Co esponding au ho : Ni Luh Desy Ayu Susilaha i
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Managemen o Gene alized Pe iodon i is S age III G ade B wi h Subgingi al
Cu e age P ocedu e
Ni Luh Desy Ayu Susilaha i *, Eka P amudi a Ramadhany, Ida Bagus P amana Pu a Manuaba, Ni Made Is a
P es iyan i, Kadek As i Asmi a P adnyana Pu i, Desak Ayu Dhyana, Riki K is an o, Pu i Ma ina Sukmadewi,
Ni Wayan A i Wulansa i and Daniel Ha ley Ha sono
Depa men o O al and Den is y, Facul y o Medicine, Udayana Uni e si y, Denpasa , Bali, Indonesia.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(02), 1111-1117
Publica ion his o y: Recei ed on 06 July 2025; e ised on 12 Augus 2025; accep ed on 15 Augus 2025
A icle DOI: h ps://doi.o g/10.30574/wja .2025.27.2.2953
Abs ac
Pe iodon i is is an in lamma o y disease o he suppo ing s uc u es o he ee h ha esul s in p og essi e damage o
he pe iodon al ligamen and al eola bone. This condi ion has become a p e alen disease wo ldwide, wi h a
p e alence a e o 74.1% in Indonesia. In his case, a 24-yea s-old male pa ien p esen ed wi h a complain o equen
gum bleeding while b ushing his ee h o pas 2 mon hs. The complain was no associa ed wi h pain. The pa ien
unde wen scaling wo weeks ago. Objec i e in ao al examina ion e ealed p obing dep h g ea e han 3 mm called
ue pocke on he in e den al su aces o ee h 11–17 and bleeding on p obing (BOP) o 32%. Pe iapical adiog aphic
examina ion showed ho izon al al eola bone eso p ion o app oxima ely 4 mm a he p oximal su aces o ee h 11–
17. The diagnosis es ablished was gene alized pe iodon i is s age III g ade B. The managemen o his case was
subgingi al cu e age. Subgingi al cu e age was pe o med o emo e he in lamed so issue om he apical po ion
o he junc ional epi helium o he connec i e issue o he co onal bone. The cu e age ea men in his case can be
conside ed success ul, as he objec i es we e achie ed—elimina ion o in lamma ion and he o ma ion o new
connec i e issue a achmen , as obse ed du ing he second ollow-up isi a e cu e age.
Keywo ds: Pe iodon i is; P obing Dep h; T ue Pocke ; Subgingi al Cu e age; Bleeding on P obing (BOP)
1. In oduc ion
Pe iodon al disease is an in ec ion o in lamma ion o he o al issues ha a ec s he suppo ing s uc u es o he ee h.
This disease is common wo ldwide, wi h se e e pe iodon al disease anked as he six h mos p e alen condi ion
globally, acco ding o he Global Bu den o Disease S udy in 2016. The p e alence o pe iodon al disease is es ima ed o
ange om 20% o 50% wo ldwide [1]. Pe iodon al disease includes gingi i is and pe iodon i is. Gingi i is is
in lamma ion o he gingi a ha is e e sible, cha ac e ized by bleeding and swelling o he gums. I le un ea ed,
gingi i is can p og ess o pe iodon i is, which is cha ac e ized by bone loss and clinical a achmen loss [2].
Acco ding o he Global Bu den o Disease S udy in 2017, 796 million people wo ldwide su e om se e e pe iodon i is
[1]. In Indonesia, he p e alence o pe iodon i is is epo ed o be 74.1% [3]. Pe iodon i is is he esul o p og essi e
and pe sis en in lamma ion o he suppo ing issues o he ee h, leading o clinical a achmen loss, al eola bone loss,
and he o ma ion o pe iodon al pocke . Pe iodon i is is a mul i ac o ial disease caused by bac e ia, hos immune-
in lamma o y esponses, local ac o s, and gene ic ac o s [4]. Local ac o s include plaque and calculus, he use o pa ial
den u es, ixed p os heses, oo h ex ac ions, he p esence o malocclusion, and poo p oximal con ac . Addi ionally,
beha io al ac o s such as imp ope oo h b ushing habi s and smoking con ibu e o he disease [5].
