• ROOT SCALING AND PLANING • OSSEOUS (GUM OR FLAP) SURGERY • LASER SURGERY • DENTAL
IMPLANTS •BONE GRAFTS • GUIDED TISSUE REGENERATION •CROWN LENGTHENINGS • FRENULECTOMY •
TOOTH ROOT REMOVAL • COSMETIC "GUMMY" SMILE PROCEDURES • GUM ABSCESSES • PERIODONTAL
MAINTENANCE • GUM GRAFTING (RECESSION) • EXTRACTIONS•
The Whole Body Connection
Take the Test
Is There a Cure?
Non-Surgical Procedures
Root Scaling and Planing
Antibiotics • Periostat • Acticite
Periodontal Maintenance
How Should I prepare for Surgery?
Diagnosis of Perio Disease
Pocket Charting
What is a Quadrant?
Soft Tissue Grafts and Recession
Tooth Root Coverage • Crown Lengthenings•
Cosmetic "gummy" Smiles
Periodontal disease is caused by bacteria entering the gum (gingival) tissue that surrounds your teeth. The infection is the result of plaque and tartar (calculus) accumulating at the base of your teeth. If left untreated, the bacterial colonies multiply in the plaque and cause an infection which then causes the gum tissue to separate or pull away from your teeth, called detachment. Think of your gums like a ‘turtleneck” around your teeth, forming a seal that keeps bacteria out. When the gum tissue is invaded by bacteria, it separates from the teeth, allowing for the formation of a channel that allows the bacteria to enter your gums and to eventually progress into your jawbone, if left untreated. Scaling and root planing and\or pocket depth reduction procedures ( gum surgery ) halts this progression.
There are two levels of infection, called gingivitis and periodontitis. Please read on to have these explained to you
According to the American Dental Association, at least 60% of adults in the United States have moderate to severe periodontal disease. In a recent survey, 63% of Americans age 18 and older exhibited some gingival (gum) bleeding. Nearly 80% of all Americans have some form of detachment (gums that have pulled away from the teeth.)
Notice in this picture how the gums become redder and how they begin to recede or pull downward and upward away from the teeth to expose the roots. As the disease progresses, these symptoms become more severe.
Pus between the teeth and gums
Loose or separating teeth (drifting)
Persistent bad breath
Changes in your “bite”
Sources: National Institute of Dental & Craniofacial Research
and American Heart Association
There is a growing body of scientific evidence suggesting possible links between periodontal disease and other systemic diseases such as diabetes and coronary artery disease. New scientific research indicates that bacteria may affect the heart. People with periodontal disease, a bacterial infection, may be more at risk for heart disease.
While further research is needed, preliminary findings suggest that people with periodontal disease may be significantly more at risk for fatal heart attacks.More than 20% of Americans have heart disease. Please advise us of any medical conditions, including heart disease. Your periodontal health may affect your overall health.
New research indicates that infections in the mouth, such as periodontal disease, may also be associated with increased risk of respiratory infection such as pneumonia and bronchitis. While further research is needed, you are well advised to maintain good periodontal health which is part of your overall health.
Scientists have known for some time that people with diabetes are more likely to have periodontal disease. New research indicates a two-way connection: periodontal disease may make it more difficult for diabetics to control their blood sugar.
Additional studies are underway, but findings suggest that controlling periodontal disease may help people control diabetes.
New evidence also suggests that pregnant women who have periodontal disease may be up to seven times more likely to have a baby that is born premature and at a low birthweight.Periodontal disease is an infection, and all infections are cause for concern among pregnant women because they pose a risk to the health of the baby.
We advise all pregnant women -- and all women of childbearing age -- to come in for a periodontal screening examination. Although the possible links between periodontal disease and premature, low birth weight babies is still not fully understood, we want to do our part to keep mother and baby as healthy as possible.
The bacteria that cause periodontal disease are not confined to the mouth. They are carried throughout the blood stream and have the potential to cause health problems that appear in other parts of the body. Please feel free to ask us if you have any questions about the potential links between periodontal disease and other systemic diseases.
