Dentistry - Unit 2 - Periodontal Disease & Common Oral Pathologies

therapy aim in gingivitis vs periodontitis

In individuals with gingivitis, the aim is to restore the tissues to clinical health; in individuals with established periodontitis, the aim of therapy is to prevent progression of disease.

parallel technique for periodontis xrays

demonstrate more accurately the features of periodontitis because this technique provides a better view of the alveolar margin and reveals more accurately the actual extent or depth of the periodontal lesion in relation to the root of the tooth. - will demonstrate deposits of subgingival calculus and defects of the cementum but may not cover a sufficient area to demonstrate extensive periodontitis lesions adequately.

When 50% of the periodontium is lost, teeth become?

mobile. The loose teeth and continued infection eventually result in tooth loss.

As gingivitis develops, plaque extends ________?

subgingivally. -Aerobes consume oxygen and a low redox potential is created, which makes the environment more suitable for growth of anaerobic species. -The aerobic population does not decrease, but with increasing number of anaerobes, the aerobic/anaerobic ratio decreases. -subgingival flora associated with periodontitis is predominantly anaerobic and consists of porphyromonas spp, Prevotella spp, Peptostreptococcus spp, Fusobacterium spp and spirochetes -High levels of Porphyromonas spp and spirochetes are consistently associated with progressive periodontitis in the dog. The bacterial flora of the normal feline gingival margin, as well as the bacteria found in subgingival plaque of cats with gingivitis and periodontitis, are similar to those found in humans and dogs under similar conditions

FISTULOUS TRACTS

- appear as smaller holes in the alveolar mucosa at the level of the root apex, or near the mucogingival line. - should be checked for as part of the overall oral exam. - These tracks are an indication of a devitalized tooth in the region. - Periodontal probing and radiographic examination will find the diseased tooth. - Fistulous tracts related to dental disease may also appear on the facial (maxillary and mandibular) skin.

dental calculus

Calcified plaque

specific plaque hypothesis

- not all gingivitis lesions invariably developed to periodontitis lesions - the view is that periodontitis is caused by specific pathogens

GINGIVAL HYPERPLASIA

-abnormal thickening of the gingiva most commonly resulting from chronic bacterial inflammation from plaque and calculus. - The gingival changes also result in the development of pseudopockets. The original tissue attachments may be normal, however, the thickening gingiva results in the development of deep pockets around teeth, subsequent entrapment of debris and the development of periodontal disease. This can be a localized problem but is usually generalized. This is more common in Boxers, Collies, Dobermans, and Dalmatians as well as dogs on the anticonvulsant diphenytoin (Dilantin). A partial gingivectomy is performed to reduce pocket depth.

normal periodontal probing depths

1-3 mm in the dog and 0.5-1.0 mm in the cat

ORAL ULCERATIONS

Common causes include: -periodontal disease -autoimmune disease -renal disease -acute necrotizing ulcerative gingivitis -neoplasia -fungal lesions -can see with FIV, FELV, FIP, feline chronic gingivostomatitis, upper respiratory viruses -certain types of malocclusion where abnormally positioned teeth rub the oral mucosa

stomatitis

Inflammation of the oral mucosa

COMMON ORAL PATHOLOGIES

PERIODONTAL DISEASE RETAINED (PERSISTENT) PRIMARY TEETH WORN TEETH (DENTAL WEAR) FRACTURED TEETH CROWDED, ROTATED, MISSING TEETH MALOCCLUSION DISCOLORED TEETH GINGIVAL HYPERPLASIA FISTULOUS TRACTS DENTAL CARIES FELINE ODONTOCLASTIC RESORPTION (Neck Lesions, Cervical Line Lesions, Resorptive Disease) ORAL ULCERATIONS

The primary cause of gingivitis and periodontitis is

accumulation of dental plaque on the tooth surfaces. Contrary to common belief, calculus (tartar) is only a secondary etiologic factor.

plaque associated with healthy gingiva mainly comprises

aerobic and facultative anaerobic bacteria.

Periodontal probing depth, gingival recession, furcation involvement and mobility measure?

extent of destruction of the periodontium, i.e. assess the presence and severity of periodontitis.

