involves full mouth periodontal probing and taking measurements of pocket depths, clinical attachment loss and recession. along with this other relevant parameters such as plaque, bleeding, furcation involvement and mobility are measured to gain an overall understanding of the level of disease. radiographs may also be performed to assess alveolar bone levels and levels of destruction. treatment phases of periodontal therapy contemporary periodontal treatment is designed based on the trimeric model, and is performed in four phases. these phases are structured to ensure that periodontal therapy is conducted in a logical sequence, consequently improving the prognosis of the patient, in comparison to indecisive treatment plan without a clear goal. non-surgical phase the non-surgical phase is the initial phase in the sequence of procedures required for periodontal treatment. this phase aims to reduce and eliminate any gingival inflammation by removing dental plaque and calculus, restoration from tooth decay and correction of defective restoration, as these all contribute to gingival inflammation, also known as gingivitis. phase i consists of treatment of emergencies, antimicrobial therapy, diet control, patient education and motivation, correction of iatrogenic factors, deep caries, hopeless teeth, preliminary scaling, temporary splinting, occlusal adjustment, minor orthodontic tooth movement and debridement. re-evaluation phase during this phase, patients are seen 3–6 weeks after initial therapy; it is required to re-evaluate the steps carried out after the phase i therapy. usually 3–6 week re-evaluation is crucial in severe cases of periodontal disease. the elements which are required to be re-evaluated are the results of initial therapy (phase i therapy), oral hygiene and status, bleeding and plaque scores and a review of diagnosis and prognosis and modification of the whole treatment plan if necessary. phase ii therapy (surgical phase) after post-phase i, it is necessary to evaluate the requirement of periodontium for surgery. factors identifying if the surgical phase is required are: periodontal pocket management in specific situations, irregular bony contours or deep craters, areas of suspected incomplete removal of local deposits, degree ii and iii furcation involvements, distal areas of last molars with expected mucogingival junction problems, persistent inflammation, root coverage and removal of gingival enlargement. phase iii therapy (restorative phase) during this phase, any defects need to be restored with removable or fixed through dental prosthesis, prosthodontics, or other restoration processes. phase iv therapy (maintenance phase) the last phase of periodontal therapy requires the preservation of periodontal health. in this phase, patients are required to re-visit through a scheduled plan for maintenance care to prevent any re-occurrence of the disease. the maintenance phase constitutes the long-term success for periodontal treatment, thus contributing to a long relationship between the oral health therapist, dentist, or periodontist and the patient. periodontal and restorative interface the prognosis of the restorative treatment is determined by the periodontal health. the goals for establishing periodontal health prior to restorative treatment are as follows: periodontal treatment should be managed to assure the establishment of firm gingival margin prior to tooth preparation for restoration. absence of bleeding tissue during restorative manipulation provides accessibility and aesthetic outcome. certain periodontal treatment is formulated to increase sufficient tooth length for retention. failure to accomplish these methods prior restorations can lead to the complexity or risk of failure of treatment such as impression making, tooth preparation and restoration. periodontal therapy should follow restorative method as the resolution of gingival inflammation may result in the repositioning of teeth or in soft tissue and mucosal changes. standard of periodontal treatment non-surgical therapy is the golden standard of periodontal therapy which consists of debridement with a combination of oral-hygiene instructions and patient motivation. it mainly focuses on the elimination and reduction of putative pathogens and shifting the microbial flora to a favourable environment to stabilize periodontal disease. debridement is thorough mechanical removal of calculus and dental biofilm from the root surfaces of the tooth. debridement is the basis of treatment for inflammatory periodontal diseases and remains the golden standard for surgical and non-surgical treatment in the initial therapy. it is conducted by hand instrumentation such as curettes or scalers and ultrasonic instrumentation. it requires a few appointments, depending on time and clinician skills, for effective removal of supragingival and subgingival calculus, when periodontal pockets are involved. it can assist in periodontal healing and reduce periodontal pocketing by changing the subgingival ecological environment. prevention of periodontal disease and maintenance of the periodontal tissues following initial treatment requires the patient's ability to perform and maintain effective dental plaque removal. this requires the patient to be motivated in improving their oral hygiene and requires behaviour change in terms of tooth brushing, interdental cleaning, and other oral hygiene techniques. personal oral hygiene is often considered an essential aspect of controlling chronic periodontitis. research has shown that it is important to appreciate the motivation of the patient behaviour changes that have originated from the patient. patients must want to improve their oral hygiene and feel confident that they have the skills to do so. it is crucial for the clinician to encourage patient changes and to educate the patient appropriately. motivational interviewing is a good technique to ask open-ended questions and express empathy towards the patient. role of the oral health therapist an oral health therapist is a member of the dental team who is dual-qualified as a dental hygienist and dental therapist. they work closely with dentists and a number of dental specialists including periodontists. it is common for the oral health therapist to be involved in the treatment of gingival and periodontal diseases for patients. their scope of practice in this area includes oral health assessment, diagnosis, treatment and maintenance and referral where necessary. they also have expertise in providing oral health education and promotion to support the patient to maintain their at-home oral care. oral health therapists are employed by the dental team to share the responsibilities of care. they are an important asset as they have been uniquely and specifically trained in preventative dentistry and risk minimization. this allows the dental team to work more competently and effectively as dentists can manage more complex treatments or significantly medically compromised patients. periodontist a periodontist is a specialist dentist who treats patients for periodontal-related diseases and conditions. they are involved in