Treatment of

stage I–III periodontitis—

The EFP S3 level clinical practice
guideline
ANNIE LIZ MANUE
I MDS
 CLINICAL RELEVANCE
Scientific rationale for the study:

Implementation of the new classification of periodontitis

should facilitate the use of the most appropriate preventive
and therapeutic interventions, depending on the stage and
grade of the disease. The choice of these interventions
should be made following a rigorous evidence-based
decision-making process
Practical implications
The application of this S3 Level Clinical Practice Guideline
will allow a homogeneous and evidence-based approach to
the management of Stage I–III periodontitis.
AIM OF THE GUIDELINE
 Highlight the importance and need for scientific evidence in
clinical decision-making in the treatment of patients with
periodontitis stages I to III

 Support the evidence-based recommendations for the

different interventions used at the different steps of
periodontal therapy, based on the best available evidence
and/or expert consensus.


 • Dental and medical professionals,
Target together with all stakeholders related to
health care, particularly oral health,
Users including patients

Target • Dental and medical academic/hospital

environments,
Environmen • clinics and practices
t
Target • People with periodontitis stages I to III
• People with periodontitis stages I to III
Populations following successful treatment
EXCEPTIONS FROM THE GUIDELINES

 This guideline did not consider the health economic cost–

benefit ratio, since

(a) it covers multiple different countries with disparate,

not readily comparable health systems

(b) there is a paucity of sound scientific evidence

available addressing this question.
 This guideline did not consider the treatment of gingivitis
(although management of gingivitis is considered as an
indirect goal in some interventions evaluated), the
treatment of Stage IV periodontitis, necrotising
periodontitis, periodontitis as manifestation of systemic
diseases and mucogingival conditions.
Periodontitis is characterized by progressive destruction of the tooth-
supporting apparatus.

Primary features : loss of periodontal tissue support manifest through

CAL and radiographically assessed alveolar bone loss, presence of
periodontal pocketing and gingival bleeding.

If untreated, it may lead to tooth loss, although it is preventable and

treatable in the majority of cases.
Importance

 Periodontitis is a major public health problem due to its high

prevalence,

 Since it may lead to tooth loss and disability, it negatively

affects chewing function and aesthetics

 is a source of social inequality and significantly impairs quality

of life.

 Periodontitis accounts for a substantial proportion of

edentulism and masticatory dysfunction,

 has a negative impact on general health and

 (Tonetti, Jepsen, Jin, & Otomo-Corgel,2017

Pathophysiology

Periodontitis is a chronic multifactorial inflammatory

disease associated with dysbiotic dental plaque biofilms.
PREVALANCE OF PERIODONTITIS
Severe form of periodontitis
11.2 (The Global Burden of Disease 2010
% study)

Severe form of periodontitis

7.4% (The Global Burden of Disease 2015
study)

Milder forms of periodontitis

50% (Billings et al
2018)

Sixth most prevalent condition in the world

(Kassebaum et al
2014)
PERIODONTAL DIAGNOSIS AND CLASSIFICATION
Periodontal diagnosis has been followed according to the classification
scheme defined in the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions
(Caton et al., 2018; Chapple et al., 2018; Jepsen et al., 2018; Papapanou et al., 2018).

A case of clinical periodontal health is defined by

 absence of inflammation (measured as presence of bleeding on
probing at less than 10% sites)
 absence of attachment and bone loss arising from previous
periodontitis.
A gingivitis case is defined by the
 presence of gingival inflammation, as assessed by BOP
at ≥10% sites
 absence of detectable attachment loss due to previous
periodontitis.

Localized gingivitis
 is defined as 10%–30% bleeding sites

Generalized gingivitis
 is defined as >30% bleeding sites
A periodontitis case is defined by the

 loss of periodontal tissue support, which is commonly assessed

 by radiographic bone loss

 or interproximal loss of clinical attachment measured by probing.

Other meaningful descriptions of periodontitis include

 the number and proportions of teeth with probing pocket depth

over certain thresholds (commonly >4 mm with BOP and ≥6
mm),

 the number of teeth lost due to periodontitis,

 the number of teeth with intrabony lesions and

 the number of teeth with furcation lesions.

 An individual case of periodontitis should be further characterized
using a matrix that describes the stage and grade of the disease.

 Stage is largely dependent upon the

 severity of disease at presentation, as well as on the

 anticipated complexity of case management,

 and further includes a description of extent and distribution of the

disease in the dentition.
Grade provides supplemental information about biological features
of the disease

 a history-based analysis of the rate of periodontitis progression

 assessment of the risk for further progression;

 analysis of possible poor outcomes of treatment

 and assessment of the risk that the disease or its treatment may
negatively affect the general health of the patient.
The staging, which is dependent on the severity of the disease and the
anticipated complexity of case management, should be the basis for the
patient’s treatment plan based on the scientific evidence of the different
therapeutic interventions.

The grade, however, since it provides supplemental information on the

patient's risk factors and rate of progression, should be the basis for
individual planning of care.

