NON-SURGICAL PERIODONTAL TREATMENT
The American Academy of Periodontology treatment guidelines stress that periodontal health should be achieved in the least invasive and most cost-effective manner. This is often accomplished through non-surgical periodontal treatment. Non-surgical periodontal treatment does have its limitations, however. When it does not achieve periodontal health, surgery may be indicated to restore periodontal health.
Scaling and root planing
Scaling and root planing is careful cleaning of the root surfaces to remove plaque and calculus [tartar] from deep periodontal pockets and to smooth the tooth roots to remove bacterial toxins. Scaling and root planing is often followed by adjunctive therapy such as local delivery antimicrobials and host modulation, as needed on a case-by case basis. Scaling and root planing is a very difficult procedure to do correctly. If you have periodontal pockets, it is best to have a periodontal office involved in the management of your condition. Most periodontists would agree that after scaling and root planing, many patients do not require any further active treatment. However, the majority of patients will require ongoing maintenance therapy to sustain health. If periodontal health is not maintained, it will return and will worsen and may result in tooth loss, studies show.
Laser treatment for gum disease
The Canadian Academy of Periodontology and the American Academy of Periodontology do not recommend or support the use of lasers in the treatment of periodontal disease. The few published studies show insufficient evidence at this time to prove that the use of a lasers is superior to, or offer additional benefit to traditional modes of periodontal treatment that have repeatedly been researched and shown to be effective in the management of periodontal diseases. Long term comparative studies are lacking on the efficacy of lasers in the treatment of periodontal disease. Claims of less post-operative pain than traditional periodontal surgery have not been documented with controlled clinical studies and therefore remain unproven. Lasers have the potential to cause permanent thermal damage to bone and tooth root structure if not used properly. For more information on lasers, please see visit the website for the American Academy of Periodontology www.perio.org or the website for the Canadian Academy of Periodontology www.cap-acp.ca.
Studies have shown that once you have been diagnosed with periodontal disease you will always be prone to recurrence. It is not a disease that is “cured” per se. Rather it is the type of disease that can be managed – with proper care. Research has also shown that frequent regular maintenance therapy after stability is achieved is paramount to success in preventing recurrence of periodontal disease and the need for more surgical therapy.
When you have periodontal disease, you will require more than a “regular cleaning” and usually more than the standard “twice per year”. You will need very detailed and comprehensive scaling and root planing that is best provided to you in a periodontal setting. Any early changes in your disease profile is picked up and treated in it’s early stages.
At home, brushing is recommended for at least two minutes, at least twice a day. Flossing is recommended at least once a day. Other oral health care aids and products are available today to help maintain your oral health.
Parafunctional activities like clenching or grinding your teeth can have detrimental effects on the supporting tissues around you teeth. Your periodontist may recommend he use of a biteplane appliance for periodontal purposes as part of your treatment.
Temporomandibular joint dysfunction (TMD)
TMD can be divided broadly into dysfunctions of the musculature of the face, mouth and neck and dysfunctions of the TM Joint and surrounding capsule itself. Halifax Periodontics & Implants focuses on the treatment of myofacial pain and utilizes a combination of treatment modalities such as biteplane therapy, physiotherapy and massage therapy.
SURGICAL PERIODONTAL PROCEDURES
Periodontal pocket reduction
The supporting tissues (bone and gum) around your teeth should fit snugly around your teeth like a turtleneck around your neck. When you have periodontal disease, these supporting tissues around your teeth are destroyed, forming “pockets” around the teeth. The gum collar becomes loose and starts to separate from the teeth making the pocket spaces longer where bacteria can be trapped. The pockets start out in the gum tissue and the bacteria can burrow deeper and destroy the bone underneath. This allows the gum to further separate from the teeth and the pockets become deeper still. If enough bone around the teeth is destroyed the teeth will become loose and eventually will be lost or need to be extracted.
A periodontal pocket reduction procedure may be recommended if deep cleanings do not resolve the pocket depths around the teeth. The goal of the this procedure is to make the “turtle neck” or pocket around the teeth smaller so that every time you clean your teeth, you do a better job (remove more bacteria) and every time you get your teeth cleaned at the dental office, they can do a better job as well (remove more bacteria). Typically, when you brush and floss your teeth, you can only reach 3 to 4 mm under the gum edge and your hygienist can only reach 4 to 5 mm with available cleaning instruments. Any pocket of 6 mm or more will have residual bacteria residing within it and can cause more breakdown of the gum and bone tissue around your teeth.
