Our Services

Periodontal Disease

What is Periodontal Disease?

Periodontal diseases are ongoing infections that affect one or more of the gingiva (gums), supporting bone and ligaments around natural teeth, they gradually destroy the support of your natural teeth. There are many diseases that affect the tooth-supporting structures, but the most common are, plaque-induced inflammatory lesions called gingivitis and periodontitis. While gingivitis (inflammation of gingiva only), the less serious of the two, may not progress into periodontitis, it always precedes periodontitis.

Dental plaque is the primary cause of gingivitis. Dental plaque is the soft deposits that form the bio film adhering to the tooth surface and are composed primarily of food particles and various types of bacteria, which adhere to your teeth at and below the gum line. Plaque constantly forms on your teeth, even minutes after cleaning. When bacteria found in plaque produces toxins and poisons that irritate the gingiva, they may become inflamed, red, swollen, or bleed easily. If this irritation is sustained, the gums separate from the teeth causing pockets to form. If daily brushing and flossing is neglected, plaque can also harden into a rough, porous substance known as calculus (or tartar) which occurs both above and below the gum line.

Periodontal disease is dangerous in that it is often painless and symptomless. To help maintain healthy gums, you should:

• Brush your teeth twice a day to remove plaque and debris from around the teeth and gums
• Floss at least once a day to remove plaque and food particles from below the gum line
• See your periodontist or dentist for a comprehensive periodontal evaluation once a year to accurately screen for periodontal disease.

To retain your teeth, you must have healthy gums, which means you must practice proper periodontal care and maintenance. If your gums become unhealthy, they can either recede or become swollen and red. In later and more severe stages of gum disease, the supporting bone is destroyed and your teeth will shift, loosen, or fall out. These changes affect your ability to chew and speak, as well as ruin your smile.

Treatment Methods

Dr. Joshi provide a variety of surgical services for the treatment of implant and periodontal issues. We pride ourselves on the fact that we limit surgery to the areas where it is absolutely necessary.

Most of the times, the early stages of periodontal disease are best treated with non-surgical periodontal therapy. In advanced cases, non-surgical periodontal therapy still precedes surgical therapy to improve the overall tissue quality before surgery and to help limit the areas requiring surgery.

Dental Implants

A dental implant is an artificial tooth root that is placed into your jaw to hold a replacement tooth or bridge. Dental implants are an ideal option for people in good general oral health who have lost a tooth or teeth due to periodontal disease, an injury, or some other reason.

Dental implants are changing the way people live. With them, people are rediscovering the comfort and confidence to eat, speak, laugh and enjoy life.

The Surgical Procedure

First, the implant, which looks like a screw, is placed into your jaw. Healing time following surgery varies from person to person and is based on a variety of factors, such as hardness of bone. Over the next few months, the implant and bone are then allowed to bond together to form an anchor for your artificial teeth. During this time, a temporary tooth replacement option can be worn. Sometimes a second procedure is needed to place an extension on the implant. This small metal post, called an abutment, completes the foundation on which your new tooth will be placed. After healing, Your restorative dentist designs the final bridgework or denture that will ultimately improve both function and aesthetics.

What Types of Prosthesis are Available?

• Single Crown – A single crown is used to replace one missing tooth each crown attaches to its own implant.
  1. A fixed bridge can replace two or more teeth and may require only two or three implants.
  2. A complete fixed dental prosthesis (fixed bridge) replaces all the teeth in your upper or lower jaw (All On Four option). The number of implants varies depending upon the location of implants and type of bone.
• Removable prosthesis – A removable prosthesis (over denture) attaches to a bar or ball in socket attachments, whereas a fixed prosthesis is permanent and removable only by a dentist every 6 month for maintenance.

What are the advantages of an implant over a bridge or denture?

