For deep periodontal pockets (greater than about 5–6 mm following healing), or where the entire attached gingiva has been lost or the tooth is mobile, additional treatment is needed. The general principles are to 'uncover' the area of unattached root that is covered with gingival tissue so that subsequent home care can prevent build-up of plaque within the pocket, and to restore a cuff of gingiva around the tooth if gingiva has been lost.
As in every clinical situation in veterinary medicine, we must consider the owner, the animal and the affected tissue. In the case of periodontitis, there are 42 teeth, each with a different set of circumstances to be considered. Which tooth/teeth to work on? The answer is simple: Do the most good in the available anesthesia time. However, there may be a mismatch between what the client wants and what would be best medically for the animal. For example, in a typical aging toy breed dog, the owner may want to "save" the mobile incisor teeth while the lower first molar teeth, which the owner rarely sees and the show judge never examines, may be causing the cortical bone of the mandible to melt away. Another important consideration is follow-up care (plaque control at home) - will it be sufficient to make involved periodontal procedures worthwhile long-term?
The purposes of treatment of periodontal disease are to restore physiologic anatomy and function, and to obtain consistent plaque retardation on all unattached tooth surfaces so as to prevent further tissue inflammation, tissue loss and eventually tooth loss. Successful implementation requires correct recognition of cases - the patient and teeth must be examined and triaged. Domesticated dogs manage very well without any teeth, and may be healthier generally if they do not have to carry severely infected periodontal pockets around with them.
First assess the owner and patient. Is the patient healthy enough to consider anesthesia? Is compliance with home care instructions likely? If compliance with home care is not clear from a first discussion with the owner and if involved treatment appears to be indicated from a brief oral examination without anesthesia, have the owner try brushing the patient's teeth for a week or two before anesthetizing the patient - this will permit appropriate treatment to be more accurately assessed. What are the owner's expectations of the treatment?
The next step is to examine the mouth. Most patients will allow examination without anesthesia to permit a rough assessment of periodontal tissues. This initial examination has three main purposes: One is to assess that there is reason to anesthetize the patient. Second is to alert the owner to what may be indicated by way of treatment. Third is to allow the veterinarian to assess how much time and equipment/expertise may be needed for treatment. Booking patients in for "routine dentals" without pre-examination is a major cause of inadequate or botched periodontal treatment - if the procedure has to be completed in 30–40 minutes from induction to recovery, there is simply no possibility for well planned and conducted involved periodontal treatment.
Look for buccal or lingual ulceration. This most likely indicates a local or systemic immunopathy. These ulcerations are painful, making home care less tolerable. The ulcerations will recur unless plaque control is excellent. A combination of scaling and systemic antibiotic therapy may permit healing to the point where brushing will be tolerated by the dog. A practical alternative is to maintain the animal on low dose metronidazole therapy following scaling.
Teeth that are very mobile should be extracted. In an animal where long-term compliance with brushing is not expected to be good, molar and pre-molar teeth that have deep pockets (> 6 mm), furcation involvement and are somewhat mobile should be extracted.
If the tooth is not mobile but has a deep pocket and there is at least 2 mm of gingival tissue around the tooth, gingival surgery is indicated. Depending on the location of the bottom of the pocket relative to the mucogingival junction, gingivoplasty or gingival flap repositioning is appropriate.
If the gingival cuff around the tooth is not intact, restoration of the cuff by rotation flap (or graft) is required.
Consider the bone support separately. Stability of a somewhat mobile tooth can be achieved; however, successful restoration of alveolar bone height is much more difficult to achieve than is rearrangement of gingiva. Simply filling a space with an osteo-conductive material will not restore bone height - involved procedures such as guided tissue regeneration are required. Osteoplasty - smoothing out rough edges of crestal bone - is often a useful part of gingival surgery; it should be performed conservatively.
No involved periodontal treatment procedure is worth undertaking if there will not be a good faith effort put into plaque and calculus retardation long-term. Oral hygiene home care procedures are described in another session. Periodic professional reexamination is indicated life-long.