The eyes may be the window to the soul, but the mouth provides an even better view of the body as a whole.Some of the earliest signs of diabetes, cancer, pregnancy, immune disorders, hormone imbalances and drug issues show up in the gums, teeth and tongue—sometimes long before a patient knows anything is wrong.There’s also growing evidence that oral health problems, particularly gum disease, can harm a patient’s general health as well, raising the risk of diabetes, heart disease, stroke, pneumonia and pregnancy complications.

“We have lots of data showing a direct correlation between inflammation in the mouth and inflammation in the body,” says Anthony Iacopino, director of the International Centre for Oral-Systemic Health, which opened at the University of Manitoba Faculty of Dentistry in Canada in 2008. Recent studies also show that treating gum disease improves circulation, reduces inflammation and can even reduce the need for insulin in people with diabetes.

Such findings are fueling a push for dentists to play a greater role in patients’ overall health. Some 20 million Americans—including 6% of children and 9% of adults—saw a dentist but not a doctor in 2008, according to a study in the American Journal of Public Health this month.

“It’s an opportunity to tell a patient, ‘You know, I’m concerned. I think you really need to see a primary care provider,’ so you are moving in the direction of better health,” says the study’s lead researcher Shiela Strauss, co-director of statistics and data management for New York University’s Colleges of Nursing and Dentistry.http://online.wsj.com/article/health_journal.html

George Kivowitz, a restorative dentist with offices in Manhattan and Newtown, Pa., says he has spotted seven cases of cancer in 32 years of practice, as well as cases of bulimia, due to the telltale erosion of enamel on the back of the upper front teeth, and methamphetamine addiction. “We call it ‘meth mouth,’ ” he says. “The outer surface of teeth just rot in a way that’s like nothing else.”

Some of the most distinctive problems come from uncontrolled diabetes, Dr. Kivowitz adds. “The gum tissue has a glistening, shiny look where it meets the teeth. It bleeds easily and pulls away from the bone—and it’s all throughout the mouth.”

An estimated six million Americans have diabetes but don’t know it—and several studies suggest that dentists could help alert them. A 2009 study from New York University found that 93% of people who have periodontal disease are at risk for diabetes, according to the criteria established by American Diabetes Association.

It’s not just that the same lifestyle habits contribute to both gum disease and high blood sugar; the two conditions exacerbate each other, experts say. Inflammation from infected gums makes it more difficult for people with diabetes to control their blood-sugar level, and high blood sugar accelerates tooth decay and gum disease, creating more inflammation.

Diabetes also complicates dental-implant surgery, because it interferes with blood vessel formation and bone growth. “When you put a dental implant in, you rely on the healing process to cement it to the jaw, so you get a higher failure rate with diabetes,” says Ed Marcus, a periodontist in Yardley, Pa., who teaches at the University of Pennsylvania and Temple University dental schools.

Dr. Marcus notes that about 50% of periodontal disease is genetic—and even young patients can have significant bone loss if they have an unusually high immune response to a small number of bacteria. Giving such patients a low dose of doxycycline daily can help modify the immune response. “It doesn’t really control the bacteria, but it helps reduce the body’s reaction,” he says.

There’s also growing evidence that the link between periodontal disease and cardiovascular problems isn’t a coincidence either. Inflammation in the gums raises C-reactive protein, thought to be a culprit in heart disease.

“They’ve found oral bacteria in the plaques that block arteries. It’s moved from a casual relationship to a risk factor,” says Mark Wolff, chairman of the Department of Cariology and Comprehensive Care at NYU College of Dentistry.

Bacteria from the mouth can travel through the bloodstream and cause problems elsewhere, which is why people contemplating elective surgery are advised to have any needed dental work performed first.

The American Heart Association no longer recommends that people with mitral valve prolapse (in which heart values close abnormally between beats) routinely take antibiotics before dental procedures, since it’s now believed that oral bacteria enter the bloodstream all the time, from routine washing, brushing and chewing food.

But the American Heart Association, the American Medical Association and the American Orthopedic Association all urge people who have had a full joint replacement to take an antibiotic one hour before any dental visit for the rest of their lives to reduce the risk of post-surgical infections. “I have my guidelines taped to the door in my hygienists’ room,” Dr. Kivowitz says.

Dentists say they also need to stay up to date with all medications, supplements and over-the-counter drugs their patients are taking. Blood thinners can create excess bleeding in the mouth. Bisphosphonates, often prescribed for osteoporosis, can severely weaken jaw bones. Both should be stopped temporarily before oral surgery.

