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Smiley CJ, Tracy SL et al. J Am Dent Assoc 2015; 146: 508–524

Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts

Smiley CJ, Tracy SL et al. J Am Dent Assoc 2015; 146: 525–535

These papers, from which a somewhat anodyne Clinical Practice Guideline is available free online, examine the efficacy of nonsurgical treatment of chronic periodontitis. The effects of adjunctive treatments on nonsurgical therapy are also examined. Those papers describing treatment outcomes for aggressive periodontitis were excluded.

In the first paper, the authors use the austere evidence-based approach. In the second paper, evidence is translated into softer specialist opinion. Authors of these papers were invited to make these contributions by the American Dental Association.

In the systematic review and meta-analysis based on studies of at least 6 months duration, 72 studies were included in the final analysis. The primary outcome measure was clinical attachment gain. There was only 0.5 mm improvement in clinical attachment with scaling and root planning compared with controls. However, in some studies, data was recorded as whole-mouth averages. Whole-mouth measurements 'may lead to underestimation of the treatment effect (in those with sites with extensive clinical attachment loss) by including healthy sites'. Only an additional 0.2-0.6 mm improvement was found with some only adjunctive therapies.

In the second paper, the key findings were: 1) scaling and root planning showed moderate benefit, with negligible adverse events that include flu symptoms and myalgia, 2) scaling and root planning should be used before any possible adjunctive therapy, and 3) when considering adjunctive therapy, although there was no differences in the benefits of systemic subantimicrobial-dose doxycycline (may not function as an antibiotic but as a matrix metalloproteinase inhibiting collagenase activity) compared with systemic antimicrobials. Nevertheless, the former is recommended because of the potential adverse effects with systemic antimicrobials. There were only weak recommendations for the use of chlorhexidine chips and photodynamic therapy with a diode laser. In addition, evidence is lacking as to the efficacy of doxycycline hyclate gel and minocycline microspheres. Of note, when considering adjunctive nonsurgical lasers, there was moderate to high certainty that 'there were no benefits or the potential harms outweigh the benefits...'.