Updated Treatments for Gummy Smile: What Works Today

Excessive gingival display (EGD), commonly referred to as a gummy smile, is a multifactorial esthetic condition in which an excessive amount of maxillary gingiva is visible during smiling.

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Although gingival exposure of approximately 1–2 mm may be considered within an esthetically acceptable range, the clinical significance of EGD depends on facial proportions, lip dynamics, tooth dimensions, gingival architecture, and patient perception.

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Current management emphasizes etiologic diagnosis rather than a single universal treatment. Altered passive eruption, dentoalveolar extrusion, vertical maxillary excess, gingival enlargement, short or hypermobile upper lip, and combinations of these factors may coexist.
Therefore, treatment selection should be based on a comprehensive periodontal, dental, orthodontic, and facial assessment.

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✅ Diagnosis Before Treatment
A predictable treatment plan begins with identifying the principal source of gingival exposure. Clinical evaluation should include:

▪️ Gingival display during posed and maximum smile.
▪️ Upper lip length and mobility.
▪️ Maxillary incisor display at rest and during smiling.
▪️ Clinical crown dimensions and tooth proportions.
▪️ Periodontal probing and assessment of the cementoenamel junction.
▪️ Incisor inclination and vertical position.
▪️ Occlusal relationships and overbite.
▪️ Facial proportions and lower anterior facial height.
▪️ Cephalometric assessment when vertical maxillary excess is suspected.
This diagnostic process is particularly important because treating only one component of a multifactorial gummy smile may produce an incomplete or unstable esthetic result.

✅ Updated Treatment Options for Gummy Smile

Etiologic Factor	Preferred Treatment Approach	Main Clinical Objective
Altered passive eruption	Esthetic crown lengthening ± osseous recontouring	Increase clinical crown exposure
Dentoalveolar extrusion	Orthodontic intrusion, frequently with TAD-supported anchorage	Reposition the incisors apically
Hypermobile upper lip	Lip repositioning or botulinum toxin type A	Reduce excessive upper-lip elevation
Vertical maxillary excess	Orthognathic surgery	Correct the underlying skeletal discrepancy
Gingival enlargement	Periodontal therapy, gingivectomy, or appropriate surgical correction	Reduce excessive gingival tissue
Multifactorial EGD	Multidisciplinary treatment	Address dental, periodontal, skeletal, and muscular components

1. Esthetic Crown Lengthening
Esthetic crown lengthening is particularly appropriate when excessive gingival display results from altered passive eruption or excessive gingival coverage of otherwise adequately proportioned teeth.
The procedure may involve gingivectomy alone or, when necessary, apical repositioning with osseous recontouring to establish an appropriate supracrestal tissue relationship. The American Academy of Periodontology recognizes crown lengthening as an approach for exposing additional tooth structure when excessive gingival tissue makes the teeth appear short.
Importantly, crown lengthening should not be used to compensate for a skeletal or muscular etiology.

2. Orthodontic Intrusion
When EGD is associated with maxillary incisor or anterior dentoalveolar extrusion, orthodontic intrusion can reduce gingival exposure while preserving the periodontal architecture.
Temporary anchorage devices (TADs) have expanded the clinician's ability to achieve controlled anterior intrusion while minimizing unwanted posterior movement. Recent evidence suggests that TAD-supported mechanics can provide favorable intrusion outcomes, although the certainty of evidence remains limited and treatment protocols vary.
This approach is especially relevant when EGD is accompanied by deep overbite, excessive incisor display, or an unfavorable vertical incisor position.

3. Lip Repositioning
Lip repositioning surgery reduces the upward movement of the upper lip by limiting vestibular muscle excursion. It is most appropriate when upper-lip hypermobility is a major contributor and there is no major skeletal discrepancy requiring orthognathic correction.
A systematic review and meta-analysis reported an overall reduction in gingival display of approximately 3 mm at 6 months, with reductions remaining measurable at 12 and 36 months. Some modified techniques, particularly those incorporating periosteal suturing, demonstrated greater reductions.
However, patient selection remains important because recurrence or partial relapse can occur, particularly during the early postoperative period.

4. Botulinum Toxin Type A
Botulinum toxin type A (BTX-A) is a minimally invasive option for patients whose EGD is predominantly associated with hyperactivity of the upper-lip elevator muscles.
Systematic reviews and meta-analyses demonstrate a clinically relevant short-term reduction in gingival exposure. One meta-analysis reported an average reduction of approximately 3.4 mm at two weeks, with the effect progressively diminishing and tending to approach baseline by approximately 24 weeks.
Consequently, BTX-A should be regarded as a temporary treatment, rather than a definitive correction of skeletal or dental abnormalities. It can be particularly useful when the patient prefers a minimally invasive approach or when muscle hyperactivity is the dominant etiologic factor.

5. Orthognathic Surgery
When vertical maxillary excess is the principal cause of excessive gingival display, Le Fort I maxillary impaction or another appropriately planned orthognathic procedure may provide the most comprehensive correction.
Unlike treatments directed primarily at gingival tissue or lip dynamics, orthognathic surgery addresses the underlying skeletal discrepancy. Current evidence supports its role particularly in patients with significant vertical maxillary excess, although treatment involves substantially greater morbidity and requires multidisciplinary planning.

6. Multidisciplinary and Combined Treatment
Many patients do not have a single etiologic factor. For example, altered passive eruption may coexist with incisor extrusion and upper-lip hypermobility.
In such cases, combined treatment may provide a more predictable result than attempting to correct all gingival exposure through one procedure. Periodontal surgery, orthodontic intrusion, lip repositioning, BTX-A, or orthognathic surgery should therefore be considered according to the dominant etiologic components rather than simply the amount of gingiva displayed.

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✅ Clinical Decision-Making
A practical treatment sequence is:
Diagnosis → Etiologic classification → Severity assessment → Identify dominant factor → Select the least invasive effective treatment → Evaluate residual EGD → Consider combined therapy when indicated.
The objective should not simply be to eliminate every millimeter of visible gingiva. Facial harmony, tooth–lip relationships, periodontal health, and patient expectations should determine the final treatment target.

