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SANZ et al .
7.4 | General recommendations for periodontal surgical procedures
Background
Intervention Dental services are organized differently in various countries. Some are structured in both primary care and specialist care (usu - ally delivered by referral to dental hospitals or specialist prac - tices/centres); in other countries, dental services are based on a single level of care and interested general practitioners acquire broader periodontal skills through continuing professional de - velopment. Optimal management of Stage III and Stage IV peri - odontitis remains limited in most health systems with significant inequalities in availability and access to advanced/specialist peri - odontal care. There is an urgent need to improve patient access to the appropriate level of care given the high burden and costs associated with the sequelae of unmanaged severe (stages III and IV) periodontitis. R3.6 | What is the importance of adequate self- performed oral hygiene in the context of surgical periodontal treatment? Expert consensus-based recommendation (3.6) We recommend not to perform periodontal (including implant) surgery in patients not achieving and maintaining adequate levels of self-performed oral hygiene. Supporting literature Expert opinion Grade of recommendation Grade A—↑↑ Strength of consensus Strong consensus (0% of the group abstained due to potential CoI)
R3.4 | What is the level of care required for management of deep residual pockets with or without presence of intrabony defects or furcation involvement after completion of steps 1 and 2 of periodontal therapy? Expert consensus-based recommendation (3.4) Surgical treatment is effective but frequently complex, and we recommend that it is provided by dentists with additional specific training or by specialists in referral centres. We recommend efforts to improve access to this level of care for these patients. Supporting literature Expert opinion Grade of recommendation Grade A—↑↑ Strength of consensus Consensus (0% of the group abstained due to potential CoI)
Background
Intervention Advanced periodontal surgery (regenerative and furcation man - agement) is beyond the scope and competence of education in general dental practice (Sanz & Meyle, 2010). Dental curricula include knowledge and familiarity with the approach but are not designed to provide competence to conduct such treatment: Additional specific training is required and is available through continuing professional development and periodontal learned so - cieties in most countries. Post-graduate periodontal education, on the other hand, is specifically designed to provide competence and proficiency towards the resolution of such complex problems (Sanz, van der Velden, van Steenberghe, & Baehni, 2006; Van der Velden & Sanz, 2010). R3.5 | If expertise is not available or referral is not an option, what is the minimum level of primary care required for management of residual pockets associated with or without intrabony defects or furcation involvement after completion of steps 1 and 2 of periodontal therapy? Expert consensus-based recommendation (3.5) As a minimum requirement, we recommend repeated scaling and root debridement 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. Supporting literature Expert opinion [and systematic reviews for access flaps (Graziani et al., 2012, 2015)] Grade of recommendation Grade A—↑↑ Strength of consensus Consensus (0% of the group abstained due to potential CoI)
Background
Intervention Proof-of-principle studies conducted in the 1970s have pointed to the negative effects (clinical attachment loss) of perform - ing periodontal surgery in subjects with inadequate plaque con - trol (Nyman, Lindhe, & Rosling, 1977; Rosling, Nyman, Lindhe, & Jern, 1976). Multiple RCTs on surgical periodontal intervention have shown a dose-dependent effect of plaque control on healing out - comes. Similar data have been reported after implant surgery (van Steenberghe et al., 1990). The level of self-performed oral hygiene is clinically assessed using a plaque control record [for an example, see (O'Leary, Drake, & Naylor, 1972)]. Plaque scores smaller than 20%–25% have been consistently associated with better surgical outcomes (see Step 1 and SPC clinical recommendations for detailed discussions on how to facilitate achieving stringent levels of self- performed oral hygiene).
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