Periodontology 2000, Vol.

51, 2009, 269275

Printed in Singapore. All rights reserved

 2009 John Wiley & Sons A/S

PERIODONTOLOGY 2000

Cost-effectiveness of various
treatment modalities for adult
chronic periodontitis
P E R E. G J E R M O & J O S T E I N G R Y T T E N

The aim of this review was to assess the cost-effectiveness of various modalities for chronic periodontitis in adults. We searched the literature for studies
where time consumption and monetary costs (where
available) were used as expressions of the resources
required to perform the following types of services:
providing information on the disease and oral
hygiene instruction for patients; removal of subgingival calculus; access surgery; and maintenance and
prevention of recurrence of the disease. The following
outcome variables were chosen: retention of teeth, or
a surrogate variable such as change in bone level
measured on X-rays taken at the start and at the end
of a 1-year (or longer) period. The literature search
did not reveal any studies where these outcome
variables could be linked to information on resources
used in treatment. Therefore, we reviewed relevant
studies where different treatment techniques were
used but where the outcome variables were different.
This review revealed that in most cases it was difficult
to assess whether one type of treatment (or intervention) is more effective than another. We conclude
that better data are needed, in particular on outcomes, so that valid comparisons can be made between different types of treatment, for different types
of studies.
Periodontal disease is an inflammatory disease
induced by bacterial plaque adhering to the tooth
surface in contact with the gingiva. A lesion that is
contained in the gingival margin is termed gingivitis.
Gingivitis may be regarded as the result of an
immunologic reaction and as an attempt by the
organism to prevent the development of the tissuedestructive component of periodontal disease called
periodontitis. Gingivitis will always precede periodontitis, but its development into periodontitis
is rare (50). The development of gingivitis into

periodontitis is multifactorial and is believed to

occur in susceptible individuals where homeostasis
is not successfully established by the host. Periodontitis is characterized by the loss of periodontal
fibers and alveolar bone, eventually leading to the
loss of teeth. The course of the disease and the rate
of progression are affected by genetic and environmental factors. These comprise variation in the
amount of bacteria (oral hygiene) and their composition in plaque (63), some medical disorders
(human immunodeficiency virus, diabetes) and
drugs affecting the immune system (steroids, calcium inhibitors) (34). In addition, life-style factors,
such as tooth-cleaning habits (58) and tobacco
consumption (9), seem to play an important role in
determining susceptibility to, and the rate of progression of, the disease. As a result of its chronic
character and the fact that the bacteria causing the
most common forms of periodontitis are microorganisms that are endogenous in the human oral
flora (and probably important for prevention of other
infections by exogenous bacteria), periodontitis has a
propensity for recurrence after treatment. In fact, the
only predictable method to eradicate periodontal
disease in a patient is to extract all teeth. However, in
spite of this as a treatment option, which would
probably be very cost-effective and one that has been
considered in special circumstances (17), it will not
be considered in this review.
Treatment of periodontitis has been directed towards the changeable risk factors, first and foremost oral hygiene and, in the later years, smoking
habits. The professional removal of bacterial plaque
from the tooth surfaces is crucial in all forms of
periodontal treatment, and training patients in the
daily self-removal of plaque is an essential part
of prevention of disease recurrence following

