How periodontitis is treated: from assessment to stability

The periodontal assessment: measuring before treating

The first consultation starts with a conversation: medical history, medication, smoking, diabetes, dental history. Then comes the clinical examination: appearance and bleeding of the gums, plaque, tooth mobility, recession, involvement of the furcations (where the roots of a molar divide). When the diagnosis or follow-up requires it, precise measurements of pocket depth and attachment loss (the height of support already lost) complete this examination.

X-ray analysis plays a central role: a series of periapical radiographs (small films placed behind the teeth), and 3D imaging if needed, shows the bone level around each root. The initial assessment relies first on the clinical examination and X-rays; further tests are chosen according to the situation. These findings serve as a baseline: comparing them later shows whether treatment has worked.

Stage and grade: what your diagnosis means

Since the 2018 international classification, periodontitis is described by a stage and a grade ^[1].

• The stage (I to IV) describes severity and complexity: how much support has been lost, whether teeth have already been lost to the disease, and whether treatment will be straightforward or complex (furcations, loose teeth, drifting). Stage I is early disease; stage IV is advanced disease that compromises chewing.
• The grade (A, B or C) estimates the rate of progression: slow, moderate or rapid. It takes into account bone loss relative to age and factors that accelerate the disease, such as heavy smoking or poorly controlled diabetes.

The extent is also noted: localised (fewer than 30% of teeth) or generalised. This diagnosis guides the treatment plan and the follow-up schedule.

The four steps of treatment

The 2020 European Federation of Periodontology (EFP) guideline organises treatment of stage I to III periodontitis into four steps ^[2]. Stage IV follows the same logic, often combined with prosthetic or orthodontic care.

Step 1: controlling plaque and risk factors. You learn to clean effectively, especially between the teeth with interdental brushes sized for each gap. Plaque and tartar above the gum line are removed. Stopping smoking and controlling diabetes are part of treatment: smoking is associated with a markedly higher risk of developing and worsening the disease ^[4], and periodontal treatment modestly improves HbA1c (by about 0.4 percentage points at 3–4 months) in people with diabetes ^[5].

Step 2: subgingival instrumentation. Often called root planing or root surface debridement, this means cleaning the root inside the pocket, under local anaesthetic, with fine ultrasonic tips and hand curettes. It can be done in stages or full-mouth within a short time: both approaches give comparable results ^[3]. Dr Hazout has chosen the latter: initial periodontal treatment is carried out on the whole mouth, all six sextants, in a single session. This is his protocol, among other possible approaches; its principle is set out further down.

Lasers are not part of this step in the European guideline: added to mechanical cleaning, they have not shown sufficient benefit in trials, and the EFP suggests not using them for this purpose ^[2]. At the practice, the diode or Er:YAG laser may nevertheless complement debridement in some pockets, after mechanical cleaning and never instead of it; the additional benefit expected is modest, and the decision is made for each patient. How the two lasers work, their uses and what studies show are detailed on the page Diode and Er:YAG lasers.

The two animations show the principle of each: the fine diode laser fibre slipped into the pocket, then the Er:YAG tip along the root. They are schematic.

A narrated animation of root debridement, with its transcript, is available on the root planing video page.

Step 3: treating pockets that persist. After healing, a re-evaluation compares the gums and the measurements with the initial assessment. The aim is to have no pockets deeper than 4 mm that bleed. Residual pockets of 4–5 mm are usually re-instrumented. For pockets of 6 mm or more, access surgery (a flap) allows cleaning under direct vision; where there is a vertical bone defect of 3 mm or more, regenerative surgery may be proposed ^[2].

Step 4: maintenance. Regular visits, at a frequency that depends on your risk, keep the results stable and detect any return of the disease early. Their content and frequency are detailed on the Periodontal maintenance page.

When teeth remain loose once inflammation is under control, a bonded splint can join them together. It does not rebuild lost bone; it improves comfort and spreads chewing forces.

The full-mouth treatment session: the principle

Initial periodontal treatment covers the whole mouth, all six sextants, in a single session, under local anaesthetic. Each root is cleared of tartar and biofilm with ultrasonic tips and curettes. Depending on the situation, a diode or Er:YAG laser complements this mechanical cleaning in some pockets, without replacing it. The practical arrangements, the course of treatment and aftercare instructions are explained at the practice, according to your situation.

At the Levallois-Perret practice, this initial full-mouth treatment costs €1,440 without laser and €1,800 with laser, for all six sextants; it is not reimbursed by French national health insurance, although some top-up insurers cover part of it. Details are on the Fees page, and a written estimate is given before any treatment.

Beyond local treatment: individual factors

Response to treatment varies from one patient to another. Smoking, poorly controlled diabetes, stress, some medicines or difficult oral hygiene can slow healing and favour relapse. Identifying them is part of the assessment, just like examining the gums and X-rays.

When useful, two tests can complete the assessment. A fingertip blood test, done in the practice with a rapid test, assesses certain markers; it does not replace laboratory tests, and an abnormal result leads to referral to the GP. A bacterial sample identifies the bacteria present in the pockets; it can help decide on an adjunctive antibiotic in some severe forms.

Diet and possible deficiencies are also discussed, as they contribute to the body's overall inflammatory state. Available data show real but modest effects: they support mechanical treatment, they do not replace it. Details are in the articles blood tests and supplements and nutrition, micronutrition and inflammation.

The results you can expect

The results of mechanical root cleaning have been measured in many trials. The systematic review prepared for the European guideline found, six to eight months after instrumentation, an average reduction in pocket depth of about 1.7 mm and the closure of roughly three pockets in four, meaning pockets that have become shallow and no longer bleed ^[3]. These averages hide wide differences from one tooth to another: very deep pockets, furcations and smoking reduce the chances of success. How these figures compare with those for lasers is explained on the lasers page.

For you, the result shows at the re-evaluation: less bleeding, shallower pockets, a firmer gum, sometimes less mobile teeth. It is then maintained provided plaque is kept under control day to day and the maintenance visits are attended.

When a deep pocket persists along a vertical bone defect, regenerative surgery can rebuild part of the support: see the Periodontal regeneration page.

The limits of treatment and follow-up

Teeth that cannot be saved. When a tooth has lost most of its support, is very loose or has a recurring abscess, treating it no longer makes sense: its extraction is discussed at the assessment, together with how it will be replaced. It is better to know this before the treatment session than after.

Furcations. Between the roots of a molar, the area where they divide is hard to clean, for the clinician and the patient alike. Pockets there respond less well to debridement and carry a higher risk of progression; they are monitored closely and may warrant surgery.

Smoking and diabetes. In smokers, healing is poorer, pockets close less often and relapse is more frequent; treatment remains worthwhile, but its results are less predictable. The same applies to poorly controlled diabetes. The assessment and the first step of treatment address both points directly.

Re-evaluation and maintenance. After healing, a re-evaluation repeats the assessment measurements and decides what comes next: monitoring, re-instrumentation of a few sites, access or regenerative surgery. Then comes maintenance, every three to twelve months depending on risk: it reduces the likelihood of relapse without removing it, and it is what detects a recurrence before it causes damage. It is presented on the Periodontal maintenance page.

Frequently asked questions