1. Maintenance of oral hygiene

performed by the owner and is often called homecare. Its effectiveness depends on the motivation and technical ability of the owner and the cooperation of the animal.

(PAL) periodontal attachment level

records the distance from the cemento-enamel junction (or from a fixed point on the tooth) to the base or apical extension of the pathologic pocket. It is thus a more accurate assessment of tissue loss in periodontitis. can either be measured with a periodontal probe or it can be calculated (e.g. PPD + gingival recession).

In gingivitis, the plaque-induced inflammation is limited to?

to the soft tissue of the gingiva

pathogenic mechanisms involved in periodontal disease include:

• Direct injury by plaque microorganisms • Indirect injury by plaque microorganisms via inflammation.

pathogenesis

-the host's response to the plaque bacteria, rather than microbial virulence per se that directly causes the tissue damage

Significance of pathology

*Undisturbed plaque accumulation results in gingivitis. 0 While some individuals with untreated gingivitis will develop periodontitis, not all untreated animals will do so. It cannot be predicted which individuals with gingivitis will develop periodontitis. However, animals in which clinically healthy gingivae are maintained will not develop periodontitis. **Consequently, the aim in periodontal disease prevention and treatment is to establish and maintain clinically healthy gingivae to prevent periodontitis.

gingivitis tx steps

- Educate the owner to understand the disease process. - Train and motivate the owner to perform daily homecare. - Institute daily homecare regimen by the owner - ideally, toothbrushing with a pet toothpaste in conjunction with a dental hygiene product. - Professional periodontal therapy (supra- and subgingival scaling and polishing) under general anesthesia to remove dental deposits (plaque and calculus). - Regular check-ups to ensure that the owner is following recommendations and to boost the owner's motivation.

PERIODONTITIS tx steps

- Educate the owner to understand the disease process. - Train and motivate the owner to perform daily homecare. - Institute daily toothbrushing regimen by the owner. - Professional periodontal therapy: this includes supra and subgingival scaling and polishing, root planing and extraction of unsalvageable teeth under general anesthesia. - Regular check-ups to ensure that the owner is following recommendations and to boost the owner's motivation. - Periodontal surgery may be indicated, but only if optimal homecare is in place.

Periodontitis clinical signs

- Halitosis is common and is often the first sign noted by the pet owner -Large amounts of dental deposits are usually present. These deposits need to be removed to allow a detailed examination of the periodontium. - Ulcers affecting mucous membranes of lips and cheeks may be present in areas where these tissues are exposed to plaque-covered tooth surfaces

Periodontitis

- Individuals with untreated gingivitis may develop -inflammatory reactions in periodontitis result in destruction of the periodontal ligament and alveolar bone. The result of untreated periodontitis is eventually exfoliation of the affected toot -site-specific disease: e. it may affect one or more sites of one or several teeth. - can generally be considered irreversible. - The aim of treatment is thus to prevent development of new lesions at other sites and to prevent further tissue destruction at sites which are already affected

Periodontitis diagnostics

- Tissue destruction assessed by measuring periodontal probing depth, gingival recession, furcation involvement and degree of tooth mobility. - In many cases, measuring or calculating the periodontal attachment level (PAL) is also useful -PPD is not necessarily correlated with severity of attachment loss - Gingival hyperplasia may contribute to a deep pocket (or pseudopocket if there is no attachment loss), while gingival recession may result in the absence of a pocket but also minimal remaining attachment. -Radiography to assess the type and extent of alveolar bone destruction is mandatory for periodontitis patients.

Consequences of gingivitis to affected animal

- Uncomplicated gingivitis is generally not associated with discomfort or pain in humans. In fact, it is an insidious process and the patient may be unaware of its existence -significance of gingivitis is that, if untreated, periodontitis may develop, as described earlier. -Gingival hyperplasia does pose an additional concern :The hyperplastic gingiva alters the position of the gingival margin and results in a false or pseudopocket. -presence of hyperplastic gingiva compromises tooth cleaning and may predispose to periodontitis. - - Radiography, to identify and thus treat concurrent periodontitis, is mandatory for patients with gingival hyperplasia.