During a pocket reduction procedure, the periodontist folds back the gum tissues and removes the disease-causing bacteria and any dead or diseased tissue and then secures the remaining healthy tissues into place at a healthier level around the teeth. The periodontist can reach areas that are not accessible to you at home or the dental hygienist. In some cases, irregular and diseased surfaces of the damaged bone are smoothed to limit areas where disease-causing bacteria can hide. This allows the gum tissue to better reattach to healthy bone. This procedure is completed using local anesthetic (regular freezing) and is done every day at a periodontal office. You can drive afterward and most people go back to work the following day.
Gum graft surgery
Exposed tooth roots are the result of gum recession, a type of periodontal disease. When you have gum recession, you know you have lost attachment around your teeth. This means that some of the soft tissue (gums and ligaments) and hard tissue (bone) that was supporting your teeth have been lost. Every time you lose a millimetre of gum tissue, you lose a millimetre of bone tissue. If enough bone tissue is lost around your teeth, the teeth will become loose.
Gum recession usually does not hurt. You will most likely not know you have a problem with gum recession unless a dental professional informs you. Your periodontist will measure how much recession you have and will also consider how much tooth support you have left in determining if the area needs treatment. Some of the indications for treatment include:
- Aesthetic coverage of exposed root surfaces
- Coverage of sensitive root areas
- To create a zone of gum tissue that will protect the underlying bone
- Pocket elimination
- To eliminate muscle pulls to the gums
- To deepen the vestibule
- To protect the bone in areas where the gum is thin (due to tooth position, thin bone / big teeth, large roots
- To minimize recession during orthodontic tooth movement
- To overcome the trauma of prosthetic or restorative dentistry requiring placement of filling margins
- To control areas of progressive recession
- To correct ridge deformities
- Enhance cleansibility of the soft tissues
Gum recession is treated with “gum grafts”. The most important thing that gum grafts so is to protect the remaining bone around your tooth. They also act to thicken the soft gum tissue (thick tissue is stronger and resilient than thin tissue) or to cover the tooth root (covering sensitive parts of the tooth, improving the look of the tooth). Gum grafts can also be used in areas where you have no teeth to improve defects in the jaw bone and improve the look of your smile. Note: gum recession is NOT treated with fillings on the roots.
Gum graft surgery involves placing donor tissue – either from yourself or “off the shelf” in the area where your gum is deficient. Using your own tissue is the most predictable method used today. Other options are available, such as donated human tissue or pig tissue (and others) but these do have higher complications and can be more expensive. Not all gum grafts will cover the roots of the teeth, however, this is usually not the primary goal. You can discuss with your periodontist which method is best for your situation.
Regenerative procedures are another way to reduce pockets around the teeth but can only be used in certain circumstances. Using different techniques and materials such membranes, bone grafts, gels etc, the tissues can be encouraged to regenerate – the ligament, bone and cementum (part of the tooth) back to its original anatomy. These procedures have varying degrees of success and will be recommended if you are a candidate.
During this procedure, your periodontist folds back the gum tissue and removes the disease-causing bacteria and cleans out any defects. Membranes, bone grafts or tissue-stimulating proteins can be used to encourage your body’s natural ability to regenerate bone and tissue. Eliminating existing bacteria and regenerating bone and tissue helps to reduce pocket depth and repair damage caused by the progression of periodontal disease. With a combination of daily oral hygiene and professional maintenance care, you’ll increase the chances of keeping your natural teeth and decrease the chances of other health problems associated with periodontal disease.
Dental crown lengthening procedure
For functional purposes:
Large restorations can have negative effects on the health of your gums and tooth supporting bone and this procedure enhances gum health by allowing the dentist to place a properly contoured restoration that does not impinge on the gum and bone tissue. If your tooth is decayed or broken below the gum line, it is difficult for your dentist to place a properly fitting crown. If a crown or filling is placed too far below the gum line, damage can occur to the gum and bone tissue. To prevent this, and to allow your dentist to place a nicely sealed restoration and optimize your oral health, crown lengthening is often recommended.
After a small collar of gum and bone tissue is removed from around the tooth, the remaining healthy gum tissue is pushed closer to the new bone level exposing more of the tooth above the level of the gum. Some side effects of this procedure include longer teeth, root exposure, tooth sensitivity (usually of short duration) and increased spaces between the teeth. You will be left with a healthy situation that is easy to maintain and is more predictable long term than to place inadequate restorations.