A dental implant provides several advantages over other tooth replacement options, including:

• Maintain the integrity of your remaining teeth – In addition to looking and functioning like a natural tooth, a dental implant replaces a single tooth without sacrificing the health of neighboring teeth. The other common treatment for the loss of a single tooth, a tooth-supported fixed bridge, requires that the adjacent teeth be ground down to support the cemented bridge. When replacing multiple teeth, bridges and partial dentures rely on support from adjacent teeth, while implant-supported bridges do not.
• Maintain bone health – Because a dental implant will replace your tooth root, your jawbone is better preserved. Implants integrate with your jawbone, helping to keep your bone healthy and intact. With a bridge or denture, some of the bone that previously surrounded the tooth starts to deteriorate.
• Long-term benefits – In the long term, implants are esthetic, functional, and comfortable. On the other hand, gums and bone can recede around a bridge or denture which leaves a visible defect, deteriorated bone from bridges and dentures can lead to a collapsed and unattractive smile, and cement holding bridges in place can wash out, allowing bacteria to decay the teeth that are anchoring the bridge.
  Finally, removable dentures can move around in your mouth, reducing your ability to eat certain foods.

Frenectomy

A frenum is a small fold of tissue that secures or restricts the motion of the lips, normally seen between the front teeth (either upper or lower). It connects the inner aspect of the lip with the gum. A lack of attached gums, combined with a high frenum attachment can result in recession. Additionally, an excessively large frenum can prevent the teeth from coming together resulting in a gap between the front teeth (Diastema). If pulling is seen or the frenum is too large to allow the teeth to come together, the frenum is surgically released from the gum with a frenectomy. A frenectomy is simply the removal of a frenum surgically or by laser.

The removal of an abnormal frenum, with or without a gingival graft, can increase stability and improve success of some orthodontic treatments.

Periodontal Plastic Surgery

Cosmetic periodontal procedures are a conventional 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. Joshi and cosmetic dentistry by your dentist.

Periodontal Plastic Surgery refers to cosmetic procedures performed on the gums to enhance the appearance and health of the smile. Also referred to as gum reduction surgery, crown lengthening may be a recommendation when too much gum tissue is present. This periodontal plastic surgery procedure can be rendered in two forms and is most often performed by a dental professional.

Although your teeth appear short, they may actually be the proper length. The teeth may be covered with too much gum tissue. We can correct this by performing the periodontal plastic surgery procedure, crown lengthening. During this procedure, excess gum and bone tissue are reshaped to expose more of the natural tooth. This can be done to more than one tooth, to even your gum line, and to create a beautiful smile.

Another cosmetic procedure is the soft tissue graft. It is used to cover unattractive tooth roots, reduce gum recession, and protect the roots from decay and eventual loss.

Tooth loss causes the jawbone to recede and can lead to an unnatural looking indentation in your gums and jaw and appearance of general aging. The original look of your mouth may not be recaptured because of spaces remaining under and between replacement teeth. They may appear too long compared to nearby teeth.

Cone Beam CT Scans

Our office utilizes state-of-the-art, cone-beam CT (computed tomography) technology that provides highly accurate, ultra-high resolution, low-dose radiation, focused-field 3D radiographic images for diagnosis, planning and surgical treatment for dental implants and bone grafting.

Three-dimensional images definitely help with the positioning of dental implants and decision making of the size of the dental implant needed as it enables a level of anatomical accuracy and patient care not possible with 2D technologies.

It also helps for the diagnosis of pathology and other conditions as well as surgical planning for dental implant placement, exposure or removal of impacted teeth, and other dental procedures.

Gum Grafting

Gum recession may result in root sensitivity to hot and cold foods as well as an unsightly appearance of the gum and tooth. Exposing the root surface might lead to root decay and/or root deformity in advanced cases.

