**5. Diagnosis**

132 A Bird's-Eye View of Veterinary Medicine

prevention of periodontal disease, taking into account the least harmful nature of bacteria in the onset of the disease and higher prevalence of supragingival plaque, it is recommended that the use of topical oral solutions such as mouthwashes is sufficient to combat bacteria in question with great advantage because of its easy application in most patients (Ciancio &

Among the chemicals, that can be used this way to reduce the accumulation of plaque on dental surfaces, the bisguanids, quaternary ammonia and phenols have been widely evaluated. Chlorhexidine appears as a substance that has the greatest efficacy in the inhibition of oral plaque (Hennet, 2002) and has good antiseptic activity against all oral pathogens, more directly on the bacterial plaque organisms (Harvey & Emily, 1993). Its main concentration is the commercial use of alcoholic solution at 0.12% and it is also found

Despite the above indications for the use of chlorhexidine in the fight against dental plaque, it presents a series of unpleasant effects when used for prolonged therapy, such as loss of taste by the patient, pigmentation of the enamel, burning and even ulceration of the buccal mucosa (Zanini et al., 1995). These effects justify the use of this material only for few days (Gioso, 2007), which makes its application not recommended in the prevention of periodontal disease, which requires a prolonged use of the antimicrobial agent chosen for

The natural sweetener xylitol has been used in human patients in chewing gum, mouthwashes and toothpastes in order to reduce plaque. There is also one xylitol based product in the veterinary market today, which when added to the animal drinking water has a lowering effect on oral bacterial plaque formation (Dunayer & Gwaltney-Brant, 2006). Recently, the ozonised sunflower oil was tested, with positive results on microbial reduction in human patients with periodontal disease (Fiorini et al., 2006) and copaiba oil was applied topically on dogs and the results were equal to those obtained with chlorhexidine on the oral microbial population (Pieri, 2010). Additionally, some in vitro tests were performed to analyse the antimicrobial activity of Copaiba oil on plaque-forming bacteria (Simões, 2004; Pieri, 2010; Valdevite et al., 2007) and the evaluation of the inhibition of *Streptococcus* sp. adherence in glass capillaries caused by the same phytotherapic (Pieri, 2010), obtaining in both cases positive results. A actual work has been conduced to evaluate the copaiba oil as antimicrobial against bacterial isolates from initial dental plaque of dogs, aiming identify a potential drug to prevent the plaque formation and consequently the periodontal disease

Many researchers continue their analysis looking for natural drugs as propolis (Swerts et al., 2005), *Camellia sinensis* (Chang et al., 2009), *Mimosa tenuiflora* (Macedo-Costa, 2009), *Vitis amurensis* (Yim et al., 2010), *Rhinacanthus nasutus* (Puttarak et al., 2010), *Murraya koenigii*, *Allium sativum* and *Melaleuca alternifolia* (Prabhakar *et al., 2009)* to its use in the prevention of periodontal disease by inhibiting plaque formation.It important that this drug combine properties such as antimicrobial activity that does not induce bacterial resistance, and inhibition of microbial adherence on tooth surfaces that suggest a great potential for use in therapies in the oral cavity and as an aid in oral hygiene (Sudo et al., 1986; Corner et al., 1988; Pieri, 2010). For the use in the treatment of domestic animals it is suggested the inclusion of this antimicrobial and non-adherent agent in formulations containing the base

flavours of chicken, beef, fish, etc. (De Marco & Gioso, 1997).

in alcohol-free solutions and in gel form (Robinson, 1995).

this purpose (Lascala & Moussalli, 1995).

Niezengard, 1997).

(personal data).

The diagnosis of periodontal disease is based on history, clinical examination and radiological evaluation. Any changes in apprehension and chewing of food, as well as in general conditions and in the behaviour of animals, can be associated with oral disorders. Certain physical and behavioral changes are highly suggestive of dental disorders, including abnormal ways of eating and drinking, acute reactions to the ingestion of cold water, selective appetite (preference for soft foods), anorexia and weight loss, salivation, bleeding, epitaxy, digging of the ground, behavior of rubbing their feet on the face, shaking of the head, oronasal fistulas, abnormal aggressive behavior (because of pain) and distress and anguish (Emily & Penman, 1994; Pachaly, 2006; Gorrel, 2004). When it comes to periodontal disease, the main complaint of the owner will always be halitosis (Emily & Penman, 1994; Gorrel, 2004; Gioso, 2007) due to tissue decay and bacterial fermentation in the sulcus or periodontal pocket (Gioso, 2007).