Antihypertensive drugs, calcium-channel blockers and some anti-inflammatory drugs can cause painful ulcerations of the gums. Many medications, from antidepressants to chemotherapy drugs, cause dry mouth, which can cause cavities to skyrocket, since saliva typically acts as a protective coating for teeth. Additional fluoride treatments can help.

Some proactive dentists have glucose monitors for another check on blood-sugar levels if they suspect diabetes. Some also take patients’ blood pressure and hold off on invasive procedures if it’s extremely high.

The Centers for Disease Control and Prevention recommends that dentists offer HIV testing, because some of the first symptoms appear in the mouth, including fungal infections and lesions. Dentists can do the HIV test with a simple mouth swab and get results in 20 minutes.

Breaking the bad news is often more difficult. “I went into oral surgery because I didn’t think I would have to deliver that kind of news to patients,” says Clifford Salm, an oral and maxillofacial surgeon in Manhattan who has found leukemia, lymphoma, AIDS and metastatic breast cancer after performing biopsies on suspicious spots. “It can be a difficult conversation,” he says, “but most patients are very grateful.”

Don’t Be Fooled by White, Shiny Teeth

A gleaming, white smile is a sign of a healthy mouth, right? Not necessarily.

“Whiteness and the health of your teeth are totally unrelated,” says Mark Wolff, an associate dean at New York University College of Dentistry.

In fact, many dentists worry that people who whiten their teeth may have a false sense of complacency, since their teeth can still be harboring tooth decay and serious gum disease.

Even people who have no cavities can still have inflamed and infected gums. It could be that their saliva is particularly protective of their tooth enamel, while their brushing and flossing habits, needed to keep gum tissues healthy, could be lax.

“I get these patients in their mid-30s who don’t have cavities, so they haven’t been to a dentist in 10 years. But they have full-blown periodontal disease,” says George Kivowitz, a restorative dentist in Manhattan. “They are losing all the supporting structure, and I have to tell them that these gorgeous teeth will fall out of your head if we don’t turn this around.”

Using whitening products more often than recommended can erode some of the enamel and cause teeth to appear translucent. But whether that actually harms teeth is controversial. “No one has really shown that it’s damaging, but no one knows the long-term results,” says Dr. Marcus, the periodontist in Yardley, Pa.

By Dr. Douglas A. Young

Tooth decay — or dental caries — is an infectious disease process that causes damage to the structure of teeth. Cavities (hollowed out spaces or holes) are the most notable consequences of dental caries. Left untreated, caries leads to pain, tooth loss — or, in rare cases, death. In this most extreme case, infection can advance to the “cavernous sinus,” an air cell behind the eye, from which it can then enter the brain. Tooth decay amounts to more than just the inconvenience of “drilling and filling”: it has the power to change a person’s diet, speech, quality of life and overall well-being. Did you know that tooth decay is one of the most common of all diseases, second only to the common cold?

Decay — A World Wide Epidemic; Painful, Costly and Preventable

Oral diseases range from cavities to cancer; they cause pain and disability for millions of Americans each year. Even more disturbing — almost all are preventable. Dental decay is a worldwide epidemic, especially among young children. The disease begins early — tooth decay affects more than one-fourth of U.S. children ages 2 to 5 and half of those ages 12 to 15. Low-income children are hardest hit: about half of those ages 6 to 19 have had decay. In addition to pain and other dysfunction, untreated cavities can cause absence from school and other social interactions, low weight and poor appearance — problems that may greatly reduce a child’s capacity to succeed in life.

Tooth decay is also a problem for U.S. adults, affecting more than ninety percent over age forty. A quarter of adults over age sixty have lost all of their teeth primarily because of decay affecting self-esteem and contributing to nutrition problems by limiting the types of foods that can be eaten.

A New Way of Looking At Dental Decay — A Dynamic Process

The mouth is an ecosystem where living organisms continually interact with every other element within their environment. The teeth are composed of an outer covering of non-living enamel (the hardest substance in the human body) and an inner core of living dentin, with a consistency and composition similar to bone. Enamel is highly mineralized and crystalline in structure, composed mainly of calcium and phosphate. The teeth are bathed in saliva, a most remarkable and seldom discussed fluid. It has many important functions in keeping mouths healthy; one of the most important is its role in maintaining a “neutral” environment — a balance between acids and bases.

(Acidity is measured scientifically by the “pH” scale that runs from 1 – 14. pH 1 is extremely acidic, pH 14 extremely basic. The pH of the mouth is generally 7 – neutral.)

The oral environment is also loaded with bacteria. There are more bacteria in a single mouth than there are people who have ever lived on the earth. Certain of these bacteria have the potential to cause decay.