the prevention, diagnosis and treatment of periodontal disease. periodontists receive further specialist training in periodontics after completing a dental degree. periodontists provide treatments for patients with severe gingival diseases or complex medical histories. periodontists offer a wide range of treatments including root scaling and planing, periodontal surgery, implant surgery and other complex periodontal procedures. dental implant list of procedures performed by a periodontist: non-surgical treatments gum graft surgery laser treatment regenerative procedures dental crown lengthening dental implants pocket reduction procedures plastic surgery procedures training before applying to any postgraduate training program in periodontology, one must first complete a dental degree. australia australian programs are accredited by the australian dental council (adc) and are three years in length and culminate with either a master's degree (mds) or a doctor of clinical dentistry degree (dclindent). fellowship can then be obtained with the royal australasian college of dental surgeons, fracds (perio). canada canadian programs are accredited by the commission on dental accreditation of canada and are a minimum of three years in length and usually culminate with a master (msc or mdent) degree. graduates are then eligible to sit for the fellowship exams with the royal college of dentists of canada. dentistry is a regulated profession. to become a licensed dentist in canada one must have a bds, dds, or dmd degree and be certified by the national dental examining board of canada. europe although each european country has its own independent system, an umbrella organization—the european federation of periodontology (efp)—has the ability to accredit post-graduate programs according to specific guidelines. the efp awards a certificate of specialized training in periodontology, periodontics and implant dentistry to every successful european candidate after three years of full-time training in an accredited post-graduate program. the graduate programs that have been approved are the following: academic centre for dentistry amsterdam, university of bern, sahlgrenska university hospital, institute for postgraduate dental education jönköping, ucl eastman dental institute, university of louvain (uclouvain), university complutense in madrid, trinity college dublin, university of strasbourg in france, paris diderot university at rothschild hospital. india periodontics is offered as a specialization field of dentistry in india. periodontists attend a master of dental surgery (m.d.s.) program affiliated with dental schools in india. the minimum qualification required for the m.d.s. degree is a bachelor of dental surgery. a majority of dental schools in india offer m.d.s. degrees specializing in periodontology. the course is three years and students are trained for implantology as well as diagnosis and treatment of peri-implant diseases along with periodontology. united kingdom the british society of periodontology exists to promote the art and science of periodontology. their membership includes specialist practitioners, periodontists, general dentists, consultants and trainees in restorative dentistry, clinical academics, dental hygienists and therapists, specialist trainees in periodontology and many others. specialist training in periodontics in the uk is either a three-year full-time program or four years at three days per week. at the end of the training, candidates are awarded a master of clinical dentistry (mclindent) before being entered on the specialist list held by the general dental council. united states ucla school of dentistry periodontics graduate clinic the american dental association (ada)-accredited programs are a minimum of three years in length. according to the american academy of periodontology, u.s.-trained periodontists are specialists in the prevention, diagnosis and treatment of periodontal diseases and oral inflammation, and in the placement and maintenance of dental implants. many periodontists also diagnose and treat oral pathology. historically, periodontics served as the basis for the speciality of oral medicine. following successful completion of post-graduate training a periodontist becomes board-eligible for the american board of periodontology examination. maintenance after periodontal treatment, whether it be surgical or non-surgical, maintenance periodontal therapy is essential for a long-term result and stabilization of periodontal disease. there is also a difference in the maintenance of different types of periodontal disease, as there are different types, such as: gingivitis the reversible inflammation of the gums is easily prevented by patients. after the removal of the inflammatory product, usually plaque or calculus, this allows the gums room to heal. this is done by patients thoroughly cleaning teeth every day with a soft bristle toothbrush and an interdental aid. this can be floss, interdental brushes, or whatever is preferred by the patient. without patient compliance and constant removal of plaque and calculus, gingivitis cannot be treated completely and can progress to irreversible periodontitis. necrotizing ulcerative gingivitis (nug) also acute necrotizing ulcerative gingivitis and necrotizing ulcerative periodontitis, it is a type of periodontal disease different than many other periodontal diseases. clinical characteristics include gingival necrosis (breakdown of the gums), gingival pain, bleeding, halitosis (bad breath), as well as a grey colour to the gingiva and a punched out appearance. it is treated through debridement, usually under local anaesthetic due to immense pain. to maintain and treat the condition completely, a chlorhexidine mouthwash should be recommended to the patient to use twice daily, oral health instruction should be provided (using a soft bristle toothbrush or electric toothbrush twice a day) and an interdental cleaning aid, such as floss or interdental brushes, which cleans the areas that the toothbrush cannot reach. the patient should also be educated on proper nutrition and diet and healthy fluid intake. smoking cessation should occur not only to completely eradicate the disease but also for the health of the patient. pain control can be done through ibuprofen or paracetamol/acetaminophen. in the case of an immunocompromised patient, antibiotics should be prescribed. assessment of treatment should be done after 24 hours of treatment and continued every 3–6 months until signs and symptoms are resolved and gingival health and function restored. chronic periodontitis the inflammation of the gums and irreversible destruction of the alveolar bone and surrounding structures of the teeth, which is usually slow progressing but can have bursts. local factors explain presence of disease, such as diet, lack of oral hygiene, plaque accumulation, smoking, etc. it is characterized by pocket formation and recession of the gingiva (shrinkage of the gums). treatment and maintenance are important in stopping disease progression and to resolve the inflammation. treatment usually consists of scaling and root planning,