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A Review of Equine Periodontal Disease

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A Review of Equine Periodontal Disease DENTISTRY, SURGERY, AND LAMENESS A Review of Equine Periodontal Disease David O. Klugh, DVM, FAVD/Equine Efficient examination and characterization of periodontal disease determines the degree of severity of the condition. Once the disease is staged, the practitioner can determine appropriate treatment; accurately prognose; and monitor progress on follow-up examination. Accurate diagnosis is facili- tated in many cases by the use of intraoral radiography. Choice of treatment strategy is based on thorough understanding of anatomy, physiology, pathogenesis, and careful characterization of the disease process. Author’s address: Columbia Equine Hospital, 27841 SE Orient Drive, Gresham, OR 97080; e-mail: [email protected]. © 2006 AAEP. 1. Introduction Periodontal disease is a general term referring to Recognition of periodontal disease and appreciat- the altered state of the periodontium and encom- ing its importance to the equine patient is part of passes both the active and resting states of the dis- good dental care. Systematic examination and ease process. characterization of tissues leads to determination of The anatomy of the gingiva can be further divided 1 severity of disease. Appropriate choice of the vari- by location. Marginal gingiva is the unattached ety of treatment options available to the practitioner terminal edge of the gingiva that surrounds the can only be made if one understands the pathogen- tooth in a collar-like fashion. The gingival sulcus is esis of the disease process. Classification of the the shallow space around the tooth bounded by the stage of the disease process leads to accurate treat- tooth on one side and the gingiva on the other. ment and prognosis and forms a basis for monitoring Attached gingiva is continuous with marginal gin- response to treatment. giva. It is tightly bound to the underlying perios- teum and alveolar bone and extends to the relatively 2. Anatomy loose alveolar mucosa at the mucogingival junction. The periodontium is composed of gingiva, periodon- The interproximal space is occupied by the interden- tal ligament, cementum, and alveolar bone. Gin- tal gingiva. Gingival anatomy is identified in Fig. 2. giva is that part of the oral soft tissue overlying the The normal probing depth of the gingival sulcus of crowns of unerupted teeth and encircling the necks equine teeth varies with location. Incisors, ca- of those that have erupted. Mucosa is the thin, nines, and second premolars have a depth of up to 3 fragile part of the oral soft tissue that is continuous mm. The remaining cheek teeth have probing with the mucous membrane of the cheek, lips, and depths of up to 5 mm. floor of the mouth. The two tissues meet at the Radiographic anatomy of the teeth and supporting mucogingival junction. The anatomy is shown in structures is similar to that of humans and small Fig. 1. Inflammation of the gingiva is gingivitis. animals. Normal structures include the alveolar Periodontitis means the active state of disease. bone, lamina dura, alveolar crest, and periodontal NOTES AAEP PROCEEDINGS ր Vol. 52 ր 2006 551 DENTISTRY, SURGERY, AND LAMENESS mentum is added to the outside of the tooth during eruption.2 Equine cementum is living tissue even above the gingival margin.2 3. Oral Flora The normal oral flora is composed of populations of different bacteria. It is the changes in these popu- lations that constitute the infectious process that becomes gingivitis and periodontitis.3 In the nor- mal state, gram-positive cocci and rods reside on the surface of the tooth. Their populations are signifi- cantly higher than other bacterial types, although other types are present. As gingival infection progresses, the populations change. Extension of the process to attachment loss involving deeper tis- sues is accompanied by significant increases in spi- rochetes and gram-negative anaerobic motile rods Fig. 1. Oral soft tissue surrounds the teeth. Gingiva is identi- and decreases in gram-positive cocci. fied as the smooth, firmly attached tissue adjacent to the tooth. It is important to note that all stages are accom- Mucosa is identified as the loose tissue that is slightly mobile and panied by mixed infections and that most of the lies above the gingiva. Note the folds in the loose mucosa. The same bacteria are present in all stages. There is mucogingival junction separates the two tissues. rarely a single organism responsible for the loss of attachment. The important pathological process is one of population change, which results in sufficient ligament space. Changes can be seen in all these numbers of pathogenic organisms to produce an in- structures. Intraoral radiographs provide visual- flammatory response and degradation of host ization of normal and abnormal conditions. tissues. Important differences exist in the anatomy of teeth and associated structures in horses compared 4. Immune Response with humans and small animals. The interproxi- The fluid produced in the gingival sulcus is called mal contact area between cheek teeth is very