Periodontal Disease-Professional Care and Home Care Part 1

Centers for Oral Care

New England & New York

Animal Dental Health Services

www.animaldentistrysolutions.com

No. 16~ 20 January2017

DH DeForge, VMD

Fellow of the Academy of Veterinary Dentistry

Periodontal Disease-Professional Care and Home Care~

Part One of a Three Part Series

Treatment of advanced periodontal disease is a multi-step process.  The term Comprehensive Oral Health Assessment and Treatment has been adopted by most veterinary dentists to describe the complexity of Periodontal Disease Diagnostics and Treatment. 

After a Dental Cleaning:

After a dental cleaning under general inhalation anesthesia, your local doctor of veterinary medicine will initiate a consultation concerning the stage of Periodontal Disease that has been identified.  Sometimes your veterinarian will recommend medications, as a first-line of treatment, before resorting to advanced surgical periodontal care algorithms and/or referral to an animal dentist.   This is directly dependant on the severity of your pet’s gum disease.

Once professional periodontal care is completed, there is a needed emphasis on Home Care Modules of Prevention.  Successful periodontal care at home is measured by the word CONSISTENT.  The most effective home care prescription will fail without consistency.  Controlling plaque and biofilm prevents the progression of periodontal disease.  Most owners want to skip to home care prior to professional care.  That does not work. 

Comprehensive Oral Health Assessment and Treatment:

Comprehensive Oral Health Assessment and Treatment by a veterinarian trained in preventive dentistry coupled directly to oral x-ray diagnostics is paramount in all periodontal control programs.  At times, a consultation with a veterinary dentist is helpful in treatment planning.

First seek the advice of your veterinary health care professional.  Have the proper pre-anesthesia testing prior to oral care.  Ask that your pet have their profession periodontal care, diagnostics, and cleaning under general inhalation anesthesia only!  Finally, there is no veterinary dentist that will ever recommend anesthesia-free dental cleanings—i.e. periodontal care without general inhalation anesthesia.  All patients must be intubated and fully monitored by a veterinary anesthesia technician.  See the statement below by the AVDC on non-professional dental scaling.

American Veterinary Dental College Position Statement

In the United States and Canada, only licensed veterinarians can practice veterinary medicine. Veterinary medicine includes veterinary surgery, medicine and dentistry. Anyone providing dental services other than a licensed veterinarian, or a supervised and trained veterinary technician, is practicing veterinary medicine without a license and shall be subject to criminal charges.

This position statement addresses dental scaling procedures performed on pets without anesthesia, often by individuals untrained in veterinary dental techniques. Although the term Anesthesia-Free Dentistry has been used in this context, AVDC prefers to use the more accurate term Non-Professional Dental Scaling (NPDS) to describe this combination.

Owners of pets naturally are concerned when anesthesia is required for their pet. However, performing NPDS on an unanesthetized pet is inappropriate for the following reasons:

1. Dental tartar is firmly adhered to the surface of the teeth. Scaling to remove tartar is accomplished using ultrasonic and sonic power scalers, plus hand instruments that must have a sharp working edge to be used effectively. Even slight head movement by the patient could result in injury to the oral tissues of the patient, and the operator may be bitten when the patient reacts.

2. Professional dental scaling includes scaling the surfaces of the teeth both above and below the gingival margin (gum line), followed by dental polishing. The most critical part of a dental scaling procedure is scaling the tooth surfaces that are within the gingival pocket (the subgingival space between the gum and the root), where periodontal disease is active. Because the patient cooperates, dental scaling of human teeth performed by a professional trained in the procedures can be completed successfully without anesthesia. However, access to the subgingival area of every tooth is impossible in an unanesthetized canine or feline patient. Removal of dental tartar on the visible surfaces of the teeth has little effect on a pet's health, and provides a false sense of accomplishment. The effect is purely cosmetic.

3. Inhalation anesthesia using a cuffed endotracheal tube provides three important advantages... the cooperation of the patient with a procedure it does not understand, elimination of pain resulting from examination and treatment of affected dental tissues during the procedure, and protection of the airway and lungs from accidental aspiration.

4. A complete oral examination, which is an important part of a professional dental scaling procedure, is not possible in an unanesthetized patient. The surfaces of the teeth facing the tongue cannot be examined, and areas of disease and discomfort are likely to be missed.

Safe use of an anesthetic or sedative in a dog or cat requires evaluation of the general health and size of the patient to determine the appropriate drug and dose, and continual monitoring of the patient. Veterinarians are trained in all of these procedures. Prescribing or administering anesthetic or sedative drugs by a non-veterinarian can be very dangerous, and is illegal. Although anesthesia will never be 100% risk-free, modern anesthetic and patient evaluation techniques used in veterinary hospitals minimize the risks, and millions of dental scaling procedures are safely performed each year in veterinary hospitals.

To minimize the need for professional dental scaling procedures and to maintain optimal oral health, the AVDC recommends daily dental home care from an early age. This should include brushing or use of other effective techniques to retard accumulation of dental plaque, such as dental diets and chew materials. This, combined with periodic examination of the patient by a veterinarian and with dental scaling under anesthesia when indicated, will optimize life-long oral health for dogs and cats.