To see if you or a loved one are at risk for periodontal disease, please answer the following:
|
Do your gums bleed when you brush? |
____ yes |
____no |
|
Are your gums red and/or swollen? |
____ yes |
____no |
|
Have you lost any of your adult teeth? |
____ yes |
____no |
|
Do you have bad breath or a foul taste in your mouth? |
____ yes |
____no |
|
Have you noticed pus draining from your gums? |
____ yes |
____no |
|
Are your teeth loose or are spaces developing between your teeth? |
____ yes |
____no |
|
Does your bite feel indifferent? |
____ yes |
____no |
|
If you wear a partial denture (plate) - does it fit properly? |
____ yes |
____no |
|
Do your teeth appear too long? Too short? |
____ yes |
____no |
|
Do you smoke cigarettes? |
____ yes |
____no |
|
Did your parents lose their teeth? |
____ yes |
____no |
|
Are you diabetic or is there a family history of diabetes? |
____ yes |
____no |
|
Are you experiencing undue stress? |
____ yes |
____no |
|
Do you have heart disease? |
____ yes |
____no |
|
Women - are you pregnant or planning to become pregnant? |
____ yes |
____no |
|
Do you have a history of respiratory disease? |
____ yes |
____no |
If you have any of the above warning signs, please contact our office - we will be happy to schedule you for a comprehensive evaluation of your periodontal health.
The emphasis in our office is conservative periodontal therapy. The earliest stage of periodontal disease, or gingivitis, is best treated with non-surgical periodontal therapy. Each case is evaluated and appropriate selections of treatment are tailor made for the individual’s needs. Perio scaling and root planing is the procedure used along with supportive medication therapy, if appropriate, and periodontal maintenance.
Bacteria has collected on your teeth, forming colorless, sticky bacterial colonies called plaque. If the plaque is not removed, it will allow bacteria to multiply and cause an infection. Plaque that remains on the tooth absorbs salt from saliva, and becomes hard. This is called calculus, or tartar and it cannot be removed by brushing or flossing. Removal requires scaling and root planing by a Periodontist.
The procedure is performed under novacane, so you will not feel even a little twinge. It takes 2 one-half hour appointments to complete. One side of the mouth is done at one visit, the other side at the next visit. There are little, if any side effects for these procedures and you should be able to resume your normal activities when you leave our office.
First, the tooth is scaled to remove plaque and calculus. Then the root is planed, or smoothed. This eliminates any rough areas on the root that can easily trap bacteria. This procedure will allow the gums to heal by eliminating the bacteria, and reducing the pockets. Scaling and root planing combined with strict home care and frequent cleanings, will keep your gums healthy.
If your infection is mild, (4 or less millimeter pockets), then this is all you will most likely need to clear the infection. If your infection has advanced to periodontitis ( pockets of 5 mm and over) then scaling and root planing is used as the first set of procedures before the surgical part. Scaling and root planing is not a replacement for surgery and in these cases is used to remove the infection from the gums near the surface of the tooth. It cannot remove infections that have pocket depths of over 4 mm because the instruments used cannot reach the more serious, deeper pockets.
Periodontists use antibiotics to treat acute infections, such as gum abscess, and after implant surgery and bone regenerations. Because periodontal disease is an infection, it would seem logical that antibiotics would eliminate the problem. Unfortunately, when treating periodontitis and gingivitis, the effects of antibiotics are short lived. The bacteria that cause the disease reform after the antibiotics are discontinued. As a rule, antibiotics are not necessary or even useful. In some advanced cases there may be very specific harmful bacteria that can be eradicated. Thorough cleanings done to remove calculus and plaque appear to be as effective as antibiotics.
Unlike periostat and antibiotic, which are taken orally, these drugs are deposited directly into the infected pockets of the gums. In the last ten years four products have been introduced into this country that sallow prolonged drug delivery directly into the pocket. Acticite utilizes a thread treated with tetracycline. Atridox uses a gel, which can be injected directly into an infected pocket, and then slowly dissolves over the next 7 days. Studies have shown decreased probing depth, reduced bleeding, and improved attachment levels when Atridox is used in conjuction with scaling and planing. Periochip is a thin wafer that contains chlorhexidine. Arestin contains small spheres of tetracycline that are implanted in the infected pockets whee they slowly release the tetracycline over a 14-21 day period.
