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4) Shallow pockets suffered sustained attachment loss following flap surgery.
5) Scaling alone resulted in sustained attachment gain in 4-6mm pockets.

The conclusions here are interesting. If there are no differences between effectiveness of treatment procedures and some clear advantages to scaling alone, what patient would give informed consent for surgery if they could likely do just as well without it. Surgery is more painful, more expensive and more debilitating causing root sensitivity, clinically long crowns, etc.

Though it is contradictory to the scientific evidence, periodontal surgery is still being prescribed for large percentages of patients when scaling alone will deliver nearly equivalent results as scaling with surgery.

Just a word about our medico legal obligations here. A large majority of my patients who have been attracted to our office by the possibility that they do not need periodontal surgery have stated they were never informed by their previous dentist(s) that there were alternatives to the surgery. Usually they were told they needed the surgery. It is part of the civil law governing medical practice in the USA that patients must be informed of risks, benefits and alternatives to any treatment proposed to satisfy informed consent. However, it appears that this is rarely satisfied prior to periodontal treatment.

Please note that the results reported by Dr Ramfjord and Nissle were indeed supported by this study as well. These studies should have resulted in significant changes in the clinical treatment standards in this country but these important changes in standard of care have yet to come about.
The next study is virtually a repeat of the previous one. Both of these follow-up studies referred to the Ramfjord, Nissle study as they were designed to repeat the first study. Deep pockets (>7mm) no difference between treatment after two years.