small animal dental equipment, materials and techniques || periodontal equipment, materials, and...

Periodontal inflammation is the most common diseaseaffecting small animals. The dedicated veterinarian anddental team can make a lifelong difference in patienthealth by concentrating on periodontal health.Periodontal care includes supragingival and subgingivalscaling, application of local medication, bone graftimplants, periodontal surgery, tooth resection, extrac-tion, and home care.

TISSUES OF THEPERIODONTIUM

The term periodontium is used to describe tissues thatsurround and support the teeth, and includes the gingi-va, alveolar bone, periodontal ligament, and cementum.Understanding the normal features and appearance ofthe periodontium is essential to appreciating the patho-logic changes that occur with gingival and periodontalinfections (Figure 6.1).

The oral cavity is lined with keratinized, parakera-tinized, and nonkeratinized mucosa. Attached gingivarefers to the tissues covering the alveolar process sur-rounding the teeth. The gingiva includes oral, sulcular,and junctional epithelium. Normal gingiva appearscoral pink, firm, and stippled, with knife-edged mar-gins. Pigment is normally present.The marginal gingivais the most coronal (toward the crown) aspect of thegingiva. Marginal gingiva is not attached to the tooth,but lies passively against it. The space between the toothand the marginal gingiva is the gingival sulcus orcrevice. The normal depth of the sulcus is 0.5–1 mm incats and 1–3 mm in dogs. The free gingival margin is thecoronal edge of the marginal gingiva. Free gingiva is dis-tinguished from attached gingiva by the free gingivalgroove, a slight depression on the coronal gingiva cor-responding to normal sulcus depth (Figures 6.2A,6.2B).

In the dog, the healthy free gingival margin of pre-molars and molars is 1–3 mm coronal to the cemento-

enamel junction (CEJ), where root cementum meets thecoronal enamel. The free gingival margin of the canineteeth is 1–3 mm coronal to the CEJ. In the feline, thefree gingival margin is .5–1 mm coronal to the CEJ.

The attached gingiva is located apical to the margin-al gingiva and normally is tightly bound to the alveolarmargin and the periosteum of alveolar bone. The widthof the attached gingiva varies in different areas of themouth. Attached gingiva is keratinized to withstand thestresses of ripping and tearing (Figure 6.2C).

6Periodontal Equipment,Materials, and Techniques

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FIGURE 6.1. (A) Tooth and surrounding peridontium;(B) gingival sulcular structures.

A

B

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GlossaryAlveolar bone, alveolar process is part of the mandible

and maxilla that surrounds the roots of erupted teethforming the sockets.

Alveolar margin is the most coronal edge or portion ofthe alveolar bone, terminating at and parallel with the con-tours of the cementoenamel junction.

Alveolar mucosa (lining mucosa) is the mucous mem-brane that covers the alveolar process and extends fromthe mucogingival line into the vestibule, covering the insideof the lips, cheeks, soft palate, and ventral surface of thetongue.

Alveoloplasty (AP) is a surgical procedure used torecontour the alveolar bone.

Alveolus, alveolar socket is the bony cavity within thealveolar process in which the root of a tooth is held by theperiodontal ligament.

Attached gingiva is that portion of the masticatorymucosa firmly attached to the underlying teeth and alveo-lar process. Attached gingiva is bound coronally by the freegingival groove and apically by the mucogingival junction.

Attachment apparatus consists of the alveolar bone,cementum, and periodontal ligament, which support theteeth.

Attachment loss (attachment level) is measured fromthe CEJ to the depth of the periodontal pocket.Attachment loss is the combination of the pocket depthand gingival recession measurements.

Biofilm is a well-oganized community of symbioticmicro-organisms.

Bone grafting is a surgical procedure using a variety ofmaterials in an effort to actively induce bone formation,deposit new bone, or act as a scaffolding for bone formation.

Bone loss is a reduction in the height of alveolar bonedue to periodontal disease.

Buccal mucosa lines the oral cavity facing the cheeks.Calculus or tartar is comprised of multiple mineralized

layers of plaque adherent to the tooth’s surface. Calculus isinert, but provides a rough surface for plaque accumulation.

Cementoenamel junction (CEJ) is a line between theanatomical root and crown where the enamel ends and thecementum covering the root begins.

Cementum is avascular calcified mesenchymal tissue,which forms the outer covering of the roots. The peri-odontal ligament fibers (Sharpey’s fibers) anchor into thecementum.

Cleft is a longitudinal fissure or opening of the margin-al gingiva, exposing the underlying tooth root.

Cribriform plate is the dense inner bony wall of thealveolus, consisting of cancellous bone.

Dental prophylaxis is the use of appropriate dentalprocedures and/or techniques to prevent dental and oraldisease.

Disclosing solution is a coloring agent applied to the

teeth to reveal dental plaque.Envelope flap is a section of gingiva raised with a hor-

izontal releasing incision for exposure.Flap is a section of gingiva and/or mucosa surgically

separated from the underlying tissues to provide visibilityand access to the underlying bone and root surfaces.

Free (marginal) gingiva is the most coronal unattachedportion of the gingiva that encircles the tooth to form thegingival sulcus.

Free gingival graft is utilized to increase the zone of gin-giva at the buccal or lingual aspects of a single tooth orgroup of teeth.

Frenectomy is the excision of the frenulum, a thin mus-cle tissue that attaches the upper or lower lips to the gin-giva, or tongue to the floor of the mouth.

Full-thickness flap (mucoperiosteal) is a surgical proce-dure used to access roots, which include the periosteum.

Furcation is the anatomic area of a multirooted toothwhere the roots diverge.

Furcation exposure occurs when both cortical walls ofa double- or triple-rooted tooth are exposed.

Furcation involvement occurs where one, or a portionof one, wall remains around a double- or triple-rootedtooth root trunk.

Gingiva is the part of the oral mucosa that covers thealveolar process.

Gingival curettage is the scraping of the gingival wall ofa periodontal pocket to remove diseased soft tissue.

Gingival hyperplasia is the proliferation of the attachedgingiva.

Gingival recession is the exposure of tooth root(s)caused by the retraction of the gingiva secondary to peri-odontal disease (apical migration), abrasion, or surgery.Gingival recession can be measured from the cementoe-namel junction to the free gingival margin.

Gingival sulcus or crevice is a normal space betweenthe free gingival margin and the epithelial attachment. Thefloor of the gingival sulcus is the most coronal aspect ofthe junctional epithelium.

Gingivitis is the reversible inflammation of the gingivaltissues.

Guided tissue regeneration (GTR) is a procedure thatuses a barrier placed on top of a periodontally treated areato protect the area while it heals and prevents unwantedcells from migrating into the wound.

Infrabony (intrabony) pocket is a periodontal defectwherein the epithelial attachment is apical to the level ofthe adjacent alveolar bone.

Junctional epithelium attaches to the tooth at the baseof the gingival sulcus or pocket.

Masticatory mucosa is the parakeratonized or kera-tinized mucosa covering the hard palate and gingiva.

Modified Widman flap uses an internally beveled, scal-loped mucoperiosteal surgical incision made to gain accessfor root treatment.

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PERIODONTAL EQUIPMENT, MATERIALS, AND TECHNIQUES

also called the mucogingival line (MGL). The mucogin-gival junction remains stationary throughout lifealthough the gingiva around it may change in heightdue to hyperplasia, recession, or attachment loss (Figure6.2D).

The alveolar (oral) mucosa is loosely attachednonkeratinized tissue apical to the mucogingival junc-tion Figure 6.2E).

The gingival epithelium can be divided into threezones:

• The oral epithelium, also called the outer gingivalepithelium, covers the oral surface of the attachedgingiva and papillae. The oral epithelium is kera-tinized or parakeratinized.

• The sulcular epithelium is a nonkeratinized exten-sion of the oral epithelium into the gingival sulcus.

• The junctional epithelium separates the periodontalligament from the oral environment. The junctionalepithelium attaches to the root cementum immedi-ately apical to the cementoenamel junction. When

The connection of firm attached gingiva with loosealveolar mucosa is the mucogingival junction (MGJ),

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Molt surgical curette is used as a periosteal elevator toseparate the periosteum from the underlying bone.

Mucogingival defects consist of pockets extending to orbeyond the mucogingival junction, absence of attachedgingiva without pocket formation, and/or isolated areas ofgingival recession.

Mucogingival flap is a surgical procedure of incisingthe gingiva and alveolar mucosa.

Mucogingival Junction (MGJ) is a line that separatesthe thick protective attached gingiva from the alveolarmucosa.

Operculum is the hood or flap of thick fibrous gingivaover an unerupted or partially erupted tooth.

Partial- (split-) thickness flap contains mucosa and con-nective tissue avoiding the periosteum.

Pellicle is a 0.1–1.0 micron thin film of salivary proteinfound on the tooth that forms within 1 hour of teeth clean-ing and adheres to the exposed tooth surfaces.

Periodontal debridement is the treatment of gingivaland periodontal inflammation through mechanicalremoval of tooth and root surface irritants to the extentthat the adjacent soft tissues maintain or return to ahealthy, noninflamed state.

Periodontal ligament attaches the cementum of the rootto the alveolar socket.

Periodontal pocket is a pathological condition created

when the depth of the sulcus exceeds 3 mm in the dog and1 mm in the cat.

Periodontitis is an inflammation of the periodontium.Periodontium (attachment apparatus) consists of the

gingiva, cementum, periodontal ligament, and alveolarbone.

Plaque is the transparent adhesive fluid on the surfaceof teeth comprised of salivary glycoproteins, extracellularpolysaccarides, and bacteria.

Pocket depth (absolute pocket depth) is the distancefrom the free gingival margin to the base of a gingivalcrevice, measured in millimeters.

Root planing is the process of using a curette to removesubgingival calculus and altered cementum from the rootsurface.

Scaling is the removal of plaque and calculus from theteeth.

Split-thickness flap contains mucosa and connective tis-sue, but does not include the periosteum.

Subgingival refers to the area located apical to the freegingival margin.

Suprabony pocket is a periodontal defect where theepithelial attachment is located coronal to the alveolarcrest.

Supragingival is the area located coronal to the freegingival margin.

FIGURE 6.2. (A) Marginal gingiva; (B) free gingivalgroove; (C) attached gingiva; (D) mucogingival junc-tion; (E) alveolar mucosa.

A

B

CD

E

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probed, the gingival sulcus floor is located on themost coronal junctional epithelial cells:• The periodontal ligament attaches cementum to

the alveolar bone by collagen fiber bundles(Sharpey’s fibers). The periodontal ligament actsas a suspensory cushion for occlusal forces and asan epithelial attachment to keep debris fromentering deeper tissues.

• Cementum surrounds the tooth root and serves asan attachment area for the periodontal ligament.Cementum anchors teeth and provides a seal forthe dentinal tubules.

The alveolus or alveolar socket is the bony openingwithin the alveolar process in which the root of a toothis held by the periodontal ligament (Figure 6.3). Thealveolar bone height exists as an equilibrium betweenbone formation and bone resorption. When boneresorption exceeds formation, the alveolar bone heightis reduced (Figure 6.4).

PERIODONTAL DISEASE

Within 20 minutes after teeth cleaning, a glycoproteinlayer (acquired pellicle) attaches to the exposed crown.Within 6 hours, bacterial colonization (plaque) formson the glycoprotein layer. In some patients, plaque irri-tates the gingiva, allowing pathogenic anaerobic Gram-negative bacteria to survive subgingivally. By-productsof these bacteria stimulate the host’s immune responseto release cytokines and prostaglandins that weakenand destroy the tooth’s support structure. The progres-sion rate of periodontal disease is dependent on thecomplex regulatory interaction between bacteria andimmune modulators of the host response (Figures6.5,6.6).

Bacteria (Gram-positive, nonmotile aerobic cocci)naturally occupy the sulcus. As periodontal infectionprogresses, the number of bacteria increases at the gin-gival margin, decreasing the subgingival oxygen. The

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FIGURE 6.4. Buccal alveolar height resorption second-ary to periodontal disease.

FIGURE 6.5. Plaque accumulation on buccal surface ofthe maxillary fourth premolar.

FIGURE 6.6. Plaque-covered calculus and periodontaldisease.

FIGURE 6.3. Alveoli of the mandibular incisors andcanine teeth.

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anaerobic conditions allow Gram-negative, motile,anaerobic rods and spirochetes to predominate.

Periodontal infection is a multifactorial disease.Many variables influence why some animals developdisease and others do not. Animals that have compro-mised health often cannot fight periodontal pathogens.Examples of some syndromes that predispose a dog orcat to periodontal disease include diabetes, hypothy-roidism, hyperadrenocorticism, pemphigus, lupus, FIV,and FeLV.

Toy canine breeds are prone to developing periodon-tal disease because:

• Smaller dogs have larger teeth relative to their jawsize, leaving less room for bone support.

• Smaller dogs tend to live longer than larger breeds.The longer an animal lives, the more time periodon-tal disease has to cause damage.

• Smaller dogs are more prone to dental malocclu-sions. Crowding abnormalities decrease the normalself-cleaning process, predisposing the animal toperiodontal disease.

Genetic factors are also responsible for periodontaldisease in some greyhounds, schnauzers, Maltese dogs,and Abyssinian cats.

Plaque and calculus appear as:

• Supragingival plaque forms on the coronal tooth sur-face within hours after a professional teeth cleaning.

