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Management of periodontal disease

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Abstract

Periodontal disease is the most common pathological condition occurring in adult dogs and cats. This chapter covers the diagnosis and management of periodontal disease, providing detailed instruction on the use of a range of equipment, instruments and materials. : Professional dental cleaning and closed periodontal therapy; Open periodontal therapy; Gingivectomy and gingivoplasty.

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Figures

Image of 7.1
7.1 (a) Magnetostrictive scaler. (b) Metal stack inserts with various tips. (© Dr Alexander M. Reiter)
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7.2 (a) Piezoelectric scaler and reservoir. (b) Piezoelectric scaler handpiece with LED light and universal tip. (a, Courtesy of Accesia, Sweden; b, Courtesy of Satelec, France)
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7.3 Ultrasonic scaling of the left maxillary fourth premolar tooth in a cat. (a) Lip retraction is performed with a dental mirror. (b) The scaler tip is directed apically, with its last 2–3 mm in contact with the tooth and at an angle of less than 15 degrees to the tooth surface. (© Dr Alexander M. Reiter)
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7.4 Scaling and polishing of the right maxillary canine tooth in a dog. (a) There is severe plaque and calculus accumulation and gingivitis. (b) Probing reveals a 6 mm deep periodontal pocket at the mesiolabial aspect of the tooth. (c) The scaler tip is directed apically, with its last 2–3 mm in contact with the tooth and at an angle of less than 15 degrees to the tooth surface. (d) The surface of the tooth is polished. (© Dr Alexander M. Reiter)
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7.5 (a) Sonic scaler. (b) Dental unit. The dotted circles indicate the attachment of the sonic scaler handpiece to a high-speed handpiece tubing in order to receive water, which is required for cooling of its tip. 1 = high-speed handpiece; 2 = air/water syringe; 3 = low-speed handpiece. (© Dr Alexander M. Reiter)
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7.6 (a) Air-powered dental cart with compressor. (b) Wall-mounted dental unit. (a, © Dr Peter Southerden; b, Courtesy of Accesia, Sweden)
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7.7 Head of a high-speed handpiece. C = coolant; CH = chuck; FGB = friction-grip bur; FOL = fibreoptic light; PB = push button. (© Dr Peter Southerden)
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7.8 High-speed handpieces. (a) The handpieces in the middle and to the right have a swivel fitting. The one to the right has a mini head used to work in areas with limited space. (b) Close-up of the heads of the three handpieces. (c) The handpieces have four-hole mid-west fittings. Note the kinked air exhaust hole (*) in the handpiece in the middle. C = coolant; CH = chuck; FOL = fibreoptic light; PB = push button. (© Dr Alexander M. Reiter)
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7.9 (a) Low-speed handpieces consisting of engine (or motor) and nose cone. (b) Low-speed handpiece with a long straight (HP) bur. (c) Low-speed handpiece with a disposable prophy angle. (d) Contra-angles. The one on the right has a 10:1 reduction gear. (a, d © Dr Alexander M. Reiter; b, c © Dr Peter Southerden)
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7.10 Shepherd’s hook (or No. 23) dental explorer (left) and 11/12 ODU dental explorer (right). (© Dr Alexander M. Reiter)
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7.11 A dental explorer being used to assess the surface of the left maxillary canine tooth in a cat for any irregularities. (© Dr Alexander M. Reiter)
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7.12 CP-15 UNC probe (left) and a probe with Williams markings (right). (© Dr Alexander M. Reiter)
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7.13 A Michigan-O probe with Williams markings being used to measure the depth of the gingival sulcus of the left maxillary canine tooth in a cat. (© Dr Alexander M. Reiter)
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7.14 Modified pen grasp. (a) The instrument is first grasped between the thumb (T) and index finger (I), and then (b) the middle finger (M) is brought towards the shank of the probe. R = ring finger. (© Dr Alexander M. Reiter)
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7.15 The modified pen grasp is shown during probing of a right maxillary canine tooth. The instrument is held with the thumb (T) and index (I) and middle (M) fingers, while the hand is supported with the ring finger (R) on an incisor tooth. (© Dr Alexander M. Reiter)
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7.16 ‘Walking’ the periodontal probe. (a) The probe has been inserted at the distolabial aspect of the right maxillary canine tooth. (b) The probe is removed and then (c) reinserted at the labial aspect of the tooth. Note that this alternative approach differs slightly from that described in Chapter 3 where the instrument is not completely removed during walking of the probe. (© Dr Alexander M. Reiter)
