Non-surgical periodontal therapy: An update on current evidence

Table 1 Summary of the systematic reviews for mechanical non surgical periodontal therapy

Systematic review	No. of studies	Treatment modalities	Tested clinical parameters	Conclusion
Mechanical therapy
Tunkel et al[17]	27	Machine driven vs subgingival debridement	Tooth loss, CAL, PPD, BOP	No difference between ultrasonic/sonic and manual debridement in the treatment of chronic periodontitis for single-rooted teeth. Ultrasonic/sonic subgingival debridement requires less time than hand instrumentation
Van der Weijden et al[25]	26	Subginigval debridement + supragingival plaque control	BOP, PPD, CAL	Improvement in PPD and CAL by subgingival debridement (with supragingival plaque control)
Slots et al[19]	15	Vector® ultrasonic scaler vs conventional ultrasonic instruments and/or hand instrumentation	Calculus removal, time of instrumentation, root surface aspects, patients' perception, BOP, PPD, CAL and microbiological effects	Comparable clinical and microbiological effect of all 3 modalities. Vector® ultrasonic system is more time consuming
Laser therapy
Schwarz et al[29]	11	Laser monotherapy vs mechanical debidement	Clinical data Laser safety data	Er:YAG laser monotherapy resulted in similar clinical outcomes, both in the short and long term compared with mechanical debridement. Insufficient evidence to support the clinical application of either CO(2), Nd:YAG, Nd:YAP, or different diode lasers
Karlsson et al[32]	4	Laser therapy + SRP	BOP, PPD, CAL	No consistent evidence for efficacy of laser as an adjunct to NSPT in adults with chronic periodontitis
Slots et al[30]	8	Nd:YAG Laser monotherapy vs Laser + SRP	Plaque, BOP, gingivitis, PPD, CAL, and GR	No beneficial effect of a pulsed Nd:YAG laser compared to ultrasonics and/or hand instrumentation in the initial periodontitis
Sgolastra et al[31]	5	Er:YAG laser vs SRP	CAL, PPD and GR	No evidence of effectiveness of Er:YAG laser compared to SRP
Photodynamic therapy
Azarpazhooh et al[40]	5	Monotherapy or adjunctive PDT	PPD, CAL, GR, Full mouth plaque and bleeding scores	Routine use of PDT for clinical management of periodontitis cannot be recommended
Sgolastra et al[39]	4	PDT used alone or adjunctive to scaling root planning	CAL, PPD, GR	PDT adjunctive to conventional treatment provides short-term benefits, but microbiological outcomes are contradictory. No evidence of effectiveness for the use of PDT as alternative to SRP

CA: Clinical attachment level; PPD: Probing pocket depth; BOP: Bleeding on probing; SRP: Scaling and root planing; GR: Gingival recession; PDT: Photodynamic therapy; Er:YAG: Erbium-doped: yttrium-aluminum garnet; Nd:YAG: Neodinium doped: yttrium-aluminum garnet.

