Management of periodontitis by three different approaches to non-surgical periodontal debridement – A randamized comparative clinical study

Management of periodontitis by three different approaches to non-surgical periodontal debridement – A randamized comparative clinical study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Management of periodontitis by three different approaches to non-surgical periodontal debridement – A randamized comparative clinical study Kodikara Mudiyanselage Chathurika Padmakumari, Uthpala Muhandiramge Gunasekara, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6712357/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Jul, 2025 Read the published version in BMC Oral Health → Version 1 posted 11 You are reading this latest preprint version Abstract Background Non-surgical periodontal therapy (NSPT) is the cornerstone of periodontitis management. This comparative clinical study evaluates the effectiveness of three different non-surgical treatment approaches in three treatment groups namely, Quadrant-wise Scaling and Root Surface Debridement (Q-Sc + RSD), Full-mouth Disinfection (FMDis) and Full-mouth Debridement (FMDeb). Methods A total of 45 patients with generalised periodontitis were randomly assigned to one of the three treatment groups. Plaque scores (PS), bleeding scores (BS) and probing pocket depths (PD) were recorded at baseline and post-NSPT. Data was analysed to compare the changes in BS and PD distribution at baseline and post-NSPT, in all three groups. Results All three treatment approaches resulted in statistically significant reductions in BS and PD distribution compared to baseline. However, FMDeb and FMDis protocols demonstrated greater reductions in BS and PD distribution compared to the Q-Sc + RSD protocol. Remarkably low BS were observed in all three study groups at the post-treatment evaluation, with statistically significant differences, compared to their respective pre-treatment BS. Conclusions All three treatment approaches were effective in reducing BS and PD in patients with periodontitis, while FMDeb and FMDis protocols demonstrated superior effectiveness in terms of reduction of BS and PD, compared to Q-Sc + RSD protocol. Further research with larger sample sizes and longer follow-up periods may be warranted to confirm these findings and evaluate the long-term clinical outcomes of these different debridement approaches of NSPT. Clinical Trial No: The UK’s Clinical Study Registry ISRCTN13350022, 28/05/2025, retrospectively registered Periodontitis Nonsurgical treatment Root-surface debridement Full-mouth Disinfection Full-mouth Debridement Quadrant-wise Scaling and Root Surface Debridement Bleeding Scores Pocket depth Clinical outcomes Effectiveness Figures Figure 1 Background Periodontitis is a chronic inflammatory disease that affects the supporting tissues of the teeth, leading to destruction of periodontal attachment and bone. The primary cause of periodontitis is microbial plaque in the dental/oral biofilm. Periodontitis, if untreated, can result in severe tooth mobility with eventual tooth loss. The rate of periodontal tissue destruction depends on the balance maintained by the microbial virulence factors and the host immune-inflammatory responses which elicit both destructive and protective components. Moreover, several modifiable and non-modifiable risk factors are associated with periodontitis progression. These include smoking, diabetes, obesity, hypertension, stressful lifestyles, socio-economic factors, and genetic predispositions 16 . According to the WHO global oral health status report, the estimated global prevalence of severe periodontal disease in 2019 was approximately 19% among individuals aged over 15 years, representing more than 1 billion cases worldwide. This reflects a 23.96% increase in the prevalence from 1990 to 2019, highlighting severe periodontal disease as a major public health issue 31 . In Sri Lanka, the situation is particularly concerning, with 25.3% of individuals in the 35-44-year age cohort exhibiting periodontal pockets greater than 4 mm 20 . The high prevalence of severe periodontal disease emphasizes the urgent need for effective management and preventive strategies in addressing this public health issue, both globally and locally. Periodontal disease, particularly periodontitis, significantly affects the quality of life of individuals. Patients with chronic periodontitis report poorer oral health-related quality of life compared to age- and gender-matched individuals without the disease, since they seem to experience functional, social, and psychological challenges such as halitosis, pain, and poor aesthetics 6 . Additionally, studies have linked periodontal disease to serious health complications, including atherosclerosis, cardiovascular disease, diabetes, and preterm low birthweight deliveries 8 . Therefore, effective preventive care and early interventions against periodontitis would invariably result in improvements in oral health outcomes and overall well-being of the affected populations. For the past many years, non-surgical periodontal treatment (NSPT) has proven to be effective in managing patients with periodontitis. NSPT is beneficial in reducing the probing pocket depths and bleeding scores in moderate and deep periodontal pockets, as well as in gaining clinical attachment levels 8 , 10 , 11 , 26 . However, the non-surgical debridement component of the NSPT can be delivered through three approaches. These are conventional quadrant-wise scaling (Sc) and root surface debridement (RSD) [Q-Sc + RSD], full mouth debridement [FMDeb] and full mouth disinfection [FMDis]. All these three mechanical non-surgical debridement approaches have been accepted as effective in the management of patients with periodontitis 26 . Conventionally, Q-Sc + RSD is performed in a quadrant-wise manner, with an interval of 1–2 weeks between the debridement of each quadrant. This method uses periodontal curettes to clean the periodontal pockets and root surfaces, typically taking 4–6 weeks or more to complete debridement of the entire mouth 15 . Numerous clinical and microbiological studies have confirmed the effectiveness of this conventional quadrant-wise debridement protocol in reducing the bacterial load and improving the clinical outcomes 3 , 10 , 11 , 14 , 19 . However, some research evidence points out the fact that the 1–2-week interval between quadrant debridement may allow recolonization of the instrumented pockets from non-instrumented pockets 15 , potentially impairing healing and pocket closure. To address this issue, the other two alternative approaches (FMDeb and FMDis) have been proposed. FMDeb involves prompt debridement of all quadrants within two consecutive days, aiming to reduce the risk of bacterial recolonization of the instrumented pockets from those non-instrumented. Similarly, FMDis entails rapid-paced RSD within two consecutive days to complete all pockets in the mouth but includes using chlorhexidine gluconate following RSD. Using chlorhexidine is expected to eliminate periodontal pathogens from other potentially infected sites in the oral cavity, such as the dorsum of the tongue, buccal mucosa, palate, and tonsils 15 . Some randomized control trials have found no significant difference in the clinical outcomes between the three different methods, Q-Sc + RSD, FMDeb or FMDis 8 , 17 . As opposed to this finding, other studies have reported significant improvements in both clinical and microbiological outcomes, when full mouth protocols were used 25 , 18 . As suggested in the recent EFP S3 level clinical practice guidelines, periodontal therapy for management of stage I-III periodontitis, consists of four steps. Step 1 involves ‘building foundations for optimal treatment outcomes’ where oral health education and preventive interventions are performed to achieve optimal plaque control by the patient and reducing gingival inflammation through professional mechanical plaque removal (PMPR). Elimination of local retentive factors and control of risk factors are also important components in step 1 therapy. The second step, known as cause-related therapy, focuses on the reduction of the subgingival biofilm and calculus, which encompasses non-surgical approaches aimed at accessing root surfaces or the subgingival locations. The guidelines indicate that subgingival periodontal instrumentation can be executed using either conventional quadrant-wise debridement or full-mouth delivery methods within a 24-hour timeframe. Step 2 therapy also involves use of adjunctives to mechanical therapy, which includes chlorhexidine antiseptic. Use of such adjunctives in step 2 therapy is at the discretion of the clinician. The step 3 of periodontal therapy involves periodontal re-evaluation and managing non-responding deep periodontal pockets either by repeating step 2 therapy, or by obtaining surgical access. Step 4 therapy is supportive periodontal care (SPC) offered to a patient who has adequately responded to achieve a stable periodontal condition following treatment. In routine clinical practice, the choice of non-surgical debridement method in step 2 therapy (among Q-Sc + RSD/FMDeb/FMDis) is often based on the clinical justification and preference of the individual clinician in concurrence with the patient. To the best of our knowledge, a systematic comparison of clinical outcomes of each method, along with a thorough analysis of their advantages and limitations, has not yet been reported. Against this backdrop, the main objective of this study was to compare the effectiveness of the three different periodontal debridement methods (Q-Sc + RSD, FMDeb and FMDis), in treating patients diagnosed with stage II and III periodontitis (AAP & EFP classification, 2017). The specific objectives of this study were to compare the probing pocket depths (PD) and bleeding scores (BS) of patients, before and after non-surgical periodontal debridement under three different debridement protocols (Q-Sc + RSD, FMDeb and FMDis). Methods Selection of study sample This randomized comparative clinical study was conducted in the Division of Periodontology, Faculty of Dental Sciences (FDS), University of Peradeniya (UOP), Sri Lanka. Adult patients who were newly diagnosed with generalized stage II and III periodontitis who conformed to the inclusion criteria of the study were included in the study. This study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki. Ethics Approval was obtained from the Ethics Review Committee of FDS-UOP (number: FRC/FDS/UOP/I/2021/05) and retrospectively registered in the UK’s Clinical Study Registry ISRCTN13350022. This clinical trial followed the CONSORT guidelines 2025 (Fig. 1 ). Informed consent was secured from all participants prior to their involvement in the research. Sample size estimation As guided by the previous literature 25 , preliminary sample size estimation revealed that the required number of patients is 36, (12 patients in one treatment group) at partial eta squared = 0.25, alpha = 0.05, beta = 0.8 with a moderate correlation between repeated measures. This estimation was done to test the hypothesis in a factorial repeated measures model. However, a more specific re-estimation of the sample size was made with our own preliminary data after 6 months from the start of patient recruitment. Accordingly, sample size was increased up to 45 (15 patients per one treatment group). Inclusion criteria The inclusion criteria were, those aged ≥ 35 years diagnosed with generalized stage II and III periodontitis, with at least three (03) treatable quadrants in the mouth requiring RSD, with a minimum of four (04) teeth in any quadrant with deep pockets. Only those patients who consented to undergo treatment according to a random assignment into any of the three methods of periodontal debridement were included. Exclusion criteria The exclusion criteria were, those who had underlying systemic conditions (uncontrolled diabetes mellitus, leukemia/haematological disorders, pregnancy, and medication-induced gingival overgrowth), and those who were current or previous smokers. The patients who had undergone periodontal treatment within the preceding 6 months, and those who were on systemic antibiotics within the last 3 months were also excluded. Additionally, those who had used oral chlorhexidine preparations or other disinfectants within the previous month were excluded from the study. Study participant recruitment and randomization All patients who fulfilled the inclusion criteria of the study underwent written informed consent process, after reading the ‘patient information sheet’, followed by clarification of queries by the patients. The patients were randomized into one of the study groups, namely (Q-Sc + RSD) or (FMDeb) or (FMDis) by using a block randomization method to generate treatment groups of equal size. Randomization and allocation of patients was done by another person who was not involved in examining or treating the patients. This allocation concealment was done in order to eliminate sampling bias where the principal investigator (PI) treated all the patients in the treatment groups. After assignment to interventions, both patients and outcome assessors were blinded to the treatment allocations, minimizing bias in the assessment of results. The patients underwent detailed periodontal assessments (pocket charting and radiological evaluation with a dental panoramic tomogram/DPT). After confirming the periodontal diagnosis, they were arranged with appointments by the same person who performed randomization, to commence periodontal treatment by the PI of the study. Periodontal assessments All patients were examined for plaque score (PLS, %), bleeding score (BS, %), and probing pocket depths (PD). The parameters were recorded in plaque charts and six-point pocket charts. Prior to these periodontal assessments of patients in