Evaluation for Procedure

A periodontal probe and dental radiographs are used diagnostically before the procedure to determine the location of the pocket and to aid in the selection of an appropriate form of therapy.

Goal of Periodontal Surgery

The goal of periodontal surgery is to eliminate pockets harboring subgingival plaque and calculus. The ultimate aim is to prevent subgingival plaque and calculus from returning.

Instruments and Materials

Periodontal surgery requires various instruments and materials (Box 13-1). The No. 3 handle is the standard type for scalpels. A variety of different blades may be used, including special periodontal knives. The No. 15c blade is extremely fine and therefore useful in periodontal surgical procedures. In addition, small tissue scissors, such as LaGrange scissors, are helpful in trimming periodontal tissue. Periosteal elevators are used to lift the gingiva away from the bone. Several types are available. The Molt elevator is one type; the Molt No. 9 is particularly popular. Many practitioners also like the ST-No. 7 instruments. Having a variety of periodontal surgical instruments available makes treating various anatomic and pathologic conditions less difficult.

Solutions for irrigating the tissue are also important in periodontal surgery. Sterile saline solution and chlorhexidine are most common. Chlorhexidine is used in a 0.1% to 0.2% solution and is available in two forms: diacetate and gluconate. Gluconate is preferred.

Tissue forceps and needle holders are necessary for suturing. Although expensive, the best is the spring-locking Castroviejo-type needle holder. For the sutures themselves, 4-0 or 5-0 absorbable material with a reverse cutting FS-2 needle is used. The high-speed handpiece is used in the removal of bone, and burs may be added for the removal of granulation tissue. Round burs (#2 or #4), crosscut fissure burs (#701L), or pear-shaped burs (#330) may be used in the appropriate handpiece. Bone files may be used to contour bone.

Treatment Techniques

Hyperplastic gingiva

Because gingivoplasty (gingivectomy) is performed only when hyperplastic gingiva is present, patients must be selected carefully. Gingivoplasty should not be used for treatment of deep periodontal pockets or as part of the routine prophy. This procedure is contraindicated when attached gingiva is minimal or absent or horizontal or vertical bone loss is present below the mucogingival junction, which is the line of demarcation where the attached gingiva and alveolar mucosa meet. These characteristics are prevalent in certain breeds and breed lines, particularly boxers and collies.

Gingivoplasty technique

The pocket depth and contour is determined by inserting a probe to the depth of the pocket at several areas around the tooth. The corresponding depth is measured on the outside of the gingiva, also with the probe. A bleeding point is made by placing the tip of the probe perpendicular to the gingiva and applying slight pressure to make a small hole or by using a small-gauge needle. Bleeding points are made around the contour of the pocket and are used as a guide for the gingivectomy. The gingivectomy is made at an angle apical to the bleeding point to create a beveled margin. At least 2 mm of healthy, attached gingiva must be present apical to the base of the incision. A multifluted bur, laser, scalpel blade, or electrosurgery blade is used to excise the gingiva by cutting below the bleeding points, with the blade held at approximately a 45-degree angle and the tip of the blade toward the crown. The ends of the excision should be tapered into the surrounding gingiva to create the normal scalloped contour, particularly if several adjacent teeth are treated. Gingival tags can be removed with the blade or a sharp curette. The exposed tooth and root surface can now be scaled and planed smooth. Hemorrhage is controlled by applying pressure with wet gauze pads or hemostatic agents. If electrosurgery is being performed, caution must be exercised because the collateral damage may extend past the desired surgical line. In Figure 13-1, a periodontal probe is used to measure and mark the pocket depth. Once marked, a scalpel blade is used to perform the gingivoplasty.

FIGURE 13-1 A, Periodontal probe gingivoplasty measurement. B, Periodontal probe gingivoplasty probe marking the pocket depth.

Follow-Up Recommendations for All Periodontal Surgery

After surgery the patient should be given a soft diet for 1 to 7 days. Oral antibiotics are administered as appropriate. The oral cavity is flushed with chlorhexidine solution for 2 weeks. After the patient’s wounds have healed, oral hygiene should be performed in the home to minimize future plaque accumulations.

After the surgical site has healed, home care must be continued. The product selected for use depends on the patient’s particular situation. Postsurgical checkups are important to monitor the patient’s progress. A minimum of two follow-up appointments should be scheduled for 10 days and 1 month after the procedure. Additional appointments may be scheduled if necessary. Because patients that have had periodontal surgery sometimes experience a relapse, monthly or quarterly follow-up visits may be necessary.

Indications for Endodontic Therapy

The most common indication for root canal therapy is fractured teeth. If the tip of the crown appears black, the patient is a candidate for a workup and evaluation of the tooth. Cats are particularly susceptible to canine tooth abscess. The pulp chamber extends close to the tip, and any exposure of dentine allows bacteria into the pulp chamber. Chronic abscess of the canine teeth is extremely common in cats; all fractured teeth necessitate root canal therapy, extraction, or close monitoring.

A worn tooth with a brown covering in the area where the pulp chamber used to be indicates that the wear has occurred slowly enough that secondary dentin was deposited by the odontoblasts lining the root canal and pulp chamber. In this case, the tooth should be evaluated radiographically. Occasionally, teeth that are completely normal in appearance may have apical disease that can be diagnosed only radiographically.

The rationale for endodontic treatment is to maintain optimal health. A tooth with endodontic disease produces various signs, including pain and irritability. Many patients with endodontic disease exhibit fluctuations in appetite. Clients frequently report halitosis, or bad breath, in pets with undiagnosed endodontic disease.

Once pulpal death occurs, most dogs and cats do not show pain. However, if the tooth is alive and recently traumatized, many patients flinch when the tooth is percussed with a probe or other instrument. Some animals chew food only on the side of the mouth opposite the traumatized tooth, or they drool and produce increased calculus on the injured side. Hunting dogs may refuse their training dummies, utility dogs may refuse their dumbbells, and attack dogs may either hesitate or bite and release repetitively because of the pain (this is referred to as typewriting). Dogs that are used for tracking scents may be less effective than usual because of the odor from the oral infection, which overwhelms the scent.

When pulp exposure is secondary to a coronal fracture or a carious erosion, pathogenic bacteria soon descend into the pulp canal and cause an abscess either within the canal itself or periapically by extension of the infection. Infection that has penetrated the apical end of the root canal can cause osteomyelitis and the subsequent loss of surrounding bone. Periapical infection can spread, contributing to pathologic fractures of the lower jaw, or the infection can extend through weakened necrotic bone and develop into an oronasal fistula from any of the maxillary teeth.

Advantage of Endodontic Therapy

Endodontic therapy is much less invasive than surgical extraction of a large canine tooth, which is a large, single-rooted tooth designed for puncturing, tearing, and grasping, or a carnassial tooth, which is a shearing tooth that is the upper fourth premolar and lower first molar in the dog and cat. This therapy can therefore be performed more easily and quickly than a surgical procedure. Standard root canal therapy is less traumatic for the patient and more aesthetically pleasing to the owner than surgical extraction. Moreover, the cost of root canal therapy is equivalent to that of surgical extraction. Another advantage of small animal endodontics is that a well-done procedure is less likely to fail in the pet’s lifetime because the patient has a relatively short life span.