Periodontics

The term “periodontics” refers to the dental specialty that pertains to the prevention, diagnosis and treatment of periodontal disease that affects the gums and jawbone. The gum tissues serve to surround and support the teeth and the underlying jawbone anchors teeth firmly in place. Periodontists have completed several years of extra dental training and are concerned with maintaining the function, health and aesthetics of the jawbone and tissues.

---

Periodontal disease is a progressive condition which begins with mild gum inflammation called gingivitis. It is the leading cause of tooth loss in adults living in the developed world, and should be taken very seriously. Periodontal disease (often called gum disease) is typically signified by red, swollen, painful, or bleeding gums, but in some cases has no noticeable symptoms.

Periodontal disease generally begins when the bacteria living in plaque cause an infection in the surrounding tissues of the teeth, causing them to become irritated and painful. Eventually, this infection will; cause the jawbone to recede and the tooth to become loose.

There are several reasons why periodontal treatment may be necessary:

Moderate/advanced gum disease – This occurs when the gums are bleeding, swollen or red around most teeth and the jawbone has begun to recede.

Localized gum recession – The infection which propagates moderate or advanced gum disease often begins in one area. Gum recession may also be caused due to over brushing with a hard bristle brush, or due to a tooth that is not positioned properly. Immediate treatment is required to prevent further spreading.

Before crown lengthening – The periodontist may lengthen the crown of the tooth by removing surrounding soft tissue to provide more tooth exposure.

Ridge augmentation – This procedure, often called “recontouring” may be required to correct an uneven gum line. Before embarking on treatment, a periodontist needs to treat any bacterial infections and periodontitis.

In the case of mild/moderate periodontal problems, the focus of the periodontist will be on curing the underlying bacterial infection and then providing advice on the most appropriate home cleaning methods.

Sometimes a deep scaling is needed to remove the bacterial plaque and calculus (tartar) from the teeth and tissues. Where periodontal disease is advanced and the jawbone has regressed significantly, more intensive cleaning may be recommended and loose teeth that cannot be saved will be removed.

The periodontist is trained in all aspects of dental implant procedures, which can restore functionality to the mouth when teeth have been affected by periodontitis.

Because periodontal disease is progressive, it is essential to remove the bacteria and calculus build up to halt the spread of the infection. Your dentist will be happy to advise you on effective cleaning methods and treatment options.

---

Periodontal disease is the leading cause of bone loss in the oral cavity, though there are others such as ill-fitting dentures and facial trauma. The bone grafting procedure is an excellent way to replace lost bone tissue and encourage natural bone growth. Bone grafting is a versatile and predictable procedure which fulfills a wide variety of functions.

A bone graft may be required to create a stable base for dental implant placement, to halt the progression of gum disease or to make the smile appear more aesthetically pleasing.

There are several types of dental bone grafts. The following are the most common:

Autogenous bone graft – In this type of graft the bone is removed from elsewhere in the body and implanted in the mouth. Common donor sites for bone grafting include the iliac section of the pelvis, the chin and the posterior third molar areas of the jaw. If large amounts of bone need to be harvested, the hip or the shin bone (tibia) is generally used.

Allograft – Synthetic bone (man made) can be created in the laboratory and used in the bone grafting procedure. Bone can also be obtained from a bone bank (cadaver bone).

Xenograft – This is the implantation of bovine (cow) bone. A xenograft is perfectly safe and has been used successfully for many years. Ample bone can be obtained and no secondary donor site is necessary.
Reasons for bone grafting

There are a wide variety of reasons why bone grafting may be the best option for restoring the jaw bone.

Dental implants – Implants are the preferred replacement method for missing teeth because they restore full functionality to the mouth; however, implants need to be firmly anchored to the jawbone to be effective. If the jawbone lacks the necessary quality or quantity of bone, bone grafting can strengthen and thicken the implant site.

Sinus lift – A sinus lift entails elevating the sinus membrane and grafting bone onto the sinus floor so that implants can be securely placed.

Ridge augmentation – Ridges in the bone can occur due to trauma, injury, birth defects or severe periodontal disease. The bone graft is used to fill in the ridge and make the jawbone a uniform shape.

