Professor Iain Chapple explains how updated clinical guidance clarifies when and how mouthwash can enhance periodontal care.
The British Society of Periodontology (BSP) Steps of Care flowchart is widely used when implementing the S3 clinical guidelines in day-to-day clinical practice, and it provides a key summary of recommendations from the BSP adolopment of the European Federation of Periodontology (EFP) S3 level clinical guidelines for managing stages one to three periodontitis.
Now, ‘adolopment’ is an odd word. What it really means is that the BSP had a separate workshop and updated any evidence from the EFP workshop, which was in 2019, and it either adopted or it adapted each recommendation according to the UK healthcare system.
The stakeholder group was broader than the EFP group, and it included representatives from organisations like the General Dental Council (GDC), the office of the chief dental officer (CDO), the Royal Colleges, the College of General Dentistry, and also specialist societies other than the BSP.
But perhaps most importantly, it included patient representatives. These are critical because they provide us with vital insights and input to ensure whatever the recommendation is that is being made has meaning for patients.
Working together
The S3 level process doesn’t just use the evidence base. It’s important to recognise this. It also takes into account things like:
- The cost of an intervention
- The impact on the environment
- Ethical issues
- Access – whether it be physical or financial – to treatment.
You’ll see that the use of chemical adjuncts to mechanical plaque control is referred to both in step one, which is for prevention of periodontal diseases, but also in step four, for supportive periodontal care (SPC).
The guideline actually downgrades the evidence from strong, which is what the systematic reviews told us, to an ‘open recommendation’ for chemical adjuncts. And it does this to account for things such as cost, access and environmental issues.
So, despite the evidence base supporting significant adjunctive benefit in reducing plaque and gingival inflammation, the open recommendation essentially leaves it open to us as oral healthcare professionals, along with our patients, working together to decide on the best regime for that individual patient.
Are adjunctive agents beneficial?
Now, it’s not shown in the flowchart, but in the document itself, recommendation R 4.13 actually goes as far as naming adjunctive agents that have been proven to offer benefit in randomised, controlled trials that have been systematically reviewed (West, 2021).
It states that: ‘If an antiseptic mouth rinse formulation is going to be adjunctively used, we suggest products containing either chlorhexidine, essential oils or cetylpyridinium chloride (CPC) for the control of gingival inflammation in periodontitis patients during supportive care.’
Note, this only refers to during supportive periodontal care because that’s what the systematic review addressed, and that’s what the focus question looked at.
And so, we can only limit the conclusion to exactly what was written on the tin, if you like.
Head to Dentistry.co.uk to complete the Digital Oral Hygiene Roadshow 2025.
References
- British Society of Periodontology (2025) BSP Treatment Flow Chart. London: BSP. Available at: https://www.bsperio.org.uk/assets/downloads/SM4822_BSP_Treatment_Flow_Chart_-_Haleon_Version_3_PRESS_READY.pdf (accessed December 2025)
- West N et al (2021) BSP implementation of European S3-level evidence-based treatment guidelines for stage I–III periodontitis in UK clinical practice. J Dent 106: 103562
This article is sponsored by Listerine.
