Periodontology 2000, Vol.
25, 2001, 77–88
Printed in Denmark ¡ All rights reserved
Nonsurgical periodontal therapy
C ONNIE H ASTINGS D RISKO
Anti-infective therapy
Successful periodontal therapy is dependent on anti-
infective procedures aimed at eliminating patho-
genic organisms found in dental plaque associated
with the tooth surface and within other niches in the
oral cavity (9, 103, 104). Since periodontal disease is
a plaque-induced infection and most patients are
not skilled in mechanical plaque removal, pro-
fessional cleaning is almost universally indicated to
sustain long-term stability of the periodontium (22,
75). Very few patients can maintain periodontal
health over a lifetime without the benefit of regular
dental care, which consists primarily of oral hygiene
instruction, and nonsurgical anti-infective therapy
(69, 121, 122).
Anti-infective therapy includes both mechanical
and chemotherapeutic approaches to minimize or
eliminate microbial biofilm (bacterial plaque), the
primary etiology of gingivitis and periodontitis.
Mechanical therapy consists of debridement of the
roots by the meticulous use of hand or power-driven
scalers to remove plaque, endotoxin, calculus and
other plaque-retentive local factors. The term mech-
anical therapy refers to both supragingival and sub-
gingival scaling as well as root planing. In theory,
these procedures are different, but in most clini-
cians’ point of view, the difference between scaling
and scaling and root planing is really a matter of de-
gree (17).
The term periodontal debridement was suggested
by Smart et al. (102) to describe the light overlapping
strokes used for instrumenting the root with a sonic
or ultrasonic scaler. However, others have used the
term more broadly to describe both hand and
power-driven scaling that is a gentle, yet thorough
subgingival instrumentation aimed at the removal of
toxic substances without overinstrumentation or the
intentional removal of cementum. The endpoint of
all periodontal debridement is to produce a root that
is biologically acceptable for a healthy attachment
(13, 14, 28, 52, 100–102, 114).
Chemotherapeutic approaches include topical ap-
Copyright C Munksgaard 2001
PERIODONTOLOGY 2000
ISSN 0906-6713
plication of antiseptics (91, 96, 97) or sustained-re-
lease local drug delivery agents that are designed to
prevent plaque accumulation and to disinfect the
root surfaces and adjacent periodontal tissues (27,
43, 54, 105, 106). Systemic approaches encompass
the selective use of antibiotics or host modulation of
tissue destructive enzymes (19, 42). Once the infec-
tion and inflammation are controlled by surgical or
nonsurgical methods, periodontal health can be sus-
tained for extended periods of time with daily plaque
control by the patient and periodic professional
maintenance by the dentist and dental hygienist (51,
55, 66, 77, 88, 89, 94).
This chapter summarizes selected representative
studies from an extensive body of literature that ad-
dresses the use of nonsurgical therapy to treat peri-
odontal diseases. Comparisons between treatment
outcomes following instrumentation with manual or
power-driven scalers are discussed as well as the evi-
dence to support the advantages and disadvantages
of the adjunctive use of pharmacotherapeutic agents
(50) found in toothpastes (20, 23, 35), mouthrinses
(31, 39, 45, 49, 62, 71) irrigation solutions/ultrasonic
lavage (10, 34, 48, 95), local drug delivery devices (27,
37, 38, 43, 46, 54, 90, 105, 106) and host modulating
drugs (19, 42).
Risk factors influencing nonsurgical
therapy outcomes
Not all patients respond well to therapy nor are they
able to maintain a stable periodontium over ex-
tended periods of time following successful peri-
odontal therapy. Factors influencing undesirable
therapeutic outcomes usually include poor compli-
ance with oral hygiene regimens and failure to return
for regular maintenance care (121, 122). Insufficient
debridement may account for some treatment fail-
ures or reinfection; however, the presence of sys-
temic conditions or diseases such as diabetes mel-
litus may also have a significant impact on long-term
77
Drisko
treatment outcomes (4, 48). Genetic susceptibility to
periodontal disease cannot be discounted and is re-
sponsible for at least some disease occurrence (30,
81, 82).
In recent years, smoking has also been shown to
be a highly significant risk factor for periodontitis.
Smokers have a decreased immune response and ex-
hibit compromised healing following both surgical
and nonsurgical therapy compared with nonsmokers
or former smokers (3, 113). Since the majority of pa-
tients who do not respond well to therapy are
smokers (3) and since smokers have more recurrent
disease, smoking education and cessation programs
should be included as an integral part of a compre-
hensive nonsurgical periodontal treatment plan
when indicated.
Other risk factors influencing nonsurgical treat-
ment outcomes include the presence of persistent
deep pockets and molars with furcation invasions.
Kaldahl et al. (55) have shown that surgical treat-
ment of pockets Ø5 mm by flap and osseous surgery
results in greater pocket reduction than nonsurgical
scaling and root planing. Single-rooted teeth and
posterior teeth with intact furcations usually re-
spond better and are more easily maintained than
multirooted teeth and molars with furcation in-
vasions. Surgical debridement in general has been
shown to provide better access to plaque and calcu-
lus removal in deep pockets and furcations than a
closed scaling and root planing approach. Deep sites
may also benefit from pocket reduction surgery fol-
lowing anti-infective therapy to make them shal-
lower and more accessible for long term mainten-
ance.
General principles of controlling
periodontal infection
Gingivitis and periodontitis are plaque-associated
infections initiated by the accumulation and matu-
ration of pathogenic biofilms on the surfaces of the
teeth and oral mucosal surfaces. Supragingival and
subgingival plaque differ dramatically in quantity
and quality and require substantially different ap-
proaches for their removal. On a daily basis, the pa-
tient can remove supragingival plaque with standard
oral hygiene procedures including brushing, flossing
and use of other oral hygiene aids. However, studies
show that adherence to oral hygiene protocols is low
and that the average patient does not possess the
motivation or skills to achieve or sustain a plaque-
78
free dentition over a substantial period of time.
Consequently, clinical trials would indicate that self-
care plaque control programs alone, without the in-
tervention of professional reinforcement, do not
usually provide for long-term success in reversing
gingivitis (22, 68, 69, 75).
Some sites may break down then spontaneously
recover or even improve; however, the overall effect
of repeated episodes of untreated active disease is
the establishment of an inflammatory lesion that ul-
timately leads to periodontal destruction. Constant
attention is needed by the patient and the pro-
fessional to keep the subgingival microbiota under
control, at least to the level that the host can estab-
lish an equilibrium that is conducive to health. Suc-
cessful control of the inflammatory process dictates
that mechanical debridement with manual or
power-driven scalers be performed approximately
every 3 months to interrupt the re-establishment of
the harmful biofilm and to prevent or reverse any
damage to the periodontal attachment apparatus
(66).
Elimination or adequate suppression of putative
periodontopathic microorganisms in subgingival
plaque is virtually impossible for the patient to
achieve on their own. Highly organized subgingival
bacterial plaques (biofilms) are difficult to reach, as
they form the apically advancing front of periodontal
pockets in close proximity to the degrading connec-
tive tissue and alveolar bone. Yet control of the sub-
gingival biofilm is crucial; without control of these
organized microcosms of periodontopathic bacteria,
periodontal disease will most likely develop by age
30 in at least 10% or more of adults, underscoring
the need for intermittent disruption of the subgingi-
val biofilm by professional cleaning (87).
