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.

Pet Orthodontics

Just as one would seek to cure a painful skin condition, or treat a sore joint in their pet, one should also consider relieving pain brought on by orthodontic abnormalities. Poorly aligned teeth can lead to serious periodontal disease. In most breeds, teeth are arranged "shoulder to shoulder," in an arch. A self cleaning mechanism occurs in the arch to push food away from the teeth and gums. If the teeth are not aligned normally, food may be retained between the teeth causing inflammation and infection.
It is important to understand the head shape when determining normal bite relationships in various breeds. There are three basic head shapes for dogs. Those with long and narrow muzzles (Rough Collies, Borzoi, Doberman, Greyhound, Saluki); those with a short and wide muzzles (Bulldog, Pug, Pekingese, Boxer, Boston Terrier, Shih Tzu); and dogs with medium length and width muzzles (Labrador Retriever, German Shepherd Dog, most Spaniels, Terriers, and Hounds). Cats also have different head shapes which vary from the short muzzled Persian to the longer muzzled Siamese.

Normal scissors bite, notice the midline of upper and lower jaws are aligned Normally, the lower canine should intersect the upper lateral incisor and upper canine

The normal bite of dogs and cats with medium or long length and width muzzles is called a scissors bite. The upper incisors are located in front of the lower incisors when the mouth is closed, and there is a smooth curve from canine to canine without misplaced or rotated teeth. The lower canines should lie exactly between the upper lateral incisors and upper canines, yet touching neither. Premolar crown tips should point to a space between the crowns of the opposing premolars. In dogs that have a short, wide muzzle, a reverse scissors bite is considered normal where the lower incisors are in front of the upper incisors. The lower canines and premolars will also be shifted forward. While the reverse scissors bite is an acceptable breed standard, at times the upper incisors cause trauma and pain to lower jaw tissues.

Genetic or Not

Normal interdigitation of premolars

Occlusion is controlled by genetics, nutrition, environment, and by mechanical forces generated by the interlock of the upper and lower teeth. Some abnormal bites (malocclusions) have been proven to be genetically influenced, such as severe over or under bites, and wry bites. Other bite abnormalities are known to be acquired (non genetic). Acquired malocclusions can result from tug of war games played with towels or ropes which move teeth into abnormal position. Traumatic birthing can also responsible for some acquired abnormalities.

This is a genetic malocclusion because the premolars do not line up in a pinking shear arrangement

To help define whether the malocclusion is genetic in origin, interdigitation of the premolars is studied. In breeds that have medium and long muzzles, the premolars should meet in a saw-toothed fashion. For example, the tip of the lower third premolar should be positioned equally between the crowns of the upper third and fourth premolars. If the tip of one premolar points to the tip of another premolar, there may be a genetically induced malocclusion. This only holds true in those breeds that do not have shortened muzzles.
Some genetic bite problems do not show up in each litter because they are recessively passed on. The goal of selective breeding is to mate one animal to another that has superior occlusion.

Retained Deciduous Teeth

Retained upper canine tooth

Normally the deciduous tooth's root is resorbed, making room for an adult tooth. Should this fail, the adult tooth may deviate from it's normal position, producing malocclusion. The resulting double set of teeth overcrowds the dental arch, causing food to become trapped between the teeth, leading to early periodontal disease. A double set of roots may also prevent normal development of the socket, and erode periodontal support around the adult tooth, resulting in early tooth loss. A retained deciduous tooth should be extracted as soon as an adult tooth is noted in the same area as the baby tooth. If extraction is performed early, the abnormally positioned adult tooth usually moves to it's normal location.
A procedure performed by some breeders is to trim or cut deciduous teeth in hopes that they will be shed early preventing orthodontic problems. By cutting the tooth in half, pulp is exposed to oral bacteria causing infection, pain, and tooth loss. Unfortunately, the remaining infected root can interfere with the emerging adult tooth, which may not come in normally.