When there is only minor recession, there is often times healthy gingiva present which is still protecting the tooth. No treatment is recommended other than modifying home care practices or occlusal adjustments to prevent further damage from occurring. Whereas in absence of healthy gingiva a root coverage procedure is recommended. During a root coverage procedure, gum tissue from your palate, or the area where third molars used to exist, is used to cover the exposed tooth roots. These procedures are used to cover roots, develop gum tissue where needed, or to make dental implants look more natural. In many cases, this procedure can cover exposed roots to protect them from decay or prepare your teeth for orthodontic treatment. Your tooth sensitivity may be reduced as well, and your smile will look much better.

The gingival graft procedure is highly predictable. It enhances both the patients function and cosmetics. Dr. Joshi provides harvest grafts from same patient or using allograft coming from donor banks.

Esthetic and Functional Crown Lengthening

Anatomical crown exposure and crown lengthening procedures are used when your periodontist or dentist must adjust the levels of gum tissue and sometimes bone around a tooth in order to create a new gum-to–tooth relationship. These procedures may be performed for esthetic or functional reasons. Crown exposure is used on patients whose teeth appear too short, or their gum line is uneven or “gummy.” During anatomical crown exposure, your dental professional removes excess gum tissue and sometimes bone tissue to expose more of the tooth crown, the white enamel covered part of the tooth. Once the excess gum and tissue is removed, the gum line is then sculpted to create a more correct proportion between gum tissue and tooth surface. This can be done to just one tooth to even out your gum or to several teeth to expose a natural and broad smile. Dr. Joshi or your restorative dentist may recommend dental crown lengthening to make a restorative or cosmetic dental procedure possible. When a tooth is decayed or broken below the gum line or has insufficient tooth structure for a restoration, such as a crown or bridge, crown lengthening allows your periodontist or dentist to adjust the gum and bone level to expose more of the tooth so it can be restored. Anatomical crown exposure and/or crown lengthening both provide a solution to optimize the health, appearance, and comfort of your teeth.

These procedures can give you a beautiful new smile and boost your overall confidence, but most importantly, they can help improve your overall periodontal health.

Bite Adjustment

Reshaping is referred to by various names: bite adjustment, occlusal adjustment, equilibration, or selective grinding, they all have the same meaning. A bite is considered to be healthy when teeth are not destroyed by normal daily usage. It is destructive when teeth show wear, looseness or when TMJ (jaw joint) damage is seen. A periodontal bite adjustment helps restore a bite that can function without damage and destruction.

Signs, Symptoms and Consequences of Teeth Touching Unevenly include

• Teeth become loose
• Teeth chip and wear
• Gums become sensitive
• Jaw joints make noise
• Jaw joints become damaged
• Muscles become tender
• Headaches, migraines
• Face, head, neck pain
• Teeth become sensitive
• Teeth move out of position
• Notches in the teeth (abfractions)

Bite therapy may include:

• Reshaping the biting surfaces of the teeth and eliminating spots of excessive pressures where the teeth are brought into contact. This is done by carefully dividing bite pressures evenly across all of the teeth.
• Bite splint therapy using a custom-fitted and adjusted plastic bite guard to keep the teeth apart, worn during the day, at night, or both.
• Braces to reposition mal-aligned or drifted teeth.
• Replacement of old, worn out, or damaged fillings.
• Reconstruction of badly worn and damaged teeth.

The therapy might involve your restorative dentist, Dr. Joshi, an orthodontist or all of them depending on the nature of your bite.

Guided Bone and Tissue Regeneration

Periodontal or gum disease causes bone loss around teeth, which can increase the chances for tooth loss. Once a tooth has been lost, the supporting jaw bone has a tendency to disappear over time. This may make wearing dentures uncomfortable, and insufficient bone can render placing dental implants impossible.

As periodontal disease progresses, pockets of degenerated bone develop in the jaw. These pockets can promote the growth of bacteria and the spread of infection. To address these pockets, Dr. Joshi may recommend tissue regeneration. During this surgical procedure, the pockets are cleaned thoroughly, and many times a bone graft combined with biologic materials or a membrane is placed between the soft tissue and the pocket in the bone.

