Periodontal Disease Treatment: What Happens at Each Step

What treatment can restore

The first question at most consultations is how much of the damage can be undone. The answer differs sharply depending on which tissue is involved, and it is worth settling before any procedure is described.

Gingivitis, the inflammation confined to the gum itself, resolves completely once the plaque that causes it is removed and kept away. Once the inflammation has reached the bone, the picture changes. The bone lost from around a root is gone, and the attachment that held the tooth in place is only partly recoverable. That is why treatment is judged on whether the disease has stopped, not on whether the original anatomy has returned.

Tissue involved	What treatment can restore
Inflamed gum tissue	A healthy, non-bleeding margin
Deepened gum pocket	Closure in most treated sites
Vertical bone defect	Partial, measured in millimetres
Horizontal bone loss	Nothing that regrows on its own
Root exposed by recession	Coverage by a gum graft
Tooth already lost	Replacement, never regrowth

The page bringing together the ways of restoring a damaged set of teeth deals with what comes afterwards, once teeth have been lost.

The assessment that sets the plan

Nothing in a periodontal treatment plan is decided from the appearance of the gums. It is decided from a chart, and that chart determines the number of appointments, whether a referral is needed, and how closely you will be followed afterwards. How that chart is built, from the basic periodontal examination through pocket charting, radiographs, stage and grade, is explained in the article on periodontitis and how it is diagnosed. What matters here is what each reading decides.

Pocket depth shows how far the attachment has been lost, and bleeding on probing shows whether that particular site is still inflamed. A deep pocket that no longer bleeds and a moderate pocket that bleeds every time call for different responses, which is why the two measurements are never merged into a single score. Radiographs add the one thing probing cannot give, the shape of each lesion: a vertical defect hollowed out alongside one root can be treated in ways that flat, horizontal bone loss spreading across a whole ridge simply cannot.

The stage and grade on your chart weigh in the same way. The UK implementation of the European guideline is built around that classification, so a slowly progressing stage III in a non-smoker and a rapidly progressing stage III in a smoker with diabetes translate into different steps of therapy and a different recall interval (West et al., 2021).

Step one: plaque control and the risk factors behind it

The first step of therapy is described in the guideline as being “aimed at guiding behaviour change by motivating the patient to undertake successful removal of supragingival dental biofilm and risk factor control” (Sanz et al., 2020). Put plainly, nothing that follows will hold if this groundwork is missing.

In practice this covers a brushing technique matched to your own teeth, daily cleaning between them with interdental brushes or floss depending on the space available, professional removal of deposits from the visible surfaces, and work on whatever is feeding the disease. Stopping smoking sits at the top of that list, followed by control of a known diabetes. The NHS lists the same help with stopping smoking alongside brushing twice daily with a fluoride toothpaste and cleaning between the teeth every day (NHS, n.d.).

Both of these change how the tissues respond to everything that comes next, which is why a course of treatment started without them tends to be repeated rather than finished.

Step two: cleaning below the gum line

The second step deals with the biofilm and hardened deposits sitting beneath the gum, where no brush reaches. It is the core of periodontal treatment, and for a good proportion of patients it is the only procedure they will ever need.

What the cleaning appointments involve

Scaling removes the calcified deposits from the tooth surfaces. Root surface debridement, still widely called root planing, continues under the gum margin: the instrument follows the root down to the base of the pocket, lifts the subgingival deposits and leaves a surface smooth enough for the tissues to reattach. The work is done under local anaesthetic, and the number of appointments depends on how many sites are involved, with the mouth usually treated a quadrant at a time.

The systematic review carried out for the guideline gives the measure of what this achieves. Six to eight months after subgingival instrumentation, the weighted reduction in pocket depth was 1.4 mm, with a confidence interval of 1.0 to 1.7 mm (Suvan et al., 2020). The same review found no significant difference between hand instruments and sonic or ultrasonic ones, and none between quadrant-by-quadrant treatment and full-mouth delivery. Which instrument your hygienist reaches for matters considerably less than how thoroughly the surfaces are cleaned and what you do between visits.

Antibiotics, mouthwashes and lasers

Systemic antibiotics are not part of routine periodontal treatment, and the numbers explain why. When added to mechanical cleaning, they produced a further 0.49 mm of pocket reduction in longer-term studies, with the amoxicillin and metronidazole combination performing best, while adverse events were reported more often in the groups receiving them (Teughels et al., 2020). Half a millimetre, set against a higher rate of side effects, belongs to specific situations such as an abscess or a rapidly progressing case rather than to every course of treatment.

