According to a 2007 UFSBD study, nearly 1 in 2 French people suffer from gum problems.
In addition to local inconvenience, these periodontal diseases are important risk factors for other very serious pathologies.
It is essential to detect, diagnose and treat these conditions.
FIRST OF ALL, WHAT IS PERIODONTITIS?
These are simply the supporting tissues of the teeth: the gum, the ligament (which connects the tooth to the gum and the bone), the alveolar bone, and the cementum (thin layer of hard tissue along the root).
The human periodontium is the site of an unstable balance between the host's (the patient's) defences and the microbial mass (bacteria and micro-organisms).
This balance can easily be upset, either by an alteration of the defences or by a quantitative or qualitative change in this microbial mass.
WHAT HAPPENS WHEN THIS BALANCE IS UPSET?
The first stage of periodontal disease is marked by inflammation of the gums, which become swollen, red and smooth (whereas normally they are pale pink and pitted). The most obvious sign of gum inflammation is that the gums start to bleed easily. Either when brushing (if it is effective), or when a little stimulation is given (with an interdental stick for example). This is GINGIVITY.
The most common cause of gingivitis is poor hygiene and the accumulation of plaque.
Repeated bleeding from the gums is ANMAL, and if it persists, you should seek medical attention.
Indeed, it is an easily treatable pathology, and if caught in time, it will not leave any sequelae.
This gingivitis affects 1 out of 2 French people and in 1 out of 2 cases, this gingivitis ends up getting worse.
GINGIVITIS WILL DEVELOP INTO PERIODONTITIS
Under the pressure of the inflammation, the system that attaches the gum to the tooth and the bone will break down, and a pocket will form, which is called a periodontal pocket. This pocket can become very deep (up to 8-9 mm) and within this pocket, bacteria will be able to develop and benefit from a favourable ecosystem. In the absence of oxygen, anaerobic bacteria will become dominant. These bacteria will organise themselves and colonise the surface of the root, which will then form subgingival tartar (which is black).
The inflammation that results from this bacterial growth is so great that the bone that supports the teeth will shrink, as if it were fleeing from this microbial attack. It is our own cells (osteoclasts) that turn against the bone and destroy it. Periodontitis is almost an auto-immune disease.
This bone loss occurs insidiously, usually without pain, sometimes with a periodontal abscess that may resolve spontaneously. It is a chronic disease, which can last for years.
Unfortunately, this bone loss is IRREVERSIBLE, and without treatment it can lead to the spontaneous loss of all teeth. This is commonly known as tooth loosening.
Bad breath is very common in periodontitis.
It is estimated that 25% of French people suffer from periodontitis.
WHAT ARE THE CONSEQUENCES FOR GENERAL HEALTH?
Although little known to the French, periodontal disease is a serious and frequent pathology that can have serious consequences. They are responsible for almost 40% of dental extractions and can cause serious complications for the patient's general health.
In fact, bacterial debris present in the periodontal pocket (lipopolysaccharides) will pass into the bloodstream and lead to chronic inflammation which favours the appearance of other more general diseases.
4 links have been formally demonstrated to date(source):
- a patient suffering from periodontitis has twice the risk of developing type 2 diabetes (conversely, a diabetic patient has 4 times the risk of developing periodontitis). Nearly 4 million French people have type 2 diabetes.
- a patient with periodontitis is 8 times more likely to give birth prematurely, or to have a low birth weight baby. Inflammatory diseases (of which periodontitis is one) are thought to be responsible for 40% of premature deliveries.
- a patient suffering from periodontitis has twice the risk of suffering from a chronic respiratory disease (COPD: Chronic Obstructive Pulmonary Disease, fifth cause of death in the world).
- a patient with periodontitis has twice the risk of having a stroke or a heart attack. When one has periodontitis, the risk of dying of a cardiovascular disease within 10 years is multiplied by 4.
According to a study by DeStefano on 20749 subjects in 1993, the risk of overall mortality was increased by 50% in a mixed American population (25-74 years) with periodontitis. Mortality increases by 50% for every 20% increase in average bone loss.
