"Teeth cleaning" (scaling) is the primary means of removing plaque and calculus. Teeth scaling is only a part, though a vital and universally required part, of management designed to permit retention of teeth.
A thorough prophylaxis consists of inspection and charting of the teeth, supra and subgingival scaling, root planing, polishing, pocket irrigation and home care instruction. Performed competently in a dog with extensive periodontitis, it can require 2–3 hours of professional working time under anesthesia, and is rarely completed in less than 30 minutes even in an animal with minimal calculus accumulation. It is a prophylactic procedure, in that it removes the plaque that causes periodontal disease and the calculus that harbors the plaque.
Some veterinary technicians are skilled in prophylaxis procedures; however, prophylaxis should not be left only to a technician - it involves diagnosis and treatment decisions, and the mouth should be checked before and after the scaling procedure by a veterinarian.
Periodontal examination includes probing. Dental probes have a rounded tip and a depth marking system and are used to examine periodontal pockets - a toothbrush applied at the correct angle cannot reach a depth of more than 4 to 5 mm, so pocket depth measurement (and assessment of mobility and inspection of the gingiva around each tooth) is essential. Successful retention of teeth with stage 3 or 4 periodontal disease requires good collaboration between the veterinarian, owner and a cooperating animal.
Charting is strongly recommended. It documents extent of disease for comparison with subsequent examinations and ensures that the indication for the procedure to be performed (scaling, scaling plus periodontal surgery or extraction) is documented.
Teeth scaling requires general anesthesia - subgingival examination and scaling cannot be accomplished satisfactorily in an awake patient.
Use of antibiotics in association with periodontal procedures is described in a separate session.
Teeth Scaling and Polishing
Scaling an animal with well-established periodontitis is not a minor procedure.
Gross calculus deposits are removed using calculus forceps or dental extraction forceps, avoiding damage to the gingiva.
An ultrasonic scaler is used to remove supragingival plaque and calculus. It is easier and quicker than hand scaling. Water flow is essential to cool the oscillating tip and flush away the debris. Gently stroking the tooth with the side of the instrument tip is best, and the tip must not be pressed firmly against the tooth surface or kept in contact with the same area for more than a few seconds.
Using gentle technique and appropriate scaling tips, ultrasonic scalers may be used subgingivally. Gently insert the tip into the pocket with the unit inactivated, then activate the unit as the tip is withdrawn from the pocket.
Ultrasonic scalers cause contamination of the immediate environment with bacteria-laden water droplets; protective eyeglasses and face masks should be worn, and sterile surgical procedures should not be performed in the same work area.
Although ultrasonic instruments can be used to accomplish most of the work, use of hand instruments is often required to perform a complete scaling procedure. The most important hand instrument is the curette. This has a sharp working side edge and a rounded tip. It is inserted gently into the pocket until resistance is felt. Tilt the curette away from the tooth to engage the sharp edge against the root surface as it is pulled firmly out of the pocket.
To determine if a root is thoroughly clean, gently run a curette over the surface - it will skip over areas of remaining calculus. If the surfaces cannot be properly cleaned using closed curettage, a flap is raised and 'open curettage' is performed.
Tooth surface irregularities created by instrumentation during scaling are smoothed out by polishing the teeth. A mildly abrasive 'prophylaxis paste' is applied to the surface of the teeth with a rubber cup mounted in a slow speed (5000 rpm) prophylaxis handpiece.
Following polishing, the gingival pocket is irrigated to flush out debris.
A surface conditioner designed to reduce adhesion of plaque and calculus is now available (OraVet, Merial); the professional agent is applied immediately post-prophylaxis and periodic use of the home application is recommended as a follow-up.
Management of Deep Periodontal Pockets
For deep periodontal pockets (anticipated to be deeper than about 5 mm following healing) or where the entire attached gingiva has been lost or the tooth is mobile, additional surgical treatment is needed. Indications and techniques for management of involved periodontal treatment are considered in a separate session.
Periodontal Home Care
The most important aspect is compliance of the owner and animal with a continuing program designed to retard plaque and calculus formation. The most practical way for most owners is to have the animal do the work. A natural diet for carnivores requires the animal to tear food material, which has a natural flossing action. Chewing materials that mimic a natural diet are raw meaty bones, rawhides or other chews. Large hard biscuits are also somewhat beneficial, particularly those that include a chemical anti-calculus agent such as hexametaphosphate or polyphosphate. Standard kibble dry food fed dry is only moderately effective in retarding plaque accumulation compared with canned food in dogs. Dentally-effective diets are now available.
The Veterinary Oral Health Council® Seal of Acceptance has been awarded to products with documented effectiveness in retarding accumulation of plaque and or calculus (www.vohc.org).
Daily tooth brushing is the ideal plaque and calculus retardant.
Chlorhexidine has proven to be the most effective anti-plaque agent, and is available to veterinarians as a palatable oral solution and gel (e.g., CHX, Virbac). Another palatable plaque retardant is CET dentifrice (Virbac). Other chemical agents are now marketed.
As for the human mouth, regular (6 months, preferably) re-evaluation helps ensure maintenance of healthy teeth and periodontium. More frequent reexamination is recommended following treatment of severe periodontal disease.
A combination of techniques (brushing, dental diet, treats) is more likely to be effective than a single technique.
The importance of good home care needs to be taught to the owner - take time in the office to discuss the possibilities and demonstrate good application technique.
Results Following Conservative Periodontal Therapy
When home oral hygiene removes plaque thoroughly daily or every other day, the periodontal tissues stay in a clinically healthy condition. The two factors that determine long-term results in dogs are the extent of disease existing prior to treatment (e.g., presence or absence of pocketing or furcation involvement that promotes plaque retention) and the efficacy of long-term plaque retardation. Few owners are scrupulously conscientious about oral hygiene in their pets, and thus there is a broad range of clinical effectiveness.