Diagnosing periodontal disease can be one of the most “exploratory” aspects encountered in veterinary dentistry. The ability to promptly interpret radiographic and oral exam findings while the patient is under anesthesia, formulate a treatment plan, and communicate these findings to the pet parent can be challenging. A working knowledge of periodontal disease, including the various stages and treatment options available, will greatly aid in one’s ability to perform these tasks and achieve outcomes that are in both the patient’s and owner’s best interest.
A VERY brief overview
Periodontal disease is a plaque induced pathology of the supporting structures of the tooth which consists of the gingiva, periodontal ligament, alveolar bone, and cementum.
There are several factors to consider when determining the appropriate treatment of periodontal disease: severity, type of attachment loss, overall health of the patient and the owners’ willingness to perform home oral care. The various stages of inflammation and progressive attachment loss which categorize the severity of periodontal disease, as determined by radiographic assessment and periodontal probing, include:
- stage I (gingivitis only without attachment loss)
- stage II (attachment loss up to 25%)
- stage III (attachment loss between 25% to 50%)
- stage IV (attachment loss greater than 50%).13
Infrabony pocketing comes in several shapes and forms and can be seen radiographically as vertical or horizontal bone loss.
Communication
From a communication standpoint, it’s important to understand how the owner would like to proceed with treatment of their pet. Ideally, this is done prior to inducing anesthesia. I find this makes communicating “exploratory” findings (radiographs and oral assessment), while the patient is under general anesthesia, go smoother. There are other benefits to this as well including, but not limited to, aiding in rapid treatment plan formulation and ultimately creating a better overall experience for the patient and owner (less time under anesthesia, quicker/smoother recovery, less chance of post-operative complications, etc.).
When I first meet a client and patient seeking consultation and treatment for periodontal disease, I will often spend the first part of the consultation educating the client on things such as stages (as previously mentioned) and treatment options for each stage:
- stage I – Prophylaxis
- stage II – Closed root planing/subgingival curettage +/- perioceutic placement. Open root planing may be necessary in hard to reach areas such as furcations.
- stage III – Open root planing, guided tissue regeneration, osseous reduction, sliding flaps, extraction, etc.
- stage IV (attachment loss greater than 50%) – extraction
In my opinion, stages 1, 2, and 4 make for easier decision making as the treatment options are limited and straight forward (see above). However, in this scenario, it is important that the operating clinician understands the principles and techniques for performing basic periodontal therapy for stage II periodontal disease beyond scaling and polishing. I will communicate to the owner that in stage 3 disease, there may be treatment options to save these teeth and we spend some time diving into the owner’s desires, taking into account things such as ability to perform home care, patient health, and willingness of the owner to return for rechecks.
Do they want to save strategic teeth if affected by stage 3 periodontal disease? If not, then the recommendation is to extract those teeth as we would with those affected by stage 4 disease. If they do want to save stage 3 teeth, then the questions remain if the owner can perform the necessary home care, if they are willing to bring the patient back for rechecks as necessary to monitor the success of the treatment and if they are okay with repeat treatment when indicated. Another important aspect to consider is whether the patient is healthy enough to undergo multiple anesthetic episodes. If co-morbidities exist, such as cardiac disease, then perhaps advanced periodontal therapy is not appropriate and treating stage 3 teeth by extraction, as would be done with stage 4, is the right course of action. If the owner is willing to perform home care, return for rechecks, and the patient is a healthy anesthetic candidate, then consideration for advanced periodontal therapy for teeth affected by stage 3 disease is a viable option. There are many other factors to consider when treating stage 3 teeth, such as teeth affected (strategic vs non-strategic), location, pattern of bone loss, and of course, potential financial constraints. This article does not focus on these areas however referral to a board-certified dental specialist who is trained in evaluating and performing this type of treatment should be considered if the owner desires advanced periodontal treatment of stage 3 affected teeth.
This leads us to the questions of internal reflection. The old saying goes: “When all we have is a hammer, everything looks like a nail”. However, one should always ask themselves, what is it that I can do to help this patient? And, if I don’t have the tools to do so, is referral a possibility?
In summary, client education and maintaining an open line of communication with the owner are very important when diagnosing and treating periodontal disease.
Kevin Haggerty, MVB, Dipl. AVDC, Dipl. EVDC
Board Certified Veterinary Dentist and EBVS European Veterinary Specialist in Dentistry
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