Plaque diseases

The two most common oral diseases — tooth decay and periodontal disease — originate in plaque, the sticky bacteria-laden film that collects on your teeth between brushings. Although both of these problems can ultimately lead to tooth loss, there are important differences. First, tooth decay and gum disease are caused by different species of oral bacteria. In addition, tooth decay attacks teeth themselves; periodontal disease affects the gum tissues and surrounding structures.

There's hardly an adult alive who doesn't show signs of one or both of these conditions. Indeed, tooth decay is second only to the common cold as the world's most prevalent ailment, and as many as half of Americans age 30 or older show signs of periodontal disease.

Tooth decay and cavities

Although many people believe that the terms "tooth decay" and "cavity" are synonymous, they are not. Tooth decay (also known as dental caries) originates when bacteria produce acid that destroys the surface of the teeth. The decay process is gradual. When decay advances to the point where a hole forms in the enamel, this is called a cavity. Initially this hole may be microscopic. If left untreated, however, the decay can penetrate through the enamel layer and into the softer tissue below.

Figure 3: The ravages of tooth decay

Tooth decay often progresses gradually, but when left untreated it can have devastating effects. Decay begins with the development of plaque, which consists of bacteria. These bacteria can dissolve the enamel of the tooth, boring a hole known as a cavity (A). At this point the damage is limited to the enamel and dentin, but as decay progresses, the damage can extend to the pulp. The pulp becomes infected and swollen; this is known as pulpitis (B). The swelling may cut off the blood supply, which can cause the pulp to die. If the infection spreads to the root, it can create an inflamed pocket called an abscess (C). Not only are abscesses quite painful, but if the infection enters the bloodstream, the problem can become life-threatening.

The tooth decay process

Here's a look at how tooth decay progresses (see Figure 3).

Bacterial growth. Bacteria from the Streptococcus family are the main cause of decay. The most prevalent species in the plaque that forms on the teeth (supragingival plaque) is Streptococcus mutans . Other varieties of bacteria are also involved in the decay process, but to a lesser extent. Lactobacilli colonize the crevices on the crown, and Actinomyces are implicated in decay around exposed portions of the root.

Demineralization. Cavity-causing bacteria thrive on a steady supply of carbohydrates, especially sugars, coupled with poor oral hygiene that enables them to feed and grow without interference. When bacteria metabolize sugar, they produce acid. This acid dissolves the enamel surface of the teeth in a process called demineralization. Ordinarily, this erosion takes place slowly, giving the body time to replenish the enamel or remineralize. But when enough bacteria accumulate, they produce sufficient acid to dissolve the enamel faster than the body can rebuild it. Tiny pits mar the surface of the tooth, and cavities begin to take hold. It usually takes many months of alternating demineralization and remineralization for decay to develop.

First-stage decay. The earliest stage of decay appears as a white or brown area on a tooth. This "white spot" is discernible only to your dentist. Another clue that decay is occurring is a "shadow," or area of lesser density, on an x-ray image. If decay is caught at this stage, there's a good chance that it can be halted and reversed (see "Treatment for first-stage decay").

Cavity formation. Unchecked, the acid eventually penetrates the enamel, and a cavity forms. This process may take three or four years. Once this stage is reached, the tooth can no longer repair itself. Both the mineral crystals and living cells that constitute the dentin are vulnerable to cavities. The decay may also travel through the dentin and destroy parts of the tooth tissue still covered by sound enamel. At this point, your tooth may ache. It may also be sensitive to hot, cold, or sweet foods.

Pulpitis. Without intervention, the cavity grows, extending into the soft tissue of the pulp and causing an infection called pulpitis. The infected pulp tissue swells, but the harder dentin surrounding it prevents it from expanding. Ultimately the swollen tissue squeezes the blood vessels, the blood supply to the pulp is cut off, and the pulp dies. At this point, you'll probably experience severe pain.

Abscess and systemic disease. The infection can continue to spread to the root of the tooth, creating an inflamed pocket called an abscess. From there, it can travel into the surrounding tissue. Finally, the infection can enter the bloodstream, causing a system-wide infection that's potentially life-threatening.

Diagnosing tooth decay

Although any tooth surface is susceptible to decay, the most vulnerable spots are the uneven or hard-to-reach areas where bacteria can take refuge. Particularly prone to decay are the crevices (known as pits and fissures) on the surface of the crown, the points where adjacent teeth meet, and the exposed neck of the tooth at the gum line. Root decay is a growing problem, particularly among people over age 55 whose gums have receded as a result of periodontal disease.

