EFP S3 guideline on stage IV periodontitis (2022): keep the teeth, close the pockets, and only then splint, move or restore

What it says#

The guideline is the EFP's companion to its 2020 S3 guideline on stages I to III. Stage IV periodontitis, in the 2018 classification, shares the severity and complexity of stage III but adds the sequelae of attachment and tooth loss. The guideline lists five: tooth loss leaving fewer than 20 teeth (under 10 opposing pairs), masticatory dysfunction, tooth mobility of grade 2 or more, severe alveolar ridge defects, and occlusal collapse with drifting and flaring. Those patients need the same periodontal therapy as anyone else, so the guideline sends the periodontal component to the stage I to III document and spends its 68 pages on what comes after: splinting, occlusal adjustment, orthodontics, prostheses on teeth or implants, and supportive care.

The method is the AWMF S3 process with GRADE. Thirteen systematic reviews were commissioned, searched to November 1, 2021, and debated in working groups and plenary votes at the XVII European Workshop in Periodontology in La Granja de San Ildefonso, Spain, November 7 to 9, 2021, with stakeholder delegates from prosthodontic, endodontic, conservative and implant societies and the Council of European Dentists. Each of the 47 numbered items carries a grade (A, "we recommend"; B, "we suggest"; O, "may be considered"; or a statement where evidence was too thin) and a consensus strength (unanimous 100%, strong over 95%, consensus 75% to 95%, simple majority 50% to 74%). Abstentions for conflicts of interest are recorded on every table; on the implant recommendations R10.3 and R10.4 a third of the group abstained.

The strategy comes first. Stage IV can be successfully managed with periodontal therapy plus rehabilitation plus supportive care (R5.1, unanimous). Tooth retention is the first line of treatment (R5.2, grade A, strong consensus); preserving the integrity of the arch by avoiding extractions where teeth can be retained is suggested (R5.3, grade B); and simple measures such as direct or indirect restorations and gingival epitheses may be considered to make keeping the teeth acceptable to the patient (R5.4, grade O). Section 4 puts it more bluntly: early extraction of teeth with a questionable, as opposed to hopeless, prognosis is strongly discouraged and not supported by evidence.

The guideline then divides the work into four case types. Type 1, hypermobility from secondary occlusal trauma that can be corrected without replacing teeth: temporary splinting and/or limited selective occlusal adjustment may be considered during all steps of therapy, particularly step 1, for comfort (R6.1, grade O, very low evidence; the two retrospective splinting studies showed 8.4% tooth loss with splints against 10.1% without), and long-term splinting may be considered when mobility persists after successful therapy (R6.2, grade O). Type 2, pathological migration amenable to orthodontics: orthodontic therapy is suggested in successfully treated patients because it does not worsen probing depths, attachment, bleeding, recession or root resorption (R7.1, grade B, moderate evidence), but it starts only once the endpoints of periodontal therapy are reached, no site with PPD 5 mm and bleeding on probing and no site with PPD 6 mm or more (R7.2, grade A, strong consensus). Where intra-bony defects have been treated regeneratively, orthodontics is recommended (grade A) and the group suggests not waiting a prolonged healing period, since one month and six months gave comparable outcomes in the trial evidence (R7.5). Fixed rather than removable appliances are suggested (R7.6, grade B); fiberotomy and skeletal anchorage may be considered (grade O). During treatment the periodontal status is checked ideally at every orthodontic visit, active movement stops if periodontitis recurs, and afterwards the patient gets life-long supportive care, life-long retention and a permanent fixed passive retainer (R7.7 and R7.8, grade A).

Types 3 and 4 are the prosthetic cases, and Section 8 sets the ground rules: identify the restorative need from the pattern of tooth loss (R8.1); place an interim prosthesis, if required, early in periodontal therapy but only after adequate oral hygiene is established (R8.2); design every prosthesis for self-performed hygiene and professional cleaning, and deliver the definitive one only after a final evaluation of the abutments (R8.3); before implants, verify surgical contraindications, tissue dimensions and the need for augmentation (R8.4); tell the patient about the increased risk for peri-implantitis and implant loss (R8.5); and avoid combined tooth-and-implant-supported fixed partial dentures when alternatives exist (R8.6, grade B). The risk in R8.5 has numbers behind it: the Carra et al. review pooled 1718 implants in patients with a periodontitis history against 2879 without and found survival of 94.7% at five years or more, but a risk ratio of 1.9 for failure of implant-supported fixed prostheses and 3.3 for peri-implantitis, with a hazard ratio of 2.11 after five years of loading.

