Den norske tannlegeforenings Tidende
13.01.2022
Abstract The recent clinical practice guidelines by the European Federation of Periodontology (EFP) are based on the best available evidence to be
... used in decision-making when treating stage I-III periodontitis patients with the intention to improve the overall quality of periodontal treatment in European countries. In the present article, we highlight the most important preventive and therapeutic aspects of the non-surgical periodontal treatment (NSPT) protocol, including the first and second steps of therapy as well as supportive periodontal therapy. This step-wise approach covers different types of interventions. While subgingival instrumentation forms a basis in NSPT, it is less clear whether adjunctive methods and agents are of benefit in an attempt to enhance treatment response and to achieve the endpoint of therapy. The aim of the present article was to compare selected EFP guidelines to be used in the NSPT protocol to those available in Nordic countries. The comparison revealed a few differences of little clinical relevance and showed that EFP and Nordic guidelines are in agreement.
Introduction
For decades, non-surgical periodontal therapy (NSPT) has proven to be an effective method in removing soft and hard deposits from deepened periodontal pockets using either hand instruments or power-driven instruments in combination with oral hygiene instructions (1,2). This golden standard" protocol, also known as cause-related therapy or anti-infective treatment, still remains the cornerstone of periodontal treatment. With or without adjunctive therapeutic means NSPT suppresses the burden and modifies the composition of dysbiotic biofilms, thus reducing the inflammatory reaction in tissues surrounding periodontitis-affected teeth.
Currently, several methods are available to be combined with NSPT. Among those, systemic antibiotics have been of interest since the 90's and, despite potential adverse effects, are sometimes used in the treatment of advanced periodontal disease (stages III and IV), while some newer adjunctive therapies still lack convincing evidence on their effectiveness or are not yet available in clinical practice.
Major clinical parameters relevant to NSPT include reduced pocket depths (ideally pocket closure) and absence of bleeding (3). To guarantee long-term treatment results, i.e., the stability of clinical attachment level and tooth survival, periodontitis patients' commitment to sufficient oral hygiene, smoking cessation, and attending maintenance visits based on an individual risk assessment is required (4,5).
In November 2019, the XVI European Workshop in Periodontology (EWP), organized by the European Federation of Periodontology (EFP), was dedicated to a structured consensus development, targeting to create evidence-based clinical guidelines for decision-making in the treatment of stage I-III periodontitis (6). The guidelines use the information from 15 systematic reviews that were prepared for this EWP where expert consensus-based recommendations were presented, discussed, voted on, and finally adopted by consensus (see the detailed description of the S3 level process (6)).
In the current paper, the following questions are addressed: 1) Which are the most important guidelines in NSPT? 2) What is the impact of adjunctive methods and when to use them? 3) In what cases is NSPT sufficient to reach the endpoint of active therapy? Then we compare selected EFP clinical practice guidelines in the first and second steps of periodontal therapy and supportive care to guidelines previously available in Nordic countries.
Treatment of stage I-III periodontitis: first and second steps of periodontal therapy
When periodontitis is diagnosed, including staging and grading (7), the patient is provided with thorough information on the disease, describing its etiology, major risk factors, and how to manage the condition. In addition, different therapeutic approaches and their expected benefits and potential risks are explained and, thereafter, an initial treatment plan is made and confirmed through patient consent (6).
Oral hygiene
For the first step of therapy, an essential goal is to achieve favorable conditions for oral hygiene practices and to commit the patient to regular homecare. At all levels of staging, a stepwise treatment should start with individually tailored oral hygiene instructions, including selected tooth brushing and interdental cleaning methods (8,9,10), which is followed by professional interventions to remove supragingival biofilms (plaque), calculus, and plaqueretentive factors to ensure effective plaque control by the patient at home (6). Sometimes additional tools, such as promoting behavioral changes to improve oral hygiene (11) and adjunctive therapies for reducing gingival inflammation (12), are needed to reach an adequate oral hygiene level. Psychological methods for motivation (motivational interviewing, cognitive behavioral therapy) are of interest. Five randomized clinical trials (RCTs), however, failed to identify any significant impact on patients' compliance with oral hygiene practices (11). Notably, it is important to enforce oral hygiene instructions throughout all steps of periodontal therapy (6).
