Journal of Clinical Periodontology 1981: 8: 57-72

Key words: Periodontal treatment ~ nonsurgical - hand instruments - ultrasonics - clinical measurements.
Accepted for publication March 19, 1980

Effect of nonsurgical periodontal

therapy
I. Moderately advanced periodontitis

ANITA BADERSTTCN, ROLF NiLvius AND JAN EGEL^LRG

School of Dentistry, University ot Lund, Malmo, Sweden and School of Dentistry,
Loma Linda University, Loma Linda, CA, U,S,A,

Abstract. Healing events after notisurgical periodonta! therapy in patients with periodontal
pockets 4-7 mm deep were investigated. Incisors, cuspids and premolars in 15 patients were
treated by plaque control and supra- and subgingival debridement using hand or ultrasonic
instruments in a split mouth approach. The results were evaluated by recordings of plaque
scares, bleeding on probing, probing pocket depths and probing attachment levels. All these
parameters were improved during the initial 4-5 months after start of therapy. Little
change occurred during the rest of the 13-month observation period. No difference of re-
sults could be observed comparing hand and ultrasonic instrumentation or comparing the
results of two different operators. Initially a total of 106 sites demonstrated probity pocket
depths > 6 mm. At 13 months only 13 such sites were observed. The apparently successful
results of cotiservative treatment of patients with 4—7 mm deep pockets in the present study
raise the question to what extent nonsurgical therapy is feasible also in patients with severe-
ly advanced lesions.

A limited number of studies seem to be
available on the effect of conservative (non-
surgical) therapy of periodontal pockets,
Tagge et al. (1975) evaluated the effect of
oral hygiene instruction and root planing in
buccal and lingual areas with an average of
3 tnm probing pocket depth. Slight improve-
ment of gingival inflammation and pocket
depth was obtained by oral hygiene alone,
Additional improvement resulted from oral
hygiene instnicticai combined with root
planing, Hughes & Caffese (1978) also stud-
ied areas with an average of 3 mm probing
pocket depth. One month following seal-
ing, root planing and oral hygiene, a reduc-
ticMi in pocket depth of 0,6 mm was oh-
served,
Hellden et al, (1979) and Listgarten et al,
(1978) reported the effect of treatment of
periodontal pockets with an average depth
of 5.5 and 7 mm, respectively. Oral hy-
giene instructions alone seemed to have a
limited effect on the probing depth, where-
as the average depth 25 weeks after oral hy-
giene instructions combined with repeated
root planing was reduced to 3,6 and 4,8
mm, respectively,
Torfason et al, (1979) studied the effect
of oral hygiene instruction and hand and ul-
trasonic instrumentation in 18 patients with
moderately advanced periodontitis, Signifi-
cant reductions of the frequency of hleed-
ing upon probing and of pocket depths were
obtained. The study failed to demonstrate
58 BADERSTEN, NILVfiUS AND EGELBERG

any differences of results after the use of pockets was performed by two operators
hand versus ultrasonic instruments. The pe- (authors J. E. and R. N.) treating eight and
riod of observation was limited to 2 months seven patients, respectively. The teeth of
and did not monitor the entire healing pe- the right and left sides of the jaw were ran-
riod. domly assigned for hand or ultrasonic in-
The present study was perfonned in or- strumentation. The hand instruments were
der to acciunulate more complete informa- selected according to the preference of each
tion about the healing events following non- operator. One of the operators used Ash
surgical periodontal therapy in patients TC 13 and 14 curettes (Amalgamated Den-
with moderately advanced periodontitis and tal, London, England) and the other used
to compare tbe effects of hand and ultra- Colombia curettes nos. 13/14 (Star Den-
sonic instrumentation. tal Manufacturing Comp., Conshohoken,
USA). A Dentsply® - Cavitron® Model
600 imit with TFl-10 tips was selected for
ultrasonic instrumentation (Cavitron Ultra-
Material and Methods
sonics Inc., Long Island City, NY, USA).
Fifteen patients, 22-60 years of age, with The setting of the power, tuning and water
moderately advanced periodontal disease irrigation was adjusted to the preference of
were used for the study. Incisors, canines each operator. The debridement was per-
and premolars in either tbe maxilla or the formed under local anesthesia during one
mandible were studied. A minimum of four visit. It was randomly decided if the opera-
and a maximum of 10 teeth were used in tes was to use hand or ultrasonic instru-
each patient. The teeth had periodontal ments first. The instrumentation was car-
bone loss amounting to one-third of the ried out until the operator felt that the
root length or more. Clinical signs of gingi- root surfaces were adequately debrided and
val inflammation and periodontal pockets planed. The average time per tooth re-
> 5 mm deep with calculus and bleeding quired for each of the methods of instru-
upon probing were present on two or more mentation was calculated.
aspK:ts of each tooth. Two and 6 months after the first debride-
The experimental design is shown in Fig. ment repeated instrumentations were con-
I. sidered. Each operator made his own eval-
uation of the need of repeated instrumen-
Oral hygiene instruction tation of the individual tooth surfaces. The
The oral hygiene instruction of the patients same type of instruments were used for the
was provided by a dental hygienist, using a same teeth as before but the order of usage
series of four to five visits during 1 month. was reversed.
Multitufted soft toothbrushes, single tufted
toothbrushes, interdental brushes, triangu-
lar toothpicks, disclosing wafers and illumi- Method of measurements
nated mouth mirrors were used. These aids The results of the treatment were evaluated
were recommended for the patients as by measurements of dental plaque, bleeding
needed. Additional instruction was given to on probing, preying pocket depth, probing
patients according to individual needs dur- attachment level and gingival recession. Re-
ing the first 7 months of the study. cordings were made at the initial examina-
tion and then once a month by one of the
Debridement of periodontal pockets authors (A.B.) who was unaware of which
The instnunentation of the periodontal instrumentation had been used for the dif-
 NONSURGICAL PERIODONTAL THERAPY 59