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💬 Discussion
The contemporary management of gummy smile has shifted from procedure-driven correction toward etiology-driven treatment planning. The available evidence supports several effective interventions, but their indications differ substantially.
Crown lengthening is highly appropriate for altered passive eruption, whereas orthodontic intrusion addresses an unfavorable dentoalveolar position. Lip repositioning and BTX-A primarily target excessive lip elevation, while orthognathic surgery is indicated when the underlying problem is skeletal.
The evidence is strongest for the principle that accurate diagnosis is fundamental, while comparative evidence between many treatment modalities remains limited. Recent systematic reviews also emphasize heterogeneity in patient selection, treatment protocols, outcome measurements, and follow-up periods.
Therefore, treatment should be individualized rather than based exclusively on a numerical gingival-display threshold.

🎯 Clinical Recommendations
1. Determine the etiology before selecting the procedure.
2. Use esthetic crown lengthening when altered passive eruption is the primary cause.
3. Consider TAD-assisted orthodontic intrusion when excessive incisor vertical position contributes to EGD.
4. Reserve lip repositioning primarily for patients with clinically significant upper-lip hypermobility.
5. Consider BTX-A when muscle hyperactivity predominates and a temporary, minimally invasive correction is acceptable.
6. Evaluate orthognathic surgery when vertical maxillary excess is clinically significant.
7. In multifactorial cases, consider sequential or combined interdisciplinary treatment rather than overcorrecting a single component.

✍️ Conclusion
Updated gummy smile treatment is increasingly based on individualized etiologic diagnosis rather than a single corrective technique. Crown lengthening, orthodontic intrusion, lip repositioning, botulinum toxin, and orthognathic surgery each have specific indications and limitations.
The most predictable results are achieved when clinicians identify the relative contribution of the periodontal, dental, skeletal, and muscular components before treatment. For complex cases, interdisciplinary planning remains essential to achieve stable and proportionate smile esthetics.

📚 References

✔ Ahmad Amro, L., et al. (2026). Prevalence of different etiologies of excessive gingival display: Identifying diagnostic patterns. The Scientific World Journal.
✔ AlMaghlouth, B., AlMubarak, A., Almaghlouth, I., AlKhalifah, R., Alsadah, A., & Hassan, A. (2021). Orthodontic intrusion using temporary anchorage devices compared to other orthodontic intrusion methods: A systematic review. Clinical, Cosmetic and Investigational Dentistry, 13, 11–19. https://doi.org/10.2147/CCIDE.S283102
✔ Dym, H., & Pierre, R. (2020). Diagnosis and treatment approaches to a “gummy smile.” Dental Clinics of North America, 64(2), 341–349. https://doi.org/10.1016/j.cden.2019.12.003
✔ Mendoza-Geng, A., Gonzales-Medina, K., Meza-Mauricio, J., Muniz, F. W. M. G., & Vergara-Buenaventura, A. (2022). Clinical efficacy of lip repositioning technique and its modifications for the treatment of gummy smile: Systematic review and meta-analysis. Clinical Oral Investigations, 26(6), 4243–4261. https://doi.org/10.1007/s00784-022-04467-0
✔ Pavone, A. F., Ghassemian, M., & Verardi, S. (2016). Gummy smile and short tooth syndrome—Part 1: Etiopathogenesis, classification, and diagnostic guidelines. Compendium of Continuing Education in Dentistry, 37(2), 102–107.
Silberberg, N., Goldstein, M., & Smidt, A. (2009). Excessive gingival display—Etiology, diagnosis, and treatment modalities. Quintessence International, 40(10), 809–818.
✔ Tomaz, A. F. G., et al. (2020). Impact of orthognathic surgery on the treatment of gummy smile: An integrative review. Oral and Maxillofacial Surgery.
✔ Vilarinho, D. F., et al. (2023). Contemporary treatment techniques for excessive gingival display caused by altered passive eruption or lip hypermobility. Journal of Esthetic and Restorative Dentistry.

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Dexamethasone Use in Periodontal Surgery: Pros & Cons

Dexamethasone use in periodontal surgery has been investigated as a perioperative strategy to reduce the inflammatory response associated with surgical manipulation of periodontal tissues.

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Because postoperative pain and edema can affect comfort, mastication, and recovery, corticosteroids may provide an adjunctive benefit when appropriately selected.

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Current evidence suggests that perioperative dexamethasone can reduce postoperative pain and swelling, particularly during the first several days after periodontal flap surgery.
However, its benefits should be balanced against patient-specific contraindications, potential adverse effects, and the limited number of high-quality periodontal studies.

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✅ How Dexamethasone Works in Periodontal Surgery
Dexamethasone is a potent glucocorticoid with anti-inflammatory activity. It suppresses multiple inflammatory pathways, including the production of prostaglandins and other mediators involved in vascular permeability, tissue edema, and postoperative pain.
In periodontal surgery, this mechanism may attenuate the acute inflammatory response produced by flap elevation, tissue manipulation, and surgical trauma.
Importantly, dexamethasone is an adjunct to surgical and analgesic management, not a substitute for atraumatic surgical technique or appropriate postoperative analgesia.

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✅ Benefits of Dexamethasone in Periodontal Surgery

1. Reduction of postoperative pain
Randomized clinical trials have demonstrated a reduction in postoperative pain following periodontal flap surgery when dexamethasone is administered perioperatively.
A randomized trial involving 60 patients undergoing open-flap debridement found that an 8-mg preoperative dose of dexamethasone provided greater pain control and reduced the need for rescue acetaminophen compared with placebo.
More recently, a randomized crossover trial found that 8 mg of intravenous dexamethasone administered before periodontal flap surgery significantly reduced pain during the first 72 hours compared with placebo.

2. Reduction of postoperative swelling
The anti-inflammatory effect of dexamethasone may also reduce postoperative edema.
In the 2022 randomized trial, intravenous dexamethasone was associated with significantly less swelling during several postoperative assessment periods, including the early postoperative phase.
A 2024 randomized clinical study also reported less swelling on the first postoperative day after submucosal administration of 8 mg dexamethasone during periodontal flap surgery.

3. Potential improvement in early postoperative function
Reduction of inflammatory edema may facilitate early oral function. The 2024 submucosal study reported improved chewing efficiency and less reduction in mouth opening during the early postoperative period. However, these findings should be interpreted cautiously because the study included only 25 patients.

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✅ Routes and Timing of Administration
Dexamethasone has been studied through several administration routes, including oral, intravenous, and submucosal administration.

