Received: 24 January 2022 Revised: 24 April 2022
DOI: 10.1002/JPER.22-0059
H UMAN RANDOMIZED CONTROLLED TRIAL
Open flap debridement compared to repeated applications
of photodynamic therapy in the treatment of residual
pockets: A randomized clinical trial
Naira M. R. B. Andere1 Nídia C. Castro dos Santos1,2
Hélvis E. S. Paz3 Luciana M. Shaddox4
Mauro P. Santamaria1,4
1 Division
of Periodontics, Institute of
Science and Technology, São Paulo State
University (Unesp), São José dos Campos,
São Paulo, Brazil
2 Dental Research Division, Guarulhos
University (UNG), Guarulhos, São Paulo,
Brazil
3 Division
of Periodontics, Piracicaba
Dental School, University of Campinas
(Unicamp), Piracicaba, São Paulo, Brazil
4 Divisionof Periodontology, College of
Dentistry, University of Kentucky,
Lexington, Kentucky, USA
Correspondence
Mauro Pedrine Santamaria, Division of
Periodontics, Institute of Science and
Technology, São Paulo State University
(Unesp), Av. Eng. Francisco José Longo,
777, São José dos Campos, São Paulo
12245-000, Brazil.
Email: mauro.santamaria@unesp.br;
maurosantamaria@uky.edu
J Periodontol. 2022;1–11.
Accepted: 25 April 2022
Cássia F. Araújo1
Renato C. V. Casarin3
Abstract
Background: The aim of the present study was to compare repeated applications
of antimicrobial photodynamic therapy (aPDT) to open flap debridement (OFD)
in the treatment of residual periodontal pockets in non-furcation sites.
Methods: Forty-six subjects with a diagnosis of Stage III or IV Grade C periodon-
titis, that had been previously treated, participated in the study. Residual pockets
were divided between two groups: (1) aPDT group: received ultrasonic periodon-
tal debridement followed by immediate application of aPDT, and repeated on1st,
2nd, 7th, and 14th days; and (2) OFD group: treated by modified papilla preserva-
tion technique, where granulation tissue and visible calculus were removed with
hand curettes and an ultrasonic device. Clinical, immunological, and microbio-
logical parameters were evaluated before and after treatment.
Results: Both treatments were effective reducing clinical parameters of disease.
OFD resulted in a greater mean probing pocket depths (PPD) reduction in deep
pockets (p = 0.001). However, aPDT resulted in a lower occurrence of gingival
recession (GR), dentin hypersensitivity (DH) and analgesic intake. Reduction in
Porphyromonas gingivalis was observed in both groups. Only the OFD group had
a significant reduction in Aggregatibacter actinomycetemcomitans. aPDT group
had greater increase in interleukin 10 (IL-10) levels and a greater reduction of
interleukin 1 beta (IL-1β) at 14 days when compared to the OFD group (p < 0.05).
Conclusion: OFD was superior in reducing PPD in deep pockets compared to
the aPDT. However, OFD resulted in greater GR. Both treatments lowered P.
gingivalis levels but only OFD reduced levels of A. actinomycemtemcomitans.
KEYWORDS
antiinfective agents, gingival recession, periodontal debridement, periodontal pocket, peri-
odontitis, photodynamic therapy, surgical procedure, ultrasonic
wileyonlinelibrary.com/journal/jper © 2022 American Academy of Periodontology. 1
2 ANDERE et al.
1 INTRODUCTION
The sequence for the treatment of periodontitis Stages I,
II, and III should follow specific steps in consonance with
the s3-level clinical practice guideline proposed by Sanz
et al.1 According to evidence-based recommendations, the
first step aims to guide patient behavior change regard-
ing biofilm removal and risk factor control. The second
step of treatment aims to reduce/modify the subgingival
biofilm and remove calculus through subgingival instru-
mentation. In this phase of treatment, adjunctive interven-
tions may be included, such as systemic antimicrobials.
Many studies have been performed to evaluate sys-
temic antibiotics as an adjunct to nonsurgical periodon-
tal treatment. Evidence has shown that adjunctive use of
systemic antibiotics such as an amoxicillin and metron-
idazole in combination2–4 or clarithromycin,5,6 leads to
clinical and microbiological benefits when compared to
scaling and root planning (SRP) alone. However, even fol-
lowing adjunctive systemic antibiotic therapy, residual,
nonresponsive sites, may persist (PPD ≥ 4 mm with bleed-
ing on probing) that may represent a risk factor for both
progression of periodontitis and future tooth loss.7 In these
cases, a third step of treatment should be implemented.1
The third step aims to treat those persistent sites that did
not respond adequately to the second step of therapy. This
third step may include open flap periodontal surgery or
additional subgingival instrumentation with or without
adjunctive therapies.
Open flap debridement (OFD) is a therapy frequently
applied to treat residual pockets because it leads to better
access for professional instrumentation when compared
to nonsurgical periodontal therapy.8 Studies9 have shown
that surgery may be effective in the reduction of probing
depth of residual pockets. Other studies have reported that
OFD results in the reduction of A. actinomycetemcomitans
and gain in clinical attachment level (CAL).10,11 Neverthe-
less, OFD presents some limitations, such as greater dis-
comfort and postoperative morbidity, increased intraop-
erative risk, and increased risk of gingival recession and
postoperative dentin hypersensitivity (DH).12
In a search for less invasive treatment protocols, antimi-
crobial photodynamic therapy (aPDT) has gained interest
as an adjunctive therapy to subgingival instrumentation.
aPDT is a noninvasive treatment modality consisting of
the activation of a photosensitizer by the use of lasers at
a specific wavelength. This procedure releases cytotoxic
free oxygen radicals that severely damage or kill bacteria.13
Clinical studies have shown that a single application of
aPDT was not able to demonstrate clinical or microbio-
logical benefits when compared to traditional periodontal
therapy.14–16 However, when used as an adjunct to SRP for
the treatment of residual pockets and applied 5 times, at
shorter intervals (days 0, 1, 2, 7, 14), improved clinical out-
comes were observed.13
Since the presence of residual pockets represents a chal-
lenge to clinical management of periodontal diseases and
no studies have attempted to compare aPDT and OFD for
their management, the present study aimed to compare
repeated applications of aPDT versus OFD in the treat-
ment of residual pockets. The null hypothesis is that there
is no significant difference between aPDT compared to the
effects of OFD for the reduction of residual pockets probing
depth.
2 MATERIALS AND METHODS
The present study was a parallel, single-blinded, ran-
domized clinical trial (ClinicalTrials.gov identifier:
NCT03140059), approved by the human subjects ethics
board of São Paulo State University (Unesp), São José
dos Campos, Brazil (CAAE: 56670616.8.0000.0077) and
conducted in accordance with the Helsinki Declaration of
1975, as revised in 2013. The methods of the present study
are in accordance with the CONSORT-STATEMENT.
2.1 Population
Forty-six subjects (40 females, 6 males), diagnosed with
Stage III or IV, Grade C periodontitis17 were recruited from
the São Paulo State University (Unesp) – Institute of Sci-
ence and Technology, clinical research center. All patients
had been previously treated and presented at least one peri-
odontal pocket in a single-rooted tooth with both probing
depth and CAL ≥5 mm along with bleeding on probing
(BoP). The patients were recruited from June 2016 until
June 2017.
2.2 Sample size calculation
The sample size was calculated using an α of 0.05 and a
type β error of 20% (power of 80%). The ideal sample size
was calculated using the end-point of mean probing-depth
reduction of 0.5 mm between groups, with a standard devi-
ation of 0.5 mm. Based on this, a sample size of 17 patients
per group was determined. Thus, 46 patients (23 per group)
were considered for this study to compensate for possible
dropouts.
2.3 Inclusion criteria
The inclusion criteria were as follows: (1) systemically
healthy volunteers, diagnosed with Stage III-IV, Grade C
ANDERE et al. 3

