What is a Periodontist?
When to See a Periodontist?
Periodontal Scaling & Root Planing (SRP)
Pocket Reduction Surgery
There are many different treatments for patients with Periodontal Disease. They range from the most conservative (scaling and root planing) to those procedures which involve surgical treatment. Many times, scaling and root planing (SRP) will lead to decreased pockets and lessens the amount of surgical treatment necessary
What is a Periodontist?
A periodontist is a dentist who specializes in the soft tissues of the mouth and the underlying jawbone which supports the teeth. A dentist must first graduate from an accredited dental school before undertaking an additional three years of study within periodontology residency training program, in order to qualify as a periodontist.
The primary focus of this residency training is on both surgical and non-surgical management of periodontal disease and the placement of dental implants.
Conditions Treated by a Periodontist
The periodontist is mainly concerned with preventing the onset of gum disease (periodontal disease), diagnosing conditions affecting the gums and jawbone, and treating gingivitis, periodontitis and bone loss. Periodontal disease is a progressive (chronic) condition and the leading cause of tooth loss among adults in the developed world.
The periodontist is able to treat mild, moderate and advanced gum disease by first addressing the bacterial infection at the root of the problem, providing periodontal treatment, then providing information and education on good oral hygiene and the effective cleaning of the teeth.
The most common conditions treated by the periodontist are:
- Gingivitis – This is the mild inflammation of the gums which may or may not be signified by pain and bleeding.
- Mild/moderate periodontitis – When the pockets between the teeth and the soft tissues are measured to be between 4-6mm it is classified as moderate periodontitis (gum disease).
- Advanced periodontitis – When the pockets between the teeth and the soft tissues in general exceed 6mm in depth, significant bone loss may occur; causing shifting or loss of teeth.
- Missing teeth – When teeth are missing as a result of bone loss, the periodontist can implant prosthetic teeth. These teeth are anchored to the jawbone and restore functionality to the mouth.
Treatments Performed by a Periodontist
The periodontist is able to perform a wide range of treatments to halt the progression of gum disease, replace missing teeth and make the appearance of the smile more aesthetically pleasing.
Here are some of the treatments commonly performed by the periodontist:
- Implant placement – When a tooth or several teeth are missing, the periodontist is able to create a natural-looking replacement by anchoring a prosthetic tooth to the jawbone.
- Bone grafting – Dental implants can only be positioned if there is sufficient bone to attach the prosthetic tooth to. If bone loss has occurred, bone grafting is an excellent way to add or “grow” bone so that an implant may be properly secured.
- Osteoplasty (hard tissue re-contouring) – Once periodontitis has been treated, the periodontist can re-contour the hard tissue to make the smile both natural-looking and aesthetically pleasing.
- Gingivoplasty (soft tissue re-contouring) – At times the gingival tissues are higher on the tooth than is desirable. The periodontist can remove tissues or straighten the gum line to make the teeth look more even.
- Deep pocket cleanings – As gingivitis and periodontitis progress, it becomes more difficult to cleanse the pockets between the soft tissues and the teeth. The periodontist can scale and root plane the teeth (most often under local anesthetic) to remove debris and infection-causing bacteria.
- Crown lengthening – In order to expose more of the natural tooth, the periodontist can remove some of the surrounding gingival tissue.
The periodontist is a highly skilled dental health professional who is able to diagnose and treat many commonly occurring soft tissue and bone problems in the oral cavity.
Be sure to ask your periodontist if you have any questions or concerns.
When to See a Periodontist?
A periodontist is a dentist specializing in the prevention, diagnosis and treatment of infections and diseases in the soft tissues surrounding the teeth, and the jawbone to which the teeth are anchored. Periodontists have to train an additional three years beyond the four years of regular dental school, and are familiar with the most advanced techniques necessary to treat periodontal disease and place dental implants. Periodontists also perform a vast range of cosmetic procedures to enhance the smile to its fullest extent.
Periodontal disease begins when the toxins found in plaque start to attack the soft or gingival tissue surrounding the teeth. This bacterium embeds itself in the gum and rapidly breeds, causing a bacterial infection. As the infection progresses, it starts to burrow deeper into the tissue causing inflammation or irritation between the teeth and gums. The response of the body is to destroy the infected tissue, which is why the gums appear to recede. The resulting pockets between the teeth deepen and if no treatment is sought, the tissue which makes up the jawbone also recedes causing unstable teeth and tooth loss.
Referrals from General Dentists and Self-Referral
There are several ways treatment from a periodontist may be sought. In the course of a regular dental checkup, if the general dentist or hygienist finds symptoms of gingivitis or rapidly progressing periodontal disease, a consultation with a periodontist may be recommended. However, a referral is not necessary for a periodontal consultation.
