Long‐term large population‐based and practice‐based studies on the efficacy of periodontal therapies including both clinical and patient‐reported outcomes (PROs) need to be initiated, which include the understanding that periodontitis is a complex disease with variation of inflammatory responses due to environment, (epi)genetics, lifestyle and ageing. In essence, although the literature is abundant on the plain presentation of probing measures in numerous clinical studies on the site level, tooth level and type of tooth with or without severe furcation problems, surprisingly, virtually absent are reports that use these commonly applied periodontal probing measures (pockets ≤4 mm, residual probing depth, change in probing depth, change in clinical attachment level or bleeding on probing) after completion of the active periodontal treatment, subsequently to be used as new baseline measures for the study of the four patient endpoints considered in this review. 1. Moreover, complete records of diagnosis, treatment… Material and methods: Eighty-four patients with AgP were re-evaluated after a mean period of 10.5 years of supportive periodontal therapy (SPT). Efficacy of alternative or additional methods to professional mechanical plaque removal during supportive periodontal therapy: A systematic review and meta‐analysis Leonardo Trombelli … The writing of this paper was funded by the authors' institutions. initial or cause-related therapy) with or without adjunctive anti- microbials and with or without surgical treatment. When active periodontal disease is present, a special deep cleaning, called “scaling and root planing,” will be presented as a part of your treatment … 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). Bruno G. Loos, Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), Gustav Mahlerlaan 3004, 1081 LA Amsterdam, The Netherlands. APT means Active Periodontal Therapy. In that respect, also a recent systematic review concluded that there is insufficient evidence to determine the superiority of different periodontal therapy protocols or adjunctive strategies to improve tooth survival during the periodontal maintenance phase (Manresa, Sanz‐Miralles, Twigg, & Bravo, 2018); no trials evaluated supportive periodontal therapy versus monitoring only. This review is limited to the most widely used periodontal probing measures, and therefore, the use of dental radiographs, microbiological and other biological or biochemical measures is not included. Calculus present under the gum line cannot be removed by brushing harder. If you do not receive an email within 10 minutes, your email address may not be registered, Use the link below to share a full-text version of this article with your friends and colleagues. However, it is unclear what constitutes tangible treatment outcomes for the patients. Are dental diseases examples of ecological catastrophes? Design long‐term large population‐based studies on the efficacy of periodontal therapies employing both tangible clinical outcomes and PROs that consider today's understanding that periodontitis is a complex inflammatory disease, probably episodic in nature and with multiple causal factors that play a role simultaneously and interact with each other. 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. Therefore, in addition to tangible clinical outcome measures such as tooth survival, PROs including oral health‐related quality of life, continuous functionality and aesthetic appearance are important. 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). 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). Aims: To investigate the incidence and reasons for tooth loss during active periodontal therapy (APT) and periodontal maintenance (PM) in a specialist institution. Position paper on endpoints of active periodontal therapy for designing treatment guidelines. Update of medical and dental histories. An endpoint is an event or outcome that can be measured objectively to determine whether an intervention being studied is beneficial (Hujoel & DeRouen, 1995). 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. AIM: To assess tooth loss in periodontally compromised patients 20 years after active periodontal therapy (APT) and to detect potential influencing factors for tooth loss on patient level. Furthermore, there are few data employing PROs. 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. DNA‐probes, measurements on deoxyribonucleic acid originating from specific target bacterial species. Periodontal Therapy Your oral health and general wellbeing is our focus and our specialist team can provide you with all types of periodontal therapy to ensure you get the care you deserve. initial or cause‐related therapy) with or without adjunctive antimicrobials and with or without surgical treatment. Guidelines will need to increasingly recognize and embrace the heterogeneity amongst patients and, therefore, the individuality of patients' response to therapy, and in addition, to the changes within an individual over time. Laser Assisted New Attachment Protocol (LANAP®). Loss of clinical attachment level was defined as ≥1.5 mm compared to 3‐month post‐treatment data by linear regression analysis or as ≥2 mm between baseline and study endpoint measurement. Therefore, we supplemented the electronic search with studies retrieved from reference lists. Position paper on endpoints of active periodontal therapy for designing treatment guidelines. Thus, periodontitis patients with a low proportion of deep residual pockets after initial therapy are more likely to have stability of clinical attachment level over a follow‐up time of ≥12 months (Renvert & Persson, 2002). However, the majority of patients will require ongoing maintenance therapy to sustain health. The tooth was the unit of analysis. Retrospectively analysed tooth loss in periodontally compromised patients: Long-term results 10 years after active periodontal therapy-Patient-related outcomes. Scaling & Root Planing . 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. 