Role of mechanical therapy: manual,
sonic and ultrasonic scalers
Meticulous subgingival debridement is inherently a
time-consuming and difficult procedure that usually
includes scaling and root planing by manual instru-
mentation and/or periodontal debridement with
sonic or ultrasonic scalers (102). It requires a great
deal of stamina on the part of the operator and the
patient. Success is highly dependent on the skill of
the clinician (6, 7) and the attention to detail in in-
strumentation (17, 26, 28). Numerous studies since
the 1950’s have indicated that manual instrumen-
tation in general takes from 20% to 50% longer to

achieve the same clinical end-points than that of
sonic and/or ultrasonic scalers (6, 7, 16, 18, 59, 64,
123).
As probing depth increases, instrumentation be-
comes less effective at removing bacterial plaque
and calculus (56, 92, 100, 101, 119). However, some
newly designed ultrasonic and sonic scaler tips have
enhanced the ability of the operator to reach into
furcations more effectively and to penetrate the
depth of the pocket more easily (15, 25, 56, 60, 61,
85). Dragoo (25) compared modified ultrasonic and
unmodified scaling tips to manual curettes for their
ability to reach the most apical extension of peri-
odontal pocket with probing depths ranging from 5
mm to 8 mm. Dragoo reported that the mean dis-
tance from the instrument limit to the depth of the
pocket was approximately 0.78 mm for modified
ultrasonic tips (microultrasonic), 1.13 mm for un-
modified ultrasonic tips, and 1.25 mm for manual
curettes. Recently, Clifford et al. (15) found that, fol-
lowing in vivo use, standard ultrasonic and micro-
ultrasonic inserts were able to reach and debride the
apical plaque border in pockets ranging from 4 to
Ø7 mm.
When manual instrumentation or sonic/ultra-
sonic scalers are used for the treatment of the sub-
gingival pockets, profound shifts in the composition
of the microbial flora are observed (9, 13, 56, 65, 84).
Some evidence supports the added effect of ultra-
sonics on bacterial viability with sonic and ultra-
sonic instrumentation, showing reduction of spiro-
chetes and motile rods in vitro (8, 72, 111). The
changes in clinical parameters usually seen after
scaling and root planing are shown in Table 1. Mean
probing depth reduction ranges from from 0.03 to
2.16 mm and attachment gains range from ª0.34 to
1.19 mm depending on the initial probing depth that
were present prior to treatment.
Mechanical therapy is usually the first mode of
treatment recommended for most periodontal infec-
tions (16). The American Academy of Periodontology
1996 World Workshop consensus report states that
ultrasonic and sonic instrumentation have shown
similar clinical effects as manual scaling and root
planing (63, 74). There are very few studies that use
a combination of therapy for root instrumentation,
which leaves some questions regarding whether
manual or power-driven scaling will produce the
best anti-infective result. However, well-documented
studies report that manual and power-driven scalers
are nearly equal in their ability to clean the root and
indicate there may be some advantages to using dif-
ferent shaped instruments with different mechan-
Nonsurgical periodontal therapy
isms of action during mechanical therapy (16). It has
been suggested that power-driven scalers alone or in
combination with manual scaler may produce the
best overall result (17, 26, 27, 40, 100, 101).
Topical antimicrobial agents to
enhance plaque control
Given the inability of most patients to practice high
levels of plaque control, other forms of chemo-
therapy are often needed to sustain gingival health
(70, 78, 79, 96) (Table 2). Since most patients are not
skilled in adequate plaque removal, many clinicians
currently include one or more adjunctive chemo-
therapeutic agents in their nonsurgical anti-infective
regimen. However, thorough mechanical debride-
ment alone is frequently sufficient to treat most peri-
odontal diseases in their early stages.
The term anti-infective therapy was first referred
to when topical antimicrobial agents such as chlor-
hexidine, hydrogen peroxide, baking soda or povi-
done iodine were applied professionally as an ad-
junct to mechanical debridement (29, 96, 97). These
early studies provided preliminary data to support
the use of various antimicrobials in conjunction with
mechanical debridement for augmenting the clinical
Table 1. The average gains in clinical attachment
following scaling and root planing in non-molar
sites from 27 studies (12)
Pocket depth Probing reduction Attachment gain
1–3 mm 0.03 mm ª0.34 mm
4–6 mm 1.29 mm 0.55 mm
±6 mm 2.16 mm 1.19 mm
Source: adapted from Cobb (16).
Table 2. Rationale for adjunctive topical or
systemic antimicrobial agents
O Mechanical therapy alone may not effectively
control infection, particularly in deep pockets (57)
O Poor plaque control increases the rate of reinfection
of the pocket (69, 99)
O Root surface, tongue, tonsils and within other niches
in the oral mucosa harbor pathogenic bacteria that
recolonize the periodontal pocket and can act as
sources for reinfection (9)
O Actinobacillus actinomycetemcomitans and other
tissue-invasive organisms are not easily irradicated
without concomitant antibiotic therapy (80)
79
Drisko
effects of nonsurgical therapy. Since then, others
have conducted small pilot studies that have gener-
ally supported these earlier findings (34, 91, 116).
Vandekerckhove et al. (116) were among the first
to report a new innovative treatment for periodontal
infections using a partial-mouth disinfection proto-
col that consisted of a thorough supragingival and
subgingival chlorhexidine application (rinses, irri-
gation and tongue brush) followed by four quadrants
of scaling and root planing within 24 hours. When
they compared these sites to traditional scaling and
root planing (scaling and root planing on one quad-
rant every 2 weeks without topical chlorhexidine),
they found substantial differences in the clinical
attachment level gains (3.7 mm test versus 1.9 mm
for control). Most interesting in this small 8-month
pilot study was the lack of gingival recession in the
test group (0.7 mm) versus 1.9 mm in the control.
Larger studies of longer duration are needed to sub-
stantiate the validity of combining antimicrobial
agents with mechanical therapy to enhance clinical
results.
A variety of patient-applied antimicrobial prod-
ucts such as mouthrinses containing essential oils,
triclosan or chlorhexidine are also useful adjuncts to
brushing and flossing in gingivitis and periodontitis
patients and can reduce plaque accumulation and
gingivitis by 0–75% (33, 39) (Table 3). Dentifrices
containing fluoride, triclosan, chlorhexidine and
other antimicrobial agents have been shown to be
effective in reducing plaque accumulation and de-
creasing gingivitis and periodontitis by 20–50% (67,
108, 109, 115). Furuichi et al. (35) reported reducing
bleeding on probing by 27.5% following scaling and
root planing with the use of a triclosan/copolymer
dentifrice following the nonsurgical treatment of re-
current periodontitis. Lindhe et al. (67) and Triritana
Table 3. Summary results of plaque and gingivitis reduction for antimicrobial agents used in a minimum
of two studies of 6 months or longer demonstrating clinical efficacy
Chemical agent Plaque reduction Gingivitis reduction
Chlorhexidine 48–61% 27–67%
Essential oils 19–35% 15–37%
Triclosan 0–30% 20–75%
Source: adapted from Fine (33).
80
et al. (115) have reported reduction of Gingival Index
scores by 20–30% in patients using dentifrice con-
taining a triclosan/Gantrez formulation compared to
a control.
It is not surprising that the root surface itself has
also been shown to harbor viable bacteria that may
provide a nidus for subgingival bacterial repopu-
lation (1, 41). Pathogens such as Prevotella interme-
dia, Porphyromonas gingivalis, Fusobacterium nucle-
atum, Bacteroides forsythus, Peptostreptococcus
micros and Streptococcus intermedius were found in
up to 53.8% of periodontally diseases roots (41). The
root may become a bacterial reservoir from which
periodontal pathogenic bacteria can recolonize pre-
viously treated pockets and contribute to the failure
of therapy or the recurrence of disease.
