1	DENTISTRY FOR BREEDERS and Concerned Owners Dr. J. Veronika Kiklevich, DVM, DABVP (Canine, Feline) San Antonio Veterinary Referral Specialists 10822 Fredericksburg Road San Antonio, TX 78240
2	Veterinary Training There are 28 Veterinary Colleges in the US. Only 8 Veterinary Schools have a recognized dental program. Texas A&M has a fine dental program (initiated in 2004). Most veterinarians have SOME dental training, but the level varies widely among schools. Does you Physician examine your teeth???????
3	Overview Normal Dentition Malocclusion Periodontal Disease Why is it important? What is it? Treatment and control Radiographs Endodontics versus Extraction Indications for Referral Home Care
4	Normal Dentition: Dental Formulas Canine Primary: 2 (I 3/3; C 1/1; P 3/3) = 28 Canine Secondary (Permanent): 2 (I 3/3; C1/1; P 4/4; M 2/3) = 42
5	Normal Dentition: Eruption Times It is important to know the general permanent tooth eruption times since abnormal tooth eruption can lead to many oral problems. Upper middle incisors: 12-14 weeks Upper second incisors: 14-16 weeks Upper third incisors: 16-18 weeks Upper canines: erupt at 20 weeks and are fully in by 24 weeks
6	Normal Dentition: Eruption Times If teeth are missing (adontia) there may be a serious underlying problem. Dentigerous Cysts Odontomas
7	Normal Occlusion
8	Malocclusion: Class I (Neutroclusion) Class I: Both jaws of proper length and teeth are in a normal mesiodistal (front to back) location Example: Anterior Crossbite
9	Malocclusion: Class 1 Other Examples of a Class I Malocclusion: Lingual Cuspids (Base Narrow Lower Canines) Facial Canines (Base Narrow Upper Canines) Posterior Crossbite Crowded or Rotated Teeth Lance Teeth (Partially Erupted Upper Canines)
10	Malocclusion: Class 1 Many can be repaired to normalcy or functionality and comfort.
11	Malocclusion: Class II Distocclusion The Mandibular Premolars are BEHIND (distal to) the Maxillary Premolars. Short Mandible Example: Mandibular Brachygnathism Long Maxilla Example: Maxillary Prognathism
12	Malocclusion: Class III Mesiocclusion The Mandibular Premolars are in front of (mesial to) the Maxillary Premolars. Long Mandible Example: Mandibular prognathism Short Maxilla Example: Brachycephalic
13	Malocclusion: Class IV Mesiodistocclusion This is a Special Classification of Wry Bite where one jaw is in Mesioclusion and one is in Distoclusion.
14	Examples of Tooth Abnormalities
15	Periodontal Disease Why is it important? Healthy Mouth = Healthy Pet Association of periodontal disease with disease at distant sites in the body Cardiac (Myocarditis or Endocarditis) Liver (Hepatitis) Kidneys (Nephritis) Pancreas (Pancreatitis, Neoplasia-humans) Joints (Polyarthritis) Brain (Meningitis) Others
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18	Periodontal Disease Adverse effects Abnormal behavior Loss of appetite Lethargy PAIN PAIN PAIN PAIN!!!!!!!!!!!!!! Fever and secondary systemic disease Loss or diminishment of the Human-Animal bond (stinky breath!!)
19	Anatomy of the Tooth
20	A Brief Word on Nomenclature
21	Pre-Dental Considerations A complete physical examination should be performed on each patient. NO DROP-OFFS! A complete general as well as a complete dental history should be collected. Let your veterinary dentist know about any pre-existing conditions and medications Blood tests and a urinalysis may be done as needed depending on age and physical findings
22	Pre-Dental Considerations Anesthetic protocol Dental treatment plan: ASK You will need to sign anesthetic release and treatment estimate form*
23	Pre-Dental Considerations Preanesthetics may or may not be needed. ASK! A catheter and fluid therapy should be done. NOT NEGOTIABLE. After the induction of anesthesia, an appropriate size intratracheal tube is placed and the cuff is properly inflated. Monitoring devices and heating pads should be placed on the patient.
24	Pre-Dental Considerations **There should be one person dedicated to monitoring anesthesia** Pack the throat with a pharyngeal sponge or gauze
25	A Word on Anesthesia Adequate dental cleaning cannot be performed without anesthesia. Your veterinarian should be able to talk to you regarding the anesthetic protocol….. DON’T BE AFRAID TO ASK In general long-acting sedatives are not required. Your pet should go home happy and bouncing if routine procedures are performed.