Dental Interlock

Jaws do not grow at equal rates. If deciduous teeth erupt during an accelerated growth phase of one jaw, an interlocking of both sets of primary teeth can maintain the abnormal bite relationship. Even genetically normal dogs can occasionally develop abnormal bites due to the interlock of primary teeth. If an under bite is noted before the permanent teeth erupt, treatment may be helpful. Removal of primary teeth from the shorter jaw that interfere with forward growth, if performed by ten weeks of age may allow the upper jaw to lengthen unimpeded. This procedure called interceptive orthodontics will correct about 50% of minor jaw length malocclusions, by the time permanent teeth erupt. Extraction does not stimulate jaw growth, it only removes a mechanical barrier to genetic control of the growth process.
Teeth that are crowded, rotated, or tilted at abnormal angles can result in:

	Early onset and increased severity of oral infection
	Damage to the soft tissues of the mouth, due to sharp teeth that penetrate the unprotected gum and mouth tissues. In addition, the lower canines can erode through the hard palate, causing food to enter the nasal cavity
	Excessive wear when abnormally aligned teeth grind against each other. Such abrasion frequently wears through enamel, causing a weakened tooth to fracture and expose the root canal system.
	Pain in joints of the jaw

Breeders, show judges, veterinarians, and others who wish to describe specific dental conditions in dogs and cats need to use proper orthodontic terms. Over bite, open bite, over jet, level bite, overshot, under bite, anterior cross bite, posterior cross bite, wry bite, and base narrow canines are orthodontic terms that are at times confusing.

Missing or Extra Teeth

Missing lower fourth premolar 8 upper baby incisor teeth in boxer puppy (normally should have only 6)

Dogs and cats may be born without the proper number of teeth. Extra (supernumerary) teeth can cause periodontal disease from over crowding. The American Kennel Club sets standards concerning minimum number of teeth accepted for each breed to be considered for show. Dental x-rays can be taken as early as ten weeks of age to evaluate if the correct number of teeth are present. X-rays are recommended as a part of the prepurchase examination in certain breeds. Missing teeth (hypodontia) usually occurs in the premolar area, but any tooth in the mouth may not erupt. Missing or extra teeth are considered genetic faults. Collies and Doberman Pinchers are most commonly affected. Sometimes the missing tooth is trapped below the gum line. A dental x-ray can be taken to determine if an unerupted tooth is present.

Misdirected Canine Syndrome

Rostrally deviated upper canine tooth treated by crown reduction or elastic to pull back tooth into normal occlusion

Misdirected canine syndrome is a bite abnormality, in which retention of the deciduous tooth tilts the erupting permanent canine tooth into abnormal location. The opposing canines may not have room to occlude properly, resulting in abnormal wear, periodontal disease, or early tooth loss.

Occlusion

The way which teeth align with each other is termed occlusion. Normal occlusion in most medium and long muzzled breeds consists of the upper (maxillary) incisors that just overlap the lower (mandibular) incisors (scissors bite). The lower canine should be located equidistant between the corner (lateral) incisor and the upper canine tooth. Premolar tips of the lower jaw should point between the spaces of the upper jaw teeth.

Malocclusion

Open bite - incisors do not meet

Malocclusion refers to an abnormal tooth alignment. Over bite (parrot mouth, over shot, class two, over jet, mandibular brachygnathism) occurs when the lower jaw is shorter than the upper. There may be a gap between the upper and lower incisors when the mouth is closed. The upper premolars are displaced at least twenty-five percent toward the front, compared to the lower premolars. An over bite malocclusion is never considered normal in any breed and is a genetic fault. The most commonly affected breeds are those with elongated muzzles (Collies, Shelties, Dachshunds, and Russian Wolfhounds).

Underbite, undershot prognathic skelatal malocclusion

An under bite (under shot, reverse scissors bite, prognathism, class 3) occurs when the lower teeth protrude in front of the upper jaw teeth. Some short muzzled breeds (Boxers, English Bull Dogs, Shih-Tzus, and Lhasa Apsos) normally have an under bite, but when it occurs in medium muzzled breeds it is abnormal. When the upper and lower incisor teeth meet each other edge to edge, the occlusion is considered an even or level bite. Constant contact between upper and lower incisors can cause uneven wear, periodontal disease, and early tooth loss. Level bite is considered normal in some breeds, although it is actually an expression of under bite.

Level Bite

Anterior Crossbite

Wry Bite

 

Base Narrow Canines

Anterior cross bite occurs when canine and premolar teeth on both sides of the mouth occlude normally but one or more of the lower incisors are positioned in front of the upper incisors. This condition can be caused by tug-of-war games, retained primary teeth, or impacted roots. Anterior cross bite is a common malocclusion. It is not considered a genetic or inherited defect. Posterior cross bite occurs when one or more of the premolar lower jaw teeth overlap the upper jaw teeth. This is a rare condition that occurs in the longer-nosed dog breeds. A wry mouth or wry bite occurs when one side of the jaw grows more than the other. Wry bites show as triangular defects in the incisor area. Some of the incisors will meet their opposing counterparts, while others will not. Wry bite is a severe inherited defect. Base canines occur when the lower canine teeth protrude inward often producing damage to the upper palate. This condition is either due to retained deciduous teeth, or an overly narrow mandible. Base narrow canines may be corrected through orthodontic devices that push the teeth into normal occlusion. An open bite occurs when some incisors are displaced vertically and do not touch. Often, the tongue will protrude. Rotated teeth, commonly affecting the upper third premolar, occurs mostly in short muzzled breeds. 

