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J Periodontol • November 2001

Longitudinal Comparison of the

Periodontal Status of Patients With
Moderate to Severe Periodontal Disease
Receiving No Treatment, Non-Surgical
Treatment, and Surgical Treatment
Utilizing Individual Sites for Analysis
Stephen K. Harrel* and Martha E. Nunn†

Background: The progression of periodontal disease without treatment

and the response of existing periodontal disease to various types of
treatment have been studied extensively. Many past studies have used
the mean of the patient’s probing depths or attachment levels to eval-
uate disease progression as opposed to following changes in individual
sites or teeth. The purpose of the current study was to evaluate the
response of individual teeth to treatment or non-treatment.

M
ultiple reports have dem-
Methods: The records from a private periodontal practice were onstrated that untreated
reviewed to find patients with complete periodontal examinations that periodontal disease will
were recorded at least 1 year apart. Patients who fit these criteria were progress, leading to degeneration
divided into those who had none of the recommended treatment of periodontal supporting struc-
(untreated, n = 30); those who had only non-surgical treatment (par- tures and eventual tooth loss.1-9
tially treated, n = 20); and a control group who had completed all rec- The progression of untreated
ommended treatment (surgically treated, n = 41). The data for each periodontal disease has been
tooth of each patient were placed in a database and analyzed using the studied in several isolated popu-
method of generalized estimating equations (GEE) to test for associa- lations that had little or no access
tions between increase or decrease in probing depths and various ini- to any form of dental care or tra-
tial clinical parameters while adjusting for significant confounders. dition of effective oral hygiene.
Results: Teeth that received no treatment or non-surgical treatment Examples of populations where
showed significant increases in probing depths, worsening of progno- epidemiological studies on peri-
sis, worsening of furcation involvement, and increases in mobility when odontal disease have been car-
compared to surgically treated teeth. Teeth that received surgical treat- ried out are tea workers in Cey-
ment showed significant decreases in probing depths. No significant dif- lon, rural African, and rural
ference was noted between teeth that had no treatment and teeth that Chinese groups.10-13 Studies of
had non-surgical treatment. these unique populations have
Conclusions: When individual teeth are used as the basis for analy- shown that in the absence of
sis, teeth that receive no treatment or non-surgical treatment show a treatment, periodontal disease
significant worsening of probing depths, furcations, mobility, and prog- will progress over time. These
nosis when compared to teeth that receive surgical treatment, while studies, while not interventional
surgically treated teeth show significant improvement in probing depths. in nature, seem to indicate that
J Periodontol 2001;72:1509-1519. without some form of treatment,
KEY WORDS periodontal destruction will con-
tinue to progress.
Disease progression; follow-up studies; periodontal diseases/
Some difficulty exists in apply-
surgery; periodontal diseases/therapy.
ing the data obtained from iso-
lated populations to patients
* Private practice, Dallas, TX and Baylor College of Dentistry, Dallas, TX. typically seen in a practice spe-
† Currently, Department of Health Policy and Health Services Research, Goldman School of Dental
Medicine, Boston University, Boston, MA; previously, Department of Public Health Sciences, Baylor cializing in periodontal treatment.
College of Dentistry. Periodontal specialty practices

