Treating stage IV periodontitis – the latest EFP guideline

David Herrera discusses the latest European Federation of Periodontology (EFP) guideline on treatment of stage IV periodontitis.David Herrera discusses the latest European Federation of Periodontology (EFP) guideline on treatment of stage IV periodontitis.

Professor David Herrera was scientific chair of Europerio10, chair of European Federation of Periodontology’s (EFP) Perio Workshop, and lead author of the main paper on the new EFP guideline.

David is a full-time professor of periodontology, associate dean for clinics and co-director of the EFP-accredited postgraduate programme in periodontology, at University Complutense of Madrid, Spain.

You are the lead author of the main paper about the new guideline on treatment of stage IV periodontitis. How pervasive is stage IV periodontitis today?

Periodontitis is the most common chronic inflammatory non-communicable disease of humans.

According to data originating from the Global Burden of Disease database, 1.1 billion cases of severe periodontitis (combining stage III and IV periodontitis) were prevalent globally in 2019. In addition, an 8.44% increase was detected between 1990 and 2019.

What are the goals of treatment of stage IV periodontitis?

Stage IV periodontitis requires an interdisciplinary approach for treatment. On one hand, the periodontal tissues need to be properly managed to control inflammation. On the other hand, there is a need for rehabilitation of the impaired dentition. This is due to sequelae as tooth loss, masticatory disfunction, and occlusal collapse.

Therefore, firstly, the recommendations to be followed are common with the ones already developed and published in the previous guideline for the treatment of periodontitis in stages I-III. Those recommendations were presented in four steps of treatment.

The four steps of treatment

  1. Step one aims to control bacterial dental plaque/biofilms around teeth. This includes proper hygiene measures to be performed by the patient, and risk factor control, focusing on the two main risk factors of periodontitis: smoking and diabetes. Thus, in step one of periodontal therapy, behavioural changes and motivation are crucial
  2. Step two aims to clean bacteria below the gum line. This includes a very important intervention called ‘subgingival instrumentation’. In specific cases, this may be associated with adjunctive interventions: use of different antimicrobials or other anti-inflammatory, host-response modulators or antioxidant micronutrients
  3. Step three may only be needed in severe cases. This is because periodontal tissues will be re-evaluated four to 12 weeks after steps one and two of therapy. If the periodontal inflammation is already controlled (bleeding and periodontal pocketing are the most important outcomes for assessing success), patients will go directly to step four. If the periodontal inflammation is still present in some teeth, step three may be considered. This will be either subgingival re-instrumentation or with periodontal surgery. This may include interventions aiming to regenerate periodontal tissues at specific sites
  4. Step four, or supportive periodontal care, is the last step. It is mandatory for all patients, as well as crucial to maintain successful results. It is based on regular professional interventions to control bacterial plaque/biofilms, as well as the patient’s compliance with oral hygiene habits and risk factor control interventions.

Still, there is a major difference between the treatment of other periodontitis and stage IV periodontitis. This is the need to maintain/re-establish a functional dentition and the necessity for a rigorous supportive care programme prior to, throughout, and following the rehabilitation phase of care.

Among the additional multidisciplinary interventions, orthodontic therapy, and implant- or tooth-supported prosthetic rehabilitations can be mentioned.

What are the most important diagnosis and treatment recommendations that should be highlighted for the general public?

Due to the complexity of stage IV periodontitis, the clinical assessment is crucial and should include five relevant aspects:

  1.  Evaluation of the amount of periodontal breakdown, patient function and aesthetics
  2.  Number of teeth already lost, and of those lost due to periodontitis
  3.  Prognosis of each remaining teeth, especially those that may be involved in a tooth-supported prosthesis
  4.  Careful evaluation of restorative factors, in order to evaluate the available options for rehabilitation, including the need of using dental implants
  5.  Overall prognosis, including the presence of systemic risk factors.

This careful analysis allows us to prepare an appropriate treatment plan. This plan will be complex and require a detailed assessment of what is technically and biologically feasible, cost-effective, and in line with the patient’s preferences and expectations.

However, and despite this complexity, most cases of stage IV periodontitis can be successfully treated, maintaining the natural dentition in a state of adequate health and function.