the study proper, intra-examiner calibration was performed on six other periodontitis patients to verify agreement within the PI for PD measurements. Plaque (disclosed with disclosing solution) was dichotomously scored as present or absent, and full mouth plaque score was obtained. Full mouth bleeding score was also obtained dichotomously, as present or absent upon probing. Probing pocket depths were measured in millimetres, by using a William’s periodontal probe at six sites of each tooth. Probing depths of 4 mm or greater with bleeding on probing were classified as deep pockets needing root surface debridement. This is in accordance with the current recommendations for achieving endpoints of non-surgical periodontal therapy 26 . The percentage of deep pocket distribution was obtained by dividing the total number of deep pockets (≥ 4 mm with bleeding), by the total number of tooth sites in the mouth. Once the clinical measurements were completed, radiographic evaluation with DPT was carried out to confirm the detailed periodontal diagnosis as stage II or stage III periodontitis. Treatment All patients underwent standard hygiene phase care of initial periodontal therapy (step 1 of EFP S3 guidelines, 2020) which included plaque disclosing, meticulous plaque control advice with oral hygiene instructions (OHI), followed by PMPR and removing plaque retentive factors. Guidance on mechanical plaque removal (toothbrushing instructions and interdental cleaning) was provided to all patients, according to the individual plaque control needs. Plaque control was monitored and reinforced at the subsequent treatment visits for all patients, by the same investigator who treated patients. Except for the fact that different treatment groups received three different periodontal debridement protocols, all patients received standard NSPT, with individually tailored OHI. This was to fulfill the objective of achieving optimal plaque control at the step 1 of periodontal therapy, in optimizing a successful treatment outcome. Three different periodontal debridement protocols for three treatment groups were as follows. i. Study Group 1 (SG1): Quadrant-wise Sc + RSD group (Q-Sc + RSD) Each patient was treated with scaling and RSD, quadrant by quadrant, starting from the upper right jaw and proceeding clockwise over four sessions at weekly intervals. All patients received standard post-operative instructions and placebo mouth rinsing (described below) for 2 weeks. ii. Study Group 2 (SG2): Full Mouth Debridement group (FMDeb) Each patient was treated with scaling and RSD in two visits, arranged on two consecutive days (within 24 hours from one another). Debridement of right maxillary and mandibular quadrants were done on the first visit, followed by the left quadrants at the second visit. All patients received standard post-operative instructions and placebo mouth rinsing (described below) for 2 weeks. iii. Study Group 3 (SG3): Full Mouth Disinfection group (FMDis) Similar to FMDeb group, each patient received scaling and RSD in two visits, within 24 hours on two consecutive days. Debridement of right maxillary and mandibular quadrants were done on the first visit, followed by the left quadrants at the second visit. Patients were advised to brush the tongue with 1% chlorhexidine gel for one minute. Additionally, the pockets were irrigated with 0.2% chlorhexidine gluconate (CHX) at the end of each RSD session, according to the disinfection step recommended in the FMDis protocol (irrigation with a syringe, 3 times for 10 minutes). As the next step, the patients were instructed to use 0.2% CHX mouthwash at home (10 ml, twice daily for 1 minute, over 2 weeks 22 . All patients received standard post-operative instructions and specific instructions regarding the use of chlorhexidine mouthwash at home. Since FMDis protocol (SG3) required therapeutic mouth rinsing with CHX, the patients in SG1 and SG2 were also instructed to perform placebo mouth rinsing at home (with warm water) in a similar manner over a period of 2 weeks. This was done with the intention of standardization across all three treatment groups. Method of subgingival instrumentation (debridement) As the step 2 treatment, scaling and RSD were performed under local anaesthesia (2% lidocaine with adrenaline 1:80,000) using periodontal curettes (Gracey) supplemented with ultrasonic scaling. All correctable local plaque-retentive factors such as overhanging/defective restorations, untreated caries, and retained roots, were removed at the quadrant-debridement session or at step 1 level. The patients were instructed to report any adverse events such as fever, feeling of being ill or any other discomfort, to the contact person through the contact numbers provided to them at the recruitment stage. This method ensured systematic monitoring of potential adverse effects throughout the study, allowing for timely intervention if necessary. Following the above treatment sessions for all patients in the three treatment groups, they were recalled every two weeks for oral hygiene assessment and reinforcement of OHI. Oral prophylaxis (PMPR) was also performed supra-gingivally. Plaque scores were obtained at every review visit for monitoring purpose. Eight weeks following completion of treatment, all patients underwent a full-mouth periodontal re-evaluation. These post-treatment measurements were tabulated, to compare them with the pre-treatment probing pocket depths, bleeding scores, and plaque scores. All patients continued to receive periodontal care/supportive periodontal therapy according to the identified periodontal care needs following re-evaluation. Data analysis Statistical analysis was performed using SPSS version 26. Normal distribution of periodontal parameters (bleeding score & deep pocket distribution) was assessed using skewness and kurtosis values. All periodontal parameters were distributed within the skewness of – 2 to + 2 while the kurtosis values were within + 7 to -7. Therefore, all periodontal parameters were considered as normally distributed. Results 1. Demographic profile of the study sample Table 1 Demographics of the study sample Treatment Group (n = number) Mean age (yrs) Lowest Age (yrs) Highest Age (yrs) Male (n) Female (n) SG1: Q-Sc + RSD (n = 15) 50.66 36 68 6 9 SG2: FMDeb (n = 15) 50.26 35 68 6 9 SG3: FMDis (n = 15) 48.33 35 86 8 7 Total (n = 45) 49.76 35 86 20 25 According to Table 1 , the total study sample consisted of 45 patients, with 25 females and 20 males. The mean age of SG1 and SG2 was almost similar (50 yrs), while the same for SG3 varied slightly (48.33 yrs). The age ranges of three treatment groups are also comparable for SG1 and SG2 (36–68 yrs & 35–68 yrs respectively). When compared with SG1 and SG2, the age range of SG3 appeared to be wider (35–86 yrs). Yet, it was due to the inclusion of only one patient who was 86 years old in SG3. It is envisaged that, a single outlier may not have significantly affected the homogeneity of the three groups, in terms of their age. Thus, the overall demographic profile of the three treatment groups was considered as comparable without significant variation in terms of sample number, age range and gender of participants. 2. Treatment outcome of three treatment groups 2.1 Treatment outcome associated with deep pocket distribution 2.1.1 Comparison of deep pocket distribution before and after NSPT Table 2.1 .1 Comparison of mean deep pocket distribution of three treatment groups before and after NSPT Treatment groups ≥ 4mm Deep pocket distribution (%) (mean)- Pre-treatment ≥ 4mm Deep pocket distribution (%) (mean)– Post-treatment, at re-evaluation Statistical test- Dependent sample t test (Significance level < 0.05*) 1.Q-wise-Sc + RSD (Standard) [n = 15] 37.30 18.03 0.000* 2. FMDeb [n = 15] 28.54 7.14 0.001* 3. FMDis [n = 15] 36.30 3.05 0.000* *At pre-treatment, the deep pocket distribution between the three groups was not significant statistically. Table 2.1 .1 compares the mean deep pocket distribution of the three study groups at pre-treatment and post-treatment, at re-evaluation stage. Accordingly, all three treatment groups revealed highly significant reductions in the mean percentage of pocket distribution, as tested by dependent sample t-test. Evidently, SG1 (Q-Sc + RSD), which had a mean deep pocket distribution of 37.3% at pre-treatment, was significantly reduced to 18% at post-treatment (p = 0.000). As for SG2 (FMDeb), the mean pre-treatment deep pocket distribution was 28.5%, which was reduced to 7.1% post-treatment (p = 0.001). Similarly, SG3 (FMDis) revealed the pre-treatment deep pocket distribution to be 36.3%, which was reduced to 3% post-treatment (p = 0.000). These findings imply that all three treatment approaches were effective in reducing deep pockets to a significant level. 2.1.2 Comparison of mean deep pocket distribution among three treatment groups at post-treatment Table 2.1 .2 Comparison of mean deep pocket distribution of 3 groups at post-treatment Comparison Between group comparisons with the ‘Standard’ (Q-Sc + RSD) Post-treatment mean deep pocket distribution (%) Statistical test- Independent sample t test (Significance level < 0.05*) (Q-Sc + RSD) Vs FMDeb SG1: (Q-Sc + RSD) 18.03 0.002* SG2: FMDeb 7.14 (Q-Sc + RSD) Vs FMDis SG1: (Q-Sc + RSD) 18.03 0.000* SG3: FMDis 3.05 As illustrated in Table 2.1 .2, a comparison is made between the post-treatment deep pocket distribution following FMDeb and FMDis protocols with the ‘Standard’ (Q-Sc + RSD). Accordingly, the reduction of post-treatment deep pocket distribution of FMDeb group (7%) was highly significant (p = 0.002) when compared with the post-treatment deep pocket distribution of Q-Sc + RSD group (18%). Similarly, a highly significant reduction (p = 0.000) of deep pocket distribution was seen in FMDis group (3%) when compared with the same for Q-Sc + RSD group (18%). While these findings may imply that both FMDeb and FMDis approaches are highly successful in achieving post-treatment pocket depth reductions, the comparison is more realistic between the FMDis Vs Q-Sc + RSD, since the pre-treatment mean deep pocket distributions in both groups were very close (36.3% Vs 37.3% respectively, Table 2.1 .1). 2.2 Treatment outcome associated with bleeding scores 2.2.1 Comparison of bleeding scores (BS) before and after treatment Table 2.2 .1 Comparison of bleeding scores (BS%) of 3 study groups at pre- and post-treatment Treatment groups Mean BS (%)- Pre-Treatment Mean BS (%)- Post-treatment, at re-evaluation Statistical test- Dependent sample t test (Significance level < 0.05*) SG1:Q-Sc + RSD [n = 15] 66.91 29.52 0.000* SG2: FMDeb [n = 15] 52.81 18.59 0.000* SG3: FMDis [n = 15] 57.88 9.02 0.000* *At pre-treatment, the mean BS (%) among the three groups was not significant statistically. Table 2.2 .1 illustrates the comparison of mean bleeding scores (BS) of the three study groups at pre-treatment and post-treatment. Accordingly, all three treatment groups revealed highly significant reductions in mean bleeding scores, as tested by dependent sample t-test. Evidently, the mean BS of SG1 (Q-Sc + RSD) at pre-treatment was 66.9%, which was significantly reduced to 29.5% at post-treatment (p = 0.000). As for SG2 (FMDeb), the mean pre-treatment BS was 52.8%, which was reduced to 18.6% post-treatment (p = 0.000). Similarly, SG3 (FMDis) revealed the pre-treatment BS to be 57.9%, and it was reduced to 9% at post-treatment (p = 0.000). Accordingly, all three treatment groups demonstrated highly significant improvements in bleeding scores following treatment. 2.2.2 Comparison of mean bleeding scores (BS%) among three treatment groups at post-treatment Table 2.2 .2 Comparison of bleeding scores of 3 groups at post-treatment Comparison Between group comparisons of post-treatment BS (%) with the ‘Standard’ Post-treatment, at re-evaluation (BS %) Statistical test Significance Independent sample t-test (Significance level < 0.05) (Q-Sc + RSD) Vs FMDeb SG1: Q-Sc + RSD 29.52 0.042 SG2: FMDeb 18.59 (Q-Sc + RSD) Vs FMDis SG1: Q-Sc + RSD 29.52 0.000 SG3: FMDis 9.02 A comparison of post-treatment bleeding scores following FMDeb approach and FMDis approach with the ‘Standard’ (Q-Sc + RSD) is depicted in Table 2.2 .2. Accordingly, the reduction in post-treatment BS, of FMDeb group (18.6%) was statistically significant (p = 0.042), when compared with the post-treatment BS of Q-Sc + RSD group (29.5%). Similarly, a highly significant reduction (p = 0.000) in post-treatment BS was seen in FMDis group (9%) when compared with the same for Q-Sc + RSD group (29.5%). While this finding may suggest that both FMDeb and FMDis approaches are highly effective in achieving post-treatment improvements in BS, SG3 (FMDis) appeared to reveal the greatest reduction of BS (9%), despite having a higher pre-treatment BS of 57.9%, compared to SG2 (FMDeb), which was 52.8%. However, as depicted in Table 2.2 .1, the pre-treatment mean bleeding scores among the three groups were not significant statistically. 2.3 Comparison of plaque scores before and after treatment Table 2.3 .1 Comparison of plaque scores (PS%) of 3 study groups at pre- and post-treatment Treatment groups Mean PS (%)- Pre-treatment Mean PS (%)-Post-treatment, at re-evaluation Statistical test-Dependent sample t test (Significance level < 0.05*) SG1:Q-Sc + RSD [n = 15] 84.93 24.20 0.000* SG2:FMDeb [n = 15] 76.61 23.60 0.000* SG3:FMDis [n = 15] 74.67 21.62 0.000* *At pre-treatment, the mean PS (%) among the three groups were not significant statistically Table 2.3 .1 compares the mean plaque scores (PS) of the three study groups at pre-treatment and post-treatment. All three treatment groups revealed highly significant reductions in mean plaque scores, as tested by dependent sample t-test. As evident, the mean PS of SG1 (Q-Sc + RSD) at pre-treatment was about 84.9%, which was significantly reduced to 24.2% at post-treatment (p = 0.000). As for SG2 (FMDeb), the mean pre-treatment PS of 76.6%, was reduced to 23.6% at post-treatment (p = 0.000). Similarly, SG3 (FMDis) showed the pre-treatment PS to be 74.7%, and it was reduced to 21.6% post-treatment (p = 0.000). Accordingly, all three treatment groups demonstrated highly significant reductions in plaque scores following treatment, denoting successful plaque control achievement by patients following treatment. Moreover, the post-treatment plaque scores among the three different treatment groups were closely comparable. 