ferent teeth. At each examination, the
bleeding scores were first taken, then the
plaque scores followed by the measurements
of probing pocket depth and attachment
level. Recordings were made at four as-
pects of each tooth: mid-buccal, disto-buc-
cal, mesio-lingual and mid-lingual. Two ini-
tial measurements of pocket depth and at-
tachment level were taken 1 week apart to
evaluate the reproducibility of the record-
ings.
Dental plaque
Presence or absence of plaque was recorded
after staining with an erythrosin disclosing
dye (Diaplac Rondell®, Astra, Sweden).
Presence of plaque was scored if an area of
clearly stained material was present along
the gingival margin and if this material
couid be removed with the side of the
probe. The percentage of surfaces with
plaque out of the total number of exam-
ined tooth surfaces was calculated.
Bleeding on probing
Bleeding upon probing was determined with
a Hilming periodontal probe no. 1 (C-G
Brinkers Dentalindustrifabrik, Hvidovre,
Denmark). If hemorrage was noted subse-
quent to the probing, a positive score was
recorded. The proportion of bleeding sur-
faces out of the total number of examined
surfaces was calculated.
During probing of each of the four as-
pects of the teeth, the probe was moved
twice in the apical direction to secure find-

EXPEHIMENTAL DESIGN

NITIAL SCORES I

1 WEEK

4IT1AL SCORES 2
RAL HYGIENE INSTRUCTION. VISITS 1
2
3
I MONTH 4
S
MONTH SCORES
NSTRUMENTATION M

1 MONTH

MONTH SCORES initrudian sitar

indiviiiual naads
1 MONTH

MONTH SCORES
(STRUMENTATION ttZ

I MONTH

iONTHLY SCORES UNTIL 7-MONTH SCORES

STRUMENTATION 1*3

3 MONTHS Fig. 1. Flow chart of the ec-

oral hygiana avaluatiftn perimental de&iga.
-MONTH SCORES .a— and yraiaaaianal laatk
ciaaning Das Ablaufschema der Ver-
3 MONTHS suchsplanmng
Organigramme du plan de
-MONTH SCORES I'expirience.
60 BADERSTEN, NILVfiUS AND EGELBERG

ing the base of the pocket. The probing Table 1. Distribution of surface by initial
force was not standardized. However, at probing pocket depth and method of instru-
the end of the study an electronic pres- mentation. Msins of the two initial recordings
Die Verteilung der Oberflachen auf die initial
sure-sensitive probe (Electronic Periodontal gemessenen Taschentiefen und auf die Behand-
Probe, model 200, Vine Valley Research, lung mit Hand- und Vhraschallinstrumenten
Middlesex, NY, U.S.A.) was used to eval- Distribution des surfaces suivant la profondeur
uate the probing force of the examiner. The initiate de sondage des poches et le type d'in-
force was found to be around 0.50-0.60N. struments employe. Moyenne des deux enregi-
strements initiaux.
Probing pocket depth and probing
No. of surfaces
attachment level Initial probing
Probing pocket depth and probing attach- pocket depth Hand Ultra-
ment level were measured to the nearest of instruments sonics
1 mm with a specially machined and cali- 1.0- 1.5 3 4
brated probe (0.5 mm in diameter, 1 mm in- 2.0- 2.5 61 62
crements). A metal onlay was used to pro- 3.0- 3.5 49 49
vide reference points for the measurements. 4.0- 4.5 58 58
The placement of the probe at the individ- 5.0- 5.5 32 46
6.0- 6.5 33 29
ual tooth surface was guided by steering 7.0- 7.5 15 10
grooves placed in the onlays. During prob- 8.0- 8.5 8 3
ing the probe was directed at a slight angle 9.0- 9.5 3 0
to the long axis of the tooth. Again, the 10.0-10.5 2 2
probe was moved twice towards the base of 11.0-11.5 0 0
12.0-12.5 0 1
the pocket to secure finding the pocket
base before the distances to the gingival Total 264 264
margin (probing pocket depth) and to the
edge of the onlay (probing attachment lev- Initial probing pocket depth (initiate Sondie-
rungstiefe, profondeur de sondage initiate des
el) were recorded. poches), no. of surfaces (Anzahl Oberflachen,
The means of the two initial recordings nombre de surfaces), hand instruments (Hand-
for pocket depth and attachment level were instrumente, instruments a main), ultrasonics
used for the comparisons with the subse- (Ultraschailinstrumente, ultra-sons).
quent monthly scores.

Gingival recession Similar distribution of surfaces with differ-

The location of the gingival margin was as-
sessed by subtraction of the figure for pock-
et depth from the figure for attachment
level.
ent pocket depths was prraent for hand and
ultrasonic instruments. The average pocket
depth was 4.3 mm for surfaces to be instru-
mented with hand instruments and 4.2 mm
for surfaces to be treated with ultrasonics.

