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.
Reasons for periodontal treatment
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.
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 check up, 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.
- Gangrene in the tissues – Gangrene is hard to self diagnose but the general dentist and periodontist will check for its presence in the soft tissues, alveolar bone and periodontal ligament.
- 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 always be performed as the initial nonsurgical treatment. In addition to tose 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.
Periodontal disease is a progressive condition which leads to severe inflammation and tooth loss if left untreated. Antibiotic treatments can be used in combination with scaling and root planning, curettage, surgery or as a stand-alone treatment to help reduce bacteria before and/or after many common periodontal procedures.
Antibiotic treatments come in several different types, including oral forms and topical gels which are applied directly into the gum pockets. Research has shown that in the case of acute periodontal infection, refractory periodontal disease, prepubertal periodontal disease and juvenile periodontal disease, antibiotic treatments have been incredibly effective.
Antibiotics can be prescribed at a low dose for longer term use, or as a short term medication to deter bacteria from re-colonizing.
Oral antibiotics tend to affect the whole body and are less commonly prescribed than topical gel. Here are some specific details about several different types of oral antibiotics:
- Tetracycline antibiotics – Antibiotics which include tetracycline hydrochloride, doxycycline, and minocycline are the primary drugs used in periodontal treatment. They have antibacterial properties, reduce inflammation and block collagenase (a protein which destroys the connective tissue).
- Macrolide antibiotics – This group of antibiotics has proven effective at reducing inflammation, and can also reduce bacterial growth associated with periodontitis.
- Metronidazole – This antibiotic is generally used in combination with amoxicillin or tetracycline to combat inflammation and bacterial growth in severe or chronic periodontitis.
Topical Gels and Strips
The biggest advantage of the direct delivery of antibiotics to the surfaces of the gums is that the whole body is not affected. Topical gels and direct delivery methods tend to be preferred over their oral counterparts and are extremely effective when used after scaling and root planing procedures. Here are some of the most commonly used direct delivery antibiotics:
- Atridox® – This doxycycline gel conforms to the contours of gum surfaces and solidifies over them. Over several days, this gel gradually releases the antibiotic medication.
- PerioChip® – This chip is placed into the actual gum pocket after root planing procedure. PerioChip® slowly releases Chlorhexidine, a powerful antibacterial antiseptic. PerioChip® reduces pocket depth in most cases in periodontitis sufferers.
- Actisite® – This thin strip is similar to dental floss and contains tetracycline hydrochloride. The thread is place temporarily directly between the tooth and gum to kill bacteria and reduce the depth of gum pockets. Several threads are sometimes placed for around 10 days to enhance the antibiotic effect.
- Elyzol® – This metronidazole antibiotic comes in gel and strip form. It is unique because it is able to destroy parasites as well as oral bacteria.
- Arestin® – This Minocycline antibiotic comes in mini capsules which are delivered into the gums after scaling and root planning.
Noticeable periodontal improvements are usually seen after systemic or oral antibiotic treatment. Your Periodontist or dentist will incorporate and recommend the necessary antibiotic treatments as necessary for the healing of your periodontal condition.
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.
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 re-positioned.
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.
Gum & Jawbone Corrective Treatments
There are many reasons why the gums and jawbone may require corrective treatment, including periodontal disease, trauma and birth defects. Periodontal disease particularly, can greatly disfigure the natural appearance of the gums and teeth and give the smile an unaesthetic appearance.
New “cosmetic surgery” procedures are now available in periodontics, which effectively correct cosmetic problems and restore natural beauty to the smile.
Here are some of the most common gum and jawbone corrective treatments:
Common Gum Treatments
- Crown lengthening (gum lift) – Crown lengthening is usually performed to correct a “gummy” smile, or to expose more of the tooth prior to a restorative surgery. In some cases, the teeth look short and stubby and partly covered by gum tissue due to genetics or gingivitis. Excess gum tissue can easily be removed to reshape the outline of the gums, expose the natural tooth length, and provide a fuller, more attractive smile. The same procedure is also an excellent way to create a more aesthetic gumline for dental crowns and other restorative procedures.
- Gum grafts – Gum grafts are generally performed to correct a crooked smile, or to restore symmetry to the gumline after periodontal disease has been treated. Periodontal disease causes the gums to recede; making the smile look overly “” During a gum graft, a thin strip of tissue is removed from the palate and stitched in place over the recession site. Gum grafts are often used to re-contour the gum line and give the teeth a more pleasing appearance.
- Pocket reduction surgery – Periodontal disease can cause the smile to be marred with unattractive teeth, brown gums and ridge indentations. The aim of pocket reduction surgery is to clean the root surfaces of the teeth e subgingivally (beneath the gum line). During this procedure, tartar, plaque and bacteria that are affecting the teeth and gums will be removed. The gum is first gently separated away from the tooth, and then the calculus (tartar) and plaque are removed using special ultrasonic and hand instruments. An antimicrobial liquid may be administered to the area to destroy bacteria colonies and ensure the pockets are given the chance to naturally heal. Pocket reduction surgery is an effective way to restore health to the gums and bone.
