Dental decisions: Strategies to treat periodontal disease
Weigh clinical, radiographic evidence as well as client expectations when approaching this preventable disease.
The goals of periodontal therapy include removing irritants as well as soft and hard debris from the tooth surfaces and periodontal pockets, minimizing pocket depth and attachment loss while maintaining at least 2 millimeters of attached gingiva. To accomplish this, companion animal periodontal therapy ranges from removing plaque and calculus in cases of gingivitis to performing mucogingival surgery to extracting affected teeth.
Periodontal therapy decisions should be based on evaluating the clinical and radiographic examination results along with client input concerning expectations, finances and ability to provide essential aftercare. Table 1 provides an overview of the stages of periodontal disease.
The complete photo package:
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal diseaseStage 1: Gingivitis
The root cause of periodontal disease is plaque that accumulates daily unless removed. Gingivitis occurs as a reaction to a plaqueladen biofilm. If the plaque is not disturbed, it solidifies into calculus (tartar). Calculus is rough compared with smooth enamel. This rough surface accumulates more plaque (Photo 1).
Photo 1: Plaque accumulating over rough calculus, causing gingival inflammation.
The complete photo package:
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal diseaseThe early colonizing bacteria are not pathogenic. They cannot cause periodontitis, but they can cause gingivitis (Photo 2). As the biofilm continues to grow, periodontal pathogens come on board as later colonizers and become the predominant species.
Photo 2: A patient with stage 1 gingivitis.
The complete photo package:
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
Gingivitis can occur without periodontal disease, but periodontal disease cannot occur without gingivitis. As veterinary dentists, our ultimate mission is to prevent periodontal disease, maintaining pain-free functional dentition.
Removing plaque and calculus through professional dental cleaning (supragingival and subgingival) and polishing the teeth with power/hand instrumentation while the patient is anesthetized removes the biofilm, allowing gingivitis to resolve (Photo 3). Oral hygiene home care prevents recurrence.
Photo 3: An ultrasonic scaler removing plaque and calculus.
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
Stage 2: Early periodontal disease
Periodontal tissues support the tooth in the alveolar socket. Stage 2 denotes the early establishment of periodontal disease with less than 25 percent support loss. Treatment involves removal of plaque and calculus previously described plus local application of antimicrobial doxycycline gel in areas of significant pocketing.
In nonpocketing defects (gingival recession), removal of irritants and debris from tooth surfaces is usually sufficient to decrease the progression of support loss (Photos 4-6).
Photo 4: A patient with gingival recession (nonpocketing defect).
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
Photo 5: A 4-mm periodontal pocket between the right and left maxillary first incisors in a German shorthaired pointer.
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
Photo 6: Local antibiotic administration of doxycycline gel (Doxirobe—Pfizer).
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
Stage 3: Moderate periodontal disease
Stage 3 periodontal disease is diagnosed when 25 to 50 percent support loss has occurred. Unless the client and patient are committed to stringent daily plaque prevention, often the best choice is tooth extraction. Patients generally do better without teeth when compared to living with painful dentition.
When there are significant probing pocket depths present, an apical position flap can be used to decrease the pocket (Photos 7 & 8). If areas of gingival recession are creating support loss without pocket depths, teeth cleaning plus stringent home care are options. In cases in which bone defects have resulted as a consequence of periodontal disease, bone grafting can be used to preserve or restore the alveolar height. This technique is effective in treating deep, narrow, three-walled infrabony pockets, such as palatal defects, that do not extend into the nasal cavity.
Photo 7: A 9-mm periodontal pocket.
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
The goals of bone grafting are to restore normal bony architecture, re-establish the periodontal ligament and soft tissue and prevent further periodontal pocket formation. Many materials have been used for dog and cat bone grafts including autogenous bone, allografts from companion animal bone (e.g., Osteoallograft Periomix — Veterinary Transplant Services) and synthetic bioactive glass ceramics (e.g., Consil, Consil Putty — Nutramax Laboratories), which become osteoconductive when implanted into an osseous defect. The ceramic is resorbed within weeks.
Photo 8: An apical repositioned flap used to decrease pocket depth.
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
Palatal pocket therapy is indicated in cases in which there is more than 25 percent attachment loss on the palatal aspect of one or both maxillary canine teeth and the periodontal probe does not enter the nasal cavity (Photo 9). If untreated, the pocket might progress until it penetrates the nasal cavity, creating an oronasal fistula.
Photo 9: A 7-mm palatal pocket.
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
The technique is as follows:
Step 1.
Make 2- to 4-mm mesial and distal incisions to the bone at 20-degree angles palatally from the affected tooth (Photo 10).
Photo 10: Palatal incisions for palatal pocket therapy.
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
Step 2.
Use a Molt or Freer periosteal elevator to gently raise a full-thickness flap (Photo 11).
Photo 11: Exposure of granulation tissue (green arrows) filling the palatal defect (black arrows).
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
Step 3.
Use a thin curette to clean accessible granulation tissue, calculus and plaque between the root and alveolus (Photo 12).
Photo 12: The partial removal of granulation tissue with a curette.
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
Step 4.
Carry bone-grafting particles into the cleaned defect (Photo 13).
Step 5.
Oppose the flap snugly against the tooth with 4-0 absorbable suture on an atraumatic needle.
Photo 13: Bone-grafting particles applied into the palatal defect.
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
Stage 4: Advanced periodontal disease
Stage 4 is diagnosed when more than 50 percent support loss has occurred (Photo 14). Extraction is the treatment of choice in most cases. Flap exposure, apical position flap, bone implants and mucogingival surgery can be attempted in the right cases with the right owners who understand the guarded prognosis. Often the best approach to care for dogs or cats with advanced periodontal disease is multiple extractions. In most cases, the surgical area heals without incident.
Photo 14: A patient with stage 4 periodontal disease.
Dr. Bellows owns Hometown Animal Hospital and Dental Clinic in Weston, Fla. He is a diplomate of the American Veterinary Dental College and the American Board of Veterinary Practitioners. He can be reached at (954) 349-5800; e-mail: dentalvet@aol.com
The complete photo package:
The stages of periodontitis
Stage 1: Gingivitis
Photo: A patient with stage 1 gingivitis
Photo: An ultrasonic scaler removing plaque and calculus
Stage 2: Early periodontal disease
Photo: A 4-mm periodontal pocket
Photo: Local antibiotic administration of doxycycline gel
Stage 3: Moderate periodontal disease
Photo: An apical repositioned flap used to decrease pocket depth
Photo: A 7-mm palatal pocket
Photo: Palatal incisions for palatal pocket therapy
Photo: Exposure of granulation tissue filling the palatal defect
Photo: The partial removal of granulation tissue with a curette
Photo: Bone-grafting particles applied into the palatal defect
Stage 4: Advanced periodontal disease
