Case Presentation: Calculus Removal

Today's patient is a great example of why you get regular dental cleanings. These teeth looked completely healthy and normal when viewed from straight on. However, a through exam revealed that the lower teeth were in definite need of dental care. 

Dental plaque tends to build up in hard-to-see areas; behind the lower teeth, around the molars, etc. Over time, this plaque hardens to form calculus (also called "tartar") and becomes impossible to remove with brushing and flossing alone (as seen here). Calculus harbors bacteria that cause periodontal disease, decay and bone loss. At a regular dental cleaning, we use instruments and techniques that rid the teeth of calculus.

This patient received a special type of cleaning called a debridement, where large collections of calculus are removed prior to a normal dental cleaning. They are well on their way to complete oral health! If you would like to know more about cleanings, gum disease or any other health topics, please give our office a call. 

Bacteria and Tooth Decay

An electron microscope image of S. Mutans, a common oral bacteria. 

As you probably know, nearly every surface of the human body is home to bacteria. In even the cleanest, healthiest individuals, bacteria outnumber human cells by a ratio of 10 to 1! Your mouth is no exception to this, as it contains one of the the highest bacterial counts and organismal diversities in the entire body. With this in mind, microorganisms play an enormous role in dentistry and oral diseases. Today, we want to take a closer look at how bacteria are major contributors to tooth decay and cavities.

Nearly every surface of your teeth are covered in a bacterial structure called a biofilm. This formation is a sticky “home” that the bacteria produce to allow them to adhere to hard surfaces. While the biofilm is still soft and removable, we call it plaque. Proper homecare can remove plaque daily and keep the bacterial count down. However, if the plaque remains undisturbed for about 48 hours, it starts to harden and turn into tartar. Once tartar forms, it creates a strong bond to enamel that needs to be removed by a dental professional.

In the dental biofilm, the most destructive bacteria is known as Streptococcus Mutans. S. Mutans likes to colonize teeth early on in biofilm formation, along with many other species of microorganisms. When we eat sugars, starches and carbohydrates, S. Mutans processes the glucose molecules to make acid. This acid, in turn, is a primary contributing factor to tooth decay. Thus, individuals with a high S. Mutans count typically have an elevated risk for cavities.

Interestingly enough, S. Mutans species are highly correlated between children and their caregivers. Even adopted children and kids who hereditarily lack teeth tend to have the same S. Mutans breeds as their mothers, fathers or nannies. With this in mind, it is important to remember not to share utensils or cups with your children (if possible). Furthermore, cleaning off pacifiers or other teething toys with your own saliva is not recommended. Ideally, you want to lower or prevent your child’s exposure to S. Mutans for as long as possible.

Fortunately, there are a number of products targeted against S. Mutans that you are likely already using. In addition to remineralizing enamel, fluoride has been shown to disable a specific bacterial enzyme and prevent it from making energy. This has a significant impact on how fast and large S. Mutans colonies can grow. Furthermore, the sugar substitute xylitol is known to interfere with how S. Mutans can adhere to tooth structure. Xylitol is a natural compound made by plants that is used in a number of sugar free gums and mints. If you are chewing Trident, Ice Breakers or Spry gum (or others), you are getting a healthy exposure of Xylitol every day!

Our office offers Dr. John's brand candies- a great treat made with xylitol!

S. Mutans represents only one of a number of oral bacteria that cause diseases in the mouth. Gingivitis and other gum problems are mediated by entirely different breeds and colonies of bacteria that survive below the gumline. But have no fear: we will be covering those (and more) in articles to come! If you would like to know more about tooth decay, how bacteria are involved and how to best prevent cavities, please give our office a call.

Video Blog on Periodontal Services

Greetings, my name is Dr. Kari Ann Hong, and I have a family dentistry practice, where I see patients from all age groups.  Approximately ⅓ to ½ of the population at large is affected by periodontal disease.  Periodontal disease is when the bacteria in the mouth causes loss of the bone surrounding the teeth.  From a patient’s perspective, gum disease can be characterized by bleeding gums, loose teeth, bad breath, and a feeling of deposits stuck to the teeth.

As a dentist, I determine if someone has periodontal disease by a combination of evaluating the bone levels and build up on a dental x-ray, measuring the gum health with something called periodontal probing depths, and by a visual inspection of the quality of the gum tissue.  Periodontal probing depths are a measurement of the height of the gum tissue to where the tissue is attaching to the tooth.  In health these measurements are 1-3mm.  Periodontal disease is diagnosed as mild, moderate, or severe and this is primarily based on the amount of bone loss present.

