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It’s the most effective way that you can remove dental plaque, maintain oral hygiene, and control gingivitis.  There are various toothbrushes in the market, and my recommendation is to use any good quality toothbrush.  In certain cases, I recommend finger brushing or cotton buds to get started.  I find cotton buds fairly useful in cats just to get them used to something in their mouth before progressing them to the toothbrush.  Finger brushes, I’m not a big fan of, and I find them quite bulky.  I don’t find the bristles effective. The ones with the rubber nipples in the end are, in my opinion, almost useless, but sometimes like them.  So, it’s what you can do to get them going.  I think a good quality toothbrush is definitely the way to go.

Regardless of what toothbrush you’re using, I would recommend an animal toothpaste.  The reason is that human toothpaste contains various things like enzymes and fluoride and flavoring.  So, the mint flavoring in our toothpaste can be quite powerful for an animal, and they don’t always like it.  The frothing agents, they don’t like, but, as I said, the biggest concern is possibly the fluoride content.

So, an animal is going to swallow a toothpaste.  Strictly speaking, a toothpaste doesn’t have many advantages in animal dentistry.  The main advantage that that it’s flavorful. The animals like it. So, they tolerate toothrbrushing better.  The Virbac toothpaste contains an enzymatic system, which is something that occurs in the saliva anyway, but it does help reduce plaque accumulation to a degree.  I like their toothpastes purely because they’re nice flavors, and the animals like them, not because they’re sponsoring the webinar this evening.  As I’ve said, I do find them effective.

The one thing that I tell my clients to do though is to squish the toothpaste into the bristles.  I find if you put it nicely on the top like we do on our own toothbrushes, the animals lick them off, and it’s gone within a few seconds.  They think they’ve had their treat, and they don’t compromise with tooth brushing.  So, my own dog, after I finish brushing her teeth, I usually give her a bit of the paste as a treat afterwards, and she loves it.  If she sees the toothpaste, she’ll come right away.  She’s not keen on the tooth brushing, but she likes the toothpaste.  So, that makes it quite peaceful.

The big thing is to always show the client how to brush the teeth.  I always recommend that the mouth is closed, usually putting your hand across the muscles, and it depends on how compliant the dog is.  So, always start at the back of the mouth and work forward.  The front of mouth is very sensitive, and the minute that you go to the upper incisors, they’ll start sneezing or they’ll lick or wriggle.  So, I always start at the back and go forward.  If you don’t tell a client that, instinctively, they’re going to the front of the mouth and start brushing from the front because that’s the area that they can see.

I do everything with the mouth that I can see, start at the back and work forward.  I gently, then, open the grip so that I can get to the gingival margin of the mandibular teeth because, remember, the maxillary premolars almost overlie the premandibular molars.  So, you need to just open the mouth just slightly to be able to get to the gum margin on the mandibular teeth.  Come forward.  Once I’ve done everything on that side, I do the other side, and then come to the front to do the incisors.

Cats. This is my own cat, Charlotte.  They’re not like dogs.  I think cats tolerate tooth brushing unlike dogs.  They quite like it, but cats, you need to get them in a headlock, tilt the head to one side.  What you want to aim for in the cat is all the bristles are inside the mouth, but the head, the plastic part of the toothbrush is usually outside the mouth.  I tilt the head slightly and pull back that lip with my thumb, gripping on the zygomatic arch and pulling the cheek back. I either do them on the ironing board or I wedge them in between my knees and do them on the carpet so that the front legs hopefully go into the cover of the ironing board and they come and pull my hands.

This is a nurse friend of mine.  You can see the size toothbrush that she was using, and these were adult cats when they started brushing their teeth.  They tolerate it extremely well, and you can see she’s taken the position of sitting on the floor, the cat wedged between her legs.  The cat can’t move back there, and they feel quite secure because they can’t move to the side.  So, that’s how I recommend tooth brushing cats.

I think we’ve discussed most of this.  The three things that I would point out would probably be, I only recommend brushing the toothbrush once only all the teeth have erupted.  The reason for that is until all the teeth have erupted, you’re getting changes in the mouth, and I think if there’s a deciduous tooth that’s starting to become loose, it can irritate the dog with the client’s tooth brushing.  That’s not to say that the animal shouldn’t be getting its mouth cleaned.  They should be getting used to their mouth handled, not to get used to the client putting bits of toothpaste on the deciduous teeth, but actually physically start using a toothbrush I usually recommend from 6 months of age.

Always warn the clients that the gums may bleed when they are tooth brushing, and this indicates that there is some gingivitis.  If you don’t warn the clients, what happens is they think they’ve done something wrong, and they stop.  They don’t come back and tell you, but they just stop.  What I usually recommend is if the gingivitis is infecting in about three to five days, they should come back and see me so I can look at the area and see why that’s occurring.  For my long term finds, they are tooth brushing every day. That’s one of the indicators that there’s a problem is when somebody gets a bleeding in an area, and it’s not reducing.  I always get them to come back and see me.

I think getting owner compliance is difficult, and I appreciate that I’m in veterinary practice.  So, immediately, I got much more bond with clients, but the clients that we get with periodontitis, a lot of the time, the disease just hasn’t been explained to them.  So, they don’t understand why they’ve got to brush.  They don’t understand benefits of tooth brushing, and so many times in practice, they would have been given chews.  They would have been given water and all sorts of things, and they spend a lot of money on things.  They think they’re doing what’s right for the animal.  It’s just purely because they want to help, but they really haven’t been given the proper instructions.