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7.17 Anti-fogging solution for prevention of condensation on the dental mirror. (© Dr Alexander M. Reiter)
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7.18 (a–f) Removal of calculus from the right maxillary fourth premolar tooth in a dog using extraction forceps. (© Dr Alexander M. Reiter)
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7.19 Scaler with pointed tip (left) and curette with rounded toe (right). (© Dr Alexander M. Reiter)
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7.20 (a) Working ends of various hand scalers. (b, c) Scalers are often used to scale supragingival grooves such as those in the crowns of maxillary and mandibular canine teeth in cats. (© Dr Alexander M. Reiter)
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7.21 (a) Working ends of various hand curettes. (b) A curette being used to scale and plane the subgingival surface of the roots of a left maxillary fourth premolar tooth in a dog. (© Dr Alexander M. Reiter)
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7.22 Assortment of periodontal surgical instruments. (a) Hoes and chisels. (b) Surgical curettes and files. (© Dr Alexander M. Reiter)
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7.23 (a) Polishing cups and brushes that can be screwed on to a prophy angle. (b) Disposable plastic prophy angle with polishing cup for single use. (© Dr Alexander M. Reiter)
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7.24 Various polishing pastes in small and large containers. Note also the white dappen dish containing some pumice. (© Dr Alexander M. Reiter)
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7.25 (a) Small container with polishing paste snapped into a chalice-like device. (b) The device is held between the middle and ring fingers. (© Dr Alexander M. Reiter)
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7.26 (a) Small container with polishing paste snapped into a ring-like device. (b) This device is worn on the ring finger. (© Dr Alexander M. Reiter)
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7.27 Orban gingival knife (left) and Kirkland gingival knife (right). (© Dr Alexander M. Reiter)
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7.28 (a) Working ends of various periosteal elevators. Note the bur mark scratches in the metal surface that are acquired when the instrument is used for tissue retraction. When the blade is damaged, the instrument should no longer be used for flap elevation. (b) Molt No. 9 periosteal elevator. (a, © Dr Alexander M. Reiter; b, © Dr Peter Southerden)
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7.29 (a) The two different tips of a pair of pocket-marking forceps. (b) The blunt tip with millimetre markings is inserted down to the bottom of the gingival pocket at the labial aspect of the right maxillary canine tooth in a dog. (© Dr Alexander M. Reiter)
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7.30 Same case as in Figure 7.29. (a) The pocket-marking forceps are closed, causing the right-angled, pointed tip to create a bleeding point on the labial or buccal side of the gingiva at the level of the base of the pocket. (b, c) This process is repeated at several points around the tooth, thus indicating (d) the proposed line of incision for gingivectomy. (© Dr Alexander M. Reiter)
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7.31 (a) No. 15 surgical blade and No. 3 flat scalpel handle. (b) No. 5 round scalpel handle. (c) Mini blade (single edge) attached to a round Beaver handle. (a, b, © Dr Alexander M. Reiter; c, © Dr Peter Southerden)
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7.32 (a) Close-ups of the tips and (b) full views of three types of thumb forceps: Adson plain (left), Adson 1 × 2 (middle) and Adson-Brown (right). (© Dr Alexander M. Reiter)
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7.33 Tissue scissors. (1) Mayo scissors. (2) Metzenbaum scissors. (3) Iris scissors. (4) Suture scissors. (© Dr Alexander M. Reiter)
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7.34 Poliglecaprone 25 is a commonly used suture material in the mouths of dogs and cats. (© Dr Alexander M. Reiter)
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7.35 (a) DeBakey needle holder. (b) Castroviejo needle holder. (c) Olsen-Hegar needle holder. (© Dr Peter Southerden)
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7.36 Cotton-tipped applicators (front), tissue protectant (left), dappen dish (middle), and topical haemostatic agent (right). (© Dr Alexander M. Reiter)
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7.37 Size 7.6 × 7.6 cm (3 × 3 inches) gauze swabs. (© Dr Alexander M. Reiter)
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7.38 (a) Cortical bone collector. (b) Side view of frontal aspect of the cortical bone collector, showing transparent chamber filled with cortical bone chips. (c) Autogenous bone being harvested using the cortical bone collector at the caudobuccal aspect of the left mandible in a dog. (d) Dappen dish filled with cortical bone chips. (© Dr Alexander M. Reiter)
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7.39 (a) Bioglass. (b) Bioglass mixed with fresh blood. (© Dr Alexander M. Reiter)
