Periodontal health addresses the health status of your gum and bone tissues around teeth - basically the entire "attachment apparatus" of teeth. Unfortunately, patients often discount the value of proper periodontal treatment. The reason for that is probably that periodontal diseases are not always immediately visible to the naked eye and by the time they become visible, the affected tooth has often a very poor prognosis.
Good periodontal health is the cornerstone of long lasting teeth. Even when a tooth brakes, the chances for your dentist to be able to restore it properly increases dramatically if the tooth is surrounded by healthy gum and bone tissues.
Since this is a lengthy page, we have included a little outline below, which can be used to hyperlink you quickly to the individual sections. Also, at the end of every section is a button, which will bring you back to the top of this page.
Periodontal therapy can be divided into four different modalities of increasing aggressiveness:
We will examine each of these periodontal therapy modalities in more detail below. All of these modalities have one common goal: to preserve your teeth for the rest of your life. Periodontal therapy may be costly at times, however it is usually a bargain when compared to the alternative: Dental Implants. We will also reference which treatment modality is best suited for some of the periodontal diseases described in the Your Gums section.
The whole idea behind oral hygiene is to remove plaque. Plaque is a film of bacteria and mucous that grows on your teeth. Some of the bacteria in the plaque make acids which decay your teeth. Other kinds of bacteria in the plaque make toxins which cause gum disease. The easiest and most effective way to remove the plaque from your teeth is to brush and floss. Plaque-removing rinses alone have not shown to be effective. When the plaque is hardened on your teeth (through mineralization from your saliva) it is called tartar or calculus, which can only be removed with a professional cleaning.
Brushing and flossing should be performed thoroughly but not too vigorously. Rough mechanical action may irritate or damage sensitive oral tissues. Sore or bleeding gums may be experienced for the first few days after flossing is begun. However, bleeding continuing beyond one week should be brought to the attention of a dentist. As a general rule, any sore or abnormal condition that does not disappear after 10 days should be examined by your dentist.
Brushing
Brushing should be performed with a toothbrush and a fluoride toothpaste at least twice a day and preferably after every meal and snack. Effective brushing must clean each outer tooth surface, inner tooth surface, and the flat chewing surfaces of the back teeth. To clean the outer and inner surfaces, the toothbrush should be held at a 45-degree angle against the gums and moved back and forth in short strokes (no more than one toothwidth distance). To clean the inside surfaces of the front teeth, the toothbrush should be held vertically and the bristles at the tip (called the toe of the brush) moved gently up and down against each tooth. To clean the chewing surfaces of the large back teeth, the brush should be held flat and moved back and forth. Finally, the tongue should also be brushed using a back-to-front sweeping motion to remove food particles and bacteria that may sour the breath.
Toothbrushes wear out and should be replaced every three months. Consumers should look for toothbrushes with soft, nylon, rounded bristles in a size and shape that allows them to reach all tooth surfaces easily.
Holding a toothbrush may be difficult for people with limited use of their hands. The toothbrush handle may be modified by inserting it into a rubber ball for easier gripping.
Flossing
Flossing once a day helps prevent gum disease by removing food particles and plaque at and below the gumline as well as between teeth. To begin, most of an 18-in (45-cm) strand of floss is wrapped around the third finger of one hand. A 1-in (2.5-cm) section is then grasped firmly between the thumb and forefinger of each hand. The floss is eased between two teeth and worked gently up and down several times with a rubbing motion. At the gumline, the floss is curved first around one tooth and then the other with gentle sliding into the space between the tooth and gum. After each tooth contact is cleaned, a fresh section of floss is unwrapped from one hand as the used section of floss is wrapped around the third finger of the opposite hand. Flossing proceeds between all teeth and behind the last teeth. Flossing should also be performed around the abutment (support) teeth of a bridge and under any artificial teeth using a device called a floss threader.
Dental floss comes in many varieties (waxed, unwaxed, flavored, tape) and may be chosen on personal preference. For people who have difficulty handling floss, floss holders and other types of interdental (between the teeth) cleaning aids, such as brushes and picks, are available.
Contrary to some people's belief that professional cleanings with a dentist or a hygienist are only necessary when Gingivitis becomes evident, or when calculus accumulates to levels depicted in the image above, professional cleanings should be done at regular, scheduled intervals. Your dentist will determine whether a six-month interval or a three-month interval is the right one for you.
