Periodontal (Gum) Surgery

Problems gum surgery may address

• Pockets that stay deep after deep cleaning. In periodontitis, the gum comes away from the tooth and pockets form. If some are still deep when your gums are measured again, surgery gives access to clean them.
• A bone defect beside the root. Where a deep pocket sits over a bone defect 3 mm or deeper beside the root (an intrabony defect), the guideline recommends regenerative surgery¹. It aims to help some of the lost support grow back.
• Disease between the roots of a back tooth (furcation involvement). Where pockets remain, the guideline says these back teeth should receive gum treatment, and that furcation involvement is no reason to take the tooth out¹.
• Receding gums. A graft can reduce how much root is exposed. Not every receded area needs one (see below).
• A narrow band of firm gum around a tooth. A graft can widen it, for example before a crown or orthodontic treatment. The evidence on how much firm gum a tooth needs is weak³.
• Too little tooth above the gum for a crown or filling. Crown lengthening removes some gum, and often some bone, so that more of the tooth shows. Changing the gum line for appearance is covered on the cosmetic gum contouring page.

When surgery is not the next step

• Before deep cleaning. Surgery for gum disease is considered only after the first two steps of treatment and a re-assessment. These are described on the deep cleaning and root planing page.
• When cleaning at home is not yet good enough. The guideline recommends not doing gum surgery in people who are not achieving and keeping up good enough cleaning at home¹. Your dentist judges this by checking how much plaque is left on your teeth.
• Moderately deep pockets. Some pockets of 4 to 5 mm may remain after deep cleaning and still bleed when probed. For these, the guideline suggests repeating the deep cleaning¹ rather than surgery.
• Receding gums without signs of disease. Receding gums are common in adults⁴. Where there are no signs of disease, monitoring the receded area⁴ is considered the appropriate approach. Exposed roots are often linked with concerns about appearance, sensitivity, and decay or wear near the gum line⁴. In some cases, surgery may be considered⁴. A graft aims to cover the exposed root, but it does not always cover it completely. Ask what else can be done first for sensitivity, decay or wear.

Tell your dentist before treatment

Tell your dentist before treatment if you take a blood thinner or any other regular medicine. Tell them too if you have diabetes or heart disease, smoke, or are pregnant. Bring a written list of your medicines. Include medicines for osteoporosis or cancer, even if you have stopped them or they are given as injections. Do not stop or change⁵ your blood thinner for dental treatment unless your doctor or dentist tells you to. The guideline says surgery needs its own consent, and your risk factors and any medical reasons against it should be considered¹. Your dentist judges whether any of these means that surgery should wait, or is not advised for you.

Whether you need gum surgery cannot be decided from photographs. It is decided from your gum measurements, often called a gum chart. The dentist measures the depth of the pocket around each tooth with a thin probe. They also record where the gums bleed, how loose the teeth are and how much support has been lost. X-rays show the bone. From these, the stage of the disease and your risk are established.

For surgery, the measurements that matter are the ones taken after deep cleaning. The gums first need time to heal; then they are measured again¹. This is the re-assessment (dentists also call it re-evaluation). The guideline sets two targets for the first two steps. No pocket deeper than 4 mm should bleed when probed, and no pocket should be 6 mm or deeper¹. Where these targets have not been reached, the third step is considered. For pockets of 6 mm or more that remain, the guideline suggests access flap surgery¹.

So if surgery is suggested to you, ask which teeth it is for, and which measurements it is based on. Ask when those measurements were taken: before deep cleaning, or at the re-assessment after it. Ask for copies of both sets of measurements. A dentist who sees you later can then compare them.

Surgery does not replace the earlier steps; it builds on them. Before surgery for gum disease, the guideline's first two steps are:

• Daily care and risk factors. You are shown how to brush and clean between your teeth in the way that suits you. Smoking and diabetes are discussed. Plaque and tartar above the gum line are cleaned off.
• Cleaning below the gum (deep cleaning). The pockets and the root surfaces are cleaned, usually under local anaesthetic. The details are on the deep cleaning and root planing page.

