.
Emdogain--periodontal regeneration based on biomimicry. Clinical Oral Investigations 2000; 4:120-125.
Hammarstrom L. Enamel matrix, cementum development and regeneration. Journal of Clinical Periodontology
1997; 24:658-668.
Hammarstrom L, Heijl L and Gestrelius S. Periodontal

regeneration in a buccal dehiscence model in monkeys after application of enamel matrix proteins.
Jepsen S, Heinz B, Jepsen K, et al. A randomized clinical
trial comparing enamel matrix derivative and membrane treatment of buccal Class II furcation involvement in mandibular molars. Part I: Study design and
results for primary outcomes. Journal of Periodontology
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Jepsen S, Topoll H, Rengers H, et al. Clinical outcomes
after treatment of intra-bony defects with an EMD/
synthetic bone graft or EMD alone: a multicentre
randomized-controlled clinical trial. Journal of Clinical
Karring T, Nyman S and Lindhe J. Healing following implantation of periodontitis affected roots into bone
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Meyle J, Gonzales JR, Bodeker RH, et al. A randomized
clinical trial comparing enamel matrix derivative and
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outcomes. Journal of Periodontology 2004; 75:1188-1195.
Meyle J, Hoffmann T, Topoll H, et al. A multi-centre
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Needleman I, Tucker R, Giedrys-Leeper E and
Worthington H. Guided tissue regeneration for periodontal intrabony defects--a Cochrane Systematic
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Needleman IG, Giedrys-Leeper E, Tucker RJ and
Worthington HV. Guided tissue regeneration for
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Nyman S, Gottlow J, Karring T and Lindhe J. The regenerative potential of the periodontal ligament. Journal
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Nyman S, Karring T, Lindhe J and Planten S. Healing
following implantation of periodontitis-affected
roots into gingival connective tissue. Journal of Clinical
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surgical treatment and root demineralization in
monkeys with periodontal disease. Journal of Clinical
Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human
periodontal disease. Journal of Clinical Periodontology.
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Schroeder HE. Biological problems of regenerative
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collagenous matrices on growing and established
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Sculean A, Donos N, Blaes A, Lauermann M, Reich
E and Brecx M. Comparison of enamel matrix
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Sculean A, Donos N, Brecx M, Karring T and Reich
E. Healing of fenestration-type defects following
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matrix proteins. An experimental study in monkeys.
Clinical Oral Investigations 2000; 4:50-56.
Sculean A, Donos N, Miliauskaite A, Arweiler N and
Brecx M. Treatment of intrabony defects with
enamel matrix proteins or bioabsorbable membranes.
A 4-year follow-up split-mouth study. Journal of Periodontology 2001; 72:1695-1701.
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Reich E and Karring T. Healing of human intrabony
defects following treatment with enamel matrix
proteins or guided tissue regeneration. Journal of
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Sculean A, Reich E, Chiantella GC and Brecx M.
Treatment of intrabony periodontal defects with
an enamel matrix protein derivative (Emdogain): a
report of 32 cases. International Journal of Periodontics
and Restorative Dentistry 1999c; 19:157-163.
Sculean A, Windisch P, Keglevich T, Fabi B, Lundgren
E and Lyngstadaas PS. Presence of an enamel matrix protein derivative on human teeth following
periodontal surgery. Clinical Oral Investigations 2002;
6:183-187.
Slavkin HC, Bessem C, Fincham AG, et al. Human and
mouse cementum proteins immunologically related
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991:12-18.
Varju I, Sotonyi P, Machovich R, et al. Hindered dissolution of fibrin formed under mechanical stress.
Journal of Thrombosis and Haemostasis 2011; 9:979-986.
Weisel JW. Structure of fibrin: impact on clot stability.
Journal of Thrombosis and Haemostasis 2007; 5(Suppl
1):116-124.
Weisel JW. Biophysics. Enigmas of blood clot elasticity.
Science 2008; 320:456-457.
Weisel JW. Stressed fibrin lysis. Journal of Thrombosis and
Haemostasis 2011; 9:977-978.
Group C
Consensus Paper
Moderator: Murakami, Shinya, Osaka University, Japan
Initiator: Bartold, Mark, University of Adelaide, Australia
Reactor: Meyle, Joerg, University of Giessen, Germany
Working Group C:
Agarwal, Ruchi, Private Practice, Melbourne, Australia
Anagnostou, Fani, Paris Diderot University, France
Bakalyan, Vardan, Yerevan State Medical University, Armenia
Bunyaratavej, Pintippa, Mahidol University, Thailand
Chitguppi, Rajeev, Terna Dental College-Navi Mumbai, India
Darby, Ivan, University of Melbourne, Australia
Gamal, Ahmed, Ain Shams University, Egypt
Jacob, Shaiju, International Medical University, Malaysia
Jin, Yan, Fourth Military Medical University, China
John, Janice, Private Practice, India (Transcriber)
Kale, Rahul, M.A.Rangoonwaala College of Dental Sciences, India
(Transcriber)
Liechter, Jonathan, University of Otago, New Zealand
Minh, Nguyen Thi Hong, National Hospital of Odonto-Stomatology,
Vietnam
Nagata, Toshihiko, University of Tokushima Graduate School, Japan
Nazreth, Bianca, India
Nishida, Mieko, Sunstar Inc, Japan
Pack, Angela, University of Otago (Retired), New Zealand
Patnaik, Samarjeet, India
Shibutani, Toshiaki, Asahi University, Japan
Singh, Preetinder, SDD Hospital & Dental College, India
Soeroso, Yuniarti, Universitas Indonesia, Indonesia
Spahr, Axel, University of Sydney, Australia
Yang, Yueh Chao, Taiwan
Yeung, Stephen, University of Sydney, Australia
Introduction
To discuss the topic of periodontal regeneration this
working group determined the need to clarify some definitions relating to the biological and clinical outcomes
of periodontal regeneration. Subsequently the group
considered two key issues:

11-13 April, 2014
Correspondence to: Murakami, Shinya, Osaka University, Japan,
E-mail: ipshinya@dent.osaka-u.ac.jp
1. What are the benefits of periodontal regeneration?

2. What are additional considerations that should be
taken into account when using regenerative agents?
A number of recommendations were thus developed.
The background for the discussion was presented in
the Initiator Paper. The fundamental question raised for
discussion was whether periodontal regeneration is fact
or fiction. To answer this question, a comprehensive
narrative review of the literature was presented. It was
noted that many regenerative techniques have been developed with the aim of obtaining reliable and clinically
Group C Consensus: Periodontal regeneration
significant periodontal regeneration. To date there has

been some success but in general the procedures are
very technique-sensitive and often clinically unpredictable. There is no doubt that periodontal regenerative
procedures have been shown to be biologically successful at the histological level. Furthermore, the clinical
outcomes of periodontal regeneration (particularly guided
tissue regeneration) have been shown to be stable over
the long term (at least up to 10 years) However, whether
the slight clinical improvements offered by periodontal
regenerative procedures are of cost or patient benefit
with regards to improved periodontal health and retention of teeth remains to be established. It was concluded
that there is more work required to move periodontal
regenerative medicine to a more reliable and clinically
predictable procedure, and that future research will need
to focus on further understanding of the biology of both
developmental and regenerative processes.
Definitions
Biological definition of periodontal regeneration
Periodontal regeneration is a biological term defined
histologically as reconstitution (restitutio ad integrum) of
the tooths supporting tissues, including alveolar bone,
periodontal ligament and cementum over a root surface
deprived of the attachment apparatus.
Clinical perspective of periodontal regeneration
From a clinical point of view periodontal regeneration
will be reflected in gain of clinical attachment and reduced
probing pocket depth. However, using these parameters
it is not possible for a clinician to differentiate between
reparative healing and periodontal regeneration. For these
reasons, and because of the wide range of regenerative
materials available, the clinical outcome can best be considered as reconstruction rather than regeneration.
Definition of periodontal reconstruction
Reconstruction of periodontal tissues is a clinical term
characterized by reparative and/or partial regenerative
healing, which results in improvement of clinical (gain
of clinical attachment, reduced probing pocket depth)
and radiographic parameters.
Question 1. What are the benefits of periodontal
regeneration?
Periodontal regeneration has the potential to improve
prognosis and longevity of the tooth. Systematic reviews
suggest that the use of membranes, grafting materials with
membranes and/or regenerative materials such as enamel
matrix proteins, yield superior outcomes in terms of clinical attachment gain, pocket reduction and radiographic
bone gain compared to open flap debridement alone
(Needleman et al. 2006; Trombelli et al., 2002; Reynolds
et al., 2003; Sohrabi et al., 2012).
55
Clinically, periodontal regeneration remains difficult

to achieve in a predictable and substantial way (Needleman, 2006). Periodontal regenerative procedures have
been shown to be technique-sensitive. The outcomes
of periodontal regeneration are influenced by patient,
defect, materials, and operator factors that may require
the use of evidence-based decision algorithms. Control
of inflammation and infection is a pre-requisite before
undertaking reconstructive/regenerative procedures.
Under ideal conditions and careful case selection, significant clinical improvement can be achieved.
Question 2. What additional considerations
which should be taken into account when using
regenerative agents?
Recognizing that approved products and devices have
been used with proven efficacy and no reported severe
adverse reactions, certain issues still exist in the use of
regenerative materials which must be acknowledged.
These include:
Cost/benefit
Ethnic, religious and cultural issues
Hybrid or copy agents
Off-label use
Risk of disease transmission
Risk of unwanted immunological reactions
Risks not apparent at the time of product release
Unrealistic dentist/patient expectations
Recommendations
From this consensus report the following recommendations regarding periodontal regeneration were made:
1. Recognize and understand the difference between
regeneration and reconstruction.
2. Control of inflammation and infection is a requisite before and after undertaking reconstructive/
3. Case selection is critical to the treatment outcome.
4. Be aware of the limitations of assessment criteria
for evaluating the outcomes of reconstructive/
5. Recognize that reconstructive/regenerative procedures are technique-sensitive and the outcome
may be variable.
Conclusion
Periodontal regeneration can result in improvement of
clinical and radiographic parameters and has the potential to enhance the prognosis and longevity of teeth.
56
References
Bartold PM. Periodontal regeneration fact or fiction?
Journal of the International Academy of Periodontology
2015; 17/1 (Supplement):37-49.
Needleman IG, Worthington HV, Giedrys-Leeper
E, Tucker RJ. Guided tissue regeneration for
periodontal infra-bony defects. Cochrane Database of
Systematic Reviews 2006; 2:CD001724.
Reynolds MA, Aichelmann-Reidy ME, Branch-Mays
GL, Gunsolley JC. The efficacy of bone replacement
grafts in the treatment of periodontal osseous
defects. A systematic review. Annals of Periodontology
2003; 8:227-265.
Sohrabi K(1), Saraiya V, Laage TA, Harris M, Blieden

M, Karimbux N. An evaluation of bioactive glass in
the treatment of periodontal defects: a meta-analysis
of randomized controlled clinical trials. Journal of
Trombelli L, Heitz-Mayfield LJ, Needleman I, Moles D,
Scabbia A. A systematic review of graft materials
and biological agents for periodontal intraosseous
defects. Journal of Clinical Periodontology 2002; 29
Suppl 3:117-135.
Group D
Initiator Paper
Implants - Peri-implant (hard and soft tissue)
interactions in health and disease: The impact
of explosion of implant manufacturers
Saso Ivanovski
School of Dentistry and Oral Health, Griffith University, QLD,
Australia
Introduction
Osseointegration is defined as a direct, structural and
functional connection between ordered, living bone
and the surface of a load-carrying implant (Listgarten
et al., 1991). Direct bone-to-implant contact was first
described by Brnemark et al. (1969) and histologically
demonstrated by Schroeder et al. (1978) as functional
ankylosis. Albrektsson et al. (1981) described successful
clinical treatment outcomes of 2895 threaded titanium
screw implants placed using a strict surgical protocol.
Subsequent animal studies showed that implants with
various designs and surface configurations become
osseointegrated, and analysis of numerous retrieved
implants documented that osseointegration is also a reality in humans (Schenk and Buser, 1998). The temporal
wound healing events leading to osseointegration were
shown to involve coagulum formation, granulation tissue formation, the development of a provisional matrix,
woven bone formation, parallel-fibered bone formation,
and eventually lamellar bone formation (Berglundh et
al., 2003).
The soft tissue attachment to implants is similar
to teeth, with the presence of junctional epithelium
and connective tissue fibers, although it is noteworthy
that some important differences exist in that the fibers
around implants are parallel rather than perpendicular
to the surface, and the connective tissue surrounding
the implant is less vascular than that surrounding teeth
(Berglundh et al., 1991). Berglundh et al. (2007b) showed
that, while the formation of a junctional epithelium