• Subgingival plaque occurs after microorganisms pen-etrate and colonize the gingival sulcus. Supragingivaland subgingival bacteria form microenvironments ofbacterial colonies called biofilms, separated from thejunctional epithelium by a wall of neutrophils.Toxins produced by biofilm bacteria causeprostaglandin stimulation and lysosome release,which can damage this neutrophil wall, allowinginvasion of the junctional epithelium.

• Supragingival calculus is mineralized plaque, fooddebris, calcium, and phosphate (Figure 6.7).

• Subgingival calculus is preceded by supragingivalplaque, which loosens the seal between tooth andgingiva. Calculus is always covered with bacteria(Figure 6.8).

Calculus plays a role in maintaining and acceleratingperiodontal disease by keeping plaque in close contactwith gingival tissues, decreasing the potential for repairand new attachment. The therapeutic importance ofremoving all calculus cannot be overemphasized.

Appreciating the difference between gingivitis andperiodontitis is important. Gingivitis is an inflammato-ry process affecting the gingiva only. This process does

not clinically extend into the alveolar bone, periodontalligament, or cementum. Periodontitis is inflammationinvolving the periodontal ligament, alveolar bone, andcementum. Periodontal disease can be further classifiedas active or quiescent, based on evidence of inflamma-tion.

Gingivitis can be present without periodontitis.Periodontal disease can also exist without gingivitis inan area of periodontitis that has been treated and con-trolled, relieving inflammation but not attachment loss.

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FIGURE 6.7. Subgingival and supragingival plaque andcalculus on mandibular canine tooth and incisors.

Table 6.1. Plaque index (PI).

Rank Plaque

0 No plaque

1 Thin film of plaque along the gingival margin

2 Moderate accumulation, plaque in sulcus

3 Large amount of plaque in sulcus

Table 6.2. Calculus index (CI).

Rank Calculus

0 No calculus

1 Supragingival calculus

2 Moderate amount of supragingival and/orsubgingival calculus

3 Large amount of supra- and/orsubgingival calculus

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THE FOUR STAGES OFPERIODONTAL DISEASE

There are numerous grading systems used to classifygingivitis and periodontal disease. Generally, gingivitisis used to describe soft tissue inflammatory changes.Periodontitis is diagnosed when attachment loss hasoccurred. The patient can be “graded” by the worsttooth (i.e., if there is one stage 4 area, the patient hasstage 4 disease). After the disease has been treated, thepatient can be reclassified.

• Stage 1 (gingivitis) appears as gingival inflammationat the free gingival margin. As gingivitis progresses,advanced gingivitis appears as gingival inflamma-tion, edema, and bleeding on probing. Advanced gin-givitis is limited to the epithelium and gingival con-

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FIGURE 6.8. Subgingival calculus visualized with flapexposure on a “cleaned” maxillary canine tooth of adog.

FIGURE 6.9. Stage 1 gingivitis affecting the caninemaxillary fourth premolar.

FIGURE 6.10. Stage 1 advanced gingivitis affecting thegingiva overlying a feline maxillary fourth premolar.

FIGURE 6.11. Gingival recession in stage 2 early peri-odontitis.

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nective tissue. There is no tooth mobility or attach-ment loss. Gingivitis is reversible with proper thera-py and aftercare at home (Figures 6.9,6.10).

• Stage 2 (early periodontitis) occurs when there is api-cal migration of the junctional epithelium, resultingin a deeper sulcus called a pocket, or gingival reces-sion. In stage 2 disease, up to 25% attachment lossoccurs (Figure 6.11).

• Stage 3 (established periodontitis) is present when25–50% attachment loss exists around a root. Slighttooth mobility often occurs in single-rooted teeth.Early furcation exposure and/or gingival recessionmay or may not exist (Figure 6.12).

• Stage 4 (advanced periodontitis) presents whenmarked (greater than 50%) attachment loss occurs.Stage 4 periodontal disease can appear as furcationexposure, abscess formation, tooth mobility, deeppockets, and/or gingival recession (Figures6.13–6.16).

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FIGURE 6.12. Stage 3 established periodontitis in themandibular molar of a cat.

FIGURE 6.13. Stage 4 periodontal disease of the maxil-lary fourth premolar and first molar of a dog.

FIGURE 6.14. Periodontal fistula (arrows) secondary tostage 4 periodontal disease of the maxillary fourth pre-molar in a dog.

FIGURE 6.15. Stage 4 periodontal disease gingivalrecession of the mandibular molar in a cat.

FIGURE 6.16. Stage 4 periodontal disease resulting ingingival recession of the maxillary fourth premolar andfirst molar in a greyhound dog.

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GINGIVAL HYPERPLASIA

Abnormal proliferation of the gingiva is termed gingivalhyperplasia. The boxer breed is more prone than othersto be affected by gingival hyperplasia. Gingival hyper-plasia results in increased pocket depths, caused byincreased gingival height, not attachment loss. Theresultant pseudopocket can accumulate plaque, which,if untreated, may progress to attachment loss. Gingivalhyperplasia is treated by gingivoplasty and strict homecare to help slow recurrence (Figure 6.17).

TOOTH MOBILITY

Normally there is physiological tooth movement of lessthan 1 mm. Teeth may become pathologically mobile inresponse to increased occlusal forces, outside trauma, ornormal forces exerted on a reduced periodontium.Mobility per se is not diagnostic of periodontal disease,but it reflects a pathologic adaptation to stresses placedon the periodontium.

With progression of periodontal disease, tooth sup-port erodes. Eventually, if enough support is lost, thetooth will be lost.

The mobility (M) index uses the following divisions:

• 0 is normal• M1 occurs when the tooth moves a distance slightly

less than 1 mm.• M2 mobility exists when the tooth moves about 1

mm.• M3 mobility is present when the tooth moves a dis-

tance greater than 1 mm, and/or may be depressedinto the alveolus.

MUCOGINGIVAL DEFECTS

Type I mucogingival defects are characterized as pock-ets that extend apically to or beyond the mucogingivaljunction. Treatment for type I mucogingival defectsincludes pocket reduction by performing apically repo-sitioned flap surgery.

Type II mucogingival defects are present when thealveolar mucosa acts as the marginal gingiva without azone of attached gingiva (fissures or clefts). Such lesionsare called nonpocket deformities. The sulcular (pocket)depth may be less than 2–3 mm (Figure 6.18).

The goal of mucogingival surgery for Type IImucogingival lesions is to obtain more resistent tissue towithstand masticatory stress. Lateral pedicle and freeautogenous gingival grafts are two examples ofmucogingival surgery to accomplish this goal. Theseadvanced procedures carry a guarded prognosis andwill fail without excellent home care.

Gingival recession is the exposure of the root surfaceby an apical migration of the gingival margin. Gingivalrecession can be measured from CEJ to the free gingivalmargin.

Gingival recession classification breaks into the fol-lowing categories:

• Class I occurs when recession is present coronal tomucogingival junction (Figure 6.19).

• Class II occurs when recession is present at themucogingival junction but is not accompanied bybone loss interproximally (Figure 6.20).

• Class III recession occurs past the mucogingivaljunction with soft tissue and bone loss interproxi-mally (Figure 6.21).

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FIGURE 6.17. Gingival hyperplasia. FIGURE 6.18. Gingival cleft: white arrows, mucogingi-val junction; black arrows.

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FURCATION INVOLVEMENT

The furcation is a normal anatomical area at the trunkof a multirooted tooth where the roots begin to diverge.Normally this area is sealed from the oral environmentby the periodontium. Furcation involvement, invasion,or exposure occurs secondary to periodontal disease.When the integrity of the periodontium has been lostand junctional epithelium migrates apically, oralmicroflora can gain access and multiply, resulting inprogressive disease. There are three clinical furcationclassifications:

• Class I involvement is diagnosed when an explorercan just detect an entrance to the furcation. A por-tion of alveolar bone and periodontal ligament isintact at the furcation. Generally, there will be lessthan 1 mm exposure (Figure 6.22).

• Class II involvement occurs when an explorer canenter the furcation, but does not exit the other side.The undermined furcation is occluded by gingiva orbone on one side (Figures 6.23,6.24).

• Class III exposure is diagnosed when the periodon-tium is destroyed to such a degree that the furcationis open and exposed. An explorer can pass from sideto side (Figure 6.25).

Radiographs are helpful in locating furcationinvolvement. The slightest radiographic change in thefurcation area should be investigated clinically.Diminished radiodensity in the furcation suggests furca-tion exposure (Figure 6.26).

Furcation involvement usually carries a guarded-to-poor prognosis. Treatment for furcation involvement isan advanced procedure, which success depends on thedegree of exposure, the skill of the veterinarian, and theability of the client to provide home care.

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FIGURE 6.19. Class I gingival recession affecting afeline’s mandibular molar.

FIGURE 6.20. Class II gingival recession affecting afeline’s mandibular molar.

FIGURE 6.21. Class III gingival recession affecting acanine’s maxillary fourth premolar and first molar. FIGURE 6.22. F1 furcation involvement of a maxillary

third premolar in a dog.

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CHRONIC ULCERATIVEPARADENTAL STOMATITIS(CUPS)

Chronic ulcerative paradental stomatitis (CUPS), alsoreferred to as contact ulcers or kissing lesions, appearsas marked ulceration of the buccal mucosa adjacent tocalculus and plaque-laden teeth. Affected animals (oftenMaltese, and other small breeds) may have a hyperim-mune response to plaque (Figure 6.27).

CUPS patients should be evaluated medically, includ-ing organ function profiles, thyroid function, autoim-mune disease evaluation, urinalysis, and lesion biopsyto rule out other causes of stomatitis. In patients whereelevated alkaline phosphatase values are reported, teststo rule out Cushing’s disease should also be performed.

Initial care involves teeth cleaning, both above and

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FIGURE 6.25. Class III through-and-through furcationexposure of the mandibular first molar in a dog.

FIGURE 6.23. Class II furcation exposure in the maxil-lary first molar of a dog.

FIGURE 6.24. Radiograph showing anadvanced ClassII furcation of the maxillary fourth premolar in a dog.

FIGURE 6.26. Radiograph of mandibular first molarshowing Class III furcation exposure.

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below the gum line, and polishing followed by intraoralradiographs. Those teeth affected by grades 3 and 4periodontal disease should be extracted. Antibiotics areindicated to help control infection. Pain medication isalso indicated. Use of the CO2 laser to photovaporizethe lesions has also been used to treat the ulcers, withmixed results. The use of steroids in control of CUPS iscontroversial. Home care, including daily teeth brush-ing; application of a gel and/or oral rinse containingzinc might be helpful in controlling plaque and for ulcercare. If initial therapy and weeks of home care are noteffective, extraction of the rubbing teeth is usually cur-ative.

RADIOGRAPHIC APPEARANCEOF PERIODONTAL DISEASE

Intraoral radiography provides critical informationwhen making periodontal therapy decisions by imagingthe supportive bone mesial (rostral) and distal to theaffected teeth. Unfortunately, due to superimposition, itis difficult to radiographically evaluate the lingual-buc-cal plane.

If clinically and radiographically greater than 50%of the bone and tooth support remains, periodontalprocedures together with a healthy patient and stringenthome care will often result in a saved tooth. A guardedprognosis is given when 50–75% bone loss exists. Ifgreater than 75% support is lost, the prognosis for sav-ing the tooth is poor (Figures 6.28–6.30).

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FIGURE 6.27. Chronic ulcerative paradental stomatitis(kissing lesions). FIGURE 6.28. Less than 50% bone loss affecting the

mesial root of the mandibular first molar. White arrowpoints to calculus attached to the root.

FIGURE 6.29. Between 50–75% bone loss affecting thedistal root of the mandibular fourth premolar.

FIGURE 6.30. Between 75–100% bone loss affecting allof the mandibular molars.

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When evaluating periodontal disease, radiographsare checked for:

• Alveolar bone changes• Trabecular patterns• Interdental bone height• Presence of the lamina dura completely around the

root• Size of periodontal ligament space• Amount of bone loss

PERIODONTAL THERAPY

Criteria the veterinarian should consider when choosingperiodontal therapy includes the following:

• The client’s ability and commitment to performaftercare, return for follow-up progress visits, andincur the related expenses. The pet owner who haslittle success in removing plaque may not be able toprovide essential home care for advanced tooth-sav-ing procedures.

• The degree of patient cooperation and generalhealth.

• The importance (function) of the tooth. The carnas-sial teeth, maxillary fourth premolar, and mandibularfirst molars are important teeth because they act asscissors to cut food into small pieces. Also importantare the molars, which grind food, and the mandibu-lar canines, which provide structure for the rostralmandible. Incisors and first, second, and third pre-molars perform the least important functions.

• The clinician’s ability to perform periodontal proce-dures to minimize attachment loss and maintain atleast 2–3 mm of attached gingiva in dogs, and 0.5–1mm in cats.

PROFESSIONAL ORAL HYGIENE

Prophy is an abbreviation of the word prophylaxis,which is defined by the American Academy ofPeriodontology as the “removal of plaque, calculus, andstains from the exposed and unexposed surfaces of theteeth by scaling and polishing as a preventative measurefor the control of local irritation factors.” The dentist isusually presented with a generally healthy mouth; thehygienist cleans the teeth and reschedules 6 months to 1year later for another prophylaxis. In human dentistry,prophys are performed to prevent dental disease.

