24.8 The BSP Stepwise Treatment Framework

1. Stepwise Management of Periodontitis (The BSP S3-Level Framework)

The BSP implementation of the EFP S3-level clinical practice guideline organizes periodontitis therapy into four logical, sequential steps:

Stepwise Treatment Algorithm for Periodontitis (BSP / EFP S3 Guideline)
  │
  ├── STEP 1: Behaviour Change, Risk Factor Modification & Supragingival Plaque Control
  │     ├── Individualised oral hygiene instruction (OHI); Interdental brushes (IDBs) FIRST-LINE
  │     ├── Risk factor modification: Smoking cessation (VBA: Ask, Advise, Act); Diabetes liaison (HbA1c < 7%)
  │     └── Professional mechanical plaque removal (PMPR) & removal of plaque-retentive factors
  │
  ├── STEP 2: Cause-Related Therapy (Subgingival Instrumentation / RSD)
  │     ├── Subgingival debridement under local anaesthesia of all sites with PPD ≥ 4 mm
  │     ├── Ultrasonic (Magnetostrictive / Piezoelectric) AND/OR Hand instrumentation (Gracey curettes)
  │     └── Re-evaluation at 8–12 weeks to determine therapeutic endpoints
  │
  ├── STEP 3: Advanced Therapy for Residual Pockets
  │     ├── For persistent pockets PPD ≥ 6 mm with BOP in compliant patients (FMPS < 20%, FMBS < 30%)
  │     ├── Repeat subgingival instrumentation OR Periodontal Surgery
  │     └── Surgical modalities: Resective (Gingivectomy / ARF) vs Regenerative (EMD / GTR / Bone grafts)
  │
  └── STEP 4: Supportive Periodontal Care (SPC)
        ├── Lifelong maintenance phase customized by risk profile (recall every 3–6 months)
        └── Continuous monitoring, plaque/bleeding charting, reinforcement of OHI, targeted debridement

Step 1: Behaviour Change, OHI, and Risk Factor Control

Step 1 aims to engage the patient in behaviour change and reduce supragingival bacterial load:

• Interdental Cleaning Selection: Interdental brushes (IDBs) are the first-line recommendation for interdental plaque removal. Floss is not an equivalent alternative; dental floss is indicated strictly for intact interdental papillae with tight contacts where the smallest interdental brush cannot pass without tissue trauma. Interdental brushes must be sized accurately using colour-coded sizing systems so the bristles lightly compress against the tooth surfaces.
• Toothbrushing Selection: Powered toothbrushes (specifically oscillating-rotating or high-frequency sonic brushes) demonstrate statistically significant, modest superiority over manual brushes in reducing plaque and gingival inflammation.
• Smoking Cessation: General dental practitioners must deliver Very Brief Advice (VBA) on smoking: Ask (identify smoking status at every visit), Advise (explain that smoking accelerates tooth loss and impairs healing), and Act (refer directly to local NHS Stop Smoking Services; prescribe or recommend nicotine replacement therapy, varenicline, or bupropion).
• Diabetes Management: Liaise with the patient's general medical practitioner (GP) or endocrinologist to optimize glycaemic control, establishing a target $\text{HbA1c} < 7.0%$ ($53\text{ mmol/mol}$).
• Supragingival PMPR: Supragingival scaling and polishing to remove plaque-retentive calculus and biofilm, alongside recontouring defective restoration margins.

Step 2: Cause-Related Therapy (Subgingival Instrumentation / RSD)

Step 2 addresses the subgingival microbial biofilm and calculus residing in pockets with PPD $\ge 4\text{ mm}$:

• Local Anaesthesia: Adequate local analgesia is mandatory to permit profound, painless root surface access.
• Therapeutic Objective: The biological objective of modern Root Surface Debridement (RSD) is to disrupt the subgingival biofilm and remove calculus while preserving as much root cementum as possible. The historical concept of aggressive "root planing" to achieve a glassy-hard, cementum-free dentine surface is obsolete, as bacterial endotoxins (lipopolysaccharides) reside within the loosely adherent superficial biofilm rather than penetrating deeply into sound root cementum.

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Steps 3 and 4 of the Framework

The stepwise framework has four steps, and candidates who can recite only the first two lose marks. Step 3 addresses sites that have not responded to Step 2: after re-evaluation, residual pockets of 4 mm or more that bleed on probing, or of 6 mm or more, are managed by repeated subgingival instrumentation with or without adjuncts, and, in patients with excellent plaque control and controlled risk factors, by consideration of surgical access or regenerative procedures where the defect morphology is suitable. Referral for specialist opinion belongs here.

Step 4 is supportive periodontal care, the indefinite maintenance phase. It comprises risk-based recall, repeated reinforcement of plaque control and risk factor management, monitoring of bleeding and probing depths, and re-treatment of sites that break down. The examinable message is that periodontitis is a chronic disease that is controlled, not cured, and that patients who are discharged from supportive care after successful treatment relapse. Failure to arrange supportive care is a recognised reason for treatment failure and, in the UK, a common source of complaint and litigation.

Adjuncts and Where They Do Not Belong

Adjunctive therapies are a favourite distractor. Systemic antibiotics are not recommended as a routine adjunct to subgingival instrumentation in the treatment of periodontitis in general practice; they are reserved for necrotising periodontal disease, periodontal abscess with systemic involvement, and selected specialist cases. Chlorhexidine mouthwash has a role in short-term chemical plaque control when mechanical cleaning is impossible, not as a long-term substitute, and causes staining, taste disturbance and, rarely, hypersensitivity reactions. Locally delivered antimicrobials, host modulation with sub-antimicrobial-dose doxycycline and lasers are not part of routine UK first-line care. Choosing an antibiotic where instrumentation and risk factor control is the correct answer is one of the most reliably wrong answers in the periodontal section.

Necrotising Periodontal Disease as an Exception

One situation departs from the stepwise framework. Necrotising gingivitis and periodontitis present with painful, punched-out, ulcerated interdental papillae, a grey pseudomembranous slough, halitosis and often systemic upset, typically in a smoker, a stressed or immunocompromised patient, or one with poor nutrition. Management is gentle debridement, hydrogen peroxide or chlorhexidine rinses, analgesia, and — uniquely in periodontal practice — systemic metronidazole where there is systemic involvement, followed by definitive periodontal care once the acute phase resolves. Severe or unexplained necrotising disease warrants consideration of underlying HIV infection or other immunosuppression.