2.3.2 Comparison of mean plaque scores (PS%) among three treatment groups at post-treatment Table 2.3 .2 Comparison of plaque scores of 3 study groups at post-treatment Comparison Comparison of post-treatment PS (%) with the ‘Standard’ Post-treatment, at re-evaluation (PS %) Statistical test-Independent sample t-test (Significance level < 0.05) (Q-Sc + RSD) Vs FMDeb SG1: Q-Sc + RSD 24.20 1.0 SG2: FMDeb 23.60 (Q-Sc + RSD) Vs FMDis SG1: Q-Sc + RSD 24.20 1.0 SG3: FMDis 21.62 A comparison of post-treatment plaque scores following FMDeb approach and FMDis approach with the ‘Standard’(Q-Sc + RSD) is depicted in Table 2.3 .2. As evident, the reduced plaque scores between Q-Sc + RSD group Vs FMDeb group at post-treatment were not significant statistically (24.2% Vs 23.6%, p = 1). Similarly, the reduced plaque scores between Q-Sc + RSD group Vs FMDis group at post-treatment were not significant statistically (24.2% Vs 21.6%, p = 1). The above finding suggests that the patients in all three treatment groups (Q-Sc + RSD, FMDeb and FMDis) have achieved comparably reduced plaque scores following treatment. Discussion The primary objective of the present study was to compare the effectiveness of three different approaches of nonsurgical debridement (RSD), namely conventional quadrant-wise scaling and root surface debridement (Q-Sc + RSD), Full Mouth Debridement (FMDeb), and Full Mouth Disinfection (FMDis) performed on adult patients diagnosed with moderate to severe periodontitis (stage II-III) according to AAP & EFP classification-2017. As recommended in the EFP clinical practice guidelines (CPG), management of stage I-III periodontitis encompasses, initial nonsurgical debridement with supra-gingival PMPR and subgingival PMPR under step 1 and step 2 therapy respectively. Both step 1 and step 2 emphasize the necessity of empowering the patient in achieving an optimal plaque control through an effective self-care oral hygiene routine. In performing self-care oral hygiene, the patient needs meticulous guidance from the clinician. Therefore, the clinician also has a crucial role to play in guiding and monitoring the patient’s routine plaque control, while performing PMPR whenever necessary 26 . Similarly, EFP CPG emphasizes the importance of subgingival instrumentation in step 2 therapy for optimal treatment outcomes 26 . Previous studies also provide evidence in support of the subgingival instrumentation as an effective intervention when managing infectious periodontal diseases 12 , 29 . While the traditional approach for RSD is Q-Sc + RSD, the risk of bacterial recolonization from the untreated periodontal sites to the treated sites was reported as a potential limitation of this protocol. Therefore, to address the risk of bacterial recolonization following Q-Sc + RSD protocol, FMDis and full-mouth debridement approaches have been proposed. Initial findings suggested that full-mouth treatment protocols resulted in superior clinical and microbiological outcomes, when compared to conventional quadrant scaling and root planing (SRP) 25 . However, more recent studies have raised concerns about the conclusiveness of this evidence. Some investigations have failed to demonstrate any significant advantage of full-mouth protocols performed within 24 hours over the standard quadrant wise approach 2 , 5 , 9 , 13 , 15 , 23 , 24 , 28 , 32 . Given that the evidence is not conclusive, the choice of the subgingival debridement protocol is ultimately at the discretion of the clinician treating the patient. In this regard, the clinician may take into account the patient's preference, logistical settings, and cost-effectiveness. The results of this study highlight the effectiveness of three different non-surgical periodontal debridement protocols, Q-Sc + RSD, FMDeb, and FMDis. While this study intended to compare the effectiveness of these three debridement approaches in reducing the PD and BS of patients with stage II/III periodontitis, the overall results indicate that all three approaches were effective in obtaining significant clinical outcomes. For example, there were significant reductions in deep pocket distribution (p = 0.000–0.001), and bleeding scores (p = 0.000) of patients who were treated through three debridement approaches. The dramatic reduction in deep pockets and bleeding scores implies the achievement of an improved periodontal status of patients in this study, underscoring the worth of all three non-surgical approaches performed in the treatment of periodontitis. However, the dramatic reduction in post-treatment plaque scores of patients in all three groups appeared to be highly beneficial for the improved clinical outcomes measured by the reduction of pocket depth distribution and bleeding scores. Irrespective of the method of periodontal debridement, improved oral hygiene status with reduced plaque scores is an established key to success from treatment. Although this study implies the potential benefits in any of the approaches for non-surgical debridement in NSPT, the full-mouth approaches, (FMDeb and FMDis) revealed slightly better outcomes when compared with the conventional Q-Sc + RSD. This is especially true regarding the deep pocket reduction and bleeding scores. This finding aligns with the previous studies advocating full-mouth treatment protocols, as they may reduce the risk of bacterial recolonization and promote better overall periodontal health outcomes 25 . Similar to the findings in our study, some previous studies have reported that there were no significant differences between Q-Sc + RSD and full-mouth protocols 1 , 2 , 5 , 9 , 13 , 15 , 23 , 30 , 32 . In our study, no significant differences were observed between the two groups treated with full-mouth protocols, in terms of reduction of deep pocket distribution or bleeding scores at post-treatment. A previous systematic review has substantiated this finding that full-mouth debridement, with or without antiseptics, does not provide clinically relevant advantages. Further, it is stated that the full-mouth protocols may not provide additional beneficial clinical outcomes over conventional staged debridement for patients with chronic periodontitis 17 . Another systematic review comparing full-mouth scaling, with or without antiseptics, to quadrant scaling found only minor differences between the different treatment strategies for adults with chronic periodontitis 7 . As recommended in the EFP S3 level clinical practice guidelines, subgingival periodontal instrumentation can be performed using either conventional quadrant-wise or full-mouth delivery within 24 hours when managing patients with stage I-III periodontitis. However, it is important to note that the protocols involving antiseptics, such as full-mouth disinfection, have not been elaborated in the EFP CPG. Yet, it does not preclude the clinicians of their choices and flexibility in deciding the most suitable approach for the individual patient. Moreover, some studies have indicated that clinical improvement of patients may depend on the duration of the follow-up. The healing response following non-surgical treatment can continue for six to nine months post-treatment 4 . For instance, one study found that, while all three treatment modalities led to improvements in clinical and microbiological parameters, significant differences were not observed after eight months 28 . Since our study includes the periodontal measurements obtained from patients only up to two months, it may limit our ability to interpret of the predictions on long-term outcomes. According to established literature, it is envisaged that thorough plaque control advice and guidance on home-care maintenance delivered to patients at the initial phase of periodontal therapy is crucial for the desired periodontal treatment outcomes following NSPT 16 . In the present study, meticulous chair-side oral hygiene instructions were provided to all patients during the initial visit with systematic reinforcement, every two weeks as they attended the follow-up appointments. At each visit, oral prophylaxis/PMPR was performed. Consequently, significant improvements in plaque scores of patients across all three treatment groups were evident after treatment, when compared with pre-treatment plaque scores. Additionally, there were no significant differences in post-treatment plaque scores among the patients in different treatment groups. This emphasizes the fact that, regardless of the debridement protocol used, meticulous plaque control is crucial in achieving the desired clinical outcomes following periodontal therapy. As evident in the literature, there is considerable variation among studies in the FMDis protocol regarding the choice of disinfectant, its concentration, method of application, and the duration of use. Such variations may also influence the clinical outcomes reported in these studies. Further, modified FMDis protocols have emerged, which incorporate strategies such as prolonged post-treatment chlorhexidine use, using amine fluoride, providone iodine, antibiotic- or probiotic supplementation, photodynamic therapy and periodontal dressings in place of chlorhexidine 22 . Research involving chlorhexidine-based protocols indicates a potential relapse in the microbiota, microbial composition and pathogenicity when chlorhexidine was ceased after its use for eight months. This may raise questions about the long-term benefit and efficacy of chlorhexidine-based FMDis 25 . Clinicians should be aware that prolonged exposure for subgingival debridement may significantly influence the release of acute-phase reactants, triggering the systemic inflammatory response in the patient. This systemic implication is concerning, if full-mouth protocols are to be used on patients with cardiovascular diseases (CVD). For instance, FMDis and FMDeb may trigger a more pronounced acute-phase response within 24 hours compared to Q-wise Sc + RSD, which is performed intermittently over several weeks 9 . Therefore, the decision-making for an intense subgingival debridement should always include careful consideration of the general health status of the patient 27 . In terms of periodontal healing time, the Q-Sc + RSD approach allows the first treated quadrant more time for healing by the time the outcomes are assessed. This may affect the results at the re-evaluation time, although the impact could be minimal, if the recommended healing period is allowed for all periodontal sites in the mouth 2 . Full-mouth debridement protocols provide comprehensive care in a single visit, enhancing patient compliance for attendance. However, the increased systemic responses may be overwhelming for some patients. An increase in body temperature and a notable acute-phase response have been observed following full-mouth treatment modalities 9 . A consensus report from the EFP and the World Heart Federation (WHF) recommends that individuals with CVD undergo non-surgical periodontal therapy in shorter sessions of 30 to 45 minutes to minimize systemic inflammation, regardless of their CVD status or medications 27 . In contrast, quadrant-wise debridement reduces acute systemic inflammation, and allows for a more focused approach for oral hygiene monitoring/reinforcement, over several treatment visits. However, it requires multiple visits, which may affect the compliance for attendance by some patients. Therefore, the clinician may need to select the most appropriate treatment approach for the individual patient, with careful consideration for overall health and specific needs. As evident in the EFP CPG 26 , the patient preferences for subgingival debridement approach and patient-reported outcomes have inconsistently been reported, with no evidence supporting one subgingival debridement approach over the other. Reports of any discomfort or side effects related to full-mouth protocols are not included in the EFP CPG. In our study, the patient-reported outcomes were not evaluated, which is identified as a limitation when considering the overall acceptance of subgingival debridement approaches by the patients. This may limit our ability for a balanced recommendation of full mouth protocols over conventional approach, despite their advantages pertaining to desirable clinical outcomes and lesser treatment visits for the patient. Moreover, the microbiological assessments are highly relevant in interpreting the treatment outcomes such as reduced pocket depths, pocket closure, bleeding scores observed in a clinical study which followed different approaches for subgingival debridement. Although microbial assessments were beyond the scope of the present study, future studies should be directed to connect the desirable clinical outcomes with the microbial profiles. Such an approach could underpin the rational use of antimicrobial supplements to mechanical subgingival debridement. Conclusion With the limitations of this study in mind, it can be concluded that although all three treatment modalities are effective in reducing the probing depths and bleeding scores of patients with periodontitis, FMDeb and FMDis protocols demonstrate superior effectiveness in terms of reduction of bleeding scores and deep pocket distribution compared to the Q-wise-Sc + RSD protocol. However, at post-treatment, all three study groups demonstrated remarkably low bleeding scores with statistically significant differences when compared with their respective pre-treatment bleeding scores. The choice of the subgingival debridement protocol is ultimately at the discretion of the clinician by taking patient's preference, medical status, and other operational factors into consideration. Abbreviations BS Bleeding Score CHX Chlorhexidine gluconate CVD Cardiovascular Disease DPT Dental panoramic Tomogram FDS Faculty of Dental Sciences FMDeb Full Mouth Debridement FMDis Full Mouth Disinfection NSPT Nonsurgical Periodontal Therapy PD Probing Pocket Depth PI Principal Investigator PLS Plaque Score PMPR Professional Mechanical Plaque Removal Q-Sc + RSD Quadrant-wise Scaling and Root Surface Debridement SG1 Study Group 1 SG2 Study Group 2 SG3 Study Group 3 SPC Supportive Periodontal Care UOP University of Peradeniya WHO World Health Organization Declarations Ethics approval and consent to participate- This study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Ethics Review Committee, FDS-UOP (FRC/FDS/UOP/I/2021/05). Informed consent was secured from all participants prior to their involvement in the research. Each participant received detailed information about the study and voluntarily agreed to participate. Consent for publication- Not applicable Availability of data and materials- The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests- The authors declare that they have no competing interests Funding- This study was self-funded. Authors' contributions KMCP -Literature review, treating patients, data collection, and data entry; writing the manuscript UG -Statistical analysis RW - contributed to the conception and design of the study including selecting appropriate statistical tests and analysis AT -Literature review, study design, random allocation of patients into groups, supervision; writing and editing the manuscript Acknowledgements- Not applicable References Afacan B, Çınarcık S, Gürkan A, Özdemir G, İlhan HA, Vural C, Köse T, Emingil G. Full-mouth disinfection effects on gingival fluid calprotectin, osteocalcin, and N‐telopeptide of Type I collagen in severe periodontitis. J Periodontol. 