1. What Really Is the Cleaning of Teeth All About?
Dr. Phillips Answers Your Dental Questions
A little on the language and structure of “having your teeth cleaned”, which we refer to more technically as ones oral hygiene treatment, or recall appointment or re-care appointment. Organized dentistry, that is dental educators, insurance companies and practitioners, have developed categories that put a name to a degree of difficulty encountered in your oral hygiene treatment. The range of degrees of difficulty has a comparable range of time, skill and sophistication necessary to accomplish the task.
In order to understand this, one must first ask, what is the hygienist cleaning, where are they cleaning and under what conditions are they working? They clean the soft masses of bacterial plaque that you see as whitish mush predominantly at the gumline. They remove the calcified plaque, technically known as calculus, which is analogous to barnacles on an ocean pier. The longer the calculus remained attached, the harder it is to remove. This is why teeth are scraped (root planning) with sharp metal instruments. Calculus is the main objective of cleaning, because calculus is a rough surface onto which the bacterial masses of plaque accumulate. Bacteria are the source of gum disease and tooth decay. The hygienist will also remove stain, which, although unsightly, is not harmful.
The hygienist cleans these deposits off the hard enamel and off the softer root. The enamel has no nerves and is painless to this process. The root is a live structure and can be non-painful or exquisitely painful to root plane. As gum recession occurs and more root becomes exposed, it becomes more difficult to clean by virtue of not only more surface area, but also an infinitely more complicated shape of root to clean around. The further under the gum that one must reach to clean the roots, the more painful the gum can be to the process.
There is also the factor of bleeding gums. Bacterial accumulations cause the gums to become inflamed. Inflamed gums bleed easily to manipulation and this makes it difficult to see the area being cleaned and thus more has to be done by “feel”. It takes more time and skill to work in that environment.
So the gradations in rating the difficulty consider the amount of root exposed, the depth of space between the gum and the tooth, how easily the gums bleed, the amount of plaque, calculus and stain present, how long it has been present, and how inherently sensitive are the gums and root structure. At some degree of sensitivity, injections with local anesthetic are used to allow a thorough job to be done.
All cleanings (oral hygiene treatments) are some variation of scraping the tooth to remove what is there and leave it clean and smooth. The types of oral hygiene treatments have come to be divided into four categories based on degree of difficulty.
Dental prophylaxsis – Accumulations are located predominantly on enamel and limited areas of root structure mostly above the gum.
Full Mouth Debridement – The first visit is spent removing as much calculus in the larger quantities as can be done in that period of time. This is followed up by a second visit of Dental Prophylaxis to remove the rest in a more detailed fashion or one proceeds to Quadrant Scaling and Root Planing is required.
Quadrant Scaling and Root Planning – Sufficient depth of space exists between the gum and the tooth so that one fourth of the mouth is selected at a session ( a quadrant) and cleaned in detail. Usually the quadrant is numbed with local anesthetic to do this because of the severity of involvement.
Periodontal Maintenance - Patient’s who have demonstrated the need for quadrant scaling and root planning inherently seem to need more follow-up care. This includes a session of Periodontal Maintenance immediately after the sessions of scaling and root planning. Patients in this category are seen more frequently during the year at subsequent Periodontal Maintenance visits.
2. What is gingivitis?
“Gingiva” is the medical name for the gums. “itis” is a medical suffix meaning inflammation, thus appendicitis is inflammation of the appendix. Gingivitis is inflammation of the gums. Gums become inflamed because of irritation caused by the masses of bacteria contained in bacterial plaque. Plaque is the white mushy appearing accumulation that collects on the surface of the tooth and especially at the junction of gums and tooth. Most of our preventative efforts of brushing and flossing are directed at removing bacterial plaque.
3. What is Periodontal Disease?
Periodontal Disease is the loss of attachment of gum and bone to tooth. It is preceded by gingivitis of sufficient time and degree of severity that varies widely from person to person before the breakdown of attachment begins. Because bone is lost from around the tooth, eventually the tooth loosens. A tooth is lost because of periodontal disease when it no longer has enough bone to support it, at which point it is extracted or eventually falls out.
4. What is Periodontal Prosthesis?
Prosthetic Dentistry refers to the artificial replacement of teeth, more specifically, crowns, bridges, removable partial dentures, and dentures. Generally, it does not include fillings on individual teeth. Periodontal prosthesis is a very specialized area of prosthetic dentistry for patients who have advanced problems with periodontal disease, loosened teeth, bites that have shifted, old deteriorating crowns and bridges, and problems arising from excessive jaw clenching and grinding.
Periodontal Prosthesis is a 3-year post graduate dental school program to be certified, and the program at the University of Pennsylvania, where Dr. Phillips attended, awards a double certificate, one in Periodontal Prosthesis and one in Periodontics.