11-13 April, 2014
Correspondence to: Saso Ivanovski, School of Dentistry and Oral
Health, Gold Coast Campus, Griffith University QLD 4222, Australia
E-mail: s.ivanovski@griffith.edu.au
occurs within approximately 2 weeks of implant placement, the maturation of the soft tissue complex needs
6-8 weeks to establish after implant placement in an
animal model. DeAngelo et al. (2007) concluded that
soft tissue maturation, as evidenced by stable probing,
was achieved in approximately 4 weeks from the time
of implant placement in humans. Importantly, it is universally accepted that adhesion of the soft tissues to the
implant is critical for the maintenance of osseointegration (Klinge et al., 2006).
In terms of evaluating the performance of dental implant
therapy, it must be recognized that it is no longer acceptable
to simply consider the continuing presence of the implant at
the site of insertion (implant survival) as a suitable measure
of clinical outcome. Instead, it is important that the implant is
free from biological, mechanical and aesthetic complications
(implant success). In this regard, recent systematic reviews
of longitudinal clinical studies of a mean 5-year follow-up
have shown that implant survival rates were high, at 96.3%
after 5 years and 89.4% after 10 years for single tooth restorations, and 96.4% after 5 years and 93.9% after 10 years for
fixed prosthesis in partially edentulous patients (Jung et al.,
2012; Pjetursson et al., 2012). However, the rate of technical,
biological and aesthetic complications is also high, at up to
a combined 33.6% (Pjetursson et al., 2012).
It is widely recognized that implant-related characteristics can influence the outcome of treatment
(Capelli, 2013). Combined with the continual increase
in implant manufacturer numbers and the associated
variations in implant design, this has the potential to
affect the establishment and maintenance of osseointegration, as well as the incidence and management of
complications. This review will evaluate implant-related
characteristics that can influence soft and hard tissue
healing around implants. Furthermore, the way that
implant factors may affect the incidence and management of complications affecting the peri-implant tissues will be explored.
58
The explosion of implant manufacturers

It is difficult to precisely estimate the number of
companies providing implant components as this
information is not available in the published scientific
literature, but anecdotal evidence suggests that numbers have continued to increase exponentially over
the years. One reason for this is that implant dentistry
has been a high growth market over the past decade,
growing at approximately 20% per year up to 2007,
and more modestly since. Furthermore, as implants
are treated as medical devices by regulatory bodies,
the requirements for registering new products are less
demanding than those required for pharmaceuticals,
providing a low barrier to entry by new manufacturers. The method used by the industry to estimate the
number of implant companies in the market is by
evaluating the number of dental implant company
exhibitors at dental conferences and trade shows. In
this regard, an analyst report issued by the investment
firm Morgan Stanley in March 2013 stated that the
number of dental implant competitors has increased by
29% in 2 years from 183 to 236 based on exhibitors
at the International Dental Show. Similarly, internal
research by a leading implant company found that the
number of implantology exhibitors at various dental
shows and conferences in 2013 was 480, compared
to 413 in 2011 and 120 in 2003. Irrespective of the
accuracy of these data, it is clear that the number of
manufacturers is large and has increased significantly
over the past decade.
Implant - peri-implant interactions in health
Albrektsson et al. (1981) concluded that there were six
major factors influencing osseointegration. These were
implant material, implant design, implant finish, status
of the bone, surgical technique and implant loading
conditions. These observations are still relevant today
and it is important to note that the first three properties
[material, (macro-) design and (micro-) finish] are related to the implant characteristics and can therefore be
subject to variation during the manufacturing process.
Implant material
The primary consideration with regards to the implant material is its biocompatibility. The original Brnemark protocol
used commercially pure titanium and this is still considered
the gold standard material for implant use. Indeed, the vast
majority of currently available implants are made of commercially pure (grade IV) titanium. Alternatives are titanium
alloys (e.g., grade V titanium (Ti-6Al-4V) or titanium- zirconia
alloy (TiZr)) and zirconia implants, made currently either of
yttria-stabilized tetragonal zirconia polycrystals (Y-TZP) or
yttria-partially stabilized zirconia (Y-PSZ) (Wenz et al., 2008;
Ehrenfest et al., 2010). The alloys are generally used for
increasing strength, especially in narrow diameter implants,
while the zirconia implants have been advocated on the

basis of improved aesthetics. Importantly, the vast majority
of long-term studies report on commercially pure titanium
implants with some short-term studies on titanium alloy
implants (Barter et al., 2012), while zirconia implants cannot
be recommended due to a lack of long-term studies (Wenz
et al., 2008; Andreiotelli et al., 2009).
Implant macro-features
The macro-design of implants can vary greatly, and there
are several key considerations in the way that implant macrodesign can affect treatment outcomes. Firstly, there is a requirement to achieve good primary stability of the implant,
without excessive trauma at the osteotomy site which may
result in necrosis. A second consideration is the ability to
achieve a good seal at the implant-abutment margin in order
to obtain good marginal integrity of the soft tissues, thus
preventing future mechanical and biological complications.
A third consideration is the ability to maintain the marginal
bone levels during the initial physiological remodeling phase,
which may be particularly important in aesthetic areas.
Implant shape and size
The shape of the implant body should allow implant insertion with adequate primary stability while minimizing
trauma to the recipient tissue. The most common current design is the solid screw threaded implant (including
parallel wall and tapered designs), which is supported by
abundant long-term data. Alternatives are hollow screws
and cylinders, which are usually inserted using the press-fit
method. A systematic review of randomized controlled
trials that compared different implant types did not find
differences in implant failures between different implant
shapes (Esposito et al., 2007). However, an earlier review
found that press-fit implants were associated with more
long-term marginal bone loss (Sennerby and Loos, 1998).
A concern in regards to hollow cylinder designs is that the
implants are impossible to treat if bone loss occurs (Baelum
and Ellegaard, 2004). It should be noted that virtually all
major implant manufacturers currently use the threaded
solid screw design, with the press-fit designs having been
abandoned some years back.
In terms of implant size, length and diameter do not
appear to be related to implant failure (Lee et al., 2005).
A systematic review investigating short implants of 5-9
mm (majority 8 mm) found high (>99%) cumulative
survival rates (Annibali et al., 2012), suggesting that
short implant length does not adversely affect treatment
outcomes. Indeed, a recent meta-analysis of 12 studies
with minimum 1-year follow-up has shown good treatment outcomes with 6 mm long implants (Srinivasan
et al., 2013). Similarly, narrow diameter implants (3.5
mm) have been shown to have good treatment outcomes
(Sohrabi et al., 2012), showing that implant diameter does
not negatively affect treatment. However, mini-implants
Group D Initiator: Peri-implant health and disease
(1.8-2.9 mm), commonly used for orthodontic and interim prosthodontic treatment, do not have sufficient
evidence to support their use in definitive treatment
(Bidra and Almas, 2013). It should be noted that implant
manufacturers continue to push the boundaries in terms
of implant length and diameter, and practitioners should
exercise caution in using implants less than 6 mm long
or 3 mm in diameter.
The implant-restoration interface
Generally implants have three components - the implant
itself, an abutment that facilitates the attachment/retention of the restoration and the restoration itself. The
design of the implant-abutment interface can have an
influence on the nature of the post-loading remodeling
process at the coronal margin of the bone crest. Traditional criteria for success of implant treatment have
allowed for early crestal bone loss of up to 1 mm and
ongoing annual bone loss of up to 0.2 mm to be considered a normal physiological response (Albrektsson et
al., 1986). However, this notion is now being challenged,
with contemporary implant designs aimed at preventing
marginal bone loss. This is achieved by improving the
nature of the connection between the implant and the
abutment/restoration, which then has the dual purpose
of minimizing early crestal bone loss due to physiological re-modelling, as well as minimizing future mechanical
and biological complications that may arise from poor
fit between the implant componentry. Several implant
design features may be important in this regard:
1. Internal vs external connection
2. Horizontal offset of the implant-abutment junction
(platform switching)
3. Macrogeometry at the implant collar
1) Internal vs external connection
The connection that allows the prosthetic superstructure
to attach to the implant can be either external (a projection outside the implant body) or internal (within the
body of the implant). The original Brnemark implant
design had an external hexagon that was developed to
facilitate implant insertion (Brnemark et al., 1985). Although this system was associated with good long-term
implant survival outcomes, it does have the drawback of
allowing micromovement under high off-axis occlusal
forces, which may in turn result in abutment screw loosening or even fatigue fracture (Jemt et al., 1991; Becker
and Becker, 1995).
Internal connection implant systems have gained popularity because of a perceived higher resistance to bending
and improved force distribution over external configurations (Asvanund and Morgano, 2011; Freitas et al., 2011).
This is achieved through their ability to dissipate lateral
loads deeply within the implant and to resist joint opening
due to a deep and rigid connection (Steinebrunner et al.,
59
2008; Bernardes et al., 2009; Sailer et al., 2009; Seetoh et al.,

2011), resulting in improved protection of the abutment
screw from stress. A systematic review assessing internal
and external connections (Gracis et al., 2012) found that
the type of connection influenced the incidence of screw
loosening, with more loose screws reported for externally
connected implant systems. However, it was acknowledged
that appropriate pre-loading may decrease the incidence
of screw loosening.
Internal connection systems adapted by various manufacturers differ in a variety of parameters, including the
intimacy of approximation between the abutments surface
and the internal implant walls, depth of penetration of
the abutment in the fixture, presence of anti-rotational
interlocking, number and shape of anti-rotational or guiding grooves and abutment diameter at the platform level
(Wiskott et al., 2007; Steinebrunner et al., 2008; Bernardes et
al., 2009; Copped et al., 2009; Tsuge and Hagiwara, 2009).
These factors can have a significant impact on clinical
procedures and protocols, including length and number
of appointments, component and laboratory costs, maintenance intervals, and incidence of complications.
Therefore, it is of great importance that clinicians
understand the detailed characteristics of any systems
that they intend to utilize. In this context, it is also noteworthy that there are a number of manufacturers who
produce compatible abutments to established systems
that may not accurately fit the parent implant (Mattheos and Janda, 2012). Clinicians should ensure that
appropriate componentry is utilized, including adequate
communication and direction to the dental laboratory.
2) Horizontal offset of abutment at implant
interface (platform switching)
It has been proposed that a horizontal mismatch between the diameter of the implant and the abutment
can result in little to no change in crestal bone height
following insertion (Lazzara and Porter, 2005). This
has resulted in the development of several implant systems that feature an abutment-implant interface that is
internally offset in relation to the external edge of the
implant, a design feature that is referred to as platform
switching.
The rationale proposed for this approach is that the
internal re-positioning of the implant-abutment interface
would shift the inflammatory cell infiltrate formed at this
interface away from the crestal bone, resulting in biologic
width re-establishment in a predominantly horizontal
rather than vertical dimension (Lazzara and Porter, 2005).
This in turn minimizes vertical bone resorption associated with the physiological remodeling associated with
biologic width formation. It has also been proposed that
platform shifted implants have a biomechanical advantage
by moving stress concentration away from the outer edges
of the implant (Maeda et al., 2007).
60
A recent systematic review and meta-analysis of nine