If you experience any of these signs and symptoms, it is important that you schedule an appointment with a periodontist without delay:
- Bleeding while eating or brushing – Unexplained bleeding while consuming food or during the course of daily cleaning is one of the most common signs of periodontal infection.
- Bad breath – Continued halitosis (bad breath) which persists even when a rigorous oral hygiene program is in place, can be indicative of periodontitis, gingivitis or the beginnings of an infection in the gum tissues.
- Loose teeth and gum recession – Longer looking teeth can signal recession of the gums and bone loss due to periodontal disease. As this disease progresses and attacks the jawbone, (the anchor holding the teeth in place) the teeth may become loose or be lost altogether.
- Related health conditions – Heart disease, diabetes, osteopenia and osteoporosis are highly correlated with periodontitis and periodontal infections. The bacteria infection can spread through the blood stream and affect other parts of the body.
Diagnosis and Treatment
Before initiating any dental treatment, the periodontist must extensively examine the gums, jawbone and general condition of the teeth. When gingivitis or periodontal disease is officially diagnosed, the periodontist has a number of surgical and non-surgical options available to treat the underlying infection, halt the recession of the soft tissue, and restructure or replace teeth which may be missing.
- Gingivitis/mild periodontal disease– When the gum pockets exceed 4mm in depth, the periodontist or hygienist may perform scaling and root planing to remove debris from the pockets and allow them to heal. Education and advice will be provided on an effective cleaning regime thereafter.
- Moderate periodontal disease– If the gum pockets reach 4-6mm in length a more extensive scaling and root planning cleaning might be required. This cleaning is usually performed under local anesthetic.
- Advanced periodontal disease– Gum pockets in excess of 6-7mm are usually accompanied by bone loss and gum recession. Scaling and root planning will usually be performed as the initial nonsurgical treatment. In addition to those nonsurgical treatments, the periodontist may recommend surgical treatment to reduce pocket depth
- Tooth loss – Where one or several teeth are missing due to periodontal disease, dental implants are an effective option. If the bone is strong enough to provide a suitable anchor for the prosthetic tooth, the implant can be placed. However, if the bone is severely eroded, bone grafts may be performed by the periodontist to provide a suitable anchor for the new tooth/teeth.
Ask your periodontist if you have questions about periodontal disease, periodontal treatment or dental implants.
Periodontal Scaling & Root Planing (SRP)
The objective of scaling & root planning is to remove etiologic agents which cause inflammation to the gingival (gum) tissue and surrounding bone. Common etiologic agents removed by this conventional periodontal therapy include dental plaque and tartar (calculus).
These non-surgical procedures which completely cleanse the periodontium, work very effectively for individuals suffering from gingivitis (mild gum inflammation) and moderate/severe periodontal disease.
Reasons for scaling and root planing
Scaling and root planning can be used both as a preventative measure and as a stand-alone treatment. These procedures are performed as a preventative measure for a periodontitis sufferer.
Here are some reasons why these dental procedures may be necessary:
- Disease prevention – The oral bacteria which cause periodontal infections can travel via the bloodstream to other parts of the body. Research has shown that lung infections and heart disease have been linked to periodontal bacteria. Scaling and root planing remove bacteria and halts periodontal disease from progressing, thus preventing the bacteria from traveling to other parts of the body.
- Tooth protection – When gum pockets exceed 3mm in depth, there is a greater risk of periodontal disease. As pockets deepen, they tend to house more colonies of dangerous bacteria. Eventually, a chronic inflammatory response by the body begins to destroy gingival and bone tissue which may lead to tooth loss. Periodontal disease is the number one cause of tooth loss in the developed world.
- Aesthetic effects – Scaling and root planing help remove tartar and plaque from the teeth and below the gum line. As an added bonus, if superficial stains are present on the teeth, they will be removed in the process of the scaling and root planning procedure.
- Better breath – One of the most common signs of periodontal disease is halitosis (bad breath). Food particles and bacteria can cause a persistent bad odor in the oral cavity which is alleviated with cleaning procedures such as scaling and root planing
What do scaling and root planing treatments involve?
Scaling and root planing treatments are only performed after a thorough examination of the mouth. The dentist will take X-rays, conduct visual examinations and make a diagnosis before recommending or beginning these procedures.
Depending on the current condition of the gums, the amount of calculus (tartar) present, the depth of the pockets and the progression of the periodontitis, local anesthetic may be used.
