Flaps and pockets sound like clothing features, and grafts and regeneration sound like steps in pruning tree limbs, but all are terms to know if facing issues with gum, or periodontal disease. Similar to clothing, gums should fit well around the teeth to keep their sensitive parts -- the roots and nerves -- from being exposed, and like to trees, tooth roots need to be firmly planted into our gums in order to stand upright and not fall over or fall out.
Gum inflammation, or gingivitis, and periodontal disease are very common, and most people in the United States will battle the tartar and bacteria that lead to build up at the gum level. A dentist can keep gum disease at bay if we do our part and brush, floss and keep regular appointments every six months or so to address cleaning at and below the gum line. If left untreated, however, minor to moderate gingivitis can become advance gum disease and more aggressive treatments will be needed to save the teeth [source: NIDCR].
According to the Centers for Disease Control (CDC), in the U.S., 4 to 12 percent of adults nationwide have advanced gum disease. Many of these individuals would be candidates for gum surgery, and even those with more moderate forms of periodontal disease may need surgical intervention [source: CDC]. With costs in the thousands and even tens of thousands of dollars, though, a dental professional will work with patients to determine whether the surgical route is necessary and if it will save a person's teeth for the long-term. Saving teeth is a primary goal in dentistry, but balancing the effectiveness with the cost will likely help determine the best course of care and treatment. An individual may or may not have sufficient health or dental insurance to cover all or most of the surgery, and that can be a factor as well.
Gum or periodontal surgery has some similarities with the tree pruning mentioned earlier because it does, in part, involve cutting away in order to stimulate growth of tissues, just as removing drying and shrinking part of trees encourages fresh growth of limbs. And sometimes, new tissue needs to be grafted in.
We'll look at when and why it might be necessary to cut into the gums, next.
Reasons for Gum Surgery
Periodontal surgery is not the first course of action for treating gum problems. Most often, it is an intervention that comes after many less-invasive and nonsurgical treatments. Although individuals seeking treatment late in the progression of their gum disease may face surgical options sooner, it is not likely to be a surprise or sudden recommendation from a dentist. Often, a dentist will be the first to notice signs of gum distress such as gingivitis or more advanced gum disease, and a treatment plan may then progress from deep cleanings to get at the roots, called scaling and planing, to complementary treatments by a periodontist, or gum specialist.
A periodontist will assess how deep areas of gum recession go and how far areas of the gums have pulled away from the teeth. They'll chart progression, usually in millimeters, by performing root cleanings, using antibiotics, antimicrobials or other medications to combat bacterial growth below the gum line, and outline a course of home care that steps up hygiene in frequency and with specialized rinses, pastes and brushes. If the depths of gum tissues, or pockets, surrounding teeth don't decrease in size and begin to tighten around teeth after treatment and over time, surgery may then be the next course of action.
It's estimated that half of the cases of severe gum disease in the U.S. are caused by smoking cigarettes, but the other half occur from poor oral hygiene, family history of gum disease and health issues or mouth injuries affecting oral care. Smokers are three times more likely to develop gum disease than those who have never smoked, but among those nonsmokers, there are individuals with meticulous oral hygiene who are just predisposed to gum recession due to genetics, others who have brushed too hard, causing damage, and some who are just born with thin or weak tissues [sources: CDC; CUCDM]
No matter the cause or source of periodontal troubles, once identified, gums can be healed and repaired with professional intervention and by following all recommendations for maintaining healthy gums once treatment is finished [source: NIDCR]. If preventative measures didn't work and if you are at the point of needing gum surgery, damage can't be reversed but it can be corrected by a dentist, periodontist or oral surgeon -- and sometimes two or more working together. Whether or not the gum correction is long-lasting, however, depends on having very conscientious hygiene once repairs are made.
Next we'll look at what happens during gum surgery and how it might feel before and after.
Gum Grafting Surgery
In cases where periodontal surgery is needed, gum tissue is almost always receded so that it no longer covers the entire tooth root or reaches high enough up on the tooth to attach well and maintain tooth stability. Teeth can become loose, and the goal of surgery will be to rebuild lost gum tissue on a clean foundation. Using a technique called flap surgery, a periodontist or oral surgeon will cut back areas of the gums needing restoration, and while the gum tissue is flapped back, the exposed parts of teeth can be deep cleaned and treated with bacteria-killing topical agents.
Because periodontitis, or gum disease, causes the gums to pull away from teeth, plaque and bacteria are drawn to the open, moist pockets between teeth and gums. The body then sends cells to fight the infection, and these natural fighters often destroy bone and tissue along with the infection. Cleaning away the buildup in the pockets allows for a clean slate to build upon. A numbing agent or local anesthesia may be used for flap surgery, and a periodontist may recommend taking pain relievers prior to the procedure to reduce pain during and after as well.
Once flap surgery is completed and roots have been debrided, the flaps are either sutured or stitched up to heal or a second surgical procedure may be necessary. If bone loss is advanced, flap surgery might include bone and tissue grafting as well. Bone may be smoothed, or recontoured, along its sides and synthetic or natural bone with be grafted in and given time to attach. Bone growth actually can occur through surgical grafting, and proteins, which promote bone regeneration naturally, also can be used to encourage bone generation.
