Bench-to-bedside review : Ethical challenges for those in directing roles in critical care units Though much attention in the medical literature has focused on the ethics of critical care , it seems to be disproportionately weighted toward clinical issues . On the presumption that the operational management of an intensive care unit -LRB- ICU -RRB- also requires ethical considerations , it would be useful to know what these are . This review undertook to identify what literature exists with regard to the non-clinical issues of ethical importance in the ICU as encountered by clinician -- managers . We found that in addition to issues of resource allocation , there exist many areas of ethical importance to clinician -- managers in the ICU that have been described only superficially . We argue that a renewed focus on ICU ethics is merited to shed light on these other , non-clinical , issues . Introduction As a specialized field of philosophy , ethics has demanded that more institutions self-assess their actions so as to implement and maintain ethical practice -LRB- see the Additional file for definitions of ` ethical practice ' and ` ethics ' -RRB- . In healthcare , technological and bureaucratic complexities have created dilemmas never before encountered , at least on the scale in which they now occur . Nowhere are these two issues , a push to self-analyze critically and an increase in novel dilemmas , more present than in the intensive care unit -LRB- ICU -RRB- . The ICU is a place both where patients are exposed to modern advances in health technology and where some of the most challenging questions for bioethicists occur . Because of the pervasiveness of ethical considerations , it is logical to assume that the ethics knowledge base would be well documented in the ICU . In fact , a cursory search of the phrase ` critical care ethics ' in PubMed between 1966 and 2004 cited an impressive 1090 articles . Because a more focused search on ` end of life ethics ' returned 986 articles , it seems that much of the published literature has a particular focus . The assumption that end-of-life issues represent the only ethical issue in the ICU was challenged by DeVita and colleagues ' review -LSB- 1 -RSB- of all of the ethics manuscripts published in Critical Care Medicine . Although they identified a spectrum of ICU ethical issues in addition to end-of-life care such as futility , research , resource distribution , informed consent , and resuscitation , three issues are apparent to us . First , the number of manuscripts that they classified as ` end-of-life ' far exceeded all other ethical topics -LRB- 45 more than the second most common topic -RRB- . Second , most of the additional ethical topics identified are issues that occur in the context of patient -- physician or patient -- nurse interactions . Third , on the presumption that the process of managing an ICU requires difficult moral decisions to be made , there seems to be a gap in the published literature with regard to the process of non-clinical decisions of ethical importance in the ICU . ICU directors and nurse managers are required to make difficult decisions with respect to protocols , staffing , and administration of the ICU . Arguably , these have equal , maybe even greater , ethical importance than decisions made at the bedside , because management decisions can affect multiple patients , in a less direct , and transparent , manner . Perhaps the bedside can be described as a simpler ethical environment in that it involves fewer external factors and agents to consider , and the consequences of actions are immediately apparent to all . If the dual roles that ICU physician directors and nurse managers occupy create unique ethical challenges that can not be adequately captured by either the traditional principalism of medical bioethics because bioethics does not take into account the fundamentals of business , or the existing models of business ethics because these fail to account for the values of medicine , it is possible they should be addressed as a separate entity . The aim of this paper is to review briefly what ethical issues faced by ICU ` clinician -- managers ' have been described , and to understand the context in which they are addressed . Method To identify publications that focused on ethical issues faced by professionals who occupy both clinical and administrative roles in ICUs , abstract and title searches were performed in Medline/PubMed and CINAHL databases using combinations of the following keywords : Ethics , Clinician-Manager , Critical Care , Intensive Care Unit -LRB- ICU -RRB- , Management , Leadership , Decision-making , Roles , Administration , Medical Directors , and Policy . Our search included primary literature , review , and opinion articles and the inclusion criteria were : 1966 to July 2004 , English language , mention of critical or intensive care , direct mention of ethics OR discussed an ethical issue . An article was considered to have discussed an ethical issue if there was recognition of uncertainty about the correct choice of action in a given situation . Thus , any article that asserted one practice to be superior to another , whether anecdotally or as demonstrated by some research , was not considered to recognize an ethical concern . Articles were excluded if managed care was the source of the ethical dilemma and/or the ethical issue was strictly clinical in nature , not including the use of treatment policies because clinician -- managers were considered to have a special interest in policy ; that is , any ICU physician dealing with the issue was qualified to decide on the appropriate course of action . In addition , references from captured articles were searched to identify additional literature that might not have been captured in the initial search . We also hand-searched the following journals : Bioethics -LRB- 1997 to present -RRB- , Critical Care , Critical Care Clinics , Critical Care Medicine -LRB- 1985 to present -RRB- , American Journal of Respiratory and Critical Care Medicine -LRB- 1994 to present -RRB- , and Intensive Care Medicine -LRB- 1993 to present -RRB- . Finally , the following key authors , identified by their previous ethics-related literature , were contacted to identify any articles that our search did not capture : Martin Strosberg , Kurt Darr , Dr G Rubenfeld , Dr C Sprung , and Dr J Luce . Results Of the roughly 1500 articles identified in our search , only 55 met the screening criteria that identified them as concerning an ethical challenge for clinician -- managers in critical care . A distribution across time of these articles can be seen in Fig. 1 . After an initial review of all the articles that met the screening criteria , broad categories were arbitrarily chosen to sort the results as follows : resource allocation ; organizational ethics -LRB- namely , how intensive care ought to be organized -RRB- ; policies and protocols -LRB- formulation and implementation -RRB- ; professional roles -LRB- namely , what the role of ` directors ' should be -RRB- ; ethics and law ; general ICU ethics -LRB- ICU ethics in the broadest sense -RRB- ; and other -LRB- Table 1 -RRB- . PubMed categorized 23 -LRB- 42 % -RRB- of the 55 articles that met all screening criteria as either review articles or editorials ; these review articles and editorials were evenly distributed between our categories . Articles classified as ` resource allocation ' papers mostly included discussions on which principles -LRB- such as justice , reasonableness as fairness -RRB- ought to apply when distributing scarce resources in the ICU . Some articles were more detailed , and described dilemmas such as age-based rationing -LSB- 2 -RSB- while still framing the question in terms of specific ethical principles and how they each affect the decision . One article sought to use cases to identify the ICU physicians ' ethical role in distributing scarce resources -LSB- 3 -RSB- . By focusing attention on the physicians ' role and not the ethical principles themselves , a whole new series of questions arose . It is noteworthy that the American Thoracic Society addresses the issue in a consensus statement outlining ethical guidelines for fair resource allocation -LSB- 4 -RSB- , and the American College of Chest Physicians and the Society of Critical Care Medicine similarly discuss the ethics of resource allocation in their moral guidelines regarding the withdrawal of intensive care -LSB- 5 -RSB- . Articles classified as ` organizational ' had a scope that ranged from what makes an ICU safe , to what should be taught to students in the ICU , to the ethical issues surrounding the use of restraints . Nelson describes an organization issue by illustrating how ethics is an everyday concern , with regard to issues like collaboration , staff conflict , and moral burnout -LSB- 6 -RSB- . This view is in contrast to the assumption that bioethics matters only when there is a specific dilemma . Additional articles on the use of restraints were