26	The Periodontium Gingiva Cementum Periodontal Ligament Alveolar bone Periodontal disease is the most common disorder encountered in practice
27	Periodontal Disease Gingivitis Periodontitis Chronic Inflammatory Infectious
28	Periodontal Disease Plaque Surface film Bacteria (+ byproducts) Saliva Food particles Sloughed epithelial cells
29	Periodontal Disease Calculus Mineralized plaque Calcium carbonate Calcium phosphate
30	Periodontal Disease** Gingivitis Reversible inflammation of the gingiva “the red line” sign Progresses to Periodontitis Deeper inflammation Loss of tooth support Irreversible without surgical intervention
31	Periodontal Disease Grading System Stage 1 Gingival inflammation No apparent attachment loss May be accompanied by calculus Malodor Slight bleeding
32	Periodontal Disease Grading System Stage 2 (Early Peroidontitis) More extensive gingival inflammation demarcated by 25% or less attachment loss Moderate bleeding Malodor Calculus likely present
33	Periodontal Disease Grading System Stage 3 (Moderate periodontitis) Edema accompanied by attachment loss of between 25 to 50% Usually heavy calculus Gingiva bleeds easily Slight tooth mobility
34	Periodontal Disease Grading System Stage 4 (Advanced periodontitis) More than 50% attachment loss Furcation involvement 2-3 mm of tooth mobility Very hyperemic gums that bleed easily Pus may be evident
35	Tertiary (reparative) Dentin
36	Prevention and Treatment of Periodontal Disease Oral examination in the unanesthetized patient Oral examination under general anesthesia Supragingival scaling Subgingival cleaning Polishing Irrigation Fluoride Post cleaning examination and diagnostics Charting Therapeutic intervention (if needed) Home care Follow-up
37	Treatment of Periodontal Pockets: Doxyrobe or Perioceutic Home care following placement is mandatory for success. Biodegradable- will breakdown after 1-4 weeks. May be considered to be expensive by many, however if it is critical to save a tooth with a deep pocket, and owners can follow up with home care, then many teeth can be saved by using these products.
38	Antibiotics: should they be used? Use for routine prophylaxis treatment is controversial If there is pre-existing evidence for underlying systemic disease at least peri-operative antibiotics should be instituted. Must be used to treat infections and associated osteomyelitis Two weeks past remission of disease. Choices Amoxicillin/clavulanate (Clavamox) Metronidazole Clindamycin
39	Periodontal Disease Follow-up The extent of follow-up care will depend largely on the amount of pre-existing disease, type of therapeutic intervention, and owner’s ability to provide home care
40	New Frontiers in Preventive Home Care: OraVet ™ A barrier product, OraVet™ should be applied by your veterinarian immediately following a dental cleaning to limit plaque attachment. Weekly treatment should be continued by the owner at home. Results of one study showed a 24% lower mean dental plaque score and a 47% lower mean dental tarter score in dogs at two months of treatment while another showed a 42% lower mean dental plaque score. Plaque prevention is key to preventing periodontal disease!
41	OraVet^TM While 96% of veterinarians recommend brushing dogs’ teeth, only 2% of owners actually do brush their dog’s teeth. Compliance is greatly improved with once weekly application of OraVet^TM. Although brushing is still recommended, OraVet^TMhas replaced brushing in most homes.
42	Radiographs: Are they REALLY necessary???? Two thirds of the tooth structure lies beneath the gum line (Think of an iceberg!)
