1. Can I see a periodontist without a referral from a general dentist?

Yes. If a person has reason to suspect they might have periodontal disease, or alternatively, if a person wishes to confirm that they do NOT have periodontal disease, they are welcome to contact the office to make an appointment directly. The receptionist who makes the appointment with you will ask you a few questions about why it is that you’d like to see a periodontist, so that the periodontist can come to the appointment as prepared as possible.

2. Who should see a periodontist?

A person should see a periodontist if they have a reason to suspect they might have some issues with their gums and the underlying bone which support their teeth, AND if those issues are not already being diagnosed and managed by their general dentist. How would a person know if they might be having gum problems? Two easy-to-spot signs are gums which bleed often ^1,2 , and teeth which are mobile ³ . Both of these signs are strongly indicative of gum-related problems, and need to be addressed as soon as possible. Another reason a person might want to consult a periodontist is if they have a history of gum disease in their family ⁴ . Certain periodontal diseases have a strong genetic link, and such a person may be at a higher risk for developing them.

3. I was told I needed to see a periodontist, but I’m not feeling any pain or discomfort in my mouth. Do I really need to go?

YES. One of the most dangerous things about periodontal disease is that often, there are no symptoms until the disease has progressed to a very severe state, by which time the affected teeth may not be able to be salvaged. General dentists, their hygienists, and other dental specialists have ways of picking up on periodontal disease. Once they inform a patient that they need to see a periodontist, the clock is ticking...periodontal disease is progressive, and the overwhelming majority of untreated periodontal disease will get worse with time ⁵ .

4. I was told I have periodontitis. What does this mean?

Periodontitis is the technical diagnosis for a disease which begins with bacteria causing inflammation in the gums. This can affect a tooth, multiple teeth, or all the teeth. If this inflammation stays in the gums, we call it gingivitis, and it is easily treatable and completely reversible, with no permanent damage. For a certain proportion of people who have gingivitis, their disease will progress to begin affecting the underlying bone and periodontal ligament which keeps the teeth in the mouth. At this point, the body’s own immune system reacts to the bacteria, causing the damage ⁶ . This is now periodontitis, and most often, while the process can be halted relatively easily with treatment, the damage is not reversible, and the best-case scenario is that the patient has to live with the bone loss they have developed. The worst-case scenario might be that the affected tooth or teeth need to be extracted. This is a major reason why it’s so important to: 1) follow your dentist’s/hygienist’s advice about good oral hygiene practices; 2) go and see a periodontist to whom you have been referred as soon as possible; and 3) undertake any periodontal treatment which has been proposed to you as soon as possible. BEWARE! The most recent estimates coming out of the United States are that 46% of the population has some form of periodontitis ⁷ .

5. Is it possible that I have any characteristics or habits that are increasing my risk of developing gum disease?

Yes. Periodontitis is a very individual disease, in that if you take a cross-section of people who have such a diagnosis, they will all present in different ways. This is because different people have different risk profiles for developing the disease, and therefore, different susceptibilities. There’s no use worrying about risk factors which are intrinsic to your body, like genetics, as there isn’t much you can do yourself to change them. However, there ARE three big things which can affect the development and progression of periodontitis, and are all things you can influence yourself. These are: 1) poor oral hygiene; 2) cigarette smoking; and 3) uncontrolled diabetes ⁸ . In the case of poor oral hygiene and cigarette smoking, what you can do to help yourself should be obvious. In the case of having diabetes which is not under control, your periodontist will most likely confer with your treating physician to see what can be done to get it under control. As a side note, more often than you think, a periodontist might have reason to suspect that you are diabetic, even if you are unaware of it. In this situation, he will most likely send you to your physician for a blood test to confirm the suspicion, and it is very important that you take this test as soon as possible.

6. My parents/siblings have gum problems. Is gum disease hereditary?

It can be. We now know that certain types of periodontitis run in families ^9,10 . These types of periodontitis affect male and female members of the family equally ¹¹ , and can be very aggressive in nature ¹² . If you have family members who have been diagnosed with periodontitis, it’s a good idea to ask your dentist if a referral to a periodontist is appropriate, or if you don’t have a dentist, contact a periodontist directly. One important thing to note is that the type of periodontitis which is most hereditary also tends to start at a very young age, even as early as puberty ¹³ . For this reason, if you have children, your periodontist might advise you to bring your children in for consultation to see if they have signs of the disease, and if you are very young and have siblings, the periodontist might ask to meet them as well.

