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TreatmentofstageI-IIIperiodontitis TheEFPS3-levelclinicalpracticeguideline Wheredoestheneedforthisguidelinecomefrom? Howdoweinterprettheseinfographics? • Implementationofthenewclassificationofperiodontitisshouldfacilitate Bluecolour:Recommendationsinfavorofaparticular theuseofappropriatepreventiveandtherapeuticinterventions,depending strategyoftreatmentorspecificprocedure. onthestageandgradeofthedisease.TheapplicationofthisS3-levelclinical practiceguidelinewillallowahomogeneousandevidence-basedapproach to Orangecolour: Openrecommendationinwhichthe themanagementofstageI–IIIperiodontitis. clinicianisresponsibleforthefinalchoice ofaparticularstrategyoftreatmentor Whatdopatientsneedtoknow? specificprocedurebasedonspecificpatient characteristics. • Anessentialprerequisitetotherapyistoinformthepatientofthediagnosis, includingcausesofthecondition,riskfactors,treatmentalternativesand Uncertainrecommendationforwhose expectedrisksandbenefitsincludingexplanationsregardingconsequencesof clarificationfurtherresearchisneeded. refusedtreatment. • Thisdiscussionshouldbefollowedbyagreementonapersonalizedcareplan. Redcolour: Recommendationsagainstaparticular • Theplanmightneedtobemodifiedduringthetreatmentjourney,depending strategyoftreatmentorspecificprocedure. onpatientpreferences,clinicalfindingsandchangestooverallhealth. Gradeofrecommendationgrade a Description Syntax TABLE Strenghofrecommendations: Werecommend gradingscheme(GermanAssociation A Strongrecommendation Werecommendnotto oftheScientificMedicalSocieties (AWMF)andStandingGuidelines Wesuggest Commision,2012) B Recommendation Wesuggestnotto O Openrecommendation Maybeconsidered aIfthegroupfeltthatevidencewasnotclearenoughttosupportarecommendation,statementswere formulated,includingtheneed(ornot)ofadditionalresearch. STEP1 Aim:guidingbehaviourchangebymotivatingthepatienttoundertake: · Successful removal of supragingival dental biofilm. · Risk factor control. It should be implemented in all periodontitis patients,irrespective ofthe stage of their disease. Itshouldbefrequentlyre-evaluatedinorderto: · Continue to build motivation and adherence,or explore other alternatives to overcome the barriers. · Develop skills in dental biofilm removal and modify as required. · Allow for the appropriate response ofthe ensuing steps of therapy. Patientsupragingivaldentalbiofilmcontrol Recommendedinterventions Recommended Suggested Recommended Oralhygienepracticesarecrucialthroughoutallstepsoftreatmentandachieved throughpatientengagementinbehaviouralchanges (seespecificrecommendationsinthesection‘Supportiveperiodontalcare’). Unclear Motivationalinterviewing orcognitivebehaviouraltherapyhavenotshown asignificantimpact. Professionalsupragingivaldentalbiofilmcontrol Recommendedinterventions Recommended Suggested Recommended Professionalmechanicalplaqueremoval(PMPR) andcontrolofplaqueretentivefactors isafundamentalpartofthefirststepoftherapy. Riskfactorcontrol Recommendedinterventions Recommended Suggested Recommended Recommended Recommended Controlofriskfactors Tobaccosmokingcessation Diabetescontrol isrecommededaspartofthefirst interventionsarerecommeded interventionsarenecessary. stepoftreatment. aspartofthefirststep oftreatment. Unclear Itisnotknownif Itisnotknownif increasingthephysicalactivity reducingweightthroughdietary hasanimpact. andlifestylehasanimpact. Thisdocumentisagraphicadaptationoftheactualclinicalpracticeguidelinesandthereaderisreferredforthecorrectexplanationto theoriginalarticle:“TreatmentofstageI-IIIperiodontitis-TheEFPS3-levelclinicalguideline”bySanzandcoworkers,JClinPeriodontology2020. https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13290 www.efp.org STEP2 Aim: · Controlling (reducing/eliminating) the subgingival biofilm and calculus (subgingival instrumentation) with possibleremovalofrootsurface(cementum). · Subgingival instrumentation may be supplemented with the following adjunctive interventions:physical orchemicalagents,host-modulatingagents(localorsystemic),topicalantimicrobials,subgingivallocally deliveredorsystemicantimicrobials. · Itshouldbeimplementedinallperiodontitispatients,irrespectiveofthestageoftheirdiseaseanditshouldbe re-evaluatedafteranadequatehealingperiod. Subgingivali nstrumentation Recommendedinterventions Recommended Suggested Recommended Recommended Suggested weeks 24H Subgingivalinstrumentation Subgingivalperiodontal Subgingivalperiodontal isrecommended to treat instrumentation instrumentationcanbe periodontitiswith reduction of isperformedwithhandor performedwitheither pocket dephts,gingival powered(sonic/ultrasonic) traditionalquadrant-wiseor inflammation and the number instruments,eitheraloneorin fullmouthdeliverywithin of diseased sites. combination. 