Lecture 7: the dental prophylaxis

Question 1

Prophylaxis means

Answer 1

uncomplicated preventative or protective treatment

Question 2

Dental disease presenting signs

Answer 2

Weight loss
Anorexia
Halitosis
Dysphagia
Salivation
Vomiting
Pawing at mouth
Facial swelling or disfigurement
Head shy
Pain on chewing
Chews on one side
Facial draining tract
Nasal/ocular discharge

Question 3

The history of the oral exam should include

Answer 3

Age – certain oral problems are more common in young versus older animals
Breed – small breeds, brachycephalic and pure breeds have more oral problems
Environmental – vaccines, diet, behavior, outdoor/indoor, access to tennis balls and bones
Past medical history – renal disease, liver disease, crate anxiety, previous issues with anesthesia, previous treatment

Question 4

What should you do in order to do a proper oral exam

Answer 4

Full oral exam may not be possible without sedation
Follow a routine so you don’t miss anything:
Visually inspect head/neck
Palpate external surfaces of head for:
Pain, swelling, mandibular joint movement etc.
Palpate external lymph nodes
Examine lips, folds, vestibule, alveolar mucosa, etc.
Externally feel the TMJ
Examine attached gingiva
Examine dentition
Examine occlusion

Question 5

What should you look for in attached gingiva on oral exam

Answer 5

Color, hyperplasia, topography (smoothness), etc.
Periodontal probing will occur under anesthesia

Question 6

How should you examine dentition

Answer 6

Count teeth
Deciduous/adult
Wear, fractures, rotation, color
Calculus/plaque buildup
Exposure of dental pulp
Caries
Furcation exposure and mobility evaluated under anesthesia

Question 7

What areas of the mouth do you have to examine

Answer 7

Floor of mouth
Lingual and palatal gingiva
Palate (hard and soft)
Tongue and sublingual salivary ducts
Oropharynx

Question 8

What to do once an oral exam is preformed

Answer 8

Once an oral exam has been performed a treatment plan should be formulated
This plan should be discussed with the client and the client should be provided with a written estimate of its cost.
After obtaining consent a contingency plan should be developed in case additional problems are discovered during the dental procedure.

Question 9

What to do if plan changes after dog is under anesthesia

Answer 9

The client should provide instructions regarding how to proceed
Options should include:
Proceed with recommended procedures
Attempt to call first; if client unavailable, proceed with recommended procedures
Do nothing if client cannot be contacted

Question 10

Consideration of dental plans

Answer 10

Preoperative blood profiles
IV fluids (very strongly recommended)
Preoperative antibiotics
Rarely needed beforehand for periodontal disease, despite severity
Up to the discretion of the veterinarian
Anesthetic protocol

Question 11

Prophylaxis and Anesthesia what needs to be done

Answer 11

General anesthesia is necessary to prevent the aspiration of fluids, dental calculus and other debris.
It is IMPOSSIBLE to safely and effectively scale and polish the teeth in an animal that is awake.
Very likely to traumatize the gum tissues with curettes if animal is awake and almost impossible to scale under the gumline
Dental charting and radiographs under anesthesia will give you the complete picture of the animal’s oral health and what treatments are necessary

Question 12

What should the dental station look like

Answer 12

Need to have a workstation that allows fluids used in dentistry to drain

Question 13

What should the patient have during a dental

Answer 13

Ensure cuff on endotracheal tube is appropriately inflated
Pack back of mouth with gauze→must ALWAYS be removed prior to waking up the patient
Mouth gags should be used for a short time only (minutes), if at all, and care should be taken not to overextend the mandible

Question 14

How to open mouth during a dental and what can happen if not done right

Answer 14

Mouth gags should be used for a short time only (minutes), if at all, and care should be taken not to overextend the mandible
Preferred method is to prop mouth open with nonworking hand
Overextension of the mandible may lead to stretching and tearing of the ligaments and muscles of the jaw.