(Papapanou et al., 2018; Tonetti, Greenwell, &Kornman,

2018)
After the completion of periodontal therapy, a stable periodontitis
patient has been defined by gingival health on a reduced
periodontium

 BOP <10% of the sites

 Shallow probing depths of 4 mm or less and no 4 mm sites with BOP).

When, after the completion of periodontal treatment,

 these criteria are met but bleeding on BOP at >10% of sites,

then the patient is diagnosed as a stable periodontitis patient
with gingival inflammation.

 Sites with persistent probing depths ≥4 mm which exhibit

BOP are likely to be unstable and require further treatment.
 It should be recognized that successfully treated and stable
periodontitis patients will remain at increased risk of
recurrent periodontitis, and hence if gingival inflammation is
present adequate measures for inflammation control should
be implemented to prevent recurrent periodontitis.
Clinical pathway for a diagnosis of periodontitis
 A proposed algorithm has been used by the EFP to assist clinicians with
this periodontal diagnosis process when examining a new patient (Tonetti &
Sanz, 2019). Identifying a patient
suspected of having
periodontitis
Confirming the diagnosis of
periodontitis

Staging the periodontitis case

Grading the periodontitis case

Differential Diagnosis
Vertical root Cervical Cemental
Gingivitis tears (Jepsen et
(Chapple et al., fracture (Jepsen decay (Jepsen et
2018) et al., 2018) al., 2018) al., 2018)

External root Tumours or other Trauma- Endo-

resorption systemic induced local periodontal
lesions (Jepsen conditions recession lesions (Herrera,
et al., 2018) extending to the (Jepsen et al., Retamal-Valdes,
Alonso, & Feres,
periodontium(Jepse 2018)
2018)
n et al., 2018)

Necrotizing
Periodontal periodontal
abscess diseases
(Herrera et al.,
(Herrera et al.,
2018)
2018)
The first step in therapy is aimed at guiding behavior change by
motivating the patient

Interventions to Adjunctive
Supragingival
improve the therapies for
dental biofilm
effectiveness of gingival
control
oral hygiene inflammation

Professional
mechanical plaque Risk factor control
removal (PMPR)
The first step of therapy should be implemented in all
periodontitis patients, irrespective of the stage of their
disease, and should be re-evaluated frequently in order to

• 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 of the ensuing

steps of therapy
The second step of therapy (cause-related therapy)
is aimed at controlling (reducing/eliminating) the
subgingival biofilm and calculus (subgingival
instrumentation)

• Use of adjunctive physical or chemical agents

• Use of adjunctive host-modulating agents (local or

systemic)

• Use of adjunctive subgingival locally delivered

antimicrobials

• Use of adjunctive systemic antimicrobials

The second step of therapy should be used for all
periodontitis

 patients, irrespective of their disease stage, only in teeth

with loss of periodontal support and/or periodontal
pocket formation.

 In specific clinical situations, such as in the presence of

deep probing depths, first and second steps of therapy
could be delivered simultaneously such as for preventing
periodontal abscess development.
 The individual response to the second step of therapy
should
be assessed once the periodontal tissues have healed.

 If the endpoints of therapy (no periodontal pockets >4 mm

with bleeding on probing or no deep periodontal pockets
[≥6 mm]) have not been achieved, the third step of therapy
should be considered.

 If the treatment has been successful in achieving the,

endpoints of therapy, patients should be placed in a
The third step of therapy is aimed at treating those areas
of the
dentition non-responding adequately to the second step of
therapy
• with the purpose of gaining further access to subgingival
instrumentation,

• aiming at regenerating or resecting those lesions that add

complexity in the management of periodontitis (intra-bony
and furcation lesions).
Repeated subgingival instrumentation
with or without adjunctive therapies

Access flap periodontal surgery

Resective periodontal surgery

Regenerative periodontal surgery

When there is indication for surgical interventions, these should
be subject to an additional patient consent and specific
evaluation of risk factors or medical contra-indications should
be considered.

The individual response to the third step of therapy should be

re-assessed and ideally the endpoints of therapy should be
achieved, and patients should be placed in SPC, although these
endpoints of therapy may not be achievable in all teeth in
severe Stage III periodontitis patients.
Supportive periodontal care is aimed at maintaining periodontal
stability in all treated periodontitis patients combining preventive and
therapeutic interventions defined in the first and second steps of therapy,
depending on the gingival and periodontal status of the patient’s
dentition.

• This step should be rendered at regular intervals according

to the patient's needs, and in any of these recall visits, any patient may
need re-treatment if recurrent disease is detected, and
in these situations,a proper diagnosis and treatment
plan should be reinstituted.
• In addition, compliance with the recommended oral hygiene
regimens and healthy lifestyles are part of SPC.
• In any of the steps of therapy, tooth extraction may be considered
if the affected teeth are considered with a hopeless prognosis.
CLINICAL RECOMMENDATIONS: FIRST STEP OF
THERAPY :

