J Clin Periodontol 2008; 35 (Suppl. 8): 8–21 doi: 10.1111/j.1600-051X.2008.01257.

A systematic review of the effects Niklaus P. Lang1, Wah Ching Tan1,

Michael A. Krähenmann2 and Marcel
Zwahlen3

of full-mouth debridement with 1

School of Dental Medicine, University of
Berne, Berne, Switzerland; 2School of Dental
Medicine, University of Zurich, Zurich,

and without antiseptics in patients Switzerland; 3Institute of Social and

Preventive Medicine, University of Berne,
Berne, Switzerland

with chronic periodontitis

Lang NP, Tan WC, Krähenmann MA, Zwahlen M. A systematic review of the effects of
full-mouth debridement with and without antiseptics in patients with chronic periodontitis.
J Clin Periodontol 2008; 35 (Suppl. 8): 8–21. doi: 10.1111/j.1600-051X.2008.01257.x.

Abstract
Objectives: To assess the clinical and microbiological effects of full-mouth
debridement with (FMD) and without the use of antiseptics [full-mouth scaling and
root planing (FMSRP)] in comparison with conventional staged debridement (CSD) in
patients with chronic periodontitis after at least 6 months.
Material and Methods: The search in MEDLINE (PubMed), covering a period of
1975 to October 2007, and hand searching yielded 207 titles. Forty-two abstracts and
17 full-text articles were screened for inclusion.
Results: Twelve articles allowed a direct comparison of FMD with CSD, FMSRP
with CSD and FMD with FMSRP. Probing pocket depth reductions were significantly
greater (0.2 mm) with FMD and FMSRP compared with CSD. Moreover, a modest
reduction in BOP (9%) favoured FMD. Likewise, clinical attachment levels were
improved by 0.2–0.4 mm in favour of FMD and FMSRP, respectively. In all
comparisons, single-rooted teeth and deep pockets benefitted slightly from FMD and
FMSRP. Limited differences in the changes of the subgingival microbiota were noted
between the treatment modalities.
Key words: chronic periodontitis; clinical trials;
Conclusions: Despite the significant differences of modest magnitude, FMD or debridement; full-mouth disinfection; initial
FMSRP do not provide clinically relevant advantages over CSD. Hence, all three therapy; RCT; root planing; scaling
treatment modalities may be recommended for debridement in the initial treatment of
patients with chronic periodontitis. Accepted for publication 20 May 2008

Realizing that in fully dentate or par- significant reservoir for the reinfection with absence of pathogens over time
tially edentulous patients, the untreated of adjacent sites following active perio- (Mombelli et al. 1996, 1997, Fourmousis
periodontal pockets may represent a dontal therapy (Mombelli et al. 1996), a et al. 1998).
concept of full-mouth debridement In order to avoid intra-oral transmis-
Conflict of interest and source of (FMD) within 1 day has been devel- sion of periodontal pathogens from
funding statement oped. Although single periodontal sites periodontal pockets to recently instru-
The authors declare that they do not have were successfully treated, reinfection mented and healing periodontal sites, a
any conflict of interests. with pathogens occurred within 2 FMD concept was propagated by the
The study was self-funded by the authors months in these sites, while an attempt Leuven group (Quirynen et al. 1995).
and their institutions and the Clinical to fully disinfect the oral cavity using The original FMD concept included the
Research Foundation (CRF) for the Pro- local tetracycline fibres in all sites with disinfection of the entire oral cavity
motion of Oral Health. probing depths 43 mm and supplemental within a period of 24 h, depletion of
The 6th European Workshop on Perio- use of antiseptics to deplete the supra- the supragingival plaque deposits and
dontology was supported by an unrest- gingival bacterial load resulted in a prevention of biofilm formation by
ricted educational grant from Straumann stable healing of the treated sites means of oral rinses with chlorhexidine
AG.
and maintenance of therapeutic effects twice daily for 1 min. for 2 weeks and
8 r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
 Full-mouth disinfection versus staged debridement 9

disinfection of bacterial reservoirs of the

RCT, randomized-controlled clinical trial; FMD, full-mouth disinfection with use of antiseptics; FMSRP, full-mouth scaling and root planing; CSD, conventional staged debridement; GI, gingival index; PlI,
PlI, BOP, PPD, CAL, % of closed pockets i.e.
tongue and tonsils by tongue scraping
and spraying the tonsillar region with
chlorhexidine. Furthermore, subgingival

PlI, SBI, BOP, PPD, REC, staining

GI, PI, BOP, PD, CAL, MicroBiol.
irrigation of all the pockets three times
within 10 min. with a 1% chlorhexidine
gel was performed and repeated after

MicroBiol. (DPCM, culture)

MicroBiol. (DPCM, culture)
Variables
8 days. It was hypothesized that perio-
dontal treatment consisting of quadrant-

PlI, BOP. PPD, CAL

PlI, BOP, PPD, CAL

DNA hybridization
or sextant-wise instrumentation at usually

GI, PlI, BOP, PPD

BOP, PPD, CAL

1–2-week intervals would lead to reinfec-

Real-time PCR
tion of the instrumented sites before the

PD44 mm
completion of the entire therapy. Hence,
an FMD should help prevent such rein-

PCR
fection of already treated pockets from
sites that were not yet instrumented.

Follow-up
While some clinicians immediately

(months)
adopted this novel concept, other clinical

8
8
8
8

6
6

6
researchers questioned the validity and/
or the superiority of FMD over the
quadrant-wise scaling and root planing
Location

49.8 Göteborg
termed ‘‘conventional staged debride-

Glasgow

Glasgow
49.6 Leuven

Leuven
Leuven
Leuven
Leuven

48.0 Leuven
Boston

50.4 Tokyo
ment’’ (CSD). Moreover, several clini-

53.1 Bonn

53.1 Bonn
cians modified the original concept by
omitting the disinfection of the oral
Mean

49.6
48.5
age

NR
NR

45

45
cavity with chlorhexidine or they applied
less efficacious antiseptic rinses than

plaque index; BOP, bleeding on probing; PPD, pocket probing depth; CAL, clinical attachment level; REC, recession.
39–62

39–62
23–69
37–69
41–69

31–70

31–70

34–66
27–70

30–75
range
Age

chlorhexidine. Hence, full-mouth scaling

NR

NR
and root planing (FMSRP) without the
use of antiseptics was also advocated.
In recent years, a number of studies
FMSRP versus CSD

FMD versus FMSRP versus CSD

FMD versus FMSRP versus CSD

have been presented with the aim of
elucidating various clinical and micro-
biological effects of FMD or FMSRP in
Interventions

comparison with CSD. The present sys-

tematic review aimed at the evaluation
FMSRP versus CSD

FMSRP versus CSD

FMSRP versus CSD

FMSRP versus CSD

FMSRP versus CSD

FMD versus CSD

CSD
CSD

CSD

of randomized-controlled clinical trials

(various rinses)

(RCT) focusing on both the clinical and

versus
versus
versus
versus

the microbiological effects.

The following focused question was
FMD
FMD
FMD
FMD

raised:
‘‘In patients with chronic periodontitis,
what are the clinical and microbiological
patients
No. of

outcomes of Full Mouth Debridement

10

10
24
36
19

40

40

36
42

71

20

20

(FMD) versus Conventional Staged Deb-

ridement (CSD) after a follow-up period
design

of at least six months?’’

Study

RCT

RCT
RCT
RCT
RCT

RCT

RCT

RCT
RCT

RCT

RCT

RCT

Material and Methods

Table 1. Characteristics of studies included

publication
Year of

Search strategy and study selection

2004b
2004a
1996

1996
1999
2000
2001

2005
2005

2006

2006

2007

A MEDLINE (PubMed) search from

1975 up to and including October 2007
was conducted. The search terms used
Wennström et al.
Vandekerckhove

were ‘‘full-mouth disinfection’’, ‘‘deb-

Quirynen et al.
Quirynen et al.
De Soete et al.

Quirynen et al

Jervøe-Storm

Jervøe-Storm
Apatzidou &

Apatzidou &
Bollen et al.

ridement’’, ‘‘scaling’’, ‘‘root planing’’,

Koshy et al.
Study

‘‘initial therapy’’, ‘‘chronic perio-

Kinane

Kinane

dontitis’’, and ‘‘clinical trial’’ (Table 1).

et al.

et al.

et al.
References

Inclusion criteria

To be eligible for inclusion in this

12

16
13

17

10
1

6
7

systematic review, studies had to be

r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
10 Lang et al.