Your dentist can often spot decay on the visible surfaces of the teeth, while cavities in unseen spots — such as in the pits and fissures or between teeth — generally show up as dark areas on x-rays. A traditional method of uncovering decay by probing for soft spots in the teeth with a sharp metal tool has fallen out of favor. Researchers began to suspect that this practice actually augmented the decay process by piercing areas of soft enamel and spreading bacteria from one tooth to another.

Still, finding cavities can be tricky. One of the biggest challenges facing the dental community is accurate detection of the more subtle manifestations of decay, including root cavities, active cavities under existing fillings, and areas of demineralization (known as incipient caries). To this end, researchers are testing several technologies. Some promising avenues include using fiber-optic light to visualize deep decay between teeth and using electrical current or laser energy to identify decreases in tooth density that signal demineralization.

Treatment for first-stage decay

If the start of a cavity is caught early enough — while it's still an area of demineralization or a "white spot" — the tooth may be able to repair itself. The goal is to arrest the decay so that the natural remineralization cycle can take hold and repair the tooth. You and your dentist may be able to encourage this process. Following are some of the techniques your dentist might use at this stage.

Fluoride application. Fluoride applied to the teeth in the form of a gel or varnish can boost remineralization. Most promising are the thick, lacquer-like varnishes that adhere to the tooth surface for about 12 hours. Your dentist may paint your teeth with this substance at your twice-yearly checkup.

Chlorhexidine treatment. Applying a gel or varnish containing this powerful antiseptic agent can reduce the level of Streptococcus mutans in your mouth, slowing the demineralization process.

Sealant application. Your dentist may apply a liquid plastic coating, which is usually hardened with UV light, to the biting surfaces of the molars to create a physical barrier against bacteria. Because 90% of decay among children occurs on these surfaces, the best time to apply sealants is shortly after the tooth first erupts. However, sealants can help at any point, even after there is evidence of decay. Applied correctly, sealants can last for several years.

Treatment for cavities

Once the decay has penetrated the surface of the enamel and a cavity has formed, the emphasis shifts from prevention to restoration. The tooth cannot repair itself; instead, your dentist must correct the damage. If the damage extends into the dentin (but has not yet reached the pulp) and the tooth is stable, repair usually means cleaning out the area and filling the cavity.

After numbing the area, your dentist will clean away the decayed enamel using a high-speed rotary drill, an air-abrasive device, or a laser system. He or she may also use a slower drill or manual scooping tool to remove damaged dentin. Once the decayed portion is removed, your dentist will cut the hole into a shape that enables the filling to adhere securely and gives the rest of the tooth the most support.

The next steps depend on the size of the hole to be filled and the material to be used. In some cases, the dentist will coat the inside of the hole with a lining material that prevents tooth sensitivity, seals against leakage, and helps the filling material adhere. This step is often taken for large or deep cavities. When tooth-colored fillings (composites) are used, the dentist must etch the interior of the prepared cavity with acid to ensure that the filling material adheres to the enamel.

Silver amalgam restorations are generally completed in one visit with no other preparatory steps. Other types may take more than one visit to complete. Inlays (which fit into the tooth) and onlays (which fill the tooth and cover part of the biting surface) must be specially made to match the size and shape of the area being filled. These restorations, which are usually reserved for larger cavities, may take two or three visits to complete.

Smart fillings

Glass ionomers, used for some white fillings, are routinely infused with fluoride to prevent cavities from forming around the restoration. Now scientists at the American Dental Association's Paffenbarger Research Center are taking the idea of decay-fighting filling materials a step further. They're researching a biologically active polymer binder that would release therapeutic remineralizing agents, such as calcium and phosphorous, in response to increased bacterial action in the mouth. Researchers predict that these materials, called ACP composites, will be used to fill small cavities, line tooth restorations, and act as an adhesive around braces.

Materials used for fillings

You and your dentist should consider several factors when choosing a filling material. These include the size and location of the filling, the health of the surrounding teeth, the chewing force the affected tooth must endure, the number of visits necessary to make the repair, the cost of the procedure, and the appearance of the completed restoration. Table 4 describes the materials commonly used to repair damaged teeth and summarizes their benefits and drawbacks.

