Dental prophylaxis vs. periodontal therapy (Proceedings)

Prevention vs. treatment

In veterinary dentistry literature, the use of more precise terminology is recommended with regard to the prevention and treatment of periodontal disease. It is important for the dentistry staff to become familiar with these differences and implement them into their vocabulary, treatment protocols and fees.

Remove the phrase "doing a dental" from the list. It doesn't specify the treatment or procedure being performed. In order to provide the best service to the client, the clinic must detail the procedures to be implemented.

Dental Prophylaxis - As we have seen, one typical mouth can have areas where plaque only is seen all the way to gum recession and inflammation. Each mouth is to be treated tooth by tooth. A prophylaxis is a preventative treatment. A tooth with plaque and/or calculus and no gingival inflammation is the only tooth that qualifies for the treatment.

Periodontal Treatment - If any gingival inflammation, recession, periodontal pockets, furcation exposure or mobility exists, a periodontal treatment is being performed.

Assess your patient and your client

The role of the veterinarian and the technician is education, treatment, and support. Management of periodontal disease requires the building and nurturing of the relationship between the owner, animal, and the environment. The owner is the one who will be investing a high level of time and commitment. It is important that the owner feels that they are part of the treatment decisions that will best suit their pet based on their ability to carry out the treatment.

It all starts in the exam room or maybe the telephone. The interview is an essential component of the treatment plan. The goal of the interview is to establish what the treatment parameters will be. The more information that you have, the better you can plan the number of cases you will be doing that day. This helps reduce staff stress and fatigue, but also provides better pre, peri and post-op care.

Oral exam on the awake patient

Evaluate the breath – Halitosis

• Does the patient have foul smelling breath?

Evaluate the head and face

• Look at the patient nose to nose. Compare the two sides of the head. Are they different?

• Look at the eyes. Compare. Do they look different? Any abnormal discharge?

• Look directly below the eye. Is there any swelling?

• Feel the submandibular lymph nodes. Any enlargement?

Evaluate each tooth

• Are there any fractures?

• Are the gums reddened and inflamed?

• Are there any missing, mobile, or extra teeth?

• Is there any discoloration of the crowns? Pink or gray?

Questions to Build the Owner–Animal–Environment Picture*

• What kind of relationship does the owner have with the pet?

• What is the owner's attitude towards dental care in general?

• How does the owner understand the problem?

• What are the financial capabilities?

• What does the owner expect from the treatment?

• What is the owner physically able to do with their pet?

• Is the pet likely to cooperate with the home care?

• Does the pet have a lifestyle that requires the use of the mouth?

• Does the pet have a medical condition that would warrant one treatment over another?

• What treats and diet does the pet readily eat?

• Are there other pets in the household?

What is periodontal disease?

With the presence of a veterinary technician specialty group in dentistry, the opportunities for technicians to gain further knowledge in this field are more available both at a local and a national level. With periodontal disease being the most frequently clinically occurring condition in dogs and cats1, it is imperative that the veterinary technician be current with the most up-to-date information regarding pathogenesis, treatment options and home care.

Part of what makes a veterinary technician an indispensable part of the medical staff is the ability to bridge the gap between the client and the veterinarian. Your level of professionalism is gauged by your knowledge and, more importantly, how well you can communicate your knowledge. The medical knowledge of the procedures used in the prevention and treatment of periodontal disease involved is crucial.

Pellicle - The oral cavity is a constantly moist environment. The pellicle is a thin film consisting of salivary proteins and glycoproteins. The pellicle protects and lubricates. Pellicle deposition occurs immediately after a dental cleaning. As the pellicle ages, it gives the oral bacteria a surface to adhere.

Dental Plaque – As bacteria colonize on the pellicle, it forms a biofilm on the inert surfaces of the tooth, namely the crown and becomes mature plaque. It is difficult to see but can be visualized using a plaque disclosing solution. The biofilm thickens as the aerobic bacteria consume oxygen and multiply, making the environment more suitable for anaerobic bacteria. An important thing to remember here is that dental plaque is not a disease, but is the cause of periodontal disease. Plaque that is allowed to accumulate will result in gingivitis.

Dental calculus – Dog and cat mouths, unlike humans are slightly alkaline, an environment in which calcium salts are more likely to be deposited. Calcium carbonate and calcium phosphate salts are found in the salivary fluid. These calcium products crystallize on the surface of the teeth and mineralize the soft plaque. The formation of dental calculus takes 2-3 days. The deep crevices along the surface of the calculus promote further growth of anaerobic bacteria because oxygen is low to unavailable. Calculus cannot be removed except by mechanical action (hand or power scaling).