When used in the veterinary context, “prophy” is amisnomer for teeth cleaning and periodontal care. Tocall proper attention to the extent of dental care per-

formed, the level of disease should appropriately identi-fy the type of necessary cleaning procedure. Examplesare: “dental cleaning-gingivitis,” “dental cleaning-established periodontitis,” and “dental cleaning-advanced periodontitis.”

THE PROFESSIONAL TEETH-CLEANING VISIT

The dental visit for oral examination and cleaning mustbe performed in a consistent manner. All procedures areimportant and interlinked. When one step is not per-formed, long-term patient benefit may be compromised.

A teeth cleaning packet example includes the follow-ing:

• Sickle scaler—H6/7 (Burns 951-9464, Schein 378-0698), S6/7 (Schein 101-9032) (Figure 6.31)

• Curette—Gracey 12/13 (Burns 950-9545), 11/12(Schein 600-7601), Barnhardt 5/6 (Burns 843-3035,Schein 600-5410, P8 Cislak), Columbia 13/14(Burns 950-9598, P10 Cislak, Schein 100-4313)(Figures 6.32–6.34)

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FIGURE 6.31. Sickle scaler.

FIGURE 6.32. Gracey 12/13 curette.

A

B

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• Calculus-removing forceps, with one eccentric longertip, which is placed over the crown, and a smallertip, which is applied under the ledge of calculus(Burns 271-9120, Schein 102-8318) (Figure 6.35)

• Periodontal probe/explorer, which is a double-endedcombination of a thin Michigan (Burns 894-3194,Schein 600-3203) type probe and a No. 23 explorer(Burns 951-2248, Schein 101-2098, Cislak P2)(Figure 6.36) (Burns 271-9105, Schein 100-4807 ST-4)

• Sterile container for the teeth cleaning packet (Figure6.37)

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FIGURE 6.35. Calculus-removing forceps.

FIGURE 6.33. Barnhardt 5/6 curette.

A

B

FIGURE 6.34. Columbia 13/14 curette.

A

B

FIGURE 6.37. Hand scaling and examination kit.

FIGURE 6.36. Periodontal probe (A) and explorer (B).

A

B

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Before treatment of the animal, the clinician shouldobtain general and dental/oral history, review pre-oper-ative diagnostics, and interview the client concerningexpectations and abilities to provide aftercare.

STEP 1 Visual oral examination on the unanesthetizedanimal. The face is examined visually for swellings andby palpation for areas of tenderness. The assessablelymph nodes are palpated for pain, texture, and size.The mouth is opened and closed to check the occlusionand pain or crepitus of the temporomandibular joints.The number of teeth is counted in each quadrant. Thelips, tongue, palate, pharynx, teeth, and gingiva areexamined for lesions. Even a small amount of plaquetouching the gingiva is abnormal. Often, fractured teethhave more calculus than the other teeth from chewingon the opposite side due to pain and discomfort (Figure6.38).

STEP 2 Visual oral examination under general anes-thesia after the patient is intubated, cuff is secured andinflated, and ophthalmic ointment is applied to thecorneal surfaces. The patient is positioned in lateral ordorsal recumbency. The head is supported with a towelto prevent injury. Each tooth is visually examined forfracture, abnormal wear, mobility, and discoloration(Figure 6.39).

128

FIGURE 6.38. Swollen muzzle secondary to an abscesscaused by a fractured maxillary canine tooth.

FIGURE 6.39. Gingival swellings and recession causedby endodontic (black arrows) and periodontic (whitearrows) disease of the mandibular first molar.

FIGURE 6.40. Radiograph of endodontic (blackarrows) and periodontal (white arrow) lesion of themandibular first molar portrayed in figure 6.39.

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STEP 3 Intraoral radiography helps the practitionerdiagnose periodontal lesions below the gingiva (Figure6.40).

STEP 4 Supragingival plaque and calculus removal isaccomplished with the help of hand instruments and/orpower scaling equipment. Before the actual teeth clean-ing procedure is started, the oral cavity is irrigated with0.12% chlorhexidine solution. Ultrasonic beavertail orP-10 tips are designed for gross debridement ofsupragingival calculus (Figures 6.41,6.42).

Periodontal bactericidal ultrasonic debridement is aterm used to describe supra- and subgingival treatment toremove plaque, plaque-retentive calculus, and toxic by-products. The removal of irritants within the gingival sul-cus is accomplished using periodontal ultrasonic scalers.Ultrasonic sound waves are made up of alternate com-pressions and rarefactions. During the low-pressure rar-efaction cycle, microscopic bubbles are formed. Throughthe high-pressure compression cycle, the bubbles collapse or implode. These implosions produce shock waves

called cavitation, which may disrupt the bacterial cellwall and lead to bacterial cell death.

Acoustic streaming occurs when a continuous tor-rent of water produces tremendous pressure within theconfined space of the periodontal pocket, resulting in adecreased number of bacteria. Gram-negative motilerods in particular are sensitive to acoustic streamingbecause of their thin cell walls.

STEP 5 Subgingival periodontal cleaning and rootplaning (if indicated). Periodontal disease occurs sec-ondary to the imbalance of subgingival bacteria withthe host. The goal of teeth cleaning is to remove irritat-ing plaque and calculus from the gingival sulcus. Calcu-lus, coated with bacteria, left on the root surfacecontributes to the progression of disease. If subgingivalcleaning is not performed, the teeth have not been ade-quately cleaned. Subgingival root cleaning can beaccomplished with curettes or special ultrasonic peri-odontal subgingival inserts (Hu-friedy) manufacturedfor subgingival use. The Fineline tips are only for clean-ing the root surface. Using them for supragingival calcu-lus removal will often lead to tip breakage (Figures6.43, 6.44).

Disclosing agents are organic dyes that reveal areasof dental plaque. Disclosing agents are useful both diag-nostically and in assessing the efficiency of cleaning pro-cedures. The disclosing solution can be swabbed on thetooth surfaces using cotton pledgets, after the teethcleaning procedure and before the animal is awakened.Stained calculus and plaque are visualized and removed.The disclosing solution may also be applied in the examroom to monitor client home care. Caution must beused when applying disclosing solution on light-hairedbreeds. The solution may temporarily stain facial hairs(Burns 951-1218, Schein 100-2491) (Figure 6.45).

129

FIGURE 6.41. Small animal extraction forceps used forgross supragingival calculus removal (better choice ofinstrument would be calculus-rmoving forceps, see fig-ure 6.35).

FIGURE 6.42. Ultrasonic instrument used to clean thecrown.

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STEP 6 Charting is performed to record the conditionof the mouth. A chart contains drawings of teeth and

areas to mark pathology and therapy suggested and/orcompleted. Charted oral pathology includes missing,mobile, fractured, and discolored teeth, as well as felineodontoclastic resorptive lesions, periodontal pocketdepths, gingival recession, and other significant lesions.Charting is usually performed before the teeth arecleaned, and may be repeated after supra- and subgingi-val calculus removal (Burns 342-0691, Schein 100-8927) (Figures 6.46, 6.47).

130

FIGURE 6.43. Subgingival insertion of specializedultrasonic tip.

FIGURE 6.44. Use of a curette to remove plaque andcalculus from the root subgingivally.

FIGURE 6.45. Disclosing solution (Virbac).

FIGURE 6.46. Technician charting the mouth.

FIGURE 6.47. Completed dental chart.

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A periodontal probe is the single most importantexamination instrument used to evaluate periodontalhealth. By gently inserting a calibrated periodontalprobe just apical to the free gingival margin and tracingthe gingival crevice from mesial to distal, a rapid deter-mination of the health of the sulcular tissues can bemade. The clinical sulcus depth is the distance from freegingival margin to the most apical point that a probereaches when gently inserted into the gingival crevice(Figure 6.48).

The probe stops where the gingiva attaches to thetooth or at the apex of the alveolus if attachment is lost.Each tooth should be probed on a minimum of six sides.Bleeding on probing is indicative of an inflammatoryprocess in the connective tissue adjacent to the junc-tional epithelium. If the sulcular lining is intact andhealthy, no bleeding will occur. If, however, periodontaldisease is present, bleeding will usually take place.

Normal dogs should have less than 3 mm probingdepths, and cats less than 1 mm. Abnormal probingdepths are noted on the dental record and discussedwith the client, and then a treatment plan is mapped outbefore therapy begins.

PocketsThe periodontal pocket is a pathologically deepenedgingival sulcus. Clinical (absolute) pocket depth is thedistance from the free gingival margin edge to the baseof a pocket, measured in millimeters.

Attachment loss (attachment level) is used to evalu-ate support loss in cases of gingival recession where lit-tle or no pocketing exists. The measurement of attach-ment loss is the backbone of a periodontal examination.The clinical pocket depth plus recession (measured CEJto free gingival margin) equals the total periodontalattachment loss (Figure 6.49).

STEP 7 Therapy to treat lesions found. When peri-odontal disease is not treated, bacteria will continue toreproduce, possibly creating deeper periodontal pocketswith more bone destruction, causing pain and eventu-ally tooth loss. Periodontal disease has been shown tobe associated with lesions in a patient’s kidney, heart,and liver.

The following are goals of periodontal therapy:

• Removing debris from the tooth surface and peri-odontal pocket(s)

• Minimizing pocket depth• Minimizing attachment loss• Maintaining at least two millimeters of attached gin-

giva• Producing a gingival contour to promote self-cleaning• Decreasing future pocket formation

131

FIGURE 6.48. Periodontal probe inserted subgingivally.

FIGURE 6.49. In areas of gingival recession, measure-ment of attachment loss is a better gauge of periodontalhealth compared to probing depth alone.

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STEP 8 Polishing smoothes minor enamel defects andremoves some of the plaque missed during previoussteps. Regardless of how careful the scaling/curettagephase of teeth cleaning is performed, minor defects(microetches) of the tooth surface occur. Polishing teethdecreases the surface area of enamel defects, retardingplaque recolonization.

Prophy paste (Burns 951-8652, Schein 100-7869) orflour pumice (Burns 907-6002, Schein 100-5836) isapplied to the tooth surface with a prophy cup attachedto the prophy angle on a low-speed handpiece. Cross-contamination can be avoided between different ani-mals by using individual paste cups or a tongue depres-sor to bring paste from the container to the teeth.Metallic prophy angles have screw-on or snap-on fit-tings. The author prefers plastic disposable polishingangles. Oscillating disposable prophy angles generateless heat on the enamel and do not tangle pet hair(Figures 6.50–6.53).

132

FIGURE 6.50. Flour pumice used for tooth polishing.

FIGURE 6.51. Large prophy paste container.

FIGURE 6.52. Individual prophy paste cups.

FIGURE 6.53. Disposable prophy angle.

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The cup is kept in contact with the tooth, using con-tinuous motion. When polishing, light pressure is useduntil the cup edge flares (Figure 6.54). Care must betaken not to hold the cup on one spot for more than afew seconds to prevent overheating and subsequentdamage to the pulp.

Air PolishingAir polishing uses sodium bicarbonate to “sandblast”the tooth surface smooth in addition or as a replace-ment to conventional polishing (Figure 6.55).

To use an air polisher, a source of compressed air,CO2 or nitrogen, plus water is necessary. The air mixeswith water and sodium bicarbonate crystals creating anabrasive slurry, which removes minor stains and partic-ulate matter on the tooth surface. Advantages of air pol-ishing include lack of potential iatrogenic pulpal ther-mal damage and the ability to polish hard-to-reachareas.

Follow these steps when performing air polishing asa prophylaxis technique:

• When using the air polisher, place a cuffed endotra-cheal tube in the patient and gauze sponges in theoropharynx to prevent aspiration.

• For patient protection, apply eye ointment and placea towel over the eyes.

• Avoid striking the unkeritinized tissue. Air polishingshould not be used on exposed cementum or dentin(Figures 6.56–6.58).

• Place the tip of the air polishing nozzle 3–4 mmslightly apically on the incisal to the middle 1/3 ofthe tooth. Using a constant circular motion, sweeparound the tooth. Do not direct the tip into the sul-cus (Figure 6.59).

133

FIGURE 6.54. Polishing technique.FIGURE 6.55. Prophy Jet air polisher (Cavitron).

FIGURE 6.56. Sodium bicarbonate port.

FIGURE 6.57. Filling the bicarbonate port.

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• Use proper angulation of the nozzle tip toward thesurface of the tooth, as follows:• Distal: 80°• Mesial: 60°• Occlusal: 90°

• Polish one or two teeth per second. Avoid applica-tion to dentin or cementum.

STEP 9 Irrigation removes loose debris from thepocket or sulcus. Water spray and/or a 0.05–0.2%chlorhexidine gluconate solution (CHX Oral LavageSolution, Virbac Products) are commonly used.Chlorhexidine is the most effective chemical agent avail-able for the prevention and retardation of plaque accu-mulation and gingivitis. Chlorhexidine does not removeestablished plaque (Figures 6.60,6.61).

Positive properties of chlorhexidine include:

• Adheres to teeth, pellicle, and soft tissues.• Gradually releases in therapeutic levels over 6 hours,

with residual antibacterial effect for 24 hours.• Is effective against both gram-negative and gram-

positive organisms.• Inhibits plaque by binding to the pellicle, thereby

reducing bacteria on the tooth surface.• When used before ultrasonic scaling, decreases the

volume of aerosolized bacteria to the operator andbacteremia to the patient.

• Does not result in bacterial resistance with long-termusage.

Disadvantages to the use of chlorhexidine in animalsinclude the following:

• Bitter taste, especially for cats

134

FIGURE 6.58. Air polisher maintenance.

