Volume 79 Number 6

Repeated Scaling Versus Surgery

in Young Adults With Generalized
Advanced Periodontitis
Jorgen Konig,* Christian Schwahn,* Jutta Fanghanel,* Jutta Plotz,* Thomas Hoffmann,
and Thomas Kocher*

Background: Residual probing depth (PD) after subgingival

scaling can be treated with repeated scaling or periodontal
surgery. Ambiguous results about the additional clinical ben-
efit of a second scaling procedure exist. Therefore, we per-
formed a prospective study comparing the clinical results of
repeated subgingival scaling versus periodontal surgery in
30- to 40-year-old subjects with generalized advanced peri- adersten et al.1 reported excellent
odontitis.
Methods: Twenty-six subjects (mean age, 37 3 years)
were treated after an initial examination (t1), initial subgingival
B clinical healing results following
non-surgical treatment with hand
and ultrasonic instruments in subjects
scaling, and baseline examination (t2) with a randomly with chronic periodontitis, but they did
assigned second subgingival scaling (test) and periodontal not show an additional benefit of repeated
surgery (control) in a split-mouth design. The final examina- instrumentation after 3 months.2 During
tion (t3) took place 6 months postoperatively. Intraindividual supportive periodontal care, a potential
comparisons of mean PD and clinical attachment level beneficial effect of repeated subgingival
(CAL) were analyzed. scaling on clinical variables, such as
Results: PD was reduced from 4.1 0.2 mm initially (t1) to probing depth (PD) and clinical attach-
3.1 0.1 mm at baseline (t2), and to 2.9 0.1 mm at the end of ment level (CAL), compared to plain
the study (t3) for the test sites; and from 4.5 0.2 mm (t1) to supragingival prophylaxis at 3-month
3.5 0.1 mm (t2), and 3.1 0.1 mm (t3) for the control sites. intervals has been questioned.3 One
The total PD decrease from t1 to t3 was significant (P <0.001) explanation is that the benefits of dis-
for both therapies. PD reduction from t2 to t3 was only signifi- turbing the subgingival flora may be
cant (P <0.001) for control sites, resulting in a significant (P = outweighed by the accumulated trau-
0.010) difference between test and control at the final exami- matic effects of repeated scaling every 3
nation. CAL increased 0.2 0.1 mm (t2) plus 0.3 0.1 mm months.4 Another is that repeated scal-
(t3) for the test sites and 0.2 0.1 mm (t2) plus 0.2 0.1 mm ing with the same instrument and tech-
(t3) for the control sites. Total CAL gain was statistically sig- nique does not necessarily increase
nificant for the test and control sites. CAL gain from t2 to t3 the effectiveness of root debridement
was only significant (P = 0.022) for the test sites. in areas that were not reached during
Conclusions: Both treatments reduced PD and increased the first instrumentation.5,6 Conversely,
CAL. A second subgingival scaling resulted in significant addi- Wennstrom et al.7 described an addi-
tional CAL gain and reduced the need for surgery. J Periodontol tional reduction in PD and gain in CAL
2008;79:1006-1013. of 1.0 and 0.7 mm, respectively, at sites
subjected to repeated scaling.
KEY WORDS
According to the literature, the great-
Periodontal attachment loss; periodontal pocket; est reduction in PD and gain in CAL oc-
periodontitis; prospective study; statistics; curs within 1 to 3 months post-scaling
subgingival scaling. and root planing, but healing and matu-
ration of the periodontium continue for
9 to 12 months.8 We performed repeated
* Unit of Periodontology, School of Dentistry, University of Greifswald, Greifswald, Germany.
Department of Periodontology, Postgraduate Dental Education Center, Public Dental debridement and periodontal surgery
Service, Orebro, Sweden. 5 months after the initial subgingival
Department of Periodontology, Faculty of Odontology, Carl Gustav Carus University,
Dresden, Germany.
doi: 10.1902/jop.2008.070380