The guideline emphasised the following key general recommendations:

  • Patients should be informed in detail about their condition, the various treatment options and associated risks. This includes the need for periodontal therapy, the design of the rehabilitation, and the sequence of interventions
  • The starting point for treatment of stage IV periodontitis initially attempts to preserve all periodontally compromised teeth that are deemed rational to treat
  • It is crucial to frequently assess motivation and adherence to self-performed dental plaque/biofilm control and risk factor control throughout the course of treatment and during supportive periodontal care
  • It is mandatory that restorations should be designed to achieve function and aesthetics while enabling effective self-performed oral hygiene and professional tooth cleaning.

David Herrera discusses the latest European Federation of Periodontology (EFP) guideline on treatment of stage IV periodontitis.

How should oral healthcare professionals encourage patients to follow advice regarding oral hygiene and control of risk factors, for example?

Patient behavioural change is crucial in the treatment of all types of periodontitis. However, it becomes even more important in stage IV periodontitis. This is due to the complexity of the cases, and the added risks.

Patient habits and behaviour are considered in the recommendations in steps one and four of periodontal therapy. In addition, they are described in our 2020 guideline for the treatment of periodontitis in stages I-III.

On one hand, dental plaque/biofilm control by the patient needs to include some intervention for oral hygiene habits. This is in terms of both training (toothbrushing with manual or powered toothbrushes, interdental cleaning, use of adjunctive agents in dentifrices or mouth rinses) and motivation for behavioural changes. This needs to be frequently re-assessed, with additional instructions and motivation.

On the other hand, intervention for systemic risks factor control includes the implementation of programmes for smoking cessation that could be performed at the dental clinic. In addition, it involves careful advice for diabetes patients to strictly follow the indications made by their medical professional.

You were scientific chair of the recently held Europerio10 in Copenhagen. What were the main novelties of the scientific programme?

At Europerio10 we kept the most attractive formats that we had seen in previous Europerios, especially those that proved to be successful at Europerio9 in Amsterdam in 2018. However, we also prepared a number of new session formats.

One of the highlights of Europerio9 was the live surgery performed by Professor Giovanni Zucchelli. Thus, this year in Copenhagen, we planned three live surgeries.

Two of them were mucogingival surgeries, performed by two experts in the field facing a similar case, but treated with different techniques: Dr Ion Zabalegui, from Spain, and Professor Massimo de Sanctis, from Italy.

And then we have had one more live surgery which focused on bone regeneration. It was performed by Dr Istvan Urban, from Hungary.

Another unforgettable session in Amsterdam was the ‘nightmare’ session. This discussed cases that went wrong and all the things that can be learnt from that.

At Europerio10 we scheduled two ‘nightmare’ sessions. One was on periodontics, chaired by Professor Lior Shapira, and another on implant dentistry, chaired by Dr Adrián Guerrero.

New formats were also introduced. As examples, clinical sessions, mainly based on clinical videos; debates, to promote discussions; or the presentation of the European Federation of Periodontology (EFP) clinical practice guidelines, both the one published in the Journal of Clinical Periodontology in 2020 on the treatment of periodontitis in stages I-III, and the one recently published this June, on the treatment of stage IV periodontitis.

Also, in many sessions, the Europerio10 app allowed attendees to be involved by voting or posing questions.

David Herrera discusses the latest European Federation of Periodontology (EFP) guideline on treatment of stage IV periodontitis.

What was the most challenging part of being scientific chair of Europerio10?

Being in charge of the scientific aspects of Europerio10 has been one of the most demanding parts. However, it was also one of the more rewarding tasks in my periodontal career.

When the chair of Europerio10, Professor Phoebus Madianos, invited me to become scientific chair, I knew that it would challenging. But, it’s fair to say that the support given by some colleagues, especially by Professor Mariano Sanz (one of the most experienced persons for this task, as he was scientific chair of Europerio2 and Europerio8, as well as chair of Europerio5) has greatly helped me to assume this role with pride and responsibility.

The main challenge was the magnitude of Europerio10. We had four big auditoriums running in parallel in the main programme over four days, from Wednesday until Saturday.

In addition, we brought on board some of the most important and best-known speakers, especially from Europe. There were also other experts from all around the world that had their role to play.

We also included new blood – young talents, with a special focus on female talents. For that, the proposals made by all our 37 EFP member societies was very useful. In the main programme, we had 135 speakers from 31 countries.

But this challenging task has also been very rewarding, especially due to the very positive responses from chairs and speakers. They are the best experts worldwide in their assigned topics.

Europerio11 will take place in Vienna, Austria in 2025. Visit for updates and the latest news.

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