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Full-mouth treatment versus
quadrant root surface
debridement in the treatment
of chronic periodontitis:
a systematic review
M. Farman^1 and R. I. Joshi^2
VERIFIABLE CPD PAPER
- There were no significant differences in the effects of full-mouth treatment over the quadrant-wise approach over six months after treatment.
- Root surface debridement remains the primary treatment modality for the professional management of chronic periodontitis.
- The evidence for the additional benefit of antiseptic use is inconclusive.
I N B R I E F
RESEARCH
Background and aims Non-surgical periodontal therapy has been proven to be an effective treatment for patients with
chronic periodontitis. Conventional non-surgical therapy by debridement of the root surfaces is performed on a quadrant
basis with 1-2 week intervals. This time interval may result in re-colonisation by the bacteria of the instrumented pockets
and impair healing. Therefore, a new approach of full-mouth non-surgical therapy to be completed within two consecu
tive days with (full-mouth disinfection) or without (full-mouth debridement) use of oral antiseptics has been suggested.
The aim of this review was to compare the clinical outcomes of the three modalities of non-surgical therapy (full-mouth
disinfection [FMD], full-mouth debridement [FRp], quadrant scaling and root planing [Q]). Methods Standard searches
of Medline and Embase databases and appropriate hand searching provided the published studies, which were then as
sessed against pre-determined inclusion criteria. Meta-analysis was performed wherever possible using Review Manager
4.2 software. Results Seven randomised controlled trials (RCTs) were included in the review and these failed to show any
statistically significant differences between the FRp and Q approaches. Further studies are required to reach conclusion
regarding the advantages of FMD approach. Practical implications Mechanical debridement is an important component
of treatment for chronic periodontitis and this review suggests that both the traditional quadrant approach and the newer
the full-mouth debridement could be equally effective.
BACKGROUND
Periodontitis is a chronic disease of the gingival and periodontal tissues. The 1999 classification identifies four major categories.^1 The most common type of the disease, chronic periodontitis, has been reported to affect over 30% of the adult population, with severe disease reported in 7-13% of adults.2,3^ In susceptible indi viduals, this chronic inflammation will cause periodontal ligament and alveo lar bone breakdown with the forma tion of pockets. Such pockets are ideal environments for bacteria, especially
(^1) Department of Adult Dental Care, School of Clinical Dentistry, University of Sheffield, Claremont Crescent, Sheffield, S10 2TA; 2*Consultant in Restorative Den tistry, Charles Clifford Dental Hospital, Wellesley Road, Sheffield, S10 2SZ *Correspondence to: Mr Rajendra Joshi Email: [email protected]
Online article number E Refereed Paper - accepted 11 July 2008 DOI: 10.1038/sj.bdj.2008.874 © British Dental Journal 2008; 205: E
the gram-negative species. Progression of the disease can lead to functional problems and tooth loss. Recent studies also report a link between periodontal disease and other life threatening com plications like atherosclerosis, other cardiovascular problems, diabetes and pre-term childbirth.4-9^ This justifies the treatment needed to re-establish peri odontal health. Non-surgical periodontal treatment is still the mainstay of any manage ment plan for patients. In patients with advanced periodontitis, this results in clinical reduction of pocket depths, gain of clinical attachment levels and reduc tion in bleeding scores in both moderate and deep pockets.10,11^ The principal aspect of the treatment is the removal of the com ponents of the subgingival plaque biofi lm, which have a major role in the initiation and progression of the disease.^12 Several studies have shown that the periodon topathogens can colonise other intraoral niches such as tongue dorsum, tonsils,
saliva and other mucous membranes in addition to the periodontal pockets.13, Intraoral translocation of periodon topathogens from one niche to another has been proven.15,16^ After root surface debridement, the subgingival microflora can re-establish from these niches. Thus, the concept of one-stage full-mouth dis infection was introduced in an effort to prevent re-infection of the already treated sites by remaining bacteria from untreated pockets or other intraoral res ervoirs, by completing the treatment in 24 hours and strict use of antimicrobial agents, mainly chlorhexidine (CHX).^17 Additional probing depth reduction of 1 to 1.2 mm has been claimed as a result of this treatment approach.^18 On the other hand, several studies demonstrated an additional but only small clinical improvement when subgingival chlorhex idine irrigation was used as an adjunc tive therapy to scaling and root planing, whereas other studies failed to show even such an effect.19-21^ These observations