clinical trials concluded that platform switching was
indeed a desirable design feature that minimizes vertical
crestal bone loss (Al-Nsour et al., 2012). The authors
identified several confounding factors that should be
considered when interpreting the results, such as the
apico-coronal position of implants in relation to crestal
bone, the presence of various implant micro-textures,
the degree of platform switching and the reliability of
examination methods.
3) Macrogeometry of threads at the implant
collar
Biomechanical modelling studies have found that peak
horizontal and vertical loading forces occur at the top
of the marginal bone (Stoiber, 1988). Based on these
observations, a smooth implant collar was advocated to
minimize the horizontal forces. However, this approach
did not yield the desired outcome, and a modified implant macro-geometry with minute threads at the collar
has been advocated as a more effective alternative (Hansson, 1999), particularly when combined with an internal
conical implant abutment connection (Abrahamsson
and Berglundh, 2009). The superiority of the microthread compared to the smooth collar design has been
supported by animal and human studies (Abrahamsson
and Berglundh, 2006; Lee et al., 2007; Nickenig et al.,
2009). In contrast, the micro-topography of the implant
surface does not appear to influence marginal bone loss
(Abrahamsson and Berglundh, 2009). However, it has
been proposed that laser micro-grooves at the implant
collar result in perpendicular, rather than parallel, orientation of fibers to the implant surface, potentially
resulting in a superior attachment, although the clinical
implications of this are not yet known (Ketabi and
Deporter, 2013). In summary, the implant-abutment/
restoration interface in contemporary implant designs
is focused on minimizing technical complications by
reducing the incidence of screw loosening, as well as
minimizing crestal bone loss during the initial remodeling phase.
While appropriately designed internal connections
are largely responsible for improved outcomes in terms
of screw loosening, reduction in crestal bone loss is
likely to be the result of a combination of features,
including internal connection, platform switching and
micro-thread design of the implant collar. However, the
precise combination of these interdependent parameters
that results in the best outcomes is yet to be determined
in long-term clinical trials.
Implant surfaces
Osseointegration is a biological process that involves
a cascade of events which occur at the tissue-implant
interface. These involve clot formation and the initial
adsorption of serum components immediately following implant placement, an immune-inflammatory

response to implant insertion, the migration and attachment of undifferentiated mesenchymal cells onto
the implant surface, their proliferation and differentiation, the formation of extracellular matrix, and finally
its mineralization and maturation. Several features of
the implant surface can influence the rate and extent
of bone-implant contact, and surface modification
has been advocated as a method for enhancing osseointegration (Junker et al., 2009; Wennerberg and
Albrektsson, 2009; Ehrenfest et al., 2010).
There are two broad methods used to modify the
implant surface (Ehrenfest et al, 2010). In the first approach, the interface is improved chemically by incorporating inorganic phases, such as calcium phosphate,
or organic molecules, such as proteins, enzymes or
peptides, on or into the TiO2 (titanium dioxide) layer.
Implants with thick hydroxyapatite (HA) layers were
initially advocated as a way to improve the speed and
extent of osseointegration, but were found to result in
implant failure due to delamination of the HA coating
(Piattelli et al., 1995). While thin calcium phosphate
coating technology may solve the problems associated
with thick calcium phosphate coatings, there is a lack
of human clinical data to support their superiority
over conventional micro-rough surface implants (Junker et al., 2011). Furthermore, there is no convincing
evidence to support the use of implants with organic
molecule coatings (Junker et al., 2011).
In the second approach, the interface is improved
physically by modifying the architecture of the surface
topography at the micrometer or nanometer level.
In particular, it has been shown that the micro-level
topography of the implant surface can influence the
extent and speed of osseointegration around the
implant (Wennerberg and Albrektsson, 2009). In the
most widely recognized classification of micro-level
topography proposed by Albrektsson and Wennerberg
(2004), smooth surfaces were proposed to have an Sa
value (arithmetic mean deviation of a surface) of <0.5
m; minimally rough surfaces have an Sa of 0.5-1 m,
moderately rough surfaces have an Sa of 1-2m, and
rough surfaces have an Sa of >2 m.
In animal studies, moderately rough titanium implants were shown to have a superior bone-to-implant
contact compared to minimally rough implants (Buser
et al., 1991), as well as superior torque removal values
(Buser et al., 1998). These results have been replicated
in histological analysis of human samples (Lazzara et al.,
1999; Ivanoff et al., 2001; Ivanoff et al, 2003; Grassi et
al., 2007). Notably, histological analysis of the sequential
healing events following implant placement demonstrated evidence of superior early healing associated
with moderately rough compared to minimally rough
surfaces (Abrahamsson et al., 2004). Furthermore, initial

bone formation around the moderately rough surface
implants occurred not only at the exposed bone wall
of the surgically created recipient site (distance osteogenesis), but also along the osteophylic implant surface
(contact osteogenesis), which was not observed on the
minimally rough implants (Berglundh et al., 2003; Abrahamsson et al., 2004).
Additional changes to moderately rough surfaces
via chemical modification has resulted in nanoscale
features and changes in chemical composition and/
or hydrophilicity, which have resulted in greater boneimplant contact in animal (Buser et al., 2004; Berglundh
et al., 2007a) and human studies (Orsini et al., 2007; Lang
et al., 2011). Notably, longitudinal time-course histomorphometric studies have shown that while moderately
rough implants result in both earlier and ultimately
greater bone-implant contact compared to minimally
rough implants (Abrahamsson et al., 2004), the chemically modified surfaces only accelerate osseointegration,
with no differences in the final bone-implant contact
values compared to moderately rough implants (Buser
et al., 2004; Berglundh et al., 2007a; Lang et al., 2011).
Many currently available implant systems employ a
combination of chemical and physical modifications.
However, it should be noted that implant surfaces are
generally poorly characterized, with microscale topography being the most widely reported parameter,
while other important parameters such as topographical uniformity, nanoscale features and purity have not
been documented (Wennerberg and Albrektsson, 2009;
Ehrenfest et al., 2010).
Clinical relevance of implant surface modification
In the clinical context, while the original machined Brnemark implants had a minimally rough topography, the vast
majority of implant systems that have been commercially
available over the past decade have a micro-rough topography, which is within or very close to the Sa values of the
moderately rough category (Sa 1-2 m). More recently,
a third generation of chemically modified surfaces with
nanoscale features has become commercially available.
It is noteworthy that there are a large number of studies
that document the clinical performance of first generation
machined and the various second generation micro-rough
implants, but there are relatively few clinical studies that
report on the medium- to long-term performance of newly
developed chemically/nanoscale modified implant surfaces.
It is important to note that excellent long-term results
have been reported with the original first generation
machined implants, with implant success of up to 99%
reported at 15 years follow-up (Lindquist et al., 1996).
However, poorer results may be obtained in achieving osseointegration with machined implants in compromised
sites, such as the posterior maxilla (Becktor et al., 2004),
61
and patients such as smokers (Balshe et al., 2008). Animal

data would suggest that moderately rough implant surfaces
may result in improved clinical outcomes, such as decreased
healing times and increased success in compromised sites
and patients. However, there is a scarcity of human clinical
studies to substantiate these hypotheses, as there are few
randomized controlled clinical trials that directly compare
the relative performance of different implant surfaces, especially in compromised situations. In a systematic review
of the few available controlled randomized clinical trials,
most of which involve a small numbers of patients, it has
been shown that there is a clear trend towards a higher
risk for implant failure in implants with machined surfaces
compared with micro-rough surface implants (Esposito
et al., 2007).
In the absence of large randomized controlled clinical
trials, a review of cohort studies may be used to ascertain
the relative performance of micro-rough and machined
implants. Lambert et al. (2009) undertook a comprehensive
assessment of 1- to 15-year survival rates of fixed implant
rehabilitations in the edentulous maxilla incorporating
32 studies, including 1,320 patients and 8,376 implants.
Implants with micro-rough surfaces showed a statistically
higher survival rate than machined implants at all intervals
(1, 3, 5, 10 and 15 year time-points). Furthermore, there is
evidence from meta-analysis of cohort studies that microrough implants perform better than machined implants in
augmented sites in the maxilla (Del Fabbro et al., 2008; Lambert et al., 2009), as well as in smokers (Balshe et al., 2008).
In the clinical context, an important consideration is the
influence of the emergence of micro-rough surfaces on
the utilization of short implants. This is because implant
survival is higher when short implants are used then when
vertical bone augmentation is utilized to overcome bone
deficiency, especially in the posterior mandible (Esposito
et al., 2009). In this context, it has been shown that short
micro-rough implants have a greater survival rate than
machined-surfaced implants (Feldman et al., 2004; Renouard and Nisand, 2005; Annibali et al., 2012).
In summary, moderately rough implants appear to
improve the speed and extent of bone-implant contact
in histomorphometric studies, which is also supported by
meta-analysis of clinical cohort studies that suggest that
these implants perform better than those with minimally
rough machined surfaces. However, it should be noted
that surface characterization of implants is generally poor,
which has implications in the context of the ever increasing number of manufacturers. Further, it should be noted
that new generation nanoscale modified implants have
inadequate surface characterization, and are generally
not supported by long-term clinical studies. So, although
there is good clinical rationale for the use of micro-rough
implants, practitioners should exercise caution when choosing implants for clinical use, and ensure that the relevant
surfaces have good long-term clinical evaluation.
62
Implant peri-implant interaction in disease

Peri-implant disease
The 6th European Workshop on Periodontology defined the term peri-implant disease as a collective
term for inflammatory reactions in the tissues surrounding an implant, with peri-implant mucositis described
as the presence of inflammation in the mucosa at an
implant with no signs of loss of supporting bone and
peri-implantitis as an inflammatory process around
an implant, characterized by soft tissue inflammation
and loss of supporting bone (Lindhe and Meyle,
2008; Zitzmann and Berglundh, 2008). Peri-implant
mucositis is a reversible disease whose pathogenesis and
diagnosis does not fundamentally differ from gingivitis
around teeth (Lang et al., 2011). Peri-implantitis is a
multi-factorial disease that is similar in clinical features
and aetiology to periodontitis, although critical histopathological differences exist between the two lesions
(Berglundh et al., 2011). Notably, the apical extension of
the lesion is more pronounced in peri-implantitis than
in periodontitis, and in contrast to periodontitis lesions,
peri-implantitis lesions lack a self-limiting process
and extend to the bony crest, exhibiting signs of acute
inflammation with large amounts of osteoclasts lining
the surface of the crestal bone (Berglundh et al., 2011;
Lang and Berglundh, 2011).
The incidence of peri-implantitis has been reported
in the range of 16 - 58%, and is highly dependent on
the definition used to describe the disease (Fransson et
al., 2005, Zitzmann and Berglundh, 2008, Koldsland et
al., 2010). A systematic review by Heitz-Mayfield (2008)
identified poor oral hygiene, history of periodontitis
and cigarette smoking as strong risk indicators for periimplant disease. The association between periodontitis
and peri-implantitis (Ong et al., 2008; Lee et al., 2012)
and the similarity in bacterial pathogens associated with
the two lesions (Mombelli and Lang, 1998; Renvert et
al., 2007) point towards a common bacterial aetiology.
Indeed, the aetiology of peri-implantitis appears to be
multi-factorial, and changes in local ecological conditions that favor the growth of bacterial pathogens may
be viewed as the true origin of peri-implant disease
(Mombelli and Dcaillet, 2011). The presence of the
implant-abutment connection at the gingival/subgingival margin is important in this context, and given that
this is the subject of great variation among different
manufacturers, the choice of implant design may be
important, especially in susceptible patients. Indeed, regardless of ones view on the relative importance of the
bacterial biofilm in the initiation of the peri-implantitis
lesion, it is widely accepted that multiple features of
implant design, and the ability of the practitioner to
appropriately manage these, have a significant impact
on the development of peri-implant disease (Lang and
Berglundh, 2011; Qian et al., 2012).
Two aspects of implants that may play a role in the

development and progression of peri-implant disease
are the implant-abutment/restoration connection and
the implant surface.
Implant-abutment connection and peri-implant
disease
It has been shown that bacteria find their way through the microgap at the implant/abutment interface and reside within
the internal components of implants, and this provides them
with an environment sheltered from host defenses (Quirynen
and van Steenberghe, 1993; Persson et al., 1996; Jansen et al.,
1997). The design of the implant/abutment interface determines the size of the microgap and therefore will influence
the degree of microleakage (Tesmer et al., 2009), with the
biological consequence being soft tissue inflammation that
can lead to bone loss (Hermann et al., 2001).
As previously discussed, the nature of the connection
(external vs internal) can have an impact on technical complications, such as screw loosening (Gracis et al., 2012). It is
reasonable to expect that loosening of the restoration would
have a negative impact on the health of the peri-implant
tissues, as the interface between the implant and abutment
is usually below the mucosal margin. Indeed, the incidence
of biological complications has been linked to technical
complications in a clinical study (Kim et al., 2013). Clearly,
the stability of the implant-abutment interface is important
in minimizing biological complications, and in this regard an
internal connection appears to offer an advantage (Gracis
et al., 2012).
It should also be considered that the nature of the
implant-abutment connection (e.g., platform switching)
may also influence the diagnosis of peri-implantitis, as it
may influence the ability to probe around implants (Lang
and Berglundh, 2011).
Another consideration in relation to the design of the
implant-abutment/restoration connection relates to the
potential for peri-implant tissue problems caused by clinician error. Incorrect seating of implant componentry, and
in particular subgingival cement retention, are problems
that can create a local environment that is conducive to
the initiation of peri-implantitis, especially in susceptible
patients. Wilson (2009) showed that excess luting cement
was associated with peri-implant disease in 81% of 39
cases. Once the excess cement was removed, the clinical
signs of disease resolved in 74% of cases. A recent study
has shown a direct correlation of the depth of implant
crown margin below the mucosal margin and the amount
of undetected residual cement (Linkevicius et al., 2013),
underlying the importance of avoiding or limiting the
sub-mucosal extent of the restorative margin.
It is generally recognized that iatrogenic factors (e.g.,
excess cement remnants, inadequate restoration-abutment seating, over-contouring of restorations, implant
mal-positioning, technical complications) can initiate
peri-implant disease (Lang and Berglundh, 2011; Qian

