A class 3 malocclusion (mandibular mesio)

A class 3 malocclusion (mandibular mesioclusion) is an abnormal skeletal relationship resulting in the mandibular dentition occluding rostral to the maxillary dentition. A genetically short maxilla is involved. This is commonly seen in brachycephalic breeds due to a genetically short maxilla. It may be considered “normal” for the breed, but it is an abnormal skull and jaw conformation with consequences such as brachycephalic airway syndrome, crowded and rotated teeth predisposing to periodontal disease, and unerupted teeth. Treatment depends on tooth and soft tissue trauma related to the malocclusion.

ABRASION

Abrasion is the mechanical wearing of a tooth from abnormal habits and foreign objects (e.g. tennis ball, cage). If the wear is at a rate faster than the tooth can produce reparative dentin, the pulp will be exposed resulting in an infected and painful tooth requiring root canal treatment or extraction.

Active Orthodontics

Orthodontic movement may be chosen to provide an pain and infection free oral cavity for the patient. It should not be done to mislead, defraud, or to propagate questionable genetic traits in the animal. A committed client is necessary to maintain oral hygiene and to present the patient for timely reevaluations in order to increase success rates and reduce the risk of treatment complications. The patient must be compliant with the appliance and the required daily cleanings, as well as being medically stable for multiple anesthetic procedures. Orthodontic movement of teeth is not intended for all patients, all clients, and all cases. It should not be attempted unless the veterinarian is appropriately trained in orthodontic tooth movement, related complications, and related sequelae. Some potential complications and sequelae to orthodontic tooth movement are: resorption of treated teeth, fracture or loss of the appliance or associated teeth, delayed movement of treated teeth, and a need re-adjustment of the appliance during treatment. There are alternative surgical and endodontic treatments that can correct a malocclusion to achieve the goal of a pain and infection free oral cavity.

Aggressive Juvenile Periodontitis

This is a pronounced generalized inflammation of the periodontal tissue (gingiva, cementum, alveolar bone, and periodontal ligament) in the young cat. It is typically diagnosed between 7-10 months of age. This juvenile form of gingivitis may represent exaggerated tooth eruption inflammation in addition to a disruption of the equilibrium between the oral bacteria and the immune system. It is distinguished from other oral inflammatory disorders in that the generalized gingivitis has not radiated to the mucosa or caudal oral tissues as in stomatitis. Typically, periodontitis changes, including alveolar bone loss, gingival resorption, pocket formation, and/or root exposure, are not seen. In many such cases, if the oral inflammation can be controlled and kept controlled for the first 2 years of life, recurrence may be decreased or prevented altogether. At this age these patients often mature into a more normal state of equilibrium between the immune system and the oral bacteria. On the other hand, juvenile cats with this form of oral inflammation who are not controlled aggressively at a young age suffer permanent anatomical changes and frequently progress to severe periodontitis or even stomatitis.

Apexification

When an adult, but immature, tooth that does not have a completely formed root is fractured and dies a root canal treatment or apexogenesis cannot be performed. In order to save the tooth and preserve function of the tooth in the patient, a procedure to clean the inside of the tooth followed by placement of an endodontic material such as calcium hydroxide and/or MTA® allows the body to create a new hard tissue/root structure. This allows the tooth to become a candidate for a root canal treatment several weeks or months later.

Apexogenesis

When immature adult tooth is fractured and the pulp is exposed, a standard root canal treatment cannot be performed because the tooth does not have a completely formed root. Instead, a partial coronal pulpectomy and direct pulp capping is performed (a few millimeters of pulp is remove and a pulp dressing material is placed) to protect the pulp and allow the root to form. This is referred to as apexogenesis. Ideally, the tooth will remain vital for the entire life of the patient. In some cases, the tooth may die in the future years. However, the majority of the teeth survive long enough for the tooth to develop a closed root apex and additional tooth structure, allowing for a successful root canal treatment at a future time.

Attrition

Attrition is the mechanical wearing of a tooth resulting from a malocclusion with tooth on tooth contact. If the wear is at a rate faster than the tooth can produce reparative dentin, the pulp will become exposed resulting in an infected and painful tooth requiring root canal treatment or extraction. Additionally, the malocclusion may result in infection around the tooth (periodontal disease) or within the tooth (endodontic disease). Often seen with malocclusions such as a class 3 malocclusion in Boxers, Bulldogs, etc.

Avulsed/Luxated Teeth

Avulsed teeth have been completely knocked out of the mouth, with or without concurrent maxillofacial fractures. Luxated teeth are clinically displaced but still in the oral cavity and supportive tissues. Subluxated teeth have been moved but return to a correct anatomical position. Regardless, the blood supply is disrupted and all these teeth require endodontic treatment. Luxated teeth are replaced into correct occlusion and splinted. Subluxated teeth are splinted. These teeth are endodontically treated and monitored radiographically for root resorption.

Ball Therapy

A paper published in the Journal of Veterinary Dentistry in the 1999 demonstrated good success in selective cases of linguoversed mandibular canine teeth. It is most appropriate to use this technique in cases where there is not a significant discrepancy in the length of the maxilla and mandibles. The interdental space between the maxillary canines and third incisor must be wide enough to accomodate the mandibular canine tooth when it is moved into appropriate location. The chosen toy or object should be round or ovoid in shape. It is not recommended to use a toy that contains a rope, as the dog may preferentially pick the toy up by the rope. Unless the rope is held by the owner and the dog is encourage to play with a rubber Kong like ball attached to the other end of the rope.

Size of the toy is critical; a toy that is too small will not apply appropriate pressures and a toy that is too large may be rejected by the dog. Additionally, it could become a life threatening pharyngeal foreign body or be swallowed and become a gastric foreign body. The toy should be wider than the distance between the cusp tips of the mandibular canine teeth, resulting in the toy resting rest at the coronal tips of the canine teeth to maximize the lateral tipping forces on the tooth. It should also rest slightly distal to the canine teeth. Care must also be taken to ensure that the dog does not hold the toy in the back of the mouth with the carnassial teeth. Dogs chew with the large carnassial teeth in the back of the mouth; they will preferentially chew or grab with those teeth, rather than the canine teeth at the front of the mouth.

The texture of the toy should be hard or firm rubber. If the toy is too soft, it cannot create enough pressure to move the teeth due to compression of the toy when chewing. If the toy is too hard, it can create abrasive damage to the teeth. The surface of the toy should be smooth.

The minimum requirements for success is to have the dog play with the toy three times daily for at least fifteen minutes. To maximize the chances of success, longer and more frequent episodes are preferred if possible. All other toys in the house and yard should be removed, to encourage use of the properly sized and shaped toy. Aggressive tug is not recommended due to the potential to traumatize the developing dentition, and, as discussed above, toys with ropes are not recommended due to improper play or use for the intended purpose.

The earliest time that benefit may be seen is three weeks after initiation of treatment. In the paper by Dr. Verhaert, the time for treatment ranged from two to twelve weeks. Typically, younger dogs had shorter treatment times, with dogs 5 months of age having shortest times and dogs seven to nine months of age requiring the longest times to achieve correction. If no progress is seen at the three-week reassessment, other treatment options should be reconsidered.

ref: Verhaert, L. A Removable Orthodontic Device for the Treatment of Lingually Displaced Mandibular Canine Teeth in Young Dogs. J Vet Dent 16(2); 69-75, 1999.

BONDED SEALANTS:

Enamel fractures and uncomplicated crown fractures expose the microscopic dentin tubules to oral bacteria and fluid. The tooth can die and become infected. There is some discussion and controversy when to “seal” uncomplicated crown fractures and enamel fractures. Dental sealants are recommended with known acute uncomplicated fractures exposing the dentin tubules in young animals (<18-24 months of age). By sealing the dentin tubules, the dental pain from the exposed odontoblastic processes can be controlled and the translocation of bacteria and oral solutions resulting in pulp death can be prevented. The sealing of older uncomplicated crown fractures in older teeth and animals without a known recent fracture history remains controversial and lacks good scientific evidence to justify the treatment and associated expense. Dental sealants may be unfilled resins, resins with filler particles, glass ionomers, and/or combinations with or without fluoride used mostly as pit and fissure sealants for human teeth.