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The p ima y e iological agen s o pe iodon al disease include bac e ia such as Po phy omonas gingi alis,
Agg ega ibac e ac inomyce emcomi ans, Tanne ella o sy hia, and T eponema den icola. In heal hy condi ions, he
pe iodon al issues a e capable o con olling bac e ial p esence h ough a ious immune mechanisms. Howe e , when
he balance be ween in ec ion con ol mechanisms and subgingi al bio ilm is dis up ed, hese bac e ia can ac i a e he
hos ’s inna e immune esponse, igge ing an in lamma o y esponse [6]. An uncon olled hos immune esponse o
pe iodon al in ec ion esul s in in lamma o y eso p ion o he al eola bone. The e o e, pe iodon i is is cha ac e ized
by deep pe iodon al pocke s, clinical a achmen loss, and bone loss [7].
Pe iodon al disease impac s speech, aes he ics, and mas ica ion, he eby a ec ing he o e all quali y o li e and well-
being [5]. The main goal o pe iodon al he apy is o elimina e in ec ion and in lamma ion in he pe iodon al s uc u es.
The subsequen goal is o es o e he s uc u e, unc ion, and aes he ics o he a ec ed pe iodon al issues [8]. Acco ding
o Ka maka and P akash in 2019 [7], app op ia e he apy o pa ien s wi h deep pe iodon al p obing dep h is cu e age
a he han jus scaling and oo planing. Cu e age is indica ed when he e a e shallow pocke s wi h su icien gingi al
wid h and hickness, he p esence o sup abony pocke no exceeding he mucogingi al junc ion, o p omo e new
a achmen in deep in abony pocke in accessible a eas, o when p obing dep h emain g ea e han 3 mm a e scaling
and oo planing [9, 10].
Cu e age p ocedu es can be pe o med using a scalpel (ENAP), chemical agen s, ul asonic ins umen s, o a y
ins umen s, lase s, o G acey cu e es, wi h he la e being he simples echnique [10]. The aim o his p ocedu e is
o con e ch onic lesions in o acu e su gical wounds o p omo e healing h ough ma ginal gingi al sh inkage and he
o ma ion o new a achmen ia epi helial adhesion o he oo h su ace [8].
This case epo will discuss pe iodon i is and i s managemen h ough he subgingi al cu e age p ocedu e.
2. Case Repo
A 24-yea s-old pa ien p esen ed o Udayana Uni e si y Gene al Hospi al wi h a chie complain o equen gum
bleeding while b ushing his ee h o pas 2 mon hs. The complain was no associa ed wi h pain. To da e, no measu es
ha e been aken by he pa ien o add ess his issue. Fo den al his o y, pa ien unde wen scaling wo weeks ago.
In ao al examina ion e ealed an o al hygiene index sco e o 0.84, ca ego ized as "good," and a plaque index sco e o
35%. The examina ion also e ealed he p esence o pe iodon al pocke wi h a mean p obing dep h o 4 mm, and he
highes papilla y bleeding index was g aded as 3.
Table 1 In ao al Examina ion o ee h #11-17
Too h
PD
(P obing
Dep h)
dis al-mesial
PBI
(Papilla
Bleeding
Index) dis al-
mesial
GOI
Gingi al
O e g ow h
Index) dis al-
mesial
TFO
(T auma ik
F om
Occlusion)
Gingi al
ecesion
(dis al-
mesial)
Local
Fac o
11
6 5 4
3 2 2
0
-
-
Dias ema in
dis al #11
12
5 3 4
2 0 3
0
-
-
Dias ema in
mesial #12
13
4 2 3
1 0 0
0
-
-
-
14
5 3 4
2 0 0
0
-
-
-
15
5 2 4
2 0 2
0
-
-
-
16
4 2 5
2 0 2
0
-
-
-
17
3 3 4
0 0 1
0
-
-
-
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(02), 1111-1117
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Figu e 1 P e-ope a i e in ao al image
Figu e 2 P e-ope a i e Pe iodon al Cha
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(02), 1111-1117
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Radiog aphy examina ion showed ha bone eso p ion occu ed almos in all p oximal o ee h 11 - 17. The e we e
ho izon al eso p ion wi h 4 mm bone eso p ion in p oximal ee h 11 – 16 and 2 mm bone eso p ion in p oximal 17.
Figu e 3 Radiog aphic examina ion showed bone eso p ion on p oximal 11-17
Based on examina ion abo e, his case was diagnosed as Gene alized Pe iodon i is S age III G ade B. T ea men choice
o his case is subgingi al cu e age. The ea men was s a ed a e checking i al signs and in o med consen pa ien .
