Journal of Clinical Periadentology 1982: 9: 115-128 Key words Periodontal surgery ~ periodontal trearment - plague control ~ raat planing - scat Accepted for publication December 10, 1986 Healing following surgical /non-surgical treatment of periodontal disease A clinical study Jan LINDHE, ELISABETH WESTEBLT, STURE NYMAN, SIGMUND S, SOcRANSKY*, LARS HEIL AND GUNILLA BRATTHALL Department of Periodontology, Faculty of Odontology, University of Goteborg, Géteborg, Sweden, and Forsyth Dental Center*, Boston, Massachusetts, U.S.A. Abstract. A clinical ttial was undertaken to study the effect of one surgical and one non-surgical treatment modality in patients with advanced periodontal disease. Fifteen patients were selected for the study. Following a Baseline examination comprising assessments of oral hygiene status, gingival conditions, probing depths and attachment levels, all participants were subjected to treatment. In each patient, scaling and root planing were cartied out in conjunction with the modified Widman flap procedure in two jaw quadrants while in the contralateral quadrants the treatment was restricted to scaling and root planing. During the phase of active treatment, ie. the period between the first and last operation, and for the subsequent 6 months of healing, the patients were subjected to “professional toothcleaning™ once every 2 weeks. From this time until the end of the tria] which was 24 months after active treatment, the patients were recalled for prophylaxis once every 3 months. Reexaminations were performed 6, 12 and 24 months after the completion of active treatment. The results demonstrated that scaling and root planing used atone were almost equally effective as their use in combination with the modified Widman flap procedure in establishing clinically healthy gingiva and in preventing further loss of attachment. Both treatment modalities prevented recurrence of periodontal disease for the 24 months of observation. The anaiysis of the probing depth data revealed that both methods of treatment resulted in a high frequency of probing depths of <4 mm. The probing depth reduction was more pronounced in initially deep than in initially shallow pockets and, for initially deep pockets, more marked in sites subjected to surgery than in sites exposed to scaling and root planing alone. The measurements also showed that sites with initially deep pockets exhibited more pronounced gain of clinical attachment than sites with initially shallow pockets. Significant loss of attachment did not occur in sites treated with scaling and root planing alone while attachment loss was found following Widman flap surgery in sites with initial probing depth of <4 mm, The long-term effect of periodontal treatment has recently been analyzed in clinical trials {Nyman & Lindhe 1979, Ramfjord et al. 1979, Axelsson & Lindhe 1981) as well as in a retrospective analysis of large patient popula- tion groups (Hirschfeld & Wasserman 1978). The studies referred to clearly showed that most Patients, incorporated in careful recall pro- grams after active treatment of periodontal disease, were able to maintain periodontal health in most parts of the dentition. It is interesting to note that evidently the type of active treatment delivered did not play a de- cisive role for the long-term result. Thus, sur- gical treatment including gingivectomy, flap procedures with or without osseous surgery as well as non-surgical treatment involving sub- gingival scaling and soft tissue curettage estab- 0303-6979/82/020115-14 $02.50/0 © 1982 Munksgaard, Copenhagen116 lished periodontal conditions which could be maintained basicly unchanged during extended periods of maintenance care. Morrison et al. (1980) examined the effect of instruction in oral hygiene, scaling, root planing and occlusal adjustment in 90 subjects suffering from moderate to advanced periodontal disease. They demonstrated that the severity of perio dontal disease assessed by gingival inflamma- tion scores, probing depth and attachment level measurements was significantly reduced as early as L month after “the hygienic phase of