Dogs and Cats 16 Flashcards
pathogenesis of periodontal disease what is the primary and secondary factor and how is calculus involved
- Primary factor = plaque bacteria -> HAS TO BE PRESENT
- Secondary factors = tooth crowding, persistent deciduous teeth, malocclusions, non-abrasive diet, periodontal trauma, genetic predisposition, systemic illnesses (FIV in cats
- Calculus
○ Bacterial plaque is often attached to calculus
○ Calculus is merely mineralised plaque and in itself is not harmful
○ However, it provides a roughened surface for plaque to adhere to
○ Gingival recession exposes cementum which is more plaque retentive
What are the first 4 steps in the pathogeneiss of periodontal disease that finishes at gingivitis
- Bacteria attach to tooth surface by adhering to tooth pellicle (salivary glycoproteins)
- Start forming seconds after teeth prophylaxis (fully formed after 4 months) - Once attached, plaque can only be removed via mechanical means
- Bacteria which attach are initially gram positive, non-motile aerobes
- Gingiva becomes irritated by this plaque -> swells and lifts from the tooth (gingivitis)
What are the 2 steps after gingivitis that leads to periodontal disease
- If plaque is left undisturbed it eventually penetrates subgingivally
○ Subgingivally, population changes to predominantly gram negative, motile anaerobes -> initiation of periodontal disease - Bacteria and their toxins penetrate the sulcular and junctional epithelium -> rapid acute inflammatory response
○ This leads to soft tissue damage and alveolar bone resorption
○ Formation of periodontal pockets & tooth mobility and eventual tooth loss
§ Allows for more subgingival movement -> cycle continues
○ Localised disease but can also lead to bacteraemia & possibly other organ involvement
What are the clinical signs and diagnosis of periodontal disease
Clinical signs - Halitosis - Difficulty or pain when eating - Hypersalivation, blood tinged saliva - Plaque and calculus - Bleeding or ulcerated gingiva - Gingival recession - Furcation Exposure - two roots split in multiple rooted teeth - Tooth mobility Diagnosis - Periodontal probing ○ Evaluate presence and degree of attachment loss - Dental radiographs ○ Evaluate bone loss as well as complications such as endodontic disease
Periodontal disease what are the 4 stages and attachment loss
STAGE 0 - NORMAL
STAGE 1. gingivitis, 0% attachment loss
STAGE 2. Early PD, 25% attachment loss
STAGE 3. moderate PD with 25-50% attachment loss
STAGE 4. severe PD with >50% attachment loss
What are 7 indications for dental treatment
1) periodontal disease
2) broken teeth - especially carnassial (UPM4)
3) discoloured teeth (pulpitis)
4) mobile teeth
5) retained deciduous teeth
6) resorptive lesions
7) stomatitis - inflammation of mucous membranes of mouth - may benefit from full mouth extraction
Endodontic disease what is the main one and causes
- Pulpitis – inflammation of the pulp
○ Can be reversible or irreversible - Pulpitis causes
○ Blunt trauma to tooth
○ Uncomplicated and complicated crown fractures
§ Uncomplicated -> no exposure of pulp cavity
§ Complicated -> exposure of pulp cavity
○ Enamel & dentine hypoplasia
○ Haematogenous route
○ Iatrogenic causes (inappropriate use of polishing or scaling devices, restorative materials)
What is the pathogenesis of pulpitis
a. Pulp injured -> pulpitis -> pulpal oedema or haemorrhage
b. Pulp exposure through fracture -> exposed to bacteria and becomes infected.
§ This leads to inflammation and oedema.
c. Inflammation + oedema + haemorrhage -> pulpitis + pain
d. If no treatment -> pulpal strangulation (compartment syndrome) -> death of dental pulp
e. Liquefaction of necrotic pulp, and escape of liquid through the apex.