Intervention 1: Supragingival dental

biofilm control (by the patient)
1.What are the adequate oral hygiene practices of
periodontitis patients in the different steps of
periodontitis therapy?
 INTERVENTION
• Supragingival dental biofilm control can be achieved by mechanical
and chemical means. Mechanical plaque control is mainly
performed by tooth brushing, either with manual or powered
toothbrushes or with supplemental interdental cleaning using dental
floss, interdental brushes, oral irrigators, wood sticks, etc.
• As adjuncts to mechanical plaque control, antiseptic agents,
delivered in different formats, such as dentifrices and mouth rinses
have been recommended.
• Furthermore, other agents aimed to reduce gingival inflammation
have also been used adjunctively to mechanical biofilm control, such
as probiotics, anti-inflammatory agents and antioxidant
 EVIDENCE
1. XI European Workshop in Periodontology (2014)
- (Chapple et al., 2015)

2. The systematic review on oral hygiene practices for the prevention

and treatment of gingivitis
- (Van der Weijden & Slot, 2015).
• OHI should be provided to reduce plaque and gingivitis.
Re-enforcement of OHI may provide additional benefits.
• Manual or power tooth brushing are recommended as a
primary
means of reducing plaque and gingivitis. The benefits of
tooth brushing out-weigh any potential risks.
• When gingival inflammation is present, inter-dental
cleaning, preferably with interdental brushes should be
professionally taught to patients.

Clinicians may suggest other inter-dental cleaning

2.Are additional strategies in motivation
useful?
 INTERVENTION
• OHI and patient motivation in oral hygiene practices should be an
integral part of the patient management during all stages of
periodontal treatment
- (Tonetti et al., 2015).

• Different behavioural interventions, as well as communication and

educational methods, have been proposed to improve and maintain
the patient's plaque control over time.
- (Sanz & Meyle, 2010).
3.Are psychological methods for motivation effective to
improve the patient's compliance in oral hygiene
practices?
INTERVENTION
• Several different psychological interventions based on social
cognitive
theories, behavioural principles and motivational interviewing
have been applied to improve OHI adherence in patients with
periodontal diseases.

• The available evidence has not demonstrated that these

psychological interventions based on cognitive constructs and
motivational interviewing principles provided by oral health
professionals have improved the patient's oral hygiene performance
Available evidence
The evidence includes two RCTs on MI (199 patients) and three RCTs
on psychological interventions based on social cognitive theories and
feedback (1,517 patients). (Carra et al 2020)

Risk of bias
The overall body of evidence was assessed at high risk of bias (four
RCTs high and one RCT low).

Consistency
The majority of the studies found no significant additional benefit
implementing psychological interventions in conjunction with OHI.
Clinical relevance and effect size
The reported effect size was not considered clinically relevant.

Balance of benefit and harm

Benefit and harm were not reported, and due to the fact that different health
professionals were involved to provide interventions, no conclusion could be
drawn.

Economic considerations
These studies did not assess a cost–benefit evaluation in spite of the
expected additional cost related to the psychological Intervention.

Patient preferences
No proper information was available to assess this issue.

Applicability
A psychological approach needs special training to be effectively performed.
INTERVENTION :
SUPRAGINGIVAL DENTAL
BIOFILM
CONTROL (PROFESSIONAL)
4.What is the efficacy of supragingival professional
mechanical plaque removal (PMPR) and control of
retentive factors in periodontitis therapy?
 INTERVENTION
• The removal of the supragingival dental biofilm and calcified deposits (calculus)
(here identified under the term “professional mechanical plaque removal”
(PMPR) is considered an essential component in the primary (Chapple et al., 2018)
and secondary (Sanz et al., 2015) prevention of periodontitis as well as within the
basic treatment of plaque-induced periodontal diseases (van der Weijden & Slot,
2011).

• Since the presence of retentive factors, either associated with the tooth
anatomy or more frequently, due to inadequate restorative margins, are
often associated with gingival inflammation and/or
periodontal attachment loss,
they should be prevented/eliminated to reduce
their impact on periodontal health.
 EVIDENCES
 Indirect evidence can be found in the 2014 European Workshop on
Prevention, in which the role of PMPR was addressed both in primary
prevention (Needleman et al., 2015) or in supportive periodontal care (SPC)
(Trombelli et al.,
2015).

 A split-mouth RCT, with a follow-up of 450 days in 25 subjects,

concluded that the performance of supragingival debridement, before
subgingival debridement, decreased subgingival treatment needs and
maintained the periodontal stability over time (Gomes, Romagna, Rossi,
Corvello, & Angst, 2014).

 In addition, supragingival debridement may induce beneficial changes

in the subgingival microbiota (Ximénez-Fyvie et al., 2000)
INTERVENTION 2: RISK
FACTOR CONTROL
5. What is the efficacy of risk factor control in
periodontitis therapy?
 INTERVENTION
• Smoking and diabetes are two proven risk factors in the
etiopathogenesis
of periodontitis (Papapanou et al., 2018), and therefore, their
control should be an integral component in the treatment of these
patients.
• Interventions for risk factor control have aimed to educate
and advice patients for behavioural change aimed to reduce them
and
in specific cases to refer them for adequate medical therapy.
• Other relevant factors associated with healthy lifestyles (stress
Papapanou et al 2018
Available evidence
In the systematic review (Ramseier et al., 2020), the authors have identified 13
relevant guidelines for interventions for tobacco smoking cessation,
promotion of diabetes control, physical exercise (activity), change of diet,
carbohydrate (dietary sugar reduction) and weight loss. In addition, 25
clinical studies were found that assess the impact of (some of) these
interventions in gingivitis/periodontitis patients.

