Rapid Revision

Series for The

Post Graduates
LANDMARK STUDIES
IN PERIODONTICS
For Better Understanding And Managing
Periodontal Diseases
 SECTION 1.
What are Landmarks, Citations
and Paradigm Shifts?
 SO WHAT IS A
LANDMARK STUDY ?
How do you IDENTIFY it?
 Is It Based On Number Of
Citations The Article Has
Received?

Well, That’s One Way To Classify Something As

A Landmark Study
 If We See The Most Frequently Cited
Papers In Periodontology i.e. How Many
Times A Given Paper Was Cited By
Another Paper.
Is It An Objective Parameter To
Determine The Impact On The Whole Of
Periodontology?
 Pros and Cons of Citations?
1. Citations are a good indication of how new
knowledge influenced other researchers, but may
not reflect the full impact on the clinical application
of the knowledge.

2. Books are infrequently cited.

3. The number of citations is influenced by when the

paper was published and whether the topic extends
beyond periodontology.
Until perhaps 20 to 30 years ago, many
leaders in our field published their data and
philosophies mostly in book form, which
generally took multiple years from initial
drafting to printed copy.

Glickman, Newman, Carranza, Lindhe,etc are

all associated with text books and not much
with citations
So I Am Going With A Broader
Criteria Here…..
TO BE ELIGIBLE TO BE CALLED A
LANDMARK STUDY

That Publication Should Have …

 CHALLENGED
EXISTING
PARADIGMS
Oral Health & Systemic Health are Two
Different Entities
 ADVANCED OUR
KNOWLEDGE
In 1965, Dental Plaque Initiated Gingivitis,
And Removal Of Plaque Reversed This Inflammation
INFLUENCED OUR
THINKING
Guided Tissue Regeneration –Predictable
Regeneration
AND CHANGED THE
ENTIRE CLINICAL
PRACTICE OF
PERIODONTOLOGY
Impossible Became not Only Possible But Predictable,
Example – Implants for Edentulousness
This Lecture Offers An Overview of The
Most Widely Cited Papers
In Periodontology And Implantology And
Additionally
Classic Papers Which Have Stood
The Test Of Time

1. Highly Cited
2. Classic Papers
 Peer-reviewed
Papers Are Among The
Top Papers To
Influence The Development Of Our
Knowledge And Practice.

1. Highly Cited
2. Strongest Evidence
3. Un-biased
Classical Papers Highlight Critical
Scientific Contributions To
Periodontology
Irrespective Of When They Were
Published

1. History of Periodontology
2. Classical Literature of Periodontology
 Classical Papers Created New
Knowledge And Translated It To
Patient Care And Thereby Shaped
The Evolution Of Periodontology In
The Past 100 Years.

Why do we need to read the Older Literature/Classical

Papers of Perio?
Hence I Will Try To Cover Both Highly
Cited Papers And The Not-So Highly
Cited (Classical) Papers But With A
Definite Impact On The Science And
Practice Of Periodontology.
Von Humboldt Argued That, ‘‘Everything
Depends On Holding To The Principle Of
Considering Knowledge As Something
Not Yet Found, Never Completely To Be
Discovered, And Searching Relentlessly
For It As Such”

Paradigm Shifts are Never Ending

 WE CONSTANTLY NEED TO REMIND
OURSELVES THAT AS WITH ALL
SCIENCE-BASED DISCIPLINES,
PERIODONTOLOGY WILL NEVER BE AT A
POINT OF PERFECT KNOWLEDGE
The more we know, the more there is to know
 We Must Teach Ourselves How To
Evaluate New Evidence And Remind
Ourselves That We Are Able To Deliver
Outstanding Prevention And Treatment Of
Periodontitis Today And Will Do Even Better In
The Future Only Because Of Those Who
Produced New Knowledge In The Past—much
Of Which Was Initially Met With Skepticism
And Annoyance
LANDMARK SHOULD NOT ONLY
BE POPULAR
But Also Have A Tremendous Impact –
What We Call A “Paradigm Shift In
Perception”
WE HAVE TO BE PROUD THAT,
PERIODONTOLOGY HAS
SPEARHEADED SEVERAL SUCH
SHIFTS IN DENTISTRY.
In the next few sections we will cover a
historical perspective on the defining
events in understanding and managing
periodontal disease and the individuals
who have influenced and continue to
develop the science of Periodontology
Paradigm Shifting Studies
in Perio can be seen under

