Periodontology 2000, Vol.
62, 2013, 218–231
Printed in Singapore. All rights reserved
Surgical and nonsurgical
periodontal therapy. Learned
and unlearned concepts
L I S A J. A. H E I T Z -M A Y F I E L D & N I K L A U S P. L A N G
Nonsurgical and surgical periodontal therapies have,
for several decades, been and remain the basis of
periodontal treatment concepts. However, one must
be aware that the way we treat patients in 2013 is
indeed different from how we treated them 30 years
ago. We now have a greater understanding of the
etiologic factors associated with periodontitis, the
mechanisms involved in periodontal wound healing
and the inter-relationship between patient factors
(such as smoking and diabetes) and treatment out-
comes. Technological advances have provided clini-
cians with a range of options for instrumentation.
Furthermore, greater emphasis has been placed on
the importance of patient-centered outcomes in
clinical research.
We have learned a lot during these past years,
having been fortunate enough to learn from the
experience of some very famous periodontists from
all over the world. Research in periodontology has,
for much of the last 50 years, exceeded that of any
other dental specialty. In addition to the sheer vol-
ume of investigative work, education and teaching in
periodontology have been underpinned by the criti-
cal evaluation of both old and new concepts. So what
have we learned in relation to nonsurgical and sur-
gical periodontal therapy, and what has changed over
the past few decades?
Gingival curettage
In the 1970s, scaling and root planing combined with
gingival curettage was a common procedure for
periodontal therapy. Gingival curettage, defined as
the removal, by means of a curette, of the inner
surface of the soft-tissue wall of the pocket, was
performed in order to promote new attachment and
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PERIODONTOLOGY 2000
tissue shrinkage, leading to pocket-depth reduction.
In the early 1980s, the value of gingival curettage was
challenged in a split-mouth clinical study where
scaling and root planing was performed in all quad-
rants and was followed, 4 weeks later, by gingival
curettage in two quadrants. Five weeks following
treatment, similar improvements in periodontal tis-
sue health were observed, regardless of treatment,
with a reduction in probing depth and gingival
inflammation, and an increase in clinical attachment
level (26). It was concluded that gingival curettage did
not result in any additional improvement in peri-
odontal tissue health and, as a result, intentional soft-
tissue curettage was phased out.
Removal of contaminated root
cementum
In the 1970s and 1980s nonsurgical periodontal ther-
apy was performed using predominately hand instru-
mentation, with the aim being to remove supragingival
and subgingival calculus and plaque, and contami-
nated root cementum. Historically it was thought that
aggressive scaling and root planing was required
to remove bacterial products (lipopolysaccharide ⁄
endotoxin) bound to the contaminated root surface
(22). We have since learned from in-vitro studies that
bacterial endotoxins are weakly adherent to root sur-
faces and therefore excessive removal of cementum is
not required to remove bacterial products (14, 45, 75,
79). The concept of removal of contaminated cemen-
tum and hard-tissue deposits as the key to successful
periodontal treatment was challenged in a clinical
study published in 1995 (73). In this study mucope-
riosteal flaps were raised following supragingival
debridement and oral-hygiene instruction, and

bone was recontoured to eliminate angular bony
defects. While the control teeth were thoroughly root
planed, the test teeth were not instrumented other
than to chip off large calculus deposits using the tip of a
scaler, followed by irrigation with sterile saline. Flaps
were apically repositioned at the level of the bone crest.
One year after therapy, clinical and microbiological
parameters showed similar improvements at test and
control teeth with reductions in probing depths and in
the proportions of periodontal pathogens (Porphyro-
monas gingivalis, Fusobacterium sp. and Campylo-
bacter rectus). It was concluded that the reduction of
selected gram-negative anaerobic organisms in the
subgingival plaque is a more important element for the
success of periodontal therapy than is the removal
of contaminated root cementum and mineralized
deposits by root planing (73). Furthermore, in an
experimental study it was observed, using electron
microscopy, that the epithelial attachment on calculus
that had been treated with chlorhexidine gluconate
had the same ultrastructure as normal epithelial
attachment on various tooth surfaces (60). Periodontal
healing occurred, even in the presence of calculus,
provided that the subgingival bacterial plaque
had been removed. From this we learned that while
the removal of calculus is important because it is a
major plaque-retentive factor, the intentional removal
of root substance and contaminated cementum is
not required for successful treatment. Thus, the term
Ôroot planingÕ is now frequently referred to as
ÔdebridementÕ.