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. Have you found the page useful? therapy to establish the best possible periodontal health is indicated. 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). The expert and highly experienced periodontal research community will need to work to develop studies that can more closely guide such treatment choices. Furcation involvement (FI) was assessed clinically at start of periodontal therapy and assigned according to Hamp et al. Periodontal Treatments and Procedures Periodontists are dentistry's e xperts in treating periodontal disease. 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. Periodontal disease affects the gums, ligaments and bone that support your teeth. Aims: To investigate the incidence and reasons for tooth loss during active periodontal therapy (APT) and periodontal maintenance (PM) in a specialist institution. Long-term outcomes after active and supportive periodontal therapy. How are for an individual patient after active periodontal therapy (a) stability of clinical attachment level, (b) tooth survival, (c) need for re‐treatment or (d) oral health‐related quality of life, related to commonly and easily applied periodontal probing measures, that is generalized pocket closure (probing depths ≤4 mm), a certain patient level of residual pockets (e.g., residual probing depths ≥5 mm), a given level of accumulated changes in probing depth and in clinical attachment level, and a patient‐based value for number or proportion of sites showing bleeding on probing. A total of 94 papers were retrieved. The assessment of clinical attachment level changes over time in periodontal sites and averaged for per patient, having received no or any kind of therapy, the relation with histological attachment levels and the appreciation of this measurement for the evaluation of periodontal therapies at the site‐ and/or patient level (tangible patient outcomes) have been critically addressed (Ryan, 2005). 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). In this review, we focused on tangible endpoints after active periodontal therapy. Indeed, those residual pockets after active periodontal therapy have been associated to the risk of periodontitis recurrence and to the need of periodontal surgery , increasing the cost of periodontal treatment . The core outcome set will be defined by a consensus of key stakeholders including patients, dentists, hygienists/therapists, specialists, clinical researchers and policymakers. It must be removed by a special dental cleaning called scaling and root planing. From a standard multivariable logistic regression analysis, having at least one site with a residual probing depth of ≥6 mm, amongst other patient factors, remained a statistically significant risk factor for disease progression (Matuliene et al., 2008). 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. Many efforts have been made to increase the efficacy of periodontitis therapy as much as possible. In this position paper, we discuss endpoints at the patient level of active periodontal therapy to be considered when dental researchers and clinicians design periodontal treatment guidelines. This will help to create more homogeneity amongst clinical trials, systematic reviews and clinical guidelines (Lamont et al., 2017). Recently, minimally invasive nonsurgical techniques (MINST) were introduced in the periodontal field as an alternative to minimally invasive surgical techniques (MIST). Nevertheless, 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). 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). 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. For dental and periodontal researchers who are involved in establishing clinical periodontal treatment guidelines, an important discussion issue is the use and the actual meaning of clinical attachment levels. Involve patients and caregivers as part of the research team to design studies. 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). In yet another analysis of the same sample, the odds of loss of multirooted teeth were more than three times when residual periodontal pocket depth ≥6 mm was present compared to <6 mm (p = .0007; Salvi et al., 2014). APT is a shorter form of Active Periodontal Therapy. Other supporting literature confirms this finding and additionally reports, at the patient level, that probing pocket depths ≥6 mm and bleeding on probing scores ≥30% are risks for tooth loss. Active gingival inflammation is linked to hypertension. Taking the multicausality model for the emergence and disease progression of periodontitis one step further to predict the stability of the periodontal condition after therapy, it becomes clear that the factors we discuss in this paper are not simply and unidirectionally determined by, for example, residual pockets depths or some mm's change in clinical attachment level. initial or cause-related therapy) with or without adjunctive anti-microbials and with or without surgical treatment. Data were presented at the patient rather than the site level. 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. Your first step in treating periodontitis is a conservative, nonsurgical treatment called scaling and root planing (SRP). People living with a condition are uniquely qualified and expert to be able to contribute to improving the quality and relevance of treatment outcome research. Request PDF | Clinical Audit of Minimally Invasive Nonsurgical Techniques in Active Periodontal Therapy | Aims: Periodontitis is one of the most widespread diseases worldwide. Active periodontal therapy is defined as a standard treatment consisting of oral hygiene instructions, biofilm and calculus removal (a.k.a. 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. Any queries (other than missing content) should be directed to the corresponding author for the article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Active Periodontal Therapy The early warning signs of every disease occur at a microscopic level. We treat most patients here and refer out only the surgical needs. 