FAQ About Periodontists and Periodontal Disease

Who is a periodontist?

In a sentence, periodontists are charged with saving teeth. That’s our mission and goal for all of our patients.  Like medical specialists, periodontists concentrate and gain expertise in a specific area of dentistry.  Periodontists receive three additional years of extensive educational training beyond four years of dental school.  We are dedicated to the prevention, diagnosis and treatment of periodontal (gum and bone) disease, and are experts in the placement of dental implants.  In addition, we perform cosmetic periodontal surgeries to help you achieve the smile you desire by utilizing the most current and advanced techniques.  With recent studies showing a link between the inflammatory process present in periodontal disease and its effects on other organ systems in your body, it is now believed that improving your periodontal condition can even improve your overall general health.

Periodontists work with your dentist to give you the most comprehensive care available. Often, dentists refer their patients to a periodontist when periodontal disease is present.  If you are beginning extensive dental work, including crowns or bridgework, your dentist may also refer you to a periodontist to ensure the long-term stability of your new restorations.  However, you don't need a referral to see a periodontist. There are many occasions where you may choose to go directly to a periodontist or to refer a family member or friend to your own periodontist.

If you value both your oral and general health, anytime is a good time to see a periodontist for a periodontal evaluation.  Sometimes the only way to detect periodontal disease is through a periodontal evaluation.  A periodontal evaluation is especially important if you exhibit signs of periodontal disease such as:

• Red, swollen or tender gums or other pain in your mouth
• Any bleeding at any time while brushing, flossing or eating hard food
• Gums that are receding or pulling away from the teeth, causing the teeth to look longer than before
• Loose or separating teeth
• Pus between your gums and teeth
• Sores in your mouth
• Persistent bad breath
• A change in the way your teeth fit together when you bite
• A change in the fit of dentures or removable appliances

What other treatments do periodontists perform?

• Bone grafts to regenerate lost bone around teeth
• Gum grafts (called free gingival grafts, autogenous gum grafts, pedicle grafts, etc.) that cover exposed roots, increase the zones of attached gingiva and thicken the gums when needed for cosmetic reasons
• Cosmetic surgeries - Excessive gum is trimmed away or thickened when needed
• Dental implants - Both for single or multiple teeth
• Remove / Extract teeth
• Adjust the bite / Occlusal adjustment
• Make occlusal guards / Night guards
• Ridge augmentations - This replaces the tissue that is lost when teeth are removed and will enhance the esthetics of bridges. In some instances ridge augmentations widen the jaw bone in places that would be too narrow to receive dental implants, or in areas that have shrunk as a result of teeth being removed.
• Maxillary sinus lifts and other jaw reconstruction techniques to construct and regenerate missing bone
• Scaling and Root planing (deep cleaning below the gumline) and maintenance (re-care) cleaning
• Biopsies of soft tissue lesions - We perform cancer inspections and remove unwanted lesions from the soft tissues of the mouth, including the lips and cheeks.

Who should get their gums checked?

Everyone should have a periodontal examination.  Make certain your periodontist, dentist or hygienist regularly checks your pocket depths when you get your teeth cleaned.  It is to your advantage to have subtle changes identified before they become serious.

What is periodontal disease?

Periodontal disease affects the gums and structures that support your teeth.  One of the first warning signs that there’s a problem is when the rim of the gums next to your teeth becomes red, swollen and bleeds easily.  Most often there is no discomfort at this stage, yet the disease has gained a foothold and is now known as "gingivitis."  Gingivitis is reversible with improved oral hygiene (home care) techniques and a professional cleaning.  Left untreated, however, the danger exists that it will progress into an irreversible periodontal disease (periodontitis) that damages the gums and bone surrounding the teeth.

Although periodontitis is a more advanced disease that destroys the bone and tissues supporting the teeth, an individual may still be unaware of the problem existing in his or her mouth.  Periodontitis causes the gum attachment to begin separating from the teeth, creating "pockets” that harbor millions of bacteria trapped in plaque that sticks to the teeth.  Unfortunately for us, the mouth is a perfect incubator.  It is warm, dark and moist, with tons of "food" for the bacteria to metabolize.  The net result is that the bacterial plaque thrives and matures.

Some individuals are more prone to periodontal disease than others. Some get a mild form, while others get a severe case.  Why?  It is likely that we inherit a genetic predisposition to periodontal disease, and this influences how severely we will be affected by it.

What causes periodontal disease?

As mentioned above, bacteria trapped in a film that sticks to the teeth - called plaque - initiates the early changes to the gums.  As the plaque matures on the teeth, the disease becomes more established to the point where it becomes irreversible.  While periodontal disease is caused by bacteria, it is not strictly "caught" in the same ways that colds and flu are caught.  There are hundreds of bacteria that live in your mouth, and under normal health circumstances they are kept in balance.  However, when a person is susceptible to gum disease, these bacteria get out of balance and cause the damage known as "pyorrhea" or periodontal disease.

Genetics, systemic disease and sometimes infrequent dental care influence the course of the disease.  In the future, a more reliable genetic test will be able to tell you from a drop of blood or cheek swab whether you have a familial tendency towards periodontal disease.  If a parent has lost teeth from gum disease, their children should consider the benefits of the new genetic testing procedure. This will enable treatment decisions to be made much earlier for a better lifetime dental outcome. Though nearly three-fourths of the world’s population has some form of periodontal disease, a genetic (inherited) predisposition is the single biggest determinant as to how serious each case gets.  A variety of factors can affect it, such as poor oral hygiene, smoking, diabetes and other systemic conditions.

Are there different kinds of gum disease?

Periodontal (gum and bone) diseases, including gingivitis and periodontitis, are serious infections that can lead to tooth loss if left untreated.  The word periodontal literally means "around the tooth."  Periodontal disease is a chronic bacterial infection that affects the gums and bone supporting the teeth.  Periodontal disease can affect one or many teeth.  It begins when the bacteria in plaque (the sticky, colorless film that constantly forms on your teeth) causes the gums to become inflamed.

Gingivitis

Gingivitis is the mildest form of periodontal disease.  It causes the gums to become red, swollen and bleed easily.  There is usually little or no discomfort at this stage.  Gingivitis is often caused by inadequate oral hygiene.  Gingivitis is reversible with professional treatment and good oral home care.

Periodontitis

Untreated gingivitis can advance to periodontitis.  Over time, plaque can spread and grow below the gum line, and toxins produced by the bacteria in plaque can irritate the gums.  These toxins stimulate a chronic inflammatory response and interact with your immune system, causing your body to essentially turn on itself.  When this happens the tissues and bone that support the teeth are broken down and destroyed.  Gums separate from the teeth, forming pockets (spaces between the teeth and gums) that become infected.  As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed.  Often this destructive process has very mild symptoms, but eventually teeth can become loose and may have to be removed.

There are many forms of periodontitis. The most common ones include the following:

• Aggressive periodontitis occurs in patients who are otherwise clinically healthy.  Common features include rapid attachment loss, bone destruction and familial tendencies.
• Chronic periodontitis results in inflammation within the supporting tissues of the teeth, progressive attachment and bone loss.  This is the most frequently occurring form of periodontitis and is characterized by pocket formation and/or recession of the gingiva.  It is most prevalent in adults, but can occur at any age. Progression of attachment loss usually occurs slowly, but periods of rapid progression can occur.
• Periodontitis as a manifestation of systemic diseases often begins at a young age.  Systemic conditions such as heart disease, respiratory disease and diabetes are associated with this form of periodontitis.
• Necrotizing periodontal disease is an infection characterized by necrosis of gingival tissues, periodontal ligament and alveolar bone.  These lesions are most commonly observed in individuals with systemic conditions such as HIV infection, malnutrition and/or immunosuppression.