Periodontal biofilms
The end of the 20th century saw some great advances
in techniques for microbial analysis. With the use of
molecular identification techniques, checkerboard
DNA–DNA hybridization, biofilm models, fluores-
cence in-situ hybridization and confocal scanning
laser microscopy, our understanding of the complex
nature, composition and role of periodontal biofilms
in health and disease expanded significantly (65, 66,
115, 118, 119). Recent elucidation of the human oral
microbiome and the identification of new species
associated with periodontitis have established that
the periodontal microflora is extremely diverse (24,
128). These advances have had a significant impact
on microbial diagnostics and on our understanding
of bacterial cell interactions and antimicrobial-resis-
tance mechanisms. In particular, they underpinned
the necessity for the thorough mechanical removal or
disruption of the periodontal biofilm when prescrib-
Periodontal therapy
ing adjunctive antimicrobials via a systemic, local or
topical route.
Evidence-based periodontology
Evidence-based periodontology has been described
as a tool to support decision-making and integrate
the best available evidence into clinical practice (80).
The systematic review, as opposed to the traditional
narrative review, provides a comprehensive appraisal
of research using transparent methods whilst aiming
to minimize bias (81). In 2002, the 4th European
Workshop on Periodontology was held in Ittingen,
Switzerland, and for the first time for a major work-
shop, all reviews were carried out as systematic re-
views. These were discussed by a select group of 60
periodontists, most of whom were unfamiliar with
the new system, so the learning curves were steep.
After much discussion and debate, the systematic
reviews were accepted and published in the Journal
of Clinical Periodontology; from this, some old con-
cepts were unlearned, some were confirmed and
some new ones were introduced.
The introduction of the systematic review process
to periodontology has also influenced the way in
which research has been designed and reported over
the past decade. The randomized controlled trial,
considered to be the highest level of evidence, has
been strongly promoted to be used when appropri-
ate. The Consolidated Standards of Reporting Trials
guidelines have also been more widely promoted.
Furthermore patient-based analyses, as opposed to
periodontal site-based analyses, are now considered
as the standard. Systematic reviews published in the
last decade have addressed a number of focused
questions related to nonsurgical and surgical peri-
odontal therapy. This has led to a greater under-
standing of the combined results of research pub-
lished over previous decades, and to identification of
areas where further research is required.
Nonsurgical periodontal therapy
Manual debridement vs. machine-driven
debridement
Most studies in the 1970s and 1980s were conducted
using hand instruments, including curettes, scalers
and hoes, and this was considered the Ôgold standardÕ.
Since the 1990s, the use of powered instruments,
including the magnetostrictive and piezoelectric
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Heitz-Mayfield & Lang
ultrasonics, the linear oscillating device (Vector-
system) and sonic instruments, have become
increasingly popular, with claims of increased efficacy
and efficiency (123, 130). Some studies have reported a
reduced time for scaling and root planing, improved
access, less damage to the root surface and less dis-
comfort for the patient using slimline tip designs (12).
However, overall, similar positive clinical and micro-
biological outcomes were achieved with the use of
machine-driven and hand instrumentation, and even
newer designs of powered instruments have so far not
shown any further benefit when compared with other
ultrasonic devices in nonsurgical periodontal therapy
(48, 123, 130).
Studies by Badersten and co-workers in the 1980s,
using hand instruments, found that the effectiveness
of calculus removal is influenced by initial pocket
depth, tooth type and surface, as well as operator
experience (5–7). As probing depths increase, elimi-
nation of calculus and associated biofilm becomes
more challenging, with studies reporting a higher
percentage of residual calculus on root surfaces in
pockets with probing depths of >6 mm (up to 44%)
compared with pockets with probing depths of 4–
5 mm (up to 29%; 30, 92). These findings have been
confirmed in studies evaluating machine-driven
instrumentation (130).
Adverse outcomes following nonsurgical debride-
ment may include patient discomfort, root-surface
damage and root-surface sensitivity (48). Overzealous
debridement should be avoided in sites with shallow
probing depths (<3 mm) to avoid trauma and sub-
sequent attachment loss and root-surface sensitivity
(57).
