Treating periodontitis: Professional cleaning and good oral care

Photo of a man at the dentist
PantherMedia / Robert Kneschke

Advanced can cause teeth to loosen. Treating the disease in a systematic way can usually at least slow down the progression of . For the treatment to be successful, good oral hygiene is absolutely essential.

Dentists can treat in various ways. Treatment is needed if there are gum pockets that are at least 4 millimeters deep.

Systematic treatment consists of the following steps:

  • Improving oral hygiene: The dentist or dental hygienist shows you how to clean your teeth properly and removes plaque and tartar (calculus) from your teeth. The professional removal of these tooth deposits is known as "scaling.”
  • Removing plaque and tartar below the gum line (subgingival scaling and root planing, also known as "deep cleaning").
  • Taking , if necessary.
  • Checking how well the treatment has worked.
  • Surgical treatment (under local anesthetic) may be considered too.
  • Structured follow-up care to improve the success of the treatment (supportive periodontal therapy).

Your dentist will advise you on the treatment steps that are needed in your case. He or she will also explain what habits or risk factors may have a negative effect on the .

In Germany, statutory health insurance will cover the costs involved in the systematic treatment of if it is medically necessary. Certain other conditions must be met too. For instance, the patient has to clean their teeth thoroughly, try to stop smoking if they smoke and – if they have diabetes – get good treatment for diabetes. Before starting systematic treatment, the dentist files a request for the statutory health insurance to cover the costs, and the health insurer makes a decision. People who need nursing care or are disabled don't need a separate request for cost coverage.

Dentists often offer other treatments too, but you usually have to pay for them yourself. For example, they often recommend having professional teeth-cleaning before starting the actual treatment. They also offer some treatments that aim to rebuild the tissues and bone that support the teeth (the periodontium), as well as approaches such as laser treatment and photodynamic therapy. In photodynamic therapy, a light-sensitive dye is applied to the affected areas and then exposed to a laser beam. This causes a reaction that produces aggressive oxygen, which is meant to kill the bacteria.

Improved oral hygiene

In order for treatment to be able to work, good oral hygiene is essential. This means thoroughly and regularly cleaning your teeth and the gaps between them, as well as taking good care of your gums. Even if the has already led to bone loss or tooth loss, regular good oral hygiene can help to keep the rest of the teeth. This is also important if you need dentures, so they can be fixed to teeth with the healthiest possible supportive tissue.

In order to improve your oral hygiene, at the start of the treatment you will be shown how to properly use a toothbrush (electric or normal), interdental brushes and dental floss. To do so, your dentist or a specially trained dental hygienist will dye the plaque on your teeth so that you can see it and learn how to clean your teeth thoroughly. This training in oral hygiene also includes practical exercises. In Germany, the costs of this training are covered by statutory health insurers if it is part of treatment for .

Tartar (calculus) is removed too. Known as scaling, this is done with the help of special hand-held instruments (called scalers or curettes), ultrasound devices or rotating instruments. In Germany, statutory health insurers cover the costs of tartar removal once a year. Protruding edges of fillings and crowns are smoothed down too, if necessary.

The dental practice may also offer professional teeth-cleaning, which you have to pay for yourself. This involves removing hard and soft deposits (tartar and plaque). The cleaned teeth are usually also treated with a gel or varnish.

Deep cleaning (non-surgical periodontal treatment)

Deep cleaning involves removing bacterial plaque and hardened deposits (tartar or calculus) that have formed below the gum line, on the surfaces of the neck of the teeth, and on the exposed roots of the teeth. A local anesthetic is typically used to numb the area beforehand. This is also known as subgingival scaling and root planing. It is done using special instruments or an ultrasound device, for instance.

Research suggests that this treatment reduces gum bleeding and can help prevent tooth loss.

There is also some initial to suggest that certain types of laser therapy could be promising: Removing bacterial plaque and hard tartar with a laser, or combining conventional deep cleaning with laser therapy, might have advantages. Initial research also suggests that certain photodynamic techniques could have advantages. But it's not yet possible to draw any reliable conclusions about how effective these approaches are.

Sometimes dentists offer the following treatments too, although it's not clear whether they have any benefits:

  • Using a gel containing enamel matrix proteins. Enamel matrix proteins are special proteins that are thought to help regenerate (build up) the bone that supports the teeth if has led to bone loss.
  • Using antiseptic substances (usually chlorhexidine) to stop from growing again.
  • Hyperbaric oxygen therapy. This involves sitting in a pressure chamber and breathing in pure oxygen. Having more oxygen in your blood and body tissues is meant to support the healing process.

Treatment with antibiotics

If the is very severe, additional treatment with (e.g. tablets) might be considered. But won't be effective enough on their own. They are only used if there are good reasons for doing so.

Research suggests that treating severe with antibiotic tablets can help to prevent tooth loss in the long term if the patient also has deep cleaning treatment. Initial research also suggests that the reduce the in the gums. It's not clear whether locally applied help.

Open surgical procedures

In open surgery, the dentist makes small cuts in the gums where they are inflamed so that they can be pulled away from the teeth (flap surgery). This makes it easier for him or her to get to the root of the tooth and clean it thoroughly. Then the gums are sewn together so that they are once again snug against the teeth. A local anesthetic is needed for this procedure.

