Efficacy of Chemical Root Surface Modifiers in the Treatment of Periodontal Disease. A Systematic Review

BACKGROUND: Periodontal regeneration has been a relentless goal of the periodontist. Perhaps the oldest and most frequently attempted type of regeneration has involved chemical modification of the root surface. Varying results from histological and clinical studies have created controversy about the clinical effectiveness of root surface decalcification. RATIONALE: This systematic review assesses the efficacy of root surface biomodification through the use of citric acid, tetracycline, or ethylenediaminetetraacetic acid (EDTA) in patients with chronic periodontitis. FOCUSED QUESTION: Does the use of chemical root declacification result in effective periodontal regeneration and improved clinical outcomes in patients with chronic periodontitis? SEARCH PROTOCOL: The Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effectiveness; Cochrane Central Register of Controlled Trials; American College of Physicians Journal Club, evidence-based MEDLINE journals; and National Center for Biotechnology Information PubMed Journals, as well as Dogpile, Google, and Copernic search engines were screened. Hand searches were performed on the Journal of Clinical Periodontology, Journal of Periodontology, Journal of Periodontal Research, and Periodontology 2000. Searches were performed for relevant clinical trials published through September 25, 2002. INCLUSION CRITERIA: Histological and clinical studies evaluating the effects of citric acid, tetracycline, or EDTA on root surfaces of patients with chronic periodontitis were considered for inclusion. EXCLUSION CRITERIA: Studies evaluating extracellular matrix proteins (e.g., fibronectin), enamel matrix proteins (e.g., amelogenins), or other proteins or growth factors applied to the root surface were not included. DATA COLLECTION AND ANALYSIS: Primary outcome measures included changes in connective tissue attachment, cementogenesis, clinical attachment levels, probing depths, and gingival recession. Secondary outcome measures included changes in bone level, gingival inflammation, and plaque levels. Results for continuous outcome measures for primary variables (clinical attachment levels, probing depths, and recession) were expressed as mean differences or standardized mean differences. Clinical attachment levels and reduction in probing depth were evaluated using meta-analysis. All papers were rated according to methodological strength of evidence. MAIN RESULTS: 1. Thirty-four studies incorporating a total patient population of 575 were analyzed: 26 for citric acid, 5 for tetracycline, and 3 for EDTA treatment. 2. Four of 8 human histological studies reported regeneration with the use of citric acid. Only 1 of 18 clinical studies reported attachment gain. 3. Of the 5 studies examined using tetracycline, 1 histological study and 1 clinical study reported attachment gain. 4. No regeneration was reported in the 3 studies evaluating the use of EDTA. 5. Meta-analysis performed on 28 clinical trials did not show any significant effects of acid root treatment on attachment level gains or probing depth. REVIEWER'S CONCLUSIONS: 1. Evidence to date suggests that the use of citric acid, tetracycline, or EDTA to modify the root surface provides no benefit of clinical significance to regeneration in patients with chronic periodontitis. 2. The best method for ascertaining the clinical efficacy of acid-treated root regeneration would be to conduct a randomized clinical trial with sufficient statistical power that is supported by quantitative histological evaluation. 3. The majority of the studies that evaluated the regenerative potential of root surface modifiers were observational in nature; therefore, the value of conclusions reached in this manuscript must be carefully considered.