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Comparison of Periodontal Treatments in Patients With Moderate to Severe Periodontal Disease
are almost universally found in developed countries.
The patients seen in a periodontal practice, unlike indi-
viduals in isolated populations, have virtually all been
exposed to some form of oral hygiene instruction.
Additionally, most patients presenting for treatment at
a periodontal office have access to basic oral hygiene
devices such as a toothbrush, which is not always the
case in isolated and often impoverished populations.
Also, most patients presenting to a periodontal prac-
tice have had professional tooth cleaning in the past,
even if on an irregular basis. In this context, it may be
incorrect to assume that periodontal destruction will
proceed in the same manner as noted in isolated pop-
ulations.
The progression of untreated periodontal disease in
an urban American population was studied by Becker
et al.14 Patients who presented to a periodontal prac-
tice for examinations but who did not follow through
with treatment recommendations were brought back for
a second examination to determine if they had expe-
rienced further periodontal degeneration. The results
of this study showed that these patients did, in fact,
have further periodontal degeneration despite their
access to oral hygiene instruction and devices. This
study can be cited to show the need for periodontal
treatment once the initial lesion of periodontitis is pres-
ent.
The results of periodontal therapy have been eval-
uated in 2 long-term studies.15-26 In both of these stud-
ies, it was found that surgical and non-surgical treat-
ment were equally effective in stopping the progression
of periodontal disease over time. However, neither of
these studies evaluated the results of periodontal ther-
apy using the individual tooth as the primary unit of
analysis. In both studies, the patient was used as the
unit of analysis, and the patient mean of the probing
depths or attachment level was used to report the
results of the study. One of these studies pointed out
that using the patient mean as the unit of analysis
might tend to mask positive or negative changes at
individual sites.26
A recent study evaluated the ability of non-surgical
periodontal treatment to reduce the number of teeth
lost in a population served under a single insurance
plan.27 This study showed that tooth mortality was
reduced by 48% to 58% in patients who had non-sur-
gical periodontal treatment performed compared to
patients who did not receive any periodontal treat-
ment. This study also found that reduced tooth mor-
tality was achieved with an increase in the number of
procedures performed. This study was viewed as an
indication that non-surgical treatment was a predictable
method of reducing tooth loss in patients with exist-
ing periodontal disease.28 While tooth loss data are
the most easily measured outcome for periodontal dis-
ease and reflect the ultimate success or failure of a
1510
Volume 72 • Number 11
treatment method, it is probably not the most feasible
measure to be used in judging treatment outcomes in
a periodontal practice because of patient loss to fol-
low-up that may be related to tooth loss. In addition,
in most periodontal practices, tooth loss related to peri-
odontal disease that occurs following completion of
treatment is a relatively rare occurrence and, hence,
it often requires following a substantial number of
patients over a long period of time to collect adequate
data for analysis.29,30 On a clinical basis, the most
commonly used outcome measure is the reduction of
probing depths.31 Probing depths have been shown to
be a clinically useful measure of periodontal health
and a good predictor of future degeneration.1,4,32-35
The success of surgical treatment in the stabiliza-
tion of probing depths is not clearly established. Long-
term studies utilizing patient mean as the unit of
study have shown that osseous surgery and modified
Widman procedures are equivalent over time to non-
surgical treatment.15-25 However, multiple studies that
followed individual sites have shown that surgical pro-
cedures utilizing regenerative techniques can produce
reductions in probing depth and improved attach-
ment levels that are stable over time.36-39 While the
use of regenerative techniques is an obvious differ-
ence, the fact that these surgical studies followed
individual teeth over time, rather than evaluating data
based on the patient mean or the group mean, may
have contributed to the apparent dichotomy between
the results of clinical studies that have followed indi-
vidual surgical sites and the long-term studies of
treatment outcome.
The current study retrospectively evaluated the effect
of no treatment, non-surgical treatment only, and a
combination of non-surgical and surgical treatment on
the progression of periodontal disease. In this study, the
individual tooth was used as the unit of analysis rather
than the mean of all the patient’s teeth (patient mean).
MATERIALS AND METHODS
The data for this study were obtained from the clini-
cal records of a private periodontal practice. All avail-
able records from 24 years of practice were searched
for patients who fit the criteria set forth as follows. All
patients had to be seen for a complete periodontal
examination with data recorded for each tooth. These
data consisted of at least 6 sites of probing depths
measured with a non-automated Michigan type probe,
bifurcation involvement (Glickman) measured with a
Nabor’s bifurcation probe, measurement of the width
of keratinized gingiva, measurement of mobility
(Miller), and analysis of occlusal relationships. All
patients must have had non-surgical and surgical peri-
odontal treatment recommended for them at their ini-
tial appointment as part of their comprehensive treat-
ment plan and must have failed to complete all of the