Links are still being investigated, but there are strong indications that periodontitis plays a role in the development of rheumatoid arthritis, certain cancers, and even Alzheimer's disease.
In 2013, the University of Lancashire in the UK published an incredible study. They studied the brains of 20 patients within 12 hours of their deaths. There were 10 patients with Alzheimer's disease, and 10 patients without. To their amazement, they found in 4 of the brains of the Alzheimer's patients, breakdown lipopolysaccharides from Porphyromonas gingivalis. One of the main bacteria involved in periodontitis.
It is therefore a real public health problem.
WHAT CAUSES PERIODONTITIS?
It is a multifactorial disease, and we still don't know exactly how and why gingivitis will develop into periodontitis, but what we must remember is that without micro-organisms, there would be no disease.
Nevertheless, several factors have been clearly identified:
- poor oral hygiene (main factor in gingivitis)
- smoking (14-fold increase in risk according to some studies)
- impaired chewing (10% more periodontitis for each missing tooth not replaced)
- hyposialia (decrease in saliva flow, beware of antidepressants and other anxiolytics which often cause this side effect). Saliva plays a very important role in the line of defence against micro-organisms.
- Diabetes (risk multiplied by 4, and it has been shown that treating periodontitis in a diabetic allows better control of blood sugar)
- obesity (and/or a diet too rich in fat)
- Gastroesophageal reflux disease (GERD: acid reflux from the stomach, which will modify the oral flora by lowering the pH)
- ENT problems can lead to mouth breathing (the nose is blocked), and thus to nocturnal hyposialia
- Vitamin D deficiency (at least 1/3 of the French population is deficient)
- lipid imbalance(hypercholesterolemia in particular)
- all pathologies with reduced immunity (Neutropenia, AIDS, chemotherapy, etc.)
- menopause (probably related to the drop in oestrogen)
- treatment with bi-phosphonates, a treatment for osteoporosis and certain cancers (link not yet proven but strong presumptions)
- a genetic predisposing factor has been identified (allele coding for an overexpression of IL-1: PST test), but it is not very predictive (many patients carrying this gene do not develop the disease, so periodontitis is not a fatality)
This is why it is fundamental to insist on the importance of prevention in the management of this type of disease. It is essential to act before the infection occurs, as the periodontium does not regenerate.
HOW IS PERIODONTITIS TREATED?
The treatment of periodontitis is carried out in several stages.
- Prophylactic assessment: during this first consultation, the practitioner will make a precise diagnosis based on examinations involving a saliva test to measure the acidity of the saliva, its flow, its buffering capacity, and possibly a bacterial test to identify pathogenic microbes. In addition, a questionnaire is conducted with the patient to find out about their eating habits and brushing methods.
- This step will also allow the patient to become the actor of his own treatment, the control of dental plaque on a daily basis is the key to success.
- Mechanical treatment: this combines classical methods involving scaling, spraying with bicarbonate and salts and polishing the affected teeth.
- Root planing: This technique consists of intervening directly at the roots to eliminate toxins and bacterial contents via ultrasound instruments. This procedure cleans the periodontal pocket and allows the gums to re-adhere to the tooth.
- Chemical treatment: from the beginning of the treatment the patient will use pastes (based on bicarbonate and hydrogen peroxide) and antiseptics. During the surfacing in the following sessions, the gum will be irrigated, then rinsed with povidone-iodine, a powerful antiseptic. In some cases, a targeted antibiotic therapy will complete the treatment.
What is decay?
Few people know this, but tooth decay is an infectious disease.
According to theWHO*, it is probably the most widespread disease in the world, affecting 3.5 billion people. Depending on the country, it affects between 60% and 90% of the population. And yet it is a simple infection whose mechanisms have been known for a long time, and the bacteria clearly identified(mainlyStreptococcus Mutans and Lactobacillus Acidophilus ).
It is thought to have appeared during the Neolithic period (about 7000 years ago in Europe), probably in connection with the consumption of cereal flour. Prehistoric man was free of cavities. Caries is therefore not inevitable...
How do cavities form?
Caries is the consequence of a bacterial imbalance in the oral flora. For a cavity to form, 5 factors must come together.
