To answer this question, let us have a look at the case below of a patient who has gum recession.
A 38-year-old patient came in last week as a new patient. She had previously lived in Bury and had been seeing a dentist locally. There was no relevant medical history and no medications. No experience with alcohol intake, but recently after splitting up with her husband, she had started to smoke 10-15 cigarettes daily again. Before this, she had not smoked for over 10 years.
Her dental history revealed that she was not experiencing any problems and her old dentist in Bury had put her on only yearly recalls. Although she had not been for 13 months now, a periodontal examination showed bleeding on probing in all areas with a BPE of 3 recorded in two sextants indicating pocketing of between 3.5 and 5.5 so a detailed 6-point charting was required here.
The oral hygiene was moderate/poor with fairly extensive calculus deposits which also showed interdentally on her bitewing radiographs. This was shown to the patient with a hand mirror and radiographs on the computer screen. She did admit to having gone through a lot of recent stress and at night felt too shattered to brush her teeth.
A hard tissue charting revealed secondary caries under two old amalgam restorations. The patient also mentioned that her lower left central incisor tooth was increasingly sensitive to hot, cold and sweet things. In addition, she also noticed that the gum around the lower left first Central incisor had started to recede which was sensitive if she touched that area with her fingernail.
Due to the patient’s periodontal disease, there had been a loss of attachment and this had resulted in exposed dentine which was sensitive. The problem was further compounded by her difficulty in achieving good oral hygiene around this area due to sensitivity. In the past, she had mentioned this to her previous dentist but all he said was that she should use Sensodyne toothpaste and the problem would go away which it did not.
There were also problems that the patient was experiencing in the upper jaw. In her upper jaw, she has a 3 Unit bridge to replace the upper left central incisor. This bridge had been placed about 13 years ago during domestic abuse with her now ex-husband, causing her to lose the upper left central incisor. She said initially that she had to have a denture made but she did not feel comfortable with the final product. So, a 3 Unit fixed dental bridge was made.
The colour was adequate however now the bridge porcelain colour appears lighter than her remaining teeth. It should be noted that fixed dental Restorations such as a porcelain Bridge will not change colour but can appear whiter when the remaining teeth become more yellow over time. There are usually two solutions to this. The first solution is to replace the bridge so that it matches the adjacent natural teeth again but the second option is to whiten the remaining teeth so that the colour becomes more in line.
In practice, we commonly tend to use a combination of both techniques in that the natural teeth are whitened first so they look as good as they possibly can be followed by replacement of the restoration itself. This we feel produces the best results over time especially as there are many new advanced teeth whitening techniques and better dental materials to use for fixed restorations.
Looking at the image, you will see that the upper left lateral incisor has suffered from extensive gum recession. This is primarily due to the underlying periodontal disease. The patient’s current stress levels and smoking habits have exacerbated the problem. It measures as a 5.5 mm pocket and therefore it may not have a good long-term prognosis.
Patients often ask if the gum can be brought back to its original position however, unfortunately, it is one of the areas in dentistry where even the best technology cannot address the situation. The best that can be done is to prevent any further gum recession from taking place.
The image also shows a black line around the margins of the fixed bridge around the upper left lateral incisor and the upper right-hand incisor. This fixed bridge is of traditional porcelain fused to metal construction. The metal is required to induce strength to the restoration and reduce flexing and prevent an eventual fracture of the bridge. Over this, porcelain is then required to mask the metallic colour underneath. This explains the reason why the overall restoration appears yellow and opaque. It does not appear translucent like a natural healthy tooth. If the technician then placed another layer of porcelain to mask the underlying metal in a better way, a bridge would appear too bulky.
On the other hand, if the dentist created more space by creating further removal of dentine, this can compromise the pulp. In this situation, it is often very difficult to get the ideal aesthetics correct, however, with new porcelain technology, the aesthetics can be improved much better. We often use zirconia restorations which do not need any metal underneath to make it for strength.
It is also fairly obvious that the gingival gum recession has caused a black triangle. The black triangle has appeared between the two upper central incisors and between the two lower central incisors. This is simply termed black triangle disease and it is due to the loss of gingival papilla. This is also almost impossible to eradicate however a new restoration would be able to largely compensate for the loss of gingival tissue. This is all assuming that the patient’s periodontal disease is under control and the patient is sufficiently motivated.