For general information on performance of dental procedures on veterinary patients, please read the AVDC Position Statement on Veterinary Dental Healthcare Providers, which is available on the AVDC web site (www.AVDC.org). For information on effective oral hygiene products for dogs and cats, visit the Veterinary Oral Health Council web site (www.VOHC.org).

For further information, send an e-mail message to the AVDC Executive Secretary (ExecSec@AVDC.org).

Adopted by the Board of Directors, April 2004

Part One-Brushing and Topical Products

In dogs, there is no better substitute for the control of plaque and biofilm after periodontal care than the mechanical brushing of the teeth twice daily.  Whether home care is accomplished utilizing a hand tooth brush and/or a sonic brushing system, the consistent use of a brush as a mechanical tool of periodontal disease control cannot be over stated.

Many clients feel uncomfortable with the idea of brushing their dog’s teeth.  This can be circumvented with an expansion of their zone of correct periodontal preventive care with the scheduling of technician appointments to demonstrate how to utilize a hand brushing or a sonic brushing system. 

Sonic Brushing and Animal Periodontal Preventive Care:

The sonic brushing system is very applicable to animal dentistry.  The brush is never activated until it is seated in the mouth and a reward is given each time the brush is removed and before it is re-inserted to work in the next quadrant of the mouth.  REWARD is the key and the reward must be a SPECIAL reward that is only given when brushing is being performed.  REPETITION and REWARD lead to SUCCESSFUL home care.  Brushing twice daily for at least two minutes is a very successful prescription for periodontal plaque control in dogs.

A soft-bristled tooth brush or a specific sonic brush insert is strongly recommended based on the pathology noted by your doctor.  Fluoride is not necessary in any dentifrice for dogs.  Poultry or meat flavored dentifrice rather than mint flavored is most acceptable to most dogs.  Advanced periodontal disease requires additional professional care and home care products that will be discussed in Part II in a future blog.

Discussed below is a Consensus Recommendation for people from the American Dental Association:

From the American Dental Association

• The consensus recommendation is for people to brush their teeth for two minutes twice a day with a toothbrush that has soft bristles.
• Replace toothbrushes every three to four months or more often if the bristles are visibly matted or frayed.
• Either manual or powered toothbrushes can be used effectively.
• A product earns the ADA Seal of Acceptance by providing scientific evidence that demonstrates safety and efficacy, which the ADA Council on Scientific Affairs carefully evaluates according to objective requirements.

The American Dental Association recommends brushing teeth twice a day for two minutes using a fluoride toothpaste. Brushing for two minutes has been shown to achieve clinically significant plaque removal¹and use of a toothpaste containing fluoride enhances fluoride concentration levels in biofilm fluid and saliva, and is associated with decreased risk of caries and remineralization of teeth.

There are a number of techniques for brushing teeth; any of which may have advantages depending on a patient’s particular needs. In general, the American Dental Association suggests that people place the toothbrush against the gum line at a 45-degree angle to remove plaque from above and just below the gingival margin, and move the toothbrush gently back and forth in short strokes. To clean the inside surfaces of the front teeth, they should tilt the brush vertically and make several up-and-down strokes.  

Regardless of the technique used, brushing should touch upon all surfaces—inner, outer and chewing. Also, when brushing, the ADA recommends that people use a soft-bristled toothbrush and apply gentle pressure, both of which may help reduce the risk of gingival injury.

Both manual and powered toothbrushes are effective at removing plaque.  While the powered toothbrushes are more expensive than most manual toothbrushes, some people prefer the powered version. People who have dexterity problems—like the elderly, people with disabilities, or children—or those who have dental appliances, like braces, may find a powered toothbrush easier to use.

A variety of powered toothbrushes that use a different types of head movement (e.g., side-to-side, counter oscillation, rotation oscillation, circular, ultrasonic) are available. ----END

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

New Technology from Oral-B:

Some very exciting innovations in sonic brushing are now available to people.  These sonic systems have definite features applicable to animal periodontal preventive care.

From Oral-B the new GENIUS SONIC SYSTEM

It’s About Brushing for the Right Length, Not Pressing Too Hard, and Never Missing a Zone

Oral-B GENIUS includes best-in-class product features, making it the most intelligent brushing system available that helps consumers smarten their daily brushing routines:

• Position Detection Technology: Senses and recognizes areas of the mouth users are cleaning via sensors built into the brush in combination with the smart phone. Oral-B research shows up to 80% of people spent insufficient time brushing in at least one zone in their mouth and 60% of people either didn’t brush their back molars at all, or spent insufficient time brushing them¹. Paired with the Oral-B App 4.1, the Position-Detection Technology in Oral-B GENIUS tracks brush position, and shows the user how to brush all zones in the mouth equally and evenly.
• Oscillating-Rotating-Pulsating Technology: Oral-B proprietary technology cleans tooth by tooth and its round brush head reaches areas that are often difficult to reach, providing a superior cleaning every session compared to a regular manual toothbrush.
• Triple Pressure Sensor Technology: Excessive pressure during brushing is one of the key reasons for gum tissue abrasions. Some manual users apply brushing forces two times the recommended pressure, which can be harmful to the gums. This technology protects gums from overaggressive brushing by visually indicating when too much pressure is applied, automatically slowing down the brush head speed, and stopping the pulsations. With Oral-B guidance system, up to 93% of aggressive brushers reduced their brushing force and the time spent brushing with excessive force was reduced by up to 88%².
• Professional Timer: Independent scientific research suggests that it is more important to brush all zones in the mouth evenly, rather than brushing longer³. Even when not connected to the App, Oral-B’s Professional Timer ensures that each quadrant of the mouth is brushed for 30 seconds, to reach the dental professional-recommended two minute brushing session. People using the Oral-B App brush on average 2 minutes and 27 seconds⁴, whereas manual brush users brush on average less than one minute.