Risk of bias
It is explained specifically for each intervention.

Consistency
The heterogeneity in study design precludes more consistent findings, but
adequate consistency may be found for studies on smoking cessation and
diabetes control.

Clinical relevance and effect size

6.What is the efficacy of tobacco smoking cessation
interventions in periodontitis therapy?
 INTERVENTION
• Periodontitis patients may benefit from smoking cessation
interventions
to improve periodontal treatment outcomes and the maintenance
of periodontal stability.
• Interventions consist of brief counselling and may include patient
referral for advanced counselling and pharmacotherapy.
 EVIDENCE
In the systematic review six prospective studies of 6- to 24-month
duration and performed at university setting were identified.

Different interventions were tested (smoking cessation

counselling, 5 A's [ask, advise, assess, assist, and arrange],
cognitive behavioural therapy [CBT], motivational interview, brief
interventions, nicotine replacement therapies).

Ramesier et al
2020
7. What is the efficacy of promotion of diabetes control
interventions in periodontitis therapy?
INTERVENTION
• Periodontitis patients may benefit from diabetes control interventions to improve
periodontal treatment outcomes and the maintenance of periodontal stability.
• These interventions consist of patient education as well as brief dietary
counselling and, in situations of hyperglycaemia, the patient's referral for
glycaemic control.
EVIDENCE
• In the systematic review ,two studies on the impact of diabetes control
interventions in periodontitis patients were identified, two of them 6-month RCTs,
all of them performed at university settings.

• Periodontal interventions were not clearly defined. Different interventions were

tested, including individual lifestyle counselling, dietary changes and oral health
(Ramseier et al., 20
8.What is the efficacy of increasing physical exercise (activity) in
periodontitis therapy?
 INTERVENTION
• Overall evidence from the medical literature suggests that the promotion of
physical exercise (activity) interventions may improve both treatment and the
long-term management of chronic non-communicable diseases.
• In periodontitis patients, the promotion may consist of patient education and
counselling tailored to the patients’ age and general health.

EVIDENCE
• In the systematic review two 12-week studies on the impact of physical exercise
(activity) interventions in periodontitis patients were identified, one RCT (testing
education with comprehensive yogic interventions followed by yoga exercises) and
one prospective study (with briefing followed by physical exercises; the control
group was a dietary intervention), (Ramseier et al., 2020), reported improved
9. What is the efficacy of dietary counselling in
periodontitis therapy?
INTERVENTION
• Periodontitis patients may benefit from dietary counselling interventions to
improve periodontal treatment outcomes and the maintenance of
periodontal stability.
• These interventions may consist of patient education including brief dietary
advices and in specific cases patient's referral to a nutrition specialist.
EVIDENCE
 Seven studies on the impact of dietary counselling (mainly addressing
lower fat intake, less free sugars and salt intake, increase in fruit and
vegetable intake) in periodontitis (with or without other comorbidities)
patients were identified: three RCTs (6 months, 8 weeks, 4 weeks) and
four prospective studies (12 months, 24 weeks, 12 weeks, 4 weeks),
performed at hospital and university settings.
(Ramseier et al.,
2020)

• Periodontal interventions were not clearly defined, although in the 6-

month RCT, periodontal treatment was part of the protocol. Some studies
showed significant
improvements in periodontal parameters, but the RCT with the longest
10.What is the efficacy of lifestyle modifications aiming at weight
loss in periodontitis therapy?
 INTERVENTIO
N
Available evidence suggests that weight loss interventions may improve
both the treatment and long-term outcome of chronic non-communicable
diseases. In periodontitis patients, these interventions may consist of
specific educational messages tailored to the patients' age and general
health. These should be supported with positive behavioural change towards
healthier diets and increase
in physical activity (exercise).
EVIDENCE
• In the systematic review (Ramseier et al., 2020), five prospective studies, in
obese gingivitis OR periodontitis patients, on the impact of weight loss
interventions were identified, with different follow-ups (18 months, 12
months, 24 weeks and two studies of 12 weeks).
• Periodontal interventions were not clearly defined. Intensity of lifestyle
modifications aiming at weight loss interventions ranged from a briefing,
followed by counselling in dietary change, to an 8-week high-fibre, low-
fat diet, or a weight reduction programme with diet and exercise-related
lifestyle modifications. Three studies reported beneficial periodontal
outcomes and, the other two, no differences.
The second step of therapy (also known as cause-related therapy) is aimed at
the elimination (reduction) of the subgingival biofilm and calculus and may be
associated with removal of root surface (cementum).

The procedures aimed at these objectives have received in the scientific literature
different names: subgingival debridement, subgingival scaling, root planning, etc.
(Kieser, 1994).

In this guideline, the term “subgingival instrumentation” was used for to all non-
surgical procedures, either performed with hand (i.e. curettes) or power-driven (i.e.
sonic/ultrasonic devices) instruments specifically designed to gain access to the
root surfaces in the subgingival environment and to remove subgingival biofilm
and calculus.

