Root Coverage: Cover „em up

In our society, esthetics and appearance have always been important. We wear good clothes so as to appear better and more aesthetic. We do not go to societal gathering without clothes, as it is considered unacceptable and unaesthetic. Similarly our gums are the clothes that our teeth wear to look aesthetic. Without them our teeth are exposed and appear unaesthetic. The image on the left shows a case of gum recession. It is clearly visible how ugly the teeth appear i.e long, yellow, asymmetric and with black spaces. So when socially we are not willing to expose otherwise, then why we are fine with keeping our teeth exposed. Also gums are not only for aesthetic purpose just to cover the teeth up. They play a far more important role in proper functioning and protection of our teeth.

Dentistry is the branch that deals with our oral health. Now, when I say oral health it includes our teeth, gums and all other supporting structures present in and around our mouth. The purpose of this blog is to make the general public aware about the importance of gums, why do we lose them, what happens when we lose them, what are root coverage procedures, how they are done, and what role and importance they play in maintaining our oral health and overall health.

The image on the left shows a case with gum recession. The black line is where the gums should actually be present, while the red line is where they are present. The gap between the black and red line is called gum recession. This area then becomes a center for sensitivity, tartar, bone loss and eventually pyorrhea.

Let‟s take a moment to understand what role our gums play in maintaining our oral and overall health that makes them so important. Gums are the supporting tissues that enclose our teeth and bone. They provide nutrition and innervation to our teeth and other surrounding structures. They are protect our teeth and underlying structures from the bacteria and viruses present in our oral cavity with their primary defense mechanisms. They contain many cells and molecules that destroy the pathogens preventing their spread. They help in maintaining oral hygiene and facilitate in brushing so that we can clean the plaque (food debris and bacteria) better. They also keep our teeth healthy and strong so that they function properly. Their health is related to several systemic organs like hearts, brain, kidneys and many more. They improve aesthetics and appearance. They also help the teeth withstand the chewing and other occlusal forces along with other supporting structures. They also resist the spread of gum disease or pyorrhea that not only is detrimental to our teeth but also to our whole body and our quality of life. Hence it is clear that our gums are one of the most important structures in our mouth.

Now let‟s understand why we lose them. The loss of gums in technical terms is called “gingival recession”. There are many reasons we can lose them. One of the most important is inadequate oral hygiene causing accumulation of plaque and calculus (tartar). They cause pyorrhea and this leads to loss of the gums. Also other reasons can be the presence of thick fold of tissue (frenum) on your gums pulling it and exerting force constantly on your gums, improper brushing technique with use of hard bristle or more force, maligned teeth, excessive chewing forces or other heavy occlusal forces either due forceful clenching habits or grinding, improper prosthesis fabrication or any fillings that irritate the gums or make it prone to plaque accumulation, traumatic injuries or self-inflicting injuries caused by holding a pin or nail biting, chemical burns, thin underlying bone or genetically predisposed thin gums that have less resistance to any irritation or injury.

Since, having learnt now about what role our gums play and how do we lose them, let‟s discuss about what happens when we lose our gums. When we lose our gums our tooth gets exposed which increases the problem of sensitivity. These areas are easy for the bacteria to get deposited. The loss of gums makes it difficult to clean the plaque by brushing, hence making the oral hygiene maintenance impossible and there by setting in a vicious cycle of gum disease, end result of which is loss of bone and eventually the loss of tooth. Once a certain amount of gums are lost they form empty spaces that appear as black triangles which are unaesthetic and also lead to food accumulation. The loss of gums also loosens the tooth. Over 70% of people over the world lose their teeth due to gum recession. The loss of gums also exposes the less stronger portion of the tooth (dentin) which then increases the risk of tooth decay. The loss of gums also increases the forces of chewing on the tooth increasing the risk of wearing of the tooth and also fractures of the tooth. Hence, if you are losing gums, you are at a high risk of losing your tooth.

Since the beginning of the blog, I have been stressing on the importance of the gums and root coverage procedures. So now let‟s understand what root coverage procedures are and how they are done. Root coverage procedures are basically procedures that are done to regrow the lost gums by using soft tissue grafts either from your own mouth or by using artificial substitutes. Root coverage procedures are basically plastic surgical procedures only, but the difference is they are done within the mouth. Just like the plastic surgical procedures that restore the aesthetics and functionality of your face, root coverage procedures restore aesthetics and functionality of your teeth which improves your smile, which is an integral part of your facial esthetics. Root coverage procedures being plastic surgical procedures require utmost skill and precision for a complete acceptance of the grafts being used. Technically, there are two types of soft tissue grafts that are “free grafts” and “pedicled grafts”. The free grafts include cutting a piece of tissue from your palate area and suturing it to the site of your gum recession. During healing, this tissue integrates with underlying tissues and forms new gums. These gums then heal over a period of time covering more of the recession and thereby form new gums. Pedicled grafts include displacing the tissue from one side where there is more to the other side where there is recession and suturing it eventually leading to new gum tissue formation.

There are several techniques available to do both of these types of grafts and now technological advancements also allow us to be minimally invasive where ever possible. There are several artificial substitutes also that are available that convert into gum tissue on healing and this reduces the morbidity of harvesting a graft from your palate. Thus essentially what‟s good news and important is that root coverage has been done from over several years and now the results are even more predictable than before. So it is now possible to regrow your lost gums if the damage is not beyond a certain level.

A common misconception among patients is if there is no pain then why to get it done. So I would say that in gum recession there is no pain but the absence of pain does not mean there is no disease. It is the nature of the disease that it does not cause pain. Thus, according to me, pain is a sign from the body that a disease is present. Now if a disease is not causing any pain and is destroying our body tissues slowly without us knowing about it, then that disease is more alarming then the one causing pain. Also if we consider diabetes, it does not cause any pain but still the absence of pain does not rule out the absence of disease, which is still present and requires intervention. Thus just like diabetes, gum disease and gum recession slowly eat away all the gums and bone eventually leading to loss of tooth. So when we diagnose that you have gum recession, it means you have the disease even if there is no pain or complain and if not intervened it will kill your teeth, just as diabetes if not intervened will damage your body.

In the end I would like to say two things. One is if you are getting your gum recession treated with root coverage then make sure you get it done only by a Periodontist as they are only the ones qualified to do it. Second is do not ignore your gum recession and get them treated as soon as possible in order to save your teeth. Thus, concluding I would only say that love the gums you have.