Your Visit With Us

We take pride in our services, staff, office and are confident you will feel comfortable and safe with us. Your treatment and care is carefully assesed and selected to match your specific needs. Choosing a health care practice is never easy. There are so many issues to consider including the reputation of the practice and the quality of the care to be received as well as issues related to cost, trust and more.

Although no one really likes to go to the doctor or dentist, we strive to make your visits with us as comfortable and as pleasant as possible. We strongly believe that our patients' comfort is an important part of quality dental care. Our mission is to treat every patient in the same manner that we would like to be treated ourselves.

Upon your first visit, a thourough examination of the location, characteristics and severity of your oral condition will be given. Your teeth and gums will be evaluated by clinical and radiographic (x-ray) procedures. Occasionally, additional laboratory or medical tests and consultations will be requested.

Techniques to treat periodontal disease have become highly sophisticated. They may include non-surgical removal of harmful pocket forming bacterial plaque, antibiotic treatment, conventional surgical procedures or regenerative therapy.

All treatment that is recommended will be performed with the greatest attention to detail with minimal discomfort, in a progressive, professional, relaxed and sensitive environment. We will listen to your questions and concerns and help provide solutions leading to your better health. Please don't hesitate to contact us if you have any questions regarding your care. 

WHAT ARE THE PERIODONTAL DISEASES?

Periodontal diseases are infections of the gums, which gradually destroy the support of your natural teeth. The disease can take on different forms. The different types of the disease each require an accurate diagnosis and different treatment approaches.

The forms of the disease include the following:

• Juvenile Periodontitis(children and adults)

• Gingivitis

• Adult Periodontitis

• Rapidly Progressive Periodontitis

• Refractory Periodontitis

Dental plaque (bacteria and their byproducts/toxins) is the primary cause of gum disease in genetically susceptible individuals. Daily brushing and flossing that is effective in removing plaque will prevent most periodontal conditions. 

Healthy Gingiva  The color of the attached and marginal gingivae is generally described as coral pink, but may vary among different persons. In heatlth it is firm and resilient and, with the exception of the movable free margin, tightly bound to the underlying bone.  The surface of the attached gingiva presents a textured surface similar to an orange peel and is referred  to as being stippled.  (Fig. a)

Gingivitis  The mildest form of the diseases, gingivitis causes the gingiva to become red, swell and bleed easily.  There is usually little or no discomfort at this stage.  Gingivitis is reversible with professional treatment and good home oral care. (Fig. b)

Mild Periodontitis   Periodontitis is defined as an inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with pockect formation, recession, or both.  The clinical feature that distinguishes periodontitis from gingivitis is the presence of clinically detectable attachment loss.  This often is accompanied by periodontal pockect formatiom and changes in the density and height of subjacent alveolar bone. It is prevalent in adults but can occur in children.  In slight periodontitis, 1 to 2 mm of clinical attachment loss is present. 

Moderate Periodontitis  In the mid-stages, periodontitis can lead to more bone and tissue destruction.  In many patients, the changes in color, contour and consistency that are frequently associated with gingival inflammation may not be visible on inspection, and inflammation may be detected only as bleeding of the gingiva in response to examination of the periodontal pockect with a periodontal probe.  3 to 4 mm of clinical attachment loss is present. (Fig. c)  

Advanced Periodontitis  The most advanced form of these diseases includes extensive bone and tissue loss.  Teeth often become loose and may have to be extracted.  Gingival bleeding, either spontaneous or in response to probing, is frequent, and inflammation-related exudates of crevicular fluid and suppuration from the pockect also may be found.  Pockect depths are variable, and both horizontal and vertical bone loss can be found.  Attachment loss is equal to or greater than 5 mm. (Fig. d) 

    (a)                                          (b)    

 (c)                                           (d)
 

WHAT ARE THE PERIODONTAL DISEASES?


Why is oral hygiene so important? Adults past the age of 35 lose more teeth due to gum diseases, (Periodontal Disease) as well as from cavities. Three out of four adults are affected at some time in their life with some form of periodontal problem. The best way to prevent cavities and periodontal diseases is when tooth brushing and flossing techniques are effectively performed daily.
Periodontal disease and decay are different diseases and are caused by different types of bacterial plaque. Plaque is a colorless invisible film, which sticks to your teeth and grows above, at and below the gum-line. Plaque consists of the living germs on your teeth. They begin to re-grow and multiply on the tooth within hours after being removed. With thorough and consistent daily plaque removal you can help prevent periodontal disease.

 

If the soft invisible plaque is not carefully and completely removed by daily brushing and flossing, plaque hardens into a rough, porous substance known as calculus (tartar). Tartar is a hard substance that is firmly attached to the tooth and can only be removed with special instruments by the dentist or hygienist. In contrast, plaque is soft and can be removed by you (as long as you can get to it). The limitation of personal plaque removal is about 3mm (or about 1/16th of an inch) under the gum line.