Here’s how it works — specific bacteria (mutans streptococci and lactobacilli) attach themselves to dental plaque, the whitish sticky film that collects on teeth in the absence of effective oral hygiene. When sugars or carbohydrates are eaten, these particular bacteria have the ability to break down the sugars to use for their own metabolism. In the process, though, they produce acid as a by-product which in turn drops the saliva pH. At about pH 5.5 the minerals in the enamel just below the surface begin to dissolve in a process known as “de-mineralization,” in which more calcium and phosphate leave the tooth surface than enter it. The effects of early de-mineralization in enamel can be seen as a white spot on the tooth.

Dentin and root surfaces have much less mineral than enamel and are much more vulnerable to acid dissolution de-mineralizing at a much higher pH (about 6.0 to 6.5).

Bacterial acid attacks of short duration can be “buffered” (neutralized) in about thirty minutes by adequate amounts of healthy saliva, thereby returning calcium and phosphate into the tooth sub-surface. Saliva contains a lot of calcium and phosphate “ions” (charged moving particles) that continually leave the surface enamel and are replaced from the saliva, and vice versa. This process is chemically the reverse of de-mineralization and is known as “re-mineralization.” Although the white spot may not disappear, re-mineralization is nature’s way of repairing early damage and returning the tooth surface back to status quo.

Nothing in nature is static, but instead it is dynamic and therefore changing constantly to maintain a status quo. Primarily composed of mineral, teeth continually swing between “DE-mineralization” from the bacteria on the tooth surface, and “RE-mineralization” from the effects of saliva. This interchange occurs on the microscopic level, but still very important in maintaining the normal balance.

The Caries Balance

Given similar habits, you might wonder why some people get cavities and others don’t. This dilemma can be better understood by picturing a balance between pathogenic (disease-causing) and protective (health promoting) factors. Each individual has his/her own unique balance that dynamically changes as time goes on. The trick is to identify what is out of balance and how to tip it towards health and protection.

Pathogenic factors include the large amounts of specific acid-producing Bad bacteria, the Absence of healthy salivary function, and poor Dietary habits. By contrast, protective factors include healthy Salivary function and Sealants (to seal the areas most likely to decay), the use of Antibacterial agents, topical Fluoride, and a healthy and Effective diet.

How to Assess Your Risk

Not everybody has the same level of risk for developing dental caries; this is further complicated by the fact that the risk is dynamic and changes daily, as well as over time. Therefore, assessing the degree of risk is crucial. And let’s not forget that prevention includes determining both pathogenic and protective factors — both sides of the balance.

Modern dentistry is moving toward an approach to tooth decay management that is “evidence-based” from years of systematic, accumulated and valid scientific research. In other words, it allows individualized treatment based on current science that is customized to the patient’s actual risk that he/she presents with, rather than a “one size fits all approach.”

Risk assessment allows preventive and treatment decisions to manage those in greatest jeopardy. This approach allows for “targeted” management appropriate for individuals whether in low, medium, high or extreme risk groups. Protocols have been recently established based on the Age One Visit (for infants and toddlers) as well as for children age 6 through adulthood.

Strategies for Prevention

You can see now that prevention doesn’t simply mean brush and floss and don’t eat sugar. It is a complicated topic with many implications. In fact, your dental office may offer some additional steps to measure your caries risk (salivary and bacterial analysis) and then recommend some products that specifically manage your risk level (sealants, antibacterial agents, topical fluoride, calcium and phosphate supplements, pH neutralizers, special toothpaste and rinses, and xylitol gum). These strategies are based on tipping the balance toward health by maximizing the protective side and minimizing or eliminating the pathogenic side. Prevention must be strategic, since it affects planning on an individual and community level.

Tipping the Balance — the Right Recipe

Simply put, for dental caries (tooth decay) to occur you need the right (or rather wrong) recipe:

• Susceptible teeth (not all teeth get caries),
• Acid producing bacteria,
• Sugars or carbohydrates — the “perfect” food for the acid producing bacteria
• Prevention aims to shift the balance in favor of promoting health in three main areas:

Protecting the teeth from caries — this is best accomplished by applying fluoride topically to the crystalline structure just after the teeth erupt into the mouth. The tooth surfaces are dynamic and will allow incorporation of fluoride ions into the surface structure. Many studies show that low doses of fluoride are safe and effective against decay. Sealants are very successful and are a companion treatment to fluoride because they seal the places where decay occurs in the tiny hidden pits and fissures [Figure 1]. Clinical studies using sealants show 99% cavity-free results during six years of clinical testing on more than 1,100 teeth studied.