Results

Distribution of material Reproducibility of initial measurements

A total of 528 surfaces were treated. Tlie The reproducibility of the initial recordings
distribution of these surfaces with respect to ctf probing pocket depth and probing attach-
initial probing pocket depths and method of ment level as evaluated from the duplicate,
instrumentation are presented in Table 1. 1 week apart measurements is presented in
 NONSURGICAL PERIODONTAL THERAPY 61

Table 2. Reproducibility of duplicate recordings of probing pocket depth and probing attachment
level. Number of surfaces and percent of surfaces with differences of 0, ± 1, and ± 2 mm, re-
spectively
Wiederholbarkeit von Doppelregistrierungen beim Sondieren der Taschentiefe und des Attach-
mentniveaus. Anzahi der Oberjlachen und Messunterschiede in Prozent bei Messungen von 0 mm
± } mm und + 2 mm
Reproductibilite des enregistrements repetes de la profondeur de sondage des poches et du niveau
de tattachement lors du sondage. Nombre de surfaces et pourcentages des surfaces presentam
des differences de 0 mm, de ± 1 mm et de + 2 mm.

Probing pocket depth Probing attachment level

Difference between
duplicate recordings No. of Percent No. of Percent
surfaces surfaces surfaces surfaces
0 mm 355 67 366 69
± 1 mm 170 32 158 30
± 2 mm 3 1 4 1

Total 528 100 528 100

Difference between duplicate recordings (Unterschied iwischen verdoppelten Registrierungen, dif-
ference entre les enregistrements repetes), probing pocket depth (sondierte Taschentiefe, profon-
deur de sondage des poches}, percent surfaces (Oberflachen in Prozent, pourcentage des sur-
faces), probing attachment level (sondiertes Attachmentniveau, niveau de Vattachement lors du
sondage).

Table 2. The majority of the measurements Bleeding on probing

were duplicated within 1 mm deviation.
Only 1 % of the measurements deviated 2
mm.
Dental plaque
Initially 65.-73 % of the tooth surfaces
showed presence of plaque. After 1 month
the plaque scores were reduced to less than
12 % where they remained throughout the
study. Differences between patients treated
by one or the other operator or between ar-
eas subjected to one or the other method of
instrumentation were negligible (Fig. 2).
Figs. 3 and 4 demonstrate the results for
the different surfaces of the teeth treated
by hand or ultrasonic instruments. It can be
seen that reductions of plaque scores occur-
red for all surfaces. The scores for the prox-
imal surfaces, however, remained higher
than the scores for the buccal and lingual
surfaces.
At the initial examination 77-90 % of the
surfaces showed bleeding upon probing. At
the 1-month examination, 1 month after
start of oral hygiene instruction and pri-
or to instrumentation, the bleeding scores
were not altered. At the 2-month examina-
tion, 1 month after the first instrumenta-
tion, the bleeding scores were reduced to
36-41 %. A further reduction took place
during the subsequent months until an
8-16 % level was reached. Both opera-
tors achieved similar reductions of bleeding
scores using either method of instrumenta-
tion (Fig. 2).
Similar patterns of improvement of bleed-
ing scores occurred for all surfaces of the
teeth and for both methods of instrumenta-
tion. The scores for the proximal surfaces
remained higher than the scores for the
buccal and lingual surfaces (Figs. 3, 4).
62 BADERSTEN, NILVfiUS AND EGELBERG

PLAOtX SCORE. \

HAND INSTHUMENIS

ULTRASONICS

m
100]

11
BLEEDING SCORES

POC«FT DEPTH mrr

\

13

3 4 S 6 13
REDUCTION OF POCKET DEPTH rr

Ir In
10

r¥if¥i
2 3 4 5 6 7 10

CHANGE Of ATTACHMENT L E V E L mrn

1 2 3 4 5 6 7 10 13
MONTHS
Fig. 2. Means of the recorded parameters by operator and method of instrumentation at the var-
ious r^istration intervals during the study.
Die Mittelwerte der registrierten Parameter wdhrend der Versuchsabschnitte - aufgeschliisselt
nach dem Behandler und der instrumentellert Methode.
Moyennes des parametres enregistres awe differents intervalles au cours de cette etude, suivant
I'operateur et suivant le type d'irtstruments employe.

Probing pocket depth for all four surfaces of the teeth were 4,1-
Initially, the mean probing pocket depths 4.5 mm. One mcmth after the start of oral
 NONSURGICAL PERIODONTAL THERAPY 63

lUMD MSTIWIMENTS
100

so
so PIJUUE scows «

40

20

100
i -ffh—n-i -i-m
=n_ 10 13

so
ao BifEOMG s c o n e s

40

20 i

rrftl
0 1 2 3 4 5 S 7 10 13

a
5

1 -I

3 4 5 6 10 13
REDUCTJON OF POCKET DEPTH, mm

4 5 S 10 13
GMOWIU. H E C E S S K H mm

3 4 5 6 10 13
OMNGE OF ATTACHMBn LEVEL, mm

4 5
TT 10
MOWTMS

Fig- 3. Means of the recorded parameters for mid-buccal (B), mid-lingUEtl (L), mesio-lingual (M)
and disto-buccal (D) surfaces treated by hand instruments by both cq)erators at the various r ^ -
istration intervals during the study.
Die Mittelwerte der registrierten Parameter fUr "mittenbukkale" (B), "mittenlinguale" (L), me-
sio-Unguale (M) und disto-bukkale (D) Oberflachen wahrend der verschiedenen Versuchsabschmt-
te, nack Behandlung mit Handinstrumenten durck beide Behandler.
Moyennes des paramitres enregistris aux differents intervalles au cours de tetiide, au niveau
du milieu des faces vestibulaires (B) et tinguales (L), et au niveau des faces mesiales du cote lin-
gual (M) et des faces distales du cote vestibulaire (D), dans les cas traitis par les deux opera-
teurs au moyen des instruments & main.
64 BADERSTEN, NILVfiUS AND EGELBERG