FIGURE 6.60. Chlorhexidine irrigation solution (iM3).

FIGURE 6.59. Proper position for air polishing.

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• Brown or black staining of the pellicle with pro-longed use (stain is easily removed through ultrason-ic scaling)

• Possible retardation of periodontal healing

The gluconate form of chlorhexidine is most com-monly used as an irrigating solution delivered with ablunt 23 gauge needle on a 6 ml syringe, or through theair/water syringe on the dental delivery system (CHXLavage Solution, Virbac Products). Chlorhexidine canalso be used as part of the home care process twice dailyfor 2 weeks followed by daily application for patientsaffected with periodontal disease (Hexarinse, VirbacProducts).

STEP 10 Fluoride application. In human dentistry,fluoride is used mainly to prevent caries. In veterinarydentistry, the use of fluoride is controversial. Caries arerare in dogs and virtually unheard of in cats.

Potential fluoride advantages in veterinary dentistryinclude the following:

• Decreases enamel surface tension• Reduces tooth sensitivity by sealing exposed dentinal

tubules• Inhibits bacterial metabolism, which might decrease

plaque accumulation• Leaves a cherry-like odor after application

(FluraFom Virbac Products)

Fluoride’s potential disadvantages include the fol-lowing:

• Toxicity if used chronically in higher than recom-mended dosages

• Extension of anesthetic time for application andremoval

• Interference with acrylic bonding polymerization

Fluoride-containing preparations include the follow-ing:

• Fluoride varnish, which is virtually ineffective insmall animals because its effect is short-lived (Burns950-9131, Schein 100-0045)

• Fluoride gel (Burns 951-7908, Schein 100-8570),Gel-Tin Topical Fluoride Phosphate Anti-caries Gel(Young Dental Manufacturing)

• Fluoride solution (Burns 269-0520, Schein 100-2105)

• Fluoride foam, which can be applied while the ani-mal is anesthetized to clean, dry teeth (FluraFomVirbac Products) (Burns 269-0520, Schein 309-0143) (Figures 6.62–6.64)

135

FIGURE 6.62. Application of fluoride foam on a gauzesponge.

FIGURE 6.61. Application of irrigation solution sub-gingivally using a syringe.

FIGURE 6.63. Application of fluoride foam on the teeth.

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When using fluoride foam, approximately 1/2 inchof the foam is rubbed over the teeth and allowed toremain for 3 minutes. The foam is removed with suctionor with a dry gauze sponge. Irrigation is not used afterfluoride application.

STEP 11 After treatment, home care involves daily(twice daily preferred) tooth brushing, and/or using oralpads to remove plaque accumulation. Before periodon-tal treatment is initiated, a discussion with the petowner concerning commitment and ability to provideaftercare should be conducted (Figure 6.65).

STEP 12 Follow-up visits are essential to monitor peri-odontal healing. The time between oral exams should

be based on the degree of disease and the client’s abilityto provide aftercare. Progress visits are initially sched-uled weekly until the owner is comfortable with thehome care process. Thereafter, advanced periodontalcases should be rechecked every other week to monthly.Pets that have been treated for stage 1 or 2 disease, andwhose teeth are brushed once or twice daily, could berechecked every 6 months. The reminder interval forrecheck can be linked by computer to the degree of peri-odontal disease (i.e., if the patient is treated for grade 3periodontal disease, a monthly progress reminder canbe automatically generated).

THERAPY OF PERIODONTALDISEASE

STAGE 1 Gingivitis care ideally includes thoroughsupra- and subgingival teeth cleaning and polishing, fol-lowed by daily brushing. Gingivitis will usually resolvewithin weeks of the oral hygiene visit.

STAGE 2 Early periodontal disease, where minimal tomoderate pockets are diagnosed associated with gingivi-tis, can be treated similarly to stage 1 disease +/- rootplaning, +/- local administration of antibiotic (LAA).Doxirobe Gel (Pfizer) contains a flowable biodegrad-able solution of 8.5% doxycycline hyclate, which can beapplied subgingivally to cleaned periodontal pocketsgreater than 3 mm in dogs older than 1 year, accordingto the manufacturer. Upon contact with the gingivalcrevicular fluid or water, the doxycycline polymer hard-ens within the periodontal pocket. The biodegradableinsertion of doxycycline allows sustained release oftherapeutic levels of antibiotic for several weeks at thesite of injection. The gel gradually biodegrades to car-bon dioxide and water. Doxirobe is not a substitute forscrupulous pocket debridement and other periodontalprocedures (Figure 6.66).

Doxycycline insertion:

• Allows direct treatment of localized periodontal dis-ease

• Is bacteriostatic against Porphyromonas gingivalis,Prevoltella intermedia, Camphylobacter rectus, andFusobacterium nucleatum, which are associated withperiodontal disease

• Inhibits collagenase enzymes, which are destructiveto the periodontal attachment apparatus

• Directly binds to dentin and cementum for pro-longed release, according to the manufacturer.

136

FIGURE 6.64. Removal of excessive fluoride foam witha dry gauze sponge.

FIGURE 6.65. Allowing pet owner to demonstratebrushing technique.

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• Decreases edema and inflammation, and promotesgrowth of junctional epithelium resulting indecreased pocket depth, according to the manufac-turer.

• Helps rejuvenate tissues of the periodontium,according to the manufacturer (LAA does not regen-erate lost tissue)

To insert doxycycline:

1. Hold the two supplied syringes upright to avoidspilling before coupling.

2. Couple the liquid containing syringe A, identifiedby a red stripe, and syringe B, doxycycline powder.

3. Inject the liquid contents of syringe A into syringe Band then push it back into syringe A, constitutingone mixing cycle.

4. Using brisk strokes, complete 100 mixing cycles ata pace of 1 cycle per second, with the final mix intosyringe A (red stripe).

5. Hold the coupled syringes vertically with syringe Aat the bottom. Pull back the plunger of syringe A,allowing the contents to flow down the barrel forseveral seconds.

6. Attach the blunt injection cannula to syringe A; thetip is bent to resemble a periodontal probe.

7. Insert the blunt syringe tip into the cleaned pocket,near the base, and inject the gel until it starts toextrude from the top of the pocket (Figures6.67–6.69).

8. Withdraw the cannula tip from the pocket. To sep-arate Doxirobe from the cannula, turn the tiptoward the tooth and press against the tooth sur-face, pinching a string of the formulation.

9. Apply water drops to the area to hasten gel hard-ening.

10. Pack the gel into the pocket with a premoistenedW-3 plastic beavertail instrument, cord packer, or#7 wax spatula. If necessary, apply more Doxirobein the pocket until full.

Advise the client not to brush the dog’s teeth wherethe gel was applied for two weeks following localantibiotic gel application.

STAGE 3 AND STAGE 4 Established and advancedperiodontal disease therapies are based on dental find-ings after the patient and radiographs are evaluated.

Therapy decisions are based on the following:

• Percentage of support loss. Greater than 50% sup-port loss carries a guarded-to-poor prognosis;greater than 75% support loss carries a poor prog-nosis for long-term success.

• Type and extent of attachment loss. Pockets formsecondary to the apical migration of the epithelial

137

FIGURE 6.67. Doxirobe Gel inserted into the pocket ofa manibular canine in a dog.

FIGURE 6.66. 4 mm periodontal pocket affecting amandibular canine in a dog.

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attachment. Absolute pockets are classified as eithersuprabony or infrabony.

Suprabony pockets are above the margin of alveolarbone. Suprabony pocket bone loss commonly occurshorizontally at similar rates on the mesial and distal sur-faces of the teeth (Figures 6.70,6.71).

When the suprabony pocket is less than 5 mm, treat-ment includes removal of supra- and subgingival plaqueand calculus, root planing, and—in the dog—installa-tion of local antibiotics (Doxirobe). This initial careusually provides tissue shrinkage, connective tissueremodeling, and gain of soft tissue attachment reducingpocket depth. Home care is essential for maintenance.

If greater than 50% of the gingiva and alveolar bone

has receded along the root, or if furcation exposurescannot be cleaned at home, extraction is the treatmentof choice unless the owner accepts a guarded to poorprognosis.

For suprabony pockets >5 mm without gingivalrecession, apical repositioned flap surgery can be per-formed to visualize and clean the roots so that adequatetreatment can be accomplished to help eliminate thepocket.

Infrabony (infra-alveolar vertical bone loss) pocketsoccur when the pocket floor (epithelial attachment) isapical to the alveolar bone. The infrabony pocketextends into a space between the tooth and the alveolarsocket. Often gingival recession will accompany theinfrabony pocket. Radiographically, infrabony pocketsappear as vertical loss of bone along the root surface.

Infrabony defects are classified, and treatment deci-

138

FIGURE 6.69. Water used to harden the Doxirobe Gel.FIGURE 6.68. Plastic applicator used to press DoxirobeGel into the pocket.

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sions are structured, by the number of walls remainingaround the tooth. An infrabony defect is shaped like abox that has no top. The floor of the box is the base ofthe pocket. One side of the box or pocket is next to theroot surface that has undergone attachment loss. Themissing box top corresponds to the entrance to thepocket. The three remaining sides of the box are thepotential walls of the defect.

Three-wall (intrabony) defects occur when the softtissue that lines the pocket is surrounded with threesides of bone and one tooth surface (example: caninepalatal defect). Three-walled pockets carry the bestprognosis for eventual bone fill after periodontal thera-py (Figure 6.72).

Two-wall bony defects are bordered by two osseouswalls and two tooth surfaces (Figure 6.73).

One-wall defects occur when only one wall of boneremains around two tooth surfaces. The facial or

139

FIGURE 6.71. Periodontal probe extending 5 mm intoa suprabony pocket.

FIGURE 6.70. Periodontal probe before insertion.

FIGURE 6.72. Three-walled infrabony defect palatal tothe left maxillary canine.

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palatal/lingual portion of the alveolar crest has beendestroyed by disease in one-wall defects (Figure 6.74).

Combined (cup) bony defects occur when the toothsits without any surrounding bony surfaces. Combinedbony defects carry the worst prognosis.

PERIODONTAL INSTRUMENTS

Periodontal surgical tray contents include the fol-lowing:

• Probe and explorer. A double-ended combination ofa thin Michigan type probe, No. 23 explorer (Burns951-8624, Schein 100-0805), and a double-endedcow horn explorer for examination of furcationareas (P2 probe/explorer Cislak, Cow horn EXP 3CH).

• Disposable number 15 or 15C scalpel blade andnumber 3 handle.

• Periodontal knife (examples include Goldman-FoxNo. 11, (Figure 6.75) (Burns 951-7840, Schein 100-1288), Orban 1-2 (Figure 6.76) (Burns 951-7792,ORB 1/2 Cislak, Schein 600-8598), Bucks 5/6(Figure 6.77) (Burns 951-7781, Schein 600-3623) or#15 scalpel blade (Burns 808-0175, Schein 953-

140

A

B

FIGURE 6.73. Two-walled defect. FIGURE 6.74. One-wall defect.

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7101). Orban knives are shaped like spears that havecutting edges on both sides of the blade. Kirklandknives are double-ended with kidney-shaped blades.

• Periosteal elevators reflect and retract periosteumfrom the surface of the bone. Molt (Figure 6.78)

(Burns 951-7875, Schein 100-4888, Cislak EX-1)and Freer (Figure 6.79) (Burns 843-2422, Schein953-0025, Cislak) are human dental elevators com-monly used in veterinary dentistry. The EX 7 and EX9 (Cislak; Burns 271-9050, 699-2598) are periostealelevators manufactured specifically for small dogsand felines (Figure 6.80).

• Curettes come in a wide selection. Popular examplesare the McCall 17/18 (Burns 950-9536, Schein 100-6283, P9 Cislak), Gracey 11/12 (Burns 950-9605,Schein 100-1982, P20 Cislak), and Gracey 13/14,(Burns 950-9605, P21 Cislak, Schein 100-4313).

• Osseous and gingival reduction contouring instru-ments include bone chisels and files for hand use, aswell as a selection of diamond burs for the high-speed handpiece.

141

FIGURE 6.75. Goldman-Fox No. 11 periodontal knife.

A

B

FIGURE 6.78. Molt periosteal elevator.

FIGURE 6.76. Orban periodontal knife.

A

B

FIGURE 6.77. Bucks periodontal knife.

A

B

FIGURE 6.79. Freer periosteal elevator.

A

B

FIGURE 6.80. EX 9 periosteal elevator.

A

B

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• Fine curved cilia scissors.• The Castroviejo needle holder allows controlled

suturing of delicate flaps (Figure 6.81) (Burns 950-6105, Schein 100-2146, 4388 Cislak).

• The No. 6 India sharpening stone is used to sharpenperiodontal instruments. The sharpening stone canbe autoclaved for use during surgical procedures(Burns 843-3204, Schein 600-2191).

FLAP SURGERY

Tissue that is raised from its bed and left attached on atleast one side is called a flap. The base through whichthe attachment and circulation is maintained is calledthe pedicle.

Flaps provide an ideal method to allow exposure ofthe root surface, preserve attached gingiva, and allowthe gingiva to be sutured in a fashion that reduces theperiodontal pocket and promotes reattachment to theroot surface.

During the surgical preparation phase, if chlorhexi-dine is used as an irrigant, it must be irrigated thor-oughly. High concentrations of chlorhexidine may devi-talize periodontal ligament cells and interfere withattachment. A strength of 0.05% chlorhexidine is con-sidered safe.

