From: Larry Burnett
Sent: Friday, March 16, 2001 02 31

I'd like to know if you sometimes have patients referred for grafting procedures
and after seeing and talking to patient you and the patient decide he really
doesn't need or want it.  If so, is it difficult to handle the situation without
alienating the referring dentist?


From: Kelly D. Douglass, DDS, MS
Sent: Thursday, March 15, 2001 18 56

I've not found it to be a problem in alienating the referring dentist....
and there have been a number of times I've recommended not doing the grafts.
Generally when a patient is referred to me it is to use my expertiese and knowledge
to determine what needs to be done......or not done.  That's the reason they refer
to me.  They don't treat me like a short order cook and just tell me what to do/cook
for them. - kelly d. douglass, dds, ms


  

  

    
   
    

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From: JB
Sent: Friday, March 16, 2001 03 32

Everyone:

Thanks for all the responses and advice, though I confess, I've not
yet had a chance to go through it all in detail.

My recession has doubtless been caused primarily from YEARS of
brushing too damn hard.  I'd always been told that I had "beautiful
teeth" or a "nice smile", and I can distinctly remember, as a kid,
thinking that brushing vigorously twice daily with my firm bristles
was the proper way to maintain my dental health and appearance.
I recall being almost disgusted by the perceived ineffectivness of soft-bristled
brushes the few times I used them.

Not until I started noticing and worrying about recession a few years
ago, did I become aware through my dentist that SOFT bristles are the
way to go. (Can someone please explain why they even MANUFACTURE the
other firmnesses? For cleaning bathroom tiles?) I can't believe that
I'm almost 37 and I heard for the first time only less than a year
ago on the NBC's "Later Today" show (now-defunct, I believe) that one
of the keys to dental health was brushing for 3 minutes!

I now use a soft brush (though the 'soft' ones I've been using are
not nearly as soft as the 'ineffectual' ones I remember from my
youth), despite this, my recession is continuing.  Thankfully my
teeth are still straight and 'pretty', so I don't have that issue,
but I'm a bit shy of smiling broadly...

Anyway, forgive my rambling, but anyone have any thoughts on the
following?:

Whether 'soft' bristles are as soft as they used to be?
Whether 'softness' varies depending on the manufacturer?
Why 'mediums' and 'firms' are manufactured at all?
And why people aren't better informed about proper brushing technique?

Thanks. -Joel


  

  

    
   
    

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From: patkeat
Sent: Friday, March 16, 2001 09 40

Hi Joel,

why don't you purchase the Sonicare toothbrush and then you don't have to
worry about whether or not you are brushing to hard.  It does the job! - Janet

Thanks for the recommendation -- I'll look into the Sonicare.  It's
just a standard electric, right?  Or is there something special about
this one in particular that has you recommend it specifically over
other brands I've heard of (OralB, etc...). - Joel

Sent: Friday, March 16, 2001 6:24 AM
Subject: RE: [Periodontal] Re: Restoring Receded Gums

You can tell this fellow to use an electric toothbrush (one that
automatically turns off after two minutes), and let it "do it's thing".
If  he holds the bristles at a 45 degree angle and allows the brush to vibrate
without him exerting additional pressure, he can get the thorough cleaning
he wants without encouraging gum recession.-  B.

From: Larry Burnett
Sent: Thursday, March 15, 2001 9:19 PM
To: Barbara Ann Burke
Subject: Fw: [Periodontal] Re: Restoring Receded Gums

Here's a guy we just save from surgery by telling him to quit scrubbing
his teeth so much like you.


  

  

    
   
    

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From: Kelly D. Douglass, DDS, MS
Sent: Friday, March 16, 2001 03 36

What kind of circumstances make  you recommend not doing the graft?

If there is adequate keratinized tissue with restorations adjacent
to the margin....if there is no restoration adjacent to the marginal tissue,
none planned, good oral hygiene and no recession.....
if recession is not progressing.....if patient is able to provide adequate
oral hygiene to the area without pain or trauma to non-keratinized tissue.

Exceptions to the above is if the patient is concerned with the esthetics
of the recession and would like the area repaired.

kelly d. douglass, dds, ms

From: David 
Sent: Friday, March 16, 2001 04 40

Dear Kelly,

I feel grafts are generally unnecessary, unless for prosthetics or
orthodontics.

