Evaluation of Furcation Region Response to Periodontal

Therapy*
Kenneth L. Kalkwarf.t Wayne B. Kaldahll4; and Kashinath D. Patil§
Accepted for publication 15 March 1988

Five hundred fifty-eight molars were treated with one of four types of periodontal
therapy: coronal scaling (CS); planing (RP); modified Widman surgery (MW); or flap
root
with osseous resectional surgery (FO). This report presents the probing depth and probing
attachment changes in the furcation region following therapy and two years of maintenance
follow-up. All types of therapy were effective in reducing probing depths. FO was the most
effective in reducing probing depth followed by MW, RP, and CS. Reduction in probing
depth was primarily due to gingival recession. FO resulted in a loss of probing attachment
in both a vertical and horizontal direction following therapy. Following two years of
maintenance care, sites treated with FO continued to exhibit a mean net loss of vertical
probing attachment. A mean net loss of horizontal probing attachment was present after
two years of maintenance care, regardless of the treatment modality employed. Many more
sites were initially removed during osseous resectional surgery to achieve treatment criteria
than were initially removed from the other groups. FO treated teeth demonstrated a lesser
percentage of furcation sites demonstrating clinically significant breakdown during the two
years of maintenance care.

Several investigators have specifically evaluated the
longitudinal response of molar teeth to periodontal
therapy,1"5 but little data exist from perspective, con-
trolled, clinical trials evaluating the response of the
furcation region to therapy.
Hamp and co-workers6 reported the five-year follow-
up of 100 individuals who had undergone pocket elim-
ination periodontal therapy around molar teeth. The
results of therapy remained stable over the five year
period. To achieve their therapy goals, this group chose
to extract 44% of the teeth with furcation involvement
prior to or during therapy. Fifty percent of the remain-
ing teeth were treated by resection of one or more roots.
Hirschfeld and Wasserman7 described 600 patients
who had been treated and followed for at least 15 years
in a maintenance program. Therapy consisted of var-
ious clinical procedures including both surgical and
nonsurgical techniques. Thirty percent of first and sec-
ond molar teeth that originally exhibited furcation in-
volvement were lost during an average of 22 years of
*
This study was supported by NIH-NIDR Grant DE06103.
t School of Dentistry, University of Texas at San Antonio, Health
Science Center, San Antonio, TX.
X College of Dentistry, University of Nebraska Medical Center,
Lincoln, NE.
§ College of Medicine, University of Nebraska Medical Center,
Omaha, NE.
794
maintenance care. In a subgroup that they classified as
"well-maintained," the loss was 18.5% over the same
period.
Ross and Thompson8 retrospectively evaluated 100
patients with 384 maxillary molars having furcation
involvement. Regions were initially treated with sur-
gical and nonsurgical therapy procedures aimed at
reducing, but not eliminating, the pocket. No osseous
surgery was performed. Evaluation of therapy results
took place following 5 to 24 years of maintenance care.
During that period, 12% of the treated teeth were
extracted. One-third of the extracted teeth had func-
tioned for 11-18 years following therapy when extrac-
tion was performed. Radiographic evaluation indicated
that 75% of the treated teeth showed no significant
changes during the observation period. Two percent
had radiographie suggestion of improvement and 11 %
demonstrated perceptible evidence of alveolar bone
loss.
Bjorn and Hjort9 evaluated, over a 13 year period,
773 mandibular molars in 221 individuals who did not
receive periodontal care. The frequency of sites exhib-
iting bone destruction in the furcation region increased
from 12% to 32% over the 13 years. Two and one-half
percent of the teeth were lost during the evaluation
period due to progressive periodontal involvement.
Becker and co-workers10 reevaluated 44 patients who
Volume 59
Number 12
had previously undergone a periodontal examination,
but had failed to initiate therapy. A mean period of
5.25 years had elapsed between examinations. Of 268
molars which were present at both examinations, 184
had no detectable furcation involvement at the first
examination. At the second examination, 31 % of these
teeth demonstrated furcation involvement. Of the 84
teeth that had furcation involvement at the first exam-
ination, 22% had worsened by the second examination.
In a later study, Becker et al.11 retrospectively evalu-
ated the clinical response of 95 patients to periodontal
therapy and an average of 6 1/2 years of maintenance
care. Therapy was said to consist of preliminary scaling