269

Gjermo & Grytten

treatment (33). The effect of tobacco consumption

has become more and more evident over the last
few decades (9), particularly concerning the more
severe forms of periodontitis (22). Therefore,
counseling regarding smoking and other forms of
tobacco use has become very important in combating this chronic disease. The treatment of
periodontitis thus includes changing life styles for
life, because the risk of recurrence will always follow a susceptible host, thus making the treatment
approach particularly complex, involving many
psychological aspects (12, 56).
The successful treatment of periodontitis is believed to prevent further progression of the tissuedestructive processes involved (13), not necessarily
to obtain an inflammation-free gingival margin.
Regeneration of lost tissue may occur, but this is rare
and of little magnitude, and is therefore usually not a
general goal for treatment. There is, however, no
agreement on how to assess treatment success. No
further tooth loss, or retention of teeth during a
definite time span, would be parameters that are
tangible for patients (10, 26). As periodontitis develops very slowly, even without treatment (39, 40), this
is difficult to assess in clinical trials. However, a few
studies have been conducted with fairly long observation periods and adequate outcome variables,
unfortunately without cost-effectiveness aspects included within their design (3, 20, 51). A concept
named quality-adjusted tooth-years (QATYs) has
been suggested (1), but this needs further development and testing before it can be recommended.
Consequently, surrogate variables are used. The most
common surrogate variables are strongly related to
the degree of inflammation of the periodontal tissues,
such as bleeding on probing, probing pocket depth
and clinical attachment level. Unfortunately, the
degree of inflammation is only vaguely predictive of
future loss of supporting tissues and teeth (36, 57).
Probably, a stable bone level, as assessed on radiographs, is the most valid assessment of no progression (27), but because of the slow development of the
disease in question, even studies with bone loss as
the outcome variable might require several years to
provide valid information about the effect of various
treatment approaches.
The systematic treatment of periodontitis thus
includes thorough information about the disease,
the causes and contributing factors (smoking, etc.),
and the impact of personal oral hygiene in addition
to the professional removal of supragingival and
subgingival plaque, calculus and overhangs on restorations and crowns (retention factors) (debride-

270

ment). In order to obtain access to subgingival root

surfaces, surgery may be necessary (33, 66). This
may comprise gingivectomy (removal of the gingiva
covering the root surfaces) or flap procedures where
the flaps are replaced and sutured after scaling and
root planing. Treatment with antibiotics, either
locally or systemically, is recommended in some
cases (30, 43, 45, 48, 61, 64). In addition, other
antimicrobial agents have been suggested (15, 18,
24, 31).
For mechanical debridement of the root surfaces a
number of techniques and instruments have been
developed, as well as suggestions on whether to treat
the entire oral cavity in one setting (to avoid contamination from untreated sites) (52), or to divide the
mouth into either sextants or quadrants that are
treated sequentially with weeks interval between
each session. Also, the sequence of treatments have
been subject to discussions about, for instance,
whether it is necessary to obtain a certain level of oral
hygiene before treatment planning, or whether prescaling before surgery should be recommended (6).
However, few studies including the economic aspects of the various approaches have been conducted, and in those that have been carried out, the
validity is often limited to one country and its social
and economic situation, the peoples needs and
requirements, and the national system for delivering
and paying for health services; therefore, these
studies have limited general validity. Some studies
have estimated the time needed for performing various periodontal treatment procedures as an expression of resources needed. In the present review we
will regard both time consumption and monetary
costs as expression of resources required to perform
treatment modalities.
Johansen et al. (28) presented the Periodontal
Treatment Need System (PTNS) which is based on
the three basic procedures: motivation and instruction in effective oral hygiene measures; subgingival
debridement of the root surfaces of periodontally
involved teeth; and debridement facilitated by
surgery. The resources needed for each of these
therapeutic measures were calculated as time consumption (7), and hypothetically applied to several
populations (8, 29). In a later study, Mubarak &
Gjermo (46) showed that the results were also
applicable to patients actually treated and with
acceptable accuracy. However, the Periodontal
Treatment Need System does not consider maintenance, which is regarded as an important and integral part of periodontal treatment and crucial for
long-term success (37, 38).