For esthetics, I've seen results that look terrible because of color and
texture changes that do not match. - David DiBenedetto

From: Larry Burnett
Sent: Friday, March 16, 2001 05 48

Generally when a patient is referred to me it is to use my expertiese and
knowledge to determine what needs to be done......or not done.
That's the reason they refer to me.  They don't treat me like a short order
cook and just tell me what to do/cook for them.
kelly d. douglass, dds, ms


  

  

    
   
    

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From: JB
Sent: Friday, March 16, 2001 08 45

Another cause of abfraction (which is recession accompanied by a
horizontal groove at the gumline) is bruxism. As far as recession,
often it is caused by frenum pull or teeth that are positioned to the
buccal. If that is the cause, then the facial gingiva must be
reinforced by a graft or it may continue to recede regardless of the
patient's habits...

Meg,

I appreciate your response, but... bruxism?  frenum pull?  buccal?
facial gingiva?  I have no idea what any of this means. - joel


From: JB
Sent: Friday, March 16, 2001 09 00

For esthetics, I've seen results that look terrible because of color
and texture changes that do not match...

This is what I'm afraid of, especially given that my interest in the
grafting surgery is primarily cosmetic to begin with.  Are there any
sites you can recommend on the 'net where I can find some 'before'
and 'after' photos that might give me a sense of the kind of results
I might expect from the grafting procedure?  And where do the take
the tissue from to begin with?  The upper palate?  And is there a lot
of  post-surgery soreness in the donor area? - Joel


From: Kelly D. Douglass, DDS, MS
Sent: Friday, March 16, 2001 09 30

Then you've not seen results from subepithelial connective tissue grafts.
They have absolute perfect color to the adjacent tissue and the
contour/texture simply blends into the existing tissue.  We are not talking
about "free gingival grafts"....those things that look like tire patches.
I've done many that if you'd not seen the before photos you'd never know
they ever had any recession.....nor that they ever had a surgical procedure
done.

Sorry....nope, I don't remember you from sci.med.dentistry......I guess I
block bad places out.  :-)


From: Larry Burnett
Sent: Friday, March 16, 2001 10 18

I agree with Kelly on this.  You can get a graft that will look fine.
If it were my I would make it clear to the surgeon that you are doing it for
esthetic reasons only and that you will be extremely disappointed if it doesn't
look great. - Larry

From: Kelly D. Douglass, DDS, MS
Sent: Friday, March 16, 2001 10 20

BTW...I have a pretty heavy cosmetic portion to my periodontal practice.....
I do a lot of esthetic surgery for root coverage and esthetic crown lengthening.
I don't really have a grasp as to how prevalent esthetics and cosmetics are in the
average periodontal practice.  Please follow Larry's suggestion and let the
periodontist know what you are expecting....then he/she can decide if it is something
they can provide or refer on to someone who will.


  

  

    
   
    

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Greetings Kelly,

Nice to hear from you.  We can all benefit by having you share your ideas with us.
I hope you can find time for more posts.

I'd like to know if you sometimes have patients referred for grafting procedures
and after seeing and talking to patient you and the patient decide he really doesn't
need or want it.  If so, is it difficult to handle the situation without alienating
the referring dentist?

A couple of quick studies to address common causes of recession.  Of course poor
plaque control is another very common etiologic factor.  But sometimes this results
in well intentioned coaching from hygienists and dentists causing the patient to
overbrush and cause more recession.  The tooth brush that is "too hard" is just
another way of causing recession by overzealous brushing without being as
overzealous as is necessary with a soft brush.  Bur I would still include that
as "overbrushing" - Larry

From: Kelly D. Douglass, DDS, MS
Sent: Wednesday, March 14, 2001 7:49 PM
Subject: Re: [Periodontal] Re: Restoring Receded Gums


I'm also not sure you have any scientific research to show that the
"most common reason" for recession is "trying to clean their teeth too hard."

kelly d. douglass, dds, ms


  

  

    
   Gingival recession: a cross-sectional clinical investigation.
 
    

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Gingival recession: a cross-sectional clinical investigation.

Goutoudi P, Koidis PT, Konstantinidis A

Department of Preventive Dentistry and Periodontology, School of Dentistry,
Aristotle University of Thessaloniki, Greece.

