Something that most patient remember about dental pain is referred to tooth pain and tissue swelling. Sometimes this problem refers to the loss of vitality of a tooth but it can also be referred to periodontal problems. We will analyze the second scenario and we will compare it with the classical tooth that needs a root canal therapy by the endodontist.

The periodontal abscess is a localized purulent inflammation of the periodontal tissues. It can be classified according to the structure that it affects in gingival, periodontal and pericoronal abscess. The gingival abscess affects the marginal gingival and interdental tissues. The periodontal abscess is an infection located in the periodontal pocket and may result in destruction of the periodontal ligament and bone. The pericoronal abscess refers to the area next to a tooth crown that is not fully erupted in the mouth.

Periodontal Abscess
The periodontal abscess is typically found in patients with active periodontitis and in association with moderate-to-deep periodontal pockets. Periodontal abscesses often arise as an acute episode of a preexisting periodontal disease. Among the difference causes, the most common is the incomplete calculus removal from a gingival pocket. Abscesses can occur after periodontal surgery, after preventive maintenance, after systemic antibiotic therapy and recurrence of periodontal disease. Other causes of periodontal abscesses can be tooth perforation or fracture and foreign body impaction. The importance of periodontal abscesses is high. Their presence is a leading cause of tooth loss. However, proper treatment and constant follow up can help to retain affected teeth for many years.

Acute versus Chronic Abscess
Abscesses are categorized as acute or chronic. The acute abscess is often a sudden episode of an existing periodontal lesion with no liquid drainage through the gums. The result is a painful, red, smooth swelling of the gingival tissues. The tooth may be percussion sensitive and feel elevated in the socket. The chronic abscess form after the infection spontaneously drains or it’s treated by the periodontist.

Periodontal versus Pulpal Abscess
The following table summarizes the main differences between Periodontal and pulpal abscesses. Sometimes symptoms are mixed and do not help with correct diagnosis and an interdisciplinary consultation with the endodontist may be necessary

Treatment of the periodontal abscess includes the resolution of the acute lesion, followed by the management of the resulting chronic condition. Treatment options include drainage through pocket retraction or incision, scaling and root planning, periodontal surgery, systemic antibiotics or tooth removal*. The treatment of pulpal abscess is usually the completion of a root canal therapy by the endodontist that in severe case may have to associate this pathology with systemic antibiotics and drainage of the swelling for acute abscesses.

Acute abscesses can be a very bad experience for the patient. Due to complexity of appearance, it may be difficult to differentiate between endodontic and periodontal abscesses, It is important to urgently contact the periodontist that is trained to tackle and treat this pathology and improve the fate of the affected tooth.

References

*(Modified from Sanz M, Herrera D, van Winkelhoff AJ: The periodontal abscess. In Lindhe, J: Clinical periodontology, Copenhagen, 2000, Munksgaard).

The body of this article is referred to Carranza’s Clinical Periodontology, 12th Edition By Michael G. Newman, DDS, Henry Takei, DDS, MS, Perry R. Klokkevold, DDS, MS and Fermin A. Carranza, Dr. ODONT.

- Lorenzo Mordini DDS, MS

The American Academy of Prosthodontists reports that more than 35 million Americans do not have any teeth, and 178 million people in the U.S. are missing at least one tooth. These numbers are expected to grow in the next two decades.

Most of the time, the teeth that are missing are the molars, either in the upper or lower jaw. After missing a molar in upper jaw, the patient experiences both bone resorption and expansion of the maxillary sinus. With the increase in popularity of dental implants and the increase quality of life of patients, rehabilitation of the edentulous posterior jaw often represents a clinical challenge.

Before the utilization of dental implants, patients with missing teeth and deficient bone in the posterior maxilla could only be rehabilitated with removable prostheses or short implants that prevent invasion of the sinus. Sometimes bone resorption and sinus expansion is so advanced that even short implants cannot be placed.

In those cases, advanced procedures like maxillary sinus elevation are needed to increase the amount of vertical bone height in the posterior maxilla for the placement of implants. Generally speaking, two procedures are available depending on the quantity of bone left.

In case of small augmentations needed, the use of a tapping motion on blunted posts can create sufficient space for implant placement (Internal or Direct Sinus Lift).

In case of more bone required, a more invasive procedure is required. A small perforation on the lateral wall of the sinus is performed and the creation of a window in that area can favor deposition of more grafting material for larger augmentation (External or Indirect Sinus Lift). Also, the quantity of bone available before the augmentation can allow the simultaneous placement of the implant, which tip will be surrounded by the graft material used for sinus augmentation.

