Twelve Steps of the Professional Teeth-Cleaning Visit

Qualified veterinary dental technician ultrasonically cleaning dog's teeth

No other procedure performed on small animals does more to help patients than periodic teeth cleaning and after care. The dental visit for cleaning must be performed in a methodical manner. All twelve steps are important and interlinked. When one step is not performed, long term patient benefit suffers.
1) Oral examination on the unanesthetized animal. Begin with the face. Check for swellings and painful areas. Look at the eyes, are they the same size? Is there swelling under one eye? Open and close the mouth to check for pain or crepitus in the temporomandibular joints. Examine the teeth and gingiva for pathology. Examine each tooth rather than the mouth globally. If there is even a small amount of tartar touching the gingiva this is disease and needs immediate removal.

Severe Bone Loss, Rear Root Mandibular 1st Molar Tooth Due to Periodontal Disease

2) Oral examination under general anesthesia. We examine individual teeth for mobility, fractures, malocclusion, and periodontal disease (probe for pocket depths after calculus is removed).
3) Supragingival (above the gumline) plaque and tartar removal using calculus removing forceps, hand instruments, and power scaling equipment.
Supragingival deposits are removed from buccal, lingual, and interproximal surfaces of the teeth.

Ultrasonic Cleaning

When used properly, the ultrasonic scaler removes plaque and tartar from the teeth. Heat generated by an ultrasonic scaler can cause severe damage to the tooth and periodontal support. Ultrasonic units must be used on crowns and exposed root surfaces only.
The ability to remove tartar and potential damage by an ultrasonic scaler depends on power settings, time of exposure, amount of pressure applied, and sharpness of the tip.
Regardless of the type of power scaler, use a feather light touch, keeping the water-cooled tip moving in constant sweeping motion to avoid thermal injury. Use the side of the tip not the point to remove tartar.
4) Subgingival (below the gumline) scaling, root planing, curettage. Curettes are used to remove subgingival deposits. If indicated, the three parts of this step include:

Cleaning calculus from below the gumline

Root scaling: removal of plaque and calculus from the root surface. The goal is to disorganize and lavage bacteria living subgingivally. This creates a healthier environment for healing and reattachment. Curettes, or slim ultrasonic tips are used.
Root planing: the smoothing of roughened root surfaces by debriding diseased cementum and removing embedded calculus produces a clean smooth surface free of endotoxin. Root planing is performed with a curette used in overlapping strokes. Crosshatch planing creates a smooth surface while maintaining root anatomy.
Removal of all exposed cementum may not be helpful to periodontal health. Cementum contains chemicals that enhance re-attachment of periodontal ligament. Bacteria do not penetrate into the cementum. Stripping cementum by root planning removes potential reattachment resources.
Subgingival Curettage is removal of the gingival pocket’s diseased soft tissue inner surface. The rationale for the procedure is to convert chronically inflamed ulcerated lesions in the soft tissue wall of a periodontal pocket, into a clean surgical wound. This promotes healing and readaptation of tissue to the tooth surface.
Subgingival curettage is done without direct visualization of the root surface. It is performed with a curette held in the reverse position, placing the blade against the soft tissue for epithelial removal. The curette tip is used to remove remains of the epithelial junction. This allows for optimal reattachment and reduction of the periodontal pocket.

Polishing Teeth

5) Polishing. Regardless of how careful we are during the scaling/curettage phase of teeth cleaning, minor defects of the tooth surface occur. Polishing smoothes out the defects and removes plaque missed during previous steps. Pumice or polishing paste is used on a polishing cup for the procedure.
When polishing, use firm pressure until the cup edge flares. Overheating is prevented by relieving pressure slightly as the cup moves over each tooth.
6) Irrigation. With irrigation, diseased tissue and plaque are removed from the pocket or sulcus. Water spray and/or a 0.1-0.2% Chlorhexidine gluconate solution are commonly used. Blunted 23G needles are available for manual irrigation. Power irrigation is supplied on many delivery systems.

Fluoride used to decrease discomfort and harden enamel

7) Fluoride is placed on dry teeth and allowed to remain undisturbed for at least four minutes.
  

Intraoral x-rays taken to evaluate degree of periodontal disease

8) Post cleaning examination and diagnostics. After cleaning, teeth are examined individually via periodontal probing, compressed air application to the gingiva to examine for retained calculus, Shepherd’s hook exploration, disclosing solution, and radiology (if indicated).
9) Charting. Record disease present before therapy. Charting must include missing , loose, fractured , and discolored teeth, as well as feline oral resorptive lesions, periodontal pocket depths, gingival recession, and other significant lesions.