Approach	Evidence in Periodontal Surgery	Main Consideration
Preoperative oral	Evidence of reduced postoperative pain	Convenient; evidence remains limited
Intravenous	Reduced pain and swelling in randomized clinical trials	Useful when IV access is already established
Submucosal	Recent evidence suggests reduced pain and swelling	Avoids the need for IV access
Repeated postoperative dosing	Less consistently studied	Greater exposure is not necessarily associated with greater benefit

Factor	Clinical implication
Timing	Preoperative or perioperative administration is the approach most consistently investigated.
Dose	Studies have commonly evaluated single doses of 4–8 mg, but no universally established periodontal surgery regimen exists.
Route	IV and submucosal administration have demonstrated clinical effects; the optimal route remains uncertain.

The evidence should therefore not be interpreted as establishing 8 mg as a universal standard dose. The 8-mg regimen has been studied in clinical trials, but patient characteristics, surgical extent, route of administration, and local prescribing regulations must be considered.

✅ Limitations and Safety Considerations

1. Evidence remains limited
A 2024 systematic review identified only six randomized clinical trials involving 250 participants evaluating preemptive steroidal and nonsteroidal analgesia in periodontal surgery. The authors noted substantial methodological limitations, including risk of bias and heterogeneity in drugs and doses.
Consequently, dexamethasone should be regarded as a selective adjunct rather than routine therapy for every periodontal surgical procedure.

2. Hyperglycemia
Systemic corticosteroids can transiently increase blood glucose concentrations. This is particularly relevant in patients with diabetes or impaired glucose regulation.
Patient-specific risk assessment is therefore important before administration, especially when systemic corticosteroids are being considered.

3. Infection considerations
Corticosteroids suppress immune responses and can potentially exacerbate or mask infection. Current prescribing information warns that corticosteroids may reduce resistance to infection and obscure clinical signs of infection.
This does not mean that a single perioperative dose inevitably causes infection. Indeed, a large Cochrane review of perioperative dexamethasone in surgical patients found no evidence of increased postoperative wound infection with a single perioperative steroid exposure.
Nevertheless, dexamethasone should not be used to mask an inadequately controlled infection or as a substitute for appropriate antimicrobial or surgical management.

4. Not a replacement for conventional analgesia
Dexamethasone primarily modifies the inflammatory component of postoperative morbidity. It should not automatically replace evidence-based analgesic therapy.
Current dental pain guidelines support NSAIDs, alone or combined with acetaminophen, as first-line pharmacologic therapy for acute dental pain when not contraindicated.

5. Limited evidence regarding long-term periodontal outcomes
Most studies evaluate short-term outcomes such as pain, swelling, trismus, and analgesic consumption. There is insufficient evidence to conclude that perioperative dexamethasone improves long-term periodontal healing, attachment gain, or regenerative outcomes.

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💬 Discussion
The current evidence supports a potential role for perioperative dexamethasone as an adjunct in periodontal surgery, particularly when postoperative inflammation is expected to be clinically significant.
The strongest periodontal evidence concerns reduction of early postoperative pain and swelling. Both intravenous and submucosal administration have demonstrated beneficial effects in randomized trials, while a recent systematic review supports the potential effectiveness of preemptive dexamethasone for postoperative pain.
However, the evidence base remains relatively small and heterogeneous. The 2024 systematic review specifically highlighted methodological limitations and the need for additional well-designed randomized trials.
Therefore, the clinical decision should be individualized rather than protocol-driven. Dexamethasone may be particularly reasonable when substantial postoperative inflammation is anticipated, while routine administration for uncomplicated periodontal procedures offers less clearly established incremental benefit.

✍️ Conclusion
Dexamethasone can reduce postoperative pain and swelling following periodontal surgery, with evidence supporting both systemic and local administration. Its anti-inflammatory effect makes it a potentially useful perioperative adjunct, particularly for procedures associated with greater tissue trauma.
Nevertheless, dexamethasone is not universally indicated. The relatively limited periodontal evidence, potential systemic effects, glucose elevation, infection-related considerations, and absence of demonstrated long-term periodontal benefits support a selective, patient-centered approach.
The most appropriate use is therefore as an adjunct to atraumatic surgical technique and evidence-based analgesia, rather than as routine medication for all periodontal surgical patients.

🎯 Clinical Recommendations
▪️ Consider perioperative dexamethasone selectively when postoperative pain or edema is expected to be clinically significant.
▪️ Do not interpret the commonly studied 8-mg dose as a universal periodontal protocol; dosing should be individualized according to the clinical situation and route of administration.
▪️ Consider submucosal administration when an IV route is unnecessary; current evidence suggests it can provide postoperative benefits without clear superiority of IV administration for pain or analgesic consumption.
▪️ Evaluate diabetes, infection, immunosuppression, corticosteroid exposure, and other relevant medical conditions before prescribing.
▪️ Maintain conventional evidence-based analgesia; dexamethasone should generally be considered an adjunct rather than a replacement for NSAID-based analgesic strategies when these are appropriate.
▪️ Avoid routine corticosteroid use when the expected inflammatory burden is low and the potential benefit is unlikely to justify systemic exposure.
▪️ Explain to patients that the principal expected benefit is short-term reduction of postoperative inflammatory symptoms, not improvement of long-term periodontal healing.

