Subgingival Instrumentation

Accepted Article
DR. JEAN SUVAN (Orcid ID : 0000-0002-6526-6235)

DR. YAGO LEIRA (Orcid ID : 0000-0001-5027-7276)
PROF. FILIPPO GRAZIANI (Orcid ID : 0000-0001-8780-7306)
DR. JAN DERKS (Orcid ID : 0000-0002-1133-6074)
DR. CRISTIANO TOMASI (Orcid ID : 0000-0002-3610-6574)
Article type : Systematic Review
Subgingival Instrumentation
for Treatment of Periodontitis.
A Systematic Review.
Suvan, J1, Leira Y1, Moreno F1, Graziani F2, Derks J3, Tomasi C3
1Periodontology Unit and Department of Clinical Research, University College

London Eastman Dental Institute, London WC1X 8LD, United Kingdom
2Department of Surgical, Medical and Molecular Pathology and Critical Care

Medicine, University of Pisa, Pisa, Italy.
3Department of Periodontology, Institute of Odontology, The Sahlgrenska

Academy at University of Gothenburg, Gothenburg, Sweden.
This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JCPE.13245
This article is protected by copyright. All rights reserved
Corresponding Author:
Accepted Article
Cristiano Tomasi
Department of Periodontology
Institute of Odontology
The Sahlgrenska Academy at University of Gothenburg
Box 450
SE 405 30 Gothenburg
Sweden
E-mail: cristiano.tomasi@odontologi.gu.se
Abstract
Objectives: To evaluate the efficacy of subgingival instrumentation (PICOS-1),

sonic/ultrasonic/hand instruments (PICOS-2) and different subgingival instrumentation delivery
protocols (PICOS-3) to treat periodontitis.
Methods: Systematic electronic search (CENTRAL/MEDLINE/EMBASE/SCOPUS/LILACS) to
March 2019 was conducted to identify randomized controlled trials (RCT) reporting on subgingival
instrumentation. Duplicate screening and data extraction were performed to formulate evidence
tables and meta-analysis as appropriate.
Results: As only one RCT addressed the efficacy of subgingival instrumentation compared to
supragingival cleaning alone (PICOS-1), baseline and final measures from 11 studies were
considered. The weighted pocket depth (PD) reduction was 1.7 mm (95%CI: 1.3-2.1) at 6/8
months and the proportion of pocket closure was estimated at 74% (95%CI: 64-85). Six RCTs
compared hand and sonic/ultrasonic instruments for subgingival instrumentation (PICOS-2). No
significant differences were observed between groups by follow-up time point or category of initial
PD. Thirteen RCTs evaluated quadrant-wise vs full-mouth approaches (PICOS-3). No significant
differences were observed between groups irrespective of time-points or initial PD. Five studies
reported patient-reported outcomes, reporting no differences between groups.
Conclusions: Nonsurgical periodontal therapy by mechanical subgingival instrumentation is an
efficacious means to achieve infection control in periodontitis patients irrespective of the type of
instrument or mode of delivery. Prospero ID:CRD42019124887

Introduction
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Periodontitis is a chronic multifactorial inflammatory disease associated with dysbiotic plaque biofilms and
characterized by progressive destruction of the tooth-supporting apparatus which may result in tooth
loss. In the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases
and Conditions the lack of available evidence supporting the distinction between aggressive and
chronic forms of periodontitis was highlighted. However, it was recognized that a substantial
variation in terms of extent and severity of the disease may be observed. In addition, population
subgroups may be identified presenting with distinct disease trajectories suggesting differences in
terms of susceptibility and exposure. As a result, a new classification was proposed which
included staging (4 disease stages) to describe extent and complexity of the disease and grading
(3 grades) to capture biological features and risk for further progression. Grading should also
implement the analysis of potentially poorer outcomes of treatment (Papapanou et al., 2018).
The main goal of the treatment of patients suffering from periodontitis is the establishment of
adequate infection control, i.e. reduction of the bacterial load below individual threshold levels of
inflammation/disease. Health behaviour strategies to facilitate patient motivation targeting high-
level self-performed supra-gingival plaque control and management of lifestyle habits such as
smoking are key in addressing the vital patient role in non-surgical therapy (Ramseier & Suvan,
2015). Supplemental to patient self-care, subgingival instrumentation serves the purpose of
altering the subgingival ecological environment through disruption of the microbial biofilm and
removal of hard deposits, i.e. periodontal debridement, thereby suppressing soft tissue
inflammation (Heitz-Mayfield & Lang, 2013; Jepsen, Deschner, Braun, Schwarz & Eberhard,
2011). A reasonable endpoint of non-surgical treatment should include shallow pocket depth (PD)
and absence of clinical signs of inflammation, i.e. oedema and bleeding on probing (BOP).
Nevertheless, mean values of probing pocket depth reduction and clinical attachment gain are the
most commonly reported outcomes in studies. An ideal endpoint of therapy, however, should be
clinically meaningful with tangible benefits for the patient. Endpoints must also be considered in
relation to the goal of therapy. The question of the most adequate outcomes to evaluate non-
surgical periodontal therapy has been discussed in the literature (Hujoel, 2004; Tomasi &
Wennström, 2017).
The efficacy (as established in strictly defined research setting to minimise confounding factors)
of nonsurgical subgingival instrumentation as part of periodontal treatment is well documented
and has been summarized in several reviews (Hallmon & Rees, 2003; Herrera, 2016; Smiley et
al., 2015; Suvan, 2005; Tomasi & Wennström, 2009; Tunkel, Heinecke, & Flemmig, 2002; Van

der Weijden & Timmerman, 2002). There is, however, a paucity of data addressing effectiveness
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(established in a real world setting such as clinical practice with potential additional confounding
factors) of nonsurgical interventions. In addition, a number of different approaches including
adjunctive measures and/or novel technologies have been suggested but not fully validated.
Thus, various instruments may be appropriate for subgingival instrumentation, demonstrating

differences in the removal of soft and hard subgingival deposits (Lea, Landini, & Walmsley, 2003;
Leknes, Lie, Wikesjo, Bogle, & Selvig, 1994). Ultrasonic devices, when compared to hand
instruments, remove less root/tooth structure and cause less soft tissue trauma (Schmidlin,
Beuchat, Busslinger, Lehmann, & Lutz, 2001). It has been suggested that they are less operator-
dependent and require less treatment time, while resulting in a rougher root surface (Breininger,
O'Leary, & Blumenshine, 1987). In contrast, hand instrumentation may result in smoother tooth
surfaces and may remove more calculus deposits (Rateitschak-Pluss, Schwarz, Guggenheim,
Duggelin, & Rateitschak, 1992). For a comprehensive review on factors influencing calculus
removal, see Jepsen et al. (2011). In clinical practice, treatment often includes a combination of
instruments. An objective of the present review is to address the efficacy of any type of
instrument in terms of treatment outcomes.
Another objective of this review is to evaluate the potential impact of mode of delivery of
subgingival instrumentation without adjunctive antiseptics. Traditionally, sessions for mechanical
instrumentation were scheduled with intervals of one week between appointments in order to
instrument one segment of the entire dentition. This staged treatment approach allows for
meticulous treatment of the target sites with the possibility for repeated re-enforcement of
patients’ self-performed infection control. An alternative to the conventional approach, a full-
mouth instrumentation protocol, was first described by Quirynen and co-workers in 1995 and
comprised two sessions of scaling and root planing within 24 hours with the use of adjunctive
antiseptics (Quirynen et al., 1995).
The aim of the present systematic review was to provide a robust critical appraisal of the
evidence of the efficacy of subgingival instrumentation for the treatment of periodontitis, the
efficacy of sonic/ultrasonic/hand instruments and the efficacy of different delivery protocols for
subgingival instrumentation in terms of timing. In order to address the aim, PICOS criteria were
set as outlined in Table 1.
Table 1. PICOS Criteria

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Based upon the outlined PICOS criteria, the three focused questions of the systematic review
were:
PICOS Question 1
In patients with periodontitis, what is the efficacy of subgingival instrumentation performed with
hand or sonic/ultrasonic instruments in comparison with supragingival instrumentation or
prophylaxis in terms of clinical and patient reported outcomes?
PICOS Question 2
In patients with periodontitis, what is the efficacy of nonsurgical subgingival instrumentation

performed with sonic/ultrasonic instruments compared to subgingival instrumentation performed
with hand instruments or compared to the subgingival instrumentation performed with a
combination of hand and sonic/ultrasonic instruments in terms of clinical and patient reported
outcomes?
PICOS Question 3
In patients with periodontitis, what is the efficacy of full mouth delivery protocols (within 24 hours)
in comparison to quadrant or sextant wise delivery of subgingival mechanical instrumentation in
terms of clinical and patient reported outcomes?
Material & Methods
This systematic review protocol was registered in PROSPERO on 22 February 2019 with ID no.
CRD42019124887. Preferred Reporting Items for Systematic Review and Meta-Analyses
(PRISMA) guidelines were followed in reporting this review (Moher, Liberati, Tetzlaff, & Altman,
2009). A PRISMA statement is attached to follow the reporting of this systematic review
(Appendix).
Eligibility Criteria
Studies were eligible for inclusion in the review if they reported on individuals from 18 years
onward suffering from periodontitis. All forms of periodontitis were included, excluding gingivitis,