In case of minimal bone levels before the augmentation, the sinus lift is performed and implants are usually placed 6 to 9 months after healing. It is very important that patients are healthy individuals with no uncontrolled systemic pathologies and conditions (uncontrolled diabetes, uncontrolled hypertensions for example). Also, the sinuses need to be clear from any diseases like cysts, sinusitis and infections.

In conclusion, sinus augmentation can be a valuable option to restore the posterior upper jaw in case of long absence of teeth, bone loss and sinus expansion.

- By Lorenzo Mordini DDS, MS

Dental implants are gaining more and more popularity among patients and dental providers. Many implants are being placed everyday in USA and in the world. The represent a tool in the hands of the dentist that can solve many problems when the natural dentition in failing or classic treatment does not provide long term expectations. Even though dental implants do not suffer from the same pathologies as teeth, they are prone to suffer from the so-called peri-implantitis.

This inflammatory and infectious process determines problems of bone resorption and gum inflammation around the implant, that can eventually lead to implant loss. The most important step to avoid peri-implantitis is to prevent it by correct professional and patient oral hygiene. This article reports the most important questions and answers on implant maintenance extracted and adapted from a book chapter “Patient’s plaque control around implants (Clinical Cases in Implant Dentistry Wyley Blackwell. Edited by Karimbux N. DMD, MMSc, Weber HP. DrMedDent. 2017)“ by the same author.

Should implants be cleaned similarly as natural teeth?
Studies demonstrated that an effective and accurate oral hygiene technique prevents an increase in the severity of gingival inflammation if performed at least once every 24 hours. Nonetheless it appears that often patients have not been taught accurate plaque removal techniques and some have difficulties with manual dexterity. It is usually recommended that a patient with implants perform oral hygiene based on their individual needs between 1-2 times a-day. Devices that are effective in removing plaque from a crown on a natural tooth will be also effective in removing plaque on an implant crown.

However, there are differences found in the shape of implant crowns when compared with a natural tooth. Thus, although plaque control techniques for dental implant supported restorations are generally similar to traditional oral hygiene procedures on natural teeth, modifications are dependent on the crown design.

Is there a contraindication to using toothpaste when cleaning implants?
The agents contained in these pastes are multiple and they offer different functions (i.e. detergents, abrasives, polishing agents, binders, humectants, water, flavoring, coloring agents, active ingredients such as fluoride, anti-plaque, anti-calculus, desensitizing). It has been noted that the abrasives in the dentifrice mainly cause hard tissue damage when proper brushing technique is not practiced. However, there has been no evidence suggesting contraindication of toothpaste for patients with dental implant prosthesis.

What brushing technique(s) should be used?
Various studies demonstrated that different brushing techniques are almost similar in plaque removal efficacy. Cleaning the gums around the implant may be more challenging for the patient because the weaker nature of the implant gums compared to teeth. It is recommended a thorough instruction from the professional dental provider in order to customized the technique for every case and patient. The wrong technique may create damage and problems on the implant. Some studies have suggested that electric toothbrushes might be more better than the manual brushes, however the most important factor is the technique used not whether the brush is powered with a battery or by hand.

What is the optimum stiffness of the bristles of a toothbrush and why?
There are many different toothbrushes available in the market. Some have harder bristles some very soft. However, it is generally recommended to prescribe soft bristle toothbrushes to avoid damage of the gingival tissue around teeth and implants and to better access the areas around the implant gums. The shape of the toothbrush is not so important. The important step is how to use it in the right way.
What interproximal oral hygiene aids are available to remove the biofilm from implants?

The oral hygiene aids for proper plaque removal around implant-supported restorations are the same as those commonly used for natural teeth. Dental floss, interdental brushes and rubber tips can be used safely around dental implants, and just as with natural dentation, it should be customized on an individual basis. The patient’s manual dexterity, the design of the prosthesis, and the type of the prosthetic component must be taken into consideration when customizing interproximal hygiene techniques.

- Dental floss: It is generally recommended to use floss around implant restorations for each individual unit, once or twice daily, doing plaque control techniques the same as for natural teeth. The number of times per day to use floss depends upon the patient’s susceptibility to peri-implant inflammation.

- Super Floss®: It is known that the use of regular dental floss can be extremely difficult when attempting to remove plaque deposits in implant supported Fixed Partial Dentures. The great advantage of Super Floss® stands in its stiff end that can be introduced between the crowns.

- Interproximal brush: Also known as interdental or proxy brush is used as an effective device in plaque removal in the interproximal tooth surfaces. It is important to select the brush head of an appropriate size to fit into the interproximal area without creating damage to the soft tissue and to the root surface. In order to minimize the risk of hard tissue abrasion it is also advised to avoid the use of dentifrice with an interproximal brush. The brush should be replaced whenever the filaments appear to be deformed.

