Go one step beyond in veterinary dental care

In most communities, the standard of care in companion animal dentistry has transformed into performing diagnostics and providing needed care in anesthetized, intubated patients. This gives us the best opportunity to conduct tooth-by-tooth examinations with probes and intraoral radiographs and remove plaque and tartar on the teeth above and below the gum line.

Thanks to this ability, we can diagnose and help more dogs and cats live happier lives. Fortunately industry has helped our efforts by providing evidence-based effective products. If your practice is not doing it already, now is the time to adopt just one more step in each of the assessment, treatment and prevention (ATP) sections of the oral visit.

Extra assessment step: Thiol diagnostics

Wouldn't it be helpful if a client could see clear-cut proof that his or her awake dog or cat on the examination table has gingivitis or periodontitis necessitating additional care? Taking one more step using diagnostic strips to test for thiols (OraStrip-Virbac) can accomplish this.

In essence, the strip is a visual representation of halitosis secondary to periodontal infection that leads to irreversible tissue and bone destruction. The darker the yellow  color reaction, the higher the concentration of thiols, which is directly related to the severity of periodontal infection.1 What does a positive result mean when the patient does not appear to have excessive plaque or tartar on the teeth? It means disease is present below the gum line. It's a call to action to find out where the elevated concentrations are coming from, whether a periodontal or an endodontic abscess hidden from the naked eye or a periodontal pocket somewhere you can't see. Either way, diagnosing and treating the cause of an abnormal thiol concentration results in your patient's breath and its health improving (Figure 1).

Figure 1. A Maltese with an elevated thiol concentration without a visual reason until tooth-by-tooth examination revealed a plaque and tartar accumulating subgingival enamel defect, which was restored: A: Molly; B: OraStrip score; C: upper incisors bleeding on probing; D: right upper canine before teeth cleaning; E: right upper canine after teeth cleaning with enamel defect; F: right upper canine after bonding. (Photos courtesy of Dr. Jan Bellows)

What happens if the strip's pad remains white, indicating the absence of thiols? It may not be time for dental scaling because even though there may be plaque and tartar present, the host has not responded with significant gingivitis or periodontitis. Routinely using the strip in all wellness examinations allows the veterinarian to better determine when anesthesia is needed for thorough oral assessment and treatment-when the bacteria have changed from good to bad (Figure 2).

Figure 2. An OraStrip used during a cat's wellness examination.

To use a strip in the exam room, you just have to:

• Open the package.

• Flip the patient's lips.

• Rub the strip from the last maxillary molar to the canine just below the marginal gingiva (where the tooth meets the gingiva) to sample the sulcular fluid (not the saliva) (Figure 3).

• Explain to your client that the yellow pad result means the patient has a periodontal infection due to anaerobic bacteria trapped under the gum line. Then you can explain that if not treated and prevented, progressive periodontal disease and worse can occur.

Figure 3. The proper location of the OraStrip at the gingival margin.

The strip is also effective as a sentinel monitor to see how the patient is doing after the procedure, thanks to removal of periodontal pathogens and tailored prevention. This is easily accomplished by including an OraStrip bundle, including once-monthly strip rechecks, after the oral ATP visit.

Extra treatment step: Local application of antimicrobials

Once you've diagnosed the stage of periodontal disease, it's time to create a treatment plan. Stage 4 advanced periodontal disease treatment is easy-extract the tooth or teeth. Treatment decisions appropriate for pets with stages 1 to 3 periodontal disease can be challenging depending on the client's ability to provide preventive plaque control and the patient's willingness to accept it.

There are two nonsystemic locally applied antimicrobial products approved for use in the oral cavity for treating pets with stage 1 to 3 periodontal disease with mild to moderate pockets-Clindoral (TriLogic Pharma) for dogs and cats and Doxirobe Gel (Zoetis) for dogs only.2,3

Clindoral is a periodontal pocket filler containing 2% clindamycin hydrochloride in a biodegrading, muco-adhesive gel matrix that releases clindamycin over seven to 10 days after a single application. As the product warms to body temperature, it increases in viscosity two- to threefold to form a soft pliable matrix the consistency of a thick jam.

Doxirobe Gel is provided in a two-syringe system requiring mixing before use. Syringe A contains the polymer delivery system-N-methyl-2-pyrrolidone and poly (DL-lactide). Syringe B contains the active ingredient-doxycycline hyclate. Once mixed, the product is a flowable solution equivalent to 8.5% doxycycline activity. The formulation is applied subgingivally to the periodontal pockets of affected teeth, and doxycycline is slowly released from the polymer providing a local antimicrobial effect particularly toward gram-negative anaerobic bacteria involved in periodontal disease. The product is nonirritating and biodegradable.