Nerve repositioning – If the inferior alveolar nerve requires movement to allow for the placement of implants, a bone grafting procedure may be required. The inferior alveolar nerve allows feeling and sensation in the lower chin and lip.

What does bone grafting treatment involve?

Bone grafting is a fairly simple procedure which may be performed under local anesthetic; however if large amounts of bone area need to be grafted, general anesthetic may be required.

Initially, the grafting material needs to either be harvested or prepared for insertion. A small incision is made in the gum tissue and then gently separated from the bone. The bone grafting material is then placed at the affected site.

The bone regeneration process may be aided by:

Gum/bone tissue regeneration – A thin barrier (membrane) is placed below the gum line over the grafting material. This barrier creates enough space for healthy tissue to grow and separates the faster growing gum tissue from the slower growing fibers. This means that bone cells can migrate to the protected area and grow naturally.

Tissue stimulating proteins – Enamel matrix proteins occur during natural tooth development. Emdogain is a matrix protein product which is usually placed on the affected site before the gum is sutured. It mediates the formation of accellular cementum on the tooth which provides a foundation to allow periodontal attachment to occur. Tissue stimulating proteins help to create lost support in areas affected by periodontal defects.

Platelet-rich growth factors –A high platelet concentration liquid can be used to create a blood clot at the site of a wound. It has recently been discovered that PRGF also stimulates bone growth – meaning a denser graft in a shorter time period.

The gum is sutured in place and a follow up appointment will need to be made within 10 days to assess progress. Bone grafting is a highly successful treatment and a good base for further periodontal restorations.

If you have any questions about bone grafting, please ask your dentist.

---

Crown lengthening is generally performed in order to improve the health of the gum tissue, or to prepare the mouth for restorative or cosmetic procedures. In addition, crown lengthening procedures can also be used to correct a “gummy” smile, where teeth are covered with excess gum tissue. Crown lengthening exposes more of the natural tooth by reshaping or recontouring bone and gum tissue. This treatment can be performed on a single tooth, many teeth or the entire gum line, to expose a pleasant, aesthetically pleasing smile.

Reasons for crown lengthening

Crown lengthening is a versatile and common procedure that has many effective uses and benefits. The vast majority of patients who have undergone this type of surgery are highly delighted with the results.

Here are some of the most common reasons for crown lengthening:

Restoration of damaged teeth – Periodontal disease can cause severe damage to the teeth, as can trauma and decay. Where teeth have been broken beneath the gum line, crown lengthening can be used to prepare the area for a new restoration to correct the damaged teeth.

Cosmetic uses – Extra gum tissue can make teeth look unnaturally short, and also increase susceptibility to periodontal infections. Removing excess gum tissue can restore a balanced, healthy look and thus improve the aesthetic appearance of the smile.

Dental crowns – Crown lengthening serves to provide more space between the supporting jawbone and dental crown. This prevents the new crown from damaging gum tissues and bone once it is in place.

What does crown lengthening involve?

Crown lengthening is normally performed under local anesthetic. The amount of time this procedure takes will largely depend in how many teeth are involved and whether a small amount of bone needs to be removed, in addition to the soft tissue. Any existing dental crowns will be removed prior to the procedure, and replaced immediately afterwards.

The dentist will make a series of small incisions around the soft tissue in order to separate the gums away from the teeth. Even if only one tooth requires the re-contour, neighboring teeth are usually treated to provide a more even reshaping. Separating the gums provides the dentist with access to the roots of the teeth and the underlying bone.

In some cases, the removal of a small amount of tissue will provide enough tooth exposure to place a crown. In other cases, the dentist will also need to remove a small amount of bone from around the teeth. The bone is usually removed using a combination of special hand instruments, and rotary instruments. The rotary instruments roughly resemble the drill that is used in cavity treatment.

When the dentist is satisfied the teeth have sufficient exposure, the wound will be cleaned with sterile water and the gum tissue will be sutured with small stitches. The teeth will look noticeably longer immediately after surgery because the gums have now been repositioned.

The dentist will secure the surgical site using an intraoral (periodontal) bandage, which serves to prevent infection. Prescriptions may be provided for pain medication, and a chlorhexidine (antimicrobial) mouth rinse may be given to help reduce any bacteria attempting to re-colonize. The surgical site will be completely healed in approximately two to three months.

