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Conceptually, the aim of this treatment approach is to eliminate both living bacteria in the microbial biofilm and calcified biofilm microorganisms, i.e. dental calculus, from the root surface and from the subgingival area without the surgical reflection of the soft tissues surrounding the teeth.

From a practical point of view the result of this treatment is a more or less complete removal of the calcified accretions covering the root surfaces, a reduction of the number of biofilm microorganisms, and a disturbance of the ecology of the microbial biofilm.

As a consequence, the host tissues can better cope with the remaining microorganisms, reducing the inflammatory changes of the soft tissues and producing a varying degree of closure of the subgingival pocket. In 1886, Black stated that the most important measure in the treatment of calcic inflammation of the periodontal membrane and gums is the removal of the concretions from the teeth, and the next most important, instilling in the mind of the patient an active determination to keep their teeth clean in the future.

Meticulous scaling and root planing is performed during the surgical and nonsurgical phases of periodontal treatment, as well as in the maintenance phase.

Until now, mechanical debridement has been performed with the help of scalers. Scalers can be divided into manual, powerdriven, and other types.

Manual instruments
Manual instruments are generally classified into five types: sickle, curette, file, hoe, and chisel types.

The sickle scaler is used for removal of supragingival calculus, while the curette type is usually used for removal of subgingival calculus and root planing.

Sickle type scalers are used for removal of supragingival calculus. University of South California #3 4(Nordent Co. Ltd., Chicago, IL).

The main sickle type scalers are University of Southern California sickle, Turner sickle, Jaquette sickle, and Morse sickle. The crosssection of the blade is triangular. Some sickle type scalers are designed for use in both anterior and posterior teeth.

Curette type scalers are more frequently used now than before. There are two basic types of curettes: universal and Gracey curette. These two types of curettes differ in the area-specificity, number of cutting edges, curve of cutting edge, and the angle of the face to terminal shank.

Columbia curettes and Gothenburg curettes are representatives of the universal curette. Gracey curettes were designed by Dr. Gracey in the 1930s and are manipulated by a push stroke, followed by a pull stroke. Initially, Gracey curettes were available as a set of 14 instruments, but now mainly double-ended Gracey curettes (7 instruments) are used

Curette type scalers are used for removal of subgingival calculus. A set of doubleended Gracey curettes, from left to right, Gracey 1-2, 3-4, 5-6, 7-8, 9-10, 11-12, 1314 curettes (Hu-Friedy Co. Ltd., Chicago, IL).

Power-driven instruments
Ultrasonic and sonic scalers are referred to as power scalers or power-driven scalers. Ultrasonic scalers are either piezoelectric or magnetostrictive. High vibrational energy generated in the oscillation generator is conducted to the scaler tip, causing vibrations with frequencies in the range of 25,00042,000 Hz . The amplitude ranges from 10 to 100 m. Microvibration crushes and removes calculus under cooling water [Walmsley , Laird & Williams 1984] [ Khambay , Walmsley 1999]

The tip movement of the piezoelectric scaler is primarily linear in direction. The tip of the magnetostrictive scalers moves in an elliptical or circular manner. Sonic instruments utilize mechanical rather than electrical vibrations of the working tip. The Sonic scaler tip vibrates by compressed air from the dental units with frequencies ranging from 2,000 to 6,000 Hz [ Gankerseer & Walmsley 1987, Shah, Walmsley et al 1994]

The advantages of power-driven instruments are less operator fatigue, ease in use, and a simultaneous flushing effect by coolant.

Disadvantages include difficulty in inserting the bulky working tips into deep periodontal pockets to perform root planing, risk of damage to the root surface, poor tactile sensation, and aerosol contamination.

In an effort to overcome these problems, the design of the working tip has been modified by several manufacturers for use in subgingival or furcation areas.

Other instruments
Apart from the mentioned types, there are instruments mounted on air turbines or microengines. Rotosonic scalers are mounted on an air turbine. A hexagon pyramid-shaped bur on the air turbine removes calculus with rotational movement.

Diamond points with fine diamond particles are also used. However, due to excessive removal of tooth substance the use of Rotosonic scalers and diamond points is limited.
The instruments mounted on microengines are mainly used for professional toothcleaning.