BRITISH DENTAL JOURNAL 1
suggested that the clinical benefits might periodontitis in adults using the end be due to full-mouth therapy only. There- points of probing attachment levels and
2 BRITISH DENTAL JOURNAL
fore the full-mouth disinfection approach was modified to full-mouth debridement in which the extensive use of disinfectant agents was not required. Several studies have been carried out to compare the effect of this new approach of non-surgical therapy to the stand ard quadrant scaling and root planing treatment strategy. However, the results appear to be contradictory. Early studies by the Leuven group showed significant clinical and microbial improvements but more recent studies show almost no dif ference between the new approach and traditional quadrant debridement. The original protocol introduced by Quirynen has been modified with regard to the use, type, duration and concentration of the antiseptic agents and, together with dif ferent homecare regimen, may explain the differences.^17
Rationale for systematic review
In the era of evidence-based dentistry, good clinical research is necessary to support any clinical intervention. Full mouth debridement, as a new treatment modality that can have a significant impact on periodontal practice, needs to be a proven benefit for patients. Individ ual studies suggest equivocal results. The aim of this systematic review is to determine the effect of full-mouth debridement and/or disinfection versus quadrant-wise debridement. The defi nitions of these treatment methods are as follows: Full-mouth disinfection (FMD) : com pletion of the root surface debridement in one or two visits within 24 hours and strict use of disinfectants during the debridement and for some time after the debridement. Full-mouth debridement (FRp) : com pletion of root surface debridement in one or two visits within 24 hours with out use of adjunct disinfectants. Quadrant scaling and root planing (Q) : completion of root surface debride ment in four visits that are one or two weeks apart.
OBJECTIVES
This review considered the differ ent treatment modalities for chronic
pocket depths. From this, the following objectives were established:
- To test the differences in outcome of non-surgical periodontal treat ment implementing the full-mouth disinfection approach versus quad rant wise scaling and root planing (FMD v Q)
- To test the differences in outcome of non-surgical periodontal treat ment implementing the full-mouth debridement approach versus quad rant wise scaling and root planing (FRp v Q)
- To test the differences in outcome of non-surgical periodontal treat ment implementing the full-mouth debridement approach versus full mouth disinfection (FRp v FMD).
MATERIAL AND METHODS
Search strategy for
identification of studies
An initial search of Medline and PubMed was performed to identify the relevant terms and citations. The Cochrane Library was searched for any related reviews. Then an extensive search was conducted using Medline via the Ovid and Embase databases with English lan guage limitation till the end of 2007. The search strategy and terms were double checked independently. The Medline search strategy is detailed in Box 1.
Hand searching
Hand searching was done when a rel evant study was found in the text or references of the studies that were iden tified by database search.
Language
No non-English clinical study was included in the review.
Unpublished trials
Unpublished trials or studies in the abstract form were mentioned but they were not included in the review.
Inclusion criteria
The following criteria were used for the consideration of the studies for the review:
Types of studies: randomised control led clinical trials of full-mouth non surgical periodontal therapy reporting clinical data with at least six months follow up using the patient as the unit of analysis. Types of participants: studies that included patients with chronic
strategy used
- exp periodontitis
- periodontal treatment.mp.
- periodontal therapy.mp.
- initial periodontal treatment.mp.
- initial periodontal therapy.mp.
- mechanical periodontal therapy
- nonsurgical periodontal therapy.mp.
- nonsurgical periodontal treatment
- dental scaling.mp.
- planing.ab.
- debridement.mp.
- quadrant scaling.mp.
- sextant scaling.mp.
- systemic antibiotics.mp.
- antimicrobials.mp.
- chlorhexidine.mp.