f. Bacteria penetrating the apical delta -> periapical granuloma
g. Severe periodontal disease
§ Bacteria may gain access through apical delta, infected cementum or lateral canals
How to diagnose pulpitis
○ History
○ Visual examination - draining tracts
○ Transillumination - shine bright light through the teeth (non-vital teeth no transfer of light - appear dull or dark)
○ Radiology - pulp cavity that is wider than the other teeth (as grows becomes narrow)
What are the main options for treatment of pulpitis
○ Two options for tooth with pulpal death
§ Endodontic Therapy
§ Extraction
○ No treatment -> chronic pain and infection
○ Endodontic therapy
§ Pulpectomy - entire pulp is removed and dental cylinders created within the pulp cavity - closed off to the rest of the body
§ Vital pulpotomy - fracture site is sealed off
§ Surgical apicectomy
dental radiography indications and equipment
- Indications ○ Teeth which are discoloured, fractured, missing, abnormally shaped or placed, mobile § Pre- and post-extraction § Oral masses/swellings § Tooth Resorption - Equipment ○ Wall-mounted vs handheld unit ○ Reusable intraoral plates ○ Processor ○ Personal protective equipment
Dental radiograph what are the 2 techniques
- Parallel Technique
○ Used generally only on mandibular premolar and molar teeth
○ Film placed parallel to long axis of tooth root and perpendicular to x-ray beam
○ Provides the most accurate image - Bisecting angle technique
○ Most common positioning technique used in veterinary patients
○ Place film as parallel as possible to long axis of tooth root(s) of tooth being radiographed
○ Then approximately bisect the angle between tooth and film
○ X-ray beam perpendicular to this plane
Dental radiography what to do with superimposition of structures, correcting elongation and foreshortening
○ Superimposition of structures
§ Change angle of incident beam
○ Correcting elongation and foreshortening
§ Angle between your incident beam and long axis of tooth root is either too acute or too obtuse
Shadow of building analogy -> if roots seem too long
What are the 12 steps within dental treatment program
1) presurgical exam and consultation
2) supragingival cleaning
3) subgingivial plaque and calculus scaling
4) residual plaque and calculus identification
5) polishing
6) sulcal lavage - optional
7) fluoride - optional
8) oral evaluation with periodontal probing and dental charting
9) dental radiographs
10) treatment planning
11) application of barrier selanat - optional
12) client education during post-surgical discharge
presurgical exam and consult for dental treatment what is involved
○ Comprehensive physical exam and pre-anaesthetic screening as required - blood work
○ Discuss findings with owner and counsel on treatment options based on anticipated level of disease (remember, though only 50% of disease present can be detected on a conscious exam)
supragingival cleaning for dental examination what is the goal and the 2 types of instruments used, what need to be careful of
○ Goal is to remove large accumulations of calculus, usually via a combination of mechanical and/or hand scaling
1. Mechanical scalers
§ The ultrasonic scaler is the most commonly used and comes in 2 main types, magnetostrictive and piezoelectric
§ Work by providing different patterns of vibration
§ Produce heat which can damage the tooth - DO NOT SPEND MORE THAN 10 SECONDS PER TOOTH
2. Hand scalers
§ Most commonly used is the universal scaler
§ Triangular instrument with two sharp cutting edges and a sharp tip
§ To be used ABOVE THE GUM ONLY - the shape and sharp back and tip can easily damage the gingiva
Subgingival plaque and calculus scaling in dental treatment how important, what equipment used and how done
○ This is THE most important step
§ Subgingival calculus is more difficult to remove due to limited access, bleeding, and adherence to tooth surfaces
○ We used to do this by hand (using a curette), but now many mechanical (ultrasonic) scaler tips are safe for use subgingivally (BUT CHECK BEFORE YOU DO SO)
○ Open root planing - raise a flap to properly clean subgingivally, if pockets >6mm (dog)
Residual plaque and calculus identification and polishing during dental treatment what is involved and what need to be careful of
Residual plaque and calculus identification
○ If possible, check with a dental explorer and/or use a plaque-disclosing solution
○ IC plaque ->stains plaque red after clean place on and make sure haven’t missed anything
5. Polishing
○ Goal is to smooth the tooth surface to help decrease plaque adherence after scaling
○ Performed with rubber prophy cup on slow-speed handpiece
○ No longer than 5 seconds at a time per tooth to avoid damage
Sulcal lavage and fluroide in dental treatment how commonly done and why
Sulcal lavage (optional?)