I was ound ha he pa ien i al signs we e wi hin no mal limi s. The cu e age p ocedu e began by pe o ming wo k
a ea asepsis wi h po idone iodine 10% as an isep ic ma e ial. Anes hesia pe o med by in il a ion anes hesia on
muccobuccal old ee h 11-17 wi h pehacaine. Following his, scaling and oo planing we e pe o med using a G acey
cu e e. Cu e age was hen ca ied ou by inse ing he cu e e in o he pocke un il i eached he pocke base, wi h he
cu ing edge acing he so issue. The non-ope a ing hand s abilized he ou e su ace o he gingi a using gauze
mois ened wi h saline and was applied wi h gen le p essu e. Cu e age o he la e al pocke wall was pe o med using
ho izon al s okes, scooping mo ions, and o e lapping s okes un il all nec o ic issues in he junc ional epi helium we e
emo ed. Bleeding con ol is achie ed by applying s e ile gauze wi h p essu e o 10-15 minu es, ollowed by
adap a ion o he gingi al issue wi h ligh p essu e. A pe iodon al pack is applied o e he su gical a ea, ex ending
co onally up o he ce ical hi d o he ee h and apically no beyond he mucogingi al junc ion, ensu ing i is ee om
occlusal con ac . The pa ien was hen medica ed wi h amoxicillin 500 mg e e y 8 hou s o 5 days and me enamic acid
500 mg i needed when he pa ien eels any pain, as well as chlo hexidine glucona e 0.12% mou hwash 2 imes a day
o a week. Then, he pa ien was ins uc ed o come one week a e su ge y o emo e he pe iodon al pack. A
pe iodon al dep h examina ion was pe o med in 2 weeks and showed he pe iodon al dep h dec eased signi ican ly.
Figu e 4 (A,B) Asepsis wi h po idone iodine 10% as an an isep ic ma e ial ex a o al and in a o al; (C). In il a ion
anes hesia a he mucobuccal old; (D,E). Subgingi al cu e age on ee h 11–17 using g acey cu e e; (F). Pe iodon al
pack manipula ion; (G). Pe iodon al pack applica ion a he su gical si e
The i s ollow-up was conduc ed one week a e he su ge y. Du ing he subjec i e examina ion, he pa ien epo ed
no pain o swelling in he su gical a ea. Ex a o al examina ion e ealed no swelling and he pa ien had no o he
complain s. In a o al objec i e examina ion showed ha he pe iodon al pack was s ill in place in he su gical a ea 1
week a e su ge y. The pe iodon al pack was hen emo ed, and any emaining ma e ial adhe ing o he gingi a and
in e den al a eas was cleaned, ollowed by i iga ion wi h an i iga ion solu ion.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(02), 1111-1117
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Figu e 5 In a o al examina ion one week a e su ge y
The second ollow-up ook place one mon h a e he su ge y. Du ing he subjec i e examina ion, he pa ien again
epo ed no pain o swelling in he su gical a ea. Objec i e examina ion e ealed no signs o in lamma ion, no
abno mali ies in gingi al colo , o bleeding. The e was no deb is (-), edema (-), edness (-), o pain (-). The O al Hygiene
Index Simpli ied Sco e (OHI-s) was 1.2 (good) and he plaque index was 13%. A signi ican educ ion in p obing dep h
was no ed (as shown in he able), and he a e age papilla y bleeding index was 0.
Figu e 6 In a o al examina ion one mou h a e su ge y
Figu e 7 In a o al examina ion p e-ope a i e (le ), ollow-up one week (middle), ollow-up one mon h ( igh )
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(02), 1111-1117
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Figu e 8 P e-ope a i e pe iodon al cha (le ), Pos -ope a i e pe iodon al cha ( igh )
3. Resul s and Discussion
Mic obial imbalance, also e e ed as dysbiosis, leads o he de elopmen o pe iodon al disease. Dysbiosis occu s due
o poo o al hygiene habi s, as seen in his case. The plaque bio ilm, which becomes mine alized in o calculus, se es as
a niche o non-calcula ing plaque accumula ion, c ea ing an ideal en i onmen o mic oo ganisms o colonize and
me abolize [11]. The pa hophysiology o his disease p og esses om he ini ial lesion o he ad anced lesion, ma ked
by he o ma ion o pocke and al eola bone eso p ion [6].
Pocke can o m due o a ious ac o s. Beha io al ac o s, such as imp ope b ushing and lack o lossing, a e p esen
in his case, as he pa ien has no adop ed p ope b ushing habi s no does he pe o m lossing, leading o he
accumula ion o calculus. Ana omical ac o s, such as poo p oximal con ac , including dias ema and plunge cusp,
p omo e ood impac ion [9]. Food impac ion can subsequen ly i i a e he ee h and su ounding issues, leading o
issues such as p oximal ca ies, gingi i is, and pe iodon i is [12]. This is he case he e, whe e pe iodon i is is exace ba ed
by mul iple dias ema causing ood impac ion on he dis al o oo h 11 and mesial o oo h 12, esul ing in plaque and
calculus accumula ion.