ETIOLOGY OF PATHOGENESIS OF MANAGEMENT OF

PERIODONTITIS PERIODONTITIS PERIODONTITIS
SECTION 2

Landmark Studies On
Etiology of Periodontitis
The Most Often-cited Papers In
Periodontology Are Those By Harald Loe And
John Silness In Which They Described The
Criteria For The Gingival Index (GI) And Plaque
Index (PI)- Cited : 4,161 & 4,368 times.

Löe H, Silness J. Periodontal disease in pregnancy. I. Prevalence

and severity. Acta Odontol Scand 1963; 21: 533-551
 These Indices Continue To Be Used
Because They Are Somewhat
Reproducible, Easy To Record, And
Emphasize That An Early Stage Of
Periodontal Disease (i.e., Gingivitis) Is
Strongly Associated With The Presence
And Amount Of Dental Plaque Adjacent To
The Gingival Margin
Löe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta
Odontol Scand 1963; 21: 533-551
 The GI and PI clinical assessments were
subsequently used by Loe and his
colleagues in a classic series of studies on
experimental gingivitis in which the
etiological link between dental plaque and
gingivitis was firmly established.
Loe H, Theilade E, Jensen SB. Experimental gingivitis
in man. J Periodontol 1965;36:177-187.
Harold Loe’s work in 1960’s provided
experimental evidence for a Direct
Relationship between The Presence Of
Dental Plaque And Gingivitis.

Periodontal disease became established as

an infectious disease and in turn affected
most aspects of clinical periodontology
 That idea that Periodontitis was an
Infectious Disease caused by Bacteria in
Dental Plaque and Removing Plaque could
halt the disease was a Game Changer for
Perio as it led to non-surgical and surgical
plaque removal therapy.

Hence this qualifies as a “Landmark Study”

Can we also Term it as a Paradigm Shift
in Periodontology?
Concept “Plaque = Periodontal
Disease”
“ No Plaque = No Disease”
Paradigm Shift -Yes / No ?
Diagnostic Aids -Probing
 Another Influential Paper Was Sigurd
Ramfjord’s Description Of How To Use A
Calibrated Periodontal Probe To
Conduct A Periodontal Examination In
Which A Site Specific Probing Depth
And Clinical Attachment Loss Could Be
Measured
Ramfjord SP. The Periodontal Disease Index
(PDI). J Periodontol 1967;38:602-610.
 IT ADVOCATED THAT A PERIODONTAL
EXAMINATION SHOULD MEASURE THE
AMOUNT OF CLINICAL DAMAGE (I.E.,
CLINICAL ATTACHMENT LOSS) BY USING A
PERIODONTAL PROBE.
Ramfjord SP. The Periodontal Disease Index
(PDI). J Periodontol 1967;38:602-610.
 Use Of The Cemento-enamel
Junction As A Fixed Reference Point
To Determine The Severity Or Amount
Of Damage(i.e., Clinical Attachment
Loss) Was A Major Contribution To
The Field.
Ramfjord SP. The Periodontal Disease Index (PDI). J
Periodontol 1967;38:602-610.
 The Idea That Clinicians Should
Measure The Amount Of Clinical
Damage In The Form Of Clinical
Attachment Loss Continues To Be A
Critical Component Of A Complete
Periodontal Examination.
Ramfjord SP. The Periodontal Disease Index
(PDI). J Periodontol 1967;38:602-610.
 An idea that has stood the test of time
– CAL measurement/Probing Pocket
Depth as a Surrogate for Periodontal
Disease…..Hence the moniker
“Landmark Study”
An interesting corollary of this study was that Pocket
Depth Measurement became the Gold standard in
Diagnosis of Periodontitis
 The Concept that
“Pocket Depth = Periodontitis”
Paradigm Shifting Idea or Not?
Ramfjord And His Colleagues Also Reported That
Probing Depths Were Important Because Deep
Periodontal Pockets Form In Many Cases Of
Periodontitis.
Deep Pockets Are Difficult Therapeutic Targets
Because The Deeper They Are, The Harder They
Are To Clean.

