The Complete Guide to Periodontal Disease and Gum Health: from gingivitis to periodontitis — staging, the treatment spectrum, and links with general health｜證據鏈

The Complete Guide to Periodontal Disease and Gum Health: from gingivitis to periodontitis — staging, the treatment spectrum, and links with general health｜證據鏈

F-Units (fact-unit ledger)

• F1｜Periodontal health is defined as the absence of clinically detectable inflammation; the case definitions for gingival health and for gingivitis are primarily predicated on presence or absence of bleeding on probing.｜source S1｜confidence=high｜basis=clinical_guideline (consensus report of workgroup 1 of the 2017 World Workshop)｜geo: universal｜period=published 2018｜caveat: this is a definition and a case delimitation, not an efficacy claim; the case definitions for clinical use and for epidemiological use are further distinguished from one another.
• F2｜Plaque-associated gingivitis is a reversible inflammatory condition; in susceptible individuals, gingivitis may lead to periodontitis and to loss of the soft tissue and bony support for the tooth.｜source S3｜confidence=high｜basis=peer_reviewed (background statement of a Cochrane systematic review)｜geo: universal｜period=published 2017 (search to 2016-09)｜caveat: 'may lead to' is a conditional statement; not all gingivitis progresses.
• F3｜Periodontitis is described as a ubiquitous and irreversible inflammatory condition.｜source S4｜confidence=high｜basis=clinical_guideline (consensus report of a working group of the 11th European Workshop on Periodontology)｜geo: universal｜period=published 2015｜caveat: this is a description of the nature of the disease; 'irreversible' refers to the attachment and bone support already lost, and does not amount to 'cannot be controlled'. This source does not itself write that 'the goal of treatment is control and maintenance', so this article has re-labelled that inference as this site's reading (see the section 'Four states' and F28) and does not attach it to this unit. The same source separately carries the sentence 'periodontitis is preventable, and treatment leads to reduced rates of tooth loss and improved quality of life'; that sentence has been given a unit of its own as F29 and written into the main text (the under-60-words answer, section 1, and FAQ question 2), so that this article does not present only the one direction, 'irreversible', and drop the positive conclusion from the same paragraph.
• F4｜Gingival health can be restored after treatment of gingivitis and of periodontitis; but the treated periodontitis patient with current gingival health remains at increased risk of recurrence and must be closely monitored. Clinical gingival health can exist on an intact periodontium, and equally on a reduced periodontium (for example in people with gingival recession, people after crown lengthening surgery, or people with a history of periodontitis who are currently stable).｜source S1｜confidence=high｜basis=clinical_guideline｜geo: universal｜period=published 2018｜caveat: the frequency of 'close monitoring' is not quantified in that consensus; it is decided clinically, case by case.
• F5｜Gingival diseases fall into two broad classes: non-dental-plaque-biofilm-induced gingival diseases (a range of conditions not caused by plaque, which usually do not resolve following plaque removal and which may be the manifestation of a systemic condition or may be confined to the mouth), and dental-plaque-induced gingivitis.｜source S1｜confidence=high｜basis=clinical_guideline｜geo: universal｜period=published 2018｜caveat: a statement of classification, not a diagnostic guideline; the classification of an individual lesion has to be determined clinically.
• F6｜Systematic review of non-plaque-induced gingival lesions (6,111 screened, 461 included): overall evidence quality moderate to very low; potentially malignant and malignant gingival lesions require careful evaluation and biopsy for diagnosis, followed in most cases by surgical management; management often requires multidisciplinary care and frequently requires referral to medical specialists or to oral medicine.｜span:「Over a total of 6111 articles initially identified, 461 met inclusion criteria」｜source S14｜confidence=high｜basis=peer_reviewed (systematic review, Part 2)｜geo: universal｜period=published online 2026｜caveat: the included designs run from case reports to randomised trials, with high heterogeneity; this article cites only its conclusions at the level of triage and referral, and does not cite the management detail for individual lesions.
• F7｜Stage I to IV is defined by severity (periodontal destruction referenced to root length, and tooth loss attributable to periodontitis) and by complexity of management (pocket depth, intrabony defects, furcation involvement, tooth hypermobility, masticatory dysfunction), with extent separately described as localised or generalised.｜source S2｜confidence=high｜basis=clinical_guideline (case definition framework of the 2017 World Workshop)｜geo: universal｜period=published 2018 (the original also carries a 2018 erratum)｜caveat: this is a case definition framework; the actual assignment of a stage has to be determined by clinical examination and imaging.
• F8｜Grade A to C is estimated with direct or indirect evidence of the rate of progression (three categories: slow, moderate, rapid); risk factor analysis is used as a grade modifier.｜source S2｜confidence=high｜basis=clinical_guideline｜geo: universal｜period=published 2018｜caveat: as above; the individual weight of each risk factor is not quantified at abstract level.
