What is the treatment for generalized recession?..i have heard about party gums..can somebody elaborate on this..

A thin ,flexible silicone strip simulating gum tissue is placed over the gums to block out the black triangles and restore smile.

free gingival graft

A free gingival graft is a dental procedure where a layer of tissue is removed from the palate of the patient's mouth and then relocated to the site of gum recession. It is stitched into place and will serve to protect the exposed root as living tissue. The donor site will heal without damage. This procedure is often used to increase the thickness of very thin gum tissue.
Disadvantage:-
Excessive bleeding from the palatal donor site does occur.
It fails also in some patients.

There are 2 varieties in this procedure..u either take the entire flap or u take only the connective tissue and leave the epithelium on the palatal bone to cover the open defect..obviously the latter one is the better out of the two..

 Cervical lesions, which have been found to be present in 85% of the population, represent a major problem for dentists to restore with composite resin materials due to the varying adhesive properties of the tooth structure, the biomechanical aspects of the cervical area, and difficulties in accessing and isolating the area to be restored.^1,2 The incidence also may be higher in individuals retaining their permanent teeth, as the aging population is increasing.1 Additionally, at a time when people are maintaining their natural teeth longer, the likelihood of developing caries in Class V areas also increases.³

When Class V cervical lesions are noncarious in nature, they are classified as abfractions, with an appearance characterized by a loss of hard dental structure near the cement-enamel junction. The lesions' shape may resemble a wedge with an inward-pointing apex.1 The cause of abfractions is thought to be occlusal stress that produces cervical cracks and, subsequently, predisposes the tooth surface to the effects of erosion and abrasion.4 Although critical literature reviews suggest that abfraction is a hypothetical component of cervical wear, it is important to determine causative factors for noncarious lesions, as treatments range from eliminating the aggravating agents to specific restorative procedures.^4,5

Gingival Recession
Typically involving at least one tooth surface, gingival recession can lead to root surface exposure at the gingival margin.⁶ This not only causes aesthetic impairment, but the fear of tooth loss, an increased susceptibility to root caries, and hypersensitivity of the dentin.6 As gingival recession is the displacement of the soft tissue margin, tooth malpositions, high muscle attachment, frenal pull, and occlusal trauma can create the conditions necessary to cause recession and root exposure.⁷ Another less obvious cause, oral jewelry, also has been linked to gingival recession.⁸ Studies have shown that piercings in the lip and tongue lead to localized gingival recession as an adverse consequence.8 In one study, individuals with tongue piercings presented an 11-times greater risk of developing gingival recession over the control group

 Gingival Recession Treatment

Traditionally, gingival recession has been treated with laser therapy, autogenous tissue grafting, flap designs, orthodontics, and guided tissue restoration.10 These types of treatments are not only costly and time consuming, but also may require long, painful recovery for patients.¹⁰ 

Laser treatment has been considered by some as the optimal option for correcting and halting gingival recession.¹¹ When gingival recession is observed in a patient with sensitivity caused by an exposed root, lasers have been used to remove the smear layer from the root surface to expose collagen fibers, which is believed to contribute to improved healing.12 Clinical studies, however, have been unable to find any significant improvements in recession and sensitivity from this type of treatment.¹² 

Tissue grafting is also considered one of the few viable treatment options to correct gingival recession.¹³ With the advent of tissue grafting techniques, periodontists have been able to correct gingival recession by grafting a patient's own oral and mucosal tissues.¹⁴ This type of procedure, however, requires surgery and can be very costly. Whether using an envelope or tunnel technique, the tissue is grafted around the area of gingival recession.^15,16 It is then sutured into place and allowed to heal.¹⁷ A protective mouthpiece is often required to allow the graft site to heal properly.17 Grafting does allow for significant increases in gingival and root coverage and has proven to be very effective as a treatment option.

Another technique for correcting gingival recession is a minimally invasive flap design procedure intended for periodontally involved restorations.¹⁸ It involves cutting the tissue on 3 sides, leaving the base attached, to open the gingival tissue to allow for cleaning of the roots.¹⁸ This procedure often works with guided-tissue regeneration to allow coverage of the root and reduce gingival recession.18 Although this treatment option demonstrates good results, it still involves a surgical procedure and recovery time for the patient.¹⁸

Orthodontics may also be used to correct gingival recession, as conditions such as cross-bites and occlusion are seen as causes.¹⁹ By using orthodontic appliances to correct the abnormalities in bite and occlusion, studies have shown that gingival recession can be stopped and, many times, reversed.¹⁹ These results, however, are typically created through multidisciplinary approaches and not merely with orthodontic treatment and appliances.19 New techniques and materials, which show promising results for root coverage, have proven effective at covering, and in some cases stopping, gingival recession.

 Noncarious Class V Lesions

As the health and appearance of gingival tissue is important to the aesthetics of a smile, many with noncarious Class V lesions and/or exposed tooth structure from gingival recession wish to have their conditions treated without the cost or inconvenience of invasive methods.²⁰ Used to treat noncarious Class V legions, glass ionomer cements, compomers, and composite resins work alone or in combination to correct the aesthetic issues and prevent further damage.¹ When unaesthetic Class V lesions display caries, a combination of glass ionomer materials for the internal aspects of the restoration and a resin-based composite material for the surface has been advocated.3 This treatment method is believed to provide aesthetic results while increasing the potential for caries reduction.³

The physical properties of resin-based composites allow a bond to tooth structure, with highly aesthetic results, so many practitioners feel that they are the best materials to use when restoring cervical defects.⁵ In a recent study, resin composite restorations that were placed to treat noncarious cervical lesions exhibited no secondary caries and far less deficiencies in marginal adaptation than compomer restorations after 3 years.²¹ There are, however, some challenges in using resin-based composites for Class V lesions.²

When placing resin-based composite restorations in the aesthetic zone, it is good to have an understanding of the composites being utilized, especially with regard to their respective optical and physical characteristics.^22,23 When used and placed properly, the polychromatic effects seen in natural teeth can be replicated.^22,23 More importantly, producing outstanding composite resin restorations is achieved thorough comprehension of natural tooth morphology and how each component of tooth structure affects aesthetics.^24,25



Resin-Based Composites and Gingival Health

In past studies, resin-based composites showed promising results for treating Class V lesions and masking the effects of gingival recession.²⁶ Through observations of composites, it was found that they do not adversely affect gingival health, and that there is typically less inflammatory response to well-finished and contoured composite resins than carious lesions that are left untreated.²⁶Another study, comparing plaque buildup around newer composite resins and conventional composites, found that there was no significant difference in plaque formation of the 2 materials.²⁷ 

Unfortunately, when composite resins are applied to teeth presenting with gingival recession, the resulting tooth-colored restorations tend to make the teeth appear very long, leading to an unaesthetic appearance.²⁷ To correct this issue, the need for resins that are gingival-colored has increased.²⁷ Manufacturers have met this demand, creating products that demonstrate the aesthetics of natural gingival tissue.²⁷ Aside from the aesthetic value of these new materials, the composites also allow for minimally invasive procedures to cover the roots and exposed tooth structure caused by the gingival recession.²⁷ 

These new resin-based composites correct the aesthetic deficits of gingival recession by framing the tooth or teeth with material in a similar pink color to the gingival tissue.²⁰ These gingival-colored composites tend to demonstrate greater color stability and resistance to wear.20 When used in collaboration with the new generation of bonding agents, which enable bonding to metal, porcelain, enamel, and dentin, gingival-colored composites have been proven to enhance the smiles of patients with gingival recession.²⁰ More importantly, this treatment option provides a clinical solution for patients that is aesthetic, economical, and practical.²⁷ 



Aesthetic Gingival Composite Resins

An aesthetic gingiva-shaded light-cured composite resin (Amaris Gingiva [VOCO America]) was recently introduced, providing practitioners with the option of correcting gingival recession with a minimally invasive and less costly procedure. This pink-colored composite (available in one translucent gingival color and 3 pink flowable opaquers that can be mixed together to better match an individual's gingival shade) was specifically developed for indications in the cervical area, including composite restorations in gingival colors, V-shaped defects, exposed cervical areas, aesthetic corrections of the gingiva area, primary splinting, and the correction of red/white aesthetics. This restorative material also gives the clinician the ability to mask exposed crown margins to improve aesthetics and patient satisfaction. 