Ramfjord SP. The Periodontal Disease Index (PDI). J

Periodontol 1967;38:602-610.
 Which Directly lead to the next
concept..How deep is too Deep?
To Deep to Treat Non-
Surgically/Surgically?

The next Landmark / Paradigm shifting study…….

 Open Flap
Scaling & Debridement
Root Planing
 Lindhe et al in 1982, Developed A
Concept Of ‘‘Critical Probing Depth’’ –
A Way For DECISION MAKING
Following The Completion Of Initial
Periodontal Therapy (Phase 1)
“Critical probing depths” in periodontal therapy J. Lindhe S.
S. Socransky S. Nyman A. Haffajee E. Westfelt J Clin
Periodontol 1982 Jul;9(4):323-36.
 The Critical Probing Depth Represents A
Baseline Probing-depth Value

Above Which The Outcome Of A Therapy Will

Result In Attachment Gain

And Below Which The Outcome Of Therapy

Will Result In Attachment Loss
“Critical probing depths” in periodontal therapy J. Lindhe S. S. Socransky S.
Nyman A. Haffajee E. Westfelt J Clin Periodontol 1982 Jul;9(4):323-36
The Critical Probing Depth For Nonsurgical
Therapy (Scaling And Root Planing) Is 2.9 Mm.

This Means That Below This Probing Depth

The Site Would Lose Clinical Attachment As A
Result Of Therapy. While, Above This Value
Attachment Gain Will Result
“Critical probing depths” in periodontal therapy J. Lindhe S. S. Socransky S.
Nyman A. Haffajee E. Westfelt J Clin Periodontol 1982 Jul;9(4):323-36
On The Other Hand, For The Access Flap
Therapy, The Critical Probing Depth Is
4.2Mm.

Again, This Means That Open Flap

Debridement Is Only Beneficial Above This
Value, While Below This Value, Attachment
Loss May Result.
“Critical probing depths” in periodontal therapy J. Lindhe S. S. Socransky
S. Nyman A. Haffajee E. Westfelt J Clin Periodontol 1982 Jul;9(4):323-36
So will you accept it as a Landmark Study ?
When to do -
Non-Surgical Treatment (AND/OR)?
Surgery?
Shifted the Treatment Paradigm? Yes/No?
“Critical probing depths” in periodontal therapy J. Lindhe
S. S. Socransky S. Nyman A. Haffajee E. Westfelt J Clin
Periodontol 1982 Jul;9(4):323-36
Talking about Pocket Depths, lets next
see a study on the Development of
Pockets and its Progression from
Shallow to Deep

The next Landmark / Paradigm shifting study…….

PERIODONAL POCKETS
The Development And Progression Of
Periodontitis Was Brought Into Limelight
By The Results Of A Highly Cited
Landmark Publication In 1986 On The
Natural History Of Periodontal Disease In
Humans.
The Sri Lankan Tea Plantation Workers
Study

Loe H, Anerud A, Boysen H, Morrison E. Natural

history of periodontal disease in man. Rapid,
moderate and no loss of attachment in Sri Lankan
laborers 14 to 46 years of age. J Clin Periodontol
1986;13:431-445. (Cited by: 595)
Natural history of periodontal disease in
man. Rapid, moderate and no loss of
attachment in Sri Lankan laborers 14 to
46 years of age.

