Dr. Mecall has made such a difference in my life. His precision and gentleness made my experience of dental implants and gum grafting a painless and stress-free experience. I can feel confident that my implant looks flawless which has created a new sense of self-confidence in my life. Dr. Mecall is truly the best there is!
~ Laura Cowley

Biopsy

Biopsies are common procedures performed when there are findings detected that are suggestive of some sort of pathology that has taken place. After the area is numb, either a section (incisional biopsy) or the entire (excisional biopsy) pathological tissue is removed and sent for an oral pathologist to analyze microscopically. A definitive diagnosis of the pathological tissue can then be determined and appropriate treatment recommended thereafter.

For areas that are suggestive of pathology, a preliminary biopsy can be performed to assess whether or not there has indeed been unfavorable cellular changes within the area of concern. A brush biopsy is a procedure whereby a small scraping of the tissue from the area of concern can be performed (usually without any anesthetic required) to assess whether there has been any changes within the cells that make up the tissue in the area of concern that is suggestive of cancer. If the brush biopsy reports that there has been no cellular changes of concern, continued and periodic observation is usually all that is required. If there has been cellular changes suggestive of oral cancer, a more intimate analysis will be required, either in the form of an incisional or excisional biopsy.

Diagnosing Periodontal Disease

Before any periodontal treatment is undertaken, a diagnosis must be made. To reach a diagnosis, the patient's dental and medical histories must be taken, a clinical examination must be performed, and dental x-rays (radiographs) must be reviewed. These steps are generally accomplished during the initial consultation appointment, although a second consultation appointment may be needed, particularly when additional information must be obtained.

Dental / Medical Histories

For decades we have known that a prime indicator for future periodontal breakdown is a past history of periodontal disease. By taking a dental history and evaluating previous x-rays, we have a better understanding about the rate of disease progression, and can determine what must be done to prevent further breakdown. In the last decade periodontists have also begun to understand that periodontal disease is a result of bacteria interacting with the patient's defense systems. How the patient's body responds to the bacterial (plaque) assault depends on the "host" resistance. Some people are fortunate, and have minor periodontal disease even with poor oral hygiene. For others, the same amount of bacteria may cause advanced periodontal disease and bone loss.

In other words, certain patients are very susceptible to periodontal disease, and these patients must be particularly diligent with their oral hygiene and maintenance to reduce the bacteria challenge. By taking a complete Medical History we can determine if the patient has certain risk factors and may modify treatment accordingly. Below are the most significant general health considerations that may affect periodontal disease susceptibility.

Clinical Examination

The periodontal examination gives the dentist a complete picture of the periodontal condition of the patient's mouth. This information is needed before an accurate diagnosis can be made. The oral exam is supplemented with information gained from the dental X-rays. Sometimes, bacterial samples are obtained and evaluated to determine the presence of an aggressive disease pattern. Often adjuntive use of antibiotics in combination with periodontal treatments are neccessary.

A major focus of the exam is to determine how much bone loss has occurred. When healthy, there is generally a 2-3 millimeter space (sulcus) between the tooth and the gum. This space deepens as bacterial plaque causes bone deterioration, and penetrates down the side of the tooth. This deepened space is called a pocket.

Mecall Periodontics - Periodontal Disease

Healthy tooth.

Mecall Periodontics - Periodontal Disease

Bone loss leading to pocket formation.

Mecall Periodontics - Periodontal Disease

Using a probe to measure pocket depth and bone loss.


Each tooth is measured (probed) (See What is Periodontal Disease?) at six places, surrounding the tooth, to determine the pocket depth. Normally anesthesia is not needed for this charting, which gives the dentist a blueprint of periodontal changes.

Mecall Periodontics - Periodontal Disease

Probe next to healthy gum.

Mecall Periodontics - Periodontal Disease

Probe inserted sulcus bottom (green line measures 3mm ).

Mecall Periodontics - Periodontal Disease

Gum inflammation indicating periodontal disease.

Mecall Periodontics - Periodontal Disease

Probe 5mm into pocket.

Mecall Periodontics - Periodontal Disease

Periodontal charting showing pocket depths, with gum (red) and bone (blue) levels outlined on teeth. "X" indicates a missing tooth.


Other important information is collected during the examination, so an accurate diagnosis can be made.

Dental Radiographs (X-RAYS)

A good series of dental x-rays is mandatory to accurately evaluate periodontal disease. They help determine the amount and location of bone loss, the size and shape of the roots, the amount of root still embedded in bone, the relationship of the teeth to each other, whether the nerve in a tooth has died, the location of the sinus and mandibular nerve when placing implants, and oral pathologies, among other things. We are not able to treat a patient unless we have adequate x-rays. The exception is gingival grafting, which normally does not require x-rays.