Identifying and reducing acid-producing bacteria — these bacteria can be identified by a simple test administered by your dentist. If these bacteria are identified, they can be modified to reduce tooth decay by the use of tooth protective products. We can further modify these harmful bacterial concentrations with the use of antibacterial mouthrinses (such as chlorhexidine) and pH neutralizing agents. It is important to note, infants are not born with the specific decay-causing bacteria but that these bacteria are actually transmitted through saliva from mothers, caregivers, or family members to young children — another reason to practice prevention.

Controlling diet — sugars and other carbohydrates can be fermented by bacteria to produce acids. It’s important to reduce refined sugars from the diet or restrict intake to mealtimes. Natural sugars (in raw fruits and vegetables) are better than the free (added) sugars found in juices, sodas, candy and the like. Total sugar intake should be less than fifty grams, about ten teaspoons, per day. Snacking between meals is dangerous because it promotes an acid environment that would take up to thirty minutes for healthy saliva to neutralize. Healthy non-sugary or non-carbohydrate snacks are therefore better, like carrots, vegetables and fresh fruits. Xylitol is an example of an “alcohol sugar” used in some chewing gums and dental products that actually reduces decay-producing bacteria, and is proving useful in decay preventing strategies. One study showed that pregnant mothers who chewed xylitol gum before giving birth reduced the transmission of these strains of bacteria to the child, thus reducing the likelihood of decay.

Today’s Treatments Can Reduce and Eliminate Tooth Decay

We understand that tooth decay, or dental caries as it is known, is a disease process, and we know the causes. As we’ll see in future articles, methods of prevention, early detection, protection and treatment have continued to improve. Dentists are using a more preventive strategy — profiling individuals’ degree of risk and implementing preventive strategies to keep their teeth decay-free for life.

By Cynthia Bollinger and Dr. Kathelene Williams-Turk

Pick up most magazines or newspapers these days and you’re likely to see an ad about dental implants. And with the advent of “implant centers” in major metropolitan areas, television ads are now delivering the message that an implant center, with everything conveniently offered under one roof, is the state-of-the-art choice for dental implant treatment. Some even extol the virtues of getting your new “Teeth In A Day!” Bombarded with so many different messages about dental implants, how does the consumer make the right decisions?

While this kind of marketing distorts the limits of our current research and knowledge, this new end of the spectrum may not necessarily end in a rainbow. This important and controversial topic will be covered in two parts. A clear understanding of the increasing options available for implant treatment is a good place to start together with alternative replacements for missing teeth and their economic impact. This first part will also educate you about the problems associated with tooth loss and why implants are considered the state-of-the-art tooth replacement system.

In part two, we’ll discuss who are the most suitable and experienced dental professionals to place implants. We will discuss the why, when and where to make your implant choices including how to navigate through the implant marketing hype.

Dental Implants: The Optimal Tooth Replacement

Let’s begin by taking a look at what makes implants the most optimal tooth replacement system today. An implant connection to the bone is different than how a tooth connects to the bone but it performs the same function. Dental implants act as substitute tooth roots in a unique way.

Implants actually stabilize bone and prevent the inevitable bone loss that occurs when teeth are lost. Commercially pure titanium, of which almost all current implant surfaces are made, has the unique property of being “osteophilic” (osseo-bone, philic – loving), thus joining biochemically to bone. Osseo-integration (osseo – bone, integrate – to join or fuse with) was discovered quite by chance and has revolutionized dentistry. The fusion is almost like a pillar in concrete, allowing no movement at all. Stresses of biting forces are transmitted directly through implants to the bone — which they allow for very well. They provide virtually the same function as natural teeth roots, including stimulating the bone, thereby stabilizing it and preventing its loss.

Consequences of Tooth Loss — Believe It or Not, It’s All About Bone

The bone that encases the teeth known as “alveolar” bone, (from alveolus – sac, an extension of the jaw bone), is the special bone that surrounds and supports the teeth. It develops with the teeth as they erupt into the mouth, accompanies the teeth in life and is lost when the teeth are removed. As one famous scientist put it, “Alveolar bone is like any other bone in the body, it just lives more dangerously,” said Dr. Harry Sicher.

When teeth are lost or removed the alveolar bone, which is fragile in structure like an ice cream cone, “resorbs” or melts away. What complicates matters is the “pattern” of resorption or the melting away process. Where the bone is thinnest, it resorbs more quickly. This is particularly true for the upper front teeth where bone, gum and even the lips can appear to cave in or collapse. The dental literature indicates that 79% of the population has a smile line that will not cover these types of “defects.” This is very noticeable when smiling and many people become quite self-conscious about their appearance as a result.

