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Periodontal Terminology and Anatomy
 Periodontal disease: A disease process that affects one or more of the periodontal tissues.
Periodontal tissue: Includes gingiva, subgingival connective tissue, alveolar bone, periodontal ligament and cementum.
Biofilm: A microscopic layer of protein and polysaccharide molecules found on all moist surfaces. Bacteria live in this "slime" layer that helps them adhere to surfaces.
Plaque: A soft material found on tooth surfaces which is made of biofilm, salivary protein, and bacteria. It is not easy to see, but it is easy to remove with toothbrushing; but returns quickly.
Tartar/calculus: Mineralized plaque deposits formed from saliva and food debris. It adheres to teeth and is difficult to remove; requires professional treatment under anesthesia for complete removal.
Gingivitis: Inflammation of the gingiva (gums); leads to redness and/or bleeding gums.
Periodontitis: The active form of periodontal disease. Bacterial infection and inflammation cause destruction of the periodontal tissues, leading to attachment loss around the teeth.
Periodontal Disease Classification (Stages)
The degree of severity of periodontal disease relates to a single tooth; a patient may have teeth that have different stages of periodontal disease in the oral cavity.
Normal (PD 0): Clinically normal - no gingival inflammation or periodontitis clinically evident.
Stage 1 (PD 1): Gingivitis only without attachment loss. The height and architecture of the alveolar margin are normal.
Stage 2 (PD 2): Early periodontitis - less than 25% of attachment loss or at most, there is a stage 1 furcation involvement in multirooted teeth. There are early radiologic signs of periodontitis. The loss of periodontal attachment is less than 25% as measured either by probing of the clinical attachment level, or radiographic determination of the distance of the alveolar margin from the cemento-enamel junction relative to the length of the root.
Stage 3 (PD 3): Moderate periodontitis - 25?50% of attachment loss as measured either by probing of the clinical attachment level, radiographic determination of the distance of the alveolar margin from the cemento-enamel junction relative to the length of the root, or there is a stage 2 furcation involvement in multirooted teeth.
Stage 4 (PD 4): Advanced periodontitis - more than 50% of attachment loss as measured either by probing of the clinical attachment level, or radiographic determination of the distance of the alveolar margin from the cemento-enamel junction relative to the length of the root, or there is a stage 3 furcation involvement in multirooted teeth. Clinical signs/symptoms include gingivitis, plaque, calculus, halitosis, bleeding gums, periodontal pockets, gingival recession, tooth mobility, purulent exudates, bone loss around teeth and tooth loss.
Initial Treatment
Plaque and calculus must be completely removed and daily homecare performed to prevent plaque buildup. Plaque can be removed by brushing, but calculus can only be thoroughly removed under anesthesia by trained professionals. Treatment ultimately depends on the stage of periodontal disease. Prevention is the best cure. Pets with no active periodontal disease still need their plaque and calculus cleaned/removed by professional dental cleaning. Stage 1 and 2 need thorough, professional cleaning to remove plaque and calculus, above and below the gumline. Specific treatment of periodontal pockets and areas of active periodontal disease must be treated by root planing/curettage, antimicrobials and appropriate homecare. Stage 3 and 4 are difficult, if impossible, to cure. Halting the progression may be the only treatment in these advanced cases. Treatment options include periodontal surgery to allow open root planing/curettage, regenerative periodontal surgery, and extraction of severely affected teeth to allow preservation of others. In areas where periodontal pockets are > 5-mm depth, periodontal surgery is required for proper treatment.
Products and Equipment Used for In-Office Treatment
Stage 0, 1, 2
Intraoral dental radiographs
Scalers
Curettes
Ultrasonic scalers (above and below the gumline)
Low-speed handpiece/Prophy polish
Antibacterials: chlorhexidine rinse (CET), perioceutic gels (Doxirobe)
Stage 3, 4
All above products
Intraoral dental radiographs
Specialized training and periodontal surgical instruments
Materials for regenerative periodontal surgery
Synthetic osteo-conductive materials/bone grafting particulate (Consil)
Periodontal tissue inductive agents (Emdogain, Bone Allografts, Gem 21, PRP)
A dental "prophylaxis" is teeth cleaning performed to prevent dental and periodontal disease. In the veterinary office, dental procedures are performed not only to clean the teeth, but also to treat active periodontal disease and to evaluate the oral cavity for other problems. In our office we employ a five-step periodontal therapy to provide patients the maximum benefit available. We prefer to use the term periodontal therapy instead of "prophylaxis" or 'teeth cleaning," because most dogs and cats have active periodontal disease. Dental procedures performed in the veterinary office entail much more than just "cleaning the teeth." The periodontal therapy not only includes what you can see (the tooth crown), but also the area under the gumline (gingival margin), which is really the most important part. We use the term professional dental cleaning for preventive or prophylactic teeth cleaning procedures in our office.
After the initial oral examination is performed, an initial treatment plan is determined. The doctor will discuss different treatment options and the client will be able to decide on a treatment plan that best suits the pet. Next, the patient is anesthetized and the initial oral examination is performed before beginning periodontal therapy. The treatment plan usually includes periodontal therapy and may include advanced procedures. After the thorough periodontal therapy, the dental chart is completed and the doctor can prepare the final treatment plan. After the animal recovers from anesthesia, the owner is instructed on how to care for the pet at home. Instructions are re-evaluated for compliance and effectiveness during follow-up visits.
Periodontal Therapy
General anesthesia is required for all dental cleaning procedures and cases that involve taking radiographs. If the patient has no active periodontal disease, the procedure is termed professional dental cleaning.