📚 References

✔ Altindal, D., Alsafadi, A., Alshujaa, B., Talmac, A. C., Ege, B., Calisir, M., & Alpaslan, N. Z. (2024). Effect of submucosal dexamethasone on postoperative pain, swelling and trismus after periodontal surgery: A randomized clinical study. Clinical Oral Investigations, 28(12), 681. https://doi.org/10.1007/s00784-024-06076-5
✔ Carrasco-Labra, A., Polk, D. E., Urquhart, O., Aghaloo, T., Claytor, J. W., Jr., Dhar, V., Dionne, R. A., Espinoza, L., Gordon, S. M., Hersh, E. V., Law, A. S., Li, B. S.-K., Schwartz, P. J., Suda, K. J., Turturro, M. A., Wright, M. L., Dawson, T., Miroshnychenko, A., Pahlke, S., Pilcher, L., Shirey, M., Tampi, M., & Moore, P. A. (2024). Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults. Journal of the American Dental Association, 155(2), 102–117.e9. https://doi.org/10.1016/j.adaj.2023.10.009
✔ Lages, L. P. de D., Bergamaschi, C. de C., Lopes, L. C., da Frota, E. G., Silva, M. T., Monte, T. L., & Motta, R. H. L. (2024). Preemptive oral analgesia with steroidal and nonsteroidal anti-inflammatory drugs in periodontal surgery: A systematic review. Frontiers in Pharmacology, 15, 1385401. https://doi.org/10.3389/fphar.2024.1385401
✔ Vieth, M. P., Deas, D. E., Palaiologou, A. A., Diogenes, A., Mader, M. J., & Mealey, B. L. (2022). Effect of intravenous dexamethasone on postoperative pain and swelling following periodontal flap surgery: A randomized controlled trial of patient-centered outcomes. Journal of Periodontology, 93(2), 237–245. https://doi.org/10.1002/JPER.21-0153
✔ Wagner, J. C., Johnson, T. M., & Gilbert, W. A. (2022). Should periodontists prescribe postoperative oral corticosteroids to control pain and swelling? A systematic review. Clinical Advances in Periodontics, 12(2), 134–142. https://doi.org/10.1002/cap.10169
✔ Sauerland, S., Nagelschmidt, M., Mallmann, P., & Neugebauer, E. A. M. (2019). Adverse side-effects of dexamethasone in surgical patients—An abridged Cochrane systematic review. Anaesthesia, 74(8), 1013–1020. https://doi.org/10.1111/anae.14610
✔ Green, V. G., Polk, D. E., Turturro, M. A., Moore, P. A., & Carrasco-Labra, A. (2025). Evidence-based clinical practice guidelines for the management of acute dental pain. American Journal of Emergency Medicine, 89, 247–253. https://doi.org/10.1016/j.ajem.2024.12.054

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What Is Peri-Implantitis? How Does It Affect Dental Implants?

Peri-implantitis is an inflammatory disease that affects the tissues surrounding a dental implant. Unlike peri-implant mucositis, which is limited to inflammation of the soft tissues, peri-implantitis is associated with progressive loss of the bone supporting the implant.

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The condition is mainly associated with the accumulation of dental plaque and bacterial biofilm, although several patient-, implant-, and prosthesis-related factors can increase the risk. If left untreated, peri-implantitis may progressively compromise implant stability and, in advanced cases, lead to implant failure.

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✅ What Is Peri-Implantitis?
Peri-implantitis is a plaque-associated inflammatory disease characterized by inflammation of the tissues around a dental implant and progressive loss of supporting bone.
It should be distinguished from peri-implant mucositis:

Condition	Main feature	Bone loss
Peri-implant health	No clinical signs of inflammation	No progressive bone loss
Peri-implant mucositis	Inflammation and bleeding around the implant	No progressive bone loss
Peri-implantitis	Inflammation with bleeding and/or suppuration	Progressive supporting bone loss

The distinction is clinically important because peri-implant mucositis can often be controlled before bone destruction occurs, whereas peri-implantitis requires assessment of both the soft tissues and the supporting bone.

✅ How Does Peri-Implantitis Develop?
The process usually begins with the accumulation of bacterial biofilm around the implant. This can trigger inflammation in the surrounding soft tissues.
If the inflammatory process persists, it may extend deeper and contribute to loss of the bone supporting the implant.
However, plaque is not the only consideration. Current evidence indicates that peri-implantitis results from the interaction of biofilm, patient susceptibility, implant characteristics, and local conditions.
Important Risk Factors
Recent AO/AAP evidence identifies several factors that may increase the risk of peri-implant diseases:
▪️ Previous periodontitis
▪️ Smoking
▪️ Poor plaque control
▪️ Uncontrolled diabetes
▪️ Obesity
▪️ Poorly positioned implants
▪️ Prosthetic factors that make cleaning difficult
▪️ Certain unfavorable peri-implant soft-tissue conditions
Among these, a history of periodontitis and cigarette smoking have particularly strong evidence as risk factors for peri-implantitis.

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✅ Signs and Symptoms of Peri-Implantitis
Peri-implantitis may not always cause pain, so patients can have disease progression without obvious symptoms.
Possible warning signs include:
▪️ Bleeding when brushing or during professional probing
▪️ Redness or swelling around the implant
▪️ Suppuration or pus
▪️ Increasing probing depth
▪️ Gum recession around the implant
▪️ Unpleasant taste or odor in some cases
▪️ Progressive radiographic bone loss
▪️ Mobility of the implant in advanced cases
A particularly important point is that implant mobility is generally a late finding. An implant that becomes mobile may already have experienced substantial loss of supporting bone.

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✅ How Is Peri-Implantitis Diagnosed?
Diagnosis requires more than simply observing redness around an implant.
The clinician evaluates the peri-implant tissues through:
1. Clinical examination
2. Gentle periodontal probing
3. Assessment of bleeding and/or suppuration
4. Comparison of probing depths with previous records
5. Radiographic evaluation of bone levels
6. Evaluation of prosthetic and implant-related factors
Whenever possible, baseline probing and radiographic measurements should be recorded after completion of the implant-supported restoration. These measurements make future changes easier to identify.
When previous records are unavailable, the 2017 classification proposed the combination of bleeding and/or suppuration, probing depths of ≥6 mm, and bone levels ≥3 mm apical to the most coronal portion of the intraosseous implant as criteria consistent with peri-implantitis.
These numerical criteria should not, however, replace clinical judgment and comparison with previous examinations.

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✅ How Does Peri-Implantitis Affect a Dental Implant?
The main concern is progressive loss of the bone that supports the implant.
As bone is lost, the implant may become increasingly exposed and its long-term stability can be compromised. Advanced disease may also create deeper areas that are more difficult for the patient to clean, potentially sustaining the inflammatory process.
The clinical consequence can therefore be summarized as:
Biofilm accumulation → inflammation → progressive bone loss → reduced implant support → possible implant failure.
Importantly, peri-implantitis does not automatically mean that an implant must be removed. Treatment depends on disease severity, bone defects, implant position, prosthetic design, patient risk factors, and the response to treatment. Current consensus recommendations emphasize individualized management rather than a single treatment protocol for every case.

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✅ How Is Peri-Implantitis Treated?
Treatment aims to control inflammation, reduce bacterial contamination, manage contributing risk factors, and preserve or restore peri-implant tissues when possible.

1. Non-Surgical Management
Initial treatment may include:
Professional mechanical debridement
Improvement of the patient's oral hygiene
Management of modifiable risk factors
Correction of local factors that interfere with plaque control
A personalized supportive maintenance program
For some patients, nonsurgical therapy can reduce inflammation, but established peri-implantitis may require additional treatment when inflammation and bone loss persist.

