Proper Periodontal Care Good For Patient, Practice

By Brook Niemiec, DVM, Dipl. AVDC

Introduction

Periodontal disease is a very common problem in veterinary patients. It has numerous severe local and systemic ramifications, but outward clinical signs occur only very late in the disease course. This means that it is significantly underdiagnosed, and even when recognized and treatment is recommended, clients can be reluctant to comply as they do not perceive the significance of the problem.

Regardless, proper and prompt therapy of periodontal disease is beneficial for the health of the patient as well as financially for the practice.

Incidence and Pathogenesis

Periodontal disease is the No. 1 diagnosed medical problem in small animal veterinary patients. In fact, by 2 years of age, 80 percent of dogs and 70 percent of cats have some form of periodontal disease.¹ Small and toy breed dogs are particularly susceptible.

As shocking as these numbers are, they likely underestimate the true incidence of disease. This is because they are based on the diagnosis of gingivitis via a color change (inflammation) of the gingiva, or “marginal gingivitis.”

While erythema and edema of the gingiva are reliable signs of disease, it is now known that increased gingival bleeding on probing or brushing occurs first.^2,3 Practical tip: Consider carefully probing or brushing tractable teeth on conscious exam to demonstrate the level of inflammation (See Photo 1).

In addition, ask clients about a history of bleeding during brushing or after chewing hard/rough toys. If this is present, a diagnosis of early gingivitis can be made despite a lack of gingival color change. 

It is true that periodontal disease is typically associated with calculus, but it is primarily elicited by plaque and can thus be seen in the absence of calculus.⁴ Conversely, widespread supragingival calculus may be present with little to no periodontal disease. It is critical to remember that calculus acts as an irritant, but is in and of itself essentially non-pathogenic.^5,6

Therefore, the degree of gingival inflammation—not calculus—should be used to judge the need for professional therapy. However, even the degree of gingival inflammation is inadequate to diagnose, as it often underestimates the severity of periodontal disease.

Consequences

The negative effect of periodontal disease on the overall health of our patients cannot be understated.

On a local and regional level, periodontal disease can cause oronasal fistulas, tooth root abscesses, eye infection and even loss, an increased incidence of oral cancer, osteomyelitis, and pathologic fractures.⁷

Systemically, it has been shown to negatively affect numerous critical organs such as the heart, liver, kidney, and lung.^8-12 In addition, it has been shown to increase diabetic complications, create adverse pregnancy effects and cause an increase in some systemic malignancies.^13-18

Finally, it has been linked to early mortality.^19,20

Photo 2: Deep periodontal pocket on the mandibular first molar of a dog despite relatively normal appearing gingiva. This could not have been diagnosed without anesthesia and a periodontal probe.

Conversely, proper oral therapy has been shown to improve renal and cardiac function, as well as glycemic control.^21-25 These dire consequences and the benefits of proper therapy should be utilized to improve client compliance with treatment recommendations. Please visit www.dogbeachdentistry.com or client educational videos on periodontal disease and therapy.

Proper Diagnosis

Significant gingivitis can exist without periodontal pockets, and conversely, deep periodontal pockets without significant gingival inflammation (See Photo 2). Periodontal pockets cannot be accurately diagnosed without a periodontal probe.^26,27

The normal sulcal depth in dogs is 0-3 mm, and in cats is 0-0.5 mm.^28,29 This is not common knowledge in most veterinary hospitals. Therefore, a color-coded probe.^A has been developed with the various depths marked in different colors (See Photo 3). It allows users of any level of expertise to quickly and easily diagnose periodontal pockets.

An additional exam room diagnostic tool is a periodontal diagnostic strip.^B OraStrip QuickCheck Canine measures the production of thiols, which are produced by periodontal pathogens. A quick swipe of the maxillary gingival margin will reveal visual evidence of the severity of periodontal infection, improving compliance with dental recommendations. 

While this product is a valuable tool for any patient, there are several presentations in which it is particularly valuable. This includes the patients with significant periodontal disease despite a lack of gingival inflammation or significant calculus and also those with dark pigmented gingiva. 

Photo 3: The color coded Niemiec probe. All Photos Courtesy of Dr. Brook Niemiec

Finally, small and toy breed dogs quite often have severe disease involving the molars while the rest of the mouth is fairly healthy. Moreover, these teeth are typically difficult or impossible to evaluate on conscious oral exam, but infection would be demonstrated on the test strip.