• F9｜Stage IV shares features of severity and complexity with Stage III, but additionally includes the anatomical and functional sequelae of tooth and periodontal attachment loss (tooth flaring and drifting, bite collapse, and so on), which require additional interventions after completion of active periodontal therapy.｜source S7｜confidence=high｜basis=clinical_guideline (EFP S3 level clinical practice guideline)｜geo: universal｜period=published 2022｜caveat: the full text of the guideline is behind a journal paywall, so this unit quotes verbatim from the PubMed abstract only and is not expanded into full-text content.
• F10｜The EFP S3 level clinical practice guideline for stage I to III periodontitis was produced from 15 specifically commissioned systematic reviews, assessments of the quality and strength of the evidence, and a GRADE process, and adopts a pre-established stepwise approach to therapy; the original text reads 「a pre-established stepwise approach to therapy that, depending on the disease stage, should be incremental, each including different interventions」 — what is written as the condition for escalation is the disease stage, not the treatment response of the preceding step.｜span:「15 specifically commissioned systematic reviews」／「a pre-established stepwise approach to therapy that, depending on the disease stage, should be incremental, each including different interventions」｜source S6｜confidence=high｜basis=clinical_guideline｜geo: universal｜period=published 2020 (with a 2021 erratum)｜caveat: the full text of the guideline is behind a journal paywall, so this unit quotes verbatim from the PubMed abstract only; its scope is limited to Stage I to III. This unit is a boundary added in the 2026-08-06 correction round: three places in this article (the surgical segment of the cost breakdown, the FAQ 'Does periodontal disease always mean surgery?', and the plain-words column of the ladder table) had written the condition for escalation as 'the response of the preceding step' with [F11] attached; that conditional variable does not appear in the abstract of any source, and all three have been changed back to 'the disease stage', with whether an individual patient proceeds re-labelled as F28.
• F11｜The recommendations on which that guideline reached consensus cover four classes of intervention: (a) behavioural changes, supragingival biofilm, gingival inflammation and risk factor control; (b) supra- and sub-gingival instrumentation, with and without adjunctive therapies; (c) different types of periodontal surgical interventions; (d) supportive periodontal care to extend the benefits over time.｜source S6｜confidence=high｜basis=clinical_guideline｜geo: universal｜period=published 2020｜caveat: (a)–(d) is an enumeration of classes of intervention; the strength grade of each recommendation is not given at abstract level; this article's reading that 'surgery is ordered later' is a direct inference from the stepwise design and does not amount to the order of management in any individual case. This unit must not be used to support the claim that 'the treatment response of the preceding step is the trigger for escalation' (for that conditional variable see the boundary note in F10).
• F12｜The interventions recommended by the Stage IV guideline include orthodontic tooth movement, tooth splinting, occlusal adjustment, tooth- or implant-supported fixed or removable dental prostheses, and supportive periodontal care; before a treatment plan, a definitive and comprehensive diagnosis and case evaluation must be completed and the relevant patient information obtained, with frequent re-evaluation during and after treatment.｜source S7｜confidence=high｜basis=clinical_guideline｜geo: universal｜period=published 2022｜caveat: as F9; the periodontal part of treatment is still carried out according to the Stage I to III guideline.
• F13｜The consensus report records: interdental brushes are the recommended device for interproximal plaque removal (original wording device of choice); floss is not recommended other than at sites of gingival and periodontal health where an interdental brush cannot pass without trauma.｜source S4｜confidence=high｜basis=clinical_guideline｜geo: universal｜period=published 2015｜caveat: in line with content compliance requirements this article does not use comparative or superlative wording, and the original vocabulary is retained in the span; the size of device suitable for an individual and the sites at which it is used have to be demonstrated by a dentist or dental hygienist.
• F14｜The use of local or systemic anti-inflammatory agents in the management of gingivitis has no robust evidence base.｜source S4｜confidence=high｜basis=clinical_guideline｜geo: universal｜period=published 2015｜caveat: this is a statement of an evidence gap, not a conclusion about safety; this article gives no instruction on the use of any medicine.
• F15｜Systematic review in children and adolescents (with no known systemic disease; 269 studies included): dental biofilm-induced gingivitis is common (52%) and is associated with poorer oral-health-related quality of life; effective management should combine supervised toothbrushing with a fluoridated toothpaste and school- or caregiver-based oral health education, and the adjunctive use of chlorhexidine may bring additional benefit in specific clinical situations.｜span:「Ultimately, 269 studies, all restricted to biofilm-induced gingivitis, were included」／「Dental biofilm-induced gingivitis was common (52%) and associated with poorer OHRQoL」／「effective management of gingivitis in children should combine supervised toothbrushing with a fluoridated toothpaste and school- or caregiver-based oral health education」｜source S8｜confidence=moderate｜basis=peer_reviewed (systematic review)｜geo: universal｜period=published 2026 (search to 2025-01)｜caveat: the population is restricted to children and adolescents with no known systemic disease and cannot be extrapolated to adults; the authors state that the diagnostic criteria and the study quality were highly heterogeneous.