Cost-effectiveness of treatments for adult chronic periodontitis

Methods
In order to approach the problem of cost-effectiveness of treatment modalities, we decided to use, as
outcome variable, either tooth loss or retention, or as
surrogate variables, bone level measured on radiographs (27) in randomized clinical trials. Variables
indicating mostly variations in the degree of inflammation (bleeding on probing, probing pocket depth,
clinical attachment level) were not accepted. Thus,
we applied level 5, according to Lundgren et al. (42),
as our end point, which is a rather coarse measure
but which is tangible to people. In order to assess,
with a certain degree of confidence, that the treatment had resulted in arrest of the progression of the
disease, we required an observation time of at least
1 year.
The terms cost-effectiveness, costbenefit and
costutility have recently been discussed by Bragger
(10) and we chose to use his definitions. This implies
that cost-effectiveness studies could include studies
where more than one treatment modality reached the
same end-point and the costs were compared, or
where different results were obtained at the same
cost using different treatment modalities. Possible
benefits (firm teeth, chewing capacity, avoiding
prosthetic replacements) and adverse effects of a
treatment type (sensitivity, antibiotic resistance,
negative cosmetics) were disregarded.
A literature search was performed using the terms
periodontal therapy and cost-effectiveness, cost,
time consumption, time factor and time, and
periodontal treatment modalities and cost-effectiveness, cost, time consumption, time factor and
time, in Medline (PubMed) and the Cochrane
Library. In addition, a hand search was performed in
relevant journals after 2003 with special attention
given to reference lists in review articles on related
subjects.

Results
No randomized clinical trials were found that satisfied the requirements for an outcome variable that
was tangible for patients (tooth loss, tooth retention,
radiographic assessments of bone level) and of
sufficient duration to disclose further progression of
the disease after treatment (1 year). Thus, a systematic review was not possible. However, some
studies that tried to address the cost-effectiveness
aspects of periodontal treatment modalities were

identified and our further comments are based on a

narrative review of those studies and on previous
reviews of related subjects.

Results and discussion of the

narrative review (four treatment
modalities are considered)
Information about the disease and
practical training of patients in
practicing home-based optimal oral
hygiene
At a population level, regular check-ups, which
include professional plaque removal, demonstrate
positive effects upon periodontal health parameters
(47), but whether this is a cost-effective strategy to
apply to entire populations is questionable because
efforts would be spent on individuals not at risk of
periodontitis. Very few studies have been published
on providing information to, and training of, adult
periodontal patients, particularly where cost assessments have been taken into consideration.
Bellini (6) performed time studies on the motivation and instruction required to reach a defined level
of plaque control in adult patients. He concluded that
he needed an average of 72 min to reach an acceptable level of oral hygiene, and that this was not
associated with baseline oral hygiene or number of
teeth. Because of to the use of advertisements in the
mass media and the increased awareness of the need
for plaque control in the general public in western
countries (22), one would predict that lower resources are now required. There are indications from
studies in adolescents that the application of extra
resources in the form of repeated group teaching
and or with parent participation programs, in
addition to individual training in oral hygiene performance, displayed marginal gains only, compared
with more simplified programs (11, 25, 44). This is in
accordance with recent studies employing motivational interviewing to obtain patient compliance
(12, 56).
Some improvement in plaque control, as a result of
the use of electrical counter-rotational toothbrushes,
has been shown in controlled trials (32, 53, 54). In this
context one should mention that the cost of an
electric toothbrush has not been evaluated in relation
to the marginal gains reported over manual brushes
in reducing plaque levels. Moreover, there are indications in the literature that quit smoking programs
may be cost-effective (16).