It Ain’t Necessarily So!

Bone resorption always occurs naturally when teeth are lost, unless measures are taken to prevent it. We are fortunate to live in an era when this melting away process can be compensated for by grafting techniques — which can work well in experienced hands. Although bone can now be restored by grafting techniques, it’s preferable and easier to prevent its loss from occurring. Bone maintained in both sufficient volume and position will allow for proper implant positioning, which in turn will stabilize the bone and prevent further resorption. The desired end result — completely natural looking teeth.

Keys to Implant Success

In the hands of an experienced “team,” implants placed surgically in the right position not only allow for the fabrication of implant-crowns that look natural, but also function properly and are maintainable — indistinguishable from real teeth. In the wrong position or without proper forethought implants can create a nightmare for the restorative dentist and dental technician who make the crowns.

The key to implant success — can be summarized by answering two questions:

• Can an implant be placed in correct position to allow for natural aesthetics and proper tooth function?
• Is there enough bone and is it in the right place to allow tooth replacement with an implant?

Implant placement and positioning is dependant upon adequate bone volume and density, which are therefore critical to success. In experienced hands, implants are extremely successful. Documented research and clinical studies indicate success rates of over 95% — which is higher than any other tooth replacement option. Even in areas of low bone density success is quite common. Once integrated and functional, implant restorations can last a lifetime.

Success from Concept to Design

The concept and design of implants has been very well researched and tested. Implant tooth replacement systems often comprise separate and interconnecting units, which can allow the crown components to be removed and replaced if the need arises. Once an implant is placed in the bone time must be allowed for the osseo-integration (bone fusion) process to take place, usually between two to four months. One of the primary reasons for early implant failure is “loading” them with biting forces too early. Only in carefully controlled circumstances where stability of the implant(s) can be assured, is it possible to place implant crowns early, with any degree of predictable success.

The “Teeth In A Day” concept is somewhat misleading, because the crowns placed on the implants are functional, but most often temporary in nature. This is more commonly effective in the lower front jaw where the bone is denser and implants can be splinted (joined) to crowns atop the implants assuring their initial stability. It is a little less predictable in the upper jaw and for single tooth replacement, but still possible in the right hands and circumstances.

Form and Function — Consequences of Tooth Loss

We tend to think about teeth as individual units, your dentist even gives each tooth a name and number, but in fact they make up a complete system, each one adding to its neighbor to function as one. Think about how the keystone in an arch holds all the other stones or bricks in place. For purposes of description we can think about the human dentition (full complement of teeth) as being composed of the anterior (front teeth) and posterior (back) teeth. The anterior teeth (the canines and incisors) are used for cutting and tearing food, and the posterior teeth (the premolars and molars) are used for grinding and chewing.

Importantly, the posterior teeth also support the vertical height of the face. If they are lost, the face tends to lose height and close down; this is called “posterior bite collapse”. Unlike implants, teeth move; not only do changes occur to the remaining back teeth affecting their spacing and biting function, these changes also put pressure on the front teeth which tend to move or splay forward.

All of these changes have implications for normal form (aesthetics) and function (bite). They also have ramifications for other facial and jaw structures which can affect anything from the skin to muscles and jaw joints. Appearance begins to change as the height of the jaw decreases, wrinkles increase and the corners of the mouth droop. Additionally, it can become difficult to eat food because the front teeth were not designed for chewing. This is to say nothing of the social consequences of tooth loss; smiling, talking, singing, laughing and enjoying a nutritionally sound diet — all leading to both poor general and mental health.

Traditional Tooth Replacement — Not So Traditional Any More

Dental implants are a relative “new kid on the block” for replacing missing teeth, but how do they really compare to other more traditional systems?

Removable options — Past methods of removable tooth replacement have included plastic “flippers” (non-precision, simple, temporary in nature and relatively inexpensive) and precision made metal based partial dentures, which are more expensive. Both can replace individual or groups of teeth. A fundamental problem with removable prostheses (replacements) is that for stability they rest on the teeth and gums tending to cause further problems all related inevitably to their design. These include tooth decay and periodontal (gum) disease and hastening the loss of bone and teeth through pressure transmitted through the gums upon which they rest. They constitute short term options with documented studies indicating that removable partial dentures are replaced about every 5 years.

For total tooth replacement whether in the upper or lower jaw full dentures (plates) have been the only option. Since they are kept in only by pressing on the gum tissues they transmit force to the underlying bone which accelerates its loss even more quickly. They also compromise the facial structures. As they continue to collapse, full dentures must be relined (made thicker) to compensate for additional bone loss and facial sagging. They also become particularly problematic in the lower jaw where there is no palate for suction and in addition tongue forces tend to destabilize them.

