Gingivectomy is periodontal surgery that removes and reforms diseased gum tissue or other gingival buildup related to serious underlying conditions. For more chronic gingival conditions, gingivectomy is utilized after other non-surgical methods have been tried, and before gum disease has advanced enough to jeopardize the ligaments and bone supporting the teeth. Performed in a dentist's office, the surgery is primarily done one quadrant of the mouth at a time under local anesthetic. Clinical attachment levels of the gum to teeth and supporting structures determine the success of the surgery. Surgery required beyond gingivectomy involves the regeneration of attachment structures through tissue and bone grafts.
Periodontal surgery is primarily performed to alter or eliminate the microbial factors that create periodontitis, and thereby stop the progression of the disease. Periodontal diseases comprise a number of conditions that affect the health of periodontium. The factors include a variety of microorganisms and host conditions, such as the immune system, that combine to affect the gums and, ultimately, the support of the teeth. The primary invasive factor creating disease is plaque-producing bacteria. Once the gingiva are infected by plaque-making bacteria unabated due to immuno-suppression or by oral hygiene, the bacterial conditions for periodontitis or gum infections are present. Unless the microorganisms and the pathological changes they produce on the gum are removed, the disease progresses. In the most severe cases, graft surgery may be necessary to restore tissue ligament and bone tissue destroyed by pathogens.
In healthy gums, there is very little space between the gum and tooth, usually less than 0.15 in (4 mm). With regular brushing and flossing, most gums stay healthy and firm unless there are underlying hereditary or immunosuppressive conditions that affect the gums. The continuum of progressive bacterial infection of the gums leads to two main conditions in the periodontium: gingivitis and periodontitis. Such external factors as smoking, and certain illnesses such as diabetes are associated with periodontal disease and increase the severity of disease in the gum tissue, support, and bone structures. Two types of procedures are necessitated by the severity of gum retreat from the teeth, represented by periodontal pockets. Both nonsurgical and surgical procedures are designed to eliminate these pockets and restore gum to the teeth, thereby ensuring the retention of teeth.
Gingivitis occurs when gum tissue is invaded by bacteria that change into plaque in the mouth due to diseasefighting secretions. This plaque resides on the gums and hardens, becoming tartar, or crystallized plaque, known also as calculus. Brushing and flossing cannot remove calculus. The gum harboring calculus becomes irritated, causing inflammation and a loss of a snug fit to the teeth. As the pockets between the gum and the teeth become more pronounced, more residue is developed and the calculus becomes resistant to the cleaning ability of brushing and flossing. Gums become swollen and begin to bleed. A dentist or periodontist can reverse this form of gum disease through the mechanical removal of calculus and plaque. This cleaning procedure is called curettage, which is a deep cleaning process that includes scraping the tartar off the teeth above and below the gum line and planing or smoothing the tooth at the root. Also known as dental débridement , this procedure is often accompanied by antibiotic treatment to stave off further microbe proliferation.
Periodontitis is the generalized condition of the periodontium in which gums are so inflamed by bacteria-produced calculus that they separate from the teeth, creating large pockets (more than 0.23 in [6 mm] from the teeth), with increased destruction of periodontal structures and noticeable tooth mobility. Periodontitis is the stage of the disease that threatens significant ligament damage and tooth loss. If earlier procedures like scaling and root planing cannot restore the gum tissue to a healthy, firm state and pocket depth is still sufficient to warrant treatment, a gingivectomy is indicated. The comparative success of this surgery over such nonsurgical treatments as more débridement and more frequent use of antibiotics has not been demonstrated by research.
According to a report by the U.S. Surgeon General in 2000, half of adults living in the United States have gingivitis, and about one in five have periodontitis. According to the same report, smokers are four times more likely than nonsmokers to have periodontitis, and three to four times more likely to lose some or all of their teeth. By region, individuals living in the Southern states have a higher rate of periodontal disease and tooth loss than other regions of the country. Severe gum disease affects about 14% of adults aged 45–54 years. One of the main risk factors for gum disease is lack of dental care. Initiatives by the Centers for Disease Control and Prevention have begun to study the relation between periodontal disease and general health. There is growing acknowledgment of the public health issues related to chronic periodontal disease.