The above information has been provided by the American Academy of Periodontology (AAP).  The AAP is the professional organization for periodontists - specialists in the prevention, diagnosis and treatment of diseases affecting the gums and supporting structures of the teeth, and in the placement of dental implants.  Periodontics is one of the nine dental specialties recognized by the American Dental Association. The AAP has 8,000 members worldwide.

How common is periodontal disease?

Periodontal disease is the leading cause of tooth loss in adults, affecting more than three-fourths of all people, regardless of race, nationality, or socioeconomic levels.  The good news is that the earlier periodontal disease is detected, the more successful are the treatment results.

How is periodontal disease diagnosed?

Before a diagnosis can be made, an examination must first occur.  The type of examination will be determined by the nature of the problem.  A complete periodontal examination differs in scope from an examination for gum recession or for a broken tooth.  A complete periodontal examination may include any or all of the following procedures:

• Oral cancer screening exam of all hard and soft tissues
• Check of the condition of the saliva
• Charting of missing, shifted or impacted teeth
• 6 pocket measurements on each tooth
• Gum recession measurements on each tooth
• Recording of the mobility (looseness) on each tooth
• Evaluation for bone damage between the roots of multi-rooted teeth
• Assessment of abrasion (wear) on exposed roots
• Detection and recording of decay and defective or worn restorations (fillings)
• Assessment and recording of sites with infection (pus) or bleeding
• Bite exam and recording of bite function and movement
• Evaluation of major muscle groups that relate to the bite and the jaws
• Evaluation of the TMJ (jaw joint) function
• Evaluation for bite trauma and tooth wear
• Measurement of maximum bite opening
• Photographs in the mouth and of the face
• X-ray evaluation
• Bacteriologic testing
• Genetic susceptibility testing
• Obtain study models

Once the data has been collected, an accurate diagnosis can be made and we can formulate a suitable treatment plan that also takes into consideration the needs, wants and desires of the patient.

How do I know if I have periodontal (gum and bone) disease?

Most people don’t know they have periodontal (gum and bone) disease, or even that the specialty of periodontics exists, until their dentist brings it to their attention.  One of the reasons it comes as a surprise is that periodontal disease (also known as periodontitis, gum disease, gum infection, or pyorrhea) is a silent disease, with few obvious symptoms in its early stages.

Periodontitis is a chronic disease much like high blood pressure or diabetes.  It develops over time and can be characterized by short periods of rapid tissue breakdown, followed by periods of remission.  Once you have periodontal disease, there is no cure.  However with treatment, periodontal disease can be monitored, maintained and treated as necessary.

The signs of periodontal disease are subtle at first, and often can only be detected by a periodontist, dentist and/or hygienist.  These professionals are trained to look for:

• Pockets: Pockets occur when the collar of gum becomes infected and detaches from the tooth - creating a space.  A pocket is not necessarily formed when food gets stuck between teeth.  A small measuring instrument - actually it’s a millimeter ruler - is gently inserted between the tooth and gum to measure the depth of the pockets.  If the depths are greater than 3 millimeters, improved oral hygiene measures and more deliberate therapy are suggested.
• Bleeding: In spite of its common occurrence, gums are not supposed to bleed any more than other body parts, such as fingers, ears or noses do on their own.  If any of those areas starts hemorrhaging, everyone knows to stop the bleeding and look into the source of the problem if it reoccurs.  But when gums continue to bleed, many simply ignore it, as if it were "normal."  Bleeding gums are not normal.  When gums bleed, at the very least, a minor, reversible problem exists.  Sometimes the bleeding indicates a deeper problem, and without some kind of treatment, pockets and bone loss will continue to occur.
• Bone loss: When taken at regular intervals, dental x-rays keep track of bone levels surrounding the teeth.  Subtle changes can be seen, and when they are observed, they are definite markers that periodontal breakdown is occurring.  Bone loss left untreated progresses until teeth are compromised.  Fact: 70% of all teeth removed from adults are from bone loss due to periodontal disease … not decay.
• Loose teeth: Early signs of loose teeth are usually detected by the periodontist, dentist, or hygienist, not by the patient.  Looseness in teeth is a sign that something is wrong.  When discovered, the cause needs to be determined and corrected.
• Spaces forming between front teeth: In general, teeth don’t shift their position, though crowding of the lower (mandibular) front incisors does occur as we age.  However, when spaces start forming between some of the upper (maxillary) front teeth, it’s time to figure out why.  Sometimes so many new dental restorations have been placed on the back teeth that the front teeth shift.  But more commonly, front teeth flare out due to advanced bone loss and the lack of tooth support that comes with progressive periodontal disease.  Once this occurs, it should be treated before it gets worse.
• Halitosis: Bad breath (halitosis) may be a sign that significant periodontal problems exist in someone’s mouth.  Once the periodontal problems are under control, bad breath often goes away.
• Abscess (localized bacterial infection): Occasionally the first time a person realizes that they have a gum problem is when they develop a periodontal abscess.  An abscess occurs when bacteria are trapped in a gum pocket.  The bacteria have no way of escaping and the pocket expands, forming an abscess.  If treated in time, little damage is done to the surrounding bone and tooth; however, not treating an abscess in time can lead to rapid and severe bone loss.  When this occurs additional periodontal treatment is needed.

Like all chronic diseases, periodontal disease does not go away and it will not get better by itself.  It can remain silent and in remission, only to flare up again at a later date.  As the condition worsens, it’s harder to successfully treat.  That’s why once gum problems are noticed or diagnosed, it’s best to initiate treatment as soon as possible and maintain treatment recommendations.

My gums are receding, is this gum disease?

Recession in a single site is not necessarily caused by periodontal disease.  The most common gum surgery in children is the gingival (gum) graft, where tissue is placed over an area of recession usually exposed by eruption patterns (when teeth start to come in).  In adults, recession can be caused by long term over-brushing with a hard toothbrush or scrubbing techniques.  These areas are most often noticed at the upper cuspids (Canines) and bicuspids (Premolars), since they are at the corners and subject to the extra pressure.

The term "long in the tooth" refers to old age, but is also an indicator of periodontal disease.  Since gum tissue will often follow bone loss, if your recession is generalized you might consider a periodontal evaluation for a definitive diagnosis.

What makes my periodontal condition worsen?

Dentists have long known that stress affects the gums.  As far back as World War I, the influence of stress was noted in the soldiers fighting in the trenches.  Their gums became acutely infected to the point where the tips between the teeth, called papillae, eroded away, leaving disfiguring craters and loss of bone.  Teeth became loose, and in severe cases, needed to be removed.  This so-called "trench mouth," has a more formal name: Acute Necrotizing Ulcerative Gingivitis.  ANUG is also known as Vincents Disease, and is a stress-related disease.

Hormones also modify periodontal disease.  It is commonly known that during pregnancies, some women’s gums become swollen, sore and bleed more easily.  On rare occasions large swellings occur, known as pregnancy tumors.  These benign growths may need to be removed if they get in the way of chewing or become unsightly.  When a woman gives birth, most problems reverse themselves and leave no lasting symptoms.  In some cases, however, pregnant women suffering from periodontal disease may find their condition is actually worse post-partum (after delivery).  Teeth may feel loose or spaces may be present between teeth that were not there before pregnancy.  When these symptoms occur, professional help is required.

To a lesser extent, some women notice that their gums get puffy and bleed with the slightest touch right before their menstrual cycle begins.  These symptoms disappear a few days after menses has started.  Women on hormone replacement therapy may also observe subtle changes in their gums.

So what’s going on?  Stress?  Pregnancy?  Bleeding gums and the menstrual cycle?  Trench mouth?  What’s the connection?  Estradiols.