In his case, he pe iodon i is is classi ied as Pe iodon i is S age III G ade B. The diagnosis o gene alized pe iodon i is
was made because mo e han 30% o he pa ien 's ee h we e a ec ed by pe iodon i is. S age III was de e mined due o
he p esence o he g ea es in e den al Clinical A achmen Loss (CAL) o 7 mm, and G ade B was assigned because he
bio ilm deposi s we e p opo ional o he le el o pe iodon al issue des uc ion.
Ini ial phase in his case including Den al Heal h Educa ion (DHE), scaling and oo planing, mino o hodon ic
ea men . The su gical phase pe o med in his case was subgingi al cu e age. The main goal o his ea men was o
emo e ch onically in lamed g anula ion issue loca ed on he la e al walls o he pe iodon al pocke s. Cu e age is no
in ended o elimina e local ac o s such as plaque and calculus, he e o e, scaling and oo planing we e pe o med p io
o his p ocedu e.
One week a e cu e age, a ollow-up appoin men was scheduled o emo e he pe iodon al pack. The pe iodon al
pack se es as a su gical d essing o p o ec he oo h-suppo ing s uc u es om pos -ope a i e complica ions.
Meanwhile, he healing o he sulcula epi helium occu s be ween 2 and 7 day pos -su ge y. By day 6, he pos -ope a i e
wound is usually co e ed wi h s a i ied squamous epi helium, and collagen begins o o m in he connec i e issue.
Gingi al ma gin sh inkage s a s one week a e su ge y. By day 16, mo e dense collagen connec i e issue becomes
isible. By day 21, inc eased collagen o ma ion is no ed in he connec i e issue, he gingi a appea s no mal, and
comple e healing is achie ed. Based on his, p obing was pe o med du ing he second ollow-up, bu no du ing he
i s ollow-up, o a oid in e e ing wi h he epi helial healing p ocess [9,10].
The p obing dep h a he second ollow-up showed signi ican imp o emen , wi h an a e age p obing dep h o 2 mm
om he mesial o oo h 11 o he dis al o oo h 17, and he deepes p obing dep h was 2 mm. The a e age Clinical
A achmen Loss (CAL) om he mesial o oo h 11 o he dis al o oo h 17 was 1 mm, wi h he g ea es CAL being 1
mm.
This indica es ha he ea men was success ul and consis en wi h exis ing heo y. Acco ding o Ka maka and
P akash in 2019 [7], su gical ea men wi h cu e age o pa ien s wi h deep pe iodon al p obing dep h has shown
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(02), 1111-1117
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be e esul s in educing pocke dep h compa ed o scaling and oo planing alone. Pocke dep h educ ion h ough
cu e age is achie ed h ough he o ma ion o new connec i e issue a achmen and issue sh inkage. I p obing dep h
dec eases wi hou a change in CAL, i indica es issue sh inkage. Howe e , i he e is a change in CAL, i signi ies he
o ma ion o new connec i e issue a achmen [8]. The e o e, in his case, he success o he cu e age ea men was
achie ed h ough he o ma ion o new connec i e issue a achmen .
4. Conclusion
This case epo p esen s a case o Gene alized Pe iodon i is S age III G ade B exace ba ed by mul iple dias ema,
diagnosed based on subjec i e, objec i e, and adiog aphic diagnos ic examina ions. The chosen ea men was
subgingi al cu e age using he basic echnique wi h G acey cu e es, aimed a elimina ing in lamma ion and p omo ing
new a achmen o ma ion. The cu e age ea men in his case can be conside ed success ul, as he goals o he
p ocedu e we e achie ed—namely, he elimina ion o in lamma ion and he o ma ion o new connec i e issue
a achmen , as obse ed du ing he second ollow-up a e cu e age.
Compliance wi h e hical s anda ds
Acknowledgemen s
The au ho s hank he e iewe s o hei insigh ul sugges ions.
Disclosu e o con lic o in e es
No con lic o in e es o be disclosed.
S a emen o in o med consen
In o med consen was ob ained om all indi idual pa icipan s included in he s udy.
Re e ences
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h ps://doi.o g/10.3390/jcm11133728
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[4] Lim, Janu, Gandhi, Palomo, john. Pe iodon al Heal h and Sys emic Condi ions. Den is y Jou nal. 2020; 8(130);
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[9] Shalu Ba hla & Manish Ba hla. (2011). Pe iodon ics Re isi ed.
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