It is virtually impossible for us to remove 100% of the plaque on our teeth every day. The most common areas of plaque accumulation are in the gum pockets and in other hard-to-reach areas. Over time the minerals in our saliva will mineralize the soft plaque and turn it into hard calculus (tartar), which is very tenacious and, thus, very difficult to remove. A skilled hygienist or dentist can easily remove this calculus with certain hand instruments. This procedure is also referred to as scaling. A professional cleaning is also the recommended treatment of choice for Gingivitis.
Dental hygienists perform traditional scaling by hand. Advances in technology have led to more modern methods such as electric scalers, which allow dental cleaning to be done in much shorter period of time. However, to achieve best results, electric and manual scaling should be combined in dental cleaning.
Ultrasonic scaling uses a machine called a cavitron, which uses sound waves to remove tartar. Ultrasonic scalers can only remove about 50% of total tartar buildup so hand scaling must follow cavitron scaling. People who wear pacemaker should consult their cardiologist prior to the scaling procedure, because the ultrasonic sound and vibration might interfere with the function of the pacemaker.
Polishing is the finishing touch of the professional cleaning. In this step the hygienist uses a polishing paste and a rotary instrument to polish the surface of your teeth.
There are two kinds of polisher, the prophy jet polishing and rubber tip polishing with prophy paste. Prophy jet polishing works by spraying high pressured water mixed with baking soda paste onto the surface of your teeth. This powered water can wash away the residue and plaque, while the baking soda removes the brown and yellow stains and neutralizes the acidic conditions in your mouth. Rubber cup polishing employs a low-speed hand piece with a rubber cup tip mounted on the top that contains a polishing paste that is made of abrasive ingredients ideal for removing stains.
The amount of time needed for dental cleaning depends on factors from plaque deposits, complication of dental restorations and your gingival health. People with more tartar and plaque buildup need longer appointments than those who have relatively cleaner teeth. In a moderate case dental cleaning should take about 25 to 30 minutes. Cleaning should be performed every six months to prevent excessive plaque build up. Lack of cleaning allows the growth of plaque, which if left unchecked can lead to the various types of conditions involved in tooth decay.
A professional cleaning can often turn an unsightly calculus and gingivitis case into a clean and healthy periodontal environment, as can be seen below.
The Scaling & Root Planing procedure, which is also often referred to as "Deep-Cleaning Procedure" is the treatment modality of choice for mild cases of Periodontitis. In moderate to severe cases of Periodontitis, it is almost always the "starting procedure" of the treatment, which may then be followed up with a Periodontal Surgery procedure (see below). The goal of this procedure (as well as the surgery) is to reduce the depth of your pockets, so that you will be able to keep your pockets clean in your oral hygiene home care. It is possible to keep 2 to 3mm pockets clean with a toothbrush and floss, however pockets that are deeper than that are nearly impossible to keep clean. The Your Gums section has a more detailed description of Periodontitis and deep pockets and how they are often inter-related.
You can expect the treatment to take three to four visits spaced about a week apart. You might be given local analgesia. During scaling, the dentist or hygienist uses a vibrating ultrasonic device to scrape tartar from the visible part of the tooth.
To get to the harder-to-reach tartar beneath the gum line, the dentist or hygienist uses a curette to probe and clean out the pockets formed around the tooth by receding gums. At the same time, he or she removes any diseased soft tissue. The dentist or hygienist then uses a curette to plane the tooth root to make the surface smooth. This removes sites where the bacteria lodge within the pockets. It also reduces the chance of more bacteria taking hold because it's harder for plaque to stick to a smooth surface. The dentist then polishes the tooth with an abrasive paste and instructs the patient on maintenance and home care, including the use of special anti-bacterial mouthwashes. Sometimes the dentist may put you on an antibiotic regimen for some time.
One of the most important parts of this treatment is follow-through. After the Scaling & Root Planning procedure is completed, the patient should follow the oral home care instructions very accurately. In addition, most doctors will recommend that your professional cleanings be done every 3 months instead of every 6 months.