In this cross-sectional study, risk and potentially causative factors of gingival
recession were examined and their relationship to apical migration of the gingival
margin evaluated. Thirty eight patients (18-60 years), displaying one or more sites
with gingival recession but without any significant periodontal disease participated.
A total of 28 parameters were evaluated in both 'test' teeth (50 teeth with gingival
recession) and 'control' teeth (50 contralateral teeth). The results revealed that
gingival margin recession was associated with both high inflammatory and plaque scores,
with decreased widths of keratinized and attached gingiva and with the subjects'
toothbrush bristle hardness.

PMID: 9487812

  

  

    
   The prevalence and distribution of gingival recession among
    U.E. students with a high standard of oral hygiene.
 
    

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3: J Philipp Dent Assoc 1995 Dec-1996 Feb;47(3):27-48 Related Articles, Books,
LinkOut

The prevalence and distribution of gingival recession among U.E. dental students
with a high standard of oral hygiene.

Carlos MC, Muyco MM, Caliwag MC, Fajardo JA, Uy HG

The aims of this study were to evaluate the prevalence and the distribution of the
attachment loss and gingival recession at facial tooth surfaces in a population
sample with a high standard of oral hygiene, at the same time, to determine the
occurrence of gingival recession. An additional aim was to study the relationship
between attachment loss and gingival recession and its relation to its etiologic
factors. The subject sample comprised of 100 male and female dental students in the
University of the East between the ages of 18 and 26 with a minimum of 25 natural
teeth, no advance periodontitis or history of periodontal surgery were examined,
gingival recession was scored as present whenever the free gingival margin was
apical to the c.e.i. and root surface was exposed. The clinical examination involved
assessment of gingivitis, probing depth, probing attachment and gingival recessions.
The results of the combined cross-sectional and longitudinal analysis performed
in the study demonstrated among 100 U.E. dental students with a high standard of
oral hygiene showed that:

1) Facial gingival recessions was a frequent finding due to the compensatory and
remodelling process caused by loss of approximal periodontal attachment;

2) Prevalence and distribution of gingival recessions is independent
with the presence of attachment loss;

3) Facial gingival recessions can exist with or without attachment loss and teeth
without gingival recessions may or may not present attachment loss;

4) And presence of gingival recessions in patients with a high standard of oral
hygiene can either be attributed to orthodontic treatment or wrong toothbrushing
technique, too much strength exerted in brushing, overbrushing, and usage of hard
toothbrush bristles.


  

  

    
   
    

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Jones writes

I have seen psuedo-pocketing occur on both connective and free gingival
grafts but they can be easily corrected with CO2 lasers.  Actually,
sometimes, if the rugae from the palatal donor tissue transfer to the graft
site, we use the laser to "smooth" out the wrinkles and recontour the graft
site.

Mr. Jones, we have a little problem with pocketing and ugliness here but I can
easily correct it by running out and getting a $25,000
Co2 laser. That wouldn't be easy for me :)  - Larry Burnett

Kelly replies

I've probably averaged 1-2 connective tissue grafts per week over the last
5-6 years and have never had a single incidence of psuedo-pocketing from
this procedure

Sent: Friday, April 13, 2001 10:29 AM
Subject: Re: [Periodontal] Re: Restoring Receded Gums

Meg says:
Current information indicates that the toothpaste when brushing causes abrasion;
nylon bristles alone don't do the damage.

Larry replies:
That's interesting but this patient wants to know about gingival recession,
not enamel abrasion


  

  

    
   
    

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Meg says:

As far as recession, often it is caused by frenum pull or teeth that are positioned
to the buccal. If that is the cause, then the facial gingiva must be reinforced by
a graft or it may continue to recede regardless of the patient's habits. I work with
a periodontist and she often will get root coverage with a connective tissue graft
that looks great and does not probe >2 mm.