RCTs of at least 6 month’s duration. interval (CI)]. A fixed-effects model was Subsequently, 17 articles meeting the
Studies were considered for inclusion if used and the extent of statistical hetero- inclusion criteria were evaluated by both
they included patients with chronic geneity was calculated. Variance impu- reviewers (Fig. 1). All studies included
periodontitis only. However, for a direct tation methods were used to estimate were evaluated for compliance with the
comparison of FMD with FMSRP and appropriate variance estimates in some CONSORT guidelines (http://www.
CSD, one study that had added the studies, where appropriate standard consort-statement.org).
FMSRP cohort to a running RCT and, deviations of the differences were not
hence, did not strictly qualify as an RCT included in study reports (Follmann
with three modalities was considered et al. 1992). Excluded studies
anyway (Quirynen et al. 2000). This For the PPD and CAL, separate ana- Of the 17 full-text articles examined,
decision was based on the fact that the lyses were performed for single- and five had to be excluded from the final
clinical investigators were the same for multi-rooted teeth as well as for moderate analysis (see reference list: # 2, 5, 11,
the three treatment groups and were (5–6 mm) and deep (X7 mm) pockets. 14, 15). The reasons for exclusion were
blinded, thus justifying comparison an inadequate mean follow-up time (o6
between the three treatment groups, months), the study not reporting on
Results
although the issue of selection bias outcome variables, the study not report-
was not addressed. From a yield of 205 titles, 42 papers
were selected and abstracts were ing on FMD with antiseptics or multiple
Studies involving patients with spe- publications on the same patients.
cifically aggressive periodontitis were obtained. k-statistic for the first screen-
not considered. ing was K 5 0.705. Following screen-
ing, both reviewers agreed on 15 titles Data extraction
for further evaluation. k-statistic for the
Outcome variables
second screening on the abstract level Finally, 12 studies were included (Fig. 1).
The primary outcome variables assessed was K 5 0.483. This lower K value was Information on changes in probing depth,
were differences at the end of the studies due to substantial diversity in papers incidence of BOP and changes in CALs,
in probing pocket depth (PPD), inci- reporting on FMD with antiseptic as well as microbiological changes and
dence of bleeding on probing (BOP) applications other than the use of chlor- adverse reactions to treatment at the 6-
and clinical attachment level (CAL). hexidine. Agreement on the included or 8-month observations was retrieved.
Differences at baseline where not taken full-text papers was reached by discus- Five studies reported on clinical out-
into account. Other outcome variables sion and consensus was obtained that comes, two studies examined both clin-
examined were microbiological changes chlorhexidine was to be evaluated as ical and microbiological outcomes,
attributed to treatment. the antiseptic accompanying FMD, while five studies reported on microbio-
whenever possible. Hand searching logical changes alone. Four studies
resulted in the addition of two papers. examined FMD with supplemental
Selection of studies

Titles and abstracts of the search results

for possible inclusion were initially First electronic and hand search
screened by two groups of independent 205 Titles
reviewers (N. P. L. and T. W. C.; M. A.
K.). The full texts of all studies of
Independently selected by 2 reviewers
possible relevance were obtained for 42 titles
independent assessment by the Abstracts obtained
reviewers. Any disagreement was
resolved by discussion.
Data were extracted independently by
Discussion
the reviewers using a data extraction Agreed on 15 abstracts
form. Disagreement regarding data Full text obtained
extraction was resolved by consensus.
Agreement concerning study inclusion Hand search
and quality assessment was determined 2 titles
by k-statistics.
Total full text articles
17
Statistical analysis

Studies were combined in meta-analyses 1: Not on full mouth disinfection with an antiseptic
to evaluate the treatment effects of 1: Mean follow-up time less than 6 months.
FMD, FMSRP and CSD, respectively. 1: Not reporting on outcomes
The meta-analyses were performed 2: Multiple publications on the same patients
using the statistical software package
STATA Version 10 (Stata Corporation, Final number of studies included
College Station, TX, USA). Results 12
were presented as weighted mean dif-
ferences [WMD with 95% confidence Fig. 1. Search strategy.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
 Full-mouth disinfection versus staged debridement 11

application of antiseptic rinses (e.g. FMD vs CSD

chlorhexidine) versus CSD six studies
Mean PPD
examined FMSRP versus CSD, and Study ID Difference (95% CI)
three studies compared all the three
treatment modalities. sd not imputed
Koshy, 2005 –0.10 (–0.40, 0.20)
Koshy, 2005 0.24 (–0.80, 1.28)
Koshy, 2005 0.20 (–0.81, 1.21)
Koshy, 2005 0.26 (–0.18, 0.70)
Differences in PPD at the end of the Quirynen, 2006 –0.60 (–1.18, –0.02)
studies Quirynen, 2006 –0.40 (–0.98, 0.18)
FMD (with the use of antiseptics) Quirynen, 2006 –0.30 (–0.78, 0.18)
Quirynen, 2006 –0.40 (–0.73, –0.07)
versus CSD Subtotal –0.20 (–0.36, –0.03)
Based on four studies (# 1, 4, 12, 16) sd imputed
totalling 87 patients, the weighted mean Quirynen, 2000 –0.75 (–1.79, 0.29)
difference (95% CI) between FMD and Quirynen, 2000 –0.90 (–1.94, 0.14)
CSD amounted to 0.27 mm ( 0.43, Quirynen, 2000 –0.80 (–1.84, 0.24)
0.12) favouring FMD (po0.0001) Quirynen, 2000 –1.30 (–2.34, –0.26)
Vandekerckhove, 1996 –0.30 (–1.92, 1.32)
(Fig. 2). Vandekerckhove, 1996 –0.90 (–2.52, 0.72)
For single-rooted teeth, the weighted Vandekerckhove, 1996 –0.40 (–2.02, 1.22)
mean difference (95% CI) between Vandekerckhove, 1996 –0.90 (–2.52, 0.72)
FMD and CSD amounted to Subtotal –0.85 (–1.28, –0.41)
0.33 mm ( 0.52, 0.13) (p 5
Overall –0.27 (–0.43, –0.12)
0.001) and 0.19 mm ( 0.44, 0.06)
(NS) for multi-rooted teeth, respectively
(Fig. 3). –0.5 0 0.5 1
For moderate pockets (5 6 mm), the favours FMD favours CSD
weighted mean difference (95% CI)
Fig. 2. Weighted mean Difference (95% CI) of PPD between FMD and CSD. p-value for
between FMD and CSD amounted to
heterogeneity: 0.206I2: 27.9% (SD not imputed studies); 0.982I2 0% (SD imputed studies).
0.20 mm ( 0.38, 0.02) ( p 5
0.025) and 0.50 mm ( 0.81,
0.19) (p 5 0.001) for deep pockets
to (X7 mm), respectively (Fig. 4).
FMD vs CSD

Mean PPD
FMSRP (without the use of antiseptics) authoryear Difference (95% CI)
versus CSD
multi-rooted
Based on six studies (# 3, 4, 12, 13, 16, Koshy, 2005 0.26 (–0.18, 0.70)
Koshy, 2005 0.20 (–0.81, 1.21)
17) totalling 178 patients, the weighted Quirynen, 2000 –0.90 (–1.94, 0.14)
mean difference (95% CI) between Quirynen, 2000 –0.80 (–1.84, 0.24)
FMSRP and CSD amounted to Quirynen, 2006 –0.40 (–0.98, 0.18)
0.13 mm ( 0.23, 0.03) favouring Quirynen, 2006 –0.30 (–0.78, 0.18)
FMSRP (p 5 0.008) (Fig. 5). Vandekerckhove, 1996 –0.30 (–1.92, 1.32)
Vandekerckhove, 1996 –0.90 (–2.52, 0.72)
Three studies (# 3, 13, 17) did not Subtotal –0.19 (–0.44, 0.06)
provide the data for the sub-analysis on
single- versus multi-rooted teeth and single–rooted
one study (# 3) lacked information to Koshy, 2005 –0.10 (–0.40, 0.20)
Koshy, 2005 0.24 (–0.80, 1.28)
allow sub-analysis on various PPD.
Quirynen, 2000 –0.75 (–1.79, 0.29)
For single-rooted teeth, the weighted Quirynen, 2000 –1.30 (–2.34, –0.26)
mean difference (95% CI) between Quirynen, 2006 –0.60 (–1.18, –0.02)
FMSRP and CSD amounted to Quirynen, 2006 –0.40 (–0.73, –0.07)
0.34 mm ( 0.55, 0.12) ( p 5 Vandekerckhove, 1996 –0.90 (–2.52, 0.72)
Vandekerckhove, 1996 –0.40 (–2.02, 1.22)
0.002) and to 0.29 mm ( 0.51, 0.07) Subtotal –0.33 (–0.52, –0.13)
(p 5 0.009),for multi-rooted teeth
respectively (Fig. 6). Overall –0.27 (–0.43, –0.12)
For moderate pockets (5–6 mm), the
weighted mean difference (95% CI)
between FMSRP and CSD amounted –0.5 0 0.5 1
to 0.13 mm ( 0.20, 0.02) (NS) and favours FMD favours CSD
to 0.43 mm ( 0.66, 0.19) (po Fig. 3. Weighted mean Difference (95% CI) of PPD between FMD and CSD, stratified based
0.0001) for deep pockets (X7 mm), on single- and multi- rooted teeth. p-value for heterogeneity: 0.245I2: 23.2% (multi-rooted);
respectively (Fig. 7). 0.271I2 20.1% (single-rooted).
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
12 Lang et al.