Loe H, Anerud A, Boysen H, Morrison E.

J Clin Periodontol 1986;13:431-440.
Drawn from a population never exposed to
any preventive or therapeutic intervention
related to oral diseases in Sri Lanka, a
cohort of 480 14- to 31-year-old male tea-
plantation laborers was initially recruited in
1970 and underwent subsequent follow-up
examinations. A third of those originally
enrolled (161 individuals) were re-examined
in 1985.
When they measured the longitudinal
attachment loss and tooth mortality rates
after 15 years :
■ 1st Group - 8% of the total, with RAPID PROGRESSION of
periodontal disease (RP)
■ 2nd Group - 11% of the total who exhibited NO
PROGRESSION (NP) of periodontal disease beyond
gingivitis;
■ 3rd Group between the two extremes - 81% with
MODERATE PROGRESSION (MP).
This Longitudinal Epidemiological Study Confirmed

1. Gingivitis Does Not Always Progress To Periodontitis;

2. Some Cases Of Periodontitis Progress Slowly,

3. And In Other Situations, Loss Of Attachment May

Occur In Rapid Episodic Bursts.

Loe H, Anerud A, Boysen H, Morrison E. J Clin Periodontol

1986;13:431-440
These Observations Led To The
Conclusion That,
Based On Rates Of Progression,
There Are Multiple Forms Of
Periodontitis.
Loe H, Anerud A, Boysen H, Morrison E. J Clin Periodontol
1986;13:431-440
Multiple Forms of
Periodontitis, 1986
Only One Single form of
Periodontitis, 2020
SECTION 3

Landmark Studies on
Classification
Numerous classification systems for
periodontal diseases have come and
gone in the past 140 years.

Prior to the 1920s, periodontal diseases were

categorized based on their clinical features and
unsubstantiated or hypothetical causes.
In the early part of the 20th century-1946,
Gottlieb grouped periodontal diseases into
three general categories: inflammatory,
degenerative, and neoplastic.

Gottlieb B. The new concept of periodontoclasia. J

Periodontol 1946;17:7-23.
Gottlieb Classified Periodontal Diseases

1) Inflammatory i.e., Periodontitis From Local Irritants,

Atrophy Following Inflammation And Local Toothbrush
Trauma

2) Degenerative i.e., Degeneration Of Cementum,

Periodontal Connective Tissue, And Alveolar Bone,

3) Periodontal Trauma i.e., Occlusal Trauma.

Gottlieb B. The new concept of periodontoclasia. J
Periodontol 1946;17:7-23.
Glickman, I. (1952). Periodontosis: A Critical Evaluation. The Journal of the
American Dental Association, 44(6), 706–714.
In 1976 It Was Convincingly Shown That
Periodontosis Was Actually An Infection, Not
A Degenerative Disease.

Newman MG, Socransky SS, Savitt ED, Propas DA,

Crawford A. Studies on the microbiology of periodontosis. J
Periodontol 1976;47:373-379.
Only in 1989 the term Periodontosis
was abandoned and officially replaced
by ‘‘PERIODONTITIS.” Including –
Localised Juvenile Periodontitis
American Academy of Periodontology-Consensus report. Nevins
M, Becker W, Kornman K, eds. Proceedings of the World
Workshop in Clinical Periodontics. Chicago: American Academy
of Periodontology; 1989:I-23–I-32
In 1999 the disease was divided into
‘‘Chronic & Aggressive periodontitis.’’ By
Armitage et al , who further renamed LJP as
LAP
Armitage GC. Development of a classification
system for periodontal diseases and conditions.
Ann Periodontol 1999;4:1-6. An impressive
2,124 citations
A new classification scheme for periodontal
and peri‐implant diseases and conditions –
Introduction and key changes from
the 1999 classification = 2017 WORLD
WORKSHOP Jack Caton, Gary Armitage Tord
Berglundh, Iain Chapple Kenneth Kornman
Brian Mealey et al
Caton J, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and
periimplant diseases and conditions – Introduction and key changes from the 1999
classification. J Clin Periodontol. 2018;45(Suppl 20):S1–S8
The new classification system now includes
3 categories under “periodontal diseases
and conditions,” with a total of 11
subcategories and 4 subcategories under
“peri-implant diseases and conditions.”
Each of the subcategories under
“periodontal diseases and conditions” is
further subdivided into specific disorders
Gingivitis is considered reversible, but once a
patient has periodontitis they have that
diagnosis for life, even if the periodontitis is
successfully treated. Life-long maintenance of
the successfully treated patient is essential.

