Contemporary Stepwise Periodontal Therapy: From Active Treatment to Supportive Periodontal Care

Abstract

eriodontitis is a chronic multifactorial inflammatory disease associated with dysbiotic dental biofilm and characterized by progressive destruction of tooth-supporting tissues. Contemporary periodontal treatment has evolved from a traditional sequence of therapeutic phases toward a stepwise model based on evidence, clinical response, and individual risk. This narrative review aims to analyze the fundamental components of stepwise periodontal therapy and the criteria determining progression between them. A structured literature search was conducted in MEDLINE/PubMed, Scopus, and Web of Science, prioritizing clinical practice guidelines, systematic reviews, meta-analyses, consensus reports, and recent clinical studies. Current therapy comprises a first step focused on behavioral change, supragingival biofilm control, and risk-factor modification; a second step involving subgingival instrumentation; periodontal re-evaluation to determine achievement of therapeutic endpoints; and a third step for residual periodontal pockets through repeated instrumentation or surgical interventions. Following active therapy, patients should enter an individualized supportive periodontal care program. Current evidence supports a dynamic decision-making model in which treatment response, rather than the mere completion of procedures, determines therapeutic progression. Re-evaluation identifies residual sites, assesses inflammation, adherence, anatomy, and modifying factors, and guides additional interventions when necessary. Supportive periodontal care represents an essential continuation of treatment and requires individualized intervals according to risk and clinical stability. Overall, the stepwise approach integrates diagnosis, treatment, re-evaluation, and maintenance, promoting individualized evidence-based decisions. Long-term maintenance of periodontal stability, function, and dentition preservation represents the ultimate objective of contemporary periodontal treatment for every patient receiving care. This framework also emphasizes that clinical endpoints should guide rather than rigidly dictate treatment decisions. Residual pockets require interpretation within the patient's overall inflammatory status, anatomy, risk profile, and capacity for self-care. Accordingly, additional nonsurgical or surgical therapy should be selected only when expected benefits justify intervention, while structured long-term follow-up remains essential for preserving achieved clinical outcomes over time.