Gum recession

[RM1961]

hi Dr. B:

I am a 48 year old female who visited the same dentist for 20 years, at least yearly and often every 6 months, for cleaning and exam. In 2009 I did not visit the dentist, but went in January 2010 - last visit being September 2008. His new hygienist pointed out I had gum recession on my lower teeth. I was absolutely shocked to see the severity of the gum missing, with V shaped areas where the root was exposed. The old hygienist of 20 years NEVER mentioned my gums to me AT ALL.

Since then I have noticed it starting on my top teeth, including my front tooth. The dentist seemed quite cavalier about it and said 'what are you worried about, you're not going to lose your teeth'. I told him I found it hard to believe that this started between 09/08 and January 2010 and that no one mentioned in the past, thus I was never told I was possibly brushing the wrong way, or that I needed to watch what was happening with my gums. The dentist says it is "anatomic" and due to the way my teeth incline towards the tongue (due to orthodontics) and at first he said I could see a perio but that he does not recommend gum grafting, after his 31 years of experience.

So I start doing a lot of research and I email him with my concerns. He says I need a full mouth X-ray which I have done and he THEN says that I could consider having gum grafts on 6 lower teeth. I ask him what should I be doing in the meantime to keep the area clean and he suggested a waterpik on a low setting. After these visits I went home and realized I was very unconsciously brushing in that awful washboard fashion and also occasionally biting down on the toothbrush which I'm sure did not help this situation. I am beside myself with worry. I asked for a copy of my dental records, there is no mention of gums, and this practice never did any measuring. From people I have talked to, periodontal charting is routine at their dentist, with "millimeters" being called out and I never once had this done to me.

Today I have an appt at a top dental school in my city with a dentist who is in training to become a periodontist. I also have an appt. with a perio in my city in two weeks. I have no dental insurance and I know I'm facing several thousand dollars and much pain and recovery if I have this treatment.

I guess my question is: how could this dentist have missed this? He claims it could be acute but he says he does not think it is due to periodontal disease, and that in his practice they don't consider what I have as "pathological".

Your thoughts and what is your experience with gum grafting? This dentist seems to think it's not worth it and he sees patients who have had it coming back in a few years to have it done again.

[mbornfeld]

Dear RM1961,

Although the experience with your dentist may have been a bit unsettling, there is nothing in your description that would seem to require any reading between the lines, and could probably be taken at face value. Some diagnosticians are "disclosers" who alert their patients to every finding, regardless of its clinical significance, while others will reserve comment for those issues that have real impact on oral health. There is nothing overtly wrong with either approach, although today's consumerist trend would favor telling all. There is a price to be paid for disclosing minutia, as your case aptly demonstrates-- being beside yourself with worry is not only unhelpful, but may be totally out of synch with the true importance of this matter. Quite obviously, I cannot answer your question as to "how could this dentist have missed this?", and I'd rather not speculate, but he very well may not have missed it at all. Trivialities (or more properly, what a dentist views as trivial) just don't merit much attention.

In fact, many cases of gingival recession are "anatomic"-- i.e., related to morphology of tooth roots and the tissues that surround them, rather than due to clinical disease. A fair number of recession cases are due to prior orthodontic treatment-- especially when that treatment was intended to compensate for skeletal discrepancies-- i.e., abnormal spacial relationships between the upper and lower jaws. This often forces teeth beyond the boundaries of their supporting bone, which promotes sometimes dramatic gum recession. The recession is usually sustained soon after conclusion of active treatment, and I suspect that you have had at least some of your gum recession for many years.

It is true that gum recession is sometimes a manifestation of inflammatory periodontal disease, and I'd like to think that your dentist has not prematurely ruled out this possibility. That you don't remember any formal periodontal evaluation by your dentist is somewhat troubling, but some patients don't notice much of what goes on in the course of a diagnostic visit, and you could have just missed it.

It is probably a good thing that you are seeking treatment in a dental school setting, because service proceeds "by the book" in this type of venue. However, your role in a dental school is intended primarily as educational, and your presence there may provide more educational value to the dental students than health value to you, depending on whether you implement gum grafting. What your dentist told you is essentially true-- gingival grafts sometimes provide lasting benefit if they are reserved for appropriate situations, but most cases tend to relapse if there is not a layer of bone covering the roots of the teeth.