○ Not routinely done in most general practices but could be beneficial - removes microscopic debris from gingival sulcus
○ Recommended to lavage with 22-25 gauge cannula, using sterile saline or 0.12% chlorhexidine solution
Fluoride (optional)
○ Controversial
○ Application may decrease patient sensitivity after subgingival scaling
Oral evaluation with periodontal probing and dental charting what technique use, normal sulcus depth and what is important to consider with this sulcus depth
○ Establish a system and do this the same each time
○ Preferred technique is to start with first incisor at each quadrant
○ Use modified triadian system to report and try to probe at least 4, possible (6), depths around EVERY TOOTH
§ Normal dog sulcus depth 0-33mm - NEED TO KNOW
§ Normal cat sulcus 0-0.5mm - NEED TO KNOW
○ In patients with gingival recession, remember that the attachment loss is the probing depth plus the gingival recession
Dental radiographs where should be taken, when and what is gold standard
○ Taken at a minimum of every area of pathology noted on your exam
§ Deep periodontal pockets, furcation
§ Fractured/chipped/mobile/discoloured teeth
§ Missing teeth (retained roots? Dentigerous cysts)
§ Masses/swellings
○ Many clinicians advocate for full mouth radiographs but we are often limited by client funds and time
treatment planning after dental examination what need to take into account and options
○ Take into account:
§ Exam findings
§ Radiographic findings
§ Overall patient health, also is the GA going well
§ Willingness of owner to perform home care
§ Likelihood of owner to follow up
§ Owner finances
○ Don’t forget that referral is an option
§ Root canal, restoration
○ Planning for extractions at the end
Application of barrier sealant (optional) during dental examination what done, why optional and what is the most commonly used product
○ Waxy substance applied to teeth at end of the procedure after all is clean and dry
○ Clinically proven to decrease plaque and calculus however some dentists do not feel this is effective
○ OraVet is the most commonly used production
Client education after dental examination what do you need to discuss and when should you do it
○ This is the best done by the treating veterinarian during the post-surgical discharge
○ Review the radiographs, discuss homecare and schedule follow up
§ Professional care has been shown to be of little valve without homecare
§ Most veterinary dentist suggest that owners should be doing at least 2 types of care, once a day
Homecare is comprised of MECHANICAL AND CHEMICAL modalities
What are 6 examples of mechanical homecare for teeth and which shouldn’t you advise - rule of thumb
1) Tooth brushing (gold standard)
® DOG/CAT TOOTHPASTE, not human
® Daily
® Start slow… lots of patience and rewards
® Small, soft brushes. I really like cotton buds/Q tips
2) Dental diets (Hill’s T/D, Royal canine dental)
3) Chews (oravet chews, greenies, dentastrix)
4) Toys
5) Pig ears -> no evidence that these works, reports of bacterial contamination
6) Bones -> NOT ADVISED, tooth fracture, GI obstruction
§ IF WOULDN’T WANT TO WHACK YOURSELF OVER THE KNEE WITH THE TOY THEN TOO HARD FOR PET
What are 6 examples of chemical homecare for teeth
1) Chlorhexidine based products (Hexarinse, curasept)
2) Zinc ascorbate (Maxiguard)
3) Xylitol (aquadent)
4) Miscellaneous (healthy mouth)
Other examples
1) Dental wipes
2) Oravet weekly application
What are the 6 reasons you MUST DO teeth extractions
- Complicated crown fracture
- Oronasal fistula caused by periodontal disease
- Advanced PD (grade 4 >50% root exposure, grade 3 furcation, excessive mobility)
- Advanced feline tooth resorption (dogs are more complicated)
- Tooth in a fracture line
- Retained deciduous teeth
What are 6 situations where extractions are negotiable
- Is the owner able/willing to perform homecare, will the animal tolerate it?
- If willing, what level/type of care will be performed
- Is this the only dental likely to be performed for a long time or will they recheck as instructed in 3,6,12 months
- Is the tooth important/strategic (canines, carnassials)
- If you extract, what are the potential consequences (mandibular carnassial contracting site of maxillar carnassial, tongue protuding, lip getting caught by canine)
- Are there other treatment options (refer for root canal, orthodontics, guided tissue regeneration, restoration
what are the 6 main tools needed for extraction
- Dental X-rays
- Luxators + elevators
- Tooth extraction forceps
- Dental base with triplex, high speed handpiece and burrs
- Periosteal evevator
- Small surgical kit with fine instruments
○ Scalpel (11,15 probably most common) and holder
○ Scissors
○ Needle drivers
○ Rat tooth tissue forceps
○ Suture material (usually 4-0, 4-0, absorbable)
What are the 7 steps in a simple extraction of a tooth
a. Dental xrays should proceed ALL extractions
b. Gingival incision
c. Luxation
d. Removal of root
e. Management of alveolus
f. Post extraction radiograph
g. Suture (usually 4/0,5/0, absorbable)
What are the 2 ways to do a double root teeth extraction and when would you do each
1) Simple extraction -> can do without use of a flap only if tooth is very diseased and you expect the roots will be removed without complication
2) creating a flap - surgical extraction
What are the 6 steps in the surgical extraction of multiple root tooth
1) Creation of vertical releasing incisions in making a mucogingival flap
§ Make incisions on the line angle of the roots of the teeth, just caudal and rostral to the target
§ Making the incisions slightly divergent will provide a broader vascular base
§ The vertical incision must be placed OFF the target tooth so as to avoid a TRAMPOLINE EFFECT on closure
§ Making an incision along the sulcus
§ Use a periosteal elevator to lift the attached gingiva, then the mucosa
- Be patient, tissue is delicate and tears easil
2) Flap is lifted exposing buccal bone and root structure, now can section and elevate
3) After sectioning the tooth, luxate the roots individually, remove buccal bone as necessary
4) To ensure extraction is complete, palpate the root tip (it should be smooth) AND take a post extraction radiograph
5) Lay the flap down, there should be no tension
6) Routine closure with simple interrupted sutures
Deciduous teeth when identify, why extract and why may fracture occur during extraction
○ Really important to identify in kittens and puppies
○ Extracted due to: fracture, crowding and malocclusion
○ Care is required when extracting - if done incorrectly
§ Damage may be done to the adjacent adult tooth - root damage or if not yet erupted, enamel damage
○ Fracture may occur
§ The roots of these teeth are VERY long, with the crown:root ratio often nearly 1:3.