periodontal therapy”. The authors suggested that the improvement of periodontal health which has been reported to result from surgical treatment (¢.g. Ramfjord et al. 1975, Zamet 1975, Waite 1976, Nyman & Lindhe 1979) could have been obtained by non-surgical measures (plaque control and debridement) alone. The present study was designed to further evaluate this hypothesis. The aim of the present clinical trial was to study the effect of one non-surgical and one surgical treatment procedure in patients suf- fering from moderately advanced periodontal disease. Material and Methods The investigation included 15 subjects, 32-57 years of age (mean age 47.9 years), selected at random from the patients referred to the De- partment of Periodontology, University of Got- henburg, for treatment of advanced periodontal disease. The sample included nine males andsix females. The periodontal tissues around all teeth were included in the trial. An initial examination (Baseline examination) was performed and included the following assessment 1. oral hygiene status (Plaque Index, Sitness & Lée 1964) 2. gingival conditions (Gingival Index, Loe & Silness 1963) 3. probing depths (measured with a calibrated probe to the nearest 1 mm; diameter of probe tip=0.5 mm) LINDHE, WESTFELT, NYMAN, SOCRANSKY, HEUL AND BRATTHALL. 4. attachment levels (measured with the cali- brated probe from well-defined landmarks on individually fabricated acrylic stents). The measurements of probing depths and attachment levels of single-rooted teeth (in- cisors, canines and premolars) were made at four sites for each tooth: at the mid-buccal and mid-lingual aspect of the tooth and, for the proximal surfaces, at the buccal aspect of the interproximal contact area. The buccal and lingual measurements for mandibular molars were made mid-buccally and mid-lingually of each toot while the interproximal measure- ments were made at the buccal and lingua! aspects of the contact area. Thus, eight mea- surements were made for each lower molar. In the maxillary molars, pocket depths and attach- ment levels were measured at nine sites. The palatal roots were measured mid-palatally and at the palatal side of the approximal contact area. Corresponding measurements for the two buccal roots were made mid-buccally and, for the proximal surfaces, at the buccal aspect of the interproximal contact area. Measurements were also made in the buccal interradicular area of each buccal root. Thus 182 measurement sites were monitored if all 32 teeth were present. Teeth scheduled for extraction were not in- cluded in the study. The various parameters were assessed in the following order: 1) gingival conditions (Gingi- yal Index), 2) probing depths, 3) attachment levels and 4) oral hygiene (Plaque Index). Following the Baseline examination all pa- tients were given, on an individual basis, a case Presentation and were subjected to detailed instruction in oral hygiene measures according to a routine previously described by Lindhe & Nyman (1975). Subsequently they were sub- jected to periodontal treatment utilizing a split mouth design. In the right or left side of the jaw (by random selection) subgingival debridement was performed in conjunction with a modified Widman flap procedure (Ramfjord & Nissle 1974) (Surgery group) while in the contralateral jaw quadrants the treatment was restricted toSURGICAL/NON-SURGICAL PERIODONTAL TREATMENT scaling and root planing (No Surgery group). The modified Widman flap procedure was performed by a staff periodontist. Following reverse bevel incisions, mucoperiosteal flaps were raised on the facial and lingual (palatal) aspects of the teeth, Granulation tissue, plaque and calculus were removed and the exposed root surfaces were carefully planed. Bone re- contouring or resection of alveolar bone was not performed. The surgical sites were irrigated with sterile saline and the flaps were replaced to their original position and secured with indi- vidual, interrupted sutures to accomplish com- plete coverage of the interdental bone, No surgical dressing was used. For 2 weeks follow- ing each surgical treatment the