Estradiols are hormones that circulate in our bloodstream.  The three most common are: adrenaline, cortisone and estrogen.  Their amounts increase in our circulation for a variety of reasons, and when they do, they provide a fertile environment for the bacteria to multiply and cause periodontal damage.

As mentioned above, it is often observed that in females gums bleed more during pregnancy or just before menstruation begins. These are two examples of how increased circulating estrogen affects the gums.  However there are other conditions, such as stress, that affect men as well as women.  When individuals suffer any sort of personal crisis - job loss, marital problems, a debilitating disease affecting a loved one, or death to a family member - the chances exist that their circulating estradiols will increase:  specifically, adrenaline and cortisone. When this happens in the face of already existing periodontal disease, chances are the problem will get worse.

Is there anything else that can affect periodontal disease?

Plenty.  The worst offender is smoking.  Study after study shows that in the face of established periodontal disease, smokers have worse gums.  Not only do they have deeper pockets and more bone loss, but they do not heal as well as non-smokers do.  This is especially relevant when periodontists and oral surgeons place dental implants in smokers.  Smokers can successfully have implants, but they tend to heal slowly, have more infections, and experience more problems with their implants.

To a lesser extent, what we eat and the vitamins we take can affect the gums.  Individuals who are overweight or those consuming high amounts of carbohydrates - especially in candies, cakes and sugared drinks - adversely affect their teeth and gums.  Constant sucking on cough drops and hard candies and sipping on sugary drinks help the bacteria metabolize more quickly and in greater numbers.  This causes a greater risk for dental decay and inflamed gums.

On the vitamin front, if an individual has anywhere near a healthy diet, then the gums will not be affected. Periodontal disease is not affected by Vitamin C or calcium supplements, and taking these supplements will have no effect on gum disease.

Many disease states can also affect the gums.  The most notable is diabetes.  Diabetics need to take good care of their teeth and gums because they are more prone to infections and oral problems than non-diabetics.

Lastly, medications can also affect the gums.  One drug group that is of concern to periodontists are  calcium channel-blockers.  These medicines - Cardizem, Procardia, Nifedipine, Verapamil, plus others - are used to treat certain heart conditions.  Though they do not affect every person the same way and may not affect all who take them, calcium channel-blockers sometimes cause the gums to swell.  These gum swellings occur between the teeth and make brushing and flossing difficult.  In some instances the gums swell so large that they can only be managed with surgery.  If you take drugs in this category and are experiencing swollen and bleeding gums, you may want to seek professional help.  Other drug groups, such as anti-seizure (Phenobarbital and Dilantin) and anti-organ rejection (Cyclosporine) medications, may also affect the gums.

Please also be aware of a common side effect to many medications: dry mouth.  When the salivary flow decreases, better oral hygiene is needed to guard against decay and inflammation.  If you sense that your mouth is dry, clean your mouth frequently and swish often with water.

How can gum disease be prevented?

You are an integral player on the team charged with caring for your teeth. Without your steady involvement, your periodontist, dentist and hygienist are fighting an uphill battle.

Regular dental visits are essential to good dental health.  In spite of daily oral hygiene measures, calculus (tartar) forms anyway.  A professional cleaning by a periodontist, dentist or hygienist will remove the hardened calculus off the teeth.  So why bother if it only forms again?  The reason is that calculus acts much the way coral reefs do.  It serves as a hiding place, with all its microscopic nooks and crannies, for the millions of bacteria hovering about the teeth.  Remove the tartar, and flossing and brushing will be that much more effective in removing plaque.

Why is oral hygiene so important?

Adults past the age of 35 lose more teeth due to gum diseases and cavities than do younger adults.  Three out of four adults are affected at some time in their life with some form of periodontal problem.  The best prevention against cavities and periodontal diseases is to perform effective tooth brushing and flossing techniques daily.

Periodontal disease and decay are two different diseases and are caused by different types of bacterial plaque.  Plaque is a colorless invisible film that sticks to your teeth and grows above, at, and below the gum-line.  Plaque consists of the living germs on your teeth.  They begin to re-grow and multiply on the tooth within hours after being removed.  With thorough and consistent daily plaque removal, you can help prevent periodontal disease.

If the soft invisible plaque is not carefully and completely removed by daily brushing and flossing, plaque hardens into a rough, porous substance known as calculus (tartar).  Tartar is a hard substance that is firmly attached to the tooth and root, and it can only be removed with special instruments by the periodontist, dentist or hygienist.  In contrast, plaque is soft and can be removed by you (as long as you can get to it).  The limitation of personal plaque removal is about 3 mm (or about 1/16th of an inch) under the gum line.

Why do I need periodontal therapy?

There are 4 main goals in periodontal therapy.  They are as follows:

• Eliminate infection and inflammation
• Teach the patient self-care skills to maintain health and prevent reoccurrence of disease
• Correct any damage to the root, bone, gum and bite
• Establish an appropriate schedule of professional dental / periodontal maintenance (re-care) therapy

What is scaling and root planing or deep cleaning?

The first step to controlling periodontal disease is done with emphasis on preventative treatment utilizing a non-surgical procedure called scaling and root planing.  This is the most basic and common procedure performed to treat periodontal disease.  Root planing is a treatment procedure that is usually done with local anesthesia to assure your comfort.  This allows us to instrument the root surfaces of each tooth without pain or discomfort to remove plaque, calculus, cementum or surface dentin that is rough, impregnated with calculus (tartar), or contaminated with toxins from bacteria (micro-organisms).  

Upon completion of the above treatment, your gum tissue will be evaluated again to determine if your gum disease is under control.  After scaling and root planing has been performed, red and swollen gums often become more pink and firm, and bleeding is reduced or eliminated.  It will now be easier for patients to practice plaque control measures that will help slow down the disease process. 

At times (depending on the severity of your gum disease), scaling and root planing may not sufficiently reach the calculus (tartar) on all the affected root surfaces and may not be enough to properly heal your mouth.  In these cases additional treatment may be necessary.

What can I expect after my scaling and root planing appointments?

You will be numb for approximately 1 ½ - 3 hours after the appointment.  We recommend waiting for all numbness to wear off before eating in order to avoid accidently chewing on your tongue, lips or cheeks. When the numbness wears off, you may feel slightly sore and sensitive.  Typically our patients do fine with mild over-the-counter pain tablets such as Advil or Tylenol.  We recommend using warm salt water rinses two times per day for a few days.  This promotes healing and soothing of the soft tissues in the mouth.  Patients are able to return to work the same day.

We expect to obtain good results with minimal discomfort.  Be assured we will do everything possible to keep you comfortable.

Will surgery be necessary after scaling and root planing?

After assessing the results from scaling and root planing, it may be necessary to recommend additional treatment to help reduce deep, lasting pockets.  In order to create a more permanent, healthier environment around the teeth, periodontal surgery may be recommended in areas of the mouth that do not respond to non-surgical treatment (scaling and root planing).  Soft tissue plastic surgery may be needed to improve cosmetics, or regenerative surgery may be necessary to rebuild and replace the lost bone support around the teeth.  During periodontal surgery, the doctor has an opportunity to visibly ensure that all calculus (tartar) on the root surfaces has been thoroughly removed related to severity of periodontal disease and location of tartar.  In addition, irregular bone surfaces may be reshaped in order to achieve optimal healing results, leaving the patient with shallower pockets.  Shallower pockets are easier to maintain both for the patients and for the dental professionals who regularly and periodically clean their teeth and treat their gums.

If You Have Diabetes...

• It's important for you to know how well your diabetes is controlled and to tell your periodontist or dentist this information at each visit.
• See your doctor before scheduling treatment for periodontal disease.  Ask your doctor to talk to the periodontist or dentist about your overall medical condition before treatment begins.
• You may need to change your meal schedule and the timing and dosage of your insulin if oral surgery is planned.
• Postpone non-emergency dental procedures if your blood sugar is not in good control.  However acute infections, such as abscesses, should be treated right away.

