Periodontal Disease-Professional Care and Home Care Part 1

Centers for Oral Care
New England & New York
Animal Dental Health Services
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
The author has no commercial conflicts of interest to disclose.


Comments


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  2. Nice post, Nowadays more people do not give any importance to their oral health it was started in a small and easy way. It may create a huge or big impact on our health so this post is helping me or saves me from the dental issues.

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