I think it’s worth spending your time, and this is where nurses are invaluable in practice.  They’ve got the time to spend with clients.  They’ve got the time to actually show them how to brush to get them more used to tooth brushing, and clients are more open with nurses.  They’ll often say, “The crazy lady old me that I’ve got to brush my cat’s teeth.  How am I going to do it?” They don’t say that directly to my face.  So, I do think nurses are invaluable here.

I do think it’s important that the client understands why they brush and that it’s not just about smelly breath.  You are doing it to prevent potentially systemic disease.  So, I think once they understand that, they’re much more like to get on board.  If they’ve got the support and encouragement of the practice and all that information is constantly reinforced with frequent checkups, they will get bonded, and they will comply.  It’s important that everyone in the practice is saying the same thing.  There’s no point in you recommending tooth brushing and trying really hard, and the receptionist says, “Why don’t you just buy a bag of food?  That’s going to be much better.”  That’s when it gets laid down because unfortunately, human nature says we are all up for an easy option if we’ll save.

Sometimes, even if an owner is really, really compliant, they’re not going to be able to toothbrush.  A lot of them can’t always cope with restraining their animal or with cats, they’re not used to gripping, getting them in a headlock.  There are some animals that just won’t tolerate tooth brushing, but as the first line, I would always recommend tooth brushing.

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This is just an example in a cat where the probe advances the whole way.  That’s 12 millimeters of attachment loss indicating a severe probing depth.  The reason why I mention probing depths is because some of the prognosis and your decision whether to extract teeth or not is going to be based on how much attachment loss there is.

Gum recession is also a useful indicator.  We measure it in millimeters, again, and it’s the distance from the cement and the enamel junction so where the base of the crown is to the where the level of the gum is.  We also check for mobility because if the tooth is loose, there’s a good chance that you’ve had significant attachment loss and that tooth needs to be extracted.

I just want to mention the difference between gum recession and periodontal probing depth.  Gum recession, you can see, and it’s on the outer surface of the teeth.  The gum has receded back along the root surface.  So, what you see is what you’ve got.  In this upper canine, for example, the gum margin should be at the level over here, and we’ve got it receding back.  There’s no periodontal pocket underneath that.  This tooth, you’ve got that deep periodontal pocket of sort of 12 millimeters past.  From the prognosis point of view, a gum recession you can see, which means you are able to keep it clean.

So, in most cases, a tooth with recession doesn’t necessarily need to be extracted, whereas with a periodontal pocket, if the owner is not going to be able to keep it clean, then that tooth should be extracted.  Though, for example, a periodontal pocket of maybe 2 or 3 millimeters, once you’ve done meticulous scaling and polishing and cleaned all the calculus, removed all the plaque from that pocket, you might get a little bit of reattachment.  If the client is tooth brushing, they’ll be able to clean probably 2 millimeters.  So, up to a 3 millimeter pocket can be acceptable on some animals, not on every tooth but just a football park figure that may be acceptable.

A 12 millimeter pocket with the best in the world, the client is never ever going to be able to keep that clean.  So, that tooth would need to be extracted, but, for example, if it was gum recession and I had 8 millimeters of recession on one aspect of the canine tooth, I wouldn’t necessarily extract the tooth if there was no probing depth and I had an owner that was going to totally care.

Coming back to gingival recession, I said that on some teeth it wasn’t an issue whereas on others it was.  On a single rooted tooth like an incisor or a canine, if you’re just getting 1 or 2 millimeters, the client keeping that clean is not a problem.  If you’re looking at your multi-rooted teeth, for example, the becomes involved very, very quickly purely because the furcation is very high in an animal compared to in a person.  If the furcation becomes involved on a multi-rooted tooth, unless your client is very, very dedicated and they’re going to be using things like teepee brushes where they can actually clean in between that area, even if it’s 1 or 2 millimeters, it may be better that that tooth is extracted rather than left in.

So, periodontal disease, it is a disease that affects animals.  It’s got systemic consequences.  It needs to be addressed, but it can also be prevented to a degree.  It’s easy.  You just need to brush the teeth, but it’s easier said than actually being practiced and done.  So, we’re going to just discuss the management of period now.  This is very brief because I think a lot people know about brushing and scaling and polishing, and I don’t want to go other things.  I’d rather use the time to perhaps other thoughts that concern you about periodontitis.

So, under an exam, general anesthetic, the mouth is examined, and all the teeth are cleaned.  They scale using an ultrasonic scaler, and that’s above and below the gum margin.  If you are using an ultrasonic scaler, you do need specific tips if you are going to be working below the gingival margin.  If you don’t have those specific tips, you should be using hand scaler, and what we say in veterinary dentistry is everything you do above the gum margin, you’re doing for the kind.  Everything you’re do below the gum margin, you’re doing for the pet.  So, you’ve got to remember that this disease is occurring at the gum margin and below the gum margin.  So, that’s an area that you really, really want to keep clean.

Root planning and subgingival curettage.  This comes in and out of favor in human dentistry, but the rationale behind that is that you’re making the root surface as smooth as possible so that you get less plaque accumulation on that root surface.  Subgingival root curettage means any diseased epithelium.  I think that’s a little bit out of favor at the moment on the human side.

