Periodontal disease is one of the most prevalent conditions seen in companion animal practice, and there are growing concerns about how it can contribute to the incidence of systemic disease in these animals. Regular oral examinations coupled with effective dental prophylaxis can help prevent periodontal disease and thus can contribute to the overall health and well-being of patients. Dental prophylaxis consists of several steps, including external and internal oral examinations followed by de-scaling (scaling), polishing and periodontal probing to measure attachment loss of the gingiva to the tooth roots. Regular preventive dental care is an area that nurses can play a vital role in to help animals live longer, healthier lives. Good nursing care and skill in dental prophylaxsis and hygiene techniques is paramount to ensure effective prevention of periodontal disease.
Periodontal disease is one of the most prevalent infectious conditions in dogs and cats, with nearly all companion animals being affected at some point by the time they reach maturity (Hoffman et al, 2007; Girard et al, 2009). Human studies show that there is a correlation between periodontal disease and a greater risk of heart disease, kidney disease, stroke and cancer; there is mounting evidence to suggest that this is also true in animals (Pavlica et al, 2008; Friedewald and Kornman, 2009; Rawlinson et al, 2011). With this in mind, it is important that regular prophylactic dental treatment is a part of every pet's preventive health care. Veterinary nurses can greatly influence the overall health and well-being of patients by providing clients with comprehensive pet oral hygiene education and by maintaining high standards ofdental care and treatment within the veterinary practice environment.
Basic dental prophylaxis
Preventive dental care is an important part of health maintenance, and many modern companion animal practices have staff dedicated to dentistry procedures. As with human dentistry, veterinary nurses can act as dental hygienists by performing routine dental prophylaxis, including charting, cleaning and polishing.
In basic terms, the dental prophylaxis consists of a thorough oral examination followed by cleaning and polishing the teeth to remove plaque and calculus build-up. In addition, oral radiographs can help reveal hidden problems and enable early detection of more serious conditions, such as tooth root abscess or bone loss, and should be included as part of the regular dental health work-up.
Initial dental examination
Routine dental prophylaxis generally begins with the collection of a comprehensive patient history followed by a preliminary oral and facial examination carried out while the patient is still conscious. All aspects are noted on the dental chart and are outlined below.
Dental history
A comprehensive dental history is taken, including details of the patient's diet, eating habits, drinking habits, chewing habits and if there are any signs of pain. Previous dental care should be noted, as well as what preventive dental care is implemented regularly by the client.
Dental charting
A comprehensive dental chart is completed (Box 1). It should include a species-specific diagram of the dentition as well as a chart to note the severity of plaque, calculus, gingivitis, periodontal disease, dental history and any dental procedures that are performed. Evidence-based evaluations are critical for objective measurements, so it is important to use objective indices on the chart so that it stands alone as a part of the patient's medical record.
Website links to some good dental charts.
Anatomic Checklist for the Oral Examination of Dogs and Cats
A visual and manual examination is carried out on the conscious patient. Good restraint and handling are important to ensure personal safety and minimize stress for the patient. The conscious examination includes the following procedures:
Visual external examination — the neck, face, eyes, nose, lips, ears and skin are evaluated, noting the presence of excess salivation, saliva staining, swellings, asymmetries, erythema, alopecia, scarring, discharge, draining tracts or malodour.
External palpation — the face is palpated, noting any evidence of pain in the nose, face, lips, ears and neck. Lymph nodes and salivary tissue are palpated for swellings and asymmetries. The temporomandibular joint is palpated and any asymmetries are noted.
Visual intra-oral examination — the lips are then parted gently to reveal occlusion and to note any abnormalities in dentition or health of the oral mucosa.
Visual examination of the oral cavity — the mouth is opened briefly and occlusion is evaluated further. Any asymmetries, crepitus or clicking of the temperomandubular joint is noted. The oral cavity is briefly viewed, noting abnormalities of the oral mucosa, tongue, palate, oropharynx and floor of the mouth.
Performing dental prophylaxis
The dental prophylaxis continues when the patient is anaesthetized. Patient positioning for the dental procedure is important to minimize the risk of aspiration from fluids associated with use of the dental instruments. The animal may be placed in lateral recumbency with the head lower than the chest and the mouth angled so that fluid can flow out rather than back into the throat. Other positions such as dorsal recumbency are acceptable as long as sufficient protection of the airway is ensured, usually by oropharyngeal packing.
To minimize the likelihood of leakage of fluid into the airway, the cuff of the endotracheal tube should be lubricated before insertion; once placed, it should be inflated just until air can no longer be heard escaping around the cuff (Robertson, 2010).