For the person with controlled diabetes, periodontal or oral surgery can usually be done in the periodontist’s or dentist's office.  Because of diabetes, healing may take more time.  But with good medical and dental care, problems after surgery are no more likely than for someone without diabetes.

Once the periodontal infection is successfully treated,
it is often easier to control blood sugar levels.

What are the types of periodontal surgeries?

A variety of techniques are available to regenerate lost periodontal tissues, both hard (bone) and soft (gum).
The most common surgery to treat periodontal disease involves reducing the pockets by reshaping and removing the gums and the jawbone.  This surgical technique is called flap osseous.

In some moderate to severe cases, bone can be regenerated using bone graft and a barrier, rather than simply reshaping and removing it.  A barrier keeps unwanted cells out of the area being grafted and encourages desirable cells to form new tissues.  The bone graft and a barrier will eventually resorb (dissolve) and be replaced by your own natural bone.  This surgical technique is called guided tissue regeneration (GTR).  Each patient is very carefully evaluated to ensure optimal results.

In areas with recession, gingival (gum) graft surgery may be necessary to cover up the root surfaces to eliminate sensitivity or to strengthen the damaged gums.

Frenectomy is a very common surgery done when orthodontic (braces) treatment is planned or initiated.  The naturally occurring muscle attachment (frenum), normally seen between the front teeth (either upper or lower), is released during this procedure.  Frenum may pull on the gum margin, which results in recession, and an excessively large frenum can prevent the teeth from coming together, resulting in a gap between the front teeth.  In areas with severe recession, a gingival graft may be added after the frenectomy to strengthen the damaged gums or to cover up the root surfaces. 

After a tooth is lost, the jawbone begins to shrink.  The shrinkage usually continues indefinitely and in certain cases where all the teeth are missing, can even lead to jaw fracture!  By rebuilding lost jawbone (ridge augmentation) we can provide better support for placement of dental implants, or for removable dentures and more cosmetic permanent bridgework, which will ultimately give your face a more full and youthful appearance.

Crown lengthening can be recommended to make a restorative or cosmetic dental procedure possible.  If your tooth is decayed, broken below the gum line, or has insufficient tooth structure for a filling or crown, a crown lengthening procedure adjusts the gum, bone level, and exposes more of the tooth so it can be restored.  If your teeth appear small and your smile seems “gummy,” your teeth may actually be the proper lengths, but hiding under too much gum tissue.  A crown lengthening procedure will reshape your excess gum and bone, exposing more of the natural tooth.  This can be done to one tooth to even your gum line, or to several teeth to bring out your beautiful smile.

Once my gums have been treated, am I finished with periodontists forever?

Not in most cases.  As mentioned earlier, periodontal disease is a chronic condition that can not be cured, but can be stabilized and maintained.  Periodontists have a great track record when it comes to getting periodontal disease under control.  Once the initial treatment has been completed, maintenance (re-care) therapy is essential for future good oral health.

Periodontal disease often follows certain patterns.  Pockets and bone loss usually begin in the maxillary (upper) molars, followed by the mandibular (lower) molars.  In time it will involve other teeth as well. Once formed, periodontal pockets do not get worse on a daily basis.  Rather, periodontal disease can remain in remission for periods of time, only to have short bursts where the pockets worsen.  We call these periodontal breakdowns "episodic."  Along the way, abscesses can occur and pockets and bone loss can progress to the point that teeth need to be removed. Treatment can slow down and possibly even stop the progressive gum and bone deterioration.  This is why the maintenance (re-care) cleaning visits are so critical.

What’s the big deal if I lose a tooth?

Besides helping us look good, teeth are important for a host of other reasons.  For one, strong firm teeth enable us to chew our food more comfortably.  Properly chewed food is necessary for good digestion.  

Everyone likes a healthy, bright smile. First impressions count.  Besides making you look and feel good, teeth serve many other practical purposes. People who have had the misfortune of losing all their teeth and wearing dentures can have difficulty speaking. They also can’t eat all the things they want, are often self-conscious about their "choppers," complain that they can’t taste their food as well as they used to, and may even have trouble breathing when they sleep.  Once teeth are lost the supporting jaw bone disappears, causing us to lose facial fullness, contributing to an accelerated aged (wrinkled) appearance.  

Those are enough reasons for most of us to want to keep our teeth, and the best way to start is with good oral hygiene!

Do I still need a dentist if I don’t have any teeth?

Most definitely!  There are still a number of things that will require dental guidance, even with dentures. Your oral tissue should be examined at least every two years for any changes that can occur under the dentures that often go unnoticed by the wearer.  The bone also deteriorates at a much greater rate without the stress of teeth to keep it in place.  If your dentures feel loose after several years, it is because the bone is thinning and not providing the support it originally had.  There are a number of dental implant options available to increase stability of "floating" dentures.  As an added benefit, dental implants provide the needed stress to prevent further collapse of the jaws and face.

FAQ About Systemic Involvement

My gums bled when I was pregnant, does this mean that I have gum disease?

The hormonal changes taking place during pregnancy often cause inflammation and bleeding gums.  While this is a sign of periodontal disease, it can be only temporary with pregnancy.  If your oral hygiene is good and you have had regular cleanings up to that point, you probably have nothing to worry about with a little bleeding.  However, there are new studies that point out an incredible link to periodontal disease and premature, low birth weight newborns.  If you have periodontal disease, your risk is 7.5 times greater that you will give birth to a premature or low birth weight baby.  This statistic is far larger than smoking or alcohol consumption.  Given the increased mortality rate, health problems, and possible learning disability risks with prematurely born babies, a check-up with your periodontist or dentist should be a part of your prenatal routine.

How does diabetes affect periodontal disease?

Diabetes changes a patient's response to infection and inflammation.  Given the same genetic tendency toward periodontal disease, a diabetic individual will have more frequent and more severe problems.  Since periodontal disease is an infection, and since inflammation is one of the results, diabetics often have multiple abscesses, heavier bleeding and earlier tooth loss.  The good news is that studies show that well-maintained and well-controlled diabetics can have the same risks as non-diabetics.  With close monitoring from you and your physician, and guidance from your periodontist and dentist, diabetes may only have a minimal effect on your oral health.

What is the Link Between Diabetes and Periodontal Disease?

Diabetic Control:  Like other complications of diabetes, gum disease is linked to diabetic control.  People with poor blood sugar management are more prone to gum disease and are more likely to loose teeth than are people with good control.  In fact, people whose diabetes is well controlled have no more periodontal disease than persons without diabetes.  Children with IDDM (insulin-dependent diabetes mellitus) are also at risk for gum problems.  Good diabetic control is the best protection against periodontal disease.

Studies show that controlling blood sugar levels lowers the risk of some complications of diabetes, such as eye and heart disease and nerve damage. Scientists believe many complications, including gum disease, can be prevented with good diabetic control.

Blood Vessel Changes:  Thickening of blood vessels is a complication of diabetes that may increase the risk for gum disease.  Blood vessels deliver oxygen and nourishment to body tissues, including the mouth, and carry away the tissues' waste products.  Diabetes causes blood vessels to thicken, which slows the flow of nutrients and the removal of harmful waste.  This process can weaken the resistance of gum and bone tissue to infection.

Bacteria: Many kinds of bacteria (germs) thrive on sugars, including glucose -- the sugar linked to diabetes.  When diabetes is poorly controlled, high glucose levels in mouth fluids may help germs grow and set the stage for gum disease.

