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SANZ et al .
the treatment journey, depending on patient preferences, clinical findings and changes to overall health. 1. The first step in therapy is aimed at guiding behaviour change by motivating the patient to undertake successful removal of su - pragingival dental biofilm and risk factor control and may include the following interventions: • Supragingival dental biofilm control • Interventions to improve the effectiveness of oral hygiene [moti - vation, instructions (oral hygiene instructions, OHI)] • Adjunctive therapies for gingival inflammation • Professional mechanical plaque removal (PMPR), which includes the professional interventions aimed at removing supragingival plaque and calculus, as well as possible plaque-retentive factors that impair oral hygiene practices. • Risk factor control, which includes all the health behavioural change interventions eliminating/mitigating the recognized risk factors for periodontitis onset and progression (smoking cessation, improved metabolic control of diabetes, and per - haps physical exercise, dietary counselling and weight loss). This first step of therapy should be implemented in all periodon - titis 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 al - ternatives 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 2. The second step of therapy (cause-related therapy) is aimed at controlling (reducing/eliminating) the subgingival biofilm and calcu - lus (subgingival instrumentation). In addition to this, the following interventions may be included: • 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 This 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 prob- ing depths, first and second steps of therapy could be delivered simulta- neously (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 (periodontal re-evaluation). 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 supportive peri - odontal care (SPC) programme.
3. The third step of therapy is aimed at treating those areas of the dentition non-responding adequately to the second step of therapy (presence of pockets ≥4 mm with bleeding on probing or presence of deep periodontal pockets [≥6 mm]), with the purpose of gaining fur - ther access to subgingival instrumentation, or aiming at regenerating or resecting those lesions that add complexity in the management of periodontitis (intra-bony and furcation lesions). It may include the following interventions:
• 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 (periodontal re-evaluation) and ideally the endpoints of therapy should be achieved, and patients should be placed in supportive periodontal care, although these endpoints of therapy may not be achievable in all teeth in severe Stage III periodontitis patients. 4. 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 ther - apy, 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 situ - ations, a proper diagnosis and treatment plan should be reinstituted. In addition, compliance with the recommended oral hygiene regimens and healthy lifestyles are part of supportive periodontal care. In any of the steps of therapy, tooth extraction may be consid - ered if the affected teeth are considered with a hopeless prognosis. The first part of this document was prepared by the steering group with the help of the methodology consultants, and it was care - fully examined by the experts participating in the consensus and was voted upon in the initial plenary session to form the basis for the specific recommendations.
Strength of consensus strong consensus (0% of the group ab - stained due to potential CoI).
5 | CLINICAL RECOMMENDATIONS: FIRST STEP OF THERAPY
The first step of therapy is aimed at providing the periodontitis pa - tient with the adequate preventive and health promotion tools to facilitate his/her compliance with the prescribed therapy and the assurance of adequate outcomes. This step not only includes the implementation of patient's motivation and behavioural changes to
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