Question:
Briefly, I am 35 years old, and have advanced periodontal disease. Went
through flap surgeries a few years ago that reduced pocket depths from
average 10-13 to 4-8. Had good home-care and was on 90 day call-back
w/periodontist.
Periodontist retired, and life happened. When originally dx'd was very
committed to keeping all teeth, slowly became lax in home care...you've
heard the crap before.
Teeth 23,24,25,26 extracted 2 years ago (flipper). Teeth 13 and 14 root
canal 1 year ago. Teeth 4 and 13 have significant movement. Teeth 7,8,9,10
now crowded and crooked - once upon a time 8 and 9 were gapped, now
beginning to overlap each other (approx. .5mm) and have posterior shifting
which prevents proper bite (when flipper is inserted).
What I want...
Pull all teeth on upper plate and replace with denture. Flipper is already
scheduled for replacement with permanent bridge.
Answer:
There are several issues here. If you have truly advanced periodontal
disease at age 35, and if you had perio surgery a few years ago that reduced
your perio pockets to 4-8 mm, you likely have one of the forms of juvenile
periodontitis. Very often, even in the presence of ideal oral hygiene, the
progression of attachment loss can be slowed at best.
Now we come into the realm of philosophy, ethics, and personal judgement.
It is perhaps unlikely anyone can give you reassurance you can retain your
teeth long-term. Under the circumstances, you are the one enduring the
surgery, the sensitivity, the cosmetic problems. It may be that under ordinary
circumstances, keeping your own teeth as long as possible is the best policy.
In your circumstances, perhaps I would substitute the phrase "as long as
feasible" for "as long as possible".
There are ways to do pocket elimination surgery that minimize the cosmetic
problems, but you are perhaps past the point where you can get a good cosmetic
result. I have also played around a bit with gingival masks (essentially fake
gums) to cover the areas of recession, but have had limited success. There are
good means at our disposal now for dealing with dentinal hypersensitivity, from
resin bonding to various desensitizing agents. My favorite is Duraphat, a 5%
NaF varnish that is painted on the sensitive areas. Sometimes multiple
applications are necessary. It has worked for my patients, and has worked for
me personally.
One of the considerations is also that you are concerned primarily with the
upper jaw. Most people do well with full upper dentures. I will usually go to
greater lengths to save a few well-placed lower teeth to avoid going to
dentures.
All things considered, your dentists should be able to sit down with you
and give you the "what ifs". If everything reasonable has been tried and you
are still uncomfortable, the dentists should respect your feelings about
retaining your teeth, or give you very good reasons for refusing extractions.
Especially in the age of implants, the calculus as to whether or not to
retain questionable teeth has changed. You (and your dentist!) should be able
to feel satisfied that you've made the best decision, based on your situation.
Yes, my DDS and I would agree that I suffer from one
of the juvenile periodontal diseases - the periodontist could probably
provide exactly which one. When I started seeing my current dentist 8 years
ago he was appalled that I had been told all my life "great teeth, terrible
gums," yet nothing had ever been done to address the problem.
Oh well, he immediately referred me to a periodontist, and the work began.
Hadn't thought about discussing resin bonding or desensitizing agents
(beyond fluoride rinse, which no longer seems to help). I will ask my DDS
about the Duraphat. Getting past the pain would definitely improve the home
care issue.
Despite the four extractions from the lower jaw, it seems to be in better
shape than the upper jaw regarding pain and shifting of teeth is concerned.
I do believe that the fixed bridge will be all that the lower jaw needs for
a long time. However, the upper jaw is quite another story...cosmetics
aside, there is a lot of pain, a couple of significantly loose teeth (I can
feel them move when I chew), and alignment shifting.
The alignment problem on the front upper jaw has become so prominent that I
can't close my mouth with the lower front flipper in place unless I hold my
lower jaw in an unnatural and uncomfortable position to avoid the posterior
of the upper front teeth from pressing against the anterior of the flipper
causing the flipper to dig into the gum tissue. Honestly, the alignment
shift in the upper jaw is the primary factor that makes a full upper denture
attractive in my situation. As long as I continue using the flipper, I can
get relief from the pain caused by holding my lower jaw in an uncomfortable
position by removing the flipper. Replacing the flipper with a permanent
bridge without addressing the alignment issue of the top front teeth sounds
to me like a recipe for disaster.
The best reason that the DDS will give for avoiding a full upper denture is
that at 35 years old, I am looking at having equally as painful problems of
a different nature by the time I am 50. Otherwise it seems to be a prideful
notion that only butchers pull healthy teeth. I consulted with a different
DDS for second opinion, that prideful notion I mentioned seems to be
prevalent in my area.