1006
J Periodontol June 2008
scaling. A combination of different scaling instruments
and techniques, such as hand, ultrasonic, and sonic
instruments with special periodontal tips, were used
for debridement. Periodontal surgery served as the
gold standard for the treatment of residual deep peri-
odontal pockets.9 The aim of our study was to com-
pare the results of repeated subgingival scaling to
periodontal surgery in a homogeneous group of
young adults with generalized advanced periodontitis.
MATERIALS AND METHODS
Study Design
A prospective treatment study with a split-mouth de-
sign was performed to compare the additional effect of
randomly assigned repeated subgingival scaling to
periodontal surgery on periodontal healing in 30- to
40-year-old adults with generalized advanced peri-
odontitis. The local ethics commission approved the
study protocol.
Subject Selection
Study subjects were recruited from a pool of patients
who were referred to the Unit of Periodontology, Uni-
versity of Greifswald, between November 1999 and
March 2001 for the treatment of periodontitis.
To participate in the study, the subjects had to meet
the following criteria: aged between 30 and 40 years,
generally healthy, and with generalized periodontal
destruction with radiographic bone loss greater than
one-third of the total root length and/or furcation involve-
ment and a minimum of eight teeth with PD 6 mm
and CAL 5 mm (reference point CAL = cemento-
enamel junction) measured with a manual probe.
At least three of these teeth had to be other than front
teeth or first molars10 to exclude subjects with lo-
calized aggressive periodontitis. Teeth with bone loss
derived from endodontic problems, root fractures,
cervical resorption, or cemental tears were excluded.
Subjects were ineligible if they received antibi-
otic therapy and/or regular administration of anti-
inflammatory drugs during the last 3 months, if they
were lactating or pregnant, if they received periodon-
tal treatment within the last 12 months, if they required
excessive prosthetic therapy, or if they had not signed
an informed consent to participate in the study.
Treatment
Initial treatment. In four sessions at weekly intervals,
a dental hygienist (JP) instructed and encouraged all
subjects in effective dental hygiene based on their in-
dividual needs and full-mouth plaque score. The sub-
jects were trained to use a conventional multitufted
toothbrush with the Bass technique11 and interdental
aids with predominantly interdental brushes. Scaling
and root planing were performed without anesthesia
by means of Gracey curets and an ultrasonic scaleri
Konig, Schwahn, Fanghanel, Plotz, Hoffmann, Kocher
with periodontal inserts. Every treatment session
ended with a professional tooth cleaning.
Four weeks later (week 8), a periodontist (JF or
TK) treated all sites with PD >4 mm with subgingival
debridement under local anesthesia in one or two con-
secutive sessions with Gracey curets and an ultra-
sonic scaler# with periodontal inserts.**
After non-surgical periodontal therapy, the dental
hygienist called the subjects for reinstruction, remo-
tivation in effective oral hygiene, and professional
tooth cleaning.
Experimental procedure. Five months after the ini-
tial subgingival scaling (week 30), eligible subjects
were treated with a repeated subgingival scaling
and periodontal surgery according to a split-mouth
design. A computer-generated randomization list was
used to assign the therapeutic approach for each
side. An experienced periodontist (JF) performed a
second subgingival debridement (test) on one side
and periodontal surgery (control) on the other side
in two sessions, 1 week apart, always starting with
the right side. An access flap without osseous resec-
tion or regenerative procedures was used for the peri-
odontal surgery. Scaling and root planing were
performed with Gracey curets and a sonic scaler with
periodontal tips, without time restrictions. The sub-
jects were instructed to refrain from the use of inter-
dental aids and to rinse with 0.12% chlorhexidine
digluconate solution for 1 week postoperatively un-
til the sutures were removed.
One, 3, 7, and 15 weeks postoperatively, the dental
hygienist recalled the subjects for reinstruction, remo-
tivation in adequate oral hygiene, and a professional
supragingival tooth cleaning (Fig. 1).
Examination
PD, CAL, and bleeding on probing (BOP) were re-
corded by the same examiner (JP) at the beginning
of initial treatment (PD at week 1 and CAL at week
2), at the baseline examination (week 20), and at 6
months after repeated scaling and periodontal sur-
gery at the final examination (week 54) (Fig. 1). PD
and CAL, the distance from an occlusal reference