Caton J, Armitage G, Berglundh T, et al. A new classification

scheme for periodontal and periimplant diseases and
conditions – Introduction and key changes from the 1999
classification. J Clin Periodontol. 2018;45(Suppl 20):S1–S8
 Definitely a Paradigm Shifting Study,
Right?

Caton J, Armitage G, Berglundh T, et al. A new

classification scheme for periodontal and
periimplant diseases and conditions – Introduction
and key changes from the 1999 classification. J
Clin Periodontol. 2018;45(Suppl 20):S1–S8
SECTION 4
Landmark Studies on
Pathogenesis
Haffajee AD, Socransky SS. Microbial
etiological agents of destructive
periodontal diseases. Periodontol 2000
1994;5:78-111. (Cited by: 1,171)

BACTERIA PLAY A CRITICAL ROLE IN THE

PATHOGENESIS OF PERIODONTAL DISEASE
The Discovery That Bacteria Of The Oral
Cavity, Which Play A Critical Role In Most
Periodontal Diseases, Organize Themselves
In A Biofilm; And That The Pathogenesis Of
Periodontitis, As That Of Any Chronic
Disease, Is Complex And Multifactorial.
Haffajee AD, Socransky SS. Microbial etiological agents of destructive
periodontal diseases. Periodontol 2000 1994;5:78-111.
Socransky SS, Haffajee AD. Dental biofilms:
Difficult therapeutic targets. Periodontol
2000 2002; 28:12-55. (Cited by: 594)

Micro-Organisms organised in a community-

Biofilm –have certain advantages and are not
easily eliminated
 Consensus Report Periodontal
Diseases: Pathogenesis and Microbial
Factors. (1996). Annals of
Periodontology, 1(1), 926–932.
Socransky’s paper on “Criteria for the
infectious agents in dental caries and
periodontal disease”

Socransky SS. Criteria for the infectious agents in dental caries

and periodontal disease. J Clin Periodontol 1979; 6: 16-21.
Socransky’s modification of criteria for the determination of an
oral pathogen deviates from Koch’s: association with disease,
the effect of elimination of the organism, the host response,
and animal pathogenicity.

This has sparked hundreds of studies all over the world which
used the study designs.

And ultimately led to a deeper understanding of the highly

complex human oral microbiome

Socransky SS. Criteria for the infectious agents in dental caries and
periodontal disease. J Clin Periodontol 1979; 6: 16-21.
Socransky’s paper on “Criteria for the infectious
agents in dental caries and periodontal disease”
had been quoted, according to Google Scholar,
just 94 times but had nevertheless an immense
impact on pivotal clinical studies designed to
“prove” that certain species or groups of species
were involved in the etiology of Periodontitis

Socransky SS. Criteria for the infectious agents in dental caries and
periodontal disease. J Clin Periodontol 1979; 6: 16-21.
Socransky’s Work on Microbial Etiology of
Periodontitis…..Is it Paradigm Shifting? Can
we have a Consensus on it?