0332_IPC_AAP_553351 11/5/01 4:51 PM Page 1511
J Periodontol • November 2001
recommended periodontal treatment. Additionally, all
patients in this group must have voluntarily chosen
not to have surgical treatment and also must have
been reexamined at least 12 months after the initial
examination. The second examination utilized in the
analysis had to include the recording of another com-
plete set of data that duplicated the data recorded at
the first examination. All patients for whom this infor-
mation was available were included in this study. All
examinations and data collection were performed by
the same examiner.
The patients who fit these criteria were then divided
into 2 groups. An untreated group consisted of
patients who had none of the recommended peri-
odontal treatment performed between the 2 exami-
nations. A partially treated group consisted of patients
who had completed the non-surgical portions of their
treatment but had not completed the recommended
surgical treatment. Most of the patients in the par-
tially treated group were either non-compliant or par-
tially compliant with periodontal maintenance rec-
ommendations. A small group (n = 4) of the partially
treated patients were fully compliant with periodontal
maintenance recommendations. For comparison, a
control group was also formed which consisted of
patients who had completed all of the recommended
periodontal treatment for at least 12 months and had
also been compliant with the recommended peri-
odontal maintenance schedule. The control group was
formed by including the first 41 patients who were
seen during routinely scheduled periodontal mainte-
nance visits and who fit the criteria specified for inclu-
sion in the control group.
All patients who met the specified criteria for these
3 groups were entered into a database which included
the following patient information: age, smoking status
(smoker or non-smoker), presence or absence of a
medical condition such as diabetes or medication such
as phenytoin known to negatively affect the peri-
odontium (negative health history), gender, oral
hygiene (good, fair, poor), compliance with treatment
recommendations (compliant, partially compliant, and
non-compliant), and the date of each examination
where complete clinical records were recorded. The
following information was recorded for each tooth for
each visit: prognosis (good, fair, poor, hopeless), deep-
est probing depth in millimeters, bifurcation involve-
ment (Glickman Class I, II, III), the presence of
occlusal discrepancies (premature contact with a ver-
tical slide ≥1 mm or balancing contact in lateral move-
ment), presence or absence of a mucogingival defect,
and mobility (Miller 1, 2, 3). The treatment performed
for each tooth was recorded as a yes or no response
for the following categories: root planing, occlusal
adjustment, osseous surgery, osseous regenerative
procedure, and soft tissue grafting.
Harrel, Nunn
The prognosis for each tooth was assigned based on
the projected treatment outcome. A tooth with a good
prognosis was projected to be retained as a functional
unit with little or no treatment. A tooth with a fair prog-
nosis was projected to be retained as a functional unit
after treatment was completed. Teeth with a good or
fair prognosis were expected to have probing depths
of 2 to 4 mm following treatment. A tooth with a poor
prognosis was projected to be lost within 1 to 2 years
following treatment. A tooth with a hopeless progno-
sis was projected to be extracted during the course of
treatment. A diagnosis of fair to poor was given to
those teeth where the treatment outcome was in ques-
tion and where probing depths were projected to be
greater than 5 mm after treatment.40,41
The data were placed in a database where they
could be evaluated for the effect of presenting factors,
non-treatment, partial treatment, and complete treat-
ment on the progression and/or resolution of peri-
odontal disease. This paper presents the relationship
between periodontal treatment or lack of treatment
and the progression of periodontal disease over time
as measured by probing depth, mobility, and clinical
prognosis.
Statistical Methods
Summary statistics or frequencies were computed for
initial patient characteristics, including gender, health
history, smoking status, oral hygiene status, and age
with patients classified according to treatment group:
untreated patients, patients treated non-surgically, and
patients treated surgically. Possible associations
between treatment group and initial patient charac-
teristics were tested using chi-squared tests of inde-
pendence for categorical patient characteristics (such
as gender, health history, smoking status, parafunc-
tional habit, etc.) and independent samples t tests for
continuous patient characteristics (such as age). Sum-
mary statistics or frequencies were also computed for
initial clinical parameters, including probing depth,
prognosis, mobility, and furcation involvement, for
teeth classified according to treatment group (no
treatment, non-surgical treatment, surgical treatment).
Because of the lack of independence of teeth within
each patient’s mouth, comparisons of each initial clin-
ical parameter by treatment group were made by
using the method of generalized estimating equations
(GEE) while assuming an exchangeable working cor-
relation structure. The method of GEE is used in place
of traditional ANOVA or regression analysis when
there is a lack of independence among observations,
as is the case with tooth-level data collected for this
study.
The changes in clinical parameters over time were
tabulated and summarized according to treatment
group. In order to more fully evaluate the relationship
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Comparison of Periodontal Treatments in Patients With Moderate to Severe Periodontal Disease Volume 72 • Number 11

