Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

August 29, 2015

This dentist wants to do gum surgery, while admitting she doesn’t understand the problem

Dr. Hall,

My front teeth developed little ‘holes’ on the surface when I was a teenager and in my 20’s. I initially had some of them bonded. That was in the 80’s. This bonding yellowed with time. So my dentist suggested crowns and veneers. My 2 front upper teeth have veneers. The 2 teeth next to the front teeth on both sides have crowns. These were done in 2003.I had no problems with this until about 3 years ago. Suddenly the gums around these teeth became inflamed. I am now 49 years old. My dentist isn’t sure what is going on. We have tried an all natural antibacterial liquid (I forget the name) with no luck. I get my teeth cleaned faithfully every 6 months. Flossing every day doesn’t help resolve this. This inflammation improves at times and gets worse at times, but it never goes away completely. I do have other crowns in my mouth. On my bottom teeth on both sides I have 2 crowns and a bridge. I also have 2 other caps in molars on my upper teeth. There is also inflammation around those but not nearly as bad. The gums around the remainder of my natural teeth are just fine.
Could these changes be because I am in peri-menopause?
I find it odd that it took 10 years for this to occur. Also, my dentist suggested trimming back the gum tissue. She won’t guarantee that this will fix the problem. I think she wants to do it for cosmetic reasons. Or she may know there is a structural/mechanical problem with the fit of the crowns but doesn’t want to admit it. I don’t want to go through this gum procedure if it’s just a bandaid and the problem will return. So far all this inflammation has not caused full on gingivitis or bone damage (so they say). The gums sometimes get friable and look almost ulcerated. Also, on a side note a few months ago I developed lichen planus on the checks of my mouth (not in the front). This is very frustrating. Sometimes my gums are sore. Sometimes they look just terrible and you can see the red border around my front teeth. It seems my teeth have separated between 2nd and 3rd tooth on both sides counting from the front teeth.
Should I have this procedure? It’s only on the front teeth. What about the inflammation on the other crowns in the back? This is what makes me think it’s systemic. Again this is just around the crowns and veneers.
Any thoughts, suggestions?
Thanks for your time!
Donna from Philadelphia

Donna,

You have a very interesting question here.
When you have gum inflammation around teeth with crowns, there are about five possibilities that come to mind.

  • One is that the cement wasn’t fully cleaned out from around the crowns.
  • Another is that there is some problem with the fit of the crowns.
  • A third is that the crowns go too deeply under the gumline.
    For all three of these situations, the reaction would have been immediate–not delayed ten years.
  • Another possibility is to have some kind of allergic reaction to the material in the crowns. This would happen with porcelain fused to metal crowns where a cheap metal was used containing nickel or some base metal. Usually the metal sensitivity reaction is immediate, but it doesn’t have to be. But veneers should be all porcelain with no metal in them, and you are having the same reaction around the teeth with the veneers, so that seems highly unlikely.
  • The fifth possibility is simple gum disease, aggravated by some things that are going on with your general health. That’s not to say that the causes are simple, but that the disease is a common one and there are some straightforward things to do to address it.

