In addition to increased pocket depth, the oral examination may reveal gingival recession. Document gingival recession in
millimeters. The sum total of gingival recession plus abnormal pocket depth is termed attachment loss. In cases of gingival recession, there can be marked attachment loss without pocket formation.
Dental radiography is another essential tool for diagnosing periodontal disease. The most common radiographic abnormality
resulting from periodontitis is alveolar bone loss. Bone loss from periodontal disease is generally horizontal (suprabony)
or vertical (infrabony) (Figures 2A & 2B). When describing bone loss in the patient record, include the percentage of bone loss, for example, "The mesial root of
the mandibular left first molar shows 75% horizontal bone loss."
Figures 2A & 2B
STAGING PERIODONTAL DISEASE
Periodontal disease can range in severity from mild gingivitis (which resolves with proper treatment) to end-stage periodontitis
(which is, for the most part, irreversible). It can be classified according to a four- or five-stage system. It is important
to know each tooth's periodontal disease stage so appropriate therapy can be administered on a tooth-by-tooth basis. For this
purpose, a convenient periodontal triage system would consist of three categories: gingivitis, treatable periodontitis, and
end-stage periodontitis. Halitosis is a hallmark sign of periodontal disease, but its presence or absence does not indicate
a specific disease stage.
In patients with gingivitis, the initial stage of periodontal disease, only gingival tissues exhibit inflammation. Patients
may have mild, moderate, or severe bacterial plaque or calculus accumulation and hyperemia and edema of the marginal gingiva.
Gently probing the gingival sulcus with a periodontal probe may induce spontaneous bleeding, but the pocket depth remains
normal (< 3 mm). No radiographic abnormalities are associated with this stage.
Clinical signs of early periodontitis are related to periodontal tissue destruction and may include increased pocket depth
(up to 5 mm), gingival recession, and furcation exposure. In veterinary dentistry, our patients come in a variety of sizes,
and there is variation in the clinical significance of a 5-mm pocket on a Mastiff's canine (minor problem) vs. a 5-mm pocket
on the first maxillary premolar of a Yorkshire terrier (probably a candidate for extraction). Horizontal or vertical alveolar
bone loss may be seen radiographically. In early periodontitis, 0% to 30% bone loss may occur.
The clinical signs of established periodontitis include deep periodontal pockets (> 5 mm), gingival recession and root exposure,
alveolar bone loss (sometimes with furcation exposure), and mild tooth mobility. Bone loss ranges from 30% to 75%.
In patients with end-stage periodontitis, one or more tooth roots exhibit > 75% bone loss. Single-rooted teeth exhibit mobility,
but multirooted teeth may not be loose if one or more roots retain some attachment to bone. Therefore, a tooth does not have
to be loose to have end-stage periodontal disease.
After the complete oral examination, update your findings and treatment recommendations in the record and discuss them with
the owner. Patients whose teeth exhibit gingivitis should undergo complete dental scaling (both supragingival and subgingival)
and polishing. The proper techniques and steps for performing dental prophylaxis are well-documented. On the other end of
the spectrum, treating patients whose teeth exhibit end-stage periodontitis is straightforward as well: dental extraction.
Patients with treatable periodontitis have diverse pathologies, and a variety of treatments are available.
Diagnosing and treating periodontitis in people consumes an entire specialty in the field of dentistry, and many textbooks
and journals are devoted to the subject. At the risk of oversimplifying the art and science of periodontology, presented below
is a framework for treating treatable periodontitis in dogs.
BEFORE STARTING TREATMENT
The key diagnostic information required is periodontal pocket depth and intraoral radiographic examination results, including
the percentage and type of bone loss. The absolute necessity of obtaining intraoral dental radiographs cannot be overemphasized.