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Modern Periodontics
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Modern Periodontics
Periodontal disease is treatable, and the comfortable use of the dentition throughout life is a realistic goal for today’s practitioner. The fact that pets lose their teeth and suffer from chronic inflammatory lesions of the gingiva, periodontal ligament and alveolar bone is primarily the result of failure to deliver well-understood, effective therapy. When patients do not receive proper periodontal care, one should assess whether recognition, motivation, clinical skill, or supportive treatment has been deficient. This document will examine these issues and discuss the means that can be used to improve the general quality of periodontal practice today.
Recognition
Healthy gingiva is firm, well adapted to the teeth, and does not bleed when touched or probed. Normal, healthy, plaque-free teeth do not have a foul odor or slimy feeling when touched. Aside from the obvious search for the common signs of inflammation, it is necessary to collect a medical and dental history for each patient. The general periodontal examination should include an assessment of the quality of the gingival contour around each tooth and the pocket depth on each surface. Areas with bleeding on probing are active and indicate the need for treatment immediately or in the near future. The level of mobility and the amount of debris, both hard and soft, on teeth should be noted. Radiographs are necessary to assess the amount of bone remaining around teeth and to look for hidden pathology such as endodontic disease.
Prevention
Even in a normal young patient, it is necessary to plan for dental health. Periodontal disease is so common that practitioners should assume that their patients would be affected by it unless preventive methods are instituted. A variety of mechanical methods have been applied to young and old animals to prevent or treat periodontal disease. These have been used with and without professional intervention to directly treat periodontal lesions. A hard diet has been used to rub plaque and, to a lesser extent, calculus, off teeth. Hard kibble and rawhide have been moderately effective but harder substances have sometimes resulted in tooth fracture. Chew toys with a fibrous or hard edge have also been utilized, but their effectiveness has been quite dependent on a dog’s individual interest in chewing. Toothbrushing and tooth rubbing has been advocated as the most effective preventive methods, but these interventions require a dedicated caretaker. Professional scaling of teeth as a preventive method or as a therapy for mild disease can be very effective, but the cost and need for general anesthesia with these procedures makes it necessary to use them strategically and at maximum time intervals.
The long-term use of systemic or surface antibiotics to control periodontal disease is problematic due to the tendency for resistant organisms to emerge and disease to reoccur [1,3]. Oral antiseptics are useful for surface decontamination and do not have the disadvantage of emergence of resistant organisms [4]. On the other hand, they are not useful for deep-seated local infections or septicemia. Also, antiseptics will not reach into deep periodontal pockets without the aid of forceful irrigation and so they are not very helpful in advanced periodontal disease without previous surgical debridement. Therefore, antiseptics are most helpful for the treatment of generalized mild periodontal disease (gingivitis) without deeper tissue damage or for postoperative care of more severe disease after thorough subgingival tooth cleaning.
The most effective antiseptic at this time is chlorhexidine [5]. This chemical kills all periodontal pathogens. It has the ability to affect pathogenic bacteria, which occur later in the tooth colonization cycle, more profoundly than early "normal" bacteria seen in healthy mouths.Chlorhexidine shares this quality with cetylpyridinium, so neither antiseptic disturbs a normal, healthy, indigenous flora - a distinct advantage when compared to antibiotics. Although chlorhexidine is very effective at reducing bacteria and gingivitis, there are some drawbacks. The cationic nature of the drug makes it susceptible to inactivation by anionic compounds and common detergents often used in dentifrices. Staining, as a result of the binding of dietary elements and the killing of bacterial cells, often discolors the teeth with long-term use. Increased calculus deposition has been noted, probably as a result of killed bacteria acting as a nidus for crystal formation within plaque. Lower concentrations of chlorhexidine used twice daily and limiting the duration of use to a few weeks at a time has improved this problem in people. This strategy may also be effective for animal patients. Taste alterations and a few cases of mucosal sensitivity have been reported in people [6]. Practitioners must also avoid using chlorhexidine to "cure" superficial gingivitis problems while failing to surgically address deeper advancing lesions of periodontitis that are inaccessible to antiseptics. In this case, the appearance of healthy gingiva may give a false sense that the advancing support loss around teeth has been halted.
