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Frequently Asked Questions
Keeping your gums healthy
Flossing and Toothpicks
Plaque and Calculus
What is Periodontal Maintenance Therapy?
A personalized program of care is helpful in maintaining healthy gums. The key word is: maintenance therapy. By exercising proper home care and having frequent periodontal maintenance treatments, you will help protect your periodontal health.
Since periodontal disease is a chronic condition like diabetes, it is helpful to establish an ongoing program to maintain the improvements achieved during active treatment. The periodontal maintenance treatment intervals are best determined by your periodontist/ dentist, and can range from 2-6 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 stabilize your bone levels. On-going treatment success is based on your conscientious home care, and the professional treatments you receive in your dentists or periodontists offices.
Why is Periodontal Maintenance Therapy Important?
Daily oral hygiene will not insure that the bacterial plaque wont return to do damage to your gums and bone. Even with the best of flossing and brushing, and using a host of oral hygiene aids, dental plaque continues to mature in the hard-to-reach places.
This can happen in 8-12 weeks. That's why its often recommended to patients completing periodontal treatment, to schedule maintenance sessions every three months.
Who should perform Periodontal Maintenance care?
Based on the severity of your problem, the responsibility for the periodontal maintenance will be worked out between you, your dentist, and your periodontist.
What is done during a Periodontal Maintenance session?
- Your mouth tissues will be examined for abnormal changes
- Changes in your health will be discussed
- Pockets will be measured, noting any changes
- Your oral hygiene will be evaluated, with suggestions on how to improve it when needed
- Your teeth will be cleaned to remove bacterial plaque and calculus (tartar)
- Necessary x-rays may be taken to evaluate the teeth and supporting bone
- Your teeth will be checked for caries (dental decay)
- The bite (the way the teeth fit together) will be checked
- Dispense appropriate recommendations for any problems discovered, e.g. tooth sensitivity and indicated dental restorations.
What is the relationship between my general dentist and periodontist?
Your periodontist, dentist, and dental hygienist form a team to provide the best possible dental care and maintenance program for your needs. The periodontist may see you periodically for periodontal maintenance therapy, but you will need to see your general dentist as well. Why? Because 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. He/she will examine for - and repair - carious lesions (dental decay), change fillings, make new crowns or bridges, perform cosmetic dentistry, and whiten or bleach your teeth. Your dentist will make appropriate referrals to other dental specialists when needed, and in general, quarterback your overall dental needs.
What is Periodontal Disease?
Periodontal disease affects the gums and structures that support your teeth. One of the first warning signs that there's a problem is when the rim of the gums next to 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 existing in their mouth. When this occurs, the gum attachment begins separating from the teeth, creating "pockets." These pockets harbor millions of bacteria trapped in a plaque that sticks to the teeth. Unfortunately for us, the mouth is a perfect incubator. It is warm, dark, and moist, with tons of "food" for the bacteria to metabolize. The net result is that the bacterial plaque thrives and matures.
Some individuals are more prone to periodontal disease than others. Some get a mild form, while others get a severe case. Why? It is likely we inherit a genetic predisposition to periodontal disease, and this influences how severely we will be affected by it.
How common is Periodontal Disease?
Periodontal disease is the leading cause of tooth loss in adults, affecting more than 75% of all people, regardless of race, nationality, or socioeconomic levels. 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 are the treatment results.
What's the big deal if I lose a tooth?
Besides helping us look good, teeth are important for a host of other reasons. For one, strong firm teeth enable us to chew our food more comfortably. Properly masticated food makes for better digestion. Everyone likes a healthy, bright smile. First impressions count. Besides making you look and feel good, teeth help us to speak clearly. People who have had the misfortune of losing all their teeth and wearing dentures, can have difficulty speaking. They also cannot eat all the things they want, are often self-conscious about their "choppers," complain that they cant 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.
What causes Periodontal Disease?
As mentioned above, bacteria trapped in a film that stick 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 worlds 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.
Is there anything else that can affect Periodontal Disease?
Plenty. The worst offender is smoking. Study after study shows that in the face of an established periodontal condition, smokers have worse gums. Not only do they have deeper pockets and more bone loss, but they don't heal as well as non-smokers do. This is especially germane when periodontists and oral surgeons place dental implants in smokers. Smokers can successfully have implants, but they tend to heal slowly, have more infections, and experience more problems with their implants.