- It requires the presence of certain so-called " cariogenic " bacteria such as Streptococcus Mutans and Lactobacillus Acidophilus. We all carry these bacteria (in greater or lesser quantities). These bacteria organise themselves and form dental plaque.
- Acidity is necessary, in fact below a pH of 5.5 the risk of caries is clearly increased. However, some foods are very acidic (Coca-Cola, for example, has a pH of 2.3), the degradation of food by certain salivary enzymes increases acidity, and finally, certain bacteria, such as Streptococcus Mutans, generate the acidity they need.
- Sugar (carbohydrates) is needed to feed the cariogenic bacteria. However, our "modern" diet is very rich in carbohydrates, and sticky ones at that.
- There are certain predispositions to tooth decay depending on the composition and resistance of theenamel, the quality and quantity of the saliva, etc. But what must be understood is that without bacteria, there is no decay.
- In addition to the above four factors, it takes time. That is, the bacteria must be present long enough, in an acidic environment, and in the presence of sugar for them to begin to dissolve enamel.
When these five factors are combined, cariogenic bacteria multiply and the acids produced by these bacteria will dissolve the enamel. The bacteria then penetrate the tooth. The microbes can then enter the deepest layers of the tooth (the dentin, then the pulp), dissolve the dental tissue, and destroy the tooth from the inside.
What can be done to prevent cavities?
I - Brushing your teeth.
Tooth brushing is a decisive element in the fight against tooth decay, it will allow to disorganize the dental plaque, to decrease the bacterial mass, and especially it will play on the time factor. This is why you should brush your teeth at least twice a day, so that between two brushings, the bacteria do not have time to reorganise. It is preferable to brush your teeth after meals, in order to eliminate the bacteria and the food that has been deposited during the meal, and to reduce the acidity. In addition, some toothpastes polish the surface of the enamel, which slows down the re-attachment of bacteria to the tooth.
As you will have understood, brushing acts on all the factors of caries formation, it is the "keystone of prophylaxis ". We recommend the use of electric toothbrushes combining rotation and pulsation movements, the effectiveness of which has been scientifically proven. We pay particular attention to brushing, so all our patients receive a prescription adapted to their needs. In some cases, the toothbrush is not enough, it must be supplemented by dental floss or interdental brushes.
II - Food
The diet will influence important factors: acidity, sugars, and time. It is absolutely necessary to limit the intake of soft drinks, as they are (very) acidic and sweet. Even sugar-free soft drinks are cariogenic because of their pH. If you can't do without soft drinks, it is better to drink them through a straw, in order to reduce their contact with the dental surfaces, and then drink a little water...
Nibbling on sweets, biscuits (all cereal-based products are broken down into sugars when they come into contact with saliva), etc., encourages the development of cavities because it affects the three factors of sugar, acidity and time. When we say carbohydrate-rich foods, we immediately think of sugars and sweets. But carbohydrate-rich foods do not necessarily taste sweet. The starch in potatoes, but also in cereals and flours, is just a long chain of sugar that certainly does not taste sweet. When we eat salted biscuits, crisps and chips, these are carbohydrate-rich products. The softer and stickier a food is, the more cariogenic it is.
Foods can therefore be classified according to their cariogenic potential:
- At the bottom of the ladder, water.
- Dairy products and fats (cheeses are excellent protective foods to finish a meal).
- Meat and fish.
- Nuts, hazelnuts, peanuts rich in fat to be preferred to extruded products as an appetizer.
- Dark chocolate, rich in cocoa.
- Fruit: presence of fructose and acidity. Beware of the apple crunching as a substitute for brushing.
- Bread, flour, rice and potatoes are all more cariogenic when cooked.
- Confectionery, sucrose, honey.
- Cereal bars, breakfast cereals.
- Snack biscuits, chips, soft drinks and colas, bananas, sultanas.
III - Fluorine
The consumption of fluoride during childhood allows this protective element to be integrated into the constitution of the enamel in formation. Fluorinated enamel is more resistant to caries. At a local level, fluoride plays an antibacterial role and protects against caries. This is why it is recommended to consume fluoridated table salt (if the tap water is not too fluoridated), and to use a fluoridated toothpaste.