Cetylpyridinium is a quaternary ammonium antiseptic which binds to mucosal surfaces. It has its antibacterial effect until it is released from the oral surface. The antibacterial effectiveness of cetylpyridinium is equivalent to chlorhexidine but it lacks the retentive properties [7]. In delivery with other multi-compound therapeutics, it may have an additive effect - perhaps compensating to some degree for the decreased activity of other agents in such combinations.
It is well known that heavy metal salts have antibacterial properties. Zinc ions disrupt bacterial enzyme systems by displacing magnesium ions. They also inhibit glycolytic enzymes. Bacterial adsorption to the tooth surface and growth of existing plaque are disturbed by zinc. Plaque acid production is also reduced by zinc. Generally, zinc is used in combination with other agents for an additive effect. It is useful in toothpaste, especially on patients who are heavy plaque formers. It does not encourage the development of resistant organisms and can reduce the risk of gingivitis developing when used as a preventative.
Hexametaphosphate is a calcium sequestrant, which decreases calculus formation by forming soluble complexes with cations in plaque. These complexes diffuse into saliva, and calcification within plaque is decreased. In research trials where dogs were fed kibble coated with hexametaphosphate, there was a significant reduction in calculus formation. Subsequently, hexametaphosphate is converted into orthophosphate in the acid environment of the stomach and metabolically digested. Although the etiologic agent of periodontal disease is bacterial plaque, calculus may be important as a cofactor in more advanced forms of periodontal disease because it consistently retains plaque on its surface. Also, in combination with other chemical agents, which may increase calculus deposition as they exert their anti-plaque activity, hexametaphosphate may have a stabilizing effect on the otherwise rapid growth of calcified tooth debris.
The best treatment is usually a combination of mechanical debridement followed by chemical control of recolonization during the first two post-operative weeks. Most dogs and cats should have their teeth cleaned professionally once a year. Where disease has become severe and lesions are deep-seated, periodontal surgery should be provided followed by two weeks of antibacterial rinsing. Owners should brush the teeth daily, provide chew toys, and keep a hard diet throughout life. When owners do not address the dental needs of the pet, the veterinarian should compensate by more frequent professional dental treatment. It would be prudent to stress that most dogs and cats will do much better with their dental health if they receive a thorough professional dental prophylaxis at least yearly. This is probably the single most helpful piece of advice that can be given to a practitioner who wants to improve the general level of dental health in their population of patients.
Treatment Planning
After examination, the resulting data should be used to develop a tentative treatment plan that includes the various periodontal procedures to be performed and subsequent reevaluation of their effectiveness. Related therapy, such as endodontics or extractions, needs to be integrated with the periodontal treatment plan in a logical sequence. Biochemical and microbiological monitoring may be helpful when used in conjunction with clinically-determined attachment level changes and follow-up radiography. In order to have truly successful long-term results, supportive periodontal treatment consisting of periodic cleaning and reevaluation should be emphasized.
The treatment plan should include client education and training in appropriate oral hygiene methods. It is helpful to divide the treatment into phases: records, systemic, hygiene, corrective, and maintenance. After collection of data (records phase) and investigation for general health issues that alter treatment (systemic phase), attention should be directed to cleaning and smoothing the teeth (hygiene phase). Root planing to remove bacterial plaque and calculus is best done several weeks before corrective phase surgical periodontics. This results in improved tissue consistency for surgical handling and better healing. It is not always possible to do this in veterinary practice due to the need for two anesthetic episodes resulting in increased risk and cost. The corrective phase of periodontal disease includes surgical treatment and occlusal therapy. Occlusal therapy is not always required in veterinary patients but minor orthodontics, occlusal adjustment of teeth which interfere with each other during closure, and splinting of mobile teeth fall under this category. Surgical treatment begins with the selective extraction of hopeless teeth. Resective procedures designed to reduce pockets and recontour periodontal architecture are performed next by gingivectomy, mucogingival flaps, ostectomy, root resection, tooth hemisection, and odontoplasty. Finally, regenerative and reconstructive procedures such as guided tissue and bone regeneration or gingival and connective tissue grafting are performed to replace anatomy lost by disease. These procedures can be combined in a single surgical appointment when necessary. Maintenance phase includes the post-operative visits to ensure healing in a clean environment as well as the recall visits for supportive periodontal treatment. When an appropriate interval for reexamination and cleaning is determined, supportive periodontal treatment visits should include updating the medical and dental history, identification and treatment of new periodontal pathology, thorough tooth cleaning, and reappointment for continued care.