Polishing teeth.  This is mostly debatable.  A lot of damage gets done when people polish badly.  So, if you are using your polisher at too high a speed, the general recommendation is if you put your polisher onto the surface of the tooth, it should be running at a speed where if you just contact the surface of the tooth, it slows down.  The cap of the polisher should also flare out so that you are able to clean under the margin, and it should be running at a speed where you’re not going to cause any friction or heat buildup.  You always need to use a fine polishing paste.

If you use anything more coarse (you get medium, you get coarse, you get extra coarse polishing paste), you’re actually going to course surface scratchers on the surface of the tooth, which is going to aggravate plaque accumulation.  So, in a lot of published texts, you will see that polishing is done to remove the scratches caused by scaling.  In an ideal world, you shouldn’t be causing those scratches by scaling.  Yes, you are always going to cause a very, very superficial, but don’t think that by you polishing, the more you’re actually going to smooth those out.  If you think about it ideologically, to remove a scratch on the surface of the teeth, you’re going to have to remove enamel, and you’re going to be removing a lot of enamel if you’re going to totally get rid of that scratch.  So, once I do recommend polishing, I always recommend slow polishing with a fine paste so that you actually don’t cause more damage to the surface of the teeth.

Part of the management of periodontics is also periodontal surgery.  So, for example, if there are areas of gum, you cut those back so you’re making the area easier for the client to look after.  You’re reducing the areas of plaque accumulation.  Tooth extraction is the ultimate treatment for periodontitis.  You know, once the tooth is gone, you don’t have to worry about it again.

Having said all of this, other than getting rid of the teeth and getting the animal pain free, there is no point of a scale and polish if they client is not going to be looking after the teeth afterwards.  We know that plaque has already started accumulating even before the dog has been discharged from surgery, and if the client is not going to be tooth brushing at home, plaque accumulates within 48 hours to the degree where it’s going to be causing harm.  So, you really, really need to discuss this with the client, and I discuss home care at the time where I diagnose the problem, when I’m booking them in for surgery.  We also discuss home care on admission, and we don’t say, “Are you willing to toothbrush?”  The question is, “How often are you willing to toothbrush?” Immediately, the client has been thinking about it, and they realize that perhaps their pet is coming in for treatment because they’ve let it down if they haven’t been tooth brushing.

It also helps me decide how many teeth I’m going to extract.  If I know what level of home care the clients are going to be doing, if you get some clients they come and they’re like, “Well, it’s a lot of rubbish.  There’s absolutely no way I’m going to be tooth brushing my dog’s teeth at home,” then, I would spend time extracting the teeth.  When I’m looking a tooth and say, “Should it stay or should it go?”  I’d rather extract it than leave it up with a problem.

So, when I’m examining these mouths, my aim when I’m doing periodontal treatment is to deal with any plaque retentive surfaces.  So, are there perhaps fracture teeth?  Are there areas where there’s gingival recession with [47:57] exposure?  Sometimes dealing with those means extracting teeth.  I also reduce areas of plaque stagnation.  For example, if there was overcrowding or if there was overlap between teeth, I may choose to extract a tooth to save another tooth or to make it easier for the client to brush their teeth and enable ongoing plaque control for the long term.

We know that the mouth is exactly in the same condition as before treatment within 3 months following dental treatment.  So, as I say, it’s really important to talk to your clients before you even do anything about home are.  The gold standard is obviously tooth brushing, and what I say to all my clients is if there was a diet that good or a chew that good or a water that’s running that’s good, we’d all be having it.  At the end of the day, we brush our teeth.  So, that’s what we should be doing for our dogs.

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So, why is this so important?  No animal is dropping dead in front of us because of periodontal disease.  Is it important to know if I’m saying that 80% of animals have got periodontitis?  Why is it causing a problem?  I think it’s not just about smelly breath.  Advanced periodontitis is painful.  These animals, if teeth become loose, the periodontal ligament has got pressure receptors.  So, if you’re getting movement on the tooth every time that they’re always eating, they do become painful.  It’s not pain that’s there all the time, but it does become just irritating in a chronic dull pain.  ‘

We know this because you’ve heard it in practice where a client has a dental treatment.  The client comes back in and says, “Oh, they’re like a different dog again.  They’re eating so much better.  They’re more playful.  They’re more social.”  In certain cases, you can also get a local abscess forming in the periodontal pocket and an abscess all around the root surface is incredibly painful.  We know because of thinking about what people feel with these conditions.

We know that when there is advance periodontitis, there is ulceration of the periodontal pocket, which means that bacteria can actually invade the tissue.  So, every time this animal eats or every time this animal chews, bacteria are potentially entering the bloodstream, and that’s going to cause problems.

Some of these I’ll illustrate with pictures here.  The only other one I’m going to comment on is the last one, which is ocular complications, and this was a relatively new one to me.  There’s two things I’m going to comment about this.  In small, brachiocephalic dogs, the roots of the carnassial and the molars, lie very close to the eye, and the complications arise purely from extension of disease where there’s severe inflammation and infection around the roots.  I had one dog recently referred.  It was actually a greyhound where the owners where brushing the teeth.  They had just never seen the back molar.  They got a root abscess, a periodontal abscess on the molar.  The dog went blind because of the extension of that abscess behind the eye, and the pressure from the abscess caused pressure on the optic nerve.  So, it was a very unfortunately complication because the owners were actually committed to home care.