2020;91(5):638–50. Apatzidou DA, Kinane DF. Quadrant root planing versus same-day full-mouth root planing. I. Clinical findings. J Clin Periodontol. 2004;31(2):132–40. 10.1111/j.0303-6979.2004.00461.x . PMID: 15016039. Badersten A, Nilvéus R, Egelberg J. Effect of nonsurgical periodontal therapy. I. Moderately advanced periodontitis. J Clin Periodontol. 1981;8(1):57–72. 10.1111/j.1600-051x.1981.tb02024.x . PMID: 6972954. Cobb CM. Clinical significance of non-surgical periodontal therapy: an evidence-based perspective of scaling and root planing. J Clin Periodontol. 2002;29(Suppl 2):6–16. PMID: 12010523. Del Ribeiro P, Bittencourt É, Sallum S, Nociti EA Jr, Gonçalves FH, Casati RB. Periodontal debridement as a therapeutic approach for severe chronic periodontitis: a clinical, microbiological and immunological study. J Clin Periodontol. 2008;35(9):789–98. Durham J, Fraser HM, McCracken GI, Stone KM, John MT, Preshaw PM. Impact of periodontitis on oral health-related quality of life. J Dent. 2013;41(4):370–6. 10.1016/j.jdent.2013.01.008 . Epub 2013 Jan 26. PMID: 23357646. Eberhard J, Jepsen S, Jervøe-Storm PM, Needleman I, Worthington HV. Full-mouth treatment modalities (within 24 hours) for chronic periodontitis in adults. Cochrane Database Syst Rev. 2015;4:CD00462. 10.1002/14651858.CD004622.pub3 . Farman M, Joshi RI. Full-mouth treatment versus quadrant root surface debridement in the treatment of chronic periodontitis: a systematic review. Br Dent J. 2008;205(9):E18; discussion 496–7. 10.1038/sj.bdj.2008.874 . Epub 2008 Oct 3. PMID: 18833208. Graziani F, Cei S, Orlandi M, Gennai S, Gabriele M, Filice N, Nisi M, D'Aiuto F. Acute-phase response following full‐mouth versus quadrant non‐surgical periodontal treatment: A randomized clinical trial. J Clin Periodontol. 2015;42(9):843–52. Haffajee AD, Cugini MA, Dibart S, Smith C, Kent RL Jr, Socransky SS. The effect of SRP on the clinical and microbiological parameters of periodontal diseases. J Clin Periodontol. 1997;24(5):324–34. 10.1111/j.1600-051x.1997.tb00765.x . PMID: 9178112. Hämmerle CH, Joss A, Lang NP. Short-term effects of initial periodontal therapy (hygienic phase). J Clin Periodontol. 1991;18(4):233–9. 10.1111/j.1600-051x.1991.tb00420.x . PMID: 1856303. Heitz-Mayfield LJ, Trombelli L, Heitz F, Needleman I, Moles D. A systematic review of the effect of surgical debridement vs. non‐surgical debridement for the treatment of chronic periodontitis. J Clin Periodontol. 2002;29:92–102. Jervøe-Storm PM, Semaan E, AlAhdab H, Engel S, Fimmers R, Jepsen S. Clinical outcomes of quadrant root planing versus full-mouth root planing. J Clin Periodontol. 2006;33(3):209–15. 10.1111/j.1600-051X.2005.00890.x . PMID: 16489947. Knowles JW, Burgett FG, Nissle RR, Shick RA, Morrison EC, Ramfjord SP. Results of periodontal treatment related to pocket depth and attachment level. Eight years. J Periodontol. 1979;50(5):225–33. doi:10.1902/jop.1979.50.5.225. PMID: 287778. Koshy G, Kawashima Y, Kiji M, Nitta H, Umeda M, Nagasawa T, Ishikawa I. Effects of single-visit full‐mouth ultrasonic debridement versus quadrant‐wise ultrasonic debridement. J Clin Periodontol. 2005;32(7):734–43. Lang NP, Berglundh T, Giannobile WV, Sanz M, editors. Lindhe's clinical periodontology and implant dentistry. Wiley; 2021 Jul. p. 28. Lang NP, Tan WC, Krahenmann 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;35:8–21. Mongardini C, van Steenberghe D, Dekeyser C, Quirynen M. One stage full- versus partial-mouth disinfection in the treatment of chronic adult or generalized early-onset periodontitis. I. Long-term clinical observations. J Periodontol. 1999;70(6):632–45. 10.1902/jop.1999.70.6.632 . PMID: 10397519. Mousques T, Listgarten MA, Phillips RW. Effect of scaling and root planning on the composition of the human subgingival microbial flora. J Periodontal Res. 1980;15:144–51. National Oral Health Survey. Sri Lanka 2015–2016. Colombo: Ministry of Health, Nutrition and Indigenous Medicine; 2018. Papapanou PN, Sanz M, et al. Periodontitis: Consensus report of Workgroup 2 of the World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol. 2018;45(Suppl 20):S162–70. 10.1111/jcpe.12496 . Pockpa AD, Soueidan A, Louis P, Coulibaly NT, Badran Z, Struillou X. Twenty years of full-mouth disinfection: the past, the present and the future. Open Dent J. 2018;12:435–42. Pontillo V, Miziak DB, Maller AC, Nassar PO, Nassar CA. Comparative Clinical Evaluation between Conventional Periodontal Treatment and Full Mouth Disinfection. J Int Acad Periodontol. 2018;20(4):123–30. Predin T, Djuric M, Nikolic N, Mirnic J, Petrovic D, Milasin J. A randomized study on clinical and microbiological effects of quadrant versus full-mouth root planning. J Dent Sci. 2014;9:400–6. Quirynen M, Mongardini C, de Soete M, Pauwels M, Coucke W, van Eldere J, van Steenberghe D. The role of chlorhexidine in the one-stage full-mouth disinfection treatment of patients with advanced adult periodontitis: Long-term clinical and microbiological observations. J Clin Periodontol. 2000;27(8):578–89. 10.1034/j.1600-051x.2000.027008578.x . Sanz M, Herrera D, Kebschull M, et al. Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020a;47:4–60. 10.1111/jcpe.13290 . Sanz M, Marco del Castillo A, Jepsen S, Gonzalez-Juanatey JR, D'Aiuto F, Bouchard P, et al. Periodontitis and cardiovascular diseases: Consensus report. Glob Heart. 2020b;15:1. Swierkot K, Nonnenmacher CI, Mutters R, Flores-de-Jacoby L, Mengel R. One-stage full-mouth disinfection versus quadrant and full-mouth root planing. J Clin Periodontol. 2009;36(3):240–9. 10.1111/j.1600-051X.2008.01368.x . Van der Weijden GA, Timmerman MF. A systematic review on the clinical efficacy of subgingival debridement in the treatment of chronic periodontitis. J Clin Periodontol. 2002;29:55–71. Wennström JL, Tomasi C, Bertelle A, Dellasega E. Full-mouth ultrasonic debridement versus quadrant scaling and root planing as an initial approach in the treatment of chronic periodontitis. J Clin Periodontol. 2005;32(8):851–9. 10.1111/j.1600-051X.2005.00776.x . PMID: 15998268. World Health Organization. Global oral health status report: towards universal health coverage for oral health by 2030. World Health Organization; 2022. Nov 18. Zijnge V, Meijer HF, Lie MA, Tromp JA, Degener JE, Harmsen HJ, Abbas F. The recolonization hypothesis in a full-mouth or multiple‐session treatment protocol: a blinded, randomized clinical trial. J Clin Periodontol. 2010;37(6):518–25. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6712357","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464746356,"identity":"ea3a1c8c-d6be-4194-8fac-172ec22a2527","order_by":0,"name":"Kodikara Mudiyanselage Chathurika Padmakumari","email":"data:image/png;base64,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","orcid":"","institution":"University of Peradeniya","correspondingAuthor":true,"prefix":"","firstName":"Kodikara","middleName":"Mudiyanselage Chathurika","lastName":"Padmakumari","suffix":""},{"id":464746357,"identity":"3defb936-6f2b-4666-983e-12c6290e7717","order_by":1,"name":"Uthpala Muhandiramge Gunasekara","email":"","orcid":"","institution":"Postgraduate Institute of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Uthpala","middleName":"Muhandiramge","lastName":"Gunasekara","suffix":""},{"id":464746358,"identity":"a47906f2-f390-4e13-a980-84e10ffc2d01","order_by":2,"name":"Ranjith Pallegama","email":"","orcid":"","institution":"University of Peradeniya","correspondingAuthor":false,"prefix":"","firstName":"Ranjith","middleName":"","lastName":"Pallegama","suffix":""},{"id":464746359,"identity":"6d8d77fb-7c01-44f1-88de-04ad6463be33","order_by":3,"name":"Aruni Tilakaratne","email":"","orcid":"","institution":"University of Malaya","correspondingAuthor":false,"prefix":"","firstName":"Aruni","middleName":"","lastName":"Tilakaratne","suffix":""}],"badges":[],"createdAt":"2025-05-21 04:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6712357/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6712357/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-025-06595-x","type":"published","date":"2025-07-17T16:04:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83899915,"identity":"51c0499d-d2aa-405e-b8db-24d50f2a8def","added_by":"auto","created_at":"2025-06-04 09:23:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64769,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eParticipant flow diagram\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6712357/v1/57c10024143de2fba0a06abc.png"},{"id":88506030,"identity":"22702544-1dd1-496c-8e12-7f45e0715511","added_by":"auto","created_at":"2025-08-07 07:29:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1881684,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6712357/v1/b3e5e386-6372-4141-82d6-296a73e415b0.pdf"},{"id":83899917,"identity":"7df0fb4e-8892-4148-b1c0-1984bea847bd","added_by":"auto","created_at":"2025-06-04 09:23:09","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12723,"visible":true,"origin":"","legend":"","description":"","filename":"researchdatasheetfinal.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6712357/v1/f6647efabc42e4db249f05c8.xlsx"},{"id":83901224,"identity":"000309d8-8967-4244-9ba9-b21bdcb6bb69","added_by":"auto","created_at":"2025-06-04 09:31:09","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":32715,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2025editablechecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-6712357/v1/b2f205a3047f96bcff4a432c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Management of periodontitis by three different approaches to non-surgical periodontal debridement – A randamized comparative clinical study","fulltext":[{"header":"Background","content":"\u003cp\u003ePeriodontitis is a chronic inflammatory disease that affects the supporting tissues of the teeth, leading to destruction of periodontal attachment and bone. The primary cause of periodontitis is microbial plaque in the dental/oral biofilm. Periodontitis, if untreated, can result in severe tooth mobility with eventual tooth loss. The rate of periodontal tissue destruction depends on the balance maintained by the microbial virulence factors and the host immune-inflammatory responses which elicit both destructive and protective components. Moreover, several modifiable and non-modifiable risk factors are associated with periodontitis progression. These include smoking, diabetes, obesity, hypertension, stressful lifestyles, socio-economic factors, and genetic predispositions\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAccording to the WHO global oral health status report, the estimated global prevalence of severe periodontal disease in 2019 was approximately 19% among individuals aged over 15 years, representing more than 1\u0026nbsp;billion cases worldwide. This reflects a 23.96% increase in the prevalence from 1990 to 2019, highlighting severe periodontal disease as a major public health issue\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. In Sri Lanka, the situation is particularly concerning, with 25.3% of individuals in the 35-44-year age cohort exhibiting periodontal pockets greater than 4 mm\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The high prevalence of severe periodontal disease emphasizes the urgent need for effective management and preventive strategies in addressing this public health issue, both globally and locally.\u003c/p\u003e \u003cp\u003ePeriodontal disease, particularly periodontitis, significantly affects the quality of life of individuals. Patients with chronic periodontitis report poorer oral health-related quality of life compared to age- and gender-matched individuals without the disease, since they seem to experience functional, social, and psychological challenges such as halitosis, pain, and poor aesthetics\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Additionally, studies have linked periodontal disease to serious health complications, including atherosclerosis, cardiovascular disease, diabetes, and preterm low birthweight deliveries\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Therefore, effective preventive care and early interventions against periodontitis would invariably result in improvements in oral health outcomes and overall well-being of the affected populations.