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Periodontal Disease

Oral Disease

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The word periodontal means “around the tooth.

The periodontal tissues are the gingiva, the periodontal ligament, the cementum, and the alveolar bone. In periodontal disease, the periodontal tissues suffer various degrees of damage. Periodontal disease can be limited to the gingiva or can extend to deeper layers to cause periodontitis (bone loss). Periodontal disease is caused by the interaction between oral bacteria (plaque) and the local immune system.

Dental plaque refers to the bacterial biofilm attached to oral surfaces (oral barrier).

The biofilm is composed of bacteria and the sticky substances they produce to attach to the teeth to avoid being washed away by saliva. Besides firm attachment to the teeth, these sticky substances provide bacteria with protection against chemicals (including antibiotics) and the local immune system. Oral biofilm is white to yellow in color and has an unpleasant smell (it’s the source of bad breath). It can be removed with a toothbrush.

The biofilm is a reservoir for oral bacteria. Most interactions between oral bacteria (dental plaque) and the local immune system take place either at the inner aspect of the gingiva, called the gingival sulcus, or at sites of disruption of the normal oral barrier.

Oral lesions are associated with very adherent oral biofilm, on which antibiotics have no (or very limited) effect. When the biofilm is able to penetrate the oral barrier, surgical cleaning of the affected tissues is needed to allow healing. This is why even simple-sounding oral treatments such as removing plaque from below the gingiva, especially when the disease is present, require intervention with surgical instruments. After the biofilm is removed, the oral barrier should be restored by suturing gingiva and mucosa and placing sealants or restorative materials on the enamel.

A lifelong commitment to daily removal of biofilm through routine oral hygiene should be implemented at home.

Dental calculus (“tartar”) is an indicator of oral disease.

Saliva contains dissolved minerals, including calcium and phosphorous. These minerals can crystallize and attach to the teeth, forming hard mineral deposits called calculus when these crystals combine with plaque components. Calculus is easily visible as rough brown deposits that cannot be removed with a toothbrush. Dental calculus is not a periodontal disease on its own but is rather the “red flag” for the existence of the periodontal disease. Although oral bacteria (dental plaque) can attach to the smooth enamel surface of the tooth, dental calculus provides a porous surface to which bacteria can attach more easily. Scaling an animal’s teeth to remove visible calculus provides instant gratification by exposing the pearly white enamel. This approach does not mean that periodontal disease was diagnosed or treated. Going the extra step of performing dental radiographs and probing (oral diagnostics) reveals and allows for the treatment of existing periodontal disease.

Similar to people, cats and dogs continuously accumulate dental plaque and calculus and eventually develop gingivitis.

After prolonged periods of untreated gingivitis, the oral barrier breaks down, and periodontitis can develop.

Gingivitis can be noted during a non-anesthetized oral examination as redness and bleeding of the gingiva. Diagnosis of the presence, severity and extent of periodontitis requires dental radiographs and periodontal probing under anesthesia.

Periodontal disease is progressive and has four stages.

After prolonged periods of untreated gingivitis, the oral barrier breaks down, and periodontitis can develop.

Gingivitis can be noted during a non-anesthetized oral examination as redness and bleeding of the gingiva, but periodontal disease is often more than just gingivitis. Diagnosis of the presence, severity and extent of periodontitis requires dental radiographs and periodontal probing under anesthesia.

In stage I, only inflammation of the gingiva (gingivitis) is present. All other stages involve varying degrees of periodontitis (inflammation and infection of the other tissues that surround and support the tooth), manifested by destruction of the periodontal ligament and alveolar bone. In stage II, 25% of the alveolar bone is destroyed, while in stage III, 50% is lost. Finally, in stage IV, more than 75% is lost. If teeth with end-stage periodontitis are not treated in time, the bone destruction can extend beyond the tooth roots into surrounding structures. Periodontitis can extend into the nasal cavity causing sneezing when material from the mouth enters the nose, or into the eye socket, causing visible swelling around or behind the eye. It can even weaken the mandibular bone to the point of causing fracture of the mandible.

As much as it is our goal to save teeth wherever possible, when periodontal disease becomes severe, the goal shifts from saving teeth to saving jaws (by preempting fracture), as advanced periodontal disease is a common cause of jaw fracture, especially in small breed dogs.

“Teeth cleaning” is only just the beginning for treating periodontal disease.

Dental prophylaxis, or “teeth cleaning” is a term used to describe the removal of dental plaque and calculus by performing dental scaling and polishing followed by daily tooth brushing as a means of preventing gingivitis. Dental prophylaxis is appropriate when oral diagnostics (dental radiographs and probing) have confirmed that periodontitis is not present, and no other treatment is necessary. Removal of dental plaque and calculus without finding and treating the underlying disease caries little or no medical benefit and in many cases (patients with periodontitis), it can be detrimental to the patient.

Once periodontal disease is confirmed by dental radiographs and probing, treatment is focused on safely cleaning the tooth roots and preventing re-invasion of periodontal tissues by oral bacteria. A variety of surgical techniques are used to achieve this, including root planing, subgingival application of locally-acting medications, and tissue grafting. These are all followed by closure of surgical sites used to access diseased periodontal tissues. In advanced stages of periodontitis and in individuals predisposed to rampant periodontitis, tooth extraction may be the only way to address the severe infection and bone destruction while preserving the integrity of the jaw bone.

After periodontal treatment, implementing a daily tooth brushing routine is important for maintaining the oral health of dogs and cats.