Frequently asked questions

Periodontal disease affects the gums and structures that support your teeth. One of the first warning signs is when the rim of the gums next to the teeth becomes red and swollen, and bleeds easily when touched. Most often there is no discomfort at this stage, yet the disease has gained a foothold and is now known as gingivitis. Gingivitis is reversible with improved oral hygiene techniques and a professional cleaning. Left untreated, however, the danger exists that it will progress into an irreversible periodontal condition — periodontitis — that damages the gums and bone surrounding the teeth.

Periodontitis is a more advanced disease. Bone and tissues supporting the teeth are destroyed, yet still an individual may be unaware of the problem. When this occurs the gum attachment begins separating from the teeth, creating pockets. These pockets harbour millions of bacteria trapped in plaque that sticks to the teeth. The mouth is a perfect incubator: warm, dark and moist, with plenty of food for the bacteria to metabolise.

Some individuals are more prone to periodontal disease than others — some get a mild form, others a severe case. It is likely we inherit a genetic predisposition, and this influences how severely we will be affected. More about periodontal disease and its treatment.

Periodontal disease is the leading cause of tooth loss in adults, affecting more than 75% of all people, regardless of race, nationality or socioeconomic level. In fact, nearly half of all twenty-year-olds in the world have at least one periodontal pocket. The good news is that the earlier periodontal disease is detected, the more successful the treatment results.

Bacteria trapped in a film that sticks to the teeth — called plaque — initiate the early changes to the gums. As the plaque matures on the teeth, the disease becomes more established, to the point where it becomes irreversible. Though nearly three-fourths of the world's population has some form of periodontal disease, a genetic predisposition is the single biggest determinant as to how serious each case gets. Once periodontal disease is diagnosed, a variety of factors can affect it.

Plenty. The worst offender is smoking. Study after study shows that in the face of an established periodontal condition, smokers have worse gums — deeper pockets, more bone loss, and poorer healing than non-smokers. This is especially relevant when periodontists and oral surgeons place dental implants in smokers: they can successfully have implants, but they tend to heal slowly, have more infections, and experience more problems.

To a lesser extent, what we eat and the vitamins we take affect the gums. Individuals who are overweight, and those consuming high amounts of carbohydrates — especially candies, cakes and sugared drinks — adversely affect their teeth and gums. Constant sucking on cough drops and hard candies helps the bacteria metabolise more quickly and in greater numbers, causing greater risk for decay and more inflamed gums.

Many disease states affect the gums, the most notable being diabetes. Diabetics need to take good care of their teeth and gums because they are prone to more infections and greater problems than non-diabetics.

Medications affect the gums too. One drug group that concerns periodontists is the calcium channel-blockers — Cardizem, Procardia, Verapamil and others, used to treat certain heart conditions. They do not affect everyone who takes them, but they sometimes cause the gums to swell between the teeth, making brushing and flossing difficult. In some instances the gums swell so large they can only be managed with surgery. If you take drugs in this category and are experiencing swollen and bleeding gums, you may want to seek professional help.

Be aware of a common side effect of many medications: dry mouth. When salivary flow decreases, better oral hygiene is needed since decay and inflammation may increase. If your mouth feels dry, clean it frequently and swish often with water.

• Gums bleeding when brushing the teeth
• Red and swollen gums. Tender gums
• Gums pulling away from the teeth, exposing roots and creating recessions
• Pus between teeth and gums
• Sudden swellings that are painful to the touch
• Loose teeth, or spaces suddenly appearing between teeth
• Teeth beginning to flare out
• A change in the way your teeth fit together — a different bite
• Chronic bad breath

It is important to note that you may have periodontal disease and not experience any of these symptoms. Periodontal disease is silent and chronic, rarely giving an advanced warning that tissue destruction is taking place. That is why it is important to have regular dental checkups.

Besides helping us look good, teeth matter for a host of other reasons. Strong firm teeth let us chew food more comfortably, and properly masticated food makes for better digestion. Teeth also help us speak clearly. People who have had the misfortune of losing all their teeth and wearing dentures can have difficulty speaking, cannot eat all the things they want, are often self-conscious, complain that they cannot taste their food as well as they used to, and may even have trouble breathing when they sleep. Those are enough reasons to keep our teeth — and the best way to start is with good oral hygiene.

A personalised programme of care helps maintain healthy gums. The key word is maintenance. By exercising proper home care and having frequent periodontal maintenance treatments, you help protect your periodontal health.