patients rinsed the mouth twice a day with 0.2% chlorhexidine digluconate solution. The scaling and root planing procedures were carried out in the contralateral jaw quadrants. While debridement in conjunction with surgery was performed during one session only, scaling and root planing without adjunctive surgery required 6-8 appointments performed within a 4-week period after the Baseline examination. During the phase of active treatment, ie. the period between the first and last operation in the individual patient, and for the subsequent 6 months of healing (the healing phase) the Patients were subjected to “professional tooth cleaning” ad modum Axelsson & Lindhe (1974) once every 2 weeks. From this time until the final control, 24 months after active treatment {the maintenance phase), the interval between the recall appointments was 3 months. Ateach tecall appointment plaque was stained with an erythrocin-containing pellet (Rondell®, Astra, Sweden). Instruction in proper oral hygiene measures was given when indicated. This in- struction comprised demonstration of the Bass method of tooth brushing (Bass 1954) and interdental cleaning with floss, toothpick or interdental toothbrush. Scaling was carried out when indicated. Finally, all teeth were polished with a rubber cup and an abrasive paste(Jodka® Polerpasta, Adaco AB, Sweden). The proximal 117 surfaces were cleaned with dental floss (John- son’s Dentotape®, Johnson & Johnson, USA) and interproximal tip (Eva Prophylaxis Sys- tem®, Dentatus, Sweden). The maintenance care program was conducted by a dental hygien- ist. All patients were reexamined with regard to oral hygiene, gingival conditions, probing depths and attachment levels 6, 12 and 24 months after the completion of active treatment. All recordings were confined to the same sur- faces and location points which had been examined at Baseline. Data were analyzed in two ways. Significance of differences between mean values of Plaque Index, Gingival Index, probing depth and at- tachment levels of the two treatment groups and changes between visits of these parameters were tested by the conventional t-test. In addition, the significance of differences in frequency distributions of each of the measurements in the two groups was tested using the Kolmogorov Smirnov two-sample test. Results The results from the Baseline examination are presented in Table 1, The individual mean Plaque Index and Gingival Index scores for the Table 1. Results from the Baseline examination. X=mean value, §.E.=standard error of the mean Die Resultate der Ausgangsuntersuchung. ¥=Mitrel- wert, S.E.= Standardirrtum des Minrelwertes. Résultats de Pexamen initial. Y= moyenne. S.E,= er- reur standard de la moyenne. Treatment group Parameter Surgery __No Surgery X SE X SE. Plaque Index 1.40.1 15401 Gingival Index 1840.1 1740.1 Probing depth 4240.2 4.1402 Surgery (chirurgische Behandlung, chirurgie), 0 surgery (nicht-chirurgische Behandlung, pas de chi- rurgie), parameter (Parameter, parambire), treatment group (Behandlungseruppe, grouped expérimentation).118 LINDHE, WESTFELT, NYMAN, SOCRANSKY, HEUL AND BRATTHALL ‘Table 2. Individual mean Plaque Index, Gingival Index and probing depth values calculated from examinations carried out at Baseline and 6, 12 and 24 months after active treatment. Alterations of attachment level between the Baseline examination and the follow-up examinations. Negative values indicate gain of clinical attachment Individuelter mittlerer Plaqueindex, Gingivalindex sowie die Werte der Sondierungstiefen der Ausgangs- und der Untersuchungen 6, 12. und 24 Monate nach der aktiven Behandlung. Die Veriinderungen des Aitachmentniveaus zwischen der Ausgangsuntersuchung und den Nackuntersuchuagen. Negative Werte zeigen Gewinn des klinischen Attachments an. Mittelwerte und Standardirrtimer der Mittelwerte. Moyennes de Indice de Plaque, de PIndice Gingival et de ta profondeur au sondage, catculés en fonction des ‘observations faites lors de Texamen initial et des rappels effectués 6, 12 et 24 mols aprés. Differences dans Je niveau @attache entre Texamen initial et les rappels. Les valeurs