FMD vs CSD FMD (with the use of antiseptics)

versus FMSRP (without the use of
Mean PPD
Study ID Difference (95% CI)
antiseptics)
Based on five studies (# 3, 4, 13, 16, 17)
deep
Koshy, 2005 0.24 (–0.80, 1.28) totalling 209 patients, the weighted
Koshy, 2005 0.20 (–0.81, 1.21) mean difference (95% CI) between
Quirynen, 2000 –0.90 (–1.94, 0.14) FMD and FMSRP amounted to
Quirynen, 2000 –1.30 (–2.34, –0.26) 0.03 mm ( 0.14, 0.07) (NS) (Fig. 8).
Quirynen, 2006 –0.60 (–1.18, –0.02)
Quirynen, 2006 –0.40 (–0.98, 0.18)
Sub-analysis for single- or multi-
Vandekerckhove, 1996 –0.90 (–2.52, 0.72) rooted teeth and for various PPD yielded
Vandekerckhove, 1996 –0.90 (–2.52, 0.72) no significant weighted mean differ-
Subtotal –0.50 (–0.81, –0.19) ences between FMD and FMSRP either.
moderate
Koshy, 2005 0.26 (–0.18, 0.70) Changes in incidence of BOP at the end of
Koshy, 2005 –0.10 (–0.40, 0.20) the studies
Quirynen, 2000 –0.80 (–1.84, 0.24)
Quirynen, 2000 –0.75 (–1.79, 0.29) FMD (with the use of antiseptics)
Quirynen, 2006 –0.30 (–0.78, 0.18) versus CSD
Quirynen, 2006 –0.40 (–0.73, –0.07)
Vandekerckhove, 1996 –0.40 (–2.02, 1.22) Based on the four studies (# 1, 4, 12, 16)
Vandekerckhove, 1996 –0.30 (–1.92, 1.32)
Subtotal –0.20 (–0.38, –0.02)
mentioned (87 patients), the weighted
mean difference (95% CI) between
Overall –0.27 (–0.43, –0.12) FMD and CSD amounted to a reduction
in BOP of 8.75% ( 15.83, 1.67)
favouring FMD (p 5 0.015) (Fig. 9).
–0.5 0 0.5 1
For single-rooted teeth, the weighted
favours FMD favours CSD
mean difference (95% CI) between
Fig. 4. Weighted mean Difference (95% CI) of PPD between FMD and CSD, stratified based FMD and CSD amounted to 6.99%
on moderate (5–6 mm) and deep (X7 mm) pockets. p-value for heterogeneity: 0.398I2: 4.2% ( 18.05, 04.07) (NS) and to 0.09%
(deep); 0.284I2 18.4% (moderate). ( 15.11, 14.93) (NS), for multi-rooted
teeth respectively.
For moderate pockets (5–6 mm), the
weighted mean difference (95% CI)
FMSRP vs CSD between FMD and CSD amounted to
Mean PPD 8.41% ( 21.10, 4.29) (NS) and to
Study ID Difference (95% CI) 0.84% ( 13.34, 11.66) (NS), for deep
pockets (X7 mm) respectively.
sd not imputed
Apatzidou, 2004 0.00 (–0.16, 0.16)
Jervoe-Storm, 2006 0.00 (–2.43, 2.43) FMSRP (without the use of antiseptics)
Jervoe-Storm, 2006 –0.10 (–0.82, 0.62) versus CSD
Koshy, 2005 0.03 (–0.68, 0.74)
Koshy, 2005 –0.03 (–0.51, 0.45) Based on six studies (# 3, 4, 12, 13, 16,
Koshy, 2005 –0.04 (–0.44, 0.36) 17) mentioned (178 patients), the
Koshy, 2005 –0.16 (–1.20, 0.88) weighted mean difference (95% CI)
Quirynen, 2006 –0.30 (–0.88, 0.28)
Quirynen, 2006 0.00 (–0.36, 0.36)
between FMSRP and CSD amounted
Quirynen, 2006 0.00 (–0.37, 0.37) to 8.45% (8.35, 8.54) favouring CSD
Quirynen, 2006 –0.60 (–1.22, 0.02) (po0.0001) (Fig. 10).
Wennstrom, 2005 0.00 (–0.43, 0.43) Only one study (# 4) provided the
Wennstrom, 2005 0.00 (–0.28, 0.28) data of a sub-analysis on single- versus
Subtotal –0.03 (–0.14, 0.07)
multi-rooted teeth. In this study, the
sd imputed mean difference (95% CI) between
Quirynen, 2000 –1.20 (–1.85, –0.55) FMSRP and CSD amounted to 12.31%
Quirynen, 2000 –1.10 (–1.75, –0.45) (12.20, 12.43) (po0.0001) for single-
Quirynen, 2000 –1.10 (–1.75, –0.45) rooted and to 0.25% (0.09, 0.42)
Quirynen, 2000 –1.10 (–1.75, –0.45)
Subtotal –1.12 (–1.45, –0.80)
(p 5 0.003) for multi-rooted teeth,
respectively.
Overall –0.13 (–0.23, –0.03) For moderate pockets (5–6 mm) (two
studies; # 4, 17), the weighted mean
difference (95% CI) between FMSRP
–0.5 0 0.5 1
and CSD amounted to 10.19% (10.06,
favours FMSRP favours CSD
10.31) (po0.0001) and to6.34% (6.19,
Fig. 5. Weighted mean Difference (95% CI) of PPD between FMSRP and CSD. p-value for 6.48) (po0.0001), for deep pockets
heterogeneity: 0.974I2: 0% (SD not imputed studies); 0.995I2 0% (SD imputed studies). (X7 mm) respectively.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
 Full-mouth disinfection versus staged debridement 13

FMSRP vs CSD FMD (with the use of antiseptics)

