PERIODONTAL DISEASE P4
2013
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.