The Landmark and Paradigm shifting studies in Periodontology

1. Rapid Revision
Series forThe
Post Graduates

2. LANDMARK
STUDIES IN
PERIODONTICS
For Better Understanding And Managing
Periodontal Diseases

3. SECTION 1.
What are Landmarks, Citations
and Paradigm Shifts?

4. SOWHAT IS A
LANDMARK STUDY
?
How do you IDENTIFY it?

5. Is It Based On Number Of
CitationsThe Article Has
Received?
Well,That’s OneWayTo Classify Something As A
Landmark Study

6. If We See The Most Frequently Cited
Papers In Periodontology i.e. How
ManyTimes A Given PaperWas Cited By
Another Paper.
Is It An Objective Parameter To
Determine The Impact On The Whole
Of Periodontology?

7. 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.
Pros and Cons of Citations?

8. 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

9. So I Am GoingWith A Broader
Criteria Here…..

10. TO BE ELIGIBLETO BE CALLED
A LANDMARK STUDY
That Publication Should Have …

11. CHALLENGED
EXISTING
PARADIGMS
Oral Health & Systemic Health areTwo
Different Entities

12. ADVANCED OUR
KNOWLEDGE
In 1965, Dental Plaque Initiated Gingivitis,
And Removal Of Plaque ReversedThis Inflammation

13. INFLUENCED OUR
THINKING
GuidedTissue Regeneration –Predictable
Regeneration

14. AND CHANGED THE
ENTIRE CLINICAL
PRACTICE OF
PERIODONTOLOGY
Impossible Became not Only Possible But Predictable,
Example – Implants for Edentulousness

15. 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

16. 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

17. Classical Papers Highlight Critical
Scientific Contributions To
Periodontology
Irrespective Of When They Were
Published
1. History of Periodontology
2. Classical Literature of Periodontology

18. 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?

19. Hence IWillTryTo Cover Both Highly
Cited Papers AndThe Not-So Highly
Cited (Classical) Papers ButWith A
Definite Impact OnThe Science And
Practice Of Periodontology.

20. 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

21. WE CONSTANTLY NEEDTO REMIND
OURSELVESTHAT ASWITHALL
SCIENCE-BASED DISCIPLINES,
PERIODONTOLOGYWILL NEVER BE AT
A POINT OF PERFECT KNOWLEDGE
The more we know, the more there is to know

22. We MustTeach Ourselves HowTo
Evaluate New Evidence And Remind Ourselves
ThatWe Are AbleTo Deliver Outstanding
Prevention AndTreatment Of Periodontitis
Today AndWill Do Even Better InThe Future
Only Because OfThoseWho
Produced New Knowledge InThe Past—much
OfWhichWas Initially MetWith Skepticism
And Annoyance

23. LANDMARK SHOULD NOT
ONLY BE POPULAR
But Also Have ATremendous Impact –
WhatWe Call A “Paradigm Shift In
Perception”

27. WE HAVETO BE PROUDTHAT,
PERIODONTOLOGY HAS
SPEARHEADED SEVERAL SUCH
SHIFTS IN DENTISTRY.

28. 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

29. Paradigm Shifting Studies in
Perio can be seen under
ETIOLOGYOF
PERIODONTITIS
PATHOGENESISOF
PERIODONTITIS
MANAGEMENTOF
PERIODONTITIS

30. SECTION 2
Landmark Studies On
Etiology of Periodontitis

33. 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

34. These Indices ContinueTo Be Used Because
They Are Somewhat Reproducible, EasyTo
Record, And EmphasizeThat An Early Stage
Of Periodontal Disease (i.e., Gingivitis) Is
Strongly AssociatedWithThe Presence And
Amount Of Dental Plaque AdjacentToThe
Gingival Margin
Löe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta
Odontol Scand 1963; 21: 533-551

35. 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.

38. 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

39. 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”

40. Can we alsoTerm it as a Paradigm Shift
in Periodontology?
Concept “Plaque = Periodontal Disease”
“ No Plaque = No Disease”
Paradigm Shift -Yes / No ?

