Nonsurgical treatment of chronic periodontitis

Chronic periodontal disease affects a significant proportion of adults over the age of 30. In America about 47% of adults are affected and a panel of experts was convened by the American Dental Association (ADA) Council on Scientific Affairs to develop a clinical practice guideline.

The aim of this document was to present an evidence-based clinical practice guideline and systematic review on nonsurgical treatment of patients with chronic periodontitis by means of scaling and root planing (SRP) with or without adjuncts.

Methods

Searches were conducted in PubMed/MEDLINE and Embase for randomized controlled trials of SRP with or without the use of adjunctive treatments with clinical attachment level (CAL) outcomes of trials at least six months in duration and published after 1960. Only studies in English were considered.

Data abstraction was carried out independently by two reviewers and study quality assessed using the Cochrane risk of bias tool. A clinical relevance scale was agreed a priori for CAL ; 0-0.2mm= zero benefit; >0.2-0.4= small benefit; >0.4-0.6 moderate benefit; >0.6mm substantial benefit.

Results

72 RCTs were included. The table below summaries the meta-analysis conducted and the level of certainty assigned to the authors findings.

	No of trials	No. of patients	Mean difference (mm) CAL(95% CI)	Level of certainty
SRP	11	331	0.49 (0.36 to 0.62)	Moderate
SRP +systemic sub-antimicrobial doxycycline	11	813	0.35 (0.15 to 0.56)	Moderate
SRP + systemic antimicrobials	24	1086	0.35 (0.20 to 0.51)	Moderate
SRP + CHX chip	6	316	0.40 (0.24 to 0.56)	Moderate
SRP+ doxycycline hyclate gel	3	64	0.64 (0.00 to 1.28)	Low
SRP + minocycline microsphere	5	572	0.24 (-0.06 to 0.55)	Low
SRP + diode laser (PDT)	10	306	0.53 (0.06 to 1.00)	Moderate
SRP + diode laser (non- PDT)	4	98	0.21 (-0.23 to 0.64)	Low
SRP + Nd:YAG laser	3	82	0.41 (-0.12 to 0.94)	Low
SRP+ erbium lasers	3	82	0.18 (-0.63 to 0.98)	Low

CHX = chlorhexidine ; Nd:YAG = neodymium-doped yttrium aluminium garnet

Conclusions

The authors concluded: –

The literature on randomized controlled trials of SRP versus no treatment or debridement is scant, but confirmed the commonly reported result of approximately 0.5 mm improvement in CAL. The literature on adjunctive therapies was varied providing only a moderate level of certainty on the benefits of the four adjunctive therapies: systemic sub-antimicrobial dose doxycycline, systemic antimicrobials, chlorhexidine chips, and photodynamic therapy with a diode laser. There was a low level of certainty on the benefits of all other adjunctive therapies. The panel also assessed the balance between the benefits and potential for adverse events and harms from each treatment. The panel makes specific recommendations for additional research on the topic of nonsurgical treatment for chronic periodontal disease to fill the gaps in knowledge and improve the evidence base.

Comments

The guidance document is base on a broad well conducted systematic review although the searches were limited to two major databases and the English language, which means that relevant studies could have been excluded and point noted by the authors. The quality of the available periodontal literature was also highlighted by them noting inconsistencies in what is considered clinically relevant, variations in the description of periodontal disease over time, limited description of the treatments delivered and the number of small studies with low statistical power.

All the documentation relating to this review and guideline is available on the ADA Centre for Evidence-Based Dentistry website. This includes the full report, Systematic review, guideline and helpful chairside guide. An earlier guideline on the prevention and treatment of periodontal diseases in primary care which was published in 2014 from the Scottish Dental Clinical Effectiveness Programme (SDCEP) is also available online (see links).