PROCEDURES

Periodontal Diseases and Prevention

Periodontal diseases are infections of the gums, which gradually destroy the support of your natural teeth. There are numerous disease entities requiring different treatment approaches. Dental plaque is the primary cause of gum disease in genetically susceptible individuals. Daily brushing and flossing will prevent most periodontal conditions.

Why is oral hygiene so important? Adults over 35 lose more teeth to gum diseases, (periodontal disease) than from cavities. Three out of four adults are affected at some time in their life. The best way to prevent cavities and periodontal disease is by good tooth brushing and flossing techniques, performed daily.

Periodontal disease and decay are both caused by bacterial plaque. Plaque is a colorless film, which sticks to your teeth at the gumline. Plaque constantly forms on your teeth. By thorough daily brushing and flossing you can remove these germs and help prevent periodontal disease.

Periodontal diseases can be accelerated by a number of different factors. However, it is ultimately caused by the bacteria found in dental plaque, a sticky colorless film that constantly forms on your teeth. If not carefully removed by daily brushing and flossing, plaque hardens into a rough, porous substance known as calculus (or tartar).
Periodontal Disease

Bacteria found in plaque produces toxins or poisons that irritate the gums, which may cause them to turn red, swell and bleed easily. If this irritation is prolonged, the gums separate from the teeth, causing pockets (spaces) to form. As periodontal diseases progress, the supporting gum tissue and bone that holds teeth in place deteriorate. If left untreated, this leads to tooth loss.
Preventing Gum Disease

The best way to prevent gum disease is effective daily brushing and flossing as well as regular professional examinations and cleanings. Unfortunately, even with the most diligent home dental care, people still can develop some form of periodontal disease. Once this disease starts, professional intervention is necessary to prevent its progress.
Other important factors affecting the health of your gums include:

  • Smoking
  • Diabetes
  • Stress
  • Clenching and grinding teeth
  • Medication
  • Poor nutrition

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Scaling and Root Planing

Many times, the early stages of periodontal disease are best treated with non-surgical periodontal therapy. Even in severe cases of periodontal disease, non-surgical periodontal therapy often precedes surgical therapy. This is done to improve the overall tissue quality prior to surgery and also to help limit the areas requiring surgery.

Treatment methods depend upon the type of disease and how far the condition has progressed. The first step is usually a thorough cleaning that may include scaling to remove plaque and tartar deposits below the gumline.


Subgingival Scaling: Cleaning the tooth below the gumline.

The tooth roots may also be planed to smooth the root surface allowing the gum tissue to heal and reattach to the tooth. In some cases, the occlusion (bite) may require adjustment.


Root Planing: Smoothing the tooth root

Antibiotics or irrigation with anti-microbials (chemical agents or mouth rinses) may be recommended to help control the growth of bacteria that create toxins and cause periodontitis. In some cases, Dr. Bridges may place an antibiotic in the periodontal pockets after scaling and planing. This may be done to control infection and to encourage normal healing.

When deep pockets between teeth and gums are present, it is difficult for Dr. Bridges to thoroughly remove plaque and tartar. Patients can seldom, if ever, keep these pockets clean and free of plaque. Consequently, surgery may be needed to restore periodontal health.

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Dental Implants
A Single Dental Implant Supports A Natural Appearing Tooth

Why Should I Replace My Missing Teeth?

Usually, when you lose a tooth, it is best for your oral health to have it replaced. Missing teeth can affect your "bite" as well as your ability to speak and chew. Their loss can increase the burden on your remaining teeth and can cause muscle pain in your jaws and headaches. And of course, losing a tooth can affect your appearance.

The good news is that, most of the time, replacing a missing tooth is not an emergency. You have time to consider what replacement option is best for you and to make an informed decision. This booklet discusses your general treatment options.

What Are My Tooth Replacement Options?

If you are missing one or more teeth and choose to have it or them replaced, several treatment options are available.

A ‘flipper’ is a removable plastic tooth that is inexpensive but fragile and temporary.

A cast partial denture also is removable but is precision cast in metal for longer service life. Wire clips help hold it in place.

A fixed bridge is cemented into place using crowns or "caps" on the teeth adjacent to the open space for support. Crown placement usually requires removing or reducing the outer layer of the tooth. In some cases, a ‘Maryland’ bridge, a fixed bridge that does not need crowns, is glued onto the back of the teeth adjacent to the space so that minimal tooth structure is removed.

