And welcome. Thanks everybody, for being here, virtually or later. So I'm just gonna go through this is just a little brief agenda of the overview of what we're gonna do.
I'm gonna start. With a review of periodontal disease, some oral anatomy, just to make sure I have no idea what everybody's background is. We're just gonna start with kind of a review of everything.
I'm, I'm happy to take questions. No question is too small. I, I don't have a problem with that.
I know that we're not really taught this very well in veterinary school, at least here in the US, so I frequently will go through this, over and over and over again, as many times as it takes. Then we'll move into just kind of a review of what kinds of therapies are available and some of the Adjunctive products we use. And then I'm gonna introduce you to Pervive.
It's a hyaluronic acid product and I'm really excited about this. So, here we go. Let's see here.
So, like I said, we're gonna start with just some, some basic anatomy. And you can see we've got this nice little cartoon on the left here. I kind of, I'm gonna kind of go through, this is how I do this with clients every day, over and over.
What you can see of a tooth is called the crown. The crown is covered in enamel. The enamel is the hardest substance in the body, but it's almost quite literally a rock.
Once it's gone, it's gone. It cannot be regrown or regenerated. And dogs get very little enamel compared to humans.
They have less than a mil millimetre of enamel on their teeth. And this is because they want. They don't live 60 or 70 years the way we do, unfortunately, hopefully longer.
And they don't grind. And chew their food the same way we do. Their teeth aren't made the same way.
I mean, the anatomy is the same, but the, the function is not exactly the same as it is in people. So they just don't get very much. In the middle of all of our teeth, you can see this, this, red.
This is the pulp. The pulp chamber, contains the pulp. The pulp is made up of blood vessels and nerves, and they enter and exit the teeth through the apical foramen and down at the, the tip of the tooth root.
Between the pulp and the outside of the tooth is another substance called dentin. Dentin is actually what gives our teeth strength and structure. We are born with a little dentin and a lot of pulp.
And as we age, and the dentin gets thicker, the pulp will get thinner. This is important when we're trying to, evaluate teeth radiographically. This can become important.
When teeth erupt through the gums, there is, an attachment of the gingival gingival tissue all the way around, the circumference of that tooth. And, you know, this is important for protecting the deeper structures of the teeth and jaws. There is a little space between the gingival tissue and the tooth itself.
And this is called a gingival sulcus. This is where we get popcorn stuck. I'm a big popcorn eater, much to my dentist's chagrin.
It is, periodontist's job security for sure. But there is this little bit of free gingiva. The enamel is too slippery.
It attaches to the root surface itself. The gingival sulcus in people and in dogs should never be more than about 3 millimetres, OK? In cats, it's, it's even tighter.
It's more like a.5 millimetre is all we really consider to be normal. When you go to the dentist and they take their little probe and they probe around your teeth, and they tell you, you know, good job, no bleeding, and, you know, they, you wanna only hear ones and twos.
You don't wanna hear fours, fives. That means that this attachment of your gingival tissue has broken down. All right.
A photograph and a radiograph of normal, normal tissue. These are, these are hard to find. This is probably a pretty, a pretty young dog, so, you know, no, no sign of, of any pathology in this one.
OK. So, what causes periodontal disease? Our enemy is actually plaque.
Plaque is the culprit. It is what causes periodontal disease and gingivitis. What is plaque?
Plaque is a biofilm of bacteria, glycoproteins, polysaccharides, and other things in our saliva. Something on the order of 300 million bacteria per gramme, and over 400 different types of bacteria in dog plaque. Many are to most of these are, are, many of these are totally, they're unidentified.
We used to think that they're, you know, were maybe just a handful that were actually causing The disease, more recent thinking is that this is actually a, what, what actually causes the infection and the periodontal disease is that we get a shift in the normal populations. You know, there's a lot of research going on in oral biomes, and things like that. So we now think that it.
There is a dysbiosis, rather than certain species of bacteria that are causing disease, it is this shift. All right. Plaque forms very, very quickly.
This says within 24 hours, but honestly, as soon as you get out of that dentist chair, as soon as you walk out of your bathroom after you've been brushing your teeth, plaque does start to form again. Minerals in our saliva will actually calcify the plaque and form calculus or tartar, which you can see on this disgusting picture on the upper left. That, that process starts to occur within about 36 to 48 hours.
So if plaque is not being removed regularly, this is what you end up with is tartar and calculus. The first plaque to form is super gingival flat plaque. It forms above the gingival margin, above the gum line on the crown of the tooth, and initially, once the calculus forms, it will sort of protect the The subgingival plaque, so plaque below the gum line.
