California Society of Periodontists
Periodontics and Dental Implants
PO Box 7875, Norco, CA 92860
310-906-9505
Bad breath can be caused by a variety of problems and at times, may involve more than one cause. Poor Periodontal (gum) Health and Oral Hygiene is one of the major reasons for bad breath. Bad breath is common in patients with advanced gum disease and poor oral hygiene.
Foods, such as garlic and onions, can also contribute to breath malodor. After eating, some components of these foods are absorbed into the bloodstream and can be expelled in the lungs.
The more common source is due to accumulation of plaque and food products which metabolizes into compounds that are associated with bad breath. Good oral hygiene habits such as brushing, flossing, good homecare, and regular dental maintenance visits with your dentist can minimize the possibility of you having bad breath.
Dry mouth (xerostomia) occurs when the flow of saliva diminishes. Saliva is necessary to cleanse the mouth and remove food particles that may cause odor. Dry mouth may be caused by various medications, salivary gland problems or continuously breathing through the mouth. Your dentist may prescribe artificial saliva or suggest increasing your fluid intake.
Tobacco products. If you use tobacco products, you can ask your dentist for suggested smoking cessation regimens.
Regular brushing and flossing your teeth along with regularly scheduled dental visits to with your general dentist or periodontist are important for good oral health and reducing bad breath.
The most popular cosmetic dental procedures include tooth whitening (bleaching), bonding of the front teeth, and the use of tooth-colored restorations which blend with the natural color of your teeth. Depending on whether your teeth are stained, discolored, chipped, have cavities or cracks, unevenly shaped, have gaps, or are broken, different options are available. You should consult with your general dentist to determine which cosmetic procedure best suits your individual dental needs.
Periodontists are often needed in these cosmetic procedures to help with the following:
Procedures are available to correct dental defects and cavities or to improve your appearance. Before starting a treatment plan, you should consider all your options and make an educated decision as these procedures generally cannot be reversed. Many of these options will require a good dental team consisting of the general dentist, a periodontist to prepare the gingival (gum) “framework”, and a dental laboratory technician. Not having a good dental team may compromise the final end results.
(source www.ada.org)
Before selecting or changing a dental plan, there are some important things to consider. Some plans require patients to choose their dentist from a limited list of providers. Choosing from a list is not the same thing as freedom of choice. If your dentist is not on such a list, don't hesitate to ask why he or she has elected not to participate.
Dental plans are typically business arrangements between an insurance company and your employer. Most plans are designed to pay only a portion of your dental expenses. The amount paid almost always provides a maximum amount of benefit payments per year, so that the actual benefit for an eligible procedure may be limited either in the amount paid for a particular procedure or in the total amount that will be paid over the course of the calendar year. Thus, it should be viewed as a “dental allowance” rather than a true insurance benefit. There also may be limitations on the types of services which are covered. For example, many plans do not offer benefits for procedures such as dental sealants (which are well documented to prevent tooth decay), cosmetic services like bleaching, or dental implants. In addition, some plans do not cover pre-existing conditions, such as missing teeth. Others may not cover dental implants, specialist referrals and other dental needs. Even when you and your dentist agree on the appropriate treatment for your condition, the contract provision of the dental plan may only pay a portion, or pay only for the least expensive alternative treatment (LEAT) as determined by the insurance company.
Dental plans may use the terms "usual, customary and reasonable" (UCR) to determine the portion of the dental treatment fee they will pay. UCR reimbursement levels are determined by different methods by the dental plan administrators. They may vary a great deal among plans — even when those plans operate in the same area. The fee the insurance company determines to be "customary" may be very low compared to the area's actual average professional fee for the same services. The plans then generally pay a certain percentage of the UCR level. The patient may then be required to pay a greater portion of the treatment costs.
It is important to carefully read a plan and know its limitations. If a plan doesn't cover a procedure that is recommended by your dentist, this does not mean that the treatment isn't appropriate or needed.
Talk to your dental office so you can make the wisest decision about your dental benefits.
Dental implants are metal "anchors" that are surgically placed into the jaw bone. After 2-6 months of healing, the bone fuses to the metal to create a solid foundation. Then a tooth restoration can be placed onto the implant and function similar to a natural tooth. Dental implants are one of the most predictable treatments in dentistry today. Dental implants are made of titanium, one of the most biocompatible materials known.
