Since the FMD technique was first described, several teams have made changes to the protocol, and we have identified a total of 8 modified protocols: full-mouth treatment without CHX [6-9], the extension of hygiene methods and an increase in the duration of posttreatment CHX use , the replacement of CHX with other antiseptics [10-13], supplementation with antibiotics [14-22] or probiotics , full-mouth antimicrobial photodynamic therapy , and the most recent modification, one-stage FMD combined with a periodontal dressing  (Table 2).
3.1. Evolution of the FMD Concept
3.1.1. Full-Mouth Treatment without CHX
In 2000, Quirynen et al. proposed the removal of CHX use from the original protocol, thereby creating the full-mouth scaling approach (FMS). Quirynen et al. conducted a longitudinal study comparing FMS (test group 1) to FMD (test group 2) and Quadrant Scaling and Root Planing (QSRP) (control group)  and observed additional benefits in the two test groups in terms of pocket depth reduction (approximately 1.5 mm) and clinical attachment gain (approximately 2 mm). However, no statistically significant differences between the test groups were observed . Additionally, motile microorganisms and spirochetes were significantly decreased in only the FMD group, and this difference lasted for up to 2 months posttreatment. However, this difference was not observed beyond 2 months . In 2009, using a similar methodology, Swierkot et al. observed a greater reduction in pocket depths and gingival bleeding with the FMS protocol than that with the FMD protocol at 2 months. However, at 8 months, no significant difference was observed . Apatzidou et al. compared the FMS group to the QSRP group and observed that patients treated with FMS had more postoperative pain compared to those who received conventional therapy with CHX . In 2013, Santos et al. investigated the treatment of chronic periodontitis in patients with type II diabetes (FMD compared with FMS + placebo) and observed no significant clinical differences between the results of these treatments for a posttreatment period of up to 12 months .
3.1.2. Extension of Hygiene Methods and Increased Duration of Posttreatment CHX Use
Bollen et al. assessed the use of CHX (mouthwashes and tonsil sprays) for a period of 2 months after treatment instead of 2 weeks . These investigators compared FMD with 2 months of CHX treatment (test group) to QSRP (control group) by evaluating the clinical and microbiological effects of these treatments after 2 and 4 months. Samples of saliva and gingival, lingual, and mucosal plaques were collected. At 2 and 4 months, Bollen et al. observed significantly higher clinical attachment gains in the test group than those in the control group (1.5 mm versus 0.3 mm in deep pockets; 0.9 mm versus 0.1 mm in pockets of moderate depth). In terms of the microbiological effect, they noted a significant decrease in Porphyromonas gingivalis (Pg), Prevotella intermedia (Pi), and spirochetes in the test group. However, at the end of this study, the authors could not demonstrate a direct relationship between the observed results and the increased CHX use. According to the authors, these results could be due to the effectiveness of the full-mouth method compared with that of the quadrant method .
3.1.3. Replacement of CHX with other Types of Antiseptics
In 2006, Quirynen et al. considered the possibility of using Amine Fluoride/stannous fluoride (AF) in the original protocol to complement or to substitute for CHX . This study compared these two regimens to the conventional quadrant method. At 8 months posttreatment, no additional benefit was observed with the use of AF either alone or combined with CHX . Using a similar methodology, Wang et al. studied the possibility of using povidone-iodine (Betadine®) in the FMD protocol  by comparing QSRP (control) to a modified FMD protocol including an irrigation treatment with either water (test 1) or povidone-iodine (test 2). Blood samples were taken before treatment and at 1, 3 and 6 months after treatment. The study aimed to compare the expression of serum antibodies in response to the following periodontal pathogens: Pg, Aggregatibacter actinomycetemcomitans (Aa), and Treponema denticola (Td). Compared to the control group, both test groups showed significant reductions in anti-Pg and anti-Aa antibodies at 1 and 3 months. These authors suggested that povidone-iodine could be a reliable alternative to CHX in the FMD protocol . A few years later, in a study investigating the use of essential oils as an adjuvant to or substitute for CHX [12, 13], the authors reported that essential oils were beneficial for the reduction of pocket depth and plaque and gingival indices [12, 13]. However, the results of the microbiological analysis were less clear.