43	Radiographs: Are they REALLY necessary????
44	Radiographs: Are they REALLY necessary????
45	Radiology Intraoral dental films are essential for complete diagnosis and treatment of many oral problems
46	Indications for tooth removal Diseased teeth that are not contributing to function Persistent primary teeth To perform interceptive orthodontics Malocclusion/malpositioned teeth (when orthodontics are declined)
47	Indications for tooth removal (cont) Advanced periodontal disease (more than 50% of PLD loss) Non-vital teeth or teeth with exposed pulp (when root canal therapy is declined) Teeth with structural damage (where restoration has been declined) Retained roots or sequestered bone
48	Indications for tooth removal (cont) Teeth showing internal or external resorptive changes (when therapy is not possible) Teeth in a fracture line that will interfere with healing of the fracture Teeth in or involved with oral neoplasia Impacted teeth
49	Indications for tooth removal (cont) Extraction = Toothanasia Although extraction is often a definitive “cure” for an oral problem, every effort should be made to maintain healthy teeth in a healthy mouth Decisions regarding tooth extraction depend on both the pathology of the tooth and the ATTITUDE OF THE OWNER
50	Extractions: Critical Procedures Osteoconductive materials should be placed in all extraction sites: Ex. Consil TCP (TriCalcium Phosphate Tribasic) and Curasorb (Calcium-Zinc Alginate)
51	Endodontics: Saving teeth Many teeth can be saved with endodontic intervention. Tooth preservation will help maintain normal occlusion and jaw structure. The ten most important teeth to maintain: Upper and lower canines (4) Upper fourth premolars (2) Upper and lower first molars (4)
52	Endodontics: Root canals The basic principle of endodontics is to meticulously clean the root canal and then fill it with an inert substance. The periodontal ligament will regenerate for tooth stability. Follow-up (6 to 8 months) is crucial.
53	Endodontics: Crowns Crowns will add strength to the tooth. A crown should be considered in all working dogs. Porcelin crowns are aesthetic but are easily broken. Disadvantages: Multiple visits Multiple Anesthetics Cost
54	Oral Analgesia (Pain Control): Nerve Blocks Local nerve blocks are indicated for any oral surgical procedures I use a 50/50 mixture of lidocaine and bupivacaine or just bupivicaine Patient must also be given post-operative pain medication Helps lower total anesthetic dose.
55	Indications for Referral Alternatives for Broken or Damaged Teeth Root Canal Therapy Extraction
56	Indications for Referral To obtain radiographs with superior detail and positioning for diagnostic purposes.
57	Indications for Referral Advanced periodontology Multiple extractions Gingivoplasty or Gingivectomy Splinting Cervical buldge reestablishment Guided Tissue Regeneration (GTR)
58	Indications for Referral Oral Surgery Difficult extractions Ankylosed roots Oronasal Fistula Repair Palatal Defects Lip and Cheek Defects Oral Fracture Repair Interdental bonding Interdental wiring and acrylic splinting
59	Indications for Referral Restorative Dentistry (caries) Crown amputation (tooth reduction) Vital Pulpotomy Crown Placement Orthodontics
60	Home Care It is important to institute a routine of oral care as early in life as possible. The form of home care that is instituted after a dental cleaning depends on the animal and the owner’s commitment to care.
61	Common Products: Active Home Care Toothbrush, Finger brush, or Gauze pad Mechanical toothbrush or Water Pick Enzymatic Dentrifices: CET^®Toothpaste Chlorhexadine: CET^®(Virbac) Zinc Ascorbate: Maxiguard Gel ^®(Addison) Oral Wipes (Dent-Acteic) OraVet: Plaque prevention system
62	Common Products: Passive Home Care Dental Diets Hill’s T/D IAMs/Eukanuba Dental Defense Royal Canin Tarter Control Biscuits
63	Look for This Label!!!
64	Recommended Common Products: Passive Home Care Rawhide Chewing Products Non-Rawhide Chewing Products
65	Preventative Care: Early and Often! In general, veterinarians perform DENTAL CLEANINGS rather than doing routine preventative care I recommend early routine preventative care, however animals are not typically brought in until they are having dental problems As breeders and concerned owners, recommend that yearly preventative care be started at about 2 years of age.
66	Preventative Care: Early and Often! Remember that when a dog or a cat is TWO years old that is more or less the equivalent of being FOURTEEN human years old! 85% of dogs and cats over the age of 4 have clinically important dental disease Periodontal disease is associated with many other serious systemic diseases
67	Preventative Care: Early and Often! If periodontal disease exists, treatment regimes should be performed at 4-6 month intervals for optimum maintenance of oral health
68	Conclusion 85% of dogs and cats over the age of 6 have clinically important dental disease. Periodontal disease is associated with many other serious systemic diseases Early dental disease is often ignored or overlooked by both veterinarians and owners Performing routine dental cleanings and therapeutics can extend the healthy life of pets.
69	How to obtain a dental referral If your veterinarian does not provide the dental care your pet requires, simply ask to be referred to me.