Lasers
In the 1990s the erbium-doped:yttrium-aluminium-
garnet (Er:YAG) laser was introduced for periodontal
therapy; however, the clinical effectiveness of the
Er:YAG laser remains controversial. A systematic re-
view, including five randomized controlled trials of
split-mouth design, evaluated the effectiveness of the
Er:YAG laser in the treatment of chronic periodontitis
as an alternative therapeutic strategy to scaling and
root planing (112). Meta-analyses showed no statis-
tically significant difference in clinical attachment
gain, probing-depth reduction or change in gingival
recession, indicating no evidence of a superior
effectiveness of the Er:YAG laser compared with
scaling and root planing (112). The results were in
agreement with an earlier systematic review, pub-
lished in 2008, which observed heterogeneity of
220
included studies and concluded that further well-
designed studies are required to determine the
effectiveness of the Er:YAG laser for nonsurgical
treatment of chronic periodontitis (107).
Photodynamic therapy
Antimicrobial photodynamic therapy, used alone or
as an adjunct to scaling and root planing, was
introduced in the late 1990s and involves the use of
low-power lasers with appropriate wavelength to
target microorganisms treated with a photosensitizer.
A systematic review published in 2011, which in-
cluded seven randomized controlled trials with a
parallel design, concluded that the use of photody-
namic therapy adjunctive to scaling and root planing
provides short-term benefits, but microbiological
outcomes are contradictory (110). Six of seven studies
included in the review evaluated photodynamic
therapy plus scaling and root planing vs. scaling and
root planing alone, whilst two studies compared
photodynamic therapy with scaling and root planing.
No evidence of the effectiveness for the use of anti-
microbial photodynamic therapy as an alternative to
scaling and root planing was found. The authors
concluded that long-term randomized controlled
trials reporting data on microbiological changes and
costs are needed to support the long-term efficacy
of adjunctive antimicrobial photodynamic therapy
(110).
Pocket irrigation with antiseptics
The use of antiseptics in nonsurgical periodontal
therapy may include pocket irrigation. Antiseptics,
including povidone-iodine, dilute sodium hypochlo-
rite and chlorhexidine gluconate, have been used for
periodontal pocket irrigation following debridement
with the aim of suppressing the biofilm. Some studies
have shown further reduction in periodontal patho-
gens and probing depths compared with scaling and
root planing alone (95, 97, 102, 103). As gingival
crevicular fluid within a periodontal pocket is re-
placed every 90 s, the effects of antiseptic pocket
irrigation are only transient and the risks of antisep-
tics penetrating the gingival tissue and causing sys-
temic effects are minimized. Nevertheless, care
should be taken to check the patientÕs medical history
as povidone-iodine can cause allergic reactions and
should not be used in patients with thyroid dys-
function or during pregnancy or breastfeeding (116).
While a recent systematic review shows that
adjunctive use of povidone-iodine irrigation of

pockets during nonsurgical periodontal therapy may
offer a small increase in probing-depth reduction
(104), overall the use of antiseptic irrigants delivered
in conjunction with powered instruments has not
shown any advantage (106).
Full-mouth disinfection
In the 1990s the convention of staged debridement
with quadrant or sextant instrumentation at 1- to 2-
week intervals was challenged with the introduction
of the full-mouth disinfection approach aimed at
preventing re-infection from untreated pockets (90).
The full-mouth disinfection protocol includes full-
mouth scaling and root planing within 24 h, in
addition to twice-daily chlorhexidine mouthrinsing,
tongue scraping, chlorhexidine tonsil spraying and
subgingival irrigation with chlorhexidine three times
within 10 min and repeated after 8 days. The full-
mouth scaling and root planing protocol includes
full-mouth scaling and root planing without anti-
septics. Two systematic reviews, combining the re-
sults of a number of randomized controlled trials,
concluded that all three treatment approaches may
be recommended for nonsurgical periodontal ther-
apy (25, 53).
Thus, while technological advances have intro-
duced a range of different instruments and novel
techniques over the past decades, the critical factor
for successful nonsurgical periodontal therapy re-
mains the thoroughness of root debridement and the
patientÕs standard of oral hygiene, rather than the
treatment modality. Therefore, operator and patient
preference may play a large part in determining the
choice of instrumentation for nonsurgical therapy,
including the choice between staged debridement,
full-mouth disinfection and full-mouth scaling and
root planing.