Smoking: The harmful effects of smoking, particularly heart disease and cancer, are well known.  Studies show that smoking also increases the chances of developing gum disease. In fact, smokers are five times more likely than nonsmokers to have gum disease.  For smokers with diabetes, the risk is even greater.  If you are a smoker with diabetes and are age 45 or older, you are 20 times more likely than a person without these risk factors to get severe gum disease.

Why do I have bad breath?

There are several causes of bad breath.  Mouth breathing from sinus problems, infection in the throat or tonsils, bacteria on the tongue or diseases of the lung or stomach can affect your breath.  But by far the most prevalent cause of bad breath is periodontal disease.  Bacteria living in the pockets around the teeth produce by-products that give off a strong odor.  Often people mask these effects with mouthwashes or mints.  It is much more effective, however, to treat the periodontal infection and see your periodontist and/or dentist for regular maintenance (re-care) therapy.  

How bad is snuff or chewing tobacco to my gums?

The effects of tobacco exist no matter how it is ingested.  Using tobacco not only increases your risk of coronary artery disease and stroke, it also reduces your immune response to viruses and bacteria.  The use of tobacco products therefore opens the door to overgrowth of bad bacteria involved in periodontal disease.  The type of periodontal infection seen with cigarette smoking is very specific to certain teeth and more difficult to address than others simply because one source of inflammation is so constant.  Similarly, with oral tobacco use you have the direct application of an irritant to the tissues.  Precancerous changes become evident within several weeks of tobacco use.  It is in the best interest of your oral and overall physical health to discontinue any type of tobacco use.

Is gum disease a strong risk factor for having a heart attack?

Periodontal (gum and bone) disease is a chronic, painless condition that gives off few warning signals, but one sign that you may notice is bleeding gums when you brush or floss vigorously.  The bacteria that develop in the pockets around the teeth by the billions can cause serious health problems.  Recent research has shown an increase in clotting of the blood when one of the most common of these bacterial species enters the bloodstream.  Blood clots can obstruct normal blood flow, restricting the amount of nutrients and oxygen required for the heart to function properly.  Also, the inflammation caused by periodontal (gum and bone) disease increases plaque build-up, which may contribute to swelling of the arteries.  This may lead to heart attacks.  Large studies indicate that those with gum disease have twice the usual risk of dying prematurely from heart disease.

FAQ About Bone Grafts

I heard you put bone grafts around teeth to regenerate new bone tissue.  Does that work and is it safe?

The bone grafting techniques used today can be very successful in helping you maintain your teeth.  We use both synthetic and human bone grafting materials to stimulate new bone growth.  The amount of new bone growth will depend on the location and type of defect or pattern of bone loss.  The human bone graft material is demineralized and sterilized at the tissue bank, so there is no risk of transmission of disease.  Because it is not a living tissue and there is no transfer of DNA (genetic information), it is safe to use.  Your bone cells migrate to the graft material (scaffolding) and the defect is actually repaired with the patient's own bone.  The graft greatly facilitates new bone growth.

FAQ About Dental Implants

What are dental implants?

Dental implants replace missing teeth and are divided into three different parts.  There is a metal post that replaces the root portion of the missing tooth, an abutment that connects the metal post and the crown, and a crown that is placed on top of the abutment.  The posts are made of titanium, which is a metal that is compatible with human tissues.  Titanium implants have been used for decades without any known ill effects.  They can be used in both the lower jaw (mandible) and the upper jaw (maxilla).  Dental implants are a unique reconstructive procedure to restore your natural smile.  Your periodontist and/or dentist may have recommended dental implants for several reasons:

• Tooth loss due to disease (decay or periodontal disease)
• Root canal failure
• Cracked tooth
• Loss of a bridge
• Painful and/or loose dentures or partials
• Trauma

Your new teeth will look, feel and function as close as possible to your natural teeth.  Clinical studies over 30 year periods have shown this procedure to be one of the most predictable in dentistry, with success rates as high as 95%.

When are dental implants needed?

Whenever teeth are missing or need to be removed, the advantages of dental implant fixtures will be discussed. We feel strongly that tooth structure and enamel should be preserved and left intact whenever possible.  As a result, we advise patients to choose single-tooth implant replacements when appropriate. Please note that the pros and cons of procedures will always be reviewed with the patient, in order to establish the best treatment plan for each individual.

What advantages do implants give me?

Dental implants can be used in a variety of ways, and in some instances they are a better solution than conventional dental restorations.  Here are some of the ways dental implants can be used:

• Dental implants can replace a single missing tooth. In this case using an implant would avoid drilling the adjacent teeth needed to support a permanently cemented bridge. This is often desirable when the abutment teeth do not have any fillings. The reason? Tooth enamel is precious. It can’t be replaced once it’s drilled. The act of drilling, no matter how carefully it’s done, can still stress the tooth’s nerve. Sometimes this compromises the vitality of the pulp tissue and a root canal is needed. Another thing to consider is that as much as we would wish otherwise, dental crowns and bridges do not last forever. They can chip or break, and decay can form under the margins, necessitating replacements. When proper and regular maintenance is performed, a single dental implant reduces the need for extra crowns and future dental work.
• Dental implants can replace a removable partial denture. Unfortunately, removable bridges are not always as firm and kind to the tissues as we would like. Oftentimes they move around a bit and can even loosen the teeth they rest on, which are called abutments. In time, abutment teeth can become so loose that they may need to be removed. When this happens, a new, larger removable denture is needed. Removable dentures collect a lot of plaque and make cleaning around some teeth quite difficult. With implants these problems tend to be avoided, or at least minimized.
• Dental implants can better stabilize (anchor) an upper or lower denture, creating a greater sense of security. Also, the denture is often smaller than the one being replaced. Most people have enough bone remaining to have implants placed in their jaws. When there’s not enough bone, we can re-build the jawbone through ridge augmentation to regenerate the amount needed to successfully have implants.
• Dental implants can be used in complex cases in order to avoid a denture if the patient still has some teeth left. These patients usually have existing bridges, a root canal has failed, a key abutment tooth has cracked, or their periodontal condition has worsened. With any of these conditions, a periodontist or dentist may suggest placing dental implants in strategic areas to avoid losing the remaining teeth and wearing removable dentures.

If I lost teeth due to periodontal disease, can I still have dental implants?

Definitely.  Even when periodontal disease is present, most patients retain adequate amounts of bone for dental implants.  In some instances where more bone is needed before placing implants, highly successful grafting procedures are available to regenerate the amount of bone needed.  Once sufficient amounts of new bone have been regenerated, dental implants can be placed to support new dental prostheses.

But still, each mouth is different. How do you know I have enough bone for dental implants?

Dental x-rays and clinical exams help to determine if enough bone exists to place the dental implants.  However, more information may be needed before making that determination.  Dental CT scans provide the most accurate information as to how much bone is present in a jaw.  Unlike dental x-rays that are two dimensional, CT scans view the jaw in three dimensions.  This gives us a view of what’s "inside" the jaw.  Ultimately, the CT scans will provide information to know if you have enough bone for dental implants.  We are proud to offer this service to patients in the convenience of our office.

Are there any possible side effects to implant placement?

Yes.  When implants are needed toward the back of the jaw (in the premolar and molar area), there is a risk of injury to the mandibular nerve.  This nerve runs through the length of the mandible (lower jaw), starting from behind the last tooth and exiting just behind the canine (or eye tooth).

How can I make certain the mandibular nerve is not in the way in my case?

X-rays, often including a dental CT scan, help visualize the course of the mandibular nerve.  While the risk of injury to the nerve exists, it is very small and seldom occurs.

Are there other anatomic areas of common concern when having implants placed?

