Thus, changes in clinical attachment level measurements are most frequently used as clinical outcomes in clinical trials (Ryan, 2005), and however, in contrast to (university‐based) clinical studies, clinical attachment levels are not routinely measured in dental and periodontal practices, and therefore, the value of this parameter needs serious consideration whilst engaged in developing clinical guidelines. This is done so that the active periodontal infection is reduced and the overall tissue quality is improved prior to surgery. Another discussion point is the concept that at the baseline starting point of clinical studies on active periodontal therapy, most patients and most periodontal pockets with corresponding clinical attachment levels may be likely to be disease‐inactive, that is in some sort of state of remission or resolution. FI, MRT, SPT: 13 : 2013 Does a pretreatment with a dentine hypersensitivity mouth-rinse compensate the pain caused by professional mechanical plaque removal? Stakeholders will be asked to prioritize outcomes and as such a core outcome set can be established. In fact, periodontal therapies should be directed at tangible benefits to the patient such as maintenance or enhanced quality of life, chewing comfort, aesthetics and decreased tooth mortality (Hujoel & DeRouen, 1995) as well as reducing negative effects on general health. A dentist or dental hygienist provides this treatment by scraping … They receive up to three additional years of specialized training in periodontal disease treatment in both non-surgical treatments and periodontal plastic surgery procedures. Involving people living with periodontitis as co‐researchers in the design of these studies would also help to improve their relevance. A literature search was conducted in Ovid MEDLINE(R) and Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations and Daily <1946 to 07 June 2019>. From our review, there are only limited data to guide treatment options based either on clinical outcomes or PROs. However, these important studies investigated prognostic factors of initial periodontal status (i.e., at baseline, prior to treatment) and this is different from the focus of the current review which was to determine the effect of treatment outcomes on future tooth loss. 2019 Sep;27:167-172. doi: 10.1016/j.pdpdt.2019.05.022. Please check your email for instructions on resetting your password. Epub 2019 May 19. Research has shown that teeth have less risk of being lost during maintenance if patients are more compliant with supportive periodontal therapy (Matuliene et al., 2010), but at the same time, based on studies, there is heterogeneity amongst the data on tooth loss during supportive periodontal therapy (Lee et al., 2015). Thus, with the current approach, it can be concluded that there is both a limited amount of data in the literature and considerable heterogeneity. The expert and highly experienced periodontal research community will need to work to develop studies that can more closely guide such treatment choices. in the patient, that is active episodes may be transient (Chapple, Garner, Saxby, Moscrop, & Matthews, 1999; Crawford, 1992; Kinane, Stathopoulou, & Papapanou, 2017; Page & DeRouen, 1992; Papantonopoulos, Takahashi, Bountis, & Loos, 2013). Active periodontal therapy is defined as a standard treatment consisting of oral hygiene instructions, biofilm and calculus removal (a.k.a. Photodiagnosis Photodyn Ther. In our search, neither short‐term studies (3–12‐month follow‐up) nor longer‐term studies (≥12 months follow‐up) appeared investigating the use of various probing measurements on the need for periodontitis re‐treatment. However, since potentially eligible studies addressed a range of research questions, designing a comprehensive search was challenging. AgP, CAL: 12 : 2014: Risk factors associated with the longevity of multi-rooted teeth. Active Periodontal Therapy The early warning signs of every disease occur at a microscopic level. The current review of treatment endpoint studies showed, perhaps not unexpectedly, that the body of evidence available for periodontal therapy is largely based on limited studies of conventional professional surrogate outcomes. Dental biofilm: Ecological interactions in health and disease, Predictors of tooth loss due to periodontal disease in patients following long‐term periodontal maintenance, Introduction of a prediction model to assigning periodontal prognosis based on survival time, Influence of residual pockets on progression of periodontitis and tooth loss: Results after 11 years of maintenance, Significance of periodontal risk assessment in the recurrence of periodontitis and tooth loss, Impact of oral health on the life quality of periodontal patients, Periodontal inflamed surface area: Quantifying inflammatory burden, The design and implementation of trials of host modulation agents, A comparison of two questionnaires measuring oral health‐related quality of life before and after dental hygiene treatment in patients with periodontal disease, Design issues specific to studies of periodontitis, Using cellular automata experiments to model periodontitis: A first theoretical step towards understanding the nonlinear dynamics of periodontitis, Issues in the evaluation of clinical trials of periodontitis: A clinical perspective, A systematic review on the use of residual probing depth, bleeding on probing and furcation status following initial periodontal therapy to predict further attachment and tooth loss, Clinical