Periodontology is a branch of dentistry concerned with the diagnosis and treatment of diseases affecting the soft and hard tissues surrounding teeth and dental implants, as well as the maintenance of their health. These tissues include the gingiva, peri-implant mucosa, cementum, and alveolar bone.
Healthy Gingiva
Healthy gingival tissue surrounding natural teeth and dental implants is pale pink (rose-colored), firm in consistency, and closely adapted to the cervical region of the tooth or implant-supported prosthesis. The gingival surface is generally matte and pale in color and may exhibit a stippled, orange-peel-like appearance. Healthy gingiva does not bleed during toothbrushing or upon gentle contact.
Development and Progression of Gingival Diseases and Factors That Adversely Affect the Disease
The formation of a soft, yellowish-white layer consisting of loosely attached microorganisms and food debris, known as materia alba, on tooth surfaces is inevitable. When oral hygiene practices are inadequate, incorrect, or neglected, the composition of this layer becomes more complex. As the number of pathogenic bacteria increases, a layer known as microbial dental plaque develops and covers the tooth surfaces. If not removed, microbial dental plaque matures and hardens over time, resulting in the formation of dental calculus (tartar). Calculus deposits increase the surface area and roughness of the teeth, allowing greater numbers and different types of bacteria to adhere. This promotes the onset of gingival diseases.
Bleeding during oral hygiene procedures, such as toothbrushing, flossing, and using interdental brushes, as well as bleeding that occurs while eating hard foods or spontaneously, is often the first warning sign of gingival disease. The disease typically begins as gingivitis, a mild form of gingival inflammation.
If left untreated at this stage, gingival disease may progress to periodontitis, a condition characterized by destruction of the jawbone surrounding the teeth (alveolar bone), potentially accompanied by severe infections. During this stage, the gingiva may become swollen and bright red. Gingival recession may expose the root surfaces of the teeth, and symptoms such as bad breath may develop. If the disease remains untreated, it may progress further, causing extensive alveolar bone loss to the point where the bone can no longer adequately support the teeth. Consequently, teeth may become spaced apart, shift from their original positions, and become mobile.
Although the presence of microbial dental plaque is essential for the development of gingivitis and periodontitis, several other factors may contribute to the onset and progression of these diseases. These risk factors include uncontrolled diabetes, genetic predisposition, smoking, muscle attachments in the cheeks and lips that complicate oral hygiene, and improperly designed dental prostheses.
Advanced periodontal diseases can also have significant effects on general health and chronic systemic conditions. Severe periodontitis has been associated with an increased risk of heart attack in individuals with chronic cardiovascular disease. In patients with diabetes, advanced gingival infections can make glycemic control more difficult, whereas periodontal treatment may improve glycemic control. Furthermore, advanced periodontal disease has been shown to be associated with an increased risk of preterm birth and low birth weight.
Certain medications used by patients with hypertension, epilepsy, and organ transplant recipients may also cause gingival swelling and enlargement. Inadequate oral hygiene can further aggravate these conditions.
Apart from infections, factors that cause chronic trauma to the gingiva may lead to gingival recession. These include improper toothbrushing techniques, parafunctional habits such as nail-biting and pen-biting, and piercings in the oral region or tongue.
In general, different types of gingival diseases may present with symptoms such as bleeding, swelling, gingival recession, destruction of the jawbone supporting the teeth, tooth spacing, and tooth mobility. Although these conditions can affect individuals' lives in many ways, ranging from aesthetic concerns to problems that compromise general health, periodontal diseases can be treated and controlled.
The fundamental requirement for restoring and maintaining oral health is recognizing that periodontal disease is a chronic condition requiring regular monitoring. Patients must actively participate in their treatment by maintaining effective oral hygiene practices and cooperating with their dental professionals.
Treatment of Gingival Diseases and Stages of Treatment
The first step in treating periodontal diseases is to reduce the bacterial burden around the teeth and gingiva.
1. Initial Treatment (Phase I)
The first stage of periodontal treatment, known as initial therapy or Phase I treatment, involves the mechanical removal of microbial dental plaque and calculus from the tooth and root surfaces using specialized instruments. The aim is to reduce abnormally deep periodontal pockets (gingival sulci) between the teeth and gingiva.
Initial treatment usually requires several sessions and includes scaling, polishing, and root surface debridement or root planing. To improve patients' oral hygiene, the clinician recommends personalized oral care products, such as toothbrushes, interdental brushes, dental floss, and oral irrigators, and demonstrates how to use them correctly.
Because inadequate oral hygiene may lead to recurrent infection and disease, patients' oral hygiene status is monitored during the initial treatment sessions and at follow-up appointments scheduled after treatment completion, as deemed appropriate by the clinician. These follow-ups may take place at one, three, and six months after initial treatment.