Yes, the maxillary sinus.  This is the large cavity in the area above the maxillary (upper) molars.  It sits under the eyes, behind the cheekbones, and to the right and left of the nose.  It’s the space that fills with mucous when we have a cold.  The reason the maxillary sinus is a concern during implant placement is that it is hollow. IT IS HOLLOW FOR EVERYONE!  The area needs to be evaluated to see if there is enough jawbone remaining to support the implant.

Is there a way to grow more bone in the sinus so I can have an implant?

Yes.  The procedure to grow more bone in the maxillary sinus is called a sinus lift.  Placing a bone graft in this area is not difficult to do and generally yields excellent results.  Once enough bone has grown, implants can be placed in an area that years ago was deemed an impossible site for dental implants.

Besides the mandibular nerve and the maxillary sinus, what else do I have to worry about when having dental implants placed?

Sometimes the bone is too narrow to hold an implant.  When this is the case, we can perform a ridge augmentation to increase the width of the bone.   Depending on the need, ridge augmentations can be performed simultaneously with the implant surgery, or months in advance of the procedure.

What about infections from dental implant surgery?

There is a slight risk of infection, however, following proper precautions can greatly reduce or even eliminate your odds of infection.  After the implant surgery we will review appropriate post-operative instructions with you.  These include, but are not limited to, the usage of antimicrobial mouth rinse, antibiotics, diet restrictions and appropriate oral hygiene care. 

Can an implant be rejected?

Yes.  Implants can be rejected, but not in the way we know "rejection" can occur in organ transplants, such as with kidneys and hearts.  We know dental implants are compatible with human tissue.  There are no known allergic reactions to commercially-pure, titanium implants, but failure can still occur.  There are many contributing factors that may affect the success or failure of dental implants, such as smoking, systemic illnesses, uncontrolled diabetes, uncontrolled high blood pressure, poor oral hygiene care and oral bacteria contaminating implants.  Before scheduling dental implant surgery, we conduct a thorough patient evaluation in our office.  In addition, our highly trained staff ensures sterile conditions during implant procedures, from the way the implants and instruments are packaged and prepared to the hygienic conditions in the operatory.

How long does it take to replace my missing tooth?

The general rule of thumb is that when a metal post (implant) is placed in the mandible (lower jaw), the site will heal in 3-4 months, while the maxilla (upper jaw) takes 4-6 months.  Once the healing is complete, the abutment and crown can be placed on the metal post (implant).  Augmenting the bone, performing sinus lifts, needing jaw reconstruction, etc., will lengthen healing periods.  Remember, healing times are related to human biology.  It takes time for the body to heal.  Healing can not be made to go any quicker than how we were intended to heal.

Is there a second surgical stage when getting implants?

Yes.  The first stage is when the implants are placed in the jaw and the bone "attaches" or integrates to the implants.  In a manner of speaking, the implant becomes part of your body.  Months later, the periodontist performs a second surgical procedure where a tiny incision is made on top of the implant to place the "healing abutment".  Soon after this is done the dentist can begin making the desired restoration.

How successful are implants?

Implants placed by most periodontists or dental surgeons today have a high degree of success.  In fact, they are close to 95% successful in the mandible (lower jaw) and 90% successful in the maxilla (upper jaw).  These percentages may vary slightly from patient to patient, but as a rule, titanium implant dental fixtures are predictably successful.

If an implant fails, can another be placed in the same spot?

Usually, yes.  If an implant fails the implant is removed, and if conditions are right, the site is prepared for another dental implant.  Sometimes this can be done at the time the implant is removed.  Other times, the periodontist or dental surgeon feels it is better to try again only after a prescribed healing period.  Regardless of when an implant is placed in the site of a failure, it can still be successful.

For more information about dental implants, you can make an appointment with our office or contact your dentist.  Also, you can contact the American Academy of Periodontology at 1-800-282-4867.

FAQs about Plaque and Calculus (tartar)

What is plaque?

Plaque is a clear, sticky film that adheres to the surfaces of teeth, gum tissues, dental restorations and even the tongue.  It is so adherent that it can not be washed or rinsed off, but must be mechanically removed.  Plaque is neither food stuck on the teeth, nor food debris.  It contains a variety of bacteria that can cause dental decay, contribute to calculus (tartar) formation, and initiate the inflammatory response associated with periodontal (gum and bone) disease.

How quickly does plaque form?

Unfortunately, plaque forms soon after it is removed.  Some studies report that it starts forming as soon as five minutes after it is removed.  Other reports state that it can take up to four hours.  Regardless of how quickly it begins reforming, effective plaque control will keep it to a minimum.  That’s why we encourage brushing your teeth twice a day, plus daily flossing.

Are all plaques equal?

No. The rate plaque forms and what it’s made of varies from individual to individual.  In fact, it even varies in different parts of the same mouth.  Studies have shown that plaque affects each of us differently ... some are more susceptible to the bacterial components in the plaque than others.  That’s why individuals have different healing responses to periodontal (gum and bone) treatment.

What’s the first sign of plaque affecting the gums?

A frequent warning sign is when the edge of the gums next to the teeth becomes red, inflamed and bleeds when touched.  This early stage is known as gingivitis and takes three weeks to form when all oral hygiene measures are suspended.  Gingivitis is a reversible condition.  With diligent flossing and tooth brushing, gingivitis usually disappears.  However, if left untreated it can progress into periodontal (gum and bone) disease.  Periodontal disease is defined as the formation of pockets (loss of gum attachment to the teeth) and the loss of bone that supports the teeth.  Periodontal disease is a chronic condition and is the number one cause of tooth loss in adults.

What is calculus (tartar)?

In some individuals, calculus forms in spite of the best oral hygiene.  So what is it?  Calculus is a hardened substance that forms from a combination of minerals in the saliva and from the dead plaque bacterial cells.  Together they precipitate a crusty deposit that, once mineralized, can grow rather quickly.  When looked at under a microscope, calculus has all the nooks and crannies of a coral reef, and a similar number of hiding places for bacteria to hide.  Left on the teeth long enough, calculus begins to irritate the gums.  The gums can swell, become ulcerated and bleed, and eventually get progressively worse resulting in pocket formation.

Can calculus form under the gums?

Yes.  There are two types of calculus.  Supragingival (above the gums) calculus is the hard deposit on top of the teeth, the kind we can see and feel.  Subgingival calculus forms below the gums.  It is just as hard and adherent as supragingival calculus, but it is a greater concern because it forms within the pockets.  This allows the bacteria to congregate in greater numbers.  Though it is difficult to remove plaque formed on top of or within subgingival calculus, it is necessary to do because these pathogens cause more periodontal tissue breakdown, resulting in deeper pocket formation.

Can calculus form at different rates?

Definitely.  Some people never form calculus, while others form it in varying amounts.  Some individuals notice it just days after a professional dental cleaning, while others hardly form any even months later.  The rate of calculus formation is not an indicator of the amount and severity of periodontal disease, nor does it indicate that an individual will ever get it.  But its continued presence can always damage the gums and the supporting bone.

How frequently should plaque and calculus be removed?

Brushing 2 times a day (minimum of 2 minutes each time) and flossing once a day is the best way for an individual to control periodontal (gum and bone) disease.  In addition, periodic (every 2, 3, or 4 months) professional removal of plaque and calculus by the periodontist, dentist or hygienist is recommended.  At these times the periodontist, dentist or hygienist can examine the periodontal tissues to determine if new pockets have formed or if previously diagnosed pockets have gotten worse.  The frequency of these periodontal maintenance (Re-care) treatments is best determined by the dental professional treating you.

FAQs about Toothbrushing

How frequently should I brush and what type of toothbrush should I use?

It is recommended that brushing twice daily (minimum of 2 minutes each time), using a soft, nylon bristled toothbrush, is most effective at removing plaque.  Harder, stiffer bristles can damage teeth and gums.

Which is better, an electric toothbrush or a manual toothbrush?