Nonsurgical therapy and
adjunctive local antimicrobial
delivery
Local delivery of antibacterial agents into periodontal
pockets has been investigated since the late 1970s,
and various antimicrobials and delivery systems have
been developed with the aim of maintaining high
levels of antimicrobial agents in the crevicular fluid
with minimal systemic uptake. All are intended for
use as adjunctive therapies, with scaling and root
planing providing substantivity of an antimicrobial
system at an effective concentration of drug over
Periodontal therapy
time. Although some of these locally applied anti-
microbial systems have been shown to offer some
benefit over scaling and root planing alone, the ef-
fects were modest and mostly short term. In a sys-
tematic review published in 2003, a meta-analysis of
19 studies that included scaling and root planing and
local sustained-release agents compared with scaling
and root planing alone, indicated significant
adjunctive probing-depth reduction or clinical
attachment gain for minocycline gel, microencapsu-
lated minocycline, chlorhexidine chip and doxycy-
cline gel (39). In a subsequent systematic review,
published in 2005, the most positive results occurred
for adjunctive tetracycline, minocycline, metronida-
zole and chlorhexidine, with modest improvements
in probing-depth reductions compared with scaling
and root planing alone (11). The authors questioned
the clinical significance of these small improvements.
Furthermore, some of the subgingival antimicrobial-
delivery systems developed for clinical use are no
longer available.
Nonsurgical therapy and
adjunctive systemic antimicrobials
The adjunctive use of systemic antimicrobials for
periodontal therapy has been discussed for many
decades. Owing to the heterogeneity of the study
designs employed to assess the efficacy of systemi-
cally administered antimicrobial agents, it is difficult
to reach a conclusion regarding whether or not there
are clinical benefits, the type of drug that should be
prescribed and the dose, and the most effective
timing of drug administration in relation to
mechanical therapy. Most studies have evaluated
systemic antimicrobials in conjunction with nonsur-
gical debridement, the rationale for their use being
the suppression of periodontal pathogens persisting
in biofilms in deep pockets, root furcations and
concavities or residing within the periodontal tissues.
In particular the periodontal pathogen Actinobacillus
actinomycetemcomitans has been reported to be dif-
ficult to eradicate with nonsurgical therapy alone (72,
74, 87). The persistence of A. actinomycetemcomitans
and other periodontal pathogens has been associated
with continued progression of disease compared with
improved clinical outcomes when these organisms
are not detected following therapy (21). Despite the
obvious possible benefits of targeting periodontal
biofilms with antimicrobials there has been a con-
sensus that, owing to the risk of adverse effects,
including the development of bacterial antimicrobial
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Heitz-Mayfield & Lang
resistance, interactions with other drugs and possible
allergic reactions (91, 108, 125), systemic antimicro-
bials should be used in select cases where microbial
diagnostics indicate the presence of high levels of
periodontal pathogens (A. actinomycetemcomitans
and P. gingivalis) or in patients diagnosed with
aggressive periodontitis.
The use of adjunctive systemic antimicrobials for
nonsurgical treatment of chronic or aggressive peri-
odontitis was evaluated in two systematic reviews:
one in 2002 (43) and the other in 2003 (38). From
the limited meta-analyses that could be performed,
a statistically significant additional benefit for
spiramycin (probing-depth change = 0.41 mm) and
amoxicillin plus metronidazole (clinical attachment
change = 0.45 mm) in deep pockets (probing depth
>6 mm) was observed (43; Table 1). We learned that
systemic antimicrobials, in conjunction with scaling
and root planing, can offer an additional benefit over
scaling and root planing alone in terms of probing-
depth reduction, clinical attachment gain and re-
duced risk of additional clinical attachment loss.
Herrera et al. (43) concluded, in their systematic re-
view, that patients with deep pockets, ÔactiveÕ or
progressive periodontitis or a specific microbiological
profile might benefit from adjunctive systemic anti-
microbials. The authors, however, cautioned that the
evidence was limited and that the decision to pre-
scribe systemic antibiotics should be made on an
individual patient basis, taking into account the
possibility of adverse events. Haffajee et al. (38)
concluded that systemically administered antimi-
crobials were uniformly beneficial in providing an
improvement in clinical attachment gain when used
as adjuncts to scaling and root planing. Overall,
adjunctive systemic antimicrobials provided a mean
benefit, at 6 months, of clinical attachment change of
0.29 mm in shallow pockets (probing depth <4 mm)
in seven (87%) of eight comparisons, of 0.29 mm in
moderate pockets (probing depth 4–5 mm or 4–
6 mm) in eight (80%) of 10 comparisons and of
Table 1. Adjunctive systemic antimicrobials for nonsurgical treatment of chronic or aggressive periodontitis in deep
pockets. Initial probing depth >6 mm.
Drug Variable
Spiramycin Probing-depth reduction
Amoxicillin ⁄ Clinical attachment gain
metronidazole
Meta-analyses of the differences in treatment effect between scaling and root planing and scaling and root planing plus systemic antimicrobials. From Herrera et al.