2. Surgical Management
More advanced cases may require surgical treatment to obtain access to the affected implant surface and manage the bone defect.
Depending on the defect and clinical situation, treatment may involve:
▪️ Access-flap surgery
▪️ Resective procedures
▪️ Regenerative procedures
▪️ Soft-tissue augmentation when indicated
▪️ Implant removal in selected cases where the implant cannot be predictably maintained
The 2025 AO/AAP consensus emphasizes that treatment should be individualized according to disease severity and patient- and site-specific factors, followed by supportive peri-implant maintenance.

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💬 Discussion
Peri-implantitis is one of the most important biological complications associated with long-term implant therapy. Current evidence supports viewing it as a multifactorial inflammatory disease, rather than simply an infection caused by poor oral hygiene.
Its clinical importance lies in the potential for progressive bone destruction around an otherwise functional implant. Prevention and early detection are therefore essential.
Recent AO/AAP evidence estimated patient-level prevalence of peri-implantitis at approximately 21%, although prevalence varies substantially according to diagnostic criteria, study populations, and follow-up periods.
The most important practical message is that implant therapy does not end when the prosthesis is delivered. Long-term maintenance, plaque control, management of risk factors, and periodic clinical and radiographic monitoring are essential components of implant care.

✍️ Conclusion
Peri-implantitis is a plaque-associated inflammatory disease that causes progressive loss of bone around a dental implant. It differs from peri-implant mucositis because bone destruction is a defining feature.
Although peri-implantitis can threaten the long-term stability of an implant, early diagnosis and appropriate management can help control disease progression. Patients with a history of periodontitis, smokers, and individuals with inadequate plaque control or other risk factors require particular attention.
Successful implant therapy therefore depends not only on implant placement and restoration, but also on lifelong peri-implant maintenance and risk-factor management.

🎯 Clinical Recommendations
▪️ Establish baseline probing and radiographic records after implant restoration whenever possible.
▪️ Do not wait for pain or implant mobility before investigating suspicious peri-implant changes.
▪️ Bleeding on probing should be taken seriously, particularly when it is persistent or accompanied by increasing probing depths.
▪️ Identify and manage modifiable risk factors, especially smoking, poor plaque control, and uncontrolled diabetes.
▪️ Assess whether the prosthesis or implant position makes effective plaque removal difficult.
▪️ Treat peri-implant mucositis early to reduce the risk of progression.
▪️ For established peri-implantitis, use a severity- and defect-specific treatment plan and maintain the patient in supportive peri-implant care.

📚 References

✔ Berglundh, T., Armitage, G., Araujo, M. G., Avila-Ortiz, G., Blanco, J., Camargo, P. M., Chen, S., Cochran, D., Derks, J., Figuero, E., Hämmerle, C. H. F., Heitz-Mayfield, L. J. A., Huynh-Ba, G., Iacono, V., Koo, K.-T., Lambert, F., McCauley, L., Quirynen, M., Renvert, S., Salvi, G. E., Schwarz, F., Tarnow, D., Tomasi, C., Wang, H.-L., & Zitzmann, N. (2018). Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. Journal of Periodontology, 89(Suppl. 1), S313–S318. https://doi.org/10.1002/JPER.17-0739
✔ Fiorellini, J. P., Mojaver, S., Sarmiento, H., & Aghaloo, T. (2025). Clinical translation of the 2024 AO/AAP consensus on prevention and management of peri-implant diseases and conditions. The International Journal of Periodontics & Restorative Dentistry, 45(4), 1–30. https://doi.org/10.11607/prd.7658
✔ Galarraga-Vinueza, M. E., Pagni, S., Finkelman, M., Schoenbaum, T., & Chambrone, L. (2025). Prevalence, incidence, systemic, behavioral, and patient-related risk factors and indicators for peri-implant diseases: An AO/AAP systematic review and meta-analysis. Journal of Periodontology, 96(6), 587–633. https://doi.org/10.1002/JPER.24-0154
✔ Renvert, S., Persson, G. R., Pirih, F. Q., & Camargo, P. M. (2018). Peri-implant health, peri-implant mucositis, and peri-implantitis: Case definitions and diagnostic considerations. Journal of Periodontology, 89(Suppl. 1), S304–S312. https://doi.org/10.1002/JPER.17-0588
✔ Wang, H.-L., Avila-Ortiz, G., Monje, A., Kumar, P., Calatrava, J., Aghaloo, T., Barootchi, S., Fiorellini, J. P., Galarraga-Vinueza, M. E., Kan, J., Lin, G.-H., Ravida, A., Saleh, M. H. A., Tavelli, L., & Rosen, P. S. (2025). AO/AAP consensus on prevention and management of peri-implant diseases and conditions: Summary report. Journal of Periodontology, 96(6), 519–541. https://doi.org/10.1002/JPER.25-0270

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Archwire Sequence for Periodontally Compromised Patients

Orthodontic treatment in periodontally compromised patients requires a different biomechanical approach from conventional orthodontic treatment.

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Reduced alveolar bone support alters the center of resistance, increases the susceptibility to unwanted tooth movement, and reduces the periodontal reserve available to tolerate excessive orthodontic forces.

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Current evidence supports orthodontic treatment in patients with a stable, treated periodontium, provided that forces are light and controlled and periodontal health is continuously monitored. However, there is no evidence-based universal archwire sequence specifically validated for periodontally compromised patients.
The sequence should therefore be individualized according to periodontal support, tooth mobility, movement objectives, anchorage requirements, and the characteristics of the orthodontic appliance.

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🔹 Why the Archwire Sequence Must Be Modified
In a reduced periodontium, the periodontal ligament may remain healthy despite substantial loss of alveolar bone. Nevertheless, the center of resistance moves apically, changing the moment-to-force relationship during tooth movement.

Consequently, conventional archwire progression may generate unnecessarily high forces or uncontrolled tipping. The principal objectives should be:
▪️ Low and controlled force delivery
▪️ Progressive alignment without excessive activation
▪️ Maintenance of periodontal stability
▪️ Adequate control of the center of resistance
▪️ Minimization of unwanted tipping and extrusion
▪️ Controlled anchorage management
A systematic review found that orthodontic treatment can be performed successfully in periodontally compromised patients when minimal, controlled forces are applied under non-inflammatory conditions, although the available evidence remains limited and heterogeneous.

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🔹 Recommended Archwire Sequence
Rather than prescribing a rigid sequence, the following progression provides a practical framework for a 0.022-inch fixed appliance. Wire dimensions should be adapted to the bracket slot, treatment objectives, and periodontal support.