Effectiveness in plaque and calculus removal

Ultrasonic Yes


Manual or other

Material & methods


Oosterwaal et al. 1987

Gracey curettes

Single-rooted teeth with 69 mm periodontal pocket in 12 patients. Split-mouth design. Bacteriologic observations

No difference in microscopic or culture data between ultrasonic and manual debridement No difference in microscopic or culture data between ultrasonic and sonic debridement

Baehni et al. 1992



66 periodontal pockets in 31 patients. Bacteriologic Observations


ultrasonic Yes


Manual or other Gracey curretes

Material & methods 90 periodontal pockets in 10 patients. Split-mouth design. Bacteriologic observations 120 formalin-stored mandibular incisors with plaque and calculus. SEM observations

Outcomes The modified ultrasonic tip effectively reduced the microbial environment in a significantly shorter time as compared to Gracey Curettes Sonic scalers removed calculus more completely but caused significantly more roughness and loss of tooth substance than ultrasonic or reciprocating Instruments The piezoelectric ultrasonic scaler was more efficient than the magnetostrictive one, but left the tooth surface roughe

Copulos et al. 1993

Jotikasthira et al 1992




Busslinger et al 2001


M23A universal curret

30 extracted teeth with supra and subgingival calculus. Profilometer and SEM observations

Therefore, it may be concluded that manual and power-driven scalers are equally effective in removal of plaque bacteria and calculus

Effects on the root surface

Most studies addressing the efficacy of nonsurgical periodontal therapy in removing the microbial biofilm and dental calculus have been performed on periodontally diseased teeth scheduled for extraction. Immediately following extraction, the teeth were processed for evaluation by light microscopy, stereomicroscopy, or scanning electron microscopy.

In most of the studies no time limit was set for the instrumentation of the root surfaces. However, in several studies the time used by the operator was recorded.

As a general observation from all studies in the literature, it is evident that subgingival scaling and root planing is an efficient method to reduce the amount of bacterial plaque and calculus attached to the subgingival root surface.
However, most studies also indicate that none of the instrumentation techniques is totally effective in eliminating all bacteria and calculus from the subgingival surface of the tooth. Hunter et al 1984 , Anderson et al 1996, Barnes & Schaffer1960, Brayer et al1989, Caffesse et al 1986, Clifford et al 1999, Drago et al 1992, Hunter et al 1984, Yukna & Scott1997, Kocher et al 2000

Pocket Depth & Residual Plaque & Calculus after SRP

With increasing probing pocket depth, the number of teeth with subgingival surfaces completely free of residual plaque or calculus decreases. [ Caffesse et al 1986] PPD

REFERENCES Clifford et al 1999, Gallin et al 1986, Rabbani et al 1981 Clifford et al 1999, Gallin et al 1986, Rabbani et al 1981, Carey & Daly 2001, Clifford et al 1999, Gallin et al 1986, Rabbani et al 1981, Lee et al 1996






Complete debridement of furcations was notably more difficult using nonsurgical techniques
( Breiniger & o Leary1987, Lee et al 1996,Oda & Ishikawa1989, Wylam et al 1993)

Surgical v/s Nonsurgical Debridement

Nonsurgical subgingival instrumentation was slightly less effective in removing subgingival plaque and calculus than access flap therapy combined with root debridement under direct visual control. [Brayer et al1989, Buchanan &Robertson 1987, Caffesse et al 1986, Johanson et al 1989] Interestingly, these studies demonstrated that even with direct visual control during surgical debridement, increasing amounts of remaining calculus and plaque were found with increasing values for probing pocket depth (Brayer et al1989, Buchanan &Robertson 1987, Caffesse et al 1986). This might indicate that the visual control of these surfaces during access flap surgery is not optimal due to anatomic factors and constraints.

Experience Matters!
The experience of the operator is an important factor for the final result of the subgingival debridement







Kocher et al 1997


Model in phantom head

Stereomicros copy

4.8-7min/ teeth

Currets, Sonic, Ultrasonic Scalers.

