Periodontal Disease
Periodontal disease is inflammation of some or all of the tooth’s support structures (gingiva, cementum, periodontal ligament, and alveolar bone). When compared to gingivitis, periodontitis indicates bone loss.
Periodontal disease is caused by bacteria. Initially a pellicle forms on the clean tooth. This pellicle attracts aerobic gram positive bacteria (mostly actinomyces and strepococci). Soon more bacteria adhere forming plaque. With in days the plaque thickens, underlying bacteria run out of oxygen and anaerobic motile rods and spirochetes begin to populate the subgingival area. Endotoxins released by the anaerobic bacteria cause tissue destruction and bone loss.
Microscopic lesions have been found affecting dog’s livers, kidneys, and brains in some animals with periodontal disease.
Dogs and cats from six months on may be affected.
Click here, or see the bottom, for pictures.
| Grade 1 |
Inflammation |
| Grade 2 |
Inflammation, edema, gingival bleeding upon probing |
| Grade 3 |
Inflammation, edema, gingival bleeding upon probing, pustular discharge -- slight to moderate bone loss |
| Grade 4 |
Inflammation, edema, gingival bleeding upon probing, pustular discharge, mobility -- severe bone loss |
Causes
Marked bone loss
secondary to
periodontal disease
|
Gingivitis - (dogs) streptococcus and actinomyces species
Periodontitis - (dogs) pigmented and non pigmented Bacteroides (Porphyromonas Gingivalis, Prevoltella sp., Bacteroides sp.), Fusobacterium
Cats: Peptostreptococcus sp., actinomyces, and porphyromonas SP.
Diet: soft diet promotes periodontal disease through accumulation of plaque.
Risk Factors
 | Toy breeds with crowded teeth |
| Dogs that groom themselves causing hair to be imbedded in the gingival sulcus |
| Other debilitating illnesses |
| Poor nutrition state |
Differential Diagnosis - phemphigus, lupus, oral neoplasia, stomatitis
Tests
CBC/CHEM/U/A - N/A
Imaging - Radiography an important diagnostic tool used in evaluating periodontal disease. As much as, 60% of disease is hidden below the gum line.
Early radiographic signs of grade 3 periodontal disease: loss of density and sharpness of the crestal bone. As periodontal disease progresses, loss of lamina dura mineralization apically is observed as well as furcation involvement in multirooted teeth. There are no radiographic changes in grades 1 and 2 disease (gingivitis).
Severe periodontal disease radiographically appears as loss of bone support around one or more roots. Bone loss may be horizontal-an decrease in bone height around one or more teeth, vertical (infrabony defect), or oblique (a combination of both).
Note widened periodontal
ligament space on distal
aspect of canine due to
periodontal disease
|
Diagnostic Procedures:
Periodontal probing - "probing depth" distance between free gingival margin and apical extent of pocket. Probing depths greater than 2mm in the dog and 1mm in the cat are abnormal.
Attachment loss measures between cementoenamel junction (CEJ) and apical extent of pocket. Normally the gingival sulcus is located at the CEJ, any attachment loss is abnormal.
Treatment
The ultimate goal of periodontal therapy is to control plaque. A willing patient and client who is able to provide home care are important considerations in creating a therapy plan.
Grade one or two - professional cleaning, hand scaling, polishing, irrigation, application of fluoride
Periceutic (oxytetracycline gel)
placed into a cleaned subgingival
pocket
|
Grade three - (pocket depths 3-6mm in dog, 2-4mm in cats) above plus closed root planing and subgingival curettage,
and application of perioceutic gel may be indicated
Grade four - (pocket depth greater than 6mm in dog, 4mm in cat). Surgery will need to be performed to either expose the root for treatment (open flap curettage), or extraction.
Marked gingival inflammation due to tartar
accumulation leading to periodontal
disease
|
If 2-3mm healthy attached gingiva present: apical reposition flap to decrease pocket depth in areas of alveolar bone loss.