négatives indiquent un gain @'attache clinique. Paleurs de fa moyenne et erreurs standard de la moyenne. Attachment level change Baseline ~ Parameter Plaque Index Gingival Index Probing depth _ 6 (12, 24) months No No No . No Group Surgery surgery Surgery surgery Surgery surgery Surgery surgery Examinations Baseline 1440.1 15801 18401 17401 4.2402 41402 6 months O3LO1 0340.1 0440.1 0440.1 24201" 2940.1 0 40.1 -0.2401 12 months O3EOL 0440.1 OSLO 05401 25401 REO 0.1401 —02+0.1 24 months 0340.1 0340.1 0440.1 0.4201 25401 28401 03401 0 401 ‘Mean values and standard errors of the mean. * significant difference (P<0.01) between treatment groups *=sichergestellter Unterschied (P<0,01) zwischen den behandelten Gruppen. Examinations (Untersuchungen, examens). jaw quadrants later to be treated with the Widman flap surgery (Surgery) or with scaling and root planing alone (No Surgery) were 1.4 and 1,5 (PII) and 1.8 and 1.7 (GI), respectively, ‘The average individual probing depths were 4,2 (Surgery) and 4.1 (No Surgery). There were no significant differences in the oral hygiene, gin- gival conditions and average probing depths between the two categories of treatment groups at the Baseline examination. Gross alterations Examinations carried out 6, 12 and 24 months after the end of active treatment revealed that (Table 2): (J) in both treatment groups the oral hygiene status had significantly (P<0.001) improved between the Baseline examination and the 6- month follow-up examination. Between the ifference significative (P<0.01) entre les groupes de traitemem, various Teexaminations (6, 12, 24 months) the plaque scores did not vary significantly. Thus, the individual mean Plaque Index score of the two treatment groups at the reexaminations varied between 0.3 and 0.4. There was no significant difference between the two treat- ment groups regarding the Plaque Index scores at any examination interval. (2) in comparison to the baseline data, the gingival conditions of the two treatment groups significantly improved. This was demonstrated by the mean Gingival Index score value which varied between 0.4 and 0.5 at the various re- examinations. The improvement (P<0.001) oc- curred between the Baseline examination and the 6-month follow-up examination and was maintained through the 12- and 24-month examination intervals. There was no significant difference between the Gingival Index scores ofSURGICAL/NON-SURGICAL PERIODONTAL TREATMENT Fig. 1. Oral hygiene conditions. Frequency distribu- tion of tooth surfaces scored Plaque Index 0, 1,2. and3 at the Baseline (BL) and follow-up examinations after 6, 12 and 24 months. Mean and standard error. Der orale Hygienestatus. Vorkommenshaufigkeit von Zahnoberfliichen mit dem Plaqueindex 0, 1, 2 und 3 bei der Ausgangs-(BL) und den Wiederholungsuntersuch- ungen nach 6, 12 und 24 Monaten. Mittelwert und Standardirrtum. Etat d’hygiene buccale. Répartition de fréquence de Vindice de Plaque 0. 1, 2 et 3 enregistré sur la surface des dents & examen initial (BI) et durant les examens effectués 6, 12 et 24 mois plus tard. Moyenne et erreur standard. the two treatment groups at the various reexa- minations. (3) surgical treatment as well as scaling and root planing alone resulted in asignificant(P<0.001) reduction of the average probing depth values. Thus, the mean probing depths were decreased from 4.2 and 4.1 mm (Baseline) to 2.4 and 2.5 (Surgery group) and 2.9 and 2.8 (No Surgery group). There was a tendency, however, that the probing depth reduction was more pronounced after surgical than after non-surgical treatment. The differences between the two groups re- garding probing depths were statistically signif- icant only at the 6-month reexamination (P< 0.01). (4) the individual mean clinical attachment level was improved following non-surgical treatment at the 6- and 12-month reexaminations but was not different from the Baseline value at the 24- month examination. Surgical treatment resul- ted in a slight overall loss of clinical attachment which at the 24-month examination amounted 119 to 0.3 mm. The alterations of the individual mean clinical attachment