Advance Dental Procedures – Options to Extraction

Oral disease is one of the most prevalent diseases in dogs and cats. Over 80% of adult dogs and cats have some form of oral disease, and unfortunately, this often leads to the extraction of teeth that might have been saved. It is vital to offer clients treatment options through referral to a veterinary dental specialist. Offering clients the opportunity for a referral is both ethically and legally important to your clinic. Owners want what is in the best interest of their pets, but may not be aware of alternative treatment options. If an owner declines the referral, it is vital to document that declination in your records. Remember never to judge what your clients will be willing to do for their pets.

Many advanced dental procedures require specialized training, experience, and equipment to perform correctly. Veterinarians can obtain training for some of these procedures through continuing education labs. For advanced procedures, it is advisable to refer patients to a well-trained or board-certified veterinary dentist. Many of these procedures should not be performed by a veterinary technician, with the exception of closed root planing (both manual and ultrasonic) and the placement of perioceutics. Although the RVT cannot perform many of the procedures discussed in this article, it is vital that they understand each one in order to better prepare for and assist the veterinarian during surgery. When the veterinarian offers a referral, the RVT should have a working knowledge of the recommended procedure so they can help educate the pet owner about it and its benefits to the patient.

As with any dental procedure, local blocks are strongly recommended to prevent undue stress and pain to the patient and to allow for a safer anesthetic procedure.

Periodontal Therapy

The first goal of periodontal therapy is to reduce the periodontal pocket and eliminate the soft tissue or bony lesions. The second goal is to slow or halt the progression of the periodontal lesion. The final goal is to return the tissues to a normal environment by removing dental deposits such as plaque and calculus through a professional dental cleaning and gold-standard home care. When dental flaps or guided tissue regeneration are to be used, it is often best to stage the periodontal surgery several weeks after a thorough periodontal cleaning.

Before any advanced periodontal procedure is selected, a complete dental evaluation should be performed, consisting of a thorough oral examination and radiographs, along with scaling and root planing (SRP) using a conservative management approach. If there is no improvement after the SRP and several weeks of good home care, a decision should be made to perform surgical periodontal therapy.

For a periodontal pocket of 5 mm or less, closed root planing, or scaling and root planing (SRP), is a viable option for removing the plaque and calculus below the gumline. This pocket-depth standard is based on human dentistry, where SRP has been confirmed to result in better attachment gain than a surgical procedure. SRP can be accomplished with an ultrasonic scaler periodontal tip specifically designed to clean below the gumline, followed by a curette to ensure that all subgingival calculus has been removed. In addition to SRP, localized delivery of antibacterial products (perioceutics) may be needed.

Perioceutics

Once a periodontal pocket has been debrided, placing a localized antibiotic, or perioceutic, into the pocket releases therapeutic levels of antibiotics directly to the site. Two antibiotic options are currently available in veterinary medicine: Doxirobe Gel (doxycycline) from Zoetis and Clindoral (clindamycin) from TriLogic Pharma. Both have been shown to be effective in reducing pocket depth after placement. The decision of which to use depends on personal preference, ease of use, cost, and availability through distribution channels.

Root Planing

Root planing is a procedure in which embedded calculus and a portion of the necrotic cementum are removed from the root to provide a clean, smooth surface that is free of bacterial toxins. This allows the root surface to be biologically acceptable to the soft tissue wall of the periodontal pocket without causing harm to the hard or soft tissues.

A curette is used to debride the cementum. The blade should be gently inserted into the periodontal pocket parallel to the tooth. The curette is then angled about 30 degrees against the root surface to engage the cutting edge, and the blade is withdrawn from the pocket in an oblique manner while applying pressure. The procedure is repeated in overlapping strokes in all directions, a technique known as cross-hatching, and should never be performed in a back-and-forth motion. The objective is to remove the calculus cleanly, not to shave it, wear it down, or pack it into the pocket.

Gingival Curettage

In addition to closed root planing, gingival curettage aids in the optimal reattachment of the soft tissue. Gingival curettage is the removal of the pocket epithelium and the infiltrated subepithelial connective tissue. This eliminates the microorganisms that create the inflammation of the diseased tissue. The procedure is performed by reversing the position of the curette from that used in root planing, placing the blade against the gingival tissue. A finger is gently placed to support the gingival tissue, and the curette is pulled along the tissues around the pocket wall to debride them. Gently irrigate the tissues with chlorhexidine and apply mild compression for several minutes to aid in the readaptation of the tissues to the teeth and to control bleeding.