periodontitis associated with systemic diseases or conditions or specific syndromes. Studies with
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unclear reporting of periodontal case definition were excluded.
Interventions and comparisons eligible for inclusion varied according to PICOS question. PICOS
1 included nonsurgical subgingival mechanical instrumentation compared to supra-gingival
prophylaxis or instrumentation. PICOS 2 included nonsurgical subgingival instrumentation
performed with sonic/ultrasonic instruments compared to the same performed with hand
instruments or a combination of sonic/ultrasonic and hand instruments. PICOS 3 included
nonsurgical mechanical subgingival instrumentation performed with full-mouth single visit
protocols with or without time restriction compared to the same performed in multiple sessions
according to quadrant or sextant sub-division of the mouth. Studies with unclear intervention or
comparison were excluded as well as any intervention or comparison groups reporting use of
adjunctive chemical therapies (local or systemic).
Studies reporting the primary outcome of reduction in mean probing pocket depth (PD) or
secondary outcomes of number or proportion of pockets closed, changes in clinical attachment
level (CAL), and changes of percentage bleeding on probing (BOP) were included. Studies
reporting patient level of analysis or site level analysis with multilevel or GEE approaches were
included with those reporting site level analysis only excluded.
Only randomised controlled trials with at least 3 months of post treatment follow-up were eligible
for inclusion. Articles published in languages other than English were excluded due to time
constraints.
Search Methods
Preliminary electronic searches designed to locate possible review articles, narrative and
systematic were conducted to facilitate development of the electronic search strategy. The
strategy was formulated using a combination of controlled vocabulary (MeSH and free text
terms), then piloted to confirm high sensitivity over high precision in search results in order to
maintain a broad search. The search strategy used consistent terms customised according to
each database a priori and included English language restriction. The search strategy for OVID
Medline is outlined in Table 2 as an example. Electronic databases searched up to 19th March
2019 with no year restrictions included Cochrane Central Register of Controlled Trials
(CENTRAL), MEDLINE (OVID), EMBASE, SCOPUS, and LILACS. Hand searching of
bibliographies of previously published reviews were also performed. Search results from all
databases were combined and duplicates removed.

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Table 2. Search strategy for OVID Medline
Study Selection
Titles and abstracts of all identified reports were independently screened by two reviewers (YL &
FM) based upon the inclusion/exclusion criteria. Full text reports were obtained and assessed
independently and in duplicate for studies appearing to meet the inclusion criteria or with
insufficient information in the title or abstract to confirm eligibility for inclusion then confirmed by a
third reviewer (JS). Disagreements following full text screening were resolved by discussion and if
necessary additional reviewers were consulted (CT & JD). Excel spreadsheets were created to
record information pertaining to the decision to include or exclude each article. Kappa statistic
was used to assess the reviewer agreement based upon the full text screening.
Data Management
Two reviewers (JD & CT) extracted data into specifically created excel spreadsheets which were
then double checked by an additional reviewer (JS). Data pertaining to study characteristics such
as population, interventions, comparisons, type of outcomes reported, and study conclusions
were then transferred into evidence tables to provide an overview of the included studies and
available data. All data in the excel spreadsheets were reviewed to consider appropriateness for
meta-analysis. Data were then entered into Stata (Stata Statistical Software: Release 15,
StataCorp LLC, College Station, TX, USA) in preparation for quantitative analysis.
Outcome measures
Outcomes at 3/4 months and 6/8 months following intervention were extracted. The primary
outcome was reduction of PD expressed in mm. Further consideration was given to proportion of
closed pockets, defined as residual PD ≤4 mm with no bleeding after probing. Additional
secondary outcomes were changes in CAL, and changes in BOP. Full mouth plaque scores were
also extracted. Patient-reported outcome measures (PROMs) were also noted together with
adverse events recording.

Risk of Bias Assessment
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Assessment for risk of bias of all included studies was undertaken independently and in duplicate
by two reviewers (YL & FM) at the time of data extraction using the ROBINS-I Tool (RoB 2.0)
recommended by the Cochrane Collaboration for assessing risk of bias in randomised controlled
trials (Higgins et al., 2016). Each study was graded according to five items (randomisation,
deviation, missing data, outcome measurement and selective reporting) and an overall score for
risk of bias was assigned.
Data Synthesis
For continuous data (changes of PD and CAL) mean values and standard deviations were used
and analysed with weighted mean differences (WMD) and 95% confidence intervals (CIs). For
dichotomous data (BOP and pocket closure), estimates of the effect were expressed as risk ratios
(RR) and 95% CIs. The variable pocket closure was not consistently defined throughout the
included studies. In the present analysis, reported data were pooled, irrespective of the individual
case definition. Study-specific estimates were pooled with the random-effect model (DerSimonian
& Laird, 1986) and grouped according to pocket depth (all, shallow (4-6 mm) or deep (≥7 mm))
and tooth type (all, single- or multi-rooted).
Two separate sets of analyses were performed. For PICOS questions 2 and 3, standard meta-
analyses were performed using changes reported for test and control groups, respectively. As
none of the selected RCTs addressed PICOS question 1, it was decided a posteriori to analyse
baseline and final clinical data extracted from included and relevant studies, considering these
findings to be independent of each other. Test and control arms were considered as separate
studies. Therefore, the overall effect of treatment in terms of PD reduction and proportion of
pocket closure was estimated. All analyses were performed with Stata (Stata Statistical Software:
Release 15, StataCorp LLC, College Station, TX, USA) using the functions metan and metaprop.
Statistical heterogeneity among studies was explored by the I2 index (Higgins, Thompson,
Deeks, & Altman, 2003) and Cochrane's Q statistic (p<0.1). Forest plots were used to illustrate
the outcomes of the different analyses. To illustrate expected treatment effect prediction intervals
(PI) were calculated (Borenstein, Higgins, Hedges, & Rothstein, 2017). Publication bias was
evaluated through Funnel plots (function: metafunnel) and Egger’s test for small-study effects
(Egger, Davey Smith, Schneider, & Minder, 1997).

RESULTS
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Search and screening
The combined total of references obtained from the electronic search strategy customised for
each database was 13,137 citations with hand searching adding 10 citations and removal of
duplicates resulting in 5033 citations to be screened. Independent screening of titles and
abstracts resulted in 85 full text articles to be retrieved. Further screening of full text articles
resulted in 19 articles eligible for inclusion in the review. Kappa score calculated for screening
agreement was 0.93. Figure 1 summarises the screening results in the PRISMA flow diagram
showing citations resulting at each step of the screening process. The final number of studies
included in the review were 19 with 18 of those suitable for inclusion in one of a number of meta-
analysis.
Figure 1. Search results PRISMA flow-chart
The search retrieved a large number of relevant articles together with a substantial number of
irrelevant hits confirming the high sensitivity and relatively low precision of the search in
accordance with the search strategy. Numerous citations excluded were related to application of
the therapy in periodontal treatment protocols but were not designed to investigate the efficacy of
nonsurgical subgingival instrumentation. During full text screening, 66 articles were excluded
primary due to inclusion of adjunctive antimicrobial or antiseptics therapies or lack of reporting of
data relevant to this review. The reasons for exclusion together with the articles excluded are
summarised in Table 3.
Table 3. Excluded studies and reasons for exclusion (Reference list provided in Appendix).
Descriptive results
An overall brief summary of noteworthy study characteristics appears in Table 4. Included

studies ranged in year of publication from 1988 to 2015, most were conducted within single
centre university settings in European regions. Descriptive summaries of the 19 included studies
highlighting specific study characteristics are presented in Table 5. Studies are listed
chronologically from 1988 onward based on publication date and thereafter alphabetically within
each year. The collective data from all studies indicated a benefit of sub-gingival instrumentation
(PICOS 1) while none found a difference in treatment outcomes when comparing hand and

ultrasonic instruments to perform the treatment (PICOS 2). Only 1 study reported clinical outcome
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differences when comparing a full-mouth with a quadrant-wise approach (PICOS 3).
Table 4. Characteristics of included studies.
Table 5 Evidence Table of PICOS Characteristics of Included Studies
Risk of bias
Summarized results of the assessment of risk of bias are illustrated in Figure 2. One of the
included studies was judged to be at high risk of bias and 11 studies presented with some
concerns, mainly related to data analysis. Detailed information in regard to specific items in
individual studies are reported in the full evidence table (Appendix).
Figure 2 Individual and summarised assessment of risk of bias for included studies
Selected studies by PICOS question
Table 6 presents an overview of relevant studies for each PICOS question, separated by
subcategory (time of follow-up and pocket depth) and outcome. Feasibility of meta-analysis is
depicted by colour-coding. In general, analysis of the reduction of BoP was not possible due to
the lack of site-specific reporting, while patient-reported outcomes and adverse events could not
be collectively assessed due to heterogeneous and inconsistent reporting. Sub analyses by tooth
type (single-, multi-rooted) was not feasible based on the lack of data.
Table 6. Overview on meta-analyses performed.
PICOS question 1
One randomised controlled trial (Kapellas et al., 2013) specifically addressed PICOS question 1,
i.e. the potential benefit of subgingival instrumentation over supragingival cleaning alone. In a
specific patient population, the study indicated a significant benefit in terms of percentage of
pocket closure at 3 months. Data on BOP reduction or patient-reported outcomes were not
presented.