Certified veterinary technician examining each tooth after cleaning

10) Therapy to treat lesions noted above.
After treatment records must include:

	Dental care performed
	Follow up recommendations
	Antibiotics dispensed
	When the next radiographs are recommended
	When the next dental exam recommended
	Home care instructions

11) Home care instructions. The pet owner is an integral part of our dental team. The dental visit is not complete until discussion is held on maintaining and improving oral health. Home care is the single most important procedure the owner can do to maintain oral health. If performed regularly, daily brushing will dramatically increase the interval between teeth cleaning appointments.
Plaque is constantly being made and deposited in the mouth. Humans have a buildup of plaque in the morning, that makes our breath smell bad. Proper home care can keep plaque buildup under control. People brush their teeth several times daily to remove plaque -- why not our pets?
The goal of dental home care is to remove plaque from tooth surfaces and gingival sulci before it mineralizes into calculus, a process that occurs within days of a teeth cleaning. Success depends on the owner's ability to daily brush the teeth, as well as the dog or cat’s acceptance of the process. True oral cleanliness can only be achieved through the mechanical action of toothbrush bristles above and below the gingiva.
Home care is best started at a young age before the adult teeth erupt. The perfect time to introduce dental home care is at the first puppy or kitten visit. The client-animal bond as well as the client-veterinary bond is enhanced when daily brushing is performed following instructions given at the animal hospital.
Our staff members are knowledgeable about tooth brushing techniques. Each teeth cleaning visit concludes with review of tooth brushing techniques. Nothing beats "hands on" instruction.
Clients often ask, "doesn’t hard food keep teeth clean?" Some believe when their dog or cat chews on hard food or biscuits, mineral deposits are broken down and the teeth stay clean. This is not true. True, animals on soft diets accumulate plaque more readily than those on dry foods, but the only way to keep teeth clean above and below the gum line is by daily brushing.
Brushing instructions must be more than telling you it would be a good idea for you to brush your pet’s teeth, then selling a toothbrush. We will show you how to properly use the tooth brush and paste, and observe you perform the procedure.
How to get the pet to accept tooth brushing. Proper technique involves applying the bristles at a 45 degree angle to the gingiva. Use small circular motions around the outside of the teeth, being sure to get the bristles under the gumline. It is not as important to brush the inside of the teeth, as dogs and cats do not have the buildup of tartar on the palatal or lingual sides of their teeth as people do.
The most important area to keep clean is the sulcus under the free gingival margin. It is plaque and tartar underneath the gumline, that is removed by daily home care. Adding products such as Oxyfresh to the drinking water or rubbing the teeth with dentifrice impregnated pads may help in home care, but understand that periodontal disease begins in the gingival sulcus. Home care is most effective when the dentifrice is brushed below the gumline.
Start with a healthy comfortable mouth. Untreated problems can cause pain, and a non-compliant patient. Dental pathology must be cared for first.

Finger Toothbrushes

Choose a proper toothbrush and toothpaste. Toothbrushes have bristles that reach under the gumline and clean the space that surrounds each tooth. Plaque accumulates in this space. Devices such as gauze pads, sponge swabs, or cotton swabs remove plaque above the gumline, but cannot adequately clean this space below the gumline.
The size of toothbrush chosen is important. There are specially made brushes to fit into the large mouths of long muzzled dogs as well as small brushes for cats.
Each dog or cat must have his or her own brush. Sharing brushes may result in cross contamination of bacteria from one pet to another.
Introduce the toothpaste and tooth brush. When you sense the pet is anxious to the brushing procedure, give reassurance by talking and try again. Expect progress not perfection. Reward progress immediately with a treat, or a play period after each cleaning session
Take time. Each pet is different. Some will be trained in one week while others will take a month or more. The payoff is well worth the learning curve.
The degree and type of home care products dispensed depends on:

	Type of dental periodontal pathology
	Stage one and two-daily brushing with dentifrice
	Stage three where periodontal disease has been established: Daily brushing with fluoride containing toothpaste, or Dentivet toothpaste plus twice weekly application of stannous fluoride gel Pulse therapy antibiotics
	Stage four-advanced periodontal disease homecare includes: zinc ascorbate spray 3-4 times daily HexaRisne (Vibrac) twice daily Or CHX-Guard (VRx Products)-combination of Chlorhexidine gluconate and zinc Pulse therapy antibiotics

At the end of two weeks, Stannous fluoride gel twice weekly can be substituted for the chlorhexidine spray.
12) Follow-up progress visits are as essential as any of the preceding steps. The time between oral exams is based on the degree of disease and the client’s ability to provide home care. Some severe periodontal cases are rechecked monthly, while pets that have been treated for grade one gingivitis, and their teeth brushed once or twice daily, can be rechecked every six months. The reminder interval for recheck can be linked to degree of periodontal disease in the computer.