and root planing followed by pocket reduction surgery
in one or more quadrants. Specific criteria for treatment
of furcations were not provided by the authors.
Of the total number of furcations (568), 323 had no
detectable furcation invasion at the first examination.
Twenty-two percent of these furcations developed de-
tectable invasion by the conclusion of the study. Twelve
percent of teeth that originally had detectable invasion
demonstrated continuing breakdown during the course
of the study.
McFall12 retrospectively reported tooth loss in a
group of 100 patients treated and maintained for at
least 15 years. Fifty-seven percent of the teeth that had
furcation involvement at the initial examination were
lost during therapy and maintenance. A subgroup of
the population termed "well-maintained" demon-
strated a 27% loss rate.
Norland and associates13 demonstrated that furcation
sites reacted less favorably to plaque control and root
debridement than molar flat surfaces and nonmolar
sites. Furcation sites demonstrated a loss of probing
attachment over a two year period following therapy,
with 5.7 to 21.1% (depending upon initial probing
depth classification) of the sites demonstrating loss that
could be classified as definite deterioration.
Several clinicians have stated that a furcation region
demonstrating periodontal destruction may anatomi-
cally limit one's ability to adequately remove or disor-
ganize bacterial accumulations that may precipitate
further loss of attachment.14"16 This study will system-
atically evaluate the longitudinal clinical response of
furcation regions to four types of periodontal therapy:
coronal scaling, root planing, modified Widman sur-
gery and osseous resection surgery.
MATERIALS AND METHODS
One thousand three hundred ninety-four (1,394) fur-
cation sites associated with 556 first and second molar
teeth (282 maxillary, 274 mandibular) in 82 patients
were evaluated during this study.
Experimental Design
Molars in each quadrant of a patient's mouth were
randomly assigned to one of four therapy modalities:
Furcation Region Response 795
Group CS (coronal scaling) received supragingival scal-
ing only; Group RP (root planing) received supragin-
gival and subgingival scaling and root planing only;
Group MW (modified Widman surgery) received su-
pragingival and subgingival scaling and root planing
followed by modified Widman surgery. Group FO (flap
with osseous resection surgery) received supragingival
and subgingival scaling and root planing followed by
flap resection and osseous resection surgery.
Phase I Therapy
During Phase I therapy, teeth that exhibited probing
depth past the apex and had no evidence of pulpal
pathology were extracted or had the involved root
removed. Carious lesions were restored and necessary
endodontic therapy was completed. Teeth that had
mobility patterns which were uncomfortable for the
patient were stabilized by provisional techniques. Pro-
visional prostheses were constructed for replacement of
esthetically essential teeth. Each subject received an
occlusal adjustment to remove centric relation-centric
occlusion prematurities and slides, lateral and protru-
sive interferences and fremitus. All dental therapy was
performed by a Board-certified periodontist in associa-
tion with restorative dentists, endodontists, and prosth-
odontists.
Patients received plaque control instructions consist-
ing of techniques for tooth brushing and interdental
cleaning. Care was taken to assure that cleaning tech-
niques were consistent in all regions of the mouth.
Plaque control was reinforced at each appointment and
a plaque index (O'Leary) was recorded. Each patient
was required to achieve and maintain a plaque index
of less than 20% to progress to Phase II.
Teeth in Group CS received supragingival scaling
and debridement with ultrasonic and hand instruments.
No instrumentation was accomplished apical to the
gingival margin. Teeth in Groups RP, MW, and FO
received complete scaling and root planing. Local infil-
tration or block anesthesia was used as necessary for
patient comfort. Root planing was continued with peri-
odontal curettes until a clinically hard, smooth surface
was achieved. Plaque control instructions and root
instrumentation were accomplished by one of two den-
tal hygienists. A mean time of 5.1 hours was needed to
complete Phase I therapy for each patient.
Four weeks following the conclusion of Phase I in-
strumentation, surgery was scheduled in sites in Group
MW and FO that exhibited residual probing depths of
5 mm or greater. Sites of lesser probing depth imme-
diately adjacent to the indicated surgery areas were, by
necessity of the procedure, also included in the surgery
field. All sites originally categorized in Groups MW
and FO and not meeting the criteria to receive surgical
therapy were eliminated from the study and not in-
cluded in any analysis.