Calculus in and of itself is almost entirely non-pathogenic. It is not what's causing disease, just because, an animal has tartar on their teeth does not mean that they have periadominal disease. But it can sort of work to not only protect the subgingival plaque, which is really the problem, but it, it can also rough in the tooth surface and give plaque more areas to hang on.
So the subgingival plaque then will extend below that gingival margin. And as that occurs, we we start seeing more anaerobic gram-negative bacteria. Like I said, we get this shift in bacterial populations.
So instead of these aerobic gramme positives, we start to see more anaerobic gramme negatives. There is evidence that there may be some other non-bacterial species in there too. All of these things together contribute to the infection, inflammation, periodontal disease that we see.
And as those pockets, as this plaque works its way down around the outside of the tooth and breaks down the attachment of the gingiva to the tooth surface, We, we see increasing virulence of the of the of the plaque. Things just get worse, the deeper these pockets get. So plaque will come along and adhere to teeth, you know, enamel is very slick by design, but no system is perfect, and plaque has figured out ways to to get around the body's natural defences and stick to to surfaces.
Anything in the mouth that makes that easier for plaque, of course. Can contribute to worsening disease. So, fractured teeth, rotated teeth, crowded teeth, gingival overgrowth, gingival enlargement, all of these things give plaque more places to hide.
The subgingival bacteria, their waste products, other pathogens as well, then lead to inflammation, all right? Inflammation and infection together, they will elicit the host response. And each individual is a little bit different.
So, depending on Your body's response to the infection that is now present in this, in this plaque, in addition to the, the, the virulence of the pathogens, that is what determines the progression of the disease, the severity, and how quickly And it will, it will, it will proceed, OK? All right, so, gingivitis, we're really gonna be talking about periodontal disease, but gingivitis, we think is kind of the early stages, right? Gingivitis is when inflammation is confined to the gingiva.
There are no radiographic signs associated with this. There's no bone loss noted, nothing. Clinical signs, the first one that we see is bleeding when you, when we go and probe the teeth or when we're brushing our teeth.
Hopefully, none of us are waiting for our gums to bleed before we go. See the dentist, but that is, in fact, what's happening to most of our, our veterinary patients. Halitosis is an early clinical sign.
Bad breath comes from the waste products of the bacteria that are living below the gum line. So the worse that gets, the deeper those pockets get, the smellier it gets. I'm sure any of us who've worked in practise for more than about 3 months have had the dog that walks into the room that you can smell before you even look in its mouth.
Erythema and edoema, are other things that we see with, with gingivitis. Key things to know that gingivitis is totally reversible. So, with a good professional subgingival cleaning, we can reverse gingivitis and keep it at bay.
We can prevent it with good, effective home care. As I said before, you could have gingivitis with no calculus at all, which is what's shown in this picture on the left. There's very, very little tartar on that tooth, whereas this cat tooth picture has really severe tartar and calculus when we chipped that off though, the gingivitis was almost done.
It was extremely minimal. So gingivitis is the reversible form of this. Early days, let's get things when they're here, rather than waiting for the inflammation to infect deeper supporting structures of the tooth.
The periodontal ligament that lives around the root, the bone that holds, you know, the bone socket, that surrounds the tooth and is in between the roots of, of multi-rooted teeth. As periodontitis, though, as Gingivitis that is not properly treated will. Continue to worsen, will work its way down.
Interfere with that, affect the gingival attachment to the tooth and work its way down into the deeper structures. Now we see attachment loss of the bone as well as the soft tissue. We can get gingival recession or periodontal pocket formation.
So the gingival can react in one of two ways. It can either separate from the tooth itself causing pockets, or it just kind of retreats, and that's when we see gal recession. In order to treat periodontal disease, we need to use advanced techniques.
All right. So here are some images of severity from mild to moderate periodontitis on the left where we just see this increase in inflammation, more plaque, maybe more calculus. We've got gingival recession going on.
We've got periodontal pocketing, and we've got some bone loss as shown on the, the X-rays. The only way to truly grade periodontal disease is by looking at dental radiographs. So, We talk about PD periodontal disease level 12340 is absolutely nothing, no gingivitis at all.
A level 1 would be just gingivitis with no bone loss at all. This here on the left, those green arrows are showing where the bone should be. The blue arrows are of course are showing where the bone is.
We We grade based on the percent of bone loss relative to the tooth root. So 25% or less bone loss would be a PD too. 25 to 50% would be a PD3 and more than 50% bone loss is a PD4.
All right, 75% or more bone loss, sorry. So that would be on the, on the right side there we've got. Even more.
We've just got really severe periodontal disease. These teeth are mostly being held in by the calculus that is bridging from tooth crown to tooth crown, and unfortunately, none of those teeth in that X-ray are salvageable. We will also see complete furcational defects.