classified as ` protocols and policies ' because their focus was primarily on the policies themselves . Also in ` protocols and policies ' was a discussion on the value of having a family presence protocol for life-saving procedures -LSB- 7 -RSB- ; that is , is allowing families to witness resuscitation the right thing to do ? The two articles under the heading ` professional roles ' discussed the changing roles of ICU physicians , especially with regard to a transition to managerial duties ; this issue is discussed below . ` General ethics ' articles included all papers that discussed ICU ethics in the broadest sense with less attention to the details ; many of these articles were brief reviews of the numerous ethical considerations in an ICU . Discussion Ethical issues are usually expressed as a conflict of ideas , values , and/or norms that are often role dependent . It should therefore be expected that ICU physician directors and nurse managers , who have both clinical and non-clinical duties , should face some of the more difficult moral conflicts in the ICU . In one respect , these professionals follow a patient-centered code of conduct , either the Hippocratic oath or the Nursing Professional Code , which in part defines them . At the same time , they are also agents of the hospital as ` a business ' , and implicitly society as a whole . Although some clinicians completely relinquish their clinical duties on transition to management , most do not ; the professional nature of medicine therefore gives the clinician a patient-centered outlook that is not as easily set aside : once a doctor or nurse , always a doctor or nurse . In summary , the physician director and nurse manager will always be in the unique position of having two separate professional standpoints from which to assess situations , which can therefore lead to unique ethical challenges . We have begun to characterize the scope and uniqueness of ethical issues that are raised by the dual roles of clinician -- managers in the ICU . In reviewing the health literature , we found that almost half of the articles identified that discussed ethical concerns for ICU clinician -- managers were concerned with resource allocation . This is probably not surprising given that ICU clinicians are increasingly adopting the role of economic rationalist -LSB- 8 -RSB- . Perhaps the real surprise of these results is how many articles concerned issues other than resource allocation . Although DeVita and colleagues pointed out that ` end-of-life ' was not the only ethical concern in the ICU -LSB- 1 -RSB- , which they took to be a common assumption , we argue that there is more to the ethics of directing roles in the ICU than issues of resource allocation . In this initial survey of the ethical issues experienced by those in dual management -- clinician roles in the ICU , important to our conclusion was the development of a categorization scheme . In the absence of any unique approach , we were arbitrary in our definition of categories . Although some of the articles we identified could have been placed in more than one category , or in categories not used , we believe our approach to be valid for the modest purposes of this survey . Additionally , some articles that discussed issues of clinical ethics in the ICU might have contained less prominent opinions or notes relevant to clinician -- managers and therefore might have been missed by our search . In spite of these potential issues , the articles selected were distributed to give both a clear and defined picture of what currently exists with regard to ICU ethics for those in both clinical and directing roles at the same time . We also believe it is likely that there were many articles that discussed ethical issues relevant to our review , yet failed to recognize the issues as being ` ethical ' in nature . For example , many articles described the nuances of resource allocation in the ICU -LRB- see the Introduction -RRB- , yet neither mentioned ethics or recognized any uncertainty with regard to the ` right ' thing to do . The fact that many articles fail to address their ethical components might indicate a lack of awareness of what constitutes an ethical dilemma , but even if this is not so , the goal of better recognition and acknowledgement of the ethical issues that suffuse the operational management of the ICU is desirable . Resource allocation is a well-defined topic of ethical interest that has stimulated much discussion . However , it is important not to perceive resource allocation as the beginning and end of the ethics discussion for clinician -- managers in critical care . Perhaps it is also time to move beyond the commentary on resource allocation and devote more research initiatives toward this topic -LRB- for example by studying the different approaches to resource allocation -RRB- . The term ` organizational ethics ' is used to denote how a business or institution ought to be organized in any number of ways , including management functions , working environments , and its infrastructure . It should not come as a surprise that organizational ethics should constitute a concern for either an ICU director or a nurse manager , yet over the past 20 years only a handful of articles have been written about the organizational ethics of intensive care and have recognized them as such . Although policies and protocols for an ICU could also fall under the heading of ` organizational ethics ' , we believe that determining and implementing policies might require ethical concerns that merit special attention . The use of any policy that deals with either patients or staff is to apply one rule to many different people , and necessarily ignores factors that make individual cases unique . Because policies tend to generalize in this way , they create unique ethical challenges . Little reflection is required to determine that both of these issues , organizational ethics and the ethics of policy , constitute ethical concerns for directors in the ICU in which further study is merited . The role of the ICU physician director , or nurse director / manager , is an ethical issue itself . Although two articles were identified that addressed this issue , we believe that the paucity of articles found indicate a need for greater consciousness of the ethical factors that influence and are influenced by clinical leaders in the dual roles of ` clinician ' and ` manager ' . Although healthcare leaders are familiar with the importance of ethics , they may be unaccustomed to thinking of their own role in terms of ethics -LSB- 9 -RSB- . Because the ICU director , or nurse manager , may engage in the decision making process from multiple professional standpoints -LRB- as both clinician and manager -RRB- , the likelihood of conflicting rational and justifiable solutions , leading to ethical dilemmas , increases . The clinician -- manager role , then , may require a higher level of ethical proficiency , or perhaps expertise . Conclusion In summary , we believe it is important that future study be directed toward understanding ethical issues surrounding the dual roles of clinician -- managers in the ICU . Although it has been acknowledged that hospitals should pay as much attention to managerial ethics as to clinical ethics -LSB- 10 -RSB- , it is not yet clear that this in fact occurs . One step in a research agenda would be to undertake a survey to determine if the published literature , identified by this review , is in fact an accurate representation of what is experienced . Understanding the scope of ethical issues experienced by clinician -- managers in the ICU will foster a more complete dialogue . Further , although there are studies that describe the process of ethical reasoning in nurses and other clinicians -LSB- 11-13 -RSB- , similar studies have not been performed with clinician -- directors , be they nurses or physicians . These investigative steps toward a better understanding of the issues , and how they are understood and dealt with , ought to include direct input from ICU clinician -- managers . Input from ICU clinician -- managers with a background in , or special knowledge of , ethics would be particularly beneficial , because they would possess the language to describe what most feel by intuition . This experiential knowledge would best be conveyed in an open-interview or narrative format in which actual dilemmas can be discussed . Finally , the resulting data will require detailed qualitative analysis and might benefit from the support of a medical sociologist . For all critical care leaders , there is now an opportunity to promote a better understanding of the complexity of the ICU environment and to prompt further learning . Abbreviations ICU , intensive care unit . Competing interests The author -LRB- s -RRB- declare that they have no competing interests . Supplementary Material Additional File 1 A complete list of categorized references for all articles captured in this review can be found here . click here for file