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Gjermo & Grytten

Subgingival debridement
Subgingival debridement is the cornerstone of all
periodontal treatment (33), and many studies confirm its effectiveness in controlling mild to moderate
periodontitis (pockets 5 mm) (41, 62), (24, 20, 35,
51). For this purpose, various techniques and
instruments, both manual and machine driven, have
been developed and their effect compared (14, 19, 60,
65). The majority of studies show only marginal differences in outcome and time consumption for performing the various procedures (59, 67). One recent
review indicates that ultrasonic instrumentation of
single-rooted teeth may yield a time gain as compared with manual debridement (65). However, because the equipment necessary for ultrasonic, laser
or other machine-driven instruments infers extra
costs, scaling and root planing with manual scalers
may be regarded as the most cost-effective treatment
modality for mild and moderate disease. In severe
cases of periodontitis, adjunctive antibacterial treatment (systemically or locally applied) seems to
provide a small additional benefit (23, 45, 48, 64).
However, while the adjunctive use of systemically
applied antibiotics may be relatively cheap, the costs
for single tooth treatment with local drug-delivery
systems are not negligible (10). Full-mouth debridement (52), used in combination with systemic antibiotics, has shown a small, but clinically insignificant,
advantage over the conventional approach (37, 38).
For severe periodontitis (periodontal pockets
6 mm), closed nonsurgical treatment may be
insufficient to arrest the disease, although this is
generally recommended as the first treatment approach. The result of the nonsurgical approach must
then be evaluated and surgery performed if satisfactory results are not obtained (33). From a costeffectiveness perspective this approach will add
to the costs when surgery is necessary, compared to
the costs if surgery had been performed immediately
(6, 7).

Access surgery
In the treatment of chronic periodontitis, periodontal
surgery is performed to obtain access to affected root
surfaces for the removal of calculus and biofilm (68).
This may be obtained by gingivectomy or various flap
procedures. The type of procedure chosen does not
influence the outcome when this is assessed as no
further progression of the disease, provided that
optimal plaque control is maintained by the patient
(55). However, lack of plaque control after perio-

272

dontal surgery always results in failure (49), regardless of the surgical technique employed. This would
tend to favor gingivectomy as a result of the simplicity of the method that probably renders it
the more cost-effective option. However, other aspects, such as unwanted side effects (sensitivity,
cosmetics), may be influenced by the technique used
and should be evaluated when the choice is made.
There are indications that prescaling before surgery
may require more time than debridement after surgery (7). This would make it cost-effective to perform
surgery without prescaling if it is obvious that surgery
will be needed. It has been suggested that performing
scaling during or after surgery requires less time than
a systematic subgingival debridement (6, 7). The
difficulty is that there are no absolute criteria to
determine when surgery would be indicated.
Adjunctive systemic antibiotics have been shown
to offer some advantage to the treatment outcome in
severe periodontitis cases and in refractory periodontitis (45, 64), but a recent report questions the
usefulness in combination with surgical approaches
(23). However, the increased cost of a single course of
antibiotics does not influence the total cost of treatment in a way that would be decisive for the costeffectiveness of the treatment.

Maintenance and prevention of

recurrence
There is widespread agreement in the literature that
patients treated for periodontitis require life-long
maintenance, with needs-related supportive care,
which includes reinforcement of oral hygiene
practices, scaling and prophylaxis (20, 37, 38). It is
disputed how often these maintenance sessions are
required, but there are indications that several times
per year is no better than once a year and the value of
routine professional removal of plaque has been
questioned when patients home care is adequate (5).
Also, there are indications that the outcome of supportive periodontal care is better when taken care of
by specialists, compared with general practitioners,
but at a higher cost (21). Noncompliance with a
maintenance program, however, predictably results
in the recurrence of the disease (49). Local application of antibiotics in affected pockets during
maintenance care has been suggested (61), but at a
higher cost (10) and with an increased risk of
developing antibiotic resistance. It seems conceivable
that cost-effectiveness gains may be obtained in
maintenance programs, but thus far data are scarce
and inconclusive.