Some of these membranes are bio-absorbable and some require removal. The membrane covers the pocket so that fast-growing soft tissue is blocked, and slower-growing bone can begin to grow, or regenerate itself.  Biological materials attract bone forming cells into the area which form new bone using the grafted bone as a scaffold.

The bone and gum tissue should fit together like a turtleneck around your neck. When gum disease is present, this supporting tissue and bone are destroyed and pockets in between the teeth and gums develop. Eventually, if too much bone is lost as a result of gum disease, the tooth will likely need to be extracted.

Guided tissue bone regeneration helps the body to regenerate lost bone. By repairing the damage caused by gum disease, this procedure will increase the chances of keeping your natural teeth by preventing further bone loss and will decrease the odds of serious health problems associated with gum disease.

The placement of dental implants may also generate the need for guided tissue regeneration. An implant requires a sufficient amount of bone for support. For those patients that would benefit from replacing missing teeth with dental implants, guided tissue regeneration may first be recommended by your doctor.

When a fixed bridge is placed, the bone under the pontic, or middle portion of the bridge where the tooth has been lost has a tendency to sink and can affect the overall facial structure. Guided tissue regeneration can be used to repair the esthetics of the bone under the bridge, adding support for the facial structures to remain in attractive form.

If you have lost bone due to missing teeth or gum disease, your doctor can help. Call us today for your consultation

Gingivectomy

Gingivectomies removes and reshapes loose gum tissue and reduces pocket depth between the teeth and gums.

The gum tissue can be very thick and large covering the tooth surface making the teeth look short. This can happen because of some medications (anti-seizure or hypertensive medications), bone that extends too close to the surface of the teeth, or inflammation due to gum disease., or rapid orthodontic movement.

Benefits of gingivectomy:

The goal is to make the teeth look normal in size, removing excess gums makes the teeth look longer and more esthetic. Gingivectomy also shrinks deep gum pockets which might require some bone work as well.

Procedure

After Anesthesia of the area is provided, Dr. Joshi will remove the excess of gum tissue either with a scalpel blade, some rotary instruments or a laser. In most cases no stitches are required. The surgical sites will be sore for couple of days, medications will be provided to alleviate any discomfort experienced.

Pocket Reduction Surgery

When you have periodontal disease, this supporting tissue and bone is destroyed, forming “pockets” around the teeth. Over time, these pockets become deeper, providing a larger space for bacteria to live. As bacteria develop around the teeth, they can accumulate and advance under the gum tissue leading to bone loss, tooth mobility and eventually the loss of the tooth as they progress.

Pockets over 5 mm deep are difficult to clean with a normal toothbrush or even with regular hygiene cleanings. Pocket Reduction surgery involves a small surgical procedure to help reattach the gum to the root surface along with decreasing the periodontal pockets.

After healing is complete, the gingival tissue might shrink depending on the amount of gingival pocketing. Also, there could be sensitivity to the teeth which can be treated with fluoride rinses or toothpastes, your gums will be healthier.

The end result is a tighter attachment of the gum to the tooth, no pocketing, improved cleansiblity with a normal toothbrush and an increased long-term prognosis of the tooth.

Osseous Surgery

Osseous surgery, sometimes referred to as pocket elimination surgery, refers to a number of different surgeries aimed at gaining access to the tooth roots to remove tartar and disease-causing bacteria along with reshaping the bone contours to the original healthy shape.

Osseous surgery, or flap surgery, is usually performed when periodontal pockets around a tooth (or teeth) have not responded to other treatments. This procedure is performed in order to create a clean environment around the tooth so that it can be retained rather than lost. The goal of osseous surgery is to reduce or eliminate periodontal pocketing. Osseous surgery is generally recommended after other treatments have been explored and attempted, and is usually performed when pocket depths have worsened over time or have not responded to other therapies.