What is a big issue is when you’re extracting these teeth because potentially the bone is going to be weaker around that area.  You have to be very careful that you don’t accidentally slip with the elevators of your [29:24] and cause damage to the eye.  There was one published in the Journal of Veterinary Dentistry that showed, I think, it was five animals that lost eyes, and one animal, she got a brain abscess following extractions.  This was purely because of poor extraction technique.  In these cases, the extraction isn’t always easy because you’re dealing with anatomy because of the bone loss.  So, just aware of that.

This is a picture of a lateral periodontal abscess in a cat.  Just out of interest, this cat was presented to me, and it was actually presented to the neurologist of the practice where I used to work because the owner saw it was having a fit every time it ate.  When you examined the teeth, it had deep periodontal pockets, and it was clearly an abscess around that tooth.  We extracted the tooth, and the cat was actually fine.

Mandibular fractures.  I’m sure some of you that are listening to me have encountered this in practice.  When little dogs get advanced periodontal disease, it’s often in the area of the lower molar or the fourth premolar or, in some cases, in the part of the lower canines, and when there is bone loss around one of the roots, it doesn’t take a lot to fracture that jaw.  So, this dog presented because the other dog just went for it, and they grounded one another and crashed.  The jaw broke, and the reason for the jaw fracture was the underlying periodontal disease that the bone was weaker.  You can see that there was only 2 or 3 millimeters that was holding that jaw in place.  Unfortunately, if you’re not taking preoperative grafts, if you’re not examining these patients and probing around these teeth, you’re not always going to pick up these problems.  If you start extracting the tooth like this, you may actually cause the mandibular fracture yourself.

This was a case that was referred.  I apologize for the poor quality radiograph, but it was destroyed.  There wasn’t much bone left, and you can see that we’ve virtually only got millimeters at the end of those teeth.  This dog, we didn’t fracture any of the jaw extracting the teeth, but you can see, this radiograph was taken prior to any calculus removal purely because I’ve had one case where the calculus was acting as a bridge as a splint from the jaw fracture.  So, in cases where I’m suspicious of severe bone loss, I will x-ray the mouth before I even touch the mouth, purely from an almost illegal point-of-view that you don’t know what you’re dealing with before you start.

In general practice, you might take one look at this and think, “I’m not touching this.  I’d rather [32:09] which is absolutely fine.  The important thing is if you do take a radiograph, I would always inform the client and warn them beforehand.  Say, “Mrs. Jones, Daisy has got severe periodontal.  This means that she’s had bone loss around the roots, and it means that the jaw’s very fragile.  The tooth or the teeth do need to be extracted because they are the source of the problem, but I just wanted to warn you that there is a risk of jaw fracture.”  It’s a much easier conversation to have than going to Mrs. Jones and saying, “Unfortunately, the jaw fractured when I was taking out the teeth.”  So, it’s all about client management, really.

In little dogs, coming back to why they break their jaws, in the little dogs, the roots of the lower molar contribute much more to the width of the mandible compared to a large dog.  There was one study on the Journal of Veterinary Dentistry that looks at small breeds, like a 20 kilogram dog, and a larger breed, and showed the relative width compared to the width of mandible.  This was a Labrador, and you can see the root finished above the mandibular canal.  Relatively, your puppy’s got the same width below the end of the root to the eventual end of mandible, compared to this dog where even if you’ve got a few millimeters of bone beyond the apex of that tooth.

Oronasal fistula.  You’ve seen this picture before.  The reason why I bring this up as a complication, why it’s important, remember we’re discussing why is periodontitis important.  In oronasal fistula, there isn’t a lot of bone between the root of the upper canine and the nose equally on the [34:01] tooth between the palatal root and the nose.  If an animal gets an infection or if you get advanced periodontitis with plaque accumulation, that dog is constantly inhaling bacteria.  So, it is an area that, particularly, can cause systemic effects for that dog.

Systemic consequences of periodontitis.  I mean there used to be a chart that showed all the arrows linking the heart and the kidneys and the liver that loads of people had in practice, and, you know, there were some studies that were published quite a few years ago that linked periodontal disease and systemic consequences.  They are all, to a degree, suspected, and what we know from [34:52], is that there are certain links with a bad mouth and bacteremias and chronic inflammation and the effect it has on the body.  The latest article that’s been published was in March this year in the Journal of the American Veterinary Medical Association that looked at things like C- reactive protein, and they looked at kidney values, things like that.  The conclusion was we really need more studies, but there is the link to potentially systemic consequences from a badly infected mouth.

So, periodontitis, coming back to it, is not just a smelly breath.  We know that, potentially, our host has got an immune response, and they’re not responding well or they’re overresponding. We potentially know that these dogs get bacteremia.  Every time they’re chewing, they get bacteremia.

So, just something that I think we should be thinking about is that most of these animals are presented to us at the time of vaccination, for example.  You examine the mouth and say, “Mrs. Jones, Daisy really needs to come in to have her teeth sorted out,” but should we be vaccinating them?  You know, if we potentially know that you’ve got C-reactive protein and you’ve got bacteremias, that animal isn’t considered healthy.  In an ideal world, it would be good to change the whole way we think about this sort of disease, and say, “Your animal is sick.”