Considering baseline and final recordings separately, the weighted PD reduction was 1.0 mm
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(95%CI: 0.8; 1.3 / PI: -0.1; 2.2) at 3/4 months (9 studies) and 1.7 mm (95%CI: 1.3; 2.1 / PI: -0.2;
3.7) at 6/8 months (11 studies). The Egger’s test indicated a high risk of bias. The proportion of
closed pockets was estimated to be 57% (95%CI: 46; 68) and 74% (95%CI: 64; 85) at the two
time points, respectively (Figure 3a-1 to 3a-4). For details on heterogeneity as evaluated by I2 and
Q statistic, see appendix.
Figure 3a. Weighted mean PD reduction and proportion of closed pockets at 6/8 months
including Funnel plots.
Analysis of initially shallow sites revealed a weighted mean PD reduction of 1.5 mm (95%CI: 1.2;
1.7 / PI: 0.3; 2.7) at 3/4 months (10 studies) and 1.6 mm (95%CI: 1.3; 1.8 / PI: 0.6; 2.5) at 6/8
months (6 studies). For initially deep sites, a weighted PD reduction of 2.6 mm (95%CI: 2.2; 3.0 /
PI: 0.7; 4.6) at 3/4 months (10 studies) and 2.6 mm (95%CI: 1.1; 3.1 / PI: 0.5; 4.7) at 6/8 months
(7 studies) was observed (Figure 3b-1 to 3b-4).
Figure 3b. Weighted mean PD reduction for shallow and deep sites at 6/8 months including
Funnel plots.
To estimate the effect of treatment on BOP, the relative reduction of patient-based scores was
calculated for studies providing the data. The weighted mean reduction of BOP scores at 3/4
months, based on 9 studies, was 56.7% ±13.9. At 6/8 months the corresponding reduction, based
on 8 studies, was 62.7% ±17.5.
PICOS question 2
Six randomised controlled trials (Ioannou et al., 2009; Laurell & Pettersson, 1988; Malali, Kadir, &
Noyan, 2012; Obeid, D'Hoore, & Bercy, 2004; Petelin, Perkič, Seme, & Gašpirc, 2015;
Wennström, Tomasi, Bertelle, & Dellasega, 2005) specifically addressed PICOS question 2, i.e.
the comparison between hand and sonic/ultrasonic instruments for subgingival treatment. Meta-
analysis was possible for PD reduction and CAL gain, but not for any of the other outcomes
considered. No significant differences were observed between treatment groups at any time point
or for different categories of initial pocket depth. Findings at 6/8 months for PD reduction and CAL
gain are illustrated in Figure 4. The Egger’s test did not reveal a significant risk of bias. One study
reported data on site-specific reduction of BOP, not identifying any significant differences

between groups (Wennström et al., 2005). Results from the remaining analyses are presented in
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the Appendix (see Table 6 for guidance).
Figure 4. WMD between hand and sonic/ultrasonic instruments for PD reduction and CAL
gain at 6/8 months including Funnel plots.
PICOS question 3
Thirteen randomised controlled trials (Apatzidou & Kinane, 2004; Del Peloso Ribeiro et al., 2008;
Fonseca et al., 2015; Jervøe-Storm et al., 2006; Koshy et al., 2005; Loggner Graff, Asklöw, &
Thorstensson, 2009; Meulman et al., 2013; Predin et al., 2014; Quirynen et al., 2006; Swierkot,
Nonnenmacher, Mutters, Flores-de-Jacoby, & Mengel, 2009; Wennström et al., 2005; Zanatta et
al., 2006; Zijnge et al., 2010) specifically addressed PICOS question 3, i.e. the comparison
between quadrant-wise and full-mouth approaches for subgingival instrumentation. Meta-analysis
was possible for the outcomes PD reduction, CAL gain and pocket closure (for details, see Table
6). No significant differences were observed between treatment groups irrespective of time point
or initial pocket depth. Findings at 6/8 months for PD reduction, CAL gain and pocket closure are
illustrated in Figure 5. The Egger’s test did not reveal a significant risk of bias. Two studies
reported site-specific reduction of BOP, indicating no significant differences between treatment
groups at 3/4 (p=0.67) and 6/8 months (p=0.78) (Del Peloso Ribeiro et al., 2008; Wennström et
al., 2005). Adverse events, addressed in 5 studies, were rare (1 event in each treatment group
reported in one study (Predin et al., 2014)) with no differences between groups. Discomfort
following instrumentation was reported in 5 studies (Apatzidou & Kinane, 2004; Del Peloso
Ribeiro et al., 2008; Koshy et al., 2005; Loggner Graff et al., 2009; Wennström et al., 2005).
Again, no differences between study groups was observed. In the study by Loggner Graff and co-
workers, operators found the quadrant-wise approach less strenuous when compared to the full-
mouth protocol (Loggner Graff et al., 2009). Findings from the remaining analyses are presented
in the Appendix.
Figure 5. WMD between quadrant-wise and full-mouth approach for PD reduction and CAL
gain at 6/8 months. RR for pocket closure at 6/8 months between treatment groups. Funnel
plots included.
DISCUSSION

The remit of the present systematic review was to critically appraise and summarise the currently
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available literature with regards to (i) the efficacy of mechanical subgingival instrumentation as
part of nonsurgical periodontal therapy, (ii) the potential impact of different types of instruments
used for mechanical removal of soft and hard debris subgingivally and (iii) the influence of
different modes of delivery of subgingival instrumentation. As the establishment of infection
control (as measured by absence of clinical signs of inflammation and increased resistance to
probing) is the main goal of treatment, reduction of pocket depth, both in terms of average
measures as well as frequencies of closed pockets (probing pocket depth ≤4 mm and absence of
bleeding on probing) were considered as relevant outcomes to address the research questions.
The results from this systematic review demonstrated that subgingival instrumentation is an
efficacious treatment in reducing inflammation, probing pocket depth and number of diseased
sites in patients affected by periodontitis. This effect was consistent, irrespective of the choice of
instrument (sonic/ultrasonic vs hand) or mode of delivery (full-mouth vs quadrant). Thus, at
shallow sites (4-6 mm) a mean reduction of PD of 1.5 mm can be expected at 6/8 months, while
at deeper sites (≥7 mm) the mean PD reduction was estimated at 2.6 mm. In addition, an overall
proportion of pocket closure of 74% at 6/8 months was observed, combined with a mean BOP
reduction of 62%. Considering the extent of disease resolution, as measured in terms of pocket
closure, it appears that well-performed nonsurgical periodontal therapy may limit the need of
other additional/alternative treatment approaches, which may entail higher costs and patient
morbidity.
The lack of randomised clinical trials addressing PICOS question 1 may not come as a surprise,
given the ethical implications of such a study design. The only study that could be included
adopted a 3-month delay in delivering the subgingival treatment in the control group (Kapellas et
al., 2013). Other studies addressing efficacy of subgingival instrumentation were often not
randomised and/or demonstrated a high risk of bias. Thus, the best option available was
analysing longitudinal changes reported in studies identified for PICOS questions 2 and 3. We
considered different treatment arms within the RCTs as separate units, which may have
introduced weaknesses due to potential lack of independence and the inclusion of studies not

designed to answer the main question. Nevertheless, given the strict inclusion criteria and the
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absence of significant differences between treatment arms the approach adopted was deemed
reasonable. The same approach was previously chosen by other authors facing similar problems
(Van der Weijden & Timmerman, 2002).
Addressing PICOS question 2, no significant differences were observed in terms of clinical

outcomes between hand and sonic/ultrasonic subgingival instrumentation. These results confirm
previously published data, as summarized in previous reviews (Drisko, 2000; Krishna & De
Stefano, 2016; Tunkel et al., 2002). It should be considered, however, that a variety of different
instruments in terms of manufacturer, design, and technology were used in the different studies,
which may have contributed to the heterogeneity among studies. In addition, clinicians may
frequently combine the use of hand and power-driven instruments in their everyday work.
The third PICOS question focused on the comparison between the traditional quadrant-wise
treatment approaches and full-mouth approaches to nonsurgical periodontal treatment. Results
confirmed findings reported in previously published reviews (Eberhard, Jepsen, Jervøe-Storm,
Needleman, & Worthington, 2015; Lang, Tan, Krahenmann, & Zwahlen, 2008), which failed to
identify differences. It was therefore concluded that the choice of treatment delivery may be
based on patients’ preferences and other practical considerations such as medical status,
tolerance for chair time or perhaps the need for repeated sessions of oral hygiene instructions. In
this context, full-mouth approaches have been implicated with higher acute systemic
inflammatory perturbation in the immediate post-operative period (Graziani et al., 2015). The
reader should be aware that studies including adjunctive measures (e. g. antiseptic agents) were
not included in the present analysis.
Analysing outcomes by initial PD (shallow or deep) and tooth category (single or multi-rooted) is
in line with then new classification of periodontitis (Papapanou et al., 2018). Thus, cases
classified as stage 1 or 2 are characterised by the presence of shallow pockets (≤5 mm), while
stages 3 and 4 are characterised by deep probing and furcation involvement. Although not
perfectly aligned in terms of thresholds for pocket depths, the present review showed that in more
advanced cases, nonsurgical therapy was shown to be more efficacious in terms of PD reduction,
while disease resolution, as measured by pocket closure, was less likely. Studies included in the