Table 4: Choosing a material to fill your cavity
Type of material	What is it?	How is it used?	Benefits	Drawbacks
Silver amalgam	Mixture of silver, mercury, and traces of other metals; silver-gray color when new, but may tarnish and turn black with age; the most common filling material used	For small to large fillings in load-bearing teeth (molars)	Strong and easy to use Repair often can be completed in one visit Inexpensive compared with other forms of repair	Limited duration; lasts an average of 10 years
Composite resin	Finely ground glass or silica mixed with an acrylic resin; various tooth colors	For small to moderate-sized fillings and for the repair of front teeth	Matches natural tooth color Preparation requires less removal of existing tooth Bonds tightly to tooth	Difficult to use for large repairs Area must be moisture-free when filling is placed Longevity of filling depends on placement technique Technique demands high level of skill by dentist Can cost two or three times more than amalgam for back teeth, depending on the size of the filling Can require more than one visit
Glass ionomer	Mixture of glass powder and an acrylic acid; white in color	For small cavities, especially around roots; as a cavity liner; as cement for crowns and bridges	Material contains fluoride, which is released to the tooth Natural tooth color Preparation preserves more of existing tooth	Demands high level of skill by dentist Moderately expensive Can require more than one visit Color may not be a good enough match for highly visible areas
Gold alloys	Gold mixed with other metals and poured into a mold made from an impression of the tooth	For inlays, onlays, and crowns in back teeth; for fixed bridges	Highly durable; can last a lifetime Restorations wear at the same rate as natural teeth, so opposing teeth do not suffer	Demands high level of skill by dentist Tooth needs to be shaped significantly to accommodate restoration Expensive Process requires multiple visits
Base metal alloys	Palladium mixed with nickel or copper	For crowns, fixed bridges, and partial dentures	Durable Resistant to wear and corrosion	Metal (nickel) causes allergic reaction in some people More expensive than glass ionomers or silver amalgam (less expensive than gold) Process requires multiple visits
Porcelain	Porcelain, ceramic, or glasslike material	For inlays and onlays, crowns, veneers, and bridges	Color and translucency closely match natural teeth	Durable but subject to fracture on impact Can wear down opposing teeth Expensive Process requires multiple visits Ceramic bridges still considered experimental
Porcelain fused to metal	Thin layer of porcelain bonded to a metal frame made of gold alloy or base metal alloy	For crowns and bridges	Stronger than porcelain alone Method of choice for bridges	Can wear down opposing teeth Gold-free alloys (such as nickel) may cause an allergic reaction in some people Expensive Process requires multiple visits

Silver amalgam, the most common filling material, has been used for more than 150 years, but it continues to be controversial. The source of the concern is fear that mercury, a component of amalgam, may promote conditions such as Alzheimer's disease, multiple sclerosis, and autism. Amalgam fillings release mercury vapor not only when they are placed in and removed from the teeth, but also during chewing.

Over the years, a variety of health organizations have examined the medical literature to determine whether silver amalgam is safe. To date, no scientific studies have demonstrated that it is harmful. As a result, organizations such as the FDA, American Dental Association, World Health Organization, National Institutes of Health, CDC, and U.S. Public Health Service have, at one point or another, stated that amalgam is safe for all but the few individuals who are allergic to the material and that banning it would eliminate an important filling option for many people.

These organizations periodically revisit the topic, however, a FDA reassessment made headlines when an advisory panel to that agency declared that more study on the safety of silver amalgam was needed. After reviewing studies on amalgam from 1997 to 2006, the FDA drafted a report that reiterated that amalgam is safe for nearly all people. But in September 2006, the advisory panel that reviewed this report said there were too many uncertainties to make that claim. The panel concluded that while there's no evidence that silver amalgam causes health problems in most people, more information is needed on how it might affect certain groups, particularly pregnant women, children, and people who are sensitive to mercury.

Nearly all the data on silver amalgam safety come from studies of adults (in many cases, people who worked in places where mercury is present in sizable quantities, like dental offices). In fact, the first randomized trials in children appeared only in April 2006. These two studies, published in the Journal of the American Medical Association, found that children whose cavities were filled with silver amalgam had no health problems as a result. Each study involved more than 500 children, who randomly received either amalgam or composite fillings. One study tested the children over several years on memory, attention, physical coordination, and speed of nerve conduction; the other study tested IQ. Researchers found no difference in test scores between the children with amalgam fillings and those with composite fillings. They did find, however, that the children with the amalgam fillings had slightly higher levels of mercury in their urine.

While these studies are reassuring, more information is still needed. In the meantime, should pregnant women and children avoid amalgam fillings? The FDA advisory panel said there wasn't enough information available to answer this question. Some other countries take a precautionary approach, avoiding the use of amalgam in pregnant women or restricting it even further.