of worsening in clinical parameters over time to Table 1.

treatment group, a multiple logistic regression
model using GEE was constructed to adjust for
Patient Characteristics by Treatment Group
potential confounders such as age, gender,
Non-Surgical Surgical
health history, smoking status, parafunctional
No Treatment Treatment Treatment
habit, occlusal treatment, initial status of clini-
cal parameters, follow-up time, and oral hygiene Gender
status. A confounder is any variable that may be Female 57% (17) 45% (11) 56% (23)
associated with the outcome of interest and also Male 43% (13) 55% (9) 44% (18)
with the variable under investigation, which, in
Health
this case, is treatment group. Similarly, change No negative history 80% (24) 100% (20) 90% (37)
in probing depth per year was calculated and Negative health history 20% (6) 0% (0) 10% (4)
compared using GEE multiple regression mod-
eling while adjusting for potential confounders Smoking status
and using an exchangeable working correlation Non-smoker 60% (18) 50% (10) 61% (25)
Smoker 40% (12) 50% (10) 39% (16)
structure. Adjusted means and confidence inter-
vals were obtained for change in probing depth Oral hygiene
by treatment group while adjusting for statisti- Satisfactory 80% (24) 75% (15) 59% (24)
cally significant confounders in the multiple GEE Unsatisfactory 20% (6) 25% (5) 41% (17)
regression modeling. Adjusted means and con-
Parafunctional habit
fidence intervals were also obtained for change No bruxism 87% (26) 80% (16) 85% (35)
in probing depth by both initial probing depth Bruxism 13% (4) 20% (4) 15% (6)
and treatment group while adjusting for signifi-
cant confounders in order to evaluate the treat- Occlusal group
ment effects on various degrees of periodontal No discrepancies 17% (5) 30% (6) 59% (24)
Treated discrepancies 0% (0) 45% (9) 41% (17)
pockets separately.
Untreated discrepancies 83% (25) 25% (5) 0% (0)
All statistical analyses were conducted using
special statistical software.‡ Age
Mean (±SD) 47.4 (±10.4) 51.1 (±13.3) 58.4 (±11.2)
RESULTS Median 46.9 51.9 58.4
Exploratory Analysis Range 28.4 to 73.2 24.9 to 88.1 21.2 to 80.5
Data were collected retrospectively on 91 Follow-up time (years)
patients who had sought consultation and/or Mean (±SD) 3.2 (±2.4) 5.9 (±3.8) 8.8 (±4.6)
treatment for moderate to severe chronic peri- Median 2.1 4.6 8.8
odontitis in the private practice of one peri- Range 1.0 to 9.2 1.0 to 13.5 1.5 to 21.2
odontist. Periodontal surgery was indicated and
recommended to all 91 patients in the study.
However, through self-selection, only 41 patients com- Table 1 shows the distribution of patient character-
pleted all treatment recommended, including surgical istics by treatment group. Associations between patient
treatment (surgical treatment group); another 20 characteristics and treatment group were tested using
patients consented to some non-surgical treatment chi-squared tests of independence. No statistically sig-
(non-surgical treatment group); and 30 patients nificant association between gender and treatment
refused any treatment whatsoever (untreated group). group (P = 0.67), between health history and treat-
Those patients refusing treatment voluntarily returned ment group (P = 0.22), between smoking status and
to the office at a future date and were reevaluated. treatment group (P = 0.70), between oral hygiene sta-
Of the 61 patients who were treated either surgically tus and treatment group (P = 0.13), or between para-
or non-surgically, 26 received some form of occlusal functional habit and treatment group (P = 0.81) was
adjustment (17 out of 41 [39%] in the surgical treat- found. However, as would be expected from the study
ment group and 9 out of 20 [45%] in the non-surgi- design, there was a significant association between
cal treatment group) to correct occlusal discrepan- treatment group (surgical, non-surgical, untreated) and
cies and alleviate potential occlusal trauma. In occlusal treatment status (P <0.0001). This result was
addition, there were 30 patients who had occlusal dis- an obvious expectation since all patients who were in
crepancies that were not treated. Of the 30 patients the surgical treatment group received occlusal adjust-
who had untreated occlusal problems, 5 patients were ments where indicated and none of the untreated
in the non-surgical group, and 25 patients were in the
untreated group. ‡ Version 8.0, SAS Institute, Inc., Cary, NC.

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J Periodontol • November 2001 Harrel, Nunn

patients received occlusal adjustments, with some of Table 2.