Stage	Suggested Archwire	Primary Objective	Periodontal Consideration
1. Initial alignment	0.012–0.014 in NiTi	Gentle alignment	Use low-deflection, low-force mechanics; avoid forcing severely displaced teeth into the arch.
2. Early leveling	0.014–0.016 in NiTi	Continue alignment and leveling	Progress only when periodontal parameters and tooth mobility remain acceptable.
3. Working/control phase	0.016 × 0.022 or 0.017 × 0.025 in NiTi/TMA	Three-dimensional control	Use only when sufficient alignment has been achieved and rectangular engagement is biomechanically justified.
4. Space closure / major tooth movement	Rectangular stainless steel, when required	Torque and root-position control	Use controlled mechanics and carefully monitor force systems, anchorage, and mobility.
5. Finishing	Rectangular SS or TMA, case dependent	Final root and occlusal control	Avoid unnecessary torque or excessive compensatory bends in teeth with limited periodontal support.

This sequence is a clinical framework rather than a standardized evidence-based protocol. Published clinical cases in severely reduced periodontium have used gradual NiTi progression followed by rectangular wires, but the available literature does not establish one archwire sequence as superior to another.

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🔹 The Most Important Biomechanical Principle: Force, Not Wire Size
The critical variable is not simply whether a clinician progresses from 0.014 to 0.016 to a rectangular wire. It is how much force and moment the wire delivers to a tooth with reduced periodontal support.
A larger or stiffer archwire can increase control but may also increase the force system when significant deflection or activation is present. Therefore, advancing to a larger rectangular wire should be based on the patient's biological response rather than on a predetermined calendar.
Light continuous forces, small activations, and adequate intervals for tissue response are preferable to aggressive wire progression. Published clinical reports of severely reduced periodontal support have successfully used gradual archwire progression with careful force verification.

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🔹 When to Slow or Modify the Sequence
The standard progression should be reconsidered when there is:

▪️ Increasing tooth mobility
▪️ Recurrent periodontal inflammation
▪️ Persistent bleeding on probing
▪️ Deep residual periodontal pockets
▪️ Progressive gingival recession
▪️ Radiographic evidence of unfavorable periodontal changes
▪️ Excessive tipping during alignment
▪️ Poor plaque control
In stage IV periodontitis, the EFP guideline recommends initiating orthodontic treatment after periodontal treatment endpoints have been achieved. During orthodontic therapy, periodontal evaluation should ideally occur at orthodontic appointments, and active tooth movement should be interrupted if periodontitis recurs.

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🔹 Periodontal and Orthodontic Treatment Must Be Integrated
The archwire sequence cannot compensate for uncontrolled periodontal disease. Active periodontal inflammation should be controlled before orthodontic tooth movement begins.
For patients with severe periodontitis and pathological tooth migration, periodontal–orthodontic treatment has been associated with improvements in clinical attachment level, probing depth, and marginal bone level. However, the certainty of evidence remains limited, and outcomes depend heavily on patient selection and interdisciplinary management.
For patients with stage IV periodontitis, the EFP specifically recommends orthodontic treatment as part of a multidisciplinary approach after periodontal therapy has achieved stability. Lifelong supportive periodontal care and individualized orthodontic retention are recommended after active treatment.

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💬 Discussion
The concept of a “best archwire sequence” in periodontally compromised patients should therefore be interpreted differently from conventional orthodontics. Current evidence does not support a single standardized sequence based exclusively on wire dimensions.
A practical approach is to begin with small, flexible NiTi wires, progress gradually to rectangular NiTi or TMA when three-dimensional control becomes necessary, and reserve rectangular stainless steel for situations requiring greater rigidity and control. The exact transition point should be determined by the periodontal phenotype, residual bone support, tooth mobility, desired movement, and anchorage requirements.
Importantly, some patients may benefit from sectional mechanics, splinting, skeletal anchorage, or shortened active mechanics rather than complete engagement of progressively larger continuous archwires. This is particularly relevant when individual teeth have markedly reduced periodontal support.
The evidence indicates that orthodontics itself does not necessarily worsen periodontal status when performed in a stable, non-inflammatory periodontium with controlled forces, but the quality of evidence remains insufficient to justify a universal biomechanical protocol.

🎯 Clinical Recommendations
1. Do not use a rigid archwire sequence solely because it is standard for conventional patients.
2. Start with the lightest wire capable of producing the intended movement.
3. Progress from round NiTi toward rectangular wires only when additional control is clinically required.
4. Measure and control force systems, particularly during space closure, intrusion, torque expression, and bodily movement.
5. Consider sectional mechanics or skeletal anchorage when full-arch mechanics would overload teeth with reduced support.
6. Reassess periodontal stability throughout treatment and stop active movement if periodontal inflammation recurs.
7. Plan retention and lifelong supportive periodontal care as integral components of treatment rather than as post-treatment additions.

✍️ Conclusion
The optimal archwire sequence for periodontally compromised patients is individualized rather than standardized. A gradual progression from light NiTi alignment wires to controlled rectangular mechanics is generally consistent with the biomechanical principles described in the literature, but wire size alone should never determine treatment progression.
The decisive factors are periodontal stability, controlled force magnitude, appropriate moment-to-force relationships, anchorage management, and continuous periodontal monitoring. In patients with substantial attachment loss, modifying the mechanics may be more important than following a conventional archwire sequence.

📚 References

✔ Erbe, C., Heger, S., Kasaj, A., Berres, M., & Wehrbein, H. (2023). Orthodontic treatment in periodontally compromised patients: A systematic review. Clinical Oral Investigations, 27(1), 79–89. https://doi.org/10.1007/s00784-022-04822-1
✔ Han, S.-H., et al. (2024). Precautions and possibilities in orthodontic treatment of periodontally compromised patients: Current recommendations. Journal of Esthetic and Restorative Dentistry, 36(4), 566–577. https://doi.org/10.1111/jerd.13166
✔ Herrera, D., Sanz, M., Kebschull, M., Jepsen, S., Sculean, A., Berglundh, T., Papapanou, P. N., Chapple, I., Tonetti, M. S., & EFP Workshop Participants and Methodological Consultant. (2022). Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology, 49(Suppl. 24), 4–71. https://doi.org/10.1111/jcpe.13639
✔ Papageorgiou, S. N., Antonoglou, G. N., Michelogiannakis, D., et al. (2022). Effect of periodontal–orthodontic treatment of teeth with pathological tooth flaring, drifting, and elongation in patients with severe periodontitis: A systematic review with meta-analysis. Journal of Clinical Periodontology, 49(Suppl. 24), 102–120. https://doi.org/10.1111/jcpe.13529

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The Connection Between Diabetes and Periodontal Disease

Diabetes and periodontal disease are closely connected in a two-way relationship. People with poorly controlled diabetes have a higher risk of developing severe gum disease, while untreated periodontal disease can make it more difficult to control blood sugar levels.