The downside of "anatomic" gum recession, provided it is not accompanied by periodontal disease, is limited to two potential issues: root sensitivity, and cosmetic liability. If these are not in evidence, there is often very little benefit to be had from gum grafts, even in the unlikely event that they endure.

Hope this helps...

[RM1961]

Thanks for your reply, Dr. Bornfeld, I do greatly appreciate your expertise and the time you took to respond. This board is a wonderful resource.

OK, I was told at my evaluation at the dental school yesterday that I do NOT have "pockets"...that I do have mucogingival defects due to improper brushing and orthodonture and perhaps genetic factors.
So if I don't have pockets, then I probably don't have active periodontal disease is what I took away from this.

The perio student said I did have "gingivitis" and that I had some very reddened gum tissue where it should be pink. The lower teeth I have the mucogingival defects with "Recession: 1-5 mm". I don't know how to read the chart she provided with the numbers.

Diagnosis: "Plaque induced moderate gingivitis with mucogingival defects localized to #4, 5, 11, 12, 13, 20, 21, 22, 27, 28, 29.

Over prognosis: Good
Individual: Fair

She said the bone level is quite good and I have had surprisingly little bone loss based on my x-rays. The faculty member (and my dentist) said where ever there is gum recession, there is bone loss.

I had my teeth cleaned at the dentist in January where the new hygienist pointed this out. The perio student is recommending "Root planing and scaling" to do next week due to plaque accumulation in the recessed areas. I have told them I would have to put off any grafting for several months as the summer is my busy season.

I am afraid the Root planing and Scaling is somehow going to make it worse. She seems to think she can save some of the top teeth which haven't recessed to the root yet and help the tissue shrink back with this "conservative" treatment.

I have attached photos And X-rays taken at my dental office in February '10. You can still see (despite my black and white scanner) where the plaque is collecting.

I am really trying not to worry Dr. Bornfeld but I will admit having major anxiety over this situation. Thanks again for your time.

[mbornfeld]

Dear RM1961,

I'd just like to clarify a definition of "periodontal disease"-- it is a broad term that denotes a reactive inflammatory change in the tissues immediately adjacent to the roots of teeth in response to the harmful effects of bacterial plaque. There are varying degrees of periodontal disease; when confined to the superficial soft tissues, it is known as "gingivitis", and when it involves the deeper soft and hard tissues (the periodontal ligament and the alveolar bone, respectively), it is called "periodontitis". Within those broad categories, there are varying severities and rhetorical qualifiers: acute, subacute, chronic, latent, indolent, progressive, or fulminant. There are also differing manifestations: changes in gingival texture, tendency toward bleeding, mobility (looseness) of teeth, presence of inflammatory exudate, and pocket depth.

Perhaps the most enlightening parameter that defines the severity of periodontal disease is pocket depth-- not because it is more important than the others, but because it is the only factor that can be objectively measured (pocket depth is the depth of the crevice between the gum and the tooth root; by convention, any crevice less than or equal to 3 millimeters in depth is considered normal, and is referred to as a periodontal "sulcus"; deeper than 3 millimeters is considered abnormal, and is considered a "pocket"). In your case, the absence of periodontal pockets in itself suggests that at the very worst, your periodontal disease could be considered a trivial gingivitis. Any gum disease of any severity and of any duration will have conspicuously deepened periodontal pockets; conversely, any gum disease without pockets would not be considered severe.

It should be pointed out that the formal definition of "root planing" is the removal of tartar and other deposits from root surfaces situated under the gum; the fact that you don't have pockets would suggest that a "supra-gingival scaling" is a more appropriate protocol. I make this distinction because "root planing" would be associated with a higher fee than a "scaling" due to the greater amount of time and labor involved. Based on your photos, a cleaning wouldn't be a bad idea. Assuming that it is administered with care, it should not promote further gum recession.