ULTRASONICS
too
PLAOUE SCORES S
so
60
40
20
r-rm—iTh r-u- n r-r-rf]
_•_ 10
-N—-^

too
80 BL£EnsiC SCORES

60
40
TO
J] Ah. -r-m 10

PnoeiNG POCKET DEPTH mm

4 5 « T 10
REDuCTKW OF POCKET DEPTH, mm

r-rrn , rfffl
4 S 6 10 13
GwavAL RECESSION mm

rrrfl
3 4 5 6 7 10 13
CMANQE O f ATTACMMeNT LEVEL mm

_ij-__r'~t , . f"*"^ |—I I I I , --^—I—I—I—^

MONTHS

f I?. 4. Means of the recorded parameters fcs- mid-buccal (B), mid-lingual (L), mesio-lingusi! (M)
and disto-buccal (D) surfaces treated by ultrasonic itistruments by both operators at the various
registration intervals during the study.
Die Mittelwerte der registrierten Parameter fur "mittenbukkale" (B), "mittenlinguale" (L), me-
sio-linguale (M) und disto-bukkale (D) Oberfldchen wahrend der verschiedenen Versuchsabschnit-
te, nach Behandlung mit VUraschaUinstrumenten durck beide Behandler.
Moyennes des parantetres enregistres aux differents intervalles au cours de I'itude, au niveau du
milieu des faces vestibulaires (B) et linguales (L), et au niveau des faces misiales du coti lingual
(M) et des faces distales du cote vestibulaire (D), dans les cas trcutis par les deux operateurs au
moyen des uhra-sora.
 NONSURGICAL PERIODONTAL THERAPY 65

Table 3. Distribution of surfaces according to place for all surfaces of the teeth and in a
residua] probing depth at 13 months and meth- corresponding pattern for both methods of
od of instrumentation
instnimentation. The reductions were most
Die VerteiluKg der Oberflachen auf die Resui-
tate der noch verbleibenden Taschentiefen nach
notable for those surfaces of the teeth
13 Moriaten sowie auf die instrumentelie Me- which showed the greatest initial pocket
thode depth, Le, the proximal surfaces (Figs.
Distribution des surfaces suivant la profondeur 3,4),
de sondage persistante au bout de 13 mois et The distribution of the 528 experimental
suivatit le type d'instruments. surfaces according to residual probing depth
No, of surfaces
at 13 months and method of instrumenta-
Residual tion is presented in Table 3, The distribu-
probing Hand Ultra- tion of surfaces with different residua! prob-
deptn instruments sonics ing depth was similar for hand and ultra-
1,0 30 23 sonic instruments. Only 31 surfaces had re-
2,0 106 109 sidual probing depths > 5 mm, A compari-
3,0 68 69 son with Table 1 shows that 184 surfaces
4,0 45 47 had pocket depths > 5 mm at the initial ex-
5,0 8 10 amination.
6,0 7 0
7,0 0 4 Reduction of pocket depth took place
8,0 0 0 also for deeper pockets, irrespective of oper-
9,0 0 0 ator and method of instrumentation (Ta-
10,0 0 1*) ble 4),
11,0 0 0
12,0 0 1»)
The number of surfaces with probing
pocket depth > 6 mm at the initial exami-
Total 264 264 nation and at 7 and 13 months is presented
in Table 5. Initially, there were 106 surfaces
*) These pockets were located on a tooth that
had an initial periodontal lesion with sus- with pockets > 6 mm. At the 7- and 13-
pected periapical involvement. The periapi- month examinations only 11 and 13 sur-
cal involvement was confirmed at the 13- faces, respectively, could be probed to such
month interval and the tooth had to be ex- depth. Again, similar results were obtained
tracted.
Residual probing depth (verbliebene Sondie-
by the two operators and by the two meth-
rungstiefe, profondeur de sondage persistante). ods of instrumentation.

hygiene instruction the mean depths were
reduced hy 0.3-0,7 mm. At the 2-month ex-
amination, 1 month after the first instru-
mentation, the mean depths were reduced
by an additional 0,5-0,7 mm, A further re-
duction took place during the suteequent
months until the 4- and 5-month examitia-
tions, when mean total reductions of 1,3-
1.7 mm had taketi place. The results were
similar for both operators and both methods
of instrumentation (Fig. 2).
ReducticHi of probing pocket depths took
Gingival recession
The mean gingival recessions for all sur-
faces at the 13-month examination were 1,4
-1,6 mm. Most of the recession took place
during the first 2-3 months (Fig, 2), The
proximal surfaces showed the greatest
amount of recession (Figs, 3, 4).
Probing attachment level
Only minor changes of prohing attachment
level occurred during the course of the
study (Figs, 2, 3, 4), Buccal surfaces showed
a tendency towards loss of attachment.
66 BADERSTEN, NILVfiUS AND EGELBERG

Table 4. Residual probing depth (mean ± standard deviation) at the 7- and 13- month examina-
tions by initial probing pocket dq)th and method of instrumentation. Pooled surfaces from all
patients
Verbleibende sondierte Taschentiefen (Mittelwerte ± Standarddeviationj anlasslich der Unter-
suchungen nach 7 und 13 Monaten in Bezug auf die initial sondierten Taschentiefen und auf die
Instrumentationsmethode. Die Oberflacken aller Patienten sind hier zusamntengefasst warden
Profondeur de sondage persistante (moyenne + ecart-type) aux examens du 7^"" et du I3^<^'
mois, suivant la profondeur de sondage initiale et le type d'instruments employe. Ensemble des
surfaces chez tous les patients.