Chlorhexidine mouthwash has a place in short courses around treatment and none as a long-term habit. As for lasers, frequently presented as a gentler alternative, the review of adjunctive laser and antimicrobial photodynamic therapy concluded that the available evidence is limited by the small number of controlled studies and by how differently they were designed (Salvi et al., 2020). A laser offered alongside proper cleaning does not replace it and does not shorten the pathway.

The review appointment

Some weeks after the last cleaning session, once the tissues have healed and the measurements have become meaningful again, the whole chart is repeated and compared tooth by tooth with the first one. This is the point at which the next step is decided, and not before.

The criteria are numerical rather than impressionistic. The recommended endpoint of active treatment is pockets of 4 mm or less with no bleeding on probing, in a patient with fewer than 30% of sites bleeding (Loos & Needleman, 2020). The guideline defines periodontal stability in similar terms: bleeding on probing at under 10% of sites, probing depths no deeper than 4 mm, and no 4 mm site that bleeds (Sanz et al., 2020). Sites that fall short, meaning 4 mm pockets that still bleed and any pocket of 6 mm or more, are what trigger the third step.

Stage of the pathway	What it is meant to achieve
Step one	Plaque control and risk factors
Step two	Cleaning below the gum line
Review	Measuring what has responded
Step three	Surgery on non-responding sites
Step four	Supportive care, for life

This is also why no responsible estimate can state at the outset how much surgery you will need. That figure appears after the cleaning phase, on the second chart.

Step three: surgery, only where cleaning has not worked

The third step of therapy is “aimed at treating those areas of the dentition non-responding adequately to the second step of therapy” (Sanz et al., 2020). It applies to particular teeth in particular mouths, not to everyone who has been diagnosed.

Flap surgery

The gum is lifted away from the necks of the teeth so that surfaces the instrument had been reaching blind come into view. The exposed roots are cleaned, infected soft tissue is removed, the bone contour is smoothed where it has become irregular, and the flap is then repositioned and sutured, often slightly lower down so that the remaining pockets are shallower.

The advantage is direct vision and a lasting reduction in pocket depth, which finally makes daily cleaning effective in those areas. The trade-off is that the gum sits lower afterwards, so the necks of the teeth show more and may be sensitive for a period after healing.

Bone grafting

Where a deep bony defect remains at the base of a pocket, grafting material can be placed during the same operation. It works as a scaffold, holding the space while the body rebuilds, rather than acting as bone in its own right.

Four families of material are used. An autograft is taken from the patient, usually from a neighbouring site in the jaw, and remains the benchmark for biological compatibility. An allograft comes from a human donor and is processed to remove any risk of transmission. A xenograft is of animal origin, most often bovine, and is deproteinised to make it biocompatible. Synthetic substitutes complete the list. The full sequence of a dental bone grafting procedure is set out separately, as are the conditions in which a bone graft is carried out in Turkey.

Grafting improves the outlook for teeth whose support has collapsed in one specific area, and it prepares the ground when a prosthetic restoration is planned afterwards. It does not give an arch back the bone height it has lost overall.

Guided tissue regeneration

Guided tissue regeneration rests on a problem of timing. Gum cells heal far faster than the cells of bone and periodontal ligament, so left alone the gum fills the space before the supporting tissues have had a chance to form. A membrane is placed to reserve that space for the slower cells, which are the only ones able to rebuild an attachment.

The indication is narrow, and stating it precisely matters more than naming the technique. Enamel matrix derivative or guided tissue regeneration, combined with a papilla preservation flap, is recommended for residual pockets associated with a deep intra-bony defect of at least 3 mm, and the authors of the underlying meta-analysis rate the overall certainty of that evidence as low to moderate (Nibali et al., 2020). Regeneration is a response to one shape of lesion rather than a general remedy for bone loss.

Gum grafting

Recession often accompanies advanced disease and sometimes becomes more noticeable after flap surgery. A graft can then cover an exposed root, thicken tissue that has become too thin, or rebuild a band of firm gum around a tooth.

These procedures protect the root from decay and sensitivity, improve the appearance of the visible part of the smile, and strengthen the tissue against further recession. They assume gums that have already been brought under control, since a graft placed over active inflammation has no reason to hold. Indications, techniques and recovery are covered in the guide to gum grafting.