796 Kalkwarf, Kaidahl, Patii
Phase IITherapy
Phase II therapy consisted of the following
proce-
dures:
Group CS: Plaque control reinforcement and supragin-
gival polishing.
Group RP: Plaque control reinforcement and evalua-
tion of root instrumentation. Additional instrumenta-
tion, if deemed necessary, was accomplished by the
treating periodontist. No soft tissue reflection or inter-
proximal suturing was utilized.
Group MW: Plaque control reinforcement and surgical
treatment of designated sites with a modified Widman
flap procedure as described by Ramfjord and Nissle.17
Group FO: Plaque control was reinforced and surgical
treatment of designated sites was accomplished with
full thickness mucoperiosteal flaps followed by osseous
resection and recontouring to eliminate all negative
osseous architecture. Tooth extraction or root resection
were utilized when necessary to achieve treatment
goals.1819 Apical repositioning was achieved during flap
closure.
All therapy was accomplished by the same periodon-
tist that coordinated Phase I therapy.
One week following Phase II therapy, each patient
was seen for suture removal in surgical regions and
reinforcement of supragingival plaque control. The
patient was seen again at two, four, and seven weeks
for plaque control reinforcement and professional su-
pragingival plaque removal.
All patients were seen at three month intervals for
maintenance recall appointments. At each recall, peri-
odontal status was evaluated, plaque control was rein-
forced in all regions, and necessary instrumentation to
remove accumulated plaque and calculus was per-
formed. Group CS quadrants received only supragin-
gival instrumentation. Groups RP, MW, and FO re-
ceived supragingival and subgingival instrumentation.
Data Collection
Clinical examinations were completed by one cali-
brated examiner, not associated with the treatment
aspects of the study, prior to the initiation of therapy
(Exam 1), four weeks following the completion of Phase
I therapy (Exam 2), ten weeks following the completion
of Phase II therapy (Exam 3), immediately prior to the
one year maintenance appointment (Exam 4), and
immediately prior to the two year maintenance ap-
pointment (Exam 5).
Sites were eliminated from the study if they demon-
strated more than 2 mm of further probing attachment
loss at any of the described exams following the initia-
tion of therapy or at interim three month evaluations
during the maintenance phase. Eliminated sites were
retreated as deemed appropriate and reclassified for
further follow-up. This report includes data from elim-
inated sites up to the time they were reclassified.
}. Periodontol.
December 1988
Seven individuals dropped out of this study because
they moved from the geographic region. Four left the
study during their first year of maintenance care and
three left during their second year of maintenance. All
were referred to periodontists in their new home area
for maintenance follow-up. A total of 106 furcation
sites were associated with these individuals.
Clinical Measurements
Clinical data were obtained at the midpoint of each
furcation site for all first and second molar teeth. Data
analyzed in this report are:
Probing Depth: Each furcation site was probed with
50 grams vertical force using an electronically con-
trolled handle* containing a periodontal probet having
a terminal diameter of 0.35 mm and calibrated at 1
mm increments. The distance from the most apical
extent of the probe tip penetration to the gingival
margin was recorded to the nearest millimeter. If gin-
gival recession was present in the furcation region,
resulting in the exposure of two root surfaces, the
probing depth along the internal portion of each root
surface was measured and the greatest measurement
was recorded.
Probing Attachment Level: The distance from the
gingival margin to a permanent fixed reference (restor-
ative margin or cementoenamel junction) at each prob-
ing site was measured and the sum of this measurement
and the probing depth was recorded as the probing
attachment level. If the fixed reference was eliminated
at some time during the trail by the placement or
replacement of a restoration, the relationship of the
former reference to the new reference was measured
and previous data were modified to reflect the new
location.
Horizontal Probing Attachment Level: A Nabers #2
furcation probe| was machined with grooves at 1 mm
intervals from the terminal tip. The probe was inserted
into each furcation site with gentle force until resistance
was met. The shank of the probe was adapted as closely
as possible to the tooth surface and the measurement
to a fixed reference was determined and recorded to
the nearest millimeter. If the fixed reference was elim-
inated during the trial, a new one was obtained and
previous data were modified accordingly. If resistance
was not met when examining the furcation, ie, com-
munication with another furcation region was present,
the maximum reading obtainable by the probe ( 15 mm)
was recorded for the site.
Examiner Calibration
Prior to the initiation of the study and periodically
throughout the investigation, the examiner was cali-
brated for consistency by remeasuring eight furcation
*
Vine Valley Research, Middlesex, NY.
t Marquis Dental Manufacturing Co, Aurora, CO.
I Hu-Friedy, Chicago, IL.
Volume 59
Number 12 Furcation Region Response 797
Table 2
regions in four molar teeth that had been randomly
selected by the recording assistant. Remeasurements Probing Depth Changes (X ± S.E.)
were completed at the end of the examination period. (E2-El)
(n =
82)
Statistical Method Coronal Subgingival
Scaling Instrumentation
Mean values for change between examinations for (345 sites) (1047 sites)
each of the treatment groups were calculated and com- mean change: decrease decrease
0.34 ± .07 mm 0.65 ± .06 mm
pared by ANOVA followed by Scheffe's test for multiple 1_