• F16｜Cochrane systematic review (51 studies, 5,345 participants) assessing chlorhexidine mouthrinse as an adjunct to mechanical oral hygiene. The authors' conclusion records: in those with mild gingival inflammation on average (mean score of 1 on the 0 to 3 gingival index) the reduction in gingivitis observed was 'not considered to be clinically relevant'; for those with mean gingival index scores of 1.1 to 3 (moderate or severe inflammation) the evidence is insufficient to determine the size of the reduction in gingivitis. That review also records a large increase in extrinsic tooth staining, together with adverse effects including taste disturbance or alteration, oral mucosal pain, irritation, mild desquamation and ulceration or erosion, and general or tongue burning sensation.｜span:「We included 51 studies that analysed a total of 5345 participants」｜source S3｜confidence=high｜basis=peer_reviewed (Cochrane systematic review)｜geo: universal｜period=published 2017 (search to 2016-09)｜caveat: 50 of the 51 included studies were at high risk of bias; this Pillar still deliberately does not cite its effect-size figures or its concentration comparisons (the reading of the effect sizes for that question belongs to canonical card KM-DENTAL-06), but the authors' conclusion sentence on clinical relevance is a necessary component of a balanced statement and is therefore cited; 'not clinically relevant' applies to the gingival index in the population with mild inflammation and cannot be extrapolated to 'ineffective' or 'no need to use it', nor extrapolated to the moderate-to-severe population; this article names no product and gives no concentration or frequency of use.
• F17｜A head-to-head comparison of CPC and chlorhexidine mouthrinse has been carried out in a systematic review and meta-analysis (424 papers screened, 14 full texts, 18 comparisons) on plaque and gingivitis measures.｜span:「The search resulted in 424 unique papers, from which 14 full-text papers providing 18 comparisons were selected」｜source S9｜confidence=moderate｜basis=peer_reviewed (systematic review + meta-analysis, GRADE rated)｜geo: universal｜period=published 2025｜caveat: this Pillar states only that this comparison exists and deliberately does not cite its direction or effect size ('which agent to choose' is the task of canonical card KM-DENTAL-06, and the Pillar level must not answer it on that card's behalf); the risk of bias among the included studies ranged from low to high; the authors disclose that some included studies had industry funding.
• F18｜Umbrella review of the Er:YAG laser as an adjunct to non-surgical periodontal treatment (472 screened, 4 systematic reviews included), conclusion: even though weak evidence of effectiveness was observed, the clinical benefits are still lacking.｜span:「A total of 472 studies were initially identified. After removing the duplicates and screening, a total of four studies were selected for the current overview」｜source S13｜confidence=moderate｜basis=peer_reviewed (umbrella review, AMSTAR 2 assessment)｜geo: universal｜period=published 2024 (search 2011–2023)｜caveat: the quality of the 4 included systematic reviews was high, moderate, low and very low respectively; this unit covers Er:YAG only and cannot be extrapolated to other laser types and wavelengths; whether other wavelengths or models have corresponding evidence requires a separate search of the literature on that class of laser, which this article did not carry out.
• F19｜Root coverage surgery for multiple gingival recessions is measured in the literature with two sets of indicators at once: professional esthetic assessment, and patient-reported outcome measures (PROMs).｜source S11｜confidence=high｜basis=peer_reviewed (systematic review + meta-analysis)｜geo: universal｜period=published 2025 (search to 2024-05)｜caveat: this Pillar cites only its outcome-measure architecture and deliberately does not cite its coverage rates or satisfaction figures (which belong to canonical cards KM-DENTAL-14/27).
• F20｜A head-to-head comparison of autogenous connective tissue grafts and xenogeneic soft-tissue substitutes has been carried out in a systematic review and meta-analysis (16 RCTs, 632 patients, 1,878 recessions) for the treatment of multiple gingival recessions.｜span:「Sixteen RCTs (632 patients, 1878 recessions) were included」｜source S10｜confidence=moderate｜basis=peer_reviewed (systematic review + meta-analysis, RoB 2)｜geo: universal｜period=published 2026 (search to 2025-10)｜caveat: this Pillar states only that this comparison exists and deliberately does not cite its direction or effect size ('which graft source to choose' is the task of canonical card KM-DENTAL-14, and the Pillar level must not answer it on that card's behalf; this discipline is the same as for F21); the population is restricted to multiple gingival recessions; the authors state that trials with larger samples and standardised outcomes are needed to confirm long-term stability.
