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SANZ et al .
less free sugars and salt intake, increase in fruit and vegetable in - take) 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), per - formed at hospital and university settings. Periodontal interventions were not clearly defined, although in the 6-month RCT, periodontal treatment was part of the protocol. Some studies showed signifi - cant improvements in periodontal parameters, but the RCT with the longest follow-up was not able to identify significant benefits (Zare Javid, Seal, Heasman, & Moynihan, 2014). In the systematic review (Ramseier et al., 2020), two studies specifically on the impact of dietary counselling aiming at carbohy - drate (free sugars) reduction in gingivitis/periodontitis patients were identified, one 4-week RCT (including also gingivitis patients) and one 24-week prospective study. Periodontal interventions were not clearly defined. Both studies reported improved gingival indices. Additional factors have been discussed in the overall evaluation of risk factor control. R1.10 | What is the efficacy of lifestyle modifications aiming at weight loss in periodontitis therapy? Evidence-based recommendation (1.10) We do not know whether interventions aimed to weight loss through lifestyle modification may have a positive impact in periodontitis therapy. Supporting literature Ramseier et al. (2020) Quality of evidence Five prospective studies Grade of recommendation Grade 0—Statement: unclear, additional research needed Strength of consensus Strong consensus (0% of the group abstained due to potential CoI)
and exercise-related lifestyle modifications. Three studies reported beneficial periodontal outcomes and, the other two, no differences. Additional factors have been discussed in the overall evaluation of risk factor control.
6 | CLINICAL RECOMMENDATIONS: SECOND STEP OF THERAPY
The second step of therapy (also known as cause-related therapy) is aimed at the elimination (reduction) of the subgingival biofilm and cal - culus 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, we have agreed to use the term “subgingival instrumentation” to all non-surgical procedures, either performed with hand (i.e. curettes) or power-driven (i.e. sonic/ul - trasonic 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. Furthermore, subgingival instrumentation may be supplemented with the following adjunctive interventions: • 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.
6.1 | Intervention: Subgingival instrumentation
R2.1 | Is subgingival instrumentation beneficial for the treatment of periodontitis? Evidence-based recommendation (2.1) We recommend that subgingival instrumentation be employed to treat periodontitis in order to reduce probing pocket depths, gingival inflammation and the number of diseased sites. Supporting literature Suvan et al. (2019) Quality of evidence One 3-month RCT ( n = 169 patients); 11 prospective studies ( n = 258) ≥6 months Grade of recommendation Grade A—↑↑ Strength of consensus Unanimous consensus (2.6% of the group abstained due to potential CoI)
Background
Intervention Available evidence suggests that weight loss interventions may improve both the treatment and long-term outcome of chronic non-communica - ble 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 to - wards healthier diets and increase in physical activity (exercise). Available evidence In the systematic review (Ramseier et al., 2020), five prospective studies, in obese gingivitis/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 life - style 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
Background
Intervention Subgingival instrumentation aims at reducing soft tissue inflam - mation by removing hard and soft deposits from the tooth surface.
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