comparisons. Furcations regions were also categorized

by probing depth (Category I: 1-4 mm, Category : 5-
6 mm, and Category III: equal to or greater than 7 mm) decrease > 2 mm: 2% 5%

and subjected to similar analysis. Frequency analysis of decrease = 2 mm: 7% 11 %

change was also completed. ± 1 mm: 88% 83%

increase =
2 mm: 2% 1%
RESULTS increase > 2 mm: 1% 0%

Examiner Calibration Cat. Increase 0.02 .04 mm -

Fifty-three calibration trails were completed during

the course of this study. Reproducibility of the clinical
examiner is shown in Table 1.
Probing Depth Change
Mean changes in probing depths between examina-
tions and frequency distribution of changes are pre-
sented in Tables 2, 3, and 4. Data in the tables are
presented as changes from one examination to another.
For example, Table 2 presents changes at the post initial
therapy exam (E2) compared to the data obtained prior
to the initiation of therapy (Ei).
CS and RP both reduced probing depths in furcations
during initial therapy. RP produced a greater reduction
(p < 0.001). Deeper pockets consistently and signifi-
cantly (p < 0.001) demonstrated greater reduction of
probing depth following initial therapy. Sites in Cate-
gory III (probing depth >7 mm) were reduced signifi-
cantly better (p < 0.001) by RP.
All groups continued to show a decrease in probing
depth following Phase II therapy (Table 3). FO pro-
duced the most decrease, followed by MW, RP, and
CS. There were statistical differences for the changes
produced by each type of therapy. The FO group dem-
onstrated the greatest percentage (46%) of pockets
showing a 2 mm or greater decrease in probing depth.
MW (29%), RP (9%), and CS (4%) exhibited fewer
regions with 2 or more millimeters of probing depth
reduction. All categories of depth demonstrated a mean
reduction of probing depth following Phase II therapy
Table 1_
Examiner Reproducibility
(56 calibration trials)
Absolute
Reproducibility
Probing Depth 73%
VerticalProbing Attachment Level 59%
Horizontal Attachment Level 63%
Cat.
Cat.
decrease 0.61
decrease 1.06
.06
.09
mm
mm
-I*
·]··.]
**
< 0.05
< 0.01
***
< 0.001
with deeper pockets consistently exhibiting more sig-
nificant reduction (p < 0.001) except Categories I and
II for CS. Within each category, the order of procedures
for magnitude of probing depth reduction was FO,
MW, RP, CS. The differences between procedures were
significant (p < 0.01) except between RP and CS for
Category III.
Regions treated with surgery (FO and MW) showed
a statistically significant (p < 0.05) increase in probing
depth during two years of maintenance therapy (Table
4). More surgical sites demonstrated an increase in
probing depth of 2 mm or more during the two years
of maintenance than nonsurgical sites. While deeper
sites continued to show a decrease in probing depth
during two years of maintenance care, shallow (1-3
mm) sites demonstrated an increase in probing depth.
Longitudinal evaluation of probing depth changes for
the treatment groups is presented in Figure 1. At the
end of two years of maintenance, all groups showed a
net decrease in probing depth, with sites treated by CS
demonstrating reduction that was significantly (p <
0.01) less than the other groups. All sites demonstrate
a general trend toward increasing probing depth during
the maintenance phase of therapy.
Probing Attachment Level Changes
Mean changes in probing attachment level between
examinations and frequency distribution of change are
presented in Tables 5, 6, and 7. All regions demon-
strated a gain of probing attachment following initial
therapy (Table 5). Regions treated with RP had signif-
± 1 mm icantly more (p < 0.05) gain than regions treated with
CS. The deeper probing depth categories responded
100%
consistently and significantly (p < 0.01) better to either
95% therapy. RP produced significantly more gain of prob-
93% ing attachment in Categories II and III than did CS.
 i. Periodontol.
798 Kalkwarf, Kaidahl, Patii December 1988

Table 3
Probing Depth Changes (X ± S.E.)
(E3-E2)
(n =
82)
Coronal Root Modified Osseous
Scaling Planing Widman Surgery
(337 sites) (376 sites) (372 sites) (289 sites)

mean change: decrease decrease decrease decrease

0.23±.06 mm 0.40 ±.07 mm 1.20±.09 mm 1.65 ± .10 mm

* * *

decrease > 2 mm: 2% 2% 1 1 % 13%

decrease =
2 mm: 2% 7% 18% 33%
± 1 mm: 94% 88% 71% 54%
increase =
2 mm: 2% 2% 1 % 0%
increase > 2 mm: 0% 1% 0% 0%

Cat. I: decrease 0.40 ± .04 mm

Cat. II: decrease 1.02 ± .07 mm
Cat. Ill: decrease 1.52 ± .15 mm
< 0.05
< 0.01
< 0.001

Table 4

Probing Depth Changes (X ± S.E.)

E3>
75)
Coronal Root Modified Osseous
Scaling Planing Widman Surgery
(258 sites) (331 sites) (328 sites) (259 sites)
mean change: increase increase increase increase
0.06±.10 mm 0.10±.10 mm 0.45 ± .08 mm 0.71 ±.09 mm

decrease > 2 mm: 1% 2% 0% 0%

decrease =
2 mm: 4% 3% 1% 0%
± 1 mm: 8% 89% 87% 87%
increase =
2 mm: 7% 4% 11% 11%
increase > 2 mm: 1% 2% 1% 2%