After Brushing…. In Advanced Periodontal Pathology

Chlorhexidine Gluconate 0.12%

Anti-plaque-Anti-Gingivitis Rinse

Chlorhexidine  0.12% rinse is applied with 3x3 lightly saturated gauze squares, after brushing is completed, in cases of advanced periodontal pathology.  This is a prescription product and should never be utilized unless recommended by your local doctor of veterinary medicine or an animal dentist.  

It works by altering bacterial adsorption and altering the bacterial cell wall leading to lysis.  It has been shown in studies to reduce plaque; gingival bleeding; and advanced gingivitis when used in conjunction with an excellent brushing program.  Clients will notice a discoloration of enamel which is completely reversible with cessation of product use and a complete periodontal cleaning with scaling and polishing of the dentition. 

The benefits of this product have been demonstrated in dogs with advanced periodontal disease; septic periodontitis; chronic progressive periodontitis, and ulcerative paradental stomatitis in dogs.  It must be understood that Chlorhexidine Gluconate does not stand alone as a treatment.  It is only effective after professional care is accomplished.  Many times oral antibiotics and other home care products are used in conjunction with Chlorhexidine Gluconate.  In the SEVERE conditions mentioned above, a veterinary dentist should be consulted for oral diagnostics and appropriate periodontal care before initiating Chlorhexidine Gluconate home care.

In Part II and Part III of this series the following will be reviewed:

1.       Home Care in the Cat with Periodontal Disease

2.     Stomatitis in Cats-What do I do?

3.     Nontraditional Natural, Alternative, and Holistic Medicines for Periodontal Home Care

4.     Esterified Fatty Acid Complex Topical Treatment

5.     Home Care impossible?……What do I do?

6.     New Professional Techniques in Removing Plaque Biofilm

7.     When do I seek a Veterinary Dentist’s input in Advanced Periodontal Problems?

Questions: Contact Dr. DeForge at 1-800-838-3368  or

E-Mail: DonDeForge100@gmail.com

The author has no commercial conflicts of interest to disclose.