O O O O O O O O O O O B I O O O O O O O O O O O O B O B I O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B I B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B I O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O B I O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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Nonsurgical

and

surgical

periodontal

therapy

in

single-rooted

teeth

The

purpose

of

this

study

was

to

compare

the

effect

of

tooth

related

and

patient

related

factors

on

the

success

of

non-surgical

and

surgical

periodontal

therapy

In

patients

-LRB-

female

-RRB-

with

untreated

and/or

recurrent

periodontitis

no

therapy

scaling

and

root

planing

-LRB-

SRP

-RRB-

or

access

flap

-LRB-

AF

-RRB-

were

assigned

according

to

probing

pocket

depth

-LRB-

PPD

-RRB-

PPD

and

vertical

relative

attachment

level

-LRB-

RAL-V

-RRB-

were

obtained

initially

and

months

after

therapy

Baseline

data

were

compared

according

to

therapy

jaw

tooth

type

and

site

Factors

influencing

clinical

parameters

were

identified

using

multilevel

analyses

Baseline

PPDs

were

deeper

interproximally

in

the

maxilla

and

at

premolars

compared

to

buccal/oral

sites

mandibular

and

anterior

teeth

At

months

PPD

reduction

and

RAL-V

gain

were

significantly

greater

at

sites

receiving

SRP

and

AF

as

compared

to

untreated

sites

-LRB-

p

-RRB-

PPD

reduction

and

RAL-V

gain

were

significantly

less

-LRB-

p

-RRB-

in

smokers

as

compared

to

nosmokers

and

at

interproximal

sites

-LRB-

p

-RRB-

as

compared

to

buccal/oral

sites

RAL-V

gain

was

less

in

aggressive

periodontitis

and

PPD

reduction

was

less

in

the

maxilla

-LRB-

p

-RRB-

In

sites

with

greater

bone

loss

and

infrabony

defects

a

poorer

response

was

observed

regarding

RAL-V

gain

or

PPD

reduction

respectively

The

conclusions

of

the

study

are

the

following

-LRB-

-RRB-

Nonsurgical

and

surgical

periodontal

therapies

are

effective

in

single-rooted

teeth

-LRB-

-RRB-

severe

interproximal

bone

loss

and

infrabony

defects

deteriorate

clinical

results

and

-LRB-

-RRB-

there

seem

to

be

more

defect-associated

-LRB-

tooth

site

-RRB-

factors

influencing

treatment

outcome

than

patient-associated

factors

Introduction

The

major

factor

in

the

etiology

of

periodontitis

is

the

dental

biofilm

i.e.

bacterial

plaque

Thus

the

aim

of

anti-infective

periodontal

therapy

is

the

reduction

in

supra

and

subgingival

microbial

plaque

to

resolve

periodontal

inflammation

Subgingival

scaling

and

root

planing

-LRB-

SRP

-RRB-

may

result

in

resolution

of

inflammation

reduced

probing

pocket

depths

-LRB-

PPD

-RRB-

and

clinical

attachment

gain

-LSB-

-RSB-

However

nonsurgical

periodontal

therapy

i.e.

SRP

is

not

found

to

be

successful

at

all

treated

sites

Although

not

all

factors

influencing

failure

of

nonsurgical

therapy

are

known

deep

periodontal

pockets

-LSB-

-RSB-

and

furcation

involvement

-LSB-

-RSB-

are

some

of

them

Recent

meta-analyses

have

shown

the

efficacy

of

nonsurgical

therapy

in

moderate

and

deep

periodontal

pockets

In

deep

pockets

access

flap

-LRB-

AF

-RRB-

techniques

result

in

better

reduction

in

PPD

and

clinical

attachment

gain

-LSB-

-RSB-

However

these

meta-analyses

like

many

other

studies

on

this

issue

before

-LSB-

-RSB-

use

mean

values

and

are

not

able

to

reflect

the

benefit

of

a

particular

technique

at

teeth

with

certain

defects

e.g.

infrabony

pockets

However

calculation

of

a

mean

value

e.g.

for

PPD

reduction

across

a

patient

in

fact

levels

out

tooth-related

characteristics

Even

if

separate

strata

for

different

baseline

PPD

are

considered

tooth-related

factors

other

than

baseline

PPD

are

leveled

out

also

This

may

lead

to

quite

similar

mean

values

for

nonsurgical

and

surgical

therapy

for

a

patient

or

across

a

whole

sample

because

tooth-related

differences

between

both

approaches

because

of

different

amounts

or

types

of

bone

loss

jaw

etc.

are

leveled

out

More

recent

statistical

methods

such

as

the

multilevel

modeling

are

considering

single-tooth

or

even

site

characteristics

while

still

regarding

the

individual

patient

as

a

statistical

unit

In

a

structured

review

of

it

was

explicitly

stated

that

the

included

studies

showed

similar

results

for

nonsurgical

and

surgical

therapy

after

year

However

insufficient

studies

are

available

to

evaluate

the

various

treatment

procedures

e.g.