41. Diagnostic Aids -Probing

44. Another Influential PaperWas Sigurd
Ramfjord’s Description Of HowTo Use A
Calibrated Periodontal ProbeTo Conduct
A Periodontal Examination InWhichA
Site Specific Probing DepthAnd Clinical
Attachment Loss Could Be Measured
Ramfjord SP.The Periodontal Disease Index
(PDI). J Periodontol 1967;38:602-610.

45. IT ADVOCATEDTHAT A PERIODONTAL
EXAMINATION SHOULD MEASURETHE
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.

46. Use OfThe Cemento-enamel Junction
As A Fixed Reference PointTo
DetermineThe Severity Or Amount
Of Damage(i.e., Clinical Attachment
Loss)Was A Major ContributionTo
The Field.
Ramfjord SP.The Periodontal Disease Index (PDI). J
Periodontol 1967;38:602-610.

47. The IdeaThat Clinicians Should
MeasureThe Amount Of Clinical
Damage InThe Form Of Clinical
Attachment Loss ContinuesTo Be A
Critical Component Of A Complete
Periodontal Examination.
Ramfjord SP.The Periodontal Disease Index
(PDI). J Periodontol 1967;38:602-610.

48. 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

49. The Concept that
“Pocket Depth = Periodontitis”
Paradigm Shifting Idea or Not?

50. Ramfjord And His Colleagues Also ReportedThat
Probing DepthsWere Important Because Deep
Periodontal Pockets Form In Many Cases Of
Periodontitis.
Deep Pockets Are DifficultTherapeuticTargets
BecauseThe DeeperThey Are,The HarderThey
AreTo Clean.
Ramfjord SP.The Periodontal Disease Index (PDI). J
Periodontol 1967;38:602-610.

51. Which Directly lead to the next
concept..How deep is too Deep?
To Deep toTreat Non-
Surgically/Surgically?
The next Landmark / Paradigm shifting study…….

52. Scaling &
Root Planing
Open Flap
Debridemen
t

54. 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.

55. The Critical Probing Depth RepresentsA
Baseline Probing-depthValue
AboveWhichThe Outcome Of ATherapyWill
Result In Attachment Gain
And Below WhichThe Outcome OfTherapy
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

56. 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

57. 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

58. So will you accept it as a Landmark Study ?
When to do -
Non-SurgicalTreatment (AND/OR)?
Surgery?
Shifted theTreatment 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

59. 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…….

60. PERIODONAL POCKETS

61. 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.

63. The Sri LankanTea PlantationWorkers
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)

66. 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.

67. 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.

68. 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).

69. This Longitudinal Epidemiological Study Confirmed
1. Gingivitis Does Not Always ProgressTo 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

70. These Observations LedToThe
ConclusionThat,
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

71. Multiple Forms of
Periodontitis, 1986
Only One Single form of
Periodontitis, 2020

73. SECTION 3
Landmark Studies on
Classification

74. 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.

76. 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.

77. Gottlieb Classified Periodontal Diseases
1) Inflammatory i.e., Periodontitis From Local Irritants,
Atrophy Following InflammationAnd LocalToothbrush
Trauma
2) Degenerative i.e., DegenerationOf Cementum,
Periodontal ConnectiveTissue, And Alveolar Bone,
3) PeriodontalTrauma i.e., OcclusalTrauma.
Gottlieb B.The new concept of periodontoclasia. J
Periodontol 1946;17:7-23.

78. Glickman, I. (1952). Periodontosis: A Critical Evaluation.The Journal of the
American Dental Association, 44(6), 706–714.