IV - Chewing Gums
Chewing gum helps to fight tooth decay, but chewing gum will never replace a good brushing, but it can be beneficial when you cannot brush your teeth after a meal. Of course, only sugar-free chewing gum should be consumed. Why is chewing gum beneficial? First of all, chewing increases the flow of saliva, which dissolves sugars, and fights acidity. This is because saliva has a number of chemical agents that help to raise the pH. The stickiness of chewing gum helps to clean the teeth and remove food residues. In addition, certain sweeteners such as Xylitol contained in certain chewing gums have a bacteriostatic effect on certain cariogenic bacteria. Finally, some chewing gums contain fluoride. So let's chew.
V - Other
Certain diseases such as diabetes, certain treatments that reduce salivation, can favour the appearance of caries. We can help these patients with a comprehensive caries assessment (salivary tests, bacterial tests, etc.), and a global treatment.
DENTAL IMPLANTS IN VERSAILLES
Dental implants have been around for more than 30 years and are now the best way to replace missing teeth while preserving healthy teeth. Indeed, it allows the replacement of the missing tooth without any trauma to the adjacent teeth, unlike a bridge (a bridge between two teeth).
Only a precise diagnosis can correctly evaluate the cost of the rehabilitation, due to the choice of implant and the specific constraints of each patient.
Indeed, the practitioner adapts the length, diameter, shape and number of implants to the clinical case thanks to an X-ray examination: the 3D Cone Beam, a kind of mini scanner, available in our practice.
An implant is a kind of artificial root made of titanium, fixed in the bone.
The implant protocol
First of all, the practitioner has to access the bone, he removes the gum in order to have a good view of his operating field. Today, 3D scanners reproducing the precise anatomy of the jawbone on a computer allow for much less invasive surgery in common cases (the so-called "flapless" technique). In 80% of cases, there is no need for an incision, and therefore no sutures, so that the postoperative period is almost non-existent.
After the implants are placed, there is a three-month healing period. During this phase, a particular process will occur, it is theOSTÉOINTÉGRATION of the implant. Indeed, the bone tissue has the particularity of being able to "weld" to the titanium of the implant. At the end of this period, the implant is completely "one with" the jaw, it only remains to take an impression to make the final prosthesis.
In some cases we can even place the implant on the day of the extraction, in order to minimize the number of interventions. In the case of anterior teeth, for obvious aesthetic reasons, we can make a temporary crown directly on the implant, the day it is placed. This is called Extraction - Immediate Implantation. Thus in the same session a condemned tooth can be replaced without the patient ever being edentulous. (see a complete case here)
Implantology is an essential breakthrough that has improved the lives of thousands of patients. Indeed, it is often the optimal solution because :
- Implants are currently the most comfortable and reliable solution over time
- This avoids unnecessary "sacrifice" of healthy teeth
- This is the only way to avoid a removable prosthesis
- The patient regains the comfort of his original teeth and thus an incomparable quality of life
- The aesthetics are optimal
- This avoids bone loss following tooth extraction.
Simply put, a dental implant is the optimal solution if one or more teeth are missing. This means that almost everyone can have a replacement for their teeth, with the same appearance and function as a natural tooth. However, it is important to have fully developed bone tissue beforehand. For this reason, dental implants are not normally placed in people under the age of 18.
See contraindications to dental implants.
When and why use Apical Microsurgery?
We perform Apical Microsurgery when traditional practice does not allow us to reach a lesion at the root tip, and when endodontic treatment and root canal filling are only partially completed, an infection may develop.
Thanks to the precision provided by the operating microscope, this operation allows a cure in a large proportion of the cases treated.
In the incompletely treated canal, the remaining pulp becomes mortified and bacteria proliferate in the unfilled portion of the canal.
A lesion(granuloma) forms at the end of the root, in the bone and ligament.
Untreated granuloma will most often progress to cyst andabscess.
The first step may be to repeat the root treatment (orthograde treatment).
When orthograde treatment does not allow the canal to be cleaned to its end, only Apical Microsurgery can remove residual bacteria.
Apical resection is the surgical removal of the remaining cyst. The root tip is cut to sanitise the infected area. The bone cavity is carefully cleaned of all cystic debris.