Other sources for bacteria colonization exist out-
side the roots in the periodontium besides tooth as-
sociated plaque. The tongue, tonsils and niches
within the mucosa of the oral cavity have all been
shown to harbor large numbers of periodontopathic
organisms (9).
Recolonization of subgingival plaque is not com-
pletely understood, but it is known that it takes sev-
eral months to repopulate the pocket following a
thorough scaling and root planing in the presence of
good daily oral hygiene by the patient. However, with
poor supragingival plaque control, the microbiota
may reestablish itself within 40–60 days following
subgingival debridement (99). Deep pockets are par-
ticularly difficult to control, since repopulation of
the subgingival plaques occurs by 120–240 days de-
spite meticulous supragingival plaque control and
multiple sessions of subgingival debridement.
Because of the inevitable re-establishment of mi-
crobial plaque, the use of full-mouth chemical
plaque control is a reasonable approach, since it has
References
Grossman et al. (49)
Löe & Schiott (70)
Löe et al. (71)
DePaola et al. (24)
Gordon et al. (45)
Lamster et al. (62)
Cubells et al. (20)
Denepitiya et al. (23)
Garcia-Dodoy et al. (36)
Svatun et al. (108)
Svatun et al. (109)

been well established that subgingival microbiota
are known to arise from supragingival and subgingi-
val plaque as well as from other intraoral niches in
the tongue, tonsils and mucosa. Results of several
studies have shown that controlling supragingival
plaque for 2 to 4 weeks with twice daily rinses of
chlorhexidine or essential oils following scaling and
root planing promotes additional healing and gener-
ally prolongs the positive effects of mechanical ther-
apy (32).
Topical antimicrobial therapy is not without its
problems. Numerous studies have shown that very
high concentrations of many drugs are required in
order to obtain bactericidal activity against many of
the known periodontal pathogens. For example,
chlorhexidine digluconate must be in contact with
Porphyromonas gingivalis for 10 minutes at concen-
trations of 0.5% to 2% (86). Only two products cur-
rently exist that contain those concentrations, that
of 0.5% or 1.0% chlorhexidine gel (not available in
the United States) and the chlorhexidine chip (Per-
iochip) that contains 2% chlorhexidine. Povidone
iodine is another excellent topical antimicrobial that
is active against most bacteria, viruses, fungi and
some spores) but must be in contact with these
pathogens for at least 5 minutes at concentrations
between 0.5% and 10% to reach bactericidal activity
(12). Triclosan, which is a phenol-based anti-
microbial agent, also has good antimicrobial effects
when exposed to biofilms for an adequate period of
time to penetrate and kill pathogens in simulated
laboratory experiments. Chlorhexidine and triclosan
as well as essential oils have all been shown to be
capable of penetrating in vitro simulations of bac-
terial biofilms with vary degrees of success (120).
Table 4. Comparison of probing depth reduction in mm from several large clinical trials (n⬎100) using
local drug delivery
Scaling and
System root planing
Tetracycline fiber (nΩ105) 1.08
Newman et al. (83)
Chlorhexidine chip (nΩ447) 0.65
Jeffcoat et al. (54)
Minocycline gel (nΩ103) 1.70
Van Steenberghe et al. (117)
Metronidazole gel (nΩ105) 1.30
Ainamo et al. (2)
Doxycycline polymer (nΩ822) 1.30
Garrett et al. (37)
Source: adapted from Greenstein & Polson (47).
Nonsurgical periodontal therapy
Role of sustained local delivery
antimicrobial agents
In the last two decades a variety of locally delivered
antimicrobial agents have emerged that are designed
to enhance healing and stabilize periodontal health.
Several pharmaceutical agents have been shown to
suppress or eradicate pathogenic microbiota, im-
prove attachment levels, and reduce probing depths
and bleeding on probing (27, 37, 38, 54, 57, 90, 93,
106, 107, 112) (Table 4).
In disease sites that are more difficult to control,
local drug delivery devices such as chlorhexidine
chips (PerioChipTM) or 10% doxycycline gel (Atri-
doxTM) may be placed directly adjacent to the in-
fected site. The rationale for using an antimicrobial
agent is to chemically kill or reduce the plaques
within the biofilm in the pocket. By placing an anti-
biotic or antiseptic in direct contact with the root
surface, pathogenic organisms that were not access-
ible to mechanical removal by hand or power-driven
instruments can be reduced or eliminated.
Radvar et al. (93) and Kinane et al. (58) compared
three types of local delivery devices, tetracycline
fiber, metronidazole gel, and minocycline gel in
combination with scaling and root planing, to scal-
ing and root planing alone. All treatments improved
attachment levels over the 6-month testing period,
but there were no significant differences between
treatments (Table 5).
The most common patients selected for treatment
include adult periodontitis patients with isolated re-
current pockets over 5 mm that bleed on probing.
When scaling and root planing (periodontal debride-
ment) have not been successful, or sites have be-
Monotherapy Combined therapy
* 1.81
* 0.95
* 1.40
1.50 *
1.30 *
81
Drisko

Table 5. Clinical attachment level gain changes in clinical and microbial parameters follow-
comparing three local delivery treatments ing treatment with two of these products, metronid-
azole gel and minocycline gel, have been mixed.
6-week 3-month 6-month
Treatment attachment attachment attachment Some studies report rather small clinical but statisti-
group gain* gain. gain∧ cally significant changes and others show no clin-
Scaling alone 0.292 0.544 0.537 ically relevant adjunctive benefit when metronidazo-
(nΩ20)
le or minocycline gels are used in conjunction with
Scalingπ 0.323 0.417 0.573
minocycline gel scaling and root planing (2, 117) (Table 4).
(nΩ21) It should be noted that the additional mean prob-
Scalingπ 0.673 0.729 0.687 ing depth and attachment level changes seen with
tetracycline fiber
(nΩ19) many of these sustained-delivery antimicrobial
Scalingπ 0.404 0.543 0.541 agents are very modest, yet even small changes may
metronidazole be important to the overall course of the disease pro-
gel (nΩ19)
cess. If the infection is controlled and the attach-
Nonsignificant *PΩ0.121.
Nonsignificant .PΩ0.378. ment is stabilized following local drug delivery ther-
Nonsignificant ∧PΩ0.768.
Source: adapted from Kinane & Radvar (58). apy, this result, in of itself, should be considered a
resounding success, no matter how small the magni-
tude of change in attachment levels and probing
depths.
Table 6. Percentage frequency attachment level If disease activity is generalized and there are
gain/probing depth reduction Ø2 mm following many sites losing attachment, local delivery may not
two applications with doxycycline hyclate be the treatment of choice. In cases of juvenile peri-
(AtridoxA) over 9 months
odontitis or severe generalized adult periodontitis,
Month 4 Month 9 systemic antibiotic therapy may be a more efficient
Attachment level gain and cost effective choice of therapy. The bacteria as-
AtridoxA (nΩ371) 26% 30%
sociated with juvenile periodontitis and rapidly ad-
Scaling and root planing (nΩ404) 27% 31%
vancing adult periodontitis are frequently found in
Probing depth reduction
AtridoxA (nΩ826) 29% 37%
the connective tissues and are seldom eliminated
Scaling and root planing (nΩ1027) 32% 37%
without the addition of surgical debridement and
Source: adapted from Garrett (38).
systemic antibiotics. Locally delivered agents have
generally not been shown to be beneficial in these
cases (29).

come reinfected, local therapy is often indicated. The

primary contraindications for local drug delivery is
allergy to the agent and women who are pregnant or
lactating.