in

angular

defects

Further

it

is

stated

that

subject

characteristics

and

their

possible

effect

on

treatment

outcome

was

not

addressed

in

the

studies

available

at

that

time

-LSB-

-RSB-

Thus

there

is

a

need

for

more

information

on

the

effect

of

patient

and

tooth-related

factors

on

nonsurgical

and

surgical

periodontal

therapy

Well

known

hypotheses

and

the

use

of

these

more

recent

statistical

methods

may

lead

to

new

information

Clinical

measurements

in

posterior

are

less

reproducible

than

in

anterior

teeth

-LSB-

-RSB-

Furcation

involvement

is

a

known

factor

to

influence

treatment

outcome

of

nonsurgical

and

surgical

therapy

To

provide

a

high

level

of

reproducibility

of

clinical

measurements

and

to

exclude

a

already

known

influencing

factor

only

single-rooted

teeth

were

considered

in

this

study

The

hypothesis

behind

this

study

is

that

different

tooth-related

factors

-LRB-

e.g.

tooth

type

site

plaque

residual

inflammation

horizontal/vertical

bone

loss

-RRB-

and

patient-related

factors

-LRB-

e.g.

age

sex

diagnosis

smoking

-RRB-

determine

the

initial

outcome

of

nonsurgical

and

surgical

periodontal

therapy

in

single-rooted

teeth

Thus

the

aim

of

the

present

study

was

to

identify

patient

and

site

factors

that

determine

the

initial

outcome

of

nonsurgical

and

surgical

periodontal

therapy

in

single-rooted

teeth

using

more

recent

statistical

methods

Materials

and

methods

Patients

The

study

group

consisted

of

patients

-LRB-

female

-RRB-

suffering

from

moderate

to

severe

periodontal

disease

These

patients

had

been

scheduled

for

periodontal

treatment

within

a

randomized

placebo-controlled

clinical

trial

evaluating

the

effect

of

a

subgingivally

delivered

doxycycline

gel

at

the

Section

of

Periodontology

Department

of

Conservative

Dentistry

Clinic

for

Oral

Dental

and

Maxillofacial

Diseases

University

Hospital

Heidelberg

Each

patient

had

to

have

three

single-rooted

teeth

that

qualified

as

test

teeth

for

the

doxycycline

study

that

is

only

three

teeth

per

patient

were

included

into

this

study

-LSB-

-RSB-

Inclusion

criteria

were

at

least

years

of

age

untreated

moderate

to

severe

periodontal

disease

or

recurrent

periodontitis

without

periodontal

surgery

at

least

for

the

last

months

effective

individual

oral

hygiene

-LRB-

plaque

control

record

-RRB-

-LSB-

-RSB-

and

written

informed

consent

Exclusion

criteria

were

local

and/or

systemic

antibiotic

therapy

within

the

last

months

before

the

baseline

examination

of

the

study

known

adverse

reactions

to

any

component

of

the

test

agent

anticoagulative

therapy

liver

kidney

gastroenteral

diseases

pregnancy

and

women

who

were

lactating

All

patients

were

asked

about

current

and

past

cigarette

consumption

A

patient

was

classified

as

a

current

smoker

if

he

smoked

one

or

more

cigarettes

per

day

and

as

a

former

smoker

if

he

had

quit

smoking

for

at

least

years

Patients

who

had

quit

smoking

within

the

last

years

were

classified

current

smokers

No

more

than

of

current

smokers

were

allowed

in

the

sample

All

patients

were

classified

as

chronic

or

aggressive

periodontitis

according

to

the

following

criteria

Aggressive

periodontitis

Patient

is

clinically

healthy

that

is

systemic

diseases

predisposing

for

periodontitis

are

not

known

radiographic

bone

loss

greater

than

or

equal

to

in

at

least

two

different

teeth

and

age

less

that

or

equal

to

years

at

time

of

diagnosis.Moderate

and

severe

chronic

periodontitis

attachment

loss

greater

than

or

equal

to

mm

and

age

greater

than

years

-LSB-

-RSB-

The

study

was

approved

by

the

Institutional

Review

Boards

for

Human

Studies

of

the

University

of

Heidelberg

Clinical

examination

After

completion

of

initial

periodontal

treatment

including

oral

hygiene

instruction

and

supragingival

scaling

PPD

were

measured

at

four

sites

of

every

tooth

If

a

patient

fulfilled

the

inclusion

criteria

the

study

protocol

risks

benefits

and

procedures

were

explained

and

informed

written

consent

was

obtained

One

week

before

test

therapy

the

Gingival

Index

-LRB-

GI

-RRB-

and

Plaque

Index

-LRB-

PlI

-RRB-

-LSB-

-RSB-

were

assessed

at

six

sites

-LRB-

mesiobuccal

midbuccal

distobuccal

distolingual

midlingual

mesiolingual

-RRB-

of

every

incisor

canine

and

premolar

PPD

and

vertical

relative

attachment

levels

-LRB-

RAL-V

-RRB-

were

measured

to

the

nearest

mm

using

a

straight

periodontal

probe

-LRB-

PCPUNC

Hu

Friedy

Chicago

IL

-RRB-

at

six

sites

per

tooth

A

reference

splint

gave

the

location

of

probing

by

notches

and

served

as

reference

for

the

RAL-V

measurements

Bleeding

on

probing

-LRB-

BOP

-RRB-

was

recorded

approximately

s

after

probing

After

the

first

course

of

measurements

all

PPD

and

RAL-V

measurements

were

repeated

The

means

of

the

pairs

of

double

measurements

were

used

for

analysis

If

a

pair

of

PPD

double

measurements

showed

a

difference

greater

than

mm

a

third

measurement

was

performed

at

the

respective

site

-LRB-

option

-RRB-

Then

the

mean

of

the

pair

of

the

closer

measurements

was

taken

for

analysis

at

the

respective

site

All

clinical

measurements

before

therapy

were

performed

by

one

examiner

-LRB-

Eickholz

-RRB-

who

also

performed

active

periodontal

therapy

-LRB-

subgingival

debridement

and

surgery

-RRB-

in

all

patients

Within

each

patient

three

test

teeth

with

PPD

mm

and

BOP

or

PPD

mm

were

selected

for

the

doxycycline

study

These

teeth

were

excluded

from

this

examination

Three

and

months

after

therapy

the

clinical

examinations

were

repeated

in

the

same

manner

by

a

second

examiner

-LRB-

Kim

-RRB-

who

did

not

have

any

information

about

baseline

data

and

the

therapy

-LSB-

-RSB-

Radiographic

examination

and

evaluation

Before

therapy

in

patients

full-mouth

sets

of

periapical

radiographs

-LRB-

Ektaspeed

plus