Cat. I: increase 0.45 ± .04 mm

Cat. II: increase 0.09 ± .11
Cat. Ill: decrease 0.01 ± .21
Sites treated with FO demonstrated a loss of probing
attachment following Phase II therapy (Table 6). All
other treatment groups demonstrated gain of probing
attachment. The FO group also had substantially more
sites (22%) that exhibited 2 mm or more of probing
attachment loss. Shallow sites continued to lose probing
attachment following Phase II therapy. Deeper sites
demonstrated more gain of probing attachment than
sites of moderate depth (p < 0.001). Sites in all cate-
mm J**
mm
p < 0.05
**
< 0.01
***
< 0.001
gories treated by CS and RP gained probing attachment.
There were no differences between the gains for each
category. Sites treated by MW in Category I lost probing
attachment, while sites in Categories II and III gained
probing attachment, with Category III sites gaining
more than Category II sites. The difference between
each category's response to MW was significant (p <
0.001). Sites in Categories I and II treated by FO lost
probing attachment. The difference between the mean
Volume 59
Number 12 Furcation Region Response 799
Probing Depth Changes
while CS regions lost a slight amount (Table 8). The
difference between the groups was statistically signifi-
cant (p < 0.05). No major differences were noted be-
tween the frequency distribution of changes for the two
Exam 2 Exam 3 Exam 4 Exam 5
(Post-Phase I) (Post-Phase III (1 Year (2 Year groups.
Maintenance) Maintenance)
All treatment groups, except RP, lost horizontal
probing attachment during Phase II therapy (Table 9).
The loss associated with FO was significantly greater
(p < 0.001 ) than the changes shown by the other groups.
The FO group also had substantially more sites (20%)
that had 2 mm or more loss of horizontal probing
: ji*} attachment loss following Phase II therapy. During two
Coronai Scale
Root Planing
Modified Widman
x

*p<0
years of maintenance therapy, all groups demonstrated
Flap with Osseous 1 *
< 0 a mean loss of horizontal probing attachment (Table
1

Figure 1. Longitudinal evaluation ofprobing depth changes. 10).

Longitudinal evaluation of horizontal probing at-
Table 5 tachment level changes is presented in Figure 3. At the
end of two years of maintenance, all groups demon-
Probing Attachment Level Changes (X ± S.E.) strated a mean net loss of horizontal probing attach-
IE, El» ment. No statistical differences
( =
82)
were present between
Coronal Subgingival group means.
Scaling Instrumentation
(345 sites) (1047 sites)
Eliminated Sites
mean change: gain gain Table 11 demonstrates the furcation sites that were
0.24 ± .08 mm 0.41 ± .07 mm
eliminated during the course of the study. Sites were
eliminated during Phases I and II by tooth extraction
gain > 2 mm: 3% 7%
or root resection if the probing depth extended past the
gain 2 mm: 11 % 10%
- apex without endodontic involvement or when the
± 1 mm: 80% 77%
loss 2 4%
presence of the tooth made it impossible to eliminate
:- mm: 5%
loss > 2 mm: 2% 1 %
negative osseous architecture in the regions treated by
FO. Sites were retreated and eliminated from evaluation
Cat. I: loss 0.1 8 ± .07 mm -, -,
during Phases II and III for CS and during Phase III for
Cat. II. gain 0.40 .08 mm J*** . other modalities when continued loss of vertical prob-
Cat. Ill: gain 0.88 11 mm
.
< 0.05 ing attachment exceeded 2 mm.
**
< 0.01 Eighty-three furcation sites were eliminated by ex-
***
< 0.001 traction or root resection during Phase I and Phase II
loss rates for Category I (0.81 mm) and Category II therapy. Most of the eliminated sites occurred due to
(0.23 mm) was statistically significant (p < 0.01). Sites tooth extraction and the majority were removed during
in Category III treated by FO gained (0.62 mm) probing Phase II therapy from FO regions during procedures to
attachment. This change was significantly different eliminate negative osseous architecture.
(p < 0.01) than the changes exhibited in the other Fifteen sites were removed by extraction or root
categories. During two years of maintenance therapy, resection during the first year of maintenance therapy
sites treated by all modalities showed a mean loss of and 42 were removed during the second year of main-
probing attachment. tenance. Only 22 of these sites actually exhibited the
Longitudinal evaluation of probing attachment level indicated criteria for removal. The number of sites
changes for the different treatment groups is presented exhibiting actual breakdown are denoted in parenthesis
in Figure 2. At the end of two years of maintenance, in Table 11. The other sites were removed when the
all groups, except FO, showed a net gain of probing offending root or tooth associated with the breakdown
attachment. site was extracted. The number of sites exhibiting actual
breakdown are denoted in parenthesis in Table 11.
One hundred forty-nine sites received retreatment
Horizontal Probing Attachment Level Changes during two years of maintenance therapy. Fifty-five of
Mean changes in horizontal probing attachment level these sites actually exhibited breakdown that met the
between examinations and frequency distribution of criteria requiring retreatment. The other sites received
changes are presented in Tables 8, 9, and 10. retreatment because they were in close physical approx-
Regions treated by RP gained a slight amount of imation with the region of breakdown and received
horizontal probing attachment during initial therapy, retreatment as a clinical necessity. The "adjusted" sec-
 J. Periodontol.
800 Kalkwarf, Kaidahl, Patii December 1988

Table 6_
Probing Attachment Level Changes (X ± S.E.)