periodontitis;17 (2) presence of ≥ 20 teeth; (3) <35 years of was continuously deposited in a coronal direction for 1
age; (4) had been previously treated for the disease with min. The site was then washed to remove any excess of
nonsurgical full-mouth ultrasonic debridement;18 (5) pres- methylene blue; the pocket was then exposed for 1 min to
ence of at least one single-rooted tooth with PPD ≥5 mm a diode laser energy beam with a wavelength of 660 nm,
and CAL ≥ 5 mm, that exhibited BoP; and (6) agreed to delivered by a fiber-optic§ filament at a power of 60 mW
participate in the study and signed a written consent form. and a fluency of 129 J/cm.2,15 The aPDT application was
All subjects were informed about the study’s objectives, as repeated on the 1st, 2nd, 7th, and 14th days after periodon-
well as the possible risks and benefits of participating in the tal therapy.
study. The exclusion criteria were as follows: (1) females
that were pregnant or breastfeeding; (2) systemic disease
2.4.2 OFD group
that could affect the risk or progression of periodontal
disease (e.g., diabetes, blood disorders, or immunodefi-
Intraoral antisepsis was performed with 0.12% chlorhexi-
ciency); (3) continuous use of anti-inflammatory drugs; (4)
dine rinse solution and extra oral antisepsis was carried
smokers or use of other tobacco products; and (5) intake of
out with 0.2% chlorhexidine. Following local anesthesia**
antibiotics [up to 3 weeks prior study-inclusion].
a modified papilla preservation technique described by
Cortellini et al.19 was performed using a 15C scalpel blade.
2.4 Treatment protocol and The tissue was reflected and granulation tissue and vis-
randomization ible calculus were removed with hand curettes and an
ultrasonic device fitted with specific subgingival tips. The
According the S3-level-guideline, all patients received one surgical flaps were replaced to their original position and
session of full-mouth supra- and subgingival debridement sutured. A single operator (N.M.R.B.A.) performed all pro-
to remove calculus, hopeless tooth extraction, and provi- cedures in both groups.
sional restorations when necessary (first and second steps
of periodontal treatment according to Sanz et al.1 ). Patients
2.5 Postoperative care
were placed on maintenance therapy and were reevaluated
after 6 months to select eligible individuals presenting at
All patients who underwent OFD received the following
least one single-rooted tooth with a residual pocket (PPD
postoperative instructions: liquid or pasty cold diet in the
and CAL ≥5 mm with BoP). A computer program gen-
first 24 h; refrain from brushing around the treated sites
erated a random sequence list with treatment codes con-
for 7 days; rinse with 0.12% chlorhexidine twice a day for 14
cealed in opaque sealed envelopes by an investigator who
days; instructed to take analgesic as needed for pain. The
was not directly involved in the examination or treatment
sutures were removed after 7 days postoperatively.
procedures (C.F.A.). Thus, the investigator responsible for
the clinical measures (N.C.C.S.) was blinded for the patient
group assignment. Each patient was randomly assigned to
2.6 Clinical measurements
one of the following groups:
A single examiner (N.C.C.S.), who was blinded, trained,
1. OFD group (n = 23): Open flap debridement as
and previously calibrated assessed all clinical measure-
described by Cortellini et al.19
ments. The examiner participated in a calibration exercise
2. aPDT group (n = 23): Nonsurgical periodontal debride-
in which the probing depth and CAL of 15 patients were
ment followed by repeated aPDT.
measured twice in a 24-h interval. The measures were sub-
mitted to the Kappa test with an agreement of 0.89 for PPD.
Clinical measures were performed in included sites
2.4.1 aPDT group
using a millimeter scaled UNC15 manual probe†† before
treatment (baseline) and at 3, 6, and 12 months after treat-
After local anesthesia, periodontal SRP using periodon-
ment. The following clinical parameters were evaluated:
tal curettes* and an ultrasonic device† with specific tips‡
(1) gingival index (GI);20 (2) full-mouth plaque score (PI);21
were performed. After mechanical therapy, a photosensi-
(3) presence or absence of plaque at the treatment sites (P);
tizer (methylene blue 10 mg/mL) was applied by placing
(4) presence or absence of bleeding on probing at treatment
the applicator at the bottom of the periodontal pocket and