Initial Hand instruments Ultrasonics

, probing
pocket No. of Depth at Depth at No. of Depth at Depth at
depth surfaces 7 months 13 months surfaces 7 months 13 months

Operator 1

4.0-4.5 34 2.6 ± 0.7 2.6 + O7 32 2.7 ± 0.6 2.8 ± 0.7

5.0-5.5 13 3.2 + 1.1 3.0 ± O8 17 3.0 ± 0.8 3.3 ± 0.8
6.0-6.5 13 2.9 ± 1.0 3.4 ± 1.0 14 3.1 ± 0.9 3.6 ± 1.0
7.0-7.5 10 3.9 ± 1.3 3.9 ± 1.0 5 4.0 ± 1.0 4.0 ± 0.7

Operator 2
4.0-4.5 24 3.0 ± 0.8 3.0 ± 0.8 26 2.5 ± 0.7 2.8 ± 0.8
5.0-5.5 19 3.4 ± 1.0 3.8 ± 0.9 29 3.3 ± 0.9 3.5 ± 1.0
6.0-6.5 20 3.8 ± 1.1 3.9 + 1.3 15 3.5 + 1.0 3.8 ± 0.9
7.0-7.5 5 3.0 ± 1.2 3.0 ± 0.7 5 3.4 ± 0.9 4.0 ± 0.0

Table 5. Number of surfaces with probing pocket dq)th > 6 mm at initial examination and at 7
and 13 months by operator and method of instrumentation. Pooled data from all patients
Anzahl der Oberflachen mit initialen Sondierungstiefen von ^ 6 mm im Vergleich zu den Werten
nach 7 und 13 Monaten. Die Resultate sind nach den individuellen Werten der Behandler und
den angewendeten Irtslrumenten aufgeschliisselt
Nombre de surfaces ou la profondeur de sondage est ^ 6 mm a I'examen initial, ainsi qu'au
jime et au 13^^' mois, suivant I'operateur et le type d'instruments employe. Donnees concer-
nant I'ensemble des patients.

Operator 1 Operator 2 Operators 1 & 2

Hand Ul- Hand Ul- Hand Ul-
instru- tra- instru- tra- instru- tra-
ments sonics ments sonics ments sonics
Initial 31 21 30 24 61 45
At 7
months 3 2 2 4 5 6 ,
At 13
months 3 2 3 5 6 7
 NONSURGICAL PERIODONTAL THERAPY 67

m liilML il RESOUAL
DEPTH

Fig. 5. Mean amounts of gingival recession, residual probing depth and gain/loss of probing at-
tachment level at 7 and 13 months. Pooled surfaces for hand (H) and ultrasonic (U) instruments
from all patients.
Mittlere Werte gingivaler Rezession, verbliebener Sondierungstiefen und Gewinn bzw^ Verlust
an sondiertem Attachmentniveau nach 7 und 13 Monaten. Die mit Hand- (H) und Ultraschall-
instrumenten (V) bekandehen Oberfiachen alter Patienten wurden hier summiert.
Moyennes du retrait gingival (gingival recession), de ta profondeur de sondage persistante et de
ta perte ou du gain en ce qui concerne le niveau de I'attachement tors du sondage, au bout de
7 mois et de 13 niois. Ensembte des surfaces pour les instruments d main (H) et a ultra-sons (U)
chez tous les patients.

while recordings for proximal surfaces indi- of different initial depth which showed
cated a slight gain of attachment. changes of probing attachment level at 7

