366 endorsements reference manual V 37

Surgical therapy

Surgical access to facilitate mechanical instrumentation of the 

roots has been utilized to treat chronic periodontitis for dec- 

ades. A surgical approach to the treatment of periodontitis is 

utilized in an attempt to: 1) provide better access for removal 

of etiologic factors; 2) reduce deep probing depths; and 3) re- 

generate or reconstruct lost periodontal tissues.

96-98

 

Clinical trials indicate that both surgical and nonsurgical 

approaches can be effective in achieving stability of clinical 

attachment levels.

60-65,99-103

 Flap reflection is capable, however, 

of increasing the efficacy of root debridement, especially at 

sites with deep probing depths or furcations.

60-65,70,72,99-104

 

Nevertheless, complete calculus removal, even with surgi-

cal access, may not always be achieved.

70,72,104

 The addition of 

osseous resection during surgical procedures appears to produce 

greater reduction of probing depth due to gingival reces-

sion,

62,64,65

 particularly in furcations.

66

 Regardless of the type of 

therapy, furcated teeth are problematic since they are still more 

likely to lose clinical attachment than nonfurcated teeth.

66,67,105

  

While these overall findings are helpful, the practitioner 

 

should base specific decisions for therapy on findings for each 

individual patient.

Regenerative surgical therapy

The optimal goal of therapy for individuals who have lost a 

significant amount of periodontal attachment is regeneration 

of lost tissues. While root debridement in combination with 

plaque control has demonstrated efficacy in resolving inflam-

mation and arresting periodontitis,

26,27,60-65

 healing typically 

results in the formation of a long junctional epithelium

106-108

 

with remodeling of the alveolus.

109

 Similarly, surgical debride-

ment alone does not induce significant amounts of new 

 

connective tissue attachment.

110,111

 However, some bone fill 

may occur in selected sites.

107,112

  Clinical trials suggest that obtaining new periodontal 

attachment or regenerating lost tissues is enhanced by the 

use of adjunctive surgical technique devices and materials. 

Chemical agents that modify the root surface, while promoting 

new attachment, have shown variable results when used in 

humans.

113-118

 Bone grafting

119-125

 and guided tissue regeneration 

(GTR) techniques, with or without bone replacement grafts,

126-133 

may be successful when used at selected sites with advanced 

attachment loss. The use of biologically engineered tissue induc-

tive proteins (eg, growth factors, extracellular matrix proteins, 

and bone morphogenic proteins) to stimulate periodontal or 

osseous regeneration has also shown promise.

134-142

 Literature  

reviews on periodontal regeneration

143,144

 and mucogingival 

therapy

145

 provide additional information regarding these 

 

therapies.

 

Regenerative therapy and other treatment modalities can 

be affected by several risk factors (eg, diabetes and tobacco 

use) which can diminish periodontal treatment outcomes.

146

 In 

this regard, cigarette smoking is associated with a high risk for 

progressive periodontitis

9-13,147

 and treatment for periodontitis 

may be less effective in smokers than non-smokers.

148-150

 These 

factors are reviewed in more depth in the Academy’s position 

paper Tobacco Use and the Periodontal Patient.

151

 To maximize 

effective prevention and treatment of periodontitis, patients 

should be encouraged to stop smoking and to stop using  

smokeless tobacco.

Occlusal management

Several studies indicated that excessive occlusal forces do not 

initiate plaque-induced periodontal disease or connective tissue 

attachment loss (periodontitis).

152-155

 However, other investiga-

tions suggest that tooth mobility may be associated with adverse 

effects on the periodontium and affect the response to therapy 

with respect to gaining clinical attachment.

156,157

 With regards to 

treatment, occlusal therapy may aid in reducing tooth mobility 

and gaining some bone lost due to traumatic occlusal forces.

158

 

Occlusal equilibration also may be used to ameliorate a variety 

of clinical problems related to occlusal instability and restorative 

needs.

159

 Clinicians should use their judgment as to whether 

or not to perform an occlusal adjustment as a component of 

periodontal therapy based upon an evaluation of clinical fac- 

tors related to patient comfort, health and function.

160

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Periodontal maintenance procedures

Periodic monitoring of periodontal status and appropriate 

maintenance procedures should be part of the long-term 

 

treatment plan for managing chronic periodontitis.

28

 Although 

experimental studies have demonstrated very successful treat-

ment outcomes when patients are professionally maintained  

at two-week intervals,

161 

such a program is impractical for  

most chronic periodontitis patients. Therefore, to maximize suc- 

cessful therapeutic outcomes, patients must maintain effective 

daily plaque control. It also appears that in-office periodontal  

maintenance at three to four month intervals can be effective  

in maintaining most patients.

4

 A more comprehensive review  

on this subject can be found in the American Academy of  

Periodontology’s position paper entitled Supportive Periodontal 

Therapy (SPT).

162

Summary

The inflammatory components of plaque induced gingivitis 

and chronic periodontitis can be managed effectively for the 

majority of patients with a plaque control program and non- 

surgical and/or surgical root debridement coupled with con- 

tinued periodontal maintenance procedures. Some patients  

may need additional therapeutic procedures. All of the 

 

therapeutic modalities reviewed in this position paper may be  

utilized by the clinician at various times over the long-term  

management of the patient’s periodontal condition.

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