Periodontal Disease - Part II

Linda J. DeBowes DVM, MS
Diplomate ACVIM (Internal Medicine), AVDC
Seattle, Washington 

Equipment

• Scaling
  • Ultrasonic scalers
    • Heat generation
    • Significant amounts of heat at their tips
    • Water is used as a coolant
    • Supragingival
    • Perio tips – subgingival
  • Sonic scalers 
    • Do not generate heat
    • Slower – clinical significance ??
    • Supra and subgingival
  • High speed handpiece with Roto pro burs
    • NOT RECOMMENDED

• Polishing
  • Low speed hand piece
  • Prophy angle
  • Generates heat!
  • Polish carefully to avoid trauma

Instruments

• Periodontal probe
  • Blunt end
  • Graded markings  
  • Measure periodontal pocket depth
• Explorer
  • Sharp point
  • Assess furcation bone loss
  • Assess subgingival irregularities
  • Calculus
  • Resorptive lesions

Hand instruments – scaling, root planing

• Scaler
  • Sharp point
  • Scaling
  • Supragingival only
  • Do Not Use - subgingival
• Curette
  • Rounded toe - tip
    • Scaling
      • - Subgingival
      • - Supragingival
    • Root planing
  • Universal – blade perpendicular to shank 
  • Graceys - Offset blade (70 degrees) with one working edge
    • After–five
      • - Longer shank
      • - Root planing
      • - Deep pockets
    • Mini-five
      • - Shorter blade
      • - Subgingival
      • - Narrow pockets

When to recommend a basic dental cleaning

• Gingivitis
  • Unresponsive to daily tooth brushing
  • Subgingival plaque, calculus
• Calculus accumulation
• Periodontitis
  • Gingival recession
  • Furcation exposure
  • Mobile teeth

Basic goals of treating periodontal disease

Remove all plaque and calculus

• above the gum line (supragingival)
• most importantly below the gum line (subgingival)
• If subgingival plaque and calculus remain
  • Continued inflammatory response
  • Increased attachment loss

Improve the health of the periodontal tissues

Prevent or slow disease progression

• Gingivitis
  • Inflammation is completely reversible
• Periodontitis
  • Attachment loss – permanent
  • Soft tissue attachment
  • Advanced procedures
  • Guided tissue regeneration (GTR)

When Treating periodontal disease 

• For complete dental evaluation and periodontal treatment.
• Cuffed endotracheal tube
  • To protect patient’s airway
• Appropriate fluid support
• Monitoring during anesthesia

Bacteria being aerosolized

• The attending personnel should wear protective face mask and eyewear
• Do not do dental procedures in surgery suite

Basic Dental Cleaning

• Aerosolized bacteria
• Magnitude of bacteremia

• Calculus forceps or extraction forceps
• Large pieces of calculus
• Do not injure tissues (gingiva or tooth)

• Removes calculus (& plaque)
• Primarily with power scaling
  • Do not use tip of instrument against tooth
  • Tips vary in working edges         
• Hand instruments
  • Difficult to reach areas

Polishing

• always done after the teeth have been scaled
• smooths the tooth surface to decrease plaque accumulation
• fine to medium grit prophy paste
• polishing action can generate a significant amount of heat
• rinse well to remove all paste

• designed to help  prevent bacteria from adhering to teeth
• professional product for use by the veterinarian
• take-home kit for the owners to use on a weekly basis at home

Deep periodontal pockets

• Closed root planing
• Open root planing
• Local antimicrobial treatment     

Antimicrobials Use in Patients with Periodontal Disease  

• Chlorhexidine – topical
• Local antibiotic delivery systems
• Systemic antimicrobials
  • Good anaerobic spectrum needed
  • Clindamycin
  • Amoxicillin and clavulanic acid
  • Metronidazole

• Bacteremia occurs during all dental manipulations
• At risk patients
• Therapeutic antibiotic levels at time of procedure

When to recommend extraction – considerations

• Extent of attachment loss
• Owners commitment to continued dental care
• Jeopardizing health of adjacent teeth
• Endodontic health
• Owner’s preferences

Basic Extraction Techniques – Simple Extractions

PATIENCE!!

Cut gingival attachment to tooth

Section tooth if multi-rooted

Severing periodontal ligament (PDL)

• Scalpel blade
• Luxators

Stretching and tearing of PDL

• Dental elevators
• Apply tension/stretch on PDL and HOLD!!
• PDL fibers have to tear

Suturing