(Eg E2)-

(n =
82)
Coronal Root Modified Osseous
Scaling Planing Widman Surgery
(337 sites) (376 sites) (372 sites) (289 sites)

mean change: gain gam gain loss

0.32 ±.09 mm 0.44±.09 mm 0.40 ±.1 1 0.36 ±.09 mm

gain > 2 mm: 2% 5% 7% 1%

gain = 2 mm: 1 1 % 1 1% 12% 6%
± 1 mm: 81% 79% 73% 71 %
loss = 2 mm: 5% 4% 5% 17%
loss > 2 mm: 1% 1% 3% 5%

Cat. I: loss 0.09 ± .06 mm

Cat. II: gain 0.28 ± .07 mm
Cat. Ill: gain 0.84 ± .13 mm
< 0.05
< 0.01
< 0.001

Table 7
Probing Attachment Level Changes (X ± S.E.)

<E5-E3>
(n = 75)
Coronal Root Modified Osseous
Scaling Planing Widman Surgery
(258 sites) (331 sites) (328 sites) (259 sites)
mean change: loss loss loss loss
0.46±.12 mm 0.42±.16 mm 0.22 +.10 mm 0.09 ±.10 mm

gain > 2 mm: 1 % 1% 1% 1%

gain = 2 mm: 4% 5% 6% 5%
± 1 mm: 78% 79% 79% 87%
loss = 2 mm: 13% 1 1 % 13% 6%
loss > 2 mm: 4% 4% 1% 1%

Cat. I: loss 0.32 ± .06 mm

Cat. II: loss 0.34 + .18 mm
Cat. Ill: loss 0.29 ± .22 mm
p < 0.05
**
< 0.01
***
< 0.001

tion at the bottom of the Phase II columns reflects only gical and nonsurgical modalities, followed by close
those sites exhibiting actual breakdown. maintenance care, were capable of reducing probing
depths and improving or maintaining vertical attach-
ment levels in furcation regions through one year of
DISCUSSION
maintenance care. During the second year of mainte-
The results of this study showed that periodontal nance care, however, furcation sites tended to exhibit
lesions associated with furcations region responded dif- loss of probing attachment regardless of the type of
ferently than lesions adjacent to other tooth surfaces. therapy rendered.
Numerous types of periodontal therapy, including sur- Probing depth was most dramatically reduced by
Volume 59
Number 12 Furcation Region Response 801

surgical therapy, especially osseous recontouring pro-
cedures with apical repositioning of the gingival margin.
The reduction in probing depth obtained during the
active phase of therapy in furcations treated with a
surgical approach demonstrated rebound during two
years of maintenance care. It is evident that the rebound
shown during the first year of maintenance was a result
of coronal movement of the gingival margin since an
accompanying change in probing attachment level did
not occur. During the second year of maintenance, the
increase in probing depth can be directly related to a
loss of probing attachment.
It may be assumed that the gain in vertical probing
attachment achieved during active therapy was a result
of the formation of a long junctional epithelium and
an increase in connective tissue tonus providing in-
creased resistance to the probe. If this is the case, the
data suggest that this tissue/tooth interface was
undergoing change during the second year of mainte-
nance care resulting in measured loss of probing attach-
ment and increased probing depth.
Quantification of vertical probing attachment was
achieved with a periodontal probe inserted into the
furcation region under a load of 50 g. If gingival reces-
Table 8

Probing Attachment Level Changes Horizontal Probing Attachment Level Changes (X -

S.E.)
(E2-El)
(n =
82)
Coronal Subgingival
Scaling Instrumentation
(345 sites) (1047 sites)

mean change: loss gain

0.05 ± .08 mm 0.1 7 ± .05 mm

Exam 5
(2 Year gain > 2 mm: 1% 2%
Maintenance)
gain = 2 mm: 6% 9%
± 1 mm: 84% 83%
loss = 2 mm: 7% 4%
loss > 2 mm: 2% 2%
Coronal Scaie
Root Planing
Modified Widman
Flap with Osseous p<0.05 Cat. I: gain 0.00 ± .07 mm
Cat. II. gain 0.23 ± .07 mm
Figure Longitudinal evaluation of probing
2. attachment level Cat. Ill: loss 0.00 ± .10 mm
< 0.05
changesfor different treatment groups. < 0.01
< 0.001

Table 9

Horizontal Probing Attachment Level Changes (X ± S.E.)

(E3-E2)
(n = 82)
Coronal Root Modified Osseous
Scaling Planing Widman Surgery
(337 sites) (376 sites) (372 sites) (289 sites)

mean change: loss gain loss loss

0.1 3 + .09 mm 0.01 ±.07 mm 0.14±.09 mm
L
*
jO.51 ±.11
*
mm

gain > 2 mm: 1% 0% 1% 0%

gain = 2 mm: 5% 4% 5% 3%
± 1 mm: 82% 89% 85% 77%
loss = 2 mm: 9% 5% 5% 11 %
loss > 2 mm: 3% 2% 4% 9%

Cat. I: loss 0.27 ± .06 mm

Cat. II: loss 0.08 ± .07 mm
Cat. Ill: loss 0.20 ± .12 mm
< 0.05
**
< 0.01
***
< 0.001
 i. Periodontol.
802 Kalkwarf, Kaidahl, Patii December 1988