\u003c/p\u003e \u003cp\u003eFor the past many years, non-surgical periodontal treatment (NSPT) has proven to be effective in managing patients with periodontitis. NSPT is beneficial in reducing the probing pocket depths and bleeding scores in moderate and deep periodontal pockets, as well as in gaining clinical attachment levels \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. However, the non-surgical debridement component of the NSPT can be delivered through three approaches. These are conventional quadrant-wise scaling (Sc) and root surface debridement (RSD) [Q-Sc\u0026thinsp;+\u0026thinsp;RSD], full mouth debridement [FMDeb] and full mouth disinfection [FMDis]. All these three mechanical non-surgical debridement approaches have been accepted as effective in the management of patients with periodontitis\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eConventionally, Q-Sc\u0026thinsp;+\u0026thinsp;RSD is performed in a quadrant-wise manner, with an interval of 1\u0026ndash;2 weeks between the debridement of each quadrant. This method uses periodontal curettes to clean the periodontal pockets and root surfaces, typically taking 4\u0026ndash;6 weeks or more to complete debridement of the entire mouth\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Numerous clinical and microbiological studies have confirmed the effectiveness of this conventional quadrant-wise debridement protocol in reducing the bacterial load and improving the clinical outcomes\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. However, some research evidence points out the fact that the 1\u0026ndash;2-week interval between quadrant debridement may allow recolonization of the instrumented pockets from non-instrumented pockets\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, potentially impairing healing and pocket closure. To address this issue, the other two alternative approaches (FMDeb and FMDis) have been proposed.\u003c/p\u003e \u003cp\u003eFMDeb involves prompt debridement of all quadrants within two consecutive days, aiming to reduce the risk of bacterial recolonization of the instrumented pockets from those non-instrumented. Similarly, FMDis entails rapid-paced RSD within two consecutive days to complete all pockets in the mouth but includes using chlorhexidine gluconate following RSD. Using chlorhexidine is expected to eliminate periodontal pathogens from other potentially infected sites in the oral cavity, such as the dorsum of the tongue, buccal mucosa, palate, and tonsils\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSome randomized control trials have found no significant difference in the clinical outcomes between the three different methods, Q-Sc\u0026thinsp;+\u0026thinsp;RSD, FMDeb or FMDis\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. As opposed to this finding, other studies have reported significant improvements in both clinical and microbiological outcomes, when full mouth protocols were used\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e As suggested in the recent EFP S3 level clinical practice guidelines, periodontal therapy for management of stage I-III periodontitis, consists of four steps. Step 1 involves \u0026lsquo;building foundations for optimal treatment outcomes\u0026rsquo; where oral health education and preventive interventions are performed to achieve optimal plaque control by the patient and reducing gingival inflammation through professional mechanical plaque removal (PMPR). Elimination of local retentive factors and control of risk factors are also important components in step 1 therapy. The second step, known as cause-related therapy, focuses on the reduction of the subgingival biofilm and calculus, which encompasses non-surgical approaches aimed at accessing root surfaces or the subgingival locations. The guidelines indicate that subgingival periodontal instrumentation can be executed using either conventional quadrant-wise debridement or full-mouth delivery methods within a 24-hour timeframe. Step 2 therapy also involves use of adjunctives to mechanical therapy, which includes chlorhexidine antiseptic. Use of such adjunctives in step 2 therapy is at the discretion of the clinician. The step 3 of periodontal therapy involves periodontal re-evaluation and managing non-responding deep periodontal pockets either by repeating step 2 therapy, or by obtaining surgical access. Step 4 therapy is supportive periodontal care (SPC) offered to a patient who has adequately responded to achieve a stable periodontal condition following treatment.\u003c/p\u003e \u003cp\u003eIn routine clinical practice, the choice of non-surgical debridement method in step 2 therapy (among Q-Sc\u0026thinsp;+\u0026thinsp;RSD/FMDeb/FMDis) is often based on the clinical justification and preference of the individual clinician in concurrence with the patient. To the best of our knowledge, a systematic comparison of clinical outcomes of each method, along with a thorough analysis of their advantages and limitations, has not yet been reported. Against this backdrop, the main objective of this study was to compare the effectiveness of the three different periodontal debridement methods (Q-Sc\u0026thinsp;+\u0026thinsp;RSD, FMDeb and FMDis), in treating patients diagnosed with stage II and III periodontitis (AAP \u0026amp; EFP classification, 2017).\u003c/p\u003e \u003cp\u003eThe specific objectives of this study were to compare the probing pocket depths (PD) and bleeding scores (BS) of patients, before and after non-surgical periodontal debridement under three different debridement protocols (Q-Sc\u0026thinsp;+\u0026thinsp;RSD, FMDeb and FMDis).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSelection of study sample\u003c/h2\u003e \u003cp\u003eThis randomized comparative clinical study was conducted in the Division of Periodontology, Faculty of Dental Sciences (FDS), University of Peradeniya (UOP), Sri Lanka. Adult patients who were newly diagnosed with generalized stage II and III periodontitis who conformed to the inclusion criteria of the study were included in the study. This study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki. Ethics Approval was obtained from the Ethics Review Committee of FDS-UOP (number: FRC/FDS/UOP/I/2021/05) and retrospectively registered in the UK\u0026rsquo;s Clinical Study Registry ISRCTN13350022. This clinical trial followed the CONSORT guidelines 2025 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Informed consent was secured from all participants prior to their involvement in the research.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample size estimation\u003c/h3\u003e\n\u003cp\u003eAs guided by the previous literature\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, preliminary sample size estimation revealed that the required number of patients is 36, (12 patients in one treatment group) at partial eta squared\u0026thinsp;=\u0026thinsp;0.25, alpha\u0026thinsp;=\u0026thinsp;0.05, beta\u0026thinsp;=\u0026thinsp;0.8 with a moderate correlation between repeated measures. This estimation was done to test the hypothesis in a factorial repeated measures model. However, a more specific re-estimation of the sample size was made with our own preliminary data after 6 months from the start of patient recruitment. Accordingly, sample size was increased up to 45 (15 patients per one treatment group).\u003c/p\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eThe inclusion criteria were, those aged\u0026thinsp;\u0026ge;\u0026thinsp;35 years diagnosed with generalized stage II and III periodontitis, with at least three (03) treatable quadrants in the mouth requiring RSD, with a minimum of four (04) teeth in any quadrant with deep pockets. Only those patients who consented to undergo treatment according to a random assignment into any of the three methods of periodontal debridement were included.\u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eThe exclusion criteria were, those who had underlying systemic conditions (uncontrolled diabetes mellitus, leukemia/haematological disorders, pregnancy, and medication-induced gingival overgrowth), and those who were current or previous smokers. The patients who had undergone periodontal treatment within the preceding 6 months, and those who were on systemic antibiotics within the last 3 months were also excluded. Additionally, those who had used oral chlorhexidine preparations or other disinfectants within the previous month were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eStudy participant recruitment and randomization\u003c/h3\u003e\n\u003cp\u003eAll patients who fulfilled the inclusion criteria of the study underwent written informed consent process, after reading the \u0026lsquo;patient information sheet\u0026rsquo;, followed by clarification of queries by the patients. The patients were randomized into one of the study groups, namely (Q-Sc\u0026thinsp;+\u0026thinsp;RSD) or (FMDeb) or (FMDis) by using a block randomization method to generate treatment groups of equal size. Randomization and allocation of patients was done by another person who was not involved in examining or treating the patients. This allocation concealment was done in order to eliminate sampling bias where the principal investigator (PI) treated all the patients in the treatment groups. After assignment to interventions, both patients and outcome assessors were blinded to the treatment allocations, minimizing bias in the assessment of results.\u003c/p\u003e \u003cp\u003eThe patients underwent detailed periodontal assessments (pocket charting and radiological evaluation with a dental panoramic tomogram/DPT). After confirming the periodontal diagnosis, they were arranged with appointments by the same person who performed randomization, to commence periodontal treatment by the PI of the study.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePeriodontal assessments\u003c/h2\u003e \u003cp\u003eAll patients were examined for plaque score (PLS, %), bleeding score (BS, %), and probing pocket depths (PD). The parameters were recorded in plaque charts and six-point pocket charts. Prior to these periodontal assessments of patients in the study proper, intra-examiner calibration was performed on six other periodontitis patients to verify agreement within the PI for PD measurements.\u003c/p\u003e \u003cp\u003ePlaque (disclosed with disclosing solution) was dichotomously scored as present or absent, and full mouth plaque score was obtained. Full mouth bleeding score was also obtained dichotomously, as present or absent upon probing. Probing pocket depths were measured in millimetres, by using a William\u0026rsquo;s periodontal probe at six sites of each tooth. Probing depths of 4 mm or greater with bleeding on probing were classified as deep pockets needing root surface debridement. This is in accordance with the current recommendations for achieving endpoints of non-surgical periodontal therapy\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The percentage of deep pocket distribution was obtained by dividing the total number of deep pockets (\u0026ge;\u0026thinsp;4 mm with bleeding), by the total number of tooth sites in the mouth.\u003c/p\u003e \u003cp\u003eOnce the clinical measurements were completed, radiographic evaluation with DPT was carried out to confirm the detailed periodontal diagnosis as stage II or stage III periodontitis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTreatment\u003c/h3\u003e\n\u003cp\u003e All patients underwent standard hygiene phase care of initial periodontal therapy (step 1 of EFP S3 guidelines, 2020) which included plaque disclosing, meticulous plaque control advice with oral hygiene instructions (OHI), followed by PMPR and removing plaque retentive factors. Guidance on mechanical plaque removal (toothbrushing instructions and interdental cleaning) was provided to all patients, according to the individual plaque control needs. Plaque control was monitored and reinforced at the subsequent treatment visits for all patients, by the same investigator who treated patients. Except for the fact that different treatment groups received three different periodontal debridement protocols, all patients received standard NSPT, with individually tailored OHI. This was to fulfill the objective of achieving optimal plaque control at the step 1 of periodontal therapy, in optimizing a successful treatment outcome. Three different periodontal debridement protocols for three treatment groups were as follows.\u003c/p\u003e \u003cp\u003ei. \u003cb\u003eStudy Group 1 (SG1): Quadrant-wise Sc\u0026thinsp;+\u0026thinsp;RSD group (Q-Sc\u0026thinsp;+\u0026thinsp;RSD)\u003c/b\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEach patient was treated with scaling and RSD, quadrant by quadrant, starting from the upper right jaw and proceeding clockwise over four sessions at weekly intervals. All patients received standard post-operative instructions and placebo mouth rinsing (described below) for 2 weeks.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eii. \u003cb\u003eStudy Group 2 (SG2): Full Mouth Debridement group (FMDeb)\u003c/b\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEach patient was treated with scaling and RSD in two visits, arranged on two consecutive days (within 24 hours from one another). Debridement of right maxillary and mandibular quadrants were done on the first visit, followed by the left quadrants at the second visit. All patients received standard post-operative instructions and placebo mouth rinsing (described below) for 2 weeks.