Examinations and Risk Factors | Teeth Cleaning | Periodontal Pocket Therapy
Crown Lengthening | Gum Grafts and Defects | Smile Enhancements | Extractions and Implants
Our Purpose
First and foremost, our focus is on saving teeth. We know that there is no replacement that compares favorably to your own tooth. To this end we will take a careful look at your teeth and assess their individual prognosis. We pride ourselves on being conservative and this is reflected in our approach. The less we have to do to your teeth and gums, to ensure health, beauty and long-term stability, the better.
Click on a topic below for more information:
Saving Teeth - Preventing Tooth Loss
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Evaluation and Exams
Comprehensive Periodontal Evaluation
Your initial visit is when we gather as much information as possible about your teeth and gums. We go through a sequence of measurements with the intent of determining the health and prognosis for each tooth. Sometimes we just need to do a limited evaluation and other times all areas of the mouth need to be evaluated. At this visit we will assess your periodontal health by examining the following:
- Your teeth and gums
- Your bite at rest and in function
- The bone supporting your teeth
- Your plaque level
- The presence of risk factors
- Oral cancer examination
Oral Hygiene Evaluation
You may be inclined to breeze over this section of our website but think again as it is truly the most valuable piece of information that we will provide you with to further your fundamental desire of keeping your teeth free of disease for a lifetime. Periodontal disease and the development of decay are largely preventable with attention to detail on a very consistent basis. Dental plaque is now understood to be a biofilm, you know that slimy film that forms on moist surfaces like rocks or surfaces. The bacteria that form a biofilm are purposefully resilient and although it really is microorganisms embedded in a soft matrix, their removal needs to be approached with tenacity. The simplest way to remove a biofilm is mechanically. We recommend using textured products like woven or unwaxed floss. The areas below the gum and between adjacent teeth are the most vulnerable - you need to clean these areas carefully with a combination of small brushes that go between the teeth and floss that goes be-low the gum. Rinses have a role to play as do water flossers but mechanical removal of the plaque with floss, interdental brushes and regular sized toothbrushes (both manual and powered) will accomplish a lot for starters. Fluoride products should be incorporated daily as they have the ability to strengthen the surface of the tooth and root, protecting it against decay.
Oral Cancer Examination
The annual prediction for the incidence of oral and oropharyngeal (throat) cancer in the US is believed to be as high as 50,000. The key benefit in participating in an oral cancer screening is to identify a potentially cancerous lesion in the earliest stage possible and thereby significantly improving the chance of a cure. A systematic screening will be efficiently carried out as part of your oral examination. It is quick, simple and painless. All our patients benefit from this but particularly those at higher risk of developing cancerous and precancerous lesions i.e. individuals with a history of tobacco use or heavy alcohol intake. A biopsy of the tissue will only be taken should a suspicious lesion be detected. The sample will be sent to an accredited oral pathology lab for evaluation and reporting.
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Identifying Risk Factors for Gum Disease
1. Dental plaque is the main cause of periodontal (gum) disease however other factors play a role.
2. AGE
The incidence of gum disease is higher in the older age groups with 70% of Americans 65 and older having periodontitis.
3. SMOKING/TOBACCO USE
Tobacco users are at much higher risk of developing gum disease and disease around dental implants. A smoker is considerably less likely to have an optimal response to regenerative surgery to repair teeth and gums so much so that surgery might even be contraindicated.
4. GENETICS
It has become apparent that a subset of the population is particularly vulnerable to the development and progression of periodontal disease. Despite meticulous oral hygiene, these people still suffer from periodontal breakdown. Genetics is believed to be a factor here and a large body of research is devoted to identifying genetic markers so that early intervention can be sought thereby facilitating keeping teeth for a lifetime.
5. STRESS
Stress which is associated with its elevated levels of cortisol is linked to a number of health problems such as heart disease, high blood pressure and cancer. Stress also is a risk factor for periodontal disease. During times of stress, the body's immune defense system can be overwhelmed making it hard-er for the body to fend off disease including gum disease.
6. POOR NUTRITION AND OBESITY
The body's immune system is also dependent on a nutritious healthy diet and when lacking the system fails to provide the same level of protection. In addition, research has shown that obesity may in-crease the risk of periodontal disease. The nutrient deficient diet that can lead to obesity has negative consequence for oral health.