the patients in the non-surgical treatment group receiv-
ing occlusal adjustments and others in this group fail-
Initial Clinical Parameters by Treatment Group
ing to receive occlusal adjustments.
Non-Surgical Surgical
Average age and time of follow-up were calculated
No Treatment Treatment Treatment
according to treatment group. The mean age of sub-
jects in the surgical group was compared to that in the Initial probing depth (n = 770) (n = 545) (n = 1,035)
non-surgical group, and to the mean age of untreated Mean (±SD) 4.83 (±1.36) 5.45 (±1.48) 4.83 (±1.26)
subjects using 1-way ANOVA. Based on the 1-way Median 5.0 5.0 5.0
ANOVA, it was found that there was a significant dif- Range 2.0 to 9.0 3.0 to 9.0 3.0 to 9.0
ference in age among treatment groups (P = 0.0007). Initial prognosis (n = 770) (n = 547) (n = 1,035)
Scheffe’s test of multiple comparisons was conducted Good 41% (317) 39% (214) 45% (462)
post hoc to determine which treatment groups differed Fair 54% (417) 53% (289) 51% (529)
with respect to age. It was found that patients who were Fair to poor 3% (21) 3% (17) 2% (23)
treated surgically were significantly older than untreated Poor 1% (9) 5% (27) 1% (15)
subjects. No other significant differences in mean age Hopeless 1% (6) 0% (0) 1% (6)
were found. The mean follow-up time of the treatment
Initial mobility (n = 770) (n = 547) (n = 1,035)
group was also compared using 1-way ANOVA. Sig- 0 74% (569) 75% (410) 82% (848)
nificant differences in follow-up times were found among 1 22% (171) 22% (123) 17% (171)
the treatment groups (P <0.0001). Again, Scheffe’s 2 3% (24) 2% (10) 1% (12)
test of multiple comparisons was conducted post hoc 3 1% (6) 1% (4) <1% (4)
to determine where these differences in follow-up time
Initial furcation (n = 218) (n = 168) (n = 291)
were significant. It was found that patients in the sur-
0 38% (83) 51% (85) 40% (117)
gical group were followed for significantly longer peri-
1 44% (96) 27% (46) 40% (116)
ods of time than patients in the non-surgical group or 2 16% (35) 15% (25) 16% (46)
untreated subjects. No significant difference in time 3 2% (4) 7% (12) 4% (12)
of follow-up was found between patients in the non-
surgical group or untreated subjects.
Table 2 shows statistics for initial clinical parame-
Table 3.
ters by treatment group with data collected for each
tooth. Associations between initial clinical parameters Categorized Changes in Clinical Parameters
in Table 2 and treatment group were tested using sim- Over Time by Treatment Group
ple GEE regression models with an exchangeable
working correlation matrix. No significant differences Non-Surgical Surgical
in initial probing depth were found among teeth accord- No Treatment Treatment Treatment
ing to treatment group (P = 0.58). In addition, no sig-
nificant differences in initial prognoses or mobility were Change in PD (n = 770) (n = 545) (n = 1,035)
Improvement 13% (101) 13% (72) 82% (848)
found among teeth according to treatment group (P =
No change 43% (330) 30% (165) 14% (148)
0.75 and P = 0.31, respectively). For comparison of
Worsening 44% (339) 57% (308) 4% (39)
initial furcation involvement, only molars were included
in the analysis since other teeth are extraneous to this Change in PD (per year)
measure. No significant differences in initial furcation Mean 0.219 0.094 –0.303
involvement among the 3 treatment groups were found 95% CI (0.132,0.306) (0.021,0.167) (–0.407,–0.199)
(P = 0.87). Change in prognosis (n = 770) (n = 547) (n = 1,035)
Table 3 shows the distribution of the categorized Improvement 18% (141) 3% (14) 48% (498)
changes in probing depth, prognosis, mobility, and fur- No change 78% (598) 65% (358) 48% (499)
cation over time and also the mean change in prob- Worsening 4% (31) 32% (175) 4% (38)
ing depth per year by treatment group. Because of the
Change in mobility (n = 770) (n = 547) (n = 1,035)
disparity in the follow-up time of the patients included
Improvement 1% (9) 1% (6) 14% (148)
in the study, very limited inference can be drawn from No change 84% (648) 81% (442) 83% (855)
this table. However, inspection of the distribution of Worsening 15% (113) 18% (99) 3% (32)
categorized change in probing depth, prognosis, mobil-
ity, and furcation involvement would appear to indi- Change in furcation (n = 210) (n = 155) (n = 267)
cate that teeth in the surgical treatment group do bet- Improvement <1% (1) 5% (7) 22% (59)
No change 70% (146) 61% (95) 77% (205)
ter over time compared to those in the non-surgical and
Worsening 30% (63) 34% (53) 1% (3)
untreated groups.

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Comparison of Periodontal Treatments in Patients With Moderate to Severe Periodontal Disease Volume 72 • Number 11