13.0 9.8%
(trained periodontist with currets.)

to 28.3 11.3%
(Inexperienced dentist with sonic scaler)

Brayer et al 1989


2mm or more ( hopeless ) (single rooted teeth)

Stereomicros copy

No time limit

Ultrasonic+ currets Training Trained Same with flap Traing Trained



0-17% 0-5%

Type of instrument & its Impact

When comparing different instruments used for the subgingival debridement during nonsurgical periodontal therapy, no major differences between these approaches could be demonstrated. These observations were further confirmed for different hand instruments such as rigid curettes and long shank curettes, sonic instruments, ultrasonic scalers, EVA reciprocating instruments, and Perio-Planer or Per-io-tor. Curved tips for ultrasonic scalers appear to allow better plaque and calculus removal in furcation areas of mandibular and maxillary molars (Oda & Ishikawa 1989)

Modified ultrasonic inserts have been developed for improved penetration into the subgingival pocket without loss of adequate cooling. (Drago 1967 ,Clifford et al 1999) The use of diamond coated ultrasonic tips does not reduce the proportions of surfaces that are still covered with remnants of plaque or calculus, but it does cut down the time needed to achieve the appropriate treatment of the subgingival root surface. (Yukna et al 1997)

Smoothness of the root surface

A smooth surface is accepted as being more likely to also be a clean surface. This was based on an experiment performed by Waerhaug in dogs (1956). He demonstrated that intentional roughening of the subgingival enamel surfaces enhances plaque formation and its transformation into subgingival calculus. As a corollary, Lindhe et al.(1984) have reported that normal healing of the dentogingival tissues occurs in contact with a smooth root surface.

Teeth with rough surfaces are also more frequently associated with the presence of gingivitis and periodontitis (Quirynen et al 1995).

In contrast to these studies, Rosenberg & Ash could not detect any significant effect of root surface roughness as produced by instrumentation with curettes or ultrasonic scalers on the retention of dental plaque or on the inflammation of the marginal gingival tissues.

Later studies could not demonstrate any relationship between the root surface texture after instrumentation according to different protocols and the healing response of the periodontal tissues, the probing pocket depth reduction and the clinical attachment level changes .
(Khatiblou et al 1983, Oberholzer & Rateitschak 1996).

Surface Roughness with Different Instruments

in vitro study done by Schalgeter 1996, in which the average surface roughness (Ra) was determined for different instruments. Instrument Ra value Gracey curettes Perio-Planer curettes 1.90 0.84m 2.10 1.03m

Sonic scaler Rotary diamond tip with 75 particle size Rotary diamond tip with 15 particle size

2.48 0.90m
2.71 1.12m 2.60 1.06m 1.640.81m

In a study with implants receiving titanium abutments with different surface roughness, it was shown that a surface roughness with values of 0.2 m or less had no influence on plaque accumulation.
If, however, the surface roughness was increased to a value of 0.8m or more, the amount of plaque accumulating on this surface increased 25-fold. (Quirynen et al 1996) Taking into account this threshold Ra value of 0.2m, the Ra values for the root surfaces after treatment with different instruments that are currently available for use during nonsurgical periodontal therapy were between 8 and 14 times higher . Schalgeter 1996

This observation indicates that with the currently available instruments for planing or smoothing the subgingival root surfaces during nonsurgical or surgical periodontal therapy, the surface roughness would still be far above the threshold Ra value where the surface roughness no longer influences the colonization by subgingival plaque bacteria.

Removal of diseased Root Cementum

The achievement of decontamination of the exposed root surface is essential for the healing, repair, and regeneration of the periodontal tissues. However, at present there is no means by which the clinician can determine whether all contaminated root cementum has been removed. Because of this, extensive and aggressive scaling and root planing has been advocated. (Cogen et al 1983,1984, Cheetham et al 1988 etc) The therapeutic endpoint of this approach is a completely smooth and hard root surface, assuming that this represents complete removal of subgingival plaque and calculus and maximum removal of contaminated root cementum.

In contrast with this aggressive approach, a gentler treatment of the root surface has been advocated based on the observation that endotoxin does not penetrate into the exposed root cementum, but rather forms a loosely attached superficial layer on its surface .
( Smart et al 1990 Chiew et al 1991 etc )

This superficial endotoxin layer could be almost completely removed by using gentle scaling with hand instruments (Cheetham et al 1988), conservative instrumentation with ultrasonic scalers (Smart et al 1990) or, on surfaces exposed during periodontal surgery, gentle brushing and washing for 1 min (Moore et al 1986).

Conceptually, the aggressive approach in which an attempt is made to remove all contaminated root cementum, may be increasingly questioned.

The first argument against this approach is the presence of endotoxin as a loosely bound superficial layer on the exposed root surface.