7. How often should I get regular dental cleanings?

It depends. In a previous frequently-asked question, we referenced the fact that gum disease is very individualized, and the reason for this is because different people have different risk profiles, and thus have different susceptibilities. If you are someone who has periodontitis, or who has had periodontitis and has undergone treatment, by definition your risk is higher than the average person, and this mean that you need cleanings more often. The currently accepted standard for someone with a high risk for periodontitis is to get regular dental cleanings every 3 months ^14,15 . Note that for people who do NOT have a high risk for periodontitis, they can be seen for dental cleanings less often, with their schedules being anything between once every 6 months to once a year. If you are unsure as to your risk profile for gum disease, a consultation with a periodontist can help you identify it.

8. I was told I need a deep cleaning. What does this mean, and why is this so much more expensive than a regular cleaning?

When a patient has been diagnosed with periodontitis, the first step toward treating the problem is eliminating the bacterial infection. In most cases this is done with a procedure called scaling and root planing, which is commonly known to the public as a “deep cleaning.” In it, ultrasonic and manual instruments are used to remove bacteria and tartar from the surfaces of the affected teeth, and also to smooth out the surface of the roots of the teeth. The periodontist will likely numb up your gums in order to perform this procedure. It is more expensive than a regular cleaning because the bacteria and tartar in question are underneath the gums, and therefore not visible to the periodontist or hygienist, thus the procedure is far more labour-intensive and time-consuming than a regular cleaning.

9. I had a deep cleaning done, and a few weeks after, I had a re-evaluation. I was told the deep cleaning had not eliminated all my gum disease, and now I would need some gum surgery. Why do I need the gum surgery?

Recall that in the previous frequently-asked question, we referenced the fact that “deep cleaning” was the first step toward treating periodontitis. Part of this first step is that about six weeks after the procedure, we schedule a re-evaluation. During the re-evaluation, we ask ourselves if the parameters we used to diagnose the problem have improved, and if yes, have they improved enough that we can safely say that the periodontitis has been successfully treated? If yes, then no further active treatment is necessary, and the patient can be placed on a regular cleaning schedule, which as discussed previously will most likely be once every 3 months. If the parameters have not improved as much as are necessary to consider the case having been treated successfully, then the periodontist will likely advise proceeding to the next step in treatment, which is most often surgical therapy. There are various kinds of surgical therapies to treat periodontitis, ranging from pocket reduction surgery to regenerative therapy, and discussing them all here would take too long. The easiest way to understand the situation when it has progressed to needing surgical therapy is that the problem is severe enough to require surgical intervention to directly access the underlying bone and root surfaces of the teeth. Most of the procedures in question are quite minor and easily accomplished. BEWARE! The available research points strongly to the notion that patients who needed gum surgery and chose not to get it were far more likely to experience further periodontitis than were patients who were advised to get gum surgery and did so ^16,17 .

10. Are there any side effects of the gum surgery?

Yes. Two common side effects are recession of the gums and tooth sensitivity. Counter-intuitively, in the case of a patient with periodontitis, recession following the procedure is not only normal but is actually desirable, as it leaves the gums in an easier-to-maintain and healthier state. In fact, a patient might even get this recession after nothing more than a deep cleaning, and this also is a sign that the gums are on their way back to being healthy. Along with recession of the gums comes tooth sensitivity, and the reason for this is that as the gums recede, the roots of the teeth become exposed. The roots of the teeth have small nerve endings close to the surface, and often foods or drinks which are cold or hot can irritate these nerve endings, leading to the sensation that the tooth is sensitive. Is this an issue? The majority of patients will adapt to the sensitivity after a few weeks, and for those who don’t, desensitizing toothpastes and in-office desensitizers can improve symptoms very rapidly. Interestingly, a well-known study looked at patients’ responses to how they felt after having had both surgical and non-surgical therapy for periodontitis. The results demonstrated that not only were the general feelings and experience with sensitivity similar for the areas which had gotten non-surgical vs. surgical therapy, but when the patients were polled after the therapy as to which one they would prefer to get done again if the need arose, the overwhelming majority stated they would agree to having surgery again, and the percentage of people who preferred no surgery to surgery was the same ¹⁸ .