(43). Studies include patients diagnosed with either chronic or aggressive periodontitis.
Pooled estimate represents the difference (in mm) in favor of scaling and root planing plus the systemic antimicrobial therapy.
222
0.45 mm in deep pockets (probing depth ‡6 mm) in
19 (83%) of 23 comparisons (38).
In the past decade there has been further evidence
to support the use of systemic antimicrobials, in
combination with nonsurgical debridement, for
treatment of patients with advanced disease and
deep pockets (probing depth >6 mm) with the aim
of reducing the need for additional therapy.
While a range of systemic antimicrobials, including
azithromycin (23, 36, 67, 105, 117), spiramycin (3, 8),
tetracycline (3, 37, 41, 55, 87, 93), clindamycin (64,
113), doxycycline (28, 82, 113), metronidazole (17, 54,
61, 62, 83, 85, 86, 100, 113, 120, 131, 137), amoxicillin
and clavulanic acid (37, 64, 89, 132) and amoxicillin
(100), has been included in clinical studies, the
combination of metronidazole and amoxicillin has
recently been the most widely documented (9, 10, 15,
27, 35, 68, 69, 100, 114, 121, 127, 133, 135, 136) for
adjunctive treatment of chronic and aggressive peri-
odontitis. Cionca et al. (15) found that systemic
metronidazole, combined with amoxicillin, signifi-
cantly improved the 6-month clinical outcomes of
full-mouth nonsurgical periodontal debridement,
thus significantly reducing the need for additional
therapy.
Ten years after the first systematic reviews were
published, a large multicenter randomized controlled
trial confirmed the adjunctive benefit of the combi-
nation of amoxicillin and metronidazole with scaling
and root planing on clinical attachment gain and
probing-depth reduction for the treatment of mod-
erate chronic periodontitis (32). At 3 months, scaling
and root planing alone resulted in pronounced
probing-depth reduction at sites with initially deep
pockets (probing depth ‡5 mm) and some clinical
attachment gain. While adjunctive antimicrobials did
not improve the clinical outcomes at 3 months, at
24 months there was significantly more clinical
attachment gain (0.5 mm) and probing-depth
reduction (0.5 mm) in the group who received
adjunctive systemic amoxicillin and metronidazole.
Pooled 95% confidence P-value References
estimate interval for estimate
0.41 mm 0.08–0.73 0.014 (3, 8)
0.45 mm 0.19–0.71 0.001 (10, 29)
 Periodontal therapy

Smoking reduced clinical attachment gain and
probing pocket-depth reduction in both treatment
groups (32).
A recent systematic review included studies (ran-
domized controlled trials and case series) in patients
diagnosed with aggressive (1, 2, 9, 13, 34, 35, 42, 49,
51, 63, 69, 76, 99, 124, 127, 135, 136) or chronic (10,
15, 16, 27, 31, 32, 70, 71, 78, 114, 126, 133, 134)
periodontitis, and aimed to estimate the size of the
effect when systemic amoxicillin and metronidazole
were combined with scaling and root planing (138;
Table 2). An indirect comparison was made with data
from another review that analyzed the overall effect
of nonsurgical therapy alone (18). The authors con-
cluded that the adjunctive use of amoxicillin and
metronidazole resulted in additional clinical benefits
compared with scaling and root planing alone (18,
138).
Another systematic review, published in 2012, in-
cluded six randomized controlled trials (9, 35, 69, 127,
135, 136) in patients with aggressive periodontitis
who had been treated with scaling and root planing,
alone, or in combination with amoxicillin and met-
ronidazole (111). The results of the meta-analysis
analyzing full-mouth data showed significantly more
clinical attachment gain (0.4 mm) and probing-depth
reduction (0.6 mm) in favour of full-mouth scaling
and root planing and systemic amoxicillin and met-
ronidazole with no significant risk of adverse events
(Table 3).
A systematic review including four randomized
controlled trials (27, 68, 114, 125, 133), which evalu-
ated the effect of systemic amoxicillin and metroni-
dazole in combination with scaling and root planing
in patients with chronic periodontitis, also reported a
clinical benefit of this antibiotic combination com-
pared with scaling and root planing alone (109). The
results of the meta-analyses showed significantly
more clinical attachment gain (0.2 mm) and probing-
depth reduction (0.4 mm) in favor of scaling and root
planing in conjunction with amoxicillin ⁄ metronida-
zole. No significant differences were found for
bleeding on probing or suppuration [Sgolastra et al.