et al., 2012). Clinicians should have appropriate clinical
training and have a thorough understanding of the relevant implant system in order to avoid these problems,
which may cause significant peri-implant tissue disease
in susceptible patients.
Implant surface characteristics and peri-implant
disease
With regard to the interaction of implant surfaces and
peri-implant disease, the two key issues are whether
certain implant surfaces are more prone to disease, and
whether implant characteristics influence the treatment
of peri-implantitis.
It has been suggested that the roughness of the implant surface as well as its chemical composition has a
significant impact on the amount and quality of plaque
formation (Teughels et al., 2006). Indeed, hydroxyapatite
(HA)-coated and rough-surfaced (Sa>2m) implants
have been associated with increased incidence of biological complications (strand et al., 2004; Piattelli et al.,
1995). However, these findings are of limited relevance
to contemporary practice, as the implant systems used
in these studies are no longer manufactured. Furthermore, the initiation of bone loss around HA-coated
implants was associated with the delamination of the
coating, and hence the biological mechanisms are different from conventional peri-implantitis pathogenesis.
A recent systematic review based on human clinical
trials found no evidence of increased susceptibility
to peri-implantitis for currently available moderately
rough surfaces, although it was acknowledged that
there is a scarcity of available data on this topic (Renvert et al., 2011). Of particular interest is a prospective,
multicenter, randomized, controlled 5-year clinical trial
comparing a hybrid implant design (coronal component
of implant was machined) with fully micro-rough implants, which showed no difference in peri-implantitis
incidence (Zetterqvist et al., 2010). However, it should
also be noted that there is experimental evidence from
pre-clinical animal studies that some currently available
moderately rough surfaces may be more susceptible to
peri-implant disease progression (Albouy et al., 2008;
Albouy et al., 2009), but these findings need to be
validated by clinical trials.
In terms of treating peri-implantitis, the ultimate goal
is to regenerate the lost bone and achieve re-osseointegration to the previously contaminated implant surface.
In this regard, better outcomes have been reported with
moderately rough compared to machined implant surfaces, although full defect resolution has not been demonstrated and there is variability in the way that different
moderately rough implants perform (Renvert et al., 2009).
This finding is somewhat surprising because it has been
shown that increased surface roughness has a significant
63
impact on biofilm formation (Teughels et al., 2006) and a

smoother surface texture may be easier to decontaminate
(Dennison et al., 1994). A possible explanation is that the
rougher surface may provide improved support for the
developing blood clot after surgery and thus facilitate
greater bone healing in contact with the implant surface
(Persson et al., 2001).
The impact of the explosion of implant
manufacturers
The obvious consequence of the increasing number of
implant manufacturers is that the clinical and scientific
community will have difficulties assessing and evaluating different systems. We can take some comfort in that
over 90% of implants worldwide are produced by fewer
than 10 of the top implant companies, most of which
are supported by sound scientific evidence. However,
many of the new manufacturers are marketing their
products on the basis of cost effectiveness, rather than
innovation aimed at achieving superior clinical outcomes.
These manufacturers often have copycat designs that
are marketed as being compatible with well-established
manufacturers. This can result in poorly fitting componentry that predisposes to future technical and biological
complications. Emerging evidence, in the form of case
reports, suggests that compatible or clone abutments
can have significantly different geometry compared to
the original abutments (Mattheos and Janda, 2012), which
may lead to future technical and biological problems.
Inevitably, the quality of the components will vary, but
the impact of this on clinical outcomes has not been
evaluated in the scientific literature.
Another challenge of the increasing number of implant manufacturers is related to the nature of implant
treatment, which often involves multiple visits over a
prolonged period, followed by essential long-term maintenance. Combined with the increasing mobility of the
population, this can result in cases where practitioners
have to complete treatment initiated elsewhere or deal
with complications involving treatment undertaken by
another practitioner. This can pose significant challenges
to even experienced clinicians and critical requirements
for successful management would be the clinicians
experience and special training, as well as access to the
appropriate tools and devices.
It is widely recognized that peri-implant disease
can be initiated by iatrogenic factors arising from poor
management or understanding of implant componentry.
Therefore, caution needs to be exercised by practitioners when choosing the source of implant componentry,
including that utilized by the dental laboratory. Central to
this is education to ensure that clinicians have a thorough
understanding of the way that implant-related characteristics may influence clinical outcomes.
64
The explosion of implant manufacturers - the

developing world context
In many ways, the challenges of the increasing
number of implant manufacturers are common to
both the developed and developing world. Inevitably, as the living standards in the developing world
improve, there will be increasing demands for dental
implant treatment. There is also the issue of dental
tourism, whereby patients from developed countries
visit developing countries in order to obtain treatment
at a lower cost (Barrowman et al., 2010). Implant
dentistry is attractive in this regard as it involves high
value work and hence the savings can be considerable. However, because of the prolonged nature of
implant treatment, the outcomes can be adversely
affected by disjointed treatment and parts being
undertaken in different countries. These problems
may be exacerbated by differences in the availability
of componentry from newer, less established manufacturers between countries.
With their focus on offering more cost-effective
dental implant components, value manufacturers
will be major suppliers in the developing markets.
Practitioners have a responsibility to carefully evaluate the implant systems that they utilize in order to
ensure that quality clinical outcomes are achieved.
The decisions should be made on the basis of a
sound evidence base from publications in quality peer-reviewed journals. Furthermore, there is a
need for manufacturer-independent undergraduate
and postgraduate education in order to ensure that
practitioners are familiar with the guiding principles
of contemporary dental implantology, in order for
them to be well placed to evaluate new products from
implant manufacturers.
Summary
1. The best-documented implants have a threaded
solid screw-type design and are manufactured from
commercially pure (grade IV) titanium. There is
good evidence to support implants 6 mm in
length, and 3 mm in diameter.
2. Integrity of the seal between the abutment and the
implant is important for several reasons, including
minimization of mechanical and biological complications and maintaining marginal bone levels.
Although the ideal design features of the implantabutment connection have not been determined, an
internal connection, micro-grooves at the implant
collar, and horizontal offset of the implant-abutment junction (platform switch) appear to impart
favorable properties.
3. Implants with moderately rough implant surfaces
provide advantages over machined surfaces in terms
of the speed and extent of osseointegration. While

the favorable performances of both minimally
and moderately rough surfaces are supported by
long-term data, moderately rough surfaces provide
superior outcomes in compromised sites, such as
the posterior maxilla.
4. Although plaque is critical in the progression of
peri-implantitis, the disease has a multi-factorial
aetiology, and may be influenced by poor integrity
of the abutment/implant connection. Iatrogenic
factors, such as the introduction of a foreign body
(e.g., cement) below the mucosal margin, can be
important contributors.
5. Clinicians should exercise caution when using a particular implant system, ensuring that the implant design
is appropriate and supported by scientific evidence.
Central to this is access to and participation in quality
education on the impact that implant characteristics
can have on clinical outcomes. Caution should be
exercised in utilizing non-genuine restorative componentry that may lead to a poor implant-abutment fit
and subsequent technical and biological complications.
References
Albouy JP, Abrahamsson I, Persson LG and Berglundh
T. Spontaneous progression of peri-implantitis at
different types of implants. An experimental study in
dogs. I: Clinical and radiographic observations. Clinical
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Group D
Reactor Report
Young-Bum Park
Yonsei University, Seoul, Korea
Introduction
The Initiator Paper for Workgroup D by Ivanovski
(Journal of the International Academy of Periodontology 2015;
17/1 Supplement) thoroughly reviews the topic of periimplant (hard and soft tissue) interactions in health and
disease and the explosion of implant manufacturers.
All of the major issues regarding this important topic
are covered and I have very few comments with regards
to the general content of this review. Below I have
noted some specific issues that should be considered
by the group in their deliberations:
Comment 1: With regard to implant shape and size it is
worth noting a recent systematic review that addresses
the long-term evidence of the same success rate of
short implant length between 6-8 mm (Karthikeyan
et al., 2012)
Comment 2: In the section covering Macrogeometry of
threads at the implant collar it would be useful to have
some discussion on transmucosal one-piece implants,
which have been developed for immediate loading or
restoration and that have no interface between fixture
and abutment near the alveolar ridge crest (Carinci,
2012)
Comment 3: In the section covering Clinical relevance
of implant surface modification, ultraviolet treatment,
photofunctionalization to re-activate the surface and
prevent aging of implant surface should be considered
(Att and Ogawa, 2012).

11-13 April, 2014
Correspondence to: Young-Bum Park, Yonsei University
College of Dentistry, Prosthodontics, Seodaemun-gu, Dental Hospital Room 727, Seoul 120-752, Republic of Korea
E-mail: dr.ybpark@gmail.com
Comment 4: In the section on Peri-implant disease

we should consider referencing both American Academy of Periodontology and European Federation of
Periodontology position statements and guidelines.
(American Academy of Periodontology, 2013, European Workshop on Periodontology, 2008). In addition,
genetic factors as contributing factors to peri-implant
diseases should be considered.
Comment 5: In the section covering The explosion
of implant manufacturers the increased usage of milled
custom abutments using various materials for aesthetics and the convenience of easily making implant restorations through the development of advanced CAD/
CAM technology should be considered (Alikhasi et al.,
2013; Kutkut et al., 2013; Oderich et al., 2012; Magne
et al., 2011; Hjerppe et al., 2011)
References
Alikhasi M, Monzavi A, Bassir SH, Naini RB, Khosronedjad N and Keshavarz S. A comparison of
precision of fit, rotational freedom, and torque loss
with copy-milled zirconia and prefabricated titanium
abutments. International Journal of Oral and Maxillofacial
Implants 2013; 28:996-1002.
American Academy of Periodontology. Peri-implant
mucositis and peri-implantitis: A current understanding of their diagnoses and clinical implications.
Att W and Ogawa T. Biological aging of implant surfaces
and their restoration with ultraviolet light treatment:
A novel understanding of osseointegration. International Journal of Oral and Maxillofacial Implants 2012;
27:753-761.
Carinci, F. Survival and success rate of one-piece implant
inserted in molar sites. Dental Research Journal (Isfahan)
2012; 9(Suppl 2): S155S159.
70
European Workshop on Periodontology. Peri-implant

diseases: Consensus Report of the Sixth European
Workshop on Periodontology. Journal of Clinical Periodontology 2008; 35(8 Suppl):282-285.
Hjerppe J1, Lassila LV, Rakkolainen T, Narhi T and
Vallittu PK. Load-bearing capacity of custom-made
versus prefabricated commercially available zirconia
abutments. International Journal of Oral and Maxillofacial
Implants 2011; 26:132-138.
Ivanovski S. Implants - peri-implant (hard and soft tissue)
interactions in health and disease, the impact of explosion of implant manufacturers Journal of the International
Academy of Periodontology 2015; 17/1 (Supplement):57-68.
Karthikeyan I, Desai SR and Singh R. Short implants: A
systematic review. Journal of the Indian Society of Periodontology 2012; 16:302-312.
Group D Reactor: Peri-implant health and disease
Kutkut A, Abu-Hammad O and Mitchell R. Esthetic

