4. S3 Steps 1 and 2 — foundations then subgingival care

Stepwise means sequential, not optional

The EFP/BSP S3 pathway for Stage I–III is four steps. You do not jump to surgery because the diary has a long appointment. You also do not instrument deep sites forever while plaque, smoking and diabetes are untouched.

Step 1 — foundations

This is the largest part of success: behaviour change, oral hygiene that the person can actually do, smoking cessation support, diabetes awareness, and professional supragingival plaque and calculus removal plus taking out ledges that stop cleaning. Interdental brushes sized to the embrasure beat floss-as-a-slogan for most periodontitis patients. Disclose if it helps them see. Agree a verbal contract: daily cleaning is not a bonus, it is the therapy.

What Step 1 is not

It is not “come back in six months for another BPE”. It is not antibiotics. It is not a 10-minute polish while you talk about the weather.

Step 2 — cause-related subgingival instrumentation

Once Step 1 is underway, remove biofilm and calculus from the root surface in pockets that need it (hand, powered, or both — evidence does not crown one magic tip). This is professional mechanical plaque removal subgingivally, not a different disease. Keep reinforcing hygiene; instrumentation without home care relapses.

Adjuncts at Step 2

Local antimicrobials and lasers are not a substitute for instrumentation. Systemic antibiotics are not routine for Step 2 in general practice. They may be considered in specific, often specialist, situations (for example some rapidly progressing Grade C presentations) — that is a practitioner-with-enhanced-skills / specialist decision, aligned with antimicrobial stewardship. Check the current BSP S3 recommendation, not a 2005 metronidazole habit.

Review after Step 2

Give tissues time to heal, then a full periodontal chart, plaque and bleeding scores. If the treatment goals in the current BSP chart are met, go to Step 4 (supportive care). If not, reinforce Step 1 or move to Step 3 — do not just repeat the same failed 30-minute scale.