If you have any questions about crown lengthening, please ask your dentist.

---

A gum graft (also known as a gingival graft or periodontal plastic surgery), is a collective name for surgical periodontal procedures that aim to cover an exposed tooth root surface with grafted oral tissue.

Exposed tooth roots are usually the result of gingival recession due to periodontal disease. There are other common causes, including overly aggressive brushing and trauma.

Here are some of the most common types of gum grafting:

Free gingival graft – This procedure is often used to thicken gum tissue. A layer of tissue is removed from the palate and relocated to the area affected by gum recession. Both sites will quickly heal without permanent damage.

Subepithelial connective tissue graft – This procedure is commonly used to cover exposed roots. Tissue is removed fairly painlessly from the outer layer of the palate and relocated to the site of gum recession.

Acellular dermal matrix allograft – This procedure uses medically processed, donated human tissue as a tissue source for the graft. The advantage of this is procedure is that there is no need for a donor site from the patient’s palate (and thus, less pain).

Reasons for gum grafting

Gum grafting is a common periodontal procedure. Though the name might sound frightening, the procedure is commonly performed with excellent results.

Here are some of the major benefits associated with gum grafting:

Reduced sensitivity – When the tooth root becomes exposed, eating or drinking hot or cold foods can cause extreme sensitivity to the teeth. Gum grafting surgery permanently covers the exposed root, helps reduce discomfort, and restores the good health of the gums.

Improved appearance – Periodontal disease is characterized by gum recession and inflammation. Gum recession and root exposure can make the teeth look longer than normal and the smile to appear “toothy.” Gum grafting can make the teeth look shorter, more symmetrical and generally more pleasing to look at. In addition, adjacent tissue can be enhanced and augmented during the procedure for aesthetic purposes.

Improved gum health – Periodontal disease can progress and destroy gum tissue very rapidly. If left untreated, a large amount of gum tissue can be lost in a short period of time. Gum grafting can help halt tissue and bone loss; preventing further problems and protecting exposed roots from further decay.

What does gum grafting treatment involve?

Once the need for gum grafting surgery has been determined, there are several treatments the dentist will want perform before gum grafting takes place. First, the teeth must be thoroughly cleaned supra and subgingivally to remove calculus (tartar) and bacteria. The dentist can also provide literature, advice and educational tools to increase the effectiveness of homecare and help reduce the susceptibility of periodontal disease in the future.

The gum grafting procedure is usually performed under local anesthetic. The exact procedure will depend much on whether tissue is coming from the patient’s palate or a tissue bank.

Initially, small incisions will be made at the recipient site to create a small pocket to accommodate the graft. Then a split thickness incision is made and the connective tissue graft is inserted into the space between the two sections of tissue. The graft is usually slightly larger than the recession area, so some excess will be apparent.

Sutures are often placed to further stabilize the graft and to prevent any shifting from the designated site. Surgical material is used to protect the surgical area during the first week of healing. Uniformity and healing of the gums will be achieved in approximately six weeks.

If you have any questions about gum grafting, please ask your dentist.

---

Gingival recession (receding gums) refers to the progressive loss of gum tissue, which can eventually result in tooth root exposure if left untreated. Gum recession is most common in adults over the age of 40, but the process can begin in the teenage years.

Gum recession can be difficult to self-diagnose in its earlier stages because the changes often occur asymptomatically and gradually. Regular dental check ups will help to prevent gum recession and assess risk factors.

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.

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.

Causes of Gum Recession

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.

The most common causes of gingival recession are:

Overaggressive brushing – Over brushing can almost be as dangerous to the gums as too little. Brushing too hard or brushing with a hard-bristled toothbrush can erode the tooth enamel at the gum line, and irritate or inflame gum tissue.

Poor oral hygiene – When brushing and flossing are performed improperly or not at all, a plaque build up can begin to affect the teeth. The plaque contains various bacterial toxins which can promote infection and erode the underlying jawbone.

Chewing tobacco – Any kind of tobacco use has devastating effects on the entire oral cavity. Chewing tobacco in particular, aggravates the gingival lining of the mouth and causes gum recession if used continuously.