considerations for reconstructing implant emergence
profile using titanium and zirconia custom implant
abutments: Fifty case series report. Journal of Oral
Implantology 2013 Oct 31 [Epub ahead of print].
Magne P, Oderich E, Boff LL, Cardoso AC and Belser
UC. Fatigue resistance and failure mode of CAD/
CAM composite resin implant abutments restored
with type III composite resin and porcelain veneers.
Oderich E, Boff LL, Cardoso AC and Magne P. Fatigue
resistance and failure mode of adhesively restored
custom implant zirconia abutments. Clinical Oral
Group D
Consensus Report
Moderator: Shibli, Jamil, University of Guarulhos, Brazil
Initiator: Ivanovski, Saso, Griffith University, Australia
Reactor: Park, Young Bum, Yonsei University, Korea
Working Group D:
Alarcon, Marco, Universidad Peruana Cayetano Heredia, Peru
Cheung, KM, Private Practice, Singapore
Duncan, Warwick, University of Otago, New Zealand
Ettiene, Daniel, Paris Diderot University, France
Giri, Dhirendra, College of Dental Surgery, Srinakharinwirot
University, Nepal
Halhal, Rita, Private Practice, France
Kakar, Mona, Private Practice, India
Kim, Sung Tae, Seoul National University School of Dentistry,
South Korea
Kim, Ti Sun, University Hospital of Heidelberg, Germany
Matheos, Nikos, Prince Philip Dental College, Hong Kong
Ouyahoun, Jean Pierre, Paris 7 Denis Diderot University, France
Panikar, Arjun, Private Practice, India (Transcriber)
Shin, Seung Il, Kyunghee University, South Korea
Wagh, Aditya, University of Texas, USA (Transcriber)
Won, Jung Ui, College of Dentistry, Yonsei University, South Korea
Introduction
This workgroup met with the objective to address the key
events in the establishment and maintenance of the soft
and hard tissues during osseointegration, and how implant
characteristics can influence these events. In addition,
implant-related factors that may affect the etiology, progression and treatment of peri-implant disease were discussed.
The initial discussion focused on clarifying definitions
relating to peri-implant health and disease. Following this
the group considered and discussed the conclusions pre-
sented in the initiators review paper. From this paper four

key questions were identified for discussion, and recommendations were made. The key questions were:
1. What are the implant-related factors that are important
for hard tissue integration?
2. What are the implant-related factors that are important
for soft tissue integration?
3. What is the recommended supportive therapy for
patients with implant-supported prostheses?
4. Is there a long-term predictable treatment that can be
recommended for peri-implantitis?
Definitions

11-13 April, 2014
Correspondence to: Shibli, Jamil, University of Guarulhos, Brazil,
E-mail: jshibli@ung.br
The definition of peri-implant disease (both peri-implant

mucositis and peri-implantitis) as defined by the 6th European Workshop on Periodontology was accepted and used
72
to determine consensus on the management of these two

conditions. It was determined that the literature provides
good evidence to support the concept that even though
dental plaque is important for the development of both
peri-implant mucositis and peri-implantitis, these conditions
are of multi-factorial etiology and may be influenced by
poor integrity of the abutment/implant connection. Other
iatrogenic factors such as excessive cement are also important
contributors in the development of peri-implant disease.
Osseointegration
A direct, structural and functional connection between ordered, living bone and the surface of a load-carrying implant
(Listgarten et al., 1991).
Peri-implant disease
A collective term for inflammatory reactions in the tissues
surrounding an implant.
Peri-implant mucositis
The presence of inflammation in the mucosa at an implant
with no signs of loss of supporting bone.
Peri-implantitis
An inflammatory process around an implant, characterized
by soft tissue inflammation and loss of supporting bone
(Lindhe and Meyle, 2008; Zitzmann and Berglundh, 2008).
Question 1. What are the implant-related factors
that are important for hard tissue integration?
It was recognised that there are a number of implant-,
patient- (systemic health, oral hygiene and pre-existing
periodontal disease) and operator-related factors that can
influence the integration of dental implants into both
hard and soft tissues. Accordingly, dentists should be
appropriately trained to understand the importance of
these factors and their roles in establishing and maintaining peri-implant health. For the purposes of this discussion other factors related to implant success, including
prosthetic design and occlusal loading, were not included.
With regard to implant design it was determined that
there is abundant and consistent long-term high level
evidence to support the use of threaded, solid screw-type
implants manufactured from commercially pure type IV
titanium. There is sufficient evidence to confirm good
stability and long-term success of implants if they have
a length of 6 mm and a diameter of 3 mm. Furthermore, there is good evidence demonstrating that implants
with moderately rough surfaces provide advantages over
machined surfaces in terms of the speed and extent of
osseointegration. While both minimally and moderately rough surfaces are supported by long-term data,
moderately rough surfaces provide superior outcomes.
Long-term data indicate that moderately rough surfaces

provide superior outcomes in compromised sites, such
as the posterior maxilla.
There is emerging evidence to indicate that horizontal
offset of the implant to abutment junction (platform switch,
platform shift) may offer benefits in reducing marginal bone
loss as compared to platform matched implant abutment
junctions.
Question 2. What are the implant-related factors
that are important for soft tissue integration?
It is recognized that the integrity of the soft tissue seal
(consisting of junctional epithelium and connective tissue
adaptation) is crucial for long-term success of dental implants. Crucial to this seal is the formation of the peri-implant
biologic width, which is established around the implant at
least 4-6 weeks after implant placement. This critical structure
must not be impinged upon or disrupted. There is no credible evidence to date indicating that any implant-related factors can improve the soft tissue seal around dental implants.
With regard to implant success it was noted that a critical
factor was the integrity of the seal between the abutment and
the implant. This seal enables minimization of mechanical
and biological complications and at the same time ensures
the maintenance of marginal bone levels.
Reasonable evidence is available to indicate that the stability of the connection is maintained better with an internal
connection as compared to an external connection. There
is evidence demonstrating loosening of abutment screws is
greater in those implants with an external connection. If the
fixture/abutment is compromised then biological complications are less likely to occur if it is located at the mucosal
margin rather than bone level.
Operator-related variables and errors, such as incorrect
abutment placement, poor restoration seating and cement
remaining at the prosthesis-abutment interface, can all affect
the marginal soft tissue integrity.
Question 3. What is the recommended supportive
therapy for patients with implant-supported
prostheses?
It is recognized that there is a physiological remodeling
around dental implants once they are loaded. After this initial
remodeling phase the condition stabilizes and provides the
baseline level for future assessment of tissue parameters
(probing depth and bone levels). Therefore, the aim of supportive implant therapy is to maintain the stability of these
parameters in health through the control of peri-implant
infection and inflammation. Crucial to this is maintaining a
good level of oral hygiene. This can be facilitated by good
patient compliance with home care of the implants and
remaining dentition and also by good prosthetic design,
which allows easy access for oral hygiene regimes. Regular
professional maintenance is also required to monitor changes
in clinical parameters and patient compliance with home care.
Group D Consensus: Peri-implant health and disease
The frequency of maintenance visits will vary depending on

the risk profile of the patient, as patient susceptibility is an important factor in the development of peri-implant diseases.
There are several key considerations in the prevention of peri-implant diseases. Good evidence supports
the need for the establishment of periodontal health
around the remaining teeth prior to implant placement.
In addition the evidence is strong supporting the need
for good maintenance of periodontal health following
implant placement.
Question 4. Is there a long-term predictable
treatment that can be recommended for periimplantitis?
There is limited long-term (5 years or more) evidence
describing techniques and procedures leading to predictable treatment of peri-implantitis. There is some
limited short-term data available supporting the use
of combined non-surgical and surgical treatment over
non-surgical treatment alone. Evidence to date indicates
that no available treatments result in total resolution of
the problem of established peri-implantitis.
Recommendations for future directions of
research
On the basis of currently limited good evidence regarding the management of peri-implant mucositis
and peri-implantitis there is need for further ongoing
research to help clarify the etiology and management
of these conditions. This group identified a number of
important areas for future research in the field of periimplant health and disease:
Improved understanding of the physiology of the
soft tissue around implants in humans.
Detailed understanding of the role and significance
of keratinized tissue around dental implants.
73
Determining if there is a critical thickness of marginal tissue for implant success, more complete
understanding of the significance and role of the
biologic width, and further exploration of the
nature of soft tissue attachment to titanium alloy
and other implant materials.
Improved understanding of the pathogenesis and
epidemiology of peri-implant diseases (mucositis
and peri-implantitis).
Investigating the susceptibility of roughened surface
implants with internal versus external abutment
connections.
Establishment of evidence-based protocols for
both professional and self-care maintenance of
peri-implant health as well as risk assessment of
the patient. These should be validated in large-scale
practice-based trials.
References
Ivanovski S. Implants - peri-implant (hard and soft tissue) interactions in health and disease, the impact
of explosion of implant manufacturers. Journal of
the International Academy of Periodontology 2015; 17/1
(Supplement):57-68.
Listgarten MA, Lang NP, Schroeder HE and Schroeder
A. Periodontal tissues and their counterparts around
endosseous implants. Clinical Oral Implants Research
1991; 2:1-19.
Lindhe J and Meyle J. Peri-implant diseases: Consensus
Report of the Sixth European Workshop on Periodontology. Journal of Clinical Periodontologyy 2008;
35:282-285.
Zitzmann NU and Berglundh T. Definition and prevalence of peri-implant diseases. Journal of Clinical
Periodontology 2008; 35(8 Suppl):286-291.
Group E
Initiator Paper
Interprofessional education and
multidisciplinary teamwork for prevention and
effective management of periodontal disease
Lijian Jin
Faculty of Dentistry, The University of Hong Kong, Hong Kong
SAR, China
Introduction
Periodontology is one of the oldest dental specialties in
the world that deals with the tooth-supporting soft tissues
and alveolar bone in both healthy and diseased conditions.
Periodontal disease usually consists of gingivitis and periodontitis (Armitage, 1999). It is arguably the most common
disease in humans (Guinness World Records, 2001), partly
due to the unique characteristics of the dento-gingival
structure and the etiopathogenic nature of the disease
(Socransky and Haffajee, 1997; Jin, 2008). Globally, gingivitis predominantly affects adolescents and adults, and
advanced periodontitis occurs in 5 to 20% of adults in
both developed and developing countries (Sder et al., 1994;
Papapanou, 1996; Petersen et al., 2005; Jin et al., 2011; Kassebaum et al., 2014). Untreated severe periodontitis is the
major cause of tooth loss in the adult population worldwide
(Pihlstrm et al., 2005; Beaglehole et al., 2009; Jin, 2011, Jin et
al., 2011). Indeed, a large proportion of prosthodontic and
implant patients have missing teeth, due to untreated and/
or poorly controlled periodontitis. It is evident that periodontal infection and inflammation are linked to various
systemic diseases, such as cardiovascular disease, diabetes
mellitus, dementia, adverse birth outcomes, respiratory
diseases and cancers (Pihlstrm et al., 2005; Williams et al.,
2008; Li et al., 2011; Tonetti and Kornman, 2013). Notably,
periodontal disease remains a major oral health burden in
both developed and developing countries, especially in
underprivileged populations (Petersen et al., 2005; Petersen,
2008; Jin et al., 2011; Petersen and Ogawa, 2012). As such,
periodontal disease has increasingly attracted the attention
of health-care professionals and the public.