To a lesser extent, what we eat and the vitamins we take, affect the gums. Individuals who are overweight, those consuming high amounts of carbohydrates - especially in candies, cakes and sugared drinks - adversely affect their teeth and gums. Constant sucking on cough drops and hard candies help the bacteria metabolize more quickly, and in greater numbers. This causes a greater risk for dental decay and more inflamed gums.
Lastly, many disease states affect the gums. The most notable is 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. One drug group that concerns periodontists is the calcium channel-blockers. These medicines - Cardizem, Procardia, Verapimil, plus others - are used to treat certain heart conditions. Though they don't affect every person the same way, and in fact, don't affect all who take them, calcium channel-blockers sometimes cause the gums to swell. These gum swellings occur between the teeth, and make 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 to many medications: dry mouth. When the salivary flow decreases, better oral hygiene is needed since decay and inflammation may increase. If you sense your mouth is dry, clean your mouth frequently, and swish often with water.
What are the signs of Gum Disease?
There are many signs of gum disease.
- Gums bleeding when brushing the teeth.
- Changes in your health will be discussed
- 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 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's why it is important to have regular dental checkup.
What are Dental Implants?
Dental implants are metal posts that replace missing teeth. Most are made of titanium, which is 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) or the upper jaw (maxilla).
What advantages do Implants give me?
Dental implants can be used in a variety of ways. In some instances they offer better solutions than conventional dental restorations. Implants are the only solution if removable or complete dentures are to be avoided. Here are some of the ways dental implants can be used:
- Dental implants can replace a single missing tooth. In this case, using an implant would avoid drilling the adjacent teeth needed to support a permanently cemented bridge. This is often desirable when the abutment teeth do not have any fillings. The reason? Tooth enamel is precious. It can't be replaced once it's drilled. The act of drilling, no matter how carefully it's done, can still stress the tooth's nerve. Sometimes, this compromises the vitality of the pulp tissue. When this happens, a root canal is needed. Another thing to consider is that as much as we'd wish otherwise, dental crowns and bridges do not last forever. They can chip or break, and decay can form under the margins, necessitating replacements. A single dental implant reduces the need for extra crowns and future dental work.
- Dental implants can replace a removable partial denture. Removable bridges are not always as firm and kind to the tissues as we would like. When they're not, they tend to move around a bit, sometimes wiggling or loosening the teeth they rest on, which are called abutments. In time, abutment teeth can become loose and sometimes need to be removed. When this happens, a new, larger removable denture is needed. Removable dentures collect a lot of plaque, and make cleaning around some teeth quite difficult. And there's always the chance that decay will form at the spot where tooth meets the gums in the remaining teeth. With implants, these problems tend to be avoided or, at least, minimized.
- Dental implants can replace a full upper or lower denture. Most people have enough bone remaining to have implants placed in their jaws. In the off-chance that there's not enough bone, new techniques exist to regenerate the amount needed to successfully have implants.
- Dental implants can provide more retention for full or partial dentures. Instead of placing five, six, or more implants, two-four implants can be inserted for increased stability. When this happens, the final prosthesis will be more stable, giving a greater sense of security. Also, the prosthesis is often smaller than the one being replaced.
- Dental implants avoid removable bridges. Often, the loss of a critical tooth eliminates a fixed bridge as an option. Either there are not enough teeth to support a fixed bridge, or the span will be too long, or a critical abutment has been removed. Regardless of the cause, a fixed (cemented) bridge cannot be employed to replace the missing teeth, so a removable bridge is suggested. Is a removable bridge the only option to replace missing teeth when there are not enough suitable abutments? This is the time to consider dental implants.
- Dental implants can be used in complex cases in order to avoid a denture while the patient still has some teeth left. These patients usually have existing bridges, and they are certainly not strangers to the dental chair. What usually happens is that a root canal has failed, or a key abutment tooth has cracked, or their periodontal condition has worsened. Any of these conditions could force a dentist to suggest that unless dental implants are placed in strategic areas, complete (removable) dentures will be needed. For most people, this step is too horrific to contemplate, let alone experience. But with the success of dental implants, complete (removable) dentures can be avoided with proper planning.
If I lost teeth due to Periodontal Disease, can I still have Dental Implants?
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 for dental implants. Once sufficient amounts of new bone have been regenerated, enough dental implants can be placed to support a new dental prostheses.
But still, each mouth is different, how do you know I have enough bone for Dental Implants?
Dental x-rays and clinical exams help determine if enough bone exists to place the dental implants. Sometimes, in conjunction with a clinical examination, the dentist feels comfortable in proceeding with the placement of a dental implant.