present review identified cases based on either chronic/aggressive periodontitis or on a minimum
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number of diseased teeth. None of the studies applied the case definitions suggested in 2018.
The primary variable chosen to evaluate treatment outcome was probing pocket depth reduction,
which is a common choice in meta-analytical approaches. Probing pocket depth serves as a
surrogate outcome variable and has been validated by its association with disease progression
and tooth loss (Badersten, Nilveus, & Egelberg, 1990; Claffey & Egelberg, 1995; Lang et al.,
2008; Matuliene et al., 2008; Westfelt, Rylander, Dahlen, & Lindhe, 1998). The goal of therapy,
however, is to obtain shallow probing pocket depth and absence of bleeding, indicating sufficient
removal of biofilm/calculus and subsequent resolution of the inflammatory lesion. Therefore, the
present review considered pocket closure as an important component to evaluate treatment
efficacy. The parameter, however, was not consistently reported and defined in different ways,
i.e. with or without the measure of BOP. Future research should highlight the frequency of pocket
closure.
The follow-up in the included studies rarely extended beyond 6 months, which may be considered
short. It should be remembered, however, that nonsurgical therapy is part of an overall treatment
strategy, constituted from many different phases, each of them needing a clinical evaluation at an
appropriate follow-up interval after its completion (Kieser, 1994). In addition, there was an
obvious variation between studies in terms of (i) follow-up, (ii) treatment strategy, (iii) self-
performed infection control and (iv) distribution of modifying factors. However, the questions
highlighted in the present review were addressed by direct comparisons within studies adapting
consistent study protocols. Thus, meta-analyses were based on differences between groups.
The external validity of the data reported in the studies included in the present review may be
discussed. While the overall risk of bias was found to be low for the vast majority of studies, most
were institutional, performed in well-controlled environments and patient samples. Therefore, the
present review probably describes efficacy rather than effectiveness of the intervention. It should
also be noted that some studies were designed to investigate different primary outcomes than
those addressed in the PICOS questions. The reader should also be aware that several of the
relevant studies were conducted prior to the development of instruments available today, i.e. thin
ultrasonic tips, micro/mini curettes). Finally, few data on adverse events or patient-reported
outcomes are presently available. Some studies with short-term patient-reported outcomes were
excluded from the review due to the inclusion criteria of 6-month follow-up. Additional limitations
of the present review are evident. For PICOS question 1, as already discussed above, baseline

and final data within the same treatment arm were considered as independent. Furthermore, a
Accepted Article
limited number of studies was available for some sub-analysis, resulting in wide confidence and
prediction intervals in the meta-analysis. The inclusion of split-mouth studies for the comparison
of different instruments may also have introduced a certain risk of bias.
In conclusion and within the limitations of the present review, a comprehensive search and
analysis of the available literature based on randomised controlled trials with a 6-month follow-up
demonstrated that mechanical subgingival instrumentation is efficacious in the nonsurgical
treatment of periodontitis, irrespective of type of instrument or mode of delivery.
ACKNOWLEDGEMENTS
The authors would like to acknowledge and thank the UCL Eastman Dental Institute librarian, Dr
Debora Marletta, for her valuable help with developing the search strategy and conduct of the
electronic database search.
CONFLICT OF INTEREST
The authors declare no conflict of interest in regard to the present work. There were no external
sources of funding to support conduct of this review.
CLINICAL RELEVANCE
Scientific rationale for the study: This systematic review provides an evidence summary of the
efficacy of subgingival instrumentation, of sonic/ultrasonic/hand instruments and of different
delivery timings in periodontitis treatment.
Principal findings: Weighted mean proportion of pocket closure was 74%. Nonsurgical
mechanical subgingival instrumentation is efficacious in achieving infection control in
periodontitis patients irrespective of whether performed by sonic/ultrasonic/hand instrument or
delivered full mouth within 24 hours or in segments over multiple visits.
Practical implications: Clinicians should consider subgingival instrumentation as a key part of
periodontal therapy and may choose instrument type and mode of delivery on an individual
patient basis.

REFERENCES
Accepted Article
Apatzidou, D. A., & Kinane, D. F. (2004). Quadrant root planing versus same-day full-mouth root
planing. I. Clinical findings. Journal of Clinical Periodontology, 31(2), 132-140.
doi:10.1111/j.0303-6979.2004.00461.x
Badersten, A., Nilveus, R., & Egelberg, J. (1990). Scores of plaque, bleeding, suppuration and
probing depth to predict probing attachment loss. 5 years of observation following
nonsurgical periodontal therapy. Journal of Clinical Periodontology, 17(2), 102-107.
Borenstein, M., Higgins, J. P. T., Hedges, L. V., & Rothstein, H. R. (2017). Basics of meta-
analysis: I2 is not an absolute measure of heterogeneity. Research synthesis methods,
8(1), 5-18. doi:10.1002/jrsm.1230
Breininger, D. R., O'Leary, T. J., & Blumenshine, R. V. (1987). Comparative effectiveness of
ultrasonic and hand scaling for the removal of subgingival plaque and calculus. Journal of
Periodontology, 58(1), 9-18. doi:10.1902/jop.1987.58.1.9
Claffey, N., & Egelberg, J. (1995). Clinical indicators of probing attachment loss following initial
periodontal treatment in advanced periodontitis patients. Journal of Clinical
Periodontology, 22(9), 690-696.
Del Peloso Ribeiro, É., Bittencourt, S., Sallum, E. A., Nociti Júnior, F. H., Gonçalves, R. B., &
Casati, M. Z. (2008). Periodontal debridement as a therapeutic approach for severe
chronic periodontitis: a clinical, microbiological and immunological study. Journal of
Clinical Periodontology, 35(9), 789-798. doi:10.1111/j.1600-051X.2008.01292.x
DerSimonian, R., & Laird, N. (1986). Meta-analysis in clinical trials. Controlled Clinical Trials, 7(3),
177-188.
Drisko, C. H. (2000). Trends in surgical and nonsurgical periodontal treatment. Journal American
Dental Association, 131 Suppl, 31S-38S.
Eberhard, J., Jepsen, S., Jervøe-Storm, P.-M., Needleman, I. G., & Worthington, H. V. (2015).
Full-mouth treatment modalities (within 24 hours) for chronic periodontitis in adults. The
Cochrane database of systematic reviews(4), CD004622.
doi:10.1002/14651858.CD004622.pub3
Egger, M., Davey Smith, G., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected
by a simple, graphical test. British Medical Journal, 315(7109), 629-634.
doi:10.1136/bmj.315.7109.629
Fonseca, D. C., Cortelli, J. R., Cortelli, S. C., Miranda Cota, L. O., Machado Costa, L. C., Moreira
Castro, M. V., . . . Costa, F. O. (2015). Clinical and Microbiologic Evaluation of Scaling
and Root Planing per Quadrant and One-Stage Full-Mouth Disinfection Associated With

Accepted Article Azithromycin or Chlorhexidine: A Clinical Randomized Controlled Trial. Journal of
Periodontology, 86(12), 1340-1351. doi:10.1902/jop.2015.150227
Graziani, F., Cei, S., Orlandi, M., Gennai, S., Gabriele, M., Filice, N.,…D’Aiuto, F. (2015) Acute
Phase Response following Full Mouth versus Quadrant Non-Surgical Periodontal
Treatment. A Randomized Clinical Trial. Journal of Clinical Periodontology, 42(9), 843–
852. doi: 10.1111/jcpe.12451
Hallmon, W. W., & Rees, T. D. (2003). Local anti-infective therapy: mechanical and physical
approaches. A systematic review. Annals of Periodontology, 8(1), 99-114.
doi:10.1902/annals.2003.8.1.99
Heitz-Mayfield, L. J. & Lang, N, P. (2013). Surgical and nonsurgical periodontal therapy. Learned
and unlearned concepts. Periodontology 2000, 62(1), 218-231. doi: 10.1111/prd.12008
Herrera, D. (2016). Scaling and Root Planning is Recommended in the Nonsurgical Treatment of
Chronic Periodontitis. Journal of Evidence Based Dental Practice, 16(1), 56-58.
doi:10.1016/j.jebdp.2016.01.005
Higgins, J. P., Sterne, J. A. C., Savović, J., Page, M. J., Hróbjartsson, A., Boutron, I., . . .
Eldridge, S. (2016). A revised tool for assessing risk of bias in randomized trials. In J.
Chandler, J. McKenzie, I. Boutron, & V. Welch (Eds.), Cochrane Methods (Vol. 10 (Suppl
1)): Cochrane Database of Systematic Reviews.
Higgins, J. P., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring inconsistency in
meta-analyses. British Medical Journal, 327(7414), 557-560.
doi:10.1136/bmj.327.7414.557
Hujoel, P. P. (2004). Endpoints in periodontal trials: the need for an evidence-based research
approach. Periodontology 2000, 36, 196-204. doi:10.1111/j.1600-0757.2004.03681.x
Ioannou, I., Dimitriadis, N., Papadimitriou, K., Sakellari, D., Vouros, I., & Konstantinidis, A. (2009).
Hand instrumentation versus ultrasonic debridement in the treatment of chronic
periodontitis: a randomized clinical and microbiological trial. Journal of Clinical
Periodontology, 36(2), 132-141. doi:10.1111/j.1600-051X.2008.01347.x
Jepsen, S., Deschner, J., Braun, A., Schwarz, F. & Eberhard, J. (2011). Calculus removal and the
prevention of its formation. Periodontology 2000, 55(1):167-88. doi: 10.1111/j.1600-
0757.2010.00382.x
Jervøe-Storm, P. M., Semaan, E., AlAhdab, H., Engel, S., Fimmers, R., & Jepsen, S. (2006).
Clinical outcomes of quadrant root planing versus full-mouth root planing. Journal of
Kapellas, K., Do, L. G., Bartold, P. M., Skilton, M. R., Maple-Brown, L. J., O’Dea, K., . . .
Jamieson, L. M. (2013). Effects of full-mouth scaling on the periodontal health of