point to the bottom of the pocket, were measured with
an electronic constant-force probe and the appro-
priate handpiece at six sites per tooth (mesio-buccal,
mid-buccal, disto-buccal, mesio-lingual, mid-lingual,
and disto-lingual). CAL was measured twice, and in
case of a disagreement >1.0 mm between the two mea-
surements, a third probing was performed and the
PCP 11, Hu-Friedy, Chicago, IL.
i Cavitron, DENTSPLY, York, PA.
FSI-SLI, DENTSPLY.
# Cavitron, DENTSPLY.
** FSI-SLI, DENTSPLY.
SONICflex, KAVO, Biberach, Germany.
Blend-a-med, Mainz, Germany.
Florida Probe FP32, Gainesville, FL.
1007
Repeated Scaling in Young Adults
Figure 1.
Study design.
average of the closest two recordings was calculated
according to the option-3 probing scheme.12 BOP
was recorded 20 seconds following the first probing
as a dichotomous value.
A dichotomous plaque index (PI) according to the
plaque control record13 was determined at six sites
per tooth during the initial treatment, at baseline, and
at the end of the study.
Subjects with at least one equivalent test and con-
trol tooth with PD 5 mm at the baseline examination
(week 20) were eligible to continue the study.
The radiographic examination consisted of a full-
mouth status in extension cone paralleling tech-
nique,14 which was performed at week 3.
Statistics
Subject-level data are presented as subject means,
based on all teeth and tooth sites (N = 3,832), with
the exception of third molars. For descriptive statis-
tics, sites were categorized into three groups accord-
ing to their initial PD: 1 to 3 mm with PD 3.4 mm; 4 to
6 mm with PD between 3.6 and 6.0 mm; and >6 mm
with PD >6.0 mm. Changes in recession (REC) were
calculated as the difference between CAL and PD:
DREC = DCAL - DPD.
Site-level data consisted of values from all sites
(N = 2,042) that received a second subgingival de-
bridement (test, N = 1,077) or additional periodontal
surgery (control, N = 965). Sites adjacent to control
teeth were excluded from further analysis. Intraindi-
1008
Volume 79 Number 6
vidual comparisons between the test and control sites
were performed, using statistical software,ii without
categorization of the initial PD to avoid regression to
the mean15 and without initial or baseline adjustment
for the analyses of change.16 The software allows an-
alyzing cluster-correlated data (sites within a specific
cluster [subject]). Cluster-correlated data were mod-
eled under exchangeable working correlations. Smok-
ing (never smoker, former smoker, and current smoker),
gender, age, PI, and tooth type (incisors, premolars,
and molars) did not meet the criteria for confounding
(i.e., that inclusion in the model led to 10% change in
the coefficient of interest, [periodontal surgery: yes/
no]) and were excluded from the final analysis.
Data on quantitative characteristics were expressed
as mean SD for observed values and as mean SE
for estimated values.
RESULTS
Subject Level
Forty-seven subjects met the inclusion criteria after the
initial examination. Twenty-one subjects (mean age,
36.3 3.4 years) were excluded from the study be-
cause of death (one subject), severe accident (one
subject), administration of antibiotics for non-dental
reasons (three subjects), non-compliance (four sub-
jects), missing baseline data (two subjects), or because
of excellent healing after the initial non-surgical treat-
ment resulting in PD <5 mm (10 subjects).
The mean age of the remaining 26 subjects (10
males and 16 females) was 37 3 years. Eleven sub-
jects were non-smokers, eight were former smokers
(four subjects ceased smoking within the last year),
and seven were current smokers (four subjects
smoked >10 cigarettes/day). They had a mean of
25.1 teeth at the initial examination and 24.7 teeth
at the end of the study, with a range of 17 to 28 teeth.
Overall, the subjects had an average of six molars,
with a range of two to eight molars. Ten teeth (six mo-
lars and four non-molars) were extracted for peri-
odontal reasons during the observation period. Three
subjects lost one molar each, and one subject lost four
non-molar teeth between the initial and baseline
examinations. After the baseline examination, three
molars were lost in two subjects.
PD. The mean PD at the initial examination was
3.9 0.7 mm; 35.4% of sites had PD of 4 to 6 mm,
and 15.4% of sites had PD >6 mm. The mean PD de-
creased to 2.9 0.4 mm at baseline and 2.7 0.4 mm
at the end of the study, primarily due to a stepwise re-
duction in the percentage of sites with PD of 4 to 6 mm
and >6 mm to 19.3% and 2.1%, respectively, at the end
of the study (Table 1, Fig. 2).
ii SUDAAN, release 7.5.3, Research Triangle Institute, Research Triangle
Park, NC.
J Periodontol June 2008 Konig, Schwahn, Fanghanel, Plotz, Hoffmann, Kocher