Table 10
Horizontal Probing Attachment Level Changes (X S.E.
( -
E,
:3'
( = 75)
Coronal Root Modified Osseous
Scaling Planing Widman Surgery
(258 sites) (331 sites) (328 sites) (259 sites)
mean change: loss loss loss loss
0.51 ±.16 mm 0.50 + .1 1 mm 0.36 ±.15 mm 0.19±.15 mm

gain > 2 mm: 1% 1% 2% 3%

gain = 2 mm: 4% 3% 6% 5%
± 1 mm: 82% 84% 79% 81%
loss = 2 mm: 4% 7% 7% 9%
loss > 2 mm: 9% 5% 6% 2%

Cat. I: loss 0.24 ± .06 mm

Cat. II: loss 0.48 ± .1 7 mm
Cat. Ill: loss 1.09 ± .29 mm
< 0.05
< 0.01
< 0.001

2.0 ment within the furcation region. These indices tyically

assign a value, usually designated by Roman numerals
Horizontal Attachment Level Changes
1 .5 I-IV, to designate the horizontal extend of clinical
attachment loss.6,20 Recent modifications have ad-
1 .0 dressed the vertical aspect of clinical attachment loss,21
Exam 4 Exam 5
Exam 2
(Post-Phase II
Exam 3
(Post-Phase II) (1Year (2 Year but none of the indices provide linear data to quantify
0.5
Maintenance) Maintenance)
changes in status of a furcation region.
This study attempted to quantitate changes of clinical
attachment within the furcation. The horizontal com-
I ponent of clinical attachment loss was measured with
i
a traditional furcation probe that had grooves machined
-0.5
at one millimeter intervals from its terminal end. The
probe was inserted into the mid-furcation region with
gentle force until resistance was met. The shank of the
probe was then adapted as closely as possible to the
-1.5 Coronal Scale tooth surface and the measurement to a fixed reference
Root Planing was determined. The curvature of the probe did not
Modified Widman
Flap with Osseous *p<0.05 allow precise adaptation to all tooth surfaces, but cali-
Figure 3. Longitudinal evaluation of horizontal probing attachment bration trials showed that the technique had good reli-
level changes. ability (93% within 1 mm).
It is interesting to note that all types of therapy
sion was present in the furcation region, exposing two resulted in a loss of horizontal probing attachment
root surfaces, the measurement was taken along the during the course of this study. This may be a result of
internal aspect of each root surface and the greatest one the inability to adequately instrument furcation regions
was recorded. This technique was used as a patient during therapy.1516,22 If that is the case, one would
protection measure. It was assumed that breakdown in expect to see continued loss of horizontal probing at-
a furcation could occur along either or both root sur- tachment, with increased rates of loss in the CS and RP
faces. By taking measurements along each root surface, groups, at subsequent evaluation intervals.
it is possible to overestimate rate of breakdown for a A total of 77 sites demonstrated greater than 2 mm
specific site within the furcation, but it is not possible of probing attachment loss during two years of main-
to underestimate breakdown which could lead to delay tenance care. Eight sites (1 CS, 4 RP, 1 MW, 2 FO)
the initiation of retreatment. were associated with breakdown due to nonperiodontal
Previous studies have used traditional clinical indices causes (endodontic failure or fracture). If these sites are
to describe and quantitate changes in clinical attach- not considered, 69 sites or 5.3% of the total available
Volume 59
Number 12 Furcation Region Response 803
Table 11
Eliminated Furcation Sites

Phase I Phase II Phase III (Year 11 Phase III (Year 2)

E2 E3 E4 E5

Removed Retreated Removed Retreated Removed Retreated

CS 7 (3) I 17 (3) 22 (9)

RP 5 (2) 28 (10) 14 (5) 38 (13)
0 (0) 11 (4) 18 (7) 25 (10)
FO 55 3 (1) 2 (1) 1 1 (4)
I
18 15(6) I 53(19) 42 (16) 96 (36)
I
_

18 65 68 138
(1.3%) (4.7%) (5.1%) (11 .4%)

Adjusted Adjusted
25 (1.9%) 52 (4.3%)

