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Periodontal disease is essentially an inflammatory response by the supporting structures of the [[:Category:Teeth - Anatomy & Physiology|teeth]] known as the periodontium. These structures include the [[gingiva]], [[Enamel Organ#Periodontal Ligament|periodontal ligaments]], [[Enamel Organ#Cementum|cementum]] and [[Enamel Organ#Alveolar Bone|alveolar bone]]. It is the most common [[:Category:Oral Diseases - Dog|dental disease in dogs]] and [[:Category:Oral Diseases - Cat|cats]] and the major cause of tooth loss in both species. There are numerous factors that contribute to the formation of the disease but the primary agent is dental plaque. Plaque accumulates at the gingival margin, partly due to insufficient [[Oral Hygiene - Small Animal|oral hygiene]].

Periodontal disease is essentially an inflammatory response by the supporting structures of the [[:Category:Teeth - Anatomy & Physiology|teeth]] known as the periodontium. These structures include the [[gingiva]], [[Enamel Organ#Periodontal Ligament|periodontal ligaments]], [[Enamel Organ#Cementum|cementum]] and [[Enamel Organ#Alveolar Bone|alveolar bone]]. It is the most common [[:Category:Oral Diseases - Dog|dental disease in dogs]] and [[:Category:Oral Diseases - Cat|cats]] and the major cause of tooth loss in both species. There are numerous factors that contribute to the formation of the disease but the primary agent is dental plaque. Plaque accumulates at the gingival margin, partly due to insufficient [[Oral Hygiene - Small Animal|oral hygiene]].

Periodontal disease is the result of the inflammatory response to dental plaque, i.e. oral bacteria, and is limited to the periodontium. It is probably the most common disease seen in small animal practice, with a large majority of dogs and cats over the age of 3 years having a degree of disease that warrants intervention.  

Periodontal disease is the result of the inflammatory response to dental plaque, i.e. oral bacteria, and is limited to the periodontium. It is probably the most common disease seen in small animal practice, with the great majority of dogs and cats over the age of 3 years having a degree of disease that warrants intervention.  

Periodontal disease is a collective term for a number of plaque-induced inflammatory lesions that affect the periodontium. It is a unique infection in that it is not associated with a massive bacterial invasion of the tissues. '''Gingivitis''' is inflammation of the gingiva and is the earliest sign of disease. Individuals with untreated gingivitis may develop '''periodontitis'''. The inflammatory reactions in periodontitis result in destruction of the periodontal ligament and alveolar bone. The result of untreated periodontitis is ultimately exfoliation of the affected tooth. Thus, gingivitis is inflammation that is not associated with destruction (loss) of supporting tissue – it is '''reversible'''. In contrast, periodontitis is inflammation where the tooth has lost a variable degree of its support (attachment) – it is '''irreversible'''. Infection of the periodontium may cause discomfort to the affected animal. There is also strong evidence that a focus of infection in the [[Oral Cavity Overview - Anatomy & Physiology|oral cavity]] has been associated with disease of distant organs. Consequently, prevention and treatment of periodontal diseases is, contrary to common belief, not a cosmetic issue, but a general health and welfare issue.

Periodontal disease is a collective term for a number of plaque-induced inflammatory lesions that affect the periodontium. It is a unique infection in that it is not associated with a massive bacterial invasion of the tissues. '''Gingivitis''' is inflammation of the gingiva and is the earliest sign of disease. Individuals with untreated gingivitis may develop '''periodontitis'''. The inflammatory reactions in periodontitis result in destruction of the periodontal ligament and alveolar bone. The result of untreated periodontitis is ultimately exfoliation of the affected tooth. Thus, gingivitis is inflammation that is not associated with destruction (loss) of supporting tissue – it is reversible. In contrast, periodontitis is inflammation where the tooth has lost a variable degree of its support (attachment) – it is irreversible. Infection of the periodontium may cause discomfort to the affected animal. There is also strong evidence that a focus of infection in the [[Oral Cavity Overview - Anatomy & Physiology|oral cavity]] has been associated with disease of distant organs. Consequently, prevention and treatment of periodontal diseases is, contrary to common belief, not a cosmetic issue, but a general health and welfare issue.

