We never get tired of covering canine roots! These are the most important teeth in your mouth. Because they are at the corners of your dental arch, their gum tissue tends to get stripped away by toothbrushing or chewing. We are grateful to be able to restore ideal gum health and positioning using microsurgical grafting techniques. Our patients are happy to routinely experience minimal discomfort and near-perfect results.
Tuesday, August 20, 2019
Wednesday, August 14, 2019
The Perio Perspective
What’s In a Name?
Periodontal disease is an enigma. Its exact causes are not known, although many of its risk factors are. Its progress in each individual is unpredictable. It depends as much on the behavior of the patient as on treatment. It tends to be episodic, with erratic patterns of activity and inactivity. It tends to recur. Sometimes teeth that appear to have a poor prognosis survive for many years, while others with an apparently better prognosis fail sooner. It affects implants, even if all the teeth have been removed first. Formulating a rational approach to treatment is difficult when every tooth and every patient seem to have a unique pattern of disease and response to therapy.
The American Academy of Periodontology recently redefined its classification of periodontitis (Tonetti, M et al, J Perio 89: S159-172, 2018). Its motivation was to make diagnosis more closely correlated with the rate of disease progress, difficulty of treatment, and prognosis, and to make research guiding our treatment more closely tied to these factors. We and our patients deserve to know which treatment modalities work best at each stage of disease, and to assign prognosis with and without treatment of each type. At present these assessments are approximate at best.
The new classification is complicated. It defines severity (staging) and then modifies it with prognosis (grading), similar to the system used for cancer. It will eventually replace the current classification used by general dentists, hygienists, specialists, and insurance carriers. We hope that it will lead to a more rational algorithm for treatment. Here is our simplified description.
There are 4 severity stages. They correspond approximately to the old categories, listed in parentheses below.
- Stage I (Mild): pockets 4 mm or less, slight bone loss (1-2 mm), no tooth loss due to periodontitis
- Stage II (Moderate): pockets 5 mm or less, moderate bone loss (3-4 mm), no tooth loss
- Stage III (Severe): pockets >5mm, severe bone loss (>4 mm), furcation involvements, up to 4 teeth lost
- Stage IV (Severe): same as Stage III with added complexity due to >4 lost teeth, Class 2-3 mobility, bite collapse, and/or loss of chewing function
Stages are modified by 3 grades based on rate of progression as well as presence of systemic risk factors (diabetes and smoking). Grading can be generalized, localized (<30% of teeth) or molar/incisor (formerly Localized Aggressive Periodontitis). Grades roughly correspond to the old modifiers listed below in parentheses.
- Grade A (Chronic): no bone loss in past 5 years, heavy plaque and calculus deposits (“For this much calculus, where is the disease?”), no smoking or diabetes
- Grade B (Chronic): <2 mm bone loss in past 5 years, moderate deposits, smoking <10/day, controlled diabetes
- Grade C (Aggressive): >2 mm bone loss in past 5 years, minimal deposits (“For this much disease, where is all the calculus?”), smoking >10/day, poorly controlled diabetes
This was a laudable effort by the AAP. But there are two glaring omissions. First, patient compliance is not included. Abundant research and decades of clinical experience have shown that this is a critical determinant of success or failure. Oral hygiene and recall attendance matter. Second, there is no research-based guidance to more accurately determine prognosis and treatment using the new classification. We will still root plane pretty much all periodontal patients, perform osseous or regenerative surgery for residual pockets 5 mm or greater, and institute a 3-month supportive periodontal therapy schedule. We will still extract teeth with severe mobility or unmanageable infection. We already knew that heavy smokers and poorly-controlled diabetics respond poorly to treatment of any type.
So periodontal disease remains enigmatic. Perhaps new research will offer better guidance based on the new classification. This will take years at best. We hope it proves to be more than just an academic exercise.
Tuesday, August 13, 2019
Our patient was in constant discomfort and was humiliated by his severely decayed dentition and missing teeth. In one day, we removed his upper teeth, placed five implants, and inserted a fixed prosthesis. We also placed an implant in his lower central incisor site. He was amazed to be free of pain and proud of his teeth for the first time in many years.
Friday, August 2, 2019
A common problem with crowns in the esthetic zone is grey show-through or actual exposure of restorative margins. This occurs with implants as well as natural teeth. The cause is inadequate bone and/or attached gingiva buccal to the restoration, or overzealous toothbrushing, or both. It is more common in patients with a thin biotype.
Esthetic problems with metal margins are difficult to correct. Avoiding them requires counseling on proper oral hygiene techniques prior to finalizing the restoration in patients with any evidence of overbrushing (we recommend use of an electric toothbrush with a pressure sensor). It also requires pre-emptively augmenting the site with attached gingiva in the case of natural teeth and with bone and attached gingiva around implants. This significantly increases cost, inconvenience, and treatment time, and consequently is often resisted by patients. But it is essential to avoid an unhappy patient with a compromised smile. Correcting these esthetic problems once they occur is difficult and unpredictable. Clinical studies suggest a minimum of 2 mm of keratinized gingiva around teeth or implants and 2 mm of facial bone around implants.
In today’s case, our patient had an implant crown with an exposed margin. She hated its effect on her appearance, so we attempted a tunneling connective tissue graft after informing her that the results were far from guaranteed. Fortunately we were able to completely cover the margin in addition to augmenting the gingiva to minimize the risk of relapse. If she is judicious with her toothbrushing, her esthetic improvement should persist. But a more predictable approach would have been grafting at the time of implant placement.
Please call us if you have questions about how we handle these cases or if you would like to discuss any patients with similar problems. As always, we appreciate your support and welcome comments.
Amy and David
Tuesday, July 30, 2019
Our patient hated seeing the grey line where her implant crown met her gums. This happens when the bone or gum tissue around an implant is thin and is not augmented by grafting prior to placing or restoring the implant. Covering the exposed metal crown margin once the recession occurs is very challenging, but in this case we were able to achieve a significant esthetic improvement using a tunneling connective tissue graft. Our patient was very happy that she would not lose her implant and that she could smile confidently once again.
Tuesday, July 23, 2019
Treating gum recession of a lower incisor is challenging due to the pulling action of the lip. For our patient, we reduced the excessive pulling force while adding attached gum tissue and completely covering the root. This is most predictably achieved via a microsurgical tunneling graft, which we have successfully performed hundreds of times.
Tuesday, July 16, 2019
The ideal position of the gumline on upper first bicuspid teeth is slightly lower than the canine tooth in front of them. This is challenging to achieve, but most predictable with a microsurgical tunneling grafting technique, which we used here. In addition to restoring the proper amount of attached gum tissue, were were able to re-create an ideal appearance when our patient smiled.