 A study that investigated the impact on treatment outcome after 12 months of different subgingival irrigation solutions during scaling and root planing (SRP) was recently published in the Journal of Periodontology by Dr. Carlos Krück et al. The randomized trial involved 51 adult volunteers with generalized chronic periodontitis who were treated by full-mouth SRP using the following subgingival irrigants during SRP: 0.9% sodium chloride, 0.12% chlorhexidine digluconate, or 7.5% povidone-iodine. Probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP) were recorded prior to SRP, after 3 months, and after 12 months. Subgingival plaque samples were analyzed for Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola. The study found that PD, CAL, and BOP were significantly improved in all groups after 12 months (P < .001 to P = .044). No significant differences were seen between the groups for all sites and sites with 4 to 6 mm PD at the baseline. The povidone-iodine group had the highest clinical improvements. The counts of A actinomycetemcomitans and P gingivalis were significantly reduced after 12 months (P = .045, P = .002) using povidone-iodine. Significant differences between the groups were seen after 3 months for A actinomycetemcomitans and P gingivalis, and after 12 months for T forsythia. The study concludes that no differences were seen between the groups in the clinical results after 12 months, although regarding the microbiological results, a slight benefit seems to derive from the use of povidone-iodine.

 Sometimes a particular case comes along that appears, at first, to be overwhelming. This case fits that description (Figures 1 to 3). However, when this patient e-mailed my office and inquired about the possibility of flying across the country to have me treat him, I had fortunately done many cases involving hundreds of teeth using the matrix system that I developed to treat dentitions afflicted with black triangles, albeit none of this magnitude. I felt absolutely confident that we could achieve a good outcome. The trick was to disassemble the case into bite-sized pieces. 

This case presents many excellent questions and the additional challenge of severe facial abrasions. I will first review the background of black triangles and of lower incisor complications and then proceed with the presentation of the clinical procedures used to treat this particular patient.

BLACK TRIANGLES: PREVALENCE AND PATIENT ATTITUDES
One third of adults have unaesthetic black triangles, which are more appropriately referred to as open gingival embrasures.¹Besides being unsightly and prematurely aging the smile, black triangles are prone to accumulate food debris and excessive plaque.² A recent study of patient attitudes found patient dissatisfaction with black triangles to rank quite highly among aesthetic defect, ranking third following carious lesions and dark crown margins.³ If you go online and search "dental black triangles," you will be able to view hundreds of patient black triangle questions and patient complaints/lawsuits resulting from adult orthodontic cases and postperiodontal therapy papilla loss. This clinical and aesthetic dilemma demands more attention from our profession. The caveat is that, until now, there has been no disciplined minimally invasive approach for treatment. Today, instead of improvising and struggling, I have developed a specific predictable protocol to treat this problem.

LOWER INCISOR AESTHETICS
The aesthetics of the lower teeth are often overlooked or simply ignored by many dentists. Recently a fellow passenger seated next to me on a flight was intrigued by the photos that were on my laptop. He asked, "Why do dentists only seem to treat the upper teeth when the lower teeth look all jacked up? Do they think no one notices? It looks ridiculous to have perfect top teeth and ugly bottom teeth!" In addition, as we age, the lower incisors become more visible as the facial muscles lose their tension on the lower lip.

LOWER INCISOR CHALLENGES AND ETHICS
Lower incisors present their own unique restorative challenges. The incisal edge is broad and thin mesiodistally. The root, in contrast, is very broad buccolingually. Imagine a butter knife that has been permanently twisted at 90° in the middle of the blade. This anatomic curiosity creates demanding draw/path of insertion issues for a porcelain laminate or full-crown preparation. A lower incisor with significant recession leads to a mutilatory tooth preparation for porcelain. When I had an opportunity to show this case to the top ceramists in Toronto, Ontario and Seattle, Wash, their answer was refreshingly candid: "Dr. Clark, to treat this case properly with porcelain laminates would require you to mutilate these teeth."

Figure 1. Preoperative view of a black triangle case. Note the pursing of lips and forced smile of a patient who is embarrassed of the aesthetics of the lower teeth.	Figure 2. The receded papilla height of the anterior teeth was not significantly lower than that of the posterior teeth, ruling out a surgical approach.

Figure 3. This view demonstrates the unique "twisted butter knife" anatomy of the lower incisor tooth.

Figure 4. High magnification (8x) of the cementoenamel junction area of the tooth. This area is virtually impossible to clean with a prophy cup and scaler, and virtually unbondable unless the dentin is clean and the surface abraded.	Figure 5. High magnification (12x) view of the root after step 9. Note how the gentle blasting has stripped away the contaminated surface dentin and yet leaves the enamel almost undisturbed.
Figure 6. Bioclear "Prophy Plus" unit snaps to the quick disconnect, and this or a prophy-jet should be part of every bonded procedure's armamentarium.	Figure 7. Close-up view of the blasting of the difficult to clean areas. They should also receive the same attention from the lingual aspect (not pictured).
Figure 8. Step 9 view at low magnification. Facial surfaces that previously had large abrasions are at full contour. Cord is still in the sulcus but not visible in photograph.	Figure 9. Yellow ContacEZ (Contact EZ) lightens the contact, allowing insertion of the matrix and at the same time removes calculus and plaque from the  contact area. So integral to the technique, they are now included in the Bioclear Matrix kit.
Figure 10. Bioclear Matrix system  complete kit includes diastema closure, anterior, and posterior matrices. Mild to wild emergence profiles are coupled with  different tooth sizes and incisal shapes. Sabre wedges, interprox­imators and other essentials round out the kit.	Figure 11. A Bioclear DC-202 matrix is ready to be placed incisogingivally once the contact is lightened. Note the curved Incisal edge and aggressive cervical  curvature.
Figure 12. The DC-203 matrix that is especially designed for diastema closure of small teeth. Side view and profile views are featured. Note the straight incisal edge and the aggressive cervical  curvature.	Figure 13. Four sectional matrices (Bioclear DC-203 matrices) are placed incisogingivally after the contact areas were lightened and gently abraded.
Figure 14. A 37% Phosphoric Acid Etchant (3M ESPE) is injected under the matrix on to the tooth. The entire tooth should be etched.	Figure 15. A familiar site to Bioclear users, yet perhaps odd to any "newcomers." The injection molded restoration has interproximal areas that are "porcelainesque" with smooth, rounded contours and flawless surfaces.

 Why Do So Many Dentists Mistrust Composite To Treat Black Triangles?