Cost-effectiveness of treatments for adult chronic periodontitis

Concluding remarks
As inflammation is variably associated with destructive disease and difficult for patients to assess, future
studies on the cost-effectiveness of periodontal
treatment modalities would benefit from focusing on
end point variables, such as tooth loss or tooth
retention, that are tangible for our patients. Because
of the slow progression of chronic periodontitis, even
in populations that do not receive treatment (39, 40),
the study period should preferably extend to several
years. The study period may be reduced if bone loss,
assessed on radiographs, is employed as a surrogate
outcome variable (27). Cost-effectiveness studies in
many other fields in medicine have the advantage of
having well-defined and distinct end points. For
example, with respect to the treatment of cancer, the
chosen end point is usually the 5-year survival rate. It
is easier to compare the costs of different types of
treatment when the expected outcome is well defined
and agreed upon, compared to when it is not.
Therefore, one challenge for periodontics is to develop outcome criteria that can be generally accepted
and to which costs can be related.
The narrative review of articles that were not accepted for our systematic review indicates that the
main cost gains in periodontal therapy would be
achieved by avoiding unnecessary surgery and by
applying intervals of 1 year or more in the life-long
maintenance phase. Variation in other modalities
would probably display only minor differences in
cost.

7.

8.

9.

10.

11.

12.

13.

14.
15.

16.

17.

References
1. Antczak-Bouckoms AA, Weinstein MC. Cost-effectiveness
analysis of periodontal disease control. J Dent Res 1987: 66:
16301635.
2. Axelsson P, Lindhe J. Effect of controlled oral hygiene
procedures on caries and periodontal disease in adults.
Results after 6 years. J Clin Periodontol 1981: 8: 239
248.
3. Axelsson P, Nystrom B, Lindhe J. The long-term effect of a
plaque control program on tooth mortality, caries and
periodontal disease in adults. Results after 30 years of
maintenance. J Clin Periodontol 2004: 31: 749757.
4. Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical
periodontal therapy. I. Moderately advanced periodontitis.
J Clin Periodontol 1981: 8: 5772.
5. Beirne P, Worthington HV, Clarkso JE. Routine scale and
polish for periodontal health in adults. Cochrane Database
Syst Rev 2007: (4): CDOO4625.
6. Bellini HT. A System to Determine the Periodontal Therapeutic Needs of a Population time evaluation and planning

18.

19.

20.

21.

22.

of treatment delivery. A Thesis. Oslo: Universitetsforlagets

trykningssentral, 1973.
Bellini HT. The time factor in periodontal therapy. A pilot
study correlating treatment time and plaque, calculus,
pocket depth, and number of teeth. J Periodontal Res 1974:
9: 5661.
Bellini HT, Gjermo P. Application of the Periodontal
Treatment Need System (PTNS) in a group of Norwegian
industrial employees. Community Dent Oral Epidemiol
1973: 1: 2229.
Bergstrom J, Eliasson S, Dock J. A 10-year prospective study
of tobacco smoking and periodontal health. J Periodontol
2000: 71: 13381347.
Bragger U. Cost-benefit, cost-effectiveness and cost-utility
analyses of periodontitis prevention. J Clin Periodontol
2005: 32(Suppl. 6): 301313.
Buischi Y, Oliveira L, Mayer M, Gjermo P. Effect of two
preventive programs on knowledge and habits among
Brazilian schoolchildren. Community Dent Oral Epidemiol
1994: 22: 4146.
Burke BL, Dunn CW, Atkins DC, Phelps JS. The emerging
evidence base for motivational interviewing: a meta-analytic and qualitative inquiry. J Cogn Psychother 2004: 18:
309322.
Claffey N, Polyzois I. Non-surgical therapy. In: Lindhe J,
Lang NP, Karring T editors. Clinical periodontology and
implant dentistry, 5th edn. Oxford: Blackwell Publishing
Ltd, 2008: 766779.
Cobb CM. Lasers in periodontics: a review of the literature.
J Periodontol 2006: 77: 545564.
Cosyn J, Wyn I. A systematic review on the effects of the
chlorhexidine chip when used as an adjunct to scaling and
root planing in the treatment of chronic periodontitis.
J Periodontol 2006: 77: 257264.
Davies I, Karring T, Norderyd O. Advances in the
behavioural and public health aspects of periodontitis.
Group D consensus report of the fifth European workshop
in periodontology. J Clin Periodontol 2005: 32(Suppl. 6):
326327.
de Baat C, van Elswijk JF, Kalk W. Serious periodontal
destruction in the elderly. Intensive treatment or an overdenture prosthesis? (Dutch with English summary).
Ned Tijdschr Tandheelkd 1997: 12: 467469.
De Lissovoy G, Rentz AM, Dukes EM, Eaton CA, Jeffcoat
MK, Killoy WJ, Finkelman RD. The cost-effectiveness of a
new chlorhexidine delivery system in the treatment of
adult periodontitis. J Am Dent Assoc 1999: 130: 855862.
Eberhard J, Ehlers H, Falk W, Acil Y, Albers H-K, Jepsen S.
Efficacy of subgingival calculus removal with Er:YAG laser
compared to mechanical debridement. An in situ study.
J Clin Periodontol 2003: 30: 511518.
Eickholz P, Kaltschmitt J, Berbig J, Reitmeir P, Pretzl B.
Tooth loss after active periodontal therapy. 1: patientrelated factors for risk, prognosis, and quality of outcome.
J Clin Periodontol 2008: 35: 165174.
Gaunt F, Devine M, Pennington M, Vernazza C, Gwynnett
E, Steen N, Heasman P. The cost-effectiveness of supportive periodontal care for patients with chronic periodontitis. J Clin Periodontol 2008: 35(Suppl. 8): 6782.
Gjermo P. Impact of periodontal preventive programs on
the data from periodontal epidemiology. J Clin Periodontol
2005: 32(Suppl. 6): 294300.