Non-removable options — Fixed bridges are non-removable prostheses (tooth replacements) which are attached to the natural teeth. They act by joining other teeth together with a false tooth or teeth between them “bridging” the gap. But the biggest disadvantage; these “abutment” or adjoining teeth are cut down into small peg shapes which compromises their long term health. As well as carrying the additional load of the missing teeth they replace, they become more prone to bacterial plaque accumulation, decay, root canal problems and periodontal (gum) disease. Bridges do not have a long life span therefore they will eventually need to be replaced. Studies indicate that bridges are only 67% successful at 15 years.

Economic aspects: Comparing the Cost of Implants to Fixed Bridgework

Consider this scenario: if you lose a single tooth, the two most common methods of tooth replacement are a tooth supported bridge or an implant supported crown. The American Dental Association (ADA) reports that bridges last an average of 10 years. Clinical studies indicate that implants are over 95% successful for 20+ years.

Even with partial insurance reimbursement, the cost of a tooth supported bridge is more expensive long term. The total cost over 20-25 years or more could be significantly higher than shown above. And with an implant supported crown, the adjacent teeth are not compromised so that additional treatment is not necessary. Consider too, the concept of amortization — the process of decreasing or accounting for the cost over the period of time they are likely to last.

Implants may seem more expensive initially. But for patients who are candidates, not only are they a better treatment choice, they will last longer, possibly a lifetime, thereby making them the ideal choice and most cost effective option long term. As we shall see in part two when we guide you through the marketing hype, well planned implants most often require a team approach in assessing whether they’re right for you. Placing implants and attaching crowns to them require precision procedures and techniques.

Benefits of Dental Implant Treatment

• Enhanced quality of life
• Integrity of the facial structures is preserved
• The smile is restored as close as possible to its natural state
• Long term health of adjacent teeth is not compromised
• Replacement teeth that look, feel and function like natural teeth
• Increased stability
• Improved health due to improved nutrition and proper digestion
• Renewed self-confidence
• Improved appearance
• Improved ability to taste foods
• Increased convenience of hygiene and maintenance

By Dr. D. Walter Cohen

The Art of Periodontal Surgery

Periodontal surgery is a plastic (reshaping) surgical procedure designed to restore and regenerate normal form and function to lost and damaged periodontal structures which support the teeth (the gum tissue, periodontal ligament and bone). This article is an overview of what a candidate for periodontal surgery can expect and a primer for further information and discussion.

Periodontal Surgery in Perspective — What makes it work

An understanding of what periodontal surgery is designed to do, what makes it successful and what sustains the results over time is critical to successful treatment of periodontal disease. Periodontal surgery is not a cure, but rather an adjunct to making long-term treatment outcomes more favorable. Unlike surgery to take out an inflamed appendix, which removes the disease with it, the potential for the recurrence of periodontal disease still remains in susceptible individuals. The long-term goal of periodontal surgery is to increase the life expectancy of the teeth.

Over a lifetime, the treatment for periodontal disease is primarily aimed at controlling its cause, microbial dental plaque. The purpose of periodontal surgery therefore is to treat deformities and tissue loss created by the disease process. This is accomplished by eliminating “pockets” of diseased tissue; regenerating and reconstructing gum and periodontal tissue attachment to the teeth and generally to provide an environment more conducive to daily oral hygiene and professional maintenance care.

The Consequence of Periodontal Infection

The end results of periodontal disease include loss of the tight attachment of the gum and periodontal tissues to the teeth. Just as one can put a hand in a pocket, a space by the side of clothing, pockets can also form around the teeth, into which fine probing instruments can be inserted to measure the degree of vertical tissue detachment [see illustration above]. This detachment, results from chronic inflammation as described above. Breakdown ultimately causes bone and periodontal tissue destruction giving rise to different patterns and shapes of bony defects which surgical treatment aims to regenerate and repair. For the most part the detached gum tissues either recede or remain as a detached curtain around the teeth.

Diagnosis

“There may be many ways to treat a case, but there is only one correct diagnosis”

Morton Amsterdam, DDS

Periodontal disease is detected when your dentist physically and visually evaluates the gingival (gum) tissues, probes to determine whether the attachment levels to the teeth are normal or abnormal, and evaluates bone changes through dental radiographs (x-rays). Depending on these findings, along with your general health status and health history, your dentist may also refer you to a periodontist, a dentist specializing in the diagnosis and treatment of periodontal diseases.