Consil® Putty Bioglass® no15

Centers for Oral Care

www.AnimalDentistrySolutions.com

No. 15 -- 19Jan2017

Fellow of the Academy of Veterinary Dentistry

1-800-838-3368

DonDeForge100@gmail.com and DoctorDeForge@yahoo.com

Consil® Putty Bioglass®

Consil® Synthetic Bone Graft Particulate has been utilized at Silver Sands Veterinary Center and at the Centers for Oral Care, for years, in periodontal and osseous defects. Originally earmarked in alveolar ridge maintenance following extraction and treatment of infrabony osseous defects, its scope of utilization has broadened significantly through the years. Consil® is an osteoconductive bioactive device used for grafting osseous defects.
Consil® has expanded into oral trauma care with oral orthopedic applications, repair of oronasal fistulas, and filling of defects after mass or cyst removal from the oral cavity. The clinical and radiographic findings demonstrate that the Bioglass® particles are progressively replaced by bone. Whenever a tooth is extracted, nature will remove the bone that used to encompass this structure. The alveolar or supportive bone is lost leaving behind cortical bone. This can be arrested with bone grafting.
Consil® particulate material has been found to be hemostatic through a mechanical effect. Following the placement of Bioglass®, soft tissue and bone bleeding decrease significantly. This allows for excellent visualization of tissues during the placement of sutures. Combined with Radiowave Radiosurgery [4.0 M Hz- Ellman International] technology, the field of vision is literally blood free. A second positive finding is that epithelial down growth is limited to the point where it meets the adherent collagen fibers overlying the restored bone. The collagen attaches to the most superficial particles immobilizing them. It has been shown that Bioglass® is bacteriostatic allowing placement in infected sites with positive results.
All bone grafting sites must be pre-radiographed, osseous surgery performed when indicated, and lavaged with normal saline 0.9% before the Consil® bone alloplast is placed. After placement of bone alloplast, there must be a combined out-patient recheck[s] as well as multiple oral radiograph appointments to assure that the area is healing properly. The patient must be monitored to be sure that no hard chewing occurs. Leash walking is advised. If infection in the bone is suspected, a broad spectrum antibiotic that will kill both aerobes and anaerobes is advised for 30 days post treatment. As with all bone surgery, analgesic protocols are essential for up to three weeks post-surgery. Because there is no subjective pain, “bad or hidden” pain must be treated for a minimal time period. This analgesic program is continued as necessitated.
The placement of the bone graft is not painful but the cutting of bone is painful and must be appreciated with pain control systems. Failure or “wash out of the bioactive glass will occur with advancement of plaque bacteria. Therefore, all bone grafting procedure success is strongly linked to compliance by the owner to effective anti-plaque homecare treatments, on a daily basis, as recommended by the veterinarian or veterinary dentist placing this material.
Bone alloplast [i.e. Consil®-Bioglass® is recommended for use after all extraction procedures in the canine and feline. As stated, pre-extraction and post-extraction radiology is paramount. In the distal mandible, this is extremely important, in toy breeds, because of the possibility of already existent incomplete pathologic fractures. These incomplete fractures can accelerate to complete fractures with forceful extraction techniques. Pre-radiology of the sites allows the practitioner to call the owner and inform them of this pathology and get permission for extraction with informed consent. The client may ask for referral to a veterinary dentist at this juncture.
Consil® is available as the original bone graft particulate and also as a Putty Synthetic Bone Graft. The Consil® Putty is a premixed composite of the bioactive calcium-phospho-silicate particulate and a synthetic, absorbable binder. The absorbable binder is a combination of polyethylene glycol and glycerin. The Consil® Putty device, as described by the manufacturer, requires no mixing or preparation prior to application.
The Consil® Putty has been found extremely beneficial in areas where there are no true physical osseous borders for retention. A prime site for oral usage is in the anterior mandibular symphysis. After radiography and osteoplasty with copious irrigation, the putty can be modeled to fit the confines of the site. It holds position perfectly until mucoperiosteal flaps are secured with absorbable sutures. Post radiography shows the same excellent bone healing as noted with the bone graft particulate. The Consil® Putty Bone Graft should be used in combination with internal or external orthopedic fixators if the symphysis is unstable. It should not be used to support load-bearing defects. As stated above, standard procedures in pain control, infection control, and plaque prevention must be followed to show success with this product. Post radiology follow-up[s] in 6-12 months is essential in all bone augmentation procedures. All Guided Bone Regeneration procedures should only be accomplished by veterinarians after successful training in orthopedics and GBR techniques.
See the photo essay below visualizing the usage of the Consil® Synthetic Bone Graft in the anterior mandible. Questions: E-Mail Dr. Don DeForge at DonDeForge100@gmail.com or write Silver Sands Veterinary Center-Milford Veterinary Hospital and Centers for Oral Care-17 Seemans Lane, Milford, CT. 06460
putty

Indirect Radiowave Radiosurgery Coagulation--no14

Centers for Oral Care

www.AnimalDentistrySolutions.com

No. 14 -- 19Jan2017

Fellow of the Academy of Veterinary Dentistry

1-800-838-3368

DonDeForge100@gmail.com and DoctorDeForge@yahoo.com

Indirect Radiowave Radiosurgery Coagulation
For hemostasis of soft tissue, the Partially Rectified Radiowave Radiosurgery waveform is chosen. It must be remembered that this waveform produces increased lateral heat and tissue shrinkage. It should not be used for coagulation in close proximity to bone or when performing osseous surgery. The Ball Shaped, #135, or Pencil Point, #117, electrode tips, [Ellman International], are commonly chosen for this procedure.
Normally, the area must be free of blood for the coagulation to occur. This means removal of blood or constant daubing or rinsing to keep the blood pool away from the electrode tip during coagulation. With Indirect Radiowave Radiosurgery Coagulation [IRWRSC], a 1"x1' gauze square becomes a sandwich interface between the active electrode tip and the area of soft tissue that needs coagulation. The insert, electrode tip, is placed over the gauze to effect coagulation and acts as a buffer to prevent a pooling of blood from accumulating before the coagulation can be completed.

If using a larger Ball Electrode, it necessitates a higher intensity of power which leads to increased lateral heat. For this reason, it is recommended to utilize the smallest coagulation electrode tip possible [i.e. Pencil Point, #117]. Always wait 10-15 seconds if performing a second coagulation. While waiting, use gentle direct pressure with a saline soaked sponge over the coagulation site. The second coagulation may not be needed. On the other hand, the second coagulation may only require a one second Direct Radiowave Radiosurgery Coagulation [DRWRSC].
Be sure that the passive electrode plate is in position when performing IRWRSC. According to Sherman, "the radiosignal is transmitted from the active electrode through the tissue…being received by the passive electrode and returned directly to the radiosurgery unit. This pathway is the most efficient and produces a more stable and consistent cutting/coagulation current." [Sherman JA, Oral Radiosurgery, An Illustrated Clinical Guide, Chapter 3, P15, Taylor and Francis, 2005].
Before the development of IRWRSC at the CT and NY Specialty Centers for Oral Care, there was no information to show that the radiosignal passes from the active electrode, through a coagulum buffer [i.e. gauze square], to the passive electrode with return to the surgery unit with such efficiency. This break through technique allows the most difficult coagulation procedures to proceed without flaw. Do not overheat the site with continual coagulation. Remember, the Partially Rectified Waveform does produce significant lateral heat. Be patient with a one to two second contact of the tissue at one time. With patience and digital pressure with a saline soaked gauze square, the hemostasis will be achieved in a maximum of two contact times.
The Pulpotomy-Vital Pulp Therapy-Endodontics and IRWRSC

