How to Treat Severe Periodontitis: From Probing to Regeneration

Severe periodontitis is not the end. It is the point where you decide whether to lose the teeth or fight to keep them. What makes the difference is who treats it, how they treat it, and how much the patient is willing to commit.

What severe periodontitis is

The 2018 classification (Tonetti, Greenwell & Kornman) distinguishes four stages. Stage III indicates clinical attachment loss ≥ 5 mm, deep pockets ≥ 6 mm, bone loss exceeding one-third of root length. Stage IV adds loss of masticatory function — migrated teeth, bite collapse, or a significant number of teeth already lost.

In both cases, teeth are mobile, gums bleed, bone recedes. But the disease is still manageable. The key is to intervene systematically.

Phase 1: non-surgical cause-related therapy

The first step is always the same, regardless of severity: remove the cause. The bacterial biofilm colonising periodontal pockets is the engine of destruction. Scaling and root planing — deep cleaning beneath the gingiva, site by site, with ultrasonic and hand instruments — is the fundamental treatment.

The EFP S3 clinical practice guidelines (Sanz et al. 2020, J Clin Periodontol) recommend subgingival instrumentation as the first step for all stages of periodontitis. On average, it reduces pocket depth by 1-2 mm. In deep sites, the reduction can be greater.

Dr. Ernesto Bruschi, periodontist in Frosinone, combines cause-related therapy with personalised oral hygiene instructions and, when indicated, adjunctive systemic antibiotic therapy. Every case is different: the diabetic patient is not treated like the smoker; the immunocompromised patient is not treated like the healthy subject.

Reassessment: the moment of truth

At 6-8 weeks after non-surgical therapy, full reassessment follows. Complete probing, six points per tooth, comparison with baseline. Sites that respond — pocket reduction, no bleeding — enter maintenance. Sites that do not respond move to the surgical phase.

This reassessment is the most underestimated step in the entire treatment. Skipping it means operating on sites that did not need it, or — worse — not operating on sites that required it.

Phase 2: regenerative surgery

In deep intrabony defects that persist after non-surgical therapy, regenerative surgery can recover clinical attachment and bone. Not in every defect — morphology matters. A three-wall defect responds better than a one-wall defect. A narrow, deep defect has more potential than a wide, shallow one.

The techniques: access flap for decontamination, biomaterials (xenografts, enamel matrix derivatives), resorbable membranes. The choice depends on defect morphology and patient biology.

The EFP guidelines for surgical step 3 (Herrera et al. 2022, J Clin Periodontol) indicate periodontal regeneration as the treatment of choice in intrabony defects ≥ 3 mm with a predominantly vertical component.

Dr. Bruschi has practised customised periodontal regeneration for over thirty years — an approach that starts from defect morphology, not from a one-size-fits-all protocol.

Phase 3: supportive periodontal therapy

Here is the point many forget, or pretend not to know. Periodontitis does not heal. It is controlled. Supportive periodontal therapy (SPT) — professional hygiene sessions and reassessment every 3-4 months — is the treatment. Not an appendix to the treatment.

Without SPT, the results of active therapy are lost within 2-5 years. With regular SPT, long-term stability is well documented. Patient compliance is the strongest prognostic factor — stronger than the surgical technique, stronger than the biomaterial chosen.

About the author

Severe periodontitis requires a periodontist — not a general dentist. It requires someone who can read a probing chart, classify a defect, decide when to operate and when not to. It requires publications, case experience, expertise in complex cases.

Dr. Ernesto Bruschi is a periodontist, implantologist and oral surgeon in Frosinone (Italy), trained in Gothenburg under Jan Lindhe. His peer-reviewed publications document his experience in periodontal and bone regeneration. He practises at Centro Odontoiatrico Denti Più, Corso Lazio 17, Frosinone — less than one hour from Rome.

For a periodontal consultation: +39 0775 889009.