Inclined Plane

Selective breeding has created undersized mouths that cannot accommodate forty two teeth in normal alignment. The rotated tooth root closest to the palate is prone to periodontal disease. Strict tooth brushing may be helpful in saving a rotated tooth, but, frequently, the tooth cannot be saved.

Orthodontic Care

Many abnormal bites can be corrected. Orthodontic care should be performed by veterinarians familiar with tooth movement principles. Breeders at times use rubber bands which may move teeth, but compromise the gum tissue around teeth leading to periodontal disease, pain, and early tooth loss. Orthodontic care should be reserved to ease pet discomfort, by realigning teeth. Tooth movement is accomplished by employing brackets, acrylic retainers, springs, and elastics.

malocclusions ( bite is not )

Malocclusions are variations of the bite from the above described normal scissors bite.  Malocclusions are classified based on the dental relationships.
They are numbered one through three with a fourth group that do not fit the first three.  They are designated "Mal 1", "Mal 2" and "Mal 3".



Mal 1; note the upper first left and right incisors rest behind the lower
first and second incisor teeth.  This is called "anterior crossbite".




Class 1 (Mal 1) Notice the upper fourth premolar tooth is positioned
in an abnormal position inside the lower first molar tooth.  This
condition is referred to as "posterior crossbite".  This condition did
not require treatment as the pet had a comfortable and functional
occlusion (bite).Class 1 (Mal 1) malocclusions are occlusions where one or more teeth are not in the normal scissors alignment.  The above two photos are examples of Class 1 malocclusion (anterior and posterior crossbite).



Class 2 Malocclusion (Mal2). Note the upper jaw
is substantially longer than the lower jaw and deep
palatal defects have developed due to trauma.
This condition is sometimes called an "overbite".
The mandibles are short relative to the maxillas or
the maxillas are long relative to the mandibles. This
also has been called mandibular brachygnathism.



Mal 2: This dog's lower jaw was more
than 1 inch shorter than the upper jaws.
The lower canines caused deep puncture
holes behind the upper canine teeth.

         

Dental radiographs provide important         Post surgical radiograph demonstrates
information to help avoid problems.           the fragile jaw structure and confirms
                                                            complete extraction of the lower canines
                                                            and incisor teeth.



Class 3 Malocclusion (Mal 3).  Notice the lower jaw is relatively longer than
the upper jaw (viewd from under the jaw).  Malocclusions that involve jaw length discrepancy are generally believed to be inherited conditions however this author is not aware of research or documentation to prove this belief.
This malocclusion is sometimes referred to as an "underbite".  The mandibles may be too long or the maxillas are too short relative to the mandibles.  It is also called maxillary brachygnathism.

         

Mal 3; Pre-operation dental radiograph.      Dental radiograph after surgery confirms
                                                            no tooth roots or fractured bone remains
                                                            within the alveoli (tooth sockets).



Harry Potter "wry bite or class 4 malocclusion.

We routinely see patients with class two and three malocclusions that have painful bites.  We refer to this as "traumatic occlusion".  Our treatment goal is to provide a comfortable bite for these patients.  Treatment options are discussed in detail to allow for informed decision making during the initial consultation.

Malocclusions may be treated with orthodontic appliances or by oral surgery.



Eli had an uncomfortable malocclusion.
View the following series of photos.



Eli's normal comfortable right side.



Eli's left side is not comfortable.
Traumatic occlusion.



Eli has teeth striking teeth.



Eli's malocclusion close up view.




This malocclusion could be treated
with orthodontic appliances but due
to the travel distance to our office
the owner choose to treat by oral surgery.



Surgical view; flap and alveoplasty
exposed the canine and third upper
incisor for careful removal.



Surgical flap was closed.

This is another Sheltie with a similar malocclusion treated a little differently.    

Zorro had the lower left canine tooth    This side view demonstrates severe tipping.
tipped out toward the lip.  The
malocclusion was caused by a retained
primary (baby) left upper canine.  The
secondary canine positioned too far
forward.  This resulted in the tipping of
this canine tooth.

    

Extraction of the canine was elected!     This is the post operative X-ray.
This is the pre-operative X-ray.             Orthodontic treatment was also possible!