Like many clinicians, Michael's (the patient in question) dentist in North Carolina hadn't heard of Bioclear and was unfamiliar with injection molding of composites. Therefore he was leery of treating Michael with "bonding." At that point Michael decided to cross the country for a different solution because porcelain veneers and periodontal surgeries did not appeal to him as ideal treatments. After he saw my "Black Triangle" and "Restoratively Driven Papilla Regeneration" articles on the Internet and videos on YouTube, he opted to fly to the west coast for treatment. 
After spending many hours working with manufacturers and tens of thousands of dentists, I compiled a "top 5" list of composite and porcelain fallacies that have steered dentists away from minimally invasive composite treatments for black triangles, or has doomed their previous attempts leaving them gun-shy to try it again:

1. "Acid-etching cleans the tooth." 
   False. Phosphoric acid barely touches plaque. Biofilm is so tenacious and we forget that phosphoric acid removes the mineral, not the organic component of tooth surfaces. Biofilm is organic, not a mineral. This residual biofilm at the margins is likely the number one reason why Class V and interproximal composites turn brown at the margins. No bonding agent can bond to biofilm, and most dentists are leaving biofilm on their hard to access margins.
2. "A stronger dentin bonding agent is the answer." 
   False. They (the manufacturers) keep selling us new and improved dentin bonding agents with higher and higher dentin bond strengths. The problem is twofold; first of all, in a case like this, most dentists are bonding to plaque, calculus, and contaminated dentin and no current resin bonds to biofilm. Secondly, with an approach using the Bioclear matrix; uncut, blasted, and rinse-etched (with phosphoric acid) enamel is leveraged to provide the bulk of the retention and reliance on the dentin is lessened. We can trust enamel bonding. The key is in the design of the Bioclear Matrix and the ability to "wrap" the tooth with seamless composite jacket.
3. "A full crown is better." 
   False. If you were the patient with otherwise healthy teeth, would you choose full crowns? Consider that a full crown destroys 70% of coronal tooth volume with a 10% to 20% chance of eventual resultant pulpal death.
4. "A porcelain veneer is better than bonding." 
   In a case like this, false. First, porcelain veneers cannot reach far enough to the lingual, so the space is blocked from view but becomes a plaque trap on the lingual. Secondly, bonding a veneer to this much cervical dentin should make you nervous. Very nervous.
5. "Direct bonding is too difficult."

In the past this may have been true. But today, false. In the modern resin era, we utilize anatomic Bioclear matrices coupled with injection molding filling technique with, for example, a universal nanocomposite, thus creating and ideal a flowable/paste interlace.

CASE WORKUP
First, I consulted 2 renowned microscope-equipped periodontists. I would have normally immediately excluded the surgical option based on this patient's situation but, in this case, because of the severity of the embrasures attrition, I felt that second and third opinions were warranted. In addition, if a follow-up surgical approach were needed, the periodontist would already be on board. 
Noted periodontist, Dr. Peter Nordlands' summary of this patient: "Dear David, the papilla height across the lower anterior teeth is located at the same level as all of the other adjacent papillae. This means that the individual papillae are not deficient but instead, the patient has suffered incisal edge wear and extrusion of the incisors. Although root coverage could be very predictable, I would recommend a restorative solution as you have so beautifully shown in the Bioclear video. My experience is that surgical papilla reconstruction is most predictable in situations where the papilla has been surgically abused previously."

CASE PRESENTATION
Figure 1 shows the functional and aesthetic dilemma. The retracted view (Figure 2) shows the magnitude of the black triangles on the lower. The patient's first priority was treating the lowers, and he would return to the west coast in a few months to treat the upper black triangles. Facial abrasions and recession tripled the complexity of treatment (Figure 3). Blasting, which is application of a mild abrasive with air-water mix, is an absolute necessity for this treatment (Figures 4 to 7). Once the facial abrasions are restored up to the line angle areas, a rubber dam is placed. The interproximal areas are nicely managed with the rubber dam and the DC-203 Bioclear matrices together (Figures 8 to 15). To try to treat the facial abrasions at the same time that the matrices are in position is not recommended. The Bioclear method is almost the inverse of the old flat matrix technique. The facial surfaces are left with some excess because this is the loading area. The interproximals, when molded, will require little or no finishing. Immediate postoperative views demonstrate the dramatic emergence profiles, mirror finish, and regenerated papillae (Figures 16 to 18). Dentists and periodontists often ask these patients, "Are these veneers? Are these crowns?" No. This is done with an injection molding technique performed with high-level magnification using a universal nanocomposite (in this case, 

 THE MIRROR FINISH: TAKING THE CASE FROM GOOD TO GREAT

Having a mirror smooth composite finish makes everyone happy; the patient, the soft tissue, and especially you, the clinician. The matte or grainy finishes of the past collect lipstick, biofilm, stain, and feel like cheap dentistry to the patient's tongue. In our traditional mindset, only porcelain stayed smooth. Those days need to end now. Composite has come of age. The first step is to use a microfill that holds its shine. I am nearly always disappointed at how miserable the composite finishing systems are that I am asked to evaluate, and how disappointing many of the composite finishes that are presented in dental journals and magazines. The folks at Kerr, 3M ESPE, and SS White have commented that they have never seen polishes like the ones I show in my lecture. That's probably because most doctors adopt a manufacturer's "system" and frankly, those systems are mediocre at best and grossly overcomplicated. To learn about my unique mirror polish visit the dentistrytoday.com video library to view Dr. David Clark's 3-step perfect composite polish technique.

Figure 16. Low magnification, postoperative view. The cord has been removed.	Figure 17. Close-up, postoperative view. The rubber dam tissue compression combined with the exacting curvature of the Bioclear matrix; together they predictably deliver a regenerated papilla as soon as the rubber dam is removed.

Figure 18. A happy patient with a younger looking smile. The patient is an anesthesiologist who was extremely grateful to have received this minimally invasive and maximally aesthetic treatment.

SUMMARY
Before the Bioclear matrix and a disciplined approach to composite treatment of black triangles, many treatments ended with significant compromise in periodontal health. Many cases debonded soon after placement. Others suffered problems with stain. Nonetheless, our patients are hopeful for a better solution. The interdental papilla serves as both a functional and aesthetic asset. Anatomically ideal interproximal composite shapes that are mirror smooth can serve as a predictable scaffold to regain this valuable gingival architecture. Clean enamel surfaces can be leveraged to permanently retain the restorations. However, the reader is cautioned that to attempt this elective procedure using no magnification, without a strict adherence to dentin detoxification with a blasting appliance, and using a flat matrix, nontreatment or referral is recommended. Our profession can change its thought processes, retrain its hands and expand its armamentarium to perform techniques that were previously impossible.