Throughout the initial treatment phase, clinicians also expect patients to discontinue harmful habits, such as smoking, and to achieve better control of systemic conditions, such as diabetes. These measures are essential for managing and treating periodontal disease, which is a chronic inflammatory condition.
Periodontists may also refer patients to physicians in other specialties to evaluate their general health and may request various laboratory tests. To support treatment, antibiotics, antiseptic mouthwashes, and gels may be recommended when clinically indicated.
After completion of initial treatment, which generally involves one to six sessions, patients are directed either to the maintenance and follow-up phase or to more advanced treatment, depending on the severity of their disease.
2. Surgical Periodontal Treatment (Phase II)
Following initial treatment, patients who have established optimal oral hygiene habits may require further treatment for conditions that have not been fully resolved, such as persistent deep periodontal pockets, gingival enlargement, gingival recession, or alveolar bone loss. Surgical procedures may also be performed to address aesthetic concerns.
This stage is known as Phase II or surgical periodontal treatment. Performed under local anesthesia, these procedures may be classified as either resective or regenerative.
Resective procedures involve the surgical removal of diseased or damaged tissues to create areas that patients and clinicians can clean more easily.
Regenerative procedures aim to reconstruct lost hard or soft tissues to restore the relationship between the teeth, gingiva, and bone as closely as possible to its original condition.
Periodontal Flap Surgery
Periodontal flap surgery is performed when the desired reduction in periodontal pocket depth cannot be achieved despite optimal oral hygiene following initial treatment, or when excessively deep pockets prevent adequate access to the root surfaces, resulting in incomplete root planing and persistent inflammation.
During flap surgery, the gingiva surrounding the tooth is surgically elevated. The diseased soft and hard tissues around the tooth are then cleaned, and the root surfaces are thoroughly debrided and planed.
Depending on the extent and configuration of the surrounding bone loss, the bone may also be reshaped or selectively recontoured to restore a more favorable anatomical form and create areas that are easier to clean.
Guided Bone Regeneration (GBR)
Following the resolution of inflammation, surgical procedures known as guided bone regeneration (GBR) may be performed to reconstruct hard tissues (bone) and soft tissues (gingiva) destroyed by periodontal disease.
These procedures commonly involve the use of grafting materials derived from animals (xenografts), obtained from the patient (autografts), or sourced from human donors (allografts). Commonly referred to as bone graft materials and barrier membranes, these products are selected by the clinician according to the patient's specific needs.
Depending on the material used, the products may integrate with the body and gradually resorb after placement in a single surgical procedure (resorbable materials). Alternatively, a second surgical procedure may be required to remove them (non-resorbable materials).
When clinically appropriate, these procedures may also be performed as part of periodontal flap surgery.
Gingivectomy and Gingivoplasty
Gingivectomy is the surgical excision of gingival tissue using lasers, electrosurgical devices, scalpels, or specialized periodontal knives. It is performed to reduce periodontal pocket depth or remove enlarged gingival tissue.
Gingivoplasty refers to surgical reshaping of the gingiva to correct the gingival margins, establish appropriate gingival levels, and create contours that resemble the natural gingival architecture.
The gingival tissue removed during gingivectomy is often followed by gingivoplasty to refine the remaining tissue. Therefore, the two procedures are frequently performed together.
Resective surgical procedures may also be used to remove high muscle attachments that complicate oral hygiene or contribute to gingival recession. These procedures, known as frenectomy or frenotomy, are frequently performed using laser technology in contemporary practice.
Mucogingival Surgery and Gingival Grafting
Surgical procedures performed on the soft tissues of the oral cavity are generally referred to as mucogingival surgery. In addition to the resective procedures described above, these interventions aim to restore lost gingival tissue, cover exposed root surfaces caused by gingival recession, and, particularly, increase the amount of inadequate attached gingiva around natural teeth and dental implants.
Depending on the patient's oral and dental condition, the clinician selects an appropriate surgical technique. The required treatment may involve gingival grafts harvested from the patient's own mouth, most commonly from the palate, or commercially manufactured gingival graft materials.
The most frequently used techniques include:
Free gingival grafts
Subepithelial connective tissue grafts
When clinically appropriate, and provided that sufficient gingival tissue is available around the tooth to be treated, the clinician may also use tissue from adjacent areas or reposition the existing gingiva from a more apical position toward the crown. These techniques include laterally positioned and coronally advanced flaps.
3. Supportive Periodontal Therapy (Phase III)
The third stage, known as Phase III, maintenance therapy, or supportive periodontal treatment, involves regular follow-up appointments and additional supportive care as needed to preserve the gingival health achieved through surgical or non-surgical periodontal treatment, prevent disease recurrence, and evaluate treatment outcomes.
Patients who have completed treatment are generally recalled every three months during the first year after treatment.
During these appointments, the clinician primarily evaluates the patient's oral hygiene. Other parameters are also assessed and recorded, including occlusal relationships between the teeth, tooth mobility, dental sensitivity, and the risk of recurrent gingival infection.