Since periodontal disease is a chronic condition like diabetes, it helps to establish an ongoing programme to maintain the improvements achieved during active treatment. Maintenance intervals are best determined by your periodontist and dentist, and can range from two to six times per year. For patients with a significant amount of periodontal disease we recommend quarterly visits. These sessions are designed to preserve the healthy state of your gums and stabilise your bone levels. Ongoing success is based on your conscientious home care and the professional treatments you receive.

Daily oral hygiene will not ensure that bacterial plaque won't return to damage your gums and bone. Even with the best flossing and brushing, and a host of oral hygiene aids, dental plaque continues to mature in the hard-to-reach places. This can happen in 8 to 12 weeks. That is why patients completing periodontal treatment are often advised to schedule maintenance sessions every three months.

Based on the severity of your problem, the responsibility for periodontal maintenance will be worked out between you, your dentist, and your periodontist.

• Your mouth tissues are examined for abnormal changes
• Changes in your health are discussed
• Pockets are measured, noting any changes
• Your oral hygiene is evaluated, with suggestions on how to improve it where needed
• Your teeth are cleaned to remove bacterial plaque and calculus (tartar)
• Necessary x-rays may be taken to evaluate the teeth and supporting bone
• Your teeth are checked for caries (dental decay)
• The bite — the way the teeth fit together — is checked
• Recommendations are given for any problems discovered, such as tooth sensitivity or indicated dental restorations

Your periodontist, dentist and dental hygienist form a team to provide the best possible dental care and maintenance programme for your needs. The periodontist may see you periodically for periodontal maintenance therapy, but you will need to see your general dentist as well — periodontal maintenance treatments are not meant to take the place of regular dental check-ups.

Remember that your general dentist is primarily responsible for your overall dental health. They will examine for and repair carious lesions (dental decay), change fillings, make new crowns or bridges, perform cosmetic dentistry, and whiten your teeth. Your dentist will make appropriate referrals to other dental specialists when needed and, in general, quarterback your overall dental needs.

Dental implants are metal posts that replace missing teeth. Most are made of titanium, a metal that is bio-compatible with human tissues. Titanium implants have been used for decades without any known ill effects. They can be used in both the lower jaw (mandible) and the upper jaw (maxilla). See eleven implant cases.

Dental implants can be used in a variety of ways, and in some instances offer better solutions than conventional dental restorations. Implants are the only solution if removable or complete dentures are to be avoided.

Replacing a single missing tooth

An implant avoids drilling the adjacent teeth needed to support a permanently cemented bridge — desirable when those teeth have no fillings. Tooth enamel is precious and cannot be replaced once it is drilled. Drilling, however carefully done, can stress the tooth's nerve and sometimes compromise the pulp, requiring a root canal. Crowns and bridges also do not last forever: they chip or break, and decay can form under the margins. A single implant reduces the need for extra crowns and future dental work.

Replacing a removable partial denture

Removable bridges are not always as firm or kind to the tissues as we would like. When they are not, they move around, sometimes wiggling or loosening the abutment teeth they rest on. In time those teeth can become loose and may need to be removed, requiring a new, larger denture. Removable dentures collect a lot of plaque and make cleaning difficult, with a risk of decay where tooth meets gum. Implants tend to avoid or minimise these problems.

Replacing a full upper or lower denture

Most people have enough bone remaining to have implants placed. Where there is not, new techniques exist to regenerate the amount needed.

More retention for full or partial dentures

Instead of placing five, six or more implants, two to four can be inserted for increased stability. The final prosthesis is more stable, gives a greater sense of security, and is often smaller than the one being replaced.

Avoiding removable bridges, and complex cases

Often the loss of a critical tooth eliminates a fixed bridge as an option — not enough teeth to support one, too long a span, or a critical abutment removed. Implants become the alternative to a removable bridge. They can also be used in complex cases to avoid a denture while the patient still has some teeth left: where a root canal has failed, a key abutment tooth has cracked, or a periodontal condition has worsened. For most people complete removable dentures are too horrific to contemplate — and with proper planning, implants can avoid them.

Definitely. Most patients present with adequate amounts of bone for dental implants. In some instances, however, more bone is needed before implants can be placed. There are predictable procedures to graft and regenerate the amount of bone needed. Once sufficient new bone has been regenerated, enough implants can be placed to support a new dental prosthesis.

Dental x-rays and clinical exams help determine whether enough bone exists to place the implants. Sometimes, in conjunction with a clinical examination, the dentist feels comfortable proceeding with placement. Our Kodak 3D CT imaging shows bone volume in three dimensions before anything is scheduled.

Though rare, infections do occur. In the dental literature the verdict is not in as to whether every implant surgery should be covered with antibiotic therapy — in fact, the weight of evidence is against routine antibiotic coverage. The final decision on using antibiotics rests with each operator and their patients.