Accepted Article Indigenous Australians: a randomized controlled trial. Journal of Clinical Periodontology,
40(11), 1016-1024. doi:10.1111/jcpe.12152
Kieser, J. B. (1994). Non-surgical periodontal therapy. Paper presented at the Proceedings of the
1st European Workshop on Periodontology, Thurgau, Switzerland.
Koshy, G., Kawashima, Y., Kiji, M., Nitta, H., Umeda, M., Nagasawa, T., & Ishikawa, I. (2005).
Effects of single-visit full-mouth ultrasonic debridement versus quadrant-wise ultrasonic
debridement. Journal of Clinical Periodontology, 32(7), 734-743. doi:10.1111/j.1600-
051X.2005.00775.x
Krishna, R., & De Stefano, J. A. (2016). Ultrasonic vs. hand instrumentation in periodontal
therapy: clinical outcomes. Periodontology 2000, 71(1), 113-127. doi:10.1111/prd.12119
Lang, N. P., Tan, W. C., Krahenmann, M. A., & Zwahlen, M. (2008). A systematic review of the
effects of full-mouth debridement with and without antiseptics in patients with chronic
periodontitis. Journal of Clinical Periodontology, 35(8 Suppl), 8-21. doi:10.1111/j.1600-
051X.2008.01257.x
Laurell, L., & Pettersson, B. (1988). Periodontal healing after treatment with either the Titan-S
sonic scaler or hand instruments. Swedish dental journal, 12(5), 187-192.
Lea, S. C., Landini, G., & Walmsley, A. D. (2003). Ultrasonic scaler tip performance under various
load conditions. Journal of Clinical Periodontology, 30(10), 876-881.
Leknes, K. N., Lie, T., Wikesjo, U. M., Bogle, G. C., & Selvig, K. A. (1994). Influence of tooth
instrumentation roughness on subgingival microbial colonization. Journal of
Periodontology, 65(4), 303-308. doi:10.1902/jop.1994.65.4.303
Loggner Graff, I., Asklöw, B., & Thorstensson, H. (2009). Full-mouth versus quadrant-wise
scaling--clinical outcome, efficiency and treatment discomfort. Swedish dental journal,
33(3), 105-113.
Malali, E., Kadir, T., & Noyan, U. (2012). Er:YAG Lasers Versus Ultrasonic and Hand Instruments
in Periodontal Therapy: Clinical Parameters, Intracrevicular Micro-organism and
Leukocyte Counts. Photomedicine and Laser Surgery, 30(9), 543-550.
doi:10.1089/pho.2011.3202
Matuliene, G., Pjetursson, B. E., Salvi, G. E., Schmidlin, K., Bragger, U., Zwahlen, M., & Lang, N.
P. (2008). Influence of residual pockets on progression of periodontitis and tooth loss:
results after 11 years of maintenance. Journal of Clinical Periodontology, 35(8), 685-695.
doi:10.1111/j.1600-051X.2008.01245.x
Meulman, T., Giorgetti, A. P. O., Gimenes, J., Casarin, R. C. V., Peruzzo, D. C., & Nociti Júnior,
F. H. (2013). One stage, full-mouth, ultrasonic debridement in the treatment of severe

Accepted Article chronic periodontitis in smokers: a preliminary, blind and randomized clinical trial. Journal
of the International Academy of Periodontology, 15(3), 83-90.
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine, 6(7),
e1000097. doi:10.1371/journal.pmed.1000097
Obeid, P. R., D’Hoore, W., & Bercy, P. (2004). Comparative clinical responses related to the use
of various periodontal instrumentation. Journal of Clinical Periodontology, 31(3), 193-199.
doi:10.1111/j.0303-6979.2004.00467.x
Papapanou, P. N., Sanz, M., Buduneli, N., Dietrich, T., Feres, M., Fine, D. H., . . . Tonetti, M. S.
(2018). Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on
the Classification of Periodontal and Peri-Implant Diseases and Conditions. Journal of
Clinical Periodontology, 45 Suppl 20, S162-S170. doi:10.1111/jcpe.12946
Petelin, M., Perkič, K., Seme, K., & Gašpirc, B. (2015). Effect of repeated adjunctive antimicrobial
photodynamic therapy on subgingival periodontal pathogens in the treatment of chronic
periodontitis. Lasers in Medical Science, 30(6), 1647-1656. doi:10.1007/s10103-014-
1632-2
Predin, T., Djuric, M., Nikolic, N., Mirnić, J., Gušić, I., Petrovic, D., & Milasin, J. (2014). Clinical
and microbiological effects of quadrant versus full-mouth root planing—a randomized
study. Elsevier. doi:10.1111/idh.12141
Quirynen, M., Bollen, C. M., Vandekerckhove, B. N., Dekeyser, C., Papaioannou, W., & Eyssen,
H. (1995). Full- vs. partial-mouth disinfection in the treatment of periodontal infections:
short-term clinical and microbiological observations. Journal of Dental Research, 74(8),
1459-1467. doi:10.1177/00220345950740080501
Quirynen, M., De Soete, M., Boschmans, G., Pauwels, M., Coucke, W., Teughels, W., & van
Steenberghe, D. (2006). Benefit of “one-stage full-mouth disinfection” is explained by
disinfection and root planing within 24 hours: a randomized controlled trial. Journal of
Ramseier, C. A., Suvan, J. E. (2015). Behaviour change counselling for tobacco use cessation
and promotion of healthy lifestyles: a systematic review. Journal of Clinical
Periodontology, 42 Suppl 16, S47-S58. doi: 10.1111/jcpe.12351
Rateitschak-Pluss, E. M., Schwarz, J. P., Guggenheim, R., Duggelin, M., & Rateitschak, K. H.
(1992). Non-surgical periodontal treatment: where are the limits? An SEM study. Journal
of Clinical Periodontology, 19(4), 240-244.

Schmidlin, P. R., Beuchat, M., Busslinger, A., Lehmann, B., & Lutz, F. (2001). Tooth substance
Accepted Article loss resulting from mechanical, sonic and ultrasonic root instrumentation assessed by
liquid scintillation. Journal of Clinical Periodontology, 28(11), 1058-1066.
Smiley, C. J., Tracy, S. L., Abt, E., Michalowicz, B. S., John, M. T., Gunsolley, J., . . . Hanson, N.
(2015). Systematic review and meta-analysis on the nonsurgical treatment of chronic
periodontitis by means of scaling and root planing with or without adjuncts. Journal of
American Dental Association, 146(7), 508-524 e505. doi:10.1016/j.adaj.2015.01.028
Suvan, J. E. (2005). Effectiveness of mechanical nonsurgical pocket therapy. Periodontology
2000, 37, 48-71. doi:10.1111/j.1600-0757.2004.03794.x
Swierkot, K., Nonnenmacher, C. I., Mutters, R., Flores-de-Jacoby, L., & Mengel, R. (2009). One-
stage full-mouth disinfection versus quadrant and full-mouth root planing. Journal of
Tomasi, C., & Wennström, J. L. (2009). Full-mouth treatment vs. the conventional staged
approach for periodontal infection control. Periodontology 2000, 51, 45-62.
doi:10.1111/j.1600-0757.2009.00306.x
Tomasi, C., & Wennström, J. L. (2017). Is the use of differences in the magnitude of CAL gain
appropriate for making conclusions on the efficacy of non-surgical therapeutic means?
Journal of Clinical Periodontology, 44(6), 601-602. doi:10.1111/jcpe.12733
Tunkel, J., Heinecke, A., & Flemmig, T. F. (2002). A systematic review of efficacy of machine-
driven and manual subgingival debridement in the treatment of chronic periodontitis.
Journal of Clinical Periodontology, 29 Suppl 3, 72-81- discussion 90-71.
Van der Weijden, G. A., & Timmerman, M. F. (2002). A systematic review on the clinical efficacy
of subgingival debridement in the treatment of chronic periodontitis. Journal of Clinical
Periodontology, 29(s3), 55-71. doi:10.1034/j.1600-051X.29.s3.3.x
Wennström, J. L., Tomasi, C., Bertelle, A., & Dellasega, E. (2005). Full-mouth ultrasonic
debridement versus quadrant scaling and root planing as an initial approach in the
treatment of chronic periodontitis. Journal of Clinical Periodontology, 32(8), 851-859.
doi:10.1111/j.1600-051X.2005.00776.x
Westfelt, E., Rylander, H., Dahlen, G., & Lindhe, J. (1998). The effect of supragingival plaque
control on the progression of advanced periodontal disease. Journal of Clinical
Periodontology, 25(7), 536-541. doi:10.1111/j.1600-051X.1998.tb02484.x
Zanatta, G. M., Bittencourt, S., Nociti Júnior, F. H., Sallum, E. A., Sallum, A. W., & Casati, M. Z.
(2006). Periodontal debridement with povidone-iodine in periodontal treatment: short-term
clinical and biochemical observations. Journal of Periodontology, 77(3), 498-505.
doi:10.1902/jop.2006.050154

Zijnge, V., Meijer, H. F., Lie, M.-A., Tromp, J. A. H., Degener, J. E., Harmsen, H. J. M., & Abbas,
Accepted Article F. M. (2010). The recolonization hypothesis in a full-mouth or multiple-session treatment
protocol: a blinded, randomized clinical trial. Journal of Clinical Periodontology, 37(6),
518-525. doi:10.1111/j.1600-051X.2010.01562.x

Criteria PICOS Question 1 PICOS Question 2 PICOS Question 3
Population Adults ≥18 years with periodontitis
Subgingival Subgingival instrumentation Subgingival instrumentation

Intervention instrumentation performed with performed full mouth in a
sonic/ultrasonic instruments single visit
Supra-gingival Subgingival instrumentation Subgingival instrumentation

instrumentation/prophylaxis performed with hand performed quadrant or
Comparison or no treatment instruments sextant wise over a series of
visits
Outcomes Clinical measures of periodontal status