Step four: supportive care, for as long as you keep your teeth

This is the least eye-catching part of the pathway, and it is the one that decides what you still have in ten years. The guideline describes it as maintaining periodontal stability in every treated patient by combining the preventive and therapeutic measures of the first two steps, adjusted to the state of the dentition (Sanz et al., 2020).

A supportive appointment goes well beyond a scale and polish. The at-risk sites are re-charted and compared with the previous reading, instrumentation is repeated wherever bleeding has returned, cleaning technique is checked, and risk factors are reviewed. The interval between appointments follows your individual risk rather than a standard calendar.

The long-term data justify the effort. Across studies of patients kept on supportive therapy including routine professional mechanical plaque removal, mean tooth loss ran at 0.15 teeth per year over five years and 0.09 teeth per year over twelve to fourteen years (Trombelli et al., 2015). The authors are careful to say that the longer-term effect still needs better assessment, but the direction is not in doubt. An NHS teaching hospital puts the same conclusion more plainly: managing gum disease means looking after your teeth and gums for the rest of your life (Guy’s and St Thomas’ NHS Foundation Trust, n.d.).

Where the disease has already gone past that point and the support of several teeth is beyond saving, the question shifts from periodontal therapy to rehabilitation. That situation has its own European guideline for stage IV disease (Herrera et al., 2022), adapted for UK practice in 2025 (Kebschull et al., 2025), and it is dealt with in the article on severe periodontal disease.

Having treatment in Turkey: what travels and what does not

Clinics and equipment

Turkey has been receiving European patients for dental care for well over a decade, and the practices that see them have organised themselves accordingly. Three-dimensional imaging, which is what allows the shape of a bony defect to be read before regenerative surgery, is the point to check before entrusting periodontal surgery to any clinic abroad. Body Expert’s partner clinic in Istanbul was selected on its facilities and on the experience of its surgeons.

Cost, and what you would pay at home

The price gap with the UK is what prompts most enquiries, and it reaches up to 70% on some procedures. It is worth knowing what you would have paid in Britain before treating that figure as the whole argument.

NHS dental treatment is free if you are under 18, pregnant or within twelve months of giving birth, or receiving certain benefits. Everyone else pays towards their treatment, and the NHS course for gum disease covers advice on cleaning, help with stopping smoking, professional cleaning, and in more severe cases cleaning deep under the gums, antibiotics, removal of teeth and gum surgery (NHS, n.d.). Access is the real variable: courses of periodontal treatment in a hospital setting can run to five or six appointments before a reassessment, and long-term supportive care is expected to be arranged with a general dental practice rather than provided by the referring service (Guy’s and St Thomas’ NHS Foundation Trust, n.d.).

Planning a trip without breaking your maintenance

A periodontal project abroad has to be sequenced the right way round. The surgical phase travels well, because it occupies a few days, can be planned from records sent ahead, and heals along a predictable timeline. Supportive care does not travel, because it is counted in years and in closely spaced appointments. A patient who comes home without a practice to carry out those reviews loses most of what was gained in theatre.

The workable order is to have the assessment and the initial cleaning done near home, discuss the result of the review, and consider travelling only for the surgical and prosthetic part, with follow-up arranged beforehand for your return. The surgical stay itself is put together by Body Expert: a five-star hotel, VIP transfers, a dedicated English-speaking patient coordinator and twelve months of post-operative follow-up. That follow-up sits alongside the supportive care your own dentist provides rather than replacing it.

If you would like your own situation looked at, our advisers will answer your questions and tell you which parts belong at home and which can sensibly be arranged in Istanbul.

Frequently asked questions

Can periodontal disease be cured for good?
It is brought to a standstill rather than cured. Treatment stops the destruction and closes most of the pockets, but lost attachment is not fully rebuilt and the gums stay more vulnerable than they were. That is precisely why supportive appointments continue, at intervals set by your own level of risk.

Does the treatment hurt?
Cleaning below the gum line is carried out under local anaesthetic, and the after-effects are usually limited to sensitivity to hot and cold for a few days while the gum tightens back around the teeth. Surgery involves more discomfort, broadly comparable with a straightforward extraction, and is covered by painkillers prescribed at the time.

How many appointments should I expect?
The cleaning phase typically runs over several appointments spread across a few weeks, followed by a healing interval before the review. Any surgery is added after that. The guideline treats the sequence as incremental, so each step is only started once the result of the previous one has been measured.

