STEP 3
Aim: Treating those sites non-responding adequately to the second step of therapy with the purpose of getting access to deep pocket sites, or aiming at regenerating or resecting those lesions, that add complexity in the management of periodontitis (infrabony and furcation lesions). 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: · Repeated subgingival instrumentation with or without adjunctive therapies.
· Access flap periodontal surgery. · Resective periodontal surgery. · Regenerative periodontal surgery.
General aspects of step 3
Recommended interventions
Recommended
Suggested
Recommended
Recommended
Suggested
4-5 mm
Surgery should be performed by dentists with additional specific training or by specialists.
As a minimum requirement, repeated subgingival instrumentation, with or without access flap of the area, in the context of high-quality step 1 and 2 treatment, and a frequent program of supportive periodontal care including subgingival instrumentation, are recommended.
In presence of moderately deep residual pockets (4-5 mm), non-surgical subgingival instrumentation should be repeated.
Not recommended
NOT recommended
NOT suggested
NOT recommended
Surgery should not perfomed in patients not achieving adequate levels of self-performed oral hygiene.
Access and resective surgery
Recommended interventions
Recommended
Suggested
Suggested
Suggested
Suggested
≥6 mm
Different flap desing can be used.
Resective periodontal surgery is recommended but increase of gingival recession is possible.
In presence of deep residual pockets (PPD ≥ 6 mm) access flap surgery should be performed.
Management of intrabony defects
Recommended interventions
Recommended
Suggested
Recommended
Recommended
Recommended
3 mm
Papilla preservation flaps should be used.
Teeth with residual deep pockets associated with intrabony defects 3 mm or deeper should be treated with periodontal regenerative surgery.
When doing regeneration either barrier membranes or enamel matrix derivative with or without the addition of bone-derived grafts should be used.
Under some specific circumstances, we also recommend limiting flap elevation to optimize wound stability and reduce morbidity.
Management of furcation lesions
Recommended interventions
Recommended
Suggested
Recommended
Recommended
Recommended
Periodontal therapy is recommended in molars with class II and III furcation involvement and residual pockets. Furcation involvement is no reason for extraction .
Class II furcation on mandibular teeth and class II buccal furcation on maxillary teeth should be treated with periodontal regenerative surgery.
Regeneration of furcation can be performed with enamel matrix derivative alone or bone-derived graft with or without resorbable membranes.
Open recommendation
In class III furcation defects and maxillary interdental class II or multiple class II defects, nonsurgical instrumentation, open flap debridement, tunneling, root separation or root resection may be considered.
Re-evaluation after step 3
Endpoints: · No periodontal pockets ≥ 5 mm with bleeding on probing. · No deep pockets [≥ 6 mm]. If these endpoints are achieved, the patient should join a SPC program.
This document is a graphic adaptation of the actual clinical practice guidelines and the reader is referred for the correct explanation to the original article: “Treatment of stage I-III periodontitis - The EFP S3-level clinical guideline” by Sanz and coworkers, J Clin Periodontology 2020 . https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13290
www.efp.org
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