PERIODONTAL DISEASE P3
2013
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.