Generally speaking local delivery antibiotics are use in the periodontal maintenance phase of therapy, when isolated areas of the mouth seems to be worsening. Their use is generally not recommended during the active phase of treatment. The effectiveness of these products are somewhat controversial, and while there is usually some improvement, whether these results are long-term has yet to be demonstrated. Certain cases seems to respond better than others. Dr. Gorman will help advise you as to whether these treatments may be beneficial in your particular case. Oral antibiotics are used conservatively in conjunction with surgery. They not used as a replacement for surgery, since surgery does an excellent job of eliminating the bacteria in deep pockets without creating resistance to bacterial strains due to overuse of antibiotics.
PERIODONTAL MAINTENANCE
Another important part of the maintenance visit is the periodontal evaluation. Dr. Gorman performs an oral exam at each periodontal maintenance visit. If you have already experienced periodontal disease, then you know that it can occur with little or no symptoms in a very short period of time. It is therefore important to track the health of your gums and bone to make certain re-infection does not occur.
SURGICAL PROCEDURES
WHAT TO EXPECT FROM SURGERY:
Years ago periodontal surgery was considered an ordeal. How things have changed! Today there is NO pain involved during the procedures, and the postoperative discomfort is very minimal. New and sophisticated medications ensure you a smooth procedure. In fact, our office has found that the apprehension of the procedures are far worse than the actual event. Most patients marvel at the fact that it was not “half as difficult or uncomfortable as I expected.” Dentistry has come a long way since you were a child!
Dr. Gorman also offers nitrius oxide ( laughing gas) to patients who request it. He will also prescribe an oral sedative (valium) for you to take before you come to the office, if requested. Our staff is especially sensitive to the needs of anxious patients, so please do not hesitate to ask for what you would like.
Dr. Gorman has performed thousands of scaling and root planings and periodontal surgeries in his practice. He has performed these procedures every day for over 25 years. (The average general dentist may only perform these procedures occasionally or a few times per month.) Dr. Gorman, as a specialist, is very quick, gentle, meticiously thorough and extremely knowledgeable when it comes to periodontal procedures and the techniques involved with these services.
Postoperative discomfort has been dramatically reduced with the use of NSAIDS (non-steroid anti-inflammation drugs). These drugs, such as Narcosis and Motrin, stop the formation of the chemicals the body normally produces that cause heightened pain. NSAIDS are not narcotics, so you can function normally when taking them. Advil or Tylenol are also very useful for any discomfort you might feel. Dr. Gorman may also prescribe a narcotic pain medication if necessary, but generally patients find they do not need them.
Some patients, especially implant and regeneration cases, are occasionally prescribed antibiotics to take after surgery. It is important to take the prescriptions as directed, to optimize healing. A prescription mouthwash called chlorahexadine is often prescribed after surgery, and may be used for 1-10 weeks. It is much more effective than any over-the-counter mouthwash, and kills bacteria throughout the mouth.
During the first 7days there is generally a periodontal dressing over the operated area (similar to putty or chewing gum), and using the mouthwash keeps the dressing clean. If you opted for laser treatment, then there is no packing or sutures. At 7 days any dressing is removed, along with sutures that may have been placed. Dr. Gorman uses dissolvable sutures as often as possible. The area is cleansed, and postoperative care of the area reviewed. This appointment generally lasts 5 minutes, and should not cause any discomfort. With most cases it is important to keep all bacteria away from the surgical site for 8-10 weeks. To help ensure optimal plaque control, periomaintenance (cleaning) appointments should be scheduled every 2-3 weeks. The prescription mouthwash may also be continued during this time. We have found that careful control of plaque during the healing phase greatly enhances surgical results.
HOW SHOULD I PREPARE FOR SURGERY ?
It is a good idea to have a light meal or snack before your procedures, as you will not want to eat immediately after your surgery. Also, if you are on coumadin or any other mediaction, you should consult Dr. Gorman about discontinuing taking them before your procedures. If you are anxious about getting a needle, then tell Dr. Gorman you would like nitrous oxide BEFORE he begins giving you novicaine.