CAUSES OF PERIODONTAL DISEASE

In general, periodontal disease involves the inflammation and destruction of tissues that surround and support the teeth, including the gums (gingiva) and supporting bone and fibers. The inflammation is caused by the bacteria found in plaque which produces toxins or poisons that irritate the gums. Oral health professionals make an important distinction between the two most common forms of periodontal disease: gingivitis and periodontitis. Gingivitis is an inflammation of the gums usually caused by the presence of bacteria in plaque, a sticky film that accumulates on teeth both above and below the gum-line. Gingivitis is reversible and does not cause destruction of the tissues that support the teeth. In contrast, periodontitis involves inflammation of the gums and a destruction of connective tissue and bone that is largely irreversible. If left untreated, gingivitis can lead to periodontitis.
In some, but not all cases of periodontitis, gums may turn red, swell and bleed easily. If this irritation is prolonged, the gums separate from the teeth, causing pockets (deep spaces under the gum line) with accompanying bone destruction around the tooth/teeth. As periodontal diseases progress, the supporting gum and the bone that holds teeth in place continues to dissolve. If left untreated, progressive bone loss leads to tooth loss.


WARNING SIGNS OF PERIODONTAL DISEASE

• Bleeding gums.
• Bad breath.
• Red, swollen, or tender gums.
• Loose teeth.
• Tooth drifting/migration, or a change in the occlusion (bite).
• Pus that appears between the teeth and gums when the gums are compressed.
• A change in the fit of a partial denture.
• A receeding gum line which has pulled away from the teeth.


It is important to note that in many cases none of these warning signs are present. All too often, periodontitis is a silent destroyer of oral health because pain is absent unless an acute infection occurs. I have seen many cases of advanced bone loss with no signs of inflammation and where no pain was present for the patient.

THE GOALS OF PERIODONTAL THERAPY

There are 4 main goals in periodontal therapy. They are as follows:

• Eliminate infection and inflammation.

• Teach the patient self-care skills to maintain health and prevent reoccurrence of  disease.

• Correct any damage to the root, bone, gum and bite and create a maintainable environment.

• Establish an appropriate schedule of professional office maintenance.

HOW DO WE DIAGNOSE PERIODONTAL DISEASE?

Before a diagnosis can be made an examination must first occur. The type of examination will be determined by the nature of the problem. A complete periodontal examination differs in scope from an examination for gum recession or for a broken tooth. A complete periodontal examination may include any or all of the following procedures:

• Oral cancer screening exam of all hard and soft tissues.

• Check of the condition of the saliva.

• Charting of missing, shifted or impacted teeth.

• 6 pocket depth measurements arond each tooth.

• Gum recession measurements on each tooth.

• Recording of the mobility (looseness) on each tooth.

• Evaluation for bone damage between the roots of multi-rooted teeth.

• Assessment of abrasion (wear) on exposed roots.

• Detection and recording of decay and defective or worn restorations (fillings).

• Assessment and recording of sites with infection (pus) or bleeding.

• Occlusal (bite) exam and recording of  function and movement.

• Evaluation of major muscle groups that relate to the occlusion and the jaws.

• Evaluation of the TMJ (jaw joint) function.

• Evaluation for occlusal trauma and tooth wear.

• Measurement of maximum bite opening.

• Photographs in the mouth and of the face.

• Radiographic (X-ray) evaluation.

• Bacteriologic testing.

• Genetic susceptibility testing.

• Obtain diagnostic (study) models.

Once all the data has been collected an accurate diagnosis can be made. With an accurate diagnosis a proper  sequencial treatment plan can be formulated based upon the findings as well as the needs, wants and desires of the patient.

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Brushing and Flossing

SCALING AND ROOT PLANING  

SCALING and ROOT PLANING

The initial therapy for gum disease is called scaling and root planing. This is a non-surgical procedure performed by a  periodontist or a licensed dental hygienist who has been periodontally trained to remove calculus (tartar) below the gum line, clean and smooth the root surface, and allow the healing process to begin. It may involve 2 to 5 appointments. A local anesthetic is used to ensure your comfort since the  gingival tissues are delicate and may be tender. Scaling scrapes off the plaque and calculus and then, root planing smoothes the root. A smooth clean healthy root surface allows the gingiva (gums) to reattach to the teeth. Since root planing is a procedure that removes the irritants, much like removing a splinter from an infected finger, patients generally experience little discomfort afterwards and the gingiva actually feels better.

There are limitations to what scaling and root planing can accomplish. Research has shown that the deeper the pocket the less effective we are at removing the plaque and calculus. Also, posterior (back) teeth are more difficult to reach and are; therefore, more difficult to effectively clean and detoxify. There will always be instances where additional therapy is needed in order to remove the irritants and correct damage to gum and bone. This may include various forms of surgical procedures.

The above photographs show the lingual (inside) view of the lower anterior teeth pretreatment with visible inflammation and heavy calculus deposits and then 8 weeks later with a significant improvement in gingival health after scaling and root planing and good oral hygiene.