Consensus Report Periodontal Diseases: Pathogenesis and

Microbial Factors. (1996). Annals of Periodontology, 1(1),
926–932
Honourable Mentions…..Slot’s work on various
pathogens and Marsh’s work on Biofilms
 As Periodontitis is called a Multi-
factorial Disease what about the other
Etiologic Factors?
Pathogenesis Of Periodontitis Is
Modulated By Various Factors, Including
Local, Host, And Environmental Factors
Smoking a Risk Factor ?
That smoking can be regarded as a major
causal contributing factor for the
development of periodontitis has been
suggested.

But intervention studies on the effects of

smoking cessation on periodontal health
are not paradigm - shifting.
What about Stress?
Selye, 1967 HPA Axis or General
Adaptation Syndrome?
Still no conclusive studies with paradigm
shifting effect on Stress Mitigation having
an effect on Periodontitis
Genetics? Role of Gene Polymorphisms
in Periodontitis?
Kornman KS, Crane A, Wang HY, di Giovine FS, Newman MG, Pirk FW, et al. (1997). The
interleukin-1 genotype as a severity factor in adult periodontal disease. J Clin Periodontol 24:72–
77.
And of course, The Famous TWIN
Studies of Michalowiz……….
Michalowicz BS (1994). Genetic and heritable risk factors in
periodontal disease. J Periodontol 65:479–488.
Michalowicz BS, Aeppli D, Virag JG (1991). Periodontal findings in adult
twins. J Periodontol 62:293–299.
Despite interesting findings from the
Michalowicz Twin Studies and Interleukin-1
Polymorphism Studies by Kornman, the
Genetic Susceptibility of Periodontitis is still
not at a Paradigm Shifting stage – Yet.
So what does seem to have a role in the
pathogenesis of Periodontitis?
SECTION 5

Landmark Studies In Perio-

Medicine
A century-old suspicion that periodontal
infections interact, in a bidirectional way,
with other systemic diseases and conditions
was revived in the last two decades.

New intervention studies address possible

beneficial effects of periodontal therapy on
general health were designed.
Causality (etio-gnosis): the
central concern of
epidemiology
Most fundamental application of
epidemiology: to identify etiologic
(causal) associations between
exposure(s) and outcome(s)

Exposure=Outcome
Probably the most often quoted early paper is by
Mattila et al., who found that the association
between
poor dental health and coronary heart disease
was independent of age, total cholesterol, high
density lipoprotein, triglycerides, C peptide,
hypertension, presence of diabetes, and
smoking
Mattila KJ, Nieminen MS, Valtonen VV, Rasi VP, Kesäniemi YA, Syrjälä SL,
et al. Association between dental health and acute myocardial infarction.
BMJ. 1989;298:779–82
Mattila KJ, Nieminen MS, Valtonen VV, Rasi VP, Kesäniemi YA, Syrjälä SL, et al. Association
between dental health and acute myocardial infarction. BMJ. 1989;298:779–82
 Frank DeStefano, later described
periodontal disease as an independent risk
factor in the US population, thus supporting
the findings of Mattila in Europe

DeStefano F, Anda RF, Kahn HS, Williamson DF, Russell CM.

Dental disease and risk of coronary heart disease and mortality.
BMJ. 1993;306:688–91
He described a two-component mechanistic
working model that linked periodontal
disease to cardiovascular disease via
systemic bacterial dissemination interacting
with the vasculature and activation of the
hepatic acute phase response as an
inflammatory trigger for CVD
DeStefano F, Anda RF, Kahn HS, Williamson DF, Russell CM. Dental
disease and risk of coronary heart disease and mortality. BMJ.
1993;306:688–91
Diabetes and Periodontitis – The Bi-
directional Relationship
And then we come to Offenbacher….

Offenbacher explored the ability of

infections with oral organisms to
induce obstetric complications in
pregnancy
Oral Organisms Like P. Gingivalis And C. Rectus Were
Capable Of Eliciting A Wide Range Of Obstetric
Complications Including Fetal Growth Restriction,
Placental Damage and Early Parturition.