The same IRWRSC technique can be utilized in the Pulpotomy Procedure in the canine or feline. The procedure is initiated with a high speed handpiece to extirpate and expose coronal pulp.
The Fully Rectified Waveform with a U-Shaped, #114, insert is utilized to remove the coronal pulp tissue. Isolated bleeding can continue after this procedure is completed. Because of this bleeding, it is difficult to effect hemostasis with the Partially Rectified Waveform.
IRWRSC can solve the problem. If a wick of gauze or paper point is placed into the canal and the Partially Rectified Waveform with a Ball Shaped, #135, or a Pencil Point, #117, electrode tip is utilized, the bleeding will stop because the electrode tip is not sitting in a pool of blood. [see Illustration]

Again, it is important to only make contact with the pulpal tissue for one second. Wait thirty seconds, if necessary, and repeat. Multiple coagulation attempts should be avoided to prevent pulp necrosis. In permanent dentition, if after two attempts there is still pulpal bleeding, it may be advisable to consider the possibility of advanced bacterial pathology within the pulp. At that point, abort the Vital PulpTherapy procedure and complete a Conventional Root Canal procedure. Intraoral radiology must always be used to confirm that the Vital Pulp Procedure or the Conventional Root Canal are indicated.

Oral Radiosurgery: CSI--no13

Centers for Oral Care

www.AnimalDentistrySolutions.com

No. 13 -- 19Jan2017

Fellow of the Academy of Veterinary Dentistry

1-800-838-3368

DonDeForge100@gmail.com and DoctorDeForge@yahoo.com

Oral Radiosurgery: CSI
As veterinary oral surgeons we face "CSI" situations within the oral cavity each and every day of our clinical lives. There is no subjective pain and not always a direct pathway to the pain site. We must use all of our senses, diagnostic tools, and history data from the client-advocate to make a diagnosis and treatment decision.
The main diagnostic tool of the oral surgeon is oral radiology1 . Detailed extra and intra oral exams must also be completed to elucidate areas of pathology.
Once a treatment algorithm is initiated and surgery is found to be indicated, the best technology must be on site to provide both excellent cutting and coagulation with rapid local hemostasis. The surgical-cutting technology must be versatile with minimal trauma to the patient. Radiosurgery produces a virtually bloodless incision. The Ellman 4.0 MHz Dual-Frequency Surgitron Radiowave Radiosurgery patented Technology2 accomplishes all of these tasks. This high frequency-low temperature equipment is fully digital and allows the veterinarian to change wavelengths with the touch of a button on the handpiece. A foot pedal control system is also available if desired by the operator.
Radiowave radiosurgery has been coined by some as 'the other laser.' I prefer to respect it, in my opinion, as 'better than' cold steel or lasers. First and foremost it is safe for the surgeon, staff, and patient. It is cost effective. Healing is accelerated with less swelling and edema occurring at the surgery site. With all new technology, there is a learning curve. Once this minimal period of understanding is accomplished, the operator will see the advantages, first hand, of Radiowave Radiosurgery in cutting, cutting and coagulation, and bipolar hemostasis. The clear field of vision provided with this cutting modality accelerates surgery time and therefore decreases the time of the patient under general anesthesia.
This Journal will feature oral technology advancements using Radiowave Radiosurgery but will also show non-oral procedures and the versatility of Radiosurgery technology. It will be showcased in general surgery, ophthalmic surgery, dermatologic techniques, avian and exotic applications, and ER and Critical Care situations.

Table One: Indications for Radiowave Radiosurgery in Dentistry and Oral Surgery

• Simple Gingivectomy and Gingivoplasty
• Oral Biopsy
• Exodontal with Full Thickness Mucoperiosteal Flap creation
• Epulis removal
• Tonsillectomies
• Frenectomy
• Periodontal Surgery
• Oral Tumors or Cyst Removal
• Lingual Surgery and Biopsy
• Palatal Surgery and Biopsy
• Establishing Hemostasis in the Oral Cavity
• Tissue Planing
• Operculectomy-removal of overgrowth of fibrous tissue over the occlusal surface of an embedded tooth
• Excision of Oral Granulomatous Tissue
• Veterinary Prosthodontics-Crown lengthening and "trough" procedures for crown impressions
• Oral Abscess incision and drainage
• Subgingival Decay exposure and the placement of a class V-restoration

Table Two: Active Electrode or Insert Variety in Ellman Surgitron 4.0 MHz Dual Frequency Technology

• Vari-Tip #118 Electrode-This electrode has the greatest versatility because the tungsten wire cutting length can be varied for the surgical application being performed. For the oral surgeon, the controlled cutting depth is critical in oral anatomy sites where cutting is in major juxtaposition to major blood vessels.
• U Shaped Electrodes #104-108-these electrodes are excellent for gingival recontouring and in tissue planing
• Loop electrodes and Loop Round Electrodes #121/122/126/129/130-excellent for biopsy techniques and in gingival collar planing techniques
• Operculectomy electrode #132-used for impacted, embedded and/or entrapped dentition
• Coagulation of soft tissues-electrodes #135-136-113F-117
• J1 Bipolar Forceps-provides pinpoint coagulation; helpful in distal oropharynx, tonsillar area, or to control hemostasis in toy breeds and felines in difficult areas to approach in the oral cavity.