24hours. Useofadjunctiv ephysicalagents tosubgingivalinstrumen tation Notrecommended NOTrecommended NOTsuggested suggested suggested Lasersasadjunct Adjunctivephoto-dynamictherapy tosubgingivalinstrumentation atwavelengthrangesofeither660-670nm arenotsuggested. or800-900nmisnotsuggested asadjuncttosubgingivalinstrumentation. U seofadjunctiveantisept ics/antibiotics (localorsystem ic)tosubgingivalinstrum entation NOTrecommended NOTsuggested Notrecommended recommended Routineuseofsystemicantibioticsasadjunct tosubgingivalinstrumentationinpatientswith periodontitisisnotrecommended. Openrecommendation CHX Chlorhexidinemouthrinsesfor Locallyadministered Specificlocallyadministered alimitedperiodoftimemaybe sustained-releasechlorhexidine sustained-releaseantibiotics consideredasadjunctsto maybeconsideredasanadjunct maybeconsideredasanadjunct subgingivalinstrumentation. tosubgingivalinstrumentation. tosubgingivalinstrumentation. Theadjunctiveuseofspecificsystemicantibiotics maybeconsideredforspecificpatientcategories (e.g.generalizedstageIIIperiodontitisinyoungadults). Use ofadjunctivehost-modul atingagents (localorsystemic) tosubgingivalinstrumen tation NOTrecommended NOTsuggested Notrecommended suggested recommended suggested Systemicadministrationof Administrationofstatingels / Probioticsarenot sub-antimicrobialdose systemicorlocalbisphosphonates / suggestedasanadjunct doxycycline systemicorlocalnonsteroidal tosubgingival isnotsuggested. anti-inflammatorydrug / omega-3 instrumentation. polyunsaturatedfattyacidsand metformingelarenotrecommended tobeaddedtosubgingivalinstrumentation. Re-evaluationafterstep2 Endpoints: · Noperiodontalpockets≥5mmwithbleedingonprobing. · Nodeeppockets[≥6mm]. Iftheseendpointsareachieved,thepatientshouldjoinaSPCprogram. Thisdocumentisagraphicadaptationoftheactualclinicalpracticeguidelinesandthereaderisreferredforthecorrectexplanationto theoriginalarticle:“TreatmentofstageI-IIIperiodontitis-TheEFPS3-levelclinicalguideline”bySanzandcoworkers,JClinPeriodontology2020. https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13290 www.efp.org STEP3 Aim: Treatingthosesitesnon-respondingadequatelytothesecondstepoftherapywiththepurposeofgetting accesstodeeppocketsites,oraimingatregeneratingorresectingthoselesions,thataddcomplexityinthe managementofperiodontitis(infrabonyandfurcationlesions). If periodontal pockets > 4 mm with bleeding on probing and/or deep pockets [≥ 6 mm] are still present at re-evaluation,different options for step 3 can be considered: · Repeatedsubgingivalinstrumentationwithorwithoutadjunctivetherapies. · Access flap periodontal surgery. · Resectiveperiodontalsurgery. · Regenerativeperiodontalsurgery. Generalaspectsofstep3 Recommended Suggested Recommendedinterventions Recommended Recommended Suggested 4-5mm Surgeryshouldbe Asaminimumrequirement, Inpresenceofmoderately performedbydentists repeatedsubgingivalinstrumentation, deepresidualpockets withadditionalspecific withorwithoutaccessflapofthearea, (4-5mm),non-surgical trainingor inthecontextofhigh-qualitystep1and2 subgingival byspecialists. treatment,andafrequentprogram instrumentationshould ofsupportiveperiodontalcareincluding berepeated. subgingivalinstrumentation,arerecommended. Notrecommended NOTrecommended NOTsuggested recommended Surgeryshouldnotperfomed inpatientsnotachievingadequatelevels ofself-performedoralhygiene. Accessandresectivesurgery Recommended Suggested Recommendedinterventions Suggested Suggested Suggested ≥6mm Inpresenceofdeepresidual Differentflapdesing Resectiveperiodontalsurgery pockets(PPD≥6mm)access canbeused. isrecommendedbutincrease flapsurgeryshouldbeperformed. ofgingivalrecessionispossible. Managementofintrabonydefects Recommendedinterventions Recommended Suggested Recommended Recommended Recommended 3mm Teethwithresidualdeeppockets Whendoingregenerationeither Papillapreservationflaps associatedwithintrabony barriermembranesorenamel shouldbeused. defects3mmordeeper matrixderivativewithor Undersomespecificcircumstances, shouldbetreatedwith withouttheadditionof wealsorecommendlimitingflap periodontalregenerative bone-derivedgraftsshould elevationtooptimizewound surgery. beused. stabilityandreducemorbidity. Managementoffurcationlesions Recommendedinterventions Recommended Suggested Recommended Recommended Recommended Periodontaltherapy ClassIIfurcationon Regenerationoffurcationcan isrecommendedinmolarswith mandibularteethandclassII beperformedwithenamel classIIandIIIfurcation buccalfurcationonmaxillary matrixderivativealoneor involvementandresidualpockets. teethshouldbetreated with bone-derivedgraftwith Furcationinvolvementisnoreason periodontalregenerative