Although the doxycycline gel was first tested as a
stand-alone product, it is generally understood that
it should be used in conjunction with scaling and
root planing or as an adjunct to maintenance when
sites have not responded to previous scaling and
root planing. Nine-month controlled clinical trials
show that subgingival application of a resorbable
doxycycline gel (AtridoxA) results in significant mean
pocket reduction of 1.3 mm and 0.8 mm mean
attachment gain. The magnitude of change is
equivalent to that achieved by scaling and root plan-
ing in these 9-month studies (37) (Table 6).
Other sustained delivery devices containing anti-
biotic agents have been shown to be useful in en-
hancing the effect of scaling and root planing in
adult periodontitis patients. However, reports of
Role of systemic antibiotics in
nonsurgical therapy
While periodontal debridement with or without loc-
ally applied chemotherapeutic agents is usually af-
fective in controlling early to moderate periodontal
lesions, more advanced cases may require antibiotics
following periodontal debridement if the sites have
not responded as well as expected (29, 44, 54, 73, 76,
118). Nonsurgical therapy alone is not always suf-
ficient to contain the disease in patients diagnosed
with aggressive forms of adult periodontitis or early-
onset periodontitis.
Radiographic bone fill and periodontal regenera-
tion has been reported following periodontal de-
bridement and systemic antibiotics in some local-
ized juvenile periodontitis cases (80); however, these
case reports do not provide enough evidence to sup-

82
 Nonsurgical periodontal therapy

Table 7. Per patient mean change in probing
depth and clinical attachment gain after treat-
ment with adjunctive 20 mg doxcycline hyclate
(PeriostatA) at month 9
0–3 mm 4–6 mm Ø7 mm
Clinical attachment loss
PeriostatA 0.25 1.03
Placebo 0.20 0.86
Probing
PeriostatA 0.16 0.95
0.05 0.69
% sites Ø2 mm clinical attachment loss
PeriostatA 1.9% 1.3%
Placebo 2.2% 2.4%
Source: adapted from Caton (11).
port predictable regeneration of lost periodontium
following nonsurgical procedures in advanced peri-
odontitis patients.
Role of host-modulating drugs
Another new nonsurgical approach includes using a
systemic subantimicrobial dose of doxycycline (Per-
iostatA) that targets tissue breakdown by blocking
bacterial and host-derived enzymes associated with
loss of alveolar bone and connective tissue (19, 42).
Clinical trials have been carried out in which a num-
ber of different subantimicrobial doses of doxycy-
cline dosing regimens and placebo were compared
in patients administered a variety of adjunctive non-
surgical therapies. Ashley (5) has reported in a sum-
mary of several studies that as an adjunct to either
scaling or root planing or supragingival scaling and
dental prophylaxis, subantimicrobial doses of doxy-
cycline were shown to reduce collagenase levels in
both gingival crevicular fluid and gingival biopsies.
It was also shown to augment and maintain clinical
attachment level gains and probing depth reduc-
tions, reduction of bleeding on probing and preven-
tion of loss of alveolar bone height.
The effect of subantimicrobial doses of doxycy-
cline in conjunction with scaling and root planing
for treating adult periodontitis has been tested in
1.55 randomized controlled clinical trials of 9 months
1.17
and 12 months duration and found to increase
1.68 attachment and decrease probing depth (Table 7).
1.20 Although mean clinical differences between ther-
apies are small, deep sites Ø7 mm sites gained 1.55
0.3%
3.6% mm of attachment when 20 mg doses of doxycycline
were given twice a day following scaling and root
planing compared to 1.17 mm for scaling and root
planing alone. Only 0.3% of sites losing Ø2 mm were
in the doxycycline group, where 3.6% of deep sites lost
Ø2 mm attachment in the placebo group. Indications
and contraindications for treatment are shown in
Table 8. Opportunistic overgrowth of bacteria is not
seen using low-dose doxycycline. Since the dose is
subantimicrobial, it appears to be a safe regimen. No
overgrowth or replacement by opportunistic oral flora
occurs according to Thomas et al. (110).
Role of periodontal disease in
maintaining total health
Just as insulin control is essential to the long-term
health of diabetics, halting the inflammatory process
in periodontitis patients is essential to the long-term
periodontal health of the patient. It is also widely
recognized that periodontal infection is a significant
risk factor for patients with diabetes (4, 48). The
presence of untreated or poorly controlled peri-
odontal infection impacts negatively on the course
of glucose control in diabetic patients.
Periodontitis may also increase the risk of devel-

Table 8. Indications and contraindications for PeriostatA

Indications Contraindications
O Patients who have not responded to nonsurgical therapy O Allergy to tetracycline
O Patients with generalized recurrent sites of 5 mm or greater that bleed on
probing
O Patients with mild to moderate adult periodontitis and a high susceptibility to
rapid periodontal disease progression
Warnings: can cause fetal harm when given to pregnant women; may cause an increase in BUN but has not been reported to occur in patients with impaired
renal function; and phosensitivity may be manifested as an exaggerated sunburn.
Precautions include potential for overgrowth by opportunistic microorganisms although none have been reported to date; use of tetracyclines may increase
vaginal candidiasis; drug interactions include impaired absorption when taken with antacids containing aluminum, calcium or magnesium and by iron-
containing preparations as well as bismuth subsalicylate. Barbiturates, carbamazepine and phenytoin decreases the half-life of doxycycline; concurrent use
of tetracycline and Penthrane has been reported to result in fatal renal toxicity; concurrent use may render oral contraceptives less effective.

83
Drisko
oping cardiovascular disease including coronary ar-
tery disease and stroke as well as increasing the like-
lihood of having preterm, low-birth-weight babies
(4). Osteoporosis and osteopenia are less well under-
stood, but merit further consideration particularly
when patients present with advanced periodontitis
in the presence of decreased bone density (4).
Retention of teeth and
quality of life
In the last two decades, scientific discoveries have
led to the development of new over-the-counter
products that have greatly benefited the periodontal
patient’s ability to control their disease. The chal-
lenge to the profession, however, is to provide cost-
effective therapies that will have long-lasting effects;
preventive based treatments that are simple, and
provide good aesthetic results while maintaining an
intact dentition.
Systemic health is intimately related to oral health
and quality of life. Retaining one’s natural teeth im-
proves the quality of the life by sustaining the ability
to chew and digest food and by improving one’s abil-
ity to interact socially with their peers. Oral health is
vitally important to total health and overall quality
of life.
Summary
Regular home care by the patient in addition to pro-
fessional removal of subgingival plaque is generally
very effective in controlling most inflammatory peri-
odontal diseases. When disease does recur, despite
frequent recall, it can usually be attributed to lack of
sufficient supragingival and subgingival plaque con-
trol or to other risk factors that influence host re-
sponse, such as diabetes or smoking.
Causative factors contributing to recurrent disease
include deep inaccessible pockets, overhangs, poor
crown margins and plaque-retentive calculus. In
most cases, simply performing a thorough peri-
odontal debridement under local anesthesia will
stop disease progression and result in improvement
in the clinical signs and symptoms of active disease.
If however, clinical signs of disease activity persist
following thorough mechanical therapy, such as in-
creased pocket depths, loss of attachment and
bleeding on probing, other pharmacotherapeutic
therapies should be considered. Augmenting scaling
84
and root planing or maintenance visits with adjunc-
tive chemotherapeutic agents for controlling plaque
and gingivitis could be as simple as placing the pa-
tient on an antimicrobial mouthrinse and/or tooth-
paste with agents such as fluorides, chlorhexidine or
triclosan, to name a few. Since supragingival plaque
reappears within hours or days after its removal, it is
important that patients have access to effective
alternative chemotherapeutic products that could
help them achieve adequate supragingival plaque
control. Recent studies, for example, have docu-
mented the positive effect of triclosan toothpaste on
the long-term maintenance of both gingivitis and
periodontitis patients.