Yes and no. Implants can be rejected, but not in the way we know rejection can occur in organ transplants, like with kidneys and hearts. We know dental implants are bio-compatible. There are no known allergic reactions to commercially pure titanium implants, which are the most prevalent kind used today.

Though it can vary for specific reasons, the general rule of thumb is that implants placed in the mandible (lower jaw) heal in 3 to 4 months, while the maxilla (upper jaw) takes 4 to 6 months. Augmenting the bone, performing sinus lifts, or needing jaw reconstruction will lengthen healing periods. Remember, healing times are related to human biology. Healing cannot be made to go any quicker than how we were intended to heal.

Implants placed by most periodontists and dental surgeons today have a high degree of success. They are close to 95% successful in the mandible (lower jaw) and 90% successful in the maxilla (upper jaw). These percentages may vary slightly from surgeon to surgeon and among implant types, but as a rule, titanium implant dental fixtures are predictably successful.

Many cases of bad breath, or halitosis, are due to protein breakdown caused by bacteria in the mouth. These odour-producing organisms can lurk anywhere: around the necks of the teeth, in pockets, next to fillings and crown margins, on the tongue, and in various other recesses. Consider how prone the mouth is to grow these bacteria — it has all the ingredients of a successful incubator: dark, moist, warm, and with all the food the bacteria need to metabolise.

Practice good oral hygiene. This includes brushing and flossing regularly and effectively, so that as much plaque as possible is removed by you. If your mouth feels dry, drink plenty of liquids during the day. If necessary, use sugar-free mints or breath-freshening products found in health and drug stores.

Brush your tongue. Your dentist may recommend a special brush or tongue scraper, but a conventional soft-bristled toothbrush will do just fine. Remember, bacterial plaque can hide in the filamentous recesses of the tongue, contributing to bad breath.

See your dentist. Make certain there are no obvious trouble spots contributing to the problem, especially an untreated periodontal condition like a gum abscess.

Once your mouth appears free of anything that might contribute to halitosis, consider consulting your physician. One of the most common medical conditions that causes bad breath is reflux from the upper gastrointestinal tract. Regardless of the cause, bad breath can usually be helped.

The main reason to use dental floss is that floss removes the hard-to-reach plaque that tooth-brushing misses. Most dental decay and periodontal disease begin where teeth touch each other — precisely where the toothbrush bristles cannot reach.

Dental floss comes waxed and unwaxed, flavoured and unflavoured, and in varying widths: thin, regular or wide. There is no best type. Unwaxed floss is favoured by many dentists because as it is used the nylon threads spread to absorb more plaque. Dental purists argue that waxed floss leaves a residue on the teeth which can collect plaque more quickly.

Our feeling is that clinically it does not matter which type of floss — or dental tape — you use, only that you use it. Toothbrushing alone does not remove enough plaque to be effective. Ask your dentist or hygienist how best to use floss under fixed bridges and around dental implants.

You should floss once each day. Though cumbersome at first, flossing will take no time at all once the skills are mastered.

Use about 18 inches of floss. Wrap it loosely around your middle fingers — not your index fingers — because you do not want to limit the range of motion of the index finger, which along with the thumb guides the floss into the right places.

With the floss wrapped around your middle fingers, guide a piece roughly 1 to 1½ inches between two teeth. Gently saw the floss back and forth, passing beyond the contact point, to where it slides down the neck of the tooth.

Once the floss is beyond the contact point, guide it around one of the teeth, avoiding the triangular gum tissue known as a papilla. Picture the tooth as a circle and your goal as swiping the plaque from one half of that circle. Slide the floss gently into the space between the gums and the tooth until you meet resistance, then, holding it firmly against the tooth, rotate it up and down as if shining shoes. After two or three strokes, lift the floss over the papilla and shift your fingers so you guide it around the half of the other tooth in the same area. Repeat, removing the plaque from that tooth. Then pull the floss back through the contact point and begin again in the next interdental area.

When the floss becomes frayed or soiled, unwind a fresh piece from your middle finger. After flossing it is a good idea to rinse your mouth with water to loosen and remove any particles next to the teeth.

Only in specific instances. A water irrigating device removes debris from between the teeth, known as loose adherent plaque. It is always good to remove this, but a residual, adherent plaque can still be found on the teeth and root surfaces, and adherent plaque is not removed by water irrigating devices. That plaque can damage the teeth and periodontal tissues by causing dental caries and periodontal disease. As a matter of fact, if a water irrigating device is angled incorrectly it may drive bacteria into the periodontal tissues, causing more harm than good.