273

Gjermo & Grytten

23. Herrera D, Alonso B, Leon R, Roldan S, Sanz M. Antimicrobial therapy in periodontitis: the use of systemic
antimicrobials against the subgingival biofilm. J Clin Periodontol 2008: 35(Suppl. 8): 4566.
24. Hoang T, Jorgensen MG, Keim RG, Pattison AM, Slots J.
Povidone-iodine as a periodontal pocket disinfectant.
J Periodontal Res 2003: 38: 311317.
25. Hugoson A, Lundgren D, Asklow B, Borgklint B. The effect
of different dental health programmes on young adult
individuals. A longitudinal evaluation of knowledge and
behaviour including cost aspects. Swed Dent J 2003: 27:
115130.
26. Hujoel PP, Powell LW, Kiyak HA. The effects of single
interventions on tooth mortality: findings in one trial
and implications for future studies. J Dent Res 1997: 76:
867874.
nerud A
, Boysen H, Leroux BG. The
27. Hujoel PP, Loe H, A
informativeness of attachment loss on tooth mortality.
J Periodontol 1999: 70: 4448.
28. Johansen JR, Gjermo P, Bellini HT. A system to classify the
need for periodontal treatment. Acta Odontol Scand 1973:
31: 297305.
29. Johansen JR, Gjermo P, Haugen E. The need for periodontal
treatment in an urban population. J Clin Periodontol 1975:
2: 226230.
30. Jorgensen MG, Slots J. The ins and outs of periodontal
antimicrobial therapy. J Calif Dent Assoc 2002: 30: 297
305.
ller W, Kleber B-M,
31. Kaner D, Bernimoulin J-P, Hopfenmu
Friedmann A. Controlled-delivery chlorhexidine chip versus amoxicillin metronidazole as adjunctive antimicrobial
therapy for generalized aggressive periodontitis: a randomized controlled clinical trial. J Clin Periodontol 2007:
34: 880891.
32. Killoy WJ, Love JW, Love JD, Tira DE. Clinical and cost
effectiveness of the counter-rotational brush in private
practice. Compend Contin Educ Dent 1993: 14(Suppl 16):
599605.
33. Kinane DF, Lindhe J, Trombelli L. Chronic periodontitis. In:
Lindhe J, Lang NP, Karring T editors. Clinical periodontology and implant dentistry, 5th edn. Oxford: Blackwell
Publishing Ltd, 2008: 420427.
34. Kinane DF, Berlundh T, Lindhe J. Pathogenesis of periodontitis. In: Lindhe J, Lang NP, Karring T editors. Clinical
periodontology and implant dentistry, 5th edn. Oxford:
Blackwell Publishing Ltd, 2008: 286306.
35. Knowles JW, Burgett FG, Nissle RR, Shick RA, Morrison EC,
Ramfjord SP. Results of periodontal treatment related to
pocket depth and attachment level. Eight years. J Periodontol 1979: 50: 225233.
36. Lang NP, Joss A, Tonetti MS. Monitoring disease during
supportive periodontal treatment by bleeding on probing.
Periodontol 2000 1996: 12: 4448.
37. Lang NP, Tan WC, Krahenmann MA, Zwahlen M. A systematic review of the effects of full-mouth debridement
with and without antiseptics in patients with chronic
periodontitis. J Clin Periodontol 2008: 35(Suppl. 8): 821.
38. Lang NP, Bragger U, Salvi GE, Tonetti MS. Supportive
periodontal therapy. In: Lindhe J, Lang NP, Karring T
editors. Clinical periodontology and implant dentistry,
5th edn. Oxford: Blackwell Publishing Ltd, 2008: 1297
1321.

