The Literature Does Not Support Traditional Periodontal Surgery vs Non Surgical Methods – Why is it still “standard of care”?
While traditional periodontal surgery (osseous or flap gum surgery) is still “standard of care” for the treatment of deep gum pockets, the literature simply does not support it. Why is it still standard of care? Great question. These methods have been “steeped in tradition, unhampered by progress” – for many decades. We encourage all periodontal sufferers to carefully review the research before undergoing any type of periodontal surgery. What will the results consistently demonstrate? How will the gums and the teeth look after surgery? Will there be long term sensitivity? Will the results be long term? It is our suggestion that “informed consent” about the results of traditional periodontal surgery be brought to the forefront of public understanding.
We strongly encourage anyone facing periodontal surgery to review pictures of surgical case results, obtain direct patient testimonials, as well as review the published research carefully. Knowledge is empowering.
Clin Periodontol. 1987 Sep ;14 (8):445-52 3308969
4 Modalities Of Periodontal Treatment Compared Over 5 Years.
S P Ramfjord , R G Caffesse , E C Morrison , R W Hill , G J Kerry , E A Appleberry , R R Nissle , D L Stults
The purpose of the present study was to assess in a clinical trial over 5 years the results following 4 different modalities of periodontal therapy (pocket elimination or reduction surgery, modified Widman flap surgery, subgingival curettage, and scaling and root planing). 90 patients were treated. The treatment methods were applied on a random basis to each of the 4 quadrants of the dentition. The patients were given professional tooth cleaning and oral hygiene instructions every 3 months. Pocket depth and attachment levels were scored once a year. 72 patients completed the 5 years of observation. Both patient means for pocket depth and attachment level as well as % distribution of sites with loss of attachment greater than or equal to 2 mm and greater than or equal to 3 mm were compared. For 1-3 mm probing depth, scaling and root planing, as well as subgingival curettage led to significantly less attachment loss than pocket elimination and modified Widman flap surgery.
For 4-6 mm pockets, scaling and root planing and curettage had better attachment results than pocket elimination surgery. For the 7-12 mm pockets, there was no statistically significant difference among the results following the various procedures.
Dr. Caffesse emphasized, and was quite surprised, that his group had shown that there is no benefit to resective pocket reduction whatsoever.
The study below actually demonstrates that patients are far worse off AFTER periodontal surgery:
J. Clin. Perio. Volume 4 Issue 4 Page 240-249, December 1977
Periodontal Surgery In Plaque-Infected Dentitions
A clinical trial was performed to study the result of periodontal treatment following different modes of periodontal surgery in patients not recalled for maintenance care. The material consisted of 25 patients distributed into 5 groups. Following an initial examination, all patients underwent presurgical treatment including case presentation and instruction in oral hygiene measures. This instruction was given once. The various patient groups were then subjected to one of the following surgical procedures: 1) the apically repositioned flap operation including elimination of bony defects 2) the apically repositioned flap operation including curettage of bony defects but without removal of bone 3) the “Widman flap” technique including elimination of bony defects 4) the “Widman flap” technique including curettage of bony defects but without removal of bone 5) gingivectomy including curettage of bony defects but without removal of bone. Six, 12 and 24 months after completion of the treatment, the patients were recalled for assessment of their oral hygiene standard and periodontal conditions.
The results showed that case presentation and oral hygiene instruction given once, only temporarily improved the patient’s oral hygiene habits. Renewed accumulation of plaque in the operated areas resulted in recurrence of periodontal disease including a significant further loss of attachment. All five different techniques for surgical pocket elimination were equally ineffective in preventing recurrence of destructive periodontitis.
The rate of destruction for “no surgical intervention” vs “perio surgery”: Nyman & Linde & Rosling of Switzerland, in Journal of Clin Perio, 4:240,1977.
The rate of bone destruction was .1-.3 mm/yr. with no periodontal surgery performed vs. 1-2mm/yr. rate of bone destruction after periodontal surgery.
Informed consent is an important issue when discussing all the options for periodontal treatment. We encourage all periodontal sufferers to thoroughly educate themselves about expected clinical outcomes of all available periodontal surgery treatment options.
What about long term outcomes with traditional periodontal therapy and surgical treatment methods? J Clin Periodontol. 2012 Jan;39(1):73-9. doi: 10.1111/j.1600-051X.2011.01811.x. Epub 2011 Nov 7.
Tooth loss in periodontally treated patients: a long-term study of periodontal disease and root caries.
Ravald N, Johansson CS.
Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Center for Oral Rehabilitation, County Council of Östergötland, Sweden. nils.ravald @lio.se
AIM: To study periodontal conditions, root caries, number of lost teeth and causes for tooth loss during 11-14 years after active periodontal treatment.
MATERIAL AND METHODS:
Sixty-four patients participated in the follow-up study. Reasons for tooth loss were identified through previous case books, radiographs and clinical photos. To identify factors contributing to tooth loss, a logistic multilevel regression analysis was used.
The number of lost teeth was 211. The main reason was periodontal disease (n = 153). Due to root caries and endodontic complications, 28 and 17 teeth, respectively, were lost. Thirteen teeth were lost for other reasons. The number of teeth (p = 0.05) and prevalence of probing pocket depths, 4-6 mm (p = 0.01) at baseline, smoking (p = 0.01) and the number of visits at dental hygienists (p = 0.03) during maintenance, significantly contributed to explain the variation in tooth loss.
Previously treated patients at a specialist clinic for periodontology continued to lose teeth in spite of maintenance treatments at general practitioners and dental hygienists. The main reason for tooth loss was periodontal disease. Tooth loss was significantly more prevalent among smokers than non-smokers. Tooth-related risk factors were smoking, low numbers of teeth and prevalence of periodontal pockets, 4-6 mm.
In many cases surgical intervention and extractions of teeth should be a last resort. It is our assertion that definitive non surgical attempts should be considered as a first phase treatment approach to reduce the need for surgical intervention and tooth extractions. We also highly recommend that sufferers of chronic periodontal disease look closely in to host factors (deficiencies, blood sugar levels, medications contributing to gum disease, genetic conditions, molecular diagnosis of pathogen levels, etc.) which may be contributing to their periodontal disease and yet go untreated. Without finding the “cause”, any treatment approach will fail in the long term, as demonstrated in the study above.