This SBU report, "Chronic Periodontitis – Prevention, Diagnosis and Treatment", is based on a systematic and critical review of the scientific literature.

• A powered toothbrush is more effective than a manual toothbrush for reducing gingivitis (Evidence Grade 3).
• Dentifrices containing stannous fluoride, amine fluoride / stannous fluoride, chlorhexidine or triclosan / copolymer are more effective than conventional fluoridated dentifrices for reducing gingivitis (Evidence Grade 3).
• Mouth-rinsing with a chlorhexidine solution (0.12–0.2 percent) or essential oils as an adjunct to tooth brushing is more effective than tooth brushing alone for reducing gingivitis (Evidence Grade 3).
• Repeated instructions by dental professionals lead to increased knowledge about oral hygiene. The findings are contradictory as to whether increased knowledge and desired behavioral changes lead to reduction of gingivitis.

Preventing Gingivitis

Diagnosing Chronic Periodontitis

• Bleeding following probing of the periodontal pocket is a sign of inflammation in the periodontal tissues (Evidence Grade 2).
• Probing pocket depth overestimates the actual depth when periodontitis is present and underestimates it when the periodontal tissues are healthy (Evidence Grade 2).
• The use of electronic pressure-sensitive probes does not improve the reproducibility of periodontal pocket measurements compared to that of manual probing (Evidence Grade 3).
• Radiographic measurements underestimate alveolar bone loss. The degree of underestimation depends on the extent of bone loss and its location in the dental arch (Evidence Grade 3).
• The accuracy of assessing alveolar bone loss from direct digital radiography is comparable to that obtained from film radiography (Evidence Grade 3).
• The number of periapical radiographs can be considerably reduced when a clinical examination, along with bitewing radiographs of the posterior teeth or a panoramic radiograph precedes a full-mouth radiographic examination (Evidence Grade 3).
• The accuracy of bitewing and periapical radiography is low for estimating small alveolar bone changes (less than 1 mm) over time (Evidence Grade 3). Thus, performing radiographic examinations at regular intervals for the purpose of assessing changes of the periodontal support over time is not justified.

Predicting Disease Progression

• The absence of “bleeding on probing” is a good predictor of periodontal stability (Evidence Grade 3).
• Scientific evidence is insufficient for assessing the value of pocket depth as a prognostic method.

Treating Chronic Periodontitis

• Mechanical infection control (scaling and root planing) reduces probing pocket depth and improves probing attachment level. Mechanical infection control combined with flap surgery eliminates 10–15 percent more pockets deeper than 4 mm than mechanical infection control alone (Evidence Grade 3).
• Local adjunctive therapy with 25 percent metronidazole gel does not result in improved probing pocket depth or probing attachment level compared to mechanical infection control alone (Evidence Grade 3). Scientific evidence is insufficient for determining the efficacy of other local antibiotics and antiseptics.
• Systemic antibiotic therapy as an adjunct to mechanical infection control does not improve probing pocket depth or probing attachment level compared to mechanical infection control alone (Evidence Grade 1). Scientific evidence for the benefit derived from using anti-inflammatory drugs is insufficient.
• Adjunctive therapy with guided tissue regeneration (GTR) or with enamel matrix derivative (EMD) in individual angular bone defects results in improved probing attachment level and bone level. An improvement in probing attachment level by more than 4 mm can be expected twice as often with GTR or EMD as with flap surgery alone (Evidence Grade 1).
• Adjunctive therapy with coralline calcium carbonate in individual angular bone defects improves bone level more effectively than flap surgery alone (Evidence Grade 3). The outcomes are contradictory regarding probing attachment level. Scientific evidence for the efficacy of using other filler materials is insufficient.
• Adjunctive therapy with GTR and EMD appears to result in less improvement in smokers than in non-smokers.
• Scientific evidence for assessing and designing programs of supportive periodontal therapy is insufficient.

Economic Aspects

• Scientific evidence is lacking for determining cost-effectiveness and patient-perceived quality with regard to the various methods of prevention, diagnosis and treatment of chronic periodontitis. The studies that were included are too limited regarding quantity and assessed quality.

Chronic Periodontitis as a Risk for Other Diseases

• Scientific evidence is contradictory as to whether individuals with chronic periodontitis are at increased risk of developing coronary heart disease or stroke.
• Scientific evidence is lacking as to whether individuals with chronic periodontitis are at increased risk of developing diabetes mellitus, chronic obstructive pulmonary disease or rheumatoid arthritis.
• Scientific evidence is insufficient and contradictory as to whether women with chronic periodontitis during pregnancy have an increased risk for preterm birth. Scientific evidence of a relationship between chronic periodontitis and low birth weight is also insufficient.

Principles of Evidence Grading Quality refers to the scientific quality of a particular study and its ability to reliably answer a specific question. Evidence Grade refers to the total scientific evidence for a conclusion, i.e., how many high-quality studies support the conclusion.

Evidence Grade 1 A conclusion assigned Evidence Grade 1 is supported by at least two studies with high quality among the total scientific evidence. If some studies are at variance with the conclusion, the evidence grade may be lower.

Evidence Grade 2 A conclusion assigned Evidence Grade 2 is supported by at least one study with high quality and two studies with moderate quality among the total scientific evidence. If some studies are at variance with the conclusion, the evidence grade may be lower.

Evidence Grade 3 A conclusion assigned Evidence Grade 3 is supported by at least two studies with moderate quality among the total scientific evidence. If some studies are at variance with the conclusion, the evidence grade may be lower.