What is the full treatment of severe periodontitis, including the order of interventions?

Treatment of Severe Periodontitis: Sequential Protocol

The treatment of severe periodontitis follows a stepwise approach beginning with non-surgical scaling and root planing (SRP) as the foundation, followed by re-evaluation at 4-6 weeks, then surgical intervention for residual deep pockets, and finally lifelong periodontal maintenance therapy. 1, 2

Phase 1: Initial Non-Surgical Therapy (First-Line Treatment)

Scaling and root planing is the gold standard and must be performed first for all patients with chronic periodontitis. 1, 3

Core Components:

• Mechanical debridement: Thorough removal of subgingival biofilm, calculus, and bacterial toxins from root surfaces using hand instruments (preferred) or ultrasonic devices 4, 2
• Patient education: Instruction in optimal home oral hygiene techniques and plaque control 1, 4
• Risk factor modification: Address smoking cessation, diabetes control, and other systemic conditions that worsen periodontal outcomes 5

Treatment Protocols - Two Options:

• Conventional staged debridement (CSD): Quadrant-by-quadrant instrumentation over multiple appointments 2
• Full-mouth scaling and root planing (FMSRP): Complete instrumentation within 24 hours 2

Adjunctive Antibiotic Therapy (Selective Use Only):

Antibiotics should NOT be routinely prescribed for chronic periodontitis. 5 However, consider adjunctive systemic antibiotics in specific situations:

• First-choice regimen: Amoxicillin 500mg + Metronidazole 500mg (combination therapy) administered at the initial phase of treatment, not after healing 5

  • This combination provides the most potent clinical benefit with probing depth reduction of 0.58mm and clinical attachment gain of 0.42mm beyond SRP alone 5

• Alternative regimen: Sub-antimicrobial dose doxycycline (20mg twice daily for 3-9 months) as adjunct to SRP 5

  • Provides probing depth reduction of 0.9mm and clinical attachment gain of 0.88mm 5

• When to consider antibiotics: Aggressive periodontitis, medically compromised patients, or failure to respond to mechanical therapy alone 5, 2

Critical caveat: The Scottish Dental Clinical Effectiveness Programme recommends against antimicrobials for chronic periodontitis, highlighting the controversy in this area 5. Insufficient evidence supports antibiotic use in smokers with chronic periodontitis 5

Phase 2: Re-Evaluation (4-6 Weeks Post-SRP)

Re-assessment is mandatory to determine treatment success and identify residual disease. 1, 2

Assessment Parameters:

• Probing pocket depths at all sites 1
• Clinical attachment levels 1
• Bleeding on probing (indicator of active inflammation) 5
• Plaque control effectiveness 2

Decision Point:

• If pockets ≤5mm without bleeding: Proceed to maintenance phase 2
• If residual pockets >5mm with bleeding: Proceed to surgical therapy 1, 2

Phase 3: Surgical Periodontal Therapy (For Residual Disease)

Surgical intervention is indicated when non-surgical therapy fails to resolve deep pockets with active inflammation. 1, 6

Surgical Options Based on Defect Type:

For suprabony defects (horizontal bone loss):

• Resective surgery (gingivectomy or flap operation with osseous recontouring) in non-aesthetic zones 6
• Access flap surgery for thorough root debridement in areas difficult to instrument non-surgically 4, 6

For infrabony defects (vertical bone loss):

• Regenerative surgery is the treatment of choice, especially in anterior regions and furcation areas 6
• Guided tissue regeneration techniques to restore lost periodontal support 6

Surgical Goals:

• Eliminate residual periodontal pockets 6
• Gain access to root surfaces that cannot be adequately debrided non-surgically 4
• Restore periodontal architecture to facilitate patient plaque control 2

Phase 4: Periodontal Maintenance Therapy (Lifelong)

Regular periodontal maintenance at individualized intervals is crucial for long-term success and tooth retention. 1, 4

Maintenance Protocol:

• Frequency: Twice-yearly visits minimum for adults; intervals adjusted based on disease activity and patient risk factors 5, 1
• Components at each visit:
  • Periodontal risk assessment 5
  • Supragingival and subgingival debridement as needed 5
  • Reinforcement of home care techniques 4
  • Monitoring for disease recurrence 2

Long-Term Monitoring:

• High numbers of residual pockets >5mm with bleeding on probing predict lower clinical stability and require more frequent maintenance 2
• Even with imperfect home care, regular professional maintenance significantly delays attachment loss 4

Critical Pitfalls to Avoid:

• Never prescribe antibiotics without mechanical debridement - antibiotics alone do not eliminate the bacterial biofilm and are ineffective 7
• Do not skip re-evaluation - proceeding directly to surgery without assessing SRP response leads to unnecessary procedures 1
• Ultrasonic instruments alone leave rough root surfaces - hand instruments should be the primary method or used to finish ultrasonic debridement 4
• Do not neglect maintenance phase - periodontal disease recurs without regular professional care regardless of initial treatment success 1, 4
• Avoid extracting restorable teeth - proper periodontal therapy can maintain teeth even with severe attachment loss 7