Root coverage

[Althingsdentist]

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Here's a case and I'm curious to know how you folks would attack/cover this case.

Chief Complaint: 29 YO female requests coverage of tooth #29 (FDI #45) for cold sensitivity.
Tooth #29: Miller class 1 gingival recession.

 

[Lidopaine82]

Give her toothpaste with potassium nitrate to try first. If it still bothers her, she could get a graft. They are typically 100% successful in Miller Class I cases.

 

[browncrack]

toothpaste with potassium nitrate, bruxism splint, graft. In that order.

 

[peg lateral]

Toothpaste with potassium nitrate.

Sometime a dentin desensitizer such as Gluma shows improvement of symptoms.

Or a graft.

 

[HupHolland]

What's the etiology? ...Abrasion? Frenum pull?

Looks like 2mm of keratinized tissue. How much does she need? The answer pissed me off while I was in dental school but makes perfect sense now: ENOUGH. Manipulate the buccal mucosa to see if pulls the gingival margin apically. If so, consider root coverage.

Some conservative options already mentioned. Potassium nitrate containing toothpaste or some bonding agent/gluma. I've had success with both.

 

[Streetwolf]

She should be more concerned about #28 😛

 

[yappy]

Was she attractive?

 

[OceanDMD]

How do you know she needs a bruxism splint(localized 1-2mm recession)?
You would actually recommend a gingival graft for this situation?
Why not simply try a fluoride varnish with your "sensitive" toothpaste?
I have had tons of success for minor situations like this using varnish. Personally I think a graft is overtreating this case unless there is complete loss of keratinized tissue. I think if you explained to her the graft procedure, expense involved, etc.. she may decide that the area is isn't THAT sensitive.

 

[DrJeff]

How do you know she needs a bruxism splint(localized 1-2mm recession)?
You would actually recommend a gingival graft for this situation?
Why not simply try a fluoride varnish with your "sensitive" toothpaste?
I have had tons of success for minor situations like this using varnish. Personally I think a graft is overtreating this case unless there is complete loss of keratinized tissue. I think if you explained to her the graft procedure, expense involved, etc.. she may decide that the area is isn't THAT sensitive.

Totally agree with Ocean here

As a past recipient of 2 gingival grafts on the buccal surfaces of #'s 22 and 27, I can also say that while they do serve their purpose, in the immediate 10 days or so post surgery, the patient tends not to be the most happy of campers as both the donor and recipient sites are pretty sore, and 10 days or so of having perio pack inplace and swishing with peridex 4 times a day isn't the most pleasant of experiences either. Sometimes as the dentist we either forget (or may not even realize) what the patient experience is like

 

[Althingsdentist]

What about a root coverage procedure with Alloderm and not harvest from the palate? Also - have you guys heard of a free CT graft - rather than a free gingival graft?

 

[SeattleRDH]

How well does potassium nitrate work anyway? I vote for fluoride varnish, have the patient use 5000 ppm Fl toothpaste at home, and monitor the recession.

 

[DrJeff]

What about a root coverage procedure with Alloderm and not harvest from the palate? Also - have you guys heard of a free CT graft - rather than a free gingival graft?

Personally I tend to refer to the expertise of my local periodontist and let him make the call as to what he thinks is the best material/technique/coverage. His preference is a split thickness graft harvested from the palate. Tends to work well for him and my patients, and I guess that's what matters most. Having a technique that is predictable and effective in one's own hands.

I will also say that having been in the chair, on the "receiving end" of 2 grafts, did really give me some perspective as to always remember that it's not just you as the dentist and what you can offer the patient that matters, but also from a patient perspective of what they experience. Graft surgery isn't (or atleast for me wasn't) a comfortable experience, and I know from talking with some of my patients that they'd agree with me. Maybe i'm biased from that event, but as such I tend to be much more aggressive with using direct desenstizing techniques (Potassium Nitrate toothpaste + flouride varnish application at each recall visit and in some cases, bonding some flowable composite to the root surface) long before I'm reaching for the referral pad for my local periodontist. And from what my patients tell me, the "topical" techniques seems to work quite well, and as such the majority of grafting referrals that I make are for significant atttachment loss situations, where at the same time, just as it seems is an issue in so many cases, occlussion (or more likely malocclussion) needs to be addressed 1st

 

[DrJeff]

How well does potassium nitrate work anyway? I vote for fluoride varnish, have the patient use 5000 ppm Fl toothpaste at home, and monitor the recession.

My personal "cocktail" for cases like this is Potassium Nitrate toothpaste (think sensodyne - easily available over the counter and I'm betting that their good marketing over the years has atleast some psychosomatic effects 😀 ) and then flouride varnish to the teeth in question at each recall visit (there's always a tube of duraflor in all of the operatories in my office - both Doc's and Hygienists). This combo seems to work well in my hands.

I've tried Gluma. Seems to work well too. Don't know if it worked that much better than duraflor to justify the cost difference - we are a business afterall

 

[browncrack]

I suggest the bruxism splint based on corresponding wear facets on 5 & 28, 6-27, loss of vertical incisal height of 6 versus 7, the incisal chip on 7, plus the crazing/possible fracture on the facial of 30. 29 looks like it has a mod amalgam- assuming it is not a new unbased amalgam creating thermal sensitivity, verify no leaking margins or crazing/fracturing to cause sensitivity. Possibly retreat 29 mod depending on clinical exam. I agree with the graft or other desensitizing as a good idea.