Periodontal disease – Periodontal disease can be a result of improper oral hygiene or caused by systemic diseases such as diabetes. The excess sugars in the mouth and narrowed blood vessels experienced by diabetics create a perfect environment for oral bacteria. The bacterium causes an infection which progresses deeper and deeper into the gum and bone tissue, eventually resulting in tooth loss.
Treatment of Gum Recession

Every case of gum recession is slightly different, and therefore many treatments are available. The nature of the problem which caused the recession to begin with needs to be addressed first.

If overly aggressive brushing techniques are eroding the gums, a softer toothbrush and a gentler brushing technique should be used. If poor oral hygiene is a problem, prophylaxis (professional dental cleaning) may be recommended to rid the gum pockets of debris and bacteria. In the case of a severe calculus (tartar) build up, scaling and root planing will be performed to heal the gingival inflammation and clean the teeth.

Once the cause of the gingival recession has been addressed, surgery of a more cosmetic or restorative nature may be recommended. Gum tissue regeneration and gum grafting are two excellent ways to restore natural symmetry to the gums and make the smile look more aesthetically pleasing.

If you have any questions or concerns about periodontal disease, periodontal treatments, or gum recession, please ask your dentist.

---

According to research conducted by the American Cancer society, more than 30,000 cases of oral cancer are diagnosed each year. More than 7,000 of these cases result in the death of the patient. The good news is that oral cancer can easily be diagnosed with an annual oral cancer exam, and effectively treated when caught in its earliest stages.

Oral cancer is a pathologic process which begins with an asymptomatic stage during which the usual cancer signs may not be readily noticeable. This makes the oral cancer examinations performed by the dentist critically important. Oral cancers can be of varied histologic types such as teratoma, adenocarcinoma and melanoma. The most common type of oral cancer is the malignant squamous cell carcinoma. This oral cancer type usually originates in lip and mouth tissues.

There are many different places in the oral cavity and maxillofacial region in which oral cancers commonly occur, including:

Lips

Mouth

Tongue

Salivary Glands

Oropharyngeal Region (throat)

Gums

Face

Reasons for oral cancer examinations

It is important to note that around 75 percent of oral cancers are linked with modifiable behaviors such as smoking, tobacco use and excessive alcohol consumption. Your dentist can provide literature and education on making lifestyle changes and smoking cessation.

When oral cancer is diagnosed in its earliest stages, treatment is generally very effective. Any noticeable abnormalities in the tongue, gums, mouth or surrounding area should be evaluated by a health professional as quickly as possible. During the oral cancer exam, the dentist and dental hygienist will be scrutinizing the maxillofacial and oral regions carefully for signs of pathologic changes.

The following signs will be investigated during a routine oral cancer exam:

Red patches and sores – Red patches on the floor of the mouth, the front and sides of the tongue, white or pink patches which fail to heal and slow healing sores that bleed easily can be indicative of pathologic (cancerous) changes.

Leukoplakia – This is a hardened white or gray, slightly raised lesion that can appear anywhere inside the mouth. Leukoplakia can be cancerous, or may become cancerous if treatment is not sought.

Lumps – Soreness, lumps or the general thickening of tissue anywhere in the throat or mouth can signal pathological problems.

Oral cancer exams, diagnosis and treatment

The oral cancer examination is a completely painless process. During the visual part of the examination, the dentist will look for abnormality and feel the face, glands and neck for unusual bumps. Lasers which can highlight pathologic changes are also a wonderful tool for oral cancer checks. The laser can “look” below the surface for abnormal signs and lesions which would be invisible to the naked eye.

If abnormalities, lesions, leukoplakia or lumps are apparent, the dentist will implement a diagnostic impression and treatment plan. In the event that the initial treatment plan is ineffective, a biopsy of the area will be performed. The biopsy includes a clinical evaluation which will identify the precise stage and grade of the oral lesion.

Oral cancer is deemed to be present when the basement membrane of the epithelium has been broken. Malignant types of cancer can readily spread to other places in the oral and maxillofacial regions, posing additional secondary threats. Treatment methods vary according to the precise diagnosis, but may include excision, radiation therapy and chemotherapy.

During bi-annual check-ups, the dentist and hygienist will thoroughly look for changes and lesions in the mouth, but a dedicated comprehensive oral cancer screening should be performed at least once each year.

If you have any questions or concerns about oral cancer, please ask your dentist or dental hygienist.

---