Winter Park Dentistry-Podcast on Gum Grafting
Dr. Ramzi Matar (Winter Park Dentistry): Hello everybody, welcome to this episode of my podcast. Today’s topic is connective tissue grafting, otherwise known as gum grafting, and today my guest is Dr. Scott Cohen. Dr. Cohen is a board certified periodontist, which is somebody who does a lot of gum treatments, gum surgery, anything involving the gums. Scott I do know that you did your training, your specialty training at the University of Washington in Seattle. Not even a week ago Seattle was not able to double up and have a Super Bowl back to back victory, so I know you are in mourning. Thanks for being here for the interview.
Dr Scott Cohen: It worked out OK because my dad’s side of the family is from the North East and his sister lives in Boston, so we won both bets, it worked out.
Dr. Ramzi Matar (Winter Park Dentistry): OK, very nice. OK, so let’s get right into it. Tell me what are the main reasons people are seeing you? Whether they are being referred or whether they are coming to you; if they are at home and they are seeing something in their gums; why are people coming to see you, mainly for consultations or for gum grafting?
Dr Scott Cohen: Most people present to our office for gum grafting after being referred by their general dentist because gum recession is an issue. It affects about fifty percent of the population and that increases with age or maturity. Thankfully this issue is most of the time asymptomatic; people don’t know they have it; so often their dentists or hygienists are the first ones to notice it. So we are concerned about gum recession because when patients are losing the gum tissue around their teeth they are not just losing the gum tissue, they are also losing the bone as well. And we are not very good at growing back the bone; we are better at growing back the gum tissue and we want a nice firm band to attach the gum tissue to protect the underlying bone. So that is the main reason why people are presented to our office for that treatment.
Dr. Ramzi Matar (Winter Park Dentistry): What are they seeing at home? What are their symptoms that they would see? Or feel?
Dr Scott Cohen: They may feel hot and cold sensitivity to drinks or certain types of foods, they may notice some inflammation or bleeding at the gum line, so that may be something that will prompt them to look into whether they may have an issue. Something else is that they may notice different colors within their teeth; the enamel or the top part of the tooth has a lighter color, the root surface has a yellower color. So as people experience gum recession the root becomes exposed so the tooth may have one or two colors, basically the yellow color may now be apparent and that may be something that the patients see.
When we have an issue with gum recession we are concerned about it again for the reasons I discussed, the main one being preservation of the bone that is there to support the teeth. So we have options on how to manage it. Ideally we’d like to do what we call a connected tissue grafting, which basically provides an aesthetic, functional result, which will ideally cover the exposed root surface and provide a firm band of attached tissue that will be there to protect it going forward.
We have a couple of options for tissue in that treatment option. We can utilize the patient’s tissue from the palate, basically inside the premolars and molar areas or we can go back in the areas where the recent teeth used to be. This is the ideal way to manage this type of issue just because you get the best integration of the soft tissue grafting as it heals aesthetically and functionally. We can use donor tissues as well which has a great advantage as you only have one surgical site (for the patients healing). The downside is the donor tissue, whether it be cadaver which is a human donor tissue or animal tissues, they don’t tend to integrate quite as well or to provide as firm a protective layer of tissue on the sites. But that being said it is attractive in that there is just one healing site for the patient. Because where we put the tissue while doing this type of gum drafting it doesn’t really bother patients much. It is more so where we get the tissue that it can bother them. But for the postoperative experience we provide patients with a clear stent, kind of like a bleaching tray, which will cover the palate site or the donor site to keep their tongue away for it so it doesn’t irritate the site. So we can make the patients very comfortable during that process.
Dr. Ramzi Matar (Winter Park Dentistry): I want to remark real quick, you said the different colors of the teeth, because I see this all the time, but for somebody watching this, you are saying the lover the root of the tooth that should be covered is more yellow. I know sometimes people come to me and say the tooth looks longer or they think that it is stained. As a matter of fact that is the root that is exposed. Correct? That is what you are saying.
Dr Scott Cohen: Right.
Dr. Ramzi Matar (Winter Park Dentistry): And you mentioned the palate, just for the audience, the palate is the roof of the mouth, correct. That is where you typically will get, if you are using the connective tissue.
Dr Scott Cohen: Correct, that is right, yes.
Dr. Ramzi Matar (Winter Park Dentistry): Then you attach it on there. I know there are different types you can get it from; other humans, I assume that is cadaver, or like you said ideally you get it from their own body as it heals the best.