Initially, the bacterial flora of the mouth tend to be non-motile aerobes or facultative anaerobes. However, as the supply of oxygen is reduced by supragingival plaque accumulation and pocket formation, the bacterial flora become more motile and anaerobic. Important bacterial flora responsible include ''Porphyromonas gingivalis, Bacteroides asaccharolyticus, Fusobacterium nucleatum, Actinomyces viscosus'' and ''Actinomyces odontolyticus''.  

Initially, the bacterial flora tend to be non-motile aerobes or facultative anaerobes. However, as the supply of oxygen is reduced by supragingival plaque accumulation and pocket formation, the bacterial flora become more motile and anaerobic. Important bacterial flora responsible include ''Porphyromonas gingivalis, Bacteroides asaccharolyticus, Fusobacterium nucleatum, Actinomyces viscosus'' and ''Actinomyces odontolyticus''.  

Gingival inflammation starts because of formation of dental calculus (tartar) from diets high in minerals and diets consisting of soft rather than hard crunchy food. Dental plaque becomes calcified and the whole [[Enamel Organ#Crown|crown]] may become covered in brown chalky material. Calculus is a brittle dirty brown covering the tooth, which may not affect the [[Enamel Organ#Enamel|enamel]] at all but may produce mild gingivitis around the edge and the gum may start to recede. This exposes more of the crown and may reach the level of the [[Enamel Organ#Dentine|dentine]]. Therefore infection may enter the alveolus and loosen ligaments holding the tooth in place and ultimately the tooth will become loose and fall out.

Gingival inflammation starts because of dental calculus (tartar) from diets high in minerals and diets consisting of soft rather than hard crunchy food. Dental plaque becomes calcified and whole [[Enamel Organ#Crown|crown]] may become covered in brown chalky material. Calculus gives brittle dirty brown covering to tooth which may not affect [[Enamel Organ#Enamel|enamel]] at all but may produce mild gingivitis round edge and the gum may start to recede. This exposes more of crown, may reach level of [[Enamel Organ#Dentine|dentine]] and infection may enter the alveolus and loosen ligaments holding tooth in and ultimately the tooth will become loose and fall out.

'''Gingivitis''' - Reversible inflammation of the marginal gingival tissues that does not affect the [[Enamel Organ|periodontal ligament or the alveolar bone]].

'''Gingivitis''' - Reversible inflammation of the marginal gingival tissues that does not affect the [[Enamel Organ|periodontal ligament or the alveolar bone]].

'''Periodontitis''' - Inflammation and irreversible destruction of the tooth's supporting structures that includes the [[gingiva]], periodontal ligament, alveolar bone and root cementum. It usually occurs after years of plaque accumulation and gingivitis. The epithelial attachments of the tooth regress apically and there is absorption of the associated alveolar bone, resulting in permanent loss of tooth support.

'''Periodontitis''' - Inflammation and irreversible destruction of the tooth's supporting structures that includes the [[gingiva]], periodontal ligament, alveolar bone and root cementum. It usually occurs after years of plaque accumulation and gingivitis. The epithelial attachments of the tooth regress apically and there is absorption of the associated alveolar bone, resulting in permanent loss of tooth support.

'''Periodontal Pocket''' - this describes the area of tissue destruction left by periodontitis. It is an attachment loss due to destruction of the fibres and bone that support the tooth which results in a pathological deepening of the gingival sulcus.

'''Periodontal pocket''' - this describes the area of tissue destruction left by periodontitis. It is an attachment loss due to destruction of the fibres and bone that support the tooth which results in a pathological deepening of the gingival sulcus.

