Proper periodontal therapy techniques
Brook A. Niemiec, DVM, DAVDC, DEVDC, FAVD
Southern California Veterinary Dental Specialties & Oral Surgery
San Diego, CA USA
Kymberley Stewart DVM
Toronto, ON, Canada
Methods and products for periodontal disease treatment and prevention can be grouped into three distinct treatment areas:
1) Control the infection (pathogen control)
2) Decrease the amount inflammation and/or bone destruction by the host (host modulation)
3) Re-grow lost bone (guided tissue regeneration)
It is well known that periodontal disease is initiated by plaque bacteria. Therefore, the basis for periodontal therapy is, and likely always will, be plaque control. Proper plaque control is a four pronged attack based on the level of disease.
A. Complete dental prophylaxis should include the following steps:
Decreases “surprises” under anesthesia
Proper and balanced anesthesia
Mostly with an ultrasonic sc aler (Remember when 2-mm are worn away need to replace)
Hand scaling ideally follows the ultrasonic step
Generally with a curette or SUBGINGIVAL tip
Hand instruments MUST be sharp (www.dogbeachvet.com)
Oral exam and charting
Niemiec color coded probes can help
Email firstname.lastname@example.org for copies of our charts
Dental radiology (Vetdentalrad.com for interpretation help)
Homecare is an absolutely critical part of periodontal therapy. This is because plaque forms in 24 hours, tarter in 3 days and gingivitis in 2 weeks. This means that even with annual cleaning, patients are infected 50 weeks a year. In fact, human studies show that professional cleanings without homecare are essentially worthless.
There are 2 major divisions of homecare, active and passive. Active homecare is defined that the client actually needs to perform work as opposed to feeding a diet or treat, the latter is considered passive.
As far as homecare is concerned, tooth brushing is still the gold standard. Educate your clients early about the benefits and compliance will increase. Brushing is performed with a toothbrush and veterinary toothpaste. However, mechanical removal of plaque by the bris the most important part of periodontal care. The toothpastes typically only provide flavorings and anti-tartar agents, neither of which is actually helpful for control of periodontal disease.
Antiseptics such as chlorhexidine and zinc ascorbate can be good adjunct therapy for periodontal disease. However, as above, plaque bacteria are very resistant to antiseptics and therefore mechanical removal of plaque is the most important part of periodontal care.
As great as effective toothbrushing is, this is rarely the case. Toothbrushing needs to be performed correctly on a very regular basis. If a client stops brushing even for a short time, gingivitis will return. Since it has been shown that less than 1% of clients brush their pets daily, this is rarely a great choice. Further, it is very difficult to access the distal teeth as well as the linguo-palatal surfaces. It has been shown that brushing is effective on rostral teeth (canines and incisors) but less so on premolar and molar teeth. Chew based “passive” homecare is more effective on the chewing teeth. Therefore, a combination of the two is likely best.
Passive homecare is mostly chew based removal of plaque. As far as “passive” methods of homecare are concerned, many available products have NO scientific evidence behind them. Essentially all pet store products have no studies.
Further, most studies just look at overall plaque and calculus reduction, not WHERE the reduction occurs. This may or may not indicate true effectiveness against periodontal disease. This is because the decrease is generally at only the incisal edge to middle of the tooth and does not reach to the gingival margin where the disease actually occurs. This may or may not indicate true effectiveness against periodontal disease Therefore, when you are determining what products to recommend to your clients, ideally look beyond just plaque and calculus control and determine where that control occurs.
Softer and more pliable products are not only safer in general, they should clean all the way to the gumline.
C. Periodontal Surgery
The other “new” form of pathogen control should be periodontal surgery. As discussed in the last article, pockets greater than 3-mm are pathologic and in need of therapy. All pockets between 3 and 6-mm should be treated with closed root planing and ideally the administration of a sustained release local antimicrobial. Pockets greater than 6-mm or furcation level II and III require periodontal flap surgery to effectively clean the root surface and allow for reattachment and infection control. These procedures can be learned by a general practitioner and require minimal investment in equipment. If this is not an option, these teeth should be extracted.
While extreme, the ultimate in plaque control is extraction. This will completely remove the plaque retentive surface of the tooth. It is the actual cure for gum disease. Dental radiographs will greatly facilitate the procedure.
This author is a big believer in minimally invasive surgery. Use small, sharp luxating elevators, minimal bone removal, and envelope flaps for extractions.
Regenerating bone lost via periodontal disease is another weapon in the fight against periodontal disease. This is combined with periodontal flap surgery to clean and regenerate the lost bone. The technique of guided tissue regeneration (GTR) has been around for decades, but recent advances in barriers and bone grafting has markedly improved the success rates. Regardless, there are only a handful of conditions which carry a good prognosis for bone regeneration. The best prognosis is seen with 3-walled periodontal pockets (typically seen on the palatal aspect of the maxillary canine and distal aspect of the distal root of the mandibular first molar) and class II furcation lesions. Since these are quite common in small breed dogs, there are a large number of patients who would benefit from these procedures.
The theory of GTR is that the down growth of faster healing soft tissue must be prevented to allow the slower growing bone and periodontal ligament to repopulate the periodontally induced bony defect. GTR involves creating a periodontal flap and performing open root planning to create a clean root surface for healing. After this is accomplished, the defect is filled with bone augmentation and a barrier membrane placed. There are numerous products currently utilized on the human side, however currently the products of choice for most veterinary dentists are cancellous freeze-dried demineralized bone for the graft and demineralized laminar bone sheets as the membrane.
This is an exciting new area of periodontal therapy. It is the use of products to decrease the inflammatory response to bacterial plaque. In this way it can lessen gingivitis and in some cases decrease the amount of alveolar bone loss. Some products are drugs, but there are and increasing number of nutraceuticals in this segment.
Probiotics have been shown to be very effective at improving oral health. They can be administered orally, bit are more effective when rubbed on the gums. Additionally, they have been shown to decrease pocket depths when injected into a periodontal pocket.
Fatty acids are well known for their anti-inflammatory effect on skin and joints. They have also been shown to be effective against periodontal disease. In particular, a veterinary labelled product can be topically applied for maximum local effect, but when swallowed also provides joint support.
Other agents in this category are CoQ10, antioxidants, and proper overall nutrition.
Periodontal disease is by far the most common disease process in small animal veterinary patients. It is particularly common in small and toy breed dogs. Not only does it create local infection and can lead to tooth loss, there are numerous negative local and systemic effects of untreated periodontal disease. In fact, on the human side periodontal disease is known as the “silent killer”. Proper care of periodontal disease is critical for the overall health of the patient.
The basis for therapy of periodontal disease is plaque control. This is achieved by a combination of professional cleanings, periodontal surgery, extractions, and most critically homecare. It is critical to select therapies (particularly homecare) which are effective at and below the gumline. Recently, guided tissue regeneration and host modulation have emerged as additional options for combatting periodontal disease.