The second is that it is almost impossible to remove all of the root cementum, especially in the middle and apical portions of the root (Borghetti et al 1987).

A third argument is found in the observations that viable bacteria were demonstrated in the dentinal tubules of mechanically treated roots of periodontally diseased teeth (Adriaens et al 1980-88, Giuliana et al 1997).

Finally, although mechanical root planing achieves almost complete if not total removal of the cementumbound endotoxin from the subgingival root surface, during the weeks following this treatment the root surface is likely to become recontaminated .

These findings would tend to support a gentler treatment approach of the root surface, leaving in place most of the root cementum but at the same time removing and disturbing as much as possible the bacterial biofilm attached to the surface of the root cementum.

Amount of root structure removed during nonsurgical therapy

Nevertheless, the question arises as to how much of the root cementum is removed during mechanical root debridement. In answering this question it should be realized that several factors might influence the amount of hard tissue being removed, such as the 1. Force applied to the instrument, 2. The number of strokes performed with the instrument, 3. The degree of mineralization of the superficial layers of the root cementum, 4. The degree of sharpness of the curette or scaler at the start of the treatment and the gradual dulling of these instruments during their continued use.

THICKNESS OF CEMENTUM The thickness of cementum on the coronal half of root varies from 16-60m or about the thickness of a hair. It attains its greatest thickness upto 150-200m in the apical third & in furcation areas. [Dastmalchi et al 1990]

In an in vitro study evaluating the amount of root surface structures removed during the mechanical treatment of the root with curettes, it was shown that an increasing number of strokes did remove increasing amounts of mineralized root structures.
After 20 strokes applied with a force of between 700 and 1200 g of force, an average of 60m was removed. The amount of material removed increased to 65m for 30 strokes, 89 m for 40 strokes, 112 m for 50 strokes, 174m for 60 strokes and 205 m for 70 strokes. Based on the average values for the thickness of the root cementum, that study also demonstrated that it can be expected that 20 strokes should be sufficient to remove all root cementum in the cervical third of the root. (Coldiron, Yukna et al 1990 )

Amount of force 3.04 N

No of strokes 5 10 20 40

Tooth material removed in m 34 65 110 149


10 20 40

165 245 343

Zappa et al in 1991 ( in vitro study effect of increasing force & strokes)

The relationship between the amount of material removed from the root surface and the forces applied to the instrument were confirmed in an in vitro study with different types of instruments by Ritz et al 1991

Force 100 p 200p 400p

No of strokes 12 12 12

Tooth material removed in m 11.6 18.2 85.9

When the number of strokes was standardized to 12 and the amount of pressure applied to the instrument to 100 p, the amount of mineralized material removed during the use of different instruments was:

Instrument Curette Sonic scaler Ultrasonic scaler Fine grid diamond bur

Material removed in m 109 94 12 119

The use of different Per-io-tor instruments resulted in the removal of less than 7.0 m of the root surface (Mengel et al 1994). It was therefore suggested that the Per-io-tor might be an instrument best suited for use during periodontal maintenance therapy.

Effects on the periodontal tissues

Changes in gingival inflammation
In many clinical studies on the effects of nonsurgical or surgical periodontal therapy, bleeding after probing was used as an indicator of (residual) disease activity. Several investigators Badersten et al 1985,87,90, Claffey et al 1988, Lang et al 1986, Joss et al 1994 have demonstrated that sites in which bleeding after probing occurred repeatedly at successive observations during the periodontal supportive therapy, had a higher probability for showing periodontal breakdown as evidenced by loss of clinical periodontal attachment.

Lang et al 1986 , used the absence of bleeding after probing as an indicator of a stable periodontal health

Data from studies in which sites with initial probing depth between 4 and 7 mm were treated by the nonsurgical approach, demonstrated an average reduction from baseline in bleeding after probing of approximately 50%
( Lindhe et al 1985, 87, Boretti et al 1995, Drisko et al 1995, Forabosco et al 1996, Haffajee et al 1997, Preshaw et al 1999, Stelzel et al 2000, Wennstrom et al 2001 etc)

Data from selected studies mentioned indicate that the decrease in bleeding after probing has a tendency to further stability or even to a slight additional improvement with an increasing length of the postoperative observation period.
The range of reduction of the occurrence of bleeding after probing was: 664% after the first month, 1280% at 3 months post-treatment, 1287% at 6 months and 3787% at 12 months after completion of the nonsurgical periodontal treatment