Ultrasonic Periodontal Debridement

There has been a shift from the traditional emphasis on treating tooth and root surfaces to a focus on establishing and maintaining healthy gingival tissue. Removing the bacterial plaque and the exotoxins it produces, as well as the plaque-retentive structures within the pocket, has been shown to heal the tissues. Ultrasonic periodontal debridement removes both supragingival and subgingival plaque while removing less of the cementum structure than manual root planing. This creates less hypersensitivity and reduces the potential for gouging of the tooth and root surfaces. A periodontal tip must be used on the scaler. These tips are longer and thinner than the tips designed for supragingival debridement. A universal tip should never be used, as it is too wide to reach into the periodontal pockets. Periodontal tips can be used in and around furcations and periodontal pockets to remove bacterial colonies. The ultrasonic action not only helps break the calculus loose, but also lyses the bacterial cell walls, while the water flushes the bacteria out of the pocket.

Periodontal Surgery

In periodontal pockets greater than 5 mm, closed root planing may be ineffective, and periodontal surgery will be required. The veterinarian should acquire advanced training before performing this procedure. A gingival flap will expose the site of the lesion for adequate debridement. These flaps are created by cutting and gently raising a section of tissue while leaving one side still attached. The tissue is gently elevated using a periosteal elevator. Following debridement of the exposed tooth surfaces, the flap must be sutured closed to prevent tissue dehiscence, bleeding, hematoma, and infection.

Regenerative Therapy

Vertical bone loss and horizontal bone loss are two different challenges in periodontal surgery. Vertical bone loss, which occurs along the long axis of the tooth, is usually easier to repair than horizontal bone loss, where many teeth and furcations may be involved. Effective regeneration of periodontal tissues requires knowledge of the relevant concepts, materials, and techniques. In addition to debriding tissue and eliminating pockets, the goals of regenerative therapy include promoting blood clot stabilization, maintaining space, and preventing gingival recession. Regenerative therapy is performed to keep the faster-growing alveolar mucosa and gingival connective tissue out of the lesion, allowing the growth of new periodontal ligament, new cementum, and new alveolar bone.

After debridement of the defect, an osteoconductive or osteoinductive material can be placed in the defect to regenerate the tissues. For regenerative therapy to be successful, the debris and granulation tissue must be removed to reveal clean, healthy bone and tooth surface. Osteoconductive products such as Consil (a biosynthetic particulate glass material by Nutramax) do not induce new bone development but act as a scaffold for new bone cells to traverse the defect. Osteoinductive products such as Osteoallograft (Veterinary Transplant Services, Kent, WA) are natural bone grafts designed specifically for veterinary dentistry. The osteoinductive material is a biological adjunct or graft material that leads to the differentiation of osteoprogenitor cells (mesenchymal stem cells) into osteoblasts.

Periodontal Splinting

Periodontal splinting should be considered when a traumatic luxation or subluxation of a tooth has occurred. Splinting provides stability and allows the tooth to heal. The tooth must be cleaned and polished to remove all debris and granulation tissue. An osteopromotive product is placed into the defect, the gingiva is sutured closed, and a band of dental acrylic is placed around the teeth in the defect. The acrylic attaches one tooth to another for stabilization. Daily rinses are essential to keep the area clean.

Gingivoplasty

A gingivoplasty is often performed in patients with gingival hyperplasia. It is the surgical removal of excess gingival tissue and is not recommended as a treatment for a deep periodontal pocket. The objective is to prevent pseudo-pocket formation caused by the overgrowth of tissue. The depth of tissue and the contour of the tooth must be determined by inserting a probe and measuring the amount of excess tissue. A scalpel blade, or an electrosurgery blade or loop, is used to excise the tissue. The blade should be held at a 45-degree angle to the crown. If using a scalpel blade, hemorrhage must be controlled with pressure or hemostatic agents. Care must be taken with electrocautery systems, which operate at low frequency and can generate incandescent heat that damages tissues and bone. Electrosurgery systems, which use high frequency, are less traumatic to the tissue.