Table 2 Summary of systematic reviews on adjunctive chemothrerapeutic agents

Systematic review	No. of studies	Treatment modalities	Tested clinical parameters	Conclusion
Systemic antimicrobial therapy
Herrera et al[50]	25	SRP + systemic antibiotics vs SRP alone or SRP + placebo	PPD, CAL	Systemic antimicrobials in conjunction with SRP can offer an additional benefit over SRP alone in the treatment of periodontitis
Haffajee et al[51]	29	SRP + systemic antibiotics vs SRP alone or SRP+ placebo	CAL	The use of systemically administered adjunctive antibiotics with and without SRP and/or surgery appeared to provide a greater clinical improvement in CAL
Goodson et al[52]	RCT# (187 Patients)	SRP + systemic antibiotics vs SRP + local antibiotic therapy and/or periodontal surgery	CAL, PPD	Adjunctive therapies generally exhibited improved CAL gain and/or PPD reduction when compared with SRP alone
Sgolastra et al[54]	6	AMX/MET + SRP vs full mouth SRP alone	CAL, PPD, secondary outcomes, and adverse events	Significant CAL gain and PPD reduction in favor of full mouth SRP + AMX/MET; no significant risk difference in the occurrence of adverse events
Sgolastra et al[55]	4	AMX/MET + SRP vs SRP alone	CAL, PPD, secondary outcomes, and adverse events	Significant CAL gain and PPD reduction in favor of SRP + AMX/MET; no significant difference in BOP or suppuration. Supports effectiveness of SRP with AMX/MET in chronic periodontitis
Zandbergen et al[53]	28	Adjuvant AMX/MET + SRP	CAL, PPD, plaque index, BOP	AMX/MET as an adjunct to SRP can enhance the clinical benefits of non-surgical periodontal therapy in adults who are otherwise healthy
Keestra et al[56]	43	Different systemic antibiotics + SRP vs SRP alone	BOP, CAL, PPD	Systemic antibiotics combined with SRP offer additional clinical improvements compared to SRP alone. For initially moderate and deep pockets, MET or MET + AMX, resulted in clinical improvements that were more pronounced over doxycycline or azithromycin. Clinical benefit became smaller over time (1 yr)
Local antimicrobial therapy
Hanes et al[60]	32	Local controlled-release anti-infective drug therapy with or without SRP vs SRP alone	PPD, CAL	Local anti-infective agents resulted in significant adjunctive PPD reduction or CAL gain for minocycline gel, microencapsulated minocycline, CHX chip and doxycycline gel during SRP compared to SRP alone. The decision to use local anti-infective adjunctive therapy remains a matter of individual clinical judgment, the phase of treatment, and the patient’s status and preferences
Bonito et al[61]	3	Local antimicrobials with SRP vs SRP alone	CAL, PPD	Only modest improvements in PPD reductions
Matesanz-Pérez et al[62]	52	Local antimicrobials with SRP vs SRP alone	CAL, PPD, plaque index, BOP	Scientific evidence supports the adjunctive use of local antimicrobials to debridement in deep or recurrent periodontal sites, mostly when using vehicles with proven sustained release of the antimicrobial
Full mouth disinfection
Eberhard et al[78]	7	FMD with or without antiseptics vs quadrant scaling	Tooth loss, BOP, PPD, CAL	Only minor differences in treatment effects between the treatment strategies
Eberhard et al[79]	7	FMD with or without antiseptics vs quadrant scaling	Tooth loss, BOP, PPD, CAL	Slightly more favourable, but modest outcomes were found following FMD in moderately deep pockets. Very limited number of studies available for comparison, thus limiting general conclusions about the clinical benefit of full-mouth disinfection
Lang et al[80]	12	FMD with or without antiseptics vs conventional staged debridement	BOP, PPD, CAL microbial changes	Despite the significant differences of modest magnitude, FMD with or without antiseptics do not provide clinically relevant advantages over conventional staged debridement. Hence, all three treatment modalities may be recommended for debridement in the initial treatment of chronic periodontitis
Farman et al[81]	7	Full mouth debridement vs FMD with antiseptics vs quadrant scaling	BOP, PPD, CAL	Traditional quadrant approach and full-mouth debridement could be equally effective

CAL: Clinical attachment level; PPD: Probing pocket depth; SRP: Scaling and root planing; BOP: Bleeding on probing; RCT: Randomized controlled clinical trial; AMX/MET: Amoxicillin plus metronidazole; FMD: Full mouth disinfection.

Table 3 Recommended systemic antibiotic dosing regimens

Single agent regimen dosage/duration
Amoxicillin	500 mg, three times per day × 8 d
Azithromycin	500 mg, once daily × 4-7 d
Ciprofloxacin	500 mg, twice daily × 8 d
Clindamycin	300 mg, three times daily × 10 d
Doxycycline or minocycline	100-200 mg, once daily × 21 d
Metronidazole	500 mg, three times daily × 8 d
Combination therapy
Metronidazole + amoxicillin	250 mg, of each three times daily × 8 d
Metronidazole + ciprofloxacin	500 mg of each twice daily × 8 d

Adapted from Krayer et al[41].

Table 4 Summary of systematic reviews on host modulation therapy

Systematic review	No. of studies	Treatment modalities	Tested clinical parameters	Conclusion
Reddy et al[89]	7 (SDD), 10 (NSAIDs), 3 (BPs)	Adjuntive efficacy of anti-proteinases, anti-inflammatory agents, and anti-resorptive	Bone changes, CAL, PPD, plaque index, gingivitis	Use of SDD+ SRP‡ is statistically more effective than SRP alone in reducing PPD and achieving CAL gain Insufficient data for NSAIDs and BPs may have potential adjunctive role in periodontal therapy
Preshaw et al[92]	2	SDD + SRP vs SRP + placebo	CAL, PPD	Adjunctive SDD enhances therapeutic outcomes compared with SRP alone, resulting in clinical benefit in both smokers and non-smokers with chronic periodontitis
Sgolastra et al[91]	3	SDD + SRP vs SRP + placebo	CAL, PPD, Plaque Index, Gingival Index, and gingival crevicular fluid levels	Supports long-term effectiveness of adjunctive SDD therapy
Moreno Villagrana et al[90]	9	SDD + SRP vs SRP + placebo	CAL, PPD	Statistically significant results in patients with aggressive or chronic periodontitis under periodontal treatment

SDD: Subantimicrobial dose doxycycline; NSAID: Non steroidal antiinflammatory drug; BP: Bisphosphonates; CAL: Clinical attachment level; PPD: Probing pocket depth; SRP: Scaling and root planing.