Gingivitis – Plaque extends subgingivally and the mixture of bacteria and cell degradation products become destructive on the periodontal soft tissues and inflammation occurs and gingivitis develops. Sulcus depths are usually normal. Gingivitis is considered reversible, meaning that once the bacterial laden dental plaque is removed, the inflammation disappears. Not all sites with gingivitis proceed to periodontitis. Gingivitis can become more severe in patients with local or systemic conditions.

Periodontitis – Inflammatory destruction of the coronal part of the periodontal ligament allows the apical migration of the bacteria. This causes the destruction of the periodontal attachment tissue (periodontal ligament, alveolar bone). In order to make a diagnosis of periodontitis, bone loss must be present. Periodontitis can have active and quiescent periods, which explains why you could see some teeth with root exposure or increased periodontal pocket depth, but no inflammation

Pathogenic bacteria cause the body to activate immune and non-immune reactions that are responsible for the tissue damage. It is the host response to plaque bacteria and not the virulence of the bacteria that causes the tissue damage. So, all dogs and cats will develop plaque, but not all will that plaque develop into periodontitis.

Putting together the estimate

Once you have established through the above interview a preliminary assessment of the patient's oral health, then you need to put together an estimate for any therapeutic treatments that could be done. This can alleviate client sticker shock and give the client a better understanding of the necessity of the treatment if visual aids are used in the presentation.

Components of the estimate

Consultation fee

Your consultation fee should include what you see in the exam room and what your findings are after the patient is under anesthesia.

Preoperative testing

Are they safe for anesthesia? Have an age range for the blood panels that you do? Compare the findings with the urgency of the treatment. Work them up if you have to. Do they need 24-48 hours of antibiotics 2 days prior to treatment? Remember to check the heart and lungs/trachea for any abnormalities.

Anesthesia

Choose your protocol based on the physical exam and preoperative work-up. Match the protocol to the patient. One size does not fit all. You can add monitoring fees in with your anesthesia. Make sure you also figure out what pain management protocols would be used i.e. pre-op injections, local blocks, post-op injections.

IV fluids

Match your patient's health status with the type of fluids and the rate.

Dental radiographs

Have a per film price and a full mouth price.

Cleaning and polishing

This does not include periodontal treatments. Figure out how much time you would spend doing a dental cleaning and polishing on a dog and cat. Also factor in: packs, polish, instrument maintenance, gloves, masks, eye protection.

Periodontal therapy

Subgingival curettage/closed root planing

This procedure is done when an early periodontal pocket is present and the subgingival debris cannot be reached with a power scaler tip. A dental curette is used to remove debris and granulation tissue from the root surface and the inside of the pocket.

Open root planing

When a periodontal pocket is too deep for easy visualization of debris and granulation tissue, an incision is made to open the periodontal pocket for better visualization and provides a more thorough debridement of the pocket. The pocket is then sutured closed.

Perioceutics

A perioceutic or locally applied antimicrobial agent is a medication that is placed inside a periodontal pocket 4mm or deeper for the local treatment of periodontal disease. Doxycycline is the common medication found in perioceutics. It slowly releases the antibiotic over a 2-4 week period. Your price should reflect a per tooth price.

Extractions

This is a very common procedure done in veterinary practices. Extractions should be priced by the type of tooth (incisor, premolar, molar), type of extraction (closed, surgical, root tip), the size of the patient (<20 lbs, 20-60 lbs, >60 lbs), and the time it would take the surgeon to do these extractions.

Suture material

It is wise to add to your estimate a suture fee to cover the costs of your commonly used dental suture materials and how much you would use per case.

Placement of synthetic bone grafting materials

If large extractions are done that could leave the bone strength compromised, synthetic bone grafting materials are used. Cover your cost of these products.

Peri-op medications

Are you going to be giving antibiotic injections during the procedure? Add this cost into your estimate.

Post-op drugs

Add post-op pain injections into your estimate.

Send home medications

Will you be sending home any antibiotics or pain medications? Add this cost to your estimate.

Home care products

In order to maintain oral health, it is imperative that clients continue treatment at home. Use your client interview and oral exam to tailor make a home care regiment that will work best for your client and best benefit your patient.