What about infections from Dental Implant surgery?
Though rare, infections do occur. With regard to 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. However, the final decision in using antibiotics rests with each operator and their patients.
Can an implant be rejected?
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.
How long does it take for the implants to "Work"?
Though it can vary for specific reasons, the general rule of thumb is that implants placed in the mandible (lower jaw) heal in 3-4 months, while the maxilla (upper jaw) takes 4-6 months. Augmenting the bone, performing sinus lifts, needing jaw reconstruction, etc., will lengthen healing periods. Remember, healing times are related to human biology. Healing can not be made to go any quicker than how we were intended to heal.
With all the things to worry about, how successful are implants?
Though it can vary for specific reasons, the general rule of thumb is that implants placed in the mandible (lower jaw) heal in 3-4 months, while the maxilla (upper jaw) takes 4-6 months. Augmenting the bone, performing sinus lifts, neMaybe this should have been the first question. But we feel strongly that the public should understand everything there is to know about implants. Implants placed by most periodontists and dental surgeons today, have a high degree of success. In fact, 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.
What is Bad Breath?
Many cases of bad breath, or halitosis, are due to protein breakdown caused by the bacteria in the mouth. These odor-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 in the mouth. Consider how prone the mouth is to grow these bacteria. It has all the ingredients of a successful incubator: it's dark, moist, warm, and has all the "food" necessary that the bacteria need to metabolize.
What can I do to overcome Bad Breath?
Practice good oral hygiene. This includes brushing and flossing regularly and effectively, so that as much of the plaque is removed by you as possible. 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.
What else can I do to keep my Breath Fresh?
Brush your tongue. Your dentist may recommend a special brush or tongue scraper for this, 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.
What should I do if Bad Breath persists?
See your dentist. Make certain there are no obvious trouble spots contributing to this problem, especially an untreated periodontal condition like a gum abscess.
Once your mouth appears free of anything that might contribute to halitosis, consider consulting with your physician about this matter. One of the most common medical conditions that cause bad breath is reflux from the upper gastrointestinal tract.
Regardless of what the cause, bad breath can usually be helped.
The main reason to use dental floss is because floss removes the hard-to-reach plaque that toothbrushing misses. In fact, most dental decay and periodontal disease begin where teeth touch each other. That's precisely where the toothbrush bristles cannot reach.
Are there different types of Dental Floss?
Dental floss comes waxed and unwaxed, flavored and unflavored, and in varying widths: thin, regular, or wide. There is no "best" type of floss to use. Unwaxed floss is favored by many dentists because as it's 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 doesn't matter which type of floss - or dental tape - you use, but just that you use it. Toothbrushing, alone, does not remove enough plaque to be effective when it comes to good oral hygiene. Ask your dentist/hygienist, how best to use floss under fixed bridges and around dental implants.
How often should I Floss?
You should floss once each day. Though cumbersome at first, flossing will take no time at all, once the skills are mastered.
How should I Floss?
Use about 18 inches of floss. Wrap it loosely around your middle fingers...not your index fingers. The reason is that you don't want to limit the range of motion of the index finger which, along with the thumb, is used to guide the floss in the right places.
With the floss wrapped around your middle fingers, guide a piece roughly 1" to 1 1/2" between two teeth. Gently saw the floss back-and-forth, passing beyond the contact point, to where the floss slides down the neck of the tooth.
Once the floss is beyond the contact point, guide it "around" one of the teeth. Avoid the triangular gum tissue, known as a papilla. A good way to picture this is to think of the tooth as a circle, and your goal is to swipe away 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 the floss firmly against the tooth, rotate it up and down, as if you were "shining shoes." After two or three strokes, lift the floss over the papilla, shifting your thumb and index finger so that you guide the floss around the half of the other tooth in the same area. Repeat the same motion again, removing the plaque from this tooth. When you've completed this, pull the floss back through the contact point and begin the process over again in the next interdental area.
When the floss becomes frayed or soiled, unwind a fresh piece from your middle finger. After flossing, it's a good idea to rinse your mouth with water to loosen and remove any particles next to the teeth.
Would a water irrigating (water-pic) device help my Periodontal condition?
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 plaque, but a residual, adherent plaque can still be found on the teeth and root surfaces. Adherent plaque is not removed by water irrigating devices. This plaque - adherent 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.
What else helps remove plaque?