Kodac

Rochester

NY

-RRB-

were

obtained

in

XCP

technique

-LRB-

XCP

Kentzler

Kaschner

Dental

Ellwangen/Jagst

Germany

-RRB-

Intraoral

size

-LRB-

maxillary

second

incisors

and

mandibular

anteriors

-RRB-

and

-LRB-

all

other

regions

-RRB-

dental

films

were

exposed

to

an

X-ray

source

-LRB-

Heliodent

DS

kV

mA

Sirona

Bensheim

Germany

-RRB-

and

developed

under

standardized

conditions

-LRB-

XR

Nova

Dürr

Dental

Bietigheim

Bissingen

Germany

-RRB-

All

radiographs

were

viewed

in

a

darkened

room

using

a

radiograph

screen

-LRB-

Dentsply

Rinn

Elgin

IL

-RRB-

Each

interproximal

surface

of

single-rooted

teeth

was

classified

for

the

type

of

bone

loss

-LRB-

horizontal/vertical

-RRB-

Further

the

prevalence

of

a

double

contour

of

the

root

was

noted

that

was

taken

as

indicative

for

a

mesial

or

distal

groove

Relative

bone

loss

in

percent

was

assessed

at

two

sites

per

tooth

-LRB-

mesial

and

distal

-RRB-

using

a

Schei

ruler

-LSB-

-RSB-

This

ruler

consisted

of

six

straight

lines

that

divert

in

the

same

angle

For

each

site

the

basic

line

of

the

Schei

ruler

was

placed

to

the

cementoenamel

junction

-LRB-

CEJ

-RRB-

of

the

respective

tooth

parallel

to

the

occlusal

plane

Then

the

ruler

was

moved

until

the

sixth

line

was

placed

tangentially

to

the

apex

Finally

the

alveolar

crest

was

located

Location

between

the

two

coronal

lines

meant

bone

loss

up

to

of

root

length

Location

between

the

second

and

third

line

meant

between

and

bone

loss

and

so

forth

If

the

CEJ

was

destroyed

or

overlapped

by

interproximal

restorations

the

restoration

margin

was

used

as

reference

If

the

alveolar

crest

could

not

be

determined

because

of

overlapping

of

adjacent

teeth

the

interproximal

site

was

classified

as

can

not

be

assessed

If

an

interproximal

surface

showed

a

double

contour

this

was

classified

as

an

interproximal

root

groove

All

radiographic

assessments

were

performed

by

an

examiner

who

was

blinded

to

the

clinical

measurements

and

therapy

assignments

-LRB-

Schenk

-RRB-

Therapy

Teeth

exhibiting

PPD

mm

were

treated

neither

by

subgingival

SRP

nor

by

AF

-LSB-

-RSB-

SRP

was

performed

when

PPD

and

mm

were

present

If

periodontal

surgery

was

necessary

at

teeth

not

adjacent

to

test

teeth

this

was

performed

week

after

SRP

AF

was

chosen

for

teeth

exhibiting

PPD

mm

However

SRP

was

performed

at

all

test

teeth

-LRB-

not

included

in

this

analysis

-RRB-

and

the

respective

neighboring

teeth

under

local

anesthesia

with

hand

instruments

even

for

baseline

PPD

mm

Thus

also

some

sites

with

PPD

mm

were

treated

exclusively

by

SRP

Further

the

decision

to

perform

AF

was

taken

per

tooth

and

not

per

site

Thus

also

sites

with

PPD

mm

were

treated

by

AF

if

the

respective

tooth

exhibited

PPD

mm

at

one

site

Thereby

effectiveness

of

SRP

and

AF

maybe

analyzed

across

the

limits

of

indications

as

the

ranges

of

PPD

for

the

three

treatment

groups

in

Table

demonstrate

Maintenance

including

oral

hygiene

instruction

and

professional

tooth

cleaning

was

done

months

after

test

therapy

Statistical

analysis

Data

handling

All

data

were

entered

into

a

personal

computer

program

-LRB-

Systat

for

Windows

version

Systat

Evanston

IL

Schenk

-RRB-

Descriptive

statistics

were

then

calculated

using

another

program

-LRB-

SPSS

version

SPSS

Chicago

IL

-RRB-

by

an

independent

statistician

-LRB-

Lungeanu

-RRB-

Multilevel

analyses

were

modeled

by

another

independent

statistician

-LRB-

Reitmeir

-RRB-

using

a

third

program

-LRB-

SAS

version

SAS

Institute

Cary

NC

-RRB-

Reproducibility

The

replicate

PPD

and

RAL

assessments

for

all

teeth

were

used

to

estimate

the

intraexaminer

reproducibility

The

intraexaminer

reproducibility

of

PPD

and

RAL

measurements

was

expressed

as

the

standard

deviation

of

single

measurements

-LSB-

-RSB-

Treatment

comparison

The

individual

patient

was

considered

as

a

statistical

unit

in

this

analysis

The

main

outcome

variable

for

the

comparison

of

the

therapeutic

effects

of

no

further

therapy

SRP

or

AF

was

chosen

to

be

the

change

of

PPD

RAL-V

was

considered

as

a

secondary

endpoint

All

other

clinical

parameters

-LRB-

GI

PlI

-RRB-

were

control

variables

Only

sites

were

included

that

could

be

assessed

at

all

three

examinations

Additionally

baseline

clinical

parameters

were

calculated

separately

according

to

therapy

-LRB-

no

therapy

SRP

AF

-RRB-

jaw

tooth

type

-LRB-

anterior/premolar

-RRB-

and

site

-LRB-

interproximal/buccal

and

oral

-RRB-

and

compared

using

multilevel

methodology

-LSB-

-RSB-

A

probability

p

was

accepted

for

a

difference

to

be

statistically

significant

Because

of

multiple

testing

a

Bonferroni

correction

was

performed

We

tested

independent

hypotheses

on

our

set

of

data

Thus

the

statistical

significance

level

that

should

be

used

for

each

hypothesis

separately

is

of

times

what

it

would

be

if

only

one

hypothesis

were

tested

i.e.

p

For

all

analyses

the

basic

level

site

was

nested

in

the

upper

level

tooth

which

itself

was

nested

in

the

next

upper

level

patient

and

patient

effects

on

the

outcome

were

assumed

to

be

random

This

technique

allows

the

identification

of

single-tooth

effects

or

parameters

while

still

considering

the

individual

patient

as

a

statistical

unit

and

the

dependencies

of

site

and

tooth

data

within

a

patient

-LSB-

-RSB-

Multilevel

regressions

were

calculated

including

only

clinical

parameters

providing

six

measurements

per

tooth

first

-LRB-

site

level

n

patient

level

n

-RRB-

Further

analyses

were

performed

that

included

also

radiographic

parameters

Radiographic

parameters

were

only

available

for

those

patients

contributing

full-mouth

radiographic

examinations

and

could

be

related

only

to

interproximal

sites

-LRB-

mesiobuccal

mesiolingual

distolingual

mesiolingual

-RRB-

i.e.