This patient was congenitally missing both lateral incisors [fig 5a]. Implants were placed in both of these spaces to support two individual crowns [fig 5b]. Further improved esthetics was achieved with veneers [fig 5c].
Depending on an individual patient’s bone levels, medical conditions and financial considerations, the number of implants or pre-implant reconstructive treatments will be determined by you, your dentist and the periodontist surgeon.
For the best treatment and maintenance of your oral health, a proper dental team will consist of your general dentist, his / her staff, a lab technician and their specialist referral network. Together, they will each participate in helping you keep a happy, healthy smile for a lifetime. The role of your periodontist on this team is to monitor and guide you through the maintenance of periodontal health, and give you surgical options for cosmetic procedures such as root coverage, dental implant placement, esthetic crown lengthening, etc. Ask your general dentist if your dental care would benefit with the addition of a periodontist to your dental team.
Dentures are a solution of last resort. Many people assume that they will need dentures as they age, but losing teeth is not a normal part of the aging process. If you care for your teeth well and guard against periodontal (gum) disease and cavities, you should be able to keep your teeth for a lifetime.
Saving even a few natural teeth is often better than losing them all. Dentures are made for people who have lost all of their teeth. They are called complete dentures. Complete dentures can be given additional support by placement of implants in the bone under the denture. Partial dentures are made for situations where some natural teeth are present and used as anchors (abutments). The stability of even these partial dentures can be at times improved with the use of dental implants for additional support.
Although dentures may look like your natural teeth, they cannot work like them. Simple actions like speaking and eating may feel different as there is some movement to the dentures. You will have to learn how to use and adjust to your dentures, which for some people can take several months.
Complete dentures cover your entire jaw, either upper or lower. Some people call them "plates." Complete dentures rest directly on the gum that covers the bone. Since there is no attachment to anything solid, there is some movement when people speak or eat. Over years of use, the underlying bone will remodel or change so that the fit may become more compromised. Dental implants can both make these dentures more stable and prevent further “melting” away of the underlying bone.
Removable partial dentures are composed of a metal framework with plastic teeth and gum areas. Traditionally, the framework includes metal clasps or other attachments, which hold the denture in place. However, partial dentures are removed easily for cleaning. Partial dentures will also cause the underlying bone to remodel so dental implants are often useful for both stabilizing the denture and preventing further bone loss.
Implant-supported over-dentures also can fit over implants instead of natural teeth. In fact, implants originally were developed to give people "artificial roots" on which to place bridges or dentures in the lower jaw. The denture can fit directly onto the implants, or a metal bar can link implants together, providing support for the denture.
This patient had a loose fitting lower denture that displaced during eating and speaking. Two implants were placed with retaining attachments in the lower jaw [fig 6a]. The lower dentures were fabricated with housing for the retaining attachments [fig 6b]. After treatment, the dentures were quite “solid” during function [fig 6c].
Fixed partial dentures, which most people call bridges, are cemented in place and better simulate natural teeth. Bridges are more expensive than removable partial dentures and require healthy adjacent teeth to support them.
A fixed or non-removable bridge can be attached to multiple implants in a variety of ways. The in the above model, a classic approach of 5 implants were placed in the lower jaw [fig 7a]. A fixed bridgework is attached to the implants [fig 7b].
Pain is the most common type of dental emergency. Should you have a broken down tooth, decay, or gum swelling, you probably need emergency care from your general dentist. Your general dentist is well-trained to diagnose your problem. A periodontist may be involved with your care if the source of the problem is a gum infection, a fractured tooth requiring crown lengthening, or extraction with the placement of a dental implant.
There are a number of simple precautions you can take to avoid accident and injury to your teeth. One way to reduce the chances of damage to your teeth, lips, cheek and tongue is to wear a mouth-guard when participating in sports or recreational activities that may pose a risk. Avoid chewing ice, popcorn kernels and hard candy, all of which can crack a tooth. Accidents do happen, and knowing what to do when one occurs can mean the difference between saving and losing a tooth.