REFERENCES
¹ An Atlas of Veterinary Dental Radiology, Second Edition-DH DeForge, Editor-Sheridan Books, Inc.-Brooklyn BookWorks, LLC (Available at Amazon.com)

² Dr. DeForge is an independent clinical investigator and has no contractual commitments or relationship with any manufacturer, distributor, or corporation. He has been a leader in the veterinary application of Radiosurgery Techniques in Oral Surgery. He shares equipment information that is state of the art with other veterinary surgeons.

Preface & Forward--no12

Centers for Oral Care

www.AnimalDentistrySolutions.com

No. 12 -- 19Jan2017

Fellow of the Academy of Veterinary Dentistry

1-800-838-3368

DonDeForge100@gmail.com and DoctorDeForge@yahoo.com

Preface by Jeffrey A Sherman, DDS, FICD, FACD
Radiowave Radiosurgery is one of the most important and versatile instruments in the field of surgery today. Its numerous usages range from performing surgical incisions to establishing hemostasis. Radiowave radiosurgery offers the advantages of a safe, fast, and efficient incision with a better field of visibility. The pressureless cut of radiosurgery, offers minimal bleeding which often requires no suturing.
Radiowave Radiosurgery is the terminology applied to the most advanced form of electrosurgery. The radiowave radiosurgical instrument uses a high frequency radio signal to perform the incisions previously accomplished with the lower frequency electrosurgical instrument. The high frequency radio signal produces a finer, less traumatic incision and therefore has seen increased usage in all forms of surgery.
The main advantage to radiosurgery is its ability to produce coagulation to an area which would often have extensive bleeding. Radiosurgery can therefore enhance the surgeon's vision of the surgical site and establish a greater ability to perform a more accurate incision. The absence or minimal amount of bleeding during surgery allows the procedure to be performed more rapidly and with more confidence.
Radiosurgery offers a variety of waveforms for making incisions. The Fully Rectified Filtered waveform is the waveform of choice for performing deep surgical incisions. This waveform mimics the cut of a scalpel blade and thus cuts with only minimal coagulation. The Filtered waveform when used with a Vari-Tip straight wire electrode produces the most delicate of incisions and histologically offers the least amount of tissue alteration. The Fully Rectified waveform produces an incision with concurrent coagulation. The advantage of using this waveform in comparison to the Filtered waveform is that increased visibility is established due to the enhanced coagulation. The Partially Rectified waveform is strictly a coagulating waveform and can be used to establish coagulation in areas of bleeding or oozing. Areas of extensive bleeding can be controlled with the aid of the bipolar coagulating electrode or the Fulguration waveform on those instruments that don't offer bipolar capabilities.
Bipolar surgery is used for excision as well as hemostasis of soft tissue. The bipolar electrode consists of 2 parallel wires, one to make the incision and the other to act as the antenna to receive the radiosignal. This modality is believed to minimize transmission of the radiosignal to the surrounding tissue and thereby eliminating any lateral heat.
A new Proprietary Advanced Composition Alloy Electrode known as the ACE Electrode, has just been developed to reduce tissue damage and heat generated to the surgical site. The ACE Electrode has been shown to produce thermal damage in micrometers no greater than 10 microns in comparison to tungsten electrodes that have produced thermal damage as high as 30 microns. Another important advantage of the ACE electrodes is their ability to minimize tissue sticking to the electrode tip. This insures a clean cutting tip providing a more precise microfine incision. These electrodes are easily identified by the orange coloring of the protective sleeve.
Dr. DeForge's publication of The Journal of Veterinary Radiowave Radiosurgery is one of the most important, innovative journals available to the practitioner today. With the aid of the internet, new advancements in the field of Radiowave Radiosurgery can be rapidly disseminated to the surgeons who perform these procedures and keep them on the cutting edge. Dr. DeForge has been a pioneer in the field of Veterinary Oral Radiowave Radiosurgery and he has decided to share his expertise will all surgeons in all disciplines of medicine, dentistry, and veterinary medicine via the 21st Century use of the internet.     

* * *

Jeffrey A. Sherman, DDS, FICD, FACD, is presently the Executive Director of the World Academy of Radiosurgery, past President of the American Academy of Dental Electrosurgery, a Diplomate of the American Board of Oral Electrosurgery as well as a Fellow of the American College of Dentists, and the International College of Dentists. Dr. Sherman has been closely involved with the research and development of electrosurgery in the dental profession. He has carried out research and clinical trials in his private practice in Oakdale, New York and has published three textbooks, " Oral Electrosurgery-An Illustrated Clinical Guide" , "Oral Electrosurgery-State of the Art Radiosurgery", "Oral Radiosurgery", a video entitled, "Oral Electrosurgery- State of the Art Radiosurgery" , in addition to numerous articles in international journals.