A definition of "mucogingival defects" is more complicated, and requires a description of periodontal anatomy that is perhaps beyond the scope of this forum. If you want to view a couple of informative but technical PowerPoint presentations on the subject from Kansas State University, I commend you to the following links:
Mucogingival therapy2, and
Gingival Recession Etiopathogenesis
(To view these presentations, you will need to either have Microsoft PowerPoint or Microsoft PowerPoint Viewer installed on your system. You can download a free copy of the PowerPoint Viewer 2007 here.) The important thing for you to know is that surgical correction of mucogingival defects does not necessarily cover exposed tooth roots or reverse the effects of previous gum recession; its primary intent is to prevent further progression of gum recession, which is usually all that's needed unless appearance or tooth sensitivity due to recession are issues of concern.

While I appreciate your anxiety, I feel compelled to put this in perspective. As dental problems go, this is essentially inconsequential. I don't mean to downplay its importance; as a dentist, these matters occupy my life more than they occupy the lives of most others, but your time and emotional turmoil would be much better spent on other things. I suspect that your gum recession is of relatively longstanding duration, and unless you see clear evidence of progression, this is certainly not a matter of urgency. As an alternative to active intervention, you might consider a strategy of watchful waiting to see if the recession is worsening. If the condition is not progressive, surgical intervention confers no additional benefit. In the absence of significant periodontal disease, I usually don't as a matter of general policy encourage my patients to have their mucogingival defects surgically corrected unless an affected tooth is structurally broken and requires crown placement.

Good luck!

[RM1961]

Thank you VERY much, Dr. Bornfeld. I hear what you are saying, that my anxiety about this situation may be unnecessary yet I want to avoid progression and further problems down the line.

Should I forego the Scaling and Root Planing procedure since I was told my "pockets" are normal? Naturally I want to avoid making the recession WORSE. I have read that this procedure can cause the gums to "shrink back" and I certainly don't want that since they are already receding or have receded dramatically (as you can see in the photos of the lower teeth.) If I don't have "pockets", then why have this procedure done?

I was thinking since my last regular cleaning was in January (and yes, the photos were taken AFTER that cleaning - which is why I wonder if my original dentist changed his tune and suggested I consider having the graft surgery) I would have another regular cleaning in early April (at a new dental practice, and thereby get a second opinion as well).

I don't think I can afford the recovery time from a Free Gingival Graft which is what the treatment plan at the dental school is. I can handle the expense, not worried about that, but I keep seeing the word "barbaric" to describe it.

In sum, I don't want to undergo the Scaling and Root Planing deep cleaning procedure if I don't need it. Since was told I have "gingivitis" and not "periodontal disease" then it seems too invasive and unnecessary at this point.

Any suggestions for home conservative treatment? I am now GENTLY brushing with a soft toothbrush 2-3 times a day, flossing 1-2 times a day and doing warm saline rinses 2-3 times a day.

THANK YOU AGAIN for your informative and very helpful response.

[mbornfeld]

Dear RM1961,

The question of whether you should receive a "root planing" is one of semantics; it simply would not be an accurate term, assuming an absence of subgingival pockets. Use of an improper procedural descriptor may simply be an innocent mistake, or it may reflect an intentional act of "upcoding" for the purpose of padding the bill. In any case, a cleaning, regardless of what you call it, would not encourage further recession if properly implemented. By the way, since we're on the subject of sematics, you should know that "gingivitis" is indeed considered a form of "periodontal disease", but is less serious than "periodontitis".

I disagree with your characterization of a free gingival graft as "barbaric", especially when considered in the context of all the other wonderful medical and dental procedures that become increasingly routine with aging. You'll have to take my word on this one.

At face value, your home care regimen seems adequate. However, it is one thing to brush and floss, and quite another thing to brush and floss well. If you've never been formally coached in the technique, you should consider requesting a coaching session with your dentist or dental hygienist. These oral hygiene procedures are not entirely intuitive in nature, and small tweaks in your approach may make a significant improvement in efficacy.

Good luck!

[RM1961]

Thanks for your reply, Dr. Bornfeld!

