Treating all teeth (full mouth) within 24 hours for chronic gum disease (periodontitis) in adults

Review question

Long lasting (chronic) gum disease causes damage to the gums and soft tissue structures around teeth. This review seeks to evaluate the effectiveness of full-mouth treatments carried out within 24 hours compared to the more conventional treatment of partial mouth scaling and root planing (SRP) usually done over a number of weeks. The treatments being reviewed are full-mouth scaling (FMS) and full-mouth disinfection (FMD). A secondary aim was to establish if there was a difference in effectiveness between FMS and FMD. This review updates our previous review published in 2008.

Background

Gum disease or periodontitis is a chronic inflammatory disease that causes damage to the soft tissue and bone around the teeth. Mild periodontitis is common in adults with severe periodontitis occurring in up to 20% of the population. Non-surgical treatments based on the mechanical removal of bacteria from infected root surfaces are used in order to arrest and control the loss of the bone and tissue that support the tooth in adults suffering from chronic gum disease. These treatments can be carried out in a different area of the mouth in separate sessions over a period of several weeks (SRP), which is the conventional method, or alternatively, can be done within 24 hours in one or two sessions, which is termed 'full-mouth scaling' (FMS). When an antiseptic agent (such as chlorhexidine for example) is added to the full-mouth scaling the intervention is called 'full-mouth disinfection' (FMD). The rationale for full-mouth approaches is that they may reduce the likelihood of re-infection in already treated sites.

Study characteristics

This review, carried out within the Cochrane Oral Health Group, is an update of one we published in 2008 and the evidence is current up to March 2015. We identified another five relevant studies for inclusion in this review and therefore this review includes 12 studies, which involved 389 participants. There is one Chinese study awaiting classification. Participants in the included studies were aged between 27 and 78 years, and there were roughly the same number of men and women involved.

The studies we included had to be randomised controlled trials with at least three months of follow-up that evaluated full-mouth scaling and root planing within 24 hours. Both FMS and FMD were compared to conventional quadrant scaling and root planing, which was the control group. Participants had to have a clinical diagnosis of chronic periodontitis according to the International Classification of Periodontal Diseases. We excluded studies of people with aggressive periodontitis, systemic disorders or who were taking antibiotics.

Key results

Treatment effects of FMS and FMD compared to conventional scaling and root planing (SRP) are modest and there are no clear implications for periodontal care. Harms and adverse events were reported in eight studies. The most important harm identified was an increased body temperature after FMS or FMD treatments. In practice, the decision to select one approach to non-surgical periodontal therapy over another can include patient preference and the convenience of the treatment schedule.

Quality of the evidence

The quality of the evidence is low for all treatment comparisons and outcomes. This is due to the small number of studies and participants involved and limitations in the study designs. Future research is likely to change findings.

Authors' conclusions: 

The inclusion of five additional RCTs in this updated review comparing the clinical effects of conventional mechanical treatment with FMS and FMD approaches for the treatment of chronic periodontitis has not changed the conclusions of the original review. From the twelve included trials there is no clear evidence that FMS or FMD provide additional benefit compared to conventional scaling and root planing. In practice, the decision to select one approach to non-surgical periodontal therapy over another should include patient preference and the convenience of the treatment schedule.

Read the full abstract...
Background: 

Periodontitis is chronic inflammation that causes damage to the soft tissues and bones supporting the teeth. Mild to moderate periodontitis affects up to 50% of adults. Conventional treatment is quadrant scaling and root planing. In an attempt to enhance treatment outcomes, alternative protocols for anti-infective periodontal therapy have been introduced: full-mouth scaling (FMS) and full-mouth disinfection (FMD), which is scaling plus use of an antiseptic. This review updates our previous review of full-mouth treatment modalities, which was published in 2008.

Objectives: 

To evaluate the clinical effects of 1) full-mouth scaling (over 24 hours) or 2) full-mouth disinfection (over 24 hours) for the treatment of chronic periodontitis compared to conventional quadrant scaling and root planing (over a series of visits at least one week apart). A secondary objective was to evaluate whether there was a difference in clinical effect between full-mouth disinfection and full-mouth scaling.

