Performing a Complete Prophylaxis
Cecilia Gorrel United Kingdom
A complete dental prophylaxis includes: 1) clinical examination and charting; 2) intraoral radiography; 3) periodontal therapy; 4) other remedial therapy as indicated; 5) homecare. Of these, the veterinarian performs the first four while the owner carries out the last at home.
Optimal treatment relies on a good diagnostic work-up. Oral diagnosis is based on the results of clinical examination and radiography with guidance from the case history. Additional diagnostic tests are used when indicated. It is good practice to record case details in a systematic way. A permanent record should be made of relevant medical and dental history, diagnostic data and details of all treatment performed.
CLINICAL EXAMINATION AND CHARTING
The examination of a conscious animal with suspect oral cavity disease involves assessing not only the oral cavity proper, but also palpation of the face (facial bones and zygomatic arch), temporomandibular joint, salivary glands (mandibular/sublingual and the parotids are usually only palpable if enlarged), and lymph nodes (mandibular, cervical chain).
The occlusion should be checked prior to anaesthesia. Most animals allow at least a cursory inspection of the oral cavity prior to anaesthesia and this should be performed. The mucous membranes of the oral cavity should be examined as well as the teeth.
Normal anatomical features of the oral cavity need to be identified and inspected. Refreshing your memory on these features from an anatomy textbook is highly recommended. It is only with knowledge of the normal that abnormalities can be identified.
The periodontium of each tooth needs to be assessed. The findings should be recorded on a chart. The following indices and criteria should be evaluated for each tooth: 1) mobility; 2) gingivitis; 3) gingival recession; 4) periodontal probing depth; 5) furcation involvement. In animals with large accumulations of dental deposits (plaque and calculus) on the teeth, it may be necessary to remove these to assess gingival recession, periodontal probing depth and furcation involvement accurately.
Pathological radiographic changes are usually discrete and therefore clarity and detail are essential. For a dental radiograph to be used for diagnostic purposes, it should be an accurate representation of the size and shape of the tooth without superimposition of adjacent structures. Intraoral radiographic techniques are thus required. Full mouth (survey) radiographs are recommended for all patients.
Optimal oral/dental treatment is not possible without a good diagnostic work-up. Oral diagnosis depends on clinical and radiographic examination. Caries, resorptive lesions, periodontal disease, endodontic pathology, fractures, bone pathology, and neoplastic lesions all require radiography for a more complete diagnosis. Many dental procedures can only be carried out under radiographic control. Checking adequacy of procedures and success of treatment relies heavily on radiography. In short, the importance of radiography and radiology in veterinary dentistry cannot be over-emphasized.
Professional periodontal therapy consists of supra- and sub-gingival scaling to remove dental deposits, and polishing and root planning to restore the tooth surfaces to smoothness. Teeth severely affected by periodontitis but which are deemed unsalvageable, should be extracted.
Periodontal surgery is never first-line treatment for periodontitis. Conservative management consisting of thorough supra- and sub-gingival scaling, rootplaning, polishing, irrigation, in combination with daily meticulous home care, is the first step. Periodontal surgery should only be performed where the owner has shown the ability to keep the teeth clean. If a client cannot maintain good dental hygiene measures for their pet, then in the interest of the well being of the animal, there is no indication for surgery.
OTHER REMEDIAL THERAPY
Pathological conditions identified should be treated or the affected teeth should be extracted.
Tooth brushing is known to be the single most effective means of removing plaque. Studies have shown that in dogs with experimentally induced gingivitis as well as in naturally occurring gingivitis, daily tooth brushing is effective in returning the gingivae to health.(1,2) In a four-year study using the Beagle, (3) it was shown that, with no oral hygiene plaque accumulated rapidly along the gingival margin with gingivitis developing within a few weeks. Dogs that were fed an identical diet under identical conditions but were subjected to daily tooth brushing developed no clinical signs of gingivitis or periodontitis. In the group that was not receiving daily tooth brushing, gingivitis progressed to periodontitis in most individuals.
While mechanical removal of plaque by means of tooth brushing is the mainstay of human dental hygiene, most dog owners do not regularly brush their dogs’ teeth. Consequently, mechanically reducing plaque accumulation by means of dietary texture becomes an important part of preventive dental care in the dog and cat. Periodontal disease has been linked with aspects of diet. Several studies have investigated the local effect of diet on plaque formation and development of gingivitis in the dog. A coarse diet may reduce plaque accumulation on some teeth and on some tooth surfaces.(4) A study performed over a six-month period investigating oral cleansing by dietary means, showed that dogs consuming a test diet (a) had significantly less plaque, calculus, and gingival inflammation than the control group.(5) Similarly, the daily use of a dental hygiene chew (b) has been shown to reduce accumulation of dental deposits and reduce gingivitis in both short and long-term studies.(6-10) The efficacy of a dental hygiene chew with a rubbery rather than hard texture (c) has also been demonstrated.(11)
There is as yet no magic bullet that we can feed our pets to prevent gingivitis. Daily tooth brushing remains the single most effective means of restoring inflamed gingivae to health and of then maintaining clinically healthy gingivae. However, mechanical reduction of accumulation of dental deposits (plaque and calculus), thus reducing the severity of gingivitis by dietary means, is a useful adjunctive measure and should be highly recommended to pet owners.
Home care is also a most important aspect of treating periodontitis. Following professional therapy, the owner must prevent or remove the accumulation of plaque on a daily basis. In fact, it is often useful to implicate daily tooth brushing prior to the professional therapy. Most animals require a three to four week habituation period before they will accept having all teeth brushed in one sitting. There are also animals that will not accept tooth brushing and the professional treatment of such cases will need to be more radical. Adjunctive use of a topical anti-plaque agent, ideally chlorhexidine digluconate, is often required. The effect of dental diets or dental hygiene chews on periodontitis has not been investigated. It is unlikely that such products are effective in treating periodontitis. In fact, they may even be contra-indicated since we know that in an individual with severe periodontitis mastication results in a transient bacteraemia.
a. Prescription Diet Canine t/d ®, Hill’s Pet Nutrition Inc.
b. Pedigree DentaRask®, Pedigree Masterfoods, Mars Inc. Marketed as Pedigree Dentabone® in North America.
c. Pedigree Rancho®, Pedigree Masterfoods, Mars Inc. Marketed as Waltham Tartar ChewTM in North America.
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