I. Disclaimer

This document is intended to be used as a reference for VA and non-VA providers. It is not intended to replace clinical judgment when determining care pathways. These guidelines do not guarantee benefits or constitute medical advice.

Eligibility for VA dental care is defined by statute and is to be provided in accordance with the provisions of existing law and VA regulations, specifically 38 U.S.C. §§1710(c) and 1712, and 38 CFR §§17.160 through 17.166.

II. Dental Clinical Determinations and Indications

1. Indications for Surgical Periodontal Procedures
2. Surgical procedures for periodontal disease are used to remove diseased or damaged tissue, reduce pocket depths, and reshape bone structures to enhance oral health and facilitate better maintenance and hygiene. The following surgical periodontal procedures listed in section III.d may be considered clinically necessary when ANY of the following criteria are met:
   • Diagnosis of Stage III or IV periodontitis based on the American Academy of Periodontology (AAP) 2018 classification
   • Periodontal pocket depths greater than or equal to 5 mm with clinical attachment loss
   • Non-responsiveness to initial non-surgical periodontal therapy, such as scaling and root planing (SRP)
   • Anatomic need for surgical access to perform effective root instrumentation or osseous contouring
   • Bone defects not suitable for regenerative procedures 
   • Gingival enlargement due to either one of the following:
     • Medications such as anticonvulsants, immunosuppressants, or calcium channel blockers
     • Systemic conditions or malnutrition 
   • To allow preservation of the biological width for restorative procedures

2. Limitations/Exclusions
   Surgical periodontal procedures are not indicated and therefore considered not clinically necessary in the following situations:
   • Poor compliance with non-surgical periodontal therapy
   • Presence of teeth with hopeless prognosis
   • Crown lengthening in areas close to the furcation that may compromise the stability and health of the tooth
   • The patient does not demonstrate the ability and willingness to maintain adequate oral hygiene
   • Insufficient attached gingiva
   • Uncontrolled systemic conditions (i.e., diabetes, hematologic, or immunosuppressive conditions)
   • Active medication that interferes with healing, such as immunosuppressants or bisphosphonates

For all other conditions or indications not listed in section II.a. of this document, surgical periodontal procedures are considered not clinically necessary due to insufficient evidence of efficacy and safety.

3. Description of Treatment
4. Periodontal surgery involves specific procedures to help manage and treat gum (periodontal) disease by removing or reshaping the gum (gingival) or bone (osseous) tissues. These surgeries may involve local anesthesia, general anesthesia or intravenous (IV) sedation, and are designed to reduce or eliminate deep pockets that can harbor bacteria, expose additional tooth structure for restorative access and make it easier for patients to maintain good oral health. These procedures are selected based on the patient’s clinical presentation and require careful planning and follow-up care for the best results.

III. Background and Supporting Information

The following information is for reference purposes only in accordance with dental eligibility as defined by statute (law). Each subsection supports VA’s determinations for clinical necessity and alignment with generally accepted standards of dental practice.

1. Background Information
2. Surgical periodontal therapy effectively treats moderate to advanced periodontitis, gingival diseases influenced by systemic factors, medications, malnutrition, or when non-surgical methods fail. It also can expose additional tooth structure for restorations and reestablish appropriate biologic width when necessary. These surgeries reduce pocket depths, improve clinical attachment, and enhance periodontal stability by addressing complex anatomical sites. Techniques such as gingivectomy, gingivoplasty, apically positioned flap surgery, crown lengthening and osseous resection are tailored to the patient’s disease presentation, for predictably favorable outcomes.

2. Research, Clinical Trials, and Evidence Summaries
3. The clinical literature strongly supports the efficacy of surgical periodontal therapy. Hayakawa et al. (2012) reported significant reductions in probing depth and gains in clinical attachment in patients undergoing flap and regenerative surgeries, especially in deeper pockets. Serino et al. (2001) found surgical therapy superior to non-surgical debridement in reducing pocket depths and preventing disease recurrence over 12 years, especially in advanced cases. Bezerra (2023) highlighted osseous resection’s reliability in creating maintainable shallow sulci. Levy et al. (2002) demonstrated that apically repositioned flap surgery significantly reduced pathogenic subgingival microbiota, supporting its role in bacterial control. These studies provide robust evidence for surgical procedures in managing periodontitis.

3. U.S. Food & Drug Administration Information
4. VA generally only approves use of medical devices that have received at least Food & Drug Administration (FDA) clearance for 510(k) Premarket Notification. The FDA has determined these Class II devices are substantially equivalent (SE) to legally marketed predicate devices, in terms of safety and effectiveness, and may be marketed in the U.S. Manufacturers must adhere to FDA regulations on labeling, manufacturing practices, and post-market surveillance. The FDA monitors adverse event reports and can mandate recalls. Manufacturer’s Instructions for Use (MIFU) must be followed.

Surgical instruments and materials used in surgical periodontal procedures, such as scalpels, lasers, and electrosurgery devices, must comply with FDA standards for safety, biocompatibility, and efficacy. Guidelines address the risk of adverse reactions and durability under clinical conditions.

To search for devices that have received FDA 510(k) clearance or Premarket Approval (PMA), please visit the FDA Devices database.