Complete dentures or ‘plates’ are the traditional solution for people who have lost all their teeth in one or both jaws. The success of a complete denture depends upon the individual’s jaw size and shape, his or her oral habits, and his or her adaptability. Some people adapt well to dentures, while others are not able to adapt.

Dental implants can be used to provide support for the replacement of one tooth or all of an indivi-dual’s teeth. After years of research and clinical trials, we can now provide this option in addition to the traditional treatments just described. Implant-supported teeth can be cemented, screw-retained, or removable and can be made attractive, stable, and comfortable for almost any patient.

Flipper (removable)
Cast partial denture (removable)
Lower complete denture

Are Dental Implants An Option For Me?

If you are considering dental implants, your mouth will be examined thoroughly and your dental and medical history will be reviewed to ensure that dental implants are appropriate for you. Dental x-rays and, frequently, panoramic (or complete) x-rays of your jaws will be taken to evaluate your jawbone and to determine if it will accommodate implants. Occasionally, more detailed information is required and can be provided by special x-rays. They will help determine if additional tests or procedures are needed to place your implants properly.

What Is A Dental Implant?

The best way to describe a dental implant is to compare it to a real tooth. A natural tooth consists of a root and a crown. The part of the tooth that you see and eat with is called the crown. Beneath the crown is the root, which anchors the tooth through the gum tissue to the jawbone. When you lose a tooth, you lose both the root and the crown. To replace a tooth, we first have to replace the root. Essentially, a dental implant is a new root. This titanium root is fitted into a socket that we create in your jaw, replacing the lost root of your natural tooth.

Dental implants come in various shapes and sizes and have different types of surfaces. The actual implant selection will depend on a variety of factors related to your specific treatment needs and the most appropriate one(s) will be used. Once an implant has been placed in the jaw, the bone around the implant will need to heal for up to six months, depending upon how hard the bone is. When this initial phase of healing is completed, a support post called an abutment will be placed on the implant itself and then a new crown will be placed on top. If all of your teeth are missing, a variety of treatment options are available to support the replacement teeth.

A dental implant is placed into the prepared socket

How Are Dental Implants Placed?

Usually, the office procedure to place a dental implant takes about an hour for one implant and no more than two or three hours for multiple implants. The placement process consists of the following steps:

If indicated, you will be given medication such as antibiotics prior to the surgery. You may be offered sedation with nitrous oxide ("laughing gas") or intravenous medications. Then, a local anesthetic will be administered to numb the areas where the implant(s) will be placed.

  • After you are comfortable, a small incision is made into the gum tissue, revealing the bone into which the implant will be placed.
  • Using special instruments, a space (socket) is created in the bone into which the implant will be placed.
  • The titanium implant is then inserted into the socket.
  • Finally, if necessary, sutures will be used.
The final crown is secured to the implant.

Once the implant is inserted, it is completed in one of two ways: First, the gum tissue will be closed (or sutured) over the implant, allowing the implant to heal for up to six months. Then a second procedure, called "uncovering surgery," will be performed after a local anesthetic has been used to numb the gum tissue. Next, the gum is moved out of the way, the implant located, and a healing cap placed into it. The gum tissue is then sutured around the healing cap. Generally, after two to four weeks, you will return to have the healing cap removed, the abutment (or support post) placed, and impressions made in order for the final crown (replacement tooth) to be fabricated. This is called a "two-stage" or "two-step" approach to implant placement and is the more traditional approach. For more aesthetically important areas, we may ask that you wait up to 12 weeks to begin the final restorative process. During this time, you will be fitted with temporary teeth. Occasionally, impressions are made at the time the implant is placed in order to have a crown ready when the implants have healed.

The final crown is secured to the implant.

After the implant is placed, the area will need to heal for as long as six months. How long your mouth will need to heal will be determined by a variety of factors. Follow-up care (one to four appointments) is usually needed to ensure that your mouth is healing well and to determine when you are ready for the restorative phase of your treatment.
An alternative approach is called the "single-stage" or "one-step approach," in which a healing cap is added at the same time as the implant is placed and the gum tissue is sutured around it. If the entire process occurs during one step, a second surgery to place the healing cap is unnecessary. Because only one surgical appointment usually is all that is needed, both patients and doctors often prefer this approach. However, it is not always the best method for placing implants. We will use the most appropriate approach to meet your particular needs.

