BSP UK Version of the S3 Treatment Guidelines for Periodontitis

The European document entitled, “Treatment of Stage I-III Periodontitis – The EFP S3 Level Clinical Practice Guideline”, on periodontal therapy, takes into account a systematic appraisal of the published evidence, as well as the clinical experience of a large group of stakeholders.

As the guideline document is, by definition, international, to ensure a broad dissemination and general applicability, it was recommended by the EFP that national member societies adopt the document or adapt it to their own healthcare system.

The BSP immediately reviewed the guidelines, by involving Public Health England/NHS England and other important stakeholders, to ensure that the guidance could be used easily and effectively by oral health practitioners in the UK. The Society worked with the moderator of the EFP guidelines, Professor Ina Kopp, to ensure the correct processes were followed. The German and Spanish Periodontal Societies performed the same process ahead of us.

To help the dental community implement the guidelines in UK practice, the BSP has put considerable effort into creating a wide range of educational resources and we suggest dental care professionals in the UK use the “BSP Implementation of Treatment of Stage I-III Periodontitis –The EFP S3 Level Clinical Practice Guideline” in their clinical practice (see Professional Information and Resources).

The BSP rapidly reviewed the European document and developed a UK version of the Guidelines, which were suitable for the UK healthcare system. This was done using the GRADE ADOLOPMENT framework.

“Adolop” simply means that we discussed the guidelines and adopted, modified or developed them as we saw fit, to ensure they were appropriate for us to share with UK dental professionals (dentists, hygienists, therapists), patients and the public.

Led by Prof. Nicola West and Prof. Moritz Kebschull, the BSP held Working Group meetings during lockdown and worked incredibly hard to review the EFP’s Evidenced-based Treatment Guidelines.

We were delighted to engage the services of Professor Ina Kopp, who kindly agreed to moderate the whole of this process for the BSP. Ina has extensive experience in leading, strengthening and supporting international collaborations in guideline development. Her excellent moderation skills and lovely manner ensured that the discussions at every meeting were relevant and useful. The BSP is extremely grateful for her contributions to the discussions, which made our collaboration with dental professionals, medical experts, stakeholders and BSP Patient Forum members run smoothly.

The meetings were held online during June and July and Prof. West remarked on the speed and success of the project,

“We were keen to involve several stakeholders in this project, from a variety of organisations, to gain a broader insight and include different perspectives when reviewing the clinical recommendations. I was delighted to have such fantastic working groups comprised of dental professionals, medical experts, stakeholders and BSP Patient Forum who were all committed to rapidly review the European guidelines.

Together, we achieved an enormous task in a very short time, and I am extremely proud to have led this initiative with Moritz. I greatly appreciate the tremendous support of all participants and would like to thank them for their time, dedication and valuable contributions which helped make this project a huge success.”

Prof. Kebschull echoed the same sentiments and added,

“It was a pleasure to work with the BSP on this important project. The BSP UK version of the guidelines will be an important document, as the recommendations provide evidence-based support for specialists, dentists, dental hygienists and dental therapists.”

The authors and workshop participants of the UK adolopment project are listed below. The list includes dental professionals, medical experts, stakeholders and BSP Patient Forum members,all of whom  dedicated a considerable amount of time to this project. Their support in reviewing the guideline document and contributing to the workshop discussions helped to make this project a huge success. 

Workshop Participants:

Neil Almond, Marie Anderson, Raimondo Ascione, Martin Ashley, Paul Baker, Leon Bassi, Sanjeev Bhanderi, Elena Calciolari, Nigel Carter, Antonio Ceriello, Iain Chapple, Marilou Ciantar, Dominic Clark-Roberton, Nick Claydon, David Cottam, Shauna Culshaw, Andrew Cundy, Francesco D'Aiuto, Thomas Dietrich, Nikos Donos, Ian Dunn, Ken Eaton, Gillian Flett, Chris Fox, Mandeep Ghuman, Jenny Godson, Gareth Griffiths, Stephen Hancocks, Peter Heasman, Debbie Hemington, Penny Hodge, Mark Ide, Matt Jerreat, Roshni Karia, Moritz Kebschull, Gerry Linden, Matt Locke, Isobel Madden, Phil Marsh, Matthew Garrett, Giles McCracken, William McLaughlin, Imogen Midwood, Mike Milward, Aidan Moran, Federico Moreno, Madeleine Murray, Rajan Nansi, Ian Needleman, Luigi Nibali, Sarifa Patel, Divyash Patel, Vipul Patel, Michael Paterson, Alexander Pollard, Philip Preshaw, Devan Raindi, Raj Rattan, Anthony Roberts, Shazad Saleem, Ross Scales (observer), Joon Seong, Praveen Sharma, Andrew Smith, Susan Smith, Jeanie Suvan, Manoj Tank, Richard Tucker, Aru Tugnait, Wendy Turner, Bobby Varghese, Jenny Walker, Nicola West, Paul Weston, Roger Yates.

Methodological Consultant:

Professor Ina Kopp

Workshop Organisation:

British Society of Periodontology and Implant Dentistry –

Professor Nicola West & Professor Moritz Kebschull

Scientific societies involved in the guideline development process:

Association of Clinical Oral Microbiologists

British Association of Dental Therapists

British Endodontic Society

British Society of Dental Hygiene and Therapy

British Society of Periodontology and Implant Dentistry

British Society of Restorative Dentistry

Restorative Dentistry UK

Other organisations involved in the guideline development process:

British Dental Association

BSP Patient Forum

Oral Health Foundation

Dental Protection

Faculty of General Dental Practice (UK)

General Dental Council (Observer)

Office of the Chief Dental Officer (OCDO) England

Public Health England

Royal College of Surgeons of England

Scottish Antimicrobial Prescribing Group

(A list of Clinical Experts/Representatives from each organisation can be viewed HERE.)

The BSP UK version of the S3 Treatment Guidelines for Periodontitis paper is now available online in the Journal of Dentistry, with open access: https://authors.elsevier.com/sd/article/S0300-5712(20)30310-9

The Guidelines communicate in a very transparent way the evidence behind all the treatment interventions that we do in dealing with a case of periodontitis (gum disease).

This is an important document, as the recommendations provide evidence-based support for specialists, dentists, dental hygienists and dental therapists. The BSP has therfore arranged to publish the paper with open access to all.

We believe that this is an incredibly important project. Poor gum health can lead to tooth loss and affect other systemic health issues, so it was wonderful that European experts came together to look at the 4 main phases of periodontal disease management with a view to creating clear guidelines for all.

Within each of the four sections below, the experts looked at specific questions within each category and systematically reviewed the literature in order to provide evidence-based answers:

• Self-care (oral hygiene) & behaviour modification (risk factor control)
• Non-surgical treatments
• Surgical therapy
• Supportive care/maintenance

As a result, the BSP UK S3 Guideline is the “go-to” document for professionals who need clarification on clinical questions and for patients keen to manage their periodontal disease.

The BSP has created a Glossary of the periodontal terminology used in the BSP Implementation of the S3 Treatment Guidelines for Periodontitis and professional flowchart resource. We hope that you find this document helpful.

We intend to treat the Glossary as a working document, so please contact the Society if there are other terms you feel need explaining.

Click HERE to download resource.

To assist members and the wider dental community in interpreting the guidelines, the BSP carefully planned and created educational resources to support the profession.

The series of four educational webinars followed the publication of the paper. The webinars may now be viewed below, without CPD. We hope that you enjoy the series:

Webinar Series 2021

10 February - Step 1: Prof. Moritz Kebschull, sponsored by GSK

24 February - Step 2: Prof. Iain Chapple, sponsored by Acteon

10 March - Step 3: Prof. Nikos Donos

24 March - Step 4: Prof. Nicola West, sponsored by Oral-B

Webinar Series 2022

20 January - Prof. Iain Chapple, Time to take periodontitis seriously

10 February - Dr Shazad Saleem, Avoidance of Doubt, sponsored by Acteon

In addition, the BSP has been kindly supported by Haleon on this project. We have worked together to record several educational videos and produce a flowchart resource to help dental care professionals implement the guidelines in clinical practice. The flowchart QR code will link to a short, informative video, guiding you through the four steps.