Periodontitis tx

- Untreated gingivitis may progress to periodontitis. - In most instances in a practice situation, periodontitis is irreversible. -important to remember that periodontitis is a site-specific disease, i.e. it may affect one or more sites of one or several teeth. - aim of tx: prevent development of new lesions at other sites and to prevent further tissue destruction at sites which are already affected. - Professional periodontal therapy removes dental deposits above and below the gingival margin. It then rests with the owner to ensure that plaque does not re-accumulate. -Meticulous supragingival plaque control, by means of daily toothbrushing and adjunctive antiseptics when indicated, will prevent migration of the plaque below the gingival margin. If the subgingival tooth surfaces are kept clean, the sulcular epithelium will reattach -In patients with suspected periodontitis: institutedaily toothbrushing 3-4 weeks prior to the planned professional periodontal therapy if the animal will allow it. This will result in less inflamed tissue at the time of professional therapy and will allow assessment of the ability of the owner to perform homecare. If homecare is not possible, the professional treatment will need to be more radical, e.g. extraction of teeth that could potentially have been retained with good homecare. - periodontal surgery:never first-line treatment for periodontal disease. -first step/line therapy: Conservative management of periodontal disease, i.e. a thorough supra- and subgingival scale, root planing, polishing and irrigation in combination with daily meticulous homecare

MALOCCLUSION

- abnormal occlusion (abnormal "bite") of the teeth. - Many types of malocclusion exist. By knowing what normal occlusion is, abnormalities can be readily recognized. - Malocclusion is a congenital/genetic problem. - Many malocclusions need no treatment. - Others that contribute to abnormal oral function do need treatment by orthodontic intervention or possibly extraction

periodontal abscess

- acute exacerbation of the process occurring in a chronic periodontal pocket - It usually occurs from partial or complete obstruction of the orifice of the pocket. - Multiple acute periodontal abscesses may occur in some cases of advanced generalized periodontitis. - An abscess may also develop in the healthy periodontium if a foreign body is forced beyond the epithelial attachment. - Grass seeds embedded in the gingival sulcus have been identified as causing acute periodontal abscessation in the dog. -The acute periodontal abscess may produce rapid and extensive bone loss. In some instances, the bone loss will extend beyond the apices of the roots of the teeth.

general tx of periodontal dz

- aimed at controlling the cause of the inflammation, i.e. dental plaque. - Conservative or cause-related periodontal therapy consists of removal of plaque and calculus, and any other remedial procedures required, under general anesthesia, in combination with daily maintenance of oral hygiene. - the treatment of periodontal disease has two components: 1. Maintenance of oral hygiene 2. Professional periodontal therapy. -The aim of treatment differs whether the patient has gingivitis only or whether the patient also has periodontitis.

dental caries

- cavities - occur in 5% of dogs. - They are found most commonly on the occlusal surfaces of the mandibular and maxillary molars. - result from bacterial acid demineralization of tooth structure. - Caries can appear as a soft (based on probing with an explorer) chalky white area or as brown or black areas with staining. - At the time of discovery, caries have usually eroded through enamel into the dentin. The dentin easily stains. The defect has a soft necrotic dentin lining. Large caries may have eroded into the pulp resulting in the need for extraction or endodontics. Occlusal surface pit and fissure staining may be just staining or may be a dental caries. - Careful observation, explorer probing and radiographs will help differentiate.

Gingivitis clinical signs

- combination of visual inspection and tactile examination. - The presence and degree of gingival inflammation is assessed based on a combination of redness and swelling, as well as presence or absence of bleeding on gentle probing of the gingival sulcus. - -Various indices can be used to give a numerical value to the degree of gingival inflammation present. - In the clinical situation, a simple bleeding index may be the most useful: Using this method the gingival sulcus of each tooth is gently probed at several points and given a score of 0 if there is no bleeding and a score of 1 if the probing elicits bleeding. (The patient with uncomplicated gingivitis will have normal periodontal probing depths (1-3 mm in the dog and 0.5-1.0 mm in the cat) and show no evidence of gingival recession, furcation involvement or tooth mobility.) - Radiography is not mandatory if the clinical examination reveals no evidence of periodontal destruction

