EFP S3 guideline on stage I to III periodontitis (2020): four steps, and a re-evaluation that decides between surgery and maintenance

What it says#

This is the guideline that governs almost every periodontitis patient in a general practice. The EFP built it after the 2017 World Workshop introduced staging and grading, on the reasoning that a classification is only useful if it points at a treatment. Fifteen systematic reviews were commissioned, plus a position paper on outcome variables; all sixteen were appraised with AMSTAR 2 by the workshop committee and then peer reviewed by the Journal of Clinical Periodontology before the panel ever met. The panel met in La Granja from November 10 to 13, 2019, ran a moderated formal consensus under the German AWMF method with GRADE, and published in April 2020. Development and publication were financed entirely from EFP internal funds, with no industry support, and panelists with a relevant conflict abstained from the votes it touched.

The grading vocabulary is worth learning because it recurs in every EFP document. Grade A is a strong recommendation, written "we recommend" or "we recommend not to." Grade B is a recommendation, "we suggest" or "we suggest not to." Grade 0 is an open recommendation, "may be considered." Where the evidence was not clear enough to support a recommendation, the group wrote a statement instead. Consensus is reported separately: unanimous is 100% agreement, strong consensus over 95%, consensus 75% to 95%, simple majority 50% to 74%.

The substance is a stepwise protocol that is incremental by stage. Step 1 aims at behavior change: supragingival biofilm control by the patient, interventions to improve oral hygiene, professional mechanical plaque removal with control of retentive factors, and risk factor control. It is recommended in all periodontitis patients irrespective of stage, and re-evaluated frequently. The grade A items here are the ones a hygienist already does: the same oral hygiene guidance enforced through every step including maintenance (1.1), engaging the patient in behavioral change (1.2), professional supragingival plaque removal (1.4), risk factor control generally (1.5), tobacco smoking cessation (1.6) and diabetes control (1.7). Motivational interviewing and cognitive behavioral therapy did not show a significant impact across five randomized trials in 1,716 subjects, so that is a statement, not a recommendation (1.3). Physical exercise, dietary counseling and weight loss are all "we do not know" (1.8 to 1.10).

Step 2 is subgingival instrumentation, again for all patients irrespective of stage, but only at teeth with loss of support or pocketing. It is recommended (2.1, grade A, unanimous), hand or powered instruments alone or in combination (2.2, grade A), and either quadrant-wise or full mouth within 24 hours (2.3, grade B). The effect size the guideline quotes for step 2 is the number to know: a mean probing depth reduction of 1.7 mm at 6 to 8 months, a mean 74% of pockets closed, and a mean 63% reduction in bleeding on probing, with 2.6 mm of reduction in sites deeper than 6 mm. Almost every adjunct is graded against. Lasers, photodynamic therapy, probiotics and sub-antimicrobial dose doxycycline are all "we suggest not to" (grade B). Statin gels, bisphosphonates, systemic or local NSAIDs, omega-3 PUFAs and metformin gel are all "we recommend not to" (grade A). What survives is grade 0: chlorhexidine rinses for a limited period, locally administered sustained-release chlorhexidine, and specific locally administered sustained-release antibiotics, whose effect on pocket depth reduction the guideline puts at about 10%. On systemic antibiotics the group was blunt: because of patient health and public health concerns, routine adjunctive use is not recommended, and specific systemic antibiotics may be considered for specific categories such as generalized stage III periodontitis in young adults, where the effect on pocket depth reduction is about 40% to 50% over debridement alone.

The gate between step 2 and step 3 is the part that changes a chart note. Response is assessed once the tissues have healed, and the endpoints of therapy are no periodontal pockets over 4 mm with bleeding on probing and no deep pockets of 6 mm or more. If they are met, the patient goes to supportive care. If not, step 3 begins.

