The Point of no Return

Abstract

The European Federation of Periodontology (EFP) through a thorough review of the evidence of various treatment modalities published the steps of periodontal treatment including end points (Sanz M, Herrera D, Kebschull M, et al.; On behalf of the EFP Workshop Participants and Methodological Consultants. Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47:4–60. https://doi.org/10.1111/jcpe.13290). Interestingly, prior to this there were really no suggestions about what the ‘ideal’ outcome for periodontal therapy should be. Essentially all pockets should be 4 mm and below. This also fits in the current classification's workshop on stable, remission and unstable outcomes (Chapple ILC, Mealey BL, 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 Periodontol. 2018;89(Suppl 1):S74–S84. https://doi.org/10.1002/JPER.17-0719). However, evidence would suggest that it is very difficult to meet these goals. So why these end points be met (Aimetti M, Romano F, Costanzo L, De Caroli M, Di Venanzio A, Mariani GM, Baima G. Outcomes of Active Periodontal Therapy in a Specialist University Setting Following EFP S3 Treatment Guideline in Stage III-IV Periodontitis Patients. J Clin Periodontol. 2026 Apr;53(4):562–571. doi:10.1111/jcpe.70087. Epub 2026 Jan 19. PMID: 41554667.). This led to the thought that maybe there is a point of no return beyond which we will not or cannot achieve an ideal outcome in periodontics and by extension across all of dentistry. If we go beyond this point, is it a disaster?

A point of no return in periodontics is obviously the change from gingivitis to periodontitis with bone loss. Once we have bone loss it that it? No. We know that periodontal therapy works very well in mild-to-moderate disease, but less in severe disease. Teeth can be kept for many years even with residual increased probing depths and a large amount of bone loss (Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol. 1978 May;49(5):225–37. doi:10.1902/jop.1978.49.5.225. PMID: 277674.). However, regarding meeting EFP standards I would argue that once a mesial or distal furcation is exposed then non-surgical treatment will be unable to reduce probing to under 4 or 5 mm due the niche provided for colonisation and inability to debride well. This is a point of no return. So, should we extract these when we know we will not get probing depths to a level that would suggest stability? Furcation exposure does not mean automatic and sudden tooth loss. There are many factors involved and these teeth can be maintained for many years (Hirschfeld & Wasserman 1978).

There are other areas of dentistry that have points of return such as the development of caries into cavitation, caries into the pulp and cracks in teeth to suggest a few.

The management of caries has changed greatly over the last few decades. There are more effective preventive measures and less surgical removal caries (Warreth A. Dental Caries and Its Management. Int J Dent. 2023 Jan 3;2023:9365845. doi:10.1155/2023/9365845. PMID: 36636170; PMCID: PMC9831703.). Carious lesions are not an automatic ‘no going back’ surgical intervention (Warreth 2023). Remineralisation of caries can be achieved through products like tooth mousse (Arifa MK, Ephraim R, Rajamani T. Recent Advances in Dental Hard Tissue Remineralization: A Review of Literature. Int J Clin Pediatr Dent. 2019 Mar-Apr;12(2):139–144. doi:10.5005/jp-journals-10,005-1603. PMID: 31571787; PMCID: PMC6749882.) and resin infiltration can work well (Miranda, S.B.; Lins, R.B.E.; Silveira, J.A.M.d.; Leal, C.d.F.C.; Souza, C.M.C.d.; Moura, H.S.; Guimarães, L.G.; Prosini, P.; Montes, M.A.J.R. Efficacy of Resin Infiltrants in Non-Cavitated Occlusal Carious Lesions: A Systematic Review. J. Clin. Med. 2026, 15, 1310. https://doi.org/10.3390/jcm15031310). There is a concept of infected and affected dentine, whereby the infected dentine only is removed and the affected dentine preventing a point-of-no-return pulpal exposure (https://decisionsindentistry.com/article/clinical-treatment-of-deep-caries/).

Obviously, a point of no return for the pulp is exposure through caries, iatrogenic perforation, fractures/cracks, trauma or root resorption. As above, caries management has evolved to reduce the incidence of pulpal exposure. Carious pulp exposure does not automatically mean pulpal removal and ‘traditional’ root canal treatment. Vital pulp therapy, where appropriate, can be very effective (Duncan HF. Present status and future directions-Vital pulp treatment and pulp preservation strategies. Int Endod J. 2022 May;55 Suppl 3(Suppl 3):497–511. doi:10.1111/iej.13688. Epub 2022 Feb 3. PMID: 35080024; PMCID: PMC9306596.). Even if a ‘full’ root canal procedure is required, it is not the end (Burns LE, Kim J, Wu Y, Alzwaideh R, McGowan R, Sigurdsson A. Outcomes of primary root canal therapy: An updated systematic review of longitudinal clinical studies published between 2003 and 2020. Int Endod J. 2022 Jul;55(7):714–731. doi:10.1111/iej.13736. Epub 2022 May 4. PMID: 35334111; PMCID: PMC9322405.). Regarding cracks, another point of return, depending on the extent, can be managed without extraction. For example, this could be cuspal protection or a root canal filling and cuspal protection, which work very well (RKaur S, Puzhankara L, Shenoy N, Kini KS, Singhal DK. Saving the split: An umbrella review on therapeutic approaches for cracked tooth syndrome. J Conserv Dent Endod. 2026 Jan;29(1):11–19. doi:10.4103/JCDE.JCDE_796_25. Epub 2026 Jan 10. PMID: 41660023; PMCID: PMC12880780.).

So, I think what I am trying to say that even though there is ‘no going back’, modern dentistry is very good at managing points of no return with great success. There are many points of no return that are not a ‘death knell’ as they were many years ago. Modern techniques, such as resin infiltration, and preventive methods work really well at stopping the teeth from tipping over the edge. I would be interested to see whether you agree or whether I have got it wrong.

Please remember I have practised as a periodontist for the last 25 years and may be out of date with all other aspects of dentistry, but I as far as I know the content of this editorial is as factually correct as I can make it. I have picked what I think are appropriate references to support my argument.

Ivan Darby: conceptualization, writing – original draft, writing – review and editing.

The author declares no conflicts of interest.