four

sites

per

tooth

-LRB-

site

level

n

patient

level

n

-RRB-

To

identify

factors

influencing

the

treatment

result

change

of

RAL-V

and

PPD

were

analyzed

by

application

of

a

multilevel

regression

model

using

backward

selection

Models

were

fitted

for

the

dependent

variables

-LRB-

-RRB-

RAL-V

change

after

months

and

-LRB-

-RRB-

PPD

change

after

months

including

the

following

independent

variables

-LRB-

-RRB-

clinical

age

sex

actual

smoking

-LRB-

yes/no

-RRB-

pack

years

diagnosis

-LRB-

aggressive/chronic

periodontitis

-RRB-

jaw

-LRB-

maxilla/mandible

-RRB-

site

-LRB-

interproximal/buccal

or

oral

-RRB-

tooth

type

-LRB-

anterior/premolar

-RRB-

therapy

-LRB-

none/SRP/AF

-RRB-

and

PlI

and

GI

at

baseline

-LRB-

-RRB-

radiographic

interproximal

bone

loss

in

percent

infrabony

defect

and

double

contour

of

the

root

For

the

analysis

including

radiographic

parameters

the

variable

site

-LRB-

interproximal/buccal

and

oral

-RRB-

dropped

out

because

only

interproximal

sites

remained

in

the

analysis

A

probability

p

was

required

for

parameters

to

be

kept

within

the

models

Results

All

patients

contributing

single-rooted

teeth

with

sites

finished

the

re-examination

The

patient

characteristics

-LRB-

age

diagnosis

smoking

status

-RRB-

are

given

in

Table

From

baseline

to

the

examination

two

single-rooted

teeth

were

lost

one

to

an

acute

periapical

periodontitis

and

another

because

of

prosthodontic

planning

After

the

re-examination

one

patient

left

the

study

Only

sites

were

included

into

the

analysis

which

could

be

assessed

at

all

three

examinations

n

in

patients

Table

population

as

related

to

age

sex

smoking

habit

and

diagnosisVariableNumber

-LRB-

n

-RRB-

Reproducibility

The

results

of

the

intraexaminer

reproducibility

of

PPD

and

RAL

measurements

as

standard

deviation

of

single

measurement

for

each

examination

time

point

are

given

in

Table

Table

reproducibility

at

baseline

and

months

examinationExaminationMeasurements

-LRB-

n

-RRB-

s

-LRB-

RAL-V

-RRB-

s

-LRB-

PPD

-RRB-

s

Standard

deviations

of

a

single

measurement

Baseline

data

The

mean

clinical

parameters

-LRB-

RAL-V

PPD

PlI

GI

-RRB-

at

baseline

over

all

sites

are

given

in

Table

The

respective

data

as

related

to

therapy

-LRB-

no

therapy

SRP

AF

-RRB-

are

given

in

Table

Whereas

no

statistically

significant

differences

for

PlI

were

observed

between

the

groups

RAL-V

PPD

and

GI

of

the

SRP

and

AF

sites

revealed

to

be

significantly

-LRB-

p

-RRB-

greater

as

compared

to

untreated

sites

-LRB-

Table

-RRB-

Clinical

parameters

as

related

to

jaw

tooth

type

and

site

are

given

in

Table

Baseline

RAL-V

and

PPD

were

statistically

significantly

-LRB-

p

-RRB-

greater

in

the

maxilla

than

in

the

mandible

whereas

for

PlI

it

was

vice

versa

-LRB-

Table

-RRB-

For

tooth

type

just

baseline

PPD

was

statistically

significantly

-LRB-

p

-RRB-

different

between

premolars

and

anteriors

with

deeper

pockets

at

the

premolars

-LRB-

Table

-RRB-

All

baseline

clinical

parameters

were

observed

to

be

statistically

significantly

-LRB-

p

-RRB-

greater

at

the

interproximal

than

at

the

buccal

and

oral

sites

-LRB-

Table

-RRB-

Table

parameters

at

baseline

and

months

after

therapy

-LRB-

mean

standard

deviation

-RRB-

-LRB-

mm

-RRB-

PPD

-LRB-

mm

-RRB-

Table

parameters

at

baseline

as

related

to

therapy

-LRB-

mean

standard

deviation

-RRB-

SitesNo

SRP

Scaling

and

root

planning

AF

access

flap

Statistically

significantly

different

from

SRP

and

AF

with

p

Table

parameters

at

baseline

as

related

to

jaw

-LRB-

maxilla/mandible

-RRB-

tooth

type

-LRB-

anterior/premolar

-RRB-

and

site

-LRB-

interproximal/buccal

and

oral

-RRB-

-LRB-

mean

standard

deviation

-RRB-

Maxillamandiblepremolaranteriorinterproximalbuccal/oralSites1

Statistically

significantly

different

with

p

Treatment

effect

The

healing

phase

passed

uneventfully

for

all

patients

Clinical

parameters

as

related

to

therapy

after

and

months

are

given

in

Table

and

their

change

after

and

months

is

given

in

Table

Whereas

in

untreated

sites

the

study

failed

to

observe

any

significant

change

SRP

and

AF

resulted

in

PPD

reduction

and

PAL-V

gain

after

and

months

-LRB-

p

Table

-RRB-

Table

parameters

at

and

months

after

therapy

as

related

to

therapy

-LRB-

mean

standard

deviation

-RRB-

months

after

months

after

therapyNo

therapySRPAFNo

therapySRPAFSites1,4402,4781981,4402,478198RAL-V

-LRB-

mm

-RRB-

PPD

-LRB-

mm

-RRB-

SRP

Scaling

and

root

planing

AF

access

flapTable

of

clinical

parameters

at

and

months

after

therapy

as

related

to

therapy

-LRB-

mean

standard

deviation

-RRB-

months

after

months

after

therapyNo

therapySRPAFNo