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GINGIVAL GRAFTING 

Periodontal plastic surgery is defined as the surgical procedures performed to correct or eliminate anatomic, developmental, or traumatic deformities of the gingiva (gum) or alveolar mucosa (elastic area beneath the gingiva). The ultimate goal of these surgical procedures is the creation and /or widening of attached (firm) gingiva around teeth and dental implants.  Grafts can be used to cover roots, develop gingival tissue where it is absent due to excessive gingival recession or to make prosthetic devices, such as dental implants, look natural. In some cases, they can cover exposed roots to protect them from decay and prepare teeth for orthodontic treatment. This may reduce tooth sensitivity and improve the esthetics of your smile as well.

Subepithelial Connective Tissue Graft 

This procedure is indicated for larger and multiple defects and is especially effective in covering unsightly areas of gingival recession. The gingival tissue is elevated adjacent to the recessive area, donor tissue is obtained internally from the palate, placed on the dended root surface and covered with the elevated gingival  tissue, which in turn provides nurishment  for the healing graft. Notice below how the large area of recession on a maxillary canine is succesfully covered and blends in to esthetically compliment the adjacent tissues.    

Pre-Op

Post-Op

Free Connective Tissue Autograph

Following site preparation adjacent to the areas of gingival recession, donor tissue is obtained  from connective tissue beneath the surface of the palate, (making the healing period more comfortable) and then transferred to the recipient site and secured with sutures.  In the above photographs, notice how unsightly root suraces beneath an existing bridge are covered, thus making the bridge more esthetic, once again.

Free Gingival Autograph 

The free gingival graft is perhaps the most predictable of peiodontal surgical procedures.  With this technique, the initial step is to prepare the recipient site and donor tissue is then obtained from the palate, transferred to the recipient site and sutured. No attempt is made at root coverage, rather the primary objective is to augment or increase the zone of attached gingiva.  To improve comfort on the palatal donor site during the healing period, a plastic device called a surgical stent can be worn for the healing period or the donor tissue can be obtained from either a retromolar area (area behind the molar teeth) or from  edentulous areas (areas where no teeth are present). Notice below how a narrow band of gingival tissue exists presugically in conjunction with a frenum (muscle) pull (Fig.a). The next photograph shows the graft in place before suturing (Fig. b). At approximately 2 months of healing, a new broader band of attached gingiva  with excellent color characteristics is present. (Fig. c).

                                          (a)                                           (b)                                             (c)

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When a tooth is removed the remaining socket can be grafted. Note how the placement of the graft materials in this socket plumps out the ridge.

Careful management of extraction sockets after tooth extraction prevents disfiguring bone loss and leads to a better cosmetic outcome of tooth replacement. Whenever a tooth within the esthetic zone (within the gummy area in the viewable smile line) is to be extracted or in sites which may later receive dental implants, it is advisable to consider socket/ridge preservation bone grafting. This will slow the process of gum and bone collapse. This atrophy occurs after the extraction of teeth, and grafting allows for less shrinkage and a more esthetic tooth replacement (either implant crown or fixed bridge around the replacement teeth).

There are many different reasons why a tooth must be extracted. It is important to consider the various long-term issues that affect the bone long after the tooth is removed. The issues include:

•Preserving the ridge (bone) for esthetics

•Continued function, strength and support of the jaws for complete or partial dentures

•Preserving bone prior to implant placement.

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RIDGE AUGMENTATION

Ridge augmentation corrects depressions in your gum line that are unnatural looking and sometimes make you seem older than you really are. It is also used to prevent the jawbone from collapsing following tooth extraction, and helps to even out replacement teeth that may seem too long compared to adjacent teeth.

If your tooth was removed many years ago, then your bony ridge may be extremely thin and you may not have enough bone left for implant placement. In this case, a bone graft can be placed next to the thin bone and allowed to heal for three to nine months. After the graft has fused to your pre-existing bone, the ridge will be re-entered and the implant placed. Usually bone grafting is a relatively comfortable procedure. Many different bone-grafting materials are available, including your own bone.

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Periodontal  diseases attack the gingiva (gums) and bone supporting the teeth. The tissues separate from the teeth, forming pockets (spaces between the teeth and gums) that become infected. As the disease progresses, the pockets deepen and more gingival tissue and bone are destroyed. Eventually, if too much bone is lost, the teeth will need to be extracted.

A pocket reduction procedure may be recommended because you have pockets that are unhealthy and too deep to clean with daily oral hygiene and a professional maintenance program.

This treatment involves retracting back the gingival tissue, removing diseased tissues and bacteria, and thoroughly cleaning the exposed root surfaces. We may also smooth and recontour the damaged bone to help set up a more optimal healing environment. 

 .

1. Periodontal disease with gingival (gum) changes and involvement (loss) of supporting bone. 

2. An incision in the gingival tissue allows for the gingiva to be retracted. This allows for access to  the diseased site.    

3. Diseased or infected tissue is removed. This includes both the affected gingival tissue and bone.  The bone is contoured so that there is no longer an anatomical defect.

4. The sculptured gingiva (healthy tissue only) is guided into place over the bone and sutured in place.

5. After the tissue has healed (approximately 7 days), the sutures are removed. Proper home care is essential in order to maintain the health of this new tissue. It is the responsibility of the patient to help reduce the recurrence of periodontal disease. Often the removal of the diseased gingival tissue, the tooth may appear longer. "It is better to have the tooth longer, than no longer".