Hence Oral Infection In Humans

Could Lead To Increased Risk For Preterm/Low
Birth Weight Deliveries,

Offenbacher S, Katz V, Fertik G, et al. Periodontal infection as a

possible risk factor for preterm low birth weight. J Periodontol
1996;67(10 Suppl.):1103-1113. (Cited by: 1,115)
The Term Periodontal Medicine was Coined
to Differentiate From Oral Medicine

THESE STUDIES SHOWED THAT FOR THE FIRST TIME,

OUR PROFESSION SOUGHT TO RESOLVE A DEBATE WITH
NAY-SAYERS BY TURNING NOT TO CLINICAL OPINION BUT
TO SCIENCE TO PROVE THAT ORAL-SYSTEMIC
CONNECTION DOES EXIST
 The Perio-systemic Link Is A Game
Changer As It Has The Potential To Alter
The Clinical Practice Of Periodontics
Profoundly

This knowledge (fueled by an even larger game changer, the

internet) is making it easier for us to convince our patients to
accept our treatment plans, and we are seeing more
collaboration with our medical colleagues
 Periodontal Medicine is
Definitely a Landmark /
Paradigm Shifting Moment in
Dentistry/Periodontics – Agree ?
SECTION 6
Landmark Studies In The
Management Of Periodontitis
 Historically Treatment for Periodontitis
Included A Range Of Therapies Including
Dietary Changes, Gingival Massage, Local
Application Of Caustic Chemicals, Removal
Of Local Irritants And Surgical Resection Of
Affected Tissues Etc
In 1869, Riggs JW First Publicly Described A
New Treatment For The Cure Of Inflammation
Of The Gum- A Thorough Curetting Of The
Gums & Alveolar Process To Remove Local
Irritation From Dental Calculus

1st Known Instance Of The Nonsurgical Removal Of Acquired

Deposits
Zinner in 1955 showed that ultrasound
could be used to remove deposits
from the teeth. stated that the instruments
were acceptable alternatives to hand
scalers as they were found to be as
effective in the removal of calculus
Zinner DD. Recent Ultrasonic Dental Studies, Including
Periodontia, Without The Use Of An Abrasive. J Dent Res.
1955;34:748–9
1983 Echeverria B and Caffesse RG,
challenged the value of gingival curettage
and concluded that Gingival curettage did
not improve the condition of the
periodontal tissues more significantly
than scaling and root planing
Effects of Gingival Curettage When Performed 1 Month After Root
Instrumentation. A Biometric Evaluation J J Echeverria, R G Caffesse J
Clin Periodontol 1983 May;10(3):277-86
Effects of Gingival Curettage When Performed 1 Month After Root Instrumentation. A Biometric
Evaluation J J Echeverria, R G Caffesse J Clin Periodontol 1983 May;10(3):277-86
The Concept
“SRP – YES, But Curettage = No”
Landmark Study/ Paradigm Shift ?
Treatment Options other than Mechanical Debridement
……Host Modulation
 The concept of Host Modulation was
introduced by Golub for local delivery to the
periodontal pocket of a sub-antimicrobial
dose of doxycycline to suppress collagenase
activity in the periodontal pocket and tissue
breakdown.
Golub LM, Lee HM, Ryan ME, Giannobile WV, Payne J, Sorsa T. Tetracyclines
inhibit connective tissue breakdown by multiple non-antimicrobial
mechanisms. Adv Dent Res 1998;12:12-26. (Cited by: 517)
Host Modulation added an Incremental
Advance….Can we call it a Landmark?
But the next study is without a doubt…..
On the Repair Potential of Periodontal Tissues A. H.
Melcher J Periodontol 1976 May;47(5):256-60
Using these basic concepts of Melcher,
Nyman et al provided Proof-of-Concept
 New cementum with inserting principal fibers
had formed on the previously diseased root
surface..This finding suggests that new
attachment can be achieved by cells originating
from the periodontal ligament and demonstrates
that the concept that the periodontitis affected
root surface can Regenerate.
Nyman S, Lindhe J, Karring T, Rylander H. New attachment
following surgical treatment of human periodontal disease. J
Clin Periodontol 1982;9: 290-296. (Cited by: 1,006)
Regeneration of Periodontium on Root
Surfaces previously denuded by
Periodontitis – Paradigm Shifting or
Not?
After Hard Tissue Grafts …Next
Comes….Soft Tissue Grafts/ Perio-Plastic
Surgery
Langer and Langer study in 1985 on
Connective Tissue Grafts shattered a long-
held principle that denuded root surfaces
could not be covered predictably with soft
tissue grafts
Langer B, Langer L. Subepithelial connective tissue graft
.
technique for root coverage. J Periodontol 1985;56:715-
720. (Cited by: 621)
Langer, B. and Langer, L. (1985) Subepithelial Connective Tissue Graft
Technique for Root Coverage. Journal of Periodontology, 56, 715-720.
Although Many Variations Have
Developed Around This Landmark
Paper, CTG Remains The Gold Standard
For Root Coverage Procedures
Predictably.