For tooth-delimited gaps (type 3), tooth-supported fixed prostheses are suggested when the abutments are maintainable and restorable, implant-supported ones when they are not, resin-bonded bridges only for small spaces (their pooled failure rate was 27.4%), and metal-framework removable prostheses as a transitional or definitive option (R9.1 to R9.4). For free-end situations, a shortened arch from second premolar to second premolar with adequate comfort may need no replacement at all (R9.6, grade O, the one recommendation that passed only on a simple majority); if more occluding units are needed, implant-supported fixed prostheses are suggested, and removable metal-framework prostheses when implants are not an option (R9.7, grade B). For full-arch cases (type 4), a tooth-supported full-arch fixed prosthesis is suggested when four or more maintainable, bilaterally distributed abutment teeth remain (R10.1), an implant-supported full-arch fixed prosthesis when teeth cannot be preserved and four or more well-distributed implants are planned (R10.3), and overdentures on teeth or implants may be considered when the numbers or positions fall short (R10.2, R10.4, grade O).

Supportive periodontal care closes the loop: regular professional SPC reduces tooth loss over five years or more and should start at 3-monthly intervals, later personalized (R11.1, grade A, moderate evidence); residual pockets of 5 mm or more after active therapy raise the risk of recurrence even in SPC (R11.2, statement); recall intervals follow the patient's risk profile (R11.3, grade A); and adjuncts to subgingival instrumentation are suggested against when treating a recurrence (R11.5, grade B). The final section reports that rehabilitating partial edentulism of at least five teeth improves quality of life (R12.5, grade A), that complete dentures do the same for the fully edentulous (R12.6, grade A), that implant overdentures are suggested over conventional full dentures for quality of life (R12.7, grade B), and that treating full edentulism improves nutritional status (R12.8, grade A).

Who it applies to#

Any patient who meets the stage IV definition, which in a practice of adults with neglected periodontitis is not rare: the guideline's own scoping describes these patients as having lost five or more teeth to periodontitis and/or needing complex rehabilitation because of bite collapse, drifting, lost posterior support, mobility of degree 2 or more, fewer than 20 teeth, or masticatory dysfunction. The recommendations are written for the whole team; R6.1's feasibility note says splinting and occlusal adjustment can be performed by a general dentist as well as a specialist, and R11.4 expects SPC to be delivered by a variety of oral healthcare professionals under a suitably trained general dentist or specialist.

It does not restate periodontal therapy, and it does not settle the question of who does the orthodontics or the implants: several recommendations note that combined perio-ortho treatment requires appropriate specialists or dentists with advanced training and that availability and funding vary widely. It is also a European document with European stakeholders; nothing in it is a US board rule.

What changed#

Before 2022 the EFP guideline stopped at stage III. This document is the first S3-level guidance for the rehabilitation phase, and its main effect is to fix an order of operations: periodontal endpoints before orthodontic movement or definitive prostheses, interim prostheses early but after hygiene is established, and supportive care as a formal step rather than an afterthought. It also names a "step R" for rehabilitation after steps 1 to 3 of therapy. On implants it is more cautious than a decade of marketing: the guideline calls the assumption that implants in treated stage IV patients will match the general population "probably optimistic" and makes disclosure of the added risk a grade A recommendation.

Where the source is#

The document is Herrera and colleagues, Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline, Journal of Clinical Periodontology 2022, volume 49, supplement 24, pages 4 to 71, published by Wiley on behalf of the EFP and funded entirely by the EFP. The link under the title is the DOI, which resolves to the Wiley page; that page refused automated access when this entry was written, so the full text was read from the published PDF deposited in the University of Liege open repository (ORBi), and the abstract from PubMed. The EFP's guideline page links the article, the supplement with all 13 systematic reviews, and three one-page infographics adapting the recommendations for each case type. The guideline is copyright John Wiley & Sons; the Wiley page may require a subscription.