Treatment of stage I–III periodontitis

Approximately 1.1 billion people worldwide suffer from severe periodontitis, here we explain the new EFP S3 level clinical practice guideline

17 October, 2022 / indepth
 Will Peakin  

The 2017 World Workshop on the classification of periodontitis, incorporating stages and grades of disease, aimed to link disease classification with approaches to prevention and treatment, as it described not only disease severity and extent but also the degree of complexity and an individual’s risk.

There has been, therefore, a need for evidence-based clinical guidelines providing recommendations to treat periodontitis. The objective of a recent project undertaken by members of the European Federation of Periodontology (EFP) was to develop an S3 Level Clinical Practice Guideline (CPG) for the treatment of stage I–III periodontitis.

This S3 CPG was developed under the auspices of the EFP, following the methodological guidance of the Association of Scientific Medical Societies in Germany and the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

For the first time we have European recommendations for the interdisciplinary and evidence-based management of all stages of this disease”

Professor Andreas Stavropoulos

The rigorous and transparent process included synthesis of relevant research in 15 specifically commissioned systematic reviews, evaluation of the quality and strength of evidence, the formulation of specific recommendations, and consensus on those recommendations, by leading experts and a broad base of stakeholders.

The S3 CPG approaches the treatment of periodontitis (stages I, II and III) using a pre-established stepwise approach to therapy that, depending on the disease stage, should be incremental, each including different interventions. Consensus was achieved on recommendations covering different interventions, aimed at:

  • Behavioural changes, supragingival biofilm, gingival inflammation and risk factor control
  • Supra- and sub-gingival instrumentation, with and without adjunctive therapies
  • Different types of periodontal surgical interventions
  • The necessary supportive periodontal care to extend benefits over time.

This guideline informs clinical practice, health systems, policymakers and, indirectly, the public on the available and most effective modalities to treat periodontitis and to maintain a healthy dentition for a lifetime, according to the available evidence at the time of publication.

It was announced during EuroPerio10 in June this year and published in the Journal of Clinical Periodontology1, the official publication of the EFP. “Periodontitis has a huge impact on people’s lives, with bleeding gums, loose teeth, halitosis, and substantial, or even complete, tooth loss if left untreated,” said Professor David Herrera, of Complutense University of Madrid, and one of the authors.

 “Those affected can experience difficulty eating and speaking clearly and some feel ashamed, frustrated and vulnerable. However, as today’s document shows, most advanced disease can be successfully treated, and teeth maintained in the long-term.”

Approximately 1.1 billion people worldwide had severe periodontitis (stages III and IV) in 2019, making it the most common chronic inflammatory non-communicable disease. Inflammation starts in the gums, and then progressively destroys the ligament and bone supporting the teeth, causing the teeth to loosen and fall out.

The new guideline focuses on stage IV periodontitis, which is the most advanced stage. In addition to the inflammation and loose teeth in stage III, patients with advanced disease have some of the following: loss of five or more teeth due to periodontitis, teeth moving out of position, flaring teeth, and difficulty in chewing.

Clinical assessment of advanced gum disease includes five components:

  1. Evaluate the extent of breakdown of structures supporting the teeth, aesthetics, and the ability to chew and speak
  2. Establish the number of teeth already lost due to periodontitis
  3. Determine which remaining teeth can be saved
  4. Assess all factors in the mouth which could hinder or enable retention of teeth and/or placing dental implants, such as spaces without teeth and the availability of bone
  5. Ascertain the patient’s overall prognosis, including the probability of disease progression or recurrence, considering the possible presence of risk factors such as smoking and diabetes.

Professor Maurizio Tonetti of Shanghai Jiao Tong University School of Medicine, Shanghai, China, co-author of the guideline, explained: “This detailed diagnostic process is crucial as it enables us to design a multidisciplinary treatment plan based on what is technically and biologically feasible, cost-effective, and in line with the patient’s preferences and expectations.”

Treatment aims to control inflammation and prevent further damage of the supporting tissues of the teeth, and restore tooth function. Therapy begins with the recommendations for stages I to III periodontitis which include good oral hygiene, not smoking, controlling diabetes, and professional cleaning of the teeth above and below the gum line to remove bacteria, as stated in the previous guideline published in 20202.

Additional treatments for stage IV disease can involve orthodontic therapy to straighten or move teeth, and construction of prostheses to replace missing teeth, either supported by teeth or by dental implants.

Professor Herrera said: “Extracting teeth to place dental implants is not a reasonable option if teeth can be retained. Behavioural change is one of the pillars of therapy and the patient’s motivation and compliance are extremely important for success. This includes toothbrushing, cleaning between the teeth, sometimes using a mouth rinse to reduce inflammation, not smoking, and controlling blood sugar for those with diabetes.

“The benefits of periodontal therapy extend beyond the mouth to improved nutrition, quality of life, and systemic health, as, for example, better control of blood sugar in patients with diabetes due to the two-way relationship between diabetes and periodontitis.” Professor Andreas Stavropoulos, EFP president, said: “This guideline for stage IV periodontitis complements that for stages I to III3, meaning that for the first time in history, we now have European recommendations for the interdisciplinary and evidence-based management of all stages of this disease.

“Application of the guideline is expected to improve the quality of periodontal treatment in Europe and worldwide. The EFP will be working with national periodontology societies to translate and adapt the guideline to the local context.”


  1. David Herrera, Mariano Sanz, Moritz Kebschull, Søren Jepsen, Anton Sculean, Tord Berglundh, Panos N. Papapanou, Iain Chapple, Maurizio S. Tonetti. Treatment of stage IV periodontitis –The EFP S3 level clinical practice guideline. J Clin Periodontol. 2022. doi:10.1111/jcpe.13639
  2. At EuroPerio10, the session “The multidisciplinary treatment of stage IV periodontitis” took place on 16 June in Copenhagen. More details available on the EuroPerio website.
  3. Mariano Sanz, David Herrera, Moritz Kebschull, Iain Chapple, Søren Jepsen, Tord Berglundh, Anton Sculean, Maurizio S. Tonetti. Treatment of stage I-III periodontitis –The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47(Suppl 22):4–60. doi:10.1111/jcpe.13290.

Tags: Guidance / Guidelines / Level / periodontitis / S3

Categories: Feature / Magazine

Comments are closed here.

Scottish Dental magazine