Cancer

Cancer of the oral cavity represents about 6% and 3% of all canine and feline tumors, respectively. Biopsy is required for diagnosis. The biopsy may be incisional or excisional depending on the size, differential diagnosis, and long-term surgical and medical plan. Oral tumors may be benign and of tooth origin (odontogenic tumors) or malignant. Many odontogenic tumors are successfully treated with surgical removal and many malignant oral tumors respond well to surgical removal. Malignant oral tumors may require additional adjunctive treatment with immunotherapy, chemotherapy, radiation, or other oncology treatment modalities

Canine Acanthomatous Ameloblastoma

Peripheral canine acanthomatous ameloblastoma (CAA) (a.k.a. acanthomatous epulis) may arise from the epithelial rests of Malessez, adjacent bone, and/or the periodontal ligament (PDL) – odontogenic tissues. CAA can aggressively invade bone, have a predilection for the mandibular incisor and premolar regions, are considered benign (do not metastasize). They can rarely transform to squamous cell carcinoma. Radiation can control 90% of ameloblastoma but 5% develop radiation necrosis and 5-20% will undergo malignant transformation at a later date. Acute and chronic radiation side effects can occur. Therefore, surgical resection is often chosen unless the patient requires the dentition to assist the owner or to perform its duties. Surgical margins should be minimally 1.0-2.0 cm. This tumor has a good prognosis with surgical resection so 1.0 – 2.0 cm margins are ideal whenever it is functionally possible. However, symphyseal sparing mandibulectomy and marginal rim excision techniques to preserve the function of the mandibular canine tooth /teeth mandibular symphysis, and ventral mandibular cortex, is possible if surgical margins can be obtained.

Canine Mucositis CUPS

canine chronic ulcerative stomatitis (previously known as chronic ulcerative paradental stomatitis or CUPS).

Common clinical findings in CUS include significant halitosis, ptyalism (excessive drooling) of thick and cloudy saliva, dermatitis of the lips and associated folds, oral discomfort and sometimes difficulty with eating or pain upon eating. There are many differential diseases for the lesions associated with CUS. Various immune mediated diseases may look similar, uremic syndrome, or other contact ulcerations from contact with caustic materials can mimic the pattern of lesions seen with CUS. For this reason, biopsy of the oral tissues is often recommended as part of the initial diagnostic process. Bloodwork is often unremarkable in the CUS patient beyond findings typical of a patient affected with chronic inflammatory disease.

Periodontal disease and CUS are two separate conditions that may present in the same patient at the same time, or separately. CUS is characterized by ulceration of the oral tissues not included in the periodontium. The four tissues of the periodontium are gingiva, alveolar bone, cementum, and periodontal ligament. Chronic ulcerative mucositis often affects the surfaces of the tongue, labial or buccal mucosa, palate, and caudal pharyngeal mucosa. The pattern of ulceration may vary, but in general, the lesions are diffuse within the oral cavity and will often affect the labial mucosa that is in contact with the larger teeth in the mouth (canines and carnassial teeth) creating a “contact mucositis.”

CUS is not felt to be a true immune dysfunction, but is more consistent with a dysregulation of the immune system in response to chronic antigenic stimuli. The antigens are felt to be contained within the bacterial plaque on the tooth surface. Some patients may have minimal appreciable plaque present on their coronal tooth surfaces with a significant inflammatory response. This finding has directed most of the current treatment modalities for CUS at meticulous control of the plaque biofilm via periodontal treatment, reduction of plaque retentive surfaces, aggressive home care, and immunomodulation, if appropriate. Conservative treatment that is limited to medical therapy is not rewarding in these patients and will only serve to delay proper treatment efforts. Antibiotics as a monotherapy are not appropriate for CUS and will not be effective in control of the plaque biofilm. A recently published paper demonstrated findings that support the potential for this condition being described as a true immune-mediated disease. Severe periodontitis and other inflammatory mucosal lesions may be misdiagnosed as canine chronic ulcerative stomatitis.

Cavalier King Charles Spaniels, Greyhounds, and Labrador Retrievers are considered to be predisposed to this condition, and some authors feel that Scottish Terriers and Cocker Spaniels should also be included on this list. There may be a familial predisposition in Maltese as well.

Initially, a periodontal examination and full mouth radiographs are part of the diagnostic process. A biopsy may be recommended to assist with differentiation of ulcerative mucosal lesions caused by ulcerative stomatitis from other autoimmune diseases including mucus membrane pemphigoid & bullous pemphigoid. Some patients may undergo dental extractions as part of their initial anesthetic procedure, and in some patients this may extend to full mouth extractions.

Conservative treatment of these cases is felt to be unrewarding and results in prolonged discomfort and inflammation for the patient. Aggressive treatment with extractions combined with medical therapy is often used to resolve the condition and return a pain and infection free oral cavity to the patient. While antibiotics may be utilized as part of the treatment protocol, it is never considered appropriate as a monotherapy and absolutely never in a pulsatile function.

Supplemental medical therapy may be utilized as part of the treatment protocol for ulcerative stomatitis.
Once the oral pain is reduced, daily brushing of the oral cavity to keep plaque (the oral biofilm) reduced to as low of levels as we can possibly maintain is combined with regular anesthetized periodontal cleanings and assessments. With brushing, the mechanical action of the nylon bristled brush will break-up the oral biofilm and reduce the overall plaque levels within the mouth.
Each protocol is tailored specifically to each individual patient.

Canine Tooth Resorption

Resorption of the hard structures of the tooth (i.e. enamel, cementum, and dentin) is the result of osteoclasts removing the mineral from the tooth. These normal cells can be activated by infection and inflammation secondary to conditions such as endodontic disease (e.g. fractured teeth, discolored teeth), periodontal disease (e.g. gingivitis, periodontitis), and trauma. Intraoral radiographs are required to diagnose and treat the condition. There are various classifications of external and internal resorption and treatment may include surgical extraction, root canal treatment, or intraoral radiographic monitoring.

Peralta, et al. (2010) identified increased frequency of tooth resorption in older and large-breed dogs with no sex predilection. A population of 224 dogs with full mouth intraoral radiographs was evaluated. Tooth resorption was detected in 53.6% of the dogs (11.1% of all teeth evaluated had tooth resorptive lesions: 8.7% External Replacement Resorption and 1.4% External Inflammatory Resorption). The human classification system could be applied to 96.3% of the affected teeth. Canine tooth resorption was a common finding. The majority of tooth resorption was External Replacement Resorption (34.4% of dogs) and External Inflammatory Resorption (25.9% of dogs).

Radiographic and Clinical Descriptions of Types of Canine Tooth Resorption
External Replacement Resorption – disappearance of the periodontal ligament space and replacement of tooth structure with alveolar bone
External Inflammatory Resorption – loss of dental tissues and adjacent alveolar bone secondary to inflammatory conditions such as endodontic and periodontal disease
External Cervical Root Resorption – resorptive process starting at cementoenamel junction of the tooth that progresses coronally and apically
External Surface Resorption – resorptive lacunae involving the cementum and dentin and not the periodontal ligament and lamina dura, the periodontal ligament remains
Internal Inflammatory Resorption – oval-shaped irregularity within the pulp canal resulting from endodontic inflammation
Internal Surface Resorption – apical third oval-shaped enlargement that may represent revascularization following a mild traumatic injury
Internal Replacement Resorption – irregular enlargement with tunnel-like appearance adjacent to pulp canal

Peralta S, Verstraete FJ, Kass PH. Radiographic evaluation of the classification of the extent of tooth resorption in dogs. Am J Vet Res 2010; 71(7): 794-798.
Peralta S, Verstraete FJ, Kass PH. Radiographic evaluation of the types of tooth resorption in dogs. Am J Vet Res 2010; 71(7): 784-793.

Chronic Inflammatory Nasal Disease and Dental Disease

Chronic lymphoplasmacytic rhinitis (LPR)/inflammatory rhinitis are a common diagnosis for nasal disease of dogs but a frustrating condition for veterinarians, owners, and veterinary specialists. This histological diagnosis is nonspecific and does not allude to a cause for the chronic inflammatory condition in many cases. In a canine computed tomography (CT) rhinitis study, 47% of the dogs had idiopathic inflammatory rhinitis. (1) Rhinitis can persist for months, or years, with associated patient morbidity while the condition remains undiagnosed, and non-responsive to empirical treatment such as corticosteroids, antihistamines, and possibly a temporary response to antibiotics.(2) The lack of a complete response to different empirical pharmaceutical therapies would suggest there are multiple etiologies for the histological diagnosis of LPR and its variants.

It is well documented that odontogenic pathology is a cause of sinusitis in humans, but the actual prevalence is debated. Respiratory mucosal pathology occurs secondary to periodontal and endodontic infections. In dogs and cats the maxillary tooth roots are juxtaposed to the nasal cavity, whereas in humans they are juxtaposed to the maxillary sinuses. In dogs and cats, the anatomical location of the roots of the maxillary incisors, canine, premolar teeth, and molar teeth are intimately involved with the nasal cavity and/or maxillary recess with millimeter(s) of maxillary bone separating the dental and nasal structures. (3,4) In either species, the respiratory mucosa can be damaged by infection and inflammation arising from the teeth.