Daily irrigation with a powered irrigation device,
with or without an antimicrobial agent, is also useful
for decreasing the inflammation associated with gin-
givitis and periodontitis. Clinically significant
changes in probing depths and attachment levels are
not usually expected with irrigation alone. Recent re-
ports, however, would indicate that, when daily irri-
gation with water was added to a regular oral hy-
giene home regimen, a significant reduction in prob-
ing depth, bleeding on probing and Gingival Index
was observed. A significant reduction in cytokine
levels (interleukin-1b and prostaglandin E2, which
are associated with destructive changes in in-
flammed tissues and bone resorption (21)) also oc-
curs.
If patient-applied antimicrobial therapy is insuf-
ficient in preventing, arresting, or reversing the dis-
ease progression, then professionally applied anti-
microbial agents should be considered including
sustained local drug delivery products. Other, more
broadly based pharmacotherapeutic agents may be
indicated for multiple failing sites. Such agents
would include systemic antibiotics or host modulat-
ing drugs used in conjunction with periodontal de-
bridement.
More aggressive types of juvenile periodontitis or
severe rapidly advancing adult periodontitis usually
require a combination of surgical intervention in
conjunction with systemic antibiotics and generally
are not controlled with nonsurgical anti-infective
therapy alone.
It should be noted, however, that, to date, no
home care products or devices currently available
can completely control or eliminate the pathogenic
plaques associated with periodontal diseases for ex-
tended periods of time. Daily home care and fre-
quent recall are still paramount for long-term suc-
cess. Nonsurgical therapy remains the cornerstone
of periodontal treatment. Attention to detail, patient

compliance and proper selection of adjunctive anti-
microbial agents for sustained plaque control are
important elements in achieving successful long-
term results. Frequent re-evaluation and careful
monitoring allows the practitioner the opportunity
to intervene early in the disease state, to reverse or
arrest the progression of periodontal disease with
meticulous nonsurgical anti-infective therapy.
References
1. Adriaens PA, DeBoever JA, Loesche WJ. Bacterial invasion
in root cementum and radicular dentin of periodontally
diseased teeth in humans. J Periodontol 1988: 59: 222–
230.
2. Ainamo J, Lie T, Ellingsen BH, Hansen BF, Johansson LA,
Karring T, Kisch J, Paunio K, Stoltze K. Clinical responses
to subgingival application of a metronidazole 25% gel
compared to the effects of subgingival scaling in adult
periodontitis. J Clin Periodontol 1992: 19: 723–729.
3. Anonymous. Tobacco use and the periodontal patient. J
Periodontol 1999: 70: 1419–1427.
4. Anonymous. Periodontal disease as a potential risk factor
for systemic diseases. J Periodontol 1998: 69: 841–850.
5. Ashley RA. Clinical trials of a matrix metalloproteinase in-
hibitor in human periodontal disease. SDD Clinical Re-
search Team. Ann N Y Acad Sci 1999: 878: 335–346.
6. Badersten A, Nilvéus R, Egelberg J. Effect of nonsurgical
periodontal therapy. I. Moderately advanced peri-
odontitis. J Clin Periodontol 1981: 8: 57–72.
7. Badersten A, Nilvéus R, Egelberg J. Effect of nonsurgical
periodontal therapy. II. Severely advanced periodontitis. J
Clin Periodontol 1984: 11: 63–76.
8. Baehni PC, Thilo B, Chapuis B, Pernet D. Effects of ultra-
sonic and sonic scalers on dental plaque microflora in
vitro and in vivo. J Clin Periodontol 1992: 19: 455–459.
9. Bollen CML, Mongardini C, Papaioannou W, Van Steeng-
erghe D, Quirynen M. The effect of a one-stage full-mouth
disinfection on different intra-oral niches. Clinical and
microbiological observations. J Clin Periodontol 1998: 25:
55–66.
10. Boretti G, Zappa U, Graf H, Case D. Short-term effects of
phase 1 therapy on crevicular cell populations. J Peri-
odontol 1996: 66: 235–240.
11. Caton JG. Evaluation of PeriostatA for patient manage-
ment. Compendium Contin Educ Dent 1998: 20: 451–460.
12. Caufield PW, Allen DN, Chiders NK. In vitro susceptibilit-
ies of suspected periodontopathic anaerobes as deter-
mined by membrane transfer assay. Antimicrob Agents
Chemother 1987: 31: 1989–1993.
13. Checchi L, Pelliccioni GA. Hand versus ultrasonic instru-
mentation in the removal of endotoxins from root sur-
faces in vitro. J Periodontol 1988: 59: 398–402.
14. Cheetham WA, Wilson M, Kieser JB. Root surface debride-
ment – an in vitro assessment. J Clin Periodontol 1991: 15:
288–292.
15. Clifford LR, Needleman IG, Chan YK. Comparison of peri-
odontal pocket penetration by conventional and microul-
rasonic inserts. J Clin Periodontol 1999: 26: 124–130.
Nonsurgical periodontal therapy
16. Cobb CM. Non-surgical pocket therapy: mechanical. Ann
Periodontol 1996: 1: 443–490.
17. Cobb CM. Oral biofilms in health and disease. In: New-
man HN, Wilson M, ed. The mechanical control of sub-
gingival plaque. Dental plaque revisited. London: East-
man Dental Institute, University College, 1999: 457–502.
18. Copulos TA, Low SB, Walker CB, Trebilcock YY, Hefti AF.
Comparative analyses between a modified ultrasonic tip
and hand instruments on clinical parameters of peri-
odontal disease. J Periodontol 1993: 64: 694–700.
19. Crout RJ, Lee HM, Schroeder K, Crout H, Ramamurthy
NS, Wiener M, Golub LM. The ‘‘cyclic’’ regimen of low-
dose doxycycline for adult periodontitis: a preliminary
study. J Periodontol 1996: 67: 506–514.
20. Cubells AB, Dalmau LB, Petrone ME, Chakins P, Volpe AR.
The effect of a triclosan/copolymer/fluoride dentifrice on
plaque formation and gingivitis. J Clin Dent 1991: 2: 63–
69.
21. Cutler CW, Stanford TW, Abraham C, Cederberg RA,
Boardman TJ, Ross C. Clinical benefits of oral irrigation
for periodontitis are related to reduction of pro-inflam-
matory cytokine levels and plaque. J Clin Periodontol
2000: 27: 134–143.
22. De la Rosa M, Guerra JZ, Johnston DA, Radike AW. Plaque
growth and removal with daily toothbrushing. J Peri-
odontol 1979: 50: 661–664.
23. Denepitiya JL, Fine DH, Singh S, DeVizio W, Volpe AR,
Person P. Effect upon plaque formation and gingivitis of
a triclosan/copolymer/fluoride dentifrice: a 6-month
clinical study. Am J Dent 1992: 5: 307–311.
24. DePaola LG, Overholser CD, Meiller TF, Minah GE, Nie-
haus C. Chemotherapeutic inhibition of supragingival
dental plaque and gingivitis development. J Clin Peri-
odontol 1989: 16: 311–315.
25. Dragoo MR. A clinical evaluation of hand and ultrasonic
instruments on subgingival debridement. I. With un-
modified and modified ultrasonic inserts. Int J Peri-
odontics Restorative Dent 1992: 12: 310–323.
26. Drisko CL, Killoy WJ. Scaling and root planing: removal of
calculus and subgingival organisms. Curr Opin Dent 1991:
1: 74–80.