Scaling – This procedure is usually performed with special dental instruments and may include an ultrasonic scaling tool. The scaling tool removes calculus and plaque from the surface of the crown and root surfaces. In many cases, the scaling tool includes an irrigation process that can also be used to deliver an antimicrobial agent below the gums that can help reduce oral bacteria.
Root Planing – This procedure is a specific treatment which serves to remove cementum and surface dentin that is embedded with unwanted microorganisms, toxins and tartar. The root of the tooth is literally smoothed in order to promote good healing. Having clean, smooth root surfaces helps bacteria from easily colonizing in future. Diseased cementum is also removed. This procedure most often requires local anesthetic.
During the next appointment, the dentist or hygienist will thoroughly examine the gums again to see how well the pockets have healed. If the gum pockets still measure more than 3mm in depth, additional and more intensive treatments may be recommended.
If you have any concerns or questions about scaling and root planing, or periodontal disease, please ask your dentist.
Scaling & Root Planing Case Example #1
Pocket Reduction Surgery
Pocket reduction surgery (also known as gingivectomy, osseous surgery and flap surgery) is a collective term for a series of several different surgeries aimed at gaining access to the roots of the teeth in order to remove bacteria and tartar (calculus). This is the PRIMARY goal of pocket reduction surgery. Studies have shown that this is necessary for deeper pockets (generally exceeding 5 mm) because non-surgical scaling & root planing is effective to only 3.5mm pocket depth!
The human mouth contains dozens of different bacteria at any given time. The bacteria found in plaque (the sticky substance on teeth) produce acids that lead to demineralization of the tooth surface, and ultimately contribute to periodontal disease.
Periodontal infections cause a chronic inflammatory response in the body that literally destroys bone and gum tissues once they invade the sub-gingival area (below the gum line). Gum pockets form and deepen between the gums and teeth as the tissue continues to be destroyed.
Periodontal disease is a progressive condition which, if left untreated, causes massive bacteria colonization in gum pockets can eventually lead to teeth falling out. Pocket reduction surgery is an attempt to alleviate this destructive cycle, and reduce the depth of the bacteria-harboring pockets.
Reasons for the pocket reduction surgery
Pocket reduction surgery is a common periodontal procedure which has been proven effective at eliminating bacteria, reducing inflammation and saving teeth. The goals of pocket reduction surgery are:
- Reducing bacterial spread – Oral bacteria has been connected to many other serious conditions such as diabetes, heart disease and stroke. Oral bacteria can travel to various parts of the body from inside the bloodstream and begin to colonize. It is important to decrease bacteria in the mouth in order to reduce the risk of secondary infection.
- Halting bone loss – The chronic inflammatory response induced by oral bacteria leads the body to destroy bone tissue. As the jawbone becomes affected by periodontal disease, the teeth lose their rigid anchor. When the teeth become too loose, they may require extraction.
- Facilitate home care – As the gum pockets become progressively deeper, they become incredibly difficult to clean by the patient. The toothbrush and dental floss cannot reach to the bottom of the pockets, increasing the risk of further periodontal infections.
- Enhancing the smile – An oral cavity that is affected by periodontal disease is not attractive to the eye. In fact, smiles may be marred by brown gums, rotting teeth and ridge indentations. Pocket reduction surgery halts the progression of gum disease and improves the aesthetics of the smile.
What does pocket reduction surgery involve?
Before recommending treatment or performing any procedure, the dentist will perform thorough visual and x-ray examinations in order to assess the condition of the teeth, gums and underlying bone. Pocket reduction surgery may be performed under local or general anesthetic depending on the preferences of the patient.
The gums will be gently pulled back from the teeth and bacteria and calculus (tartar) will be eliminated. Scaling and root planing will generally be required to fully remove the ossification (tartar) from the surface of the tooth root. If the root is not completely smooth, a planing procedure will be performed to ensure that when the gums do heal, they will not reattach to rough or uneven surfaces.
The gum is then sutured with tiny stitches that dissolve in 5-10 days. A periodontal bandage may be placed to cover the surgical site during healing.
Though the gums will be more sensitive immediately following the procedure, there will be a significant reduction in pocket depth and a vast improvement in the condition of the teeth and gums.
One of the first surgical procedures used in periodontics, the gingivectomy consists of removal of part of the gum tissue. This procedure is useful when there has been an overgrowth of tissue, as in dilantin hyperplasia, or when a pocket has formed without bone problems. The excess tissue is cut away to remove the pocket, so the patient and hygienist can more easily clean the gum and tooth.
The gingiva is thick and irregular. Supra-bony pockets are present.
