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Veterinary Forum October 2007 (Vol 24, No 10)

Dental Dilemma: A Hairy Dental Problem

by Jan Bellows

    Case Presentation

    A 5-year-old, 19-kg, spayed English bulldog presented for annual examination with vaccinations. According to the owner, the dog had no known medical problems and was eating and drinking normally. The physical examination was unremarkable, except for gingival inflammation around the maxillary incisors and hair shafts in the gingival sulci (

    Figure 1

    ). There was no evidence of alopecia, skin inflammation, or the presence of fleas or ticks.

    The client was advised that a thorough oral assessment, treatment, and prevention (oral ATP) visit would be needed to further evaluate and treat the maxillary inflammation and remove the sulcular hair. Results of a complete blood count and liver, kidney, and glucose laboratory tests were within normal limits, as was a preanesthetic electrocardiogram.

    The patient was premedicated with 75 mg of clindamycin PO, and 0.1 mg/kg of hydromorphone IM combined with 0.1 mg/kg of acepromazine IM. Anesthesia was induced with 0.5 mg/kg of diazepam IV and 10 mg/kg of ketamine IV. An intravenous catheter was placed for administration of lactated Ringer's solution during anesthesia. The dog was then intubated and maintained on 2% isoflurane, and its body temperature was controlled in a warm-air Bair Hugger (Arizant Healthcare).

    General anesthesia allowed an in-depth tooth-by-tooth examination, which revealed major gingival pathology rostral to the right and left maxillary first and second incisors. Tufts of coarse guard hairs were lodged in the rostral incisor gingival sulci. A periodontal probe was used to measure attachment levels. The right and left maxillary second incisors had 2- to 3-mm gingival recession. The right first incisor had evidence of gingival dehiscence with root exposure from the gingival margin past the mucogingival line. The left first incisor sulcus contained a tuft of hair that extended to a gingival swelling located 2 mm coronal to the mucogingival line.

    An 8-mm labial probing depth of the second incisors was present rostrally, and a 10-mm probing depth on the left first incisor and 12-mm depth on the right first incisor also were present rostrally. Mesial probing depth measurements were normal at 2 mm. All other dental probing depths were within normal limits. There were no other clinical oral abnormalities (

    Figure 2

    ).

    Intraoral radiographs revealed greater than 50% horizontal bone loss around the right maxillary first and second incisors and less than 25% horizontal bone loss around the left maxillary first and second incisors (

    Figure 3

    ).

    A dermatologic cause of the sulcular hair was discussed with the owner, who declined a skin workup, including allergy testing and referral to a veterinary dermatologist.

    Treatment Plan

    The treatment plan included surgical extraction of the maxillary right and left first and second incisors by means of gingival flap exposure. The surgical site was irrigated with 0.12% chlorhexidine. Vertical incisions using a No. 15 scalpel blade were carried from the interdental gingival margin of the right and left maxillary second and third incisors past the mucogingival line. The scalpel blade was used to incise circumferentially around the incisors. Molt and Freer periosteal elevators were used to elevate the gingiva for tension-free scalloped closure of the freshly cut gingival edges of the extraction defects (

    Figure 4

    ).

    A winged-tipped elevator helped elevate the incisors until they were mobile, and they were removed using extraction forceps. Alveoloplasty using a No. 2 bur on a water-cooled high-speed handpiece was used to reduce the sharp alveolar ridges remaining after the incisors were extracted. A bone curette was used to remove granulation tissue from the alveolus before closure.

    Radiography confirmed complete extraction (

    Figure 5

    ). Polyglactin 4-0 sutures were used to close the operative site without tension.

    The client was instructed to feed the dog a soft diet for 1 week. Clindamycin at 5 mg/kg bid PO for 1 week to treat any underlying infection and meloxicam at 0.1 mg/kg q24h PO for 5 days to decrease postoperative pain and for its antiinflammatory effects were prescribed for home administration.

    Two weeks after surgery, follow-up examination confirmed normal healing (

    Figure 6

    ). The client was instructed to begin plaque control by daily wiping of the tooth and gingiva interface using sodium hexametaphosphate wipes (Dentacetic dental wipes, DermaPet) and daily feeding of a rawhide chew impregnated with chlorhexidine (C.E.T. oral hygiene chews, Virbac Animal Health) and a dental chew (Greenies dental chews, Mars). Monthly rechecks were scheduled to follow the healing progress of the surgical site and monitor other areas of the mouth for evidence of periodontal disease.

    Discussion

    Normally, the alveolus completely surrounds the roots (

    Figure 7B

    ). The position of gingival margin is partially determined by the height and thickness of underlying bone, thickness of the gingiva, and tooth alignment. Gingival recession is characterized by the displacement of the gingival margin apically from the cementoenamel junction following bone loss over the root. The loss of this attachment is the result of inflammatory pro­cesses in connective tissue. Recession can be localized, affecting one tooth, or generalized, involving segments of teeth or arches. The incisor teeth have a thinner alveolar plate rostrally that may predispose the animal to mucogingival disease.

    Gingival disease occurring secondary to a foreign body reaction to trapped hair in the gingival sulci is common in dogs with a short, coarse coat and a predominance of guard hairs affected by inflammatory skin disease, such as atopy, demodicosis, or fleabite allergy, resulting in excessive self-grooming. In this patient, the entrapped hair led to chronic destructive periodontal infection and disease, gingival recession, clefts, and alveolar dehiscence.1

    Chronic destructive periodontal disease is a serious condition affecting bone. The height of the alveolar bone is normally maintained by equilibrium between bone formation and bone resorption, which is regulated by local and systemic influences. When resorption exceeds formation, bone height is reduced. Bone destruction in periodontal disease is caused primarily by the local factors that cause gingival inflammation. In this case, it was caused by hair acting as a foreign body. Gingival clefts resemble V-shaped notches in the marginal gingiva. If the gingival cleft is caused by loss of the underlying alveolar plate, then dehiscence may occur and extend from the free gingival margin, thus apically exposing the root through the alveolus (

    Figure 7B

    ).

    In this case, extraction of the affected teeth allowed affected tissues to heal and not be further inflamed by coarse-hair foreign-body reaction. The underlying reason for the dog's self-grooming, however, needs to be addressed to prevent further occurrence in other areas of the mouth.2

    Dr. Bellows reported no potential conflict of interest relevant to this article.

    Reviewer Comment

    This interesting case is an example of a problem that exemplifies two occurrences:(1) local periodontal disease and foreign body entrapment as a result of self-grooming and (2) ectopic hairs arising from the gingival tissue (they are more commonly found on the dorsal surface of the tongue). This condition is occasionally seen in general practice.

    1. Wiggs R, Lobprise H: Veterinary Dentistry: Principles and Practice. Baltimore, Lippincott Williams & Wilkins, 1997, pp 191-199.

    2. Niemiec B: Dental/dermatology interaction. Proceedings of the North American Dermatology Seminar, 2006.

    References »

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