Periodontics

gum disease

I believe this can be one of the most difficult areas or specialties in the field of dentistry. The progress of the disease can be well along before the patient notices anything and a patient may present to you for treatment of “cavities”, never having significant periodontal problems address by a previous practitioner.

Your ethical and diplomatic skills must be prepared to inform such a patient of their current periodontal status without casting aspersions on past neglect by others (this goes for many undiagnosed or untreated conditions you will diagnose and be required to relate to the patient.)

Typical scenario- Patient presents with a broken tooth which you restore nicely, and then he wants to become your patient and obtain a full exam. You do so, discover a carious tooth or two and Type III periodontitis. If you simply tell him he has advanced gum disease, will need four quadrants of periodontal scaling/surgery and may loose some teeth nevertheless, and that the fee will be several thousand dollars, you will get a patient who is upset over your diagnosis and fees, angry that this has not been brought to his attention before, and fearful of the idea of having his “gums cut”! (Heard it a million times!) Some diplomatic explanation beforehand may help:

Mr. Smith, we in dentistry today are not just focused on your teeth but the health of your entire mouth. Having healthy teeth not only means no cavities but strong bone and gum support too. Sometimes you can feel or see a cavity but very often, gum disease can develop very slowly and not cause any pain until teeth start to loosen or gums start receding. You have some significant areas of gum problems that are affecting the support of several teeth because of the amount of bone loss I can see in the x-rays and measure with my probe.

“But Doctor, why hasn’t anybody ever told me about this before? I’ve been seeing Dr. Jones for twenty years!”

Here is where a little Golden Rule diplomacy can help, (and maybe avoid a witness stand).
Well Mr. Smith, we know that gum disease can have very quiet and very active periods and since I have not ever seen you before, I have no way of truly knowing (and you don’t) what the condition of your mouth was at times in the past. I believe in dealing with my patient’s current dental situation. I treat their needs to the best of my ability, and try to keep them in as best health as possible through prevention and not try to second guess what might have existed in the past. Let’s start with today and look forward, not back.

Some periodontal procedures explained-

A gentle explanation might begin as- Mr Smith, several places in your mouth have a deep space between the tooth and gum where your toothbrush and floss can’t reach. We call these areas “pockets” like on a shirt. To keep the bone strong and the gums healthy, these pockets should be shallow , like no more than 3 millimeters, about this much (show) so you can keep them clean with good brushing and flossing. Many patients won’t want to know any detail about such procedures but many will ask.
I want to carefully measure around every tooth and see exactly where these problems are and then I want to schedule a couple of appointments where I can thoroughly remove this hard buildup under the gum. Then we’ll wait some weeks for healing and I’ll go back and measure those pockets again to see if there are any remaining places that your toothbrush can’t reach. If an area did not respond well enough, there are techniques that a Periodontist, the gum specialist in dentistry, can do to stabilize those teeth.

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I believe the term “deep cleaning” is inappropriate for periodontal procedures. Patients all understand the term “cleaning” to mean what we call a prophylaxis or “prophy”.   And when we use the term “deep cleaning” for PSRP (periodontal scaling and root planing) we infer that it is just a minor variation of a regular cleaning (and just a minor increase in time and expense) when indeed it is no such thing. Make a clear distinction between deposits on the crown* of the tooth v. deposits “under your gums on the roots” of the teeth. Use the term “scaling” to describe a PSRP- “We have special instruments that can reach between the gum and tooth to remove those hard deposits on the root surface, where they are causing gum inflammation and bone loss. This procedure is called a scaling and we usually do just one part of your mouth at a time and with numbing to make it more comfortable for you.”


*use “tooth” to mean the clinical crown and “root” as patients are confused when you use “crown” to describe the clinical crown of a tooth. They think you are talking about a lab crown.

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