The debate about amalgam has prompted some dental professionals to substitute more expensive restorations for intact silver fillings for all patients. But there is no evidence that removing your amalgam fillings will benefit your health.

Most amalgam fillings wear out in 10 years or less and need to be replaced. At that time, you and your dentist should discuss which restoration material is best for your dental needs.

Prevent dry mouth to protect your teeth and gums

For some people, dry mouth (xerostomia) is merely an occasional annoyance. For others, it's persistent enough to jeopardize their oral health. Dry mouth can cause difficulty eating and swallowing, bad breath, and irritation and infection of the mouth tissues. It also raises the risk for tooth decay and gum disease. A shortage of saliva inhibits the remineralization process so severely that the number of cavities begins to rise within as little as three months after dry mouth begins.

Causes of dry mouth

These are some of the factors that can lead to dry mouth:

chronic diseases such as diabetes, Parkinson's disease, HIV, and an autoimmune condition called Sjögren's syndrome

medications for many conditions, including high blood pressure, depression, and asthma (see "Common oral side effects of medications")

radiation therapy that damages the salivary glands

chemotherapy drugs

damage to the nerves in the head and neck that control the salivary glands.

Self-care techniques

You can fend off the effects of dry mouth by taking action to increase the flow of saliva and by paying special attention to preventing tooth decay. Here are some steps that can help:

Use over-the-counter artificial saliva products, such as Salivart Synthetic Saliva, Saliva Substitute, or Salix.

Drink plenty of sugar-free liquids.

Suck on sugarless hard candy or chew sugarless gum.

Avoid alcohol, caffeine, and tobacco. These substances can dehydrate you.

Limit the amount of sugar in your diet.

Use a fluoridated toothpaste and mouth rinse regularly.

Practice good brushing and flossing habits.

Ask your dentist about professional fluoride applications.

Gum disease

Gum disease is the primary culprit in adult tooth loss. Without rigorous dental hygiene, plaque formation spirals into disease and, eventually, the destruction of the teeth and surrounding structures.

As with cavities, periodontal disease is caused by bacteria in the mouth. But the bacteria that cause cavities need oxygen to survive, while the bacteria that attack the gums prefer an oxygen-free environment. The effects of periodontal disease range from mild redness and swelling of the gum tissue (gingivitis) to complete destruction of the tooth's bony support structure (advanced periodontitis).

How gum disease develops

Periodontal disease gets its foothold when plaque forms in the sulcus, a shallow trough at the point where the gum meets the tooth. Without proper cleaning, plaque can build up here like leaves in a gutter. Successive layers of bacteria prevent oxygen from reaching the innermost recesses of the sulcus. This enables the anaerobic bacteria to prosper. Thus, these pockets at the margins of the gum become a fertile breeding ground for the bacteria (see Figure 4).

Figure 4: The progression of gum disease

Gum disease develops when decay spreads to the tissues that support the teeth. Healthy gums (A) are firm, embracing the teeth tightly. But without proper cleaning, plaque can build up where the gum tissue meets the tooth. As plaque accumulates, the gum tissue pulls away from the tooth, creating a tiny pocket. The gums become inflamed, a condition called gingivitis (B). Gingivitis sometimes progresses to more severe gum disease, known as periodontitis (C). Here, the pocket widens as the gum pulls back from the root of the tooth. The disease also destroys the periodontal ligament and bone, reaching the tooth socket. Eventually, the ligament and bone damage cause the tooth to become loose, and it may fall out.

Toxins released by the bacteria inflame the surrounding tissue. Meanwhile, the surface of the plaque hardens into tartar, which further irritates the gums. When inflammation becomes apparent, dentists say you have gingivitis.

Your immune system responds to the bacterial activity by sending a legion of antibodies to the site. How well the antibodies combat the bacteria depends on several factors, including the type and number of bacteria present as well as your ability to fight off disease. As periodontal disease advances, enzymes your body releases as a by-product of the immune response begin attacking the gum tissue itself.

The connective tissue attaching the tooth to the gum is the first structure to be destroyed. The detached gum then pulls back from the root of the tooth, deepening the gingival pocket and leaving the exposed portion of the tooth root vulnerable to cavity-causing bacteria.

Next the disease attacks the underlying periodontal ligament. The diagnosis officially switches from gingivitis to periodontitis when the destruction reaches the tooth socket in the alveolar bone. As the periodontal ligament continues to break down and more bone is lost, the tooth loosens in its socket. Eventually, it may fall out.