Flap design should meet the following criteria:

• Flaps should be planned for maximum utilizationand retention of keratinized gingival tissue to main-tain a functional zone of attached keratinized gingi-va.

• Flap design should allow adequate access and visibil-ity. Flaps should have ample length to fully evaluatethe root surface not covered with bone.

• Involvement of adjacent areas should be avoided.• Primary closure is preferred to secondary intention

healing.• The base of a flap should be 1 1/2 times as wide as

the coronal aspect to allow adequate vascularity.• Tissue tags should be removed to allow rapid healing

and prevent granulation tissue.

• Adequate flap stabilization is necessary to preventdisplacement, bleeding, hematoma formation, boneexposure, and infection.

Flap closure should meet these criteria:

• Sutures should be placed from movable to nonmov-able tissue when possible. The sutured flap should betension-free.

• Knots should be tied three to five times (dependingon suture type) to prevent loosening. Surgical knotsshould not lie on the incision line.

• The suture needle should be held anterior to the cur-vature but not at the tip.

• Rapidly absorbable 3-0 to 5-0 suture materialattached to curved P1 or P3 Ethicon needles are pre-ferred by the author. A reverse cutting edge is used tominimize inadvertent tissue tears. In human peri-odontal surgery, many procedures finish with onlytissue approximation, and few—if any—sutures.Sutures impose an additional insult on the tissue,which can slow wound healing, and are plaque-retentive. Additionally, suture tracts provide a sitefor bacterial invasion.

• A continuous suture pattern should be used if possi-ble, because it reduces the number of knots.

• Inverted knots are preferred, minimizing plaqueretention.

Flap ClassificationThe full-thickness flap is used to gain visibility and accessfor osseous surgery, root planing, and pocket elimination.A full-thickness flap, which includes the periosteum, canbe elevated by blunt dissection using a periosteal elevatorin a rocking motion until the periosteum is peeled awayfrom the underlying bone (Figure 6.82)

142

FIGURE 6.81. Castroviejo needle holder.

FIGURE 6.82. Full-thickness mucoperiosteal flaparound the mandibular fourth premolar in a dog.

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The partial- or split-thickness (mucosal) flap leavesthe periosteum at the donor site, avoids larger bloodvessels, and allows suture placement in the periosteum(Figure 6.83). Partial-thickness flaps are indicated:

• Where there are thin bony plates.• In areas of dehiscence or fenestration where bone

must be protected.• In areas where bone loss is permanent.

Envelope flapsEnvelope flaps are conservative full-thickness elevationscoronal to the mucogingival line, used to expose gingivalpockets through intrasulcular incisions. The horizontalincision is made along the alveolar margin at least onetooth distal to two teeth mesial to the site of operation.In the unmodified envelope flap, there are no verticalreleasing incisions. After the root surface is cleaned andirrigated, sutures are placed to close the flap (Figure6.84).

Modifications of a basic envelope flap include thefollowing:

• An envelope flap can also be made with one verticalreleasing incision. The papilla is included in themesial extent of the incision to make repositioningand suturing easier (Figure 6.85).

143

FIGURE 6.83. Partial-thickness flap over the maxillarysecond premolar in a dog.

FIGURE 6.84. Envelope flap for the maxillary caninetooth in a cat.

FIGURE 6.85. Triangular flap over the maxillarycanine in a dog.

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• An envelope flap made with two vertical relaxingincisions (pedicle flap).

• Curved or semilunar flaps do not involve the gingi-val sulcus. They are placed in attached or unattachedgingiva for periapical endodontic surgical access orretrieval of small root tips (Figure 6.86).

• Access flaps expose the involved root surface(s) andalveolar margins for visualization and instrumenta-tion. The access flap, which is not reflected past thecrestal bone, gives the clinician entrance to infrabonydefects and root surfaces. Under direct vision, defectscan be carefully curetted and root surfaces planed.Access flaps are replaced and sutured at their origi-nal height.

Access flapUse the following technique to perform access flap sur-gery:

1. Make mesial and distal vertical interdental incisions2 mm apical to the deepest level of the pocket.Placing the incision totally in attached gingiva pre-serves the rich blood supply during and after sur-gery and takes advantage of the rapid epithelialmigration encountered in this area during woundhealing (Figures 6.87,6.88). If the flap is to bereplaced in its original location, it need not be ele-vated past the mucogingival line.

2. Angling the blade tip toward the root, make a 360°incision in the pocket (Figure 6.89).

3. Use a periosteal elevator (Molt or Freer) to exposethe tooth’s root surface for cleaning and root plan-ing (Figures 6.90,6.91).

4. Perform minor alveoloplasty (removing sharp bonyspicules), if needed, using either bone-cutting for-ceps, hand chisels, or a diamond bur in a water-cooled high-speed handpiece.

144

FIGURE 6.86. Semilunar flap for apicoectomy expo-sure of the maxillary canine tooth in a dog.

FIGURE 6.87. Distal interdental incision of the gingivaof a maxillary canine tooth in a dog.

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5. Plane the root surface and remove granulation tis-sue with a curette.

6. Place interdental 4-0 absorbable, simple, interrupt-ed sutures to replace the flap.

Apically Repositioned FlapAn apically (re)positioned flap is created to decrease thedepth of pockets in areas of alveolar bone loss withoutsacrificing the attached gingiva. The objective is to repo-sition the gingiva so it overlies the remaining alveolarbone with the margin extending 2 mm coronally.

The following are indications that an apically posi-tioned flap is needed:

• Suprabony pockets (Figure 6.92)• Moderate one- and two-walled infrabony pockets

• Crown lengthening• Furcation involvement to get the furcation exposed

for the pet owner to provide home care

The following are contraindications for such a flap:

• Marked bone loss leaving minimal tooth support• Grade 3 tooth mobility• Inadequate (less than 2 mm) attached gingiva present

pre-operatively• Non-pocket mucogingival deformity (dehiscence or

fenestration)

To create an apically positioned flap:

1. Insert a number 15 blade 360° around the tooth toincise the epithelial attachment.

145

FIGURE 6.88. Mesial interdental incision past themucogingival junction for greater exposure of the max-illary canine in a dog.

FIGURE 6.89. Scalpel blade incising the coronal peri-odontal attachment of a maxillary canine in a dog.

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2. Make vertical releasing line angle incisions from thegingival margin and carry them apically past themucogingival line (Figure 6.93).

3. With a curette, remove loose alveolar connectivetissue, muscle, and granulation tissue at the alveo-lar margin. Debride bone defects to remove residualsoft tissue. Use irrigation and compressed oil-freeair to disclose missed plaque and calculus (Figure6.94).

4. After cleaning the exposed root, suture the flapwith 4-0 or 5-0 absorbable suture material to aposition at the alveolar margin, reducing pocketdepth. Leave the redundant tissue to fibrose natu-rally (Figure 6.95).

5. Apply gentle but firm digital pressure on the gingi-va for 60 seconds. The pressure thins the fibrin clot,stimulates initial adhesion between wound edges,and reduces bleeding and hematoma formation.

Reverse Bevel FlapIn the reverse bevel flap (excision new attachment pro-

146

FIGURE 6.90. Elevator used to dislodge the attachedgingiva from the buccal alveolar plate of the maxillarycanine in a dog.

FIGURE 6.91. Full-thickness mucoperiosteal flap of themaxillary canine in a dog..

FIGURE 6.92. Suprabony pocket affecting the attachedgingiva in a mandibular canine in a dog.

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cedure, ENAP), a portion of the diseased pocket epithe-lium is removed to gain access for root treatment.

Indications for a reverse bevel flap include the fol-lowing:

• Inflamed and necrotic free gingival margins• Access to three-walled infrabony defects treated with

bone grafts• Mild-to-moderate cases of gingival hyperplasia• Suprabony pockets extending apically to the

mucogingival junction without osseous deformities

Use the following technique to create a reverse bevelflap:

1. Make the initial reverse beveled incision 1 mm api-cal to the gingival margin, 10° toward the long axisof the tooth between the diseased and healthy-appearing attached gingiva. The incision leaves acollar of diseased tissue attached to the tooth,which can be removed with a curette (Figures6.96,6.97).

147

FIGURE 6.94. Curette used to remove subgingival calcu-lus exposed by a flap over a mandibular canine in a dog.

FIGURE 6.95. Sutured apically repositioned flap over amandibular canine in a dog.

FIGURE 6.93. Vertical line angle incison of amandibular canine in a dog.

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2. Make interdental releasing incisions mesial (and, ifneeded, distal) to adjacent healthy teeth (Figure6.98).

3. When there are no bony defects, use a periostealelevator to elevate the flap to the alveolar margin.If infrabony defects are found, make a full-thick-ness mucoperiosteal flap to gain exposure to thediseased bone (Figures 6.99,6.100).

4. Perform root planing.5. Perform alveoloplasty, using a hand chisel or a

small round bur to create a smooth parabolic flowof the alveolar margin.

6. Place 4-0 or 5-0 absorbable sutures to appose“healthy” attached gingival incised edges (Figure6.101).

7. With moistened gauze sponges, apply several min-utes of digital pressure to help adaptation of the tis-sues.

148

FIGURE 6.96. Reverse beveled incision (illustration byMichael Leonard, provided by courtesy of NutramaxLaboratories, Inc.).

FIGURE 6.97. Reverse beveled incision carried distally.

FIGURE 6.98. Vertical releasing incisions (illustrationby Michael Leonard, provided by courtesy of NutramaxLaboratories, Inc.).

FIGURE 6.99. Flap elevation (illustration by MichaelLeonard, provided by courtesy of NutramaxLaboratories, Inc.).

FIGURE 6.100. Removal of diseased gingival collar.Note: gingival exposure is extreme.

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Laterally Positioned (Pedicle) FlapA laterally positioned pedicle flap is an advanced surgi-cal procedure that is indicated where a localized gingi-val cleft exposes the tooth’s root. The apical portion ofthe cleft defect is usually bound by alveolar mucosa andfrequently found in an inflamed state. If the mesial anddistal interadicular bone bordering such a defect hasnormal bone height, the laterally positioned pediclegraft can partially cover the denuded root when healed.

The laterally positioned flap surgery should not beattempted in teeth that are mobile due to periodontaldisease, when furcation exposure exists, or in a patientwhose caregiver cannot provide adequate aftercare.

Use the following technique to create a lateral posi-tioned flap:

1. Make a vertical incision 2–3 mm on each side of thedefect. The vertical incisions on either side of thedefect are designed differently. The incision on theside away from the donor site is beveled toward thedefect to create a broad recipient connective tissuesurface for suturing. The vertical incision on thesame side as the donor tissue is beveled away fromthe defect. The pedicles are elevated further thanthe mucogingival line because periosteum of theattached gingiva does not allow stretching. Thebeveled incisions should be generous enough toallow about 3 mm beyond the denuded root forplacement and suturing of the donor flap (Figures6.102,6.103).

2. Remove granulation tissue with a curette after theincisions are made and donor tissue is removed(Figure 6.104).

3. Delineate the distal extent of the split-thicknessdonor pedicle flap by making a vertical incision api-cally into the alveolar mucosa. The split-thickness

flap (which leaves no denuded bone at the donorsite) is harvested attached at its base. There must besufficient dissection apical to the mucogingival junc-tion or the flap will not have adequate mobility.

149

FIGURE 6.101. Sutured “healthy” attached gingivareverse beveled incision.

FIGURE 6.102. Localized gingival cleft along the labialsurface of the maxillary corner incisor in a dog.

FIGURE 6.103. Incisions on either side of the defect.

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close to the bone surface. Join the vertical incisionswith a horizontal incision.

2. Separate the flap from the underlying connectivetissue by sharp dissection. Position the flap apicallyand suture to provide a host bed of the desired size(Figure 6.107).

To secure donor tissue:

1. Harvest donor tissue for the free gingival graft fromthe wide attached gingival area apical to the maxil-lary canine on the same side of the defect (Figure6.108).

2. Determine the size of the graft needed by measuringthe length and width of the recipient bed with aperiodontal probe. The graft should be approxi-mately 20% larger than the recipient site to allowshrinkage and tension-free suturing.

150

FIGURE 6.104. Cleaned root surface.

FIGURE 6.105. Resutured flap covering the originaldefect.

FIGURE 6.106. Marked gingival recession affecting thedistal root of the maxillary first molar in a dog.

FIGURE 6.107. Flap exposure for cleaning the calculusand plaque from the root surface.

4. Move the flap laterally over the recipient area witha tissue forceps.

5. Suture the flap in place using 4-0 or 5-0 absorbablesuture. The graft should be completely immobilized(Figure 6.105).

Free Gingival GraftA free gingival graft can be used to establish or increaseareas of attached gingiva where there is inadequatewidth, and where neighboring areas are unable to pro-vide adequate donor tissue (lateral sliding flap). Thisadvanced dental procedure is not indicated where thereis moderate-to-marked tooth mobility (Figure 6.106).

To prepare the recipient area:

1. Use an apically positioned partial-thickness flap asa recipient bed of periosteum. Establish the lateralborders of the bed with vertical incisions carried

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A No. 15 or preferably 10A blade on a scalpel han-dle is used to incise the graft tissue. The round shape ofthe No. 10A blade permits apical, mesial, and distalmovement of the blade and facilitates removal of a 1mm split-thickness donor graft (Figure 6.109).