Tufts dental researchers conducted a three-year follow-up study that examined the stability of a treatment option for receding gums and found that complete root coverage — the goal of the surgery — had been maintained. This specific tissue regeneration application, developed at Tufts, reduces the considerable pain and recovery time of gum grafting surgery.
The case study of six patients is published in the July 2009 issue of the Journal of Periodontology.
“Patients have a less invasive treatment option for receding gums and we now have evidence to support the stability of this relatively painless procedure. Instead of leaving the dental office with stitches in the roof of their mouth, a patient leaves with a small bandage on the arm that can be removed in an hour,” said Terrence Griffin, DMD, associate professor, chair of the department of periodontology, and director of postdoctoral periodontology at Tufts University School of Dental Medicine in Boston.
“One of our previous research studies showed that all of the post-operative bleeding and most of the post-operative pain were related to the gum tissue removed from the roof of the mouth for use as a graft,” he continued.
Traditional gum grafting surgery requires surgically excising tissue from the roof of the mouth (the palate) to replace the gum tissue lost around the teeth. Unfortunately, removing tissue from the roof of the mouth extends recovery time and is a major source of patients’ discomfort or pain. According to the American Academy of Periodontology, periodontal disease is the primary cause of tooth loss in adults aged 35 and older. Periodontal disease includes gum recession, also called gingival recession, which can result in tooth root decay and tooth loss.
The new tissue regeneration application from Tufts uses platelet concentrate gel applied to a collagen membrane as the graft instead of using tissue from the roof of the mouth. The graft is soaked in the patient’s platelets, using blood drawn in the same visit. Placed over the receding tooth root, the graft is then surgically secured.
In order to examine three-year efficacy of the treatment, measurements were taken from six patients in the gum recession area at baseline, 6, and 36 months after surgery. At six months, 24 out of 37 teeth from the six patients had complete root coverage (65 percent). At 36 months, 21 out of 37 teeth from the six patients had complete root coverage (57 percent). The authors said that the recession over three years was minimal and that the results are comparable to traditional gum grafting surgery.
“Our previous research determined that pain and discomfort were barriers to receiving traditional gum grafting surgery. We have also shown previously that this treatment for gum recession results in proper coverage of the tooth root, better esthetics than those found with traditional gum grafting surgery, and enhanced patient satisfaction with the results,” said co-author Wai Cheung, DMD, MS, assistant professor in the department of periodontology at Tufts University School of Dental Medicine.
Over the last decade, Griffin and his colleagues, including Cheung, have studied alternatives to traditional gum grafting surgery and have more than 20 publications on the topic.
“Gum disease affects most American adults and research is linking periodontal disease to other health problems, including heart disease. Encouraging patients to undergo surgery to fix receding gums can be difficult because the mere thought of this dental surgery is often associated with considerable pain. This treatment, while only marginally more expensive for the patient, is more time-consuming and technically more difficult for us but the end result — improved esthetics, reduced pain, and, most importantly, improved oral health for the patient — make it a valuable and important alternative,” said Griffin.

- A team of engineers and clinical researchers from West Virginia University (WVU) and the University of Pittsburgh is making progress in their quest to develop a 3D ultrasound system for assessing gingival tissue and inflammation and diagnosing gingivitis.

While ultrasound is best known in dentistry for its scaling and surgical abilities, the WVU team has been studying the use of high-frequency ultrasound to construct 3D images of hard and soft tissues in the oral cavity. In previous research, they demonstrated the ability to construct 3D images of the mandible and surrounding tissues.

At the International Association for Dental Research (IADR) meeting in Brazil this week, they will present findings from a new study using this technology to assess gingival tissue.

"We are in the early stages of developing 3D ultrasound to measure tissue alterations in gingivitis," said Eros Chaves, DDS, MS, DMD, an associate professor at WVU who will be presenting the study at the IADR meeting on June 22. "We know that we can do it in vitro; for this study, we compared histologies with the ultrasound in vitro."

Clinical and research applications

Dr. Chaves and his colleagues collected in vitro ultrasound scans via a proprietary high-resolution system that uses a 55-MHz single-element transducer. Gingival tissue samples were immersed in water near the ultrasound transducer focus, and continuous acquisition with a 400-MHz data acquisition card was synchronized with a high-precision 2D positioning system to acquire measurements of the gingival tissue samples.

The researchers found that ultrasound scans for tissues with gingivitis exhibited higher values of integrated backscatter, time variance, time entropy, frequency integrated backscatter, wavelet root mean square value, and wavelet integrated backscatter than normal tissue samples or samples with mild gingivitis.

When they compared the ultrasound scans with the tissue histologies, both revealed similar changes in the tissue, the researchers noted.

These findings indicate that parametric ultrasound has the potential to be used for diagnosing gingivitis, the researchers concluded, although more research is needed to investigate the diagnostic value of ultrasound for clinical research and chairside use.

Before joining the faculty at WVU, Dr. Chaves was in private practice and also worked in product testing doing studies for some of the major toothbrush and toothpaste suppliers, he said. He sees a need for a better diagnostic tool for product testing.

"It was all based on subjective criteria of gingivitis and plaque," he said. "And knowing the cost of the examiners and the subjectivity, it felt like we needed a better tool. So we are trying to see if ultrasound, which has been demonstrated to be effective in soft tissue in other medical areas, could work in gingival tissue also. I see this more for the research field, but my partners see it more as a diagnostic tool that could be used in the dental office."

Ultrasound advantages

Ultrasound imaging offers several advantages over conventional imaging methods for assessing gingival tissue, according to Dr. Chaves. There is no exposure to ionizing radiation, it is potentially more accurate than manual probing, and it is noninvasive.

"In clinical diagnostics of gingivitis, you have to probe the gingival tissue, which is an irreversible index because when you touch the tissue, it changes," he said. "If it starts bleeding and you have second examiner, they will see something different. Ultrasound is noninvasive and reversible. It doesn't change anything."

In addition, ultrasound technology is getting increasingly sophisticated, Dr. Chaves noted.

"The waves are much higher intensity now, so you can scan the tissue much better," he said. "CT scans can give a 3D image of the mandible, and now ultrasound can do the same thing with sound waves instead of x-rays."

Even so, there is more work to be done. While they originally had to use the same kind of ultrasound machine that is used in obstetrics and other medical examinations, the researchers have been able to reduce the size of the ultrasound scanner so they can now do more precise intraoral imaging rather than extraoral. The next challenge will be to image more of the oral cavity during a scan, rather than just specific areas. This will enable them to then begin in vivo studies.

"At this point, we are really learning and developing," Dr. Chaves said. "Every time we learn that it is possible to do this, then we have to learn how to do it in the patient, then the entire mouth of the patient, then in a patient population, very fast. It is going to take some work and creativity to learn how to do this in the entire mouth of the patient, rather than just specific parts of the gingival tissue."

The latest research and science behind periodontal disease is your biggest tool to convince a patient to begin—and stick with—preventive and SPT appointments. The first step is to clearly understand the information behind your case to the patient. The following are key points about periodontal disease to have in your toolbox when you talk to patients.

Periodontal disease is an inflammatory disease that affects the soft and hard tissues that support the teeth. The early stage of this disease is gingivitis. In later stages, the teeth may become loose, and the bone surrounding the teeth can degenerate. The most advanced stage of periodontitis is termed chronic periodontitis.1 Major risk factors for this disease include an inherited or a genetic predisposition, smoking, lack of routine home care, age, diet, certain systemic diseases, and various medications.2

Any time bleeding is present, pathological change is occurring in your patient's mouth that needs to be evaluated and appropriately treated sooner rather than later. When periodontal disease is present, the potential for bone loss has already begun. Depending upon the patient's risk factors, bone loss can occur quickly and become aggressive very easily. In patients with few or no risk factors, periodontal disease can be reversed with early nonsurgical intervention.3 With this knowledge, a patient will be much more likely to say yes to your treatment plan.