Infrabony defects in periodontitis

- diagnosed by a combination of exploration with a periodontal probe (the probe meets the firm resistance of bone when angled away from the tooth) and radiography. - described by depth and by the extent of the bony circumference involved. The surrounding alveolar bone is thought of as forming four walls (mesial, buccal, distal, palatal/lingual). - When bone is present around the entire circumference of the pocket, a four-wall defect is present. - When bone is missing on one face, a three-wall defect is present. - Two- and one-wall defects have two and three surfaces of the tooth root without bony support, respectively

FELINE ODONTOCLASTIC RESORPTION (Neck Lesions, Cervical Line Lesions, Resorptive Disease)

- disease of unknown origin - affects approximately 68% of domestic cats. -characterized by progressive resorption and destruction of teeth. These "cavity-like" lesions are found usually at the gingival margin of affected teeth. - Mandibular premolars are most commonly affected but all teeth are susceptible. -As the teeth resorb, the resulting rough tooth surfaces result in varying degrees of dental calculus formation with resulting local gingivitis. - If one lesion is found during the oral exam performed on the anesthesized patient, full-mouth radiographs are recommended as other teeth are often involved. - Oral exam alone may not detect all involved teeth. This is a progressive degenerative process and affected teeth are extracted. - As teeth resorb, the pulp is exposed and the resulting discomfort is a common cause of food dropping from the mouth; difficulty chewing, especially hard food; and ptyalism. Weight loss is found in chronic cases.

CROWDED, ROTATED, MISSING TEETH

- genetic and/or congenital abnormalities. - Crowded teeth are ideal for accumulation of calculus and the development of caries. - Rotated teeth are most common in brachycephalic dogs and usually cause no problem unless crowding is present. - Missing teeth usually cause no problems. A radiograph should be made to see in the permanent tooth is present and not erupted or if the tooth is absent. - Non-erupted teeth can cause future fistulous tract development and local infection. Surgical intervention is considered for non-erupted teeth

'dental prophylaxis' or 'prophy'

- has been used to encompass clinical examination and professional periodontal therapy. - This is misleading since the real prophylaxis, i.e. steps taken to prevent disease development and progression, is not the professional periodontal therapy carried out under general anesthesia but the daily homecare regime to remove plaque.

FRACTURED TEETH

- have sharp edges to the fracture margin in contrast to worn teeth. - may involve the enamel only; enamel and dentine and enamel, dentin with exposure of the pulp. - The dark colored dot on these teeth is the exposed pulp chamber. It there is any question, an explorer tip can be introduced into the tooth which confirms pulp exposure. - Sharp edges of the fracture site are smoothed. - Exposed dentin is sealed with a bonding agent. - Fractured teeth with pulp exposure are extracted or treated endodontically. - The wait-and-see or ignoring options are not appropriate. -Not all fractured teeth can be saved even if the owner desired it. -A radiograph and careful visual inspection with trans illumination is needed to evaluate fractured teeth before any treatment.

periodontal surgery

- is used to encompass specific surgical techniques aimed at achieving normal anatomic relationships to allow optimal homecare. - techniques allow reattachment or regeneration of periodontal attachment. - includes various flap procedures, gingivoplasty, guided tissue regeneration and implants. - never first-line treatment for periodontal disease. - should only be performed where the owner has shown the ability to keep the mouth clean. If a client cannot maintain good oral hygiene measures in their pet then in the interest of the wellbeing of the animal there is no indication for surgery.