• F21｜Open-flap and minimally invasive flapless techniques in esthetic crown lengthening have been compared in a systematic review and meta-analysis of randomised trials (5 RCTs, 180 patients included).｜source S12｜confidence=moderate｜basis=peer_reviewed (systematic review + meta-analysis)｜geo: universal｜period=published 2025｜caveat: this Pillar states only that this comparison exists and deliberately does not cite its direction or effect size (which belongs to canonical card KM-DENTAL-17); the population of the original study is restricted to the esthetic indication of excessive gingival display (EGD) and does not cover restorative, biologic-width or other indications; this boundary has been written into the main text and the down-link table; this unit does not contain an anatomical definition of crown lengthening (that definition does not appear in the abstract of this source, and the unsourced sentence has been deleted from this article).
• F22｜Global burden of disease systematic review and meta-regression (72 studies, 37 countries, 291,170 participants aged 15 or older): severe periodontitis was the sixth-most prevalent condition in the world; between 1990 and 2010 the global age-standardised prevalence stayed static at 11.2%; prevalence rises with age, with a peak in incidence at around 38 years.｜span:「72 studies, including 291,170 individuals aged 15 yr or older in 37 countries」／「the global age-standardized prevalence of SP was static at 11.2%」／「SP was the sixth-most prevalent condition in the world」／「peak in incidence at around 38 yr of age」｜source S5｜confidence=high｜basis=peer_reviewed (systematic review + meta-regression, GBD 2010 model)｜geo: universal｜period=1990–2010 (published 2014)｜caveat: the data period ends in 2010, so this is not an estimate of the present; the case definition of 'severe periodontitis' predates the 2017 staging and grading system and cannot be mapped directly onto current staging and grading. A search on 2026-08-06 also turned up more recent global burden literature, which this article has not verified item by item and has therefore not adopted, so this unit represents only the estimate for the 1990–2010 period; the ranking 'sixth-most prevalent' belongs, like the 11.2%, to the estimate for that period, and the year boundary has been annotated in the main text. The 11.2% in S16 is a carry-over of the same GBD 2010 estimate as this unit, the two share a source and are not mutually independent support; they are set side by side only to show that this estimate has been carried over at the level of a society consensus, and they are neither added together nor treated as double counting.
• F23｜EFP and World Heart Federation joint workshop consensus report: severe periodontitis affects 11.2% of the world's population and is the sixth most common human disease; that report updates the evidence for epidemiological associations between severe periodontitis and cardiovascular disease, the mechanistic links, and the impact of periodontal therapy on cardiovascular and surrogate outcomes, and sets out the risks and complications of periodontal therapy in patients undergoing antithrombotic therapy, with recommendations.｜span:「being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease」｜source S16｜confidence=high｜basis=clinical_guideline (joint consensus report of international societies)｜geo: universal｜period=published 2020｜caveat: the original wording is 'associations', not a causal claim; the 11.2% is a carry-over of the same GBD 2010 estimate as F22, the two units share a source and must not be read as independent support; this article sets them side by side without adding them together, and states this explicitly in the main text.
• F24｜EFP and International Diabetes Federation joint workshop consensus report: there is strong evidence that people with periodontitis have elevated risk for dysglycaemia and insulin resistance; cohort studies in diabetic populations show higher glycated haemoglobin in those who also have periodontitis, but data in type 1 diabetes are insufficient; periodontitis is associated with an increased risk of incident type 2 diabetes; periodontal therapy in people with diabetes is 'safe and effective' and is associated with reductions in glycated haemoglobin of 0.27% to 0.48% after 3 months, although studies involving longer-term follow-up are inconclusive.｜span:「Periodontal therapy is safe and effective in people with diabetes, and it is associated with reductions in HbA1C of 0.27-0.48% after 3 months, although studies involving longer-term follow-up are inconclusive」｜source S15｜confidence=high｜basis=clinical_guideline (joint consensus report and guidance of international societies)｜geo: universal｜period=published 2018｜caveat: the 0.27% to 0.48% figure is a population estimate at 3 months and cannot be used to infer the size of an individual's blood-glucose improvement; the original states that the conclusions on longer-term effects are inconsistent.
• F25｜Cochrane systematic review (updated version): the review records that high-certainty evidence from one trial of adults shows little to no difference between risk-based and 6-month recall intervals in the proportion of sites with gingival bleeding over 4 years of follow-up (mean difference 0.78%, 95% CI −1.17% to 2.73%, 1,472 participants).｜span:「there is little to no difference between risk-based and 6-month recall intervals in the number of tooth surfaces with any caries, gingival bleeding and oral-health-related quality of life over a 4-year period (high-certainty evidence)」／「proportion of sites with gingival bleeding (MD 0.78%, 95% CI -1.17% to 2.73%; 1472 participants)」／「One study was conducted in a public dental service clinic in Norway and involved participants under 20 years of age who were regular attenders at dental appointments. It compared 12-month with 24-month recall intervals」｜source S17｜confidence=high｜basis=peer_reviewed (Cochrane systematic review, GRADE)｜geo: universal｜period=published 2020 (search to 2020-01)｜caveat: the population is adults who were regular attenders in primary dental care, and what is compared are general periodic oral check-up intervals; it does not cover recall intervals for periodontitis patients in supportive periodontal care; only 2 studies were included, with 1,736 participants in total, of which the adult segment is a single study (UK general dental practices; the original reads from one trial of adults), the other being a Norwegian population under 20 years of age comparing 12-month with 24-month intervals — the evidence base is a single trial and must not be read as 'a pooled finding across several reviews'; this article did not search the literature on recall intervals within supportive periodontal care itself, and therefore makes no universal statement about that setting.
