No new clinical procedure for the non-surgical and surgical treatment o f moderate or advanced periodontal disease has been introduced in the past 40 years. Subgingival scaling with instruments o f traditional design is still the
mainstay o f periodontal therapy. Surgical elimination o f periodontal pockets using gingivectomy or flap procedures has been in use for the last century (Loe, 1993).
According to the earlier epidemiological studies based on conventional concept o f periodontal disease, there is a large need estimated for normative treatment for periodontal disease in any population group. The need is always unrealistic and beyond the resources available. For example, a report o f a study in Dental Manpower for North Carolina (Bawden and DeFreise, 1981) showed that 602,000 hours o f dentists’ time was needed per year to treat periodontal disease and 44,000 hours in addition for treating the new incidence for the population o f the state. Over 1 million people needed periodontal treatment and almost 400,000 required advanced treatment. However, the report also showed that the current annual services for periodontal treatment was 126,000 hours and demand was about 13%. Oliver et al (1989) also estimated 120-130 million hours annually o f periodontal treatment needs for the US adult population; o f which 89% was for prophylaxis, 8% for scaling and root planing and 3% for surgery. The annual cost was 5-6 billion US dollars. The discrepancies between need and resources is worse in developing countries. A study o f manpower for periodontal treatment in Thailand (Dusadeepan, 1986) using CPITN and WHO guidelines estimated a need for 21,910 personnel, working full-time on periodontal care. In 1986, the total number of dental personnel in Thailand was under 3,000. A similar study in Kenya (Manji and Sheiham, 1986), estimated that 1,432 to 4,297 working year would be required to provide periodontal treatment. It was also estimated that Kenya’s 200 dentists would require between 7 to 21 years to provide treatment for just one cohort of 5-15 year-olds. In dental treatment need projection o f
the West Malaysian Population (Kadir, 1992), 8.2 million hours per year was estimated for periodontal treatment. While the number o f registered dentists in M alaysia in 1989 was only 1401 and the budget proportion o f the Dental Division was approximately constant over the decade.
However, the current concept that most gingivitis does not progress to periodontitis has raised the question about the need for regular professional prophylaxis. It was shown that the mineralized part o f both supragingival and subgingival calculus are not in contact with the periodontal tissues, and that calculus is invariably covered by a soft, non-mineralized plaque that lies in immediate contact with the epithelial cells of the gingival sulcus (Waerhaug, 1952). Pilot (1980) concluded that in gingival inflammation without loss o f connective tissue attachment, proper oral hygiene may eliminate the disease. Professional care may not be necessary in all cases. Particularly, from the public health viewpoint, it should be considered that there is no populations or major group of individuals who, in the absence o f active prevention or removal, go through life without calculus (Komman and Loe, 1993). A workshop on Public Health Aspects o f Periodontal Disease (Frandsen, 1984) considered that it is unrealistic, and possibly undesirable, that the public responsibility should be to eliminate incipient gingival inflammation.
For gingival inflammation combined with loss o f connective tissue attachment, non-surgical treatment has been shown to be effective in eliminating inflammation, reducing probing depth and maintaining acceptable attachment levels. In areas of inaccessability o f root surfaces, surgical flaps may be needed to achieve access (Frandsen, 1984). Evaluation o f the various therapeutic modalities have shown that whether the competent clinician treats
the advanced lesion surgically or non-surgically makes no major difference (Rosling et al, 1976). Antczak-Bouckoms (1993) used meta-analysis method to analyse five studies comparing surgical and non-surgical periodontal treatment. The results showed that surgical treatment offered a greater benefit in consideration of pocket depth reduction, and in increase o f attachment loss only for pockets with an initial pocket depth o f 7 mm or more. Non-surgical therapy resulted in a greater increase in attachment level than surgical therapy for the initial pocket depth less than 7 mm. Antczak-Bouckoms and Weinstein (1987) used quality-adjusted tooth years as an outcome measure to evaluate alternatives o f periodontal control. The decision analysis favoured conservative, non-surgical approaches for all levels o f disease severity. The most cost-effective method was non-surgical treatment for teeth with 4-6 mm pocket depth and ^10 mm loss o f attachment by general dentists, while the least cost-effective was for teeth with ^3 mm pocket depth and no loss o f attachment. Matthews and McCulloch (1993) used patient’s perception as outcomes to compare surgical and non-surgical periodontal treatment and showed that patients experienced postoperative discomfort such as pain, swelling, and dissatisfaction with aesthetics and functional limitation twice as often from surgical compared to non-surgical treatment.
High-risk individuals for periodontal treatment need can only be identified by having excessive loss o f attachment. They represent only a small part o f a population (Oliver et al, 1993). While the rest can maintain their dentitions through a population strategy that focuses on educating the public to improve their periodontal awareness and oral hygiene (Sheiham, 1991).