* Hu-Friedy,
Chicago, IL, USA. § TheraLase DMC,São Carlos, SP, Brazil.
† Cavitron,
Dentsply, Tulsa, OK, USA. ** Articaine,
DFL, Rio de Janeiro, RJ, Brazil.
‡ UI25KSF10S, Hu-Friedy, Chicago, IL, USA. †† Hu-Friedy, Chicago, IL, USA.
4 ANDERE et al.
sites (BoP); (5) probing pocket depths (PPD); (6) gingival
recession (GR); (7) CAL.22
2.7 Microbiologic evaluation
All patients had subgingival biofilm samples collected
from the residual periodontal pockets at baseline and 3
and 6 months. Samples were obtained using the follow-
ing technique: supragingival biofilm was removed and the
site was isolated with cotton rolls. A sterile paper point
(N#35) was then inserted into the pockets for 30 s. The
paper points were placed in sterile tubes and stored in
−20◦ C until processed. The presence of two periodon-
tal pathogens, A.actinomycetemcomitans and P. gingivalis,
were evaluated using quantitative polymerase chain reac-
tion (qPCR). DNA was extracted from the subgingival
biofilm using commercial kits.‡‡ A real-time PCR reaction
was then performed as reported by Casarin et al.3 Concen-
tration of the DNA used in each run was 10 μg/mL.
2.8 Biomarker analysis
Gingival crevicular fluid (GCF) was collected as previously
described23 at baseline and at 7 and 14 days, and at 3 and
6 months postoperatively. Sampled were stored at −20◦ C
until analyzed by multiplex. The inflammatory markers
interferon (IFN)-γ, interleukins (IL)-10, -1β, -4, and tumor
necrosis factor (TNF)-α were determined using the high
sensitivity human cytokine plex.§§ The mean concentra-
tion of each biomarker was quantitated and expressed as
pg/mg of total protein using a standard Bradford reaction.
2.9 Patient-centered outcomes
DH was evaluated after a 3-s air-blast from a syringe
applied on the selected tooth. Patients used a visual ana-
log scale (VAS) to score the DH (0 = no pain, 10 = extreme
pain) at baseline, at 7, 15 days, and at 3, 6, and 12 months
postoperatively. At the 7-day postoperative visit, patients
also completed a questionnaire regarding postoperative
pain and were asked whether they took analgesic medica-
tions during the previous week.
2.10 Soft tissue analysis
All patients were evaluated according to the pink esthetic
score (PES), which is an assessment of seven variables
including the mesial papilla, distal papilla, soft tissue level,
‡‡ DNA Qiaprep, Qiagen, Germantown, MD, USA.
§§ MilliporeCorporation, Billerica, MA, USA.
soft tissue contour, alveolar process deficiency, soft tis-
sue color, and soft tissue texture.24 As this evaluation was
not designed to assess esthetic results after surgical access
in non-furcation teeth, we considered it appropriate to
exclude the alveolar process deficiency variable here. Each
variable was given a score of 0, 1, or 2. A score of 0 indicated
the worst result and a score of 2 indicated the best result
for each variable. Photographs of treated sites from base-
line, 3, 6, and 12 months after surgery were set in a panel
and evaluated by two different and previously calibrated
examiners.
2.11 Statistical analyses
Mean and standard deviations were calculated for each
parameter at each time point. The normal distribution
was analyzed with the Shapiro–Wilk test. The numeric
demographic parameters that presented normal distribu-
tion were analyzed by a t-test, and the ones that fell into
a non-normal distribution were analyzed using a Mann–
Whitney U rank-sum test. Data from clinical measure-
ments were analyzed by a two-way analysis of variance
(ANOVA)/Tukey test for inter- and intragroup compar-
isons. The frequency of detection of each species (A. acti-
nomycetemcomitans and P. gingivalis) at baseline and 6
months was evaluated by McNemar for intragroup and chi-
squared for intergroup comparisons. Microbiologic and
biomarker analysis and other variables that did not present
normal distribution were analyzed by the Friedman test to
detect intragroup differences and by the Mann–Whitney U
test to detect intergroup differences. The significance level
was set to 0.05.
3 RESULTS
3.1 Clinical outcomes
Demographic characteristics are presented in Table S1 (see
Table S1 in the online Journal of Periodontology). There
were no statistically significant differences at baseline
between treatment groups for any of the parameters evalu-
ated. A flowchart of patient numbers is shown in Figure S1
(see Figure S1 in the online Journal of Periodontology). All
patients kept GI and PI parameters below 25% throughout
the study period without differences between groups. Both
treatment groups had a significant reduction in PPD when
compared to baseline. However, OFD showed lower PPD
means at 12 months when compared to aPDT (p = 0.04). In
addition, significantly greater PPD reduction was observed
for OFD compared to aPDT group at this timepoint
(1.42 ± 1.2 mm and 1.02 ± 1.02 mm, respectively, p = 0.001).
When CAL was analyzed, the aPDT group showed signifi-
cant CAL gain at both 6 and 12 months, whereas the OFD
ANDERE et al. 5

TA B L E 1 Clinical findings at baseline, 3, 6, and 12 months of treated sites (n = 46)

Clinical parameters Period OFD (n = 23) aPDT (n = 23) Intergroup p-value
PPD (mm) Baseline 5.52 ± 1.18A 5.69 ± 1.33A 0.5
3 months 4.32± 1.28 B
4.71 ± 1.52 B
0.1
6 months 4.06± 1.1B 4.5 ± 1.84B 0.09
12 months 4.32 ± 1.13 B
4.67 ± 1.39 B
0.04
0–12 months difference 1.42 ± 1.2 1.02 ± 1.02 0.001
CAL (mm) Baseline 6.36 ± 1.93 A
6.52 ± 2.17 A
0.7
3 months 6.28± 1.93A 6.1 ± 2.5A 0.7
6 months 5.97 ± 2.1 A
5.91 ± 2.42 B
0.8
12 months 6.06 ± 2.1A 5.91 ± 2.5B 0.8
0–12 months difference 0.36 ± 1.52 0.61 ± 1.18 0.3
GR (mm) Baseline 0.84 ± 1.29A 0.82 ± 1.65A 0.9
3 months 1.93± 1,76 B
1.41 ± 2.12 B
0.1
6 months 1.89± 1.84B 1.36 ± 1.85B 0.1
12 months 1.73 ± 1.84 B
1.23 ± 2.03 B
0.09
0–12 months difference 1.06 ± 1.15 0.41 ± 0.83 0.001
A A
BoP (%) Baseline 100% 100% 1a
A A
3 months 74% 78% 0.9a
6 months 43%B 50%B 0.9a
B B
12 months 65% 50% 0.9a
P (% sites) Baseline 22%A 30%A 0.9a
B B
3 months 61% 48% 0.7a
6 months 57%B 43%B 0.7a
A A
12 months 30% 15% 0.4a
% sites PD ≤ 4 mm without BoP 52% 48% 0.9a
Note: Different uppercase letters indicate intragroup statistically significant differences (p < 0.05). ANOVA two-way repeated measures.
Abbreviations: aPDT, antimicrobial photodynamic therapy; BoP, bleeding on probing; CAL, clinical attachment level; GR, gingival recession; OFD, open flap
debridement; P, % sites treated with plaque; PPD, probing pocket depths.
a
Chi-squared test.