attachment level change as an outcome measure for therapies that slow the progression of periodontal disease, Risk factors associated with the longevity of multi‐rooted teeth. Today we understand that periodontitis is an inflammatory disease and that a proportion of the population is susceptible (Bartold & Van Dyke. The need for periodontal maintenance treatment after active therapy due to the potential for disease recurrence. In the process of developing guidelines for periodontal therapy, in the evaluation of “best practice” effects on clinical attachment levels, the proportion of threshold changes such as ≥2 mm or ≥3 mm in clinical attachment levels are preferable, rather than mean changes in this parameter; for the vast majority, mean differences in changes of clinical attachment levels between two or more treatment modalities reported in many treatment studies are considered by many dental professionals to be clinically insignificant. Developers of guidelines for periodontal therapy can apply the current pathophysiological paradigm that shallow periodontal pockets after active periodontal therapy (non‐surgical and surgical therapy) are providing the least hazardous ecological sites for the re‐outgrowth of a dysbiotic biofilm and therefore for the patient to have a better chance for further long‐term stability of his/her periodontal attachment. However, in a multivariate regression analysis for tooth loss in the maintenance phase, statistically significant clinical outcomes at the patient level were full‐mouth bleeding scores ≥30%, baseline disease classification and numbers of years of maintenance therapy; whilst residual periodontal pocket depth was important, the number of residual periodontal pockets ≥5 mm was not significantly associated with risk of tooth loss and the number of residual periodontal pockets ≥6 mm was close to significantly predictive (p = .053; Matuliene et al., 2008). Whilst the current review has focused on single measures, composite outcomes may have more value in defining desirable endpoints of therapy. Objectives: To assess prognostic factors for tooth loss after active periodontal therapy (APT) in patients with aggressive periodontitis (AgP) at tooth level. The monthly reevaluation of periodontal therapy should involve periodontal charting as a better indication of the success of treatment, and to see if other courses of treatment can be identified. An endpoint is an event or outcome that can be measured objectively to determine whether an intervention being studied is beneficial (Hujoel & DeRouen, 1995). Active periodontal therapy is defined as a standard treatment consisting of oral hygiene instructions, biofilm and calculus removal (a.k.a. Aim of this study was to evaluate tooth loss (TL) during 10 years of supportive periodontal therapy (SPT) in periodontal compromised patients and to identify factors influencing TL on patient level. In this context, we might differentiate between true and surrogate endpoints of treatment (Hujoel & DeRouen, 1995). Active periodontal therapy — which usually consists of a locally administered antimicrobial agent delivered into the gum pockets — costs an average of $75 per tooth. APT is an abbreviation for Active Periodontal Therapy. We found only one systematic review to investigate residual probing depth and bleeding on probing following initial periodontal therapy to evaluate the stability of clinical attachment level over time (Renvert & Persson, 2002). Although the research base is limited both in quantity and strength, the most reasonable recommendation for developers of guidelines for periodontal therapy is that the achievement of shallow pockets following active periodontal therapy confers the highest chance of stability of periodontal attachment and lowest risk of tooth loss. Indeed, it was stated in a recent consensus report on prevention issues related to both caries and periodontal diseases that modern preventive practice should focus on the identification of risk in individuals using validated risk assessment tools (Chapple et al., 2017). Guidelines for periodontal therapy should take into consideration tangible clinical outcomes (tooth survival, reduced need for re‐treatment) and PROs including oral health‐related quality of life, no pain (i.e., lack of discomfort), improved, or at least continuous, dental functionality, improved aesthetic appearance and a general quality of life. Many efforts have been made to increase the efficacy of periodontitis therapy as much as possible. Matuliene and co‐workers identified that after active periodontal therapy, residual pockets ≥6 mm and full‐mouth bleeding scores of ≥30%, represented a risk for tooth loss for the patient (Matuliene et al., 2008). Future endpoints of periodontal treatment may include the absence of systemic signs of inflammation, for example C‐reactive protein levels <3 mg/L; these may suffice as endpoints to consider periodontal treatment successful for the health of the patient, and therefore, for example, tooth loss becomes an indirect or surrogate parameter. In fact, periodontal A further challenge to periodontal outcome research, in general, is the low rate of disease progression for periodontitis patients following treatment enrolled in maintenance care. Author information: (1)Department of Periodontics, Case Western Reserve University, Cleveland, OH 44106-4905, USA. A further consideration is that randomized controlled trials (RCTs) on periodontal treatment do not necessarily represent the standard of care