7. OTHER SYSTEMIC DISEASES
Other systemic diseases that interfere with the body's inflammatory system may worsen the condition of the gums. These include heart disease, diabetes, and rheumatoid arthritis. Recent studies have linked gum disease with the development of Alzheimer's Disease through commonality of causative micro-organisms. Respiratory disease can be caused by the inhalation of oral micro-organisms into the lungs. Lastly, research has shown that the risk of developing cancer of the pancreas or the kidney, is much higher for those with a diagnosis of gum disease. This can be the case especially in men.
8. MEDICATIONS
Some drugs, such as oral contraceptives, anti-depressants, and certain heart medicines, can affect your oral health. Just as you notify your pharmacist and other health care providers of all medicines you are taking and any changes in your overall health, you should also inform your dental care provider.
9. CLENCHING OR GRINDING YOUR TEETH - BRUXISM
Clenching or grinding your teeth can put excess force on the supporting tissues of the teeth and could speed up the rate at which these periodontal tissues are destroyed.
Teeth Cleaning
Plaque is a microbial laden film, a "biofilm" that coats the surface of the teeth and gums. You may be making a big effort daily to clean your teeth and wonder why plaque is still present even though you have just had a professional cleaning. The reason for this is that plaque accumulation is ongoing, and the cycle restarts immediately after the last cleaning. In addition, some surfaces are harder to reach than others and if the plaque has been undisturbed for enough time, then it may start to mineralize making it challenging to remove thoroughly. This is the basis for recommending a professional cleaning on a regular schedule.
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Prophylaxis
When the gums are relatively healthy around the teeth with minimal periodontal pockets and light bleeding, a prophylaxis "prophy" will be recommended to remove any re-maining plaque biofilm. A "prophy" usually occurs on a 6 month schedule but this may vary.
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Periodontal Maintenance
Patients who have been diagnosed with periodontal disease and have received treatment are considered high risk for relapse or further breakdown. They need to have cleanings every 3 or 4 months. Periodontal maintenance is a critical part of their over-all treatment plan in ensuring long term stability.
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Scaling and Root Planing
When plaque is allowed to accumulate for longer periods around the tooth and root, it starts to mineralize. This tartar or calculus has to be scaled off. The root surface is now rough with micro-organisms colonizing the remaining tartar and embedding themselves in the cementum. It is neces-sary to smoothen out the root surface, this process is called root planing. Sometimes antimicrobials are also introduced into the pocket to further decontaminate the site and promote normal healing. Your gums may be slightly tender afterwards, but this is easily managed with over the counter medica-tion such as Ibuprofen, naproxen or acetaminophen.
Periodontal Pocket Therapy
When gums are healthy there is a collar of tissue around the tooth that typically ranges from 2-3 mm probe depth. This is favorable as it is a depth that is easily maintainable. When the bacterial plaque or biofilm is allowed to accumulate around the tooth over a period of time then the resulting infection causes the gum and bone attachment to deteriorate and spaces develop around the tooth. As the pockets persist and deepen, the gums become red, swollen and they bleed easily. The individuals' breath may smell bad and the teeth may begin to shift positions and become loose, because of the ongoing bone loss. There are procedures to reduce periodontal pocketing and they can be divided into Non-Surgical and Surgical methods.
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Non-Surgical Periodontal Pocket Therapy = Scaling and Root Planing
This is typically the first course of action when periodontal pockets are detected. The patient sees the periodontal hygienist who uses a combination of hand instruments and powered devices to remove the bacteria from the root and smooth out the surfaces, to limit further accumulation. The root surface is now rough with micro-organisms colonizing the remaining tartar and embedding themselves in the cementum. This tartar or calculus must be scaled off and the root surface smoothed out, this process is called root planing. Sometimes antimicrobials are also introduced into the pocket to further decontaminate the site and promote normal healing. Your gums may be slightly tender afterwards, but this is easily managed with over the counter medication such as Ibuprofen, naproxen or acetaminophen. A key component of this phase of therapy is effective oral hygiene coaching for the patient so that they can consistently remove the biofilm on a daily basis.
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Surgical Pocket Therapy
Surgical pocket therapy refers to the surgical reduction of periodontal pockets. Of course, it is preferable to regenerate the lost bone and attachment where possible and this can be achieved with Guided Tissue Regeneration. By using specialized techniques, involving bone grafts and protective membranes, we can restore lost tooth support. The other general option for the reduction of pockets is re-shaping the bone and gums around the teeth, this is called Osseous Surgery. At times, the best solution involves a combination of regeneration and re-section. The surgical approach gives us a tremendous opportunity to remove any resident micro-organisms and decontaminate the root surfaces to allow for health to ensue.