Patient reported outcomes
Study Randomised Controlled Trials

Table 2. Search strategy for OVID Medline
1 exp Periodontitis/
2 (periodontiti* or pericementitid* or pericementiti* or gum* diseas* or
gum* bleed* or periodont* diseas*).mp.
3 1 or 2
4 exp Dental Scaling/
5 (dent* scal* or root* scal* or subging* scal* or "sub gingiv* scal*" or
supraging* scal* or supra ging* scal*).mp.
6 exp "Root Planing"/
7 root* plan*.mp.
8 exp Subgingival Curettage/
9 (subging* curettag* or root* debridement*).mp.
10 (curettag* adj4 (ging* or "sub ging*")).mp.
11 (debridement* adj4 (periodont* epithelial or root* surface* or full mouth
or dent* quadrant)).mp.
12 exp Dental Prophylaxis/
13 (prophylaxis adj4 (dent* or teeth or tooth or oral)).mp.
14 exp Dental Deposits/
15 (deposit$1 adj4 (tooth or teeth or oral)).mp.
16 (dent* adj3 (plaque or calculus or tartar)).mp.
17 exp Dental Polishing/
18 (polish* adj4 (dent* or tooth or teeth)).mp.
19 (mechanic* adj3 debridement*).mp.
20 (instrument* adj3 (supra ging* or supraging* or "sub ging*" or subging*
or full mouth)).mp.
21 *Dental Instruments/
22 (root* instrument* or manual instrument* or hand instrument* or
handheld instrument* or power instrument*).mp.
23 (periodontit* therap* or "non surgic* periodontit* therap*").mp.
24 exp Dentistry/
25 dental.mp.
26 24 or 25
27 (sonic* or ultrasonic* or "ultra sonic*" or oscillat* or reciprocat* or rotat*
or diamond* or perioplan* or rootsharp* or power driven or curette* or
scaler*).mp.
28 26 and 27
29 OR/4-23
30 28 or 29
31 30 and 3
32 limit 31 to (clinical trial, all or clinical trial or randomized controlled trial)
33 (((single adj (blind* or masked)) or double) adj (blind* or masked)).ab.
or (((single adj (blind* or masked)) or double) adj (blind* or masked)).ti.
34 (randomized or randomly or placebo or trial or (controlled adj
study)).ab. or (randomized or randomly or placebo or trial or (controlled
adj study)).ti.
35 (randomized controlled trial or controlled clinical trial).pt. or
randomized.ab. or placebo.ab. or drug therapy.fs. or randomly.ab. or
trial.ab. or groups.ab.
36 33 or 34 or 35
37 31 and 36
38 32 or 37
39 limit 38 to humans
40 limit 38 to animals
41 38 not 40
42 limit 41 to "all adult (19 plus years)"
Reason for exclusion First author, year
Aimetti 2011, Al-Mubarak 2000, Arpağ 2017, Babaloo 2018, Bollen

Inclusion of antibacterial or 1996, Bollen 1998, Christgau 2006, Christgau 2007, Drisko 1998, Eren
antiseptic adjunctive therapy 2002, Farahmand 2016, Hellden 1979, Jones 1994, Kahl 2007, Knöfler
(n=29) 2007, Knöfler 2011, Konopka 2012, Maze 1995, Mongardini 1999,
Polson 1996, Quirynen 1995, Roman-Torres 2018, Rotundo 2010, Rupf
2005, Santuchi 2015, Santuchi 2016, Silveira 2017, Vandekerckhove
1996, Walsh 1986
Alves 2004, Alves 2005, Apatzidou 2004b, Apatzidou 2004c, Åslund

No relevant data reported 2008, Braun 2003, Chung 2011, Copulos 1993, Dahiya 2013, Del
(n=28) Peloso Ribeiro 2007, Forabosco 2006, Friesen 2002, Gomes 2014,
Kaldahl 1988, Kamma 2009, Kocher 2005, Koshy 2001, Lopes 2010,
Pawlowski 2005, Sato 1993, Sculean 2004, Southard 1989, Türktekin
2018, Tomasi 2006, Tomasi 2007, Ueda 2014, Verrusio 2018, Zee 2006
Chapper 2005, D'Ercole 2006, Dragoo 1992, Jenkins 2000, Kocher

Not randomised 2001, Lim 1996, Quirynen 2000
(n=7)
Non-English language Nonhoff 2006

(n=1)
Review article Greenstein 2004

(n=1)
Study Characteristic Number of First Author, Year
Studies
(N=19)
Region
Europe 13 Laurell & Pettersson 1988, Apatzidou & Kinane 2004, Obeid et al. 2004,
Wennström et al. 2005, Jervøe-Storm et al. 2006, Quirynen et al. 2006,
Swierkot et al. 2009, Ioannou et al. 2009, Loggner Graf et al. 2009, Zijnge et al.
2010, Malali et al. 2012, Predin et al. 2014, Petelin et al. 2015
South America 4 Zanatta et al. 2006, Del Peloso Ribeiro et al. 2008, Meulman et al. 2013,
Fonseca et al. 2015
Australasia 2 Koshy et al. 2005, Kapellas et al. 2013
Setting
Private 1 Zijnge et al. 2010
Private & University 1 Wennström et al. 2005
University
16 Laurell & Pettersson 1988, Apatzidou & Kinane 2004, Obeid et al. 2004, Koshy
et al. 2005, Jervøe-Storm et al. 2006, Quirynen et al. 2006, Zanatta et al. 2006,
Del Peloso Ribeiro et al. 2008, Swierkot et al. 2009, Ioannou et al. 2009,
Loggner Graf et al. 2009, Malali et al. 2012, Meulman et al. 2013, Predin et al.
2014, Fonseca et al. 2015, Petelin et al. 2015
Public
1 Kapellas et al. 2013
Year of Publication
1988-2000
1 Laurell & Pettersson 1988
2001-2010
12 Apatzidou & Kinane 2004, Obeid et al. 2004, Wennström et al. 2005, Koshy et
al. 2005, Jervøe-Storm et al. 2006, Quirynen et al. 2006, Zanatta et al. 2006,
Del Peloso Ribeiro et al. 2008, Swierkot et al. 2009, Ioannou et al. 2009,
Loggner Graf et al. 2009, Zijnge et al. 2010
2011-Present
6 Malali et al. 2012, Meulman et al. 2013, Kapellas et al. 2013, Predin et al.
2014, Fonseca et al. 2015, Petelin et al. 2015
Table 5. Evidence Table of PICOS Characteristics of Included Studies.
Author, year, country, Study Findings

Population of study Treatment Groups Treatment Outcomes
title
Laurell & Pettersson, (1988) Setting: University (single center) RCT Design: Split mouth PICOS: 1 and 2 Pico 1: clinical benefit of
subgingival instrumentation
Sweden N = 12 Test: Subgingival debridement Values reported:
(completed within 1 week) with sonic Full-mouth BOP reduction Pico 2: no difference between
Periodontal healing after Age: 36 - 55 years scaler Pocket closure (PPD <4 mm) hand and ultrasonic
treatment with either the Titan- Full-mouth plaque score instruments
S sonic scaler or hand Gender: Female n=7 Male n=5 Control: SRP (completed within 1 week)
instruments with hand instruments Reported for: Pico 3: n/a
Smoking status: Not specified All sites ≥4mm
No retreatment.
Periodontal disease status: Other Outcomes:
Moderate Teeth included: Not reported
Single and multi-rooted
Timepoints: 3 months
Apatzidou & Kinane, (2004) Setting: University (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
subgingival instrumentation
Scotland N = 40 Test: FM-SRP performed on the same day Values reported:
with a combination of hand and ultrasonic Mean PPD reduction Pico 2: n/a
Quadrant root planing versus Age: 31 - 70 years instruments Mean CAL gain
same-day full-mouth root Full-mouth BOP reduction Pico 3: no difference between
planing. I. Clinical findings Gender: Female n=17 Male n=23 Control: Q-SRP one hour per quadrant Pocket closure (PPD <5 mm) full mouth and quadrant
with hand and ultrasonic instruments Full-mouth plaque score approach
Smoking status: n=15 smokers
Teeth included: Reported for:
Periodontal disease status: Single and multi-rooted All sites ≥5 mm
Moderate to severe
At 13 weeks, retreatment of sites with PD Other Outcomes:
VAS scale of patient comfort
≥5 mm & BOP.
Obeid et al. Setting: University (single center) RCT Design: Split mouth PICOS: 1 and 2 Pico 1: clinical benefit of
(2004) subgingival instrumentation
N = 20 Test: UD (2 minutes/tooth) ultrasonic Values reported:
Belgium Mean PPD reduction Pico 2: no difference between
Age: 40 - 69 years Control: SRP (3 minutes/tooth) hand Mean CAL gain hand and ultrasonic
Comparative clinical instruments Full-mouth BOP reduction instruments
responses related to the use Gender: Female n=10 Male n=10 Pocket closure (PPD 5 mm)
of various periodontal Teeth included: Pico 3: n/a
instrumentation Smoking status: n=4 smokers Single and multi-rooted Reported for:
All sites
Periodontal disease status: 4 treatment groups (only 2 considered). 6 Shallow sites 3-5 mm
Moderate to severe chronic periodontitis, 2 months duration. Recall at 1 month for Deep sites ≥6 mm
OHI.
molars and 3 sites single rooted PPD ≥4 mm in Other Outcomes:
each quadrant Not reported
Timepoints: 3 and 6 months

