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Periodontal disease
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Summary
Periodontal disease is a major cause of tooth loss in small animals, humans and equines. The predisposing feature to periodontitis in horses is food sequestration in the gingival sulcus, which is usually predisposed by inappropriate interproximal spaces between teeth (diastemata).
Diastema may be categorised as primary or congenital diastemata are a result of abnormally spaced dental buds, or the teeth developing with insufficient angulation, whereas secondary or acquired diastemata are due to other disorders, such as CT displacements, supernumerary or focally overgrown teeth that become secondarily displaced. Peripheral caries may result in loss of interproximal cementum allowing food to trap in an acquired ‘diastema’. Treatment of periodontal disease involves:
- Removal of impacted food from all diastema / interproximal spaces
- Equilibration of the teeth e.g. removing focal overgrowths
- Treatments to prevent further food impaction – widening of diastema, packing or bridging to prevent food influx and allow periodontal healing and regeneration
Definitions and anatomic considerations
A diastema (Greek: an interval; pl.: diastemata) is defined as a space between 2 adjacent
teeth in the same dental arcade with such a space being a pathological condition. The space between the incisors and cheek teeth is best described as the interdental space. The region between adjacent teeth, normally a tight junction is referred to as the interproximal space. The angulation, physical shape and constant eruption of hypsodont teeth along their eruption pathway normally result in the teeth being forces together in close apposition. The increased production of cementum immediately sub-gingivally extending out to the clinical erupted crown, and the increased height of the gingival attachment lingually and buccally further augments the security of the interproximal space and prevents influx or entrapment of food material.
Equine periodontal disease has been documented in several studies and reports since the early 1900’s and in 1905 was described as ‘the scourge of the horse’. Incidences have ranged from 37% to 50% in different studies[1-3]. Periodontal disease appears to be particularly common in donkeys[4].
Any alteration or abnormality of the anatomical and physiological parameters can result in food impaction within the interproximal space. Once entrapped, food material stagnates, bacteria proliferate (notably gram negative) resulting in establishment of a viscous circle of pain, inflammation, soft and hard tissue loss and further food entrapment ad infinitum. The resultant periodontal disease has been shown to be mostly reversible once the impacted food material is removed. Horses are skilled eaters and are able to selectively avoid masticating in painful areas of the mouth. Eventually horses will become symptomatic as they decompensate, but it is the job of the modern dental practitioner to identify the changes well in advance of this stage.
Depending on their shape, diastemata can be divided into open or valve types[5]. Open diastemata have a similar width at their occlusal and gingival aspects, with a ratio of 1.07 for these two measurements[6].
Treatment of diastemata
Meticulous cleaning of diastemas is required using picks, angled crocodile forceps, flushing units and scalers. Endodontic files (e.g. ‘K-flex’ files) held in long haemostats or needle holders are especially useful for removing trapped food from deep pockets. Haemorrhage is likely, and may be considered beneficial as this indicates deep debridement. Peripheral caries lesions should be debrided and any sharp cemental ridges smoothed. This process can be painstakingly slow, and may require significant levels of sedation and analgesia. Flushing is used repeatedly. Nerve blocks may be required, however care is required for mandibular nerve blocks if performed bilaterally (bilateral lingual nerve blockade could result in severe tongue self-trauma) and local anaesthesia of periodontal pockets may be preferable e.g. lidocaine viscous thermosetting gels (e.g. ‘Oraqix’).
The condition of the tooth and periodontium is examined for gingival inflammation and erosion, condition of sulcular epithelium, pocket depth and mesial/distal length, condition of the supragingival and subgingival cementum, attachment loss, and tooth mobility. The interproximal spaces should be examined particularly carefully to assess the type of junctional contact between the teeth i.e. parallel or otherwise, and for displacements, rotations and fractures.
Any mobile teeth may be graded according to the tooth mobility / periodontal disease index (Wiggs & Lobprise) as follows:
- Grade 0 no periodontal attachment loss
- Grade 1 Gingivitis, no attachment loss
- Grade 2 <25% attachment loss
- Grade 3 <50% attachment loss
- Grade 4 >50% attachment loss
A number of treatments are advocated for the management and treatment of diastemata. These include corrective dental floating, removal of necrotic food material impacted in interproximal spaces, use of abrasive prophy powders mixed with water and propelled by pressurised gas, widening of interproximal spaces using motorised burrs, application of temporary ‘patches’ of dental impression material, application of semi-permanent interproximal ‘bridges’, the use of perioceutic agents and exodontia.
The treatment may be broken down into simple steps which will cover all types of periodontal disease:
- Meticulous cleaning of interproximal spaces and periodontal pockets
- Short term measured to improve periodontal health
- Corrective floating, equilibration
- Perioceutic agents e.g. doxycycline gel
- Temporary ‘patches’ to prevent immediate influx of food material e.g. polysiloxane putty
- Long term measures to prevent further periodontal disease
- Diastema widening[5; 7]
- Bonded hard ‘bridges’ to occlude diastemata more permanently
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[1] Baker, J.G. (1969) Incidence of caries and periodontal disease in horses. J Bone Joint Surg Br 51, 384.
[2] Anthony, J., Waldner, C., Grier, C. and Laycock, A.R. (2010) A survey of equine oral pathology. J Vet Dent 27, 12-15.
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