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Understanding this connection helps patients protect both their oral health and overall health through early prevention and regular dental care.

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✅ What Is Periodontal Disease?
Periodontal disease, commonly called gum disease, is a chronic infection that affects the tissues supporting the teeth. It begins as gingivitis, which causes swollen and bleeding gums, and may progress to periodontitis, where the bone and connective tissues around the teeth become damaged.
Without treatment, periodontal disease can eventually lead to tooth loss.

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✅ How Does Diabetes Affect Gum Health?
People with diabetes—especially those with poor blood sugar control—are more likely to develop gum disease because high blood glucose levels can:

▪️ Reduce the body's ability to fight infections.
▪️ Slow wound healing.
▪️ Increase inflammation.
▪️ Decrease saliva flow, leading to a dry mouth.
▪️ Promote bacterial growth in dental plaque.
As a result, gum infections may become more severe and progress faster.

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✅ How Can Periodontal Disease Affect Diabetes?
The relationship also works in the opposite direction.
Chronic gum inflammation releases inflammatory molecules into the bloodstream. These substances may increase insulin resistance, making it harder for the body to regulate blood glucose levels.
Research has shown that treating periodontal disease may contribute to modest improvements in blood sugar control, particularly when combined with proper diabetes management.

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✅ Common Signs and Symptoms
People with diabetes should watch for:

▪️ Bleeding gums
▪️ Red or swollen gums
▪️ Persistent bad breath
▪️ Gum recession
▪️ Loose teeth
▪️ Pain while chewing
▪️ Pus between teeth and gums
▪️ Changes in bite
Early diagnosis greatly improves treatment outcomes.

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✅ Who Is at Greater Risk?
The risk increases in people who have:

▪️ Poorly controlled diabetes
▪️ Smoking habits
▪️ Poor oral hygiene
▪️ Obesity
▪️ Long-standing diabetes
▪️ A family history of periodontal disease
▪️ Irregular dental visits
Managing these risk factors can significantly reduce disease progression.

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✅ Diagnosis
Dentists diagnose periodontal disease through:

▪️ Clinical examination of the gums
▪️ Measurement of periodontal pocket depth
▪️ Evaluation of gum bleeding
▪️ Dental X-rays to assess bone loss
▪️ Review of the patient's medical history, including diabetes status
Regular dental check-ups are especially important for individuals with diabetes.

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✅ Treatment
Treatment depends on disease severity and may include:

▪️ Professional dental cleaning
▪️ Scaling and root planing (deep cleaning)
▪️ Improved daily oral hygiene
▪️ Antibacterial mouth rinses when indicated
▪️ Periodontal maintenance visits
▪️ Surgical treatment in advanced cases
Good communication between the dentist and the physician helps achieve better overall health outcomes.

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✅ Can Periodontal Disease Be Prevented?
Yes. Prevention focuses on controlling both oral bacteria and blood sugar levels.

Key preventive measures include:
▪️ Brush twice daily with fluoride toothpaste.
▪️ Clean between teeth every day using floss or interdental brushes.
▪️ Maintain good blood glucose control.
▪️ Avoid tobacco products.
▪️ Eat a balanced diet.
▪️ Visit the dentist every 3–6 months, depending on individual risk.
▪️ Follow diabetes treatment recommendations.

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✅ Why Blood Sugar Control Matters
Maintaining stable blood glucose levels benefits the entire body, including the gums.

Studies consistently show that individuals with well-controlled diabetes experience:
▪️ Less gum inflammation
▪️ Better healing after dental treatment
▪️ Lower risk of periodontal disease progression
▪️ Improved long-term tooth retention
Good diabetes management and good oral hygiene work together to improve health.

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💬 Discussion
Scientific evidence strongly supports a bidirectional relationship between diabetes and periodontal disease. Poor glycemic control increases susceptibility to gum infections, while chronic periodontal inflammation may worsen metabolic control through systemic inflammatory pathways.
Although periodontal treatment alone is not a cure for diabetes, maintaining healthy gums can contribute to improved overall health and may support better glycemic management as part of comprehensive diabetes care. This highlights the importance of collaboration between dental and medical professionals.

✍️ Conclusion
Diabetes and periodontal disease influence each other in important ways. Poorly controlled diabetes raises the risk of severe gum disease, and untreated periodontal disease can make blood sugar management more challenging.
With early diagnosis, consistent oral hygiene, regular dental visits, and proper diabetes control, most patients can successfully reduce complications and maintain healthy teeth and gums.

🎯 Recommendations
▪️ Maintain good blood glucose control through medical care and healthy lifestyle habits.
▪️ Schedule regular periodontal examinations, especially if you have diabetes.
▪️ Brush twice daily and clean between your teeth every day.
▪️ Do not ignore bleeding gums, as they may be an early sign of disease.
▪️ Quit smoking, as it significantly increases periodontal risk.
▪️ Inform your dentist about your diabetes diagnosis and medications.
▪️ Follow both medical and dental treatment plans for the best long-term results.

📚 References

✔ Chapple, I. L. C., Genco, R., & Working Group 2 of the Joint EFP/AAP Workshop. (2013). Diabetes and periodontal diseases: Consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. Journal of Clinical Periodontology, 40(Suppl. 14), S106–S112.
✔ Löe, H. (1993). Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care, 16(1), 329–334.
✔ Preshaw, P. M., Bissett, S. M., & Periodontology and Diabetes Working Group. (2019). Periodontitis and diabetes. British Dental Journal, 227(7), 577–584.
✔ Sanz, M., Ceriello, A., Buysschaert, M., Chapple, I., Demmer, R. T., Graziani, F., Herrera, D., Jepsen, S., Lione, L., Madianos, P., Mathur, M., Montanya, E., Shapira, L., Tonetti, M., & Vegh, D. (2018). Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the Joint Workshop on Periodontal Diseases and Diabetes by the International Diabetes Federation and the European Federation of Periodontology. Journal of Clinical Periodontology, 45(2), 138–149.
✔ Simpson, T. C., Weldon, J. C., Worthington, H. V., Needleman, I., Wild, S. H., Moles, D. R., Stevenson, B., Furness, S., & Iheozor-Ejiofor, Z. (2022). Treatment of periodontal disease for glycaemic control in people with diabetes mellitus. Cochrane Database of Systematic Reviews, 4(4), CD004714.