When used properly, both types of toothbrushes are equally effective at removing plaque.  It has been our experience that if someone exercises good plaque control with a manual toothbrush, there’s no reason to change.  However, those persons needing a "boost" in motivation when it comes to plaque control sometimes do better with an electric toothbrush.  Whichever works best in your hand to get the job well-done is the best toothbrush for you.

When is it time to get a new toothbrush?

When the bristles are no longer straight, but tend to flare outward.  This can happen in as little as three weeks, or in three months.  If the bristles flare out within three to four weeks, it may be an indication that your brushing technique needs to be modified.  Be sure to check with your dental professionals for additional assistance.

How should I brush my teeth?

Start on the inside (tongue and palatal side) of the teeth, placing the tip of the brush at the area where the gum and tooth meet.  Use a small circular motion, and with gentle pressure brush each tooth individually, working your way around the upper and lower teeth allowing 1-2 minutes.  Then brush the outside (cheek side) of the teeth in the same manner allowing 1-2 minutes.  Brush the chewing surfaces (occlusal surfaces) of both upper and lower teeth.  Lastly, brush the tongue. 

Be careful not to scrub too hard or you might cause erosions to form on the teeth at the gum line, and can even "brush away" the gums, causing gum recession.

Should I brush my gums, too?

Yes, but in a specific, safe way.  Brushing at the gum line improperly can cause the gums to recede.  When this happens, the teeth become sensitive, especially to cold drinks.

The best way to remove the plaque at the gum line is to slant the toothbrush head on a 45 degree angle to the tooth.  This means that when you’re brushing the mandibular (lower) teeth, the bristles are slanted downward, and for the maxilla (top) teeth, the bristles are slanted upward.  Use a short, gentle stroke that "wiggles" the bristles at the gum line. This technique effectively removes the plaque and should not traumatize the gums.  Think about it – when you do it this way, you’re essentially only removing the plaque from one or two teeth at a time, not a large group of them.  After finishing one area, move on to other teeth until all - outside and inside - teeth have been cleaned.  Though cumbersome and slow at first, this plaque-removal technique can skillfully be performed in the 2 minutes of recommended brushing time.

It is also a good idea to brush your cheeks, roof of your mouth, and tongue for fresher breath.

How can I check to see if I have removed all the plaque from my teeth?

Dental plaque is hard to see unless it is stained.  Plaque can be stained by chewing red "disclosing tablets" sold at grocery stores and drug stores, or by using a cotton swab to smear green food coloring on the teeth.  The color left on the teeth shows where there is still plaque.  Extra flossing and brushing will remove this plaque.

But is brushing enough to remove all the plaque from my teeth?

No, it is not.  In fact it’s been estimated that toothbrushing removes as little as 30% of the plaque, and the plaque it does remove is not in the areas that cause tooth decay or periodontal (gum and bone) disease.  Why?  Because toothbrush bristles do not reach in between teeth and barely get below the gum line, where the more harmful plaque is harbored.  For this reason dental professionals – periodontists, dentists and hygienists - recommend dental flossing and the judicious use of toothpicks.

FAQs about Bad Breath

What is bad breath?

Many cases of bad breath, or halitosis, are due to protein breakdown caused by the bacteria in the mouth.  These odor-producing organisms can lurk anywhere: around the necks of the teeth, in pockets, next to fillings and crown margins, on the tongue and in various other recesses in the mouth.  Consider how prone the mouth is to growing these bacteria.  It has all the ingredients of a successful incubator: it’s dark, moist, warm and has all the "food" necessary that the bacteria need to metabolize.  Left to their own devices, these odor-causing bacteria can thrive to the extent of causing bad breath.

What can I do to prevent bad breath and help keep my breath fresh?

Practice good oral hygiene.  This includes brushing and flossing regularly and effectively, so that as much of the plaque is removed by you as possible.  If your mouth feels dry, drink plenty of liquids during the day.  If necessary, use sugar-free mints or breath-freshening products found in health and drug stores.

In addition, brush your tongue.  Your periodontist, dentist or hygienist may recommend a special brush or tongue scraper for this, but a conventional, soft-bristled toothbrush may do just fine.  Remember, bacterial plaque can hide in the irregular surfaces of the tongue, contributing to bad breath.

What should I do if bad breath persists?

See your periodontist or dentist. Make certain there are no obvious trouble spots contributing to this problem, especially an untreated periodontal condition like a gum abscess.

Once your mouth appears free of anything that might contribute to halitosis, consider consulting with your physician about this matter.  One of the most common medical conditions that cause bad breath is reflux from the upper gastrointestinal tract.  

Regardless of what the cause is, bad breath can usually be helped.

FAQs about Flossing and Toothpicks

Why floss? It’s such a drag!

The main reason to use dental floss is because floss removes the hard-to-reach plaque that toothbrushing misses.  In fact, most dental decay and periodontal disease begin where teeth touch each other – at or under the contact points.  And that’s precisely where the toothbrush bristles cannot reach.

What is floss?

Dental floss is composed of gently twisted nylon or Teflon (Gore-Tex) threads.

Are there different types of dental floss?

Dental floss comes waxed and unwaxed, flavored and unflavored, and in varying widths: thin, regular or wide.  There is no "best" type of floss to use.  Unwaxed floss is favored by many periodontists and dentists because as it’s used, the nylon threads spread to absorb more plaque.  Our office believes that clinically it doesn’t matter which type of floss - or dental tape - you use, but just that you use it, and that it works well for you.  Tooth brushing alone does not remove enough plaque to be effective when it comes to good oral hygiene.

Ask your periodontist, dentist or hygienist how best to use floss under fixed bridges and around dental implants.

How often should I floss?

You should floss at least once a day.  Though cumbersome at first, flossing will take no time at all once the skills are mastered.

How should I floss?

Use about 18 inches of floss.  Wrap it loosely around your middle fingers, not your index fingers.  This is because you don’t want to limit the range of motion of the index finger which, along with the thumb, is used to guide the floss in the right places.

With the floss wrapped around your middle fingers, guide a piece roughly 1" to 1 1/2" between two teeth.  Gently saw the floss back-and-forth, passing beyond the contact point, to where the floss slides down the neck of the tooth.

Once the floss is beyond the contact point, guide it "around" one of the teeth.  Avoid the triangular gum tissue, known as a papilla.  A good way to picture this is to think of the tooth as a circle, and your goal is to swipe away the plaque from one half of that circle.  Slide the floss gently into the space between the gums and the tooth until you meet resistance.  Then, holding the floss firmly against the tooth, rotate it up and down, as if you were "shining shoes."  After two or three strokes, lift the floss over the papilla, shifting your thumb and index finger so that you guide the floss around the half of the other tooth in the same area.  Repeat the same motion again, removing the plaque from this tooth.  Once completed, pull the floss back through the contact point and begin the process over again in the next interdental area.

When the floss becomes frayed or soiled, unwind a fresh piece from your middle finger.  After flossing it’s a good idea to rinse your mouth with water to loosen and remove any particles next to the teeth.

Would a water irrigating device help my periodontal condition?

Only in specific instances.  A water irrigating device removes debris from between the teeth, known as "loose adherent" plaque.  It is always beneficial to remove this plaque, but a residual, adherent plaque can still be found on the teeth and root surfaces.  Adherent plaque is not removed by water irrigating devices.  This plaque - adherent plaque - can damage the teeth and periodontal tissues by causing dental caries and periodontal disease.  As a matter of fact, if a water irrigating device is angled incorrectly, it may drive bacteria into the periodontal tissues, causing more harm than good.

What else helps remove plaque?