versus FMSRP (without the use of
Mean PPD
antiseptics)
Study ID Difference (95 % CI)
Based on three studies (# 4, 12, 16)
multi-rooted mentioned (76 patients), the weighted
Koshy, 2005 0.03 (–0.68, 0.74) mean difference (95% CI) between
Koshy, 2005 –0.03 (–0.51, 0.45) FMD and FMSRP amounted to
Quirynen, 2000 –1.10 (–1.75, –0.45) 5.72% ( 12.65, 1.21) (NS) (Fig. 11).
Quirynen, 2000 –1.10 (–1.75, –0.45) Only one study (# 4) provided the
Quirynen, 2006 0.00 (–0.37, 0.37) data of a sub-analysis for single- or
Quirynen, 2006 –0.30 (–0.88, 0.28)
multi-rooted teeth as well as for various
Subtotal –0.29 (–0.51, –0.07)
PPD and yielded no significant
differences between FMD and FMSRP
single - rooted
either.
Koshy, 2005 –0.04 (–0.44, 0.36)
Koshy, 2005 –0.16 (–1.20, 0.88)
Quirynen, 2000 –1.10 (–1.75, –0.45) Changes in CAL at the end of the studies
Quirynen, 2000 –1.20 (–1.85, –0.55)
Quirynen, 2006 0.00 (–0.36, 0.36)
FMD (with the use of antiseptics)
Quirynen, 2006 –0.60 (–1.22, 0.02)
versus CSD
Subtotal –0.34 (–0.55, –0.12)
Based on three studies indicated (# 4,
Overall –0.31 (–0.46, –0.16) 12, 16), the weighted mean difference
(95% CI) between FMD and CSD
amounted to 0.21 mm (0.02, 0.40)
–0.5 0 0.5 1 favouring FMD (p 5 0.032) (Fig. 12).
favours FMSRP favours CSD
For single-rooted teeth, the weighted
Fig. 6. Weighted mean Difference (95% CI) of PPD between FMSRP and CSD, stratified mean difference (95% CI) between
based on single- and multi-rooted teeth. p-value for heterogeneity: 0.006I2: 69.2% (multi- FMD and CSD amounted to 0.41 mm
rooted); 0.003I2 72.7% (single-rooted). (0.04, 0.77) (p 5 0.029) and to 0.06 mm
( 0.18, 0.31) (NS) for multi-rooted
teeth, respectively (Fig. 13).
For moderate pockets (5–6 mm), the
FMSRP vs CSD
weighted mean difference (95% CI)
Mean PPD between FMD and CSD amounted to
Study ID Difference (95% CI) 0.10 mm ( 0.12, 0.32) (NS) and to
0.56 mm (0.16, 0.95) (p 5 0.006) for deep
deep
pockets (X7 mm), respectively (Fig. 14).
Jervoe-Storm, 2006 0.00 (–2.43, 2.43)
Koshy, 2005 0.03 (–0.68, 0.74)
Koshy, 2005 –0.16 (–1.20, 0.88)
FMSRP (without the use of antiseptics)
Quirynen, 2000 –1.20 (–1.85, –0.55)
Quirynen, 2000 –1.10 (–1.75, –0.45) versus CSD
Quirynen, 2006 –0.30 (–0.88, 0.28)
Quirynen, 2006 –0.60 (–1.22, 0.02)
Based on the six studies indicated (# 3,
Wennstrom, 2005 0.00 (–0.43, 0.43) 4, 12, 13, 16, 17), the weighted mean
Subtotal –0.43 (–0.66, –0.19) difference (95% CI) between FMSRP
and CSD amounted to 0.36 mm (0.23,
moderate 0.49) favouring FMSRP (po0.0001)
Jervoe-Storm, 2006 –0.10 (–0.82, 0.62) (Fig. 15).
Koshy, 2005 –0.04 (–0.44, 0.36)
Koshy, 2005 –0.03 (–0.51, 0.45)
Two studies (#12, 16) provided the
Quirynen, 2000 –1.10 (–1.75, –0.45) data for sub-analysis on single- versus
Quirynen, 2000 –1.10 (–1.75, –0.45) multi-rooted teeth and five studies (# 4,
Quirynen, 2006 0.00 (–0.36, 0.36) 12, 13, 16, 17) provided information to
Quirynen, 2006 0.00 (–0.37, 0.37) allow sub-analysis on various PPD.
Wennstrom, 2005 0.00 (–0.28, 0.28)
Subtotal –0.13 (–0.28, 0.02)
For single-rooted teeth, the weighted
mean difference (95% CI) between
Overall –0.22 (–0.34, –0.09) FMSRP and CSD amounted to 0.88 mm
(0.57, 1.19) (po0.0001) and to 0.69 mm
(0.42, 0.96) (po0.0001) for multi-rooted
–0.5 0 0.5 1 teeth, respectively (Fig. 16).
favours FMSRP favours CSD For moderate pockets (5–6 mm), the
Fig. 7. Weighted mean Difference (95% CI) of PPD between FMSRP and CSD, stratified weighted mean difference (95% CI)
based on moderate (5–6 mm) and deep (X7 mm) pockets. p-value for heterogeneity: 0.027I2: between FMSRP and CSD amounted
55.8% (deep); 0.007I2 63.8% (moderate). to 0.30 mm (0.12, 0.48) (p 5 0.001)
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
14 Lang et al.

FMD vs FMSRP and to 0.68 mm (0.43, 0.92) (po

0.0001) for deep pockets (X7 mm),
Mean PPD
respectively (Fig. 17).
Study ID Difference (95% CI)

sd not imputed FMD (with the use of antiseptics)

Apatzidou, 2004 0.00 (–0.16, 0.16)
Jervoe - Storm, 2006 –0.10 (–0.82, 0.62)
versus FMSRP (without the use of
Jervoe - Storm, 2006 0.00 (–2.43, 2.43) antiseptics)
Koshy, 2005 0.03 (–0.68, 0.74)
Koshy, 2005 –0.16 (–1.20, 0.88) Based on the three studies indicated (#
Koshy, 2005 –0.03 (–0.51, 0.45) 4, 12, 16), the weighted mean difference
Koshy, 2005 –0.04 (–0.44, 0.36) (95% CI) between FMD and FMSRP
Quirynen, 2006 0.00 (–0.37, 0.37) amounted to 0.26 mm ( 0.48,
Quirynen, 2006 0.00 (–0.36, 0.36) 0.05) (p 5 0.016) favouring FMSRP
Quirynen, 2006 –0.60 (–1.22, 0.02)
Quirynen, 2006 –0.30 (–0.88, 0.28) (Fig. 18).
Wennstrom, 2005 0.00 (–0.28, 0.28) Sub-analysis for single- or multi-
Wennstrom, 2005 0.00 (–0.43, 0.43) rooted teeth was based on two studies
Subtotal –0.03 (–0.14, 0.07) only. For single-rooted teeth, the
weighted mean difference (95% CI)
sd imputed
Quirynen, 2000 –1.10 (–3.35, 1.15)
between FMD and FMSRP amounted
Quirynen, 2000 –1.10 (–3.35, 1.15) to 0.25 mm ( 0.60, 0.11) (NS) and
Quirynen, 2000 –1.20 (–3.45, 1.05) to 0.41 mm ( 0.71, 0.12) (p 5
Quirynen, 2000 –1.10 (–3.35, 1.15) 0.006) for multi-rooted teeth, respec-
Subtotal –1.12 (–2.25, 0.00) tively (Fig. 19).
Overall –0.04 (–0.14, 0.06)
Based on the three studies mentioned
above, the weighted mean difference
(95% CI) between FMD and FMSRP
–0.5 0 0.5 1 amounted for moderate pockets (5–
favours FMD favours FMSRP 6 mm) to 0.19 mm ( 0.46, 0.08)
(NS) and to 0.39 mm ( 0.75,
0.04) (p 5 0.030) for deep pockets
(X7 mm), respectively (Fig. 20).
Fig. 8. Weighted mean Difference (95% CI) of PPD between FMD and FMSRP. p-value for
heterogeneity: 0.974I2: 0% (SD not imputed studies); 1.0I2 0% (SD imputed studies).
Changes in the subgingival microbiota

Owing to the heterogeneity of the various

microbiological techniques applied in the
studies, no meta-analyses could be per-
FMD vs CSD
formed for microbiological parameters.
Mean BOP
Study ID Difference (95% CI) FMD (with the use of antiseptics)
versus CSD
sd not imputed
Based on four studies (# 6, 7, 8, 16)
Quirynen, 2000 –20.00 (–32.80, –7.20)
totalling 77 patients, the subgingival
Quirynen, 2006 8.00 (–10.45, 26.45) microbiota before and after either
Quirynen, 2006 –10.00 (–28.45, 8.45) FMD or CSD was evaluated. For both
Quirynen, 2006 –16.00 (–41.87, 9.87) clinical approaches, the subgingival
Quirynen, 2006 –6.00 (–20.57, 8.57) microbiota improved substantially from
Subtotal –9.90 (–17.32, –2.49) baseline to the first evaluation as docu-
mented by both dark-field microscopy
sd imputed and cultivating presumptive periodontal
Koshy, 2005 4.00 (–24.29, 32.29) pathogens. The improvements in the
Vandekerckhove, 1996 1.00 (–42.83, 44.83) FMD patients when compared with the
Subtotal 3.12 (–20.65, 26.89) improvements with CSD patients were
more favourable for FMD in two studies
(# 6, 7, Bollen et al. 1996, Quirynen
Overall –8.75 (–15.83, –1.67)
et al. 1999) applying dark-field micro-
scopy as well as cultural data, and
another study from the same research
–15 0 15
group (# 8, De Soete et al. 2001)
favours FMD favours CSD
confirmed similar results when using
Fig. 9. Weighted mean Difference (95% CI) of BOP between FMD and CSD. p-value for DNA–DNA hybridization. In contrast,
heterogeneity: 0.165I2: 38.4% (SD not imputed studies); 0.910I2 0% (SD imputed studies). one study applying polymerase chain
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
 Full-mouth disinfection versus staged debridement 15