4. American Dental Association Current Dental Terminology Coding Information
5. The following CDT codes listed in this section are provided for informational purposes only. Inclusion or exclusion of a code does not constitute or imply VA coverage or provider reimbursement. The list of codes may not be all-inclusive since the American Dental Association (ADA) code updates may occur more frequently than dental CDI updates. Please refer to section II.a. in this document to review indications and clinical criteria for clinical necessity.

CDT Code	Description
D4210	Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant
D4211	Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant
D4240	Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant
D4241	Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant
D4249	Clinical crown lengthening – hard tissue
D4260	Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant
D4261	Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant

Current Dental Terminology (CDT), Copyright ^© 2026 American Dental Association. All rights reserved.

IV. Definitions

Term	Definition
Apically positioned flap	Surgical technique where a flap of gingival tissue is repositioned apically to reduce pocket depth and improve access for cleaning
Biologic width	The combined vertical dimension of the junctional epithelium and the supracrestal connective tissue attachment to the tooth, which together separate the alveolar bone from the base of the gingival sulcus
Clinical attachment loss	Loss of connective tissue attachment of the tooth to the periodontal ligament and alveolar bone
Gingivectomy	Surgical procedure that involves the removal of gingival tissue to eliminate supra-alveolar pockets and achieve optimal gingival contour
Gingivoplasty	Surgical procedure aimed at reshaping the gingiva to create a more esthetic and functional contour
Osseous resection	Surgical recontouring of the alveolar bone to eliminate osseous defects and reduce periodontal pocket depth
Periodontal maintenance	Supportive therapy to maintain periodontal health following initial treatment, involving regular cleanings, periodontal charting, and oral hygiene education to prevent disease recurrence
Periodontitis (Stage I)	Gingival inflammation, bleeding on probing, pocket depth approximately 4 mm, less than15% bone loss, 1–2 mm clinical attachment loss
Periodontitis (Stage II)	Pronounced gingival bleeding, approximately 5 mm pocket depth, possible tooth mobility, 15–33% bone loss, 3–4 mm clinical attachment loss
Periodontitis (Stage III)	Deep pockets greater than or equal to 6 mm, significant gum recession, increased tooth mobility, bone loss to the middle third of the root, greater than or equal to 5 mm clinical attachment loss, possible vertical bone loss or furcation involvement
Periodontitis (Stage IV)	Very deep pockets, severe gum recession, severe tooth mobility, extensive bone loss with furcation involvement, substantial clinical attachment loss (greater than 5 mm), potential bite collapse or pathologic tooth migration
Scaling and root planing	Non-surgical periodontal therapy designed to remove dental plaque, calculus, and bacterial toxins from tooth surfaces above and below the gingiva, promoting gum reattachment and reducing inflammation

V. References

American Academy of Periodontology. (2018). Staging and Grading of Periodontitis.

Bezerra, B. (2023). Pocket reduction therapy – Resective approach. In Newman and Carranza’s Clinical Periodontology and Implantology (14th ed., pp. 750-755). St. Louis: Elsevier.

Cohen, E. S. (2007). Gingivectomy and gingivoplasty. In Atlas of Cosmetic and Reconstructive Periodontal Surgery (3rd ed.). Shelton, CT: People’s Medical Publishing House.

Hayakawa, H., Fujinami, K., Ida, A., et al. (2012). Clinical outcome of surgical periodontal therapy: A short-term retrospective study. Bulletin of Tokyo Dental College, 53(4), 189-195.

Klokkevold, P. R., Mealey, B. L., & Otomo-Corgel, J. (2023). Periodontal treatment of medically complex patients. In Newman and Carranza’s Clinical Periodontology and Implantology (14th ed., pp. 784-805). St. Louis: Elsevier.

Levy, R. M., Giannobile, W. V., Feres, M., et al. (2002). The effect of apically repositioned flap surgery on clinical parameters and the composition of the subgingival microbiota: 12-month data. International Journal of Periodontics & Restorative Dentistry, 22(3), 209-219.

Melnick, P. R., & Takei, H. H. (2023). Preparation of the periodontium for restorative dentistry. In Newman and Carranza’s Clinical Periodontology (14th ed., pp. 780-783). St. Louis: Elsevier.

Newman, M. G., Takei, H. H., Klokkevold, P. R., et al. (2023). Periodontal surgical therapy. In Newman and Carranza’s Clinical Periodontology and Implantology (14th ed., pp. 730-749). St. Louis: Elsevier.

Schmidt, J. C., Sahrmann, P., Weiger, R., Schmidlin, P. R., & Walter, C. (2013). Biologic width dimensions–a systematic review. Journal of clinical periodontology, 40(5), 493–504.

Serino, G., Rosling, B., Ramberg, P., Socransky, S. S., & Lindhe, J. (2001). Initial outcome and long-term effect of surgical and non-surgical treatment of advanced periodontal disease. Journal of clinical periodontology, 28(10), 910–916.

VI. Dental CDI History/Revision Information

Date	Summary of Update(s)
06/01/2026	New dental CDI created describing clinically necessary and not clinically necessary indications

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