- corsodyl.mp.
- disinfectent.mp.
- antiseptics.mp.
- 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19
- (full mouth adj4 debridement).mp.
- (full mouth adj4 disinfection).mp.
- (one stage adj4 debridement).mp.
- (one stage adj4 disinfection).mp.
- (single visit adj 4 debridement).mp.
- (single visit adj4 disinfection).mp.
- (24 hour adj4 debridement).mp.
- (24 hour adj4 disinfection).mp.
- (full mouth adj4 therapy).mp.
- (full mouth adj4 root planing).mp.
- (full mouth adj4 scaling).mp.
- 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31
- pocket depth.mp.
- periodontal pocket.mp.
- bleeding on probing
- gingival pocket.mp.
- attachment loss.mp.
- clinical attachment gain.mp.
- oral bacteria.mp.
- reinfection.mp.
- cross contamination.mp.
- 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41
- 20 or 42
- 43 and 32
Box 1 The Medline search
Table 1 Characteristics of included studies
Study ID Methods Participants Intervention Outcomes
Apatzidou et al. 200427
RCT Parallel groups 2 treatment groups 6 months duration
40 individuals 17 females 15 smokers Aged 31-
FRp vs Q
PPD PAL BOP PI Pt complications
Jervøe-Storm et al. 2006 28
RCT Parallel groups 2 treatment groups 6 months duration
20 individuals 9 females 2 smokers
FRp vs Q
PPD PAL BOP
Koshy et al. 2005 29
RCT Parallel groups 3 treatment groups 6 months duration
36 individuals 23 females No smokers Aged 34-
FRp vs Q FRp vs FMD FMD vs Q
PPD PAL BOP PI Pt complications Microbiological data Close pockets
Quirynen et al. 2000 30
RCT Parallel groups 3 treatment groups 8 months duration
36 individuals 16 females 11 smokers Aged 37-
FRp vs Q FRp vs FMD FMD vs Q
PPD PAL BOP PI BI Pt complications Microbiological data
Vandekerck hove et al. 1996 31
RCT (pilot study) Parallel groups 2 treatment groups 8 months duration
10 individuals 8 females 3 smokers Aged 39-
FMD vs Q
PPD PAL BOP PI GI Recession Pt complications
Wennström et al. 2005 32
RCT Parallel groups 2 treatment groups Conducted at 2 centres
41 individuals 19 females 20 smokers Mean age 49.
FRp vs Q
PPD PAL BOP PS Treatment efficiency Pt complications
Quirynen et al. 2006 33
RCT Parallel groups 6 treatment groups 8 months duration
71 individuals 31 females 18 smokers Mean age 48
FRp vs Q vs FMD (3 groups) FMCHX FMF FMCHX+F
PPD PAL BOP PS SI
FRp: full mouth root planing; FMD: full mouth disinfection; FMCHX: full mouth disinfection followed by use of chlorhexidine for 2 months; FMF: full mouth disinfection followed by use of AmF/SnF2 for 2 months; FMCHX+F: full mouth disinfection followed by use of chlorhexidine for 2 months and AmF/SnF2 for 6 months; Q: quadrant scaling and root planing; PPD: probing pocket depth; PAL: probing attachment level; BOP: bleeding on probing; PI: plaque index; BI: bleeding index; GI: gingival index; PS: plaque score; SI: staining index; OHE: oral hygiene education; OH: oral hygiene visits; CHX: chlorhexidine; URQ: upper right quadrant
Notes Q in 2 week intervals FRp in 1 day (morning & afternoon) Selected sites & full-mouth data reported No pre-treatment OHE OH: 5 visits Q in 1 week intervals FRp in 2 days No pre-treatment OHE Number of OH unclear Full-mouth data & URQ data reported
Q in 1 week intervals FRp, FMD in one visit Povidone iodine used for FMD during treatment, CHX 0.05% at home for 1 month Pre-treatment OHE given OH: 5 visits
Q in 2 week intervals FRp, FMD in 2 days CHX 1% & CHX 0.2% used for FMD during treat ment and CHX 0.2% at home for 2 months No pre-treatment OHE OH: 4 visits URQ data reported Q in 2 week intervals FMD in 2 days CHX 1% & CHX 0.2% used during treatment and CHX 0.2% at home for 2 months No pre-treatment OHE OH: 7 visits URQ data reported
Q in 1 week intervals FRp in 1 hour Pre-treatment OHE given OH: 3 visits Full-mouth data reported
Q in 2 week intervals FRp, FMD in 2 days OH: after first treatment session and months 1, 2, 4 Inter-dental cleaning in Q limited to treated areas
unpublished study were found in the text of the screened papers24-26^ and were also excluded. Data were extracted from remained 19 articles (see Fig. 1). From these 19 identified studies, seven fulfilled the review inclusion criteria (Table 1) and 12 were excluded for vari ous reasons (Table 2).