To apply the graft:

1. Suture (using 5-0 or 6-0 absorbable suture with anatraumatic needle) and/or affix the graft with tissueadhesive. Adhesive must not run below the graft orthe flap will fail because it won’t be able to revas-cularize (Figure 6.110).

2. Hold a warm, wet gauze sponge against the surfaceof the graft for several minutes to express excessblood from between the graft and the bed, initiate

hemostasis, and allow a thin fibrin layer to providegood adaptation of the graft to the periosteal bed.

AlveoloplastyBone defects revealed after flap exposure should betreated before resuturing. Treatment involves recon-touring unsupported bone with diamond burs and/orchisels, as well as leveling interproximal craters to allowoptimal flap adaptation.

Aftercare for Flap and Graft SurgeryInitial home care instructions include a soft diet,removal of chew toys, and hard treats for 3 weeks. Theowner is cautioned not to brush the teeth around thegraft site during this period. Chlorhexidine oral rinse isapplied to the surgical site twice daily. Oral antibioticsand pain relief medication are also administered (Figure6.111).

151

FIGURE 6.108. Template outlined in the attached gin-giva overlying the maxillary canine in a dog.

FIGURE 6.109. Harvesting spit-thickness donor tissue.

FIGURE 6.110. Graft sutured on recipient periosteal bed.

FIGURE 6.111. Area healed 2 months post-operatively.

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PERIODONTAL SPLINTING

Periodontal splinting stabilizes mobile teeth by attach-ing them to nonmobile adjacent teeth. This advancedprocedure has a low percentage of long-term successand should only be used in selected cases.

Periodontal splinting can be used:

• To accompany the healing phase of periodontal ther-apy

• For stabilization after trauma

• For stabilization before and during periodontal sur-gery

• As a method of temporarily saving teeth that wouldhave been extracted because of advanced supportloss. The client should be made aware that peri-odontal splinting is a controversial procedure thatmight not be in the patient’s best interest because ofcontinuing periodontitis beneath the splint (Figures6.112–6.116).

After a splint is placed, home care is vital. The areaunder the splint is difficult to keep clean. If the ownerwill not agree to home care or if the patient will notallow aftercare, splinting should not be attempted. Thesplint may be left in place permanently or until the

152

FIGURE 6.112. Mobile mandibular incisors in a dogbefore splinting.

FIGURE 6.113. Radiograph showing marked bone lossaround the mandibular incisors in a dog.

FIGURE 6.114. Flap exposure for cleaning subgingivalplaque and calculus from the root surface of themandibular incisors in a dog.

FIGURE 6.115. Phosphoric acid gel to etch the teethbefore splinting.

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underlying healing periodontium provides stability.Materials used in periodontal splinting include the

following:

• Dental acrylic (Triad) or composite (Protemp Garant)• Composite filling material (Burns 950-9043, Schein

100-1673)• Bondable reinforcement ribbon (Ribbond) (Figure

6.117).

To fabricate a composite resin splint using Ribbondbondable reinforcement ribbon:

1. Place a narrow strip of tin foil along the labial sur-face of maxillary or mandibular incisors to deter-mine the length of Ribbond needed.

2. Cut the Ribbond to the predetermined length andplace on a clean glass slab. Do not handle theRibbond with bare hands.

3. Apply and light cure two layers of composite to thelabial surfaces of the affected teeth, which are cleanand pumice-polished.

4. Place composite on top of the splint without lightcuring.

5. Place adhesive on the Ribbond.6. Place Ribbond over the bonded teeth and light cure.

Place an additional layer of composite over thesplint; then light cure, shape, and polish.

7. Check occlusion after the animal is extubated.Make adjustments if indicated.

PROCEDURES FORPERIODONTALREGENERATION

Regeneration procedures include a variety of surgicaltechniques that attempt to restore the periodontal tis-sues (alveolar bone, cementum, periodontal ligament)lost through disease. The goal of periodontal regenera-tion is to replace the bone and lost attachment.Regenerative procedures consist of flap exposure, rootplaning, and placement of bone, bone induction prod-ucts, or a membrane over the treated area before resu-turing.

BONE GRAFTING

Ideally, bone grafting restores normal bony architecture,rebuilds the periodontal ligament and soft tissue, andprevents further periodontal pocket formation.

The following are areas where bone grafts are indi-cated:

• Deep extraction sites, in order to preserve the alveo-lar ridge

• Deep, narrow, three-walled infrabony pockets, suchas palatal defects, that do not extend into the nasalcavity (infrabony (below the bone) defects are moreamenable to bone regeneration compared tosuprabony pockets)

• Endodontic-periodontic defects

Bone grafts should not be used on the following:

• Patients receiving chronic anticoagulant therapy• Patients receiving immunosuppressant medication• Patients receiving, or that have received, radiation

treatment at the surgical site• Poorly controlled insulin-dependent diabetics.• Patients that have an active infection at recipient site

153

FIGURE 6.116. Bonded (splinted) mandibular incisors.

FIGURE 6.117. Ribbond.

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The following is a partial list of materials used forbone grafting:

• Synthetic bioactive ceramic, Consil (NutramaxLaboratories) develops a direct bond to tissue andbecomes osseoconductive when implanted into anosseous defect. The ceramic is resorbed within 14months, leaving bone and periodontal ligamentbehind. Consil, due to its high pH, can also be usedin minimally infected sites to help inhibit bacterialgrowth (Figure 6.118).

• Autogenous (the patient’s) bone harvested from thealveolar margin from an unrelated area or from oneof the long bones (humerus or tibia).

• Frozen cadaver bone.• H.T.R. (hydroxyapatite-coated resin polymer).

A bone grafting instrument setup should include thefollowing:

• No. 3 scalpel handle (Burns 950-2150, Schein 100-7520, Cislak 4208) with No. 15c scalpel blade(Burns 950-2175, Schein 953-7101)

• Molt No. 2 (Burns 699-3504, EX 20 Cislak, Schein600-6125)), No. 4 (EX 21 Cislak, Schein 600-9526,Burns 699-3504, Schein 100-4888), or Molt double-ended 2/4 (Burns 271-9008, Cislak EX 20/21 DE,Schein 586-9560) periosteal elevators

• Curette (EX 2—#10 Miller Cislak, Burns 843-0572,Schein 600-7080)

• Citric acid for root therapy• Thumb forceps (Burns 605-1020, Schein 100-5162)• Needle holder (Burns 700-8650, Schein 100-1125)

and 5-0 absorbable suture material with a needle• Curved iris scissors (Burns 958-1276, Schein 100-

5880)• Consil (Nutramax Laboratories) (Burns 277-0350)• Dappen dish (Burns 950-9662, Schein 100-9211)

ALVEOLAR MARGINMAINTENANCE

Use the following technique for alveolar margin main-tenance using Consil material (Figure 6.119):

1. If chlorhexidine is used as an irrigant during sur-gery, rinse it thoroughly. Chlorhexidine can devital-ize periodontal ligament cells and interfere withattachment.

2. Create an access flap with interdental and sulcularincisions (Figure 6.119A).

3. Plane the root smooth with a curette and removeexcess granulation tissue.

4. Apply several drops of citric acid gel on the root.After 30 seconds, irrigate the area with saline toremove the citric acid.

5. Add four to six drops of the patient’s blood, sterilewater, or saline to 0.5 ml of Consil material in adappen dish (Figure 6.119B).

154

FIGURE 6.118. Consil.

FIGURE 6.119. (A) Gingival recession and bone lossbetween the maxillary fourth premolar and first molar;(B) mixture of the patient’s blood and Consil crystals.

A

B

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6. Mix the liquid and granules in the dappen dish witha spatula for 10 seconds to achieve the consistencyof firm wet sand and apply it into the defect area.Alternatively, carry the Consil granules to the defectand mix with the patient’s blood. In 2–3 minutes, achemical change occurs within Consil that initiatesthe process of bone regeneration.

7. Suture the access flap.

Post-operative care includes the following:

• Pain and antimicrobial medication are dispensed.• The patient is fed a soft diet for several weeks.• Gentle brushing can begin 1 week after surgery.• The surgical site is reexamined every 2–3 weeks.• The area is probed and radiographed in 4 months to

follow healing.

PALATAL DEFECT SURGERY

Canine palatal defect therapy is indicated in cases wherethere is >25% attachment loss on the palatal aspect ofone or both maxillary canine teeth, and the periodontalprobe does not enter the nasal cavity. When deep pock-ets are diagnosed, pocket therapy should be performedor the tooth extracted and the defect closed. If untreat-ed, the pocket will usually progress until it penetratesthe nasal cavity (Figure 6.120).

Use this technique for palatal pocket therapy:

1. Make 4–8 mm mesial and distal incisions to thebone at 20° angles palatally from the affected tooth(Figure 6.121).

2. Use a Molt or Freer periosteal elevator to gentlyraise a full-thickness flap (Figure 6.122).

3. Use a thin curette to clean accessible granulationtissue, calculus, and plaque between the root andalveolus (Figure 6.123).

4. Optionally, place several drops of citric acid gel intothe defect. After 30 seconds, irrigate the area withsaline to remove the citric acid.

155

FIGURE 6.120. 10 mm palatal probing depth of themaxillary canine tooth in a dog.

FIGURE 6.121. Interdental incisions.

FIGURE 6.122. Palatal defect exposed with a periostealelevator.

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5. Carry bone-grafting particles into the cleaneddefect (Figure 6.124).

6. Appose the flap snugly against the tooth and suturewith 4-0 absorbable suture on an atraumatic needle(Figure 6.125).

GUIDED TISSUEREGENERATION (GTR)

Granulation tissue growing from the periodontal liga-ment and bone marrow spaces carries the potential forregeneration. The goal of guided tissue regeneration(GTR) is to repopulate the affected area with periodontalcells that have the capability of redeveloping cementumon the root surface to generate healthy attachment.Barriers are used to avoid the proliferation of the gingivalepithelial and connective tissues along the exposed rootsurface and to selectively guide the growth of bone andperiodontal ligament cells into an area where they havebeen lost. This is considered an advanced periodontalsurgical procedure used mostly in Class II furcationdefects and two- and three-walled infrabony pockets.

GTR membranes are thin sheets of pliable materialplaced subgingivally following full-thickness flap expo-

156

FIGURE 6.123. Curette used to debride the palatal sur-face of the pocket.

FIGURE 6.125. Sutured flap.

FIGURE 6.124. Consil material placed in the freshlydebrided palatal pocket.

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sure. The material is custom-fitted or seated to the spe-cific defect area to allow optimal flap apposition underthe periosteum. Nonabsorbable membranes areremoved according to manufacturer’s directions 1–9months post-operatively. Absorbable membranes dis-solve within 2 months.

ORONASAL FISTULAS

Oronasal fistulas result from periodontal disease of themaxillary teeth, creating communication between theoral and nasal cavities. Oronasal fistulas allow fluid andfood to enter the turbinates of the nose, perpetuatingnasal discharge and chronic infection. One or bothmaxillary canines may be affected. Clinical signs includesneezing and/or nasal discharge that is sometimesblood-tinged (Figure 6.126).

If the periodontal probe enters the nasal cavity dur-ing exploration of the palatal surface, extraction fol-lowed by single- or double-layered flap surgical closureis indicated. If the probe does not extend into the nasalcavity, palatal therapy (described earlier) can be used todecrease pocket depth and increase maxillary caninesupport.

Single-Layer Flap Oronasal FistulaRepairA buccal, single-layer sliding flap is usually used forsmall and acute fistulas that occur after the canine isextracted or exfoliated.

Use the following technique to create a buccal single-layer sliding flap:

1. Circumferentially remove a thin mucosal epithelialmargin around the opening left after the toothremoval, using a No. 15 blade.

2. Harvest a buccal mucoperiosteum gingival flap bymaking divergent incisions mesially and distallythrough the mucogingival line, extending into thebuccal mucosa.

3. Gently elevate the flap using a No. 2 and/or 4 Moltor EX 21 (Cislak) periosteal elevator, exposing theperiosteum.

4. To improve flap mobility, incise the periosteal layerof the flap in the apical region. If this surgicalmaneuver is not performed, the flap might failbecause of insufficient length to cover the defectwithout tension (Figure 6.127).

5. Position the flap over the opening to ensure there isno tension before closure.

6. Suture the flap to the edge of the defect using 4-0 to5-0 absorbable suture material on a reverse cuttingneedle in a simple interrupted pattern.

7. Confirm that the mandibular canine does not trau-matize the flap. If it does, perform a crown reduc-tion and restoration procedure.

Double-Layer Oronasal Fistula RepairThe double-flap technique to repair oronasal fistulas isused where the fistula is chronic, large, or when a morepredictable outcome is needed than that with the single-layer closure. In the double-flap technique, part of thepalatal soft tissue is used to cover the defect; the result-ing palate defect area is then covered with buccalmucosa to ensure a double seal:

1. Excise the buccal mucosal edge of the fistula to pro-vide a fresh clean surface for primary healing.Leave the soft tissue lining the palatal edge of thedefect intact (Figure 6.128).

157

FIGURE 6.126. Oronasal fistula.

FIGURE 6.127. Scalpel used to incise the periosteallayer to increase its length.

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2. Make perpendicular incisions extending palatallyfrom the mesial and distal aspects of the defect. Thetwo incisions are connected on the palate extendingseveral millimeters past the midline. Elevate a full-thickness flap using a periosteal elevator. Controlbleeding by prolonged compression with gauzesponges.