FMSRP vs CSD Leuven as opposed to the patients trea-

ted by CSD where a rebound of perio-
Mean BOP dontal pathogens was observed.
Study ID Difference (95% CI)

sd not imputed
FMSRP (without the use of antiseptics)
Apatzidou, 2004 –3.00 (–7.04, 1.04)
versus CSD
Jervoe-Storm, 2006 –11.60 (–27.91, 4.71)
Jervoe- Storm, 2006 –19.30 (–52.20, 13.60)
Based on four studies (# 9, 10, 12, 16)
totalling 108 patients, the subgingival
Quirynen, 2000 –26.00 (–37.32, –14.68)
microbiota before and after either
Quirynen, 2006 15.00 (14.85, 15.15)
FMSRP or CSD was evaluated. Again,
Quirynen, 2006 8.00 (7.82, 8.18)
for both clinical approaches, the subgin-
Quirynen, 2006 4.00 (3.78, 4.22)
gival microbiota improved from base-
Quirynen, 2006 –5.00 (–5.26, –4.74)
line to the first evaluation as
Subtotal 8.45 (8.36, 8.55)
documented by PCR amplification for
presumptive periodontal pathogens. The
sd imputed improvements, however, did not differ
Koshy, 2005 0.00 (–7.70, 7.70) between FMSRP and CSD except for
Wennstrom, 2005 –1.00 (–6.90, 4.90) Treponema denticola. The reductions in
Subtotal –0.63 (–5.31, 4.05) pathogens were maintained for 6 months
with either clinical approach (# 9,
Overall 8.45 (8.35, 8.54) Apatzidou et al. 2004). With two differ-
ent microbiological identification meth-
ods [PCR and real-time (RT)-PCR], no
–15 0 15 differences between the microbiological
favours FMSRP favours CSD results of FMSRP and CSD for either
Fig. 10. Weighted mean Difference (95% CI) of BOP between FMSRP and CSD. p-value for
short-term or longer-term reductions in
heterogeneity: 0.000I2: 100% (SD not imputed studies); 0.840I2 0% (SD imputed studies). pathogens could be demonstrated (# 10,
16, Jervøe-Storm et al. 2007, Koshy
et al. 2005).
FMD vs FMSRP On the other hand, the research group
of the University of Leuven presented
Mean BOP significantly greater reductions in patho-
gens following FMSRP than following
Study ID Difference (95% CI)
CSD as documented by dark-field
microscopy and culturing (# 12,
sd not imputed Quirynen et al. 2000).
Quirynen, 2000 6.00 (–5.32, 17.32)
Quirynen, 2006 –21.00 (–35.82, –6.18) FMD (with the use of antiseptics)
versus FMSRP (without the use of
Quirynen, 2006 –18.00 (–32.82, –3.18)
antiseptics)
Subtotal –7.73 (–15.42, –0.04)
Based on two studies (#12, 16) totalling
48 patients, the subgingival microbiota
sd imputed before and after either FMD or FMSRP
Koshy, 2005 3.00 (–13.00, 19.00) was evaluated. For both clinical modal-
ities, the subgingival microbiota
Subtotal 3.00 (–13.00, 19.00)
improved from baseline to the first eva-
luation as documented by dark-field
Overall –5.72 (–12.65, 1.21) microscopy, cultivating presumptive
periodontal pathogens and RT-PCR.
No differences between the microbiolo-
gical results of FMD and FMSRP for
–15 0 15
either short-term or longer-term reduc-
favours FMD favours FMSRP tions in pathogens could be demon-
Fig. 11. Weighted mean Difference (95% CI) of BOP between FMD and FMSRP. p-value strated (# 12, 16, Quirynen et al. 2000,
for heterogeneity: 0.005I2: 81.1% (not imputed); 0.007I2 75.0% (overall). Koshy et al. 2005).

reaction (PCR) amplification (# 16, CSD. The more favourable reductions

Koshy et al. 2005) failed to yield sig- in the FMD patient cohort were gener- Discussion
nificant differences in the microbiologi- ally maintained up to 8 months in the The focused question of this systematic
cal improvements between FMD and studies performed at the University of review was: ‘‘In patients with chronic
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
16 Lang et al.

FMD vs CSD periodontitis, what are the clinical and

microbiological outcomes of Full Mouth
Mean CAL Disinfection (FMD) versus Conven-
Study ID Difference (95% CI) tional Staged Debridement (CSD) after
a follow-up period of at least six
sd not imputed months?’’ Following the literature
Koshy, 2005 –0.07 (–0.35, 0.21) searches, another clinical protocol that
Koshy, 2005 –0.36 (–1.08, 0.36) did not include the use of antiseptics for
Koshy, 2005 0.11 (–0.37, 0.59)
the FMD concept became apparent and
was included in the review as the
Koshy, 2005 –0.09 (–1.05, 0.87)
FMSRP concept. Adequate information
Subtotal –0.06 (–0.28, 0.17)
was available to separate the outcomes
for the three modalities and, hence, to
sd imputed test the additional effects of antiseptic
Quirynen, 2000 0.90 (–0.06, 1.86) regimes within the concept of FMD.
Quirynen, 2000 1.50 (0.54, 2.46) While a total number of 12 studies
Quirynen, 2000 0.80 (–0.16, 1.76) were identified by the search processes
Quirynen, 2000 1.70 (0.74, 2.66) (five reporting solely clinical, five
Quirynen, 2006 0.50 (–0.38, 1.38) reporting microbiological and two re-
Quirynen, 2006 0.70 (–0.18, 1.58) porting both clinical and microbiologi-
Subtotal 0.99 (0.61, 1.37)
cal data), the number of available RCTs
for the pure FMD, the FMSRP and
the CSD concepts were four, six and
Overall 0.21 (0.02, 0.40)
seven, respectively. This allowed the
direct comparison of the effects of
FMD versus CSD based on four articles,
–0.5 0 0.5 1 the direct comparison of the effects
favours CSD favours FMD of FMSRP versus CSD based on six
Fig. 12. Weighted mean Difference (95% CI) of CAL gain between FMD and CSD. p-value articles and the direct comparison of
for heterogeneity: 0.765I2: 0% (SD not imputed studies); 0.421I2 0% (SD imputed studies). the effects of FMD versus FMSRP
based on three articles. Owing to the
homogeneity of the clinical outcomes,
meta-analyses were performed. Data
FMD vs CSD from patient cohorts not classified as
‘‘chronic periodontitis’’ were excluded
Mean CAL from the analyses.
authoryear Difference (95% CI) The primary outcome variable of
interest was the differences in the reduc-
multi-rooted tion in PPD at the end of the studies.
FMD resulted in a significantly greater
Koshy, 2005 –0.36 (–1.08, 0.36)
difference of PPD, when compared with
Koshy, 2005 –0.07 (–0.35, 0.21) CSD. Likewise, FMSRP yielded signifi-
Quirynen, 2000 0.90 (–0.06, 1.86) cantly greater differences of PPD than
Quirynen, 2000 1.50 (0.54, 2.46) did CSD. In contrast, the comparison of
Subtotal 0.06 (–0.18, 0.31) the FMD concept with and without the
application of antiseptics did not result
single -rooted in any differences in the PPD at the end
of the studies.
Koshy, 2005 0.11 (–0.37, 0.59)
Comparing FMD with CSD, it has to
Koshy, 2005 –0.09 (–1.05, 0.87) be realized that the DPPD were signifi-
Quirynen, 2000 0.80 (–0.16, 1.76) cantly greater only for single-rooted
Quirynen, 2000 1.70 (0.74, 2.66) teeth and were more pronounced for
Subtotal 0.41 (0.04, 0.77) deeper PPD. The fact that the differ-
ences reached not 40.5 mm in these
Overall 0.17 (–0.03, 0.37)
particular sites renders the FMD concept
to be of questionable clinical value as a
routine to be preferred in daily practice
over the CSD concept. Even though the
–0.5 0 0.5 1 single-rooted teeth with deep pockets
favours CSD favours FMD may benefit from being instrumented
Fig. 13. Weighted mean Difference (95% CI) of CAL gain between FMD and CSD, stratified under the FMD concept, the instruction
based on single- and multi- rooted teeth. p-value for heterogeneity: 0.004I2: 77.9% (multi- in meticulous oral hygiene practices that
rooted); 0.018I2 70.1% (single-rooted). should precede the instrumentation would
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
 Full-mouth disinfection versus staged debridement 17