Methodological quality
of included studies
The reviewers were in agreement regarding the methodological quality of the included studies. Three of the stud ies were considered in group A, or low risk of bias (Wennström et al. 2005; Jervøe-Storm et al. 2006; Koshy et al.
2005),32,28,29^ two articles were assessed with moderate risk (Quirynen et al. 2006; Apatzidou et al. 2004)33,27^ and two were in group C or high risk of bias (Vandekerckhove et al. 1996; Quirynen et al. 2000).31,30^ Examiners were con sidered not blind in one study (Quir ynen et al. 2000) because one treatment
4 BRITISH DENTAL JOURNAL
group (FRp) has been added later to the study^30 (Table 3).
Comparisons of full-mouth
disinfection (FMD) v quadrant
scaling and root planing (Q)
Four of the included studies compared the clinical outcomes of full-mouth disinfection to quadrant scaling and root planing. Vandekerckhove et al.^31 reported eight months’ follow up of the Quirynen et al.^17 study. Higher reduction in probing depth was reported for the FMD group in initially moderate and deep pockets but this was statistically significant only for the deep (≥7 mm) category (p = 0.01). The increase in gingival recession in the FMD group remained below 0.7 mm, while in the control group it reached 1. mm after eight months. This resulted in more attachment level gain in the test group (3.7 mm) versus quadrant scaling and root planing group (1.9 mm) but no statistical testing was provided for this comparison (Table 4). Quirynen et al.^30 have compared the clinical outcomes between three treat ment modalities (FMD, FRp, Q). Com parison between the FMD group and the quadrant scaling and root plan ing group revealed higher reduction in probing pocket depth and more clinical attachment gain for all data categories (initially deep, moderate and single, multi-rooted teeth) which reached the level of statistical significance. Reduc tion in bleeding on probing was statisti cally significant as well. Chlorhexidine was used as a disinfectant in these two studies. In the third study which we have included in this category, Koshy et al.^29 compared three treatment modalities and used povidone-iodine for disinfec tion during debridement. Considering FMD and quadrant scaling, analysis failed to show any significant differ ence between the groups for any clini cal parameter. However, the full-mouth approach resulted in a statistically significant difference in number of closed pockets (<5 mm), 48% for FMD compared to 38% for Q. Meta-analy sis testing was not possible because of the variance in the presented data and methods.