Other studies could not find any short-term or longterm differences between the results of both treatment modalities in reducing the periodontal inflammation. (Philstrom et al 1981, 83, Renvert et al 1990 et al etc)

Changes in probing pocket depth and clinical attachment level

The reduction in probing pocket depth is the result of both a gain in clinical attachment level and a recession of the marginal gingival tissues. [Proye et al 1982] The gingival recession results from the reduction in swelling of the marginal gingival tissue.
The inflamed tissue with its inflammatory cell infiltrate and the increased numbers of capillaries present in the gingival connective tissue is gradually replaced by a more collagen-rich tissues.[Biagini et al 1988]

These changes are accompanied by a gradual shrinkage of the tissue in an apical direction and towards the root surface. The interface between the root surface and the former pocket epithelium is partially transformed into a long junctional epithelium (Caton et al 1979, 80). Both the presence of the long junctional epithelium and the increased content in collagen fibers in the gingival connective tissue result in the gain in clinical attachment level, i.e. an increased resistance of the tissues against the penetration of a periodontal probe.

Although only few studies have tested the stability of a long junctional epithelial attachment to the root surface, no difference could be found in resistance to disease between a long junctional epithelial adhesion and a true connective tissue attachment. [Beaumount et al 1984]

The evaluation of clinical changes occurring in the periodontal tissues following nonsurgical therapy should ideally not be performed earlier than 4 weeks after the nonsurgical periodontal treatment was performed (Caton et al 1982, Dahlen et al 1992 ).

Clinical changes at nonmolar sites

Based on a series of studies published between 1979 and 2002 [ Cobb 1996,2002, van der Weijden et al 2002 ] The follow-up period in these studies varied between 1 and 68 months.

It was calculated that for pockets with an initial probing pocket depth of 3 mm or less Nonsurgical periodontal therapy resulted in a negligible reduction of the probing pocket depth of 0.03 mm, however, this reduction in probing pocket depth was accompanied by a mean loss of clinical attachment of 0.34 mm, with values ranging from a loss of 0.80 mm to a slight gain of 0.29 mm in clinical attachment level.

For nonmolar defects with an initial probing pocket depth between 4 and 6 mm
Mean probing pocket depth reductions ranged from 0.30 mm to 2.1 mm. The mean values for the changes in clinical attachment level in these sites with initial moderate probing pocket depth ranged from a loss of 0.07 mm to a gain of 1.20 mm.

In deep sites, i.e. sites with initial probing pocket depth values of 7 mm or more:
The mean reduction in probing pocket depth was between 1.38 mm and 2.85 mm , whereas the mean gain in clinical attachment varied between 0.55 and 2.50 mm .

Clinical changes at molar sites

The clinical changes occurring at molar furcation sites following nonsurgical periodontal therapy are documented in a limited number of clinical studies (Claffey et al 1990,Loos1988, 89 etc).
A total of 141 patients with over 500 molar sites with class 2 furcation defects were included in these studies, with observation periods ranging between 3 and 42 months .

For molar sites with an initial probing pocket depth of 14 mm the mean probing pocket depth reduction was 0.4 mm and these sites lost an average of 0.2 mm in clinical attachment level .

For molar sites with a moderate initial probing pocket depth (between 4 and 6 mm) the mean probing pocket depth reduction varied between 0.00 mm and 1.02 mm and the mean changes in clinical attachment level varied between a loss of 0.80 mm and a gain of 0.28 mm .

For molar sites with initially deep probing pocket depth values (7 mm or more) the changes in probing pocket depth varied between 0.00 mm and 1.52 mm . The mean values for the changes in clinical attachment levels ranged between a loss of 0.50 mm and a gain of 0.84 mm .

These observations combined with data from previous

studies showing an inferior long-term prognosis for molars with furcation involvement , have led to the use of more aggressive treatment protocols being advocated for the treatment of molars with furcation lesions, including

mainly resective procedures or, to a lesser extent,

regenerative techniques for class 2 lesions

Gingival recession
For nonmolar sites with initial probing pocket depths of between 1 and 3 mm, the amount of gingival recession was approximately 1 mm For sites with moderately deep (46 mm) or deep (7 mm or more) probing pocket depth at baseline, the mean values for the gingival recession were 1.2 mm and 1.9 mm, respectively.
No significant changes occurred for the amount of recession when hand instruments or ultrasonic instruments were used. (Badersten et al 1984,85,87, Claffey et al 1990)

Although the amount of gingival recession observed on the molar flat surfaces was similar to that observed around nonmolar teeth, there was significantly less gingival recession at the molar furcation sites .