If, for example, we had an area equivalent to the area of a Yorkshire terrier’s mouth that’s dripping or inflamed that has plaque accumulation, if that area was on the skin, we’d probably have a good time to circle off skin inflammation and skin infection.  We wouldn’t think twice about saying, “Mrs. Jones, you can’t have the vaccination today.  Take her a course of antibiotics.  Let’s get this infection cleared up, and then we will vaccinate her,” but, for some reason, people don’t view the mouth like that.  It’s because the animal just carries on.  They’re still eating.  They’re still coping.  So, the owner doesn’t perceive a problem, and it’s down to us to show them and to highlight the issues that are going on in this animal’s mouth.

So, some of the diagnosis of periodontal disease is easy where you can look at the mouth, and you can see attachment loss.  So, for example, when there is severe gum recession, you can see the roots overexposed, and you can see the furcation’s exposed, but the actual diagnosis can only truly be made under an anesthetic because that’s where you can see the degree of damage. That’s where we can assess whether there’s a periodontal pocket or not.

This makes is very difficult in general practice when you’re actually trying to book an animal for dental treatment and give estimates and explain what’s involved to a client because sometimes you think this animal isn’t going to need any extractions.  Then, you get them under and anesthetic, and they need six or seven teeth taken out.  So, it’s really important beforehand to explain this to a client that you get an initial look in a consultation, but the diagnosis is only made under and anesthetic.

Okay, this is just an example again.  I was convinced, in this patient, that we would have deep periodontal depths, given how marked the gingivitis was, but when examined, the mouth showed absolutely no sign of periodontal pockets anywhere.  So, once again, purely gingivitis.  I just said, “Strictly speaking, the general anesthetic, just take some scale and polish,” if the client had just been tooth brushing.

When they are under the anesthetic, we want to take a periodontal probe, which is a blunt-ended instrument.  It’s got graduated markings, and we want to check the whole circumference around the tooth.  We want to ensure that there is no attachment loss, that it isn’t advanced where the ligament has been lost around the tooth.  We measure that in millimeters.

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Attachment loss, as I say, is where you get changes in the gum margin.  So, in the top picture, we can see how the root has become exposed of the upper carnassial and post-molar.  We can see that there’s no bone between the distal root of the upper carnassial and the first root of the molar.  We can also see in the bottom picture how the area between the roots is exposed once again, called furcation exposure.

What’s possibly more of a problem for us is if a periodontal pocket forms because you can’t always see those.  Those you need to assess and add an anesthetic. So, in the top picture, that is a periodontal probe that’s been used to examine the whole circumference of the tooth, and probe has been inserted a good 12 millimeters.  So, it goes a long way down, and that’s indicating that the ligament of the bone has all been lose around that area, which has enabled me to insert that probe.  The problem, as I say, is you cannot see that.  You only just take a problem like that under an anesthetic.  Also, a client is never going to keep that area clean because no toothbrush is going to go 12 millimeters under the gum margin.  So, a tooth like that would need to be extracted.

The bottom picture’s just indicating how teeth get loose.  You know, mobility is usually a result of periodontal disease.  There are other courses of mobility, and if, for example, you’re examining your mouth and you find a tooth that is loose with no apparent attachment loss if you can’t see gingivitis or you can’t see root exposure or a periodontal pocket, then I would always be suspicious for a root fracture.  In general practice, most of the cases that we see are because of attachment loss.

So, this dog, in this day and age, this should never be happening to a mouth.  There’s no reason why a dog should be left like this.  This doesn’t happen in days or weeks.  This is months of accumulation.  What we can’t tell by looking at this picture is truly how bad or what the extent of the problem is.  The teeth look terrible.  We can see a lot of calculus accumulation.  We can see a lot of plaque accumulation, but we don’t know what the pocket depths are.  We can’t see furcation exposure.  So, it’s when that enamel is under and anesthetic that we can fully assess the periodontal status of that patient.

As I’ve said before, a lot of research now is looking at the rate of progression, destruction.  Looking at factors, why do some dogs have a huge mouth calculus but actually no deterioration in the actual supporting structures whereas others will get mouth gingivitis or just plaque accumulation on the tooth with gingivitis? Yet, when you probe the mouth, it’s got deep periodontal pockets.  So, we’ll look at these individually.

The way I approach periodontitis is I look at areas where there’s going to be increased plaque build-up, and that’s either going to be due to plaque retention or plaque stagnation areas.  For example, plaque retention.  Calculus would contribute to plaque retention.  It’s a much rougher surface so bacteria can accumulate on that surface a lot more readily.  Fractured teeth, for example, this picture where you’ve got an abnormal continuity to the tooth or where dentin’s exposed will favor plaque retention.  If there are enamel defects on the surface of the surface of the tooth where the enamel hasn’t formed properly, you get a much rougher surface to the tooth.  So, that will favor plaque retention and exposed root cementum as you will see in cases of periodontitis.  It’s a much rougher area so more plaque is going to accumulate.

