FULL MOUTH VERSUS QUADRANT

TREATMENT IN CHRONIC PERIODONTITIS

ANJANA SAGAR
Prim Dent J. 2014;3(3):66-69

recolonisation of bacteria in a previously

ABSTRACT disinfected area by bacteria from an
untreated region before the completion
Aim The aim of this review is to discuss the evidence for the management of of treatment. A potential consequence is
chronic periodontitis, including methods of non-surgical therapy such as full impaired healing, treatment failure and
mouth disinfection, full mouth debridement and conventional quadrant-by- disease recurrence.
quadrant therapy.
Methods Manual searches of Medline and Embase databases provided the Full mouth non-surgical therapy is the
relevant studies. completion of full mouth treatment in one
Results Multiple randomised controlled trials (RCTs) selected for the paper visit or two visits within 24 hours, with
failed to show any significant differences between the quadrant-wise treatment (full mouth disinfection) or without (full
and full mouth debridement and modalities. mouth debridement) the use of additional
Practical implications This review demonstrates that there is no known chemical antiseptics. This technique was
difference in treatment outcomes between full mouth debridement and proposed in 1995 by a research group
traditional quadrant therapy. Further RCTs are necessary to assess clinical at Leuven University to avoid re-infection
effectiveness of chemical adjunct use. of instrumented pockets by residual
pathogenic bacteria from untreated
pockets or other intraoral niches.8

Introduction
Periodontal disease is a common chronic
inflammatory disease that affects the
soft and hard structures that support the
teeth. Chronic periodontitis, the most
common presentation of the disease, has
considerable impact on individuals and
communities, affecting approximately
47% of adults and over 60% of over
65-year-olds in the adult US population.1
The World Health Organization (WHO)
has shown that deep periodontal pockets
(≥6mm) in advanced disease affect
approximately 10 –15% of the adult
population worldwide.2 Periodontitis is
associated with impaired masticatory
function and poor aesthetics and is
responsible for a substantial proportion
of edentulism. It also has an impact
on escalating dental costs, reduces
the quality of life and has a possible
impact on general health.3
The primary goal in periodontal
disease management is the reduction
or elimination of periodontal pathogens,
resulting in a preserved natural dentition
and healthy functional periodontium. This
transpires via the continuous and regular
disruption of the microbiological biofilm,
which has a major role in the initiation
and progression of periodontal disease.4
The term ‘periodontal debridement’ was
proposed to describe light, overlapping
strokes used when instrumenting a tooth.5
It is now used to describe gentle but
systematic instrumentation aimed at
the removal of plaque, calculus and
endotoxins and avoiding the removal
of cementum, which was traditionally
removed during root planing.6
Non-surgical mechanical periodontal
therapy, by either hand instrumentation
or ultrasonic use, has been demonstrated
as an effective control for patients with
periodontitis.7
Conventional non-surgical therapy by
quadrant is performed on a quadrant-by-
quadrant basis in four visits with one- to
two-week intervals between treatment
sessions. This time delay may result in
AUTHOR
Anjana Sagar BDS, MFDS RCSEd
Senior House Officer in Restorative Dentistry and
Oral Surgery, Guy’s and St Thomas’ NHS
Foundation Trust, London
Comparisons of full mouth
disinfection versus quadrant
scaling
Quirynen et al (1995)8 compared the
clinical and microbiological effects of
standard consecutive quadrant scaling
and one-stage, full mouth disinfection.
Ten patients with advanced chronic
periodontitis were randomly allocated
to a test group and a control group. The
test group received full mouth scaling in
two visits within 24 hours, with additional
irrigation of the pockets using 1%
subgingival chlorhexidine, use of 0.2%
chlorhexidine mouthrinse for two minutes
and brushing of the tongue with a 1%
chlorhexidine gel for one minute at each
visit. Additionally, a daily oral hygiene
regimen was instituted and 0.2%
chlorhexidine mouthwash was used for
a period of two weeks. The control group
received oral hygiene instruction and
scaling per quadrant at two-week
KEY WORDS
Periodontal Disease, Non-surgical
Periodontal Treatment, Full mouth
Disinfection