79. In 1976 ItWas Convincingly ShownThat
PeriodontosisWas 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.

80. 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, BeckerW, Kornman K, eds. Proceedings of theWorld
Workshop in Clinical Periodontics. Chicago: American Academy
of Periodontology; 1989:I-23–I-32

82. 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

84. A new classification scheme for
periodontal and peri‐implant diseases and
conditions – Introduction and key changes
from
the 1999 classification = 2017WORLD
WORKSHOP Jack Caton, Gary Armitage
Tord Berglundh, Iain Chapple Kenneth
Kornman Brian Mealey et al
Caton J, Armitage G, BerglundhT, 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

86. 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

89. 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, BerglundhT, 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

90. Definitely a Paradigm Shifting Study,
Right?
Caton J, Armitage G, BerglundhT, 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

91. SECTION 4
Landmark Studies on
Pathogenesis

92. HaffajeeAD, Socransky SS. Microbial
etiological agents of destructive
periodontal diseases. Periodontol 2000
1994;5:78-111. (Cited by: 1,171)
BACTERIA PLAY A CRITICAL ROLE INTHE
PATHOGENESIS OF PERIODONTAL
DISEASE

94. 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.
HaffajeeAD, Socransky SS. Microbial etiological agents of destructive
periodontal diseases. Periodontol 2000 1994;5:78-111.

95. 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

97. Consensus Report Periodontal Diseases:
Pathogenesis and Microbial Factors.
(1996). Annals of Periodontology, 1(1),
926–932.

99. 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.

101. 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.

102. 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.

103. Socransky’sWork 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

104. Honourable Mentions…..Slot’s work on various
pathogens and Marsh’s work on Biofilms

105. As Periodontitis is called a Multi-factorial
Disease what about the other Etiologic
Factors?

106. PathogenesisOf Periodontitis Is
Modulated ByVarious Factors, Including
Local, Host, And Environmental Factors

108. Smoking a Risk Factor ?

109. 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.

110. What about Stress?

111. Selye, 1967 HPA Axis or General
Adaptation Syndrome?

112. Still no conclusive studies with paradigm
shifting effect on Stress Mitigation having an
effect on Periodontitis

113. Genetics? Role of Gene Polymorphisms
in Periodontitis?

115. 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.

116. And of course,The FamousTWIN
Studies of Michalowiz……….

117. Michalowicz BS (1994). Genetic and heritable risk factors in
periodontal disease. J Periodontol 65:479–488.

118. Michalowicz BS, Aeppli D,Virag JG (1991). Periodontal findings in adult
twins. J Periodontol 62:293–299.

120. Despite interesting findings from the
MichalowiczTwin Studies and Interleukin-1
Polymorphism Studies by Kornman, the
Genetic Susceptibility of Periodontitis is still
not at a Paradigm Shifting stage –Yet.

121. So what does seem to have a role in the
pathogenesis of Periodontitis?

122. SECTION 5
Landmark Studies In Perio-
Medicine

123. 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.

124. 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

125. 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,ValtonenVV, RasiVP, KesäniemiYA, Syrjälä SL, et
al. Association between dental health and acute myocardial infarction. BMJ.
1989;298:779–82

126. Mattila KJ, Nieminen MS,ValtonenVV, RasiVP, KesäniemiYA, Syrjälä SL, et al. Association
between dental health and acute myocardial infarction. BMJ. 1989;298:779–82

127. 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

129. 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

130. Diabetes and Periodontitis –The Bi-
directional Relationship

133. And then we come to Offenbacher….
Offenbacher explored the ability of
infections with oral organisms to
induce obstetric complications in
pregnancy

135. Oral Organisms Like P. GingivalisAnd C. RectusWere
Capable Of Eliciting AWide Range Of Obstetric
Complications Including Fetal Growth Restriction,
Placental Damage and Early Parturition.
Hence Oral Infection In Humans
Could LeadTo Increased Risk For Preterm/Low
BirthWeight Deliveries,
Offenbacher S, KatzV, 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)

136. TheTerm Periodontal Medicine was Coined
to Differentiate From Oral Medicine
THESE STUDIES SHOWEDTHAT FORTHE FIRSTTIME,
OUR PROFESSION SOUGHTTO RESOLVEA DEBATE
WITH NAY-SAYERS BYTURNING NOTTO CLINICAL
OPINION BUTTO SCIENCETO PROVETHAT ORAL-
SYSTEMIC CONNECTION DOES EXIST

137. The Perio-systemic Link Is A Game
ChangerAs It HasThe PotentialTo 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

