Jan Bellows, DVM

Diplomate, American Veterinary Dental College

All Pets Dental Clinic

9111 Taft St.

Pembroke Pines, Fl. 33024

(954) 432-1111

PERIODONTICS

The periodontal tissues are the gingiva, cementum, periodontal ligament, and

alveolar supporting bone. More than 85% of dogs and cats older than four

years have periodontal pathology.

Periodontal disease starts with the formation of plaque, a transparent

adhesive fluid composed of mucin, sloughed epithelial cells, and aerobic,

gram positive cocci. Plaque starts forming two to five days after dental

cleaning. If the plaque is not removed, mineral salts in the food will

precipitate to form hard dental calculus The calculus is irritating to the

gingival tissue, changing the ph of the mouth allowing pathogenic aerobic

gram negative bacteria to survive subgingivally. By-products of these

bacteria "eat away" at the tooth's support structures eventually causing the

tooth to be lost

There are two grading systems commonly used to classify the degree of

periodontal disease. The mobility index evaluates the looseness of the tooth.

With Class I mobility, the tooth only moves slightly. Class II is when a

tooth moves less than the distance of it's crown width. Class III mobility

move a distance greater than its crown width. Class III teeth have lost more

than 50% of their support and in most cases should be extracted. Periodontal

disease can also be graded from I to V.

Stages of Periodontal Treatment at the Five

Disease Stages

1 normal~coral pink 1.home care

2.edema 2 polishing

3 edema-pockets 3.scaling, root planing,polishing

4.edema-pockets deeper 4`above plus possible

beginning bone loss apical reposition flap surgery

5 more advanced 5` above plus possible

with tooth mobility osteoplasty, flaps, and splinting

PERIODONTAL DISEASE

When periodontal disease is not treated the subgingival anaerobic bacteria

can continue to reproduce creating deeper periodontal pockets through bone

destruction. Eventually, this progression can cause tooth loss and other

internal medicine problems.

Imagine a giant tooth sitting in a ten foot garbage can containing mud and

industrial waste. Continue to pretend it is your job to clean the tooth and

you are only supplied with equipment five feet long. What happens? The top is

cleaned and the bottom is allowed to remain in the toxic waste until it eats

through the can. How can you solve this problem? Try opening the side of the

can to clean the waste out in order to save the tooth. Here is the essence of

periodontal surgery.

What decisions should the veterinarian make when considering periodontal

surgery? The correct client, a cooperative patient, a treatable tooth, and

choice of which periodontal surgery procedure to use.

The client needs to be committed to save their animal's teeth This commitment

includes daily brushing home care to remove plaque, which begins to colonize

within twelve hours after a prophy procedure. Frequent veterinary dental

progress re-examinations, and expense should also be considered and discussed

prior to periodontal care. The patient must also be a willing partner If the

dog or cat will not allow home care the best dental surgeon and most caring

owner will not make a difference. Unless there is strong owner commitment and

patient compliance, it is much

wiser to extract the tooth rather than letting the pet suffer.

Choosing appropriate teeth to operate upon is equally important. Every dental

prophylaxis should include probing and charting. A periodontal probe is the

single most important instrument used to evaluate periodontal health. A probe

is marked in millimeter gradations and gently inserted in the space between

the gingival margin and tooth. A probe will stop where the gingiva attaches

to the tooth or at the apex of the alveolus if the attachment is gone. Dogs

should have less than two millimeter probing depths and cats less than one.

Each tooth is probed on a minimum of four sides. Probing depths of all

teeth are noted on the dental record and a treatment plan is mapped out

before therapy begins. Pocket depths up to five millimeters can usually be

cleaned adequately with curettes. Depths greater than five millimeters need

flap surgery or "garbage can side exposure" to evaluate and clean the root

surfaces.

Intraoral radiography supplies important information when deciding which

tooth can benefit from surgery. Radiographs help evaluate the supportive bone

mesally (rostral) and distal to the affected tooth. Unfortunately it is

difficult to evaluate the lingual-buccal plane through intraoral films. As a

general rule, if there is greater than 75% horizontal or vertical bone loss

around a tooth, only heroics may provide long term success. Radiographs

should also be examined for other pathology including endodontic lesions that

can be treated prior to and may effect the outcome of periodontal care.

Once the clinician is convinced that he or she is working on the right

patient and tooth, the appropriate type of periodontal surgery is chosen. an

ideal method allows exposure of the root surface, preserves the attached

gingiva, and to allow the gingiva to be resutured in a fashion to eliminate

the periodontal pocket and promote reattachment to the root surface

At one time gingivectomy was the treatment of choice to eliminate pocket

depth and allow exposure of the root surface for cleaning. Unfortunately part

of the important attached gingiva is sacrificed in the gingivectomy

procedure. Gingivectomies should only be used in cases of gingival

hyperplasia where there is an overgrowth of tissue. The gingivectomy

procedure employs a scalpel or electrosurgical blade to incise the exuberant

gingival tissue at 45 degree angle toward the crown.

Flap surgery is the most appropriate procedure to expose the pathology and

render care. There are four commonly used methods in small animal dentistry.

Open flap curettage- 360 degree incisions are made internally into the

pockets angling the blade tip toward the tooth The incision is rarely made

past the mucogingival line. A periosteal elevator is used to elevate the flap

exposing the tooth's root surface for cleaning and root planing. Interdental

sutures are placed with 4-0 chronic gut on an atraumatic needle

Apical Repositioned Flap- procedure is used where the clinician wants to

decrease the height of the pocket in areas of alveolar bone loss. The blade

is inserted 360 degrees around the tooth incising the epithelial attachment.

Vertical incisions apical to the mucogingival line are made two to three

millimeters mesial and distal to the affected teeth A periosteal elevator is

used to reflect the gingiva exposing the alveolar bone. Sharp projections of

the alveolus are smoothed, necrotic debris removed from the root surface, and

the area irrigated with chlorhexidine. The horizontally incised gingiva is

resutured to the new height of the alveolar bone thus reducing the pocket

depth.

Reverse Bevel Flap- indicated where there are inflamed and n~crotic free

gingival margins. A portion of the attached gingiva is removed, care must be

taken to make sure that enough attached gingiva remains after the procedure.

The initial incision is mode parallel to the tooth between the diseased and

healthy appearing attached gingiva. A half to one millimeter of attached

gingiva is left as a collar around the affected tooth~ The collar is removed

with a sharp curette, the root planed, alveolar defects repaired, and

opposing edges of the "healthy" attached gingiva resutured.

Canine Palatal Flap - indicated where there are greater than five millimeter

pockets on the palatal or lingual side of the canine teeth. If there is an

oro-nasal fistula as evidenced by sneezing or nasal discharge, then this

procedure is not indicated and extraction followed by single or double

layere; flap surgical closure of the defect is indicated. Incisions are made

to the bone partially extending at a 20 degree angle flare from the affected

tooth for four to eight millimeters. A periosteal elevator is used to expose

the root for cleaning and the alveolus for application of various bone

filling materials in order to decrease the dead space and promote osseous

integration . The area is closed with 4-0 chromic gut on an atraumatic

needle.