in clinical dental practice. Furcation involvement (FI) was assessed clinically at start of periodontal therapy and assigned according to Hamp et al. The full search results are accessible as Appendix. Have you found the page useful? Of these, tooth survival, the need for re‐treatment and oral health‐related quality of life can be considered tangible patient outcomes. Therefore, it has been argued that all periodontal treatment procedures for periodontitis should aim to achieve low levels of bleeding on probing (e.g., ≤15% of sites), shallow probing pocket depths (≤4 mm) and absence of suppuration (Sanz et al., 2015; Tonetti et al., 2017). The association of risk factors with loss of MRT was analysed with multilevel logistic regression. Please use the following to spread the word: About | Contact Us iOS app | Android Notably, from the British practice‐based cross‐sectional study (Sharma et al., 2018), the PROs oral pain/discomfort, dietary restrictions and dental appearance correlated with poor periodontal conditions. Active periodontal therapy has always been provided to periodontitis patients to establish conditions which allow the patient to maintain a dentition without further … Nevertheless, loss of clinical attachment level was informative for later tooth loss in a Norwegian population (Hujoel, Loe, Anerud, Boysen, & Leroux, 1999). The question was as follows: How are, for an individual patient, commonly applied periodontal probing measures—recorded after active periodontal therapy—related to (a) stability of clinical attachment level, (b) tooth survival, (c) need for re‐treatment … These symptoms may be a sign of gum disease, which can often be treated with active periodontal therapy (APT). Data were presented at the patient rather than the site level. In this review, we focused on tangible endpoints after active periodontal therapy. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. APT is a non-surgical procedure which aims plaque and calculus deposits from the tooth and root surface. Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline. The reviewers report from the Claffey and Egelberg (1995) study a significant inverse correlation between the stability of clinical attachment level over follow‐up time and the patient‐mean proportion of sites having residual probing depths ≥6 mm at the 3‐month time point after active periodontal therapy. Nevertheless, tooth loss as an endpoint of periodontal therapy could be questioned today. Laser Assisted New Attachment Protocol (LANAP®). Position paper on endpoints of active periodontal therapy for designing treatment guidelines. Periodontal therapy treats and helps to prevent periodontitis by removing plaque and calculus deposits from the tooth and root surface (called debridement). Aims: To investigate the incidence and reasons for tooth loss during active periodontal therapy (APT) and periodontal maintenance (PM) in a specialist institution. A total of 94 papers were retrieved. Tooth loss after therapy is also to a limited degree dependent on the level of compliance during the supportive periodontal therapy (maintenance) (Lee, Huang, Sun, & Karimbux, 2015). Several studies were found from reference lists and not from our search, which on the first view might inform on this topic, for example (Chambrone, Chambrone, Lima, & Chambrone, 2010; Faggion, Petersilka, Lange, Gerss, & Flemmig, 2007; Martinez‐Canut, 2015; Martinez‐Canut et al., 2018). Therefore, recommendations about treatment options should take these limitations into account. Involve patients and caregivers as part of the research team to design studies. Ortiz P(1), Bissada NF, Palomo L, Han YW, Al-Zahrani MS, Panneerselvam A, Askari A. APT means Active Periodontal Therapy. Practical implication: The use of CHX rinsing during the active phase of therapy lead to a more beneficial re-colonization of the recently scaled pockets, and consequently to a better periodontal … A total of 172 subjects were examined before (T0) and after active periodontal therapy (APT)(T1) and following a mean of 11.5 ± 5.2 (SD) years of SPT (T2). In our search, neither short‐term studies (3–12‐month follow‐up) nor longer‐term studies (≥12 months follow‐up) appeared investigating the use of various probing measurements on the oral health‐related or general quality of life. Deep residual pockets form a favourable niche for biofilms dominated by asaccharolytic, proteolytic and anaerobic pathobionts (Bartold & Van Dyke, 2019; Kilian et al., 2016; Marsh, 2003). We treat most patients here and refer out only the surgical needs. Active periodontal therapy is defined as a standard treatment consisting of oral hygiene instructions, biofilm and calculus removal (a.k.a. And thus, periodontal inflammation as measured by bleeding on probing, and periodontal inflamed surface area measurements (Nesse et al., 2008), could be valid surrogate markers for systemic endpoints. Scaling and root planing is sometimes followed by adjunctive therapy such as local delivery antimicrobials, systemic antibiotics, and host modulation, as needed on a case-by-case basis. The full text of this article hosted at iucr.org is unavailable due to technical difficulties. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. The tooth was the unit of analysis. Results: Fifty molars were extracted during active periodontal therapy (APT) and 154 molars over the average SPT period of 13.2 ± 2.8 years. maintenance programs following active therapy 1, once termed maintenance is called as Supportive Periodontal Therapy (SPT) according to 5th American Academy of Periodontology (AAP), 1986.6 In 1989 the World Workshop in Clinical Periodontics described by the term ‘supportive periodontal treatment’ (SPT).7 In 2003 AAP, position paper Efficacy of alternative or additional methods to professional mechanical plaque removal during supportive periodontal therapy: A systematic review and meta‐analysis Leonardo Trombelli … As such, for clinicians and dental researchers who will be engaged in the development of clinical guidelines for periodontal therapy, the following can be recommended: In addition to the observations above we propose the following: orcid.org/https://orcid.org/0000-0002-8794-552X, orcid.org/https://orcid.org/0000-0003-4696-1651, I have read and accept the Wiley Online Library Terms and Conditions of Use, Measuring oral health‐related quality‐of‐life using OHQoL‐GE in periodontal patients presenting at the University of Berne, Switzerland, A multilevel analysis of factors affecting pocket probing depth in patients responding differently to periodontal treatment, Activation of resolution pathways to prevent and fight chronic inflammation: Lessons from asthma and inflammatory bowel disease, An appraisal of the role of specific bacteria in the initial pathogenesis of periodontitis, Cross‐talk between microbiota and immune fitness to steer and control response to anti PD‐1/PDL‐1 treatment, Validity and limitations of self‐reported periodontal health, Predictors of tooth loss during long‐term periodontal maintenance: A systematic review of observational studies, Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: Consensus report of group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases, Prediction and diagnosis of attachment loss by enhanced chemiluminescent assay of crevicular fluid alkaline phosphatase levels, The effect of the loss of teeth on diet and nutrition, Clinical indicators of probing attachment loss following initial periodontal treatment in advanced periodontitis patients, Issues of individual study analysis and synthesis of studies specific to evaluation of studies of periodontitis, Periodontal disease and pregnancy outcomes: Overview of systematic reviews, The link between periodontal disease and cardiovascular disease is probably inflammation, Searching deep and wide: Advances in the molecular understanding of dental caries and periodontal disease, Age and periodontal health‐immunological view, Aging, inflammation, immunity and periodontal disease, Prognostic model for tooth survival in patients treated for periodontitis, The application of multilevel modelling to periodontal research data, Re: A review of longitudinal studies that compared periodontal therapies, Endpoints in periodontal trials: The need for an evidence‐based research approach, A survey of endpoint characteristics in periodontal clinical trials published 1988–1992, and implications for future studies, The informativeness of attachment loss on tooth mortality, The oral microbiome – An update for oral healthcare professionals, Core outcomes in periodontal trials: Study protocol for core outcome set development, Absence of bleeding on probing. A more recent landmark paper concluded essentially the same as above: based on the long‐term follow‐up of 172 patients in periodontal maintenance therapy, it was found that the presence of deep (≥6 mm) residual pockets was a risk factor for patients to have further periodontal disease progression (Matuliene et al., 2008). Most patients at this point will require Active Periodontal Therapy and/or a referral to a gum specialist. Aims: To investigate the incidence and reasons for tooth loss during active periodontal therapy (APT) and periodontal maintenance (PM) in a specialist institution. Presentation of an evaluation criteria staircase for cost‐benefit use, Supportive periodontal therapy (SPT) for maintaining the dentition in adults treated for periodontitis, Microbial ecology of dental plaque and its significance in health and disease. Along with brushing and flossing after every time eating, individuals can also in increase their periodontal well-being by being intentional about the food and drink they consume. Surrogate endpoints, which include probing pocket depth reduction and gain in clinical attachment level, may not provide unambiguous evidence that a certain treatment yields concrete patient benefits. Today we understand better that from the aspect of creating unfavourable ecological niches for the pathogenic microbiota, the goals of periodontal therapy and subsequent maintenance should be to reduce or eliminate residual probing depths whilst keeping the resistance and resilience of the patient at a high level. The EFP S3 Level Clinical Practice Guideline. Update of medical and dental histories. From the literature search and the additional supporting papers, for example (Matuliene et al., 2008, 2010; Salvi et al., 2014) as well as based on biological plausibility, it is clear that periodontitis patients with residual periodontal pockets ≤4 mm after active periodontal therapy are more likely to have stability of clinical attachment level over a follow‐up time of beyond 1 year (Renvert & Persson, 2002). We urgently need multilevel statistics and multifactorial algorithms including all, and more, host, microbial and local oral and dental parameters, to predict future re‐emergence of periodontitis and to estimate local or generalized further breakdown of periodontal tissues (Axtelius, Soderfeldt, & Attstrom, 