Sent: Thursday, March 15, 2001 09 36
Subject: Re: [Periodontal] Re: Restoring Receded Gums

Agreed...current grafting techniques utilizing connective tissue have shown
excellent results.  Another type of graft that may be performed is a pedical
graft in which adjacent tissue is released and sutured into position over the
concerned area.  There are a few individuals who are also utilizing a
material called Emdogain with the connective grafting procedure to aid in
tissue attachment, Emdogain is a porcine derivative material that stimulates
guided tissue regeneration.  Of course root coverage is limited by the height
of the immediate papillae and gingival tissues; therefore, if there is a fair
amount of bone loss present, root coverage may not be attained.  Free
gingival grafts normally don't provide adequate root coverage for this type
of procedure but it will create a more healthy site of attached gingivae.
Another product I have seen is the allograft material...donor tissue, but I
have seen mixed results.  Personally, I say go with your own tissue bank :)

Things to consider as possible etiologies for recession may be tooth
positioning (lingual tipping), frenum involvement, minimal or lack of
attached gingivae, prominent roots (cuspids), bruxism, oral habits (smokeless
tobacco), brushing habits and  orthodontic treatment to name a few.

In regards as to whether the procedure is cosmetic or preventative, I think
we should consider the oral health of the patient.  As Dr. Larry stated,
without actually completing an examination this is hard to establish.
Personally, I think that if an individual has a high risk for caries, has dry
mouth symptoms and or poor home care, then this procedure could be invaluable
in decreasing future root caries activity.

The healing time for these procedures really varies from patient to patient.
Typically, the donor sites from the palate tend to heal faster due to the
fact that the excision is deep rather than wide which allows for complete
closure with suturing whereas the free gingival graft is wide and shallow and
would then leave an open site that tends to heal slower and be more
uncomfortable to the individual...if you ever had a bad pizza burn on the
roof of your mouth than you know what this feels like.  Sometimes, a surgical
stent can be fabricated prior to the surgical visit to help alleviate some of
this discomfort.  The graft sites themselves tend to heal a little slower if
it is a connective tissue graft, while a free gingival graft tends to heal
much faster.  There may be localized swelling at the graft site as well.

I have seen psuedo-pocketing occur on both connective and free gingival
grafts but they can be easily corrected with CO2 lasers.  Actually,
sometimes, if the rugae from the palatal donor tissue transfer to the graft
site, we use the laser to "smooth" out the wrinkles and recontour the graft
site.

Anyway, I hope this helps.  Plenty of things to discuss with your
periodontist at your next appointment I am sure.  Good luck!

S. Valdez -Dental Hygiene Student....former periodontal assistant

Now.....back to studying for my national board exams....March 27th!!!


  

  

    
   
    

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Larry replies: No matter what the cause of the recession, the cause of the recession
must be removed in order for the recession to halt.  A gingival graft will never stop
the recession, nor is it intended to.  There is no evidence anywhere I know of that
suggests gingival recession is a cause of further recession if it is not covered over
with a graft.

If a frenum pull is the cause (doubtfull) placing a graft will not stop further
recession unless the frenum causing the problem is removed.  If the recession is
caused by teeth moving labial or buccal, the recession will continue as long as the
teeth continue to drift in that direction.  A graft will not stop it.

When recession occurs, you identify the cause and stop it.  Then the patient can decide
if the recession that has occurred requires a graft to make him look better.  To tell
a patient they need a graft to stop the recession is an example of confusing esthetic
dentistry with therapeutic treatment and misinforming the patient.  This patient
assumed or had heard that a gingival graft was in some way needed to maintain his
oral health.  I say it isn't, but if you have some literature suggesting that it is,
I and he would certainly be interested in hearing about it. I also include the myth
that a certain amount of keratinized gingiva is necessary.

I'm glad you brought this up because many patients are sold gingival grafts with the
idea that it is needed for their health.

The first study is to suggest "try the easy way first:

The second one is to suggest finding one of these causes, stop the habit that is causing
it and the recession will no longer continue.  Now if the recession happens to be on a
19 year old female who wants to pose for adds in a dental magazine, a nice graft could be
the perfect treatment after the recession is halted.

PS.  If anyone  would like to know if your patient's recession is continuing over time,
simply take an alginate impression at one appointment and then continue to compare those
models with the patients gingival margin as the years go by.  I'll bet you will end up
suggesting a lot less grafting procedures. - Larry


  

  

    
   Improvement of multiple facial gingival recession by non-surgical and supportive periodontal therapy: a case report.
 
    

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Improvement of multiple facial gingival recession by non-surgical and supportive
periodontal therapy: a case report. - Ando K, I to K, Murai S

Department of Periodontology, Nihon University School of Dentistry, Tokyo, Japan.