11-13 April, 2014
Correspondence to: Professor Lijian Jin, Faculty of Dentistry
The University of Hong Kong, Prince Philip Dental Hospital, 34
Hospital Road, Hong Kong SAR, China. E-mail: ljjin@hku.hk
Contemporary periodontology has been a highly dynamic and evolutionary field for many decades. Novel concepts
in periodontal etiopathogenesis and innovative clinical approaches have been made available to periodontal educators,
general dental practitioners, periodontists, medical professionals and government agencies. This article firstly updates
readers on the major advances in clinical periodontology, and
elaborates the common pitfalls and drawbacks confronting
dental practitioners in periodontal practice as well as the
potential risk and impacts involved in providing periodontal
treatment. In addition, the key issues and proactive strategies
for effective management of periodontal patients through
interprofessional teamwork and a multidisciplinary approach
are highlighted. Finally, directions and perspectives for innovative periodontal research are addressed.
Major advances in clinical periodontology
The past 20th century saw great advances in the discipline of
periodontology. Revolutionary concepts and substantial new
knowledge, balanced with clinical reality, were developed and
verified, thereby laying down the contemporary periodontal
paradigm and professional care strategies (Le et al., 1986;
Kornman and Le, 1993; Page et al., 1997; Armitage, 1999
and 2002; Pihlstrm et al., 2005; Kornman, 2008; Armitage
and Robertson, 2009; American Academy of Periodontology, 2011; Jin, 2011; Jin et al., 2011; Tonetti and Kornman,
2013). The key discoveries and advances are listed in Table 1.
Table 1. Key discoveries in periodontology in the
20th century.
Role of dental plaque and plaque biofilms
Natural history of periodontal disease
Periodontal risk factors/assessment and concept
of host susceptibility
The reality of periodontal regeneration
Periodontal medicine and integration of oral
health and general health
Group E Initiator: Prevention and management of periodontal disease
Common pitfalls and drawbacks in periodontal

practice
Low awareness of periodontal health and
periodontal negligence
Oral health and oral care are highly neglected in both
national and international health politics and agendas
(Editorial, Lancet, 2009). Because periodontal disease
is a relatively silent infection and inflammation many
patients are unaware of this common oral problem
in their daily life. However, its overall impact on patients becomes increasingly noticeable during the long
course of disease onset and development, starting with
gingival redness, swelling, and bleeding during brushing
at the early stage, followed by increased tooth mobility,
pathological tooth drifting and migration, eventually
ending with multiple tooth loss. These pathological
changes seriously affect various oral functions, thereby
causing psychological problems with low self-esteem
and reduced quality of life, as well as creating a large
financial burden for periodontal care and related dental treatments (Jin, 2008; Jin, 2010; Chapple, 2014)
(Figure 1).
Unfortunately, a large number of patients in the underprivileged population suffer from untreated severe
gingivitis and various forms of periodontitis, and these
subjects have a relatively low awareness of their oral/
periodontal health. These individuals usually do not seek
periodontal care in the first instance; rather they make
symptom-driven dental appointments at a relatively late
stage of disease development, and only if such professional
care is available and affordable (Jin, 2010). It is anticipated
that the required periodontal treatment and subsequent
other dental care needs then become more complicated,
costly and less predictable. Indeed, poor management of
periodontal patients has emerged as one of the major risks
in clinical practice. Moreover, there is a great variability in
periodontal referrals due to various reasons (Ong, 1990;
Buckley, 1993; Lee et al., 2009). Considering the common
occurrence of periodontal disease and the low awareness
among the public, significant risk may often arise from
periodontal negligence, with increased litigation and periodontally related legal cases (Zinman, 2001); e.g., implant
failure due to severe peri-implantitis in periodontal patients
and those with periodontal destruction due to poorly delivered and detrimental adjunctive orthodontic treatment.
Figure 1. The increasing impacts of periodontal disease on affected patients during the
disease course.
Fig 1
75
76
Non-evidence-based periodontal practice

In many developing countries, it is assumed that periodontal training in dental curricula remains inadequate
and relatively poorly updated, partly due to limitations
of well-qualified teaching staff and learning resources.
Likewise, in addition to the issue of periodontal negligence, periodontal care in daily practice seems to be
delivered through an empirically driven approach following outdated dogma, instead of evidence-based and
scientifically verified approaches. The common pitfalls
and drawbacks of periodontal care in general dental
practice are listed in Table 2.
Table 2. Common pitfalls and drawbacks of periodontal
care in general dental practice.
Lack of updated concepts and knowledge in
periodontal science
Lack of patient communication on disease prevention and health promotion
Lack of assessment and control of risk factors
(e.g., smoking)
Inappropriate diagnosis, prognosis and poorly
sequenced treatment planning with a focus on
restorative/reconstructive treatments (e.g., dental
implants)
Limited non-surgical periodontal treatment
without appropriate re-evaluation and long-term
regular supportive care even in managing susceptible patients
Undertaking non-evidence-based certain adjunctive periodontal treatments
Inadequate communication and inappropriate
decisions on periodontal referrals
Lack of multidisciplinary management of complex
patients through teamwork with specialists in
endodontics, orthodontics, prosthodontics and
implant dentistry
Low awareness and engagement in periodontal
care through integration of oral and general health
Key issues for effective management of

periodontal patients
Effective periodontal care should be the primary and essential component of general dental practice; otherwise
any dental treatment for periodontal patients may be
greatly compromised or ultimately fail (Pihlstrom, 2001).
Unfortunately, general dentists tend to show less interest
in treatment of periodontal diseases and prefer to focus
on restorative procedures (Ong, 1990; Buckley, 1993).
Thus, the problem arises that they may eventually have to
deal with the consequences of periodontitis-related tooth
loss or edentulism, rather than effectively controlling the
root cause of the problem uncontrolled periodontal
infection and inflammation. In recent years, evidencebased, common risk factors-targeted, health-integrated
preventive and care strategies have been advocated and
implemented in dental education and clinical practice.

Some of the key points for prevention and effective
control of periodontal disease have been well addressed
(Baehni and Giovannoli, 2004; Jin, 2010), and these critical
issues are updated and presented in Table 3.
Table 3. The key issues for prevention of periodontal
disease and effective patient management.
Patient motivation, awareness of oral/periodontal
health and reflection of holistic health
Early prevention through effective plaque control
at home and regular professional care
Routine periodontal screening and recognition,
record keeping and appropriate risk assessment
through a patient-centered approach
Appropriate diagnosis, prognosis and formulation of
individualized treatment planning through addressing the causes, risk and host susceptibility factors
Setting achievable treatment goals through good
communication with patients
Avoiding and controlling periodontal risk factors
via a common risk factor approach
Assurance of controlling the root of the problem
(periodontal disease) and achieving periodontal
clearance, prior to undertaking corrective, regenerative, restorative and prosthodontic treatments
Long-term, regular periodontal and implant supportive care
Appropriate arrangements for periodontal referral
Multidisciplinary management of complex patients through good teamwork and collegiality
One of the most critical issues to be considered is

recognition of patients risk profiles through appropriate risk assessment and effective control of these risk
factors. Identification of the risk is essential, and this
strategy should be fully incorporated in clinical practice
(Lang and Tonetti, 2003; Nunn, 2003; American Academy of Periodontology, 2008; Jin et al., 2011). This approach has important clinical implications and enables
clinicians to address the underlying risk for periodontal
disease, and thereby carry out individualized and clearly
targeted treatments for more cost-effective therapies and
ongoing regular supportive care (American Academy of
Periodontology, 2008). A periodontal risk assessment
system has been proposed and validated in a longitudinal
study (Lang and Tonetti, 2003; Matuliene et al., 2010).
Common non-communicable diseases (NCDs)
such as cardiovascular disease, cancer, diabetes and
respiratory disease collectively account for about 60%
of human deaths worldwide (Ash et al., 2012; Ezzati
and Riboli, 2012; FDI, 2013a). Periodontal disease as
a common oral NCD shares an array of common risk
factors with other NCDs (United Nations General Assembly, 2011; FDI, 2013a,b,c; Jin, 2013), such as tobacco
usage, obesity, unhealthy life style and socio-economic
factors. From the general health perspective, it is crucial
to incorporate periodontal health issues into the general

health agenda, through the Common Risk Factor Approach (Sheiham and Watt, 2000; Petersen, 2008; FDI,
2013b,d; Jin, 2013) for optimal oral and general wellbeing of the population.
Management of periodontal patients via
multidisciplinary teamwork
It is well recognized that periodontology is closely interlinked with other dental specialties, and periodontal care
and patient management should therefore be undertaken
on a multidisciplinary basis, especially in complex cases,
involving various experts in medicine, endodontics,
orthodontics, prosthodontics and implant dentistry
(Figure 2). Comprehensive, well-sequenced treatments
and properly conducted multidisciplinary care are
crucial for optimal treatment outcomes, especially in
medially compromised patients, susceptible individuals
(e.g., heavy smokers) and those with severe periodontitis.
Some important issues should be highlighted to address
the specific interdisciplinary interactions in effective
management of periodontal patients. Taking the periodontal-restorative interface as an example, some critical
points need to be carefully elaborated and executed to
achieve the best treatment outcomes. These key issues
have been well addressed by Goldberg and colleagues
(2001), and they are modified and summarized in Table
4. The interactions of periodontics with other specialties
such as endodontics, orthodontics and implant dentistry,
as well as the relevant clinical implications, have been
intensively discussed and presented elsewhere (Yi et al.,
1995; Zachrisson, 1996; Gunne et al., 1999; Sanders et
al., 1999; Jorgensen and Nowzari, 2001; Nowzari, 2001;
Witter et al., 2001; Harrington et al., 2002; Ong and Wang,
2002; Zehnder et al., 2002; Esposito et al., 2003; Reddy,
2003; Rotstein et al., 2004; Levin et al., 2012; Raj, 2013;
Sgolastra et al., 2013).
Table 4. The critical issues related to periodontalrestorative interface in clinical practice.

Assurance of controlling periodontal disease prior
to restorative treatments
Protection of the biological width via crown lengthening procedure when necessary and appropriate
Obtaining excellent dental impression and modelmaking
Precise design for crown, denture and implant
treatments
Refining crown contour and emergence profile in
harmony with gingival tissues
Appreciation of the clinical value of fabricating
provisional restorations for predictable outcomes
Periodontally friendly placement of restorative
margins, selection of compatible materials, achieving optimal marginal fit and undertaking effective
plaque control daily
Recognition of the critical role of occlusion in periodontal and implant treatments
Mucogingival considerations on the attached
gingiva close to the restorative margins
Critical consideration of the option of shortened
dental arches in periodontitis patients
Perspectives and future directions in

periodontal research
Periodontal disease is recognized as a major global oral
health burden in connection to oral and general health,
and it significantly accounts for the global oral health
inequality, which is of significant concern to the leading
international organizations, such as the World Health
Organization (WHO), International Association for
Dental Research (IADR) and FDI World Dental Federation (Jin et al., 2011; Petersen and Ogawa, 2012; FDI,
2013b). Although considerable progress has been made
in understanding the complex nature and pathogenesis
of periodontal disease, as well as its effective management
strategy (Page et al., 1997; Kornman, 2008; American Acad-
Figure 2. The periodontal specialty is interlinked with medicine and other dental disciplines,
and periodontal care should be undertaken comprehensively through a multidisciplinary
team approach for optimal treatment outcomes.
Fig 2
77
78
emy of Periodontology, 2011), a substantial knowledge gap

remains that needs to be addressed through further basic,
translational and clinical studies. Future research directions
and needs in periodontology could be further explored and
identified on the basis of current knowledge, good evidence
and scientific perspectives (Pihlstrm et al., 2005; Jin et al.,
2011). Hopefully, new discovery and innovative approaches
in oral/periodontal science could further enhance the effectiveness of prevention and control of periodontal disease
in the near future for optimal oral health and general health.
Acknowledgements
This work was supported by the Hong Kong Research
Grants Council and the Modern Dental Laboratory/
HKU Endowment Fund.
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therapy. Periodontology 2000 2001; 25:114-130.
Group E
Reactor Report
Enhancing global periodontal and oral health
by standardizing education systems
Vincent J. Iacono
Stony Brook University, Stony Brook, NY
Introduction
In the Initiator Paper for Workshop E on periodontal
education, Professor L. J. Jin clearly stated that common pitfalls and drawbacks in periodontal practice are
the result of the fact that in many emerging populations, periodontal components of dental curricula
remain highly inadequate and not updated due to
limitations in qualified teaching staff and educational
resources (Jin 2015). I can add a more significant reason
that addresses the lack of a standardized periodontal
education, reflecting the epitome of pedagogy. The
model I refer to is that used in the United States and
Canada, with prescriptive educational standards at
the predoctoral and postdoctoral levels. Educational
programs are evaluated on a regular basis to ensure
compliance with the standards and documentation of
outcome measures. Educational standards are established, maintained, and applied by the American Dental
Association (ADA) and the Commission on Dental
Accreditation (CODA). Every dental curriculum and
postdoctoral education program in the United States
must adhere to the requirements of CODA. For dental
education, each program must include a competency
statement and institutional learning objectives for
periodontology. Instruction in this area is offered
throughout the curriculum and provides the needed
foundation skills, knowledge and values. The goal of
the predoctoral curriculum at Stony Brook University
is to provide students with the knowledge, skills and
values to attain competency in the ability to manage
patients with moderate and severe periodontitis, and to
perform nonsurgical periodontal therapy for gingivitis