On occasion, it may be necessary to perform a "soft tissue graft" to obtain stronger, more easily cleaned and natural appearing "gum" tissue in the area around the implant. This process involves moving a small amount of gum tissue from one part of your mouth to the area around the implant. Most often, it is a brief and relatively comfortable procedure.

When Are The Implants Placed?

Approximately three months after the tooth is removed, the implant is placed where the missing tooth was located. Once a tooth is removed, if your socket walls of bone are intact and fairly thick, your body will grow new bone to replace or refill the empty socket. Your socket will usually be completely filled in with bone by the time you are ready for placement of your implant (about three months later). Occasionally, it is possible to take out the tooth and place the implant at the same time. This may involve a little more risk, but it simplifies the process—you won’t have to wait three months for the bone to refill the socket. Again, there are times when this is appropriate and other times (when infection or other problems with the bone are present) when immediate implant placement is not the best treatment.

If your tooth has been missing for some time, the adjacent bone is likely to grow thinner because the root of the tooth itself has stimulated the bone. Once the tooth root is removed, the bone loses this stimulation and starts to disappear. As much as one third of your jaw’s thickness can be lost in the year following tooth extraction. If you are missing quite a bit of bone, you may need to have additional bone grafted into the area so that the implant will be supported adequately when it is placed.

Do I Have Enough Bone?

Again, if after tooth extraction the walls of the socket are very thick, they will usually fill with bone in three months. However, if the walls of your socket are very thin (such as in your upper and lower front teeth), then this type of healing will not be as predictable. After waiting three months for the bone to fill in, you may have only a very thin ridge of bone. Sometimes, a bone graft is placed at the time of tooth extraction to help your body fill in the socket with bone. This step will maintain the width or volume of bone you will need for implant placement. It is most commonly performed on thin-walled extraction sockets, especially in such visible areas as the front of the mouth.

The jaw bone undergoes atrophy following tooth loss.

If your tooth was removed many years ago, then your bony ridge may be extremely thin and you may not have enough bone left for implant placement. In this case, a bone graft can be placed next to the thin bone and allowed to heal for three to nine months. After the graft has fused to your pre-existing bone, the ridge will be re-entered and the implant placed. Usually bone grafting is a relatively comfortable procedure. Many different bone-grafting materials are available, including your own bone.

Bone can be grafted to widen a narrow jawbone.

You also may need bone grafting if the sinus cavities in your upper jaw are very large or very low and extend into the tooth-bearing areas. This often occurs when teeth in the back of a person’s upper jaw have been removed many years before, and the amount of bone available for implant placement is thus limited. This condition requires what is called a "sinus grafting procedure." Most often, it is performed in the office with local anesthesia and perhaps sedation. During this procedure, the membrane that lines the sinus will be located and elevated. Bone will then be added to restore the bone height and ensure that dental implants of an adequate length can be placed. This procedure often can be performed at the time of implant placement.

How Many Implants Do I Need?

Most frequently, one implant per missing tooth is placed. Because many of the larger teeth in the back of your jaws have two or three roots, the most common approach is to replace missing back teeth with larger implants or more than one implant per tooth, especially if there has been moderate bone loss or if there is evidence of excessive biting force.

What If I’m Missing All Of The Teeth In My Lower Jaw?

If you are missing all of the teeth in your lower jaw, you may consider a number of treatment options. Although many patients have no problem wearing an upper denture, some find it difficult to wear lower dentures.

The first option is to have two implants placed in your lower jaw and a denture made that snaps onto these implants. This option allows your lower denture to be more stable while chewing than without implants. This is a viable option if your jaw’s support ridge is big enough. There will still be movement of your lower denture, however, and you can still get sore spots if any food particles, especially seeds, are caught under it. As with all removable replacement teeth, you still will need periodic appointments for denture adjustment.

A second option involves placing four to six implants, depending on your jaw size or shape, into your lower jaw. After healing is complete, the implants are connected with a custom-made support bar. Your denture will be made with special retention clips inside that attach onto the support bar, allowing the denture to snap firmly into place. This is called an "overdenture." The advantage of this option is that it is much more stable than the first option, allowing very little denture movement. Your denture still will be removable for easy cleaning and maintenance.