Table 1. REC. The mean changes in REC

compared to the initial examina-
Clinical Parameters (mean SD) at the Initial, Baseline, and
tion were 0.9 0.9 mm at baseline
Final Examinations and 0.8 mm 0.9 mm at the final
examination (Table 1).
Examination CAL. The mean gain in CAL
Parameter Initial Baseline Final between the initial examination
and baseline was 0.2 0.7 mm,
Teeth (N) 25.1 2.6 24.9 2.7 24.7 2.8 whereas it was 0.4 0.6 mm be-
PI (%) 47 20 25 13 23 13 tween the initial examination and
the end of the study (Table 1).
BOP (% of sites) 39 30 16 12 15 12
PD (mm) 3.9 0.7 2.9 0.4 2.7 0.4 Site Level
PD. Intraindividual comparisons
REC (mm) (compared to initial examination) 0 0.9 0.9 0.8 0.9 of sites showed a decrease in mean
CAL (mm) (compared to initial examination) 0 0.2 0.7 0.4 0.6 PD for test sites from 4.13 0.15
mm to 3.05 0.08 mm at baseline
and 2.93 0.08 mm at the end of
the study. The mean PD for the
control sites was 4.54 0.15 mm, 3.45 0.1 mm,
and 3.06 0.08 mm, respectively (Fig. 3). The
change in mean PD between the initial examination
and the end of the study was statistically significant
(P <0.001) for the test and control sites, without a
statistically significant difference between the treat-
ments. With a focus on additional PD changes follow-
ing surgery (-0.39 mm) compared to a second
subgingival scaling (-0.12 mm), only the additional
surgery promoted a statistically significant reduction
in PD (P <0.001). This additional PD reduction at the
control sites resulted in a statistically significant (P =
0.010) difference between the test and control sites
Figure 2. favoring surgical treatment.
Percentage distributions on subject level of shallow (1 to 3 mm),
One course of scaling resulted in 74.5% of sites with
medium (4 to 6 mm), and deep (>6 mm) sites at initial, baseline,
and final examinations. PD <6 mm. Repeated scaling increased the amount of
sites with PD <6 mm to 82.1%, primarily in favor of shal-
low pockets with PD of 1 to 3 mm. The additional re-
duction in PD increased with deeper initial PD (Fig. 4).
CAL. Mean CAL gain at the test sites was 0.17
0.14 mm at baseline and an additional 0.25 0.10 mm
at the end of the study, resulting in a total attachment
gain of 0.42 0.14 mm. The corresponding values
for the control sites were 0.22 0.14 mm and 0.17
0.10 mm, for a total CAL gain of 0.38 0.14 mm
(Fig. 3). The total gain in attachment between the ini-
tial and final examinations was statistically significant
for both treatment procedures (test: P = 0.008; con-
trol: P = 0.012), with a non-statistically significant dif-
ference between the test and control sites. Between
the baseline and final examinations, test sites showed
a statistically significant gain in attachment (P =
0.022).
Figure 3. REC. At test sites, there was an increase in REC of
Intraindividual comparisons of PD (mm) and changes in CAL (mm) 0.90 0.20 mm at baseline and a reversal of REC
and REC (mm) at test (repeated scaling) and control sites (access
of 0.14 0.10 mm at the final examination, resulting
flap) at the initial, baseline, and final examinations.
in a total REC of 0.77 0.19 mm. Control sites