11-13 April, 2014
Correspondence to: VJ Iacono, Department of Periodontology
School of Dental Medicine, Stony Brook University, Stony Brook, NY,
USA 11794-8703. E-mail: vincent.iacono@stonybrookmedicine.edu
and slight periodontitis. The predoctoral curriculum of

Stony Brook Universitys Department of Periodontology includes both didactic (approximately 100 hours)
and clinical (approximately 120 hours) components to
ensure that this goal is achieved (Department of Periodontology, Stony Brook University Syllabus, 2014).
The courses are sequenced to allow students to utilize
the knowledge and skills attained from the basic science
courses and to relate this information to patient care.
Students are introduced to the field of periodontics in
the first year through lectures and problem- and casebased learning and they progress through an intense
curriculum through the fourth year. The fourth year
component of clinical periodontics is conducted in a
general practice setting in which the student provides
comprehensive care, including diagnosis and nonsurgical periodontal therapy under the supervision of
general dentistry faculty. This experience enables the
student to understand the primary care role of general
dentists in treating and managing periodontal patients,
including referral to a specialist when indicated. Specific guidelines for referral to a periodontal postdoctoral student are distributed to faculty instructors and
calibrated on an annual basis. The periodontology
faculty provide coverage for consultations and three
competency examinations (periodontal scaling and
root planing, periodontal diagnosis/treatment planning
of implants, and periodontal evaluation of treatment
provided), and periodontal surgical procedures. In
addition, students are required to observe and encouraged to participate in periodontal and implant surgical
procedures performed by periodontal postdoctoral
students. Student progress and clinical competency
in periodontal therapy are evaluated in a series of
formative assessments and competency examinations,
as listed in Table 1.
Group E Reactor: Prevention and management of periodontal disease
81
Table 1. Summary of Stony Brook University predoctoral curriculum and the determination of competency for
the practice of periodontics in general dentistry.
Year 1
Year 2
Year 3
Year 4
Formative Assessments
Basic science courses
Daily clinical assessments
Dental didactic courses
Outcomes of care:
Clinic II courses
Outcomes of care:
Clinic III courses
Competency Examinations
Pediatric diagnosis/treatment planning HDC 621
Comprehensive patient
treatment plan (HDI 705)
Periodontal scaling/root
planing (HDP 821, 822)
Periodontal diagnosis/
treatment planning (HDG
621/Year II Periodontics
Clinic)
Periodontal diagnosis
treatment plan type 2
(HDP 721)
treatment planning implants (HDP 821, 822)
treatment plan type 3/4
(HDP 721)
Periodontal evaluation of
treatment (HDP 821, 822)
The significance of graduation from a CODA accredited curriculum relates to the graduating dentists
ability to obtain a license to practice dentistry in the
United States and enhanced ability to matriculate in a
specialty program. A dental specialty is defined as an
area of dentistry that has been formally recognized
by the ADA as meeting the requirements for recognition of dental specialties as presented by the ADA
Council on Dental Education and Licensure (CDEL)
(American Dental Association, 2001). Periodontics
is one of nine recognized specialties and is defined
as that specialty of dentistry which encompasses the
prevention, diagnosis and treatment of diseases of the
supporting and surrounding tissues of the teeth or
their substitutes, and the maintenance of the health,
function and esthetics of these structures and tissues
(Accreditation Standards for Advanced Specialty
Education Programs in Periodontics, 2013). There are
six standards for which all United States postdoctoral
periodontal programs must demonstrate compliance.
The six standards include:
1. Institutional commitment/program effectiveness,
2. Program director and teaching staff
3. Facilities and resources
4. Curriculum and program duration
5. Advanced education students/residents
6. Research
There are more than 50 CODA accredited advanced specialty education programs in periodontics
(American Academy of Periodontology [AAP], 2007).
It is important to note that every accredited program
must be administered by a director who is certified by

the American Board of Periodontology (ABP). The
ABP was formed by the AAP to elevate the standards
and advance the science and art of periodontology
by encouraging its study and progressing its practice
(American Board of Periodontology, 2008). Each
program must submit annual reports to CODA and all
programs are reviewed through self-study documents
and CODA site visits every seven years to ensure
continued compliance with the education standards.
CODA accredited programs must be a minimum of
30 months in length and have developed clearly stated
goals and objectives appropriate to advanced specialty
education, addressing education, patient care, research
and service. The goals and objectives of Stony Brook
Universitys advanced specialty education program in
periodontics are to produce clinically competent and
highly educated periodontists who will be proficient in
the prevention, diagnosis, treatment and/or management of the various periodontal diseases and interrelated systemic diseases and conditions seen in specialty
practice. They will also have in-depth instruction and
extensive clinical training in periodontal plastic surgery,
oral reconstructive surgery, and dental implants. In
addition, program graduates are trained to critically
review the periodontal literature, so that they will be
able to scientifically evaluate new models of therapy
during their careers. Specifically, the programs primary
goals and objectives are as follows (Advanced Specialty
Education Program in Periodontics, Stony Brook
University, 2013):
82
Goal 1: Educate dentists to become periodontists who

are proficient in the diagnosis, treatment planning and
therapies that define the specialty of periodontics.
Objective 1. To provide the postdoctoral students with
an in-depth knowledge of relevant basic and biomedical sciences as they relate to the etiology, treatment and
management of the periodontal diseases and interrelated
systemic diseases and conditions, and dental implants.
Objective 2. To develop periodontists who are proficient with the diagnoses, treatment planning, and
therapies of periodontal diseases and dental implants,
employing the classic and current literature to support
appropriate decision-making.
Objective 3. To evaluate postdoctoral students in
appropriate methods of patient management and
treatment planning through formal and informal
opportunities to present, discuss and defend their
patient care cases of record with periodontal faculty
and their peers.
in-depth instruction and extensive clinical training in
periodontal plastic surgery, oral reconstructive surgery
and dental implants.
Goal 2: Educate postdoctoral students to be proficient
in developing appropriate long-term maintenance
therapy for their periodontal and implant patients.
an in-depth knowledge of the theory and practice of
periodontics, including dental implants, pertinent to
the provision of appropriate maintenance therapy.
Goal 3: Educate postdoctoral students in basic research
methods related to periodontal research in order to critically evaluate the periodontal literature.
fundamental knowledge of biostatistics and research
design, including the ability to conduct a literature
review and critical analysis of new developments in
periodontology.
Objective 2. To provide postdoctoral students with
opportunities to conduct and publish research and
matriculate into Stony Brook University postgraduate
degree programs.
Goal 4: Prepare postdoctoral students for the achievement of diplomate status in the American Board of
Periodontology.

the abilities, motivation and support to enter the board
certifying process and with the knowledge and skills to
become Diplomates.
Goal 5: Prepare postdoctoral students to integrate
other disciplines to result in optimal comprehensive
oral health care and to work in cooperation with referring dentists.
Goal 6: Encourage service to the profession including, but not limited to, didactic and clinical education,
involvement in organized dentistry and outreach efforts.
CODA accredited programs must also document
their effectiveness using a formal and ongoing outcome
assessment process to include measures of advanced
education student/resident achievement. As an example of compliance with this standard, the postdoctoral
periodontal program at Stony Brook University uses the
following outcome measures to evaluate the programs
effectiveness in meeting its goals and objectives:
1. Student evaluation of faculty and the program
occurs at the end of each academic year.
2. Student academic performance is monitored
through oral and written examinations, written
papers, and class participation.
3. Student clinical performance is monitored continuously through the use of electronic records
of completed procedures, quarterly reviews, and
completed documented cases.
4. Evaluation of the students research activity is
accomplished by assessing the quality of their
oral presentations, and whether the resulting
written manuscripts are accepted for publication
in a professional journal.
5. Monitoring student performance in the American Academy of Periodontology In-Service
Examination.
6. Each student must submit a portfolio that includes 20 case reports and Power Point presentations of their surgical seminars.
7. Students must satisfactorily complete an oral
comprehensive examination, which consists of
a student clinical case presentation, followed by
a simulated American Board of Periodontology
certifying examination evaluated by an examination committee of attending faculty.
Group E Reactor: Prevention and management of periodontal disease
8. Analysis of anonymous student evaluations

of both didactic and clinical faculty and of the
program evaluation questionnaire completed by
each student upon graduation.
9. Evaluation of anonymous exit questionnaires
completed by those patients who have received
treatment by students of the advanced education
program in periodontics.
10. The program maintains an active alumni association with annual meetings that serve as a venue for
discussion and provide opportunity for program
enhancement suggestions.
11. In order to receive feedback, we have implemented a survey of program graduates about their
professional standing, diplomate status, faculty
appointments, presentations at regional and national meetings, and retrospective evaluation of
the faculty and program.
12. A formal annual review of the faculty is conducted
by the program director that includes an evaluation of the prior year performance and discussion
and suggestions for its enhancement in the next
academic year.
The well-organized system of predoctoral periodontal
education and advanced specialty education in periodontics in the United States is certainly not global. This is true
for not only countries with emerging populations but also
for highly developed countries. For example, although
Japan has institutions that train qualified postgraduate
students in the field of periodontics, Japan does not
have well-organized advanced periodontal programs and
standards for advanced specialty programs in periodontics
that compare to those in the United States (Osawa et al.,
2014). As indicated in Professor L. J. Lins initiator paper,
the inadequacy of periodontal dental curricula has led to
83
the significantly less than optimal global oral health (Jin,

Journal of the International Academy of Periodontology 2015;
17/1 Supplement). A major step to correct this issue
would be the development of comprehensive standardized
curricula for dental and advanced periodontal education
programs that could use the CODA model as a resource.
Each country would ideally establish its own accrediting
agency to establish, maintain and apply relevant education standards. The process may be difficult among
emerging populations due to resource and manpower
issues. However, once initiated there will be tangible
benefits toward evidence-based dentistry, with the
elimination of variability of quality and contents among
teaching programs that in time will lead to optimal global
periodontal health.
References
Accreditation Standards for Advanced Specialty Education Programs in Periodontics. Commission on
Dental Accreditation 2013; 1-34.
American Academy of Periodontology. Careers in periodontics. At www.perio.org/education.
American Board of Periodontology. At www.abperio.org.
American Dental Association. Requirements for recognition of dental specialties and national certifying
boards for dental specialists. Chicago: American
Dental Association, 2001.
Department of Periodontology Stony Brook University
Syllabus, 2014.
Jin LJ. Interprofessional education and multidisciplinary
of periodontal disease. Journal of the International Academy of Periodontology 2015; 17/1 (Supplement):74-79.
Osawa G, Nakaya H, Mealey BL, Kalkwarf K and
Cochran DL. Specialty education in periodontics in
Japan and the United States: Comparison of programs at Nippon Dental University Hospital and the
University of Texas Health Sciences Center at San
Antonio. Journal of Dental Education 2014; 78:481-495.
Group E
Consensus Paper
Interprofessional education and
multidisciplinary teamwork for prevention and
effective management of periodontal disease
Moderator: A. Kumarswamy, Yerla Medical Trust Dental College,
India
Initiator: Jin, Lijian, The University of Hong Kong, Hong Kong,
SAR, China
Reactor: Iacono, Vincent, Stony Brook University, USA
Working Group E:
Byakod, Girish, Rangoonwaala Dental College, India
Chiu, Gordon, Private Practice, Hong Kong
Duygu, Ilhan, Private Practice, Istanbul, Turkey
Fernandes, Benette, Srinivas Institute of Dental Sciences, India
Loomer, Peter, New York University College of Dentistry, USA
Masud, Mahayunah, University Institute Technology Mara, Malaysia
Pillai, Nihar, Private Practice, India (Transcriber)
Shorab, Mohammed, Fiji National University, Fiji
Tan, Benjamin, National University of Singapore
Thakur, Roshni, DY Patil Dental College, India (Transcriber)
Xuan, Dong-Ying, Southern Medical University, China
Zhang, Jin Cai, Southern Medical University, China
Introduction
The background for this groups discussion was presented in the Initiators review (Jin 2015). This paper
focused on the key issues relating to interprofessional
education and a multidisciplinary teamwork approach
for the prevention and effective management of periodontal disease. A number of important issues were
identified for effective periodontal management, including the role of general dental practitioners in identification of risk factors and risk management as well as the
emerging evidence on the link of periodontal disease to
a number of systemic diseases and conditions. The need
for a multidisciplinary approach in managing periodontal