Dr Scott Cohen: Right. One other option is to do a pre-gingival graft. This is a more traditional way to manage gingival recession where it provides a firm band of protective tissue right at the existing gum line. It does not cover the exposed root surface, so the healing is a little bit easier for the patient. There is less swelling on the site, but aesthetically it is not as ideal in that the color match is not the same, the tissue is a little bit lighter and also the root is still exposed. But form a health stand point you don’t have to have the root covered. It is more so just maintaining or providing a firm band of protective tissue that will withstand the rigors of function and provide a nice bacterial seal.
Dr. Ramzi Matar (Winter Park Dentistry): So it is a little easier to do that and it sounds like what you are saying is that it doesn’t add the gums it just supports the gums. It makes them stronger as opposed to putting it back. Is that correct?
Dr Scott Cohen: Technically yes. It is an adequate procedure, correct. We usually reserve that procedure for the lower front teeth, because it’s not really an aesthetic area and unfortunately you get or there is a strong muscle pull from your chin muscles that will want to retract the tissues when we are doing the connective tissue grafting. So the root coverage that we can achieve in that area is not as predictable on the lower front teeth. So usually we do that second procedure, the pre-gingival graft, in the lower front teeth just because again it is not an aesthetic area, because you don’t see it and technically it is more challenging for the tissues to be maintained in a more ideal position.
Dr. Ramzi Matar (Winter Park Dentistry): What about with cosmetic dentistry, are you doing grafting for people that are doing cosmetic dentistry, veneers, stuff like that? Tell the audience a little bit about that.
Dr Scott Cohen: Sure, yes. Gingival grafting or connective tissue grafting can be a nice adjunct to a restorative treatment as far as bonding upper front teeth or veneering or crowning upper front teeth, because the gum levels are very important when providing aesthetic dentistry for patients. We have to make sure they have the correct proportions of the teeth and the gingival tissues or gum tissues. When they are not at the right level that can provide some asymmetries or some discrepancies that people are going to see, so if we can level off the gum lines and put them at the appropriate levels than that can definitively improve and complement the general dentist’s or restorative dentist’s fantastic porcelain work. So absolutely.
Dr. Ramzi Matar (Winter Park Dentistry): I have to tell you; you taught me this and I have to brag on you in closing, I think you gave me this little quote that rings true all the time. The cosmetic work a lot of time is the picture, but the gum work around there is the picture frame. I don’t know if it was you that told me that, but somebody that was clearly smarter than me told me that and it really brought a lot of things into light. Because a lot of times you see this very fancy tooth pictures of veneers or Hollywood smiles or whatever and a large percentage, a huge portion of how nice it looks are the gums. It’s the frame around the picture and how level they are and I know you have done that for several of my cases.
One patient comes to mind who came to me, I don’t know, five, six year ago. I hope you remember her. She came to me telling me I have very long teeth, they are discolored (like you said), she was seeing the root surface and she came to me wanting veneers and crowns and all sorts of very elaborate work. Fortunately you are my friend and I have talked to you about this kind of stuff and you were teaching me some of the things that grafting can do and I said, you know, I think this might be something that grafting can do versus me cutting up half your teeth and nubing all your teeth and doing all the things that I do. She came to see you and I think within one or two visits you did grafting all over her mouth and she absolutely looks great. I just saw her a few days ago and all her grafting looks great. We didn’t end up doing a single veneer; we didn’t cut a single tooth. Everything about it was her teeth very long, she had lost a lot of gums. I think probably it was hereditary in her case. She was very young and to this day she raves about it. I see here for cleaning, she is so happy about her teeth. I am sure she would do that over again a million times as she always tells me how happy she is with it. I just have to close by bragging on you a little bit because it’s always a highlight case for me. Whenever I’m looking at cosmetic work or whenever I see some recession the first thing I think about is if we can do this very conservatively. The other thing, with gum grafting you are not cutting teeth, you are doing very, very conservative work, which anybody likes that word and you can help out a lot.
So Scott I really appreciate you being on the podcast. I hope anybody watching this learned something. Reach out to a periodontist or a gum surgeon, somebody who does this. Ask any questions on this YouTube channel, we’ll do our best to answer for anybody watching us. Thanks a lot.
Dr Scott Cohen: Thanks so much Ramzi.