Will the bone grow back?
Bone does not rebuild itself once it has been lost. Partial regeneration is achievable in deep vertical defects of at least 3 mm, with enamel matrix derivative or a membrane technique, and the evidence behind it is rated as low to moderate certainty. Horizontal bone loss does not regenerate, and the aim there becomes holding the level that remains.

Do loose teeth have to come out?
Extraction is not the automatic answer to a loose tooth. Looseness sometimes improves once the inflammation settles and the swelling resolves, and splinting can keep a tooth in service. The decision is made after the cleaning phase, based on how much attachment is left and on how the tooth fits into the wider plan.

Can everything be done in a single trip abroad?
The surgical and prosthetic work can realistically be planned across one or two trips. The initial cleaning, and above all the years of supportive care that follow, need a dental practice you can reach easily from home.

Sources

Guy’s and St Thomas’ NHS Foundation Trust. (n.d.). Managing advanced gum disease by undergraduate students. Retrieved 13 September 2026. Read the leaflet

Herrera, D., Sanz, M., Kebschull, M., Jepsen, S., Sculean, A., Berglundh, T., Papapanou, P. N., Chapple, I., & Tonetti, M. S. (2022). Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology, 49(Suppl. 24), 4–71. https://doi.org/10.1111/jcpe.13639

Kebschull, M., Chapple, I., D’Aiuto, F., Donos, N., Fleming, P. S., Jerreat, M., McCracken, G., Needleman, I., Nibali, L., & West, N. X. (2025). UK implementation of “Treatment of stage IV periodontitis: The EFP S3-level clinical practice guideline”: Rehabilitation of severe periodontitis patients. Journal of Dentistry, 162, 105847. https://doi.org/10.1016/j.jdent.2025.105847

Loos, B. G., & Needleman, I. (2020). Endpoints of active periodontal therapy. Journal of Clinical Periodontology, 47(Suppl. 22), 61–71. https://doi.org/10.1111/jcpe.13253

NHS. (n.d.). Gum disease. Retrieved 13 September 2026. Read the page

Nibali, L., Koidou, V. P., Nieri, M., Barbato, L., Pagliaro, U., & Cairo, F. (2020). Regenerative surgery versus access flap for the treatment of intra-bony periodontal defects: A systematic review and meta-analysis. Journal of Clinical Periodontology, 47(Suppl. 22), 320–351. https://doi.org/10.1111/jcpe.13237

Salvi, G. E., Stähli, A., Schmidt, J. C., Ramseier, C. A., Sculean, A., & Walter, C. (2020). Adjunctive laser or antimicrobial photodynamic therapy to non-surgical mechanical instrumentation in patients with untreated periodontitis: A systematic review and meta-analysis. Journal of Clinical Periodontology, 47(Suppl. 22), 176–198. https://doi.org/10.1111/jcpe.13236

Sanz, M., Herrera, D., Kebschull, M., Chapple, I., Jepsen, S., Berglundh, T., Sculean, A., & Tonetti, M. S. (2020). Treatment of stage I–III periodontitis: The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology, 47(Suppl. 22), 4–60. https://doi.org/10.1111/jcpe.13290

Suvan, J., Leira, Y., Moreno Sancho, F. M., Graziani, F., Derks, J., & Tomasi, C. (2020). Subgingival instrumentation for treatment of periodontitis: A systematic review. Journal of Clinical Periodontology, 47(Suppl. 22), 155–175. https://doi.org/10.1111/jcpe.13245

Teughels, W., Feres, M., Oud, V., Martín, C., Matesanz, P., & Herrera, D. (2020). Adjunctive effect of systemic antimicrobials in periodontitis therapy: A systematic review and meta-analysis. Journal of Clinical Periodontology, 47(Suppl. 22), 257–281. https://doi.org/10.1111/jcpe.13264

Trombelli, L., Franceschetti, G., & Farina, R. (2015). Effect of professional mechanical plaque removal performed on a long-term, routine basis in the secondary prevention of periodontitis: A systematic review. Journal of Clinical Periodontology, 42(Suppl. 16), S221–S236. https://doi.org/10.1111/jcpe.12339

West, N., Chapple, I., Claydon, N., D’Aiuto, F., Donos, N., Ide, M., Needleman, I., & Kebschull, M. (2021). BSP implementation of European S3-level evidence-based treatment guidelines for stage I–III periodontitis in UK clinical practice. Journal of Dentistry, 106, 103562. https://doi.org/10.1016/j.jdent.2020.103562