Surgical Versus Non-Surgical Treatment of Periodontitis: The Past, the Present, the Future

Overall, the goal of periodontal therapy is to maintain the natural dentition in health, comfort, and function. For decades, dentists have considered, discussed, and debated the fundamental question of whether to use surgical or non-surgical therapy to treat periodontitis [1, 2]. Historically, decisions for or against using various treatments were based on anecdotal evidence and clinical experience. Over the last 50 years or so, clinical research has provided objective data to support both methods of therapy. This led to the current management of periodontitis, which involves a combination of both non-surgical and surgical interventions. One of the main questions facing clinicians today is how to monitor the stability of periodontitis following treatment so they can intervene to prevent or reverse further loss of periodontal support. While future treatment strategies cannot be predicted, advances in periodontal diagnosis, new technology, cost-effectiveness, precision care, artificial intelligence, and new ways to control periodontal inflammation are likely to influence future methods of periodontal treatment.

It should be noted that these studies used practitioner-measured outcomes of probing depth and CAL rather than the patient-centered outcome of tooth retention. This was necessary because tooth loss from periodontitis occurs over many years, making it impractical to use as an outcome measure in shorter studies. However, CAL is generally accepted as a valid measure of periodontal support and, importantly, CAL loss ≥ 2 mm has been validated as an informative surrogate for tooth loss in a large 26-year population study [20].

In the past, surgical and non-surgical treatment for periodontitis were often viewed as distinct and separate treatment strategies. Today there is more emphasis on integrating non-surgical and surgical treatment into a continuum of therapy. Depending on specific diagnoses, systemic health, risk factors, and other considerations, both are frequently used and have been endorsed by the American Academy of Periodontology [23] and the European Federation of Periodontology [24].

It is impossible to predict the future of any discipline, but current trends can provide some insight into what may transpire in coming years. Regardless of future treatment methods, controlling periodontal inflammation and the oral biofilm will remain essential for successful surgical and non-surgical periodontal therapy. New developments in helping patients improve oral hygiene and comply with supportive care and new ways to change harmful behaviors such as substance and tobacco use could have profound effects on periodontal treatment methods. Rather than using a periodontal probe and laborious methods of physical clinical measurement (i.e., CAL, probing depth, BOP), future clinicians will likely use improved diagnostic methods and biomarkers that will allow precise identification of patients or sites within patients at risk for progressive periodontitis in real time. There is also a significant potential for artificial intelligence to have a central role in future periodontal diagnosis, prognosis, and treatment [35-37]. Today, generic periodontal treatment plans are used for most patients, but there is recent evidence that not all individuals respond equally to periodontal therapy because of varying environmental, microbial, immunological, and systemic health conditions [38]. Given rapid advances in artificial intelligence, one can easily imagine a future when artificial intelligence uses specific patient and periodontal information to make data-driven diagnoses and recommend precision treatment that is personalized for individual patients. Minimally invasive non-surgical and surgical treatments, microsurgery, and periodontal regenerative procedures are showing promise [4, 19, 39, 40]. As new technologies become available, it is likely that future periodontal therapy will be less invasive and more targeted at specific periodontal sites that are progressive or more likely to respond to treatment. Coupled with new developments in periodontal regeneration, this could result in increased cost-effectiveness, better patient acceptance and adherence to periodontal therapy, fewer treatment complications, less patient discomfort, and better treatment outcomes. Overall, the future is likely to bring advances in periodontal therapy that will likely render the distinction between surgical and non-surgical therapy irrelevant and mainly of historical interest.