In a black and white world, treatment of periodontal disease would be straightforward.
Healthy tooth? Clean and polish. Diseased tooth? Extract.
However, just as in every aspect of life, there are shades
of gray to periodontal disease.
Making the diagnosis of periodontal disease is easy. The
challenge is accurate quanti-fication of severity of each
tooth’s disease and understanding the decision making
process to treat each tooth individually.
Periodontal disease in dogs and
cats tends to be a
disease that may
be presented to you
at varying stages
of severity. Table
1 shows the staging nomenclature
used by the American Veterinary Dental College
loss can be lumped
into two categories:
horizontal and vertical bone loss.
loss is a term de-
bone loss that oc-
curs along the al-
veolar margin of
the mandible or
maxilla, resulting in root expo-
sure and furcation exposure of
multi-rooted teeth (Figure 1A).
Vertical bone loss is alveolar
bone loss that occurs along the
long axis of a root (Figure 1B).
These two processes may occur simultaneously around alveolar bone of the same tooth,
or even the same root. Of the
two processes, vertical bone
loss is easier to combat than
horizontal bone loss, since
there are often three walls of
bone surrounding the vertical
defect that can retain osteoconductive or osteoinductive
Discussed below is one approach to dealing with cases of
vertical bone loss, such as what
often occurs on the mesial or
distal surface of the mandibular
first molar tooth in dogs.
Therapy vs. Extraction
Has the periodontal disease
progressed to the point where
endodontic disease is now also
likely? If so, the “double wham-my” of periodontal disease and
endodontic disease makes extraction the more practical choice.
Before deciding whether to
pursue periodontal therapy for
borderline teeth, it is important
to have a heart-to-heart conversation with the pet owner.
Is the affected tooth functionally important based on the
patient’s role in life (police dog
or couch potato)? Is the owner
concerned about loss of teeth?
Is the patient healthy enough to
undergo future anesthetic follow-up and treatment, since advanced periodontal disease often
requires multiple treatments? Is
the owner able and willing to
perform daily home care?
If not, even the best periodontal surgeries may fail over
time due to progression of periodontal disease. Another question to ask yourself: Do you
have the equipment, materials
and experience to provide advanced periodontal therapy?
Tools of the Trade
Osteoconductive substances (such as bioglass) are ones
that act as a scaffold for bone
cells to traverse a defect. Osteoinductive substances (such
as autografts or allografts) not
only act as a scaffold, but also
contain bone morphogenetic
proteins, which recruit osteoblast progenitors and stimulate
differentiation to create new
bone formation in a defect.
Absorbable membranes are
used to retain osteoconductive
or osteoinductive materials
within a defect and to prevent
faster growing tissues (
epithelium) from filling defects before
bone has a chance to.
Placement of a “perioceutic,”
such as doxycycline gel, into
treated pockets with minimal
bone loss may reduce pocket
depths and improve chances of
reattachment of the gingival soft
tissue to the surface of the tooth.
However, what you put into
a periodontal defect is the second part of the story.
Prior to placement of any material, it is important to perform
Dealing with borderline teeth
By John Lewis, VMD,
FAVD, Dipl. AVDC
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TABLE 1: Stages of periodontal disease
PD 0 (Normal) Clinically normal - no gingival inflammation or periodontitis clinically evident.
PD 1 (Stage 1) Gingivitis only without attachment loss. The height and architecture of the alveolar margin are normal.
PD 2 (Stage 2) Early periodontitis - less than 25 percent of attachment loss or at most, there is a stage 1 furcation involvement in multi-rooted teeth.
There are early radiologic signs of periodontitis. The loss of periodontal attachment is less than 25 percent as measured either by probing
of the clinical attachment level, or radiographic determination of the distance of the alveolar margin from the cementoenamel junction
relative to the length of the root.
PD 3 (Stage 3) Moderate periodontitis - 25-50 percent of attachment loss as measured either by probing of the clinical attachment level, radiographic
determination of the distance of the alveolar margin from the cementoenamel junction relative to the length of the root, or there is
stage 2 furcation involvement in multi-rooted teeth.
PD 4 (Stage 4) Advanced periodontitis - more than 50 percent of attachment loss as measured either by probing of the clinical attachment level, or radio
graphic determination of the distance of the alveolar margin from the cementoenamel junction relative to the length of the root, or there
is stage 3 furcation involvement in multi-rooted teeth.