FMD vs CSD require a staged approach (Söderholm

& Egelberg 1982, Söderholm et al.
Mean CAL 1982, Glavind 1990).
Study ID Difference (95% CI) Obviously, the adjunctive use of
chlorhexidine as an antiseptic appeared
deep to be of limited value when comparing
Koshy, 2005 –0.09 (–1.05, 0.87) the DPPD of FMD versus CSD and the
Koshy, 2005 –0.36 (–1.08, 0.36) FMSRP versus CSD. While the first
Quirynen, 2000 1.50 (0.54, 2.46)
comparison resulted in a 0.27 mm great-
er reduction in favour of FMD, the
Quirynen, 2000 1.70 (0.74, 2.66)
second comparison only yielded a dif-
Quirynen, 2006 0.70 (–0.18, 1.58)
ference in reduction of 0.13 mm favour-
Subtotal 0.56 (0.16, 0.95) ing FMSRP, a borderline relevant
preference in clinical practice. More-
moderate over, the comparison of the DPPD of
Koshy, 2005 0.11 (–0.37, 0.59) the FMD with the FMSRP concept
Koshy, 2005 –0.07 (–0.35, 0.21) showed no difference between the two
Quirynen, 2000 0.90 (–0.06, 1.86) treatments. This, in turn, means that the
Quirynen, 2000 0.80 (–0.16, 1.76) adjunctive application of chlorhexidine
Quirynen, 2006 0.50 (–0.38, 1.38) or any other antiseptic most likely failed
Subtotal 0.10 (–0.12, 0.32) to have an effect on DPPD. Chlorhex-
idine may, however, be effective in
depleting the supragingival bacterial
Overall 0.21 (0.02, 0.40)
colonization (Löe & Schiøtt 1970,
Brecx 1997). In studies on the subgin-
gival irrigation using chlorhexidine as
–0.5 0 0.5 1 an agent, permanent effects on the sub-
favours CSD favours FMD gingival microbiota could not be estab-
Fig. 14. Weighted mean Difference (95% CI) of CAL gain between FMD and CSD, stratified lished (Wennström 1992).
based on moderate (5–6 mm) and deep (X7 mm) pockets. p-value for heterogeneity: 0.002I2: When analysing the microbiological
76.6% (deep); 0.144I2 41.7% (moderate). results of the studies included in the
present systematic review, no superior
FMSRP vs CSD reductions in either bacterial load or
Mean CAL specific presumptive periodontal patho-
Study ID Difference (95% CI) gens were identified for any of the three
modalities when modern microbiologi-
sd not imputed cal identification methods, such as PCR
Apatzidou, 2004 0.00 (–0.32, 0.32) or RT-PCR, were used. However, one
Jervoe-Storm, 2006 0.10 (–0.72, 0.92) laboratory (de Soete et al. 2001) was
Jervoe-Storm, 2006 –0.80 (–2.44, 0.84) able to document higher reductions
Koshy, 2005 0.19 (–0.29, 0.67) of ‘‘red’’ and ‘‘orange’’ complex bacteria
Koshy, 2005 0.38 (–0.28, 1.04) applying DNA–DNA hybridization tech-
Koshy, 2005 0.47 (–0.37, 1.31) niques. The controversy in the results of
Koshy, 2005 0.18 (–0.20, 0.56) the seven microbiological studies may
Wennstrom, 2005 0.10 (–0.33, 0.53) only be explained on the basis of meth-
Wennstrom, 2005 0.00 (–0.31, 0.31)
odological variability. The three labora-
Subtotal 0.09 (–0.06, 0.25)
tories applying PCR (Apatzidou
sd imputed
et al. 2004, Koshy et al. 2005, Jervøe-
Quirynen, 2000 1.80 (1.14, 2.46) Storm et al. 2007) failed to reveal any
Quirynen, 2000 2.00 (1.34, 2.66) significant differences in the subgingival
Quirynen, 2000 1.30 (0.64, 1.96) microbiota between FMSRP and CSD,
Quirynen, 2000 1.40 (0.74, 2.06) and one laboratory (Koshy et al. 2005)
Quirynen, 2006 0.25 (–0.35, 0.85) assessed FMD in addition to FMSRP
Quirynen, 2006 0.30 (–0.30, 0.90) and CSD without any difference in
Subtotal 1.12 (0.86, 1.38) microbial recolonization.
The significant differences in micro-
Overall 0.36 (0.23, 0.49) bial recolonization following FMD and
in one study following FMSRP pre-
sented by the laboratory of the Univer-
–0.5 0 0.5 1 sity of Leuven are dificult to interpret
favours CSD favours FMSRP in the light of the results presented by
Fig. 15. Weighted mean Difference (95% CI) of CAL gain between FMSRP and CSD. p-value the remainder of the research commu-
for heterogeneity: 0.885I2: 0% (SD not imputed studies); 0.000I2 81.7% (SD imputed studies). nity. Earlier studies applied culturing
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
18 Lang et al.

FMSRP vs CSD techniques for bacterial identification

(Bollen et al. 1998, Quirynen et al.
Mean CAL 1999, 2000). It is evident that results
Study ID Difference (95% CI) with those techniques may be even
harder to reproduce because sampling,
multi - rooted transportation to the laboratory, proces-
sing in the anaerobic atmosphere and
Koshy, 2005 0.38 (–0.28, 1.04)
disruption of the samples are crucial
Koshy, 2005 0.18 (–0.20, 0.56) issues requiring standardization and
Quirynen, 2000 1.80 (1.14, 2.46) calibration of methods among labora-
Quirynen, 2000 1.40 (0.74, 2.06) tories (Mombelli et al. 1989). On the
Subtotal 0.69 (0.42, 0.96) other hand, using DNA–DNA hybridi-
zation, standardization of the time elap-
single - rooted
sing between sampling and processing
of the microbiological samples may be
Koshy, 2005 0.19 (–0.29, 0.67)
of importance (Katsoulis et al. 2005 a,
Koshy, 2005 0.47 (–0.37, 1.31) b). Hence, the results obtained with
Quirynen, 2000 2.00 (1.34, 2.66) various microbiological identification
Quirynen, 2000 1.30 (0.64, 1.96) techniques are extremely difficult to
Subtotal 0.88 (0.57, 1.19) compare, a fact that led to the decision
of not meta-analysing microbiological
Overall 0.77 (0.57, 0.97)
results in the present systematic review.
The parallel comparison of cultural
microbiological data with RT-PCR
data (Jervøe-Storm et al. 2005) revealed
–0.5 0 0.5 1 excellent agreement only for Aggrega-
favours CSD favours FMSRP tibacter actinomycetemcomitans and
Fig. 16. Weighted mean Difference (95% CI) of CAL gain between FMSRP and CSD Porphyromonas gingivalis, but fair
stratified based on single- and multi-rooted teeth. p-value for heterogeneity: 0.000I2: 87.1% agreement for Tannerella forsythia and
poor agreement for Fusobacterium
nucleatum and Prevotella intermedia.
FMSRP vs CSD Another study performed by the same
research group (Jervøe-Storm et al.
Mean CAL 2007) analysed the microbiological
Study ID Difference (95% CI) data for short- and long-term effects of
FMSRP and CSD on the subgingival
deep microbiota on day 1 and 1, 2, 4, 8,
Jervoe -Storm, 2006 –0.80 (–2.44, 0.84)
12,and 24 weeks. If the concept of
Koshy, 2005 0.38 (–0.28, 1.04)
FMSRP was to prevent recolonization
Koshy, 2005 0.47 (–0.37, 1.31)
of already-instrumented sites, this study
Quirynen, 2000 2.00 (1.34, 2.66)
should reveal significant reductions fol-
Quirynen, 2000 1.80 (1.14, 2.46)
Quirynen, 2006 0.30 (–0.30, 0.90)
lowing FMSRP in the microbiota during
Wennstrom, 2005 0.10 (–0.33, 0.53) at least the first 12 weeks. However, no
Subtotal 0.67 (0.43, 0.92) such significant differences for any of
the microbiological parameters could be
moderate demonstrated.
Jervoe -Storm, 2006 0.10 (–0.72, 0.92) The two additional parameters of
Koshy, 2005 0.19 (–0.29, 0.67) interest in the studies of the present
Koshy, 2005 0.18 (–0.20, 0.56) systematic review included reduction
Quirynen, 2000 1.40 (0.74, 2.06) in the percentage of BOP sites and
Quirynen, 2000 1.30 (0.64, 1.96) changes in clinical attachment levels
Quirynen, 2006 0.25 (–0.35, 0.85) (DCAL). With very few exceptions,
Wennstrom, 2005 0.00 (–0.31, 0.31) both parameters confirmed the results
Subtotal 0.30 (0.12, 0.48) obtained for the primary outcome
variable (DPPD).
Overall 0.43 (0.29, 0.58) Significantly higher BOP reductions
were revealed for FMD and FMSRP,
respectively, when compared with the
–0.5 0 0.5 1 CSD concept. These differences, how-
favours CSD favours FMSRP ever, were very small (8.75% for FMD
Fig. 17. Weighted mean Difference (95% CI) of CAL gain between FMSRP and CSD, and 8.45% for FMSRP) and may not be
stratified based on moderate (5–6 mm) and deep (X7 mm) pockets. p-value for heterogeneity: of any clinical relevance. Moreover, no
0.000I2: 84.8% (deep); 0.000I2 75.2% (moderate). differences were demonstrated between
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
(SD not imputed studies); 0.000I2 86.1% (SD imputed studies).
 Full-mouth disinfection versus staged debridement 19