Dr. Sherman has lectured at dental schools and meetings throughout the world, including Yale University, New York University, Tufts University, Louisiana State University, Cairo University, and Seoul Dental Institute. Dr Sherman has been listed in Dentistry Today's Top 100 Leaders in Continuing Dental Education. Dr. Sherman maintains a private general dental practice in Oakdale, NY and can be reached at 631-567-2100 or via Email at: ESURG@aol.com.

Foreward by Jon C. Garito, PhD; CEO, LifeSciences Technology
During the past 35 years I have patented and introduced numerous innovative surgical products that have become important necessities in clinics, hospitals, and private practices within the veterinary, dental, and medical professions. I consider my most significant contribution to be the introduction of the 4 megahertz Radiowave Radiosurgery device and its range of radiofrequency (RF) accessories.
A notable highlight of this novel radiowave surgical technology is its exclusive use in the successful separation of the human conjoined twins by Dr. James Goodrich at Montefiore Medical Center in New York. Another newsworthy surgical case that appeared on the world stage was Peru's "Mermaid Girl ". Dr. Luis Rubio at the Solidarity Hospital in Lima, Peru used my patented Radiowave 4 megahertz device to successfully separate the legs of this one year old girl.
Dr. Donald DeForge of Silver Sands Veterinary Hospital in Connecticut, a distinguished practitioner, author, and lecturer of veterinary medicine has supported the value of Radiowave Radiosurgery. He has incorporated the many techniques into his surgical practice. For over a decade he has offered hands-on workshops on Radiowave Radiosurgery and its use in the oral cavity surgery.
Today Dr. DeForge, as a noted expert in Oral Radiowave surgery, continually strives to enlighten and train veterinary practitioners to appreciate and implement Radiowave RF technology as a safe and prudent choice for the betterment of patient quality of life.
With the introduction of the online e-journal, veterinarians worldwide will be able to benefit from the numerous accepted radiowave surgical methods and procedures that can easily be performed on the oral and gingival mucosa. These indications are being refined and implemented in thousands of private practices around the world.
This new e-journal will be a platform for Dr. DeForge to illustrate and update the many techniques of radiowave surgery. I encourage all veterinarians to learn about this simple and effective technique from Dr. DeForge.

Feline Stomatitis II

Centers for Oral Care

www.AnimalDentistrySolutions.com

No. 11 -- 19Jan2017

A BLOG by DH DeForge, VMD

Fellow of the Academy of Veterinary Dentistry

1-800-838-3368

DonDeForge100@gmail.com and DoctorDeForge@yahoo.com

See Blog #5 for Feline Stomatitis Part I

Dr. DeForge Develops Breakthrough Surgery for Treatment of Cat Stomatitis Part II

Feline Stomatitis Radiowave Radiosurgery with GBR: PART II
The Treatment of Feline Stomatitis: A New Surgical Protocol Combining Radiosurgery with Guided Bone Regeneration [GBR] utilizing Consil®/Bioglass® Synthetic Resorbable Bone Graft Particulate.