This second step of therapy requires the successful implementation of the

measures described in the first step of therapy.
INTERVENTION 1:
SUBGINGIVAL
INSTRUMENTATION
11. Is subgingival instrumentation beneficial for the treatment of
periodontitis?
INTERVENTION
• Subgingival instrumentation aims at reducing soft tissue inflammation by
removing hard and soft deposits from the tooth surface.
• The endpoint of treatment is pocket closure, defined by PPD ≤4 mm and
absence of BOP
 EVIDENCE
One RCT on 169 patients with 3-month outcomes addressed the PICOS
question.
Further 11 prospective studies (n = 258) with a follow-up of ≥6 months
which considered baseline measures and post-treatment reductions in
probing pocket depth (primary outcome) and bleeding on probing and
percentage of closed pockets (secondary outcomes) were(Suvan et al. 2019)
analysed.
Risk of bias
Study quality assessment identified a low risk of bias in all but one study, which
had a high risk of bias.

Consistency
Evidence was consistent across all 11 studies that were included in the pre- and
post-treatment analysis and was therefore considered strong. Patient-reported
outcomes were inconsistently reported and adverse events, when reported,
were rare. No indications of publication bias were observed but heterogeneity
was high.

Clinical relevance and effect size

The evidence suggested a mean reduction of PPD of 1.7 mm at 6/8 months, a
mean proportion of closed pockets of 74% and a mean reduction of BOP of 63%.
Deeper sites (>6 mm) demonstrated a greater mean PPD reduction of 2.6 mm.
Balance of benefits and harm
An overall consideration of the benefit versus harm of subgingival
instrumentation supports the strength of the recommendation.

Ethical considerations
Evaluation of the efficacy of subgingival debridement is ethically challenging as
it would entail comparison with no subgingival intervention.
Due to the lack of relevant RCTs, prospective studies were included and their
data analysed.

Applicability
The majority of studies were conducted in well-controlled research
environments and included specifically selected populations, that is those with
no systemic disease.
While results from studies involving populations with systemic diseases were
not included in the systematic review, there is a consensus that subgingival
instrumentation is efficacious in these groups (Sanz et al., 2018, 2019), but the
magnitude of the effect requires further study.
12. Are treatment outcomes of subgingival instrumentation
better after use of hand, powered (sonic/ultrasonic) instruments
or a combination thereof?
 INTERVENTIO
instrumentation. N
Numerous types of instruments are available to perform subgingival

EVIDENCES
Four RCTs (n = 132) with a low overall risk of bias were included. Findings were
evaluated at 6/8 months for PPD reduction (primary outcome) and clinical
attachment level (CAL) gain (secondary outcome).

(Suvan et al 2019)
Risk of bias
Study quality assessment identified all four studies to be at low risk of bias.

Consistency
The evidence demonstrated that outcomes of treatment were not dependent on
the type of instrument employed. The evidence was considered strong and
consistent.

Clinical relevance
No clinically or statistically significant differences were observed between the
different types of instruments.

Balance of benefits and harm

Patient-reported outcomes and adverse events were inconsistently reported. If
present, no obvious differences between hand and powered instruments in terms
of post-operative sensitivity were noted.
Ethical considerations
There is a potential ethical dilemma in that patient preference may conflict with
the clinician's preference in terms of type of instrument.

Economic considerations
Cost-effectiveness has not been evaluated in these studies.

Applicability
Clinicians should be aware that new instrument choices (i.e. mini instruments)
were not evaluated in the available studies. The choice of instrument should be
based upon the experience/skills and preference of the operator together with
patient preference.
13.Are treatment outcomes of subgingival instrumentation better when
delivered quadrant-wise over multiple visits or as a full mouth procedure
(within 24 hr)?
INTERVENTION
Subgingival instrumentation has traditionally been delivered during multiple
sessions (e.g. quadrant-wise). As an alternative, full-mouth protocols have been
suggested. Full-mouth protocols included single stage and two-stage therapy
within 24 hr; however, protocols including antiseptics (full-mouth disinfection) were
not included in this analysis.

EVIDENCES
Eight RCTs (n = 212) with a follow-up of ≥6 months were included demonstrating a
low risk of bias. Outcome measures reported were PPD reduction (primary
outcome), CAL gain, BOP reduction and pocket closure (secondary outcomes).
(Suvan et al 2019)
Risk of bias
The evidence was considered strong and consistent. No indications of publication
bias were observed, and heterogeneity was low. The results confirm the findings of
a recent Cochrane systematic review. (Eberhard, Jepsen, Jervoe-Storm, Needleman, &
Worthington, 2015).

Clinical relevance
No substantial differences were observed between the two treatment modalities.

Balance of benefits and harm

Clinicians should be aware that there is evidence of systemic implications (e.g.
acute systemic inflammatory response) with full-mouth protocols. Thus, such an
approach should always include careful consideration of the general health status
of the patient.