did not show significant CAL improvement at any of these
timepoints. However, differences in CAL gain between
groups were not significant (p = 0.3). Additionally, the
OFD resulted in greater difference between baseline to 12
months compared to the aPDT group (p = 0.001) when
GR was analyzed. The BoP was significantly reduced in
both groups. Finally, both groups had similar percentages
of pockets with PPD ≤ 4 mm without BoP after 12 months
of treatment, with no significant differences between the
groups (Table 1).
3.2 Moderate and deep sites
Table 2 shows the pocket stratification data, moderate
and deep pockets, that is, PPD of 5 mm to 6 mm and
≥7 mm, respectively, for both groups. Moderate pockets
of both groups showed statistically significant reductions
when compared to baseline, with no significant differences
between groups. However, aPDT group presented less GR
than OFD group after 12 months (p = 0.001). When deep
pockets were evaluated, OFD group presented greater PPD
reduction and greater CAL gain at all timepoints than
aPDT group (p = 0.001).
3.3 Patient-centered outcomes
Results based on patients’ evaluations (VAS) showed
that the OFD group presented greater dentin sensitivity
(p = 0.03) after 15 days and postoperative pain after 7 days
(p = 0.03) compared to aPDT group. Moreover, patients
who received OFD reported more analgesic intake during
the first week postoperatively compared to aPDT patients
(p = 0.03) (Table 3).
3.4 Esthetic evaluation
Table 4 shows that patients in the aPDT group presented
better esthetic results when compared to the OFD group.
6 ANDERE et al.

TA B L E 2 Evaluation of treatments in moderate and deep pockets

Clinical parameters Period OFD aPDT p-value (intergroup)
PPD of moderate pockets Baseline 5.0 ± 0.68A 5.14 ± 0.8A 0.4
(5–6 mm; n = 12)
3 months 4.02 ± 1.07B 4.17 ± 1.12B 0.4
6 months 3.9 ± 0.92B 4.08 ± 1.01B 0.4
12 months 4.05 ± 1.05 B
4.22 ± 1.01 B
0.4
0–12 months difference 0.95 ± 1.21 0.94 ± 1.02 0.9b
CAL of moderate pockets Baseline 5.77 ± 1.43 A
6.11 ± 2.25 A
0.4
(5–6 mm; n = 12)
3 months 5.85 ± 1.57A 5.65 ± 2.48A 0.7
6 months 5.6 ± 1.94 A
5.51 ± 2.36 B
0.8
12 months 5.8 ± 1.74A 5.54 ± 2.58B 0.6
0–12 months difference 0.03 ± 1.33 0.57 ± 1.21 0.09b
GR of moderate pockets Baseline 0.77 ± 1.08 A
0.97 ± 1.8 A
0.3
(5–6 mm; n = 12)
3 months 1.82 ± 1.56B 1.48 ± 2.29A 0.3
6 months 1.74 ± 1.61 B
1.42 ± 1.98 A
0.4
12 months 1.74 ± 1.66B 1.34 ± 2.24A 0.2
0–12 months difference 0.97 ± 1.15 0.37 ± 0.91 0.001b
PPD of deep pockets (≥7 mm; Baseline 7.3 ± 0.48A 7.6 ± 1.07A 0.5
n = 11)
3 months 5.4 ± 1.5B 6.6 ± 1.34B 0.02
6 months 5 ± 1.24B
6.1 ± 1.85B 0.02
12 months 5.3 ± 0.94 B
6.3 ± 1.41 B
0.04
0–12 months difference 2 ± 0.66 1.3 ± 1.05 0.0001b
CAL of deep pockets (≥7 mm; Baseline 8.5 ± 2.01A 7.9 ± 1.28A 0.6
n = 11)
3 months 7.7 ± 2.54A 7.6 ± 2.17A 0.9
6 months 7.4 ± 2.22 B
7.3 ± 2.31 A
0.9
12 months 7.2 ± 2.89B 7.2 ± 1.93A 0.7
0–12 months difference 1.3 ± 1.56 0.7 ± 1.15 0.00c
GR of deep pockets (≥7 mm; Baseline 1.2 ± 1.93 A
0.3 ± 0.94 A
0.1
n = 11)
3 months 2.3 ± 2.49B 1 ± 1.63A 0.1
6 months 2.4 ± 2.59 B
1.2 ± 1.54 B
0.04
12 months 1.9 ± 1.9A 0.9 ± 1.19A 0.04
0–12 months difference −0.7 ± 1.2 −0.6 ± 0.51 0.7b
Note: Different uppercase letters indicate statistically significant differences (p < 0.05). ANOVA two-way repeated measures.
Abbreviations: aPDT, antimicrobial photodynamic therapy; CAL, clinical attachment level; GR, gingival recession; OFD, open flap debridement; PPD, probing
pocket depths.
b
t-test.
c
Mann–Whitney rank sum.