==Aetiology==

==Aetiology==

The microbiota in periodontal pockets is in a continual state of flux; periodontitis is a dynamic infection caused by a combination of bacterial vectors that change over time. As a result, the molecular events that trigger and sustain the inflammatory reactions constantly change. Many microbial products have little or no direct toxic effect on the host. However, they possess the potential to activate inflammatory reactions that cause the tissue damage. It is now well accepted that it is the host’s response to the plaque bacteria, rather than microbial virulence per se, that directly causes the tissue damage. In gingivitis, the plaque-induced inflammation is limited to the soft tissue of the gingiva. As periodontitis occurs, the inflammatory destruction of the coronal part of the periodontal ligament allows apical migration of the epithelial attachment and the formation of a pathological periodontal pocket (i.e. [[Dental Indices and Criteria#Periodontal Probing Depth (PPD)|periodontal probing depths]] around the tooth increase). If the inflammatory disease is permitted to progress, the crestal portion of the alveolar process begins to resorb. Alveolar bone destruction type and extent are [[Radiographic Interpretation of Periodontal Disease - Small Animal|diagnosed radiographically]].  

The microbiota in periodontal pockets is in a continual state of flux; periodontitis is a dynamic infection caused by a combination of bacterial vectors that change over time. As a result, the molecular events that trigger and sustain the inflammatory reactions constantly change. Many microbial products have little or no direct toxic effect on the host. However, they possess the potential to activate inflammatory reactions that cause the tissue damage. It is now well accepted that it is the host’s response to the plaque bacteria, rather than microbial virulence per se, that directly causes the tissue damage. In gingivitis, the plaque-induced inflammation is limited to the soft tissue of the gingiva. As periodontitis occurs, the inflammatory destruction of the coronal part of the periodontal ligament allows apical migration of the epithelial attachment and the formation of a pathological periodontal pocket (i.e. [[Dental Indices and Criteria#Periodontal Probing Depth (PPD)|periodontal probing depths]] around the tooth increase). If the inflammatory disease is permitted to progress, the crestal portion of the alveolar process begins to resorb. Alveolar bone destruction type and extent are [[Radiographic Interpretation of Periodontal Disease - Small Animal|diagnosed radiographically]].  

Disease progression is generally an episodic occurrence rather than a continuous process. Tissue destruction occurs as acute bursts of disease activity followed by relatively quiescent periods. The acute burst is clinically characterized by rapid deepening of the periodontal pocket as periodontal ligament fibres and alveolar bone are destroyed by inflammatory reactions. The quiescent phase is not associated with clinical or radiographic evidence of disease progression. However, complete healing does not occur during this quiescent phase, because subgingival plaque remains on the root surfaces and inflammation persists in the connective tissue. The inactive phase can last for extended periods. Other conditions, such as physical or psychological stress and malnutrition, may impair protective responses, such as the production of antioxidants and acute phase proteins, and can aggravate periodontitis, but do not actually cause destructive tissue inflammation.

Disease progression is generally an episodic occurrence rather than a continuous process. Tissue destruction occurs as acute bursts of disease activity followed by relatively quiescent periods. The acute burst is clinically characterized by rapid deepening of the periodontal pocket as periodontal ligament fibres and alveolar bone are destroyed by the inflammatory reactions. The quiescent phase is not associated with clinical or radiographic evidence of disease progression. However, complete healing does not occur during this quiescent phase, because subgingival plaque remains on the root surfaces and inflammation persists in the connective tissue. The inactive phase can last for extended periods. Other conditions, such as physical or psychological stress and malnutrition, may impair protective responses, such as the production of antioxidants and acute phase proteins, and can aggravate periodontitis, but do not actually cause destructive tissue inflammation.

A genetic predisposition to destructive inflammation of the periodontium may be important in some individuals.

A genetic predisposition to destructive inflammation of the periodontium may be important in some individuals.

== Signalment ==

== Signalment ==

Pure bred cats are particularly susceptible. Susceptible breeds include: Burmese, Persian, Siamese and Maine Coon. The disease affects the majority of cats over two years of age.  

Pure bred cats are particularly susceptible and include: Burmese, Persian, Siamese and Maine Coon. The disease affects majority of cats over two years of age.  

Certain breeds of dogs are thought to be susceptible to an aggressive form of the disease and these include: Greyhound and Maltese. Small breed dogs are more prone to tooth crowding, predisposing the animal to the initiation and rapid progression of the disease.