Dental procedures can be lengthy, so anaesthetic hypothermia can be a concern. Every effort should be made to maintain the patient's normal body temperature. Wool or synthetic blankets should be used so that moisture is wicked away and the patient is kept warm if it should get wet. Supplemental heat may be provided, but great care should be taken to avoid contact burns or electrocution when using electric heat pads around water. Every effort should be taken to prevent the patient from getting wet, including providing good drainage around the face and using non-absorbent ties for securing the endotracheal tube.
The dental treatment for the anaesthetized patient includes:
Sedated intra-oral examination — a comprehensive intra-oral examination of the teeth, gingivae, lips, oropharynx and tonsils is carried out. Any abnormalities are noted, including evidence of inflammation, infection, foreign bodies, swellings, malocclusion, missing teeth, extra teeth, worn teeth, abnormal-coloured teeth and fractures (Figure 1). The degree of gingivitis, plaque, calculus and periodontal disease are recorded using objective indices (Table 1a; Table 1b). The sharp tip of the shepherd's hook/explorer tool can be used to evaluate thickness of plaque as well as calculus margins, pulp exposure and enamel grooves, fractures or lesions.
An intra-oral examination reveals asymmetrical swelling around the right canine tooth.
Grading periodontal disease — indices for gingivitis, plaque and calculus
Charting Indices
Normal
Stage 1
Stage 2
Stage 3
Gingival Index
No evidence of inflammation
Minimal inflammation with slight change in colour but little change in texture
Moderate inflammation with swelling; bleeds on probing
Marked inflammation and swelling; bleeds easily
Plaque Index
No evidence of plaque
Minimal thin film of plaque at gingival margin
Moderate accumulation of plaque in sulcus
Abundant plaque in sulcus
Calculus Index
No evidence of calculus
Minimal supragingival calculus; little or no subgingival calculus
Moderate supra- and subgingival calculus
Abundant supra- and subgingival calculus
Furcation Index
No loss of bone support
Minimal horizontal loss of supporting tissues, not exceeding one-third of the tooth width
Moderate horizontal loss of supporting tissues exceeding one-third of the tooth width but not encompassing the total width of the furcation area
Complete horizontal loss of supporting tissues
Mobility Index
No mobility
Perceptible mobility but not exceeding 1 mm lateral movement
Moderate movement between 1-2 mm laterally
Marked mobility exceeding 2 mm laterally and/or vertical movement
Nerve blocks — if the patient exhibits any sign of pain during the conscious examination or under light sedation, the veterinarian should be notified immediately. Regional nerve blocks may be administered if needed.
Dental radiography — dental radiographs should always be taken if possible since they can reveal the presence of hidden disease and help determine if other treatments are needed. Good positioning is critical to ensure quality radiographs (Figure 2).
Correct positioning is critical for oral radiographs.
Protection of the airway — an unconscious dental procedure can pose many risks to the patient's airway from fluid and debris. To prevent this, a throat pack or sponge tied with a strong cord can be used to pack the oropharynx before starting the procedure.
Minimizing aerosolized pathogens — to reduce aerosolized pathogens in the environment during the dental procedure, the mouth can be irrigated with a 0.12% chlorhexidine gluconate solution (Logothetis and Martinez-Wells, 1995).
Dental cleaning — large pieces of calculus can be removed with dental forceps, but care should be taken to avoid damaging the delicate gingivae; this is particularly important in cats as extensive damage to the delicate gingival papillae can result from rough handling. The teeth are then cleaned of plaque and calculus using a manual or motorized de-scaling instrument (Figure 3). Of the various types of motorized de-scalers, the most common are sonic and ultrasonic models that use an oscillating/vibrating tip to rapidly remove plaque and calculus. These vibrations can cause a great deal of friction, which may result in overheating and thermal damage to the pulp cavity; therefore, it is important that the tip receives continuous water flow to keep it cool. Additional prevention against thermal damage can be ensured by moving the instrument between several teeth at a time so that it is only in contact with a single tooth for a few seconds at a time. The instrument should be held in a modified pen grip for the best control and should be rotated in concentric circles until the entire tooth surface has been covered. The oscillating tip can cause damaging microabrasions to the enamel, so it is vitally important that it is never directed perpendicular to the tooth surface. Typically, it is the curved side edge of the instrument that is the working surface in contact with the tooth.
The tip of the ultrasonic scaler should always be held parallel to the tooth surface so that enamel etching is minimized.
Checking effectiveness of cleaning — after de-scaling is complete, the teeth should be checked to ensure that plaque and calculus have been thoroughly removed. Missed calculus can be visualized by drying the tooth with an airgun; calculus will show up as bright white when dried. Missed plaque can be visualized by applying a plaque indicator solution and rinsing gently; plaque will show up with the applied stain (Figure 4). The hand scaler instrument is useful for removing remaining plaque and calculus that may be present in hard-to-reach areas. It is also held using a modified pen grip, and the curved edge is used to scrape from the gumline to the tip of the tooth crown.