The furcation is that space in between the roots of multi-rooted teeth, and We can see bone loss all the way through. We, we also have grades for vocational defects. I'll get to that in just a minute.
There are a lot of comorbidities that we can see with periodontal disease. Locally, probably the, the most common one that I see is oronasal fistula. If it's a doxund, that's Highly likely that we not only have that periodontal disease, but oronasal fistula is incredibly common.
We can see all sorts of ophthalmic issues, everything from anterior uveitis to actually globe rupture, secondary to, to peridonal disease. Periodontal endodontic lesions where that infection works its way down the route, all the way to the apex and then back up into the, into the root, . Osteomyelitis, bone infection, pathologic fractures of the mandibles in particular, are, are not, not uncommon.
And then, there are a number of studies that have linked periodontal disease with systemic ramifications in both humans and veterinary species. So, we know, again, because teeth have blood vessels in the centre that connect with the rest of the body's circulatory system. That plaque bacteria can and do gain access to the bloodstream, through inflamed vessels.
We get bacteremia, we can spread the infection throughout the body. Now, notable that there was a recent study in dogs, and there have been similar studies in people showing that After cleaning, your bacteremia goes away. So, cleaning will cause bacteremia like 75% or something in humans, but within 15 minutes, it's gone.
And the study in dogs showed that it was And by the time they were put back into the cage for recovery, and that's without antibiotics. That's a talk for a different day. But it does exist.
And if you already, it does happen. Every time you chew food, if you've got this kind of infection, you are spreading bacteria through, through the body. And that can affect other organ systems.
In people, it's been comorbidity has been shown, it's been shown to be periodontal disease has been shown to be correlated with, with osteoporosis, low birth weights, preeclampsia, generalised early mortality, and there is evidence that This state of chronic inflammation that we have with periodontal disease may also predispose to certain oral cancers. It does not, you do not have to have a, a long standing infection. It can be just established gingivitis.
That is enough to, to cause systemic consequences. All right, and if there are no pressing questions about anything there, Charlotte, we're gonna move on to the review of periodonmal therapies and some of the adjuncts that we use. So what do we do about this?
The first and most important thing is a thorough, adequate, professional dental cleaning. All right. Now, this says it's a 10-step treatment for periodontal disease.
It could be 8, it could be 12, it could be 15. It just depends on how you want to break things down. These are kind of the high points.
They do not necessarily need to be done in this order. I don't do everything in exactly this order. So, I'll just briefly hit on these.
Pre-surgical exam is really important. One, we need to know if there are any comorbidities that may, prevent or change the way we're going to do anaesthesia because the only way to adequately do this procedure is under general anaesthesia. So, we wanna know if there are comorbidities.
It also gives us a chance to look in the mouth, do an awake exam, which is never perfect, but can give us an idea of what we, what we might be getting into so that we can educate the client beforehand so that we're not trying to do this over the phone while we've got the patient under, under anaesthesia. We generally start with a, a quick rinse of the oral cavity with a chlorhexidine, a 0.12% chlorhexidine rinse.
It just kind of tamps down the bacteria a bit, makes us feel better, makes me feel a little bit better about my, my veterinary nurse, my, registered veterinary technicians, health and well-being as well. It's also kind of, it's viscous. So it, Kind of tamps down some of the aerial aerialization we see.
Wow, might be Monday again. We then move on to super gingival scaling. So scaling above the gum line.
Most of our scaling is done with, we use an ultrasonic, there are also piezoelectric units out there, but it's You know, a powered scaling device. We go through the entire oral cavity. Every surface of the, of the tooth crown, and we scale it.
We may also use some hand instruments for some certain tight or very difficult to clean spaces. The next step is really the most important one, and that's the subgingival scaling. We may change our tip a little bit and make sure that we're being safe.
We wanna make sure we've got a good safe tip for, for doing subgingival scaling, and we're gonna get down there and we're gonna really clean because the most important thing to do is to get all of the bacteria and infection out from under the gum lines. That's where the disease is lurking. We're then gonna polish the teeth.
We're careful with this so that we don't do damage to the tooth. But polishing gives us a nice smooth surface again after our ultrasonics, and even our hand scaling, we can get micro pitts and fissures, from, from the actual scaling. We're then gonna just rinse out the, the gingival sulcus with, with a rinse.
We can do fluoride or not. We wanna do a really thorough dental and oral exam, including charting. All right.
And this is, we're gonna be looking for pockets. We're gonna be going around every single tooth, checking for furcational defects, checking for bone loss, checking for bleeding on probing, which is a sign of gingivitis. We're then gonna get full mouth dental X-rays so that we can appropriately and accurately grade the level of periodontal disease that a patient may have.