Proper Therapy
The basis of periodontal therapy is plaque control. This is best accomplished with a combination of a professional dental cleaning and consistent homecare. However, it must be stressed that the teeth must be completely cleaned to eradicate the infection. Therefore, proper cleaning requires hands-on training and proper equipment.

If dental care is initiated before the initiation of periodontal disease, a complete dental prophylaxis and homecare is all that is required. However, the vast majority of canine patients receiving dental cleanings will have established periodontal disease (pockets greater than 3 mm). These pathogenic pockets need additional treatment to rid the root surface of the pathogenic plaque.

In dogs, pockets between 3 and 5 mm which are not associated with tooth mobility or furcation exposure are best treated with scaling and closed root planing.^30,31 In addition, local anti-microbial administration has been shown to decrease bacterial counts further than SRP alone.³² They are effective in decreasing periodontal inflammation and increasing attachment gains. These simple techniques are commonly necessary and should be learned by the veterinary staff and charged for when utilized.

However, pockets deeper than 5 mm and/or those associated with other pathology (especially furcation level II and III exposure) will not be effectively cleaned without direct root visualization.^33-35 Root visualization is best afforded by periodontal flap surgery.³⁶

Therefore, interested clients should be referred to a local veterinary dentist for these tooth-saving surgeries. These procedures are technique sensitive, but can be learned by the general practitioner. If the client is unwilling to consider periodontal surgery or the tooth is unsalvageable, extraction is the best therapy. 

For a list of classes of periodontal disease, therapy, and surgery, or extraction and radiology techniques, please visit www.vetdentaltraining.com.

Conclusion

Periodontal disease is a very common but misunderstood disease process, which can have many severe ramifications locally and systemically within the body. Utilizing the tools and information provided in this article will aid clinicians in diagnosing and treating this common but significant disease process. 

This Education Series story was underwritten by PDX BioTech of Lexington, Ky.

REFERENCES
A. Niemiec periodontal Probe®: Dentalaire Products, Fountain Valley CA.
B.Orastrip: PDX diagnostics.

FOOTNOTES
1. Wiggs RB, Lobprise HB: Periodontology, in Veterinary Dentistry, Principals and Practice: Philadelphia, PA, Lippincott – Raven. 1997: pp 186-231

2. Fiorellini JP, Ishikawa SO, Kim DM: Clinical Features of Gingivitis, in: Carranza’s Clinical Periodontology. St. Louis, Mo, WB Saunders, 2006, pp 362- 72.

3. Meitner SW, Zander H, Iker HP, et al: Identification of inflamed gingival surfaces. J Clin Periodontol. 6:93, 1979.

4. Hinrichs JE: The role of dental calculus and other predisposing factors, in: Carranza’s Clinical Periodontology. St. Louis, Mo, WB Saunders, 2006, pp 170-192.

5. Wiggs RB, Lobprise HB: Periodontology, in Veterinary Dentistry, Principals and Practice: Philadelphia, PA, Lippincott – Raven. 1997: pp 186-231.

6. Niemiec BA. Periodontal disease. Top Companion Anim Med.23 (2):72-80, 2008.

7. Niemiec BA. Periodontal disease. Top Companion Anim Med.23 (2):72-80, 2008.

8. Glickman LT, Glickman NW, Moore GE, Goldstein GS, Lewis HB. Evaluation of the risk of endocarditis and other cardiovascular events on the basis of the severity of periodontal disease in dogs. J Am Vet Med Assoc. 234(4):486-94, 2009.

9. Mercanoglu F, Oflaz H, Oz O, et al: Endothelial dysfunction in patients with chronic periodontitis and its improvement after initial periodontal therapy. J Periodontol. 75(12):1694-700, 2004.

10. Hayes C, Sparrow D, Cohen M, Et Al. The association between alveolar bone loss and pulmonary function: the VA Dental longitudinal study. Ann Periodontol 3: 257, 1998.

11. Pavlica Z, Petelin M, Juntes P, et al: Periodontal disease burden and pathological  changes in the organs of dogs. J Vet Dent 25 (2), 97-108, 2008.

12. Debowes LJ, Mosier D, Logan E, Harver CE, Lowry S, Richardson DC: Association of periodontal disease and histologic lesions in multiple organs from 45 dogs. J Vet Dent 13(2): 57-60, 1996.

13. Nishimura F, Soga Y, Iwamoto Y, Kudo C, Murayama Y. Periodontal disease as part of the insulin resistance syndrome in diabetic patients. J Int Acad Periodontol. 2005 Jan;7(1):16-20.