Attachment changes as related to initial

probing pocket depth
In Fig. 5 the data from all surfaces of all
patients have been pooled and grouped ac-
cording to initial probing pocket depth of
the individual surfaces. Sites with initially
deeper probing pocket depth showed more
gingival recession and deeper residual depth
at 7 and 13 months than sites where the ini-
tial depth was shallow. Surfaces with initial
2.0-3.5 mnj probing pocket depth had a
slight average loss of attachment. Surfaces
with 7.0-7.5 mm initial pocket depth dem-
onstrated 1.1-1.5 mm average gain of at-
tachment.
Computation of the data of Fig. 5 was
also performed using patient means of sur-
faces of different initial probing pocket
depth. These calculations showed the same
average changes of the parameters as the
pooled data of the individual surfaces.
Fig. 6. presents the percentage of pockets
mi
Fig. 6. Proportion (%) of surfaces with gain or
loss of probing attachment level > 1.5 mm at
7 and 13 months grouped by initial probing
pocket depth. N = number of available sur-
faces.
Oberftachen (in %} mit Gewinn oder Verlust
an sondierbarem Attachmentniveau von '> I.S
mm, nach 7 und 13 Monaten. Die Werte wur-
den, den Sondierungsergebnissen der initial
vorhandenen Taschentiefen entsprechend, grup-
piert. N = Anzahl verfUgbarer Oberftachen,
Proportions (%} des surfaces presentant un
gain ou une perte en ce qui concerne le niveau
de I'attachement lors du sondage > 1,5 mm au
bout de 7 mois et de 13 mois, groupees suivant
la profondeur initiate de sondage des poches.
N ^= nombre des surfaces a considerer.
68 BADERSTEN, NILVfiUS AND EGELBERG
RESIXML PROBMG DEPTH
Fig. 7. Mean change of probing attachment lev-
el for surfaces with different residual probing
depth at 13 months. Pooled surfaces from all
patients.
Veranderungen des sondierten Attachmentni-
veaus (Mittelwerte} an Oberflachen mit unter-
schiedlicher Tiefe verbliebener Taschen nach
13 Monaten. Die behandelten Oberfldchen al-
ler Patienten sind hier summiert angegeben.
Changement moyen du niveau de Vattachement
lors du sondage, suivant la profondeur de son-
dage persistante au bout de 13 mois. Ensemble
des surfaces chez tous les patients.
•I.
60-,
Dlos^iS ^Ks mm
50-
40-
30-
20-
10- N=S3
1 2 3 i S 6
Fig. 8. Proportion (%) of surfaces with gain or
ioss of probing attachment level > 1.5 mm at
13 months grouped by residual probing depth
at 13 months. N = number of available sur-
faces.
Verhaltnis (in %) zwischen den Oberflachen an
denen nach 13 Monaten Gewinn oder Verlust
des sondierbaren Attachmentniveaus von ^ 7.5
mm konstatiert wurde. Die Werte wurden so
gruppiert, dass sie den Residualtiefen nach 13
Monaten entsprachen.
N — Anzahl verfUgbarer Oberfldchen
Proportions (%) des surfaces presentant un
gain ou une perte en ce qui concerne le niveau
de Vattachement lors du sondage > 1,5 mm au
bout de 13 mois, groupies suivant la profon-
deur de sondage persistante au bout de 13
mois. N — nombre des surfaces & considerer.
100-, initial
90- 7 months
eo- 13 "
70-
60-
50-
4D-.
30-
20-
Fig. 9. Proportion (%) of surfaces showing
bleeding upon probing at initial examination
and at 7 and 13 months grouped by initial pro-
bing pocket depth. Pooled data from all pa-
tients. N = number of available surfaces.
Oberfldchen (in %) an denen bei der initialen
Untersuchung sowie nach 7 und 13 Monaten
Blutungsbereitschaft nach Sondierung konsta-
tiert wurde. Die Werte sind, den initial son-
dierten Taschentiefen entsprechend, gruppiert.
Die Daten aller Patienten sind summiert.
N — Anzahl verfUgbarer Oberflachen.
Proportions (%) des surfaces presentant un
saignement lors du sondage a I'examen initial
et au bout de 7 et de 13 mois, suivant la pro-
fondeur initiate de sondage des poches. Don<-
nees pour I'ensemble des patients. N = nombre
des surfaces a considerer.
7
mm
and 13 months. OtUy surfaces demonstra-
ting loss or gain of attachment level > 1.5
tntn have been included. Loss of attachment
of this magnitude was encountered for some
surfaces with initially shallow pockets while
gain of probing attachment level occurred
for deep pockets.
Changes of probing attachment level as
related to residual probing pocket depth
Fig. 7. presents the mean changes of prob-
ing attachment level for pooled surfaces of
different residual probing depths at 13
months. Surfaces with a residual probing
 NONSURGICAL PERIODONTAL THERAPY
100- I 7 months
90- 113 ••
80-
70- zz
60-
50-
iO-
30-
20-
10-
2 3 4 5 »6
mm
Fig. 10. Proportion (%) of surfaces showing
bleeding upon probing at 7 and 13 month ex-
aminations grouped by residual probing depths
at 7 and 13 months. Pooled data from all pa-
tients. N = number of available surfaces.
Oberflachen (in %) an denen bei den Unter-
suchungen nach 7 und 13 Monaten Blutungsbe-
reitschaft nach dem Sondieren bestand. Die
Werte sind nach den verbteibenden, nach 7 und
13 Monaten sondierten, Taschentiefen grup-
piert. Die Daten alter Patienten sind summiert.
N — Anzahl verfUgbarer Oberftachen,
Proportions (%) des surfaces presentant un
saignement lors du sondage au bout de 7 mois
et de 13 mois, groupees suivant la profondeur
de sondage persistante au bout de 7 mois et de
13 mois. Donnees pour Vensemble de tous les
patients. N = nombre des surfaces a conside-
rer.
depth of 1-2 mm seem to have lost a slight
amount of attachment while surfaces with a
residual depth of 3-6 mm seem to have un-
dergone a minor improvement of probing
attachment level. Four surfaces that had 7
mm residual probing depth showed ati aver-
age attachment loss of 0.8 mm.
If only surfaces showing loss or gain of
attachment > 1.5 mm are considered (Fig.
8), it appears that loss of attachment of this
magnitude had occurred for some surfaces
69
with \-A and 7 mm residual probing depth.
Gain of > 1.5 mm attachment had taken
place for 10-14 % of surfaces with 4-6 mm
residual probing depth.
Relationship of bleeding on probing and
probing pocket depth
The percentage of bleeding surfaces at the
initial examination was higher for surfaces
with probing pocket depth of 4-7 mm than
for surfaces with 2-3 mm depths (Fig. 9).
At the 7- and 13-maath examinations, the
bleeding frequencies were markedly re-
duced not only for the shallow pockets, but
also for pockets of greater initial probing
depth. Bleeding upon prcAing was encoun-
tered more often in deeper residual probing
depths than in shallow depths (Fig. 10).
Time of instrumentation
The total time required for instrumentation
varied between the two operators (Table 6).
They both used somewhat less time with ul-
trasonics than with hand instruments.
Discussion
The results of the present study demon-
strated that marked improvement of gingi-
val conditions can be obtained after oral hy-
giene instruction, scaling and root planing
in patients with moderately advanced perio-
dontitis.
The design of this study does not allow
separate interpretations of the effect of the
improved oral hygiene and the effect of in-
strumentation. Only 1 month of observation
was scheduled between the start of the oral
hygiene instruction and the first instrumen-
tation. During this month, the bleeding
scores were unaffected but some gingival re-
cession was observed. During the subse-
quent months gradual reductions of bleed-
ing scores and pocket depths occurred. Af-
ter 4-5 monAs little further improvement
seemed to take place.
70 BADERSTEN, NILVfiUS AND EGELBERG