Question 15

Steps to complete prophy

Answer 15

Preliminary examination/evaluation (initial oral exam)
Supragingival gross calculus removal
Dental radiographs
Periodontal probing and charting
Scaling and subgingival calculus removal
Detection of missed plaque and calculus
Polishing
Sulcus irrigation and fluoride treatment (sealant application – if applicable)
Periodontal diagnostics and extractions
Final charting
Client education/home care plan

Question 16

1.Preliminary Examination/Evaluation of the mouth should include

Answer 16

Ideally a complete preliminary examination will have already been performed prior to the dental prophy
Wear gloves!
Remember occlusion is best evaluated in the conscious patient
However, some patients may not allow this exam to be thorough, if at all.
First step is a more complete evaluation to confirm or determine diagnostic and treatment measures
Colour of gingiva, grade of gingivitis
Grade of plaque and calculus
Presence of gingival hyperplasia and oral masses
Missing teeth and retained deciduous teeth
Malocclusions
Fractures, exposed pulp, excess wear
Mobile teeth - not salvageable and should be extracted
Abnormal teeth

Question 17

2. Supragingival Gross Calculus Removal should start with and why

Answer 17

Prior to removing any tartar, apply dilute chlorhexidine rinse to the teeth
Usually use a syringe to apply the solution to all of the tooth surfaces (not directly from the bottle)
This reduces the overall bacterial load in the mouth
Reduced bacterial load means that fewer bacteria will enter the bloodstream during a routine prophylaxis

Question 18

How to remove Supragingival Gross Calculus properly

Answer 18

Hand scaler using a pull stroke is effective in removing calculus
Calculus removal forceps cleave off calculus – caution required to prevent damage to gingiva or create iatrogenic slab fracture
Ultrasonic or sonic scalers break up or pulverize calculus; caution required to prevent etching of tooth or thermal heating
Minimize patient manipulation:

Question 19

How to grasp power instruments

Answer 19

Light hold - not tight
Should be balanced in the hand
Hand piece does the work, not your hand
A modified pen grip is not as important as it is in hand scaling.
The hand piece is balanced on the index or middle finger
To decrease stress on the hand, the cord may be looped over the little finger
A fulcrum is not required but is good practice

Question 20

How to use ultrasonic instruments on the tooth

Answer 20

Do not use the tip; use the side of the instrument
Start with sweeping cross strokes, followed by various directions
Keep the instrument moving to prevent thermal damage → do not spend more than 10 – 12 seconds on a tooth at one time
To reach furcations use tips designed for that purpose, or hand instruments
Avoid pressing the scaler tip too hard on the tooth surface as it may create thermal damage or etching

Question 21

What setting should you use for ultrasonic settings

Answer 21

Higher power settings should be used for broad tips; lower settings with thin tips
Failure to decrease power may cause the instrument to not work at its full potential or damage it.

Question 22

3. Dental radiographs are good for

Answer 22

Radiographs will evaluate the structures hidden below the gumline
Dental x-ray will give a better representation of teeth and supporting structures than regular x-ray
Performing them early in the prophylaxis will save you time:
No point scaling and polishing teeth that will be removed
Vet can evaluate radiographs while the tech performs other parts of the procedure

Question 23

How to use dental probe

Answer 23

Determines depth of the sulcus
Probe has measurement markings usually calibrated in 1 - 2 mm intervals and may be color-coded
Probe is held parallel to the long axis of the tooth for accurate readings
It is inserted gently into gingival crevice and is gently walked along the entire circumference of the tooth or placed in at least 6 locations around the tooth
A healthy gum will bleed if more than 20 grams of pressure is applied to the probe
Too much pressure can cause the probe to puncture the junctional epithelium

Question 24

Common locations for deep periodontal pockets

Answer 24

Crowded locations
between 108/109 and 208/209
Between 309/310 and 409/410
Buccal aspect of mandibular canines and palatal aspect of maxillary canines (oronasal fistula)
Between misaligned and crooked teeth (especially noted in brachycephalic dogs)

Question 25

What does periodontal pockets equate to

Answer 25

Pocket depth does not always equate to attachment loss
Gingival hyperplasia can give false pocket depth scores

Question 26

What to do for Periodontal Charting

Answer 26

Use a consistent method (always start in same location in the mouth):
Mobility, furcation exposure, probing depth, and attachment loss are assessed at this stage
You may also find other defects in the teeth at this stage as well (tooth resorption, caries, fractures, wear) that may not have been noticed during the preliminary examination
This is also a good time to follow up from abnormalities that were noted on radiographs

Question 27

Why is accurate periodontal charting important

Answer 27

Because periodontal disease is progressive, charting is an important aid for follow up visits.
Accurate records establish a baseline
Subsequent measurements of pockets, furcation exposure, etc, are compared to aid in evaluating the progression of the disease and also the treatment plan

Question 28

Subgingival Calculus Removal is

Answer 28

Removal of subgingival plaque and calculus from root surface
If subgingival plaque and calculus remains, the patient will not receive long-term benefits from treatment and bacterial plaque will continue to destroy the periodontium
Leads to bone deterioration and eventual tooth loss