Search strategy: 

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 26 March 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2015, Issue 2), MEDLINE via OVID (1946 to 26 March 2015), EMBASE via OVID (1980 to 26 March 2015) and CINAHL via EBSCO (1937 to 26 March 2015). We searched the US National Institutes of Health Trials Register (ClinicalTrials.gov) and the WHO International Clinical Trials Registry Platform for ongoing studies. There were no restrictions regarding language or date of publication in the searches of the electronic databases. We scanned reference lists from relevant articles and contacted the authors of eligible studies to identify trials and obtain additional information.

Selection criteria: 

We included randomised controlled trials (RCTs) with at least three months of follow-up that evaluated full-mouth scaling and root planing within 24 hours with adjunctive use of an antiseptic such as chlorhexidine (FMD) or without the use of antiseptic (FMS), compared to conventional quadrant scaling and root planing (control). Participants had a clinical diagnosis of chronic periodontitis according to the International Classification of Periodontal Diseases. We excluded studies of people with aggressive periodontitis, systemic disorders or who were taking antibiotics.

Data collection and analysis: 

Several review authors independently conducted data extraction and risk of bias assessment (which focused on method of randomisation, allocation concealment, blinding of examiners and completeness of follow-up). Our primary outcome was tooth loss and secondary outcomes were change in probing pocket depth (PPD), bleeding on probing (BOP) and probing attachment (i.e. clinical attachment level; CAL), and adverse events. We followed the methodological guidelines of The Cochrane Collaboration.

Main results: 

We included 12 trials, which recruited 389 participants. No studies assessed the primary outcome tooth loss.

Ten trials compared FMS and control; three of these were assessed as being at high risk of bias, three as unclear risk and four as low risk. There was no evidence for a benefit for FMS over the control for change in probing pocket depth (PPD), gain in probing attachment (i.e. clinical attachment level; CAL) or bleeding on probing (BOP). The difference in changes between FMS and control for whole mouth PPD at three to four months was 0.01 mm higher (95% CI -0.17 to 0.19, three trials, 82 participants). There was no evidence of heterogeneity. The difference in changes for CAL was 0.02 mm lower (95% CI -0.26 to 0.22, three trials, 82 participants), and the difference in change in BOP was 2.86 per cent of sites lower (95% CI -7.65 to 1.93, four trials, 120 participants).

We included six trials in the meta-analyses comparing FMD and control, with two trials assessed as being at high risk of bias, one as low and three as unclear. The analyses did not indicate a benefit for FMD over the control for PPD, CAL or BOP. The difference in changes for whole-mouth PPD between FMD and control at three to four months was 0.13 mm higher (95% CI -0.09 to 0.34, two trials, 44 participants). There was no evidence of heterogeneity. The difference in changes for CAL was 0.04mm higher (95% CI -0.25 to 0.33, two trials, 44 participants) and the difference in change in BOP being 12.59 higher for FMD (95% CI -8.58 to 33.77, three trials, 68 participants).

Three trials were included in the analyses comparing FMS and FMD. The mean difference in PPD change at three to four months was 0.11 mm lower (-0.34 to 0.12, two trials, 45 participants) indicating no evidence of a difference between the two interventions. There was a difference in the gain in CAL at three to four months (-0.25 mm, 95% CI -0.42 to -0.07, two trials, 45 participants), favouring FMD but this was not found at six to eight months. There was no evidence for a difference between FMS and FMD for BOP (-1.59, 95% CI -9.97 to 6.80, two trials, 45 participants).

Analyses were conducted for different teeth types (single- or multi-rooted) and for teeth with different levels of probing depth at baseline, for PPD, CAL and BOP. There was insufficient evidence of a benefit for either FMS or FMD.

Harms and adverse events were reported in eight studies. The most important harm identified was an increased body temperature after FMS or FMD treatments.

We assessed the quality of the evidence for each comparison and outcome as 'low' because of design limitations leading to risk of bias and because of the small number of trials and participants, which led to imprecision in the effect estimates.

Share/Save