-LRB-

mm

-RRB-

PPD

-LRB-

mm

-RRB-

GI

SRP

Scaling

and

root

planing

AF

access

flap

Statistically

significantly

different

from

no

therapy

with

p

Prognostic

factors

RAL-V

gain

was

less

favorable

in

current

smokers

in

aggressive

periodontitis

and

at

interproximal

sites

-LRB-

Table

-RRB-

PPD

reduction

was

poorer

in

current

smokers

at

premolars

in

the

maxilla

and

at

interproximal

sites

-LRB-

Table

-RRB-

Whereas

baseline

PPD

was

related

to

better

PPD

reduction

and

RAL-V

gain

-LRB-

p

-RRB-

baseline

RAL-V

was

related

to

better

RAL-V

gain

but

to

less

favorable

PPD

reduction

-LRB-

Tables

and

-RRB-

Baseline

PlI

was

associated

with

poorer

PPD

reduction

-LRB-

p

Table

-RRB-

AF

and

SRP

-LRB-

p

-RRB-

were

associated

with

better

PPD

reduction

-LRB-

Table

-RRB-

Table

multilevel

linear

regression

analysis

dependent

variable

RAL-V

reduction

months

after

therapy

n

patients

sites

EstimateSEdfF

valuep

valueIntercept

Current

smoking

Site

-LRB-

interproximal

-RRB-

Aggressive

periodontitis

Baseline

Baseline

Table

multilevel

linear

regression

analysis

dependent

variable

PPD

reduction

months

after

therapy

n

patients

sites

EstimateSEdfF

valuep

valueIntercept

Current

smoking

Jaw

-LRB-

maxilla

-RRB-

Site

-LRB-

interproximal

-RRB-

Tooth

type

-LRB-

premolar

-RRB-

Baseline

Baseline

RAL-V

Baseline

Plaque

Index

Scaling

and

root

Access

Taking

radiographic

parameters

into

consideration

current

smoking

resulted

in

less

favorable

and

baseline

PPD

in

better

RAL-V

gain

and

PPD

reduction

respectively

-LRB-

Tables

and

-RRB-

Further

tooth

type

-LRB-

premolar

-RRB-

and

aggressive

periodontitis

were

associated

with

poorer

RAL-V

gains

-LRB-

Table

-RRB-

Location

in

the

maxilla

and

baseline

PlI

resulted

in

less

favorable

PPD

reduction

-LRB-

Table

-RRB-

Generally

sites

with

greater

interproximal

bone

loss

demonstrated

poorer

RAL-V

gain

-LRB-

p

-RRB-

and

sites

with

infrabony

defects

were

associated

with

inferior

PPD

reduction

-LRB-

p

Tables

and

-RRB-

Table

linear

regression

analysis

dependent

variable

RAL-V

reduction

months

after

therapy

n

patients

sites

EstimateSEdfF

valuep-valueIntercept

Current

smoking

Tooth

type

-LRB-

premolar

-RRB-

Aggressive

periodontitis

Baseline

Baseline

Bone

loss

in

Table

linear

regression

analysis

dependent

variable

PPD

reduction

months

after

therapy

n

patients

sites

EstimateSEdfF

valuep

valueIntercept

Current

smoking

Jaw

-LRB-

maxilla

-RRB-

Baseline

Baseline

Plaque

Index

Infrabony

defect

Discussion

Study

population

Patients

treated

in

this

study

ranged

from

to

years

of

age

with

chronic

and

aggressive

periodontitis

Original

measurements

were

performed

in

the

setting

of

a

randomized

placebo-controlled

clinical

trial

evaluating

the

effect

of

a

subgingivally

delivered

doxycycline

gel

at

the

Section

of

Periodontology

Department

of

Conservative

Dentistry

Clinic

for

Oral

Dental

and

Maxillofacial

Diseases

University

Hospital

Heidelberg

Each

patient

had

to

provide

three

single-rooted

teeth

that

qualified

as

test

teeth

for

the

doxycycline

study

To

blind

the

examiner

for

the

test

teeth

not

only

those

but

all

single-rooted

teeth

were

assessed

in

all

patients

-LSB-

-RSB-

Despite

the

test

teeth

and

their

direct

neighbors

all

single-rooted

teeth

were

treated

according

to

the

following

criteria

Teeth

exhibiting

PPD

mm

were

treated

neither

by

subgingival

SRP

nor

by

AF

SRP

was

performed

when

PPD

mm

was

present

AF

was

chosen

for

teeth

exhibiting

PPD

mm

-LSB-

-RSB-

However

teeth

directly

adjacent

to

test

teeth

were

treated

only

by

SRP

irrespective

of

baseline

PPD

Thus

also

some

sites

with

PPD

mm

were

treated

exclusively

by

SRP

Further

the

decision

to

perform

AF

was

taken

per

tooth

and

not

per

site

Thus

also

sites

with

PPD

mm

were

treated

by

AF

if

they

were

located

at

a

tooth

with

one

or

more

sites

with

PPD

mm

Thereby

effectiveness

of

SRP

and

AF

may

be

analyzed

across

the

limits

of

indications

as

the

ranges

of

PPD

for

the

three

treatment

groups

in

Table

demonstrate

How

could

we

exclude

that

the

topically

delivered

doxycycline

had

any

influence

on

the

treatment

results

of

the

sites

that

were

evaluated

in

this

study

The

subgingivally

delivered

agent

or

vehicle

control

may

be

partially

absorbed

and

thereby

have

systemic

effects

at

the

other

test

teeth

A

pharmacokinetic

study

had

found

doxycycline

only

in

the

blood

of

of

patients

-LSB-

-RSB-

Thus

a

systemic

additional

effect

on

the

other

teeth

is

quite

unlikely

It

has

to

be

kept

in

mind

that

in

the

sample

investigated

in

this

study

only

one

tooth

of

the

whole

dentition

per

patient

received

the

active

agent

i.e.

