Perhaps Dr. Donley missed the focus of my article, which was on patient evaluation before, during and after periodontal treatment. Emphasis was placed on overall patient management (surgical and nonsurgical) including a short discussion of adjunctive therapy.
Dr. Donley raised the question that he wished future "practical" articles would conclude "with clinically realistic decision pathways that could guide the practitioner in determining which sites during initial therapy and which sites in maintenance therapy could benefit from adjunctive therapy."
It is quite obvious that such clinical information regarding "deteriorating or active disease" sites can only be obtained by close continuous evaluation of the patient’s periodontal condition. To date, no diagnostic aids are available to reliably detect active disease.
Also, adjunctive therapies used as local delivery therapy in site-specific areas have only shown marginal improvements over conventional periodontal therapy of periodontal scaling and root planing and good plaque control.
Even though new adjunctive products were mentioned and recommendations made to clearly follow their approved use, no guidelines were given because of the lack of long-term studies. At this stage, "decision pathways" would be merely speculative.
In conclusion, we all hope that technological advances in the area of genetics, molecular biology, immunology and microbiology will provide more definitive decision pathways for disease detection and therapy.