1009
Repeated Scaling in Young Adults Volume 79 Number 6

categories, mean PD changes

between baseline and the
final examination favored
surgical treatment. With re-
spect to CAL, only sites with
initial PD >6 mm showed a
tendency toward higher CAL
gain after periodontal surgery
compared to repeated sub-
gingival scaling.
Table 2 presents site-level
data on changes in CAL and
PD between the initial and fi-
nal examinations for the two
treatment procedures and
the three different categories
Figure 4. of initial PD for non-molar
Percentage distribution of sites with PD 1 to 3, 4, 5, and >6 mm after one course of scaling (S1) and and molar teeth. The gain in
repeated scaling (S1+2) in relation to initial PD (PD[in]). attachment and reduction in
PD increased with deeper ini-
tial PD, irrespective of treat-
ment procedure and tooth type. In
general, pocket reduction was
greater for non-molar teeth relative
to molars. With respect to initial
PD, the gain in CAL and reduc-
tion in PD was more pronounced
for non-molar teeth compared to
molars with initially deep pockets
>6 mm. With regard to treatment
procedure, CAL and PD changes
were similar, except for initially
shallow non-molar sites and me-
dium molar sites, in which the CAL
gain was greater after non-surgical
treatment compared to surgery. In
deep molar sites, the attachment
gain was greater following surgery.

DISCUSSION
Figure 5. The removal of supragingival and
Mean differences (mm) in PD change and CAL change between the two treatment modalities accessible subgingival plaque
(repeated scaling and combined scaling/flap surgery) for initially shallow (1 to 3 mm), medium and calculus is accomplished by
(4 to 6 mm), and deep (>6 mm) pockets. periodontal scaling.17 Subgingival
scaling and root planing of peri-
odontal pockets immediately re-
experienced increases in REC of 0.87 0.17 mm and sults in an attachment loss of up to 1 mm due to
0.21 0.10 mm = 1.09 0.19 mm (Fig. 3). The total trauma from instrumentation, irrespective of the in-
change in REC was statistically significant in both struments used;18-21 in most cases, this is followed
groups, with a statistically significant (P = 0.004) dif- by repair. The greatest amount of periodontal healing
ference between test and control sites for changes af- occurs up to 3 months post-scaling.8 Because residual
ter baseline in favor of repeated scaling. PDs 6 mm are associated with further disease pro-
Figure 5 illustrates the difference in PD and CAL gression,22 these sites require additional treatment,
changes between repeated subgingival debridement such as repeated subgingival scaling or periodontal
and combined subgingival scaling/periodontal sur- surgery.23 A second instrumentation may destroy
gery for the three initial PD categories. For all three the newly formed immature tissues and prevent

1010
J Periodontol June 2008 Konig, Schwahn, Fanghanel, Plotz, Hoffmann, Kocher

Table 2.
Changes in CAL (DCAL) and PD (DPD) Between the Initial and Final Examination
at Non-Molar and Molar Teeth

Scaling/Periodontal Surgery
Initial PD Repeated Scaling (mean SE) (mean SE)

Non-molar teeth
DCAL 1 to 3 mm 0.17 0.14 (n = 315) -0.20 0.17* (n = 246)
4 to 6 mm 0.54 0.15 (n = 254) 0.63 0.15 (n = 258)
>6 mm 0.97 0.27 (n = 121) 1.00 0.21 (n = 189)
DPD 1 to 3 mm 0.30 0.07 0.27 0.09
4 to 6 mm 1.59 0.14 1.87 0.13
>6 mm 3.12 0.29 3.27 0.23

Molar teeth
DCAL 1 to 3 mm 0.06 0.14 (n = 143) -0.07 0.16 (n = 100)
4 to 6 mm 0.58 0.19 (n = 152) 0.25 0.20 (n = 101)
>6 mm 0.73 0.26 (n = 92) 0.92 0.25 (n = 71)
DPD 1 to 3 mm 0.24 0.10 0.22 0.10
4 to 6 mm 1.27 0.13 1.10 0.16
>6 mm 2.71 0.32 2.72 0.40
Calculated with software for the analysis of cluster-correlated data (sites within subjects).
* Statistically significant difference (P <0.001) between repeated subgingival scaling and combined subgingival scaling/periodontal surgery.