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eiii. \u003cb\u003eStudy Group 3 (SG3): Full Mouth Disinfection group (FMDis)\u003c/b\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSimilar to FMDeb group, each patient received scaling and RSD in two visits, within 24 hours on two consecutive days. Debridement of right maxillary and mandibular quadrants were done on the first visit, followed by the left quadrants at the second visit. Patients were advised to brush the tongue with 1% chlorhexidine gel for one minute. Additionally, the pockets were irrigated with 0.2% chlorhexidine gluconate (CHX) at the end of each RSD session, according to the disinfection step recommended in the FMDis protocol (irrigation with a syringe, 3 times for 10 minutes). As the next step, the patients were instructed to use 0.2% CHX mouthwash at home (10 ml, twice daily for 1 minute, over 2 weeks\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. All patients received standard post-operative instructions and specific instructions regarding the use of chlorhexidine mouthwash at home.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSince FMDis protocol (SG3) required therapeutic mouth rinsing with CHX, the patients in SG1 and SG2 were also instructed to perform placebo mouth rinsing at home (with warm water) in a similar manner over a period of 2 weeks. This was done with the intention of standardization across all three treatment groups.\u003c/p\u003e\n\u003ch3\u003eMethod of subgingival instrumentation (debridement)\u003c/h3\u003e\n\u003cp\u003eAs the step 2 treatment, scaling and RSD were performed under local anaesthesia (2% lidocaine with adrenaline 1:80,000) using periodontal curettes (Gracey) supplemented with ultrasonic scaling. All correctable local plaque-retentive factors such as overhanging/defective restorations, untreated caries, and retained roots, were removed at the quadrant-debridement session or at step 1 level. The patients were instructed to report any adverse events such as fever, feeling of being ill or any other discomfort, to the contact person through the contact numbers provided to them at the recruitment stage. This method ensured systematic monitoring of potential adverse effects throughout the study, allowing for timely intervention if necessary.\u003c/p\u003e \u003cp\u003e Following the above treatment sessions for all patients in the three treatment groups, they were recalled every two weeks for oral hygiene assessment and reinforcement of OHI. Oral prophylaxis (PMPR) was also performed supra-gingivally. Plaque scores were obtained at every review visit for monitoring purpose. Eight weeks following completion of treatment, all patients underwent a full-mouth periodontal re-evaluation. These post-treatment measurements were tabulated, to compare them with the pre-treatment probing pocket depths, bleeding scores, and plaque scores.\u003c/p\u003e \u003cp\u003eAll patients continued to receive periodontal care/supportive periodontal therapy according to the identified periodontal care needs following re-evaluation.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS version 26. Normal distribution of periodontal parameters (bleeding score \u0026amp; deep pocket distribution) was assessed using skewness and kurtosis values. All periodontal parameters were distributed within the skewness of \u0026ndash; 2 to +\u0026thinsp;2 while the kurtosis values were within +\u0026thinsp;7 to -7. Therefore, all periodontal parameters were considered as normally distributed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e1. Demographic profile of the study sample\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of the study sample\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment Group (n\u0026thinsp;=\u0026thinsp;number)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean age (yrs)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLowest Age (yrs)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHighest Age (yrs)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMale (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFemale (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG1: Q-Sc\u0026thinsp;+\u0026thinsp;RSD (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG2: FMDeb (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG3: FMDis (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the total study sample consisted of 45 patients, with 25 females and 20 males. The mean age of SG1 and SG2 was almost similar (50 yrs), while the same for SG3 varied slightly (48.33 yrs). The age ranges of three treatment groups are also comparable for SG1 and SG2 (36\u0026ndash;68 yrs \u0026amp; 35\u0026ndash;68 yrs respectively). When compared with SG1 and SG2, the age range of SG3 appeared to be wider (35\u0026ndash;86 yrs). Yet, it was due to the inclusion of only one patient who was 86 years old in SG3. It is envisaged that, a single outlier may not have significantly affected the homogeneity of the three groups, in terms of their age. Thus, the overall demographic profile of the three treatment groups was considered as comparable without significant variation in terms of sample number, age range and gender of participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2. Treatment outcome of three treatment groups\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e2.1 Treatment outcome associated with deep pocket distribution\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section4\"\u003e \u003ch2\u003e2.1.1 Comparison of deep pocket distribution before and after NSPT\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2.1\u003c/span\u003e.1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of mean deep pocket distribution of three treatment groups before and after NSPT\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4mm Deep pocket distribution (%) (mean)- Pre-treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4mm Deep pocket distribution (%) (mean)\u0026ndash; Post-treatment, at re-evaluation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical test- Dependent sample t test\u003c/p\u003e \u003cp\u003e(Significance level\u0026thinsp;\u0026lt;\u0026thinsp;0.05*)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.Q-wise-Sc\u0026thinsp;+\u0026thinsp;RSD (Standard) [n\u0026thinsp;=\u0026thinsp;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. FMDeb [n\u0026thinsp;=\u0026thinsp;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. FMDis [n\u0026thinsp;=\u0026thinsp;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e*At pre-treatment, the deep pocket distribution between the three groups was not significant statistically.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2.1\u003c/span\u003e.1 compares the mean deep pocket distribution of the three study groups at pre-treatment and post-treatment, at re-evaluation stage. Accordingly, all three treatment groups revealed highly significant reductions in the mean percentage of pocket distribution, as tested by dependent sample t-test. Evidently, SG1 (Q-Sc\u0026thinsp;+\u0026thinsp;RSD), which had a mean deep pocket distribution of 37.3% at pre-treatment, was significantly reduced to 18% at post-treatment (p\u0026thinsp;=\u0026thinsp;0.000). As for SG2 (FMDeb), the mean pre-treatment deep pocket distribution was 28.5%, which was reduced to 7.1% post-treatment (p\u0026thinsp;=\u0026thinsp;0.001). Similarly, SG3 (FMDis) revealed the pre-treatment deep pocket distribution to be 36.3%, which was reduced to 3% post-treatment (p\u0026thinsp;=\u0026thinsp;0.000). These findings imply that all three treatment approaches were effective in reducing deep pockets to a significant level.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e2.1.2 Comparison of mean deep pocket distribution among three treatment groups at post-treatment\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2.1\u003c/span\u003e.2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of mean deep pocket distribution of 3 groups at post-treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBetween group comparisons with the \u0026lsquo;Standard\u0026rsquo; (Q-Sc\u0026thinsp;+\u0026thinsp;RSD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-treatment mean deep pocket distribution (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical test-\u003c/p\u003e \u003cp\u003eIndependent sample t test (Significance level\u0026thinsp;\u0026lt;\u0026thinsp;0.05*)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(Q-Sc\u0026thinsp;+\u0026thinsp;RSD) Vs FMDeb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG1: (Q-Sc\u0026thinsp;+\u0026thinsp;RSD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG2: FMDeb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(Q-Sc\u0026thinsp;+\u0026thinsp;RSD) Vs FMDis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG1: (Q-Sc\u0026thinsp;+\u0026thinsp;RSD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG3: FMDis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs illustrated in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2.1\u003c/span\u003e.2, a comparison is made between the post-treatment deep pocket distribution following FMDeb and FMDis protocols with the \u0026lsquo;Standard\u0026rsquo; (Q-Sc\u0026thinsp;+\u0026thinsp;RSD). Accordingly, the reduction of post-treatment deep pocket distribution of FMDeb group (7%) was highly significant (p\u0026thinsp;=\u0026thinsp;0.002) when compared with the post-treatment deep pocket distribution of Q-Sc\u0026thinsp;+\u0026thinsp;RSD group (18%). Similarly, a highly significant reduction (p\u0026thinsp;=\u0026thinsp;0.000) of deep pocket distribution was seen in FMDis group (3%) when compared with the same for Q-Sc\u0026thinsp;+\u0026thinsp;RSD group (18%).\u003c/p\u003e \u003cp\u003eWhile these findings may imply that both FMDeb and FMDis approaches are highly successful in achieving post-treatment pocket depth reductions, the comparison is more realistic between the FMDis Vs Q-Sc\u0026thinsp;+\u0026thinsp;RSD, since the pre-treatment mean deep pocket distributions in both groups were very close (36.3% Vs 37.3% respectively, Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2.1\u003c/span\u003e.1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Treatment outcome associated with bleeding scores\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Comparison of bleeding scores (BS) before and after treatment\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e2.2\u003c/span\u003e.1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of bleeding scores (BS%) of 3 study groups at pre- and post-treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean BS (%)- Pre-Treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean BS (%)- Post-treatment, at re-evaluation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical test-\u003c/p\u003e \u003cp\u003eDependent sample t test\u003c/p\u003e \u003cp\u003e(Significance level\u0026thinsp;\u0026lt;\u0026thinsp;0.05*)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG1:Q-Sc\u0026thinsp;+\u0026thinsp;RSD [n\u0026thinsp;=\u0026thinsp;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG2: FMDeb [n\u0026thinsp;=\u0026thinsp;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG3: FMDis [n\u0026thinsp;=\u0026thinsp;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e*At pre-treatment, the mean BS (%) among the three groups was not significant statistically.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e2.2\u003c/span\u003e.1 illustrates the comparison of mean bleeding scores (BS) of the three study groups at pre-treatment and post-treatment. Accordingly, all three treatment groups revealed highly significant reductions in mean bleeding scores, as tested by dependent sample t-test. Evidently, the mean BS of SG1 (Q-Sc\u0026thinsp;+\u0026thinsp;RSD) at pre-treatment was 66.9%, which was significantly reduced to 29.5% at post-treatment (p\u0026thinsp;=\u0026thinsp;0.000). As for SG2 (FMDeb), the mean pre-treatment BS was 52.8%, which was reduced to 18.6% post-treatment (p\u0026thinsp;=\u0026thinsp;0.000). Similarly, SG3 (FMDis) revealed the pre-treatment BS to be 57.9%, and it was reduced to 9% at post-treatment (p\u0026thinsp;=\u0026thinsp;0.000). Accordingly, all three treatment groups demonstrated highly significant improvements in bleeding scores following treatment.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e2.2.2 Comparison of mean bleeding scores (BS%) among three treatment groups at post-treatment\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e2.2\u003c/span\u003e.2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of bleeding scores of 3 groups at post-treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBetween group comparisons of post-treatment BS (%) with the \u0026lsquo;Standard\u0026rsquo;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-treatment, at re-evaluation (BS %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical test Significance\u003c/p\u003e \u003cp\u003eIndependent sample t-test\u003c/p\u003e \u003cp\u003e(Significance level\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(Q-Sc\u0026thinsp;+\u0026thinsp;RSD) Vs FMDeb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG1: Q-Sc\u0026thinsp;+\u0026thinsp;RSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG2: FMDeb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(Q-Sc\u0026thinsp;+\u0026thinsp;RSD) Vs FMDis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG1: Q-Sc\u0026thinsp;+\u0026thinsp;RSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG3: FMDis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA comparison of post-treatment bleeding scores following FMDeb approach and FMDis approach with the \u0026lsquo;Standard\u0026rsquo; (Q-Sc\u0026thinsp;+\u0026thinsp;RSD) is depicted in Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e2.2\u003c/span\u003e.2. Accordingly, the reduction in post-treatment BS, of FMDeb group (18.6%) was statistically significant (p\u0026thinsp;=\u0026thinsp;0.042), when compared with the post-treatment BS of Q-Sc\u0026thinsp;+\u0026thinsp;RSD group (29.5%). Similarly, a highly significant reduction (p\u0026thinsp;=\u0026thinsp;0.000) in post-treatment BS was seen in FMDis group (9%) when compared with the same for Q-Sc\u0026thinsp;+\u0026thinsp;RSD group (29.5%).