Gingival hyperplasia

- may be the result of plaque-induced inflammation, i.e. hyperplastic gingivitis. - It may also be of idiopathic or familial origin, and it can be induced by certain drugs, e.g. hydantoin, ciclosporins. - common in some breeds, e.g. Boxer, Springer Spaniel. -There is an increase in periodontal probing depths owing to the gingival overgrowth. - overformation of gum tissue

RETAINED (PERSISTENT) PRIMARY TEETH

- may result in an abnormal eruption direction of the secondary (permanent) teeth which may then result in malocclusion. - In addition, the resulting crowding of teeth will result and the tight interdental space between the retained and permanent tooth provide for calculus accumulation and potential periodontal disease. - Retained primary teeth should be extracted. Ideally, preoperative radiographic evaluation is performed to determine the remaining tooth root length.

pseudopocket

-the increased periodontal probing depth is not due to destruction of periodontal ligament and alveolar bone with apical migration of the junctional epithelium, as in periodontitis. Instead, the increased periodontal probing depth is due to the overgrowth of the gingiva. -the hyperplastic gingiva alters the position of the gingival margin and results in this false pocket

bisecting angle xray technique for periodontitis

- may show greater destruction of the alveolar bone than is actually present, because the central ray is directed obliquely to the long axis of the teeth and jaw, which produces dimensional distortion. Moreover, with the bisecting angle technique, subgingival calculus may be superimposed on alveolar bone and would thus not be detected - In the maxilla and anterior mandible, bisecting angle and parallel views of the same region may be required to visualize the extent of the tissue destruction more accurately.

DISCOLORED TEETH

- occur as a result of trauma, often unknown to the owner like chewing on hard objects. - A slight pink discoloration indicates pulpitis and, if the tooth survives, the discoloration is usually gone in 2-3 weeks. - Anti-inflammatory medications are usually needed. - A gray, reddish-purple, or gray black discoloration of the crown is caused from blood products staining the dentin tubules secondary to severe pulp trauma and probable necrosis. This is a non-vital tooth. Endodontic treatment (root canal) or extraction should be considered

what conditions can aggravate periodontitis but do not actually cause destructive tissue inflammation?

- physical or psychologic stress and malnutrition, may impair protective responses such as the production of antioxidants and acute phase proteins & aggravate periodontitis -A genetic predisposition to destructive inflammation of the periodontium may be important in some individuals

Diagnosis of periodontal disease

- relies on clinical examination of the periodontium in the anesthetized animal -radiography is mandatory if there is evidence of periodontitis on clinical examination. -essential to differentiate between gingivitis and periodontitis in order to institute appropriate treatment. -Oral examination and recording of findings -The following parameters need to be assessed and recorded for each tooth in all patients: 1. Gingivitis and gingival index 2. Periodontal probing depth (PPD) 3. Gingival recession (GR) 4. Furcation involvement 5. Mobility. -do not assess and record the extent of plaque and calculus accumulation in patients that are seen for the first time. These deposits will be removed during periodontal therapy. Instead, I assess and record plaque at follow-up visits to assess the efficacy of the homecare regimen that has been instituted. Plaque accumulation is visualized using a plaque-disclosing solution and the teeth that have plaque at the gingival margin are noted and recorded. The amount of plaque is graded subjectively as mild, moderate or severe depending on the depth of staining achieved by the plaque-disclosing solution.

WORN TEETH (DENTAL WEAR)

- results from chronic chewing on hard objects. -Dental tissues (enamel and dentin) are mechanically worn away. - shortened, usually smooth without sharp edges and may appear malformed due to wear. - As worn teeth are shorted, the pulp recedes as it produces additional dentin to keep the pulp covered. - often have a "brownish " dot at the center of the occlusal surface. This dot is either reparative dentin or debris in an entry to an open pulp chamber. The dot is probed with a dental explorer. Reparative dentin keeps the tooth sealed and the explorer tip will not enter the tooth. The explorer will enter the tooth with an open pulp chamber. These teeth need extraction or root canal therapy.

Gingivitis tx

- reversible -Removal or adequate reduction of plaque will restore inflamed gingivae to health. - Once clinically healthy gingivae have been achieved, these can be maintained by daily removal or reduction in the accumulation of plaque. - In short, the treatment of gingivitis is to restore the inflamed tissues to clinical health and then to maintain clinically healthy gingivae thus preventing periodontitis. - The purpose of the professional periodontal therapy in the gingivitis patient is removal of dental deposits, mainly calculus (which is not removed by toothbrushing). - Once the teeth have been cleaned it remains up to the owner to remove the plaque that re-accumulates on a daily basis

clinical signs of gingivitis

- swelling, reddening and often bleeding of the gingival margin & accompanied by halitosis