sites demonstrated breakdown. Breakdown rate, ad- REFERENCES

justed for periodontally initiated breakdown, over the
first two years of maintenance care for the different
treatment modalities was: CS 22/330 (6.7%) [if the six
sites are included that broke down in this group during
Phase II, the rate becomes 28/336 (8.3%)]; RP 30/358
(8.4%); MW 21/354 (5.9%); FO 7/271 (2.6%).
Five of the initial 138 teeth (3.6%) that underwent
CS therapy were extracted during the maintenance
phase of therapy because of active periodontal break-
down that had progressed past the apex of the tooth,
2.1% of teeth treated by RP and 4.2% of the teeth
treated by MW were extracted during two years of
maintenance because of active Periodontitis that had
progressed past the apex of the tooth. One must remem-
ber, however, that pretherapy extractions were per-
formed only if teeth exhibited total lack of periodontal
support. Many of the treated teeth in these groups had
an extremely compromised periodontium. No teeth in
the FO group exhibited periodontal breakdown that
required extraction. It must be remembered, however,
that 22 teeth (19.0%) in this group were extracted or
received root amputation during active therapy.
The clinical data obtained in this study confirm the
observations of others13 23 that progression of Periodon-
titis in the furcation is different than that found on
other tooth surfaces. More controlled, prospective, eval-
uations of periodontal therapy in the furcation region
are indicated. Further longitudinal evaluation is neces-
sary to determine if breakdown leading to tooth extrac-
tion continues at a reduced rate in regions that have
received more aggressive active therapy. It is yet to be
determined whether removal of teeth or roots during
active therapy to achieve a desired level of probing
depth reduction in adjacent furcation regions is bene-
ficial to the long-term maintenance of periodontal at-
tachment and retention of teeth.
1. Knowles, J., Burgett, F., Morrison, E., et al.: Comparison of
results following three modalities of periodontal therapy related to
tooth type and initial pocket depth. J Clin Periodont 7: 32, 1980.
2. Ramfjord, S. P., Knowles, J. W., Morrison, E. G, et al.:
Results of periodontal therapy related to tooth type. / Periodontol
51:270, 1980.
3. Lindhe, J., Westfelt, E., Nyman, S., et al.: Healing following
surgical/nonsurgical treatment of periodontal disease. J Clin Perio-
dont* 115, 1982.
4. Rosling, . G., Slots, J., Christersson, L. ., et al.: Clinical
and microbiological effects of surgical and nonsurgical treatment of
multi-rooted teeth in adult Periodontitis (abstr. 311). J Dent Res 63:
205, 1984.
5. Pihlstrom, B. L., Oliphant, T. H., and McHugh, R. B.: Molar
and nonmolar teeth compared over 6 1 /2 years following two meth-
ods of periodontal therapy. J Periodontol 55: 499, 1984.
6. Hamp, S., Nyman, S., and Lindhe, J.: Periodontal treatment
of multirooted teeth. J Clin Periodont 2: 126, 1975.
7. Hirschfeld, L., and Wasserman, B.: A long term survey of
tooth loss in 600 treated periodontal patients. J Periodontol 49: 225,
1978.
8. Ross, I. F., and Thompson, R. H., Jr.: A long term study of
root retention in the treatment of maxillary molars with furcation
involvement. / Periodontol 49: 238, 1978.
9. Bjorn, ., and Hjort, P.: Bone loss of furcated mandibular
molars. J Clin Periodont 9: 402, 1982.
10. Becker, W., Berg, L. E., and Becker, . E.: Untreated peri-
odontal disease: A longitudinal study. J Periodontol 50: 234, 1979.
11. Becker, W., Berg, L., and Becker, . E.: The long-term eval-
uation of periodontal treatment and maintenance in 95 patients.
Internat J Perio Rest Dent 4: 55, 1984.
12. McFall, W. T., Jr.: Tooth loss in 100 treated patients with
periodontal disease. A long-term study. J Periodontol 53: 539, 1982.
13. Nordland, P., Garrett, S., Kiger, R., et al.: The effect of plaque
control and root debridement in molar teeth. / Clin Periodont 14:
231, 1987.
14. Waerhaug, J.: The furcation problem. J Clin Periodont 7: 73,
1980.
15. Bower, R. C: Furcation morphology relative to periodontal
treatment. Furcation root surface anatomy. / Periodontol 50: 366,
1979.
16. Bower, R. C: Furcation morphology relative to periodontal

804 Kalkwarf, Kaidahl, Patii
treatment. Furcation entrance architecture. J Periodontol 50: 23,
1979.
17. Ramfjord, S. P., and Nissle, R. R.: The modified Widman
flap. J Periodontol AS: 601, 1974.
18. Schluger, S., Youdalis, R. ., and Page, R. C: Periodontal
Disease. Philadelphia, Lea and Febiger, 1977, pp. 496-509.
19. Ochsenbein, C: Osseous resection in periodontal surgery.
JPeriodontol29: 15, 1958.
20. Glickman, I.: Clinical Periodontology, ed. 2, Philadelphia,
W. B. Saunders Co., 1950, pp. 694-696.
21. Tarnow, D., and Fletcher, P.: Classification of the vertical
component of furcation involvement. J Periodontol 55: 283, 1984.
J. Periodontol.
December 1988
22. Leon, L. E., and Vogel, R. I.: A comparison of the effectiveness
of hand scaling and ultrasonic debridement in furcations as evaluated
by differential dark-field microscopy. J Periodontol SS: 86, 1987.
23. Payot, P., Bickel, M., and Cimasoni, G.: Longitudinal quan-
titative radiodensitometric study of treated and untreated molar
furcation involvements. / Clin Periodont 14: 8, 1987.
Send reprint requests to: Kenneth L. Kalkwarf, D.D.S., M.S.,
UTHSC/SA, School of Dentistry, 7703 Floyd Curl Drive, San An-
tonio, TX 78284.