Once the gums have healed, they are measured again. Areas that have responded well go on to supportive care. For areas that still have pockets, cleaning them again is one option. Surgery is another, mainly for deeper pockets. One hospital in London tells its surgery patients that they will already have had their teeth cleaned and been taught how to clean them⁶. It says surgery is used for gum disease that still needs treatment after deep cleaning.

Your own cleaning matters too. The same hospital says the result depends on how well you brush your teeth in the future⁶. It also depends on how severe the disease was at the start. Smoking weakens⁷ the response to gum treatment; stopping can prevent further deterioration.

Which procedure is used depends on what the re-assessment shows. For the third step, the guideline lists repeated deep cleaning, access flap surgery, resective surgery and regenerative surgery¹. Gum grafts and crown lengthening are used for other problems.

• Access flap surgery (open flap debridement). The gum is lifted so that the root surfaces can be cleaned under direct view. It is then stitched back in place. The guideline found not enough evidence to recommend one flap design over another¹.
• Resective (pocket reduction) surgery. As well as the cleaning, the gum and sometimes the bone are reshaped. The pockets then become shallower and easier to clean. The guideline suggests it for deep pockets, while taking into account that the gum may recede more¹. The teeth can then look longer.
• Regenerative surgery. After cleaning, a material is placed to help lost bone and attachment grow back around the tooth. Attachment means the fibres that hold the tooth to the gum and the bone. The guideline recommends barrier membranes or a protein gel (enamel matrix derivative), with or without bone-derived grafts¹. Some regenerative materials are of pig or cow origin¹. Ask what will be used if this matters to you.
• Gum graft for receded gums (root coverage). The gum next to the exposed root is moved to cover it. This is often done with a small graft of connective tissue from the roof of your mouth. In a Cochrane review, this graft reduced recession more than a barrier membrane under the flap⁸, while the membrane gave more attachment gain⁸. The graft also gave a wider band of firm gum than a membrane or a protein gel⁸. The quality of this evidence was low or very low, and only one of the 48 trials was at low risk of bias. A collagen material of animal origin can be used instead of your own tissue. Three of four trials reported less pain after surgery⁹ with it, and the review's authors describe a shorter operation⁹. But complete root coverage was more frequent with your own tissue¹⁰ in trials of several receded teeth.
• Graft to widen the firm gum (free gingival graft). A thin piece of gum from the palate is placed where the band of firm gum is narrow. Your own tissue is still considered the established method³. Options that avoid taking tissue from the palate also exist. Patients treated with them appear to have reported less discomfort³. This evidence comes mainly from case reports and case series.
• Crown lengthening. Gum, and often some bone, is removed so that more of the tooth shows before a crown or filling. Ask how much would be removed, and how much support would remain for the tooth and its neighbours. Afterwards, the gum may grow back part of the way over the tooth (rebound), mostly in the first three months¹¹.
• Removing a tooth. When gum disease is severe, having teeth taken out might be a treatment option⁶. The gap can then be filled with a denture, a bridge or implants. Which teeth can be kept is decided after the examination and measurements.
• No further treatment. The gum disease could get worse, your teeth might become painful, and you might lose them sooner⁶.

For deep cleaning, the European guideline suggests not using lasers in addition to cleaning below the gum¹. That recommendation is about deep cleaning, not surgery. If a laser is suggested for your surgery, ask what it adds and what evidence supports it.

Gum surgery is usually done under local anaesthetic: injections numb the area and you stay awake. The hospital in London quoted above describes it like this. A cut is made around the edge of the gum, and the gum is lifted so the roots can be seen and cleaned⁶. A few stitches then hold it back in place. Sometimes the gum and bone are reshaped, or a material is placed to help support grow back. At a hospital in Cambridge, a gum graft procedure usually takes one hour¹². How long yours takes depends on the procedure and on how many teeth are treated.

