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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