Step 3 treats the sites that did not respond. Deep residual pockets of 6 mm or more in stage III get access flap surgery, moderately deep residual pockets of 4 to 5 mm get repeated subgingival instrumentation (3.1, grade B). Resective surgery is suggested for deep residual pockets while accounting for the recession it causes (3.3, grade B). Regeneration is recommended for residual deep pockets with intrabony defects 3 mm or deeper (3.7, grade A), with an adjunctive benefit of 1.34 mm of attachment gain and 1.20 mm of pocket depth reduction over the control, an 80% improvement. Barrier membranes or enamel matrix derivative, with or without bone-derived grafts, are the recommended materials (3.8, grade A; 1.27 mm for enamel matrix derivative, 1.43 mm for guided tissue regeneration, 1.5 mm for membrane plus graft). Mandibular Class II furcations are recommended for regeneration (3.11, grade A), where furcation improvement carried an odds ratio of 21. Two grade A recommendations here are about who does the work: surgery should be provided by dentists with additional specific training or by specialists in referral centers, with efforts to improve access (3.4), and no periodontal or implant surgery in patients who are not achieving and maintaining adequate self-performed oral hygiene (3.6).

Step 4 is supportive periodontal care. Visits at intervals of 3 to a maximum of 12 months, tailored to the risk profile and the periodontal condition after active therapy (4.1, grade A). Adherence should be strongly promoted (4.2, grade A). Tooth brushing supplemented by interdental brushes where anatomically possible (4.6, grade A), with flossing suggested against as the first choice (4.7, grade B). Routine professional mechanical plaque removal is suggested to limit tooth loss (4.14, grade B), against a background weighted mean yearly tooth loss rate of 0.15 at five years and 0.09 at 12 to 14 years.

Who it applies to#

Everyone with periodontitis stages I, II or III, treated or in maintenance. That is the bulk of the periodontal work in a general practice: the stage IV guideline covers the collapsed cases and defers its periodontal component back to this document, and the AAP staging and grading chart is what tells you which side of that line a patient is on. The target users named are dental and medical professionals and all health care stakeholders including patients, across academic, hospital and private settings.

The guideline explicitly does not cover gingivitis treatment, stage IV periodontitis, necrotizing periodontitis, periodontitis as a manifestation of systemic disease, or mucogingival conditions. It did not weigh cost-effectiveness. It is European and voluntary; nothing in it is a US board rule, and it declared a validity date of 2025 with a plan to update on demand.

What changed#

Before 2020 there was no S3-level European guideline for periodontitis treatment at all. Compared with common practice, three things move. The first is that the recall interval stops being a habit and becomes a graded recommendation with a stated range and a stated basis, risk profile rather than the calendar. The second is the sheer weight of grade A and grade B recommendations against adjuncts: the ADA's 2015 scaling and root planing guideline in this directory was weakly in favor of several of the same adjuncts on small gains, while the EFP group in 2020 recommends against lasers, photodynamic therapy, probiotics, statins, bisphosphonates, NSAIDs, omega-3 and metformin as adjuncts to instrumentation. The third is the endpoint. "No pocket over 4 mm with bleeding, none 6 mm or deeper" is a number a hygienist can chart, and it is what decides whether a case is finished or goes to surgery.

Where the source is#

The document is Sanz, Herrera and colleagues, Treatment of stage I-III periodontitis: The EFP S3 level clinical practice guideline, Journal of Clinical Periodontology 2020, volume 47, supplement 22, pages 4 to 60, DOI 10.1111/jcpe.13290. It is open access. The link under the title opens the complete full text on Europe PMC (PMC7891343), which is what was read for this entry, tables and recommendation boxes included; the Wiley page at the DOI refused automated access when this entry was written. PubMed carries the abstract and records an erratum at J Clin Periodontol 2021;48(1):163. The EFP's own page for the guideline links the article and a set of free one-page infographics, one per step plus a combined file, which are graphic adaptations and say so. The article is copyright John Wiley & Sons A/S; the infographics are the EFP's.