3. Rotate the palatal flap on its basilar attachmentonto the fistula and suture in place with 4-0absorbable suture material in a simple interruptedpattern. Turn the oral epithelium to face theturbinates (Figure 6.129).

4. Harvest the second layer as a partial-thickness pedi-cle flap from the buccal mucosa. Take care todesign a mucosal flap large enough to cover theinverted palatal flap and denuded area over thejunction between the incisive and maxillary bone.Form the pedicle flap by making two incisions per-pendicular to the mucogingival line, extending fromthe buccal aspect of the defect (Figure 6.130). Thespace between the two incisions should be at least 11/2 times the width of the defect. To gain addition-al non-tension coverage, partially incise the non-epithelial side in a perpendicular fashion at thebase. Suture the second flap (Figure 6.131).

Post-operative instructions after oronasal fistularepair should include the following:

• Administer broad-spectrum antibiotics orally post-operatively for 10 days.

• Dispense pain relief medication for 7 days.• Pre-wet food to soften for 10 days after surgery.• Examine the surgical site 3 and 10 days post-opera-

tively to evaluate primary intention healing.

158

FIGURE 6.128. Palatal flap harvested for double flaptechnique.

FIGURE 6.129. Palatal flap sutured over the oronasaldefect.

FIGURE 6.130. Buccal flap releasing incisions.

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MANDIBULAR FRENECTOMY

Frenula are tough bands of tissue connecting the insidesurfaces of the lip to the mandibular gingiva behindcanine teeth and between the lip and maxillary centralincisors. In the presence of marked periodontal disease,the frenulum attachment may trap food and debrisagainst inflamed labial gingiva (Figure 6.132).

Mandibular frenectomy is indicated in patients withgingival recession or pocket formation on the distallabial side of mandibular canine teeth or when peri-odontal disease around the maxillary central incisors iscaused or aggravated by a tight frenulum. By excisingthe attachment, food will not accumulate as readily inthe affected areas.

Frenectomy is performed with the following tech-nique:

1. Local anesthesia.2. Dissect the frenulum close to the gingival margins

with a scalpel blade, iris scissors, radiosurgery, orlaser (Figures 6.133,6.134).

3. Suture the detached labial mucosa close to theperiosteum.

4. Root plane the exposed abnormal cemental surface.

GINGIVAL HYPERPLASIA (GH)

Relative, pseudo-, or false pockets exist when there isgingival enlargement (hyperplasia) without destructionof periodontal tissues. If gingival hyperplasia is greaterthan 2–3 mm when probed, the treatment of choice toreduce pocket depth is a gingivectomy (Figure 6.135).

159

FIGURE 6.131. Completed double flap. FIGURE 6.132. Tight frenulum around the mandibularcanine tooth in a dog, predisposing it to periodontaldisease.

FIGURE 6.133. Radiosurgical tip used to incise frenu-lum.

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Gingivectomy is a coronally directed, externallybeveled incision, used primarily for the removal ofexcess gingiva when no underlying osseous lesions arenoted. An adequate band (greater than 2 mm) of

attached gingiva must be present both pre-operativelyand post-operatively to protect the tooth.

At one time, gingivectomy was the treatment ofchoice to eliminate pocket depth and to allow exposureof the root surface for cleaning. Although gingivectomymay eliminate a suprabony pocket, healing time ofexposed tissue is longer than a repositioned flap proce-dure. Gingivectomies should be used only in cases ofgingival hyperplasia where there is an overgrowth of tis-sue and at least 2 mm of attached gingiva remains aftersurgery.

Use the following steps for gingivectomy afer localanesthesia is injected:

1. Place a periodontal probe onto the pseudo-pocketfloor, then outside to the measured depth, makingslight indentions or bleeding points on the gingivaat the level of attachment.

160

FIGURE 6.136. Scalpel blade angle used for gingivecto-my.

FIGURE 6.134. Incised frenulum before suturing.

FIGURE 6.135. Gingival hyperplasia.

FIGURE 6.137. Gingivectomy site 1 month post-opera-tively.

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2. Using a scalpel with 15 or 15c blade attached or anelectrosurgical or radiosurgical blade, incise abeveled edge to approximate the normal gingiva(Figures 6.136,6.137).

3. Administer post-operative anti-inflammatory andpain medication; recommend that the patient be feda soft diet for several days.

HEMISECTION TO SAVE PARTOF THE TOOTH

Furcation exposure occurs secondary to periodontaldisease. In Class I and Class II disease, periodontal ther-apy together with a patient able to accept aftercare mayresult in a saved tooth. Goals of furcation exposuretherapy are to decrease pocket depth, eliminate bonylesions, and create a cleanable tooth that is easier toclean to decrease further invasion.

In patients with marked furcation involvement,where one root has at least 50% bone support and theother root(s) have less, the tooth can be sectioned and

root canal therapy or vital pulp therapy performed,resulting in preserving a portion of the tooth (Figures6.138–6.142).

161

FIGURE 6.140. Hemisection of the distal root and par-tial coronal pulpectomy (note overhang remaining afterhemisection).

FIGURE 6.141. Hemisected root.FIGURE 6.138. 9 mm pocket affecting the distal rootof the mandibular first molar in a dog.

FIGURE 6.142. Remaining vital hemisected mandibu-lar first molar.

FIGURE 6.139. Radiograph showing vertical bone lossaround distal root.

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USE OF SYSTEMICANTIBIOTICS INPERIODONTAL DISEASE

Antibiotics by themselves will not cure periodontal dis-ease. Antibiotics may be prescribed in patient manage-ment, together with scaling, root planing, polishing, orextraction.

Antibiotics may be used in the following circum-stances:

• In pretreatment to help decrease bacteremia andoperator bacterial exposure in stages 3 and 4 peri-odontal disease

• The week following treatment in stages 3 and 4 peri-odontal disease

• In a pulse therapy fashion wherein periodic (first 5days of each month) doses of an antibiotic approvedfor small animal dental care is administered on along-term basis as an adjunct to home care. Pulsetherapy is for those cases of treated stage 3 and 4periodontal disease. This extra-label use of pulsedosing is used extensively in veterinary dermatologiccare, and may provide benefits in the periodontallyaffected patient by;• Reducing the bacteria load once monthly,

decreasing logarithmic replication• Weakening the biofilm glycocalyx, which keeps

plaque and calculus together• Temporarily decreasing halitosis

Pulse therapy should not be considered a substitutefor proper surgical treatment and home care; even in thepatient, that is an anesthetic risk. Further research needsto be performed to substantiate the use and investigatelong-term benefits and risks of pulse antibiotic use inthe therapy of periodontal disease.

HOME CARE

Regardless of what dental procedures are performed,clinical success is diminished if not combined with anongoing program of home care. The goal of dentalhome care is to remove plaque from tooth surfaces andgingival sulci before it mineralizes into calculus, aprocess that occurs within days of a teeth cleaning.Success depends on the owner’s ability to brush teethdaily, as well as the dog or cat’s acceptance of theprocess. True oral cleanliness can be achieved onlythrough the mechanical action of toothbrush bristlesabove and below the gingiva.

Home care is best started at a young age before theadult teeth erupt. An ideal time to introduce toothbrushing is at the first puppy or kitten visit. The client-animal bond as well as the client-veterinarian bond isenhanced when daily brushing is performed followinginstructions given at the animal hospital.

Brushing instruction involves more than telling a petowner it would be a good idea for them to brush theirpet’s teeth and dispensing a toothbrush. The client needsto be shown how to properly use a pet toothbrush andpaste followed by observing the client perform toothbrushing and follow-up examinations to monitorprogress.

The small animal client needs to:

• Start with a healthy comfortable mouth. Untreatedoral lesions can cause a painful mouth and a non-compliant patient. Dental pathology must be treatedbefore the client is instructed to begin brushing teeth.

• Start early. At 8–12 weeks of age, brushing once ortwice weekly helps familiarize the pet with the toothbrushing routine. At 5–7 months, while the second-ary (adult) teeth are erupting, teeth brushing shouldbe performed daily.

• Choose a proper toothbrush and toothpaste (denti-frice). Plaque accumulates in the sulcus or periodon-tal pocket. Toothbrushes have bristles that reachunder the gingival margin and clean the space thatsurrounds each tooth. Devices such as gauze pads,rubber finger toothbrushes, sponges, or cotton swabsremove plaque above the gum line, but cannot ade-quately clean the sulcus.

Virbac and other companies manufacture tooth-brushes specifically for use in small animals. Each dogor cat should have its own brush. Sharing brushes mightresult in cross-contamination of bacteria from one petto another. Toothbrushes should be thoroughly cleanedafter each use, stored in a clean location, and replacedat least monthly.

• The fingerbrush (Virbac Products) is popular forbeginners. It fits on the end of the owner’s index fin-ger, which reduces resistance of both the pet andowner. Unfortunately, the finger brush’s bristles arerubber and do not extend subgingivally to removeplaque. The fingerbrush should be used as the firststep to get a pet comfortable with brushing so a petowner can introduce a bristled brush into daily homecare later. The finger toothbrush can be cleaned in adishwasher (Figure 6.143).

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• The mini-toothbrush (Virbac Products) has nylonbristles that can extend subgingivally to removeplaque (Figure 6.144).

• The dual-ended toothbrush has head sizes to adaptto both small and large tooth surfaces (Figure6.145).

• The pet toothbrush has a single reverse-angle headand extra soft bristles, which makes it ideal for catsand small to medium-sized dogs (Figure 6.146).

• The cat toothbrush allows a stroking or swabbingmotion in a small cat’s mouth. Bristles are soft toensure a gentle application (Figure 6.147).

• The two-brush system brushes both sides of the teethat the same time (Petosan, Norway) (Figure 6.148).

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FIGURE 6.143. Rubber finger toothbrush (Virbac).

FIGURE 6.144. Mini-toothbrush (Virbac).

FIGURE 6.145. Dual-ended toothbrush (Virbac).

FIGURE 6.146. The pet toothbrush (Virbac).

FIGURE 6.147. Cat toothbrush (Virbac).

FIGURE 6.148. Two-brush toothbrush (Petosan).

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Tooth Brushing TechniqueTooth brushing should be at the same time each day.Before dinner works well using the meal as a reward forcooperating. Follow these steps:

1. Place the pet’s head at a 45° angle.2. With the same hand used to hold the head up, pull

the commisure of the lips backward, exposing thecheek teeth, while keeping the mouth closed (Figure6.149).

3. Rub the toothbrush bristles in small circularmotions under the gum line at a 45° angle to thegingiva. Generally, only the outside (facial) surfacesof the maxillary teeth are brushed. Plaque accumu-lates faster on the buccal surfaces of the maxillarycanines and cheek teeth. The incisors, mandibularcanines and cheek teeth accumulate less plaque(Figure 6.150). For cats, cotton-tipped applicatorscan also be used to remove plaque from the gumline (Figure 6.151).

4. Repeat and reward.5. If the pet is anxious with the brushing procedure,

give reassurance through gentle praise. Expectprogress, not perfection. Reward progress immedi-ately with a treat or a play period after each clean-ing session.

Each pet is different. Some will be trained in 1 week,and others will take a month or more.

In the author’s opinion, scalers and/or curettesshould not be used by clients. Hand scaling withoutproper chemical immobilization and training can injurethe gingiva or tooth.

Toothpaste (dentifrice) is used to help clean and pol-ish the tooth surfaces. Human toothpaste should not beused on dogs and cats because it contains detergentsand fluoride, which may be irritating to the stomachwhen swallowed.

Plaque RetardantsSalivary peroxidase enzyme-enhanced products (C.E.T.,Virbac Products) bind to plaque. Peroxidases are foundin a number of biologic fluids and in saliva. The anti-bacterial action of salivary peroxidase takes placebecause of the peroxidase-catalyzed oxidation of thio-cyanate. The mode of action for salivary peroxidaseappears to include inhibition of bacterial enzymes con-taining essential thiol groups:

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FIGURE 6.149. Cheek teeth exposed for brushing.

FIGURE 6.150. Proper toothbrush position.

FIGURE 6.151. Q-tip used to remove plaque in cat’steeth.

The Veterinary Oral Health Council (VOHC)evaluates the effectiveness of dental products, con-firming manufacturer’s claims. The VOHC is sim-ilar to the American Dental Association’s (ADA)seal of approval for human dental products.

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• Virbac’s C.E.T. “dual-enzyme” system consists ofglucose oxidase and lactoperoxidase. When salivaand oxygen are added, hypothiocyanite is formed,which produces an antibacterial (antiplaque) effect.

• C.E.T. Tartar Control Toothpaste is marketed fordog and cat owners that do not brush teeth daily.

• DentAcetic Wipes (Dermapet) contains sodiumHMP to help chemically decrease calculus while thewipes mechanically remove plaque accumulation(Figures 6.152,6.153).

For dogs and cats with periodontal disease,chlorhexidine is an effective product to inhibit plaqueformation. Chlorhexidine has bactericidal and virocidal

effects against most oral bacteria and some viruses.Chlorhexidine binds to the dental pellicle for 24 hoursafter application, reducing plaque-forming bacteria.Additionally, chlorhexidine renders existing plaque lesspathogenic.

Potential disadvantages using chlorhexidine includestaining of the pellicle, unpleasant taste, and desensi-tized taste buds. Additionally, chlorhexidine canenhance the precipitation of salivary minerals to speedthe development of calculus.