27. Drisko CL, Cobb CM, Killoy WJ, Michalowicz BS,
Pihlstrom BL, Lowenguth RA, Caton JG, Encarnacion M,
Knowles M, Goodson JM. Evaluation of periodontal treat-
ments using controlled-release tetracycline fibers: clinical
response. J Periodontol 1995: 19: 692–699.
28. Drisko CL, Lewis LH. Ultrasonic instruments and anti-
microbial agents in supportive periodontal treatment and
retreatment of recurrent or refractory periodontitis. Peri-
odontol 2000 1996: 12: 90–115.
29. Drisko CH. Non-surgical pocket therapy: Pharmacothera-
peutics. Ann Periodontol 1996: 1: 491–566.
30. Engebretson SP, Lamster IB, Herrera-Abreu M, Celenti TS,
Timms JM, Chaudhary AG, di Giovine FS, Kornman KS.
The influence of interleukin gene polymorphism on ex-
pression of interleukin-1beta and tumor necrosis factor-
alpha in periodontal tissue and gingival crevicular fluid. J
Periodontol 1999: 70: 567–573.
31. Ernst CP, Prockl K, Willershausen B. The effectiveness and
side effects of 0.1% and 0.2% chlorhexidine mouthrinses:
a clinical study. Quintessence Int 1998: 29: 443–448.
32. Fine DH, Letizia JK, Mandel ID. The effect of rinsing with
Listerine antiseptic on the properties of developing dental
plaque. J Clin Periodontol 1985: 12: 660–666.
85
Drisko
33. Fine DH. Chemical agents to prevent and regulate plaque
development. Periodontol 2000 1995: 8: 87–107.
34. Forabosco A, Galetti R, Spinato S, Calao P, Casolari C. A
comparative study of a surgical method of scaling and
root planing using the OdontosonA. J Clin Periodontol
1996: 23: 611–614.
35. Furuichi Y, Rosling B, Volpe AR, Lindhe J. The effect of a
triclosan/copolymer dentifrice on healing after non-sur-
gical treatment of recurrent periodontitis. J Clin Peri-
odontol 1999: 26: 63–66.
36. Garcia-Godoy F, DeVizio W, Volpe AR, Ferlauto RJ, Miller
JM. Effect of a triclosan copolymer/fluoride dentifrice on
plaque formation and gingivitis: a 7-month clinical study.
Am J Dent 1990: 3: 515–526.
37. Garrett S, Johnson L, Drisko CH, Adams DF, Bandt C, Beis-
wanger B, Bogle G, Donly K, Hallmon WW, Hancock EB,
Hanes P, Hawley CE, Kiger R, Killoy W, Mellonig JT, Polson
A, Raab FJ, Ryder M, Stoller NH, Wang HL, Wolinsky LE,
Evans GH, Harrold CQ, Arnold RM, Atack DF, Fitzgerald
B, Hill M, Isaacs RL, Naser HF, Newell DH, MacNeil R,
MacNeil S, Spolsky VW, Duke SP, Southard GL. Two multi-
center clinical studies evaluating locally delivered doxycy-
cline hyclate, placebo control, oral hygiene, and scaling
and root planing in the treatment of periodontitis. J Peri-
odontol 1999: 70: 490–503.
38. Garrett S. Local delivery of doxycycline for the treatment
of periodontitis. Compendium Contin Dent Educ 1998:
20: 437–446.
39. Gjermo P, Bonesvoll P, Rölla G. Relationship between
plaque-inhibiting effect and retention of chlorhexidine
in the human oral cavity. Arch Oral Biol 1974: 19: 1031–
1034.
40. Gellin RG, Miller MC, Javed T, Engler WO, Mishkin DJ. The
effectiveness of the Titan-S sonic scaler versus curettes in
the removal of subgingival calculus. J Periodontol 1986:
57: 672–680.
41. Giuliana G, Ammatuna P, Pizzo G, Capone F, D’Angelo M.
Occurrence of invading bacteria in radicular dentin of
periodontally diseased teeth: microbiological findings. J
Clin Periodontol 1997: 24: 478–485.
42. Golub LM, Lee HM, Ryan ME, Giannobile WV, Payne J,
Sorsa T. Tetracyclines inhibit connective tissue breakdown
by multiple non-antimicrobial mechanisms. Adv Dent Res
1998: 12: 12–26.
43. Goodson MA, Cugini MA, Kent RL, Armitage GC, Cobb
CM, Fine D, Fritz ME, Green E, Imoberdorf MJ, Killoy WJ.
Multicenter evaluation of tetracycline fiber therapy: II.
Clinical response. J Periodontal Res 1991: 26: 371–379.
44. Gordon JM, Walker CB, Lamster I, West T, Socransky S,
Seiger M, Fasciano R. Evaluation of clindamycin hydro-
chloride in refractory periodontitis: 12-month results. J
Periodontol 1985: 56(suppl): 75–80.
45. Gordon J, Lamster I, Seiger M. Efficacy of Listerine anti-
septic in inhibiting the development of plaque and gingi-
vitis. J Clin Periodontol 1985: 12: 697–704.
46. Greenstein G. Conceptualization vs reality in the treat-
ment of periodontal diseases. Compendium Contin Dent
Educ 1998: 20: 410–425.
47. Greenstein G, Polson A. The role of local drug delivery in
the management of periodontal diseases: A comprehen-
sive review. J Periodontol 1998: 69: 507–520.
48. Grossi SG, Genco RJ. Periodontal disease and diabetes
mellitus: a two-way relationship. Ann Periodontal 1998: 3:
51–61.
86
49. Grossman E, Reiter G, Sturzenberger OP, De La Rosa M,
Dickinson TD, Ferretti GA, Ludlam GE, Meckel HH. Six-
month study of the effects of a chlorhexidine mouthrinse
on gingivitis in adults. J Periodontol Res 1986: 21: 33–38.
50. Hancock EB. Prevention. Ann Periodontol 1996: 1: 234–
241.
51. Hill RW, Ramfjord S, Morrison EC, Appleberry EA, Caffes-
se RG, Kerry GJ, Nissle RR. Four types of periodontal treat-
ment compared over two years. J Periodontol 1981: 52:
655–662.
52. Holbrook TE, Low SB. Power-driven scaling and polishing
instruments. In: Hardin J, ed. Clark’s clinical dentistry.
Volume 3, Chapter 5A. Philadelphia: JB Lippincott, 1991:
1–24.
53. James J, Sayers NM, Drucker DB, Hull PS. Effect of to-
bacco products on the attachment and growth of peri-
odontal ligament fibroblasts. J Periodontol 1999: 70: 518–
525.
54. Jeffcoat M, Bray KS, Cianico SG, Dentino AR, Fine DH,
Gordon JM, Gunsolley JC, Killoy WJ, Lowenguth RA,
Magnusson NI, Offenbacher S, Palcanis KG, Proskin HM,
Finkelman RD, Flashner M. Adjunctive use of a subgingi-
val controlled-release chlorhexidine chip reduces probing
depth and improves attachment level compared with
scaling and root planing alone. J Periodontol 1998: 69:
989–997.
55. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK.
Long-term evaluation of periodontal therapy. I. Response
to 4 therapeutic modalities. J Periodontol 1996: 67: 93–
102.
56. Kawanami M, Sugaya T, Kato S, Iinuma K, Tate T, Hannan
MA, Kato H. Efficacy of an ultrasonic scaler with a peri-
odontal probe-type tip in deep periodontal pockets. Adv
Dent Res 1988: 2: 405–410.
57. Kerry G. Tetracycline-loaded fibers as adjunctive treat-
ment in periodontal disease. J Am Dent Assoc 1994: 12:
1199–1203.