The delivery of oral surgery, or even dental care, to individuals in the United States is difficult to determine. Race, ethnicity, and poverty level stratified individuals making dental visits in a year. While 70% of white individuals made visits, only 56% of non-Hispanic black individuals and only 50% of Mexican-American individuals made visits. Seventy-two percent of individuals at or above the federal poverty level made visits, while only 50% of those below the poverty level made visits. Since it is also estimated that more than 100 million Americans lack dental insurance, it is likely that periodontal surgery among the people most likely to have periodontal disease (low-income individuals with nutritional issues, with little or no preventive dental care, and who smoke) are the least likely to have periodontal surgery.
Periodontal procedures for gingivitis involve gingival curettage, in which the surgeon cuts away some of the most hygienically unhealthy tissue, reducing the depth of the pocket. This surgery is usually done under a local anesthetic and is done on one quadrant of the mouth at a time.
Gingival or periodontal flap surgery (gingivectomy) is indicated in advanced periodontal disease, in which the stability of the teeth are compromised by infection, which displaces ligament and bone. In gingivectomy, the gingival flap is resected or separated from the bone, exposing the root. The calculus buildup on the tooth, down to the root, is removed. The surgery is performed under local anesthetic.
Small incisions are made in the gum to allow the dentist to see both tooth and bone. The surrounding alveolar, or exposed bone, may require reforming to ensure proper healing. Gum tissue is returned to the tooth and sutured. A putty-like coating spread over the teeth and gums protects the sutures. This coating serves as a kind of bandage and allows the eating of soft foods and drinking of liquids after surgery. The typical procedure takes between one and two hours and usually involves only one or two quadrants per visit. The sutures remain in place for approximately one week. Pain medication is prescribed and antibiotic treatment is begun.
Many factors contribute to periodontal disease, and the process that leads to the need for surgery may occur early or take many months or years to develop. Early primary tooth mobility or early primary tooth loss in children may be due to very serious underlying diseases, including hereditary gingival fibromatosis, a fibrous enlargement of the gingiva; conditions induced by drugs for liver disease; or gum conditions related to leukemia. Patient-related factors for chronic periodontal disease include systemic health, age, oral hygiene, various presurgical therapeutic options, and the patient's ability to control plaque formation and smoking. Another factor includes the extent and frequency of periodontal procedures to remove subgingival deposits. Gum inflammation can be secondary to many conditions, including diabetes, genetic predisposition, stress, immuno-suppression, pregnancy, medications, and nutrition.
The most telling signs of early gum disease are swollen gums and bleeding. If gingivectomy is considered, consultation with the patient's physician is important, as are instruction and reinforcement with the patient to control plaque. Gingiva scaling and root planing should be performed to remove plaque and calculus to see if gum health improves.
The protective responses of the body and the use of dental practices to overcome the pathology of periodontal disease may be thwarted and the concentration of pathogens may be such that plaque below the gum line leads to tissue destruction. Refractory periodontitis, or the form of periodontal disease characterized by its resistance to repeated gingival treatments, and often also associated with diabetes milletis and other systematic diseases, may require surgery to remove deep pockets and to offer regenerative procedures like tissue and bone grafts.
The level of damage is determined by signs of inflammation and by measuring the pocket depth. Healthy pockets around the teeth are usually between 0.04–0.11 in (1–3 mm). The dentist measures each tooth and notes the findings. If the pockets are more than 0.19–0.23 in (5–6 mm), x rays may be taken to look at bone loss. After conferring with the patient, a decision will be made to have periodontal surgery or to try medications and/or more gingival scaling.