Like any other clinical examination, the examination in dentistry should be preceded by thorough history and general physical examination. At the end, the oral cavity should be examined. It is necessary to do a complete oral examination to assess the presence of periodontal disease and other diseases, such as fractures or dental malocclusions. The intraand extraoral structures should be assessed, including bone surfaces, the jaw muscles, salivary glands and regional cervical lymph nodes (Gorrel., 2004). Ideally, the complete periodontal examination should be performed in anaesthetised dogs (Harvey, 1992; Gorrel, 2004; Gioso, 2007). The evaluation of the tooth must be made with an explorer and periodontal probe (Gioso, 2007). The examination must be careful; incorrect handling of the probe may damage the soft tissues and lead to misdiagnosis of periodontal lesions (Gorrel, 2004). The changes observed should be recorded in an appropriate medical record and serve as the basis for the therapeutic treatment (Pachaly, 2006).

The periodontal examination includes the evaluation of teeth mobility, of injuries or furcation exposure, gingival retracting or hyperplasia, the evaluation of the depth, the presence of dental plaque, of gingivitis and dental calculus The furcation is the area between the roots of teeth that have more than one root. This area is usually filled with alveolar bone. During exploration, a depression can be felt while passing the extremity of a probe perpendicular to the tooth crown and below the gingival margin. In the presence of periodontitis, the furcation bone can be resorbed and probe inserted between the roots. Changes in the furcation are classified on a scale ranging from 0 to 3, where in grade 3 lesions the probe passes freely through the furcation, from the vestibular part to the lingual/palatal tooth (Gorrel, 2004).

The gingival sulcus is the space between the free gingiva and the tooth crown. In dogs, the depth of the gingival sulcus should be less than 3mm, and in giant breed dogs less than 4 mm (Gioso, 2007). When periodontitis is established, the junctional epithelium, the region of the gingival tissue inserted to the tooth surface, migrates apically along the root. If the apical migration is not accompanied by a receding gingiva then the periodontal pocket is formed, which has a depth greater than 3mm (Gorrel, 2004). Values above 3 mm mean loss of clinical attachment of the junctional epithelium with bone destruction (periodontitis) and periodontal pocket formation (Gioso, 2007)

The periodontal probe is essential in the examination and diagnosis of periodontal disease. This thin probe has a tip calibrated in millimetres, measuring the depth of the gingival

Periodontal Disease in Dogs 135

two-dimensional representation of three-dimensional structures. Sometimes, the radiographs do not show adequately the severity of the disease. Early lesions of bone destruction are sometimes not observed radiographically. Buccal and lingual alveolar bones are particularly difficult to assess because of the overlap. In addition to the radiological findings, the clinician must rely on clinical examination, including sulcular depths, tooth mobility, and gingival appearance, in order to decide on the diagnosis and treatment plan

The earliest radiographic sign of periodontitis is loss of definition of the bone ridge. In healthy animals, the bony ridge appears as a radiopaque line, which follows one or two millimetres in the apical direction, in parallel to an imaginary line drawn between the cementoenamel junction of two adjacent teeth (Harvey, 1992). This loss of definition of the bone ridge is always accompanied by progressive demineralisation of the lamina dura (Harvey & Emily, 1993). Other radiographic signs of periodontal disease include rounding of the alveolar margin, the discontinuity of the lamina dura, widening of the periodontal

In some cases, pathological fractures of the jaw are seen as a consequence of severe bone loss. This situation occurs especially in small breed dogs, typically in the inferior first molar,

Once the diagnosis is established, treatment plan should be developed that will range from just dental curettage and polishing to extraction. In some situations the extraction of the involved tooth is the best treatment option, especially if the loss of adhesion and mobility is very pronounced. However, for moderate disease cases there are a variety of other

Harvey and Emily (1993) described that the goal of periodontal treatment is to control microorganisms, restore normal anatomy and physiology and avoid new adhesion of bacterial plaque on tooth surfaces. Furthermore, periodontal pockets should be eliminated and re-adhesion of tissue to the tooth should be promoted, aiming, wherever possible, to do