level data were not statistically significant. Oral hygiene conditions Fig. 1 presents the frequency distribution of different Plaque Index scores calculated from assessments made at the Baseline and follow-up examinations. Prior to treatment, on the aver- age 12-13 % of the tooth surfaces were free from plaque (score 0). The frequency distribution of Plaque Index scores 2 and 3 were around 50 and 5%, respectively. At the reexaminations 6, 12 and 24 months after active treatment, the percentage of plaque-free tooth surfaces had, in comparison to the Baseline data, significantly (P<0.001) increased. Hence, between 70 and 80% of all tooth surfaces were free from plaque while the frequency of Plaque Index scores 2 and 3 varied between 2 and 8%. There was no statistically significant difference in the fre- quency distribution of various Plaque Index GINGIVAL INDEX Fig. 2. Gingival conditions. Frequency distribution of gingival units scored Gingival Index 0, 1,2. and 3 at the Baseline (BL) and follow-up examinations after 6, 12 and 24 months. Mean and standard error. Der gingivale Gesundheitsstatus. Vorkommenshdufig- keit von gingivalen Einheiten mit dem Gingivalindex 0, 1, 2, und 3 bei der Ausgangs-(BL) und den Wieder- holungsuntersuchungen nach 6, 12 und 24 Monaten. Mittelwert und Standardirrtum. Etat gingival. Répartition de fréquence de I'Indice Gingival 0, 1, 2¢t 3 d Pexamen initial (BL) et durant les examens effectués 6, 12 et 24 mois plus tard. Moyenne et erreur standard.120 scores between the tWo treatment groups at any examination interval. Gingival conditions (Fig. 2) At the Baseline examination only around 2-3% of all gingival units examined were free from clinical signs of gingivitis (Gingival Index score 0). Around 70% of the gingival units showed obvious signs of gingival inflammation (Gin- gival Index scores 2 and 3). At all the re- examinations the frequency distribution of cli- nically healthy gingival units in comparison to the Baseline data had significantly (P<0.001) increased. Around 65-70% of the units were non-inflamed at the 6-, 12- and 24-month reexaminations while no gingival unit received a Gl score of 3 and only between 2 and 8% of the units received a Gingival Index score of 2. There was no significant difference in the frequency distribution of different Gingival Index scores between the two treatment groups at any of the examinations. Probing depths ‘The percentage distribution of probing depths <4, 4-6, 7-9, and >9 mm are presented in Fig. 3. At the Baseline examination around 40% of all pockets examined were less than 4 mm deep and around 12% were more than 7 mm deep. Six months following active treatment, in both treatment groups. the percentage distribution of probing depths <4 mm had significantly increased (P<0.001), while probing depths in the 46 and 7-9 mm categories had significantly decreased (P<0.001). Between the 6-month and 12-and24-month reexaminations there was no significant alteration of the probing depth data. The reduction of the probing depths was more pronounced in the Surgery than in the No Surgery group. Thus, the frequency distribu- tion of probing depths <4 mm was significantly (P<0.05) higher in the Surgery than in the No Surgery group, while the frequency of probing depths 4-6 mm was significantly higher (P< 0.05) in the No Surgery than in the Surgery group at the reexaminations. LINDHE, WESTFELT, NYMAN, SOCRANSKY, HEL AND BRATTHALL Attachment levels Fig. 4 illustrates attachment level alterations for probing depths <4 mm, 4-6 mm and >6 mm for the two treatment groups. Between the Baseline examination and the reexamination after 6 months the attachment level for probing Gepths <4 mm had shifted apically in the Surgery group (0.9+0.1, P<0.01) while the attachment level of the corresponding No Sur- gery sites was unchanged. For probing depths of 4-6 mm and >6 mm there was in both groups at the 6-month follow-up examination a slight, gain of clinical attachment. This gain was most pronounced (P<0.001) in the deeper pockets and tended to be larger in the Surgery than in PROBING DEPTH Osegery BS No meer sere eeeg a Lew