Clinical Suite: Periodontal Disease

Overview

Mary Ann Vande Linde, DVM, Vande Linde & Associates, LLC, Brunswick, GeorgiaThomas Phillips, DVM, FAVD, Nassau Veterinary Hospital, Nassau, New York__

A study by the American Veterinary Dental Society showed that 80% of dogs and 70% of cats had developed periodontal disease by 3 years of age, making dental disease the most prevalent disease in companion animals.¹ Multiple studies have found an association between periodontal disease and pathologic changes in internal organs and other measures of systemic inflammation.^2-6 Oral infection, oral trauma, or malocclusions can cause pain and loss of function.

Periodontal disease results from the formation of biofilm (ie, a complex accumulation and organization of microbes) at the gingival margins, which develops microhabitats that promote both aerobic and anaerobic bacteria growth. Biofilm bacteria develop significantly greater resistance to antimicrobials, making antibiotics alone ineffective and potentially causing greater antimicrobial resistance; thus, plaque must be removed through dental cleaning.

Related Article: Clinic Protocol for Dental Disease

Common dental abnormalities in dogs include fractured teeth with or without pulp exposure, persistent deciduous teeth, impacted teeth that appear to be missing, and malocclusions with teeth causing trauma to apposing teeth or soft tissue. Common dental lesions in cats include tooth resorption and mucogingival stomatitis.

Dental disease can often initially be evaluated in an awake patient; however, because much of the tooth structure is not visible on visual examination, a complete assessment is only possible through a comprehensive oral examination (with intraoral radiographs) in an anesthetized patient. Only then can a final treatment plan be made; thus, clients should be advised of potential treatment at the initial examination and must be present or available by phone at the time of examination to finalize the treatment plan and cost estimate.

The primary care veterinarian may perform dental therapy if he or she has appropriate training and proper equipment, or the patient may be referred to a veterinary dental specialist for advanced therapies.

Treatment Plan

Mary Ann Vande Linde, DVM, Vande Linde & Associates, LLC, Brunswick, GeorgiaThomas Phillips, DVM, FAVD, Nassau Veterinary Hospital, Nassau, New York__

The veterinary technician should “lift the lip” for a quick inspection of the patient’s teeth. The veterinarian should focus on the patient’s overall health status and oral examination findings. Cardiac, renal, hepatic, or other diseases can affect the anesthetic procedure or the patient’s immune system and recovery. Appropriate preanesthetic screening includes CBC, blood chemistry, urinalysis, and ECG. Consider chest radiographs or an echocardiogram if evidence of cardiac disease is present.

On oral examination, evaluate for an abnormal bite that may be traumatizing other structures. Facial swelling or thickening of the bone covering the roots may indicate endodontic disease. The presence of gingival recession or the amount of plaque and tartar accumulation or mucogingival inflammation can indicate periodontal disease, while mobile teeth or exposure of root surfaces indicate significant bone recession. Identify persistent deciduous teeth or missing teeth. Diagnostic test strips help reveal pathogenic bacteria, several of which produce thiols that will change the strip’s color after it is swiped along the gingival margin.

Cleaning Process

The goal of a comprehensive cleaning is the removal of all plaque and tartar from the teeth and subgingival areas. A chlorhexidine solution is sprayed or lavaged through the oral cavity to reduce potential aerosolization of bacteria. Plaque and calculus are removed supragingivally with an ultrasonic scaler and hand instruments and subgingivally with a hand scaler or ultrasonic instruments. Appropriate training and correct instrumentation are necessary for this procedure.

Polish teeth with a dental paste to remove any remaining plaque and smooth the tooth surface to slow the adhesion of plaque microbes. Thoroughly lavage the gingival sulcus to clear debris, and apply a dental sealant if desired.

Follow-Up Examination

Gently probe the gingival sulcus in multiple sites around each tooth to measure the depth and identify any periodontal pockets. Measure any gingival recession and identify furcation exposure.

Carefully examine the crown of each tooth for attrition or fractures and identify sites of pulp exposure. In cats, examine teeth for evidence of tooth resorption (eg, inflamed painful granulomatous lesions) along the neck of the tooth. Cats also develop mucogingival stomatitis with diffuse painful inflammation and mouth ulceration that may initially occur in the caudal oral cavity but can involve the whole mouth. Record each abnormality in the patient’s medical file.