The periodontal soft tissues quickly re-adhere to the cementum after the debridement, which removes the dead space of the pocket. However, this union could be weaker than the original depending on the type of tissue that repopulates the root surface; gingival epithelium, gingival connective tissue, alveolar bone and periodontal ligament; the latter being more desirable. When replacement by the alveolar bone occurs, the result is root resorption or ankylosis. Epithelium and gingival connective tissue are not desirable because they are extremely weak. Grafts or barrier materials can be used to delay or exclude the gingival tissue growth, favouring the growth of periodontal ligament growth (Wiggs &

According to Gioso (2007), treatment is based on the elimination of plaque or calculus, normal gingival depth restoration and monitoring through a preventive program. General anaesthesia is essential to perform the scraping and it is a procedure that can last around 2 to 3 hours in more advanced cases. The main treatment options for periodontal curettage are

space and the gradual disappearance of the alveolar bone (Gorrel, 2004).

this by destroying the minimum of healthy tissue and keeping the gingiva.

whose roots reach the ventral cortex of the lower jaw (Gorrel, 2004).

treatment strategies (Wiggs & Lobprise, 1997).

(Bellows, 2001).

**6. Treatment** 

Lobprise, 1997).

sulcus when it is inserted between the gingiva and the tooth (Grove, 1998). The probe depth is defined as the distance between the coronal margin of the free gingiva and apical junctional epithelium (Gorrel, 2004). It is measured by positioning the tip of the periodontal probe parallel to the long axis of the tooth (or following the contour of the crown), and gently inserting between the teeth and free gingiva until the bottom of the sulcus is felt. In cases of gingival recession, periodontal destruction usually does not cause the formation of periodontal pockets. Gingival recession is measured in millimetres from the cementoenamel junction, where the gingival attachment should be normally at the gingival margin. The most profound measure for each tooth must be registered in the dental chart. Normally the junctional epithelium is located near the cementoenamel junction. In cases of gingival hyperplasia, in other words, in the presence of excessive amounts of soft tissues, the pseudopocket formed is measured with the probe, defined as the distance between the junctional epithelium and gingival margin. Since the areas deeper than 5 mm are difficult to clean mechanically, surgery might be needed to remove the deep pockets and pseudopockets, depending on the care undertaken by the owner (Gorrel, 2004).

The accumulation of dental deposits (plaque and calculus) and the severity of gingivitis can be quantified by standardised indices that correspond to the numerical expression of the presence or absence of disease severity. These indexes are extremely useful when there is a need for assessment of periodontal disease. The accumulation of plaque and calculus can be quantified in terms of coverage or thickness for all teeth (Gorrel, 2004).

The plaque is not always visible to the dental inspection, therefore solutions that highlight the plaque may be used (Gorrel, 2004; Gioso, 2007). The calculus is evident, presenting as a hard mass on the tooth surface, intra-or extra-sulcular, yellowish, brownish, sometimes greenish, which is not removed by scraping or brushing with gauze. The calculus most frequently occurs in fourth premolar and first superior molar teeth, as close to them are the openings of the parotid ducts and zygomatic glands, however, over time, almost all teeth can be affected (Gioso, 2007).

Bleeding during the survey, which indicates an inflammatory process in the connective tissues within the junctional epithelium, is a particularly useful method for evaluating an active gingivitis (Grove, 1998). Dogs rarely show signs of pain due to periodontal disease, even when there is loss of many teeth or exposed root dentine, which can cause sensitivity. There may be ulcers on the buccal mucosa (cheek) or on the tongue, because of the direct contact with areas of severe periodontal disease (Gioso, 2007). However, to form a definitive diagnosis, loss of tooth support must be present (Grove, 1998). The full-mouth radiographic examination is mandatory for patients with periodontal disease to get information from bone and periodontal structures (Gorrel, 2004). The results obtained by clinical and radiographic examinations are complementary and the diagnosis requires the completion of both (Harvey & Emily, 1993). Although radiographs provide essential data for determining the state of periodontal disease, this diagnostic test has low sensitivity to assess the progression of periodontitis. This is due to the inability to accurately repeat the positions, exposure and development time. Thus, any comparison between two different radiographs of the same animal becomes limited (Gorrel, 2004).