Tissues are now thin and parabolic. Craters have been removed and pockets decreased.
The gingivectomy is only done when the bone does not have to be accessed, and when there is adequate “hard” gum. In most cases that are treated by a periodontist, the bone itself has become involved, and unless that bone is treated, the case is not successful. In these circumstances, the gingivectomy is not appropriate. In addition, it is necessary to have a margin of “hard” or keratinized gum, and if the gingivectomy would remove all the hard gum, it should not be used.
By far the most common surgery used in periodontal therapy is flap surgery. Moderate to advanced periodontal disease involved gum pockets that are too deep to clean without reflecting back the gum tissue for access. Without this access, deep calculus and plaque cannot be removed from the root, and the disease will progress leading to further bone loss and eventually tooth loss.
Deep pocket with calculus
Flap reflected to access calculus
Once the pocket is cleaned, the gum may be returned to its original level.
A) Gum sutured back to normal height, leaving a deepened space
This results in a clean root, but the deepened space is still present. Frequent cleanings by the hygienist are necessary to remove the plaque in the residual pocket that the patient cannot reach with flossing and brushing. Even when there is good oral hygiene and regular quarterly recalls, the bacteria may still continue to cause the pocket to become re-infected. When cosmetics are not a concern (on the lower teeth, the inside of the upper teeth, and the outside of the upper back teeth), the surgeon may elect to suture the gum down to where the bone has resorbed, reducing the depth of the space.
B) Gum sutured down to bone to reduce residual space
If the space is reduced to 3 millimeters or less, the patient is able to reach the bottom of the space with daily brushing and flossing, eliminating the disease.
In the majority of advanced cases, the bacteria have caused the bone to resorb and become pitted. In these cases flap surgery gives access not only for root cleansing, but allows for re-contouring of the bone itself. By performing this osseous surgery, and reshaping the bone to its natural scalloped shape, it is generally possible to eliminate moderate pockets. The patient is then able to prevent recurrence of the disease by keeping the shallow space clean with brushing and flossing.
A study was done which compared approach A (replacement of the flap in its original position) with B (placing the flap at the bone crest) after osseous [bone] re-contouring. After 1 year both procedures achieved equal results. After 5 years however, the pockets in group B remained decreased while those in group A recurred. Thus, for long term health it is essential to eliminate bone irregularities. (Olsen, International Journal of Periodontics & Restorative Dentistry 4/1985)
In summary, for most moderate and advanced cases, it is important to be able to reach far under the gum to treat the infection and diseased tissues. By using flap surgery, the periodontist is able to access these areas to provide the optimal care available. With today’s medications, surgery should be painless with only a minimal amount of post-operative discomfort.
Bone re-contoured after flap reflected.
Tissue sutured down to smooth bone to eliminate pocket.
Flap surgery is also needed if regeneration procedures are to be performed. Here the gum is reflected back to allow insertion of bone or guided tissue regeneration membranes
Flap reflected to allow bone implant
Flap re-sutured over bone implant
Flap reflected to insert membrane
Flap re-sutured over membrane
The ideal outcome in the treatment of periodontal disease is to return the tissues to their original state, as they were before the infection started. While we cannot do this with all cases, today more and more pockets can be restored, at least partially, with regenerative surgery.
Three Types of Regenerative Surgery
There are three primary types of regenerative surgery:
- Bone Grafting
The oldest technique used in regeneration surgery calls for placing various materials in the bone defect, to stimulate the patient’s bone to re-grow. Bone grafting has been used for over 75 years, but today’s materials are much superior in stimulating new bone to form. The implanted material is resorbed by the body, and after 6-12 months has completely disappeared, replaced by the patient’s own new bone. Various materials are available, with the selection made on a case by case basis.
Placing substitute bone
Substitute bone placed in defect
Placing bone stimulates patient’s natural bone to regenerate
- Guided Tissue Regeneration
A more recently developed type of regenerative surgery depends on guiding the proper tissue to heal the periodontal lesions. Gum tissue heals very quickly, and after surgery migrates down into the bone pocket quickly. Unfortunately, this does not allow time for the bone to refill the pocket, so the defect persists. With guided tissue regeneration, the gum tissue is excluded from the bone defect with a re-absorbable membrane, allowing time for the bone to fill back in. This technique has been available for 18 years, and in certain areas is extremely predictable. It is utilized with or without bone graft materials.