66 P R I M A R Y D E N TA L J O U R N A L
intervals. The test group patients revealed
a significantly higher reduction in probing
depth than the control group for deep
pockets at both follow-up visits. Following
collection of plaque samples from the
upper right quadrant at baseline and after
one and two months, differential phase
contrast microscopy revealed that the test
group had significantly lower proportions
of spirochaetes and motile rods; culture
showed that they harboured significantly
fewer pathogenic organisms at one month.
Vandekerckhove et al (1996)9
investigated the eight-month follow-up
period of the 10 adult patients with
advanced chronic periodontitis from the
Quirynen et al (1995)8 study. Regarding
pockets ≥7mm, full mouth disinfection
showed a statistically greater reduction
in probing depths (of 4mm) at each
follow-up visit compared to traditional
therapy, which was 3mm at eight
months. Gingival index and bleeding
tendency showed similar improvements
with time. The full mouth disinfection
group showed lower increase in gingival
recession and more clinical attachment
gain compared to the quadrant group
(3.7mm vs 1.9mm, respectively) after
eight months. This study suggests that
a full mouth disinfection produces
an enhanced clinical outcome in
chronic periodontitis as compared
to quadrant therapy.
Quirynen et al (2000)10 compared full
mouth disinfection with chlorhexidine, full
mouth debridement and quadrant scaling
from a clinical and a microbiological
perspective, using three groups of
12 patients, each with advanced
periodontitis, over eight months.
Conclusions from this study were
that full mouth treatments revealed a
higher reduction in probing depth (of
approximately 1.5mm) and 2mm more
clinical attachment gain for pockets
≥7mm. Microbiological samples were
VOL 3 NO 3 AUGUST 2014
taken from intraoral sites and the two full
mouth groups had a greater reduction
of spirochetes and motile organisms,
especially in subgingival plaque samples.
Differences between full mouth disinfection
and debridement patients were negligible,
therefore this study demonstrated that the
additional use of chlorhexidine adjunct
has a very limited effect.
Using 36 subjects with chronic
periodontitis randomly allocated to three
groups, Koshy et al (2005)11 considered
the effects of full mouth ultrasonic scaling
using povidone-iodine or water (both in
single visits) and quadrant-wise scaling
with ultrasonics. Following treatment, there
was no significant difference between the
groups regarding plaque score, probing
depth and clinical attachment level.
Microbiological samples showed no
change in the frequency of periodontal
pathogens between groups. However, the
full mouth groups demonstrated a greater
reduction in the percentage of both closed
pockets ≥5mm and bleeding on probing
sites compared to the quadrant therapy
group. This study also showed that similar
treatment outcomes could be achieved
in less time with full mouth disinfection
(2hrs 19mins) compared to full mouth
debridement (2hrs 7mins) and in
significantly less time compared to
quadrant therapy (2hrs 58mins). This
indicates that single-visit, full mouth
therapy has limited additional benefits
over quadrant-wise therapy in the
treatment of periodontitis, but may be
worthwhile as it can be completed in
a shorter time.
Quirynen et al (2006)12 randomly
allocated 71 patients with moderate
periodontitis to several groups, including
quadrant scaling at two-week intervals,
full mouth debridement within two
consecutive days, and three full mouth
disinfection groups using chlorhexidine
within two days and follow-up with
either chlorhexidine for two months,
amine fluoride/stannous fluoride for two
months, or chlorhexidine for two months
followed by amine fluoride/stannous
fluoride for another six months. The
chlorhexidine groups showed statistically
significantly more pocket depth reduction
and attachment gain of 0.5–0.7mm
compared to quadrant group; however,
no established difference was detected
compared to full mouth debridement
group.
Kinane et al (2008)13 showed no
significant differences in the clinical,
microbiological or immunological
outcome between quadrant therapy
and full mouth debridement but they
highlighted that when determining the
treatment options, the clinician should
consider practical implications such as
time needed for procedures and patient
preference.
Swierkot et al (2009)14 tested 25 patients
with generalised chronic periodontitis
and arranged them into three groups:
quadrant-by-quadrant scaling at one-week
intervals, full mouth disinfection group
with chlorhexidine, and a full mouth
debridement group. Initially, the full
mouth debridement produced a higher
reduction in probing depth and bleeding
on probing after one and two months;
however, all three treatment methods
resulted in an improvement of the clinical
and microbiological parameters without
any significant group differences after
eight months.
67
 Caption
FULL MOUTH VERSUS here?
QUADRANT
TREATMENT IN CHRONIC PERIODONTITIS