Ethical considerations
There is a potential ethical dilemma in that patient preference may conflict with
the clinician's recommendation in terms of mode of treatment delivery. Patient
autonomy should be respected.
Legal considerations
Potential adverse systemic effects of full-mouth treatment protocols in certain
risk patients should be considered.

Economic considerations
Limited evidence on the cost-effectiveness of different modes of delivery is
available.

Patient preferences
Patient-reported outcomes were inconsistently reported, and there is no
evidence supporting one approach over the other. Reports of increased
discomfort and side effects, evident in studies on full-mouth disinfection, were
not included in the present analysis.
Applicability
The majority of studies were conducted in well-controlled environments,
included specifically selected populations and were undertaken in a number of
different continents.
INTERVENTION 2: USE OF
ADJUNCT PHYSICAL AGENTS
TO SUBGINGIVAL
INTSRUMENTATION
14. Are treatment outcomes with adjunctive application of laser
superior to non-surgical subgingival instrumentation alone?
INTERVENTION
Lasers offer the potential to improve outcomes of subgingival root surface
treatment protocols when used as adjuncts to traditional root surface
instrumentation
Depending upon the wavelength and settings employed, some lasers can
ablate subgingival calculus and exert antimicrobial effects.
The evidence reported to inform the current guidelines has grouped lasers
into two main wavelength categories:
lasers with a wavelength range of 2,780–2,940 nm and
lasers with a wavelength range of 810–980 nm.
 EVIDENCES
Evidence was available from five RCTs (total n = 147) with a follow- up of
≥6 months and a single laser application.

Only RCTs reporting mean PPD changes were considered and this
recommendation is made in the light of this approach to the systematic
review.’
(Salvi et al 2019)

Risk of bias
The majority of studies displayed unclear risk of bias.

Consistency
Studies differed in terms of laser type, tip diameter, wavelength, mode of
periodontal treatment, number of treated sites, population and several
possible combinations of these parameters.
Clinical relevance and effect size
There is insufficient evidence to recommend adjunctive application of lasers to
subgingival instrumentation.

Balance of benefits and harm

The majority of the studies did not report on potential harm/adverse effects.

Economic considerations
Additional costs associated with adjunctive laser therapy may not be justified.

Patient preferences
Patient-reported outcomes were rarely reported.

Applicability The majority of studies were conducted in university settings,

included specifically selected populations and were undertaken in a number of
different countries.
Are treatment
15.Are outcomesoutcomes
treatment with adjunctive
withantimicrobial
adjunctive photodynamic
antimicrobial
therapy (aPDT) superior to non-surgical subgingival instrumentation
photodynamic therapy (aPDT) superior to non-surgical
alone?
subgingival instrumentation alone?
 INTERVENTION
Adjunctive antimicrobial photodynamic therapy (aPDT) is an approach used to
improve the antimicrobial effects of traditional root surface decontamination
methods. It functions by attaching a photosensitizing dye to the normally
impermeable outer cell membrane of Gramnegative bacteria and then uses
laser light to generate reactive oxygen species through the membrane-bound
dye to locally destroy those bacteria.

EVIDENCES
Evidence was available from five RCTs (n = 121) with a follow-up of ≥6 months
and a single aPDT application. Only RCTs reporting mean PPD changes were
included in the meta-analysis, and this recommendation is made in the light of
this approach to the systematic review.

(Salvi et al. 2019)

Risk of bias
The majority of studies displayed unclear risk of bias.

Consistency
Substantial heterogeneity across the studies was identified, in terms of laser
type, photosensitizer, wavelength, mode of periodontal treatment, number of
treated sites, population and several possible combinations of these
parameters.

Clinical relevance and effect size

No benefits were observed with the adjunctive application of aPDT.

Balance of benefits and harm

The majority of the studies reported on adverse events with no harm associated
with the adjunctive application of aPDT.
Economic considerations
Additional costs associated with adjunctive laser therapy may not be
justified.

Clinical relevance and effect size

No benefits were observed with the adjunctive application of aPDT.

Balance of benefits and harm

The majority of the studies reported on adverse events with no harm
associated with the adjunctive application of aPDT.

Economic considerations
Additional costs associated with adjunctive laser therapy may not be
justified.
INTERVENTION 3: USE OF ADJUNCTIVE HOST
MODULATING AGENTS TO SUBGINGIVAL
INSTRUMENTATION
Does the adjunctive use of local statins improve the clinical outcome of
subgingival instrumentation?
INTERVENTION
Statins are known to have pleiotropic pharmacological effects in addition to their
hypolipidemic properties. These include antioxidant and anti-inflammatory
effects, the stimulation of angiogenesis, improvements in endothelial function
and the positive regulation of bone formation pathways (Adam & Laufs, 2008;
Mennickent, Bravo, Calvo, & Avello, 2008; Petit et al., 2019).