Periodontal disease

- the most common dental disease and the major reason for loss of teeth. - It may range from localized inflammation of the gingiva (gingivitis) to inflammation and destruction of the periodontium (periodontitis). - result of the inflammatory response to dental plaque, i.e. oral bacteria, and is limited to the periodontium. - collective term for a number of plaque-induced inflammatory lesions that affect the periodontium. The term infection refers to the presence and multiplication of a microorganism in body tissues. -Periodontal disease is a unique infection in that it is not associated with a massive bacterial invasion of the tissues. - Gingivitis is inflammation of the gingiva and is the earliest sign of disease. Individuals with untreated gingivitis may develop periodontitis - The inflammatory reactions in periodontitis result in destruction of the periodontal ligament and alveolar bone. The result of untreated periodontitis is ultimately exfoliation of the affected tooth. Thus, gingivitis is inflammation that is not associated with destruction (loss) of supporting tissue. It is reversible. periodontitis is inflammation where the tooth has lost a variable degree of its support (attachment) & is irreversible - can cause discomfort to affected individuals. Moreover, there is strong circumstantial evidence that a focus of infection in the oral cavity may cause disease of distant organs

Consequences of periodontitis to affected animal

- uncomplicated periodontitis is not associated with severe pain or discomfort. In contrast, complications such as the development of a lateral periodontal abscess or ulcers in the mucous membranes are very painful. -shown that a severe infection in the oral cavity, as with extensive periodontitis, will lead to a transient bacteremia on chewing - an association has been demonstrated between periodontal disease and histopathologic changes in kidney, myocardium, and liver in the dog

periodontal pathology

-As periodontitis occurs the inflammatory destruction of the coronal part of the periodontal ligament allows apical migration of the epithelial attachment and the formation of a pathologic periodontal pocket (i.e. periodontal probing depths increase). -If the inflammatory disease is permitted to progress, the crestal portion of the alveolar process begins to resorb. Alveolar bone destruction type and extent are diagnosed radiographically. - The resorption may proceed apically on a horizontal level. Horizontal bone destruction is often accompanied by gingival recession, so periodontal pockets may not form (Fig. 9.1D). -If there is no gingival recession, the periodontal pocket is supra-alveolar, i.e. above the level of the alveolar margin. The pattern of bone destruction may also proceed in a vertical direction along the root to form angular bony defects. The periodontal pocket is now intra- or subalveolar, i.e. below the level of the crestal bone.

Dental plaque

-biofilm composed of aggregates of bacteria and their by-products, salivary components, oral debris and occasional epithelial and inflammatory cells - accumulation starts within minutes on a clean tooth surface. -The initial accumulation of plaque occurs supragingivally but will extend into the sulcus and populate the subgingival region if left undisturbed -dental plaque occurs whether food passes through the oral cavity or not, i.e. food debris does not attach to the teeth to form plaque - supragingival plaque bacteria derive their main nutrients from dietary particles dissolved in saliva. -Within the pathologic periodontal pocket, the major nutritional source for bacterial metabolism comes from the periodontal tissues and blood. - Differences in the composition of the subgingival plaque have been attributed in part to the local availability of blood products, pocket depth, redox potential and PO2

formation of plaque

-involves two processes: initial adherence of bacteria and then the continued accumulation of bacteria due to a combination of multiplication and further aggregation of bacteria to those cells that are already attached - As soon as a tooth becomes exposed to the oral cavity, its surfaces are covered pellicle (an amorphous coating of salivary proteins and glycoproteins). - The pellicle alters the charge and free energy of the tooth surfaces, which increases the efficiency of bacterial adhesion - The first bacteria to adhere to the pellicle are aerobic Gram-positive organisms. -in dogs and cats, the main bacteria in supragingival plaque are Actinomyces and streptococci. - As the plaque thickens, matures and extends further down the gingival sulcus, the environment becomes suitable for growth of anaerobic organisms, motile rods and spirochetesf

