Trial design explores pathways for periodontal challenges

Fraser Macdonald, Dental Tribune International

Tue. 17 June 2025

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LONDON, England: Grade III furcation defects represent one of the most challenging scenarios in periodontal care, and robust evidence to guide their treatment remains scarce. To address this gap, a feasibility study has explored an innovative, adaptive trial design to assess outcomes in treating these lesions. Using a sequential, multiple assignment randomised trial (SMART) approach, the researchers aimed to determine whether a dynamic, responsive treatment pathway could improve both clinical and patient-reported outcomes.

The study enrolled 20 adults with at least one molar exhibiting a Grade III furcation defect. Participants were initially randomised to receive either non-surgical periodontal therapy or open-flap debridement. After six months, treatment response was evaluated using a combined outcome measure that included both probing pocket depth reduction and patient-reported health assessments. Participants who did not meet predefined success criteria were then re-randomised to receive additional treatment—mimicking real-world clinical adaptation—and followed for another six months, completing a 12-month study period.

Generally applicable across the medical research space, this SMART design allowed the trial to assess not only the effectiveness of each individual treatment but also the viability of stepped-care pathways for those who do not respond initially. Importantly, this is one of the first applications of SMART methodology in periodontics, offering a more nuanced view of therapeutic outcomes by accommodating non-responders and tailoring follow-up interventions accordingly.

From a clinical perspective, the study provides actionable insights. Open-flap debridement produced a statistically greater reduction in probing pocket depth compared with non-surgical periodontal therapy after the initial six-month period. However, success rates were relatively comparable (70% for open-flap debridement, 60% for non-surgical periodontal therapy), underscoring that a personalised, stepwise approach—beginning with non-surgical therapy—remains appropriate even in challenging Grade III furcation cases, particularly when patient-reported outcomes are favourable. Moreover, the study emphasises the importance of incorporating patient-reported outcomes into treatment evaluation, reflecting a shift towards patient-centred care.

Despite its small sample size, the trial was successful in demonstrating protocol adherence and outcome tracking. Recruitment, however, proved to be a limiting factor, suggesting that future trials may require broader outreach or multicentre coordination.

In conclusion, this feasibility study supports the clinical value of adaptive, personalised treatment pathways for Grade III furcation defects. By combining rigorous clinical metrics with patient-reported feedback and flexible reallocation of care, the SMART design represents a meaningful evolution in periodontal research and practice—potentially offering a more realistic and responsive approach to managing complex periodontal lesions.

The study, titled “Clinical and patient-reported outcomes in Grade III furcations: A randomized feasibility trial with SMART design”, was published online on 4 June 2025 in the Journal of Clinical Periodontology, ahead of inclusion in an issue.