Toothpicks are another “tool” that can be used to effectively remove plaque.  They get to those last nooks and hiding places that both floss and toothbrushing may miss.  The most effective way to remove plaque is by brushing your teeth in conjunction with utilizing another “tool” such as floss, proxabrush, toothpicks or other professionally recommended dental aids to clean between the teeth.

Do I hold the toothpick with my fingers?

Holding a toothpick with your fingers is minimally effective.  That’s because after reaching those in-between spots in the front teeth, it’s hard to maneuver the toothpick toward the back of your mouth, and near-impossible to clean the inside (tongue side) of your teeth.  Instead, we recommend using a Perio-Aid.  A Perio-Aid is a plastic tool that is specially designed to hold the toothpick in the proper angle for cleaning in between all teeth, both outside and inside.  If you have periodontal disease but do not use a Perio-Aid, ask your periodontist, dentist or hygienist for his/her opinion.

FAQs about Keeping Healthy Gums

A personalized plan of care is helpful in maintaining healthy gums.  The key word is: maintenance (Re-care) therapy.  By exercising proper home care and having routine periodontal maintenance treatments, you will help protect your periodontal health.

What is periodontal maintenance (Re-care) therapy?

Since periodontal disease is a chronic condition like diabetes, it is helpful to establish an ongoing program to maintain the improvements achieved during active treatment.  The periodontal maintenance (Re-care) treatment intervals are best determined by your periodontist or dentist, and can range from 3-6 times per year.  Studies show that after 8-12 weeks, calculus (tartar) tends to repopulate in deep pockets where toothbrush bristles cannot reach.  Therefore, for patients with periodontal disease, we recommend quarterly visits.  These sessions are designed to preserve the healthy state of your gums and stabilize your bone levels.  On-going treatment success is based on your conscientious home care, and the professional treatments you receive in your periodontist’s or dentist’s office.

Why is periodontal maintenance (Re-care) therapy important? 

Daily oral hygiene will not insure that the bacterial plaque will not return to damage your gums and bone.  Even with a dedicated combination of flossing, brushing and using oral hygiene aids, dental plaque continues to mature in the hard-to-reach places.

This can happen in 8-12 weeks, which is why it is often recommended to patients completing periodontal treatment to schedule maintenance (Re-care) sessions every three months.

Who should perform periodontal maintenance (Re-care) therapy?

Based on the severity of your problem, the responsibility for the periodontal maintenance (Re-care) will be worked out between you, your dentist and your periodontist.

What is done during a periodontal maintenance (Re-care) session?

• Your mouth tissues will be examined for abnormal changes (Oral cancer screening)
• Changes in your health will be discussed
• Pockets will be measured, noting any changes
• Your oral hygiene will be evaluated, with suggestions on how to improve it when needed
• Your teeth will be cleaned to remove bacterial plaque and calculus (tartar)
• Necessary x-rays may be taken to evaluate the teeth and supporting bone
• Your teeth will be checked for caries (dental decay)
• The bite (the way the teeth fit together) will be checked
• Dispense appropriate recommendations for any problems discovered, e.g. tooth sensitivity and indicated dental restorations

What is the relationship between my general dentist and my periodontist?

Your periodontist, dentist and hygienist form a team to provide the best possible dental care and maintenance (Re-care) program for your needs.  The periodontist may see you periodically for periodontal maintenance (Re-care) therapy and the assessment of your overall periodontal health, but you will still need to see your general dentist as well.  Why?  Because periodontal maintenance (Re-care) treatments are not meant to take the place of regular dental check-ups.  Remember that your general dentist is primarily responsible for your overall dental health.  He/she will examine - and repair - carious lesions (dental decay), change fillings, make new crowns or bridges, perform cosmetic dentistry and whiten or bleach your teeth.

FAQs for Antibiotics and Antimicrobials

What is an antimicrobial?

Antimicrobials are substances that will inhibit or eliminate the growth of a microorganism.  They include antibiotics, antiseptics and other disinfectants (disinfecting agents).

What are antiseptics?

Antiseptics are chemical disinfectants that are applied at the gum surface or under the gum line to inhibit the growth of microorganisms.  A mouthwash is a type of antiseptic.

What is an antibiotic?

An antibiotic is a substance that is injected or taken orally.  It passes through the entire body in order to get to a site of infection, or it can be used to prevent infection.  An antibiotic prevents the existing organism from growing further or destroys the current growth.

Some studies suggest that scaling and root planing with antimicrobial support will eliminate the need for periodontal surgery, and that it is a more cost-effective, user-friendly means of periodontal treatment.  However, other recent studies have concluded that surgery may provide a better long-term outcome with less need for additional treatments than non-surgical therapy.  The American Academy of Periodontology (AAP) is concerned that these studies have initiated debate that is confusing for practitioners and patients and may thwart thoughtful discussion and better understanding of the key issue: what is the most effective means to keep periodontal diseases at-bay for each individual patient?

Periodontal health should be achieved in the least invasive and most cost-effective manner.

AAP treatment guidelines have always stressed that periodontal health should be achieved in the least invasive and most cost-effective manner.  This is often accomplished through non-surgical periodontal treatment, including scaling and root planing (a careful cleaning of the root surfaces to remove plaque and calculus [tartar] from deep periodontal pockets and to smooth the tooth root to remove bacterial toxins), followed by adjunctive therapy such as systemic and local delivery antimicrobials and host modulation.  Most periodontists would agree that after scaling and root planing, many patients do not require any further active treatment, including surgical therapy. However, the majority of patients will require ongoing maintenance (Re-care) therapy to sustain a stable periodontal condition.  Non-surgical treatment does have its limitations, however, and when it does not achieve periodontal stability, surgery may be indicated to restore periodontal anatomy damaged by periodontal diseases.

Some studies propose that patients receive antibiotics at the time of scaling and root planing.  This blanket use of antibiotics is not necessary for most patients, because they usually respond well to non-surgical treatment without antibiotics.  Blanket antibiotic use disregards the Centers for Disease Control (CDC) recommendations for appropriate antibiotic use for healthcare providers.  It is important for all periodontists and dentists to consider antibiotic usage guidelines in treatment planning so that the effectiveness of their use is preserved for patients who do not initially respond to therapy.  This helps to avoid contributing to one of the world's most pressing health problems: antibiotic resistance.

The AAP continually monitors emerging research to identify therapies that further its members understanding of cost-effective, minimally invasive procedures in the treatment of periodontal diseases.  Unfortunately, when the overly simplistic dispute over non-surgical versus surgical procedures arises, it often misleads patients and the dental community into thinking it's an "either-or" debate.  In actuality the procedures are complementary, with each having their place in treatment and each having their limitations.

What is Local Delivery of Antimicrobial Drugs (LDD)?

Specific bacteria play a central role in the cause and promotion of destructive gum disease.  Under suitable conditions, the bacteria (bugs) grow under the gum into a mass or colony of bacteria that are strongly embedded to the tooth root surfaces.  This invisible mass or colony is what we call plaque.  Successful treatment of the disease depends on our ability to remove the bacteria from the root and to detoxify the root surface.  Scaling and root planing (deep scraping) is the foundation procedure that is designed to transform the toxic root surface into a clean, smooth root that can be returned to stable periodontal condition.

After the initial therapy (scaling and root planing) is completed, routine periodontal maintenance (Re-care) therapy is recommended.  In isolated areas of deep pockets during maintenance therapy, antibiotics may be administered to help control or eliminate the bacteria causing periodontal disease.  However, it is important to note that the antibiotics alone do not control or eliminate the bacteria; it is the combination of the periodontal maintenance (Re-care) therapy and a selective use of antibiotics that promote periodontal stability.  Please ask your periodontist and/or dentists for more information regarding Local Delivery of Antimicrobial Drugs (LDD).
Current brands of LDDs include the following names:

• Actisite
• Atridox
• Arestin
• Periochip