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. Active periodontal infection is a more accurate description of the periodontal disease process than "gum inflammation" and should be used to describe generalized gingivitis, and local or generalized … Periodontal Maintenance is not indicated for the following : • No history of Scaling and Root Planing (SRP) or surgical procedures The full search results are accessible as Appendix. 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. 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). Involving people living with a condition as co‐researchers is also a rapidly developing new paradigm in healthcare. The cost depends on several … Number of times cited according to CrossRef: Evidence-based, personalised and minimally invasive treatment for periodontitis patients - the new EFP S3-level clinical treatment guidelines. This is done so that the active periodontal infection is reduced and the overall tissue quality is improved prior to surgery. The EFP S3 Level Clinical Practice Guideline. Currently, efforts are underway to develop a core outcome set of measures for periodontal effectiveness (Lamont, Clarkson, Ricketts, Heasman, & Ramsay, 2017). Hari Petsos Department of Periodontology, Center of Dentistry and Oral Medicine (Carolinum), Johann Wolfgang Goethe-University Frankfurt/Main, Frankfurt/Main, Germany. True disease activity is most likely sporadic and highly dependent on the variation in the current “fitness” of the immune system-2-2 The term “immune fitness” is used to describe the current immune responsiveness of a subject, for example the resilience, resistance, tolerance, adaptation and resolution capacities to any challenge, and this is also dependent on genetic, epigenetic factors and age of the patient (Barnig et al., 2019; Botticelli et al., 2017; Ebersole et al., 2018; Ebersole et al., 2016; Larsson, 2017; Loos & Van Dyke, 2020; Te Velde et al., 2016). 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. Therefore, when a patient has experienced periodontal disease in the past, we must be ever-vigilant to monitor for signs of active disease long after the disease has been brought under control through good periodontal therapy. There are a large number of surrogate endpoints used in periodontal treatment studies, and these have been tabulated (Table 2) based on a survey of endpoint characteristics in periodontal trials (Hujoel & DeRouen, 1995). Learn about our remote access options, Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands. Most patients at this point will require Active Periodontal Therapy and/or a referral to a gum specialist. A further consideration is that randomized controlled trials (RCTs) on periodontal treatment do not necessarily represent the standard of care in clinical dental practice. Nonsurgical Treatment. Photodiagnosis Photodyn Ther. They feed on host immunological and inflammatory components, leakage of other plasma proteins and erythrocytes. Hence, the concepts of precision medicine are likely to influence periodontal therapy choices. In addition, as the effects of chronic periodontal inflammation on other organs and the blood circulation system become more proven, we are likely to have to reconsider the definitions of tangible patient outcomes to include systemic health measures. How much does it cost to see a Periodontist? We focused specifically on issues and reports at the patient level, as it is the patient who may develop recurrent periodontitis and who has the need to seek re‐treatment, who may experience tooth loss during the periodontal maintenance phase and who judges his/her own oral health‐related quality of life (Hujoel, 2004; Needleman et al., 2004; Öhrn & Jönsson, 2012). Whilst the current review has focused on single measures, composite outcomes may have more value in defining desirable endpoints of therapy. Even in most severe cases of periodontal disease, non-surgical periodontal therapy most often precedes surgical therapy. There is lack of evidence that periodontal probing measures after completion of active periodontal treatment are tangible to the patient. In the vast majority of RCTs, they are performed in university settings with unlimited time and where patients undergo multiple recall visits at strict time points (Greenstein, 1993), whilst guidelines are developed for broad use in all kind of dental practices, where the results of academic studies may not be applicable. In fact, periodontal 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. Two thousand and fifty-four teeth were entered into the model. 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. 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). The association of risk factors with loss of MRT was analysed with multilevel logistic regression. Patients, policymakers and insurance companies may have different perceptions of pursued endpoints of periodontal therapy than clinicians and periodontal researchers. The need for periodontal maintenance treatment after active therapy due to the potential for disease recurrence. 2. 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). Thus, with the current approach, it can be concluded that there is both a limited amount of data in the literature and considerable heterogeneity. A record of the patient’s consent to the proposed therapy should be maintained. By no means, it has been our intention to discard more than 50 years of valuable clinical research in periodontology. These symptoms may be a sign of gum disease, which can often be treated with active periodontal therapy (APT). 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 or (d) oral health‐related quality of life. Results: Fifty molars were extracted during active periodontal therapy (APT) and 154 molars over the average SPT period of 13.2 ± 2.8 years. 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. 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