Risk factor control: tobacco smoking
Tobacco smoking is strongly linked to periodontal disease, increasing the risk for periodontitis by 85% (13). It is also established that the outcomes of periodontal therapy are inferior in smokers compared to non-smoking patients. Tomasi et al. (3) reported that the likelihood to obtain pocket closure at 3 months after subgingival instrumentation was three times lower in smokers (Odds ratio 0.33). The pronounced negative impact on the periodontal status and on outcomes of therapeutic intervention makes smoking cessation a relevant target of risk factor control in conjunction with periodontitis-related interventions, and existing data do suggest that smoking cessation significantly reduces the risk to develop periodontitis (14). In the systematic review by Ramseier et al. (15), assessing six relevant studies on the effect of smoking cessation interventions, the proportion of patients actually quitting tobacco smoking ranged from 4% to 30% at 1 to 2 years, and quit rates were higher following more intensive behavioral interventions. On the basis of two included studies (16,17), the effect of periodontal therapy was found to be greater in the subgroup of quitters compared to oscillators (serial quitters) or those who continued smoking. Thus, it was concluded that interventions for smoking cessation are effective and should be included in periodontal care (15). Approaches to subgingival instrumentation
Dental professionals can choose between different evidence-based delivery protocols when planning subgingival instrumentation. In addition, different categories of instruments are available. In the systematic review by Suvan et al. (18), the efficacy of full-mouth protocols was compared to more traditional quadrant/sextantwise approaches. The authors also addressed the potential differences between the use of hand or ultrasonic instrumentation. The primary outcomes considered were the reduction of probing pocket depth (PPD) and the proportion of closed pocket (PPD ?4 mm and absence of bleeding on probing (BOP)) at 3/4 and 6/8 months. A total of 19 studies with a minimum follow-up period of ?6 months were identified. In all, NSPT resulted in an estimated PPD reduction of 1.4 mm at 6/8 months and 74% of all pockets were closed. Interestingly, the PPD reduction at initially deep sites (PPD ?7 mm) amounted to 2.6 mm. No differences between the fullmouth protocol, where subgingival instrumentation is performed less time-intensively, and traditional quadrant/sextant-wise setups were observed in terms of PPD reduction or pocket closure. Likewise, no differences were noted between subgingival instrumentation carried out with either hand instruments or ultrasonic devices (18).
Notably, the patient populations in these studies demonstrated high levels of self-performed biofilm control. This is particularly relevant when considering the lack of differences between the fullmouth and quadrant/sextant-wise protocols. In the former, behavioral change (step 1 therapy) had been addressed prior to the limited, e.g. 1-hour subgingival instrumentation (19). It is also noteworthy that patient preference was only rarely considered and could not be evaluated in the systematic review by Suvan et al. (18).
Residual problems following non-surgical periodontal therapy
While NSPT in combination with self-performed biofilm control (steps 1 and 2) is widely effective in the management of periodontitis, residual pockets and BOP may be expected in patients with stage III or IV periodontitis. The systematic review by Suvan et al. (18) found that 74% of periodontal pockets were resolved at 6 to 8 months after initial treatment. In addition to the patient-related factor smoking, the strongest indicator for treatment outcomes is the initial probing depth (19,20), typically associated with the presence of intra-bony defects. While the mean PPD reduction may be greater, the likelihood of pocket closure was still reduced. Also, sites with deep furcation involvement (class II or III) responded less favorably to NSPT. Tomasi & Wennström (21) observed that as little as 25% of sites with initial furcation involvement class II were reduced to class I or resolved at 3 months, and 94% of sites still demonstrated BOP. In the effort to personalize treatment approaches, patients should be informed on expected treatment outcomes prior to NSPT.