Toothpicks. They get to those last nooks and hiding places that both floss and toothbrushing miss. Studies have shown that the most effective way to remove plaque is when all three methods are used: toothbrushing, flossing, and using a toothpick.

Holding a toothpick with your fingers is minimally effective. After reaching the in-between spots in the front teeth it is hard to manoeuvre the toothpick toward the back of your mouth, and near-impossible to clean the inside (tongue side) of your teeth. Instead we recommend a Perio-Aid — a plastic tool specially designed to hold the toothpick at the proper angle for cleaning between all teeth, both outside and inside. If you have periodontal disease but do not use a Perio-Aid, ask your dentist for their opinion.

It is recommended that brushing twice daily is most effective at removing plaque.

Any brush with soft, nylon bristles. Harder, stiffer bristles can damage teeth and gums and should be avoided.

When used properly, both types are equally effective at removing plaque. It has been our experience that if someone exercises good plaque control with a manual toothbrush, there is no reason to change. However, those needing a boost in motivation sometimes do better with an electric toothbrush. Dr. Bankhead is cautious about recommending an electric brush to anyone with thin gums.

When the bristles are no longer straight but tend to flare outward. This can happen as soon as three weeks, or in three months. Toothbrushes were never meant to last a lifetime.

Any way you want. Scrub all the tooth surfaces, trying to remove food debris and plaque. Be careful not to scrub too hard, or you might cause erosions to form on the teeth at the gum line — and can even brush away the gums, causing gum recessions.

Yes, but in a specific, safe way. Brushing at the gum line improperly can cause the gums to recede, and when this happens the teeth become sensitive, especially to thermal changes. The best way to remove plaque at the gum line is to slant the toothbrush head at a 45 degree angle to the tooth — bristles slanted downwards for the lower teeth, upwards for the upper. Use a short, gentle stroke that wiggles the bristles at the gum line. This removes the plaque without traumatising the gums. Think about it: done this way you are only removing plaque from one or two teeth at a time, not a large group. After finishing one area, move on until all teeth, outside and inside, have been cleaned. Though cumbersome and slow at first, this technique can be performed skilfully in very little time.

No, it is not. Toothbrushing removes only a small portion of the plaque on teeth — it has been estimated at about 30% — and the plaque it does remove is not in the areas that cause tooth decay or periodontal disease. Why? Because the toothbrush bristles do not get in between the teeth, and barely get below the gum line, and this is where the more harmful plaque is harboured. For this reason dental professionals recommend dental flossing and the judicious use of toothpicks.

Plaque is a clear, sticky film that adheres to the surfaces of teeth, gum tissues, dental restorations and even the tongue. It is so adherent that it cannot be washed or rinsed off but must be mechanically removed. Plaque is neither food stuck on the teeth nor food debris. It contains a variety of bacteria that can cause dental decay, contribute to calculus (tartar) formation, and initiate the inflammatory response associated with periodontal disease.

Unfortunately, plaque forms soon after it is removed. Some studies report that it starts forming as soon as five minutes after removal; other reports state it can take up to four hours. Regardless of how quickly it begins reforming, effective plaque control will keep it to a minimum. That is why we encourage brushing twice a day plus daily flossing.

A frequent warning sign is when the edge of the gums next to the teeth becomes reddened and inflamed, and bleeds when touched. This early stage is known as gingivitis.

Calculus is a hardened substance that comes from a combination of minerals in the saliva and dead plaque bacterial cells. Together they precipitate a crusty deposit that, once mineralised, can grow rather quickly. Under a microscope, calculus has all the nooks and crannies of a coral reef and a similar number of hiding places for bacteria. Left on the teeth long enough, calculus begins to irritate the gums: they can swell, become ulcerated and bleed, and eventually get progressively worse, forming pockets.

Yes. There are two types. Supragingival calculus is the hard deposit on top of the teeth — the kind we can see and feel. Subgingival calculus forms below the gums. It is just as hard and adherent, but when present it is a greater concern because it forms within the pockets, allowing bacteria to congregate in greater numbers.

Definitely. Some people never form calculus while others form it in varying amounts. Some notice it days after a professional cleaning, while others hardly form any even months later. The rate of calculus formation is not an indicator of the amount and severity of periodontal disease, nor does it indicate that an individual will ever get it — but its continued presence can always damage the gums.

Periodic removal of plaque and calculus is the best way to control periodontal disease. At these visits the dentist or hygienist can examine the periodontal tissues to determine whether new pockets have formed, or previously diagnosed pockets have worsened. The frequency of these periodontal maintenance treatments is best determined by the dental professional treating you.