I diagnose a service called scaling and root planing when the probing depths are 4mm or more, the gum tissue bleeds when touched, bone loss is present, and there is tartar build up under the gum tissue.  Scaling and root planing is done with local anesthesia and is usually billed by quadrant and/or the number of appointments required to adequately remove all of the build up. In severe cases, scaling and root planing can take as many as four separate appointments.  

There are some practices that will recommend procedures called irrigation,  localized antibiotic placement (Arrestin), or laser treatment to help with the treatment of periodontal disease.  Irrigation involves squirting an antibacterial prescription mouth wash called Chlorhexidine or Peridex around the teeth.  Arrestin is an antibiotic called doxycline that is injected directly into the deeper pocket depth areas.  Laser treatment involves shining a specific wavelength of light in the pocket area to kill the bacteria.  In my opinion, the irrigation and Arrestin treatment are helpful at the time of treatment, but do not have enough long term benefits to justify doing the procedure.  Laser treatment is an effective way at killing bacteria and has longer acting benefits than the irrigation and Arrestin, but is not a cure all for periodontal disease.  Those with periodontal disease need to adhere to a consistent professional periodontal maintenance routine in order to maintain their dental health.

If you are interested in periodontal services, please fill out the contact us information at the bottom of this page.

Cleanings and Periodontal Maintenance

The most common and essential function of our office (and any dental office) is the administration of routine cleanings and exams. These are critical steps to your long term tooth preservation, decay prevention and gum care. However, many patients would likely be surprised to learn that there are an array of services offered under the “realm” of cleanings. In this article, we will uncover the different types of dental cleanings, who gets them, and their overall “goals” in terms of your oral health.

Before going into the different types of cleanings, it is important to understand a few key terms in diagnosing and treating gum disease. Please consider the following:

Plaque- A biofilm created by bacteria to allow it to better attach and anchor itself to the tooth.

Tartar/Calculus- The result of plaque hardening on tooth structure. This substance can cause rapid tooth decay and progression of gum disease. Additionally, it is very difficult to remove with home hygiene techniques.

Periodontal pockets- The depth of space between teeth and gums as measured by a “perio probe.” Pockets ranging between 1-3mm are considered healthy and maintainable with normal brushing. Anything deeper is the result of plaque/calculus irritating the gum tissue away from the tooth root.

Bone Loss- The loss of bone height around a tooth as a result of the body’s immune response to the long term presence of plaque and calculus.

A perio probe- The indentations show 1mm and 5mm intervals for measuring pocket depths. 

The majority of patients that come to our office receive what is called a prophylactic cleaning (or “prophy”). This is typically considered a standard cleaning that you would receive twice a year on a 6 month recall. The word “prophylactic” indicates that this type of cleaning is strictly preventative care. Here, the patient’s gum tissue is considered to be within the healthy spectrum- mild plaque and calculus, shallow periodontal pockets and no bone loss. Our hygienists will remove any buildup you have incurred since your last visit and make sure there is no progression of gum disease. The purpose of this appointment is to “prevent” your healthy gum tissue from progressing into the spectrum of periodontal disease.

Some patients fall within an in-between state of periodontal disease. While they do not have aggressive bone loss, their levels of calculus, gum recession and periodontal pockets are not within a healthy spectrum. For these patients, we usually recommend a periodontal recall cleaning. This service, usually administered in three month intervals, is a more aggressive maintenance of the teeth and gums. We are no longer preventing periodontal disease; widespread calculus inflammation and tissue detachment marks the clinical presence of disease. These patients are receiving dental scaling for multiple pockets over 4mm- much deeper than a toothbrush can clean. The ultimate goal of this appointment is to prevent moderate disease from progressing further, with the hopes that you will soon be back to normal “prophy” cleanings.

A diagram visualizing the difference between healthy and diseased gum tissue and bone. 

A final category of cleanings exist for individuals who typically have not seen a dentist in a number of years. These patients have excessive calculus, periodontal pockets greater than 4mm on almost every tooth and excessive bone loss over the entire mouth. Not only will home hygiene be insufficient to keep up with the progression of disease, but standard cleaning techniques will fall short as well. Here, we provide scaling and root planing for the the most invasive levels of calculus and plaque removal. The entire mouth is cleaned over two or four appointments, usually with an anesthetic. This type of procedure is usually recommended once to give your mouth a complete, thorough evaluation and cleaning. The goal is to set a healthier baseline for your mouth, so that it can be better managed by regular scheduled cleanings and your personal home care routine.

We recommend all of these periodontal services to a number of our patients for a number of reasons. Sometimes, unique situations will require a combination of approaches, the expertise of specialist or even surgical intervention. Only a thorough evaluation by Dr. Kari or one of our skilled hygienists will give us a true picture of your gum health. If you would like schedule an exam or cleaning, please contact our office. We are here to listen to your concerns and guide you every step of the way!