optimal periodontal healing, if it is performed before
the tensile strength of the soft tissue is restored during
the final phase of wound healing after weeks and
months of remodeling and collagen synthesis.24
Repeated subgingival scaling at 3-month intervals
during supportive therapy has been questioned
because of accumulated traumatic effects.4 Accumu-
lated trauma might explain why repeated instrumen-
tation 3 months after initial non-surgical therapy had
no additional positive effect on PD and CAL in the clin-
ical study of Badersten et al.,2 especially in older sub-
jects, because age is associated with delayed clinical
healing.25 Our young adults received a second scaling
and periodontal surgery 5 months after the initial sub-
gingival debridement. To our knowledge, there are no
in vivo studies available comparing healing results,
i.e., changes in PD and CAL, between repeated scal-
ing versus periodontal surgery combining different
scaling instruments and techniques. In this study,
hand, sonic, and ultrasonic instruments were used
for depuration.
A split-mouth design enabled us to analyze treat-
ment results independent of interindividual variance
at the subject and site level using statistical software.
The models describe the relationship between treat-
ment and response across clusters (subjects). They
are more suitable to analyze model agenthost rela-
tionships regarding periodontitis than random effects
and mixed models, which characterize how the ex-
pected response for a site within a subject depends
on treatment.26 An intraindividual comparison was
performed excluding smoking habits because we
did not observe that smoking had a confounding or
modifying effect on treatment results. This observa-
tion is in contrast to the literature,27 but it may be ex-
plained by the low number of smoking subjects (N = 4)
with cigarette consumption >10 cigarettes/day.
Our subject population was very homogeneous.
Subject selection was based on predefined clinical signs
of disease and the subjects age. Homogeneity of the
subjects regarding age is an additional strength.28 All
participants were of European white ethnicity.
It is remarkable that 28% (10/36) of the subjects
were excluded because of an excellent healing re-
sponse after a single course of subgingival debride-
ment. This fact confirms a well-performed first scaling.
In contrast to the study by Badersten et al.,2 but in
concordance with the study by Wennstrom et al.,7
we observed additional attachment gains in our sub-
jects after repeated scaling. Badersten et al.2 com-
pared single versus repeated instrumentation for all
sites on single-rooted teeth, whereas our group and
Wennstrom et al.7 only performed repeated scaling
at sites with deep residual PD at non-molar and molar
teeth. Unlike Badersten et al.2 and Wennstrom et al.,7
we performed a combined root debridement with
hand, ultrasonic, and sonic instruments with special
periodontal tips to increase effectiveness; 74.5% of
all sites had PD <6 mm after a single course of subgin-
gival scaling. Repeated scaling resulted in 82.1% of
sites with PD <6 mm. Consequently, the second
course of scaling resulted in an additional 30%