1999; Gilthorpe, Griffiths, Maddick, & Zamzuri, 2000; Lopez, Frydenberg, & Baelum, 2009; Lundgren, Asklow, Thorstensson, & Harefeldt, 2001; Tu et al., 2004a, 2004b). The best available evidence suggests that—following active periodontal therapy—the achievement of shallow periodontal pockets (≤4 mm) that do not bleed on probing in patients with full‐mouth bleeding scores <30% confers the highest chance of stability of periodontal health and lowest risk of tooth loss. Most periodontists would agree that after scaling and root planing, many patients do not require any further active treatment. Special Issue: Treatment of Stage I‐III Periodontitis. We would like to stress that our purpose of this position paper focused on patient endpoints, and therefore, classical papers providing parameters related to tooth survival or clinical attachment level stability in the absence of bleeding on probing or in the absence of inflammation around teeth or at individual sites were not retrieved, for example (Lang, Adler, Joss, & Nyman, 1990; Schätzle et al., 2004). Retrospectively analysed tooth loss in periodontally compromised patients: Long-term results 10 years after active periodontal therapy-Patient-related outcomes. How much does it cost to see a Periodontist? initial or cause-related therapy) with or without adjunctive anti-microbials and with or without surgical treatment. In that review, only publications on chronic or adult forms of periodontitis were eligible for inclusion, excluding aggressive periodontitis. Scientific rationale for the study: To investigate what we know about tangible patient outcomes after active periodontal therapy and to make recommendations for practice and research. Nevertheless, few experimental (as opposed to observational) periodontal treatment studies have investigated true endpoints such as tooth retention, perhaps because of the duration of follow‐up required to make this outcome meaningful to measure. However, it is unclear what constitutes tangible treatment outcomes for the patients. Only 5% of individuals in periodontal maintenance demonstrated clear disease progression leading to tooth loss over a period of some years of follow‐up (Crawford, 1992; Greenstein, 1993; Page & DeRouen, 1992). By no means, it has been our intention to discard more than 50 years of valuable clinical research in periodontology. A long‐term follow‐up study (9.5 ± 4.5 years) showed that about 50% of the patients in maintenance did not lose any tooth (Matuliene et al., 2010). Today we realize with the arrival of an alternative for a tooth, that is a dental implant, that tooth extractions are indicated much more often by the dental profession. Clearly, the duration of follow‐up and the number of participants required to show meaningful differences in outcomes of clinical attachment levels will be substantial and could constitute a barrier to future research. However, with our current knowledge, we realize that chronic inflammation of the periodontal tissues (clinically visible as red and swollen gingiva and professionally assessed by bleeding on probing or noticed by the patients as bleeding after tooth brushing) even when none or when minimal periodontal attachment loss and alveolar bone loss are incurred (e.g., pregnancy gingivitis) may give rise to a systemic inflammation affecting other organs, such as the cardiovascular system or the course of a pregnancy and development of the embryo in utero (Daalderop et al., 2018; Dave & Van Dyke, 2008; Linden, Lyons, & Scannapieco, 2013; Sanz et al., 2019; Schenkein & Loos, 2013). Therefore, we supplemented the electronic search with studies retrieved from reference lists. The perceived solution by both the dentist and the patients for loss of a tooth has sparked a worldwide increase in tooth extractions (Levin & Halperin‐Sternfeld, 2013). From the literature search, it was found that periodontitis patients with a low proportion of deep residual pockets after active periodontal therapy are more likely to have stability of clinical attachment level over a follow‐up time of ≥1 year. Reports have indicated that teeth may more easily be extracted than before the millennium shift, with a view to replacing teeth with implants, despite the evidence that periodontally involved but well‐maintained teeth, out survive—and are cheaper—than implants (Levin & Halperin‐Sternfeld, 2013; Schwendicke, Graetz, Stolpe, & Dorfer, 2014). This will help to create more homogeneity amongst clinical trials, systematic reviews and clinical guidelines (Lamont et al., 2017). These subgingival dysbiotic microcosms in deep residual pockets after therapy re‐challenge the periodontitis patients who have already demonstrated to have an aberrant immune response, that is the onset of periodontitis has occurred. Another true outcome, quality of life, has been included although the number of trials reporting this measure is low and it is not clear how responsive such tools are to assess treatment response as compared to their original application, which was in cross‐sectional epidemiological studies. Periodontal disease affects the gums, ligaments and bone that support your teeth. The aim of the present position paper was to answer the following questions: How are, for an individual patient, commonly applied periodontal probing measures—recorded after active therapy—related to (a) stability of clinical attachment level, (b) tooth survival, (c) need for re‐treatment or (d) oral health‐related quality of life? 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