Fix the fixable: Treating periodontal and orthodontic disease

In veterinary medicine, many axioms stick in your mind: Old age is not a disease. All bleeding will eventually stop. Cancer affects the young and the old. And, as Dr. Michael Schaer at the Animal Medical Center drilled into our souls in the mid 1970s-treat the treatable.

This is the third in a series on deciding which teeth can and should be extracted, which should be fixed (i.e. treated) and which only require monitoring when affected by oral pathology. In this installment, we will explore treatment for periodontal and orthodontic diseases. 

Before you attempt either periodontal or orthodontic care, carefully consider the patient as well as pet owner who will accept the care and provide preventive steps to control recurrence. 

Fixing the periodontium

The periodontium includes dynamic tissues that surround and support the tooth, including the root covering (cementum), the attachment of the tooth to the alveolar socket (the periodontal ligament), the bone of the alveolar process, and the gingiva. 

Infection and inflammation of these tissues can result in swelling, pain, bleeding, tooth mobility and tooth loss. Once diagnosed, many periodontal diseases can be treated and controlled to eliminate bleeding, pain and disease progression. 

Gingivitis. Periodontal disease starts with plaque. Daily plaque biofilm accumulates on the teeth, especially over the maxillary cheek teeth, which are bathed with saliva. If the biofilm is left undisturbed, minerals in saliva convert the plaque to rough calculus, attracting more plaque, which inflames the gingiva in many dogs and cats. 

Once plaque, calculus and gingivitis are apparent, dental scaling, irrigation and polishing are indicated for treatment. Application of dental sealants and daily use of VOHC-accepted products help to reverse the gingival inflammation (Figures 1A-1D). 

Figure 1A. Marginal gingivitis secondary to plaque-covered calculus. (Photos courtesy of Dr. Jan Bellows)

Figure 1B. Ultrasonic scaling to remove the plaque and calculus.

Figure 1C. Polishing with fine pumice.

Figure 1D. One week later, the gingivitis has resolved.

Early periodontal disease. If gingivitis is left untreated, early periodontal disease (less than 25 percent support loss) often occurs. Treatment in cases of early periodontal disease without pocketing involves cleaning, irrigation and polishing-the same as for gingivitis. Local antimicrobial administration of clindamycin hydrochloride (Clindoral-Trilogic Pharm) or doxycycline hyclate (Doxirobe-Zoetis) is indicated in teeth affected by early periodontal disease with pocketing (Figures 2A and 2B).

Figure 2A. Bleeding on probing and 4-mm probing depth consistent with early periodontal disease.

Figure 2B. Application of clindamycin gel.

Moderate periodontal disease. Moderate periodontal disease is diagnosed when 25 to 50 percent of the tooth support is lost. Advanced dental procedures including mucogingival surgery and strict daily or, even better, twice-daily home care are usually needed to save the teeth from further disease progression. Although any veterinarian is licensed to perform these advanced procedures, only someone who understands the anatomy and physiology and has the proper training and equipment should provide them. 

Treatment includes open flap exposure for cleaning and débridement to expose tooth roots where the periodontal pocket extends greater than 5 mm. Apical reposition surgery can be used in pockets greater than 5 mm to decrease pocket depths. In cases of advanced gingival recession, lateral repositioned flaps may be used to repair the defect and save teeth (Figures 3A-3C).

Figure 3A. A tooth with gingival recession and no abnormal probing depth.

Figure 3B. Lateral sliding flap surgery to treat the recession.

Figure 3C. One-year postoperative appearance of the tooth; the recession has been eliminated.

Advanced periodontal disease. Teeth affected with advanced periodontal disease where greater than 50 percent support is lost can often be saved when three-walled infrabony pockets are present that can be cleaned followed by placement of bone graft material and stringent aftercare (Figures 4A-4C). 

Figure 4A. Bone graft material (Periomix-Veterinary Transplant Services) placed in an intrabony defect affecting the distal root of a mandibular first molar.

Figure 4B. The filled defect prior to membrane placement.

Figure 4C. The sutured flap.

Gingival enlargement. Some dogs (especially boxers and springer spaniels) and, rarely, cats develop enlarged gingival tissues, which can create a false pocket extending coronally. This pseudopocket traps food and oral debris similarly to probing depth pockets seen in early, moderate and advanced periodontal diseases. This condition, commonly called gingival hyperplasia, is a histologic diagnosis. Clinically what we can see is gingival enlargement. 

Fixing the teeth affected by gingival enlargement involves removing the pseudopocket. In most cases, a gingivectomy can be done with a scalpel, a laser, or both. Active daily plaque control aftercare is critical in these cases in that some researchers think the gingival enlargement is secondary to the inflammation caused by plaque (Figures 5A and 5B). 

Figure 5A. Maxillary gingival enlargement in a boxer.

Figure 5B. The appearance two weeks after scalpel and laser-assisted gingivectomy.

Fixing oral cavity trauma from malpositioned teeth

When some pet owners hear that veterinary dentists place braces on dogs' teeth, they are amazed. Once they understand that we do not place orthodontic appliances to give pets a pretty smile but to move malpositioned teeth to functional positions, it make sense to fix these hurting mouths. (See AKC regulations for canine orthodontics.)

Dental malposition. Occasionally only one or two teeth are out of place, causing a nonfunctional bite even though the maxillae and mandibles line up properly. The offending teeth can often be fixed using orthodontic appliances to achieve movement. Examples include rostral crossbite, where one or more mandibular incisor teeth lie in front of their maxillary counterparts (Figures 6A-6C); rostrally (mesially) deviated canines (Figures 7A-7C); and the effects of retained deciduous teeth pushing the maxillary canine teeth rostrally and the mandibular canines lingually (Figures 8A-8D).

Figure 6A. A rostral crossbite where the mandibular right and left first and second incisors are positioned mesial (rostral) to their maxillary counterparts.

Figure 6B. An arch bar with elastics to move the right third and left first and second incisors rostrally.

Figure 6C. Normal occlusion achieved, creating an excellent long-term prognosis.

Figure 7A. Rostral deviation (mesioversion) of the left maxillary canine causing labioversion of the mandibular canine.

Figure 7B. An orthodontic button, elastics and a bite block were used to move the maxillary canine caudally, relieving pressure on the mandibular canine to return to normal position.

Figure 7C. Functional occlusion established within three months.

Figures 8A and 8B. Right and left maxillae displaying retained deciduous canines pushing the adult canines forward, decreasing space for the mandibular canines.

Figures 8C and 8D. After four months of orthodontic care, including orthodontic buttons and elastics, occlusion returned to a functional state.

Skeletal malocclusion. When there is mandibular mesioclusion (underbite) or distoclusion (overbite), often the canines and incisors interfere with the lips or gingiva. Reducing the crown height of the offending canine or canines, performing vital pulp therapy and restoring the teeth with light cured composite can help alleviate this condition (Figures 9A-9D). 

Figures 9A and 9B. Mandibular mesioclusion (underbite) in a cat, resulting in the mandibular canines and incisors exposed to the environment.

Figures 9C and 9D. Crown reduction, vital pulp therapy and restoration resulted in elimination of the exposure.

Conclusion

The ultimate goal of dental treatment is to return our patients to pain-free function. Fortunately, the oral cavity is most forgiving and generally heals well once the cause is fixed. The next installment of this series will cover fixing oral trauma and neoplasia. 

Dr. Jan Bellows owns All Pets Dental in Weston, Florida. 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; email: dentalvet@aol.com.