11. Are there any instructions I have to follow after my gum surgery?

Yes. You will receive detailed instructions, both verbally and in writing, after the procedure has been completed. To give you an idea of what they’ll say:

• Bleeding is normal during the post-operative period. If the bleeding is bothering you, applying pressure for 30-45 minutes with a wet piece of gauze or a wet tea bag will usually stop the blood flow. If you feel that your bleeding is excessive, contact your periodontist.
• Pain is normal during the post-operative period. Use the pain medication that your periodontist has prescribed exactly as is written on the prescription.
• Swelling is normal during the post-operative period. Swelling can be slightly decreased by applying ice to the face in the area of the surgery, using a routine of 15 minutes on, followed by 15 minutes off, for the first 24 hours. Swelling may be accompanied by bruising on the face and neck, and this is normal.
• Avoid smoking. Smoking is directly linked to complications and failures after surgery.
• Avoid eating or drinking anything hot or spicy, and avoid eating anything hard, during the post-operative period. In fact, if you can manage to avoid chewing anywhere near the surgical area, you will be less likely to develop complications.
• Avoid brushing and flossing in the surgical area during the first two weeks of the post-operative period.
• Avoid strenuous physical activity for the two weeks following the procedure.
• Use the special mouth rinse that has been given to you or prescribed by the periodontist in the following manner: swish with 15mL (1 tablespoon) for 30 seconds, twice a day, for two weeks. Do not swallow this mouth rinse. Do not use any other mouth rinse in place of this mouth rinse. Let this mouth rinse fall gently from your mouth, rather than spitting it out.
• Your stitches will dissolve by themselves. Do not attempt to remove them yourself, and do not attempt to touch the surgical area with your hands, as they are not clean.

12. What are the consequences of not treating my gum disease?

An excellent question. As has been mentioned in a previous frequently-asked question, periodontitis is a progressive disease, and the overwhelming majority of cases will get worse without treatment ⁵ . How quickly these cases will deteriorate is dependent on a number of factors, and is very difficult to predict for the individual patient ^19-22 . Because of this difficulty, once diagnosed, most periodontists will advise prompt and aggressive treatment of periodontitis, however they choose to go about it. The “wait and watch” approach is not advised in cases of periodontitis, for both the reason that the rate of progression is unpredictable, and also because it is MUCH easier to treat this disease in its early stages. In fact, another frequently-asked question referenced the fact that treatment involved side effects. BEWARE! The longer a patient waits to treat the periodontitis, the more severe the side effects will be.

13. I was told I need a gum graft. What does this mean?

Mucogingival conditions, which is a fancy way of saying that there are issues with your oral soft tissues, are another area of responsibility for a periodontist. This category of disease has multiple entities, but to make things a little easier to understand, most of the time when we make a diagnosis of a mucogingival condition, we are either referring to the fact that a recession has occurred, or that there is a risk that a recession is about to occur. In both cases, a periodontist may advise performing a gum graft, either to cover a root surface that has been exposed through existing recession (a root coverage procedure), or to prevent recession from occurring/prevent it from getting worse than it already is (a gingival augmentation procedure). There are minor differences between the two approaches, and your periodontist will explain them to you. NOTE: In the case of a patient who has already had bone loss due to periodontitis, the recession that has resulted from successful treatment most likely cannot be reversed. In this situation, if a graft is advised, the reason is likely to prevent its progression.

14. Are there any instructions I have to follow after my gum graft?

Yes. You will receive detailed instructions, both verbally and in writing, after the procedure has been completed. To give you an idea of what they’ll say:

• Bleeding is normal during the post-operative period. If the bleeding is bothering you, applying pressure for 30-45 minutes with a piece of wet gauze or a wet tea bag will usually stop the blood flow. Note that especially on the palate, using a wiping motion will only cause the area to bleed more. Firm, stationary pressure is the best technique to use. If you feel that your bleeding is excessive, contact your periodontist.
• Pain is normal during the post-operative period. Use the pain medication that your periodontist has prescribed exactly as is written on the prescription.
• Swelling is normal during the post-operative period. Swelling can be slightly decreased by applying ice to the face in the area of the surgery, using a routine of 15 minutes on, followed by 15 minutes off, for the first 24 hours. Swelling may be accompanied by bruising on the face and neck, and this is normal.
• Avoid eating or drinking anything hot or spicy, and avoid eating anything hard, during the post-operative period. In fact, if you can manage to avoid chewing anywhere near the surgical area, you will be less likely to develop complications.
• Avoid smoking. Smoking is directly linked to complications and failures after surgery.
• Avoid brushing and flossing in the surgical area during the first two weeks of the post-operative period.
• Avoid strenuous physical activity for the two weeks following the procedure.