Once we have all of that information, we are going to make a treatment plan for that individual patient. And that may include additional therapies, anything from extraction to root planning, guided tissue regeneration. We do have a lot of things, at our disposal, and this is the step where some of these novel therapies may really be of benefit.
All right. So, quick, I promised that we would go through furcational defects. The nice little, radiograph on the left shows you PD2, PD3, PD4, with a PD1, which is gingivitis only, no bone loss.
We just wanna make sure that we're doing a really good cleaning. Up to 25% bone loss or so, we need to do root cleaning. Once we have more bone loss, then we start getting into deeper pockets.
We need to talk about doing either open root planing or even guided tissue regeneration. But for something like this, this is a furcational defect. This would be a class one furcational defect.
You can see we've taken the probe and we've put it horizontally into the furcational area. This is less than about 25% of bone loss at the furcation. So this we would classify as a class one.
A class 2 furcational defect is one in which we can go anywhere from 25% up to about 75% or even a little more. I've had some of these that I'm like, oh, if I push too hard, I'm gonna, I'm gonna make this a class 3. This would be a class 2 forcational defect.
These defects do require open root planing at a minimum and for Big important strategic teeth in, in cases where the owner is game and wants to save teeth, these teeth may be treated with guided tissue regeneration as well. If you have a class 3 furcational defect, that is a through and through. There is no bone in between those roots, and short of getting in with a water pick a couple of times a day and really, really significant.
Home care, brushing twice a day, like I said, a water pick. There's, they're just really not savable. Even in our hands, these are incredibly difficult, teeth to save, and especially for a non-strategic tooth extraction is the recommended treatment.
This is just a little reminder that periodontal pockets can be pretty camouflaged. So we need to make sure that we're looking and we're looking well. We're being careful and, and again, going all the way around the full circumference of these teeth, you know, this, this canine tooth up.
Neither of these canine teeth, none of these three canine teeth look all that bad. Yes, there's gingivitis, but I don't think looking at this tooth and in the wake animal, you would guess that you have a 6 millimetre pocket up there on the top and an even greater, like 9 to 10 millimetre pocket there on the bottom. Again, the bottom left picture is to remind you that we need to be probing at full circumference around these teeth because pockets can be hidden on the palatal or lingual side of teeth as well.
All right, so, like I said, subgivable scaling, thorough cleaning is the mainstay of treatment and prevention, but when we have a pocket, when we actually have a periodontal pocket, that's We've lost the attachment of the gum tissue to the tooth. If those pockets are between 3 and about 6 millimetres deep, we can do a procedure that's called closed root planing. Closed root planing means that we're not cutting anything, we're just taking specialised instruments, .
Cleaning first again with our subgingival ultrasonic scalar, and then following that up with hand scaling with a subgingival currette, we move the instrument to the bottom of the pocket, as you can see in the cartoon, and then we scrape all of that out. This is a really important thing to be doing, . The vast majority of pets, have some level of periodontal disease by the time they're 1 or 2 years old.
And really, because cleaning is the most important thing, knowing how to do this and arresting these pockets at 3 to 6 millimetres deep is much better than waiting for things to get worse, right? We have our little sneak peek, I think one of the the great places to be using our hyaluronic acid, parasitic medications are down here in this pocket. So you get it all nice and clean, and HA can help speed the healing of that.
We'll get to that more. That's just your sneak peek. This is open root planing.
So if we have periodontal pockets that are deeper than about 5 to 6 millimetres, we, if we try and do that blindly with closed root planing, we run a risk of just shoving, debris and calculus and bacteria, and infection further down, which is the opposite of what we want to be doing. OK? So open root planing for pockets that are greater than about 5 or 6 millimetres for class 2 furcational defects, and for these really inaccessible areas.
So, these are all places where you cannot adequately clean without directly visualising the bottom of the pocket to make sure that you are really getting everything out. So we make periodontal flaps. These can be very simple, envelope flaps as shown in, in the images.
We can, in some cases, we can actually use guided tissue regeneration or bone grafting to, to try and, even better improve these. And again, our hyaluronic acids have been shown to help speed healing. So, debridement is the first most important thing, and again, there is a note here that if, if the owners don't want to do any of these advanced techniques, when you have this degree of Of bone loss, greater than 6 millimetres, class 2furcational defects, really inaccessible areas.
If they're not willing to do, to allow you to do things like open root planing, you might be better off just extracting the tooth. All right. So, some of the adjuncts that we have available to to debridement, barrier membranes such as Osiflex or doxy robe, these are used generally with, guided tissue regeneration, where we're putting a bone graft in, and then we're using a barrier membrane to prevent the ingress of soft tissue regrowth.
Soft tissue grows faster than Bone does. And when we're trying to regrow bone, we need to prevent, we need to kind of stop that soft tissue from getting in there and, displacing our bone graft. So we use these barrier membranes.