The end of the canal is hermetically sealed, this is the retrograde filling under the operating microscope. Only the use of an operating microscope (x25 magnification) allows to work on such small surfaces.
Bone healing gradually fills the cavity left by the operation. After several months, the bone has healed and the infection has completely disappeared.
We make precise and small incisions under a microscope. Our operations are therefore better controlled, without unnecessary damage, and the procedures performed are very precise. We thus respect the concept of "minimal surgery" and our results are all the more satisfactory.
See the contraindications to this surgery.
When and why do we whiten our teeth?
Tooth whitening is used to lighten the colour of the teeth, the correct term is tooth lightening.
These techniques are reserved for special cases and should not be used as an excuse for poor oral hygiene.
The colour of the teeth is influenced by different elements:
- EXTRINSIC stains: outside the tooth = Nicotine, Coffee, Tea, etc. stains
- INTRINSIC stains: inside the tooth = natural stains, stains due to antibiotics taken during childhood, enamel anomalies etc...
Tooth whitening removes or reduces intrinsic discolouration by using a hydrogen peroxide derivative that penetrates the enamel to dissolve the pigments at the enamel/dentin junction.
Outpatient gutter treatment includes:
- A preliminary dental check-up, to see if a lightening is possible and recording of the initial shade.
- Taking impressions of the upper & lowerjaws.
- The production of the 2 thermoformed gutters for the product.
- The supply of the product(Carbamide Peroxide for bleaching, Amorphous Calcium Phosphate, to reduce sensitivities, and even to strengthen and remineralize the enamel) until the desired shade is obtained.
- Control visits to check the progress of the colour.
- Polishing if necessary.
These trays will be applied every night for about two weeks or for 2 hours a day. The patient inserts the whitening gel into the tray and wears it for a period of time determined by the practitioner. During the treatment, the teeth are a little more sensitive to temperature differences, which is why we recommend the parallel application of fluoride gels.
Veneers are ceramic coatings that are bonded to the tooth. This new technique allows a clear improvement of the aesthetics of the smile.
- Correcting the colour of teeth when bleaching is not enough.
- Correcting tooth shape anomalies.
- To improve aesthetic problems related to slight malposition of the teeth.
The realisation :
Thanks to our CAD/CAM system, we can produce veneers in-house, sometimes in one day! Preparation, optical impression, design of the veneers on our software, machining of the parts, make-up, baking and fitting the same day. Changing your smile in one day is now possible.
Please note that this is not systematically the case, it is only possible for some facets in simple cases. Do not hesitate to ask us for more details.
In fact, dental implants do have one constraint... In order to place an implant reliably, sufficient bone volume is required. In the upper jaw, above the molars, there is a hollow cavity in the middle of the jawbone, this "pneumatic cavity": it is the maxillary sinus. The maxillary sinus is lined with a mucous layer: this is Schneider's membrane. Very often, when the maxillary molars are extracted, the amount of residual bone under the maxillary sinus is too small to be able to place implants (at least 6-8 mm of bone is needed to place an implant).
What to do?
As early as the 1970s, practitioners had the idea of performing a bone augmentation under the maxillary sinus, by removing Schneider's membrane and interposing a filling material.
Today, there are two techniques for bone augmentation under the sinus:
- Elevation and partial filling of the maxillary sinus by the alveolar (or crestal) route, known as the Summers technique.
- Elevation and partial filling of the maxillary sinus using the Tatum technique or " Sinus Lift ".
These two techniques have different indications.
The Summers technique can be used when at least 4-5 mm of bone remain under the sinus. It involves "pushing" the sinus membrane through the alveolus created for implant placement. Today, this elevation is achieved using special drills that rotate in opposite directions, collecting bone shavings during drilling, condensing them and gently injecting them under the sinus membrane, which is then gently pushed. Depending on the bone volume to be gained, a filling material can be interposed before the implant is placed, in the same operating time. The post-operative course is generally minor.