FMD vs FMSRP the treatment modalities when single-

rooted teeth were compared with multi-
Mean CAL rooted teeth or sites of moderate to those
Study ID Difference (95% CI) of deep PPD. This is owing to the small
number of studies and the small sample
sd not imputed sizes within the studies reporting on this
Koshy, 2005 –0.25 (–0.66, 0.16) parameter and hence, the limited amount
Koshy, 2005 –0.74 (–1.31, –0.17) of data available for the analysis. The
Koshy, 2005 –0.08 (–0.56, 0.40)
direct comparison of the reductions of
BOP percentages applying the FMD con-
Koshy, 2005 –0.56 (–1.49, 0.37)
cept with and without the use of antisep-
Subtotal –0.33 (–0.59, –0.07)
tics was only 5.72% and did not show any
statistically significant difference. Again,
sd imputed such reductions in BOP may only repre-
Quirynen, 2000 –0.50 (–1.43, 0.43) sent inter-examiner variability, because
Quirynen, 2000 –0.30 (–1.23, 0.63) BOP assessments are substantially depen-
Quirynen, 2000 –0.50 (–1.43, 0.43) dent on the pressure applied to the perio-
Quirynen, 2000 –0.30 (–1.23, 0.63) dontal probe (Lang et al. 1991). No data
Quirynen, 2006 0.25 (–0.61, 1.11) on reproducibility of intra- and inter-
Quirynen, 2006 0.40 (–0.46, 1.26) examiner variability were reported for
Subtotal –0.13 (–0.50, 0.24)
any of the studies included in the present
systematic review.
CAL gains were significantly greater
Overall –0.26 (–0.48, –0.05)
(0.21 mm) for FMD than for CSD.
Again, this difference is hardly clini-
cally relevant and did not reach signifi-
–0.5 0 0.5 1 cance for multi-rooted teeth and
favours FMSRP favours FMD moderate PPD (5–6 mm) analysed sepa-
Fig. 18. Weighted mean Difference (95% CI) of CAL gain between FMD and FMSRP. p- rately. The comparison between the
value for heterogeneity: 0.328I2: 12.9% (SD not imputed studies); 0.594I2 0% (SD imputed FMSRP and CSD concepts yielded
studies). 0.36 mm in favour of FMSRP, and the
direct comparison of the FMD with and
without the use of antiseptics (FMSRP)
FMD vs FMSRP showed a difference in favour of
FMSRP of 0.26 mm in DCAL. This
Mean CAL significant difference is in contrast to
Study ID Difference (95% CI) the expected tendency and questions the
values of studies reporting on non-
multi-rooted calibrated CAL measurements.
The changes in PPD and CAL gains
Koshy, 2005 –0.74 (–1.31, –0.17)
revealed in the present systematic
Koshy, 2005 –0.25 (–0.66, 0.16) review have to be put into perspective
Quirynen, 2000 –0.30 (–1.23, 0.63) with changes reported previously in
Quirynen, 2000 –0.50 (–1.43, 0.43) clinical trials on periodontal therapy,
Subtotal –0.41 (–0.71, –0.12) especially the effects of the initial
(hygienic) phase of periodontal care
single -rooted (e.g. Morrison et al. 1980, Pihlstrom
et al. 1983). PPD reductions of approxi-
Koshy, 2005 –0.56 (–1.49, 0.37)
mately 1.0 mm for pockets with PPD of
Koshy, 2005 –0.08 (–0.56, 0.40) 4–6 mm and approximately 2.2 mm for
Quirynen, 2000 –0.30 (–1.23, 0.63) pockets with PPD of X7 mm would
Quirynen, 2000 –0.50 (–1.43, 0.43) have to be expected with CSD. In the
Subtotal –0.25 (–0.60, 0.11) light of these expected reductions, the
additional benefits of FMD or FMSRP
Overall –0.35 (–0.57, –0.12)
are small and, hence, are hardly relevant
from a clinical point of view.
Most recently, another systematic
review (Eberhard et al. 2008) comparing
–0.5 0 0.5 1 the clinical effects of the treatment
favours FMSRP favours FMD modalities discussed in the present
Fig. 19. Weighted mean Difference (95% CI) of CAL gain between FMD and FMSRP, paper was performed through the
stratified based on single- and multi-rooted teeth. p-value for heterogeneity: 0.575I2: 0% (SD Cochrane Collaboration Oral Health
not imputed studies); 0.753I2 0% (SD imputed studies). Group. In this systematic review, no
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
20 Lang et al.

FMD vs FMSRP review are identified with numericals

in brackets.
Mean CAL Apatzidou, D. A. & Kinane, D. F. (2004a)
Study ID Difference (95% CI) Quadrant root planing versus same-day full-
mouth root planing. Journal of Clinical
Periodontology 31, 152–159.
deep
Apatzidou, D. A. & Kinane, D. F. (2004b)
Koshy, 2005 –0.74 (–1.31, –0.17) Quadrant root planing versus same-day full-
Koshy, 2005 –0.56 (–1.49, 0.37) mouth root planning. I. Clinical findings.
Quirynen, 2000 –0.30 (–1.23, 0.63) Journal of Clinical Periodontology 31,
Quirynen, 2000 –0.30 (–1.23, 0.63) 132–140. (3).
Apatzidou, D. A., Riggio, M. P. & Kinane, D. F.
Quirynen, 2006 0.40 (–0.46, 1.26)
(2004) Quadrant root planing versus same-day
Subtotal –0.39 (–0.75, –0.04) full-mouth root planning. II. Microbiological
findings. Journal of Clinical Periodontology
moderate 31, 141–148. (9).
Koshy, 2005 –0.08 (–0.56, 0.40) Bollen, C. M., Vandekerckhove, B. N.,
Papaioannou, W., Van Eldere, J. & Quirynen,
Koshy, 2005 –0.25 (–0.66, 0.16)
M. (1996) Full- versus partial-mouth disinfec-
Quirynen, 2000 –0.50 (–1.43, 0.43) tion in the treatment of periodontal infections.
Quirynen, 2000 –0.50 (–1.43, 0.43) A pilot study: long-term microbiological
Quirynen, 2006 0.25 (–0.61, 1.11) observations. Journal of Clinical Perio-
Subtotal –0.19 (–0.46, 0.08) dontology 23, 960–970. (6).
Brecx, M. (1997) Strategies and agents in
supragingival chemical plaque control.
Overall –0.26 (–0.48, –0.05) Periodontology 2000 15, 100–108.
De Soete, M., Mongardini, C., Pauwels, M.,
Haffajee, A., Socransky, S., van Steenberghe,
–0.5 0 0.5 1 D. & Quirynen, M. (2001) One-stage full-
favours FMSRP favours FMD mouth disinfection. Long-term microbiological
results analyzed by checkerboard DNA–DNA
Fig. 20. Weighted mean Difference (95% CI) of CAL gain between FMD and FMSRP, hybridization. Journal of Periodontology 72,
stratified based on moderate (5–6 mm) and deep (X7 mm) pockets. p-value for heterogeneity: 374–382. (8).
0.296I2: 18.7% (SD not imputed studies); 0.708I2 0% (SD imputed studies). Eberhard, J., Jervøe- Storm, P.-M., Needleman,
I., Worthington, H. & Jepsen, S. (2008) Full-
mouth treatment concepts for chronic perio-
significant differences between FMSRP in the light of the documented changes dontitis. A systematic review. The Cochtane
and CSD for DPPD were reported. Only of 1–2 mm for the cause-related phase of Library 1, (http://www.thecochranelibrary.
minor differences in CAL gain were periodontal therapy. Hence, all three com).
demonstrated for FMD when compared treatment approaches may, without any Follmann, D., Elliott, P., Suh, I. & Culer, J.
(1992) Variance imputation for overviews of
with CSD in single-rooted moderately preference, be recommended for debri-
clinical trials with continuous response. Jour-
deep pockets (5–6 mm). More CAL gain dement in the cause-related phase of nal of Clinical Epidemiology 45, 768–773.
was revealed for FMSRP than for FMD periodontal therapy in patients with Fourmousis, I., Tonetti, M. S., Mombelli, A.,
in deep multi-rooted teeth. Slightly chronic periodontitis. No conclusions Lehmann, B., Lang, N. P. & Brägger, U.
more BOP% reductions were found for could be made about the different (1998) Evaluation of tetracycline fiber ther-
FMD than for FMSRP, in moderate microbiological outcomes reported, apy with digital image analysis. Journal of
pockets of single-rooted teeth. The mainly due to the differences in the Clinical Periodontology 25, 737–745.
authors concluded no advantages of microbiological techniques utilized. Glavind, L. (1990) Means and methods in oral
FMSRP against CSD. Furthermore, hygiene instruction of adults. A review. Tan-
very limited evidence for little addi- dlægebladet 94, 213–246.
Jervøe-Storm, P. M., Al Ahdab, H., Semaan, E.,
tional benefits of FMD in comparison Acknowledgements
Fimmers, R. & Jepsen, S. (2007) Micro-
with CSD were stated and, hence, This systematic review was supported biological outcomes of quadrant versus full-
FMSRP as well as CSD may be con- by the Clinical Research Foundation mouth root planing as monitored by real-time
sidered as evidence-based treatment var- (CRF) for the Promotion of Oral Health, PCR. Journal of Clinical Periodontology 34,
iations for chronic periodontitis patients. University of Berne, Switzerland. Dr. 156–163. (10).
In conclusion and in agreement with Tan Wah Ching was the recipient of Jervøe-Storm, P. M., Koltzscher, M., Falk, W.,
the recently performed systematic an ITI Scholarship 2006–2007. The Dörfler, A. & Jepsen, S. (2005) Comparison
review (Eberhard et al. 2008), FMD or of culture and real-time PCR for detection
authors would like to acknowledge the and quantification of five putative period-
FMSRP do not provide clinically rele- premature access to the publication of
vant advantages over the conventional ontopathogenic bacteria in subgingival pla-
the Cochrane Collaboration Oral Health que samples. Journal of Clinical
quadrant-wise staged debridement. Group (Eberhard et al. 2008). Periodontology 32, 778–783.
Although statistically significant differ- Jervøe-Storm, P. M., Semaan, E., Al Ahdab, H.,
ences between FMD and CSD as well as Engel, S., Fimmers, R. & Jepsen, S. (2006)
between FMSRP and CSD were found References
Clinical outcomes of quadrant root planing
for some PPD reductions and CAL Publications considered for inclusion versus full-mouth root planing. Journal of
gains, they were inconsistent and small in or exclusion from this systematic Clinical Periodontology 33, 209–215. (17).
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
 Full-mouth disinfection versus staged debridement 21