Goals of Osseous Surgery

• Facilitating Home Care:
  As the gum pocket deepens, it becomes very hard to brush and floss adequately. Osseous surgery reduces pocket size, making it easier to brush and floss, and thereby prevent further periodontal disease.
• Reducing Bacterial Spread:
  Bacteria from the mouth can spread throughout the body to other organs such as heart disease and respiratory disease. Removing deep tartar and thereby bacteria can help reduce the risk of bacteria spreading.
• Preventing Bone Loss around teeth:
  The immune system’s inflammatory response prompted by periodontal bacteria can lead to bone loss around teeth, and cause teeth to fall out. Osseous surgery seeks to stop periodontal disease before it progresses to this level.
• Improving the Smile:
  Osseous surgery can help reduce bacteria and disease and thereby restore your mouth to its former radiance, while restoring confidence at the same time.

Scaling & Root Planing

Scaling and Root planing is a common non-surgical treatment for periodontal disease The initial stage of treatment for periodontal disease is usually a thorough cleaning that may include scaling and root planning to remove etiologic agents such as dental plaque and tartar, or calculus, which cause gingival inflammation and disease.

When scaling is performed, calculus and plaque that attaches to the tooth surfaces is removed. The process targets the area above and below the gum line, along the root. Root planing is performed to remove diseased cementum and dentin that covered with unwanted microorganisms, toxins and tartar. The root of the tooth is literally smoothed which promotes healing and also helps prevent bacteria from easily colonizing in the future. A smooth and clean tooth surface provides a much better environment for the periodontal ligaments to reattach. This reattachment results in a reduced pocket size. This reduces the environment in which the bacteria can grow.

Anti-microbials agents such as antibiotics may be recommended to help control the growth of bacteria that create toxins and cause periodontitis. In some cases, Dr. Joshi may place antibiotic fibers in the periodontal pockets after scaling and planing.

Periodontal Pockets 5mm or greater are great candidates for this initial Periodontal treatment. If the pockets do not resolve within 6 weeks then definitive periodontal procedures maybe needed.

Benefits of Treatment

Scaling and root planing helps prevent bacteria from periodontal infections travel through the blood stream and affect other areas of the body, sometimes causing heart and respiratory diseases, and reduce bad breath caused from food particles and bacteria in the oral cavity. It protects teeth against tooth loss; when gum pockets exceed 3mm in depth, the risk for periodontal disease increases. Scaling and root planing also make gums and teeth more aesthetically pleasing, superficial stains on the teeth are removed during scaling and planing, adding an extra bonus to the procedures.

Socket & Ridge Augmentation

“Ridge augmentation/modification” may be needed if you don’t have enough bone to support an implant. This bone loss could be caused by periodontal disease, wearing dentures, injury, or trauma. During this procedure, bone or bone substitute is added where needed to ensure a proper foundation for implants.

“Socket augmentation/preservation” is sometimes needed to preserve bone and minimize bone loss adjacent to a tooth that has been removed. One common technique is to fill the socket with bone or bone substitute and allow the bone to heal for approximately four to six months before implant placement.

Ridge augmentation is a common procedure performed to help recreate the natural contour of the gums. Often the diminished jaw bone density is due to having one or more teeth lost . In most cases, your jaw bone density begins to deteriorate immediately. Your natural teeth stimulate the jaw bone; without the stimulation, deterioration occurs. Over a period of time, the jawbone associated with missing teeth can continue to atrophy. In these situations, most patients are not candidates for placement of dental implants. Another purpose of ridge augmentation is to increase the amount of gum tissue in areas of deficit for tooth replacement, so that the teeth appear to rise from the gum tissues. This procedure may be necessary in order to place a dental implant. If the bone tissue has deteriorated too much, placing a dental implant may not be possible without an additional procedure.

There are many techniques to preserve a ridge. Depending on the amount of infection or bone loss present, a variety of different materials can be utilized to achieve preservation or repair damage to the bone. Bone grafting can repair implant sites with inadequate bone structure due to previous extractions, gum disease, or injuries. The bone (human, animal, or synthetic) is often obtained from a tissue bank. Special membranes may be utilized that dissolve under the gum and protect the bone graft and encourage bone regeneration. This is called guided bone regeneration or guided tissue regeneration.