Additional approaches
Laser or antimicrobial photodynamic treatment
The systematic review by Salvi et al. (22) examined the adjunctive use of laser (10 RCTs) and antimicrobial photodynamic therapy (aPDT; eight RCTs) in connection to NSPT. The studies tested five different lasers (diode, Er:YAG, Er.Cr:YAG, Nd:YAG, and KTP) and four dif
Gå til medietIntroduction
For decades, non-surgical periodontal therapy (NSPT) has proven to be an effective method in removing soft and hard deposits from deepened periodontal pockets using either hand instruments or power-driven instruments in combination with oral hygiene instructions (1,2). This golden standard" protocol, also known as cause-related therapy or anti-infective treatment, still remains the cornerstone of periodontal treatment. With or without adjunctive therapeutic means NSPT suppresses the burden and modifies the composition of dysbiotic biofilms, thus reducing the inflammatory reaction in tissues surrounding periodontitis-affected teeth.
Currently, several methods are available to be combined with NSPT. Among those, systemic antibiotics have been of interest since the 90's and, despite potential adverse effects, are sometimes used in the treatment of advanced periodontal disease (stages III and IV), while some newer adjunctive therapies still lack convincing evidence on their effectiveness or are not yet available in clinical practice.
Major clinical parameters relevant to NSPT include reduced pocket depths (ideally pocket closure) and absence of bleeding (3). To guarantee long-term treatment results, i.e., the stability of clinical attachment level and tooth survival, periodontitis patients' commitment to sufficient oral hygiene, smoking cessation, and attending maintenance visits based on an individual risk assessment is required (4,5).
In November 2019, the XVI European Workshop in Periodontology (EWP), organized by the European Federation of Periodontology (EFP), was dedicated to a structured consensus development, targeting to create evidence-based clinical guidelines for decision-making in the treatment of stage I-III periodontitis (6). The guidelines use the information from 15 systematic reviews that were prepared for this EWP where expert consensus-based recommendations were presented, discussed, voted on, and finally adopted by consensus (see the detailed description of the S3 level process (6)).
In the current paper, the following questions are addressed: 1) Which are the most important guidelines in NSPT? 2) What is the impact of adjunctive methods and when to use them? 3) In what cases is NSPT sufficient to reach the endpoint of active therapy? Then we compare selected EFP clinical practice guidelines in the first and second steps of periodontal therapy and supportive care to guidelines previously available in Nordic countries.
Treatment of stage I-III periodontitis: first and second steps of periodontal therapy
When periodontitis is diagnosed, including staging and grading (7), the patient is provided with thorough information on the disease, describing its etiology, major risk factors, and how to manage the condition. In addition, different therapeutic approaches and their expected benefits and potential risks are explained and, thereafter, an initial treatment plan is made and confirmed through patient consent (6).
Oral hygiene
For the first step of therapy, an essential goal is to achieve favorable conditions for oral hygiene practices and to commit the patient to regular homecare. At all levels of staging, a stepwise treatment should start with individually tailored oral hygiene instructions, including selected tooth brushing and interdental cleaning methods (8,9,10), which is followed by professional interventions to remove supragingival biofilms (plaque), calculus, and plaqueretentive factors to ensure effective plaque control by the patient at home (6). Sometimes additional tools, such as promoting behavioral changes to improve oral hygiene (11) and adjunctive therapies for reducing gingival inflammation (12), are needed to reach an adequate oral hygiene level. Psychological methods for motivation (motivational interviewing, cognitive behavioral therapy) are of interest. Five randomized clinical trials (RCTs), however, failed to identify any significant impact on patients' compliance with oral hygiene practices (11). Notably, it is important to enforce oral hygiene instructions throughout all steps of periodontal therapy (6).