11-13 April, 2014
Correspondence to: A. Kumarswamy, Yerla Medical Trust Dental
College, India, E-mail: kumar.smiline@gmail.com
patients through the teamwork among general dental

practitioners, specialist dentists and medical practitioners
was identified as key to successful treatment outcomes.
An overarching theme of periodontal literacy for patients, dentists and allied health professionals was then
developed. From this framework four key questions
were identified for further discussion:
1. What are the challenges that we face to achieve
global periodontal literacy?
2. What are the strategies which can be embraced to
achieve global periodontal literacy?
3. What resources would be needed to achieve global
periodontal literacy?
4. What would be the operational plan to achieve
global periodontal literacy?
In these deliberations a prime consideration was the
particular role, if any, that the International Academy
of Periodontology (IAP) could play in these processes.
Group E Consensus: Prevention and management of periodontal disease
Definition of global periodontal literacy

Following some discussions the group agreed that
global periodontal literacy should be defined as the
understanding and awareness of periodontal health
and diseases by the dental profession and the public.
Question 1. What are the challenges that we
face to achieve global periodontal literacy?
This question needs to be addressed at a number of
different levels that recognize that the challenges we
face to achieve global periodontal literacy are present in
dental education, the healthcare profession, regulatory
agencies, governments and among the public.
With regard to the dental profession it was clear that
there is a need to change the mindset and attitude of
dental educators, students and practitioners to understand the importance of appropriate periodontal evaluation and patient management. In order to achieve this,
the shortfalls in effective accreditation processes need to
be overcome and processes that will ensure compliance
of educational standards need to be in place. In order to
maintain educational standards, core competencies for
the delivery of periodontal care need to be established.
This can best be achieved through the development
of formative and summative assessment methods that
ensure achievement of the competencies.
The public must also be educated to achieve global
periodontal literacy. However, a number of obstacles
have been identified that hinder the progress. Demographic, socio-economic and cultural diversity is always
an issue as we try to gain acceptance by the public of
good oral and periodontal health, and this is usually
linked to a general lack of awareness of periodontal
health and appreciation of the benefits of periodontal
care. With the emergence of the electronic age and easy
access to medical information via the worldwide web,
the significance of the public obtaining misinformation
from alternative resources is ever increasing. Finally, a
general level of insufficient understanding of risk factors for periodontal diseases (i.e., smoking) continues
to hamper efforts to fully inform the public regarding
periodontal disease and its management. Clearly there
are very significant issues with regard to behavioral
modification and public understanding of periodontal
disease and periodontal care.
Question 2. What are the strategies that can be
embraced to achieve global periodontal literacy?
Strategies to address the above issues were determined to
be leveled at the dental profession and the public. With
regard to strategies to enhance the professions role in attaining global periodontal literacy, the group determined
a number of approaches that should be considered. The
formation of a pool of experts to develop and propose
guidelines to achieve periodontal health was considered
85
to be an essential starting point to achieve this goal.

Through these panels, dental educators and practitioners could be fully informed at an evidence-based level
on the ability of periodontal therapy to enhance the
outcomes of dental treatments. Subsequently, models of
formative and summative assessment methods should
be developed to ensure the achievement of core competencies. In doing so, guidelines could be formulated
for accreditation, which would promote the development of educational standards, their compliance and
the identification of core competencies.
Other novel approaches to enhance the professions
role in attaining global periodontal literacy included the
establishment of an award system to recognize contributions to the achievement of global periodontal literacy.
Furthermore, it was considered important to develop
an interactive website by creating segments for the
profession and to utilize the social media outreach to
enhance the professions perception of the importance
of periodontal health and care.
Strategies to enable the publics role in attaining
global periodontal literacy also require consideration of
a number of approaches. In order to engage the public
it was considered desirable to partner with stakeholders
in developing an educational campaign. For example,
media campaigns to improve public perception on the
importance of periodontal health and care must be undertaken. By working with appropriate agencies access to
periodontal care could be enhanced. It was considered
that one of the best ways to achieve this was to encourage global bodies to establish Periodontal Healthcare
Week following World Oral Health Day on March
20 yearly. As with the profession, it was also considered
desirable that an interactive website be developed for
the public; this could also utilize social media outreach
approaches to enhance public perception on the importance of periodontal health and care.
Question 3. What resources would be needed
to achieve global periodontal literacy?
In order to achieve the above goals it was considered
essential to recognize there will be significant resource
implications. The greatest resource we have is the
dedicated educators willing to participate in programs
to train both dentists and the public. This resource
must continue to be carefully nurtured to ensure the
future is well supported by these experts. Contemporary education models must be adopted globally. For
example, vertical models for dental education should
be embraced, as they will enhance the training of dental
students in a more holistic approach to patient care
and management. In parallel with maintaining a good
educational model and pool of educators, and notwithstanding the role universities play in this process, other
sources of support must be recognized and developed.
86
These would include education and research foundations

by recognized specialist bodies such as the American
Academy of Periodontology, European Federation of
Periodontology, Asian Pacific Society of Periodontology,
and other regional dental and periodontal societies. The
role of the media (both print and electronic) cannot
be underestimated, and when further formulating the
goals of global periodontal literacy this powerful conduit to the public must not be overlooked. In addition,
government and non-government agencies could be
pivotal in providing valuable resource support for our
goal of global periodontal literacy. Finally, we cannot
discount the valuable support that can be provided by
commercial partners to achieve this goal. An excellent
example of this is the outstanding support by the dental
industry for this International Academy of Periodontology Conclave.
Question 4. What would be the operational
plan to achieve global periodontal literacy?
In order to further this plan for global periodontal literacy, an action plan was discussed. Initial needs were
identified for the IAP Board to prioritize the strategies
for their implementation in a reasonable timeline and to
identify the appropriate resources to achieve the goals.
To ensure good ongoing outcomes these processes
would need to be continuously assessed and reviewed.
Recommendations
From this consensus report the following recommendations are made to achieve global periodontal literacy:
1. Role of the International Academy of
Periodontology
IAP to form a pool of experts to give guidelines
for minimal and optimal periodontal health care,
while considering logistical difficulties in different
regions of the world.
2. Training the educators for dental students
Must be equipped with skills to train dental students
to evaluate the periodontal status of their patients,
including risk assessment and treatment planning.
Be able to help the students to understand the
importance of assessing the periodontal needs of
their patients.
Must have the necessary skills to evaluate and assess dental students knowledge of periodontal
health care.
Be able to demonstrate to students the importance
of interdisciplinary dentistry.
Be able to encourage students to participate in
outreach/extension activities as expected by socially
responsible clinicians.
3. Training the educators for postgraduate/

post-doctoral students
Agencies need to be identified that would ensure
postgraduate/post-doctoral periodontal educational
standards on a global basis.
Development of an international pool of academic
and clinical periodontists who would serve as a
mentoring source for those programs in the process
of either initiating and/or enhancing their postgraduate/post-doctoral programs. The IAP would
be seen as a logical contributor to such a program.
4. Research
Research must be recognized as the cornerstone to
advance periodontal health literacy.
International periodontal societies should pool
their resources and knowledge to develop or initiate
research protocols that could be universally applied
for the enhancement of periodontal health. The
IAP would be seen as an appropriate body to coordinate such a program.
Engagement of the corporate sector as a resource
and mutual colleague should be encouraged so as
to enable global research initiatives.
5. IAP awards as an effective mechanism to
enhance global periodontal literacy
It was discussed and decided that awards at various
levels could be granted to dental students, undergraduate/pre-doctoral and graduate/post-doctoral
educators for the recognition of their achievements
in educational and research programs related to
periodontal education.
Incentives by the IAP for every institution through
essays/competitions/projects for innovations in
periodontal health care for all patient demographics
from pediatric through geriatric patients.
Reference
Iacono, VJ. Enhancing global periodontal and oral
health by standardizing education systems . Journal
of the International Academy of Periodontology 2015; 17/1
(Supplement):74-79.
Jin, LJ. Interprofessional education and multidisciplinary
of periodontal disease. Journal of the International Academy of Periodontology 2015; 17/1 (Supplement):74-79.
Organized
INTERNATIONAL ACADEMY OF PERIODONTOLOGY
IAP MEETING
CHILE 2015
Update and New Developments in
Periodontics and Implants for the
Specialist and General Dentist
Santiago-Chile
A p r i l 1 7 t h -1 8 t h / 2 0 1 5
Aula Magna Universidad San Sebastin
Campus Bellavista,Bellavista N 07 (intersection with Pio Nono)
Speakers:
Niklaus Lang; ThomasVan Dyke; George Hajishengallis;
Gustavo Garlet; Ricardo Teles; Alp Kantarci; Sebastian
Ciancio; Magda Feres; Ahmed Gamal; Mark Bartold;
Anton Sculean; Vincent Iacono; Joerg Meyle; Lisa
Mayfield, Jamil Shibli, Jorge Gamonal; Rolando Vernal;
Fernando Fuentes; Gustavo Mazzey and Antonio Sanz
Poster competition: cash prizes for the outstanding poster presentations
_
Contact_
Romina Fiabane SPCh
02 - 23357692
soc.periodoncia@gmail.com
REGISTRATION FEES_
> students USD 200
> peridontal society members USD 250
> non members USD 300

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Journal of the International

Volume 17 Number 1 Supplement

Journal of the International Academy of Periodontology 2015 17/1 Supplement 12

The 1st IAP Conclave

This issue of the Journal of the International Academy of

Journal of the International Academy of Periodontology (2015) 17/1 Supplement

Leung, Keung, University of Hong Kong, China

RECOMMENDED AND USED BY DENTAL PROFESSIONALS

The science behind this trust:

dental associations worldwide

Know the Science. Get the Facts.

Journal of the International Academy of Periodontology 2015 17/1 Supplement: 415

Presented at the First IAP Conclave, Bangkok, Thailand,

Group A Initiator: Developing country home remedies for plaque control

The eligibility criteria were as follows:

Screening and selection

Box 1. Search terms used for PubMed-MEDLINE and Cochrane-CENTRAL.

{ <Intervention: [MeSH terms] Toothbrushing OR (Home Care Dental Devices) OR [text

Journal of the International Academy of Periodontology (2015) 17/1 Supplement

Figure 1. Search and selection results.

Excluded by title and abstract

Selected for fulltext reading

Included from the reference

= Calculated by the review authors

Slot et al., 2012

Mode of analysis (methodology, metaanalysis, vote

The dental professional should determine, on an individual

The efficacy in plaque removal following a brushing exercise

Original review authors conclusions

Two studies included

Two included studies reported the same

Group A Initiator: Developing country home remedies for plaque control

Authors estimated quality

Authors estimated quality score

Oral hygiene device evaluated

Group A Initiator: Developing country home remedies for plaque control

tematic reviews with respect to the databases searched,

Journal of the International Academy of Periodontology (2015) 17/1 Supplement

Group A Initiator: Developing country home remedies for plaque control

Based on the individual papers in the review by

in patients with periodontitis (Walsh and Heckman,

Journal of the International Academy of Periodontology (2015) 17/1 Supplement

Group A Initiator: Developing country home remedies for plaque control

Journal of the International Academy of Periodontology (2015) 17/1 Supplement

Cooper AM, OMalley LA, Elison SN, et al. Primary

Group A Initiator: Developing country home remedies for plaque control

Monse B, Naliponguit E, Belizario V, Benzian H and van

Sackett DL, Strauss SE, Richardson WD, Rosenberg W

Journal of the International Academy of Periodontology 2015 17/1 Supplement: 16

Medicinal or herbal anti-plaque preparations

The scholarly review by Slot and Van der Weijden (Journal

A number of herbal or traditional medicine preparations are marketed as anti-plaque or anti-gingivitis

Chemical plaque control

Presented at the First IAP Conclave, Bangkok, Thailand,

Journal of the International Academy of Periodontology 2015 17/1 Supplement: 1720

Presented at the First IAP Conclave, Bangkok, Thailand,

There were three key questions that were ultimately

Journal of the International Academy of Periodontology (2015) 17/1 Supplement

Methods used during the deliberation

Objective 1- The current status of mechanical methods for

Objective 1. What is the current status of

The data on the toothbrush and floss groups were very

Table 1. Summary of findings from systematic reviews

Group A Consensus: Developing country home remedies for plaque control