title
Koshy et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
N = 24 Test: FMS (1 appointment) ultrasonic Values reported:
Japan Mean PPD reduction Pico 2: n/a
Age: 34 - 66 years Control: Q-SRP (no time limit) ultrasonic Mean CAL gain
Effects of single-visit full- Full-mouth BOP reduction Pico 3: no difference between
mouth ultrasonic debridement Gender: Female n=15 Male n=9 Teeth included: Pocket closure (PPD <5mm) full mouth and quadrant
versus quadrant-wise Single and multi-rooted Full-mouth plaque score approach
ultrasonic debridement Smoking status: non-smokers
3 treatment groups (only 2 considered), Reported for:
Periodontal disease status: All sites ≥5mm
Moderate to severe All subjects were recalled every month for Shallow sites 5-6 mm
re-inforcement of oral hygiene instructions Deep sites ≥7 mm
and professional tooth cleaning with a
rubber cup and polishing paste. Other Outcomes:
Number of adverse events
Wennström et al. Setting: University (Sweden) & private practice RCT Design: Parallel PICOS: 1, 2, and 3 Pico 1: clinical benefit of
(2005) (Italy) subgingival instrumentation
Test: Full mouth debridement with 1 hour Values reported:
Sweden & Italy N = 41 time limit with ultrasonic instrument Mean PPD reduction Pico 2: no difference between
Mean CAL gain hand and ultrasonic
Full mouth ultrasonic Age: 25 - 75 years Control: Quadrant SRP without time limit Full-mouth BOP reduction instruments
debridement versus quadrant with hand instruments Pocket closure (PPD 4 mm)
scaling and root planing as an Gender: Female n=19 Male n=22 Full-mouth plaque score Pico 3: no difference between
initial approach in the Teeth included: full mouth and quadrant
treatment of chronic Smoking status: n=20 smokers Single and multi-rooted Reported for: approach
periodontitis All sites ≥5 mm
Periodontal disease status: At 3 months, retreatment of sites with PPD Shallow sites 5-6 mm
Moderate to severe Deep sites ≥7 mm
≥5 mm.
Other Outcomes:
Root sensitivity ≥5 days post-treatment

title
Jervøe-Storm et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
N = 20 Test: FMRP (2 sessions within 24h) with Values reported:
Germany combination hand and ultrasonic Mean reduction PPD Pico 2: n/a
Age: 53 years instruments for about 1 hour per quadrant Mean reduction CAL
Clinical outcomes of quadrant Full-mouth BOP reduction Pico 3: no difference between
root planing versus full-mouth Gender: Female n=9 Male n=11 Control: QRP, combination hand and Relative change BoP full mouth and quadrant
root planing ultrasonic instruments, approximately 1 Pocket closure (PPD 4 mm) approach
Smoking status: n=2 smokers hour per quadrant Site with CAL gain 2 mm.
Periodontal disease status: Teeth included: Reported for:

Chronic periodontitis defined as ≥2 teeth per Single and multi-rooted All sites ≥5 mm
Shallow sites 5-6 mm
quadrant with PPD ≥5 mm with presence of BOP No retreatment Deep sites ≥7 mm
Other Outcomes:
Not reported

Quirynen et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
N = 29 Test: FM-SRP (2 sessions within 24h) Values reported:
Belgium with hand instruments Mean reduction PPD Pico 2: n/a
Age: 31- 75 years Mean reduction CAL
Benefit of "one-stage full- Control: Q-SRP (no time limit) with hand BOP reduction Pico 3: no difference between
mouth disinfection" is Gender: Female n=15 Male n=14 instruments Plaque surface extension full mouth and quadrant
explained by disinfection and approach
root planing within 24 hours: a Smoking status: n=8 smokers Teeth included: Reported for:
randomized controlled trial Single and multi-rooted All sites ≥4 mm
Periodontal disease status: Shallow sites 4-5.5 mm
Moderate 5 treatment groups (only 2 considered) Deep sites ≥6 mm
No retreatment
Other Outcomes:
Staining index
Zanatta et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
N = 25 Test: FMS (45 minutes) ultrasonic Values reported:
Brazil Mean reduction PPD Pico 2: n/a
Age: 27 - 62 years Control: Q-SRP (no time limit) hand Mean reduction CAL
Periodontal debridement with instruments Full-mouth bleeding score Pico 3: no difference between
povidone-iodine in periodontal Gender: not specified full mouth and quadrant
treatment: short-term clinical Teeth included: Reported for: approach
and biochemical observations Smoking status: not specified Single and multi-rooted All sites ≥5 mm
Periodontal disease status: 3 treatment groups (only 2 considered) Deep sites ≥7 mm
Moderate Oral hygiene reinforcement and
supragingival polishing twice-weekly Other Outcomes:
during study period Not reported

title
Del Peloso Ribeiro et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
N = 25 Test: FMS (45 minutes) ultra Values reported:
Brazil Mean PPD reduction Pico 2: n/a
Age: 30 - 66 years Control: Q-SRP (no time limit) Mean CAL gain
Periodontal debridement as a combination Full-mouth BOP reduction Pico 3: no difference between
therapeutic approach for Gender: Female n=18 Male n=7 Pocket closure (PPD ≤5 mm and no full mouth and quadrant
severe chronic periodontitis: a Teeth included: approach
clinical, microbiological and Smoking status: non-smokers Single and multi-rooted BoP)
immunological study Full-mouth plaque score
Periodontal disease status: At 3 months, retreatment of sites with PPD
Severe
≥5 mm and BOP. Reported for:
All sites ≥5 mm
Deep sites ≥7 mm
Other Outcomes:
Body temperature
Number of analgesics taken
Ioannou et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 2 Pico 1: clinical benefit of
N = 33 Test: Q-UD (3-4 sessions, no time Values reported:
Greece restriction) ultra Mean reduction PPD Pico 2: no difference between
Age: 33 – 68 years Mean reduction CAL hand instruments and
Hand instrumentation versus Control: Q-SRP (3-4 sessions, no time Full-mouth plaque score ultrasonic according to authors
ultrasonic debridement in the Gender: Female n=20 Male n=13 restriction) control
treatment of chronic Reported for: Pico 3: n/a
periodontitis: a randomized Smoking status: 51% smokers Teeth included: All sites
clinical and microbiological Single and multi-rooted Shallow sites 4-6 mm
trial Periodontal disease status: Deep sites >6 mm
Advanced chronic periodontitis: ≥4 sites with No retreatment.
Other Outcomes:
PPD ≥5 mm and BOP in at least two quadrants. Not reported
Furcation excluded.

title
Loggner Graf et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
Sweden combination ultrasonic and hand Mean reduction PPD Pico 2: n/a
Age: 28 – 65 years instruments Full-mouth BOP reduction
Full-mouth versus quadrant- Full-mouth plaque score Pico 3: no difference between
wise scaling--clinical outcome, Gender: Female n=15 Male n=3 Control: Q-SRP (no time limit) full mouth and quadrant
efficiency and treatment combination ultrasonic and hand Reported for: approach
discomfort Smoking status: n=9 smokers instruments All sites
Periodontal disease status: Teeth included: Other Outcomes:

Advanced chronic periodontitis Single and multi-rooted VAS scale of patient comfort
Re-scaling and oral hygiene instructions at Timepoints: 6 months

3 months.
Swierkot et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
N = 16 Test: FMS (2 sessions within 24h) Values reported:
Germany combination ultrasonic and hand Mean reduction PPD Pico 2: n/a
Age: 28 – 63 years instruments Mean reduction CAL
One-stage full-mouth Full-mouth BOP reduction Pico 3: no difference between
disinfection versus quadrant Gender: Female n=13 Male n=3 Control: Q-SRP (no time limit) Full-mouth plaque score full mouth and quadrant
and full-mouth root planing combination ultrasonic and hand approach
Smoking status: n=4 smokers instruments Reported for:
All sites
Periodontal disease status: Teeth included: Shallow sites 4-6 mm
Generalized chronic periodontitis, at least 6 sites Single and multi-rooted Deep sites ≥7mm
with PPD ≥5 mm and BOP 3 treatment groups (only 2 considered) Other Outcomes:
No retreatment. Number of adverse events
Zijnge et al. Setting: Private dental practice (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
N = 38 Test: FM-SRP (3 hours) hand instruments Values reported:
Netherlands Mean reduction PPD Pico 2: n/a
Age: 25 – 75 years Control: Q-SRP (1 hour per quadrant) Full-mouth BOP reduction
The recolonization hypothesis hand instruments Pocket closure (PPD <3 mm when Pico 3: no difference between
in a full-mouth or multiple- Gender: Female n=16 Male n=22 full mouth and quadrant
session treatment protocol: a Teeth included: initial PPD was ≥5 mm) approach
blinded, randomized clinical Smoking status: n=0 smokers Single and multi-rooted Full-mouth plaque score
trial
Periodontal disease status: Chronic No retreatment. Reported for:
All sites ≥4 mm
periodontitis, >10% sites with PPD ≥6 mm Shallow sites 4-6 mm
Deep sites ≥7 mm
Other Outcomes:
title
Malali et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 2 Pico 1: clinical benefit of
N = 20 Test: UD (4 to 6 sessions) ultrasonic Values reported:
Turkey instruments only Mean reduction PPD Pico 2: no difference between
Age: Not specified Mean reduction CAL hand and ultrasonic
Er:YAG lasers versus Control: SRP (4 to 6 sessions) hand Full-mouth BOP reduction instruments
ultrasonic and hand Gender: Not specified instruments only Full-mouth plaque score
instruments in periodontal Pico 3: n/a
therapy: clinical parameters, Smoking status: n=0 smokers Teeth included: Reported for:
intracrevicular micro-organism Single and multi-rooted All sites
and leukocyte counts Periodontal disease status: Shallow sites 4-6 mm
Chronic periodontitis, ≥2 sites with PPD 4-6 mm 3 treatment groups (only 2 considered). Deep sites ≥7 mm
No retreatment.
and ≥2 sites with PPD ≥7 mm with BOP and Other Outcomes:
mobility 0-2 Not reported
Kapellas et al. Setting: Public dental clinics (multiple clinical RCT Design: Parallel PICOS: 1 Pico 1: clinical benefit of
(2013) centers) subgingival instrumentation
Test: SRP (1 session, no time limit) hand Values reported:
Australia N = 169 and ultra Pocket closure (PPD <4 mm) Pico 2: n/a
Full-mouth plaque score
Effects of full-mouth scaling on Age: Mean age of 40 Control: no treatment Pico 3: n/a
the periodontal health of Reported for:
Indigenous Australians: a Gender: Female n=62 Male n=107 Teeth included: All sites ≥4 mm
randomized controlled trial Single and multi-rooted
Smoking status: n=87 smokers Other Outcomes:
No retreatment. Number of adverse events
Periodontal disease status:
Chronic Periodontitis, ≥2 proximal sites with CAL Timepoints: 3 months
≥4 mm or with PPD ≥5 mm
Meulman et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
N = 20 Test: FMUD (1 session 45 minutes) Values reported:
Brazil ultrasonic instruments only Mean reduction PPD Pico 2: n/a
Age: Mean age of 43 years Mean reduction CAL
One stage, full-mouth, Control: Q-SRP (1 week interval) hand Full-mouth BOP reduction Pico 3: no difference between
ultrasonic debridement in the Gender: Female n=9 Male n=11 instruments only Pocket closure (PPD <5 mm and no full mouth and quadrant
treatment of severe chronic BoP) approach
periodontitis in smokers: a Smoking status: n=20 smokers (≥5 pack years) Teeth included: Full-mouth plaque score
preliminary, blind and Single and multi-rooted
randomized clinical trial Reported for:
Periodontal disease status:
3 treatment groups (only 2 considered) All sites
Severe chronic periodontitis, ≥9 teeth with PPD Monthly recall for SPT.
≥5 mm and BOP Other Outcomes:
Not reported