• F26[structural summary]｜The four-part cost breakdown 'diagnosis and assessment / non-surgical / surgical / maintenance' is a reading framework constructed by this site from the ladder structure of S6; it is not a factual claim, not any organisation's classification of charges, and contains no monetary amount.｜confidence=n/a｜basis=editorial｜geo: universal｜caveat: must not be labelled as pending verification; coverage and charging rules across systems are outside the scope of this article throughout.
• F27[editorial declaration]｜The oral-health-education positioning of this article, its geographic scope statement, its down-link rule (specific questions from the queue of 69 receive only a one-sentence summary plus an internal citation), and the decision to leave the attachment block empty.｜confidence=n/a｜basis=editorial｜geo: universal｜caveat: an editorial declaration, not a claim of medical fact; the jurisdictional determination of medical-advertising compliance follows the rules of the place of publication and is confirmed by the publishing side before going live.
• F28[editorial suggestions and this site's readings]｜The sentences in this article explicitly marked 'this site suggests' or 'this site reads', listed item by item: (1) understanding periodontal management as long-term control and maintenance rather than a return to the pre-treatment state of the tissues (from reading F3 and F11 together); (2) going back to the dentist to have the diagnosis re-evaluated when the characteristics of a non-plaque-induced lesion appear, rather than pressing on with more cleaning (once each in sections 2 and 8); (3) confirming the model and wavelength with the dentist before judging the evidence on lasers, and then checking against the literature for that class of laser; (4) whether antimicrobial rinse products are used at all, and at what concentration and for how long, being decided by the dentist according to diagnosis; (5) telling the dentist about the medication history before treatment; (6) reading the four classes of intervention in F11 as an order, which is a reading based on the 'stepwise, incremental' design (the guideline abstract does not state the order word for word); (7) this article's division of surgery into three lines, which is this article's own way of drawing the map and not any source's classification; (8) 'the high-certainty evidence this article is able to cite falls in an adjacent setting', which is a statement of this article's own search scope, not a universal denial about the world literature.｜confidence=n/a｜basis=editorial｜geo: universal｜caveat: every sentence listed above is an editorial, safety-oriented suggestion or reading, and is not a clinical instruction, a diagnostic criterion or a treatment prescription from any source; the individual situation is determined by a dentist in every case. The purpose of setting up this unit is to prevent unsourced sentences prescribing clinical action from disguising themselves as sourced by taking the [Fn] form.
• F29｜Periodontitis is preventable; treatment can reduce rates of tooth loss and improve quality of life.｜source S4｜confidence=high｜basis=clinical_guideline (consensus report of a working group of the 11th European Workshop on Periodontology, PMID 25639826)｜geo: universal｜period=published 2015｜span: 「preventable and treatment leads to reduced rates of tooth loss and improved quality of life」 (retrieved by E-utilities efetch on 2026-08-06, verbatim match confirmed)｜caveat: this and F3's 'irreversible' are two sides of the same paragraph of the same consensus report, and the two must be read together — 'irreversible' refers to the attachment and bone support already lost, while 'preventable, and treatment is of benefit' refers to the course of the disease being controllable; when citing, one side alone must not be taken. This is a conclusion at population level, not an assurance about the prognosis of any one individual.
• F30｜In patients with gingivitis, once-daily interdental cleaning is recommended, and in that group the adjunctive use of chemical plaque control agents offers advantages.｜source S4｜confidence=high｜basis=clinical_guideline (same as F29, PMID 25639826)｜geo: universal｜period=published 2015｜span: 「In patients with gingivitis once daily inter-dental cleaning is recommended and the adjunctive use of chemical plaque control agents offers advantages in this group」 (retrieved and verified verbatim on 2026-08-06)｜caveat: the population is restricted to patients with gingivitis and must not be extrapolated to the periodontally healthy or to periodontitis patients (the same consensus rates chemical adjuncts differently for other populations); this article specifies no product, concentration or duration of use, those decisions being made by the dentist according to diagnosis.