xrays and periodontitis

-mandatory -assess the type and extent of alveolar bone destruction -full mouth radiographs should be performed prior to the institution of any therapy -taken at regular intervals to monitor outcome of any treatment -detailed examination of the periodontal ligament space and interproximal alveolar margin requires the use of an intraoral radiographic technique - radiographic changes associated with periodontal disease include: resorption of the alveolar margin, widening of the periodontal space, a break in the path or loss of the radiopacity of the lamina dura and destruction of alveolar bone resulting in supra- or infrabony pockets -parallel vs bisecting angle techniques -As periodontitis develops, the crestal portion of the alveolar process begins to resorb. Radiographically, the destruction is evident as a cup-shaped notch or as scalloping of the alveolar margin. The resorption may proceed apically on a horizontal level. Beyond this, the lamina dura appears to be normal and there is no widening of the periodontal space. - Horizontal bone destruction is often accompanied by gingival recession so periodontal pockets may not form. If there is no gingival recession, the periodontal pocket is supra-alveolar, i.e. above the level of the alveolar margin. The pattern of bone destruction may also proceed in a vertical direction along the root to form angular bony defects. Radiographically these are usually evidenced by a vertical or V-shaped flaw, with the root of the tooth forming one side of the defect . The periodontal pocket is now infra- or subalveolar, i.e. below the level of the crestal bone

disease progression

-progression is generally an episodic occurrence rather than a continuous process. -Tissue destruction occurs as acute bursts of disease activity followed by relatively quiescent periods. - The acute burst is clinically characterized by rapid deepening of the periodontal pocket as periodontal ligament fibers and alveolar bone are destroyed by the inflammatory reactions -The quiescent phase is not associated with clinical or radiographic evidence of disease progression. However, complete healing does not occur during this quiescent phase, because subgingival plaque remains on the root surfaces and inflammation persists the connective tissue. - The inactive phase can last for extended periods

MASS LESIONS

Small or large benign or malignant oral neoplasms or other benign lesions such a granulomas may be present. A careful oral exam including inspection of the tonsils and palpation of the floor of the mouth, tongue base and tongue frenulum and lips should be performed.

non-specific plaque hypothesis

direct relationship was assumed to exist between the total number of bacteria that accumulated on a tooth surface and the amplitude of the pathogenic effect

Clinical signs of pain

have a very gradual onset. Pain from periodontal disease is a result of inflammation from infection. Signs may include decreased appetite, preference for soft foods, food dropping from the mouth during mastication and slow, deliberate mastication. Anecdotal evidence of discomfort and systemic illness is abundant. After treatment of periodontal disease (usually including some extractions and oral antibiotics) many owners report increased activity and appetite at the two-week follow-up exam.

Periodontal disease and tissue destruction

initial bacteria are aerobic gram positive organisms (mainly strep and actinomyces). As plaque and calcus thickens and extends into the gingival sulcus, the environment is more favorable to anaerobes and spirochetes. It is the anaerobes that are largely responsible for the accompanying periodontal tissue inflammation and tissue destruction. As the plaque advances subgingivally, the gingival margin and epithelial attachment (gingiva attachment to the tooth) recede. Once the epithelial attachment has receded beyond the cementoenamel junction, a periodontal pocket forms. (A gingival sulcus no longer exists.) The inflammation not only creates severe gingivitis, but also destroys the alveolar bone and periodontal ligament. The response of the host to these bacteria is very complex. It is this response that also results in tissue destruction.

dental calculus

mineralized plaque. -a layer of plaque always covers calculus. Both supragingival and subgingival plaque becomes mineralized. Supragingival calculus per se does not exert an irritant effect on the gingival tissues. - been shown that sterilized calculus may be encapsulated in connective tissue without causing marked inflammation or abscess formation - main importance of calculus in periodontal disease thus seems to be its role as a plaque retentive surface.

2. Professional periodontal therapy

performed under general anesthesia and includes: • Supra- and subgingival scaling • Root planing • Tooth crown polishing • Subgingival lavage • Sometimes periodontal surgery.

Periodontal disease may result in?

systemic bacteremia and have a deleterious effect on tissues such as the liver, kidneys, and heart valves.