For esthetic purposes:
You may have asked your periodontist about procedures to improve a “gummy” smile because your teeth appear short. Your teeth may actually be the proper lengths, but they’re covered with too much gum tissue. To correct this, your periodontist performs a dental crown lengthening procedure.
During the dental crown lengthening procedure, excess gum and bone tissue is reshaped to expose more of the natural tooth. This can be done to one tooth, to even your gum line, or to several teeth to expose a natural, broad smile.
While the goal of periodontal treatment is save your teeth, sometimes a tooth will need to be removed. There are several treatment options to replace missing teeth (removable dentures, bridges and implants). A dental implant is an artificial tooth root that is placed into your jaw to hold a replacement tooth, bridge or sometimes dentures.
What is a dental implant procedure like?
This procedure is a team effort between you, your dentist / prosthodontist and your periodontist. Your periodontist and dentist will consult with you to determine where and how your implant should be placed. Depending on your specific condition and the type of implant chosen, your periodontist will create a treatment plan tailored to meet your needs.
- Replacing a Single Tooth If you are missing a single tooth, one implant and a crown can replace it.
- Replacing Several Teeth If you are missing several teeth, implant-supported bridges can replace them.
- Replacing All of Your Teeth If you are missing all of your teeth, an implant supported full bridge or full denture can replace them.
- Sinus Augmentation A key to implant success is the quantity and quality of the bone where the implant is to be placed. The upper back jaw has traditionally been one of the most difficult areas to successfully place dental implants due to insufficient bone quantity and quality and the close proximity to the sinus. Sinus augmentation can help correct this problem by raising the sinus floor and developing bone for the placement of dental implants.
- Ridge Modification Deformities in the upper or lower jaw can leave you with inadequate bone in which to place dental implants. To correct the problem, the gum is lifted away from the ridge to expose the bony defect. The defect is then filled with bone or bone substitute to build up the ridge. Ridge modification has been shown to greatly improve appearance and increase your chances for successful implants that can last for years to come.
What can i expect after receiving a dental implant?
As you know, your own teeth require conscientious at-home oral care and regular dental visits. Dental implants are like your own teeth and will require the same care. In order to keep your implant clean and plaque-free, brushing and flossing still apply! After treatment, your periodontist will work closely with you and your dentist to develop the best care plan for you. Periodic follow-up visits will be scheduled to monitor your implant, teeth and gums to make sure they are healthy.
Single tooth dental implants
If you are missing a single tooth, one implant and a crown can replace it. A dental implant replaces both the lost natural tooth and its root.
What are the advantages of a single-tooth implant over a bridge?
A dental implant provides several advantages over other tooth replacement options. In addition to looking and functioning like a natural tooth, a dental implant replaces a single tooth without sacrificing the health of neighbouring teeth. The other common treatment for the loss of a single tooth, a tooth-supported fixed bridge, requires that adjacent teeth be ground down to support the cemented bridge.
Because a dental implant will replace your tooth root, the bone is better preserved. With a bridge, some of the bone that previously surrounded the tooth begins to resorb (deteriorate). Dental implants integrate with your jawbone, helping to keep the bone healthy and intact.
In the long term, a single implant can be more esthetic and easier to keep clean than a bridge. Gums can recede around a bridge, leaving a visible defect when the metal base or collar of the bridge becomes exposed. Resorbed bone beneath the bridge can lead to an unattractive smile. And, the cement holding the bridge in place can wash out, allowing bacteria to decay the teeth that anchor the bridge.
How will the implant be placed?
First, the implant, which looks like a screw or cylinder, is placed into your jaw. Over the next two to six months, the implant and the bone are allowed to bond together to form an anchor for your artificial tooth. During this time, a temporary tooth replacement option can be worn over the implant site.
Often, a second step of the procedure is necessary to uncover the implant and attach an extension. This temporary healing cap completes the foundation on which your new tooth will be placed. Your gums will be allowed to heal for a couple of weeks following this procedure. There are some implant systems (one-stage) that do not require this second step. These systems use an implant which already has the extension piece attached. Your periodontist will advise you on which system is best for you.
Finally, a replacement tooth called a crown will be created for you by your dentist or prosthodontist and attached to a small metal post, called an abutment. After a short time, you will experience restored confidence in your smile and your ability to chew and speak. Dental implants are so natural-looking and feeling, you may forget you ever lost a tooth.
Every case is different, and some of these steps can be combined when conditions permit. Your dental professional will work with you to determine the best treatment plan.