The Sinus Augmentation Procedure

Sinus augmentation may be needed to place implants in the upper back jaw, where your bone is very close to your sinus. In this procedure, the sinus floor is raised so there is more room for new bone to grow to provide a proper foundation for implants. After healing time, you will be ready to have your implants placed. All of these procedures have been shown to greatly increase your chances for successful implants that can last for years to come

If enough bone between the upper jaw ridge and the bottom of the sinus is available to stabilize the implant well, sinus augmentations and implant placement can sometimes be performed as a single procedure. If not enough bone is available, the sinus augmentation will have to be performed first, then the graft will have to mature for several months, depending upon the type of graft material used. Once the graft has matured, the implants can be placed.

The sinus graft makes it possible for many patients to have dental implants when years ago there was no other option besides wearing loose dentures.

The Procedure

There are two types of sinus lift procedures. The type that you receive depends upon your individual needs and the amount of bone that is present.

In one type of the sinus lift procedure, Dr. Joshi will create a small opening in the bone above the level of the roots to access the sinus cavity. Using a small instrument, Dr. Joshi will gently lift the sinus into a more favorable position. This procedure helps to encourage natural bone growth to fill the space created, but a bone grafting material is also placed beneath the raised sinus cavity along the existing bone. This grafting material will then interact with your existing bone, thus creating more bone.

A second type of the sinus lift procedure involves gaining access to the sinus cavity through an opening created in the bone (osteotomy) while drilling for implant placement. Bone is grafted to the floor of the sinus to increase the bone height along with placement of the implant at the same time.

After the Procedure

Six to Eight months are usually needed to heal from the sinus lift procedure before Dr. Joshi can place dental implants (if they were not placed at the same time of sinus lifting). This increase in bone will compensate for bone that has been lost or was not present to begin with and will allow for one or more implants to be placed. Without this procedure, some patients will not qualify for dental implants in the upper premolar or molar regions of the mouth.

Periodontal Maintenance

Periodontal maintenance is usually necessary for patients who have been diagnosed with and treated for periodontal disease. Maintenance therapy is an ongoing program designed to prevent disease in the gum tissues and bone supporting your teeth. In addition to conscientious home oral care, regularly scheduled maintenance therapy visits with your dentist or Dr. Joshi will give you a higher chance of keeping your teeth for your lifetime. Treating the disease in its early stages can help to save you from not only oral and overall health problems, but also money!

Gum disease is caused by the bacteria found in plaque. The toxins produced by these bacteria cause our bodies to destroy the bone that supports the teeth. If plaque is not removed, it can harden and form calculus (tartar) that can exacerbate the periodontal problem.

Even someone dedicated to good oral hygiene will be unable to completely prevent the formation of all calculus on the teeth. Calculus forms when the minerals in the saliva harden, or calcify, the plaque on the teeth. Plaque is soft and sticky, and is continually forming. It is therefore important to ensure proper, thorough brushing and flossing on a daily basis to remove the plaque before it has the chance to solidify into calculus.

Flossing and brushing will help to keep the calculus formation to a minimum, but regular maintenance is needed to professionally remove what has accumulated. During your maintenance cleaning, Dr. Joshi will evaluate and record your periodontal pocket depths and check for hidden periodontal problems.

Your dentist and Dr. Joshi work together as a team to provide you with the best possible care. They combine their experience to formulate the best maintenance plan for you. They keep each other informed about your progress. Although Dr. Joshi may see you periodically for maintenance therapy, you will need to see your general dentist as well. Appointments for periodontal maintenance do not replace regular dental checkups. If Dr. Joshi detects tooth decay during a maintenance visit, he will refer you to your general dentist for treatment. Your general dentist is primarily responsible for your overall dental health, including such dental needs as filling new or recurrent cavities or making changes in fillings, crowns or bridges.