- Cell Stimulation
The most recent development in periodontal regeneration is the use of proteins to induce the formation of tooth supporting structures lost to periodontal disease. Available since 1999, the procedure calls for placing embryonic cells into the defect, which in turn stimulate production of new bone and tissue cells which reform the normal periodontal complex. These cells are porcine (pig), and carry no risk of disease transmission. While long-term studies are not yet available, the research to date warrants use of this approach under certain circumstances. Many other regenerative chemicals are available today.
The periodontist must decide in each case whether the chances of improvement warrant the added expense of bone regeneration. However, restoring bone and the periodontal complex is the gold standard, and periodontal regeneration is being used more and more.
Root amputation is a specialized dental procedure, whereby one root is removed from a multi-root tooth. The tooth is then stabilized and rendered fully functional with a crown or filling. The multi-root teeth best suited to the root amputation procedure are the molars at the back of the mouth. These large flat teeth have either two or three roots depending on whether they are situated on the upper or lower jaw.
The general purpose of root amputation is to save an injured or diseased tooth from extraction. Most dentists agree that there is no better alternative than retaining a healthy natural tooth, and the root amputation procedure makes this possible. Dental implants, extensive bridgework and custom-made tooth replacements can be expensive and time-consuming. Generally, root amputation and the necessary crown work are less expensive and can be completed in 1-3 short visits.
When is root amputation necessary?
It is important to note that root amputation can only be performed on an otherwise healthy tooth. Even in the case of a “key” tooth, extraction will be performed if the tooth is diseased, badly fractured or otherwise injured. Suitable teeth for root amputation have a healthy tooth surface, strong bone support and healthy underlying gums.
There are several problems that may lead to root amputation including:
- Broken, fractured or injured teeth and roots.
- Embedded bacteria within the structure of the root.
- Severe bone loss in a concentrated area due to periodontitis.
- Tooth decay in a concentrated area of the tooth.
What does root amputation involve?
Prior to or after root amputation, it is necessary to perform root canal treatment. The amputation itself involves cutting deep into the tooth where blood vessels and nerves are located. For this reason, the pulp of the tooth including these vessels and nerves needs to be removed due to re-sectioning the roots. The root canal and amputation treatments will be performed under local anesthetic.
During the root amputation procedure, a small incision will be created in the gum to fully expose the roots of the affected tooth. The root will be sectioned off from the rest of the tooth and then removed. To kill any remaining bacteria, the whole area will be cleansed with saline solution, and then sutures (stitches) will be applied to seal the incision.
Finally, a temporary crown or filling will be placed to secure the tooth. Depending on the specific situation, painkillers, antibiotics and a medicated anti-microbial mouthwash may be prescribed. In 7-10 days, the stitches will be removed and the gum will have healed. Arrangements can now be made to place the permanent crown or filling.
If you have any questions or concerns about root amputation, please ask your dentist.
Root Amputation Case Example
Bruxism refers to an oral parafunctional activity which occurs in most humans at some point in their lives. The grinding of the teeth and the clenching of the jaw are the two main characteristics of this condition, which can occur either during the day or at night.
Bruxism is one of the most common known sleep disorders and causes most of its damage during sleeping hours. The clenching and grinding which accompanies bruxism is symptomatic of a malfunctioning chewing reflex, which is turned off in non-sufferers when sleeping. For sufferers, deep sleep or even naps, cause the reflex nerve control center in the brain to turn off, and the reflex pathways to become active.
Typically, the incisors and canines (front 6 upper and lower teeth) of opposing arches grind against each other laterally. This side to side action puts undue strain on the medial pterygoid muscles and the temporomandibular joints. Earache, depression, headaches, eating disorders and anxiety are amongst the most common symptoms of bruxism; which often accompanies chronic stress, Alzheimer’s disease and alcohol abuse.
Bruxism is frequently misdiagnosed or not diagnosed at all, because it is only one of several potential causes of tooth wear. Only a trained professional can tell the difference between bruxing wear and wear caused by overly aggressive brushing, acidic soft drinks and abrasive foods.
Reasons for the Treatment of Bruxism
Here are some of the main reasons why bruxism should be promptly treated:
- Gum recession and tooth loss– Bruxism is one of the leading causes of gum recession and tooth loss; firstly because it damages the soft tissue directly, and secondly because it leads to loose teeth and deep pockets where bacteria can colonize and destroy the supporting bone.
- Occlusal trauma– The abnormal wear patterns on the occlusal (chewing) surfaces can lead to fractures in the teeth, which may require restorative treatment.
- Arthritis – In severe and chronic cases, bruxing can eventually lead to painful arthritis in the temporomandibular (TMJ) joints (the joints that allow the jaw to open smoothly).