Areas of plaque stagnation are areas where plaques are going to get reduced or where plaque’s going to accumulate because it cannot be dislodged, and that we see in cases of tooth crowding or malocclusion, misalignment of teeth, or sometimes where there’s missing teeth. For example, in this picture, the cat has got an extra mandibular premolar.  Because they have such a large angle, you’re going to get more plaque accumulation between the teeth, making those teeth more prone to periodontitis.  I’m sure you’ve seen this in cases in your own clinics where perhaps you extract an upper carnassial in a dog, and when you go back and look at the dog a few months down the line, there will be more plaque accumulation and perhaps a little bit more gingivitis on the lower molar purely because those teeth aren’t biting against one another, and the plaque is not being disrupted.

Probably the biggest concern for us is a periodontal pocket because periodontal pocket is that area that we don’t see where you’re perhaps getting a 3, 4, 5, in some cases, 12 millimeter pocket, which is area where bacteria can accumulate and be completely undisrupted.  So, with a toothbrush, you’re not going to get to them.  Eating and chewing is not going to be effective.  So, this bacteria can just flourish.  So, those are areas of plaque stagnation and also if there’s an abnormal gingival margin.  So, for example, if there was gingival hyperplasia like you see in boxes and the gum actually grows over the tooth, it almost creates a false pocket so bacteria can sit under that tissue and disturb.

The important thing always to remember with periodontal disease and I know there is a lot in the Times and the Letter Pages about this, that diet alone is not the cause of periodontitis.  You know, it doesn’t matter what you’re feeding an animal, they will get periodontitis.  They will get plaque accumulation on the teeth.  We know this because wild animals get periodontitis.  The difference between wild animals and our pet dog is wild animals have got a much better conformation in most cases.  Wild animals also don’t live as long, and we know that adult onset periodontitis is progressive with age.  So, a wild dog that may live until 6 or 7 is not going to be the same as Mrs. Jones’s Yorkshire terrier that she’s hoping it will live until it’s 17 or 18 years of age.  You know, you’re dealing with completely different disease progression.

We know that raw meaty bones, well some people do advocate them and they can cause more problems.  Unfortunately, we see a lot of fractured teeth related to raw meaty bones, and fractured teeth may result in more plaque accumulation.  The raw meaty bone people have has no actual study showing that a raw meaty bone diet will reduce the incidence of periodontitis.  One study that was done where they looked at feeding dogs and bovine tractors, and it did show that there was a reduction of plaque and gingivitis in the short term, but no long term studies have been done.

One of the quoted statistics that you see is that 75% of cats under a certain age have got periodontitis, and when you reference all that back, it goes back to the Talbot’s study that was done in 1989.  You know, when you think of that, those dogs weren’t on very natural diets.  They weren’t on a dry kibble.  They were probably on taper scraps.  So, periodontitis is not a new disease.  It’s been around for years and years and years and not the cause of periodontitis.  Certainly, diet can be a contributing factor.  We know that sticky, soft foods will accelerate plaque accumulation in the mouth, and the ideal can prevent some of the plaque accumulation but it can reduce periodontitis completely.

We also know that plaque is going to form whether food passing through the mouth or not, and you see this in some cat good when you put the feeding chips.  If you’re not going the put the feeding chip, you’ll just see how much plaque accumulation occurs on the teeth.  Some studies have shown that there’s no difference between the wet food and the dry food, and it all depends on how you interpret all these statistics in cat’s dry food, which tends to be somewhat better but is not clinically relevant.  When I mention these dry foods and wet foods, I’m talking about a commercial diet, not a specific dental diet.

Everyone talks self-cleansing mechanism of the tooth, and unfortunately, I think that’s about as significant as a self-cleansing oven.  It corrects to a degree, but it’s not the be-all-end-all.  Chewing does have an effect in that it encourages salivary production.  It encourages tongue movement, and you do get a little bit of dislodgement of plaque, but as I said before, the food and the chew gets deflected away from the gum margin.  It’s at that gum margin and the gingival sulcus that you really want to control the bacteria. So, no product is actually going to clean that area.  The only thing that works in that area is really a toothbrush.

In some animals with excessive salivary flow, you actually get more calculus accumulation because the tartar or the plaque will mineralize because of minerals in saliva.  So, salivary flow can be good for some animals, but in some animals, it is detrimental as well.

Ideally, if we are feeding our dogs, we want them to be on a tough, non-sticky diet.  You want maximum tooth contact so it does cleanse the teeth, but we also want them to chew their food to exercise the periodontal ligament and to keep that area stimulated to keep it healthy.  At the end of the day, the periodontal ligament is a ligament, and, like any other ligament in the body, if it not’s exercised particularly, you can get some changes.  I don’t think there’s any definite studies showing that this is the case, but it makes sense that you want some chewing activity to keep the teeth healthy.

The net thing were going to look at is host response, and this is a big, big thing in a human periodontology at the moment.  They’ve looked at various studies, probably at the last five years, and the general though now is that it’s actually host response, rather than the bacteria themselves, that are responsible for the destruction that you get around the tooth.  So, the host response.

There’s supposed to be three aspects.  One thing is genetics.  When we look at our dogs, definitely we see a difference in size and in breed.  We all know that Yorkshire terriers, for example, get really bad teeth, and this might be because relatively, they’ve got a much bigger surface area to gum margin compared to a dog like Labradors.  This doesn’t fit in with greyhounds though.  Greyhounds got a nice mouth.  They’ve got long muscles so there’s no overcrowding, but they’ve got very active tissue destruction.  So, you can’t always say that the smaller dogs have the worst teeth.  We know that certain breeds, for example [24:10] have got very healthy gums whereas dogs, for example Yorkshire terriers or greyhounds get very aggressive periodontal disease.