Fig. 3. Probing depths. Frequency distribution of probing depths <4 mm, 4-6 mm, 7-9 mm and >9 mm calculated from measurements made at the Baseline (BL) and reexaminations. At the reexaminations the frequency of probing depths <4 mm was higher (P<0.05) in the Surgery than in the No Surgery group. Mean and standard error. Sondierungstiefen. Vorkommenshdufigkeit der Sor dierungstiefen <4 mm, 4-6 mm, 7-9 mm und >9 mm. bei Messungen der Ausgangs-(BL) und der Wieder- holungsuntersuchungen. Bei den Wiederholungsunter- suchungen war die Vorkommenshaufigkeit der Son dierungstiefen von <4 mm in der Chirurgiegruppe hoher (P<0,05) als in der nicht-chirurgisch behan- delien Gruppe. Mittelwert und Standardirrtum. Profondeurs au sondage. Répartition de fréquence de profondeurs au sondage <4 mm, 4-6 mm. 7-9 mum ¢ >9 mm, calcutées lors de Pexamen initial (BL) et de rappels. Aux rappels. la proportion des profondeurs at sondage <4 mm é1ait plus importante (P<0,05) dans ‘groupe opéré que dans le groupe non opéré. Moyenne ¢ erreur standard.SURGICAL/NON-SURGICAL PERIODONTAL TREATMENT ATTACHMENT LEVEL CHANGE Fig. 5. Reduction of mean Plaque Index scores for single-rooted (incis- fs, canines and premolars) and multi- rooted teeth between the Baseline and the 6-, 12- and 24-month reexamina- tions. Mean and standard error. 121 Fig. 4. Attachment level change be- tween Baseline and the follow-up exa- minations for probing depths <4 mm, 4-6 mm and >6 mm. For sites with probing depths <4 mm there was loss of attachment while probing depths >6 mm showed gain of attachment. Mean and standard error. Verdnderung des Aitachmentniveaus zwischen der Ausgangs- und den Wie- derholungsuntersuchungen fir die Son- dierungstiefen von <4 mm, 4-6 mm und >6 mm. In Regionen mit Sondierungs- tiefen von <4 mm wurde Attachment- verlust festgestellt, wihrend bei Son dierungstiefen von >6 mm Attachment gewinn verzeichnet wurde. Mittelwert und Standarddeviation. Modification du niveau d'aitache entre examen initial et les rappels pour des profondeurs au sondage <4 mm, 4-6 mm et >6 min, Les sites de profondeur <4 mmm présentatent une perte fat tache, tandis que lorsque les profon- deurs étaient >§ mm, ily avait un gain attache. Movenne et erreur standard. CO Suegery BS No surgery REDUCTION OF PLAQUE INDEX Cissy FOR DFERENT TEETH AND PROBING DEPTHS SYNo amgury Die Reduktion der mittleren Beurteil- ungseinheiten (scores) des Plaqueindex wischen der Ausgangs- und den Nach- Untersuchungen nach 6, 12 und 24 Mo- naten, bei einwurzeligen Unzisiven, Eckzdhnen und Priémotaren) und mehr- wurzeligen Zdhnen. Mittelvert und Standardirrtum. Réduction des enregistrements d Indice de Plaque moyen pour les dents mono- radiculées (incisives, canines et prémo- aires) et piuriradiculées entre Fexamen initial et fes examens effectués 6, 12 et 24 mois aprés. Moyenne et erreur stan- dard. the No Surgery group (P<0.05). The reexami- nations after 12 and 24 months revealed that the attachment levels obtained 6 months after ac- tive treatment remained unchanged during the maintenance period. There was a tendency, however, for the attachment level of the4-6 mm Pockets in the Surgery group to shift apically vith increasing observation time. Comparison between single-rooted and mutti- rooted teeth* Fig. 5 illustrates the reduction of the mean Plaque Index scores in the two treatment groups (calculated for single-rooted and multi-rooted * Single-rooted teeth include incisors, canines and premolars. Multi-rooted teeth include molars.122 LINDHE, WESTFELT, NYMAN, SOCRANSKY, HEIJL AND BRATTHALL teeth separately) between the Baseline examina- tion and the 6-, 12- and 24-month reexamina- tions. There was a tendency in both treatment REDUCTION OF GINGIVAL INDEX FOR OVFFERENT TEETH AND PROBING DEPTHS groups for the reduction of the mean Plaque Index scores to be more pronounced in single- rooted than in multi-rooted teeth. It is obvious O Surgery No surgery Fig. 7, Reduction of probing depths between Baseline and the 6-, 12- and 24-month reexaminations. The prob- ing depth reduction was (1) more pro- nounced in initially deep sites than in initially shallow