3.1.4. Supplementation with Antibiotics
The hypothesized benefit of adding antibiotics to the FMD protocol has been the subject of several studies [14-22]. In 2007, Gomi et al. compared the QSRP protocol (control group) an FMD protocol with Azithromycin (AZT) added (test group) . AZT was administered during the three days preceding the mechanical treatment. The clinical and microbiological parameters were recorded over a 6 month period, and an improvement in the clinical parameters at 2 and 6 months posttreatment was observed in the AZT group . At 2 months, the elimination of periopathogenic bacteria was significantly greater in the test group than that in the control group . The authors concluded their study by claiming that the addition of AZT to the FMD protocol was clinically and microbiologically effective . Similar observations were noted by Yashima et al. . However, recently, Fonseca et al. showed that the addition of AZT did not provide additional clinical benefits compared to the FMD technique alone . In this study, the authors divided the samples into 6 groups and compared different protocols: (a) a full-mouth approach without CHX (FMS), (b) FMD alone, (c) FMD + AZT, d) QSRP without CHX, e) QSRP + CHX, and f) QSRP + AZT. At 3 months, a significant reduction in the depth of deep pockets, gingival inflammation, plaque index, and clinical attachment gain was observed in each group . Compared to the other groups, the group receiving FMD alone exhibited a greater reduction in pocket depth and a lower rate of PD at 6 months . Cionca et al. investigated the addition of Amoxicillin (Amox) and Metronidazole (MTZ) to the FMD protocol using a regimen of 375 mg of Amox and 500 mg of MTZ three times a day for 7 days [16, 17]. At 6 months, Cionca et al. observed a greater reduction in the depth of deep pockets in the test group than that in the control group . Moreover, the test group had a smaller number of residual pockets of more than 4 mm in depth than the control group (p = 0.005) and had a significantly reduced need for complementary surgical treatment . However, beyond 6 months, no significant differences in these clinical parameters were observed . In terms of the microbiological effect, Cionca et al. observed the elimination of Aa in the test group but not in the control group at 3 months posttreatment. Additionally, lower levels of Pg (p = 0.013) and Tannerella forsythia (Tf) (p = 0.007) were observed in the test group than those in the control group . However, these results were not confirmed at 6 months . Similarly, Varela et al. reported that, at 3 months, an additional clinical benefit in the treatment of aggressive periodontitis was observed with the addition of Amox and MTZ to the FMD protocol (500 mg amoxicillin + 250 mg metronidazole, three times a day for 10 days) . However, according to a similar study by Aimetti et al., the microbiological effects of the addition of Amox and MTZ remained for up to 6 months . Preus et al. evaluated the efficacy of the addition of MTZ monotherapy to the FMD protocol . They compared 4 protocols: a) FMD + 400 mg MTZ (three times a day for 10 days), b) FMD + placebo, c) QSRP + 400 mg MTZ (three times a day for 10 days), and d) QSRP + placebo. They reported that the addition of MTZ increased clinical attachment gains and reduced pocket depth . However, at 12 months, FMD either with or without MTZ did not improve the clinical conditions beyond those obtained by conventional therapy .
3.1.5. Addition of Probiotics
The addition of probiotics (Lactobacillus reuteri (LR) in tablet form) to the FMD protocol has also been considered . Teughels et al. compared FMD with the twice daily administration of LR for 12 weeks (test group) to FMD with a placebo (control group). At 12 weeks, the authors observed a significant improvement in clinical and microbiological parameters, including a significant improvement in pocket depth and clinical attachment gain and a reduction in the periopathogenic bacterial load. They concluded that the oral administration of probiotic LR tablets in addition to scaling and surfacing by a comprehensive disinfection method would be useful in the treatment of chronic periodontitis .
3.1.6. Full-mouth Antimicrobial Photodynamic Therapy
Sigush et al. conducted a study to evaluate the efficacy of dynamic phototherapy in addition to FMD on the eradication of Fusobacterium nucleatum (Fn) . Patients received either FMD with a photosensitive solution that was activated by a laser (test group) or FMD with the unactivated photosensitive solution (control group). Compared to the control group at 3 months posttreatment, the patients in the test group had a greater reduction in pocket depth, better clinical attachment, and a significant reduction in Fn load .
3.1.7. FMD Combined with a Periodontal Dressing
Keestra et al. evaluated the effects of adding the use of a periodontal dressing (Coe-Pak® type) to the FMD protocol . This approach resulted in a greater reduction in shallow and moderate-depth periodontal pockets. However, only deep pockets showed a tendency for improvement. According to the authors, this technique would provide additional short-term clinical benefit and would reduce postoperative pain .