**6. Treatment**

Harvey and Emily (1993) described that the goal of periodontal treatment is to control microorganisms, restore normal anatomy and physiology and avoid new adhesion of bacterial plaque on tooth surfaces. Furthermore, periodontal pockets should be eliminated and re-adhesion of tissue to the tooth should be promoted, aiming, wherever possible, to do this by destroying the minimum of healthy tissue and keeping the gingiva.

The periodontal soft tissues quickly re-adhere to the cementum after the debridement, which removes the dead space of the pocket. However, this union could be weaker than the original depending on the type of tissue that repopulates the root surface; gingival epithelium, gingival connective tissue, alveolar bone and periodontal ligament; the latter being more desirable. When replacement by the alveolar bone occurs, the result is root resorption or ankylosis. Epithelium and gingival connective tissue are not desirable because they are extremely weak. Grafts or barrier materials can be used to delay or exclude the gingival tissue growth, favouring the growth of periodontal ligament growth (Wiggs & Lobprise, 1997).

According to Gioso (2007), treatment is based on the elimination of plaque or calculus, normal gingival depth restoration and monitoring through a preventive program. General anaesthesia is essential to perform the scraping and it is a procedure that can last around 2 to 3 hours in more advanced cases. The main treatment options for periodontal curettage are

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supragingival curettage, subgingival curettage, root planing, gingivectomy, gingivoplasty and gingival grafts.

Manfra-Marretta et al. (1992) highlighted the importance of subgingival curettage, where the plaques accumulated in the marginal gingiva that cause inflammation and affect the supporting structures of the tooth are removed. A curette to subgingival scrapping may be used. In some cases it is necessary to do a gingivectomy of periodontal pockets.

After removing all of the dental calculus, teeth must undergo a polishing with a rubber cup. It is not necessary to put a lot of pressure on the tooth and polishing should not exceed 15 seconds per tooth (Manfra-Marretta et al., 1992).

If there is severe bone loss, with roots exposure, an elevation of a gingival flap, complete curettage and displacement of the gingival margin closer to the apex of the tooth may be necessary, followed by fixating it with sutures. In the case of failure of this treatment, the extraction is the next step (Gioso, 2007).

Some surgical techniques are also indicated in the treatment of periodontal disease. According to Gioso (2007), when the periodontal pocket has more than 2 mm depth, partial gingivectomy is indicated, eliminating the pocket and re-forming the normal depth of the gingival sulcus (gingivoplasty). Another indication of the gingivectomy is gingival hyperplasia. In this surgery, excess gingiva is excised with a scalpel blade or electrocautery, which controls bleeding and is therefore preferred.

Another surgical technique described is the simple gingiva flap (or retail), which is indicated to obtain access to deeper periodontal structures through the creation of mucogingival flap. For its realisation an incision along the longitudinal axis of the root should be made, preserving the interdental papillae. Subsequently, the gingival flap should be completely translocated with the aid of a periosteum elevator and then root planing and repair of bone defects should be proceeded with. At the end of the procedure the flap should be sutured to its source with separate sutures (Wiggs & Lobprise, 1997).

The sliding flap can also be done in order to cover the root in cases of secondary exposure to gingival defect or periodontal disease. In order to do this an adjacent donor site must be identified and a flap at least 2.5 times wider than the defect to be covered must be created. The flap should contain full thickness of the epithelium and connective tissues. The periosteum should be maintained at the donor site, which will be left exposed. The proceeding finishes with the lateral slip of the flap and its suturing with simple interrupted technique, with stitches 1.5 mm apart, in its receptor place (Wiggs & Lobprise, 1997). This surgical technique is also indicated for closure of oronasal fistulas, which are abnormal communications between the oral and nasal cavities. In these cases it is very important to provide hermetic sealing of the suture without tension (Bolson & Pachaly, 2004).