We report a case of multiple facial gingival recession which was improved by non-surgical
and supportive periodontal therapy. The patient, a 28-year-old Japanese woman, presented
for treatment of multiple facial gingival recession ranging from 1 to 4 mm on
teeth 5 through 12 and 19 through 30. Periodontal plastic surgery to cover the exposed
multiple root surfaces was suggested. However, because of emotional problems, the patient
did not wish to undergo the procedures and instead accepted non-surgical periodontal
therapy including oral hygiene instruction, scaling, and root planing. The exposed root
sites were monitored at periodic maintenance visits, and gradual improvement through a
coronal increase of the gingival margin was noted. The possible etiologic factors and
healing process associated with this case are discussed.

PMID: 10476900


  

  

    
   Gingival recession and toothbrushing in an Italian School of Dentistry: a pilot study. 
    

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2: J Clin Periodontol 1999 May;26(5):276-80 Related Articles, Books, LinkOut

Gingival recession and toothbrushing in an Italian School of Dentistry: a pilot study.
Checchi L, Daprile G, Gatto MR, Pelliccioni GA

School of Dentistry, University of Bologna, Italy. lchecchi@alma.unibo.it

The aim of this pilot study was to evaluate the prevalence of gingival recession at
buccal tooth surfaces in a student population of Bologna University Dental School.
A total of 55 subjects, attending the 1st and 5th year of the course were examined.
The clinical examination involved assessment of plaque, calculus, width of keratinized
gingiva, buccal probing depth and buccal gingival recession. Information about
toothbrushing behavior was collected in an interview. The multiple regression analysis
showed that level of education (p=0.002), toothbrushing technique (p=0.013) and
toothbrushing frequency (p=0.016) are significant contributors to gingival recession.
Notwithstanding the limits of a preliminary study, a higher prevalence of buccal
recession is observed in the final year students, which have also a significantly
lower % of buccal surfaces with calculus (p=0.014). In addition, it clearly appears
that there is the necessity to investigate other factors connected with toothbrushing
(pressure, time, toothpaste quantity) in order to provide an oral hygiene education
without undesired effects.

PMID: 10355616


  

  

    
   
    

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Kelly writes

Not only will root coverage grafting improve the ability of one to keep an area clean
by leveling the gingival margin and adding keratinized tissue which is much kinder to
oral hygiene than non-keratinized tissue.....but there is actually histological research
to show cementum and bone growth on the root surface where a connective tissue graft
has been done.  I've not seen a single report where proper connective tissue grafting
has created a "gum pocket" as you describe.  I'm also not sure you have any scientific
research to show that the "most common reason" for recession is "trying to clean their
teeth too hard."

From: JB
Sent: Wednesday, March 14, 2001 1:47 PM
Subject: [Periodontal] Re: Restoring Receded Gums

Thanks for the quick response.  Yes, my concerns are primarily
cosmetic, but I suppose from a dental health standpoint, the
procedure probably does help protect the teeth as well, no?

Also, I imagine the procedure is not inexpensive, although I know the
cost must vary significantly depending on the extent of the grafting
done.  I guess I'd have to go in for a consultation to get a quote...

Joel


Larry Replies:

It would really be rare for that procedure to add anything as far as
dental health is concerned.

You should understand that the most common reason for recession is a person trying
to hard to clean their teeth and literally scrubbing too hard with the toothbrush over
time.  If you recognize this as the cause, just stop scrubbing and make sure recession
is not continuing.  As long as recession does not continue, it will only be a matter
of appearance you should base your decision on.  Perhaps you can avoid that expensive
surgery.

Also the graft itself may create a gum pocket where one never existed before.
So if the appearance doesn't bother you, save yourself some money and trouble.

Please understand, I haven't seen your mouth and their could be some unusual
circumstance which would call for a different opinion.

Any one else have any thoughts about this? - Larry Burnett

Are you having it done for appearance, or is there some other reason
for the grafting procedure? - Larry

From: JB
Sent: Wednesday, March 14, 2001 11:44 AM
Subject: [Periodontal] Restoring Receded Gums

I have some advanced gum recession, and am interested in having some
grafting done.  Is there anyone on this board who has had this
procedure?  I'm interested in getting a sense of the healing process,
ultimate cosmetic effect, etc.  Thanks.  JB


  

  

    
   
    

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