Despite the strong structure of dental implants, they should be respected and treated like a normal tooth. Even though patients are the responsible for everyday oral hygiene, implants should be evaluated regularly by a periodontist and dental hygienist to complement their cleaning.

-By Lorenzo Mordini DDS, MS

Thanks to advances in modern technology, there’s an option for the rising number of Omaha patients curious about a metal-free alternative to dental implants. That option is pure white ceramic implants, which we’re now proud to offer at Metro West Dental Specialty Group.

How Do Metal-Free Implants Work?

For starters, ceramic white implants have a natural-looking ivory color that makes them mimic the appearance of a natural tooth. While you may think a ceramic implant wouldn’t be as strong as a titanium implant, pure ceramic white implants undergo a 100% proof test to ensure reliable implant strength. With a 97.6% success rate, they’re just as dependable as traditional titanium implants.

Made from pure ceramic, these implants qualify as a high-end esthetic solution for missing teeth. Patients who receive pure white ceramic implants can expect an implant that is strong, natural looking and comes with a variety of other benefits.

The Advantages of Metal-Free Implants

The fact pure ceramic implants don’t contain metal is a benefit in itself, but what other advantages to metal-free implants offer? While traditional implants are a perfectly adequate solution for a large number of patients, some in Omaha may consider the following benefits reason enough to choose pure white ceramic implants instead:

• Strong and reliable: As mentioned above, metal-free implants go through rigorous testing to ensure reliable implant strength and a long life.
• Metal-free: The entire implant is made from 100% premium ceramic and doesn’t contain any metal.
• Esthetic: Unlike titanium implants, pure white ceramic implants have a natural appearance even below the gumline, making them ideal for patients with receding gums or thin gum tissue.
• Clinically proven: Pure white ceramic implants also have a high predictability rate. They’ve been clinically proven to be predictable and stable, and fuse easily with the bone in your mouth via osseointegration.

To learn more about your metal-free dental implant options in Omaha, schedule a consultation with Metro West Dental Specialty Group today!

Smoking is very diffused and can be considered a world wide epidemic. In 2012 roughly 44 million American were smokers, with 9 million people suffering from a severe smoking-related disease and almost half a million deaths attributable to smoking and exposure of secondhand smoking each year. Tobacco kills up to a half of its users. Globally, smoking accounts for 1 in 5 deaths among men 30 years old and older and 1 to 20 deaths among women 30 years old and older (WHO 2013).

Smoking is harmful to almost every part of the body. It is associated with multiple diseases that reduce life expectancy and quality of life (lung cancer, heart disease, stroke, bronchitis, and cancers of the oral cavity among all). Almost half of long-term smokers will die early as a result of smoking, and those who die before the age of 70 years will lose an average of 20 years of life (Doll 1994). Tobacco smoke contains thousands of dangerous chemicals (carbon monoxide, ammonia, formaldehyde, hydrogen cyanide are some) and many substances that can lead to cancer.

Smoking and Periodontal Disease

Besides the effect on the general health, smoking is the major risk factor for periodontal disease. It affects the occurrence, the magnitude, and severity of disease. Studies demonstrated that, on average, smokers were 4 times more prone to periodontitis as compared with persons who had never smoked. Former smokers were 1.7 times more likely to have periodontitis than persons who had never smoked. Is important to understand that that approximately 42% of periodontitis cases in the US adult population are linked to current smoking and that approximately 11% to former smoking (Tomar 2000).

Smoking can be deceiving. Smokers wouldn’t see many signs of inflammation in their gums (redness and bleeding gums), but they would hide higher incidence of bone loss deep pockets and increased chances to loose teeth if compared to non-smoking individuals. People may think that her gum status is not bad but they would be wrong. The effect of smoking is slow and subtle.

FIG 1

Fig 1. Global Smoking Prevalence. Percentage of smokers among world adult population. North America shows prevalence between 20 to 25%.

Periodontal Therapy

Numerous studies have indicated that current smokers do not respond as well to periodontal therapy as nonsmokers or former smokers do. The pocket depth reduction and gain of tissue destroyed by periodontitis is more effective in nonsmokers than in smokers after nonsurgical and surgical periodontal therapy (including oral hygiene instruction, scaling, and root surface debridement)*.

Research showed that short- and long-term outcomes of implant therapy in smokers increased the risk of implant failure* (implant loss, implant bone loss, mobility, pain, and periimplantitis). Overall, the risks for implant failure in smokers appears to be approximately double the risk for failure in nonsmokers.