138. Periodontal Medicine is
Definitely a Landmark /
Paradigm Shifting Moment in
Dentistry/Periodontics – Agree ?

139. SECTION 6
Landmark Studies InThe
Management Of Periodontitis

140. HistoricallyTreatment for Periodontitis
Included A Range OfTherapies Including
Dietary Changes, Gingival Massage, Local
Application Of Caustic Chemicals, Removal
Of Local Irritants And Surgical Resection Of
AffectedTissues Etc

141. In 1869, Riggs JW First Publicly Described A
NewTreatment ForThe Cure Of Inflammation
OfThe Gum- AThorough Curetting OfThe
Gums & Alveolar ProcessTo Remove Local
Irritation From Dental Calculus
1st Known Instance Of The Nonsurgical Removal Of Acquired
Deposits

142. 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, WithoutThe Use Of An Abrasive. J Dent Res.
1955;34:748–9

143. 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 CurettageWhen Performed 1 Month After Root
Instrumentation. A Biometric Evaluation J J Echeverria, R G Caffesse J Clin
Periodontol 1983 May;10(3):277-86

145. 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

146. The Concept
“SRP –YES, But Curettage = No”
Landmark Study/ Paradigm Shift ?

147. Treatment Options other than Mechanical Debridement
……Host Modulation

148. 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, SorsaT.Tetracyclines
inhibit connective tissue breakdown by multiple non-antimicrobial
mechanisms. Adv Dent Res 1998;12:12-26. (Cited by: 517)

150. Host Modulation added an Incremental
Advance….Can we call it a Landmark?

151. But the next study is without a doubt…..

152. On the Repair Potential of PeriodontalTissues A. H.
Melcher J Periodontol 1976 May;47(5):256-60

154. Using these basic concepts of Melcher,
Nyman et al provided Proof-of-Concept

156. 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, KarringT, Rylander H. New attachment
following surgical treatment of human periodontal disease. J
Clin Periodontol 1982;9: 290-296. (Cited by: 1,006)

157. Regeneration of Periodontium on Root
Surfaces previously denuded by
Periodontitis – Paradigm Shifting or
Not?

158. After HardTissue Grafts …Next
Comes….SoftTissue Grafts/ Perio-Plastic
Surgery

159. 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)

161. Langer, B. and Langer, L. (1985) Subepithelial ConnectiveTissue Graft
Technique for Root Coverage. Journal of Periodontology, 56, 715-720.

162. 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)

163. Periodontal Plastic/Esthetic Surery
Procedures - Root Coverage Procedures with
SoftTissue Grafts became Routine after this
–Landmark/ Paradigm Shifting ?

164. Next Landmark Study…..

165. Adell R, Eriksson B, Lekholm U,
Branemark PI, JemtT. 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)

166. AlbrektssonT, 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)

167. Adel and Albrektsson provided proof that
osseo-integrated implants can survive in the
oral cavity for a long time – just like natural
teeth

169. 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
PeriodonticsWas Forever Changed.

170. Indeed, This Shift Was So Dramatic That
Some Feel It Has Threatened The
Profession, With Many Clinicians
Practicing More Like Implantologists
Than ‘‘True’’ Periodontists.

171. 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

172. INTHIS PRESENTATION I HAVE
PROVIDED A HISTORICAL
PERSPECTIVE ONTHE DEFINING
EVENTS IN UNDERSTANDING AND
MANAGING PERIODONTAL DISEASE
To Conclude……

173. 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……

174. AND FINALLYWE SHOULD REMEMBERTHE
ENORMOUS CONTRIBUTIONS OF ALLWHO
SHAPED OUR PROFESSION.WE STAND ONTHEIR
SHOULDERS, BUTWE ALSO HAVEA
RESPONSIBILITYTO HONORTHEIR MEMORIES
BY ASSURINGTHATWE KNOWTHE HISTORY OF
PERIODONTOLOGY
To Conclude……

175. Dr. Ganesh Puttu
Periodontist &
Implantologist
Chennai.
Lecture by

176. THANKYOU
ganeshputtu@gmail.com