Management of periodontitis

The European Federation of Periodontology (EFP) produced the latest S3-clinical guidelines which outline a structured and evidence-based approach to treating periodontitis that progresses through three main steps:

Step 1:

The aim is to engage the individual in controlling supragingival (above the gum-line) plaque biofilm and managing risk factors, with an overall aim to develop patient adherence and skills, which is essential for treatment success.

It has been recommended to:

• Motivate individuals to practice effective oral hygiene with tailored oral hygiene instructions (OHI) utilising a toothbrush and interdental brushes
• Perform professional mechanical plaque removal (PMPR)
• Control any plaque retentive factors – for example, suboptimal restorations (fillings, crowns etc), and removal of calculus (tartar)
• Control risk factors with a particular focus on tobacco smoking cessation interventions and diabetes control interventions.
  • NB: At present, there is unclear evidence to support whether increasing physical activity or reducing weight through dietary and lifestyle choices have a positive impact on the treatment of periodontitis.

Step 2:

This step focuses on reducing or eliminating the subgingival (below the gum-line) biofilm and calculus with subgingival instrumentation.

It has been recommended to:

• Remove plaque and calculus (tartar) from root surfaces via subgingival instrumentation which can be performed with either hand or powered instruments. This can be performed over multiple sessions treating each quadrant separately (a quadrant is each quarter of the mouth) or via full mouth delivery within 24-hours.

There are open recommendations to use the following adjuncts to subgingival instrumentation:

• Chlorhexidine mouth rinses for a limited period of time
• Locally administered sustained-release Chlorhexidine
• Specific locally administered sustained-release antibiotics
• Specific systemic antibiotics – considered for stages III or IV periodontitis in young adults

The following adjuncts (supplemental therapies) are NOT suggested or NOT recommended to use:

• Lasers or adjunctive photo-dynamic therapy
• Routinely use systemic antibiotics as adjuncts (supplemental therapy) to subgingival instrumentation
• Systemic sub-antimicrobial dose Doxycycline
• Administration of statin gels, systemic or local bisphosphonates, systemic or local non-steroidal anti-inflammatory drugs, omega-3 polyunsaturated fatty acids and metformin gel
• Probiotics

Following a sufficient period of healing, a re-assessment by your dental professional is necessary to assess whether you have achieved the endpoints of treatment (no periodontal pocket depths (PPDs) ≥5mm with bleeding on probing (BoP) or no PPD ≥6mm). If these endpoints have not been achieved, the individual should enter step 3. If the endpoints have been achieved, the individual should enter step 4 – a supportive periodontal care (SPC) programme.

Step 3:

Areas that have not responded adequately to the above may require further treatment to improve access to the deep sites or managing any local anatomical factors that increase the complexity of the disease process in that area.

This may involve:

• Repeating subgingival instrumentation ± adjunctive therapies (as described in step 2) in the presence of moderately deep residual PPD of 4-5mm
• Surgical interventions for PPD ≥6mm in individuals with adequate levels of oral hygiene. Such interventions should only be carried out by dentists with additional specific training or specialists and can include:
  • Access flap surgery – involves raising a gum flap, cleaning the affected area and closing the flap
  • Resective periodontal surgery – involves raising a gum flap, gum ± bony recontouring to remove any irregular defects
  • Regenerative periodontal surgery – using biomaterials ± bone-derived grafts to aim to reconstruct specific bony defects around teeth

Following a sufficient period of healing, a re-assessment by your dental professional is necessary to assess whether you have achieved the endpoints of treatment (no periodontal pocket depths (PPDs) ≥5mm with bleeding on probing (BoP) or no PPD ≥6mm). If these endpoints have not been achieved, further therapy may be required. If the endpoints have been achieved, the individual should enter step 4 (SPC programme).

Step 4:

SPC is the maintenance phase which should be performed on all individuals. During these visits, the dentist or periodontist checks for any signs of disease progression, assesses the individuals’ oral hygiene practices, and provides personalized recommendations to address any risk factors. SPC is essential for sustaining the results of prior treatments, helping patients maintain healthy gums and reducing the likelihood of further disease progression.

It has been recommended to:

• Schedule SPC visits every 3 to 12 months with the interval being tailored specifically to the individual’s risk of recurrence or progression
• Emphasise adherence to SPC is crucial for long-term stability and possibly continued further improvements to their periodontal health
• Repeat individually tailored OHI including toothbrushing advice with supplemental use of interdental brushes. In hard-to-reach areas other interdental cleaning devices may be suggested
• Perform routine PMPR