ADA guideline on scaling and root planing for chronic periodontitis (2015): about half a millimeter of attachment gain, and adjuncts that add 0.2 to 0.6 mm

What it says#

The guideline was written by a panel the ADA Council on Scientific Affairs convened, following the ADA's evidence-based guideline development method, and published in the July 2015 Journal of the American Dental Association alongside the systematic review and meta-analysis it rests on. The review searched PubMed (MEDLINE) and Embase for randomized controlled trials of scaling and root planing with or without adjuncts, in English through July 2014, that reported clinical attachment level (CAL) at 6 months or later. Seventy-two articles met the criteria. The panel assessed bias with the Cochrane Risk of Bias Tool, pooled effects by meta-analysis, and rated the overall certainty of the evidence with a modified version of the US Preventive Services Task Force method.

Each recommendation carries one of six strengths: strong, in favor, weak, expert opinion for, expert opinion against, and against. The chairside guide defines them. Strong means high certainty of benefit and the benefits outweigh the harms. In favor means either high certainty with benefits balanced against harms, or moderate certainty with benefits outweighing harms. Weak means moderate certainty and either a balanced benefit-harm picture or uncertainty about the size of the benefit; the intervention is suggested only after alternatives have been considered. Expert opinion for means low certainty of benefit and an uncertain balance. Expert opinion against means low certainty that there is no benefit, or that harms outweigh benefits. Against means moderate or high certainty of no benefit.

The findings, in the review's words: with a moderate level of certainty, SRP alone produced approximately a 0.5-millimeter average improvement in CAL, and combinations of SRP with the assorted adjuncts produced a range of average CAL improvements between 0.2 and 0.6 mm over SRP alone. The panel judged four adjuncts beneficial with moderate certainty (subantimicrobial-dose doxycycline, systemic antimicrobials, chlorhexidine chips, and photodynamic therapy with a diode laser) and had low certainty in the benefits of the rest.

The recommendations, as the chairside guide states them. For patients with chronic periodontitis, clinicians should consider SRP as the initial treatment: in favor. For patients with moderate to severe chronic periodontitis, clinicians may consider systemic subantimicrobial-dose doxycycline, 20 mg twice a day for 3 to 9 months, as an adjunct with a small net benefit expected: in favor. Systemic antimicrobials as an adjunct, small net benefit expected: weak. Locally delivered chlorhexidine chips, moderate net benefit expected: weak. Locally delivered doxycycline hyclate gel and minocycline microspheres, net benefit uncertain: expert opinion for. Photodynamic therapy using diode lasers, moderate net benefit expected: weak. And three statements that clinicians should be aware the current evidence shows no net benefit from diode (non-PDT) lasers, Nd:YAG lasers, or erbium lasers as adjuncts to SRP: expert opinion against.

The guideline explains the one apparent inconsistency itself. Subantimicrobial-dose doxycycline and systemic antimicrobials showed similar magnitudes of benefit, but they were recommended at different strengths, in favor and weak respectively, because of the higher potential for adverse effects with higher doses of antimicrobials. And it warns that expert opinion for does not imply endorsement; it signifies that evidence is lacking and the level of certainty is low.

Who it applies to#

The SRP recommendation reaches any patient with chronic periodontitis. Every adjunct recommendation is written for patients with moderate to severe chronic periodontitis, so the adjunct question does not arise for a mild case under this guideline. The evidence is about clinical attachment level at 6 months or more; the review did not pool shorter trials or other endpoints.

Nothing here is about surgery, the timing of a referral to a periodontist, or maintenance intervals. An adjunct that was not among the interventions in the 72 articles has no rating, for or against. One vocabulary note: the guideline uses the 1999 classification's term, chronic periodontitis, which the 2017 World Workshop replaced with a single periodontitis category described by stage and grade; the recommendations were not rewritten for that system.

What changed#

The guideline set expectations in numbers. Against the common practice of adding a local antimicrobial or a laser to SRP as a matter of course, the guideline puts the whole adjunct category at 0.2 to 0.6 mm of additional attachment gain, rates the two most heavily marketed local antimicrobials as expert opinion for, and rates three laser families as expert opinion against. The reception was not quiet: JADA printed three comment letters on the guideline in December 2015 and two on the systematic review in April 2016. The ADA's evidence-based dental research pages still carry the 2015 guideline with its recommendations unchanged.

Where the source is#

The document is Smiley and colleagues, Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts, Journal of the American Dental Association 2015, volume 146, issue 7, pages 525 to 535; the link under the title resolves through the DOI to the publisher's page, which requires a subscription for the full text. The companion systematic review and meta-analysis is in the same issue at pages 508 to 524. When this entry was written the JADA site refused automated access, so the abstracts were read from PubMed (PMIDs 26113100 and 26113099), the recommendation wording and the strength definitions from the ADA's chairside guide PDF, and the guideline's status from the ADA's evidence-based dental research page, all listed above.