The image on the left is a good representation of a Scaling & Root Planing procedure on a tooth model. The red layer represents plaque and calculus that needs to be removed. After that the root surfaces need to be smoothened again. Pockets that are as deep as the tip of the scaler represents, could never be cleaned by brushing and flossing alone.
Click on the image to see this tooth cleaned (Allow Active-X)
If you still have deep pockets after scaling and root planing, with or without antibiotics, your dentist will likely recommend surgery to reduce their size. You may also need surgery to remove diseased tissue, reshape bone or regenerate new gum and bone tissue. You may be sent to a Periodontist to have this treatment done. Periodontists are Dentists who, through several years of specialized training, specialize in periodontal treatment. Many periodontists also place dental implants and perform cosmetic gum surgeries.
Periodontal Surgery for purposes of maintaining compromised teeth, can be sub-classified into roughly 3 different categories:
We will examine each of these categories in more detail below:
During pocket depth reduction, which is also called flap surgery, your periodontist folds the gum back away from the tooth. After scraping away the bacteria-laden plaque and tartar, the dentist removes diseased tissue and smoothes the surface of damaged bones. Then the dentist sews the tissue back into place. Removing or smoothing damaged tissue allows the gum tissue to better reattach to healthy bone. After several weeks of tissue healing and maturation, pockets should be drastically reduced. The teeth usually exhibit a longer appearance, since some of the tissue had to be removed in order to reduce the pocket height.
Often dentists run into a scenario where instead of teeth that look too long because of receding gums, they look too short because gums are overgrown. To repair that, your periodontist removes some gum and bone tissue to expose more of the crown of the tooth. This becomes necessary particularly, when your dentist needs to put a crown on such a tooth. If a tooth fractures to a degree where only a small portion is visible above the gums and your dentist feels that it can still be restored, then a Crown Lengthening is almost always indicated.
Finally, a Crown Lengthening can also be done for cosmetic reasons. This is usually performed on patients that have a very "gummy" smile. The periodontist will re-sculpt the gum tissues to a more desirable gum architecture.
You may need a tissue regeneration procedure if your gums are damaged or the bone supporting your teeth has been destroyed. To regenerate gum tissue, your periodontist will do a soft tissue graft by taking tissue from your palate and sewing it to the damaged site. This helps reduce further gum recession and covers exposed roots, which protects them from decay and makes them less sensitive to hot or cold foods and liquids. The procedure may also be done for cosmetic reasons. Gums that have receded make your teeth look too long. By bringing your gums down where they belong, soft tissue grafts can correct the problem.
Bone, too, can be regenerated using grafts. After exposing the damaged bone by flap surgery, your periodontist surgically places a bone graft into the defect. The graft stimulates new bone growth at the site.
Periodontists have new weapons in their arsenal: special materials and tissue-stimulating proteins that enhance regeneration. In one technique, the periodontist sews a piece of special fabric (membrane) around the tooth after flap surgery. This keeps gum tissue from growing down into the area where bone should be, and allows bone to grow instead. In another technique, the periodontist applies a gel onto the diseased root surface during surgery. It contains proteins found in tooth enamel that tricks the body into believing a new tooth is being formed. That, in turn, stimulates the growth of tooth-supporting tissues.
The above pictured procedure is another type of Tissue Regeneration Procedure, called a Connective Tissue Graft. This is predominantly used to increase firm tissue in certain areas. In the example above to the left you can see that the lower canine and lateral incisor (arrows) exhibit approximately 3mm of gum recession, so that there is only a very thin band of firm gum tissue left.
The graft tissue is taken from the palatal area, as you can see in the upper right image. This tissue is very vascular and is thus ideal for grafting purposes.
As you can see the palate is sutured in a way that will leave virtually no visible scaring when completely healed.
Above to the right you can see how the connective tissue covers the outer root surface of the two teeth in question and is sutured in place as such.
The health and the architecture of your gum tissues are a very important element in dental esthetics. If beautiful teeth are the "pictures" the healthy gums are the "frames" to the pictures. Click on the image below to illustrate this concept on a simulation (make sure your "Active X" is enabled - right click the alert bar in your browser) .
This image shows a beautiful white teeth with healthy gum tissues. However, what would happen if those beautiful white teeth were surrounded with unhealthy gum tissues? Click on the picture to find out!