\u003c/p\u003e \u003cp\u003eWhile this finding may suggest that both FMDeb and FMDis approaches are highly effective in achieving post-treatment improvements in BS, SG3 (FMDis) appeared to reveal the greatest reduction of BS (9%), despite having a higher pre-treatment BS of 57.9%, compared to SG2 (FMDeb), which was 52.8%. However, as depicted in Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e2.2\u003c/span\u003e.1, the pre-treatment mean bleeding scores among the three groups were not significant statistically.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Comparison of plaque scores before and after treatment\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e2.3\u003c/span\u003e.1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of plaque scores (PS%) of 3 study groups at pre- and post-treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean PS (%)- Pre-treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean PS (%)-Post-treatment, at re-evaluation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical test-Dependent sample t test\u003c/p\u003e \u003cp\u003e(Significance level\u0026thinsp;\u0026lt;\u0026thinsp;0.05*)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG1:Q-Sc\u0026thinsp;+\u0026thinsp;RSD [n\u0026thinsp;=\u0026thinsp;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG2:FMDeb [n\u0026thinsp;=\u0026thinsp;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG3:FMDis [n\u0026thinsp;=\u0026thinsp;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e*At pre-treatment, the mean PS (%) among the three groups were not significant statistically\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e2.3\u003c/span\u003e.1 compares the mean plaque scores (PS) of the three study groups at pre-treatment and post-treatment. All three treatment groups revealed highly significant reductions in mean plaque scores, as tested by dependent sample t-test. As evident, the mean PS of SG1 (Q-Sc\u0026thinsp;+\u0026thinsp;RSD) at pre-treatment was about 84.9%, which was significantly reduced to 24.2% at post-treatment (p\u0026thinsp;=\u0026thinsp;0.000). As for SG2 (FMDeb), the mean pre-treatment PS of 76.6%, was reduced to 23.6% at post-treatment (p\u0026thinsp;=\u0026thinsp;0.000). Similarly, SG3 (FMDis) showed the pre-treatment PS to be 74.7%, and it was reduced to 21.6% post-treatment (p\u0026thinsp;=\u0026thinsp;0.000). Accordingly, all three treatment groups demonstrated highly significant reductions in plaque scores following treatment, denoting successful plaque control achievement by patients following treatment. Moreover, the post-treatment plaque scores among the three different treatment groups were closely comparable.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e2.3.2 Comparison of mean plaque scores (PS%) among three treatment groups at post-treatment\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e2.3\u003c/span\u003e.2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of plaque scores of 3 study groups at post-treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComparison of post-treatment PS (%) with the \u0026lsquo;Standard\u0026rsquo;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-treatment, at re-evaluation (PS %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical test-Independent sample t-test (Significance level\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(Q-Sc\u0026thinsp;+\u0026thinsp;RSD) Vs FMDeb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG1: Q-Sc\u0026thinsp;+\u0026thinsp;RSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG2: FMDeb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(Q-Sc\u0026thinsp;+\u0026thinsp;RSD) Vs FMDis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG1: Q-Sc\u0026thinsp;+\u0026thinsp;RSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSG3: FMDis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA comparison of post-treatment plaque scores following FMDeb approach and FMDis approach with the \u0026lsquo;Standard\u0026rsquo;(Q-Sc\u0026thinsp;+\u0026thinsp;RSD) is depicted in Table \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e2.3\u003c/span\u003e.2. As evident, the reduced plaque scores between Q-Sc\u0026thinsp;+\u0026thinsp;RSD group Vs FMDeb group at post-treatment were not significant statistically (24.2% Vs 23.6%, p\u0026thinsp;=\u0026thinsp;1). Similarly, the reduced plaque scores between Q-Sc\u0026thinsp;+\u0026thinsp;RSD group Vs FMDis group at post-treatment were not significant statistically (24.2% Vs 21.6%, p\u0026thinsp;=\u0026thinsp;1). The above finding suggests that the patients in all three treatment groups (Q-Sc\u0026thinsp;+\u0026thinsp;RSD, FMDeb and FMDis) have achieved comparably reduced plaque scores following treatment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary objective of the present study was to compare the effectiveness of three different approaches of nonsurgical debridement (RSD), namely conventional quadrant-wise scaling and root surface debridement (Q-Sc\u0026thinsp;+\u0026thinsp;RSD), Full Mouth Debridement (FMDeb), and Full Mouth Disinfection (FMDis) performed on adult patients diagnosed with moderate to severe periodontitis (stage II-III) according to AAP \u0026amp; EFP classification-2017.\u003c/p\u003e \u003cp\u003e As recommended in the EFP clinical practice guidelines (CPG), management of stage I-III periodontitis encompasses, initial nonsurgical debridement with supra-gingival PMPR and subgingival PMPR under step 1 and step 2 therapy respectively. Both step 1 and step 2 emphasize the necessity of empowering the patient in achieving an optimal plaque control through an effective self-care oral hygiene routine. In performing self-care oral hygiene, the patient needs meticulous guidance from the clinician. Therefore, the clinician also has a crucial role to play in guiding and monitoring the patient\u0026rsquo;s routine plaque control, while performing PMPR whenever necessary\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Similarly, EFP CPG emphasizes the importance of subgingival instrumentation in step 2 therapy for optimal treatment outcomes\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Previous studies also provide evidence in support of the subgingival instrumentation as an effective intervention when managing infectious periodontal diseases\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhile the traditional approach for RSD is Q-Sc\u0026thinsp;+\u0026thinsp;RSD, the risk of bacterial recolonization from the untreated periodontal sites to the treated sites was reported as a potential limitation of this protocol. Therefore, to address the risk of bacterial recolonization following Q-Sc\u0026thinsp;+\u0026thinsp;RSD protocol, FMDis and full-mouth debridement approaches have been proposed. Initial findings suggested that full-mouth treatment protocols resulted in superior clinical and microbiological outcomes, when compared to conventional quadrant scaling and root planing (SRP)\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. However, more recent studies have raised concerns about the conclusiveness of this evidence. Some investigations have failed to demonstrate any significant advantage of full-mouth protocols performed within 24 hours over the standard quadrant wise approach\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Given that the evidence is not conclusive, the choice of the subgingival debridement protocol is ultimately at the discretion of the clinician treating the patient. In this regard, the clinician may take into account the patient's preference, logistical settings, and cost-effectiveness.\u003c/p\u003e \u003cp\u003eThe results of this study highlight the effectiveness of three different non-surgical periodontal debridement protocols, Q-Sc\u0026thinsp;+\u0026thinsp;RSD, FMDeb, and FMDis. While this study intended to compare the effectiveness of these three debridement approaches in reducing the PD and BS of patients with stage II/III periodontitis, the overall results indicate that all three approaches were effective in obtaining significant clinical outcomes. For example, there were significant reductions in deep pocket distribution (p\u0026thinsp;=\u0026thinsp;0.000\u0026ndash;0.001), and bleeding scores (p\u0026thinsp;=\u0026thinsp;0.000) of patients who were treated through three debridement approaches. The dramatic reduction in deep pockets and bleeding scores implies the achievement of an improved periodontal status of patients in this study, underscoring the worth of all three non-surgical approaches performed in the treatment of periodontitis. However, the dramatic reduction in post-treatment plaque scores of patients in all three groups appeared to be highly beneficial for the improved clinical outcomes measured by the reduction of pocket depth distribution and bleeding scores. Irrespective of the method of periodontal debridement, improved oral hygiene status with reduced plaque scores is an established key to success from treatment.\u003c/p\u003e \u003cp\u003eAlthough this study implies the potential benefits in any of the approaches for non-surgical debridement in NSPT, the full-mouth approaches, (FMDeb and FMDis) revealed slightly better outcomes when compared with the conventional Q-Sc\u0026thinsp;+\u0026thinsp;RSD. This is especially true regarding the deep pocket reduction and bleeding scores. This finding aligns with the previous studies advocating full-mouth treatment protocols, as they may reduce the risk of bacterial recolonization and promote better overall periodontal health outcomes\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Similar to the findings in our study, some previous studies have reported that there were no significant differences between Q-Sc\u0026thinsp;+\u0026thinsp;RSD and full-mouth protocols\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our study, no significant differences were observed between the two groups treated with full-mouth protocols, in terms of reduction of deep pocket distribution or bleeding scores at post-treatment. A previous systematic review has substantiated this finding that full-mouth debridement, with or without antiseptics, does not provide clinically relevant advantages. Further, it is stated that the full-mouth protocols may not provide additional beneficial clinical outcomes over conventional staged debridement for patients with chronic periodontitis\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Another systematic review comparing full-mouth scaling, with or without antiseptics, to quadrant scaling found only minor differences between the different treatment strategies for adults with chronic periodontitis\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. As recommended in the EFP S3 level clinical practice guidelines, subgingival periodontal instrumentation can be performed using either conventional quadrant-wise or full-mouth delivery within 24 hours when managing patients with stage I-III periodontitis. However, it is important to note that the protocols involving antiseptics, such as full-mouth disinfection, have not been elaborated in the EFP CPG. Yet, it does not preclude the clinicians of their choices and flexibility in deciding the most suitable approach for the individual patient.\u003c/p\u003e \u003cp\u003eMoreover, some studies have indicated that clinical improvement of patients may depend on the duration of the follow-up. The healing response following non-surgical treatment can continue for six to nine months post-treatment\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. For instance, one study found that, while all three treatment modalities led to improvements in clinical and microbiological parameters, significant differences were not observed after eight months\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Since our study includes the periodontal measurements obtained from patients only up to two months, it may limit our ability to interpret of the predictions on long-term outcomes.\u003c/p\u003e \u003cp\u003eAccording to established literature, it is envisaged that thorough plaque control advice and guidance on home-care maintenance delivered to patients at the initial phase of periodontal therapy is crucial for the desired periodontal treatment outcomes following NSPT\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. In the present study, meticulous chair-side oral hygiene instructions were provided to all patients during the initial visit with systematic reinforcement, every two weeks as they attended the follow-up appointments. At each visit, oral prophylaxis/PMPR was performed. Consequently, significant improvements in plaque scores of patients across all three treatment groups were evident after treatment, when compared with pre-treatment plaque scores. Additionally, there were no significant differences in post-treatment plaque scores among the patients in different treatment groups. This emphasizes the fact that, regardless of the debridement protocol used, meticulous plaque control is crucial in achieving the desired clinical outcomes following periodontal therapy.