Introduction:
The classic treatment of feline Stomatitis with whole mouth extraction or extraction of the teeth distal to the canine teeth has proven to be non-productive.
Anywhere between 50-65% of these felines have only short term improvement with a return of the oral inflammatory condition in 6 to18 months.  On the other hand, the alternative surgery, herein described, utilizing Radiowave Radiosurgery to create full thickness mucoperiosteal flaps, combined with osseous surgery, and bone augmentation have proven to be completely successful. 
Dr. Robert Wiggs, identified by many as the “Father of Modern Veterinary Dentistry” writes in Veterinary Dentistry Principles and Practice: Lippincott-Raven-1997 about the importance of Guided Tissue Regeneration.
“As advances in veterinary dentistry occur, new techniques and materials and being utilized to offer treatment for teeth with advancing periodontal lesions that previously would have been extracted.  Periodontal disease progresses in a cyclic manner of alternating periods of active destruction and dormancy, rather than being linearly continuous.   Many forms of periodontitis exist, each progressing to cause attachment loss at variable rates.  The actual cause of attachment loss is generally considered to include interactions of bacteria, their by-products, and the various components of the host immune system in response.  Periodontal pockets on the palatal aspect of the maxillary cuspids are easily overlooked, yet they are not an uncommon finding in the dog and when encountered have a strong probability of eventual oronasal fistula development.  While tooth extraction with appropriate flap closure addresses the problem, preservation of the tooth structure and resolution of the defect using regenerative therapeutic means represent a possible positive alternative.”
Dr. Wiggs continues:
“Ultimately, regeneration of the supporting tissues to attain a more normal and healthy anatomic and physiologic state may help in maintaining disease control. Guided Tissue Regeneration [GTR] in veterinary dentistry principally deals with the regeneration of periodontal tissue lost due to disease or injury.  Tissue regeneration has been demonstrated with alveolar bone, cementum, and periodontal ligament in specific therapies, locations, and type of materials. Bulk osseous replacement packing materials generally come in small natural particulate, granular, or spherical shapes available in non-absorbable and absorbable substances.”
From Dentistry.com-the following definitions from human dentistry might help explain the terms GTR and GBR.
Guided Tissue Regeneration (GTR)
Refers to procedures that attempt to regenerate lost periodontal structures, such as bone, periodontal ligament and the connective tissue attachment that support our teeth. This is accomplished using biocompatible membranes, often in combination with bone grafts or tissue stimulating proteins.
Guided Bone Regeneration (GBR)
Refers to procedures that attempt to regenerate bone prior to the placement of bridges or, more commonly, implants. This is accomplished using bone grafts and biocompatible membranes that keep out tissue and allow the bone to grow.
Also:
Bioactive glass materials such as PerioGlas (Biomaterials) or BioGran (Orthovita) are a form of glass particles upon which a layer of apatite forms, thus promoting bone formation. [ Wheeler DL, Stokes KE, Hoellrich RG, et al. Effect of bioactive glass particle size on osseous regeneration of cancellous defects. J Biomed Mater Res. 1998;41:527-533.]. 
In the Journal of Veterinary Dentistry, Vol 14, No. 4-Dec 1997-Evaluation of Bioglass®/PerioGlas™ [Consil®] Synthetic Bone Graft Particulate in the Dog and Cat-DH DeForge, VMD -GBR is described.  Bioglass® Synthetic Bone Graft Particulate [PerioGlas™/Consil™] was utilized to treat osseous periodontal defects, and in post-extraction sites to maintain the vertical height and width of the alveolar ridge.  The material is easy to use, inhibits epithelial down growth, and acts as a mechanical hemostatic agent.  Radiographic follow-up in 36 dogs and 5 cats demonstrated significant bone fill.  In the osseous periodontal defect treatment group, clinical probing depths deceased significantly, and there was an apparent gain in attachment level.  This synthetic bone graft particulate improves the rate of osseous growth while being resorbed and replaced with bone during the healing process.
This original work led to the utilization of Consil®/Bioglass®, synthetic bone graft particulate, in a feline stomatitis surgery technique developed by Dr. DH DeForge.  When implanted in stomatitis felines, a material surface reaction results in the formation of a calcium phosphate layer that is similar in composition and structure to the hydroxyapatite found in bone mineral.  This apatite layer provides the scaffolding onto which the patient’s new bone will grow allowing repair of the bone defects in feline oral stomatitis.  Diseased bone is removed and new bone is created to allow the patient to fully recover from the inflammation and pain caused by the pre-surgical oral pathology. 
The hypothesis that the cats affected with stomatitis suffer from a bone disease rather than a dental disease has been confirmed by Dr. DeForge with this new surgical approach to the disease. The confirmation is the actualization of complete and permanent clinical improvement after Dr. DeForge’s GBR surgery in the edentulous patient [i.e. patients having had earlier whole mouth extraction surgery by other surgeons prior to referral to Dr. DeForge].   In these felines, where the whole mouth extraction technique had failed, GBR Feline Stomatitis Surgery succeeds confirming the origin of the pathology as a bone-centered pathology.
Before patients can be treated by Dr. DeForge with his surgery utilizing radiosurgery combined with GBR, a very comprehensive pre-anesthetic screening must be completed.  This screening includes clinical chemistry, serology, hematology, and special imaging to rule out other medical problems that might co-exist with stomatitis.  Feline Cardiomyopathy and Low Grade Lymphoma and Chronic Lymphocytic Leukemia [CLL] are problems that have been noted in felines referred to Dr. DeForge for his surgical treatment of stomatitis. 
    
 Cats with HC are examined by a cardiologist and pre-treated prior to surgery with cardiologist approval for anesthesia.  The Lymphoma patients and CLL patients are not candidates that will be helped with stomatitis surgery.  Other patients present with Feline Immunodeficiency Virus infection.  These patients are confirmed as true FIV + patients by Western Blot testing at the National Veterinary Lab.  The FIV+ patient can be treated with stomatitis surgery with the client realizing that the recovery period will be lengthy.      
    
All cats undergoing this surgery are Feline Bartonella tested by the National Veterinary Laboratory.  Dr. William Hardy at the National Veterinary labs identifies a subset of Feline Bartonella positive felines with a stomatitis-like pathology, under a year of age, that respond very well to treatment with Azithromycin. 
Feline Stomatitis cats over twelve months of age that are Feline Bartonella positive, as identified by Western Blot testing at Dr. Hardy’s laboratory, will not respond with Azithromycin.   They are still treated with Azithromycin prior to surgery because of the fact that Bartonella poses a zoonotic threat.  The older Feline Bartonella + positive feline with stomatitis will need GBR surgery to recover.  All patients that are presented for feline stomatitis surgery have biopsies to rule out oral cancer and confirm that they are truly oral stomatitis affected felines.
The following pictures are before and after pictures from two different patients who both had Dr. DeForge's Feline Stomatitis Radiowave Radiosurgery with GBR Parts I and II performed. Notice the significant decrease in inflammation and ulceration in the after photographs in comparison to the before photographs.

The photo gallery included in this report shows the improvement of patient’s after Dr. DeForge’s GBR surgery.  Questions about this surgery should be directed to Dr. DeForge at: DonDeForge100@gmail.com