The implant support structure and clip-retained denture.

 

A clip-retained, implant supported denture holds securely.

A third option involves placing five or more implants in your jaw and attaching a permanent denture. Your denture is held in place by screws or clasps that secure it to the support posts or bar. It doesn’t touch the gum tissue, which allows you to clean under the denture without removing it. This denture will replace all your missing lower teeth and will not be removed except at maintenance visits. Although cleaning under your denture without removing it is more time consuming and requires more dexterity, many patients who want a permanent denture prefer this option.

The final option is to have all your teeth individually replaced so that they will appear to be growing out of your gum tissue and will most closely resemble the appearance of your natural teeth. This option usually requires eight or more implants. Separate abutments or support posts for each one of these implants will be made and crowns for each missing tooth will be placed. The teeth are then frequently joined together for strength and support. Overall, this is the most costly option, because (among other reasons) it requires the most implants. In addition, your options may be limited by the current size and shape of your jawbone

What If I’m Missing All Of My Upper Teeth?

A similar range of treatment options is also available for your upper jaw. However, because the bone is not as hard as that in the lower jaw, people often need more implants to support their replacement teeth.

Depending upon the number of implants to be placed, it may be possible to eliminate the need for covering the roof of your mouth with the denture. This option will allow you to better taste your food and to better sense food temperature, and it will make your denture feel more natural. You will still have a removable denture, which makes cleaning the support bar and denture much easier. If you want a restoration that is similar to your natural teeth and therefore not removable, you probably will need eight to ten implants placed. This is followed after healing by the placement of the abutments and crowns.

What Can I Use For Teeth While The Implants Are Healing?

Many options are available, and they are tailored to your specific needs. If you need a replacement tooth while the implants are healing, temporary removable teeth or a temporary bridge can be made. If all your teeth are missing, we can usually modify your present complete denture or make you a new temporary denture. If you would prefer nonremovable teeth during the healing phase, temporary transitional implants usually can be placed along with the permanent implants, and temporary teeth may be made and inserted the same day.
What Are The Potential Problems?

Although it is natural to be concerned about the pain that may be caused by these procedures, most patients do not experience severe or significant postoperative pain. Pain medication and antibiotics will be prescribed for you to make your recovery as easy as possible. Occasionally, some people develop postoperative infections that require additional antibiotic treatment. In addition, there is a chance that the nerve in the lower jaw, which provides sensation to your lower lip and chin, may be affected. If you are missing quite a lot of bone, it might be difficult to place an implant without infringing on the nerve space. Although we take great care to avoid this nerve, occasionally it is irritated during the procedure, resulting in tingling, numbness or a complete lack of sensation in your lip, chin or tongue. Although these altered sensations will usually resolve with time, they can be permanent and/or painful. If you notify us of postoperative numbness as soon as possible, it will allow us to manage your care in the most appropriate way.

How Long Will The Implants Last?

Implants last a long time. Of patients who were missing all of their teeth, long-term studies (more than 30 years) show an 80 to 90 percent success rate. For patients missing one or several teeth, six-year studies show a success rate of greater than 90 percent, which compares favorably with other areas in the body that receive implant replacement (such as hips or knees). However, if one of your dental implants either doesn’t heal properly or loosens after a period of time, you may need to have it removed. After the site heals (or on occasion at the time of removal), another implant usually can be placed.

What Happens After The Implants Have Healed?

In most cases, after four to six months of healing, your jawbone is firmly fused to the implants. The restorative phase of your treatment, when your missing teeth are actually replaced, is now ready to begin. Depending on a variety of factors, it may be possible to begin this phase of your treatment as early as six weeks after implant placement. We will review the most appropriate treatment sequence and timing for your particular situation.

In some cases, depending on the density or hardness of your bone, it is helpful to gradually increase the work on your implants. Various types of temporary replacement teeth are used during this phase. Information we obtain at the time of implant placement will help us to determine what is the most appropriate approach for you.

The dental work required to complete your treatment is complex. It is, however, considered more comfortable and more pleasant than conventional dental care. Frequently, most of the work can be done without using even local anesthesia.

Your restorative treatment begins with specialized impressions that allow us to produce a replica of your mouth and implants. We will also make "bite" records so that we see the relationship of your upper and lower jaws. With this information, we will make the abutments (support posts) that attach your replacement teeth to your implants. Various types of abutments exist.

