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SANZ et al .
7 | CLINICAL RECOMMENDATIONS: THIRD STEP OF THERAPY
R3.1 | How effective are access flaps as compared to repeated subgingival instrumentation? Evidence-based recommendation (3.1) In the presence of deep residual pockets (PPD ≥ 6 mm) in patients with Stage III periodontitis after the first and second steps of periodontal therapy, we suggest performing access flap surgery. In the presence of moderately deep residual pockets (4–5 mm), we
The treatment of Stage III periodontitis should be carried out in an incremental manner, first by achieving adequate patient's oral hy - giene practices and risk factor control during the first step of therapy and then, during the second step of therapy by professional elimina - tion (reduction) of supra and subgingival biofilm and calculus, with or without adjunctive therapies. However, in periodontitis patients, the complete removal of subgingival biofilm and calculus at teeth with deep probing depths (≥6 mm) or complex anatomical surfaces (root concavities, furcations, infra bony pockets) may be difficult, and hence, the endpoints of therapy may not be achieved, and further treatment should be implemented. The individual response to the second step of therapy should be assessed after an adequate healing period (periodontal re-eval - uation). If the endpoints of therapy (no periodontal pockets >4 mm with bleeding on probing or deep pockets [≥6 mm]) have not been achieved, the third step of therapy should be implemented. If the treatment has been successful in achieving these endpoints of ther - apy, patients should be placed in a SPC program. The third step of therapy is, therefore, aimed at 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). It may include the following interventions:
suggest repeating subgingival instrumentation. Supporting literature Sanz-Sanchez et al. (2020)
Quality of evidence Thirteen RCTs (500 patients) with moderate-to- high risk of bias. Five studies were restricted to pockets associated with intrabony defects. Limited number of studies presented data for quantitative analyses. High consistency of results. Grade of recommendation Grade B— ↑ Strength of consensus Consensus (1.4% of the group abstained due to potential CoI)
Background
Available evidence Statistically significantly greater PPD reduction was observed in access flaps (AF) than in subgingival debridement at 1 year. The difference was more pronounced at initially deep sites (PPD ≥ 6 mm) (four studies, WMD = 0.67, 95% CI [0.37; 0.97], at 1 year; WMD = 0.39; 95% CI [0.09; 0.70] at >1 year). The rela - tive effect was 27.5%. These differences in PPD reduction also occurred in pockets associated with infrabony defects (four stud - ies; WMD = 0.49, 95% CI [0.11; 0.86]). No statistically significant differences in CAL gain at initially deep pockets were observed between procedures. However, CAL gain was significantly greater in the subgingival debridement group at initially moderately deep pockets, and AF resulted in statistically significantly more attach - ment loss at sites with initial PPD ≤ 4 mm. Statistically significantly higher percentage of shallow pockets was achieved with AF than with subgingival debridement (three studies, WMD = 11.6%, 95% CI [6.76; 16.5]). The need of re-treatment (four studies) was 8%– 29% in the subgingival debridement group and 0%–14% in the AF. There were no statistically significant differences in PROMs be - tween the interventions.
• Repeated subgingival instrumentation with or without adjunctive therapies
• Access flap periodontal surgery • Resective periodontal surgery • Regenerative periodontal surgery
Surgical approaches are subject to specific, additional patient consent and specific risk factors/presence of medical contra-in - dications should be considered. The individual response to the third step of therapy should be assessed (periodontal evaluation), and ideally, the endpoints of therapy should be achieved, and patients should be placed in SPC. These endpoints of therapy may not be achievable in all teeth in severe Stage III periodontitis patients.
7.2 | Intervention: different access flaps procedures
7.1 | Intervention: access flap procedures
The second relevant question was whether there are specific surgi - cal conservative surgical procedures that are more efficacious for achieving the endpoints of in the treatment of patients with Stage III periodontitis. Conservative surgical procedures have been defined as those aiming to access the affected root surfaces without eliminating sig - nificant amounts of hard and soft tissues. These procedures have been classified depending on the amounts of marginal gingiva and interdental papillary tissue removal into:
The first relevant question to evaluate the relative efficacy of the surgical interventions in the third step of therapy, for the treatment of Stage III periodontitis patients with residual pockets after the second step of periodontal therapy, is whether access flap proce - dures are more efficacious than subgingival re-debridement for achieving the endpoints of therapy [probing depth (PD) ≤4 mm without BOP].
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