The diagnosis of the specific type of periodontal disease that may require surgical treatment is important, because it will have a direct bearing on the techniques used and long-term outcome of treatment.

Diagnosis may also include risk assessment, to aid in determining long term outcomes, known as prognosis. Both personal and professional assessments of individual risk are available (American Academy of Periodontology www.perio.org).

Initial Preparation Sets the Stage for Surgery

Behavior Change: Consistent behavior change is the most important element in maintaining long-term periodontal health, since daily plaque removal in large part will set the stage for sustained, successful surgical treatment. For many people this involves forming new oral hygiene habits, along with cessation of smoking and other lifestyle changes.

Calculus (Tartar) Removal: Your dentist will also see that your teeth receive a thorough cleaning to remove the deposits of calcified plaque called calculus or tartar and other bacterial toxins which become ingrained into the root surfaces. This process of mechanical cleaning is generally known as scaling and root planing, using hand scaling, ultrasonic or laser instruments and will sometimes require local anesthesia.

Occlusal Bite Therapy: Generally, attention to the bite or bite disorders are treated during or after initial therapy once an inflammation free environment has been established. It is important to stabilize loose teeth prior to surgery, because this in itself encourages healing of the periodontal structures and bone.

Re-evaluation Following Initial Therapy

After three or four weeks your dentist/periodontist will evaluate the response of your periodontal tissues to the initial therapy which is being used to control the inflammation and infection induced by dental plaque. This includes oral hygiene instruction, scaling and root planing (deep cleaning) among other possible treatments. In cases where pockets are deep, 5 mm and above, the chances of successfully removing all the bacterial deposits from the root surfaces diminish, which means that they may only be removed at surgery when they can be visualized. This also applies to areas that are impossible to clean adequately because of their shapes, like “furcations,” the areas of bone loss between roots of “multi-rooted” teeth, which may only be accessed surgically.

Superficial gum tissue health in response to plaque control is critical to surgical success. If the gum tissues have not responded adequately then bacteriological testing may be indicated to ensure removal of pathogenic (disease causing) strains of bacteria by either local (applied at the site) or systemic (bodily) antibiotic treatment, or review of the diagnosis for medical conditions that may be limiting the response to initial treatment.

Surgical Therapy

Periodontal surgical treatment today encompasses a variety of sophisticated plastic surgical procedures. These include techniques to repair and regenerate soft (gingival) [Figure 1 and 2] and hard (bony) tissues and replacement of missing teeth with dental implants. Procedures are usually performed by a periodontal specialist trained in these techniques and in some cases general dentists who have taken advanced training in periodontal surgery. Most procedures are performed with local anesthesia (numbing of the gum/periodontal tissues and teeth), sometimes with the additional use of oral anti-anxiety/sedation medication or intravenous conscious sedation (twilight sleep).

The objective of surgery is generally to eliminate pockets, regenerate attachment and to create more normal periodontal form, function and esthetics. The goal is to provide an environment more conducive to oral hygiene and maintenance care so that teeth can be kept for a longer period.

Risks, Benefits and Alternatives

It is important to have a discussion with your periodontist or general dentist to educate yourself regarding the risks, benefits and alternatives before undergoing treatment:

• The specific procedure you need should be discussed so you can understand what is involved. It should include what to expect after the surgery; generally mild to moderate discomfort for a day or two, usually managed by non-steroidal anti-inflammatory and analgesic medication of the Ibuprofen or Celebrex family, antibiotics and antibacterial rinses. No vigorous activity should be undertaken for the first few days to ensure that bleeding does not occur. It is also likely that the teeth will be somewhat more sensitive to cold which will disappear over time, particularly with the application of fluoride varnishes.
• What are the benefits and likely outcomes of treatment including a determination of prognosis — what results to expect and how long they will last;
• What are the alternatives to surgical treatment; this will depend upon the type and the extent of periodontal disease you have and the procedure that is recommended.
• These issues will differ somewhat depending upon the type of periodontal surgical procedures. This process is called an informed consent, and you will probably be asked to acknowledge this process in writing.