Many cases of chronic nasal disease require advanced imaging, with CT or MRI, followed by rhinoscopy and biopsy. Advanced imaging for nasal disease is beneficial for differentiating neoplasia from other nasal diseases.(5) Odontogenic infections should be considered in cases of inflammatory rhinitis prior to long term medical management, potentially reducing associated morbidity and financial costs. A multi-disciplinary approach (i.e., internal medicine and dentistry), based on the medical history, signalment of the individual patient, and diagnostic modalities should be wisely chosen early in the diagnostic phase.

A recently published study in the Journal of Veterinary Dentistry demonstrated that an association between odontogenic infection and inflammatory rhinitis was identified in 55% of cases evaluated, undetermined in 35%, and unlikely in 10% of cases assessed. (6) Of the cases with an association, radiographic signs identified in patients were consistent with endodontic disease (60%), periodontal disease (45%) and retained tooth roots (25%). This paper not only supports odontogenic disease as a significant contributor to canine lymphoplasmacytic rhinitis, but it also indicates that in some cases, oral examination and intraoral radiographs may be a more direct and cost effective approach for diagnosis and treatment of inflammatory rhinitis.

CROWDED AND ROTATED TEETH:

Crowded and rotated teeth often present in the brachycephalic and toy breed dogs. Crowding predisposes to the development of periodontal disease. Gingiva, a tissue of the periodontium, should surround each tooth for normal periodontal health and protection of the subgingival periodontal tissues. Interceptive extractions, following intraoral radiographs and periodontal examination, to remove the less strategic premolars and incisors to preserve strategic teeth should be considered on an individual patient basis. Selective extraction of a few teeth can help prevent chronic periodontal infection and loss of several teeth and the important strategic teeth. Regardless, daily meticulous home care and preventive annual dental cleanings are recommended.

CROWNS

Metal crowns may be used to protect a tooth after a root canal treatment and/or restore the normal architecture for the tooth, optimizing structure and function. Unlike people, the bite and shearing forces in dogs are too great to allow use of gold crowns, which are too soft with withstand wear and strain. Instead, noble metal alloys or metal alloys are used to protect the teeth. The use of metal crowns are chosen based on the amount of tooth missing, the purpose of the dog, the potential wear and future trauma to the dogs teeth, and overall systemic health of the dog. Tooth colored zirconium crowns are sometimes also used in veterinary dentistry. Potential complications of crowns can be loss of tooth vitality (if applied to a vital tooth), fracture at the crown base of some teeth (depending on anatomical structure), or loss of the crown and the need for refabrication or recementation.

Crown Reduction

In some cases where a tooth is causing trauma to the soft tissue in the oral cavity, an opposing tooth, and/or creating holes in the hard palate [e.g. base narrow (linguoversed) mandibular canine teeth)] the offending tooth can be reduced in height. However, since the pulp cavity will be exposed when crown reduction is performed, a partial coronal pulpectomy and direct pulp capping (vital pulpotomy) must be done with the procedure to protect the pulpal tissues and encourage formation of a hard tissue to protect the bridge.

CT

Computed tomography uses x-rays to obtain images that are processed by a computer to allow geometric reconstruction of the region (3-D) and digital slices of the anatomy for assessment. In dentistry and oral surgery CT is often used for treatment planning for oral tumors, maxillary and mandibular fractures, intruded roots into the nasal cavity or mandibular canal, problems with the temporomandibular joints, difficulties or pain opening and closing the mouth, and assessment of some soft tissue diseases of the head.

Dental Extractions

The teeth in the dog and cat are much more difficult to extract compared to human teeth. Surgery is the cutting of tissues. In order to extract teeth the gingival tissues, the bone tissues, and the tooth tissues require cutting, removal, and sectioning. Therefore, “extraction” of teeth is a surgical procedure in the dog and cat. Following surgical removal of the tooth, the alveolus is cleaned and lavaged. Finally, the bone is smoothed to remove sharp fragments and the extraction site is sutured closed. Even if the teeth are so diseased they “fall out” the infected soft tissues and bone should be cleaned, contoured, resected, and fresh surgical margins sutured to promote rapid healing and minimize complications such as bone infections, bone necrosis, oronasal fistulas, and chronic pain and infection. All surgical extractions and extractions referred to Pacific NW Veterinary Dentistry and Oral Surgery Service are performed by our Veterinary Dental Specialists.

Dentigerous Cyst

Unerupted teeth (embedded or impacted) can lead to dentigerous cyst formation and destruction of the bone and adjacent teeth. This condition is preventable so all regions of missing teeth should be evaluated with intraoral radiographs in the young animal after the time period in which adult dentition should be present (greater than 6 months of age). Unerupted teeth should be extracted as indicated. Dentigerous cysts need to be surgically debrided and the cystic lining removed with the offending tooth.

Diabetes and oral dz

Management of diabetes mellitus and the oral cavity is a two-way street. Diabetes mellitus decreases local oral immunity and changes microvascular circulation, resulting in increased risk for and incidence of periodontitis. Increased periodontitis increases systemic inflammatory mediators which can make insulin management more difficult. Daily oral care and professional periodontal cleanings are important to help manage oral health. Likewise, fractured teeth with endodontic infection and hidden periapical infections below the gumline can also result in counter acting inflammatory mediators, resulting in increased insulin requirements. It has been found that addressing inflammatory and infectious diseases within the oral cavity can improve blood glucose regulation. After a diabetic patient has received treatment for periodontal or endodontic disease, their insulin needs should be closely monitored for potential needed adjustments; some patients may have increased risk of hypoglycemia due to reduced insulin requirements.

Direct Pulp Capping (Vital Pulpotomy)

When a tooth is fractured or a caries (cavity) is present and the pulp is nearly exposed, or acutely exposed, an indirect or direct pulp capping (vital pulpotomy), respectively, is used to stimulate reparative dentin by the tooth. A composite restoration is normally placed over the pulp capping material.

Electrical Cord Burn

ORAL ELECTRICAL INJURY
Chewing on electrical cords may cause severe injury to the soft tissue, bone, and dentition. Necrosis, fibrosis and wound contracture are sequelae to oral electrical injuries. Developing tooth buds and/or dentition may be damaged. Low voltage (<1000 V) conduction and arcing currents generate 2000 C to 4000 C temperatures. Injuries to the tissues may take many days or weeks to delineate and demarcate. Blanched, pale, gray, tan, ulcerative mucosa with secondary infection results. Oronasal fistula, functional disfigurement, dysphagia, secondary infection, and severe morbidity may result. Multiple organ failure and non-cardiogenic pulmonary edema may result. Long-term osteonecrosis of the bone, non-vital teeth, and infected teeth and bone, soft tissue wound contracture and fibrosis may result requiring multiple and staged surgical treatments in some cases for tissue debridement, bone debridement, and tooth related injuries.

Enamel Hypomineralization

Enamel hypomineralization refers to inadequate mineralization of the enamel matrix during tooth development. The defect often involves multiple teeth and is characterized by soft, flaky enamel that is worn off rapidly. Exposed dentin resulting in pain and infection can follow. Intraoral radiographs and treatment as indicated are recommended.

Enamel Hypoplasia

Enamel hypoplasia refers to inadequate deposition of enamel matrix during tooth development. This may be secondary to trauma, high fever, and/or infection. One or multiple teeth may be affected. Exposed dentin resulting in pain and infection can follow. Intraoral radiographs and treatment as indicated are recommended.

ENDODONTICS – Caries

A progressive destruction of the tooth structure secondary to bacterial microorganisms, on the tooth structure, that ferment carbohydrates (sugars) to acid that destroy the mineralized portions of the tooth while the bacterial enzymes destroy the connective tissues of the tooth. Treatment options include pit and fissure sealants, cavity restoration, or endodontics depending on the stage of the caries lesion.

Eosinophilic granuloma complex

Not all lesions in the eosinophilic granuloma complex are perfectly described by the name. There are three different classes of this condition; not all lesions are granulomas and not all lesions involve eosinophils. Eosinophilic granuloma complex lesions are symptoms of a variety of underlying causes such as allergy, contact reactivity, or even bacterial infection. Eosinophilic granuloma complex lesions represent a temporary or chronic disorder of eosinophil function.

The three classes of eosinophilic granuloma complex are:
1. indolent ulcer: most commonly found as an erosion on the margin of the upper lip and/or a proliferative lesion on the tongue
2. eosinophilic plaque: most common appearance is a raised, thickened, ulcerated lesion most commonly found on the belly, inner thigh, perineal, or throat area
3. eosinophilic granuloma: typically presents as a swollen lower lip or chin, or a long, narrow lesion on the caudal thigh

An individual cat may have any combination of these lesions; they may have one or potentially all of them. Most commonly, it is felt that these cats have an underlying reactivity, but it is not always possible to determine what that reaction may be to. It may be a parasite reactivity, a contact with a medication, an environmental reactivity, or other substance. The development of any lesion consistent with eosinophilic granuloma complex does not definitively mean has any specific type of allergy. There is some evidence suggesting that many cases begin as simple allergic reaction to an external substance, that is then compounded by a reaction to “self” proteins when released by the pet scratching or a break in then skin.