CROWN LENGTHENING

There are situations that require a procedure called  crown extension or lengthening.

When decay or a fracture of tooth structure occurs below the gumline it may be necessary to remove a small amount of bone and gum tissue. This will move the tissue away from the hidden problem area and effectively make the tooth or teeth longer. Now, your dentist can see the problem area, access the fractured or decayed area and properly restore it. Your dentist may ask for this procedure before he or she makes a new crown for your tooth. Sometimes excess tissue is in the way and reshaping the gum and supporting tissues is necessary. Crown extension will allow your restorative dentist adequate room to place a quality final restoration that will not collect plaque, is more maintainable and; therefore, will not promote periodontal disease. The needed space has now been established the supporting tissues and the final position of the restoration.

Another indication for crown lengthening is when the front teeth are too short or of uneven length.

This patient had decay that destroyed the heads of her teeth. There was not enough tooth structure exposed to reliably rebuild the tooth. In order to rebuild these teeth, Crown lengthening surgery was needed.	The gum, and underlying bone was raised (upward) so that more of the roots of the teeth were exposed. A set of temporary crowns was fabricated to fit on the newly exposed tooth roots so that the patient had teeth with which to function. The edges of the temporary crowns were kept shy of the gums, so as not to interfere with their healing.	After healing was complete, the teeth were crowned. What was a devastated (dental) situation, was salvaged,. The teeth were returned to their original function and health. Not too long ago, before these techniques were widely used, these teeth would have been extracted and replaced by a removable denture.

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ARE DENTAL IMPLANTS AN OPTION FOR ME?

If you are considering dental implants, your mouth will be examined thoroughly and your dental and medical history will be reviewed to ensure that dental implants are appropriate for you. Dental x-rays and frequently, panoramic (or complete) x-rays of your jaws will be taken to evaluate your jawbone and to determine if it will accommodate implants. Occasionally, more detailed information is required and can be provided by more specialized digital or CAT scan x-rays. They will help determine if additional tests or procedures are needed to place your implants properly.

WHAT IS A DENTAL IMPLANT?

The best way to describe a dental implant is to compare it to a real tooth. A natural tooth consists of a root and a crown. The part of the tooth that you see and eat with is called the crown. Beneath the crown is the root, which anchors the tooth to the jawbone and extends through the gum tissue. When you lose a tooth, you lose both the root and the crown. To replace a tooth, we first have to replace the root. Essentially, a dental implant is a new root. This titanium root (fixture) is fitted into a socket that we create in your jaw, replacing the lost root of your natural tooth,where it will undergo a process called osseointegration. This means that the bone grows onto the surface of the implant.Sometimes the implants are submerged under the gum during this healing phase. 

Dental implants come in various shapes and sizes and have different types of surfaces. The actual implant selection will depend on a variety of factors related to your specific treatment needs and the most appropriate one(s) will be used. Once an implant has been placed in the jaw, the bone around the implant will need to heal for two to six months, depending upon how hard the bone is. When this initial phase of healing is completed, a support post called an abutment will be placed into the implant itself and then a new crown will be placed on top. If all of your teeth are missing, a variety of treatment options are available to support the replacement teeth.

HOW ARE DENTAL IMPLANTS PLACED?

Usually, the office procedure to place a dental implant takes about an hour to and hour and a half for one implant and no more than two or three hours for multiple implants. The placement process consists of the following steps:

-You will be given prescriptions for your medications such as antibiotics and pain relievers to begin prior  the surgery.

-In most cases a local anesthetic Lidocaine will be used to numb the area.

-You may request oral sedation or intravenous sedation. If sedation is utilized, the local anesthetic will still be administered to numb the areas where the implant/s will be placed.

-After you are comfortable, a small incision is made into the gingival (gum tissue), revealing the bone into which the implant will be placed.

-Using special instruments, a socket is carefully created. The titanium implant (post) is then inserted into the socket. Finally, if necessary, sutures will be used. Sometimes the implants are submerged under the gum during this healing phase. Sometimes they are left exposed flush with the gum. If they are submerged, then a second procedure will be needed to expose the implant after it has integrated with the. If the implant was not submerged, the prosthetic phase can begin once osseointegration is complete.

  IMPLANT PLACEMENT

1. Bone is exposed through small incision.	2. Numbed area is prepared for insertion of post.	3. Implant post is gently inserted.	4. Post in its final position.	5. Sutures are applied to aid healing.	6. Osseo-integration process begins.

After the implant is placed, the area will need to sit undisturbed for as short as three and as long as six months. The exact amount of time will be determined by a variety of factors. Follow-up care (one to six appointments) is usually needed to ensure that your mouth is healing well and to determine when you are ready for the restorative phase of your treatment.

  IMPLANT UNCOVERING

If the implants were submerged at the time of placement, a second procedure will be needed to expose the implants. This is minor procedure in which a small incision is made in the gum in the area of the dental implants. A titanium healing abutment is placed on top of the implant and the gum is sutured around it. The prosthetic phase can usually begin in 2-3 weeks time.