Frequently, we can use "off the shelf" abutments. Other times, custom abutments must be made of gold or a tooth-colored ceramic material. As you can imagine, these custom-made abutments add to the cost and treatment time involved. Which abutment to use is a decision that often cannot be made until after healing is complete and impressions have been made.

The number of appointments and the amount of time required for each appointment is different for each patient. No two cases are exactly the same and regardless of the number of teeth replaced, the work must be completed with great precision and attention to detail. If you are having only a few teeth replaced, as few as three short appointments may be required. Between appointments, we will need time to complete the necessary lab work to make your replacement teeth.

If your final restoration is a removable denture, you will need to come to as many as five office appointments (although it may be fewer) over the following several months. During these appointments, we will perform a series of impressions, bites and adjustments in order to make your new teeth, as well as the custom support bars, snaps, magnets, or clips that will secure your teeth to the implants. During this period we will make every effort to make certain you have comfortable temporary replacement teeth.

In general, once your implants are placed, you can expect your treatment to be completed anywhere from two to 12 months. For these reasons, it is difficult for us to tell you exactly how much the restorative phase of your treatment will cost, although you should receive a reasonable estimate of costs . It also is difficult to give you a specific timeframe for completion of your treatment until after the implants are ready for restoration.

How Do I Clean My Implants?

As with natural teeth, it is important that you clean implant-supported restorations regularly with toothbrushes, floss and any other recommended aids. You also should visit your dentist several times each year for hygiene and maintenance. As with regular dentures and other tooth replacements, your implants and their associated components are subject to wear and tear and eventually will need repair, including clip replacement, relines, screw tightening, and other adjustments.

Will One Doctor Do Everything?

In some situations, your dental implants can be placed and restored in the same office. At other times, one dentist places the implant(s) and performs any other necessary additional surgical procedures while another dentist provides the temporary teeth and restores the dental implants after healing is complete. In this case, both doctors are involved in planning your dental treatment. Also, depending upon a variety of factors, different dental specialists will help with your dental care.

What Do These Services Cost?

Before treatment begins, every effort will be made to give you an accurate estimate of all the expenses involved in placing and restoring your dental implants. This includes the implant placement itself plus any bone and soft tissue grafting procedures that are needed. In many cases, there is an initial charge for the diagnostic work-up, including study models, x-rays, and the fabrication of a surgical template to ensure the best possible result. You also will be charged for the abutment or support post(s), plus the crown, dentures, or anything else that will be placed over the implants, including temporary restorations, as well as for periodic maintenance such as hygiene visits, tissue conditioners, denture relines and other repairs.

We will try to assist you in estimating what your actual payments will be after we evaluate your insurance coverage or other third party payments, if any. Your ultimate restorative choice should be guided by your sense of what is best for you based on the information we have provided you. You also should consider the financial impact of each treatment option as some insurance companies provide no or limited coverage. If different doctors are involved, they will charge you separately for their services.

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Cosmetic Periodontal Procedures

Cosmetic Enhancement

These procedures are a predictable way to cover unsightly, sensitive or exposed root surfaces and to prevent future gum recession. If you are unhappy with the appearance of short unsightly teeth this can be greatly improved by a combination of periodontal procedures by Dr. Bridges and cosmetic dentistry by your dentist.

Gum Grafting Procedures

(Subepithelial connective tissue grafts)

When recession of the gingiva occurs, the body loses a natural defense against both bacterial penetration and trauma. When gum recession is a problem gum reconstruction using grafting techniques is an option.

When there is only minor recession, some healthy gingiva often remains and protects the tooth, so that no treatment other than modifying home care practices is necessary. However, when recession reaches the mucosa, the first line of defense against bacterial penetration is lost.

In addition, gum recession often results in root sensitivity to hot and cold foods as well as an unsightly appearance to the gum and tooth. Also, gum recession, when significant, can predispose to worsening recession and expose the root surface, which is softer than enamel, leading to root caries and root gouging.

A gingival graft is designed to solve these problems. A thin piece of tissue is taken from the roof of the mouth, or gently moved over from adjacent areas, to provide a stable band of attached gingiva around the tooth. The gingival graft may be placed in such a way as to cover the exposed portion of the root.

The gingival graft procedure is highly predictable and results in a stable healthy band of attached tissue around the tooth.