EPULIS:

By definition, an epulis is any gingival growth. Hence, gingival hyperplasia or any malignant tumor is also, by definition, an epulis. However, historically “epulides” were referred to as benign locally invasive tumors. Epulides compromise approximately 20-30% of oral tumors.

An “acanthomatous epulis” is an odontogenic tumor termed acanthomatous ameloblastoma and a “fibromatous epulis” or “ossifying epulis” are odontogenic tumors termed peripheral odontogenic fibroma. A “fibrous epulis” is not a tumor but actually a reactive inflammatory lesion. Surgical removal of these tumors, associated teeth, and regional bone is necessary to stop the progressive local destruction and growth.

Expectations for Cleft Surgery

1. Due to the defect between the oral and upper respiratory system, aspiration pneumonia is a concern in the perioperative period and leading up to the time of surgery. Please monitor signs for lethargy, coughing, anorexia and call a veterinarian immediately if you have concerns. Thoracic radiographs may be necessary pre-operatively in some cases.
2. Due to the defect rhinitis and nasal discharge is a concern. If thick green or yellow nasal discharge occurs, please call a veterinarian.
3. Although the best chance of surgical repair is the first surgery, small defects can persist and revision surgery may be needed in the future in order to repair small defects; particularly in the regions over the nasopalatine fissures or the region over the caudal choanae where the hard palate and soft palate intersect. A prolonged (6-8 week) time frame may be necessary between surgical revision attempts.
4. Post-operative care and restricted activity are an important part of the surgical repair in order to keep foreign objects out of the oral cavity. In addition to leash control while outside at all time for the first two weeks, If there is a tendency or risk of putting foreign objects or feet in the mouth a basket muzzle and/or elizabethan collar may be necessary.
5. The type of surgery planned will expose the major palatine artery. The exposed bone and artery will heal by second intention.
6. Surgical dehiscence is a possibility even if done correctly due to the movement of the tongue and food boluses through the oral cavity. Soft food is necessary for 4 weeks post-surgery. Canned food only or kibble this softened with water. Feeding tubes may be used in referred cases with multiple failed repairs have failed but, I do not choose them for first time repairs.

7. Hemorrhage from major arteries is a possibility and avoided, but a risk due to the anatomical location of the major arteries in the skull.

FELINE CAUDAL MUCOSITIS/STOMATITIS

Feline caudal mucositis (a.k.a. “stomatitis”) is a frustrating oral condition for clients and veterinarians. The pathogenesis of the disease is not fully understood but it appears that an immunological mechanism is involved. However, this true immunological “stomatitis” needs to be differentiated from common other conditions such as periodontitis and diseases such as epitheliotropic lymphoma, autoimmune conditions, eosinophilic granulomas, etc. Particularly, aggressive periodontitis and adult onset periodontitis secondary to a plaque and bacterial biofilm and the inflammatory, may be mistaken and mistreated as “stomatitis”. It is important to recognize that “stomatitis” involves extension of the inflammation beyond the gingiva and mucogingival junction and involves the caudal pharynx, palatoglossal folds, the palatal mucosa, and the buccal mucosa. In some cases, it just involves the caudal oral mucosa (caudal mucositis). Caudal mucositis is a defining clinical pattern of inflammation for the consideration of “stomatitis”. Biopsy of the gingiva in these conditions results in a similar histopathological diagnosis of a cat with true immune dysregulated stomatitis.

Definitive treatment recommendations may differ depending on the consulting specialist and specialty. In many boarded veterinary dentists’ opinion, at this time, full mouth extractions provide the best long-term resolution. However, not every specialist may recommend the same treatment plan for each case. In some cases every tooth will be extracted where as in others, every tooth except the canine teeth will be extracted. Intraoral radiographs and clinical disease help determine the plan in each case. Ultimately, most cats with “stomatitis” end up with all the dentition completely extracted and many veterinary dentists will extract all the dentition in one surgical procedure.

Professional periodontal cleanings and home care cannot control the clinical inflammation and pain. Anecdotally, many patients who present refractory to chronic immunosuppression (long term steroid use) seem to have cross-reacted to additional dietary, environmental, and auto-antigens resulting in poorer surgical outcomes to full mouth extractions. However, a complete assessment and individual treatment plan must be made with each client and patient in order to meet the needs of the patient, the client, and to achieve the best possible outcome for each situation.

Full mouth extractions may not completely resolve all the inflammation and adjunctive therapy may be necessary. Intraoral radiographs and aggressive multimodal pain control are necessary. If continued medical management is necessary, fatty acids, appropriate lowest dose possible prednisolone treatment, and possibly cyclosporine, with appropriate clinical, blood, and drug monitoring, has been effective in some cases. After removal of all the teeth, corticosteroids may still be necessary in some cases. However, the dosage and frequency, along with their side effects, is often greatly reduced. Laser ablation therapy to remove chronically inflamed tissue and create scar formation has seen some success. Novel antigen diets and Omega-3 fatty acids may be of benefit in some refractory cases. Certain antimicrobial combinations and/or additional immunosuppressive therapy may be necessary post-extraction for the partial and non-responding patients. However, chronic long-term therapy with antibiotics is never indicated as a monotherapy for this condition or any condition of the oral cavity.

Treatment options include partial mouth extractions preserving the canine teeth or full mouth surgical extractions. Based on the inflammation of the canine teeth, clinical signs, and response to previous treatment. Full mouth surgical extractions are recommended. Expected outcomes and response to treatment were discussed (60% resolution, 20% greatly improved and some short term medical therapy needed, 13% improved but long term medical therapy needed, 7% minimal to no response).

Feline Malocclusion

Brachycephalic cats often have a scissors or level occlusion of the incisors. However, the mandibles have bowed laterally during growth. As a result the central cusp of the maxillary 4th premolar contacts the mesial/buccal tooth and periodontium of the mandibular 1st molars resulting in periodontal dehiscence and disease. This can result in a few different scenarios.

1. If the malocclusion is not readily apparent to the veterinarian, the lower 1st molar may be extracted and later will identify that the surgical site is not healing and/or identify a mass pre or post extraction that has a histological description such as pyogenic granuloma, lymphoplasmacytic gingivitis, etc. This mass or failure to heal is secondary to the trauma created by the maxillary 4th premolars on the soft tissues of the mandible.

2. Surgical extraction of a periodontally expired mandibular 1st molar with surgical extraction or appropriate crown reduction and endodontic and/or restorative treatment to remove the offending cusp(s) of the maxillary fourth premolar tooth.

3. If identified in the very early stages, prior to excessive trauma to the mandibular first molar, this condition may sometimes be treated with extraction or appropriately performed crown reduction of the maxillary 4th premolar. Teeth treated with endodontic or restorative therapy need radiographic reassessment 6-12 months after the initial treatment.

FELINE TOOTH RESORPTION

Feline tooth resorptive lesions are one of the most common problems in a cat’s mouth. Tooth resorption is a common and frustrating dental problem in the feline patient. It has been known previously by many names. The prevalence of the disease, in cats, has been reported in the literature as 20-75%. The cause of tooth resorption is not fully understood. The cause of these lesions may be multifactorial. One cause is oral inflammation secondary to periodontal disease. The lesions may sometimes be obvious on examination, but often are only identified with anesthesia, complete oral exam and dental radiographs. They lead to destruction of the tooth, inflammation of the gums, compromise of the root canal system, exposure of tooth nerves, and severe pain.

The idiopathic replacement resorption has had several theories proposed and the lesions are likely a combination of these factors. The lesions begin in the root, and can occur anywhere on the root surface and not just the cervical region. The resorption progresses into the dentin and enamel of the tooth root and crown. These lesions are painful, but, as with all dental and oral disease, the range of clinical signs can vary from partial anorexia, weight loss, halitosis, ptyalism, dysphagia, etc., to no obvious clinical signs at all. If the lesions remain below the gingival attachment, they are often asymptomatic since they dentin tubules and pulp are not exposed to the oral environment. The diagnosis of tooth resorption requires clinical examination and intraoral radiographs, while the patient is anesthetized; regardless of the cause, professional veterinary dental care is needed to address the teeth.

Teeth with tooth resorption require extraction or subgingival crown amputation following assessment with intraoral radiographs to assess the type of tooth resorption to determine the proper treatment.

If the roots are resorbing and being replaced by bone (Type 2), subgingival crown amputations are often elected because they are less invasive compared to surgical extractions of ankylosed teeth. If the roots are not being replaced by bone (Type 1), surgical extraction is chosen.

