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Orthodontics/Receding Gums and Gingivitis

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QUESTION: Hi my name is Erica and I am 21. I never used to floss growing up and I would only brush 2 times a day. However I went to the dentist for the first time in a year and she told me that my gums were really bad and I had a gingivitis. So she did a PSR on which is the quick method of the periodontal exam and all my numbers were code 1's. She scheduled me for a full debridement and told me to floss everyday and brush my teeth times a day and use mouthwash. She said the gingivitis is reversible since I don't have any bone loss. However, that was three months ago. MY gums have healed up competly. and I floss everyday and use mouthwash and also changed to a sonicare brush. However, I feel like i am going crazy I worry that I have periodontal pockets and when I began flossing I noticed that the floss was able to go down into my lower too front teeth. Its feels uncomfortable when I do it as well I am not sure if that's normal?. I worry that my lower gums are receding and I need your help to tell me if you they look like they are receding and how bad do you think it is. Also my teeth have always been sensitive but my lower two front teeth are especially sensitive now and I am worried I going to have bone loss they the recession is extremely bad! My next followup appointment which she said is the examination of my teeth is next week and I am worried. Also do you feel that she should do a full periodontal exam the next time she sees me??Also could tell me if my gums look healthly?

ANSWER:


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Dear Erica,

Your letter is one of the most interesting I have received in a long time. Please allow me to first say that what I write here are only my opinions based on very limited information. My comments should not be viewed as any form of diagnosis, definitive or otherwise,  or any form of  treatment recommendation.  Indeed, in the ultimate analysis all final decisions, particularly clinical ones, should  only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.

Okay… having said  that…  your  questions focused on changes in root length and shape in conjunction with orthodontic treatment..  You  had a number of questions,  at the end of which you wrote:  “. Also do you feel that she should do a full periodontal exam the next time she sees me??   “

Interesting.  So let us parse your letter section by section.

You wrote, “Hi my name is Erica and I am 21. I never used to floss growing up and I would only brush 2 times a day.”

While it is not impossible, most people age 21 do not suffer from profound periodontal problems relative to the far more serious issues frequently found on many older adults. Indeed your diagnosis so far from the doctor is that of “gingivitis”.  Gingivitis is a reversible form of gum disease, and often simple enhanced dental hygiene ( brushing) along with  a mouth rinse such as Listerine to help control plaque,  can perform major improvements. Indeed, the American Dental Association (ADA) has awarded certain mouthwashes a seal of approval for this. Here are two additional resources that you might find helpful:

The American Dental academy of Periodontology website :
http://www.perio.org/sites/default/files/files/parameters.pdf

You Tube Review by Dr. John Burch:
https://www.youtube.com/watch?v=v3aiH0kAmco

Gingivitis is the mildest in a series of gum inflammations and conditions which the lay person often collectively  calls ”gum disease”.  The gingiva is the gum tissue and ‘itis’ the term characterizing an inflammation. It is however, often rather easily reversible, and may not be an issue at this stage to be overly concerned about. By all means don’t ignore it, and do what is necessary to  reverse the condition. The fact that you brush twice a day and floss is commendable. If done more carefully, this  should reverse and address most of the gum areas exhibiting “gingivitis”.

You also said. “  However I went to the dentist for the first time in a year and she told me that my gums were really bad and I had a gingivitis. “

Based on your photos I must say that if you did originally present with strong gingivitis, you  have certainly improved a great deal. The periodontal ‘probings’ which you describe also fail to reveal any deep pockets.  I suppose “bad” is a relative term but if all you manifest is gingivitis, this is the mildest of a range of conditions.  I will defer to the actual doctor  who has personally examined you, but the rhetorical question I pose remains.

You also write, “  I worry that my lower gums are receding and I need your help to tell me if you they look like they are receding and how bad do you think it is. Also my teeth have always been sensitive but my lower two front teeth are especially sensitive now and I am worried I going to have bone loss they the recession is extremely bad! “

I am not able to discern these conditions on the attached images.  Perhaps radiographs reveal bony changes, but that would be inconsistent with the diagnosis which you received, namely having gingivitis. Recall, gingivitis by definition, does not involve any bone loss.  Some gum recession, in the absence of any periodontal conditions, including mild gingivitis, sometimes can be due to harsh,  excessively forceful tooth brushing. In your zeal for perfect dental hygiene you may be brushing your gums too forcefully thereby causing recession like changes.  You already have an electric toothbrush, so brush your teeth more gently.  Also use a tooth paste with a low abrasive index. Your tooth sensitivity could be to lack of sufficient gum coverage on the front of the lower front incisors.    If you have been using tooth whitening products, these too can contribute to hypersensitivity.

