Periodontal Decision Making and Treatment Planning
John Robinson United Kingdom
This lecture is limited to “adult onset” periodontal disease in cats, dogs (and people). Treatment of periodontal disease is not simply going through the stages of a dental prophylaxis on an “as and when” basis. Periodontal disease has to be managed with a programme of care almost from birth until death. The appropriate treatment and provision of care needs to be tailored to the requirements of the individual animal. These requirements will change with time as the individuals’ susceptibility to periodontal disease becomes apparent and the failing of previous care takes its toll.
AETIOPATHOGENESIS OF PERIODONTAL DISEASE
A working knowledge of the aetiology and pathogenesis of periodontal disease is essential to understanding how to make prevention and treatment of the condition effective. The fundamental cause is dental plaque but its effects are greatly modified by many factors.
The individual’s host response is a key factor in the establishment and progression of periodontal disease. It is of practical use to be able to identify individuals of higher susceptibility to periodontal disease and so direct greater care to the more needy. It is generally accepted that dogs of smaller body weight are higher risk candidates for gum disease. A cat fits on the same scale at the position of a dog of roughly equivalent body weight. Pure breed cats and dog are higher risk than cross breeds. Some pure breeds are particularly prone.
Once periodontal disease becomes established the local environment changes in favour of the disease and so the progression gathers momentum. For this reason prevention and early intervention are the best ways of controlling the disease. Once periodontal attachment and bone support is lost, it is largely impossible to regain.
REACTIVE Vs. PROACTIVE
Reactive treatment of a disease is waiting for the disease to become established and then treating it. This is all too often the case in periodontal disease, especially in past years. The prevalence of periodontal disease is so great that all individuals should be assumed to be at risk until shown otherwise. Proactive care is a more appropriate approach.
TREATMENT OF PERIODONTAL DISEASE
Regular oral hygiene (Home care).
Supra and sub gingival scaling.
The above lists the main components in the treatment of periodontal disease. Proper treatment is not a simple matter of working down the list. With an understanding of the aetiopathogenesis of the disease, the operator should understand how each aspect of treatment would benefit the patient. The longer-term benefits of scaling, root planning, and polishing are dependent on follow-up home care. The treatment efforts should be modified depending on many factors, the main one being home care. Decisions can be made on potential level of home care achievable or on actual care being performed.
Before deciding on any treatment plan, the case should be assessed. Reassessment will be necessary periodically and the treatment management altered as appropriate. When assessing a case, the following factors have to be determined:
Home care achievable (and reality).
Periodontal status of each individual tooth and of the whole mouth.
Age of the animal.
General health status of the animal.
Previous dental history.
Home Care Achievable
The long-term benefits of any treatment by the veterinary practice will depend on the level of daily home care. Initially the parameter will be what the owners are prepared to consider and attempt. It can take some time for the level of home care to be established and a baseline set. Without home care to give ongoing plaque control, other treatment modalities loose their benefits. Scaling and polishing teeth becomes merely “gum gardening.”
Parameters to look at, conscious:
Previous dental chart.
Parameters to look at, under GA:
Periodontal pocket depth.
Residual bone support—Radiography.
The presence or absence of calculus is not indicative of periodontal health. The true periodontal status can only be determined by examination under general anaesthetic. All the factors that are assessed whilst conscious are only indicators. It is wise to inform the owner that the conscious examination provides a “guesstimate” and that the real treatment requirement will only be known after proper examination under anaesthetic. It is not uncommon for the periodontal status to be dramatically different (better or worse) from the initial appraisal. When a problem that requires treatment under anaesthetic is clearly found, it gives a reason to proceed and allows the other teeth to be assessed at the same time. Sometimes the need for a proper examination becomes the reason to perform dental treatment.
The most accurate and important parameter for the prognosis of each tooth in periodontal disease is the deepest periodontal pocket depth at any site on that tooth.
Age of the Animal
A more advanced stage of periodontal disease at a younger than expected age, means the treatment and control needs to be provided at a higher level. It may indicate a high-risk individual or another predisposing factor.
General Health Status of the Animal
The benefits of treatment should outweigh risk. As all treatment requires a general anaesthetic, all aspects associated with an anaesthetic need to be assessed according to good practice. There is a “catch 22” situation—there may be medical problems that affect the anaesthetic risk but the same problems may be exacerbated by the ongoing periodontal disease.
Diseases that reduce the immune status of an animal may result in a more rapidly progressive periodontal disease. There is growing evidence to support the hypothesis that any tooth site with advanced periodontitis can have a harmful effect on other disease processes and at other body sites.
Previous Dental History
Number of previous treatments.
Time since last dental treatment.
Findings at previous dental examination(s) as part of dental treatment (recorded on the dental chart).
Comparison over time.
The previous dental history gives accurate information as to the periodontal status at a time in the past (findings at previous dental examination) and provides a time frame for the disease process.
Ideally, the disease should be prevented by instigation of adequate oral hygiene procedures from a young age. Simple gingivitis can be reversed if the necessary oral hygiene can be attained. Once calculus has accumulated, the efficacy of home care techniques is reduced in plaque control. Calculus removal by scaling is required to return the mouth to optimal health. It must be remembered that the benefit of performing professional periodontal therapy (PPT, a “dental” or “dental prophylaxis”) is short lived if not followed up by home care procedures. In mouths with early periodontal disease, home care should be established prior to PPT.
The actual stage of gum disease at each tooth and in the mouth generally, can only be established by a definitive dental examination under general anaesthetic. When there is significant calculus present, it becomes more difficult to estimate the periodontal condition. It may be justified to perform a PPT on the basis of establishing a baseline by a complete examination. It is still useful to know what home care is being achieved or may be possible before commencing PPT.
In mouths with excessive calculus or advanced periodontal disease, a “phase 1” PPT should be performed as soon as is practical. This treatment will include a full examination, extraction of teeth with advanced periodontal disease, and a basic scaling. Once the “dead wood” is cleared and the mouth cleaned up, the best possible home care can be established. Attempts of home care before phase 1 would appear futile to the owner and they would be unmotivated. A second phase treatment would be arranged once the best home care has become established.
When it is known that little or no home care will be given, the treatment should shift towards more aggressive selection of teeth for extraction and less time spent on “conservative” measures. With higher levels of home care achievable, the greater the benefits of professional tooth cleaning and so greater effort and time spent on scaling, polishing, root planing etc is justified.
After PPT, there needs to be follow up to monitor the condition of the mouth and the ongoing oral hygiene. It is known that a high percentage of owners slip in the level of ongoing mouth care as time elapses from instruction.
No forms of periodontal surgery, other than simple removal of gingival hyperplasia, should be considered until an ongoing “gold standard” of oral hygiene is proven. The trend in human periodontal treatment is to remain in the areas of conservative treatment and to avoid the use of periodontal surgery. Surgical treatment will have no long-term benefit without adequate plaque control. It has to be questioned as to whether it is appropriate to embark on surgical periodontal procedures.
The minimum standard of care that should be set is to provide enough treatment that no tooth reaches the advanced stages of periodontal disease. It is in the advanced stages of periodontal disease that a real threat is posed to the health and well being of the animal. In advanced periodontal disease pain becomes a possibility, especially with increasing tooth mobility. Deep periodontal pockets and soft tissue inflammation allow for the real possibility of bacteraemic showers from tissue movement. This may aggravate disease in other sites or even be a reason for reduced life expectancy.
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