1011
Repeated Scaling in Young Adults
(7.6%/25.5%) reduction in residual sites with PD 6
mm (Fig. 4).
With respect to CAL changes in deep molar teeth
sites, surgical treatment was superior to repeated
scaling and resulted in attachment gain comparable
to that at single-rooted teeth. The increase in attach-
ment level after surgery was similar to the results re-
ported by Pihlstrom et al.29 and superior to the results
described by Lindhe et al.30
Overall, our findings are independent of a differ-
ent statistical approach, mainly in concordance with
the results from other studies analyzed on a site-level
basis. This confirmed the statement of DAiuto et al.31
that 80% of variability in PD reduction following non-
surgical periodontal therapy is attributed to site-level
parameters, especially when dealing with a homoge-
neous subject population. Even on a subject level,
changes in PD and CAL are generally comparable
to studies32,33 with subject populations in the range
of 22 to 68 years of age. We observed a relatively
low attachment loss in shallow sites because these
sites primarily were not subjected to repeated de-
bridement.
The generalizability of our results is unknown be-
cause of the study design and subject selection. Addi-
tional studies have to demonstrate that repeated
subgingival debridement, in combination with dif-
ferent types of scaling techniques (hand, sonic, and
ultrasonic instruments), reduce the need for peri-
odontal surgery. We cannot differentiate whether
our results are a synergistic effect of an extended heal-
ing period and the combined use of different scaling
instruments and techniques. Comparing the healing
results of subgingival scaling versus periodontal sur-
gery is difficult because it is unlikely to identify the op-
timal individual healing period for both therapies. Our
study design and the homogeneous subject popula-
tion did not enable us to draw any conclusions about
the optimal healing period with regard to subject age.
The split-mouth design did not permit comparison
with a combined treatment of a single scaling plus ad-
ditional antibiotic treatment.
Within the limitations of our study, the clinical re-
sults can be summarized as follows. Repeated subgin-
gival debridement and combined treatment (subgingival
debridement and periodontal surgery) significantly
reduced PD. Both treatment approaches produced a
significant increase in attachment; an additional sig-
nificant gain in CAL was only apparent following re-
peated subgingival scaling. Both treatments produced
significant recessions; in contrast to additional peri-
odontal surgery, a second subgingival debridement
reduced the total amount of recession. A second
course of subgingival scaling further reduced the
number of initially deep pockets and the need for ad-
ditional periodontal surgery.
1012
Volume 79 Number 6
CONCLUSIONS
In our study, young adults with generalized advanced
periodontitis showed similar treatment responses in
the setting of similar clinical parameters, such as PD,
REC, and CAL, after non-surgical and surgical ther-
apy, as has been reported for the treatment of subjects
with generalized chronic periodontitis. The benefit
of repeated scaling compared to periodontal surgery
was an additional gain in CAL and a reduced need for
surgical treatment.
ACKNOWLEDGMENTS
The German Federal Ministry of Technology, Berlin,
Germany, supported this study (research grant num-
ber 01 ZZ 9603). The authors report no conflicts of
interest related to this study.
REFERENCES
1. Badersten A, Nilveus R, Egelberg J. Effect of nonsur-
gical periodontal therapy. II. Severely advanced peri-
odontitis. J Clin Periodontol 1984;11:63-76.
2. Badersten A, Nilveus R, Egelberg J. Effect of nonsur-
gical periodontal therapy. III. Single versus repeated
instrumentation. J Clin Periodontol 1984;11:114-124.
3. Heasman PA, McCracken GI, Steen N. Supportive
periodontal care: The effect of periodic subgingival
debridement compared with supragingival prophylaxis
with respect to clinical outcomes. J Clin Periodontol
2002;29(Suppl. 3):163-172.
4. Jenkins WM, Said SH, Radvar M, Kinane DF. Effect of
subgingival scaling during supportive therapy. J Clin
Periodontol 2000;27:590-596.
5. Anderson GB, Palmer JA, Bye FL, Smith BA, Caffesse
RG. Effectiveness of subgingival scaling and root
planing: Single versus multiple episodes of instrumen-
tation. J Periodontol 1996;67:367-373.
6. Kocher T, Tersic-Orth B, Plagmann HC. Instrumenta-
tion of furcation with modified sonic scaler inserts: A
study on manikins (II). J Clin Periodontol 1998;25:
451-456.
7. Wennstrom JL, Tomasi C, Bertelle A, Dellasega E.
Full-mouth ultrasonic debridement versus quadrant
scaling and root planing as an initial approach in the
treatment of chronic periodontitis. J Clin Periodontol
2005;32:851-859.
8. Cobb CM. Clinical significance of non-surgical peri-