  PROSTHETIC PHASE

Your dentist will make the replacement teeth that are held in place by the dental implants. This will take varying lengths of time depending on the type of restoration planned. Your dentist will discuss this with you before treatment begins. Your implant restoration may be cemented onto the implants, or it may be screwed into place. Implants can be used to replace a single tooth, a segment of missing teeth, or a whole arch of missing teeth. Implants can also be used to secure a loose denture.

Most patients experience minimal disruption to their daily lives when undergoing dental implant treatment. Most people never have to walk around without teeth during the entire process. This will be discussed with you before any treatment takes place. 

The dental work required to complete your treatment may seem complex.  It is; however, considered more comfortable and pleasant than some forms of conventional dental care. Frequently, many aspects of the the treatment can be done without using even local anesthesia.

IMPLANT MAINTENANCE

The daily care of dental implants is very similar to the care of natural teeth. Restored dental implants should be kept clean and plaque free twice a day using a brush and floss. Cleaning is especially important after meals. This is accomplished by gently brushing, giving special attention to all sides of the implant. Oral hygiene aids may include:

• Small, soft, manual toothbrush or an electric brush

• Low-abrasive, tartar-control toothpaste

• Dental floss for cleaning around the abutments

Other supplies that may be recommended by the doctor can include:

• Antimicrobial mouth rinses

• Inter-dental brushes or other aids for removing plaque between the teeth on either side of the implant(s)

• Disclosing tablets to stain the locations of plaque accumulation 

You must be committed not only to daily performance of dental hygiene at home, but to regular visits to your dentist and periodontist. It is recommended that you see them every 3–6 months for a professional exam and cleaning. The implant(s) should be examined with an x-ray annually. We offer you a no cost, annual implant check-up and x-ray for the first three years after implant placement as part of our implant care program.

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What are dental implants and what can they do for me? 

A dental implant is an artificial tooth root placed into your jaw to hold a replacement tooth, bridge or removable appiance in place.  While high-tech in nature, dental implants are actually more tooth-saving than traditional bridgework, since implants do not rely on neighboring teeth for support. They are so natural-looking and feeling, you may forget you ever lost a tooth.

Advantages of dental implants over dentures or bridges.

In many ways that you look at it, dental implants are a better solution to the problem of missing teeth.

Esthetic  Dental implants look and feel like your own teeth.  Since dental implants integrate into the structure of your bone, they prevent the bone loss and gingival recession tah often accompany bridework and dentures.  no one will ever know that you have a replacement tooth.

Tooth-saving  Dental implants do not sacrifice the quality of your adjacent teeth like a bridge does because neighboring teeth are nott alteredto support the implant.  More of your own teeth are left untouched, a significant long-term benefit to your oral health.

Confidence  Dental implants will allow you to once again speak and eat with comfort and confidence.  They are secure and offer freedom from the irksome clicks and wobbles of dentures.  They will allow you to say goodbye to worries about misplaced dentures and messy pastes and glues. 

Reliable  The success rate of dental implants is highly predictable.  They are considered an excellent option for tooth replacement.

Am I a candidate for dental implants?

The ideal candidate is in good general and oral health. Adequate bone in your jaw is needed to support the implant, and the best candidates have healthy gum tissoes that are free of active periodontal disease.  Dental implants are intimately connected withthe gum tissues and underlying bone in the mouth.  Since periodontists are the dental experts who specialize in precisely thes areas, they are ideal members of your dental implant team.  Your dentist and periodontist will work together as a team to make your implants successful.       

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Here you can see an x-ray of a pneumatized or very large sinus again (outlined in red). The top of the upper jaw ridge is outlined in blue. Notice that there is virtually no room between the bottom of the sinus and the top of the ridge to place any implants. This patient will need a sinus augmentation.

A key to implant success is the quantity and quality of the bone where the implant is to be placed.

The upper back jaw has traditionally been one of the most difficult areas to successfully place dental implants due to insufficient bone quantity and quality and the close proximity to the maxillary sinus.  If you have lost bone in that area due to reasons such as periodontal disease or tooth loss, you may be left without enough bone to place implants.

Sinus augmentation can help correct this problem by raising the sinus floor and developing bone for the placement of dental implants.  Several techniques can be used to raise the sinus and allow for new bone to form.  In one common technique, an incision is made to expose the bone, then a small circle is cut into the bone.  This bony piece is lifted into the sinus cavity, much like a trap door, and the space underneath is filled with bone graft material.  Your periodontist can explain your options for graft materials, which can regenerate lost bone and tissue.

Finally, the incision is closed and healing is allowed to take place.  Depending on your individual needs, the bone usually will be allowed to develop for about 8 to 12 months before implants can be placed.  After the implants are placed, an additional healing period is required.  In some cases, the implant can be placed at the same time that the sinus is augmented. 

Sinus augmentation has been shown to greatly increase your chances for successful implants that can last for years to come. Most patients experience minimal discomfort during this procedure.