The student periodontist admitted that there would be no root planing in the absence of pockets but it is just terminology that they use. She said I need a good cleaning as I have marginal gingivitis and that bacteria is trapped in the gum line. (I just had a cleaning at my long time dentist on January 8, 2010 where the recession was pointed out.) She said it would be mostly scaling but in the context of periodontal assessment (which I guess would differ from scaling done by a dental hygienist?). I thought I even heard her mention that novocaine might be used (?) - I have emailed her about this.

I am afraid she is going to cause more sensitivity by digging around and cleaning in the exposed roots. Right now I have minimal sensitivity. I do see plaque collecting in the mucogingival defect areas. I am gently brushing those areas but afraid of making it worse. I also fear she will somehow make the recession worse. The period student is a dentist but apparently has a BDS from another country (Saudi Arabia?) The appointment is for Friday 3/12.

Other options I am considering: getting a second opinion from a DENTIST who came highly regarded, prior to doing this cleaning procedure with the student.

I also have an appointment with a private periodontist for 3/17 and I don't know if that is worth keeping either if I don't plan on having gum grafting surgery (at least not right away). The costs of all these appointments will certainly add up.

You have opined that my anxiety is unfounded but when I look in my mouth and see how badly receded the gums are, especially in the lower teeth, it is freaking me out. You can't completely see it in the photos. What is the WORST thing that can happen if I don't get these teeth grafted?

Thanks again for your expertise.

[mbornfeld]

Dear RM1961,

The worst that could happen if you don't have a gingival graft is perhaps some additional recession; this would not be dramatic, but gradual. Since you are obviously vigilant, you will know if and when it happens, and implement an appropriate remedial strategy.

Good luck!

[RM1961]

hi Dr. Bornfeld -

Had an upsetting conversation with the student perio who told me if I did not have gum grafting this was going to get worse and I would LOSE MY TEETH in 5 to 10 years. She also was "offended" when I questioned her about the price if I did not need root planing, and when I said that I wanted to get a second opinion. I am not comfortable with this person cutting in my mouth.

Regarding what is the worst thing that could happen. My feeling is that this could get worse - both my original dentist and the student perio said that it could/would. I don't you can see how dramatic the recession is from the photos (I believe I saw 7mm on the perio chart). So with no gum tissue on the roots, there is the high possibility of increased sensitivity and risk for dental caries. Say I do develop unbearable sensitivity and/or root caries. From a dental point of view, what would be the treatment - root canal? How are root caries treated? And are root canals common on the lower incisors?

Have you had patients with severe recession on 6 teeth who just "live with it" and it doesn't progress to root caries, intense sensitivity, etc?

Thank you.

[mbornfeld]

Dear RM1961,

Actually, the worst thing that could happen is if some hapless patient submitted to all that treatment recommended by the dental student, paid the fees in full, and wound up under a bus after walking out of the dental school clinic. I will not engage in speculations of worst-case scenarios, because I'm not clairvoyant, and my wife wants me to practice having a more optimistic temperament. The one thing that can be said is that no dentist can provide absolutely reliable treatment outcome predictions, much less a dental student with less than three years of clinical experience.

In my 32 years of practice, I have in fact had many patients with significant gum recession that did not conspicuously progress, and who did not experience rampant root decay or sensitivity.

I will chalk up your dental student's comments to inexperience. However, there is a pervasive arrogance within the dental profession-- a way of looking at patients as naive and unsophisticated and needy of the profession's guidance. Dental students are indoctrinated into this patronizing attitude early on in their training, and it persists throughout the professional lives of too many dentists. In their view, patients who accept complicated and expensive dental treatment are wise, virtuous, and worthy of respect; patients who decline dentistry as too fearsome, complicated, or expensive are misguided, cheap, and have bad priorities. Your dental student is just playing the good little soldier.

Sadly, dentistry has become a business first and an altruistic endeavor second-- or maybe third. Your "upsetting conversation" should be viewed as a sales pitch. While there may indeed be value in the recommended treatment, real life is never as clear cut as she implied by her "my way or the highway" approach.

Get that second opinion. Your student will get over it.