odontal therapy: An evidence-based perspective of
scaling and root planing. J Clin Periodontol 2002;
29(Suppl. 2):6-16.
9. Lindhe J, Nyman S, Lang NP. Treatment planning. In:
Lindhe J, Karring T, Lang NP, eds. Clinical Periodon-
tology and Implant Dentistry, 4th ed. Oxford, U.K.:
Blackwell Munksgaard; 2003:414-431.
10. Gunsolley JC, Califano JV, Koertge TE, Burmeister
JA, Cooper LC, Schenkein HA. Longitudinal assess-
ment of early onset periodontitis. J Periodontol 1995;
66:321-328.
11. Bass CC. An effective method of personal oral hy-
giene. J LA State Med Soc 1954;106:100-112.
12. Clark WB, Magnusson I, Namgung YY, Yang MC. The
strategy and advantage in use of an electronic probe
for attachment measurements. Adv Dent Res 1993;7:
152-157.
J Periodontol June 2008
13. OLeary TJ, Drake RB, Naylor JE. The plaque control
record. J Periodontol 1972;43:38.
14. Updegrave WJ. The paralleling extension-cone
technique in intraoral dental radiography. Oral Surg
Oral Med Oral Pathol 1951;4:1250-1261.
15. Tu YK, Baelum V, Gilthorpe MS. The relationship
between baseline value and its change: Problems in
categorization and the proposal of a new method. Eur
J Oral Sci 2005;113:279-288.
16. Glymour MM, Weuve J, Berkman LF, Kawachi I,
Robins JM. When is baseline adjustment useful in
analyses of change? An example with education and
cognitive change. Am J Epidemiol 2005;162:267-
278.
17. American Academy of Periodontology. Guidelines for
periodontal therapy (position paper). J Periodontol
2001;72:1624-1628.
18. Claffey N, Loos B, Gantes B, Martin M, Heins P,
Egelberg J. The relative effects of therapy and peri-
odontal disease on loss of probing attachment after
root debridement. J Clin Periodontol 1988;15:163-169.
19. Nylund K, Egelberg J. Antimicrobial irrigation of peri-
odontal furcation lesions to supplement oral hygiene
instruction and root debridement. J Clin Periodontol
1990;17:90-95.
20. Alves RV, Machion L, Casati MZ, Nociti FH Jr., Sallum
AW, Sallum EA. Attachment loss after scaling and root
planing with different instruments. A clinical study.
J Clin Periodontol 2004;31:12-15.
21. Alves RV, Machion L, Casati MZ, Nociti FH Jr., Sallum
EA, Sallum AW. Clinical attachment loss produced by
curettes and ultrasonic scalers. J Clin Periodontol 2005;
32:691-694.
22. Renvert S, Persson GR. A systematic review on the use
of residual probing depth, bleeding on probing and
furcation status following initial periodontal therapy
to predict further attachment and tooth loss. J Clin
Periodontol 2002;29(Suppl. 3):82-89.
23. Wennstrom J, Heijl L, Lindhe J. Periodontal surgery:
Access therapy. In: Lindhe J, Karring T, Lang NP, eds.
Clinical Periodontology and Implant Dentistry, 3rd ed.
Copenhagen: Munksgaard; 1997:508-549.
24. Clark RAF. Wound repair. Overview and general con-
siderations. In: Clark RAF, ed. The Molecular and
Konig, Schwahn, Fanghanel, Plotz, Hoffmann, Kocher
Cellular Biology of Wound Repair. New York: Plenum
Press; 1996:3-50.
25. Phillips C, White RP Jr., Shugars DA, Zhou X. Risk fac-
tors associated with prolonged recovery and delayed
healing after third molar surgery. J Oral Maxillofac Surg
2003;61:1436-1448.
26. Shah BV, Barnwell BG, Bieler GS. SUDAAN Users
Manual, release 7.5. Research Triangle Park, NC:
Research Triangle Institute; 1997:9-19-79.
27. Bergstrom J. Periodontitis and smoking: An evidence-
based appraisal. J Evid Based Dent Pract 2006;6:33-41.
28. Rothman KJ, Greenland S. Precision and validity in
epidemiologic studies. In: Rothman KJ, Greenland S,
eds. Modern Epidemiology, 2nd ed. New York: Lip-
pincott Williams & Wilkins; 1998:115-134.
29. Pihlstrom BL, Oliphant TH, McHugh RB. Molar and
nonmolar teeth compared over 6 1/2 years following
two methods of periodontal therapy. J Periodontol 1984;
55:499-504.
30. Lindhe J, Westfelt E, Nyman S, Socransky SS, Heijl L,
Bratthall G. Healing following surgical/non-surgical
treatment of periodontal disease. A clinical study. J Clin
Periodontol 1982;9:115-128.
31. DAiuto F, Ready D, Parkar M, Tonetti MS. Relative
contribution of patient-, tooth-, and site-associated
variability on the clinical outcome of subgingival de-
bridement. I. Probing depths. J Periodontol 2005;76:
398-405.
32. Heitz-Mayfield L. How effective is surgical therapy
compared with nonsurgical debridement? Periodontol
2000 2005;37:72-87.
33. Heitz-Mayfield L, Trombelli L, Heitz F, Needleman I,
Moles DA. A systematic review of the effect of surgical
debridement vs. non-surgical debridement for the
treatment of chronic periodontitis. J Clin Periodontol
2002;29(Suppl. 3):92-102.
Correspondence: Dr. Jorgen Konig, Department of Peri-
odontology, Postgraduate Dental Education Center, Public
Dental Service, P.O. Box 1126, SE-701 11 Orebro, Sweden.
Fax: 46-19-6024024; e-mail: jorgen.konig@orebroll.se.
Submitted July 7, 2007; accepted for publication October
7, 2007.
1013