Table 6. Mean time of instrumentation (minutes per tooth) by opetator and method of instru-
meatation
Mittelwerte der instrumentellen Bekandiungszeit (Minuten pro Zahn) in Bezug auf den Bekand-
ler und die instrumentelle Methode
Duree moyenne du traitement instrumental (minutes par dent) suivant I'operateur et le type
d'instrumerus employe.

Operator 1 Operator 2
Hand Hand
instru- Ultra- instru- Ultra-
ments sonics ments sonics
Instrumentation # 1
(at 1 mcnth) 4.7 3.6 7.6 7.1
Instrumentation # 2
(at 3 months) 1.3 1.0 1.2 1.0
Instrumentation #3
(at 7 months) 0.6 0.3 0.2 0.4

Total 6.6 4.9 9.0 8.5

The similarity of results foUowing hand
and ultrasonic instrumentation agrees with
the findings by Torfason et al. (1979). Pre-
vious laboratory studies have shown that ul-
trasonic instruments remove less root struc-
ture and leave a rougher surface behind
than hand instruments (see Suppipat 1974,
Torfason et al. 1979 for review). Apparent-
ly, these differences in mechanical perfor-
mance of the two types of instruments do
not seem to influence the gingival healing
as observed from clinical methods of eval-
uation. Adequate debridement of the con-
taminated root surfaces aj^jarently can be
accomplished by ultrascmic instrumentation
as well. Results from a recent in vitro study
by Nishimine & O'Leary (1979) support this
view. These authors found that ultrasonic
instrumentation can remove most of the eo-
dotoxin found in contaminated root sur-
faces.
Most of the examined surfaces showed
bleeding on probing at initial examinaticoi.
The therapy resulted in marked reduction
of the bleeding frequency including sites
with 6.0-7.5 mm probing pocket icpth ini-
tially. Some surfaces still showed bleeding
after treatment. The proportion of surfaces
where bleeding could be provoked after
therapy was somewhat higher for surfaces
with deeper residual probing depth than for
surfaces with shallow residual depth. These
circumstances seem to indicate that bleed-
ing on probing is a valuable clinical para-
meter. On the other hand, 7 % of surfaces
with 2 mm residual probing depth and 16-
17 % of the surfaces with 3 mm residual
probing depth showed bleeding after thera-
py. This raises the question as to what
extent bleeding may be encountered in
sites which seem to have bren successfully
treated.
The probing pocket depths of sites ini-
tially 4.0L-7.5 mm deep were markedly re-
duced in the present study using nonsurgical
therapy. The probing attachment levels wrae
also improved. More pocket reduction and
more gain of attachment were obtained for
surfaces with 6.0-7.5 mm initial depth than
fcff surfaces with 4.0i-5.5 mm initial depth.
In fact, the improvements of pocket depth
and attachment level were ^milar to thc»c
 NONSURGICAL PERIODONTAL THERAPY
obtained by Knowles et al. (1979) using dif-
ferent surgical treatment modalities. These
findings give rise to the question whether
surgical therapy is needed for pockets up
to 7 mm deep in the "average" periodon-
titis case. Also, they emphasize that clini-
cal studies evaluating periodontal surgery
should be performed only after adequate
periods of nonsurgical therapy. Only sites
which were not successfully treated with
root planing should be included in such
studies.
Some loss of probing attachment level
was observed for sites with initially shallow
probing pocket depth. The majority of these
sites were located on buccal surfaces of the
teeth. The attachment loss seemed to occur
soon after start of therapy. For buccal sur-
faces this initial attachment loss was not
followed by a subsequent improvement of
attachment levels in the way which could be
observed for proximal surfaces. Similar
findings with some loss of attachment for
sites with initially shallow probing depth
and for buccal surfaces have been reported
by Ramfjord et al. (1975) and Knowles et
al. (1979) following various forms of surgi-
cal therapy.
The results of the present study must be
interpreted within the limitations of the ma-
terials and methods utilized. A limited
number of patients, treated by two opera-
tors only, was used for the study- Molars
were excluded from observations because of
frequent interference from furcation in-
volvements in these teeth. A limited num-
ber of surfaces with initial pocket depth >
7 mm was available. However, the satisfac-
tory results of ncmstirgical therapy which
were obtained in the present investigation
motivate extension of these studies to pa-
tients with advanced periodontitis.
Acknowledgmani*
Sincere thanks are due to Solveig Eriksson
71
and Bodil Gustavsson for devoted dental
hygiene and technical assistance.
Zusammenfassung
Der Erfolg nicht-chirurgischer Parodontat-
therapie I