title
Predin et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
Serbia combination hand and ultrasonic Mean reduction PPD Pico 2: n/a
Age: 32 – 75 years instruments Mean reduction CAL
Clinical and microbiological Pocket closure (PPD4mm) Pico 3: no difference between
effects of quadrant versus full- Gender: Female n=31 Male n=9 Control: SRP (4 sessions) combination Full-mouth plaque score full mouth and quadrant
mouth root planing - A hand and ultrasonic instruments approach
randomized study Smoking status: n=7 smokers Reported for:
Teeth included: All sites
Periodontal disease status: Single and multi-rooted All sites ≥4 mm
Chronic Periodontitis, ≥2 teeth/quadrant with Shallow sites 5-6 mm
No retreatment Deep sites ≥7 mm
PPD ≥5 mm and BOP
Other Outcomes:
Fonseca et al. Setting: University (2 clinical centers) RCT Design: Parallel PICOS: 1 and 3 Pico 1: clinical benefit of
N = 28 Test: FM-SRP (2x1 hour within 24 hours) Values reported:
Brazil hand instruments Mean reduction PPD Pico 2: n/a
Age: Not specified Mean reduction CAL
Clinical and microbiologic Control: Q-SRP (30 minutes per Pocket closure (PD <4 mm when CAL Pico 3: no difference between
evaluation of scaling and root Gender: Not specified quadrant) hand instruments 3 mm) full mouth and quadrant
planing per quadrant and one- Full-mouth plaque score approach
stage full-mouth disinfection Smoking status: Not specified Teeth included:
associated with azithromycin Single and multi-rooted Reported for:
or chlorhexidine: a clinical Periodontal disease status: All sites
randomized controlled trial Mild/moderate 6 treatment groups (only 2 considered) Shallow sites 4-5 mm
No retreatment Deep sites ≥6 mm
Other Outcomes:
Not reported

title
Petelin et al. Setting: University (single center) RCT Design: Parallel PICOS: 1 and 2 Pico 1: clinical benefit of
N = 18 Test: UD ultra Values reported:
Slovenia Mean reduction PPD Pico 2: no difference between
Age: 37 – 64 years Control: SRP hand Mean reduction CAL hand and ultrasonic
Effect of repeated adjunctive Full-mouth BOP reduction instruments
antimicrobial photodynamic Gender: Female n=10 Male n=8 Teeth included: Pocket closure (PPD 4 mm)
therapy on subgingival Single and multi-rooted Pico 3: n/a
periodontal pathogens in the Smoking status: n=0 smokers Reported for:
treatment of chronic 3 treatment groups (only 2 considered) All sites
periodontitis Periodontal disease status: Retreatment every 3 months Shallow sites 4-5 mm
At least 4 teeth with PPD ≥4 mm in every Deep sites >6 mm
quadrant Other Outcomes:
Not recorded
Timepoints: 3, 6 and 12 months

SRP: Scaling and root planning; PPD: Probing pocket depth; RCT: Randomised controlled trial; CAL: Clinical attachment level; FMRP: Full mouth root planing;
FM-SRP: Full mouth scaling and root planing; Q-SRP: Quadrant scaling and root planing; QRP: Quadrant root planing; VAS: Visual analogue scale; Q-UD:
Quadrant ultrasonic debridement; UD: Ultrasonic debridement; FMUD: Full mouth ultrasonic debridement; BOP: bleeding on probing.
Table 6. Overview on meta-analyses performed.
All sites Shallow sites Deep sites
PICOS Q1 PICOS Q2 PICOS Q3 PICOS Q1 PICOS Q2 PICOS Q3 PICOS Q1 PICOS Q2 PICOS Q3
9 studies 4 studies 6 studies 10 studies 3 studies 7 studies 11 studies 3 studies 8 studies

PD red
Appendix F1 Appendix F4 Appendix F7 Appendix F2 Appendix F5 Appendix F8 Appendix F3 Appendix F6 Appendix F10
3/4 months 4 studies 4 studies 4 studies 5 studies

CAL gain
Appendix F4 Appendix F7 Appendix F8 Appendix F10
Pocket 5 studies 4 studies

closure Appendix F1 Appendix F7
11 studies 4 studies 8 studies 6 studies 3 studies 4 studies 7 studies 3 studies 5 studies

PD red
Figure 3a Figure 4 Figure 5 Figure 3b Appendix F5 Appendix F9 Figure 3b Appendix F6 Appendix F11
6/8 months 4 studies 6 studies 3 studies 4 studies

CAL gain
Figure 4 Figure 5 Appendix F9 Appendix F11
Pocket 5 studies 5 studies

closure Figure 3a Figure 5
Meta-analysis - significant Meta-analysis - no significant

No meta-analysis
risk for bias risk for bias
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Accepted Article L L L L L L
Wennström et al. 2005
2013 C C L
Apatzidou & Kinane 2004 L C L C L C
et al. 2010
Jervøe-Storm et al. 2006 CL L L L L L
C C L
Koshy et al .2005 L L L L L L
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Quirynen et al. 2006 CL C L L L C
Del Peloso Ribeiro et al. 2008 L L L L L L

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Swierkot et al. 2009 L C L C L C
Zanatta et al. 2006 L C L L L C
Zijnge et al. 2010 L C L L L C
Fonseca et al. 2015 L C L L L C
Ioannou et al. 2009 L C L L L C

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Malali et al. 2012 C C L L L C
Loggner Graf et al. 2009 C C L L L C

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Meulman et al. 2013 L C L L L C
Obeid et al. 2004 L C L L L C

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Petelin et al. 2015 H H L C L H
Laurell & Pettersson 1988 L L L L L L
Kapellas et al. 2013 L L L L L L
Predin et al. 2014 L C L L L C

Outcome
measurement
Deviation
Missing data
Randomisation
Overall risk
Selective
reporting

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Subgingival Instrumentation

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Accepted Article

DR. JEAN SUVAN (Orcid ID : 0000-0002-6526-6235)

Article type : Systematic Review

1Periodontology Unit and Department of Clinical Research, University College

2Department of Surgical, Medical and Molecular Pathology and Critical Care

3Department of Periodontology, Institute of Odontology, The Sahlgrenska

Objectives: To evaluate the efficacy of subgingival instrumentation (PICOS-1),

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Thus, various instruments may be appropriate for subgingival instrumentation, demonstrating

Table 1. PICOS Criteria

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In patients with periodontitis, what is the efficacy of nonsurgical subgingival instrumentation

Material & Methods

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closed pockets, defined as residual PD ≤4 mm with no bleeding after probing. Additional

adverse events recording.

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and tooth type (all, single- or multi-rooted).

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Figure 1. Search results PRISMA flow-chart

An overall brief summary of noteworthy study characteristics appears in Table 4. Included

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Table 4. Characteristics of included studies.

Table 5 Evidence Table of PICOS Characteristics of Included Studies

Selected studies by PICOS question

Table 6. Overview on meta-analyses performed.

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instrument (sonic/ultrasonic vs hand) or mode of delivery (full-mouth vs quadrant). Thus, at

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Addressing PICOS question 2, no significant differences were observed in terms of clinical

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Population Adults ≥18 years with periodontitis

Subgingival Subgingival instrumentation Subgingival instrumentation

Supra-gingival Subgingival instrumentation Subgingival instrumentation

Outcomes Clinical measures of periodontal status

Study Randomised Controlled Trials

Aimetti 2011, Al-Mubarak 2000, Arpağ 2017, Babaloo 2018, Bollen

Alves 2004, Alves 2005, Apatzidou 2004b, Apatzidou 2004c, Åslund

Chapper 2005, D'Ercole 2006, Dragoo 1992, Jenkins 2000, Kocher

Non-English language Nonhoff 2006

Review article Greenstein 2004

Australasia 2 Koshy et al. 2005, Kapellas et al. 2013

Private 1 Zijnge et al. 2010

Private & University 1 Wennström et al. 2005

Author, year, country, Study Findings

Timepoints: 3 and 6 months