Endodontics

Endodontics is defined as the treatment of the pulp of the tooth. The pulp consists of blood vessels, nerves, and connective tissue that support the odontoblastic cells lining the pulp chamber. The odontoblasts produce dentin throughout the life of the tooth. When the pulp is damaged or infected, the animal feels pain because of the nerves that run through the pulp chamber and through the apex of the root into the surrounding bone.

Indications for endodontic therapy include discolored teeth due to pulpitis and fractured teeth with either an exposed vital or nonvital pulp. Nonvital teeth may show apical root resorption or abscess formation in the surrounding bone. Preventive endodontics can be used in cage chewers, working or police dogs, and dogs that participate in agility or flyball, where constantly carrying toys (such as tennis balls) causes wear.

Most dogs with endodontic disease are in pain. Symptoms of oral pain include salivation, inappetence, lethargy, inability to eat or drink, malodor, swelling or redness, draining tracts, reluctance to chew, inability to close the mouth properly, head shyness, changes in socialization, food dropping, ear or eye pain, and ocular discharge. The advantages of endodontic therapy include a faster recovery time, a less invasive approach than extraction, maintenance of jaw integrity, and a successful, efficient procedure with a cost comparable to that of extraction.

There are three types of endodontic therapy: vital pulp therapy, standard root canal therapy, and surgical root canal therapy. The veterinary dentist can help the client choose the best option for the patient.

Vital Pulp Therapy

Vital pulp therapy is considered when the tooth is recently fractured, and the pulp is still vital. The age of the animal, which tooth is fractured, and the length of time the tooth has been fractured must all be considered before this procedure. It should not be performed if the fracture is more than 48 hours old. The first 5 mm of exposed pulp is removed, followed by a thin layer of lining cement or calcium hydroxide. This irritates the pulp and forces the formation of a bridge over the exposed pulp. An intermediate restorative layer, such as a glass ionomer, is placed between the cement layer and the final restoration. Owners should be warned that this procedure can fail and will require monitoring for the remainder of the animal's life.

Standard Root Canal Therapy

Standard root canal therapy involves the removal of all of the pulp and nerve, disinfecting the canal, filling the canal, and capping the tooth. This makes the tooth nonvital, but in doing so it removes the pain and allows the animal to keep the tooth and maintain jaw integrity and occlusion.

Surgical Root Canal Therapy

Surgical root canal therapy can be performed along with standard root canal therapy when there is disease at the apex of the root. A window is opened in the gingiva and bone overlying the apex of the root where the abscess is located. This area is then curetted, and all granulation and diseased tissue is removed. The apex of the root is amputated, and a cement material is placed in the apex, sealing it off from both the top and the bottom. Once completed, the gingiva is sutured back into place.

Radiography plays a major part in endodontic therapy. Multiple radiographs are taken throughout the procedure to ensure proper placement of materials.

When recommending endodontic therapy, it is important to educate the client about all available options. It is best to try to save the tooth whenever possible.

Prosthodontics

One of the most common reasons to place a crown or restoration on an animal's tooth is to protect an endodontically treated tooth, especially a large tooth such as the maxillary fourth premolar or canine. Restorations protect the integrity of the tooth crown and help return the tooth to its previous form and function. Crowns in veterinary dentistry are often made of metal alloys such as titanium or stainless steel. These materials are used instead of the porcelain commonly used in human dentistry because of the animal's stronger bite and potential for aggressive chewing.

Restorative crowns are custom-made and require preparation of the tooth and construction of a model. These procedures take additional training and experience to perform.

Bonded Sealants

Bonded sealants can be placed on teeth that have an uncomplicated crown fracture with no pulp exposure. In this situation, the dentin has been exposed. Dentin is porous and contains approximately 45,000 to 52,000 dentinal tubules per square millimeter in the coronal dentin. These tubules contain fluid, and some contain nerves extending from the pulp. Tooth pain may result from fluid shifts that stimulate the nerve endings due to changes in temperature and chewing. In addition, bacteria may migrate directly into the pulp through these tubules. Smoothing the fracture site and applying a bonded sealant can decrease plaque adherence and calculus accumulation, reduce tissue irritation, decrease sensitivity, and help prevent infection of the pulp chamber. After the sealant is placed, the tooth may form a permanent layer of restorative dentin beneath the sealant.