Certain breeds of dogs are thought to be susceptible to an aggressive form of the disease and include: Greyhound and Maltese. Small breed dogs are more prone to tooth crowding, predisposing the animal to the initiation and rapid progression of the disease.  

== Clinical Signs ==

== Clinical Signs ==

An [[Oral Examination - Introduction|oral examination]] should be performed. This is the most important part of the diagnostic procedure and should include inspection of extraoral structures (looking for swelling, atrophy or asymmetry), such as face, lips, muscles of mastication, temporomandibular joints, salivary glands, lymph nodes, maxillae and mandibles. Intraoral structures such as the dentition, gingiva, mucosa, tongue, tonsils and dental occlusion should also be thoroughly examined. On visual inspection of the intraoral structures, an animal with periodontitis may demonstrate oral mucosal ulceration, inflammed and bleeding gingiva, loss of normal gingival contour, purulent discharge from the periodontal pocket, gingival recession, loose teeth and presence of variable quantities of plaque and calculus on the tooth surface.  

An [[Oral Examination - Introduction|oral examination]] should be performed. This is the most important part of the diagnostic procedure and should include inspection of extraoral structures (looking for swelling, atrophy or asymmetry), such as face, lips, muscles of mastication, temporomandibular joints, salivary glands, lymph nodes, maxillae and mandibles. Intraoral structures such as the dentition, gingiva, mucosa, tongue, tonsils and dental occlusion should also be thoroughly examined. On visual inspection of the intraoral structures, an animal with periodontitis may demonstrate oral mucosal ulceration, inflammed and bleeding gingiva, loss of normal gingival contour, purulent discharge from the periodontal pocket, gingival recession, loose teeth and presence of variable quantities of plaque and calculus on the tooth surface.  

Periodontal disease is associated with loss of the attachment apparatus of the tooth. Clinically this is hard to detect and there is no correlation between the amount of calculus seen on the tooth and the degree of destruction. Loss of attachment usually involves the periodontal ligament, bone, root cementum and gingiva. Clinically, [[Dental Indices and Criteria#Tooth Mobility|mobile teeth]] may be evident and some teeth may have evidence of [[Dental Indices and Criteria#Gingival Recession|gingival recession]] and root exposure indicating that there is periodontal disease but for a full assessment, an examination has to be performed under [[Oral Examination Under General Anaesthesia|general anaesthesia]]. A [[Periodontal Probe|periodontal probe]] is used to assess the depth of the gingival sulcus and whether there is loss of bone or periodontal ligament. A [[Dental Indices and Criteria#Periodontal Probing Depth (PPD)|probing depth]] greater than 3mm in most dogs would be considered abnormal. This varies based on the tooth and the size of the dog. Any depth over 0.5mm in cats is considered abnormal. The periodontal probe is used to assess the degree of gingivitis, measure the pocket depth, check whether the tooth is mobile, whether there is bone loss between the roots, ([[Dental Indices and Criteria#Furcation Involvement|furcation exposure]]) and measure the amount of gingival recession. The whole circumference of the tooth needs to be evaluated.  

Periodontal disease is associated with loss of the attachment apparatus of the tooth. Clinically this is hard to detect and there is no correlation between the amount of calculus seen on the tooth and the degree of destruction. Loss of attachment usually involves the periodontal ligament, bone, root cementum and gingiva. Clinically, [[Dental Indices and Criteria#Tooth Mobility|mobile teeth]] may be evident and some teeth may have evidence of [[Dental Indices and Criteria#Gingival Recession|gingival recession]] and root exposure indicating that there is periodontal disease but for a full assessment, an examination has to be performed under [[Oral Examination Under General Anaesthesia|general anaesthesia]]. A [[Periodontal Probe|periodontal probe]] is used to assess the depth of the gingival sulcus and whether there is loss of bone or periodontal ligament. A [[Dental Indices and Criteria#Periodontal Probing Depth (PPD)|probing depth]] greater than 3mm in most dogs would be considered abnormal. This does vary based on the tooth and the size of the dog. Any depth over 0.5mm in cats would be considered abnormal. The periodontal probe is used to assess the degree of gingivitis, measure the pocket depth, check whether the tooth is mobile, whether there is bone loss between the roots ([[Dental Indices and Criteria#Furcation Involvement|furcation exposure]]) and measure the amount of gingival recession. The whole circumference of the tooth needs to be evaluated.  