Plaque

the major cause of periodontal disease. A soft, cream-light gray amorphous deposit. It consists of bacteria, salivary glycoproteins, extracellular polysaccharides mixed with epithelial cells, macrophages, lipids, carbohydrates, inorganic substances (calcium, carbonate, phosphates) and water. It adheres to the teeth and must be mechanically removed. begins to calcify about 3 days after it is deposited. The heaviest concentrations of calculus are near salivary gland papilli. The high electrolyte concentration in saliva results in extensive plaque calcification. This is most evident at the buccal surfaces of maxillary fourth premolar and molars due to the close proximity of the parotid salivary papillae. The rough surface of calculus promotes additional rapid plaque accummulation with subsequent calcification. The high local concentration of plaque/calculus bacteria promotes gingivitis. As this circle of plaque/calculus buildup continues, plaque can accumulate subgingivally. This plaque may be free floating, sticking to the tooth or gingival sulcus epithelial lining or invading these gingival soft tissues.

Periodontal disease affects

the supporting structures around teeth which are the gingiva, alveolar bone, cementum, and periodontal ligament

If no homecare is instituted, what will happen?

then plaque will rapidly reform after a professional periodontal therapy procedure and the disease will progress. Before any treatment is instituted, the owner must be made aware that homecare is the most essential component in both preventing and treating periodontal disease. Whenever possible it is useful to institute a homecare programme before any professional periodontal therapy is performed.

Gingivitis

usually a reversible process with proper treatment to remove and prevent accumulation of plaque and calculus. Uncontrolled gingivitis results in periodontitis which is an irreversible (but usually manageable) disease defined as: a reversible plaque-induced inflammation limited to the gingiva (i.e. no loss of periodontal attachment).

Periodontal dz treatment begins with a complete oral examination with the patient anesthetized:

• A complete dental cleaning is performed. • Dental and periodontal pathology is charted • For periodontal evaluation, particular attention is paid to: -gingival health -normal sulcus or periodontal pocket -periodontal pocket depth -presence of subgingival calculus -mobile teeth -exposed furcations and roots -missing teeth • A periodontal probe is essential to find periodontal pockets and for the measurement of pocket depth. • Dental curets are essential for removal of subgingival calculus, root planning, and periodontal pocket soft tissue debridement. • After the oral examination, dental radiographs are made to help with treatment planning.

Staging and Treatment of Periodontal Disease

• Normal gingiva Gingival tissue is coral pink or pigmented. It is firm and resilient. On close inspection there is defined stippling, and sharp knife-like border, and minimal sulcular depth. (Normal sulcus depth-Cats 0.0-0.5mm; Dogs 2.0mm, may be greater in larger dogs or around maxillary canines in any dog.) • Stage One (Gingivitis) Gingival edema, erythema, and loss of stippling occur. Bleeding is found with minimal manipulation in more advanced cases. There is no attachment loss. This stage of periodontal disease is completely reversible with performance of a complete dental cleaning and some form of at-home dental care. • Stage Two (Early periodontitis) This is the same as stage one, however, minor attachment loss is present. Treatment is the same. • Stage Three (Moderate Periodontal Disease) There is moderate loss of attachment with the development of moderate to deep pockets. Gingival hyperplasia and/or recession may be present. Sometimes there is gingival recession and bone loss to cause tooth root exposure without periodontal pockets. This is still serious disease. Bone loss of 30-50% may be found and only slight tooth mobility is present. Treatment is dental cleaning, root planning and possible gingival surgery. This stage is manageable, not curable. • Stage Four (Severe Periodontal Disease) Severe pocket depth and major gingival recession and bone loss is present. There is greater than 50% bone loss. Teeth are very mobile. Treatment is complete cleaning. Root planning and gingival surgery can be performed on less involved teeth. Severely mobile teeth with greater than 50% bone loss are usually extracted. This stage is manageable, not curable.

Oral exam w/ periodontal dz will reveal some or all of the following:

•Gingivitis - Gingiva will be swollen and inflamed. The knife-like edge of the normal gingival margin will not be present. • Bleeding gingiva on slight manipulation of the ginigva during dental cleaning and periodontal probing • Dental calculus • Exposed tooth furcations and tooth roots • Mobile teeth • Halitosis