It is not necessary to have anyone drive you to or from the office, as all surgery is done under a local anesthetic. Even Nitrous Oxide ( laughing gas) shoud not prohibit you from driving home, as it has a very short effect on your abilities.
A periodontal pocket is the result of the bacterial infection, which causes the gum tissue to separate from the tooth. The probe is an instrument that measures the depth of infected pockets. It measures how much the bone has receded. Each tooth is measured in 6 different places to determine the depth of the pocket and thus the seriousness of the infection. All 32 teeth will be examined in this way to create charting, which is a complete printed measurement of the depths of all periodontal pockets in your mouth as well as healthy normal gum tissue.
Xrays consisting of either a full mouth series or a panorax will be needed in most cases to make a proper diagnosis. These radiographs will show the amount of bone loss, the size and shape of your tooth roots, the amount of roots imbedded in the bone, the relationship of your teeth to one another, where a nerve has died, the location of the sinus and mandibular nerve when placing implants, and oral pathologies, among other things. We are not able to diagnose a patient properly unless we have adequate xrays. The exception is gingival ( gum) grafting, which normally does not require xrays.
Once the clinical data is gathered and correlated with the xray findings, Dr. Gorman will be able to organize and systematically evaluate the results to make his diagnosis.
1-2 millimeter normal
3-4 millimeter gingivitis
4-5 millimeter mild periodontitis
6-7 millimeter moderate periodontitis
8-10 millimeter severe periodontitis
There are 4 quadrants in your mouth with 8 teeth in each one. The upper right (your right hand side) quadrant has teeth 1-8, counting from the back wisdom tooth on the top and counting forward to the front tooth. The upper left (your left hand) quadrant is the top teeth 9-16, the lower left quadrant (starting from the wisdom tooth) bottom teeth 17-24, counting from the wisdom tooth to the front tooth, and the lower right quadrant bottom teeth 25-32, starting with the front tooth and ending with the wisdom tooth once again.
• Gingivectomy - Trimming excess tissue when the bone contour has not been altered.
• Flap Surgery - The most common procedure, where an incision is made between the gum and the tooth. The gum is peeled back away from the neck of the tooth and the edge of the bone. This gives Dr. Gorman access to the deeper pockets ( 5mm. and higher) so he can clean out the bacteria in the affected pocket.
•Regeneration Surgery - Ideally, periodontal therapy would regenerate bone and tissue back naturally. If you have too much bone loss, then a bone graft can be done to increase your chances of regeneration ( new growth).
Dr. Gorman usually performs surgical procedures in 2 visits( 4 visits in all) doing one or two quadrants on one side of the mouth in one visit and the other two quadrants on the opposite side during a second visit, with a dressing/suture removal visit ( lasting 5 - 10 minutes or less) one week after the surgery. If you opt for laser surgery, then you will not need to come in for a post operative check until a later date. Each visit, except the dressing removal visit, lasts approximately 45 minutes, except for laser therapy, which is one-half hour. We are committed to keeping you comfortable and relaxed during all phases of your treatments. Please go to the patient comfort menu button to see how we can help you!
These procedures are done under a local anesthestic, Novacain, and should pose no post operative problems for the patient. The procedures takes approximately 30 - 45 minutes. An analgesic may be taken, if needed. You will need to return to our office in 1 week for a suture removal or a check appointment, which lasts about 5 minutes.
After the procedure, you may go about your regular routine with the exception of exercise of any kind for 24-48 hours. You do not need to have anyone drive you to the appointment or home or back to work, as Dr. Gorman performs the procedure with a variety of local anesthetics.
A bone graft procedure is one that promotes bone re-growth, restoring stability of your teeth in your jaw bone. The bone may come from synthetic bone or a bone bank. Small fragments of graft material are packed into the areas where bone has been lost. Bone grafts are generally placed during pocket reduction surgery, but not always. New bone growth is stimulated by the bone graft as the graft material fills in the defect and speeds up the process, providing strong support for the tooth.
Guided Tissue Regeneration (GTR) is a membrane that is placed over the bone graft and is used as a protective agent to facilitate the success of the bone graft. At times, but not all the time, your gums can grow into the bone graft, making it less effective for the bone to make new bone (regenerate).
