Issue No. 139
Summarized from Journal of Clinical Periodontology, Volume 52, Issue 7, July 2025, 932–939
Editor: James Deschner, chair, EFP scientific affairs committee
How do clinical and patient-reported outcomes compare in treatment of teeth with grade III C furcation?
Authors: Priya Bahal, Pasquale Santamaria, Zainab Malaki, Jeremy Redman, Luigi Nibali
Background
Furcation involvement, characterized by horizontal and vertical clinical attachment loss, significantly increases the risk of tooth loss. Teeth with furcation involvement (especially grade II C and grade III C) frequently do not respond well to non-surgical therapy and there are no clear treatment guidelines.
Indeed, the complex configuration of the lesion renders both non-surgical and surgical procedures challenging because of the difficulty of access and decontamination, especially in grade III C.
There is therefore a need for stronger clinical evidence to support the management of advanced furcation involvement, along with a more significant move toward individualized periodontal care that considers each patient’s unique characteristics and preferences to develop personalized treatment strategies.
Aim
The aim of this study was to assess the feasibility of applying the sequential, multiple assignment, randomized trial (SMART) design in periodontology and to assess the response of grade III furcation-involved molars to different treatments (non-surgical periodontal treatment and open flap debridement) by using a composite outcome.
Materials & Methods
- A single-centre, single-masked, randomized feasibility clinical trial using a SMART design, with a 12-month follow-up to assess outcomes—patient-reported outcome measures (PROMs), periodontal probing depth (PPD) reduction, gingival recession—in grade III furcation-involved molars.
- Patients referred to Guy’s Dental Hospital were assessed by a full periodontal examination including medical and dental history, intraoral examination, full-mouth periodontal probing (full-mouth plaque score, PPD, and gingival recession were recorded), and periapical radiographs.
- All patients had professional plaque removal within six months. The selected molar had confirmed grade III C furcation lesion without endodontic or mobility issues.
- Participants were randomly assigned to non-surgical periodontal treatment (NSPT) or open-flap debridement (OFD) using sealed envelopes. The outcome examiner remained blinded until data collection ended.
- Success was defined clinically as the absence of PPD ≥6mm with bleeding on probing (BoP), while the participant-reported parameter for success was defined as ≤1 “Yes” response to questions in a furcation-specific questionnaire. Patients answered Yes/No questions related to discomfort, bleeding, and sensitivity immediately after treatment and then six and 12 months later.
- Healing was reviewed by the same examiner at one, three, six, and 12 months after initial treatment.
Results
- Twenty participants (mean age 56 ± 10.1 years; 55% female) were randomized equally to NSPT or OFD for treatment of grade III C furcation-involved molars.
- At six months, clinical success was achieved in six out the 10 participants treated by NSPT and seven of the 10 participants treated by OFD.
- Non-responders from both groups then followed the SMART protocol (Figure 1):
- Of the four NSPT non-responders, two received OFD and two were placed in supportive care because of complications or lack of indication.
- None of the three OFD non-responders received further surgery either because they refused or because of their poor plaque control.
- One NSPT responder was misclassified and received unnecessary OFD.
- At 12 months, 18/20 participants were reviewed (one was lost to follow-up, one had the relevant tooth extracted).
- Considering all patients independently of the type of treatment provided, mean PPD reduction (baseline: 2.9mm ± 1.6, 12 months: 2.4mm ± 1.3 (p < 0.001)), mean clinical attachment loss (CAL) reduction (baseline: 4.2mm ± 2.7, 12 months: 3.5mm ± 2.4 [p < 0.001]) and mean reduction of the number of sites with PPD ≥5 mm (baseline: 20.4mm ± 14; 12 months: 11.8mm ± 7.8 [p = 0.046]) were measured.
- Interestingly, the deepest sites at teeth treated with OFD displayed a more significant reduction of the PPD (baseline: 7.3mm ± 2.54; 12 months: 4.2mm ± 0.97) with a difference of -3.1mm (p < 0.01), compared to teeth treated with NSPT, which evolved from 6.8mm to 5.1mm with a mean difference of -1.7mm, which was not statistically significant (p=0.06).
- Clinical success was obtained for 80% of the test teeth at six months and 83% at 12 months. Patient-reported success was 80% at both six and 12 months.
- Clinical and patient-reported outcomes coincided in 12 of the 20 cases (60%) at six months and in 14 of the 18 cases (78%) at 12 months, highlighting the value of dual outcome measures.
Limitations
- A small sample size.
- This is a single-site study.
- The examiner- or patient-driven deviations from the allocation of retreatment.
Conclusions and impact
- The first randomized clinical trial in periodontology to use a SMART design demonstrated the feasibility of its use.
- It also highlighted the value of combining clinical and patient-reported outcomes to define success.
- The trial also provided a comparison of surgical and non-surgical treatments for grade III furcation lesions.
The SMART study design offers many advantages and could be used more extensively in research in dentistry.
Rapporteur: Simone Sbalchiero, Aikaterini Vasileiou, Eirini Militsi, supervised by Pierre-Yves Gegourt and Prof. Olivier Huck
Affiliation: Postgraduate programme in periodontology,University of Strasbourg, France
With kind permission from Wiley Online Library. Copyright © 1999-2025 John Wiley & Sons, Inc. All rights reserved
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