PERIODONTAL DISEASE

VetSuite Veterinarians
Dentistry & Oral Medicine

Periodontitis is inflammation of the structures that support teeth: the gingiva, periodontal ligament, alveolus and cementum. Periodontitis is the most common cause of oral infection and tooth loss in dogs, cats and humans, making it truly a global disease.

Periodontal disease occurs in two forms: gingivitis and periodontitis. Gingivitis is a reversible inflammation of the gingival. Periodontitis involves deeper inflammation with loss of tooth support and permanent damage.

DIAGNOSIS OF PERIODONTAL DISEASE

ETIOLOGY AND RISK FACTORS

• Causes - Periodontitis is caused by an accumulation of large amounts of bacteria at the junction of the tooth and the gingiva. Prolonged retention of these bacteria, usually years, results in a change of the predominant flora from gram-positive aerobic cocci to gram-negative anaerobic rods.
• Risk factors
• Age - Periodontitis affects over 80 percent of dogs and cats over 3 years of age, although it can be seen at almost any age
• Breed/genetics - No known risk
• Sex - No known risk
• Geographic/environmental - No known risk
• Other medical disorders - Untreated gingivitis can lead to periodontitis. In addition, local irritants and some diseases such as plasmacytic gingivitis and chronic bacterial mouth inflammation also may lead to periodontitis.

• Prevention - Daily tooth brushing using a pet dental product is important. Options include chlorhexadine gel, toothpaste and rinses and regular toothpaste.

HISTORY AND CLINICAL SIGNS

• Species affected - Dogs and cats
• Presenting signs and historical problems - Common signs of periodontal disease include halitosis, swollen gingival margins that bleed after the application of light pressure, ulceration, mobile teeth, tooth loss, facial swelling, tooth extrusion, hyperplasia and gingival recession.

PHYSICAL EXAMINATION FINDINGS

Examination of the oral cavity may reveal ulceration, dental calculi, periodontal abscesses, tooth loss, periapical inflammation, loose teeth, gingival bleeding and gingival recession. In some animals, facial swelling, oronasal fistulas and nasal discharge may be present.

The rest of the physical examination is normal.

DIAGNOSTIC STUDIES

• Special examination techniques - The diagnosis of periodontal disease is based on a thorough oral and periodontal examination and periodontal probing.
• Clinical laboratory tests
• CBC - Often within normal limits but the white blood cell count may be elevated in advanced cases, indicating inflammation or infection.
• Serum biochemical tests - Usually unremarkable
• Urinalysis - Usually unremarkable
• Microbiology - Chronic, refractory cases may benefit from anaerobic culture and sensitivity.
• Diagnostic imaging
• Radiographs (other body areas) - Full mouth radiographs should be performed, as 70 percent of the tooth structure is below the gumline and periodontitis cannot be diagnosed properly without them. Radiographs can identify bone loss, which most frequently is horizontal or parallel to the cemento-enamel junction (CEJ), which separates the crown from the root. Radiographic review determines therapy, as 90 percent of teeth that have 90 percent bone loss can be saved.

DIAGNOSIS AND PROGNOSIS

• Differential diagnosis - Because other dental problems can lead to similar symptoms, excluding them before establishing a diagnosis of periodontitis is important.
• Gingivitis, a precursor to periodontitis looks similar, but does not have deep pockets.
• Endodontic lesions, which can be mixed with or can be precipitated from periodontal lesions.
• Periapical abscesses, fractured teeth and any other cause of tooth pain.
• Fractured mandible secondary to periodontal disease
• Recommended tests - CBC, biochemical profile, oral examination under anesthesia, dental probing and radiographs.
• Summary of diagnostic criteria - Radiographs reveal bone loss and destruction. Dental probing reveals periodontal pockets. Oral examination reveals the physical exam findings described above.
• Prognosis - The prognosis for periodontitis is good, but the damage to the teeth is permanent. Many teeth with up to 90 percent bone loss can be saved.

TREATMENT OF PERIODONTAL DISEASE

TREATMENT PRINCIPLES

The goal of treatment for periodontitis is to delay further progression and to prevent further tooth destruction and tooth loss. Treatment for periodontitis involved anesthesia and oral surgery.

INITIAL/HOSPITAL THERAPY

Anti-microbials are those that target gram-negative anaerobic bacteria such as clindamycin and a combination of enrofloxacin and metronidazole and should be given 1 hour pre-operatively if indicated.

Chlorhexidine (0.12%) should be sprayed in the oral cavity to reduce aerosolized bacteria by 95 percent at the start, middle and end of the procedure.

Surgical procedures include both supragingival and sub-gingival ultrasonic scaling, root planing, and tooth polishing.

Periodontal pockets greater than 5mm. may require open-flap curetage in order to gain access to the calculus and bacterial biofilms.

Single pockets may benefit from a locally instilled perioceutic product.

Extractions are indicated if the tooth is unsalvageable as indicated by full-mouth radiographs.

LONG-TERM/HOME THERAPY

Daily tooth brushing is the single most important home care act that can be done. The use of dental care diets may be helpful. Chlorhexidine rinses or toothpastes are excellent at killing plaque above the gumline and should be used daily in chronic or refractory cases.

FOLLOW-UP CARE

Periodontal lesions can be progressive so they must be monitored closely. Dental examinations should be performed every 3 to 6 months. Frequent ultrasonic scalings and root planings may be necessary to prevent recurrence.