All right. The bone graft itself can be something such as perioics. People do use, endogenous, they use, we can collect bone from the patient.
I find it much easier to use, product that I just purchased. So perial mix, is a Cancellus bone mix. Synergy is, an artificial one, but both of these products help to amplify bony regrowth.
And again, like I said, we generally use these in conjunction with a barrier membrane when we're doing guided tissue regeneration. We also have parasitics, so things like Clinderol and doxyob. And these are both antibiotic-based ones, and they are meant to minimise bacterial invasion post debridement.
All right? OK. Now, I'm gonna introduce you guys to Pao Vive.
All right. So Periovive is a novel hyaluronic acid adjunct. Hyaluronic acid is, it's a, it's been a therapeutic biomaterial for a very long time.
It was first discovered in 1934 and we had, the first, don't ask me to, to tell you this molecular thing. I can tell you it's a glycos amino glycan, right? It's a It's hyaluronic acid.
And we had the first academic publication on the use of HA and equine osteoarthritis was back in 1976. So, in 1989, 13 years after that, we had our first HA filler used for humans, and then in 2011, we got our first equine our first product for cor corneal ulcerations in horses. In Oh my gosh, 1997 though, we got canine adequin, which is a hyaluronic acid, so, you know, this is something that we all have been using, I think, for a very long time, .
And you know, there are now not only corneal, not only eye drops and things for horses, but we have them for small animal patients as well. And these have been used in humans for a very long time for everything from Osteoarthritis. My, my husband has had HA now injected into his knees.
It's in eye drops. It's in periodontal, parasitic type medications. But Periovive is the first HA product made for veterinary dentist dentistry specifically, OK?
It's, there are, right down here, FDA has approved human versions for every veterinary HA product but not vice versa, which is interesting because the The data, the research that the human studies were all based on, the human trials are based on all come from dogs. So we know this works in dogs, it was tested in dogs first. We can think about HA as an extra secular extracellular scaffold.
So it amplifies the beneficial activity of endogenous cells across a variety of effects. So if you think about rebar in concrete, makes it stronger, helps it keep its form and everything, it helps make it more better. HA kind of acts like the rebar in concrete.
It's an extracellular scaffold. All right, and it, it. It's effective by multiple mechanisms.
First, it, it forms this sort of biofilm. It it it. It, it just this really thin coat, wherever we put it, that then physically inhibits microbial adhesion, all right?
It also kind of calls all these anti-inflammatory, cells, to come in, the healing, right? To, to Boost the anti-inflammatory effects of the body's natural response. It enhances osteoblast and chondrocyte activity.
It drives, angiogenesis. And if you think about, you've got these wounds, and, you know, it's, it's not exactly analgesic, but when you've got these wounds with these, you know, nerve ending, it's just kind of out flapping around in the breeze and And being sensitive, the HI can kind of come in and protect those free nerve endings and Inhibit the pain response. OK, so let me see, this is, this is a slide just showing We're just trying to give you an idea of the vast amount of data that is out there on HA.
I mean, this stuff is incredibly safe. It's, it exists in all organisms anyway, and we've just learned to take advantage of it for our benefit. So, These are just some of the review articles and how many studies each of these 5 review articles went through and you can see, it's anywhere from 10 up to more than 35.
They looked at it in non-surgical approach to interdental papillary defects, versatile applications in dentistry, perinontal tissue regeneration, and intrabony defects. Just, there's just, there's a lot. There's a lot out there.
I am not the expert on, on the, all the data, but we do have, you know, we, I'm gonna share with you a few of these now. These are These are studies that were done in dogs, in research dogs. So these were, unfortunately, terminal studies, but these were done in anticipation of Eventually moving to human trials.
So Over on the left, we've got the author and the year, and I'm gonna go through some of the, some of the details on some of these, but you can see everything from gingival recessions to infected stra extraction sockets and class 2 and 3 furcational defects. And these are the end points that they looked at. And everything from increased bone formation, increased ligament attachment, Increased pain post-peridonmal therapy and tooth extraction, decreased probing pocket depths.
This is really big for, for me and my line of work, decreased bleeding on probing, which tells you that it does help with gingivitis as well, since bleeding on probing is the, first sign of gingivitis. All 5 of these studies were done with split mouth design, so dogs served as their own controls. OK.
All right, so this is that Shirakata 2021 . Paper. And this, this study showed twice the improvement in cementum, ligament, and bone formation with the application of hyaluronic acid.
So what they did was, these were coronal advancement flaps on, I believe it was all on canine teeth in dogs and again split mouth, so one side, both sides, they, they created these gingival clefts. They Then repaired those with coronal advancement flaps, and on one side they used HA and on the other side they didn't. OK, so same dog, they're comparing dogs to themselves and I, I know this, when I first looked at this, it's a little bit confusing, but this is showing all of the statistically significant results.