Comparisons of full mouth
disinfection versus full
mouth debridement
Three studies mentioned above
compared the effect of full mouth
disinfection to full mouth debridement,
which showed no significant difference
in clinical outcome measures between
the two groups.10 -12 These observations
suggest that the clinical benefits might
be contributed by full mouth debridement
only and that there is little additional
benefit in using chemical adjuncts.
A meta-analysis with seven randomised
control trials compared full mouth
scaling with or without the use of
antiseptics and quadrant scaling as
the control.15 This showed 0.33mm gain
in clinical attachment level and 0.53mm
weighted mean difference for reduction
in pocket depth in moderately deep
pockets of single-rooted teeth between
full mouth disinfection and quadrant
scaling. Comparing full mouth disinfection
and debridement, 0.74mm weighted
mean difference for gain in clinical
attachment level and a weighted mean
difference for reduction of bleeding
on probing of 18% favoured full
mouth disinfection for deep pockets
of single-rooted teeth. This systematic
review highlights modest improvements
of full mouth disinfection over debridement
from the limited number of studies that
were available.
In a Cochrane systematic review16 seven
randomised control trials met the entry
criteria. Following full mouth disinfection,
improvement in clinical attachment levels
and probing depths were limited and no
net benefit could be determined by using
full mouth disinfection. Lang et al (2008)17
also concluded that all three treatment
options may be used for the initial
treatment of patients with chronic
periodontitis. Farman and Joshi (2008)18
did not find any significant differences
in clinical outcomes for full mouth
debridement with antiseptics, debridement
without antiseptics and conventional
quadrant treatment. They concluded that
all these therapeutic modalities can be
equally effective.
Currently there is limited evidence to
demonstrate the effects of subgingival
chlorhexidine gel application. A
systematic review including eight studies19
showed that, depending on the frequency
of gel application, when used as a
monotherapy the gel reduces bleeding
on probing in the short-term. The data
does not justify the use of chlorhexidine
gel in the routine treatment of chronic
periodontitis. Subgingival pocket
irrigation with povidone-iodine showed
a small to moderate but statistically
significant reduction in probing depth of
0.28mm when compared to water, saline
or no rinse in the treatment of chronic
periodontitis.20 In this meta-analysis
there were many low quality studies and
povidone-iodine was used in different
ways, making comparisons between
studies difficult. It is important to note that,
when considering the cost implications of
these adjuncts, the clinical significance of
these results becomes difficult to justify.21
Full mouth debridement
versus quadrant scaling
Six studies compared the effect of full
mouth debridement to full mouth quadrant
scaling, including three studies mentioned
previously. Koshy et al (2005)11 found
no statistically significant difference,
Quirynen et al (2000)10 showed
significantly better results, and Quirynen
et al (2006)12 showed borderline
statistically significant improvements
for the full mouth debridement group.
Apatzidou et al (2004)22 compared
same-day full mouth scaling to quadrant
scaling at two-week intervals over four
consecutive sessions on 40 patients with
chronic periodontitis. Both therapies
produced improvements in clinical
measurements at reassessment after six
weeks of therapy and reassessment after

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68 P R I M A R Y D E N TA L J O U R N A L
six months. The deepest site in each
quadrant was analysed before and after
each therapy and pockets ≥7mm showed
a significantly greater gain in clinical
attachment level for the full mouth
debridement group compared to the
quadrant group after six months. These
results should be interpreted with care due
to the limited number of deep pocket sites.
Wennström et al (2005)23 evaluated the
difference in clinical efficacy of a single
session of full mouth subgingival ultrasonic
instrumentation compared to quadrant
scaling using hand instrumentation using
41 patients with an average of 35
periodontal sites with a pocket depth
≥5mm. After three months, residual sites
with pocket depths ≥5mm had a repeated
course of debridement using either
ultrasonic or hand devices. The
percentage of closed pockets ≤4mm at
three months was 58% for the full mouth
debridement approach and 66% for the
quadrant approach. Treatment efficacy of
the initial clinical phase was measured in
time taken for instrumentation/number of
pockets closed, which was significantly
higher for the full mouth group (3.3
min/closed pocket) than the quadrant
approach (8.8 min/closed pocket). This
time difference can also be due to the
differing instruments used rather than
the treatment approach.
Apatzidou et al (2004)22 and
Wennström et al (2005)23 failed to show
any statistically significant difference
between the treatment groups but both
modalities were found to be equally
efficacious. It was notable however that
the Wennström study23 compared one
hour of full mouth ultrasonic debridement
(test) against four hours of traditional
scaling and root planing with hand
instruments (control) and still found
no difference in treatment outcomes
between the two groups. Therefore in
practice, clinicians should select the
treatment modality based on such
practical considerations related to
patient preference, cost-effectiveness
and the clinical environment in which
they are working.
Jervøe-Storm et al (2006)24 used 20
patients with chronic periodontitis
(≥2 teeth per quadrant with pocket
depths ≥5mm) and split them into a
test group with patients treated in
two sessions within 24 hours by
subgingival scaling and a control
group treated quadrant by quadrant
in four sessions in intervals of one
week. The study showed no evidence
for a difference between the clinical
parameters and equally favourable
clinical results following both treatment
modalities.
Conclusion
Non-surgical periodontal treatment is
the cornerstone of the management
of chronic periodontitis. The 2008
Cochrane review16 suggests that when
comparing the traditional quadrant-wise
therapy and a full mouth approach,
there is no significant difference in
periodontal clinical outcome measures.
Evidence in this field is still inconclusive
due to the low number of studies
performed, and further exploration
is required to demonstrate the ideal
treatment in the management of chronic
periodontitis.
It has been highlighted that patient
outcome measures have not been fully
demonstrated in the studies; for example,
time taken for treatment, post-operative
side effects of different instrumentation
modalities, and the cost-effectiveness
of the procedures. The data collected
suggest that less treatment time may
be needed for full mouth debridement
therapy compared to conventional
quadrant scaling. That would result in less
overall chairside time and less travelling
or absence from work for the patient.
Comprehensive studies focusing on
efficiency and cost-effectiveness are
needed to determine whether it is
beneficial to perform certain clinical
measures in periodontal practice.

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14 Swierkot K, Nonnenmacher CI,
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