- Myofascial pain – The grinding associated with bruxism can eventually shorten and blunt the teeth. This can lead to muscle pain in the myofascial region and debilitating headaches.
Treatment Options for Bruxism
There is no single cure for bruxism, though a variety of helpful devices and tools are available. Here are some common ways in which bruxism is treated:
- Occlusal Adjustments – Uneven pressures on the dentition can lead to bruxism. The dentist can alter the way the teeth meet by grinding on the enamel of the tooth to erode an even distribution of forces.
- Mouthguards – An acrylic mouthguard can be designed from tooth impressions to minimize the abrasive action of tooth surfaces during normal sleep. Mouthguards should be worn on a long-term basis to help prevent tooth damage, damage to the temporomandibular joint and help to stabilize the occlusion.
Other methods of treatment include relaxation exercises, stress management education and biofeedback mechanisms. When the bruxing is under control, there are a variety of dental procedures such as crowns, gum grafts and crown lengthening that can restore a pleasant aesthetic appearance to the smile.
If you have questions or concerns about bruxism, please ask your dentist.
Gum recession is an incredibly widespread problem that dentists diagnose and treat on a daily basis. It is important to thoroughly examine the affected areas and make an accurate diagnosis of the actual underlying problem. Once the cause of the gum recession has been determined, surgical and non-surgical procedures can be performed to halt the progress of the recession, and prevent it from occurring in the future.
About Gum Recession
The following symptoms may be indicative of gum recession:
- Sensitive teeth – When the gums recede enough to expose the cementum protecting the tooth root, the dentin tubules beneath will become more susceptible to external stimuli.
- Visible roots – This is one of the main characteristics of a more severe case of gum recession. When there is root exposure it also means there is bone loss.
- Longer-looking teeth – Individuals experiencing gingival recession often have a “toothy” smile. The length of the teeth is perfectly normal, but the gum tissue has been lost, making the teeth appear longer.
- Halitosis, inflammation and bleeding – These symptoms are characteristic of gingivitis or periodontal disease. A bacterial infection causes the gums to recede from the teeth and may cause tooth loss if not treated promptly.
In health, there are two types of gum tissues that surround the tooth. The part that is around the neck of the tooth is firmly attached to the tooth and underlying bone, and is called attached gingiva. The attached gingiva is immovable and tough, and deflects food as it hits the gum. Below the attached gingiva is looser gum, or alveolar mucosa. This tissue contains muscle, and is flexible to allow movement of the cheeks and lips. The muscles in the alveolar mucosa are constantly contracting, which pulls on the bottom edge of the attached gingiva. However, normally the attached gingiva is wide and strong enough to act as a barrier, which prevents the gum from being pulled down (receding).
Adequate attached (hard) gum to prevent spontaneous recession. No grafting needed.
Some people are born without sufficient attached gingiva to prevent the muscle in the alveolar mucosa from pulling the gum down. In these cases the gum slowly continues to recede over time, even though the patient may be very conscientious with their oral health. This is not an infection, as is seen with periodontal disease, but rather simply an anatomic condition. Unfortunately, bone recession is occurring at the same time the gum is receding. This is because the bone, which is just under the gum, will not allow itself to become exposed to the oral cavity and moves down with the gum.
A lack of attached gingiva is sometimes associated with a high frenum attachment, which exaggerates the pull on the gum margin. A frenum is a naturally occurring muscle attachment, normally seen between the front teeth (either upper or lower). It is normal to have a frenum, but it should not pull on the gum margin or recession will occur. If pulling is seen, the frenum is surgically released from the gum with a frenectomy. Often a new band of hard gum is also added to re-establish an adequate amount of attached gingiva (see below).
Child with naturally occuring high frenum attachment
High frenum with lack of attached gum causing muscle pull and tooth separation
After frenum removal, and addition of adequate attached gingiva
With the wear and tear of time, even normal attached gum can be worn away, generally from vigorous brushing. This often happens in people with naturally thin tissues, or when the tissues have been stretched during orthodontics. If there is still adequate attached gum to act as a barrier to the muscle, the treatment for recession is to ensure further damage isn’t done when brushing. However, if the attached gum is worn to the point where it cannot resist the constant pull of the mucosa, recession will continue unless a new hard band of gum is placed. Unchecked, the recession can cause tooth loss as the bone recedes with the tissue and tooth support weakens.
Soft Tissue Grafting
Soft tissue grafting is an extremely versatile procedure that has many uses. Recent developments in dental technology have made soft tissue grafting more predictable and less intrusive. Here are some of the main benefits associated with soft tissue grafting treatment:
- Increased comfort – Root exposure can cause substantial pain and discomfort. Eating hot, cold or even warm foods can cause severe discomfort. Soft tissue grafts cover the exposed root, decreases sensitivity and restore good health to the gum area.