And on the left, you know, we've got probing pocket depth in millimetres, clinical attachment level in millimetres, gingival recession in millimetres, and the width of that recession in millimetres, OK. We would like to see that HA has smaller numbers on this side of the graph, because it means that we have less pocket depth. So that is a positive result for HA on the right side, it's actually looking at new cementum, new attachment, and new bone formations.
So yes, we want those numbers to be bigger. I had to really look at this for a minute, but this is all. Showing that that HA was really quite, quite effective.
All right, so. This is just, again, showing that along with some of our advanced periodontal flap techniques, hyaluronic acid promotes periodontal wound healing and regeneration, OK. All right, this is the, the 2023 article, and they actually were looking at class two for furcations, and again, on the left is absolute change in millimetres squared or in millimetres, and on the right is the restoration relative to the defect, and I think these bar charts show pretty pretty clearly, that, that the, The HA treated defects with open flap debridement or open root planing were much, much more, we had much better results with the presence of HA than without it.
Now, you'll see that, that last bar on the right side of each of these charts is epithelial downgrowth, and it did occur when HA was not used. It did not occur when HA was used. So this is important to me again.
When we're doing procedures where we don't want that, epithelium to grow in, we want the bone to regrow, so this is, this is all very, very positive. Infected bone sockets, again, similar to the epithelial downgrowth. You don't really want bone marrow in there.
You want bone, you want mineralized bone, and it was 1.3 times greater in mineralized bone and 1/3 less marrow when HA was used. Versus control again split mouth design, so the dogs all served as their own control.
This is back to that, the kernel advancement flap. The Shirakata 2021 paper. So they made these gingival clefts.
These are the baselines, and this is open flap debridement without HA across the top and with HA across the bottom, and these, they, they made the flap, closed the advanced the flap down over the tooth to try and And diminish the size of those gingival clefts. And you can just see how much less inflammation there is in these, in these bottom images. So HA really does kind of boost the, the healing and kind of give us that head start so that the body can, can finish what it needs to do.
We do have some cross trial comparisons here for you. So, These are, let's see, 7 different, Different papers, . Orange is hyaluronic acid, blue is clierol, green is doxyrobe.
And you can see that 3 of these studies had no significant differences. But With the HA we showed a 30, there was a 35% improvement over the control as opposed to Clinderol, which at most had a 17, 18% improvement and doxyobe was less than 15%. And again, we do have several studies in those showing that there was no significant improvement at all, OK?
Human meta-analysis of 77 randomised controlled trials looking at probing pocket depth across 8 different therapies with, again, hyaluronic acid in orange, macrolides and tetracyclines, doxorubin Clierol. These are the things that we have available to us in, in veterinary medicine. And again, I think that this is all just, you know, I'm, I'm all for a good bar chart or, or pie chart.
This really helps me to kind of put things into perspective. And I know these numbers are very small, but 1.6 millimetres in a 4 millimetre pocket or 5 millimetre pocket is very significant.
It gets us nearly back to a normal, so depth, right? So this, this is, very encouraging to me and I'm really excited. All right.
So when do we apply it? We can use it in a really broad range of settings as an adjunct to standard of care. And like I said, just the fact that we, we see, a decrease in bleeding on probing tells me that this helps even with when we don't have pockets.
So, I would, I have no qualms about using this kind of everywhere, honestly. . Again, it's only gonna speed healing, and help with some of that possible discomfort, but You know, you can use it in post-extraction sockets.
We can use it in these, I, I mean, class 3 furcations again, I think extraction is really the way to go. But you can then use it in the post-extraction socket if you need to. I'm using it in, in my GTR cases now too, for my, class 2 furcations near class 3.
Though not quite, and my deep pockets that, that need, open root planing. OK, so let me make sure I can make this work. So, it's really easy to apply.
It has, it comes in a prefilled Lorala syringe. It's a 2 cc syringe with 1 cc of perio5 in it. It comes with two applicator tips.
If you don't use it all in just two applications, I just have other blank blunt cannulas that, I use for . Acid etch and things like that, and I, I just move those, put those on. I use a clean tip every time, of course.
Apply it generously to the sub gingival space until it's full. After full complete debridement, I know I keep saying it, but it really is the most important part of this whole thing. All right, let's see if my video goes.
Look at this, it's gonna go. Maybe it's thinking. Here we go.
All right. So this is just showing this dog's already been cleaned. It's had incisors extracted, and we're just putting it down into the bottom of the, of the pocket of the sulcus and filling it until you see it kind of, gloop back out.