After scaling, residual plaque can be detected by applying the stain and then rinsing gently; any missed areas will be visibly stained.
Assessing periodontal disease — after cleaning has taken place, the mouth is assessed for evidence and severity of periodontal disease by using a periodontal probe to explore the gingival sulcus. Clinical attachment loss is determined by measuring the depth of the sulcus from the cemento-enamel junction (Figures 5 and 6).
Tooth anatomy.Periodontal probing to measure attachment loss.
Root planing and subgingival scaling — if periodontal disease is detected, the veterinarian may determine that root planing or subgingival scaling of the affected teeth is warranted. These procedures effectively promote reattachment of the gingiva to the tooth root by removing debris from the root surface.
Polishing — the teeth can then be polished using a low-speed hand piece with attached disposable prophy cup. The instrument is pressed lightly onto the tooth and moved in concentric circles to cover all surfaces (Figure 7). As with the ultrasonic de-scaler, the polisher can cause friction and overheating, which can result in thermal damage to the pulp cavity, so it is important to move the polisher between several teeth so that it is not in contact with a single tooth for more than a few seconds at a time. Polishing paste must be used at all times to prevent thermal damage and to ensure any microabrasions from the de-scaling process are sufficiently removed to ensure a smooth tooth surface that resists plaque adhesion. Polishing paste can be loaded into the prophy cup as each tooth is polished, but this sometimes results in insufficient coverage of the teeth with paste. To ensure good distribution of polishing paste before polishing, a slurry of paste can be applied to all the teeth using a soft disposable or sterilized toothbrush. Once polishing is complete, the mouth should be rinsed of excess paste and subgingival irrigation should be carried out (Figure 8) (Holmstrom et al, 2005).
Gentle flaring of the polishing cup so that it extends slightly under the gumline.Rinsing away debris and polishing paste residue.
Other procedures — once cleaning and polishing is complete, fluoride treatments, extractions and other procedures can be performed. When all procedures have been completed the protective oropharyneal packing can be removed. The oropharynx is then carefully examined using an angled dental mirror to ensure that there is no foreign matter or debris present (Figure 9).
Figure 9. Using a dental mirror to check that no foreign objects are present in the oropharynx after the procedure.
Recovery and discharge of the dental patient
During recovery of the dental patient, extra care should be taken to ensure the patient is monitored closely for signs of dyspnoea. Signs of oral pain should be noted and reported to the veterinarian promptly so that pain relief can be provided if needed. The patient's face and neck should be cleaned and groomed if necessary to ensure it is comfortable and presentable for the client. The patient should be encouraged to eat once nerve blocks have worn off and the animal is fully alert and able to swallow normally.
When the animal is ready to go home, the client should be informed how to care for the pet's mouth during the healing process, including watching for signs of pain or infection. Depending on the procedure, soft food may be advised for a week or more to minimize discomfort when eating. The client should be telephoned the day after the procedure to ensure the patient is recovering well and that the client has been able to carry out any medicating or treatments. The patient should return to the practice for a revisit a few days after the procedure to evaluate healing in the mouth and ensure there are no signs of infection or discomfort. When healing is complete, the client should be encouraged to begin daily tooth brushing, which has been proven to be the single best preventive measure against plaque build-up (Hoffman et al, 2007). Thorough instructions should be provided to the client to ensure a successful brushing regimen.
Oral examinations should take place every 3–6 months; if the patient has severe periodontitis, it should receive monthly oral examinations until the disease is controlled (Holmstrom et al, 2005). Ideally, an appointment for the next regular visit should be made when the animal is discharged to help ensure compliance with a regular dental health maintenance schedule.
Conclusions
Regular dental health care is extremely important for the maintenance of patient health and well-being. The routine dental prophylaxis includes a thorough examination, charting, teeth cleaning and polishing. These procedures should ideally be carried out once or twice a year to prevent plaque build-up, which can lead to gingivitis and periodontitis. With good follow-up care, daily maintenance of oral health and regular examinations and dental cleanings, periodontitis can be prevented and the animal's overall well-being will benefit from improved oral health.
Suggested reading
Promoting Dentistry in the Veterinary Practice (link requires registration to view)
Plaque build-up can lead to gingivitis and periodontal disease, which can contribute to systemic diseases in animals as well as in people.
Dental prophylaxis consists of the oral examination as well as cleaning and polishing the teeth, and can help maintain overall health by preventing periodontitis.
After dental prophylaxis the patient should be monitored and given pain relief if needed.
On discharge the client should be told how to care for the pet's mouth during the healing process.
Dental prophylaxis should be carried out once or twice a year in most cases.
Daily home brushing of the pet's teeth can prevent plaque build-up.