15. What are the consequences of not getting a gum graft if I was told I need one?

The most likely consequence of not getting a gum graft if you have been advised to get one is that recession will occur, or if it has already occurred, it will get worse. ²³ .

16. I hear a lot about dental implants. Should I get implants, and if yes, am I a candidate?

Dental implant placement is one option for restoring a missing tooth or teeth, or for planning to restore a tooth/teeth that is/are still present but that your dentist has told you will be lost eventually. For most patients, it may be the best value option, if only because it has better longevity than some other options, and unlike some other options does not affect the neighbouring teeth. So in that sense, depending on what your expectations are as a patient, coupled with what the situation is in your mouth, you should get an implant IF that’s the best/the only way to get you what you want with what resources you have available.

Whether or not you are a candidate for an implant or implants is a separate issue. Between the dentist who will be restoring the implant (this means placing the crown, bridge or denture on the implant(s) in question), and the periodontist or other surgeon who would place the implant, they can identify whether or not you are a candidate. This will require a consultation.

17. I’m having a tooth extracted, and an implant placed in a few months. I was told to get a bone graft at the same time as the extraction, which is much more expensive than a regular extraction. Is it really necessary?

The great American statesman and scientist Benjamin Franklin one said, “An ounce of prevention is worth a pound of cure.” This statement applies to many areas of periodontics, but rings especially true in this case. Often, when a tooth needs to be extracted, the decision is made to replace it with an implant. If the implant cannot be placed the same day as the extraction is performed, then there will generally be a 3-6 month healing period before the implant is placed. In this situation, the person extracting the tooth will frequently recommend the placement of a bone graft at the same time as the extraction, in order to keep the height and width of the available bone adequate for an eventual implant (for this reason it is referred to as a ridge preservation). It is more expensive than a regular extraction because of the extra materials involved (the bone graft and usually a special membrane to over the graft). Bone grafts and membranes come in different forms and come from different sources, and each comes with advantages and disadvantages. Whoever is placing the bone graft will discuss with you all the details about the bone graft.

Is it necessary? Well, the consequences of NOT doing ridge preservation when one has been so advised are that after the healing period, the region might not have adequate bone to place an implant. The bone can most often be built up after the fact, but this is more expensive and invasive to do, and increases the total time before the patient gets the implant, as it introduces an additional healing period. Does this always happen without ridge preservation? No, but unfortunately, it’s quite difficult to predict to whom it will happen and to whom it won’t. For this reason, we commonly err on the safe side, and advise our patients to have ridge preservation performed.

18. I was told I would need a bone graft prior to getting an implant. What does this mean?

Sometimes a patient is planning to get an implant in a region where a tooth was extracted many years before, or was extracted recently but WITHOUT ridge preservation. In these situations, there is a possibility that the volume of bone may not be adequate for implant placement. If it isn’t, often whoever is placing the implant will advise the patient to have a bone graft performed to increase the volume of bone in the region, hence the proper term ridge augmentation.

19. Are there any instructions I have to follow after my bone graft/dental implant placement?

Yes. You will receive detailed instructions, both verbally and in writing, after the procedure has been completed. To give you an idea of what they’ll say:

• Avoid any activity or motion that might create pressure inside your mouth. Common examples of things to avoid are: smoking, sucking liquids through a straw, and spitting.
• Bleeding is normal during the post-operative period. If the bleeding is bothering you, applying pressure for 30-45 minutes with a piece of wet gauze or a wet tea bag will usually stop the blood flow. If you feel that your bleeding is excessive, contact your periodontist.
• Pain is normal during the post-operative period. Use the pain medication that your periodontist has prescribed exactly as is written on the prescription.
• Infection can be a significant complication of a bone graft or implant surgery. Take the antibiotic you have been prescribed exactly as written.
• Swelling is normal during the post-operative period. Swelling can be slightly decreased by applying ice to the face in the area of the surgery, using a routine of 15 minutes on, followed by 15 minutes off, for the first 24 hours. Swelling may be accompanied by bruising on the face and neck, and this is normal.
• If you notice little pieces of bone in your mouth, it does not mean that you have lost the entire bone graft. Sometimes, little pieces of bone may come out of the surgical area before the gums have had a chance to completely cover it, and this is normal.
• Avoid eating or drinking anything hot or spicy, and avoid eating anything hard, during the post-operative period. In fact, if you can manage to avoid chewing anywhere near the surgical area, you will be less likely to develop complications.
• Avoid brushing and flossing in the surgical area during the first two weeks of the post-operative period.
• Avoid strenuous physical activity for the two weeks following the procedure.
• Use the special mouth rinse that has been given to you or prescribed by the student dentist in the following manner: swish with 15mL (1 tablespoon) for 30 seconds, twice a day, for two weeks. Do not swallow this mouth rinse. Do not use any other mouth rinse in place of this mouth rinse. Let this mouth rinse fall gently from your mouth, rather than spitting it out.
• Your stitches will either dissolve by themselves, or be taken out by your periodontist. Do not attempt to remove them yourself, and do not attempt to touch the surgical area with your hands, as they are not clean. Do not attempt to pull on your lip or cheek to see the surgical area in the mirror or to show it to other people, as this can cause failure of the bone graft or implant.

20. I was told I would need a sinus lift, either before or at the same time as my dental implant. What does this mean?

Specifically in the region of the upper back teeth, just above the roots of these teeth lies a large air space called the maxillary sinus. This is commonly the sinus which gets inflamed when we talk of getting a sinus infection. Sometimes, we want to place an implant to replace an upper back tooth, BUT, the height of the bone in that region is inadequate, because the sinus space is so large. To address this, we can do a special bone graft where we take the floor of the sinus and push it upwards (thus the terms sinus lift or sinus augmentation). This procedure is quite simple, and can often be done at the same time as extraction and ridge preservation or dental implant placement.

21. I have sinus problems. Will the sinus lift make them worse?

Whoever is performing your sinus lift will assess your sinus to make sure there are no signs of problems. If there are, or if you describe symptoms of sinus problems, you will likely be referred to an otolaryngologist, a physician who specializes in ears, noses and throats. This physician will evaluate your sinus and either give the OK to proceed with the sinus lift, or will treat the issue until it has been resolved, and then the sinus lift can be performed.

22. Will the sinus lift cause me sinus problems afterward?

According to the latest research, the incidence of chronic sinus problems following a sinus lift is quite low at 2.3% ²⁴ . If chronic sinus problems do occur, then a referral to an otolaryngologist for evaluation and treatment will generally fix the problem ²⁵ .

23. Are there any instructions I have to follow after my sinus lift?

Yes. You will receive detailed instructions, both verbally and in writing, after the procedure has been completed. All the same instructions for a bone graft/dental implant placement apply to a sinus lift, HOWEVER, there are a few very special instructions that are specific to a sinus lift which must be followed. To give you an idea of what they’ll say:

• Avoid blowing your nose. This creates pressure in your sinus, because the nasal cavity and the sinus are connected. Excess pressure in the sinus following a sinus lift can cause failure of the procedure. If you’re feeling stuffed up following the procedure, get an over-the-counter nasal decongestant at the pharmacy, and use it so that you are able to breathe normally through your nose.
• Avoid sneezing through your nose, as this will also cause pressure in the sinus. If you have to sneeze, try to expel the sneeze through your mouth.
• Avoid any activity which places your head below the rest of your body (e.g. gymnastics, yoga etc.) for two weeks following the procedure.
• Avoid any activity which requires full immersion of your head under water. For example, swimming in a pool might cause water to travel up your nose and into your sinus. The bacteria in the water can cause a sinus infection, and can lead to failure of the procedure.
• Avoid flying in an airplane, SCUBA diving, or any other activity which might cause a significant pressure change in the air around you for two weeks after the procedure. Extreme or sudden pressure changes in the sinus can cause failure of the procedure.
• Nosebleeds are completely normal for several days after the procedure. Treat them as you would any other nosebleed.