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Frenum pretreatment	Frenum after treatment

Frenae (plural of frenum) are generally minor strands or bands of muscle attaching the lips, cheeks, and tongue to the bone in the mouth. Because no significant functional problems are encountered when a frenectomy is completed, there is a minimal role in the function of the tongue or muscles of facial expression. Individual needs or problems may dictate when a frenectomy is preformed. For the upper front frenum, a frenectomy is often postponed until the permanent lateral incisors and permanent canines erupt (permanent canines usually erupt about 11-13 years old). This recommendation is based on the fact that when the laterals and canines erupt, they will generally close the early diastema (space) between the permanent central incisors. If a frenum is large it may be done sooner and as early as 7 or 8 years old. If the diastema is not closed by normal eruption of the upper anterior permanent teeth, a frenectomy may be helpful, although orthodontics may also be necessary. Exceptions to postponing the frenectomy would be evidence on a radiograph of a notching in the bone between the central incisors or evidence of recession on the adjacent teeth. Many times an untreated frenum pull will cause gum recession to occur. If recession has already occurred a gum graft may also be necessary. 

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The most frequently encountered post-orthodontic problem is the retention of re-established tooth position. Relapse (drifting of the tooth back to it’s position prior to orthodontic correction) may occur anywhere, but it is often associated with teeth that have undergone rotation (twisting) as part of the orthodontic therapy. A fiberotomy involves the detachment of the fibers that attach the tooth to the bone via the gum. The fibers act like rubber bands and releasing the pressure between the fibers and the tooth reduces the forces that want to pull the tooth back to its original position. It is performed near the completion of the orthodontics and is shown to be effective in preventing the relapse of teeth.

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After Dr. Urling has completed the active phase of periodontal treatment, your periodontal disease will be under control. He will provide you with a personalized maintenance program of care to keep your gums healthy.

Maintenance therapy is an ongoing program designed to prevent disease in the gum tissues and bone supporting your teeth. Remember that periodontal disease is treatable and maintainable but is not "curable". Adherence to a program of conscientious home oral care and regularly scheduled maintenance therapy visits with your dentist and Dr. Urling will give you an excellent chance of keeping your teeth for your lifetime.

Why is supportive periodontal care important?

As you have learned, you are susceptible to gum disease. And, you have probably learned, too, that the main cause of gum disease is bacterial plaque, a sticky, colorless film that constantly forms on your teeth. The bacteria in this plaque produce toxins, or poisons, which constantly attack your gums and teeth. Unless plaque is removed, it hardens into a rough, porous deposit called calculus, or tartar. Daily brushing and flossing will help to minimize the formation of calculus, but it won't completely prevent it. No matter how careful you are in cleaning your teeth and gums, bacterial plaque can cause a recurrence of gum disease from two to four months after your last professional cleaning. Therefore, a dental professional must check for hidden problems and remove the hardened plaque at time intervals appropriate for you so that your teeth and gums stay healthy.

Who should perform maintenance therapy?

The answer depends on you and the severity of your gum disease before treatment. Generally, the more severe your periodontal disease is initially, the more often Dr. Urling needs to oversee your care. Together, you, your general dentist and Dr. Urling will work out the most effective schedule for your supportive periodontal care.

Your maintenance visit may include:

• Discussions of any changes in your health history.
  
• Examination of your mouth tissues for abnormal changes.
  
• Measurement of the depth of pockets around your teeth and in between the roots.
  
• An updated bleeding index.
  
• Assessment of your oral hygiene habits and re-instruction as needed.
  
• Removal of bacterial plaque and tartar and root smoothing.
  
• X-ray film studies to evaluate your teeth and the bone supporting your teeth as needed.
  
• Examination of your teeth for decay and other dental problems.
  
• Checkup on the way your teeth fit together when you bite.
  
• Application or prescription of medications to reduce tooth sensitivity or other problems you may have.

How often should you have maintenance visits?

Your periodontal condition is the deciding factor. The interval between your maintenance visits might be as often as every few weeks or as frequent as every six months. Everyone's situation is different. The frequency of your maintenance visits will be influenced by:

• The type of periodontal disease you have.
  
• The type of periodontal treatment you had.
  
• Your response to treatment.
  
• Your rate of plaque growth.
  
• Your personal commitment to, and effectiveness of, good oral care at home.
  

What is the relationship between my dentist and Dr. Urling?

Your dentist and Dr. Urling work together as a team to provide you with the best possible care. They combine their experience to formulate the best maintenance plan for you. They keep each other informed about your progress. Although Dr. Urling may see you periodically for maintenance therapy, you will need to see your general dentist as well. Appointments for periodontal maintenance do not replace regular dental checkups. If Dr. Urling detects tooth decay during a maintenance visit, he will refer you to your general dentist for treatment. Your general dentist is primarily responsible for your overall dental health, including such dental needs as filling new or recurrent cavities or making changes in fillings, crowns or bridges.

Are supportive periodontal care visits worth the cost?

Without question! By treating disease in the early stages, you save dollars-and discomfort-in the long run. Maintenance visits help to protect your periodontal health and prevent future dental problems. They are a wise investment in your dental health. If you have dental insurance, it may pay for just one dental examination every six months. Because you are susceptible to periodontal disease, you may need to be seen more often. So, you may need to personally pay for some of your maintenance visits.