The Key to Successful Periodontal Treatment
The golden rule for successful periodontal treatment is effective cooperation between the clinician and the patient.
Even when appropriate and effective treatment is provided, missed follow-up appointments, failure to establish adequate oral hygiene habits, poor control of systemic diseases that adversely affect periodontal tissues, and continued smoking or other harmful habits can lead to disease recurrence within a short period. These factors may also result in renewed and severe tissue destruction.
Dental Implant Placement in Patients with Periodontal Disease
In patients with existing periodontal disease or a history of tooth loss due to periodontal disease, infection control, extraction of teeth with a hopeless prognosis, and optimization of oral hygiene are essential before dental implant placement to replace missing teeth.
Individuals who have lost teeth due to periodontal disease have a three- to fourfold greater risk of peri-implant bone destruction or implant loss than periodontally healthy individuals.
However, when infection has been controlled following periodontal treatment, regular maintenance visits are attended, and oral hygiene is maintained at an optimal level, the likelihood of complications following dental implant placement is considerably reduced.
Infections of the Soft and Hard Tissues Around Dental Implants and Their Treatment
The tissues surrounding dental implants are broadly similar to those surrounding natural teeth. However, the most important difference lies in how natural teeth and implants attach to the jawbone.
Natural teeth are anchored in the alveolar bone by periodontal ligament fibers extending from the tooth root. In contrast, dental implants attach directly to the bone through a process called osseointegration, in which the implant makes direct contact with the bone without an intervening layer of soft tissue or connective tissue fibers.
The attachment of the gingiva to natural teeth and implants also differs. Because the tissue surrounding an implant is not attached to a natural tooth and the underlying attachment mechanism is structurally different, the soft tissue around an implant is referred to as the peri-implant mucosa, rather than the gingiva.
Due to these structural differences, infections caused by microbial dental plaque may progress more rapidly and readily around dental implants than around natural teeth.
Peri-implant diseases resemble periodontal diseases affecting natural teeth. The infection initially develops in the mucosa surrounding the implant, a condition known as peri-implant mucositis. If the disease progresses and involves the bone surrounding the implant, it is called peri-implantitis.
Treatment of peri-implant infections follows principles similar to those used for periodontal diseases and may involve either non-surgical or surgical procedures.
In some cases involving bone loss around natural teeth, the disease can be controlled without surgery. However, when bone loss occurs around dental implants, surgical intervention is frequently required to control the infection.
As with natural teeth, bone defects around implants may be reconstructed using grafting materials and similar products. However, treatment outcomes may be less predictable because dental implants are not natural components of the body and lack the biological attachment mechanisms of natural teeth.
Systemic conditions that may contribute to chronic inflammation or infection, such as uncontrolled diabetes and rheumatoid arthritis, can adversely affect both the success of implant placement and the treatment of peri-implant diseases.
All patients with dental implants, including those who have undergone treatment for diseases affecting the tissues around their implants, should understand that dental implants are prosthetic replacements that require regular care, just like natural teeth. This includes brushing, using interdental brushes and dental floss, and using oral irrigators when appropriate. Patients should also attend regular dental check-ups and seek professional evaluation whenever discomfort or other symptoms arise.
Recent Developments in Periodontal Treatment
With advances in technology, significant improvements have been made in the diagnosis and treatment of periodontal diseases.
One of the most important developments is the increasing use of microsurgical techniques instead of conventional surgical methods in periodontal and peri-implant procedures. These techniques allow smaller wound surfaces to be created and promote faster healing. They also aim to minimize or eliminate common postoperative complications, such as pain and swelling.
As in many other fields of dentistry, the growing use of lasers in periodontology has contributed to more efficient treatment procedures and improved treatment effectiveness.
Advances in Three-Dimensional Printing and Imaging Technologies
With the development of three-dimensional printers and milling systems, customized block bone grafts can now be produced for grafting procedures involving large areas. These grafts can be designed to match the specific shape of an individual's bone defect.
Advances in radiology and medical imaging have also made it easier to determine the dimensions of bone defects and obtain increasingly precise assessments. These developments can shorten surgical procedures and improve patient comfort.
However, because such technologies and procedures have not yet become widely available, their costs remain relatively high.
Stem Cells and Blood-Derived Products
Rapidly expanding research on stem cells and blood-derived products has begun to yield increasingly promising results in the reconstruction of lost soft and hard tissues.
In particular, the use of platelet-rich fibrin (PRF) in periodontal treatment is becoming increasingly common. PRF is obtained by centrifuging a sample of the patient's own blood to produce a fibrin matrix enriched with platelets. It can accelerate wound healing and enhance the effectiveness of grafting materials used in treatment.
Research into stem cell applications is also progressing rapidly, and these technologies are expected to be used more frequently and effectively in periodontal treatment in the near future.
