The complete dental cleaning procedure (Proceedings)
Performing a complete dental prophylaxis entails much more than removing plaque and calculus from the teeth. A thorough dental prophylaxis consists of educating the client, an oral examination, charting disease process, pathology and anomalies, radiographs, both supra and sub-gingival plaque and calculus removal, hand scaling, polishing, irrigation and home care instructions.
There are many ways in which to educate the client on the importance of dental health. Education should include an explanation of the disease progression starting with dental plaque formation advancing to calculus or tartar, gingivitis, eventual destruction of the periodontal tissues, and supportive and subsequent tooth loss.A picture is worth a thousand words. Visual aids such as posters in the treatment rooms showing the progression of oral disease and the impact on the internal organs can be used to gain the client's interest. Pictures of healthy mouths versus diseased mouths are another useful tool. The use of plastic models that have a healthy side and a diseased side is a hands-on way to show disease. These are all helpful in the educational element of dental prophylaxis.
Preventive Antibiotic Therapy
Questions are often asked about the use of prophylactic antibiotic therapy in patients who present for a dental prophylaxis. The main objective of preventive antibiotic therapy is to prevent treatment induced bacteremia. Bacteremia will typically clear in approximately 20 minutes. The use of preventive antibiotics should only be necessary in patients that are not able to cope with this treatment induced bacteremia. Geriatric or debilitated animals, patients with a pre-existing heart or system disease or immunocompromised patients should receive preventive antibiotic therapy.
Preventive antibiotic therapy will also aid in controlling wound infections. Therefore animals with gross infections (marked swelling, pus formation, fever, lymphadenopathy, and elevated WBC count) chronic stomatitis, multiple extractions, may also benefit from receiving antibiotics prior to treatment. Clinical judgment should be used in diagnosis of the infection and the use of antibiotic therapy.
The choice of antibiotic and protocol for delivery is controversial. The antibiotic chosen must be active against Gram-positive and Gram-negative aerobes and anaerobes. Just as important as the choice of antibiotic is the timing of delivery. The generally accepted protocol should have antibiotics administered within two hours of the surgery and not continued for more than four hours after the procedure. In addition, antibiotics must be delivered at a dose high enough to reach a tissue level four times higher than the MIC of the causative organisms.
In addition to preventive antibiotic therapy, antiseptics have a role in veterinary dental prophylaxis and oral surgery. Antiseptics help to reduce the number of bacteria in the oral cavity prior and during procedures. Chlorhexidine gluconate is the antiseptic of choice for use in animals. Rinsing the oral cavity with an antiseptic prior to procedures gives a cleaner environment to work in and can reduce bacteremia induced by dental procedures. It will also reduce the number of bacteria that are aerosolized by dental equipment such as ultrasonic scalers. Which will benefit the persons involved in the procedure. Bacteria may still be present in the operatory for up to 12 hours post treatment. Remember to always wear eye protection, masks and gloves.
An oral examination on a conscious patient is important but often limited to a visual inspection and digital palpation. The examination involves more than just the oral cavity. Palpation of the facial bones and zygomatic arch, temporomandibular joint, salivary glands and lymph nodes are also important. Dental occlusion should also be evaluated. This can be done by gently retracting the lips to look at the soft tissue, the bite and the buccal aspects of the teeth.
Once the animal is anesthetized, a thorough oral examination can be completed. All the structures of the oral cavity must be evaluated to include the oropharynx, lips and cheeks, mucous membranes, hard palate, floor of the mouth and tongue as well as the teeth. The periodontium (gingiva, periodontal ligament, cementum and alveolar bone) of each tooth needs to be evaluated. In animals with large amounts of calculus on the teeth, it may be necessary to remove these deposits to accurately access the periodontium. The use of a calculus removal forceps is a recommended method to remove supragingival calculus. Use care when using this instrument to ensure that the gingivia and tooth crown are not damaged.
When evaluating the periodontium a periodontal probe, a dental explorer and a dental mirror are used. The following indices should be evaluated for each tooth; gingivitis, periodontal probe depth, gingival recession, furacation involvement, mobility and periodontal attachment levels. Details of these indexes will be covered in other presentations.