When evaluating each parameter individually, significant 3.5 Biomarker analysis

differences were observed between groups for the follow-
ing parameters: mesial papilla (p = 0.01), distal papilla
(p = 0.01), and soft tissue contour (p = 0.01), favoring the
aPDT group.
Table 5 shows the GCF levels of each cytokine at base-
line, at 7 and 14 days, and at 3 and 6 months post-therapy.
No significant differences were observed for any biomarker
between groups at baseline (p > 0.05). Intergroup analysis
ANDERE et al. 7

TA B L E 3 Patient-centered outcomes (n = 46)

Clinical parameters Period OFD (N = 23) aPDT (N = 23) Intergroup p-value
VAS Baseline 2.83 ± 3.55A 1.82 ± 2.47A 0.3
scale 15 days 5.6 ± 3.96 B
3.28 ± 3.39 A
0.03
dentin
3 months 4.56 ± 3.83B 2.69 ± 3.02A 0.8
hypersensitivity
6 months 2.54 ± 3.27 A
2.04 ± 2.8 A
0.7
12 months 2.72 ± 2.91A 1.31 ± 2.1A 0.5
VAS scale postoperative pain 7 days 2.00 ± 3.05 0.6 ± 1.72 0.03b
Analgesic (Y/N) 7 days 12/11 4/19 0.03c
Note: Different uppercase letters indicate statistically significant differences (p < 0.05).
Abbreviations: aPDT, antimicrobial photodynamic therapy; OFD, open flap debridement; VAS, visual analog scale.
b
t-test.
c
Mann–Whitney rank sum.

TA B L E 4 Esthetic evaluation after 12 months (n = 46)

OFD (n = 23) PDT (n = 23) P-value
Mesial papilla 0.66 ± 0.65 1.07 ± 0.57 0.001b
Distal papilla 0.82 ± 0.54 1.05 ± 0.53 0.001b
Level of soft-tissue margin 1.28 ± 0.85 1.62 ± 0.47 0.08c
Soft-tissue contour 1.09 ± 0.79 1.62 ± 0.63 0.001c
Soft-tissue color 1.95 ± 0.21 1.92 ± 0.26 0.8c
Soft-tissue texture 1.35 ± 0.65 1.77 ± 0.41 0.5c
Note: Parameters of the PES26 (pink esthetic score).
b
t-test.
c
Mann–Whitney rank sum test.
Abbreviation: OFD, open flap debridement; aPDT, antimicrobial photodynamic therapy.

showed that aPDT group presented a greater increase in IL-
10 levels and a greater reduction of IL-1β at 14 days when
compared to the OFD group (p < 0.05). Intragroup anal-
ysis showed that the aPDT group had an increase in IL-4
at 7 and 14 days and a reduction of TNF-α at 14 days when
compared to baseline, whereas OFD group presented an
increase of IFN-γ (at 3 and 6 months) and IL-4 (at 7 days)
and a reduction of IL-10 (at 7 and 14 days) and IL-1β (at 14
days), when compared to baseline.
In the aPDT, A. actinomycetemcomitans was detected in 14
out 23 (60.8%) at baseline and in 10 out 23 (43.4%) at 6
months (p = 0.1). P. gingivalis was detected in 14 (60.8%)
patients at baseline and in 9 (39.1%) after 6 months in the
OFD group (p = 0.07), whereas in the aPDT group, it was
detected in 15 (65.2%) patients at baseline and in 7 (30.4%)
at 6 months (p = 0.013). There were no significant inter-
group differences in the frequency of detection of these two
species at any timepoint.

3.6 Microbiologic evaluation
Microbiological analysis revealed that only OFD group
had a significant reduction of A. actinomycetemcomitans
at 6 months from baseline (p < 0.001). However, the
difference in mean A. actinomycetemcomitans reduction
between groups was not significant (Figure 1). Both groups
presented reduction in P. gingivalis from baseline, with no
difference between groups (Figure 1).When the frequency
of detection was analyzed, A. actinomycetemcomitans was
detected in the OFD group in 15 out of 23 patients (65.2%) at
baseline and in 8 out of 23 at 6 months (34.7%) (p = 0.023).
4 DISCUSSION
The present study findings showed that both aPDT and
OFD treatments resulted in improvements in periodontal
clinical parameters when compared to baseline. In moder-
ate pockets, both aPDT and OFD groups showed compara-
ble results. However, in deep pockets (PPD ≥ 7 mm), OFD
presented greater mean PPD reductions at residual sites at
3, 6, and 12 months when compared to the aPDT group.
Our results are in agreement with the literature. Studies
have shown that, in pockets deeper than 6 mm, surgical
therapy resulted in greater pocket depth reductions and
greater attachment level gains than nonsurgical therapy,
8 ANDERE et al.

TA B L E 5 GCF concentration (pg/mg protein) of each marker in the OFD and aPDT groups (mean ± SD)
Cytokines Period OFD aPDT
IFNγ Baseline 15.5 ± 6 Aa 17.8 ± 5.9 Aa
7 days 16.7 ± 11.1 Aa 27.0 ± 40.5 Aa
14 days 16 ± 6 Aa 24.1 ± 31.5 Aa
3 months 20.1 ± 6.8 Ba 19.4 ± 13.1 Aa
6 months 20 ± 6.9 Ba 18.5 ± 6.8 Aa
IL-10 Baseline 52.6 ± 46.7 Aa 62.5 ± 50.1 Aa
7 days 24.4 ± 24 Ba 51.2 ± 66 Aa
14 days 20.7 ± 12.4 Ba 60.1 ± 87.4 Ab
3 months 104.9 ± 93 ACa 55.8 ± 45 Ab
6 months 113.8 ± 88.6 ACa 78 ± 97.5 Aa
IL-1β Baseline 999.9 ± 2140.8 Aa 925.3 ± 2191.9 Aa
7 days 914.5 ± 1972.7 Aa 190.4 ± 518.8 Aa
14 days 112 ± 111.5 Ba 25.5 ± 23.6 Bb
3 months 1549± 2441 Aa 631.8 ± 1229.2 Aa
6 months 1456.8 ± 2009.7 Aa 489.5 ± 922.6 Ab
IL-4 Baseline 28.8 ± 24.2 Aa 27.7 ± 19.5 Aa
7 days 45.3 ± 35.4 ABa 60.6 ± 53.6 Ba
14 days 37.4 ± 24.6 Aa 46 ± 40.4 Ba
3 months 28.6 ± 16.7 ACa 23.7 ± 19.3 Aa
6 months 37.1 ± 29.7 Aa 29.1 ± 24.5 Aa
TNF-α Baseline 43.9 ± 43.9 Aa 62.3 ± 57 Aa
7 days 38.1 ± 32.9 Aa 57.9 ± 84.9 Aa
14 days 33 ± 29.8 ABa 26.9 ± 26 Ba
3 months 65.7 ± 64.6 ACa 43.1 ± 40.1 Aa
6 months 83.5 ± 102.1 ACa 43.1 ± 36.1 Aa
Note: Different uppercase letters indicate intragroup statistically significant differences (p < 0.05) – by the Friedman test. Different lowercase letters indicate
intergroup statistically significant differences (p < 0.05) – by the Mann–Whitney U test.
Abbreviations: aPDT, antimicrobial photodynamic therapy; IFN, interferon; IL, interleukin; OFD, open flap debridement; TNF, tumor necrosis factor.

