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SANZ et al .
R2.2 | Are treatment outcomes of subgingival instrumentation better after use of hand, powered (sonic/ ultrasonic) instruments or a combination thereof? Evidence-based recommendation (2.2) We recommend that subgingival periodontal instrumentation is performed with hand or powered (sonic/ultrasonic) instruments, either alone or in combination. Supporting literature Suvan et al. (2019) Quality of evidence Four RCTs ( n = 132) with a follow-up of ≥6 months. Grade of recommendation Grade A—↑↑ Strength of consensus Unanimous consensus (6.2% of the group abstained due to potential CoI)
The endpoint of treatment is pocket closure, defined by probing pocket depth (PPD) ≤4 mm and absence of bleeding on probing (BOP). Available evidence One RCT on 169 patients with 3-month outcomes addressed the PICOS question. Further 11 prospective studies ( n = 258) with a follow-up of ≥6 months which considered baseline measures and post-treatment reductions in probing pocket depth (primary out - come) and bleeding on probing and percentage of closed pockets (secondary outcomes) were analysed. Risk of bias Study quality assessment identified a low risk of bias in all but one study, which had a high risk of bias. Consistency Evidence was consistent across all 11 studies that were included in the pre- and post-treatment analysis and was therefore con - sidered strong. Patient-reported outcomes were inconsistently reported and adverse events, when reported, were rare. No indi - cations of publication bias were observed but heterogeneity was high. Clinical relevance and effect size The evidence suggested a mean reduction of PPD of 1.7 mm at 6/8 months, a mean proportion of closed pockets of 74% and a mean reduction of BOP of 63%. Deeper sites (>6 mm) demonstrated a greater mean PPD reduction of 2.6 mm. Balance of benefits and harm An overall consideration of the benefit versus harm of subgingival instrumentation supports the strength of the recommendation. Ethical considerations Evaluation of the efficacy of subgingival debridement is ethically challenging as it would entail comparison with no subgingival inter - vention. Due to the lack of relevant RCTs, prospective studies were included and their data analysed. Applicability The majority of studies were conducted in well-controlled re - search environments and included specifically selected popu - lations, that is those with no systemic disease. While results from studies involving populations with systemic diseases were not included in the systematic review, there is a consensus that subgingival instrumentation is efficacious in these groups (Sanz et al., 2018, 2019), but the magnitude of the effect requires fur - ther study. The evidence presented illustrates “efficacy” rather than “effec - tiveness”; therefore, generalizability to general dental practice set - tings is unclear.
Background
Intervention Numerous types of instruments are available to perform subgingival instrumentation. Available evidence Four RCTs ( n = 132) with a low overall risk of bias were included. Findings were evaluated at 6/8 months for PPD reduction (primary outcome) and clinical attachment level (CAL) gain (secondary outcome). Risk of bias Study quality assessment identified all four studies to be at low risk of bias. Consistency The evidence demonstrated that outcomes of treatment were not dependent on the type of instrument employed. The evidence was considered strong and consistent. No indications of publication bias were observed but heterogeneity was high. Clinical relevance No clinically or statistically significant differences were observed between the different types of instruments. Balance of benefits and harm The use of all types of instruments is technique-sensitive and there - fore requires specific training. Patient-reported outcomes and ad - verse events were inconsistently reported. If present, no obvious differences between hand and powered instruments in terms of post-operative sensitivity were noted. Ethical considerations There is a potential ethical dilemma in that patient preference may conflict with the clinician's preference in terms of type of instru - ment. Patient autonomy should be respected.
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