Le Sinus Lift est réservé aux pertes osseuses plus importantes (hauteur résiduelle < 4-5 mm). Il s’agit de réaliser une fenêtre osseuse en regard du sinus maxillaire, puis la membrane de Schneider est minutieusement décollée. Un matériau de comblement est ensuite glissé sous cette membrane, et la fenêtre est refermée. Il est parfois possible de placer les implants en même temps, mais dans la plupart des cas, il est préférable de laisser cicatriser 3-4 mois et de poser les implants après un contrôle radiographique 3D. Les suites postopératoires sont plus importantes qu’avec la technique de Summers, elles sont comparables à l’extraction de dents de sagesse incluses. Œdème et hématome surviennent parfois.
These two meticulous operations require a large technical platform and an experienced team. This is why Dr Michaël LUMBROSO holds a University Diploma in Maxillofacial Rehabilitation Surgery(University of Paris VII), and is fully qualified to carry out this type of operation. Indeed, the main risk of these operations is a tear of Schneider's membrane without the practitioner noticing it.
This is why in our practice these operations are performed in our Operating Theatreunder rigorous aseptic conditions (Sterilization chain HEPA filter, Traceabilityetc ...). During a Sinus Lift, in order to limit as much as possible the risk of tearing the Schneider's membrane, we use a very special equipment: the PIEZZOCHIRURGY. This instrument uses ultrasound and allows the bone window to be made without damaging the membrane underneath, as it is inactive on the soft tissue.
Furthermore, in our practice, this procedure is performed under an operating microscope. This considerably increases the precision of our actions, and thus reduces the risk of tearing the membrane. And if a perforation should occur, it is almost impossible for it to go unnoticed thanks to the operating microscope. The operation is then stopped and the window closed, without any consequences for the patient's health. However, it will be necessary to intervene again after a few weeks.
For this type of bone augmentation procedure, strict hygiene and aseptic conditions are required, and an operating theatre is preferable.
The French National Authority for Health (HAS) published a summary in 2008 on these subjects ("conditions for performing oral implantology procedures: technical environment"): "Bone ridge expansion, techniques using osteotomes such as Summers osteotomies, sinus floor enhancement with the use of intraoral bone harvesting material or bone substitute material and bone autografts can be performed in specific or adapted operating rooms or in the operating theatre. "
This chain consists of several steps. Let's take a complex case with the extraction of a front tooth such as an upper incisor, its replacement on the same day by an implant with a custom-made surgical guide, the fitting of a temporary crown on the same day and the final restoration 3 months later.
Optical impression with our digital camera (PrimeScan®), which allows us to obtain a virtual double of your mouth. No more impression paste, no more nausea reflexes, taking an impression is easy and almost fun for the patient who sees his or her mouth virtually reconstructed before their eyes.
Virtual tooth extraction
Virtual reconstruction of the ideal tooth
A Cone Beam CT scan (CBCT ) is performed to determine the bone volume and to place the implant virtually.
Digital registration and merging of files, optimal virtual positioning of the implant, according to the future tooth.
Surgical guide design, design, etc...
Machining of the surgical guide in our milling machine
Surgery with fully guided implant placement. This allows for minimal surgery (without having to remove the gum most of the time), very high precision, speed, very little post-operative... The implant is placed exactly as planned in the virtual implant planning. To summarize a 21st century surgery
Optical impression of the exact position of the implant and immediate fabrication of the temporary crown on implant. In this case, we use extra-hard resin blocks (PMMA), which combine aesthetics and biological qualities to guide healing.
Machining of the prosthetic part, sandblasting of the titanium part that will connect the PMMA prosthesis to the implant (this is called a Ti-Base), assembly of the two parts, polishing, and fitting of the restoration. In less than two hours, the patient leaves with an artificial tooth from A to Z (implant + temporary crown).
10 years ago, all these steps took more than 6 months and many hours in the office.
3 months after the operation, healing and maturation of the gingiva, we take an optical impression, then design the crown and mill it, this time in a pre-fired ceramic block (e-Max®). This material combines aesthetic, mechanical and biological qualities.
The crown is then polished, made up, glazed...
... and then fired in our special kiln which rises to 800°.
Sandblasting of the titanium part (the Ti-Base), assembly of the two parts, polishing, and fitting of