Please refer to our video on Periodontal Pocket Therapy for details on this procedure.
Why we do it
Removal of tartar from around the teeth will allow the inflammation to resolve. Pockets will be reduced through surgery and through resolution of inflammation. The porous lining of the pocket wall will heal so that the barrier to the blood vessels and the rest of the body is se-cured. Tissues once red, swollen and puffy will become pink, firm and smooth. Elimination of the periodontal pockets will return the depth of the collar of tissue around the tooth to a more manageable level of around 3 mm, facilitating ongoing maintenance and disease prevention. Of course, you will have the added plus of a fresh clean smile!
Crown Lengthening for Crown Placement
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Functional Crown Lengthening
There are times when a cavity will extend below the gum line or a tooth will fracture close to support-ing bone. In such cases your dentist needs to have a functional crown lengthening procedure carried out to allow him/her to access a clean margin on the tooth so that the restoration can safely be seat-ed. In order to save and properly restore the remaining tooth, we will selectively remove gum tissue and or bone to expose adequate tooth structure for your dentist. This does make the tooth appear longer, but it will prolong the lifespan of the new restoration and keep the tooth in function.
Please refer to our video on Clinical Crown Lengthening for details on this procedure.
Gum Grafts and Gum Defects
Healthy gums form the "framework" for the teeth. Thick tissues covering the root protect the tooth against decay and also protect the underlying bone. Gum defects present themselves as either root exposure/recession or a lack of thickness to the tissue identified by a lack of adequate attached keratinized tissue.
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Root Coverage
Teeth that have exposed root surfaces can appear longer than normal. This can be very unsightly. Recession can also make the teeth sensitive to hot, cold, or touch and most importantly the exposed dentin is at risk for decay. Soft tissue grafting involves covering up the roots. By covering the roots and rebuilding the lost gum tissue, recession can be reversed, sensitivity decreased, and decay susceptibility reduced, resulting in a healthier, younger looking and attractive smile. A number of grafting materials are available for this procedure. The patients' own tissue is the gold standard of course as it is most compatible however donor tissue and synthetic grafts can also be considered.
Please refer to our video on Gum Grafts for details on this procedure.
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Soft Tissue Augmentation (increase in attached keratinized tissue)
Sometimes the gum tissue around teeth is very thin and vulnerable. A lack of thicker keratinized tissue means that a small amount of trauma, especially in the presence of inflammation can lead to recession. In recent years, long term research has pointed to the benefits of keratinized tissue around both teeth and dental implants with an increase in the volume of bone being detected under some previously grafted sites.
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Frenectomy
A frenum is a small fold of tissue that attaches the gums to the cheeks, inner lips and tongue. During everyday activities like eating, speaking, or brushing these attachments can pull on the gums when the cheeks, lips, or tongue move. Over time, this "pull" can destabilize the gum margin causing the gums to recede or shrink away from the tooth and this can result in root exposure and a risk of increased sensitivity at the site.
A frenectomy is a procedure where the frenum is repositioned so that it no longer creates ten-sion on thin vulnerable gum tissue around the tooth. It is a simple procedure, oftentimes in-corporated in the gum grafting surgery. Lasers or standard scalpels can be used to remove the frenum. There will be little to no post-surgical discomfort or swelling.
Cosmetic Periodontal Surgery - Smile Enhancement
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Crown Lengthening for Smile Enhancement - Aesthetic Crown Lengthening (Gum Lift)
There are times during normal growth and development of an individual that the gum tissue and or bone fails to recede to its standard place on the tooth. This is called Altered or Delayed Passive Erup-tion. Because of this altered growth pattern, the teeth will appear small and the gums may overgrow giving the patient "a gummy smile", a smile that lacks harmony. In such cases the periodontist can selectively trim the gum tissues and or bone, to restore the gum position to its typical location on the tooth. This is called a Gum Lift or an Aesthetic Crown Lengthening procedure. It will facilitate effective maintenance of the teeth and gums and also enhance the smile by restoring the normal height and width relationships to the dentition in general. Please refer to our video on crown lengthening for technical details explaining how our doctors can carefully sculpt the gum margins to achieve a pleasing, harmonious smile.
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Root Coverage
Looking "long in the tooth" is not pleasing to the eye. Our doctors can use a variety of gum grafting techniques to restore gum tissue and re-create a natural and balanced smile. Please refer to our video on Root Coverage for technical details on the procedure.
