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Dentistry/Gum Disease

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Question
Hi Dr Craig,

My mum went for a general cleaning 1 month ago and was told that she needed "root planing". After taking all the necessary xrays, the dentist told her that she has severe gum problem with multiple deep pocketing (some as deep as 10mm). The dentist then proceed to clean up all the pocketing under injection. Yesterday, she went back to see her dentist for a follow up appointment. She was told that she needed to see a gum specialist for a gum surgery as her pocketings are not healing well. I would like to check is such treatment really needed? My mum is all well and she has no pain on any of her teeth. She has been diligently cleaning her teeth with some special brushes as instructed by her dentist, and do not have any bleeding on brushing. If she is not keen to do the gum surgery, does it help if she continues to see her dentist for the routine cleaning bi-annually?

Many thanks!

Answer
Dear Chloe, many thanks for your question and let me firstly express my respect for you for taking such an interest in mom and her oral health.

Your mom has been diagnosed with periodontal disease, which in brief, is the gradual destruction of the periodontium - the supporting structure of teeth, which includes the periodontal ligament contained within the periodontal space, between the root surface of the tooth and the bone under the gum, the gum, the bony casing of the tooth socket and the cementum of the outer surface of the tooth root.  There are many forms this disease can have with many sub-types, each with their own set of common characteristics such as age of onset, speed of development, aggresivity and prognosis, but the underlying outcome of the disease is the same - the destruction of the supporting framework of the teeth thereby making them more prone to increased mobility, tooth decay and early tooth loss.  Bare in mind that what we are talking about, is usually a process which develops over a period of time.  The exact cause of this disease is not completely understood by clinicians, but it is thought to be of multifactorial origin with the key players being oral hygiene and oral bacteria, diet, physical wellness, emotional stress and an unknown trigger factor which sets the process in motion.

A healthy periodontium measures pockets depths of between 1-3mm, without any bleeding on probing or signs of gum inflammation/infection.  The gum margins are even, light pink in color with good firm texture and slightly "stippled" in textured with no areas of gum recession. As soon as this disease sets in, it starts to degrade to bone around the tooth - in quality and quantity and because the periodontal ligament is attached to the bone, the integrity of this ligament in undermined to the extent that it cannot offer the tooth any support.  What the dentist measures when he does the probing, is the amount of loss loss that has occurred underneath the gum margin, which cannot be seen with the naked eye - which is why it is often only identified some time after its onset, giving it time to carry on with its destructive path. The reason for the bone loss in this disease, is due to the complex bacterial environment of the mouth and of the periodontal pocket and it is the bacterial by-products of their metabolism that cause most of the damage. These bacteria feed on whatever we eat and drink, especially high carbohydrate (white starches) and high sugar food and drinks. The bacteria convert these substances very easily and quickly into acidic compounds which have the ability of eat away at the bone, destroy the periodontal ligament and cause gum infection and discomfort - but not always.

Everyone of us have a unique composition of resident oral bacteria which as essential for our oral health, but in some patients and for the reasons mentioned earlier, one finds an abnormal overgrowth of pathogenic or harmful bacteria at the cost of the non-pathogenic bacteria. Also, the more destruction that occurs and the deeper the pocket becomes, the more pathogenic the bacteria evolve into and the harder it is to bring the situation under manageable control because of accessibility limitations and as this carries on, the tooth becomes weaker and the treatment options available to save this tooth also become less.  The sad thing is that once the bone has been eaten away and the gums have receded, they will never return to their original height again - not without surgical intervention in the form of a bone graft, gum grafting and other augmentation procedures. What must happen, though, is that the condition must be brought under proper control first, before these are considered, so that the grafts which are then done, do not have the same fate of the natural tissues had while the disease was carrying on unmanaged. If this is left untreated, the fate of your moms oral health is almost certain - she will experience early tooth loss and associated loss of function and aesthetics. And she might say that at her age she isn't too concerned about what her smile looks like, but once the tooth loss starts, it often spreads to adjacent teeth and in no time at all, one finds a situation where several teeth are lost which poses a huge strain on the remaining teeth to maintain the function of the ones lost.  And with these remaining teeth being affected by the same disease, they are very often not capable of this task and one often sees sporadic tooth or root fractures, as well as teeth moving out of alignment and drifting into the open spaces left after the worst affected teeth have been lost or extracted. This naturally alters the bite and changes how one use to function, making eating less enjoyable and affecting the quality of ones life. Many patients have also reported changes in sleep pattern as a result, due to an increase in abnormal jaw patterns which develop due to the change in bite.

A pocket depth of 10mm indicates severe bone loss, but whether the condition has been developing slowly over several years or has had an aggressive course over a matter of months, is hard for me to say, but without specialist intervention by a periodontist, your mom will not be able to withstand the onslaught of the ever-growing groups of oral bacteria causing the damage. the aim is to bring the disease under full control and stop it progressing and then consider ways of dealing with the loss of support and/or teeth. In order to do this, a comprehensive and detailed treatment has to be designed with regular monitoring and full cooperation of your mom. Your mom must understand what this disease is, what she must do, what she mustn't do, what the prognosis is and be in full agreement to have this done. It is of course her mouth and her body and she has full control over what happens to it, which is why I have gone into huge depths with you, trying to make you understand the principles of this disease. An educated and informed patient is a huge asset to any practice and perio disease, it applies even more because home care is a vital part of recovery and maintenance. If allowed to slip back to what it was, this disease will continue its destruction and patients must be made aware that what they are instructed to do by their specialist does not only apply while they are being treated - they must ensure a life-long dedication to continuing with maintaining an optimal oral health, above a normal level. This is why regular oral hygienist and dentist appointment in between are also useful and vital for identifying any problem early on and addressing it before the disease has a chance to manifest itself on a larger scale. Successful treatment of periodontal disease is best achieved with a multi-tiered approach which covers all aspects of oral health - teeth and soft tissues.