Gum tissue, however, has a limited ability to heal or regrow. Once gum tissue is lost, it is irreversible. After bone grafts are set in place and healing is progressing or complete, a procedure called guided tissue regeneration can begin. Soft tissue doesn't actually regenerate out of nowhere, but it can be taken from other areas (usually from the roof of the mouth) and grafted in places where gum tissue has receded and roots may be exposed. Sometimes a piece of material similar to mesh is placed between the hard tooth or bone surface and the gum tissue, and the new tissue regrows and connects around the tooth. Another method is to remove a portion of tissue, which is also called a flap, from another site and then to graft it underneath the remaining, receded tissue. The new tissue is placed above the area of recession to cover exposed root areas and is stitched to the tissue around the tooth [sources: AAP; CUCDM].
We haven't mentioned something obvious about all of this cutting, stitching and flapping: whether or not it's painful and for how long. What to expect after gum surgery, next.
What to Expect After Gum Surgery
Anyone who has had a piece of food stuck between the tooth and gums knows that gum tissue is very sensitive, to the point of causing an all-consuming pain. Gum surgery focuses on areas of the mouth with many nerve endings, but in cases needing surgical intervention, it is likely that teeth and gums have been causing some degree of discomfort for some time. Tooth sensitivity, gum irritation or trapped particles in dental pockets may already be common irritations for someone facing periodontal surgery, and numbing the area with a local anesthetic will likely be enough to prevent much of the pain during the procedure. After the surgery, however, pain and sensitivity may be moderate to high but is typically relieved with over-the-counter pain relievers or short-term prescribed pain killers. If pain persists after about three days, a call to the surgeon is advisable.
Most surgical procedures involving gum tissue are followed with a periodontal dressing, which is a molded, soft "packing" of the site that protects the grafted areas of tissue for about two weeks, more or less. Stitches will either be self-dissolving or will require removal about 10 days after surgery, which is also around the time for a follow-up exam with the oral surgeon or periodontist [source: AAP]. Keeping the mouth and teeth clean without disturbing the surgical site during this time is very important in order to prevent infection and dislodging of the newly placed tissue. An antimicrobial mouth rinse also may be part of the oral care plan after surgery.
Bleeding and swelling, which can increase the infection risk, also might occur for two to three days after the procedure, and eating and drinking also may bring some discomfort, as the gums and teeth can be very sensitive after any periodontal procedures and especially after an invasive one. It's also possible to experience long-term sensitivity to hot and cold food and other stimuli [source: AAP]. These issues can be discussed with your dentist or after-care hygienist at post-procedure appointments several months after surgery or sooner.
Caring for teeth and gums after any periodontal procedure is especially important. Grafted areas of gum tissue may be prone to receding more quickly and cavities at the root level also can develop if oral care is neglected -- but be gentle. A gentle cleaning with a soft brush and following any specialized recommendations of your dentist or periodontist will give you a gum up in keeping your teeth where they belong, often for life.
More Great Links
- American Academy of Cosmetic Dentistry (AACD). "Periodontal Plastic Surgery." 2011. (Jan. 21, 2012) AACD.com. http://www.aacd.com/index.php?module=cms&page=578
- American Academy of Periodontology (AAP). "Periodontal Procedures." Perio.org. March 2, 2011. (Jan. 21, 2012) http://www.perio.org/consumer/procedures.htm
- Centers for Disease Control and Prevention (CDC). "Preventing Cavities, Gum Disease, Tooth Loss, and Oral Cancers at a Glance 2011." CDC.gov. July 29, 2011. (Jan. 21, 2012) http://www.cdc.gov/chronicdisease/resources/publications/AAG/doh.htm
- Columbia University College of Dental Medicine (CUCDM), ed. "Bone Grafts (Periodontal Regenerative Surgery)." SimpleStepsDental.com. May 20, 2009. (Jan. 20, 2012) http://www.simplestepsdental.com/SS/ihtSSPrint/r.WSIHW000/st.32226/t.32539/pr.3/c.510784.html
- Columbia University College of Dental Medicine (CUCDM), ed. "Gingival Flap Surgery." SimpleStepsDental.com. Dec. 22, 2010. (Jan. 20, 2012) http://www.simplestepsdental.com/SS/ihtSSPrint/r.WSIHW000/st.32576/t.32536/pr.3/c.310273.html
- Columbia University College of Dental Medicine (CUCDM), ed. "Soft-Tissue Grafts." SimpleStepsDental.com. Feb. 23, 2009. (Jan. 20, 2012) http://www.simplestepsdental.com/SS/ihtSSPrint/r.WSIHW000/st.32576/t.32537/pr.3/c.310389.html
- National Institute of Dental and Craniofacial Research (NIDCR). "Periodontal (Gum) Disease: Causes, Symptoms, and Treatments." NIH.gov. July 2011. (Jan. 21, 2012) http://www.nidcr.nih.gov/OralHealth/Topics/GumDiseases/PeriodontalGumDisease.htm