Risk factor control: tobacco smoking
Tobacco smoking is strongly linked to periodontal disease, increasing the risk for periodontitis by 85% (13). It is also established that the outcomes of periodontal therapy are inferior in smokers compared to non-smoking patients. Tomasi et al. (3) reported that the likelihood to obtain pocket closure at 3 months after subgingival instrumentation was three times lower in smokers (Odds ratio 0.33). The pronounced negative impact on the periodontal status and on outcomes of therapeutic intervention makes smoking cessation a relevant target of risk factor control in conjunction with periodontitis-related interventions, and existing data do suggest that smoking cessation significantly reduces the risk to develop periodontitis (14). In the systematic review by Ramseier et al. (15), assessing six relevant studies on the effect of smoking cessation interventions, the proportion of patients actually quitting tobacco smoking ranged from 4% to 30% at 1 to 2 years, and quit rates were higher following more intensive behavioral interventions. On the basis of two included studies (16,17), the effect of periodontal therapy was found to be greater in the subgroup of quitters compared to oscillators (serial quitters) or those who continued smoking. Thus, it was concluded that interventions for smoking cessation are effective and should be included in periodontal care (15). Approaches to subgingival instrumentation
Dental professionals can choose between different evidence-based delivery protocols when planning subgingival instrumentation. In addition, different categories of instruments are available. In the systematic review by Suvan et al. (18), the efficacy of full-mouth protocols was compared to more traditional quadrant/sextantwise approaches. The authors also addressed the potential differences between the use of hand or ultrasonic instrumentation. The primary outcomes considered were the reduction of probing pocket depth (PPD) and the proportion of closed pocket (PPD ?4 mm and absence of bleeding on probing (BOP)) at 3/4 and 6/8 months. A total of 19 studies with a minimum follow-up period of ?6 months were identified. In all, NSPT resulted in an estimated PPD reduction of 1.4 mm at 6/8 months and 74% of all pockets were closed. Interestingly, the PPD reduction at initially deep sites (PPD ?7 mm) amounted to 2.6 mm. No differences between the fullmouth protocol, where subgingival instrumentation is performed less time-intensively, and traditional quadrant/sextant-wise setups were observed in terms of PPD reduction or pocket closure. Likewise, no differences were noted between subgingival instrumentation carried out with either hand instruments or ultrasonic devices (18).
Notably, the patient populations in these studies demonstrated high levels of self-performed biofilm control. This is particularly relevant when considering the lack of differences between the fullmouth and quadrant/sextant-wise protocols. In the former, behavioral change (step 1 therapy) had been addressed prior to the limited, e.g. 1-hour subgingival instrumentation (19). It is also noteworthy that patient preference was only rarely considered and could not be evaluated in the systematic review by Suvan et al. (18).
Residual problems following non-surgical periodontal therapy
While NSPT in combination with self-performed biofilm control (steps 1 and 2) is widely effective in the management of periodontitis, residual pockets and BOP may be expected in patients with stage III or IV periodontitis. The systematic review by Suvan et al. (18) found that 74% of periodontal pockets were resolved at 6 to 8 months after initial treatment. In addition to the patient-related factor smoking, the strongest indicator for treatment outcomes is the initial probing depth (19,20), typically associated with the presence of intra-bony defects. While the mean PPD reduction may be greater, the likelihood of pocket closure was still reduced. Also, sites with deep furcation involvement (class II or III) responded less favorably to NSPT. Tomasi & Wennström (21) observed that as little as 25% of sites with initial furcation involvement class II were reduced to class I or resolved at 3 months, and 94% of sites still demonstrated BOP. In the effort to personalize treatment approaches, patients should be informed on expected treatment outcomes prior to NSPT.
Additional approaches
Laser or antimicrobial photodynamic treatment
The systematic review by Salvi et al. (22) examined the adjunctive use of laser (10 RCTs) and antimicrobial photodynamic therapy (aPDT; eight RCTs) in connection to NSPT. The studies tested five different lasers (diode, Er:YAG, Er.Cr:YAG, Nd:YAG, and KTP) and four dif