58. Kinane DF, Radvar M. A six-month comparison of three
periodontal local antimicrobial therapies in persistent
periodontal pockets. J Periodontol 1999: 70: 1–7.
59. Kocher T, Ruhling A, Momsen H, Plagmann H-C. Effec-
tiveness of subgingival instrumentation with power-
driven instruments in the hands of experienced and inex-
perienced operators. A study on manikins. J Clin Peri-
odontol 1997: 24: 498–504.
60. Kocher T, Gutsche C, Plagmann H-C. Instrumentation of
furcation with modified sonic scaler inserts: study on
manikins. Part I. J Clin Periodontol 1998: 25: 388–393.
61. Kocher T, Tersic-Orth B, Plagmann H-C. Instrumentation
of furcation with modified sonic scaler inserts. A study on
manikins. Part II. J Clin Periodontol 1998: 25: 451–456.
62. Lamster IB, Alfano MC, Seiger MC, Gordon JM. The effect
of Listerine antiseptic on reduction of existing plaque and
gingivitis. Clin Prev Dent 1983: 5: 12–16.
63. Laurell L. Periodontal healing after scaling and root plan-
ning with the Kavo Sonicflex and Titan-S sonic scalers.
Swed Dent J 1990: 14: 171–177.
64. Laurell L, Pettersson B. Periodontal healing after treat-
ment with either the Titan-S sonic scaler or hand instru-
ments. Swed Dent J 1988: 12: 187–192.
65. Lie T, Meyer L. Calculus removal and loss of tooth sub-
stance in response to different periodontal instruments:
A scanning electron microscope study. J Clin Periodontol
1977: 4: 250–262.

66. Lindhe J, Nyman S. Long-term maintenance of patients
treated for advanced periodontal disease. J Clin Peri-
odontol 1984: 11: 504–514.
67. Lindhe J, Rosling B, Socransky SS, Volpe AR. The effect of
triclosan containing dentifrice on established plaque and
gingivitis. J Clin Periodontol 1993: 20: 227–334.
68. Listgarten MA, Lindhe J, Helldén LB. Effect of tetracycline
and/or scaling on human periodontal disease. J Clin Peri-
odontol 1978: 5: 246–271.
69. Listgarten MA, Schifter CC, Laster L. 3-year longitudinal
study of the periodontal status of an adult population
with gingivitis. J Clin Periodontol 1985: 12: 225–238.
70. Löe H, Schiott CR. The effect of mouthrinses and topical
application of chlorhexidine on the development of den-
tal plaque and gingivitis in man. J Periodontal Res 1970:
5: 79–83.
71. Löe H, Schiott CR, Glavind L, Karring T. Two years’ oral
use of chlorhexidine in man. I. General design and clin-
ical effects. J Periodontal Res 1976: 11: 135–144.
72. Loesche WJ, Laughon BE. Role of spirochetes in peri-
odontal disease In: Genco RJ, Mergenhagen SE, ed. Host
parasite interactions in periodontal disease. Washington,
DC: Am Soc Microbiol, 1982: 62–75.
73. Loesche WJ, Giordano JR, Hujoel P, Schwarcz J, Smith BA.
Metronidazole in periodontitis: reduced need for surgery.
J Periodontol 1992: 19: 103–112.
74. Loos B, Kiger R, Engelberg J. An evaluation of basic peri-
odontal therapy using sonic and ultrasonic scalers. J Clin
Periodontol 1987: 14: 29–33.
75. McGregor IDM, Rugg-Gunn AJ, Gordon PH. Plaque levels
in relation to the number of toothbrushing strokes in un-
instructed English schoolchildren. J Periodontol 1986: 1:
577–582.
76. Magnusson I, Clark WB, Low SB, Maruniak J, Marks RG,
Walker CB. Effects of nonsurgical periodontal therapy
combined with adjunctive antibiotics in subjects with re-
fractory periodontal disease. I. Clinical results. J Clin Peri-
odontol 1989: 16: 647–653.
77. Magnusson I, Lindhe J, Yoneyama T, Liljenberg B. Recol-
onization of a subgingival microbiota following scaling in
deep pockets. J Clin Periodontol 1984: 11: 193–207.
78. Mandel ID. Antimicrobial mouthrinses: overview and up-
date. J Am Dent Assoc 1994: 125(suppl 2): 2s–2s10.
79. Maruniak J, Clark WB, Walker CB, Magnusson I, Marks
RG, Taylor M, Clouser B. The effect of 3 mouthrinses on
plaque and gingivitis development. J Clin Periodontol
1992: 19: 19–23.
80. Mattout P, Moskow BS, Fourel J. Repair potential in local-
ized juvenile periodontitis. A case in point. J Periodontol
1990: 61: 653–660.
81. Michalowicz BS. Genetic and inheritable risk factors in
periodontal disease. J Periodontol 1993: 65: 479–488.
82. Michalowicz BS, Wolff LF, Klump D, Hinrichs JE, Aeppli
DM, Bouchard TJ Jr, Pihlstom BL. Periodontal bacteria in
adult twins. J Periodontol 1999: 70: 263–273.
83. Newman MG, Kornman KS, Doherty FM. A 6-month
multicenter evaluation of adjunctive tetracycline fiber
therapy used in conjunction with scaling and root planing
in maintenance patients: clinical results. J Periodontol
1994: 65: 685–691.
84. Nyman S, Sarhed G, Ericson I, Gottlow J, Karring T. Role
of ‘‘diseased’’ root cementum in healing following treat-
ment of periodontal disease. J Clin Periodontol 1986: 21:
496–503.
Nonsurgical periodontal therapy
85. Oda S, Ishikaqa I. In vitro effectiveness of a newly de-
signed ultrasonic scaler tip for furcation areas. J Peri-
odontol 1989: 60: 634–639.
86. Oosterwaal PHM, Mikx FHM, van den Brink ME, Renggli
HH. Bactericidal concentration of chlorhexidine-digluco-
nate, amine-fluoride gel and stannous fluoride gel for
subgingival bacteria tested in serum at short contact
times. J Periodontal Res 1989: 24: 155–160.
87. Page R, Offenbacher S, Schroeder HE, Seymour GJ, Korn-
man K. Advances in the pathogenesis of periodontitis:
summary of developments, clinical implications and fu-
ture directions. Periodontol 2000 1997: 14: 216–248.
88. Pihlstrom BL, Ortis-Campos C, McHugh RB. A ran-
domized four year study of periodontal therapy. J Peri-
odontol 1981: 52: 227–242.
89. Pihlstrom BL, McHugh RB, Oliphant TH. Molar and non-
molar teeth compared over 6.5 years following two
methods of periodontal therapy. J Periodontol 1984: 55:
499–504.
90. Polson AM, Garrett S, Stoller NH, Bandt CL, Hanes PJ,
Killoy WJ, Southard GL, Duke SP, Bogle GC, Drisko CH,
Friesen LR. Multi-center comparative evaluation of sub-
gingivally delivered sanguinarine and doxycycline in the
treatment of periodontitis. II. Clinical results. J Peri-
odontol 1997: 68: 119–126.
91. Quirynen M, Bollen CML, Vandeherckhove BNA, Dekeys-
er C, Papaioannou W, Eyssen H. Full-vs. partial mouth
disinfection in the treatment of periodontal infections:
short-term clinical and microbiological observations. J
Dent Res 1995: 67: 1456–1467.
92. Rabbani GM, Ash MM, Caffesse RG. The effectiveness of
subgingival scaling and root planing in calculus removal.
J Periodontol 1981: 52: 119–123.