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Systemic Antibiotics in Periodontal Emergencies: When Are They Needed?

Periodontal emergencies are acute conditions involving the gums and supporting tissues of the teeth that often cause pain, swelling, bleeding, or difficulty chewing.

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While many patients expect antibiotics for immediate relief, systemic antibiotics are not required for every periodontal emergency. In most cases, local treatment remains the primary approach, while medications serve as supportive therapy when indicated.

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✅ Introduction
Periodontal emergencies include conditions such as periodontal abscesses, necrotizing periodontal diseases, acute pericoronitis, and severe inflammatory episodes associated with periodontal infections.
The primary goal of treatment is to eliminate the source of infection through professional dental care. Antibiotics should be prescribed only when there are signs of systemic involvement or when local treatment alone is insufficient.

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✅ When Are Systemic Antibiotics Indicated?
Systemic antibiotics may be recommended when periodontal infections are accompanied by:

▪️ Facial swelling
▪️ Fever
▪️ Lymph node enlargement
▪️ Cellulitis
▪️ Spread of infection beyond periodontal tissues
▪️ Immunocompromised status
▪️ Severe necrotizing periodontal diseases with systemic symptoms

Commonly prescribed antibiotics may include:
▪️ Amoxicillin
▪️ Amoxicillin plus Metronidazole
▪️ Metronidazole
▪️ Clindamycin (for selected patients with penicillin allergy)
The choice depends on the patient's medical history, allergy status, and clinical presentation.

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✅ Role of Anti-Inflammatory Medications
Anti-inflammatory drugs help reduce pain and swelling but do not eliminate the infection.

Common options include:
▪️ Ibuprofen
▪️ Naproxen
▪️ Acetaminophen (paracetamol) for patients who cannot take NSAIDs
These medications improve comfort while definitive periodontal treatment is performed.

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✅ Conditions That May Require Medication Support

Periodontal Abscess
A localized collection of pus within periodontal tissues. Drainage and debridement are the primary treatments. Antibiotics are reserved for cases with systemic involvement.

Necrotizing Periodontal Diseases
These conditions are characterized by pain, ulceration, bleeding, and tissue necrosis. Mechanical debridement is essential, while antibiotics may be beneficial in severe cases.

Acute Pericoronitis
Inflammation around a partially erupted tooth, commonly a mandibular third molar. Local cleaning is the main treatment, with antibiotics reserved for spreading infections.

📊 Summary Table: Systemic Antibiotics and Anti-Inflammatories in Periodontal Emergencies

Clinical Situation	Recommended Approach	Key Considerations
Localized Periodontal Abscess	Drainage and mechanical debridement	Antibiotics usually not required without systemic signs
Periodontal Abscess with Fever or Facial Swelling	Local treatment plus systemic antibiotics	Indicates possible spread of infection
Necrotizing Periodontal Disease	Debridement, oral hygiene support, possible antibiotics	Medication may be needed in severe cases
Acute Pericoronitis	Local irrigation and cleaning	Antibiotics reserved for spreading infections
Pain and Inflammation	Anti-inflammatory medication	Reduces symptoms but does not eliminate infection
Immunocompromised Patient	Individualized treatment plan	Higher risk of infection progression
Antibiotic Prescription	Use only when clinically indicated	Supports antibiotic stewardship and reduces resistance

💬 Discussion
Current evidence supports responsible antibiotic stewardship in dentistry. Overprescribing antibiotics contributes to antimicrobial resistance and exposes patients to unnecessary adverse effects.
Research consistently shows that local periodontal treatment remains the cornerstone of emergency management, while systemic antibiotics should be reserved for clearly defined clinical situations. Likewise, anti-inflammatory medications improve symptoms but should never replace definitive treatment.

🎯 Recommendations
▪️ Prioritize local treatment whenever possible.
▪️ Prescribe antibiotics only when clinical indications are present.
▪️ Avoid self-medication and incomplete antibiotic courses.
▪️ Use anti-inflammatory medications as supportive therapy, not as a substitute for treatment.
▪️ Monitor patients with systemic symptoms closely.
▪️ Educate patients about antibiotic resistance and proper medication use.

✍️ Conclusion
Systemic antibiotics are valuable tools in selected periodontal emergencies but are not routinely required for all cases. Effective management depends primarily on eliminating the source of infection through appropriate periodontal treatment. Anti-inflammatory medications can improve comfort, but long-term success relies on timely professional care and evidence-based prescribing practices.

📚 References

✔ Herrera, D., Alonso, B., de Arriba, L., Santa Cruz, I., Serrano, C., Sanz, M., & European Workshop in Periodontology Group A. (2023). Acute periodontal lesions (periodontal abscesses and necrotizing periodontal diseases) and endo-periodontal lesions. Journal of Clinical Periodontology, 50(Suppl. 26), S230–S246. https://doi.org/10.1111/jcpe.13769
✔ Jepsen, S., Caton, J. G., Albandar, J. M., Bissada, N. F., Bouchard, P., Cortellini, P., Demirel, K., de Sanctis, M., Ercoli, C., Fan, J., Geisinger, M. L., Genco, R. J., Glogauer, M., Goldstein, M., Griffin, T. J., Holmstrup, P., Johnson, G. K., Kapila, Y., Lang, N. P., ... Yamazaki, K. (2018). Periodontal manifestations of systemic diseases and developmental and acquired conditions. Journal of Clinical Periodontology, 45(Suppl. 20), S219–S229. https://doi.org/10.1111/jcpe.12951
✔ Slots, J. (2017). Periodontitis: Facts, fallacies and the future. Periodontology 2000, 75(1), 7–23. https://doi.org/10.1111/prd.12221
✔ Teoh, L., Stewart, K., Marino, R. J., & McCullough, M. J. (2019). Antibiotic resistance and relevance to general dental practice in Australia. Australian Dental Journal, 64(4), 296–303. https://doi.org/10.1111/adj.12712

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