A few application pointers:

• Both products are supplied in 0.5-ml syringes with 0.25-ga blunt-nosed cannulas.

• Both products are applied subgingivally to the periodontal pockets of affected teeth, achieving slow release from their polymer matrix and providing a local antimicrobial effect. Clindoral forms a soft pliable matrix that conforms to the pocket and stays in place because of its bioadhesive properties. Doxirobe forms a hard matrix that stays in place via mechanical force.

• Clindoral works best in dried tissue (either by forced air or gauze), whereas Doxirobe often requires additional liquids to make it set up after application.

• Clindoral can be stored and reused as long as it is recapped until the expiration date of the product. Doxirobe not used on the day of mixing should be stored in its resealable foil pouch and used within three days of reconstitution.

• Although Clindoral thickens at body temperature, it remains a pliable matrix that forms to the shape of the sulcus or pocket.

Doxirobe is liberally applied in the sulcus to create a wedge-like effect to hold it in place. Because of Clindoral's pliable matrix, you can apply it in sulci where bleeding on probing exists. In our practice we commonly use Clindoral to help decrease the cause of bleeding and return the gingiva to normal (Figures 4-6).

Figure 4. A right maxillary canine bleeding on probing.

Figure 5. Drying the sulcus with an air/water syringe.

Figure 6. Application of Clindoral into the pocket.

Neither product takes the place of thorough teeth cleaning and pocket débridement or periodontal surgery. But both have proven to be effective in decreasing pocket depth, which is one of our major goals of periodontal care.

Extra preventive step: Sealant application

The 2013 AAHA Dental Care Guidelines offer clear recommendations to decrease plaque accumulation in both dogs and cats, including the application of antiplaque substances such as fluoride and barriers. Barrier products typically bind to the surfaces of teeth. A barrier gel system, OraVet (Merial), is positioned to reduce plaque formation in companion animals.4,5 The professional product is applied as a last step before the pet awakens from anesthesia.

In human dentistry, sealants prevent caries, or cavities. They are applied to the chewing surfaces of the back teeth (premolars and molars) where decay most often occurs. Sealants protect these vulnerable areas by bonding to the enamel, sealing out plaque and bacteria produced acids. As long as the sealant remains intact, the tooth surface is protected from decay. Sealants hold up well under the force of normal chewing and may last several years in humans before a reapplication is needed.

Dogs and cats are rarely affected by caries and are not protected with the same sealants as used in human dentistry. There are two veterinary approved products: OraVet and Sanos (AllAccem). Both are applied into the sulcus to help prevent the accumulation of plaque (Figures 7 and 8).

Figure 7. OraVet applied in an anesthetized cat.

Figure 8. A polishing angle used to place OraVet into the sulcus.

After application, OraVet is recommended to be applied to the marginal gingiva weekly (Figure 9).

Figure 9. Demonstrating home application of OraVet.

Sanos, a Veterinary Oral Health Council-accepted product, is applied after the teeth cleaning and irrigation to the dried sulcus while the dog or cat is still anesthetized. It has been shown to be effective at least six months (Figure 10).6

Figure 10. Sanos application into the left mandibular second premolar sulcus.

References

1. Manfra Marretta S, Leesman M, Burgess-Cassler A, et al. Pilot evaluation of a novel test strip for the assessment of dissolved thiol levels, as an indicator of canine gingival health and periodontal status. Can Vet J 2012;53(12):1260-1265. 

2.Johnston TP, Mondal P, Pal D, et al. Canine periodontal disease control using a clindamycin hydrochloride gel. J Vet Dent 2011;28(4):224-229.

3.Zetner K, Rothmueller G. Treatment of periodontal pockets with doxycycline in beagles. Vet Ther 2002;3(4):441-452. 

4. Gengler WR, Kunkle BN, Romano D, et al. Evaluation of a barrier dental sealant in dogs. J Vet Dent 2005;22(3):157-159.

5.Bellows J, Carithers DS, Gross SJ. Efficacy of a barrier gel for reducing the development of plaque, calculus, and gingivitis in cats. J Vet Dent 2012;29(2):89-94.

6.Sitzman C. Evaluation of a hydrophilic gingival dental sealant in beagle dogs. J Vet Dent 2013;30(3):150-155.