274

39. Lindhe J, Haffajee AD, Socransky SS. Progression of periodontal disease in adult subjects in the absence of periodontal therapy. J Clin Periodontol 1983: 10: 433442.
nerud A
, Boysen H, Morrison E. Natural history of
40. Loe H, A
periodontal disease in man. Rapid, moderate and no loss of
attachment in Sri Lankan laborers 1446 years of age. J Clin
Periodontol 1986: 13: 431445.
41. Lvdal A, Arn O, Schei O, Waerhaug J. Combined effect of
sub-gingival scaling and controlled oral hygiene on the
incidence of gingivitis. Acta Odontol Scand 1961: 19:
537555.
42. Lundgren D, Asklow B, Thorstensson H, Harefeldt AM.
Success rates in periodontal treatment as related to choice
of evaluation criteria. Presentation of an evaluation criteria
staircase for cost-benefit use. J Clin Periodontol 2001: 28:
2330.
43. Mariotti A, Monroe PJ. Pharmacologic management of
periodontal diseases using systematically administered
agents. Dent Clin North Am 1998: 42: 245262.
44. Mayer MPA, Buischi YP, Oliveira LB, Gjermo P. Long term
effect of an oral hygiene training program on knowledge
and behaviour. Oral Health Prev Dent 2003: 1: 3743.
45. Mombelli A. Antibiotics in periodontal therapy. In: Lindhe
J, Lang NP, Karring T editors. Clinical periodontology and
implant dentistry, 5th edn. Oxford: Blackwell Publishing
Ltd, 2008: 882897.
46. Mubarak A, Gjermo P. Assignment of dental school
patients using periodontal treatment need indices. Brief
communication. J Dent Educ 1990: 54: 213215.
47. Needleman I, Suvan J, Moles DR, Pimlott J. A systematic
review of professional mechanical plaque removal for
prevention of periodontal diseases. J Clin Periodontol 2005:
32(Suppl. 6): 229282.
48. Niederman R, Abdelshehid G, Goodson JM. Periodontal
therapy using local delivery of antimicrobial agents. Dent
Clin North Am 2002: 46: 665677.
49. Nyman S, Lindhe J, Rosling B. Periodontal surgery in plaque-infected dentitions. J Clin Periodontol 1977: 4:
240249.
50. Page RC, Schroeder HE. Periodontitis in man and other
animals. A comparative review. Basel: S. Karger, 1982.
51. Paulander J, Axelsson P, Lindhe J, Wennstrom J. Intra-oral
pattern of tooth and periodontal bone loss between the age
of 50 and 60 years. A longitudinal prospective study. Acta
Odontol Scand 2004: 62: 214222.
52. Quirynen M, Bollen CM, Vandekerckhove BN, Dekeyser C,
Papaionno W, Eyssen H. Full- vs. partial-mouth disinfection in the treatment of periodontal infections: short-term
clinical and microbiological observations. J Dent Res 1995:
74: 14591467.
53. Robinson PG, Deacon SA, Deery C, Heanue M, Walmsley
AD, Worthington HV, Glenny AM, Shaw WC. Manual versus
powered toothbrushing for oral health. Cochrane Database
Syst Rev. 2005: (2): CD002281.
54. Roscher T, Rosing CK, Gjermo P, Aass AM. Effect of
instruction and motivation in the use of electric and
manual toothbrushes in periodontal patients. A comparative study. Braz Oral Res 2004: 18: 296300.
55. Rosling B, Nyman S, Lindhe J, Jern B. The healing potential
of the periodontal tissues following different techniques of
periodontal surgery in plaque-free dentitions. A 2-year
clinical study. J Clin Periodontol 1976: 3: 233255.