It usually takes about a week for the wound to heal. The stitches can then be removed. Sometimes the gums permanently recede somewhat after the operation, making the teeth look a bit "longer.” Part of the reason why this happens is because the inflammation and the swelling of the gums goes down.

Research hasn't shown that open surgical procedures are any more effective than "closed" deep cleaning. But more research is needed to be able to draw any reliable conclusions about the pros and cons of open surgery.

In Germany, statutory health insurances pay for an open surgical procedure to treat severe if "closed" deep cleaning and improved oral hygiene hasn't helped enough. The costs will only be covered if the gum pockets are at least 6 millimeters deep.

The procedure can be combined with treatments that you have to pay for yourself. For instance, it's possible to combine open surgery with one of the three treatments mentioned below. But there's either a lack of good studies on the effectiveness of these combinations, or the currently available research has found that they don't have any advantages compared to "closed" deep cleaning.

  • Osteoplasty: When causes bone damage, the bones sometimes have an uneven surface with crater-like pits on them. Osteoplasty is surgery to smooth this uneven surface.
  • Barrier membrane: During open surgery, the dentist can also place a special biodegradable membrane between the gums and the tooth. This is done to help bone tissue grow back. The membrane is also meant to prevent the gum tissue from attaching to the root of the tooth before the periodontium has recovered. This procedure is called guided tissue regeneration (GTR).
  • Enamel matrix proteins: These "growth proteins" are applied to the damaged bone with the aim of encouraging the bone tissue to grow again.

Follow-up care

In order for treatment to be able to work, good oral hygiene afterwards is essential. It can help to prevent the disease from coming back too. You can only stop from returning if you also take good care of your teeth and gums at home. This means brushing your teeth at least twice a day and cleaning the gaps between them with an interdental brush or dental floss.

Three to six months after having “closed” deep cleaning treatment, the dentist takes a close look at the teeth, gums and bone again to check whether the treatment has been successful. If the depth of the gum pockets hasn’t decreased enough, the dentist will clean the part of the teeth under the gum line again. In other words, the "closed" deep cleaning is repeated on the affected teeth. Open surgery is typically recommended if the gum pockets are 6 millimeters deep or more.

The structured follow-up treatment of is known as “supportive periodontal therapy.” It is done to check how successful the treatment has been and to help stop things from getting worse. It starts after three to six months and lasts two years. In Germany, the costs are covered by statutory health insurers. It is possible to apply for an extension – usually of up to six months. The frequency of appointments for supportive periodontal therapy will depend on how severe the is.

These appointments involve checking how good your oral hygiene is and whether your gums bleed easily. If needed, you will be shown how to maintain and improve good oral hygiene. The supportive periodontal therapy includes professional teeth-cleaning too. Here the dentist removes plaque and tartar that have re-formed above and below the gum line. He or she also checks whether you have deep gum pockets or any loose teeth. X-rays are taken to see whether there is any bone loss.

What can help you to cope with periodontitis?

Some people who have problems with their gums feel guilty about not doing enough for their oral hygiene or because they continue to smoke even though they know that it's bad for their teeth. They may be worried about losing teeth too.

An understanding dentist can help you and encourage you to stick to your goal of improving your oral hygiene. It is also helpful to stay well-informed and regularly talk with your dentist about how the treatment is going. That includes discussing what is working well and how you might be able to improve your oral hygiene.

Good oral hygiene is absolutely essential for managing after the treatment and for keeping the supportive tissues and bone healthy for as long as possible. Having to brush your teeth regularly, using the right technique, and remembering to use interdental brushes and dental floss can be bothersome and sometimes hard to stick to. Introducing daily dental care routines can help you keep it up. Many people say that they find it easier to maintain good oral hygiene when they see how it improves the health of their teeth and gums.

Deutsche Gesellschaft für Parodontologie (DG PARO), Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde (DGZMK). Adjuvante systemische Antibiotikagabe bei subgingivaler Instrumentierung im Rahmen der systematischen Parodontitistherapie (S3-Leitlinie). AWMF-Registernr.: 083-029. 2018.

Deutsche Gesellschaft für Parodontologie (DG PARO), Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde (DGZMK). Subgingivale Instrumentierung (S3-Leitlinie). AWMF-Registernr.: 083-030. 2019.

Gemeinsamer Bundesausschuss (G-BA). Richtlinie des Gemeinsamen Bundesausschusses für eine ausreichende, zweckmäßige und wirtschaftliche vertragszahnärztliche Versorgung (Behandlungsrichtlinie). March 1, 2006.

Gemeinsamer Bundesausschuss (G-BA). Richtlinie zur systematischen Behandlung von Parodontitis und anderer Parodontalerkrankungen (PAR-Richtlinie): Erstfassung. December 17, 2020.

Institute for Quality and Efficiency in Health Care (IQWiG, Germany). Assessment of the systematic treatment of parodontopathies; Commission N15-01. March 5, 2018. (IQWiG reports; Volume 602).

Karlsson E, Lymer UB, Hakeberg M. Periodontitis from the patient's perspective, a qualitative study. Int J Dent Hyg 2009; 7(1): 23-30.

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Stenman J, Hallberg U, Wennström JL, Abrahamsson KH. Patients' attitudes towards oral health and experiences of periodontal treatment: a qualitative interview study. Oral Health Prev Dent 2009; 7(4): 393-401.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Updated on September 6, 2021
Next planned update: 2024

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Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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