Toothpicks.The last ingredient to effective plaque removal is the use of toothpicks. Why? Because toothpicks 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 of removal are used: toothbrushing, flossing, and using a toothpick.
Do I hold the toothpick with my fingers?
Holding a toothpick with your fingers is minimally effective. That's because after reaching those in-between spots in the front teeth, it's hard to maneuver the toothpick toward the back of your mouth, and near-impossible to clean the inside (tongue side) of your teeth. Instead, we recommend using a Perio-Aid. A Perio-Aid is a plastic tool that is specially designed to hold the toothpick in the proper angle for cleaning in between all teeth, both outside and inside. If you have periodontal disease, but do not use a Perio-Aid, ask your dentist for his/her opinion.
How frequently should I brush?
It is recommended that brushing twice daily is most effective at removing plaque.
What type of Toothbrush should I use?
Any brush with soft, nylon bristles. Harder, stiffer bristles can damage teeth and gums and should be avoided.
Which is better: An electric or a manual Toothbrush?
When used properly, both types of toothbrushes are equally effective at removing plaque. It has been our experience that if someone exercises good plaque control with a manual toothbrush, there's no reason to change. However, those persons needing a "boost" in motivation when it comes to plaque control, sometimes do better with an electric toothbrush. Dr. Bankhead is cautious to recommend an electric brush to anyone with thin gums.
When is it time to get a new Toothbrush?
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.
How should I brush my teeth?
Anyway 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.
Should I brush my gums too?
Yes, but in a specific, safe way. Brushing at the gum line improperly can cause the gums to recede. When this happens, the teeth become sensitive, especially to thermal changes. The best way to remove the plaque at the gum line is to slant the toothbrush head on a 45 degree angle to the tooth. This means that when you're brushing the mandibular (lower) teeth, the bristles are slanted downwards, and for the maxilla (top) teeth, the bristles are slanted upwards. Use a short, gentle stroke, that "wiggles" the bristles at the gum line. This technique effectively removes the plaque and should not traumatize the gums. Think about it…when you do it this way, you're essentially only removing the plaque from one or two teeth at a time, not a large group of them. After finishing one area, move on to other teeth, until all - outside and inside - teeth have been cleaned. Though cumbersome and slow at first, this plaque-removal technique can skillfully be performed in very little time.
Is brushing enough to remove all the plaque from my teeth?
No, it is not. Toothbrushing removes a small portion of the plaque on teeth. As a matter-of-fact, it's been estimated that toothbrushing only removes about 30% of the plaque…and the plaque it does remove is not in the areas that cause tooth decay or periodontal (gum) 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 harbored. For this reason dental professionals - dentists and hygienists - recommend dental flossing and the judicious use of toothpicks.
What is Plaque?
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 can not 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.
How quickly does Plaque form?
Unfortunately, plaque forms soon after it is removed. Some studies report that it starts forming as soon as five minutes after it is removed. Other reports state that it can take up to four hours. Regardless of how quickly it begins reforming, effective plaque control will keep it to a minimum. That's why we encourage brushing your teeth twice a day, plus daily flossing.
What's the first sign of Plaque affecting the gums?
A frequent warning sign is when the edge of the gums next to the teeth, become reddened and inflamed, and bleed when touched. This early stage is known as gingivitis.
What is Calculus (Tartar)?
Calculus is a hardened substance that comes from a combination of minerals in the saliva and from the dead plaque bacterial cells. Together, they precipitate a crusty deposit that, once mineralized, can grow rather quickly. When looked at under a microscope, calculus has all the nooks and crannies of a coral reef, and a similar number of hiding places for bacteria to hide. Left on the teeth long enough, calculus begins to irritate the gums. The gums can swell, become ulcerated and bleed, and eventually get progressively worse... forming pockets.
Can Calculus form under the gums?
Yes. There are two types of calculus. 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 as supragingival calculus, but when present, is a greater concern because it forms within the pockets. This allows the bacteria to congregate in greater numbers.
Can Calculus form at different rates?
Definitely. Some people never form calculus while others form it in varying amounts. Some individuals notice it days after a professional dental 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 it's continued presence can always damage the gums.
How frequently should Plaque and Calculus be removed?
Periodic removal of plaque and calculus is the best way to control periodontal disease. At these times, the dentist/hygienist can examine the periodontal tissues to determine if new pockets have formed, or previously diagnosed pockets have gotten worse. The frequency of these periodontal maintenance treatments is best determined by the dental professional treating you.