Both this smaller gingival recession and the smaller gain, or sometimes even loss, of clinical attachment level at molar furcation sites explain the less favorable values for probing pocket depth reduction at the furcation sites treated with nonsurgical therapy.

Changes in alveolar bone structures

Comparing the effect of different surgical and nonsurgical periodontal treatment modalities on changes in bone height, Isidor et al1985. observed that nonsurgical periodontal therapy did not produce any changes in the bone height for sites with horizontal bone loss . Although a mean gain in bone height of 0.5 mm was observed for intraosseous defects following surgical therapy with a classical modified Widman flap procedure, the changes in bone height after nonsurgical periodontal treatment of these sites were not significant.

In intraosseous defects treated with nonsurgical periodontal therapy there is an increase in bone probing levels of 0.2 mm at 6 months, 0.3 mm at 12 months and 0.5 mm at 24 months after therapy ( Renvert et al 1985,1990).

These values are 5060% lower than the increase in bone probing levels obtained following surgical access flap therapy including full coverage flap procedures combined with root planing and citric acid conditioning of the roots.

Using subtraction radiography on standardized intraoral radiographs it could be determined that 60% of the sites receiving nonsurgical periodontal therapy demonstrated some amount of bone gain at the 314 months post-treatment observation . In contrast with this finding, in 95% of the sites that received access flap surgery some amount of bone loss occurred during the same observation period

Changes in bone density in interproximal intraosseous defects depend on when the observation is made .

During the initial 2 months, there is a decrease in bone density. This decrease is followed by a significant increase in bone density in the next 4 months.
Only minor changes occur 612 months after therapy, indicating a further maturation of the osseous structures.

In an animal study with surgically treated periodontal defects the use of hand instruments and ultrasonic instruments resulted in similar amounts of changes in bone density .[Glick& Freeman1980]

Adjunctive effects of chlorhexidine as irrigants during ultrasonic scaling

Nosal et al.1991 evaluated the penetration depth of the water coolant for medicament lavage of an ultrasonic (Cavitron with EWPP tip) device into the periodontal pocket and concluded that the ultrasonic scaler may be an effective system to mechanically remove plaque and calculus at the same time as delivering a chemotherapeutic agent.

Taggart et al.1990 reported that 0.02% chlorhexidine had a slight adjunctive effect in terms of reduction of pocket depth when used as a coolant during ultrasonic root planing (Cavitron) for the treatment of chronic periodontitis. Reynolds et al. 1992 studied the clinical and microbial effects of a single episode of simultaneous ultrasonic scaling and subgingival irrigation with 0.12% chlorhexidine, and reported that subgingival irrigation with chlorhexidine during ultrasonic scaling (CaviMedTM200; Dentsply) provided differential clinical benefits that were site-dependent.

However, Chapple et al.1992 failed to show any significant benefits of using 0.2% chlorhexidine as irrigant during ultrasonic (CaviMedTM200) scaling and root planing.

SRP is an efficient method to reduce the amount of calculus and biofilm bacteria attached to the subgingival root surface, none of the currently used techniques or instruments is totally effective in completely eliminating all calculus and bacteria. Initial probing pocket depth, root anatomy, instrument design, and operator skill and experience influence the efficacy of the calculus and biofilm removal from the subgingival surfaces.

Smoothness of the treated root surfaces is determined by the nature of the instruments used during the treatment.
The amount of root substance removed during nonsurgical periodontal therapy is determined by the nature of the instruments used, the force applied during their use, and the number of strokes performed on a given part of the root surface. It induces beneficial changes to the periodontal tissues, as expressed by a reduction of the gingival inflammation, a reduction of probing pocket depth, and a gain in clinical attachment level.

The magnitude of the changes is related to the initial defect size as expressed by initial probing pocket depth, tooth type (nonmolar sites versus molar sites), and other environmental factors such as the quality of oral hygiene and smoking status of the patient.

Changes in probing pocket depth and clinical attachment are also accompanied by changes in the position of the gingival margin and changes to the crestal parts of the alveolar bone.