\u003c/p\u003e \u003cp\u003eAs evident in the literature, there is considerable variation among studies in the FMDis protocol regarding the choice of disinfectant, its concentration, method of application, and the duration of use. Such variations may also influence the clinical outcomes reported in these studies. Further, modified FMDis protocols have emerged, which incorporate strategies such as prolonged post-treatment chlorhexidine use, using amine fluoride, providone iodine, antibiotic- or probiotic supplementation, photodynamic therapy and periodontal dressings in place of chlorhexidine\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Research involving chlorhexidine-based protocols indicates a potential relapse in the microbiota, microbial composition and pathogenicity when chlorhexidine was ceased after its use for eight months. This may raise questions about the long-term benefit and efficacy of chlorhexidine-based FMDis\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eClinicians should be aware that prolonged exposure for subgingival debridement may significantly influence the release of acute-phase reactants, triggering the systemic inflammatory response in the patient. This systemic implication is concerning, if full-mouth protocols are to be used on patients with cardiovascular diseases (CVD). For instance, FMDis and FMDeb may trigger a more pronounced acute-phase response within 24 hours compared to Q-wise Sc\u0026thinsp;+\u0026thinsp;RSD, which is performed intermittently over several weeks\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Therefore, the decision-making for an intense subgingival debridement should always include careful consideration of the general health status of the patient\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn terms of periodontal healing time, the Q-Sc\u0026thinsp;+\u0026thinsp;RSD approach allows the first treated quadrant more time for healing by the time the outcomes are assessed. This may affect the results at the re-evaluation time, although the impact could be minimal, if the recommended healing period is allowed for all periodontal sites in the mouth\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFull-mouth debridement protocols provide comprehensive care in a single visit, enhancing patient compliance for attendance. However, the increased systemic responses may be overwhelming for some patients. An increase in body temperature and a notable acute-phase response have been observed following full-mouth treatment modalities\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. A consensus report from the EFP and the World Heart Federation (WHF) recommends that individuals with CVD undergo non-surgical periodontal therapy in shorter sessions of 30 to 45 minutes to minimize systemic inflammation, regardless of their CVD status or medications\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn contrast, quadrant-wise debridement reduces acute systemic inflammation, and allows for a more focused approach for oral hygiene monitoring/reinforcement, over several treatment visits. However, it requires multiple visits, which may affect the compliance for attendance by some patients. Therefore, the clinician may need to select the most appropriate treatment approach for the individual patient, with careful consideration for overall health and specific needs.\u003c/p\u003e \u003cp\u003eAs evident in the EFP CPG\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, the patient preferences for subgingival debridement approach and patient-reported outcomes have inconsistently been reported, with no evidence supporting one subgingival debridement approach over the other. Reports of any discomfort or side effects related to full-mouth protocols are not included in the EFP CPG. In our study, the patient-reported outcomes were not evaluated, which is identified as a limitation when considering the overall acceptance of subgingival debridement approaches by the patients. This may limit our ability for a balanced recommendation of full mouth protocols over conventional approach, despite their advantages pertaining to desirable clinical outcomes and lesser treatment visits for the patient.\u003c/p\u003e \u003cp\u003eMoreover, the microbiological assessments are highly relevant in interpreting the treatment outcomes such as reduced pocket depths, pocket closure, bleeding scores observed in a clinical study which followed different approaches for subgingival debridement. Although microbial assessments were beyond the scope of the present study, future studies should be directed to connect the desirable clinical outcomes with the microbial profiles. Such an approach could underpin the rational use of antimicrobial supplements to mechanical subgingival debridement.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWith the limitations of this study in mind, it can be concluded that although all three treatment modalities are effective in reducing the probing depths and bleeding scores of patients with periodontitis, FMDeb and FMDis protocols demonstrate superior effectiveness in terms of reduction of bleeding scores and deep pocket distribution compared to the Q-wise-Sc\u0026thinsp;+\u0026thinsp;RSD protocol. However, at post-treatment, all three study groups demonstrated remarkably low bleeding scores with statistically significant differences when compared with their respective pre-treatment bleeding scores. The choice of the subgingival debridement protocol is ultimately at the discretion of the clinician by taking patient's preference, medical status, and other operational factors into consideration.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBleeding Score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHX\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChlorhexidine gluconate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiovascular Disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDPT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDental panoramic Tomogram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFaculty of Dental Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFMDeb\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFull Mouth Debridement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFMDis\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFull Mouth Disinfection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNSPT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNonsurgical Periodontal Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProbing Pocket Depth\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrincipal Investigator\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePlaque Score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePMPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProfessional Mechanical Plaque Removal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQ-Sc\u0026thinsp;+\u0026thinsp;RSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuadrant-wise Scaling and Root Surface Debridement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSG1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStudy Group 1\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSG2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStudy Group 2\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSG3\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStudy Group 3\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSupportive Periodontal Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversity of Peradeniya\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate-\u003c/strong\u003e This study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Ethics Review Committee, FDS-UOP (FRC/FDS/UOP/I/2021/05).\u0026nbsp;Informed consent was secured from all participants prior to their involvement in the research. Each participant\u0026nbsp;received detailed information about the study and voluntarily agreed to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication-\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials-\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests-\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding-\u003c/strong\u003eThis study was self-funded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKMCP\u003c/strong\u003e-Literature review, treating patients, data collection, and data entry; writing the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUG\u003c/strong\u003e-Statistical analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRW\u003c/strong\u003e- contributed to the conception and design of the study including selecting appropriate statistical tests and analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAT\u003c/strong\u003e-Literature review, study design, random allocation of patients into groups, supervision; writing and editing the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements-\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAfacan B, \u0026Ccedil;ınarcık S, G\u0026uuml;rkan A, \u0026Ouml;zdemir G, İlhan HA, Vural C, K\u0026ouml;se T, Emingil G. 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J Clin Periodontol. 2005;32(8):851\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1600-051X.2005.00776.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1600-051X.2005.00776.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 15998268.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global oral health status report: towards universal health coverage for oral health by 2030. World Health Organization; 2022. Nov 18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZijnge V, Meijer HF, Lie MA, Tromp JA, Degener JE, Harmsen HJ, Abbas F. The recolonization hypothesis in a full-mouth or multiple‐session treatment protocol: a blinded, randomized clinical trial. J Clin Periodontol. 2010;37(6):518\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Periodontitis, Nonsurgical treatment, Root-surface debridement, Full-mouth Disinfection, Full-mouth Debridement, Quadrant-wise Scaling and Root Surface Debridement, Bleeding Scores, Pocket depth, Clinical outcomes, Effectiveness","lastPublishedDoi":"10.21203/rs.3.rs-6712357/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6712357/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNon-surgical periodontal therapy (NSPT) is the cornerstone of periodontitis management. This comparative clinical study evaluates the effectiveness of three different non-surgical treatment approaches in three treatment groups namely, Quadrant-wise Scaling and Root Surface Debridement (Q-Sc\u0026thinsp;+\u0026thinsp;RSD), Full-mouth Disinfection (FMDis) and Full-mouth Debridement (FMDeb).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 45 patients with generalised periodontitis were randomly assigned to one of the three treatment groups. Plaque scores (PS), bleeding scores (BS) and probing pocket depths (PD) were recorded at baseline and post-NSPT. Data was analysed to compare the changes in BS and PD distribution at baseline and post-NSPT, in all three groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll three treatment approaches resulted in statistically significant reductions in BS and PD distribution compared to baseline. However, FMDeb and FMDis protocols demonstrated greater reductions in BS and PD distribution compared to the Q-Sc\u0026thinsp;+\u0026thinsp;RSD protocol. Remarkably low BS were observed in all three study groups at the post-treatment evaluation, with statistically significant differences, compared to their respective pre-treatment BS.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAll three treatment approaches were effective in reducing BS and PD in patients with periodontitis, while FMDeb and FMDis protocols demonstrated superior effectiveness in terms of reduction of BS and PD, compared to Q-Sc\u0026thinsp;+\u0026thinsp;RSD protocol. Further research with larger sample sizes and longer follow-up periods may be warranted to confirm these findings and evaluate the long-term clinical outcomes of these different debridement approaches of NSPT.\u003c/p\u003e\u003ch2\u003eClinical Trial No:\u003c/h2\u003e \u003cp\u003eThe UK\u0026rsquo;s Clinical Study Registry ISRCTN13350022, 28/05/2025, retrospectively registered\u003c/p\u003e","manuscriptTitle":"Management of periodontitis by three different approaches to non-surgical periodontal debridement – A randamized comparative clinical study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-04 09:23:04","doi":"10.21203/rs.3.rs-6712357/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-25T09:36:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-24T19:05:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-23T13:11:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74381837212905039806525641346527261767","date":"2025-06-06T19:30:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263170256686691569430123396793712104951","date":"2025-06-06T18:12:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240728567481470165563110553768151274263","date":"2025-06-04T19:15:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272053536885621036430489674696740383604","date":"2025-05-31T04:56:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-30T15:56:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-29T10:00:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-29T05:31:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-05-29T05:30:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"faaf25df-286d-4e32-b4be-23e63bdebb4a","owner":[],"postedDate":"June 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-07T07:11:44+00:00","versionOfRecord":{"articleIdentity":"rs-6712357","link":"https://doi.org/10.1186/s12903-025-06595-x","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2025-07-17 16:04:56","publishedOnDateReadable":"July 17th, 2025"},"versionCreatedAt":"2025-06-04 09:23:04","video":"","vorDoi":"10.1186/s12903-025-06595-x","vorDoiUrl":"https://doi.org/10.1186/s12903-025-06595-x","workflowStages":[]},"version":"v1","identity":"rs-6712357","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6712357","identity":"rs-6712357","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}