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programme prior to, throughout, and following the rehabilitation phase of care. It has been shown that patients with stage IV periodontitis, when compared with stage I, have a higher risk of periodontal-related tooth loss over a period of follow-up of 10 – 30 years (hazard ratio 3.73) (Ravida et al., 2020) as well as a higher risk for pathological tooth migra- tion and other functional consequences (Kwok & Caton, 2007).
sufficient rehabilitation or correction of the masticatory dysfunction), the risk of additional loss of tooth-supporting tissues increases and may lead to complete edentulism. Untreated severe periodontitis may result in substantial tooth loss in adults (Ramseier et al., 2017) and ranks 77th among the 100 most relevant human conditions resulting in disability (Marcenes et al., 2013). Severe periodontitis and dental caries account for more years lost to disability than any other human disease (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018). Furthermore, periodontitis is associated with a range of systemic dis- eases including diabetes (Sanz et al., 2018), cardiovascular diseases (Tonetti, Van Dyke, & Working group 1 of the joint EFP/AAP Workshop, 2013; Sanz, Marco Del Castillo, et al., 2020) and adverse preg- nancy outcomes (Sanz, Kornman, & Working group 3 of joint EFP/AAP Workshop, 2013). It is also independently associated with premature death from all causes or cardiovascular disease (Garcia et al., 1998; Soikkonen et al., 2000; Soder et al., 2007; Linden et al., 2012), in particu- lar in multi-morbid populations where the impact of periodontitis is equiv- alent to having co-morbid diabetes mellitus (Sharma et al., 2016), and also results in increased medical expenditure (Sato et al., 2016).
1.1.2 | Pathophysiology
Periodontitis is initiated by the accumulation of a dental plaque bio- film at and below the gingival margin, which becomes increasingly dysbiotic (Meyle & Chapple, 2015) and which results in dysregulation of the host immune-inflammatory response, which further drives the dysbiosis and results in the destruction of periodontal tissues (Hajishengallis & Chavakis, 2021).
1.1.3 | Prevalence
Periodontitis is the most common chronic inflammatory non- communicable disease of humans. According to data originating from the Global Burden of Disease (GBD) database, 1.1 billion cases of severe periodontitis were prevalent globally in 2019, and an 8.44% (95% confidence interval — CI [6.62; 10.59]) increase in the age- standardized prevalence rate of severe periodontitis was observed between 1990 and 2019 (Chen et al., 2021). In a Swedish population, the prevalence of severe masticatory dysfunction was found to be low (Salonen et al., 1990), but in a popu- lation of institutionalized older adults (65 years or more) in Italy, the prevalence of masticatory dysfunction, mainly caused by untreated edentulism, was 35% and it was associated with all-cause mortality after 9 years (Laudisio et al., 2016). The prevalence (global age-standardized prevalence) of complete edentulism in 12-year or older individuals was 4.4% in 1990 and 2.4% in 2010, with incidences of 374 and 205 per 100,000 person-years cases, respectively, with no differences between sexes, and a gradual increase with age, peaking at 65 years (Kassebaum et al., 2014). Geo- graphic differences were evident, with European countries presenting high incidences (Kassebaum et al., 2014). In the United States, data from NHANES 2005 – 2016 showed 4.5% complete edentulism with 10.3% of subjects lacking a functional dentition (i.e., having only one and up to 19 remaining teeth) (Al-Zahrani et al., 2021). Complete and partial edentulism were more frequent in persons with systemic co- morbidities or with a compromised systemic condition (Parker et al., 2020). The negative impact of edentulism on quality of life, nutri- tion and systemic health has been well established (Griffin et al., 2012).
1.1.5 | Financial aspects
On a global scale, periodontitis of all stages is estimated to cost $54 billion in direct treatment costs and further $25 billion in indirect costs (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018). Periodontitis, and especially severe periodontitis (including stages III and IV periodontitis), contributes significantly to the total expenditure allocated to manage dental diseases due to the need to replace lost teeth. In 2015, the total cost of dental diseases was estimated to amount to $544.41 billion, run on billion being $356.80 billion direct costs (dental expenditures), and $187.61 billion indirect costs (productivity losses) (Righolt et al., 2018). Although the economic impact of edentulism has not been clearly established, at least two factors may support its importance: on the one hand, the need of rehabilitation; on the other hand, and in case of lack of rehabilitation, the negative consequences already listed in quality of life, nutrition, systemic health, etc. In addition, it has also been concluded that individual- and community-level social inequal- ities have a strong impact on edentulism (Ito et al., 2015).
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AIM OF THE GUIDELINE
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This guideline aims to highlight the importance of, and need for scien- tific evidence in, clinical decision-making in the treatment of patients with stage IV periodontitis. Its main objective, therefore, is to summarize the evidence-based recommendations for the individual interventions involved in the multidisciplinary management of stage IV periodontitis, based on the best available evidence and/or expert consensus. In so doing, this guideline aims to (i) inform sound multidisciplinary therapeu- tic approaches to the treatment of stage IV periodontitis, and thereby improve the overall quality of periodontal treatment rendered in Europe
1.1.4 | Consequences of failure to treat
If no treatment is provided for stage IV periodontitis, or if the treat- ment is inadequate and/or not comprehensive (e.g., does not result in
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