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7.40 (a) Allograft. (b) Open periodontal therapy (creation of flap, root planing and bone contouring) was performed at the buccocaudal aspect of the right maxillary fourth premolar tooth in a dog. (c) Allograft has been placed over the denuded root surfaces. (© Dr Alexander M. Reiter)
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7.41 Same case as in Figure 7.40 . (a) Flexible bone membrane. (b) Membrane sutured in position prior to (c) closure of the flap. (© Dr Alexander M. Reiter)
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7.42 (a) Chlorhexidine (0.12%) solution. (b) Sodium fluoride foam (left; to be applied by the veterinary dentist) and stannous fluoride gel (right; to be applied by the client). (© Dr Alexander M. Reiter)
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7.43 (a) Palm grip. (b) Modified pen grasp. (© Dr Peter Southerden)
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7.44 (a) Before and (b) after professional dental cleaning, closed periodontal therapy and extraction of selected teeth in a dog. (© Dr Alexander M. Reiter)
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7.45 Proper lip retraction with a mirror during (a) supragingival and (b) subgingival ultrasonic scaling. Copious water irrigation should be used to cool the tip (not shown). (c) As the crown is polished, the prophy cup should be flared underneath the gingival margin to polish (d) the subgingival crown and exposed root surfaces. (© Dr Alexander M. Reiter)
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7.46 Inappropriate use of an ultrasonic scaler. (a) Tip perpendicular (arrowed) to the tooth surface risks structural damage to dental hard tissue and heat injury to the pulp. (b) Tip pointing in a coronal direction risks the uncooled part of the scaler (*) making contact with and causing burn injury to the oral mucosa or skin. (© Dr Alexander M. Reiter)
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7.47 Same case as in Figure 7.4 . (a) Removal of subgingival plaque and calculus with a hand curette. (b) The blade is inserted in the periodontal pocket with the back towards the inner gingival surface and the face towards the tooth surface. (c) The instrument is gently advanced apically until resistance is felt (i.e. to the bottom of the sulcus or pocket). (d) The handle is then tilted away from the tooth until the blade is at 60–80 degrees to the tooth surface, engaging the cutting edge on the tooth surface with a pulling action to remove subgingival plaque and calculus. (© Dr Alexander M. Reiter)
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7.48 Same case as in Figure 7.4 . (a) Gingival curettage with a hand curette. (b, c) The sharp edge of the curette is pressed against the inner surface of the gingiva to gently remove inflamed and infected pocket epithelium and connective tissue. (© Dr Alexander M. Reiter)
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7.49 (a, b) Doxycycline gel (8.5%) is supplied with two syringes and a cannula. (c, d) Syringe A (containing liquid polymer) is attached to syringe B (containing doxycycline powder) to mix the contents. (© Dr Alexander M. Reiter)
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7.50 Same case as in Figure 7.4 . (a) The cannula is inserted into a cleaned periodontal pocket for (b) injection of doxycycline gel. (c) A few drops of cold water are added to make the gel more pliable. (d–f) A beaver-tail composite instrument is used to gently pack the hardened gel deeper into areas of interest so that it is positioned subgingivally. (© Dr Alexander M. Reiter)
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7.51 (a) Front and (b) occlusal views of the mandibular incisor teeth with moderate periodontal disease in a dog. (c) Front and (d) occlusal views after creating labial and lingual flaps with releasing incisions. (© Dr Alexander M. Reiter)
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7.52 Same case as in Figure 7.51 . (a) Front and (b) occlusal views after removal of inflamed and infected soft tissue, planing of exposed root surfaces and recontouring the alveolar margin. (c) Front and (d) occlusal views after apposition of the flaps towards the alveolar bone and teeth in a slightly apical position. (© Dr Alexander M. Reiter)
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7.53 Left maxillary jaw quadrant in a dog (a) prior to and (b) immediately after gingivectomy and gingivoplasty. (c) Same area 3 months later. (© Dr Alexander M. Reiter)
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7.54 Same case as in Figure 7.29 . (a, b) An external bevel incision is made (slightly apical to the bleeding points) with the blade held at a 45-degree angle. (c) The excess gingiva is removed. (d) A bullet-shaped 12-fluted bur on a high-speed handpiece with water cooling provides instant haemostasis while fine-contouring the cut gingival surface. (© Dr Alexander M. Reiter)
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7.55 (a) Maxillary incisor teeth with gingival enlargement in a dog. (b) The excess gingiva is removed with an electrosurgical loop. (c) Front view following gingivectomy and gingivoplasty. The activated loop should never come into contact with the tooth and bony surfaces. (© Dr Alexander M. Reiter)