(109); Table 3].
Thus, in 2012 we have a greater body of research to
support the adjunctive use of some systemic antimi-
crobials in nonsurgical periodontal therapy. The main
effect of this adjunctive benefit is observed in patients
with deep pockets (initial probing depth >6 mm) or in
patients diagnosed with aggressive periodontitis. The
most well-documented systemic antimicrobial drug
regimen is the combination of amoxicillin and met-
ronidazole, which is most commonly administered for
7–14 days at the completion of scaling and root plan-
ing. The prescribed dosage varies from to 250–500 mg
of amoxicillin three times a day and 250–400 mg of
metronidazole three times a day.
This, however, does not mean that indiscriminate
use of systemic antimicrobials should be advocated.
The decision to use adjunctive systemic antimicro-

Table 2. Probing-depth reduction (A) and clinical attachment gain (B) (pre- and post-treatment) following scaling
and root planing in conjunction with the combination of amoxicillin and metronidazole

Baseline Weighted mean 95% References For comparison

probing difference ± standard confidence (scaling and root
depth deviation (mm) interval planing alone) Cobb (18)

(A) Probing-depth reduction

4–6 mm 1.47 ± 0.22 1.52–1.42 (34, 35, 76, 133) 1.29

>4 mm 2.17 ± 0.62 2.3–2.04 (15, 16, 32, 70, 98)

‡6 mm 2.59 ± 033 2.65–2.53 (1, 124, 126, 134)

‡7 mm 3.72 ± 0.66 3.83–3.61 (13, 34, 35, 51, 76, 98, 133) 2.16
Baseline Weighted mean 95% References For
probing difference ± standard confidence comparison,
depth deviation (mm) interval Cobb (18)
(B) Clinical attachment gain
4–6 mm 1.31 ± 0.33 1.24–2.73 (51, 70, 71, 124) 0.55
>4 mm 1.49 ± 0.42 1.40–1.58 (15, 16, 32, 70)
‡6 mm 1.66 ± 0.66 1.54–1.78 (1, 126, 134)
‡7 mm 2.66 ± 0.88 2.51–2.81 (13, 34, 35, 51, 76, 98, 133) 1.19
From Zandbergen et al. (138).
Results presented according to initial probing-depth categories.
For comparison, data from Cobb (18), describing the pre- and post-treatment effect of scaling and root planing alone, are presented. Studies include patients
diagnosed with either chronic or aggressive periodontitis.

223
Heitz-Mayfield & Lang
Table 3. Clinical therapeutic efficiency of scaling and root planing vs. scaling and root planing plus systemic
amoxicillin + metronidazole in patients with chronic periodontitis* (A) (109) and aggressive periodontitis  (B) (111)
Mean difference 95% confidence P-value for estimate in favor of scaling
Full-mouth analysis (mm)
(A) Chronic periodontitis
Clinical attachment gain 0.21
Probing-depth reduction 0.43
Full-mouth analysis Mean
difference
(mm)
(B) Aggressive periodontitis
Clinical attachment gain 0.42
Probing-depth reduction 0.58
*From Sgolastra et al. (109): randomized controlled trials included refs (27, 68, 114 and 133). Follow-up varied from 3 to 24 months.
 From Sgolastra et al. (111): randomized controlled trials included refs (9, 35, 69, 127, 135 and 136).
bials should be made on an individual basis, and
adequate debridement, good oral hygiene and
maintenance care are still the most important criteria
for successful treatment outcomes. The reliance on
patient compliance must be taken into account when
considering the use of adjunctive systemic antimi-
crobials.
Surgical periodontal therapy
In the 1970s and 1980s we learned, from some
important clinical trials, that nonsurgical periodontal
therapy is effective in eliminating inflammation in
deep pockets and in improving clinical attachment
levels (4, 44, 77). However, we also learned that, de-
spite our best efforts at meticulous nonsurgical
instrumentation, residual plaque and calculus may
still be found (129). It was accepted that in situations
where signs of inflammation persist, surgical therapy
may be indicated.