Treatment
There are several techniques which have been consistently useful in treating periodontal disease. They range from conservative techniques with little soft tissue surgery to complicated techniques for bone regeneration. Scaling and root planing are conservative techniques designed to remove etiologic factors from the tooth surface (scaling) and produce a surface which is smooth (root planing). Usually scaling is done in veterinary practice with ultrasonic instruments whereas root planing must be done with hand instruments.
Gingivectomy and gingivoplasty are methods of removing supra-alveolar soft tissue pockets or poorly-contoured tissue. Special knives are sometimes used, but an angled incision to leave physiologic normal contour can be made with standard scalpel blade or electrosurgery units. Healing is prolonged with gingivectomy compared to flap surgery due to the size of the surface left to granulate on the oral surface. Gingivectomy is not suitable for the removal of intrabony pockets and cannot be used when all the attached gingiva would be removed.
Flap surgery has several variations. Flaps for exposure and open curettage are performed by modified Widman approaches. Little gingiva is removed and pockets may remain after surgery but the advantage is quick comfortable healing, better exposure of roots for cleaning, and less surgical recession. Flaps for pocket elimination, such as inverse bevel apically-positioned flaps, cause more tissue loss and are more difficult to design properly. They have the advantage of repositioning the attached gingiva when necessary. Flaps for osseous surgery allow the recovering of traumatized bone for quick comfortable healing. They also provide a seal over regenerating areas, which need isolation from the oral environment.
Intrabony periodontal defects can be regenerated by hard tissue grafts and membranes. Various materials and techniques have been proposed but defect morphology plays a major role in determining success. Deep, narrow defects have the best prognosis, while shallow, wide defects are least likely to regenerate. More infected pockets, especially with certain bacteria, are less likely to regenerate. Better soft tissue closure over defects improves results as does tenting to preserve space - for example, with titanium-reinforced membranes. Maintenance of the blood clot and prevention of membrane exposure early in the healing period are positive factors. Surface necrosis, discoloration of the membrane, fragile tissue, and a stormy postoperative period are negatively correlated with good results.
Presurgical preparation of sites by root planing and a period of enforced hygiene will improve tissue quality for surgical procedures. Intrasulcular incisions preserve tissue for covering grafts and membranes. Mesial and distal extension or releasing incisions provide access, visualization, and mobilization of flaps. Radiography and clinical measurements can be equally valid when compared to clinical reentry evaluation, if they agree, so presurgical record-taking can help post-treatment evaluation.
Barriers used to exclude epithelium and gingival connective tissue from intrabony defects during healing can be classified variously. Simple barriers, like collagen tape, can be compared with complex manufactured barriers. Attached and unattached membranes either have suture or not. Unformed barriers are represented by sprays applied to the undersurface or around the coronal border of flaps and materials that can be flowed into defects such as polymers containing various bioactive or antibiotic substances. Multiple descriptive terms can be used to describe barriers e.g., "preformed, unattached, simple barrier". Bioabsorbable barriers have an advantage in that they can be impregnated with bioactive chemicals that improve predictability and regeneration. If it is certain it will not be possible to get full defect coverage, usually a non - resorbable barrier should be used. Also, in oral-nasal or oral-antral fistulas, or in especially deep placements, a bioabsorbable is indicated. Resorbable membranes can be used to manage failing endodontic cases with large periapical lesions or with root resection with sinus involvement. Resorbable membranes can be used for ridge preservation to contain graft material in extraction sites. Bioabsorbable membranes are easier to apply and require fewer postoperative appointments. Fewer anesthetic procedures are required because they need not be removed. Because healing is not disrupted by removal, there may be less chance of disrupting healing new attachment. Disadvantages are that the collagen bioabsorbable barriers often collapse into vertical defects and that they are antigenic because they are xenografts. Collagen membranes are slippery when wet and are more difficult to see because they become more translucent. Most bioabsorbable membranes are of polylactic and galactic acid and collagen (dermal, tendon, periosteal, or free grafts of collagen and epithelium). Other barriers have been made of bone and non-viable materials such as plaster of Paris or rubber dam. There are multiple graft materials which can be used under barriers to form a scaffolding for bone growth. It is likely that these will be supplanted in the near future by biologically active molicules like BMP (bone morphogenic protein) which stimulate division and differentiation of healing tissue into periodontal support. At the present time, the use of graft material gives a very slight improvement in regeneration of periodontal support compared to the use of barriers without graft material.