If a tooth is lost, a patient may choose dental implants to restore his/her smile. However, even dental implants need a healthy jawbone before they can be placed. Guided Tissue Regeneration (GTR) or Ridge Augmentation restores the bone before the placement of implants. Biocompatible membranes and bone grafts keep the tissue out, thus allowing the bone to grow.
The recent advances in technology have led to a higher success rate for keeping your teeth using this procedure. Bone grafts lead to healthy bone regeneration and resolves the tooth loss and shifting teeth problems that periodontal disease creates.
Emdogain is a synthetic bone grafting product that promotes the regeneration of hard and soft tissues lost through periodontal disease. Emdogain’s main ingredient is amelogenin, a protein that aids in the creation of teeth and supporting structures but produced only when our teeth are developing.
Emdogain is applied to the root surface. By doing so, the body thinks it is forming a natural tooth attachment, much like when your teeth first developed. Thus, the development of a natural tooth attachment and bone starts over.
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.
Insufficient attached gum results in recession starting.
Insufficient attached gum without treament results in continued loss of gum and bone.
Lack of attached gum with resulting recession.
Note gum pulling away when cheek muscle retracted. The bone that previously covered the root has also receded.
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.
FRENDULECTOMY
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, and is commonly referred to as gum recession. 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.
Recession associated with a lack of attached gingiva. The bone has also receded. Untreated, this may result in tooth loss.
After placement of a gum graft, adequate attached gingiva to prevent further bone/tissue loss.
Recession with no attached gum. Without treatment, the recession will continue. The root is difficult to clean, leading to plaque formation and inflammation.
After placement of new attached gum.
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 an available source, often the roof of the mouth, 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 donor source 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 prevention pills post-operatively (ibuprofen). The most difficult part of the surgery is not chewing on the area for 2 weeks.
Routine gum recession grafts ("free gingival grafts") do not cover up the exposed. Covering the root makes the tooth stronger, which actually holds the tooth in place, and will not change regardless of the new gum level. However, root coverage procedures are primarily done for cosmetic reasons, when there is root sensitivity after recession when there is decay on the root surface or when an old gum line filling needs replacement.
Recession with a lack of attached gingiva.
Gum graft placed, resulting in adequate attached gingiva and health. The root is not covered.
BEFORE AFTER
The replacement of missing attached gum is called gingival grafting. A small piece of tissue from your mouth or donor tissue (which ever you prefer) is placed over the recessed area and the underlying muscle causing the pulling down of the gums is disconnected from the gum. The new tissue reforms a new layer of attached gum to the tooth, which should last a lifetime with proper care. The recession is halted and should not receded any further, thus halting tooth loss. These procedures are very easy on the patient, and rarely require more than over-the-counter pain pills post-operatively (ibuprofen).
When the gum has receded and the root is showing, it is often desirable to re-cover the root surface. Root coverage, or a connective tissue graft, is done for cosmetic reasons , but also if there is root sensitivity. A small piece of tissue is grafted onto the area where the recession is located.
If your gums recede too far, your teeth will not have gums or bone to support them. This will result in tooth loss. The Root coverage procedure is designed to help correct that problem as well as give you a better smile.
Generally there is little post-operative discomfort, although some swelling is normal. The procedure is done under local anthesia, novacaine. Both soft tissue grafting and connective tissue gum grafting will give your gums a better appearance as well as eliminate root sensitivity.
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 tooth. This is called crown lenghtening. There are two situations in which crown lengthening is commonly performed: to place a crown on a tooth when the dentist does not have enough tooth root to cement the crown on to and to allow a dentist better access to decay.
If you are having a crown placed on your tooth, and the decay of the tooth is such that there is little left of the tooth for the Dentist to cement the crown onto, then a crown lengthening is prescribed for you.
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 root will be lost. As a rule, simply trimming back the gum is not sufficient, for the bone would be exposed. Rather, the periodontist must 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 1 week.
If a crown is to be placed in a cosmetic area, the restorative dentist should wait 6-12 weeks following crown lengthening before taking final impressions. This ensures that the gum is in its final position. If the margin of the crown is placed at the gum level before final healing, the results may be unsightly. A temporary crown can be placed two weeks after surgery if the patient desires to cover the exposed root during this healing period.