Finally you wrote, “  My next follow up appointment which she said is the examination of my teeth is next week and I am worried. Also do you feel that she should do a full periodontal exam the next time she sees me?? Also could tell me if my gums look healthy?  “  

A good current follow up periodontal examination ( with careful probings ) certainly seems harmless. As a young person, it would be rather atypical to see a lot of severe traditional periodontal or gum disease, particularly since your dentist said you simply manifested gingivitis.   I like to believe that most dental care professionals care a great deal for their patients, but sometimes communications break down due to medical terminology, misinterpretations of what was said by doctor as well as patient, and a myriad of other factors.

Erica, from a practical perspective, here are my thoughts;

1) Consider having a complete periodontal examination done, including possibly some intra oral close up pictures of your teeth and gums,

2) Ask the doctor to explain exactly what you have, and if simple improved brushing, flossing, use of an electric toothbrush, and special oral mouth rinses (mouth washes).  Ask if  “Listerine” brand mouth wash or other certain prescription mouth rinses such as one called “Peridex” might be of help.

3) If you still have unresolved questions then you can always consider getting another opinion or ask for a referral to a Periodontist. This is a dentist who is a dental specialist in the treatment of gums, and often sees cases which the general dentist finds to be too complex. In you case it appears to be a relatively simple situation, but a Periodontist could certainly offer a very informed opinion.

Pardon the delay in the question Erica, as I am currently away from my office and in Chicago in the freezing cold.  Please feel free to submit a follow up question.


Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.












---------- FOLLOW-UP ----------

Bone Loss?
Bone Loss?  

bone loss?
bone loss?  
QUESTION: I requested my x rays from my doctor. I wanted you too give me your medical advice on it. I feel that based on some small research the bone levels in these two areas of the teeth don't seem healthly. Could you give me some advice on whether they or don't

Answer
Dear Erica.,

Thank you again for writing. I appreciate the attachment of two very nice radiograph images. before i say anything else, again let me say the normal disclosure, namely that what I write here are only my opinions based on very limited information. My comments should not be viewed as any form of diagnosis, definitive or otherwise,  or any form of  treatment recommendation.  Indeed, in the ultimate analysis all final decisions, particularly clinical ones, should  only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.

Now you again asked about the radiographs. Let me say that I prefer not to really diagnose conditions based on images of radiographs like this sent over the computer. I will say that, without rendering anything that should be deemed as a diagnosis or recommendation, that based on the images submitted, I do not see and frank and profound radiographic evidence of strong periodontal disease, although I obviously  can not entirely rule out the possibility of it being there.

This comment (not a diagnosis) is consistent with the comments rendered by your dentist which, f i remember correctly,  declared that the condition was limited to gingivitis, a reversible and early condition which, by definition,  does NOT involve bone loss.

If you wish to have a truly expert opinion rendered, I would recommend that you please see a Board Certified Periodontist. This is a dental specialist who focuses on gum disease and associated conditions such as bone loss. The American Academy of Periodontology website is

 <url> http://www.perio.org/ </url>

You seem very interested in all this, and I share your concern in trying to get to the bottom of this. I believe I have tried to extensively as possible answer your questions, without unethically giving you an official diagnosis based on limited and indirect clinical records and without the benefit of a direct clinical examination.  Telemedicine and teledentistry is a wonderful thing, but it has its limits.

I hope this has been helpful to you Erica. If all my patients were to be so fortunate as to have radiographs as sound as yours, I would be very happy, and they would be very fortunate. If you continue to have concerns Erica, I am sure a personal consultation and examination by a Periodontist will  provide you with that last level of comfort and assurance.

You question was one of the best I have received over the years. Thank you for submitting it.  

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Paul Supan, DDS, MA, MPH

Expertise

First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.

Experience

Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

Organizations
American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

Publications
Available upon Request.

Education/Credentials
BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

Past/Present Clients
Available upon Request

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