Bitten Lip or Tongue Clean the area gently with a cloth and apply a cold compress to reduce any swelling. If the bleeding doesn’t stop, go to a hospital emergency room immediately.
Broken Tooth Rinse your mouth with warm water to clean the area. Use cold compresses on the area to keep any swelling down. Call your dentist immediately.
Knocked Out Tooth Hold the tooth by the crown and rinse off the root of the tooth in water if it’s dirty. Do not scrub it or remove any attached tissue fragments. If possible, gently insert and hold the tooth in its socket. If that isn’t possible, put the tooth in a cup of milk and go to the dentist as quickly as possible. Remember to take the tooth with you.
Objects Caught Between Teeth Try to gently remove the object with dental floss; avoid cutting the gums. Never use a sharp instrument to remove any object that is stuck between your teeth. If you can’t dislodge the object using dental floss, contact your dentist.
Toothache Rinse your mouth with warm water to clean it out. Gently use dental floss or an interdental cleaner to ensure that there is no food or other debris caught between the teeth. Never put aspirin or any other painkiller against the gums near the aching tooth because it may burn the gum tissue. If the pain persists, contact your dentist.
Oral sedation is a management technique that utilizes oral medications and sometimes nitrous oxide (laughing gas) to create a state of conscious sedation (relaxation and at times unawareness). This technique is advantageous for patients that have mild anxiety and fear. This technique may be used for children and adults depending upon the behavior of the child and level of anxiety of the adult patient. Oral sedation is not recommended for very young children.
Intravenous conscious sedation is a technique that utilizes intravenous agents and sometimes nitrous oxide to help relax a patient who is anxious. This is a good technique for patients who have mild to moderate anxiety or fear of dental procedures. This technique is also advisable for adult patients who require a great deal of dental treatment and wish to have more treatment completed in fewer visits. Patients treated with conscious sedation frequently have little to no memory of the dental procedure being performed.
General Anesthesia is an anesthetic management technique, which uses intravenous and/or inhalation agents to render a patient completely unconscious (asleep) for the dental procedure. This technique is recommended for very young children, the very resistant child, severe dental phobics, and special needs patients who are unable to cooperate for dental treatment.
In California, dentists utilizing these modalities of sedation are required to obtain a special permit from the Dental Board of California (Department of Consumer Affairs). These providers completed additional continuing education and an on-site inspection requirements in order to maintain these sedation privileges.
Bruxism is the term for grinding or gnashing your teeth. Often, bruxism occurs during sleep.
The wear on teeth in someone who grinds on their incisors and canines will present as chips in teeth and ‘flattening’ of the edges. Over time, bruxism can cause shortening of the teeth and may lead to jaw joint disorders, headaches, fractured teeth, and other problems. However, not all people who grind their teeth have major dental issues.
If someone has any or all of the above, seeking a dentist for possible treatment advice is suggested.
Therapies a dentist may recommend include Dental Bite Splints (Night-guard or Occlusal Splint), Occlusal Adjustment (Adjusting the biting surfaces of the teeth), Stress Management and/or Behavior Therapy. The correct treatment is dependent on individual variances between patients; your dentist will discuss the options with you.
Fig 8: A plastic nightguard is fabricated from models of your teeth. During periods when you grind/clench your teeth, the nightguard may be worn to minimize damages to your tooth structures.
Periodontal (gum) diseases are chronic infections of the tissues which surround and support the teeth. Not only can these diseases lead to tooth loss, but there is increasing evidence that they can also affect your overall general health.
Periodontal diseases begin with an accumulation of dental plaque, which is a collection of bacteria that constantly forms around your teeth. Plaque is a soft, sticky film which can be easily removed with a toothbrush and dental floss. If plaque is left on the teeth, it mineralizes to form a hard deposit (tartar, or calculus).
The early form of the disease is called gingivitis and the signs of this disease can be quite subtle. They include swelling, redness and bleeding of the gums. The treatment for gingivitis is usually a thorough cleaning of the teeth at the dentist's office. If left untreated, gingivitis can often progress to periodontitis. This is a more severe form of the disease in which bacteria and the body's own immune system attack the ligaments and bone that hold teeth in place. If periodontitis is not treated, it will lead to bone loss and loss of teeth.