AVAILABLE EVIDENCE
Twelve placebo-controlled RCTs (n = 753), all derived from the same research
group, assessed the effect of local statin gels in adjunctive non-surgical therapy
for infrabony or furcation Class II defects. PPD reduction (primary outcome) was
reported at 6 and 9 months for 1.2% atorvastatin (6 RCTs, n = 180), 1.2%
simvastatin gel (five RCTs, n = 118) and 1.2% rosuvastatin g el (four RCTs, n =
122). Meta-analysis was performed in nine RCTs (n = 607).
(Donos et al. 2019)
Risk of bias
There was a moderate overall risk of bias in the studies analysed. Three of 12 studies
presented with a high risk of bias in at least one domain. One study was moderately
underpowered. While pharmaceutical companies provided the statins in the included
studies, the level of involvement of industry in the analysis and interpretation of the
results is unclear.
Consistency
Meta-analysis of nine RCTs where statins had been applied to a single site per patient
demonstrated that adjunctive local application of 1.2% statin gels in infrabony
defects led to a mean difference in PPD reduction of 1.83 mm (95% confidence
interval (CI) [1.31; 2.36]) at 6 months and of 2.25 mm (95% CI [1.88; 2.61]) at 9
months. Only one study investigated locally delivered statins in Class II furcation
Clinical relevance
Although the mean estimates suggested a clinically meaningful benefit from adding
statin gels to subgingival instrumentation, there was a large prediction interval for
PPD reduction at 6 months (−0.08 mm to 3.74 mm) and the I2 (95.1%) indicating
wide heterogeneity of data and therefore caution needs to be adopted when
assessing the efficacy of statins. While the prediction interval at 9 months (1.16–
3.34 mm) improved over 6-month results, heterogeneity (I2 statistic) of 65.4% still
indicated moderate inconsistency in results
Balance of benefits and harms
All studies included in the review reported that patients tolerated local statins well,
without any complications, adverse reactions/side effects or allergic symptoms.

Economic considerations
There is an additional cost associated with the use of statins that is borne by the patient.

Ethical and legal considerations

The statin formulations included in the systematic review are “off label” and an approved
formulation with appropriate good manufacturing practice quality control (Good
Manufacturing Practice, GMP) and patient's safety validation is not available.
Applicability
The same research group published all data within the RCTs, thereby restricting the
generalizability of the results, which need to be confirmed in future larger (multicentre)
RCTs by independent groups, with multilevel analyses to account for potential
confounding factors
17.Does the adjunctive use of probiotics improve the clinical outcome of
subgingival instrumentation?
 INTERVENTIO
N
 Probiotics are defined as “live microorganisms which, when administered in adequate
amounts, confer a health benefit on the host” (FAO/WHO).

 It has been suggested that probiotics may alter the ecology of micro-environmental niches
such as periodontal pockets, and as such, they may disrupt an establish interaction with
the host via several mechanisms including modulation of the immune inflammatory
response, regulation of antibacterial substances and exclusion of potential pathogens via
nutritional and spatial competition
(Gatej, Gully, Gibson, & Bartold,
2017).
EVIDENCES
 Five placebo-controlled RCTs (n = 176) assessed the adjunctive effect of
probiotics to subgingival instrumentation.
 Two studies from the same group used a preparation containing L.
ramnosus SP1 (2 × 107 colony forming units).
 Two other RCTs from another research group used a preparation
containing L. reuteri. One study evaluated a combination of S. oralis KJ3,
S. uberis KJ2 and S. rattus JH145. Meta-analysis was performed on PPD
reduction (primary outcome) at 6 months.
(Donos et al 2019)
Risk of bias
All studies had an overall low risk of bias. Two out of the five studies declared
industrial sponsorship, and three received the probiotics from industry.

Consistency
Meta-analysis of five RCTs demonstrated that, compared with placebo, treatment
with probiotics resulted in a mean difference in PPD reduction of 0.38 mm (95%
CI [−0.14; 0.90]) at 6 months. The confidence interval and I2 statistic (93.3%)
suggested considerable heterogeneity for the effect of the treatment with the
different formulations.

Clinical relevance
The mean estimated difference in PPD reduction between probiotics and
placebo was not statistically significant and of limited clinical relevance
(difference < 0.5 mm). Preparations containing Lactobacillus reuteri were the
only ones to demonstrate improved PPD reductions. Given that probiotics
embrace a broad range of micro-organisms and types of preparations,
combining such data within the same meta- analysis poses an interpretational
challenge.
Balance of benefits and harms All formulations appeared to be safe and
patients did not report adverse effects.

Economic considerations There is an additional cost associated with the

use of probiotics that is borne by the patient.

Applicability All studies were conducted in two countries, and no

conclusions can be drawn on the effectiveness of probiotics as adjuncts to
subgingival instrumentation.
18. Does the adjunctive use of systemic sub-antimicrobial dose doxycycline
(SDD) to subgingival instrumentation improve clinical outcomes?
INTERVENTION
 Sub-antimicrobial dose doxycycline (up to 40 mg a day) is a systemic drug
employed specifically for its anti-inflammatory as opposed to its antimicrobial
properties.

 The formulation offers anti-collagenolytic activity, which may have utility in

reducing connective tissue breakdown and augmenting healing responses
following subgingival instrumentation in periodontitis patients

EVIDENCES
 Eight placebo-controlled RCTs (14 publications, n = 610) reported on the
systemic use of a sub-antimicrobial dose doxycycline (SDD) (up to 40 mg a day)
in combination with subgingival instrumentation.