Contra-indications

It is important for people undergoing surgery to be in general good health and not overly stressed. It is also important to give your dentist/periodontist a full medical history with all current conditions and medications you are taking, including those to which you are allergic. Situations exist medically where it is not advisable for individuals to undergo surgical treatment. These mainly fall into the following categories:

• Uncontrolled periodontal disease
• Smoking and alcohol — can not only make periodontal disease worse, but will delay healing following surgery
• Systemic (bodily) or medical conditions which are uncontrolled, e.g. diabetes, HIV (AIDS), immuno-compromised patients (in whom resistance to disease is diminished), cardiovascular (heart and blood vessel) disease, to name a few
• Medications that can affect periodontal disease or surgery, e.g. aspirin, coumadin which may cause bleeding that is difficult to stop; medications that cause gum overgrowth, e.g. calcium channel blocking drugs used to control cardiovascular disease, other medications used to control transplant rejection, and more

Current Techniques

Current techniques are based on a sound understanding of wound healing and therefore enhance and maximize the body’s healing potential. For descriptive purposes, a rather broad distinction can be drawn between periodontal surgical techniques used to treat:

• Periodontal disease that has resulted in loss of periodontal attachment with pocket formation
• Aesthetic techniques to re-contour or graft new tissue in cosmetic areas (like the upper front teeth) where there is excessive tissue, or to cover exposed roots where gum tissue has been lost
• Bone and gum tissue regeneration to develop sites for future implant placement following tooth loss or other prosthetic (false) teeth replacement
• Implant placement to replace missing teeth

Surgical techniques to treat periodontal disease have been documented as far back as 1862 when Robicsek in Hungary developed the “gingivectomy” (gingiva-gum, ectomy-removal) to treat gum overgrowth, a technique still in limited use today, in a modified form. He is also credited with early “flap procedures,” which are still the “work horse” basis of many periodontal surgical procedures today.

Flap surgery is the most conservative and versatile of procedures and consists of making an internal opening allowing a “flap” to be raised, much like opening the flap of an envelope. This allows the surgeon to work within the periodontal tissues to:

• Remove inner diseased and detached tissue lining of pockets
• Gain access to further clean and treat root surfaces
• Repair and regenerate bone, periodontal ligament tissue complex
• Close the tissues completely leaving no open wounds for rapid and comfortable healing
• Tiny suture placement to retain the gum tissues in place. Sutures either self-dissolve or are removed after a week or so. In some cases an unobtrusive dressing is applied to protect tissues while healing ensues.

Innovations in regeneration

The last two decades have seen an explosion of knowledge and new techniques to regenerate periodontal tissues. Up until the 1980’s most surgery was “resective” in nature — removing diseased tissue. From the 1960s to the 1980s soft tissue gingival (gum) grafting techniques to increase gum tissue were predictably successful. Regeneration techniques were already understood from wound healing studies and knowledge of the cell types that “coded” for new gingival, gum tissue. However techniques were less predictable when attempting to regenerate lost alveolar (tooth supporting bone) and the adjacent periodontal ligament.

Regenerating Periodontal Tissues

• • The periodontal ligament is a thin, fibrous ligament that connects the tooth root to the bony socket. Normally, teeth do not contact the bone directly; a tooth is suspended in its bony socket by the periodontal ligament which is attached to the tooth root via cementum.
  • Without new periodontal ligament formation, new attachment and bone regeneration is impossible. In the past, the difficulty had been stopping gum tissue cells growing down the freshly cleaned roots before the new periodontal ligament cells had a chance to grow and reattach to the root surface cementum. Stopping the gum tissue cells from advancing was the race that science needed to win in order to regenerate new periodontal attachment.

Guided Tissue Regeneration

• • Periodontal tissue regeneration was ingeniously solved with the advent of sub-gingival (sub-under, gingival-gum) “barrier membranes,” sort of minute subterranean band-aids. These barriers stop the growth of gum tissue cells and allows regeneration of new periodontal ligament by guiding cell growth. This technique is known as “Guided Tissue Regeneration.” Membrane technology has now advanced to the point where membranes will last exactly the appropriate amount of time needed for healing and then dissolve so that they don’t have to be removed.

Growth Factors — Magic Molecules

• • Most recently, basic science has further demystified wound healing with an understanding of growth factors. The process of inflammation, the body’s response to injury and infection causes the attraction of particular cells and liberation of their components, so-called growth factors — “magic molecules” which initiate and promote wound healing. The ability to isolate these substances, determine their roles and then to be able to manufacture them has allowed periodontal and other surgical specialists to use growth factors to regenerate tissues, making results more predictable and healing uneventful.

Summary

Today’s highly sophisticated and meticulous surgical techniques allow the periodontal surgeon to regenerate and reconstruct lost and missing tissues. Modern procedures are kinder to the patients; are carried out with local anesthesia (numbing the area/s) in combination with either oral (anti-anxiety) sedation or intravenous conscious sedation (twilight sleep). There are minimal post surgical issues, minimal discomfort and little bleeding, either during or after surgery. Periodontal surgery includes elements of art, experience and a great deal of scientific knowledge of techniques and wound healing to prolong the life of your teeth with greater predictability than ever before.