Source list (17 entries, all accessed 2026-08-06)

Every verbatim span is taken from the abstract text returned by PubMed E-utilities (efetch); whitespace characters have been normalised (some originals contain a non-breaking space and a thin space), and every other character is exactly as in the original. The full texts of guidelines and consensus reports are mostly paywalled by the journals and could not be retrieved locally, so all spans are taken from PubMed abstracts only, and the main text is not expanded into full-text content. The retrieval annotation that follows each URL below, `（取用 …）`, is carried over verbatim from the zh-Hant source (取用 = retrieved), because the URL string and the annotation immediately after it are treated as a single invariant token.

S1｜Chapple ILC, Mealey BL, Van Dyke TE, et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol. 2018;45 Suppl 20:S68-S77. PMID 29926499. （取用 2026-08-06, HTTP 200） span: 「Periodontal health is defined by absence of clinically detectable inflammation」／「case definitions are primarily predicated on presence or absence of bleeding on probing」／「the treated and stable periodontitis patient with current gingival health remains at increased risk of recurrent periodontitis, and accordingly, must be closely monitored」／「usually do not resolve following plaque removal」

S2｜Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Periodontol. 2018;89 Suppl 1:S159-S172. PMID 29926952. （取用 2026-08-06, HTTP 200） span: 「Stage I to IV of periodontitis is defined based on severity」／「Grade of periodontitis is estimated with direct or indirect evidence of progression rate in three categories: slow, moderate and rapid progression (Grade A-C)」／「Risk factor analysis is used as grade modifier」

S3｜James P, Worthington HV, Parnell C, et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev. 2017;3(3):CD008676. PMID 28362061. （取用 2026-08-06, HTTP 200） span: 「Dental plaque associated gingivitis is a reversible inflammatory condition」／「In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth」／「There is high-quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant」／「There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation」／「There was a large increase in extrinsic tooth staining」／「taste disturbance/alteration (reported in 11 studies)」

S4｜Chapple IL, Van der Weijden F, Doerfer C, et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol. 2015;42 Suppl 16:S71-S76. PMID 25639826. （取用 2026-08-06, HTTP 200） span: 「Periodontitis is a ubiquitous and irreversible inflammatory condition」／「Periodontitis is preventable and treatment leads to reduced rates of tooth loss and improved quality of life」／「IDBs are the device of choice for interproximal plaque removal」／「Use of local or systemic anti-inflammatory agents in the management of gingivitis has no robust evidence base」

S5｜Kassebaum NJ, Bernabé E, Dahiya M, et al. Global burden of severe periodontitis in 1990-2010: a systematic review and meta-regression. J Dent Res. 2014;93(11):1045-1053. PMID 25261053. （取用 2026-08-06, HTTP 200） span: 「72 studies, including 291,170 individuals aged 15 yr or older in 37 countries」／「SP was the sixth-most prevalent condition in the world」／「the global age-standardized prevalence of SP was static at 11.2%」／「peak in incidence at around 38 yr of age」

S6｜Sanz M, Herrera D, Kebschull M, et al. Treatment of stage I-III periodontitis—The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47 Suppl 22:4-60. PMID 32383274. （取用 2026-08-06, HTTP 200）※ anchor-file source #06 span: 「15 specifically commissioned systematic reviews」／「pre-established stepwise approach to therapy」／「(a) behavioural changes, supragingival biofilm, gingival inflammation and risk factor control; (b) supra- and sub-gingival instrumentation, with and without adjunctive therapies; (c) different types of periodontal surgical interventions; and (d) the necessary supportive periodontal care to extend benefits over time」

S7｜Herrera D, Sanz M, Kebschull M, et al. Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline. J Clin Periodontol. 2022;49 Suppl 24:4-71. PMID 35688447. （取用 2026-08-06, HTTP 200） span: 「anatomical and functional sequelae of tooth and periodontal attachment loss (tooth flaring and drifting, bite collapse, etc.), which require additional interventions following completion of active periodontal therapy」／「orthodontic tooth movement, tooth splinting, occlusal adjustment, tooth- or implant-supported fixed or removable dental prostheses and supportive periodontal care」／「it is critically important to undertake a definitive and comprehensive diagnosis and case evaluation」

S8｜Tsilingaridis G, Tewari N, Seremidi K, Papaioannou W, López R. Dental Biofilm-Induced Gingivitis in Children and Adolescents Without Known Systemic Involvement: A Systematic Review. J Clin Periodontol. 2026;53(7):1226-1252. PMID 41905896. （取用 2026-08-06, HTTP 200）※ anchor-file source #07 span: 「Ultimately, 269 studies, all restricted to biofilm-induced gingivitis, were included」／「Dental biofilm-induced gingivitis was common (52%) and associated with poorer OHRQoL」／「effective management of gingivitis in children should combine supervised toothbrushing with a fluoridated toothpaste and school- or caregiver-based oral health education」