Periodontal surgery was historically advocated for
the removal of diseased tissue, with the predominant
technique being excision of the diseased gingival
tissue by gingivectomy and removal of what was
thought to be necrotic bone. Upon the discovery that
periodontal disease did not result in necrosis of bone,
and that gingival inflammation and bone loss repre-
sented a defense reaction, this concept was aban-
doned. Pocket elimination then became the main
objective of periodontal therapy, and the gingivec-
tomy or apically positioned flap procedures were
commonly performed to eliminate the periodontal
pocket and allow access to the root surface for scaling
and oral-hygiene procedures. In the 1980s, with a
greater understanding of the biology of the peri-
224
interval and root planing + amoxicillin ⁄ metronidazole
0.02–0.4 <0.05
0.24–0.63 <0.05
95% P-value for estimate in favor of scaling and
confidence root planing + amoxicillin ⁄ metronidazole
interval
0.23–0.61 <0.00001
0.39–0.77 <0.0004
odontal tissues, the pathogenesis of periodontal
disease and the mechanisms of periodontal wound
healing, the necessity for pocket elimination was also
challenged. We learned that the main goal of peri-
odontal surgery was to gain access to the root surface
for adequate debridement and to establish gingival
contours that are optimal for the patientÕs self-per-
formed plaque control. The access flap (including
the numerous techniques described over nearly
100 years: the original Widman flap described in
1918, the Neumann flap described in 1920, the
modified flap operation described by Kirkland in
1931, the apically repositioned flap described by
Friedman in 1962 and the modified Widman flap
described by Ramfjord & Nissle in 1974) enabled
access to the root surfaces, root concavities and fur-
cations for adequate debridement. The type of sur-
gery performed in the 1970s and 1980s was largely
dependent on the philosophy of each dental school.
A number of clinical trials in the 1970s and early
1980s, evaluating the potential of periodontal sur-
gery, revealed that in patients meeting high standards
of oral hygiene the surgical technique used to gain
access for thorough debridement of the root surfaces
was of minor importance for the overall long-term
result (52, 94, 101). We also learned the importance of
postoperative plaque control in determining the
outcome of periodontal surgery. In a study evaluating
periodontal surgery, patients who did not have ade-
quate plaque control continued to lose attachment,
irrespective of the type of surgery they received (84).
Patients who had adequate plaque control had long-
term maintenance of clinical attachment levels,
demonstrating that the success of surgical peri-
odontal therapy is aligned to the quality of the
maintenance care and plaque control (84). Provided

that proper postoperative plaque-control levels are
established and maintained, most surgical-treatment
techniques will result in conditions that favor the
long-term maintenance of the periodontium.
We also learned the importance of subject-related
factors, including compliance and smoking, as they
relate to periodontal wound healing and treatment
outcomes following surgical therapy (47).
In recent years, refinement of periodontal surgical
techniques has been possible with development of
new instrumentation and the use of illumination and
magnification. Minimally invasive periodontal surgi-
cal approaches and microsurgical techniques are
currently being evaluated and may show advantages
in wound-healing outcomes and less recession and
patient morbidity (19, 20, 33, 96, 122). A recent sys-
tematic review showed that periodontal surgery for
the treatment of intrabony defects was associated with
high tooth retention and improvement of periodontal
clinical parameters, and that clinical attachment gain
may be greater when a papilla preservation flap is
used in comparison with an access flap (33). The pa-
pilla preservation technique is one of a number of
techniques developed as part of the surgical approach
to regenerative therapy, which is discussed in another
article in this volume of Periodontology 2000.
Surgical debridement vs. nonsurgical
debridement
In 2002, Heitz-Mayfield et al. (40) evaluated the
effectiveness of surgical vs. nonsurgical therapy for
the treatment of chronic periodontitis in a systematic
review. Six randomized controlled studies of split-
mouth design, published from 1982 to 1996 (46, 50,
56, 59, 88, 94) and comparing surgical with nonsur-
Table 4. Clinical therapeutic efficiency of nonsurgical therapy vs. surgical therapy 12 months after treatment
Initial Outcome variable Weighted
probing mean
depth difference
(mm)a
1–3 mm Clinical attachment gain )0.51
4–6 mm Probing-depth reduction 0.35
4–6 mm Clinical attachment gain )0.37
>6 mm Probing-depth reduction 0.58
>6 mm Clinical attachment gain 0.19
The results are presented according to initial probing-depth categories.
*(Weighted mean difference between surgical therapy and nonsurgical therapy (scaling and root planing).
From Heitz-Mayfield et al. (40).
