Full-mouth treatment versus quadrant root surface debridement in the treatment of chronic periodontitis: a systematic review

IN BRIEF • There were no significant differences in RESEARCH Full-mouth treatment versus quadrant root surface debridement in the treatment of chronic periodontitis: a systematic review the effects of full-mouth treatment over the quadrant-wise approach over six months after treatment. • Root surface debridement remains the primary treatment modality for the professional management of chronic periodontitis. • The evidence for the additional benefit of antiseptic use is inconclusive. M. Farman1 and R. I. Joshi2 VERIFIABLE CPD PAPER Background and aims Non-surgical periodontal therapy has been proven to be an effective treatment for patients with chronic periodontitis. Conventional non-surgical therapy by debridement of the root surfaces is performed on a quadrant basis with 1-2 week intervals. This time interval may result in re-colonisation by the bacteria of the instrumented pockets and impair healing. Therefore, a new approach of full-mouth non-surgical therapy to be completed within two consecu tive days with (full-mouth disinfection) or without (full-mouth debridement) use of oral antiseptics has been suggested. The aim of this review was to compare the clinical outcomes of the three modalities of non-surgical therapy (full-mouth disinfection [FMD], full-mouth debridement [FRp], quadrant scaling and root planing [Q]). Methods Standard searches of Medline and Embase databases and appropriate hand searching provided the published studies, which were then as sessed against pre-determined inclusion criteria. Meta-analysis was performed wherever possible using Review Manager 4.2 software. Results Seven randomised controlled trials (RCTs) were included in the review and these failed to show any statistically significant differences between the FRp and Q approaches. Further studies are required to reach conclusion regarding the advantages of FMD approach. Practical implications Mechanical debridement is an important component of treatment for chronic periodontitis and this review suggests that both the traditional quadrant approach and the newer the full-mouth debridement could be equally effective. BACKGROUND Periodontitis is a chronic disease of the gingival and periodontal tissues. The 1999 classification identifies four major categories.1 The most common type of the disease, chronic periodontitis, has been reported to affect over 30% of the adult population, with severe disease reported in 7-13% of adults.2,3 In susceptible indi viduals, this chronic inflammation will cause periodontal ligament and alveo lar bone breakdown with the forma tion of pockets. Such pockets are ideal environments for bacteria, especially 1 Department of Adult Dental Care, School of Clinical Dentistry, University of Sheffield, Claremont Crescent, Sheffield, S10 2TA; 2*Consultant in Restorative Den tistry, Charles Clifford Dental Hospital, Wellesley Road, Sheffield, S10 2SZ *Correspondence to: Mr Rajendra Joshi Email: Online article number E18 Refereed Paper - accepted 11 July 2008 DOI: 10.1038/sj.bdj.2008.874 © British Dental Journal 2008; 205: E18 the gram-negative species. Progression of the disease can lead to functional problems and tooth loss. Recent studies also report a link between periodontal disease and other life threatening com plications like atherosclerosis, other cardiovascular problems, diabetes and pre-term childbirth.4-9 This justifies the treatment needed to re-establish peri odontal health. Non-surgical periodontal treatment is still the mainstay of any manage ment plan for patients. In patients with advanced periodontitis, this results in clinical reduction of pocket depths, gain of clinical attachment levels and reduc tion in bleeding scores in both moderate and deep pockets.10,11 The principal aspect of the treatment is the removal of the com ponents of the subgingival plaque biofi lm, which have a major role in the initiation and progression of the disease.12 Several studies have shown that the periodon topathogens can colonise other intraoral niches such as tongue dorsum, tonsils, saliva and other mucous membranes in addition to the periodontal pockets.13,14 Intraoral translocation of periodon topathogens from one niche to another has been proven.15,16 After root surface debridement, the subgingival microflora can re-establish from these niches. Thus, the concept of one-stage full-mouth dis infection was introduced in an effort to prevent re-infection of the already treated sites by remaining bacteria from untreated pockets or other intraoral res ervoirs, by completing the treatment in 24 hours and strict use of antimicrobial agents, mainly chlorhexidine (CHX).17 Additional probing depth reduction of 1 to 1.2 mm has been claimed as a result of this treatment approach.18 On the other hand, several studies demonstrated an additional but only small clinical improvement when subgingival chlorhex idine irrigation was used as an adjunc tive therapy to scaling and root planing, whereas other studies failed to show even such an effect.19-21 These observations BRITISH DENTAL JOURNAL 1 © 2008 Macmillan Publishers Limited. All rights reserved. RESEARCH suggested that the clinical benefits might be due to full-mouth therapy only. Therefore the full-mouth disinfection approach was modified to full-mouth debridement in which the extensive use of disinfectant agents was not required. Several studies have been carried out to compare the effect of this new approach of non-surgical therapy to the stand ard quadrant scaling and root planing treatment strategy. However, the results appear to be contradictory. Early studies by the Leuven group showed significant clinical and microbial improvements but more recent studies show almost no dif ference between the new approach and traditional quadrant debridement. The original protocol introduced by Quirynen has been modified with regard to the use, type, duration and concentration of the antiseptic agents and, together with dif ferent homecare regimen, may explain the differences.17 Rationale for systematic review In the era of evidence-based dentistry, good clinical research is necessary to support any clinical intervention. Full mouth debridement, as a new treatment modality that can have a significant impact on periodontal practice, needs to be a proven benefit for patients. Individ ual studies suggest equivocal results. The aim of this systematic review is to determine the effect of full-mouth debridement and/or disinfection versus quadrant-wise debridement. The defi nitions of these treatment methods are as follows: Full-mouth disinfection (FMD): com pletion of the root surface debridement in one or two visits within 24 hours and strict use of disinfectants during the debridement and for some time after the debridement. Full-mouth debridement (FRp): com pletion of root surface debridement in one or two visits within 24 hours with out use of adjunct disinfectants. Quadrant scaling and root planing (Q): completion of root surface debride ment (...truncated)