large, gingival crevicular fluid.4 It is an inflammatory making the interdental gingiva significantly wider exudate. It contains leukocytes along with bacteria bucco-lingually. There is no cementoenamel junc- and desquamated epithelial cells. Antibodies are tion. The tooth is enveloped by cementum at erup- present as are electrolytes, enzymes, and other or- tion. The teeth are radicular hypsodont, meaning ganic compounds. The amount of fluid produced that root formation occurs as the horse ages and increases with inflammation and mastication. eruption of reserve crown is continuous. New ce- Salivary secretions assist in the defense of the periodontium by mechanically cleansing the oral surfaces; by buffering acids produced by bacteria; and control of bacterial activity through direct enzy- matic and immune system action.5 Antibodies pro- duced within the glands are secreted into the oral cavity and combined with the leukocytic response, providing substantial defense against infectious pro- cesses. Salivary buffers reduce acidity that con- tributes to the decay process and increase pH to inhibit bacterial growth. These characteristics are of critical importance when considering the patho- genesis of periodontal disease in horses. 5. Pathology The event that incites the change in bacterial pop- ulation is decay. In humans and small animals, decay is initiated by the accumulation of plaque and calculus. While plaque and calculus are seen on equine teeth, they rarely lead to periodontitis. The difference in horses is that the triggering event is Fig. 2. Gingival anatomy is identified. The periodontal probe 6–8 is inserted into the gingival sulcus. The tooth borders the gin- stasis of feed material. Feed material decays gival sulcus on one side, whereas the marginal gingiva serves as when it remains lodged in the small depressions the outer border. Located apically, the attached gingiva is se- around and between teeth. Figure 3 shows feed cured to the underlying bone. accumulation in the gingiva. The decay process 552 2006 ր Vol. 52 ր AAEP PROCEEDINGS DENTISTRY, SURGERY, AND LAMENESS Fig. 3. Feed accumulates in the depressions around teeth to Fig. 4. Hooks on upper 6s can result in mesial tipping of the initiate the events leading to periodontal disease. tooth allowing accumulation of feed material between the 6 and 7. causes inflammation of the gingiva and breaks down interproximal space, where feed material can accu- cementum and gingival attachment by the mecha- mulate and decay. nisms well described in other publications.9 The same forces that create orthodontic move- Periodontal attachment loss is a continuation of the ment can also limit normal mesial drift of teeth as same process. Because equine crowns are covered the patient ages. In so doing, interproximal spaces by cementum, its decay becomes part of the patho- are created, especially in older horses, such as in logical process. Cemental decay may proceed both Fig. 5. In geriatrics, these spaces are rarely reduced apically and interproximally. Destruction of bone to normal, because the periodontal mechanism for and other tissues follows. resolving it is compromised by an age-related reduc- The problem of feed stasis and decay is created by tion in function. The elastic trans-septal fibers of contributions from several factors. The concept of the periodontal ligament are partly responsible for range of motion of mastication is impor- mesial drift. Because an increased interproximal tant. Reduced range of motion results in increased space involves a recession of the interdental gingiva, crushing direction of mandibular action. It also in- this compromises the elastic fibers. If compro- volves, either by cause or result, uneven attrition of mised, they cannot function to keep the teeth in occlusal surfaces. The elongated teeth or parts thereof combined with the increased crushing mo- tion cause feed material to be packed into any small depressions that exist in the normal topography of the periodontium. These elongated teeth can also directly abrade the gingiva, thereby opening gingi- val epithelium to direct infection and beginning the cascade of events. A second important concept associated with de- creased range of motion of mastication is that of orthodontic movement of teeth, that is, how teeth move within the arcade. For example, it is well recognized that when rostral hooks (Fig. 4) are present on upper second premolars (6s in the Tri- adan system), these teeth occasionally are tipped in a mesial direction by forces of mastication. This movement can result in the creation of widened in- terproximal spaces. Reduction of this malocclusion often results in closure of the interproximal space. Orthodontic movement can be seen in other teeth as Fig. 5. The teeth in a geriatric horse are not able to return to well. As overlong teeth develop, abnormal masti- normal once large interproximal spaces develop. Abnormal in- cation forces result. These abnormal forces can terproximal wear, loss of elastic trasseptal fibers, reduced erup- cause movement of either of the occlusal pair of tion potential, and age-related reduction in physiologic function teeth.
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