Phase 1 treatment is complete after the patient undergoes scaling and root planing, followed by a successful postoperative report from the 6-week re-evaluation appointment. This 6-week re-evaluation appointment is the first of the SPT appointments. During the early stage of periodontal disease and at the end of phase 1, the periodontium has the best chance to reverse the diseased state and, in many cases, halt the progression of further oral and systemic disease. Patients need to know, however, that this is not the end of the story. After phase 1 therapy is complete, a patient is now and forever considered a periodontal patient, which means regular SPT is a must to prevent active disease. A regular prophy just won't do. If your patient were to ask, alternating prophylaxis appointments with SPT appointments is not appropriate and should not be considered as an appropriate phase for future treatment. Bone loss is not reversible, and it is imperative that patients understand this. Removal of the biofilm and microbiological factors also becomes very important for future health of the patient.4

For years, we have understood that periodontal disease is episodic. Make sure your patients understand what that means. It is another key point to use when explaining why regular periodontal maintenance is crucial. Periodontal pathogens will repopulate a healthy and recently scaled sulcus as early as 9 to 12 weeks post-scaling.5 That means a patient can brush and floss all day long, or even see the dental hygienist every 3 months; yet this may not be enough to prevent the return of periodontal pathogens. Without these pathogens removed, bone loss is likely to continue. Other clinical studies have shown that even with the supragingival environment as the single source for colonizing bacteria, a complex subgingival microbiota can develop within one week.6

You can strengthen your case for preventive care even more when your patient is aware that oral health affects the whole body. Countless studies have emerged during recent years suggesting a strong link between periodontal health and systemic health. For example, when patients with Crohn's disease receive the appropriate treatment for periodontal disease, research reports a decrease in the enzymes that would normally increase inflammation in the sulcus—and the body.7 In addition, much research states that when a patient with type 2 diabetes mellitus is diagnosed with periodontal disease, nonsurgical periodontal therapy was associated with improved glycemic control.8 The role of the dental hygienist becomes extremely valuable when patients' teeth are not merely "cleaned." Scaling, root planing, and various adjunct chemotherapeutic intervention along with lasers can improve a patient's oral health8,9 and thus may actually help a patient live a longer, healthier life.

Your chances of getting a yes to nonsurgical periodontal therapy and routine SPT appointments will increase when patients understand the vital link between their oral health and systemic health. On that note, what's even more effective is to share science's good news. Decades of research and advances in periodontal therapy have proven that the majority of patients who receive routine preventive care can retain their dentition throughout their lifetimes.10 Many patients who do routine, long-term, supportive, nonsurgical therapy can maintain optimal gingival health that is free from reinfection.

If you have your patients' attention at this point, they will probably want to know how often they need to come in for periodontal therapy. Although each patient will need an individualized treatment plan, dental hygiene appointments for routine preventive care will ideally range from 2- to 6-month intervals.11 Presenting the scientific evidence to patients takes good communication, and their understanding will leap forward, giving them a reason to sit up, listen, and take action, saying, "Yes!" to case acceptance of nonsurgical periodontal treatment.

Written by Debra Seidel-Bittke, RDH, BS

Each patient has a different healing potential that can directly influence the response to treatment. The patient-related factors that have a negative influence on the regeneration of these lesions include smoking, stress, diabetes mellitus, acquired immunodeficiency syndrome and other acute and debilitating diseases, and the presence of multiple deep periodontal pockets. Age, gender and type of periodontal disease do not seem to play a major role in regenerative therapy (10,16).

Smoking. Epidemiological and longitudinal studies have shown an increased prevalence of periodontal disease and progression rate among smokers compared to non-smokers (17). Evidence has indicated that smokers present a less favorable response following both non-surgical and surgical periodontal therapy (18).

Various factors contribute to the deleterious periodontal effects of smoking, including alterations of the microflora and host response (17). The proposed mechanisms of the negative periodontal effects of smoking are decreased vascular flow, altered neutrophil function, decreased IgG production and lymphocyte proliferation, increased prevalence of periopathogens, altered fibroblast attachment and function, difficulty in eliminating pathogens by mechanical therapy, and negative local effects on cytokine and growth factor production (17). These deleterious effects have been related to the presence of more than 4000 toxic constituents in cigarette smoke (19).

Cigarette smoking has been associated with a reduced healing response following GTR treatment (14,19,20). Evidence indicates that the impact of smoking on regenerative therapy is more significant in the tissue maturation phase (19,20). Machtei et al. (20) recommended that when GTR is performed for class II furcation defects in smokers, anti-infective therapy should be incorporated into the treatment protocol to enhance the regenerative outcome. In that study, the experimental (anti-infective therapy) and control groups gained similar levels of tissue at membrane retrieval; however, the experimental group exhibited significantly less tissue loss between retrieval and 1-year reentry, indicating that the effect of smoking is crucial at the tissue maturation phase. Thus, while smoking prevented tissue maturation and mineralization, the anti-infective protocol enhanced these processes, resulting in a more favorable outcome. Adjunctive systemic or local antimicrobial therapy has been recommended in smokers due to evidence suggesting that subgingival pathogens are more difficult to eliminate in smokers following scaling and root planing (17).

Ah et al. (18) reported that smokers of more than 10 cigarettes a day respond less favorably to both conservative and surgical periodontal therapy than do non-smokers. Kaldahl et al. (21) noted that heavy smokers (>20 cigarettes per day) respond less favorably than light smokers (<20 cigarettes per day). It is important to note that former smokers respond to non-surgical and surgical therapy in a similar manner to those who have never smoked (17). Thus, tobacco cessation may result in better predictability and an improved regenerative response; however, the period that is required for host responses to return to normality following cessation is yet to be determined.

Stress. The influence of stress on periodontal regenerative therapy has not yet been studied. However, recently, psychological stress has been considered to be a possible risk factor for periodontal breakdown. The proposed mechanisms for the negative periodontal effects of stress include neglect of oral hygiene, changes in diet, increase in smoking and other pathogenic oral behaviors, bruxism, alterations in gingival circulation, changes in saliva, endocrine imbalances and lowered host resistance (22).

Diabetes mellitus. The diabetic's susceptibility to periodontal disease and impaired wound healing can affect the progression of diabetes mellitus and the response to periodontal therapies such as GTR (23). Various features or events seem to be responsible for delayed wound healing in diabetic patients, such as impaired cell function, decreased tissue oxygenation, microvascular complications, increased collagenase production, deficiency in growth factors activity, deregulation of cytokines at the wound site, and decreased migration of periodontal ligament cells, which can interfere in the regenerative process (23,24).

A negative prognosis might be anticipated in patients with insulin-dependent diabetes mellitus, especially if their glucose levels vary (14). Treating furcation defects with GTR can be an option in well-controlled diabetics; however, the possibility of postsurgical complications should be considered. If complications arise because of delayed wound healing, treatment results may be less successful than expected. Thus, patients with diabetes require close supervision and frequent monitoring of the regenerated site to achieve long-term success.

Other systemic conditions. A negative prognosis might be anticipated in HIV-positive patients with other clinical or immunological deficiencies, in patients with rheumatoid arthritis, and other immune-complex diseases. High doses of irradiation in patients with a history of head and neck tumors might be detrimental to the regenerative process (14).

Presence of multiple deep periodontal pockets. GTR should be performed in patients with low levels of pathogens in the oral cavity. Barrier membranes are at risk of becoming contaminated within 3 min of intra-oral membrane manipulation in individuals with multiple deep periodontal pockets, bleeding on probing in other parts of the dentition, and high subgingival levels of putative periodontopathogens. Research has shown a negative correlation between bacterial contamination of the membrane and clinical attachment gain (25).