Radiographs are used to evaluate the root structures, examine alveolar bone and tissue for bone recession, and determine the presence of periapical lesions. In cats, radiographs help determine if intact roots need to be extracted or the roots have undergone ankylosing resorption. Resorption requires crown amputation with marginal bone contour and a gingival flap to cover the extraction location.

Therapy

Fractured teeth with pulp exposure should be extracted or treated with root canal therapy. Periodontal pockets may require root planing, and a perioceutic may be applied or a guided tissue regeneration with bone augmentation performed to regenerate boney tissues and enhance healing.

Most veterinarians recommend full-mouth extractions for cats with stomatitis; however, some cats respond to caudal mouth extractions if no disease is present in or around the canines and incisors. Orthodontic movement of maloccluded teeth or selected extractions may be required.

Team Roles

Nan Lillard, MA (Organizational Management), University of Tennessee

Team Training Plan

Nan Lillard, MA (Organizational Management), University of TennesseeThomas Phillips, DVM, FAVD, Nassau Veterinary Hospital, Nassau, New York__

Basic Training

The team plays an important role in providing a successful dental program. Develop a plan that includes each team member’s role, and periodically review the plan. Effective training includes clarification of each team member’s role and responsibilities (see Team Roles), as well as information on client communication about periodontal disease and treatment options, risks, and financial considerations. Team members should review the practice’s client education materials, such as handouts and websites, to ensure they are current and accurate.

Training should also include presentations from the practice manager, a veterinarian, and a veterinary technician on dental health, types of assessments, typical treatments, and required follow-up care. Use role-play to practice presenting and discussing dental care with clients, including explaining the importance of a thorough dental assessment, listening to client concerns, and checking for understanding.

Related Article: Implementing a Dental Care Program in Your Practice

Suggested content for the practice manager’s presentation:

• The challenges of communicating with clients who do not comply with the recommended treatment

• Communicating with clients concerned about treatment costs

• Educating clients about at-home management

• Following up with clients whose pet has received dental care.

Suggested content for the veterinarian’s presentation:

• The importance of dental health

• How dental conditions and diseases are diagnosed and treated

• Typical treatments and costs

• At-home care and preventive options.

Suggested content for the veterinary technician’s presentation:

• Educating clients about diet management and at-home care.

Continuing Education

Veterinary dentistry is a relatively new area of treatment, and many veterinarians received minimal training in veterinary school; thus, continuing education (CE) is crucial to learn and develop proper diagnostic and treatment skills. Additionally, with proper training in prophylaxis, charting, and radiograph techniques, veterinary technicians can provide valuable assistance to the veterinarian. Dental CE opportunities include the annual Dental Forum that includes lectures and wet labs. Many of the national veterinary meetings also have sections on dentistry, and there are several private practice facilities that provide training programs.

Communication Keys

Nan Lillard, MA (Organizational Management), University of Tennessee

Veterinary dental care is an important component of routine healthcare. Clients may not understand that good dental health contributes to their pet’s quality of life, or that a complete dental assessment includes multiple phases to provide needed treatment. Team members should educate clients about the dental assessment process, time required, benefits and risks, and associated costs.

Communicate the following points to ensure client understanding and compliance:

• Dental care is a multi-step process. In many cases, the total cost of care cannot be determined until the veterinarian examines the patient’s mouth and completes radiographs of the oral cavity.

• Routine dental care at home and by the veterinary team benefits the patient’s health and quality of life.

• Patients often do not show signs of dental pain, but may clearly be more comfortable after dental care.

• The costs for dental care may seem high, but they reflect the time and attention required from the veterinary team, which is more than required for human patients. Be sure to provide information regarding the available payment options.

• Some risks are associated with dental procedures (eg, infection, jaw fracture).

Related Article: Battling the 'Difficult Sell' of Veterinary Dentistry

Support clients in the following ways:

• Ask questions about prior experiences. Some clients have had negative experiences that can influence their current decisions about treatment.

• Invite and answer questions about the dental health assessment process.

• Listen to the client’s concerns about care costs, time constraints, a lack of understanding of dental disease and its effects, and a lack of confidence in his or her ability to provide at-home care.

• Provide educational material and additional resources.

• Provide short explanations and check for understanding of the complex dental process.

Using Technology

Technology can increase client engagement and understanding. Digital pictures taken with a wifi-enabled camera can be quickly transferred to a tablet or computer and shown to the client or added to the patient's medical file to track the progression of the disease.