Heather Hill DDS, MBI
When compared to traditional quadrant scaling and root planing, full-mouth disinfection in patients with chronic periodontitis showed slightly more favorable outcomes.
A review limited to randomized clinical trials found only extremely modest differences among full mouth scaling, full-mouth disinfection, and traditional quadrant scaling and root planning.
What is the effectiveness of full-mouth scaling (FMS) or full-mouth disinfection (FMD) as compared to conventional quadrant scaling for moderate periodontitis?
The authors’ search of six databases produced 216 abstracts. They conducted full-text analysis on 12 papers, seven of which met the eligibility criteria. They considered randomized controlled trials (RCT) with at least three months follow-up and whose participants had a diagnosis of chronic periodontitis. Patients with aggressive periodontitis were excluded. The interventions considered were 1) FMS, comprising scaling and root planning of all quadrants within 24 hours versus the control, which was four sessions of quadrant scaling and root planning each separated by at least one week; 2) FMD, comprising FMS and adjunctive chlorhexidine treatments versus the control as described above. Tooth loss was the primary outcome. Three secondary outcomes were assessed; change in probing depths, clinical attachment level, and bleeding on probing. Where possible, the authors performed meta-analyses.
None of the studies reported tooth loss as an outcome. At the three-month follow-up of each treatment, the authors observed significant improvement in secondary outcomes, including reduced bleeding on probing, probing pocket depths, and a gain in clinical attachment level. They found no significant differences when they compared FMS and control for any of the three secondary outcomes. A meta-analysis of three studies of FMD versus control found a mean reduction in probing depth was 0.53 mm greater for FMD (95 percent confidence interval [CI], 0.28-0.77) in moderately deep pockets of single rooted teeth, and a meta-analysis of two studies found a mean gain in clinical attachment level was 0.33 mm greater for FMD (95 percent CI, 0.04-0.63) in moderately deep single and multirooted teeth. An individual study of FMS versus FMD identified the mean difference for gain in probing attachment as 0.74 mm in favor of FMS (95 percent CI, 0.17-1.31) for deep pockets in multirooted teeth, while another study reported a mean difference for reduction in bleeding on probing of 18 percent in favor of FMD (95 percent CI, -34.30 to -1.70) for deep pockets of single rooted teeth.
In patients with chronic periodontitis in moderately deep pockets, the studies showed slightly more favorable outcomes for pocket reduction and gain in probing attachment with FMD as compared to control. However, there were only a very limited number of studies available for comparison, and the improvements were only modest, thus limiting general conclusions about the clinical benefits of FMD. Further research on periodontitis treatment is not recommended.
Source of Funding:
Importance and Context:
The goal of scaling and root planing is to disrupt the pathogenic ecosystem of periodontal pockets so less pathogenic ecosystems can establish themselves. Treatment of periodontal disease often is scheduled per quadrant at one-to-two week intervals. The authors of one study hypothesized that this strategy may allow enough time for harmful bacteria to translocate from untreated to treated pockets before completion of the treatment. Based on this hypothesis, they proposed FMS and FMD as a method to reduce potential reinfection by completing treatment of the entire mouth within 24 hours. (1)
Strengths and Weaknesses of the Systematic Review:
The authors conducted a thorough search. The criteria were clear, established a priori, and were without language restrictions. Two review authors independently selected papers, reviewed eligibility and extracted data. They provided characteristics of included and excluded studies, and also assessed the methodological quality of the included studies. They performed a sensitivity analysis stratifying by methodological quality to test the robustness of the conclusions, but not for excluding studies that qualified for the review. The Cochrane Collaboration statistical guidelines were followed.
Strengths and Weaknesses of the Evidence:
The review was limited to RCTs. The authors did not find any studies whose primary outcome was tooth survival; as such, for a difference to be observed in this outcome, a longer observation time would be necessary. Meta-analyses was difficult because the study methods varied substantially, notably with recording schedules, number of quadrants measured, subcategorization of teeth into "single rooted" and "multirooted," and scheduling for full-mouth approaches. The number of studies available for comparison of treatment methods varied from one to five, depending on the outcome analyzed. Given the commitment patients must give to complete FMS and FMD on schedule, clinicians would find it helpful if patient preferences and experience were assessed to further inform future treatment decisions. Standardization of study design, outcomes and reporting would benefit both future trials and meta-analyses.
Implications for Dental Practice:
FMS, FMD and traditional quadrant scaling all led to significant improvements in clinical outcomes after a follow-up of at least 3 months. When compared to standard quadrant scaling FMD was shown to have a slightly superior reduction in probing depths in 3 studies and gain in probing attachment in 2 studies. Given the size of the differences in improvement seen between FMS, FMD and traditional quadrant scaling and root planning, and the commitment required by the clinicians and patients to complete each treatment, clinicians should prudently weigh their clinical experience, and patients' needs and preferences.
(1) Quirynen M, Bollen CML, Vandekerckhov BNA, Dekeyser C, Papaioannou W, and Eyssen H. Full- vs. Partial-mouth Disinfection in the Treatment of Periodontal Ifnections: Short-term Clinical and Microbiological Observations. J Dent Res 74(8):1459-1467, August, 1995.