Will you be protected from unnecessary x-rays?

Dr. Urling takes x-ray films, or radiographs, only when essential to diagnose your periodontal problems. Generally, Dr. Urling or your general dentist takes a full set of x-ray films every two to four years unless a patient's disease requires more frequent x-ray studies. X-ray studies are important to disease diagnosis because they allow Dr. Urling and your dentist to see conditions that are not evident on a visual examination, thereby helping him detect periodontal disease in its early stages. When films are taken at our office, our office shares these x-ray series with your general dentist to minimize your exposure to x-rays.  We will not take bitewing x-rays to detect decay. This will always be done by your general dentist. Dr. Urling will make this determination when requesting diagnostic films. 

 
To prevent periodontal disease, the major cause of tooth loss in adults, and keep your natural teeth for your lifetime; carefully and conscientiously follow the guidelines of the maintenance program that our office recommends. Protecting your periodontal health through preventive maintenance has great benefits for you. You will be able to chew with more comfort, and you will be able to smile and speak with greater confidence. You will be able to keep dental costs down by preventing future problems. Your commitment to maintenance therapy is your commitment to your better oral health.

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Many years ago the lack of bone posed a considerable problem and sometimes implant placement was impossible because of that. Today, however, we have the ability to grow bone where needed. This not only gives us the opportunity to place implants of proper length and width (and for Rootform Implants we always try to go for as long and wide as possible), it also gives us a chance to restore the esthetic appearance and functionality better.

B E F O R E	A F T E R
BONE GRAFTS
Pre-Op	After Grafts

BONE GRAFTS
Pre-Op	After Grafts

CROWN LENGTHENING
Problem: Tooth fractured below gum and bone margin	After Crown Lengthening

Problem: "Gummy smile" teeth appear short

Estheic Crown Lengthening with minor gum tissue surgery

Gingival Augmentation Procedures
Problem: Mucogingival Defect	Gingival (gum) Graft
Problem: Gingival (gum) recession with exposed root surface	Connective Tissue Graft

(courtesy of Dr. Cary Shapoff)
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These suggestions have been prepared for us with the help of a nutritionist. It is not necessary to follow these menus strictly, however, we feel it is a useful guide to nutrition following periodontal and oral surgery.

If you have great difficulty chewing, we would also suggest the use of baby foods, yogurt or foods put through a high-speed blender or food processor.

MENU PLANS

BREAKFAST	SAMPLE 1	SAMPLE 2	SAMPLE 3	SAMPLE 4
Nectar * Cereal Egg Soft Bread Butter or Margarine Honey Beverage	Peach Nectar Buttered Grits Poached Egg Bread-whole wheat Butter or Margarine Honey Beverage	Apricot Nectar Buttered Grits Poached Egg Bread- whole wheat Butter or Margarine Honey Beverage	Apple Juice Oatmeal Soft Boiled Egg Bread- whole wheat Butter or Margarine Honey Beverage	Prune Juice Cream of Wheat Fried Egg Bread-whole wheat Butter or Margarine Honey Beverage
LUNCH	SAMPLE 1	SAMPLE 2	SAMPLE 3	SAMPLE 4
Cream Soup Crackers Bland Meat (Ground) Soft Side Dish Cooked Vegetables Soft Desert Soft Bread or Roll Butter or Margarine Beverage	Cream of Pea Soup Crackers Roast Turkey (Ground) Mashed Potatoes Corn Lime Gelatin Soft Bread or Roll Butter or Margarine Beverage	Cream of Turkey Soup Crackers Tuna Rice Peas Crushed Banana Soft Bread or Roll Butter or Margarine Beverage	Cream of Vegetable Soup Crackers Baked Veal (Ground) Baked Potato Green Beans Cottage Cheese w/ Fruit Soft Bread or Roll Butter or Margarine Beverage	Cream of Mushroom Soup Crackers Chicken (Ground) Boiled Noodles Squash Ice-Cream Soft Bread or Roll Butter or Margarine Beverage
DINNER	SAMPLE 1	SAMPLE 2	SAMPLE 3	SAMPLE 4
Bland Meat (Ground) Soft Side Dish Cooked Vegetable Soft Desert Soft Bread or Roll Butter or Margarine Beverage	Baked Fish Parsleyed Potatoes Broccoli Lemon Sherbet Soft Bread or Roll Butter or Margarine Beverage	Tenderloin (Ground) Mashed Potatoes Cauliflower Strawberry Gelatin Soft Bread or Roll Butter or Margarine Beverage	Beef Stew Rice Carrots Tapioca Soft Bread or Roll Butter or Margarine Beverage	Pork (Ground) Sweet Potato Green Beans Apple Sauce Soft Bread or Roll Butter or Margarine Beverage

Citrus juices, because of their high acid content, may cause pain to the surgical site, and should be avoided for the first few days.