Radiographs are evaluated for changes in alveolar bone, interdental bone height, presence of lamina dura, trabecular pattern, periodontal ligament and severity of bone loss. X-rays show

sulcus when it is inserted between the gingiva and the tooth (Grove, 1998). The probe depth is defined as the distance between the coronal margin of the free gingiva and apical junctional epithelium (Gorrel, 2004). It is measured by positioning the tip of the periodontal probe parallel to the long axis of the tooth (or following the contour of the crown), and gently inserting between the teeth and free gingiva until the bottom of the sulcus is felt. In cases of gingival recession, periodontal destruction usually does not cause the formation of periodontal pockets. Gingival recession is measured in millimetres from the cementoenamel junction, where the gingival attachment should be normally at the gingival margin. The most profound measure for each tooth must be registered in the dental chart. Normally the junctional epithelium is located near the cementoenamel junction. In cases of gingival hyperplasia, in other words, in the presence of excessive amounts of soft tissues, the pseudopocket formed is measured with the probe, defined as the distance between the junctional epithelium and gingival margin. Since the areas deeper than 5 mm are difficult to clean mechanically, surgery might be needed to remove the deep pockets and

pseudopockets, depending on the care undertaken by the owner (Gorrel, 2004).

quantified in terms of coverage or thickness for all teeth (Gorrel, 2004).

can be affected (Gioso, 2007).

of the same animal becomes limited (Gorrel, 2004).

The accumulation of dental deposits (plaque and calculus) and the severity of gingivitis can be quantified by standardised indices that correspond to the numerical expression of the presence or absence of disease severity. These indexes are extremely useful when there is a need for assessment of periodontal disease. The accumulation of plaque and calculus can be

The plaque is not always visible to the dental inspection, therefore solutions that highlight the plaque may be used (Gorrel, 2004; Gioso, 2007). The calculus is evident, presenting as a hard mass on the tooth surface, intra-or extra-sulcular, yellowish, brownish, sometimes greenish, which is not removed by scraping or brushing with gauze. The calculus most frequently occurs in fourth premolar and first superior molar teeth, as close to them are the openings of the parotid ducts and zygomatic glands, however, over time, almost all teeth

Bleeding during the survey, which indicates an inflammatory process in the connective tissues within the junctional epithelium, is a particularly useful method for evaluating an active gingivitis (Grove, 1998). Dogs rarely show signs of pain due to periodontal disease, even when there is loss of many teeth or exposed root dentine, which can cause sensitivity. There may be ulcers on the buccal mucosa (cheek) or on the tongue, because of the direct contact with areas of severe periodontal disease (Gioso, 2007). However, to form a definitive diagnosis, loss of tooth support must be present (Grove, 1998). The full-mouth radiographic examination is mandatory for patients with periodontal disease to get information from bone and periodontal structures (Gorrel, 2004). The results obtained by clinical and radiographic examinations are complementary and the diagnosis requires the completion of both (Harvey & Emily, 1993). Although radiographs provide essential data for determining the state of periodontal disease, this diagnostic test has low sensitivity to assess the progression of periodontitis. This is due to the inability to accurately repeat the positions, exposure and development time. Thus, any comparison between two different radiographs

Radiographs are evaluated for changes in alveolar bone, interdental bone height, presence of lamina dura, trabecular pattern, periodontal ligament and severity of bone loss. X-rays show two-dimensional representation of three-dimensional structures. Sometimes, the radiographs do not show adequately the severity of the disease. Early lesions of bone destruction are sometimes not observed radiographically. Buccal and lingual alveolar bones are particularly difficult to assess because of the overlap. In addition to the radiological findings, the clinician must rely on clinical examination, including sulcular depths, tooth mobility, and gingival appearance, in order to decide on the diagnosis and treatment plan (Bellows, 2001).

The earliest radiographic sign of periodontitis is loss of definition of the bone ridge. In healthy animals, the bony ridge appears as a radiopaque line, which follows one or two millimetres in the apical direction, in parallel to an imaginary line drawn between the cementoenamel junction of two adjacent teeth (Harvey, 1992). This loss of definition of the bone ridge is always accompanied by progressive demineralisation of the lamina dura (Harvey & Emily, 1993). Other radiographic signs of periodontal disease include rounding of the alveolar margin, the discontinuity of the lamina dura, widening of the periodontal space and the gradual disappearance of the alveolar bone (Gorrel, 2004).

In some cases, pathological fractures of the jaw are seen as a consequence of severe bone loss. This situation occurs especially in small breed dogs, typically in the inferior first molar, whose roots reach the ventral cortex of the lower jaw (Gorrel, 2004).

Once the diagnosis is established, treatment plan should be developed that will range from just dental curettage and polishing to extraction. In some situations the extraction of the involved tooth is the best treatment option, especially if the loss of adhesion and mobility is very pronounced. However, for moderate disease cases there are a variety of other treatment strategies (Wiggs & Lobprise, 1997).