And then also on the other side, all the way around, all the pockets of this tooth, and in that extraction socket. All right. You just fill it till it's full.
Pretty easy peasy. Apply it generously. See it kind of overflowing.
It does not stick around long. This isn't like clinger oil. You don't have to, I mean, doxy, you don't have to mix it and then wet it, and then wait for it and put it in the pot.
You're just gonna stick it in there until it overflows. And even if it wipes out or is blown out or rinsed out within minutes after that, just very quickly after that, it doesn't matter. The HA has attached, it's in there.
It is doing what it needs to do. All right? And There we go.
This is what it looks like. Right now you can order directly through, Brian. You can email Brian right there, or go to periovive.com, if you, if you wanna get on the list and get some ordered.
Thank you very much. I appreciate it. You know, I'll tell you guys, I am, I am using this.
I've been using it for about 4 months now, and I'm using it in all of my, root plannings, open and closed root planings. I'm using it, to prepare the, The cleaned defect when I'm doing guided tissue regeneration, . I'm kind of using it everywhere.
I've, I've been really impressed. I have seen 0, not a single. Adverse effect at all, and, you know, they come back two weeks later and their inflammation is really pretty much gone.
So, I'm very excited about it. I'm very happy about it. I think that, you know, my colleagues and I are gonna be working with, with Perryvive to investigate some other applications too.
So hopefully, you know, in the next few months, we'll have some, some more really interesting and exciting news, about all of the different things that HA can do. I mean, if it can keep our skin looking great, and keep my husband, keep his knees working, I think we're probably, on to something. And I'm happy to take any questions.
Thank you, Erin, for presenting, tonight's webinar. That was a great informative session, and we have had quite a few questions submitted, so, we'll see what we can get through. I'm just gonna bring them up now.
Let's have a look what we have. So first we've got, I have some soft tissue lymph node infections near the jaw post dental and a couple of small dogs with terrible, periodontal disease. They have to be anaesthetize, abscess lance, drain antibiotics, etc.
So with multiple extraction, severe disease, what do you recommend, do you recommend, for example, a dose of IV antibiotics during the procedure, plus or minus post procedure oral antibiotics? So, so like I, I kind of alluded to it earlier, that is a whole other lecture, right? I can tell you that we, I hardly ever.
It is very, very rare for me to use antibiotics if, not for anything dental. I mean, really, and, and it's just not necessary. You know, we use it for other comorbidities, perhaps, but not for the dentistry itself.
The key thing to remember with dentistry and antibiotics is basically that you have to get rid of the source of the infection. The source of the infection is the teeth. All of the antibiotics in the world are not going to change anything until you get the teeth out.
Yeah, so you have to get rid of the source of the infection. I, I tell people all the time like I could, I could put your dog on enough antibiotics to kill it before it would actually, do anything to the dental infection. Yeah, great advice there.
Next one we've got is, we are now being told in the UK by the BVDA that we should not be polishing teeth since it wears the enamel, which dogs don't have a lot of in the first place. What is your take on this? I.
Don't agree. I, you know, we know that our scaling does cause these micro pits and fissures, and I didn't have it in this lecture. I, you know, I can lecture about periodontal disease or periodontal therapy for an hour each.
So this was very much an overview. But when you look at, micrographs, electron scanning, micrographs of A tooth that has been scaled versus a tooth that has been polished. The difference is, is incredible.
So I think really it comes down to proper training and proper equipment. You cannot put a polisher and just sit it there. It has to be quick.
It doesn't take long, and you have to be quick. And it's not actually the rubber that's doing anything. We actually use a, a flower pumice, rather.
Than the pre-made pastes. I think the grit on the paste is maybe too abrasive. And I think in a lot of cases, people are not appropriately trained and they're holding the polisher far too long, far too long.
And that actually can, yes, we know that it can damage teeth. You can thermally burn and, and permanently injure, fatally injure a tooth, with inappropriate technique. So.
Yeah. That actually sort of goes on to the next question in the sense of, yeah, is there a certain amount of time, each tooth should be power scaled? You know, meaning like, is it never going past for 5 seconds each too, or, you know, stuck for longer.
With ultrasonic scaling, we say as long as it is properly water cooled, it's really hard to do too much damage. if, if, if you don't have water coming out of it or the water's coming out in the wrong spot, and it's not cooling that tip and the tooth while you're working, yes, you can seriously damage the tooth. I mean, I think work quickly, keep it moving is key.
You don't want to keep it in one place. We always say. With the polisher, you don't want to be on, any one area of a tooth for more than 5 seconds, and it really shouldn't even take that long.
With the scalar, you've got a little more time. You're just moving it, constantly moving it, holding it in one place and sitting it there. Yeah, you can, you can certainly do some damage.