A final note, don't be lulled into a false sense of security by thinking that because there is no bleeding or gum inflammation, that there is no periodontal disease. There are forms of perio disease where no or little bleeding is noticed due to the change of the blood flow in the tissues caused by the bacteria in the pockets. As I said, the final decision must rest with your mom, but educating her properly about her condition will enable her to make an informed decision which suits her best.  Obviously, leaving the condition as is, is not advisable, given what we now know about the close inter-connection between oral health and general health. I am sure you can appreciate the possibility of this condition having some impact on your moms general health - if not directly, then indirectly as it affects her appetite and level of nutrition, emotional well-being and overall happiness.

I didn't mean for what I wrote to upset you or your mom, but I want to make the severity of this disease very clear and stress that she does not have to go through this alone. There are well trained professional at hand to help, treat and offer assistance and guidance every step of the way - all your mom needs to do, is ask for it and know that what she is doing is the best for her. I wish you and your mom all the very best further and trust her condition will be brought under control in due time. Take care

Kind regards
Dr Craig Peck

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Dr Craig W Peck ( B.Med.Sc., B.Ch.D., Clin. Botox, Cosmet. Derm.)

Expertise

I am a General Dental Practitioner, with special interests in Cosmetic Dentistry & facial aesthetics and Periodontology, placing a strong emphasis on the establishment and maintenance of a healthy periodontium (the support structure of the tooth) before cosmetic options are considered. I uphold all principles of prevention above interventional treatment and try as far as possible, to remain conservative in my approach. I believe in detailed, open and honest patient discussion, establishing what the patients expectations are and what the reality is of achieving this and involving the patient at every level of the treatment. I have strong principles on ethical treatment and appropriate patient management. I have chosen to treat and rehabilitate many nervous and phobic patients, who, for whatever reason, find it impossible to take part in the very important task of even a routine check-up. I will accept questions relating to general and cosmetic dentistry (in conjunction with the use of facial cosmetic procedures) and dental fears/phobias. I will be more than willing to answer any academic questions in dentistry, biology, physiology, psychology and health sciences in general. As most dentists will tell you, there is often not only one way of dealing with a dental issue - so very often, there is no precise right and wrong way of approaching the problem. All clinicians vary when it comes to treatments and what works best in their hands is often the treatment that is advised. Be understanding of this and bear in mind that nothing lasts forever! Patients are happy to accept only a one-years warrantee when buying a new car, but seem to expect that dental work is going to last them their lifetime.

Experience

I have worked for many years in the UK and RSA as a general dental practitioner - within the NHS, private practice and the government dental health services. I am certificated for the administration of Botox and Dermal Fillers for facial lines and wrinkles as I have attended further courses in minimally invasive facial cosmetic procedures. I started seeing an increasing number of patients who presented with severe to moderate dental fears, even with full-blown phobias, so I started with the slow and patient task of tackling this problem and have successfully rehabilitated many patients. The key is good, effective, concise and understandable communication, shifting control from the dentist to the patient in order to slowly, but confidently, regain their trust back in dentistry, thereby giving them the feeling of achievement and this self-empowerment which drives them to the next level of treatment.

Organizations
Academy of General Dentistry. American Dental Education Association. IAPAM (International Association for Physicians in Aesthetic Medicine). Professional Speakers, Writers and Managements Consultants in Dentistry. The British Dental Association. UK Aesthetics Group. ARC - Aesthetic Professionals. Botox. Aesthetics & Beauty. American Association for Dental Research. FDI - World Dental Federation. SOURCE1uk. World Dental Hygiene Forum. ProDentalCPD. Public Health Dentistry. Dentist Network. LinkedIn. Who's Who of South Africa.

Education/Credentials
B.Med.Sc. Degree (Medical Physiology and Medical Virology; Physiology Cum Laude; Stell 1994). B.Ch.D. Degree (Bachelor of Dental Surgery; Clinical Dentistry Cum Laude; Stell 1997). CPR and CPR-Advanced Courses (2000/2001; UK). Clinical Botox (UK, 2001). Cosmetic Dermatology (Botox and Dermal Fillers; RSA 2011).

Awards and Honors
Placed on the Dean's List at University for academic achievement (1994). Highest achievement in the subject Dental Materials. Medal from 3M and the Radiology Association of South Africa for highest achievement in the subject Dental Radiology and Imaging. Medal from The Periodontal Association of South Africa for highest achievement in the subject Periodontology. Highest achievement for Oral Medicine. Highest achievement in Oral Pathology. Received the DASA (Dental Ass. of South Africa) Gold Medal for highest achieving dental student across the 5 1/2 years of the Degree. Passed the subject, Clinical Dentistry with distinction in final year.

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