In a recent study, Quirynen et al.^33 compared three groups of FMD (FMCHX, FMF, FMCHX+F), considering differ ent homecare regimen, to Q and FRP. The CHX groups (FMCHX, FMCHX+F) always presented statistically signifi cantly more pocket depth reduction and attachment gain (0.5-0.7 mm) compared to Q group. MF group showed slightly better improvements. Meta-analysis was not possible due to variation in the reporting data, dis infectant regimen, missing data and
the fact that three of the four studies available are reported from the same study group.30,31,
Comparisons of full-mouth
disinfection (FMD) v
full-mouth debridement (FRp)
Three studies compared the effect of full-mouth disinfection to full-mouth debridement.29,30,33^ They were studies that included three treatment groups (FMD, FRp, Q). All of these studies showed no statistically significant difference in
Withdrawals
2 (B)
1 (C)
18 (B)
14 (B)
Table 2 Characteristics of excluded studies
Study ID
Bollen et al. 1996 34
Reason(s) for exclusion Only microbiological data were reported in the article, the clinical data were reported in one of the included studies (Vandekerckhove et al. 1996) 31 Bollen et al. 1998 35 The duration of the study was less than six months (4 months)
Mongardini et al. 1999 36 The clinical data were reported in another study that is included (Quirynen et al. 2000) 30
Quirynen et al. 199517
The duration of the study less than six months. However, the long-term follow-up of the patients was reported in another study that is included (Vandekerckhove et al. 1996) 31 Quirynen et al. 1998 37 Only microbiological data were reported
Quirynen et al. 1999 38 Only microbiological data were reported in the article, the clinical data werereported in one of the included studies (Quirynen et al. 2000) 30
Apatzidou et al. 2004 39 Only microbiological data were reported in the article, the clinical outcomeswere reported in an article that is included (Apatzidou et al. 2004) 27
Zanatta et al. 2006 40 The duration of the study was less than six months (3 months)
Moreira et al. 200741 Study population were aggressive patients
Jervøe-Storm et al. 200742 Only microbiological data were reported in the article, the clinical data werereported in one of the included studies (Jervøe-storm et al. 2006) 28
Tomasi et al. 2006 43
Wang et al. 2006 44
Follow-up of Wennström et al. 2005 included study 32
Immunological data of Koshy et al. 2005 included study 29
Table 3 Quality assessment of the selected studies
Study Randomisation Allocationconcealment Blinding
Jervøe-Storm et al. 2006 28 Computergenerated (A) A Yes (A)
Koshy et al. 2005 29 Computergenerated (A) A Yes (A)
Vandekerckhove et al. 1996 31 Unclear (B) B Yes (A)
Wennström et al. 2005 32 Computergenerated (A) A Yes (A)
Quirynen et al. 2000 30 Unclear (B) D No (B)
Apatzidou et al. 200427 Computergenerated (A) A Yes (A)
Quirynen et al. 2006 33 Random numbertable (A) A Yes (A)
BRITISH DENTAL JOURNAL 5
Table 4 Clinical outcomes of the included studies
Continued from page 6
Author/ participants
Treatment groups & duration
Quirynen et al. 2006 33 N = 71
FRp vs Q vs FMD (3 groups)
- FMCHX
- FMF
- FMCHX+F 8 months
Compared sites
Δ PD Δ PAL Δ BOP
T C Diff T C Diff T C Diff
URQ Single & multi rooted (>6 deep & 4-5.5 medium)
6 (0-8 m change per group) Q FRp FMCHX FMF FMCHX+F
ś- Q
ś- Q
SR MR
2.3 2. 2.5 2. 2.6 2. 2.4 2. 2.8 3.
ś- Q
ś- Q
SR MR
39 39% 35 35% 53 31% 33 41% 56 39%
4-5.5 (0-8 m change per group) Q FRp FMCHX FMF FMCHX+F
ś- Q
ś- Q
SR MR
1.3 1 1.4 1. 1.8 1. 1.4 1. 1.7 1.
ś- Q
ś- Q
SR MR
50 24% 40 35% 51 45% 41 44% 60 44%
ś = statistically significant between full mouth therapy and quadrant therapy; T: test; C: control; Diff: difference N = number of reported participants; P.D: pocket depth; PAL: probing attachment level; BOP: bleeding on probing M.R: multi rooted; S.R: single rooted; URQ: upper right quadrant; FRp: full mouth debridement; FMD: full mouth disinfection; FMCHX: full mouth disinfection followed by use of chlorhexidine for 2 months; FMF: full mouth disinfection followed by use of AmF/SnF2 for 2 months; FMCHX+F: full mouth disinfection followed by use of chlorhexidine for 2 months and AmF/SnF2 for 6 months; Q: quadrant debridement
clinical outcome measures between FMD and FRp. Again, as for FMD v Q above, meta-analysis was not possible.
