Periodontal Therapy - Long Answer Question (LAQ)

Definition

Goals of Periodontal Therapy (Carranza)

1. Remove etiologic factors (plaque and calculus)
2. Eliminate or reduce periodontal pockets
3. Restore physiologic gingival architecture
4. Regenerate lost periodontal tissues where possible
5. Maintain the results achieved through supportive periodontal therapy (SPT)

Phases of Periodontal Treatment

Phase I - Etiotropic (Cause-Related) Phase

• Plaque control instructions (Bass technique, modified Bass, Charters technique)
• Interdental cleaning - floss, interdental brushes
• Tongue cleaning, chemical plaque control (chlorhexidine)

• Scaling: removal of supragingival and subgingival plaque, calculus, and stain from crown and root surfaces
• Root planing: removal of residual calculus and altered cementum from root surface to create smooth, hard, clean surface
• Can be done by hand (curettes - Gracey, Universal) or ultrasonic/sonic instruments
• Endpoint: smooth, glassy, hard root surface

• Occlusal therapy (adjustment, splinting)
• Extraction of hopeless teeth
• Caries control and temporary restorations
• Treatment of acute periodontal conditions (ANUG, periodontal abscess)

• Systemic antibiotics: amoxicillin + metronidazole (Socransky protocol), doxycycline, azithromycin
• Local drug delivery: doxycycline hyclate gel (Atridox), minocycline microspheres (Arestin), chlorhexidine chip (PerioChip), tetracycline fibers
• Indications: aggressive periodontitis, refractory cases, systemic compromise

• Reassess pocket depths, BOP, plaque scores
• Decide if surgical phase is needed
• Many pockets resolve with Phase I alone

Phase II - Surgical Phase

• Modified Widman Flap (MWF): access for deep scaling, preserve tissue, close adaptation; preferred for esthetics
• Undisplaced (unrepositioned) flap: pocket elimination, good access
• Papilla Preservation Flap: used in regenerative procedures to protect papilla

• Bone grafts: autografts (gold standard), allografts (FDBA, DFDBA), alloplasts (HA, TCP, bioactive glass), xenografts (Bio-Oss)
• Guided Tissue Regeneration (GTR): resorbable (collagen, PGLA) or non-resorbable (expanded PTFE) membranes to exclude epithelium and allow PDL/bone cells to repopulate
• Enamel Matrix Derivatives (EMD): Emdogain (amelogenin) - promotes cementogenesis and PDL formation
• Growth factors: PDGF (GEM 21S), rhBMP-2
• Combination therapy: bone graft + GTR membrane

• Free gingival graft (FGG): increase attached gingiva
• Connective tissue graft (CTG): root coverage, gold standard
• Pedicle flaps: laterally positioned flap, coronally advanced flap (CAF) - Miller's classification
• Frenectomy

• Implant placement after extraction
• Bone augmentation, sinus lift procedures

Phase III - Restorative Phase

• Final restorations after periodontal health is established
• Crown lengthening surgery (if needed) before restorations
• Alignment of gingival margins
• Management of embrasures, contact points, occlusal harmony

Phase IV - Maintenance Phase (Supportive Periodontal Therapy - SPT)

1. Update medical/dental history
2. Oral hygiene assessment and reinforcement
3. Periodontal examination (pocket depths, BOP, mobility, furcation)
4. Radiographic review (bitewings annually or as needed)
5. Full mouth debridement (scaling/root planing as needed)
6. Polishing
7. Fluoride application (if indicated)
8. Risk assessment and interval determination

Rationale for Periodontal Therapy

• Plaque biofilm is the primary etiologic agent (Loe et al., 1965 - classic experimental gingivitis study)
• Removal of biofilm reverses gingivitis completely
• In periodontitis, tissue destruction results from host response to subgingival pathogens (Gram-negative anaerobes - P. gingivalis, T. forsythia, T. denticola - "red complex" - Socransky, 1998)
• SRP reduces probing depths by 0.3-2.1 mm and gains clinical attachment (CAL) of 0.5-1.8 mm depending on initial pocket depth
• Surgical therapy provides additional CAL gain (0.5 mm) in deeper pockets (>6 mm) compared to non-surgical therapy

Healing After Periodontal Therapy

Factors Affecting Prognosis and Outcome

• Diabetes (poor glycemic control worsens periodontitis and vice versa - bidirectional relationship)
• Smoking: major risk factor - reduces treatment response by ~50%; nicotine causes vasoconstriction, reduces neutrophil function
• HIV/AIDS, medications (phenytoin, cyclosporine, nifedipine - gingival enlargement)
• Osteoporosis, stress (elevated cortisol, RANKL/OPG imbalance)

• Plaque control (most important modifiable factor)
• Tooth anatomy (root trunk length, furcation involvement, root proximity)
• Pocket depth and CAL at baseline
• Furcation involvement (Class I, II, III - Hamp et al.)

• Good, Fair, Poor, Questionable, Hopeless
• Individual tooth prognosis vs. overall prognosis

Outcomes Measured

• Probing depth reduction (PD)
• Clinical attachment level gain (CAL)
• Bleeding on probing (BOP) - most sensitive indicator of active inflammation
• Radiographic bone levels
• Tooth survival
• Patient-reported outcomes (aesthetics, function, comfort)

Recent Evidence (2023-2025)

• Non-surgical periodontal therapy remains effective even in patients with concurrent systemic conditions such as diabetes and cardiovascular disease (Joseph et al., 2023 - PMID 38147183)
• Probiotics as adjuncts to SRP show modest but significant benefits in reducing PD and BOP (Benavides-Reyes et al., 2025 - PMID 40186219)
• Herbal adjuncts (turmeric, aloe vera, green tea) show anti-inflammatory benefit as adjuncts to conventional therapy (Malcangi et al., 2025 - PMID 40077632)

Summary Table