There are a number of different types of dental x-rays, each with a specific purpose, but for periodontal treatment a full series of periapical films is generally required. Below is a list of the commonly taken x-ray views, and the indications for each.

Many people have a legitimate concern about the amount of radiation they receive with dental x-rays. It's un-nerving to watch the technician set the machine and run out of the room to expose the film! However, recent advances in dental x-rays make this an unnecessary concern. The film "speed" has improved dramatically, meaning that very little radiation is needed to expose the film. In fact, it is estimated that the amount of body radiation received with a full mouth series is much less than one would receive at a day at the beach.

Diagnosis

Once the clinical data is gathered and correlated with the x-ray findings, your periodontist is able to organize and systematically evaluate the results to make a diagnosis. This is critical, for while there may be various approaches to treat a problem, there can be only one correct diagnosis. Once the diagnosis is determined, various treatment options can be formulated. With this information the periodontist and the patient can determine which treatment plan to follow.

Treating Periodontal Disease

The treatment of periodontal disease involves these main steps:

The following is an overview of the components of each treatment step.

STEP ONE: Initial Preparation

The first step of treatment is to eliminate all of the known causes of the periodontal disease. Mouth bacteria found in saliva forms colonies on the teeth and tissues, which is called plaque. This clear film of bacteria is the primary cause of periodontal inflammation and breakdown. Calculus (also known as tartar) is formed when salts from the saliva precipitate into the plaque. This forms a hard substance, which adheres tightly to the tooth, similar to barnacles on a boat's hull. Both the calculus and the plaque must be removed to achieve a successful result. The patient is taught to remove the plaque, while the dental professional must remove the calculus. Initial preparation also includes creating an environment that makes plaque removal by the patient as easy as possible. The following outline lists factors that may be addressed during initial preparation.

Following Initial Preparation, the tissues are re-evaluated after they have a chance to heal to determine if more periodontal therapy is needed. If the disease has been arrested, the optimal periodontal maintenance (cleaning) schedule is determined for the patient. If the disease persists, further non-surgical treatment may be performed. If surgery is needed to eliminate pockets that persist, a surgical treatment plan is formulated.

STEP TWO: Perioscopy - endoscopically assisted root planing

Perioscopy is a procedure using a miniature dental endoscope with advanced video, lighting and 48 times magnification that enables the periodontist and hygienist to see, accurately diagnose and effectively treat periodontal and other dental conditions, which might otherwise go undetected. While Perioscopy is not a substitute for surgical treatment, however it can greatly reduce the need in specific situations. This is especially true in the esthetic zone, the area seen when you smile. The goal of Perioscopy treatment is to get a tooth root exceptionally clean so that the gums and other surrounding tissues can become healthier. Because of the intricate clinical nature of Perioscopy, the procedures tend to take longer than a standard appointment with the periodontist or hygienist. Depending on the condition and location of the teeth being cared for, treatment usually takes one to two hours.

The benefits of Perioscopy include:

  1. Provides comfortable, non-surgical treatment option
  2. Pinpoints unseen deposits associated with bleeding and inflammation
  3. Enables early detection and management of dental problems
  4. Increases level of health care by using a new level of visualization to fight periodontal disease

STEP THREE: Surgical Treatment

Initial Preparation generally produces shrinkage of the inflamed gum, and thus a reduction of the pocket depth. Often, if the patient has excellent oral hygiene habits and keeps regular maintenance appointments, this is enough to stabilize a case. However, with pockets that continue to bleed when probed, or with pockets deeper than 5mm, there is a high probability the disease process will continue. In those cases elimination of the remaining pockets is the best treatment.

There are three primary surgical procedures that may be used to reduce or eliminate pockets that remain after Initial Preparation.

STEP FOUR: Periodontal Maintenance

The two most important factors in determining long-term success are patient home care, and regular periodontal maintenance (cleanings). It has been shown that without routine maintenance there is a 20-fold increase in the chance of recurrent disease. Most patients who are susceptible to periodontal disease must be seen for periodontal maintenance appointments every three months, rather than the typical twice yearly cleanings. Often, maintenance appointments are alternated between the general dentist and the periodontist. There is nothing a patient can do that is more important to maintaining a healthy mouth than daily flossing and brushing along with consistent periodontal maintenance.

For Patients

Dental Procedures