F I G U R E 1 Microbiologic findings at baseline, 3 and 6 months. (A) DNA copies of A. actinomycetemcomitans (Log 10); (B) DNA copies
of P. gingivalis (Log 10). Different uppercase letters indicate statistically significant intragroup differences (p < 0.05) – Friedman test. Different
lowercase letters indicate statistically significant intergroup differences (p < 0.05) – Mann–Whitney U test

whereas in shallow pockets, attachment loss was observed
after surgery.25–28 In accordance, Ahad et al.,29 observed
that aPDT improved deep pockets sites and reduced gingi-
val inflammation. However, no significant reductions were
observed for PPD and CAL parameters.
In the current study, aPDT produced significant reduc-
tions in mean PPD of deep pockets compared to baseline.
Indeed, Moreira et al.30 reported that aPDT resulted in
greater PPD reduction in deep sites when compared to
SRP alone. Moreover, our present findings showed that
ANDERE et al.
the surgery procedure resulted in more gingival recession.
This is noteworthy as gingival recession leads to undesir-
able symptoms, such as dentine hypersensitivity and aes-
thetic concerns, as also observed here. At 15 days post-
treatment, patients who underwent OFD presented more
DH when compared to baseline and aPDT group. At 3
months, the occurrence of hypersensitivity in this group
remained high, only showing return to baseline levels
at 6 months post-treatment. DH impacts quality of life,
which may impact other important functions in patients’
daily life, such as speech, eating and brushing.31,32 We also
observed that, at 7 days following aPDT treatment, subjects
reported less pain and took fewer analgesics when com-
pared to OFD patients. These data confirm that aPDT may
result in less overall discomfort to patients,33 which may
impact the initial choice of treatment.
Additionally, the present study also showed the nega-
tive impact of surgery on aesthetics results. OFD group
presented worse aesthetic scores, especially for mesial and
distal papillae and the soft tissue contour, which are the
parameters mostly affected by surgical approaches. Treat-
ment that alters a patients aesthetic presentation is likely
to influence post-treatment satisfaction. Therefore, these
parameters need to be considered and discussed carefully
with the patient before the choice for surgical treatment
planning is made.
It is known that oral bacteria play a pivotal role in the
etiology of periodontitis.34,35 Thus, it would be biologically
plausible to associate antimicrobial therapies to reach bet-
ter clinical results. Park et al.36 demonstrated bactericidal
effect of aPDT against periodontopathogens. Our results
also showed that aPDT was able to reduce P. gingivalis
when compared to baseline, however, no differences were
found compared to OFD treatment. aPDT failed to reduce
A. actinomycetemcomitans, while the OFD group reduced
this species from baseline levels. These findings may help
explain the clinical results of this study, in which the sur-
gical approach presented a greater reduction in PPD and
a greater CAL gain in deep pockets compared to aPDT.
Petelin et al.37 also found similar results, showing that
aPDT failed to reduce both A. Actinomycetemcomitans and
P. gingivalisin in deep sites.
Woodruff et al.38 showed that low-level lasers are able
to result in tissue photobiomodulation and can reduce
inflammation of the periodontium. Very few studies eval-
uated the effect of aPDT on immunological parameters
after periodontal treatment. Kolbe et al.33 assessed adjunct
use of aPDT following SRP and observed an increase in
IL-4 levels at 3 months and a reduction in IL-1β levels at
both 3 and 6 months. Giannoppoulou et al.39 compared the
effects of aPDT to laser and SRP. These authors observed
a reduction in IFN-γ and TNF-α levels after 2 months in
both groups with no intergroup differences. Our results
9
showed significantly greater increase of IL-10 and greater
reduction of IL-1β after 14 days in the aPDT group com-
pared to OFD. Moreover, intragroup analysis showed an
increase of IL-4 at 7 and 14 days only for the aPDT group. It
is known that IL-1β is a pro-inflammatory cytokine that has
been associated with periodontal tissue destruction, while
IL-4 suppresses the expression of pro-inflammatory mark-
ers, such as IL-1β and IFN-γ, and upregulates the secre-
tion of anti-inflammatory cytokines by Th2 cells, through
a positive feedback autoregulation of IL-4.40 One of these
anti-inflammatory cytokines is IL-10, which has an impor-
tant regulatory role on Th1 cell differentiation, controlling
the Th1/Th2 balance.41 Therefore, results here may suggest
that the aPDT applications performed within the first 14
days after periodontal debridement may positively influ-
ence host modulation. However, it should be considered
that patients who underwent surgery in the present study
discontinued toothbrushing around the surgical sites for
approximately 7 days, and this may have influenced the
biomarkers levels, despite the patients having rinsed with
0.12% chlorhexidine twice a day for 14 days.
Other limitations of this study should be highlighted.
First, we used a parallel-arm design with a limited sam-
ple size of very few residual sites. In addition, other mini-
mally invasive surgical techniques should be evaluated as
well. Finally, the microbiological and immunological anal-
ysis here only evaluated a few targets and should be inter-
preted with caution. However, other studies that assessed
treatment of residual pockets have not reported variables
that were address in the present study, such as aesthetic
evaluation and DH.13,30
Moreover, it is important to emphasize that this is the