It is a requirement to utilize intraoral radiographs in order to determine the type of TR and therefore develop the treatment plan. Type 1 tooth resorption will have normal root opacity with a surrounding lamina lucida and usually a definable root canal. There may be associated periodontal or endodontic disease. With Type 2 (replacement resorption), the teeth have undergone significant resorption and have opacity more similar to the surrounding alveolar bone. There is loss of the lamina lucida and dentoalveolar ankylosis is present. There may be no discernable root structure present. Type 3 occurs when one root is Type 1 and one root is Type 2. It is essential that the surgeon use intraoral dental radiographs and understand Type 1, Type 2, and Type 3 lesions for treatment planning. Diagnosis requires anesthesia, a clinical exam, the use of a dental probe and explorer, and full mouth intraoral dental radiographs. Teeth with type 1 lesions must be extracted. Type 2 lesion teeth may be treated with subgingival crown amputation and intentional root retention.

If the teeth are candidates for subgingival crown amputations, the procedure is faster and less traumatic compared to extractions. However, a follow up procedure in 12 months to evaluate the resorbing roots is necessary. The disease is a progressive process. Therefore, follow up care to evaluate remaining teeth is also recommended.

After determination of type, tooth resorption can be staged. A staging scheme has been outlined by the American Veterinary Dental College.

Stage 1 (TR1): Mild dental hard tissue loss (cementum or cementum and enamel)
Stage 2 (TR2): Moderate dental hard tissue loss (cementum or cementum and enamel with loss of dentin that does not extend into the pulp cavity)
Stage 3 (TR3): Deep dental hard tissue loss (cementum or cementum and enamel with loss of dentin that does extend into the pulp cavity)
Stage 4 (TR4): Extensive dental hard tissue loss (cementum or cementum and enamel with loss of dentin that does extend into the pulp cavity; most of the tooth has lost its integrity)
TR4a (crown = root), TR4b (crown>root), TR4c (crownGingival Hyperplasia

Pseudopockets are created when the gingiva enlarges (often gingival hyperplasia and hypertrophy) and the marginal bone remains at the appropriate level. The gums enlarge and overgrow the teeth. Breeds such as Boxers, Bull dogs, and Collies have a genetic predilection for gingival hyperplasia. Common veterinary medications such as cyclosporine and amlodipine may cause gingival enlargement and should the oral cavity should be evaluated and kept clean when these drugs, particularly cyclosporine, are being administered.

Guided Tissue Regeneration

Osseous additive surgery (Guided tissue regeneration, aka GTR) is the new formation of periodontal tissues (i.e. cementum, periodontal ligament, and alveolar bone) that had been destroyed from periodontitis. GTR involves open periodontal flaps, +/- root surface preparations, +/- grafting materials, +/- biological modifiers, and periodontal membranes. Intraoral radiographs, in conjunction with general anesthesia, are required for assessment, treatment planning, and treatment execution. The patient needs to be medically stable and daily home care is necessary post-operatively.

INTERCEPTIVE EXTRACTIONS:

Removal of teeth before chronic trauma and/or periodontal disease results is called interceptive extractions. Crowded teeth can predispose and potentiate periodontal disease. Likewise, retained (persistent) teeth can also lead to periodontal infection. Sometimes adult teeth that are involved in malocclusion are contacting and traumatizing other teeth or soft tissue, and extraction will alleviate the contact and associated pain infection

Intraoral Radiographs

Dental disease is very common in dogs and cats. Unfortunately, they normally do not show obvious clinical signs. Additionally, much of the disease process is below the gumline (gingiva) involving the tooth root and bone. Intraoral radiographs (x-rays) are required to make a diagnosis. The black and white images allow assessment of the tooth roots and surrounding bone.

Intraoral radiographs are invaluable in the assessment and identification of dental disease in dogs and cats. Published literature supports that intraoral radiographs will reveal significantly more information about the state of a pet’s oral health, allowing more complete treatment.

Juvenile Feline Gingival Hyperplasia

Feline juvenile gingivitis (aka juvenile hyperplastic gingivitis) is a pronounced generalized inflammation of the gingival tissues in the young cat. Certain breeds are over-represented including Maine Coons and Siamese. It is typically diagnosed between 7-10 months of age. This juvenile form of gingivitis may represent exaggerated tooth eruption inflammation. It is distinguished from other oral inflammatory disorders in that the generalized gingivitis has not radiated to the mucosa or caudal oral tissues as in stomatitis. Typically, periodontitis changes, including alveolar bone loss, gingival resorption, pocket formation, and/or root exposure, are not seen. In many such cases if the oral inflammation can be controlled and kept controlled for the first 2 years of life, recurrence may be decreased or prevented altogether. At this age these patients often mature into a more normal state. On the other hand, juvenile cats with this form of oral inflammation who are not controlled aggressively at a young age suffer permanent anatomical changes and frequently progress to severe periodontitis or even stomatitis.

Magnetic Resonance Imaging (MRI)

MRI uses strong magnetic fields to obtain images that are processed by a computer to allow geometric reconstruction of the region (3-D) and digital slices of anatomy for assessment. MRI does not use ionizing radiation (x-rays). MRI use in dentistry and oral surgery is for oral tumors of soft tissue nature, salivary disease, muscular disease, and atypical swellings of the head and neck.

Maxillary (Face) swelling and draining tracts

Maxillary (Face) swelling and draining tracts should be investigated for odontogenic (tooth) infections, such as periodontal disease or endodontic disease, prior to extensive dermatological or neoplastic work ups including advanced imaging and biopsy. Teeth should be the primary differential for the maxillofacial swellings and draining tracts. The pathology is easily diagnosed with an appropriate anesthetized examination and intraoral radiographs. Extraction of affected teeth is the most commonly applied treatment. Endodontic therapy is occasionally a treatment option, but is less often employed due to concurrent loss of periodontal tissues and factors that reduce the success rate of therapy.

The most common cause of odontogenic infections secondary to endodontic disease is tooth fracture. All fractured teeth with pulp exposure require endodontic treatment or extraction. Intraoral dental radiographs for assessment and treatment are required. Many teeth with uncomplicated crown fractures and enamel fractures may also have endodontic disease requiring treatment that can only be found via intraoral radiographs. Localized intrinsic staining (discolored) is consistent with a non-vital tooth. In a published study, total or partial pulp necrosis was found in 92.2% of intrinsically stained teeth. Radiographic signs consistent with endodontic disease were absent in 42.9% of the teeth, supporting that in discolored teeth treatment is often indicated even without supporting radiographic changes. Radiographic changes of endodontic disease lag behind microscopic and gross clinical lesions. Endodontically infected teeth require surgical extraction or root canal treatment.

Root canal treatment includes mechanical and chemical removal of pulp, bacteria, dentin, and toxins while shaping the canal for a 3-dimensional obturation. The canal is obturated with endodontic sealants and core materials. Finally, a restoration or crown, as indicated, is placed to complete the procedure and restore the tooth.

Dogs and cats are carnivores and their teeth are important for oral function, but the primary goal of treatment is a pain-free and infection-free mouth. The teeth in the dog and cat are much more difficult to extract compared to human teeth. Surgery is the cutting of tissues and, in order to extract teeth, the gingival tissues, the bone tissues, and the tooth tissues require cutting, removal, and sectioning. Therefore, “extraction” of teeth is a surgical procedure in the dog and cat. Following surgical removal of the tooth, the alveolus is cleaned and lavaged. Finally, the bone is smoothed to remove sharp fragments and the extraction site is sutured closed. Even if the teeth are so diseased they “fall out” the infected soft tissues and bone should be cleaned, contoured, resected, and fresh surgical margins sutured to promote rapid healing and minimize complications such as bone infections, bone necrosis, oronasal fistulas, and chronic pain and infection.

Not all patients have an obvious fracture with pulp exposure. Some patients may present with abrasion of the cusp or “closed” trauma that resulted in damage to the pulp tissue and endodontic death leading to abscessation or sterile granuloma formation. As previously emphasized, intraoral radiographs and periodontal assessment are needed to determine the source and remove or treat it to resolve the situation.

Maxillary and mandibular fractures

Maxillary and mandibular fractures often occur secondary to trauma and/or severe dental disease (e.g. periodontal disease, endodontic disease). A tape muzzle may be used to temporarily stabilize the fractures while other associated life threatening trauma induced conditions are treated. Once your pet is stable for anesthesia, oral fractures can be repaired.

Prior to surgical intervention radiography and/or advanced imaging with CT scans are required to plan the surgery and peri-operative labwork is collected.

Mandibular and maxillary fractures are repaired with preservation of teeth and maintenance of normal occlusion as a goal. By returning the occlusion to a normal position without damaging root structures, the neurovascular bundles, and teeth the bone can heal without damaging teeth unnecessarily. Additionally, infected and abscessed teeth, in and near the fracture site, need treatment to allow healing of the bone. Interfragmentary and interdental wire techniques reinforced with composite intraoral splints achieve a goal of normal occlusion and preservation of teeth. Placing the teeth in occlusion via the use of non-invasive intraoral fracture techniques using interdental wire and composite material allows rapid return to function and maintenance of an appropriate occlusion. A composite material is temporarily bonded to the teeth to align the teeth and bones. Composite splints are reinforced with wire to give added strength to the surgical construct.