I. Miissig forigeschrittene Parodontitis
In dieser Studie werden die Heilungserfolge
nicht-chJnirgischer Parodontaltherapie bei Pa-
tienten mit Taschentiefen von 4—7 mm unter-
sucht. Schneidezahne, Eckzahne und Pramola-
ren von 15 Patienten wurden bei Anwendung
der "spllt-mouth"-Versuchsstrategie (die eine
Halfte des Mundes wird beiiaadelt, die andere
wird als KontroUgnipire nicht oder anders be-
handelt), mit PlaquekontroUe und der Entfer-
nung von sub- und supragingivalem 21ahnstein
behandelt. Es kamen Hand- oder Ultraschall-
instrumcDte zur Anwendung.
Plaque-Bewertungseinheiten, die Beurteilimg
der Blutungsbereitschaft beim Sondieren sowie
die Sondiemng der Taschen und der Attach-
mentniveaus wurden als Parameter zur Erfcdgs-
bewertung herangezogen. AUe diese Parameter
verbesserten sich wahrend der ersten 4-5 Mo-
nate nach dem Therapiebeginn. Wahrend des
dann verbleibenden Zedtabschnittes der 13 Mo-
nate dauemden Beobachtui^speriode, wurden
nur wenige Veranderungen ge&ehen. Bra der
Anwendung von Hand- Oder Ultraschailgera-
ten wurden keine unterschiedlichen Behand-
lungsergebnisse gesehen. Dasseibe gilt fur den
Vergleich zwischen den Behandlungsei^ebnis-
sen zweier verschiedener Behandler. Urspriing-
lich wurde bei der Taschensondienmg an 106
Stellen Taschentiefen von ^ 6 mm konstatiert.
Nach 13 Monaten wurden solche Taschentiefen
nur an 13 Stdlen regi&triert. Das augenschein-
lich erfolgreiche Resultat einer kcmservativen
Behandlung von Patienten mit Taschentiefen
von 4-7 mm lasst die Frage entstehen, inwie-
weit nicht-chirurgische Therapie auch bei Pa-
tienten mit fortgeschrittenen parodontalen La-
sionen moglich ist.
Action du traitement parodontal non
chirurgical.
I. Parodontite moderement avancee
Cette etude porte sur la fagcai dont evolue
la guerison apres traitement parodontal nan
chirurgical chez des patients pr^soitant des
poches parodontales de 4-7 mm de profondeur.
72 BADERSTEN, NILVfiUS AND EGELBERG
Chez 15 patients, les incisives, canines et pr^-
molaires ont ete traitees par Elimination de la
plaque et par curetages supra- et subgingivaiK
a l'aide d'instruments k main mi a l'aide des
ultra-sons, en utilisant une methode dite "de
bouche divisee" (split mouth). Les resultats ont
ete evalues par l'enregistrement des scores de la
plaque, des scores du saignement lois du son-
dage (bleeding scores), de la profondeur des
poches et du niveau de I'attachement lors da
sondage. Tons ces parametres se sont ameliores
pendant les 4-5 premiers mois apres le debut
du traitement. II ne s'est produit que peu de
cfaangement pendant le reste des 13 mois de la
periode d'observation. II n'a pas ete possible
d'observer de difference entre les resultats ob-
tenus avec les deux types d'instruments, ni en-
tre les resultats obtenus par !es deux opera-
teurs. Au depart, un total de 106 localisations
presentaient des profondeurs de sondage ^ 6
mm. Au bout de 13 mois, on n'a pu observer
que 13 localisations ayant une telle profondeur.
Le succes apparent obtenu dans cette etude lors
du traitement conservateur de patients presen-
tant des poches de 4—7 mm de profondeur
mene a se demander dans quelle mesure un
traitement non chirurgical serait praticable
Chez des patients presentant des lesions forte-
meQt avancees.
References
H e l l d ^ L. B., Listgarten, M. A. & Lindhe, I.
(1979) The effect of tetracycline and/or scal-
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Clinical Periodontology «, 222-230.
Hughes, T. P. & Caffesse, R. G. (1978) Gingi-
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and oral hygiene. A biometric evaluation.
Journal of Periodontology 49, 245-252.
Knowles, J. W., Burgett, F. G., Nissle, R. R.,
Shick, R. A., Morrison, E. C. & Ramfjord,
S. P. (1979) Results of periodontal treatment
related to pocket d ^ t h and attachment level.
Eight years. Journal of Periodontology SO,
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Listgarten, M. A., Lindhe, J. & Hellden, L.
(1978) Effect of tetracycline and/or scaling
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Ramfjord, S. P., Knowles, J. W., Nissle, R. R.,
Burgett, F. G. & Shick, R. A. (1975) Results
following three modalities of periodontal
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526.
Suppipat, N. (1974) Ultrasonics in periodontics.
Journal of Clinical Periodontology 1, 206-
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H. (1975) The clinical and histological re-
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and oral hygiene. Journal of Periodontology
46, 527-534.
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Address:
Dr. Anita Badersten
School of Dentistry
Carl Gustavs vag 34
S-214 21 Malmo
Sweden