Kits are available that include all the materials needed to apply bonded sealants to exposed vital dentin.

Orthodontics

The goal of veterinary orthodontics is not to create a perfect bite, but to create a comfortable, functional bite for the animal. The principle of orthodontic movement involves applying force to the crowns of the teeth. This force is transmitted to the roots, which press against the alveolar bone.⁴ Bone is resorbed on the side under pressure, and new bone forms on the tension side.

There are two main types of orthodontic treatment: interceptive and corrective. Interceptive orthodontics is the process of removing improperly aligned teeth in the hope of preventing further problems as the patient ages and the jaw grows. An example of interceptive orthodontics would be removing the 106 and 206 on a Pug to allow more room for the teeth and avoid crowding. Another reason for interceptive orthodontics would be retained deciduous teeth. Retained teeth can lead to crowding and infection and can contribute to malocclusion.

Corrective orthodontics involves the use of appliances to move the teeth into a more functional alignment. These appliances can include an acrylic splint or incline plane, expansion splints and bands, hooks, and buttons.

Placing corrective orthodontics on purebred or breeding animals is an ethical issue that each veterinarian must discuss with the animal's owner. Malocclusions tend to be genetic; therefore, orthodontic procedures should not be performed on animals intended for breeding or show, and whenever possible, the animal should be altered before the procedure.

Exodontics

Exodontics is defined as the extraction of a tooth and is considered oral surgery. While some states in the U.S. allow veterinary technicians to perform extractions, the American Veterinary Dental College and the Academy of Veterinary Dental Technicians state that this procedure should be performed by the veterinarian. The veterinary technician plays a large role in extractions by ensuring all equipment is set up and in proper working order and by assisting the veterinarian during the extraction.

Position Statements

AVDC: https://avdc.org/PDF/Dental_Health_Care_Providers.pdfAVDT: https://www.avdt.us/avdt-extraction-position-statement

There are two basic types of extraction: simple and surgical. A simple extraction is usually performed on a mobile, single-rooted tooth. It is vital to determine the reason for the extraction by taking a radiograph, as there can be many reasons for a tooth to be mobile. These include bone loss due to periodontal disease, a fractured tooth root, or even a cancerous process causing destruction of the bone surrounding the tooth.

A surgical extraction is performed on a solid single-rooted tooth, a multi-rooted tooth, or a severely infected or fractured tooth. A surgical extraction is performed to reduce the anesthetic time needed to elevate the tooth from the socket and to minimize damage to the surrounding structures. As with any extraction, radiographs are a must before and after the procedure. The pre-extraction radiograph determines the status of the tooth and surrounding structures, while the post-extraction radiograph ensures that the entire tooth root has been removed.

Whether the extraction is simple or surgical, the extraction site should be curetted to debride any necrotic material and flushed with an antimicrobial. All extraction sites, except for primary tooth extractions, must be sutured closed. Suturing a primary extraction site closed may cause scar tissue to form and could lead to entrapment of the permanent tooth. When determining whether to suture the first maxillary molar extraction site, the location of the salivary duct should be considered, as there have been reported cases of the duct being occluded by suturing this site.

References

1. Lobprise H, Dodd J. Wiggs' Veterinary Dentistry: Principles and Practice. 2nd ed. Wiley Blackwell; 2019.

2. Heitz-Mayfield LJ, Trombelli L, Heitz F, et al. A systematic review of the effect of surgical debridement vs. non-surgical debridement for the treatment of chronic periodontitis. J Clin Periodontol. 2002;29(Suppl 3).

3. Holmstrom S, Frost P, Eisner E. Veterinary Dental Techniques for the Small Animal Practitioner. 2nd ed. W.B. Saunders; 1998.

4. Perrone J. Small Animal Dental Procedures for Veterinary Technicians and Nurses. Wiley Blackwell; 2020.

5. Berg ML. Companion Animal Dentistry for the Veterinary Technician. Bluedoor Publishing; 2021.