Hi and welcome or welcome back to The Perio Patient Podcast a podcast for my patients and anyone else who cares to listen. My name is Dr. Ben Young and you might be patient of mine. If you are, then you know who I am and what I do, but for everyone else, I am a periodontist in private practice in the beautiful city of San Antonio and in the great state of Texas.
If this is your first episode, you have jumped in on number 94. My last one was about my mom, which I really enjoyed making – you might want to check that one out. Sticking with the personal another moment, I will be flying out to visit her in a few days. She is 97 years old, unfortunately now completely confined to bed, and under 24-hour care. She is a beautiful lady and I am looking forward to seeing her along with my brother and his family who take such great care of her.
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This episode comes out of a conversation I had with someone recently about the problem of gum recession.
To begin, recession can be a part of a bigger problem, that being periodontal disease. In this case the recession is but one of many problems and the primary concern up front will be addressing the chronic infection that is causing the inflammation of the gums – the swelling and redness, as well as the losing of bone support.
But let’s say that there is no periodontal disease or periodontitis, as it is also called. The gums are pink and firm and yet there is this area or many areas of recession. What might be causing this problem?
First, I think there is a genetic component in most cases. People with small jaws and thin gums are more likely to have recession than people with large jaws with lost of bone around the teeth.
Orthodontics is sometimes associated with recession because the movement of teeth can position them on the outside of the bone where they then are more susceptible to receding gums. On the other hand, orthodontic movement of teeth can also move them more into the center of bone.
If the recession was present at the start of orthodontic treatment, it might persist or even get worse, but sometimes this problem improves on its own.
If orthodontics is being considered, it might be wise to get a consultation about possible recession, but only if some recession already exists. If there is no initial a problem with recession, then it would not be necessary to come see me ahead of time.
Sometimes, depending on findings, it may be smart to graft soft tissue back to address recession ahead of orthodontics, but sometimes, it is reasonable to press on with the orthodontics and then evaluate again at the end. All of this is case specific so don’t be surprised either way.
So now we have talked about three possibilities for recession. The first is periodontal disease and the second has to do with thin bone. We can also add to this number three — that teeth can be crowded out of the arch and so orthodontics is part of the consideration on how to correct the problem.
Another reason (number 4) for recession – with those with thin gums to begin with – is heavy brushing. When you brush the teeth like someone buffing their shoes it injures the soft tissues. When this happens and then continues over time, the gums essentially find another place to live. They recede away from the trauma. Sometimes by stopping this behavior we can see a slight rebound with the gums cautiously returning to live where they once did.
Which brings up another important point. Should you go through some corrective surgery to cover the exposed root once again, it is possible for you to remove what was gained by the grafting procedure completely by continuing with the aggressive tooth brushing. For this reason, I always recommend gentle brushing with the softest bristles you can find. It is frequency, not intensity. Also, understand that periodontal disease being caused by plaque – or colonies of bacteria sitting and growing for days and weeks – does not start up where recession occurs.
Now let’s talk about dental insurance and recession.
If the recession is an esthetic problem only – meaning when you smile the root looks long due to recession, and we are usually only talking about your upper front teeth from canine to canine, the insurance company will not cover the expense to repair this because it is not a disease. The tooth is not in danger of being lost because of this recession.
Are there recessions the insurance companies will cover?
These are usually not in the esthetic zone (but might be) and they are called mucogingival defects.
The word mucogingival is describing two types of gums. The first part “muco” is a short way of saying mucosa. This is the skin in the mouth that is like what you find on the inside of your lip or your cheeks. Mucosa is skin that operates in a moist environment. In the mouth, this moisture is saliva coming from salivary glands.
The second part of the word mucogingival is gingiva – this is specialized bound down thicker skin that surrounds the teeth. When we talk about gums, we generally mean gingiva. Gingiva resists trauma. When you eat, the food bounces off gingiva, but it springs off mucosa. The mucosa is like a trampoline. The gingiva is like a wrestling mat – its built to take a pounding. Gingiva has a very fast turn-over rate. This is how it survives. It is thicker and repairs quickly.
When you lose – through recession – all the gingiva and the mucosa is all that is up against the tooth, you have a mucogingival defect.
Will you possibly lose the tooth because this exists? Not immediately, normally. The greater concern is further soft tissue stripping and damage – and yes, eventually, if the problem is never addressed, you might lose the tooth. Because there is poor soft tissue quality against the root of the tooth it can cause food to settle in this area. When this occurs you will find yourself always having to pick it out. If it stays there, the root is at greater risk for tooth decay – and decay of the root is extremely difficult to treat.
Finally, what can you expect from treatment?
The normal treatment for a mucogingival defect is to place thick tissue back into this area. This tissue can come from another area where there is a lot of accessible gingiva – this might be your hard palate area or behind the furthest back molars. Another option is to utilize human derived collagen out of a sterile package. This is safe and assures there is enough material to accomplish the procedure. Sometimes there is simply not enough material available in the individual for all the areas that need treatment.
The outcome of the procedure has a high probability result and one that is less predictable.
It is highly probable that thick gingiva can be placed back into the area of the mucogingival defect.
It is not as predictable that all the recession back up to where the enamel meets the root surface will be covered and remain there. The body will heal and it will decide where the gingiva is healthiest. Sometimes this is not back to you having no recession at all. However, if this is not in the esthetic zone, an ideal esthetic type response is not necessary, only a biologically healthy response. This means if we can return thick gingival tissue to the area but there is still some recession, this is an acceptable outcome. In fact, the attempt to completely cover a root, if it results in a pocket forming behind the tissues, then the gums can become inflamed and send us down the periodontal disease pathway.
Finally. Let’s talk a moment about tooth or root sensitivity. If this is the primary reason for considering soft tissue grafting, I would caution you that it might not work. If there are other reasons, and one of them happens to be root sensitivity, then by all means proceed and you might find the sensitivity improves or even resolves, but it is also possible that if the sensitivity is coming for a particular tiny spot, say right at the point where the enamel meets the root, then covering everything except this spot will not change the sensitivity.
Sensitivity, as with all pain, is subjective, meaning personal. We all feel things differently. The difference between a toothache and tooth sensitivity is that the toothache is specific to a tooth or at least an area of the mouth. Tooth sensitivity is more generalized and it is like that uncomfortable feeling when you breath in cold air or drink ice cold water. Some people’s teeth are generally sensitive and the question we all should ask is whether or not this is affecting our day. If it results in an everyday problem, then have it looked at. If it is an occasional problem and due to extreme temperatures, then modify the temperatures you take in.
If you have your teeth cleaned and the teeth are more sensitive afterword, assuming you are not aggressively trying to fix this with intense cleaning procedures, it will reset to your baseline in a few days to about a week. If you have just had periodontal surgery, it might go up to two months. The problem is that everyone is tired of the increased sensitivity after a few days – a much shorter time compared to how long it takes to reset. But now that you know, try to hang in there if possible, modify temperatures of food and drink temporarily, and be gentle with your brushing and flossing. Don’t try to fix this yourself, just try to give it enough time to resolve on its own.
Well, that’s it for today.
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