Planning your schedule

When adding dental procedures to your surgery schedule, it is a good idea to block time according to the level of disease in your patient. This can be facilitated easily using the 4 common grades of periodontal disease. Your time allotted should start from the time the patient is induced through recovery. The time will vary depending on the experience of the person doing the procedure. Combine different stages into one surgery day that will best fit.

Stage 1 - Gingivitis

Signs - gingival inflammation at the free gingival margin. It is limited to the epithelium and connective tissue. There is NO mobility or attachment loss. It is reversible.

Treatment - thorough supra and subgingival cleaning and polishing. The gingivitis will usually resolve within weeks. No perioperative or postoperative medications should be needed unless there is a preexisting systemic condition.

Homecare - daily brushing

Average surgical time - 30 - 60 minutes.

Stage 2 - Early Periodontitis

Signs - there will be pocket formation or gingival recession causing up to 25% attachment loss.

Treatment - thorough supragingival and subgingival cleaning and polishing and the use of perioceutics applied subgingivally to cleaned periodontal pockets greater than 3 mms in dogs and 1 mm in cats. The perioceutic starts as a gel that once it is exposed to moisture, hardens, binds to the dentin and cementum and starts releasing therapeutic levels of the antibiotic doxycycline. The doxycycline decreases inflammation and edema, promoting growth of junctional epithelium thereby decreasing the periodontal pocket.

Homecare - no brushing in the areas where the perioceutic was applied for 2 weeks. Then resume brushing. Antibiotics and pain medications should be sent home.

Average surgical time - 45 - 60 minutes

Stage 3 - Established Periodontitis

Signs - there will be a 25-50% attachment loss around the root causing slight mobility in single-rooted teeth. There may also be early furcation exposure and/or gingival recession.

Stage 4 - Advanced Periodontitis

Signs - there will be a greater than 50% attachment loss around the root causing mobility in multi-rooted teeth. Marked furcations exposure, deep pocket formation, gingival recession and abscess formation can also be seen.

Treatment for Stages 3 and 4 - Pockets greater than 50% - 75% have a guarded to poor prognosis. For stage 3 with no mobility if a client is able to commit to doing homecare then a through supra and subgingival cleaning and polishing, open or closed root planing and insertion of a perioceutic or synthetic bone grafting material will stop the damage that has already occurred.

Homecare for stages 3 and 4 - short term antibiotic therapy and pain medication should be sent home. Oral rinses might be used shortly after surgery until the mouth heals then daily brushing is resumed. Aggressive home care is crucial to keeping the damage in check. The periodontal bacterin might also be an option for more advanced disease cases.

Average surgical time Stage 3 - 1 - 2 hours

Average surgical time Stage 4 - 1 - 3 hours

References

Bellows J. Periodontal equipment, materials, and techniques. In: Small Animal Dental Equipment, Materials, and Techniques: A Primer. Ames: Blackwell Publishing; 2004: 115-173.

Cleland WP Jr. Nonsurgical periodontal therapy. Clin Tech Small Anim Pract. 2000 Nov 15(4): 221-5.

DuPont GA. Prevention of periodontal disease. Vet Clin North Am Small Anim Pract. 1998 Sep; 28(5): 1129-45.

Gorrel C, Derbyshire S. Periodontal disease. In: Veterinary Dentistry for the Nurse and Technician. Edinburgh: Elsevier Butterworth Heinemann; 2005: 69-85.

Gorrel C, Derbyshire S. Preventative dentistry. In: Veterinary Dentistry for the Nurse and Technician. Edinburgh: Elsevier Butterworth Heinemann; 2005: 109-117.

Hale FA. The owner-animal-environment triad in the treatment of canine periodontal disease. J Vet Dent. 2003 Jun 20(2): 118-122.

Harvey CE. Management of periodontal disease: understanding the options. Vet Clin North Am Small Anim Pract. 2005 Jul; 35(4): 819-36.

Holmstrom SE, Bellows J, Colmery B, Conway ML, Knutson K, Vitoux J. AAHA dental care guidelines for dogs and cats. In: J Am Anim Hosp Assoc; 2005, 41.

Holmstrom SE, Frost Fitch P, Eisner ER. Periodontal therapy and surgery. In: Veterinary Dental Techniques for the Small Animal Practitioner, Third Edition. Philadelphia: Saunders; 2004: 233-290.