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ORAL PATHOLOGY

The inside of the mouth is normally lined with a special type of skin (mucosa) that is smooth and coral pink in color. Any alteration in this appearance could be a warning sign for a pathological process. The most serious of these is oral cancer. The following can be signs of the beginning of a pathologic process or cancerous growth:

 
Reddish patches (erythroplasia) or whitish patches (leukoplakia) in the mouth

A sore that fails to heal and bleeds easily

A lump or thickening on the skin lining the inside of the mouth

Chronic sore throat or hoarseness

Difficulty in chewing or swallowing

These changes can be detected on the lips, cheeks, palate, and gum tissue around the teeth, tongue, face, and/or neck. Pain does not always occur with pathology and, curiously, is not often associated with oral cancer. However, any patient with facial and/or oral pain without an obvious cause or reason may also be at risk for oral cancer.

We would recommend performing an oral cancer self-examination monthly, especially if you smoke.  Please remember that your mouth is one of your body's most important warning systems. Do not ignore suspicious lumps or sores, please contact us so we may help.

If you feel that you or someone you know, have any of the symptoms that have been discussed or if you have any questions or concerns, please do not hesitate to contact our office so we may be of some assistance to you.

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These procedures are a predictable way to cover unsightly, sensitive or exposed root surfaces and to prevent future gum recession. Other procedures remove excessive tissue to improve your gums architecture and aesthetic appearance. If you are unhappy with the appearance of long and/or short unsightly teeth this can be greatly improved by a combination of periodontal procedures by Dr. Urling and cosmetic dentistry by your dentist.

Susan presented to the office unhappy with her gummy smile and the look of her teeth. She reported that every time she brushed her teeth there was profuse bleeding. You can see the inflamed tissues and the excessive amount of gum tissue in this first picture. Her treatment plan included crown extension surgery and porcelain crowns and veneers. This photo was taken several weeks after the tooth extension procedure. This is the final photo showing her smile after all the work has been completed. Susan is thrilled with the result and her gums are now healthy and no longer bleed.

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Osteoporosis  

Osteoporosis is a medical condition in which bones are thin and weakened. The first sign of osteoporosis may be when a bone breaks. Risk factors that a person can change include diet, inactivity, smoking, use of alcoholic beverages (beer, wine, whiskey, etc.), hormone levels, and being underweight. Increasing calcium and vitamin D in the diet, exercising, limiting alcohol use, Quitting smoking, and certain medications may help prevent osteoporosis.

Researchers have suggested that a link between osteoporosis and bone loss in the jaw. Studies suggest that osteoporosis may lead to tooth loss because the density of the bone that supports the teeth may be decreased, which means the teeth no longer have a solid foundation. However, hormone replacement therapy may offer some protection.

A study published in the August 1999 Journal of Periodontology concludes that estrogen supplementation in women within five years of menopause slows the progression of periodontal disease. Researchers have suspected that estrogen deficiency and osteopenia/osteoporosis speed the progression of oral bone loss following menopause, which could lead to tooth loss. The study concluded that estrogen supplementation may lower gingival inflammation and the rate of attachment loss (destruction of the fibers and bone that support the teeth) in women with signs of osteoporosis, thus helping to protect the teeth.

Consider the following statistics:

• The early years following menopause result in annual loss of bone mass between 3%-5%.
  
• 28 million Americans have low bone mass.
  
• The risk of a woman developing a hip fracture is equal to a woman’s combined risk of developing breast, uterine and ovarian cancer.
  
• 1.5 million fractures of hip, vertebrae and wrist occur annually
  
• After age 50 the number of women with low bone mass increases sharply to include more than half the women by age 70.
  
• Today’s medications cannot rebuild bone mass that has been lost. They can only strengthen the remaining bone. “When it’s gone…it’s gone!.”
  

Prevalence of Low Bone Mass and Osteoporosis Affects Significant Percentage of Men and Women in U.S. 50 and Older (February 21, 2002) Osteoporosis and low bone mass are a major public health threat for approximately 55 percent of the U.S. population aged 50 and older, according to new figures released today by the National Osteoporosis Foundation (NOF). Details are profiled in a new NOF report: America's Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. The report, based on 2000 census figures, provides estimates of the prevalence of osteoporosis and low bone mass for the years 2002, 2010 and 2020, broken out by state, Congressional district and the top 25 metropolitan areas.The total number of people aged 50 and older estimated to be at risk for osteoporosis and low bone mass is 44 million in 2002. The estimated prevalence rate of osteoporosis and low bone mass among men is 14 million. For women, the estimated prevalence rate for osteoporosis and low bone mass is 30 million."This prevalence report signals that this is a public health issue of major proportions," says C. Conrad Johnston, Jr., MD, president of NOF.
"Additionally, the current estimated price tag for America in direct medical costs for treating fractures resulting from osteoporosis is $17 billion annually. These costs will surge if people do not take steps today to build
stronger and healthier bones," Johnston adds."Bone health must be considered a top priority for all Americans. The report underscores the importance of focused efforts on bone health, as well as the prevention, diagnosis and treatment of osteoporosis. Obviously, an overriding goal is finding a cure for the disease," says Judith Cranford, acting executive director of NOF.To view the executive summary of the report on-line, go to www.nof.org/advocacy/prevalence