A diagnosis and treatment were formulated in discussion with the patient. To rewind a little bit further back, a dental check-up starts with history taking. The history taking will consist of taking down the patient’s details such as name, date of birth, address and all contacts numbers, email address and mobile number. This should also include the patient’s work or office number as often when a dental practice will call the patient, it will be during working hours. Having said this, it is important that when you phone a patient’s workplace, confidentiality is maintained as much as possible.
The next stage will be to take down the patient’s medical history. This is usually accomplished by using pre-printed forms. Once the medical history has been checked and verified with the patient, social and dental history is taken. The patient’s dental history should include the patient’s main concerns and past dental history experience.
Once this has been collected, the patient can then be examined and recorded through the stages of carrying out an extra oral examination and an intra-oral examination. The intra-oral examination consists of a soft tissue check before carrying on to examine the hard tissues and occlusion. For new patients, it is also necessary to take radiographs, which may be bitewings or periapical radiographs.
For this particular patient, bitewing radiographs were taken but due to the chronic periodontal disease, periapical radiography was taken for all teeth. In particular, periapical radiographs were taken of the patient’s upper fixed bridge and the lower central incisors where gum recession had taken place.
Although her previous dental recalls had been set to one-year intervals, this was now changed to 3 monthly intervals. The reason for shortening her recall intervals was based on her changing lifestyle and the presence of periodontal disease which she had been unaware of.
This Case Study Conveys;
Recall intervals should not be set in stone and must be continually reviewed with the patient’s needs. Dental recall intervals are extremely important in maintaining the best Dental Health for a patient. If your recall intervals are too long, this can have dramatic consequences for a patient’s dental disease. This is even more pertinent when the patient suffers from acute or chronic periodontitis. Although it is still important for dental caries, we know that on the whole dental caries progress more slowly unless the patient has a very high and frequent sugar intake.
When recall intervals are too long, it can also cause the patient to lose motivation and one of the most important factors to bear in mind is that recalled intervals are an opportunity for the dentist to enthuse the patient and get them involved in looking after the dental health. It is always a two-way process with the dentist and the patient working in unison. Even as many patients do, they think that it is the dentist’s total responsibility to look after their dental health, however, it is the dentist’s job to convey the message to the patient but it is a two-way procedure.
The dentist must be excellent in his or her job in carrying out treatment; however, the patient has a vital role in controlling their oral hygiene and managing their sugar intake. There will always be patients in a practice who still do not realise or want to accept the responsibility that they have in oral health and this is always a losing game.
Dental recall intervals which are too short also can be detrimental to a patient and you are probably thinking why that is? Most patients do not have unlimited resources to spend on their dental health. Certainly, every dentist will come across patients for whom money is never an object, this becomes an advantage. However, for the majority, there will always be an upper limit to financial resources. Dentists, therefore, have some responsibility in making sure that the patient’s finances are being used in the best possible and most effective manner.
I do know some dentists who say that they do not care at all about the patient’s financial resources but usually this comes ultimately to the detriment of the dentist when the patient decides to go elsewhere.
In conclusion, a dental recall interval must not be too short which causes problems for the patient financially. However, there are other important factors as well. One of them is the patient’s availability for dental appointments because we all live in a very busy world where everybody has priorities and deadlines on a typical day. After all, we can only accomplish a certain amount in a typical day.
When a patient has this extra job to do in day-to-day life, it can become cumbersome and this is when things are detrimental because the patient has made an appointment and then has to cancel the appointment. Often, patients will change their appointments many times and this can get on a dentist or the dental team including the receptionist’s annoyance. We always try to have a wide range of appointments for patients which includes early morning appointments from 8 am onwards but also late nights until 8 pm. Finally, many of our patients can only come in on a Saturday and that’s why we work almost every Saturday or at least three Saturdays in a month.
In agreeing with a patient’s dental recall intervals, we first educate and inform the patient as to why they have to be seen religiously every 6 months or every 12 months in the past and this is no longer the case. Dental recall intervals are primarily guided by a patient’s ongoing dental needs and dental condition. Recall intervals are suggested but also the patient should be informed that this can change to being more often or less often as their dental care progresses.
The case above highlights how a patient’s circumstances can dramatically impact their oral health. It also highlights how dentists can support and give confidence to patients when their oral habits have lapsed so that they can get back on track.