Crown Lengthening

When decay occurs below the gumline, it may be necessary to remove a small amount of bone and gum tissue. Your dentist may ask for this procedure before he or she makes a new crown for your tooth. Reshaping the gum and supporting tissues allows your general dentist adequate room to place a quality final restoration.

Another indication for crown lengthening is when the front teeth are too short or of uneven length.

When decay occurs below the gumline, it may be necessary to remove a small amount of bone and gum tissue. Your dentist may ask for this procedure before he or she makes a new crown for your tooth.

Reshaping the gum and supporting tissues: This will allow your general dentist adequate room to place a quality final restoration.

Final Restoration: Another indication for crown lengthening is when the front teeth are too short or of uneven length.

Osseous Surgery

Traditionally, gum disease is treated by eliminating the gum pockets. The infected gum tissue is trimmed away, and uneven bone tissue re-contoured. Although this is still an effective way of treating gum disease, new and more sophisticated procedures are available under certain case situations.

Guided Tissue Bone Regeneration

This surgical procedure "regenerates" the previously lost gum and bone tissue. Most techniques utilize membranes, which are inserted over the bone defects. Some of these membranes are bio-absorbable and some require removal. Other regenerative procedures involve the use of bioactive gels.

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Bone Grafting

Over a period of time, the jawbone associated with missing teeth atrophies or is reabsorbed. This often leaves a condition in which there is poor quality and quantity of bone suitable for placement of dental implants. In these situations, most patients are not candidates for placement of dental implants.

We now have the ability to grow bone where needed. This gives us the opportunity to place implants of proper length and width, and it also gives us a chance to more effectively restore esthetic appearance and functionality.

Ridge Preservation

Careful management of extraction sockets after tooth extraction prevents unsightly bone loss and a better cosmetic outcome of tooth replacement.

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Oral Pathology

The inside of the mouth is normally lined with a special type of skin (mucosa) that is smooth and coral pink in color. Any alteration in this appearance could be a warning sign for a pathological process. The most serious of these is oral cancer. The following can be signs at the beginning of a pathologic process or cancerous growth:

  • Reddish patches (erythroplasia) or whitish patches (leukoplakia) in the mouth
  • A sore that fails to heal and bleeds easily
  • A lump or thickening on the skin lining the inside of the mouth
  • Chronic sore throat or hoarseness
  • Difficulty in chewing or swallowing

These changes can be detected on the lips, cheeks, palate, and gum tissue around the teeth, tongue, face, and/or neck. Pain does not always occur with pathology and, curiously, is not often associated with oral cancer. However, any patient with facial and/or oral pain without an obvious cause or reason may also be at risk for oral cancer.

We would recommend performing an oral cancer self-examination monthly and remember that your mouth is one of your body's most important warning systems. Do not ignore suspicious lumps or sores. Please contact us so we may help.

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Non-Surgical Services

We can use modern techniques to help rebuild lost bone support. The emphasis in Dr. Bridges’ practice is conservative periodontal therapy. Many times, the early stages of periodontal disease are best treated with non-surgical periodontal therapy. This usually consists of placing a fine ultrasonic tip in between the tooth and gum tissue to remove any plaque and calculus below the gum line. This procedure is called root planing. Four to six weeks later, periodontal pockets are eliminated due to gum shrinkage. Then the patient can personally maintain these areas with routine brushing and flossing.

Even in most severe cases of periodontal disease, non-surgical periodontal therapy most often precedes surgical therapy. This is done so that the overall tissue quality is improved prior to surgery and also limits the areas of required surgery.

Treatment Methods

Treatment methods depend upon the type of disease and how far the condition has progressed. The first step is usually a thorough cleaning that may include scaling to remove plaque and tartar deposits beneath the gumline. The tooth roots may also be planed to smooth the root surface allowing the gum tissue to heal and reattach to the tooth. In some cases, the occlusion (bite) may require adjustment.

Antibiotics or may be recommended to help control the growth of bacteria that create toxins and cause periodontitis. In some cases, Dr. Bridges may place antibiotic fibers in the periodontal pockets after scaling and planing. This may be done to control infection and to encourage normal healing.

When deep pockets between teeth and gums are present, it is difficult for Dr. Bridges to thoroughly remove plaque and tartar. Patients can seldom, if ever, keep these pockets clean and free of plaque. Consequently, surgery may be needed to restore periodontal health.