Occasionally, deep pockets close up at the top, walling off the pus in a bubble of inflamed gum tissue called an abscess. The swelling and inflammation often loosen adjacent teeth and hasten the destruction of the surrounding alveolar bone.

Dentists gauge the severity of periodontal disease by how fast it degenerates from one stage to the next and how well the person responds to treatment. Inflammation doesn't always progress to periodontitis. How and why the transformation takes place is still a subject of speculation. According to the American Academy of Periodontology, 30% of the population may have a genetic predisposition to gum disease. This tendency makes them six times more likely to succumb to periodontitis, despite their best oral hygiene efforts.

Gingivitis

Gingivitis, the earliest manifestation of gum disease, can cause redness, swelling, bleeding, and sometimes tenderness of the gums. Inflammation is usually limited to the surface tissue. If the inflammation is very mild, your dentist may detect it even before you notice any discomfort.

Gingivitis usually results from poor oral hygiene. With no brushing at all, a previously healthy mouth will begin to show evidence of gingivitis in less than three weeks. Some factors can make gum disease more likely or accelerate its pace. These include

hormonal changes associated with puberty, pregnancy, or menopause

certain medications for epilepsy, heart disease, and other chronic conditions

poor nutrition

poorly fitting braces, dentures, or restorations

smoking

diabetes

HIV infection.

Gingivitis is almost always correctable when it's caught early. The first step is a thorough professional cleaning to remove plaque and tartar from the sulcus. This treatment, along with better brushing and flossing habits, usually does the trick.

Several rare forms of gingivitis are brought on by factors other than plaque accumulation. These forms of the disease include

acute necrotizing ulcerative gingivitis, also called trench mouth or Vincent's infection

desquamative gingivitis, a rare form targeting primarily postmenopausal women

gingivostomatosis, painful ulcers on the gums and oral mucosa caused by the herpes simplex virus

pericoronitis, the inflammation of the gum around an impacted wisdom tooth.

Antibiotics in gum disease treatment

As researchers learn more about the specific organisms that cause periodontitis, antibiotic treatment has begun to play a greater role. In mild or moderate cases of periodontitis, pairing scaling and root planing with a combination of amoxicillin and metronidazole can often resolve the problem. This approach can also help patients with advanced disease, according to a 2002 study in the Journal of the American Dental Association . A group of individuals diagnosed with advanced periodontitis were treated with scaling and root planing plus antibiotic therapy. They also received maintenance treatment every three months over the next five years. At the end of the study, the participants were able to avoid surgery or extraction on 87% of the teeth that were treated in this way.

There is a downside, though. Experts worry that overusing oral antibiotics could create drug-resistant strains of bacteria. But using sustained-release medications in the form of gels, fibers, and chips that deliver antibiotics directly into the periodontal pocket may avert this problem. Focusing treatment only on the bacteria that are causing the problem may avoid exposing other bacteria throughout the body to unnecessary doses of antibiotics.

Periodontitis

Left untreated, gingivitis can progress into periodontitis. The gingival pockets deepen, inflammation increases, and the tissues that support the teeth deteriorate. While periodontitis always begins with gingivitis, not all cases of untreated gingivitis develop into periodontitis.

Periodontitis can start as early as adolescence, but it's more common after age 30. Although periodontitis tends to worsen with age, it doesn't always pro-gress in a linear fashion. Researchers believe that short episodes of intense disease activity are followed by periods of remission. Periodontitis appears to come and go randomly at different sites in the mouth. The disease doesn't actually disappear; it merely subsides for a while or reactivates in another area.

Periodontitis comes in several forms, with chronic adult periodontitis being the most common. One relatively rare type of adult periodontitis advances very rapidly and often doesn't respond to treatment. Two other forms of periodontitis — prepubertal and juvenile — affect children and teenagers. These variations tend to be linked to a systemic disorder or a family history of periodontal disease.

Receding gums

Periodontal disease is by far the most serious cause of gum recession. However, bacteria and plaque aren't always to blame. Your gums may pull back from the neck of the tooth for mechanical reasons. Using a hard toothbrush or brushing too forcefully can actually wear away the gum tissue at the point where it meets the tooth. In addition, it's common for gums to recede with age.

If gum recession leaves the roots of your teeth exposed, your teeth may become more sensitive to hot, cold, sweet, or sour foods and drinks. Your dentist may recommend using a soft toothbrush, special toothpaste, or a fluoride rinse.