Human dental patients are advised to use chlorhexi-dine as a rinse swished in the oral cavity for approxi-mately 2 minutes. The contact time of application isimportant for chlorhexidine to bind to the tooth andgingival sulcus. In animals, 2-minute oral rinsing is notpractical. Oral contact time in animals is facilitatedthrough incorporation in a gel or chew.

For animals, chlorhexidine is available as:

• C.E.T. Oral Hygiene Rinse (Virbac Products) is com-posed of chlorhexidine gluconate 0.12% plus zincgluconate to promote healing of ulcerated tissue. Therinse also includes Cetylpyridinium chloride todecrease malodor.

• C.E.T. 0.12% Chlorhexidine Rinse (Virbac Products)is used in the clinic as an oral irrigant before dentalprocedures.

• C.E.T. Oral Hygiene Gel (Virbac Products) is com-posed of chlorhexidine gluconate plus 0.12% zincgluconate. The gel allows greater binding time witha pleasant taste.

• Nolvadent (Fort Dodge Laboratories) is composed ofchlorhexidine diacetate 0.1% (Figure 6.154),chlorhexidine solution (Burns 606-3620, Schein 309-3732).

• C.E.T. HEXtra Chews are chlorhexidine-impregnat-ed rawhide chews (Figure 6.155).

Chlorhexidine should not be used with fluorideproducts at the same time. The binding of both prod-ucts may inactivate each other. A 30-minute to 1-hourwait between use of a dentifrice containing fluoride, anda chlorhexidine rinse or gel is recommended.

Zinc ions disrupt bacterial enzyme systems by dis-placing magnesium ions. Zinc reduces halitosis byinhibiting the production and release of volatile sulfurcompounds. Zinc ascorbate stimulates collagen produc-tion to help repair diseased tissue.

Zinc also enhances the antiplaque activity ofchlorhexidine. Zinc and chlorhexidine are combined inC.E.T. oral hygiene rinse and C.E.T. oral hygiene gel(Virbac Products).

Zinc and vitamin C are combined in MAXI/GUARDOral Cleansing Gel (Addison Biological Laboratories).

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FIGURE 6.152. DenAcetic Wipes.

FIGURE 6.153. Dental wipes to remove plaque fromthe maxillary fourth premolar.

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MAXI/GUARD should be mixed (vitamin C added)before it is dispensed to the client. This ensures propercombination and gives the veterinarian or technician anopportunity to discuss application, shelf life, and the

166

FIGURE 6.156. MAXI/GUARD Gel.FIGURE 6.154. Nolvadent.

FIGURE 6.155. C.E.T. HEXtra Chews.

FIGURE 6.157. Application of MAXI/GUARD Gel to acat’s gingiva.

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product’s unique color change feature. The mixture hasa shelf life of 6 months in a cool, dark cabinet, or 1 yearin the refrigerator. The product is still effective as longas the color remains blue or green. A brown or yellowcolor indicates the product should be replaced.MAXI/GUARD is also positioned for use in animalsthat will not tolerate tooth brushing and has beenshown to decrease plaque and gingivitis compared tocontrols (Figures 6.156, 6.157).

Fluoride decreases plaque, desensitizes dentin, andstrengthens enamel. Fluoride binds to enamel and dentin (not soft tissues). Fluoride should not beused in conjunction with chlorhexidine preparations. In patients with stages 3 and 4 periodontal disease, 0.4% stannous flouride strength can be used daily. Fluoride preparations include Omni Gel(Dunhill Pharmaceuticals), Gel-Kam (Colgate OralPharmaceuticals), and Qygel 0.4% Gel (VeterinaryProduct Labs).

FluraFom (Virbac Products) contains 1.23% acidu-lated phosphate fluoride. The foam is supplied for in-clinic application after teeth cleaning. Fluoride foamshould not be used as part of a home care programbecause of the danger of ingestion toxicity. Fluoride

should not be directly placed into a periodontal pocket.Fluoride may delay healing and gingival reattachment(Figure 6.158).

OraVet (Merial) is a waxy polymer applied on teethafter the oral hygiene procedure. The product providesan inert, invisible barrier that, according to the manu-facturer, decreases bacteria adhering to the teeth. In the-ory, the polymer remains on the tooth for up to 8 daysfollowing application-repelling plaque. After the 8 days,the client is instructed to apply a thinner polymer week-ly. OraVet does not adhere to fluoride-treated teeth. Theuse of non-fluoride prophy polish and toothpaste arerecommended in conjunction with OraVet.

Chew Toys, Dental Devices, andDental DietsThe main benefit of dental devices and toys is chewingstimulation. Chewing removes some of the plaque andprovides exercise to the periodontal ligament. Food andtoy manufacturers have tried to create products toreplace the need for tooth brushing. Some dental chewdevices and foods are effective in decreasing plaque andgingivitis. All chew toys and devices must be monitored.Any pet can abuse a dental device. If the product is toosoft, an aggressive dog can break it apart and swallowpieces. If the product is too hard, tooth fractures mayoccur (Figure 6.159).

The following are potentially dangerous chew prod-ucts:

• Cow hooves• Nylon bones• Ice cubes• Hard plastic toys

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FIGURE 6.158. C.E.T. FluraFom. FIGURE 6.159. Dog chewing on bone.

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• Tennis balls (chronic chewing will cause attrition andmay cause pulpal exposure through enamel anddentin loss)

• Any object that is harder than the tooth• Knotted rawhide chews (can cause intestinal obstruc-

tion)• Bones

The following are some of the products currentlyavailable:

• Rawhide strips, which are helpful in controllingplaque—especially when combined with toothbrushing. Rawhide chews are generally safelychewed and digestible if swallowed. Unfortunately,some dogs are “gulpers” who swallow the rawhide

without chewing, potentially causing gastrointestinalproblems. Examples include C.E.T. Chews for dogs(Figure 6.160) and C.E.T. Hextra (fortified withchlorhexadine) (Virbac Products), Chew-eez Beef-hide Treats (Friskies Petcare) (Figure 6.161), H.M.P.Rawhide Dental Maintenance System (HarpersLeather Goods, Inc.) (Figures 6.162A–6.162C). EachH.M.P System box contains a 15-day supply ofchews—12 Dental Strips (flat, dark brown strips)and 3 Dental Rolls (Dental Strips wrapped inrawhide). The manufacturer recommends a 5-daycycle: on days 1–4, the dog is given a Dental Strip; onday 5, the dog is given a Dental Roll.

• Kong Toys, also sold under the Tuffy label, help sat-isfy a dog’s need for exciting object play. The toybounces in an unpredictable fashion, simulating flee-ing prey. As the dog chews the Kong, teeth impingeon the resilient rubber. Kongs come in three chewer-friendly hardness styles: red, black, and blue. KongBlue toys are autoclavable, radiopaque, and avail-

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FIGURE 6.160. C.E.T. Chews for dogs.

FIGURE 6.161. Chew-eez.

A

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able only through veterinarians. Kong Blue’s rubberhas 20% greater tensile strength than the black toys(Schein: King 259-6683, Kitty 259-1891, Original259-9086, Ultra 259-1789) (Kong Company)(Figure 6.163, 6.164).

• Dental Kongs contain “chew-clean” grooves wheretoothpaste may be applied. The small and medium

sizes have floss rope attached. According to the man-ufacturer, the rope helps clean the back teeth.Caution should be observed, because the ropes mightlacerate gingiva.

• Pedigree RASK/DENTABONE (Waltham) is an oralhygiene chew made from rice and milk protein.When fed as a daily supplement, according to the man-ufacturer, RASK/DENTABONE reduced gingivitis,calculus, and malodor (Figure 6.165).

• Dental Chew (Nylabone Products) is made from aplastic material softer than nylon. Dental Chew ispositioned for nonaggressive chewers. Fortunately, if

169

FIGURE 6.162. HMP rawhide dental products: (A)Dental Chews plus with plus core, (B) HMP Rawhidewith HMP strips, and (C) HMP strip combined withrawhide rolls (Harpers).

B

C

FIGURE 6.163. Kong Blue toys.

FIGURE 6.164. Dental Kongs stuffed with treats.

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swallowed, Dental Chews are detectable radiograph-ically.

• Roar-Hide (Nylabone Products) is designed to avoidproblems sometimes associated with large rawhidechews. The rawhide in Roar-Hide is ground intosmall digestible rice-sized pieces, heated, and theninjected into a mold (Figure 6.166).

• Nylon chewing devices (Dental Dinosaur, Hercules,Galileo, and Plaque Attacker) (Nylabone Products)have “dental tips,” which the company claims aidteeth cleaning and gum massage.

• Gumabone (Nylabone Products) is more pliable thanthe nylon bones.

• Rhino (Nylabone Products) is a rubber dog dentaldevice with special dental “pyramids to maximizechewing enjoyment while cleaning the teeth andexercising the jaws,” according to the manufacturer.

• C.E.T. Chews for cats are made from freeze-driedfish, treated with an antibacterial enzyme system toprovide abrasive cleansing action. According to themanufacturer, the coarse texture of the processedfish cleans teeth by helping remove plaque and fooddebris (Figure 6.167).

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FIGURE 6.165. RASK/DENTABONE (Waltham).

FIGURE 6.166. Roar-Hide (Nylabone).

FIGURE 6.167. C.E.T. cat chews.

FIGURE 6.168. Greenies.

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• Greenies are digestible chews, which when fed daily,according to the manufacturer, decrease calculusaccumulation (Figure 6.168).

• Kong Stuff-A-Ball is a nontoxic natural rubber fetchtoy marketed to hold toothpaste and clean teethabove and below the gum line. Kong Stuff-A-Ball issold in three sizes and two hardnesses (Figure 6.169).

Diets/TreatsDry foods decrease plaque while the pet is chewing.“Dental” diets claim to control plaque and gingivitis bychemical and/or mechanical methods. Feeding a special-ized calculus-control diet does not take the place ofdaily tooth brushing. Dental diets are not treats; theyare a complete food and should be fed as the pet’s onlyfood, rather than as an occasional treat. For clients thatfeed specialized dental diets and brush their pet’s teeth,the interval between professional teeth cleaning visits isusually months longer than with clients that do not feeda dental diet.

The following dental diets are available:

• Canine and Feline t/d (Hills Pet Nutrition) is a kibbleformulation with transverse fibers that “squeegee”plaque and calculus from the tooth surface. Theunique fiber structure resists crumbling as the toothpenetrates. When fed as a sole diet, t/d decreasessupragingival plaque better than regular kibble.Canine and Feline t/d has been approved by theVOHC to help control plaque and calculus (Figure6.170–6.174).

• Science Diet Oral Care is positioned for pets thathave healthy mouths and has been VOHC-approvedto help control plaque and tartar.

• Tartar Check (Heinz Pet Products) is a snack biscuitcontaining sodium hexametaphosphate (HMP) tohelp control calculus. Sodium hexametaphosphatesequesters calcium, forming soluble complexes thatdiffuse into the saliva and are subsequently swal-lowed. The hexametaphosphate and pyrophosphate

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FIGURE 6.169. Kong Stuff-A-Ball dental device.

FIGURE 6.170. Canine and feline t/d.

FIGURE 6.171. Diet mechanical placque removal.

FIGURE 6.172. Screwdriver coated with paint beforeinsertion into t/d food.

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act as calcium chelators, binding calcium anddecreasing mineralization of plaque into calculus.Tartar Check has been approved by the VOHC tohelp control tartar (Figure 6.175).

• Friskies Dental Diet for cats has larger kibbles and aunique texture that has been approved by the VOHCto help control plaque and tartar.

• Eukanuba Dental Defense incorporates sodiumhexametaphosphate on the outside of the kibble inthe canine diet and pyrophosphates in the feline diet.In addition to the chemical binding to the substancesin plaque for easier elimination, these additives alsomake the kibble tougher to puncture, providingmechanical cleansing action. The Iams Chunk DentalDefense Diet for Dogs and the Eukanuba AdultMaintenance Diet for Dogs have been approved bythe VOHC to help control tartar. (Figure 6.176).

Table 6.3 summarizes periodontal care.

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FIGURE 6.173. Food stays intact during insertion.

FIGURE 6.174. Paint removed from tip.

FIGURE 6.175. Tartar Check.

FIGURE 6.176. Eukanuba dental defense diet.

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PERIODONTAL EQUIPMENT, MATERIALS, AND TECHNIQUES 173

Table 6.3. Periodontal care at a glance.

Pathology Present Treatment

Stage 1 gingivitis Minimal calculus and inflammation Teeth cleaning, subgingival handprogressing to gingival edema instrumentation, polishing, irrigation,

home care.

Stage 2 early periodontitis Bleeding on probing, less than 25% As above plus root planing, closedattachment (support) loss curettage (if indicated), instillation of

Doxirobe into cleaned pockets.

Stage 3 established periodontitis As above, plus andattachment Case-by-case and tooth-by tooth loss between 25%–50%, determination similar to stage 4 diseaseClass I and early II furcations; M1 based on the tooth’s importance, client’smobility may be observed in ability to provide home care, mobility,single-rooted teeth and absolute pocket depth. Stringent

home care.

Stage 4 advanced periodontitis As above, plus possible tooth As above plus flap surgery and or mobility and/or attachment extraction.loss >50%

Pockets >5 mm with suprabony Apical reposition flap and osteoplastyledges, infrabony (1- or 2-walled) replacing the flap margins at the

new height of bone.

3-walled infrabony pockets Flap exposure and placement of bonegraft materials.

Class III furcation exposure Extraction if support loss is >50%.

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