1. Supragingival ultrasonic and hand scaling
2. Subgingival cleaning/root planing
3. Polishing
4. Irrigation and chlorhexidine rinse
5. Complete exam, X-rays, and dental charting
Step 1: Supragingival Scaling
The first step in treatment is the removal of supra- and subgingival calculus. This can be accomplished by using hand instruments and/or a mechanical scaler. The majority of the plaque and calculus is removed with a mechanical scaler (ultrasonic or sonic). These instruments are faster and less technique sensitive than hand instruments. They increase the speed that the cleaning can be performed, which decreases anesthetic time. The most efficient area of the mechanical scaling instrument is the side of the instrument tip 1?2 mm from the point. The back and point of the instrument should not be used as these are not effective areas for cleaning. The instrument tip is placed in contact with the tooth surface utilizing a feather touch. The tip is run across the tooth surface in sweeping overlapping strokes, maintaining contact as much as possible. The working end of ultrasonic instruments should be utilized with sufficient water coolant and not be in contact with the tooth for more than 5?10 seconds to avoid overheating the tooth.
Hand instruments and uses:
Curettes: Subgingival calculus and curettage
Scalers: Used on the crown surface only - for removing gross calculus
Perio Probe: Locating and measuring periodontal pockets
Explorer: Tip detects enamel defects or tooth irregularities
The basic hand instruments used in professional periodontal therapy are scalers and curettes. Keep the sharpened instruments in an autoclavable instrument tray. Hand instruments should be sharpened frequently to maintain a sharp cutting edge for greater efficiency in calculus removal. Scalers have a triangular shape to the blade on cross-section and should only be used on the crown surface. Scalers are held in a modified pen grip and used in a pull stroke away from the gumline. The scaler is designed to remove supragingival calculus with a sharp pull stroke. Double-ended instruments allow the operator to clean the rostral surface of the tooth, and then use the opposite end of the instrument to clean the caudal surface. Curettes are hand instruments with fine, blunt working tips with a half-moon shape on cross-section designed for use in the gingival sulcus or periodontal pocket to clean the root surface. They are inserted into the sulcus or pocket used in a pull stroke away from the gumline. Dental instruments should be held with a modified pen grip. The scaler or curette is grasped at the junction of the handle and shank with the thumb and index finger; the pad of the middle finger is placed on the shank as close to the working tip as possible, and the ring finger is positioned on a solid surface and used as a fulcrum.
Step 2: Subgingival Scaling
Next, the root surface is root planed. This cleaning of the area under the gumline (gingival margin) is one of the most important steps. Subgingival plaque and calculus are the causes of gingivitis, which if unchecked may progress to periodontal disease. Subgingival cleaning is performed with hand instruments called curettes. The curved curette is designed with rounded back and toe. It is held with a modified pen grasp, and a sharp pull stroke is used to remove subgingival calculus. To root plane, use short, quick, overlapping pull strokes. As the root surface becomes smooth, the sound will change from "scritch" to "squeak" to almost no sound. Root planing usually requires 10 to 20 overlapping strokes. Recent developments in sonic and ultrasonic scalers have allowed for the utilization of these instruments below the gingival margin. There are several manufacturers that produce these instruments with subgingival tips. Make sure to ask your dealer if your unit is safe for subgingival use.
Step 3: Polishing
Power scalers and hand instruments make small scratches in the tooth surface, and scaling should be followed up with polishing using a prophy paste. When polishing, apply gentle pressure that will just flatten the cup slightly, moving over the entire tooth surface and just under the gumline. It is important to flare the edges of the prophy cup to polish the critical subgingival area. This flaring is accomplished by putting slight pressure downward on the tooth. If root surfaces are exposed, polish the cementum lightly. Residual plaque and calculus can be identified either with an explorer, a disclosing solution or by drying the tooth with an air-water syringe. Air drying is especially useful for residual subgingival plaque by gently blowing the gingival sulcus open. Dried calculus will appear chalky white. Any remaining calculus can be removed with hand instruments. The goal of professional periodontal therapy is completely clean teeth.
Step 4: Irrigation
Irrigation and chlorhexidine rinse are the final steps in a dental prophylaxis. For irrigation, water or a dilute chlorhexidine solution is used. Then the final rinse of CET (CHX) Oral Hygiene Solution is used and left in the mouth. Chlorhexidine aids in inhibiting bacterial plaque formation.
Step 5: Oral Examination and Charting
The thin, curved explorer tip is used to detect irregularities on the tooth surface. It can be used under the gumline to detect subgingival calculus or erosions of the tooth root. Probing is performed using a periodontal probe that is inserted into the gingival sulcus in several areas around each tooth to check for areas of pocket formation. Root irregularities, tooth mobility and gingival bleeding are also evaluated. Pocket depths can be measured in millimeters by the marks on the periodontal probe. All dental and gingival abnormalities should be recorded on the dental chart. The periodontal probe is graduated in millimeter increments. Deeper periodontal pockets (> 5 mm) usually mean that bone loss has occurred. With proper treatment (removal of subgingival calculus and smoothing the root surface by root planing), repeating the periodontal therapy as often as needed (every 3 to 6 months in severe disease), and homecare by the owner, the mouth can be returned to good health.
Additional Treatments
Dental radiographs should be taken for each patient. Any abnormalities identified during the oral examination should be radiographed. Even if no obvious dental or periodontal abnormalities have been identified, a series of dental radiographs should be taken in each patient. The dental radiographs combined with the oral exam may identify teeth that need further treatment.
Oral antibiotics can be dispensed to patients that have periodontal disease. It has been shown that bacteremia will occur during routine dental cleaning and extractions. Geriatric patients and patients with kidney or heart disease can be started on antibiotics before periodontal therapy. Patients that suffer from severe periodontal disease may require longer-term antibiotic dosing and additional post-dental medications
*Quotation from VIN
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