GEE Regression Analysis about 80% as likely to worsen in furcation involvement

Table 4 shows the relationship of treatment type to over time as untreated teeth, although this difference
worsening in prognosis, mobility, and furcation involve- was not statistically significant (P = 0.58).
ment over time while adjusting for significant con- Table 5 shows the results for the multiple GEE
founders. For worsening in each of these parameters, regression model for average change in probing depth
a GEE multiple logistic regression model was fit with per year, while Table 6 shows the adjusted mean
inclusion of follow-up time and significant confounders change in probing depth per year by treatment group.
included in the model. When considering worsening in Teeth in the untreated group had significantly greater
prognosis over time, teeth in the non-surgical treat- increases in probing depths per year compared to teeth
ment group were significantly more likely to worsen in the surgical (P <0.001) and non-surgical group (P
compared to surgically treated teeth (OR = 24.9, P = 0.036). Both untreated and non-surgically treated
<0.001). Teeth in the untreated group were also sig- teeth showed statistically significant increases in prob-
nificantly more likely to worsen in prognosis when ing depth per year (P <0.001), while surgically treated
compared to surgically treated teeth (OR = 12.5, P teeth showed a statistically significant decrease in prob-
<0.001). Conversely, non-surgically treated teeth were ing depth per year (P <0.001). Figure 1 shows the pro-
more likely to worsen in prognosis compared to jected changes in probing depth for each treatment
untreated teeth (OR = 2.0, P = 0.018). group over time based on this regression model.
For worsening in mobility over time, non-surgically
treated teeth were significantly more likely to worsen Table 5.
compared to surgically treated teeth (OR = 5.9, P
<0.001). In addition, teeth in the untreated group were Multiple Regression for Change in Probing
about 4.4 times as likely to worsen in mobility com- Depth Per Year (n  2,289)
pared to surgically treated teeth (P <0.001). Teeth in
the non-surgical group were slightly more likely to Parameter Estimate SE P
worsen in mobility over time compared to untreated
Intercept 0.04 0.094 0.658
teeth (OR = 1.3), although this finding was not statis-
tically significant (P = 0.37). Periodontal treatment
When considering worsening in furcation involve- No treatment 0.61 0.096 <0.001
ment over time, non-surgically treated teeth were more Non-surgical treatment 0.46 0.074 <0.001
than 80 times as likely to worsen compared to sur- Surgical treatment 0.00 — —
gically treated teeth (P <0.001), and untreated teeth Occlusal treatment
were more than 100 times as likely to worsen in fur- Untreated occlusal discrepancy 0.17 0.048 <0.001
cation involvement compared to surgically treated teeth Treated occlusal discrepancy –0.03 0.032 0.373
(P <0.001). Teeth in the non-surgical group were only No occlusal discrepancy 0.00 — —

Initial PD –0.12 0.016 <0.001

Table 4.
Initial mobility 0.05 0.025 0.041
Odds Ratios for Categorized Changes in
Initial furcation 0.13 0.038 <0.001
Clinical Parameters Individually Over Time*
Follow-up time (years) 0.02 0.009 0.013
Odds
Ratio 95% CI P
Table 6.
Worsening in prognosis (n = 2,340)
Non-surgical vs. surgical 24.85 (13.9,44.4) <0.001
Change in Probing Depth Per Year by
Non-surgical vs. no treatment 1.99 (1.13,3.52) 0.018 Treatment Group Adjusted for Significant
No treatment vs. surgical 12.48 (6.58,23.7) <0.001 Confounders
Worsening in mobility (n = 2,345)
Non-surgical vs. surgical 5.88 (3.19,10.8) <0.001 Adjusted Change in
Non-surgical vs. no treatment 1.34 (0.35,1.79) 0.374 Treatment Group PD Per Year (mm) 95% CI
No treatment vs. surgical 4.38 (2.23,8.59) <0.001
No treatment* 0.298 (0.181,0.416)
Worsening in furcation (n = 610)
Non-surgical treatment* 0.155 (0.068,0.242)
Non-surgical vs. surgical 83.80 (22.9,306.9) <0.001
Non-surgical vs. no treatment 0.79 (0.35,1.39) 0.578 Surgical treatment† –0.307 (–0.421,–0.193)
No treatment vs. surgical 105.52 (24.4,456.6) <0.001
* Statistically significant increase in probing depth per year (P <0.001).
* Adjusted for follow-up time and significant confounders. † Statistically significant decrease in probing depth per year (P <0.001).

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J Periodontol • November 2001 Harrel, Nunn

Data were divided into groups according to initial
probing depths: 2 to 4 mm, 5 to 6 mm, and ≥7 mm,
and the previous multiple GEE regression model was
repeated for each of these groups. Adjusted mean
changes in probing depth per year by treatment group,
along with 95% confidence intervals and P values for
differences in the change in probing depth per year
among treatment groups, are given in Table 7. Signif-
icant differences in the change in probing depth per
year were found among treatment groups for all initial
probing depths. In addition, statistically significant
increases in probing depth per year were found for
untreated and non-surgically treated teeth for initial
probing depths of 2 to 4 mm and 5 to 6 mm. In addi-
tion, teeth in the untreated group also had a statisti-
cally significant increase in probing depth per year for
initial probing depths ≥7 mm. There also appeared to
be a slight trend toward greater increases in probing
depths with increased initial probing depths among
untreated teeth. However, there was not a statistically
significant change in probing depth for non-surgically
treated teeth with initial probing depths ≥7 mm, and
the trend for these teeth appeared to be the opposite
of that noted for untreated teeth. That is, teeth in the
non-surgical group demonstrated a smaller increase
in probing depth per year with increasing initial prob-
ing depth. Surgically treated teeth demonstrated sig-
nificant decreases in probing depth per year for all
groups of initial probing depths, and in this case, the
trend was for greater reductions in probing depth per
year with increased initial probing depths. Figures 2,
3, and 4 show the projected changes in probing depth
for each treatment group over time based on regres-
sion models for each grouping of initial probing depths.
This graphically demonstrates the trends noted above.