Multiple tooth implants
If you are missing several teeth, implant-supported bridges can replace them. Dental implants will replace both your lost natural teeth and some of the roots.
What are the advantages of implant-supported bridges over fixed bridges or removable partial dentures?
Dental implants provide several advantages over other teeth replacement options. In addition to looking and functioning like natural teeth, implant-supported bridges replace teeth without support from adjacent natural teeth. Other common treatments for the loss of several teeth, such as fixed bridges or removable partial dentures, are dependent on support from adjacent teeth.
In addition, because implant-supported bridges will replace some of your tooth roots, your bone is better preserved. With a fixed bridge or removable partial denture, the bone that previously surrounded the tooth root may begin to resorb (deteriorate). Dental implants integrate with your jawbone, helping to keep the bone healthy and intact.
In the long term, implants are esthetic, functional and comfortable. Gums and bone can recede around a fixed bridge or removable partial denture, leaving a visible defect. Resorbed bone beneath bridges or removable partial dentures can lead to a collapsed, unattractive smile. The cement holding bridges in place can wash out, allowing bacteria to decay teeth that anchor the bridge. In addition, removable partial dentures can move around in the mouth and reduce your ability to eat certain foods.
Ridge Modification and Implants
Deformities in the upper or lower jaw can leave you with inadequate bone in which to place dental implants. This defect may have been caused by periodontal disease, wearing dentures, developmental defects, injury or trauma. Not only does this deformity cause problems in placing the implant, it can also cause an unattractive indentation in the jaw line near the missing teeth that may be difficult to clean and maintain.
To correct the problem, the gum is lifted away from the ridge to expose the bony defect. The defect is then filled with bone or bone substitute to build up the ridge. Your periodontist can tell you about your options for graft materials, which can help to regenerate lost bone and tissue.
Finally, the incision is closed and healing is allowed to take place. Depending on your individual needs, the bone usually will be allowed to develop for about four to 12 months before implants can be placed. In some cases, the implant can be placed at the same time the ridge is modified.
Ridge modification has been shown to greatly improve appearance and increase your chances for successful implants that can last for years to come. Ridge modification can enhance your restorative success both aesthetically and functionally.
Periodontal plastic surgery procedures
Periodontists are often considered the plastic surgeons of dentistry. If you are looking to improve your smile, a periodontist may be able to help.
Gummy smile or uneven gum line
Do you feel your teeth look too short and your smile is too gummy or your gums cover too much of some teeth while leaving the others the right length? If so, dental crown lengthening might be the solution for you. During this procedure, excess gum tissue is removed to expose more of the crown of the tooth. Then your gumline is sculpted to give your new smile just the right look.
Long teeth / exposed roots
Sometimes gum recession causes the tooth root to become exposed, which makes your teeth look long and can make you look older than you are. This recession can happen as a result of a variety of causes, including periodontal diseases.
Gum graft surgery and other root coverage procedures are designed to cover exposed roots, to reduce further gum recession and to protect vulnerable roots from decay.
Fillings do not treat gum recession. Several things contribute to the formation of recession (the loss of supporting tissues around your teeth) including: thin gum tissues, muscles pulls on the gum, bacteria, hard toothbrushing to name a few. Fillings do not treat these causes. The gums needs to be treated to prevent recession from worsening.
Tooth loss can cause an indentation in the gums and jawbone where the tooth used to be. This happens because the jawbone recedes when it no longer is holding a tooth in place. Not only is this indention unnatural looking, it also causes the replacement tooth to look too long compared to the adjacent teeth.
Ridge augmentation can fill in this defect recapturing the natural contour of the gums and jaw. A new tooth can then be created that is natural looking, easy to clean and beautiful.
Some periodontal conditions need to be diagnosed by performing a biopsy. This can be required if there are suspicious oral lesions. The biopsy involves the surgical removal of a sample of tissue so that it can be examined in detail by a pathologist.
While we strive at Halifax Periodontics & Implants to save your teeth if at all possible, extraction may be needed if it is determined that the tooth cannot be saved, due to active infection and/or excessive bone loss in the area. The tooth is removed gently while attempting to preserve as much bone as possible. Once the tooth is removed, the site is prepared, by thorough cleaning. In some cases a bone graft will be placed into the cleaned socket. Sometimes a soft tissue graft is also placed. Sutures are then added, along with a dressing. If the tooth is at the front of the mouth, a provisional partial may be recommended. This will be determined at the time of your initial examination.