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Advanced Periodontal Therapy for Veterinarians and Technicians Benita Altier, LVT, VTS (Dentistry) Pawsitive Dental Education Prosser, WA

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Advanced Periodontal Therapy for Veterinarians and Technicians Benita Altier, LVT, VTS (Dentistry) Pawsitive Dental Education Prosser, WA Advanced Periodontal Therapy for Veterinarians and Technicians Benita Altier, LVT, VTS (Dentistry) Pawsitive Dental Education Prosser, WA As veterinary practices have become more modern, sophisticated and technologically advanced, so has our ability to perform veterinary dentistry to a much higher level than was ever thought possible. Through specialization of the profession and a wider availability of these specialists, we are able to offer our clients’ referrals for more advanced care to board certified veterinary dentists. As veterinary technicians and veterinarians we need to be completely aware of what kinds of dental care and treatments are available, and when to offer a referral instead of opting for more basic dental care in hospital. The primary concern that we often see in dogs and cats is periodontal disease; however if teeth can be salvaged instead of extracted through periodontal surgical techniques and home care, then through these treatments we could benefit the patient over the long term, to retain important teeth for their function. Dental radiographs Radiographs must be obtained to fully assess the extent of any suspected bone loss. Evaluation of a full set of intraoral dental radiographs will help determine the success of any proposed advanced dental procedure, as well as give the veterinarian a baseline to monitor the progress of treatment. If your veterinary practice does not have the ability to obtain those dental radiographs and the client is interested in advanced dental care and saving teeth rather than extraction, then considering referral from the onset may be in the best interest of the patient. Advanced periodontal therapy Larger and more important teeth can be difficult to extract even with significant periodontal disease, which can result in horizontal or vertical bone loss, furcation bone loss and tooth mobility due to loss of attachment. When we look at teeth through clinical observations and measurements as well as radiographically, we must assess the true extent of the pathology. A tooth can be evaluated on a root by root basis as well as an individual side of each tooth root. A tooth with significant bone loss (>50%) on a tooth root’s surface may have a very poor prognosis even with advanced periodontal surgery, especially if the bone loss is all the way around the root or what is called a four-walled defect.1, 3 The area in between a multi-rooted tooth’s roots is called a furcation and if the bone is lost from this area it reduces the success of an advanced procedure even further.1, 3 Total attachment loss This is the sum of the measurement of any gingival recession on the root’s surface, as well as any pocket depth beyond that gingival recession. If gingival recession is not present then it is just the measurement of any periodontal pocket depth beyond what may be considered to be a normal sulcular depth for that specific tooth, in that specific pet’s mouth. This differs depending on the size of the animal, size of the tooth and length of the tooth root specifically. In order to measure total attachment loss you must use a periodontal probe with clearly marked 1mm increments and measure from the marginal gingival edge to the bottom of the sulcus or periodontal pocket if there is attachment lost.1, 3 The bottom of the sulcus is normally attached to the tooth’s surface at or very near to the cementoenamel junction (CEJ).1 When attachment is lost at this point a periodontal pocket is created and a pathological process begins. The periodontal probe should be used with a gentle hand, in line with the vertical axis of the tooth and walked around the tooth’s structure recording measurements in at least four places around each tooth root. Whenever these measurements are greater than what would be considered a normal sulcular depth around that particular tooth, the measurement should be recorded on the patient’s dental chart.1 Conditions such as gingival enlargements further diagnosed by histopathology as gingival hyperplasia, can create a false pocket depth and not true attachment loss so careful measurement of the excess gingival tissue and noting if the bottom of the sulcus is at the CEJ is important to determining the extent of attachment on these teeth.1 If the bone loss or total attachment loss is <50% and there is not significant furcation involvement, or less than a four walled defect, it may be possible for advanced periodontal surgical techniques, frequent follow up care (possibly under anesthesia) and daily homecare which is a commitment that the client must make when attempting to “save” important or strategic