Gum recession may also leave the dentin in the root exposed and vulnerable to decay. Root decay or root cavities may follow. This problem is particularly serious among older adults.

In some cases, your periodontist may recommend treating gum recession with graft surgery. This involves moving gum tissue from another part of your mouth to the affected area, covering the exposed part of the tooth.

Diagnosing gum disease

Your dentist can calculate the extent of your periodontal disease using a series of measurements, laboratory tests, and x-rays.

Gingival bleeding index. Your dentist scores the severity of the disease based on how easily the gum bleeds when the sulcus is prodded gently.

X-rays. X-rays can reveal bone disintegration and track the level of bone loss over time.

Pocket probing. The dentist measures the depth of the gingival pockets with tiny rulers or electronic devices. The results range from 1–3 millimeters (less than one-eighth inch) for healthy gums to more than 7 millimeters (about one-quarter inch) for advanced periodontitis.

Bacterial tests. This kind of testing identifies the types of bacteria in the plaque and helps pinpoint areas of active disease.

Host response tests. These tests detect markers in blood, saliva, or gingival fluid that indicate areas where the disease is active. Scientists are trying to develop forms of the test that can identify people who are at greater risk for periodontitis.

Treating gingivitis and periodontitis

When treating gum disease, the goal is to eliminate plaque, reduce bacterial activity, and protect the teeth from further damage. The specific therapies your dentist recommends will depend on your particular circumstances. Most treatment, however, involves some or all of the following procedures.

Scaling and root planing (debridement). Your dentist or hygienist removes accumulated plaque and tartar above and below the gum line with either a manual scaler or an ultrasonic instrument. This is known as scaling or deep scaling. Depending on the circumstances, he or she may also scoop damaged tissue out of the bottom of the gum pockets to spur the healing process (a procedure called curettage). The final step — root planing — smooths the root surface so that the gum tissue can reattach more easily. These procedures are usually performed under local anesthesia.

Surgery. Occasionally with moderate to advanced disease, the periodontist must surgically remove the degenerated gum tissue and reduce the depth of the pocket before the tooth root can be properly cleaned. Surgery (see below) is recommended only in cases where it will prevent the loss of the tooth and when more conservative measures have failed to stop the progression of the disease.

Drug therapy. Short courses of oral antibiotics, as well as antibiotic and antiseptic medications applied directly to the gums, can reduce bacteria and inflammation. For example, the medication Periostat helps halt disease progression by blocking the enzyme that attacks tooth and gum tissue. In some cases of moderate disease, drug therapy along with regular debridement can avert the need for surgery.

Maintenance. After initial treatment, plaque levels must be kept low to avoid a resurgence of the disease. A good plan includes visiting the dentist or hygienist every three months, brushing and flossing without fail, and using an antimicrobial mouth rinse.

Types of gum surgery

If more conservative treatment measures don't solve the problem, your dentist will probably recommend gum surgery. The type of procedure used depends on the level of damage to your gum and bone tissue. Generally, your periodontist will perform these procedures in his or her office, using local anesthesia.

Curettage. The periodontist scoops out the infected gum tissue. This promotes healing.

Flap surgery. After making an incision in the side of the pocket, the periodontist folds back a flap of gum tissue. This procedure exposes the interior of the pocket, the tooth root, and the alveolar bone for cleaning. The periodontist removes the infected tissue and scales and planes the root. Finally, he or she stitches the flap back into position, closing up the gum pocket.

Tissue regeneration. During flap surgery, the periodontist inserts bioactive membranes or tissue-stimulating proteins under the gum. This promotes the regrowth of bone that's been damaged by gum disease.

Bone surgery. To reduce the chance of new pocket formation, the periodontist smooths irregularities on the bone's surface caused by degeneration.

Gum grafts. The periodontist grafts tissue from the roof or other areas of the mouth onto the gum, at the tooth line, to cover portions of the root that have been left exposed by a receding gum. This procedure is usually done to halt gum recession, cut down on tooth sensitivity, and improve appearance.

Bone grafts. The periodontist grafts new tissue onto areas where the alveolar bone has degenerated. The graft may consist of bone taken from another part of the mouth, bone from a donor, or synthetically manufactured material.

If several of your teeth need work, you may have to return a few times. After surgery, the periodontist will cover the affected gum with quick-drying protective putty so you can eat normally while it heals.

Review Date: 2007-04-01

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