DISCUSSION
The results of this study are similar to previous studies
in regard to the progression of periodontal destruction
in the presence of untreated periodontal disease. The
World Workshop in Periodontics reviewed the existing
literature concerning disease progression and indicated
that untreated periodontal disease will progress between
0.1 and 0.23 mm per year. The higher figure was
strongly influenced by the studies of tea workers in Cey-
Figure 1.
Change in probing depth over time by treatment group.
lon.42 In our study, the rate was 0.298 mm per year of
increased probing depth in the untreated group. This
somewhat higher rate of destruction may be related to
the fact that all patients within
Table 7. this study were referred for
Change in Probing Depth Over Time by Group and Initial Probing periodontal treatment with
existing periodontal disease,
Depth while most of the studies
evaluated at the World Work-
Adjusted Change in
shop in Periodontics looked
Initial Probing Depth Treatment Group Probing Depth Per Year 95% CI P*
at populations with varying
2-4 mm No treatment † 0.305 (0.201,0.409) degrees of periodontal health.
Non-surgical treatment† 0.247 (0.156,0.337) The current study varies
Surgical treatment –0.069 (–0.141,0.003) <0.001 from most other studies in
that periodontal destruction
5-6 mm No treatment† 0.300 (0.131,0.470)
Non-surgical treatment† 0.109 (0.021,0.197) continued to progress in
Surgical treatment ‡ –0.399 (–0.517,–0.281) <0.001 the non-surgically treated
group. When adjusted for
≥7 mm No treatment† 0.329 (0.069,0.590) significant confounders, the
Non-surgical treatment 0.071 (–0.074,0.216) non-surgically treated group
Surgical treatment‡ –0.853 (–1.183,–0.523) 0.003
had 0.155 mm per year of
* P values are for treatment differences using GEE regression analysis while adjusting for occlusal treatment and increased probing depth. It
time followed.
† Statistically significant increase in probing depth per year (P <0.05).
was assumed that a major
‡ Statistically significant decrease in probing depth per year (P <0.05). factor in this finding was