orwithoutresorbable forextraction. surgery. membranes. Openrecommendation InclassIIIfurcationdefectsandmaxillaryinterdentalclassIIormultipleclassIIdefects, nonsurgicalinstrumentation,openflapdebridement,tunneling,rootseparationorrootresection maybeconsidered. Re-evaluationafterstep3 Endpoints: · Noperiodontalpockets≥5mmwithbleedingonprobing. · Nodeeppockets[≥6mm]. Iftheseendpointsareachieved,thepatientshouldjoinaSPCprogram. Thisdocumentisagraphicadaptationoftheactualclinicalpracticeguidelinesandthereaderisreferredforthecorrectexplanationto theoriginalarticle:“TreatmentofstageI-IIIperiodontitis-TheEFPS3-levelclinicalguideline”bySanzandcoworkers,JClinPeriodontology2020. https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13290 www.efp.org STEP4: Supportiveperiodontalcare(SPC) Aim: Preventingperiodontitisrecurrence/progressionaftersuccessfulcompletionofactivetreatment.Itmustbe performedinallpatients,regardingtheirconditionofbeingathighriskforperiodontitisrecurrence/progression. This step comprises specifically designed supportive periodontal care (SPC),consisting on a combination of preventive and therapeutic interventions rendered at different intervals: · NOpresenceofpockets>4mmwithbleedingonprobing. · NO presence of deep periodontal pockets [≥ 6 mm]. Professionalcare Recommended Suggested Recommendedinterventions Recommended Recommended Recommended Supportiveperiodontalcare Adherencetosupportive Repeatedindividuallytailored visitsshouldbescheduledat periodontalcareiscrucial instructionsinmechanicaloral intervalsof3toamaximumof12 forlong-termperiodontal hygiene,includinginterdental months,andoughttobetailored stabilityandpotentialfurther cleaning,inordertocontrol accordingtopatient´sriskprofile improvementsinperiodontal inflammationandavoid status. potentialdamageforpatients andperiodontalconditionsafter activetherapy. insupportiveperiodontalcare. Suggested Performing routineprofessionalmechanicalplaqueremoval(PMPR), as a part of supportive periodontal care,to limit the rate of tooth loss and provide periodontal stability/improvement. Notrecommended NOTrecommended NOTsuggested NOT NOT suggested suggested Theuseofadjunctivemethods Thereplacementofconventional (sub-antimicrobialdosedoxycycline, professionalmechanicalplaqueremoval(PMPR) photodynamictherapy) withtheuseofalternativemethods toprofessionalmechanicalplaqueremoval(PMPR) (Er:YAGlasertreatment) insupportiveperiodontalcare insupportiveperiodontalcare isnotsuggested. isnotsuggested. Supra gingivalbiofilmcontrolb ythepatient Recommendedinterventions Recommended Suggested Recommended Recommended Suggested Takingintoaccountpatients Toothbrushingshouldbe Ininterdentalareasnotreachable needsandpreferenceswhen supplementedbytheuseof bytoothbrushes,supplementing choosingatoothbrushand interdentalbrushes. toothbrushingwiththeuseof interdentalbrushdesign. otherinterdentalcleaningdevices inperiodontalmaintenancepatients issuggested. Openrecommendation Open Poweredtoothbrushmaybeconsideredas analternativetomanualtoothbrushing. NOTrecommended NOTsuggested Notrecommended suggested Flossingisnotsuggestedasafirstchoiceofinterdentalcleaning inperiodontalmaintenancepatients. Adjunctivemeasuresforgingivalinflammation Recommendedinterventions Recommended Suggested Suggested Suggested Ifanantisepticdentifriceformulation Ifanantisepticmouthrinse isgoingtobeadjunctivelyused, formulationisgoingtobe productscontainingchlorhexidine, adjunctivelyused, products triclosan-copolymerand containingchlorhexidine, stannousfluoride-sodium essentialoilsandcetylpyridinium hexametaphosphatearesuggested. chloridearesuggested. Openrecommendation Recommended The use of adjunctive antiseptics may be considered in periodontitis patients in supportive periodontal care in helping to control gingival inflammation,in specific cases. Unclear Unclear Itisunknownifotheradjunctiveagents (suchasprobiotics,prebiotics,anti-inflammatoryagents,antioxidantmicronutrients) areeffectiveincontrollinggingivalinflammationinpatients insupportiveperiodontalcare. Riskfactorcontrol Recommended Suggested Recommendedinterventions Recommended Suggested Tobaccosmokingcessation Diabetescontrol interventionsneedstobe interventionsarenecessary. implemented. Unclear Unclear Itisnotknownifincreasingthephysicalactivityandreducingweightthroughdietaryand lifestylemodificationhasanimpactinpatientsinsupportiveperiodontalcare. Thisdocumentisagraphicadaptationoftheactualclinicalpracticeguidelinesandthereaderisreferredforthecorrectexplanationto theoriginalarticle:“TreatmentofstageI-IIIperiodontitis-TheEFPS3-levelclinicalguideline”bySanzandcoworkers,JClinPeriodontology2020. https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13290 www.efp.org