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Veterinary Forum August 2009 (Vol 26, No 8)

Dental Dilemma — Biting Be Gone

by Jan Bellows

    Romeo, a 4-year-old, 3.5-kg, neutered Italian greyhound, presented for chronic oral pain so severe that the dog's owners could not approach the dog's face without being bitten.

    The dog's teeth were cleaned and polished at 2 years of age, and semi-monthly to monthly repositol steroid injections were administered by the referring veterinarian for 1 year prior to presentation. The injections resulted in dramatic behavioral improvement that lasted 2 to 3 weeks. The referring veterinarian recommended daily oral hygiene with toothbrush and dentifrice and weekly application of a plaque preventative wax polymer. Unfortunately, the owner was unable to provide consistent oral hygiene.

    Bilateral caudal vestibular mucositis, cheilitis, glossitis, and ulceration adjacent to the maxillary canines and incisors were present (Figure 1, Figure 2 , and Figure 3). Other physical examination findings were unremarkable. The maxillary and mandibular incisors were mobile secondary to stages 3 and 4 periodontal disease. The client was advised that a closer examination of the oral cavity was needed under general anesthesia.

    Further communication with the owner included an explanation of the oral assessment, treatment, and prevention (Oral ATP) process. Recommendations for the initial preoperative laboratory testing (CBC, serum profile, and thyroid panel), anesthesia, intraoral radiography, and a tooth-by-tooth examination were accepted with the understanding that a treatment plan would be formulated and discussed after the initial assessment. The client was advised that treatment of chronic oropharyngeal inflammation typically included multiple extractions.

    Laboratory test results were within normal limits. The dog was premedicated with hydromorphone at 0.1 mg/kg IM combined with acepromazine at 0.02 mg/kg IM; induced with propofol at 3 mg/kg IV; and intubated and maintained on 2% isoflurane mixed with oxygen. The body temperature was controlled with the Hot Dog patient warming system (Hot Dog USA).

    Individual clinical and radiographic tooth examination revealed stages 2 and 3 mobility of the maxillary and mandibular incisors.

    A recommendation for extraction of the right and left maxillary first and second incisors, canines, third and fourth premolars, first, second and third molars, and mandibular incisors was made to the owner. These extractions would be needed to relieve gingival inflammation, even in areas where the underlying radiographs appeared normal. The treatment plan was approved.

    The oral cavity was irrigated with 0.12% chlorhexidine solution. Maxillary and mandibular regional blocks were accomplished with 0.2-ml injections of bupivacaine. Envelope gingival flaps were created using a #15 scalpel blade to incise vertically into the gingival sulcus circumferentially around the teeth to be extracted. A Freer periosteal elevator was used to expose the alveoli of the teeth to be extracted. A #2 round carbide bur loaded on a sterile saline-irrigated high-speed drill was used to remove the coronal aspect of the alveoli for ease of visualization and extraction. The multirooted teeth were sectioned using a #701 surgical bur to create single-rooted segments. A sharpened wing-tipped elevator was gently rotated perpendicular to the alveolar margins to help create sufficient mobility to deliver the tooth segments from the oral cavity using extraction forceps.

    Alveoloplasty using a #2 carbide round bur loaded on a sterile saline-irrigated high-speed drill was performed on all exposed areas to smooth the coronal extent of the alveolus before closure. Intraoral radiographs were obtained and examined to confirm the extraction sites were free from root fragments. The incised gingiva was closed with 4-0 monocryl (Ethicon) suture using a continuous pattern. Romeo made an uneventful recovery from anesthesia. The owner was instructed to medicate with clindamycin at 15 mg/kg q12h, firocoxib at 5 mg/kg q24h, and tramadol HCl at 2 mg/kg PO q12h.

    Follow-up examinations at 1 and 6 months after surgery revealed total clinical resolution of the oropharyngeal inflammation (Figure 4 and Figure 5) and the aggressive behavior. Recommendations for home oral care included twice-daily use of a dental wipe infused with sodium hexametaphosphate (DentAcetic Wipes, Dermapet) and application of a wax polymer (OraVet, Merial Ltd.) every other day.

    Discussion

    This case presented many dilemmas, including the cause of Romeo's painful mouth. Chronic ulcerative paradental stomatitis (CUPS) is a term commonly used to describe inflamed areas adjacent to teeth in the oral cavity. The etiology is thought to be a hyperimmune reaction to plaque. Oropharyngeal inflammation is better classified by the affected anatomic areas instead of the catch-all term "CUPS," which in some cases is not ulcerative or generalized enough to merit the term stomatitis (see sidebar).

    Generally, affected dogs display unifocal or multifocal areas of oropharyngeal inflammation. The pain secondary to ulceration does not allow owners the opportunity to provide home care. Common signs include halitosis, drooling, and pain on oral examination. The exact etiology is unknown, although plaque hypersensitivity is suspected. Maltese are predisposed, but any canine breed can be affected.

    Other immune-mediated diseases, such as discoid lupus, pemphigus, and bullous pemphigoid, are syndromes that may appear similar but typically affect the mucocutaneous junctions in many areas, such as the eyes, nostrils, prepuce or vulva, or anus, which Romeo's lesions did not.

    The second dilemma involved therapeutic options. Conservative treatment would have involved dental scaling, polishing, application of a wax polymer plaque preventative, and twice-daily home care. The other option was extraction of the teeth opposing the inflamed areas. If the inflammation and ulceration were secondary to a reaction to plaque and calculus, then extracting the teeth in close contact with the facial, buccal, and vestibular gingiva would have been curative.

    On the surface this might appear to be overkill, but in retrospect it was successful for the patient and owner. Romeo needed to be free from pain, which was accomplished by removing those teeth.

    For more information:

    Holmstrom SE (guest editor). Dentistry. Veterinary Clinics of North America: Small Animal Practice 35(7). Philadelphia: WB Saunders, 2005.

    Holmstrom SE, Frost P, Eisner ER. Veterinary Dental Techniques. ed 3. Philadelphia: WB Saunders; 2004.

    Verstraete FJM. Self-Assessment Color Review of Veterinary Dentistry. Ames, Iowa, Manson Publishing, London & Iowa State University Press; 1999.

    Wiggs RB, Lobprise HB. Veterinary Dentistry Principles & Practice. Philadelphia: Lippincott-Raven; 1997.

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