• Download S3 Professional flowchart

We have worked with Haleon to distribute the flowcharts to UK dental practices. The flowchart will be coated in N9 Pure Silver, which is designed to provide anti-microbial performance and is the safe and natural way to protect the printed surface.

By creating a series of short video clips, which we have shared via social media and our website, we aim to help spread the important educational message to the wider dental profession, patients and the public. 

We are often asked similar questions via our website, during lectures and on social media. Dr Viren Vithlani & Dr Ian Dunn have, therefore, collated the frequently asked questions with the BSP answers:

Q: What does S3 mean? I thought there were four main steps in the treatment guidance.

A: The new treatment guidance is based on a ‘stepwise’ approach to treatment. The guidance has been developed with the highest quality level for guidance development (S3 format) which considers both a systematic appraisal of the published evidence as well as clinical experience. S3 simply refers to the highest level of guideline production.

Q: Why did we need a new set of guidelines for the treatment of periodontitis?

A: Following the publication of the new classification, guidance was developed to support treatment of patients, to allow for an individualised treatment approach. The guidelines are there to support clinicians when treating periodontal disease, helping them make up to date evidence based treatment decisions and focus on personalised patient education. This in turn should empower patients to take more responsibility for their health, ultimately improving outcomes.

Q: The guidelines published by the European Federation of Periodontology are different to the BSP version? Why are we using a different version to the European document?

A: Internationally produced guidelines are not always transferable to each country’s working systems. After the guidance was published in May 2020, the BSP moved rapidly to take the European document and develop a British version of the guidelines, making sure they were suitable for our UK healthcare system. This was something that all EFP societies were encouraged to do and it was done using the ‘grade adolopment’ framework. For each of the individual recommendations, an adolopment process was carried out. ‘Adolop’ simply means that the guidelines are accepted unchanged, adopted, modified, or developed in line with the evidence, to ensure they were appropriate for dental professionals and patients in the UK healthcare system.

Q: What does PMPR mean and why have we got new terminology?

A: PMPR stands for ‘Professional Mechanical Plaque Removal’ and it can be supragingival or subgingival. We have all used different ways of describing what we have done in the past and it is important that we use universal professional language. It replaces ALL previous terminology. Subgingival PMPR is an umbrella term and replaces root surface debridement or root planing. It does not mean that what we did before was wrong or unreasonable and it does not change what we use practically. It does mean the death of the term ‘scale and polish’ which can be misleading to a patient with periodontitis. We are doing much more than just that!

Q: What is the difference between PMPR in step 1 and PMPR in step 2? In Step 1, it mentions Supra and Subgingival PMPR of the clinical crown. I thought we did not go subgingival in Step 1.

A: In Step 1, PMPR includes the removal of plaque and calculus supra and subgingivally. This acknowledges that at this step you are not attempting to do any root surface management but are looking to remove visible or detectable subgingival deposits located on the crown of the tooth, part of which may be subgingival either due to false pocketing or the disease being mild. Essentially you are creating an environment for the patient to clean better. In Step 2, you are carrying out subgingival instrumentation (root surface debridement or PMPR) on the root surface. What you use (hand / powered or a combination) does not matter. It is important to consider patient needs, site level needs and preferences. The quality of the instrumentation is important.

Q: Do we have to write PMPR in our notes or can we still describe what we did i.e., subgingival debridement with hand instruments?

A: The BSP accepts that it will take time for new terminology and language to be adopted universally in the UK but practitioners should make the effort to familiarise themselves with the new terminology. You can still describe and provide more detail on what has actually been carried out, for example subgingival instrumentation with ultrasonic and hand instruments.

Q: Engaged and Non-engaged patients - if a patient fails to hit the required scores to be classed as an engaged patient, can we withhold Step 2 forever? Is that medico-legally robust?