pockets, and(2}more Pronounced in initially deep sites treated by surgery than by scaling Mean and standard error. Die Reduktion der Sondierungstiefen zwischen der Ausgangs- und den Nach= untersuchungen nach 6, 12 und 24 Mo- naten. Diese Reduktion war (1) deut- licher in Regionen mit initiat tiefen, als ‘mit initial flachen Taschen und (2) in Regionen mit initial tiefen Taschen deutlicher nach chirurgischer als nach der Zabnsteinbehandlung. Mittelwert und Standardirrtum. Réduction des profondeurs au sondage entre Fexamen initial er 6, 12 et 24 mois apres celui-ci. La réduction de pro- fondeur au sondage était (1) plus pro~ noncée dans les sites & pockes initiale- ‘ment profondes que dans ceux & poches initialement peu profondes. e1 (2) plus marquée dans tes sites initialement pro- fonds et opérés que dans ceux unique- ‘ment détartrés, Moyenne et erreur standard. Fig. 6. Reduction of mean Gingival Index scores for single-rooted (inci- sors, canines and premolars) and mul- ti-rooted (molars) teeth between the Baseline and the reexamination after 6, 12 and 24 months. Mean and stan- dard error. Die Reduktion der mititeren Beurteit- ungseinheiten (scores) des Gingivalin- dex zwischen der Ausgangs- und den Nachuntersuchungen nach 6, 12 unl 24 Monaten, bei einwurzeligen (Inzisiven, Eckzithnen und Pramolaren) und mehr- wurzeligen Zihnen. Mittehwert und Standardirrtum. Réduction des enregistrements de 'In- dice Gingival moyen pour les dents monoradiculées (incisives, canines et prémolaires) et pluriradiculées (molai- res) entre Fexamen initial er tes exa-~ mens effectués 6, 12 ¢t 24 mois apres Moyenne et erreur standard.SURGICAL/NON-SURGICAL PERIODONTAL TREATMENT that in both the Surgery and the No Surgery group the improvement in oral hygiene was similar for surfaces with shallow and deep pockets. Fig. 6 describes the improvement of the gingival conditions, ie. the reduction of the Gingival Index scores between the Baseline examination and the reexaminations. The re- duction of the mean Gingival Index scores was slightly more pronounced in single-rooted than in multi-rooted teeth, The improvement was similar in surgically treated and scaled sites and also similar in units with deep and shallow pockets. The probing depth alterations for sites with different initial probing depths are presented in Fig. 7. The reduction of the probing depth values was smailer in initially shallow than in ATTACHMENT LEVEL CHANGE 123 initially deeper pockets, Thus, the degree of reduction increased subsequent to treatment with increasing initial probing depth. In surgi- cally treated units, the probing depth reduction was significantly larger (for initial probing depths of 4 mm and more) in single-rooted than in multi-rooted teeth. In the No Surgery group, however, the reduction of the probing depths was similar in the two categories of teeth. The alterations of the attachment levels are presented in Fig, 8. In both single-rooted and multi-rooted teeth attachment loss was obser- ved between the Baseline and 6-month exami- nation in sites with <4 mm of initial probing depth. For sites with initial probing depths of 6 mm and more there was in both categories of teeth and treatment groups a slight gain of attachment. The degree of attachment gain was Fig. 8 Gain and loss of clinical at- tachment between the Baseline and the reexaminations are described for sin- ‘gle-rooted (incisors, canines and pre~ molars) and multi-rooted (molars) teeth and for initial probing depths <4 mm, 4-6 mm and >6 mm, Mean and standard error. Veranschaulickung von Gewinn und Verlust klinischen Attachments zwi- sehen der Ausgangs- und den Nach- untersuchungen bei einwurzeligen (n- zisiven, Eckzéhnen und Priimolaren) und mehrwurzeligen (Molaren) Zahnen fir initiale Sondierungstiefen von <4 mm, 4-5 mm und >6 mm. Mittelwert und Standardirrnam Gain er perte d'atrache clinique entre examen initial et les rappels indiqués pour les dents monoradiculées finci- Sives, canines et prémolaires) et pluri- radicuiées (molaires) et pour ies pro~ _fondeurs au sondage initial <4 mm, 4-6 mm et >6 mm. Moyenne et erreur standard.124 similar