Common Jawbone Treatments
- Sinus augmentation – This procedure is usually performed prior to the placement of dental implants, to ensure that the prosthetic teeth are both functional and firmly affixed to the bone. The success of an implant hinges on the quantity and quality of the jawbone to which it will be attached. If the jawbone has receded or been injured, a sinus augmentation can slightly elevate the sinus floor to allow new bone to form. Generally, a small incision is made in the bone and the underlying space is packed with grafting material. The incision is sutured closed, and the implant will be placed when healing has occurred.
- Ridge modification – Ridge modification procedures are used to treat deformities in the jawbone which have occurred due to periodontal disease, trauma or birth defects. Birth defects particularly, can leave an unattractive indentation in the jaw, which makes placing dental implants difficult. During the ridge modification procedure, the gum is gently pulled away from the bone to fully expose the defect. The defect is filled with bone graft material or a similar synthetic product and then sutured closed. When healing occurs, the cosmetic appearance of the jaw is much improved and implants can be successfully placed where necessary.
- Bone grafts – There are a wide variety of reasons why a bone graft may be necessary. Bone grafting thickens the jawbone to allow for the successful placement of implant anchors. Bone grafts can also help elevate the sinus floor, fill craters or deformities in the jawbone itself, or allow for successful nerve repositioning. The grafting material may be harvested from the lower jaw, the iliac section of the pelvis, or synthetically created. In most cases, a small opening is made in the jawbone and packed with the bone graft material. Sutures are placed and restorative treatments are performed when healing is complete.
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 “” 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.
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.
Periodontal disease is a progressive condition which leads to gum inflammation, the recession of bone and gum tissue, and tooth loss if left untreated. There are a variety of effective treatments and procedures available, including pocket irrigation, which can assist in treating the progression of the disease.
Pocket irrigation aims to cleanse plaque from the interdental (between teeth) and subgingival (under the gumline) regions of the mouth in order to prevent the colonization of harmful oral bacteria. This procedure is also used to deliver antibacterials to the subgingival areas.
Reasons for pocket irrigation
Pocket irrigation, which is also known as oral irrigation, is a versatile dental treatment used for several different preventative purposes. Pocket irrigation may be performed as part of a professional dental cleaning, or at home with a specially modified oral irrigator.
Here are the main ways in which pocket irrigation can be beneficial:
- Interdental cleaning – Pocket irrigators blast plaque, food particles and other debris from between the teeth. The removal of harmful materials and bacteria keep the gum pockets cleaner and shallower; thus helping the gum tissue remain healthy.
- Halitosis prevention – Halitosis (or bad breath) is generally a result of old food particles between the teeth, and tooth decay. A toothbrush or dental scraper alone may not be able to reach into the depths of the gum pockets, but water jets can flush out food particles and help clean above and below the gumline.
- Subgingival cleaning – Pocket irrigators have a rounded tip which eliminates the risk of tissue damage while cleaning under the gumline. The side port opening facilitates extensive cleansing by flushing out bacteria, particles and toxins from below the gumline.
- Antimicrobial application – Antimicrobial substances have proven effective for eliminating and preventing some strains of harmful oral bacteria. Antimicrobial substances can be combined with water, or used as a stand-alone treatment for successful pocket irrigation.
What does pocket irrigation treatment involve?
Pocket irrigation is generally performed in combination with other dental treatments; for example, as part of a professional dental cleaning or in combination with pocket reduction surgery.
In the case of a pocket reduction surgery, the tartar and subgingival plaque will be removed with special scaling and root planing instruments. When the pockets are free of debris, an antimicrobial agent may be applied using an oral irrigator. This will help reduce harmful oral bacteria which still remain in the pockets.
During a deep cleaning procedure, a pocket irrigator may be used after scaling and root planing to cleanse the pockets. Again, an antimicrobial agent may be applied to help reduce subgingival oral bacteria.
Pocket irrigation can be performed at home as part of the daily oral routine using a water jet or water pick. Flushing the interdental area with water is less harmful to soft tissue than dental floss, but should not be used as a substitute for professional dental cleaning.
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).
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 subgingival 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 final part of the surgery is usually the administration of an antimicrobial liquid to eliminate any remaining bacteria and promote healing. The gum is then sutured with tiny stitches that are left in place for 5-10 days.
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.
Periodontal disease is an extremely serious progressive condition which can lead to tooth loss if left untreated. Periodontal disease occurs when a bacterial infection in the gum pockets causes the bone and gum tissue to recede away from the teeth. The quality and quantity of bone and gum tissue is greatly reduced as the gum pockets continue to deepen. Fortunately, prompt diagnosis combined with effective regenerative procedures can halt the progression of the disease and save the teeth.
There are many regenerative dental procedures available to restore health to the gums, bone and teeth. The following are the most commonly used regenerative procedures:
Dental implants and other restorative procedures depend on the jawbone being sufficiently strong and thick. When periodontal disease has taken hold, the jawbone may have become too thin to successfully support an implant. Natural bone regeneration (or bone grafting) is one of the best ways to promote growth and thicken the jawbone.