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Oral Hygiene

While brushing the outside surfaces of your teeth, position the brush at a 45-degree angle where your gums and teeth meet. Gently move the brush in a circular motion several times using small, gentle strokes. Use light pressure while putting the bristles between the teeth, but not so much pressure that you feel any discomfort.

When you are done cleaning the outside surfaces of all your teeth, follow the same directions while cleaning the inside of the back teeth.

To clean the inside surfaces of the upper and lower front teeth, hold the brush vertically. Make several gentle back-and-forth strokes over each tooth. Don't forget to gently brush the surrounding gum tissue.

Next you will clean the biting surfaces of your teeth. To do this use short, gentle strokes. Change the position of the brush as often as necessary to reach and clean all surfaces. Try to watch yourself in the mirror to make sure you clean each surface. After you are done, rinse vigorously to remove any plaque you might have loosened while brushing.

If you have any pain while brushing or have any questions about how to brush properly, please be sure to call the office.

How to Floss:

Periodontal disease usually appears between the teeth where your toothbrush cannot reach. Flossing is a very effective way to remove plaque from those surfaces. However, it is important to develop the proper technique. The following instructions will help you, but remember it takes time and practice.

Start with a piece of floss (waxed is easier) about 18" long. Lightly wrap most of the floss around the middle finger of one hand. Wrap the rest of the floss around the middle finger of the other hand.

To clean the upper teeth, hold the floss tightly between the thumb and forefinger of each hand. Gently insert the floss tightly between the teeth using a back-and-forth motion. Do not force the floss or try to snap it in to place. Bring the floss to the gumline then curve it into a C-shape against one tooth. Slide it into the space between the gum and the tooth until you feel light resistance. Move the floss up and down on the side of one tooth. Remember there are two tooth surfaces that need to be cleaned in each space. Continue to floss each side of all the upper teeth. Be careful not to cut the gum tissue between the teeth. As the floss becomes soiled, turn from one finger to the other to get a fresh section.

To clean between the bottom teeth, guide the floss using the forefinger of both hands. Do not forget the back side of the last tooth on both sides, upper and lower.

When you are done, rinse vigorously with water to remove plaque and food particles. Do not be alarmed if during the first week of flossing your gums bleed or are a little sore. If your gums hurt while flossing you could be doing it too hard or pinching the gum. As you floss daily and remove the plaque your gums will heal and the bleeding should stop.

Caring for Sensitive Teeth

Sometimes after dental treatment, teeth are sensitive to hot and cold. This should not last long, but only if the mouth is kept clean. If the mouth is not kept clean the sensitivity will remain and could become more severe. If your teeth are especially sensitive consult with Dr. Bridges. He may recommend a medicated toothpaste or mouth rinse made especially for sensitive teeth.

Choosing Oral Hygiene Products

There are so many products on the market it can become confusing and choosing between all the products can be difficult. Here are some suggestions for choosing dental care products that will work for most patients.

Automatic and "high-tech" electronic toothbrushes are safe and effective for the majority of the patients. Oral irrigators (water spraying devices) will rinse your mouth thoroughly, but will not remove plaque. You need to brush and floss in conjunction with the irrigator. We see excellent results with electric toothbrushes called Rotadent and Interplak.

Some toothbrushes have a rubber tip on the handle, this is used to massage the gums after brushing. There are also tiny brushes (interproximal toothbrushes) that clean between your teeth. If these are used improperly you could injure the gums, so discuss proper use with Dr. Bridges.

Fluoride toothpastes and mouth rinses if used in conjunction with brushing and flossing can reduce tooth decay as much as 40%. Remember, these rinses are not recommended for children under six years of age. Tartar control toothpastes will reduce tartar above the gum line, but gum disease starts below the gumline so these products have not been proven to reduce the early stage of gum disease.

Anti-plaque rinses, approved by the American Dental Association, contain agents that may help bring early gum disease under control. Use these in conjunction with brushing and flossing.

Your periodontist is the best person to help you select the right products that are best for you.

Professional Cleaning

Daily brushing and flossing will keep dental calculus to a minimum, but a professional cleaning will remove calculus in places your toothbrush and floss have missed. Visit your periodontist, as he or she is an important part of your program to prevent gum disease. Keep your teeth for your lifetime.

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