in single-rooted and multi-rooted teeth. There were only minor alterations noted be- tween the 6-, 12- and 24-month reexaminations. Discussion The present investigation demonstrated that in patients maintained on a properly controlled oral hygiene regimen (Rosling et al. 1976a,b), careful scaling and root planing was a measure in the treatment of periodontal disease which was equally effective used alone as in combina- tion with the modified Widman flap procedure in establishing clinically healthy gingiva and preventing further loss of attachment. Thus, measurements carried out 6 months after active treatment revealed that both the non-surgical and the surgical modality of treatment estab- lished a dentition with low Gingival Index scores and, in comparison to the Baseline examination, an improved or unaltered clinical attachment level. During the subsequent 18 months of maintenance care including pro- phylaxis once every 3 months there was in both treatment groups hardly any sign of progression or recurrence of periodontal disease. The patients of the present study were main- tained for 6 months after active treatment on a plaque control program which involved profes- sional tooth cleaning once every 2 weeks. This treatment resulted in the establishment of a dentition in which 70-80% of the tooth surfaces were free from plaque and around 70% of the gingival units were clinically healthy. The find- ing that professional tooth cleaning repeated once every 2 weeks results in proper oral hygiene conditions and gingival health agrees with observations reported from similar studies by Nyman et al. (1975) and Rosling et al. (1976a,b) describing the effect of treatment of periodontal disease in incisor, canine and pre- molar areas. In the present patient material, molars were also included in the treatment and the examinations. It is obvious that the profes- sional tooth cleaning program was slightly less effective in multi-rooted than in single-rooted LINDHE, WESTFELT, NYMAN, SOCRANSKY, HEIJL AND BRATTHALL teeth. The reason for this variation can only be speculated on, but may be related tothe patients” inability to clean effectively the posterior partsof the dentitions and/or to the presence of furca- tion involvements in the molar areas which created additional problems with respect to oral hygiene measures. After the initial 6 months of supervised plaque control the patients were placed on a recall program which included prophylaxis on- ce every 3 months. The data from the examina- tions after 12 and 24 months revealed that this recall program was sufficient to maintain gingi- val health and to prevent recurrence of perio- dontal disease. This is in agreement with reports by Ramfjord et al. (1973, 1975, 1979), Lindhe & Nyman (1975), Nyman & Lindhe (1979), Know- les et al. (1980), and Axelsson & Lindhe (1981). In the present analysis of probing depth and attachment level alterations, the variations ob- served have been related to the initial probing depth values as recommended by Ramfjord et al. (1979), Knowles et al. (1980) and Morrison et al. (1980). The analysis regarding probing depth alterations revealed that both treatment moda- lities tested resulted in a high frequency of probing depths of less than 4 mm. This corro- borates findings reported by Axelsson & Lindhe (1981) who showed that following treatment with a modified Widman flap procedure, more than 90% of all treated sites had probing depths less than 4 mm. The data also showed that the probing depth reduction was more pronounced in initially deep than in initially shallow poc- kets and that the probing depth reduction for initially deep pockets was more marked in sites subjected to surgery than in sites exposed to scaling and root planing alone. This obser- vation is in accordance with data previously reported by Ramfjord et al. (1979), Knowles et al. (1980) and Morrison et al. (1980). It is important to realize that probing depth alterations as a result of treatment should always be related to alterations of clinical attachment levels. The careful analysis of the present data revealed that not only did the