Unfortunately, there are a lot of dentists who simply don’t pay that much attention to the health of the gums, and I am concerned that your dentist is saying that she doesn’t understand what is going on here.
I would recommend a second opinion for you. I don’t think this should be that mysterious–maybe to your dentist, but not to a dentist with strong knowledge about the gums. I would absolutely not let her do this gum surgery on you. I’m not impressed with her aggressive treatment for your yellowed bonding ten years ago. You’re a little suspicious that there might be some structural problem with the crowns that she doesn’t want to admit. That’s possible–there could be some irregularities in the fit of these crowns and veneers that aggravates the gum disease. Your being peri-menopause is probably a contributing factor, also. Hormone imbalances can exacerbate gum inflammation. You mentioned lichen planus. That condition is exacerbated by stress just as gum disease is. It’s possible that a good, thorough deep scaling of your teeth could take care of this, but I feel you need a dentist with more expertise.
Think about what your dentist is telling you–she doesn’t understand why this is happening and yet she wants to do gum surgery to address it. One of the most fundamental principles of health care is that you first diagnose, then you treat. Don’t let anyone attempt any kind of serious treatment here like gum surgery without first having a good diagnosis.
As I think over what you have told me, it’s a little puzzling why your dentist hasn’t referred you to a gum specialist (periodontist). You’re in Philadelphia. There have to be a number of gum specialists you could go see. Maybe she doesn’t want another dentist to see her work. Anyway, since she hasn’t referred you, just self-refer. Just find a periodontist with good reviews. If you have any doubts about who to pick, call a couple of well-respected general dentists and ask what periodontists they refer to. Don’t ask your dentist for a name because of this suspicion we have that she may be trying to hide something. But you do want the periodontist to contact your dentist after you’ve made the appointment and get records that will help him or her assess what is going on.
And then get back to me, if you would, on what they find out. I’d be interested to know what is discovered about your condition.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

May 18, 2007

Gum inflammation from crown work

Filed under: gum disease around crowns,Porcelain crowns — mesasmiles @ 9:46 pm

Dr Hall:
I had a crown put on my front right upper tooth and a veneer on the front top left. After this was done, my gums became inflamed, and they have not come back to normal after many months. I’ve seen a new dentist, a periodontist (who treated the gumline to try to fix), and most recently, a prosthodontist, because my new dentist and the periodontist were stumped about how to resolve this, as they think the Empress porcelain used on the crown is fine and that perio surgery might not resolve the gum inflammation and could risk cosmetic damage, so they said. The prosthodontist saw me yesterday, and she said it’s likely not a fixable problem. That the dentist that put in the crown went too deep and close to the bone, and that could be causing the gum inflammation. Furthermore, she stressed that if my gums aren’t treated it’s a health risk to me as inflammation there can lead to worse diseases, but I am not getting any solutions! She said perio surgery could possibly resolve this, but that cosmetic damage to the papilla(?) – the gum area between my two top front teeth – is quite possible as a result. I am so upset. I don’t want a health risk issue but don’t want to damage my smile via perio surgery (and there’s no guarantee the perio surgery will resolve the gum inflammation anyway!). Any ideas? THANK YOU.
– Mark from Maryland

Mark,

The porcelain crown and porcelain veneer have violated the biologic width of your teeth–they are too deep under the gums. The porcelain in Empress crowns is very gentle on the gums, so that’s not the problem. It’s interesting that this stumped your dentists for so long. This isn’t a widely understood phenomenon, because it’s a relatively recently researched concept. But I’m disappointed that they’re being so timid with recommending a solution. Your case is an interesting study in the “dentist personality.” They’re saying you should have the gum surgery, but it’s like they don’t want to say it too directly for fear of being sued. The prosthodontist wants to call the change in appearance of the papilla between the teeth “cosmetic damage.” But the damage has been done already, and I think you should have the surgery. Yes, that won’t look perfect, but it doesn’t look good now, and your present condition certainly isn’t healthy. You have gum disease on these two teeth. I don’t think you should just let that go. And I don’t think your prosthodontist thinks you should just let it go, either. She just wants to be sure you feel thoroughly warned so she doesn’t get flak when you see the results.

It’s not right to say there isn’t a solution. It would be more accurate to say there isn’t a perfect solution.

I hate that when they say, “there’s no guarantee.” Of course there’s never a guarantee, but what’s the point of dwelling on that? Ask what results you’re likely to get, and then go on recommendations. No wise dentist is going to “guarantee” anything.

Meanwhile, I would think an antibacterial rinse such as Peridex would help reduce the inflammation some. But be careful. Peridex stains the teeth, and if you use it, you should also brush with Supersmile toothpaste, since that’s the only toothpaste known that keeps this stain from forming.
– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

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