If sedation is suggested, ask what kind it is and why. A 2022 Turkish regulation on private dental facilities covers where sedation may be given. Under it, treatment under sedation or general anaesthesia may not be carried out in a single-dentist practice (muayenehane) or a polyclinic (poliklinik)¹³. Your written plan names the place where any sedation is given; ask who will give it.

A UK national standard for sedation in dentistry sets an escort rule. For adults, it requires an escort for every form of sedation other than inhalation sedation¹⁴. If an escort cannot be assured, it says, treatment under sedation must not be given. The same standard expects advice on eating and drinking beforehand, given verbally and in writing¹⁴. It also expects written and spoken aftercare instructions for you and your escort, and arrangements for advice out of hours¹⁴. Ask us before the day whether the method planned for you needs an escort, and plan who will take you home. If you have sedation, do not drive or operate machinery for as long as the sedation team tells you. More is on the conscious sedation page.

You can say no, or ask to stop, at any stage. Turkey's patient rights regulation gives you the right to refuse treatment or ask for it to be stopped¹⁵; the possible consequences are explained to you. Once gum or bone has been reshaped, that step cannot be undone.

After-effects you may notice

The London hospital's information quoted above lists what patients may notice after gum surgery.

• The gums feel sore⁶, and painkillers may be needed for a few days.
• Some bleeding, and bruising or swelling of the gums or the face near the treated teeth. Swelling can take 2 to 3 days to appear and up to 2 weeks to go down completely⁶.
• Teeth that feel looser after the surgery; this is usually temporary.
• Teeth that are sensitive to hot, cold or sweet food and drink. For dentine sensitivity, toothpastes containing stannous fluoride or arginine are recommended among the first options¹⁶. This recommendation is based on studies of dentine sensitivity in general, not on gum surgery.
• Teeth that look longer, and larger spaces between them. As the gum heals and shrinks, more of the tooth shows. How much depends on how much the gum was reshaped⁶. One year after resective surgery, gum recession was greater than after an access flap¹.

Other risks and problems

• The Cambridge hospital's leaflet on gum grafts lists bleeding, infection, swelling, an uneven gum line and the need for further surgery¹² among the risks.
• In the trials of regenerative surgery the guideline reviewed, no serious adverse event was reported. The problems reported were local wound problems and the usual after-effects of surgery¹.
• The palate, if tissue is taken from it. Gum may be taken from the roof of the mouth and left to heal as an open wound. Pain there is most pronounced in the first three days¹⁷. A protective dressing or plate can reduce it, although results vary. The review notes that such an open wound can take up to four weeks to heal completely¹⁷.

We cannot say on this page how often each of these happens; the sources above give no rates.

Limits of what surgery can do

• Not every tooth reaches the target. The guideline notes that the aims of treatment may not be achievable in all teeth¹ in severe periodontitis.
• Lost bone largely does not come back. Damage caused by periodontitis is irreversible, but the disease can be stabilised¹⁸. Regenerative surgery aims to regain some support, and only in suitable defects.
• A graft does not always cover the whole root. Some studies followed single receded areas, with no loss of gum or bone between the teeth, for 5 years or more. With a flap and a connective tissue graft, they reported complete root coverage in 66.7 to 88.2 per cent¹⁹. With a flap alone, the figure was 33 to 60 per cent¹⁹, leaving out one flap-alone group with much poorer results. The studies were small and differed from each other, so their results were not pooled. Several of them counted treated teeth or sites, not patients. These figures come from published studies, not from our own records.
• The gum line can move again. After root coverage, the gum margin showed a tendency to recede again over time²⁰. Grafts shrink somewhat while they heal³, and the source gives no figure for how much. After crown lengthening, the gum can grow back part of the way over the tooth, mostly in the first three months.
• The disease can come back. After treatment for periodontitis, the risk of it coming back remains increased². See supportive care below.

