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Veterinary Forum April 2007 (Vol 24, No 4)

Dental Dilemma: "Full-Mouth Extraction in a Dog with Multiple Dental Anomalies"

by Jan Bellows

    A 10-month-old, maltese-poodle mix was referred for dental evaluation and care. The owner and referring veterinarian noted that the dog was missing numerous teeth and the teeth that were present were discolored with enamel defects. No history of dental pathology in the parents or siblings of this dog was available.

    Click here for Glossary

    Case strategy

    Initial assessment included preanesthetic blood work and electrocardiographic examination, general anesthesia, full-mouth intraoral radiography, and a tooth-by-tooth morphology, mobility, and probing-depth examination.

    Results of a complete blood count as well as liver, kidney, and glucose testing were within normal limits, as was the preanesthetic electrocardiogram. The patient was premedicated intramuscularly with 0.1 mg/kg of hydromorphone combined with 0.010 mg/kg of acepromazine. Anesthesia was induced intravenously with 0.5 mg/kg of diazepam and 10 mg/kg of ketamine, and the dog was intubated and maintained on 2% isoflurane. Pulse oximetry, respiratory rate, blood pressure, and electrocardiographic monitoring were conducted throughout the procedure, and the patient's temperature was controlled in a warm-air Bair Hugger.

    Oral examination revealed multiple defects, including embedded and impacted teeth, partially erupted teeth, areas of enamel and dentin loss with pulp exposure (similar to a carious lesion or cavity), dilacerated roots, an irregular radio-opaque mass with dental elements (possibly a complex odontoma), as well as missing teeth. All exposed teeth had areas of enamel loss consistent with enamel hypomaturation and hypoplasia (Figure 1). Full-mouth radiographs exposed the extent of disease, with every tooth being affected (Figure 2), and after discussion with the client, the decision to proceed with full-mouth extraction was made.

    The gingival attachment of all visible teeth was incised circumferentially at the base of the sulcus using a No. 15 scalpel blade, and the interdental gingiva was incised in each quadrant. An envelope flap positioned apically to the mucogingival line in each quadrant was used to expose the lateral alveolus. The gingiva was reflected apically to the mucogingival line using Molt and Freer periosteal elevators. The alveolar bone overlying the lateral (buccal) aspect of the roots was removed using a round dental bur in a water-cooled, high-speed handpiece. Multirooted teeth were sectioned into single-root segments using a crosscut fissure bur, and a wing-tipped dental elevator was used to elevate the roots from their alveoli. Extraction forceps were used to deliver mobile tooth segments from the alveoli.

    Alveoloplasty was performed after extraction to eliminate sharp, protruding edges. Synthetic bone graft material (Consil, Nutramax Laboratories, Inc.) was placed in the remaining alveolar defects before the gingiva was sutured closed, and postoperative radiography confirmed complete extraction (Figure 3 and Figure 4).

    Postoperatively, the patient was medicated with 0.2 mg/kg of IM morphine sulfate, along with clindamycin at 10 mg/kg PO immediately after surgery. The owner was instructed to continue the antimicrobial medication for 1 week, feed the dog a soft diet, and administer the prescribed NSAID as directed at 5 mg/kg q24h for 5 days. Ten days after surgery, the patient was reexamined (Figure 5). All surgical sites appeared to be healing normally. A follow-up visit 1 month after surgery showed clinical healing, with no apparent adverse effects to the dog's ability to eat kibble and thrive.

    Discussion

    A host of developmental abnormalities, including malformations, changes in numbers, inherited disturbances, and environmental influences, can affect teeth. Some of these conditions arise from actions that occur during tooth development, whereas others arise after tooth eruption.

    Enamel hypoplasia refers to a quantitative defect in which enamel (typically the hardest substance in the body) is normal but is not present over the entire crown or is diminished in thickness.1 More often, however, there is a qualitative defect in which enamel is present in a normal amount but is hypomineralized (hypocalcified) and appears soft and chalky.1 In most cases presented in small animal medicine, both conditions — that is, reduced quality as well as quantity — occur. The defect can be isolated to one tooth or a given area of a tooth or can be widespread throughout the dental arcade, as occurred in this case. The teeth are only slightly weaker than normal but are considerably more susceptible to wear because underlying dentin is not as resistant to wear as enamel is.

    If exposed, the dentin tubules may serve as a pathway for bacteria or toxins from the oral cavity to invade the pulp. Because extensions of pulpal nerves are in the tubules, exposure also may lead to sensitivity. In pets younger than 1 year of age, the dentin is still relatively thin and the root is not fully formed. As a tooth matures, the dentin becomes thicker and the tooth stronger.

    The causes of abnormal enamel development include systemic febrile illness (distemper, parvovirus) or serious nutritional deficiency. The extent of the defect(s) depends on the intensity of the causative factor, the duration of the factor's presence, and the time at which the factor occurs during tooth development.1

    Options for treating teeth affected by enamel hypoplasia/hypocalcification include extraction or potential restoration1 after intraoral radiographs have been evaluated. Restoration of the lesions can help seal the exposed dentinal tubules and protect the tooth, allowing it to mature. Because of the shearing forces exerted on the teeth, these restoratives will wear off over time. When this occurs, the bonding agent and residual composite will still be present within the dentin tubules, thus maintaining the seal on the teeth. Typically, the worn composite is not replaced unless the owner requests it for cosmetic reasons.

    Pet owners should be counseled on the importance of routine home-care programs combined with regular professional cleanings, as plaque and calculus tend to accumulate more rapidly because of the rougher than normal surfaces of these teeth. In the case presented here, the affected teeth were extracted because of the extent of severe malformations and undereruption, making effective home care doubtful if any teeth were retained. Genetic counseling was provided to the owner, with strong recommendations against breeding this dog or its siblings.

    Both mandibular first molars and several premolars exhibited loss of enamel and dentin in a pattern similar to carious lesions (cavities). True cavities are the result of bacterial decay and demineralization of tooth surfaces, often on a grinding surface (not always), and are certainly more common in humans than in dogs.2 Because of the weakened state of the enamel in this patient, however, bacterial decay could have been enhanced. With any carious lesion, the introduction of bacteria into the dentinal tubules could impact a tooth's health, so full evaluation is essential in teeth that are being considered for restoration and salvage. The lesions on this patient's teeth were severe enough to warrant extraction.

    Odontomas appear as either irregular masses of calcified material (complex) or as a collection of numerous tooth-like structures within a mass (denticles found in compound odontomas).3 Generally, compound odontomas are found in the rostral arch (canine and incisor teeth), whereas complex odontomas are found in the posterior dental arch (premolar and molar teeth). Confirmation may be made through histopathology, which was not performed in this case. A tentative diagnosis was based on radiographic findings, although extremely dilacerated or malformed teeth may appear similar.

    1. Wiggs BW, Lobprise HB: Veterinary Dentistry: Principles and Practice. Philadelphia, Lippincott-Raven, 1997.

    2. Hale FA: Dental caries in the dog. J Vet Dent 1998;15:79-83.

    3. Sowers J, Gengler W: Diagnosis and treatment of maxillary compound odontoma. J Vet Dent 2005;21(1):26.

    References »

    NEXT: Diagnostic Dilemma: "Gastrocutaneous Fistula Secondary to Wooden Foreign Body"

    didyouknow

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