LOCAL FACTORS INFLUENCING SUCCESSFUL REGENERATION

The predictability of GTR in class II furcations is also strongly influenced by local factors, such as furcal anatomy, defect morphology, thickness of gingival tissue, and tooth mobility (8,10,26-29).

Furcal Anatomy

The furcal anatomy-related factors are the presence of cervical enamel projection, enamel pearls, root or root trunk concavities, bifurcation ridge, accessory canals, furcation entrance dimension and length of root trunk.

Cervical enamel projections and enamel pearls. Cervical enamel projections and enamel pearls may contribute to plaque accumulation and furcal invasion, hence, should be removed by odontoplasty during regenerative procedures. New attachment cannot be observed over these anatomical conditions (27).

Root concavity. Areas of root concavity also contribute to plaque accumulation and are covered by more cementum than are the adjacent convexities. This may have clinical significance because of the ability of the cementum to hold toxic bacterial products (27). Root surfaces exposed to the environment of a periodontal pocket may become hypermineralized. In addition to a direct cytotoxic effect on host cells, these surfaces may represent a poor substrate for plasma protein adsorption and subsequent fibrin adhesion (30). Thus, ultrasonic, hand and rotary instruments must be used for more effective decontamination in furcation areas, as well as the chemical conditioning of the scaled roots.

Root trunk concavities. The presence of root trunk concavities in molars, especially mandibular molars, has been reported to have possible effects on the regenerative results. Pustiglione et al. (31) and Kon et al. (32) reported that 100% of mandibular molars have root trunk concavities with a mean depth of 1.12 mm in first molars and 1.05 mm in mandibular second molars. Dunlap and Gher (33) determined the location of the first detectable buccal and lingual root concavities at 0.7 mm and 0.3 mm apical to the cemento-enamel junction, respectively, which progressively deepened to reach the furcation. The concavities of the root trunks negatively influence the results of GTR because adequate adaptation of the membranes, when placed 2 to 3 mm apical to the cemento-enamel junction, does not occur. This permits apical migration of the junctional epithelium, thus impeding the regeneration process. This was demonstrated by Novaes et al. (8), who evaluated the effect of the concavities on the regeneration of class II furcation lesions histomorphometrically in dogs. The authors suggested that a modification in the design of the membrane collars would allow more intimate adaptation of the membranes to the surface of the root trunk concavities, favoring the regeneration of periodontal tissues. In lesions treated with the modified membrane there was significant regeneration with less junctional epithelium migration and more bone regeneration. Villaça et al. (9) confirmed these results in humans and reported greater horizontal resolution of class II furcation defects treated with the modified membrane. Thus, these studies concluded that the collars of the membranes should be modified to improve regenerative results when root trunk concavities are present (8,9).

Bifurcation ridge. The bifurcation ridge is an anatomic structure formed mostly of cementum that originates from the mesial surface of the distal root, runs across the bifurcation and ends high up on the mesial root. This creates niches for plaque accumulation and has been found in 70-73% of mandibular molars. Odontoplasty should be considered in the presence of severe bifurcation ridges to ensure proper root surface preparation (27).

Accessory canal. Histologic studies have demonstrated accessory canals in the region of furcation (27). Endodontic infections can cause periodontal disease in the furcation region of molars by accessory canals and impair the healing response following GTR.

Entrance of the furcation. The architecture of the furcation entrance is an important factor for root preparation access, representing a major determinant of treatment success. Bower (34) has shown that the diameter of the furcation entrance in molars is smaller than the blade width of commonly used curettes in 58% of the furcations examined, hindering effective instrumentation of these areas. Matia et al. (35) showed that calculus removal in narrow furcations (less than 2.3 mm) is significantly better with open ultrasonic debridement than with open hand debridement; however, in wide furcations, there is no significant difference between the two approaches of calculus removal. Hence, it appears that hand instrumentation alone may not be adequate for complete root surface preparation in all furcation areas.

Length of root trunks. Molars with short root trunks are generally considered to be at higher risk for developing furcation involvement than teeth with long root trunks and are also the best candidates for tooth resection procedures (27). Bowers et al. (10) demonstrated that molars with the longest root trunks (5-6 mm) tended to respond more often with complete furcation closure following GTR therapy than teeth with shorter root trunks (100% versus 71%, respectively), although this difference failed to reach statistical significance. Hutchens (36) suggested that short root trunk length is considered to be less favorable for membrane coverage, coronal positioning and flap adaptation against the tooth. In contrast, Horwitz et al. (26) reported that long root trunk has a negative influence on the success of regenerative therapy. The results of this study indicated that long root trunks were associated with less favorable clinical horizontal probing attachment gains.

Type of tooth. Mandibular first and second molars frequently exhibit differences in root morphology and furcation access, which may affect surgical management (10). Mandibular first molars have shorter root trunks, which may account for the higher prevalence of furcation defects in mandibular first molars compared to second molars. Mandibular first molars frequently exhibit complex cementum morphology, an intermediate bifurcation ridge and intraradicular root concavities. Mandibular second molars have the longest root trunks and smaller root divergence, which may impair access for root preparation. Bowers et al. (10) demonstrated that despite comparable percentages of first and second molars with incomplete furcation closure, second molars exhibited a trend towards a higher proportion of defects with residual class II furcation. However, Machtei et al. (16) showed that first and second molars responded similarly to regenerative treatment.

The GTR procedure has a limited application for class II furcations of maxillary molars. Pontoriero and Lindhe (12) observed the largest clinical improvement in class II furcations of mandibular molars, followed by buccal class II furcations of maxillary molars and with interproximal furcation lesions exhibiting the least or no improvement. The authors reported that the reason for the different outcome of GTR in maxillary and mandibular furcation defects is most likely related to the anatomy of the defects, the presence of deep grooves in the root surface of the maxillary furcation, the limited access for root surface debridement, and the amount of remaining periodontium facing the defect. Furthermore, in interproximal furcation lesions, adaptation of the membranes is more difficult.

Defect Morphology

The clinical success of furcation therapy also appears to be strongly related to defect morphology. In a prospective study performed by Bowers et al. (10), multiple factors predictive of clinical outcome in the treatment of facial class II furcations in mandibular molars were identified: a) probing pocket depth, b) horizontal probing attachment level, c) distance of furcation roof to base of defect, d) distance of furcation roof to crest of bone, e) interproximal bone height, f) distance of bone crest to base of defect, g) root divergence, h) horizontal depth of defect, and i) furcation defect volume.

Probing pocket depth. Increases in presurgical pocket depth were associated with a significant reduction in complete furcation closure. However, Horwitz et al. (26) reported that a deep probing depth at the furcation site at baseline increases the likelihood for more favorable horizontal attachment gain in furcations. Machtei et al. (16) also demonstrated that the greater the initial pocket depth, the greater the potential for periodontal regeneration, suggesting that initial probing depth might be a useful indicator for the regenerative potential of a given site.

Horizontal probing attachment level. Increased baseline horizontal probing attachment level was associated with decreased clinical closure. Furcations with horizontal probing depths of 5 mm or greater demonstrated a lower likelihood of complete closure.

Distance of bone crest to base of defect. This measurement failed to account for differences in outcome relative to furcation closure. However, Cortellini et al. (37) reported that the depth of the infraosseous component of the defect is one of the most important factors in achieving the maximum regenerative potential. Anderegg et al. (38) also reported that the deeper the vertical component, the greater the repair.