Benefits

• Surgery gives access to deep pockets that deep cleaning did not bring under control. At one year, access flaps reduced pocket depth more than repeated deep cleaning, especially in pockets that were 6 mm or deeper¹ to start with. In the trials the guideline reviewed, there was no clear difference between the two in what patients themselves reported¹.
• In deep pockets over a bone defect, regenerative surgery gave shallower pockets and more attachment gain than flap surgery alone¹ in most studies.
• The London hospital quoted above says that reshaping the gum can make your teeth easier to keep clean⁶.

Follow the written instructions your dentist gives you, because they depend on the procedure. As an example of what to expect, this is how the hospital in London quoted above advises its patients after gum surgery.

• Brushing. Do not brush the area where you had surgery⁶; brush the rest of your mouth as usual. At the review, you are told when you can clean the area normally again.
• Mouthwash. A chlorhexidine mouthwash is used 2 or 3 times a day for 2 to 3 weeks⁶. After a gum graft, it is used for 2 to 4 weeks²¹. Chlorhexidine is advised for short-term use⁷, so use it only for as long as your dentist tells you. It can stain the teeth²²; in the trials, staining was measured after 4 to 6 weeks of use. Altered taste and irritation inside the mouth have also been reported. Ask your dentist when to use the mouthwash in relation to brushing. If you are allergic to chlorhexidine, ask your dentist about another mouthwash.
• Painkillers. The hospital advises starting painkillers such as paracetamol or ibuprofen before the local anaesthetic wears off⁶. Do not take more than the recommended dose. Ask your dentist or pharmacist which painkiller to use if you take a blood thinner or other regular medicines. Do the same if you have had problems with these painkillers before. Discomfort should start to feel better after a week⁶.
• Food and activity. Eat a soft diet for a week⁶, and chew on the other side. Avoid vigorous exercise for 24 hours⁶. After a gum graft, avoid activities that could knock your mouth or face for 2 to 4 weeks²¹.
• Swelling. On the day of surgery, a cold pack wrapped in a cloth can help. Do not put ice directly on your skin.
• Bleeding. You may notice some bleeding in the first two days. If bleeding does not stop, press firmly on the area with gauze or a clean cotton handkerchief for at least 30 minutes⁶.
• Antibiotics. Some people are given antibiotics⁶ after surgery to lower the risk of infection. If you are, take them exactly as prescribed, and tell your dentist about any allergy.
• Smoking. If you smoke, stop. If you cannot stop completely, the same hospital advises stopping for at least 2 weeks after the surgery⁶ to help the gums heal.
• Stitches and review. Stitches that do not dissolve are usually removed at a review appointment. This is 1 to 2 weeks after gum surgery⁶, or 2 to 4 weeks after a gum graft²¹. The hospital in Cambridge gives 7 to 21 days¹² for graft stitches. Ask which kind of stitches you will have, and when your review is.
• Healing plate. After a gum graft, you may be given a plastic plate that protects the area²¹.

Once the area has healed, clean between your teeth every day again. For people who have been treated for periodontitis, interdental brushes are recommended as the first choice¹. Floss is an option where the brush does not fit. After brushing, spit the toothpaste out and do not rinse²³ your mouth with water.

Surgery does not end the treatment. After treatment for periodontitis, the risk of the disease coming back remains increased², and it needs close monitoring. The European guideline recommends supportive care at intervals of at least 3 and at most 12 months¹, set according to your risk. The hospital in London says the routine its surgery patients follow is often decided about 3 months after surgery⁶.

Supportive care means regular check-ups, gum measurements and professional cleaning, with your own daily cleaning in between. A review looked at 33 studies of people who kept up professional gum care for at least 5 years after treatment. On average, 0.1 teeth per patient were lost each year, and most patients lost no teeth²⁴. Most of these studies looked back at records, and they include only people who kept coming to their appointments. These figures come from published studies, not from our own records, and they cannot predict what will happen to one person.