Dr. Phillips is not a Periodontist. Although the certificate he earned is the same as that required of other practicing Periodontists, his interest is mainly in Prosthetic dentistry and implants. The Periodontics serves as useful working knowledge necessary to do Periodontal Prosthesis, and the surgical training forms the basis for implant placement and bone grafting. Dr. Phillips works closely with full time Periodontists regularly as treatment needs arise.
5. Does Dr. Phillips take regular patients?
Yes, not everyone has generalized advanced problems but often has localized or individual sites of advanced problems in a mouth that is otherwise relatively healthy. In addition, the training in Periodontal Prosthesis is intense in cosmetic concerns and Dr. Phillips enjoys doing Cosmetic Dentistry.
6. What are Dental Implants?
Dental Implants are a long awaited achievement within the dental profession – an artificial tooth system. For the first time we are able to treat single or multiple teeth that are lost with replacements that feel and look like natural teeth without having to alter the neighboring teeth. In most cases, the bone loss that occurs as teeth fail can be regrown in order to provide sufficient bone to support an implant.
The implant system consists of a titanium (metal) cylinder that is placed in a surgically prepared site in the jaw. The most common form of implant today is called a “root form” implant, because it resembles the natural tooth root. After the implant is placed, bone grows up to and touches the surface of the implant and locks it into place over a 3-6 month healing period. At this point, a conservative reentry incision is made and a post-like component called an abutment is attached to the implant. There is now something that comes up through the gum and is available to support whatever the intended dental use might be. This ranges in possibility from supporting crowns to bridges to partial or full dentures. This sequence can vary. There are times when it is possible to extract a tooth and immediately place an implant and even circumstances where the implant can also have an immediate crown placed upon it.
Implants do not have a prescribed lifetime within which they are expected to fail. The intention is that they last for many years, if not indefinitely. Statistically there are failures, so we know that lasting indefinitely is not always possible and no guarantees can be made in that regard. That is, however, the intent. An implant can fail during the healing phase or after it is out and in function. As the whole area of implants has matured over the past thirty years, the failures have become less and less and the successes more predictable.
The standard of care today when planning out dental treatment for the replacement of currently missing teeth or teeth to be extracted is to first consider the use of implants. This does not infer that they are always possible to do given a number of circumstances that might exist, but it does speak to the dependable reputation that they hold, where they must first be ruled as being “not applicable” before other methods of treatment are advocated.
The use of dental implants is often coordinated with one of several methods of “bone grafting”, where the bone that is naturally lost from around a failing tooth can be regrown. The result of re-growing such bone provides a healthier and more abundant body of bone into which the implant can be placed. This provides for maximum stabilization and thus greater prognosis for having a successful, lasting implant.
7. Who in dentistry places implants?
Any licensed dentist is legally permitted to surgically place an implant or do a bone graft. Historically, Oral Surgeons and Periodontists were the first to be involved as an identifiable group, although some of the real pioneers in implant development were general dentists who happened to take up an interest and be in on them right from the beginning. Oral Surgeons and Periodontists still place most of the implants currently done, but that is changing rapidly as implants have now matured to the point where they are taught in dental schools and many independent courses are now available for the post graduate practicing dentist.
8. Why do I grind my teeth?
The psychiatrists tell us that grinding of teeth is a normal expression of nervous energy. It is a very complex subject in neuromuscular physiology. Grinding is side-to-side movement of one jaw against the other. Clenching is the force with which your jaws come together. Grinding and clenching is medically called Bruxism. Most people combine the two into “forceful grinding”. The greater the force, the worse is the problem.
9. Is it bad for me to grind my teeth?
Damage from grinding occurs on three levels and these can happen individually or combined. The first is that, like any contact of moving parts, one can experience wear. A little wear is relatively harmless or a lot can be severely destructive resulting in wearing away of large portions of the teeth, chipping of teeth edges and cosmetically disfiguring the teeth. Sometimes it can make the worn surface sensitive to cold or chewing. Secondly, grinding and clenching can loosen the teeth. This can become a serious issue for any of the teeth involved or the “bite” in general. Lose teeth tend to shift in position resulting in changes in “the bite”. Thirdly, one can grind or clench their teeth with so much force that it exceeds the comfort limit of the jaw muscles. This results in pain, stiffness, and/or cramping of the jaw muscles, headaches and neck aches. These symptoms can be very innocent and only at the awareness level or can range up to being serious pain and loss of normal jaw function.
10. What can be done about my teeth grinding and clenching?
It depends on which of the three categories of symptoms are present. Usually it will at least involve a recommendation for a night guard if the problem is significant.
11. What is a night guard?
It is an acrylic appliance worn at night. Night guards differ in design and it depends on the individual as to which is recommended. They prevent further wear, they can stabilize loose teeth and they provide an environment that tends to lessen the force with which you grind and clench thus lessening the pain.