Langer B, Langer L. Subepithelial connective tissue graft technique

for root coverage. J Periodontol 1985;56:715-720. (Cited by: 621)
Periodontal Plastic/Esthetic Surery
Procedures - Root Coverage Procedures
with Soft Tissue Grafts became Routine
after this –Landmark/ Paradigm Shifting ?
Next Landmark Study…..
 Adell R, Eriksson B, Lekholm U,
Branemark PI, Jemt T. Long-term follow-
up study of osseointegrated implants in
the treatment of totally edentulous
jaws. Int J Oral Maxillofac Implants
1989;5: 347-359.
(Cited by: 1,531)
 Albrektsson T, Zarb G, Worthington P,
Eriksson AR. The long-term efficacy of
currently used dental implants: A review
and proposed criteria of success. Int J
Oral Maxillofac Implants 1986;1:11-25.
(Cited by: 2,140)
Adel and Albrektsson provided proof that
osseo-integrated implants can survive in
the oral cavity for a long time – just like
natural teeth
The Introduction Of Implants As Part Of
Periodontics Shifted The End Points Of
Treatment For Periodontitis Almost
Instantaneously With Branemark’s
Seminal Studies In The Mid-1980’s And
Periodontics Was Forever Changed.
Indeed, This Shift Was So Dramatic
That Some Feel It Has Threatened The
Profession, With Many Clinicians
Practicing More Like Implantologists
Than ‘‘True’’ Periodontists.
In rare instances transformational changes
occur and they can have profound effects
on the way we treat patients. Implants is
one such Game Changer for Periodontists
and is truly a Paradigm Shifting Procedure
 To Conclude……

IN THIS PRESENTATION I HAVE

PROVIDED A HISTORICAL
PERSPECTIVE ON THE DEFINING
EVENTS IN UNDERSTANDING AND
MANAGING PERIODONTAL DISEASE
 To Conclude……
THE CONTINUED GROWTH OF OUR
PROFESSION DEPENDS ON OUR ABILITY TO
RECOGNIZE THESE ‘‘GAME CHANGERS’’
AND USE THEM TO OUR PATIENT’S
ADVANTAGE.
 To Conclude……

AND FINALLY WE SHOULD REMEMBER THE

ENORMOUS CONTRIBUTIONS OF ALL WHO
SHAPED OUR PROFESSION. WE STAND ON THEIR
SHOULDERS, BUT WE ALSO HAVE A
RESPONSIBILITY TO HONOR THEIR MEMORIES BY
ASSURING THAT WE KNOW THE HISTORY OF
PERIODONTOLOGY
Lecture by

Dr. Ganesh Puttu

Periodontist &
Implantologist
Chennai.
THANK YOU
ganeshputtu@gmail.com