Maxillectomy/Mandibulectomy

What to Expect and Post-operative Sequelae:

Post-operative expectations include, but are not limited to, the following:

The goal is to have a pain free, infection free, and functional oral cavity with removal the oral tumor and/or necrotic bone/tissue. Although it is preferred to have acceptable cosmesis, every client has different opinions and assessments and what is acceptable for them and what they are comfortable with. The lips may have to be positioned more inwards, there may be additional unsupported soft tissue with bone removal, etc. with the goal to remove the tumor and have a tumor and pain free oral cavity. Unlike in people where multiple anesthetic procedures and surgeries over months and years may be undertaken for complete maxillofacial reconstruction, that is not the goal or standard in veterinary medicine and surgery.

Surgical sites may have dehiscence (come apart) due to the movement of the oral cavity, tongue, and/or air moving through the nose (for maxillectomy procedures). This may require additional surgery to revise the surgical site in some cases.

Drooling, having food and water fall from the oral cavity, and/or combination can occur and be temporary or permanent, depending on the type and location of surgery.

Minor blood tinged saliva discharge from the oral cavity for several days will likely occur.

The occlusion and position of teeth in relation to the jaws and soft tissue may change and require augmentation or extraction to provide a harmonious occlusion.

Rechecks to assess healing are necessary and long term follow up is based on the diagnosis of the tumor and until surgical margins and tumor types are known absolute recheck plans may not be known.

With mandibulectomy surgery there may be tongue lolling (tongue deviating from mouth), there may be increased saliva or water they may leak from the mouth due to the necessary change in conformation to achieve surgical goals.

With maxillectomy surgery the skin on the noise may move in and out for several weeks following a maxillectomy due to surgical exposure of the nasal cavity. There may be some mild bloody discharge and sneezing from the nasal cavity on the side of the surgery. The surgical wound may pull apart (surgical dehiscence) depending on the reason and location of the surgery. It is more common to have these problems with surgery in areas of the maxilla (upper jaw).

Not every possible sequelae, scenario, or outcome can be addressed in these notes as each occlusion, patient, medical diagnosis, and surgical plan is different.

Generally the goals are to remove the tumor and/or diseased tissue, provide a comfortable, functional, pain free, and infection oral cavity and occlusion.

Mesioversed canine

A mesioversed tooth is anatomically in the correct position in the jaw, but when the tooth is abnormally angled in a mesial (forward) direction. Mesioversed maxillary canine teeth are encountered commonly in Shelties however other breeds and cats may be affected. Correction of this condition requires orthodontic movement or extraction of the misplaced tooth. If left untreated, mesioversed canine teeth, and the adjacent dentition, are predisposed to periodontal disease due to crowding. Additionally, the tooth may be in a position of traumatic occlusion with the opposing mandibular canine tooth, leading to pulpitis, pain, and pulp necrosis.

Odontoplasty

Odontoplasty is the reshaping/re-contouring of the tooth surface (enamel and dentin) to enhance plaque control as well as to correct crowded, uneven, and roughened tooth surfaces. In veterinary dentistry, this procedure is utilized for teeth with enamel fractures and uncomplicated crown fractures. Dental sealants must be applied following odontoplasty to seal the exposed dentin tubules. Odontoplasty may also be used to help correct traumatic malocclusions where there is tooth on tooth contact or tooth on soft tissue contact.

ORAL MASS/TUMOR:

Cancer of the oral cavity represents about 6% and 3% of all canine and feline tumors, respectively. Biopsy is required for diagnosis. The biopsy may be incisional or excisional depending on the size, differential diagnosis, and long-term surgical and medical plan. Oral tumors may be benign and of tooth origin (odontogenic tumors) or malignant. Many odontogenic tumors are successfully treated with surgical removal and many malignant oral tumors respond well to surgical removal. Malignant oral tumors may require additional adjunctive treatment with immunotherapy, chemotherapy, radiation, or other oncology treatment modalities.

ORONASAL FISTULA/OROANTRAL FISTULA:

An oronasal fistula (ONF) or Oroantral fistula (OAF) is a communication between the oral and nasal cavity. There may be an obvious defect in the upper jaw secondary to trauma, extracted tooth, or lost tooth. The size of a defect on the surface is not typically a good indicator of if the underlying defect in the bone is small or large, and we know that the bone defect must be at least as large as the tooth that originally or currently occupied the space. There may also be inapparent hidden ONF associated with a diseased tooth. The communication can result in chronic inflammation of the nasal cavity (rhinitis) and nasal discharge (e.g. blood, mucous, clear fluid). Regardless of the cause the defect requires surgical repair with a mucoperiosteal flap.

A recent retrospective publication reported 47.3% of ONF/OAF in Dachshunds and 21.3% in the matched control group. If one ONF/OAF was present then 62.8% and 55.5% of the patients had 2 or more ONF/OAF present, respectively. The maxillary canine teeth were the most commonly affected dentition.

Sauve CP, MacGee SE, et al. Oronasal and Oroantral Fistulas Secondary to Periodontal Disease: A Retrospective Study Comparing the Prevalence Within Dachshunds and a Control Group. J V Dent 2019; 36(4): 236-244

Post-Treatment Recommendations:
1. Feed softened food or canned food (you may soak the dry food for 10-15 minutes) for the next 14 days.
2. Feed 1/2 of the normal amount of food tonight. Divide this into two smaller meals, separated by an hour.
3. No exercise toys, chew sticks, ice cubes or hard toys of any kind for the next 14 days.
4. Leash control while outside to urinate and defecate for 14 days.
5. Recheck in 2-3 weeks, there will likely be resorbing suture at that time.
6. A periodontal cleaning in ^ months is recommended.
7. There may be some drainage/discharge from the mouth with possible blood tinged saliva present for the next several days. It should decrease each day, however if it does not resolve, please contact us.
8. Mild to moderate facial swelling may develop over the next 24-48 hours. This will typically resolve quickly.
9. Some of the medications used for anesthesia can result in increased vocalization in a small number of patients; this typically will resolve later this evening or by the following day.

ORTHODONTICS – Normal Occlusion

“With orthocclusion (normal occlusion), the mandibular incisors occlude on the cingulums of the maxillary incisors; the mandibular canines interdigitate, without touching, between the maxillary third incisors and canine teeth. The mandibular and maxillary premolars interdigitate, and the tips of the upper and lower second premolars are at the same horizontal level. Malocclusions are deviations from the normal occlusion. Considered to be genetic or developmental in origin, malocclusions can be the result of skeletal and/or tooth abnormalities. Malocclusions result in trauma from abnormal tooth to tooth contact and tooth to soft tissue trauma.”

https://avdc.org/avdc-nomenclature/ (reprinted with permission, AVDC)

Pathologic Fracture

Severe bone loss from periodontal disease and/or endodontic disease in the mandible of the dog, particularly small breed dogs, weakens the bone and forces that would not normally lead to fracture can cause the mandible to easily break. Treatment requires removal of all infected teeth and roots from the fracture site. Repair may include inter-fragmentary wires, interdental wires and non-invasive intraoral splints, maxillofacial mini-plates, or tape muzzles. In order to repair maxillofacial fractures the oral surgeon needs to be skilled and knowledgeable of a variety of techniques and respect the occlusion and teeth in order to return the patient to appropriate occlusion and function.

Periodontal disease in Dog’s

Periodontal disease is an insidious subgingival (below the gumline) disease caused by the subgingival plaque biofilm (Plaque is a biofilm of bacteria and products in the oral cavity) and the pet’s inflammatory response to the biofilm. Mineralization of the plaque biofilm results in calculus (tarter). Periodontal disease is caused by the subgingival bacterial plaque biofilm and the associated inflammatory response. Significant periodontal disease can be present without calculus. Calculus is not the cause of periodontal disease. The periodontal infection and inflammation lead to local oral pain, tooth loss, regional disease and infection, and systemic changes. General anesthesia, oral examination, and intraoral radiographs are necessary to diagnose, stage, develop a treatment plan, and treat the periodontal disease. End stages of disease often require tooth extractions, some teeth may be saved with periodontal surgery, and the progression of disease can be slowed with professional periodontal cleanings and home care programs.