 Meta-analysis on PPD reduction (primary outcome) at 6 months post-subgingival

instrumentation was performed in five RCTs (n = 484).
(Donos et al
2019)
Risk of bias

• One study was considered to be at high risk of bias and the remaining
studies presented some concerns in certain domains.
• Of the five studies included in meta-analysis, three declared industrial
sponsorship, one was sponsored by the academic institution, and the
fifth did not declare funding.

Legal considerations
SDD is not approved or available in some European countries.
Economic considerations
There is a cost associated with the use of SDD that is borne by the
patient.

Applicability

• SSD is mainly effective in deep sites (≥7 mm), although SDD is used
as a systemic rather than a site-specific treatment.
• The clinical significance in deep sites (0.68 mm at 6 months and
0.62 mm at 9 months) is small, given that re-treatment with non-
surgical root debridement might yield additional PPD reductions,
and local drug delivery systems may yield similar effect sizes
19. Does the adjunctive use of systemic/local bisphosphonates to
subgingival instrumentation improve clinical outcomes?
INTERVENTION
 Bisphosphonates (BPs) are a class of antiresorptive agents that act mainly by
inhibiting osteoclast activity. BPs can also directly inhibit host degradative enzymes
like matrix metalloproteinases released by osteoclasts and other cells of the
periodontium.
 There is also evidence that BPs reduce osteoblast apoptosis, thus increasing bone
density as an overall therapeutic outcome. It is therefore rational to speculate that
BPs may benefit the management of inflammation mediated alveolar bone
resorption in periodontitis patients
(Badran,Kraehenmann, Guicheux, & Soueidan,
2009).
EVIDENCES
 Seven placebo-controlled RCTs (n = 348), all from the same research group, on local
delivery of 1% alendronate gel (six studies) and 0.5% zolendronate gel (one study)
in infrabony or furcation Class II defects were identified.
 A meta-analysis on PPD reduction at 6 months in five RCTs (n = 228) using either
single or multiple sites per patient in infrabony defects was undertaken. Two
placebo-controlled RCTs (n = 90) evaluated systemic administration of BPs
(alendronate and risedronate).
Risk of bias
Of the nine studies included, two were at high risk of bias and seven presented
some concerns in at least one of the domains of the risk of bias assessment tool.

Consistency
Nine RCTs were available, two involving systemic administration of BPs. No meta-
analysis was therefore undertaken for systemic BPs. Out of the seven RCTs
involving local application of BPs, five were on infrabony defects (four employed
1% Alendronate gel and one study used 0.5% Zolendronate gel), while two were
undertaken on furcation Class II defects (all using 1% Alendronate gel).
Clinical relevance
Although the mean estimates suggested adjunctive benefits from adjunctive use of
BP gels, the combined use of studies considering single and multiple sites per
patient in the meta-analysis should be taken into consideration.

Applicability
The same research group/centre published all data on locally delivered BPs;
therefore, the generalizability of the results requires substantiating in future larger
(multicentre) RCTs, with multilevel analyses accounting for potential confounding
factors (e.g. medical history, smoking history).
20.Does adjunctive use of systemic/local non-steroidal anti-inflammatory
drugs to subgingival instrumentation improve the clinical outcomes?
NTERVENTION
 Periodontitis is an inflammatory disease in which altered immune inflammatory
responses to a dysbiotic biofilm drives connective tissue destruction and bone loss.
 It is reasonable therefore that nonsteroid anti-inflammatory drugs (NSAIDs), may be
effective as adjunctive periodontal therapies.

EVIDENCES
 Two placebo-controlled RCTs (n = 88) on local application, one using 1% flurbiprofen
toothpaste twice daily for 12 months and a second using subgingival daily irrigation with
200 ml buffered 0.3% acetylsalicylic acid, were identified.
 Two placebo-controlled RCTs (n = 133) on systemic applications, one RCT using systemic
celecoxib (200 mg daily 6 months) and another using a cyclical regime of diclofenac
potassium (50 mg 2-months, then 2 months off, then 2 months on),were included.

(Donos et al 2019)
Clinical relevance
Local NSAIDs did not enhance the clinical outcomes of subgingival
instrumentation. Systemic NSAIDs exhibited limited clinical benefits, but their
heterogeneity did not permit the drawing of clinically meaningful conclusions.

Ethical considerations
Long-term use of systemic NSAIDs carries a well-known risk of unwanted side
effects, which raises concerns over their use as adjuncts to subgingival
instrumentation.
Economic considerations
There would be a cost to using NSAIDs which would ultimately transfer to the
patient.

Applicability
We do not encourage everyday clinical use of systemic NSAIDs or to conduct
future studies to test these medications in their current standard formulations
or dosage regimes.

• No meaningful conclusions could be made regarding use of local NSAIDs.

• Based on the current limited evidence, local NSAIDs did not provide a clinical
benefit.
 CONCLUSION

This S3 guideline informs clinical practice, health systems,

policymakers and, indirectly, the public on the available and
most effective modalities to treat periodontitis and to maintain
a healthy dentition for a lifetime, according to the available
evidence at the time of publication.
THANK YOU