Agree with your dentist who will provide your supportive care, and at what interval. If you change dentist, take copies of your records with you, so that each check can be compared with the last.

After gum surgery, contact the dentist who treated you if you notice any of the following.

• Bleeding that does not stop after you have pressed firmly on the area⁶
• Pain that is not getting better, or is getting much worse, after 7 days⁶
• Pain or swelling that keeps getting worse, or a high temperature
• A rash or other side effects from antibiotics

Swelling that appears suddenly after dental treatment and crackles when touched should be checked without waiting²⁵. If you cannot reach your dentist straight away, go to a hospital emergency department.

Emergencies. The following need urgent medical help²⁶. Do not wait for a dental appointment or for the clinic's reply. Go to a hospital emergency department or call 112.

• Swelling that makes it hard to breathe, speak or swallow
• Swelling of the eye or the neck²⁷, a painful eye, or sudden problems with your eyesight
• A lot of swelling inside the mouth
• Finding it hard to open your mouth

If you have gum surgery at our clinic, it is carried out by one of our dentists. Turkish law authorises every dentist²⁸ to diagnose and treat the teeth, the gums and the tissues of the mouth and jaw. Periodontology, the branch of dentistry that deals with the gums, is one of the nine dental specialties set by law²⁸. The law ties the specialist title to a specialist certificate²⁸, issued and registered by the Ministry of Health²⁹.

The European guideline says gum surgery is effective but frequently complex. It recommends that surgery is provided by dentists with additional specific training, or by specialists in referral centres¹.

If you ask, you have the right to be told who is treating you, and their role and title¹⁵. Ask who will measure your gums, who will decide that surgery is needed, and who will carry it out. Ask what their titles are, where they qualified, and what training in gum surgery they have. Ask whether any of them holds a Ministry-registered specialist certificate in periodontology. Ask for the answers in writing. Before you decide, you can also ask for another dentist's opinion¹⁵.

Turkey's patient rights regulation says what you are told before treatment. It includes who will carry out the treatment, where and how, and how long it is expected to take¹⁵. It also includes the other options with their benefits and risks, the possible complications, and how to reach medical help when you need it¹⁵. Ask for your plan in writing as well. It should answer these questions:

1. Which teeth or areas need surgery, and which measurements is this based on? Were they taken after deep cleaning, once the gums had healed?
2. Which procedure is planned, and which graft or other material will be used?
3. Will the stitches dissolve? If not, when is the review?
4. How many appointments will the surgery take, and how much rest should you plan after each one?
5. Whom do you contact about the wound, and how? What do you do outside opening hours?
6. Who carries out the re-assessment after surgery and the supportive care, and at what interval?
7. If extra treatment turns out to be needed, how would the plan and the cost change?

In private dental clinics, you are asked to sign a consent form for every treatment¹³. The form is signed in two copies, and one copy is given to you¹⁵. Ask for your copy.

These clinics also record the diagnosis, the treatment and any X-rays in detail, including the tooth numbers¹³. You can look at your records and get a copy¹⁵. For gum surgery, ask for a record that shows:

• your gum measurements before and after deep cleaning, and later after surgery
• which teeth were treated, and with which procedure
• any graft or regenerative material used
• anything that still needs to be done, and by when

Ask for copies of any X-rays as well. A dentist who treats you later can then see what was done.

This page does not give prices. Your treatment plan is prepared for you after the examination. The main factors that shape the plan are:

• Whether deep cleaning and a re-assessment are still needed before any surgery
• Which procedure is planned, and for how many teeth or areas
• Whether a graft or a regenerative material is used
• Whether sedation is used
• X-rays, if needed
• The wound review and stitch removal
• The re-assessment after surgery and the supportive care

Ask for the plan in writing, showing what is included and which procedures will be assessed separately. Ask too how further treatment would be handled if there is a complication.