There are a number of methods that grade the severity of periodontal disease. It must be remembered though that different teeth in the mouth may be affected by different severities of the disease and even around each tooth, the degree of attachment loss may vary. Grading is based on the extent of attachment loss as this is indicative of periodontal destruction.  

There are a number of methods that grade the severity of periodontal disease. It must be remembered though that different teeth in the mouth may be affected by different severities of the disease and even around each tooth, the degree of attachment loss may vary. Grading is based on the extent of attachment loss as this is indicative of periodontal destruction.  

== Treatment ==

== Treatment ==

Treatment of periodontitis is two stage – periodontal therapy performed under general anaesthesia, and the most important stage is then follow up home care following an oral hygiene program.  

Treatment of periodontitis is two stage – periodontal therapy performed under general anaesthesia, and the most important stage is then follow up home care following an oral hygiene program.  

===Gingivitis===

'''Gingivitis'''

 

 

====Summary for Treatment of Gingivitis:====

Treatment of gingivitis relies heavily on owner compliance. It is important to stress to the owner that the disease is reversible and treatment and control may prevent this disease from becoming peridontitis, which is a lot more severe.  

*Educating the owner to understand the disease process.

*Training and motivating the owner to perform daily home care.

*Instituting a daily home care regimen by the owner – ideally, toothbrushing with a pet toothpaste in conjunction with a dental hygiene product.

*Regular check-ups to ensure that the owner is following recommendations and to boost the owner’s motivation.

Professional periodontal therapy removes dental deposits above and below the gingival margin. It then rests with the owner to ensure that plaque does not reaccumulate. Meticulous supragingival plaque control, by means of daily toothbrushing and adjunctive antiseptics when indicated, will prevent migration of the plaque below the gingival margin. If the subgingival tooth surfaces are kept clean, the sulcular epithelium will reattach.

Educate the owner of the disease process and also educate them on good daily dental home care such as tooth brushing and diet.  

Perform a dental scale and polish and root surface debridement. Teeth with severe periodontitis will need to be extracted and periodontal surgery may be necessary.

*Instituting a daily toothbrushing regimen by the owner.

*Professional periodontal therapy – this includes supra- and subgingival scaling and polishing, rootplaning and extraction of unsalvageable teeth under general anaesthesia.

*Regular check-ups to ensure that the owner is following recommendations and to boost the owner’s motivation.

*Periodontal surgery may be indicated (if the owner has shown the ability to maintain adequate plaque control).

Educate the owner about the disease process and also educate them on good daily dental home care such as tooth brushing and diet. Regular examinations to assess the condition of the teeth are vital and the owner needs to be made aware of this.

Regular examinations to assess the condition of the teeth are vital and the owner needs to be made aware of this.

===Periodontal Pockets===

'''Periodontal pockets'''

With pocket depths below 5mm, dental scaling and polishing should be performed, and then subgingival curettage and the placement of an antibiotic gel in the pocket may help rejuvenate the periodontal tissues and reduce pocket depth.

With pocket depths below 5mm, dental scaling and polishing should be performed, and then subgingival curettage and the placement of an antibiotic gel in the pocket may help rejuvenate the periodontal tissues and reduce pocket depth.

[[Category:To Do - Dentistry questions]]

[[Category:To Do - Dentistry questions]]

[[Category:To Do - Dentistry preMars]] <!----GEMMA, after you have done this page, put it into "Category:LisaM reviewing" rather than the usual. Ta, B---->

[[Category:To Do - Dentistry preMars]] <!----GEMMA, after you have done this page, put it into "Category:LisaM reviewing" rather than the usual. Ta, B---->