Postoperative Care
Postoperative care consists primarily of keeping the teeth clean during healing. Chemoprophylaxis with antiseptics, mechanical cleaning at home, and regular recall for professional prophylaxis are appropriate methods for dealing with recurring plaque. Diet, chew toys, and systemic antibiotic therapy may he useful adjuncts if chosen appropriately. Periodic professional cleaning on an appropriate schedule is very important for long-term success in controlling the reccurrence of periodontal disease.
Supportive Periodontal Therapy (SPT)
Supportive periodontal therapy (SPT) is an extension of periodontal treatment, which is designed to monitor and maintain the results of therapy. It is unlikely that most periodontal treatment can be successful over a long period of time without adequate periodic cleaning and occasional other therapeutic interventions. The goals of SPT are to prevent recurrence of disease, prevent tooth loss, and to find other oral problems as they develop. In veterinary practice, most animals will need cleaning and examination at least yearly. If there is clinical or radiographic evidence of progressive attachment loss, the interval should be shortened. The clinician should evaluate probing depth, bleeding tendency, plaque and calculus levels, and tooth mobility at a minimum. It is very helpful to maintain a specific interval for radiographic examination of the entire mouth.
Recent Advances and the Future
Digital radiography has not developed to the point that images offer the detail found in plain radiographs. However, digital subtraction radiography offers substantial diagnostic advantages in detecting increase or decrease in bone density - a fundamentally important factor in determining the direction of this disease. The first of these systems has become available to practitioners and further improvements are expected.
Automated probes (e.g. the "Florida Probe") have been developed to standardize operator measurement variables and interface with computer histories to detect changes as small as 0.1- 0.2mm. This appears to be most helpful in determining refractory sites within the mouth and treating these areas specifically. Recognition at these levels provides an opportunity to avoid larger losses (1-2 mm) which would need to occur to be detected by conventional probing.
Computerized generation of risk profiles based on the integration of data collected from many sources (e.g. combining radiographic, probing, history, and microbiologic data) and assigned a weighting value is being developed to help practitioners make treatment decisions. Obviously, these will need tremendous refinement before they will be capable of the subtle discrimination it takes to dictate treatment. However, simple probability profiles may be very useful for simplifying practitioner decisions and for education and behavior modification.
Polymer technology will improve our ability to deliver chemicals to the periodontal area and have them released on a therapeutic "schedule". There are factors which can be added to these polymers to inactivate microorganisms or to stimulate the body to grow new tissue in specific sites after surgical therapy. Our ability to manage the local environment of periodontal tissues should improve considerably in the future, perhaps enough to avoid side effects such as drug resistance and suppression of normal flora in other parts of the body seen when systemic antibiotics are utilized. Where these polymers are biodegradable, a second anesthetic/surgical session can be avoided.
Improvements in power-driven instrumentation for calculus removal has allowed the development of ultra - thin tips, which can reach deeply into pockets without breaking. There is less tissue damage and greater comfort with these units. Additional instrumentation for evacuation and fiberoptic inspection of the root surface has been developed and is being improved. Ease of operation is now better with footswitch systems.
Get access to all handy features included in the IVIS website
- Get unlimited access to books, proceedings and journals.
- Get access to a global catalogue of meetings, on-site and online courses, webinars and educational videos.
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1. Genco RJ. Antibiotics in the treatment of human periodontal diseases. J Periodontol 1981; 52:545-558.
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Florida Veterinary Dental Clinic, Vero Beach, Florida, USA.
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