14. Hujoel PP, Drangsholt M, Spiekerman C, Weiss NS. An exploration of the periodontitis-cancer association. Ann Epidemiol. 2003;13:312–316.

15. Michaud DS, Liu Y, Meyer M, Giovannucci E, Joshipura K.Periodontal disease, tooth loss, and cancer risk in male health professionals: a prospective cohort study. Lancet Oncol. 9(6):550-8, 2008.

16. Lopez NJ, Smith PC, Gutiererrez J. Higher risk of preterm birth and low birth rate in women with periodontal disease. J Dent Res 81:58, 2002.

17. Offenbacher S, Katz V, Fertik G, et al: Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol. 67:1103-13, 1996.

18. Nagata T. Relationhip between diabetes and periodontal disease Clin Calcium.19(9):1291-8, 2009.

19. Avlund K, Schultz-Larsen K, Krustrup U, Effect of inflammation in the periodontium in early old age on mortality at 21-year follow-up. J Am Geriatr Soc. 57(7):1206-12, 2009.

20. Holm-Pedersen P, Schultz-Larsen K, Christiansen N, Avlund K. Tooth loss and subsequent disability and mortality in old age J Am Geriatr Soc. 56(3):429-35, 2008.

21. Tervonen T, Knuuttila M. Relation of diabetes control to periodontal pocketing and alveolar bone level. Oral Surg Oral Med Oral Pathol 1986;61:346-9.

22.  Tsai C, Hayes C, Taylor GW. Glycemic control of type 2 diabetes and severe periodontal disease in US adult population. Community Dent Oral Epidemiol 2002;30:182-92.

23. Artese HP, Sousa CO, Luiz RR, Sansone C, Torres MC.Effect of non-surgical periodontal treatment on chronic kidney disease patients. Braz Oral Res.24(4):449-54, 2010.

24. Graziani F, Cei S, La Ferla F, Vano M, Gabriele M, Tonetti M. Effects of non-surgical periodontal therapy on the glomerular filtration rate of the kidney: an exploratory trial. J Clin Periodontol.37(7): 638-43. 2010.

25.  Mercanoglu F, Oflaz H, Oz O, et al: Endothelial dysfunction in patients with chronic periodontitis and its improvement after initial periodontal therapy. J Periodontol. 75(12):1694-700, 2004.

26. Carranza FA, Takei HH: Clinical diagnosis, in Carranza’s Clinical Periodontology. St. Louis, Mo, WB Saunders, 2006, pp 540-60.

27. Niemiec BA: Veterinary dental radiology. In: Small Animal dental, oral and maxillofacial disease, A color handbook (Niemiec BA ed.). London, Manson, 2010, pp 63-87.

28. Wiggs RB, Lobprise HB: Oral exam and diagnosis, in Veterinary Dentistry, Principals and Practice.  Philadelphia, PA, Lippincott – Raven, 1997, pp 87-103.

29. Debowes LJ: Problems with the gingiva.In: Small Animal dental, oral and maxillofacial disease, A color handbook (Niemiec BA ed.). London, Manson, 2010, pp159 – 181.

30. Pattison AM, Pattison GL: Scaling and root planing, in Carranza’s Clinical Periodontology. St. Louis, Mo, WB Saunders, 2006, pp 749-97

31. Wiggs RB, Lobprise HB: Periodontology, in Veterinary Dentistry, Principals and Practice.  Philadelphia, PA, Lippincott – Raven, 1997, pp 186-231

32. Goodson, JM. Antimicrobial Efficacy of Arestin in Periodontitis Therapy. Presented at the
35th Annual Meeting of the American Association for Dental Research; March 8-11, 2006; Orlando, FL.

33. Carranza FA, Takei HH: Phase II periodontal therapy, in Carranza’s Clinical Periodontology. St. Louis, Mo, WB Saunders, 2006, pp 881-6

34. Perry DA, Schmid MO, Takei HH: Phase I periodontal therapy, in: Carranza’s Clinical Periodontology. St. Louis, Mo, WB Saunders, pp 722-7, 2006.

35. Wiggs RB, Lobprise HB: Periodontology, in Veterinary Dentistry, Principals and Practice.  Philadelphia, PA, Lippincott – Raven, 1997, pp 186-231.

36. Wiggs RB, Lobprise HB: Periodontology, in Veterinary Dentistry, Principals and Practice.  Philadelphia, PA, Lippincott – Raven, 1997, pp 186-231