Image of 7.56
7.56 Same case as in Figure 7.29 . (a) Cotton-tipped applicators are used to apply an astringent to the cut gingival surface. (b, c) They are then used to coat the astringent with a layer of surface protectant. (© Dr Alexander M. Reiter)
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7.57 (a) A palatal flap was raised to expose a palatal pocket at the left maxillary canine tooth in a dog. Note the vertical bone loss and the brownish lesion in the root surface (inflamed and infected soft tissue has already been removed). (b) Same view after planing of the exposed root surface and recontouring the alveolar margin. (© Dr Alexander M. Reiter)
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7.58 Same case as in Figure 7.57 . (a) A graft material was placed into the bone defect. (b) A custom-fitted, absorbable barrier membrane was secured over the site. (c) The palatal flap was sutured closed. The releasing incision allowing the flap to adapt to the tooth is left to granulate and epithelialize. (© Dr Alexander M. Reiter)
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7.59 Partial tooth resection. (a) The main cusp of the left mandibular first molar tooth in a dog is fractured (*). In addition, there is an axial fracture affecting the distal crown-root segment of the tooth (arrowed). (b) Resection of the distal crown-root segment was performed, followed by root canal therapy of the mesial crown-root segment and grafting of the extraction site with bioglass. (c) Radiograph and (d) clinical photograph of the tooth at the 6-month recheck examination. Note the height of the alveolar bone at the extraction site and the band of gingiva (arrowed) at the distal aspect of the remainder of the tooth. (© Dr Alexander M. Reiter, reproduced from with permission from the )
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7.60 Laterally positioned flap. (a) Clinical photograph and (b) radiograph of the left maxillary canine tooth with a gingival cleft in a dog. (c) The planned incision was outlined with a surgical marking pen. (d) The incision was executed, the flap raised (note the atraumatic handling by means of a stay suture), the first premolar extracted, inflamed and infected soft tissue removed, the root surface planed and the alveolar margin recontoured. (e) Grafting material (bioglass) was placed and (f) the flap was sutured closed. (g) Postoperative radiograph. (h) Clinical photograph and (i) radiograph of the treated tooth 3 months later. (© Dr Alexander M. Reiter, reproduced from with permission from the )
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7.61 Apically positioned flap (‘summer dress’ technique, Alexander M. Reiter). (a) Lateral and (b) occlusal views of the fractured right maxillary canine tooth in a dog. The fracture involves both the crown and root of the tooth (crown-root fracture). The white dotted lines indicate planned incisions (staying about 1 mm away from the adjacent teeth). The yellow dotted line borders the extra piece of palatal tissue removed prior to suturing the flap closed. (© Dr Alexander M. Reiter)
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7.62 Same case as in Figure 7.61 . (a) Labial and (b) palatal flaps are elevated. Bone is reduced until (c) the end of the fracture has been found and (d) there is sufficient clinical crown height. (e) The flaps are slightly thinned at their connective tissue side and (f) a half-moon-shaped piece of tissue is removed from the edge of the palatal flap. (© Dr Alexander M. Reiter)
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7.63 Same case as in Figure 7.61 . (a–c) The fingers of the palatal flap are sutured to periosteum at the base of the labial flap, thus avoiding unwanted coronal pulling on that flap. (d) The labial flap is then sutured closed. Note the resulting clinical crown height (e) labially and (f) palatally at the end of the procedure. (© Dr Alexander M. Reiter)
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©Dr Alexander M. Reiter ©Dr Alexander M. Reiter
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©Dr Alexander M. Reiter ©Dr Alexander M. Reiter
Image of (© Dr Alexander M. Reiter, reproduced from Lewis and Reiter (2005) with permission from the Journal of Veterinary Dentistry)
(© Dr Alexander M. Reiter, reproduced from Lewis and Reiter (2005) with permission from the Journal of Veterinary Dentistry) (© Dr Alexander M. Reiter, reproduced from with permission from the )
Image of (© Dr Alexander M. Reiter, reproduced from Lewis and Reiter (2005) with permission from the Journal of Veterinary Dentistry)
(© Dr Alexander M. Reiter, reproduced from Lewis and Reiter (2005) with permission from the Journal of Veterinary Dentistry) (© Dr Alexander M. Reiter, reproduced from with permission from the )
Image of (© Dr Alexander M. Reiter, reproduced from Lewis and Reiter (2005) with permission from the Journal of Veterinary Dentistry)
(© Dr Alexander M. Reiter, reproduced from Lewis and Reiter (2005) with permission from the Journal of Veterinary Dentistry) (© Dr Alexander M. Reiter, reproduced from with permission from the )

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