There are many factors which can affect a person's susceptibility to periodontal diseases, including genetics, smoking, diabetes and hormonal changes associated with puberty or pregnancy. Certain medications can also affect your gum tissues.
For further information about periodontal diseases, visit the American Academy of Periodontology's web site. There is even a quiz to help you assess your risk for periodontal disease. If you have any doubts, it is best to see your dentist or a periodontist (link to directory of CSP Periodontists).
Gum recession is where the gum has receded from the edge of the crown of the tooth. Resulting in some of the root becoming exposed. At times, these areas may cause transient sensitivity to cold, hot, sweet, sour, and the touch of dental instruments during your cleaning appointment. In addition, with excessive recession, there may be inadequate width of sturdy (“keratinized”) gum tissue around your teeth. Though this occurs to a limited extent to everyone with age, rapid or excessive recession can be problematic.
Your periodontist can surgically reposition or replace the lost soft tissue so a protective width of the sturdy (keratinized) gum tissue can be replaced. With dental sensitivity, it is desirable to also cover as much of the exposed root as possible. There are procedures for this if the gum anatomy permits these procedures. Ask your periodontist to help you determine what is possible!
Do you see any of these in your mouth? If you do, it is suggested that you see your dentist or a periodontist to have these lesions evaluated. This is important as some of these may be cancerous. To identify these lesion early is important for continue management and treatment.
Your periodontist has received advanced training in the diagnosis and management of medical conditions of the mouth. Therefor your general dentist may refer you for evaluation, diagnosis, and management of oral lesions. At times, the lesions may be simple to diagnose where others may require a biopsy so the diagnosis can be confirmed by an oral histopathology laboratory. One of the reasons for a definitive and correct diagnosis is that oral cancer is a very serious threat. Early detection can make a significant difference in your dental team’s ability to manage this problem.
A second situation where your dentist could be involved is with the management of your gum problems that are secondary to your medical condition or a medication you may be taking. Certain systemic diseases and conditions such as diabetes, pregnancy, and immune suppression often cause an increase incidence of periodontal problems. In addtion, some medications prescribed to control blood pressure, convulsions or to alter immune functions may cause gum enlargement or overgrowth. Your periodontist can work with your physician to reduce or eliminate the oral adverse reactions from your medication. At times, surgical intervention may be needed to reduce enlarged gum tissue, thereby improving your appearance and your ability to perform adequate oral home care.
Fig 9: This patient had a severe gum recession associated with the lower central incisor. A gum graft procedure was performed to restored losted tissue and to decrease thermal sensitivity.
The fundamental foundation for periodontal care is prevention. Though surgical procedures can re-establish a healthy environment, it is essential that your dental team providing you with a well defined preventative plan. The role of your periodontist is to make sure that periodontal health is maintained. Your general dentist’s responsibility is to monitor tooth decay and verify all restorative prosthesis is functioning well. The combination of this dental team is often useful for continual maintenance care.
During your supportive periodontal maintenance care, your periodontist will also monitor oral changes secondary to systemic problems and medications. Changes with the gums or periodontium are often seen as a secondary effect to diabetes and certain medications. Your periodontist is trained to recognize these changes and the impact of various mediations.
A recent concept in medicine is the oral-systemic health link. Studies are providing strong evidence that poor oral health is linked with poor cardiovascular-respiratory health and pregnancy problems. More information can be found at http://www.perio.org/consumer/media/media-faq.htm and http://www.perio.org/perio-bin/hypergrasp_sitesearch.
X-rays or radiographic images are essential, useful, and indispensable diagnostic aids to the dental examination. The clinical and radiographic examinations complement each other and both should be used for accurate assessment of both tooth decay (caries) and supporting bone loss due to periodontal diseases. Additionally, they may be used to ascertain the health of the dental pulp (nerve tissue), signs of pathology, and the adequate volume of bone for dental implants. Though there are several x-ray formats that may be taken, each format has distinct advantages. For an evaluation of the supporting bone around your teeth, the length of your teeth, and associated bony architecture, your periodontist may request additional x-rays to be taken in addition to the films forwarded by your general dentist. Additional x-rays may provide an accurate assessment of the situation so the appropriate treatment plan can be formulated.