93. Radvar M, Pourtaghi N, Kinane DF. Comparison of 3 peri-
odontal local antibiotic therapies in persistence peri-
odontal pockets. J Periodontol 1996: 67: 860–865.
94. Ramfjord SP, Caffesse RG, Morrison EC, Hill RW, Kerry GJ,
Appleberry EA, Nissle RR, Stults DL. Four modalities of
periodontal treatment compared over 5 years. J Clin Peri-
odontol 1987: 14: 445–452.
95. Reynolds M, Lavigne D, Minah G, Suzuki J. Clinical effects
of simultaneous ultrasonic scaling and subgingival irri-
gation with chlorhexidine: Mediating influence of peri-
odontal probing depth. J Clin Periodontol 1992: 19: 595–
600.
96. Rosling RB, Slots J, Webber RL, Christersson LA, Genco RJ.
Microbiological and clinical effects of topical subgingival
antimicrobial treatment on human periodontal disease. J
Clin Periodontol 1983: 10: 487–514.
97. Rosling BG, Slots J, Christersson LA, Genco RJ. Topical
anticicrobial therapy and diagnosis of subgingival bac-
teria in the management of inflammatory periodontal
disease. J Clin Periodontol 1986: 13: 975–981.
98. Ryder MI, Pons B, Adams D, Beiswanger B, Blanco V,
Bogle G, Donly K, Hallmon W, Hancock EB, Hanes P,
Hawley C, Johnson L, Wang HL, Wolinsky L, Yukna R,
Polson A, Carron G, Garrett S. Effects of smoking on lo-
cal delivery of controlled-release doxycycline as com-
pared to scaling and root planing. J Clin Periodontol
1999: 26: 683–691.
99. Sbordone L, Ramaglia L, Guletta E, Iacono V. Recoloniza-
tion of the subgingival microflora after scaling and root
planing in human periodontitis. J Periodontol 1990: 61:
579–584.
87
Drisko
100. Sherman PR, Hutchens LH Jr, Jewson LG, Moriarty JM,
Greco GW, McFall WT Jr. The effectiveness of subgingival
scaling and root planing. I. Clinical detection of residual
calculus. J Periodontol 1990: 61: 3–8.
101. Sherman PR, Hutchens LH Jr, Jewson LG. The effective-
ness of subgingival scaling and root planing. II. Clinical
responses related to residual calculus. J Periodontol 1990:
61: 9–15.
102. Smart GJ, Wilson M, Davies EH, Kieser JB. The assessment
of ultrasonic root surface debridement by determination
of residual endotoxin levels. J Clin Periodontol 1990: 17:
174–178.
103. Slots J. Subgingival microflora and periodontal disease. J
Clin Periodontol 1979: 6: 351–382.
104. Slots J, Ting M. Actinobacillus actinomycetemcomitans
and Porphyromonas gingivalis in human periodontal dis-
ease: occurrence and treatment. Periodontol 2000 1999:
20: 82–121.
105. Soskolne WA, Heasman PA, Stabholz A, Smart GJ, Palmer
M, Flashner M, Newman HN. Sustained local delivery of
chlorhexidine in the treatment of periodontitis: a multi-
center study. J Periodontol 1997: 68: 32–38.
106. Soskolne WA, Chajek T, Flashner M, Landau I, Stabholtz
A, Koolatch B, Lerner EI. An in vivo study of the chlorhex-
idine release profile of the PerioChip in the gingival cre-
vicular fluid, plasma and urine. J Clin Periodontol 1998:
25: 1017–1021.
107. Stelzel M, Flores-de-Jacoby L. Metronidazole gel appli-
cation as an adjunct to subgingival scaling. J Dent Res
1996: 75(spec issue): 159(abstr 1129).
108. Svatun B, Saxton CA, Rolla G, van der Ouderaa FGH. A 1-
year study on the efficacy of a dentifrice containing zinc
citrate and triclosan to maintain gingival health. Scand J
Dent Res 1989: 97: 242–246.
109. Svatun B, Saxton CA, Rolla G. Six month study on the ef-
fect of a dentifrice containing zinc citrate and triclosan
on plaque, gingival health and calculus. Scand J Dent Res
1990: 98: 301–334.
110. Thomas JG, Metheny RJ, Karakiozis JM, Wetzel JM, Crout
RJ. Long-term sub-antimicrobial doxycycline (Periostat)
as adjunctive management in adult periodontitis: effects
on subgingival bacterial population dynamics. Adv Dent
Res 1998: 12: 32–39.
111. Thilo BE, Baehni PC. Effect of ultrasonic instrumentation
on dental plaque microflora in vitro. J Periodontal Res
1987: 22: 518–521.
112. Timmermans MF, van der Weijden GA, van Steenbergen
TJM. Evaluation of the long-term efficacy and safety of
88
locally applied minocycline in adult periodontitis pa-
tients. J Clin Periodontol 1996: 23: 707–716.
113. Tonetti MS. Cigarette smoking and periodontal diseases:
etiology and management of disease. Ann Periodontol
1998: 3: 88–101.
114. Torfason T, Kiger R, Selvig KA, Egelberg J. Clinical im-
provement of gingival conditions following ultrasonic ver-
sus hand instrumentation of periodontal pockets. J Clin
Periodontol 1979: 6: 165–176.
115. Triratana K, Tuongratanaphan S, Rustogi KN, Petrone
M, Volpe AR, Petrone D. Plaque/gingivitis effect of a
triclosan/copolymer dentifrice. J Dent Res 1993: 72:
334–abstr.
116. Vandekerckhove BNA, Bollen CML, Dekeyser C, Darius P,
Quirynen M. Full- versus partial-mouth disinfection in
the treatment of periodontal infections. Long-term clin-
ical observations of a pilot study. J Periodontol 1996: 67:
1251–1259.
117. van Steenberghe D, Bercy P, Kohl J, De Boever J, Adriaens
P, Vanderfaeillie A, Adriaenssen C, Rompen E, De Vree H,
McCarthy EF, Vandenhoven G. Subgingival minocycline
hydrochloride ointment in moderate to severe chronic
adult periodontitis: a randomized, double-blind, vehicle
controlled, multicenter study. J Periodontol 1993: 64: 637–
644.
118. Van Winkelhoff AJ, Tijhof CJ, de Graaff J. Microbiological
and clinical results of metronidazole plus amoxicillin
therapy in actinombacillus actinomycetemcomitans-as-
sociated periodontitis. J Periodontol 1992: 63: 52–57.
119. Waerhaug J. Healing of the dentoepithelial junction fol-
lowing subgingival plaque control. II. As observed in hu-
man biopsy material. J Periodontol 1978: 49: 1–8.
120. Wilson M, Pratten J. Laboratory assesment of anti-
microbials for plaque-related diseases. Oral biofilms in
health and disease. In: Newman HN, Wilson M, ed. The
mechanical control of subgingival plaque. Dental plaque
revisited. London: Eastman Dental Institute, University
College, 1999: 503–521.
121. Wilson TG Jr. Supportive periodontal treatment introduc-
tion-definition, extent of need, therapeutic objectives, fre-
quency and efficacy. Periodontol 2000 1996: 12: 11–15.
122. Wilson TG Jr. Compliance and its role in periodontal ther-
apy. Periodontol 2000 1996: 12: 16–23.
123. Yukna RA, Scott JB, Aichelmann-Reidy ME, LeBlanc DM,
Mayer ET. Clinical evaluation of the speed and effective-
ness of subgingival calculus removal on single-rooted
teeth with diamond-coated ultrasonic tips. J Periodontol
1997: 68: 436–442.