§ This conformation requires extensive elevation before extraction is possible
§ These teeth have large pulp chambers with thin dentinal walls and are not tolerant of the exertional forces typically used to extract adult teeth
What are 6 main complication of teeth extractions
- Root fracture -> displacement of root tips (into places that you might not want to retrieve them from)
- Jaw fracture
- Oronasal fistula
- Haemorrhage
- Soft tissue injury (need to be careful of the tongue)
- Injury to the operator or assistant
What are 6 main ways to avoid complication
- Be patient!
- Don’t use excessive force
- Use proper technique
- Know your anatomy, radiographs will help
- Use extractions forceps ONLY when the root is loose
- Alevoplasty before closing the flap; no tension on closure
Feline chronic gingivostomatitis other names, what is it and causes
- Nomenclature: Stomatitis, Caudal Stomatitis, Caudal Mucositis, Feline immune dysregulated stomatitis
- Persistent inflammation of the oral mucosa
Aetiology - Aetiology has not been identified
- Multiple aetiologies may exist
- Viral (Calicivirus, FIV), Bartonella henselae, altered immune status & exaggerated inflammatory response to bacterial plaque have all been postulated
Feline chronic gingivostomatitis diagnosis and goals of treatment/management
Diagnosis
1. Visual examination
○ Affected gingiva and oral mucosa have varying amounts of inflammation, proliferation and ulceration
○ Lesions are often bilaterally symmetrical, friable oral tissue that bleed easily
- Gingivostomatitis and periodontal disease can present with severe gingival inflammation
○ Main differentiating clinical sign is the presence of caudal inflammation (Distal to the teeth)
2. Biopsy can help rule out neoplasia
Goal of treatment/management
- Goal is complete resolution of oral inflammation
- Managing a state of reduced inflammation is in some cases the best that can be achieved
Feline chronic gingivostomatitis what are the 2 main treatment options and options within
○ Surgical management
§ Extraction of all molars/premolars
§ Full mouth extraction
§ Laser treatment to remove inflammatory tissue - generally not done
○ Medical management - differing views on effectiveness
§ Chronic immune-suppressive treatment (i.e. cyclosporine, corticosteroids, Imuran)
§ anti-inflammatory treatment (Corticosteroids, NSAIDs)
§ antibiotics
§ feline omega interferon
Feline chronic gingivostomatitis what is the most successful long-term therapy, response and what if bad
- Most successful long-term therapy is extraction of all pre-molars and molars
○ Extraction of canines and incisors is indicated when the inflammation extends to include the gingiva surrounding them
○ If choose to keep in then need good dental homecare - Majority of cats will have an excellent response to the treatment
- Poor response may require medical management
○ These are cats which have already had chronic immunosuppressive drugs
○ These cats may respond to low doses of immunosuppressive drugs and antibiotics
○ Check for retained root tips – DENTAL RADIOGRAPHS
Tooth resorption what also called, where originates, type based on and cause
- AKA Feline odontoclastic resorptive lesions, neck lesions, cervical erosive lesions, dental resorptive lesions
- Typically originates in the cementum, may progress into root dentin and then either progress through root, into the crown or both.
- Tooth Resorption type based on radiographic appearance
- Many hypotheses but the cause has not been proven