Risks for infection must be assessed prior to surgery. Certain conditions, including damaged heart valves, congenital heart defects, immunosuppression, liver disease, and such artificial joints as hip or knee replacements , put the oral surgery patient at higher risk for infection. Ultimately, the decision for surgery should be based upon the health of the patient, the quality of life with or without surgery, their willingness to change such lifestyle factors as smoking and bad nutrition, and the ability to incorporate oral hygiene into a daily regimen. Expense is also a factor since periodontal surgery is relatively expensive. Long-term studies are still needed to determine if such medications as antibiotic treatments are superior to surgery for severe chronic periodontal disease.
Surgery will take place in the periodontist's office and usually takes a few hours from the time of surgery until the anesthetic wears off. After that, normal activities are encouraged. It takes a few days or weeks for the gums to completely heal. Ibuprofen (Advil) or acetaminophen (Tylenol) is very effective for pain. Dental management after surgery that includes deep cleaning by a dental hygienist will be put in force to maintain the health of the gums. Visits to the dentist for the first year are scheduled every three months to remove plaque and tartar buildup. After a year, periodontal cleaning is required every six months.
Periodontal surgery has few risks. There is, however, the risk of introducing infection into the bloodstream. Some surgeons require antibiotic treatment before and after surgery.
The gold standard of periodontal treatment is the decrease of attachment loss, which is the decrease in tooth loss due to gingival conditions. Normal immediate results of surgery are short-term pain; some gum shrinkage due to the surgery, which over time takes on a more normal shape; and easier success with oral hygiene. Long-term results are equivocal. One study followed 600 patients in a private periodontal practice for more than 15 years. The study found tooth retention was more closely related to the individual case of disease than to the type of surgery performed. In another study, a retrospective chart review of 335 patients who had received non-surgical treatment was conducted. All patients were active cases for 10 years, and 44.8% also had periodontal surgery. The results of the study showed that those who received surgical therapy lost more teeth than those who received nonsurgical treatment. The factor that predicted tooth loss was neither procedure: it was earlier or initial attachment loss.
Morbidity and mortality rates
The most common complications of oral surgery include bleeding, pain, and swelling. Less common complications are infections of the gums from the surgery. Rarer still is a bloodstream infection from the surgery, which can have serious consequences.
Alternatives to periodontal surgery include other dental procedures concomitant with medication treatment as well as changes in lifestyle. Lifestyle changes include quitting smoking, nutritional changes, exercise , and better oral hygiene. There have been some medication advances for the gum infections that lead to inflammation and disease. Medication, combined with scaling and root planing, can be very effective. New treatments include antimicrobial mouthwashes to control bacteria; a gelatin-filled antibiotic "chip" inserted into periodontal pockets; and low doses of an antibiotic medication to keep destructive enzymes from combining with the bacteria to create plaque.
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Delaney, J. E., amd M. A. Keels. "Pediatric Oral Health." Pediatric Clinics of North America 47, no. 5 (October 2000).
Matthews, D. C., et al. "Tooth Loss in Periodontal Patients." Journal of the Canadian Dental Association, 67 (2001): 207–10.
Periodontal (Gum) Diseases. National Institute of Dental and Craniofacial Research, National Institutes of Health. Bethesda, MD 20892-2190. (301) 496-4261. http://www.nidcrinfo.nih.gov. .
"Cigarette Smoking Linked to Gum Diseases." National Center for Chronic Disease Prevention and Health Promotion. http://www.cdc.gov/nccdphp. .
"Gingivectomy for Gum Disease." WebMD Health. http://www.webmd.com .
Nancy McKenzie, PhD
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Periodontal surgery involving gingivectomy and regenerative grafts are performed by a dentist specializing in diseases and surgery of the gums; the specialist is known as a periodontist. This is usually through a referral from the patient's general dentist. The procedure is performed in a dentist's office.
QUESTIONS TO ASK THE DOCTOR
- How many quadrants for surgery will be performed at each visit?
- Can the gum scaling and root planing be repeated with antibiotic treatment as an alternative to gingivectomy?
- How effective have you found antibacterial, antibiotic, or anti-microbial treatment in slowing down disease progression?
- How often must I return to have periodontal cleaning after the surgery? Can my regular dentist do that?
- Besides dental care and home hygiene, what can I do to keep the disease from reoccurring after surgery?