S9｜Windhorst ER, Joosstens M, van der Sluijs E, Slot DE. The Effect of Cetylpyridinium Chloride Compared to Chlorhexidine Mouthwash on Scores of Plaque and Gingivitis: A Systematic Review and Meta-Analyses. Int J Dent Hyg. 2025;23(4):665-681. PMID 40530503. （取用 2026-08-06, HTTP 200）※ anchor-file source #08 span: 「The search resulted in 424 unique papers, from which 14 full-text papers providing 18 comparisons were selected」／「For brushing, no significant differences were found between CPC-MW and CHX-MW」／「CHX-MW tends to stain more than CPC-MW.」

S10｜Koppolu P, ElHaddad SA, Abushama AA, et al. Comparative Effectiveness of Autogenous Connective Tissue Grafts and Xenogeneic Soft Tissue Substitutes for Multiple Gingival Recessions: A Systematic Review and Meta-Analysis. Medicina (Kaunas). 2026;62(2):366. PMID 41752765. （取用 2026-08-06, HTTP 200）※ anchor-file source #09 span: 「Sixteen RCTs (632 patients, 1878 recessions) were included」／「CTG continues to have superior clinical outcomes in the treatment of multiple GR」／「xenogenic materials are a promising alternative, particularly when patient comfort and satisfaction are prioritized」

S11｜Stefanini M, Mounssif I, Figuero E, Zucchelli G, Sculean A, Cosgarea R. Esthetical and patient-reported outcomes after root coverage procedures for multiple gingival recessions: A systematic review and meta-analysis. Periodontol 2000. 2025;99(1):21-41. PMID 42130372. （取用 2026-08-06, HTTP 200）※ anchor-file source #10 span: 「To systematically review and conduct a meta-analysis of the available literature on professional esthetic assessments and patient-related outcome measures (PROMs) following surgical root coverage procedures for the treatment of multiple gingival recessions」

S12｜Oqlah MD, Dashti H, Aldhafairi LF, et al. Open-Flap Versus Minimally Invasive Flapless Techniques in Esthetic Crown Lengthening: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cureus. 2025;17(10):e95150. PMID 41281135. （取用 2026-08-06, HTTP 200）※ anchor-file source #11 span: 「We aimed in this systematic review and meta-analysis to compare the clinical outcomes between OF and FL in ECL surgeries」／「We included five RCTs with 180 patients in the analysis」／「randomized controlled trials including EGD patients undergoing ECL surgery with either OF or FL techniques」

S13｜Gufran K, Alqahtani AS, Alasqah M, et al. Effect of Er: YAG laser therapy in non-surgical periodontal treatment: an umbrella review. BMC Oral Health. 2024;24(1):1347. PMID 39548487. （取用 2026-08-06, HTTP 200）※ anchor-file source #12 span: 「A total of 472 studies were initially identified. After removing the duplicates and screening, a total of four studies were selected for the current overview」／「Even though weak evidence of effectiveness was observed for Er: YAG laser application in non-surgical periodontal treatment, the clinical benefits are still lacking」

S14｜Carra MC, Wasielewski C, Špiljak B, Sabalić-Schoener M, Jungo S, Alajbeg I. Management of Non-Plaque-Induced Gingival Conditions: A Systematic Review—Part 2: Inflammatory and Immune Conditions; Neoplasms; and Gingival Pigmentation. J Clin Periodontol. 2026 Jun 19 (online ahead of print). PMID 42321019. （取用 2026-08-06, HTTP 200）※ anchor-file source #13 span: 「Over a total of 6111 articles initially identified, 461 met inclusion criteria」／「Overall evidence quality was moderate to very low」／「Potentially malignant and malignant gingival lesions required careful evaluation and biopsy for diagnosis, followed by surgical management」／「NPIGD management is challenging due to the heterogeneity of these conditions and often requires multidisciplinary care」

S15｜Sanz M, Ceriello A, Buysschaert M, et al. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology. J Clin Periodontol. 2018;45(2):138-149. PMID 29280174. （取用 2026-08-06, HTTP 200） span: 「There is strong evidence that people with periodontitis have elevated risk for dysglycaemia and insulin resistance」／「Periodontitis is also associated with an increased risk of incident type 2 diabetes」／「Periodontal therapy is safe and effective in people with diabetes, and it is associated with reductions in HbA1C of 0.27-0.48% after 3 months, although studies involving longer-term follow-up are inconclusive」

S16｜Sanz M, Marco del Castillo A, Jepsen S, et al. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol. 2020;47(3):268-288. PMID 32011025. （取用 2026-08-06, HTTP 200） span: 「being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease」／「has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes」／「has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy」