Things like the general health status are going to influence the rate of destruction of periodontitis, and the reason for that are multiple.  If the body covers onto bacteria or the bacterial capsule at the surfaces of the tooth and the gum margin, you’re going to get more active tissue destruction.  So, immunocompromised, diabetic animals will be more prone to periodontitis.

The host immune response is possibly one of the biggest factors, at the moment, that people are looking at as the cause of active tissue destruction.  What happens is the body feels the bacteria accumulating on the surface of the tooth.  Those bacteria release enzymes. They release chemical mediators that trigger inflammatory response. Body is going to respond to that inflammatory response in various ways, and that inflammatory response, once it’s started, is progressive.  Some animals will get much worse destruction than others.  There’s two things that occur.  One is direct entry by the plaque and bacteria themselves.  There are certain bacteria that will release toxins that do destroy tissue, but most of the destruction is actually caused by the immune response where the body is releasing enzymes, interleukins that actually cause destruction of the collagen, destruction of the bone.  We also know that you get changes in the inflammatory response and you get changes in the body’s DNA that then make that animal more prone to periodontitis.  So, once the whole disease has started, there’s no going back, and that’s important because if you can’t go back that means that these cases are a lot of management.  You’re never going to cure them.  Once again, a cat like this should never be happening.  This years of neglect.  So ideally we want to get them while they are early gingivitis cases and not to this degree.

PERIODONTAL DISEASE

Oct
2013
01

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Lisa Milella:

So, I’m no longer president of the BVDA.  Simone Cody is, but, anyway, this seminar on periodontal disease.

I think is a really important subject in this whole animal practice because so many of us are faced with these cases every day and so little, unfortunately, is talked about this subject, sort of its goal.  A lot of us brush our teeth every day but have actually got no real understand why we brush our own teeth.  So, we can’t explain our own clients to understand that either.  So, hopefully, after this evening, we’ll have a bit of understanding.

There’s a little bit about everything in here, as far as periodontal disease goes, and we’ll take questions at the end.  I would like to thank Virbac for supporting this webinar, and I do discuss some of their products purely because I do use them. You know, I have no affiliation with Virbac.  I know some of their products are excellent, and some of them I don’t rate, which we’ll discuss as well.  On the whole, they are very supportive of dentistry.  So, thank you Virbac.

Periodontitis.  It is, by far, the most common disease affecting dogs, cats, and it just doesn’t affect domestic animals.  It affects wild animals, too.  There are various puppy studies showing disease.  The most common one that is noted is that animals over the age of three have periodontitis requiring treatment.  When you look at that study, that’s a range of periodontitis stages, anything from gingivitis all the way up to severe periodontitis.

So, when they say requiring treatment, it might just be tooth brushing versus major extraction.  So, you’ve got to read everything.  So, to me, in everyday practice, probably 80% of animals coming in and seeing you have got some form of gum disease, whether that is just gingivitis or not, you should be discussing oral hygiene at the minimum.

Just as a refresher, the tooth end is basically a calcified pick that is sticking out of bone and is basically coming out of the bone with the soft tissue attachment.  The gingiva or the gum tissue, that just lies flat against the tooth.  It’s a very unstable junction.  So, you get a little gap just between the gingival margin and the margin of the tooth, and that should be sitting at the base of the crown.   That actual junction where soft tissue meets the tooth is a very unstable junction.  It’s what we call junctional epithelium, which is really a succor attachment made up of hemidescent zones.

It means that if there’ a little bit of inflammation or a little bit of infection or epithelial trauma, for example, if something got stuck in the junction, it pulls away from the teeth very, very easily.  When that happens, you start getting all sorts of changes that favor the production of plaque or the accumulation of plaque, and it favors a different sort of bacteria because you get changes in oxygen tension as it pulls away.  You get a very anaerobic, which favors more pathogenic bacteria.

So, it’s a really bad design, but it’s the way it is.  So, we have to deal with what we’ve got.  What’s important to remember about this when you’re looking at the slide is the tooth has got a crown bulge, and that crown bulge basically deflects food away from the gingival margin, and if you look at the area here where it comes down the food will move away from the gum.  Remember that area that we always need to keep clean in periodontal disease and gum disease is gym margin.  So, again, I’ll come back to this when we’re talking about diet and when we’re talking about tooth brushing, and things like that, but all the diets and things like that aren’t always [4:20] because they’re not cleaning the area that needs to be cleaned.

So, if we look to this mouth, and perhaps, this dog came in for a booster examination, most people would never even comment on the mouth and when you’re in the superficial glands, the teeth all look okay.  They’re mostly white, and when we look at the canine tooth, for example, we can see a very, very slight discoloration, but what’s important is we’ve got very early gingivitis.  You’re just starting to see the reddening of the gum margins, and this, if we all program for preventive dental decay, is where we should be discussing dental care with the client.

By the time that York Terrier comes in and needs 40 teeth extracted, we’ve let that patient down, and we’ve let the client down.  This is where we can make the difference. The treatment for a dog like this where there is just minor gingivitis isn’t going to be coming in for a scale and polish, but it’s going to be discussing oral hygiene.   This is where you want to start because this is really where you can make the difference as far as prevention goes.