- Improved aesthetics– Gum recession due to periodontal disease can cause the smile to look “toothy” or the teeth to appear uneven in size. Soft tissue grafting can be used as a cosmetic procedure to re-augment the gums, and make the smile appear more symmetrical.
- Improved gum health– Periodontal disease is a progressive condition that can destroy soft tissue very rapidly. When used in combination with deep cleaning procedures, soft tissue grafting can halt tissue and bone loss, and protect exposed roots from further complications.
Three Types of Common Soft Tissue Grafts
The three different types of common soft tissue grafts include:
- Free gingival graft– A strip of tissue is removed from the roof of the mouth and stitched to the grafting site in order to promote natural growth. This type of graft is most commonly used for thickening existing tissue.
- Connective tissue graft– For larger areas or root exposure, subepithelial tissue is needed to remedy the problem. This subepithelial connective tissue is removed from a small flap in the mouth and sutured to the grafting site. This is the most common treatment for root exposure.
- Pedicle graft– This type of graft involves the “sharing” of soft tissue between the affected site and adjacent gum. A flap of tissue is partially cut away and moved sideways to cover the root. The results of this type of graft are excellent because the tissue that is moved to the adjacent area includes blood vessels that are left in place.
The replacement of missing attached gum is called gingival grafting. The muscle that is pulling down on the edge of the gum is first surgically resected and repositioned away from the gum margin. Then a small piece of attached gingiva is taken from the roof of the mouth, just adjacent to the back teeth, and transplanted to the site in question. The new tissue reattaches and reforms a new layer of attached gum, which should last a lifetime with proper care. The roof of the mouth heals quickly, just like a skinned knee might. With this procedure the root is not covered, and the tissue stays at the same level as before, except with attached gingiva at the margin. These procedures are very easy on the patient, and rarely require more than over-the-counter pain pills post-operatively (ibuprofen). The most difficult part of the surgery is not chewing on the area for 2 weeks.
Routine gum grafts (“free gingival grafts”) do not cover up the exposed root surface – if this is desired, a different technique is used. Covering the root does not make the tooth stronger, for the bone, which actually holds the tooth in place, does not change regardless of the new gum level. Root coverage procedures are primarily done for cosmetic reasons, treatment of root sensitivity, prevention of root decay and stabilization of the gingival margin.
Soft Tissue Graft Case Examples
Soft Tissue Graft Case #1
Soft Tissue Graft Case #2
Soft Tissue Graft Case #3
The part of the tooth that is seen above the gum is called the clinical crown. When not enough of the clinical crown is showing, the gum must be moved up the root to expose more teeth. This is called crown lengthening.
About Crown Lengthening
There are three situations in which crown lengthening is commonly performed:
- To improve esthetics,
- To allow the dentist better access to decay, and
- To increase retention of the final crown.
A second indication for crown lengthening is to access decay.
Below is an example of how the procedure works to enhance the esthetics of a smile.
Short clinical crown is cosmetically unpleasing
After crown lengthening, a new crown results in a beautiful smile
A second common use of crown lengthening is to access decay. If the dentist is unable to reach decay that is deep under the gum, the tooth will be lost. As a rule, simply trimming back the gum is not sufficient, for the bone would be exposed. Rather, the periodontist must reflect a flap (See Flap Surgery), trim back the bone to allow for access to the decay, and then suture the gum back at the lower level. Sufficient bone must be removed to allow room below the decay for the gum to reattach to the tooth.
Most crown lengthening procedures are very straightforward, and there is little or no post-operative discomfort. Sutures and dressing are removed after about 2 weeks.
If a crown is to be placed in a cosmetic area, the restorative dentist should wait 8-12 weeks following crown lengthening before taking final impressions. This ensures that the gum, which shrinks slightly as it re-attaches to the tooth during healing, is in its final position. If the margin of the crown is placed at the gum level before final healing, and additional shrinkage occurs, the results may be unsightly. A temporary crown can be placed two to three weeks after surgery if the patient desires to cover the exposed root during this healing period.
The third indication for crown lengthening is to increase retention of the final prosthesis. Following removal of severe decay or due to severe tooth wear, sometimes there is inadequate tooth structure to firmly retain a crown. Crown lengthening exposes more of the clinical tooth, providing more tooth structure for the prosthesis to hold on to.