Distance of furcation roof to base of defect. Increases in this measurement were associated with decreased clinical closure. Complete furcation closure was observed in 63% of defects with a distance of furcation roof to base of defect of 4 mm or greater. Machtei and Schallhorn (14) reported that if this measurement is lower than 4 mm and associated with defects that are mainly intra-osseous there is a better prognosis than the same measurement associated with defects that are mainly supra-osseous.

Distance of furcation roof to crest of bone. Increases in the distance of furcation roof to crest of bone were associated with a lower probability of complete furcation closure. Over 90% of defects with this measurement of 2 mm or less demonstrated complete furcation closure, compared to 67% of sites with a measurement of 3 mm or more.

Interproximal bone height. Teeth with interproximal bone height at the same level or superior to the roof of the furcation resolved with complete closure in a significantly higher percentage of cases (94% complete closure) than sites where interproximal bone was below the roof of the furcation (70% complete closure). Horwitz et al. (26) reported that, if there is bone coronal to the furcation fornix at the mesial and distal aspect of the tooth, coverage and stabilization of the membrane may be achieved with a coronally positioned flap. Under these conditions, the area of periodontal ligament available to provide cells to colonize the blood clot within the defect is larger than in the situation where the fornix is located coronal to the alveolar crest.

Root divergence. Increases in root divergence measured at crest of bone were associated with decreases in complete furcation closure. Complete furcation closure was achieved in 61% of defects with associated root divergence of 4 mm or greater, compared to 93% of defects with root divergence of 3 mm or less. However, it should be noted that furcation defects must have a root divergence sufficient to allow root preparation with hand, rotary, and ultrasonic instrumentation. Horwitz et al. (26) also demonstrated that a wide furcation entrance has a negative influence on the success of GTR therapy.

Horizontal defect depth. Furcation defects with a horizontal depth of 5 mm or greater measured at the level of the crest ofbone demonstrated a lower probability of complete closure (10). Complete furcation closure was obtained in 52% of cases, whereas defects with a horizontal depth of 4 mm or less responded with complete furcation closure in 84% of cases. Thus, in general, the findings of this study suggest that the less severe the defect, the greater the likelihood of achieving complete clinical furcation closure.

Thickness of Gingival Tissue

The amount and quality of the gingival tissue that will cover the membrane is also important. Inadequate gingival width and thin keratinized tissue should be analyzed because it can lead to gingival recession. Anderegg et al. (29) demonstrated that there is less post-treatment recession for tissue thickness greater than 1 mm than tissue thickness less than or equal to 1 mm. Thus, these authors suggest that the thickness of gingival tissue covering the membrane appears to be a factor to consider if post-treatment recession is to be minimized or avoided.

Many factors can account for this. The revascularization of any flap may be further compromised by blockage of the potential blood supply from the periodontal ligament and bone defect to the connective tissue flap by a membrane. The thicker the connective tissue, the better the potential circulatory pool and the greater the chance for flap survival. Mormann and Ciancio (39) demonstrated that flaps under tension become ischemic leading to necrosis. The blood supply in thin flaps is more likely to become compromised by tension than in thicker flaps of equal mobility. The likelihood of increased flap contraction associated with thin tissues might be magnified when placed over an ePTFE membrane, resulting in more postsurgery recession. Novaes et al. (40) reported that flaps with thin connective tissue are at greater risk for inflammation-induced postsurgery recession than thick flaps.

Tooth Mobility

Conflicting results exist concerning the effect that presurgical hypermobility has on surgical healing and, thus, on the post-therapeutic clinical outcome. Because of the scarcity of data available about the effect that tooth mobility has on periodontal regenerative therapy, the clinical relevance of mobility in regenerative therapy has not yet been elucidated. Trejo and Weltman (28) reported that intraosseous defects of teeth with Miller's class 1 and 2 mobility responded favorably to regenerative therapy. In contrast, Cortellini et al. (41) reported that the greater the tooth mobility is at baseline, the smaller the clinical attachment level gain would be 1 year after regenerative therapy.

In clinical practice, the question of whether to splint mobile teeth prior to regenerative therapy to improve the healing outcome often arises. Further studies are needed to validate or refute the regenerative potential of splinting. Machtei and Schallhorn (14) recommended that very mobile teeth be splinted prior to GTR in class II furcation defects. Trejo and Weltman (28) recommended the splinting of hypermobile teeth to improve patient comfort during post-therapeutic healing. However, the clinician must recognize progressing tooth mobility due to trauma, teeth under premature centric occlusal contact, and teeth under traumatic excursional interferences. Such occlusal discrepancies should be removed to minimize trauma and thus tooth mobility prior to regenerative therapy

More adults in the United States have gum disease than one would think.

A new study shows that about 50 percent of American adults age 30 and older have gum disease. The study appears in a recent issue of the Journal of Dental Research.

Periodontitis is a major problem and leads to tooth loss in many cases.

To compile the data for this study, a research team looked through data from a previous study involving 3,700 adults age 30 and older. There were 47 percent of the people who had periodontitis—9 percent had mild gum disease, 30 percent suffered from moderate gum disease and 8.5 percent had severe gum disease. According to this information, roughly 65 million American adults have gum disease.

The research also concluded that 64 percent of adults age 65 and older had some type of periodontitis that could at least be considered moderate. This estimation is much larger than previous studies have indicated, according to the lead author Paul Eke.

The study also showed that the gum disease rates were highest for males, Mexican Americans, adults with less than a high school education, adults whose income would be considered below the poverty line and people that currently smoke.

There are several warning signs for gum disease, including swollen, tender, or bleeding gums. Chronic bad breath is another sign of gum disease.

Scaling and Root Planing: Manually removing the plaque and tarter from the root surfaces of your teeth below the gum line.
Antibiotics: Because bacteria cause periodontitis antibiotics may be prescribed as pills or as an Antibiotic fiber. The fibers are used in conjunction with scaling and root planing. They are placed directly into the pockets and are removed within 7-10 days later. Antibacterial mouth rinses may also be recommended to help plaque control.
Bite correction: An imbalanced bite may accelerate bone destruction. Your teeth may be adjusted for proper and better function. A Bite-guard (removable retainer fitting over teeth) may be required to protect teeth surfaces and relax tense muscles.
Splinting: This technique attaches weak teeth together, combining them into a stronger single unit, making them more stable and offering more comfortable chewing.
Surgical Therapy

Flap Surgery: Our periodontist separates the gum from the teeth creating a "flap" and accesses the infected pocket. It aims to reduce pocket depth and increase the ability to maintain the remnant pockets clean.
Gingivectomy: This procedure is performed when excess amounts of gum growth around the teeth have occurred. This results in false pocket formation and the inability to keep them clean.
Osseous (bone) surgery: This procedure is done to smooth shallow craters and defects in the bone due to mild or moderate bone loss. Guided Tissue Regeneration: This procedure is done in combination with a surgical flap operation where gum growth into a defect is barriered off to allow slower growing bone, cementum and ligament cells to populate a bony defect.
Bone Grafts: Tiny fragments of the patient's bone, synthetic bone or bone obtained from a bone bank are used to fill a bony defect around the teeth. These grafts act as a scaffold on or around which patients own bone is conducted or induced to grow.
Soft Tissue Graft: In cases of gum recession a graft is usually taken from the palate and transplanted onto the receding area to reinforce the thin gum and to inhibit further gum recession.
Flap and Bone Surgery

When gum is inflamed severely (periodontitis), alveolar bone will be absorbed, and defected. Periodontal ligaments which connect between the alveolar bone and the teeth will disappear. Sever bone lose will cause tooth moving and missing. Flap and bone surgery is order to contour the bone, deeply clean the tooth to reduce the inflammation, and promote bone re-growing and connections firm.