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0332_IPC_AAP_553351 11/5/01 4:51 PM Page 1516
Comparison of Periodontal Treatments in Patients With Moderate to Severe Periodontal Disease
Figure 2.
Change in probing depth over time by treatment group for initial
probing depth of 2 to 4 mm.
Figure 3.
Change in probing depth over time by treatment group for initial
probing depth of 5 to 6 mm.
the fact that non-surgically treated patients were, for
the most part, non-compliant with periodontal main-
tenance recommendations. Many studies have shown
that periodontal treatment will be more successful when
patients are seen frequently for periodontal mainte-
nance and cleaning.16,43,44 To assess this further, the
4 patients within the non-surgically treated group who
were compliant with periodontal maintenance and
maintained good oral hygiene were evaluated sepa-
rately. When this group was evaluated for disease pro-
gression, the results were similar to the entire non-sur-
gically treated group. Additionally, when the remainder
of the non-surgically treated group was evaluated, sim-
ilar disease progression was noted as in the entire non-
surgically treated group. Unfortunately, the small num-
ber (n = 4) of compliant patients within the non-
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Volume 72 • Number 11
Figure 4.
Change in probing depth over time by treatment group for initial
probing depth of ≥7 mm.
surgically treated group did not allow for an adequately
powered statistical analysis. In addition, because of
the small number of patients in this group, there is a
risk of bias inherent in the method of generalized esti-
mating equations that has been previously noted in
small samples. However, based on the limited sample
size of this compliant group, it does appear that peri-
odontal destruction continues to progress in all partially
treated patients, whether they were or were not com-
pliant with oral hygiene and periodontal maintenance
recommendations.
The current study also varies from previous stud-
ies in the response noted to surgical treatment. As
previously noted, in the 2 large, long-term studies
that evaluated various periodontal treatment modal-
ities, it was shown that surgical and non-surgical
treatment yielded similar results over time.15-25 In our
study, surgical treatment yielded much more favor-
able results than did non-surgical treatment alone.
Patients who had been treated surgically demonstrated
an improvement in probing depth of 0.307 mm per
year, while the untreated group lost 0.298 mm per
year and the partially treated group lost 0.155 mm
per year. Compliance to periodontal maintenance rec-
ommendations may be a major contributor to this
finding. Because all surgically treated patients were
in the fully treated group and this group was selected
from periodontal maintenance patients, all surgical
patients fell into the category of compliant patients.
In contrast, all but 4 of the non-surgically treated
group would be considered partially compliant or
non-compliant, and all of the untreated patients were
non-compliant.
The fact that the non-surgical treatment group had
0332_IPC_AAP_553351 11/5/01 4:51 PM Page 1517
J Periodontol • November 2001
a significant worsening of prognosis while the
untreated group did not may be explained by the fact
that the follow-up time for the non-surgical group was
almost twice as long as for the untreated group (3.2
years for the untreated group versus 5.9 years for the
partially treated group). The longer observation period
may have allowed more periodontal degeneration to
occur and thus a worsening of prognosis. While there
was an increase in probing depth during the shorter
observation time for the untreated group, the shorter
time period did not allow an adequate increase in
probing depth to cause a change in prognosis. In con-
trast, during the longer observation period for the non-
surgical group, the changes in probing depth were
adequate to cause a change in the prognosis.
The reason for the lack of a significant increase in
probing depth for the non-surgically treated group
within the subgroup that had initial probing depths of
≥7 mm is unknown. It may be that in deeper pockets,
the response to non-surgical treatment is more pro-
nounced due to more shrinkage of the inflamed tis-
sue. This may lead to a greater reduction in probing
depth in the short term and, therefore, less long-term
increase in probing depth in the deeper pockets. It
should be pointed out that for all subgroups of the
untreated and non-surgical treatment groups, there
was an increase in probing depths, including the ≥7
mm subgroup. However, it was only in the ≥7 mm sub-
group that the increase in probing depth did not reach
significance.
A potential reason for the differences in our results
compared to other studies may be the manner in which
the data were entered into the database and in which
the results were analyzed statistically. As noted previ-
ously, most of the past studies grouped the data for
each patient into a patient mean, and these patient
means were then evaluated for changes on a patient
and group basis. In contrast, our study used the tooth
as the basis for evaluation. This allowed for the analy-
sis of isolated deeper pockets without the potential
dilution of the data from areas of the patient’s mouth
that were relatively healthy. The evaluation of deeper
areas separate from areas of relative health is more
reflective of the evaluation of periodontal disease in a
periodontal office than is the evaluation of a mean
probing depth for the patient. In previously published
studies using these data, the role of occlusal discrep-
ancies was found to be much more important than
previous studies had found.40,41 This difference was
attributed to what was felt to be a more accurate analy-
sis made possible by using the tooth as the basis for
analysis rather than the patient mean. Likewise, at
least part of the reason for the differing results in the
current study can possibly be attributed to using the
individual tooth as the basis for analysis.
Another reason for the differences in our results and
Harrel, Nunn
those found in previous studies may be the different sur-
gical treatments used as well as differences among prac-
titioners. In the 2 previously noted long-term studies,
no regenerative therapy was included in the analysis,
whereas some patients in our study underwent regen-
erative therapy in isolated areas. Also, the earlier stud-
ies included a number of different practitioners, some
of whom may have been inexperienced. In contrast, this
study evaluates the results from a single practitioner.
The difference in ability and experience of the practi-
tioners may also contribute to the differences that we
found between surgical and non-surgical treatments.
Hence, the results reported in this paper may be con-
sidered to be what is optimally achievable from a com-
prehensive approach to periodontal therapy.
In the private practice of periodontology, the prac-
titioner’s primary interest is the overall periodontal
health of the patient. However, due to the nature of
periodontal destruction, most treatment will be con-
centrated in isolated areas of deeper pockets. Epi-
demiological studies that evaluate the progression of
periodontal disease in large populations may yield
results that are relevant for the population as a whole
but may bear little relevance to the progression of indi-
vidual sites of periodontal destruction. However, iso-
lated areas of severe periodontal destruction and
deeper pockets are the focus of most treatment per-
formed by periodontists. Also, studies which evaluate
the results of various forms of periodontal treatment
in large groups of patients using the mean of pockets
existing around all the patient’s teeth that are then
combined and expressed as a patient mean may not
be fully relevant to individual patients and individual
sites of periodontal destruction. For example, if a
patient has a mean probing depth of 3.5 mm post-
treatment, this may indicate that they have many areas
with pockets <3 mm while having several isolated deep
pockets. From an epidemiological point of view, this
patient would seem to represent periodontal health
and a successful treatment outcome. In contrast, from
the patient’s perspective as well as from a legal point
of view, this could represent a treatment failure.
CONCLUSIONS
This study demonstrates that teeth with untreated peri-
odontal disease and those that had been treated non-
surgically showed progression of periodontal disease
and statistically significant increases in probing depth
over time. Teeth that had surgical periodontal treat-
ment showed improvement in periodontal status, with
statistically significant improvements in probing depth
over time. The results of this study support the need
for further studies on the outcome of periodontal treat-
ments using the tooth as the basis for analysis rather
than the mean of all sites.
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Comparison of Periodontal Treatments in Patients With Moderate to Severe Periodontal Disease
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