Crown Lengthening Case Examples
Crown Lengthening Case #1
Crown Lengthening Case #2 – Esthetic Enhancement
Crown Lengthening Case #3
Systemic Antibiotic Therapy
Systemic antibiotics are drugs that, when given, affect the whole body. Normally they are administered in pill form when used in periodontal treatment. Periodontists use systemic antibiotics to treat acute infections, such as a gum abscess (gum boil), and also before treatment when patients have certain medical conditions, such as congenital heart defects and artificial heart valves or joints. (See Prophylactic Antibiotics). Systemic antibiotics are also recommended for two weeks after regeneration procedures and when implants are placed. This is done to make sure there is no infection during the early healing stages, which are critical with these surgical procedures.
Because periodontal disease is an infection, it would seem logical that antibiotics would eliminate the problem. Unfortunately, when treating routine periodontal breakdown, the effects of antibiotics are short-lived. This is because the bacteria that cause the disease reform immediately after the antibiotics are discontinued. In fact, periodontal cleanings done to remove calculus and plaque appear to be as effective as antibiotics in controlling the infection.
As a rule, for most routine periodontal conditions, systemic antibiotics are not necessary or even useful. In some advanced cases there may be very specific harmful bacteria that can be eradicated with systemic antibiotics. For these cases, a short-term treatment of antibiotics may be useful. In cases where traditional treatment does not produce the expected results, the mouth may be cultured to analyze which specific bacteria are present. This will guide the therapist on which antibiotic to use.
Because overuse of systemic antibiotics can cause patient sensitivity and bacterial resistance, they should be used only when specifically indicated.
Low Dose Antibiotics
Recently there has been interest in the use of low dose antibiotics. The dose is so low the drug does not act to kill bacteria, but rather to change the way the body responds to infection.
One interesting effect of certain antibiotics is they not only kill the bacteria that may cause periodontal disease, but they also reduce the body’s production of collagenase, an enzyme that destroys gingival tissues. We all need some collagenase as older tissue is removed and replaced with new tissue.
However, in periodontal disease there seems to be an overproduction of collagenase, causing the body to destroy healthy gum tissue. The antibiotic doxycycline was found to combat these enzymes, even in doses so small that there was not an antibiotic effect. The advantage of a smaller dose is decreased formation of resistant bacteria and fewer unwanted side effects.
Periostat is a 20 mg capsule of doxycycline, and two clinical studies have shown that patients who take 2 capsules daily have a reduction in clinical inflammation. The studies were limited to 9 months, and so there is no official recommendation to take the product for a longer period. From a practical standpoint it seems that Periostat can be taken indefinitely. However, some preliminary work indicates that there is a positive residual effect for 3 months after stopping the drug, and so some practitioners recommend taking Periostat three months on, three months off. The daily 40mg doses are so low as not to qualify as an antibiotic, and there is no known effect on the pocket bacteria. Thus Periostat must be used in conjunction with other therapies that address bacterial removal. Indications for Periostat are generally seen in recall patients who are not responding well to conventional treatment, and have generalized inflammation in spite of reasonable oral hygiene.
Local Antibiotic Therapy
While systemic antibiotics have a very limited use in treating typical periodontal disease, there has been much interest in local antibiotic delivery. If an antibiotic can be delivered directly to the pocket, without the patient having to take systemic doses, there are far fewer side effects and fewer chances of resistant bacteria forming. In addition, with direct local delivery, the concentration of the antibiotic at the diseased site can be 100 times greater than taking the medication orally. However, it is important to note that all local delivery antibiotics are recommended as adjuncts to scaling and root debridement, and not as stand-alone treatments.
Systemic antibiotics are diluted before reaching the pocket. With local application, the antibiotic is inserted directly into the pocket, resulting in much higher concentrations
The most recent local antibiotic therapy introduced consists of small spheres of minocycline, a derivative of tetracycline. This drug is very effective in killing the bacteria that are thought to cause periodontal disease. The primary advantage of this new product is the ease of use. The spheres, which look like a fine powder, are contained in a small plastic canula, and are injected into the pocket. This requires no anesthesia. The spheres are bioadhesive, and stick to the pocket wall where they slowly release minocycline over a 14-21 day period. Because the spheres are also bioresorbable, they do not require removal.
Generally speaking, local delivery antibiotics are used in the Periodontal Maintenance phase of therapy, when isolated areas of the mouth seem to be deteriorating. Their use is generally not recommended during the active phase of treatment. The effectiveness of these products is somewhat controversial, and while there is usually some improvement, whether there are any long-term benefits has yet to be demonstrated. Certain cases appear to respond better than others, and your periodontist will help advise you whether these treatments may be beneficial in your particular case.