doxycycline

-LSB-

-RSB-

Further

amounts

of

the

subgingivally

delivered

substance

may

leave

the

pocket

via

sulcus

fluid

and

affect

the

other

test

teeth

Split-mouth

studies

designed

to

compare

active

agent

and

vehicle

of

topical

antibiotics

have

made

the

provision

that

teeth

selected

as

test

sites

should

be

separated

by

at

least

one

tooth

-LSB-

-RSB-

minimizing

the

interaction

between

therapy

modes

In

a

pharmacokinetic

study

from

control

sites

much

smaller

amounts

of

doxycycline

could

be

detected

in

the

gingival

crevicular

fluid

than

from

another

site

that

had

received

the

particular

doxycycline

gel

subgingivally

in

the

same

dentition

-LSB-

-RSB-

Thus

it

is

unlikely

that

the

topical

doxycycline

had

any

additional

effect

on

the

treatment

results

of

all

teeth

but

the

test

teeth

Treatment

effect

The

results

observed

in

this

study

after

SRP

are

in

agreement

with

observations

reported

by

other

authors

and

months

after

nonsurgical

debridement

of

single-rooted

teeth

-LSB-

-RSB-

Our

PPD

reductions

and

RAL-V

gains

achieved

months

after

therapy

confirm

data

by

a

meta-analysis

on

nonsurgical

vs

surgical

periodontal

therapy

that

reports

PPD

reduction

of

mm

and

vertical

attachment

-LRB-

PAL-V

-RRB-

gains

of

mm

at

sites

with

baseline

PPD

mm

months

after

SRP

However

PPD

reductions

months

after

AF

for

mean

baseline

PPD

of

mm

were

mm

which

is

less

than

the

meta

analysis

lists

for

baseline

PPD

mm

PPD

reduction

mm

PAL-V

gain

after

AF

was

mm

which

comes

quite

close

to

the

mm

reported

by

the

meta

analysis

-LSB-

-RSB-

Serino

et

al.

report

results

months

after

treatment

-LSB-

-RSB-

For

baseline

PPD

mm

they

report

PAL-V

gains

of

mm

and

PPD

reduction

of

mm

after

non-surgical

as

well

as

mm

and

mm

after

surgical

therapy

This

is

quite

similar

to

the

results

of

this

study

regarding

PAL-V

gain

and

PPD

reduction

after

SRP

However

the

PPD

reduction

after

surgical

therapy

is

more

favorable

than

ours

-LSB-

-RSB-

Prognostic

factors

Current

smoking

was

generally

associated

with

less

favorable

PPD

reduction

and

RAL-V

gain

in

all

models

Smoking

is

the

most

significant

external

risk

factor

for

periodontitis

-LSB-

-RSB-

and

is

known

to

deteriorate

the

results

of

periodontal

therapy

in

general

-LSB-

-RSB-

However

smoking

was

the

only

patient-associated

factor

that

was

kept

in

all

models

The

diagnosis

of

aggressive

periodontitis

was

associated

with

less

favorable

RAL-V

gains

whereas

it

was

not

kept

in

the

models

to

explain

PPD

reduction

It

is

interesting

to

note

that

the

other

patient-associated

factors

i.e.

age

and

sex

were

kept

in

neither

model

This

confirms

observations

of

D'Aiuto

et

al.

-LSB-

-RSB-

It

is

interesting

to

note

that

the

diagnosis

of

aggressive

periodontitis

affected

RAL-V

gains

but

not

PPD

reduction

It

seems

that

patients

suffering

from

aggressive

periodontitis

have

a

higher

risk

for

recessions

than

patients

with

chronic

periodontitis

Several

tooth

and

site-associated

factors

were

identified

by

multilevel

analysis

to

influence

clinical

outcomes

Generally

baseline

PPD

was

related

to

better

PPD

reduction

and

RAL-V

gain

-LRB-

p

-RRB-

PPD

reduction

and

RAL-V

gain

was

less

pronounced

in

the

premolars

and

at

interproximal

sites

-LRB-

p

-RRB-

and

PPD

reduction

was

less

pronounced

in

the

maxilla

-LRB-

p

-RRB-

These

results

are

plausible

because

compared

to

anterior

teeth

premolars

are

less

accessible

and

interproximal

sites

are

more

difficult

to

debride

than

oral

and

lingual

sites

Less

favorable

PPD

reduction

in

premolars

than

in

incisors

was

also

recently

reported

by

other

authors

-LSB-

-RSB-

However

D'Aiuto

et

al.

observed

more

favorable

PPD

reduction

at

interproximal

sites

whereas

this

study

observed

the

contrary

The

multilevel

analysis

performed

in

this

study

was

adjusted

for

baseline

PPD

Baseline

pockets

were

deeper

interproximally

than

at

buccal

or

palatal/lingual

sites

This

might

explain

more

favorable

PPD

reduction

at

interproximal

sites

without

adjusting

for

baseline

PPD

Considering

the

different

therapies

SRP

and

AF

provided

better

PPD

reduction

than

no

therapy

However

the

analysis

failed

to

reveal

statistically

significant

differences

between

both

therapies

in

single-rooted

teeth

It

seems

that

AF

provides

no

advantages

over

SRP

in

single-rooted

teeth

Taking

radiographic

parameters

into

consideration

current

smoking

and

baseline

PPD

were

kept

in

the

models

However

the

greater

the

interproximal

bone

loss

the

poorer

the

RAL-V

gain

-LRB-

p

-RRB-

and

infrabony

defects

were

associated

with

inferior

PPD

reduction

-LRB-

p

-RRB-

Total

amount

of

bone

loss

seems

to

be

associated

with

poor

prognosis

of

the

respective

tooth

generally

irrespective

of

the

type

of

treatment

This

has

also

been

observed

for

long-term

stability

-LSB-

-RSB-

D'Aiuto

et

al.

-LSB-

-RSB-

did

not

assess

radiographic

parameters

However

they

considered

tooth

mobility

and

found

mobility

was

correlated

with

less

favorable

PPD

reduction

It

is

interesting

to

note

that

interproximal

grooves

that

had

been

assessed

as

root

double

contours

failed

to

influence

the

outcomes

of

therapy

Up

to

our

best

knowledge

this

is

the

first

analysis

on

the

influence

of

baseline

bone

loss

on

the

outcome

of

nonsurgical

or

surgical

periodontal

therapy

that

does

not

use

patient

means

but

individual

tooth

parameters

Within

the

limitations

of

the

present

study

the

following

conclusions

may

be

drawn

-LRB-

-RRB-

Nonsurgical

and

surgical

periodontal

therapies

are

effective

in

single-rooted

teeth

-LRB-

-RRB-

severe

interproximal

bone

loss

and

infrabony

defects

deteriorate

the

clinical

results

and

-LRB-

-RRB-

there

seem

to

be

more

defect-associated

-LRB-

tooth

site

-RRB-

factors

influencing

treatment

outcome

than

patient-associated

factors

O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

periodontal therapy
clinical trial
smoking

surgical/nonsurgical therapy
single-rooted teeth