Treatment of stage IV periodontitis The EFP S3-level clinical practice guideline
Where does the need for this guideline come from? • Implementation of the new classification of periodontitis should facilitate the use of appropriate preventive and therapeutic interventions, depending on the stage and grade of the disease. 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. What do patients need to know? • An essential prerequisite to therapy is to inform the patient of the diagnosis, including causes of the condition, risk factors, treatment alternatives and expected risks and benefits including explanations regarding consequences of refused treatment. • This discussion should be followed by agreement on a personalized care plan. • The plan might need to be modified during the treatment journey, depending on patient preferences, clinical findings and changes to overall health.
How do we interpret these infographics?
Blue colour:
Recommendations in favor of a particular strategy of treatment or specific procedure. Open recommendation in which the clinician is responsible for the final choice of a particular strategy of treatment or specific procedure based on specific patient characteristics. Uncertain recommendation for whose clarification further research is needed. Recommendations against a particular strategy of treatment or specific procedure.
Orange colour:
Red colour:
TABLE Strengh of recommendations: grading scheme (German Association of the Scientific Medical Societies (AWMF) and Standing Guidelines Commision, 2012)
Grade of recommendation grade a
Description
Syntax
We recommend We recommend not to
A
Strong recommendation
We suggest We suggest not to
B
Recommendation
O
Open recommendation May be considered a If the group felt that evidence was not clear enought to support a recommendation, statements were formulated, including the need (or not) of additional research.
Aim: This guideline aims to provide information on: · multidisciplinary therapeutic approaches in the treatment of stage IV periodontitis, · how to minimize tooth loss associated with periodontitis, · how to improve overall systemic health and quality of life. for patients in periodontitis stage IV Cases Type 3 and 4. Case Type 3: Partially edentulous patient who can be prosthetically restored without full-arch rehabilitation. Case Type 4: Partially edentulous patients who need to be restored with full-arch rehabilitation, either tooth or implant-retained.
General recommendations for Cases Type 3 and Type 4
Timepoint of definitive prosthesis
Recommended interventions
Recommended
Suggested
Recommended
Recommended
Recommended
Interim/dental final prosthesis should allow optimal self-performed oral hygiene measures and professional mechanical plaque removal.
An interim dental prosthesis should be placed , if required, early during periodontal therapy.
The definitive prosthesis should be delivered after a final evaluation of the maintainability and prognosis of abutment teeth/implants.
General considerations when incorporating dental implants
Recommended interventions
Recommended
Suggested
Recommended
Recommended
Recommended
Following points should be evaluated when incorporating dental implants: (I) absence of contraindications to surgery (II) hard and soft tissue dimensions (III) the potential need for soft/hard-tissue augmentation (IV) the increased risk for peri-implantitis and implant loss should be evaluated and provided.
Considerations for the design of fixed partial dental prostheses
Recommended interventions
Not recommended
NOT
Suggested
Suggested
It is suggested to avoid combined tooth/implant-supported fixed partial dental prostheses if alternatives are feasible.
Specific recommendation for Case Type 3: Partially edentulous patient who can be prosthetically restored without full-arch rehabilitation
Case Type 3 patients with one/multiple tooth-delimited gaps and periodontally maintainable teeth
Open recommendation
Open
Open
Open
Open
Various prosthetic treatment options (tooth-supported fixed dental prostheses, implant-supported fixed dental prostheses, removable dental prostheses), or no prosthetic rehabilitation may be considered .
Recommended interventions
Recommended
Suggested
Suggested
Tooth-supported fixed dental prostheses are suggested when abutment teeth are periodontally maintainable and restaurable.
Not recommended
Recommended interventions
Suggested
NOT
It is suggested not to use resin-bonded fixed dental prostheses for large edentulous spaces.
Resin-bonded fixed dental prostheses may be considered in certain circumstances (e.g., small tooth-delimited edentulous spaces).
Recommended interventions
Recommended
Suggested
Suggested
Suggested
Implant-supported fixed dental prostheses are suggested when abutment teeth are not periodontally maintainable and restorable.
Open
Metal-based frame removable dental prostheses may be considered as transitional or definitive treatment option when a fixed solution is not indicated.
Case Type 3 patients with unilateral or bilateral posterior free-end situation
Open recommendation
Open
Open
Open
Different prosthetic treatment options (namely shortened dental arch, implant-supported restorations or removable dental prostheses) may be considered .
Case Type 3 patients with shortened dental arch with sufficient occluding/masticatory units
Open recommendation
Open
In cases with a shortened dental arch with sufficient occluding/masticatory units (e.g., from second pre-molar to second pre-molar, no evident risk for flaring or tooth elongation and adequate patient comfort), tooth replacement may not be considered in the free-end situation .
Case Type 3 patients with shortened dental arch without sufficient occluding/masticatory units
Recommended interventions
Recommended
Suggested
Suggested
Suggested
Implant-supported fixed dental prostheses or removable dental prostheses with a metal-based framework, are suggested .
Specific recommendation for Case Type 4:
Partially edentulous patients who need to be restored with full-arch rehabilitation, either tooth or implant-retained
Case Type 4 patients with sufficient number of adequately distributed and restorable teeth in the maxillar/mandible
Recommended interventions
Recommended
Suggested
Suggested
The use of a tooth-supported full-arch fixed dental prosthesis is suggested .
Case Type 4 patients with compromised dentition and insufficient number/distribution of maintainable teeth
Open recommendation
Open
Open
The use of a tooth-supported full-arch removable prostheses may be considered .
Case Type 4 patients with compromised dentition with impossible tooth preservation
Recommended interventions
Recommended
Suggested
Suggested
In cases where a sufficient number (≥4) of bilaterally distributed and adequately sized dental implants are planned in the maxilla and/or mandible, an implant-supported full-arch fixed dental prosthesis is suggested .
Open recommendation
Open
Open
In cases with a reduced number of adequately sized dental implants, and/or adequate position, an implant-supported full-arch removable dental prosthesis (overdenture) may be considered .
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 IV periodontitis: The EFP S3 level clinicalpractice guideline” by Herrera and coworkers, Journal of Clinical Periodontology 2022, https://www.efp.org/education/continuing-education/clinical-guidelines/guideline-on-treatment-of-stage-iv-periodontitis/
www.efp.org
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