first randomized clinical trial that directly compared the
use of adjunct aPDT to mechanical debridement versus
open flap debridement to treat residual pockets in Grade C
periodontitis patients. We showed that surgery was supe-
rior to aPDT therapy in the reduction of probing depth in
deep pockets. However, aPDT protocol should be consid-
ered as an alternative to the treatment of moderate pockets,
especially in aesthetic areas. Questions regarding the effect
of aPDT on other bacteria species, comparison between
aPDT and other therapies (e.g., antibiotics), and the results
of both treatments in the long-term are still unanswered.
Therefore, more randomized clinical trials are necessary
to elucidate these points.
5 CONCLUSION
Within the limits of the present study, it can be concluded
that OFD was superior in reducing PPD in deep pockets
compared to the aPDT protocol used in this study. How-
ever, OFD resulted in greater GR and esthetic concerns
10
after treatment. Both treatments lowered P. gingivalis levels
but only OFD reduced A. actinomycemtemcomitans levels.
AC K N OW L E D G M E N T S
The authors appreciate the financial support provided by
Research Funding Agency from São Paulo State (FAPESP),
Brazil, grant #2016/15143-0 and 2017/05101-0. In addi-
tion, this study was funded in part by the Coordina-
tion for the Improvement of Higher Education Personnel
(CAPES), Brazil – Finance Code 001.Dr Mauro P Santa-
maria is supported by the National Council for Scientific
and Technological Development from Brazil, CNPq (grant
# 304269/2019-0).
AU T H O R CO N T R I B U T I O N S
Dr. Andere contributed to the design of the study, treated
the patients, and wrote the manuscript with input from
other authors. Dr. dos Santos evaluated the patients. Dr.
Araújo implemented the study. Drs. Casarin and Paz ana-
lyzed the microbiological and immunologic parameters.
Dr. Shaddox contributed to data interpretation, helped
to edit, and revised the manuscript. Dr. Santamaria con-
tributed to the design of the study, directed the implemen-
tation of the research, helped interpret the results, and was
the study coordinator. All authors reviewed and approved
the submitted manuscript.
CONFLICT OF INTEREST
The authors report no conflicts of interest related to this
study.
ORCID
Cássia F. Araújo https://orcid.org/0000-0002-8918-5472
Hélvis E. S. Paz https://orcid.org/0000-0002-0619-2547
Renato C. V. Casarin https://orcid.org/0000-0003-1743-
5855
Mauro P. Santamaria https://orcid.org/0000-0001-
9468-0729
REFERENCES
1. Sanz M, Herrera D, Kebschull M, et al. Treatment of stage I-III
periodontitis-The EFP S3 level clinical practice guideline. J Clin
Periodontol. 2020;47:4-60.
2. Varela VM, Heller D, Silva-Senem MX, Torres MC, Colombo AP,
Feres-Filho EJ. Systemic antimicrobials adjunctive to a repeated
mechanical and antiseptic therapy for aggressive periodontitis: a
6-month randomized controlled trial. J Periodontol. 2011;82:1121-
1130.
3. Casarin RC, Peloso Ribeiro ED, Sallum EA, Nociti FH,
Gonçalves RB, Casati MZ. The combination of amoxicillin
and metronidazole improves clinical and microbiologic results
of one-stage, full-mouth, ultrasonic debridement in aggressive
periodontitis treatment. J Periodontol. 2012;83:988-898.
ANDERE et al.
4. Miller KA, Branco-de-Almeida LS, Wolf S, et al. Long-term clin-
ical response to treatment and maintenance of localized aggres-
sive periodontitis: a cohort study. J Clin Periodontol. 2017;44:158-
168.
5. Andere N, Castro Dos Santos NC, Araujo CF, et al. Clar-
ithromycin as an adjunct to one-stage full-mouth ultrasonic peri-
odontal debridement in generalized aggressive periodontitis: a
randomized controlled clinical trial. J Periodontol. 2017;88:1244-
1252.
6. Araujo CF, Andere N, Castro Dos Santos NC, et al. Two dif-
ferent antibiotic protocols as adjuncts to one-stage full-mouth
ultrasonic debridement to treat generalized aggressive periodon-
titis: a pilot randomized controlled clinical trial. J Periodontol.
2019;90:1431-1440.
7. Tonetti MS, Lang NP, Cortellini P, et al. Effects of a single topical
doxycycline administration adjunctive to mechanical debride-
ment in patients with persistent/recurrent periodontitis but
acceptable oral hygiene during supportive periodontal therapy.
J Clin Periodontol. 2012;39:475-482.
8. Graziani FD, Alonso B, Herrera D. Nonsurgical and surgical
treatment of periodontitis: how many options for one disease?
Periodontol 2000. 2017;75:152-188.
9. Graziani F, Karapetsa D, Mardas N, Leow N, Donos N. Surgical
treatment of the residual periodontal pocket. Periodontol 2000.
2018;76:150-163.
10. Christersson LA, Zambon JJ. Suppression of subgingival
Actinobacillus actinomycetemcomitans in localized juvenile
periodontitis by systemic tetracycline. J Clin Periodontol.
1993;20:395-401.
11. Mandell RL, Socransky SS. Microbiological and clinical effects of
surgery plus doxycycline on juvenile periodontitis. J Periodontol.
1988;59:373-379.
12. Chandra RV, Savitharani B, Reddy AA. Comparing the out-
comes of incisions made by Colorado microdissection nee-
dle, electrosurgery tip, and surgical blade during periodontal
surgery: a randomized controlled trial. J Indian Soc Periodontol.
2016;20:616-622.
13. Lulic M, Leiggener Görög I, Salvi GE, Ramseier CA, Mattheos
N, Lang NP. One-year outcomes of repeated adjunctive photo-
dynamic therapy during periodontal maintenance: a proof-of-
principle randomized-controlled clinical trial. J Clin Periodontol.
2009;36:661-666.
14. Castro dos Santos NC, Andere N, Araujo CF, et al. Local adjunct
effect of antimicrobial photodynamic therapy for the treat-
ment of chronic periodontitis in type 2 diabetics: split-mouth