A: The idea is to take each step at a time, to give patients more responsibility. A non-engaging patient could be held at step 1 and not move to step 2 until they are demonstrating that they can improve their plaque control. Of course, this is only true if we have educated our patients on the importance of oral hygiene and demonstrated how to do it. This is medico-legally robust as long as we have followed the steps and are documenting the patient’s oral hygiene routines, the treatment carried out and the reasons why they are not able to move to step 2. Having an objective way of measuring our patient’s plaque control using a plaque score is a great way of demonstrating this.

Q: What happens if a patient declines treatment or is not-engaging at all?

A: These patients can be entered into ‘palliative care’ for their gum disease with step 1 repeated regularly. It is also important that we do not write patients off, you never know when a patient may change their behaviour and engage. Always consider whether we are engaging them enough? Do we need to change our approach or maybe they will engage more with another member of your dental team?

Q: Should subgingival PMPR in Step 2 be carried out using local anaesthesia?

A: There is no significant evidence base that addresses this question. Successful periodontal treatment relies on high quality non-surgical treatment and if you can achieve this without local anaesthetic then it is not required. If you cannot, then it is. This will vary from patient to patient and is something that should be discussed with the patient prior to treatment. 

Q: At Step 3, the guidance talks about referring patients to a level 2 or 3 practitioner if required, for non-responding or residual deep sites. What happens if a referral is not possible?

A: There may be instances where a specialist or level 2 practitioner is not available in the area, or the patient cannot travel or cannot afford treatment. In these cases, the onus is on the practitioner or dental professionals within their team to continue with some form of therapy i.e., repeating subgingival PMPR or providing regular supportive periodontal care that includes subgingival PMPR. If a patient refuses or cannot access specialist of level 2 care they should be made aware of the consequences of their decisions i.e., that the disease may progress and teeth may be lost.

Q: Is it important that every patient has step 4 (supportive periodontal care)?

A: Supportive periodontal care (maintenance) should be encouraged strongly to all patients. Several long-term studies show that it is crucial to long term stability. It allows oral hygiene to be reviewed, reinforced, targeted and it allows monitoring of the disease situation together with PMPR. Oral hygiene is not a one-off event in Step 1, it needs to be practiced throughout all the steps. Maintenance is a crucial part of periodontal therapy and it is the most cost-effective thing patients can do to keep their teeth!

Q: The guidance only talks about treating Stage 1-3 disease, what about Stage 4?

A: The current set of guidance reviewed Stages 1, 2 and 3 disease and guidance for Stage 4 is currently being evaluated and will be published separately. You can read more about the BSP UK Clinical Practice Guidelines for the Treatment of Periodontitis and view other resources by visiting: www.bsperio.org.uk/S3-Guidelines

With the kind support of Haleon, the BSP has also created a lay version of the guidelines for the public and patients, which conveys the importance of gum health in a simplified, informative way. It was extremely important to the BSP to involve patients, who could present their important viewpoints in the Workshops. They have also been involved in the process of creating a lay version of the guidelines.

This lay version will allow patients to empower themselves with evidence-based information to both take responsibility for aspects of their disease management and know that they are being offered appropriate, contemporary, evidence-based treatment.

Our aim in creating resources for patients and the public include:

• Help the public understand what gum disease is
• Raise awareness of how you can look after your gums and maintain good oral health
• Reduce the stigma associated with gum disease (as highlighted in “The Sound of Periodontitis” video) by identifying the many causes including smoking, diabetes etc.
• Highlight that more can be done to aid gum health in addition to brushing your teeth
• Encourage the patient to take ownership of their disease and highlight the ways they can do this

View explanatory letter from BSP HERE.

The lay flowchart can be viewed or downloaded:

MOBILE FRIENDLY VERSION

PRINT VERSION

We would encourage you to share this informative document with your patients, by printing the flowchart or sending
it to your patients electronically. We believe that this is the most sustainable way to share this resource with patients
and the public.

You may also find it helpful to display a copy of this flowchart in your waiting room and take the opportunity
to talk through the flowchart at your consultations.