Periodontal disease: the most prevalent disease in veterinary medicine
ORLANDO, FL – Periodontal disease is the most prevalent medical condition affecting our dogs and cats. In fact, it is suggested that most pets over the age of three years of age experience some level of periodontal disease, explained Vickie Byard, CVT, VTS (Dentistry), speaking at the North American Veterinary Conference.
Periodontal disease is a disorder of structure associated with the tissues that surround and support the teeth, including the gums, cementum, periodontal ligament, and alveolar bone.
Primary cause of periodontal disease
Bacteria in the mouth form a thin, slimy film on the teeth, otherwise known as biofilm. When that biofilm covers the teeth, it is called plaque. If the plaque is not removed, the minerals in the saliva join with the plaque and harden into a substance called tartar or calculus. The bacteria secrete toxins, which initiate an inflammatory response.
Ms. Byard explained that periodontal disease is much more than just an aesthetic issue for pets and their owners, although the odour may be the reason the client visits the clinic. Periodontal disease can lead to oral discomfort as well as tooth loss. In human medicine, a link has been demonstrated between periodontal disease and numerous problems including an increased risk of stroke, myocardial infarction, atherosclerosis, and difficulty regulating diabetes due to inflammation. It has also been suggested that periodontal disease may cause diminished memory in people over 60 years of age. Studies in dogs now exist demonstrating a correlation between periodontal disease and microscopic changes in heart, liver, and kidney tissue.
The structures of a tooth
Enamel: hard white substance covering the crown of a tooth.
Dentin: the main boney part of the tooth beneath the enamel and surrounding the pulp chamber and root canals.
Gingiva: the gums of the mouth. The gingiva is made up of epithelial tissue that is attached to the bones of the jaw and surrounds and supports the bases of the teeth.
Gingival sulcus: the groove between the surface of the tooth and the epithelium lining the free gingiva.
Free marginal gingiva: the portion of the gingiva that surrounds the tooth and is not directly attached to the tooth surface.
Attached gingiva: the portion that is firm, resilient, and bound to the underlying cementum and alveolar bone.
Cementum: a bonelike substance covering the root of a tooth.
Alveolar bone: the alveolar process is the thickened ridge of bone that contains the tooth sockets on bones that bear teeth.
Periodontal ligament: the fibrous connective tissue that surrounds the root of a tooth, separating it from and attaching it to the alveolar bone, and serving to hold the tooth in its socket.
Furcation: the space between two roots.
Diagnosing periodontal disease
The periodontal patient should have a thorough assessment, cleaning, and charting to determine the degree and severity of the disease process. Radiographs are needed to determine if there are teeth endodontically challenged secondary to the periodontal disease. Ms. Byard said that a critical piece of the puzzle is determining the ability and willingness of the owner to provide care, and this includes brushing the pet’s teeth, feeding a dental diet, using a water additive to help clean the teeth, and taking the pet for annual cleanings at the vet. She stressed that if the owner is not willing to provide meticulous home care, severely affected teeth should be extracted.
Stages of periodontal disease
Normal |
Clinically normal. No inflammation evident. |
Stage 1 |
Gingivitis without any attachment loss. |
Stage 2 |
Early periodontal disease. There is less than a 25% attachment loss and/or a stage 1 furcation involvement. |
Stage 3 |
Moderate periodontitis. There is a 25-50% attachment loss and/or a stage 2 furcation involvement. |
Stage 4 |
Advanced periodontitis. There is a greater than 50% attachment loss and/or a stage 3 furcation involvement. |
Periodontal therapy
Root planing and subgingival curettage
When periodontal pockets have been identified, it is imperative that the plaque and calculus be removed from the root surface using ultrasonic and sonic hand pieces while the patient is under general anesthesia. Scalers have therapeutic advantage in that they vibrate at a frequency that breaks down bacterial cell membranes, however, the tips lack a horizontal flat surface for use as hand instruments. Therefore, it is recommended that ultrasonic pocket treatment be followed by engaging the curette with the root surface and pulling with a downward motion in a crosshatch fashion.
The goal of root planing is to scale the root to remove the roughened cementum, impregnated with toxins. Since the cementum is softer, it is more affected by tartar build up and inflammatory by-products.
Ms. Byard stressed that care needs to be taken to avoid being overly aggressive in planing since cementum contains substances that augment attachment.
A curette is then used to debride the diseased tissue from the pocket, leaving a healthier tissue bed for healing and reattachment.
Perioceutics
These are products employed to provide a medication to the disease periodontal pocket.
Doxirobe Gel (Zoetis) is a doxycycline polymer preparation that comes as a two-syringe system. Using polymer and syringes, the plungers are depressed in a back and forth motion 100 times. A blunt cannula is attached, and a gel combined with a little water is introduced into the treated periodontal pocket (greater than 3mm deep). A plastic filling instrument or titanium covered beaver tail instrument is used to pack the material into the pocket. This will remain in place for 2-3 weeks.
Clindoral (TriLogic Pharma) is a preloaded syringe system that is ready to use. Clindoral is inserted into the periodontal pocket with a blunt cannula. The pet’s head should be held upright in the same position for 1-3 minutes for complete gelling. An instrument can be used to pack the material. The material slowly resorbs over a 7-10 day period.
Consil and Osteoallograph/Guided Tissue Regeneration are synthetic bone graft materials. This is a more advanced procedure and referral to a dental specialist may be indicated. This is a material that is most effective for areas where there has been vertical bone loss. It is a surgical procedure necessitating a surgical flap, and care must be taken to rule out any oral nasal fistulae or antral nasal fistulae otherwise these materials will migrate into the sinuses causing irritation.
Systemic antibiotic use can be used in certain situations, including:
- When local tissue is severely infected and periodontal therapy required surgery to expose bone or if teeth were extracted from severely infected bone.
- Osteomyelitis
- CUPS (chronic ulcerative paradental syndrome): mucosal immunopathy
- Prevention of bacteremia in specific cases
- Patients with clinically evident cardiac disease
- Patients with clinically evident renal or hepatic disease
- Patients with prostheses: ocular, total hip replacements, patients with anterior cruciate repairs using nonabsorbable material
- Patients with splenectomies
- Patients with clean surgical procedures (e.g. an older dog getting spayed) with severe periodontal disease
- Chemotherapy patients
- Patients with concurrent autoimmune disease
Home care
When periodontal therapy is provided, it is critical to provide explicit home care instructions, such as listing:
- All dispensed medications and when the client should start medications
- When the patient may eat next and what they may eat
- When the client can resume or begin tooth brushing
- When their recheck appointment is scheduled
- When the next dentistry should be scheduled (this is influenced by the client, the size and breed of patient, the budget of the client, etc.)
Ms. Byard concluded by saying that since periodontal disease is the most common condition in the companion pet population, prevention is the gold standard and that includes daily tooth brushing. In fact, prevention is probably one of the most important activities the technician can perform in educating the client on how to maintain a healthy mouth.CVT