Initially, bone grafting material is obtained from elsewhere on the body or from a bone bank. The gums are gently pulled back, and an opening is made in the jawbone where the grafting material will be packed in tightly. A membrane is used to maintain the shape of the new bone, and tissue stimulating proteins and a platelet-rich growth factor may be applied to promote faster healing. The surgical site will be sutured and packed with protective material. The bone will naturally regenerate and become strong enough to eventually support an implant.
Gum Tissue Regeneration
Gum tissue regeneration is usually performed by way of gum grafting. When gum tissue has been lost as a result of periodontal disease, the smile may appear discolored, toothy or unpleasant. A gum graft aims to symmetrically contour the gum line, cover any exposed tooth roots and restore health to the gums. Initially, a small strip of tissue will be removed from the roof of the mouth and placed in the middle of a split-thickness incision at the recipient site. The surgical site will be covered with a protective membrane which promotes tissue regeneration, covered in platelet-rich growth factor and tissue stimulating proteins, and then sutured closed. The soft tissue surrounding the teeth will naturally regenerate, producing a healthy, smile.
Pocket Reduction Surgery
The aim of pocket reduction surgery is to reduce the depth of the gum pockets and make it much harder for bacteria to invade the gum tissue. Initially, the gum tissue is pulled back from the teeth and the subgingival area is thoroughly cleansed under local anesthesia. Extensive scraping may be required to fully remove the plaque, debris and tartar from below the gum line. An antimicrobial agent may then be applied to the affected area to kill any remaining bacteria, and the surgical site will be sutured closed. Pocket reduction surgery is very effective for halting tissue loss and promoting the natural healing of the gums.
Scaling and Root Planing
The term “scaling” refers to the removal of plaque and calculus (tartar) from the supragingival region (above the gum line). This treatment is usually conducted in the course of a routine professional cleaning, and performed under local anesthetic. Root planing usually accompanies scaling and is performed in the subgingival region (below the gum line). Tartar and toxins are initially removed, and then the tooth root is smoothed down to promote good healing in the gum tissue. The planing of the tooth root provides a smooth area which prevents bacteria from recolonizing. If these procedures do not completely eradicate the infection, surgical measures may be required.
Ridge modification is an effective procedure for treating deformities in the upper and lower jaws. These deformities can occur as a result of periodontal disease, trauma, injury, wearing dentures, or developmental problems. Such defects can leave insufficient bone for the placement of dental implants and an additional unattractive indentation in the jaw line adjacent to the missing teeth.
During the ridge modification procedure, the gum is lifted away from the ridge to fully expose the defect in the bone. The bony defect can be filled with bone graft material which can help regenerate lost bone, or a bone substitute. Finally, the incision is closed and several months of healing will be required. Depending on the case and type of implant and procedure, a dental implant may be placed during the ridge modification procedure or when healing is complete; much depends on the precise condition of the bone. Ridge modification improves the cosmetic appearance, functionality of the mouth, and the chance of enjoying dental implants for many years.
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 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 before resectioning 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.
A dental implant is essentially an artificial tooth root which is attached to the jaw bone. Eventually, a replacement tooth or bridge will be firmly fixed to this root, restoring complete function to the tooth. The key to a successful and long-lasting implant is the quality and quantity of jawbone to which the implant will be attached. If bone has been lost due to injury or periodontal disease, a sinus augmentation can raise the sinus floor to allow for new bone formation.
In the most common sinus augmentation technique, a tiny incision is made near the upper premolar or molar region to expose the jawbone. A small opening is cut into the bone and the membrane lining the sinus on the other side of the opening is gently pushed upward. The underlying space is filled with bone graft material and the incision is closed. The bone which is used for this procedure may be from your own body or from a cadaver. Sometimes the dentist might use synthetic materials which can also stimulate bone formation. The implants are placed after healing has occurred; this will depend on the individual case. Sinus augmentation has been shown to increase the success of dental implant procedures.
Soft Tissue Grafting
Soft tissue grafting is often necessary to combat gum recession. Periodontal disease, trauma, aging, over brushing, and poor tooth positioning are the leading causes of gum recession which can lead to tooth-root exposure in severe cases.
When the roots of the teeth become exposed, eating hot and cold foods can be uncomfortable, decay is more prevalent and the aesthetic appearance of the smile is altered. The main goal of soft tissue grafting is to either cover the exposed root or to thicken the existing gum tissue in order to halt further tissue loss.
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.
Reasons for 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.
What does soft tissue grafting treatment involve?
Initially, deep cleaning will be performed both above and below the gum line to clear the teeth and roots of calculus (tartar). The grafting procedure itself will generally be performed under local anesthetic, but this will depend on the size of the areas receiving grafts. A small incision will be made at the recipient site in order to create a small pocket. A split thickness incision is made in this pocket and the donor tissue is placed between the two sections of this area. The donor tissue strip is generally larger than the incision, so some excess will be apparent.
Platelet rich growth factors which stimulate natural tissue growth and promote good healing may be applied to the site before suturing. In addition, tissue-stimulating proteins may be added to encourage quicker tissue growth. Finally, the wound site will be sutured to prevent shifting, and surgical material will be placed to protect the sensitive area. Gum uniformity and substantial healing will take place in the first six weeks after the procedure.