Stepwise approach

The first step of therapy, which is relevant to all patients, aims to build the foundations for optimum treatment in terms of risk factor control and behaviour change. For some patients (i.e. those with a diagnosis of health or gingivitis), this step of therapy may be all that is required. However, for patients with periodontitis, it is the start of the process of stabilising disease.

The following components are included in Step 1:

• Explaining to the patient their disease status and risk factors, along with a discussion on the risks and benefits of treatment or no treatment;
• Explaining the importance of patient-performed oral hygiene to control inflammation and providing instruction/coaching in effective toothbrushing and use of appropriate interdental aids;
• Building patient motivation and confidence to adhere to daily oral hygiene (and any other lifestyle changes that might be needed, including quitting smoking and diabetes control) and attendance for professional visits;
• Reducing risk factors (e.g. smoking and diabetes control interventions; removal of plaque retentive factors);
• Professional mechanical plaque removal (PMPR; see Professional mechanical plaque removal), including both supra- and subgingival plaque biofilm and calculus removal from the clinical crown.
  N.B. It is acceptable to remove accessible calculus from root surfaces as part of Step 1 of treatment.
• Ongoing monitoring of the response to treatment by assessing plaque levels, gingival bleeding and patient engagement.

Once this first phase of treatment is complete and adequate time has passed, reassessment of the patient’s condition using appropriate outcome measures is performed to inform further management. The time period between the first phase of treatment and reassessment will depend on the initial presentation of disease, the anticipated response to treatment and also on clinician and patient preferences and could range from a few weeks to a few months.

The second step of therapy aims to control inflammation and subgingival plaque biofilm and calculus in patients with a diagnosis of periodontitis where complete calculus removal has not been possible during Step 1 of therapy, by providing further, targeted subgingival PMPR (see Professional mechanical plaque removal). Ongoing support for, and reinforcement of, risk factor control messages (e.g. oral hygiene instruction, smoking cessation, diabetes control) is also provided where necessary. Additionally, ongoing support for motivation is likely to be needed for many patients, including identifying and discussing real or perceived barriers.

Prior to undertaking Step 2 of therapy, the likely benefits of further active treatment should be assessed based on the outcome of Step 1. Repetition of Step 1, rather than moving to Step 2 of therapy, may be more appropriate for some patients, for example those who lack motivation for further treatment, as Step 2 is time consuming and will fail if plaque control is not optimised.

Step 2 of therapy is followed by an assessment of the response to treatment. If the goals of treatment, for example improved plaque control and reduced probing pocket depths (see Treatment goals), have been reached, then the patient can progress to Step 4 of therapy (i.e. maintenance). However, if treatment has not controlled disease in the desired way, then the clinician can consider repeating Step 1 of therapy or, alternatively, moving to Step 3 of therapy.

The third step of therapy aims to treat non-responding sites i.e. pockets with residual deep probing depths which have failed to resolve with Steps 1 and 2 of therapy.

During this phase, further subgingival PMPR at non-responding sites may be provided, or alternatively, referral for specialist care may be considered. 

As with Step 2, ongoing support for, and reinforcement of, risk factor control messages (e.g. oral hygiene instruction, smoking cessation, diabetes control) is provided where necessary. During this phase, the motivation of the patient for further treatment or referral, and the availability of specialist referral services when developing a treatment plan, should be considered. 

If referral to specialist or enhanced services is not a management option, then subgingival instrumentation at deep sites should be repeated with the aim of achieving as much improvement as possible, followed by progression to Step 4 of therapy.

The fourth step of therapy encompasses a programme of supportive periodontal care (SPC) which aims to prevent deterioration in the periodontal condition, maintain stability, and identify and manage any sites which show deterioration at an early stage. It combines aspects of both prevention and treatment and relies on the patient’s ongoing efforts with oral hygiene, and risk factor control, along with monitoring of disease status by the dental team.

In patients where further treatment is unlikely to result in improvement, the transition from Step 3 to Step 4 is not well defined. However, if it has not been possible to achieve periodontal stability, Step 4 of therapy aims to maintain the patient at a steady state while accepting that some residual sites with probing depth >4 mm may persist.

The recall interval and level of care provided during maintenance is based on the individual patient’s periodontal status and risk profile and will likely range between intervals of 3-12 months. If initial disease or recurrence is detected, (re)treatment should be considered (see Management of disease recurrence) and provided as appropriate in agreement with the patient. Longer term, the recall interval can be varied in response to individual patient risk and presentation (see Risk assessment tool).