S17｜Fee PA, Riley P, Worthington HV, Clarkson JE, Boyers D, Beirne PV. Recall intervals for oral health in primary care patients. Cochrane Database Syst Rev. 2020;10(10):CD004346. PMID 33053198. （取用 2026-08-06, HTTP 200） span: 「We found high-certainty evidence from one trial of adults that there is little to no difference between risk-based and 6-month recall intervals」／「proportion of sites with gingival bleeding (MD 0.78%, 95% CI -1.17% to 2.73%; 1472 participants)」／「We included two studies with data from 1736 participants」／「One study was conducted in a public dental service clinic in Norway and involved participants under 20 years of age who were regular attenders at dental appointments. It compared 12-month with 24-month recall intervals」／「The other study was conducted in UK general dental practices and involved adults who were regular attenders」

WRITER-ADDED SOURCES (9 entries, added beyond the anchor file, with locally tested evidence)

Reason for the additions: the geo_scope of this article is global, and per the owner's instruction of 2026-08-06, entries in the anchor file that belong to the local system of a single country (#01–#05) are not used as the basis of this article and have not been used in any medical or systems statement, so they are not included in this article's source list; their local content is down-linked to the corresponding local canonical cards. The internationally usable entries in the anchor file are #06–#13, 8 in all, and all of them are used (= S6, S8–S14). To meet the Pillar-level coverage requirement of 'a graded map of the domain / anatomical and physiological background / a cross-question decision framework / systems context', 9 further international sources were added (S1–S5, S7, S15–S17), all of them tested locally.

>

Testing method (three pieces together): (1) PubMed E-utilities `efetch` used to retrieve the full abstract (HTTP 200); (2) `esummary` used to check pubtype, confirming no Retracted Publication and no WITHDRAWN in the title; (3) the landing page `https://pubmed.ncbi.nlm.nih.gov//` returning HTTP 200; (4) every sentence and every figure cited in this article compared verbatim by program against the text returned by efetch (after whitespace normalisation all matched, FAIL COUNT 0).

Commands run and output (2026-08-06):

[1] Abstract retrieval (17 records in a single efetch, including the 9 additions)
curl -s "https://eutils.ncbi.nlm.nih.gov/entrez/eutils/efetch.fcgi?db=pubmed&id=<17 PMIDs>&rettype=abstract&retmode=xml"
→ [HTTP:200], 17 abstracts saved

[2] Retraction check (esummary pubtype scan)
curl -s ".../esummary.fcgi?db=pubmed&retmode=json&id=<17 PMIDs>"
→ [HTTP:200]; 17/17 all ok (no Retract / WITHDRAWN)

[3] Landing pages tested (the 9 additions)
29926952 -> HTTP 200    29926499 -> HTTP 200    25639826 -> HTTP 200
25261053 -> HTTP 200    35688447 -> HTTP 200    29280174 -> HTTP 200
32011025 -> HTTP 200    28362061 -> HTTP 200    33053198 -> HTTP 200

[4] Verbatim span comparison (every quoted sentence and figure in this article)
FAIL COUNT: 0 (after whitespace normalisation; the 3 places where the original contains a non-breaking / thin space are annotated)

The 9 additions and their roles:

⚠️ This section records only the source additions made for the writing of this article; it did not modify `ida-pillars/anchors/P05-anchors.md`.

Internal citation chain

• Grading of, and immediate-care red flags for, painful swollen gums: How do I bring down painful swollen gums quickly? When should I see someone? (`km-drafts/km-05-gum-swelling.md`, KM-DENTAL-05)
• The agent, concentration and duration of use of antimicrobial mouthrinse: How do I choose a mouthrinse? Which bottle for periodontal disease? (`km-drafts/km-06-mouthwash-selection.md`, KM-DENTAL-06; this article and that card share sources S3 and S6. This article does not cite the effect-size figures and makes no comparison between agents; it cites only the review authors' conclusion sentence on clinical relevance, as a necessary component of a balanced statement, while the full reading of it and the choice among the four classes of agent are the responsibility of that card)
• The effect figures, recovery period and cost breakdown of soft-tissue grafting: Gum grafting surgery: cost, insurance and recovery period explained in one go (`km-drafts/km-14-gum-graft.md`, KM-DENTAL-14; this article and that card share source S11, but this article cites only its outcome-measure architecture)
• The choice of technique, rebound and waiting period in crown lengthening: What is crown lengthening? Cost, insurance, and whether it hurts (`km-drafts/km-17-crown-lengthening.md`, KM-DENTAL-17)

Draft status reminder: this article is a Pillar-level draft. It has not yet been through the machine gate (km-gate.py 9 checks + `--spans` + scan-med-ad.sh), cross-architecture adversarial review, or the commander's own verification; until all four language versions (zh-Hans / en / ja) exist, it must not enter the publication queue. The clinic attachment block is left empty until the owner decides.