If not enough healthy gingiva remains for apical reposition flap: rotated flap (from adjacent gingiva), free gingival flap, or extraction
may be necessary.
Bone replacement procedures - may be helpful to save teeth affected by
two or three walled infrabony pockets.
Guided tissue regeneration - use of tissue barriers (Gore-Tex) separating gingival tissue and root surface
Periodontal splinting - can be used especially in the incisor areas to help stabilize mobile teeth. Criteria for splinting:
normal periodontal support on both sides of the tooth (teeth) to be
stabilized, strict home care, and a cooperative patient who will not chew on hard
objects.
Medications - Clindamycin is an antibiotic approved for dental infections. It may be used pre treatment for a week before periodontal treatment, perioperative fifteen minutes before anesthesia, postoperative for 7-10 days, and/or in a pulse therapy fashion given the first five days of each month (extra-label).
Use of a soft-bristled
toothbrush, which will clean
under the gingival margin, is
the foundation of veterinary
dental home care
|
Home Care
Fluoride - Stannous fluoride preparations have advantages in helping control periodontal disease by reducing plaque by being deposited on the surface of enamel, and also decreases dental pain. 0.4% strength should be used in patients with stage 3 and 4 periodontal disease, especially those with exposed root surfaces. Available as Omni Gel and Gel Kam.
Chlorhexidine is the most effective product to inhibit plaque formation in humans. Chlorhexidine produces bacteriostatic and bactericidal effects against bacteria, fungi, and some viruses. Once absorbed it continues to be effective for up to 24 hours. In humans, to be maximally effective, chlorhexidine is swished in the mouth for one minute twice daily. The contact time of application is important for chlorhexidine to bind to the tooth and gingival sulcus. One minute oral rinsing is difficult to accomplish in animals. Chlorhexidine can be applied with a gauze sponge, cotton tipped applicators, as a spray or with finger brushes.
For animals, Chlorhexidine is available as:
| VRx Products Harbor City, Ca: CHX Guard solution composed of Chlorhexidine gluconate 0.12% plus zinc gluconate which promotes healing of ulcerated tissue; CHX gel Chlorhexidine gluconate 0.12% -- the gel allows greater binding time and a pleasant taste; CHX Guard LA-long acting ZincChlorhexidate gel. |
| Virbac, Fort Worth, Tx: DentiVet toothpaste containing chlorhexidine gluconate, zinc, and sodium hexamethaphosphate; Hexarinse containing 0.12 chlorhexidine. |
| Novaldent (chlorhexidine acetate) 0.1% |
Lactoperoxidase system enhanced enzyme products - have antibacterial properties decreasing plaque. (CET , CET Forte toothpastes, CET Chews, CET Spray-VRx Product, Harbor City, Ca.
The degree and type of home care products dispensed depends on:
| Stages 1 and 2
 | Daily brushing with dentifrice |
|
| Stage 3, where periodontal disease has been established
| Daily brushing with fluoride containing toothpaste |
| Twice weekly application of stannous fluoride gel |
| Pulse therapy antibiotics |
|
| Stage 4, advanced periodontal disease homecare includes
| Zinc ascorbate spray 3-4 times daily |
| 0.2% chlorhexidine spray twice daily or CHX-Guard (VRx Products) -- combination of Chlorhexidine gluconate and zinc |
| Pulse therapy antibiotics |
| At the end of two weeks, Stannous fluoride gel twice weekly can be substituted for the chlorhexidine spray |
|
Precautions - N/A
Possible Interactions - Chlorhexidine should not be used with fluoride products at the same time. The binding of both products may inactivate each other. A thirty-minute to one-hour wait between use of a dentifrice containing fluoride, and a chlorhexidine rinse or gel is recommended.
Alternative Drugs - Tetracycline, Clavamox, Flagyl have been used to treat periodontal disease
Follow-Up
Patient Monitoring - the degree of periodontal pathology dictates recall interval -- some patients are monitored weekly while others can be evaluated every three to six months.
Grade 1
Grade 2
Grade 3
Grade 4
|
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