Cost-effectiveness of treatments for adult chronic periodontitis

56. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis.
Br J Gen Pract 2005: 55: 305312.
nerud A
, Boysen H, Lang
rgin W, A
57. Schatzle M, Loe H, Bu
NP. Clinical course of chronic periodontitis. I. Role of
gingivitis. J Clin Periodontol 2003: 30: 887901.
58. Schei O, Waerhaug J, Lovdal A, Arno A. Alveolar bone loss
related to oral hygiene and age. J Periodontol 1959: 30: 716.
59. Schwarz F, Aoki A, Becker J, Sculean A. Laser application in
non-surgical periodontal therapy: a systematic review.
J Clin Periodontol 2008: 35(Suppl. 8): 2944.
60. Schwarz F, Sculean A, Georg T, Reich E. Periodontal
treatment with an ER:YAG laser compared to scaling and
root planing: a controlled clinical study. J Periodontol 2001:
72: 361367.
61. Slots J, Jorgensen MG. Efficient antimicrobial treatment in
periodontal maintenance care. J Am Dent Assoc 2000: 131:
12931304.
62. Soumi JD, Greene JC, Vermillion JR, Doyle J, Chang JJ,
Leatherwood ER. The effect of controlled oral hygiene
procedures on the progression of periodontal disease in
adults: results after third and final year. J Periodontol 1971:
42: 152160.

63. Tatakis DN, Trombelli L. Modulation of clinical expression

of plaque-induced gingivitis. J Clin Periodontol 2004: 31:
229238.
64. Tinoco EMB, Beldi MI, Campedelli F, Lana M, Lourero
CA, Bellini HT, Rams TE, Tinoco NMB, Gjermo P, Preus
HR. Clinical and microbiologic effects of adjunctive
antibiotics in treatment of localized juvenile periodontitis. A controlled clinical trial. J Periodontol 1998: 69:
13551363.
65. Tunkel J, Heinecke A, Flemming TF. A systematic review of
efficacy of machine-driven and manual sugingival
debridement in the treatment of chronic periodontitis.
J Clin Periodontol 2002: 29(Suppl. 3): 7281.
66. Waerhaug J. Healing of the dento-epithelial junction following subgingival plaque control. I. As observed in human
biopsy material. J Periodontol 1978: 49: 18.
67. Walmsley AD, Lea SC, Landini G, Moses AJ. Advances in
power driven pocket root instrumentation. J Clin Periodontol 2008: 35(Suppl. 8): 2228.
68. Wennstrom JL, Heijl L, Lindhe J. Periodontal surgery:
access therapy. In: Lindhe J, Lang NP, Karring T editors.
Clinical periodontology and implant dentistry, 5th edn.
Oxford: Blackwell Publishing Ltd, 2008: 783824.

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