double-blind randomized controlled clinical trial. Lasers Med
Sci. 2016;31:1633-1640.
15. Bechara Andere NMR, Dos Santos NCC, Araújo CF, et al.
Evaluation of the local effect of nonsurgical periodontal treat-
ment with and without systemic antibiotic and photodynamic
therapy in generalized aggressive periodontitis. A random-
ized clinical trial. Photodiagnosis Photodyn Ther. 2018;24:115-
120.
16. Salvi GE, Stähli A, Schmidt JC, Ramseier CA, Sculean A, Walter
C. Adjunctive laser or antimicrobial photodynamic therapy
to non-surgical mechanical instrumentation in patients with
untreated periodontitis: a systematic review and meta-analysis.
J Clin Periodontol. 2020;47:176-198.
ANDERE et al.
17. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of
periodontitis: framework and proposal of a new classification
and case definition. J Periodontol. 2018;89:S159-S172.
18. Wennström JL, Tomasi C, Bertelle A, Dellasega E. Full-mouth
ultrasonic debridement versus quadrant scaling and root plan-
ing as an initial approach in the treatment of chronic periodon-
titis. J Clin Periodontol. 2005;32:851-859.
19. Cortellini P, Prato GP, Tonetti MS. The modified papilla preser-
vation technique. A new surgical approach for interproximal
regenerative procedures. J Periodontol. 1995;66:261-266.
20. Mühlemann HR, Son S. Gingival sulcus bleeding – A leading
symptom in initial gingivitis. Helv Odontol Acta. 1971;15:107-113.
21. Ainamo J, Bay I. Problems and proposals for recording gingivitis
and plaque. Int Dent J. 1975;25:229-235.
22. Listgarten MA. Periodontal probing: what does it mean? J Clin
Periodontol. 1980;7:165-176.
23. Miguel MMV, Mathias-Santamaria IF, Rossato A, et al.
Microcurrent electrotherapy improves palatal wound healing:
randomized clinical trial. J Periodontol. 2021;92:244-253.
24. Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek
G. Evaluation of soft tissue around single-tooth implant crowns:
the pink esthetic score. Clin Oral Implants Res. 2005;16:639-644.
25. Heitz-Mayfield LJA, Trombelli L, Heitz F, Needleman I, Moles
D. A systematic review of the effect of surgical debridement vs.
non-surgical debridement for the treatment of chronic periodon-
titis. J Clin Periodontol. 2002;29:92-102.
26. Pihlstrom BL, McHugh RB, Oliphant TH, Ortiz-Campos C.
Comparison of surgical and nonsurgical treatment of periodon-
tal disease. A review of current studies and additional results
after 6½ years. J Clin Periodontol. 1983;10:524-541.
27. Pihlstrom BL, Oliphant TH, McHugh RB. Molar and nonmolar
teeth compared over 6½ years following two methods of peri-
odontal therapy. J Periodontol. 1984;55:499-504.
28. Lindhe J, Westfelt E, Nyman S, Socransky SS, Heijl L, Bratthall
G. Healing following surgical/non-surgical treatment of peri-
odontal disease. A clinical study. J Clin Periodontol. 1982;9:115-
128.
29. Ahad A, Lamba AK, Faraz F, Tandon S, Chawla K, Yadav N.
Effect of antimicrobial photodynamic therapy as an adjunct to
nonsurgical treatment of deep periodontal pockets: a clinical
study. J Lasers Med Sci. 2016;7:220-226.
30. Moreira AL, Novaes AB, Grisi MF, et al. Antimicrobial photody-
namic therapy as an adjunct to non-surgical treatment of aggres-
sive periodontitis: a split-mouth randomized controlled trial. J
Periodontol. 2015;86:376-386.
31. Boiko OV, Baker SR, Gibson BJ, et al. Construction and valida-
tion of the quality of life measure for dentine hypersensitivity
(DHEQ). J Clin Periodontol. 2010;37:973-980.
32. Gillam DG, Seo HS, Bulman JS, Newman HN. Perceptions of
dentine hypersensitivity in a general practice population. J Oral
Rehabil. 1999;26:710-714.
11
33. Kolbe MF, Ribeiro FV, Luchesi VH, et al. Photodynamic ther-
apy during supportive periodontal care: clinical, microbiologic,
immunoinflammatory, and patient-centered performance in a
split-mouth randomized clinical trial. J Periodontol. 2014;85:277-
286.
34. Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J
Periodontol. 1965;36:177-187.
35. Curtis MA, Diaz PI, Van Dyke TE. The role of the microbiota in
periodontal disease. Periodontol 2000. 2020;83:14-25.
36. Park D, Kim M, Choi JW, Baek JH, Lee SH, Baek K. Antimicro-
bial photodynamic therapy efficacy against specific pathogenic
periodontitis bacterial species. Photodiagnosis Photodyn Ther.
2020;30:101688.
37. PetelinM PK, Seme K, Gašpirc B. Effect of repeated adjunctive
antimicrobial photodynamic therapy on subgingival periodontal
pathogens in the treatment of chronic periodontitis. Lasers Med
Sci. 2015;30:1647-1656.
38. Woodruff LD, Bounkeo JM, Brannon WM, et al. The efficacy of
laser therapy in wound repair: a meta-analysis of the literature.
Photomed Laser Surg. 2004;22:241-247.
39. Giannopoulou C, Cappuyns I, Cancela J, Cionca N, Mombelli
A. Effect of photodynamic therapy, diode laser, and deep scaling
on cytokine and acute-phase protein levels in gingival crevicular
fluid of residual periodontal pockets. J Periodontol. 2012;83:1018-
1027.
40. Garlet GP, Cardoso CR, Mariano FS, et al. Regulatory T cells
attenuate experimental periodontitis progression in mice. J Clin
Periodontol. 2010;37(7):591-600.
41. Mitchell RE, Hassan M, Burton BR, et al. IL-4 enhances IL-10
production in Th1 cells: implications for Th1 and Th2 regulation.
Sci Rep. 2017;7:11315.
S U P P O RT I N G I N F O R M AT I O N
Additional supporting information can be found online
in the Supporting Information section at the end of this
article.
How to cite this article: Andere NMRB, Castro
dos Santos NC, Araújo CF, et al. Open flap
debridement compared to repeated applications of
photodynamic therapy in the treatment of residual
pockets: A randomized clinical trial. J Periodontol.
2022;1-11. https://doi.org/10.1002/JPER.22-0059