An anesthetized oral assessment with radiographs is required to fully identify all oral disease and pain in the oral cavity. It has been demonstrated that it is not possible to completely assess the full level of dental disease in our animal patients based on an awake assessment alone. Intraoral radiographs are required to make an appropriate determination. Much of the disease process is below the gumline (gingiva), involving the tooth root and bone. Intraoral radiographs (x-rays) are required to make a diagnosis. The black and white images allow assessment of the tooth roots and surrounding bone. Published literature supports that intraoral radiographs will reveal significantly more information about the state of a pet’s oral health, allowing more complete treatment. Doctors Verstraete, Kass and Terpak published a paper in the Journal of The American Veterinary Medical Association about the value of dental radiographs in dogs. They found that radiographs of teeth without clinical lesions yielded incidental or clinically important findings in 41.7 and 27.8% of dogs, respectively. Radiographs of teeth with clinical lesions confirmed the findings in 24.3% of dogs; they found additional information in 50% of patients and clinically essential information in 22.6% of patients. Older dogs derived more benefit from full-mouth radiography than did younger dogs.

Periodontal disease in Cats

Periodontal disease is an insidious subgingival (below the gumline) disease caused by the subgingival plaque biofilm (Plaque is a biofilm of bacteria and products in the oral cavity) and the pet’s inflammatory response to the biofilm. Mineralization of the plaque biofilm results in calculus (tarter). Periodontal disease is caused by the subgingival bacterial plaque biofilm and the associated inflammatory response. Significant periodontal disease can be present without calculus. Calculus is not the cause of periodontal disease. The periodontal infection and inflammation lead to local oral pain, tooth loss, regional disease and infection, and systemic changes. General anesthesia, oral examination, and intraoral radiographs are necessary to diagnose, stage, develop a treatment plan, and treat the periodontal disease. End stages of disease often require tooth extractions, some teeth may be saved with periodontal surgery, and the progression of disease can be slowed with professional periodontal cleanings and home care programs.

An anesthetized oral assessment with radiographs is required to fully identify all oral disease and pain in the oral cavity. It has been demonstrated that it is not possible to completely assess the full level of dental disease in our animal patients based on an awake assessment alone. Intraoral radiographs are required to make an appropriate determination. Much of the disease process is below the gumline (gingiva), involving the tooth root and bone. Intraoral radiographs (x-rays) are required to make a diagnosis. The black and white images allow assessment of the tooth roots and surrounding bone. Published literature supports that intraoral radiographs will reveal significantly more information about the state of a pet’s oral health, allowing more complete treatment. Doctors Verstraete, Kass and Terpak published a paper in the Journal of The American Veterinary Medical Association about the value of dental radiographs in cats. They found that radiographs of teeth without clinical lesions yielded incidental or clinically important findings in 4.8 and 41.7% of cats, respectively. Radiographs of teeth with clinical lesions confirmed the findings in 13.9% of cats; they found additional information in 53.9% of patients and clinically essential information in 32.2% of patients. Radiographs in cats with visible clinical lesions were found to provide diagnostic value 100% of the time. ‘s teeth have clinical findings, indicating that deeper periodontal disease will likely be found.

Persistent Deciduous

Dogs and cats have two sets of teeth. There are 28 deciduous teeth (baby) teeth in the dog and 26 in the cat. When adult dentition is erupting the deciduous teeth should exfoliate. When the adult dentition has moved into position (average 4-6 months of age) there should be no remaining deciduous teeth. If this occurs, the pet has retained (persistent) deciduous dentition. No two teeth of the same type can occupy the same space at the same time. Retained deciduous teeth lead to, and potentiate, malocclusions and periodontal disease (periodontal infection). It is recommended that retained (persistent) deciduous teeth be extracted as soon as possible when identified.

POF

Peripheral Odontogenic Fibroma, formerly called an ossifying or fibromatous epulis. An epulis is a non-specific descriptive term applied to focal, exophytic gingival enlargements. The term “epulis” gives no information with respect to behavior of the mass, etiology, or patient prognosis. Masses that have been historically classed as epulides may be more accurately identified as tumors of odontogenic origin once they have been examined histopathologically. These odontogenic tumors are commonly found in the dog, and the most commonly found types are divided into two groups based on their behavior and appearance. They are the benign POF, both ossifying and fibromatous, and the locally invasive canine acanthomatous ameloblastoma (CAA). Additionally, focal fibrous hyperplasia (FFH), an inflammatory lesion, is often misdiagnosed as POF. An ossifying epulis is considered a clinical descriptive term, rather than a histologic diagnosis. The term epulis has become pervasive in the literature. Attempts to apply more correct histologic diagnoses to masses that have been diagnosed as epuli have been made. Clinically the masses are smooth, tend to occur in middle aged dogs and may have a predilection for the rostral maxilla, incisors and premolars. The presence of ossification does not denote a completely separate mass, rather a variant of a POF.

Most masses diagnosed as fibromatous or ossifying epuli are peripheral odontogenic fibromas, but some may be focal fibrous hyperplasias (FFH) that have been misclassified. Verstraete et. al. examined 154 oral tumors that were clinically diagnosed as epulides. Seventy-four of these lesions had been previously classified as fibromatous or ossifying epulides. Of these seventy-four lesions, 68% were reclassified as FFH and 28% were classified as POF. The potential for misclassification can create an additional layer of difficulty in assessment and treatment planning. This underscores the importance of sending tissue samples to pathologists skilled in oral pathology to obtain the most accurate diagnosis. FFH is an inflammatory lesion while POF is an odontogenic tumor. A diagnosis of FFH would indicate that clinical recommendations should be made to decrease focal inflammation in attempt to reduce recurrence. This recommendation could be increased homecare efforts, more frequent professional periodontal examinations and cleanings, or oral surgery to alleviate a pre-disposing factor such as crowding or malocclusion. Follow-up recommendations for POF consists of monitoring for recurrence combined with standard homecare recommendations such daily brushing. Potentially additional surgery to remove the mass to the level of the periosteum and alveolar bone could be performed if the initial biopsy was incisional, the mass was incompletely removed, or if regrowth after excision is identified.

En bloc excision of the tumor and the underlying bone is recommended for treatment of POF and is considered curative. This does not necessarily mean that a large maxillectomy or mandibulectomy must be performed. Current evidence supports removal to the level of the periosteum or superficial bone is sufficient for removal of a POF. It has been suggested that POFs originate from the periodontal ligament, leading to the clinical suggestion to extract closely associated teeth. This recommendation is not supported histologically. The noted fibroblastic proliferation, and often accompanying epithelial hyperplasia, are of gingival origin. In some cases, it may not be possible to remove the mass and spare the associated or adjacent teeth. In order to completely remove the mass, the periodontal support structures of regional teeth may be compromised; this may necessitate extraction of closely associated teeth. The presence or absence of boney tissue does not change the surgical recommendations, as evidence has not been found to differentiate clinical behavior between POF that have osseous metaplasia and those that do not. This histologic, and often gross, differentiation does not change the behavior or prognosis for POFs, rendering them essentially different variants of the same mass.

While metastasis has not been identified in POF, there is concern about recurrence after excision, reportedly varying from 0-17%. Combine the possibility of recurrence after excision with the suggestion that the mass arises from the periodontal ligament, and often lack of tooth extraction to remove periodontal ligament cells is blamed as a possible cause for recurrence. The human counterpart to a POF does not tend to recur after excision. It has been suggested that possibly recurrence could be due to failure to completely remove the tumor down to the bone or incomplete removal from the lingual and interdental aspects, areas that may be more difficult to navigate surgically. Additionally, misclassification of a FFH lesion or a canine acanthomatous ameloblastoma (CAA) as a POF could also lead to erroneous assumptions about the mass’ expected clinical behavior.

RECOMMENDATIONS FOR FRACTURED TOOTH WITH PULP EXPOSURE:

A fractured tooth with pulp exposure (complicated fracture) requires either root canal treatment or surgical extraction. As discussed, the goal of veterinary dentistry is to have a pain free and infection free oral cavity. This can be achieved with either a root canal treatment where the inside of the tooth (pulp and infection) is removed, disinfected, filled, and the tooth restored, or a surgical extraction.

With a root canal treatment, the function of the tooth will be preserved and the procedure is less invasive. However, follow up rechecks in future years are recommended. This will require additional, short anesthetic events and therefore some additional future expenses. After the initial reassessment, the tooth may be able to be monitored when the opportunity arises, depending on the initial reassessment findings. Additionally, loss of a strategic tooth may result in increased periodontal disease in adjacent teeth.

Surgical extraction is more invasive as the gum tissue needs to be cut and lifted off of the alveolar bone, bone needs to removed to access the tooth root structure, and the tooth surgically extracted. With surgical extraction the function of the tooth is lost and there is a longer post-operative recovery period. However, the procedure may be less costly compared to a root canal treatment, depending on the tooth involved.

The strategic teeth canine teeth (104, 204, 304, and 404), maxillary 4th premolars (108 and 208) and the mandibular first molars (309 and 409) are important teeth to consider root canal treatment to preserve form and function of the oral cavity and dentition. Additionally, incisors are often elected for root canal treatment for esthetic reasons.