Question 29

What to use for subgingival calculus removal

Answer 29

Use a curette not a scaler
Curette - cutting edge held at between 45 and 90 degrees to tooth surface
A horizontal pulling or oblique stroke is used
Can use an ultrasonic scaler if you are using a subgingival tip

Question 30

Modified pen grasp is

Answer 30

The thumb and forefinger are placed at the junction of the handle and the shank of the instrument. The grasp is relaxed
Pad of middle finger is placed on the shank near the working end
This triangle is very stable
The ring finger is held straight and placed on the surface closest to the tooth being worked on (fulcrum)
Modified Pen Grasp

Question 31

Modified pen grasp and wrist rock works for

Answer 31

Ring finger is placed on the quadrant you are working on
The ring finger serves as a fulcrum on which you rotate
DO NOT PUT YOUR FULCRUM ON THE NOSE OR EYE SOCKET
Practice by holding a pen and drawing a small circle by rotating on the fulcrum (ring finger). The fingers should not flex at all during this motion and the wrist should remain in alignment
Scaling will be more effective with the fulcrum close to the tooth you are working on!
Rotation of the wrist in a rocking motion is used to remove calculus (keep wrist straight!)
Wrist Rock

Question 32

Adapting of the tooth is and useful for

Answer 32

If the curette does not fit the curvature of the tooth, the opposite end of the instrument is used (mirror images)

As the curette is inserted into the pocket, the face of the instrument is facing the root surface (closed position)
This allows the smooth part of the instrument to roll into the sulcus and prevents gingival trauma
The instrument is moved over the calculus and then repositioned so that the cutting surface is under the calculus ledge (open position)
45-90 degrees to tooth surface
With a rocking pull, the calculus is cleaved from the root surface (wrist rock technique)

Question 33

Root planning objectives and how to do it

Answer 33

The objective is to remove calculus and cementum from the root surface to create a clean, smooth root surface to prevent bacterial growth and allow for reattachment of the gingiva
The technique uses a curette, a gracey is preferred
The blade of the curette is positioned against the root surface inside the periodontal pocket (<5 mm deep)
You use 10 – 20 overlapping strokes in the horizontal, coronal, left oblique, and right oblique angles to smooth the root surface

Question 34

Gracey curettes are numbered by

Answer 34

7-8 and 13-14 are most commonly used in veterinary dentistry
1-2 and 3-4 are used on incisors
5-6 are used on canines
7-8 and 9-10 are used on most of the premolars (but not 108/208)
11-12 and 13-14 are used on the upper 4th premolar and molars

Question 35

What is used for Detection of Missed Plaque and Calculus and why

Answer 35

An explorer is used to evaluate the tooth surface
Heightened tactile sense to feel smoothness of tooth surface
Application of a disclosing solution enables you to visualize missed plaque and calculus.
can also be done via compressed air drying tooth – missed deposits will appear chalky
This method must be used with caution (air embolus)

Question 36

Polishing is done because

Answer 36

To maximize smoothness of enamel and remove micropitting of enamel (especially if ultrasonic scaler is used)

Question 37

How to do polishing of teeth properly

Answer 37

Done with a slow speed prophylaxis cup and prophy paste
Because polishing generates considerable heat, a liberal amount of prophy paste should be used
The prophy cup must be kept moving and should never linger over one area
The rim of the cup should be applied both supra and subgingivally (flare the cup)
Rinse sulcus with water after as prophy paste can be irritating to surrounding gingiva

Question 38

Different grits for polishing

Answer 38

Fine paste should be used in most cases
Coarse paste may remove enamel
If coarser pastes are used (ie: to remove stains) → always finish with a fine paste

Question 39

Sulcus irrigation is doen by

Answer 39

Gentle flushing of the sulcus to remove any traces of dislodged debris
Use a saline, stannous fluoride, fluoride foam or diluted chlorhexidine solution
Use a blunted 23-gauge needle

Question 40

Flouride application is done by and used for

Answer 40

Strengthens enamel and helps desensitize teeth
After irrigation the teeth must be dried
Apply fluoride per manufacturer’s instructions
When removing, the fluoride is wiped (not rinsed) off of the tooth surface

Question 41

Application of a sealer is done by and for

Answer 41

Applied to the clean tooth surface with a sponge applicator or gloved finger
Reduces plaque and tarter formation by repelling water and preventing bacteria from attaching to the teeth
Requires weekly application at home*

Question 42

Final charting is and done because

Answer 42

Involves reviewing of the previously performed diagnostic and periodontal charting
Should include any additional treatment performed

Question 43

Home care and education is

Answer 43

Home care instructions are developed and discussed with owner prior to sending client home. (to be discussed further)