Even with more intensive maintenance therapy given every month for 6 months after surgery (Scabbia 2001) smokers had deeper and more residual pockets than nonsmokers. Smokers also tend to experience additional tissue destruction than nonsmokers after therapy (MacFarlane 1992, Magnusson 1996). Tobacco smoking is associated with tooth loss even when regular recall maintenance care was performed (Chambrone 2010).

FIG 2 a and b

Fig 2. (a) Smoker subject affected by periodontal disease. Notice the bleeding, inflammation and tobacco staining.

(b) Outcome of non-surgical therapy alone and smoking cessation. Tissues appear healthy, pockets were reduced and no bleeding was present. The teeth are now ready for esthetic improvement.

Strategies to Quit*

There are some ways for a smoker to quit. These are listed in order of success.

1. Willpower Alone
This is the least effective method of smoking cessation, with only 3% of smokers managing to quit after 12 months.
2. Self-Help Materials
3. Brief Intervention Program
4. Nicotine Replacement Therapy. Success rate at 12 months is 10% to 20%. Nicotine replacement therapy generally doubles the success rate of smoking cessation (patches, gums, nasal spray, 
inhalator).
5. Other Methods. Intensive counseling, motivational interviewing, behavioral therapy, hypnosis, and acupuncture.

In conclusion, smoking is the major risk factor for periodontitis, and smoking cessation should be considered as a strong part of periodontal therapy in smokers.
Smoking cessation should be treated as a priority for the management of periodontitis in smokers. The result of smoking cessation improves periodontal health and increases the success of therapy delivered by the hygienist and periodontist.

*Carranza’s Clinical Periodontology. 12th edition.

- Lorenzo Mordini DDS, MS

Recent studies report that more than 35 million Americans miss all their teeth, and almost 180 million are missing at least one tooth. The projections of these numbers are expected to grow in the next twenty years.

Over the past decades, the use of dental implants to replace missing teeth has been considered the standard long-term treatment alternative in different situations due to its high success rate. Through the years, the validity of this treatment option has been investigated and confirmed by several long-term studies.

An insight in the future shows that implants are becoming the treatment of choice for more edentulous patients if compared to 25 years ago. Implant improved quality and newer technologies of use, improved patient’s’ lifestyle and request for a more permanent solution than complete dentures, increase esthetic expectation, increased success rate for implants and diffuse knowledge on their existence, are some of examples. Advancements in implant designs, bone grafting procedures, and analysis of extensive outcome data have greatly narrowed the range of absolute contraindications for implant therapy. Also, more dental insurance companies are covering some parts of implant treatment and patients are more likely this option.

Despite the promising and shining future of implant therapy, there is also the other side of the coin: the peri-implant disease. This term includes two categories: peri-implant mucositis and peri-implantitis. The common trait of these two scenarios is the inflammation of the tissues surrounding the implant with bone loss only occurring in peri-implantitis. Generally speaking they can be seen as the gingivitis and periodontitis that affect teeth. Most of the time, peri-implant disease is “silent” and only a visit to the dentist or periodontist can identify it. Peri-implant mucositis can be very mild and determine only bleeding and gum redness. In some other cases, the patient can experience acute pain, pus discharge with “bad taste in the mouth”, severe bleeding and mobility of the implant. There are different grades and stages of this disease. Some cases can be identified early and treated, while others are deemed to fail ending with implant removal.

Peri-implant disease is a serious reality that affects the present and the future of dentistry. It is a global burden that is present on up to 47% of implant patients and it constitutes one of the major challenges in modern implant dentistry, where primary prevention holds all the endeavors.

With the increasing number of implant that are placed everyday, the frequency of peri-implant disease has greatly expanded. However, still many questions need an answer regarding its true cause and features. No official diagnostic criteria and classification of the disease have been introduced yet. Many factors contribute to the disease appearance and manifestation but there is no agreement on which one is the predominant. Systemic condition of the patient (diabetes), calculus deposit, crown cement deposit, smoking, lack of oral hygiene and maintenance are all contributing to appearance of peri-implant disease. The other bad news is that there is not a commonly accepted treatment for it.

On the other hand, the good news is that the patient can maintaining the implant free of plaque and keep the inflammation away. Routine visit to the dentist can identify and treat this disease on time. In fact, some cases can be treated with a simple professional debridement sessions. It is important that the patient is constantly trained and instructed on how to maintain the area.

In conclusion, while dental implants are an important tool to help to improve patient oral health and life, they have to be treated and maintained in the proper way. The baseline is patient understanding and ability on oral hygiene maneuvers. Second, it is very important to respect a meticulous and regular professional maintenance schedule with the dental hygienist or periodontist. Regular investigations on Pocket depth and follow up radiographs are paramount.

- Dr. Lorenzo Mordini