Periodontal therapy
gical treatment of chronic periodontal disease, were
included. Meta-analyses indicated that 12 months
following treatment, surgical therapy resulted in
0.6 mm more probing-depth reduction and in
0.2 mm more clinical attachment gain than did
nonsurgical therapy in deep pockets (>6 mm). In
pockets of 4–6 mm, scaling and root planing resulted
in 0.4 mm more clinical attachment gain and 0.4 mm
less probing-depth reduction than did surgical ther-
apy. Therefore, when considering surgery in pockets
of 4–6 mm, the advantage in probing-depth reduc-
tion should be balanced against the disadvantage in
clinical attachment gain. In shallow pockets (1–
3 mm), nonsurgical therapy resulted in 0.5 mm less
clinical attachment loss compared with surgical
therapy (Table 4). From this systematic review it was
concluded that both scaling and root planing alone
and scaling and root planing combined with a flap
procedure are effective methods for the treatment of
chronic periodontitis, in terms of attachment gain and
reduction in gingival inflammation. Furthermore, in the
treatment of deep pockets (probing depth >6 mm),
open-flap debridement results in greater probing-depth
reduction and clinical attachment gain (40). Long-
term treatment outcomes available from studies
comparing nonsurgical with surgical treatment sug-
gest that both treatment modalities are equally
effective in establishing gingival health and prevent-
ing further loss of attachment (40).
Critical probing depth for decision
making
On the basis of clinical outcome data from a longitu-
dinal randomized controlled clinical trial in 15 patients
95% P-value for Conclusion
confidence weighted
interval mean
difference
)0.73 to )0.29 0.000 Favors scaling
and root planing
0.23 to 0.45 0.000 Favors surgery
)0.49 to )0.26 0.000 Favors scaling
and root planing
0.38 to 0.79 0.000 Favors surgery
0.04 to 0.35 0.017 Favors surgery
225
Heitz-Mayfield & Lang
with advanced periodontitis (58), a concept of ‘‘critical
probing depth’’ was developed for decision making
following the completion of a hygienic phase [initial
periodontal therapy (non-surgical therapy + oral hy-
giene instruction)]. The critical probing depth repre-
sents a baseline probing-depth value above which the
outcome of a therapy will result in attachment gain and
below which the outcome of therapy will result in
clinical attachment loss (Fig. 1). In the present illus-
tration the critical probing depth for nonsurgical ther-
apy (scaling and root planing) is 2.9 mm. This, in turn,
means that below this probing depth the site would lose
clinical attachment as a result of therapy. However,
above this value clinical attachment gain will result. On
the other hand, for the access flap therapy, the critical
probing depth is 4.2 mm. Again, this means that open
flap debridement is only beneficial above this value,
while below this value, attachment loss may result.
Looking at the data from both scaling and root
planing and access flap surgery, another critical
probing depth is 5.4 mm. This, in turn, means that
flap surgery is indicated predominantly with a prob-
ing depth of ‡5.4 mm, while between 2.9 mm and
5.4 mm nonsurgical therapy is to be preferred.
It has to be borne in mind, however, that these
critical probing-depth values represent mean scores
with a modest variation. Nevertheless, the principle
226
Fig. 1. Regression analysis leading
to critical probing depth as a basis
for the decision-making process in
periodontal therapy (from Lindhe
et al. (58)). MWF, modified Widman
flap; RPL, scaling and root planing.
may be used as a guideline in the clinical decision-
making process on periodontal therapy.
Conclusions
While we have learned a great deal over the past
decades and have been introduced to new techniques
and technologies, this new information has not
diminished our recognition of the importance of
thorough mechanical debridement and optimal pla-
que control for successful nonsurgical and surgical
periodontal therapy.
• We have learned that while a thorough disruption
and removal of the periodontal biofilm is required
for successful treatment outcomes, removal of the
root surface is not necessary.
• We have learned that the use of specific systemic
antimicrobials, in patients with advanced or
aggressive periodontitis and deep probing depths,
may be beneficial as an adjunct to nonsurgical
periodontal therapy, thereby reducing the need for
additional therapy.
• We have learned that full-mouth disinfection and
full-mouth scaling and root planing protocols can
be an equivalent treatment option to conventional
quadrant debridement.

• We have learned that in patients with deep pockets
(>6 mm), access flap surgery may be beneficial,
provided the patient receives regular supportive
periodontal therapy and has adequate oral hygiene.
• We have learned that the value of new technologies
and concepts may not be known for some time
after their introduction. Proper evaluation requires
adequate follow-up in well-conducted studies of
sufficient sample size.
• We have learned that an unbiased and transparent
appraisal of the literature, using the systematic
review process, may change our paradigms.
• Sometimes we need to be prepared to unlearn old
concepts in order to learn new ones.
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