What causes periodontal disease?  Well, periodontal disease is a called a plaque, and plaque is an accumulation of salivary glycoproteins and bacteria in a polysaccharide matrix.  Now, we get bacteria eliminated on other surfaces of the body, for example, in our skin or your intestines.  The difference between the tooth and those areas is the tooth is a non-shedding surface.

So, if the plaque is not disrupted, the bacteria carry up and build up, which then creates problems.  With time, this layer thickens, matures, and changes within that layer, and it actually forms a biofilm.  Studies have shown that you keep changing because of changing oxygen tension, and once again, the thicker the plaque gets, the more pathogenic the bacteria gets.

Within two days, it has been shown that the bacteria builds up to the level where it actually starts causing harm with candid gingivitis, and if you think about yourselves, occasionally you’ll brush your teeth.  One day, you’ll brush your teeth, and when you spit out this bit of blood, that indicates that you’ve got an area of gingivitis somewhere in your mouth.  It probably means that you didn’t brush that area properly the day before, had a bit of plaque accumulating, and gingivitis siting in.

The next day, there’s no gingivitis.  There’s no bleeding because you’ve removed the plaque, and you’ve reverted that tissue back to health.  If it’s left to carry on, it will cause harm, and in some animals, this plaque will start to enlyse and form tartar or calculus within two days.

Some studies have shown that after a certain period of time, that volume stabilizes and the degree of harm factors out.  Where there’s a lot of research at the moment is why or how long that interval is before the thing goes on to develop all of that and will then develop the full-blown periodontitis or where you start  getting active tissue destruction.  There’s a lot more work being on that to look at why some animals are more prone to tissue destruction than others.

In general practice, it’s really, really important to important that it’s plaque.  It’s a soft, sticky film on the tooth that causes the harm.  Calculus is just mineralized plaques.  So, it’s basically almost just like a coral reef, and that coral reef can contain bacteria.  Calculus, in itself, does not do anything.  It doesn’t irritate the gum.

It’s the plaque accumulation on top of the calculus that does everything, and in so many, times, you see it time and time again, that an animal’s object for dental treatment is based on the amount of calculus present in the mouth.  If you look at this picture, yes, there is a mineralization on the surface of the teeth, but relatively, there’s not a lot gingivitis.  You know, that gum doesn’t look inflamed.  It doesn’t look reddened, and if the client was able to brush that calculus, there’s absolutely no reason why that animal would need to come for a scale and polish.  We know that if you don’t start brushing afterwards, that, perhaps, that calculus is going to start forming in two days.  So, what’s the point in getting an animal for a sit-in if there’s not a medical benefit?

What I think is important to remember about calculus is that it is a rough surface, and, as I say, it’s like a coral reef.  So, more plaque is going to attach to the surface of calculus a lot easier than it would to the surface of the tooth, making it an area where a lot potentially pathogenic bacteria can sit and can aggravate the gingivitis and periodontitis.  So, if that’s the cause, it’s useful to remove it in the management of periodontitis cases.

Gingivitis, in itself, is purely inflammation of the gum margin, and the cause of gingivitis is plaque.  When I say it’s purely inflammation of the gum margin, I mean that there’s actually been no involvement of the periodontal ligament or the bone or the root of the teeth.  The condition is completely reversible.  If you toothbrushed and you removed the plaque on a daily basis, you should be able to reverse gingivitis.  So, in a case like this where the gums are terribly red and swollen, you cannot assess if there is attachment loss, if there is periodontal pocket among those teeth, and if you examine that patient under an anesthetic, if it I purely gingivitis where there is no attachment loss, the condition should be fully reversible despite tooth brushing.

Periodontitis, however, is when it’s gone one step beyond where you actually get lost of the supporting structure of the tooth.  The supporting structures of the tooth are things like gingiva, the root cement, the alveoli bone, and the periodontal ligament.  So, for example, if we look at the upper carnassial in the picture, we can actually see the gum is receded so that it’s now attaching on to the root surface.  We can see that there is root exposure, and we can see that there is carnassial exposure.  Furcation is the area between the two roots.

Now, unfortunately what happen is as you get periodontitis progressing, you get changes in the anatomy of the tooth that favor periodontitis.  So, the minute that you get root cement exposure, for example, it’s a much rougher surface, more bacteria can accumulate on that.  If the furcation’s exposed, there’s a nice little niche where plaque can accumulate, and when the dog chews, or even with tooth brushing, sometimes it will go and disrupt it.

So, the change in periodontitis then favor the ongoing cycle of periodontitis.  What’s important is that these changes are irreversible.  So, when the gum is gone, the gum is gone.  When the bone is lost, the bone is lost, and you cannot easily replace those.  Certainly, there are procedures.  There are various procedures where you can do things like periodontal graft and bone graft and guided tissue regeneration, but without absolutely meticulous home care, those procedures would never work.  So, the use is very, very limited in veterinary medicine.

This is also important because when it comes to decision-making about whether to extract a tooth or not, the way I view these is only if you’re going to be able to keep these clean or is this a problem area that’s waiting to happen?  So, if I’ve had changes in the anatomy of the tooth where it’s just going to accelerate problem or where it’s going to be very difficult for the client to keep the tooth clean, it’s better that the tooth is extracted.  Periodontitis is always preceded by gingivitis, but gingivitis will not always progress to periodontitis.

Periodontal Disease from Virbac on Vimeo.



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