This might be a little bit controversial, but as in, we've got clients out there who might not be able to afford, you know, a proper clean. You know, what's your, approach on, you know, opposing, sedating a pet, doing a hand scale. Obviously it's not the the best approach.
It's something better than nothing. No, no, I actually argue that it's worse. Because, one, it, you can, sure you can crack the calculus off, the calculus is not what's causing the disease.
And I don't have as much of a problem here in Louisiana with this, but at our California practises, We see a lot of patients come in with, you know, they've had every 6 months non-anesthetic dentistry done, and we end up having to do full mouth extractions because the teeth may cosmetically look good and they make the owner feel like they're doing something, but below the gum line, they're completely rotten and that, that animal is living in pain. We actually are, hopefully we'll have a paper on this coming out soon, but it's absolutely, in my opinion, worse than doing nothing. I think you shouldn't do it.
Yeah. Get, get, get people, when they're, when they're young, when they're puppies, when they're kittens, discuss and get them doing home care. Yeah, and just brush.
Yeah. Yeah, get him doing home care from the very get-go. And, you know, we think, I, I believe that every animal should have its first professional cleaning done by the time they're about one year of age.
And the owners just need to build it into this is what we're gonna do. And If I'm doing home care every day and I'm getting the teeth professionally cleaned once a year, we should hopefully be able to prevent those big expensive dentistries where I'm taking out 26 teeth at one time. Yeah, yeah, so.
Yeah, which also ties into the next question of do you have a recommendation for frequency for regular prophy dentals. So for example, like a cat that's prone tey tarta on the molars and things like that. I mean, obviously, you know, we know that some, Cats and dogs are, you know, more predisposed to having like genetic, issues and, and that, but yeah, same in people.
So my general rule is once a year, right? That's kind of the baseline for everybody. Are there some individuals that can go 18 to 24 months?
Sure. Are there some that All of our oodles, all of our schnauzers, all of our dachshunds that need to come in maybe every 6 to 9 months. Yes, right?
So, I basically start at a year. When I have those, those patients that come in that I have to do massive numbers of, you know, I'm doing just a lot of work. I'm doing guided tissue regeneration because they really want to save teeth.
And I've taken 12 or 15 or 20 teeth out. You know, I always tell those people, don't wait a year to come back and see me. I want to see you, you know, within 6 to 9 months.
Because I think, you know, we do a lot of work at the first one. We do a modern amount of work, mild to moderate amount of work at the 2nd 19 months later. And then hopefully, we can get you on a yearly.
Right, but some, you know, some, there was a period in my life. I, I'm embarrassed to admit it that I had to go every 4 months to have my teeth cleaned cause it was, I was just not keeping up with it. And, it was really hard and, I did that for a few years and then now I'm on a 6 month I go tomorrow to have my teeth cleaned.
So like a little spa day exactly, exactly, exactly. So, no, I, I, I think one year is a good place to start. I've got a question in regards to sort of post dental.
Is there anything that you'd recommend after, as in like topical probiotics or anything like that, so someone's using a probiotic dental spray? No, I, I mean, honestly, I'm, I'm so excited about Perry vibe. I think that, when we've had a couple of intrepid, veterinarians who are using this for all sorts of other things, so we've we've, we've had somebody in the southwest United States who had a dog with really bad inflammation.
They didn't want to take the rest of the teeth out. And she just sent some Periovi home with the owner and they were just rubbing it on the gums and every day, and within a week it looks much better. So, you know, there, there are a lot of products out there.
I think, you know, the gold standard still is and will always be brushing. But when I've done a bunch of extractions, or a lot of work in the mouth, I tell people not to brush for, you know, a week or two after, and I think something like Periovive could actually be quite beneficial, . You know, right now it's just in the little syringe and everything.
But, I've, I've spoken with Brian about, can you get me a rinse? Can you give me something that, that the owners can just kind of spray in there and squirt in there. So we'll see.
I mean, it's early days, but I think they're, I think there's a lot of potential here. Yeah. And obviously, they say the results show.
Right. Right. Exactly.
So, yeah. . I think that pretty much brings us bang on now.
So that is, yeah, and made such, we had, we do have quite a few, a couple of questions that we just unfortunately didn't get time to, but we'll obviously make sure that we get back to everyone, with the questions that we didn't unfortunately get to answer. But I'd just like to say a big thank you, Erin, for today's webinar. It's been obviously.
A great, a great session. We've had loads of interactions, we've had, obviously, you know, see what's out there, and obviously a big thank you again to, Harry Avive for sponsoring tonight's session as well. And I just wanna say we hope everyone enjoyed today's webinar.
Thank you all for joining us at the webinar there, and we hope to see you all again. Thanks for watching.