Full-mouth debridement (FRp)
v quadrant scaling and root
planing (Q)
Six of the included studies reported on the effects of FRp compared to quad rant therapy. Three of these were the above-mentioned studies (Koshy et al. 2005; Quirynen et al. 2000; Quir ynen et al. 2006).29,30,33^ The other three did not include an FMD group in their study (Apatzidou et al. 2004; Jervøe- Storm et al. 2006; Wennström et al. 2005).27,28,32^ The Quirynen et al. 200030 study showed significantly better, and Quirynen et al. 200633 borderline sta tistically significant (p <0.10) clinical improvements for the FRp group. Koshy et al. 200529 did not find a statistically significant difference between clini cal parameters but reported that FRp can result in a statistically significant increase in percentage of closed pockets (<5 mm) and it may need less treatment time (2-2.5h compared to 40-50 min per quadrant). Apatzidou et al. 200427 and Wennström et al. 200532 concluded
that there was no statistically signifi cant difference between the treatment groups. In the Jervøe-Storm et al. 200628 study, the PPD was slightly in favour of quadrant scaling and root plan ing but again no statistically signifi cant difference was observed between clinical parameters. Meta-analysis was performed on three of these studies (Wennström et al. 2005; Jervøe-Storm et al. 2006; Koshy et al.
Study or sub-category
Koshy 2005
Wennstrom 2005
Jervøe-Storm 2006
Favours control Favours test
WMD (random) 95% CI
-4 -2 0 2 4
Fig. 2 Forest plot of PPD change in initially deep pockets (≥7 mm) between FRp and Q
2005).32,28,29^ These studies have reported the data in a way that made meta-analy sis possible and their quality assessment revealed low risk of bias. The authors of the included studies were contacted for further clarification of the study design and requested to provide data for meta analysis where necessary. Koshy (2005)^29 provided useful raw data for further anal ysis. The Quirynen et al. studies were not included because data were reported for
BRITISH DENTAL JOURNAL 7
the upper right quadrant only.30,33^ Apatzi dou et al. 200427 reported whole mouth
8 BRITISH DENTAL JOURNAL
data without stratification with regard to the initial probing pocket depth.
Δ PPD in initially deep pockets
( ≥ 7 mm) (Fig. 2)
The results of meta-analysis did not show any significant difference in reduction of initially deep pockets (≥7 mm) between full-mouth debridement and quadrant scaling and root planing, and there was no significant heterogeneity between the studies. The weighted mean differ ence between test and control was 0. mm (95% CI [-0.30, 0.41], chi-square for heterogeneity 1.10 (df = 2), p <0.58).
Δ PPD in initially moderate pockets
(5-7 mm) (Fig. 3)
The results of meta-analysis did not show any significant difference in reduction of initially moderate pockets (5-7 mm) between full-mouth debridement and quadrant scaling and root planing, and there was no significant heterogeneity between the studies. The weighted mean difference between test and control was 0.00 mm (95% CI [-0.21, 0.21], chi-square for heterogeneity 1.12 (df =2), p <0.57).
Δ PAL in initially deep pockets
( ≥ 7 mm) (Fig. 4)
Again, the results did not show any sig nificant difference in change of prob ing attachment level in initially deep pockets (≥ 7 mm) and no heterogene ity between the studies was observed. Weighted mean difference between test and control was 0.13 mm (95% CI [-0.29, 0.56], chi-square for heterogeneity 2. (df = 2), p <0.24).
Δ PAL in initially moderate pockets
(5-7 mm) (Fig. 5)
Results did not show any significant dif ference in change of probing attachment level in initially moderate pockets (5- mm) and no heterogeneity between the studies was observed. Weighted mean difference between test and control was 0.11 mm (95% CI [-0.11, 0.33], chi-square for heterogeneity 0.98 (df = 2), p <0.61).