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Correct Jawbone Defects
Sometimes, following tooth loss or trauma the gum and boney framework surrounding the teeth may be irregular and lack harmony. Our doctors have the ability to rebuild the supporting tissues around the teeth to re-create a natural and balanced smile. Please refer to our video on bone grafting for technical details on the procedure.
If Teeth Are Not Salvageable - We Replace Them
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Extractions
Despite our best efforts there are times when teeth cannot be saved. This may happen for a variety of reasons - structurally weak teeth, fractures, root canal failures or teeth that have been impacted by root resorption or periodontal disease. When it is time to extract a tooth, it is of the utmost importance that we proceed by gently removing it with the least amount of trauma to the remaining bone. In order to further preserve the dimensions of the jawbone we will also need to perform a socket preservation procedure (addition of bone graft and a membrane to support it) at the extraction surgery. Without such socket preservation, as much as 40% of the jawbone volume can be lost. Protecting the boney architecture is vital, especially if we are planning to replace the tooth with a dental implant but also if we want to minimally impact the supporting bone of adjacent teeth. Healthy smiles need a good bone foundation.
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If teeth are not salvageable - what are our options?
You may find yourself missing a tooth or multiple teeth as a consequence of trauma, gum disease or decay. There are generally 4 options when considering replacements:
- Do nothing - decide not to replace the missing dentition
- Replace with a removeable appliance, also known as a "flipper"
- Replace with a fixed bridge, connecting to the adjacent teeth by means of full coverage resto-rations i.e. crowns
- Replace by means of a dental implant. The implant essentially acts as a new root that con-nects to an anatomically correct crown and results in a natural looking tooth
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Dental Implants
If you are missing a single tooth (or multiple teeth), you will want to consider a dental implant sup-ported crown as it can be the most natural looking replacement option available. It functions like a regular tooth and unlike a bridge, it does not connect to and compromise the adjacent teeth. An implant encased in bone will preserve the natural looking jawbone contours over time. In addition, maintenance of a single-restored dental implant is much easier than that of a bridge as floss does not have to be threaded under the restoration so as to access all contours. If multiple teeth are missing, you have the option of several individual restorations or an implant supported bridge. Fixed restorations are clearly superior to removable partial dentures in terms of restoring comfort, functionality and aesthetics.
Bone Augmentation in Preparation for a Dental Implant
When someone comes to us looking for a dental implant to replace a missing tooth our first step will be to assess the dimensions of the remaining bone with a 3D radiograph (CBCT). Should there have been a history of periodontal disease (gum disease) or trauma, it is quite possible that a critical amount of the jawbone will be missing and will need to be reconstructed. If the underlying boney architecture allows, we will proceed with rebuilding the boney ridge through the process of Guided Bone Regeneration. After many years of clinical experience, our doctors have developed excellent clinical skillsets. They combine this with an in depth understanding of the most suitable regenerative materials currently available, so that they can predictably restore the lost jawbone and allow for placement of a dental implant. Some materials may be harvested from the patient's own mouth and some may come from a tissue bank. If indicated, we will consider the use of biologics (proteins that speed healing) and special protective membranes to reconstruct the jaw. In view of the long-term stability of the implant, it is imperative that we place the dental implant in a site so that it is completely encased in healthy bone.
Sinus Augmentation in Preparation for a Dental Implant
The maxillary sinuses are in the upper jaw behind the cheeks. They are empty air-filled spaces above the upper teeth and sometimes the roots of the upper teeth extend up into the floor of the sinus. When these teeth are removed, there may be just a thin wall of bone separating the maxillary sinus and the mouth. Dental implants need bone to hold them in place, so if bone loss has occurred due to injury, periodontal disease or resorption as a consequence of prolonged absence of the teeth, a sinus augmentation can be completed to raise the sinus floor and allow for new bone formation.
The most common sinus augmentation procedure involves making a small incision in the gums to expose the outer wall of the upper jaw, in the premolar or molar region. An opening is cut into the bone to provide access to the membrane. The sinus lining is then gently pushed upward. The underlying space that is created is typically filled in with bone grafting material and the wound is then sealed up. After several months of healing, the bone becomes part of the patients' jaw and dental implants can be inserted, where they become attached to the newly formed bone.
Sometimes there is enough bone in the upper jaw ridge to simultaneously lift the sinus and place a stable implant of adequate length. This sequence speeds up the treatment time, allowing the patient to get the crown placed and the tooth back in function sooner rather than later. The sinus graft procedure makes it possible for many patients to have dental implants when years ago the only other option was dentures.
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