Katsoulis, J., Heitz-Mayfield, L., Weibel, M., Quirynen, M., Bollen, C. M., Vandekerckhove, planing as an initial approach in the treatment
Hirschi, R., Lang, N. P. & Persson, G. R. B. N., Dekeyser, C., Papaioannou, W. & of chronic periodontitis. Journal of Clinical
(2005a) Impact of sample storage on the Eyssen, H. (1995) Full- vs. partial-mouth Periodontology 32, 851–859. (13).
detection of periodontal bacteria. Journal of disinfection in the treatment of periodontal
Oral Microbiology and Immunology 20, infections: short-term clinical and microbio-
128–130. logical observations. Journal of Dental
Katsoulis, J., Lang, N. P. & Persson, G. R. Research 74, 1459–1467.
Excluded articles
(2005b) Proportional distribution of the red Quirynen, M., Mongardini, C., Pauwels, M.,
complex and its individual pathogens after Bollen, C. M., Van Eldere, J. & van Steen- Bollen, C. M., Mongardini, C., Papaioannou,
sample storage using the checkerboard DNA– berghe, D. (1999) One stage full- versus W., Van Steenberghe, D. & Quirynen, M.
DNA hybridisation technique. Journal of partial-mouth disinfection in the treatment (1998) The effect of a one-stage full-mouth
Clinical Periodontology 32, 628–633. of chronic adult or generalized early-onset disinfection on different intra-oral niches.
Koshy, G., Kawashima, Y., Kiji, M., Nitta, H., periodontitis. II. Long-term impact on micro- Clinical and microbiological observations.
Umeda, M., Nagasawa, T. & Ishikawa, I. bial load. Journal of Periodontology 70, Journal of Clinical Periodontology 25, 56–
(2005) Effects of single-visit full-mouth 646–656. (7). 66. (11) Exclusion criteria: Follow-up
ultrasonic debridement versus quadrant-wise Quirynen, M., Mongardini, C., de Soete, M., timeo6 months.
ultrasonic debridement. Journal of Clinical Pauwels, M., Coucke, W., van Eldere, J. & Gomi, K., Yashima, A., Nagano, T., Kanazashi,
Periodontology 32, 734–743. (16). van Steenberghe, D. (2000) The role of M., Maeda, N. & Arai, T. (2007) Effects of
Lang, N. P., Nyman, S., Senn, C. & Joss, A. chlorhexidine in the one-stage full-mouth full-mouth scaling and root planing in con-
(1991) Bleeding on probing as it relates to disinfection treatment of patients with junction with systemically administered azi-
probing pressure and gingival health. Journal advanced adult periodontitis. Long-term clin- thromycin. Journal of Periodontology 78,
of Clinical Periodontology 18, 257–261. ical and microbiological observations. Jour- 422–429. (5) Exclusion criteria: Not on
Löe, H. & Schiøtt, C. R. (1970) The effect of nal of Clinical Periodontology 27, 578–589. FMD.
mouthrinses and topical application of chlor- (12). Mongardini, C., van Steenberghe, D., Dekeyser,
hexidine on the development of dental plaque Quirynen, M., De Soete, M., Boschmans, G., C. & Quirynen, M. (1999) One stage full-
and gingivitis in man. Journal of Periodontal Pauwels, M., Coucke, W., Teughels, W. & versus partial-mouth disinfection in the treat-
Research 5, 79–83. van Steenberghe, D. (2006) Benefit of ‘‘one- ment of chronic adult or generalized early-onset
Mombelli, A., Lehmann, B., Tonetti, M. & stage full-mouth disinfection’’ is explained periodontitis. I. Long-term clinical obser-
Lang, N. P. (1997) Clinical response to local by disinfection and root planing within 24 vations. Journal of Periodontology 70, 632–
delivery of tetracycline in relation to overall hours: a randomized controlled trial. Journal 645. (2) Exclusion criteria: Multiple publica-
and local periodontal conditions. Journal of of Clinical Periodontology 33, 639–647. (4). tions.
Clinical Periodontology 24, 470–477. Söderholm, G. & Egelberg, J. (1982) Teaching Tomasi, C., Bertelle, A., Dellasega, E. & Wenn-
Mombelli, A., Minder, C. E., Gusberti, F. A. & plaque control. II. 30-minute versus 15-min- strom, J. L. (2006) Full-mouth ultrasonic
Lang, N. P. (1989) Reproducibility of micro- ute appointments in a three-visit program. debridement and risk of disease recurrence:
scopic and cultural data in repeated subgin- Journal of Clinical Periodontology 9, a 1-year follow-up. Journal of Clinical Perio-
gival plaque samples. Journal of Clinical 214–222. dontology 33, 626–631. (14) Exclusion cri-
Periodontology 16, 434–442. Söderholm, G., Nobréus, N., Attström, R. & teria: Multiple publications.
Mombelli, A., Tonetti, M., Lehmann, B. & Egelberg, J. (1982) Teaching plaque control. Tomasi, C., Leyland, A. H. & Wennström, J. L.
Lang, N. P. (1996) Topographic distribution I. A five-visit versus a two-visit program. (2007) Factors influencing the outcome of
of black-pigmenting anaerobes before and Journal of Clinical Periodontology 9, non-surgical periodontal treatment: a multi-
after periodontal treatment by local delivery 203–213. level approach. Journal of Clinical Perio-
of tetracycline. Journal of Clinical Perio- Vandekerckhove, B. N., Bollen, C. M., Dekey- dontology 34, 682–690. (15) Exclusion
dontology 23, 906–913. ser, C., Darius, P. & Quirynen, M. (1996) criteria: Not on outcomes of therapy.
Morrison, E. C., Ramfjord, S. P. & Hill, R. W. Full- versus partial-mouth disinfection in the
(1980) Short-term effects of initial, nonsurgi- treatment of periodontal infections. Long-
cal periodontal treatment (hygienic phase). term clinical observations of a pilot study.
Journal of Clinical Periodontology 7, Journal of Periodontology 67, 1251–1259.
199–211. (1).
Pihlstrom, B. L., McHugh, R. B., Oliphant, T. Wennström, J. L. (1992) Subgingival irrigation Address:
H. & Ortiz-Campos, C. (1983) Comparison systems for the control of oral infections. Niklaus P. Lang
of surgical and nonsurgical treatment of International Dental Journal 42 (Suppl. 1), University of Hong Kong
periodontal disease. A review of current 281–285. Prince Philip Dental Hospital
studies and additional results after 61/2 years. Wennström, J. L., Tomasi, C., Bertelle, A. & 34 Hospital Road
Journal of Clinical Periodontology 10, Dellasega, E. (2005) Full-mouth ultrasonic Hong Kong SAR
524–541. debridement versus quadrant scaling and root E-mail: nplang@dial.eunet.ch

Clinical Relevance in clinical outcomes (PPD, BOP, tional benefits of FMD are of such a
Scientific rationale for the study: and CAL) between the debridement small magnitude that all three proto-
FMD propagated during the last dec- protocols or favoured FMD slightly . cols of FMD, FMSRP and CSD can
ade was evaluated in a systematic Practical implications: Because the be recommended for the initial phase
review against CSD. Also, FMSRP most significant effect in PPD and of periodontal therapy.
was compared with FMD and CSD. BOP reductions and CAL gains is
Principle findings: The meta-ana- attributable to systematic debride-
lyses yielded either no differences ment per se (1.0–2.2 mm), the addi-

r 2008 The Authors

Journal compilation r 2008 Blackwell Munksgaard