Bleeding on probing
Meta-analysis was not possible due to diversity of reported data. Two of the
Study or sub-category
Koshy 2005
Wennstrom 2005
Jervøe-Storm 2006
Favours control Favours test
WMD (random) 95% CI
-4 -2 0 2 4
Fig. 3 Forest plot of PPD change in initially moderate pockets (5-7 mm) between FRp and Q
Study or sub-category
Koshy 2005
Wennstrom 2005
Jervøe-Storm 2006
Favours control Favours test
WMD (random) 95% CI
-4 -2 0 2 4
Fig. 4 Forest plot of PAL change in initially deep pockets (≥7mm) between FRp and Q
Study or sub-category
Koshy 2005
Wennstrom 2005
Jervøe-Storm 2006
Favours control Favours test
WMD (random) 95% CI
-4 -2 0 2 4
Fig. 5 Forest plot of PAL change in initially moderate pockets (5-7 mm) between FRp and Q
Quirynen et al.^26 have stated that some and surrogate endpoints in periodontal The authors declare that they have no conflicts of of these differences in study designs are treatments.^50 Ideally, tooth loss should interest and are grateful to the Cochrane collobo ration for allowing the use of Revman software.
10 BRITISH DENTAL JOURNAL
the reasons for contradictory results. The original full-mouth treatment protocol was based on three major elements that may have an impact on the outcome of the non-surgical therapy. The fi rst two were based on the previous microbio logical observations that proved trans location of periodontal pathogens from one pocket to another and from other oral niches to periodontal pockets.14, Full-mouth debridement and use of dis infectants such as chlorhexidine was suggested to control the re-infection, which may happen during conventional periodontal therapy. The other sug gested explanation for achieving bet ter outcomes by implementing the FMD approach was the release of more anti gens (LPS) in the blood circulation and the consequent body reaction and there fore acute inflammation and ultimately better healing, which was described as the Schwartzman reaction.^17 This was used to explain the greater rise in body temperature after the second session of scaling and root planing for patients in the test group. 30 According to Quirynen, the time scale of 24h between the start and completion of the debridement is critical to take advantage of this sys temic reaction. Apatzidou tested the immunological changes in the body fol lowing full-mouth and quadrant therapy and failed to show any significant dif ferences. However, the patients in this study were treated in less than 24h. They concluded that both therapies were asso ciated with a reduction in antibody titres and an increase in the binding ability of antibodies.^49 In relation to the possible role of disinfectants on the outcomes, costs or side-effects, there is insufficient and inconclusive research. The FMD approach may be useful in patients with poor oral hygiene during the early heal ing phase and could allow the patient to become accustomed to new oral hygiene measures. 26
Other considerations
The choice of appropriate end points and outcome measures will determine the study design for any clinical trial. Hujoel has made a strong case for ensur ing a direct relationship between true
be used as a true end point but the stud ies would have to include a large number of patients and be of very long duration. Patient level outcome measures such as quality of life, cost effectiveness, swift ness of treatment and side-effects have not been comprehensively tested in these studies.
Limitations of the review
The review is limited by the quality of the reported data. None of the studies reported actual data accessible for easy transformation in the meta-analysis. Clinical studies should, at least, report standard deviation around the mean and the standard error of mean for the appro priate data types. The authors of the studies were contacted for the raw data or any clarification or missing informa tion when necessary.
CONCLUSIONS
Implications for practice
The review suggests that mechanical or non-surgical periodontal treatment is effective but showed no difference in the periodontal clinical outcome meas ures between FRp and Q. The data sug gested that less treatment time may be needed for full-mouth debridement ther apy compared to conventional quadrant scaling and root planing. Limited data from the Leuven group shows advan tages for the FMD approach, consid ering strict use of CHX, compared to Q. However, this is still inconclusive and further studies are required in this field.
Implication for research
Randomised controlled trials (RCTs) with longer duration seem necessary. The researchers may find it useful to follow the Consolidated Standards of Reporting Trials (CONSORT) guidelines. The study designs should adhere to an agreed standard protocol for both full mouth disinfection and full-mouth debridement and have agreed standard outcome measures. In addition, the data should be presented in standard statisti cal manner to allow easy transformation for future reviews.
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