Retrobulbar Swelling

Infection and inflammation in the retrobulbar and caudal maxillofacial region are common. Puncture wounds from sticks, plant material, and oral foreign bodies traumatize and inoculate the soft tissues of the caudal oropharyngeal region. Regional hidden periodontal and endodontic disease (odontogenic infection) can lead to inflammation and infection in the retrobulbar space due to the close proximity (millimeters) and incomplete ventral orbit of dogs and cats. Pain on opening the mouth and resistance to opening during the examination are common. Retropulsion of the ipsilateral (same side) eye is painful and an intraoral swelling or region of trauma may be identified in the pterygopalatine fossa. The ipsilateral eye may have chemosis and prolapse of the third eyelid. Diagnosis includes intraoral dental radiographs and advanced imaging as indicated. Treatment involves extraction of the offending tooth if it is related to an odontogenic infection (intraoral radiographs and periodontal examination are required to make the diagnosis). If it is not odontogenic infection or a zygomatic mucocele, then the patient is treated with antibiotics and anti-inflammatories. If the condition resolves then reoccurs, following cessation of medical therapy, investigation for a hidden plant or wood foreign body may be necessary.

ROOT CANAL TREATMENT

Total pulpectomy (root canal treatment) is used to treat teeth with complicated crown or crown-root fractures. Often root canal treatment is chosen for strategic teeth (mandibular and maxillary canine teeth, maxillary 4th premolars, mandibular 1st molars) and esthetic teeth (incisors). However, root canal treatment may be elected for any tooth depending on the purpose of the patient and the client’s desires. Root canal treatment includes mechanical and chemical removal of pulp, bacteria, dentin, and toxins while shaping the canal for a 3-dimensional obturation. The canal is obturated with endodontic sealants and core materials. Finally, a restoration or crown, as indicated, is placed to complete the procedure and restore the tooth.

SURGICAL ROOT CANAL TREATMENT

Surgical endodontics involves removing the apical portion of the tooth and adjacent infection. If re-instrumentation, disinfection, and obturation of a poorly performed or problematic endodontic procedure can resolve the endodontic lesion, then standard endodontics should be considered first. Indications for surgical endodontics include failed yet skillfully performed standard root canal treatment, procedural blockage that cannot be resolved, open apex [apexogenesis, apexification, apical stop, and/or normograde apical mineral trioxide aggregate (MTA®) placement is not possible], apical fenestration, periradicular drainage, or damaged, severely infected apex requiring removal and debridement. The objective is to remove severely damaged apical and periapical tissue and seal the endodontic canal with a retrograde filling. The commonly treated teeth are the canine and carnassial teeth in the dog.

TMJ

The temporomandibular joint (TMJ) is comprised of a transverse condylar process of the mandible that articulates with the mandibular fossa of the temporal bone. There is a dorsal and ventral compartment separated by fibrocartilaginous tissue. The retroarticular process and the articular eminence are bony boundaries that strengthen the articulation. The lateral ligament tightens as the jaw opens. The TMJ moves in flexion, extension, and translation (rostral and lateral movement). Translation is decreased in strict carnivores such as the cat. Canines and felines have a mandibular symphysis that joins and allows independent movement of the two mandibles.

TMJ Dysplasia

TMJ Dysplasia with Coronoid Displacement/Entrapment (open mouth jaw locking): The patients will present with the mouth locked wide open. The history often includes yawning that proceeds the open mouth jaw locking. Additionally, the history may include increase frequency of similar episodes, rubbing the face, and pawing at the face, in which the patient had unlocked the entrapment. The dorsal aspect of the coronoid is trapped ventral or lateral to the zygomatic arch on the contralateral side where the dysplastic TMJ joint allowed subluxation of the TMJ. Treatment includes anesthesia, partial zygomatic arch resection and/or dorsal coronoidectomy.

TMJ Luxation

TMJ Luxation (with or without fracture): TMJ luxation may occur with or without associated maxillofacial fractures. Often, but no always, the mandibles will deviate away from the contralateral (opposite) side involving the TMJ luxation. The mouth will often be slightly open but cannot be closed completely which is different from open mouth jaw locking. Treatment requires anesthesia, reducing the luxation, followed by a tape/nylon muzzle or interdental bonding for approximately 2 weeks.

Patients that have sustained trauma to the TMJ are at risk of ankylosis (fusing of the bone) or pseudankylosis (scar tissue stopping joint movement) can occur which may not allow the patient to open the mouth. This can occur months into the future, reportedly as late at 18 months.

TMJ Fracture

A fracture of the temporomandibular joint has special issues to consider. Even with correct repair ankylosis (fusing of the bone) or pseudankylosis (scar tissue stopping joint movement) can occur which may not allow the patient to open the mouth. This may occur as late at 18 months after the time of injury. A condylectomy surgery to remove the joint may then be required. A TMJ fracture is often repaired with a tape muzzle or interdental bonding, as indicated, followed by a rapid return to function and rehabilitation to minimize the risks of TMJ ankylosis.

Tooth Fractures

A “chipped tooth” is better termed a fractured tooth. A tooth fracture classification system is used to categorize various types of tooth fractures. Intraoral dental radiographs for assessment and treatment are required. All fractured teeth with pulp exposure require endodontic treatment or extraction. Classification of tooth fractures can be found at www.avdc.org/nomenclature.html. Enamel infraction (an incomplete fracture of the enamel without loss of tooth substance), enamel fracture (a fracture with loss of crown substance confined to the enamel), uncomplicated crown fracture (a fracture of the crown involving enamel and dentin that does not expose the pulp), complicated crown fracture (a fracture of the crown that does expose the pulp), uncomplicated crown-root fracture (a fracture of the crown and root that does not expose the pulp), complicated crown root-fracture (a fracture of the crown and root that does expose the pulp), and a root fracture (a fracture involving the root). Uncomplicated crown fractures may lead to the death of the tooth by translocation of bacteria and toxins across exposed dentin tubules or the force that fractured the tooth (concussive pulpitis). Complicated and uncomplicated crown root fractures may lead to periodontal disease since the normal anatomical structures of the subgingival periodontium are altered. All fractured teeth with pulp exposure require endodontic treatment or extraction.

A tooth fracture classification system is used to categorize various types of tooth fractures and a “chipped tooth” is more appropriately termed a fractured tooth. Intraoral dental radiographs for assessment and treatment are required to completely assess fractured teeth.

Classification of tooth fractures can be found at https://avdc.org/avdc-nomenclature/
-Enamel infraction: an incomplete fracture of the enamel without loss of tooth substance
-enamel fracture: a fracture with loss of crown substance confined to the enamel
-uncomplicated crown fracture: a fracture of the crown involving enamel and dentin that does not expose the pulp
-complicated crown fracture: a fracture of the crown that does expose the pulp
-uncomplicated crown-root fracture: a fracture of the crown and root that does not expose the pulp
-complicated crown root-fracture: a fracture of the crown and root that does expose the pulp
-root fracture: a fracture involving only the root

TRAUMA OF OCCLUSION/TRAUMATIC OCCLUSION:

A traumatic occlusion, tooth on tooth contact and/or tooth on soft tissue contact may result from a malocclusion. Endodontic disease (i.e. fractured teeth, concussive pulpitis) and/or periodontitis may result secondarily to the distorted occlusion.

Specifically, to periodontal disease, occlusal trauma results in injury to the periodontium due to occlusal forces exceeding the reparative capacity of the attachment apparatus. Trauma from occlusion is the tissue injury from the abnormal occlusion. In dogs and cats this is mostly from the developmental occlusion. The occlusion that causes these injuries is termed a traumatic occlusion.

VPT info

Reduction of crown height will expose the pulp and a direct pulp cap (vital pulpotomy) is used to stimulate reparative dentin by the tooth. A composite restoration is normally placed over the pulp capping material. A 2014 paper published in JAVMA by Luotonen et al demonstrated a 92% success rate in teeth treated with MTA compared to 58% in teeth treated with calcium hydroxide. Vital pulpotomy will allow the tooth to continue to mature and produce additional secondary dentin. A 2001 paper, reported an 88% overall success rate of vital pulpotomy. If the tooth becomes non-vital in future years a root canal treatment will be necessary. Reassessment 6-12 months after treatment, and then annually or when the opportunity arises is recommended.

VP APG vs. APX vs. RC

1. Discussed open apices, partial coronal pulpectomy and direct pulp capping (vital pulpotomy) ^; if non – vital and not apical root formation, then apexification or extraction may be necessary. If tooth is non-vital and root apex is formed, then normograde root canal treatment is possible.

2. Discussed duration of fractures and if vital and VP procedure teeth elected, the tooth may still die in the future but the plan is to have the tooth survive long enough for apexogenesis to occur and allow future normograde root canal treatment.