Teeth whitening is one of the most popular dental procedures today, but it often comes with the undesirable side effect of tooth sensitivity.

Now a new study has found that a calcium-containing 35% hydrogen peroxide gel can reduce tooth sensitivity during in-office dental bleaching (Journal of the American Dental Association, December 2012, Vol. 143:12, pp. e81-e87).

Manufacturers have attempted to reduce bleaching-related sensitivity by adding desensitizing agents such as fluorides and potassium nitrate to the formulation of bleaching gels, but the benefits of including these agents remain unclear, the study authors noted.

Some studies have shown the effects of calcium-containing compounds in bleaching gels with the aim of preventing the mineral loss and reduction in enamel microhardness produced by bleaching, they added. If these components do indeed prevent mineral loss, it is possible that hydrogen peroxide penetration may occur at a lower diffusion rate, reducing sensitivity.

"To our knowledge, no clinical study investigators have evaluated the clinical benefits of such inclusion," wrote the study authors, which prompted them to conduct a randomized clinical trial to assess the whitening efficacy and sensitivity associated with a 35% hydrogen peroxide gel containing 2% calcium gluconate.

Stable pH key

The researchers recruited 40 study participants from the State University of Ponta Grossa School of Dentistry in Brazil. Participants were at least 18 years old and had good general and oral health. The study took place in the dental school's clinic from March 2009 through April 2010.

They randomly divided the participants into two groups, in which one received bleaching with the calcium-containing gel and the other received bleaching with a calcium-free gel.

The researchers performed two bleaching sessions with a one-week interval in between. They registered the color at baseline and after the first and second bleaching sessions by using a shade guide. They also gauged the participant's perception of tooth sensitivity as registered on a scale from 0 (none) to 4 (severe).

They found that both groups had similar and significant teeth color enhancement with an average bleaching of seven to eight shade-guide units. Most of the participants from the calcium-free group (80%) experienced sensitivity, while 40% of participants from the calcium-containing group reported experiencing sensitivity. The intensity of sensitivity was significantly higher for the calcium-free group during in-office dental bleaching.

"It is likely that the addition of calcium gluconate and the stable and high pH of the calcium-containing product were responsible for the reduced sensitivity reported by participants receiving this bleaching agent in our study," the authors concluded. "The calcium-containing hydrogen peroxide gel caused less sensitivity during in-office dental bleaching without any deleterious effects on bleaching effectiveness."

Related research

This is not the first time that calcium gluconate has been tested as an addition to bleaching gels. A study presented last year at the International Association for Dental Research meeting tested whether the addition of 2% calcium gluconate to bleaching gels reduces whitening efficacy.

The authors of that study reported that the addition of calcium in the bleaching gels does not interfere with the whitening effect. These results can be considered favorable for the clinical performance of bleaching agents since the advantageous effects of adding remineralizing agents to reduce the possible adverse effects to enamel did not impair the bleaching result of gels tested, they noted.

The efficacy of calcium compounds in relieving bleaching-related sensitivity also has been tested, and not just as an addition to gels. One study looked at whether chewing sugar-free gum containing Recaldent (casein phosphopeptides-amorphous calcium phosphate [CPP-ACP]) could reduce the incidence, duration, and intensity of whitening-induced tooth sensitivity.

The authors of that study looked at 88 patients who had their teeth whitened in a single in-office visit, and following the procedure, each patient was randomly assigned to one of three study groups, in which one used a sugar-free chewing gum with Recaldent, one group did not use any desensitizing agent, and the third used a sugar-free chewing gum without Recaldent.

The participants returned for a 24-hour follow-up visit where they completed a questionnaire regarding tooth sensitivity.

"This study suggested that using a sugar-free chewing gum (both with and without CPP-ACP) could reduce the intensity of tooth sensitivity associated with in-office whitening procedures," the authors concluded. "However, it failed to demonstrate conclusively that using a sugar-free chewing gum with CPP-ACP could provide additional therapeutic benefits.

New research from Queen Mary, University of London in collaboration with research groups in the USA sheds light on why gum disease can become more common with old age.

The study, published in Nature Immunology, reveals that the deterioration in gum health which often occurs with increasing age is associated with a drop in the level of a chemical called Del-1.
The researchers say that understanding more about Del-1 and its effects on the body's immune system could help in the treatment or prevention of serious gum disease.
Periodontitis is a disease of the gums which causes bleeding and bone loss which can, over time, lead to loss of teeth. It affects about 20 per cent of the UK population and is caused by an over-active immune response to bacteria that grow in the mouth.
As people age they are more likely to suffer from inflammatory diseases, including gum disease.
The new research investigated gum disease in young and old mice and found that an increase in gum disease in the older animals was accompanied by a drop in the level of Del-1. This protein is known to restrain the immune system by stopping white blood cells from sticking to and attacking mouth tissue.
Mice that had no Del-1 developed severe gum disease and elevated bone loss and researchers found unusually high levels of white blood cells in the gum tissue.
When they treated the gums of the mice with Del-1, the number of white blood cells dropped, and gum disease and bone loss were reduced.
The researchers say their findings could be the basis for a new treatment or prevention of gum disease.
Mike Curtis is Professor of Microbiology at Queen Mary, University of London, Director of the Blizard Institute and the lead on the microbiological studies in the research. He said: "Periodontitis is an extremely common problem and we know that the disease tends to be more common as we get older.
"This research sheds some light on why aging makes us more susceptible and understanding this mechanism is the first step to an effective treatment."

The capsule of Porphyromonas gingivalis, the bacterium that causes gum disease, provides stealth, boosting the bacterium's virulence, according to a paper published in the November Infection and Immunity. Call it a sugar coating, if you will, for in fact, the capsule is made from sugar molecules, which do not ordinarily elicit immunity. Thus it hides the bacterium's proteins within, preventing immune response\
In the study, the researchers, led by Janina P. Lewis of Virginia Commonwealth University, Richmond, compared the ability of normal, and mutant bacteria that were missing the capsule, to activate the immune system, to enter eukaryotic cells (the kind that are present in multicellular organisms), to cause disease, and to survive in mice. "The mutant bacteria activated the host to a greater extent, and thus, were more easily killed by eukaryotic cells," says Lewis. "Thus, the capsule protects the bacteria and allows them to survive unnoticed in our bodies."
Capsules also protect both bacteria and fungi, including P. gingivalis, as per this report, from being engulfed by the immune system's phagocytes (phago=eat; cyto=cell) and from being identified by dendritic cells as dangerous, thus marking them for destruction by antibodies. Conversely, in the study, mutant, non-encapsulated P. gingivalis were rapidly engorged by immune cells, and killed.
"Thus, anything that would interfere with generation of capsule, such as drugs interfering with the action of enzymes involved in synthesis of the sugar coat, could be used in treatment of periodontal disease, and importantly, could have broader implications for prevention of more serious diseases," by other encapsulated bacteria, such as pneumonia, anthrax, meningitis, endocarditis, and gastroenteritis, says Lewis.