teeth. If a periodontal pocket depth exceeds 5mm, it is recommended that open root planing: RP/O (root planing-open) be performed with the use of flap surgery to facilitate the visualization of the bony defect and exposed root surface and allows the practitioner to treat the area to the best of their ability to get the best possible outcome from periodontal therapy.1 If the periodontal pocket depth is less than 5mm, root planing-closed can be performed (RP/C). This technique involves the use of a hand curette instrument below the gingival margin, adapted to the surface of the root that requires cleaning. Using the sharp blade of the curette, we want to carefully remove the bacterial laden debris from the cementum of the root surface. Thus improving the health of the local periodontal tissues and smoothing the rough root surfaces allowing the re-attachment of the periodontal ligament as possible. 820 The use of any curette involves four basic steps: 1. Holding the curette in a modified pen grasp, create a fulcrum by placing your ring finger near the tooth area to be instrumented but not in the “line of fire” to avoid the blade cutting your finger. 2. Insert the curette with the face of the blade in the “closed position” face towards the tooth root, this allows for adaption of the curette beyond the calculus below the gingival margin. 3. Rock blade handle so as to bring the terminal shank into a parallel position to the root, thus engaging the sharp edge of the blade into the root surface. 4. Working stroke: pull the instrument in either a vertical direction towards the crown tip, oblique direction across the crown or horizontal direction. 5. Readapt and repeat the motions in overlapping strokes to ensure the cementum of the root is free from bacterial laden debris and smooth to the touch of the instrument. Periodontal bactericidal ultrasonic debridement The final step in ultrasonic cleaning. A specially made periodontal tip insert is required for this procedure or some dental ultrasonic units are already equipped with a tip that can be safely inserted sub-gingivally. Please consult your ultrasonic equipment manual regarding which tips are safe to insert under the gum line into the sulcus, and at what setting the machine should be turned down to, reducing the frequency of vibrations to a safe level for this purpose. Periodontal bactericidal ultrasonic debridement occurs due to the ultrasonic sound waves causing microscopic bubbles to form and then implode in the gingival sulcus, cavitation. These implosions can cause the bacterial cell walls to be disrupted and along with the water rinsing through the area at a certain pressure further reduces the concentration of bacteria within the space.1 Advanced periodontal flap surgeries Techniques to perform flap surgeries are fully described in several dental text books and can be learned by veterinarians at wet labs taught by veterinary dentists on the subject, however if surgical procedures are indicated that are beyond the practitioner’s skill level then referral may be the preferred option. Apically repositioned flap This technique can be used to help attached gingiva lay over any remaining alveolar bone, it requires that there is at least 2mm of gingiva to extend towards the crown.1 This surgery moves the gingiva down onto the root surface after the area is cleaned of unhealthy bone, granulation tissue and debris; and then the area is allowed to heal.2 This procedure can be performed on mandibular incisors to allow for a reduction in periodontal pocket depths, allow for daily cleaning by the client and to allow easier cleaning of areas of furcation exposure on multi-rooted teeth.2 Contraindications for this procedure would be >50% bone loss especially on a four-walled defect, grade three (3) tooth mobility and the presence of less than 2mm of attached gingiva before surgery.1 Laterally positioned (pedicle) flap Indications When the root surface of a single tooth is exposed significantly due to a cleft that extends to or near the mucogingival line.1 Contraindications Tooth mobility due to loss of bone on more than one wall of the alveolar socket, furcation bone loss or lack of commitment on the client’s part for daily homecare and more frequent follow up professional dental care.1 Carefully created and planned vertical releasing incisions, and the creation of a donor flap which is moved laterally over the area and sutured, is required for this technique.1 The goal is to partially cover this exposed root surface and allow for at least 2mm of attached gingiva to help preserve the health of this particular tooth, the area of tissue that is exposed from the donor site will heal in by second intention.1, 3 Free gingival graft Indicated in specific individual teeth with a cleft like defect that are free of endodontic disease and tooth mobility is not present.3 Contraindicated if endodontic disease is the cause and endodontic disease
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